Ulcerative colitis is an idiopathic chronic inflammatory disease involving the colon and the rectum. It is different from the other major category of inflammatory bowel disease, Crohn's disease (regional ileitis). Symptoms of ulcerative colitis (UC) are bloody diarrhea and abdominal pain. Evaluation of the colon with either flexible sigmoidoscopy or colonoscopy is mandatory for establishing the diagnosis as well as the extent of disease. Different degrees of involvement of the colon are important in selecting treatment.
Patients may have universal colitis (involvement of the entire colon), left sided colitis or procto-sigmoiditis. Based upon this information, and the severity of symptoms, an appropriate regimen can be selected by your physician.
Barium enemas may be useful in evaluating patients with ulcerative colitis. This study has limited use because of complications associated with this procedure during an acute episode of ulcerative colitis. Therefore, sigmoidoscopy or anoscopy may be preferable to barium enema for patients with an acute flare of ulcerative colitis or who have bloody diarrhea of undetermined etiology.
Medical therapy of ulcerative colitis is similar to that of Crohn's disease. Both diseases are treated with amino salicylates. The active ingredient in amino salicylates is Mesalamine.
The oldest drug in this category is sulfasalazine, also known as Azulfidine. This compound is made of two amino salicylate portions joined by a sulfur bond. When the compound reaches the colon, the sulfur bond is broken by the colonic bacteria. This releases the amino salicylate portions to become effective in the colon. The usual dose for this disease is 500 mg twice a day. Patients may then be advanced to a standard dose of 2 500 mg tablets by mouth twice a day.
Side effects associated with Azulfidine include headaches, vomiting, abdominal pain, diarrhea, nausea, hair loss and skin rashes. Patients may develop liver function test abnormality as well as bone marrow abnormalities. Folic acid should be utilized in all patients taking Azulfidine. In addition, as reversible sensitivity of sperm counts in men using Azulfidine has been identified.
Other preparations of this medication include Asacol and Pentasa.
Olsalazine is also utilized. However, it has a higher incidence of diarrhea. For this reason Olsalazine is less commonly used to treat patients with ulcerative colitis. Another major treatment for ulcerative colitis is glucocorticoids. Glucocorticoids are immune suppressive medications, which allow rapid reduction of the inflammatory process involved in ulcerative colitis. Patients with refractory left sided colitis or universal colitis are usually treated with these emdications. Prednisone treatment is usually 2-4 months in duration. Initial treatment ranges between 20 and 60 mg per day for the first several weeks. Afterwards, as the symptoms improve, the Prednisone is tapered over 2-3 months. Amino salicylates, as described above, are then utilized to provide maintenance therapy for patients.
Immunosuppressives such as 6-mercaptopurine have use in some patients. These agents are particularly effective for individuals who cannot be weaned off Prednisone. This medication has been used effectively in many patients. Its major side effect is that of bone marrow suppressants. Therefore, routine blood counts and office visits are required for individuals who are being treated with 6-mercaptopurine.
Cyclosporin, a strong immune suppressant, has also been utilized in limited patients who are severely ill with ulcerative colitis. This is best used under extremely controlled circumstances, usually in the hospital. Patients requiring IV Cyclosporin often require surgical intervention. A major side effect of Cyclosporin is nephrotoxicity. For this reason, Cyclosporin has limited use.
Complications associated with ulcerative colitis include toxic megacolon. Toxic megacolon is a condition where ulcerative colitis becomes out of control. The colon then becomes dilated. In this case, the colon may rupture causing peritonitis. Emergency surgery is required for treatment of toxic megacolon. In some patients IV Cyclosporin, under controlled circumstances, can be useful in order to provide a bridge for patients.
Other complications associated with this disease include colon cancer, dehydration, electrolyte abnormalities, infection and anemia.
Most patients should be examined for the development of colon cancer on a yearly basis with a colonoscopy. This allows for multiple biopsies to be obtained from the colon. Patients who have universal colitis have a 10 percent chance of developing colon cancer somewhere in the colon at the end of 10 years. Because of this, patients with universal colitis are instructed to have a colonoscopy on a yearly basis starting 8 years after their onset of symptoms. Should any evidence of abnormal cells be identified, a total colectomy is indicated.
After 10 years of therapy, the incidence of colon cancer rises for these patients at approximately 1 percent per year.
Patients with disease limited to the left side have been shown to have colon cancer develop at a later date (usually 15 years after the onset of symptoms). These individuals should be screened starting approximately 15 years after their initial symptoms.
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