Ulcerative Colitis is an inflammatory recurrent disease of the digestive tract with flare up and remission periods. UC affects the large bowel, starting usually in the rectum. There’s usually extra-intestinal envolvement, mostly in the joints, skin and eyes. There’s also a significant increase in the risk of colon cancer after 10 years of disease. The quality of life is quite acceptable during remission periods and drops considerably during flare ups. The pathogenesis of the disease isn’t well understood, although an abnormal immune reaction to host’s bowel flora is suspected. The main hypothesis says that a deregulation of the immune system leads to abnormal reactions towards bacterial and food antigens in predisposed individuals. Other theories establish a previous infection as the cause of the disease. With the current evidence we must think UC is a multifactorial disease.
Endoscopic vision of an ulcerated bowel
The symptoms depend on the extension and severity of inflammation in the colon. In UC the rectum is usually compromised and this manifests itself through bleeding and mucus in faeces. Abdominal pain that eases after bowel movements may be present. Depending on the extension, location and severity of the flare, fever may be present. The disease usually starts in young people (mean of 27 years) but this is not always the case. In some people it may even start as late as in their ’60s. UC is not related to gender and it’s more common in western countries. There are genetic factors that predispose to the disease.
The conventional treatment varies depending on the severity of the disease. Intestinal anti-inflammatory drugs such as 5-asa are used for the manteinance of remission and prednisone is the gold standard when the patient flares. In cases that do not respond to prednisone, immunosuppresive drugs such as antiTNF are used, but with less success than in rheumathic diseases. The worst cases or the appearence of cancer cells in the intestine may need surgery.
Image of a resected bowel with UC
The current situation of UC patients isn’t optimystic. Between 20 and 30% of them will end up having surgery and more than a half of them will need to use high doses of cortisone in order to mantain low disease activity. Only 30% of the patients think that they have acceptable quality of life 10 years after diagnosis.
It should be said that many patients can’t be properly diagnosed at first because the intestinal lesions are indistinguishable between Crohn and UC. In that case, the patient will receive the diagnosis of Indeterminated or Inespecific Colitis.
There’s also an important possibility of misdiagnosis between acute self limited colitis and UC as the histology of both is quite similar, especially if the ASLC is resolving. Histopathologists must take into account the clinical history and symptoms of the patient as these will lead them to the correct interpretation of the biopsy.
Our theory about the origin of Ulcerative Colitis:
UC patients show a marked decrease in both Bacteroidetes and Firmicutes in their flora. Both these phyla are implicated in the development of innate and adaptative immunity. This decrease may have its origin in prolonged antibiotic treatments, deficient diets or genetical impairment of the microbiota. As these two groups disappear, there’s a dysregulation of the immune system, which turns its activity against host’s mucosal barrier through the release of cytokines such as IL-5, IL-13 and IL-17. In absence of immunesuppressive flora, the damage in the mucus gets bigger and bigger. The drugs currently used in the treatment of UC stop the production of these inflammatory cytokines but can’t stop the immune activity. According to this theory, the future cure of UC will come with the modification of the bowel flora, especially with the restorement of immunesuppressive strains. If all the money invested in the development of immunesuppresive drugs would have been dedicated to study how to modify intestinal flora, we would be very close to a cure of this disease. The truth is that research is often linked to economical interests and it doesn’t seem there is much interest in this area nowadays. With the means available now, we can try to modify bowel flora with fecal transplants and lessen the symptoms with diet and supplements. These measures are usually more effective than standard therapies and can be used alone or together with drugs.
Great graph showing the pathogenesis of UC. Attention to the role of IL cytokines
Our treatment for Ulcerative Colitis:
Diet: There’s high evidence of the utility of dietary changes in the treatment of UC. In one study, following an anti-inflammatory diet all (24) patients were able to discontinue their drugs and entered remission. Lutz treated almost 100 UC patients with his low carb diet. Almost 90 entered remission without drugs. The specific carbohydrate diet has many followers and a few nicely conducted studies that prove its utility. Several studies show that a diet rich in carbohydrates, grains and trans fats increases chances of being diagnosed with UC. Internet is full of success stories of people treating UC with different diets such as Keto, GAPS or Paleo. All these diets promote the exclusion of processed foods, sugar and grains so each one of them would be a step in the right direction. From our experience the dietetic treatment of UC would consist in the elimination of all grains, legumes and dairy except for butter and kefir. Carbohydrates (especially those coming from fruit) should represent less than 20% of our caloric intake and vegetables should be consumed cooked until remission is achieved. We strongly recommend reading Seignalet’s book, which can be bought clicking on the image below.
Boswellia: Four different studies support the use of Boswellia gum resin (900mg divided in three doses per day) in the treatment of Ulcerative Colitis. Boswellia showed better results than 5-asa in induction and maintenance of remission. One of the studies showed that 14 out of 20 patients using Boswellia entered remission, and histologic findings improved in all. In another study, 18 out of 26 entered remission and again, all histological markers improved. Boswellia should be used as a first line therapy given its risk/benefit profile against 5-asa. You can buy Boswellia on Amazon:
Butyrate: This short chain fatty acid has been proven useful in the treatment of UC given that this disease only affects the external epithelium of the bowel and doesn’t produce abscesses or fistulas. Butyrate enemas were more effective than placebo in distal UC. Oral butyrate has also been found effective in the treatment of this disease. As oral butyrate is expensive and enemas uncomfortable, we recommend supplementation with butyrate producing bacteria such as Clostridium butyricum mixed with fermentable fiber such as psyllium seeds in order to increase short chain fatty acid production in the colon. Click on the images to purchase Psyllium Seed, Clostridium butyricum and Butyrate:
Probiotics: Some probiotics have enough scientific background to be recommended. One of them is VSL#3. This mix of lactic acid bacteria improved the symptoms of 80% of the patients in one study and was better than placebo in another. Mutaflor, basically composed by Escherichia coli Nissle, was equal to mesalamine in the maintenance of remission in one study.
Intermittent fasting: During Ramadan, which consists of fasting during 16 hours each day, inflammatory markers of UC patients improved, as one study found. These is supposed to happen because when the bowel is resting, damaged tissues can rebuild. We recommend intermittent fasting to UC patients. This can be achieved through skipping breakfast or dinner everyday.
Fecal transplant: The treatments mentioned before help with the symptom management to the point patients can live in permanent remission. However, fecal transplants have been the only treatment that has provided complete and longstanding cures. A recent revision of fecal transplant studies has shown that out of 200 patients treated, 65% improved and 42% entered remission, something that clearly outperforms any of the drugs used to control the disease. The best part of it is that in many cases, the obtained remission is sustained in time.
During the last 50 years, IBD incidence has raised exponentially due to the each time more common use of antibiotics, antibacterial soaps, deficient diets, high level of stress and environmental pollution. These factors are wiping out our flora generation after generation, as several studies have found.
Increase in the incidence of IBD in the last years. Is there still anybody who thinks that the indiscriminated use of antibiotics and western diet have nothing to do with this?
We’re seeing more and more children getting IBD these days. Parents don’t realize that their antibiotic use, C-section births and shortened breastfeeding periods influence their children’s flora. Remember that microbiota is transferred from mother to child during birth and breastfeeding.
Summary of our Ulcerative Colitis treatment:
- Diet excluding grains, legumes and dairy. Low in carbohydrates and insoluble fiber at the beginning. Read Seignalet’s book.
- Clostridium butyricum mixed with psyllium seeds
- Boswellia gum resin
- VSL#3 and Mutaflor
- Intermittent fasting 16/8
- Fecal transplant once the patient is in remission
- Conventional drugs will be used only to induce remission
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