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Ulcerative Colitis

Also indexed as: UC

Illustration

Keeping an eye on your diet is essential to caring for colon inflammation. According to research or other evidence, the following self-care steps may help treat UC symptoms and reduce your risk for relapse and complications:

What you need to know

  • Don’t forget the fish oil
  • Help reduce inflammation and prevent relapses by taking a daily supplement delivering 5.4 grams of omega-3 fatty acids
  • Drink aloe juice
  • Improve your symptoms, and your chances for remission, by drinking 100 ml of an Aloe vera herbal extract twice a day
  • Try herbal boswellia
  • Reduce severity and encourage remission by taking 550 mg of boswellia gum resin three times a day
  • Watch what you eat
  • Forego fast food and other sources of excessive animal fats, margarine, and sugars to reduce risk
  • Protect yourself from a related disease
  • Reduce your risks of developing UC-related colon cancer by avoiding alcohol and taking a daily folic acid supplement
  • Check up on nutrition
  • Visit a qualified health professional regularly to detect and treat nutritional deficiencies caused by colitis

These recommendations are not comprehensive and are not intended to replace the advice of your doctor or pharmacist. Continue reading the full ulcerative colitis article for more in-depth, fully-referenced information on medicines, vitamins, herbs, and dietary and lifestyle changes that may be helpful.

About ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory disease of the colon, which is relatively common but remains poorly understood.

Diagnosis must be made by a healthcare practitioner—typically a gastroenterologist. Irritable bowel syndrome, a completely unrelated and less serious condition, was sometimes called mucous colitis in the past. As a result, the general term “colitis“ is still sometimes used inappropriately to refer to irritable bowel syndrome. It is critical that people who are diagnosed with “colitis” find out whether they have irritable bowel syndrome or UC.

Product ratings for ulcerative colitis

Science Ratings Nutritional Supplements Herbs
2Stars

Butyrate (enema)

Fish oil

Folic acid

Probiotics

Aloe

Boswellia

DHEA

Psyllium

Wheat grass (juice)

1Star  

Calendula

Chamomile

Curcumin

Flaxseed

Licorice

Marshmallow

Myrrh

St. John’s wort (oil, taken as an enema)

Yarrow

3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support and/or minimal health benefit.

What are the symptoms?

UC is characterized by frequent abdominal pain and bloody diarrhea. Other symptoms may include fatigue, weight loss, decreased appetite, and nausea.

Medical options

The over-the-counter antidiarrheal drug loperamide (Imodium AD) may be used in ulcerative colitis patients with diarrhea. Anal irritation and loose stools may sometimes be improved by giving bulk-forming laxative such as methylcellulose (Citrucel) or psyllium (Fiberall, Konsyl, Metamucil, Perdiem).

Diphenoxylate with atropine (Lomotil) and loperamide (Imodium AD) are the prescription drugs most often used to control diarrhea. Cramps may be treated with anticholinergic drugs, such as L-hyoscyamine (Levsin, Levbid) and belladonna (Belladonna Tincture). These drugs must be used with extreme caution to prevent toxic dilation of the colon. Sulfasalazine (Azulfidine) is used in individuals with mild to moderate colitis. Oral corticosteroids, such as prednisone (Deltasone), may be used during acute flare-ups; however, long-term corticosteroid therapy may be more harmful than good. Therapy with corticosteroids, such as hydrocortisone enema (Cortenema) is commonly recommended. Mesalamine (Asacol, Pentasa, Rowasa) may be prescribed in some cases, as an enema, orally, or in suppository form. Certain immunosuppressive drugs may also be effective, including azathioprine (Imuran), cyclosporine (Sandimmune), and6-mercaptopurine (Purinethol). Other medications, such as osalazine (Dipentum), balsalazide (Colazol), and infliximab (Remicade) might benefit some people. Secondary bacterial infections are managed with antibiotics.

Other treatment of UC includes avoiding raw fruits and vegetables. Sometimes a milk-free diet is suggested. Toxic colitis, a grave medical emergency complication of UC, is treated intensively in emergency departments with antibiotics, such as tobramycin (Nebcin), amikacin (Amikin), and gentamicin (Garamycin), intravenous fluid replacement, and either corticosteroids or adrenocorticotropic hormone (ACTH). Emergency surgical removal of the colon is sometimes necessary in the most severe cases. Elective surgery may be recommended for milder cases.

Dietary changes that may be helpful

Some studies have shown that high sugar intake is associated with an increase in risk for UC.1 2 Other research has failed to find any association between UC and sugar intake.3 4 Until more is known, persons with inflammatory bowel diseases, including UC, should consider limiting their intake of sugar.

In two studies, people with a high intake of animal fat, cholesterol, or margarine had a significantly increased risk of UC, compared with people who consumed less of these fats.5 6 Although these associations do not prove cause-and-effect, reducing one’s intake of animal fats and margarine is a means of improving overall health and possibly UC as well.

There is preliminary evidence that people who eat fast food at least twice a week have nearly four times the risk of developing UC than people who do not eat fast food.7

More than a half-century ago, several doctors reported that food allergies play an important role in some cases of UC.8 9 Since that time, many doctors have observed that avoidance of allergenic foods will often reduce the severity of UC and can sometimes completely control the condition. In other old studies, milk has been reported to trigger UC,10 and people with UC were found to have antibodies to milk in their blood, a possible sign of allergy.11 Today the relationship between food allergies and UC remains controversial12 and is not generally accepted by the conventional medical community. People who wish to explore the possibility that food sensitivities may trigger their symptoms may wish to consult with an appropriate healthcare provider.

In a preliminary study, 39 patients with mild to moderate ulcerative colitis experienced significant improvement after receiving 30 grams (about 1 oz) per day of a germinated barley product for four weeks.13 Controlled trials are needed to confirm this report.

Lifestyle changes that may be helpful

For unknown reasons, smokers have a lower risk of UC. The nicotine patch has actually been used to induce remissions in people with UC,14 although this treatment has been ineffective in preventing relapses.15 On the other hand, Crohn’s disease, which is in many ways similar to UC, is made worse by smoking.16 Despite the possible protective effect of smoking in people with UC, a strong case can be made that risks of smoking outweigh the benefits; even the use of nicotine patches carries its own side effects and remains experimental.

Vitamins that may be helpful

UC is linked to an increased risk of colon cancer. Studies have found that people with UC who take folic acid supplements or who have high blood levels of folic acid have a reduced risk of colon cancer compared with people who have UC and do not take folic acid supplements.17 18 19 Although these associations do not prove that folic acid was responsible for the reduction in risk, this vitamin has been shown to prevent experimentally induced colon cancer in animals.20 Moreover, low blood folic acid levels have been found in more than half of all people with UC.21 People with UC who are taking the drug sulfasalazine, which inhibits the absorption of folic acid,22 are at a particularly high risk of developing folic acid deficiency. Folic acid supplementation may therefore be important for many people with UC. Since taking folic acid may mask a vitamin B12 deficiency, however, people with UC who wish to take folic acid over the long term should have their vitamin B12 status assessed by a physician.

Alcohol consumption is known to promote folic acid deficiency and has also been linked to an increased risk of colon cancer.23 People with UC should, therefore, keep alcohol intake to a minimum.

Preliminary24 and double-blind trials25 26 27 have found that fish oil supplementation reduces inflammation, decreases the need for anti-inflammatory drugs, and promotes normal weight gain in people with UC. However, fish oil has not always been effective in clinical trials for UC.28 Amounts used in successful clinical trials provided 3.2 grams of EPA and 2.2 grams of DHA per day—the two important fatty acids found in fish oil.

A fatty acid called butyrate, which is synthesized by intestinal bacteria, serves as fuel for the cells that line the small intestine. Administration of butyrate by enema has produced marked improvement in people with UC in most,29 30 31 32 33 34 but not all,35 preliminary trials. Butyrate taken by mouth is not likely to be beneficial, as sufficient quantities do not reach the colon by this route. Although butyrate enemas are not widely available, they can be obtained by prescription through a compounding pharmacy, which prepares customized prescription medications to meet individual patient needs.

In a preliminary trial, 6 of 13 people with ulcerative colitis went into remission after taking 200 mg per day of DHEA for eight weeks.36 This large amount of DHEA has the potential to cause adverse side effects and should only be used under the supervision of a doctor.

In preliminary37 and double-blind38 trials, a probiotic supplement (in this case, a non-disease-causing strain of Escherichia coli) was effective at maintaining remission in people with UC. In a double-blind trial, a combination probiotic supplement containing Lactobacilli, Bifidobacteria, and a beneficial strain of Streptococcus has been shown to prevent pouchitis, a common complication of surgery for UC.39 People with chronic relapsing pouchitis received either 3 grams per day of the supplement or placebo for nine months. Eighty-five percent of those who took the supplement had no further episodes of pouchitis during the nine-month trial, whereas 100% of those receiving placebo had relapses within four months. Preliminary evidence suggests that combination probiotic supplements may be effective at preventing UC relapses as well.40

In a preliminary trial, people with UC significantly improved on a sugar-free, low-allergen diet with additional nutritional supplementation that included a multivitamin-mineral supplement (2–6 tablets per day); a fish oil supplement (400 mg per day); borage oil (400 mg per day); flaxseed oil (400 mg per day); and a probiotic formula containing Lactobacillus acidophilus and other species of beneficial bacteria.41 Some participants received slight variations of this regimen. Since so many different supplements were given and since the trial was not controlled, it is not possible to say which, if any, of the nutrients was responsible for the improvement observed by the researchers.

Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful

A small clinical study found that people with UC taking 550 mg of boswellia gum resin three times daily for six weeks had similar improvement in symptoms and the severity of their disease as people with UC taking the drug sulfasalazine.42 Overall, 82% of patients receiving boswellia, along with 75% of patients taking sulfasalazine, went into remission.

In a preliminary trial, people with UC remained in remission just as long when they took 20 grams of ground psyllium seeds twice daily with water as when they took the drug mesalamine.43 The combination of the two was slightly more effective than either alone. Controlled trials are now needed to confirm a therapeutic effect of psyllium for UC.

In a controlled trial, supplementation with wheat grass juice for one month resulted in clinical improvement in 78% of people with ulcerative colitis, compared with 30% of those receiving a placebo.44 The amount of wheat grass used was 20 ml per day initially; this was increased by 20 ml per day to a maximum of 100 ml per day (approximately 3.5 ounces).

German doctors practicing herbal medicine often recommend chamomile for people with colitis.45 A cup of strong tea drunk three times per day is standard, along with enemas using the tea when it reaches body temperature.

Curcumin is a compound in turmeric (Curcuma longa) that has been reported to have anti-inflammatory activity. In a preliminary trial, five of five people with chronic ulcerative proctitis (a condition similar to ulcerative colitis) had an improvement in their disease after supplementing with curcumin. The amount of curcumin used was 550 mg twice a day for one month, followed by 550 mg three times a day for one month.46

Enemas of oil of St. John’s wort may also be beneficial.47 Consult with a doctor before using St. John’s wort oil enemas.

Aloe vera juice has anti-inflammatory activity and been used by some doctors for people with UC. In a double-blind study of people with mildly to moderately active ulcerative colitis, supplementation with aloe resulted in a complete remission or an improvement in symptoms in 47% of cases, compared with 14% of those given a placebo (a statistically significant difference).48 No significant side effects were seen. The amount of aloe used was 100 ml (approximately 3.5 ounces) twice a day for four weeks. Other traditional anti-inflammatory and soothing herbs, including calendula, flaxseed, licorice, marshmallow, myrrh, and yarrow. Many of these herbs are most effective, according to clinical experience, if taken internally as well as in enema form.49 Enemas should be avoided during acute flare-ups but are useful for mild and chronic inflammation. It is best to consult with a doctor experienced with botanical medicine to learn more about herbal enemas before using them. More research needs to be done to determine the effectiveness of these herbs.

Are there any side effects or interactions?
Refer to the individual herb for information about any side effects or interactions.

References:

1. Reif S, Klein I, Lubin F, et al. Pre-illness dietary factors in inflammatory bowel disease. Gut 1997;40:754–60.

2. Tragnone A, Valpiani D, Miglio F, et al. Dietary habits as risk factors for inflammatory bowel disease. Eur J Gastroenterol Hepatol 1995;7:47–51.

3. Thornton JR, Emmett PM, Heaton KW. Diet and ulcerative colitis. BMJ 1980;1:293–4.

4. Jarmerot G, Jammark I, Nilsson K. Consumption of refined sugar by patients with Crohn’s disease, ulcerative colitis or irritable bowel syndrome. Scand J Gastroenterol 1983;18:999–1002.

5. Reif S, Klein I, Lubin F, et al. Pre-illness dietary factors in inflammatory bowel disease. Gut 1997;40:754–60.

6. Kono S. Dietary and other risk factors of ulcerative colitis. A case-control study in Japan. J Clin Gastroenterol 1994;19:166–71.

7. Persson PG, Ahlbom A, Hellers G. Diet and inflammatory bowel disease: a case-control study. Epidemiology 1992;3:47–52.

8. Rowe AH. Chronic ulcerative colitis—allergy in its etiology. Ann Intern Med 1942;17:83–100.

9. Andresen AFR. Ulcerative colitis—an allergic phenomenon. Am J Dig Dis 1942;9:91–8.

10. Truelove SC. Ulcerative colitis provoked by milk. Brit Med J 1961;5220:154–60.

11. Taylor KB, Truelove SC. Circulating antibodies to milk proteins in ulcerative colitis. Brit Med J 1961;5257:924–9.

12. Candy S, Borok G, Wright JP, et al. The value of an elimination diet in the management of patients with ulcerative colitis. S Afr Med J 1995;85:1176–9.

13. Kanauchi O, Iwanaga T, Mitsuyama K. Germinated barley foodstuff feeding: a novel neutraceutical therapeutic strategy for ulcerative colitis. Digestion 2001;63 Suppl:60–7.

14. Pullan RD, Rhodes J, Ganesh S, et al. Transdermal nicotine for active ulcerative colitis. N Engl J Med 1994;330:811–5.

15. Thomas GA, Rhodes J, Mani V, et al. Transdermal nicotine as maintenance therapy for ulcerative colitis. N Engl J Med 1995;332:988–92.

16. Rhodes J, Thomas GA. Smoking: good or bad for inflammatory bowel disease? Gastroenterol 1994;106:907–10 [editorial].

17. Lashner BA, Heidnreich PA, Su GL, et al. Effect of folate supplementation on the incidence of dysplasia and cancer in chronic ulcerative colitis. Gastroenterol 1989;97:255–9.

18. Lashner BA. Red blood cell folate is associated with the development of dysplasia and cancer in ulcerative colitis. J Cancer Res Clin Oncol 1993;119:549–54.

19. Lashner BA, Provencher KS, Seidner DL, et al. The effect of folic acid supplementation on the risk for cancer or dysplasia in ulcerative colitis. Gastroenterol 1997;112:29–32.

20. Kim YI, Salomon RN, Graeme-Cooke F, et al. Dietary folate protects against the development of macroscopic colonic neoplasia in a dose responsive manner in rats. Gut 1996;39:732–40.

21. Elsbord L, Larsen L. Folate deficiency in chronic inflammatory bowel disease. Scand J Gastroenterol 1979;14:1019–24.

22. Halsted CH, Gandhi G, Tamura T. Sulfasalazine inhibits the absorption of folates in ulcerative colitis. N Engl J Med 1981;317:1513–7.

23. Kaltsky AL, Armstrong MA, Friedman GD, Hiatt RA. The relations of alcoholic beverage use to colon and rectal cancer. Am J Epidemiol 1988;128:1007–15.

24. Salomon P, Kornbluth AA, Janowitz HD. Treatment of ulcerative colitis with fish oil n--3-omega-fatty acid: an open trial. J Clin Gastroenterol 1990;12:157–61.

25. Stenson WF, Cort D, Rodgers J, et al. Dietary supplementation with fish oil in ulcerative colitis. Ann Intern Med 1992;116:609–14.

26. Hawthorne AB, Daneshmend TK, Hawkey CJ, et al. Treatment of ulcerative colitis with fish oil supplementation: a prospective 12 month randomised controlled trial. Gut 1992;33:922–8.

27. Aslan A, Triadafilopoulos G. Fish oil fatty acid supplementation in active ulcerative colitis: a double-blind, placebo-controlled, crossover study. Am J Gastroenterol 1992;87:432–7.

28. Dichi I, Frenhane P, Dichi JB, et al. Comparison of omega-3 fatty acids and sulfasalazine in ulcerative colitis. Nutrition 2000;16:87–90.

29. Scheppach W, Sommer H, Kirchner T, et al. Effect of butyrate enemas on the colonic mucosa in distal ulcerative colitis. Gastroenterol 1992;103:51–6.

30. Scheppach W. Treatment of distal ulcerative colitis with short-chain fatty acid enemas. A placebo-controlled trial. German-Austrian SCFA Study Group. Dig Dis Sci 1996;41:2254–9.

31. Vernia P, Marcheggiano A, Caprilli R, et al. Short-chain fatty acid topical treatment in distal ulcerative colitis. Aliment Pharmacol Ther 1995;9:309–13.

32. Steinhart AH, Brzezinski A, Baker JP. Treatment of refractory ulcerative proctosigmoiditis with butyrate enemas. Am J Gastroenterol 1994;89:179–83.

33. Patz J, Jacobsohn WZ, Gottschalk-Sabag S, et al. Treatment of refractory distal ulcerative colitis with short chain fatty acid enemas. Am J Gastroenterol 1996;91:731–4.

34. Breuer RI, Buto SK, Christ ML, et al. Rectal irrigation with short-chain fatty acids for distal ulcerative colitis. Preliminary report. Dig Dis Sci 1991;36:185–7.

35. Steinhart AH, Hiruki T, Brzezinski A, Baker JP. Treatment of left-sided ulcerative colitis with butyrate enemas: a controlled trial. Aliment Pharmacol Ther 1996;10:729–36.

36. Andus T, Klebl F, Rogler G, et al. Patients with refractory Crohn's disease or ulcerative colitis respond to dehydroepiandrosterone: a pilot study. Aliment Pharmacol Ther 2003;17:409–14.

37. Rembacken BJ, Snelling AM, Hawkey PM, et al. Non-pathogenic Escherichia coli versus mesalazine for the treatment of ulcerative colitis: a randomised trial. Lancet 1999;354:635–9.

38. Kruis W, Schutz E, Fric P, et al. Double-blind comparison of an oral Escherichia coli preparation and mesalazine in maintaining remission of ulcerative colitis. Aliment Pharmacol Ther 1997;11:853–8.

39. Gionchetti P, Rizzello F, Venturi A, et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology 2000;119:305–9.

40. Venturi A, Gionchetti P, Rizzello F, et al. Impact on the composition of the faecal flora by a new probiotic preparation: preliminary data on maintenance treatment of patients with ulcerative colitis. Aliment Pharmacol Ther 1999;13:1103–8.

41. Edman JS, Williams WH, Atkins RC. Nutritional therapies for ulcerative colitis: literature review, chart review study, and future research. Altern Ther Health Med 2000;6:55–63.

42. Gupta I, Parihar A, Malhotra P, et al. Effects of Boswellia serrata gum resin in patients with ulcerative colitis. Eur J Med Res 1997;2:37–43.

43. Fernandez-Banares F, Hinojosa J, Sanchez-Lombrana JL, et al. Randomized clinical trial of Plantago ovata seeds (dietary fiber) as compared with mesalamine in maintaining remission in ulcerative colitis. Am J Gastroenterol 1999;94:427–33.

44. Ben-Arye E, Goldin E, Wengrower D, et al. Wheat grass juice in the treatment of active distal ulcerative colitis: a randomized double-blind placebo-controlled trial. Scand J Gastroenterol 2002;37:444–9.

45. Weiss RF. Herbal Medicine. Beaconsfield, UK: Beaconsfield Publishers Ltd, 1989, 26.

46. Holt PR, Katz S, Kirshoff R. Curcumin therapy in inflammatory bowel disease: a pilot study. Dig Dis Sci 2005;50:2191–3.

47. Weiss RF. Herbal Medicine. Beaconsfield, UK: Beaconsfield Publishers Ltd, 1989, 114–5.

48. Langmead L, Feakins RM, Goldthorpe S, et al. Randomized, double-blind, placebo-controlled trial of oral aloe vera gel for active ulcerative colitis. Aliment Pharmacol Ther 2004;19:739–47.

49. Weiss RF. Herbal Medicine. Beaconsfield, UK: Beaconsfield Publishers Ltd, 1989, 114–5.

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