Brief overview
- Symptoms: Bloody-mucous diarrhea, crampy lower abdominal pain, colicky pain in left lower abdomen, flatulence, loss of performance.
- Treatment: medications to relieve symptoms (5-ASA such as mesalazine, cortisone, etc.), surgery if necessary.
- Causes: Unknown; probably a genetic predisposition in combination with various risk factors.
- Risk factors: Probably environmental factors (western lifestyle), possibly also psychological factors
- Diagnosis: Physical examination, blood and stool tests, colonoscopy, ultrasound, possibly further imaging procedures.
- Prognosis: The symptoms can usually be controlled by therapy; cure is currently only possible if the colon and rectum are removed.
- Course of the disease: Usually relapses with individually very different duration of the relapses and the symptoms.
- Prognosis: The more extensive the inflammation, the more difficult the treatment and prognosis.
What is ulcerative colitis?
Normally, the inflammation in ulcerative colitis begins in the rectum, the last section of the large intestine. If it is limited to this section of the intestine, doctors also refer to it as proctitis. About 50 percent of those affected suffer from this relatively mild form of the disease.
Under certain circumstances, however, the disease spreads to other sections of the colon. If it also extends to the left side of the colon, the patient has left-sided colitis. This is the case in about a quarter of sufferers. In the remaining 25 percent of sufferers, the inflammation extends even further up the colon. In so-called pancolitis, the entire colon is affected. The severity of the symptoms increases with the extent of the colitis.
Ulcerative colitis or Crohn’s disease?
In addition, in ulcerative colitis, a patchy spread of inflammation develops that is usually confined to the uppermost layer of the intestinal wall, the intestinal mucosa. In contrast, in Crohn’s disease, there are patchy foci of inflammation involving all layers of the intestinal wall.
Ulcerative colitis usually affects young people between the ages of 16 and 35. In principle, however, it is possible to contract the disease at any age. Even small children sometimes suffer from the chronic inflammation of the colon.
What are the symptoms of ulcerative colitis?
Ulcerative colitis often begins insidiously, so that those affected often only notice it late. However, an acute course with sudden onset of severe symptoms is also possible. The further the inflammation spreads in the intestine, the more severe the symptoms become. In an acute episode of ulcerative colitis, symptoms are sometimes so severe that sufferers have to be treated in hospital.
- bloody-mucous diarrhea
- painful urge to defecate (tenesmus)
- frequent, often also nocturnal urge to defecate
- cramping or colicky lower abdominal pain, especially before bowel movements
- flatulence
- loss of appetite, weight loss, fatigue and loss of performance
- anemia (due to bloody diarrhea)
- mild to high fever
- in children, growth disorders
In a mild course, the bloody stools and more frequent trips to the toilet (up to five times a day) are the main symptoms; otherwise, sufferers are usually fine. In rarer cases, affected individuals In a more severe course of the disease, the number of toilet visits increases further, and fever, abdominal cramps, and other symptoms are added. Sufferers often feel very ill and powerless.
An episode of ulcerative colitis rarely passes without diarrhea. Some people with ulcerative colitis report constipation instead. However, these are not among the typical symptoms of the disease.
In some cases, symptoms also occur outside the intestine. However, this happens less frequently in ulcerative colitis than in Crohn’s disease. The most common symptoms are inflammation of the joints (arthritis), the spine or the sacrum. Sometimes inflammation develops in the area of the eyes or bone loss (osteoporosis) occurs. Inflammation of the joints often causes joint pain in ulcerative colitis, and inflammation of the spine may cause back pain in ulcerative colitis.
The skin may develop small ulcers, suppurations, or red-purple nodules (especially on the front of the lower legs). Other skin rashes, however, are not typical symptoms of ulcerative colitis. In some cases, there is inflammation of the bile ducts inside and outside the liver (primary sclerosing cholangitis).
How can ulcerative colitis be treated?
In particular, various drugs are available for the treatment of ulcerative colitis. They are used both in an acute attack (attack therapy) and for maintenance therapy after an acute attack to prolong the disease-free period.
Surgery is considered in severe or complicated cases of ulcerative colitis or in complications such as bleeding, for example to stop the bleeding.
Relapse therapy for ulcerative colitis
In ulcerative colitis, medications work best directly at the site of inflammation in the intestines, such as suppositories or enemas. This targeted local application of the medication means that side effects are less likely to occur than with medications that act throughout the body (systemically), such as tablets.
The following drugs are available for relapse therapy:
- Corticoids (“cortisone”) also have an anti-inflammatory effect (e.g. prednisolone). In mild cases, they are applied locally (e.g. as suppositories or enemas); in more severe cases, they are administered in tablet form.
- Immunosuppressants are active substances that dampen the activity of the immune system (e.g. azathioprine, ciclosporin A, tacrolimus). They are used in severe or complicated ulcerative colitis, for example when cortisone is not effective or is intolerable.
- Therapeutic antibodies, such as adalimumab, infliximab, vedolizumab or ustekinumab, also inhibit the immune system and thus the inflammatory response in different ways. They are also considered in more severe cases of ulcerative colitis when cortisone is not effective or is intolerable.
Which of these drugs the physician uses for colitis ulcerosa therapy depends on several factors. In addition to the extent of the symptoms, the strength and extent of the inflammation in the intestine play a role (step therapy). In addition, when planning the therapy, the physician takes into account how well the affected person has responded to the medication so far and how great his or her risk for colorectal cancer is. In the event of a severe acute episode, treatment in hospital is advisable.
Doctors speak of severe ulcerative colitis when the following criteria are met: six or more episodes of severe bloody diarrhea per day, fever, palpitations (tachycardia), anemia, and a decreased erythrocyte sedimentation rate.
Maintenance therapy for ulcerative colitis
If a relapse occurs despite the daily 5-ASA application, the physician expands the future maintenance therapy (therapy escalation): For example, the physician increases the 5-ASA dosage or prescribes immunosuppressants or TNF antibodies instead.
Cortisone, on the other hand, is not suitable for maintenance therapy in ulcerative colitis: it is not effective for this purpose and, if used for a long time, can cause severe side effects (osteoporosis, cataracts, etc.).
For sufferers who cannot tolerate 5-ASA, a probiotic containing the live bacterium Escherichia coli Nissle is available. These are non-disease-causing intestinal bacteria that should prolong symptom-free intervals.
Ulcerative colitis: surgery
During the procedure, the surgeon removes the entire large intestine with the rectum (proctocolectomy). He forms a sack from part of the small intestine, which he connects to the anus. Once everything has healed, this sac acts as the new rectum. Until then, the surgeon temporarily creates an artificial anus.
After surgery, sufferers no longer need colitis ulcerosa medications. However, bowel habits may change: Some sufferers have more frequent bowel movements after surgery than before. In addition, the stool may be thinner and smearier.
Ulcerative colitis: What you can do yourself
See your doctor at the first sign of blood in the stool. If he or she initiates the relapse therapy early, it is possible to shorten and mitigate the relapse. During a severe acute attack, you should stay in bed.
Join a self-help group for people with ulcerative colitis (or chronic inflammatory bowel disease in general). Exchanging ideas with others affected helps many people cope with the disease.
To improve quality of life and well-being and reduce stress, relaxation techniques, yoga, meditation or regular exercise (such as jogging) are recommended, for example.
At best, the measures mentioned complement conventional medical treatment, but they do not replace it. Talk to your doctor about how you can best support the therapy yourself.
Nutrition in ulcerative colitis
In general, there is no diet plan or special guidelines for the diet in ulcerative colitis. Those affected should pay attention to a balanced, varied diet.
In such cases, an individually adapted diet is very useful, such as many calcium-rich foods for weak bones. Those affected should ask their doctor or a nutritionist for advice.
In the case of severe deficiency symptoms, those affected should additionally take preparations containing the missing vitamins or minerals in consultation with the attending physician.
Some people with ulcerative colitis generally or during an episode of the disease tolerate certain food components only poorly. It is advisable to take this into account in the diet. For example, it makes sense to avoid or limit the consumption of milk and dairy products such as cheese or yogurt if people are intolerant to lactose (lactose intolerance).
Whether alcohol promotes an attack in ulcerative colitis has not yet been clearly researched. However, it is generally advisable to consume alcohol only in small quantities or to avoid it altogether.
Ulcerative colitis cannot be cured by diet, but it may be possible to alleviate symptoms.
Causes and risk factors
Causes and risk factors for ulcerative colitis are poorly understood, as are the triggers of an ulcerative colitis flare-up.
Presumably, among other things, a genetic predisposition plays an important role. This is because ulcerative colitis sometimes occurs more frequently in families. For example, siblings of affected individuals have a ten- to 50-fold higher risk of also developing ulcerative colitis compared to the normal population. However, the genetic predisposition alone probably does not lead to the onset of the intestinal disease; ulcerative colitis is therefore not hereditary in the classical sense.
Is ulcerative colitis an autoimmune disease?
Active smoking does not appear to increase the risk of ulcerative colitis or influence its severity, according to current knowledge. Ex-smokers, on the other hand, have an approximately 70 percent higher risk of disease.
Psychological stress may exacerbate or even trigger an episode of ulcerative colitis in patients who already have the disease.
Examinations and diagnosis
The diagnosis of ulcerative colitis consists of several components. First, the physician will talk in detail with the affected person in order to obtain his or her medical history (anamnesis): Among other things, he or she will ask for a detailed description of the patient’s symptoms, any previous illnesses, and whether there are any known cases of ulcerative colitis in the family.
Other important information for the doctor is, for example, whether the patient smokes or has smoked, takes medication regularly or has an intolerance to certain foods.
Physical examination
Blood tests
The next important step is a blood test: Important are, for example, the inflammation values CRP (C-reactive protein) and blood sedimentation. The electrolytes sodium and potassium are also often altered, as a corresponding deficiency usually develops as a result of the frequent diarrhea.
Elevated levels of the liver enzymes gamma-GT and alkaline phosphatase (AP) in the blood indicate whether inflammation of the bile ducts inside and outside the liver (primary sclerosing cholangitis) may have developed – a complication of ulcerative colitis. In addition, blood values provide information about a possible anemia or iron deficiency.
Stool examination
Colonoscopy
A reliable method of detecting ulcerative colitis and determining its extent is a colonoscopy. In this procedure, the doctor inserts a thin, flexible, tube-shaped instrument (endoscope) into the intestine through the anus and advances it into the colon.
At the tip of the endoscope is a tiny camera and a light source. The doctor uses this to examine the intestine from the inside. In this way, mucosal changes and inflammations can be detected, as they occur in ulcerative colitis. If necessary, the doctor takes tissue samples directly through the endoscope to have them analyzed in the laboratory.
Once ulcerative colitis has been diagnosed, regular colonoscopies are performed for control purposes.
The entire small intestine can be viewed more closely from the inside with the aid of capsule endoscopy. The tiny endoscope, the size of a vitamin capsule, is swallowed and films the inside of the digestive tract on its way to the anus. It sends the images via the built-in transmitter to a data recorder that the patient carries with him or her.
Imaging procedures
Both for diagnosis and repeatedly during the further course of the disease, the physician examines the abdomen by ultrasound (sonography). In this way, he can detect inflamed sections of the intestine, for example. A severely dilated intestine (megacolon) as a dangerous complication can also be detected by ultrasound.
In certain cases, other imaging procedures are necessary. For example, if there is a narrowing in the colon (colon stenosis), the doctor will order a computer tomography or magnetic resonance imaging (MRI) and take a tissue sample from the abnormal area to rule out colon cancer.
Course of disease and prognosis
Like its onset, the course of ulcerative colitis is unpredictable. In more than 80 percent of patients, ulcerative colitis progresses in relapses: phases with more or less severe symptoms (acute relapses) alternate with phases without inflammation and symptoms. Physicians speak of a chronic-recurrent course. The duration of a relapse in ulcerative colitis varies from person to person and cannot be predicted.
In about ten percent of patients, the disease takes a chronic-continuous course: In this case, the symptoms do not completely subside after an episode.
In a few cases, ulcerative colitis takes a fulminant course: The disease begins quite suddenly with severe, bloody diarrhea, severe abdominal pain and high fever. Those affected quickly become dehydrated and may develop symptoms of shock. About three out of ten sufferers die in the course of the disease.
What is the prognosis for ulcerative colitis?
Depending on the spread of the inflammation, the prognosis for ulcerative colitis varies. Although ulcerative colitis cannot be cured with medication, the symptoms and the course of the disease can be kept under control. If ulcerative colitis is confined to the rectum and directly adjacent parts of the colon, this is usually sufficient for sufferers to lead a reasonably normal life with a normal life expectancy.
The more extensive the inflammation in the intestine, the more difficult the treatment and prognosis of ulcerative colitis often are. However, even with pancreatitis, more than 80 percent of those affected are still alive after 20 years. Currently, the disease can only be cured by removing the entire colon.
Complications of ulcerative colitis
There is also a risk that the massively enlarged intestine will burst (intestinal perforation). Intestinal contents (feces) then empty into the abdominal cavity – peritonitis develops. In such cases there is danger to life!
A further complication of ulcerative colitis is severe bleeding: The ulcers of the intestinal mucosa that form as a result of the inflammation sometimes rupture and bleed. In severe cases, the blood loss is so severe that the affected person faints.
Ulcerative colitis may cause growth retardation in children, which is further aggravated by inadequate nutrition.
Long-term therapy with mesalazine can reduce the risk of colon cancer by about 75 percent!
A possible consequence of the removal of the colon and rectum is so-called pouchitis: Doctors refer to the sac-like reservoir of the small intestine, which the surgeon forms into an artificial rectum during the operation, as a “pouch. This becomes inflamed in about half of those affected in the years following the operation. Signs of pouchitis include diarrhea, bleeding from the bowel, and fever. Enemas with cortisone or antibiotics help fight the inflammation.
Effects on pregnancy
Degree of disability in ulcerative colitis
The so-called degree of disability (GdB) is a measure of the severity of a disability and the associated functional impairments. It varies in ulcerative colitis depending on the severity of the disease between 20 and 80 (the maximum value for the GdB is 100). From a GdB of 50, physicians speak of a severe disability in ulcerative colitis. The GdB is relevant because people with disabilities are entitled to compensation for disadvantages in certain situations.
It is not possible to give a general answer as to whether ulcerative colitis entitles a person to an early retirement pension. If in doubt, ask your doctor for advice.
