Ulcerative colitis

Overview

Ulcerative colitis is a type of inflammatory bowel disease (IBD) that causes inflammation and sores, called ulcers, in the colon. Ulcerative colitis (UL-sur-uh-tiv koe-LIE-tis) affects the innermost lining of the colon and rectum. The condition typically begins in the rectum and then may extend upward through part or all of the colon. The colon also is called the large intestine.

Ulcerative colitis symptoms usually develop over time, rather than starting suddenly. It is a chronic condition that sometimes can lead to life-threatening complications if not properly treated.

While there is no current cure with medicine, treatment can greatly reduce symptoms and heal the lining of the colon, which can lead to long-term remission.

Types

Healthcare professionals often classify ulcerative colitis according to its location. Types of ulcerative colitis include:

• Ulcerative proctitis. Inflammation is limited to the rectum. This is the area closest to the anus. Rectal bleeding or urgency may be the only sign of the disease. But constipation also can be a symptom.
• Left-sided colitis. In left-sided colitis, inflammation extends from the rectum up through the sigmoid colon and descending colon. Proctosigmoiditis is a type of left-sided colitis. Inflammation involves the rectum and sigmoid colon, which is the lower end of the colon. Symptoms of left-sided colitis include bloody diarrhea, belly cramps and pain, and not being able to pass stool despite the urge to do so, called tenesmus.
• Widespread colitis. This sometimes is called pancolitis. This type often affects the entire colon and causes bouts of bloody diarrhea that may be severe, belly cramps, and pain, fatigue and weight loss.

Crohn's disease and microscopic colitis are other conditions that cause inflammation in the digestive tract. Crohn's disease can affect any part of the gastrointestinal system, often including the small intestine, and it may involve deeper layers of the bowel wall. This differs from ulcerative colitis, which is limited to the colon and rectum.

Microscopic colitis, which includes lymphocytic and collagenous colitis, also can cause ongoing watery diarrhea, but it is different from ulcerative colitis. In microscopic colitis, the colon shows no signs of disease during colonoscopy, and inflammation is visible only under a microscope.

Causes

The cause of ulcerative colitis isn't known. In the past, diet and stress were thought to be causes. But today healthcare professionals understand that these factors may make symptoms worse rather than cause the disease. Stress, in particular, can affect the immune system and gut function. This may increase urgency to pass stool, diarrhea or belly pain during a flare.

Possible causes may include:

• Immune system issue. Something may go wrong with the immune system. When the immune system tries to fight off an invading virus or bacterium, an irregular immune response causes the immune system to attack the cells in the digestive tract too.
• Genetic traits. Several genetic markers have been associated with ulcerative colitis. Heredity also seems to play a role. The condition is more common in people who have family members with the disease. However, genetic testing is not helpful to diagnose or screen for the condition.
• Gut bacteria. The natural bacteria in the gut make up the gut microbiome. An imbalance in the gut microbiome may contribute to the immune response.
• Environmental factors. Where a person lives and other environmental influences such as diet and the use of antibiotics also may increase risk, though the exact role is still unclear.

Complications

Possible complications of ulcerative colitis include:

• Severe bleeding.
• Severe dehydration.
• Loss of red blood cells, known as anemia.
• Bone loss, called osteoporosis.
• Inflammation of the skin, joints and eyes.
• An increased risk of colon cancer.
• A rapidly swelling colon, called toxic megacolon.
• Increased risk of blood clots in veins and arteries.
• Delayed growth and development in children.

Treatment

Ulcerative colitis treatment involves medicines or surgery when medicines fail to control inflammation.

Several categories of medicines may be effective in treating ulcerative colitis. Medicines that work well for some people may not work for others, so it may take time to find a medicine that helps you. In addition, because some medicines have serious side effects, you need to weigh the benefits and risks of any treatment.

Treatment choices depend on how severe the disease is and where it occurs in the colon. In general, mild disease is often treated with aminosalicylates. Moderate disease may require corticosteroids, immunomodulators, biologic agents or small molecule medicines.

People with severe disease may need hospitalization for intravenous medicines, and they may need surgery if medicines do not work. The location of inflammation also matters. For example, rectal disease often responds well to topical treatments, while extensive colitis usually needs oral or intravenous medicines.

Medicines cannot cure ulcerative colitis, but they can control symptoms, reduce inflammation and help people stay in remission for long periods. The only true cure is surgery to remove the colon and rectum.

Anti-inflammatory medicines

Anti-inflammatory medicines often are the first step in the treatment of ulcerative colitis. They are used to calm inflammation in the colon and control symptoms. They include:

• Oral 5-aminosalicylates. These medicines are taken by mouth. Examples include sulfasalazine (Azulfidine), mesalamine (Apriso, Lialda, others) and balsalazide (Colazal). They often are taken long term to prevent flare-ups. Which one is recommended depends on the area of the colon that's affected. Some medicines also are available as an enema or suppository.
• Corticosteroids. These medicines, which include prednisone and budesonide, are generally reserved for moderate to severe ulcerative colitis that doesn't respond to other treatments. Corticosteroids are used to quickly control severe flares, but they are not safe for long-term use.

Immunomodulators

These medicines reduce inflammation by suppressing the immune system response that starts the process of inflammation. For some people, a combination of these medicines works better than one medicine alone.

Immunomodulators include:

• Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol, Purixan). These are the most widely used immunomodulators for the treatment of inflammatory bowel disease. Taking them requires that you follow up closely with your healthcare team and have your blood checked regularly to look for side effects, including effects on the liver and pancreas.

Biologic medicines

Also called biologics, this class of therapies targets proteins made by the immune system. Types of biologics used to treat ulcerative colitis include:

• Infliximab (Remicade), adalimumab (Humira) and golimumab (Simponi). These medicines, called tumor necrosis factor (TNF) inhibitors, work by neutralizing a protein produced by the immune system. They are for people with severe ulcerative colitis who don't respond to or can't tolerate other treatments.
• Vedolizumab (Entyvio). This medicine is approved for treatment of ulcerative colitis for people who don't respond to or can't tolerate other treatments. It works by blocking inflammatory cells from getting to the site of inflammation.
• Ustekinumab (Stelara). This medicine is approved for treatment of ulcerative colitis for people who don't respond to or can't tolerate other treatments. It works by blocking a protein that causes inflammation.
• Mirikizumab (Omvoh). Mirikizumab is a biologic medicine recently approved to treat ulcerative colitis.
• Risankizumab (Skyrizi). Risankizumab is another biologic medicine recently approved to treat ulcerative colitis.
• Guselkumab (Tremfya). This is the latest approved therapy in the same class as risankizumab and mirikizumab.

Small molecules

More recently, orally delivered agents also known as small molecules have become available for ulcerative colitis treatment. Types of small molecule medicines include:

• Tofacitinib (Xeljanz) and upadacitinib (Rinvoq). These medicines are known as Janus kinase (JAK) inhibitors. JAK inhibitors are small molecule medicines that help reduce inflammation by targeting parts of the immune system that cause inflammation in the intestines.
• Ozanimod (Zeposia) and etrasimod (Velsipity). These are another type of small molecule medicine available for ulcerative colitis. These are known as sphingosine 1-phosphate (S1P) receptor modulators.

Other medicines

You may need additional medicines to manage specific symptoms of ulcerative colitis. Always talk with your healthcare team before using medicines that you get without a prescription. One or more of the following medicines may be recommended:

• Antidiarrheal medicines. For severe diarrhea, loperamide (Imodium A-D) may be effective. Use antidiarrheal medicines with great caution and after talking with your healthcare team, because they may increase the risk of an enlarged colon, called toxic megacolon.
• Pain relievers. For mild pain, your care team may recommend acetaminophen (Tylenol, others). But not ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) and diclofenac sodium. They can worsen symptoms and increase the severity of disease.
• Antispasmodics. Sometimes care professionals prescribe antispasmodic therapies to help with cramps.
• Iron supplements. If you have ongoing intestinal bleeding, you may develop iron deficiency anemia and be given iron supplements.

Surgery

Surgery for ulcerative colitis usually is needed if medicines no longer control the disease or if they cause serious side effects. Surgery also may be recommended if ulcerative colitis leads to complications, such as bleeding, colon rupture or cancer. The operation is called a proctocolectomy. A proctocolectomy removes the entire colon and rectum. This surgery cures ulcerative colitis.

In most cases, proctocolectomy involves another procedure called ileoanal anastomosis (J-pouch) surgery. A J-pouch eliminates the need to wear a bag to collect stool. The surgeon constructs a pouch from the end of the small intestine. The pouch is then attached directly to the anus, allowing for a relatively typical way to expel waste.

In some cases, a pouch is not possible. Instead, surgeons create a permanent opening in the belly, called an ileal stoma, through which stool is passed for collection in an attached bag.

In another type of procedure known as a continent ileostomy, also called a Kock pouch, the surgeon creates an ileal stoma opening in the belly, then places a one-way valve in the opening. A continent ileostomy does not collect stool in a bag. Instead, a tube is placed into the valve when stool needs to be emptied. This allows for control over the timing of bowel elimination.

Cancer surveillance

You will likely need more-frequent screening for colon cancer because of your increased risk. The recommended schedule depends on the location of your disease and how long you have had it. People with proctitis are not at increased risk of colon cancer.

If your disease involves more than your rectum, you will require a colonoscopy every 1 to 2 years, beginning as soon as eight years after diagnosis. The frequency depends on how much inflammation there is and how much of the colon is involved.

Alternative medicine

Many people with digestive diseases have used some form of complementary and alternative medicine. However, there are few well-designed studies showing the safety and effectiveness of complementary and alternative medicine.