Definition

Ulcerative colitis is a disease that causes inflammation and sores, called ulcers, in the lining of the rectum and colon, it does not affect the small bowel or upper GI tract. Ulcers form where inflammation has killed the cells that usually line the colon, and then bleed and produce pus. Inflammation in the colon also causes the colon to empty frequently, causing urgent and frequent diarrhea.

Ulcerative colitis is an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation in the GI tract. It can be difficult to diagnose because its symptoms are similar to other intestinal disorders and to another type of IBD called Crohn’s disease. Crohn’s disease differs because it causes inflammation deeper within the intestinal wall and can occur in other parts of the digestive system, including the small intestine, mouth, esophagus, and stomach. Ulcerative colitis starts in the rectum.  If it only effects this area then it is proctitis.  If can progress through the colon and if it effects the entire large intestine it is called pancolitis.

Causes

Many theories exist about what causes ulcerative colitis. People with ulcerative colitis have abnormalities of the immune system, but doctors do not know whether these abnormalities are a cause or a result of the disease. The body’s immune system is believed to react abnormally to the bacteria in the digestive tract.

Ulcerative colitis is not caused by emotional distress or sensitivity to certain foods or food products, but these factors may trigger symptoms in some people. The stress of living with ulcerative colitis may also contribute to the worsening of symptoms.

Ulcerative colitis can occur in people of any age, but it usually starts between the ages of 15 and 30, and less frequently between 50 and 70 years of age. It affects men and women equally and appears to run in families, with reports of up to 20 percent of people with ulcerative colitis having a family member or relative with ulcerative colitis or Crohn’s disease. A higher incidence of ulcerative colitis is seen in Whites and people of Jewish descent.

Symptoms

The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea. Patients also may experience:

  • Anemia
  • Fatigue
  • Weight loss
  • Loss of appetite
  • Rectal bleeding
  • Loss of body fluids and nutrients
  • Skin lesions
  • Joint pain
  • Growth failure (specifically in children)

About half of the people diagnosed with ulcerative colitis have mild symptoms. Others have frequent fevers, bloody diarrhea, nausea, and severe abdominal cramps. Ulcerative colitis may also cause problems such as arthritis, inflammation of the eye, liver disease, and osteoporosis. It is not known why these problems occur outside the colon. Scientists think these complications may be the result of inflammation triggered by the immune system. Most of these problems go away when the colitis is treated.

Diagnosis

Many tests are used to diagnose ulcerative colitis. A physical exam and medical history are the first step. Blood tests may be done to check for anemia, which could indicate bleeding in the colon or rectum, or they may uncover a high white blood cell count, which is a sign of inflammation somewhere in the body. A stool sample can also reveal white blood cells, whose presence can indicate ulcerative colitis or inflammatory disease. In addition, a stool sample allows the doctor to detect bleeding or infection in the colon or rectum caused by bacteria, a virus, or parasites.

A colonoscopy or sigmoidoscopy are the most accurate methods for making a diagnosis of ulcerative colitis (biopsy) and ruling-out other possible conditions, such as Crohn’s disease, diverticular disease, or cancer. For both tests, the doctor inserts an endoscope—a long, flexible, lighted tube connected to a computer and TV monitor—into the anus to see the inside of the colon and rectum. The doctor will be able to see any inflammation, bleeding, or ulcers on the colon wall. During the exam, the doctor may do a biopsy, which involves taking a sample of tissue from the lining of the colon to view with a microscope. Sometimes MRI or CT scans are also used to diagnose ulcerative colitis or its complications.

Treatment

Care is typically directed by a gastroenterologist, a physician specially trained in procedures, work up and medical treatment of IBD. There are a variety of medications that are affective in decreasing the degree of inflammation in the colon and improving the symptoms of the disease. The medications prescribed will depend in the severity of the disease. . There is currently no medical cure for this condition and continued visits with a doctor are the best way to assure good outcomes

Some patients have relatively mild symptoms that rapidly improve with medical treatment and have little problem with their disease.  Other patients experience flairs of worsening symptoms intermittently and occasionally require admission to the hospital for IV steroids and other medications to bring their disease under control again.  Other patients have a very aggressive form of the disease and despite the best and strongest medications, they continue with severe symptoms and require an operation to remove the colon very early in their course of treatment. 

An important aspect of having this disease, particularly in patients with pancolitis, is the fact that these patients have an increased risk of developing colorectal cancer due to long standing inflamation. This risk increases slowly year by year.  Therefore, it is imperative that even if their symptoms seem to have resolved it is important that these patients continue to be seen by their doctor and have colonoscopies on a regular basis to evaluate the status of the colon. If it is found during these colonoscopies that the patient has either developed a cancer or microscopic changes (called severe dysplasia) indicating that a cancer is in the process of forming, a colon operation will be needed.

When is surgery necessary?

A surgeon usually sees patients with ulcerative colitis when their gastroenterologist is no longer able to get their symptoms improved adequately with medications. These patients may have unrelenting diarrhea or bleeding that is confining them to the hospital.  Others, although not hospitalized, have such frequent, urgent stools that they find they can no longer lead a reasonable life. Some patients require an operation because they have developed serious side effects from high doses of steroids or other medications. An unusual and serious complication is fulminate colitis, which is when there is risk for sudden perforation of the colon. Even patients whose disease is well controlled or have been relatively symptom free may require a colectomy if they are found to have developed severe dysplasia or a cancer within the colon.

What operation is done for ulcerative colitis?

The type of operation performed for ulcerative colitis will depend on the clinical setting, the indication for surgery and the health status of the patient. Because ulcerative colitis will eventually involve the entire colon, the overwhelming majority of patients will need their entire colon and rectum removed. Some patients, because of their age or other health issues, will be best served with removal of the anal canal as well; this necessitates the creation of a permanent ileostomy. An ileostomy is created by bringing a portion of the small intestine through the abdominal wall and sewing the opening to the skin.  An appliance (or bag) is attached to the skin around the ileostomy to collect fecal matter. Fortunately, because the anal canal is not affected by ulcerative colitis, most patients with ulcerative colitis do not have to have a permanent ileostomy. Using modern surgical techniques, a new “rectum” can be created out of the last portion of the small intestine (called a ‘J-pouch’ or IPAA: ileal pouch anal anastomosis) and this can be connected to the top of the anal canal. This will restore intestinal continuity and restore the patient’s ability to move their bowels thorough the anus naturally. Because of its complexity, this reconstruction often requires the patient to have an ileostomy temporarily created upstream from the J-pouch to allow time for the suture lines to heal.  This temporary ileostomy will then be closed at a second surgery in about three months. This is a complex surgery requiring a great deal of expertise.  All of our surgeons have been trained in this operation and have extensive experience with this procedure.  This surgical cure for ulcerative colitis can rid the patient of their disease and their risk of colon cancer.

Visit the American Society of Colon & Rectal Surgeons website for more information