Ulcerative Colitis

*The information on this website is not intended to diagnose, treat, cure or prevent any disease.

WHAT IS ULCERATIVE COLITIS?

Ulcerative colitis is an inflammatory bowel disease, similar to Crohn’s disease. It has some of the same symptoms and potential genetic therapy targets, but also has some distinct symptoms and causes. The major difference between these two diseases is the extent of the inflammation in the intestinal tract. Ulcerative colitis causes diffuse, continuous inflammation in the colon, without any areas of healthy tissue, but it does not extend past the innermost layer (the mucosal layer). It does not affect any other area of the GI tract, unlike Crohn’s disease, which can occur anywhere from the mouth to the anus, and can affect all the layers of the intestinal tissue.

Ulcerative colitis can be an extremely painful condition with a heavy impact on quality of life. Both adults and children can be diagnosed with ulcerative colitis, and it tends to become more severe as time goes on. Globally, more than 11 million people suffer from ulcerative colitis and it appears to have become more common in the last 50 years, particularly in Westernized countries.

COMMON SYMPTOMS

The primary symptoms associated with ulcerative colitis are usually gastrointestinal (GI) in nature, or associated with the severe changes to the GI tract, however there can be a diverse range of symptoms in those afflicted. Major GI symptoms include:

Mucoid, blood tinged diarrhea
Weight loss
Abdominal pain
Straining to defecate
Urgent defecations
Rectal pain and/or bleeding

Ulcerative colitis causes severe inflammation in the body, and can result in other odd symptoms which may seem unrelated. These include:

Arthritis (especially in teenagers and young adults)
Fever
Fatigue
Failure to thrive in young children
Anemia due to chronic GI bleeding
Muscle pain (especially neck/lower back)
Rashes/Eczema
Ocular pain or vision changes
Kidney and liver disease

Additionally, ulcerative colitis is an extremely stressful condition, and mental health can also be impacted. The sleep quality of people with ulcerative colitis is often very poor, which can lead to an increased risk for depression and significant difficulties in daily life. Urgency of defecation can cause high psychological stress. The psychological impact of these symptoms can be debilitating, making social activities and work difficult. Patients also often feel a general sense of malaise because of the stress placed on their bodies.

DIAGNOSIS

Diagnosis of ulcerative colitis is difficult because it can present in many different ways, affecting only certain parts of the colon or not showing characteristic symptoms. There is a new gene analysis that can differentiate between ulcerative colitis and similar conditions, but it doesn’t work for all cases, since there tends to be some overlap. The best and most reliable way to diagnose ulcerative colitis at this point is through colonoscopy, which allows direct visualization of the colon and permits taking small biopsies.Biopsies are often required to definitively distinguish ulcerative colitis from Crohn’s disease.

Important lab tests which may be helpful in diagnosing ulcerative colitis often include:

Systemic bloodwork to assess:
- Electrolyte levels
- Red blood cell counts
- Inflammatory markers like C-reactive protein
- Serum albumin levels (a blood protein which is lost during intestinal inflammation)

Other tests which may be recommended may include imaging studies including computerized tomography (CT) scans and barium studies to evaluate the anatomy of the GI tract and determine the extent of disease.

TREATMENT OPTIONS

Ulcerative colitis is progressive, so early treatment is crucial. Many of the same treatments for Crohn’s disease work for ulcerative colitis, using immunosuppressants and anti-inflammatories. Steroids are also helpful for ulcerative colitis patients. Like Crohn’s disease, surgeries are often necessary, but ulcerative colitis can require massive surgical intervention, including removal of the entire colon. A patient’s response to early treatments, like steroids and other medication, is a good predictor of whether they will have more severe disease in the future. Transplants of healthy bacteria are also being tested as a treatment for the imbalances caused by ulcerative colitis, since they’ve been successful in some similar conditions.

Pharmaceuticals:

Corticosteroids: Corticosteroids are powerful anti-inflammatories which are most useful during acute flare ups. Due to their side effect profile, they are not used for maintenance therapy once inflammation is back under control.
5-aminosalicylates: Drugs like sulfasalazine can be useful in keeping ulcerative colitis in remission, particularly in mild to moderate cases.
Immunosuppressants: There are now a number of drugs available which target the immune system and pathways leading to inflammation. Many of these drugs are derived from human antibodies to target tumor necrosis factor (TNF) – a major inflammatory compound which is overactive in ulcerative colitis. Examples of immunosuppressive drugs used include:
- Golimumab
- Infliximab
- Adalimumab
- Tofacitinib
- Etrolizumab
- Azathioprine
- Cyclosporine
Antibiotics: In some patients, antibiotics may be needed due to infections which can occur from the severe damage to the colon.
Analgesics: Pain management can be very important. Although inflammation is a major component of ulcerative colitis, it is important to avoid Non-Steroid Anti-inflammatories like ibuprofen or naproxen which can cause further damage to the intestines. Acetaminophen is a much safe option.

Surgery/Procedures

Colectomy: The colon and rectum are typically both removed, and the end of the small intestine is then attached to a hole (called a stoma) made in the body wall. A colostomy bag can be attached to this hole to allow collection of waste.
Ileo-anal pouch: This is similar to a colectomy, however instead of permanent stoma being created in the body wall, the end of the small intestine is made into a J-shaped pouch and attached to the anus. This will allow passage of waste through the anus rather than collecting into a colostomy bag. As this requires time to heal, a temporary stoma is made in the body wall to allow passage of waste, and then it is closed after several months.
Leukocyte apheresis: This is a procedure which actually removes specific white blood cells from the body (cells involved in immunity and inflammation). Removing these cells can help relieve and reduce inflammation in the colon.
Fecal transplant: This procedure involves transplantation of fecal material from healthy donors into the intestinal tract of people with ulcerative colitis. Changing the bacterial population can be extremely effective for relieving symptoms of ulcerative colitis.

Non-pharmaceutical/Alternative Therapies

Reducing GI inflammation
- Diet
  - Dietary modification
  - Elemental liquid diet
  - Low residue diets
  - Anti-fungal diet
  - Smaller, more frequent meals
  - Eliminate alcohol and caffeine
  - Increase omega-3 and Omega-6 Fatty Acids
Rebalancing GI flora
- Probiotics
- Eating fermented foods
  - Yogurt
  - Kimchi
  - Kombucha
  - Kefir
  - Tempeh
- Avoid artificial sweeteners: these may be toxic to normal GI bacteria
Relaxation training: Stress management training can significantly improve symptoms of ulcerative colitis, as well as improving anxiety and mood.
Cognitive Behavior Therapy: Psychotherapy can be extremely beneficial in ulcerative colitis due to the concomitant depression which occurs. Management of depressive symptoms through cognitive behavior therapy improved both depression scores and lessened symptoms of ulcerative colitis.
Biofeedback: This is a technique which allows a person to visualize a biologic parameter and helps them develop skills to manage that particular issue. This allows a person to reduce their own pain, and eventually, manage it without external visualization of their tension or pain.
Hypnosis
Yoga
Supplements
- Turmeric/curcumin
- Psyllium
- Probiotics
- Aloe Vera
- Slippery Elm
- B-vitamins
- Fish Oil
- Boswellia
- Kratom
Biofield Therapy: Manipulation of biofields which surround and penetrate the body. The goal is to promote healing within the body.
Bioelectromagnetic Therapy: The application of electromagnetic fields to manipulate the natural electrical currents in the body.
Sauna/detox
Acupuncture
Moxibustion: A traditional Chinese therapy which involves burning dried mug wort on the body. Sometimes combined with acupuncture.
Parasite Therapy: Intentional self-infection with parasites.

PREVENTION

There are no proven ways to prevent ulcerative colitis from occurring, however the most important factors are likely maintaining good overall health. This should include things like exercise, maintaining a healthy body weight, eating a well-balanced, nutritious diet, and managing stress levels. There may be a link between ulcerative colitis and low vitamin D levels, so supplementing this vitamin, especially at high latitudes, may be important. Oddly, smoking decreases the risk of ulcerative colitis, however it is difficult to recommend this particularly treatment given the huge amount of negative health effects of smoking.

The success of fecal transplants in ulcerative colitis may also suggest that the microbiome in the gut plays an important role in regulating gut health and possibly preventing ulcerative colitis. Therefore, it may be tempting to supplement probiotics, particularly if ulcerative colitis runs in your family. Unfortunately, the understanding of which bacteria are beneficial and which are harmful is not well-understood, and may vary from individual to individual. In some people, probiotics help prevent flare-ups, while they make them more frequent or worse in others. Probiotics have not been proven to prevent the development of ulcerative colitis.

Once ulcerative colitis occurs, preventing flare-ups becomes paramount. Many of the alternative therapies listed above which are aimed at stress management and psychological well-being are key strategies to preventing flare-ups. Additionally, dietary management like avoiding spicy/hot foods, eating a low-fiber/low-residue diet, and eating smaller meals can be extremely helpful. Other strategies to improve overall well-being include avoiding or limiting alcohol and caffeine.

Prevention of severe complications is an important part of ulcerative colitis treatment, and in order to prevent illness, patients must often be on multiple medications at once. The colon can bleed profusely, requiring a blood transfusion. Current medications and treatments cannot fix the underlying cause of the inflammation, though, so any prevention is geared toward maintenance. Like Crohn’s disease, there is no definitive genetic test for ulcerative colitis, but there are a number of genes that play a role.

CAUSES

Ulcerative colitis appears to be an overly-reactive immune system, which is why many therapies are geared toward suppressing the immune-response (or even removing the white blood cells responsible). What triggers this hyper-response of the immune system is unclear, however there are likely many possible factors. These might include things like bacterial or viral infections, which may trigger an inappropriate response. Agents such Salmonella, Shigella, E. coli, and Clostridium difficile species all have the potential to set up long-standing infections or damage the intestinal wall in such a way that the body misidentifies normal intestinal materials as foreign invaders. Furthermore, these infections often disrupt the normal bacterial communities, shifting the ratios of beneficial and harmful bacteria (a condition called dysbiosis).

Dysbiosis (and Clostridium difficile infections) are often a consequence of antibiotic use, and it is possible the rise in antibiotic use has contributed to the prevalence of ulcerative colitis. Beneficial bacteria also have an important role in “feeding” the cells of the colon and promoting GI health. These bacteria ferment sugars which are undigestible, and produce short-chain fatty acids which are a preferred source of energy for colonic cells. If these bacteria are wiped out or replaced with other bacteria, the cells of the colon are deprived of an important energy resource, resulting in impairment of the normal host defense mechanisms and leakiness of the barrier which prevents intestinal bacteria from crossing into the blood stream. As bacteria cross over, the body may begin to view normally beneficial bacteria as hostile invaders, setting up repeated bouts of inflammation.

Ulcerative colitis also runs in families, so some people are likely genetically pre-disposed to develop this dysfunctional immune response.

Stress may also play a role. Chronic stress on the body has many impacts on the immune system and body, and is a known trigger for a broad array of autoimmune disorders. This is likely why stress management strategies are so important in preventing flare-ups.

As ulcerative colitis is on the rise, it begs the question as to why. This suggests that there are factors about our modern lives which are contributing to ulcerative colitis. Although chronic stress and diet changes may explain it, there are other possibilities including our high levels of hygiene and cleanliness, and our relative lack of parasites. The hygiene hypothesis, which attempts to explain allergies and other autoimmune disorders, suggests that our lack of exposure to true pathogens and immunological threats means that our bodies never received the proper training to identify truly problematic organisms, and therefore overreacts to either our own tissues or beneficial bacterial. Additionally, some parasites like hookworms actually secrete anti-inflammatory compounds (which help them survive in the GI tract). Because until recently, humans likely always had a parasite burden, it is possible that co-evolved with these organisms and may actually benefit from their anti-inflammatory compounds. Indeed, people have intentionally infected themselves with parasites after all else had failed and have had profound improvements in their symptoms.