Ulcerative colitis is one form of the debilitating intestinal condition known as inflammatory bowel disease, or IBD. How is it diagnosed and treated, and what other strategies might help manage its symptoms? Read on to find out.
What Is Ulcerative Colitis?
Inflammatory bowel disease (IBD) is an umbrella term for two types of debilitating intestinal disease: ulcerative colitis and Crohn’s disease.
Ulcerative colitis (UC) differs from Crohn’s in that it produces chronic inflammation and ulceration of the large intestine (the colon), where Crohn’s disease tends to be centered higher up in the digestive tract, in the small intestine. Ulcerative colitis is also focused on the innermost lining of the colon wall, where Crohn’s can damage much broader swaths of tissue [1, 2, 3].
UC and Crohn’s are very similar diseases, which is why they are grouped together under the IBD diagnosis. They must both be diagnosed by a doctor, often a specialist.
How is IBD Diagnosed?
IBD is relatively poorly understood and will often be diagnosed by ruling out other possible explanations for gastrointestinal symptoms. To confirm a diagnosis of IBD, your doctor may order some of the following tests.
Blood Tests
Your doctor may order blood tests to detect anemia or infection, or they may order a fecal occult blood test, which checks for blood in the stool. These tests screen for both intestinal bleeding and the anemia that may result from chronic blood loss [4, 5, 6, 7, 8, 9].
Endoscopy
Endoscopic procedures use a tiny camera and light to visually inspect diseased tissues. There are many types of endoscopy that may be useful to diagnose IBD, including:
- Colonoscopy: this procedure is considered the most important and the most reliable for the endoscopic diagnosis of IBD, producing an accurate diagnosis of either Crohn’s disease or ulcerative colitis in up to 90% of cases [10].
- Flexible sigmoidoscopy: a far less common procedure, flexible sigmoidoscopy is used in cases when doctors believe a full colonoscopy is dangerous, such as when the colon is very inflamed. It is very similar to a colonoscopy, except that only the last section of the colon is observed [11, 12].
- Upper endoscopy: this procedure observes the upper section of the digestive tract, usually the esophagus, stomach, and even parts of the small intestine. This is not a common procedure in IBD, but may be recommended for certain cases [11, 13].
- Capsule endoscopy: for this procedure, the patient swallows a capsule that contains a tiny camera. For the next 8-12 hours (until the battery runs out), the camera sends 2-6 images per second to a gastroenterologist, who reviews the images [14, 15].
- Balloon-assisted enteroscopy: this procedure uses tiny balloons to compress the walls of the intestine so that a camera can reach and treat less accessible portions of the digestive tract [14, 16].
Imaging
Non-invasive imaging techniques may sometimes be used in place of (or in addition to) endoscopy. These include X-rays, CT scans, or MRIs [17, 18].
How is IBD Treated?
IBD (as either ulcerative colitis or Crohn’s disease) is a significantly more serious condition than IBS. Although your doctor will likely recommend holistic strategies to manage IBD symptoms, more often than not you will be prescribed special diets immediately after diagnosis. Be sure to follow any and all prescriptions and recommendations from your doctor, which may or may not include therapies and strategies described here. Never use any of the following strategies in place of what your doctor recommends or prescribes.
Dietary Interventions
Low FODMAP Diet (Possibly Effective)
Some nutritionists recommend a low FODMAP diet to help control the symptoms of ulcerative colitis and Crohn’s disease. FODMAPs are a group of carbohydrates which, in the last decade or so, have been identified as some of the prime irritants in IBD. FODMAPs is a catchy acronym that stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols [19, 20, 21].
The major FODMAPs include [22, 23]:
- Fructose
- Lactose
- Fructans and galactans
- Galacto-oligosaccharides
- Polyols (sugar alcohols, or any sweetener that ends with -ol)
The low FODMAP diet isn’t appropriate for everyone. Talk to your doctor to determine whether an elimination diet could be right for you.
For more about the low FODMAP diet, check out this post on how it works and this post on which foods are included.
Specific Carbohydrate Diet
The specific carbohydrate diet (SCD) is a type of elimination diet that completely removes most types of carbs in an attempt to slow the growth of harmful bacteria that may be causing inflammation and damage in the gut [24].
The SCD is considered a relatively extreme elimination diet. It should only be attempted under the careful supervision of a trained nutritionist or dietitian [25, 24].
Other Elimination Diets
A great deal of research indicates that diet is a factor in the development and severity of ulcerative colitis. A meta-analysis identified several potentially problematic foods, including [26]:
- Margarine and certain cooking oils (omega-6 PUFAs)
- Animal protein (may also be linked to omega-6 content of meat; fish and omega-3s appeared protective)
- Processed meat
- Alcohol
Your doctor may or may not advise you to gut certain foods out of your diet to see if your symptoms improve. You may want to work with a specialized nutrition or dietitian to find the best diet to manage your condition.
Nutritional Support Therapies
The inability to digest food and pass normal feces can cause serious nutritional problems; up to 85% of IBD patients may be malnourished or underweight. In severe cases, people with IBD may require special nutritional interventions. They may require enteral (tube) feeding or parenteral nutrition (nutrients injected into a vein) to allow diseased intestinal tissue time to rest and heal [27, 28].
A doctor may also recommend a “low-residue” diet to reduce the risk of food getting stuck in inflamed tissues and causing a blockage [29].
Lifestyle Changes
In order to control the symptoms of IBS and improve your quality of life, your doctor may recommend a few lifestyle changes. If your doctor has prescribed medication, however, these strategies should never be used in place of those prescriptions.
Exercise
Moderate exercise (and improved physical fitness) is among the best remedies for gut inflammation and overall health. According to many studies, physical activity actually changes the composition of the gut flora, resulting in an increase of beneficial species [30].
People with IBD may or may not be advised to adjust their physical activity to help manage inflammation and symptoms. Broadly speaking, exercise may have a mild protective effect on the development of IBD; that is, people who are already physically active are somewhat less likely to develop ulcerative colitis than those who are sedentary [31].
Some people with severe IBD may not be able to exercise as strenuously as healthy peers. However, if the intensity of exercise is limited, then physical activity is believed to be beneficial for IBD patients. Physically fit people have less inflammation, a healthier immune response, lower weight, better mental health, and stronger bones [31, 32, 33].
If you have IBD, we recommend talking to your doctor about how much physical activity would be beneficial in your case.
Stress Management
Many people with IBD develop anxiety and depression associated with their debilitating gastrointestinal symptoms. Furthermore, psychological stress is broadly believed to worsen symptoms of IBD. Because of this potential feedback loop, many doctors emphasize the importance of managing the mental health of IBD patients [34, 35, 36, 37].
If you have clinical symptoms of anxiety or depression, your doctor may refer you to a psychologist for further evaluation and treatment. Regardless, you may want to try other stress-busting activities like yoga or meditation, provided that they don’t interfere with your doctor’s treatment plan.
Acupuncture & Moxibustion
Two unusual stress management strategies that have seen some interesting experimental results in IBD are acupuncture and its offshoot, moxibustion.
Moxibustion is a traditional Chinese therapy that involves burning dried mugwort on acupuncture points, stimulating them with heat. Multiple studies have found that either acupuncture or moxibustion by a licensed professional improved the symptoms of ulcerative colitis [38, 39].
However, acupuncture and moxibustion are difficult to study because it is difficult to create “placebo” groups. Additional research is required to determine exactly how effective acupuncture and moxibustion may be in reducing the symptoms of IBD.
Meditation
Researchers are increasingly finding that meditation interventions focusing on relaxation, breathing, and movement improved both psychological and physical symptoms of IBD. While meditation should never be used to replace anything your doctor recommends or prescribes, it is a safe and potentially useful complementary strategy for IBD patients with psychological symptoms [40, 41].
Supplements for IBD
The FDA has not approved any natural substances for medical use in IBD, and supplements generally lack solid clinical research. Speak with your doctor before using any of these substances, and never use them in place of something your doctor recommends or prescribes.
To Prevent Deficiency
IBD has been linked with poor nutrient absorption, leading to a number of nutrient deficiencies and subsequent health complications. As such, your doctor may recommend certain supplements. It’s important not only to follow your doctor’s instructions and take any recommended supplements, but to discuss how these might interact with anything else you are doing to manage your condition.
Iron
Chronic internal bleeding may lead to iron deficiency anemia; according to some estimates, between 60-80% of IBD patients become deficient in iron and as many as 74% become anemic. As such, iron is one of the most common supplements recommended or prescribed to people with IBD [42, 43].
However, caution is recommended when taking iron supplements; oral iron may actually worsen colitis and further damage the microbiome. We strongly recommend against taking iron supplements unless your doctor has recommended them [44].
Calcium & Vitamin D
Ulcerative colitis has been linked to calcium and vitamin D deficiencies and subsequent osteoporosis. Your doctor will monitor your vulnerability to these deficiencies, and if appropriate, prescribe supplements [45, 46, 47, 48].
Possibly Effective
1) Andrographis
Andrographis paniculata, known as the “King of Bitters,” is traditionally used in Ayurveda and traditional Chinese medicine. Andrographis might improve symptoms of ulcerative colitis [49].
Taking 1,200 – 1,800 mg Andrographis daily for 8 weeks reduced symptoms of mild-to-moderate colitis in adults. In the same study, the group taking the 1,800 mg dose had relatively higher mucosal healing rate over the 1,200mg and placebo groups [50].
However, andrographis did not affect remission rates any more than the placebo [50].
2) Probiotics
People with IBD often have gut dysbiosis; that is, their gut microbiome is out of balance, which may worsen their disease. A meta-analysis of a blended probiotic containing Bifidobacteria, Lactobacillus, and Streptococcus species (VSL#3) found that remission rates rose by 1.7x in ulcerative colitis patients taking the probiotic compared to the placebo [51].
Bifidobacteria and Lactobacillus species generally appear to be beneficial in patients with ulcerative colitis [51, 52, 53, 54].
The VSL#3 combination probiotic has also been found to reduce symptoms and inflammation in pouchitis, a complication of surgery to treat ulcerative colitis [55, 56].
3) Psyllium
Psyllium is a robust herb that grows around the world but is most commonly found in India, which remains the largest producer of psyllium husk today. The outer coat (the husk) of the seed is ground down into mucilage, a term describing clear, colorless, gelatinous dietary fiber that confers the majority of health benefits in both humans and animals [57].
A placebo-controlled trial of 29 subjects with ulcerative colitis in remission found superior control of gut symptoms using psyllium husk vs. placebo. Four patients were unable to finish the trial due to relapse; of these, three were taking the placebo [58].
Another study of 105 patients found that fiber from psyllium maintained remission in ulcerative colitis almost as well as mesalamine, the conventional treatment. Psyllium and mesalamine together were more effective than either alone [59].
However, some contradictory evidence exists. As such, psyllium may be considered a potentially beneficial fiber supplement, but we strongly recommend consulting your doctor before using it [60].
4) Boswellia
Boswellia resins, also known as frankincense or olibanum, are obtained from Boswellia trees. Incisions are made in the trunks of the trees to produce exuded gum, which appears as milk-like resin and hardens into orange-brown gum resin called frankincense [61, 62].
Boswellia serrata oleo-gum extract (BSE), has antioxidant activity and is believed to protect the intestinal epithelial barrier from inflammatory damage [63].
It was effective in the treatment of 30 patients with chronic colitis with minimal side effects [64].
In another trial, gum resin of B. serrata (350 mg, 3 times daily for 6 weeks) improved ulcerative colitis in patients with 80-82% remission [65].
5) Phosphatidylcholine
Phosphatidylcholine (PC) is a molecule that contains two fatty acids attached to a glycerol backbone with a phosphate group and choline. It is found in every single cell of your body as a key component of the cell membrane [1].
In four studies of 316 patients with ulcerative colitis, PC supplementation reduced disease severity, improved quality of life, and induced remissions. It also decreased dependence on corticosteroids and resulted in complete therapy withdrawal in some patients [66, 67, 68, 69].
Modified-release PC (3.2 grams daily for 12 weeks) even improved the symptoms of drug-resistant ulcerative colitis. However, this trial was funded by the supplement manufacturer, which indicates a potential conflict of interest [67].
6) Propionyl-L-Carnitine
Carnitine is an amino acid found in nearly every cell of the body. It is a generic name for a variety of compounds such as L-carnitine, acetyl-L-carnitine, and propionyl-L-carnitine. Of these, propionyl-L-carnitine has been studied for its potential benefits in ulcerative colitis [70].
In a handful of studies, propionyl-L-carnitine supplementation reduced symptoms of ulcerative colitis (but not Crohn’s disease). The effects were large enough that researchers recommended the further exploration of propionyl-L-carnitine as a co-treatment for mild to moderate ulcerative colitis [71, 72, 70].
7) Vitamin A
A study of 143 ulcerative colitis patients found that vitamin A supplementation reduced the severity of symptoms and increased the rate of healing compared to the placebo. However, the authors of the study warned that larger sample sizes and longer durations were needed before vitamin A should be considered a standard supplement for UC. Talk to your doctor to see if you might benefit [73].
8) Omega-3 Fatty Acids
An increased ratio of omega-3 fats to omega-6 fats is associated with reduced inflammation and reduced rates of IBD, including ulcerative colitis. The more omega-3 and the less omega-6 fatty acids people consumed the less likely they appeared to be to develop IBD. It is currently unclear whether omega-3 supplementation could help with existing cases of ulcerative colitis [26].
9) Curcumin
At least two clinical studies so far have found a possible benefit for curcumin supplementation in ulcerative colitis, either alone or in combination with conventional medications. Remember to never combine supplements with medications without first discussing these combinations with your doctor [26].
Other Medical Procedures
Medications
If you are diagnosed with IBD, your doctor is likely to prescribe medication to help improve your quality of life. We strongly recommend against taking any of these medications without a doctor’s prescription.
Medications that may be prescribed to treat IBD include [74]:
- Anti-inflammatory drugs (corticosteroids and aminosalicylates)
- Immune suppressors
- Antibiotics
- Anti-diarrheal medication
- Pain relievers
Biologics
Biologics are prescription drugs which are made or extracted from a living organism. Several biologics are available to treat ulcerative colitis, including the anti-TNF antibodies infliximab and adalimumab [75].
Biologics are an emerging class of drugs for IBD; the best ways to use them and the appropriate cases to prescribe are still topics of debate [75].
Surgery
Unfortunately, IBD can be a very serious diagnosis, and many people with IBD will require surgery over the course of their lifetimes: according to some data, as many as 20% of people with ulcerative colitis and 80% of people with Crohn’s have at least one operation [76].
When surgery is required for ulcerative colitis, the surgeon often removes the entire colon and rectum in a procedure called a proctocolectomy. After the colon is removed, the surgeon constructs a pouch from the end of the small intestine; this pouch serves the approximate function of the removed colon [77, 78, 79].
Fecal Transplant
Fecal transplants are a relatively new procedure for the treatment of intestinal disorders and diseases. In brief, the bacteria from a healthy person’s gut are introduced into the colon of a person with intestinal disease. This is typically done with a direct transplant of carefully-screened feces from the healthy donor into the recipient [80, 81].
Fecal transplants are not common practice to treat ulcerative colitis, but a recent surge in research suggests that this development might be right around the corner [80, 81, 82].
Takeaway
Ulcerative colitis (UC) is one of the two types of inflammatory bowel disease (IBD). It differs from Crohn’s in that it produces chronic inflammation and ulceration of the large intestine (the colon), where Crohn’s disease can damage any part of the digestive tract, though it tends to be centered higher up, in the small intestine.
UC is typically diagnosed using blood tests, endoscopic procedures (most commonly colonoscopy), and occasionally non-invasive imaging techniques (like CT scan or MRI). After the diagnosis is made, a doctor will prescribe medication and recommend dietary and lifestyle changes to manage symptoms and improve quality of life. Dietary changes typically include some form of elimination diet, which aims to remove any foods that trigger worse symptoms in the individual patient. In severe cases of malnutrition, enteral or parenteral nutrition may be required. In the case of deficiency, a doctor may also prescribe iron, vitamin D, and calcium supplements.
UC patients may benefit from moderate exercise and stress management therapies like yoga, meditation, acupuncture, and moxibustion. Some supplements have also been the focus of research in UC patients; these include probiotics, fiber (from psyllium), some herbs (andrographis, curcumin, and boswellia), and some nutrients (phosphatidylcholine, propionyl-L-carnitine, vitamin A, and omega-3s).
Doctors also commonly prescribe medication to UC patients, and surgery may be required for severe cases. A surgeon typically removes the entire colon and replaces it with a “pouch” constructed of small intestinal tissue. Unfortunately, this pouch is vulnerable to infection (pouchitis); this is one reason why fecal transplantation for UC is currently under clinical investigation.
