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Ulcerative Colitis

Ulcerative colitis ImageWhat is ulcerative colitis?
Ulcerative colitis is inflammation or irritation of the lining of the colon, which starts in the rectum. This shows up on endoscopic exams as a diffuse redness that may have spontaneous bleeding or mucus on the surface. Discrete ulcers are not seen visually although they are readily seen under the microscope. The most common area to be affected is the rectum (this may be called ulcerative proctitis). In time it may advance higher in the colon or it may start with the entire colon being diseased. Inflammation and scar tissue (sclerosing cholangitis) can affect the bile ducts. Liver disease or pericholangitis occurs occasionally. As part of the overall ulcerative colitis disease, 5% of people experience joint and low back pain, a variety of skin and eye diseases, fever and anemia.

What is the cause for ulcerative colitis?
Although no one knows what starts this disease, many aspects of the inflammatory process are known. There appears to be a genetic predisposition to the disease. Ulcerative colitis may start after a gastrointestinal infection where certain inflammatory cells get stimulated and stay that way for uncertain reasons.

What is the long-term outlook for people with ulcerative colitis?
This disease becomes active and goes into remission without any predictability. After a person gets into a drug-induced remission, relapse occurs in 25-50% after 1 year and 40-65% after 2 years. Approximately one third to one half of people with ulcerative colitis require surgery to remove the colon. In surgical cases, an internal intestinal pouch can be created so there is no external bag or ostomy. When the colitis has been extensive the risk for colon cancer starts to increase after having the disease for a period of 7-10 years. After this time period approximately 1% of patients per year develop colon cancer. Undergoing a regular surveillance program with colonoscopy and biopsies can prevent cancer. If a biopsy shows evidence of dysplasia, colon surgery can prevent cancer.

What is the treatment for ulcerative colitis?
Usually the first treatment is one of the 6-ASA medications: Asacol, Rowasa, Pentasa, Dipentum, Colazal and Azulfidine. Colazal has been shown in a recent study to be more effective and better tolerated than Asacol in the treatment of ulcerative colitis. This class of medications decreases mucosal permeability, inhibits antibody production, inhibits chemotactic factor production and stimulates prostaglandin production. For moderate or severe disease, an anti-inflammatory steroid called prednisone is commonly prescribed. This drug is similar to a chemical that our own body makes but when used in high doses it has many short-term and long-term side effects. A third class of medications called immunosuppressant's or immunomodulating medications are useful in minimizing the dose or replacing the use of steroids. Examples include Purinethol (6-MP: 6-mercaptopurine), Imuran (azathiaprine) and Methotrexate. Each of these medications potentially has significant side effects that require careful monitoring by your doctor. Heparin and Plaquenil are occaisonally useful treatments. Finally, surgery is indicated for patients who have dysplasia or when medical therapy has failed. Surgery is a curative procedure as opposed to Crohn’s disease. A surgery called the internal ileoanal pull through pouch is a good alternative to an ileostomy (extended appliance or bag). Inflammation of the internal pouch may require antibiotic therapy.

How should the diet be modified?
Certain modifications in diet are indicated. When there is active inflammation in the intestine, raw fruits and vegetables should be avoided. Caffeine may also be a factor in contributing to diarrhea. We do not limit dairy products although a lactose enzyme supplement is indicated for those who are intolerant to the milk sugar. A balanced nutritious diet with vitamin supplementation is important. A vitamin called folic acid may be protective against the development of cancer. After surgical resection of part of the small intestine a low oxylate diet and increased fluid intake may be indicated to prevent kidney stones.