Ulcerative colitis

Diagnosis

The definitive way to diagnose ulcerative colitis is through endoscopic procedures that involve taking tissue samples. Other tests can be used to rule out complications or other forms of inflammatory bowel disease, such as Crohn’s disease.

To confirm a diagnosis of ulcerative colitis, doctors may perform one or more of the following tests and procedures:

• Imaging test:
  • X-ray: A routine abdominal X-ray can be used if the patient exhibits severe symptoms to rule out serious complications such a megacolon or a perforated colon.
    Computerized tomography (CT) scan: If an ulcerative colitis complication is suspected, a CT scan of the abdomen or pelvis may be carried out. The extent of the colon’s inflammation may be determined using a CT scan.
  • Computerized tomography (CT) enterography and magnetic resonance (MR) enterography: To rule out any small intestinal inflammation, several noninvasive tests might be suggested. Compared to standard imaging tests, these techniques are more sensitive to the detection of intestinal inflammation. An alternative without radiation is MR enterography.
• Laboratory test
  • Blood tests: Blood tests may be recommended to evaluate for infections or inflammation as well as anemia, a condition in which there are not enough red blood cells to provide enough oxygen to your tissues.
  • Stool studies: The stool may contain white blood cells or certain proteins that suggest ulcerative colitis. A stool sample can also be used to rule out other conditions, such as diseases brought on by viruses, bacteria, or parasites.
• Endoscopic procedures
  • Colonoscopy: Using the use of a small, flexible, illuminated tube with a camera on the end, this examination enables the healthcare provider to see the whole colon. Tissue samples are collected during the operation for laboratory analysis. This procedure is called a tissue biopsy. To make the diagnosis, a tissue sample is required.
  • Flexible sigmoidoscopy: The rectum and sigmoid colon, the lower end of the colon, are examined by a healthcare provider using a thin, flexible, lit tube. A partial colonoscopy may be suggested in cases where your colon is significantly irritated.

Treatment

The treatment of ulcerative colitis typically includes medication therapy or surgery. Various types of medications can be effective in treating this condition, and the specific medication prescribed will depend on the severity of the individual’s case. However, the effectiveness of a medication may vary from person to person, and it may take some time to find the appropriate medication. As some medications have significant side effects, it is important to carefully consider the risks and benefits of any treatment.

• Anti-inflammatory medications: The initial approach to manage ulcerative colitis typically involves the use of anti-inflammatory drugs, which are usually suitable for most individuals with this condition. Such medications may include:
  • 5-aminosalicylates: 5-aminosalicylates come in several forms, such as sulfasalazine, mesalamine, balsalazide, and olsalazine. Depending on which part of the colon is affected, they can be taken orally or administered as an enema or suppository.
  • Corticosteroids: Prednisone and budesonide, are usually only used for moderate to severe cases of ulcerative colitis that haven’t responded to other treatments. These medications work by suppressing the immune system, but they can have significant side effects, so they’re not typically prescribed for long-term use.
• Immune system suppressors: Immunosuppressant medications work by inhibiting the immune system’s response that initiates the process of inflammation, thereby reducing inflammation. Some individuals may benefit from a combination of these medications, as opposed to a single medication. Examples of immunosuppressant medications are:
  • Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol, Purixan):  Immunosuppressants are medications that are commonly used to treat inflammatory bowel disease, often in combination with biologics. It is important to closely follow up with your healthcare provider and regularly monitor your blood for potential side effects. This is because these medications can affect the liver and pancreas.
  • Cyclosporine (Gengraf, Neoral, Sandimmune). Cyclosporine is a medication that is usually only prescribed to individuals who have not had success with other medications. It can cause severe side effects and should not be used for an extended period of time.
  • Small molecule medications:  New treatments for IBD are available in the form of orally delivered drugs known as “small molecules.” These include tofacitinib (Xeljanz), upadacitinib (Rinvoq), and ozanimod (Zeposia), which may be used when other treatments have failed. However, these medications can have side effects such as an increased risk of shingles infection and blood clots. Recently, the FDA has issued a warning about the potential risks of tofacitinib, which include serious heart-related problems and cancer. If you are taking tofacitinib for ulcerative colitis, it is important to consult with your healthcare provider before stopping the medication.
• Biologics: There is a type of therapy that focuses on proteins produced by the body’s immune system. Within this therapy, there are various biologics that are utilized to treat ulcerative colitis.
  • Infliximab (Remicade), adalimumab (Humira) and golimumab (Simponi): Tumor necrosis factor (TNF) inhibitors such as infliximab (Remicade), adalimumab (Humira), and golimumab (Simponi) neutralize a protein produced by the immune system and are used to treat severe cases of ulcerative colitis in individuals who have not responded to or cannot tolerate other treatments. These medications are classified as biologics
  • Vedolizumab (Entyvio):  Is used to treat ulcerative colitis by preventing inflammatory cells from reaching the site of inflammation. This treatment is suitable for people who do not respond to or cannot tolerate other treatment options.
  • Ustekinumab (Stelara): Is a medication that is also approved for the treatment of ulcerative colitis in individuals who do not respond to or cannot tolerate other treatments. It works by blocking a specific protein that causes inflammation.
• Other medications: Before using over-the-counter medications, it is important to consult with your healthcare provider as you may require additional medications to manage certain symptoms of ulcerative colitis. Your healthcare provider may suggest one or several of the following options.
  • Anti-diarrheal medications: Loperamide (Imodium A-D) could be useful in treating severe diarrhea. However, if an individual has ulcerative colitis, they should not use anti-diarrheal drugs without consulting a healthcare provider first. The reason being that these medications might escalate the risk of toxic megacolon, which is an enlarged colon.
  • Pain relievers:  Your healthcare provider may suggest using acetaminophen (such as Tylenol) for mild pain. However, they might advise against using ibuprofen (like Advil or Motrin IB), naproxen sodium (like Aleve), and diclofenac sodium, as these medicines could potentially make the symptoms worse and the disease more severe.
  • Antispasmodics: Antispasmodic treatments are occasionally recommended by healthcare providers to treat cramps.
  • Iron supplements: The patient may develop iron deficiency anemia and need iron supplements if they have chronic intestinal bleeding.
• Surgery: Ulcerative colitis can be treated surgically, which requires removing the patient’s whole colon and rectum (proctocolectomy).
  • Proctocolectomy and ileoanal pouch: The most common surgery for ulcerative colitis is proctocolectomy and ileoanal pouch surgery, where the colon and rectum are removed, and a new rectum is made from a part of the small intestine. A temporary ileostomy may be necessary during healing. The ostomy bag can be covered for discretion and should not smell with proper care. After healing, the ileostomy can be removed, and the new pouch will allow waste to exit the body normally, but with more frequent bowel movements. The surgery can alleviate pain and cramping from ulcerative colitis.
  • Proctocolectomy and ileostomy: If an ileoanal pouch is not suitable for a patient, their healthcare team may suggest a permanent ileostomy instead. This involves the removal of the patient’s colon and rectum through a surgical procedure called proctocolectomy. At the same time, the patient will undergo another surgical procedure to have a permanent ileostomy, which is the surgical creation of an opening (called a stoma) in the abdominal wall for waste to exit the body.
  • Cancer surveillance: Based on your increased risk for colon cancer, you will need to undergo more frequent screening. The recommended screening schedule will be determined by the location and duration of your disease. If you have inflammation of the rectum, also known as proctitis, you are not at a higher risk for colon cancer.

However, if your disease affects more than just the rectum, you will require a colonoscopy for surveillance purposes every 1 to 2 years. The timing of this colonoscopy will depend on the extent of your colon involvement. If the majority of your colon is affected, the colonoscopy will begin eight years after diagnosis. If only the left side of your colon is involved, the colonoscopy will begin 15 years after diagnosis.