Ulcerative colitis

Ulcerative colitis (Chronic Ulcerative Colitis/CUC) is an inflammatory disorder of the lining of the rectum and colon.  It is not due to any known infection, and no one knows what causes it.  The future discoverer of the cause will surely win the Nobel Prize for medicine.  It is probably a very similar disease to idiopathic ulcerative proctitis, discussed elsewhere on this site, but, unlike proctitis, the inflammation is more extensive and involves the colon as well as the rectum.  Hence the name ‘colitis’.  Except in very unusual cases, the rectum (the lowest foot of the bowel) is always involved in ulcerative colitis, but the extent of inflammation spreading upward from the rectum varies in ulcerative colitis from case to case.  Some may have involvement of just a small portion of the colon above the rectum.  Others will have involvement of the rectum plus half of the colon (left-sided ulcerative colitis), or the rectum plus all of the colon (universal ulcerative colitis).

CUC presents with frequent, often bloody, urgent diarrhea (may be up to 20 – 30 times per day), abdominal cramps, and weight loss.  There may also be fatigue, fever, joint aches and unusual skin rashes on the shins.  Getting up at night to have diarrhea is a classic symptom.  In serious cases there may even be life-threatening perforation of the colon.  The diagnosis will require some sort of scoping into the bowel to identify the inflammation.  The extent of inflammation can usually be inferred initially from how sick the patient is, so examining the entire colon initially may not be necessary or even safe (higher risk of perforation by the instrument).  In general, the sicker the patient, the more extensive the disease, and treatment is guided accordingly.  An infectious cause of the colitis needs to be ruled out early so that treatment will be correctly prescribed.  Some infections such as Pseudomembranous Colitis caused by the bacteria Clostridium difficile can mimic ulcerative colitis and can be lethal if not treated promptly by antibiotics.  Crohn’s Disease is another inflammatory bowel disease that may mimic ulcerative colitis.  Unlike in Ulcerative Colitis, Crohn’s Disease may affect any part of the gastrointestinal tract, from lips to anus.  The small intestine is its most common location, but when it involves only the colon, differentiating it from CUC can be difficult, at least initially.

In mild to moderate cases of ulcerative colitis, treatment is by administration of the intestinal anti-inflammatory called 5-ASA.  More severe cases may require stronger and more sophisticated medications such as steroids or monoclonal antibody-based treatments.  In fulminant (very severe) cases in which medications cannot establish control, the colon may need to be removed in emergency surgery in order to save the patient’s life.  Sometimes if the disease is not severe enough to require emergency surgery but cannot be controlled by medications, non-emergency surgery is planned to remove the colon.  This essentially cures the disease and lets the patient finally get off medications.  Often, the patient can subsequently be ‘reconnected’ by a sophisticated operation called the ‘pelvic pouch procedure’ in which the small intestine is used to recreate a new internal reservoir to permit the restoration of bowel movements through the anus.

In patients with mild, long-standing universal colitis, who have managed to retain their colons for over 10 years since the disease onset,  there is a higher risk of colon cancer than in the general public.  In these individuals, yearly (beginning at ten years) colonoscopy and multiple biopsies are performed in order to keep track of the colon lining so as to identify any tendency to change into a cancer.  This tendency can be identified under the microscope by a pathologist and is called ‘dysplasia’.  In patients with less than universal colitis, the risk of cancer developing is lower so that in left-sided colitis patients there is not thought to be an increased risk of cancer over the long term.

© Pezim Clinic, Vancouver, British Columbia, Canada