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What is ulcerative colitis?
Ulcerative colitis is a type of inflammatory bowel disease (IBD) in which there is chronic inflammation of the digestive system. Ulcerative colitis mainly affects the large bowel. It causes inflammation and ulcers in the lining of the bowel, which results in pain and bloody diarrhoea.
There are an estimated 33,000 diagnosed cases of ulcerative colitis in Australia, equally affecting both men and women. 
The lining of your bowel normally secretes mucus and absorbs water from your stool (faeces). In ulcerative colitis, this lining becomes inflamed, swollen and develops erosions that turn into ulcers. This causes pain and spasms with watery, profuse diarrhoea. These ulcers can bleed easily and quite badly.
There is no known cause for ulcerative colitis, but there is much research being conducted to find an answer.
Common theories on the cause of ulcerative colitis include:
One theory is that the immune system mistakenly attacks the bowel. The trigger for this is unknown, although an infection is thought to be one possibility.
It is thought that ulcerative colitis may be caused by genetic mutations, which could be passed down through generations. This is supported by the finding that individuals with ulcerative colitis often have relatives with inflammatory bowel disease (IBD), such as ulcerative colitis or Crohn's disease.
Risk factors for ulcerative colitis include:
- Age - it is more common among people 15-40 years of age, though it can happen at any age, and;
- Ethnicity - ulcerative colitis has a higher incidence among Caucasian people whose ancestry is European, in particular those who hail from the Ashkenazi Jewish community who lived in Russia and Eastern Europe. It is also common among Africa people, but rare among Asian people  .
The unique feature of ulcerative colitis is that it almost always starts at the rectum and travels back along the bowel. The degree to which it extends back up the bowel can vary. This is often used to assess the severity of the condition, as follows:
The mildest form of the disease, this is when ulcerative colitis only affects the rectum and is the mildest form of the disease.
This is when the condition affects the rectum and the lowest part of the large intestine. The symptoms are often bloody diarrhoea, cramping on the left-hand side of the abdomen and the inability to have a bowel movement even though you feel the urge.
This type affects the rectum and extends up to involve all of the large intestine on the left-side of the abdomen. Symptoms may include severe diarrhoea, bleeding, left-sided pain, loss of appetite and weight loss.
This is a very rare type of ulcerative colitis where all areas of the bowel - both the small and large intestines - are involved. This is the most severe form of the disease, with symptoms including severe cramping, diarrhoea and weight loss. Complications requiring surgery or hospitalisation are common.
Signs and symptoms
The symptoms of ulcerative colitis tend to happen in bouts or flare-ups and most appear to be worse in the mornings. You may have no symptoms for months at a time, then have a severe flare-up that may last weeks. The symptoms of a flare-up can include:
- Diarrhoea - it can contain blood, mucus and/or pus. Commonly, there can be urgent waves of diarrhoea and occasionally, you can lose control of your bowels;
- Abdominal and anal pain;
- Weight loss, reduced appetite and nausea;
- Tiredness and fatigue;
- Rectal ulcers and bleeding, and;
- Occasionally, fevers and chills.
You may also experience painful joints, mouth ulcers, irritated eyes and vision problems, or skin rashes. In rare cases, there may be symptoms of liver and bile duct disease, such as itchy skin and jaundice.
Methods for diagnosis
Full physical examination and medical history
Your doctor will likely order blood tests, such as a full blood count, to assess for possible causes of your symptoms and exclude potential complications (see below).
An analysis of your stool can help identify the presence of inflammation or infection in the digestive system.
This procedure involves inserting a thin, flexible tube attached to a small camera through the anus to view the inside lining of the bowel. Biopsies of the lining of the bowel are often taken at the time of colonoscopy, which are then sent to a laboratory.
A colonoscopy is generally performed under light sedation to keep you relaxed and pain-free. Often it is necessary to take medications, such as laxatives and enemas, beforehand to clean out the bowel, so that there is a clear view of the inside of the bowel.
Samples of tissue taken at the time of colonoscopy are assessed for characteristic changes under a microscope, which can confirm the diagnosis of ulcerative colitis.
Types of treatment
The treatment offered will depend on the severity of your symptoms and the part of your bowel affected by ulcerative colitis. Medications are the main form of treatment. Surgery is rarely needed and used only if the symptoms become unmanageable or there is a life-threatening complication.
The main medications used in ulcerative colitis aim to reduce inflammation in the bowel. The can be taken as a tablet, rectal suppository or enema, or occasionally, administered intravenously. These include:
- 5-aminosalicyclic acid agents (5-ASA), such as sulfasalazine;
- Corticosteroids, such as prednisolone, and;
- Biological therapies, such as infliximab, which are medications that contain antibodies that target specific chemicals involved in the inflammatory process.
Surgery can be used to remove the affected part or all of your bowel and rectum. This may be necessary if the disease cannot be controlled sufficiently with medications, if there are precancerous or cancerous changes in the bowels, or if there are certain severe symptoms that develop outside the bowel (see Potential complications). Removing the entire bowel and rectum can potentially cure a person from ulcerative colitis; however, this procedure carries a significant risk and in most cases the condition can be sufficiently controlled through medications.
Occasionally, emergency surgery may be needed to remove the affected part or all of the bowel, if a patient is admitted with certain complications. Complications can include severe bleeding from the bowel, bowel obstruction or toxic colitis (see Potential complications), which are life-threatening and generally do not improve with medications only.
If your colon and rectum are removed (proctocolectomy), a special opening (stoma) can be created in your abdomen, which connects to a bag that collects your waste matter. A specially trained stoma nurse can teach you how to care for your stoma.
If you have had surgery to remove your colon and rectum, a further operation may be an option to allow you to pass stools without needing a stoma. In this procedure, part of your small intestine is used to create a pouch within your abdominal cavity, which is then attached to your anus. This helps to collect the stools and allows you to control when you go to the toilet.
This is a major surgical procedure with potential complications. Recovery in hospital can take least a week. You may not entirely regain full control of your bowels and it takes time to adapt to the new physiology.
- Living with ulcerative colitis can be difficult and may sometimes make you feel depressed. Finding a local or online support group (see link) to connect with others who are experiencing similar issues can be useful;
- Talk to your doctor or dietitian about foods that may be better during flare-ups, such as low-fibre foods;
- Keeping a food diary may help you to keep track of any items that aggravate your bowels;
- Eating small meals often may help, such as six small meals each day instead of three larger ones;
- Visiting a dietitian may help address any dietary issues you have, and;
- Find ways to relax, as lowering stress may reduce the incidence of flare-ups.
Internal bleeding due to ulcers can lead to anaemia. Sudden heavy bleeding can be life-threatening and if this happens, you are advised to straight to hospital.
This is a potentially life-threatening condition in which the inflammation in the bowel is so extensive that the whole bowel wall is involved. This causes the bowels to stop and distend (bloating). The distension can be so severe that the bowel perforates, releasing its contents throughout the abdomen, which may lead to blood poisoning (sepsis). Symptoms of toxic colitis include severe abdominal pain, fever and a racing heart. Immediate surgery may be required to repair the bowel and remove any leaked bowel contents from the abdominal cavity.
If you have ulcerative colitis, there is an increased risk of developing bowel cancer. The longer you have had ulcerative colitis and the more severe it is, the greater your chances become. Your doctor may suggest that you have regular check-ups with a colonoscopy to detect any early changes that may be bowel cancer.
Disorders outside the colon
In a small number of people with ulcerative colitis, the inflammation can also affect other areas of the body. Some of these include:
- Eyes - inflammation that causes a red, sore eye;
- Skin - there are conditions that cause ulcers on the skin or small painful nodules on the legs;
- Joints - joint pain is commonly reported and can affect your lower back, hips, knees and other joints;
- Liver - inflammation of the bile ducts within your liver that can cause liver failure, and;
- Bones - osteoporosis due to long-term corticosteroid use.
Ulcerative colitis is a lifelong condition with periods of remission that can vary in length, followed by flare-ups. There is a greater risk than normal of developing bowel cancer, usually after 7-10 years with ulcerative colitis, so regular check-ups are essential.
There are lifestyle measures you can take that may reduce flare-ups of ulcerative colitis, such as: