Once Ulcerative colitis, a type of inflammatory bowel disease (IBD) that affects the lining of the large intestine (colon) and rectum, confirmed, you may then be referred to a gastroenterologist (a doctor who specialises in conditions of the digestive system) so the severity of your condition can be assessed and a treatment plan drawn up.
The severity of the condition is judged using a number of factors, including:
- how many times you are passing stools,
- whether those stools are bloody,
- whether you have symptoms of fever,
- how much control you have over your bladder, and
- your general wellbeing.
There are two types of treatment: treating the symptoms until they go into remission (managing active ulcerative colitis), and using treatment to prevent the return of symptoms (maintaining remission).
Managing Active Ulcerative Colitis
There are three main types of medicines that are used to manage active ulcerative colitis: aminosalicylates, steroids and immunosuppressants.
Aminosalicylates
The first treatment option, for mild to moderate ulcerative colitis, is an aminosalicylate. Amniosalicylates help reduce inflammation. They can be taken orally – as a tablet, topically – as a cream rubbed into the affected area, as a suppository – a capsule that you insert into your rectum where it then dissolves, and through an enema – where fluid is pumped into your colon.
How the aminosalicylates are administered will depend on the severity and extent of your condition. Mild forms may only require oral and topical aminosalicylates. A more serious form of the condition that involves the entire colon may require an enema – as a suppository or cream can only reach certain parts of the colon. Side effects of aminosalicylates include diarrhoea, nausea, headaches, and skin rashes.
Steroids
If your ulcerative colitis is more severe or it is not responding to the aminosalicylates then steroids may be used. Steroids act much like aminosalicylates in reducing inflammation, except they are a lot stronger. As with aminosalicylates, steroids can be administered orally, topically, or through a suppository or enema. Long-term use of steroids, especially oral steroids, is not recommended as they can cause potentially serious side effects. Therefore, once your colitis responds to treatment, it is likely that their use will be discontinued.
Side-effects of short term steroid use include changes in the skin such as acne, sleep and mood disturbance, indigestion, and swelling. Side-effects of prolonged steroid use (more than 12 weeks) include osteoporosis (fragile bones), high blood pressure (hypertension), diabetes, weight gain, cataracts and glaucoma (both disorders of the eye), skin-thinning, easy bruising, and muscle weakness.
In order to minimise the risk of prolonged steroid use you should:
- eat a healthy and balanced diet with plenty of calcium,
- maintain a healthy body weight,
- stop smoking,
- not drink more than the safe limits of alcohol (the recommended daily levels are three to four units of alcohol for men and two to three units for women. A unit of alcohol is equal to about half a pint of normal strength lager), and
- take regular exercise.
You will also require regular appointments to check for high blood pressure, diabetes and osteoporosis if your treatment requires long-term use of steroids.
Immunosuppressants
If your condition is still not responding to treatment, you may be given immunosuppressants in combination with, or in preference to, other medicines. You may also be given them if it is decided to withdraw your steroid treatment, in order to reduce possible side effects. Immunosuppressants work by reducing or suppressing your body’s immune system. This will then stop the inflammation caused by ulcerative colitis.
The effects of immunosuppressants can take a while to become apparent – typically two to three months. The drawback of immunosuppressants is that they are non-specific – meaning they will not just affect your colon, but your whole body. This may make you more prone to infection so it is important to report any signs of infection, such as inflammation, fever or nausea, promptly to your doctor.
They can also lower the production of red blood cells making you prone to anaemia. You will require regular blood tests to monitor your levels of blood cells and check for the presence of any other problems.
The preferred immunosuppressant used in the treatment of ulcerative colitis is a medicine known as azathioprine. This is because it causes no side effects in most people.
Possible side effects of taking azathioprine include nausea, diarrhoea, liver damage, anaemia, increased risk of infection, and increased risk of bruising. Long-term use of azathioprine has been linked to a small increase in the risk of cancer, particularly skin cancer. If you have to take azathioprine for several years, you may wish to minimize the risk by avoiding strong sunlight, and using appropriate ultra-violet (UV) protection, such as sunblock.
Azathioprine is not normally recommended for pregnant women. However, if it is the only treatment that successfully controls your condition, it is likely that you will be recommended to continue taking it. Any risk to you or your child is far outweighed by the risks presented by ulcerative colitis.
Managing severe active ulcerative colitis
Severe active ulcerative colitis will need to be managed at hospital. This is because severe colitis could put you at risk of dehydration, malnutrition and potentially fatal complications such as your colon rupturing (splitting). You will be given intravenous (injected directly into your vein) fluid to treat dehydration and nutrients through a feeding tube to prevent malnutrition. The condition itself can be treated using injections of steroids and/or immunosuppressants.
Maintaining remission
Once the symptoms are in remission, taking a regular dose of aminosalicylates should help prevent the symptoms from reoccurring. If the condition does reoccur on a frequent basis, a regular dose of an immunosuppressant such as azathioprine may be recommended. If your ulcerative colitis was extensive, a lifelong maintenance therapy is normally recommended. If your ulcerative colitis was limited to a small part of your colon, you may be able to stop therapy, if two years pass without a return of symptoms.
Surgery
If ulcerative colitis does not respond to intensive medical treatment then surgery may be required. You may also wish to consider surgery if your maintenance therapy is not working, and the condition is adversely impacting on your quality of life. Surgery involves permanently removing the colon – a colectomy. As part of the surgery, your small intenstine will have to be rerouted from the colon so it can pass waste products out of your body. This used to be achieved by carrying out an ileostomy, where an incision is made in your stomach, and the small intestine is then pulled slightly out of the hole and connected to a pouch. The pouch is then used to collect waste materials.
In recent years, another technique known as the ileo-anal pouch has been increasingly preferred. This is an internal pouch constructed by the surgeon out of the small intestines and then connected to the muscles surrounding your anus. The pouch can then be emptied much in the same way we empty our colon when we defecate. The advantage of this technique is that you are not required to carry an external pouch.
Nicotine patches
As smokers have less chance of developing the condition, some researchers have tried using nicotine patches to relieve the symptoms of ulcerative colitis. While they were of some benefit, studies have shown that conventional medicines are far more effective.
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- Complications of a colostomy
- Complications of ileostomy
- Gluten intolerance – Coeliac disease
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