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Ulcerative Colitis

Ulcerative colitis is an inflammatory, commonly chronic disease that causes ulcerations of the mucosa in the colon. It usually begins in the rectum and sigmoid colon and may extend upward into the entire colon; it rarely affects the small intestine, except for the terminal ileum. Ulcerative colitis produces congestion, edema (leading to mucosal friability), and ulcerations. Severity ranges from a mild, localized disorder to a fulminant disease that can cause many complications.

Ulcerative colitis occurs primarily in young adults, especially women; it's also more prevalent among Jewish people and higher socioeconomic groups. The incidence of the disease is unknown, but some studies indicate that as many as 1 out of 1,000 persons are affected. Onset of symptoms seems to peak between ages 15 and 30 and again between ages 50 and 70.

Causes

The causes of ulcerative colitis and Crohn's disease are unknown. To date, there has been no convincing evidence that these two diseases are caused by infection.

People with ulcerative colitis have abnormalities of the immune system, but doctors do not know whether these abnormalities are a cause or a result of the disease. The body’s immune system is believed to react abnormally to the bacteria in the digestive tract.

Signs and Symptoms

Usually, the patient's history reveals periods of remission and exacerbation of symptoms. During an exacerbation, the patient generally reports mild cramping, lower abdominal pain, and recurrent bloody diarrhea as often as 10 to 25 times per day. She may also experience nocturnal diarrhea. During these periods, she may complain of fatigue, weakness, anorexia, weight loss, nausea, and vomiting.

On inspection, the patient's stools may appear liquid, with visible pus and mucus. Check for blood in the stools, a cardinal sign of ulcerative colitis.

Diagnostic tests

Sigmoidoscopy confirms rectal involvement in most cases by showing increased mucosal friability, decreased mucosal detail, and thick inflammatory exudate..

Colonoscopy may be used to determine the extent of the disease and to evaluate the areas of stricture and pseudopolyps. This test isn't performed when the patient has active signs and symptoms.

Biopsy, performed during colonoscopy, can help confirm the diagnosis.

Barium enema is used to evaluate the extent of me disease and to detect complications, such as strictures and carcinoma. This study isn't performed in a patient with active signs and symptoms.

Stool specimen analysis reveals blood, pus, and mucus, but no pathogenic organisms.

Other supportive laboratory tests show decreased serum levels of potassium, magnesium, hemoglobin, and albumin, as well as leukocytosis and increased prothrombin time. An elevated erythrocyte sedimentation rate correlates with the severity of the attack.

Treatment

The goals of treatment are to control inflammation, replace nutritional losses and blood volume, and prevent complications. Supportive treatment includes dietary therapy, bed rest, I.V. fluid replacement, and medications. Blood transfusions or iron supplements may be needed to correct anemia.

Dietary measures depend on the severity of the disease. Patients with severe disease usually receive total parenteral nutrition and are allowed nothing by mouth. Parenteral nutrition is also used for patients awaiting surgery or showing signs of dehydration and debilitation from excessive diarrhea. The goals of parenteral nutrition are to rest the intestinal tract, decrease stool volume, and restore positive nitrogen balance.

The patient with moderate signs and symptoms may receive Ensure or another brand of elemental feeding to provide adequate nutrition with minimal bowel stimulation. A low-residue diet may be ordered for the patient with mild signs and symptoms. As signs and symptoms subside, the diet may gradually advance to include a greater variety of foods.

Drug therapy to control inflammation includes corticotropin and adrenal corticosteroids, such as prednisone, prednisolone, and hydrocortisone; sulfasalazine, which has anti-inflammatory and antimicrobial properties; and mesalamine, given rectally or orally. Antispasmodics, such as belladonna tincture, and anti-diarrheals, such as diphenoxylate and atropine, are used only for the patient with frequent, troublesome diarrhea whose ulcerative colitis is otherwise under control. These drugs may precipitate massive dilation of the colon (toxic megacolon) and are generally contraindicated.

Surgery, the treatment of last resort, is performed if the patient has toxic megacolon, if she fails to respond to drugs and supportive measures, or if she finds signs and symptoms unbearable.

The most common surgical technique is proctocolectomy with ileostomy. Total colectomy and ileorectal anastomosis is done less often because of its mortality (2% to 5%). This procedure is done to remove the entire colon and anastomose the rectum and terminal ileum. It requires observation of the remaining rectal stump for any signs of cancer or colitis.

Pouch ileostomy, in which a pouch is created from a small loop of the terminal ileum and a nipple valve is formed from the distal ileum, is gaining popularity. The resulting stoma opens just above the pubic hairline; the pouch empties through a catheter inserted in the stoma several times a day. In ulcerative colitis, colectomy to prevent colon cancer is controversial.

Ileoanal reservoir is a surgery that preserves the anal sphincter and provides the patient with a reservoir made from the ileum and attached to the anal opening. The procedure is performed in two steps. First, the rectal mucosa is excised. An abdominal colectomy is performed; then a reservoir is constructed and attached. After that, a temporary loop ileostomy is created to allow the new rectal reservoir to heal. Finally, the loop ileostomy is closed after a 3- or 4-month waiting period. Stools from the reservoir are similar to stools from an ileostomy.



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