Ulcerative Colitis (UC)

Most patients who are affected by UC have mild to moderate disease, but a small percentage of patients experience severe symptoms. Many factors can cause exacerbations, with older adults at high risk for impaired fluid and electrolyte balance due to diarrhea, including: 

• Dehydration

• Hypokalemia 

The intestinal mucosa becomes: 

• Hyperemic (has increased blood flow)

• Edematous

• Reddened

Severe inflammation may cause: 

• Bleeding

• Small erosions

• Ulcers

• Abscesses

• Tissue necrosis

The patient with UC or CD may present with:  

• Blood and mucus in stool

• Tenesmus (an unpleasant and urgent sensation to defecate)

• Lower abdominal colicky pain relieved with defecation

• Malaise

• Anorexia

• Anemia

• Dehydration

• Fever

• Weight loss 

Extraintestinal manifestations are present in many patients, such as: 

• Migratory polyarthritis

• Ankylosing spondylitis

• Erythema nodosum

Possible causes of ulcerative colitis

Genetic Factors

A genetic basis of the disease has been supported as it is often found in: 

• Families

• Twins

Immunologic Factors

Immunologic causes include: 

• Autoimmune dysfunction

• Epithelial antibodies in the immunoglobulin G (IgG) 

  
  

Long-term disease causes cellular changes and increases the risk for colon cancer.

Proinflammatory cytokines have cytotoxic effects on the colonic mucosa, such as: 

• Interleukins (ILs)

• Tumor necrosis factor (TNF)-alpha

Lifestyle Factors

Risk factors include: 

• Cigarette smoking 

• Diets high in animal fats and sugar

• Diets low in fruits and vegetables

Recognize Cues: Assessment 

Collect data on: 

• Family history of inflammatory bowel disease (IBD)

• Previous and current therapy

• Dates and types of surgery

• Nutrition history, including intolerance of milk and/or fried, spicy, or hot foods

The nurse should ask about: 

• Bowel elimination pattern

  • Color

  • Number

  • Consistency

  • Character

• Abdominal pain

• Tenesmus

• Anorexia

• Fatigue

• Relationship between diarrhea, timing of meals, emotional distress, and activity

• Recent (past 2 to 3 months) exposure to antibiotics

• Travel to or emigration from tropical areas

• Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

Inquire about any extraintestinal symptoms, such as: 

• Arthritis

• Mouth sores

• Vision problems

• Skin disorders

Physical Assessment:

Symptoms of UC vary as vital signs in mild disease are within normal limits and in severe cases may have low-grade fever (99° to 100°F [37.2° to 37.8°C]):

• Physical assessment findings are usually nonspecific.

• Milder case findings may be normal.

• Viral and bacterial infections can cause similar symptoms.

Note any abdominal distention along the colon. Fever associated with tachycardia may indicate: 

• Dehydration

• Peritonitis

• Bowel perforation

Assess for signs and symptoms associated with extraintestinal complications, such as: 

• Inflamed joints

• Lesions inside the mouth

Assessments and tests used to diagnose Ulcerative Colitis

A chronic disease state and anemia due to chronic blood loss results in low: 

• Hematocrit 

• Hemoglobin 

Inflammatory disease is consistent with an increased: 

• WBC count

• C-reactive protein

• Erythrocyte sedimentation rate (ESR)

Frequent diarrheal stool and malabsorption may result in low levels of: 

• Sodium

• Potassium

• Chloride

Hypoalbuminemia (decreased serum albumin) is found in patients with extensive disease from losing protein in the stool.

Magnetic resonance enterography (MRE) is the main examination used to study the bowel for chronic IBD, allowing visualization of the bowel lumen and wall, mesentery, and surrounding abdominal organs. 

Patient teaching includes:  

• Fasting for 4 to 6 hours before the test

• Requirement to drink a large amount of contrast medium, which may cause abdominal discomfort and diarrhea

• Use the restroom before positioning on the MRI table

• The patient must lie prone while the first of two doses of glucagon are given subcutaneously, which will slow the bowel’s activity and motility.

Other Diagnostic Assessments

An upper endoscopy and/or colonoscopy may be done to aid in diagnosis, but the bowel preparation can be uncomfortable for patients with chronic inflammatory bowel disease (IBD). Frequent colonoscopies are recommended when the patient has a longer than 10-year history of UC involving the entire colon due to the high risk for colorectal cancer. 

A CT scan may be done to confirm the disease or its complications. 

Barium enemas with air contrast can: 

• Show differences between UC and Crohn’s disease (CD)

• Identify complications

• Show mucosal patterns

• Show distribution and depth of disease

During early disease, the barium enema may show incomplete filling because of inflammation and fine ulcerations.

Drugs Commonly Used

The 5-aminosalicylates are drugs commonly used to treat mild to moderate UC and maintain remission due to their anti-inflammatory effect on the lining of the intestine by inhibiting prostaglandins; they are effective in 2 to 4 weeks. 

Sulfasalazine is a 5-aminosalicylate metabolized by the intestinal bacteria into: 

• 5-ASA delivering beneficial effects

• Sulfapyridine responsible for unwanted side effects

Patients require a folic acid supplement because sulfasalazine decreases its absorption. 

Mesalamine does not contain sulfapyridine and is better tolerated than sulfasalazine. 

Mesalamine can be given as an enema or a suppository, resulting in: 

• Minimal systemic absorption 

• Fewer side effects

Delayed-release drug works in the terminal ileum and beyond within the colon. Extended-release drug works throughout the colon and rectum.

Glucocorticoids are corticosteroid therapies prescribed during exacerbations. 

Prednisone is prescribed and the dose increased as acute flare-ups occur but is tapered when condition improves due to adverse effects associated with long-term steroid therapy, such as: 

• Hyperglycemia

• Osteoporosis

• Peptic ulcer disease

• Increased potential for infection

• Adrenal insufficiency

For patients with rectal inflammation, topical steroids in the form of small retention enemas or suppositories may be prescribed. Medications such as budesonide, steroids that are thought to work mostly in the bowel, produce fewer systemic side effects

Immunomodulators are drugs that alter an individual’s immune response. In combination with steroids, they may offer a synergistic effect to a quicker response, decreasing the steroid dose needed, but are not effective alone as treatment. 

Biological response modifiers (BRMs) used for UC include: 

• Infliximab

• Adalimumab

Although not approved as a first-line therapy for UC, infliximab may be used for refractory (not responsive to other therapies) disease or for severe complications, such as: 

• Toxic megacolon

• Extraintestinal manifestations

Infliximab is an immunoglobulin G (IgG) monoclonal antibody that reduces the activity of tumor necrosis factor (TNF) to decrease inflammation. 

• Adalimumab is another monoclonal antibody approved for refractory cases

• BRMs are used more commonly in management of Crohn’s disease (CD)

These drugs cause immunosuppression and should be used with caution. Teach the patient to: 

• Report any signs of infection

• Avoid large crowds

• Avoid others who are sick 

Several newer monoclonal antibodies have recently been approved by the U.S. Food and Drug Administration (FDA) for use in patients with chronic IBD. 

• Vedolizumab is an intestine-specific leukocyte traffic inhibitor in that it prevents white blood cells from migrating to inflamed bowel tissue

Best Practice for Patient Safety and Quality Care

Preoperative Care

If a temporary or permanent ileostomy is planned, provide an in-depth explanation to the patient and family. An ileostomy is a procedure in which a loop of the ileum is placed through an opening in the abdominal wall (stoma) for drainage of fecal material into a pouching system consisting of a: 

• Solid skin barrier (wafer) to protect the skin

• Fecal collection device (pouch) 

If an ileostomy is planned, the surgeon consults with a certified wound, ostomy, and continence nurse (CWOCN) before surgery for recommendations on the best location for the stoma. A visit before surgery from an ostomate (a patient with an ostomy) may be helpful.

Operative Procedures

Any one of several surgical approaches may be used for the patient with UC. Minimally invasive procedures are common in large tertiary centers, such as: 

• Laparoscopic surgery

• Laparoscopic-assisted surgery

• Hand-assisted surgery

• Robotic-assisted surgery

Laparoscopic surgery involves several small incisions, which takes longer to perform than the open surgical approach. 

The natural orifice transluminal endoscopic surgery (NOTES) procedure can be performed via the anus or vagina, but availability depends on the training of the surgeon. Patients may have moderate sedation or general anesthesia and are not typically admitted to critical care units for postoperative care. 

A patient may not be a candidate for laparoscopic procedures due to:

• Obesity

• Previous abdominal surgeries

• Dense scar tissue (adhesions) 

A conventional open surgical approach involves general anesthesia, and an abdominal incision requires admission to critical care units for short-term stabilization.

RPC-IPAA has become the gold standard and in some cases is performed via laparoscopy (laparoscopic RPC-IPAA). It is a two-stage procedure that includes the removal of the colon and most of the rectum; the anus and anal sphincter remain intact.

	Stage 1.  After removal of the colon, a temporary loop ileostomy is created, and an ileoanal reservoir is formed. The reservoir is created in an S-shaped reservoir (using three loops of ileum) or a J-shaped reservoir (suturing a portion of ileum to the rectal cuff, with an upward loop).
	Stage 2. After the reservoir has had time to heal—usually several months—the temporary loop ileostomy is reversed, and stool is allowed to drain into the reservoir.

Total proctocolectomy with a permanent ileostomy is done for patients who are not candidates for or do not want the ileoanal pouch. The procedure involves the removal of the colon, rectum, and anus with surgical closure of the anus:

(A) Total proctocolectomy with a permanent ileostomy. This involves removal of the colon, the rectum, and the anus with closure of the anus. (B) Ileostomy surgical stoma placement. (C) Ileostomy with ostomy appliance attached.