Ulcerative colitis: the FAQs answered

Ulcerative colitis is the name given to the a condition that results in the inflammation of the colon and can lead to the production of ulcers. Leading gastroenterologist and expert in inflammatory bowel disease, Professor Stuart Bloom, explains what exactly the condition is. The London-based consultant discusses how common it is, signs to be aware of, who is most commonly affected, and how the condition is treated, both medically and dietary. 

What is ulcerative colitis? 

Ulcerative colitis is a disease that was first described approximately 150 years ago. It refers to an inflammatory condition of the colon, also called the large bowel.

The word colitis, in fact, can mean inflation due to any one of a variety of causes like infection, radiation, or drugs. Ulcerative colitis, however, refers to a particular disease. Sometimes ulcerative colitis is classified together with a different disease, called Crohn’s disease, as one of the two common inflammatory bowel diseases.

How common is ulcerative colitis?

Surprisingly, although it is not often talked about because it is unpleasant and causes embarrassment, it is not rare. It probably affects 250,000 people in the UK. Together with Crohn’s disease, approximately 400,000 to 500,000 people in the UK suffer from inflammatory bowel diseases.

What are the signs and symptoms of ulcerative colitis?

The clearest indication of ulcerative colitis is bloody stools or bloody diarrhoea. Stool frequency increases to more than three times a day but there is also blood or mucus mixed in with it. This is because of the inflammation in the colon that causes an inflammatory exudate mixed in with the stools.

Is there a specific age group that is at higher risk of developing ulcerative colitis? Why is this?

One of the reasons why ulcerative colitis is such an important condition is because it affects people at two very key stages of their life.

It can affect adolescents and young adults when they are completing their schooling or training, establishing careers, starting relationships, or considering having children. There appears to be a second peak a bit later on in the economically most productive years of life: the mid-thirties to mid-fifties. During this time, ulcerative colitis is very common and can impair work, having severe consequences.

How is ulcerative colitis treated?

Most commonly, we use drugs to treat this condition, although there is interest in the role of diet. In general, we don’t know what triggers this disease, so it can be difficult to give precise advice as to lifestyle modification or particular activities to avoid. Most of the time, drugs are used.

The simplest drug used is an anti-inflammatory, almost like aspirin, which is called mesalamine or mesalazine in the UK. It’s very safe and it is used in mild-to-moderate cases of colitis. It is also effective in preventing flares of colitis because the disease can come and go at unpredictable intervals.

If mesalazine doesn’t work, then we often have to use a type of steroid medication. Although we don’t like using it, because of its side effects, it can be very effective when used as a short-term measure.

The next treatment, above steroids, would be to suppress the body’s immune reaction to the cause of ulcerative colitis. We use drugs such as azathioprine, mercaptopurine, or methotrexate, which modify the immune system.

The most sophisticated and rapidly-growing group of drugs is loosely referred to as biologics. These constitute a range of molecules which are generally monoclonal antibodies that target particular inflammatory pathways.

Ulcerative colitis is an area of very active research and the number of new biologics that are becoming available is increasing almost month by month. At the moment, we have drugs in at least three or four classes. One of them is anti-TNF antibodies which include infliximab, adalimumab, and golimumab. Another is anti-integrin antibodies, which include vedolizumab. Finally, there are some antibodies used to inhibit signaling pathways like ustekinumab. There are other drugs that work in different ways. They’re called small molecules and are orally active. The most common being tofacitinib or xeljanz. In addition, there are many other drugs expected in the next 5 to 10 years that will treat ulcerative colitis.

What foods can trigger ulcerative colitis and how should people manage it alongside treatment?

It’s a great question and one that isn’t asked enough. So many patients want to know what they can do to influence the progress of their colitis.

Most of the textbooks will say that diet doesn’t have a huge role to play, except people with colitis can be lactose intolerant due to a lactase deficiency and they can’t tolerate dairy products. Some people with active colitis or colitis that has been active and is now in remission have to modify their dairy intake.

Another major factor is the role of dietary fibre, which is not frequently referred to in textbooks. My 30 years of experience in inflammatory disease have told me that people with colitis, especially if it is limited to the lower part of the colon, simply can’t tolerate high amounts of insoluble vegetable fibre. The population is bombarded with the importance of eating their 5-a-day fruit and vegetables and for most people, this is perfectly good advice. For people with colitis, especially as it can involve a degree of faecal hold-up above the level of inflammation, eating too much fibre can cause a lot of problems. 

If you would like to arrange a consultation with Professor Stuart Bloom to find out more about ulcerative colitis, or IBD, you can do so by visiting his Top Doctors profile.