Ulcerative colitis is one of two main types of inflammatory bowel disease, which is sometimes abbreviated as IBD. Ulcerative colitis is named for its characteristic ulcerations located on the inner lining of the rectum and colon, also known as the large intestine or large bowel.
Ulcerative colitis begins with inflammation in the rectum that can extend contiguously up the entire large intestine to where it meets the small intestine at the ileocecal junction. Severe inflammation can cause damage to the mucosa, or intestinal lining, and result in ulcers prone to bleeding. Ulcers may heal as pseudopolyps and scar tissue, decreasing the amount of functioning tissue and leaving lasting damage. Multiple cycles of inflammation and healing over time can also affect the size and shape of the colon, making it shorter, thicker, and narrower.
Onset of ulcerative colitis can occur at any age, but symptoms generally develop in the greatest percentage of patients between the ages of 20 and 40. The second largest group of patients develops ulcerative colitis after age 60. This distribution of age is sometimes referred to as bimodal because it has two peaks. The age of onset seems to be influenced by multiple factors and varies slightly by country. Additionally, there has been an increased incidence of ulcerative colitis and inflammatory bowel disease in general in the past several decades, and these patterns may be shifting.
After the initial onset, patients may experience periods of flare-ups, or exacerbation of symptoms, and periods of remission with mild or no symptoms. Ulcerative colitis is more common in patients who have a family member with the disease, although hereditary patterns responsible for developing ulcerative colitis have not yet been identified. The initial cause of ulcerative colitis remains unclear. Patients with ulcerative colitis are also at increased risk of developing colon cancer.
The inflamed intestinal tissue present in ulcerative colitis can be visualized through a colonoscopy or sigmoidoscopy, during which a camera is inserted into the rectum and advanced to the target area of the colon. Contrast introduced to the colon through a barium enema is visible with a subsequent x-ray, which can show deviations from the colon’s normal size and shape. Bleeding ulcers can cause blood to be present in the stool, and blood loss can result in anemia.
Because the colon is the main site of water reabsorption in the gastrointestinal tract, disrupting its normal function with inflammation leads to diarrhea or liquid stools. Diarrhea may contain mucus, pus, and blood from ulcers in the colon. Irritation and damage to the mucosal lining also contribute to an increased urge to defecate, and a patient may have six or more bowel movements per day during a flare-up. Frequent diarrhea can lead to dehydration if the patient is not able to compensate for water losses by increasing oral fluid intake.
Abdominal pain and cramping are also common symptoms in patients experiencing an ulcerative colitis flare-up. Decreased appetite, fatigue, and weight loss can occur, with some symptoms causing or exacerbating others.
Severe flare-ups can require hospitalization for intravenous medications, such as corticosteroids, immunosuppressants to decrease inflammation, and IV fluids if the patient is dehydrated. Complications of ulcerative colitis are serious but not common. If the inflammation extends into the muscle layers responsible for motility surrounding the large intestine, the muscles become paralyzed and the bowel dilates or enlarges, which also causes abdominal distension. Signs of systemic toxicity, including tachycardia, hypotension, fever, and increased inflammatory markers, combined with dilation of the colon result in the condition known as toxic megacolon. Toxic megacolon is treated with medication and supportive care for about 72 hours. If the patient’s condition deteriorates or does not improve after that time a colectomy is considered.
Rupture or perforation of the colon from repeated ulceration and healing, toxic megacolon, or occasionally a colonoscopy procedure, can also occur. Peritonitis may result after a rupture or perforation as the bowel contents leak out of the large intestine and irritate the peritoneum.
Most patients with ulcerative colitis are treated and managed with medications and diet. Remissions can last months or years, but ulcerative colitis is not considered to be cured unless the colon has been removed.
Let’s look at a question for practice.
The nurse is caring for a 30-year-old patient who was admitted with abdominal pain. The nurse knows that which of the following are potential signs and symptoms of ulcerative colitis? Select all that apply.
- The patient has patches of inflammation surrounded by normal tissue in the colon.
- The patient has ulcers present in several places in the gastrointestinal tract.
- The patient has had diarrhea with blood eight times in 24 hours.
- The patient has a palpable abdominal mass, or
- The inner lining of the patient’s rectum, sigmoid, and ascending colon are inflamed.
The correct answers are C and E, diarrhea with blood and inflammation of the lining of the colon. A, B, and D are typically associated with another inflammatory bowel disease called Crohn’s.
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