Digestive Problems
Diseases: Colon and Rectum: Ulcerative and Crohn's Colitis
Find out about the Charleston area Crohn's & Colitis support group.
Just like some people get arthritis which is an inflammation of the joints, it is also possible to get inflammation of the colon. Inflammation of the colon (large intestine) is called colitis. Germs can cause colitis. Poor blood supply can cause colitis. Some medications can cause colitis. However, in most cases, the cause of colitis is not known.
When no other cause can be found for the inflammation, it falls into either one of two categories, ulcerative colitis or Crohn's colitis (Crohn's disease of the colon). Diet and psychological factors do not cause ulcerative colitis or Crohn's colitis. No germs have been found to cause these conditions. Colitis is not infectious; it cannot be passed from one person to another like the flu or a common cold.
Endoscopic image of ulcerative colitis
affecting the left side of colon.
Ulcerative colitis causes inflammation only in the mucosal (superficial) lining of the colon. It does not affect the small intestine or the stomach. Ulcerative colitis generally starts in the rectum and spreads from the rectum toward the first part of the colon in a steady progression.
Crohn's colitis involves the entire thickness of the wall of the colon, and can also involve other parts of the intestines such as the small intestine. Since Crohn's disease can involve the entire thickness of the intestine, sometimes long ulcers are seen in the colon lining. These ulcers look as if someone had pulled a grass rake across the lining of the colon. They are called rake ulcers or bear claw ulcers. Crohn's disease can be patchy. It can be present in one part of the colon, absent in another, and then present in the next part.
Crohn's disease involves the small intestine, but ulcerative colitis does not. The last one to two feet of the small intestine are called the ileum. If ulcers and extensive inflammation are seen in the ileum the colitis may be due to Crohn's disease.
The colitis associated with Crohn's disease is often associated with anal problems such as fissures, fistulas, abscesses and skin tags; whereas, ulcerative colitis never causes anal problems.
Ulcerative colitis can be cured by removing the entire colon if necessary. Crohn's disease can never be completely cured. If areas of the small intestine or colon which are involved with the Crohn's disease are removed, the surgery will generally relieve the person's symptoms for a while, sometimes for many years. However, at some point in the future, symptoms may recur.
Whether colitis is due to ulcerative colitis or Crohn's disease is generally not important unless surgery is required. If surgery is required, then ulcerative colitis is treated differently than Crohn's colitis. If surgery is not required, ulcerative colitis is generally treated with medications in the same manner as is Crohn's colitis.
Medicines for Colitis
The treatments for colitis due to ulcerative colitis or Crohn's colitis include many medications which decrease inflammation. These include: Prednisone, other steroids, Imuran (azathioprine) and Cyclosporin. There are also a number of other medications which relieve the colitis, including A 11/27/2007 asa enemas.
Azulfidine (sulfasalazine) was one of the early medications used against colitis, and is still quite effective. Azulfidine is a pill. It has been used many years and is less expensive than some of the newer pills. It does have some side effects which are not present in the newer medications. For example, it may cause low blood counts, headaches, kidney problems, and a serious skin rash. It cannot be taken by people with a sulfa allergy.
New medications such as Dipentum, Asacol and Pentasa have the same active ingredients as Azulfidine, but they do not cause problems in people with sulfa allergies. These pills are taken by mouth, and reduce inflammation in the intestine.
If the inflammation is only in the rectum, then Rowasa suppositories can be used. These suppositories contain the same active ingredient found in Azulfidine, Pentasa, Asacol and Dipentum. However, because Rowasa is a suppository, the medication is applied directly to the inflamed area of the rectum.
If the inflammation involves only the bottom two feet, that is, the left side of the colon and the rectum, then Rowasa enemas can be used. These enemas also contain the same active ingredient as Azulfidine, Asacol and Dipentum, but apply it directly to the lining of the colon.
The pills and the enemas or suppositories can be used together. Often suppositories or enemas are used to get the colitus under control. Then, they are gradually tapered off, and the person continues to take one of the pills.
The next line of therapy involves the use of steroids. Prednisone is the main steroid used in the treatment of colitis. Prednisone is fairly inexpensive. When taken in high doses, it has side effects which include lessened immunity to infections, weight gain, nervousness and mental hyperactivity, some emotional changes, facial changes or fattening, and stretch marks on the skin. These side effects generally occur only if the steroids are used for more than a few weeks. Usually, the steroids are used in high doses for only a few days or weeks, to gain control of the disease. Then, their use is tapered off over a week or two. The colitis is then controlled by using a pill such as Dipentum or Asacol, with or without the enemas or suppositories. Sometimes steroids must be used longer.
If the medications do not control the colitis or if the side effects from the medical treatment become intolerable, then physicians consider surgery. Symptoms of colitis include rectal bleeding, abdominal pain, diarrhea, passage of mucus and bloody stools. Indications for surgery include rupture of the colon, severe bleeding, very frequent diarrhea, severe weight loss and chronic illness which never gets better.
Ileal Pouch for Ulcerative Colitis
A new surgical technique, developed within the last twenty years, can cure ulcerative colitis without the need for a colostomy or ileostomy bag.
The Ileal Pouch technique is a surgical procedure which removes the entire colon, from the point of its attachment at the small intestine to the point of its attachment at the anus. The anal sphincter muscles and the anus are left intact. The last 10 inches of the small intestine (the ileum) are then used to make a U-shaped sac (pouch) which is attached to the anus at the anal opening.
This pouch acts as a new rectum. The anal sphincter is left in place so that the person can still control his bowel movements. A person generally moves his bowels 4 to 8 times per day following this operation. However, he has reasonably good control, and no longer has any symptoms of the colitis.
The ileal pouch procedure requires two operations. During the first operation, the surgeon removes the entire colon, creates the pouch and hooks it to the anus. He makes an ileostomy, which means that the person must temporarily wear a bag on the abdomen to collect stool. This prevents bowel contents from entering the pouch until it is healed. After about three months, the surgeon removes the ileostomy. The pouch then begins to function as a rectum, and the person no longer needs the ileostomy bag.
No Pouch for Crohn's Disease
Because Crohn's disease can attack the small intestine as well as the colon, the pouch is not used for Crohn's disease. When surgeons tried the pouch for Crohn's disease, the complication rate was very high. In most cases, the Crohn's disease attacked the pouch and it could no longer be used.
For those with Crohn's disease, if the colon is very diseased but the rectum is not, then the colon can be removed except for the rectum, and the small intestine can be connected directly to the rectum. In many cases, if the Crohn's disease involving the rectum is not severe, it can be controlled with Rowasa enemas or Rowasa suppositories.
Treatment of Anal Crohn's Disease
When there is perianal disease associated with Crohn's disease, the antibiotic Flagyl (metronidazole) may help. However, it can cause side effects such as tingling of the nerves and headaches.
A common treatment for fistulas in the anal area due to Crohn's disease is the use of setons. Setons are simply elastic "rubber bands" which are placed through the fistulas. Setons do not cure the fistulas. But, they do prevent pus from accumulating which may also help to reduce pain.
Stomas
Sometimes surgeons must bring a portion of the intestine through the abdominal muscles out to the skin. This is called an "ileostomy" if the small intestine is used and "colostomy" if the colon is used. The intestinal contents come out through the opening of the skin (stoma) and are collected in a bag worn on the surface of the body.
Fortunately, with today's techniques a permanent stoma is only necessary if the anal sphincters are permanently damaged by, for example, cancer, infection or inflammation.