Ulcerative Colitis
Introduction
The colon is also known as the large bowel. It is the last segment of the intestine just above the rectum. Ulcerative colitis is a recurrent inflammation of the colon. When the inflammation just involves the rectum, it is known as ulcerative proctitis. When it involves the entire colon, it is called pan colitis. In most cases, the inflammation is somewhere in between proctitis and pan colitis.What Causes the Inflammation?
Medical experts don’t know the cause of this disorder. Genetics is likely important. The body’s immune system also seems to be important as there is an overreaction of certain immune factors. There is no evidence that any specific food is a cause. Finally, there are more than a thousand different types of bacteria that normally live in the colon and provide health benefits to the colon and the body. Some experts feel that these bacteria in some way may be a factor. One bacteria makes a toxic gas called hydrogen sulfide. There is some research to implicate this gas as contributing to inflammation.Anything Else?
Ulcerative colitis seems to be a disease of developed countries. However, in America the incidence is falling. This disorder can strike anyone at almost any age. Commonly, it seems to occur in younger people in their 20′s and 30′s. It develops in Caucasians and Jewish-Europeans more often than African-Americans. There is also a family history of the disease with various members in a family being involved or having any one of a variety of immune type disorders. It is more common in those who live in an urban setting, developed country and the Northern climate.The bottom line is that there are likely multiple factors going on here. The medical experts just have not been able to figure it all out yet, which means that while the disease may wax and wane, there is no cure except to surgically remove the colon.
What Do I Feel and What Do I See?
Rectal bleeding is usually the first and often the only sign you will see. Intermittent abdominal crampy discomfort is common. So is diarrhea, especially at night. When you have had the disorder for awhile, fatigue, weakness and even fever can occur.Most importantly, these symptoms wax and wane. Even so and especially if rectal bleeding has occurred, medical attention should always be sought immediately.
Testing
While the physician may be suspicious of ulcerative colitis just by the medical history, colonoscopy will almost always be required to make the diagnosis. When this is done, the physician will see a characteristic pattern of minute bleeding points, each of which is a tiny ulcer. Inflammation will also be present visually and confirmed when a biopsy is taken. Blood tests are needed to evaluate the effect of the disorder on your general health. A barium x-ray exam of the colon may occasionally be indicated.What Complications Can Occur?
It is reassuring that most people with ulcerative colitis do just fine. They respond to medication and go about their lives as before with few problems. However, there are certain more serious things that can occur.- An attack may be very severe and sudden, requiring hospitalization, bowel rest and intravenous medications to get the disorder under control. It can even reach a point where the colon becomes very weak and dilated. This is a surgical emergency.
- Colon leakage or perforation – This complication is rare but serious. It results in peritonitis and requires surgery.
- Diseases of the liver and/or bile ducts – In a small group of people with ulcerative colitis, disorders of the liver and/or inflammation of the bile ducts can occur.
Colon Cancer
This is a special consideration for everyone with ulcerative colitis. Some 8-10 years after the onset, the cells that line the colon may become increasingly disorganized and the first indications of approaching cancer may occur. This is why regular surveillance exams by colonoscopy are required to perform multiple biopsies of the colon in order to detect any such change. The frustrating thing for patients and physicians alike is that cancer can occur even when the disorder is under good control.Treatment
There is a great deal that can be done to treat ulcerative colitis. Medications fall into four main categories:- Prednisone, steroids, cortisone – These drugs are often used initially when the disorder is most severe. The physician will usually reduce the dose in a gradual manner until a low maintenance dose is satisfactory. More often, these medications will be stopped entirely.
- Mesalamine type anti-inflammatory drugs – These medications induce an anti-inflammatory response in the colon. They can usually be used safely long term. They are given by pill form or by enemas. The trade names include Azulfidine, Dipentum, Asacol, Pentasa, Rowasa and Lialdia.
- Immune suppressors – Since the immune system is clearly implicated in ulcerative colitis, certain drugs that can dampen the immune response in the body can be useful. Imuran, 6-MP, Neoral, and methotrexate belong in this group.
- Inflammation cascade blockers – The inflammation of ulcerative colitis begins with a series of chemical changes leading finally to inflammation. Remicade is an intravenous drug that has been shown to block this domino-like cascade of factors that leads to tissue damage. This drug is usually given every 4-8 weeks, frequently for a prolonged period of time.
Surgery
There are instances, fortunately not very often, where all medical treatments are ineffective. When this happens, the entire colon is surgically removed and this, in effect, cures the disease. In most instances, the surgeon will create a pouch from the small intestine and so avoid a bag on the abdominal wall. The pouch is attached to the rectum. Patients handle this type of surgery and the presence of a pouch very well.Pregnancy
If you are considering pregnancy, your physician will want to know and advise you. There are risks to the mother and to the fetus as well, both with the disease and from some of the medications that are used to treat the disorder. If you are already pregnant at the time of diagnosis, close consultation with a physician with expertise in this situation is needed.Dietary Therapy
For the most current detailed recommendations on diet, go to Ulcerative Colitis Dietary Therapy. It is a fact that ulcerative colitis occurs in a part of the intestine where food fiber and waste end up. It is certainly reasonable to think that foods in some way or another effect the disorder. Despite a lot of research, no cause and effect has been found with any specific food. However, there is much you should know about diet.Colon Bacteria
The colon is home to tens of trillions of bacteria. One would think that surely, somehow, there must be a role played by these bacteria. To date, however, there has been nothing specific demonstrated, although the gas, hydrogen sulfide, which is produce by certain bacteria in the colon, is suspected by some researchers to be a factor. Again, you are referred to Ulcerative Colitis Dietary Therapy for further considerations of this aspect of the disease.Prebiotics
A prebiotic is a special type of food fiber that is not digested by the body but rather is used by certain colon bacteria as a food source. Measurable beneficial changes may then occur within the colon itself and for the body as well. By increasing the acidity in the colon by the use of prebiotics, the bacteria that make hydrogen sulfide will not grow. As noted, there is new evidence that this gas is particularly damaging to the colon of ulcerative colitis patients, and may even play a role in causing Ulcerative Colitis.Probiotics
Probiotics are bacteria that are taken with the hope that they will take up residence in the colon and produce good results. A few of these have been studied on patients with ulcerative colitis. Ask your physician about probiotics. VSL#3 is one such probiotic that has had some encouraging early reports in ulcerative colitis patients.For a full essay on probiotics, please click here.
Summary
For the patient with ulcerative colitis, there is a lot to be learned by medical researchers. A close working relationship with a physician knowledgeable about this disease is needed. Most people with this disorder do very well and are able to exercise, eat, marry and raise a family. There are many avenues of promising research being explored even now.Medical References
Guarner F; Br J Nutr. 2007; 137(Suppl 1): P-S85-9
In genetically susceptible individuals, an altered mucosal immune response against some commensal bacteria of the gut ecosystem appears to be the principal mechanism leading to intestinal lesions in inflammatory bowel disease (IBD). The information currently available does not provide an exact explanation about the origin of this important dysfunction of the interaction between host and commensal bacteria, but an altered microbial composition has been detected in the gut ecosystem of patients with Crohn's disease or ulcerative colitis. Prebiotics are food ingredients not digested nor absorbed in the upper intestinal tract that are fermented by intestinal bacteria in a selective way promoting changes in the gut ecosystem. Experimental and human studies have shown that inulin and oligofructose stimulate saccharolysis in the colonic lumen and favour the growth of indigenous lactobacilli and bifidobacteria. These effects are associated with reduced mucosal inflammatio n in animal models of IBD. Strong experimental evidence supports the hypothesis that inulin and oligofructose can offer an opportunity to prevent or mitigate intestinal inflammatory lesions in human Crohn's disease, ulcerative colitis, and pouchitis. Encouraging results have been obtained in preliminary clinical trials.
Abrams SA et al; Am J Clin Nutr 2005; 82(2): P-471-6
BACKGROUND: Short-term studies in adolescents have generally shown an enhancement of calcium absorption by inulin-type fructans. Results have been inconsistent; however, and no studies have been conducted to determine whether this effect persists with long-term use. OBJECTIVE: The objective was to assess the effects on calcium absorption and bone mineral accretion after 8 wk and 1 y of supplementation with an inulin-type fructan. DESIGN: Pubertal adolescents were randomly assigned to receive 8 g/d of a mixed short and long degree of polymerization inulin-type fructan product (fructan group) or maltodextrin placebo (control group). Bone mineral content and bone mineral density were measured before randomization and after 1 y. Calcium absorption was measured with the use of stable isotopes at baseline and 8 wk and 1 y after supplementation. Polymorphisms of the Fok1 vitamin D receptor gene were determined. RESULTS: Calcium absorption was significantly g reater in the fructan group than in the control group at 8 wk (difference: 8.5 +/- 1.6%; P < 0.001) and at 1 y (difference: 5.9 +/- 2.8%; P = 0.04). An interaction with Fok1 genotype was present such that subjects with an ff genotype had the least initial response to fructan. After 1 y, the fructan group had a greater increment in both whole-body bone mineral content (difference: 35 +/- 16 g; P = 0.03) and whole-body bone mineral density (difference: 0.015 +/- 0.004 g/cm(2); P = 0.01) than did the control group. CONCLUSION: Daily consumption of a combination of prebiotic short- and long-chain inulin-type fructans significantly increases calcium absorption and enhances bone mineralization during pubertal growth. Effects of dietary factors on calcium absorption may be modulated by genetic factors, including specific vitamin D receptor gene polymorphisms.
Hedin C et al; Proc Nutr Soc. 2007; 66(3): P-307-15
Human subjects and their enteric microbiota have evolved together to reach a state of mutual tolerance. Mounting evidence from both animal models and human studies suggests that inflammatory bowel disease (IBD) represents a malfunction of this relationship. The enteric microecology therefore represents an attractive therapeutic target with few side effects. Probiotics and prebiotics have been investigated in clinical trials as treatments for IBD, with conflicting results. The evidence for the use of probiotics in the management of pouchitis is persuasive and several studies indicate their effectiveness in ulcerative colitis. Trials of probiotics and prebiotics in Crohn's disease are less convincing. However, methodologies vary widely and a range of probiotic, prebiotic and combination (synbiotic) treatments have been tested in a variety of patient groups with an assortment of end points. Conclusions about any one treatment in a specific patient group can therefore only be drawn on evidence from relatively small numbers of patients. The present article reviews the role of the intestinal microbiota in the pathogenesis of IBD and addresses the clinical evidence for the therapeutic manipulation of bowel microbiota using probiotics, prebiotics and synbiotics in IBD.
Roediger WE et al; Dig Dis Sci. 1997; 42(8): P-1571-9
A role for colonic sulfide in the pathogenesis and treatment of ulcerative colitis (UC) has emerged based on biochemical, microbiological, nutritional, toxicological, epidemiological, and therapeutic evidence. Metabolism of isolated colonic epithelial cells has indicated that the bacterial short-chain fatty acid n-butyrate maintains the epithelial barrier and that sulfides can inhibit oxidation of n-butyrate analogous to that observed in active UC. Sulfur for fermentation in the colon is essential for n-butyrate formation and sulfidogenesis aids disposal of colonic hydrogen produced by bacteria. The numbers of sulfate-reducing bacteria and sulfidogenesis is greater in UC than control cases. Sulfide is mainly detoxified by methylation in colonic epithelial cells and circulating red blood cells. The enzyme activity of sulfide methylation is higher in red blood cells of UC patients than control cases. Patients with UC ingest more protein and thereby sulfur amino acid s than control subjects. Removing foods rich in sulfur amino acids (milk, eggs, cheese) has proven therapeutic benefits in UC. 5-Amino salicylic acid reduces fermentative production of hydrogen sulfide by colonic bacteria, and aminoglycosides, which inhibit sulfate-reducing bacteria, are of therapeutic benefit in active UC. Methyl-donating agents are a category of drugs of potential therapeutic use in UC. A correlation between sulfide production and mucosal immune responses in UC needs to be undertaken. Control of sulfidogenesis and sulfide detoxification may be important in the disease process of UC, although whether their roles is in an initiating or promoting capacity has yet to be determined.
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