Ulcerative Colitis

Ulcerative Colitis (UC) is an intestinal bowel disorder (IBD) like Crohn's disease that is also caused by an over-reaction of the immune system (autoimmunity). It affects the bottom portion of your intestines, called the colon. It is also restricted to the surface, mucosal layers of the colon and not the deeper layers, which are affected in the other IBD, Crohn's. It is most likely to develop when someone is aged between 15 and 30 years, although it can occur at any age.

The prevalence of ulcerative colitis is similar to that of Crohn's affecting up to 1 in 400 of us. There are other types of colitis, such as microscopic colitis which is as common as ulcerative colitis. It occurs more frequently in older people and especially women. It is generally not as serious as ulcerative colitis and Crohn's.

Causes

As with Crohn's disease a definite cause is not known, but we do know that there are genetic and environmental factors that affect risk.

Genetic factors

These do not seem to play as important a role in ulcerative colitis as in Crohn's. However, there are a number of genes that predispose to the disease. Some of these are the same genes that are associated with increased risk of Crohn's disease.

Environmental factors include

  1. Whether you were breast fed as a baby. There is evidence that this reduces risk of colitis(1). The likely reason is that breast feeding helps our immune system to develop by feeding gut bacteria and providing antibodies and other elements of the immune system. All this is likely to improve the tolerance that our immune system later displays to what we eat.
  2. One dietary factor that affects colitis is how much of different types of fat you consume. Omega 3 (w3) and omega 6 (w6) fats have different and normally opposing effects on hormones in our body.  The w6 fats are normally inflammatory with w3 being anti-inflammatory. The ratio between the level of these two fats is thought to affect how much inflammation there is in our bodies. Inflammation is not always bad, but it is thought that most of us eat too much w6 in comparison to w3, leading to a more inflammatory set of hormones being released in our bodies. There is evidence from animal experiments that supports the notion that too much w6 in comparison to w3 can increase the amount of inflammation experienced with colitis(2).
  3. The absolute amount of w6 fats. In some studies the w6 fat called arachidonic acid (AA), when present in the lipid membranes of the cells lining our guts, has been powerfully linked with colitis(2a). The presence in the cell membranes is believed to be closely matched to dietary intake of AA and its w6 precursors, such as linoleic acid. The foods that feature AA and its precursors include red meat, margarine and most oils (safflower and sunflower are especially high in w6 (>50%)). Olive oil, butter and coconut oil are pretty low (<5%).
  4. A 2nd dietary factor involves substances (glycoalkaloids) found in potato skins. These substances disrupt the inner surface of the intestines, leading to contact between the immune system and foreign substances that trigger an inflammatory response that could lead to colitis(3).
  5. A final dietary factor, as with Crohn's is vitamin D. This has anti-inflammatory effects within the gut and helps the immune system to maintain a normal response to substances and microbes within the gut(3a).
  6. Some drugs, in particular NSAIDs (non-steroidal anti-inflammatories) such as aspirin, ibuprofen and naproxen are associated with increased cases of UC(4).
  7. Smoking and air pollution do not seem to play much of a role in ulcerative colitis, whereas in Crohn's disease they do.
  8. The food additive carrageenan (a thickener) can be particularly problematic for some colitis sufferers. Check on food packaging.

Symptoms

The most common symptoms of colitis include:

  1. Abdominal pain including cramping.
  2. Diarrhoea, which can contain blood and mucus.
  3. Bloating
  4. Fatigue - can be caused by blood loss, lack of sleep or as a side effect of the drugs used to treat colitis.
  5. Weight loss - while the disease is restricted to the colon, it is still able to cause dehydration as the colon absorbs water. A few nutrients are also absorbed from the colon and so malnutrition can result.

Nutritional therapy

Many of the dietary issues that are important for Crohn's disease are also important for ulcerative colitis. Firstly, in both diseases there is a lack of absorption of nutrients due to problems with the surface layers of the gut, secondly appetite reduces, and thirdly there is a loss of nutritients due to diarrhoea.

Vitamins needed

Fat soluble vitamins such as vitamin A and D are needed as well as the B vitamin, folic acid for at least two reasons.

  1. An inflamed gut does not allow for as much absorption of these vitamins.
  2. One of the main drugs used to treat colitis, sulfasalazine can deplete folic acid and works better when the patient has good vitamin A and D status.

Eating plenty of dairy such as butter and cheese as well as eggs will provide a broad range of fat soluble vitamins. It will also provide butyrate, a short chain fatty acidthat helps repair damaged cells in the colon. Folic acid is found in green leafy vegetables and these should be included in at least 2-3 of your meals every week.

Quercitrin may help

Diarrhoea, and other symptoms of chronic inflammation associated with Colitis can be treated with quercitrin, which is a glycosylated form of the better known quercetin. It has been found to relieve colitis in animal experiments. Quercitrin is found in good amounts in foods such as capers, onions, cocoa powder and peppers(5b). It may well be more effective to consume the food form of this flavanoid rather than buying quercetin supplements, which in some studies have not performed as well(5). Quercetin has also been associated with a reduction in histamine release from mast cells, a factor associated with developing a leaky gut(5a)

Vitamin D and melatonin

Spending time out of doors in the sun is likely to be especially helpful as vitamin D deficiency is common with colitis. Both vitamin D and the hormone, melatonin help relieve colitis symptoms. You receive most of your vitamin D from the sun and can induce greater melatonin release by getting out in the sun early in the day, but limiting your exposure to bright light in the evening.

Conventional medical  treatment

The most common drugs used to treat colitis are the amino-salicylates (5-ASAs) and for more serious disease or flare ups, corticosteroids. Both reduce the inflammation. 

Aminosalicylates can be delivered with sulfapyridine (sulfasalazine) or without (mesalamine, olsalazine or balsalazide(6,7)). These last 3 have fewer side effects than sulfasalazine, which in a significant number of people, can cause headaches, nausea and rashes. For those who can tolerate sulfasalazine, it is the cheaper option. All aminosalicylates work by suppressing folic acid synthesis and it is important to ensure adequate folic acid intake if you are taking these drugs. These drugs only work effectively when the patient has a good status for vitamins A and D.

All of the 5-ASA drugs appear useful when the disease is mild to moderate or in remission. These drugs can also be used with Crohn's, but are only really effective when the disease is limited to the colon.

In serious cases of ulcerative colitis, surgery can be an effective option. The surgery normally involves the removal of the whole colon. Typically their are 3 possibilities.

  1. The small intestine is connected either to the skin above right hand side of the groin area and a bag is adhered to the skin to collect the output which needs emptying 2-4 times per day.
  2. The teminal end of the small intestine is formed into a pouch, which grows in the weeks after surgery.

Faecal therapy 

One of the underlying problems in all IBDs is that the bacterial species that inhabit your colon become unbalanced. This situation is termed dysbiosis. Basically it means that there is less variety of bacteria in your intestines and the wrong sorts of bacteria predominate.

A quick way to resolve this issue is to transfer bacteria from another persons healthy gut into the gut of someone with IBD. Often this person is another family member. The common way of doing this is by a faecal transplant. Yes, these sound pretty nasty, but they have saved lives(8). Currently faecal transplantation is a pretty new therapy. In the UK and US it is currently only allowed for people with C. Difficile infection(9). However, there are many case reports fo it being used successfully to treat IBD.

References 

1) http://ajcn.nutrition.org/content/80/5/1342.long - breastfeeding and UC risk

2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909993/ - w3 oils and UC risk

2a) http://www.gastrojournal.org/article/S0016-5085(10)01463-0/fulltext - Arachidonic acid and colitis

3) http://link.springer.com/article/10.1007%2Fs10620-010-1158-9 - potato skins may trigger UC

3a) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4009525/ - vitamin D levels lower in IBD patients

4) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3369539/ - NSAIDs causing colitis

5) http://www.ncbi.nlm.nih.gov/pubmed/15668926 - quercitrin for colitis

5a) http://www.ncbi.nlm.nih.gov/pubmed/6202731 - quercetin preventing leaky gut

5b) http://www.quercetin.com/overview/food-chart - quercetin in foods

6http://www.ccfa.org/assets/pdfs/aminosalicylates.pdf - conventional medical treatment

7) https://www.youtube.com/watch?v=-ittHMcSbCk - ASA on youtube

8) http://www.nytimes.com/2010/07/13/science/13micro.html?pagewanted=1&_r=0 how the human microbiome improves our health

9) http://www.nice.org.uk/guidance/ipg485/resources/guidance-faecal-microbi...