Ulcerative colitis is a disease that causes inflammation and
sores, called ulcers, in the lining of the large intestine. The
inflammation usually occurs in the rectum and lower part of the
colon, but it may affect the entire colon. Ulcerative colitis rarely
affects the small intestine except for the end section, called the
terminal ileum. Ulcerative colitis may also be called colitis or
The inflammation makes the colon empty frequently, causing
diarrhea. Ulcers form in places where the inflammation has killed
the cells lining the colon; the ulcers bleed and produce pus.
Ulcerative colitis is an inflammatory bowel disease (IBD), the
general name for diseases that cause inflammation in the small
intestine and colon. Ulcerative colitis can be difficult to diagnose
because its symptoms are similar to other intestinal disorders and
to another type of IBD called Crohn's disease. Crohn's disease
differs from ulcerative colitis because it causes inflammation
deeper within the intestinal wall. Also, Crohn's disease usually
occurs in the small intestine, although it can also occur in the
mouth, esophagus, stomach, duodenum, large intestine, appendix, and
Ulcerative colitis may occur in people of any age, but most often
it starts between ages 15 and 30, or less frequently between ages 50
and 70. Children and adolescents sometimes develop the disease.
Ulcerative colitis affects men and women equally and appears to run
in some families.
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Theories about what causes ulcerative colitis abound, but none
have been proven. The most popular theory is that the body's immune
system reacts to a virus or a bacterium by causing ongoing
inflammation in the intestinal wall.
People with ulcerative colitis have abnormalities of the immune
system, but doctors do not know whether these abnormalities are a
cause or a result of the disease. Ulcerative colitis is not caused
by emotional distress or sensitivity to certain foods or food
products, but these factors may trigger symptoms in some
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The most common symptoms of ulcerative colitis are abdominal pain
and bloody diarrhea. Patients also may experience
About half of patients have mild symptoms. Others suffer frequent
fever, bloody diarrhea, nausea, and severe abdominal cramps.
Ulcerative colitis may also cause problems such as arthritis,
inflammation of the eye, liver disease (hepatitis, cirrhosis, and
primary sclerosing cholangitis), osteoporosis, skin rashes, and
anemia. No one knows for sure why problems occur outside the colon.
Scientists think these complications may occur when the immune
system triggers inflammation in other parts of the body. Some of
these problems go away when the colitis is
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A thorough physical exam and a series of tests may be required to
diagnose ulcerative colitis.
Blood tests may be done to check for anemia, which could indicate
bleeding in the colon or rectum. Blood tests may also uncover a high
white blood cell count, which is a sign of inflammation somewhere in
the body. By testing a stool sample, the doctor can detect bleeding
or infection in the colon or rectum.
The doctor may do a colonoscopy or sigmoidoscopy. For either
test, the doctor inserts an endoscope-a long, flexible, lighted tube
connected to a computer and TV monitor-into the anus to see the
inside of the colon and rectum. The doctor will be able to see any
inflammation, bleeding, or ulcers on the colon wall. During the
exam, the doctor may do a biopsy, which involves taking a sample of
tissue from the lining of the colon to view with a microscope. A
barium enema x ray of the colon may also be required. This procedure
involves filling the colon with barium, a chalky white solution. The
barium shows up white on x ray film, allowing the doctor a clear
view of the colon, including any ulcers or other abnormalities that
might be there.
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Treatment for ulcerative colitis depends on the seriousness of
the disease. Most people are treated with medication. In severe
cases, a patient may need surgery to remove the diseased colon.
Surgery is the only cure for ulcerative colitis.
Some people whose symptoms are triggered by certain foods are
able to control the symptoms by avoiding foods that upset their
intestines, like highly seasoned foods, raw fruits and vegetables,
or milk sugar (lactose). Each person may experience ulcerative
colitis differently, so treatment is adjusted for each individual.
Emotional and psychological support is important.
Some people have remissions-periods when the symptoms go
away-that last for months or even years. However, most patients'
symptoms eventually return. This changing pattern of the disease
means one cannot always tell when a treatment has helped.
Some people with ulcerative colitis may need medical care for
some time, with regular doctor visits to monitor the condition.
The goal of therapy is to induce and maintain remission, and to
improve the quality of life for people with ulcerative colitis.
Several types of drugs are available.
- Aminosalicylates, drugs that contain 5-aminosalicyclic
acid (5-ASA), help control inflammation. Sulfasalazine is a
combination of sulfapyridine and 5-ASA and is used to induce and
maintain remission. The sulfapyridine component carries the
anti-inflammatory 5-ASA to the intestine. However, sulfapyridine
may lead to side effects such as include nausea, vomiting,
heartburn, diarrhea, and headache. Other 5-ASA agents such as
olsalazine, mesalamine, and balsalazide, have a different carrier,
offer fewer side effects, and may be used by people who cannot
take sulfasalazine. 5-ASAs are given orally, through an enema, or
in a suppository, depending on the location of the inflammation in
the colon. Most people with mild or moderate ulcerative colitis
are treated with this group of drugs first.
- Corticosteroids such as prednisone and hydrocortisone
also reduce inflammation. They may be used by people who have
moderate to severe ulcerative colitis or who do not respond to
5-ASA drugs. Corticosteroids, also known as steroids, can be given
orally, intravenously, through an enema, or in a suppository,
depending on the location of the inflammation. These drugs can
cause side effects such as weight gain, acne, facial hair,
hypertension, mood swings, and an increased risk of infection. For
this reason, they are not recommended for long-term use.
- Immunomodulators such as azathioprine and
6-mercapto-purine (6-MP) reduce inflammation by affecting the
immune system. They are used for patients who have not responded
to 5-ASAs or corticosteroids or who are dependent on
corticosteroids. However, immunomodulators are slow-acting and may
take up to 6 months before the full benefit is seen. Patients
taking these drugs are monitored for complications including
pancreatitis and hepatitis, a reduced white blood cell count, and
an increased risk of infection. Cyclosporine A may be used with
6-MP or azathioprine to treat active, severe ulcerative colitis in
people who do not respond to intravenous corticosteroids.
Other drugs may be given to relax the patient or to relieve pain,
diarrhea, or infection.
Occasionally, symptoms are severe enough that the person must be
hospitalized. For example, a person may have severe bleeding or
severe diarrhea that causes dehydration. In such cases the doctor
will try to stop diarrhea and loss of blood, fluids, and mineral
salts. The patient may need a special diet, feeding through a vein,
medications, or sometimes surgery.
About 25 percent to 40 percent of ulcerative colitis patients
must eventually have their colons removed because of massive
bleeding, severe illness, rupture of the colon, or risk of cancer.
Sometimes the doctor will recommend removing the colon if medical
treatment fails or if the side effects of corticosteroids or other
drugs threaten the patient's health.
Surgery to remove the colon and rectum, known as proctocolectomy,
is followed by one of the following:
- Ileostomy, in which the surgeon creates a small opening
in the abdomen, called a stoma, and attaches the end of the small
intestine, called the ileum, to it. Waste will travel through the
small intestine and exit the body through the stoma. The stoma is
about the size of a quarter and is usually located in the lower
right part of the abdomen near the beltline. A pouch is worn over
the opening to collect waste, and the patient empties the pouch as
- Ileoanal anastomosis, or pull-through operation, which
allows the patient to have normal bowel movements because it
preserves part of the anus. In this operation, the surgeon removes
the diseased part of the colon and the inside of the rectum,
leaving the outer muscles of the rectum. The surgeon then attaches
the ileum to the inside of the rectum and the anus, creating a
pouch. Waste is stored in the pouch and passed through the anus in
the usual manner. Bowel movements may be more frequent and watery
than before the procedure. Inflammation of the pouch (pouchitis)
is a possible complication.
Not every operation is appropriate for every person. Which
surgery to have depends on the severity of the disease and the
patient's needs, expectations, and lifestyle. People faced with this
decision should get as much information as possible by talking to
their doctors, to nurses who work with colon surgery patients
(enterostomal therapists), and to other colon surgery patients.
Patient advocacy organizations can direct people to support groups
and other information resources.
Most people with ulcerative colitis will never need to have
surgery. If surgery does become necessary, however, some people find
comfort in knowing that after the surgery, the colitis is cured and
most people go on to live normal, active lives.
Researchers are always looking for new treatments for ulcerative
colitis. Therapies that are being tested for usefulness in treating
the disease include
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About 5 percent of people with ulcerative colitis develop colon
cancer. The risk of cancer increases with the duration and the
extent of involvement of the colon. For example, if only the lower
colon and rectum are involved, the risk of cancer is no higher than
normal. However, if the entire colon is involved, the risk of cancer
may be as much as 32 times the normal rate.
Sometimes precancerous changes occur in the cells lining the
colon. These changes are called "dysplasia." People who have
dysplasia are more likely to develop cancer than those who do not.
Doctors look for signs of dysplasia when doing a colonoscopy or
sigmoidoscopy and when examining tissue removed during the test.
According to the 2002 updated guidelines for colon cancer
screening, people who have had IBD throughout their colon for at
least 8 years and those who have had IBD in only the left colon for
12 to 15 years should have a colonoscopy with biopsies every 1 to 2
years to check for dysplasia. Such screening has not been proven to
reduce the risk of colon cancer, but it may help identify cancer
early should it develop. These guidelines were produced by an
independent expert panel and endorsed by numerous organizations,
including the American Cancer Society, the American College of
Gastroenterology, the American Society of Colon and Rectal Surgeons,
and the Crohn's & Colitis Foundation of America Inc., among
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NIDDK, through the Division of Digestive Diseases and Nutrition,
conducts and supports research into many kinds of digestive
disorders, including ulcerative colitis. Researchers are studying
how and why the immune system is activated, how it damages the
colon, and the processes involved in healing. Through this increased
understanding, new and more specific therapies can be
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Crohn's & Colitis Foundation of America Inc.
Park Avenue South, 17th floor
New York, NY 10016-8804
1-800-932-2423 or 212-685-3440
Pediatric Crohn's & Colitis Association Inc.
Newton, MA 02468
Reach Out for Youth With Ileitis and Colitis Inc.
Melville, NY 11747
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Bethesda, MD 20892-3570
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NIH Publication No. 03-1597
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