Ulcerative colitis

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What is Ulcerative Colitis?

Ulcerative Colitis is a slow progressing long term condition that affects the large intestine and manifests as inflammation and ulceration of the colon and the rectum. It is one of the diseases that constitute the irritable bowel syndrome.

Is Ulcerative Colitis a Medical emergency?

Ulcerative Colitis is not a medical emergency.

Types

Depending on the location of the inflammation and ulceration may be of the following types:

  • Ulcerative proctitis: It is the mildest form, and the area just above the anus is affected
  • Proctosigmoiditis: The rectum and the sigmoid colon are involved
  • Left-sided colitis: The rectum, sigmoid colon, and the descending colon are affected
  • Pancolitis: It affects the entire colon and the rectum
  • Acute severe Ulcerative Colitis: It affects the entire colon and is the most severe form of the disease

Causes

The exact cause is not known but genetic causes, immune dysfunction, environmental, and lifestyle factors are implicated in its development.

Risk factors

The following may increase the risk of Ulcerative Colitis:

  • Family history or other inflammatory bowel diseases
  • Vitamin A & E deficiency
  • Psychological and psychosocial stress
  • Excessive use of NSAIDs
  • Consumption of milk may increase symptoms in some individuals

Signs & symptoms

The following symptoms and signs are seen in Ulcerative Colitis:

  • Frequent stools
  • Rectal bleeding
  • Blood or mucus from the rectum
  • Cramping rectal pain with a frequent urge to have a bowel movement (tenesmus)
  • Lower abdominal pain
  • Purulent discharge from the rectum (in the elderly)
  • Weight loss

In fulminant (severe) Ulcerative Colitis the symptoms may include:

  • Severe diarrhea with cramps
  • Fever
  • Abdominal bloating, swelling and severe pain
  • Rapid heart rate

Investigations

The following investigations may be done for establishing a diagnosis are:

  • Laboratory tests:
    • Serological markers: Such as Anti Neutrophil Cytoplasmic Antibodies (ANCA) and Anti Saccharomyces Cerevisiae Antibodies (ASCA)
    • CBP & ESR
    • C-Reactive Protein
    • Serum Metabolites
    • Other Inflammatory markers: Fecal Calprotectin, Fecal Lactoferrin, Alpha 1 antitrypsin
  • Stool Examination
  • Endoscopy & Biopsy: Flexible sigmoidoscopy, followed by colonoscopy with multiple biopsy samples
  • Imaging tests:
    • Ultrasound
    • X-ray
    • CT/MRI
    • Radionuclide studies - Useful in fulminant Ulcerative Colitis

Diagnosis

A diagnosis of Ulcerative Colitis is established based on medical history, clinical evaluation, and the investigations' results.

Course & Stages

Ulcerative Colitis may be graded as follows:

  • Mild Ulcerative Colitis: Bleeding per rectum with less than 4 bowel movements per day
  • Moderate Ulcerative Colitis: Bleeding per rectum with more than 4 bowel movements per day
  • Severe Ulcerative Colitis: Bleeding per rectum with more than 4 bowel movements per day and with systemic illness and hypoalbuminemia

Treatment options

The treatment of this disease depends on the stage (whether it is active or in remission), the location, and the grade of the disease. Initial medical management, followed by surgical intervention if required may be done to treat and managed.

Medical management

Medical management is done to reduce the symptoms and prevent complications. Medical management may include the following:

  • Corticosteroids: Act by reducing the inflammation; they are used in the initial management of moderate to severe Ulcerative Colitis
  • Antidiarrheals: Such as diphenoxylate hydrochloride, or loperamide; for the management of diarrhea and frequency of stool
  • 5 Aminosalicylic acid derivative: To reduce inflammation
  • Immunosuppressant agents: Such as azathioprine, cyclosporine, tacrolimus; are useful in steroid-resistant disease
  • Alpha 4 Integrin Inhibitors: Such as Vedolizumab; used in moderate to severe active disease
  • JAK inhibitors: Such as Tofacitinib; useful in the management of moderate to severely active disease
  • Probiotics: Such as E.coli Nissle, help in maintaining remission

Interventional including surgery and indications for surgery

Surgical management of this disease is indicated under the following circumstances are:

  • Emergency surgery
    • Toxic megacolon not responding to medical management
    • The fulminant attack not responding to medical management
    • Uncontrolled bleeding from the colon
  • Elective surgery
    • Long term steroid dependency
    • Disease lasting for more than 7-10 years
    • Evidence of cancerous transformation on biopsy

Surgical procedures for the management of this disease may include the following:

  • Proctocolectomy: Removal of the entire colon and rectum
  • Ileal Pouch Anal Anastomosis: A pouch is created using a part of the small intestine, and the pouch is attached to the remaining part of the anal canal. This procedure is done as a 2 or 3 step procedure and involves the creation of an opening in the abdomen to collect stool via a bag before the small intestine is connected to the anus.

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

Some measures that can help in the management of this disease may include:

  • Dietary modification: By avoiding dairy products, or any food that is known to increase the symptoms such as coffee, alcohol, spicy food, high fiber diet, etc.
  • Eating small regular meals
  • Hydration: By increasing the oral intake of water and fluids
  • Avoiding stress
  • Regular exercise

Complications

The following maybe some of the complications as it is known to manifest and create morbidity in other organs and organ systems are:

  • Severe bleeding and anemia
  • Perforated colon
  • Toxic megacolon
  • Colon Cancer
  • Uveitis
  • Pyoderma gangrenosum
  • Pleuritis
  • Erythema Nodosum
  • Ankylosing spondylitis
  • Spondyloarthropathies
  • Deep Vein Thrombosis and Thromboembolism

Prognosis

The prognosis is generally good, and individuals with the disease have periods of activity followed by periods of remission. Improperly managed can result in morbidity and reduced quality of life, and there is a risk of developing colon cancer and death.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek medical attention if the symptoms are noticed.

Indications for hospitalization if required

Hospitalization may be required for surgical management.

Screening methods

Individuals should get regular screening for colorectal cancer through colonoscopy.

Suggested clinical specialist/ Departments to consult for this condition

It will be attended by specialists from the Departments of Bowel Disease, Gastroenterology.

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