Ulcerative colitis is a chronic, non-specific, idiopathic, inflammatory and ulcerative disease of the colon and the rectum that has no known etiology. Many factors have been suggested, but none are proven. Possible risk factors include immunologic factors, infectious agents (such as bacteria, virus or ameba), dietary factors (including chemicals and drugs), and psychosomatic factors. Ulcerative colitis usually occurs between the ages of 15 to 30, or 50 to 70. (1) When diagnosing, doctors look for chronic history of bloody diarrhea with pus and mucus in the stool that indicate possible ulcerative colitis. Definitive diagnosis is made by sigmoidoscopy, which provides a direct visualization of the rectal mucosa. A colonoscopy is sometimes helpful to differentiate ulcerative colitis from Crohn's disease. A biopsy is performed if cancer is suspected. (2)
Clinical Manifestation
Clinical presentation of ulcerative colitis varies depending on the extent and severity of the illness. The initial presentation begins with a gradual onset of diarrhea with mucus and blood. There are symptomatic and asymptomatic intervals of diarrhea. Patients may also experience tenesmus and left lower quadrant pain and cramps. Systemic symptoms are usually not mild or absent in the early stages of ulcerative colitis. If the ulceration involves only the rectosigmoid area, the stool may be normal. Rectal discharge of mucus, RBC's and WBC's will still be present. Systemic symptoms are usually mild or absent.
Occasionally, ulcerative colitis may present as an acute and fulminant attack characterized by violent diarrhea and severe abdominal pain. The abdominal pain and tenderness is most obvious in the left lower quadrant. The patients may have 10 to 20 bowel movements per day, often accompanied by severe cramps and distressing rectal tenesmus. The stool is filled with mucus, pus and blood. In addition, malaise, anorexia, weight loss, high fever, signs of peritonitis, toxemia and other systemic symptoms may be present. (2)
Toxic colitis and toxic megacolon represent the most severe cases of ulcerative colitis. In toxic colitis, there is a transmural extension of the ulcerative process leading to localized ileus and peritonitis. The colon loses its muscle tone and gas begins to accumulate inside the colon resulting in dilation and paralysis of the colon. When the colon expands beyond six centimeters in diameter, the condition is defined as toxic megacolon (or toxic dilation). In such cases, there is high fever (40 degrees Celsius or 104 degrees Fahrenheit), tachycardia, leukocytosis, abdominal pain and distention, along with rebound tenderness. The patient needs to be hospitalized if toxic colitis or toxic megacolon is present to avoid such complications as perforation, peritonitis and septicemia. (2)
Crohn's disease and ulcerative colitis are both inflammatory diseases of the bowel. Crohn's disease may affect any part of the gastrointestinal tract, while ulcerative colitis only affects the colon and the rectum. Bloody stool is usually absent in Crohn's disease, but is consistently present in ulcerative colitis. In addition, small bowel involvement, segmental colitis, rectal sparing, and intestinal fistula are diagnostic keys of Crohn's disease. Other diseases with similar clinical presentation as ulcerative colitis include: acute infections of the gastrointestinal tract, ischemic colitis, drug-induced colitis and colon carcinoma. (2, 5)
Treatment
Since there is no known etiology for ulcerative colitis, there is no specific therapy available. Drug treatment focuses on relieving the symptoms and are divided into the following classes:
Differential Diagnosis
Similar to Crohn's disease, ulcerative colitis may be caused by constitutional deficiencies, invasion of the exterior pathogenic factors or an unbalanced diet. Constitutional deficiencies usually refer to spleen, stomach and kidney deficiencies. Invasion of exterior pathogenic factors refers to damp-heat or damp-cold. Lastly, an unbalanced diet high in raw or cold can injure the spleen and stomach by obstructing their functions in transforming and transporting food and nutrients.
Depending on the severity and characteristics, ulcerative colitis can be divided into seven major categories: damp-heat in the large intestine, damp-cold affecting the spleen, alternation of heat and cold attacks, liver overacting on the spleen, qi and blood stagnation, damp accumulation with spleen deficiency, and spleen and kidney yang deficiency.
Damp-heat in the large intestine is commonly caused by excessive consumption of sweet, fatty and greasy food and is characterized by an acute and sudden onset of intestinal symptoms. Diarrhea is usually sudden and violent with pus, mucus and blood. There is a feeling of tenesmus, abdominal fullness and distention, abdominal cramp and pain which diminishes after defecation. In addition to intestinal symptoms, the patient may also experience fever, poor appetite, dry mouth, yellow urine, a yellow greasy tongue coat and a rapid pulse.
Damp-cold affecting the spleen is commonly caused by excessive consumption of cold or raw food, fruits or vegetables. There is a sudden onset of diarrhea with pus, mucus and blood. The patient also experiences abdominal fullness, distention, and pain. Abdominal pain is mild to moderate but does increase with exposure to cold. There is a vague feeling of heaviness in the body and the extremities. Tongue coat is white and greasy. Pulse is soft and slippery.
Alternation of heat and cold attack is a chronic condition and may be caused by many different factors such as invasion of the exterior pathogenic factors or an unbalanced diet. The patient experiences constant watery diarrhea or bloody diarrhea. When there is more heat than cold, bloody diarrhea predominates and the patient experiences abdominal pain, bitter taste in the mouth, dry mouth, urgency to defecate and fever. When there is more cold than heat, watery diarrhea predominates and the patient experiences abdominal pain. Pain increases with exposure to cold, aversion to cold, and muscle wasting. Tongue is red with thin yellow or thin white coat.
Liver overacting on the spleen represents an excess condition in which the wood element overacts on the earth element. The patient has obvious liver qi stagnation evident by emotional disturbance. This corresponds with the psychosomatic cause of ulcerative colitis suggested by Western medicine. Clinically, the patient will experience emotional disturbance such as anger, irritability and a short-temper. The severity of diarrhea is directly proportional to the severity of emotional disturbance. Other gastrointestinal symptoms include diarrhea with pus, mucus and blood, abdominal pain, fullness and distention, borborygmus, acid regurgitation, bitter taste in the mouth and lack of appetite. Tongue is slightly red with thin white coat.
Both qi and blood stagnation usually occurs as a result of damp-heat injuring the middle jiao leading to stagnation in the stomach and the intestines. This condition is characterized by constant pain at a fixed location. Palpation may not be possible as pain increases with touch and pressure. Other symptoms and signs of qi and blood stagnation include borborygmus, abdominal distention, chest fullness and distention, acid regurgitation, lack of appetite, and dark facial complexion. Tongue is purple with petechia. Pulse is knotted.
Damp accumulation with spleen deficiency represents a chronic condition of ulcerative colitis. Spleen deficiency may be due to congenital deficiency, or secondary to excess intake of raw or cold food injuring the spleen. Damp accumulates as the spleen loses its function to transform and transport food. Clinically, the patient experiences chronic incessant diarrhea. Stool is watery, or sticky with pus, mucus and blood. Other local symptoms include dull pain and distention in the abdomen. Malabsorption and malnutrition are common due to the chronic nature of spleen deficiency. The patient usually experiences fatigue, shortness of breath, lack of appetite, and decreased sense to taste the flavors of food. Tongue is flabby with teeth marks. Tongue coat is thin and white. Pulse is soft.
Spleen and kidney deficiencies also represent a chronic condition of ulcerative colitis. This condition may be due by congenital deficiency or secondary to chronic ulcerative colitis damaging the spleen and the kidney. The patient has chronic incessant watery diarrhea with pus, mucus and blood. Diarrhea may occur early in the morning at approximately 5 a.m. and throughout the day. Diarrhea worsens with exposure to cold. Other symptoms include fatigue, lack of energy, cold body and extremities and abdominal pain that diminishes with exposure to warmth. Tongue is pale with thin white coat. Pulse is deep.
Herbal Treatment
I. Damp-heat in the large intestine
Clinical Manifestation: Acute and sudden onset of intestinal symptoms and signs; sudden and violent diarrhea with pus, mucus and blood; tenesmus; abdominal fullness and distention; abdominal cramp and pain which diminishes after defecation; fever; poor appetite; dry mouth; yellow urine; yellow greasy tongue coat; slippery or rapid pulse. (9)
Herbal Formula: shao yao tang (Peony Decoction). This formula eliminates heat and toxin and is common used to treat diarrhea due to damp-heat in the large intestine. (6,7,8) Modification (9-12):
II. Damp-cold affecting the spleen
Clinical Manifestation: Sudden onset of diarrhea with pus, mucus and blood; abdominal fullness, distention and pain; abdominal pain that increases with exposure to cold; vague feeling of heaviness in the body and the extremities; white and greasy tongue coat; and soft slippery pulse. (9)
Herbal Formula: wei ling tang (calm the stomach and poria decoction). This formula regulates the qi of the spleen and the stomach and dispels damp-cold. (6,7,8)
Modification (9-12):
III. Alternation of heat and cold attack
Clinical Manifestation: When there is more heat than cold: bloody diarrhea predominates and the patient experiences abdominal pain; bitter taste in the mouth; dry mouth; urgency to defecate and fever. When there is more cold than heat: watery diarrhea predominates and the patients experiences abdominal pain. Pain increases with exposure to cold; aversion to cold; and muscle wasting. Tongue is red with thin yellow or thin white coat. Pulse is wiry and thready. (9)
Herbal Formula: wu mei wan (mume pill). This formula has pungent warm herbs which eliminate the cold, and bitter cold herbs which purge the heat. It is commonly used to treat diarrhea or dysentery with mixed symptoms of cold and heat. (6,7,8)
Modification (9-12):
IV. Liver overacting on the spleen
Clinical Manifestation: Emotional disturbance such as anger, irritability and short-temper; diarrhea with pus, mucus and blood; abdominal pain, fullness and distention; borborygmus; acid regurgitation; bitter taste in the mouth; lack of appetite; red tongue with thin white coat; wiry pulse. (9)
Herbal Formula: tong xie yao fang (Important Formula for Painful Diarrhea): This formula regulates liver qi, strengthens the spleen and stops diarrhea. (6,7,8)
Modification (9-12):
V. Qi and blood stagnation
Clinical Manifestation: Constant abdominal pain at a fixed location; abdominal pain worsens with touch and pressure; abdominal distention; chest fullness and distention; acid regurgitation; borborygmus; lack of appetite; dark facial complexion; purple tongue with petechia; wiry and knotted pulse. (9)
Herbal Formula: shao fu zhu yu tang (drive out blood stasis in the lower abdomen decoction). This formula is commonly used to activate blood circulation to remove blood stasis and activate qi circulation to relieve pain. It is especially effective if the pain and blood stasis is located in the lower abdominal region. (6,7,8)
Modification (9-12):
VI. Damp accumulation with Spleen deficiency
Clinical Manifestation: Chronic incessant diarrhea; watery or sticky stool filled with pus, mucus and blood; dull pain and distention in the abdomen; malabsorption; malnutrition; fatigue; shortness of breath; lack of appetite; decreased sense of taste to flavors of food; flabby tongue with teeth marks; thin white tongue coat; and soft pulse. (9)
Herbal Formula: shen ling bai zhu san (ginseng, poria, and atractylodes macrocephala powder). This is an excellent formula to tonify qi, strengthen the spleen and remove damp. (6,7,8)
Modification (9-12):
VII. Spleen and kidney deficiencies
Clinical Manifestation: Chronic incessant watery diarrhea with pus, mucus and blood; diarrhea early in the morning at approximately 5 a.m. and throughout the day; diarrhea worsens with exposure to cold; fatigue; lack of energy; cold body and extremities; abdominal pain that diminishes with exposure to warmth; pale tongue with thin white coat; and deep and thready pulse. (9)
Herbal Formula: zhen ren yang zang tang (True Man's Decoction for Nourishing the Organs). This formula is used to tonify the spleen and the stomach, warm up yang and relieve diarrhea. (6,7,8)
Modification (9-12):
Acupuncture
I. Acute Ulcerative Colitis
Point Selection (9): neiting (ST 44), tianshu (ST 25), yinbai (SP 1), qihai (CV 6), zhaohai (KI 6), neiguan (PC 6), zhongwan (CV 12), yinlingquan (SP 9), zusanli (ST 36), and sanyinjiao (SP 6).
Technique: Use even or sedative method and leave the needles in place for 30 minutes.
Modification:
II. Chronic Ulcerative Colitis
Point Selection (9): zhongwan (CV 12), pishu (BL 20), zhangmen (LR 13), tianshu (ST 25), shenshu (BL 23), zusanli (ST 36), tianzhu (BL 10), shangjuxu (ST 37), weishu (BL 21), guanyuan (CV 4), and shenshu (BL 23).
Technique: Use tonic technique and leave the needle in for 30 minutes. Moxa may be applied with or without acupuncture.
Modification:
Prevention
Both Western and Oriental medicines recognize the importance of diet and its role in prevention and treatment of ulcerative colitis. Western medicine acknowledges dietary intake of certain factors (such as certain chemicals and drugs) may be linked to increased incidence of ulcerative colitis; while Oriental medicine recognizes that dietary intake with excessive cold or raw food may injury the spleen and the stomach. Therefore, diet plays an important role in both prevent and effective treatment of the illness.
Patients should be encouraged to avoid any food which may trigger recurrence, such as certain chemicals, raw or cold food. Milk, cheese and other dairy products should be avoided especially if the patients have lactose intolerance. High roughage food such as raw fruits or vegetables sometimes worsen intestinal obstruction and colic and may need to be avoided. Alcohol should be avoided as it may be irritating to the stomach and the intestines. In addition to avoiding the "wrong food," it is equally important to make sure the patients have adequate calorie and fluid intake as malnutrition and dehydration are common problems associated with ulcerative colitis.
Oral iron supplements may be necessary if there is anemia due to chronic loss of blood through diarrhea. If the patient has a sensitive stomach and cannot tolerate regular oral iron supplements, sustained release iron products is preferred. Certain over-the-counter or prescription antidiarrheal drugs may worsen the condition and create toxic megacolon. These drugs should not be taken unless supervised by a qualified health care provider. (2,3,5)
According to Western Medicine, ulcerative colitis is a chronic non-specific idiopathic gastrointestinal inflammatory disease. Several etiologic factors have been suggested, but none are proven at the present time. Since there is no known cause, specific therapy is not available and all available drug treatment focus on symptomatic relief. Surgery cures the disease but will require permanent ileostomy in addition to physical and emotional burden.
Oriental medicine offers effective treatment for mild to moderate ulcerative colitis. Herbal and acupuncture treatments listed in this chapter are based on historical treatment guideline for abdominal pain, diarrhea and dysentery. Modern science and clinical experience greatly contribute to the understanding and treatment of this disease. Oriental medicine, however, has its limitations. If the patient has such complications as toxic colitis or toxic megacolon, immediate hospitalization is required. In addition, serious complications such as massive hemorrhage, free perforation, or fulminating toxic colitis require immediate surgical intervention.
References:
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