Ulcerative colitis is a chronic inflammatory disease of the large intestine (also known as the large bowel or colon). The most common symptoms are bloody diarrhea and abdominal pain Figure 01. Ulcerative colitis involves periodic inflammation and loss of tissue (ulceration) of the lining of the large intestine. The condition produces frequent bouts of urgent, bloody diarrhea, and sometimes with abdominal cramping. It usually begins in childhood or early adulthood, and is characterized by periods of exacerbations and remissions. During remissions, the person may feel well and be free of symptoms.
Ulcerative colitis shares many common characteristics with Crohn’s disease, another inflammatory bowel disease. About 15% of patients with inflammatory bowel disease have features of both conditions, and cannot be clearly diagnosed with one or the other.
Figure 01. Anatomy of the digestive system
The more the bowel is inflamed, the more severe the disease. The inflammation and ulceration of ulcerative colitis is present in the rectum, and may spread up through the large intestine in a characteristically continuous manner. Disease severity depends in part on how much of the intestine is affected. If disease is confined to the rectum (proctitis), symptoms are often relatively minor. Proctosigmoiditis is the term used when both the rectum and sigmoid colon are involved. Those who have disease in the entire colon (pancolitis) usually have the most severe symptoms.
Colitis can be a serious disease requiring hospitalization, surgical removal of the colon, and an increased risk of colon cancer. Because colitis usually begins in young adulthood, it can disrupt a person’s education, career goals, and social life. Although it is not considered to be a fatal disease, it can cause serious anemia, malnutrition, and disability during prolonged attacks, and sometimes requires hospitalization. Although effective medicines can help most people keep the disease in check, for some, the colon must eventually be removed for relief.
Two of the most dangerous complications of ulcerative colitis are holes (perforations) in the intestine and a condition known as toxic megacolon, in which the colon becomes expanded (distended) and is in immediate danger of perforation. Both perforation and toxic megacolon are medical emergencies that must be treated at once, usually by removal of part or the entire colon.
Ulcerative colitis also brings the long-term risk of colon cancer. Patients are advised to undergo periodic screening with colonoscopy on a schedule determined by the extent and duration of their disease. During a colonoscopy the doctor inserts a long and flexible lighted tube, an endoscope, into the anus to see if there is inflammation, bleeding, or ulcers on the colon wall. In screening for cancer and pre-cancerous changes, the doctor will do a number of biopsies—that is, take samples of tissue from the lining of the colon to examine under a microscope. Some people opt to have their colon removed to prevent cancer from developing.
A small percentage of patients with ulcerative colitis also have inflammation in other parts of their body. Less than 5% of patients with ulcerative colitis also have primary sclerosing cholangitis, an inflammatory disease of the biliary tract that delivers bile (a digestive fluid) from the liver to the intestines. The skin, joints, and eyes are also sometimes affected.
The precise reason some people develop ulcerative colitis is not understood. Colitis results from an abnormal immune response, perhaps to substances in food. Ulcerative colitis has been blamed on genetic factors, bacteria, viruses, stress, and diet, but no theory offers a clear-cut explanation of the disease. It tends to run in families, and is more common in certain ethnic groups, indicating that genetics are at least partially responsible.
Whatever the reason, the body mounts an inflammatory response in the colon as if a foreign invader, such as a bacterium, a virus, or an allergen, were present. The abnormal response may continue even after the provoking agent is no longer present.
People with ulcerative colitis may be considerably emotionally distressed, leading some to suspect that stress is a primary cause of the disease. There is no evidence, however, that psychological factors cause the disease. Instead, most experts believe that emotional stress is an understandable and common response to a problem that frequently recurs beyond one’s control.
Ulcerative colitis is characterized by frequent, urgent bouts of bloody diarrhea. Ulcerative colitis involves periods of frequent diarrhea, which may come on so suddenly that making it to the bathroom in time may not always be possible. Usually only small amounts of bloody stool are passed at a time. The amount of diarrhea and blood vary with the extent of the disease. If the disease is only in the rectum, the person may in fact feel constipated, with firm, infrequent stools accompanied by bloody mucus.
Cramping pain is another common symptom during flare-ups. Some people experience nausea. With severe disease, weight loss and extreme fatigue due to nutrient and blood loss may develop. Some people also have inflammation in places other than their intestines, and may develop skin lesions, pains in the joints, and eye irritation.
Fever, vomiting, severe pain, and debility are the most worrisome symptoms, and may require immediate hospitalization for evaluation of dehydration, malnutrition, or a perforation in the intestine. One of the most severe complications of ulcerative colitis is toxic megacolon, a condition in which the entire colon becomes extremely distended and stops functioning. This condition almost invariably requires immediate surgical removal of the colon.
Table 1. Symptoms of Ulcerative Colitis
Periodic bouts of Urgent diarrhea with visible blood Cramping pain Nausea Weight loss Fatigue In some cases Skin lesions Joint pains Itchy or irritated eyes Symptoms requiring immediate medical evaluation Fever Severe pain Vomiting Severe debility
Ulcerative colitis usually appears before age 30. People of European Jewish descent have the highest incidence. Ulcerative colitis usually strikes in young adulthood, but may begin in childhood. It sometimes runs in families. People of Ashkenazi (European) Jewish descent are affected more than any other group.
Diagnosis consists of a physical exam, tests to rule out infectious causes, visualization of the intestine, and biopsies (when a physician examines tissue samples under a microscope) to detect tell tale signs of the disease. A thorough physical examination with a family doctor is done in addition to blood tests and stool samples to look for parasites and other infectious agents.
If no infectious causes are evident, the doctor may do more invasive diagnostic tests on the colon, including a barium enema, in which the colon is filled with a chalky solution (barium) that shows up on x-rays; and flexible sigmoidoscopy, which involves inserting a flexible tube with a light into the anus and examining the rectum and sigmoid colon. Small tissue samples can be taken of suspicious areas and sent to a pathologist to examine microscopically. In this way, the doctor can determine if there is evidence of ulcerative colitis or other problems, such as Crohn’s disease (another inflammatory bowel disease), diverticular disease (involving abnormal outpouchings of the colon), or colon cancer.
Complete colonoscopy is considered the “gold standard” of diagnosing the problem, but is best performed during remission of the disease. It is similar to flexible sigmoidoscopy but allows the visualization and tissue sampling of the entire colon, enabling the doctor to determine the extent of the problem. Colonoscopy is also periodically performed to monitor ulcerative colitis and check for early signs of cancer.
The diagnosis and treatment of ulcerative colitis usually involves a team of health care providers, including the patient’s primary-care doctor, a gastroenterologist (a doctor who specializes in disorders of the digestive tract), and possibly a surgeon. A dietitian and counselor can also be helpful.
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