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| | __NOTOC__ |
| | {| class="infobox" style="float:right;" |
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| | | [[File:Siren.gif|30px|link=Ulcerative colitis resident survival guide]]|| <br> || <br> |
| | | [[Ulcerative colitis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| {{DiseaseDisorder infobox | | | {{DiseaseDisorder infobox | |
| Name = Ulcerative colitis | | | Name = Ulcerative colitis | |
| Image = UC granularity.png | | | Image = UC granularity.png | |
| Caption = [[Colonoscopy|Endoscopic]] image of a [[sigmoid colon]] afflicted with ulcerative colitis. Note the vascular pattern of the colon granularity and focal friability of the [[mucosa]]. | | | Caption = [[Colonoscopy|Endoscopic]] image of a [[sigmoid colon]] afflicted with ulcerative colitis. Note the vascular pattern of the colon granularity and focal friability of the [[mucosa]]. | |
| ICD10 = {{ICD10|K|51||k|50}} |
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| ICD9 = {{ICD9|556}} |
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| DiseasesDB = 13495 |
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| OMIM = 191390 |
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| medlineplus = 000250|
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| }} | | }} |
| {{Ulcerative colitis}} | | {{Ulcerative colitis}} |
| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{CMG}} | | {{CMG}}; {{AE}}{{TarekNafee}}, {{USAMA}} |
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| {{SK}}: Colitis ulcerosa, colitis, distal colitis, pancolitis, ulcerative proctitis | |
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| ==Overview==
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| '''Ulcerative colitis''' ('''''[[Colitis ulcerosa]]''''', '''[[UC]]''') is a form of [[inflammatory bowel disease]] (IBD). Ulcerative colitis is a form of [[colitis]], a [[disease]] of the [[intestine]], specifically the large intestine or [[colon (anatomy)|colon]], that includes characteristic [[ulcers]], or open sores, in the colon. The main symptom of active disease is usually [[diarrhea]] mixed with blood, of gradual onset. Ulcerative colitis is, however, a [[systemic]] disease that affects many parts of the body outside the intestine. Because of the name, IBD is often confused with [[irritable bowel syndrome]] ("IBS"), a troublesome, but much less serious condition. Ulcerative colitis has similarities to [[Crohn's disease]], another form of IBD. Ulcerative colitis is an intermittent disease, with periods of exacerbated symptoms, and periods that are relatively symptom-free. Although the symptoms of ulcerative colitis can sometimes diminish on their own, the disease usually requires treatment to go into [[Remission (medicine)|remission]].
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| ==Incidence==
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| Ulcerative colitis is a [[rare disease]], with an incidence of about one person per 10,000 in North America. The disease tends to be more common in northern areas. Although ulcerative colitis has no known cause, there is a presumed [[genetics|genetic]] component to susceptibility. The disease may be triggered in a susceptible person by environmental factors. Although dietary modification may reduce the discomfort of a person with the disease, ulcerative colitis is not thought to be caused by dietary factors. Although ulcerative colitis is treated as though it were an [[autoimmunity|autoimmune disease]], there is no consensus that it is such. Treatment is with anti-inflammatory drugs, [[immunosuppression]] (suppressing the immune system), and [[Biological therapy for inflammatory bowel disease|biological therapy]] targeting specific components of the immune response. [[Colectomy]] (partial or total removal of the large bowel through surgery) is occasionally necessary, and is considered to be a cure for the disease.
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| ==Causes==
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| While the cause of ulcerative colitis is unknown, several, possibly interrelated, causes have been suggested.
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| ===Genetic factors===
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| A [[genetics|genetic]] component to the etiology of ulcerative colitis can be hypothesized based on the following:<ref>Orholm M, Binder V, Sorensen TI, Rasmussen LP, Kyvik KO. Concordance of inflammatory bowel disease among Danish twins. Results of a nationwide study. ''Scand J Gastroenterol'' 2000;35:1075-81. PMID 11099061.</ref>
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| *Aggregation of ulcerative colitis in families.
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| *Identical twin concordance rate of 10% and dizygotic twin concordance rate of 3%<ref>{{cite journal|author=Tysk C, Lindberg E, Jarnerot G, Floderus-Myrhed B | title="Ulcerative colitis and Crohn's disease in an unselected population of monozygotic and dizygotic twins. A study of heritability and the influence of smoking | journal=Gut |volume= 29 | date=1988 |pages=990–996}}</ref>
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| *Ethnic differences in incidence
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| *[[Genetic marker]]s and [[Genetic linkage|linkages]]
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| There are 12 regions of the [[genome]] which may be linked to ulcerative colitis. This includes chromosomes 16, 12, 6, 14, 5, 19, 1, 16, and 3 in the order of their discovery.<ref name=Baumgart>{{cite journal | author=Baumgart DC, Carding SF| title="Inflammatory bowel disease: cause and immunobiology"| journal=Lancet | volume=369 | issue=9573 | date=May 2007 | Pages=1627-1640 | doi=10.1016/S0140-6736(07)60750-8 }}</ref> However, none of these loci has been consistently shown to be at fault, suggesting that the disorder arises from the combination of multiple genes. For example, chromosome band 1p36 is one such region thought to be linked to inflammatory bowel disease.<ref>Cho JH, Nicolae DL, Ramos R, Fields CT, Rabenau K, Corradino S, Brant SR, Espinosa R, LeBeau M, Hanauer SB, Bodzin J, Bonen DK. Linkage and linkage disequilibrium in chromosome band 1p36 in American Chaldeans with inflammatory bowel disease. ''Hum Mol Genet'' 2000;9:1425-32. [http://hmg.oxfordjournals.org/cgi/content/full/9/9/1425 Fulltext]. PMID 10814724.</ref> Some of the putative regions encode transporter proteins such as OCTN1 and OCTN2. Other potential regions involve cell scaffolding proteins such as the MAGUK family. There are even [[HLA]] associations which may be at work. In fact, this linkage on chromosome 6 may be the most convincing and consistent of the genetic candidates.<ref name=Baumgart/>
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| Multiple autoimmune disorders have been recorded with the neurovisceral and cutaneous genetic porphyrias including ulcerative colitis, [[Crohn's disease]], [[celiac disease]], [[dermatitis herpetiformis]], systemic and discoid [[lupus]], [[rheumatoid arthritis]], [[ankylosing spondylitis]], [[scleroderma]], Sjogren's disease and [[scleritis]]. Physicians should be on high alert for porphyrias in families with [[autoimmune]] disorders and care must be taken with potential porphyrinogenic drugs, including sulfasalazine.
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| ===Environmental factors===
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| Many hypotheses have been raised for environmental contributants to the pathogenesis of ulcerative colitis. They include the following:
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| *[[Diet (nutrition)|Diet]]: as the [[Colon (anatomy)|colon]] is exposed to many different dietary substances which may encourage [[inflammation]], dietary factors have been hypothesized to play a role in the [[pathogenesis]] of both ulcerative colitis and [[Crohn's disease]]. There have been few studies to investigate such an association, but one study showed no association of refined [[sugar]] on the prevalence of ulcerative colitis.<ref>Jarnerot G, Jarnmark I, Nilsson K. Consumption of refined sugar by patients with Crohn's disease, ulcerative colitis, or irritable bowel syndrome. ''Scand J Gastroenterol'' 1983;18:999-1002. PMID 6673083.</ref>
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| *[[Tobacco smoking|Smoking]]: unlike Crohn's disease, ulcerative colitis has a lesser [[prevalence]] in smokers than non-smokers.<ref>Calkins BM. A meta-analysis of the role of smoking in inflammatory bowel disease. ''Dig Dis Sci'' 1989;34:1841-54. PMID 2598752.</ref>
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| *[[Breastfeeding]]: There have been conflicting reports of the protection of breastfeeding in the development of inflammatory bowel disease. One Italian study showed a potential protective effect.<ref>Corrao G, Tragnone A, Caprilli R, Trallori G, Papi C, Andreoli A, Di Paolo M, Riegler G, Rigo GP, Ferrau O, Mansi C, Ingrosso M, Valpiani D. Risk of inflammatory bowel disease attributable to smoking, oral contraception and breastfeeding in Italy: a nationwide case-control study. Cooperative Investigators of the Italian Group for the Study of the Colon and the Rectum (GISC). ''Int J Epidemiol'' 1998;27:397-404. PMID 9698126.</ref>
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| *Other childhood exposures, or infections
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| ===Autoimmune disease===
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| Some sources list ulcerative colitis as an [[autoimmunity|autoimmune disease]], a disease in which the [[immune system]] malfunctions, attacking some part of the body. As discussed above, ulcerative colitis is a systemic disease that affects many areas of the body outside the digestive system. Surgical removal of the large intestine often cures the disease, including the manifestations outside the digestive system.<ref name=ACGGuideline/> This suggests that the cause of the disease is in the colon itself, and not in the immune system or some other part of the body.
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| ===Alternative theories===
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| Levels of [[sulfate-reducing bacteria]] tend to be higher in persons with ulcerative colitis. This could mean that there are higher levels of [[hydrogen sulfide]] in the intestine. An alternative theory suggests that the symptoms of the disease may be caused by toxic effects of the hydrogen sulfide on the cells lining the intestine.<ref name=Roediger>Roediger WE, Moore J, Babidge W. Colonic sulfide in pathogenesis and treatment of ulcerative colitis. ''Dig Dis Sci'' 1997;42:1571-9. PMID 9286219.</ref><ref>Levine J, Ellis CJ, Furne JK, Springfield J, Levitt MD. Fecal hydrogen sulfide production in ulcerative colitis. ''Am J Gastroenterol'' 1998;93:83-7. PMID 9448181.</ref>
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| ==Epidemiology==
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| The [[incidence (epidemiology)|incidence]] of ulcerative colitis in North America is 10-12 cases per 100,000, with a peak incidence of ulcerative colitis occurring between the ages of 15 and 25. There is thought to be a bimodal distribution in age of onset, with a second peak in incidence occurring in the 6th decade of life. The disease affects females more than males.<ref name=Hanauer/>
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| The geographic distribution of ulcerative colitis and [[Crohn's disease]] is similar worldwide,<ref name=Podolsky>Podolsky DK. Inflammatory bowel disease. ''N Engl J Med'' 2002;347:417-424. PMID 12167685.</ref> with highest incidences in the United States, Canada, the United Kingdom, and Scandinavia. Higher incidences are seen in northern locations compared to southern locations in Europe and the United States<ref>Shivananda S, Lennard-Jones J, Logan R, Fear N, Price A, Carpenter L, van Blankenstein M. Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD). ''Gut'' 1996;39:690-7. PMID 9014768.</ref>
| | {{SK}} Colitis ulcerosa; distal colitis; ulcerative proctitis |
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| As with [[Crohn's disease]], ulcerative colitis is thought to occur more commonly among Ashkenazi Jewish people than non-Jewish people.
| | == [[Ulcerative colitis overview|Overview]] == |
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| ==Clinical presentation== | | == [[Ulcerative colitis historical perspective|Historical Perspective]] == |
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| ===GI symptoms=== | | == [[Ulcerative colitis classification|Classification]] == |
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| The clinical presentation<ref name=Hanauer>Hanauer SB. Inflammatory bowel disease. ''N Engl J Med'' 1996;334:841-848. PMID 8596552.</ref> of ulcerative colitis depends on the extent of the disease process. Patients usually present with [[diarrhea]] mixed with blood and [[mucus]], of gradual onset. They also may have signs of weight loss, and blood on rectal examination. The disease is usually accompanied with different degrees of abdominal pain, from mild discomfort to severely painful cramps.
| | == [[Ulcerative colitis pathophysiology|Pathophysiology]] == |
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| Ulcerative colitis is a systemic disease that affects many parts of the body. Sometimes the extra-intestinal manifestations of the disease are the initial signs, such as painful, arthritic knees in a teenager. It is, however, unlikely that the disease will be correctly diagnosed until the onset of the intestinal manifestations. | | == [[Ulcerative colitis causes|Causes]] == |
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| ====Extent of involvement====
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| Ulcerative colitis is normally continuous from the rectum up the [[Colon (anatomy)|colon]]. The disease is classified by the extent of involvement, depending on how far up the colon the disease extends: | | == [[Differentiating ulcerative colitis from other diseases|Differentiating Ulcerative colitis from other Diseases]] == |
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| *''Distal colitis'', potentially treatable with enemas:<ref name=ACGGuideline>Ulcerative Colitis Practice Guidelines in Adults, Am. Coll. Gastroenterology, 2004. [http://www.acg.gi.org/physicians/guidelines/UlcerativeColitisUpdate.pdf PDF]</ref>
| | == [[Ulcerative colitis epidemiology and demographics|Epidemiology and Demographics]] == |
| **''[[Proctitis]]'': Involvement limited to the [[rectum]].
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| **''Proctosigmoiditis'': Involvement of the rectosigmoid colon, the portion of the colon adjacent to the rectum.
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| **''Left-sided colitis'': Involvement of the descending colon, which runs along the patient's left side, up to the splenic flexure and the beginning of the transverse colon.
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| *''Extensive colitis'', inflammation extending beyond the reach of enemas:
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| **''Pancolitis'': Involvement of the entire colon, extending from the rectum to the cecum, beyond which the small intestine begins.
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| | == [[Ulcerative colitis risk factors|Risk Factors]] == |
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| | == [[Ulcerative colitis screening|Screening]] == |
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| <div align="center">
| | == [[Ulcerative colitis natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
| <gallery heights="175" widths="175">
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| Image:Intestine.png|Diagram of the Human Intestine
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| </gallery>
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| </div>
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| ====Severity of disease==== | | == Diagnosis == |
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| In addition to the extent of involvement, UC patients may also be characterized by the severity of their disease.<ref name=ACGGuideline>Ulcerative Colitis Practice Guidelines in Adults, Am. Coll. Gastroenterology, 2004. [http://www.acg.gi.org/physicians/guidelines/UlcerativeColitisUpdate.pdf PDF]</ref>
| | [[Ulcerative colitis history and symptoms|History and Symptoms]] | [[Ulcerative colitis physical examination|Physical Examination]] | [[Ulcerative colitis laboratory findings|Laboratory Findings]] | [[Ulcerative colitis abdominal x ray|Abdominal X Ray]] | [[Ulcerative colitis CT|CT]] | [[Ulcerative colitis other imaging findings|Other Imaging Findings]] | [[Ulcerative colitis other diagnostic studies|Other Diagnostic Studies]] |
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| *''Mild disease'' correlates with fewer than four stools daily, with or without blood, no [[systemic]] signs of toxicity, and a normal [[erythrocyte sedimentation rate]] (ESR). There may be mild abdominal pain or cramping. Patients may believe they are [[constipation|constipated]] when in fact they are experiencing [[tenesmus]], which is a constant feeling of the need to empty the bowel accompanied by involuntary straining efforts, pain, and cramping with little or no fecal output. Rectal pain is uncommon.
| | == Treatment == |
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| | [[Ulcerative colitis medical therapy|Medical Therapy]] | [[Ulcerative colitis surgery|Surgery]] | [[Ulcerative colitis alternative treatments|Alternative Treatments]] | [[Ulcerative colitis primary prevention|Primary Prevention]] | [[Ulcerative colitis secondary prevention|Secondary Prevention]] | [[Ulcerative colitis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Ulcerative colitis future or investigational therapies|Future or Investigational Therapies]] |
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| <div align="center">
| | == Case Studies == |
| <gallery heights="175" widths="175">
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| Image:Chronic Ulcerative Colitis 1.jpg|[[Colon (anatomy)|Colonic]] pseudopolyps of a patient with intractable '''ulcerative colitis'''. [[Colectomy]] specimen.
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| </gallery>
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| </div>
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| | [[Ulcerative colitis case study one|Case #1]] |
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| *''Moderate disease'' correlates with more than four stools daily, but with minimal signs of toxicity. Patients may display anemia (not requiring transfusions), moderate abdominal pain, and low grade [[fever]], 38 to 39 °C (99.5 to 102.2 °F).
| | ==Related Chapters== |
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| *''Severe disease'', correlates with more than six bloody stools a day, and evidence of toxicity as demonstrated by fever, [[tachycardia]], anemia or an elevated ESR.
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| *''Fulminant disease'' correlates with more than ten bowel movements daily, continuous bleeding, toxicity, abdominal tenderness and distension, blood transfusion requirement and colonic dilation (expansion). Patients in this category may have inflammation extending beyond just the mucosal layer, causing impaired colonic motility and leading to [[toxic megacolon]]. If the [[serous membrane]] is involved, colonic perforation may ensue. Unless treated, fulminant disease will soon lead to death.
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| ===Extraintestinal features=== | |
| As ulcerative colitis is a [[systemic]] disease, patients may present with [[symptom]]s and [[complication (medicine)|complications]] outside the colon. These include the following:
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| *[[Mouth ulcer|aphthous ulcers]] of the mouth
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| *Ophthalmic (involving the eyes):
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| **[[Iritis]] or [[uveitis]], which is inflammation of the iris
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| **Episcleritis
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| *Musculoskeletal:
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| **Seronegative [[arthritis]], which can be a large-joint [[arthritis|oligoarthritis]] (affecting one or two joints), or may affect many small joints of the hands and feet
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| **[[Ankylosing spondylitis]], arthritis of the spine
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| **[[Sacroiliitis]], arthritis of the lower spine
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| * Cutaneous (related to the skin):
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| **[[Erythema nodosum]], which is a [[panniculitis]], or inflammation of subcutaneous tissue involving the lower extremities
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| ** [[Pyoderma gangrenosum]], which is a painful ulcerating lesion involving the [[skin]]
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| *[[Deep venous thrombosis]] and [[pulmonary embolism]]
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| *[[Autoimmune hemolytic anemia]]
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| *[[clubbing]], a deformity of the ends of the fingers
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| *[[Primary sclerosing cholangitis]], or inflammation of the bile ducts
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| <div align="center">
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| <gallery heights="175" widths="175">
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| Image:Canker sore.jpg|Patients with '''ulcerative colitis''' can occasionally have [[mouth ulcer|aphthous ulcers]] involving the [[tongue]], [[lips]], [[palate]] and [[pharynx]]
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| </gallery>
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| </div>
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| ===Similar conditions===
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| The following conditions may present in a similar manner as ulcerative colitis, and should be excluded:
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| * [[Crohn's disease]]
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| * [[Infectious]] colitis, which is typically detected on stool cultures
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| ** [[Pseudomembranous colitis]], or ''[[Clostridium difficile]]''-associated colitis, bacterial upsets often seen following administration of antibiotics
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| * [[Ischemic colitis]], inadequate blood supply to the intestine, which typically affects the elderly
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| * Radiation colitis in patients with previous pelvic [[radiotherapy]]
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| * [[Chemical colitis]] resulting from introduction of harsh chemicals into the colon from an enema or other procedure.
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| [[Image:UC endo 2.jpg|center|thumb|200px|[[Endoscopic]] image of '''ulcerative colitis''' affecting the left side of the [[Colon (anatomy)|colon]]. The image shows confluent superficial ulceration and loss of mucosal architecture. Crohn's disease may be similar in appearance, a fact that can make diagnosing UC a challenge.]]
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| ===Comparison to Crohn's Disease===
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| The most common disease that mimics the symptoms of ulcerative colitis is [[Crohn's disease]], as both are inflammatory bowel diseases that can affect the [[colon (anatomy)|colon]] with similar symptoms. It is important to differentiate these diseases, since the course of the diseases and treatments may be different. In some cases, however, it may not be possible to tell the difference, in which case the disease is classified as '''indeterminate colitis'''.
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| {| class="prettytable" cellpadding=1 style="text-align:left"
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| |+ '''Comparisons of various factors in Crohn's disease and ulcerative colitis'''
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| ! !! Crohn's Disease !! Ulcerative Colitis
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| | Involves [[terminal ileum]]? || Commonly || Seldom
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| | Involves colon? || Usually || Always
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| | Involves rectum? || Seldom || Usually
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| | Peri-anal involvement? || Commonly || Seldom
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| | Bile duct involvement? || Not associated || Higher rate of [[Primary sclerosing cholangitis]]<ref>Broome U, Bergquist A. Primary sclerosing cholangitis, inflammatory bowel disease, and colon cancer. ''Semin Liver Dis'' 2006 February;26(1):31-41. PMID 16496231.</ref>
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| | Distribution of Disease || Patchy areas of inflammation || Continuous area of inflammation
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| | Endoscopy || Linear and serpiginous (snake-like) [[ulcer]]s
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| || Continuous ulcer
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| | Depth of inflammation || May be transmural, deep into tissues || Shallow, mucosal
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| | [[Fistula]]e, abnormal passageways between organs || Commonly || Seldom
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| | Biopsy || Can have [[granuloma]]ta ||
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| | Surgical cure? || Often returns following removal of affected part || Usually cured by removal of colon, can be followed by [[pouchitis]]
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| | Smoking || Higher risk for smokers || Lower risk for smokers
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| | Autoimmune disease? || Generally regarded as an autoimmune disease || No consensus
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| | Cancer risk? || Lower than ulcerative colitis || Higher than Crohn's
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| |}
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| ==Diagnosis and workup==
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| ===General===
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| The initial [[diagnosis|diagnostic]] workup for ulcerative colitis includes the following:<ref>Al-Ataie MB, Shinoy VN. eMedicine: Ulcerative colitis. [http://www.emedicine.com/med/topic2336.htm Fulltext].</ref><ref name=ACGGuideline>Ulcerative Colitis Practice Guidelines in Adults, Am. Coll. Gastroenterology, 2004. [http://www.acg.gi.org/physicians/guidelines/UlcerativeColitisUpdate.pdf PDF]</ref>
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| *A [[complete blood count]] is done to check for anemia; [[thrombocytosis]], a high [[platelet]] count, is occasionally seen
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| *[[Electrolyte]] studies and [[renal function|renal function tests]] are done, as chronic [[diarrhea]] may be associated with [[hypokalemia]], [[hypomagnesemia]] and pre-renal failure.
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| *[[Liver function tests]] are performed to screen for bile duct involvement: [[primary sclerosing cholangitis]].
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| *[[X-ray]]
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| *[[Urinalysis]]
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| *Stool culture, to rule out parasites and infectious causes.
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| *[[Erythrocyte sedimentation rate]] can be measured, with an elevated sedimentation rate indicating that an inflammatory process is present.
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| *[[C-reactive protein]] can be measured, with an elevated level being another indication of inflammation.
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| Although ulcerative colitis is a disease of unknown causation, inquiry should be made as to unusual factors believed to trigger the disease.<ref name=ACGGuideline/> Factors may include: recent cessation of tobacco smoking; recent administration of large doses of [[iron]] or [[vitamin B6]]; [[hydrogen peroxide]] in enemas or other procedures.
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| [[Image:Ulcerative colitis (2) active.jpg|thumb|center|H&E stain of a colonic biopsy showing a crypt abscess, a classic finding in ulcerative colitis]]
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| ===Endoscopic===
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| The best test for diagnosis of ulcerative colitis remains [[endoscopy]]. Full colonoscopy to the cecum and entry into the terminal ileum is attempted only if diagnosis of UC is unclear. Otherwise, a flexible sigmoidoscopy is sufficient to support the diagnosis. The physician may elect to limit the extent of the exam if severe colitis is encountered to minimize the risk of perforation of the colon. Endoscopic findings in ulcerative colitis include the following:
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| *Loss of the vascular appearance of the colon
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| *[[Erythema]] (or redness of the [[mucosa]]) and friability of the mucosa
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| *Superficial ulceration, which may be confluent, and
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| *[[Polyp (medicine)|Pseudopolyps]].
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| Ulcerative colitis is usually continuous from the [[rectum]], with the [[rectum]] almost universally being involved. There is rarely peri-anal disease, but cases have been reported. The degree of involvement endoscopically ranges from [[proctitis]] or inflammation of the rectum, to left sided colitis, to [[Colitis|pancolitis]], which is inflammation involving the ascending colon.
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| [[Image:Ulcerative colitis (2) endoscopic biopsy.jpg|thumb|center|230px|Biopsy sample ([[H&E stain]]) that demonstrates marked [[lymphocyte|lymphocytic]] infiltration (blue/purple) of the intestinal mucosa and architectural distortion of the crypts.]]
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| ===Histologic===
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| [[Biopsy|Biopsies]] of the mucosa are taken to definitively diagnose UC and differentiate it from [[Crohn's disease]], which is managed differently clinically. Microbiological samples are typically taken at the time of endoscopy. The [[pathology]] in ulcerative colitis typically involves distortion of [[Intestine|crypt]] architecture, inflammation of crypts (cryptitis), frank crypt [[abscess|abscesses]], and hemorrhage or inflammatory cells in the [[lamina propria]]. In cases where the clinical picture is unclear, the histomorphologic analysis often plays a pivotal role in determining the management.
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| ==Course and complications==
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| ===Progression or remission===
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| Patients with ulcerative colitis usually have an intermittent course, with periods of disease inactivity alternating with "flares" of disease. Patients with [[proctitis]] or left-sided colitis usually have a more benign course: only 15% progress proximally with their disease, and up to 20% can have sustained [[remission (medicine)|remission]] in the absence of any therapy. Patients with more extensive disease are less likely to sustain remission, but the rate of remission is independent of the severity of disease.
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| ===Ulcerative colitis and colorectal cancer===
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| There is a significantly increased risk of [[colorectal cancer]] in patients with ulcerative colitis after 10 years if involvement is beyond the [[Colon (anatomy)|splenic flexure]]. Those with only [[proctitis]] or rectosigmoiditis usually have no increased risk.<ref name=ACGGuideline/> It is recommended that patients have screening colonoscopies with random biopsies to look for [[dysplasia]] after eight years of disease activity<ref>Leighton JA, Shen B, Baron TH, Adler DG, Davila R, Egan JV, Faigel DO, Gan SI, Hirota WK, Lichtenstein D, Qureshi WA, Rajan E, Zuckerman MJ, VanGuilder T, Fanelli RD; Standards of Practice Committee, American Society for Gastrointestinal Endoscopy. ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease. ''Gastrointest Endosc'' 2006;63:558-65. PMID 16564852.</ref>
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| ===Primary sclerosing cholangitis===
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| Ulcerative colitis has a significant association with [[primary sclerosing cholangitis]] (PSC), a progressive inflammatory disorder of small and large [[bile duct]]s. As many as 5% of patients with ulcerative colitis may progress to develop primary sclerosing cholangitis.<ref>Olsson R, Danielsson A, Jarnerot G, Lindstrom E, Loof L, Rolny P, Ryden BO, Tysk C, Wallerstedt S. Prevalence of primary sclerosing cholangitis in patients with ulcerative colitis. ''Gastroenterology'' 1991;100(5 Pt 1):1319-23. PMID 2013375.</ref>
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| ===Mortality===
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| The effect of ulcerative colitis on [[death|mortality]] is unclear, but it is thought that the disease primarily affects quality of life, and not lifespan.
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| ==Treatment==
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| {{main|Treatment of ulcerative colitis}}
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| {{main|Biological therapy for inflammatory bowel disease}}
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| Standard treatment for ulcerative colitis depends on ''extent of involvement'' and disease ''severity''. The goal is to induce [[Remission (medicine)|remission]] initially with medications, followed by the administration of maintenance medications to prevent a relapse of the disease. The concept of induction of remission and maintenance of remission is very important. The medications used to induce and maintain a remission somewhat overlap, but the treatments are different. Physicians first direct treatment to inducing a remission which involves relief of symptoms and mucosal healing of the lining of the colon and then longer term treatment to maintan the remission.
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| ===Drugs used===
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| ====Aminosalicylates====
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| [[Sulfasalazine]] has been a major agent in the therapy of mild to moderate UC for over 50 years. In 1977 Mastan S.Kalsi et al determined that 5-aminosalicyclic acid (5-ASA and [[mesalazine]]) was the therapeutically active compound in [[sulfasalazine]]. Since then many 5-ASA compounds have been developed with the aim of maintaining efficacy but reducing the common side effects associated with the sulfapyridine moiety in [[sulfasalazine]].<ref> {{cite web | author=S. Kane |year=2006 | title=Asacol - A Review Focusing on Ulcerative Colitis|url=http://www.touchalimentarydisease.com/articles.cfm?article_id=6364&level=2}}</ref>
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| *[[Mesalazine]], also known as 5-aminosalicylic acid, 5-ASA, Asacol, Pentasa and Mesalamine.
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| *[[Sulfasalazine]], also known as Azulfidine.
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| *[[Balsalazide]], also known as Colazal.
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| *[[Olsalazine]], also known as Dipentum.
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| ====Corticosteroids====
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| *[[Cortisone]]
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| *[[Prednisone]]
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| *[[Prednisolone]]
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| *[[Hydrocortisone]]
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| *[[Methylprednisolone]]
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| *[[Beclometasone]]
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| *[[Budesonide]]
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| ====Immunosuppressive drugs====
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| *[[Mercaptopurine]], also known as 6-Mercaptopurine, 6-MP and Purinethol.
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| *[[Azathioprine]], also known as Imuran, Azasan or Azamun, which metabolises to 6-MP.
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| *[[Methotrexate]], which inhibits folic acid
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| *[[Tacrolimus]]
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| ====[[Biological therapy for inflammatory bowel disease|Biological treatment]]====
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| *[[Infliximab]]
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| *[[Visilizumab]]
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| ===Surgery===
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| Unlike Crohn's disease, ulcerative colitis can generally be cured by surgical removal of the large intestine. This procedure is necessary in the event of: [[exsanguination|exsanguinating]] [[internal bleeding|hemorrhage]], frank perforation or documented or strongly suspected [[carcinoma]]. Surgery is also indicated for patients with severe colitis or toxic megacolon. Patients with symptoms that are disabling and do not respond to drugs may wish to consider whether surgery would improve the quality of life.
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| Ulcerative colitis is a disease that affects many parts of the body outside the intestinal tract. In rare cases the extra-intestinal manifestations of the disease may require removal of the colon.<ref name=ACGGuideline/>
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| ===Alternative treatments===
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| ====Dietary modification====
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| Dietary modification may reduce the symptoms of the disease.
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| *[[Lactose intolerance]] is noted in many ulcerative colitis patients. Those with suspicious symptoms should get a lactose breath hydrogen test.
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| *Patients with abdominal cramping or diarrhea may find relief or a reduction in symptoms by avoiding fresh fruits and vegetables, caffeine, carbonated drinks and [[sorbitol]]-containing foods.
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| *Many dietary approaches have purported to treat UC, including the Elaine Gottschall's specific carbohydrate diet and the "anti-fungal diet" (Holland/Kaufmann).
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| ====Fats and oils====
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| * '''Fish oil'''. [[Eicosapentaenoic acid]] (EPA), derived from fish oil. This is an [[Eicosanoid]] that inhibits [[leukotriene]] activity. It is effective as an adjunct therapy. There is no recommended dosage for ulcerative colitis. Dosages of EPA of 180 to 1500 mg/day are recommended for other conditions. [http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-fishoil.html]
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| * '''Short chain fatty acid (butyrate) enema'''. The colon utilizes butyrate from the contents of the intestine as an energy source. The amount of butyrate available decreases toward the rectum. Inadequate butyrate levels in the lower intestine have been suggested as a contributing factor for the disease. This might be addressed through butyrate enemas. The results however are not conclusive.
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| ====Herbals====
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| *Herbal medications are used by patients with ulcerative colitis. Compounds that contain sulphydryl may have an effect in ulcerative colitis (under a similar hypothesis that the sulpha moiety of [[sulfasalazine]] may have activity in addition to the active 5-ASA component).<ref>{{cite journal | author = Brzezinski A, Rankin G, Seidner D, Lashner B | title = Use of old and new oral 5-aminosalicylic acid formulations in inflammatory bowel disease. | journal = Cleve Clin J Med | volume = 62 | issue = 5 | pages = 317-23 | year =|id = PMID 7586488}}</ref> One randomized control trial evaluated the over-the-counter medication methionine-methyl sulphonium chloride (abbreviated MMSC, but more commonly referred to as Vitamin U) and found a significant decreased rate of relapse when the medication was used in conjunction with oral [[sulfasalazine]].<ref>{{cite journal | author = Salim A | title = Role of sulphydryl-containing agents in the management of recurrent attacks of ulcerative colitis. A new approach. | journal = Pharmacology | volume = 45 | issue = 6 | pages = 307-18 | year = 1992 | id = PMID 1362613}}</ref>
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| ====Bacterial recolonization====
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| *Probiotics may have benefit. One study which looked at a probiotic known as VSL#3 has shown promise for people with ulcerative colitis.<ref name=Fedorak>Bibiloni R, Fedorak RN, Tannock GW, Madsen KL, Gionchetti P, Campieri M, De Simone C, Sartor RB. VSL#3 probiotic-mixture induces remission in patients with active ulcerative colitis. ''Am J Gastroenterol'' 2005 Jul;100(7):1539-46. PMID 15984978.[http://www.vsl3.com VSL#3 company site]</ref>
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| *[[Fecal bacteriotherapy]] involves the infusion of human probiotics through fecal enemas.<ref name=Borody>Borody TJ, Warren EF, Leis SM, Surace R, Ashman O, Siarakas S. Bacteriotherapy using fecal flora: toying with human motions. ''J Clin Gastroenterol'' 2004;38:475-83. PMID 15220681.[http://www.cdd.com.au/pdf/paper12.pdf Fulltext(PDF)]</ref> It suggests that the cause of ulcerative colitis may be a previous infection by a still unknown pathogen. This initial infection resolves itself naturally, but somehow causes an imbalance in the colonic bacterial flora, leading to a cycle of inflammation which can be broken by "recolonizing" the colon with bacteria from a healthy bowel. There have been several reported cases of patients who have remained in remission for up to 13 years.<ref>Borody TJ, Warren EF, Leis S, Surace R, Ashman O. Treatment of ulcerative colitis using fecal bacteriotherapy. ''J Clin Gastroenterol'' 2003;37:42-7. PMID 12811208.[http://www.cdd.com.au/pdf/paper17.pdf Fulltext(PDF)]</ref>
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| ====Intestinal parasites====
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| Inflammatory bowel disease is less common in the developing world. Some have suggested that this may be because intestinal parasites are more common in underdeveloped countries. Some parasites are able to reduce the immune response of the intestine, an adaptation that helps the parasite colonize the intestine. The decrease in immune response could reduce or eliminate the inflammatory bowel disease
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| [[Helminthic therapy]] using the [[whipworm]] ''Trichuris suis'' has been shown in a randomized control trial from Iowa to show benefit in patients with ulcerative colitis. The therapy tests the [[hygiene hypothesis]] which argues that the absence of helminths in the [[colon (anatomy)|colons]] of patients in the developed world may lead to [[inflammation]]. Both [[helminthic therapy]] and [[fecal bacteriotherapy]] induce a characteristic Th2 white cell response in the diseased areas, which is somewhat paradoxical given that ulcerative colitis immunology was thought to classically involve Th2 overproduction<ref>Summers RW, Elliott DE, Urban JF Jr, Thompson RA, Weinstock JV. Trichuris suis therapy for active ulcerative colitis: a randomized controlled trial. ''Gastroenterology'' 2005;128:825-32. PMID 15825065.</ref>
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| [[Nicotine]] It has been shown that smokers on a dose-based schedule have their ulcerative colitis symptoms effectively reduced by cigarettes. The effect disappears if the user quits.
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| ==Ongoing research==
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| Recent evidence from the ACT-1 trial suggests that [[infliximab]] may have a greater role in inducing and maintaining [[disease]] remission.
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| An increased amount of colonic [[sulfate-reducing bacteria]] has been observed in some patients with ulcerative colitis, resulting in higher concentrations of the toxic gas [[hydrogen sulfide]]. The role of hydrogen sulfide in pathogenesis is unclear. It has been suggested that the protective benefit of smoking that some patients report is due to hydrogen cyanide from cigarette smoke reacting with hydrogen sulfide to produce the nontoxic isothiocyanate. Another unrelated study suggested sulphur contained in red meats and alcohol may lead to an increased risk of relapse for patients in remission<ref name=Roediger/>
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| There is much research currently being done to elucidate further genetic markers in ulcerative colitis. Linkage with [[HLA-B27|Human Leukocyte Antigen B-27]], associated with other autoimmune diseases, has been proposed.
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| [[Low dose naltrexone]] is under study for treatment of Crohn's disease and ulcerative colitis.
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| ==See also==
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| * [[Crohn's disease]] | | * [[Crohn's disease]] |
| * [[Ileo-anal pouch]] | | * [[Ileo-anal pouch]] |
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| * [[Primary sclerosing cholangitis]] | | * [[Primary sclerosing cholangitis]] |
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| ==External links==
| | {{Gastroenterology}} |
| ;General Information
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| *[http://healthcarebase.com/ulcerativecolitis.php Ulcerative Colitis - the possible causes, symptoms, diagnosis and treatment ]
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| *[http://www.ulcerativecolitis.org.uk Information on Ulcerative Colitis - including diet and supplements]
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| *[http://www.crohns.org.uk/ Resourses for the treatment of Inflammatory Bowel Diseases]
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| Organizations
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| *[http://www.ccfa.org Crohn's and Colitis Foundation of America]
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| *[http://www.efcca.org/ European Federation of Crohns and Colitis Associations] has [http://www.efcca.org/membership.htm member associations] in most European countries.
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| *[http://www.nacc.org.uk National Association for Colitis and Crohn's disease] UK
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| *[http://www.ccfc.ca/English/index.html Crohn's & Colitis Foundation of Canada]
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| ==References==
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| {{Reflist|2}}
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| {{Gastroenterology}}
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| [[ar:التهاب قولون تقرحي]]
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| [[de:Colitis ulcerosa]]
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| [[es:Colitis ulcerosa]] | | [[es:Colitis ulcerosa]] |
| [[eo:Kojlito]]
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| [[fr:Rectocolite hémorragique]] | | [[fr:Rectocolite hémorragique]] |
| [[hr:Ulcerozni kolitis]]
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| [[he:קוליטיס כיבית]]
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| [[nl:Colitis ulcerosa]]
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| [[ja:潰瘍性大腸炎]] | | [[ja:潰瘍性大腸炎]] |
| [[no:Ulcerøs kolitt]]
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| [[pt:Colite ulcerosa]] | | [[pt:Colite ulcerosa]] |
| [[fi:Colitis ulcerosa]]
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| [[sv:Ulcerös kolit]]
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| [[pl:Wrzodziejące zapalenie jelita grubego]] | | [[pl:Wrzodziejące zapalenie jelita grubego]] |
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| {{WikiDoc Help Menu}} | | {{WS}} |
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| [[Category:Autoimmune diseases]] | | [[Category:Autoimmune diseases]] |
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| [[Category:Conditions diagnosed by stool test]] | | [[Category:Conditions diagnosed by stool test]] |
| [[Category:Abdominal pain]] | | [[Category:Abdominal pain]] |
| [[Category:Signs and symptoms]]
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