An inflammatory condition that affects the surface of the colon, ulcerative colitis causes friability and erosions with bleeding. The disease usually begins in the rectal area and may extend through the entire bowel. Less frequently, it extends into the splenic flexure, or more proximally extends upward into the entire colon. It rarely affects the small intestine, except for the terminal ileum.
Severity ranges from a mild, localized disorder to a fulminant disease that may lead to a perforated colon, progressing to peritonitis and toxemia.
Although the etiology of ulcerative colitis is unknown, it’s thought to be related to an autoimmune response. Stress is no longer thought to be a cause. However, it may precipitate or increase the severity of the attack.
Ulcerative colitis occurs primarily in young adults, especially women; it’s also more prevalent among the Jewish population and individuals in higher socioeconomic groups. Onset of symptoms seems to peak in the 15- to 30-year-old age-group, with another peak occurring in the 50- to 70-year-old age-group.
The hallmark of ulcerative colitis is bloody diarrhea. The intensity of these attacks varies with the extent of inflammation. Patients with mild to moderate disease may experience five or fewer bowel movements per day with intermittent bleeding and mucus production. Individuals may experience left lower quadrant pain relieved by defecation, along with fecal urgency and tenesmus. Patients with more severe disease will have more than five bowel movements per day, which may result in anemia, hypovolemia, and impaired nutrition. Extracolonic manifestations also may be present, including erythema nodosum, pyoderma gangrenosum, episcleritis, thromboembolic events, and arthritis.
Ulcerative colitis may lead to complications affecting the following organs and systems:
❑ Blood: anemia from iron deficiency, coagulation defects due to vitamin K deficiency
❑ Skin: erythema nodosum on the face and arms; pyoderma gangrenosum on the legs and ankles
❑ Eye: uveitis
❑ Liver: pericholangitis, sclerosing cholangitis, cirrhosis, possible cholangiocarcinoma
❑ Musculoskeletal: arthritis, ankylosing spondylitis, loss of muscle mass
❑ GI: strictures, pseudopolyps, stenosis, and perforated colon, leading to peritonitis and toxemia.
CLINICAL TIP: The risk of colorectal cancer in patients who have had ulcerative colitis for more than 10 years increases by approximately 1% per year. Also, patients with disease proximal to the sigmoid colon have an increased risk of developing colon carcinomas.
❑ History and physical examination should include questions regarding frequency of stools, rectal bleeding, cramps, abdominal pain, weight loss, and tenesmus. Peritoneal inflammation should be assessed, as well as volume status and nutritional levels.
❑ Sigmoidoscopy establishes a diagnosis by demonstrating increased mucosal friability, decreased mucosal detail, edema, and erosions. Biopsy can help confirm the diagnosis.
❑ Colonoscopy may be used both to determine the extent of the disease and for cancer surveillance after the patient’s flare-up has resolved.
CLINICAL TIP: Colonoscopy should not be performed during an acute episode because of the risk of perforation.
❑ Stool specimen should be cultured and analyzed for leukocytes, ova, and parasites.
The goals of treatment are to relieve symptoms of the acute attack and prevent recurrent attacks, to replace nutritional losses and blood volume, and to prevent complications.
Supportive treatment includes I.V. fluid replacement and a clear-liquid diet. For patients awaiting surgery or showing signs of dehydration and debilitation from excessive diarrhea, total parenteral nutrition rests the intestinal tract, decreases stool volume, and restores positive nitrogen balance. Blood transfusions or iron supplements may be necessary to correct anemia.
Medications to control inflammation include corticotropin and adrenal corticosteroids, such as prednisone, prednisolone, and hydrocortisone; sulfasalazine, which has antiinflammatory and antimicrobial properties, may also be used. Options to decrease attacks include 5-aminosalicylates such as mesalamine and immunomodulators such as azathioprine, 6-mercaptopurine.
UNDER STUDY: Dehydroepiandrosterone is a steroid hormone that’s marketed as an over-the-counter drug in the United States. In pilot studies, it was proven safe to use in patients with ulcerative colitis. Dosage adjustments may further improve treatment outcomes.
Patients with mild to moderate disease may eat a regular diet, excluding caffeinated beverages and gas-producing foods. Anticholinergics and a low-roughage diet without milk or milk products may be used to reduce bowel movement frequency. Fiber supplementation may be used to control diarrhea and rectal symptoms. Antidiarrheal agents should be used only in patients with mild symptoms, not in those with the acute phase of this illness.
Patients with disease primarily affecting the rectum or rectosigmoid should be managed with topical agents such as mesalamine. Topical steroids may be used, but they may be less effective.
Patients with mild to moderate disease extending above the sigmoid colon who fail to improve after 2 to 3 weeks on sulfasalazine or mesalamine should have a corticosteroid added to their regimen.
Severe colitis is usually managed with nothing-by-mouth status and parenteral alimentation. Volumizers and blood should be provided as needed. Surgical consultation should be obtained in all patients with severe disease.
Surgery is recommended for patients who have toxic megacolon or who fail to respond to drugs and supportive measures.
The ileoanal restorative proctocolectomy with ileoanal pouch anastomosis is being performed more frequently. This procedure entails performing a total proctocolectomy, creating a pouch from the terminal ileum, and anastomosing the pouch to the anal canal. A temporary ileostomy is created to divert stools and allow the rectal anastomosis to heal. This technique is now more common than total proctocolectomy with ileostomy. The ileostomy is closed in 2 to 3 months.
Total proctocolectomy (with ileostomy) provides complete cure of disease. However, the patient’s self-image and social interactions may be affected by wearing an external appliance.
Pouch ileostomy (Kock pouch or continent ileostomy), in which the surgeon creates a pouch from a small loop of the terminal ileum and a nipple valve from the distal ileum, may be an option. The resulting stoma opens just above the pubic hairline, and the pouch empties periodically through a catheter inserted in the stoma. Patients may experience six or more bowel movements per day. A low-residue diet should be maintained to promote pouch adaptation. Patients may also need bulking agents or antidiarrheals to slow stool output. This procedure is performed less often now than in the past.
A colectomy may be performed after 10 years of active ulcerative colitis because of the increased incidence of colon cancer in these patients. Performing a partial colectomy to prevent colon cancer is controversial.
❑ Accurately record intake and output, particularly the frequency and volume of stools.
❑ Watch for signs of dehydration and electrolyte imbalances, specifically signs of hypokalemia (muscle weakness, paresthesia) and hypernatremia (fever, tachycardia, flushed skin, dry tongue).
❑ Monitor hemoglobin and hematocrit, and transfuse if necessary.
❑ Provide good mouth care for the patient who is allowed nothing by mouth.
❑ After each bowel movement, thoroughly clean the skin around the rectum.
❑ Administer medication. Watch for adverse effects of prolonged corticosteroid therapy (moonface, hirsutism, edema, gastric irritation). Be aware that such therapy may mask infection.
❑ If the patient needs total parenteral nutrition, change dressings, assess for inflammation at the insertion site, and check blood glucose every 6 hours.
❑ Take precautionary measures if the patient is prone to bleeding. Watch closely for signs of complications, such as a perforated colon and peritonitis (fever, severe abdominal pain, abdominal rigidity and tenderness, and cool, clammy skin), and toxic megacolon (abdominal distention, decreased bowel sounds).
❑ Prepare the patient for surgery, and provide teaching related to the care of an ileostomy. Consult the enterostomal therapy nurse for preoperative teaching and stoma marking. Provide a bowel preparation.
❑ After surgery, provide education regarding ostomy care as well as psychological support. Arrange for the patient to consult an enterostomal therapy nurse.
❑ Keep the nasogastric tube patent. After removal of the tube, provide a clear-liquid diet. Gradually advance to a low-residue diet as tolerated.
❑ After a proctocolectomy and ileostomy, provide education regarding ostomy care. Wash the skin around the stoma with soapy water and dry it thoroughly. Apply karaya powder around the base of the stoma to prevent irritation and provide a tight seal. Cut an opening in the ring to fit over the stoma, and secure the pouch to the skin. Empty the pouch when it’s one-third full.
❑ After a pouch ileostomy, uncork the catheter every hour to allow contents to drain. After 10 to 14 days, gradually increase the length of time the catheter is left corked until it can be opened every 3 hours. Then remove the catheter and reinsert it every 3 to 4 hours for drainage. Teach the patient how to insert the catheter and how to take care of the stoma.
❑ Encourage the patient to have regular physical examinations.
Review other book chapters online related to Colitis:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5 
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