Physician's Weekly Article - Effective Strategies To Diagnose & Treat Ulcerative Colitis

       The diagnosis of ulcerative colitis can be challenging, but once the disease is identified, effective treatments are available and should be provided based on the severity and extent of the condition.

      Ulcerative colitis (UC) is a chronic disease with recurrent symptoms and significant morbidity that affects between 250,000 and 500,000 Americans. The disease is also associated with significant financial costs, which reach nearly $500 million annually. “UC accounts for about a quarter of a million physician visits and 20,000 hospitalizations per year,” says Robert C. Langan, MD. “The hallmark symptoms of UC include intermittent bloody diarrhea, rectal urgency, and tenesmus, but ascertaining an appropriate diagnosis can be challenging for physicians because these symptoms often mimic other diseases. It’s important to differentiate the condition from other common diagnoses, including Crohn’s disease, ischemic colitis, infectious colitis, irritable bowel syndrome (IBS), and pseudomembranous colitis.”

      Differentiating the Diagnosis

      When diagnosing UC, Dr. Langan says there are several important clues elicited during patient presentations that can help physicians differentiate types of colitis (Table 1). “Differentiating Crohn’s disease from UC, for example, can be particularly challenging, especially early in the disease. It’s important, however, because appropriate treatments and potential complications vary for each condition. Having an experienced pathologist review biopsies is critical to making the final diagnosis, but 10% to 15% of patients may still have a diagnosis of indeterminate colitis.”

      The patient’s clinical history can be used to differentiate various etiologies of chronic diarrhea when UC has not been previously diagnosed. “In many cases, recent antibiotic use might suggest pseudomembranous colitis,” explains Dr. Langan. “Recent travel may indicate infectious colitis whereas abdominal pain relieved with bowel movements could represent IBS. However, a definitive diagnosis of UC often cannot be made accurately until patients undergo a colonoscopy with biopsy.”

      Manage Symptoms & Maintain Remission

      Dr. Langan says the overall strategy to treating UC has remained largely unchanged. “When managing UC, the therapeutic approach is determined by the severity of the symptoms and the degree of colonic involvement. About two-thirds of UC patients will achieve clinical remission with medical therapy, and about 80% of treatment-compliant patients will maintain remission.”

      First-line medical therapies for UC include 5-aminosalicylic acids (5-ASA), agents that have been effective for many years. “UC is a methodical disease in that it starts in the rectum and progresses sequentially,” says Dr. Langan. “Patients with disease limited to the rectum—or proctitis—will typically benefit from using topical 5-ASA suppositories [Figure 1]. If there is a failed response to this approach or the disease is more extensive, then oral 5-ASA agents should added. Steroids can be added if adequate responses still aren’t achieved.”

      Recent studies have assessed the efficacy of disease-modifying agents for UC that act on inflammation. “Steroids have been shown to effectively reduce inflammation, but their side effect profiles are severe, especially if used for the long term,” says Dr. Langan. “Infliximab, azathioprine, and cyclosporine have been used for moderate-to-severe UC and may be effective when patients fail to respond to maximal medical therapy. When patients fail all medical therapies, surgical management may be required. Indications for surgery include resistance to maximal medical therapy and massive hemorrhaging, perforation, or toxic megacolon. Patients with toxic megacolon—dilation of the transverse colon—require emergent surgical evaluation.” Surgery for UC is considered curative and has been shown to improve quality of life, but studies indicate that the complications can be severe, including bowel obstruction, pouchitis, stricture, pouch dysfunction, and decreased fertility in women.

      Be a Patient Advocate

      According to Dr. Langan, physicians should become advocates for patients suffering from UC. “The disease is characterized by flare-ups and remissions, so patients may not see the need to continue recommended treatments if they’re doing well. These treatments, however, can prevent more flare-ups over the long haul if used consistently and appropriately. Alternative therapies should also be explored to perhaps reduce the risk of side effects of currently available UC treatments; some of these therapies may be as efficacious as first-line agents. Physicians should also emphasize to patients that UC increases their risk for colon cancer. The more severe the UC, the higher the risk for colon cancer. Patients need to understand the importance of undergoing colonoscopies as recommended by guidelines.”

      Robert C. Langan, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.