Ulcerative Colitis

What is ulcerative colitis?

Ulcerative colitis is a chronic, or long-lasting, disease, in which there is inflammation (irritation, swelling, or sores) in the large intestine (the colon, which is the lower part of the intestine). It varies in intensity and may sometimes go into remission (a period with no symptoms). It may cause diarrhea, rectal bleeding, urgency to have bowel movements, or other symptoms. The inflammation may affect the rectum only, the rectum and lower part of the colon (the sigmoid colon), or the entire colon.

What are the symptoms of ulcerative colitis?

The most common symptoms of ulcerative colitis are diarrhea, rectal bleeding, urgency to have bowel movements, and abdominal pain or cramping. Other possible symptoms include fatigue, fever, anemia, joint pains, eye irritation, a skin condition called erythema nodosum with tender, red bumps under the skin, or a skin condition called pyoderma gangrenosum with a large are of open sore and inflammation. The location of the inflammation and Crohn's disease will affect what symptoms occur.

What causes ulcerative colitis?

Autoimmune Disease: Ulcerative colitis occurs when the immune system reacts against the lining of the intestine. Normally, the immune system attacks germs, foreign substances, or cells that have become defective. If the immune system mistakenly attacks healthy cells, this is called an autoimmune disease. Ulcerative colitis is an autoimmune disease that involves the large intestine. Other intestinal autoimmune diseases are Crohn’s disease and microscopic colitis.

Genes: Ulcerative colitis may run in families, indicating that the genes contribute to ulcerative colitis. Many genes have been implicated in ulcerative colitis, and scientists are just beginning to understand the link between specific genes and ulcerative colitis. Genes alone do not explain why a particular person gets ulcerative colitis, so random or environmental factors also must play a role.

Environment: There is a slight increase in the risk of developing ulcerative colitis with use of antibiotics, oral contraceptives, or nonsteroidal anti-inflammatory drugs, and with a high-fat diet. Ulcerative colitis is more common in non-smokers and people who have had their appendix removed. The many bacteria that normally live in the intestine (the microbiome) probably have an effect on ulcerative colitis. However no specific contagious bacteria or virus has ever been found to cause ulcerative colitis . Stress, emotional distress, and specific foods may cause worsening of symptoms, but they do not cause ulcerative colitis.

Diagnosis of Ulcerative Colitis

Dr. Harary diagnoses ulcerative colitis by using a combination of medical history, the physical examination, laboratory tests (on blood or stool), and colonoscopy. He will first see the patient in his New York City office and then arrange for any appropriate testing. Colonoscopy or flexible sigmoidoscopy are used to visualize the colon (large intestine). These tests are described in the colonoscopy and flexible sigmoidoscopy pages of Services We Provide. They are the key tests used in diagnosing ulcerative colitis, and Dr. Harary also uses them to assess activity of the inflammation and as a preventive screening test for cancer in ulcerative colitis patients. Occasionally, it is not clear if the patient has ulcerative colitis or Crohn’s disease; in this situation, further testing may be needed to examine the small intestine. These tests include a small bowel series, wireless capsule endoscopy (which is performed by Dr. Albert Harary in his New York City office), and CT or MRI enterography.

Complications of Ulcerative Colitis

Anemia: The blood loss from chronic inflammation can cause iron deficiency, which can cause anemia (a low red blood cell count).

Inflammation outside the GI tract: Ulcerative colitis can cause inflammation to occur in the joints, eyes (uveitis or scleritis), the bile ducts in the liver (primary sclerosing cholangitis) or the skin (erythema nodosum or pyoderma gangrenosum).

Colon cancer: There is a higher risk of developing colon cancer in patients with ulcerative colitis. Effective long-term control of the inflammation reduces the risk. After as little as 8 years of disease, frequent colonoscopies become advisable to search for precancerous changes (dysplasia) or early cancer.

Primary sclerosing cholangitis: This is liver condition in which the bile ducts that carry bile from the liver to the intestine become inflamed and narrowed. It can cause abdominal pain, yellow jaundice, fever, itching, or serious damage to the liver.

Treatment of Ulcerative Colitis

Dr. Harary treats ulcerative colitis with medications. Infrequently, surgery also becomes necessary.

Medications are used to decrease inflammation and heal the intestine (induction of remission), to maintain the remission, and to control his symptoms. The following medications can be used:

Aminosalicylates (mesalamine, olsalazine, balsalazide, and sulfasalazine): These medications decrease inflammation in the intestine. These can be taken orally in pill form or can be applied directly to the lining of the rectum and/or lower colon in the form of suppositories or medicated enemas. They are the safest choices but are not as strong as the other options. They are a key part of treatment in patients with mild or moderate colitis.

For more severe ulcerative colitis or when the aminosalicylates are not working, it is necessary to use stronger medications that reduce the activity of the immune system but also have more potential to cause serious side effects, especially serious infections:

Corticosteroids (also known as steroids, but not the type used by certain athletes) reduce the activity of the immune system and decrease inflammation. They include budesonide (Uceris, Entocort), prednisone, hydrocortisone, and methylprednisolone. These can be taken orally in pill form or can be applied directly to the lining of the rectum and/or lower colon in the form of suppositories or medicated enemas. They can be given intravenously in hospitalized patients. These drugs are effective for the short term in inducing a remission in ulcerative colitis, but are not safe for long-term use. Corticosteroids can produce many side effects, including a higher chance of developing infections, loss of bone calcium, death of bone tissue that can cause permanent joint problems, acne, mood swings, insomnia, high blood sugar, high blood pressure, and weight gain. Budesonide has fewer side effects than the other steroids.

Biologic therapies block certain proteins made by the immune system. They include anti-TNF (tumor necrosis factor) antibodies: infliximab (Remicade), adalimumab (Humira) and certolizumab (Cimzia), and golimumab (Simponi). Another new biologic drug is vedolizumab (Entyvio). These medications are the most potent available for general use. They can profoundly improve the activity of ulcerative colitis. Allergic reactions, mostly skin rashes, especially with infliximab, and serious infections, such as tuberculosis, can occur. They are administered intravenously or by patients injecting themselves and are usually used for years.

Immunomodulators: 6-mercaptopurine and azathioprine) decrease the activity of the immune system and can be used for long-term treatment of ulcerative colitis, alone or in combination with biologic therapies. They can take 3 weeks to 3 months to start working. Like biologic drugs, they can cause serious side effects, including serious infections, pancreatitis, skin cancers, a slight increase in the risk of lymphoma (lymph node cancer), and liver injury.

NSAID’s (nonsteroidal anti-inflammatory drugs), such as ibuprofen (Motrin, Advil, etc.), naproxen (Aleve) and aspirin should be avoided, as they can worsen intestinal inflammation.

Although diets containing healthy amounts of fiber are generally good, Dr. Harary advises his patients with active inflammation of the colon to minimize fiber intake.

Surgery: When medications cannot control the colitis or if the disease is too severe to wait for medications to work, surgery may become necessary. Surgery will permanently eliminate the colitis and the cancer risk. It involves removing the entire colon and rectum. There are 2 options:

1. Proctocolectomy and ileostomy. If the anus also needs to be removed, then the patient can no longer pass bowel movements normally, and the bowel movements come out through a hole in the belly and are collected in a plastic bag.

2. Proctocolectomy and ileo-anal pouch: It is sometimes possible to connect the end of the small intestine to the anus. This would allow bowel movement to come out through the normal route. Frequent and loose bowel movements usually occur after this surgery. Complications of this operation include incontinence (accidental passage of solid or liquid stool), infections, pouchitis (inflammation of the lining of the internal intestinal pouch that is created), and female infertility.