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Photo © pablocalvog - Fotolia.com GI Society 1 when they appear, and how you feel. As you discuss targeted to reduce the underlying inflammation. The these symptoms with your physician, he or she will goal is to heal the lining of the colon and to stay in be in a better position to form a diagnosis for you. remission. Your physician will determine which of several procedures is best to assess your intestinal symptoms. X-rays allow the physician to view the contours of the Dietary and Lifestyle Modifications bowel. The procedure requires the patient to undergo a barium . This provides contrast that helps As most nutrients are absorbed higher up in the intestine show up on X-ray. Scopes may help to the digestive tract, persons with ulcerative colitis determine the nature and extent of the disease. In generally do not have nutrient deficiencies; however, these procedures, the physician inserts an instrument other factors may influence the patient’s nutritional into the body via the anus (sigmoidoscope/ state. Disease symptoms may cause food avoidance, colonoscope) to allow for visualization of the colon. leading to food choices that might not provide a The scopes are made of a hollow, flexible tube balanced diet. If bleeding is excessive, problems such with a tiny light and video camera. An advantage as anemia may occur, and modifications to the diet of these procedures over a barium X-ray or virtual will be necessary to compensate for this. (CT scan) is that a physician may Better overall nutrition provides the body with suspicious-looking tissue at any time during the the means to heal itself. Depending on the extent examination for subsequent laboratory analysis. and location of inflammation, patients may have to Once all of this testing is complete, and other follow a special diet, including supplementation. It is possible conditions are ruled out, your physician may important to follow Canada’s Food Guide, but this make a diagnosis of ulcerative colitis. is not always easy for individuals with ulcerative colitis. We encourage each patient to consult a registered dietitian, who can help set up an effective, personalized nutrition plan by addressing disease- specific deficiencies and the patient’s sensitive digestive tract. Some foods may irritate the bowel and increase symptoms even though they do not affect the disease course. In more severe cases, it might be necessary to allow the bowel time to rest and heal. Specialized diets, easy to digest meal substitutes (elemental formulations), and fasting with intravenous feeding (total ) can achieve incremental Colon degrees of bowel rest.

Rectum Symptomatic Therapy Anus The symptoms are the most distressing components of ulcerative colitis, and direct treatment Area Affected by Ulcerative Colitis Inflammation starts at the anus and extends of these symptoms, particularly pain and diarrhea, up into the colon. It may involve only a short will improve quality of life for the patient. A number segment or as much as the entire colon. of treatments exist to address diarrhea and pain. Dietary adjustment may be beneficial and anti- diarrheal have a major role to play. For Management painful symptoms not controlled by other drugs, The treatment of ulcerative colitis is multi- analgesics can be helpful, with acetaminophen faceted; it includes managing the symptoms and (Tylenol®) being the preferred choice. consequences of the disease along with therapies There are two types of anti-diarrheal medications

2 GI Society Ulcerative Colitis www.badgut.org directed at preventing cramps and controlling 5-Aminosalicylic Acid (5-ASA) . One group alters the muscle activity of 5-ASA medication is safe and well tolerated for the intestine, slowing down content transit. These long-term use in mild cases of ulcerative colitis. include: nonnarcotic (Imodium®); These medications, taken orally, include mesalamine narcotic agents (Lomotil®), codeine, (Asacol®, Asacol 800®, Mesasal®, Mezavant®, opium tincture and paregoric (camphor/opium); Pentasa®, Salofalk®) and sodium and anti-spasmodic agents hyoscyamine sulfate (Dipentum®). Quicker results might occur when (Levsin®), dicyclomine (Bentylol®), propantheline medication is used in a topical form, taken rectally. (Pro-Banthine®), and hyoscine butylbromide Salofalk® is available in 500mg and 1g suppositories. (Buscopan®). Salofalk® 1g and Pentasa® 1g suppositories are The other group adjusts stool looseness and once-a-day therapies. In a more difficult case, you frequency by soaking up (binding to) water, may receive 5-ASA enema therapy (Salofalk® 4g regulating stool consistency so it is of a form & 2g/60mL and Pentasa® 1g, 2g, or 4g/100mL) and consistency that is easy to pass. These work for a short course, followed by suppositories, as in different ways; some, such as Metamucil® the inflammation improves. Some patients may or Prodiem®, come from plant fibres, whereas benefit from a combination of orally and rectally cholestyramine resin (Questran®) is a bile salt administered 5-ASA therapies in cases that do not binder. Interestingly, plant fibres are also useful for respond to rectal therapy alone. constipation, due to their stool regulating effects. Patients use rectal medications nightly at first If extra-intestinal signs of ulcerative colitis occur, and, as the disease improves, treatments become less such as or inflamed eyes, the physician will frequent. Sometimes your doctor will stop treatment address these conditions individually, as the patient and start it again if there is a flare up, and sometimes may require referrals to other specialists. If anxiety maintenance therapy two to three times a week may and stress are major factors, a program of stress be required long-term. Typically, a patient starts on management may be valuable. Ask for our pamphlet one type of preparation and if there is inadequate on Stress Management. response, then switches to another type. Individuals with ulcerative colitis may be anemic 5-ASA helps to settle acute inflammation and, from chronic blood loss. Adding dietary supplements when taken on a long-term basis (maintenance), could help improve this condition, with heme iron it tends to keep the inflammation inactive. It is polypeptide (Proferrin®) being the preferred choice, important to keep up your medicine regimen even due to its quick-acting and low side effect profiles. if your symptoms disappear and you feel well again. The most widely prescribed antibiotics are Maintenance therapy can be at the full initial dosage ciprofloxacin (Cipro®) and metronidazole (Flagyl®, or at a reduced dosage and interval, depending on the Florazole ER®). Broad-spectrum antibiotics are disease response. important in treating secondary manifestations of the disease, such as peri-anal abscess and fistulae. To reduce inflammation for the short-term Anti-inflammatory Medication Therapy in moderate to severe cases of ulcerative colitis, corticosteroids can help. These are and This comes in many forms, using various body (Entocort®) taken orally, although systems to effect relief. A physician may prescribe prednisone tends to have greater side effects. These any of the following medications alone or in medications can be helpful to induce remission but combination. It could take some time to find the right should not be used long-term, or for maintenance. mix for any specific patient, as each case of ulcerative For topical relief in the colon, budesonide colitis is unique. Depending on the location of your (Entocort®) and hydrocortisone (Betnesol®, disease, the combination of drug delivery method Cortenema®, Cortifoam®, Proctofoam®) are (oral and rectal) could help to ensure that all areas of available for patients to administer rectally (, the disease are covered. foams, and suppositories). However, if the patient

www.badgut.org Ulcerative Colitis GI Society 3 has significant diarrhea, then the rectal medications Since ulcerative colitis only involves the large may be difficult to hold. Cortifoam® is a foam bowel, removing this organ will remove the disease preparation of a smaller volume so the patient may but it is not a cure; removing the colon can lead retain the treatment in the longer, thereby to other symptoms and complications. Although increasing the amount of time it has to work. there are many variations to possible surgical Physicians can prescribe hydrocortisone (Solu- procedures, typically, after removing all or part of Cortef®) and (Solu-Medrol®) the colon (), a surgeon brings the end of the for administration intravenously in-hospital. remaining intestine through a new surgical opening in the abdominal wall (ostomy) to which the patient Immunosuppressive Agents can attach a removable appliance to collect stool. These drugs are used to treat ulcerative An ostomy may be either temporary or permanent, colitis, to reduce dependence on steroids, and for depending upon the particular situation. those who have steroid-resistant disease. They In recent years, new techniques have arisen include (Imuran®), cyclosporine, whereby surgeons can preserve the anal muscle /6-MP (Purinethol®), and and create an internal pouch, or reservoir, from sodium (Rheumatrex™). It could take the remaining intestine. Emptying pouch contents up to six months or more of therapy to see results. via the anus more closely resembles the normal anatomical route. However, with the loss of colon Biologics function, bowel movements have very high water Biologic medications are important treatment content and move very frequently. This means that options for those who have moderate to severe even after surgery, patients could face troublesome ulcerative colitis. Biologics are specially developed gastrointestinal symptoms. One that antibodies, which selectively block molecules can occur is , which is inflammation within that are involved in the inflammatory process. the surgically-created pouch. Gastroenterologists routinely prescribe biologics, An emerging surgical therapy is intestinal which include (Remicade®), transplantation, but there are barriers yet to (Simponi®), and (Humira®) to control overcome, such as tissue rejection and inflammation the symptoms (induce clinical remission) of in the newly transplanted organ. inflammatory bowel diseases. Remicade® has indications to induce and maintain clinical remission and mucosal healing, and Outlook for reducing or eliminating use, since Ulcerative colitis is a chronic, systemic 2006. Simponi® has indications for use to induce inflammatory disease manifesting in the colon. and maintain clinical remission and mucosal healing Intensity of this condition varies greatly from person use, since 2013. Humira® has indications for use to to person and during a lifetime. Some patients may induce and maintain clinical remission, since 2013. have an initial episode and then go into remission Both Humira® and Simponi® are self- for a long period, some may have occasional flare- administered under the skin (subcutaneously), ups, and some others may have ongoing disease. Humira® about every 2 weeks, and Simponi® Although there is no cure, ulcerative colitis patients about every 4 weeks. A health care professional require ongoing medical care, and must adhere to a administers Remicade® by intravenous (IV) proper nutrition and medication regimen, even when infusion about every 8 weeks, usually in a Janssen- things appear to be going well. Your physician will provided BioAdvance® clinic. work with you to create an appropriate treatment plan for you and to monitor your disease regularly, even during periods of remission. For more information Surgery on ulcerative colitis, visit www.badgut.org. In patients with ongoing active disease that fails to respond to all forms of medical management, surgery may be necessary.

4 GI Society Ulcerative Colitis www.badgut.org Notes: About Us As the Canadian leader in providing trusted, evidence-based information on all areas of the gastrointestinal (GI) tract, the Gastrointestinal Society is committed to improving the lives of people with GI and liver conditions, supporting research, advocating for appropriate patient access to healthcare, and promoting gastrointestinal and liver health. The Inside Tract® newsletter provides the latest news on GI research, disease and disorder treatments (e.g., medications, nutrition), and a whole lot more. If you have any kind of digestive problem, then you’ll want this timely, informative publication.

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The GI Society, in partnership with the Canadian Society of Intestinal Research, produced this pamphlet under the guidance of affiliated healthcare professionals. This document is not intended to replace the knowledge, diagnosis, or care of your physician.

© Gastrointestinal Society 2014

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