Introduction
What Should I Know About Ulcerative Colitis?
Ulcerative colitis is one of two forms of inflammatory bowel disease (IBD), the other form being Crohn’s disease. Unfortunately, the cause of this form of IBD remains unknown, but diagnosis is still possible through excluding other possible conditions and by a full review of the symptoms. Ulcerative colitis is a condition in which the moist tissue layer that lines the colon and rectum, called the mucosa, has become inflamed.
Even though we don’t know the exact causes of ulcerative colitis, there are some good theories involving the role of the immune system and/or infections. (1) The infectious theory assumes that the body is reacting normally to an as-of-yet unrecognized pathogen. The immunologic theory, on the other hand, proposes that the immune system is responding inappropriately to a substance which is causing the body to create antibodies. Sometimes these substances, called antigens, are thought to create an autoimmune reaction, or a reaction in which the immune system acts in response to things which are normal to most people. (2) Some of the microorganisms suspected of being involved in the IBD include viruses, protozoans, micoplasmas, and other bacteria.
Ulcerative colitis is confined to the rectum and colon, and affects the mucosa. In some instances, a short segment of the lower section of the small intestine called the terminal ileum may also be inflamed. This condition is referred to as backwash ileitis. Unlike Crohn’s disease, the deeper longitudinal muscular layers, and regional lymph nodes are usually not involved. (3) Since the inflammation is usually confined to the mucosa and submucosa, tears and obstruction are uncommon. However, depending on how much damage has been done to the mucosa, there may be diarrhea and possibly some bleeding.
The complications of ulcerative colitis may range from mild to even life threatening. Some of the complications seen most frequently in individuals with this condition include hemorrhoids, anal fissures or slits, or abscesses in or around the rectum. These complications are most likely to occur during active colitis episodes. A major complication that may occur in a small number of people with ulcerative colitis or Crohn’s disease is called toxic megacolon. In this condition, the patient usually has a high fever, swollen or distended abdomen, elevated white count, and a dilated colon that can be observed on an x-ray. There are other very serious complications that may also occur, but these occur infrequently. It is important to realize that the risk of colon cancer increases in patients with ulcerative colitis when compared to the normal population.
The inflammatory condition that occurs with ulcerative colitis has been blamed for other complications as well. Complications that lie outside of the colon are called systemic complications. Approximately 11% of patients with ulcerative colitis have been reported to have complications involving the liver. (4) These would involve such complications as fatty liver, chronic active hepatitis, and cirrhosis.
Other systemic complications that occur include joint complications in the form of arthritis. This form of arthritis does not deform or destroy the joints. The joints most commonly affected are the knees, hips, ankles, wrists, and elbows, and severity is usually associated with the severity of the ulcerative colitis. Complications of the eyes may occur in up to 10% of patients with IBD. Finally, several studies report that 5 to 10 percent of patients with ulcerative colitis may have complications involving their skin. (5)
Statistic
National Institutes of Health (NIH) Publication No. 95-1597, April 1992.
Ulcerative colitis occurs most often in people ages 15 to 40, although children and older people sometimes develop the disease.
Ulcerative colitis affects men and women equally and appears to run in some families.
About 25 to 40 percent of ulcerative colitis patients must eventually have their colons removed because of massive bleeding, severe illness, rupture of the colon, or risk of cancer.
About 5 percent of people with ulcerative colitis develop colon cancer.
Signs and Symptoms
The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.
Ulcerative colitis can be divided into mild, moderate, and severe. Mild forms have less than 4 diarrhea stools per day, but other symptoms in different areas of the body may be present also. Sometimes patients suffer from arthritis at the same time they are having active ulcerative colitis problems. Other problems that may happen at the same time are eye infections or inflammations, or skin problems. These problems may actually be the reason for seeking advice of a doctor. Moderate ulcerative colitis usually has from 4 to 6 diarrhea stools a day, and generally has more severe cramping and a mild fever. Severe ulcerative colitis usually has greater than 6 diarrhea stools a day and includes severe cramping and fever. The presence of blood in the diarrhea is common at this severity of the disease. The heart rate may be rapid, dehydration often occurs, and blood pressure may be lower than normal.
General
- Symptoms generally come and go
- The most common symptom is diarrhea, often containing blood or mucus
- Crampy pain in the lower abdomen
- Fever
Treatment Options
Conventional
Many people who have active ulcerative colitis have mild to moderate disease and do not require any medications other than the oral medication prescribed by their physician which may be taken at home. Two of the drugs that are often prescribed are oral sulfasalazine or an oral mesalamine derivative. The goal of this therapy is to gain control of active inflammation. Improvement usually can be seen in two to three weeks, or in some cases, longer. The dosage of sulfasalazine that can be given is usually limited by the patient’s tolerance to the drug. Most of the adverse side effects of sulfasalazine are dose related and include GI disturbances, headache, and arthralgia. (6)
If the condition is moderate to severe, the healthcare professional in charge may prescribe steroids such as prednisone especially if other drugs have not been found to be successful. Sometimes the dosages of steroids have to be increased in order to get the condition under control. Higher dosages of prednisone have proven successful in controlling ulcerative colitis. (7) Sometimes, nicotine may be recommended for those individuals who have a flare up of the condition during the time when they have stopped smoking. This is done transdermally with a patch and is usually only used in mild to moderate cases. (8)
Occasionally the disease progresses to a point where it is necessary for the patient to be hospitalized. Then other medications which can be given intravenously are used. In some cases, surgery may be required. In these most severe cases, efforts are made to control the disease with medication first. Usually a drug called cyclosporine, is used and often this treatment reduces the need for surgery. (9) Once the disease is under control, the less aggressive drugs are again used for maintenance.
Nutritional Suplementation
Eicosapentaenoic Acid (EPA), Docosahexaenoic Acid (DHA)
There have been several published studies supporting the use of EPA and DHA, two fatty acids which are found in fish oil. In one study, the patients were able to reduce their use of steroids while they were in an active period of the disease, but did not find much benefit for maintenance. (10)
Other studies have indicated that EPA and DHA helped with the inflammation to a degree that the dosage of the prescribed drugs could be lowered. Numerous other studies have reported similar outcomes. In general, treatment with fish oils in patients with ulcerative colitis reduces inflammatory activity and the use of various anti-inflammatory medications with varied levels of symptomatic improvement. (11) , (12)
One study, however, reported that there was little improvement in the number of relapses over a two year period, (13) and in another study, fish oil therapy was not as effective as sulfasalazine at reducing inflammation. (14) Results such as these suggest that fish oil supplementation can provide benefits in ulcerative colitis, but they may not be effective as a sole treatment for the disease. A qualified healthcare professional can help to determine if supplementing with DHA and EPA would be indicated.
L-Glutamine
Glutamine is considered to be a nitrogen donor and is involved in processes in the body that are important when wounded tissues are healing and rebuilding. (15) Glutamine levels have been found to be reduced in patients with ulcerative colitis, with the greatest depletions being found in cases of moderate to severe inflammation. (16) It is thought that glutamine reduces the production of chemicals that are considered to be inflammatory agents. (17) If inflammation is reduced, the necessary healing may take place.
Lactobacillus, Bifidobacteria
The bowel is the home of some very beneficial bacteria, namely acidophilus and bifidobacteria. These wonderful microorganisms help to keep the bowel healthy in a variety of ways. (18) Studies have indicated that using these microorganisms, called probiotics, may help with the symptoms and the number of relapses that someone suffering with ulcerative colitis may have. (19) , (20) , (21)
Folic Acid
One of the drugs used with ulcerative colitis, sulfasalazine, is known to cause folic acid depletion. (22) Therefore, it would be wise to make sure that folic acid levels are in the normal range if taking sulfasalazine.
Vitamin C
Two studies have reported finding lower levels of vitamin C in individuals with ulcerative colitis. (23) , (24) Therefore, supplementing with vitamin C may be wise.
Vitamin A, Vitamin E
One study reported finding that children and young adults with various forms of irritable bowel disease frequently have low serum levels of vitamin A and vitamin E. (25) Similarly, another study reported that patients with ulcerative colitis appear to have an impaired ability to utilize fat and retinol. (26)
Dehydroepiandrosterone (DHEA)
While it is not known yet whether or not low levels of DHEA are related to ulcerative colitis, studies have found that people with this condition have lower than normal levels of this hormone. (27) , (28)
Herbal Suplementation
Cat’s Claw
Cat’s claw has chemicals which reportedly reduce inflammation and edema. (29) Cat’s claw is thought to have the ability to soothe irritated and inflamed tissues and help eliminate pathogens from the GI tract, (30) thereby helping to maintain a healthier colon.
Olive Leaf
Olive leaf extract has been reported to be effective in fighting against some of the pathogens that are responsible for intestinal tract infections. (31) The component usually associated with olive leaf’s antimicrobial properties is called oleuropein. (32) , (33) As an antifungal and antiviral agent, olive leaf extract is currently used as a supportive agent in maintaining bowel flora and therefore thought to be beneficial in problems such as ulcerative colitis.
Grapefruit Seed
Grapefruit seed extract is believed to inhibit the growth of H. pylori and C. jejuni, both causative agents in gastrointestinal ulcers. (34) Studies indicate that using grapefruit seed is helpful in maintaining bowel integrity. (35)
Peppermint
Various studies have reported positive benefits in IBS when using enteric-coated peppermint oil capsules. This is thought to be because peppermint oil has antispasmodic, pain-relieving actions. (36) , (37) , (38) However, there has been one study that showed no effect in relieving symptoms of IBS at all, (39) so it is wise to consult a healthcare professional for recommendations.
Evening Primrose
Evening primrose oil (EPO) is rich in gamma-linolenic acid which is an omega-6 fatty acid. (40) , (41) Omega-6 fatty acids reportedly decrease inflammation through inhibiting the formation of some of the chemicals involved in the inflammatory process. Supplementation with essential fatty acids such as EPO has been shown to prevent zinc deficiency, thereby potentially improving immunity. (42) Fatty acids are an important part of maintaining homeostasis. The human body can produce all but two fatty acids – omega-3 and omega-6 fatty acids. Both must be obtained through the diet or by the use of supplements. Obtaining a balance of these two fatty acids is essential. Essential fatty acids are needed for building cell membranes and are precursors for production of hormones and prostaglandins. Modern diets tend to be lacking in quality sources of fatty acids.
Psyllium Seed
Psyllium has been reported effective in supporting the management of irritable bowel syndrome (IBS) and ulcerative colitis. (43) , (44) , (45) One report, an open label, parallel-group, multicenter, randomized clinical trial, was conducted on patients with ulcerative colitis who were in remission. (46) The patients received oral treatment with psyllium seeds (10 gm twice a day), mesalamine (500mg three times a day), and psyllium seeds plus mesalamine at the same doses. The primary efficacy outcome was maintenance of remission for 12 months. The authors concluded that psyllium seeds may be as effective as mesalamine in maintaining remission in ulcerative colitis.
Bromelain
Bromelain is used as an anti-inflammatory and analgesic agent in treating the symptoms of conditions such as arthritis (47) , (48) and therefore may be useful in treating the inflammation experienced in ulcerative colitis.
Aloe Vera
A small study showed that taking aloe vera orally for 4 weeks produced more of a response than placebo, although more studies are needed. (49)
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