What is ulcerative colitis?

Ulcerative colitis is a chronic disorder affecting the large intestine (colon). The digestive system (including the stomach, small and large intestines) converts food into nutrients and absorbs them into the bloodstream to fuel our bodies. The colon’s main role is to absorb water and salts from undigested food waste. This action helps to thicken and solidify the stool, which is then expelled from the body through the anus. 

Ulcerative colitis causes inflammation (redness and swelling) and ulceration (sores) along the lining of the colon which can lead to abdominal pain, cramps, bleeding and diarrhea. The disease usually begins in the rectal area, which holds stool until you go to the bathroom, and may involve the entire colon over time. Ulcerative colitis is classified as an inflammatory bowel disease (IBD), due to the inflammation that occurs in the intestines. Another common form of IBD is called Crohn’s disease. Although the symptoms of ulcerative colitis are similar to Crohn’s disease, the conditions are different in several ways. 

While both ulcerative colitis and Crohn’s disease are types of IBD, they should not be confused with Irritable Bowel Syndrome (IBS), a disorder that affects the muscle contractions and the sensitivity of the colon. Unlike ulcerative colitis and Crohn’s disease, IBS does not cause intestinal inflammation nor damage the bowel.

Can I prevent ulcerative colitis?

There is currently no known way to prevent or cure for ulcerative colitis (IBD) but the proper strategy for managing your disease can help you lead a happier, healthier, fulfilling life.

The exact cause of ulcerative colitis is unknown. However, it is believed to be due to a combination of factors, including a person’s genes (inherited traits) and triggers in the environment. This interaction of genetic and environmental factors activates an abnormal response of the body’s immune system.

Normally, the immune system protects the body from infection. In people with ulcerative colitis, however, the immune system can mistake microbes (such as bacteria that are normally found in the intestines), food, and other material in the intestines, as invading substances.

When this happens, the body launches an attack, sending white blood cells into the lining of the intestines where they cause inflammation and ulcerations.

Living positively

Ulcerative colitis is a chronic (long-term) condition with symptoms that can disappear and then flare up again throughout your life. Living with the unpredictable nature of ulcerative colitis can pose physical and emotional challenges that may seem overwhelming at times. However, there are several things that you can do to contribute to your health and well-being.

Be informed, proactive, and involved in your care. By establishing a solid partnership with your health care team, developing coping skills, and maintaining a positive outlook, it is possible to stay healthy and happy, despite living with ulcerative colitis.

Diet and lifestyle changes

Although diet and stress do not cause ulcerative colitis, there may be times when changes in your lifestyle may help control your symptoms and lengthen the time between flare-ups. The following changes may help to ease your symptoms:

• Limit milk/dairy products. If you are lactose intolerant (cannot digest the sugar in milk), milk and dairy products can produce symptoms of excess gas and diarrhea.
• Restrict intake of certain high-fibre foods: such as nuts, seeds, and raw vegetables.
• Limit intake of caffeine, alcohol, carbonated drinks and fatty foods. .
• Eat small, frequent meals, rather than large meals..
• Exercise regularly to promote movement of the colon and reduce stress..
• Minimize stress. Yoga, meditation and slow, relaxed breathing techniques can help people with ulcerative colitis manage stress..

Ask your doctor or pharmacist if one of these formulations may be right for you. It is important to take the probiotic in the dose and duration recommended by the manufacturer to achieve the best results.

Statistics

• It is estimated that 104,000 Canadians had ulcerative colitis in 2012, with 4,500 new cases annually. (Crohn’s and Colitis Foundation of Canada 2012)
• In 2008, physician visits for ulcerative colitis were estimated to cost the Canadian health care system $54 million/year. The total costs of hospitalization have been estimated to be $120 million in 2008. (Canadian Digestive Health Foundation 2009; Fedorak et al. 2010)
• Total indirect costs for ulcerative colitis were estimated to be $693 million in 2012. (Crohn’s and Colitis Foundation of Canada 2012)
• People with ulcerative colitis are at increased risk for colorectal cancer, although there is no excess risk of premature mortality.
• For more information, see Inflammatory Bowel Disease.

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_Citations: 

_{Canadian Digestive Health Foundation. 2009. Establishing digestive health as a priority for Canadians. The Canadian Digestive Health Foundation – National Digestive Disorders Prevalence & Impact Study Report.}

_{Crohn’s and Colitis Foundation of Canada. 2012. The impact of inflammatory bowel disease in Canada - 2012 Final report and recommendations.http://crohnsandcolitis.ca/Crohns_and_Colitis/documents/reports/ccfc-ibd-impact-report-2012.pdf?ext=.pdf [accessed 3 September 2018] [accessed 3 September 2018]}

_{Fedorak RN et al. Canadian Digestive Health Foundation Public Impact Series 4: Inflammatory bowel disease in Canada. Incidence, prevalence, and direct and indirect economic impact. Can J Gastroenterol. 2010 Nov;24(11):651-5.}

Signs & Symptoms

The most common symptoms of ulcerative colitis are abdominal pain, diarrhea, blood in the stool and false urges to have a bowel movement.

• Abdominal pain (cramping): Ulcerative colitis pain can be felt anywhere throughout the abdomen, but it is typically located in the lower left side.
• Diarrhea: Diarrhea (frequent, loose or watery stools) can range from mild to severe and, in some cases, may involve as many as 20 or more trips to the bathroom a day.
• Blood and/or mucus in the stool: Ulcers may form where inflammation has damaged the intestinal lining. These areas bleed and produce pus and mucus, which may appear in the stool.
• False urges to have a bowel movement: The urge to have a bowel movement may arise frequently, even though there is little stool to pass. This urge is caused by inflammation of the rectum.

Other symptoms of ulcerative colitis may include:

• Weight loss
• Anemia
• Fatigue
• Nausea
• Fever
• Vomiting

Alarm Symptoms of Ulcerative Colitis:

If you are already diagnosed with ulcerative colitis, there are several alarm symptoms to look out for. A change in your ulcerative colitis symptoms may mean that additional treatment is needed. Talk to your doctor immediately if you experience a new symptom, a change in your current symptoms or any of the following:

• An unusual amount of cankers or sores in your mouth
• Unexplained or unintentional weight loss
• Failure to gain weight (especially in children)
• Delayed puberty in teens
• Drainage of pus from, or severe pain near, the anus which is usually caused by an abscess.
• Anemia – this blood condition results in fatigue and weakness. It is usually caused by heavy blood loss or a lack of dietary iron
• Rectal bleeding
• Fever
• Change in bowel habits
• Eye redness / pain
• Severe joint pains
• Nausea / vomiting - inability to keep food / drink down

Who is at Risk of Ulcerative Colitis?

• Age: Ulcerative colitis may affect any age group, although there are peaks at ages 15 to 30 years, and again at ages 50 to 70 years.
• Race/ethnic background: Ulcerative colitis is more common among caucasians and in people of Ashkenazi Jewish descent.
• Family history: People with a first-degree relative (parent or sibling) with ulcerative colitis are at greater risk of developing the condition.

What Complications are Associated with Ulcerative Colitis?

Yes. There are some complications related to ulcerative colitis. Possible complications include:

• Severe bleeding
• Dehydration
• Perforated colon (a hole in the colon)
• Kidney stones
• Osteoporosis (loss of bone strength)
• Toxic megacolon (severe abdominal swelling accompanied by a fever, rare)
• Liver disease (rare)

People with ulcerative colitis are also at increased risk of developing colon cancer. The risk of colon cancer is related to the length of time since you were diagnosed and how much of your colon is affected by inflammation. However, a regular examination by your doctor and colorectal cancer screening tests can help to reduce the risk of cancer and detect problems early.

Tests and Treatment

Testing for Ulcerative Colitis

Often, symptoms alone can provide doctors with the information they need to diagnose ulcerative colitis. Your doctor will perform a physical examination and take a complete medical history that includes a careful review of your symptoms. For this reason, it is important to be candid and specific with your doctor about the problems you are having.

There is no one specific laboratory test, X-ray or scope to diagnose ulcerative colitis, however, to help confirm the condition and rule out other problems, your doctor may send you to have one or more of the following tests:

• Blood tests: Blood tests can help to identify anemia (low blood count), infection and inflammation.
• Stool sample tests: A stool analysis can detect blood in the stool and rule out infection, malabsorption, parasites and other digestive problems.
• Imaging tests: Your doctor may order tests to see your lower digestive organs. These safe tests can help to diagnose ulcerative colitis or Crohn’s disease and identify other problems such as ulcers, polyps (growths on the lining of the intestines) and colon cancer. A sample of the lining of the intestine (biopsy) may be taken to examine under a microscope.
• Flexible sigmoidoscopy:A slim, flexible tube (sigmoidoscope) equipped with a light and a tiny camera is guided through the rectum into the colon. The sigmoidoscope allows your doctor to examine the lining of the lower part of the colon only.
• Colonoscopy: In a procedure similar to a flexible sigmoidoscopy, a flexible scope allows your doctor to view the lining of both the upper and lower parts of the colon.
• Barium enema: A small tube is placed in the rectum and filled with barium liquid and air. Barium coats the lining of the colon and rectum so they can be seen on an X-ray, allowing your doctor to see areas of damage or inflammation.
• CT (computerized tomography) scan: A CT scan produces cross-sectional X-ray images of the abdomen and pelvis to help diagnose ulcerative colitis and rule out other possible disorders and conditions.
• MRI (magnetic resonance imaging) scan: An MRI is similar to a CT scan, but it does not use X-rays to capture an image. An MRI uses magnetism, radio waves, and a computer to produce highly-detailed images of the body. It offers an extremely accurate method of detecting inflammation and disease in the colon and throughout the body.

How is ulcerative colitis treated?

There is no cure for ulcerative colitis at the present time, however, there are effective treatments available that may control your disease and even place it into remission. Remission means that your symptoms disappear completely. Your treatment plan will depend upon the types of symptoms you have, their severity and how they affect your daily life.

Medications:

Medications may be needed to control the inflammation in your colon and/or to reduce your body’s immune response. The goals of treatment are to manage your symptoms and prevent them from coming back so that you can live life to its fullest. You and your physician should discuss and carefully consider the risks and benefits associated with any available treatment options. Often, medications are prescribed in a ‘stepped’ approach, beginning with relatively safe medications with few risks or side effects, and progressing to more powerful medications with additional risks and side effects, if your symptoms do not respond. The following list outlines the most common medications used to treat ulcerative colitis.

• Mesalamine: also referred to as 5-ASAs (5-amino salicylic acid), is often a first treatment option for mild-to-moderate ulcerative colitis. This medication helps reduce inflammation in the colon and control diarrhea. Amino salicylates can be taken as an oral pill, suppository (a capsule you insert into your rectum) or enema. Suppositories and enemas allow us to locally treat inflammation and help with symptoms of urgency.
• Corticosteroids:(such as prednisone and budesonide) also reduce inflammation by controlling the body’s immune system response. Steroid medications are effective for short-term control of a flare-up, however they are not recommended for long-term use because of their significant side-effects.
• Immunosuppressants: (such as 6-MP and azathioprine) may be recommended if your condition does not respond to other treatments. These medications suppress (reduce) the activity of the body’s immune system to control inflammation, however, they also weaken the body’s ability to fight infection. Immunosuppressants typically take 2 to 3 months to begin working.
• Biologics: (such as infliximab, adalimumab and Golimumab) are powerful medications used for people with moderate-to-severe ulcerative colitis when other treatments have been unsuccessful. Biologics target and block the specific protein molecules causing inflammation in ulcerative colitis, yet they still allow the immune system to work and fight infections.
• Biosimilars:(such as: Infliximab-dyyb (Inflectra®️)) A biosimilar biologic drug, or biosimilar, is a drug demonstrated to be highly similar to a biologic drug that has already authorized for sale (known as the reference biologic drug). Biosimilars were previously known in Canada as Subsequent Entry Biologics (SEBs).Health Canada states that biosimilars are not generic biologics.Health Canada only approves biosimilars for marketing in Canada when the manufacturer demonstrates that their product is of similar quality, safety, and efficacy to the original reference drug. However, long term studies are still required to confirm these attributes.
• JAK Inhibitors: (Such as XELJANZ® (tofacitinib)) is a new oral treatment option for adult patients with moderate to severe ulcerative colitis (UC) that may help achieve and maintain remission. XELJANZ® (tofacitinib) is a Janus kinase (JAK) inhibitor. JAK inhibitors are small molecules in a pill form that interfere with a number of key pro-inflammatory cytokines involved in the origination and development of inflammatory bowel disease. Treatment of UC in the past 10 to 20 years have been through injectables or intravenous agents, now XELJANZ, the first Janus kinase (JAK) inhibitor approved by Health Canada, provides a new option for individuals with UC. Use of XELJANZ in combination with biological therapies for UC or with potent immunosuppressant’s such as azathioprine and cyclosporine is not recommended.

Surgery:

About 10 to 15% of people with ulcerative colitis may eventually need surgery to treat their condition, if medical therapy is not successful or complications arise. Ulcerative colitis surgery usually involves removing the entire colon and rectum (proctocolectomy).

When the colon is completely removed, a small opening (stoma) is created in the lower abdomen and feces (digestive waste) are collected into a small bag worn on the outside of the body. For some people, a second operation (called a pouch procedure) can be performed. This operation creates a new rectum, which allows feces to collect inside the body and be expelled by normal passage through the anus. People with pouches often still pass 4-6 stools per day, but without blood or pain.

Symptomatic treatment:

The symptoms of ulcerative colitis can be disruptive, debilitating and embarrassing. In addition to medication to control inflammation, your doctor may recommend additional products to help relieve your symptoms, including antibiotics (for fever), pain relievers (for abdominal pain), antidiarrheals (to control diarrhea) and iron supplements (for anemia). Talk to your doctor about which medications are safe for you to take.

Probiotics:

Studies have found that, in some cases, probiotics may help to improve symptoms of ulcerative colitis. Probiotics are live microorganisms that, when taken in adequate amounts over sufficient time, may provide a health benefit. They are natural, ‘healthy’ bacteria that may help with digestion and offer protection from harmful bacteria in the intestines.

Probiotics are not medicine. They are available to purchase as capsules, tablets or powders, and can also be found in some fortified yogurts and fermented milk products. However, not all probiotics are the same. Although many products claim to have benefits, only two probiotics formulations – E. coli Nissle and VSL#3 – have been shown to be effective in ulcerative colitis.

Ask your doctor or pharmacist if one of these formulations may be right for you. It is important to take the probiotic in the dose and duration recommended by the manufacturer to achieve the best results.

FAQs

Am I going to get cancer because I have (Ulcerative Colitis) IBD? 

People with IBD are at an increased risk of developing colon cancer. Having regular endoscopies will help identify polyps that could potentially develop into cancer.

Does diet affect Ulcerative Colitis (IBD)?

Diet alone is not effective in treating Crohn's disease or ulcerative colitis. However, it is important that patients with IBD have a well-balanced diet. Calcium is important to protect bones. Fibre may not be tolerated during flare ups. Certain vitamins (for example, B12) may be required. Selected patients may sometimes be helped by a registered dietician.

How is Ulcerative Colitis (IBD)different than IBS?

Although both illnesses can be seriously debilitating, there are several primary differences between Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS). IBD is an autoimmune disorder that causes swelling and ulcerations (sores) in the bowel. IBS involves problems with motility (how the bowel moves contents through our intestines) and sensitivity (how the brain interprets sensations in the bowel). Symptoms of IBS may wax and wane and possibly disappear altogether whereas IBD is a chronic condition.

How can I tell if my treatment is working?

For some people, ulcerative colitis symptoms will significantly improve within a short time after starting medication or making lifestyle and dietary changes. For others, finding relief from symptoms is a slow process and it may take longer for a definite improvement to be noticed. It is important for you and your doctor to work together to determine what triggers your symptoms and to find the right treatment to manage your symptoms effectively.

How can I prepare for an appointment with my GI to discuss my ulcerative colitis?

Good communication with your doctor is an important part of effective management of a gastrointestinal disorder like ulcerative colitis. Before your appointment, take the time to keep a symptom journal that can help you and your doctor see patterns in your activities and identify specific triggers for your symptoms.Include the following information in your journal:

• Write down the symptoms that are bothering you and for how long you have had them.
• Write down key personal and medical information, including any recent changes or stressful events in your life.
• Make a list of the triggers (food, stress, activity) that seem to make your symptoms worse.
• Make a list of medications you are taking, including the conditions you take them for. Also note if any of your medications seem to affect your symptoms.
• Talk to your family members and find out if any relatives have been diagnosed with ulcerative colitis or another digestive disorder.

Also, create a list of questions to ask your doctor during your appointment. Specifically, you may want to ask your doctor questions such as:

• What do you think is causing my symptoms?
• Are there other possible causes for my condition?
• What diagnostic tests do I need?
• Do these tests require any special preparation?
• What treatment approach do you recommend trying first?
• If the first treatment doesn’t work, what will we try next?
• Are there any side effects associated with these treatments?

Benefit and Risk Assessment Tool for IBD Treatments

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This e-learning tool was made possible due to an unrestricted educational grant from Pfizer Canada

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