Ulcerative colitis is a disease that causes inflammation and sores, called ulcers, in the top layers of the lining of
the large intestine. The inflammation usually occurs in the rectum and lower part of the colon, but it may affect the entire
colon. Ulcerative colitis rarely affects the small intestine except for the lower section, called the ileum. Ulcerative colitis
may also be called colitis, ileitis, or proctitis.
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.
Ulcerative colitis is an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation in the
intestines. 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's disease. Crohn's disease differs from ulcerative
colitis because it causes inflammation deeper within the intestinal wall. Crohn's 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 occurs most often in people ages 15 to 40, although children and older people sometimes develop the
disease. Ulcerative colitis affects men and women equally and appears to run in some families.
Stomach acid can cause inflammation that may lead to bleeding at the lower end of the esophagus. This condition is called
esophagitis or inflammation of the esophagus. Sometimes a muscle between the esophagus and stomach fails to close properly
and allows the return of food and stomach juices into the esophagus, which can lead to esophagitis. In addition, enlarged
veins (varices) at the lower end of the esophagus may rupture and bleed massively. Cirrhosis of the liver is the most common
cause of esophageal varices. Esophageal bleeding can be caused by Mallory-Weiss syndrome, a tear in the lining of the esophagus.
Mallory-Weiss syndrome usually results from prolonged vomiting but may also be caused by increased pressure in the abdomen
from coughing, hiatal hernia, or childbirth. What Are the Common Causes of Bleeding in the Digestive Tract?
Esophagus
Inflammation (esophagitis)
Enlarged veins (varices)
Mallory-Weiss syndrome
Stomach
Ulcers
Inflammation (gastritis)
Small Intestine
Duodenal ulcer
Large Intestine and Rectum
Hemorrhoids
Inflammation (ulcerative colitis)
Colorectal polyps
Colorectal cancer
Diverticular disease
The stomach is a frequent site of bleeding. Alcohol, aspirin, aspirin-containing medicines, and various other medicines
(particularly those used for arthritis) can cause stomach ulcers or inflammation (gastritis). The stomach is often the site
of ulcer disease. Acute or chronic ulcers may enlarge and erode through a blood vessel, causing bleeding. Also, patients suffering
from burns, shock, head injuries, or cancer, or those who have undergone extensive surgery may develop stress ulcers. Bleeding
can occur from benign tumors or cancer of the stomach, although these disorders usually do not cause massive bleeding.
The most common source of bleeding from the upper digestive tract is ulcers in the duodenum (the upper small intestine).
Researchers now believe that these ulcers are caused by excess stomach acid and infection with Helicobacter pylori bacteria.
In the lower digestive tract, the large intestine and rectum are frequent sites of bleeding. Hemorrhoids are probably
the most common cause of visible blood in the digestive tract, especially blood that appears bright red. Hemorrhoids are enlarged
veins in the anal area that can rupture and produce bright red blood, which can show up in the toilet or on toilet paper.
If red blood is seen, however, it is essential to exclude other causes of bleeding since the anal area may also be the site
of cuts (fissures), inflammation, or tumors.
Benign growths or polyps of the colon are very common and are thought to be forerunners of cancer. These growths can
cause either bright red blood or occult bleeding. Colorectal cancer is the second most frequent of all cancers in the United
States and usually causes bleeding at some time.
Inflammation from various causes can produce extensive bleeding from the colon. Different intestinal infections can cause
inflammation and bloody diarrhea. Ulcerative colitis can produce inflammation and extensive surface bleeding from tiny ulcerations.
Crohn's disease of the large intestine can also produce spotty bleeding.
Diverticular disease caused by diverticula--outpouchings of the colon wall--can result in massive bleeding. Finally,
as one gets older, abnormalities may develop in the blood vessels of the large intestine, which may result in recurrent bleeding.
The signs of bleeding in the digestive tract depend upon the site and severity of bleeding. If blood is coming from the
rectum or the lower colon, bright red blood will coat or mix with the stool. The stool may be mixed with darker blood if the
bleeding is higher up in the colon or at the far end of the small intestine. When there is bleeding in the esophagus, stomach,
or duodenum, the stool is usually black or tarry. Vomited material may be bright red or have a coffee-grounds appearance when
one is bleeding from those sites. If bleeding is occult, the patient might not notice any changes in stool color.
If sudden massive bleeding occurs, a person may feel weak, dizzy, faint, short of breath, or have crampy abdominal pain
or diarrhea. Shock may occur, with a rapid pulse, drop in blood pressure, and difficulty in producing urine. The patient may
become very pale. If bleeding is slow and occurs over a long period of time, a gradual onset of fatigue, lethargy, shortness
of breath, and pallor from the anemia will result. Anemia is a condition in which the blood's iron-rich substance, hemoglobin,
is diminished.
The site of the bleeding must be located. A complete history and physical examination are essential. Symptoms such
as changes in bowel habits, stool color (to black or red) and consistency, and the presence of pain or tenderness may tell
the doctor which area of the GI tract is affected. Because the intake of iron or foods such as beets can give the stool the
same appearance as bleeding from the digestive tract, a doctor must test the stool for blood before offering a diagnosis.
A blood count will indicate whether the patient is anemic and also will give an idea of the extent of the bleeding and how
chronic it may be.
Endoscopy
Endoscopy is a common diagnostic technique that allows direct viewing of the bleeding site. Because the
endoscope can detect lesions and confirm the presence or absence of bleeding, doctors often choose this method to diagnose
patients with acute bleeding. In many cases, the doctor can use the endoscope to treat the cause of bleeding as well.
The endoscope is a flexible instrument that can be inserted through the mouth or rectum. The instrument allows the
doctor to see into the esophagus, stomach, duodenum (esophago-duodenoscopy), colon (colonoscopy), and rectum (sigmoidoscopy);
to collect small samples of tissue (biopsies); to take photographs; and to stop the bleeding.
Small bowel endoscopy, or enteroscopy, is a new procedure using a long endoscope. This endoscope may be introduced during
surgery to localize a source of bleeding in the small intestine.
Other Procedures
Several other methods are available to locate the source of bleeding. Barium x-rays, in general,
are less accurate than endoscopy in locating bleeding sites. Some drawbacks of barium x-rays are that they may interfere with
other diagnostic techniques if used for detecting acute bleeding; they expose the patient to x-rays; and they do not offer
the capabilities of biopsy or treatment.
Angiography is a technique that uses dye to highlight blood vessels. This procedure is most useful in situations when
the patient is acutely bleeding such that dye leaks out of the blood vessel and identifies the site of bleeding. In selected
situations, angiography allows injection of medicine into arteries that may stop the bleeding.
Radionuclide scanning is a noninvasive screening technique used for locating sites of acute bleeding, especially in the
lower GI tract. This technique involves injection of small amounts of radioactive material. Then, a special camera produces
pictures of organs, allowing the doctor to detect a bleeding site.
In addition, barium x-rays, angiography, and radionuclide scans can be used to locate sources of chronic occult bleeding.
These techniques are especially useful when the small intestine is suspected as the site of bleeding since the small intestine
may not be seen easily with endoscopy.
Treatment for ulcerative colitis depends on the seriousness of the disease. Most people are treated with medication.
In severe cases, a patient may need surgery to remove the diseased colon. Surgery is the only cure for ulcerative colitis.
Some
people whose symptoms are triggered by certain foods are able to control the symptoms by avoiding foods that upset their intestines,
like highly seasoned foods or milk sugar (lactose). Each person may experience ulcerative colitis differently, so treatment
is adjusted for each individual. Emotional and psychological support is important.
Some people have remissions--periods when the symptoms go away--that last for months or even years. However, most patients'
symptoms eventually return.
This changing pattern of the disease means one cannot always tell when a treatment has helped.
Someone with ulcerative colitis may need medical care for some time, with regular doctor visits to monitor the condition.
Drug Therapy
Most patients with mild or moderate disease are first treated with 5-ASA agents, a 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. Patients who do not
do well on sulfasalazine may respond to newer 5-ASA agents. Possible side effects of 5-ASA preparations include nausea, vomiting,
heartburn, diarrhea, and headache.
People with severe disease and those who do not respond to mesalamine preparations may be treated with corticosteroids.
Prednisone and hydrocortisone are two corticosteroids used to reduce inflammation. They can be given orally, intravenously,
through an enema, or in a suppository, depending on the location of the inflammation. Corticosteroids can cause side effects
such as weight gain, acne, facial hair, hypertension, mood swings, and increased risk of infection, so doctors carefully watch
patients taking these drugs.
Other drugs may be given to relax the patient or to relieve pain, diarrhea, or infection.
Occasionally, symptoms are severe enough that the person must be hospitalized. For example, a person may have severe
bleeding or severe diarrhea that causes dehydration. In such cases the doctor will try to stop diarrhea and loss of blood,
fluids, and mineral salts. The patient may need a special diet, feeding through a vein, medications, or sometimes surgery.
Surgery
About 25 percent to 40 percent of ulcerative colitis patients must eventually have their colons removed because
of massive bleeding, severe illness, rupture of the colon, or risk of cancer. Sometimes the doctor will recommend removing
the colon if medical treatment fails or if the side effects of corticosteroids or other drugs threaten the patient's health.
One of several surgeries may be done. The most common surgery is a proctocolectomy with ileostomy, which is done in two
stages. In the proctocolectomy, the surgeon removes the colon and rectum. In the ileostomy, the surgeon creates a small opening
in the abdomen, called a stoma, and attaches the end of the small intestine, called the ileum, to it. This type of ileostomy
is called a Brooke ileostomy. Waste will travel through the small intestine and exit the 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, and the patient empties the pouch as needed.
An alternative to the Brooke ileostomy is the continent ileostomy. In this operation, the surgeon uses the ileum to create
a pouch inside the lower abdomen. Waste empties into this pouch, and the patient drains the pouch by inserting a tube into
it through a small, leakproof opening in his or her side. The patient 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.
An ileoanal anastomosis, or pull-through operation, allows the patient to have normal bowel movements because it preserves
part of the rectum. This procedure is becoming increasingly common for ulcerative colitis. In this operation, 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.
Not every operation is appropriate for every person. Which surgery to have depends on the severity of the disease and
the patient's needs, expectations, and lifestyle. People faced with this decision should get as much information as possible
by talking to their doctors, to nurses who work with colon surgery patients (enterostomal therapists), and to other colon
surgery patients. Patient advocacy organizations can direct people to support groups and other information resources.
Most people with ulcerative colitis will never need to have surgery. If surgery ever does become necessary, however,
some people find comfort in knowing that after the surgery, the colitis is cured and most people go on to live normal, active
lives.
Research
Researchers are always looking for new treatments for ulcerative colitis. Several drugs are being tested
to see whether they might be useful in treating the disease:
Budesonide. A corticosteroid called budesonide may be nearly as effective as prednisone in treating mild ulcerative colitis,
and it has fewer side effects.
Cyclosporine. Cyclosporine, a drug that suppresses the immune system, may be a promising
treatment for people who do not respond to 5-ASA preparations or corticosteroids.
Nicotine. In an early study, symptoms
improved in some patients who were given nicotine through a patch or an enema. (Using nicotine as treatment is still experimental--the
findings do not mean that people should go out and buy nicotine patches or start smoking.)
Heparin. Researchers overseas
are examining whether the anticoagulant heparin can help control colitis by preventing blood clots.
About 5 percent 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.
However, if the entire colon is involved, the 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". People who
have dysplasia are more likely to develop cancer than those who do not. (Doctors look for signs of dysplasia when doing a
colonoscopy and when examining tissue removed during the test.)
According to 1997 guidelines on screening for colon cancer, people 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 should have a colonoscopy every 1 to 2 years
to check for dysplasia. Such screening has not been proven to reduce the risk of colon cancer, but it may help identify cancer
early should it develop. (These guidelines were produced by an independent expert panel and endorsed by numerous organizations,
including the American Cancer Society, American College of Gastroenterology, American Society of Colon and Rectal Surgeons,
and the Crohn's & Colitis Foundation of America Inc., among others.)
