Colitis (Ulcerative)

Ulcerative colitis is a chronic disease in which the large intestine becomes inflamed and ulcerated, leading to episodes of bloody diarrhea, abdominal cramps, and fever. Unlike Crohn's disease, ulcerative colitis usually doesn't affect the full thickness of the intestine and never affects the small intestine. The disease usually begins in the rectum or sigmoid colon and spreads partially or completely through the large intestine (see illustration on page IPR). The cause of ulcerative colitis is not known, but heredity and an overactive immune response are suspected factors. Food allergies may also be a factor (D'Arienzo et al. 2000).

Poor absorption of food and nutritional deficiencies often result due to degeneration of the intestinal mucosa. In addition, many people with colitis have a decreased food intake which adds to nutritional deficiencies.

Conventional treatment aims to reduce inflammation, reduce symptoms, and replace any lost fluid or nutrients. While symptoms can be alleviated by dietary changes and drug therapies, there are specific nutritional therapies that have been shown to be effective without inducing side effects.

The first part of this protocol is a succinct description of the various conventional and alternative therapies that have been shown in published studies to be useful. At the conclusion, a specific supplement menu is provided that reveals the actual doses required to obtain the beneficial effects.

Conventional and Alternative TherapiES

Fish Oil Studies
Fish oil may be a useful therapeutic agent in the management of colitis. Studies on the use of dietary supplements of fish-oil-derived fatty acids have indicated a beneficial effect on inflammatory bowel disease (Ross 1993; Steinhart 1997; Almallah et al. 1998). Many published studies suggest that marine fish-oil supplements, which are rich in omega-3 fatty acids, may reduce the inflammation associated with ulcerative colitis. Fish oils may exert their anti-inflammatory effects by modulating tissue levels of certain immune factors that promote inflammation. In prospective, randomized, and controlled studies, omega-3 fatty acids have been shown to be therapeutically useful (Hillier et al. 1991; Aslan et al. 1992). These studies also show that fish oil reduces the doses needed of toxic steroid drugs (Hawthorne et al. 1992; Grimminger et al. 1993; Williams 1993).

Butyrate and Mucin Synthesis
Butyrate is the major fatty acid fuel source for the epithelial cells lining the colon, and there is evidence to suggest that butyrate metabolism is impaired in ulcerative colitis (Roediger 1980; Chapman et al. 1994; Chapman et al. 1995). The human in vitro model system suggests that topical treatment using sodium butyrate may reverse symptoms in ulcerative colitis (Thomas et al. 1996). Several reports on the use of butyrate enemas for the treatment of distal ulcerative colitis have appeared (Burke et al. 1997). One study showed a striking increase in colon cell mucin synthesis in response to butyrate added to standard nutrient medium (Finnie et al. 1995). Boosting the rate of mucin synthesis and restoring the colon's mucous lining may explain the therapeutic effect of butyrate in colitis (Christl et al. 1996). Butyrate enemas are prescribed by alternative physicians for the treatment of Crohn's disease and colitis.

Butyrate enemas may be ordered from the following pharmacies:

1. Lloyd Center Pharmacy
   (800) 358-8974
   
   • The Butyrate Enema Kit includes 2 reusable enema bottles, with 200 mL of concentrated butyrate, which makes 2800 mL of reconstituted butyrate (a 2-week supply). The patient supplies distilled water. The kit also includes directions.
2. Key Pharmacy
   (800) 878-1322
   
   • The Butyrate Enema Kit includes 28 disposable single-use enema bottles with tops, 12 oz of concentrated butyrate (which when reconstituted is a 2-week supply), a funnel, and a measuring cup. The patient must supply the distilled water. The kit also includes complete directions.

A prescription from your physician is needed when ordering butyrate enemas.

Glutamine and Endotoxin Levels
Colitis can enable toxins to be absorbed into the blood from the intestines. The effect of oral glutamine was studied in a guinea pig model of experimentally induced colitis. The mean endotoxin level in the blood of guinea pigs fed a glutamine-enriched elemental diet was 64% lower compared with animals given a standard elemental diet. The scientists concluded that a glutamine-enriched diet may be therapeutically beneficial in patients with inflammatory bowel disease (Fujita et al. 1995).

The Effects of RNA and Arginine on Ulcerative Ileitis
A study showed that dietary supplementation of RNA and arginine promoted healing of small-bowel ulcers in experimental ulcerative ileitis. Rats with experimental ileitis who received yeast RNA and/or arginine showed a significant decrease in ulcer number compared to controls. The scientists concluded that yeast RNA-supplemented diets, alone or in combination with arginine, accelerated ulcer healing by promoting increased cell proliferation (Sukumar et al. 1997). Additional research has shown that arginine suppresses the growth of some strains of unfavorable bacteria and inhibits bacterial toxin release, a common problem in those suffering from chronic colitis (Karasawa et al. 1997). Other studies, however, contraindicate the use of arginine for some models of colitis. Arginine promotes nitric oxide synthesis, and several studies have found excess nitric oxide production to be detrimental to colitis patients. Most people benefit from the healthy effects of arginine-induced nitric oxide synthesis, but some colitis patients may not (Mourelle et al. 1995; Neilly et al. 1995).

Fiber
Dietary fiber is found in many plant foods, such as fruit, vegetables, beans, nuts, and whole grains, and is essential to good health. Insoluble fiber found in such foods as fruit pulp, vegetable peels and skins, and grain brans adds bulk to stools and hastens the movement of food through the digestive tract, helping to prevent constipation and diarrhea. Soluble fiber found in fruits, vegetables, grains, oatmeal, and dried beans helps to lower cholesterol and prevent such diseases as colon cancer and diabetes.

A high fiber diet may be helpful in the prevention of colitis. However, during active cases of colitis, fiber should be avoided due to its harshness in the intestinal tract. Juice from green leafy vegetables is a better alternative. After healing occurs, soluble fibers can be reintroduced into the diet.

Colitis and Bone Loss
Osteoporosis is a serious complication of inflammatory bowel disease that has not received adequate recognition despite its high prevalence and potentially devastating clinical effects (Scharla et al. 1994; Compston 1995). Data derived from a retrospective survey of 245 patients with inflammatory bowel disease suggest that the prevalence of bone fractures is unexpectedly high, particularly in patients with a long duration of disease, frequent active phases, and high cumulative doses of corticosteroid intake (Bischoff et al. 1997). Recent advances in the diagnosis and management of osteoporosis have facilitated early detection of bone loss and identified means by which this may be prevented. Bone-density measurements to predict fracture risk and define thresholds for prevention and treatment should be performed routinely in patients with inflammatory disease. Those with colitis should consider reducing the risk of incurring a bone fracture (see the Osteoporosis protocol).

Long-Term Nutritional Deficiencies
Colitis patients often suffer from multiple nutrient deficiencies (Wasser et al. 1995). Supplementation with a multinutrient formula such as Life Extension Mix could prevent complications of long-term nutritional deficiencies. Studies have shown potential lethal effects caused by colitis-induced nutritional deficiencies. Free radicals have been implicated in the colitis inflammatory process (Ramakrishna et al. 1997). Vitamin E and selenium are two nutrients that appear to be especially effective in suppressing free radical-generated inflammation.

Folate and Colon Cancer
Two case-control studies have shown that folate may protect against the development of colon cancer caused by ulcerative colitis. The most recent study showed that folate use for at least 6 months reduced the risk of colon cancer by 28% in 98 patients who had ulcerative colitis for at least 8 years. Of the ulcerative colitis patients, 29.6% developed cancerous lesions, indicating the high risk for colon cancer in colitis patients. The greater the dose of supplemental folate consumed, the lower the rate of colon cancer. The scientists concluded that "daily folate supplementation may protect against the development of neoplasia in ulcerative colitis" (Lashner et al. 1997).

Drug Therapy
Successful conventional drug treatments for inflammatory bowel disease include topically active or rapidly metabolized steroids that have fewer long-term side effects than the standard steroid drugs. The cancer chemotherapy drug methotrexate can promote remission in approximately 50% of patients, but is less effective in maintaining remission. Cyclosporin is valuable for treating patients with severe ulcerative colitis, but is less valuable for patients with Crohn's disease. In patients with distal colitis, lignocaine appears to be effective (Debinski et al. 1995).

Cytokine Modulation Therapy
There are specific inflammatory cytokines that, when elevated, may be implicated in colitis (Eliakim et al. 1998; Grool et al. 1998; Barbara et al. 2000; Koss et al. 2000; Ko et al. 2001; Lampinen et al. 2001; Liu et al. 2001; Sun et al. 2001). Those who are afflicted with colitis should consider the following blood tests to measure autoimmune cytokine activity:

• Tumor necrosis factor-alpha (TNF-a)
• Interleukin-6
• Interleukin 1(b)
• Leukotriene B(4)

If the blood test shows elevations of interleukin-6, supplemental DHEA (50-100 mg a day) and vitamin K (10-30 mg a day) may reduce this. Refer to the DHEA Replacement Therapy protocol before initiating DHEA therapy. Do not take vitamin K if you use Coumadin.

If TNF-a levels are elevated, nettle leaf extract may help suppress them. An expensive drug called Enbrel also lowers TNF-a, but it may not be affordable, requires twice weekly injections, and may have some side effects.

An inexpensive prescription drug that has been shown to lower TNF-a is pentoxifylline. This drug was approved to reduce blood viscosity and treat occlusive arterial disease, but a beneficial side effect is its ability to down-regulate the release of TNF-a, interleukin 1(b), and interleukin 6. The suggested dose of pentoxifylline to reduce these inflammatory cytokines is 400 mg, twice a day.

Fish oil has been shown to suppress TNF-a, interleukin 1(b), and leukotriene B(4), which helps explain why fish oil supplements have worked so well against colitis in human clinical studies.

Lifestyle ChangES

Avoidance of Stress
Since exacerbation of colitis seems to be associated with stress, scientists evaluated the influence of stress on experimental colitis in rats. The results showed that stress may exacerbate experimental colitis in rats (Gue et al. 1997). (Refer to the Anxiety and Stress protocol for information about alleviating the physiological effects of stress.)

Dietary Intake
Colitis patients should avoid raw fruits and vegetables to reduce physical injury to the inflamed lining of the large intestine. Avoiding foods that provoke reactions in the gut have been shown to help improve symptoms (Candy et al. 1995). Elimination diets may be tried to determine if certain foods are adding to or causing a problem. Common foods that cause allergic reactions are wheat, corn, dairy products, and processed foods containing stabilizers and suspending agents.

The chief purpose of the gut is to digest and absorb nutrients in order to maintain life. Studies have shown that colitis is often associated with a reduction in pancreatic enzyme secretion. Supplementation with pancreatic enzymes could enable better absorption of many critical nutrients.

SUMMARY

The use of nutrients, such as fish oils and glutamine, on gut inflammation and permeability, bacterial translocation, and immune cell profiles have been shown to be effective therapies for those with inflammatory bowel disease (Seidman et al. 1991). The major nutrients for the large bowel and small bowel mucosa are, respectively, butyrate and glutamine (Chapman et al. 1997). The use of butyrate enemas, along with yeast-derived RNA, the amino acid glutamine, and fish oil capsules, represent novel nutritional therapies for patients with chronic inflammatory bowel disease.

Here is a protocol of nutritional therapies for the ulcerative colitis patient to consider:

1. Glutamine, four to six 500-mg capsules a day.
2. Fish oil, 8-10 capsules a day of the MEGA EPA supplement (provides 5600-5700 mg of EPA/DHA).
3. RNA, four to six 500-mg capsules a day.
4. Life Extension Mix, 3 tablets 3 times a day (basic multinutrient formula).
5. Life Extension Booster, 1 capsule a day (for extra folate, selenium, and vitamin E).
6. Gamma-Linolenic Acid (GLA), 4 capsules of the MEGA GLA supplement (provides 1200 mg of GLA).
7. Butyrate enemas, 2 a day are suggested.
8. Soluble fiber such as 1-3 tbsp a day of Fiber Food as a preventative and if not having an active attack of colitis.
9. Pancreatin, one to two 500-mg capsules right before each meal.
10. Supplemental DHEA (50-100 mg a day) and vitamin K (10-30 mg a day) if blood testing shows elevations of interleukin-6 (see the DHEA Replacement Therapy protocol before beginning DHEA therapy).
11. • Do not take vitamin K if you are currently taking Coumadin (warfarin) to prevent blood clots.
12. An elimination diet may pinpoint allergenic foods that cause or exacerbate the problem.
13. Follow the recommendations in the Osteoporosis and the Anxiety and Stress protocols.

For more informatiON

Contact the Crohn's and Colitis Foundation of America (800) 343-3637.

MEGA EPA (fish oil), glutamine, arginine, Fiber Food, Pancreatin, Life Extension Mix, Life Extension Booster, Mega GLA, vitamin K, DHEA, and other supplements are available by calling (800) 544-4440 or by ordering online. Butylate enemas are available from the compounding pharmacies mentioned in this protocol. Certain drugs such as pentoxifylline require a prescription.