Introduction
Millions of people worldwide visit emergency departments with abdominal pain as their chief complaint and are diagnosed with one of the inflammatory bowel diseases (IBDs). As soon as chronic inflammation reaches a colon, there is a risk of having IBDs, either ulcerative colitis or Crohn’s disease (Roberts-Thomson et al., 2019). Ulcerative colitis is one of the IBD forms that is characterized by long-lasting inflammation and the presence of sores in the digestive tract (Verma et al., 2020). Approximately 1.5 million Americans have ulcerative colitis, and between $8-14 billion are the related costs (Poojary et al., 2017; Ungaro et al., 2017).
Although these numbers are not as critical as those of cancer, depression, or diabetes statistics, their multifactorial pathogenesis, associated readmissions, and possible complications cannot be ignored. As a rule, this disease is observed in patients before their 30s, but there are also cases when children or older adults are affected by ulcerative colitis. In this paper, attention will be paid to ulcerative colitis pathophysiology, etiology, signs, incidence, and prevalence in the United States to clarify which diagnosing tools, treatment methods, nutrition plans, and medications are commonly recommended.
Pathophysiology
As well as in the case of another IBD, Crohn’s disease, the pathogenesis of ulcerative colitis remains to be a poorly investigated and understood area. It is known that inflammation begins in the rectum and extends proximally in the entire colon. Sometimes, ulcerative colitis could touch upon a large bowel at the same time. Colonic epithelial cells and epithelial barriers are influenced by this disease, with their functions being changed. According to Ungaro et al. (2017), “the expression of peroxisome proliferator-activated receptor gamma” is reduced (p. 1757). At the beginning of the disease, the mucous membrane stays granular with asymmetric hemorrhagic areas. If a severe form of ulcerative colitis is observed, purulent mucosal ulcers grow.
In the majority of cases, the pathophysiology of the chosen disease is introduced as a number of defects in several areas. In the discussion developed by Lynch and Hsu (2019), these areas are the “epithelial barrier, immune response, leukocyte recruitment, and microflora of the colon” (par. 9). For example, luminal antigens play an important role in tolerating dietary antigens. However, defects in colonic mucin promote the absorption of these antigens because of tight junctions and the increase in Toll-like receptors (Ungaro et al., 2017).
In addition, the immune system is also challenged, provoking new inflammatory processes and the creation of antibodies in the bowel. Change in the intestinal microbiota is another part of the pathogenesis of the disease (imbalance between host-microbe immune responses and enteric microflora) (Lynch & Hsu, 2019; Roberts-Thomson et al., 2019). The progress of mucosal inflammation can be considerably extended to other proximal segments.
Finally, the role of neutrophils in the pathogenesis of ulcerative colitis should be mentioned. Neutrophils are representatives of an innate leukocyte subset in the blood, and they increase in number as soon as inflammation is detected (Zhou & Liu, 2017). This type of recruitment includes the adhesion of leukocytes to musical tissue, which helps to control the condition of the endothelium during inflammation-caused changes. All these movements could also cause bleeding, erosions, and erythema in the bowel (Gajendran et al., 2019). The presence of such a variety of factors and reactions of the body to an inflammatory process make ulcerative colitis a complex subject for discussion from the point of view of its pathophysiology.
Etiology and Genetic Risk
As soon as a person is diagnosed with ulcerative colitis, one of the first questions posed to a doctor presumes its causes. People want to know what genetic risks exist, that is why the etiology of a disease is defined as a critical topic for discussion in many research projects. Lynch and Hsu (2019) say that there is no specific cause that can be given to IBDs. However, at the same time, a primary genetic component cannot be ignored because approximately 8-14% of patients have a family history (Lynch & Hsu, 2019).
Taking into consideration the lack of information in this area, the etiology of ulcerative colitis turns out to be an area that is open for suggestions and research. Roberts-Thomson et al. (2019) use diet as one of the potential risk factors because dietary changes during the last 100 years demonstrated minor changes in IBD patients. As a matter of fact, these problems were defined as “of uncertain significance” (Roberts-Thomson et al., 2019, p. 275). Still, it is possible to agree that diet may be added to the epidemiological list in this case.
Ulcerative colitis is associated with changes in the intestinal microbiota and weakened immune responses. Following this explanation, Roberts-Thomson et al. (2019) use environmental associations as a cause of the disease. The environment is a broad topic in health care and medicine, and the causes could be connected to the preferred lifestyle or the offered living conditions. There are also situations when people, especially children, are exposed to unfavorable microorganisms or events related to feeding, working, or studying (Roberts-Thomson et al., 2019). Sulfide production is another significant cause of ulcerative colitis in patients.
Sulfate-reducing bacteria aim at creating sulfides that, in combination with nitric oxide, provoke toxicity and inflammation with time (Roberts-Thomson et al., 2019). Attention to hygiene is also required because sometimes inflammation begins because of other bacteria reach the bowel due to poorly washed hands or products, and the organism has to react to unknown (and usually dangerous) substances.
Among risk factors, patients should be aware of the conditions that could increase their chances of having ulcerative colitis. For example, the age of a person is not significant because it is possible to have problems either at the age of 1, 30, or 60 years. However, a smoking habit usually creates controversial discussions about IBD. Roberts-Thomson et al. (2019) state that smoking increases the risk of Crohn’s disease but decreases the risk of ulcerative colitis.
Lynch and Hsu (2019) also discovered that smoking protects people against the development of inflammations that lead to ulcerative colitis. Still, no specific and evidence-based recommendations are developed at this moment. The racial factor is also investigated to prove that high risks of IBD are detected among European and American Jewish populations (Gajendran et al., 2019). African Americans and Hispanics have a lower prevalence compared to whites.
Incidence
The 20th century was the period when the number of IBDs was increased in European and North American countries. Roberts-Thomson et al. (2019) connect the growth with such processes as industrialization and westernization when people could not resist the progress and contributed to such fields as technology, manufacturing, mining, etc. Industrialized countries put their citizens under threat because of the necessity to live under specific conditions, with millions of people working with chemicals or other dangerous substances. Worldwide, the incidence of cases of ulcerative colitis varies from 9 to 20 per 100,000 individuals annually (Gajendran et al., 2019; Lynch & Hsu, 2019).
The researchers explain its nature as bimodal age distribution, and its first incidence peak is observed in the 20ies or the 30ies, and the following peak is between the 50es and the 60ies (Gajendran et al., 2019). Some studies indicate that ulcerative colitis is frequently observed among male patients, but Lynch and Hsu (2019) give no preferences to a gender factor. However, in general, incidence rates are considered stable during the last several decades, with more attention being paid to other aspects of ulcerative colitis.
In the 21st century, the incidence situation has been stabilized in industrialized countries. First of all, no dramatic changes occurred after the process of westernization. Secondly, IBD has become a global disease with increased incidence in Asian, African, and South American countries (Ng et al., 2017).
Gajendran et al. (2019) investigate immigration as another critical element in the distribution of ulcerative colitis in the United Kingdom because Asian immigrants increase the incidence of the disease compared to other European countries. Despite the fact that much information has already been discovered and published, many developing countries have limited access to diagnostic tools to detect new cases of ulcerative colitis and help patients within a short period. Therefore, developed countries continue sharing their experiences and achievements to predict and control incidence around the globe.
Prevalence in the USA
Many studies are developed to identify the prevalence of ulcerative colitis in the United States, as well as worldwide. Using the reports of professional organizations, Lynch and Hsu (2019) conclude that the current global prevalence of the disease is between 156 and 291 cases per 100,000 patients annually. For example, using the results of the Rochester Epidemiology Project, Gajendran et al. (2019) describe the changes in the field as follows: 214 cases per 100,000 people in 2000 and 286 cases per 100,000 in 2011.
In comparison to other IBDs, ulcerative colitis is frequently diagnosed among adult patients, and children have more chances to have Crohn’s disease (Lynch & Hsu, 2019). Regarding the already mentioned risks and causes, there is an increased prevalence of the chosen disease among non-smokers or those people who have recently quick smoking.
The Centers for Disease Control and Prevention is one of the most reliable sources with statistical data about diseases and their prevalence or incidence. In its reports, it is possible to find good evidence to support this research project. Dahlhamer et al. (2016) revealed that about 3 million Americans are currently diagnosed with IBDs (including either ulcerative colitis or Crohn’s disease). For comparison, in 1999, this number was about 1.6 million, meaning the amount of sick people continues growing (Dahlhamer et al., 2016). Female patients prevail over male patients, 1.7 million over 1.3 million respectfully (Dahlhamer et al., 2016).
American citizens are also divided into specific age groups: young people aged between 18 and 24 – about 150,000, 22-44 years – 865,000, 45-64 years– 1.3 million, and more than 65 years – 805,000 (Dahlhamer et al., 2016). The prevalence of ulcerative colitis is not as critical as the number of other diseases among the American population, but many organizations focus on evaluating its signs and diagnostic tools to develop an effective treatment.
Signs and Symptoms
The first signs that should provoke a person to visit a doctor and be checked for IBD include abdominal pain, diarrhea, and blood in the stool. Being an idiopathic inflammatory disease, ulcerative colitis has a number of clinical symptoms that have to be examined by a medical worker along with specific tests (Keshteli et al., 2019; Tripathi & Feuerstein, 2019). As a rule, the presence of signs depends on the severity of the condition, and they develop with time (not suddenly) (Verma et al., 2020).
However, to make sure that the patient has some inflammatory bowel problems, much attention is paid to its common local signs like abdominal cramps, rectal pain, and tenesmus (Verma et al., 2020). In addition, some individual changes occur, and patients should report on them immediately to be properly assessed. These symptoms are appetite changes (people with ulcerative colitis have decreased appetite), weight loss, mouth sores, and nausea (Verma et al., 2020). The main outcome of these problems is dehydration, with a burning necessity to stabilize a patient.
Rheumatologic involvement is another area of complaint among patients with ulcerative colitis. This group of symptoms is related to the functions of small and large joints that are challenged by the bowel condition (Gajendran et al., 2019). Joint pain and swelling may bother people who, in their turn, fail to recognize other health problems related to these symptoms, including arthritis, osteoporosis, or even cancer. To avoid misdiagnosis, blood and stool samples have to be gathered and analyzed.
Ulcerative colitis is a result of an inflammatory process, and fever is one of the expected symptoms among patients. In the majority of cases, people experience fatigue and unwillingness to do something. Reduced physical activities and mood changes should not be ignored because they could provoke cases of depression or the development of other mental disorders. Poojary et al. (2017) explain depression as one of the major comorbidities for patients with ulcerative colitis, which results in treatment improvements and medication adherence.
Finally, eye inflammation is mentioned as one of the potential signs of the disease under analysis (Verma et al., 2020). Lack of vitamins and dehydration leads to decreased tear production and increased possibilities of eye infection. Therefore, when people are diagnosed with ulcerative colitis, it is recommended to visit an ophthalmologist and check the conditions of the eyes.
Diagnosing Tools
The diagnosis of ulcerative colitis is a complex process that consists of several stages. In addition to the evaluation of signs patients report, endoscopic findings and histology are taken into consideration (Ungaro et al., 2017). Regarding such symptoms as diarrhea and abdominal pain, the patient’s stool has to be analyzed. In clinical trials, it is recommended to focus on stool frequency and quality and identify the level of the disease (Gajendran et al., 2020):
- mild – four or fewer stools per day;
- moderate – more than four stools per day;
- severe – more than six blood stools per day).
The assessment of stool culture is another integral step in the diagnosis. Stool samples and Clostridium difficile assay show if it is possible to rule out other infections and problems like anemia or iron deficiency (Ungaro et al., 2017). There are also many markers of inflammation (C-reactive protein or erythrocyte sedimentation rate) to be detected for the chosen diagnosis. Ungaro et al. (2017) admit that the elevation of antibodies is usually non-specific and low sensitive among ulcerative colitis patients, and this tool is not recommended in the majority of cases. The presence of white blood cells in the stool usually indicates the disease.
Another diagnostic method is based on the results of blood tests. Doctors use it to detect anemia and other signs of infection in the body. As well as stool samples, blood samples measure the number of inflammatory markers (Keshteli et al., 2019). However, laboratory evaluation is not enough to diagnose ulcerative colitis, and medical workers should rely on the findings obtained from endoscopy and biopsy. There are also several classifications and criteria with the help of which the severity of the disease is identified. They include Truelove and Witt’s criteria, Mayo’s classification, and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) with definitions and explanations being properly given (Tripathi & Feuerstein, 2019). These scores are effective for doctors to identify what stage of colitis is developed in a patient at the moment.
The severity of the disease indicates different signs and symptoms in patients. Ungaro et al. (2017) introduce endoscopy with biopsies as one of the common ways to establish the diagnosis. These findings include the loss of normal vascular pattern, erosions, bleeding, erythema, and friability (Ungaro et al., 2017). There is a clear demarcation of mucosa with its normal and inflamed areas. Lynch and Hsu (2019) also say about the usefulness of radiological examinations, but they also understand that the application of this tool is not critical.
Colonoscopy may help to reveal the changes in vascular patterns and the entire image of the colon, using a thin tube with a camera. This method allows taking tissue samples for biopsy, relying on the results of other findings, and confirming the diagnosis. Finally, in severe cases of ulcerative colitis, doctors insist on using X-ray and computerized tomography (CT) to scan the abdomen and investigate inflamed areas for other complications and a potential spread of infections.
Treatment and Management Care
As soon as the results of clinical and laboratory tests prove the diagnosis of ulcerative colitis, it is expected to develop an effective treatment plan and manage health care. Today, many studies and recommendations are introduced to identify the best options for patients with this disease (Keshteli et al., 2019; Tripathi & Feuerstein, 2019; Verma et al., 2020). According to Lynch and Hsu (2019), treatment choices for patients are determined by the disease extent and severity.
There are also such factors as previous medications, disease duration, and manifestations that play a key role in treatment. In the majority of cases, similar goals are set, including the improvement of the quality of life, the achievement of steroid-free remissions, and the minimization of risks of complications (Gajendran et al., 2019). As a rule, medical therapy in the form of a rectal application is applied via suppository or enema (Lynch & Hsu, 2019). To reduce symptoms and relieve pain, systemic therapy is targeted to decrease tenesmus in the distal colon (Ungaro et al., 2017). Remission (cessation of bleeding) contributes to the stabilization of bowel functions and endoscopic healing.
Hospitalization is frequently recommended for patients who have ulcerative colitis. About 1.5 million patients are diagnosed with ulcerative colitis that is identified as a debilitating disease that can lead to life-threatening complications (Verma et al., 2020). Therefore, regular observations, real-time monitoring, and clinical assessments are required at the initial stages. The quality of life is challenged when ulcerative colitis progresses, and managing this disease is usually time-consuming and expensive. Care management includes not only the required dosage of medications but also the analysis of adverse reactions and the changes in patient social and professional lives.
Physical exercises and dietary control turn out to be an integral part of care management (Keshteli et al., 2019). All these activities and interventions require the participation of many people, so collaboration and communication between care providers and patients (as well as their families) become another significant element of a treatment process. Depression and mood changes in patients with ulcerative colitis also need management, and psychological and emotional support cannot be ignored. Treatment and care management are intertwined with such activities as screening, monitoring, and recommended therapies.
Medication
There are two main forms of treatment of ulcerative colitis, including medications or surgery. In mild and moderate cases, 5-aminosalicylic acid (5-ASA) formulations introduce the first stage of intervention (Gajendran et al., 2020):
- sulfasalazine, 500 mg orally;
- mesalamine, 375 mg (capsule) or 800 mg (tablet) orally;
- balsalazide, 750 mg orally;
- olsalazine, 500 mg orally;
- mesalamine enema, 4 g rectally.
Corticosteroids are used in moderate and severe cases as the first-line treatment method. They include prednisone or budesonide orally or rectally during 2-4 weeks (Tripathi & Feuerstein, 2019). In the study by Gajendran et al. (2019), methylprednisolone (60 mg during 24 hours) or hydrocortisone (100 mg four times per day) are offered as a part of drug therapy for patients. However, if no response to these drugs is observed during the next 24 hours, other immunomodulators or biologic drugs should be considered. For example, cyclosporine and infliximab aim at neutralizing the number of proteins in the immune system (Gajendran et al., 2019). If there is still no response, surgery (colectomy) is the only option to predict health complications and mortality.
In addition to the necessity to treat the disease, it is important to deal with inflammation. Therefore, thiopurines and immunomodulators improve the work of the immune system and control the progress of inflammation in the blood. Azathioprine has a steroid-sparing effect to maintain remission and may be taken for a long period to achieve its pharmacological effect (Tripathi & Feuerstein, 2019). Finally, one should remember that ulcerative colitis has a number of other symptoms, not associated with the condition of the bowel. Therefore, the use of such drugs as loperamide (to control diarrhea), ibuprofen (to relieve pain), and eye drops (to predict eye infections) must be discussed with a doctor individually.
Nutrition
As well as the majority of bowel diseases, ulcerative colitis has specific nutritional recommendations. However, Lynch and Hsu (2019) and many other researchers report that, at this moment, no specific diet is developed. At the same time, lifestyle changes and the improvement of nutrition help to control the signs of the disease and predict its complications. Sometimes, parental nutrition is prescribed during hospitalization to allow the bowel to rest and avoid unnecessary external irritations.
Regarding the pathophysiology of ulcerative colitis, the limitation of dairy products and meat as the sources of sulfur and vegetables as the sources of nitrogen may be required (Roberts-Thomson et al., 2019). The investigation by Keshteli et al. (2019) show that not all dietary changes have positive contributions to treatment as well. On the one hand, it is possible to choose a low-fat diet and expect it might help. On the other hand, the same diet is effective in the reduction of other health problems.
There is no connection between this type of nutrition and the recovery from ulcerative colitis. Doctors usually recommend what nutrients are needed to strengthen the condition after medication therapy or surgery. Healthy fats in the form of vegetable oils are frequently chosen due to its price and an overall effect.
Conclusion
Ulcerative colitis is one of the inflammatory bowel diseases that influence the quality of life of millions of Americans. It is characterized by long-lasting inflammations and sores that are developed in the digestive tract. Despite the fact that many preventive measures, recommendations, and quality interventions are available to people, it is not always possible to predict the risks of this disease. Its treatment and management have different forms, and much depends on the severity of the condition and patient history. If doctors see no improvements after a medical therapy is applied, surgery is prescribed to stabilize the functions of the bowel.
Although lower (compared to such public health concerns) mortality risks connected with ulcerative colitis are observed, its threats cannot be ignored. Patients must visit their doctors, ask for help, take physical and clinical examinations, and report on their complaints properly to identify all signs of the disease, clarify its severity, and choose a treatment path with fewer or no adverse effects and a clear dietary and lifestyle guide.
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