Ulcerative colitis is a type of inflammatory bowel disease (IBD) that affects the large intestine and rectum. The disease usually begins in the rectal area and may eventually extend through the entire large intestine. Repeated swelling (inflammation) leads to thickening of the wall of the intestine and rectum with scar tissue. Death of colon tissue or sepsis (infection) may occur with severe disease.

Causes

The cause of ulcerative colitis is unknown. There is likely an interaction between a person's genetic makeup and their environment which triggers the disease process. Many factors can lead to attacks, including respiratory infections or physical stress.

Symptoms

Symptoms of ulcerative colitis can vary and may include:

• Abdominal pain or cramping
• Diarrhea
• Blood in stool
• Constant feeling of needing to empty the bowels
• Weight loss
• Poor growth
• Delayed puberty
• Fatigue
• Poor appetite
• Joint pains
• Fever
• Vomiting

Exams and Tests

Tests to diagnose ulcerative colitis may include:

Blood Tests

• CBC (Complete Blood count) - measures red and white blood cells and platelet count
• ESR (Erythrocyte Sedimentation Rate) - a marker of inflammation in the body
• CRP (C-Reactive Protein) - a marker of inflammation in the body
• Chemistry Panel - measures liver and kidney function, nutritional status
• Inflammatory Bowel Disease Antibody Panel - looks for specific antibodies (proteins) in the blood that may support a diagnosis of ulcerative colitis or Crohn's Disease

Stool Tests

• Hemoccult - detects blood in the stool that cannot be seen
• Culture - detects a bacterial infection of the intestine
• Clostridium difficile (C. diff) - detects specific bacteria in the colon which can cause diarrhea

Endoscopy

All children suspected to have IBD will need a test called Upper GI endoscopy and colonoscopy. While your child is asleep under the care of an anesthesiologist, a pediatric GI specialist will use a long lighted tube containing a camera to see the lining of the intestine and take biopsy (tissue) samples to help determine the areas that are inflamed. The Upper GI endoscopy examines the esophagus (swallowing tube), stomach, and upper small intestine. A colonoscopy examines the end of the small intestine and the entire large intestine. Your child will feel no pain or discomfort during these procedures.

X-rays

• Small bowel barium X-ray - Your child will be asked to drink a small amount of barium, and several x-rays will be done to follow the barium as it passes through the small intestine. This study looks for disease in the small intestine which cannot be seen with endoscopy.
• Ultrasound, CT scan, MRI - These are special X-rays to look for problems with other organs (liver, pancreas, gall bladder, kidneys). These tests should not be painful to your child. An IV may be required for a CT scan or MRI.
• Capsule endoscopy – This test is used for examining areas in the digestive tract that cannot be visualized during standard endoscopic examination. Your child will be asked to swallow a capsule containing a camera that takes pictures throughout the small intestine. The capsule may be placed endoscopically in very young children or children who have trouble swallowing. The capsule transmits a radio signal to a belt which is worn for eight hours following ingestion of the capsule.

Treatment

Medicines provide the best treatment options for ulcerative colitis. The following medicines are the most common, but other medications may be prescribed as needed.

• Aminosalicylates (5-ASAs) are medicines that help control mild to moderate inflammation. Some forms of the drug are taken by mouth; others must be given rectally.
• Corticosteroids (prednisone and methylprednisolone) are used to treat moderate to severe ulcerative colitis. They may be taken by mouth or inserted into the rectum.
• Immunomodulators such as azathioprine or 6-mercaptopurine help reduce the need for corticosteroids and can help heal some fistulas.
• Antibiotics may be prescribed for abscesses or fistulas.
• Biologic therapy is used to treat patients with severe ulcerative colitis that does not respond to any other types of medication. Infliximab (Remicade) and adalimumab (Humira) are approved for ulcerative colitis. They belong to a class of drugs called monoclonal antibodies, which help block an immune system chemical that promotes inflammation. Infliximab is also approved for patients with fistulous disease. Other related drugs are being studied.

If medicines do not work, a type of surgery called bowel resection may be needed to remove a damaged or diseased part of the intestine or to drain an abscess. A procedure called anastomosis is done to connect the remaining two ends of the bowel.

Growth

No specific diet has been shown to improve or worsen ulcerative colitis. However, eating a healthy amount of calories, vitamins, and protein is important to avoid malnutrition and weight loss.

Children with ulcerative colitis frequently lose weight and stop getting taller before they are diagnosed. Our pediatric GI team believes growth is a critical outcome in treating pediatric patients with Inflammatory Bowel Disease. We tailor our treatment with medications to help children regain lost weight and begin growing taller. However, many children require more intense nutritional therapy to improve their growth. At each clinic appointment, we will carefully measure your child's height and weight. We work carefully with our dieticians to find the most appropriate nutrition plan for our patients with IBD.

Oral Nutritional Supplements

Patients who have Inflammatory Bowel Disease frequently get pain or cramping when they eat, or feel full more quickly after eating only a small amount of food. Supplements like Pediasure®, Boost®, or Ensure® provide excellent nutrition in addition to a regular diet. Modulen® was designed specifically for patients with Inflammatory Bowel Disease. Any of these can be taken once or more daily with meals or as a snack.

Calcium and Vitamin D

Inflammatory Bowel Disease can lead to premature thinning of the bones. This can be worsened by steroids. It is critical that patients with Inflammatory Bowel Disease receive an adequate amount (above what a normal child would require) of Calcium and Vitamin D. Your physician will recommend a specific amount of Calcium and Vitamin D based upon the age of your child. Each 8 ounce glass of milk contains 300 mg of Calcium. Some children may require a Calcium supplement such as Tums®, Viactiv®, or Caltrate®.

Parenteral Nutrition

Parenteral nutrition is sugar, fat, and protein which are given through an IV. This is only rarely required in children with severe Inflammatory Bowel Disease who are unable to take enough nutrition by eating and drinking or have had severe weight loss prior to their diagnosis. If parenteral nutrition is required, your physician will carefully manage the ingredients in the parenteral nutrition by following several blood tests.

Coping

It is natural that some children may become overwhelmed with the thought of having a lifelong illness. They will need the support of family, friends, and sometimes, a professional counselor. Many of our patients and their families benefit from attending support groups and summer camps for children with Inflammatory Bowel Disease. Many of these activities are sponsored by the Crohn's and Colitis Foundation of America (CCFA), and information is available at ccfa.org.

Research

The pediatric GI specialists at Riley Hospital for Children Gastroenterology at Indiana University Health are actively participating in a large variety of local and national research studies. These studies are examining new treatments and new tests to help with diagnosis. We are also participating in studies about the quality of life in children with Inflammatory Bowel Disease. Finally, we are performing sophisticated studies about protein and calorie metabolism in these children. We are the recipients of several grants to continue this research. Your physician may ask you about your interest in participating in these studies.

Points to Remember

• Ulcerative colitis is a form of inflammatory bowel disease that can cause inflammation in the large intestine and rectum.
• Symptoms are varied and can come and go with periods of "flare-ups." Some of the most common symptoms include abdominal pain, diarrhea, blood in stool, weight loss and vomiting.
• Ulcerative colitis is a life-long condition but can often be treated with medications.
• Eating a healthy diet is important to avoid malnutrition and weight loss.

For More Information

Crohn's and Colitis Foundation of America - ccfa.org/chapters/

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition - NASPGHAN.org

Children's Digestive Health & Nutrition Foundation - cdhnf.org