Ulcerative Colitis

Ulcerative colitis is a chronic, recurring disease of the large bowel. The large bowel (colon) is the 5 to 6 foot segment of intestine that begins in the right, lower abdomen, extends upward and then across to the left side, and downward to the rectum. It dehydrates the liquid stool that enters it and stores the formed stool until a bowel movement occurs.

When ulcerative colitis affects the colon, inflammation and ulcers, or sores, form in the lining of the colon. The disease may involve the entire colon (pancolitis), only the rectum (ulcerative proctitis) or, more commonly, some area between the two.

Causes

The cause of ulcerative colitis is unknown. Some experts believe there may be a defect in the immune system in which the body's antibodies actually injure the colon. Others speculate that an unidentified microorganism or germ is responsible for the disease. It is probable that a combination of factors, including heredity, may be involved in the cause.

Who Develops Ulcerative Colitis?

The disorder can occur in both sexes, all races and all age groups. It is a disease that usually begins in young people.

Symptoms

The disorder typically begins gradually, with crampy abdominal pain and diarrhea that is sometimes bloody. In more severe cases, diarrhea is very severe and frequent. Loss of appetite and weight loss occur. The patient may become weak and very sick. When the disease is localized to the rectum, the symptoms are rectal urgency and passage of small amounts of bloody stool. Usually the symptoms tend to come and go, and there may be long periods without any symptoms at all. Usually, however, they recur.

Diagnosis

Diagnosis of ulcerative colitis can be suspected from the symptoms. Certain blood and stool tests are performed to rule out an infection that can mimic the disorder. A visual examination of the lining of the rectum and lower colon (sigmoidoscopy) or the entire colon (colonoscopy) is always required. This exam typically reveals a characteristic pattern. Small, painless biopsies are taken which show certain features of ulcerative colitis. A barium enema x-ray of the colon is also needed at some point during the course of the disease.

Complications

Most patients with this disease respond well to treatment and go about their lives with few interruptions. However, some attacks may be quite severe, requiring a period of bowel rest, hospitalization and intravenous treatment. In rare cases, emergency surgery is required. The disease can affect nutrition causing poor growth during childhood and adolescence. Liver, skin, eye or joint (arthritis) problems occasionally occur, even before the bowel symptoms develop. Other problems can include narrowing and partial blocking of the bile ducts which carry bile from the liver to the intestine. Fortunately, there is much that can be done about all of these complications.

In long-standing ulcerative colitis, the major concern is colon cancer. The risk of developing colon cancer increases significantly when the disorder begins in childhood, has been present for 8 to 10 years, or when there is a family history of colon cancer. In these situations, it is particularly important to perform regular and thorough surveillance of the colon, even when there are no symptoms. Analysis of colon biopsies performed during colonoscopy can often predict if colon cancer will occur. In these cases, preventive surgery is recommended.

Treatment

• There are several types of medical treatments available:
• Cortisone, Steroids, Prednisone-These powerful drugs usually provide highly effective results. A high dose is often used initially to bring the disorder under control. Then the drug is tapered to low, maintenance doses, even to a dose every other day.
• These medications are given by pill, enema or intravenously during an acute attack. In time, the physician will usually try to discontinue these drugs because of potential long-term, adverse side effects.
• Other Anti-inflammatory Drugs-There are increasing numbers of these drugs available. They can be given by pill or enema. The generic and trade names of some of these drugs are sulfasalazine (Azulfidine), olsalazine (Dipentum), and mesalamine (Asacol, Pentasa and Rowasa).
• Immune System Suppressors-An overactive immune system is probably important in causing ulcerative colitis. Certain drugs such as azathioprine (Imuran), 6-MP (Purinethol), cyclosporine (Neoral, Sandimmune), and methotrexate (Rheumatrex) suppress the immune system and at times are effective.

Diet and Emotions

There are no foods known to injure the bowel. However, during an acute phase of the disease, bulky foods, milk, and milk products can increase diarrhea and cramping. Generally, the patient is advised to eat a healthy, well-balanced diet with adequate protein and calories. A multiple vitamin is often recommended. Iron may be prescribed if anemia is present.

Stress and anxiety may aggravate symptoms of the disorder, but are not believed to cause it or make it worse. Any chronic disease can produce a serious emotional reaction in the patient. This can usually be handled through discussion with the physician. There are excellent support groups available in most communities. The Ileitis and Colitis Foundation is one of them.

Surgery

For patients with longstanding disease that is difficult or impossible to control with medicine, surgery is a welcomed option. In these rare cases, the patient's lifestyle and general health have been significantly affected. Surgical removal of the colon cures the disease and returns good health and a normal lifestyle to the patient. In the past a bag, or ileostomy, was required for this surgery. Advances in surgery now can avoid this problem. The colon is removed and a pouch or reservoir is created from the small intestine. Three to six liquid bowel movements occur daily. Most patients are extremely pleased with this new surgery.

Summary

Most people with ulcerative colitis lead normal, active lives with few restrictions. Although there is no cure (except by surgery), the disorder can be managed with present treatment. For a few patients, the course of the disease may be more difficult and complicated, requiring more testing and intensive therapy. Surgery is sometimes required. In all cases, follow-up care with the physician is essential to monitor the disease and prevent and treat any complications that arise.

 Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD) is a term that refers to both ulcerative colitis and Crohn's disease. Ulcerative colitis causes inflammation of the lining of the large intestine. Crohn's disease causes inflammation of the lining and wall of the large and/or small intestine. When inflamed, the lining of the intestinal wall is red and swollen, becomes ulcerated, and bleeds.

What Causes IBD?

The causes of IBD are not known, but there are several theories. One theory is based on genetics indicating that IBD does run in families. About 15 percent to 30 percent of patients with IBD have a relative with the disease. There is research going on to find out if a specific gene or a group of genes makes a person more susceptible to getting the disease.

Many changes in the body's immune system (body's natural defense system against disease) have been discovered in patients with IBD. What is still unknown is what causes those changes to happen. There is a large amount of research being done in this area.

There is little evidence that stress causes IBD. As with other illnesses, stress may aggravate symptoms and require a treatment program.

IBD occurs most frequently in people in their late teens and twenties. There have been cases in children as young as two years old and in older adults in their seventies and eighties. Men and women have an equal chance of getting the disease.

Ulcerative Colitis

Most often ulcerative colitis occurs in young people 15 to 40 years of age. Ulcerative colitis occurs only in the inner lining of the colon (large intestine) or rectum. When it is located only in the rectum, it is called proctitis. Inflammation of the rectum and colon keeps water from being absorbed into the bloodstream and results in diarrhea.

Symptoms of Ulcerative Colitis

The most common symptoms of ulcerative colitis are diarrhea, abdominal cramps, and rectal bleeding. Some people may be very tired and have weight loss, loss of appetite, abdominal pain, and loss of body fluids and nutrients. Bleeding may be serious, leading to anemia (low red blood cell count). Joint pain, redness and swelling of the eyes, and liver problems can also occur. No one knows for sure why problems outside the colon are linked with colitis. These problems may improve when the colitis is managed.

Ulcerative colitis is an illness that has periods of remission (time when you feel well) and relapse (time when you feel ill). Half of the people who have ulcerative colitis have only mild symptoms. Others have frequent fever, bloody diarrhea, nausea, and severe abdominal cramps.

Some people with severe symptoms of ulcerative colitis must go to the hospital to correct malnutrition and stop diarrhea and loss of blood. In the hospital, a patient may need a treatment program including a special diet and feeding through a vein. Sometimes surgery is needed.

How Do I Know if I Have Ulcerative Colitis?

To find out if you have ulcerative colitis, your doctor must take your medical history and perform a physical examination. The exam may include blood tests and samples of a bowel movement. Other tests include:

Flexible Sigmoidoscopy or Colonoscopy - A small flexible tube inserted by your doctor into the anus. The flexible tube is slowly passed into the lower third of the colon in flexible sigmoidoscopy and through the entire colon in a colonoscopy, allowing your doctor to see the lining of the colon. If necessary, the doctor can take tissue sample called a biopsy to make a diagnosis of your condition.

Does Ulcerative Colitis Increase the Risk of Colon Cancer?

Risk of colon cancer is higher in ulcerative colitis patients with involvement of the entire colon and in patients who have had the diagnosis for eight to ten years. Patients with a diagnosis of left-sided ulcerative colitis for 15-20 years also fall into a higher risk group for developing cancer. Individuals in these groups should consult their doctor and plan for periodic colonoscopy with biopsy.

Crohn's Disease

Crohn's is a chronic disease that has periods of remission (time when person feels well) and relapse (when a person feels ill).

Crohn's disease is an inflammation and ulceration process that occurs in the deep layers of the intestinal wall. The most common areas affected are the lower part of the small intestine, called the ileum, and the first part of the colon. This type of Crohn's disease is called ileocolitis.

Crohn's disease can infrequently affect any part of the upper gastrointestinal tract. Aphthous ulcers, which are similar to cold sores, are common. Ulcers can also occur in the esophagus, stomach, and upper small intestine (duodenum). It is difficult to tell these ulcers from peptic ulcers except by biopsy exam.

Symptoms of Crohn's Disease

The most common symptoms of Crohn's disease are pain in the abdomen, often in the lower right side, diarrhea, and weight loss. There may also be rectal bleeding and fever: Chronic bleeding may lead to a low red blood cell count called anemia. Children who develop Crohn's disease may have delayed development and stunted growth.

How Do I Know if I Have Crohn's Disease?

To find out if you have Crohn's disease, your doctor must take your medical history and do a physical exam. The exam may include blood tests and samples of a bowel movement. Other tests are the same as described in the section on Ulcerative Colitis; a barium enema and a colonoscopy examination. In addition, a small bowel -ray may be required.

Complications Associated with Crohn's Disease

The most common complication of Crohn's disease is blockage of the intestine. Blockage or stricture occurs when the disease thickens the bowel wall with swelling and scar tissue. The intestine passage becomes smaller and smaller, until it is completely closed.

Fistulas are a common complication of this disease. Fistulas occur when ulcers in the intestine break through the intestine wall making tunnels into surrounding tissues of the bladder, vagina, or into the skin. Fistulas occur frequently around the anus and rectum.

These fistulas can become infected and may result in abscess formation. Treatment programs are used to manage infected fistulas, but often surgery is needed.

What is the Treatment for IBD?

Your doctor will discuss with you a treatment plan that may include any of the following:

• Nutrition
• Emotional Support
• Surgery
• Drug Therapy

There are many different types of treatment plans that your doctor can prescribe to control the symptoms of IBD, and each of these has specific actions and side effects. Be sure to follow all of your doctor's directions. Never stop your treatment plan until you have completed it or your doctor instructs you to stop.

Should I Modify or Change My Diet?

What you eat does not cause IBD, but can cause symptoms when the disease is active. The goal of nutritional management for people with IBD is to modify the diet to decrease gastrointestinal (GI) symptoms while maintaining adequate nutrient intake. Your doctor may do a nutritional assessment to determine if you are taking in enough calories, vitamins, and minerals. When nutritional needs are not being met, your doctor may suggest a liquid supplement.

How Do I Cope with IBD?

Although IBD is a chronic disease that has periods of remission and relapse, most people have a normal life span and a good quality of life. For those who have chronic and continuing symptoms, the following apply:

• Know your body and how IBD affects you
• Learn to care for yourself - have control over those things you can control
• Develop a support system that works for you: family, friends, and support groups
• Be sure to follow instructions from your medical team

When is Surgery Needed?

Most people who have IBD respond to their treatment program, including medications and nutritional planning. Many patients have mild episodes of illness after long periods of feeling well. Your doctor will consider surgery usually when certain conditions are present. Surgery may be needed if there is:

• A large amount of bleeding
• Long-lasting and serious illness
• Ulceration that makes a hole in the intestinal wall
• Medical treatment plan is not controlling the disease
• Obstruction

There are several surgical choices. Each has advantages and disadvantages. The surgeon and patient must decide on the best option. Staying informed is an important aspect of dealing with IBD.

Irritable Bowel Syndrome

Medically, irritable bowel syndrome (IBS) is known by a variety of other terms: spastic colon, spastic colitis, mucous colitis and nervous or functional bowel. Usually, it is a disorder of the large intestine (colon), although other parts of the intestinal tract even up to the stomach-can be affected.

The colon, the last five feet of the intestine, serves two functions in the body. First, it dehydrates and stores the stool so that, normally, a well-formed soft stool occurs. Second, it quietly propels the stool from the right side over to the rectum, storing it there until it can be evacuated. This movement occurs by rhythmic contractions of the colon.

When IBS occurs, the colon does not contract normally. Instead, it seems to contract in a disorganized, at times violent, manner. The contractions may be terribly exaggerated and sustained, lasting for prolonged periods of time. One area of the colon may contract with no regard to another. At other times, there may be little bowel activity at all. These abnormal contractions result in changing bowel patterns with constipation being most common.

A second major feature of IBS is abdominal discomfort or pain. This may move around the abdomen rather than remain localized in one area.

These disorganized, exaggerated and painful contractions lead to certain problems. The pattern of bowel movements is often altered. Diarrhea may occur, especially after meals, as the entire colon contracts and moves liquid stool quickly into the rectum. Localized areas of the colon may remain contracted for a prolonged time. When this occurs, which often happens in the section of colon just above the rectum, the stool may be retained for a prolonged period and be squeezed into small pellets. Excessive water is removed from the stool and it becomes hard.

Also, air may accumulate behind these localized contractions, causing the bowel to swell. So bloating and abdominal distress may occur.

Some patients see gobs of mucous in the stool and become concerned. Mucous is a normal secretion of the bowel, although most of the time it cannot be seen. IBS patients sometimes produce large amounts of mucous, but this is not a serious problem.

The cause of most IBS symptoms-diarrhea, constipation, bloating, and abdominal pain-are due to this abnormal physiology.

Although the symptoms of IBS may be severe, the disorder itself is not a serious one. There is no actual disease present in the colon. In fact, an operation performed on the abdomen would reveal a perfectly normal appearing bowel.

Rather, it is a problem of abnormal function. The condition usually begins in young people, usually below 40 and often in the teens. The symptoms may wax and wane, being particularly severe at some times and absent at others. Over the years, the symptoms tend to become less intense.

IBS is extremely common and is present in perhaps half the patients that see a specialist in gastroenterology. It tends to run in families. The disorder does not lead to cancer. Prolonged contractions of the colon, however, may lead to diverticulosis, a disorder in which balloon-like pockets push out from the bowel wall because of excessive, prolonged contractions.

Causes

While our knowledge is still incomplete about the function and malfunction of the large bowel, some facts are well-known. Certain foods, such as coffee, alcohol, spices, raw fruits, vegetables, and even milk, can cause the colon to malfunction. In these instances avoidance of these substances is the simplest treatment.

Infections, illnesses and even changes in the weather somehow can be associated with a flare-up in symptoms. So can the premenstrual cycle in the female.

By far, the most common factor associated with the symptoms of IBS are the interactions between the brain and the gut. The bowel has a rich supply of nerves that are in communication with the brain. Virtually everyone has had, at one time or another, some alteration in bowel function when under intense stress, such as before an important athletic event, school examination, or a family conflict.

People with IBS seem to have an overly sensitive bowel, and perhaps a super abundance of nerve impulses flowing to the gut, so that the ordinary stresses and strains of living somehow result in colon malfunction.

These exaggerated contractions can be demonstrated experimentally by placing pressure sensing devices in the colon. Even at rest, with no obvious stress, the pressures tend to be higher than normal. With the routine interactions of daily living, these pressures tend to rise dramatically. When an emotionally charged situation is discussed, they can reach extreme levels not attained in people without IBS. These symptoms are due to real physiologic changes in the gut-a gut that tends to be inherently overly sensitive, and one that overreacts to the stresses and strains of ordinary living.

Diagnosis

The diagnosis of IBS often can be suspected just by a review of the patient's medical history. In the end it is a diagnosis of exclusion; that is, other conditions of the bowel need to be ruled out before a firm diagnosis of IBS can be made.

A number of diseases of the gut, such as inflammation, cancer, and infection, can mimic some or all of the IBS symptoms. Certain medical tests are helpful in making this diagnosis, including blood, urine and stool exams, x-rays of the intestinal tract and a lighted tube exam of the lower intestine. This exam is called endoscopy, sigmoidoscopy or colonoscopy.

Additional tests often are required depending on the specific circumstances in each case, If the proper medical history is obtained and if other diseases are ruled out, a firm diagnosis of IBS then can usually be made.

Treatment

The treatment of IBS is directed to both the gut and the psyche. The diet requires review, with those foods that aggravate symptoms being avoided.

Current medical thinking about diet has changed a great deal in recent years. There is good evidence to suggest that, where tolerated, a high roughage and bran diet is helpful. This diet can result in larger, softer stools which seem to reduce the pressures generated in the colon.

Large amounts of beneficial fiber can be obtained by taking over-the-counter bulking agents such as psyllium mucilloid (Metamucil, Konsyl) or methylcellulose (Citrucel).

As many people have already discovered, the simple act of eating may, at times, activate the colon. This action is a normal reflex, although in IBS patients it tends to be exaggerated. It is sometimes helpful to eat smaller, more frequent meals to block this reflex.

There are certain medications that help the colon by relaxing the muscles in the wall of the colon, thereby reducing the bowel pressure. These drugs are called antispasmodics. Since stress and anxiety may play a role in these symptoms, it can at times be helpful to use a mild sedative, often in combination with an antispasmodic.

Physical exercise, too, is helpful. During exercise, the bowel typically quiets down. If exercise is used regularly and if physical fitness or conditioning develops, the bowel may tend to relax even during non-exercise periods. The invigorating effects of conditioning, of course, extend far beyond the intestine and can be recommended for general health maintenance.

As important as anything else in controlling IBS is learning stress reduction, or at least how to control the body's response to stress. It certainly is well-known that the brain can exert controlling effects over many organs in the body, including the intestine.

Summary

Patients with IBS can be assured that nothing serious is wrong with the bowel. Prevention and treatment may involve a simple change in certain daily habits, reduction of stressful situations, eating better and exercising regularly.

Perhaps the most important aspect of treatment is reassurance. For most patients, just knowing that there is nothing seriously wrong is the best treatment of all, especially if they can learn to deal with their symptoms on their own.