There's more to ulcerative colitis treatment than medication & surgery...
Inflammatory bowel diseases (IBD) are a group of autoimmune conditions of the gastrointestinal tract.
The gut becomes chronically inflamed, which can be life changing for many sufferers.
The aim of the Coho Functional Medicine approach to ulcerative colitis is put it into remission.
As the name suggests ulcerative colitis is where the mucosa layers of the colon (col) and rectum becomes swollen and inflamed (itis) – colitis and ulcers form (ulcerative).
This inflammation and damaged tissue leads to symptoms locally in the gut, but also affects other areas in the body.
Table of Contents
Signs and symptoms of ulcerative colitis
Ulcerative colitis is an inflammatory condition that also affects nutrient absorption, and therefore there are many signs and symptoms associated with this condition.
The signs and symptoms can be wide ranging, and are not just digestive system related:
Intestinal symptoms
- Abdominal pain (specifically left side)
- Diarrhoea
- Urgency to pass stools
- Mucus, blood or pus in stools
- Rectal bleeding
- Weight loss
- Loss of appetite
- Dehydration (from loss of fluids)
- Fatigue (from blood loss and malabsorption of nutrients)
Extra intestinal symptoms
- Joint pain
- Mouth ulcers
- Sore eyes
- Erythema nodosum (bumps under the skin) (1)
Complications from ulcerative colitis can include haemorrhage and anaemia from iron, folate, and B12 deficiencies, as well as osteoporosis, and colorectal cancer.
As with most autoimmune diseases, there is no cure for ulcerative colitis, and it has periods of flares and remission.
Remission and reduction in symptoms can be achieved, and this is our aim here at Coho Health.
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Who does ulcerative colitis affect?
There are 500,000 people living with Inflammatory Bowel Disease (IBD) in the UK, and at least 1 in every 227 people in the UK has been diagnosed with ulcerative colitis.
This amounts to around 296,000 people with ulcerative colitis (1,2)
The condition can develop at any age, but is most often diagnosed in people between 15 and 35 years old.
Both men and women seem to be equally affected by ulcerative colitis.
It’s more common in white people of European descent and black people, and rarer in people from Asian backgrounds, although the reasons for this are unclear.
You are at higher risk if you have a close relative, such as a parent, sibling or child, with the disease of developing ulcerative colitis – suggesting a genetic link that is common in autoimmune conditions.
Ulcerative colitis: conventional medicine treatment options
As we’ve mentioned, ulcerative colitis is an autoimmune condition, which means the immune system, the body’s defence against infection, goes wrong and attacks healthy tissue.
In conventional medicine your doctor will check blood and stool samples, perhaps perform a colonoscopy, and then use medications to dampen the immune system and reduce inflammation to try to alleviate your symptoms.
Examples of the medications used are:
- Mesalamine and other 5-aminosalicylic acid (5-ASA) – anti-inflammatories that block the activity of cyclooxygenase and lipoxygenase, thereby, reducing the production of prostaglandins
- Thiopurines - immunosuppressive drugs, aimed to deactivate key processes in T lymphocytes that lead to inflammation
- Corticosteroids – to reduce inflammation by suppressing the multiple inflammatory genes that are activated in chronic inflammatory diseases
- Anti-TNF monoclonal antibodies – to suppress the immune system. TNF (Tumor necrosis factor alpha) is a cytokine involved in the pathogenesis of some inflammatory and autoimmune diseases
However these medications can come with some severe side effects and for some patients who may be unresponsive to medical therapy, a surgical option called colectomy may be required.
The Coho Functional Medicine approach to ulcerative colitis
The Coho Functional Medicine approach to ulcerative colitis tries to do is to understand why the immune system has been triggered.
What we do know is that there is and interaction between a genetically-susceptible person and environmental factors.
Genetics
There are at least 163 genes involved in IBD.
Many are shared between both ulcerative colitis and Crohn’s Disease, but some are unique to each condition (3)
This combination of genetic and environmental factors can cause the immune system to mistake harmless bacteria inside the colon as a threat.
This in turn triggers overly aggressive T-cell responses, and attacking the tissues of the colon, causing it to become inflamed.
Mucosal lining
Damage to the mucosal lining is very much associated with ulcerative colitis.
Exactly what causes the immune system to behave in this way is unclear, but certain environmental factors that can alter mucosal barrier integrity, the immune response, and the balance within the microbiome are:
- Medication use: Antibiotics, NSAIDs, oral contraception.
- Smoking
- Stress
- Infections - current or latent infections e.g. viral infections
- Gut Infections and dysbiosis, an imbalance in beneficial and harmful gut bacteria
- Poor diet – high refined foods and sugars, low omega 3 and high omega 6 arachidonic acid, food additives such as carrageenan (4,5,6,7)
Microbiome
As we’ve mentioned, an altered gut microbiome can be a reason the immune system reacts inappropriately in ulcerative colitis.
This is something we explore thoroughly with advanced, comprehensive stool testing, as there are some specific bacterial patterns that are often seen.
These specific bacterial patterns include:
- Mycoplasma pneumoniae and pathogens such as Escherichia coli, Clostridium difficile, and Fusobacterium varium (8).
- Mycoplasma pneumoniae is associated with gastrointestinal symptoms including anorexia, nausea, vomiting, and transient diarrhea.
- Very low or missing Akkermansia spp., which is mucus protective and anti-inflammatory
- Very high amounts of Ruminococcus gnavus and Ruminococcu torques which are mucus degraders (9,10)
- Raised gram-negative bacteria (e.g., Fusobacterium nucleatum) create a high Lipopolysaccharide (LPS) load, which in itself increases the immune response.
Raised gram-negative bacteria is also found in the mouth, driving both local and systemic inflammation (11)
- Bacteroides fragilis (enterotoxigenic) has also been associated as a trigger for IBD, its toxins can destroy intestinal tight junctions. (12)
- Lower numbers of Faecalibacterium prausnitzii, a bacterium that generates anti-inflammatory metabolic by-products, e.g., Short Chain Fatty Acids (SCFA) including butyrate necessary for mucosal tissue repair (13).
Functional testing in ulcerative colitis
Advanced gut function and microbiome tests can also give us valuable information such as markers relating to intestinal permeability (leaky gut), like Zonulin.
In ulcerative colitis, the epithelial barrier integrity and function is also critical for the disease onset:
How increased intestinal permeability is involved in autoimmune conditions in general is explored in more detail in this infographic:
The epithelium houses the microbial flora, whose role in innate immunity is to recognise and distinguish between friendly (commensal) bacteria and foe (invading) bacteria to try to maintain tolerance and homeostasis.
We also test a marker called Secretory IgA.
Depending on whether SIgA is very raised (or low), can indicate how the immune system is responding to gut infections and dysbiosis, or potentially food intolerances like gluten, dairy and high sugar diets (which can further disrupt the microbiome and intestinal barrier).
Another important marker is faecal calprotectin, which is a marker of colon inflammation.
High levels can be indicative of ulcerative colitis, or other inflammatory bowel disease.
Due to the malabsorption issues associated with ulcerative colitis, it is important to also assess for any nutrient deficiencies.
Nutrient status can be checked through several options, including comprehensive blood tests such as a FunctionalDX panel:
Ulcerative colitis: nutrition strategies
Given that the microbiome, barrier function and immune response are both greatly negatively and positively influenced by diet, appropriate nutritional and supplemental protocols are essential.
Here are some general dietary changes you could start straight away :
- Remove inflammatory foods / beverages (e.g. dairy, gluten, refined sugars, coffee, alcohol, damaged oils)
- Include easy to digest but nourishing foods, such as soups, stews and broths, slow-cooked at a low temperature helps to break down the food first
- Increase omega-3 foods (e.g. oily fish - may require supplementation)
- Fresh green juices (chlorophyll rich and very anti-inflammatory)
- Try to reduce environmental toxins by eating organic, avoiding plastic containers
- Maintain healthy gut microflora by eating plenty of nutrient dense fibre rich fruits and vegetable (cooked rather than raw)
Dietary models used for the management of ulcerative colitis, (14-20) have differing results, and can be difficult to adhere to.
The right dietary model should be specific to your unique requirements which is something your Coho practitioner would ensure, as well as providing support on how best to implement your dietary changes, and making sure you’re getting optimal nutrient intake.
These strategies include:
Autoimmune protocol
Focusing on the elimination of potentially immunogenic or intolerant food groups has the potential to improve symptoms and endoscopic inflammation in patients with IBD (14)
SCD
SCD is an elimination diet that is grain free, starch free, sugar free and avoids most dairy, which in studies showed “perceived clinical benefit” (15)
Ulcerative colitis exclusion diet
The ulcerative colitis exclusion diet is a dietary approach aimed at specifically modifying the composition of the gut microbiota. However, this was only a pilot study and more robust research is needed (16)
Low-fat, high-fibre diet
A low-fat, high fibre diet showed a reduction of markers of inflammation and dysbiosis, and improved quality of life, in patients with ulcerative colitis (17)
Low FODMAP
A low FODMAP diet may reduce symptoms of ulcerative colitis, but can simultaneously reduce gut biodiversity and therefore negatively impact overall gut health (18)
Some studies suggest that diet may play an adjunct role to induce or maintain clinical remission alongside standard medical IBD therapies. (19)
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Ulcerative colitis: nutrient deficiencies
Due to the nature of the disease and the impact it has on the ability to digest and absorb nutrients, it is important to test for potential nutrient deficiencies.
Nutrient status can be investigated using comprehensive blood tests as mentioned above.
Nutrient deficiencies that are specific to ulcerative colitis include iron (due to bleeding), potassium (diarrhea) and zinc (poor absorption and faecal loss).
However, it’s important to note that other important vitamins and minerals can also be deficient in ulcerative colitis due to:
- Food restriction because of poor tolerance or worsening of your symptoms
- Undertaking a long term elimination diet without focus on replenishing nutrients that may be lacking because foods are being avoided
- Small Intestinal Bacteria Overgrowth (SIBO), as many patients with ulcerative colitis also have SIBO, which can impact nutrient absorption
We use targeted supplementation, in addition to dietary changes, to optimise nutrient levels.
Ulcerative colitis: nutritional supplements
Some common nutritional supplemental support considered in ulcerative colitis include:
Fish Oils
Fish oils, specifically EPA / DHA, have profound anti-inflammatory effects, inhibiting pro-inflammatory cytokines TNF-α and IL-6, and regulating NF-κB.
Vitamin A, N-acetyl glucosamine, zinc carnosine, L-glutamine
These nutrients support the repair and function of the intestinal mucosal lining. The cells of the intestinal lining can become damaged in ulcerative colitis and further exacerbate symptoms. Providing support to these cells, can in turn help lower inflammation and pain, as well as increase nutrient absorption.
Prebiotics
Prebiotics, for example FOS and psyllium, react with gut bacteria to produce short chain fatty acids (SCFAs), such as butyrate, which is beneficial to colon cells. SCFAs support the gut barrier which then keeps bacteria and other microbes from entering your blood and setting off an immune response.
Probiotics
Probiotic species of Lactobacilii (E.g., L. acidophilus, L. casei) and Bifidobacteria have been shown to strengthen epithelial barrier function and reduce inflammation.
Please note that probiotics should not be used in a flare, or if you have a low white cell count due to recent infection or immunosuppressant medication.
As in all conditions, when people are taking prescribed medications, it is important that your practitioner checks for any negative interactions between supplements and medications.
Ulcerative colitis: inhibiting inflammation (LOX, COX, TNF-α)
There are other specific herbs and phytonutrients which have proven benefits in ulcerative colitis.
In fact, some herbs and phytonutrients are able to modulate immune function in ways that medications cannot.
Lets take a look at a few examples:
– Ginger can inhibit several pro-inflammatory molecules – try fresh or powdered in food, e.g., grated ginger steeped in hot water
– Turmeric is likely the most powerful natural anti-inflammatory, having a significant inhibitory action on inflammation processes. The active component of turmeric is called curcumin. Try fresh turmeric grated in curries or make a golden latte.
– Quercetin is an anti-inflammatory and immune system modulator, as well helping to reduce histamine release from mast cells. Naturally found in apples, onions and garlic. Try making some stewed apples (skin can be peeled off), enjoy with cinnamon powder and (for example), coconut flakes, a great immune-modulating food.
– Green tea, specifically the EGCG found in green tea, is another great anti-inflammatory phytonutrient. Try to include two cups of organic green tea daily, decaffeinated options are available if avoiding caffeine.
Ulcerative colitis: mucosal barrier support
Other mucosal barrier supportive nutritional strategies are:
- Aloe vera
- Green Tea
- Chamomile
- Lion’s mane mushroom
- Demulcent herbs (such as marshmallow root and slippery elm)
Ulcerative colitis: the 5R approach
The Coho Functional Medicine approach to ulcerative colitis uses a 5R approach, which is a gut restoration protocol, an example of which can be found in a case study here. (22)
You can find out more about the 5R protocol below (click to expand) and you can read our full 5R article here.
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The Wrap...
Ulcerative colitis is an autoimmune disease that can progressively get worse and that requires stronger and stronger immune-suppressing medications to manage the symptoms.
Your quality of life can be significantly affected by the bowel symptoms, but also commonly associated symptoms such as fatigue and low mood.
Whilst conventional medications may be necessary to sufficiently down regulate the immune response in some cases, there are a host of other, more natural and evidence-based strategies that if included, can provide much improved health outcomes (whether taking medications or not).
Achieving remission through a tailored approach, can reduce future potential need for medications.
The Coho Functional Medicine approach to ulcerative colitis helps you take back control of the disease, and helps you finally understand your unique underlying causes, triggers, and associated factors for this disease.
With the right tools, you can take the right steps to heal your intestinal system, improve your nutrient status, reduce further autoimmune risk and reboot your energy levels and overall quality of life.
How does that sound to you?
To your optimised, healthy future,
Dee & the Coho Health team
How can we help you? Send us a message below and we’ll come right back to you…
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https://www.nhs.uk/conditions/ulcerative-colitis/
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