“Psychoanalysts are not occupied with the minds of their patients; they do not believe in the mind but in a cerebral intestine.” Bernard Berenson

Ulcerative Colitis

What is Ulcerative Colitis? Ulcerative Colitis (UC) is an inflammatory condition of the colon ('colitis' = 'colon-itis'). It affects about 1 in 1000 people and is commonest in northern latititudes - affecting Northern Europe, Canada and the USA more than populations in the south of Europe. There is a strong genetic component with an increased risk in family members. There is also an association with affluence, being less common in poorer populations. The commonest age to present with UC is 15-25 years, with a second peak of incidence in the 6th decade. There is a higher incidence in women than men, although it affects both sexes.

What are the symptoms of Ulcerative Colitis? UC presents with increased bowel frequency, loose motions and bleeding. In severe cases, there may be general unwellness due to the extent of the inflammation in the bowel and this can cause anaemia, a fever, loss of appetite and weight loss. There may be abdominal pain which may be cramping and eased by opening the bowels or constant. Sometimes painful red nodules can occur on the arms and legs ('erythema nodosum') or rarely there can be inflamed superficial ulcers forming on the skin 'pyoderma gangrenosum'. The eyes can be inflamed and irritated, and the joints may be stiff and painful.

Are there different tpes of ulcerative colitis? People often get confused by the terminology of colitis (which can be any cause of inflammation of the bowel). UC only causes inflammation in the colon (large bowel) and not the small intestine. It may just affect the very lowest part of the colon called the 'rectum', and it is then called 'proctitis' or 'ulcerative proctitis'. In about a quarter of cases, it may start in this way and then affect the bowel further up as well. Another pattern of colitis is for it just to affect the lower half of the bowel, which lies on the left hand side of the abdomen and this is therefore often known as 'left-sided colitis'. Alternatively it can affect the entire colon and this is known as 'pan-colitis'. In general, the greater the extent of the condition the more severe it is, but proctitis and left sided colitis can sometimes be difficult to treat.

What causes Ulcerative Colitis? The cause of ulcerative colitis is still unknown. The features can be difficult to distinguish from an infection in the early stages. It is most likely that the immunity of the bowel - which maintains a state of equilibrium with the many millions of bacteria that live there - is disturbed and leads to an exaggerated or inappropriate inflammatory response. It certainly appears that there are genetic factors - which affect the immune system - and environmental factors that interact to cause the condition.

How is ulcerative colitis diagnosed? Inspection of the lining of the colon with a flexible sigmoidoscopy or colonoscopy shows characteristic ulcers, inflammation and bleeding and loss of the normal pattern of blood vessels that are usually seen. However, this appearance can also be seen with infection - which can last up to 3-4 weeks in some cases - and a biopsy is usually taken at the time of inspection of the bowel lining. Under the microscope, characteristic features of UC are often - but not always seen, to make the diagnosis. Given the similarity of UC to infection, it is important to make sure that there are no harmful bacteria in the stools - generally 2-3 stool samples are required. Blood tests are non specific but may show anaemia and increased inflammation.

What treatment is available for ulcerative colitis? The treatment depends on the extent and the severity of the colitis. For mild or moderately severe colitis, a tablet called 'Mesalazine' is used. This works only on the lining of the bowel and therefore has be to delivered in a form that allows it to reach the part of the colon that is affected. This might require suppositiores (for proctitis) or enemas for left sided colitis. In severe cases, steroids are used and these may have to be given intravenously in hospital in very severe cases. Other potent immunosuppressive agents such as Cyclosporin or anti-TNF antibodies may be required in the most severe presentations of colitis.
Steroids are only useful to get the condition under control and not for 'maintenance' treatment, which requires other forms of medications that suppress the immune system of the bowel such as Azathioprine.

Does ulcerative colitis require an operation? Unfortunately it is not always possible to bring a severe attack of colitis under control and medical therapies fail in about 1 in 4 cases. These patients will require an urgent operation to remove the large bowel. Whilst this usually results in the necessity for a stoma, this can be reversed with the intestine joined back to the lower part of the bowel at a later stage.

What is the long term course of ulcerative colitis? Ulcerative colitis is a chronic condition that tends to have periods of inactivity interspersed with 'flares' or attacks. The use of regular maintenance therapy to keep the inflammation suppressed generally reduces the frequency of attacks and is continued until many years have passed without a flare.

What are the long term complications of ulcerative colitis? There is an increased risk of colonic cancer with ulcerative colitis, although recent evidence suggests that this is not as common as we previously thought. This may be due to the improved treatments that are available. However, to be safe we usually recommend a check colonoscopy after 10 years and then at regular intervals depending on the extent and the severity of the colitis.

What resources are available? There is an excellent charity available for patients with both forms of inflammatory bowel disease called 'Crohn's and Colitis UK' available on this link.

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