Ulcerative Colitis

The main serious complications of ulcerative colitis include

• Bleeding

• Fulminant colitis (toxic colitis)

• Colon cancer

Bleeding, the most common complication, often causes iron deficiency anemia.

Fulminant colitis (also called toxic colitis) is a particularly severe complication. In some people who have ulcerative colitis, a rapidly progressing first attack becomes very severe, with massive bleeding, rupture (perforation) of the colon, or widespread infection. Damage to the nerves and muscles of the bowel wall causes ileus (a condition in which the normal contractile movements of the intestinal wall temporarily stop), and thus the intestinal contents are not propelled along their way. Abdominal expansion (distention) develops.

As fulminant colitis worsens, the large intestine loses muscle tone and within days—or even hours—it starts to expand (a condition sometimes referred to as toxic megacolon). This complication may cause a high fever and abdominal pain. Sometimes there is a perforation of the large intestine and the person develops peritonitis. X-rays or other imaging tests of the abdomen may show expansion of the bowel and the presence of gas inside the wall of the paralyzed sections of intestine.

Colon cancer starts to become more common by about 7 years from when ulcerative colitis started in people with extensive colitis. The risk of colon cancer is highest when the entire large intestine is affected and increases the longer the person has had ulcerative colitis. However, people who have both inflammatory bowel disease and inflammation of the bile ducts (primary sclerosing cholangitis) are at a higher risk of colon cancer starting from the time when the colitis is diagnosed.

Colonoscopy (examination of the large intestine using a flexible viewing tube) every 1 to 2 years is advised for people who have had ulcerative colitis for more than 8 to 10 years or who have primary sclerosing cholangitis. During colonoscopy, tissue samples are taken from areas throughout the large intestine for examination under a microscope to detect the early warning signs of cancer (dysplasia). This removal and examination of tissue is called a biopsy. In a newer type of colonoscopy called chromoendoscopy, dyes are inserted into the colon during colonoscopy to highlight cancerous (malignant) and precancerous areas and may better help doctors identify areas for biopsy.

Other complications can occur, as in Crohn disease. When ulcerative colitis causes a flare-up of gastrointestinal symptoms, people also may have the following:

• Inflammation of the joints (arthritis)

• Inflammation of the whites of the eyes (episcleritis)

• Inflamed skin nodules (erythema nodosum)

When ulcerative colitis is not causing a flare-up of gastrointestinal symptoms, people still may have complications that occur entirely without relation to the bowel disease such as the following:

• Dusky purple skin sores that may contain pus (pyoderma gangrenosum)

• Inflammation of the spine

• Inflammation of the pelvic joints (sacroiliitis)

• Inflammation of the inside of the eye (uveitis)

Although people with ulcerative colitis commonly have minor liver dysfunction, only about 1 to 3% have symptoms of liver disease, which vary from mild to severe. Severe liver disease can include inflammation of the liver (chronic active hepatitis), inflammation of the bile ducts (primary sclerosing cholangitis), which narrow and eventually close, and replacement of functional liver tissue with scar tissue (cirrhosis). Inflammation of the bile ducts may appear many years before any intestinal symptoms of ulcerative colitis. The inflammation greatly increases the risk of cancer of the bile ducts and also seems to be associated with a sharp increase in the risk of colon cancer.

Doctors examine people when their typical symptoms return, but they do not always do tests. If symptoms have been more frequent or longer-lasting than usual, doctors may do sigmoidoscopy or colonoscopy and a blood count. Doctors may do other tests to look for infection or parasites.

Usually, if the large intestine is swollen, people should eat a low-fiber diet (in particular, avoiding foods such as nuts, corn hulls, raw fruits, and vegetables) to reduce injury to the inflamed lining of the large intestine. However, a high-fiber diet should be resumed once the IBD flare resolves.

A diet free of dairy products may decrease symptoms and is worth trying but does not need to be continued if no benefit is noted.

All people who have ulcerative colitis should take calcium and vitamin D supplements. Iron supplements may offset anemia caused by ongoing blood loss in the stool.All people who have ulcerative colitis should take calcium and vitamin D supplements. Iron supplements may offset anemia caused by ongoing blood loss in the stool.

Small doses of loperamide are taken for relatively mild diarrhea. For more intense diarrhea, higher doses of loperamide may be needed. In severe cases, however, a doctor must closely monitor the person taking these antidiarrheal medications because of the risk of fulminant colitis.Small doses of loperamide are taken for relatively mild diarrhea. For more intense diarrhea, higher doses of loperamide may be needed. In severe cases, however, a doctor must closely monitor the person taking these antidiarrheal medications because of the risk of fulminant colitis.

Routine health maintenance measures, particularly vaccinations and cancer screening, are important.

For people with mild symptoms and disease confined to the left side of the colon, mesalamine enemas or suppositories are usually used first. In people for whom this treatment is not effective, other options include oral mesalamine (5-ASA), tacrolimus or beclomethasone suppositories, or oral budesonide MMX., mesalamine enemas or suppositories are usually used first. In people for whom this treatment is not effective, other options include oral mesalamine (5-ASA), tacrolimus or beclomethasone suppositories, or oral budesonide MMX.

For people with moderate or extensive disease, biologic agents (infliximab, adalimumab, golimumab, guselkumab, risankizumab, mirikizumab, ustekinumab, vedolizumab) sometimes with an immunomodulator (azathioprine or 6-mercaptopurine) are used. Other options include high-dose steroids or small molecule medications (tofacitinib, upadacitinib, ozanimod, or etrasimod)., biologic agents (infliximab, adalimumab, golimumab, guselkumab, risankizumab, mirikizumab, ustekinumab, vedolizumab) sometimes with an immunomodulator (azathioprine or 6-mercaptopurine) are used. Other options include high-dose steroids or small molecule medications (tofacitinib, upadacitinib, ozanimod, or etrasimod).

People with severe disease, which can include more than 6 bowel movements daily, elevated heart rate, fever, or severe abdominal pain, are cared for in the hospital and typically receive biologic agents and/or high-dose IV steroids. They may need IV fluids or blood transfusions. They should also receive treatment to prevent blood clots. Combinations of medications, or other medications that suppress the immune system (cyclosporine, tacrolimus) may be used in patients who do not get better with the initial treatment. Surgery is sometimes needed., which can include more than 6 bowel movements daily, elevated heart rate, fever, or severe abdominal pain, are cared for in the hospital and typically receive biologic agents and/or high-dose IV steroids. They may need IV fluids or blood transfusions. They should also receive treatment to prevent blood clots. Combinations of medications, or other medications that suppress the immune system (cyclosporine, tacrolimus) may be used in patients who do not get better with the initial treatment. Surgery is sometimes needed.

For people with life-threatening (fulminant) colitis (more than 10 stools per day with continuous blood, enlargement of the colon with fever, elevated heart rate, and laboratory tests indicating inflammation), hospitalization is required. People may not eat or drink and receive IV fluids and electrolytes, antibiotics, and IV treatment such as steroids, cyclosporine, or infliximab.(more than 10 stools per day with continuous blood, enlargement of the colon with fever, elevated heart rate, and laboratory tests indicating inflammation), hospitalization is required. People may not eat or drink and receive IV fluids and electrolytes, antibiotics, and IV treatment such as steroids, cyclosporine, or infliximab.

Aminosalicylates are medications used to reduce the inflammation of ulcerative colitis and to prevent flare-ups of symptoms. Medications such as sulfasalazine, olsalazine, mesalamine, and balsalazide are types of aminosalicylates. For ulcerative colitis, mesalamine by enema or suppository is most often used. Whether given orally or rectally, these medications are at best moderately effective for treating mild or moderately active disease, but they are more effective for preventing symptoms from reappearing (maintaining remission).Aminosalicylates are medications used to reduce the inflammation of ulcerative colitis and to prevent flare-ups of symptoms. Medications such as sulfasalazine, olsalazine, mesalamine, and balsalazide are types of aminosalicylates. For ulcerative colitis, mesalamine by enema or suppository is most often used. Whether given orally or rectally, these medications are at best moderately effective for treating mild or moderately active disease, but they are more effective for preventing symptoms from reappearing (maintaining remission).

People with moderately severe disease usually take steroids (such as prednisone) in fairly high doses, which frequently induces a dramatic remission. After steroids control the inflammation of ulcerative colitis, sulfasalazine, olsalazine or mesalamine, or an People with moderately severe disease usually take steroids (such as prednisone) in fairly high doses, which frequently induces a dramatic remission. After steroids control the inflammation of ulcerative colitis, sulfasalazine, olsalazine or mesalamine, or animmunomodulating medication, a biologic agent, or tofacitinib or ozanimod is often given to maintain the improvement. Gradually, the prednisone dosage is decreased, and ultimately the prednisone is discontinued. , or tofacitinib or ozanimod is often given to maintain the improvement. Gradually, the prednisone dosage is decreased, and ultimately the prednisone is discontinued.

Budesonide is another steroid that may be used in a long-acting oral form for ulcerative colitisBudesonide is another steroid that may be used in a long-acting oral form for ulcerative colitis

Long-term steroid treatment almost always causes side effects (see sidebar Corticosteroids: Uses and Side Effects).

If the disease becomes severe, the person is hospitalized, and steroids and fluids are given by vein (intravenously).

Immunomodulating medications modify the action of the body's immune system, decreasing its activity. Medications such as azathioprine, and mercaptopurine have been used to maintain remissions in people with ulcerative colitis who would otherwise need long-term steroid treatment. These medications inhibit the function of T cells, which are an important component of the immune system. However, these medications are slow to act, and a benefit may not be seen for 1 to 3 months. They also have potentially serious side effects that require close monitoring by the doctor.Immunomodulating medications modify the action of the body's immune system, decreasing its activity. Medications such as azathioprine, and mercaptopurine have been used to maintain remissions in people with ulcerative colitis who would otherwise need long-term steroid treatment. These medications inhibit the function of T cells, which are an important component of the immune system. However, these medications are slow to act, and a benefit may not be seen for 1 to 3 months. They also have potentially serious side effects that require close monitoring by the doctor.

CyclosporineCyclosporine has been given to some people who have severe flare-ups and have not responded to steroids. Most of these people respond initially to the cyclosporine, but some may still ultimately require surgery.has been given to some people who have severe flare-ups and have not responded to steroids. Most of these people respond initially to the cyclosporine, but some may still ultimately require surgery.

TacrolimusTacrolimus is given by mouth. This medication has been given as short-term treatment to people whose ulcerative colitis is difficult to manage while they begin treatment with other medications. Tacrolimus may help maintain remission.is given by mouth. This medication has been given as short-term treatment to people whose ulcerative colitis is difficult to manage while they begin treatment with other medications. Tacrolimus may help maintain remission.

Biologic agents are medicines that are created by living organisms.

Before starting treatment with other biologic agents, people should be tested for tuberculosis, hepatitis B infection, and hepatitis C infection.

Infliximab,Infliximab, which is derived from monoclonal antibodies to tumor necrosis factor (called a tumor necrosis factor inhibitor or TNF inhibitor) and given intravenously, is beneficial for some people with ulcerative colitis. This medication may be given to people who do not respond to steroids or who develop symptoms whenever steroid doses are lowered, despite the optimal use of other immunomodulating medications. Infliximab, adalimumab, and golimumab are beneficial for people whose ulcerative colitis is difficult to treat or for people who depend on steroids.which is derived from monoclonal antibodies to tumor necrosis factor (called a tumor necrosis factor inhibitor or TNF inhibitor) and given intravenously, is beneficial for some people with ulcerative colitis. This medication may be given to people who do not respond to steroids or who develop symptoms whenever steroid doses are lowered, despite the optimal use of other immunomodulating medications. Infliximab, adalimumab, and golimumab are beneficial for people whose ulcerative colitis is difficult to treat or for people who depend on steroids.

Side effects that may occur with infliximab include worsening of an existing uncontrolled bacterial infection, reactivation of tuberculosis or hepatitis B, and an increase in the risk of some types of cancer. Some people have reactions such as fever, chills, nausea, headache, itching, or rash during the infusion (called infusion reactions). Before starting treatment with infliximab or other TNF inhibitors such as adalimumab and golimumab, people must be tested for Side effects that may occur with infliximab include worsening of an existing uncontrolled bacterial infection, reactivation of tuberculosis or hepatitis B, and an increase in the risk of some types of cancer. Some people have reactions such as fever, chills, nausea, headache, itching, or rash during the infusion (called infusion reactions). Before starting treatment with infliximab or other TNF inhibitors such as adalimumab and golimumab, people must be tested fortuberculosis and hepatitis B infections.

VedolizumabVedolizumab is a medication for people who have (1) moderate to severe ulcerative colitis that has not responded to TNF inhibitors or other immunomodulating medications or who (2) are unable to tolerate these medications. The most serious side effect it causes is increased susceptibility to infection. Vedolizumab has a theoretical risk of a serious brain infection called is a medication for people who have (1) moderate to severe ulcerative colitis that has not responded to TNF inhibitors or other immunomodulating medications or who (2) are unable to tolerate these medications. The most serious side effect it causes is increased susceptibility to infection. Vedolizumab has a theoretical risk of a serious brain infection calledprogressive multifocal leukoencephalopathy (PML) because this infection has been reported with the use of a related medication called natalizumab.(PML) because this infection has been reported with the use of a related medication called natalizumab.

UstekinumabUstekinumab is another kind of biologic agent given to people who have moderate to severe ulcerative colitis that has not responded to TNF inhibitors or other immunomodulating medications or who are unable to tolerate these medications. The first dose is given by vein and then by injections under the skin every 8 weeks. Side effects include injection-site reactions (pain, redness, swelling), cold-like symptoms, chills, and headache.

Adalimumab, golimumab, guselkumab, risankizumab, mirikizumab, (other biologic agents) are prescribed for moderate to severe Crohn disease or ulcerative colitis. For some of these medications, liver tests are checked before and during treatment to monitor for liver damage. Doctors also monitor the person for other symptoms, including injection site reactions, skin rashes, and viral infections.Adalimumab, golimumab, guselkumab, risankizumab, mirikizumab, (other biologic agents) are prescribed for moderate to severe Crohn disease or ulcerative colitis. For some of these medications, liver tests are checked before and during treatment to monitor for liver damage. Doctors also monitor the person for other symptoms, including injection site reactions, skin rashes, and viral infections.

TofacitinibTofacitinib is a medication given by mouth twice a day for adults with moderate to severe ulcerative colitis. This medication is a Janus kinase (JAK) inhibitor. It is not actually a biologic agent because it is created by chemical processes rather than by living organisms. However, it shares many characteristics with biologic agents, including many of their side effects. Tofacitinib interferes with the communication between cells that coordinate inflammation by inhibiting an enzyme (Janus kinase, or JAK). Serious side effects include increased susceptibility to infection, blood clot (such as in deep vein thrombosis or pulmonary embolism), heart attack, and stroke.

UpadacitinibUpadacitinib is a medication given by mouth once a day for adults with moderate to severe ulcerative colitis. It is also a JAK inhibitor (described above). In general, the side effects are similar to those of other JAK inhibitors (such as tofacitinib). JAK inhibitors may cause blood disorders, in which case the medication is discontinued. They are also given with caution to people who are at risk of certain gastrointestinal disorders, and they should be avoided in people with an increased risk of cardiovascular events such as heart attack, stroke, or even death.

OzanimodOzanimod is a medication given by mouth for adults with moderate to severe active ulcerative colitis. This medication should not be used by people who have had a heart attack, chest pain (unstable angina), stroke or mini-stroke (transient ischemic attack or TIA), or certain types of heart failure in the last 6 months. This medication also should not be taken by people who have or have had a history of certain types of an irregular or abnormal heartbeat (arrhythmia) that is not corrected by a pacemaker, by people with severe untreated sleep apnea, or by people who take a monoamine oxidase inhibitor (MAOI—such as selegiline, phenelzine, and linezolid). Ozanimod can increase the risk of infections, slow the heart rate, lower the number of white blood cells, and cause liver damage., or by people who take a monoamine oxidase inhibitor (MAOI—such as selegiline, phenelzine, and linezolid). Ozanimod can increase the risk of infections, slow the heart rate, lower the number of white blood cells, and cause liver damage.

EtrasimodEtrasimod works by modifying the immune response, thus reducing the movement of white blood cells into inflamed tissue. This is the mechanism by which the medication controls inflammation in the gastrointestinal tract. However, this mechanism can also suppress the immune system enough to increase the risk of infections, some of which can be serious. People with certain cardiovascular disorders (for example, myocardial infarction, stroke, and heart failure) should not take etrasimod.works by modifying the immune response, thus reducing the movement of white blood cells into inflamed tissue. This is the mechanism by which the medication controls inflammation in the gastrointestinal tract. However, this mechanism can also suppress the immune system enough to increase the risk of infections, some of which can be serious. People with certain cardiovascular disorders (for example, myocardial infarction, stroke, and heart failure) should not take etrasimod.

People with ulcerative proctitis, or colitis that affects only the part of the colon near the rectum, are given mesalamine enemas. Steroid and budesonide enemas are given to people who are not helped by or cannot tolerate mesalamine. or colitis that affects only the part of the colon near the rectum, are given mesalamine enemas. Steroid and budesonide enemas are given to people who are not helped by or cannot tolerate mesalamine.

People with moderate or extensive disease are given mesalamine by mouth in addition to mesalamine enemas. People with severe symptoms and those who still have symptoms while using mesalamine usually take oral steroids such as prednisone. Prednisone in fairly high doses frequently induces a dramatic remission. After prednisone controls the inflammation of ulcerative colitis, sulfasalazine, olsalazine, or mesalamine often is given to maintain the improvement. Gradually, the prednisone dosage is decreased, and ultimately the prednisone is discontinued because prolonged steroid treatment almost always causes side effects.are given mesalamine by mouth in addition to mesalamine enemas. People with severe symptoms and those who still have symptoms while using mesalamine usually take oral steroids such as prednisone. Prednisone in fairly high doses frequently induces a dramatic remission. After prednisone controls the inflammation of ulcerative colitis, sulfasalazine, olsalazine, or mesalamine often is given to maintain the improvement. Gradually, the prednisone dosage is decreased, and ultimately the prednisone is discontinued because prolonged steroid treatment almost always causes side effects.

People whose symptoms return when prednisone is decreased are sometimes given an immunomodulating medication (azathioprine or mercaptopurine). Additionally, some people benefit from infliximab, adalimumab, vedolizumab, golimumab, ustekinumab, tofacitinib, or ozanimod. People whose symptoms return when prednisone is decreased are sometimes given an immunomodulating medication (azathioprine or mercaptopurine). Additionally, some people benefit from infliximab, adalimumab, vedolizumab, golimumab, ustekinumab, tofacitinib, or ozanimod.

People with severe colitis are hospitalized, and high-dose steroids and fluids are given intravenously. Doctors may continue to give mesalamine. People with heavy rectal bleeding may require blood transfusions. People who do not respond to these treatments within 3 to 7 days may be given intravenous infliximab, vedolizumab, or cyclosporine or may need surgery to remove their colon. People who have severe or difficult-to-treat colitis but who do not need to be hospitalized may be given tacrolimus.are hospitalized, and high-dose steroids and fluids are given intravenously. Doctors may continue to give mesalamine. People with heavy rectal bleeding may require blood transfusions. People who do not respond to these treatments within 3 to 7 days may be given intravenous infliximab, vedolizumab, or cyclosporine or may need surgery to remove their colon. People who have severe or difficult-to-treat colitis but who do not need to be hospitalized may be given tacrolimus.

People whose disease occurs suddenly, rapidly, and with great pain or who may have toxic colitis are hospitalized. All antidiarrheal medications are stopped, no food or medications are given by mouth, and doctors pass a tube through the nose and into the stomach or small intestine to remove contents from the stomach or small intestine. People are given intravenous fluids and electrolytes and high-dose intravenous steroids or cyclosporine. Doctors also give antibiotics. People may be given infliximab. People whose disease occurs suddenly, rapidly, and with great pain or who may have toxic colitis are hospitalized. All antidiarrheal medications are stopped, no food or medications are given by mouth, and doctors pass a tube through the nose and into the stomach or small intestine to remove contents from the stomach or small intestine. People are given intravenous fluids and electrolytes and high-dose intravenous steroids or cyclosporine. Doctors also give antibiotics. People may be given infliximab.

People are monitored closely for signs of infection or a perforation. People whose condition does not improve in 24 to 48 hours need immediate surgery to remove all or most of the large intestine.

To prevent symptoms from reappearing (that is, to maintain remission), people generally continue taking the medication that successfully treated their disease. However, if a steroid was used to treat their disease, the dose is lowered and they are eventually stopped (and a different medication used). Oral or rectal mesalamine is often used in combination with other medications as maintenance therapy.To prevent symptoms from reappearing (that is, to maintain remission), people generally continue taking the medication that successfully treated their disease. However, if a steroid was used to treat their disease, the dose is lowered and they are eventually stopped (and a different medication used). Oral or rectal mesalamine is often used in combination with other medications as maintenance therapy.

About 20 to 40% of people with extensive ulcerative colitis require surgery. Some reasons for surgery include chronic colitis that is disabling or that constantly requires high doses of steroids, cancer, and narrowing of the large intestine or growth failure in children. Emergency surgery may be necessary for sudden life-threatening attacks with massive bleeding, perforation, or fulminant colitis.

Complete removal of the large intestine, rectum, and anus (total proctocolectomy) permanently cures ulcerative colitis, restores life expectancy to normal, and eliminates the risk of colon cancer. However, inflammation develops in the small intestine in about 25% of people after surgery even though their small intestine was not previously affected.

The most common surgery is a procedure called proctocolectomy with ileal pouch-anal anastomosis (IPAA). In this procedure, the large intestine and most of the rectum are removed, and a small reservoir (pouch) is created out of the small intestine and attached to the remaining rectum just above the anus. Because the muscles of the anus (anal sphincter) are not removed, this procedure allows people to remain in control of their bowels (continence). However, because a small amount of tissue of the rectum can remain, the risk of cancer is significantly decreased but not eliminated.

A common complication of IPAA is inflammation of the reservoir (called pouchitis). To treat pouchitis, doctors give antibiotics. Most cases of pouchitis can be controlled with medications, but a small percentage cannot. For these cases, doctors create an ileostomy to correct the problem. In an ileostomy, a surgeon brings the end of the lowest portion of the small intestine (ileum) out through an opening in the abdominal wall (stoma). People who have an ileostomy must always wear a plastic bag (ileostomy bag) over the opening to collect the stool that comes out. An ileostomy used to be the traditional price of this cure.

Ileal Pouch

3D Model

The long-term survival rate for people with colon cancer caused by ulcerative colitis is about 75%. People are more likely to survive if the diagnosis is made during the early stages and the colon is removed in time.