Ulcerative Colitis
Sheila Mulhern & Stephanie Howard
Overview & Statistics
• Irritable Bowel Disease (IBD) is a chronic condition of
immune response and inflammation of the GI tract
• Two most common forms are ulcerative colitis and Crohn’s
disease
• Ulcerative colitis is a chronic disease of inflammation
affecting the lining of the colon and the rectum
• More than 1.5 million Americans have Crohn's disease or
ulcerative colitis, the most common forms of inflammatory
bowel disease.
• Video
http://www.youtube.com/watch?v=FjUke8TMwhU&feature=r
elated
CDC Statistics
• IBD doesn’t have a medical cure and
commonly requires a lifetime of care
• IBD is one of the five most prevalent
gastrointestinal disease burdens in the US
• IBD has an overall health care cost of more
than $1.7 billion
• IBD accounts for more than 700,000 physician
visits, 100,000 hospitalizations, and disability
in 119,000 patients in the US
Ulcerative Colitis
Is a chronic
Inflammatory Bowel
Disease (IBD) which
only affects the lining
of the colon
The lining of the colon
becomes inflamed and
develops tiny open
sores, or ulcers that
produce pus and
mucus
Digestive Functions
Structure
Activity
Functions
Lumen
Bacterial activity
Breaks down undigested
nutrients to be expelled as
feces or absorbed and
detoxified in liver;
synthesizes certain B
vitamins and vitamin K
Mucosa
Secretes mucus
Lubricates colon and
protects mucosa
Solidifies feces and
contributes body’s water
balance
Absorption
Muscularis
Haustral Churning
Peristalsis
Mass peristalsis
Defecation reflex
Series of muscular
contractions that moves
the contents through large
intestines to rectum for
elimination
Etiology
• The exact cause of ulcerative colitis is unknown, proposed
causes includes; genetics, immune reactions and
environmental factors
• Genetically susceptible individuals have abnormalities of
humoral and cell-mediated immunity or generalize enhanced
reactivity against commensal intestinal bacteria and this
deregulated mucosal immune response predisposes these
individuals to colonic inflammation
• Immune reactions to foreign substances (antigens) that
stimulate the bodies defense to produce inflammation that
continues without control progressing into IBD/UC
• Environmental factors such as sulfate-reducing bacteria which
produce sulfides, are found in large numbers of patients with
UC than in other people
Clinical Manifestations
• Ulcerative Colitis (UC)symptoms may vary depending
on the severity of inflammation or its location
• For therapeutic and prognostic purposes, Doctors
usually classify UC according to its location and
presentation
• The severity of the symptoms often correlates with
the anatomic extent of the disease, another
parameter that will guide treatment
• The Mayo scoring system is one instrument that has
been used to judge disease severity and monitor
patients during therapy.
• Scores range from zero to 12, with higher scores
correlating with more severe disease.
Ulcerative Colitis Symptoms
• Half of the patients have mild symptoms, others have more severe
attacks that occur often.
• Symptoms vary in severity and may start slowly or suddenly
• Bowel movements become looser and more urgent
• Persistent diarrhea accompanied by abdominal pain and blood in
the stool
• Tenesmus (rectal pain)
• Bloody stool
• Crampy abdominal pain
• Loss of appetite
• Weight loss
• Low energy and fatigue
• Children suffering with UC may have delayed growth and
development
Other UC Symptoms
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Fever
Gastrointestinal bleeding
Joint pain and swelling
Mouth sores (ulcers)
Nausea and vomiting
Skin lumps or ulcers
Possible Complications of
Ulcerative Colitis
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Severe bleeding
Anemia
Malabsorption of nutrients
Perforated colon (hole in colon)
Severe dehydration
Kidney stones
Liver disease (rare)
Osteoporosis
Inflammation of skin, joints and eyes
Increase risk of colon cancer
Rapidly swelling colon (toxic megacolon)
Risk Factors
• Sex According (The Crohn’s and Colitis Foundation of America)
UC is more common in women than men, but the Mayo Clinic
studies found Ulcerative Colitis to be about equal
• Age UC occurs at any age, but most often in the 30’s with a
second peak in the 50’s and 60’s
• Race or ethnicity UC affects all ethnic groups, but more
common in Caucasians and Ashkenazi Jewish descent
• Family History You’re at a higher risk if you have first degree
family members (parents, siblings, child etc.)
• Medications have been cited as possible linked to UC, such as
Isotretinoin use to treat scarring cystic acne that doesn't
respond to other treatments. Sold under brand names
Accutane, Amnesteem, Claravis and Sotret, also Tetracycline.
Goals of Treating UC
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Induce and maintain remission
Prevent reoccurrence
Control impact of complications
Improve nutritional status
Improve quality of life
Correct with surgery if necessary
Understanding Quality of Life
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May avoid travel or activity
Fear of being in public
Limited social interaction
Needs to plan ahead for
bathroom locations,
medications or personal
supplies
• May resist exercise
• Avoidance of foods
• Support group: Crohn’s and
Colitis Foundation of America
(CCFA)
UC vs. Crohn’s Disease
In UC, inflammation is limited to the colon and continuous.
In Crohn’s disease inflammation can occur anywhere along the
GI tract, most common areas are the terminal ileum and the
colon. Pattern is patchy.
UC vs. Crohn’s Disease
Comparison factor
UC
CD
Type of IBD
Yes
Yes
Prevalence
About equal
About equal
Area affected
Colon
Lesions
Shallow ulcerations
Colon and small
intestine
Deep ulcerations
Ulceration pattern
Continuous, snake-like
Patchy
Surgical option
25-40% will ultimately
have surgery
66-75% will eventually
undergo surgery
Colorectal cancer risk
Higher than CD
Lower than UC
Abnormal Colonoscopy
Results Analysis
Diagnosis: Tests for Ulcerative Colitis
• Colonoscopy with biopsy
is used to diagnose UC
• Other tests which can
supplement diagnosis
– Barium enema
– Fecal sample
– Complete blood count
(CBC)
– C-reactive protein (CRP)
– Sedimentation rate (ESR)
Treatment: Medications
• Anti-inflammatory – first step in treatment
– Sulfazine (Azulfidine), Mesalamine (Asacol, Lialda),
Corticosteroids (prednisone)
• Immune System suppressors – reduce inflammation by
targeting immune system response
– Azathioprine (Azasan, Imuran), Mercaptopurine
(Purinethol), Cyclosporine (Gengraf, Neoral),
– Infliximab (Remicade) – blocks inflammatory pathways
• Additional medications:
– Antibiotics, anti-diarrheal, mild pain relievers (Tylenol/
acetaminophen; excludes Advil, Motrin, aspirin), iron
supplements
Treatment: Surgery
• Surgery needed if medication treatment is
unresponsive
• The CCFA estimates this option is used for 2540% of cases
• Surgery is considered a cure – two main
options
– Proctocolectomy ileostomy
– Ileoanal anastomosis
Treatment: Surgery
Proctocolectomy Ileostomy
• Removal of the large intestine and rectum, leaving the lower
end of the small intestine (the ileum).
• The anus is sewn closed and the doctor makes a small
opening called a stoma in the skin of the lower abdomen.
• The ileum is connected to the stoma, creating an opening to
the outside of the body. The surgery that creates the opening
to the intestine is called an ileostomy.
• Stool empties into a small plastic pouch called an ostomy bag
that is applied to the skin around the stoma. The bag is
emptied several times a day.
Proctocolectomy Ileostomy
•Hospital stay ranges from
several days to two weeks after
surgery
•For those who can’t tolerate
anesthesia for long periods (age,
illness)
Treatment: Surgery
Ileoanal anastomosis
– Some or all of
the colon and the diseased
lining of the rectum is
removed.
– The end of the small
intestine (the ileum) is
connected to the anal
canal. This allows bowel
movements without an
ostomy.
Proctocolectomy vs Ileoanal
Anastomosis
Nutritional Risks
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Malabsorption, maldigestion
Dehydration
Protein deficiency, loss of lean muscle mass
Vitamin and mineral deficiencies
Vitamin D and calcium deficiency, risk for
osteopenia and osteoporosis
Guidelines for Medical
Nutrition Therapy
• Energy needs of UC patients are not generally
increased
– Disease increases BMR and physical activity decreases
• Protein requirements may be increased
– Inflammation treatment drugs induce negative nitrogen
balance and cause a loss of lean muscle mass
– Additional protein loss in ulcers and tissue damage from
disease
– Increase protein 1.3-1.5 g/kg/day
• Supplements of omega fatty acids
– Shown to reduce disease activity for inflammation and
immune response
Guidelines for Medical
Nutrition Therapy
• Reduce excessive intake of lactose, fructose and
sorbitol – may contribute to abdominal cramping,
gas and diarrhea
• Avoid foods that are not well tolerated
• Use foods containing prebiotics and probiotics
– Findings are still being investigated but many show
beneficial bacteria is introduced and reduces chemicals
causing inflammation
– Some studies didn’t show a difference when a placebo was
used
– Studies still trying to show whether they actually alter GI
microflora and immunologic response in the gut
Guidelines for Medical
Nutrition Therapy
• Supplements needed – folate, B6, B12, minerals and trace
minerals
– Replace those lost due to maldigestion, malabsorption, drug-nutrient
interaction or inadequate intake
– Folic acid needed to digest protein
• Supplements needed – zinc, potassium, selenium
– Due to aggravation from diarrhea
• Supplements of vitamin D and calcium
– Due to intermittent corticosteroids (inflammation/ immune)
– Find alternate sources: fortified soy milk, fortified juices, yogurt
– At risk for osteopenia and osteoporosis
• Reduce fiber intake, moderate as needed
• Enteral formula or parenteral nutrition if necessary
Guidelines for Medical
Nutrition Therapy
• Eat several small meals instead of three large meals
• Avoid caffeine, alcohol, fried, spicy intake
• Avoid gas forming, sulfer containing foods – lactose, eggs,
carbonated beverages, certain vegetables and fruit
• Drink plenty of fluids
• Low residue
– More refined grains, white pasta, white rice, soluble fiber (oatmeal,
applesauce – no sugar added)
– Avoid tough, fibrous fruits (pineapple), vegetables, whole grain breads,
celery
– Reduce fiber to 10 g fiber a day; high fiber is 20-35 g/day
– Slowly add fiber back to diet
Diet Planning: Post-surgery
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Name: Mr. Goldstein
Age: 44
Weight: 195 lbs.
Height: 5' 10"
Gender: Male
BMI: 28
Activity Level: Sedentary (post-surgery)
Diet Planning: Post-surgery Menu
Breakfast
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Egg White, Cheddar Cheese, Shredded, 0.25 c, Spinach, Chopped, Boiled, Drained
0.5 c., Cranberry Juice Drink with Vitamin C Added 8 fl. oz.
Kellogg’s Rice Krispies Cereal 1.5 c., Soy Milk, Calcium Fortified 8 fl. Oz.
Lunch
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Low Fat Plain Yogurt 1 c, Grape Juice, Unsweetened, with Added Vitamin C 8 fl. oz.
Plain English Muffin, Enriched, Toasted, Peanut Butter, Smooth 2 T., 0.5L water
Dinner
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Tilapia, baked or broiled 100 g, Whole Green Beans, Canned 0.5 c., Long Grain
White Rice, Enriched, Parboiled, Cooked 0.5 c.
Tilapia, baked or broiled 100 g, Mixed Vegetables, Canned 0.5 c., Boston Market
Home-style Mashed Potatoes 0.75 c.
1L water
Snacks
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Applesauce, Unsweetened, Canned 0.5 c.
Lucerne No Salt Added 1% Fat Cottage Cheese 0.5 c.
Oatmeal, Cooked with Water 1 c.
Diet Analysis: Post-surgery
Recommended Yours
Carbohydrates 45%-65% 949-1371 kCal
53% 1133 kCal
Proteins 10%-35% 211-738 kCal
25% 539 kCal
Fats 20%-35% 422-738 kCal
22% 479 kCal
Diet Analysis: Post-surgery
Energy
Kilocalories
2109 kcal, 2142.22 kcal, 102%
Carbohydrate
237 - 343g, 287.97 g
Fat, Total
47 - 82g, 54.07 g
Protein(g/kg/day)
70.76 g, 134.63 g, 190%
Fat
Saturated Fat < 10%, 21.89 g
Monounsaturated Fat, 16 g
Polyunsaturated Fat, 10.4 g
Cholesterol 300 mg, 188.36
mg, 63%
efa
Omega-6 Linoleic, 17 g, 8.69 g, 51%
Omega-3 Linolenic, 1.6 g, 0.7 g, 44%
Carbs
Dietary Fiber, Total 38 g, 19.7g,
52%
Sugar, Total, 131.61 g
Diet Analysis: Post-surgery
Other
Water, 3.7 L, 3.03 L, 82%
Alcohol, 0 g
Vitamins
Thiamin, 1.2 mg, 1.7 mg, 142%
Riboflavin, 1.3 mg, 2.8 mg, 215%
Niacin, 16 mg, 28.93 mg, 181%
Vitamin B6, 1.3 mg, 2.05 mg, 157%
Vitamin B12, 2.4 mcg, 9.89 mcg,
412%
Folate (DFE), 400 mcg, 658.8 mcg,
165%
Vitamin C, 90 mg, 196.02 mg, 218%
Vitamin D (ug), 5 mcg, 3.92 mcg, 78%
alpha-tocopherol (Vit E), 15 mg, 7.41
mg, 49%
Vitamins
Vitamin A (RAE), 900 mcg, 956.91
mcg, 106%
Vitamin A (IU), 3000 IU, 12670.48 IU,
422%
Minerals
Calcium, 1000 mg, 1425.45 mg,
143%
Iron, 8 mg, 17.44 mg, 218%
Magnesium, 420 mg, 427.1 mg,
102%
Potassium, 4700 mg, 3280.19 mg,
70%
Zinc 11 mg, 11.33 mg, 103%
Sodium 1500 mg 3042.59 mg 203%
Resources
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Krause’s Food and Nutrition Care Process, 13th edition
UC image - Monroe Carell Jr. Children's Hospital at Vanderbilt
http://www.childrenshospital.vanderbilt.org/services.php?mid=5806
PubMed colonoscopy image http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001296/
Barium enema image
http://www.emedicinehealth.com/script/main/art.asp?articlekey=138576&ref=128928
Colonospocy abnomalities image http://www.tabletprep.com/colonoscopy/index.aspx
MayoClinic http://www.mayoclinic.com/health/ulcerative-colitis/DS00598
MayoClinic, UC medications http://www.mayoclinic.com/health/ulcerativecolitis/DS00598/DSECTION=treatments-and-drugs
John’s Hopkin’s surgery images http://www.hopkinsgi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=AF793A59-B736-42CB-9E1FE79D2B9FC358&GDL_Disease_ID=b329650a-f196-4b6e-89d2-1d9bae11538b
Print out for students http://www.tabletprep.com/docs/colonoscopy.pdf
References
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http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001296/
http://ibdcrohns.about.com/od/
http://www.ccfa.org/assets/pdfs/ulcerative-colitis-the-a-to-z.pdf
http://emedicine.medscape.com/artoc;e/183084-0verview
http://www.mayoclinic.com/health/ulcerative-colitis/DS00598/METHOD=print