Colitis Overview

Colitis (also called ulcerative colitis) is an acute or chronic inflammation of the membrane lining the colonyour large intestine or bowel. Colitis causes inflammation and sores, called ulcers, in the top layers of the lining of the large intestine. Ulcerative colitis rarely affects the small intestine except for the lower section, called the ileum. The inflammation makes the colon empty frequently, causing diarrhea. Ulcers form in places where the inflammation has killed colon lining cells. The ulcers bleed and produce pus and mucus. You may have abdominal pain, diarrhea, rectal bleeding, painful spasms (tenesmus), lack of appetite, fever, and fatigue.

Ulcerative colitis is an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation in the intestines.
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Ulcerative colitis can be difficult to diagnose because its symptoms are similar to other intestinal disorders such as irritable bowel syndrome and to another type of IBD called Crohn disease (also called Crohns disease). Crohn disease differs from ulcerative colitis because it causes inflammation deeper within the intestinal wall. Crohn disease usually occurs in the small intestine, but it can also occur in the mouth, esophagus, stomach, duodenum, large intestine, appendix, and anus. Ulcerative colitis affects only the colon. Another confusing condition called irritable bowel syndrome is not like either ulcerative colitis or Crohn disease. Irritable bowel syndrome is a common disorder of the intestine that leads to cramps, excessive production of gas, bloating, and changes in bowel habits.

Up to 2 million people in the US are estimated to have either ulcerative colitis or Crohn disease. Ulcerative colitis is generally found in younger people, before they reach age 30. But the disease can occur in people in their 60s and later in life. It affects both men and women equally and tends to run in families. Jewish people tend to have more incidence of ulcerative colitis than non-Jewish people.

Colitis Causes
No theories about the causes of ulcerative colitis have been proven. But researchers think the bodys immune system reacts to a virus or bacteria by causing ongoing inflammation in the intestinal wall. Although this is considered to be a problem with your immune system, some doctors think the immune system reaction may be a result, not the cause, of the disease.

Ulcerative colitis is not caused by emotional distress or sensitivity to certain foods or food products, but these factors may trigger symptoms in some people.

Chronic inflammation, even though the cause is not known, produces the 2 major forms of inflammatory bowel disease: Crohn disease and ulcerative colitis. Certain features of these diseases have suggested several contributing factors:
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Family connection: Both conditions are more common if you have firstdegree relatives with the condition, such as a mother, father, sister, or brother.

Genetic: There is a high similarity of symptoms among identical twins, particularly with Crohn disease.

Infectious agents or environmental toxins: No single agent has been associated consistently with either form of inflammatory bowel disease. Viruses have been reported in tissue from people with inflammatory bowel disease, but there is no compelling evidence.

Immune system: Several changes in the immune system have been identified as contributing to inflammatory bowel disease. But none have been specific for either ulcerative colitis or Crohn disease.

Smoking: Smokers increase their risk of developing Crohn disease twofold. In contrast, smokers have only half the risk of developing ulcerative colitis.

Oral contraceptive pill: Birth control pills have been implicated as a possible cause of Crohn disease.

Psychological factors: There is little evidence relating possible emotional factors as a cause of inflammatory bowel disease. Psychological factors may modify the course of the disease, however, and your response to therapy.

Other causes of colitis may be placed in the following categories:

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Infectious colitis: A variety of bugs may cause colitis. They have developed a variety of ways to overcome our natural defenses and ultimately cause colitis. The germs include these: Bacteria: Commonly found in food or contaminated water, bacteria may produce toxins that trigger intestinal cells to secrete salt and water and interfere with their normal functions. Salmonella, Shigella species, Campylobacter jejuni, and Clostridium are examples of bacteria associated with infectious colitis.

Viruses: Viruses such as rotavirus or Norwalk can damage the mucous membrane lining your intestine and disturb fluid absorption.

Protozoa: People infected with these tiny organisms may show no symptoms (carrier state), or they may have chronic, mild, loose, bowel movements or acute severe dysentery. Colitis due to E histolytica, also known as amebiasis, has become an important sexually transmitted disease in homosexual men.

Radiation-associated colitis: Localized areas of colitis may occur at variable periods after treatment of the pelvic region with radiotherapy.

Ischemic colitis: This disease often affects the elderly. The mechanism of ischemiamassive decrease in the blood supply to the bowelis not known, but shunting of blood away from the intestinal lining may be an important contributing factor.

Antibiotic-associated colitis: Usually this condition occurs in people receiving antibiotics, but gastrointestinal surgery remains an important risk factor.

Colitis Symptoms

Depending on the cause of your colitis, you may have some of the more common symptoms:
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Frequent loose bowel movements with or without blood Urgency to have a bowel movement and bowel incontinence Lower abdominal discomfort or cramps Fever, lethargy, and loss of appetite Weight loss with continuing diarrhea

If you develop chronic inflammatory bowel disease, you may also have complications, possibly because your immune system triggers inflammation in other parts of your body, such as these:
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Eye problems or pain Joint problems Neck or lower back pain Skin rashes Liver and kidney problems

When to Seek Medical Care

Tell your health care provider about any persistent changes in your bowel habits. If you are already under treatment for inflammatory bowel disease or irritable bowel syndrome, contact your provider if you experience any prolonged changes or pass blood in your stools. Also seek medical care if you have any of these conditions associated with colitis:

Diarrhea lasting more than 3 days Severe abdominal or rectal pain Signs of dehydration such as dry mouth, anxiety or restlessness, excessive thirst, little or no urination Frequent loose bowel movements during pregnancy More than 1 other person who shared food with you who has symptoms like yours, for example abdominal pain, fever, and diarrhea Blood or mucus in your stool Progressively looser bowel movements and appearance of other symptoms such as fever and diarrhea Fever with diarrhea Pain moving from the area around your belly to your right lower abdomen

You should go to a hospitals emergency department for any of these reasons:

Abdominal pain with fever

Severe acute attacks if you are already diagnosed with inflammatory bowel disease Signs of dehydration in an old or very young person Progression or appearance of new symptoms over a few hours Blood in your stool along with fever and loose bowel movements

Exams and Tests

A thorough physical exam and a series of tests may be required to diagnose ulcerative colitis. Some diseases such as inflammatory bowel disease may mimic other conditions, and symptoms may vary widely. The correct diagnosis of colitis may take some time. Your health care provider will check for other causes of bloody diarrhea such as a bacterial or infectious disease or food poisoning. History: Your provider may ask you several questions to find out possible causes of your colitis. Your answers to these questions will help assess your condition and plan treatment.

How long have you had loose bowel movements? Have you ever had similar bouts in the past? How many times per day do you normally pass stool? How many times did you pass today? Compared to yesterday, do you have looser bowel movements? Any blood or mucus in your stool? Any history of urgency or incontinence? Do you sometimes have the desire to go to the toilet, but when you are there nothing comes out? Do you have any other symptoms? Any changes in your appetite? Any changes in your body weight? Do you have any pains in your stomach? Describe it. Could you indicate with your finger the site of your pain? Any relationship between your stomach pain and your loose bowel movements? Do you feel better after passing stools? Have you been around anyone with symptoms like this? Have you shared food with anyone who became ill like you? Have you traveled recently? Do you feel sick? Have you thrown up? Any hospital admission or investigations for similar illness? Are you pregnant? Are you using contraceptive pill? If yes, for how long? Do you smoke cigarettes? When did you start smoking? How many cigarettes do you smoke per day? Do you drink alcohol? Coffee? Tea?

Do you use drugs? Any medications? Have you ever had surgery? What surgery? When? Any joint pain, eye problems, back or neck pain, or skin rash? What is your sexual preference? Do you have a family history of inflammatory bowel disease?

Physical exam: Your health care provider will examine your abdomen and other body systems. The doctor may do a rectal examination to check for any anal changes, blood in your stool, or other problems. Laboratory tests: Your provider will decide which tests you need based on your symptoms, medical history, and clinical findings. Some of the most commonly used tests are these:

Stool samples to assess for any red blood or white blood cells, mucous cells, any ova, or parasites Blood tests, particularly if you have fever, abdominal pain, and diarrhea Full blood count and blood film (Anemia is common in inflammatory bowel disease that may be due to blood loss and iron deficiency. Anemia in people with Crohn disease may be caused by vitamin B12 deficiency.) Raised white cell count during activity of inflammatory bowel disease Raised erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) during active inflammatory bowel disease (These tests are normal in irritable bowel syndrome.) Electrolyte imbalance (decreased serum sodium and potassium) and rise of blood urea in severe diarrhea and excessive fluid loss Low serum albumen in severe inflammatory bowel disease due to protein loss from the inflamed intestine and impairment of liver function (This test is normal in irritable bowel syndrome.) Mild elevation of a panel of liver function tests (Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (AP), and or bilirubin may be present in inflammatory bowel disease. These tests are normal in irritable bowel syndrome.)

Imaging: Certain x-rays and other imaging tests will further pinpoint a diagnosis of colitis:

Upright x-ray of your chest and abdomen may show free air or dilation of the colon. A small bowel follow-through may demonstrate the involved segments in Crohn disease. Barium enema may reveal the extent of the ulcerative colitis. This procedure involves filling the colon with barium, a chalky white solution. The barium shows up white on x-ray film, allowing the doctor a clear view of the colon, including any ulcers or other abnormalities that might be there. In Crohn disease, a barium enema may help to distinguish it from ulcerative colitis.

Ultrasound and CT scanning are both useful to distinguish thickened inflamed bowel loops from abscesses in the abdominal cavity.

Procedures: Your health care provider may evaluate the condition of your colon with these procedures:

Sigmoidoscopy: A flexible, lighted instrument is placed into your rectum and lower colon to view the inflammation, bleeding, or ulcers on the wall of the colon. Colonoscopy: More likely, your doctor will use a flexible, lighted instrument that views not only the rectum but the entire length of your colon. This procedure helps by ruling out more serious disorders. During the test, the doctor usually takes tissue biopsies for further studies to assess the cause underlying your symptoms. This involves taking a small sample of the lining of the colon to view with a microscope in the laboratory.

Colitis Treatment
Treatment for ulcerative colitis depends on the seriousness of the disease. Most people are treated with medication. In severe cases, you may need surgery to remove the diseased colon. Surgery is the only cure for ulcerative colitis. Each person may experience ulcerative colitis differently, so treatment is adjusted for your needs. Emotional and psychological support is important. Remission periods occur. The symptoms go away for months or even years. But you don't know if or when they will return. That's why it's difficult to tell which treatments, if any, work. With ulcerative colitis, you may need regular medical visits to monitor your condition.

Self-Care at Home
For a mild case of diarrhea, you can manage your discomfort by doing the following:

Drink clear fluids such as water, lemonade, light lemon tea, and light soup. Drink at least 8-10 glasses of water and other liquids daily to prevent complications such as dehydration. As your symptoms improve or your stools become formed, start to eat low-fiber foods. Do not eat greasy or fatty foods for few days. For example, avoid milk, cream, or soft cheese.

Proper nutrition is important if you have colitis. Although specific foods do not cause the disease, some may trigger your discomfort, such as spicy or high-fiber foods, especially when the diarrhea phase is active. Keep a food diary to track the culprits. A wellbalanced diet is always a smart choice.

You may need psychotherapy, counseling, and education. This approach will help both you and your family to accept illness and learn to take greater responsibility in managing it.

Medical Treatment
Your health care provider will consider the possible causes of your colitis and any complications that need urgent treatment. The treatment goal for active ulcerative colitis is to relieve the inflammation and replace nutritional losses from diarrhea and loss of fluid. About 80% of people improve with this approach.

Drugs to control mild diarrhea, for example, diphenoxylate (Lofene, Lomotil), loperamide (Imodium, Kaopectate), codeine, and anticholinergics (Anaspaz, Cystospaz, Bentyl) may help to reduce the number of bowel movements and relieve the feeling that you have bowel urgency. However, you should avoid these drugs if you have inflammatory bowel disease along with acute severe diarrhea. Cholestyramine (Questran), an agent that binds bile salts, helps to manage diarrhea associated with Crohn disease, particularly in people who have had part of their small intestine removed. Bentyl may relieve intestinal spasms. Severe attacks of inflammatory bowel disease require hospital admission and supportive care including bowel rest, IV fluids, and correction of any electrolyte imbalance. You likely will be given a restricted diet.

Medications
If you have mild or moderate colitis, the first line of treatment might be with 5-ASA agentsa combination of the drugs sulfonamide, sulfapyridine, and salicylate that helps control inflammation. Sulfasalazine is the most commonly used of these drugs. Sulfasalazine can be used for as long as needed and can be given along with other drugs. If you do not do well on sulfasalazine, you may respond to newer 5-ASA agents. Possible side effects of 5-ASA preparations include nausea, vomiting, heartburn, diarrhea, and headache.

Drug therapy for active inflammatory bowel disease may include the following:
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Mesalazine-deriving drug (Asacol, Pentasa): These are usually used for colitis and ulcerative colitis.

Antibiotics, imidazole (Clotrimazole, Lotrimin), ciprofloxacin (Cipro, Ciloxan) for pelvic Crohn disease

Predigested liquid (elemental) or predigested (polymeric) diet for small bowel Crohn disease

If you have severe colitis or do not respond to mesalamine preparations, you may be treated with corticosteroids. Prednisone, methylprednisolone, and budesonide are used to reduce inflammation. They are taken during a flare-up but do not maintain you in remission. These pills can be taken by an IV, through an enema, or in a suppository, depending on the location of the inflammation.

Corticosteroids (some brand names are Cortone, Decasone, Predair) can cause side effects such as weight gain, acne, facial hair, high blood pressure, mood swings, and increased risk of infection.

A doctor will monitor you closely if you are given these drugs. The idea is to take them for flare-ups for a short period of time. They do not stop the condition from coming back.

If you respond only partially to these treatments or have early relapse, your provider may consider aggressive therapy. Aggressive therapy may include the following steps:

Hospital admission

IV steroids instead of oral steroids

Increasing steroid dose

Adding an immunosuppressive agent (azathioprine [Imuran], methotrexate [Folex, Rheumatrex], cyclosporine [Neoral, Sandimmune])

Use of antibiotics (imidazole or ciprofloxacin or both) for Crohn disease in your pelvis or colon

If these aggressive measures do not work, your doctor may consult with you and the treating team about other options, including surgery. If your colitis improves, your doctor will establish a maintenance therapy including the following:

Mesalazine-deriving drugs (for colitis and Crohn disease ileitis [inflammation of the small intestine] and after removal of the diseased portion)

Drugs to suppress your immune system (azathioprine, methotrexate, cyclosporine)

Antibiotics (for pelvic Crohn disease)

Biologic drugs, such as infliximab (Remicade) or etanercept (Enbrel) (These may be prescribed for moderate-to-severe Crohn disease or ulcerative colitis.)

The following new treatments are being tested to see whether they might be useful in treating this disease:

Nicotine delivered through a patch or enema helped some people improve. This is still experimental. Do not start smoking or use patches used to help stop smoking.

Heparin, an anticoagulant, may help by preventing blood clots. This research is still early.

Surgery
Most people with ulcerative colitis will never need to have surgery. If surgery becomes necessary, however, your colitis is cured. You can live a normal, active life. Sometimes the doctor will recommend removing the colon if medical treatment fails or if the side effects of corticosteroids or other drugs threaten your health. For the 25-40% of people who eventually may have their colons removed because of massive bleeding, severe illness, rupture of the colon, or risk of cancer, various surgical techniques are used. What is right for you may not be the type of surgery for someone else.

The most common surgery is a proctocolectomy with ileostomy, which is done in 2 stages. The surgeon removes the colon and rectum, then creates a small opening in the abdomen, called a stoma, and attaches the end of the small intestine, called the ileum, to it. Waste will travel through your small intestine and exit your body through the stoma. The stoma is about the size of a quarter and is usually located in the lower right part of the abdomen near the beltline. A pouch is worn over the opening to collect waste. You empty the pouch as needed.

An alternative is the continent ileostomy. In this operation, the surgeon uses the ileum to create a pouch inside your lower abdomen. Waste empties into this pouch, and you drain the pouch by inserting a tube into it through a small, leakproof opening in your side. You must wear an external pouch for only the first few months after the operation. Possible complications of the continent ileostomy include malfunction of the leakproof opening, which requires surgical repair, and inflammation of the pouch (pouchitis), which is treated with antibiotics. A procedure that is becoming increasingly common is the ileoanal anastomosis, or pull-through operation. It would allow you to have normal bowel movements because it preserves part of the rectum. The surgeon removes the diseased part of the colon and the inside of the rectum, leaving the outer muscles of the rectum. The surgeon then attaches the ileum to the inside of the rectum and the anus, creating a pouch. Waste is stored in the pouch and passed through the anus in the usual manner. Bowel movements may be more frequent and watery than usual. Pouchitis is a possible complication of this procedure.

Other Therapy
Lifestyle modification

If you have been on steroid medications for a long time, you may have some added risk because the medications lower bone mass. High-impact exercise such as aerobics or running may put too much stress on fragile bones causing stress fractures or outright breaks. Lower-impact exercises may be more appropriate, such as cycling or swimming. A bone density screening arranged through your doctor can look at your bone mass and assess if you are at risk. Strength training (resistance activity) with moderate weights or machines, even stretch bands, may help you build bone density. Traveling with ulcerative colitis can be a challenge if you feel you need to use the restroom frequently. Sometimes you simply "can't wait," so experts have some prudent suggestions: o Become aware of public restrooms where you are traveling and plan your day's activities so you have a comfort level (and another adult to watch the children) in being close to a facility. o Carry a card that says I CANT WAIT and explains that you have a medical condition in which you urgently need to use the bathroom. If you encounter a long line and are desperate, hand the card to the first person in line. o Look for familiar and usually clean roadside restrooms at fast-food places. o Airplane travel presents its own challenges. If youre not traveling first class, know that the restrooms up front are usually not as crowded as those in coach. Explain your concerns to the flight attendants when you board: I probably wont have to use the facilities up front, but in case I do, I have a medical condition, and I cant wait in line.

If trip anxiety makes you even more anxious about accidents, do wear an adult diaper. Women may opt for a maxipad or panty shield. Pack and bring an extra change of underwear and pants in your carryon and keep them with you in a day-pack while sightseeing.

Some foods may be unfamiliar and their effects uncertain. Know what foods you are eating. Buy familiar items at local grocery stores and carry them with you on tours if youre just not sure you want to tackle native cuisine or worry that it may trigger your condition.

Next Steps
You and your family must educate yourselves about colitis to better control it. Close contact and follow up with your health care provider help with early detection of complications such as a tear in your colon, narrowing of your colon, massive bleeding, or joint problems.

Follow-up
About 5% of people with ulcerative colitis develop colon cancer. The risk of cancer increases with the duration and the extent of involvement of the colon. For example, if only the lower colon and rectum are involved, the risk of cancer is not higher than normal. But if your entire colon is involved, your risk of cancer may be as great as 32 times the normal rate. Sometimes precancerous changes occur in the cells lining the colon. These changes are called dysplasia. If you have dysplasia, your risk for developing colon cancer is higher. Your doctor can look for signs of dysplasia when doing the procedure called a colonoscopy. This is the insertion of a lighted, flexible scope into your rectum and colon. Tissue samples can be taken and tested during the test. Talk with your doctor about how often you should have a colonoscopy. For those who have had IBD throughout their colon for at least 8 years and those who have had IBD in only the left colon for at least 15 years, expert groups recommend that you have a colonoscopy performed every 1-2 years. This form of early detection will not prevent dysplasia or cancer risk, but with it you can get life-saving treatment much sooner.

Prevention
You can prevent short-term colitis associated with infectious germs by using proper hygiene and sanitation measures, especially handling food.

Outlook
The type of surgery you may have depends on how serious your illness is, and on your needs, expectations, and lifestyle. If you are making a decision about surgery, talk with

your health care providers, to nurses who work with people who undergo this type of surgery, and with others who have had surgery for ulcerative colitis. Emotional stress, while not thought to be the cause of ulcerative colitis, can be a reaction to the distressful symptoms that come and go. Therefore, it is important for you and your family to receive understanding and emotional support. Support groups can help you and your family cope. Ulcerative colitis is not a fatal illness, but it may be a lifelong illness. Most people with ulcerative colitis continue to lead normal, useful, and productive lives, even though they may need to take medications every day and occasionally need to be hospitalized. Maintenance medication has been shown to decrease flare-ups of ulcerative colitis.