Understanding Ulcerative Colitis

Overview of Ulcerative Colitis

Ulcerative Colitis (UC) is an inflammatory condition that primarily affects the lower gastrointestinal tract. Formally recognized as Idiopathic Inflammatory Bowel Disease (IBD), UC primarily impacts the colon, leading to symptoms such as rectal bleeding, bowel urgency, and diarrhea. The inflammation characteristic of UC can be identified through endoscopic procedures.

Causes and Demographics

The exact origins of UC remain unclear. However, several theories propose that it may be triggered by an immune response to foreign substances in the colon, genetic factors, and imbalances in intestinal microflora. Notably, UC is more prevalent among individuals aged 20 to 40, with a higher incidence reported in developed nations compared to developing ones. This discrepancy is often attributed to the hygiene hypothesis, which suggests that better sanitation and reduced early-life exposure to infections may lead to an underdeveloped immune system, consequently increasing the risk for autoimmune diseases, including UC.

Chronic Nature of UC

UC is classified as a chronic condition, as approximately 90% of patients experience inflammatory relapses despite receiving treatment.

Treatment Options for Ulcerative Colitis

5-Aminosalicylates

The first-line treatment for mild to moderate UC episodes includes oral or topical 5-aminosalicylates. These medications work by inhibiting immune system activity, thereby reducing inflammation. A recent review highlighted the efficacy of the oral drug mesalazine, noting success rates for inflammatory remission up to 70%. Side effects may include headache, abdominal pain, nausea, vomiting, skin rashes, and diarrhea. Topical 5-aminosalicylates, delivered through enemas and suppositories, show even higher success rates, achieving up to 80% remission. The combination of oral and topical treatments further enhances effectiveness. Mesalazine and sulfasalazine remain foundational treatments even after remission, although mesalazine is often better tolerated. Regular monitoring of renal function is advised every three months during treatment.

Glucocorticoids

For severe UC episodes characterized by six or more bloody stools daily, glucocorticoids become the preferred treatment option, with remission rates reaching up to 80%. These steroid hormones inhibit inflammation. However, careful monitoring for potential side effects—such as infections, weight gain, hyperglycemia, acne, excessive hair growth, hypertension, and bone loss—is critical, particularly for prolonged use beyond three months. Calcium and Vitamin D supplements may help preserve bone health, especially in patients over 65. Bone density scans are recommended after three months of glucocorticoid therapy.

Biologics

In cases where glucocorticoids fail to provide relief within three to five days, anti-tumor biological agents like infliximab and adalimumab are recommended, with remission rates of up to 60%. Biologics are derived from natural sources unlike traditional drugs, which are chemically formulated. Potential mild side effects include headache, nausea, vomiting, and muscle pain, while more severe risks include tuberculosis and lymphoma. Cyclosporin is another effective agent with success rates comparable to infliximab.

Immunosuppressants

The cyclical nature of inflammation in UC often necessitates the use of immunosuppressants such as azathioprine and mercaptopurine from the thiopurine class. However, their efficacy is generally limited. Side effects may include bone marrow suppression, infections, liver damage, immune hypersensitivity, and an increased risk of skin cancer. A test for thiopurine methyl transferase (TPMT) activity is essential before starting thiopurines to prevent bone marrow suppression. Other noteworthy immunosuppressants include tacrolimus and golimumab.

Surgery

Approximately 10% of UC patients may need to consider colectomy due to frequent relapses despite medication. Research indicates that patients who undergo this surgery often achieve a quality of life comparable to those without UC within a year. As with any surgical procedure, complications may arise, including reduced fertility in women and pouchitis, which can be treated with antibiotics and probiotics.

Additional Medical Considerations

Patients with UC should receive vaccinations against herpes (varicella zoster), hepatitis B, influenza, pneumococcus, and human papillomavirus. It is essential to avoid tuberculosis skin tests or interferon-based tests while undergoing treatment with glucocorticoids, biologics, or thiopurines. Routine check-ups for non-melanoma skin cancers are also crucial.

Individuals with UC are twice as likely to develop colorectal cancer, making surveillance important from ten years after the onset of symptoms. Women with UC may face additional risks during pregnancy, including spontaneous abortions, premature births, low birth weight, congenital anomalies, and a higher likelihood of cesarean sections. Thiopurines can harm the fetus and should be stopped during the third trimester. Interestingly, smokers have a lower incidence of UC compared to non-smokers, and about 5% of UC cases are misdiagnosed and actually represent Crohn’s disease.

If diagnosed with ulcerative colitis, it is advisable to consult a gastroenterologist for further guidance and information.

References

Ford, A.C., Moayyedi, P., Hanauer, S.B. and Kirsner, J.B. “Ulcerative colitis.” British Medical Journal 346:f432. February 5, 2013.
Written by Julia Yusupova