Clinical features

Ulcerative colitis is a disease of the lining layer of the large bowel. It can occur at any age. Its principal symptoms are chronic unpredictable diarrhoea accompanied by heavy anal bleeding, weight and appetite loss and abdominal pain. Its causes are unknown. There is presently no medical cure. For the moment the mainstays of treatment are rectal and systemic 5-aminosalicylic acid derivatives and corticosteroids, with azathioprine in steroid-dependent or resistant cases (Ghosh et al., 2000).

The complications of colitis can be severe. There may be perforation of the bowel, and the effects on the overall health of the patient can be extremely serious. Where the disease is present for more than 10 years there is a very greatly enhanced risk of the development of bowel cancer. At present, the best treatment option available in the face of unremitting symptoms and grave deterioration in the patient’s health or the development of cancer is the surgical removal of the bowel. This involves either creating an internal pouch to collect the waste matter of digestion with normal anal evacuation, or simply redirecting the faeces through the abdominal wall via a stoma, a procedure called panproctocolectomy and ileostomy. The operations are major and in the case of ileostomy have profound effects on appearance because the small bowel protrudes externally, and although patients are cured of the colitis, they are incontinent of faeces. They will always have to wear a bag to collect the products of digestion.

Onset

When the first symptoms – usually diarrhoea – appear, the typical response by the sufferer is to minimize or ignore them. Diarrhoea is quite common, so the sufferer often makes the assumption that the symptoms will remit of their own accord, as diarrhoea usually does. This response may continue until such time as blood appears in the motion. This is usually regarded by the patient as very significant and frightening. Whereas diarrhoea is common, anal bleeding is not. Contact with the medical profession is frequently made some time after the appearance of blood, although some patients do seek help for their diarrhoea. When the symptoms of diarrhoea are presented they are sometimes misdiagnosed.

I was working. I had two children …

I began to feel, y’know, unwell. Went to my GP. Didn’t examine me at all, and told me I was suffering from piles, haemorrhoids, and gave me some medication. The piles wouldn’t go away, and I was back there. And by this time it was terribly painful. And I started to get really worried because I was losing blood. So I made another appointment with another doctor in the practice, and she took me into the examination room, examined me straight away, and within a week I was up at St George’s Hospital

(38-year-old teacher: Kelly, 1992).

The important social–psychological concept involved here is help-seeking (see pp. 88–89). Diarrhoea comes well within the range of the normal experience of most people. They generally wait and to see whether it passes in a day or two (temporizing behaviour). The observation of blood in their motion signals something out of the ordinary and acts as the trigger for them to consult the doctor. From a medical point of view rectal bleeding is something requiring investigation. It is however quite unlikely to engender the same degree of anxiety as experienced by the patient. As far as colitis is concerned, bleeding does not necessarily indicate an exacerbation of the illness. Thus the patient’s estimation of the seriousness of the symptom may not necessarily correspond to the doctor’s. However, in order to manage the patient’s symptoms and anxieties successfully the doctor must be aware not only of the physical symptoms but also how they are being interpreted by the patient. The fact that the patient believes a symptom to be grave is what is important in understanding why the patient has consulted.