A Functional Medicine Ulcerative Colitis (UC) Protocol: Testing, Nutrition, and Supplements

Living with ulcerative colitis is a daily battle that millions of individuals around the world face. For patients, each day brings the uncertainty of managing debilitating symptoms that disrupt the normal rhythm of life. For healthcare providers, navigating the complexities of treating ulcerative colitis involves a delicate balance of science, empathy, and determination to provide the best care possible. Despite advances in disease management, many patients still experience frequent flares, highlighting the need for effective preventive strategies. 

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What Is Ulcerative Colitis?

Ulcerative colitis (UC) is the most prevalent subtype of inflammatory bowel disease (IBD), a group of gastrointestinal disorders characterized by chronic digestive tract inflammation. UC is limited to the colon, most commonly afflicting adults before age 30 or after age 60. It is distinguished from other forms of IBD by its characteristic relapsing and remitting mucosal inflammation and ulceration that starts in the rectum and extends continuously upwards through the colon. (3) 

Doctors will classify UC based on the portion of the affected colon. Types of UC include:

• Ulcerative Proctitis: inflammation confined to the rectum
• Proctosigmoiditis: inflammation involves the rectum and the lower end of the colon 
• Left-Sided Colitis: inflammation extends through the descending portions of the colon
• Pancolitis: inflammation affects the entire colon

Ulcerative Colitis Signs & Symptoms

UC symptoms generally begin gradually and worsen over time without treatment. They can range in severity, often flaring in between periods of remission. The hallmark symptom of UC is bloody diarrhea, which can occur anywhere from less than four times to more than ten times a day, depending on disease severity. Other gastrointestinal (GI) symptoms may include: 

• Tenesmus: the constant urge to defecate despite the bowels being empty
• Mucus and pus in stool 
• Abdominal and rectal pain
• Nausea and vomiting
• Weight loss 
• Failure to thrive in children
• Fatigue
• Fever

Up to 30% of patients with UC will also experience inflammatory symptoms outside of the GI tract. These extraintestinal symptoms may include:

• Joint pain and arthritis
• Eye pain and swelling
• Skin rashes and lesions

Root Causes of Ulcerative Colitis

UC is believed to result from genetic, environmental, and immunological factors. While the exact cause remains unclear, it's thought that a malfunction in the immune system triggers an abnormal and overactive autoimmune response in the colon and rectum. 

Genetic predisposition also plays a role, as individuals with a family history of UC or certain ethnic backgrounds are at a higher risk of developing the condition. 

Environmental factors such as diet, stress, environmental pollutants, and certain medications may exacerbate symptoms in susceptible individuals. The interaction between these factors can disrupt the balance of gut bacteria, leading to chronic inflammation and tissue damage in the intestinal lining characteristic of UC. 

How to Diagnose Ulcerative Colitis

UC is diagnosed through a combination of medical history review, physical examination, and diagnostic tests. These tests often include blood tests to check for signs of inflammation, stool tests to rule out infections and assess for blood in the stool, and imaging studies to directly visualize the colon and biopsy intestinal tissue samples. A conclusive diagnosis of UC is based on the presence of characteristic signs and symptoms, supported by findings from diagnostic tests and imaging.

Step 1: Narrow the Differential

The differential diagnosis for ulcerative colitis includes any condition that can cause chronic diarrhea, including Crohn's disease (CD), infectious gastroenteritis, irritable bowel syndrome (IBS), pseudomembranous colitis, celiac disease, and colon cancer. (29, 31) 

The following laboratory tests help narrow the differential as doctors begin the investigative process: 

• Ova and parasite stool testing
• Stool culture
• Clostridium difficile toxin
• Inflammatory markers: CRP, ESR, fecal calprotectin, and lactoferrin 
• Complete blood count (CBC)
• Basic metabolic panel (BMP)

Initial lab findings that indicate UC is more likely include elevated inflammatory markers, anemia from chronic blood loss, and electrolyte imbalances from persistent diarrhea. 

Once IBD has been established as a likely diagnosis, ordering pANCA (perinuclear antineutrophil cytoplasmic antibodies) and ASCA (anti-Saccharomyces cerevisiae antibodies) can help differentiate CD from UC. pANCA is present in 60-80% of patients with UC, whereas ASCA is more commonly present in patients with CD. (34)  

Step 2: Endoscopic Evaluation

Colonoscopy or proctosigmoidoscopy and biopsy are the tests of choice to diagnose ulcerative colitis definitively. Endoscopic findings consistent with UC include loss of typical vascular pattern, mucosal granularity, friability, and ulceration that affects the distal rectum and travels proximally. (31) 

Step 3: Labs That Can Individualize an Ulcerative Colitis Treatment Plan

Specialty tests aid in the personalization of effective treatment plans that target the root cause of disease and monitor patient progress through time. 

Comprehensive Stool Analysis

Dysbiosis in UC patients can trigger disease onset and relapse; research suggests that rebalancing the intestinal microbiome with microbiota therapies can promote disease remission (33). One of the following comprehensive stool tests can screen for characteristic dysbiotic patterns and metabolic defects in short-chain fatty acid (SCFA) oxidation that have been linked to UC:

• GI-MAP by Diagnostic Solutions
• GI360 by Doctor's Data
• GI Effects Comprehensive Profile - 3 day by Genova Diagnostics

SIBO Breath Test

Research suggests that small intestinal bacterial overgrowth (SIBO) is more prevalent in UC patients than in the general population. Successful eradication of SIBO correlates with clinical improvement in IBD symptoms. SIBO can be diagnosed with one of the following breath tests: 

• SIBO - 3 Hour by Genova Diagnostics
• trio-smart SIBO Breath Test by Gemelli Biotech
• SIBO/IMO Lactulose Breath Test by Commonwealth Diagnostics International, Inc.

Food Sensitivities

Nearly two-thirds of patients with UC self-report food intolerances and sensitivities contributing to disease severity. A blood test to identify food sensitivities can help customize dietary plans to eliminate foods from the diet that sustain bowel inflammation and prevent ulcerations from healing:

• 96 IgG Food Sensitivity Panel by Alletess Medical Laboratory
• foodANALYZER IgG Food Sensitivity by Access Med Labs
• Basic Food Sensitivity Panel - 96 Foods by Ayumetrix

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Treatment Plan for Ulcerative Colitis

Management of ulcerative colitis involves acute treatment of all inflammatory symptoms, followed by ongoing therapy to prevent disease relapse.

1. Induce Remission

Here's Why This Is Important: 

Inducing UC remission alleviates the distressing symptoms and prevents complications associated with the disease (discussed in more detail below), thus improving the patient's quality of life. 

How Do You Do This?

Standard-of-care treatment guidelines recommend the use of pharmacotherapy. The prescribed agent is determined by the severity of symptoms, degree of colonic involvement, and patient response to therapy. 

The following medications are most commonly used in treating UC:

• Topical or oral 5-aminosalicylic acid (5-ASA)
• Oral corticosteroids
• Azathioprine
• Infliximab
• Intravenous corticosteroids 

Approximately 66% of patients will achieve clinical remission with medical therapy. Surgical intervention may be required for patients with disease resistant to maximum medical therapy or who experience life-threatening complications. (29) 

Patients with UC are commonly motivated to pursue complementary medical therapies because of the side effects, cost, and limited efficacy of current medical treatment. 

Nutritional therapy aims to eliminate inflammatory triggers and allow the bowels to rest during symptom flares. Common trigger foods that should be avoided during IBD relapses include: 

• High-fiber foods, such as fruits with skin and seeds, raw vegetables, nuts, and whole grains
• Lactose
• Gluten 
• Refined sugars
• Artificial sweeteners
• Fried, fatty foods
• Spicy foods
• Alcohol, caffeine, and sugar-sweetened beverages

Instead, a low-residue diet reduces dietary fiber and the digestive burden on the intestines:

• Eat: white bread, white rice, poultry, fish, eggs, oil, butter, soup broth
• Avoid: whole grains, fruits, vegetables, fatty cuts of meat, nuts, seeds

The elemental diet (ED) is a medical protocol consisting of a hypoallergenic liquid formula of nutrients broken down into their simplest form for easy digestion. Studies have found that the ED safely reduces intestinal inflammation and IBD activity to induce symptom remission as effectively as steroid medications.

The anti-inflammatory properties of many herbs also prove beneficial in reducing intestinal inflammation. For example, clinical trials have shown that aloe vera, Boswellia serrata, Artemisia absinthium, and curcumin modulate inflammation and decrease the production of inflammatory chemicals to effectively treat UC, as effectively as mesalamine in some cases. 

2. Maintain Remission

Here's Why This Is Important:

Maintaining remission reduces the need for hospitalizations, surgeries, and long-term use of medications with potential side effects, thereby reducing healthcare costs and burden on patients and healthcare systems. 

How Do You Do This?

Maintaining a healthy, gut-healing diet cannot be overstated in the long-term management of UC. An anti-inflammatory diet, such as the Mediterranean diet, has been shown to prevent malnutrition, reduce IBD activity, and improve quality of life over six months.

• Eat: whole fruits and vegetables, whole grains, legumes, nuts, seeds, seafood, poultry, dairy, olive oil, avocado, herbs, and spices
• Avoid: processed meats, refined grains, added sugars, trans and saturated fats, ultra-processed foods, and sugary desserts

Vitamin D deficiency may increase the risk of developing IBD. Supplementing vitamin D to achieve optimal serum levels may prevent IBD symptom onset by regulating the GI microbiota and modulating the immune system to favor anti-inflammatory and self-tolerant pathways. Each patient's needs will differ, so dosage should be modified accordingly. (22)

Studies suggest that certain probiotic strains may help support remission in UC patients by helping to restore balance to the gut microbiota, exert anti-inflammatory actions directly to the colonic mucosal lining, and maintain the integrity of the intestinal lining. Results of one study suggested that Lactobacillus GG was as effective as 5-ASA in preventing UC relapse, although its important to note this study was unblinded. Saccharomyces boulardii has also shown high efficacy in maintaining UC remission when administered in doses of 250 mg three times daily for four weeks with mesalazine. 

The Risks of Untreated Ulcerative Colitis

Without proper management, UC can progress and result in severe complications such as dehydration, colon perforation, severe bleeding, toxic megacolon (a life-threatening condition characterized by severe inflammation and dilation of the colon), and an increased risk of colorectal cancer. These complications can lead to hospitalizations, surgeries, and even mortality if left untreated.

Living with severe UC symptoms can take a toll on mental health, leading to increased stress, anxiety, and depression. The unpredictable nature of UC symptoms, including frequent bowel movements, abdominal pain, and urgency, can significantly impact daily activities, work, social interactions, and emotional stability.

The costs associated with hospitalizations, emergency room visits, surgeries, medications, and long-term management of complications impose a substantial economic burden on healthcare systems and individuals. The indirect costs stemming from lost productivity, missed workdays, and reduced quality of life further contribute to the economic burden of UC.

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Key Takeaways:

• Ulcerative colitis is a chronic inflammatory condition characterized by unpredictable flare-ups and potential complications that can significantly impact the lives of patients. 
• With the right approach, including comprehensive management strategies aimed at inducing and maintaining remission, there is hope for improved outcomes and enhanced quality of life for patients. 
• Healthcare providers must embrace a holistic approach to UC care, incorporating medical and lifestyle interventions, regular monitoring, and patient education to optimize outcomes and reduce the burden on healthcare systems.