Ulcerative colitis

Treating ulcerative colitis

Once the diagnosis is confirmed, you may then be referred to a gastroenterologist (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
  • your general wellbeing

Mild to moderate cases can be treated on an outpatient basis (meaning treatment can be carried out through a series of appointments at a hospital or clinic) or at home. More severe cases will require admission to hospital.

There are two types of treatment:

  • managing active ulcerative colitis - treating the symptoms until they go into remission
  • maintaining remission - using treatment to prevent the return of symptoms

Managing active ulcerative colitis

There are three main types of medicines that are used to manage active ulcerative colitis: aminosalicylates, steroids and immunosuppressants.

Aminosalicylates

Aminosalicylates are the first treatment option for mild to moderate ulcerative colitis. They help reduce inflammation and can be taken:

  • orally - as a tablet
  • as a suppository - a capsule that you insert into your rectum, where it then dissolves
  • 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 a combination of oral aminosalicylates and an enema. This is because a suppository can only reach certain parts of the colon.

Side effects of aminosalicylates include:

  • diarrhoea
  • nausea
  • headaches
  • skin rashes 

Steroids

If your ulcerative colitis is more severe or 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 you will need to stop using them.

Side effects of short-term steroid use include:

  • changes in the skin such as acne
  • sleep and mood disturbance
  • indigestion
  • 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)
  • thinning of the skin
  • easy bruising
  • muscle weakness

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)
  • 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, sometimes in combination with other medicines. You may also be given them if it is decided to withdraw your steroid treatment 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.

Iimmunosuppressants can take a while to start working - 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 GP.

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
  • 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 need 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 you will be advised 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. The condition itself can be treated using injections of steroids and/or immunosuppressants.

Infliximab

Infliximab is a new type of medication that is only used to treat severe active ulcerative colitis if you are unable to take steroid medication for medical reasons, such as being allergic to it.

It works by targeting a protein called TNF-alpha, which the immune system uses to stimulate inflammation.

Infliximab is given through a drip in your arm over the course of two hours. This is known as an infusion.

You will be given further infusions after two weeks and again after six weeks. Infusions are then given every eight weeks, if treatment is still required.

Around one in four people have an allergic reaction to infliximab and experience symptoms such as:

  • joint and muscle pain
  • itchy skin
  • high temperature
  • rash
  • swelling of the hands and/or lips
  • problems swallowing
  • headaches

Symptoms can range from mild to severe and they usually develop in the first two hours after the infusion has finished. Rarely, people have experienced a delayed allergic reaction days or even weeks after an infusion. If you begin to experience the symptoms listed above after having infliximab, seek immediate medical assistance.

Due to the significant (one in four) risk of having a severe allergic reaction, your health will be carefully monitored after your first infusion and, if necessary, powerful anti-allergy medication, such as epinephrine, may be used.

There have been a number of cases where infliximab has ‘reactivated’ a previously dormant tuberculosis (TB) infection. Therefore, it may not be suitable if you have a previous history of TB. The same is also true with the viral infection hepatitis B.

Infliximab is also not recommended for people with a history of heart disease.

Infliximab will make you more vulnerable to infection, so you should avoid contact with people who have a known chickenpox or shingles infection.

You should report any symptoms of a possible infection, such as coughs, a high temperature or a sore throat, to your GP.

Maintaining remission

Once the symptoms are in remission, taking a regular dose of aminosalicylates should help prevent the symptoms 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 affecting your quality of life.

Surgery involves permanently removing the colon - a colectomy. As part of the operation, your small intenstine will have to be re-routed 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 pulled slightly out of the hole and connected to a pouch (which collects waste materials).

However, 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 be emptied in much the same way as when you defecate.

The advantage of this technique is that you are not required to carry an external pouch.

For more information see the Health A-Z topic on Ileostomy.

Other treatments

Nicotine patches

As smokers have less chance of developing ulcerative colitis, some researchers have tried using nicotine patches to relieve the symptoms. 

While they were of some benefit, studies have shown that conventional medicines are far more effective and most experts would not recommend nicotine patches as a routine treatment. 

Omega-3 fish oil

Some research has been carried out to see if omega-3 fish oil proved effective in treating the condition. No benefit could be found.

Probiotics

There has been limited research into whether probiotics could help achieve remission of the symptoms of ulcerative colitis. While the results of the research were positive, the trials looking at the treatment were relatively small and further research is required to confirm the results.

Probiotics are so-called friendly bacteria that are available in capsule, liquid and powder form.

Some probiotics may not be suitable if you are taking immunosuppressants as they could cause a serious infection. Check with your GP if you are currently taking probiotics and are thinking of trying immunosuppressants.

Glossary

Acute
Acute means occurring suddenly or over a short period of time.
Enemas
An enema is an injection of fluid into the large intestine / colon to empty the bowel. It can also be used to make the bowels show up more clearly in an X-ray.
Corticosteroids
Corticosteroid is a naturally occurring hormone produced by the adrenal gland, or a synthetic hormone having similar properties. It is used to reduce inflammation, so reducing swelling and pain.
Remission
Remission is when the symptoms of a condition are reduced (partial remission) or go away completely (complete remission).
Antidiarrhoeals
Antidiarrhoeal medicine is used to treat diarrhoea. For example, dicyclomine.
Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Intravenous
Intravenous (IV) means the injection of blood, drugs or fluids into the bloodstream through a vein.
Last updated: 27 January 2012

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