Ulcerative colitis (UC) is a chronic nonspecific inflammatory bowel disease (IBD) involving the mucosa and submucosa of the colon. It involves the rectum and is characterized by ulceration, bloody diarrhea, and rectal bleeding. Disease severity depends on degree and extent of inflammation and proximal colonic involvement. UC may present at all ages, but onset peaks between 15 and 30 years with a secondary onset peak between 60 and 70; it is a serious, relapsing–remitting disease with significant morbidity and mortality affecting at least 50 per 100,000 people in the United States. Higher incidence in Jewish population. Familial incidence is established; 10% to 20% of UC patients have at least one family member affected with IBD. Medical management controls symptoms in most cases, but colectomy is necessary in about 25% of those affected.

Unknown. Infectious, genetic, immunologic, and psychological causes likely.

• Jewish ethnicity (Ashkenazi Jews in particular)
• Positive family history
• A diet high in margarine or chemically modified fat (diet of combined western foods)
• Psychological disturbances

UC typically manifests as bloody diarrhea interspersed with asymptomatic intervals. Onset may be acute and fulminant, but more often is insidious, with progressively severe urgency to defecate, mild abdominal cramps, and blood and mucus in stools. Symptoms may include violent diarrhea, high fever, malaise, abdominal tenderness or pain, anemia, anorexia, weight loss, and arthralgias. In UC confined to the rectosigmoid area, stool may be normal or hard and dry, with mucus discharged between or accompanying bowel movements. Stool abnormality increases with proximal involvement, with up to 20 bowel movements a day, diffuse cramping, distressing tenesmus, passage of pus, nocturnal sweats, pain, and diarrhea.

• Crohn's disease
• Hemorrhoids
• Viral, bacterial, and parasitic infections
• Diverticulitis
• Irritable bowel syndrome
• Radiation proctitis
• Drug- or toxin-induced enterocolitis
• Vasculitis of the intestinal tract
• Colonic carcinoma
• Tuberculosis
• Diarrhea associated with infection
• Diarrhea associated with antibiotics

Patients with mild or moderate disease usually look well and exhibit few abnormal signs; bowl sounds and rectal exam (apart from blood) are often normal. Those with severe disease may also look deceptively well, but usually exhibit tachycardia, tender colon, and systemic complications. Diagnosis is made on the basis of history, absence of fecal pathogens, and endoscopic and histological appearances of the colon.

Mild inflammatory changes include the following.

• Loss of normal vascular pattern
• Fine granularity of mucosa
• Pinpoint hemorrhage to mucosal swabbing
• Exudation of mucopus

Progressive inflammatory changes include the following.

• Coarse granularity and pinpoint ulceration
• Confluent hemorrhage
• Confluent mucopus progressing to gross ulcerations
• Spontaneous hemorrhage
• Exudation of pus
• Pseudopolyps
• Epithelial dysplasia

Acute disease stage includes the following.

• Loss of haustrations
• Thickening of smooth muscle of colon
• "Lead pipe" appearance of colon
• Occasional colonic stricture

• Nonspecific Iron-deficiency anemia
• Leukocytosis Hypoalbuminemia
• Elevated ESR Electrolyte imbalance

Endoscopic appearance of mucosa ranges from normal-appearing to complete denudation; UC is characterized by an even "microcarpet" of tiny ulcers. Sigmoidoscopic appearance is rarely normal even during asymptomatic intervals. Pathologic changes include:

• Degeneration of reticulin fibers beneath mucosal epithelium
• Occlusion of subepithelial capillaries
• Infiltration of lamina propria with plasma cells, eosinophils, lymphocytes, mast cells, and polymorphonuclear leukocytes
• Crypt abscesses, epithelial necrosis, and mucosal ulceration

• Radiography (plain view of abdomen)
• Air contrast barium enema
• Ultrasonography and CT may help determine extent of disease and complications

• Stool samples
• Rectal exam
• Endoscopy with biopsy
• Presence of IL-1ra allele 2 gene is marker for disease severity
• State-Trait Anxiety Inventory (Form Y); Sacks' sentence completion tests (psychological influences)

The goal of treatment is to control inflammation, prevent complications, and replace nutritional and blood losses. Severe cases may require hospitalization; perforations and hemorrhage may occur without warning. Control of active disease with drug therapy depends upon extent and severity of mucosal ulceration. Most widely used are steroids and 5-aminosalicylic acid (5-ASA) drugs. Corticosteroids can induce remissions but do not prevent relapses. When indicated, total proctocolectomy with ileoanal pull through and pouch is the preferred surgical procedure. Indications for surgery include:

• Severe inflammation unresponsive to medical therapy
• Chronic active disease
• Cancer prophylaxis
• Growth retardation in children

Sulfasalazine is the treatment of choice for flare-ups, chronic treatment, and to reduce frequency of relapse (1 to 4 g/day). Diarrhea may be treated cautiously with diphenoxylate, loperamide, or opiates. Use of antidiarrheal agents in severe disease could precipitate toxic megacolon. Toxic megacolon requires immediate surgery if no improvement within 24 hours after hospitalization.

• Ulcerative proctitis and proctosigmoiditis may be treated topically with corticosteroid or mesalamine enema, foam, or suppository; oral prednisone if refractory (20 to 60 mg/day); osmotic purgation to relieve constipation.
• Parenteral or oral corticosteroids (prednisone 20 to 60 mg/day) for more severe flare-ups; patients with chronic activity (10% to 15%) require continuous low-dose corticosteroids.
• Immunomodulators such as 6-mercaptopurine and azathioprine reduce need for corticosteroids .
• Oral prednisone (20 to 60 mg/day) or parenteral corticosteroids and sulfasalazine (1 g bid or tid) and parenteral ACTH are useful in severe active disease; iron and parenteral hyperalimentation if indicated; antibiotics in toxic megacolon.
• A new class of topically-acting corticosteroids (budesonide, fluticasone, beclomethasone dipropionate, prednisolone-21-methasulphobenzoate, tixocortol pivalate) is an alternative in treating active UC.
• Cyclosporine may induce remission.
• Nicotine patches may induce remission but are not helpful in maintaining remission.

Nutritional and herbal support, mind-body techniques, and physical aids can help reduce the frequency and severity of ulcerative colitis as well as improve the integrity of intestinal mucosa and correct nutritional deficiencies. Stress reduction techniques through biofeedback, hypnosis, or counseling can help patients to deal productively with stress. Other mind-body therapies such as: yoga, tai chi, meditation, psychotherapy; stress management such as yoga, deep breathing, stretching, regular exercise (walking), meditation, prayer, visualization, and hypnotherapy; and support groups such as the Crohn's-Colitis Foundation of America (CCFA) may also be helpful.

• Decrease refined foods, sugars, and saturated fats.
• Eliminate all food allergens from the diet. The most common allergenic foods are dairy, soy, citrus, peanuts, wheat, fish, eggs, corn, and tomatoes. An elimination/challenge trial may be helpful in uncovering sensitivities. Remove suspected allergens from the diet for two weeks. Re-introduce foods at the rate of one food every three days. Watch for reactions which may include gastrointestinal upset, mood changes, headaches, flushing, and exacerbation of symptoms.
• A rotation diet, in which the same food is not eaten more than once every four days, may be helpful in reducing symptoms.
• Specific foods that may exacerbate ulcerative colitis are dairy, Brassica vegetables (cabbage, brussels sprouts, broccoli, cauliflower, and kale) and gluten-containing grains (wheat, oats, barley, triticale, rye).
• Fiber supplementation can help reduce abdominal pain, cramping, and gas. These supplements include psyllium, flaxmeal, slippery elm (Ulmus fulva) powder, and marshmallow root (Althaea officinalis) powder. There may be increased bloating and gas initially but this should resolve within 7 to 10 days.
• Pro-flora supplements taken bid to tid can help to rebalance normal bowel flora and reduce gas and bloating.
• Essential fatty acids may be protective of intestinal mucosa. Max-EPA or fish oil (3 to 4 g, up to 18 g/day).
• Bromelain (250 to 500 mg between meals) is a proteolytic enzyme that reduces inflammation.
• Minimum 48 oz. of water/day
• Eliminate caffeine and alcohol.

IBD is associated with low levels of the following nutrients due to poor absorption, competitive inhibition from medications, or increased requirement.

• Biotin (300 mcg/day)
• Beta-carotene (50,000 IU/day)
• Vitamin A (50,000 IU/day for one month, then 10,000 IU/day)
• Vitamin C (1,000 mg tid)
• Vitamin D (100 to 200 IU/day) is associated with secondary hyperparathyroidism and osteomalacia, possibly due to poor calcium absorption and utilization.
• Vitamin K (10 mg/day) may help normalize prothrombin levels and decrease bleeding.
• B vitamins, specifically thiamine (100 to 250 mg/day), pantothenic acid (100 mg/day), riboflavin (50 mg/day), B₁₂ (1,000 mcg/day), and folic acid (800 mcg/day). Folic acid may be depleted with sulfasalazine use, which is a competitive inhibitor with folic acid.
• Magnesium (200 mg bid to tid) is associated with weakness, hypotension, and tetany.
• Calcium (1,000 mg/day)
• Zinc (100 mg bid for one month, then 20 to 30 mg/day)
• Elemental iron (30 mg bid), especially with chronic blood loss. Glycinate form is least constipating and 30% more absorbable than ferrous sulfate.
• Selenium (200 mcg/day) protects against oxidative damage.

Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted. The goal of herbal therapy is to relieve spasm, reduce inflammation, and encourage healing of the intestinal mucosa.

• Enteric-coated peppermint oil: one to two capsules (0.2 ml peppermint oil/capsule) tid after meals. Peppermint oil (Mentha piperita) is a potent spasmolytic that reduces bowel irritability.
• A tincture of equal parts of the following herbs may be taken before meals (20 to 30 drops tid): Cramp bark (Viburnum opulus), passionflower (Passiflora incarnata), meadowsweet (Filipendula ulmaria), wild yam (Dioscorea villosa), valerian (Valeriana officinalis), and lemon balm (Melissa officinalis). Combined, they enhance digestion and relieve spasm.
• For acute exacerbation with bleeding, use equal parts of the following herbs in a tincture (30 drops qid): coneflower (echinacea purpurea), goldenseal (Hydrastis canadensis), and geranium (Geranium maculatum)
• Licorice root (Glycyrrhiza glabra) and marshmallow root (Althaea officinalis) are soothing and promote healing of gastrointestinal mucosa. Make a tea of licorice root by steeping 1 tsp. in one cup of hot water for 20 minutes. Drink 3 cups/day. (Contraindicated in hypertension.) For marshmallow root tea, soak 1 heaping tbsp. of root in one quart of cold water overnight. Strain and drink throughout the day.
• Quercetin (250 to 500 mg before meals) may help reduce reactions to food sensitivities.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Arsenicum album for intense cramping and burning, with scanty dark blood in stool. Patient is restless, chilly, and anxious about their health.
• China for extreme bloating and gurgling in abdomen; bloody stools and exhaustion.
• Phosphorus for painless diarrhea with prostration and thirst for cold drinks.
• Sulphur for morning diarrhea that drives patient out of bed.
• Mercurius vivus for IBD associated with canker sores and metallic taste.

Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory. Apply oil directly to skin, cover with a clean soft cloth (e.g., flannel) and plastic wrap. Place a heat source (hot water bottle or heating pad) over the pack and let sit for 30 to 60 minutes. For best results, use for three consecutive days.

Ulcerative colitis may respond to acupuncture, which can help alleviate spasm and normalize digestive function.

Regularly scheduled appointments to evaluate disease activity, and psychological well-being. The extreme variability and high incidence of relapse and morbidity predispose patients to anxiety and depression.

Severely ill patients must be monitored closely for peritonitis, perforation, and toxic megacolon; long-term patients for epithelial dysplasia and cancer. Annual liver tests and cholangiography for cholestasis are recommended. Laboratory parameters measured serially during treatment are useful indicators of disease activity.

Local:

• Hemorrhage
• Perforations
• Peritonitis
• Strictures
• Perianal abscesses
• Rectovaginal fistulas
• Pseudopolyposis
• Toxic megacolon
• Carcinomatous changes
• Colon cancer

Systemic:

• Peripheral arthropathy
• Ankylosing spondylitis
• Erythema nodosum
• Pyoderma gangrenosum
• Episcleritis
• Aphthous ulceration of the mouth
• Fatty liver
• Primary sclerosing cholangitis
• Cholangiocarcinoma
• Growth retardation in children
• Depression and anxiety

The typically relapsing–remitting course of UC depends upon severity of initial attack, extent of proximal colonic involvement, and response to medical treatment. There is no cure excepting colectomy. Left-sided and ulcerative proctitis have the most favorable prognosis. Drug treatment is effective for about 70% to 80% of patients; surgery becomes necessary in the remaining 20% to 30%. About 45% of patients are symptom-free at any given time; most suffer at least one relapse in any 10-year period. About 5% succumb to fulminant UC or require immediate colectomy; a smaller percentage have a single attack without recurrence; and about 15% experience continuous symptoms refractory to medication and rarely achieve full remission. In the 25% of patients with ulcerative proctitis (disease localized to the rectum), 10% to 30% experience late proximal spread. UC in children affects the entire colon in 50% of cases. The prognosis is affected by the extent and the severity of the disease, and by the physical condition of the patient.

Maintenance treatment should be continued, with pregnancy timed to inactive phase of disease and relapses treated aggressively with corticosteroids. Corticosteroids and sulfasalazine are safe and nonteratogenic; immunosuppressive agents are not recommended. Goldenseal, geranium, and quercetin are contraindicated in pregnancy. In addition, high doses of vitamins should be avoided.

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