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Ulcerative Colitis

Ulcerative colitis can just involve the rectum (called proctitis) or can involve more or all of the colon (called pancolitis at its most extensive)
Mild ulcerative colon - the pattern of blood vessels cannot be seen - there is a granular appearance to the lining of the colon
Another example of UC at colonoscopy - this is moderate inflammation
Severe ulcerative colitis - deeper ulceration and loss of mucosa

What is ulcerative colitis?

  • This is an inflammatory disease of unknown cause that is limited to the large bowel (colon).
  • It begins in the rectum and spreads back up the colon.
  • The mucosa(lining of the bowel) is inflamed (reddened with a granular surface – like a rash).
  • Despite the name actual ulcers do not occur except during severe acute attacks.

What are the main symptoms?

  • The main symptom is diarrhoea (often with blood and mucus).
    • As well as frequent bowel motions there is usually urgency and a feeling of incomplete emptying.
    • There may be some discomfort in the left lower abdomen.
  • The disease is characterised by remission and relapses. The extent of disease is variable.
    • ¼ have total colitis (pancolitis).
    • ½ have limited colitis (only rectum and part of colon involved).
    • ¼ have involvement of the rectum only(proctitis).
    • When only the rectum is involved there may not be loose motions and the main symptoms are bleeding and urgency.
  • Colonoscopy is very helpful to determine extent and severity of disease.
  • Most patients (90%) go into remission after first episode but have continue to have a relapsing course.
  • There is a risk of the disease progressing to involve more of the colon.
    • The risk of progression is about 30% for rectal involvement (proctitis).
    • There may be a decrease in this risk with more aggressive treatment.
    • Early treatment of relapses is important. This is often better with "self-management". That usually means knowing when to start steroids rather having to consult a doctor first.


Symptoms other than diarrhoea.

  • There can be other symptoms that do not involve the bowel.
    • Arthritis. This affects mainly knees, ankles, elbows and wrists and tends to relapse and remit with the activity of the colitis.
    • Less commonly there is sacro-ileitis which gives persistent backache and morning back stiffness.
    • Iritis is a condition that gives a painful red eye with blurring of vision – urgent treatment is required.
    • Rarely there can be serious effects on the liver that gradually progress over time.



Treatment - medications


  • This is a brief summary - more details are given in sections on each medication
  • A mild relapse is managed with increased dose of oral salicylates (a 5-ASA / mesalazine  preparation such as Pentasa, Asacol or Dipentum.
  • A more severe attack will require oral steroids (Prednisone)
  • Oral 5-ASA compounds are usually continued as long term maintenance treatment.
    • They reduce the risk of relapse by 50% (usual doses are 2-3 g per day)

  • Immunomodulators such as azathioprine are being used more commonly to maintain remission usually for periods up to 5-10 years (see section on azathioprine).

  • Monoclonal antibodies against TNF (infliximab and adalimumab) have a role.  IN NZ infliximab is available for severe cases through the gastroenterology departments
  • What about diet and natural /alternative treatments.  There is no evidence-based  advice that can be given.  A lot of people get some benefit from diets suggested for irritable bowel syndrome. There is no widely accepted IBD diet.
  • There is a lot of interest in probiotics (see section of alternative treatments - main menu)
  • High-strength fish oil may have some anti-inflammatory effect - most trials were negative but this may relate to doses to low to have an effect 
  • Arthritis usually resolves with effective treatment of the colitis.  However sometimes specific changes are required.  The older drug Salazopyrin is effective for arthritis when the newer formulations like Pentasa and Asacol have no activity.  The best immunomodulator for arthritis is Methotrexate rather than azathioprine

  • Adalimumab is often effective for arthritis associated with IBD (colitis or Crohn's disease) and is also used for ankylosing arthritis - a more specific condition associated with IBD
  • Many new treatments are available or in clinical trials.  Both vedolizumab and ustekinumab have a useful role  -  currently for more severe disease, but likely to be used more commonly as experience grows and costs reduce.




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