If you have received a diagnosis of ulcerative colitis, you may be feeling overwhelmed by the many different treatment options.
Each individual case of colitis is a bit different based on individual symptoms and underlying causes, so each treatment plan will also be different. But, colitis treatment usually begins with the following foundations:
Eat an anti-inflammatory diet.
Support your gut with probiotics and anti-inflammatory supplements as needed.
Include behavioral and lifestyle supports such as decreasing stress and sun exposure.
In this article, we will look at how to discover and address possible underlying causes, the best diet for ulcerative colitis, and an actionable plan for colitis treatment.
What Is Ulcerative Colitis?
Ulcerative colitis is an inflammatory disease of the gastrointestinal tract that affects the colon (large intestine). Quick tip: You can think of colitis as “colon” plus “itis” (inflammation) which means inflammation of the colon.
Ulcerative colitis often starts at the rectum and moves up through the colon. The inflammation can be in a few parts of the colon or could lead to pancolitis, affecting the whole colon. Colitis is the most common form of inflammatory bowel disease (IBD) worldwide (the other type of IBD is Crohn’s disease, which can affect any part of the gastrointestinal tract) and is most common in adults.
Ulcerative Colitis Symptoms
Ulcerative colitis symptoms are usually not constant. Rather, you might feel well for a while and then have symptom flare-ups. When people talk about UC symptoms, they mostly refer to digestive symptoms, but there are others to be aware of.
A gastroenterologist may use a few helpful tests to diagnose ulcerative colitis and rule out any other diseases that may cause similar symptoms (especially Crohn’s.) It is also helpful in the diagnostic process to track your symptoms and share those with your doctor.
Here are some diagnostic tests a gastroenterologist may use:
Endoscopy, colonoscopy, biopsy of colon/rectal tissue, and barium enema may be used to check for abnormal tissues, inflammation, and colorectal cancer.
A few different blood tests can be helpful. C-reactive protein can check for general inflammation. Perinuclear anti-neutrophil (a type of white blood cell) antibodies (P-ANCA) seem to be associated with ulcerative colitis.
In order to rule out Crohn’s, an anti-saccharomyces cerevisiae antibodies (ASCA) tests may be done. ASCA antibodies seem to be associated with Crohn’s disease.
Stool test to rule out infections
C-reactive protein (CRP) or erythrocyte (red blood cell) sedimentation rate (ESR) to check for inflammation level
Ulcerative Colitis Causes and Risk Factors
Ulcerative colitis does not have a definitive cause, but evidence suggests that it is associated with an inappropriate immune response, which can arise from many different environmental factors, imbalances in the microbiome, as well as genetics [3 Trusted SourcePubMedGo to source, 4 Trusted SourcePubMedGo to source].
The body creates temporary inflammation as part of a normal immune system response to threats and foreign particles that may cause harm. An inappropriate immune response occurs when the immune system attacks something that is probably not harmful or overreacts to a possible pathogen. This creates unnecessary or excessive inflammation that can become chronic.
For example, in addition to toxins and infections, the immune system may attack food particles or beneficial gut bacteria. The immune system may also attack its own tissues: this is called autoimmunity. In the case of colitis, the immune system is attacking the lining of the large intestine (colon) [3 Trusted SourcePubMedGo to source].
This can happen anywhere along the entire colon, and the resulting inflammation can lead to sores along the lining of the colon.
So, what causes this inappropriate immune response and inflammation in the colon?
Some of the risk factors for inflammatory bowel disease (IBD), including ulcerative colitis, are:
Leaky gut: One systematic review of 47 observational studies found that IBD is one of the chronic conditions most strongly associated with increased intestinal permeability (“leaky gut”) [5 Trusted SourcePubMedGo to source, 6 Trusted SourcePubMedGo to source]. Leaky gut is a loosening of the tight junctions between the cells that line your small intestine. This lets large molecules such as undigested food particles and bacterial fragments enter into your bloodstream. The immune system attacks those molecules, which can cause inflammation in the GI tract. What exactly causes leaky gut in any one person can be different. This is where environmental factors and genetics often come into play.
Environment in early life: Studies have shown that antibiotic use early in life increases the risk of IBD [9 Trusted SourcePubMedGo to source, 10 Trusted SourcePubMedGo to source]. A 2017 meta analysis of the medical literature also found that rates of IBD were higher in people who were not breastfed as babies .
SIBO (small intestinal bacterial overgrowth): A 2019 meta analysis concluded that incidence of SIBO was higher in people with IBD compared to people without IBD [12 Trusted SourcePubMedGo to source].
Here are a few other potential causes of or contributing factors to colitis:
The first step towards treating ulcerative colitis is to identify inflammatory triggers and reduce your exposure to them. Fortunately, there are many things to do at home that can help lower inflammation and repair leaky gut:
1. Anti-Inflammatory Diet
An anti-inflammatory diet is one of the best steps you can take to decrease the symptoms of ulcerative colitis. There are some foods that are generally inflammatory, such as processed foods and sugar, while other foods are inflammatory to an individual based on their sensitivities and immune system response. Gluten, dairy, and legumes (beans) are among the most common food sensitivities.
All of the diets here remove processed foods and keep sugar levels lower. They all help decrease inflammation and support a healthy gut.
Paleo and Autoimmune Paleo (AIP)
I often recommend starting with a Paleo diet, especially if you are currently eating a diet high in inflammatory foods.
The AIP diet is like the Paleo diet but with a few more foods removed because they contain compounds that are often inflammatory to people with autoimmune diseases such as IBD, arthritis, and Hashimotos. Some of the additional removed foods on an AIP diet are nightshades (i.e. tomatoes and peppers), eggs, and coffee.
If you have already been eating a Paleo diet and have not seen improvements, or you know that you have other contributing conditions such as SIBO, you may want to move on to a low-FODMAP diet.
In the case of colitis, clinical trials have shown the low-FODMAP diet to be effective for colitis treatment. A low-FODMAP diet removes foods that have certain carbohydrates that may feed pathogenic bacteria or cause a bacterial overgrowth.
Foods typically removed in a low-FODMAP diet are cruciferous vegetables (ie, broccoli and cabbage); certain fruits like apricot, mango, apple, and avocado; legumes (i.e, beans and lentils); some nuts such as cashews; dairy; grains (especially wheat); and some sweeteners (fructose and even “healthier” sweeteners like agave and xylitol).
When one of the anti-inflammatory diets is still not working, or you are in an acute flare, an elemental diet can provide rapid and effective relief.
The elemental diet is a meal replacement supplement that gives your gut a rest. It’s easily digestible, anti-inflammatory, and provides all the nutrients you need. The elemental diet is one of the most effective treatments I use with my IBD patients.
People often use these diets to calm and heal the gut for two to three weeks and then move on to a more sustainable, long term anti-inflammatory diet (such as a Paleo diet).
2. Supplements to Support the Gut
There is a large body of research supporting using probiotics to maintain good gut health and decrease symptoms of inflammatory bowel disease:
One systematic review found that taking probiotics, especially taking multiple strains together, is effective at putting active ulcerative colitis into remission [35 Trusted SourcePubMedGo to source].
Probiotics were found to be as effective as the medication mesalamine in preventing relapse of ulcerative colitis [36 Trusted SourcePubMedGo to source].
More research is needed to know how well probiotics could work at preventing relapse in people who are not having an active colitis flare. One systematic review found that probiotics did not help maintain remission [37 Trusted SourcePubMedGo to source].
But since gut health is a contributing factor in inflammatory bowel disease, probiotics may be a good supplement to have in your colitis treatment toolbox, especially during a flare-up.
Digestive enzymes were also found to be helpful when used in combination with the anti-inflammatory drug mesalamine. When taking digestive enzymes, patients have been shown to have a decrease in symptoms of abdominal pain, cramping, bloating, and gas [38 Trusted SourcePubMedGo to source].
Curcumin (which has antimicrobial and anti-inflammatory properties) was shown in a meta-analysis to be better than a placebo at maintaining remission of colitis. However, another meta analysis found that curcumin may not be better than placebo in creating remission of active colitis [41 Trusted SourcePubMedGo to source].
The antimicrobials and anti-inflammatories Boswellia serrata (Indian frankincense) gum resin and Plantago ovata (desert Indian wheat) seeds were as effective as the medication mesalamine at preventing colitis relapse.
Prescription antimicrobials, or antibiotics more specifically, are often used in the treatment of IBD in general, but they are used more often in Crohn’s disease rather than ulcerative colitis. Antibiotics are usually only used in colitis when ileal pouch-anal anastomisis surgery has resulted in pouchitis (inflammation of the pouch that was created during surgery) [40 Trusted SourcePubMedGo to source, 42 Trusted SourcePubMedGo to source].
4. Decrease Stress and Get Some Sun
Reducing stress is beneficial for health in general. However, with IBD in particular, stress reduction can help calm symptoms and decrease inflammation. A few studies have found that patients who learned how to engage in breath work and relaxation techniques had significant improvements in ulcerative colitis symptoms, quality of life, and a decrease in inflammation (shown with a decrease in c-reactive protein levels) [43 Trusted SourcePubMedGo to source, 44 Trusted SourcePubMedGo to source].
Some studies indicate that low vitamin D is associated with leaky gut. Moderate sun exposure is one way to increase vitamin D — it has been shown to decrease inflammation in inflammatory bowel disease [45 Trusted SourcePubMedGo to source, 46 Trusted SourcePubMedGo to source]. Getting 15-20 minutes of sun exposure early in the day will increase vitamin D levels as well as help set your circadian rhythm so that you can sleep better at night, which can also help lower your stress levels and decrease inflammation.
Traditional Ulcerative Colitis Treatment
The first-line of traditional treatment tends to focus on lowering inflammation through medication and surgery, although these anti-inflammatory treatments don’t necessarily address the cause of the inflammation. These treatments may be recommended by your doctor depending on your case of IBD and used alongside diet and lifestyle changes and may include:
Decreasing inflammation with anti-inflammatories such as sulfasalazine and 5-aminosalicylates
Using immunosuppressants (biologics) such as azathioprine and Remicade (infliximab) and immunomodulators such as and Humeria (adalimumab). Xeljanz (tofacitinib) has often been used to treat rheumatoid arthritis and colitis. However, the FDA alerted the public in February 2021 that this drug showed an increased risk of serious heart-related problems and cancer. Remicade was found to have less side effects in comparison .
Glucocorticoids (oral or rectal corticosteroids, such as prednisone) if you don’t see a remission of flare-ups within two weeks
Undergoing surgery, such as a colectomy or ileal pouch-anal anastomosis (IPAA) is sometimes used in severe ulcerative colitis, especially in cases of toxic megacolon, perforation, or cancer.
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