Ulcerative colitis, an inflammatory bowel disease (IBD) that causes chronic inflammation of the digestive tract, is characterized by abdominal pain and diarrhea. Like Crohn's disease, another common IBD, ulcerative colitis can be debilitating and sometimes can lead to life-threatening complications.
Ulcerative colitis usually affects only the innermost lining of your large intestine (colon) and rectum. It occurs only through continuous stretches of your colon, unlike Crohn's disease, which occurs in patches anywhere in the digestive tract and often spreads deep into the layers of affected tissues.
There's no known cure for ulcerative colitis, but therapies are available that may dramatically reduce the signs and symptoms of ulcerative colitis and even bring about a long-term remission.

What Causes Ulcerative Colitis?

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. Neither disease is contagious.
Ulcerative colitis and Crohn's disease are caused by abnormal activation of the immune system in the intestines. The immune system is composed of immune cells and the proteins that these cells produce. These cells and proteins serve to defend the body against harmful bacteria, viruses, fungi, and other foreign invaders. Activation of the immune system causes inflammation within the tissues where the activation occurs. (Inflammation is, in fact, an important mechanism of defense used by the immune system.) Normally, the immune system is activated only when the body is exposed to harmful invaders. In patients with Crohn's disease and ulcerative colitis, however, the immune system is abnormally and chronically activated in the absence of any known invader. The continued abnormal activation of the immune systems causes chronic inflammation and ulceration. The susceptibility to abnormal activation of the immune system is genetically inherited. First degree relatives (brothers, sisters, children, and parents) of patients with IBD are thus more likely to develop these diseases.

What are the Symptoms of Ulcerative Colitis?

Common symptoms of ulcerative colitis include rectal bleeding and diarrhea, but there is a wide range of symptoms among patients with this disease. Variability of symptoms reflects differences in the extent of disease (the amount of the colon and rectum that are inflamed) and the intensity of inflammation. Generally, patients with inflammation confined to the rectum and a short segment of the colon adjacent to the rectum have milder symptoms and a better prognosis than patients with more widespread inflammation of the colon. The different types of ulcerative colitis are classified according to the location and the extent of inflammation:

1. Ulcerative proctitis refers to inflammation that is limited to the rectum. In many patients with ulcerative proctitis, mild intermittent rectal bleeding may be the only symptom. Other patients with more severe rectal inflammation may, in addition, experience rectal pain, urgency (sudden feeling of having to defecate and a need to rush to the bathroom for fear of soiling), and tenesmus (ineffective, painful urge to move one's bowels).
2. Proctosigmoiditis involves inflammation of the rectum and the sigmoid colon (a short segment of the colon contiguous to the rectum). Symptoms of proctosigmoiditis, like that of proctitis, include rectal bleeding, urgency, and tenesmus. Some patients with proctosigmoiditis also develop bloody diarrhea and cramps.
3. Left-sided colitis involves inflammation that starts at the rectum and extends up the left colon (sigmoid colon and the descending colon). Symptoms of left-sided colitis include bloody diarrhea, abdominal cramps, weight loss, and left-sided abdominal pain.
4. Pancolitis or universal colitis refers to inflammation affecting the entire colon (right colon, left colon, transverse colon and the rectum). Symptoms of pancolitis include bloody diarrhea, abdominal pain and cramps, weight loss, fatigue, fever, and night sweats. Some patients with pancolitis have low-grade inflammation and mild symptoms that respond readily to medications. Generally, however, patients with pancolitis suffer more severe disease and are more difficult to treat than those with more limited forms of ulcerative colitis.
5. Fulminant colitis is a rare but severe form of pancolitis. Patients with fulminant colitis are extremely ill with dehydration, severe abdominal pain, protracted diarrhea with bleeding, and even shock. They are at risk of developing toxic megacolon (marked dilatation of the colon due to severe inflammation) and colon rupture (perforation). Patients with fulminant colitis and toxic megacolon are treated in the hospital with potent intravenous medications. Unless they respond to treatment promptly, surgical removal of the diseased colon is necessary to prevent colon rupture.

While the intensity of colon inflammation in ulcerative colitis waxes and wanes over time, the location and the extent of disease in a patient generally stays constant. Therefore, when a patient with ulcerative proctitis develops a relapse of his disease, the inflammation usually is confined to the rectum. Nevertheless, a small number of patients (less than 10%) with ulcerative proctitis or proctosigmoiditis can later develop more extensive colitis. Thus, patients who initially only have ulcerative proctitis can later develop left-sided colitis or even pancolitis.

Tests and  Investigation

Your doctor will likely diagnose ulcerative colitis only after ruling out other possible causes for your signs and symptoms, including Crohn's disease, ischemic colitis, infection, irritable bowel syndrome (IBS), diverticulitis and colon cancer. To help confirm a diagnosis of ulcerative colitis, you may have one or more of the following tests and procedures:

• Blood tests. Your doctor may suggest blood tests to check for anemia or infection. Tests that look for the presence of certain antibodies can sometimes help diagnose which type of inflammatory bowel disease you have, but these tests can't definitely make the diagnosis.
• Stool sample. The presence of white blood cells in your stool indicates an inflammatory disease, possibly ulcerative colitis. A stool sample can also help rule out other disorders, such as those caused by bacteria, viruses and parasites. Your doctor can also check for a bowel infection, which is more likely to occur in people with ulcerative colitis.
• Colonoscopy. This exam allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis. Sometimes a tissue sample can help confirm a diagnosis.
• Flexible sigmoidoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the sigmoid, the last portion of your colon. The test may miss problems higher up in your colon.
• Barium enema. This diagnostic test allows your doctor to evaluate your entire large intestine with an X-ray. Barium, a contrast dye, is placed into your bowel using an enema. Sometimes, air is added as well. The barium coats the lining , creating a silhouette of your rectum, colon and a portion of your small intestine. This test is usually only performed if a colonoscopy can't be done.
• X-ray. A standard X-ray of your abdominal area may be done to rule out toxic megacolon or a perforation if these conditions are suspected because of severe symptoms.
• CT scan. A CT scan of your abdomen or pelvis may be performed if your doctor suspects a complication from ulcerative colitis or inflammation of the small intestine that might suggest Crohn's disease.

Treatments and Pharmacology

The goal of medical treatment is to reduce the inflammation that triggers your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to long-term remission. Ulcerative colitis treatment usually involves either drug therapy or surgery.
Doctors use several categories of drugs that control inflammation in different ways. But drugs that work well for some people may not work for others, so it may take time to find a medication that helps you. In addition, because some drugs have serious side effects, you'll need to weigh the benefits and risks of any treatment.
Anti-inflammatory drugs
Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:

• Sulfasalazine (Azulfidine). Sulfasalazine can be effective in reducing symptoms of ulcerative colitis, but it has a number of side effects, including nausea, vomiting, diarrhea, heartburn and headache. Don't take this medication if you're allergic to sulfa medications.
• Mesalamine (Asacol, Rowasa, others), balsalazide (Colazal) and olsalazine (Dipentum). These medications tend to have fewer side effects than sulfasalazine has. You take them in tablet form or use them rectally in the form of enemas or suppositories, depending on the area of your colon affected by ulcerative colitis. Your doctor may prescribe a combination of two different forms, such as oral and an enema or suppository. Mesalamine can relieve signs and symptoms in more than 90 percent of people with mild ulcerative colitis. People with proctitis tend to respond better to combination therapy with oral mesalamine and suppositories. For left-sided colitis, a combination of oral mesalamine and mesalamine enemas seems to work better than either agent alone if symptoms are mild to moderate.
• Corticosteroids. Corticosteroids can help reduce inflammation, but they have numerous side effects, including weight gain, excessive facial hair, high blood pressure, type 2 diabetes, osteoporosis and an increased susceptibility to infections. Doctors generally use corticosteroids only if you have moderate to severe inflammatory bowel disease that doesn't respond to other treatments. Corticosteroids aren't for long-term use and are generally prescribed for a period of three to four months.
  They may also be used in conjunction with other medications as a means to induce remission. For example, corticosteroids may be used with an immune system suppressor — the corticosteroids can induce remission, while the immune system suppressors can help maintain remission. Occasionally, your doctor may also prescribe short-term use of steroid enemas to treat disease in your lower colon or rectum.
  

Immune system suppressors
These drugs also reduce inflammation, but they target your immune system rather than treating inflammation itself. Because immune suppressors can be effective in treating ulcerative colitis, scientists theorize that damage to digestive tissues is caused by your body's immune response to an invading virus or bacterium or even to your own tissue. By suppressing this response, inflammation is also reduced. Immunosuppressant drugs include:

• Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol). Because azathioprine and mercaptopurine act slowly — taking three months or longer to start working — they're sometimes initially combined with a corticosteroid, but in time, they seem to produce benefits on their own.
  Side effects can include allergic reactions, bone marrow suppression, infections, and inflammation of the liver and pancreas. There also is a small risk of development of cancer with these medications. If you're taking either of these medications, you'll need to follow up closely with your doctor and have your blood checked regularly to look for side effects. If you've had cancer, discuss this with your doctor before starting these medications.
  
• Cyclosporine (Gengraf, Neoral, Sandimmune). This potent drug is normally reserved for people who don't respond well to other medications or who face surgery because of severe ulcerative colitis. In some cases, cyclosporine may be used to delay surgery until you're strong enough to undergo the procedure; in others, it's used to control signs and symptoms until less toxic drugs start working. Cyclosporine begins working in one to two weeks, but because it has the potential for severe side effects, including kidney damage and fatal infections, talk to your doctor about the risks and benefits of treatment. There's also a small risk of cancer with these medications, so let your doctor know if you've previously had cancer.
• Infliximab (Remicade). This drug is specifically for those with moderate to severe ulcerative colitis who don't respond to or can't tolerate other treatments. It works by neutralizing a protein produced by your immune system known as tumor necrosis factor (TNF). Infliximab finds TNF in your bloodstream and removes it before it causes inflammation in your intestinal tract.
  Some people with heart failure, people with multiple sclerosis, and people with cancer or a history of cancer can't take infliximab. The drug has been linked to an increased risk of infection, especially tuberculosis and reactivation of viral hepatitis, and may increase your risk of blood problems and cancer. You'll need to have a skin test for tuberculosis before taking infliximab.
  Also, because infliximab contains mouse protein, it can cause serious allergic reactions in some people — reactions that may be delayed for days to weeks after starting treatment. Once started, infliximab is often continued as long-term therapy, although its effectiveness may wear off over time.
  

Nicotine patches
These skin patches — the same kind used to quit smoking — seem to provide short-term relief from flare-ups of mild ulcerative colitis for some people. How nicotine patches work isn't exactly clear, and the evidence that they provide relief that's better than other therapies is contested among researchers. Talk to your doctor before trying this treatment. One thing that is clear, however, is that the overall health risks from smoking far outweigh any potential benefit that nicotine might provide, so don't begin smoking to treat ulcerative colitis.
Other medications
In addition to controlling inflammation, some medications may help relieve your signs and symptoms. Depending on the severity of your ulcerative colitis, your doctor may recommend one or more of the following:

• Antibiotics. People with ulcerative colitis who run fevers will likely be given antibiotics to help prevent or control infection.
• Anti-diarrheals. A fiber supplement such as psyllium powder (Metamucil) or methylcellulose (Citrucel) can help relieve signs and symptoms of mild to moderate diarrhea by adding bulk to your stool. For more severe diarrhea, loperamide (Imodium) may be effective. Use anti-diarrheal medications with great caution, however, because they increase the risk of toxic megacolon.
• Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others). Don't use nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen (Aleve). These are likely to make your symptoms worse.
• Iron supplements. If you have chronic intestinal bleeding, you may develop iron deficiency anemia. Taking iron supplements may help restore your iron levels to normal and reduce this type of anemia once your bleeding has stopped or diminished.

Surgery
If diet and lifestyle changes, drug therapy or other treatments don't relieve your signs and symptoms, your doctor may recommend surgery.
Surgery can often eliminate ulcerative colitis. But that usually means removing your entire colon and rectum (proctocolectomy). In the past, after this surgery you would wear a small bag over an opening in your abdomen (ileostomy) to collect stool. But a procedure called ileoanal anastomosis eliminates the need to wear a bag. Instead, your surgeon constructs a pouch from the end of your small intestine. The pouch is then attached directly to your anus. This allows you to expel waste more normally, although you may have more-frequent bowel movements that are soft or watery because you no longer have your colon to absorb water.
If you have surgery, ask your doctor whether an ileostomy or an ileoanal pouch is right for you. Between 25 and 40 percent of people with ulcerative colitis eventually need surgery.
Pregnancy
Women with ulcerative colitis can usually have successful pregnancies, especially if they can keep the disease in remission during pregnancy. There is a slight increase in the risk of premature delivery and babies with low birth weights. Ideally, you'll become pregnant when your disease is in remission. Some medications may not be indicated for use in pregnancy, especially during the first trimester, and the effects of certain medications may linger after you stop them. Talk with your doctor about the best way to manage your illness before you conceive. If you stop certain medications, their effects may linger. It's estimated that the risk of passing ulcerative colitis to your offspring if your partner doesn't have ulcerative colitis is less than 5 percent.

 

 Sources

1. About ulcerative colitis and proctitis. The Crohn's and Colitis Foundation of America. http://www.ccfa.org/info/about/ucp. Accessed June 30, 2009.
2. Ulcerative colitis. The Merck Manuals: The Merck Manual for Healthcare Professionals. http://www.merck.com/mmpe/print/sec02/ch018/ch018c.html. Accessed June 30, 2009.
3. Peppercorn MA, et al. Medical management of ulcerative colitis. http://www.uptodate.com/home/index.html. Accessed June 30, 2009.
4. Ulcerative colitis. National Institute of Diabetes and Digestive and Kidney Diseases. http://digestive.niddk.nih.gov/ddiseases/pubs/colitis/. Accessed June 30, 2009.
5. Accutane (prescribing information). Nutley, N.J.: Roche; 2008. http://www.rocheusa.com/products/accutane/pi.pdf. Accessed June 23, 2009.