Ulcerative colitis (UC) is a persistent condition characterized by inflammation in the colon, leading to ulcers. It is a prevalent form of inflammatory bowel disease (IBD), often accompanied by symptoms such as bloody stools, abdominal cramping, and weight loss. Individuals with UC typically undergo periods of symptom flare-ups followed by remission without symptoms. The condition can be classified based on the location of inflammation in the colon, ranging from ulcerative proctitis to pancolitis.

Overview

Ulcerative colitis is a lifelong ailment that induces inflammation and ulcers within the colon, constituting a major type of IBD alongside Crohn’s disease. It frequently manifests as bloody diarrhea and abdominal cramping, accompanied by an increased frequency of bowel movements. The disease's course is marked by alternating phases of symptomatic flare-ups and asymptomatic remission.

Types of Ulcerative Colitis

Healthcare practitioners categorize UC based on the affected segments of the colon. The inflammation often initiates in the rectum, progressing to involve various portions of the colon:

• Ulcerative Proctitis: Limited to inflammation in the rectum.


• Proctosigmoiditis: Inflammation encompasses the rectum and sigmoid colon.


• Left-sided Colitis: Affects the left side of the colon.


• Pancolitis: Inflammation extends throughout the entire colon.

The severity of UC varies, with fulminant ulcerative colitis being the rare and most severe form, necessitating urgent medical intervention due to life-threatening complications.

Prevalence

In North America and Europe, UC, combined with Crohn’s disease, impacts up to 1 in 250 individuals. In the United States alone, an estimated 900,000 people are living with UC, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

Symptoms and Causes

Symptoms

UC symptoms tend to exacerbate over time, with initial signs often including:

• Diarrhea (potentially bloody).


• Increased bowel movements.


• Urgent bowel movements.


• Tenesmus (a persistent urge to defecate without relief).


• Mild abdominal cramping or tenderness.

As the disease progresses, individuals may experience more severe symptoms such as frequent bowel movements, blood, mucus, or pus in the stool, severe abdominal cramping, fatigue, sudden weight loss, nausea, and fever. Approximately 25% of UC patients develop extraintestinal symptoms affecting areas like bones, joints, eyes, skin, and liver.

Causes

The etiology of ulcerative colitis is multifaceted and involves various risk factors. While the exact cause remains elusive, researchers posit an overactive immune response as a central component. Factors influencing the risk of UC include age, race, genetics, and alterations in the gut microbiome. Stress and diet, though not directly linked to UC development, can act as triggers for symptom flare-ups.

Risk Factors:

• Age: Most diagnoses occur between 15 and 30 years old or after the age of 60.


• Race and Ethnicity: Higher risk for white individuals, particularly those of Ashkenazi Jewish descent.


• Genetics: Increased likelihood with a first-degree relative (parent, sibling, or child) having UC or Crohn’s disease.


• Gut Microbiome: Differences observed in the microbiomes of individuals with UC compared to those without.

Complications associated with UC include anemia, increased risk of colon cancer, osteoporosis, primary sclerosing cholangitis, and growth and development issues in children.

Diagnosis and Tests

Diagnosing UC

To diagnose UC, healthcare providers conduct a thorough physical examination, inquire about symptoms and family history of IBD, and order tests to rule out similar conditions. Diagnostic measures include blood tests, stool samples, imaging tests (such as barium enema, CT scans, and MRI), and endoscopic tests (colonoscopy and sigmoidoscopy).

Management and Treatment

Treatment Goals

The primary objective of UC treatment is to induce remission during flare-ups and maintain remission during asymptomatic periods. Treatment modalities encompass medications and, in severe cases, surgery.

Medications

Various medications target inflammation within the large intestine, alleviating symptoms and promoting tissue healing. Commonly prescribed drugs include:

• Aminosalicylates: Sulfasalazine or sulfa-free alternatives like mesalamine for mild to moderate UC.


• Corticosteroids: Prednisone or budesonide for short-term use in severe cases.


• Immunosuppressants: 6-mercaptopurine, azathioprine, or methotrexate to modulate the immune response.


• Biologics: Infliximab, adalimumab, golimumab, certolizumab pegol, vedolizumab, and ustekinumab for moderate to severe UC.


• Janus Kinase (JAK) Inhibitors: Tofacitinib, upadacitinib, and ozanimod to inhibit inflammation-triggering enzymes.

Surgery

Surgery becomes an option if medications prove ineffective or complications arise. Roughly 30% of individuals with UC may require surgery, and about 20% of affected children may undergo surgical intervention. Surgical procedures involve proctocolectomy, wherein the colon and rectum are removed, with options including ileal pouch creation or ileostomy.

Prevention

Flare-Up Prevention

Reducing the likelihood of flare-ups involves identifying and avoiding triggers. Strategies for mitigating flare-ups include:

• Stress Management: Prioritize sufficient sleep, regular exercise, and stress-relieving activities like meditation.


• NSAID Avoidance: Opt for acetaminophen instead of NSAIDs to alleviate pain or fever, as NSAIDs can exacerbate UC symptoms.


• Dietary Modifications: Although individual triggers vary, some people find relief by avoiding dairy and high-fiber foods. Collaborate with healthcare providers to tailor a personalized meal plan.

Maintaining a diary to track triggers facilitates effective communication with healthcare providers for personalized management strategies.

Outlook / Prognosis

Disease Course

The prognosis for individuals with UC varies, with some experiencing a single flare-up and others grappling with chronic, challenging symptoms. Most individuals undergo periods of remission interspersed with flare-ups, while about 30% may witness symptom exacerbation, eventually necessitating surgery.

Long-Term Management

While there is no cure for UC, effective management through medications, lifestyle modifications, and, in severe cases, surgery can help individuals lead fulfilling lives. Regular monitoring, including colonoscopies for colon cancer screening, is essential, with healthcare providers tailoring care plans to each patient’s unique circumstances.

Living With

When to Seek Medical Attention

Immediate medical attention is warranted in the presence of:

• Heavy, persistent diarrhea.


• Blood in the stool with clots.


• Continuous pain accompanied by a high fever.

Questions for Healthcare Providers

Engaging with healthcare providers is crucial for comprehensive UC management. Key questions include:

• Prognostic Impact: How does the type of UC I have influence my prognosis?


• Complication Risks: What is my risk of complications from UC?


• Recommended Treatments: What treatments do you recommend, and what are their associated risks or side effects?


• Lifestyle Modifications: How can I adapt my lifestyle to prevent flare-ups?


• At-Home Management: What steps can I take at home to manage symptoms during a flare-up?

Collaborating closely with the healthcare team, adhering to prescribed medications even during asymptomatic periods, and understanding individualized care plans enhance the likelihood of maintaining remission and overall well-being.

In conclusion, ulcerative colitis is a complex condition requiring a multifaceted approach to diagnosis, treatment, and ongoing management. Individuals navigating UC benefit from a comprehensive understanding of their condition, proactive engagement with healthcare providers, and adherence to personalized treatment plans.