Ulcerative Colitis

Ulcerative colitis is a chronic disease in which the large intestine becomes inflamed and ulcerated, leading to episodes of bloody diarrhoea, abdominal cramps, and fever.

Ulcerative colitis may start at any age but usually begins between ages 15 and 30. A small group of people have their first attack between ages 50 and 70.

Unlike Crohn's disease, ulcerative colitis usually doe not affect the full thickness of the intestine and never affects the small intestine.

The disease usually begins in the rectum or the sigmoid colon (the lower end of the large intestine) and eventually spreads partially or completely through the large intestine. In some people, most of the large intestine is affected early on.

About 10 per cent of people who appear to have ulcerative colitis have only a single attack. However, some of those cases may actually be an undetected infection rather than true ulcerative colitis.

The cause of ulcerative colitis is not known, but heredity and overactive immune responses in the intestine may be contributing factors.

Symptoms

An attack may be sudden and severe, producing violent diarrhoea, high fever, abdominal pain, and peritonitis (inflammation of the lining of the abdomen). During such attacks, the person is profoundly ill. More often, an attack begins gradually, and the person has an urgency to defecate, mild cramps in the lower abdomen, and visible blood and mucus in the stool.

When the disease is limited to the rectum and the sigmoid colon, the stool may be normal or hard and dry; however, mucus containing large numbers of red and white blood cells is discharged from the rectum during or between bowel movements. General symptoms of illness, such as fever, are mild or absent.

If the disease extends farther up the large intestine, the stool is looser, and the person may have 10 to 20 bowel movements a day. Often, the person has severe abdominal cramps and distressing, painful rectal spasms that accompany the urge to defecate.

There is no relief at night. The stool may be watery and contain pus, blood, and mucus. Frequently, it consists almost entirely of blood and pus. The person also may have a fever and a poor appetite and may lose weight.

Complications

Bleeding, the most common complication, often causes iron deficiency anemia. In nearly 10 per cent of those with ulcerative colitis, a rapidly progressive first attack becomes very severe, with massive bleeding, perforation, or widespread infection.

In toxic colitis, a particularly severe complication, the entire thickness of the intestinal wall is damaged. The damage causes ileus - a condition in which the motion of the intestinal wall stops, so that the intestinal contents are not propelled along their way. Abdominal distention develops.

As toxic colitis worsens, the large intestine loses muscle tone, and within days - or even hours - it starts to dilate. X-rays of the abdomen show gas inside the paralyzed sections of intestine. When the large intestine becomes greatly distended, the condition is called toxic megacolon. The person is severely ill and may have a high fever.

The person also has pain and tenderness in the abdomen and a high white blood cell count. However, of the people who receive prompt, effective treatment for their symptoms, fewer than 4 per cent die. If the ulceration perforates the intestine, the risk of death is great.

The risk of colon cancer is higher in people with long-standing, extensive ulcerative colitis. The risk of colon cancer is highest when the entire large intestine is affected and the person has had ulcerative colitis for more than 10 years, regardless of how active the disease is. Colonoscopy (examination of the large intestine using a flexible viewing tube) at regular intervals - preferably during symptom-free periods - is advised for people with a high risk of cancer.

During colonoscopy, tissue samples are obtained throughout the large intestine for microscopic examination. As many as one in every 100 people with this disease may develop colon cancer each year. Most survive if the diagnosis of cancer is made during the cancer's early stages.

Like Crohn's disease, ulcerative colitis is associated with disorders affecting other parts of the body. When ulcerative colitis causes a flare-up of intestinal symptoms, the person also may experience inflammation of the joints (arthritis), inflammation of the whites of the eyes (episcleritis), inflamed skin nodules (erythema nodosum), and blue-red skin sores containing pus (pyoderma gangrenosum).

When ulcerative colitis is not causing intestinal symptoms, the person still may experience inflammation of the spine (ankylosing spondylitis), inflammation of the pelvic joints (sacroiliitis), and inflammation of the inside of the eye (uveitis).

Although people with ulcerative colitis commonly have minor liver dysfunction, only about 1 to 3 per cent have symptoms of mild to severe liver disease. Severe disease can include liver inflammation (chronic active hepatitis); inflammation of the bile ducts (primary sclerosing cholangitis), which narrow and eventually close; and replacement of functional liver tissue with fibrous material (cirrhosis). Inflammation of the bile ducts may appear many years before any intestinal symptoms of ulcerative colitis, and it increases the risk of cancer of the bile ducts.

Diagnosis

The patient's symptoms and a stool examination help establish the diagnosis. Blood tests reveal anemia, increased numbers of white blood cells, a low albumin level, and an elevated erythrocyte sedimentation rate. A sigmoidoscopy (an examination of the sigmoid colon using a flexible viewing tube) confirms the diagnosis and permits a doctor to directly observe the severity of the inflammation.

Even during symptom-free intervals, the intestine rarely appears normal, and a tissue sample removed for microscopic examination shows chronic inflammation.

X-rays of the abdomen may indicate the severity and extent of the disease. Barium enema X-ray studies and colonoscopy (an examination of the entire large intestine using a flexible viewing tube) are not usually done before treatment begins because they pose a risk of perforation when done during the active stages of the disease.

At some point, however, the whole large intestine is usually evaluated by colonoscopy or by barium enema X-ray studies to determine the extent of the disease and to ensure that no cancer is present.

Inflammation of the large intestine has many causes other than ulcerative colitis. Thus, a doctor determines whether the inflammation is caused by an infection with bacteria or parasites. Stool samples obtained during sigmoidoscopy are examined under the microscope and cultured for bacteria.

Blood samples are analysed to determine whether the person may have acquired a parasitic infection, for example, during travel.

Tissue samples are taken from the lining of the rectum and examined microscopically. A doctor also checks for sexually transmitted diseases of the rectum - such as gonorrhea, herpesvirus, or chlamydial infections - especially if the patient is a homosexual male.

In elderly people with atherosclerosis, inflammation may be caused by poor blood supply to the large intestine. Colon cancer seldom produces a fever or a discharge of pus from the rectum, but a doctor must consider cancer as a possible cause of bloody diarrhoea.

Treatment

Treatment aims to control the inflammation, reduce symptoms, and replace any lost fluids and nutrients. The person should avoid raw fruits and vegetables to reduce physical injury to the inflamed lining of the large intestine. A diet free of dairy products may decrease symptoms and is worth trying. Iron supplements may offset anemia caused by ongoing blood loss in the feces.

Anticholinergic drugs or small doses of loperamide or diphenoxylate are taken for relatively mild diarrhoea. For more intense diarrhea, higher doses of diphenoxylate or deodorised opium tincture, loperamide, or codeine may be needed. In severe cases, a doctor closely monitors the patient taking these antidiarrheal drugs to avoid precipitating toxic megacolon.

Sulfasalazine, olsalazine, or mesalamine often is used to reduce the inflammation of ulcerative colitis and to prevent flare-ups of symptoms. These drugs usually are taken orally, but they can be given as an enema or a suppository.

People with moderately severe disease who are not confined to bed usually take oral corticosteroids such as prednisone. Prednisone in fairly high doses frequently induces a dramatic remission. After prednisone controls the inflammation of ulcerative colitis, sulfasalazine, olsalazine, or mesalamine often is given as well. Gradually, the prednisone dosage is decreased, and ultimately, the prednisone is stopped.

Prolonged corticosteroid treatment almost invariably produces side effects, although most subside when the drug is stopped. When mild or moderate ulcerative colitis is limited to the left side of the large intestine (descending colon) and the rectum, enemas with a corticosteroid or mesalamine may be given.

If the disease becomes severe, the person is hospitalised, and corticosteroids are given intravenously. People with heavy rectal bleeding may require blood transfusions and intravenous fluids.

Azathioprine and mercaptopurine have been used to maintain remissions in people with ulcerative colitis who would otherwise need long-term corticosteroid therapy. Cyclosporine has been given to some people who have suffered severe attacks and have not responded to corticosteroid therapy, but about half of these people eventually require surgery.

Surgery

Toxic colitis is an emergency. As soon as a doctor detects it or suspects impending toxic megacolon, all antidiarrheal drugs are discontinued, the patient is given nothing to eat, a tube is inserted through the nose and into the stomach or small intestine and attached to intermittent suction, and all fluids, nutrition, and medication are given intravenously.

The patient is monitored closely for indications of peritonitis or a perforation. If these measures fail to improve the person's condition in 24 to 48 hours, emergency surgery is needed: All or most of the large intestine is removed.

Surgery is performed on a nonemergency basis when cancer is diagnosed or precancerous changes are identified in the large intestine. Such surgery also may be performed because of narrowing of the large intestine or growth retardation in children.

The most common reason for surgery is unremitting chronic disease that would otherwise make the person an invalid or chronically dependent on high doses of corticosteroids. In rare cases, severe colitisrelated problems outside the intestine, such as pyoderma gangrenosum, may make surgery necessary.

Complete removal of the large intestine and rectum permanently cures ulcerative colitis. Living with a permanent ileostomy (a surgically created connection between the lowest portion of the small intestine and an opening in the abdominal wall) and an ileostomy bag has been the traditional price of this cure.

However, various alternative procedures are available, the most common one being a procedure called ileoanal anastomosis.

In this procedure, the large intestine and most of the rectum are removed, and a small reservoir is created out of the small intestine and attached to the remaining rectum just above the anus.

This procedure maintains continence, though some complications, such as inflammation of the reservoir, may occur.

Submitted By
Dr. Maswoodur Rahman Prince

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