Ulcerative Colitis

Ulcerative colitis (UC) is an inflammatory bowel disease affecting the colon and rectum. The colon and rectum are the final parts of the gastrointestinal system and together are known as the large bowel. They receive the end products of digestion from the small bowel and their role is to absorb water and salt. During this process, faeces are formed and stored by the colon and rectum until the person wishes or is able to go to the toilet.

Inflammation of the lining in the colon and/or rectum reduces the ability of the large bowel to absorb water and form faeces. Therefore, patients with UC typically develop diarrhoea that is sometimes bloody.

There are no obvious causes for UC, but undoubtedly it is a combination of genetic and environmental factors. Some families contain more members with UC than would be found in the general population, and there is an increased incidence in identical twins. However, it cannot be said that children will definitely develop UC if one of their parents has the disease.

Some researchers have suggested that certain types of food are associated with UC, but other studies have not confirmed this. Overall, the cause(s) of UC are still unknown. Stress and worry are not causes, but may trigger a relapse of UC or make its symptoms worse.

People with UC involving only the last part of the large bowel generally have milder symptoms. They may have only one flare-up in their lifetime and never have problems with UC afterwards. However, about 15% of people with initially mild UC may go on to develop more severe disease. Unfortunately, those patents with more extensive disease at the outset are less likely to achieve remission and are likely to have increasingly severe problems with UC.

We do know that there is an association between UC and an increased risk of bowel cancer. In people with UC affecting more than half of the large bowel (pancolitis) and the inflammation is particularly severe, there is an increased risk of colorectal cancer after 10 years. For this reason, patients with more extensive UC are offered annual screening colonoscopy for bowel cancer starting eight years after their diagnosis of active UC. There is no increased risk of bowel cancer in people with milder forms of the disease.

UC is diagnosed by colonoscopy. UC continues to be an area of extensive research, but as yet no major breakthroughs have been made.

Treatment

Medication

There are many medications that can help to reduce the symptoms of UC and induce remission, and others that can help to prevent flare-ups of the disease. These include the anti-inflammatories, steroids, immunosuppressants, and newer biological therapies. Each agent has specific uses and indications. Severe forms of UC can result in having many episodes of severe diarrhoea in a day, requiring intensive medical therapy that comes with side effects.

Women with UC are encouraged to time their pregnancies during periods of remission, so that their medications can be kept to a minimum. Some medications used in UC have no effect on the reliability of contraception, becoming pregnancy, or development of the unborn baby. Unfortunately others do, and women taking these are encouraged to use contraception. The chances of a woman with UC becoming pregnant are no different to the rest of the population, and the risks of pregnancy are the same.

Surgery

The milder versions of UC are not dangerous and only need treatment if symptoms warrant. However, the more severe forms of UC are associated with complications, some of which present needing emergency surgery. Other patients may opt for elective (planned) surgery for UC because medical therapy has not reduced the severity of the disease.

The most common procedure (emergency or elective) performed for UC is a total colectomy. This procedure is usually performed by laparoscopic surgery. When a total colectomy is performed as an emergency, the bowel ends are not joined together and the end of the small bowel is brought out through the right lower abdominal wall. This is known as an ileostomy. Effluent from the small bowel then collects into a bag that the patient empties as needed.

When the patient has recovered, there are several options available if the colon has been removed but the rectum is left inside. If the patient is still having trouble in terms of bloody or mucous discharge, the rectum will need to be removed at some stage. In this situation, the patient can decide whether they want to keep their ileostomy or wish to be considered for ileal pouch surgery. Pouch surgery is generally suitable for people younger than 45 years with good anal muscles and a clear understanding of the long-term nature of this procedure and its potential complications. In the small number of people in whom the rectum is not particularly inflamed, rejoining the small bowel to the top of the rectum is a possibility. All of these paths have advantages and disadvantages as well as complications, and these will be discussed in detail with you.

For more information on ulcerative colitis, please visit www.crohnsandcolitis.org.uk/about-inflammatory-bowel-disease/ulcerative-colitis