Ulcerative colitis

What is ulcerative colitis?

Ulcerative colitis is an inflammatory disease of the lining layer (mucosa) of the large bowel or colon. This layer becomes inflamed and develops many tiny breaks in its surface (ulcers) which may bleed. The inflamed lining also produces an excess amount of normal intestinal lubricant (mucus) which may contain some pus. Ulcerative colitis is a chronic condition — that is to say it has a tendency to flare-up from time to time over many years.

What is the colon?

The colon (otherwise known as the large bowel) is that part of the bowel between the small intestine (where your digested food is absorbed into your system), and the anus or back passage, from which faeces (stools, motions, wastes) are discharged. The part of the colon immediately above the anus is the rectum. Ulcerative colitis always involves the rectum, but involvement of the rest of the colon varies from patient to patient.

What does the colon do, and how does ulcerative colitis alter its functions?

The colon does two things. Firstly, it extracts fluid from the liquid waste which enters it from the small intestine, concentrating this waste down to make solid faeces. In more severe ulcerative colitis, this concentrating function becomes defective and the patient has liquid diarrhoea in addition to the discharge of blood and mucus. Secondly, the colon acts as a reservoir for solid faeces, allowing about 1-3 bowel motions daily. In active or longstanding ulcerative colitis, this reservoir capacity is decreased, leading to more frequent bowel motions even in the absence of diarrhoea.

What causes ulcerative colitis?

We do not know exactly what causes ulcerative colitis, but there are clearly some genetic factors that make some people more likely to develop ulcerative colitis as well as other environmental factors that might cause the initial inflammatory insult to occur. As such, our treatment for ulcerative colitis is based on controlling the inflammation rather than curing it. The disease probably represents an abnormal and prolonged response of the body to various forms of damage, infections and other similar injuries to the bowel wall that would normally be of trivial importance.

Is ulcerative colitis infectious?

No, it is not infectious, though various acute infectious diarrhoeas (usually acquired from contaminated food or water) can closely mimic the beginning of chronic ulcerative colitis. For this reason you may well have had samples of faeces sent to the laboratory at the onset of your illness in order to determine whether you have infectious diarrhoea, or ulcerative colitis.

Does stress or worry cause ulcerative colitis?

No, almost certainly not. However, flare-ups of ulcerative colitis can often occur at times of personal stress, though often the condition flares up for no obvious reason. Even simple colds and the flu may spark off attacks.

Can I pass ulcerative colitis on to my children?

Ulcerative colitis is not strictly hereditary, for its transmission from one generation of a family to the next cannot be accurately predicted. However, it can occur in more than one member of the same family (for example, father and son, two sisters). Ulcerative colitis is known to have a genetic predisposition so, given that you do pass on half of your genes (DNA) to your biological children, they would have a slightly increased chance of developing ulcerative colitis compared to the general population. It is very important to remember, however, that you do not give the disease to your children. Although they may inherit genes that might predispose them to developing ulcerative colitis, the likelihood of your children inheriting or developing ulcerative colitis is small.

Is ulcerative colitis to do with something in my diet?

No, special diets have little part to play in the treatment of ulcerative colitis, and we know of nothing definite in the diet which might cause or worsen the condition, though it is logical to go on looking. However,

  • Occasionally, ulcerative colitis patients who are not responding satisfactorily to treatment improve greatly on cutting one type of food, such as milk products, out of their diets. However, this is a very variable, and individual response.
  • A high fibre (bran) diet helps the constipation which often accompanies cases of ulcerative colitis limited to the rectum and lower colon.

Is ulcerative colitis a form of cancer?

Absolutely not. Cancer is an uncontrolled excess growth of one part of tissue — colonic inflammation of ulcerative colitis is quite a different process which is benign (non-cancerous).

Can ulcerative colitis go on to become bowel cancer?

Occasionally, patients whose entire colon is diseased and who have had ulcerative colitis for many years may develop cancers in the colon lining. This group of patients will be followed and examined closely and carefully by their specialist, because the lining of their bowel can develop ‘precancerous’ changes, often years before the appearance of an actual cancer growth. By looking for these changes, the doctor can decide which patients are at risk and advise surgery to remove the colon before any actual cancer develops.

How is ulcerative colitis diagnosed?

Ulcerative colitis is suspected on the basis of a history of bleeding from the colon, with or without diarrhoea, mucus, and discomfort or pain. Once infection has been ruled out, the diagnosis is confirmed by the typical abnormal appearances of the rectal mucosa as seen by direct inspection with a special instrument (sigmoidoscope), which is rather like a telescope. At the same time a tiny portion of mucosa (biopsy) is often taken to be looked at in the labo-ratory. The mucosa of patients with ulcerative colitis has a particular appearance when examined under the microscope. Sigmoidoscopy or colonoscopy (examination of the whole of the large bowel) may need to be repeated at future dates to assess whether the ulcerative colitis is active or quiescent (inactive), and to gauge response to treatment. Initially it may be an embarrassing and uncomfortable test, but with continuing experience and a more relaxed attitude most patients learn to accept it as a minor inconvenience.

Does localised ulcerative colitis spread further up the colon over the years?

Usually the amount of colon involved remains more or less the same from one attack to the next. Sometimes, however, in a minority of people it can spread with successive attacks.

Will my ulcerative colitis ever go away completely?

The symptoms and signs of ulcerative colitis can certainly disappear for many years and even for a lifetime without any treatment. Unfortunately the more usual course is one of periodic flare up of symptoms.

Is ulcerative colitis treatable?

Yes, very much so, but it is not curable. A course of treatment will not stop it from ever coming back again — very few chronic medical conditions are curable. In this sense the only “cure” is to remove the diseased colon by surgery.

Treatment with tablets and self administered liquid or foam enemas is aimed at settling down flare-ups of the disease, though many flare-ups would probably settle eventually on their own but usually more slowly. Long term treatment with medicines such as Pentasa®, AsacolTM, Asamax®, or Salazopyrin® is aimed at reducing the likelihood of a flare-up.

What medical (drug) treatments are there available for ulcerative colitis?

Treatments for ulcerative colitis can usually be divided into medications that are used to treat active inflammation, and medications that are used to maintain control and lessen the likelihood of future flare-ups.

Why do some people with ulcerative colitis have operations?

All or most of the colon may be removed at an operation for various reasons:

  • If a very severe attack of ulcerative colitis is not getting better in spite of intensive medical treatment.
  • If repeated attacks over the years are harming the patient’s well-being and not responding quickly to medical treatment, particularly in patients with involvement of most or the entire colon.
  • If the patient has repeated attacks of inflammation in other systems, such as the eyes, skin or joints, accompanying their attacks of ulcerative colitis.
  • If there are any pre-cancerous changes in the colon.

What operations are available to treat ulcerative colitis?

The two alternatives are:

  • Total proctocolectomy and ileostomy
  • Proctocolectomy and ileoanal anastomosis (“pouch” operation)

Is ulcerative colitis a dangerous illness?

Ulcerative colitis is most dangerous if the attack is very severe, particularly if this attack fails to come under control with medical treatment and requires emergency surgery. In the long term, relapsing disease is a threat to good health rather than to life. In people with rectal disease (proctitis) only, good health is generally maintained and the only problems are an urgent need to open the bowels, and rectal bleeding.

If I have a mild ulcerative colitis does it need treating?

Many patients accept rectal bleeding or diarrhoea without seeking medical advice for surprisingly long periods. However, regular bleeding can lead to iron deficiency and anaemia. Also it is possible that continued colonic inflammation can lead to scarring and narrowing of the lower colon and rectum with the likely consequence of irreversible frequency and urgency of bowel action.

Will ulcerative colitis affect my relationship?

Though ulcerative colitis may start at any age from newborn to well over 80, it most commonly appears for the first time in the 20-40 age group, when one hopes for good health in order to cope with a career, relationships and bringing up a family. As with any other chronically recurring disorder, sympathy and understanding from the patient’s partner and family will help greatly to lessen the strains imposed by that feeling of “not being quite up to it”. The intimate details of one’s bowel functions are not something easily discussed, even with a partner.

Ulcerative colitis, pregnancy and contraception

Pregnancy in ulcerative colitis should be a planned event and discussed with your specialist first.

Regarding contraception, the pill will not worsen your ulcerative colitis and ulcerative colitis should not affect the efficacy of the pill.

Do I need to make adjustments in my lifestyle in order to bring about improvements in the disease?

There are no specific things that can improve the disease course, but simple and common sense advice is to keep active and fit, eat a well balanced diet, and avoid drinking excess alcohol. Some who smoke can find that stopping cigarettes can make the ulcerative colitis flare up but this is not a recommended reason for people to take up smoking! Except for severe flare-ups of ulcerative colitis, you will probably not require bed-rest in hospital or at home or absence from work. However, people with ulcerative colitis will naturally make adjustments in their patterns of work, domestic and social activities in order to help cope with the frequency and urgency of bowel actions which can accompany active phases of the disease. Prolonged travel and visits to supermarkets, for example, may be viewed as distressing prospects. Here again, the sympathy and understanding of your family will lessen the stress of desperate searches for a ‘toilets’ sign.

Is any research done on ulcerative colitis?

A considerable amount of research is being done on ulcerative colitis and a related bowel disorder called Crohn’s disease. It doesn’t usually make headline news in the media because diarrhoea and rectal bleeding lack the emotional appeal of heart disease, stroke, or cancer.

Research both in the laboratory and in the clinics is directed towards trying to find the cause or causes of the disease, in order to plan more effective treatment.