Ulcerative Colitis

Ulcerative colitis (UC) is a chronic disease that causes inflammation and ulcers (open sores) in the innermost layers of the large intestine. UC is an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation in the intestines. In UC, swelling typically occurs in the rectum and lower colon, but the inflammation can spread throughout the entire colon. The ulcers bleed and produce pus and mucus, and the inflammation causes the colon to empty frequently, resulting in diarrhea.

UC is a rare, but serious disease that affects 50 out of every 100,000 people in the United States. Although the condition most commonly affects those between the ages of 15 and 35, children and older adults may also develop the disease. UC occurs five times more frequently in those with a Jewish heritage than it does in the general population. Although most people with UC can be successfully treated without surgery, roughly 25% will need a colectomy (surgical removal of the colon).

Signs and Symptoms

The most common signs and symptoms of UC include abdominal pain and bloody diarrhea. The symptoms can range from mild to severe and may come on either very suddenly or more gradually.

Other common symptoms of UC include:

• Frequent, even continuous diarrhea
• Bloody stool
• Urgent desire to defecate
• Abdominal cramps and pain
• High fever
• Rapid heartbeat
• Weight loss
• Anemia
• Loss of appetite
• Joint aches

People with UC are at increased risk for malnutrition. UC can also cause a host of other problems, including arthritis, eye infections, liver disease, skin rashes, blood clots, or gallstones. Although it is not clear why such problems occur outside the colon, some researchers speculate that they may be linked to a faulty immune response.

Causes

There are many theories regarding the cause of UC, but none have been proven. The most likely theory is that UC is caused by a variety of factors ranging from genetics, faulty immune system reactions, stress, environmental influences, and even diet. For example, some people are genetically at risk for UC (it runs in their family), and an infection or other toxin may stimulate inflammation of the large intestine. In some cases, stressful events or sensitivities to certain foods may trigger symptoms of UC.

Risk Factors

• Family history of UC
• Jewish heritage, especially Ashkenazi Jews
• A diet high in sugar, cholesterol, and fat (particularly from meat and dairy products)
• Stress

Diagnosis

A healthcare practitioner will perform a thorough physical exam as well as a series of tests to diagnose UC. Blood tests may reveal a high white blood cell count (a sign of inflammation somewhere in the body). Stool samples may indicate whether there is bleeding or infection in the colon or rectum.

A procedure called colonoscopy—in which an endoscope (a long, flexible, lighted tube connected to a computer and television monitor) is inserted into the anus to enable investigation of the inside of the colon and rectum—may be performed. A colonoscopy can reveal any inflammation, bleeding, or ulcers on the colon wall. Tissue samples (biopsies) may be taken from the colon wall for examination under a microscope in order to make a definitive diagnosis of UC.

Preventive Care

A daily dose of sulfasalazine, one of the most common medications used to treat UC, is an effective means of reducing the number of UC relapses. Diet (especially a low-fat diet rich in fruits, fluids, magnesium, and vitamin C), exercise, and stress reduction techniques (including hypnosis) may also help prevent recurrences. Supplements and herbs are used successfully to treat UC, but whether or not they can prevent recurrences or stave off the disease in those who are genetically at risk is unknown.

Treatment Approach

The primary goal in treating UC is to control inflammation and replenish lost nutrients. The choice of treatment for UC depends on the severity of the disease. For example, people with mild to moderate UC are usually treated with medications that reduce swelling and suppress the immune response. More severe cases of UC may require surgery. In addition to medications, many people with inflammatory bowel diseases such as UC commonly turn to complementary and alternative remedies. Although these remedies still require extensive research, preliminary studies indicate that lifestyle changes, including stress reduction, dietary adjustments (such as including a rich variety of fruits and vegetables and maintaining low levels of fat and sugar), specific herbs and supplements (such as psyllium and Salai guggal) and mind/body techniques (such as hypnosis) can help prevent and/or treat the disease.

Lifestyle

At least one study has shown that IBD often begins within 1 year of a very stressful life event, such as the death of a family member. In addition, people with UC report that stress worsens their symptoms. Therefore, relaxation techniques, such as yoga, tai chi, and meditation are worth considering, particularly for people with chronic stress in their lives.

Exercise may also be very helpful for those with UC. Although exercise is generally considered safe for people with UC, those with the condition must take certain precautions when exercising and should talk to their healthcare practitioners before starting an exercise program. It is especially important for people with UC to drink one to two glasses of water before exercising and one glass of water every twenty minutes while exercising to prevent dehydration. Exercise should be avoided during symptom flare-ups or if the individual has a fever.

Medications

The following medications can help reduce the symptoms of UC and decrease the likelihood of recurrences:

• Sulfasalazine — the most commonly used medication for UC; taken orally; decreases inflammation, reduces frequency of recurrences
• Mesalamine — decreases inflammation; taken orally or as an enema
• Corticosteroids — reduce inflammation by decreasing the production of prostaglandins (fatty acids that produce pain and inflammation); taken orally, given intravenously in severe cases, or may be prescribed as an enema
• Medications that suppress the immune system (such as azathioprine and cyclosporine)
• Antibiotics

Medications used to treat diarrhea (such as diphenoxylate, loperamide, or opiates) must be used only under medical supervision and with extreme caution. These medications slow down the normal movements of the gastrointestinal tract and, in severe cases of UC, may cause a complication known as toxic megacolon.

Surgery and Other Procedures

Approximately 20% to 30% of people with UC must eventually have their colons removed (colectomy) because of massive bleeding, severe illness, rupture of the colon, or the risk of cancer. There are several different types of surgery available for UC, and choosing the appropriate surgery depends on the severity of the disease and the individual's needs, expectations, and lifestyle.

Many people with UC must have a proctocolectomy—a procedure in which the colon, anus, and rectum are surgically removed. The surgery cures UC, and removes any risk of colon or rectal cancer. When the intestines are removed, however, the body needs a new way for waste to leave the body so the surgeon creates a small opening (stoma) in the abdomen for stool to pass through. A pouch is worn over the opening to collect waste, and the individual empties the pouch as needed. Different types of procedures may be performed depending on which parts of the intestines are involved:

• Ileostomy — colon and rectum are removed and the surgeon attaches the bottom of the small intestine to the stoma; waste travels through the small intestine and exits the body through the stoma
• Colostomy — rectum is removed and the surgeon attaches the colon to the stoma (a temporary colostomy may be performed when part of the colon is removed and the rest needs to heal)
• Ileorectal and ileoanal reservoir surgery — diseased part of colon and/or rectum is removed and the surgeon creates an internal pouch from the small intestine; waste is stored in the pouch and passed through the anus in the usual manner; bowel movements occur more frequently (on average, 5 to 7 times per day); risks include leakage of stool at night and infection of the pouch

Nutrition and Dietary Supplements

Diet
Preliminary evidence suggests that certain dietary patterns may be associated with UC. For example, some studies indicate that low fruit and vegetable consumption and high fat and sugar consumption may increase an individual's risk for developing UC. Studies also suggest the following:

• A bland, low-fiber diet is best during acute flare-ups.
• Regular intakes of fruits and vegetables, and lowered fat and sugar consumption when UC is not active may reduce the likelihood of flare-ups.
• High intakes of fluids and foods rich in magnesium and vitamin C on a regular basis may lower the risk of developing inflammatory bowel diseases.
• Certain foods may aggravate symptoms of UC (including chocolate, dairy products, fats, and artificial sweeteners) and should be avoided by people with the condition.
• After surgery, people with UC should avoid foods high in organic acids known as oxalates (for example, spinach, rhubarb, beets, coffee, tea, diet sodas, and chocolate) because oxalates can increase the risk of kidney stones.

People with significant malnourishment, severe symptoms, or those awaiting surgery may require total parenteral nutrition (nutrition maintained entirely by intravenous injection).

Vitamins and Minerals
Because many people with UC have vitamin and mineral deficiencies (due to decreased nutritional intake and absorption by the colon and excessive diarrhea), a multivitamin is recommended. Further research is needed to determine whether specific vitamin or mineral supplements may help treat the symptoms of UC.

Omega-3 Fatty Acids
At least one study has found that, compared to placebo, fish oil supplements containing omega-3 fatty acids may reduce symptoms of UC and prevent recurrence of the condition. The supplements are less effective than sulfasalazine, however, at reducing inflammation in people with mild to moderate UC. Some experts suggest that omega-3 fatty acids may prove particularly valuable when used in combination with sulfasalazine or other medications.

Vitamin B9 (Folate)
People with UC often have low levels of folate in their blood cells and some experts suggest that this may be due, at least in part, to sulfasalazine use. Some researchers speculate that folate deficiencies contribute to the risk of colon cancer in those with UC. Although preliminary studies suggest that folate supplements may help reduce tumor growths in people with UC, further research is needed to determine the precise role of folate supplementation in people with inflammatory bowel diseases.

N-acetyl glucosamine
Preliminary evidence suggests that N-acetyl glucosamine supplements or enemas may improve symptoms of UC in children with IBD who did not improve after using other treatments, but further research is needed to determine whether the substance is safe and effective for the treatment of UC.

Probiotics
Animal studies and preliminary human studies have found that probiotics, or "good" bacteria such as lactobacillus, may improve symptoms of UC and help prevent flare-ups. Further research is warranted.

Bromelain
There have been a few case reports in the medical literature about people with mild forms of ulcerative colitis who have gotten better by taking bromelain. Bromelain is an enzyme that comes from pineapples and has properties that both reduce inflammation and help digestion. In theory, therefore, this supplement may prove beneficial for people with ulcerative colitis. But, this idea must be tested on large groups of people with this inflammatory bowel condition before conclusions can be drawn.

Herbs

Psyllium seeds (Plantaginis ovatae)
A study comparing the use of psyllium seeds to the prescription drug mesalamine in people with UC reveal that the fiber-based supplement may be as effective as the medication in decreasing recurrences of the disease. More research is needed to confirm the conclusion of the authors of this study.

A professional herbalist may also recommend the following herbs to reduce inflammation and diminish abdominal cramps associated with UC:

• Marshmallow root (Althaea officinalis)
• Siberian ginseng (Eleutherococcus senticosus)
• Turmeric (Curcuma longa)
• Ginger (Zingiber officinale)
• Green tea (Camillia sinensis)
• Bromelain (Ananas comosus)
• Wild yam (Dioscorea villosa)
• German chamomile flower (Matricaria recutita)
• Yarrow (Achillea millefolium)

Mind/Body Medicine

Hypnosis
Studies have shown that hypnosis improves immune function, increases relaxation, decreases stress, and ease feelings of anxiety. Many healthcare practitioners and people with UC have reported that symptoms of the disease improve with relaxation methods such as hypnosis, meditation, and biofeedback.

Ayurveda

Salai guggal (Boswellia serrata)
Salai guggal is a traditional Ayurvedic therapy used to treat symptoms of IBD. Findings from one small study suggest that this remedy may prove to be as effective as sulfasalazine for the treatment of UC. Side effects of salai guggal use include nausea, abdominal fullness, stomach pain, and anorexia.

Other Considerations

Pregnancy

Fifty percent of women in remission experience a recurrence of UC when they become pregnant, usually during the first trimester or during the postpartum period. For this reason, such women should continue maintenance therapy under the guidance of their healthcare practitioner. Corticosteroids or sulfasalazine are considered safe during this time because these drugs do not harm the fetus. Pregnant women with UC do not have increased risk for stillbirths or premature deliveries. Pregnant women should avoid high doses of vitamins. An obstetrician can provide instructions regarding appropriate multivitamin use during pregnancy.

Warnings and Precautions

People with UC should avoid herbs that loosen the bowels. These include:

• Buckthorn bark (Rhamnus frangula)
• Cascara sagrada bark (Rhamnus purshiana)
• Senna leaf and senna pod (Senna alexandrina)

The following foods should also be avoided by people with UC because they worsen symptoms of the disease:

• Milk (and milk products)
• Spicy foods
• Fats
• Sugars

Following surgery, people with UC should avoid the following foods as they may increase the risk for kidney stones:

• Spinach
• Rhubarb
• Beets
• Coffee
• Tea
• Diet sodas
• Chocolate

Prognosis and Complications

If left untreated, people with UC can develop a wide range of chronic, sometimes dangerous complications. Fortunately, however, most of these complications can be treated successfully. They include:

• Hemorrhage (abnormal bleeding)
• Perforation of the colon
• Narrowing of the colon, which may cause obstruction
• Abscesses (pus-filled pockets of infection) in the colon
• Toxic megacolon (grossly swollen colon that may rupture)
• Colon cancer
• Nutritional problems (including weight loss and reduced muscle mass)
• Joint pain and arthritis (such as ankylosing spondylitis)
• Skin rashes, including erythema nodosum
• Eye infections/inflammation including uveitis
• Mouth ulcers
• Liver damage
• Blood clots
• Depression and anxiety

Although there is no complete cure for UC other than surgical removal of the colon, many people with the disease lead active lives by controlling their symptoms with medication. In fact, drug treatment is effective for about 70% to 80% of all people with the condition. About 45% of all people with UC are free of symptoms at any given time, but most suffer at least one relapse in any 10-year period. Although extensive research is still needed in the area of complementary and alternative medicine for UC, preliminary studies indicate that lifestyle changes, including stress reduction, dietary adjustments, and mind/body techniques can work well with conventional therapies to help prevent and/or treat the disease.

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