A number of infections and other conditions can cause the rectum to become irritated and inflamed, but few of them cause lasting symptoms. Ulcerative colitis, however, is a lifelong condition that begins with rectal inflammation and can worsen to involve much or all of the large intestine. Ulcerative colitis most often begins to cause symptoms between the ages of 15 and 40.

Research suggests that ulcerative colitis is genetic (inherited). The illness may begin with a breakdown in the lining of the intestine. Normally, the lining of the intestines keeps bacteria that normally live in the colon carefully sealed within the digestive "pipeline." As long as the bacteria are perfectly contained, it remains invisible to your immune cells and does not provoke a reaction. When the intestine's lining fails, bacteria that usually are harmless can activate your immune system. Ulcerative colitis is an autoimmune disease, meaning that the immune system attacks part of the body. In ulcerative colitis, cells from the immune system collect in the bowel wall and cause inflammation, injuring the bowel. Once the bowel inflammation has started, it can continue, even if the immune system stops being exposed to the bowel bacteria.

Ulcerative colitis affects the inner lining of the rectum and colon, causing it to wear away in spots (leaving ulcers), and to bleed or to ooze cloudy mucus or pus. Sometimes, other parts of the body are affected by the inflammation, including the eyes, skin, liver, back and joints. One serious concern about ulcerative colitis is that it substantially increases the risk of colon cancer.

The disease is not contagious, even within families, so contact with another person cannot spread the disease.

The symptoms of ulcerative colitis vary. Some people with the disease have a burst of symptoms every few months. Others have symptoms either all the time or very rarely.

Typical symptoms include:

• Cramping abdominal pain, especially in the lower abdomen
• Bloody diarrhea, often containing pus or mucus
• A feeling that you have little warning before you need to have a bowel movement
• The need to wake from sleep to have bowel movements

Ulcerative colitis also may cause fever, fatigue, decreased appetite and weight loss. It also can lead to dehydration by causing you to lose fluids.

To confirm a diagnosis of ulcerative colitis, most patients will need to have either flexible sigmoidoscopy or colonoscopy. Both procedures involve the use of a small movable camera and a light to view the insides of your large intestine. During either procedure, a biopsy may be done. In a biopsy, small samples of tissue are clipped from the lining of the intestine so that they can be examined under a microscope for signs of inflammation.

Because many temporary conditions, such as infections, cause the same symptoms as ulcerative colitis, your doctor will want to test your stool for other conditions that could explain your symptoms or make your symptoms worse. Tests for parasites and for bacterial infections will be done. Blood tests will be done to check for a low blood count or low iron levels, which can occur in ulcerative colitis. Blood tests also can help to detect inflammation. Blood tests should be done to check on your liver because inflammation of the liver ducts (called sclerosing cholangitis) occurs in some people with ulcerative colitis.

Ulcerative colitis is a lifelong condition, unless the large intestine is removed by surgery. Most people with ulcerative colitis do not choose to have their colon removed, because their symptoms can be controlled with medication or because they only have symptoms once in a while. In ulcerative colitis, the inflammation is not always active, so there can be long breaks between symptoms. Each time ulcerative colitis acts up, symptoms can occur for weeks or months. Often these flare-ups are separated by months or years of good health with no symptoms. Some people are able to identify triggers that aggravate their symptoms. By managing their diet, these people can increase the time between flare-ups.

There is no way to prevent ulcerative colitis. However, some people are able to decrease the frequency of symptoms by avoiding certain foods, such as spicy foods or milk products. If you have ulcerative colitis, you can decrease the toll the condition takes on your body by eating a well-balanced, nutritious diet. By storing up vitamins and nutrients, even between episodes of symptoms, you can decrease complications from malnutrition, such as weight loss or a low blood count.

It's important to know that ulcerative colitis increases your risk of colon cancer. People with extensive inflammation in the whole colon have the highest risk. When the entire colon is involved, the risk of cancer can be as much as 32 times normal. About 5% of people with ulcerative colitis will develop cancer in the colon. Because of the higher cancer risk, it is important to have your colon checked frequently for early signs of cancer. If you have had ulcerative colitis affecting the entire colon for 8 years or more, or if you have had just the bottom half of the colon affected for 15 years, you should start being screened regularly for cancer. One good strategy is to have a colonoscopy every 1 to 2 years.

Poor nutrition or the effect of colitis medicines can lead to osteoporosis, a disease that weakens bones and can cause bones to break. Osteoporosis can be prevented with specific medicines, as well as adequate exercise, calcium and vitamin D. If you have ulcerative colitis, you should discuss this issue with your doctor.

Medications
Medications are very effective at improving the symptoms of ulcerative colitis. Most of the medications that are used work by preventing inflammation in the intestine.

The medicines that commonly are tried first are a group of anti-inflammatory medicines called aminosalicylates. These medicines are chemically related to aspirin, and they suppress inflammation in the gut and in joints. They are given either by mouth or directly into the rectum, as a suppository (a waxy capsule that is inserted into the rectum) or an enema (liquid that is squeezed from a bag or bottle into the rectum). Some medicines in this group include sulfasalazine (Azulfidine), mesalamine (Asacol, Pentasa, Rowasa) and olsalazine (Dipentum). These medicines clear up symptoms in most people, but you may need to be treated for three to six weeks before you are free of symptoms.

Other, more powerful anti-inflammatory medicines are helpful, but they suppress the immune system, which causes an increased risk of infections. For this reason, they are used less often for long-term treatment. These medicines include prednisone (sold under several brand names), methylprednisolone (Medrol), budesonide (Entocort), azathioprine (Imuran), mercaptopurine (Purinethol), infliximab (Remicade) and cyclosporine (Neoral, Sandimmune).

You may also be given medicines that make symptoms less painful by decreasing spasms of the colon. One example is hyoscyamine (Levsin, NuLev).

When symptoms are severe or when diarrhea causes dehydration, you may need to be admitted to the hospital to get fluids and, sometimes, nutrition intravenously (through a vein) while the colon recovers.

Surgery
Surgery is used in people who have severe symptoms that are not controlled by medicines, who have unacceptable side effects from medicines, or who have a very high risk of colon cancer because of extensive inflammation in the whole colon. One of several surgeries may be used to treat ulcerative colitis, depending on the amount of colon that is affected. Either part of the colon or the entire colon can be removed. After some surgeries, bowel movements will have to leave the body through an opening called a stoma in the abdominal wall. The stoma replaces the function of the rectum, and may be connected to a drainage bag. It may be used temporarily or permanently. Newer surgical techniques allow many patients to keep the layer of the rectum that contains its muscles, even though the lining of the rectum needs to be removed. This type of surgery (called ileoanal anastomosis, or pull-through surgery) has a cosmetic advantage, and it allows bowel movements to pass through the rectum and to be near normal, except that bowel movements are more frequent (usually five to six times per day) and contain more liquid.

New or changing symptoms often mean that additional treatment is needed to keep ulcerative colitis under control. For this reason, people who have ulcerative colitis should be in frequent contact with their physicians. Common symptoms that require a doctor's immediate attention are fever, which could indicate infection or a ruptured intestine, and heavy bleeding from the rectum. A serious, but uncommon, complication, called megacolon, results when the colon inflammation is so severe that it stops the colon's motion. Megacolon causes the abdomen to swell, which can cause vomiting or severe abdominal pain and bloating. Megacolon requires emergency treatment.

Ulcerative colitis can affect people very differently. Many people have only mild symptoms and do not require continuous treatment with medicines. Others might require multiple medicines or surgery. Unless it is treated with surgery, this disease is a lifelong condition. Ulcerative colitis requires people to pay special attention to their health needs and to seek frequent medical care, but it does not prevent most people from having normal jobs and productive lives. As is the case for any chronic illness, it can be helpful for a person newly diagnosed with ulcerative colitis to seek advice from a support group of other people with the disease.

Crohn's and Colitis Foundation of America
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National Institute of Diabetes and Digestive and Kidney Disorders
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Bethesda, MD 20892-2560
Phone: 301-496-3583
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