Ulcerative colitis (UC) is a chronic disease affecting the large intestine and rarely terminal small intestine ; with an increasing incidence worldwide. Management of this disease has grown increasingly complex with availability of newer medications.
It is a chronic immune-mediated inflammatory condition of the large intestine that causes continuous mucosal inflammation of the colon & rectum. The absence of rectal involvement has been noted in fewer than 5% of adult patients with ulcerative colitis (UC) at diagnosis but is seen more in pediatric patients. ulcerative colitis (UC) is characterised by a relapsing and remitting course.
The initial presentation of new ulcerative colitis (UC) is characterized by bleeding PR / bloody diarrhoea, mucous in stools, urgency, abdominal cramping and tenesmus (a sense of pressure / painful incomplete evacuation), nighttime stools / diarrhea & frequency, fecal incontinence. In the absence of an alternate cause, it should trigger the doubt of ulcerative colitis (UC).
Patients with active disease also complain of rectal urgency, tenesmus, mucopurulent exudate, nocturnal defaecation, and crampy abdominal pain. In contrast, patients with proctitis usually present with rectal bleeding, urgency, tenesmus, and occasionally severe constipation.
The onset of ulcerative colitis (UC) is usually insidious; symptoms are often present for weeks or even months before medical advice is sought. Presentation with a severe attack occurs in about 15%, with systemic symptoms including weight loss, fever, tachycardia, nausea, and vomiting. EIMs may accompany the presentation in about 10–20% of cases and can precede intestinal symptoms in 10% of patients
Weight loss, fatigue, fever, extraintestinal manifestations, including joint, skin, ocular, and oral manifestations, and symptoms suggesting hepatobiliary involvement are other features of ulcerative colitis (UC).
Intestinal infections that can mimic ulcerative colitis (UC) e.g. infection with Escherichia coli, Salmonella, Shigella, Yersinia, and Campylobacter and parasitic infections such as amebiasis in the right clinical setting. These are usually food & water borne infections. Infections like C. Difficile and some viral infections (CMV) can also mimic an attack or relapse.
The condition may present at any time and at all ages, but there is a predominant age distribution of onset that peaks between ages 15 and 30 years. The second peak is after 50.
The pattern of disease activity is most often described as relapsing and remitting, with symptoms of active disease alternating with periods of clinical quiescence (symptoms & disease activity settled), which is called remission.
Some patients with ulcerative colitis (UC) have persistent disease activity despite diagnosis and medical therapy, and a small number of patients present with the rapid-onset progressive type of colitis known as fulminant disease .
Stopping Smoking, using strong painkillers (nonsteroidal anti-inflammatory drug -NSAID), enteric infections like C. difficile, treatment noncompliance (improper timing, skipping) are some of the reasons for precipitation of a fresh attack or relapse.
There are no specific protective factors or measures against ulcerative colitis (UC). Appendicectomy in young age is sometimes observed to have protected against Ulcerative colitis (UC).
The diagnosis of ulcerative colitis (UC) requires a lower gastrointestinal endoscopic examination & histologic confirmation (biopsy). Blood tests CBC CRP LFT, albumin, antibody tests pANCA & ASCA, stool based tests stool routine, stool culture, fecal C. Diff Ag & fecal calprotectin.
Small bowel study (radiology, by follow-through, computer tomographic [CT] or magnetic resonance [MR] enterography, or capsule endoscopy and small bowel endoscopy) is not routinely recommended in ulcerative colitis (UC). When differential diagnosis is difficult in the presence of rectal sparing, atypical symptoms, and/or macroscopic backwash ileitis (UC affecting small intestine), an extended diagnostic workup (small bowel study) to exclude Crohn’s disease is warranted.
ulcerative colitis (UC) causes significant morbidity and a described low incidence of mortality. Patients with active disease are more likely to have comorbid psychological conditions of anxiety and depression and are more likely to have impaired social interactions or career progression. Long-standing ulcerative colitis (UC) is also associated with a defined risk of dysplasia and colorectal cancer, which is believed to be related to long-standing unchecked inflammation
Management of ulcerative colitis (UC) must involve a prompt and accurate diagnosis, assessment of the patient’s risk of poor outcomes, and initiation of effective, safe, and tolerable medical therapies. The optimal goal of management is a sustained and durable period of steroid-free remission, accompanied by appropriate psychosocial support, normal health-related quality of life (QoL), prevention of morbidity including hospitalization and surgery, and prevention of cancer. To achieve these goals, effective diagnostic, treatment, and preventive strategies are necessary involving patient preference too.
The goal of treatment is to induce & achieve remission (control of symptoms, disease activity & intestinal healing), maintain remission / healthy state without use of steroids, prevent relapse / recurrence & avoid cancer & surgery if possible.
Symptom control and intestinal healing does not necessarily go hand in hand in all cases. Patient with active disease may not have much symptoms and patients with symptoms may not show active inflammation in intestine. Hence patient’s goal and treating physician’s goal may not always align. Most of the times, however the improvement in endoscopic findings is accompanied by clinical improvement. Improvement & not complete healing is what is required to avoid problems & surgery.
The targets for ulcerative colitis (UC) treatment are resolution of rectal bleeding, normalization of bowel habits, and healing of intestine as seen on endoscopy. These should be assessed at a minimum every 3 months during the active phase of disease.
Treatment for inducing & achieving remission, maintaining remission &/or preventing a relapse & that of a relapse is decided by disease extent, severity, and prognosis.
Treatment of ulcerative colitis (UC) is predominantly medical i.e. drug therapy. The drugs include special anti-inflammatory agents (5-ASA derivatives), steroids, immunomodulators & newer immunosuppressants. Some of these induce remission (e.g. 5-ASA, steroids & new immunosuppressants), some are used to maintain remission & prevent relapse (5-ASA, immunomodulators & immunosuppressants). The permutation & combination of drugs used depend upon the extent & severity of disease and the experience of treating team. The route of giving the medication (per oral, rectal – suppository or enema, intramuscular / subcutaneous / intravenous) depends on the extent and severity of disease and the drug used. Even though there are various guidelines about the usage of medications and combinations, a liberty is often taken to change the combination based on experience. The main aim is to achieve remission early preferably without steroid use, maintain remission without steroid use, avoid long use of steroid and steroid dependence, identify steroid resistant / refractory disease and use new immunosuppressants & immunomodulators where appropriate & necessary.
The new drugs are often expensive increasing cost of care significantly and often disease is resistant even to them or patient has steroid dependence or has significant tolerance issues with drugs or develops drug induced problems; in these situations an elective surgery is a better option. Surgery is also the treatment when there are complications like perforation, toxic megacolon, massive bleeding, multicentric precancerous lesions or cancer.
An emergency surgery is necessary when there are complications like perforation, toxic megacolon, massive bleeding or cancer. It is also necessary in elective setting when disease is refractory to medical line of treatment or there is steroid dependence or patient is unable to tolerate the medications and side effects. These are indications for elective surgery. Surgery should also be considered when cost of medical treatment is prohibitive.
Elective surgery involves removal of entire colon and rectum by open or laparoscopic route. It is followed by creation of a new rectum in the form of a pouch from terminal small intestine, which is joined to the anal canal. Sometime this surgery is performed in two or 3 stages. These stages include end ileostomy after the 1st stage (removal of colorectum) and loop diverting ileostomy after the 2nd stage (pouch anal anastomosis). 3rd stage is closure of ileostomy. Surgery is sometimes modified in that rectum is retained if it is spared by the disease and the small intestine is joined to it. However this retained rectum needs significant monitoring, can cause complaints due to disease activation there or develop cancer. A single stage surgery & laparoscopic surgery is usually avoided in emergency situation.
Many patients remain on permanent ileostomy either voluntarily (to avoid another major surgery and associated risk of complications), or out of compulsion (fecal incontinence, fear of complications like sexual dysfunction, failure after pouch surgery due to recurrence in the pouch or pouch malfunction, original surgery performed for rectal cancer wherein anal canal had to be removed etcetera).
Most patients get well adjusted to the ileostomy over a period and quality of life is good.
Yes, 20-30% patients with pouch have a pouch failure for some or other reason. It can be recurrent inflammation in the pouch (pouchitis), stricture / narrowing, pouch prolapse, torsion, ischemia, cancer in the pouch etcetera. Any of this can finally result in need to remove the pouch and do a permanent ileostomy or in rare favorable circumstance reconstruct a new pouch-anal anastomosis.
Yes pouch needs regular surveillance with clinical examination, investigations and endoscopy when necessary.
How does one decide the response to medical treatment? / measures of remission Patient-reported outcomes (PROs) (improvement in symptoms like urgency, frequency, bleeding and normalization of bowel habits),inflammatory burden (endoscopic assessment including extent and severity and markers of inflammation, improvement in parameters like CRP & FC), objective markers of inflammation can be considered such as normalization of CRP and FC. More recent measures of remission now include symptomatic remission (no rectal bleeding and no urgency) and endoscopic evidence of mucosal healing. endoscopic mucosal response and remission as treatment targets.
Remission is defined as stool frequency < 3/day, no rectal bleeding, and normal mucosa at endoscopy. Absence of a histological acute inflammatory infiltrate predicts quiescent course of disease.
Patient complaints (bleeding, urgency, pain), rising FC & CRP, recurrent disease on endoscopy & biopsy indicate that disease has relapsed.
Blood tests like CBC, CRP, LFT; FC, stool test for microbial assessment (especially C. difficile) , histology, test for CMV infection are some of the investigations necessary during a relapse.
Fecal calprotectin (FC) can be used in patients with ulcerative colitis (UC) as a noninvasive marker of disease activity and to assess response to therapy and relapse. Also it is used to differentiate IBD from IBS
Extensive colitis, need for systemic steroids, young age at diagnosis, elevated CRP or ESR, previous hospitalizations are associated with higher possibility of surgery & poor response to medical line of treatment
Treatment at centers and physicians with experience in management of this chronic illness, strict compliance with treatment (diet, medication, psychological management), avoiding factors that precipitate an acute attack in this chronic illness are few things in the hands of the patient. Screening / monitoring for disease related complications, surveillance / monitoring for drug related complications, routine visits for monitoring relapse and early pickup if any, psychological support whenever necessary are also vital.
Yes, patients with ulcerative colitis (UC) are at a higher risk for colorectal cancer compared to average population. This is especially true with male patients or when disease is going on for more than 8 years (longstanding), is extensive and is severe. Also the risk is very high when patient has PSC (a type of biliary inflammation) with ulcerative colitis (UC).
Since patients with ulcerative colitis (UC) are at high risk to develop colorectal cancer, these patients are advised to undergo regular screening 8-years after onset of symptoms. The screening is done by regular colonoscopy performed every 1-3 years. Patients at highest risk e.g. those with PSC, active severe colitis, extensive disease, young patients; may be advised endoscopy every year, others are advised once in 2 or 3 years. Those with very limited disease (only rectum) and without high risk cofactors are not advised surveillance. Surveillance colonoscopy may permit detection of precancerous disease or early detection of colorectal cancer with a corresponding improved prognosis. A secondary gain is of improved disease control.
These surveillance programs involve not only a systematic colonoscopic assessment, but also a revision of the patients’ symptoms, medications, and laboratory test results, as well as an update of personal and family medical histories. At the onset of these programs, an initial screening colonoscopy is performed to reassess disease extent and confirm the absence of precancerous lesions.
The most effective way to prevent cancer is to keep disease under control. Medications like mesalamine given during management may be helpful too. However advanced medications that work through immune system modulations / suppression may have a double edge effect. Keep disease under control and hence cancer too or suppress immunity and allow cancer to enter.
Many of such lesions can be removed endoscopically whenever possible depending on availability of technology and expertise and patient is put back on surveillance. However sometimes a surgery / colectomy may be required. In situations where decisions are debatable patient is put on frequent follow up endoscopies (enhanced surveillance).
Treatment of extraintestinal manifestations is essentially the same medications previously mentioned.
Ulcerative colitis & Chrohn’s disease (IBD-Inflammatory bowel disease) are very complex problems with lots of permutations and combinations followed during treatment. There may be many more questions in the mind of a patient, relative or reader and are best answered by treating physician only.