Ulcerative colitis

What is ulcerative colitis?

Ulcerative colitis is a type of inflammatory bowel disease (IBD), the other which is Crohn’s disease.

Ulcerative colitis generally only affects the lining of the colon (large intestines) and rectum/anus, which then can become very inflamed. Ulcerative colitis does not normally affect any other part of the gastrointestinal tract (small intestines, stomach, oesophagus, mouth) other than the large intestines and anus.

If the anus (rectum) is the only part that becomes inflamed the condition is then known as ulcerative proctitis.

Ulcerative colitis does not require surgery in most cases – only about 1% of people with this condition require their bowel removed. This type of surgery is only recommended for people with very severe forms of ulcerative colitis that does not respond to conventional treatment, seriously impacts quality of life or where there are pre-cancerous or cancerous cells.

Facts about ulcerative colitis

• Ulcerative colitis mainly affects the mucosa lining of the large intestine and/or rectum
• Bowel cancer incidence is higher in people that have ulcerative colitis for at least ten years, so regular colonoscopy is recommended
• More people have Crohn’s disease than ulcerative colitis (in a ratio of 3:2)
• More men than women seem to be diagnosed with ulcerative colitis than with Crohn’s disease
• Smoking does not seem to affect incidence of ulcerative colitis

Symptoms of ulcerative colitis

The symptoms of ulcerative colitis depend on how inflamed the bowel (or rectum) is at any given moment.

Ulcerative colitis main symptoms

• Abdominal pain – vague discomfort to cramps
• Anaemia – from malabsorption of iron and/or passing blood in the stools
• Diarrhoea – sometimes with blood and/or mucous (diarrhoea may not occur for everyone with ulcerative colitis)
• Constipation – especially if the ulcers/lesions are closest to the rectum and not many in the large colon
• Fever – when the disease is active
• Incontinence – inability to control the flow
• Lethargy and fatigue
• Loss of appetite
• Nausea
• Passing fresh, bright red coloured blood in the stools or it can be passed separately from the stools
• Shooting pain up the backside (tenesmus)
• Vomiting
• Weight loss

Other symptoms associated with ulcerative colitis

• Blurred vision
• Eye problems – inflammation and sensitivity to light
• Headache
• Joint pain
• Mouth ulcers
• Swelling or stiffness of the wrists, elbows, knees, ankles

Ulcerative colitis can also make a person more likely to develop gall stones, kidney stones, other kidney and circulatory problems.

Causes of ulcerative colitis

The exact cause of ulcerative colitis is not known. Scientists are yet to find the cause.

Science has put forward a few theories (which are still unproven) about why ulcerative colitis occurs:

• Auto immune disease – ulcerative colitis could be due to the way the immune system responds to certain triggers in the intestines
• Bacterial or viral infection – some scientists believe that a bacterial or viral infection that occurs in the intestines could trigger ulcerative colitis in some people
• Environment – current research shows ulcerative colitis is not common in people who work outdoors, were breastfed as babies and are from middle-lower socio-economic backgrounds
• Ethnicity – research shows that people who are Jewish are 2-4 times more likely to get ulcerative colitis than people who are not of Jewish ethnicity
• Food sensitivities – some scientists suggest that ulcerative colitis could be partly due or triggered by certain food sensitivities which cause a problem in the functioning of the intestines
• Genetics – research shows that about 20% of all people who have ulcerative colitis also have a relative with the condition

Prevention of ulcerative colitis

Non-preventable risk factors

Ulcerative colitis may be unpreventable in certain circumstances:

• Bacterial or viral gut infection – some medical experts believe that a trigger for ulcerative colitis is a bacterial or viral infection that somehow causes the immune system to function inappropriately. It is believed that this malfunction of the immune system could be one of the reasons why ulcerative colitis is triggered in some people
• Contraceptive pill – studies show that women who have ulcerative colitis and who also take the contraceptive pill often suffer from more flare-ups of symptoms, than women who do not take the contraceptive pill
• Food sensitivity – people with any type of food sensitivity may experience a triggering of worse symptoms, due to the intestines not being able to properly digest and absorb the food, which aggravates inflammation and bloating symptoms
• Genetics – people from certain ethnic backgrounds seem to be more likely to develop ulcerative colitis. There are many reasons hypothesised about this and one of them is the lack of omega-3 fatty acids in their diet and the ratio of omega-3:omega-6 fatty acids being too high in omega-6. This has not been proven, but is one reason that has interesting possibilities because it means that more cases of ulcerative colitis could be preventable based on dietary recommendations
• Lactose intolerance – people who have lactose intolerance can cause ulcerative colitis symptoms to be triggered in the bowel when the lactose is not able to be digested and this causes gas, inflammation and bloating. In addition to this, when symptoms of Crohn’s disease are at their worst, it can cause a temporary (few weeks) lactose intolerance to occur

Preventable risk factors

There are ways to prevent ulcerative colitis symptoms from getting worse and even from occurring:

• Antibiotics – some studies show that use of antibiotics (especially long-term) can trigger worsening of ulcerative colitis symptoms
• Diet – while diet is not a currently known cause of ulcerative colitis, it is known that following a diet that includes mostly fresh, unprocessed and low fat foods, with plenty of soluble fibre (that has been gradually added to the diet) seems to help symptoms
• Environment – many studies show that ulcerative colitis is not common in people who work outdoors (as they tend to get enough sunlight, exercise and socialising), were breastfed as babies (get the extra immunity from the mother) and are from middle-lower socio-economic backgrounds (maybe because they tend to eat less meat and more legumes)
• Stress – while not directly causing ulcerative colitis in the first place, stress can aggravate it and make the symptoms worse, so reducing stress is encouraged through some type of relaxation therapy (meditation, tai chi, yoga are all good examples)

Complications of ulcerative colitis

There are a great number of complications of ulcerative colitis:

• Abscesses – if any part of the bowel becomes infected and inflamed, it can fill up with pus and cause an abscess to develop, which are treated by antibiotics; sometimes the abscess needs to be drained if the antibiotics do not heal the infection
• Anaemia – many people with ulcerative colitis have deficiency of intrinsic factor, associated with a lack of vitamin B12 (cyanocobalamin) due to malabsorption and this can result in anaemia
• Arthritis – people with inflammatory bowel disease are also at very high risk of also developing arthritis, because this condition is also due to inflammation in the body, so this is yet another complication
• Dehydration – the person with ulcerative colitis may becomes dehydrated due to the malabsorption problems
• Malnutrition – people with ulcerative colitis may have malnutrition and deficiency in a number of nutrients, despite eating a healthy diet and this is because of the colon’s malfunction and inability to absorb any nutrients properly or at all. Especially at risk of deficiency are the fat-soluble vitamins and this is because of the colon’s inability to deal properly with fat absorption and these vitamins need some dietary fat in order to be absorbed properly: vitamin A, vitamin D, vitamin E, vitamin K
• Weight loss – people with ulcerative colitis can experience weight loss, due to malabsorption of nutrients from food eaten, due to the colon’s malfunction and inability to absorb nutrients properly or at all

Rare and serious complications

There are also a number of rarer, but very serious complications of ulcerative colitis:

• Bowel obstruction – if any part of the bowel becomes blocked, either by an abscess, a fistula, stricture or immovable waste, this is a very serious problem. A blocked bowel needs immediately surgery to remove the blockage, otherwise it can be fatal
• Bowel perforation and peritonitis – if there are cysts in the colon and if there is enough pressure on these cysts, it can cause them to burst. If the force of the burst cysts is great enough, it can cause the bowel (colon) to perforate (burst) too. The infected substance within the cysts can leak into the peritoneum (bowel cavity) and can spread to other abdominal organs. This is very severe and can be fatal if untreated with immediate surgery to remove the infected substance out of the abdominal cavity, removed damaged tissue and provide high dose antibiotics to stop the infection
• Colon cancer – people with long term, chronic and severe ulcerative colitis may have a higher risk of developing colon cancer, especially because this condition can cause polyp development in the colon, which can become malignant over time
• Inability of the blood to clot properly – the red blood cells may not be able to clot properly, which means wounds or injuries do not heal properly and this is a high risk factor for internal bleeding. This complication may be due to deficiency of intrinsic factor, associated with a lack of vitamin B12 (cyanocobalamin) due to malabsorption
• Severe internal bleeding – this can occur during a very severe episode of ulcerative colitis and cause heavy bleeding through the rectum. This condition is life threatening as the patient will need a blood transfusion and possibly surgery to remove the bowel if it does not stop bleeding
• Toxic megacolon – also known as acute dilation. This occurs during a severe episode of ulcerative colitis, which causes the transverse colon to get much bigger than normal and this is life threatening and needs to be treated in hospital with potassium and intravenous fluids or surgery to remove the bowel if it does not improve with treatment

When to see a doctor about ulcerative colitis

People who have any of the symptoms associated with ulcerative colitis should see a doctor for proper diagnosis to confirm this condition (or to rule it out and confirm another diagnosis).

It is important to see a doctor and not self-medicate, because ulcerative colitis can cause major damage to the intestines and can cause complications if left untreated for a prolonged period.

People with existing ulcerative colitis need to see their doctor (and registered dietician) on a regular basis, to monitor their condition, to ensure they are not suffering from complications and to help with dietary management.

People with existing digestive disorders such as leaky gut syndrome or IBS may also need to see their doctor to rule out ulcerative colitis.

Diagnosis of ulcerative colitis

Initial diagnosis of ulcerative colitis includes:

• Medical history of symptoms – the doctor will ask a series of questions about your symptoms (especially the duration and severity), your diet, your family medical history (if anyone else has similar symptoms or other gastrointestinal disorders)
• Physical examination – the doctor (or gastroenterologist) will examine your abdominal area for pain or discomfort, as well as examining other parts of your body if needed (your hands, eyes and mouth)

Further tests

Once the doctor (or gastroenterologist) has reviewed the medical history and determines that further investigation is warranted, the following tests can be ordered:

• Blood test – this is ordered to test iron, haemoglobin, vitamin B12 and other items. A blood test can determine if you are malnourished or have Crohn’s disease
• Stool sample – this is ordered to determine if there is any blood in the stools or if there is a bacterial infection in the bowel present

Diagnostic tests

Further diagnostic tests can be ordered if symptoms continue despite treatment:

• Barium meal – is often performed to rule out any other disorders of the bowel, such as ulcers and IBS, as it can show ulcerations of the bowel and stomach, narrowing of the bowel and fistulas in the bowel (little pockets in the bowel). This test is not performed much in Australia any more as a CAT scan can show the same information without having to enduring the ingestion of the barium (less invasive)
• Gynaecological exam – many women with abdominal pain may need to undergo a gynaecological exam to rule out any gynaecological problems, if their symptoms warrant
• CAT scan – a computerised x-ray of the abdominal area which can show if there are any abscesses, ulcerations or any other abnormality in any part of the bowel
• MRI – magnetic resonance imaging can show clear pictures of the body tissues and organs, so it can show abscesses, ulcerations and any other abnormalities in the bowel
• Colonoscopy – a gastroenterologist performs this test and it involves having a colonoscope (small, flexible tube with a camera and light at the end) being inserted into the colon (from the anus) to get a better view of the colon (or bowel) and determine level of inflammation and disease progression. The gastroenterologist will take a sample of the colon (a biopsy), especially of any parts that are inflamed, ulcerated or in any way abnormal. The colonoscopy is usually performed under light sedation and takes only about 10-15 minutes to be completed. Having ulcerative colitis means there is a higher risk for developing colon cancer, so regular colonoscopy is recommended to prevent this

Conventional treatment of ulcerative colitis

Mild to moderate ulcerative colitis

Treatment of mild ulcerative colitis (less than four stools per day with no other major gastrointestinal symptoms):

• Topical treatment – a variety of topical treatments can be used to treat symptoms, especially of they occur in the lower end of the colon:
  • Enema – a corticosteroid enema is placed in the rectum as a retention enema to help reduce symptoms
  • Suppository or foam – a corticosteroid suppository is placed in the rectum as a retention suppository to help reduce symptoms
• Medication – a number of different medications are prescribed depending on symptoms:
  • Aminosalicylates – such as sulfasalazine, mesalazine, olsalazine are used to treat all forms ulcerative colitis
  • Antibiotics – are used to treat ulcerative colitis if there is an infection or abscess of some sort in the bowel
  • Glucocorticoids – such as prednisolone, hydrocortisone, budesonide are used to treat ulcerative colitis (and Crohn’s disease) and because their anti-inflammatory properties act very quickly to reduce symptoms. Long-term, these types of drugs can cause a variety of side effects and should never be stopped abruptly as this can cause disruption to hormone levels and cause serious ill health (the dose needs to be tapered gradually to avoid this)
  • Vitamin B12 and iron shots – these are given through shots or via a drip as the intestines may not absorb them properly and can cause anaemia through the lack of iron and/or vitamin B12 (a deficiency of either can cause anaemia

Moderate to severe ulcerative colitis

Treatment of moderate to severe ulcerative colitis (more than four stools per day with other major gastrointestinal symptoms):

• Immunosuppressants – such as cyclosporine, methotrexate and thiopurine agents are used to treat active ulcerative colitis (and Crohn’s disease) and to maintain remission in people that have not responded to other drug therapy (glucocorticoids and antibiotics). Thiopurine agents are excellent at helping to heal fistulas. The only downside to these medications is that they can often take months to reach their full effects. The other disadvantage is that using these drugs long term may suppress the immune system too much and raise risk of infection, plus there is also a small risk of lymphoma (cancer of the lymph glands) when using these drugs long term
• Intravenous iron and vitamin B12 – these nutrient are given through a drip (or shots administered by the doctor) as the intestines may not be able to absorb them properly and this can cause anaemia through the lack of iron and/or vitamin B12 (a deficiency of either can cause anaemia)
• Electrolyte and fluid replacement – when ulcerative colitis is really severe, replacement fluids including the electrolyte minerals (chloride, sodium, potassium) are given via a drip (usually in hospital) to replace the fluids and electrolytes lost through diarrhoea (and vomiting)
• Total parenteral nutrition – if the ulcerative colitis is really severe and absorption of food is greatly impaired because of bowel obstruction, or due to inability to absorb nutrients at all because of the severity of the disease, then total parenteral nutrition must be given via drip in hospital, which allows the gastrointestinal tract to rest and heal. This provides all the nutritional requirements through the blood so that nothing goes through the bowel and this enables the inflammation and other symptoms of the bowel to be healed

Surgery

Surgery is recommended as a treatment for serious complications of this condition, such as:

• Abscesses and ulcerations of the colon
• Blockages (partial or full) of any part of the bowel
• Cancer of any part of the colon
• Fistulas
• Internal bleeding
• Perforation of the colon or peritoneum
• Strictures in any part of the bowel

Living with ulcerative colitis

Self care strategies

Ulcerative colitis requires some diligence in maintaining a healthy diet and some supplementation may be required to help heal the digestive system and reduce severity and duration of symptoms. The following are the strategies most recommended to achieve this:

• Avoid alcohol – it may be necessary to stop drinking any alcohol while the intestines and the rest of the digestive system are in the process of healing and this is because alcohol is known to irritate the intestines
• Avoid cigarette smoke – people who smoke have to give up. This is just another reason to help with the decision to stop smoking. Cigarette smoke causes a number of problems with digestion and should be avoided. People who do not smoke should avoid exposure to second hand smoke from people who smoke around them
• Digestive and pancreatic enzymes – the digestive and pancreatic enzymes are released by the digestive to help digest foods that are eaten so that their nutrients can be absorbed through the bloodstream. Digestions starts mainly in the stomach and ends in the small intestine. The digestive and pancreatic enzymes help to increase the amount of food digested by reducing the load on the digestive system and this reduces the amount of undigested foods that may escape into the bloodstream and cause the immune system to respond with an allergic reaction
• Essential fatty acids – the essential fatty acids, especially the omega 3 (DHA/EPA) and omega 6 (GLA) are vital for a properly functioning gastrointestinal system as they reduce inflammation that may be associated with this digestive disorder and this reduces severity and duration of symptoms. The best way to get adequate levels of the essential fatty acids is to eat 3-4 servings of oily fish each week and ensure it is deep ocean, wild fish (not farmed). The fish with the highest levels of omega-3 fatty acids are: mackerel, salmon, sardines, trout, tuna. People who cannot eat fish should try a supplement with balanced levels of each of the essential fatty acids and ensure it has been tested for mercury
• Exercise regularly – physical activity is a must for anyone with a digestive disorder as it helps to increase blood and lymphatic circulation. This helps to eliminate any toxins or unwanted substances more quickly out of the body. Exercise also increases the endorphins released and reduces stress
• Fibre – increasing the amount of fibre in the diet is vital for ensuring healthy digestion. The best types of soluble fibres is psyllium, which helps the intestinal flora digest food properly. The best ways to add psyllium or slippery elm to the diet are in: smoothies, milkshakes, sauces, yoghurt, breakfast cereal, muesli, dips. Suggested dosage is up to 2-3 teaspoons per day, but add it gradually if fibre hasn’t been an integral part of the diet previously, start with 1/2 teaspoon for a few days and add another 1/2 teaspoon every 4 days until at the 2-3 teaspoons a day level
• Food intolerance or sensitivity – these can be confirmed (if not known) through either an elimination diet or a blood test. An elimination diet involves removal of all the suspected allergens (such as dairy, gluten) as well as all processed foods and associated food additives and then re-introducing these foods, one at a time to determine if they have an adverse effect on digestion, or any other part of the body
• Organic – another strategy to reduce the stress on the gastrointestinal system is to avoid foods which are not grown organically (without the use of pesticides and other chemicals and antibiotics). This helps the digestive system because it does not have to also try to detoxify the chemicals in the food in addition to trying to digest foods normally (which is not occurring in this condition). Not only this, but studies show that organic food has higher levels of all their nutrients than food not grown organically
• Probiotics – the “good” bacteria may be in short supply in the digestive system which could be contributing to the symptoms. Acidophilus and other probiotic bacteria are required to help re-populate the intestines with “good” bacteria, which help to properly digest foods and reduce the amount of undigested food that escapes the gut. People who are not lactose intolerant should also include yoghurt that has live cultures
• Reduce stress and relax – prolonged and unrelenting stress is not good for healthy digestion. While stress is not known to cause leaky gut syndrome, it certainly can make symptoms worse because it causes the parasympathetic nervous system to remain in stress mode, which means digestion and absorption is not effective as the nerve that controls it prevents it from happening properly
• Slippery elm – the herb slippery elm is necessary for intestinal health as it is required to heal the intestinal mucosa by providing a mucilaginous layer over the intestinal wall, which reduces the stress on the intestines and helps to heal the intestines more quickly
• Smaller meals – eat smaller meals to help reduce the load on the digestive system, which is not working properly and cannot handle larger meals, which can cause worsening of symptoms when the stomach and intestines struggles to handle the large amount of food eaten. Aim to have around 6 smaller meals each day
• Supplements – certain supplements may be required to help in the healing process by reducing the load on the intestines and reduce symptoms. The fat-soluble vitamins may especially be required because this digestive disorder causes a problem with fat digestion, as well as a general multivitamin which contains all the vitamins and minerals to prevent malnutrition due to malabsorption and the amino acids (especially taurine and glycine) which help to reduce the inflammation associated with this disorder

Caring for someone with ulcerative colitis

Partner

The best way to help a partner with ulcerative colitis is to be supportive and sympathetic, but also the following can be helpful too:

• Avoiding smoking inside – people with ulcerative colitis need to be away from any cigarette smoke, as it can exacerbate their symptoms
• Eating smaller meals – help your partner to eat smaller meals by joining them in eating smaller meals, as this helps support your partner a great deal. Cooking and eating smaller meals is one way to help reduce the load on the digestive system by reducing the amount of food that needs to be digested and absorbed
• Encourage a healthy diet – a healthy diet is one which has adequate amounts of fresh fruit and vegetables, wholegrains, legumes, protein and healthy fats and has little or no processed foods
• Encourage exercise – going for walks (or joining a gym together) with your partner is a great way to bond. Exercise helps to improve circulation, reduces stress and encourages better health overall

Friends

People who have a friend who has ulcerative colitis can support their friend by the following:

• Dinner parties – if you invite your friend to a dinner party, try to ensure there is food that they can eat. The best way to do this is to ask what foods are off limits for them and ensure to let them know beforehand which foods they should avoid
• Discourage alcohol – if your friend has ulcerative colitis, they should be limiting alcohol intake as it can cause a worsening of symptoms, so try to make your social meetings ones that are alcohol free

Parents

Parents of a child who has ulcerative colitis can support their child by:

• Avoid smoking inside – people with ulcerative colitis need to be away from any cigarette smoke, as it can exacerbate their symptoms
• Cooking smaller meals – this is one way to help reduce the load on the child’s digestive system by reducing the amount of food that needs to be digested and absorbed
• Probiotics – introduce some probiotics to the child’s diet, preferably in powder form as it can be more easily assimilated into other foods, but the tablets can also be taken if this is not successful
• Slippery elm – find creative ways to add slippery elm to foods (smoothies, breakfast cereal, muesli) in the child’s diet. Slippery elm is one of the herbs most beneficial for any type of digestive disorder, but especially one in which there is irritation and damage to the intestinal wall and the intestinal mucosa

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Last reviewed and updated: 14 May 2024