Of the inflammatory bowel diseases, ulcerative colitis is the most common subtype worldwide, affecting 600,000-900,000 people in the United States. Ulcerative colitis accounts for a quarter-million medical appointments and over four billion dollars in medical costs annually. These numbers are expected to increase as its incidence is rising globally. (2, 3)

Treatment strategies aim to induce and maintain remission of colonic inflammation to resolve gastrointestinal symptoms, promote mucosal healing, and prevent unfavorable health outcomes. Conventional therapies rely on pharmacologic medications that reduce inflammation and suppress the immune system. However, given the multifactorial etiology of ulcerative colitis, including epithelial barrier defects and immune dysregulation, a functional medicine approach to treatment thrives in addressing imbalances contributing to inflammatory responses and gastrointestinal damage. This article will discuss an effective complementary and integrative protocol that can be implemented in clinical practice with patients seeking alternative ulcerative colitis treatment options. (1)

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What is Ulcerative Colitis?

Ulcerative colitis (UC) is the most prevalent subtype of inflammatory bowel disease (IBD), a group of gastrointestinal disorders characterized by chronic digestive tract inflammation. UC is limited to the colon, most commonly afflicting adults before age 30. It is distinguished from other forms of IBD by its characteristic relapsing and remitting mucosal inflammation and ulceration that starts in the rectum and continuously extends upward to the proximal portions of the colon. (1, 4)

UC is classified based on the location of the disease, which include (3, 4):

• Ulcerative proctitis: inflammation is confined to the rectum
• Proctosigmoiditis: inflammation involves the rectum and sigmoid colon
• Left-sided colitis: inflammation extends from the rectum to the descending colon
• Pancolitis: inflammation affects the entire colon

Chronic gastrointestinal inflammation and ulceration increase the risk for potentially life-threatening complications. Surgical removal of the colon is required in up to 15% of patients with UC to manage these complications, which include severe bleeding, dehydration, swelling of the colon (toxic megacolon), perforation, and colon cancer. (1, 4)

Ulcerative Colitis Symptoms

UC's gastrointestinal symptoms depend on the location and severity of the disease. Symptoms of each UC type often overlap and commonly include (5):

• Rectal bleeding
• Bloody diarrhea
• Abdominal cramps and pain
• Tenesmus: the inability to defecate despite the urge to do so
• Fecal urgency
• Fatigue
• Weight loss
• Fever

Chronic gastrointestinal inflammation can manifest in areas outside of the digestive tract. These extraintestinal symptoms are present in up to 30% of patients with UC and include (5):

• Eye pain and inflammation
• Joint pain and arthritis
• Skin lesions

What Causes Ulcerative Colitis?

While the exact cause of UC is poorly understood, several factors have been postulated to affect the development of UC and other forms of IBD. Genetic and environmental factors contribute to mucosal and epithelial barrier defects and immune dysregulation. Environmental factors that increase risk in genetically susceptible individuals include bacterial dysbiosis, infection, drug reactions, and stress. (6)

Functional Medicine Labs That Can Help Individualize Treatment of Ulcerative Colitis

Gastrointestinal endoscopic procedures with biopsy are required for the definitive diagnosis of UC. Other imaging techniques, like computerized tomography (CT) and magnetic resonance imaging (MRI), may be necessary after diagnosis to better visualize the extent of the disease and the presence of extraluminal complications. (2, 7)

While imaging is essential to UC diagnosis and management, it does not provide insight into the underlying factors contributing to the disease progression. Functional medicine labs help practitioners personalize treatment options for their patients. Below are some of the most common labs ordered for patients suffering from UC.

Complete Blood Count (CBC)

A  CBC with differential is a screening panel that measures the distribution of blood cells within the body. By measuring quantifying and qualifying markers of red blood cells, white blood cells, and platelets, the CBC is a good screening tool for overall health and the presence of anemia, infection, clotting disorders, and cancer.

Comprehensive Metabolic Panel (CMP)

The CMP is a metabolic screening that includes 14 biomarkers of blood sugar, electrolytes, pH balance, blood proteins, and kidney and liver function. Abnormal markers may indicate secondary health complications and the need for additional evaluation.

Inflammatory Markers

Serum and fecal inflammatory markers help in the early diagnostic process to differentiate gastrointestinal symptoms of IBD from irritable bowel syndrome (IBS) and to noninvasively monitor patient response to treatment. Serum CRP and ESR are more likely to be elevated in UC than in IBS cases and can help with medical decision-making to order endoscopic and/or advanced imaging. Elevated fecal inflammatory markers calprotectin and lactoferrin are sensitive and specific markers for the presence and activity of IBD.

Perinuclear antineutrophil cytoplasmic antibodies (pANCA) are immune proteins made by the lamina propria and lymphocytes in 60-80% of patients with UC. It is commonly ordered with anti-Saccharomyces cerevisiae antibodies (ASCA), more commonly present in Crohn's disease, to differentiate between these two IBD subtypes.

Comprehensive Gut Testing

Ordering a comprehensive stool test and SIBO breath test can assess the microfloral balance within the small and large intestines, quantify intestinal inflammation, and measure microbial metabolites that influence colonic health and immune function. Dysbiosis, encompassing the undergrowth of beneficial bacteria and overgrowth of opportunistic microbes within the digestive tract, is implicated in the pathogenesis of UC and can perpetuate bowel inflammation and defects in the mucosal barrier.

Food Sensitivities

Nearly two-thirds of patients with UC self-report food intolerances and sensitivities contributing to disease severity. A blood test to identify food sensitivities can help customize dietary plans to eliminate foods from the diet that sustain bowel inflammation and prevent ulcerations from healing.

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Conventional Treatment for Ulcerative Colitis

Pharmacologic anti-inflammatories, steroids, immunomodulators, and biologics can induce and maintain UC remission. Treatment decisions are made on the extent and severity of the disease. Surgical intervention may be required in patients who fail to respond to pharmacologic therapy or to manage severe disease complications. (2, 8)

Functional Medicine Treatment Protocol for Ulcerative Colitis

While pharmacologic therapy may be incorporated in an integrative treatment protocol for UC, the functional medicine approach also embraces natural remedies and behavior modifications to correct immune dysregulation, intestinal barrier dysfunction, and inflammatory responses.

Ulcerative Colitis Diet

During symptomatic UC flares, common IBD-trigger foods that are difficult to digest and can perpetuate inflammation should be avoided. These foods include insoluble fiber-rich fruits, vegetables, nuts, and whole grains; dairy; gluten; refined sugars; fried foods; alcohol and caffeine; and yeast. (3)

An elemental diet (ED), a predigested and hypoallergenic powdered formula mixed in water, can be initiated at the onset of flare symptoms for at least 2-4 days. The ED meets the patient's nutritional needs while allowing bowel rest for repair. It has been proven effective in inducing and maintaining IBD remission, reducing intestinal inflammation, and improving IBD-related symptoms. To follow an ED, measure the number of daily scoops required to meet caloric needs; mix each scoop with at least eight ounces of water and sip throughout the day. Transitioning back to food after ED should be done slowly by reincorporating low-residue foods, like boiled chicken and broth, and adding more variety over 1-2 weeks as tolerated. (9)

According to treatment guidelines, no specific diet is recommended for UC patients that best maintains remission. However, a functional nutritional approach customizes an anti-inflammatory diet based on the patient's food sensitivities and dietary preferences to incorporate a variety of whole fruits, vegetables, herbs and spices, and unsaturated fats. Incorporating prebiotic and probiotic foods, like legumes, garlic, whole grains, sauerkraut, and kimchi, can nourish the beneficial flora of the gut microbiome to prevent dysbiotic patterns and symptom flares (10).

Supplements Protocol for Ulcerative Colitis

Several well-documented supplements can be added to an integrative treatment plan to expedite intestinal healing and reduce inflammation. A few popular dietary and herbal supplements among functional medicine practitioners are described below.

Butyrate

Butyrate is a short-chain fatty acid (SCFA) naturally derived in the colon from bacterial fermentation that acts as an important energy source for cells lining the large intestine and an immune system modulator. Butyrate's efficacy has been proven in clinical trials as monotherapy or in combination with conventional treatments in patients with UC when administered orally or in enema form. (11)

Dose: 4 grams by mouth daily ‍

Duration: at least six weeks

BCQ^®

This herbal and proteolytic enzyme formula by Vital Nutrients combines Boswellia, curcumin, quercetin, and bromelain to support healthy levels of inflammation within the digestive tract and joints. These ingredients exert anti-inflammatory and analgesic effects by inhibiting inflammatory pathways and modulating substance P, a neuropeptide that modulates pain perception. Various studies confirm that Boswellia and curcumin are as effective as conventional treatment with mesalamine and confer additional therapeutic effects when used with conventional interventions. (11-14)

Dose: 3 capsules 2-4 times daily in between meals

Duration: at least three months

Saccharomyces boulardii

Because a disturbance in the commensal microflora contributes to the onset of intestinal inflammation, using probiotics to maintain a healthy bacterial balance can be helpful in the management of UC. S. boulardii is a probiotic yeast shown to induce remission and reduce relapse rates in IBD patients concurrently taking anti-inflammatory medication (15, 16).

Dose: 5 billion CFU once daily

Duration: 7 weeks-6 months

Vitamin D

Vitamin D deficiency is likely a contributing factor to IBD development, given its important role in regulating the immune system. Supplementing vitamin D to achieve optimal serum status may prevent IBD onset and ameliorate active disease severity by regulating gastrointestinal microbiota function and promoting anti-inflammatory and self-tolerant immune responses. (17)

Dose: 2,000-10,000 IU daily; the dose should be determined by the patient's serum vitamin D level

Duration: Ongoing

When to Retest Labs

It is common for patients to experience symptomatic relief within days to weeks of initiating a treatment protocol for their UC. Remeasuring basic lab markers, like CBC, CMP, and inflammatory markers, can be considered a month after initiation to monitor patient response to treatment and follow up on abnormal baseline results. Given their cost, repeating specialty labs, like comprehensive stool analysis and food sensitivities, is typically postponed until at least 3-6 months after treatment initiation.

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Summary

The best approach to ulcerative colitis is an integrative protocol that addresses diet, lifestyle factors, and dietary supplements that contain targeted nutrients and herbs based on the patient's lab results. Depending on disease severity, this strategy can be used alone or in conjunction with conventional pharmaceutical interventions. Although it can be challenging, achieving long-term remission of ulcerative colitis is possible to prevent severe health complications and the need for surgical intervention.