Inflammatory Bowel Diseases form a major chunk of the gastrointestinal group of disorders falling under the class of autoimmune diseases. As the name connotes it refers to a syndicate of inflammatory conditions affecting the colon and the small intestine. They are frequently misdiagnosed and mismanaged. Due to their production of an array of amorphous symptoms these disorders have a greater likelihood of being missed. If not properly investigated. The two major typical constituents of these set of disorders is Crohn’s disease and Ulcerative Colitis. Atypical constituents of IBDs encompass Behçet’s disease, Diversion colitis and Microscopic colitis. They might present with similar symptoms but are differentiated on the basis of a number of other diagnostic factors. Since IBDs is a very vast topic my focus would be primarily on Ulcerative Colitis and its relevant features.
ULCERATIVE COLITIS SYMPTOMS
The symptoms befall in accordance with the severity index of the disease. It primarily affects individuals aged between 15-30 years but rarely may manifest over 60 years of age as well. The majority of patients present with complaints such as a gradual onset of diarrhea. Which is usually accompanied by blood and mucus. And this perpetuates through a period of weeks without actually resolving by itself. This is also marked by a crampy abdominal pain and discomfort followed by tenesmus; a feeling of incomplete defecation. Continual bleeding from the large intestine accompanied by the fear of eating due to the recapitulating occurrence of diarrhea leads to a long-standing anemia and weight loss.
Ulcerative colitis predominantly affects the colon and rectum. However its extra-intestinal manifestations present themselves in a high percentage of patients. This disease involves patchy areas of the colon and rectum and hence is classified and treated accordingly. Proctitis is the inflammation limited to the rectal part of the intestine. Whereas Pancolitis involves the entire colon and the rectum. Apart from these Proctosigmoiditis which occurs less frequently involves the Rectosigmoid colon. Another occurrence is in the form of left-sided colitis. This primarily involves the descending colon extending up to the emergence of the transverse colon and Splenic flexure which is present on the left side of the patient. Lastly another variant is Extensive Colitis. Which involves large patchy and indefinite areas of the colon and rectum and may extend beyond that as well.
The severity index of this disease is a prerequisite to stratify the patient as to what category of treatment he/she falls in. This can be consigned as a mild, moderate, severe or Fulminant disease. Generally speaking a milder form of the disease represents itself with constipation and about 4 or less episodes of diarrhea per day and is tolerable. A moderate form of the disease is also not relatively dangerous and may be presented with a slight anemia.
The major concerns are raised in the severe and Fulminant forms of the disease whose complications can be markedly life-threatening. They both evince a corroboration of toxicity which can be exhibited by severe anemia, a high grade fever, tachycardia and elevated C-reactive protein and ESR values. While the moderate form of disease corresponds to about 6 bloody stools per day. A Fulminant manifestation can lead to a recurrence of more than 10 stools per day. This can effectuate the production of a minacious complication, a Toxic Megacolon. It is marked by acute colonic distension, abdominal bloating, tachycardia, severe dehydration and fever which can lead to a septic shock.
ULCERATIVE COLITIS CAUSES
The forthright cause of Ulcerative Colitis is still idiopathic. Hence it is safe to discuss other factors that may play a significant role in its occurrence. A number of theories have come into play but the most concrete ones involve environmental and genetic factors. The cardinal environmental factor is the effect of diet. Studies indicate an increased prevalence of ulcerative colitis in individuals who consume large amounts of vitamin B6 and unsaturated fats. A large consumption of alcohol is also a contributory factor.
There are also studies being conducted in favor of low sulfur diets aggravating this condition due to mucosal sulfide detoxification. But there is not substantial evidence yet to support it. Genetic factors elaborate mutations in the transporter proteins OCTN1 and OCTN1. Alongside these cell scaffolding proteins belonging to the MAGUK family also show evidence of involvement. Currently 12 genomes have been identified corresponding to chromosomes 1, 3, 5, 6, 12, 14, 16 and 19 which may be involved with ulcerative colitis.
Ulcerative colitis presents with extra-intestinal features which may be mild or severe depending again on the severity index. These include a wide array of symptoms affecting the skin, joints and other organs. The joints can be affected in the form of seronegative arthritis, ankylosing spondylitis and sacroiliitis. The skin conditions manifest as erythema nodusum and pyoderma gangrenosum. It can also affect the eyes causing uveitis and episcleritis. Moreover other organs may get involved such as the bile ducts which get inflamed in primary sclerosing cholangitis.
ULCERATIVE COLITIS DIAGNOSIS
The diagnosis of Ulcerative colitis demands a detailed work-up. And clinical examination to find out the extent of the disease in order to decide its line of treatment. The basic lab investigations involved are the complete blood count – for an anemic picture and a high platelet count. X-rays of the abdomen which show a characteristic thumb-printing sign due to thickening of haustral folds. ESR and CRP which are significantly raised. The standard diagnostic test for Ulcerative colitis is however sigmoidoscopy and colonoscopy. Direct visualization can provide a detailed scenario of the disease and the areas involved.
ULCERATIVE COLITIS TREATMENT
The first line treatment options for Ulcerative colitis are oral medications. They are adjusted according to the severity index of the disease and consequently switched over to higher doses and a more aggressive treatment. They belong to the class of 5- Aminosalicylic acid drugs which include Sulfasalazine and Mesasalazine.
Corticosteroids are an indispensable mantle in the treatment of Ulcerative Colitis. The disadvantage however arising from their long-term use, they are not exactly favorable. But due to their immunosuppressant attributes and healing properties, Prednisolone is frequently resorted to. Other drugs include Immunosuppressants such as Azathioprine and Methotrexate. Tumor Necrosis factor inhibitors such as Infliximab and Adalimumab are also used.
Surgical treatments such as the removal of the affected part of the bowel are often employed in the treatment of Ulcerative colitis. As it is more responsive to them. An Ileo-anal Pouch procedure has been deemed to be effective. This involves removal of a significant part of the large intestine and a temporary ileostomy is made. The rectal stump and anus is left behind as after a period of six to twelve months an internal pouch is made. Which is reconnected to the rectal stump and the ileostomy is reversed thus resulting in a normally functional bowel system of the patient.
Ulcerative Colitis is a long-standing and perturbing ailment with restricted treatment options. Its response to treatments varies from patient to patient. Requires a great degree of patience from the patient himself. In some it resolves without any complications. While in others it can lead to an increased risk of development of Colorectal Carcinoma in case of the disease progression being more than 10 years. Prevention of such risks can be done by getting regular screening colonoscopies and biopsies to rule out dysplastic changes. After every 1 to 2 years in patients with a long-standing disease of more than 8 years.