Acute Haemorrhagic Ulcerative Colitis
Acute haemorrhagic ulcerative colitis is a severe form of inflammatory bowel disease that causes bloody diarrhea, severe abdominal pain, and dangerous complications. Understanding this medical emergency can help patients recognize when urgent care is needed and what treatment options are available.
Table of contents
- What Is Ulcerative Colitis
- Understanding Severe Forms of the Disease
- Symptoms and Warning Signs
- Serious Complications
- How Doctors Diagnose the Condition
- Treatment Approaches
- Managing Life with Ulcerative Colitis
What Is Ulcerative Colitis
Ulcerative colitis is a lifelong condition that causes inflammation (swelling) and ulcers inside your colon, which is also called your large intestine[1]. The condition is one of the most common types of inflammatory bowel disease (IBD), a group of diseases that cause inflammation of the intestine[2].
The inflammation from ulcerative colitis affects the inner lining of the colon, spreading upward from the rectum (the last part of your large intestine that connects to your anus) through the colon[3]. Unlike other forms of bowel disease, ulcerative colitis only affects this inner lining. It does not reach through other layers of the intestine wall[3].
The disease causes swelling and ulcers all along its path, leaving no healthy tissue. This continuous pattern of damage is one of the key features that helps doctors identify ulcerative colitis[3].
- Colon (large intestine)
- Rectum
Understanding Severe Forms of the Disease
Most people with ulcerative colitis have mild symptoms during flare-ups. However, about 10 to 15 percent of people have severe inflammation when first diagnosed, and another 15 percent will develop an acute severe flare requiring hospitalization during their lifetime[9].
Acute severe ulcerative colitis is defined as passing six or more loose stools with blood per day, along with evidence that the body is being affected systemically[9]. This is a medical emergency that requires immediate hospital care.
The most severe form, called fulminant ulcerative colitis, is rare. It can cause life-threatening complications that require urgent medical treatment[2]. Patients with fulminant disease may have 10 or more bloody stools per day and continuous symptoms[9].
The mortality rate for severe ulcerative colitis has drastically improved. In the time before steroids were available, mortality was between 30 and 60 percent. At present, specialist centers report mortality rates of less than 1 to 2.9 percent[8].
Symptoms and Warning Signs
Ulcerative colitis symptoms often get worse over time. In the beginning, people may notice signs of mild disease, including diarrhea that may or may not be bloody, increased bowel movements, urgent need to poop, feeling like you have to poop but being unable to, and mild abdominal cramping[2].
As the condition progresses to moderate or severe stages, symptoms become more serious. People may experience frequent bowel movements (four or more episodes daily), blood, mucus or pus in stool, severe belly cramping, extreme tiredness, sudden weight loss, nausea, and fever[2].
One symptom that helps distinguish ulcerative colitis from other bowel diseases is stool with blood or mucus, caused by ulcers in the colon. People also commonly experience stomach cramping with bowel movements and an urgent need to have a bowel movement[3].
About half of people have mild symptoms during flare-ups, while others experience frequent fevers, bloody diarrhea, nausea and severe abdominal cramps[2]. Severe bleeding from the rectum can happen when ulcers cause a lot of blood to pass from the anus during a bowel movement[3].
About 25 percent of people with ulcerative colitis eventually develop conditions that affect body parts other than their colon. The inflammation can spread to bones, joints, eyes, skin and liver. This causes symptoms like joint pain and swelling, red or itchy eyes, and painful bumps or rashes on skin[2].
Serious Complications
Ulcerative colitis can put people at increased risk of developing serious health complications. The most severe complications generally stem from serious damage to the affected area, meaning the colon and rectum[3].
Emergency complications that require immediate care include severe dehydration, which can result from the colon’s reduced ability to absorb water and from fluid loss during frequent trips to the bathroom[3].
Severe bleeding from the rectum occurs when ulcers cause a lot of blood to pass from the anus during a bowel movement. If you think you are experiencing severe bleeding with symptoms like fainting, dizziness, shortness of breath, chest pain, or severe pain, you need emergency medical attention[7].
A perforated (torn) colon can happen when ulcers and chronic inflammation cause a hole in the colon[3]. This is one of the most dangerous complications and requires immediate surgical intervention.
Toxic megacolon occurs when inflammation spreads to the deeper tissues of the intestines, causing inflammation so severe the colon stops working[3]. This life-threatening condition requires urgent treatment.
Longstanding ulcerative colitis is associated with an increased risk of colon cancer. Patients should receive an initial screening colonoscopy eight years after the onset of disease affecting the entire colon, and 12 to 15 years after the onset of left-sided disease. Follow-up colonoscopy should be repeated every two to three years[11].
How Doctors Diagnose the Condition
To diagnose ulcerative colitis, healthcare professionals perform a colonoscopy, a test that uses a thin, flexible, lighted tube with a camera to view the entire colon[10]. During this procedure, doctors collect tissue samples called biopsies from the lining of the colon. A tissue sample is necessary to make the diagnosis[10].
The diagnosis is made through viewing the colon with the colonoscope. Doctors look for specific patterns of inflammation and ulceration that are characteristic of ulcerative colitis[5].
Blood tests may be suggested to check for anemia (a condition in which there aren’t enough red blood cells to carry oxygen to the tissues) or signs of infection. Sometimes, markers of inflammation are also checked[10].
Stool studies help as well. White blood cells or certain proteins in stool can suggest ulcerative colitis. A stool sample also can help rule out other conditions, such as infections caused by bacteria, viruses or parasites[10].
If the colon is severely inflamed, doctors may perform a flexible sigmoidoscopy instead of a full colonoscopy. This test uses a shorter tube to look at just the rectum and sigmoid colon, which is the lower end of the colon[10].
If symptoms are severe, a standard X-ray of the abdominal area may be done to rule out serious complications like a dilated or torn colon[10].
Treatment Approaches
Initial Medical Management
While mild or moderate flare-ups can usually be treated at home, more severe flare-ups should be managed in hospital to minimize the risk of dehydration and potentially fatal complications, such as the colon rupturing[13].
Patients with acute severe ulcerative colitis should be admitted to hospital for intensive treatment. Initial medical management includes intravenous corticosteroids (medicines that reduce inflammation), prevention of blood clots, oral or tube feeding as tolerated, and testing to rule out infections[9].
In hospital, patients receive medicine and sometimes fluids directly into a vein[13]. Intravenous corticosteroids are the mainstay of therapy for severe cases[8].
When Initial Treatment Doesn’t Work
Response to steroids should be assessed at day 3 of admission. Patients who do not respond or only partially respond should be considered for alternative medical therapy or surgery[8].
Failure of initial medical management by day 3 of corticosteroids should prompt escalation to rescue therapy with either ciclosporin or infliximab, or referral for surgery[9].
Ciclosporin is given slowly through a drip in the arm at a dose of 2 milligrams per kilogram per day, and treatment is usually continuous for around 7 days[8][13]. Approximately 75 percent of patients have short-term response and 50 percent have long-term response to ciclosporin[8].
Infliximab is administered as a single dose intravenous infusion of 5 milligrams per kilogram. It also has a response rate of approximately 70 percent in the short term and 50 percent in the long term[8].
Both cyclosporin and infliximab are equally effective medical rescue therapies, as demonstrated in recent studies[8].
Surgical Treatment
Colectomy (surgical removal of the colon) should be considered for patients who do not respond to rescue therapy within 7 days of starting it[9]. Patients not responding to infliximab or cyclosporin should be considered for surgery[8].
Surgical treatment of ulcerative colitis is reserved for patients who fail medical therapy or who develop severe hemorrhage, perforation, or cancer[11].
Patients with intestinal perforation, severe uncontrolled bleeding, or toxic megacolon should be considered for immediate surgery[9].
Medications for Less Severe Disease
Aminosalicylates, also known as 5-ASAs, are medicines that help to reduce inflammation. They’re usually the first treatment option for mild or moderate ulcerative colitis[13]. These can be taken as tablets, suppositories that you insert into your bottom, or through an enema where fluid is pumped into your large intestine[13].
Corticosteroids can be used with or instead of 5-ASAs to treat a flare-up if 5-ASAs alone are not effective. However, unlike 5-ASAs, corticosteroids are not used as long-term treatment to maintain remission because they can cause serious side effects when used for a long time[13].
Immunosuppressants are medicines that reduce the activity of the immune system. They’re usually given as tablets to treat mild or moderate flare-ups, or maintain remission if symptoms have not responded to other medicines[13].
Managing Life with Ulcerative Colitis
Understanding the Disease Pattern
Most people with ulcerative colitis experience periods when they experience symptoms, called flare-ups, followed by longer periods of no symptoms, called remission[2]. This pattern of symptoms coming and going is characteristic of the disease.
An ulcerative colitis flare-up is the return of symptoms after not having any for a period of time. This may involve diarrhea, belly pain and cramping, rectal pain and bleeding, fatigue, and urgent bowel movements[15].
Diet and Nutrition
Most people with ulcerative colitis are recommended to follow a healthy, balanced diet and drink plenty of fluids. This is to avoid dehydration and ensure you get all the nutrients you need[16].
A specific diet is not thought to play a role in causing ulcerative colitis. But some people with inflammatory bowel disease may be recommended to make temporary changes to their diet after surgery, or to help control symptoms during a flare-up[16].
Keeping a food diary that documents what you eat can be helpful. You may find you can tolerate some foods, while others make your symptoms worse. By keeping a record of what and when you eat, you should be able to identify problem foods and eliminate them from your diet[16].
Changes in diet and lifestyle may help control symptoms and lengthen the time between flare-ups. Some people find that certain foods and beverages can make symptoms worse, especially during a flare-up. Dairy foods are one possible cause for some people[15].
High-fiber foods, such as fresh fruits and vegetables and whole grains, are generally excellent sources of nutrition. However, if you have ulcerative colitis, these foods may make your symptoms worse during a flare[15].
Eating smaller meals more often, rather than three main meals, may help some people feel better[16].
Stress Management
Although stress does not cause ulcerative colitis, successfully managing stress levels may reduce the frequency of symptoms. Exercise has been proven to reduce stress and boost mood. Relaxation techniques like breathing exercises, meditation and yoga are good ways of teaching yourself to relax[16].
Emotional Support
Living with a long-term condition that’s as unpredictable and potentially debilitating as ulcerative colitis can have a significant emotional impact. In some cases, anxiety and stress caused by ulcerative colitis can lead to depression[16].
It may be useful to talk to others affected by ulcerative colitis, either face-to-face or via the internet. Support groups can connect you with others who understand what you’re going through[16].
Planning for Pregnancy
The chances of a woman with ulcerative colitis becoming pregnant are not usually affected by the condition. The majority of women with ulcerative colitis who decide to have children will have a normal pregnancy and a healthy baby[16].
However, if you’re pregnant or planning a pregnancy, you should discuss it with your care team. If you become pregnant during a flare-up or have a flare-up while pregnant, there’s a risk you could give birth early or have a baby with a low birthweight[16].
Most ulcerative colitis medicines can be taken during pregnancy, including corticosteroids, most 5-ASAs and some types of immunosuppressant medicine[16].
