Diagram of the Human Intestine
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Ulcerative colitis

Ulcerative colitis is an inflammatory disease of the bowel that usually affects the distal end of the large intestine and rectum. It has no known cause, although there is a genetic component to susceptibility. more...

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Symptoms

  • Chronic diarrhoea (sometimes bloody). Other symptoms may include abdominal pain and discomfort, bloating, and nausea.
  • No infective cause of diarrhea found.
  • Inflammatory changes are most often confined to the left side and distal parts of the large intestine, however, any part of the colon can be affected. Inflammatory changes can expand over time and affect larger areas of the colon. Long periods of inflammaton lead to fibrotic changes and can cause colon de-haustration, which results in the characteristic narrowing of the bowel.
  • Disease variable in severity from patient to patient and time to time. This makes long-term prognosis very difficult, since a specific patient may remain in clinical remission for years between exacerbations.
  • Significant risk of carcinoma after 10 years, which may in some cases require frequent surveillance biopsies or even prophylactic bowel removal.
  • Patients may have other auto-immune features and extra-bowel complications including but not limited to iritis, uveitis, episcleritis, migratory polyarthritis, sacroiliitis, erythema nodosum, fingertip clubbing, ankylosing spondylitis and primary sclerosing cholangitis.
  • Fistula formation is rare but does occur. However, unlike Crohn's disease, the probability of recurrence is low. Anal fissures are unfortunately much more common, and are in fact the very mechanism through which fistulas can be formed (although rarely) in ulcerative colitis patients - deep fissures can reach glands in the anal walls which then become infected and form abscesses which, in turn, lead directly to fistula formation.
  • Often found in former smokers. Stopping smoking can cause a reduction in the protective mucus lining the colon. When this protective mucus is reduced, the bacteria in the colon can attack the colon lining causing the immune system to become active and fight the bacteria. For unknown reasons, this causes damage to the lining (ulcers) of the colon walls in one or more places. Resumption of nicotine either through patches or smoking can extend remission time although the benefits versus the other health risks of smoking are questionable.

Comparison to Crohn's disease

Ulcerative colitis is similar to Crohn's disease, but there are characteristic differences. Ulcerative colitis affects only the colon and cannot "migrate" to the small intestine, while Crohn's disease can affect the entire digestive tract. Complete colon removal can thus be considered a "cure" for ulcerative colitis. Ulcerative colitis is usually confined to the mucosal and submucosal lining of the colon, and affects whole areas of intestine. Crohn's disease, on the other hand tends to be patchy, and affect more layers of intestine, being transmural in nature. Due to the nature of the inflammation, ulcerative colitis rarely requires resection surgery in contrast to Crohn's disease where such surgery is often needed due to dangerous bowel obstructions and other complications. However, the risk of colorectal cancer development in ulcerative colitis patients is significantly greater (up to 5 times) than general population after 10 years following the diagnosis.

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Probiotic useful for preventing relapse of ulcerative colitis
From American Family Physician, 5/15/05 by Allen F. Shaughnessy

Clinical Question: In patients with ulcerative colitis currently in remission, is the probiotic Escherichia coli Nissle 1917 as effective as standard treatment to prevent relapse?

Setting: Outpatient (any)

Study Design: Randomized controlled trial (double-blinded)

Allocation: Uncertain

Synopsis: Probiotics are live, nonpathogenic microorganisms used to alter the microbial balance in the intestinal tract. Although most probiotics are gram-positive species (e.g., Lactobacillus species), E. coli Nissle 1917 is a gram-negative probiotic of a different strain than toxic E. coli that may work by causing an immune response or preventing invasion of other bacteria.

In this trial, the investigators enrolled 327 patients with ulcerative colitis in remission who had a history of at least two acute attacks. Patients were assigned to receive E. coli Nissle 1917 probiotic in a dosage of 200 mg once daily or controlled-release mesalamine (called mesalazine everywhere but in the United States) three times daily for 12 months. The patients were examined once a month for three months, then every three months for the remainder of the study.

The investigators incorrectly entered or failed to follow up with 32 percent of the patients. Dropouts were common; by the end of the study, 50 percent of patients receiving E. coli Nissle 1917 and 43 percent of patients receiving mesalamine had discontinued therapy because of various problems or protocol violations. The authors did not mention whether additional therapy could be used or how acute relapse was managed, although they prohibited patients from using antibiotics, sulfonamides, or steroids at entry to the study.

The main outcome was the number of patients experiencing a relapse during the 12 months of the study, as measured by an undescribed clinical activity index. In patients who maintained therapy (per-protocol analysis), 36.4 percent of the patients in the E. coli Nissle 1917 group relapsed compared with 33.9 percent of patients receiving mesalamine. Relapse rates were similar between the groups when using intention-to-treat analysis (45.1 versus 37.0 percent). Discontinuation rates because of adverse effects were similar in the two groups. The study had a power of 20 percent to find at least a 20 percent difference (not a 20 percentage-point difference) in the rate of relapse, if one exists.

Bottom Line: Treating ulcerative colitis with the probiotic E. coli Nissle 1917 is as effective as prophylactic mesalamine in the prevention of relapse. No commercially available products containing this nonpathogenic bacteria were located, and the strain (Nissle 1917) is crucial. (Level of Evidence: 1b-)

Study Reference: Kruis W, et al. Maintaining remission of ulcerative colitis with the probiotic Escherichia coil Nissle 1917 is as effective as with standard mesalazine. Gut November 2004;53:1617-23.

Used with permission from Shaughnessy AF. Probiotic useful for ulcerative colitis. Accessed online March 1, 2005, at: http://www.lnfo POE Ms.com.

COPYRIGHT 2005 American Academy of Family Physicians
COPYRIGHT 2005 Gale Group

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