Ulcerative colitis

Ulcerative colitis is a chronic disease affecting the colonic mucosa (inner layer of the large intestine) that most commonly presents with blood in the stool and diarrhea. Almost 15% of patients can initially present with severe forms of the disease. Symptoms include:

• Bleeding from the rectum
• Urgency
• Feeling of the need to pass stool
• Abdominal pains and cramps
• Fever (in severe cases)
• Urinary incontinence (loss of bladder control)
• Fatigue
• Increased frequency of bowel movements
• Mucus discharge
• Rectal pain
• Weight loss
• Bowel movements at night
• Weight loss (in severe cases)
• Involvement of muscles and skin

Note: Symptoms are similar in children with ulcerative colitis (pediatric ulcerative colitis) and may also include delayed or poor growth.

Don’t let poor nutrition hamper your child’s growth.

• Ulcerative colitis generally begins in the rectum and may remain localized or extend proximally, sometimes involving the entire colon (the longest part of the large intestine). It rarely involves the entire bowel at once.
• The exact cause of ulcerative colitis remains unknown; however, there are numerous risk factors that can lead to its development.
• Both Crohn’s disease and ulcerative colitis are characterized by bowel symptoms, which can be seen in 25-40% of patients with inflammatory bowel disease.
• Manage the symptoms by adding these 6 superfoods.

Ulcerative colitis is a multifactorial condition and the risk factors include:

• Age: Studies show that the onset of ulcerative colitis is typically seen at a younger age, specifically under 40 years. The main onset peaks between 15 and 30 years of age.
• Race: Ulcerative colitis was previously considered a disease primarily affecting Caucasian patients; however, studies have documented increased incidences among non-white populations as well.
• Family history of IBD: The strongest identifiable risk factor for the development of inflammatory bowel disease (IBD) is a positive family history. IBD includes Crohn's disease (which causes swelling of the digestive tract) and ulcerative colitis.
• Medications: Drugs that can increase the likelihood of developing ulcerative colitis include:
  • Contraceptive pills: The use of combined oral contraceptive pills has been associated with the development of ulcerative colitis.
  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): These pain medications have been shown to be associated with flare-ups of the disease.
  • Antibiotics: These can precipitate flare-ups of the disease for some individuals.
• Smoking: Former cigarette smoking is one of the strongest risk factors associated with ulcerative colitis. Studies demonstrate that active smokers are less likely to develop ulcerative colitis compared to former and non-smokers.
• Appendectomy: This surgery involves the removal of the appendix (a small, thin pouch connected to the large intestine) when it is infected. Research shows that a history of appendectomy in patients with ulcerative colitis is rare.
• Diet: Although less common, increased consumption of polyunsaturated fatty acids (a type of dietary fat found in salmon, nuts, etc.) may contribute to digestive health issues that can lead to ulcerative colitis.
• Childhood hygiene: Low hygiene and exposure to infections may be associated with an increased risk for ulcerative colitis, particularly in children.

Ulcerative colitis is a chronic illness that is usually detected only at the later stages. Diagnosis consists of the following investigations:

1. Medical History

A thorough history, including travel history to rule out other causes, along with detailed drug history and recent antibiotic use, should be considered.

2. Laboratory Tests

These tests are done to diagnose anemia, thrombocytosis (a condition in which the body produces platelets in excess), low vitamin D, and raised inflammatory markers. Tests include:

• Complete blood count (CBC)
• Blood urea
• Serum electrolytes
• C-reactive protein
• Vitamin D profile
• Bone profile
• Iron serum
• Folate test (Vitamin B9)
• Vitamin B12 test
• Liver function tests

3. Stool Cultures

These are done to determine if there are any infections. The stool culture should be negative in the case of ulcerative colitis, but bacterial infections such as C. difficile can co-exist.

4. Fecal Calprotectin

It is a very sensitive marker for inflammation in the gastrointestinal tract and is useful for differentiating inflammatory bowel disease (IBD) from irritable bowel syndrome (IBS).

5. Imaging Tests

• Colonoscopy or Proctosigmoidoscopy: It might reveal loss of typical vascular pattern, granularity, friability, and ulceration that involves the rectum.
• Sigmoidoscopy: It helps in examining the level and extent of bowel inflammation. A sigmoidoscopy can also be used to remove a small sample of tissue from your bowel for laboratory testing.
• Endoscopy: It helps in examining the inside of your colon and rectum with a lighted tube inserted through your anus.
• Abdominal X-ray: Plain abdominal radiographs are useful for acute onset of ulcerative colitis. They are often entirely normal in inflammatory bowel disease.
• CT Scan or MRI: These are used for small bowel imaging and can help differentiate between ulcerative colitis and Crohn’s disease.

6. Biopsy

Usually, at least two biopsies from each bowel segment for histological assessment are recommended. However, no histological features are diagnostic of ulcerative colitis, but distortion irregularity can suggest ulcerative colitis.

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Ulcerative colitis is a form of inflammatory bowel disease that is generally detected only at later stages. By taking certain preventive measures, you can decrease your chances of developing ulcerative colitis. These include:

• Staying hydrated: Proper hydration helps prevent ulcerative colitis. It is recommended to drink at least 2 liters of water every day while avoiding coffee, alcohol, and carbonated beverages, which can exacerbate diarrhea.
• Making probiotics your friend: Probiotics are beneficial bacteria that can maintain gut health. They prevent harmful bacteria from adhering to the walls of the large intestine, thereby reducing the risk of ulcerative colitis.
• Giving importance to mental health: Managing stress can help alleviate the signs and symptoms of ulcerative colitis, as stress may disrupt normal digestive processes. Engage in activities that promote relaxation and calmness.
• Adding exercise to your routine: Regular physical activity is known to benefit overall health. Exercise can help maintain bowel health and prevent diarrhea.

Ulcerative colitis can progress proximally in 10–19% of patients after 5 years, and in up to 28% of patients at 10 years. The primary aim of medical management is to induce and maintain remission.

Staging of ulcerative colitis based on the severity of disease:

The severity of ulcerative colitis can be graded depending upon rectal bleeding. It includes:

• Mild: Less than four rectal bleeding episodes per day
• Moderate: More than four rectal bleeding episodes per day
• Severe: More than four rectal bleeding episodes per day along with systemic features of an illness combined with hypoalbuminemia (a condition in which there is a lack of albumin protein that's responsible for keeping fluid in your blood vessels).

Treatment depends on the stage of ulcerative colitis and consists of:

A. In mild-moderate ulcerative colitis

• Mesalamines: These are the first-line therapy for induction of remission in mild-moderate cases of ulcerative colitis. There are different formulations of mesalamine, including oral, suppository, or liquid enema.
• Corticosteroids: Second-line therapies for patients who do not respond to mesalamine are corticosteroids. The drugs used are:
• Prednisone
• Budesonide-multimatrix (MMX)

B. In moderate-severe ulcerative colitis

• Immunomodulators: These are drugs that modulate the immune system by working on the underlying inflammatory processes. They include:
• Infliximab
• Adalimumab
• Golimumab
• Vedolizumab
• Tofacitinib

C. In acute severe ulcerative colitis

It is defined as the presence of more than 6 bloody stools per day with increased heart rate, fever, and signs of infection. Medications include:

• Infliximab
• Cyclosporine
• Steroids

D. Maintenance of remission

The most appropriate maintenance treatment for an individual patient is established by several factors, such as disease extent and severity, treatment for induction of remission, and failure of previous maintenance treatments. Mesalazine is the basis of treatment for the maintenance of remission in ulcerative colitis.

E. Surgery

Absolute indications for surgery include uncontrolled bleeding, perforation, and colorectal cancer. Surgery is also indicated in acute severe ulcerative colitis. The most commonly performed surgeries for ulcerative colitis are:

• Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA): This surgery removes the entire colon and rectum while preserving the seal in the anus for normal bowel functioning and to avoid fecal incontinence.
• Total proctocolectomy: This surgery removes all of the colon and rectum and may be indicated if there are intestinal manifestations.

F. The newer agent

Mirakizumab is an antibody currently in a clinical trial for patients with moderate-severe ulcerative colitis. However, additional studies are required to determine the efficacy and dose of mirakizumab.

• Aloe vera: Aloe gel has been shown to reduce inflammation. However, caution is advised with aloe vera juice, as it can have a laxative effect and may cause issues for individuals with diarrhea.
• Wheatgrass (Gehun): Studies indicate that wheatgrass juice is effective and safe for managing active ulcerative colitis.
• Turmeric (Haldi): Research demonstrates that curcumin (found in turmeric) is immunomodulatory and well tolerated without significant side effects.
• Pineapple (Ananas): The enzyme bromelain, present in pineapple, may help alleviate UC symptoms and reduce the frequency of flares by decreasing intestinal inflammation and enhancing intestinal cell function.
• Ginseng: According to a 2015 study, the roots of this plant may be effective in treating UC by reducing inflammation and protecting against cellular damage.

Note: In addition to these remedies, maintaining overall health through regular exercise, incorporating probiotics and vitamin supplements into your diet, and following a well-balanced diet are essential for managing the symptoms of ulcerative colitis.

Ulcerative colitis is a chronic disease characterized by periods of remission and relapse. Here are the complications that can occur from ulcerative colitis:

• Pelvic abscess: Pus-filled lesions in the lower abdomen due to inflammation.
• Enterocutaneous fistulas: Abnormal connections between the intestines or stomach and the skin, resulting from leakage of intestinal contents into the skin after bowel surgery.
• Bowel obstruction: Early postoperative small-bowel obstruction occurs in up to 15% of patients after surgery for ulcerative colitis.
• Pouch prolapse: A rare but significant complication in patients with ulcerative colitis who have undergone total proctocolectomy.
• Poor growth and development: Individuals with ulcerative colitis may experience poor growth and delayed puberty while undergoing treatment.
• Primary sclerosing cholangitis: A condition that may develop in individuals with ulcerative colitis, characterized by progressive inflammation and damage to the bile ducts.
• Pouchitis: Inflammation of the lining of a pouch created during surgery for ulcerative colitis.
• Incontinence: Individuals with ulcerative colitis may experience fecal incontinence, which is the inability to control bowel movements.
• Osteoporosis: Increased risk of developing osteoporosis, a condition where bones become weak and more susceptible to fractures.
• Sexual dysfunction: Certain medications used to treat ulcerative colitis may affect sex drive and sexual function.
• Toxic megacolon: Swelling and inflammation that extend into the deeper layers of the colon.
• Colon or rectal cancer: The risk of cancer in individuals with ulcerative colitis increases by 2% after 10 years of diagnosis.
• Leakage from anastomosis: A serious complication following ileal pouch-anal anastomosis (IPAA), which can lead to postoperative sepsis and pouch failure.

• Hyperbaric oxygen therapy: Studies show that this therapy has proven beneficial in acute severe ulcerative colitis. It is based on the theory that pure excess oxygen delivery might reverse tissue hypoxia (low oxygen levels) and induce healing.
• Ayurveda: An ayurvedic approach may help in providing relief from symptoms and flare-ups associated with ulcerative colitis, as it includes dietary measures to balance the doshas, massages, meditation, and yoga.
• Acupuncture: A 2016 study found that acupuncture can be helpful for people with IBD, showing improvement in pain relief and symptoms.
• Tai Chi: Also known as shadowboxing, Tai Chi is an internal Chinese martial art practiced for defense training and health benefits. Studies indicate that it can improve the quality of life in patients with ulcerative colitis and other inflammatory bowel diseases by focusing on internal balance and healing from within.

Being well-informed about your chronic illness is important, as learning all you can about your diagnosis and how it may affect you can significantly aid in managing your condition. Here are a few tips that can help you with ulcerative colitis:

• Avoid certain medications: Painkillers such as ibuprofen and naproxen are not usually recommended for individuals with ulcerative colitis, as they can cause ulcers in the stomach and intestines. Additionally, some contraceptives and antibiotics may trigger flare-ups.
• Eat smaller meals: Making changes to your diet can help control the condition. The best approach is to eat small meals rather than three main meals, which may help manage your symptoms.
• Maintain a food journal: Keeping a food journal allows you to document what you eat and understand which foods you can tolerate and which exacerbate your symptoms. This practice can help you identify and eliminate problem foods from your diet.
• Keep a high-fiber diet at bay: For some individuals, fiber can aggravate symptoms during a flare-up of ulcerative colitis. Consuming a low-fiber diet can reduce the amount and frequency of stools. Examples of low-fiber foods include:
  • White bread
  • Cornflakes
  • White rice
  • Lean meat and fish
  • Eggs
• Add necessary supplements: Ulcerative colitis can lead to malnutrition, as certain foods may not be well tolerated by the body. Additionally, some medications used in the treatment can cause deficiencies in folate and vitamin B12. Consider adding the following supplements:
  • Vitamin D
  • Folic acid
  • Iron
  • Vitamin B12
  • Omega-3 fatty acids
• Communicate your feelings: Living with a long-term condition like ulcerative colitis can impact your mental health. Anxiety and stress may lead to depression in some cases. It's important to communicate with your loved ones about your feelings. You may also find yoga, breathing exercises, and meditation helpful.
• Ulcerative colitis in kids: Ulcerative colitis can occur in children under 15 years of age, leading to physical, emotional, and social challenges. Proper management and treatment are crucial. Children may experience the following mental symptoms:
  • Mood swings
  • Teasing at school
  • Anger and frustration
  • Embarrassment
  • Worry about physical appearance
  • Poor concentration
  Children need mutual support from family members, and it is important for the entire family to understand the disease and be empathetic. Seeking a psychiatrist's help may be beneficial for your child in managing the challenges associated with ulcerative colitis.