Ulcerative colitis

Ulcerative colitis is a type of inflammatory bowel disease (Crohn’s Disease being a separate but related entity).  Ulcerative colitis is confined to the mucosa (inner lining) of the large intestine (colon and rectum) and starts in the rectum extending proximally into the colon in a continuous pattern of spread.  There are no “skip lesions” or intervening segments of normal, unaffected bowel as can be seen in Crohn’s disease.  These are two of the chief differences between ulcerative colitis and Crohn’s disease, which can affect any portion of the gastrointestinal tract and involve full-thickness damage to the affected organ.

What causes Ulcerative Colitis?
The underlying cause of ulcerative colitis has not been fully explained.  Current thought suggests a malfunction of the intestinal immune system leading to an over-amplification of the normal defense mechanism to microflora commonly found within the gastrointestinal tract.  This in turn leads to ongoing inflammation and damage to the lining of the involved organ (colon and/or rectum) that the body is trying to protect.  Approximately 250,000 to 500,000 persons in the United States have ulcerative colitis, accounting for 20,000 hospitalizations per year.  Men and women are equally affected by the disease with initial onset usually occurring between 15-40 years of age or between 50-80 years of age.

What are the symptoms of Ulcerative Colitis?
Patients with mild disease often have few if any symptoms.  As the disease worsens the chief complaints of intermittent rectal bleeding, diarrhea, rectal urgency (tenesmus) and abdominal pain begin to surface.

Rectal bleeding is a common complaint among patients with ulcerative colitis.  This often occurs as passage of frank fresh blood, blood covering the surface of normal stool or bloody diarrhea.  Although diarrhea is common, up to a third of patients may actually complain of constipation.  Fecal urgency and episodes of incontinence may occur as the severity of rectal inflammation worsens.  Vague abdominal discomfort and cramping prior to passage of stool can occur, but significant abdominal pain is not usually present unless the disease activity is severe.  If the disease is allowed to progress to this level of severity, patients will experience nausea, vomiting, anorexia and weight loss.  Rapid heart rate, fever and abdominal pain are worrisome developments which should be immediately assessed within a hospital setting.

Ulcerative colitis is also associated with extra-intestinal symptoms in anywhere from 6 to 47% of patients.  These include arthritic pain, skin lesions (pyoderma gangrenosum and erythema nodusum), blurred vision and eye pain (iritis, scleritis, uveitis) and liver disease (primary sclerosing cholangitis).  The severity of these is often related to the underlying colonic disease activity. 

How is ulcerative colitis diagnosed?
A detailed interview by your primary physician, gastroenterologist or surgeon will often lead to the suspicion of inflammatory bowel disease.  Laboratory tests, imaging studies and direct visualization of the intestinal tract with colonoscopy and subsequent microscopic evaluation of the tissue samples obtained are used to confirm the diagnosis and assess the extent/severity of the disease.

What is the treatment of ulcerative colitis?
After confirming the diagnosis of ulcerative colitis, the extent and degree of inflammation determine the appropriate therapy.  This is done by assessing laboratory studies, colonoscopic findings and symptom severity.

Disease limited to the rectum and distal colon may be treated with local therapy (i.e suppositories, foams or enemas). Mild to moderate disease requires oral medication.  Antidiarrheal medications may also be added if needed.  For continued symptoms or “flare-ups” after successful treatment, steroids may be used on a short-term basis to induce remission. Newer medications, coined “biologics” (i.e. Remicade, Humira) have shown great success in managing refractory cases.

Surgery is indicated for three main reasons:

1)    when medical therapy fails to control symptoms

2)    for life-threatening complications (bleeding, perforation or infection)

3)    development of precancerous or cancerous lesions within the colon or rectum

Unlike Crohn’s disease, ulcerative colitis can be cured by removal of the diseased organs – the colon and rectum.

Currently, the most common approach is an Ileal Pouch Anal Anastomosis (IPAA).  In this procedure, the entire colon and rectum are removed.  However, rather than creating a permanent ileostomy, the last part of the small intestine is created into a pouch-reservoir and connected to the anal canal.  It can then act as a new rectum and allows for a normal route of evacuation.  This is typically done in 2 or 3 staged operations.

The classic procedure for this is called a “proctocolectomy”, which removes the entire colon and rectum.  The last part of the small intestine (terminal ileum) is brought to the surface of the abdominal wall to create an “ileostomy”, which acts as a new exit point for intestinal waste.  This completely eliminates the disease and effectively removes all risk of developing cancer in the colon or rectum in one operation.

A less complete resection can be achieved by removing only the colon and then connecting the small intestine directly to the rectum (ileorectal anastomosis) which has been left in place.  This avoids the need for a permanent ileostomy, but leaves the patient at risk for continued inflammation of the retained rectum, difficulty with stool frequency/urgency and the risk of developing rectal cancer in the future. For all of these reasons, this procedure is rarely performed especially since the development of the Ileal-Pouch-Anal Anastomosis.

The choice of procedure is made after careful evaluation and discussion with your Colon and Rectal surgeon and decision as to which procedure is best suited to your specific condition.

What is the prognosis of ulcerative colitis after surgery?
The vast majority of patients, over 95%, are very pleased with the function of the IPAA, but rarely the pouch can malfunction, develop pouchitis (inflammation of the pouch) or a patient who was felt to have ulcerative colitis proves to have Crohn’s disease.  In these events the pouch may need to be removed with conversion to a permanent ileostomy.