Ulcerative colitis, or ulcerative colitis (often abbreviated UC) is a disease in which inflammation develops in the mucosa of the rectum. The disease is characterized by a chronic course with the change of exacerbations and periods of remission.
Among the main causes of ulcerative colitis, there is a combination of genetic factors of predisposition to the pathology and negative impact of the external environment. The incidence of ulcerative colitis ranges from 40 to 117 cases per 100 thousand population. The most vulnerable part of the population of 20-40 years. The highest frequency of deaths from ulcerative colitis noted in the first year after onset of the disease when it is severe fulminant course and rapid development of the cancer process, and 10 years later after the demonstrations.
The etiology of ulcerative colitis
Ulcerative colitis is a disease with an incompletely understood trigger factors. It is known that the presence among the relatives of patients with ulcerative colitis or Crohn’s disease, also characterized by chronic inflammation of the intestinal walls increases the risks of developing ulcerative colitis.
Most often, the pathology is recorded at a young age, 20 to 25 years, the second most vulnerable age group of 55-65 years.
There is evidence on the likely impact on the development of ulcerative colitis infections of bacterial and viral nature, however, a clear correlation has yet to be achieved.
For reliable data include some environmental factors influencing the occurrence of disease and its exacerbation. The most thoroughly studied such as oral contraceptives and some hormone drugs, Smoking, fascination with certain types of diets. Dependence on hormonal methods and natural fluctuations in hormonal levels (mainly by increasing the level of estrogen in the blood) is indirectly confirmed by statistics: the number of female patients with a diagnosis of ulcerative colitis exceeds the male part of almost 30%.
There is a correlation between increased disease risk and long-term administration of nonsteroidal anti-inflammatory drugs, the presence of uncorrected diet and/or medications food allergies, expressed or prolonged stress.
The basic theory of disease is based on the presence of immunological factors and autosensibilization of the patient.
Protective and preventive factors in ulcerative colitis
In various studies identified factors that reduce the likelihood of developing ulcerative colitis, and to improve its diagnosis and treatment.
- Likely that the operation of appendectomy in true appendicitis, moved at a young age, reduces the risk of development of ulcerative colitis.
- Potential protective factor is breastfeeding: women do not to suppress lactation after childbirth, ulcerative colitis is less common.
- The correlation between the disease and Smoking mixed: among the Smoking part of the population, the prevalence of ulcerative colitis is higher than among non-Smoking. However, the frequency of the disease increases dramatically have quitters in this connection, a study was conducted on the effect of nicotine on the expression of symptoms of ulcerative colitis. According to the results the conclusion about the possibility of including the preparations of nicotine (in the form of patches, etc.) in the General course of standard therapy for ulcerative colitis.
- Oleic acid is considered a means of preventing the onset and course of disease, having the ability of locking is responsible for the inflammation of the walls of the intestine chemical compounds can be included in the diet of patients and patients from risk groups to prevent the development or exacerbation of the disease. The average recommended dose based on the acid in the food composition, for example, 2-3 tablespoons of olive oil.
Signs, symptoms of ulcerative colitis
The disease is characterized by long, chronic nature of the flow in which the clinical picture of the disease combines periods of exacerbation and remission. The severity and specificity of the symptomatic manifestations depends on the location of the destructive process and its intensity, and the depth of tissue damage.
The initial phase of the disease is accompanied by swelling and hyperemic changes of the intestinal mucosa. After a certain time (depending on the speed of development of disease, the body’s resistance and timeliness of diagnosis and therapy) begins the ulceration of the intestinal wall with the defeat of the submucosal layer, and in severe form of the disease in the process of destruction can be involved and muscle tissue. Likely the formation of the so-called pseudopolyps, narrowing of the lumen of the intestine and other complications.
With the development of ulcerative colitis symptoms are subdivided into intestinal and extraintestinal, depending on the localization of the symptoms. Both types of symptoms depending on the stage of disease and General condition of the body may occur in severe form, and minimal or absent completely.
Among the intestinal symptoms of ulcerative colitis are:
- the frequency of liquid, pasty chair with a variety of inclusions (mucus, blood, pus);
- false and imperative urge to defecate;
- pain in the abdomen, mostly in left lower quadrant. However, depending on the localization of pathology may experience pain in the lower abdomen, accompanied by false urge to defecate pain. Pain with left-sided localization can wear cutting, cramping, waves, etc.;
- violation of appetite (usually decrease), loss of body weight, with a long acute stage, up to cachexia;
- violations of water-electrolyte balance of varying severity;
- the increase in body temperature from subfebrile to febrile indicators (from 37 to 39°C);
- General malaise, weakness, pain in the joints.
To extraintestinal manifestation with high prevalence include skin to the subcutaneous tissue inflammation (gangrenous pyoderma, nodulary Eritrea), lesions of the mucous membranes of the mouth (aphthous stomatitis and other) manifestations of inflammation in joint tissues (arthralgia, ankylosing spondylitis), eyes are also likely to develop uveitis, episcleritis, primary sclerosing cholangitis, and pathologies of the cardiovascular system, kidneys, liver, biliary tract, etc. in the presence of these diseases, especially in combination with intestinal symptoms to identify the etiology should undergo a diagnostic study of the gastrointestinal tract to confirm or exclude ulcerative colitis.
Types of ulcerative colitis: classification of diseases
Ulcerative colitis vary in types depending on localization of the inflammatory process, the disease and its severity.
The classification of the types of ulcerative colitis for localization of inflammation:
- when inflammation of the rectal mucosa diagnosed with proctitis;
- in case of combined lesions of the mucous membranes of the sigmoid and rectum ulcerative talking about proctosigmoiditis;
- destruction of a significant part of the intestinal mucous membrane make the diagnosis of total ulcerative colitis, the most severe form of the disease;
- frequent localization of the inflammatory process in the left part in a separate specified diagnosis as left-sided ulcerative colitis with inflammation in the intestine, located above the rectum and restricted to the splenic flexure of the colon;
- rest of the localization are combined in the diagnosis of regional “ulcerative colitis” with the specification of the lesion.
Depending on the dynamics of the disease there are forms of it:
- recurrent form of ulcerative colitis.
The clinical picture and severity of symptoms allow to classify the disease on the severity of the leak:
- Ulcerative colitis in mild form is characterised by pasty stools with a frequency of no more than 5 times in 24 hours, satisfactory General condition, a slight amount of impurities in the stool (blood, mucus, pus), absence of other marked symptoms, including violations of water-electrolyte balance and the resulting tachycardia and other complications. The laboratory investigations hemoglobin level is usually normal, fever is not registered;
- medium gravity form is accompanied by pain in the abdomen, palpitations (up to 8 times) liquid stool with the admixtures, presence of subfebrile body temperature, symptoms of anemia, tachycardia;
- in severe marked diarrhea, liquid stool, more than 8 times a day, a significant amount of impurities in the stool, febrile body temperature (above 38°C), anemia (hemoglobin level of no more than 90 g/l), severe tachycardia, General condition is unsatisfactory up to the heavy. Prolonged internal bleeding can not only be accompanied by anemia, hypoproteinemia, avitaminosis, but also lead to hemorrhagic shock, dangerous, fatal.
The diagnostic criteria of the disease
Definite diagnostic criteria of ulcerative colitis has not been developed due to the complex manifestations of the disease and the similarity of symptoms for a variety of other pathologies. Diagnosis requires differentiation from helminthic invasions, acute intestinal infections (dysentery), protozoan infestation (amebiasis), Crohn’s disease, tumor formations in the cavity of the colon.
In General, the clinical picture and the study can accurately determine the presence of ulcerative colitis with the following diagnostic methods:
- medical history through a review of medical records and patient interviews. Diagnostic importance of complaints and information about the presence of close relatives with bowel pathologies of inflammatory and noninflammatory nature, a list of the drugs taken, trips to countries with a high epidemiological level for certain diseases, a history of intestinal infections, food poisoning, Smoking, allergies and food intolerance in a patient;
- data detailed physical examination with assessment of heart rate, body temperature, blood pressure levels, indicators of body mass index, assessment of the peritoneal (abdominal) symptoms, detecting the presence or absence of signs of enlargement of the intestine, and inspection of the oral mucosa, skin, sclera and joints;
- inspection of the anus, digital examination and/or sigmoidoscopy of the rectum;
- plain radiography of the gastrointestinal tract;
- total colonoscopy with the inclusion of ileoscopy in the study;
- biopsy of the mucous membranes of the colon or other departments in local, regional inflammation;
- Ultrasound of the abdominal space, small pelvis, etc.;
- laboratory testing of stool, urine, blood.
To differentiate the diagnosis it is possible to assign different research methods, including magnetic resonance, computed tomography, transabdominal and transrectal ultrasound of the intestine, x-ray with injection of contrast, capsule endoscopy and others.
Complications of the disease
Ulcerative colitis is a disease that requires constant care and compliance with doctor’s appointments, in the appointment of drugs, and adherence to the rules of the diet. Violations of the mode of therapy, depending on the assignments and untreated forms of ulcerative colitis, in addition to the pathologies of the various organs and the development of inflammatory processes in contiguous with the intestinal mucosa tissues, and can cause serious complications that require urgent hospitalization because of the high level of fatal outcomes of diseases.
- megacolon toxic species, or extension of the intestine, most of the transverse colon with violation of the tone of the walls. The diameter of the dilation of 6 cm or more is characterized by severe intoxication, exhaustion, without extra treatment leads to death;
- acute inflammatory process in the mucosa every 30 patient leads to perforation, perforation of the colon and also contributes to total sepsis, and death;
- profuse intestinal bleeding leads to severe anemia, exhaustion;
- complications localized in the perianal region fissures, fistulous changes, abscess, etc.;
- according to research, with complete lesions of the colon up to the hepatic flexure patients with ulcerative colitis more than 10 years in history have the highest risk of developing bowel cancer.
To extraintestinal complications include pronounced pathology and dysfunction of the vascular system, blood vessels (thrombophlebitis, thrombosis), kidneys, liver, etc. Long-lasting inflammatory process of the intestine has a significant impact on the entire body and without proper treatment becomes a cause of disability and death of the patient.
Methods of treatment of ulcerative colitis of the bowel: treatment and prevention of exacerbations
The choice of therapy in ulcerative colitis is based on the localization of the inflammatory process and the degree of coverage, severity of disease, extent of disease, presence of extraintestinal manifestations and complications, and their risk, and on evaluating the effectiveness of previously conducted courses of treatment.
Easy stage ulcerative colitis and moderate course of the disease of remission do not require hospitalization, and therapy can be carried out independently at home. Severe forms of the disease require stay in hospital for examination, relief of the acute stages of treatment.
Ulcerative colitis: diet patients
Regardless of the stage of the disease, severity of symptoms and the presence of all exacerbations is strongly recommended to adhere to the principles of gentle nutrition and diet with the following restrictions in the diet:
- all products containing coarse fiber, can irritate the inflamed intestinal mucosa. These include flour, fruits, vegetables, fiber-rich, grains, preserving the shell, legumes, nuts, etc.;
- any dish made using hot spices, pickles, high in salt, vinegar, etc.
In drawing up the diet of patients with ulcerative colitis are recommended to focus on the following groups of products and methods for their treatment:
- the basis of the diet consists of lean meats, poultry, fish, egg whites, cottage cheese in the absence of contraindications to the products that are associated with a high incidence of hypoproteinemia in this disease (lack of protein);
- all food that requires processing must be boiled or steamed;
- it is strongly recommended to grind the food before eating to almost homogeneous state.
Conservative treatment of nonspecific ulcerous colitis
Conservative treatment of ulcerative colitis based on the principles of suppression of the inflammatory process of nonsteroidal anti-inflammatory drugs, hormonal drugs (corticosteroids) and immune suppression autoreactive body’s immunosuppressants. These groups of drugs are used sequentially, with a good therapeutic response to anti-inflammatory drugs additional medication to course of treatment not to connect.
Main groups of medications and their purpose:
- 5-acetylsalicylic acid (acetylsalicylic acid of prolonged action with a long period of release of the active substance, which allows the effects on the mucous membrane of the intestine at the desired location of the gut. Such drugs include the Pentas, Mefalsim, Salofalk, Sulfalen, etc. the Use of conventional acetylsalicylic acid (Aspirin) is not recommended because of possible increase in symptoms;
- hormones-corticosteroids. Apply short (3-4 months) courses to achieve remission and reduce the severity of the disease. Corticosteroid drugs equally affect inflammation throughout the body, affecting the mechanisms of tissue reaction. However, prolonged use can cause multiple side effects. The most common include night sweats, increased body hair skin, including the facial region, sleep disorders (insomnia), irritability, hyperactive state, a decrease in General immunity with increased susceptibility to the effects of pathogenic microorganisms. Prolonged therapy may develop diabetes type II diabetes, hypertensive response (increase blood pressure), cataracts, osteoporosis and susceptibility to injury because of the violation of calcium absorption. In the treatment in children may slow growth of the body. The objective of this course of corticosteroids is warranted in persistent severe ulcerative colitis not responding to other types of treatment;
- drugs that suppress the immune system response (immunosuppressants) affect the severity of the inflammatory process by reducing the autoimmune aggression of the organism. The main effect is suppression of the immune protection – leads to increased susceptibility to infections, resulting in the drugs prescribed short courses and under the careful supervision of a physician. During therapy and for 2 months after it was recommended to refrain from contact with virus and bacteria carriers, to avoid crowded places during the season of increased epidemiological risk.
Ulcerative colitis (proctitis, proktoshigmoidit, colitis and other varieties) may require additional methods of conservative therapy in severe, symptoms (elevated body temperature, severe pain, severe diarrhea, etc.).
In such cases, the specialists can add to the course of therapy, the following groups of drugs:
- group of antibiotics. When unfolded the inflammatory process, accompanied by increased body temperature and growth of pathogenic bacterial flora select antibacterial drugs in accordance with the accounting data of the patient (age, General condition, allergic reactions or hypersensitive, etc.). Use of intestinal antibiotics and antibacterial drugs with low absorption and systemic medications depending on the severity of the condition;
- antidiarrheal remedies for ulcerative colitis even in the severe stage of the disease with severe diarrhea apply only on prescription. The combination of the inflammatory process of the mucous membrane of the intestine and fixing the drugs can lead to acute toxic megacolon (enlargement of the colon, loss of tone of the intestine) that without emergency aid may lead to death. If necessary, use antidiarrheal means the drugs of first choice are Loperamide and Imodium;
- pain medications also selected the specialist. Receiving common non-steroidal anti-inflammatory drugs (ibuprofen, aspirin, etc.) can worsen the disease because of the increased risk of side effects from the gastrointestinal tract;
- to replenish iron deficiency and decrease the severity of iron deficiency anemia, often accompanied by the development of ulcerative colitis because of blood loss, prescribers iron as mono and multivitamin complex;
- to maintain electrolyte balance can receive rehydration solutions, and also preparations of potassium, magnesium, etc.
With the development related to ulcerative colitis diseases medication and supportive therapy is selected based on the primary diagnosis and the effects of drugs on the affected intestinal wall. Therapy possible recommended to the period of remission.
Surgical methods for the treatment of ulcerative colitis
Ulcerative colitis requires prompt treatment in the following cases:
- acute, transient form of the disease lack of therapeutic response to conservative therapy for 14-28 days;
- in subacute, relapsing, progressive form of the patients with unsuccessful result from medical therapy within six months;
- in the chronic form of the disease with the change of exacerbations and remissions and irreversible changes in the mucous membranes of the large intestine;
- in severe, life-threatening complications, regardless of the stage of the disease.
Surgical treatment of ulcerative colitis may require emergency, urgent and planned surgery. Indications for emergency surgery are perforation of the intestine and peritonitis, and intestinal obstruction. If not diagnosed with acute intestinal obstruction, the operation may be transferred to the category of urgent or requires clarification, however, perforation of the bowel any level is an absolute indication for emergency intervention because the mortality when perforation is up to 40% of the total number of patients with this pathology.
Urgent surgical intervention is performed in the diagnosis profuse bleeding of the walls of the colon, abdominal abscesses, acute toxic dilatatie (megacolon, extension) of the colon.
Elective surgical treatments are assigned:
- for refractory (resistant) to medical treatment form of the disease, hormone-dependent form, etc.;
- if the duration of disease more than 10 years with average or high degree of dysplasia of the epithelium of the intestinal wall;
- at the beginning of a carcinogenic process, the degeneration of the tissue of the mucous membrane in tumor formation.
The total number of patients with ulcerative colitis undergoing surgical methods of treatment is about 10%, of which about a quarter of patients with bowel pancolitis.
Various methods of surgical treatment of ulcerative colitis conventionally divided into three main groups:
- the former include palliative intervention on the autonomic nervous system. This type of surgical treatment is recognized as ineffective with short-term effect and is not recommended currently, when choosing a method of therapy of ulcerative colitis. For urgent and emergency operations, this practice is not applicable;
- ileostomy, colostomy and similar methods of operative surgery. Conducted on the section above the place of registration of the destructive process with the aim of eliminating from the digestive process of the affected area of the intestine. This type of palliative intervention in most cases is a pre-support phase before the next method of surgical therapy. However, in some patients, such operations are followed combined with conservative treatment may lead to prolonged remission of the disease;
- radical surgical intervention is the removal of a section or the entire colon affected by inflammatory changes.
The option of appendicostomy used earlier, today is not recommended in surgical practice for the treatment of ulcerative colitis and other inflammatory and destructive pathologies of the bowel (Crohn’s disease, etc.).
Options segmental and Subtotal resection (partial removal) colon currently recognized as not very effective methods because of the high risk of disease recurrence in the remaining section.
A best practice is coloproctectomy with formation of end ileostomy. This type of surgical treatment has the lowest number of postoperative complications and need for repeat surgery. If coloproctectomy formed ileostomy is easy to care for and access.
However, the patients because of the arrangement ileostomy prefer colostomies operation where the formed holes out of dense fecal masses, not the liquid contents of the small intestine, as in ileostoma. However, the effectiveness of ileostomies methods is much higher and allows to talk about a possible recovery of the patient without radical intervention. Any type of hole after recovery the patient can be eliminated.
Methods of washing the colon antiseptic, antibacterial solutions via formed in the operation hole rarely lead to the desired effect. It is worth remembering that after these types of palliative interventions should critically assess the condition of separating long-term remission and complete recovery of the mucosa. In the event of incorrect assessment may require re-operation or a similar radical removal of the colon.
Radical surgery is indicated for patients with a severe form of the disease, often is recommended in two stages. On the ground carried out an operation overlay ileostomies holes, which allows to improve the General condition of the patient at shutdown of the digestive process of the colon. After a recovery period for the stabilization of appetite, sleep, growth, body mass, improved performance of protein levels of hemoglobin and reduction of the deficiency, and also when restoring the mental equilibrium carry out a radical surgical treatment with removal of the colon. On average, the restoration of physical and mental resilience, reactivity and resistance of the organism may require several months to half a year. It is important not to stop at this stage, if earlier indications for radical treatment.
Since the exact causes of the disease are not identified, the methods of prevention include a healthy lifestyle, balanced diet, prompt treatment of intestinal infections, correction of food allergic reactions etc. are very important preventive preventive measures in people with inflammatory bowel disease family history.