Inflammatory bowel disease part I: ulcerative colitis—pathophysiology and conventional and alternative treatment options

Alternative Medicine Review, August, 2003 by Kathleen A. Head, Julie S. Jurenka

Abstract

Ulcerative colitis (UC), a subcategory of inflammatory bowel disease, afflicts 1-2 million people in the United States, and many more worldwide. Although the exact cause of ulcerative colitis remains undetermined, the condition appears to be related to a combination of genetic and environmental factors. While conventional treatments can be effective in maintaining remission and decreasing the length of active disease periods, the treatments are not without side effects, and a significant number of people suffering from UC fail to respond to even the strongest drugs. This article reviews potential unconventional treatments--transdermal nicotine, heparin, melatonin, DHEA, probiotics, fiber, dietary changes, botanicals, essential fatty acids, and other nutrients--that may be considered in conjunction with conventional approaches or as part of a comprehensive alternative treatment protocol. In addition this review addresses risk factors, pathogenesis, nutrient deficiencies, conventional treatment approaches, and extra-intestinal manifestations of the disease.

Introduction

Inflammatory bowel disease (IBD) encompasses several chronic inflammatory conditions, most significantly ulcerative colitis (UC) and Crohn's disease (CD). While these two conditions share many common features--diarrhea, bloody stools, weight loss, abdominal pain, fever, and fatigue--each has unique features (Table 1). A complete discussion of Crohn's disease will be addressed in a future article. This review focuses on ulcerative colitis and associated risk factors, pathogenesis, nutrient deficiencies, conventional treatment approaches, natural treatment approaches, and extra-intestinal manifestations of the disease.

Description and Symptomology

Ulcerative colitis affects the colon and rectum and typically involves only the innermost lining or mucosa, manifesting as continuous areas of inflammation and ulceration, with no segments of normal tissue. The Crohn's and Colitis Foundation of America defines several varieties of UC. Disease involving only the most distal part of the colon and the rectum is termed ulcerative proctitis; disease from the descending colon down is referred to as limited or distal colitis; and disease involving the entire colon is called pancolitis. (1)

UC may be insidious, with gradual onset of symptoms, or the first attack may be acute and fulminate. More mild symptoms include a progressive loosening of the stool, abdominal cramping, and diarrhea. As the disease progresses from mild to more severe, the patient may also experience weight loss, fatigue, loss of appetite that may result in nutrient deficiencies, mucus in the stool, severe rectal bleeding, fever, and anemia. (1,2)

Epidemiology and Risk Factors

It is estimated that 1-2 million Americans suffer from IBD; approximately half of these have ulcerative colitis. UC can occur anytime in life, but is usually diagnosed prior to age 30. The disease appears to affect men and women equally. Approximately 20 percent of people with UC have a close relative with IBD. (1) Caucasians have a higher incidence of UC, with Jewish people of European descent 3-6 times more likely to develop the disease. (3) Regions with a low incidence of UC include Asia, Japan, Africa, and South America. (4)

Breast feeding, (5,6) appendectomy, (7,8) and smoking, (8,9) are associated with reduced risk of UC. Consumption of a "Western diet," (10-12) left-handedness, (13,14) and depression (15,16) may increase risk for ulcerative colitis.

Diagnosis of Ulcerative Colitis

Since the early symptoms of UC are similar to irritable bowel syndrome (IBS), Crohn's disease, diverticulitis, and colorectal cancer, a complete patient history is essential. In addition, it is initially necessary to rule out infectious causes of diarrhea and cramping with stool cultures and ova and parasite analysis. Other tests that may be performed early in the diagnostic process are fecal occult blood and a complete blood count (CBC) to check for intestinal blood loss and anemia. If UC is not ruled out, confirmation is usually via either flexible sigmoidoscopy or colonoscopy. (1,3)

Factors in the Etiopathogenesis of Ulcerative Colitis

Although the exact cause of ulcerative colitis remains undetermined, the condition appears to be related to a combination of genetic and environmental factors. Whole genome scans have found susceptibility genes for UC on chromosomes 1 and 4, although these loci have not been uniformly confirmed. (17)

Among the pathological findings associated with UC are an increase in certain inflammatory mediators, signs of oxidative stress, a deranged colonic milieu, abnormal glycosaminoglycan (GAG) content of the mucosa, decreased oxidation of short chain fatty acids (SCFAs), increased intestinal permeability, increased sulfide production, and decreased methylation. While no one factor has been identified as the initial trigger for ulcerative colitis, pieces of the puzzle have been elucidated; fitting them together to create a complete picture remains to be accomplished.