Ulcerative colitis: causes, symptoms and treatment

By Cristiano Antonino On Nov 24, 2022

Ulcerative colitis is a disease of the gastro-intestinal system and, together with Crohn’s disease, is one of the ‘chronic inflammatory bowel diseases’

What is ulcerative colitis?

In ulcerative colitis there is a major inflammation of the large intestine, the colon, which primarily affects the mucosa of the rectum and may extend to part or all of the colon continuously from the anus to the cecum.

It can be classified according to its extension:

Proctitis, when the inflammation is localised only to the rectum-sigma;
Left colitis, when the inflammation affects the entire descending colon (left, in fact);
Pancolitis, when the entire colon is involved.

A further classification is made according to the severity of the lesions:

Mild colitis
Moderate colitis
Severe colitis.

An attempt has been made to calculate how many people might be affected each year, and an incidence of between 6 and 8 new cases per 100,000 inhabitants has been assumed, considering the adult population, distributed almost evenly in both sexes.

Signs and symptoms of ulcerative colitis

The leading symptom is the radical change in alvus, i.e. diarrhoeal discharges with stools mixed with blood and mucus, which are all the more frequent the more severe the disease is.

In fact, ulcerative colitis may begin in a milder form, but also with a particularly severe acute attack.

It has a chronic recurrent course with alternating phases of remission, characterised by a certain well-being, and phases of flare-up with reappearance of symptoms.

The inflammatory processes of the mucous membrane may in some cases include actual ulcerations, which cause bleeding and mucus effusion into the intestinal lumen.

In the most severe forms, general disorders are present: fever, increased heart rate (tachycardia), anaemia, loss of strength and appetite, decrease in circulating protein and imbalance of important substances such as potassium, sodium and chlorine.

In short, the whole organism suffers from the combination of inflammation, malabsorption and blood loss.

Extra-intestinal manifestations, which can involve almost the entire organism, are not uncommon:

osteoarticular
dermatological
ocular
hepatobiliary, etc.

Diagnosis of ulcerative colitis

The diagnosis of ulcerative colitis involves a multidisciplinary approach (clinical, endoscopic and anatomo-pathological), in fact it is made when certain conditions are recognised

documented rectal inflammation
exclusion of other causes for the inflammation, such as non-steroidal anti-inflammatory drugs (NSAIDs), an infection or some other physical or chemical agent;
presence of persistent and protracted inflammation.

The first point calls for endoscopy, in particular colonoscopy: with this examination, the specialist immediately sees macroscopically whether the mucosa is inflamed and the nature of the lesions.

He can also take biopsies of the mucosa, i.e. take parts of it for analysis.

The histological examination of the biopsies will then confirm the presence and characteristics of the inflammation.

Often, especially for the initial diagnosis in the first examinations, during which the patient is not adequately prepared for colonoscopy, more limited endoscopies can be performed, which, however, only visualise the last part of the intestine (rectal-sigmoidoscopy), but for the purposes of the correct diagnosis of certainty and the evaluation of possible complications caused by the disease, it is essential to perform a colonoscopy as soon as possible.

The latter examination is also important in order to clearly establish other localisations, thus also defining the full extent of the inflammation.

In some cases direct radiological examination of the abdomen, ultrasound and computed axial tomography can be used to investigate special conditions or to rule out complications.

For the second point the key examinations are the search for parasites or other infectious agents in the faeces, or blood sampling to exclude the presence of recent infections.

For the third point, a biopsy helps to identify the nature of the inflammation: in the case of ulcerative colitis, there is a subversion of the normal architecture of the mucosa, an increase in inflammatory cells, which vary according to the activity of the disease.

Therapies for ulcerative colitis

In the treatment of ulcerative colitis, a customised approach is increasingly being refined, thus taking into account the patient’s specific condition and his or her response to different treatment options.

To this end, four main classes of drugs exist and are used:

Aminosalicylates: of these the most frequently used is 5-ASA (5-aminosalicylic acid or more commonly Mesalazine), which acts locally on the colon mucosa, administered orally or rectally (suppositories or enemas). The great advantage of these drugs is that they are the only drugs capable of reducing the incidence of colorectal cancer in patients with ulcerative colitis.
Corticosteroids: particularly used for the treatment of flare-ups, they are not useful in maintenance treatment as they do not prevent relapses or change the natural history of the disease, and they have several side effects, particularly when taken systemically and long-term. Also in this class, there are several active ingredients with high potency systemic or topical (oral or rectal) action.
Immunomodulators: as their name implies, they have a modulatory action on the action of the immune system, which plays a very important role in this pathology; they are mainly used in long-term maintenance therapies and make it possible to reduce the dosages of corticosteroids or in patients who do not respond to the previously mentioned therapies. They must be taken under strict medical supervision and with regular check-ups to try to prevent any side effects.
Biological drugs: these are drugs directed against specific targets (mainly TNF-alpha, but also others) implicated in the inflammation that characterises this disease; they are indicated in moderate to severe ulcerative colitis, in patients who do not respond or do not tolerate other treatments.

There are also a number of other drugs used to control specific symptoms and conditions (e.g. antibiotics, painkillers, etc.).

In the event that the disease begins with a severe attack, i.e. with more than six daily discharges, bloody-mucous stools and general complaints, hospitalisation may be necessary.

Here, specialists subject the patient to intensive treatment, with higher doses of corticosteroids, lasting about seven to ten days.

In cases with more severe dehydration and malabsorption, liquids, plasma and electrolytes as well as high-calorie substances are also administered.

In more than half of the cases, 50 to 70%, the response obtained is very good; surgery is thus avoided.

When is surgery necessary?

Surgery in cases of ulcerative colitis can be performed either as an alternative therapy in the event of failure of medical therapy, in severe forms or with specific complications, or as a therapeutic choice in the event of impoverished quality of life.

It should no longer be experienced, however, as a dramatic event since, thanks to improvements in surgical technique, it must be considered as a valid therapeutic tool capable of eliminating the disease; it is in fact considered the only truly curative treatment.

The surgery can be performed according to a traditional technique, i.e. ileo-rectal anastomosis, which, as the word implies, involves the removal of the diseased colon and the coupling of the ileum with a small residual tract of rectum.

Since the rectum is the portion of the intestine almost always affected, it is obvious that one must continue for long periods with local therapies and control of the rectal mucosa.

This is why it is now reserved for emergency surgery.

The other surgery consists of the reconstruction of a new rectal pouch with the mucosa of the small intestine, by means of its coupling with the anal margin (ileo-anal anastomosis).

This latter operation has the advantage of favouring the elimination of any diseased area even though a percentage – fortunately small – of patients may develop a new inflammatory condition of the new ampulla (pouchitis).

This picture, however, is well controlled with various drug therapies.

Ulcerative colitis and cancer risk – what is the correlation?

Although only 1% of colorectal carcinomas are due to chronic inflammatory bowel disease, the risk is 1-5 times higher than in the general population after 30 years of disease.

For this reason, regular check-ups and careful screening are essential for the prevention of this dreaded complication: in particular after 8 years from diagnosis, a colonoscopy check-up is necessary every 1-2 years (with some variability depending on the individual patient).

The incidence of cancer has probably decreased considerably as patients are being treated more and better and are themselves more diligent in their follow-ups.

In addition, medical treatment reduces the number of attacks and their severity and, probably, the inflammation-induced stimulus is reduced.

Surgery then eliminates those situations that are considered to be at risk, such as onset at a young age, extensive and often relapsing very active forms, and cases in which dysplasia of the intestinal mucosa is already present (i.e. an alteration that if of a high degree can precede the development of a malignant neoformation).

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