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Ulcerative Colitis

An inflammatory condition that affects the surface of the colon, ulcerative colitis causes friability and erosions with bleeding. The disease more commonly affects the rectum and sigmoid colon. Less frequently, it extends into the splenic flexure, or more proximally extends upward into the entire colon. It rarely affects the small intestine, except for the terminal ileum.

Severity ranges from a mild, localized disorder to a fulminant disease that may lead to a perforated colon, progressing to peritonitis and toxemia.

Causes

The exact cause of ulcerative colitis is unknown. Hereditary, infectious and immunological factors have been proposed as possible causes.

Ulcerative colitis occurs primarily in young adults, especially women; it's also more prevalent among the Jewish population and individuals in higher socioeconomic groups. Onset of symptoms seems to peak in the 15- to 20-year-old age-group, with another peak occurring in the 55- to 60-year­old age-group.

Signs and symptoms

The hallmark of ulcerative colitis is bloody diarrhea. The intensity of these attacks varies with the extent of inflammation. Patients with mild to moderate disease may experience approximately five or fewer bowel movements per day with intermittent bleeding and mucus production. Individuals may experience left lower quadrant pain relieved by defecation, along with fecal urgency and tenesmus. Patients with more severe disease will have more than five bowel movements per day, which may result in anemia, hypovolemia, and impaired nutrition. Extracolonic manifestations also may be present, including erythema nodosum, pyoderma gangrenosum, episcleritis, thromboembolic events, and arthritis.

Ulcerative colitis may lead to complications affecting the following organs and systems:

• Blood: anemia from iron deficiency, coagulation defects due to vitamin K deficiency
• Skin: erythema nodosum on the face and arms; pyoderma gangrenosum on the legs and ankles
• Eye: uveitis
• Liver: pericholangitis, sclerosing cholangitis, cirrhosis, possible cholangio­carcinoma
• Musculoskeletal: arthritis, ankylosing spondylitis, loss of muscle mass
• GI: strictures, pseudopolyps, stenosis, and perforated colon, leading to peritonitis and toxemia.

Diagnosis

• History and physical examination should include questions regarding frequency of stools, rectal bleeding, cramps, abdominal pain, weight loss, and tenesmus. Peritoneal inflammation should be assessed, as well as volume status and nutritional levels.
• Sigmoidoscopy establishes a diagnosis by demonstrating increased mucosal friability, decreased mucosal detail, edema, and erosions. Biopsy can help confirm the diagnosis.
• Colonoscopy may be used both to determine the extent of the disease and for cancer surveillance after the patient's flare-up has resolved.

Treatment

The goals of treatment are to relieve symptoms of the acute attack and prevent recurrent attacks, to replace nutritional losses and blood volume, and to prevent complications.

Supportive treatment includes I.V. fluid replacement and a clear-liquid diet. For patients awaiting surgery or showing signs of dehydration and debilitation from excessive diarrhea, total parenteral nutrition rests the intestinal tract, decreases stool volume, and restores positive nitrogen balance. Blood transfusions or iron supplements may be necessary to correct anemia.

Drug therapy :- Medications to control inflammation include corticotropin and adrenal corticosteroids, such as prednisone, prednisolone, and hydrocortisone; sulfasalazine, which has anti-inflammatory and antimicrobial properties, may also be used.

Patients with mild to moderate disease may eat a regular diet, excluding caffeinated beverages and gas-producing foods. Fiber supplementation may be used to control diarrhea and rectal symptoms. Antidiarrheal agents (loperamide, atropine [Lomotil], and tincture of opium) should be used only in patients with mild symptoms, not in those with the acute phase of this illness.

Patients with disease primarily affecting the rectum or rectosigmoid should be managed with topical agents such as mesalamine. Topical steroids may be used, but they may be less effective.

Patients with mild to moderate disease extending above the sigmoid colon who fail to improve after 2 to 3 weeks on sulfasalazine or mesalamine should have a corticosteroid added to their regimen.

Severe colitis is usually managed with nothing-by-mouth status and parenteral alimentation. Volumizers and blood should be provided as needed. Surgical consultation should be obtained in all patients with severe disease.

Surgery :- Surgery to remove the colon will cure ulcerative colitis and removes the threat of colon cancer. Patients may need an ostomy or an ileal pouch-anal anastomosis, a procedure that connects the small intestine to the anus to help the patient gain more normal bowel function.

Elimination Diet :- Some people, whose symptoms are triggered by certain foods, are able to control the symptoms by avoiding foods that upset their intestines, like highly seasoned foods or dairy products (lactose).

Prevention

Because the cause is unknown, prevention is also unknown.

In patients with ulcerative colitis, nonsteroidal anti-inflammatory drugs (NSAID's) may exacerbate symptoms.

Due to the risk of colon cancer associated with ulcerative colitis, screening with colonoscopy is recommended after 8 years of disease.