Ulcerative Colitis

Treatment

Ulcerative colitis is an inflammatory disease affecting only the colon (large intestine). Some people have long periods of remission, which can last for years. Unfortunately, the disease usually recurs periodically during an individual's lifetime. Predicting when a flare-up may occur is not possible, but early recognition of symptoms results in a better response to treatment.

Patients with this disease are divided into three groups based on the site of involvement, which is important for treatment and prognosis.

• Proctitis (involving the rectum, the last part of the colon near the anus)
• Left-sided colitis (from the rectum to the splenic flexure — the area below the ribs on the left side)
• Pancolitis (involvement more extensive than the other two)

Therapy is aimed at quieting inflammation or relieving symptoms. It can usually control symptoms, but surgery may be required when therapy fails or if signs of colon cancer develop. Ulcerative colitis is cured by removing the colon.

Drug Therapy

Several types of medications are used to control inflammation or reduce symptoms caused by ulcerative colitis. The treatment of ulcerative colitis depends on its severity, location and the presence of complications, so drug therapies must be custom-designed for each patient. Finding which medications best alleviate the symptoms may take time.

Anti-inflammatory drugs

These drugs are often the first step in the treatment of ulcerative colitis. Most ulcerative colitis patients have mild to moderate cases, which are treated with medications containing mesalamine. The medications are usually very well tolerated, but patients may experience nausea, headache and diarrhea. In cases where disease in the rectum is causing symptoms, enema or suppository therapy with mesalamine is also helpful. Mesalamine is useful to achieve and maintain remission.

Some patients may need corticosteroids (e.g., prednisone) to control inflammation and induce remission. These individuals often have severe active disease or have not responded to mesalamine therapy. Corticosteroids are very effective but have significant side effects, such as increased susceptibility to infection, mood swings, anxiety, depression, elevated blood pressure, glaucoma, cataracts and osteoporosis. These drugs are tapered once a patient has achieved remission, and mesalamine or a drug that suppresses the immune system is used long term to maintain remission.

Immune system suppressors

Immunosuppressives (drugs that suppress the immune system) treat ulcerative colitis by blocking inflammation. The most commonly prescribed are 6-mercaptopurine (Purinethol) and azathioprine (Imuran). They are very effective but may cause side effects such as nausea, vomiting, liver problems or pancreatitis. Long term they work by suppressing the bone marrow and, as a result, the immune response. Because of these potential side effects, frequent monitoring, including blood tests and clinic visits, is important. These medications take on average 12 to 16 weeks to work. Usually, remission will first be induced with another medication (e.g., prednisone) and then be maintained with either azathioprine or 6-mercaptopurine. These medications can help wean patients from corticosteroids. Most patients tolerate them well.

Infliximab (Remicade) was approved for use in ulcerative colitis by the Food and Drug Administration in September 2005. It works by neutralizing a protein produced by your immune system known as tumor necrosis factor (TNF). Infliximab finds TNF in your bloodstream and removes it before it causes inflammation in your intestinal tract. Some people with heart failure and people with multiple sclerosis and those with cancer or a history of cancer can't use infliximab. The drug has been linked to an increased risk of infection, especially tuberculosis, and may increase the risk of blood problems and cancer. Because infliximab is partly a mouse protein, it can cause serious allergic reactions in some people  --  reactions that may be delayed for days to weeks after starting treatment. Once started, infliximab is often continued as long-term therapy, although its effectiveness may wear off over time.

Methotrexate and antibiotics found to be helpful in Crohn's disease have not been helpful in ulcerative colitis.

Surgery

Surgery for ulcerative colitis may become necessary for a number of reasons. The most common reason for surgery is the inability of diet, lifestyle changes, medications or other treatments to keep patients symptom free. Surgery may also be recommended for cancer or high risk of cancer. Since ulcerative colitis involves only the colon, when the colon is removed, the disease is cured.

Conventional open surgery and minimally invasive (laparoscopic) techniques are used. Laparascopic surgery for ulcerative colitis has long-term outcomes comparable to conventional surgery with the benefits of shorter hospital stays and easier recovery. Mayo has done more of these procedures than any other institution.

Not every patient is a candidate for minimally invasive surgery. Patients must consider how each procedure will impact their lives and should choose the procedure carefully with the help of their physician and a colorectal surgeon.

Ileal-anal pouch surgery
This procedure, which removes the entire colon and rectum and has been used for 20 years, is the most common surgery for ulcerative colitis. It eliminates the need to wear a bag. The surgeon constructs a pouch from the end of the small intestine and attaches it to the anus. The patient can defecate normally, although there may be five to seven watery bowel movements a day because the patient no longer has a colon to absorb water. This procedure can be performed laparoscopically in some patients.

Each year, Mayo Clinic surgeons perform approximately 120 ileal-anal anastomoses (also called ileal pouch-anal anastomosis or restorative proctocolectomy), more than any other medical center. Recent studies have shown that 92 percent of patients who had this procedure at Mayo Clinic had a successful outcome.

Proctocolectomy
This surgery also involves removing the colon and rectum, which eliminates ulcerative colitis. After removal, an opening (end-ileostomy) is created on the outside of the patient's body, typically in the lower abdomen. The patient wears a small bag over the opening to collect waste.