Ulcerative colitis is an inflammatory condition of the colon that leads to erosions and bleeding. It is the most common type of inflammatory bowel disease worldwide. It affects 600,000-900,000 people in the United States and accounts for 250,000 annual medical office visits. Conventional management of ulcerative colitis typically includes some combination of medications and surgery. This article will discuss alternative strategies that can be implemented in combination with or independently from conventional therapies for a holistic approach to treatment. (1, 2)

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What is Ulcerative Colitis?

Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) that causes ulcerations and inflammation within the large intestine. The inflammation of UC differs from Crohn's disease, another type of IBD, in two main ways. First, bowel inflammation is restricted to superficial layers of the colon (the mucosa and submucosa). Second, the disease is contained to the colon; inflammation starts in the rectum and continuously ascends the large intestine. (2)

There are subtypes of UC, classified by the location within the colon. UC types include (3):

• Ulcerative Proctitis: inflammation is confined to the rectum
• Proctosigmoiditis: the rectum and lower end of the colon (sigmoid colon) are inflamed
• Left-Sided Colitis: inflammation extends from the rectum to the descending colon
• Pancolitis: inflammation involves the entire colon

UC is more common in specific populations. Family history is the most important independent risk factor of the disease. Having a first-degree relative with UC increases the risk of disease by four times. UC is also seen most commonly in patients aged 15-30 and 50-70. Additionally, UC incidence is highest among Caucasians and those of Ashkenazi Jewish descent. (2, 3)

Ulcerative Colitis Symptoms

Ulcerative colitis generally begins gradually and worsens over time without treatment; however, symptom onset can sometimes be sudden. Symptoms range in severity and often come in flares between remission periods. Symptom remission can last for weeks to years, and treatment aims to maintain remission for as long as possible. (1)

The most common symptom of UC is bloody diarrhea, often with mucus or pus. Other associated symptoms with the disease include (1-3):

• Rectal bleeding
• Abdominal pain and cramping
• Rectal pain
• Tenesmus: the constant urge to defecate despite the bowels being empty
• Weight loss
• Failure to grow in children
• Fatigue
• Fever

10-30% of patients will also experience increased inflammation outside the large intestine, causing symptoms like arthritis, eye pain, and skin rashes (2).

UC is not benign and will increase your risk for other health conditions, including anemia, blood clots, colorectal cancer, primary sclerosing cholangitis (a type of chronic liver disease), and osteoporosis (1).

What Causes Ulcerative Colitis?

Ulcerative colitis is an inflammatory bowel disease that affects the colon and rectum. The exact cause of ulcerative colitis is unknown, but it is believed to be caused by a combination of genetic, environmental, and immune system factors. Here are some possible factors that may contribute to the development of ulcerative colitis:

Genetics

Genetic predisposition is involved in the etiology of UC, especially considering the high prevalence of UC in patients with a family history of the disease. Over 100 gene loci have been associated with IBD, with 23 associated explicitly with UC.

Immune Dysfunction

Exaggerated immune responses that target tissues of the large intestine appear to play a role in the development of UC. Autoantibodies against colonic epithelial cells have been measured in many UC patients.

Dysbiosis

Disruptions in the normal gut microbiota can lead to immune dysregulation that harms the intestinal barrier, increases intestinal permeability, and increases inflammatory activity. Reduced populations of Firmicutes bacteria and increased growth of Bacteroidetes and anaerobic bacteria (e.g., Enterococcus and Enterobacter) are consistently observed in patients with UC.

Environment

Westernized diet and lifestyle appear to increase the risk of UC and other types of IBD (2). A rapid increase in the prevalence of UC has been noted in urbanized areas over developing countries. Diet, use of medications (like NSAIDs and oral contraceptives), air and water pollution, and stress may all play a role in disease development (5).

Differential Diagnosis for Ulcerative Colitis Patients

The differential diagnosis for UC in patients with bloody diarrhea includes Crohn's disease, colorectal cancer, and infectious colitis caused by parasitic, bacterial, and viral pathogens (4).

Other causes of gastrointestinal symptoms similar to UC include radiation treatment, NSAID-induced colitis, and ischemic colitis. If non-bloody diarrhea is present, microscopic colitis, celiac disease, and food intolerance should be considered.

Functional Medicine Labs to Test for Ulcerative Colitis Patients

Functional medicine practitioners commonly run specialty labs to help diagnose the root cause of ulcerative colitis and use the results to create individualized treatment plans for their patients. Below are the most common run labs for UC patients.

Conventional Diagnostics

Blood work, including a CBC, CMP, CRP, and ESR, is routinely ordered for patients experiencing diarrhea and abdominal pain. Findings of this initial blood work may include anemia (low red blood cells, hemoglobin, and/or hematocrit), elevated platelets, low albumin, and elevated CRP/ESR. Still, at the time of diagnosis, fewer than half of patients will have abnormal findings on these tests. (4)

Stool testing should be performed to rule out infectious colitis agents. Patient history can help to guide suspicion of one type of infection over another. For example, Clostridium difficile infection is most common in patients with recent antibiotic exposure. (4)

Fecal calprotectin and lactoferrin are proven to be sensitive biomarkers of IBD. They are routinely elevated in active disease due to increased activity of white blood cells and inflammation within the intestines.

A colonoscopy with biopsy is required to confirm and distinguish a UC diagnosis from other forms of IBD.

Comprehensive Stool Test

A comprehensive stool test, such as the GI-MAP, screens for common pathogens and dysbiotic patterns of the intestinal microbiome implicated in the pathogenesis of UC. Calprotectin and lactoferrin are routinely included or can be added to comprehensive stool tests.

Perinuclear Antineutrophil Cytoplasmic Antibodies (pANCA)

Regardless of disease stage or progression, pANCA is present in 60-70% of UC patients. Anti-saccharomyces cerevisiae antibodies (ASCA) are present in Crohn's disease and UC but are more prevalent in Crohn's. Therefore, testing for both pANCA and ASCA has utility in distinguishing between IBD types. (2)

SIBO Breath Test

A 2019 systematic review and meta-analysis concluded a substantially increased prevalence of SIBO, a type of small intestinal dysbiosis, in patients with IBD. The frequency of SIBO occurrence in patients with ulcerative colitis is 4-17.8% when using a hydrogen breath test like the 3-Hour SIBO test by Genova for diagnosis.

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Integrative Nutrition for Ulcerative Colitis

There is no specific diet recommended for the treatment of UC flares or maintenance of UC remission. However, high intake of omega-6 fatty acids, saturated fats, animal protein, and food additives are associated with increased inflammation and risk of IBD. A high intake of whole fruits and vegetables has the opposite effect. Additionally, soluble fiber intake encourages butyrate formation by the beneficial bacteria of the gut microbiome and has anti-inflammatory effects. (8, 9)

Therapeutic Dietary Restriction

Certain restrictive diets have been researched for their ability to reduce intestinal inflammation and improve IBD symptoms. While some of these diets appear to be effective in managing IBD, there are risks of nutritional deficiencies and unfavorable alterations in the microbiome that need to be considered with long-term restrictions. It is always recommended that a patient work closely with a trained nutritionist or dietician while implementing dietary modifications to mitigate risks.

The Specific Carbohydrate Diet (SCD) is a diet initially designed to manage celiac disease that emphasizes eliminating most grains, sugars, and processed foods. Research has demonstrated the efficacy of the SCD in inducing remission of IBD in patients as soon as two months and maintaining remission for up to two years.

The low FODMAP diet excludes particular carbohydrates and is less restrictive than the SCD. Research has demonstrated its efficacy in reducing IBS-like symptoms in IBD patients without active disease. (9)

Supplements & Herbs for Ulcerative Colitis

Inflammation-modulating herbs, such as Boswellia (frankincense) and Curcuma (turmeric), are indicated in managing acute flares and maintaining disease remission. Research has demonstrated both herbs' safety and efficacy for managing IBD (10, 11).

Spasmolytic and carminative herbs promote the relaxation of the intestinal smooth muscles to relieve abdominal pain, cramping, and flatulence. Peppermint, ginger, and chamomile are indicated botanicals that can reduce symptoms in patients with UC. (12)

Aloe vera is an example of a mucilaginous herb that modulates inflammation and the immune system and is healing to inflamed intestinal tissues. One study concluded that aloe vera gel supplemented for four weeks was superior to placebo at inducing remission in patients with mild-to-moderate ulcerative colitis.

Butyrate or mixed-short chain fatty acid (composed of mixed acetate, propionate, and butyrate) enemas have shown benefit for patients with mild-to-moderate distal and left-sided UC as both a primary and adjunctive treatment option. Enema therapy is a safe and cost-effective alternative to conventional pharmaceutical therapies, improving clinical symptoms and histological inflammation. (13)

Probiotics are highly indicated for managing acute UC and maintaining remission by maintaining microbiome homeostasis, reducing intestinal permeability, and modulating immune responses.  

Complementary and Alternative Medicine for Ulcerative Colitis Patients

A 2007 meta-analysis of 11 papers concluded that acupuncture and moxibustion are superior to conventional pharmacotherapy with higher safety profiles in treating UC.

Stress management is an important aspect of UC treatment. Stress negatively impacts IBD by impairing intestinal barrier function, disturbing the gut microbiome, and dysregulating immune function. Non-pharmacologic interventions, including cognitive behavioral therapy, hypnosis, and mindfulness meditation, have been shown to reduce IBD-related gastrointestinal symptoms. (14)

Fecal microbiota transplantation (FMT) is an emerging therapy that introduces fecal material from a healthy donor into the recipient to correct disruptions in the gastrointestinal ecosystem. A study including 85 patients with UC showed that FMT was associated with a four-fold incidence of inducing clinical remission and endoscopic improvement in active UC by influencing distinct positive changes in the intestinal microbiome.

Summary

Ulcerative colitis is an inflammatory bowel disease that first affects the distal portion of the colon and travels proximally. It can cause significant impairment to quality of life during symptom flares. Although the exact cause of UC is unknown, the interplay of genetics and environmental stimuli will predispose a person to develop the disease. A functional approach to diagnosing UC includes screening for imbalances in the gut microbiome and environmental triggers that overstimulate the immune system and cause colonic inflammation and ulceration. Alternative evidence-based therapies effectively induce and maintain UC remission to improve quality of life and prevent disease complications.