Ulcerative Colitis

Ulcerative colitis is a form of inflammatory bowel disease that is closely related to Crohn's disease. It differs from Crohn's in that it only affects the innermost lining of the rectum and large intestine (colon) - the terminal portion of the digestive system. It affects both men and women alike and usually appears between the ages of 15 and 40 years. This chronic disease is intermittent with periods of exacerbated symptoms and periods that are symptom-free.

Causes

The exact causes of ulcerative colitis are unknown. The most popular theory is that it is an autoimmune disease. Simply put, the cells responsible for protecting and defending the body attack both harmful viruses as well as healthy tissue - the lining of the rectum and large intestine (colon), in this case. It has been observed that those with a family history of inflammatory bowel disease are more at risk.

Symtoms

Symptoms are episodic and can therefore be very acute one moment (attack) and disappear for undetermined periods (days, months and even years), only to reappear with the next attack. The symptoms of ulcerative colitis vary widely from mild to severe but usually include pain or abdominal cramping and chronic diarrhea. Some sufferers have to make 15 to 20 trips to the bathroom a day. The course of the disease varies from person to person. Some experience only a few episodes throughout their lifetime while others live with a form of the disease that constantly recurs. The following symptoms can also present during an attack:

• loss of appetite
• fatigue
• fever
• rectal bleeding
• weight loss
• loss of intestinal control (feeling of constant need to empty bowel with littleo fecal output, incontinence)
• blood in stool
• frequent stool, even at night

Diagnosis

Diagnosing ulcerative colitis can be partly based on medical and family history. Your physician may also request stool, blood or tissue samples. Other examinations however may be necessary to ensure that there are no other infections and to assess the course of the disease. Your physician will most likely suggest a colonoscopy or a barium enema. A colonoscopy involves inserting a thin tube fitted with a small camera into the anus. This allows the physician administering the colonoscopy to examine the lining of the rectum and colon and assess the extent of the inflammation. A barium enema is an examination that involves introducing barium (a radiopaque substance) into the anus in order to coat the walls of the intestine. Radiographies are then taken to see whether there are any lesions on the lining or if all is normal.

Diagnosing ulcerative colitis is not always easy. About 10% of colitis cases cannot be classified as either Crohn's disease or ulcerative colitis and are therefore labelled as indeterminate colitis.

Treatment

Because the cause of ulcerative colitis remains unknown, treatment is directed towards alleviating symptoms and preventing complications.

A variety of medications are used to help reduce the inflammation that triggers the symptoms. Some drugs work well for some people, but not others. It may take time to find the combination that is right for you, and since certain drugs have serious side effects, it is always important to assess whether the benefits outweigh the risks.

Physicians use several categories of drugs to help control the symptoms in different ways, including:

• Anti-inflammatory medications (ex: Asacol®, Pentasa®, Salofalk®) can be taken orally or rectally;
• Corticosteroids (ex: prednisone, budesonide); to reduce inflammation and tissue damage; generally used in moderate to severe cases that do not respond to other treatments;
• Immune response modifiers (ex: azathioprine, methotrexate) also used to treat other immune diseases;
• Antibiotics (ex: Cipro®) to prevent or treat infected wounds in the bowels;
• Biological response modifiers such as infliximab (Remicade®) given intravenously to people with more severe symptoms and relapses. They work by blocking a chemical substance in the body known as tumour necrosis factor (TNF), a substance that in excess, leads to inflammation.

Promising new therapies are currently being explored. More research is needed.

Additional medication

To help relieve your symptoms, your physician may also recommend some of the following types of medication:

• Antidiarrheals: such as Metamucil®, as a fibre supplement or Imodium® for more severe diarrhea;
• Analgesics: acetaminophen (ex: Tylenol®). Do not take nonsteroidal anti-inflammatory drugs (NSAIDs) such as Aspirin®, Advil® or Motrin®, as they are likely to worsen your symptoms.
• Iron supplements: chronic intestinal bleeding may cause iron deficiency anemia. Iron supplements may help restore normal iron levels.

Do not hesitate to discuss any treatment program with your physician or pharmacist. They will be able to help you understand the purpose of your medication and its effects, including possible adverse reactions.

When surgery is required...

When the disease does not respond to treatment or when the colon becomes precancerous or cancerous, surgery to remove the entire colon may be required. Emergency surgery is also performed in cases of toxic megacolon or severe haemorrhaging. The surgery, known as an ileostomy, consists of removing the colon and rectum and connecting the terminal portion of the small intestine out onto the surface of the skin (towards the abdomen). Feces are then collected in a specially designed bag. This type of surgical intervention eliminates ulcerative colitis.

Complications

Complications associated with ulcerative colitis range from skin problems and arthritis to toxic megacolon (acute distension of the colon due to gas which may lead to a perforation of the intestine). Patients occasionally become anaemic (due to an iron deficiency resulting from blood loss), while other complications are associated with medication. Corticosteroids, for example, can lead to weight gain, ocular disorders (glaucoma, cataracts) and calcium loss from the bones, if taken for long periods.

If you are diagnosed with ulcerative colitis, make sure that you are monitored by a health professional to track any changes. Typically, bone density scans are recommended to monitor the condition of your bones as well as periodic eye examinations by an ophthalmologist to detect any eye problems resulting from the disease or medication.

Furthermore, since people with ulcerative colitis have a higher risk of developing intestinal cancer, it is important to be screened regularly. Your physician will be able to tell you how often you should be screened. Fortunately, this type of cancer responds well to treatment when diagnosed in its early stage.

Living with ulcerative colitis

Rest assured that there are people who can help you cope with this disease. Once your physician has established a treatment plan, your pharmacist will be able to help you better understand your medication.

Keep in mind that there are therapies that can significantly reduce your signs and symptoms and even bring about long-term remission. For many sufferers, it is a question of learning how to live with the disease one day at a time and trying to maintain a positive attitude. Most have to learn to live with a fair amount of discomfort and an awareness that the disease comes and goes.

Here are a few tips to help you cope with the disease:

• Information: Keep informed about the disease and the development of potential therapies. Besides your physician and pharmacist, other sources of information include books, the Internet, and your local support group for ulcerative colitis. Research is constantly changing the face of treatment.
• Diet: Consult a registered dietician to establish a healthy meal plan. Some people find that they can lessen their symptoms by eliminating certain foods (fatty foods, spicy foods, and daily products) which seem to aggravate symptoms. Eating a diet that is high in protein but low in fibre may also help, as may eating frequent small meals (5 or 6 a day), drinking lots of water, and taking multivitamin and mineral supplements.
• Exercise: Regular (preferably daily) exercise will help normalize your bowel function and reduce the risk of depression.
• Stress : Stress can be a positive element in your life when it involves facing and overcoming challenges and not letting your condition get the better of you. If, however, you feel that stress is exacerbating your symptoms (or at least your perception of them), talk to your physician about seeing a stress management specialist, a psychologist, or a social worker. Yoga, meditation, biofeedback, progressive relaxation exercises, and hypnosis have also been used to great or lesser effect. The choice is up to you.

Although living with ulcerative colitis can be overwhelming at times, try to keep in mind that therapies have significantly improved in the last few years and that the outlook is getting brighter all the time.

For more information or for support :

Crohn's & Colitis Foundation of Canada (CCFC)

www.crohnsandcolitis.ca