Ulcerative Colitis

Definition

Ulcerative colitis is a form of inflammatory bowel disease (IBD). It causes swelling, ulcerations, and loss of function of the large intestine.

Description

The primary problem in IBD is inflammation, as the name suggests. Inflammation is a process that often occurs in order to fight off foreign invaders in the body, including viruses, bacteria, and fungi. In response to such organisms, the body's immune system begins to produce a variety of cells and chemicals intended to stop the invasion. These immune cells and chemicals, however, also have direct effects on the body's tissues, resulting in heat, redness, swelling, and loss of function. No one knows what starts the cycle of inflammation in IBD, but the result is a swollen, boggy intestine.

In ulcerative colitis, the inflammation affects the lining of the rectum and large intestine. It is thought that the inflammation begins in the last segment of the large intestine, which empties into the rectum (sigmoid colon). This inflammation may spread through the entire large intestine, but only rarely affects the very last section of the small intestine (ileum). The rest of the small intestine remains normal.

Ulcerative colitis differs from Crohn's disease, which is a form of IBD that affects both the small and large intestines. The inflammation of ulcerative colitis occurs only in the lining of the intestine (unlike Crohn's disease which affects all of the layers of the intestinal wall). As the inflammation continues, the tissue of the intestine begins to slough off, leaving pits (ulcerations) which often become infected.

Like Crohn's disease, ulcerative colitis occurs in all age groups, with the most common age of diagnosis being 15-35 years of age. Men and women are affected equally. Whites are more frequently affected than other racial groups, and people of Jewish origin have 3-6 times greater likelihood of suffering from any IBD. IBD is familial; an IBD patient has a 20% chance of having other relatives who are fellow sufferers.

Causes and symptoms

No specific cause of ulcerative colitis has been identified. Although no organism (virus, bacteria, or fungi) has been found to set off the cycle of inflammation that occurs in ulcerative colitis, some researchers continue to suspect that some such organism is responsible for initiating the cycle. Other researchers are concentrating on identifying some change in the cells of the colon that would make the body's immune system accidentally begin treating those cells as foreign invaders. Other evidence for such a disorder of the immune system includes the high number of other immune disorders that tend to accompany ulcerative colitis.

The first symptoms of ulcerative colitis are abdominal cramping and pain, a sensation of urgent need to have a bowel movement (defecate), and blood and pus in the stools. Some patients experience diarrhea, fever, and weight loss. If the diarrhea continues, signs of severe fluid loss (dehydration ) begin to appear, including low blood pressure, fast heart rate, and dizziness.

Severe complications of ulcerative colitis include perforation of the intestine (in which the wall of the intestine develops a hole), toxic dilation of the colon (in which the colon become quite large in diameter), and the development of colon cancer.

Intestinal perforation occurs when long-standing inflammation and ulceration of the intestine weakens the wall to such a degree that a hole occurs. This is a life-threatening complication, because the contents of the intestine (which under normal conditions contains a large number of bacteria) spill into the abdomen. The presence of bacteria in the abdomen can result in a massive infection called peritonitis.

Toxic dilation of the colon is thought to occur because the intestinal inflammation interferes with the normal function of the muscles of the intestine. This allows the intestine to become lax, and its diameter begins to increase. The enlarged diameter thins the walls further, increasing the risk of perforation and peritonitis. When the diameter of the intestine is quite large, and infection is present, the condition is referred to as "toxic megacolon."

Patients with ulcerative colitis have a significant risk of developing colon cancer. This risk seems to begin around 10 years after diagnosis of ulcerative colitis. The risk becomes statistically greater every year:

• At 10 years, the risk of cancer is about 0.5-1%.
• At 15 years, the risk of cancer is about 12%.
• At 20 years, the risk of cancer is about 23%.
• At 24 years, the risk of cancer is about 42%.

The overall risk of developing cancer seems to be greatest for those patients with the largest extent of intestine involved in ulcerative colitis.

Patients with ulcerative colitis also have a high chance of experiencing other disorders, including inflammation of the joints (arthritis), inflammation of the vertebrae (spondylitis), ulcers in the mouth and on the skin, the development of painful, red bumps on the skin, inflammation of several areas of the eye, and various disorders of the liver and gallbladder.

Diagnosis

Diagnosis is first suspected based on the symptoms that a patient is experiencing. Examination of the stool will usually reveal the presence of blood and pus (white blood cells). Blood tests may show an increase in the number of white blood cells, which is an indication of inflammation occurring somewhere in the body. The blood test may also reveal anemia, particularly when a great deal of blood has been lost in the stool.

The most important method of diagnosis is endoscopy, during which a doctor passes a flexible tube with a tiny, fiberoptic camera device through the rectum and into the colon. The doctor can then examine the lining of the intestine for signs of inflammation and ulceration that might indicate ulcerative colitis. A tiny sample (biopsy) of the intestine will be removed through the endoscope, which will be examined under a microscope for evidence of ulcerative colitis. Because of the increased risk of cancer in patients with ulcerative colitis, endoscopic exam will need to be repeated frequently. Biopsies should be taken regularly, to closely monitor the intestine for the development of cancer or precancerous changes.

X-ray examination is helpful to determine the amount of intestine affected by the disease. However, x-ray examinations requiring the use of barium should be delayed until treatment has begun. Barium is a chalky solution that the patient drinks or is administered through the rectum and into the intestine (enema). The presence of barium in the intestine allows more detail to be seen on x-ray pictures. However, because of the risk of intestinal perforation in ulcerative colitis, most doctors begin treatment before stressing the wall of the intestine with the barium solution.

Treatment

Treatment for ulcerative colitis addresses the underlying inflammation, as well as the problems occurring due to continued diarrhea and blood loss.

Inflammation is treated with a drug called sulfasalazine. Sulfasalazine is made up of two parts. One part is related to the sulfa antibiotics; the other part is a form of the anti-inflammatory chemical salicylic acid (related to aspirin ). Sulfasalazine is not well-absorbed from the intestine, so it stays mostly within the intestine, where it is broken down into its components. It is believed to be primarily the salicylic acid component that is active in treating ulcerative colitis, by fighting inflammation. For patients who do not respond to sulfasalazine, steroid medications (such as prednisone) are the next choice.

Depending on the degree of blood loss, a patient with ulcerative colitis may require blood transfusions and fluid replacement through a needle in the vein (intravenous or IV). Medications that can slow diarrhea must be used with great care, because they may actually cause the development of toxic megacolon.

A patient with toxic megacolon requires close monitoring and care in the hospital. He or she will usually be given steroid medications through an IV, and may be put on antibiotics. If these measures do not improve the situation, the patient will have to undergo surgery to remove the colon. This is done because the risk of death after perforation of toxic megacolon is greater than 50%.

Similarly, a patient with proven cancer of the colon, or even a patient who shows certain signs thought to indicate a precancerous condition, will need his or her colon removed. Removal of the colon is called a colectomy. When a colectomy is performed, a piece of the small intestine (ileum) is pulled through an opening in the abdomen. This bit of intestine is fashioned surgically to allow a special bag to be placed over it, in order to catch the body's waste (feces) which no longer can be passed through the large intestine and out of the anus. This opening, which will remain for the duration of the patient's life, is called an ileostomy.

Prognosis

Remission refers to a disease becoming inactive for a period of time. The rate of remission of ulcerative colitis (after a first attack) is nearly 90%. Those individuals whose colitis is confined primarily to the left side of the large intestine have the best prognosis. Those individuals with extensive colitis, involving most or all of the large intestine, have a much poorer prognosis. Recent studies show that about 10% of these patients will have died by 10 years after diagnosis. About 20-25% of all ulcerative colitis patients will require colectomy. Unlike the case for patients with Crohn's disease, however, such radical surgery results in a cure of the disease.

Resources

ORGANIZATIONS

Crohn's and Colitis Foundation of America, Inc. 386 Park Avenue South, 17th Floor, New York, NY 10016-8804. (800) 932-2423.

KEY TERMS

Endoscopy— A type of medical examination in which an instrument called an endoscope is passed into an area of the body (the bladder or intestine, for example). The endoscope usually has a fiberoptic camera, which allows a greatly magnified image to be projected onto a video screen, to be viewed by the operator. Many endoscopes also allow the operator to retrieve a small sample (biopsy) of the area being examined, in order to more closely view the tissue under a microscope.

Immune system— The system of the body that is responsible for producing various cells and chemicals that fight off infection by viruses, bacteria, fungi, and other foreign invaders. In autoimmune disease, these cells and chemicals are turned against the body itself.

Inflammation— The result of the body's attempts to fight off and wall off an area that is infected. Inflammation results in the classic signs of redness, heat, swelling, and loss of function.

ULCERATIVE COLITIS

DEFINITION

Ulcerative colitis (pronounced UHL-suh-RATE-ihv kuh-LY-tiss) is an inflammation of the large intestine that causes swelling, ulcerations (open sores), and loss of function in the large intestine.

DESCRIPTION

Ulcerative colitis is a form of inflammatory bowel disease (IBD). The term inflammatory bowel disease refers to a large group of disorders that affect the gastrointestinal (pronounced gas-troh-ihn-TESS-tuh-nuhl) system. Also known as the digestive system, the gastrointestinal (GI) system includes the stomach, small intestine, and large intestine.

Inflammation is a process that occurs when the body's immune system begins to fight off foreign invaders, such as viruses, bacteria, and fungi. The immune system is a network of organs, tissues, cells, and chemicals designed to kill invading organisms. Some of the chemicals produced by the immune system irritate the body's own tissues. They cause heat, redness, swelling, and loss of function. These changes are all characteristic of inflamed tissue.

In ulcerative colitis, inflammation occurs in the lining of the large intestine and the rectum. In rare cases, it may extend into the small intestine. In most cases, however, the small intestine remains normal.

Ulcerative colitis is one of two common forms of IBD. The other form is called Crohn's disease (see Crohn's disease entry). The major difference between the two diseases is that Crohn's disease may occur in both large and small intestines while ulcerative colitis is usually found only in the large intestine and rectum. Another difference is the damage done to tissues. Ulcerative colitis occurs only in the lining of the intestine while the damage caused by Crohn's disease can extend to all layers of the intestinal wall.

The inflammation associated with ulcerative colitis can eventually cause portions of the intestinal lining to peel off, exposing open pits, or ulcerations, which can easily become infected.

Ulcerative colitis occurs in all age groups and affects men and women equally. The most common age of diagnosis is between fifteen and thirty-five years of age.

CAUSES

No one knows for sure what causes inflammatory bowel disease. A number of theories have been developed to explain the condition. Some researchers believe that the disorder is caused by some organism, such as a bacterium or virus. No such organism has been found, however. Other researchers think the body's immune system becomes confused and begins to attack the body's own cells as though they were foreign invaders that needed to be killed.

Ulcerative Colitis: Words to Know

Colonoscopy:

A procedure in which a long, thin tube is inserted through a patient's rectum into the colon to permit examination of the inner walls of the colon.

Crohn's disease:

A form of inflammatory bowel disease that affects the large and small intestine.

Inflammation:

A series of events that may result from the immune system's attempt to fight off foreign invaders. Inflammation involves heat, redness, swelling, and loss of function in the part of the body that is affected.

Inflammatory bowel disease:

A group of disorders that affect the gastrointestinal (digestive) system.

Intestinal perforation:

A hole in the lining of the intestine, which allows partially digested foods to leak into the abdominal cavity.

Sulfasalazine:

A drug commonly used to treat inflammatory bowel diseases, consisting of an aspirin-like part to reduce inflammation and an antibiotic part to fight bacteria.

Toxic dilation of the colon:

An expansion of the colon that may be caused by inflammation due to ulcerative colitis.

Ulcer:

An open sore.

SYMPTOMS

The first symptoms of ulcerative colitis are abdominal pain and cramping. The patient is likely to feel an urgent need to have a bowel movement. Blood and pus may appear in the stool. Some patients experience diarrhea, fever, and weight loss. If the diarrhea continues, signs of dehydration may appear. Dehydration occurs when the body loses water too rapidly. It results in low blood pressure, fast heart rate, and dizziness.

There are three serious complications of ulcerative colitis: intestinal perforation, toxic dilation of the colon, and colon cancer (see colon cancer entry).

Intestinal perforation is a life-threatening condition. It develops when a hole forms in the intestinal wall, which is caused by long-standing inflammation of the intestinal lining. First, an ulcer forms. Then the ulcer expands and breaks through the intestinal wall. The danger arises because contents of the intestine may spill out into the abdomen. These contents contain bacteria that can cause massive infection. The infection can quickly become so severe that it causes death. An infection of this kind is called peritonitis (pronounced per-i-tuh-NIE-tiss).

Toxic dilation of the colon refers to a significant increase in the size of the intestine. Inflammation is thought to cause intestinal muscles to relax. As they relax, the intestine gets larger and larger. Stretching of the intestinal walls

causes them to become thinner. At some point, the intestinal lining may break. When this happens, peritonitis may result.

Colon cancer occurs when cells in the intestinal lining begin to grow uncontrollably. The cells may form tumors that can interfere with normal body functions or spread to other parts of the body. The risk of colon cancer increases in the years after ulcerative colitis is diagnosed. Ten years after diagnosis, the risk for colon cancer is less than 1 percent. After fifteen years, however, the risk increases to about 10 percent. After twenty and twenty-five years, the risk increases to about 23 percent and 42 percent, respectively.

DIAGNOSIS

A doctor may suspect a patient has ulcerative colitis if the patient has the symptoms described. Examination of the stool may reveal the presence of blood and pus. Pus consists largely of white blood cells. The presence of white blood cells suggests an infection somewhere in the body.

The usual method used to confirm a diagnosis of ulcerative colitis is colonoscopy (pronounced KO-lon-OSS-kuh-pee). Colonoscopy is a procedure that involves inserting a long, thin tube into a patient's rectum. The tube is then pushed upward into the colon. The tube may have a light, a camera, and a small knife attached at the end. The light and camera allow the doctor to examine the walls of the large intestine. The knife makes it possible to remove a small sample of tissue, which can then be studied under a microscope. The appearance of white blood cells in the tissue may confirm the presence of ulcerative colitis.

TREATMENT

The first step in treating ulcerative colitis is to reduce inflammation. A drug known as sulfasalazine (pronounced SULL-fuh-SAL-uh-zeen) is used for this purpose. Sulfasalazine consists of two parts. One part is a form of salicylic acid, the major component of aspirin. The salicylic acid compound helps reduce inflammation. The second part of sulfasalazine is an antibiotic. The antibiotic kills any harmful bacteria that may be present in the intestine.

Complications caused by ulcerative colitis may require other treatments. For example, a patient with toxic dilation of the colon may require hospitalization. The patient may be given steroids and antibiotics intravenously (through a needle in the vein). Steroids are a powerful anti-inflammatory medication. In the most severe cases, surgery may be required to remove the colon.

Colon cancer is treated in much the same way as other forms of cancer: with surgery, radiation treatments, or chemotherapy.

Alternative Treatment

There are natural remedies that may help reduce inflammation associated with ulcerative colitis. Omega-3 fatty acids, which are found in fish oil and flaxseed, are available in pill form or as enemas.

PROGNOSIS

The prognosis for ulcerative colitis depends on how severe the first attack is. About 10 percent of all patients die if the first attack comes on suddenly and is quite severe. Prognosis is especially poor for patients over the age of sixty. Among these patients, a severe initial attack is fatal in more than 25 percent of cases.

Mild cases of the disorder can usually be treated quite successfully. However, the disease can reappear after it has been inactive for a period of time. Overall, about 20 to 25 percent of all patients eventually require removal of the colon. This procedure is very successful, however, and generally results in a complete cure of the disease.

PREVENTION

There are no known methods of preventing ulcerative colitis.

FOR MORE INFORMATION

Books

Long, James W. The Essential Guide to Chronic Illness. New York: Harper-Perennial, 1997.

Saibil, Fred. Crohn's Disease and Ulcerative Colitis. Buffalo, NY: Firefly Books, 1997.

Thompson, W. Grant. The Angry Gut: Coping With Colitis and Crohn's Disease. New York: Plenum Press, 1993.

Organizations

Crohn's & Colitis Foundation of America, Inc. 386 Park Avenue South, 17th Floor, New York, NY 10016–8804. (800) 932–2423.

ULCERATIVE COLITIS

Organic in its etiology, ulcerative colitis remains an enigmatic disease, although current understanding puts it in the group of autoimmune disorders, thus increasing its interest for those involved in psychosomatic medicine.

It involves continuous damage to the mucous lining of the colon but can also affect the rectal mucosa. The latter are eroded, sometimes abscessed, and can rupture, making this a serious condition. It progresses through a series of attacks of varying degrees of severity and can occasionally necessitate a colectomy with a colostomy.

Its main symptom, bleeding (the mucosa "weep" blood), the psychological profile often associated with it (depression, regression), and its evolution, which is variable and unpredictable but is often correlated with a psychoaffective trauma, have put this disease under the spotlight among psychoanalysts specializing in psychosomatic disorders.

The circumstances that trigger the onset of the disease or attacks have been identified by the majority of authors. These appear to be fortuitous during the early stages of investigation but may become more defined in the course of psychotherapy with the gradual emergence of latent content. Often, although not always, the following are found: experiences of object-loss, experiences of wounded narcissism with feelings of worthlessness, self-depreciation, and a sense of the impossibility of taking on new responsibilities. These experiences may result from new real-life situations (with a traumatic valence) or situations that are fantasized and retroactively reconstructed. In "Étude psychosomatique de dix-huit cas de recto-colite hémorragique" (Psychoanalytic study of eighteen cases of ulcerative colitis; 1958), Michel de M'Uzan and his collaborators wrote: "The common element in these factors is their ability to provoke in the patient a loss of self-esteem, along with the belief that he is unloved or incapable of overcoming a difficulty."

Thus, to a greater degree than with other organic pathologies, these causes point toward a narcissistic destabilization along with a certain degree of melancholia. Inspired by the bleeding mucosa, certain authors have speculated a "melancholia of the organ"—a theoretical fantasy on the part of the analyst or a structural reality?

The fact remains that a somewhat mechanistic approach would posit the existence of: an affective block or immaturity; strong ambivalence (the depressive pole of which is deeply repressed) toward persons close to the patient as well as toward the therapist; and a depressive tendency different from the reactive depression of the disorder. This depression, sometimes carried along on the tide of a massive regression, has even led to indications for treatment with antidepressants (see Guy Besançon's article "Le corps présent, réflexions sur une série de recto-colites hémorragiques" [The body as presence; reflections on a series of cases of ulcerative colitis]; 1977).

This correlation between ulcerative colitis and a narcissistic axis of depression remains a pivotal element in attempts at a psychoanalytic interpretation. Some authors have thus invoked the idea of a somatic dramatization of melancholia and have sought its source in the mother-child relationship, thereby suggesting that this disorder may be part of a psychogenetic given. Kleinians see this disease in terms of incorporation of a bad maternal imago: According to Melitta Sperling (1946), "As the object is incorporated sadistically, it is a hostile inner danger and has to be eliminated immediately. The faeces and blood (in severe attacks, only blood and mucus) represent the devaluated and dangerous objects. . . . The severe form of ulcerative colitis shows a great resemblance in behavior, personality structure and dynamics to melancholia, and seems to represent the somatic dramatization of the same conflict, with relatively little mental pain, that in depression is expressed psychologically" (p. 326).

There is no consensus on this approach. However, it seems probable that these patients have been unable to constitute and develop a mental space wherein they could find themselves by finding objects other than the primary object to which they felt and feel extremely bound, in an inexorable and often conflicted way.

See also: Psychosomatics.

Bibliography

Besançon, Guy. (1977). Le corps présent, réflexions sur une série de recto-colites hémorragiques. Revue française de psychosomatique, 19 (2).

Caïn, Jacques, R. Sarles, and F. Berretti. (1984). Aspects psychosomatiques de la recto-colite hemorrhagique. Encéphale, 44.

Fine, Alain. (1984). Quelques réflexions et interrogations autour de la recto-colite hémorragique. In M. Fain and C. Dejours (Eds.), Corps malade et Corps érotique (pp. 59-76). Paris: Masson.

Sperling, Melitta. (1946). Psychoanalytic study of ulcerative colitis in children. Psychoanalytic Quarterly, 15 (3), 302-329.

M'Uzan, Michel de, S. Bonfils, and A. Lambling.Étude psychosomatique de dix-huit cas de recto-colite hémorragique. Semaine des Hôpitaux de Paris, 34 (15), 1-7.

Further Reading

Cushing, M. (1953). Psychoanalytic treatment of man with ulcerative colitis. Journal of the American Psychoanalytic Association, 1, 510-518.

Lefebvre, P. (1988). The psychoanalysis of a patient with ulcerative colitis. International Journal of Psychoanalysis, 69, 43-54.

Sperling, Melitta. (1957). The psychoanalytic treatment of ulcerative colitis. International Journal of Psychoanalysis, 38, 341-349.

ulcerative colitis (ul-ser-ay-tiv) n. see colitis.

ulcerative colitis See colitis.