Once the diagnosis is confirmed, you may 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 by the following:
- how many times you are passing stools
- whether those stools are bloody
- whether you also have more wide-ranging symptoms such as fever, rapid heartbeat and anaemia (shortness of breath, irregular heartbeat, tiredness and pale skin)
- how much control you have over your bladder
- your general wellbeing
If your symptoms are mild you may not require specific treatment as mild ulcerative colitis often clears up within a few days.
Moderate ulcerative colitis is often treated using a medication called aminosalicylates. If this is not effective, alternatives such as corticosteroids (steroid medication) and immunosuppressants (medications that suppress the workings of your immune system) can be used.
Once your symptoms are under control it may be recommended you continue to take aminosalicylates as these can help prevent further flare-ups; this is known as maintenance therapy.
If you experience a severe flare-up you may need to be admitted to hospital where you can be given injections of corticosteroids or immunosuppressants.
There is also a relatively new type of medication called infliximab that can be used to treat severe ulcerative colitis where corticosteroids cannot be used for medical reasons.
Surgery may be recommended to remove a section of colon if medications fail to control symptoms or you are having frequent "flare-ups" of symptoms.
Treatment options are discussed in more detail below.
Aminosalicylates are the first treatment option for mild to moderate ulcerative colitis. They help reduce inflammation and can be taken:
- orally: as a tablet or capsule that you swallow
- 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 you take aminosalicylates will depend on the severity and extent of your condition.
The side effects of aminosalicylates can include:
Corticosteroids (steroid medication) may be used if your ulcerative colitis is more severe or not responding to aminosalicylates. 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.
The side effects of short-term steroid use can include:
- changes in the skin such as acne
- sleep and mood disturbance
Side effects of prolonged steroid use (more than 12 weeks) include:
- osteoporosis – weakening of the bones
- high blood pressure (hypertension)
- diabetes – or worsening of existing diabetes
- weight gain
- cataracts – where cloudy patches in the lens of the eye can make vision blurred or misty
To minimise the risk of prolonged steroid use, it is important that you:
- Eat a healthy and balanced diet with plenty of calcium.
- Maintain a healthy body weight.
- Stop smoking.
- Don't drink more than the safe limits of alcohol (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 corticosteroids.
You may be given immunosuppressants if your condition is still not responding to treatment, sometimes in combination with other medicines.
They may also be recommended if it is decided to withdraw your steroid treatment to reduce possible side effects. This is known as steroid-sparing therapy.
Immunosuppressants work by reducing or suppressing your body's immune system. This will then stop the inflammation caused by ulcerative colitis.
Immunosuppressants take a while to start working (typically two to three months).
The drawback is they affect your whole body, not just your colon. This may make you more prone to infection, so it is important to report any signs of infection, such as inflammation, fever or sickness, promptly to your GP.
They can also lower the production of red blood cells, making you prone to anaemia. You will need regular blood tests to monitor your levels of blood cells and check for any other problems.
The preferred immunosuppressant used in the treatment of ulcerative colitis is a medicine known as azathioprine. This is because it rarely causes side effects in most people.
Long-term use of azathioprine has been linked to a small increase in the risk of cancer, particularly skin cancer.
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 should be managed in hospital to minimise the risk of dehydration, malnutrition and potentially fatal complications such as your colon rupturing.
You will be given intravenous (injected directly into your vein) fluid to treat dehydration. The condition itself can be treated using injections of steroids or immunosuppressants.
Infliximab is a new type of medication 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
- swelling of the hands or lips
- problems swallowing
Symptoms range from mild to severe and 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.
You 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 avoid contact with people who have a known chickenpox or shingles infection.
It's important to report any symptoms of a possible infection, such as coughs, high temperature or sore throat, to your GP.
Once the symptoms are in remission, taking a regular dose of aminosalicylates should help prevent symptoms reoccurring. If the condition frequently reoccurs, 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.
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 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 used. 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 when you pass stools.
The advantage of this technique is that you are not required to carry an external pouch.
Read more about ileostomies and ileo-anal pouches.