Ulcerative Colitis

Ulcerative colitis is a long-term condition that causes inflammation and ulcers in the inner lining of the large intestine, primarily affecting the colon and rectum. It is one of the main types of inflammatory bowel disease (IBD) and can lead to recurring episodes of abdominal discomfort, diarrhoea, and other digestive symptoms.

While the exact cause remains unclear, a combination of genetic, immune, and environmental factors is believed to play a role. In the sections that follow, we’ll take a closer look at what ulcerative colitis involves—its causes, symptoms, diagnosis, and the ways it can be treated or managed for better quality of life.

Ulcerative Colitis is a chronic inflammatory condition that causes long-lasting inflammation and ulcers (sores) in the innermost lining of the large intestine (colon) and rectum. The inflammation typically begins in the rectum and spreads continuously upwards through the colon. It's an autoimmune condition, meaning the body's immune system mistakenly attacks healthy tissues, leading to inflammation. 

Unlike Crohn's disease, another form of IBD that can affect any part of the digestive tract and cause patchy inflammation, UC is confined to the large bowel and affects a continuous segment of tissue. This chronic inflammation can lead to a range of debilitating symptoms, significantly impacting an individual's digestive health and overall well-being.

Ulcerative Colitis is classified based on the extent of the colon affected by inflammation:

• Ulcerative Proctitis: This is the mildest form of UC, with inflammation limited to the rectum. Symptoms often include rectal bleeding, urgency, and tenesmus (the feeling of needing to pass stools even when the bowel is empty).
• Proctosigmoiditis: Inflammation affects the rectum and the sigmoid colon (the lower part of the colon). Symptoms may include bloody diarrhoea, abdominal cramps, and tenesmus.
• Left-Sided Colitis: This type affects the rectum, sigmoid colon, and descends into the descending colon. Symptoms typically include bloody diarrhoea, abdominal cramping on the left side, and weight loss.
• Pancolitis (or Extensive Colitis): This is the most severe form, involving the entire colon. Symptoms are usually more severe and include frequent bloody diarrhoea, severe abdominal pain, fatigue, and significant weight loss.
• Fulminant Colitis: A rare but severe form of pancolitis, leading to intense inflammation, severe pain, profuse bleeding, and a risk of toxic megacolon (a life-threatening complication where the colon rapidly expands).

The exact cause of Ulcerative Colitis remains unknown, but it is believed to be a complex interplay of several factors:

• Genetics: UC tends to run in families, suggesting a genetic predisposition. Several genes have been identified that increase the risk, but having these genes doesn't guarantee developing the condition.
• Immune System Dysfunction: The prevailing theory is that UC is an autoimmune disorder. The immune system, which normally protects the body from harmful invaders like bacteria and viruses, mistakenly attacks the healthy cells in the lining of the large intestine, leading to chronic inflammation.
• Environmental Factors: Lifestyle and environmental elements are thought to trigger UC in genetically susceptible individuals. These might include:
  • Diet: While no specific foods cause UC, certain dietary patterns or individual food sensitivities can exacerbate symptoms during a flare-up.
  • Gut Microbiome: The balance of bacteria and other microorganisms in the gut (the microbiome) is believed to play a significant role. An imbalance (dysbiosis) may contribute to inflammation.
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): While not a direct cause, some studies suggest that NSAIDs can worsen UC symptoms or trigger flare-ups in some individuals.
  • Infections: Past infections might alter the immune response, potentially contributing to UC development.
  • Hygiene Hypothesis: Some theories suggest that improved hygiene and reduced exposure to microbes in early life might lead to an altered immune system, making it more prone to autoimmune conditions.
• Stress: While stress does not cause UC, it is widely acknowledged that stress can exacerbate symptoms and trigger flare-ups.

The symptoms of Ulcerative Colitis can vary greatly depending on the extent and severity of the inflammation, but commonly include:

• Diarrhoea, often with blood or pus: This is the most common symptom, ranging from mild to severe, and can be urgent.
• Abdominal Pain and Cramping: Discomfort in the abdomen, which can be mild or severe.
• Rectal Pain: Discomfort or pain in the rectum.
• Rectal Bleeding: Passage of fresh blood with stools or on toilet paper.
• Urgency to Defecate (Tenesmus): A strong, sudden urge to have a bowel movement, even if the bowel is empty.
• Inability to Defecate Despite Urgency: Feeling the need to go but being unable to pass stools.
• Weight Loss: Unintentional weight loss due to poor nutrient absorption or reduced appetite.
• Fatigue: Persistent tiredness, often related to inflammation, anaemia, or sleep disturbances.
• Fever: Especially during severe flare-ups.
• Anaemia: Due to chronic blood loss.
• Malnutrition: In severe cases, due to poor absorption of nutrients.

Beyond the digestive system, Ulcerative Colitis can also cause symptoms in other parts of the body, known as extraintestinal manifestations:

• Joint Pain and Swelling (Arthritis): Affecting large joints like the knees, ankles, and hips.
• Skin Lesions: Including painful sores (pyoderma gangrenosum) or red, tender nodules (erythema nodosum).
• Eye Inflammation: Conditions like uveitis or episcleritis.
• Liver and Bile Duct Inflammation: Such as primary sclerosing cholangitis (PSC), a serious condition that can lead to liver damage.

Diagnosing Ulcerative Colitis involves a combination of medical history, physical examination, laboratory tests, and endoscopic procedures.

• Medical History and Physical Exam: The doctor will ask about symptoms, family history of IBD, and perform a physical examination.
• Blood Tests:
  • Full Blood Count (FBC): To check for anaemia.
  • Inflammatory Markers: Such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), which are often elevated during inflammation.
  • Liver Function Tests (LFTs): To check for liver complications.
  • Electrolyte Levels: To check for imbalances due to diarrhoea.
• Stool Tests:
  • Stool Culture: To rule out infections that can cause similar symptoms.
  • Faecal Calprotectin: A protein released by neutrophils (a type of white blood cell) into the bowel when there is inflammation. Elevated levels strongly suggest intestinal inflammation and can help differentiate IBD from Irritable Bowel Syndrome (IBS).
• Endoscopic Procedures: These are crucial for a definitive diagnosis.
  • Colonoscopy with Biopsy: This is the gold standard. A thin, flexible tube with a camera is inserted into the rectum and guided through the colon. The doctor can visualise the lining of the colon, identify inflammation and ulcers, and take tissue samples (biopsies). The biopsies are then examined under a microscope to confirm the diagnosis and assess the extent and severity of the inflammation.
  • Sigmoidoscopy: A shorter procedure that examines only the rectum and sigmoid colon.
• Imaging Studies:
  • CT Scan or MRI: May be used in some cases to assess the extent of inflammation or rule out complications.

The goal of Ulcerative Colitis treatment is to reduce inflammation, alleviate symptoms (induce remission), and maintain remission, thus preventing flare-ups. Treatment is highly individualised and depends on the severity and extent of the disease.

Medications

• Aminosalicylates (5-ASAs): These are often the first-line treatment for mild to moderate UC. They work by reducing inflammation in the colon. Examples include mesalazine (mesalamine), sulfasalazine, and olsalazine, available as oral tablets, suppositories, or enemas.
• Corticosteroids: Such as prednisolone (Brands available: Wysolone, Omnacortil) or budesonide, are potent anti-inflammatory drugs used to induce remission during moderate to severe flare-ups. They are generally used for short periods due to potential side effects with long-term use.
• Immunosuppressants: Medications like azathioprine, mercaptopurine, or methotrexate suppress the immune system to reduce inflammation. They are used for long-term maintenance of remission, especially in those who don't respond to 5-ASAs or corticosteroids.
• Biologics: These are advanced medications that target specific proteins in the immune system involved in the inflammatory process. Examples include infliximab, adalimumab, golimumab, vedolizumab, and ustekinumab. They are often used for moderate to severe UC that hasn't responded to other treatments.
• JAK Inhibitors: Newer oral medications, such as tofacitinib, that block specific pathways involved in inflammation.

Surgery

• Surgery is considered when medication isn't effective in controlling symptoms, if there are serious complications like toxic megacolon, severe bleeding, or a high risk of colon cancer.
• The most common surgical procedure for UC is a proctocolectomy, which involves removing the entire colon and rectum.
• After proctocolectomy, options include an ileostomy (where the end of the small intestine is brought through an opening in the abdomen, and waste is collected in an external pouch) or an ileal pouch-anal anastomosis (IPAA), also known as a J-pouch, where a pouch is created from the small intestine and connected to the anus, allowing for bowel movements through the natural route.

• Family history of UC or other IBD.
• Age (most common diagnosis between 15-30 and 50-70).
• Ethnicity (more common in Caucasian and Ashkenazi Jewish descent).
• Environmental factors (e.g., Western diet, certain infections).
• Use of NSAIDs (can exacerbate symptoms).

• Severe bleeding and anaemia.
• Toxic megacolon (rapidly widening and swelling colon, life-threatening).
• Perforated colon (a hole in the colon).
• Severe dehydration and malnutrition.
• Increased risk of colon cancer (especially with extensive or long-standing disease).
• Osteoporosis (due to long-term steroid use or malabsorption).
• Extraintestinal manifestations (e.g., arthritis, skin issues, eye problems, liver disease).

Living with Ulcerative Colitis can be challenging, but many people manage their condition effectively and lead fulfilling lives. Here are five practical tips:

• Work Closely with Your Healthcare Team: Your gastroenterologist, nurse specialist, and dietitian are your best allies. Be open about your symptoms, medication adherence, and any concerns. Regular check-ups are vital.
• Understand Your Triggers: While there's no universal "UC diet," many individuals find certain foods or situations exacerbate their symptoms. Keep a food and symptom diary to identify your personal triggers and adjust your diet accordingly, especially during flare-ups.
• Prioritise Stress Management: Stress doesn't cause UC, but it can worsen symptoms and trigger flare-ups. Incorporate stress-reducing activities like yoga, meditation, gentle exercise, or engaging in hobbies you enjoy into your daily routine.
• Stay Hydrated and Nourished: During flare-ups, diarrhoea can lead to dehydration and nutrient loss. Focus on staying well-hydrated and consuming nutrient-dense foods that are easy to digest. Consider supplements if recommended by your doctor or dietitian.
• Build a Strong Support System: Connect with family, friends, or support groups (online or in person) who understand what you're going through. Sharing experiences and advice can reduce feelings of isolation and provide practical tips for managing the condition.

"Ulcerative Colitis is caused by stress or a poor diet." 

While stress and diet can exacerbate UC symptoms or trigger flare-ups, they do not cause the disease. UC is an autoimmune condition driven by a complex interplay of genetic, immune, and environmental factors. Blaming oneself for the condition due to stress or diet is inaccurate and unhelpful.

"It's just a bad case of IBS or food poisoning." 

Ulcerative Colitis is a serious, chronic inflammatory disease that causes structural damage to the colon and can lead to severe complications. Irritable Bowel Syndrome (IBS) is a functional disorder of the gut without inflammation or damage. Food poisoning is an acute, temporary infection. Confusing UC with these conditions can delay proper diagnosis and treatment, which is crucial for managing the disease.

"You'll always need surgery." 

While surgery (proctocolectomy) is an option for some individuals, especially those with severe, unmanageable disease or complications, the vast majority of people with UC are successfully managed with medication. Advances in medical treatments mean that many can achieve and maintain remission without needing surgical intervention.

If you experience persistent changes in your bowel habits or any of the symptoms associated with Ulcerative Colitis, such as prolonged diarrhoea, bloody stools, abdominal pain, or unexplained weight loss, it's crucial to consult your GP. Early diagnosis and treatment are vital for managing the condition effectively and preventing complications.

Seek immediate medical attention (call emergency services or go to A&E) if you experience severe symptoms such as:

• Profuse bloody diarrhoea.
• Severe, unremitting abdominal pain.
• High fever.
• Rapid heart rate or signs of shock.
• Severe dehydration.

These could be signs of a serious complication like toxic megacolon or a perforated bowel.

• What is the specific type and extent of my Ulcerative Colitis?
• What are the recommended treatment options for my condition, and what are their potential side effects?
• How long will it take for my medication to work, and how will we know if it's effective?
• What are the signs of a flare-up, and what should I do if one occurs?
• What are the risks of colon cancer with my specific type of UC, and how often will I need surveillance colonoscopies?
• Are there any dietary or lifestyle changes you recommend to help manage my symptoms or prevent flare-ups?

• Learning about UC, its symptoms, treatments, and challenges will help you understand what your loved one is going through and anticipate their needs.
• During flare-ups, everyday tasks can be overwhelming. Offer practical support like cooking meals, helping with errands, or simply being a listening ear. Show empathy and understanding for their pain, fatigue, or mood changes.
• Understand that they might have dietary restrictions or need frequent access to bathrooms. Be flexible and accommodating when planning activities or meals.
• Remind them gently about medication schedules and encourage them to attend appointments. Support their efforts in stress management and maintaining a healthy lifestyle.

Ulcerative Colitis is a chronic and often challenging inflammatory bowel disease that profoundly impacts the lives of those affected. While its exact cause remains elusive, a combination of genetic, immune, and environmental factors is believed to contribute to its development. Effective management hinges on early and accurate diagnosis, followed by an individualised treatment plan, often involving medication, and in some cases, surgery. Despite the complexities, ongoing research continues to uncover new therapies, offering hope for improved quality of life. 

By fostering awareness, promoting understanding, and encouraging proactive self-management alongside robust medical care, individuals with Ulcerative Colitis can navigate their condition and lead fulfilling lives.