The gut (gastrointestinal tract) is the long tube that starts at the mouth and ends at the anus.
Food passes down the oesophagus (gullet), into the stomach, then into the small intestine.
The
small intestine has three sections - the duodenum, jejunum and ileum.
The small intestine is where food is digested and absorbed into the
bloodstream. The structure of the gut then changes to become the large
intestine (colon and rectum, sometimes called the large bowel).
The
colon absorbs water, and contains food that has not been digested, such
as fibre. This is passed into the last part of the large intestine
where it is stored as faeces.
Faeces (motions or stools) are then passed out of the anus into the toilet.
What is ulcerative colitis (UC)?
Ulcerative colitis (UC) is a disease of the large intestine (the colon and rectum).
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Colitis means 'inflammation of the colon'.
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Ulcerative means that ulcers tend to develop, often in
places where there is inflammation. An ulcer is where the lining of the
gut is damaged and the underlying tissue is exposed. If you could see
inside your gut, an ulcer looks like a small, red crater on the inside
lining of the gut. Ulcers that occur in UC develop in the large
intestine and have a tendency to bleed.
The inflammation and ulcers in the large intestine cause the common symptoms of diarrhoea, and passing blood and mucus.
Who gets ulcerative colitis?
About 1 in 1000
people in the UK develop UC. It can develop at any age but most
commonly first develops between the ages of 15 and 40. About 1 in 7
cases first develop in people over the age of 60.
What causes ulcerative colitis?
The
cause is not known. UC can affect anyone. About 1 in 5 people with UC
have a close relative who also has UC. So, there is probably some
genetic factor. The common theory is that some factor may 'trigger' the
immune system to cause inflammation in the large intestine in people
who are genetically prone to develop the disease.
The most
likely 'trigger' for UC to develop is a bacterium or virus (germ).
However, it is not clear which bacterium or virus is the culprit. But
other triggers that may cause a flare up of UC include
anti-inflammatory drugs and withdrawal from nicotine in people who give
up smoking. In people who are known to have UC, a common trigger for a
flare-up of symptoms is a bout of gastroenteritis (infection of the
gut) caused by various bacteria.
What are the symptoms during a flare-up of ulcerative colitis?
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Diarrhoea.
This varies from mild to severe. The diarrhoea may be mixed with mucus
or pus. An urgency to get to the toilet is common. A feeling of wanting
to go to the toilet but with nothing to pass is also common (tenesmus).
Water is not absorbed so well in the inflamed colon, which makes the
diarrhoea watery.
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Blood mixed with diarrhoea is common ('bloody diarrhoea').
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Crampy pains in the abdomen.
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Pain when passing stools.
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Proctitis (inflammation of the rectum). Symptoms may be
different if a flare-up only affects the rectum, and not the colon. You
may have fresh bleeding from the rectum, and you may form normal stools
rather than have diarrhoea. You may even become constipated further
'upstream' in the unaffected higher part of the colon, but with a
frequent feeling of wanting to go to the toilet.
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Feeling generally unwell is typical if the flare-up affects
a large amount of the large intestine, or lasts a long time. Fever,
tiredness, feeling sick, weight loss, and anaemia may develop.
How does ulcerative colitis progress?
UC is
a chronic, relapsing condition. Chronic means that it is persistent and
ongoing. Relapsing means that there are times when symptoms flare-up
(relapse), and times when there are few or no symptoms (remission). The
severity of symptoms, and how frequently they occur, varies from person
to person. The first episode (flare-up) of symptoms is often the worst.
UC starts in the rectum in most cases. This causes a proctitis, which means 'inflammation of the rectum'. In some cases it only
affects the rectum, and the colon is not affected. In others, the
disease spreads up to affect some, or all, of the colon. Between
flare-ups the inflamed areas of colon and rectum heal, and symptoms go
away. The severity of a flare-up can be classed as mild, moderate or
severe:
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Mild - you have fewer than four stools
(motions) daily, with or without blood. You do not feel generally
unwell ('no systemic disturbance').
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Moderate - you have four to six stools a day and feel mildly unwell in yourself ('minimal systemic disturbance').
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Severe - you have more than six stools a day containing
blood. You also feel generally unwell with more marked 'systemic
disturbance' with things such as fever, a fast pulse, anaemia, etc.
About half of people with UC have mild and infrequent symptoms.
The other half have more frequent flare-ups with moderate or severe
symptoms. During a flare-up, some people develop symptoms gradually -
over weeks. In others, the symptoms develop quite quickly - over a few
days.
Are there any complications with ulcerative colitis?
A very severe flare-up
This is uncommon, but
if it occurs it can cause serious illness. In this situation the whole
of the large intestine becomes ulcerated, inflamed, and dilated
(megacolon). A part of the colon may perforate (puncture), or severe
bleeding may occur. Urgent surgery may be needed if a flare-up becomes
very severe and is not responding to medication (see later).
Related conditions
Other problems in other
parts of the body occur in about 1 in 10 cases. It is not clear why
these occur. The immune system may trigger inflammation in other parts
of the body when there is inflammation in the gut. These 'outside of
the gut' problems include:
- Those that may flare up when gut
symptoms flare up. That is, they are related to the activity of the
colitis and go when the gut symptoms settle. These include:
- Erythema nodosum (an unusual rash on the legs).
- Aphthous ulcers (mouth ulcers).
- Episcleritis (a type of eye inflammation).
- Acute arthropathy (painful joints).
- Those that are usually related to the activity of the
colitis and usually go, but not always, when the gut symptoms settle.
These include:
- Pyoderma gangrenosum (an unusual skin condition).
- Anterior uveitis (a type of eye inflammation).
- Those that are not related to the activity of the
colitis. So, they may persist even when the gut symptoms settle. These
include:
- Sacroiliitis (inflammation of the joints between the sacrum and the lower spine).
- Ankylosing spondylitis (a type of arthritis that affects the spine).
- Primary sclerosing cholangitis (which causes inflammation of the bile ducts of the liver).
Cancer
The risk of developing cancer of the colon is increased if you have UC (more details later).
How is ulcerative colitis diagnosed?
The
usual test is for a doctor to look inside the large intestine by
passing a special telescope up through the anus into the rectum and
colon. These are a short sigmoidoscope or a longer flexible
colonoscope. See separate leaflets called 'Colonoscopy' and 'Sigmoidoscopy'
for more detail. The appearance of the inside lining of the rectum and
colon may suggest UC. Small samples (biopsies) are taken from the
lining of the rectum and colon and looked at under the microscope. The
typical pattern of the cells seen with the microscope may confirm the
diagnosis. Also, various blood tests are usually done to check for
anaemia and to assess your general wellbeing.
Special X-ray
tests such as a barium enema are not often done thesedays as the above
tests are usual to confirm the diagnosis, and assess the disease
severity.
A stool sample (sample of faeces) is commonly done
during each flare-up and sent to the 'lab' to test for bacteria and
other infecting germs. Although no germ has been proven to initially
cause UC, infection with various known germs can trigger a flare-up of
symptoms. If a germ is found, then treatment of this may be needed in
addition to any other treatment for a flare-up (described below).
What are the treatment options for a flare-up of ulcerative colitis?
When
you first develop UC it is usual to take medication for a few weeks
until symptoms clear. A course of medication is then usually taken each
time symptoms flare-up. The drug advised may depend on the severity of
the symptoms and the main site of the inflammation in the large
intestine. Drug options include the following:
Aminosalicylate drugs
These include
mesalazine, olsalazine, balsalazide and sulfasalazine. The active
ingredient of each of these drugs is 5-aminosalicylic acid, but each
drug is different in how the active ingredient is released or activated
in the intestine. Mesalazine is the most commonly used. Each of these
drugs comes in different brand names and different preparations such as
oral tablets, sachets or suspension, liquid or foam enemas, or
suppositories. The type of preparation (for example, tablets or enemas)
may depend on the main site of the inflammation in the intestine.
Aminosalicylate
drugs often work well for mild flare-ups. The exact way these drugs
work is not clear but they are thought to counter the way inflammation
develops in UC. However, they do not work in all cases. Some people
need to switch to steroid medication if an aminosalicylate drug is not
working, or if the flare-up is moderate or severe.
Side-effects
with the more modern aminosalicylate drugs (mesalazine, olsalazine, and
balsalazide) are uncommon. The older drug, sulfasalazine, had a higher
rate of side-effects so is not commonly used these days.
Steroids
Steroids work by reducing
inflammation. If you develop a moderate or severe flare-up of UC a
course of steroid tablets (corticosteroids) such as prednisolone will
usually ease symptoms. The initial high dose is gradually reduced and
then stopped once symptoms ease. A steroid enema or suppository is also
an option for a mild flare-up of proctitis. Steroid injections directly
into a vein may be required for a severe flare-up.
A course of
steroids for a few weeks is usually safe. Steroids are not usually
continued once a flare-up has settled. This is because side-effects may
develop if steroids are taken for a long time (several months or more).
The aim is to treat any flare-ups, but to keep the total amount of
steroid treatment over the years as low as possible.
Immune suppressant drugs
Powerful drugs that
suppress the immune system (immunosuppressants) may be used if symptoms
persist despite the above treatments. For example, azathioprine,
ciclosporin or infliximab are sometimes needed to control a flare-up of
UC.
Laxatives
Although most people with UC have
diarrhoea during a flare up, as mentioned 'high' constipation may
develop if you just have proctitis (inflammation of the rectum only).
In this situation, laxatives to clear any constipation may help to ease
a flare-up of proctitis.
Note: antidiarrhoeal medication such as
loperamide should NOT be used during a flare-up of UC. This is because
they do not reduce the diarrhoea that occurs with UC and increase the
risk of developing a megacolon (a serious complication of UC - see
below).
What are the treatment options to prevent flare-ups of symptoms?
Medication
Once an initial flare-up of
symptoms has cleared, you will usually be advised to take a drug each
day to prevent further flare-ups. If you have UC and do not
take a regular preventive drug, you have about a 7 in 10 chance of
having at least one flare-up each year. This is reduced to about a 3 in
10 chance if you take a preventative drug each day.
An
aminosalicylate drug, usually mesalazine (described above), is commonly
used to prevent flare-ups. A lower 'maintenance dose' than the dose
used to treat a flare-up is usual. You can take this indefinitely to
keep symptoms away. Most people have little trouble taking one of these
drugs as side effects are uncommon. However, some people develop
side-effects such as abdominal pains, feeling sick, headaches, or
rashes.
If a flare-up develops whilst you are taking an
aminosalicylate drug then the symptoms will usually quickly ease if the
dose is increased, or if you switch to a short course of steroids.
Another drug may be advised if an aminosalicylate drug does not work,
or causes difficult side-effects. For example, azathioprine or
6-mercaptopurine are sometimes used.
Probiotics
Probiotics are nutritional
supplements that contain 'good' bacteria. That is, bacteria that
normally live in the gut and do no harm. Taking probiotics may increase
the 'good' bacteria in the gut which may help to ward off 'bad'
bacteria that may trigger a flare-up of symptoms. There is little
scientific proof that probiotics work to prevent flare-ups. However, a
probiotic strain (Escherichia coli Nissle 1917) and the probiotic
preparation VSL3 have shown promise. Further research is needed to
clarify the role of probiotics.
Who needs surgery?
Unfortunately, not
everyone with UC has their symptoms well controlled with medication.
About a quarter of people with UC need surgery at some stage. The
common operation is to remove the large intestine. There are different
techniques used for this. It is helpful to discuss the pros and cons of
the different operations with a surgeon. Removing the large intestine
will usually cure symptoms of UC permanently.
Surgery is considered in the following situations.
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During a life-threatening flare-up. Removing the large intestine may be
the only option if it swells greatly ('megacolon'), perforates
(punctures), or bleeds uncontrollably.
- If UC is poorly controlled by medication. Some people remain in
poor health with frequent flare-ups which do not settle properly. To
remove the large intestine is a serious step, but for some people the
operation is a relief after a long period of ill health.
- If cancer or 'pre-cancer' of the large intestine develops.
General treatment measures
- A special
diet is not usually needed. A normal, healthy, well balanced diet is
usually advised. If you have UC just in the rectum (proctitis), a high
fibre diet may help to avoid constipation.
- You may be advised to take iron tablets if you develop anaemia.
- You may need painkillers when symptoms flare-up.
Ulcerative colitis and cancer of the colon
The
chance of developing cancer of the large intestine (colon) is higher
than average in people who have had UC for several years or more. It is
more of a risk if you have frequent flare-ups affecting the whole of
the large intestine. For example, about 1 in 10 people who have UC for
20 years which affects much of their large intestine will develop
cancer.
Because of this risk, people with UC are usually advised
to have their large intestine routinely checked after having had UC for
about 8-10 years. This involves a look into the large intestine by a
flexible telescope (colonoscopy) every now and then. Your specialist
will advise exactly how often you should have this test. Commonly, a
colonoscopy is done every three years in people who have had UC for
10-20 years, every two years in people who have had UC for 20-30 years,
and every year in people who have had UC for 30 or more years. But
there are exceptions to this 'rule of thumb' and your specialist will
advise.
In most cases, any changes are noticed from biopsies
(small samples) taken during colonoscopy long before any cancer
develops. (This is a similar principle to cervical screening in women.)
If changes are found, surgery to remove the large intestine is advised
to prevent cancer developing.
Recent studies indicate that the
risk of cancer is reduced in people who take regular long-term
aminosalicylate medication (described above). In one study, patients
with ulcerative colitis who regularly took mesalazine had a 75% reduced
risk of developing colon cancer.
What is the prognosis (outlook)?
With modern
medical and surgical treatment, there is just a slight increase in the
risk of death in the first two years after diagnosis compared to the
general population. After this there is little difference in life
expectancy from the general population. However, a severe flare-up of
UC is still a potentially life threatening illness and needs expert
medical attention.
As mentioned, if you do not take medication
to prevent flare-ups, about half of people with UC have a relapse on
average once a year. This is much reduced by taking regular medication.
However, even in those who take regular medication, some people have
frequent flare-ups and about a quarter of people with UC eventually
have an operation to remove their colon.
A year from diagnosis,
about 9 in 10 people with UC are fully capable of work. So, this means
that in the majority of cases, with the help of treatment, the disease
is manageable enough to maintain a near normal life. However, UC causes
significant employment problems for a minority.
Treatment for UC
is an evolving field. Various new drugs are under investigation and may
change the treatment options over the next ten years or so, and improve
the prognosis.
What is inflammatory bowel disease?
When
doctors talk of 'inflammatory bowel disease' they usually mean people
who either have UC or Crohn's disease. Both of these conditions can
cause inflammation of the large intestine with similar symptoms such as
bloody diarrhoea, etc. Although these conditions are similar, and
treatments are similar, there are differences. For example, the
inflammation of UC tends to be just in the inner lining of the
intestine, whereas the inflammation of Crohn's disease can spread
through the whole wall of the intestine. Also, UC only affects the
large intestine whereas Crohn's disease can affect any part of the gut.
See separate leaflet called 'Crohn's Disease' for more detail.
However,
up to 1 in 20 people with 'inflammatory bowel disease' affecting just
the colon cannot be classified as either UC or Crohn's disease because
they have some features of both conditions. This is sometimes called
indeterminate colitis.
Note: inflammatory bowel disease is
sometimes shortened to 'IBD'. This is not the same is 'IBS' which is
short for irritable bowel syndrome - a very different disease.
Disclaimer: This article is for information only and should not
be used for the diagnosis or treatment of medical conditions. EMIS and
PiP have used all reasonable care in compiling the information but make
no warranty as to its accuracy. Consult a doctor or other health care
professional for diagnosis and treatment of medical conditions.
© EMIS and PiP 2008 Reviewed: 26 Aug 2008
