Ulcerative Colitis

Ulcerative colitis is a long-standing (chronic) inflammatory bowel disease affecting the inner surface of the large bowel (the colon) and the rectum.

The disease usually begins in the rectum and, in some patients, spreads continuously towards the higher parts of the large bowel. It may be confined to the rectum alone, or it may affect the whole of the large bowel.

In ulcerative colitis, the periods when the disease worsens are called flares, and the periods when the complaints reduce markedly or disappear are called remission.

Ulcerative colitis is not contagious and it is not cancer. But the risk of colon cancer can rise in long-standing and extensive disease, so regular follow-up matters.

What causes ulcerative colitis?

The precise cause of the disease is not known.

It is thought that in people with a genetic predisposition, the immune system mounts an inappropriate and continuing inflammatory response against the inner surface of the bowel.

The following may play a part together in the development of the disease:

• Genetic predisposition
• Dysregulation of the immune system
• Changes in the gut microbiota
• Environmental factors

Ulcerative colitis does not pass from person to person, and it is not a disease that arises from eating habits alone.

Which parts of the bowel does ulcerative colitis affect?

The extent of the disease varies from person to person.

Proctitis

The disease is confined to the rectum.

Left-sided colitis

The inflammation begins in the rectum and extends towards the left side of the large bowel.

Extensive colitis

The disease affects a wider part of the colon.

Pancolitis

Most or all of the large bowel is affected.

The extent of the disease matters in deciding the treatment and follow-up plan.

What are the symptoms?

Symptoms vary with the extent and the severity of the disease.

The most common complaints are:

• Frequent bowel movements and diarrhoea
• Blood in the stool
• Mucus in the stool
• Bleeding from the back passage
• A sudden, urgent need to open the bowels
• Difficulty reaching the toilet in time
• The sense of not having emptied the bowel despite the urge to go (tenesmus)
• Abdominal pain and cramps
• Fatigue and tiredness
• Loss of appetite
• Weight loss

In more severe flares there may be fever, anaemia, palpitations and a deterioration in general condition.

Does ulcerative colitis affect only the bowel?

No. Some patients also develop findings in organs outside the bowel.

These can include:

• Joint pain or joint inflammation
• Certain skin conditions
• Inflammation in the eye
• Mouth ulcers
• Primary sclerosing cholangitis (PSC), affecting the bile ducts

Ulcerative colitis is therefore regarded in some patients as a systemic disease that is not confined to the bowel.

How is the diagnosis made?

Ulcerative colitis cannot be diagnosed on a single blood or stool test.

The diagnosis brings together the patient’s complaints, the physical examination, laboratory investigations, stool tests and endoscopic findings.

Blood tests

The blood count, CRP and other investigations can help to assess the severity of the inflammation, anaemia and nutritional status.

Stool investigations

Stool tests matter particularly for excluding infections of the bowel.

Faecal calprotectin can help in assessing inflammation in the bowel and in following up known ulcerative colitis.

Colonoscopy and biopsy

This is one of the most important methods in reaching the diagnosis.

During colonoscopy the inner surface of the large bowel is assessed and biopsies are taken from the necessary areas. Pathological examination of the biopsies helps to confirm the diagnosis and to distinguish it from other causes of colitis.

In severe acute colitis, a more limited endoscopic examination may be preferred instead of a full colonoscopy, depending on the patient’s condition.

How is ulcerative colitis treated?

The aims of treatment are:

• To bring the active inflammation under control
• To reduce bleeding and diarrhoea
• To achieve remission
• To maintain that remission
• To prevent new flares
• To reduce complications
• To preserve the patient’s quality of life.

Treatment is planned individually according to the severity and extent of the disease and the response to previous treatments.

5-ASA (mesalazine) treatment

This is one of the mainstay treatments commonly used in mild and moderate ulcerative colitis.

Mesalazine can be taken by mouth as a tablet, and it can also be given rectally as a suppository or enema depending on where the disease is.

Using oral and rectal treatment together can be more effective in some patients, particularly those with rectal and left-sided involvement.

Corticosteroids

These can be used to bring moderate or severe flares under control.

Corticosteroids are not generally used for long-term maintenance treatment. The aim is to remove the need for steroids once the flare has been controlled.

Immunomodulators and advanced treatments

Medicines that modulate the immune system can be used depending on the severity of the disease and the response to previous treatments.

The following can be used today in suitable patients:

• Biological treatments
• Small-molecule medicines
• Other targeted treatments

Which treatment to choose has to be assessed separately for each patient.

When is surgery needed?

Surgical removal of the large bowel may be needed in some patients where the disease cannot be brought under control despite medical treatment, or where serious complications have developed.

Surgery comes into consideration particularly in:

• Severe disease resistant to treatment
• Serious bleeding that cannot be controlled
• Toxic megacolon
• Perforation of the bowel
• Cancer
• The finding of certain high-risk precancerous changes (dysplasia)

The decision to operate is assessed individually for the patient by the gastroenterology and colorectal surgery teams.

What should the diet be in ulcerative colitis?

There is no single special diet proven to eliminate ulcerative colitis altogether.

Adequate and balanced eating matters in general. The foods a patient cannot tolerate vary from person to person.

Attention should be paid to fluid and electrolyte loss during flares, because of the amount of diarrhoea. Eating can be temporarily reorganised according to the patient’s condition.

Deficiencies of iron, B12, folate, vitamin D and other nutrients should be investigated and replaced where necessary.

Unnecessary and excessively restrictive diets should be avoided.

Does the disease go away completely?

Ulcerative colitis generally follows a chronic course. Medical treatment does not eliminate the disease altogether, but long-term remission can be achieved.

Inflammation can continue in the bowel even when the patient feels entirely well. What matters is therefore not only that the complaints have reduced, but that disease activity is checked where necessary with laboratory tests, stool tests and endoscopic assessment.

Stopping the medicines without a doctor’s advice can lead to a flare.

Does the risk of colon cancer rise?

The risk of colorectal cancer can rise in long-standing ulcerative colitis affecting a wide part of the colon.

The risk is influenced by factors such as:

• The duration of the disease
• The extent of involvement in the colon
• The severity of the inflammation
• A family history of colorectal cancer
• The presence of primary sclerosing cholangitis

Regular colonoscopic cancer surveillance is therefore needed after a certain duration of disease. The interval between colonoscopies is decided according to the patient’s individual risk.

What are the signs of a flare?

An increase in the number of bowel movements, blood appearing in the stool, an increased urgency to open the bowels, opening the bowels at night, abdominal pain and a deterioration in general condition can all suggest that the disease has become active again.

It is more appropriate for the patient to speak to their doctor at this point than to change the dose of their medicine themselves.

When should you go to hospital urgently?

The following can be signs of a severe flare or a complication:

• Heavy or steadily increasing bleeding
• Very frequent bloody diarrhoea
• Severe or steadily increasing abdominal pain
• Marked swelling of the abdomen
• High fever
• Persistent vomiting
• Fainting or marked weakness
• Palpitations and a rapidly deteriorating general condition
• Being unable to pass wind or stool

Medical assessment should not be delayed in these situations.

Is a normal life possible with ulcerative colitis?

Yes.

There are many effective options in the treatment of ulcerative colitis today. In a substantial proportion of patients, long-term remission can be achieved with appropriate treatment and regular follow-up, and a normal or near-normal life can be maintained.

The patient taking their medicines regularly, not missing their check-ups and going to their doctor when new symptoms appear all matter to the success of the treatment.

Remember

Ulcerative colitis is chronic, but it is a disease that can be treated and kept under control.

The fundamental aim of treatment is not merely to reduce diarrhoea and bleeding, but to bring the inflammation in the bowel under control, to achieve lasting remission and to prevent long-term complications.