Ulcerative Colitis Blog

Researchers are always on the hunt for novel therapies to treat UC and Crohn's. A recent study examined the effect of rosiglitazone, a drug used for management of type II diabetes mellitus, in mild to moderately active UC. How can a diabetes drug be useful for treating UC? The receptor that the drug affects is present both in fat cells and colon cells. It is hypothesized that the drug may act on the receptors on colon cells and send signals to decrease inflammation.

In this study, 105 patients with mild to moderately active UC despite current medical therapy were randomized to take rosiglitazone 4mg twice a day or placebo. At the end of 12 weeks of treatment, 44% of those treated with rosiglitazone had a clinical response as compared to 23% of those receiving placebo. Improvement in symptoms was noted as early as 4 weeks into the study; and patients who had a good response reported an improved quality of life by 2 months. It should be noted, however, that while many patients reported feeling better, colonoscopies performed after treatment continued to show some degree of inflammation. As the study was only 12 weeks in duration, the long-term effects of such a treatment remain unknown.

With regard to side effects there has been some concern raised regarding an increased risk of bone fractures and heart attacks in diabetics using rosiglitazone. In the UC study, no patients reported having fractures or heart attacks. The most common side effects were headache and swelling of the extremities.

While the use of such a medication in mainstream UC treatment is a ways off, it is reassuring to see potential progress on the horizon.

A common question asked by patients is whether they need to change their diet after being diagnosed with UC. As discussed in previous blogs, there is no evidence that specific foods contribute to inflammation in IBD. While there is not a "colitis diet" that individuals need to adhere to, certain foods or their components may produce symptoms of loose stools or gas. Some general considerations regarding diet for UC patients:

1) Eating smaller more frequent meals may help alleviate cramping and gas associated with larger meals.

2) Dietary fiber intake may have differential effects depending on the segment of the colon involved with colitis. Some patients with colitis limited to the rectosigmoid region find that fiber helps to bulk stool and aid with passage of bowel movements. Others with more extensive colitis, may develop discomfort with higher amounts of fiber as these products pass through inflamed segments.

3) It is possible to have lactose intolerance in addition to UC. Lactose intolerance is caused by gradual loss over time of the enzyme that digests lactose in dairy products. Symptoms of gas, bloating, and or/diarrhea after dairy products could suggest a diagnosis of lactose intolerance. Simple elimination of these foods from the diet or ingestion of a tablet containing a lactase enzyme usually results in symptom improvement.

4) Eating a balanced diet is more important restricting specific foods.

5) Alcohol will not affect inflammation in the gut related to UC, but can result in flatulence and diarrhea. Alcohol can be consumed in moderation in IBD.

6) In general, consumption of a daily multivitamin is a good idea. Patients with a history of steroid use or osteopenia/osteoporosis should also take 1500mg of calcium daily and 400-800 IU of vitamin D daily. Take note that an excess of vitamins can result in toxicity. Consult your physician or pharmacist if you are unsure regarding the dosage of vitamins and minerals that should be taken daily.

7) While fish oil has a theoretical anti-inflammatory effect, research studies regarding fish oil in UC have shown only a mild improvement in symptoms if any. Although fish oil is not harmful, there is insufficient evidence that it produces any significant benefit in UC at this time.

Many individuals with UC identify stress as a trigger for colitis flares. While the mind-body connection remains somewhat elusive, there is strong evidence to suggest that stress contributes to physiologic changes in hormones and the immune system. As such, stress reduction is beneficial for maintaining an overall healthy balance in life. Some tips and ideas for management of stress from Helpguide.org include the following:

1) Learn how to adapt to stress
- Many things that happen in life are out of our control. Instead stressing out over things you cannot control, try to focus on how you can adapt and react to situations.

- Reach out to others and share your feelings.

- Focus on the positive. While it is difficult to see the positive aspects of stressful situations, many people skilled at dealing with stress are able to use such situations as opportunities for personal growth.

2. Adopt a healthy lifestyle
- Regular exercise has been shown to be beneficial for stress management. In general, there are no exercise restrictions placed on UC patients outside of serious flares or recent surgeries.

- Eat a balanced diet and reduce caffeine and sugar. The swings that come with caffeine and sugar ingestion may leave you feeling fatigued when the effects wear off.

- Obtain adequate and restful sleep. The restorative properties of sleep help provide both physical and mental rest for our bodies.

3) Nurture yourself
- Set aside time for relaxation. Whether you enjoy massage, acupuncture, exercise, or simply going for a walk, it is important to set aside time for yourself to relax.

- Connect with others. Having a strong support network provides a buffer in stressful times.

- Do something you enjoy everyday.

While ileal pouch-anal anastomosis surgery after colectomy provides individuals with a way to maintain continuity of the GI tract for defecation, pouches are not without problems. In a previous blog, the issue of pouchitis, or inflammation of the pouch was discussed. Another pouch problem encountered by some individuals is a recently recognized condition called "irritable pouch syndrome" or IPS for short.

IPS is a condition of the pouch that is akin to irritable bowel syndrome (IBS) of the intestine. Symptoms of IPS are similar to pouchitis and include: change in stool consistency, abdominal pain or cramping, and perianal or pelvic discomfort. A diagnosis of IPS is considered when pouch patients with such symptoms are found to have normal intestinal lining on endoscopic exam but remain symptomatic. As opposed to pouchitis which is due to inflammation of the pouch, IPS is believed to be secondary to changes in nerve sensation to the pouch after surgery.

Symptoms may be relieved by dietary changes, such as low fat and low carbohydrate diets. Avoidance of diary products or excessive caffeine and alcohol may also be of benefit. Treatment with antidiarrheals (diphenoxylate, loperamide, cholestyramine), anti-spasm medication (dicyclomine, hyoscyamine), or medication for chronic abdominal pain (amitriptyline) may help alleviate symptoms that do not respond to dietary changes.

One of the more unpleasant tasks for patients undergoing colonoscopy is having to take a bowel preparation to cleanse the colon. Among the most common complaints with bowel preps are nausea, vomiting, and feeling dehydrated (fatigued, lightheaded, dizzy). Some tips on how to minimize or eliminate these problems include the following:

1) Stay well hydrated before you begin your bowel preparation. Two days before your colonoscopy, be mindful of your fluid intake and losses. The 48 hours before your test, the average adult consume at least eight 8oz glasses of fluid. The day before the procedure, it is recommended that an individual drinks 8 oz of fluid every 1-2 hours before taking the bowel prep. Drinks that contain electrolytes (ie; sodium, potassium) such as Gatorade or Propel are helpful in maintaining a balance of electrolytes during the prep. Patients with heart, lung, or fluid balance problems should speak with their doctor regarding how they should modify their fluid intake before a test. The key point to remember is to stay well hydrated.

2) Many bowel preparations instruct individuals to take a morning laxative the day before the test, followed by a stronger bowel preparation beginning that evening. Much of the nausea and vomiting associated with bowel preps is precipitated by rapid consumption of the prep. As such, individuals taking a bowel prep may want to consider starting the prep earlier in the afternoon and consuming at a slower pace to mitigate these symptoms.

3) A variety of bowel preparations exist that vary in volume and type (pill vs. liquid). Patients who have difficulty consuming large amounts of liquid preps, may want to speak with their physicians regarding alternative preps that come in a different formulation or smaller volume. Some preparations are not appropriate for patients with heart or kidney problems. Patients with such conditions should discuss this with their doctor before taking a bowel prep.

4) Individuals who have had problematic nausea and vomiting with bowel preps in the past may want to discuss with their doctor obtaining a prescription for anti-nausea medicine to take before the prep.

One of my patients recently diagnosed with UC became quite tearful during her last office visit. When I inquired what had upset her, she replied that she had been seeking information about UC on the internet and was frightened by some of the stories she read. She encountered uncensored websites with postings that did not contain medically accurate information, as well as patient stories that seemed to indicate to her that a surgery was inevitable so she should start planning now. We had a long discussion about the wide spectrum of disease severity in UC and how "you should not believe everything you read," particularly on the internet. While the World Wide Web has opened new avenues to obtaining information about almost everything you could want to know at any given time, it is important to review medical information from the internet with your doctor to verify its validity. Below are a few internet sites that contain reliable information and resources for patients regarding UC and Crohn's:

General Resources

The Crohn's and Colitis Foundation of America
http://www.ccfa.org/

The American Gastroenterology Association
http://www.gastro.org

The American College of Gastroenterology
http://www.acg.gi.org

National Institutes of Health
http://www.nlm.nih.gov/medlineplus/ulcerativecolitis.html#cat10

Living with UC
http://www.livingwithuc.com/livingwithuc/home.html

Pediatric IBD Resources

Boston Children's Hospital
http://www.experiencejournal.com/ibd/

American Pediatric Surgical Association
http://www.eapsa.org/parents/resources/ulcer_coli.cfm

Ostomy Resources

United Ostomy Associations of America
http://www.uoaa.org/

Kevin wrote into the blog recently to share his experience with probiotics in UC:

"Just wanted to mention something that really has worked for me. I have pancolitis (entire colon affected). I seem to flare up every two years and need a round of steroids to get back in remission. This last time, I flared again when I had tapered down off the prednisone a bit. For me, what finally got me off the steroids was a probiotic (live bacteria and other helpful "bugs") called Primal defense. I have been almost as colitis free as before I was diagnosed. Primal defense is soil organisms, similar to what you would ingest if you ate fresh vegetables out of a garden. Apparently they crowd out the unhealthy bugs that tend to accumulate in the guts of IBD sufferers. I can't guarantee it will work for anyone else, but it sure did the trick for me. Of course, check with your GI Doc before trying anything. Most will say stuff like "well, at least it won't harm you."

As discussed in a prior blog, probiotics have been studied for use in UC and Crohn's disease. Thus far, probiotics have only shown definitive benefit for treatment of pouchitis. Results from studies evaluating the utility of probiotics for UC and Crohn's have shown equivocal results. That being said, certainly there are some individuals such as Kevin who have noted improvement which they attribute to the probiotic. For the most part, probiotics are felt to be safe and the majority of physicians are not opposed to patients using them. As not all formulations are the same, however, it is wise discuss probiotics with one's physician before selecting one to take.

A common question from patients is: "Why is it recommended that non-steroidal anti-inflammatory medications (NSAIDS), such as ibuprofen, be avoided in IBD?"

While NSAIDs can serve as potent anti-inflammatory medications to treat things such as joint pains and backaches, they can have a paradoxical pro-inflammatory effect on the GI tract. The reason this happens is that the GI tract needs multiple lines of defense to protect its inner lining (think of all things the GI tract must be able to withstand - food, stomach acid, bile, medications, alcohol). One of the defense mechanisms our body uses to protect the GI tract is the secretion of hormone-like chemicals called prostaglandins. Prostaglandins help protect the intestinal lining against ulcer formation and aid in healing the GI tract when the protective barrier is broken. NSAID medications inhibit the production of prostaglandins throughout the body, and therefore leave the lining of the GI tract vulnerable to various insults. Furthermore, studies have demonstrated an association between NSAID use and increased risk of IBD flares. It is thought that a reduction in prostaglandin levels in the GI tract may account for this observation.

As such, IBD patients are counseled to avoid products pain relievers and cold medicines that contain ibuprofen. Alternative pain medications that are safe for most IBD patients include acetaminophen and tramadol. Patients with questions about which pain medication is best for them should consult with their physician

The inflammation in ulcerative colitis (UC) and ulcerative proctitis (UP) is dynamic and the extent of the colon involved can change over time. UC and UP uniformly affect the rectum (the lowest part of the colon) and the inflammation extends for a variable length upwards through the colon. Studies of UP patients suggest that the disease moves further up to involve more of the colon in about 25% of patients after diagnosis. The probability of disease extension appears to increase over time, with cumulative probabilities of extension estimated to be 20% and 55% at 5 and 10 years, respectively. Why the amount of colon involved remains stable in some patients and extends over time in others is not known. Risk factors for extension of disease include severe, and poorly controlled UP and UC. It is noteworthy that extension of disease can occur even in patients who are asymptomatic. Understanding the anatomic location of inflammation in the colon is important because we know that segments that have been inflamed are at greater risk of developing cancer than uninflammed segments. As such, taking medications as prescribed and staying on schedule for colon cancer screening are important for UP and UC patients.