Ulcerative colitis

Symptoms Of Ulcerative Colitis

Ulcerative colitis is a chronic disease affecting the colonic mucosa (inner layer of the large intestine) that most commonly presents with blood in the stool and diarrhea. Almost 15% of patients can initially present with severe forms of the disease. Symptoms include:

• Bleeding from rectum
• Urgency
• Feeling of the need to pass stool
• Abdominal pains and cramps
• Fever (in severe cases)
• Urinary incontinence (loss of bladder control)
• Fatigue
• Increased frequency of bowel movements
• Mucus discharge
• Rectal pain 
• Weight loss
• Bowel movements at night
• Weight loss (in severe cases)
• Involvement of muscles and skin.

Note: Symptoms are similar in kids with ulcerative colitis (pediatric ulcerative colitis) and may also include delayed or poor growth.

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Types Of Ulcerative Colitis

Ulcerative colitis can affect different parts of your colon and rectum and the intensity of your condition depends on the amount of inflammation and the area affected. The major types include:

1. Ulcerative proctitis: In this type, bowel inflammation is limited only to the rectum and typically affects less than six inches of the rectum. Ulcerative proctitis is not associated with an increased risk of cancer.

2. Left-sided colitis: In this form of ulcerative colitis, there is continuous inflammation that begins at the rectum and extends up to the splenic flexure (a bend in the colon near the spleen).  

3. Proctosigmoiditis: In this form of ulcerative colitis, inflammation is limited to rectum and sigmoid colon (lower end of the colon) only. 

4. Extensive colitis: This type of ulcerative colitis affects the entire colon with continuous inflammation beginning at the rectum and extending beyond the splenic flexure (bend in your colon to meet the stomach).

Causes Of Ulcerative Colitis

Ulcerative colitis generally begins in the rectum and may remain localized or extend proximally, sometimes involving the entire colon (the longest part of the large intestine). But, It rarely involves the entire bowel at once. The exact cause of ulcerative colitis still remains unknown, however, there are numerous risk factors that can lead to its development.

Both Crohn’s disease and ulcerative colitis are characterized by bowel symptoms which can be seen in 25-40% of patients with inflammatory bowel disease.

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Risk Factors For Ulcerative Colitis

Ulcerative colitis is a multifactorial condition and the risk factors include:

1. Age

Studies show that the onset of ulcerative colitis is seen at a younger age, i.e less than 40 years. And the main onset peaks between 15 and 30 years of age.

2. Race

Ulcerative colitis was previously considered to be a disease of Caucasian patients, but studies have documented increased incidences among non-white populations as well. 

3. Family history of IBD

Studies suggests that the strongest identifiable risk factor for the development of Inflammatory bowel disease (IBD) is a positive family history. IBD consists of Crohn's disease (causing swelling of the digestive tract) and ulcerative colitis.

4. Medications

Drugs that can increase the likelihood of the development of ulcerative colitis include:

• Contraceptive pills: Studies show that the use of combined oral contraceptive pills was associated with the development of ulcerative colitis.
  
  
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): These are pain medications that have been shown to be associated with flare-ups of the disease.
  
  
• Antibiotics: These have been shown to precipitate flare-ups of the disease for some people.

5. Smoking

Former cigarette smoking is one of the strongest risk factors associated with ulcerative colitis. Studies demonstrate that active smokers are less likely to develop ulcerative colitis compared with former and non-smokers.

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6. Appendectomy

It is a surgery to remove the appendix (a small, thin pouch connected to the large intestine) when it is infected. Research shows that a history of appendectomy in patients with ulcerative colitis is rare.

7. Diet

Though it is a less common risk factor for ulcerative colitis, increased consumption of polyunsaturated fatty acids (a type of dietary fat found in salmon, nuts, etc) may contribute to issues with digestive health that can lead to ulcerative colitis.

8. Childhood hygiene

Low hygiene and exposure to infections may be associated with an increased risk for ulcerative colitis, especially in kids. 

Diagnosis Of Ulcerative Colitis

Ulcerative colitis is a chronic illness that is usually detected only at the later stages. Diagnosis consists of the following investigations:

1. Medical history

A thorough history, including travel history to rule out other causes along with detailed drug history and recent antibiotic use should be considered.

2. Laboratory tests

These tests are done to diagnose anemia, thrombocytosis (a condition in which the body produces platelets in excess), low vitamin D and raised inflammatory markers Tests include:

• Complete blood count (CBC)
• Blood urea
• Serum electrolytes
• C-reactive protein
• Vitamin D profile
• Bone profile
• Iron serum
• Folate test (Vitamin B9)
• Vitamin B12 test
• Liver function tests

3. Stool cultures

These are done to determine if there are any infections. The stool culture should be negative in case of ulcerative colitis, but bacterial infections such as C difficile can co-exist.

4. Fecal calprotectin

It is a very sensitive marker for inflammation in the gastrointestinal tract, and useful for the differentiation of inflammatory bowel disease (IBD) from irritable bowel syndrome (IBS). 

5. Imaging tests

• Colonoscopy or proctosigmoidoscopy: It might reveal loss of typical vascular pattern, granularity, friability, and ulceration that involves the rectum.
  
  
• Sigmoidoscopy: It helps in examining the level and extent of bowel inflammation.A sigmoidoscopy can also be used to remove a small sample of tissue from your bowel so it can be tested in a laboratory. 
  
  
• Endoscopy: It helps in examining the inside of your colon and rectum with a lighted tube inserted through your anus.
  
  
• Abdominal X-ray: Plain abdominal radiographs are useful for acute onset of ulcerative colitis. They are often entirely normal in inflammatory bowel disease.
  
  
• CT scan or MRI: These are used for small bowel imaging and can help differentiate between ulcerative colitis and Crohn’s disease.

6. Biopsy

Usually at least two biopsies from each bowel segment for histological assessment is recommended. However, no histological features are diagnostic of ulcerative colitis, but distortion irregularity can suggest ulcerative colitis.

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Prevention Of Ulcerative Colitis

Ulcerative colitis is a form of inflammatory bowel disease that is generally detected only at later stages. By taking certain preventive measures you can decrease your chances of getting ulcerative colitis. These include:

1. Staying hydrated

Proper hydration helps prevent ulcerative colitis. One must drink at least 2L of water every day, along with avoiding coffee, alcohol, and carbonated beverages, which can make your diarrhea worse.

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2. Making probiotics your friend

Probiotics are nothing but good bacteria that can keep your gut healthy. These can prevent the ‘bad bacteria’ from sticking to the walls of the large intestine thus preventing ulcerative colitis.

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3. Giving importance to mental health 

Managing your stress can help alleviate the signs and symptoms of ulcerative colitis as stress may cause your regular digestive process to change. Try learning new things or do whatever works for you to keep calm.

4. Adding exercise to your routine

We all know the benefits of being active and exercising can help prevent ulcerative colitis by keeping your bowel healthy and avoiding diarrhea.

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Doctor To Visit

Treating and diagnosing ulcerative colitis may require a comprehensive approach. Specialists that can help include:

• Gastroenterologist
• General physician
• Colon and rectal surgeon
• Pediatric gastroenterologist (in kids)
• Dermatologist

A gastroenterologist is a doctor specializing in the diagnosis and treatment of disorders of the gastrointestinal tract and related organs.

A colon and rectal surgeon diagnoses and treats various diseases of the small intestine, colon, rectum, and anal canal along with the liver, urinary and female reproductive system.

A dermatologist is a specialist who treats skin diseases.

When to call a doctor?

Seek medical attention immediately if you have the following symptoms:

• Persistent and heavy diarrhea.
• Blood from your anus
• Clots of blood in your stool
• Continuous pain along with high fever

Do not take your gut health lightly. If you have any of the symptoms, seek advice from our trusted doctors.

Treatment Of Ulcerative Colitis

Ulcerative colitis can progress proximally in 10–19% of patients after 5 years, and in up to 28% of patients at 10 years. The primary aim of medical management is to induce and maintain remission. 

Staging of ulcerative colitis based on the severity of disease:

The severity of ulcerative colitis can be graded depending upon rectal bleeding. It includes:

• Mild: Less than four rectal bleeding episodes per day
  
• Moderate: More than four rectal bleeding episodes per day
  
• Severe: More than four rectal bleeding episodes per day along with systemic features of an illness combined with hypoalbuminemia (a condition in which there is lack of albumin protein that's responsible for keeping fluid in your blood vessels).

Treatment depends on the stage of ulcerative colitis and it consists of:

A. In mild-moderate ulcerative colitis

1. Mesalamines: These are the first-line therapy for induction of remission in mild-moderate cases of ulcerative colitis. There are different formulations of mesalamine, including oral, suppository, or liquid enema.
   
2. Corticosteroids: Second-line therapies for patients who do not respond to mesalamine are corticosteroids. The drugs used are:

1. 1. Prednisone

   2. Budesonide-multimatrix (MMX)

B. In moderate-severe ulcerative colitis

1. Immunomodulators: These are drugs that modulate the immune system by working on the underlying inflammatory processes. They include:

• Infliximab
• Adalimumab
• Golimumab
• Vedolizumab
• Tofacitinib

C. In acute severe ulcerative colitis

It is defined as the presence of more than 6 bloody stools per day with increased heart rate, fever, and signs of infection.
Medications include:

• Infliximab
• Cyclosporine
• Steroids.

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D. Maintenance of remission

Most appropriate maintenance treatment for an individual patient is established by several factors, like disease extent and severity, treatment for induction of remission, and failure of previous maintenance treatments. Mesalazine is the basis of treatment for the maintenance of remission in ulcerative colitis.

E. Surgery

Absolute indications for surgery include uncontrolled bleeding, perforation, and colorectal cancer. Surgery is also indicated in acute severe ulcerative colitis and the most commonly performed surgery for ulcerative colitis are:

1. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA): This surgery removes the entire colon and rectum while preserving the seal in the anus for normal bowel functioning and to avoid fecal incontinence.
   
2. Total proctocolectomy: It is a surgery to remove all of the colon and rectum that may be indicated if there are intestinal manifestations.
   

F. The newer agent

Mirakizumab is an antibody currently in a clinical trial for patients with moderate-severe ulcerative colitis. However, additional studies are required to determine the efficacy and dose of mirakizumab.

Home-care For Ulcerative Colitis

Ulcerative colitis needs medical attention, but there are certain home remedies that have been found to alleviate the symptoms. These include:

1. Aloe vera: Aloe gel has been shown to reduce inflammation. However, you may have to be careful with aloe vera juice, as it has a laxative effect and causes trouble for people having diarrhea.
   
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2. Wheatgrass (Gehun): Studies have shown that wheatgrass juice appeared to be effective and safe for active ulcerative colitis.
   
   
3. Turmeric (Haldi): Studies demonstrate that curcumin (turmeric) is immunomodulatory and is well tolerated without significant side effects.
   
   
4. Pineapple (Ananas): Studies demonstrate an enzyme bromelain, present in pineapple may help ease UC symptoms and reduce the frequency of flares.The enzyme helps in decreasing intestinal inflammation and enhance intestinal cell function. 
   
   
5. Ginseng: It is a plant whose roots may be effective in the treatment of UC by reducing inflammation and protecting against cellular damage according to a 2015 study. 
   
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Note: Along with these, taking care of your general health with regular exercise, adding probiotics and vitamin supplements to your diet, and eating a well-balanced diet are important to manage the symptoms of ulcerative colitis. Read more about 6 easy ways to eat healthily.

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Complications Of Ulcerative Colitis

Ulcerative colitis is a chronic disease with periods of remission and relapse. Here are complications that can occur from ulcerative colitis:

1. Pelvic abscess: It is pus-filled lesions in the lower stomach due to inflammation.
   
   
2. Enterocutaneous fistulas: These are the abnormal connections between the intestines or stomach and the skin. They occur due to leakage of contents of the stomach or intestines into the skin after bowel surgery.
   
   
3. Bowel obstruction: Studies have shown that early postoperative small-bowel obstruction occurs in up to 15% of patients after surgery for ulcerative colitis.
   
   
4. Pouch prolapse: Research demonstrates that it is a rare but important complication to consider in patients with ulcerative colitis who have undergone a total proctocolectomy.
   
   
5. Poor growth and development: Individuals with ulcerative colitis and undergoing treatment for the same can have poor growth and delayed puberty. 
   
   
6. Primary sclerosing cholangitis: Individuals with ulcerative colitis may develop another digestive condition called primary sclerosing cholangitis (PSC). In PSC the bile ducts become progressively inflamed and damaged.
   
   
7. Pouchitis: It is an inflammation in the lining of a pouch created during surgery in the treatment of ulcerative colitis.
   
   
8. Incontinence: Individuals with ulcerative colitis are generally affected by fecal incontinence, i.e. inability to control bowel movement.
   
9. Osteoporosis: Individuals with ulcerative colitis are at an increased risk of developing osteoporosis, when the bones become weak and are more likely to fracture.
   
   
10. Sexual dysfunction: Certain medications used to treat ulcerative colitis can impact their sex drive and ability to have sex.
    
    
11. Toxic megacolon: It is swelling and inflammation that spread into the deeper layers of your colon. 
    
    
12. Colon or rectal cancer: The risk of cancer in individuals with ulcerative colitis increases by 2% after 10 years of diagnosis.
    
    
13. Leakage from anastomosis: This is a serious complication after ileal pouch-anal anastomosis (IPAA) leading to postoperative sepsis and pouch failure.

Alternative Therapies For Ulcerative Colitis

Ulcerative colitis is a long-standing disease that needs comprehensive care. Along with regular treatments certain complementary therapies can be useful to relieve the symptoms. However, consult your doctor before starting anything new. Alternate therapies that work best for ulcerative colitis include:

1. Hyperbaric oxygen therapy

Studies show that this therapy has proven beneficial in acute severe ulcerative colitis. It is based on the theory that pure excess oxygen delivery might reverse tissue hypoxia (low oxygen levels) and induce healing.

2. Ayurveda

An ayurvedic approach may help in providing relief from symptoms and flare-ups associated with ulcerative colitis as it includes dietary measures to balance the doshas, massages, meditation, and yoga.

Know more about 6 ayurvedic herbs that can improve your digestion.

3. Acupuncture 

A 2016 study has found out that acupuncture can be helpful in people with IBD  and found an improvement in pain relief, and symptoms.

4. Tai chi

Also known as shadowboxing, Tai Chi is an internal Chinese martial art practiced for defense training and health benefits. Studies show that it can improve the quality of life in patients with ulcerative colitis and other inflammatory bowel diseases as it focuses on internal balance and healing from within.

Living With Ulcerative Colitis

Being well-informed about your chronic illness is important as learning all you can about your diagnosis and how it may affect you can take you a long way in managing your condition. Here are a few tips that can help you with ulcerative colitis:

1. Avoid certain medications

Pain killers, such as ibuprofen and naproxen are not usually recommended if you have ulcerative colitis as they can cause ulcers in the stomach and intestines. Also, some contraceptives and antibiotics can flare up ulcerative colitis.

2. Eat smaller meals

Some changes to your diet can help control the condition. The best way to do this is to 

eat small meals rather than 3 main meals. This may help control your symptoms.

3. Maintain a food journal

Keeping a food journal helps you document what you eat, and understand what food you can tolerate and what makes your symptoms worse. This way, you can identify problem foods and eliminate them from your diet.

4. Keep a high-fiber diet at bay

Fiber can aggravate symptoms during an episode of ulcerative colitis flare for some people. Eating a diet that is low in fiber can reduce the amount and frequency of the stools you pass.
Examples of foods include:

• White bread
• Cornflakes
• White rice
• Lean meat and fish
• Eggs.

5. Add necessary supplements

Ulcerative colitis can lead to malnutrition as certain foods are not taken well by the body. Also, certain medications used in the treatment of ulcerative colitis can cause folate and vitamin B12 deficiency. Supplements to be added if you have ulcerative colitis include:

• Vitamin D
• Folic acid
• Iron 
• Vitamin B12
• Omega-3 fatty acids
  

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6. Communicate your feelings

Living with a long-term condition like ulcerative colitis can take a toll on your mental health. Anxiety and stress caused by ulcerative colitis can lead to depression in some cases. The best way to manage it is to communicate with your loved ones about your feelings. You can also try yoga, breathing exercises, and meditation.

7. Ulcerative colitis in kids

Sometimes ulcerative colitis can occur in children below 15 years of age and they may experience physical, emotional, and social problems because of the disease. This increases the importance of proper management and treatment.
Children can experience the following mental symptoms: 

• Mood swings
• Teasing at school
• Anger and frustration
• Embarrassment
• Worry about physical appearance stamina
• Poor concentration

Children need mutual support from all family members and it is important for the entire family to learn about the disease and try to be empathetic. Seek a psychiatrist’s help for your child to manage such challenges of ulcerative colitis.