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Ulcerative

National Digestive Diseases Information Clearinghouse

What is (UC)? sensitivity to certain foods or food products does not cause UC, it may trigger symptoms Ulcerative colitis is a chronic, or long-lasting, in some people. disease that causes and sores, called , in the inner lining of the large U.S. Department of Health and intestine, which includes the colon and the What are the symptoms of UC? Human Services ––the end part of the colon. The most common symptoms of UC are abdominal discomfort and or pus in NATIONAL UC is one of the two main forms of chronic INSTITUTES inflammatory disease of the gastrointestinal . Other symptoms include OF HEALTH tract, called inflammatory bowel disease • (IBD). The other form is called Crohn’s • fatigue disease. • Normally, the absorbs water from stool and changes it from a liquid to a • solid. In UC, the inflammation causes loss of • the lining of the colon, leading to bleeding, • loss of appetite production of pus, diarrhea, and abdominal discomfort. • rectal bleeding • loss of body fluids and nutrients What causes UC? • skin lesions The cause of UC is unknown though theories • growth failure in children exist. People with UC have abnormalities Most people diagnosed with UC have mild of the immune system, but whether these to moderate symptoms. About 10 percent problems are a cause or a result of the have severe symptoms such as frequent , disease is still unclear. The immune system bloody diarrhea, nausea, and severe abdomi- protects people from infection by identifying nal cramps.1 UC can also cause problems and destroying bacteria, viruses, and other such as joint pain, eye irritation, kidney potentially harmful foreign substances. With stones, disease, and . Scien- UC, the body’s immune system is believed tists do not know why these problems occur, to react abnormally to bacteria in the diges- but they think these complications may be tive tract. UC sometimes runs in families the result of inflammation triggered by the and research studies have shown that certain immune system. Some of these problems go gene abnormalities are found more often in away when UC is treated. people with UC. UC is not caused by emotional distress, but the stress of living with UC may contribute to 1Doherty GA, Cheifetz AS. Management of a worsening of symptoms. In addition, while acute severe ulcerative colitis. Expert Review of and . 2009;3(4):395–405. Who develops UC? While UC can occur in people of any age, it usually develops between the ages of 15 and 302 and less frequently between the ages of 60 and 80.3 The disease affects men and women equally. People with a family member or first-degree relative with an IBD are at higher risk for developing UC, as are Liver Caucasians and people of Jewish descent.

How is UC diagnosed? Colon Ulcerative colitis can be difficult to diagnose (shaded) because its symptoms are similar to those of other intestinal disorders and to Crohn’s disease. Crohn’s disease differs from UC in that Crohn’s disease causes inflammation deeper within the intestinal wall and can occur in other parts of the digestive system, Rectum including the , mouth, esopha- Small gus, and stomach. intestine Anus People with suspected UC may be referred to a gastroenterologist, also called a gastro- enterological specialist, a doctor who special- • . Stool tests can show WBCs, izes in digestive diseases. A physical exam which indicate UC or another IBD. and medical history are usually the first steps The doctor will give the person a pan in diagnosing UC, followed by one or more and a container for catching and storing tests and procedures: the stool. The sample is returned to the health care provider or a commercial • Blood tests. A blood test involves draw- facility and sent to a lab for analysis. ing blood at a health care provider’s The sample also allows doctors to detect office or commercial facility and send- bleeding or infection in the colon or ing the sample to a lab for analysis. The rectum caused by bacteria, a virus, or blood test can show a high white blood parasites. cell (WBC) count, which is a sign of inflammation somewhere in the body. • Flexible and . Blood tests can also detect anemia, These tests are the most accurate which could be caused by bleeding in methods for diagnosing UC and ruling the colon or rectum. out other possible conditions, such as Crohn’s disease, diverticular disease, or . The tests are similar, but colo- 2Garud S, Peppercorn MA. Ulcerative colitis: current treatment strategies and future prospects. Therapeutic noscopy is used to look inside the rectum Advances in Gastroenterology. 2009;2(2):99–108. and entire colon, while flexible sigmoid- 3Inflammatory bowel disease. In: Fauci AS, oscopy is used to look inside the rectum Braunwald E, Kasper DL, et al., eds. Harrison’s and lower colon. For both tests, the Principles of Internal Medicine. 17th ed. New York: doctor will provide written bowel prep McGraw-Hill Companies; 2008: 1886–1903. 2 Ulcerative Colitis instructions to follow at home before the interpreted by a radiologist––a doctor who test. The person may be asked to follow specializes in ; anesthe- a clear liquid diet for 1 to 3 days before sia is not needed. A barium x ray the test. A laxative may be required involves the injection of contrast medium, the night before the test. One or more called barium, into the colon to make the may be required the night before colon, rectum, and lower part of the small and about 2 hours before the test. intestine more visible in x-ray images. The procedure is performed in a hospital or For both tests, the person lies on a table outpatient center by an x-ray technician, while the doctor inserts a flexible tube and the images are interpreted by a radi- into the anus. A small camera on the ologist; anesthesia is not needed. These tube sends a video image of the intes- tests can show physical abnormalities and tinal lining to a computer screen. The are sometimes used to diagnose UC. doctor can see inflammation, bleeding, or ulcers on the colon wall. The doctor may also perform a by snipping How is UC treated? a bit of tissue from the intestinal lin- Treatment for UC depends on the severity of ing. The person will not feel the biopsy. the disease and its symptoms. Each person The doctor will look at the tissue with experiences UC differently, so treatment is a microscope to confirm the diagnosis. adjusted for each individual. These tests are performed at a hospital or outpatient center by a gastroenterolo- Therapy gist. In most cases, a light sedative, and While no medication cures UC, many can possibly pain medication, helps people reduce symptoms. The goals of medication relax. The test can show problems in the therapy are to induce and maintain remission–– rectum or lower colon that may be caus- periods when the symptoms go away for ing symptoms. months or even years––and to improve quality Cramping or bloating may occur dur- of life. Many people with UC require medi- ing the first hour after the test. Driving cation therapy indefinitely, unless they have is not permitted for 24 hours after the their colon and rectum surgically removed. test to allow the sedative time to wear The type of medication prescribed depends on off. Before the appointment, a person the severity of the UC. should make plans for a ride home. Full recovery is expected by the next day. • , that contain 5-aminosalicyclic acid (5-ASA), • Computerized tomography (CT) scan help control inflammation. One medi- and barium enema x ray. A CT scan uses cation, (Azulfidine), is a a combination of x rays and computer combination of sulfapyridine and 5-ASA. technology to create three-dimensional The sulfapyridine component carries the (3-D) images. A CT scan may include anti-inflammatory 5-ASA to the intestine. the injection of a special dye, called Sulfapyridine may lead to side effects such contrast medium. CT scans require the as nausea, vomiting, heartburn, diarrhea, person to lie on a table that slides into and headache. Other 5-ASA agents, such a tunnel-shaped device where the x rays as (Dipentum), mesalamine are taken. The procedure is performed (Asacol, Canasa, Lialda, Rowasa), and in an outpatient center or hospital by (Colazal), cause fewer side an x-ray technician, and the images are effects, and can be used by people who

3 Ulcerative Colitis cannot take sulfasalazine. Depending WBC count, and an increased risk of infec- on which parts of the colon and rectum tion. Cyclosporine is only used with severe are affected by UC, 5-ASAs can be given UC, because one of its frequent side effects orally; through a rectal suppository, a is toxicity, which means it can cause harm- small plug of medication inserted in the ful effects to the body over time. rectum; or through an enema––liquid • (Remicade) is an anti-tumor medication put into the rectum. Unless factor (anti-TNF) agent prescribed the UC symptoms are severe, people are to treat people who do not respond to the usually first treated with aminosalicy- other UC medications or who cannot take lates. These medications are also used 5-ASAs. People taking Infliximab should when symptoms return after a period of also take immunomodulators to avoid remission. allergic reactions. Infliximab targets a • , such as , protein called TNF that causes inflamma- methylprednisone, and hydrocortisone, tion in the intestinal tract. The medication also reduce inflammation. They are is given through intravenous infusion— used for people with more severe symp- through a vein—every 6 to 8 weeks at a toms and people who do not respond hospital or outpatient center. Side effects to 5-ASAs. Corticosteroids, also known may include toxicity and increased risk of as steroids, can be given orally, intrave- infections, particularly . nously, or through an enema, a rectal Other medications may be prescribed to foam, or a suppository, depending on decrease emotional stress or to relieve pain, which parts of the colon and rectum are reduce diarrhea, or stop infection. affected by UC. Side effects include weight gain, acne, facial hair, hyperten- Hospitalization sion, diabetes, mood swings, bone mass Sometimes UC symptoms are severe enough loss, and an increased risk of infection. that a person must be hospitalized. For Because of harsh side effects, steroids example, a person may have severe bleeding or are not recommended for long-term diarrhea that causes dehydration. In such cases, use. Steroids are usually prescribed for health care providers will use intravenous fluids short-term use and then stopped once to treat diarrhea and loss of blood, fluids, and inflammation is under control. The other mineral salts. People with severe symptoms may UC medications are used for long-term need a special diet, tube feeding, medications, symptom management. or surgery. • Immunomodulators, such as (Imuran, Azasan), 6- Surgery (6-MP) (Purinethol), and cyclosporine About 10 to 40 percent of people with UC (Neoral, Sandimmun, Sandimmune), eventually need a proctocolectomy––surgery suppress the immune system. These to remove the rectum and part or all of the medications are prescribed for people colon.1 Surgery is sometimes recommended if who do not respond to 5-ASAs. Immu- medical treatment fails or if the side effects of nomodulators are given orally, but corticosteroids or other medications threaten a they are slow-acting and can take 3 to person’s health. Other times surgery is per- 6 months to take effect. People taking formed because of massive bleeding, severe these medications are monitored for illness, colon rupture, or cancer risk. Surgery is complications including nausea, vomiting, performed at a hospital by a surgeon; anesthesia fatigue, , , a reduced will be used. Most people need to remain in the 4 Ulcerative Colitis hospital for 1 to 2 weeks, and full recovery can • is an operation that attaches take 4 to 6 weeks. the to an opening made in the abdomen, called a . The stoma is A proctocolectomy is followed by one of the about the size of a quarter and is usually following operations: located in the lower right part of the • Ileoanal pouch anastomosis, also called abdomen near the beltline. An ostomy “pouch surgery,” makes it possible for pouch is then attached to the stoma and people with UC to have normal bowel worn outside the body to collect stool. movements, because it preserves part The pouch needs to be emptied several of the anus. For this operation, the times a day. An ileostomy performed surgeon preserves the outer muscles for UC is usually permanent. A spe- of the rectum during the proctocolec- cially trained nurse will teach the person tomy. The ileum––the lower end of the how to clean, care for, and change the small intestine––is then pulled through ostomy pouch and how to protect the the remaining rectum and joined to the skin around the stoma. anus, creating a pouch. Waste is stored The type of surgery recommended will be in the pouch and passes through the based on the severity of the disease and the anus in the usual manner. Bowel move- person’s needs, expectations, and lifestyle. ments may be more frequent and watery People faced with this decision should get as than before the procedure. Inflamma- much information as possible by talking with tion of the pouch, called , is their doctors; enterostomal therapists, nurses a possible and can lead who work with colon surgery patients; other to symptoms such as increased diar- health care professionals; and people who rhea, rectal bleeding, and loss of bowel have had colon surgery. Patient advocacy control. Pouch surgery is the first type organizations can provide information about of surgery considered for UC because it support groups and other resources. avoids a long-term ileostomy. Eating, Diet, and Nutrition Dietary changes may help reduce UC symp- toms. A recommended diet will depend on Ileum the person’s symptoms, medications, and reactions to food. General dietary tips that may alleviate symptoms include Ileal reservoir • eating smaller meals more often • avoiding carbonated drinks Rectal cuff • eating bland foods • avoiding high-fiber foods such as corn and nuts Anus Anal sphincter For people with UC who do not absorb enough nutrients, vitamin and nutritional supplements may be recommended.

Ileoanal pouch anastomosis 5 Ulcerative Colitis Is colon cancer a concern panel and endorsed by numerous organi- zations, including the American Cancer with UC? Society, the American College of Gastroen- People with UC have an increased risk terology, the American Society of Colon and of colon cancer when the entire colon is Rectal Surgeons, and the Crohn’s & Colitis affected for a long period of time. For Foundation of America. example, if only the lower colon and rectum are involved, the risk of cancer is no higher than that of a person without UC. But if the entire colon is involved, the risk of cancer Points to Remember is higher than the normal rate.4 The risk of colon cancer also rises after having UC for • Ulcerative colitis (UC) is a chronic, 8 to 10 years and continues to increase over or long-lasting, disease that causes time. Effective maintenance of remission inflammation and sores, called by treatment of UC may reduce the risk of ulcers, in the inner lining of the colon cancer. Surgical removal of the colon colon and rectum. eliminates the risk of colon cancer. • Ulcerative colitis is one of the two With UC, precancerous changes––called main forms of chronic inflamma- ––sometimes occur in the cells lin- tory disease of the gastrointestinal ing the colon. People with dysplasia are at tract, called inflammatory bowel increased risk of developing colon cancer. disease (IBD). Doctors look for signs of dysplasia when per- • The most common symptoms of forming a colonoscopy or flexible sigmoid- UC are abdominal discomfort and oscopy and when examining tissue removed bloody diarrhea. during these procedures. • Flexible sigmoidoscopy and colo- According to the U.S. Preventive Services noscopy are the most accurate Task Force guidelines for colon cancer methods for diagnosing UC and screening, people who have had IBD ruling out other possible condi- throughout the colon for at least 8 years and tions, such as Crohn’s disease, those who have had IBD in only the left side diverticular disease, or cancer. of the colon for 12 to 15 years should have a • Treatment for UC depends on the colonoscopy with every 1 to 2 years severity of the disease and its symp- to check for dysplasia. Such screening has toms. Each person experiences UC not been proven to reduce the risk of colon differently, so treatment is adjusted cancer, but it may help identify cancer early for each individual. Treatment may and improve prognosis. These guidelines include medication therapy, hospi- were produced by an independent expert talization, or surgery to remove the rectum and part or all of the colon. • Most people with UC never develop colon cancer, but two fac- tors that increase the risk are the 4Colorectal cancer: early detection. American duration of the disease and how Cancer Society website. www.cancer.org/Cancer/ much of the colon is affected. ColonandRectumCancer/MoreInformation/ ColonandRectumCancerEarlyDetection/index. Updated June 14, 2011. Accessed August 3, 2011. 6 Ulcerative Colitis Hope through Research For More Information The National Institute of Diabetes and Crohn’s & Colitis Foundation of America Digestive and Kidney Diseases (NIDDK), 386 Park Avenue South, 17th Floor through the Division of Digestive Dis- New York, NY 10016 eases and Nutrition, conducts and sup- Phone: 1–800–932–2423 ports research into many kinds of digestive Email: [email protected] disorders, including UC. Researchers are Internet: www.ccfa.org studying how and why the immune system Reach Out for Youth with and is activated, how it damages the colon, and Colitis, Inc. the processes involved in healing. Through P.O. Box 857 this increased understanding, new and more Bellmore, NY 11710 specific therapies for UC can be developed. Phone: 631–293–3102 Participants in clinical trials can play a more Email: [email protected] active role in their own health care, gain Internet: www.reachoutforyouth.org access to new research treatments before United Ostomy Associations of America, Inc. they are widely available, and help others P.O. Box 512 by contributing to medical research. For Northfield, MN 55057–0512 information about current studies, visit Phone: 1–800–826–0826 www.ClinicalTrials.gov. Email: [email protected] Internet: www.ostomy.org

Acknowledgments Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This publica- tion was originally reviewed by the Crohn’s & Colitis Foundation of America.

7 Ulcerative Colitis You may also find additional information about this National Digestive Diseases topic by visiting MedlinePlus at www..gov. Information Clearinghouse This publication may contain information about medications. When prepared, this publication 2 Information Way included the most current information available. Bethesda, MD 20892–3570 For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll- Phone: 1–800–891–5389 free at 1–888–INFO–FDA (1–888–463–6332) or visit TTY: 1–866–569–1162 www.fda.gov. Consult your health care provider for more information. Fax: 703–738–4929 Email: [email protected] Internet: www.digestive.niddk.nih.gov The National Digestive Diseases Information The U.S. Government does not endorse or favor any specific commercial product or company. Trade, Clearinghouse (NDDIC) is a service of the proprietary, or company names appearing in this National Institute of Diabetes and Digestive document are used only because they are considered and Kidney Diseases (NIDDK). The necessary in the context of the information provided. If a product is not mentioned, the omission does not NIDDK is part of the National Institutes of mean or imply that the product is unsatisfactory. Health of the U.S. Department of Health and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health

NIH Publication No. 12–1597 October 2011

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