Ulcerative colitis is a chronic inflammation of the large intestine (colon). The colon is the part of the digestive system where waste material is stored. The rectum is the end of the colon adjacent to the anus. In patients with ulcerative colitis, ulcers and inflammation of the inner lining of the colon lead to symptoms of abdominal pain, diarrhea, and rectal bleeding.

Ulcerative colitis is closely related to another condition of inflammation of the intestines called Crohn's disease. Together, they are frequently referred to as inflammatory bowel disease (IBD). Ulcerative colitis and Crohn's diseases are chronic conditions that can last years to decades. They affect approximately 500,000 to 2 million people In the United States. Men and women are affected equally. They most commonly begin during adolescence and early adulthood, but they also can begin during childhood and later in life.

It is found worldwide, but is most common in the United States, England, and northern Europe. It is especially common in people of Jewish descent. Ulcerative colitis is rarely seen in Eastern Europe, Asia, and South America, and is rare in the black population. For unknown reasons, an increased frequency of this condition has been recently observed in developing nations.

Causes of Ulcerative Colitis

The causes of ulcerative colitis and Crohn's disease are unknown. To date, there has been no convincing evidence that these two diseases are caused by infection. Neither disease is contagious.

Ulcerative colitis and Crohn's disease are caused by abnormal activation of the immune system in the intestines. The immune system is composed of immune cells and the proteins that these cells produce. These cells and proteins serve to defend the body against harmful bacteria, viruses, fungi, and other foreign invaders. Activation of the immune system causes inflammation within the tissues where the activation occurs. (Inflammation is, in fact, an important mechanism of defense used by the immune system.)

Normally, the immune system is activated only when the body is exposed to harmful invaders. In patients with Crohn's disease and ulcerative colitis, however, the immune system is abnormally and chronically activated in the absence of any known invader. The continued abnormal activation of the immune systems causes chronic inflammation and ulceration. The susceptibility to abnormal activation of the immune system is genetically inherited. First degree relatives (brothers, sisters, children, and parents) of patients with IBD are thus more likely to develop these diseases.

Treatments for Ulcerative Colitis

Both medications and surgery have been used to treat ulcerative colitis. However, surgery is reserved for those with severe inflammation and life-threatening complications. There is no medication that can cure ulcerative colitis. Patients with ulcerative colitis will typically experience periods of relapse (worsening of inflammation) followed by periods of remission (resolution of inflammation) lasting months to years. During relapses, symptoms of abdominal pain, diarrhea, and rectal bleeding worsen. During remissions, these symptoms subside. Remissions usually occur because of treatment with medications or surgery, but occasionally they occur spontaneously, that is, without any treatment.

Medications

Since ulcerative colitis cannot be cured by medication, the goals of treatment with medication are to
1) induce remissions
2) maintain remissions
3) minimize side effects of treatment
4) improve the quality of life. Treatment of ulcerative colitis with medications is similar, though not always identical, to treatment of Crohn's disease.

Medications treating ulcerative colitis include 1) anti-inflammatory agents such as 5-ASA compounds, systemic corticosteroids, topical corticosteroids, and 2) immunomodulators.

Anti-inflammatory medications that decrease intestinal inflammation are analogous to arthritis medications that decrease joint inflammation (arthritis). The anti-inflammatory medications that are used in the treatment of ulcerative colitis are:


Topical 5-ASA compounds such as sulfasalazine (Azulfidine), olsalazine (Dipentum), and mesalamine (Pentasa, Asacol, Rowasa enema) that need direct contact with the inflamed tissue in order to be effective.

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Systemic anti-inflammatory medications such as corticosteroids that decrease inflammation throughout the body without direct contact with the inflamed tissue. Systemic corticosteroids have predictable side effects with long term use.

Immunomodulators are medications that suppress the body's immune system either by reducing the cells that are responsible for immunity, or by interfering with proteins that are important in promoting inflammation. Immunomodulators increasingly are becoming important treatments for patients with severe ulcerative colitis who do not respond adequately to anti-inflammatory agents. Examples of immunomodulators include 6-mercaptopurine (6-MP), azathioprine (Imuran), methotrexate (Rheumatrex, Trexall), cyclosporine (Gengraf, Neoral).
It has long been observed that the risk of ulcerative colitis appears to be higher in nonsmokers and in ex-smokers. In certain circumstances, patients improve when treated with nicotine.

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