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Ulcerative colitis

Ulcerative colitis is a long-term condition affecting your large bowel and rectum. It causes symptoms such as frequent diarrhoea, which can come and go. There are a number of treatments available which can help to control your symptoms. However, if these treatments don’t help to ease your symptoms, you may consider having surgery. If you have severe ulcerative colitis that hasn’t improved with medications, you may be offered more urgent, or emergency surgery.

Ulcerative colitis is the most common type of inflammatory bowel disease. In ulcerative colitis, the lining of your large bowel and rectum (back passage) become inflamed and may develop ulcers. This means that your large bowel can't absorb as much water as usual, which causes you to have diarrhoea.

The condition affects about one in 500 people in the UK. It usually develops between the ages of 15 and 25. The condition is rare in childhood, but it can occur at any time in your life. It’s equally common in men and women.

Ulcerative colitis is usually an ongoing condition that can last throughout your lifetime. However, you may find that your symptoms follow a relapsing and remitting pattern. This means that your symptoms can disappear and flare-up again from time to time. Flare-ups of ulcerative colitis can be unpredictable. There are a number of treatment options which can help to control your symptoms and prevent flare-ups from happening.

Types of ulcerative colitis

Ulcerative colitis usually starts in the lowest part of your bowel called the rectum, but it can affect your entire large bowel. The amount of large bowel affected by the condition can differ from person to person but usually doesn’t change over time.

Your symptoms can depend on the extent of inflammation in your large bowel. Therefore, it can be helpful to know how much of your large bowel is affected. Your gastroenterologist (a doctor who specialises in identifying and treating conditions affecting the digestive system) may define your condition using terms such as the following.

  • Proctitis – ulcerative colitis that only affects your rectum. Symptoms of proctitis tend to be less severe because only your rectum is affected.
  • Proctosigmoiditis – inflammation in your rectum and sigmoid colon (the part of your large bowel closest to your rectum).
  • Left sided colitis – inflammation that begins in your rectum and continues into the left side of your large bowel.
  • Extensive colitis – ulcerative colitis that affects most, or all, of your large bowel.
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Details

  • Symptoms Symptoms of ulcerative colitis

    The symptoms of ulcerative colitis usually come and go. You may have periods without any symptoms, known as remission, and periods when you have symptoms, known as flare-ups.

    You may find that you feel perfectly well between flare-ups, when you have no symptoms at all. During a flare-up, the main symptom of ulcerative colitis is frequent diarrhoea, which may be mixed with blood or mucus. You may also have lower abdominal (tummy) pain or cramps and need to rush to the toilet. Other symptoms include:

    • feeling generally unwell
    • loss of appetite
    • weight loss
    • having a high temperature
    • feeling tired

    If you have proctitis, you may not have diarrhoea, but still frequently feel an urgent need to have a bowel movement. You may also have bleeding or mucus from your rectum.

    If you have ulcerative colitis, there is a chance that you could develop problems in other parts of your body. These can include mouth ulcers, skin rashes and inflammation (redness or pain) in your eyes, skin or joints. Problems outside the large bowel often occur during a flare-up but can also happen while you’re in remission.

    These symptoms may be caused by problems other than ulcerative colitis. If you have any of these symptoms, see your GP for advice.

  • Diagnosis Diagnosis of ulcerative colitis

    Your GP will ask about your symptoms and examine you. He or she may also ask about your medical history, if you have any family members with bowel problems and if you’ve travelled abroad recently.

    Your GP may ask you for a sample of faeces (also called a stool sample) to rule out a bacterial infection. He or she may also ask you to have a blood test. This is to check for a number of things including anaemia and signs of inflammation.

    Depending on the results, your GP may refer you to a gastroenterologist. He or she may advise you to have more tests, which can include the following.

    • Faecal calprotectin. This test allows your gastroenterologist to rule out other conditions, such as irritable bowel syndrome. You will be asked to provide a sample of faeces, which can be sent to the laboratory for testing.
    • Colonoscopy. This allows your gastroenterologist to look at the lining of your entire large bowel using a narrow, flexible, tube-like camera called a colonoscope. The colonoscope is carefully passed through your anus and rectum. Your gastroenterologist will then check for any ulcers or inflammation present on the inside of your bowel.
    • Flexible sigmoidoscopy. This allows your gastroenterologist to look inside your rectum and the lower part of your bowel using a sigmoidoscope. This is a tube-like camera similar to a colonoscope but shorter.
    • Biopsy. A biopsy is a small sample of tissue. Your gastroenterologist may take a small sample of the tissue from inside your bowel during a colonoscopy or sigmoidoscopy. This will be sent to a laboratory for testing.
    • Barium enema X-ray. This test helps to show how much of your large bowel is affected by the condition. It involves placing a fluid containing barium (a substance that shows up on X-rays) into your bowel via your rectum. Your gastroenterologist can then view X-ray images of your bowel.
  • Treatment Treatment of ulcerative colitis

    At the moment, there isn’t a medical cure for ulcerative colitis. However, there are treatments that can help to settle flare-ups and prevent complications.

    Medicines

    Your gastroenterologist can prescribe you medicines to control your symptoms and prevent flare-ups. You may need different treatments for when you’re in remission and when you’re having a flare-up. Medicines for ulcerative colitis include the following.

    • Aminosalicylates, such as mesalazine. You can take these by mouth, as a rectal suppository or as an enema (inserted into your rectum). These are used both during a flare-up and between them to increase the length of periods of remission.
    • Steroids. You may need to take these if aminosalicylates don’t control your symptoms or if you’re having a flare-up. You can take steroids as tablets, as a rectal suppository or as an enema. You may also be given steroids through a drip if your flare-up is very severe. Steroids can cause side-effects over the long term, so your gastroenterologist will make sure you’re taking only the minimum amount needed to control your symptoms.
    • Immunosuppressants, such as azathioprine. These are tablets that suppress your immune system. Your gastroenterologist may prescribe these if your symptoms haven’t improved with other treatments.
    • During a severe flare-up, you could be offered stronger medicines such as ciclosporin or infliximab. You will need to go to hospital and may be given these through a drip in your arm.

    Your gastroenterologist will advise which treatment is best for you. This may depend on the type of medicine you would prefer and how severe your symptoms are. Always ask your gastroenterologist for advice and read the patient information leaflet that comes with your medicine.

    Surgery

    If medicines don't improve your symptoms, your gastroenterologist may recommend an operation to remove your large bowel (a colectomy). Your small bowel will be redirected so that your body is still able to get rid of waste products. There are three ways to do this. You will be given the chance to talk to your gastroenterologist about which kind of operation is best for you.

    • Proctocolectomy with permanent ileostomy. Your surgeon will remove your entire large bowel, rectum and anus, closing off your back passage permanently. Your small bowel will then be brought onto the surface of your abdomen, usually to the right of and below your tummy button. This is called a stoma (ileostomy). You will need to use an external bag placed over the opening, called an ileostomy bag, to collect waste.
    • Pouch surgery. Your surgeon will remove your large bowel and rectum. Your surgeon will then make a pouch from the end of your small bowel, which is stitched to your anus. This means that your bowel movements can pass through your anus. However, you may need a temporary ileostomy for a couple of months so that waste can be diverted while the new pouch heals. Your surgeon will close the ileostomy once the pouch has healed.
    • Colectomy with ileorectal anastomosis. Your surgeon will remove your large bowel and join the end of your small bowel directly to your rectum. This means that you won’t have an ileostomy and will be able to pass bowel movements through your anus. This operation will probably only be suitable for you if you have very low levels of inflammation in your rectum.

    You may need a more urgent operation if you develop toxic megacolon. It’s likely that a surgeon will remove your large bowel but not your rectum. This means you can choose to have a pouch or permanent ileostomy once you have recovered.

    Speak to your gastroenterologist if you would like more information about these procedures.

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  • Causes Causes of ulcerative colitis

    The exact reasons why you may develop ulcerative colitis aren't fully understood at present. It’s likely that a combination of factors are involved. The condition may run in families. If you have a close family member with ulcerative colitis, you’re about 10 times more likely to develop the condition. It's also thought that other factors, such as eating certain types of food or getting some infections, could trigger it.

  • Complications Complications of ulcerative colitis

    Ulcerative colitis can lead to a number of complications.

    • If you lose a lot of blood through your bowel movements, you may develop anaemia. This is a condition in which your blood is unable to carry enough oxygen around your body. It can make you feel very tired. There are many treatment options available for anaemia, which can include iron supplements from your GP.
    • You may develop a complication known as toxic megacolon. This is when your large bowel becomes large and full of gas. Symptoms of toxic megacolon include a high temperature and a painful, tender abdomen. If you have these symptoms, you must seek urgent medical attention.
    • Having ulcerative colitis can slightly increase your risk of developing bowel cancer. Your risk is greater if you have had ulcerative colitis for a long time, and if a large amount of your bowel is affected. You will need to have regular colonoscopies to check for any signs of cancer developing.
    • Treatments for ulcerative colitis can have side-effects. For example, corticosteroids (steroids), can increase your risk of osteoporosis, diabetes and can make you put on weight. Osteoporosis can make your bones weaker. To prevent this, your gastroenterologist will recommend that you have calcium or vitamin D tablets while taking oral steroids.
  • Living with ulcerative colitis Living with ulcerative colitis

    Having ulcerative colitis can have an emotional impact on your life and you may find that you feel stressed at times. Although stress doesn’t cause ulcerative colitis, it may contribute to your flare-ups. If you start to feel stressed, you could try some simple stress-reduction techniques to help you relax.

    Having a long-term condition like ulcerative colitis can affect your sense of wellbeing. Because flare-ups can be unpredictable, you might feel anxious about going out. Having a flare-up plan can help you overcome these feelings. Before going out, it might be useful to find out where public toilets are located. If you’re worried about having an accident, carry spare clothing in your bag so you can change. Talk to your gastroenterologist about what to do when you have a flare-up, as you may need to adjust your medication. You may find it useful to carry a supply of steroid tablets with you when you travel on holiday. This way, if you have a flare-up, you will be able to treat it straight away. If you would like more information about how to manage your flare-ups, talk to your gastroenterologist.

    Although getting enough rest is important, regular exercise can help to relieve any tiredness that you may feel. Physical activity can also improve your general health and help to keep your bones strong. This is important because people with ulcerative colitis are more likely to develop osteoporosis (thinning of the bones). Aim to do 30 minutes of activity that gets you slightly breathless at least five days each week.

    If you feel like you need some further support, you could attend a self-help group to talk about your feelings. You may also find it helpful to read internet-based blogs or take part in online chat forums and message boards.

  • FAQs FAQs

    Can certain types of food cause ulcerative colitis?

    Answer

    The reasons why some people develop ulcerative colitis aren’t fully understood. There has been a lot of research investigating whether certain types of food can cause the condition or not. At the moment, there isn’t any evidence to suggest that any particular foods can cause ulcerative colitis. However, you may find that some types of food can make your symptoms worse.

    Explanation

    Some people find that certain foods can trigger their symptoms, or make them worse. These may include:

    • foods high in fibre
    • raw fruit and vegetables
    • spicy foods
    • dairy products, such as milk, cream and cheese

    You could try keeping a food diary to record what you eat and how severe your symptoms are. By doing this, you could see whether any particular types of food make your symptoms worse. If you identify any problem foods, you may wish to stop eating them to see if this helps. However, don't cut any food groups from your diet without speaking to your GP first. Try to make sure that you’re always eating a healthy, balanced diet. Having diarrhoea can cause you to become dehydrated so make sure you drink enough fluid to prevent this.

    Probiotics (foods containing live bacteria called lactobacillus) may help to control your symptoms or reduce your risk of having another flare-up. These can be found in some live yoghurts and milk drinks. More research needs to be carried out to find out how effective probiotics are for people with ulcerative colitis.

    What is the difference between Crohn's disease and ulcerative colitis?

    Answer

    Crohn's disease can affect any part of your digestive system from your mouth to your anus. Ulcerative colitis only affects your large bowel (colon).

    Explanation

    Crohn's disease and ulcerative colitis are both inflammatory bowel diseases. They can both cause inflammation of your bowel. Symptoms can include blood in your diarrhoea and weight loss. However, ulcerative colitis only affects the surface of your large bowel and rectum (back passage). Crohn's disease can affect any part of your bowel wall throughout your digestive system, from your mouth to your anus. Unlike ulcerative colitis, it may be patchy and affect a number of parts of your bowel.

    Treatment with medicines is similar for both conditions. If you have ulcerative colitis and medicines aren’t helping, you may be able to have an operation to remove your large bowel. If you have Crohn's disease however, the condition can’t be cured with surgery.

    I've heard that having ulcerative colitis increases your risk of developing cancer. Is there anything I can do to reduce my risk?

    Answer

    If you have ulcerative colitis, you may be able to help reduce your risk of bowel cancer by regularly taking certain medicines known as 5-aminosalicylates. There are also a number of lifestyle changes that could help lower your risk such as trying to stay a healthy weight. It’s also important to monitor your condition by having colonoscopies when your gastroenterologist recommends them.

    Explanation

    If you have ulcerative colitis, you have a slightly increased risk of developing bowel cancer. Your risk is greater if a large portion of your bowel is affected or you have had severe ulcerative colitis for over eight years.

    Studies show that your risk of getting bowel cancer is lower if you regularly take certain medicines known as 5-aminosalicylates. This is because these medicines can help to reduce long-term inflammation.

    Lifestyle changes, such as doing regular physical activity, have also been shown to reduce your risk of bowel cancer. Aim to do 30 minutes of physical activity on at least five days each week.

    The following healthy eating advice could also help to reduce your risk of developing bowel cancer.

    • If possible, try to eat foods that are high in fibre such as fruits, vegetables and wholegrain cereals.
    • Try to eat less processed meats such as bacon, ham and sausages. Instead, you can replace these with fish or skinless chicken.
    • Eat less red meat, including beef, lamb and pork. Try to eat less than 500g of red meat per week.
    • Make sure you drink enough water.
    • Don’t drink alcohol to excess.
    • Aim to reduce your intake of drinks containing caffeine.

    If you have problems with eating foods that contain fibre, speak to your gastroenterologist. He or she may recommend that you speak to a dietitian.

    In addition to these lifestyle changes, it’s also important to monitor your condition so that any signs of cancer can be spotted early. Your gastroenterologist may advise you to have regular colonoscopies to check your bowel for early signs of cancer. A colonoscopy is a test where your gastroenterologist looks inside your bowel. This is done using a narrow, flexible, tube-like camera called a colonoscope. Your gastroenterologist may take a small sample of the tissue from inside your bowel during the colonoscopy. This will be sent to a laboratory for testing. Your gastroenterologist will advise you on how often you need to have a colonoscopy. This can depend on how long you have had ulcerative colitis, how much bowel is involved and how severe your symptoms are.

    If you need further information, ask your gastroenterologist for advice.

  • Resources Resources

    Further information

    Sources

    • Ulcerative colitis. Management in adults, children and young people. National Institute for Health and Care Excellence (NICE), 2013. www.nice.org.uk
    • Ulcerative colitis. Crohns and Colitis UK. www.crohnsandcolitis.org.uk, reviewed January 2011
    • Ulcerative colitis. NICE Clinical Knowledge Summaries. cks.nice,org.uk, reviewed June 2010
    • Simon C, Everitt H, van Dorp F. Oxford handbook of general practice. 3rd ed. Oxford: Oxford University Press, 2010: 422 ̶ 25, 516, 662
    • Quality care: service standards for the healthcare of people who have inflammatory bowel disease (IBD). The IBD Standards Group, 2009. www.ibdstandards.org.uk
    • Joint Formulary Committee. British National Formulary (online) London: BMJ group and Pharmaceutical Press. www.medicinescomplete.com, accessed 18 October 2013 (online version)
    • Wyatt JP, Illingworth RN, Graham CA, et al. Oxford handbook of emergency medicine. 3rd ed. Oxford: Oxford University Press, 2006: 515
    • Colonoscopic surveillance for prevention of colorectal cancer in people with ulcerative colitis, Crohn's disease or adenomas. National Institute for Health and Care Excellence (NICE), 2011. www.nice.org.uk
    • Bones and IBD. Crohns and Colitis UK. www.crohnsandcolitis.org.uk, reviewed November 2012
    • Mowat C, Cole A, Windsor A, et al. Guidelines for the management of inflammatory bowel disease in adults. Gut 2011; 60(5):571̶ 607. doi:10.1136/gut.2010.224154
    • Acute upper gastrointestinal bleeding: management. National Institute for Health and Clinical Excellence (NICE), 2012. www.nice.org.uk
    • Faecal calprotectin diagnostic tests for inflammatory diseases of the bowel. National Institute for Health and Care Excellence (NICE), 2013. www.nice.org.uk
    • Ulcerative colitis. Map of Medicine. www.mapofmedicine.com, published 2 October 2012
    • Staying well with IBD. Crohns and Colitis UK. www.crohnsandcolitis.org.uk, reviewed November 2012
    • Start Active, Stay Active. A report on physical activity for health from the four home countries’ Chief Medical Officers. Department of Health, 2011. www.gov.uk
    • Food and IBD. Crohns and Colitis UK. www.crohnsandcolitis.org.uk, reviewed September 2012
    • Crohns disease. Crohns and Colitis UK. www.crohnsandcolitis.org.uk, reviewed October 2013
    • Diet and Bowel Cancer UK, www.bowelcanceruk.org.uk, accessed 23 October 2013
    • Bowel Cancer and IBD. Crohns and Colitis UK. www.crohnsandcolitis.org.uk, reviewed January 2013
    • Why is exercise so important. Bowel Cancer UK. www.bowelcanceruk.org.uk, published 11 January 2011
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    Reviewed by Hemali Parekh, Bupa Health Information Team, December 2013.

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