Ulcerative colitis

Quick Overview

• What is Colitis Ulcerosa? A chronic inflammatory bowel disease that affects the rectum and often the large intestine.
• symptoms: u. a. bloody-slimy diarrhea, spasmodic pelvic pain, colicky lower abdominal pain, bloating, loss of power
• risks: massive enlargement of the intestine (megacolon) with the risk of intestinal perforation and peritonitis (peritonitis); severe and possibly life-threatening bleeding; Growth disorders in children; increased risk of colorectal cancer (colon carcinoma, colon cancer).
• Causes: unknown; presumably a genetic predisposition in combination with various risk factors is responsible for the pathogenesis.
• investigations: physical examination, blood tests, stool examination, colonoscopy, ultrasound of the abdomen, possibly further imaging procedures (X-ray, computed tomography, magnetic resonance imaging)
• Treatment: Medications to relieve the symptoms (5-ASA such as mesalazine, cortisone, etc.), surgery if necessary
• Forecast: With the right therapy can usually get the complaints of ulcerative colitis under control. A chance of recovery exists so far only with removal of large intestine and rectum.

Ulcerative colitis: description

Ulcerative colitis, as well as Crohn’s disease, are among the chronic inflammatory bowel disease (CED). Often it is difficult to distinguish the two diseases. A big difference though is that in ulcerative colitis Only the rectum and possibly the large intestine inflamed while Crohn’s disease may affect the entire digestive tract (from the mouth to the anus).

In addition, ulcerative colitis develops flat spread inflammationthat is usually limited to the uppermost layer of the intestinal wall (intestinal mucosa), In Crohn’s disease, however, patchy inflammatory foci occur, which can affect all layers of the intestinal wall.

Ulcerative colitis usually affects young people between the ages of 16 and 35 years. In principle, the disease can occur at any age.

Extent of ulcerative colitis

Ulcerative colitis always starts from the rectum. From there it can spread more or less widely to the large intestine:

In many patients, however, the inflammation is limited to the rectum. Then one speaks of one proctitis, If it also extends to the left-side colon, lies one Linksseitencolitis in front. In some patients, the inflammation extends even further up the colon. Finally, if the entire large intestine (next to the rectum) inflamed, it is called pancolitis.

With the incidence of colitis, the severity of symptoms also increases.

Ulcerative colitis: Different courses

More than 80 percent of those affected are ulcerative colitis relapsing: Phases with more or less severe symptoms (acute relapses) alternate with phases without inflammation and discomfort. Doctors speak of one chronic-relapsing course.

In about ten percent of patients, the disease takes one chronic-continuous course: Here, the complaints do not completely stop after a boost.

In a few cases, ulcerative colitis shows one fulminant courseThe disease starts suddenly with severe, bloody diarrhea, severe abdominal pain and high fever. Patients can quickly dry out and develop shock symptoms. About three out of ten sufferers die in the process.

Ulcerative colitis: symptoms

Ulcerative colitis often begins insidiously and is perceived late by those affected. The further the inflammation spreads in the intestine, the stronger the symptoms become. With an acute ulcerative colitis thrust so severe symptoms may occur that sufferers must be treated in the hospital.

Depending on the severity and course of the disease occur differently strong Symptoms (in thrust) on. This includes:

• bloody-slimy diarrhea several times a day and also at night
• painful stool urgency (Tenesmen)
• spasmodic pelvic pain, especially before bowel movements
• colicky abdominal pain, usually in the left lower abdomen, possibly associated with mild fever
• nocturnal chair urge
• Flatulence, which can lead to involuntary excrement (fecal incontinence)
• Weight loss, fatigue and loss of performance
• Anemia (due to the bloody diarrhea)

In addition, you can Discomfort outside the intestine (but less common than Crohn’s disease). The most common are inflammation of the joints (arthritis), the spine or the sacrum. Some patients develop inflammation of the eyes or bone loss (osteoporosis). On the skin may form small ulcers, suppurations or red-violet nodules (especially on the front of the lower leg). In some cases, inflammation of the bile ducts occurs inside and outside the liver (primarily sclerosing cholangitis).

Ulcerative colitis: complications

A dreaded complication of ulcerative colitis is the so-called toxic megacolonWhen the inflammation spreads to the whole intestinal wall, the intestine can expand acutely. The stool can no longer be transported, because the intestine is paralyzed (intestinal paralysis, paralytic ileus). It shows the picture of the acute abdomen (acute abdomen): The abdomen is distended, hard and hurts strongly. The patients have a high fever.

In addition, there is a risk that the massively enlarged intestine bursts (Darmdruchbruch, Perforation). Then gut content (feces) emptied into the abdominal cavity – it develops one Peritonitis (Peritonitis). In such cases exists risk of death!

Another complication can be ulcerative colitis heavy bleeding The ulcers of the intestinal mucosa, which form as a result of inflammation, can break and bleed. In severe cases, the blood loss can be so severe that the patient faints. The bleeding can even be life threatening!

A colitis ulcerosa in children can stunted growth cause. These can worsen by a poor diet.

People with ulcerative colitis have an increased risk in addition to colon cancer (Colon cancer, colon carcinoma).

Ulcerative colitis: treatment

Since the causes of ulcerative colitis are not yet known, it can not be treated causally. But there is much that can be done to alleviate the discomfort and prolong the time between episodes of illness. There are various drugs to disposal. Complications may require additional medication (for example, antibiotics for additional bacterial infection).

A surgery comes in severe or complicated cases of ulcerative colitis in question. In addition, patients can help themselves to manage their illness and alleviate the symptoms. Read more about the individual components of colitis-ulcerative treatment in the following sections.

Ulcerative colitis: medications

In ulcerative colitis, medications work best at the site of inflammation in the gut, such as suppositories or enema. This targeted local application of the drugs is less likely to cause side effects than those used systemically (such as tablets).

The following medications are available for ulcerative colitis treatment:

• 5-ASA (5-aminosalicylic acid): has anti-inflammatory and is administered as a precursor, usually as mesalazine. Possible dosage forms include suppositories, enemas, foams (introduced over the anus) and tablets.
• Corticosteroids (“Cortisone”): also act as anti-inflammatory (e.g., prednisolone). In lighter cases, they are used locally (as a suppository or enema), in case of severe symptoms in tablet form.
• immunosuppressants: Agents which attenuate the activity of the immune system (e.g., azathioprine, methotrexate, ciclosporin A, tacrolimus). This can positively influence the course of the disease. They are used in severe or complicated ulcerative colitis (for example, when cortisone is not effective or is not tolerated).
• TNF antibody: Agents that inhibit the inflammatory messenger TNF (e.g., adalimumab, golimumab, infliximab). Can be considered in more severe cases of ulcerative colitis, if cortisone is not effective or is not tolerated. TNF inhibitors are among the so-called biologics (biotechnologically produced drugs that specifically intervene in certain body processes).

Which drugs are used in individual cases for ulcerative colitis therapy depends on several factors. In addition to the extent of the symptoms, the strength and extent of the inflammation in the intestine play a role. In addition, the doctor takes into account in therapy planning how well the patient has responded to ulcerative colitis drugs and how high his risk for colon cancer.

Last but not least one distinguishes between the Thrust therapy (Treatment of a recent episode) and the maintenance treatment (to prolong symptom-free intervals between attacks, also called remission maintenance).

Thrust therapy

In case of an acute disease progression of ulcerative colitis, the treatment is gradually increased, adjusted to the severity of the disease.

at mild to moderate ulcerative colitis As a rule, 5-ASA (more precisely: mesalazine) is used. In case of pure endartitis (proctitis), a mesalazine suppository (or mesalazine rectal foam or enema) is usually sufficient once a day. If this is not enough, patients additionally receive mesalazine in oral form (tablets, granules) or a topical cortisone (for example, Budenoside rectal foam).

If the inflammation also extends to the large intestine, mesalazine is given both locally (as a foam or enema) and systemically (as a tablet). The dosage depends on the extent of inflammation in the intestine. If mesalazine fails to work or is not tolerated, the doctor prescribes cortisone tablets.

A severe ulcerative colitis is treated from the outset with cortisone (and inpatient in the hospital). The drug is administered in tablet form or via a vein (as an infusion / injection). If the cortisone is insufficient, the patient receives immunosuppressants or TNF antibodies.

Severe ulcerative colitis is referred to when several criteria are met. These include about six or more severe bloody diarrhea during the day, fever, rapid heartbeat (tachycardia) and anemia.

maintenance treatment

Once a disease has passed, patients should still 5-ASA for at least two years daily (preferably mesalazine). This can help prevent relapses and reduce the risk of colorectal cancer. Depending on the extent of the inflammation, a local application (foam, suppositories) or a systemic application (tablets) may be useful. Sometimes it is also necessary to administer mesalazine both locally and systemically.

Besides mesalazine, sulfasalazine is also a 5-ASA preparation. Both substances are equally effective. However, sulfasalazine carries a higher risk of side effects. Therefore mesalazine should be preferred for maintenance therapy.

If the daily 5-ASA application causes a renewed boost, the future Maintenance therapy “developed” (therapy escalation)For example, the doctor may increase the 5-ASA dosage or instead prescribe immunosuppressants or TNF antibodies. The optimal duration of application of the last two groups of drugs is known but not yet.

Cortisone is not suitable for the maintenance treatment of ulcerative colitis: It is not effective for this purpose and can cause serious side effects with prolonged use (osteoporosis, cataracts, etc.).

When mesalazine is not tolerated, ulcerative colitis patients sometimes receive preparations Escherichia coli Nissle, These are non-pathogenic intestinal bacteria, which should prolong the symptom-free intervals. So far, however, there are only a few studies on the use of E. coli Nissle as maintenance therapy for ulcerative colitis. Therefore, there is no final evaluation by experts.

Ulcerative colitis: surgery

Sometimes ulcerative colitis can no longer be controlled with medication. Then an operation is inevitable. The same applies if colon cancer or a precursor has been detected. In the case of a toxic megacolon as well as severe, non-digestible bleeding, surgery must be carried out as quickly as possible!

During surgery, the surgeon removes the entire colon from the rectum (proctocolectomy). From one part of the small intestine he forms a sac, which he connects with the anus. Once everything is healed, this sac acts as a new rectum. Until then, the stool can be emptied through an artificial bowel outlet, which the surgeon temporarily applies.

After surgery, patients no longer need ulcerative colitis drugs. However, the stool behavior can change: Some patients have more bowel movements after the procedure than before. In addition, the chair can be thinner and smoother.

Ulcerative colitis: You can do that yourself

Go to the doctor at the first sign of blood in the stool. Starting with push therapy at an early stage can shorten and relieve the thrust. During a severe acute push you should stay in bed.

Take psychological help in claim! A psychologist or psychotherapist can help you cope better with your condition. In turn, a better deal can relieve the discomfort – do not underestimate the influence of the psyche!

Join one support group for people with ulcerative colitis (or generally with inflammatory bowel disease). Sharing with other sufferers can help with disease management.

In addition, alternative treatments for ulcerative colitis, such as TCM (including acupuncture) or herbal medicine, are sometimes used to support orthodox medicine. To increase the quality of life and well-being, you can try relaxation, yoga, meditation or regular exercise (like jogging).

Ulcerative colitis: diet

For the diet in ulcerative colitis, there are generally no specific requirements. Those affected should pay attention to a balanced, varied diet.

In ulcerative colitis it can be quite easy too deficiency come. These include, for example, lack of iron, zinc, vitamin B12 or folic acid as well as anemia. Reduced bone density (osteopenia) or bone loss (osteoporosis) as well as malnutrition can also be the result of ulcerative colitis. In such cases, a customized diet is very useful, such as many calcium-rich foods in weak bones. Patients should ask their doctor or nutritionist for advice.

In case of severe deficiency symptoms, additional preparations containing the missing vitamins or minerals should be taken in consultation with the attending physician.

Some ulcerative colitis patients generally or poorly tolerate certain nutritional components during a disease spurt. The diet should take this into account accordingly. So you should, for example, at a intolerance of lactose (lactose intolerance) avoids or at least limits the consumption of milk and milk products such as cheese or yoghurt.

In acute episodes, experts advise low fiber to eat (so for example wholemeal bread or legumes). Because the insoluble fibers make the stool swell and stimulate the bowel movement – very unfavorable, if you already have diarrhea. Also Coffee and hot spices one should rather avoid, because they can additionally irritate the intestinal mucosa.

Ulcerative colitis: causes and risk factors

As with most chronic inflammatory bowel disease, ulcerative colitis also applies: causes and risk factors are poorly understood.

Obviously, a genetic predisposition plays an important role here. Because ulcerative colitis sometimes occurs frequently in families. Thus, siblings of patients compared to the normal population have a 10 to 50 times higher risk of also suffering from ulcerative colitis.

The genetic predisposition alone does not lead to the outbreak of ulcerative colitis. Diet, infections and a disturbed immune system could also be involved in the pathogenesis. The psyche may also have an influence, such as separation fears.

Mental stress can also trigger or exacerbate a disease in existing ulcerative colitis.

There are indications that people whose cecum has been removed have a lower risk of developing ulcerative colitis. The reason for this is unknown.

Ulcerative colitis: examinations and diagnosis

The clarification of a (suspected) ulcerative colitis is composed of several building blocks. First, the doctor will talk in detail with the patient to whom To raise medical history (Anamnesis): Among other things, he can describe the symptoms exactly and asks for any pre-existing conditions and for known ulcerative colitis in the family. Other important information for the doctor, for example, is whether the patient has smoked or smoked and is taking any medication regularly.

Physical examination

After the anamnesis interview, a physical examination follows. This also includes that the doctor with one finger scans the patient’s anus (digital-rectal examination). In ulcerative colitis, a complication can form a tumor in the rectum, which can often be felt in this way.

blood tests

The next important step is one blood testIn the blood of the patient, various parameters are measured, for example the inflammatory values ​​CRP (C-reactive protein) and blood sedimentation (erythrocyte sedimentation rate, BSG). The electrolytes sodium and potassium are also determined. Due to frequent diarrhea, a corresponding deficiency may have developed.

The amount of blood albumin provides evidence of the nutritional status of the patient. Elevated levels of liver enzymes Gamma-GT and alkaline phosphatase (AP) may indicate whether inflammation of the bile ducts inside and outside the liver (primary sclerosing cholangitis) has developed – a complication of ulcerative colitis. Other blood parameters are also determined, for example white blood cells (leukocytes), iron levels and renal values.

stool examination

In ulcerative colitis, certain germs (bacteria, viruses, parasites) can easily spread in the intestine – especially during an acute push. To rule out such an infection will be one stool examination made.

colonoscopy

A reliable method to detect ulcerative colitis and determine its extent is one Colonoscopy (colonoscopy), A thin, flexible, tubular instrument (endoscope) is inserted over the anus and advanced into the colon. At the tip of the endoscope are a tiny camera and a light source. This allows the doctor to examine the intestine from the inside. Thus, mucosal changes and inflammation, as they occur in ulcerative colitis, can be seen. The doctor can also use the endoscope to extract a tissue sample for analysis in the laboratory.

After diagnosis of ulcerative colitis, regular colonoscopies are performed as controls.

Often, it is not easy to differentiate between the two chronic inflammatory bowel diseases, ulcerative colitis and Crohn’s disease. In doubtful cases must therefore also the remaining digestive tract is examined endoscopically become. In Crohn’s disease, inflammation and mucosal changes can also be found there. By means of the so-called esophagogastroduodenoscopy esophagus, stomach and duodenum (upper section of the small intestine) are examined by means of an endoscope. The doctor can also take tissue samples.

The entire small intestine can be better controlled from the inside using capsule endoscopy. The tiny endoscope the size of a vitamin capsule is swallowed and films the inside of the digestive tract on its way to the anus. The images are sent via the built-in transmitter to a data recorder that the patient carries with him. The method is very gentle. However, no tissue samples can be taken.

Imaging procedures

Both for diagnosis and repeatedly in the further course of the disease, the abdomen per Ultrasonic (Sonography) examined. For example, the doctor can detect inflamed intestinal sections. Even a greatly enlarged intestine (megacolon) as a dangerous complication can be detected in the ultrasound. In this case, the doctor will additionally one X-ray of the intestine let make.

In certain cases are still other imaging techniques necessary. For example, in the case of a narrowing in the large intestine (colonic stenosis), the doctor will order a computed tomography or magnetic resonance imaging (MRI) and take a tissue sample from the conspicuous area. There is a suspicion of colon cancer here!

Patients with ulcerative colitis have an increased risk of developing colon cancer. Therefore, they should go to the doctor for regular check-ups.

Ulcerative colitis: disease course and prognosis

Like the onset, the course of the disease in ulcerative colitis is unpredictable. Most of the time the disease is relapsing. Physical and mental stress can trigger a boost. The time between two consecutive spurts can be different. Also, the discomfort during a push is not the same for every push and every patient.

Depending on the spread of inflammation, the prognosis for ulcerative colitis varies. By means of medical treatment, the symptoms and the course of the disease can be kept under control. If the ulcerative colitis is limited to the rectum, this is usually sufficient for those affected to live a reasonably normal life with normal life expectancy. However, the more extensive the inflammation in the intestine, the more difficult is often the treatment and prognosis of ulcerative colitis. The disease is currently curable only by removing the entire colon.

pouchitis

One possible consequence of the removal of the large intestine and rectum is the so-called pouchitis: “pouch” is the sac like small intestine reservoir called, which is formed in the course of surgery to an artificial rectum. This inflames in about half of the patients in the years after the operation. Signs of pouchitis include diarrhea, intestinal bleeding, and fever. Enemas with cortisone or antibiotics can help against the inflammation.

Pouchitis can also become chronic.

Increased cancer risk

Ulcerative colitis increases the risk of colon cancer – especially when the inflammation of the bowel is very extensive. The disease duration also plays a role: after 15 to 20 years of ulcerative colitis, about eight percent of patients get colon cancer. Failure to detect and treat it in time can significantly reduce the life expectancy of those affected. Therefore, in case of ulcerative colitis, regular check-ups (colonoscopy with sampling) are recommended. In what time intervals the investigations are meaningful, experienced Ulcerative colitisPatients from their attending physician.

Additional information

Books:

• Inflammatory Bowel Disease: Crohn’s Disease / Ulcerative Colitis from German Crohn’s Disease / Ulcerative Colitis Association – DCCV e.V., HIRZEL, 2006
• The Great Patient Guide to Crohn’s Disease and Ulcerative Colitis by Julia Seiderer-Nack, Zuckschwerdt, 2013

guidelines:

• Guideline “Ulcerative Colitis” of the German Society of Gastroenterology, Digestive and Metabolic Disease (2018)

Self-help:

• DCCV e.V. – German Crohn’s Disease / Ulcerative Colitis Association