Ulcerative Colitis: Symptoms, Causes, and Treatment

Ulcerative colitis is classified as an inflammatory bowel disease (IBD) that primarily affects the digestive tract and can also affect other parts of the body. Ulcerative colitis can cause symptoms of abdominal pain, blood in loose stool, and fecal incontinence. Diagnosis and treatment of ulcerative colitis can be complicated since the symptoms differ for everyone. However, some common symptoms are shared and seem to be the most prevalent.

Ulcerative colitis is usually a progressive disease and starts with ulceration in the last part of the intestine and then spreads up through the rest of the colon, causing inflammation along the way. Depending on the form of ulcerative colitis, some of the symptoms may vary. However, the most common symptoms of ulcerative colitis include:

• Abdominal cramps
• Bloody diarrhea
• Fecal incontinence
• Loss of appetite

• Ulcerative proctitis: The mildest form of ulcerative colitis causes inflammation in the rectum due to fine ulcerations in the colon lining. The inflammation of ulcerative proctitis can cause diarrhea, bloody stool, rectal pain, and fecal incontinence.
• Proctosigmoiditis: This form of ulcerative colitis affects the last section of the colon that attaches to the rectum. Inflammation in this area can cause bloody diarrhea, fecal incontinence, and pain on the left side of the abdomen.
• Distal colitis: Inflammation with distal colitis starts in the rectum and extends up the left colon, causing bloody stools, weight loss, loss of appetite, and sometimes severe pain on the left side.
• Pancolitis: The most severe form of ulcerative colitis is pancolitis when the entire colon is inflamed. This inflammation throughout the whole colon causes diarrhea, cramps, significant weight loss, and severe abdominal pain.

Although there is no exact confirmed cause for ulcerative colitis, some factors contribute to it, such as a complex interaction of genetics, immune response, and environmental triggers. Some early research pointed at stress, mental illness, and diet as being potential triggers. However, it is now known that ulcerative colitis is not caused by stress or eating the wrong food.

Let’s take a look at how these factors may contribute to ulcerative colitis.

We have many genes in our bodies, and many of those genes get passed down to children. Therefore, a person is more likely to develop ulcerative colitis if there is a family history of the disease. However, that does not mean that a person will develop ulcerative colitis just because they have the genes associated with the disease. There are a variety of other factors that can contribute to ulcerative colitis beyond just genetics.

Since ulcerative colitis is an autoimmune disease, the immune system isn’t working properly to fight against bacteria and viruses. Instead, the immune system attacks healthy cells throughout the body, and in the case of ulcerative colitis, it attacks the large intestine. In addition, medications used to treat ulcerative colitis suppress the immune system, causing fewer flare-ups.

Other factors to consider in developing ulcerative colitis beyond genetics and the immune system response may be related to a person’s environment. Some of these environmental factors that could trigger a flare-up are:

Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

This type of pain medication is often used as a treatment in people with ulcerative colitis because it has been shown to decrease flare-ups of the disease. However, the continuous, long-term use of NSAIDs can cause irritation and bleeding in the digestive tract.

Antibiotics

Antibiotics have been shown to trigger flare-ups of ulcerative colitis for some people. In addition, when antibiotics are taken for an extended period or used in young people, it can be associated with a higher risk of developing a form of ulcerative colitis.

Geographic Location & Ethnicity

Ulcerative colitis tends to occur in people who live in cities within Northern Europe and North America and closely linked to a westernized environment and lifestyle. Ulcerative colitis also has a higher incidence in Jewish populations compared to any other ethnicity.

Ulcerative colitis can cause complications both within the digestive system and outside of it. Inside the digestive system, these problems are referred to as intestinal, and outside the digestive system, they are called extra-intestinal.

Intestinal complications from ulcerative colitis can include:

• Fissure: A fissure is a tear in the lining of the anal canal that can cause severe pain and bleeding during bowel movements. Anal fissures can be acute or chronic and are usually treatable at home without medical intervention.
• Bowel perforation: Intestinal perforation can happen when the colon’s wall becomes so weak due to chronic inflammation and ulceration of the intestine resulting in a hole. This perforation is life-threatening and needs immediate attention. Bacteria can spill into the abdomen, causing infection and toxicity.
• Toxic megacolon: Considered the most severe intestinal complication of ulcerative colitis, toxic megacolon needs emergency treatment. With toxic megacolon, the colon dilates, resulting in painful and uncomfortable abdominal distention. In addition, the colon loses its ability to contract and move gas along, and if not treated immediately, the colon could rupture.
• Colon cancer: The risk of developing colon cancer from Ulcerative colitis increases with the duration and severity of the disease. It is essential to schedule routine colon cancer screenings with a gastroenterologist.

Extra-intestinal complications from ulcerative colitis can include:

• Arthritis: Different forms of arthritis can occur in people with ulcerative colitis. The most common include:
  • Peripheral arthritis: Inflammation in the large joints such as knees, elbows, ankles, and wrists.
  • Rheumatoid arthritis: An autoimmune disease where the immune system attacks healthy cells, causing inflammation in many joints at once.
  • Axial arthritis: Inflammation in the lower spine, hips, pelvis, and buttocks.
  • Ankylosing spondylitis: Inflammation affecting the neck and back can cause the vertebrae to fuse, affecting the spine’s ability to flex.
• Delayed bone growth in teens: Many older medications for ulcerative colitis patients contain steroids. Unfortunately, steroids can stunt bone growth, causing teens with ulcerative colitis to have delayed bone growth.
• Mouth ulcers: With an ulcerative colitis flare-up, it is common to get mouth sores or canker sores. These mouth ulcers are small lesions at the base of the gums and can make eating and drinking painful.
• Skin problems: Ulcerative colitis can also cause painful skin rashes and irritations due to the inflammation within the body or from the medications used for treatment. Some of the skin conditions include:
  • Psoriasis: An immune disorder where skin cells build up and form red patches or silver scales on the skin.
  • Vitiligo: White patches of skin develop due to this autoimmune disorder where the cells that produce the skin pigment are destroyed.
  • Hives: These red, itchy rashes can occur anywhere on the body and are often caused by the medication used to treat ulcerative colitis.
  • Erythema nodosum: The most common skin problem for those with ulcerative colitis is erythema nodosum, where red nodules form on the legs and arms, appearing like bruises.
  • Pyoderma gangrenosum: This second most common skin issue is when small blisters form and spread to create a deep and painful ulcer. This skin problem is usually around the shin and ankles but can also form on the arms.
• Eye diseases: Several eye conditions such as glaucoma, uveitis (inflammation in the middle layer of the eye causing redness and blurred vision), episcleritis (redness on the whites of the eye), and dry eye are associated with ulcerative colitis or the treatments for the disease.

A gastroenterologist will discuss a treatment plan based on the form of ulcerative colitis and how long a person has been experiencing symptoms. Over-the-counter and prescription medications may be considered as well as lifestyle modifications. Probiotics may also be recommended to help restore healthy gut bacteria. In addition, surgical procedures may be discussed in more severe cases to remove diseased parts of the colon and help reduce the risk of developing colon cancer.

OTC medications may be used to relieve some symptoms of ulcerative colitis. However, they are used in conjunction with prescription drugs because they do not address the underlying causes of the disease.

Some of the most common OTC medications are:

• Antidiarrheal medications: Imodium (loperamide) can help with diarrhea but should be used with caution, as they can increase the risk of toxic megacolon.
• Pain relievers: For mild pain, Tylenol (acetaminophen) can be used. Advil or Motrin (ibuprofen), Aleve (naproxen sodium), and Voltaren (diclofenac sodium) should be avoided as these OTC medications can worsen symptoms.
• Enemas and suppositories: Those containing butyrate may effectively treat ulcerative colitis in the very last sections of the colon. Butyrate has been shown to be beneficial to the cells in the intestinal tract by combating inflammation, preventing cells from becoming cancerous, and reducing the effects of oxidative stress
• Iron supplements: In chronic intestinal bleeding, a person is at risk for developing iron deficiency anemia. The inflammation from ulcerative colitis disrupts the body’s ability to use stored iron or absorb it through food. Iron supplements may be able to help.

A gastroenterologist may use one or more combinations of prescription medications to treat the symptoms of ulcerative colitis. Some may be taken regularly, while other fast-acting drugs are given on a short-term basis to treat an active flare-up.

Anti-Inflammatories

As a first step in treating ulcerative colitis, gastroenterologists turn to anti-inflammatory medications, which can include:

• 5-aminosalicylates: Depending on which part of your colon is affected, these are taken orally or as an enema or suppository. Some examples include Azulfidine (sulfasalazine), Asacol HD (mesalamine), Colazal (balsalazide), and Dipentum (olsalazine).
• Corticosteroids: Prednisone and hydrocortisone are two types of corticosteroids used to treat ulcerative colitis and are reserved for moderate to severe ulcerative colitis. These medications’ potential unwanted side effects are weight gain, fluid retention, high blood pressure, mood changes, and osteoporosis.

Immune System Suppressors

Immune system suppressor medications control inflammation in the body by suppressing the immune system response. These medications are typically used in people who haven’t responded to or cannot tolerate other treatments and include:

• Azasan and Imuran (azathioprine); Purinethol and Purixan (mercaptopurine): These medications suppress the immune system by interfering with the body’s production of DNA molecules. The doctor will monitor their patient closely and take regular bloodwork, as side effects can affect the liver and pancreas.
• Gengraf, Neoral, and Sandimmune (cyclosporine): These immunosuppressants are generally reserved for people who haven’t responded well to other medications. Cyclosporine is believed to work by suppressing lymphocytes, a type of white blood cell. However, because cyclosporine has the potential for serious side effects, it is not intended for long-term use.
• Entyvio (vedolizumab): This medication works by blocking inflammatory cells from getting to the site of inflammation.
• Remicade (infliximab), Humira (adalimumab), and Simponi (golimumab): These drugs, called biologics or tumor necrosis factor (TNF) inhibitors, control the abnormal immune response.
• Xeljanz (tofacitinib): This is an oral medication that can regulate immune cell function, and it is used to treat moderate to severe ulcerative colitis.

Antibiotics

If an infection in the colon is suspected, the gastroenterologist may prescribe antibiotics to treat ulcerative colitis. However, it is essential to note that antibiotics can cause diarrhea and lead to uncomfortable and painful flare-ups.

If prescription medication side effects are too severe and other alternative treatment options have failed, the gastroenterologist will discuss surgical procedures to relieve the symptoms. There are two types of surgeries that involve removing the large intestine that are the most common in treating ulcerative colitis; “J-Pouch” and total proctocolectomy surgeries.

A proctocolectomy with ileal pouch-anal anastomosis (IPAA), or “J-Pouch” surgery, involves removing the large intestine and most of the rectum. The end of the small intestine is then used to form an internal pouch shaped like a J, hence “J-Pouch.” A temporary ileostomy is created by diverting the small intestine out of the abdomen to form a stoma. An ileostomy pouch is used to collect stool as the “J-Pouch” heals. After approximately 12 weeks, a second surgery is performed to reconnect the small intestine and allow regular bowel movements since the muscles of the anus remain intact.

“J-Pouch” surgery is not a cure for ulcerative colitis and does not entirely put a person in the clear for developing colon cancer.

This surgery involves complete removal of the large intestine, rectum, and anus and is a permanent cure for ulcerative colitis. A total proctocolectomy also eliminates the risk of colon cancer. However, because the rectum and anus are removed, the ileostomy is permanent, and ostomy supplies will be required for the rest of life.

Some patients with ulcerative colitis have responded well to complementary medicines. Although each person’s symptoms are different, the risk of using supplements, herbs, and other homeopathic remedies is low but should always be discussed with a gastroenterologist.

A few CAMs to consider discussing with a doctor may be:

Probiotics & Prebiotics

Probiotics act as a barrier by lining the bowels, so harmful bacteria cannot reach the intestinal wall. As a result, these microorganisms help “good” bacteria grow and are often able to reduce inflammation and improve the protective mucus lining of the gut.

Prebiotics are found in fibrous foods such as bananas, garlic, onions, asparagus, artichoke, and oats. These foods aid in the “good” bacteria in the colon. The undigestable prebiotic fibers from these foods help build up the gut lining, protecting it from harmful bacteria.

Boswellia

Boswellia is a medicinal herb derived from a tree native to India that has anti-inflammatory properties. The active ingredient is found in the resin of the bark. It has been used to treat inflammatory conditions such as rheumatoid arthritis without causing stomach irritation that some OTCs or prescription medications can cause.

Aloe Vera Gel

Aloe vera gel in its pure form is from inside the leaf of the aloe plant. This complimentary medicine has been found to have an anti-inflammatory effect in people with ulcerative colitis. It is critical to note that most stores carry aloe vera juice which is not the same as pure aloe vera gel. Aloe vera juice has a laxative effect and can cause diarrhea. For those with ulcerative colitis, aloe vera juice should be avoided.

Making a few changes to your lifestyle and diet may significantly impact relieving ulcerative colitis symptoms and prolong the time between flare-ups. Here are some examples to consider:

• Try eating small meals: Five or six small meals a day rather than two or three larger ones may help you digest more easily and efficiently.
• Limit fiber: High-fiber foods, such as fresh fruits and raw vegetables, and whole grains, may worsen ulcerative colitis symptoms for some. Grilling, sauteeing, or roasting raw foods may be an option to try.
• Limit dairy: Diarrhea, abdominal pain, and gas may improve by limiting or dairy from your diet. In addition, if you are lactose intolerant, your body is unable to digest the milk sugar (lactose) in dairy foods. There are many products in stores that cater to those with lactose intolerance, such as Lactaid, Almond Breeze, and various dairy-free cheeses and yogurts.
• Incorporate fatty fish: Omega-3 fatty acids found in salmon, mackerel, trout, Pollock, and swordfish may keep inflammation at bay. These healthy fats have been known to ease ulcerative colitis symptoms. Think of them as lubing up your intestines and joints.
• Avoid spicy foods, alcohol, and caffeine: These choices may increase your symptoms, lead to dehydration, diarrhea, or worsen a flare-up.

With the symptoms associated with a flare-up from ulcerative colitis, it can be challenging to know which are an emergency and which can wait. However, symptoms that should prompt contacting a gastroenterologist right away include:

• Severe abdominal pain
• Bloody diarrhea
• Light-headedness
• Painful cramps in the legs
• Decreased urination

Calling the gastroenterologist before heading to a hospital might help in deciding what level of care is needed. For example, it may be necessary to change treatments or adjust the current treatment plan to get any inflammation under control quickly.

However, if a severe condition such as a bowel perforation or toxic megacolon is suspected, it may be necessary to call 911 because these are medical emergencies.

Ulcerative colitis symptoms and treatment will vary from person to person. If you are confused about the disease and all of the medications and therapies available, have a discussion with your gastroenterologist. They will discuss the benefits and risks and help you make informed decisions together about your care.

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Disclaimer: Important Notice Regarding Medical Advice

The information provided in this blog is intended for general informational purposes only and should not be considered a substitute for professional medical advice, diagnosis, or treatment.