FEATURE
and optimise adherence to treatments through simple discussion, taking the opportunity to signpost patients to local support groups and websites for further information as well.
ULCERATIVE COLITIS
Ulcerative colitis is the most common form of inflammatory bowel disease, affecting an estimated 240 in 100,000 people throughout the UK3
. The peak
incidence is between 15 and 25 years old, but there is another smaller peak in incidence among those aged 55 to 65 years old3
.
Unlike Crohn’s disease, ulcerative colitis affects only the mucosa of the colon and rectum. It can be classified into one of three categories according to disease extent: • Ulcerative proctitis, where inflammation affects only the rectum
• Left-sided colitis, where inflammation does not extend beyond the splenic flexure, and
• Pancolitis where inflammation extends proximally further than the splenic flexure to include the entire colon3
.
Classic symptoms of ulcerative colitis include: • Bloody diarrhoea persisting for more than six weeks
• Rectal bleeding
• Nocturnal defecation • Tenesmus
• Abdominal pain, usually left- lower quadrant
• Pre-defecation pain
• Fever and malaise indicate severe colitis
CROHN’S AND ULCERATIVE COLITIS: TREATMENT Anti-inflammatories are the mainstay of treatment, with antibiotics and/ or other supportive therapies added on when required. The four main groups of anti-inflammatories are aminosalicylates, corticosteroids, immunosuppressants and biologics4
.
Drug treatments alleviate disease symptoms but the extent to which they affect or alter disease progression is unclear6
.
MANAGING DIARRHOEA Diarrhoea can be associated with other causes, such as diet, medicines including laxatives and iron preparations, and antibiotic- associated colitis (C. Diff infection). Loperamide and other anti-diarrhoeals are not recommended with ulcerative colitis as they can increase the risk of toxic megacolon. Loperamide can be prescribed for Crohn’s disease, but only under specialist supervision. Codeine and loperamide both work to reduce gastrointestinal motility and therefore increase fluid and nutrient
Table 2: Risk factors associated with Ulcerative Colitis3 Risk factors for Ulcerative colitis Family History
Description
First degree relatives of those with ulcerative colitis have a 10-15% increased risk of developing the disease in comparison to the rest of the population without a family history
Oral contraceptives
The Faculty of Sexual and Reproductive Health found no link between the use of oral contraceptives and the development of Ulcerative Colitis, however a meta-analysis found a relationship between the use of oral contraceptives and inflammatory bowel disease
Not Smoking
Against what most would think, those who smoke actually had lower rates of ulcerative colitis than those who smoked. A systematic review and meta-analysis found the odds ratio for the risk of ulcerative colitis in smokers compared with non-smokers to be 0.58. However, ex-smokers have a 70% increased risk of developing ulcerative colitis compared with those who have never smoked.
absorption3,5 . Colestyramine is another
option with Crohn’s disease, however it is only effective in those with ileal involvement or resection. Patients who experience a lot of diarrhoea can be tempted to decrease their food and water consumption; it is extremely important to discourage this and to reinforce the value of keeping well- nourished and hydrated.
MANAGING CONSTIPATION Symptoms such as abdominal pain, distention, vomiting or lack of passing stools or flatulence can indicate bowel obstruction and should be treated as a medical emergency. Encouraging patients to ensure they consume plenty of water and soluble fibre is recommended. If a laxative has to be used, bulk-forming laxatives such as methylcellulose, sterculia and ispaghula husk are recommended, as these are made up of soluble fibre.
MANAGING PAIN Persistent or recurring abdominal pain is common in inflammatory bowel disease. In ulcerative colitis, this pain is often caused by intestinal dilatation, inflammatory exacerbations, bowel obstructions or less commonly, adhesion. With Crohn’s disease, pain can be caused by intestinal inflammation or dilatation, incomplete or complete intestinal obstruction, fistulas or adhesion. Ectopic pregnancy should be ruled out in sexually active women of child-bearing age who have Crohn’s disease. Paracetamol is the mainstay of treatment for pain, with opiates used only under the supervision of a specialist as they can increase the risk of developing toxic megacolon. NSAIDs should be avoided as they can exacerbate or aggravate inflammatory bowel disease.
MANAGING FATIGUE Fatigue is a common symptom for those with inflammatory bowel disease. Although it is often directly associated with Crohn’s and ulcerative colitis, other conditions such as depression and anaemia should be ruled out in a patient with fatigue. Where appropriate, any other factors involved in contributing to or causing fatigue should be addressed, such as stress, workload, personal relationships, chronic pain and drug or alcohol usage5.
NUTRITION Whilst there have not been any foods solely identified in causing Inflammatory bowel disease, there
are food groups known to trigger symptoms, such as spicy foods and foods with a high fat or sugar content. Many patients have found it useful to keep a food diary so as to record foods which may be affiliated with their condition. Malnutrition is common, and patients should be aware of maintaining a healthy, balanced diet, ensuring they are getting enough vitamin D, calcium, fat-soluble vitamins, zinc, iron and B12. Although there is no evidence to support the use of probiotics in Crohn’s disease, there is evidence to support multi-species probiotic use in active ulcerative colitis4
.
SURGERY Around 75% of Crohn’s patients will undergo surgery after ten years of the disease. This surgery is not curative. Patients who undergo vast numbers of surgery are often left with very little of their gastro-intestinal tract, therefore relying on parenteral nutrition for the rest of their lives. In ulcerative colitis, surgery is a curative measure. The risk of developing colorectal cancer with ulcerative colitis rises to over 20% after three decades of the disease.
Indications for surgical intervention in patients with IBD: • failure to respond to intensive medical therapy
• perforation of the colon • massive or recurrent haemorrhage • toxic megacolon • growth retardation in children
• prevention of carcinoma in high-risk patients
• colonic polyps REFERENCES
1. CKS. 2015. Available at:
cks.nice.org. uk/crohns-disease#!backgroundsub
2. The University of Edinburgh. 2015. Crohn’s study seeks to find disease causes. Available at:
www.ed.ac. uk/news/2015/crohnsstudy- 150115 [Accesses 10/11/15]
3. CKS. 2015. Ulcerative Colitis. Available at:
http://cks.nice.org.uk/ ulcerative-colitis#!backgroundsub:2 [Accessed 10/11/15]
4. Dr Brown, J. NICPLD. Inflammatory Bowel Disease. 2014. Accessed 10/10/15
5. CKS. Tiredness/fatigue in adults. 2015. Available at:
cks.nice.org.uk/ tirednessfatigue-in-adults#!scenario [Accessed 10/10/15]
6. The IBD Standards Group. 2013. Standards for the Healthcare of People who have Inflammatory Bowel Disease (IBD) http://www.
ibdstandards.org.uk/uploaded_files/ IBDstandards.pdf#page=14 [Accessed 10/11/15]
SCOTTISH PHARMACIST - 47
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