Ulcerative colitis (inflammatory bowel disease)

• What is Ulcerative Colitis (Inflammatory Bowel Disease)
• Statistics on Ulcerative Colitis (Inflammatory Bowel Disease)
• Risk Factors for Ulcerative Colitis (Inflammatory Bowel Disease)
• Progression of Ulcerative Colitis (Inflammatory Bowel Disease)
• Symptoms of Ulcerative Colitis (Inflammatory Bowel Disease)
• Clinical Examination of Ulcerative Colitis (Inflammatory Bowel Disease)
• How is Ulcerative Colitis (Inflammatory Bowel Disease) Diagnosed?
• Prognosis of Ulcerative Colitis (Inflammatory Bowel Disease)
• How is Ulcerative Colitis (Inflammatory Bowel Disease) Treated?
• Ulcerative Colitis (Inflammatory Bowel Disease) References

What is Ulcerative Colitis (Inflammatory Bowel Disease)

Ulcerative colitis (UC) is a form of inflammatory bowel disease characterised by chronic and widespread inflammation of the colorectal mucosa. Inflammation of the mucosa leads to the formation of ulcers.

For more information on the bowel, see Anatomy of the Gastrointestinal System.

UC is similar to another form of irritable bowel disease called Crohn’s disease in that both conditions are characterised by inflammation which is not caused by infection. Unlike Crohn’s disease, which can affect any part of the gastrointestinal tract (e.g. stomach, intestines), UC is confined to the large colon. It is often challenging for doctors to distinguish between the two conditions.

In UC, the inflammation extends from the rectum in a circumferential manner, typically affecting both sides of the colon in an uninterrupted pattern. Inflammation affects the rectum in over 95% of UC cases. Depending on the extent of the inflammation, UC can be further classified as:

• Proctitis: The least severe form of the disease, proctitis is characterised by inflammation of the rectal mucosa;
• Left-sided colitis: Characterised by limited inflammation of the colon;
• Extensive colitis: Characterised by extensive inflammation of the colon; or
• Pancolitis: Characterised by inflammation involving the entire colon.

UC may also be classified according to symptoms, as either:

• Mild: When the person passes < 4 stools daily (with or without blood) and no evidence of systemic toxicity;
• Moderate: When the person passes > 4 stools daily with minimal systemic toxicity;
• Severe: When the person passes > 6 bloody stools per day with signs of systemic toxicity, which may include fever, tachycardia (rapid heartbeat), and anaemia;
• Fulminant: When the person passes > 10 stools per day, continuous rectal bleeding needing blood transfusion, abdominal tenderness and distension, and systemic toxicity.

The image below shows the diffuse inflammatory changes of UC:

Statistics on Ulcerative Colitis (Inflammatory Bowel Disease)

Australia

While there are relatively few deaths caused by UC (only 26 deaths occured as a result of UC in 2008, accounting for 0.53% of all deaths caused by diseases of the digestive system), a considerable number of Australians are affected by the disease. Estimates of the number of people affected by UC in Australia vary significantly between studies; however, overall they suggest that between 16,000 and 33,000 people have ulcerative colitis at any given time, and over 800 new cases are diagnosed each year.

A recent population-based study reported an annual incidence (new cases of UC per year) of 11.2/100,000 people, one of the highest rates reported from a scientific study. As this was the first incidence study conducted in Australia and examined people living in only one city, it is not known whether incident cases have remained stable or if incidence of UC is the same in the wider Australian population.

Global

From a global perspective, studies have reported an annual incidence of UC ranging from 0.5 to 24.5 cases per 100,000 people. The condition affects a similar number of men and women. UC is more common in Northern Europe and North America, although the incidence of the disease has remained stable over the past 50 years in these countries. On the other hand, incidence has been rising in Asian and Southern European countries. In the United States, UC affects an estimated 500,000 people and is the cause of 250,000 doctor visits and 30,000 hospitalisations each year.

Children

UC also affects children, and cases have been recorded in babies as young as 6 months old. About 10% of UC cases are recorded in individuals < 18 years of age. One study reported an annual incidence in Danish children of 2.6 per 100,000 people in the 2002–2004 period, an increase from 1.8 per 100,000 people in the 1998–2000 period. A British study reported that incidence of the disease had increased five-fold between 1988–1998, at which time the annual incidence in children ≤ 16 years was 1.4 per 100,000 people. Between 2000 and 2004, the incidence of UC increased to 2.7 per 100,000 people, while the incidence of Crohn’s disease appeared to have stayed the same.

Risk Factors for Ulcerative Colitis (Inflammatory Bowel Disease)

Family history

Having a first-degree relative with the disease increases one’s risk of UC by 3 to 20 times. Approximately 10–25% of affected people have a first-degree relative with inflammatory bowel disease. However, data suggest that UC is perhaps less heritable than Crohn’s disease, and that environmental factors such as diet or infective agents may play a greater role.

While the aetiology of the disease is not yet fully understood, many genetic susceptibility factors (characteristics of the genes that increase an individual’s susceptibility to a health condition such as UC) have been identified for inflammatory bowel disease, of which 25 are shared between UC and Crohn’s disease in adults. Many of these genetic factors relate to genes that affect the part of the immune system that regulates the intestine. The development of UC in children appears to share many genetic susceptibility factors of the adult disease; however, research suggests there may also be some distinct pathways leading to the childhood condition.

Research has shown differences in risk depending on birth order and gender of the child. One study reported that the last-born daughters of women with UC and males who are the only child of a mother with UC have a significantly increased risk of developing the condition compared to others. One study reported that 41% of males who were the only child of a woman with UC also had the condition compared to 18% of those who were not, while 48% of last-born daughters of these women developed UC compared to 28% of those who were not last-born to a mother with UC.

Abnormal immune response

UC is characterised by an abnormal response of the immune system, in which the immune system tries to attack food and other substances in the intestine – normally, the immune system would only try to attack foreign bodies such as infective agents. This attack can also focus on the cells of the colon. The intestine responds to the immune attack by concentrating white blood cells in the intestinal lining. This movement of white blood cells causes inflammation and the symptoms of UC. This also occurs in Crohn’s disease.

Age

The risk of developing UC depends on a person’s age. The condition is most common in the 15–35-year-old age group. Individuals aged 50–75 years are also more likely to have UC compared to the general population (all age groups).Research from Norway reports one of the highest incidences of UC (21.5 per 100,000 people annually) to date in the 25–34-year-old age group.

Race and ethnicity

Individuals who are of Jewish or Eastern European origin have an increased risk of UC. Caucasians also have an increased risk compared to individuals of other ethnicities.

Personality type

Individuals who exhibit anxious or obsessive personality traits and/or are introverted or emotionally immature have a higher risk of UC than those who do not. One study reported that 84% of individuals with UC have these personality traits.

Urban living

The incidence of UC is higher in developed countries compared to developing countries. However, the extent of the difference between these countries is reducing as incidence increases in developing countries (with increasing urbanisation). This suggests that elements of an urban lifestyle may contribute to the aetiology of UC. Changes in diet, patterns of exposure to sunlight, pollution and industrial chemicals characteristic of a Western lifestyle are thought to play a role.

Diet

Although dietary habits do not cause UC, factors relating to a person’s diet may influence the development of the condition.  High dietary intakes of total fats, polyunsaturated fatty acids, omega-6 fatty acids and meat seem to increase the risk of UC, while high vegetable intake may reduce the risk of UC.

Other factors

Factors that do not cause UC but may exacerbate its symptoms include:

• Stress;
• Oral contraceptive use;
• Infection as a baby or child;
• History of appendectomy (removal of the appendix); or
• History of infection with mycobacteria (e.g. bacteria that cause tuberculosis and leprosy).

Progression of Ulcerative Colitis (Inflammatory Bowel Disease)

UC is a chronic or long-term disease. A person with UC usually experiences periods in which UC symptoms do not occur and periods in which the symptoms do occur. In the early stages of the disease, asymptomatic periods are often lengthy. However, after having UC for 10 years, only 5% of people experience asymptomatic periods.

UC is further classified depending on which area of the colon is affected. Early stage disease is characterised by inflammation of the rectum which has not yet spread to the colon. When the inflammation extends into the colon but is limited to the lower part of the colon, the condition is classified as left-sided colitis. Cases involving inflammation to the upper section of the colon or the entire colon are referred to as extensive and pancolitis respectively.

UC can also be classified as mild, moderate, severe or fulminant, depending on the severity of the symptoms experienced.

Symptoms of Ulcerative Colitis (Inflammatory Bowel Disease)

If a doctor suspects you have ulcerative colitis, they will ask about the symptoms you have been experiencing to help them diagnose your condition. The classical symptoms of UC are bloody diarrhoea and mucus discharge from the rectum. Lower abdominal cramping and faecal urgency and/or incontinence (inability to control bowel movement) are also common symptoms. The disease is usually long term with symptomatic periods and asymptomatic periods.

Systemic symptoms include malaise, tiredness, fever and weight loss. The specific nature of symptoms depends on the extent of disease.

Proctitis or mild UC

Proctitis or mild UC is the most common form of the disease in adults, and is the stage of disease at which about half of adults with UC first visit their doctor. This mild form of the disease is less common in children and accounts for only 25% of first doctor visits.

The main symptoms are rectal bleeding, mucus discharge, faecal urgency and increased frequency of defecation; symptoms such as abdominal pain and fever are rare. In rare and severe cases of proctitis, constipation characterised by the passing of stools 1–2 times per week and the passing several times daily of blood and/or mucus from the rectum may occur.

Left-sided colitis or moderate UC

30% of adults and 30% of children with UC will present for the first time with left-sided colitis (moderate UC) or inflammation confined to the lower area of the colon.

Extensive colitis or severe UC

Extensive colitis, or pancolitis, is seen in approximately 15% of cases.

Non-intestinal symptoms of UC

While UC is a condition that affects the colon, up to 40% of people with UC experience symptoms that affect other organs, called extra-intestinal symptoms. The doctor is likely to enquire about your experience of extra-intestinal symptoms. The following extra-intestinal symptoms are associated with UC:

Systemic health

The doctor may also enquire about your general health and provide routine health interventions. For example, the doctor may assess whether you need any vaccinations or, if you are female, offer a pap smear test if you have not had one in the last two years.

Clinical Examination of Ulcerative Colitis (Inflammatory Bowel Disease)

The doctor will perform a physical examination, including an examination of your rectum, looking particularly for fresh blood or mucus. Weight loss is also a common symptom of UC, so the doctor may weigh you and ask about recent changes to your body weight. The doctor may also conduct examinations aimed at diagnosing extra-intestinal manifestations of UC, such as examining your skin for signs of dermatological complications.

UC shares symptoms with a number of other gastrointestinal conditions, and the doctor may need to conduct tests to determine whether your symptoms are caused by UC or another condition. These include:

• Crohn’s disease, another form of irritable bowel disease characterised by inflammation. It causes similar symptoms to UC. Distinguishing between these two conditions is often challenging and sometimes it is not possible for the doctor to definitively diagnose one or the other for several years after you begin experiencing symptoms. However, unless surgery is being considered, treatment of both conditions is similar;
• Anal fissure (a tear in the mucous membrane that lines the rectum and anus);
• Infectious colitis (colitis caused by an infection);
• Pseudomembranous colitis (colitis caused by infection following antibiotic use);
• Food-sensitive colitis (a short-term form of colitis caused by food intolerance, affecting young children);
• Ischaemic colitis (caused by inadequate blood flow to the colon, affecting adults only);
• Diverticulitis (an infected pouch in the colon, affecting adults only); and
• Colonic tumours (adults only).

How is Ulcerative Colitis (Inflammatory Bowel Disease) Diagnosed?

If the doctor suspects you have UC after asking about your symptoms and conducting an examination, tests may be performed to enable a definitive diagnosis to be made and/or other causes of the symptoms to be excluded. These tests include:

If UC is still suspected after these routine tests have been conducted, further tests may be performed, including a biopsy and/or colonoscopy.

Biopsy

A biopsy is a procedure in which tissue or cells are removed from the body for further examination, for example under a microscope. In cases of suspected UC, the doctor may take a biopsy of the mucous membrane lining the rectum.

Sigmoidoscopy and colonoscopy

Sigmoidoscopy and colonoscopy are both techniques that allow the doctor to view the inside of your rectum. A special instrument (a sigmoidoscope or colonoscope), with a light and camera on one end, is inserted into the rectum. The doctor can examine the internal colon and identify features characteristic of UC using these methods.

Imaging techniques

Ultrasound (US), magnetic resonance imaging (MRI), CT (CT) scanning and x-ray may also be used to help in the diagnosis of UC. Each of these techniques allows the doctor to view your internal organs.

Prognosis of Ulcerative Colitis (Inflammatory Bowel Disease)

The prognosis varies depending on the severity of UC. Individuals with mild UC/proctitis have a very good prognosis, and only 5–10% will go on to develop a more severe form of the disease.

Overall, 66% of people with UC are able to relieve their symptoms with medications, and of those 80% who take their medicine correctly, as prescribed by the doctor, remain symptom free.

People with more severe forms of colitis may require other treatments to control symptoms, including colectomy, a surgical procedure in which part (partial colectomy) or all (total colectomy) of the colon is removed. Up to one third of patients will require such surgery after 20 years of UC.

The life expectancy of people with UC is not unlike that of the general population, although there is a significant risk of colorectal cancer that increases with the severity and duration of the disease.

The following risk factors have been identified for the development of colorectal cancer in individuals with UC:

Onset of disease in childhood or adolescence may also increase the risk of cancer.

How is Ulcerative Colitis (Inflammatory Bowel Disease) Treated?

Treatment of UC is targeted at relieving symptoms and ensuring the symptoms do not return. This can improve the person’s quality of life.

Medical treatment

Medicines called aminosalicylates (a type of anti-inflammatory medicine) are most commonly used to treat UC. These medicines typically relieve symptoms and prevent symptoms recurring. However, these medicines can cause poisoning in individuals who have problems with their kidneys. They may also cause side effects such as headache, nausea, gastrointestinal pain, diarrhoea, oligospermia (low sperm production) in men and, rarely, more serious side effects.

There are many different aminosalicylate preparations, including tablets and rectal suppositories. The most appropriate preparation for you depends on the extent of your disease. Oral administration of aminosalicylate is complicated by digestion of the active components of the medicine before it reaches the part of the intestine affected by ulcerative colitis. Attempts have been made to prevent release of the aminosalicylate until it reaches the target area by binding it to carrier substances (called prodrugs) or coating the active drug with an acid resistant layer.

Mild cases

Treatment of proctitis/mild UC is conducted in an out-patient setting (that is, through visits to the doctor when symptoms arise, rather than admission to hospital). It is important to promptly seek medical attention if you experience recurring symptoms of UC, as prompt treatment can reduce the need for specialist care.

Topical aminosalicylates such as enemas or suppositories are the best treatment for proctitis, in which the inflammation is limited to the rectum. These preparations are inserted into the anus. If you feel uncomfortable or unsure about how to properly place the medicines in your anus, talk to your doctor for advice. Topical agents are usually sufficient for mild cases. However, if your proctitis is resistant to the treatment, the doctor may also prescribe oral medications.

Moderate to severe cases

For moderate to severe disease, it is common to use a topical aminosalycilate agent in combination with an oral medication. Individuals who do not improve or who are unable to tolerate oral aminosalicylates (about 10% of patients) may be prescribed oral corticosteroids (another type of anti-inflammatory medicine) instead of oral aminosalicylates. However, these medications are usually only prescribed for short-term use. Medicines that suppress the immune system may also be prescribed.

Severe cases

Individuals with severe UC require admission to hospital for aggressive treatment with intravenous steroids. They may also require:

• Intravenous fluids;
• A blood transfusion if they have experienced significant rectal bleeding;
• Feeding via a tube if they are experiencing malnutrition;
• Antibiotics; or
• Treatment for anaemia.

People with severe UC are monitored closely while in hospital. If symptoms such as fever persist, different medications may be used or surgery may be performed.

Surgery

Colectomy surgery to remove all or part of the colon may be needed in acute severe cases (fulminant colitis) and in chronic severe cases that cannot be treated with medication. Individuals with a high risk of colorectal cancer may also need surgery.

Maintenance therapy

Maintenance therapy consists of ongoing treatment to prevent the recurrence of symptoms and maintain symptom-free disease. The same type of medicines (aminosalicylates) are used for maintenance therapy, but the doctor will usually prescribe a lower dose.

Medication compliance

Medication compliance refers to the extent to which a person complies with their medication schedule – that is, the extent to which they take their medicine when they are supposed to. Patients who take the medication when they are supposed to at least 80% of the time are five times less likely to experience symptoms, compared to those who take their medicine correctly less than 80% of the time. Correct use of medicines for maintenance therapy also reduces the risk of colorectal cancer by as much as 75%.

However, medication compliance can be difficult, even with medications taken for short periods of time. Treatment for UC is life-long and many people fail to take their medications correctly. One study reported that only 40% of people adhered to their maintenance therapy medication schedule. Reasons for non-compliance included that they forgot to take the medicine, did not experience symptoms, found taking the medication inconvenient or had too many pills to take each day. There are many reasons why you might find it difficult to take your medications correctly. If you do, make sure you talk to your doctor or pharmacist for advice to help you adhere to your medication schedule.

New preparations of aminosalicylates which only need to be taken once a day are now available. Research has demonstrated that these medicines are as effective as those needing to be taken more than once a day. Taking medicines only once a day may reduce the challenges associated with medication compliance for individuals with UC.

Psychosocial intervention

UC can significantly affect quality of life, and individuals with UC are more likely to have psychological conditions such as depression. Such conditions may occur, for example, because of concerns regarding limitations the disease may place on lifestyle, personal relationships and financial stresses. They may also make medication compliance more difficult. If you feel like you are having difficulty coping emotionally with UC, talk to your doctor, who may provide you with a referral for further care such as support or evaluation by a specialist.

Nutritional intervention

Individuals with UC should maintain good nutritional habits. If you have trouble maintaining a healthy diet, talk to your doctor or ask about a referral to a nutritionist.

Complementary therapies

As yet, no complementary therapies have been demonstrated to be effective in the treatment of UC.

Screening for colorectal cancer

People with UC (with the exception of the mild form proctitis) have an increased risk of colorectal cancer. After 8–10 years of disease, some 2% develop cancer, increasing to 18% after 30 years. People with UC should therefore undergo periodic screening for colorectal cancer by colonoscopy, according to the following schedule:

• Moderate UC/left-sided proctitis: Every 5 years;
• Extensive colitis causing mild inflammation: Every 3 years; and
• Extensive proctitis causing moderate to severe inflammation: Annually.

More information

For more information on inflammatory bowel disease, including how the digestive system works, types of IBD and useful videos, see Inflammatory Bowel Disease (IBD).

 

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Symptoms of Ulcerative Colitis:

• Abdominal Pain
• Inflammation
• Gastrointestinal Fistulas
• Rectal Bleeding (Haematochezia)

Treatments Used in Ulcerative Colitis:

• Aminosalicylates

Drugs/Products Used in the Treatment of Ulcerative Colitis:

• Mezavant Gastro-Resistant Prolonged-Release Tablets (Mesalazine)
• Azapin (Azathioprine)
• Colazide (Balsalazide sodium)
• Dipentum (Olsalazine sodium)
• Salofalk Enemas (Mesalazine)
• Salofalk Foam Enemas (Mesalazine)
• Salofalk Granules (Mesalazine)
• Salofalk Tablets (Mesalazine)
• Thioprine (Azathioprine)