Ulcerative colitis

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Ulcerative colitis

Classification and external resources

Endoscopic image of a bowel section known as the sigmoid colon afflicted with ulcerative colitis. The internal surface of the colon is blotchy and broken in places.

ICD-10

K51

ICD-9

556

OMIM

191390

DiseasesDB

13495

MedlinePlus

000250

eMedicine

med/2336

MeSH

D003093

Ulcerative colitis (Colitis ulcerosa, UC) is a form of inflammatory bowel disease (IBD) . Ulcerative colitis is a form of colitis, a disease of the colon (large intestine), that includes characteristic ulcers, or open sores. The main symptom of active disease is usually constantdiarrhea mixed with blood, of gradual onset. IBD is often confused with irritable bowel syndrome(IBS), a troublesome, but much less serious, condition. Ulcerative colitis has similarities toCrohn's disease, another form of IBD. Ulcerative colitis is an intermittent disease, with periods of exacerbated symptoms, and periods that are relatively symptom-free. Although the symptoms of ulcerative colitis can sometimes diminish on their own, the disease usually requires treatment to go into remission. Ulcerative colitis occurs in 35100 people for every 100,000 in the United States,[1] or less than 0.1% of the population. The disease is more prevalent in northern countries of the world, as well as in northern areas of individual countries or other regions. Although ulcerative colitis has no known cause, there is a presumed genetic component to susceptibility. The disease may be triggered in a susceptible person by environmental factors. Although dietary modification may reduce the discomfort of a person with the disease, ulcerative colitis is not thought to be caused by dietary factors. Ulcerative colitis is treated as anautoimmune disease. Treatment is with anti-inflammatory drugs, immunosuppression, andbiological therapy targeting specific components of the immune response. Colectomy (partial or total removal of the large bowel through surgery) is occasionally necessary, and is considered to be a cure for the disease.
Contents
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1 Signs and symptoms

o o

1.1 Gastrointestinal 1.2 Extraintestinal features

2 Causes

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2.1 Genetic factors 2.2 Environmental factors 2.3 Autoimmune disease 2.4 Alternative theories 2.5 Comparison to Crohn's disease

3 Pathophysiology 4 Diagnosis

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4.1 Endoscopic 4.2 Histologic 4.3 Differential diagnosis

5 Management

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5.1 Medication 5.2 Surgery 5.3 Bacterial recolonization 5.4 Alternative medicine

6 Prognosis

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6.1 Progression or remission 6.2 Ulcerative colitis and colorectal cancer 6.3 Primary sclerosing cholangitis 6.4 Mortality 6.5 Other long-term features

7 Epidemiology 8 Research 9 References 10 External links

[edit]Signs

and symptoms

Symptoms in Crohn's disease vs. ulcerative colitis (v d e)

Crohn's disease

Ulcerative colitis

Defecation

Often porridge-like[2], Often mucus-like sometimes steatorrhea and with blood[2]

Tenesmus

Less common[2]

More common[2]

Fever

Common[2]

Indicates severe disease[2]

Fistulae

Common[3]

Seldom

Weight loss Often [edit]Gastrointestinal

More seldom

The clinical presentation[4] of ulcerative colitis depends on the extent of the disease process. Patients usually present with diarrhea mixed with blood and mucus, of gradual onset that persists for an extended period (weeks). They also may have weight loss and blood on rectal examination. The disease may be accompanied with different degrees of abdominal pain, from mild discomfort to painful bowel movements or painful abdominal cramping with bowel movements. Ulcerative colitis is associated with a general inflammatory process that affects many parts of the body. Sometimes these associated extra-intestinal symptoms are the initial signs of the disease, such as painful, arthritic knees in a teenager and may be seen in adults also. The presence of the disease may not be confirmed immediately, however, until the onset of intestinal manifestations.

[edit]Extent of involvement

Diagram of the Human Intestine

Ulcerative colitis is normally continuous from the rectum up the colon. The disease is classified by the extent of involvement, depending on how far up the colon the disease extends:

Distal colitis, potentially treatable with enemas:[5]

Proctitis: Involvement limited to the rectum. Proctosigmoiditis: Involvement of the rectosigmoid colon, the portion of the colon adjacent to the rectum.

Left-sided colitis: Involvement of the descending colon, which runs along the patient's left side, up to the splenic flexure and the beginning of the transverse colon.

Extensive colitis, inflammation extending beyond the reach of enemas:

Pancolitis: Involvement of the entire colon, extending from the rectum to the cecum, beyond which the small intestine begins.

[edit]Severity of disease

Colonic pseudopolyps of a patient with intractable ulcerative colitis. Colectomyspecimen.

In addition to the extent of involvement, people may also be characterized by the severity of their disease.[5]

Mild disease correlates with fewer than four stools daily, with or without blood, no systemicsigns of toxicity, and a normal erythrocyte sedimentation rate (ESR). There may be mild abdominal pain or cramping. Patients may believe they are constipated when in fact they are experiencing tenesmus, which is a constant feeling of the need to empty the bowel accompanied by involuntary straining efforts, pain, and cramping with little or no fecal output. Rectal pain is uncommon.

Moderate disease correlates with more than four stools daily, but with minimal signs of toxicity. Patients may display anemia (not requiring transfusions), moderate abdominal pain, and low grade fever, 38 to 39 C (100 to 102 F).

Severe disease, correlates with more than six bloody stools a day or observable massive and significant bloody bowel movement, and evidence of toxicity as demonstrated by fever, tachycardia, anemia or an elevated ESR.

Fulminant disease correlates with more than ten bowel movements daily, continuous bleeding, toxicity, abdominal tenderness and distension, blood transfusion requirement and colonic dilation (expansion). Patients in this category may have inflammation extending beyond just the mucosal layer, causing impaired colonic motility and leading to toxic megacolon. If the serous membrane is involved, colonic perforation may ensue. Unless treated, fulminant disease will soon lead to death.

[edit]Extraintestinal

features

Patients with ulcerative colitis can occasionally have aphthous ulcers involving the tongue, lips, palate and pharynx

Pyoderma gangrenosum on the leg of a person with Crohn's disease.

As ulcerative colitis is believed to have a systemic (i.e., autoimmune) origin, patients may present with comorbidities leading to symptoms and complications outside the colon. The frequency of such extraintestinal manifestations has been reported as anywhere between 6 and 47 percent.[6]These include the following:

aphthous ulcers of the mouth Ophthalmic (involving the eyes):

Iritis or uveitis, which is inflammation of the iris Episcleritis

Musculoskeletal:

Seronegative arthritis, which can be a large-joint oligoarthritis (affecting one or two joints), or may affect many small joints of the hands and feet

Ankylosing spondylitis, arthritis of the spine

Sacroiliitis, arthritis of the lower spine

Cutaneous (related to the skin):

Erythema nodosum, which is a panniculitis, or inflammation of subcutaneous tissue involving the lower extremities

Pyoderma gangrenosum, which is a painful ulcerating lesion involving the skin

Deep venous thrombosis and pulmonary embolism Autoimmune hemolytic anemia clubbing, a deformity of the ends of the fingers. Primary sclerosing cholangitis, a distinct disease that causes inflammation of the bile ducts

[edit]Causes
There are no direct causes for ulcerative colitis, but there are many possible factors such as genetics and stress.

[edit]Genetic

factors

A genetic component to the aetiology of ulcerative colitis can be hypothesized based on the following:[7]

Aggregation of ulcerative colitis in families. Identical twin concordance rate of 10% and dizygotic twin concordance rate of 3%[8] Ethnic differences in incidence Genetic markers and linkages

There are 12 regions of the genome that may be linked to ulcerative colitis, including, in the order of their discovery, chromosomes 16, 12, 6, 14, 5, 19, 1, and 3,[9] but none of these loci has been consistently shown to be at fault, suggesting that the disorder arises from the combination of multiple genes. For example, chromosome band 1p36 is one such region thought to be linked to inflammatory bowel disease.[10] Some of the putative regions encode transporter proteins such as OCTN1 and OCTN2. Other potential regions involve cell scaffolding proteins such as the MAGUK family. There may even be human leukocyte antigen associations at work. In fact, this linkage on chromosome 6 may be the most convincing and consistent of the genetic candidates.[9] Multiple autoimmune disorders have been recorded with the neurovisceral and cutaneous genetic porphyrias including ulcerative colitis,Crohn's disease, celiac disease, dermatitis herpetiformis, diabetes, systemic and discoid lupus, rheumatoid arthritis, ankylosing spondylitis,scleroderma, Sjogren's disease and scleritis. Physicians should be on high alert for

porphyrias in families with autoimmune disorders and care must be taken with potential porphyrinogenic drugs, including sulfasalazine.

[edit]Environmental

factors

Many hypotheses have been raised for environmental contributants to the pathogenesis of ulcerative colitis. They include the following:

Diet: as the colon is exposed to many dietary substances which may encourage inflammation, dietary factors have been hypothesized to play a role in the pathogenesis of both ulcerative colitis and Crohn's disease. There have been few studies to investigate such an association, but one study showed no association of refined sugar on the prevalence of ulcerative colitis.[11]

Breastfeeding: There have been conflicting reports of the protection of breastfeeding in the development of inflammatory bowel disease. One Italian study showed a potential protective effect.[12]

Several scientific studies have posted that Accutane is a possible trigger of Crohn's Disease and Ulcerative colitis in some individuals. Three cases in the United States have gone to trial thus far, with all three resulting in multi-million dollar judgements against the makers of isotretinoin. There were an additional 425 cases pending as of.[when?][13][14][15][16][17]

[edit]Autoimmune

disease

Some sources list ulcerative colitis as an autoimmune disease,[18] a disease in which the immune system malfunctions, attacking some part of the body. In contrast to Crohn's disease, which can affect areas of the gastrointestinal tract outside of the colon, ulcerative colitis usually involves the rectum and is confined to the colon, with occasional involvement of the ileum. This so-called "backwash ileitis" can occur in 1020% of patients with pancolitis and is believed to be of little clinical significance.[19] Ulcerative colitis can also be associated withcomorbidities that produce symptoms in many areas of the body outside the digestive system. Surgical removal of the large intestine often cures the disease.[5]

[edit]Alternative

theories

Levels of sulfate-reducing bacteria tend to be higher in persons with ulcerative colitis. This could mean that there are higher levels of hydrogen sulfide in the intestine. An alternative theory suggests that the symptoms of the disease may be caused by toxic effects of the hydrogen sulfide on the cells lining the intestine.[20][21]

[edit]Comparison

to Crohn's
Risk factors in Crohn's disease vs. ulcerative colitis.
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disease

Ulcerative colitis and Crohn's disease are the main types of inflammatory bowel disease, and may mimic each other to great extent, but differ somewhat in etiology and pathophysiology:

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Crohn's disease

Ulcerative colitis

Smoking Higher risk for smokers Lower risk for smokers[22] Age Usual onset between 15 and 30 years[23] Peak incidence between 15 and 25 years

[edit]Pathophysiolog

y
An increased amount of colonic sulfate-reducing bacteria has been observed in some patients with ulcerative colitis, resulting in higher concentrations of the toxic gas hydrogen sulfide.

Pathophysiology in Crohn's disease vs. ulcerative colitis

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Crohn's disease Autoimmune disease

Ulcerative colitis

Widely regarded as No consensus an autoimmune disease Associated with Th17[24] Vaguely associated with Th2

The role of hydrogen sulfide Cytokine response in pathogenesis is unclear. It

has been suggested that the protective benefit of smoking that some patients report is due to hydrogen cyanidefrom cigarette smoke reacting with hydrogen sulfide to produce the nontoxic isothiocyanate. Another unrelated study suggested sulphur contained in red meats and alcohol may lead to an increased risk of relapse for patients in remission.[20]

[edit]Diagnosis

H&E stain of a colonic biopsy showing a crypt abscess, a classic finding in ulcerative colitis

The initial diagnostic workup for ulcerative colitis includes the following:[1][5]

A complete blood count is done to check for anemia; thrombocytosis, a high platelet count, is occasionally seen

Electrolyte studies and renal function tests are done, as chronic diarrhea may be associated with hypokalemia, hypomagnesemia and pre-renal failure.

Liver function tests are performed to screen for bile duct involvement: primary sclerosing cholangitis.

X-ray Urinalysis Stool culture, to rule out parasites and infectious causes. Erythrocyte sedimentation rate can be measured, with an elevated sedimentation rate indicating that an inflammatory process is present.

C-reactive protein can be measured, with an elevated level being another indication of inflammation.

Although ulcerative colitis is a disease of unknown causation, inquiry should be made as to unusual factors believed to trigger the disease.[5]Factors may include: recent cessation of tobacco smoking; recent administration of large doses of iron or vitamin B6; hydrogen peroxide in enemas or other procedures.[citation needed]

[edit]Endoscopic

Biopsy sample (H&E stain) that demonstrates marked lymphocytic infiltration (blue/purple) of the intestinal mucosa and architectural distortion of the crypts.

The best test for diagnosis of ulcerative colitis remains endoscopy. Full colonoscopy to the cecum and entry into the terminal ileum is attempted only if diagnosis of UC is unclear. Otherwise, a flexible sigmoidoscopy is sufficient to support the diagnosis. The physician may elect to limit the extent of the

exam if severe colitis is encountered to minimize the risk of perforation of the colon. Endoscopic findings in ulcerative colitis include the following:

Loss of the vascular appearance of the colon Erythema (or redness of the mucosa) and friability of the mucosa Superficial ulceration, which may be confluent, and Pseudopolyps.

Ulcerative colitis is usually continuous from the rectum, with the rectum almost universally being involved. There is rarely peri-anal disease, but cases have been reported. The degree of involvement endoscopically ranges from proctitis or inflammation of the rectum, to left sided colitis, to pancolitis, which is inflammation involving the ascending colon.

[edit]Histologic
Biopsies of the mucosa are taken to definitively diagnose UC and differentiate it from Crohn's disease, which is managed differently clinically. Microbiological samples are typically taken at the time of endoscopy. The pathology in ulcerative colitis typically involves distortion of cryptarchitecture, inflammation of crypts (cryptitis), frank crypt abscesses, and hemorrhage or inflammatory cells in the lamina propria. In cases where the clinical picture is unclear, the histomorphologic analysis often plays a pivotal role in determining the diagnosis and thus the management. By contrast, a biopsy analysis may be indeterminate, and thus the clinical progression of the disease must inform its treatment.

[edit]Differential

diagnosis

Endoscopic image of ulcerative colitis affecting the left side of the colon. The image shows confluent superficial ulceration and loss of mucosal architecture. Crohn's disease may be similar in appearance, a fact that can make diagnosing UC a challenge.

The following conditions may present in a similar manner as ulcerative colitis, and should be excluded:

Crohn's disease Infectious colitis, which is typically detected on stool cultures

Pseudomembranous colitis, or Clostridium difficile-associated colitis, bacterial upsets often seen following administration of antibiotics

Ischemic colitis, inadequate blood supply to the intestine, which typically affects the elderly Radiation colitis in patients with previous pelvic radiotherapy Chemical colitis resulting from introduction of harsh chemicals into the colon from an enema or other procedure.

The most common disease that mimics the symptoms of ulcerative colitis is Crohn's disease, as both are inflammatory bowel diseases that can affect the colon with similar symptoms. It is important to differentiate these diseases, since the course of the diseases and treatments may be different. In some cases, however, it may not be possible to tell the difference, in which case the disease is classified as indeterminate colitis.

Findings in diagnostic workup in Crohn's disease vs. ulcerative colitis

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Sign Terminal ileuminvolvement Colon involvement Rectum involvement Involvement around the anus Bile duct involvement Commonly Usually Seldom Common[3]

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Crohn's disease Seldom Always

Ulcerative colitis

Usually[22] Seldom Higher rate[25] Continuous area of inflammation[22] Continuous ulcer Shallow, mucosal Seldom Non-peri-intestinal crypt granulomas not seen[22]

No increase in rate of primary sclerosing cholangitis

Distribution of Disease Patchy areas of inflammation (Skip lesions) Endoscopy Deep geographic and serpiginous (snakelike) ulcers

Depth of inflammation May be transmural, deep into tissues[9][3] Stenosis Granulomas on biopsy Common May have non-necrotizing non-peri-intestinal cryptgranulomas[3][26][27]

[edit]Management
Main article: Management of ulcerative colitis Standard treatment for ulcerative colitis depends on extent of involvement and disease severity. The goal is to induce remission initially with medications, followed by the administration of maintenance medications to prevent a relapse of the disease. The concept of induction of remission and maintenance of remission is very important. The medications used to induce and maintain a remission somewhat overlap, but the treatments are different. Physicians first direct treatment to inducing a remission which involves relief of symptoms and mucosal healing of the lining of the colon and then longer term treatment to maintain the remission and prevent complications.

[edit]Medication
Ulcerative colitis can be treated with a number of medications including aminosalicylates such as sulfasalazine, corticosteroids such asprednisone, immunosuppressive medications such as azathioprine, and biological agents such as infliximab.

[edit]Aminosalicylates
Sulfasalazine has been a major agent in the therapy of mild to moderate UC for over 50 years. In 1977, Mastan S. Kalsi et al. determined that 5-aminosalicylic acid (5-ASA and mesalazine) was the therapeutically active in sulfasalazine.[citation needed] Since then many 5-ASA compounds have been developed with the aim of maintaining efficacy but reducing the common side effects associated with the sulfapyridine moiety in sulfasalazine.[28]

[edit]Nicotine
Unlike Crohn's disease, ulcerative colitis has a lesser prevalence in smokers than non-smokers. Patients who choose to use smoking as a treatment should keep a record regarding smoking cessation and the onset or relapse of ulcerative colitis to verify associations.[29][30]Studies using a transdermal nicotine patch have shown clinical and histological improvement.[31] In one double-blind, placebo controlled, study conducted in the United Kingdom 48.6% of patients who used the nicotine patch, in conjunction with their standard treatment, showed complete resolution of symptoms. Another randomized, double-blind, placebo-controlled, single-center clinical trial conducted in the United States showed that 39% of participants showed significant improvement vs. 3% of placebo.[32] Use of a transdermal nicotine patch without the addition of other standard treatments such as mesalazine has relapse occurrence rates similar to standard treatment without the use of nicotine.

[edit]Surgery Management in Crohn's disease vs. ulcerative colitis

Unlike Crohn's disease, ulcerative colitis can generally be cured by surgical removal of the large intestine, also known as a colectomy. This procedure is necessary in the event of: exsanguinating hemorrhage, frank perforation or documented or strongly suspected carcinoma. Surgery is also indicated for patients with severe colitis or toxic megacolon. Patients with symptoms that are disabling and do not

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Mesalazine Less useful[33]

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Crohn's disease

Ulcerative colitis More useful[33]

Antibiotics Effective in long-term[34] Generally not useful[35] Surgery Often returns following Usually cured by removal of affected part removal of colon

respond to drugs may wish to consider whether surgery would improve the quality of life. Ulcerative colitis (UC) is a disease that affects many parts of the body outside the intestinal tract. In rare cases the extra-intestinal manifestations of the disease may require removal of the colon. [5] Another surgical option for ulcerative colitis that is affecting most of the large bowel is called the ileoanal pouch procedure. This procedure is a two to three step procedure in which the large bowel is removed, except for the rectal stump and anus, and a temporary ileostomy is made. The next part of the surgery can be done in one or two steps and is usually done at six to twelve month intervals from each prior surgery. In the next step of the surgery an internal pouch is made of the patients' own small bowel and this pouch is then hooked back up internally to the rectal stump so that patient can once again have a reasonably functioning bowel system, all internal. The temporary ileostomy can be reversed at this time so that the patient is now internalized for bowel functions, or in another step to the procedure, the pouch and rectal stump anastamosis can be left inside the patient to heal for some time, while the patient still uses the ileostomy for bowel function. Then on a subsequent surgery the ileostomy is reversed and the patient has internalized bowel function again.

[edit]Bacterial

recolonization

Probiotics may have benefit. One study which looked at a probiotic known as VSL#3 has shown promise for people with ulcerative colitis.[36]

Fecal bacteriotherapy involves the infusion of human probiotics through fecal enemas.[37] It suggests that the cause of ulcerative colitis may be a previous infection by a still unknown pathogen. This initial infection resolves itself naturally, but somehow causes an imbalance in the colonic bacterial flora, leading to a cycle of inflammation which can be broken by "recolonizing" the colon with bacteria from a healthy bowel. There have been several reported cases of patients

who have remained in remission for up to 13 years.[38] In the United States it can be difficult to find doctors who perform this procedure so some patients have performed the procedure at home using a protocol outlined in a published study.[39]

[edit]Alternative

medicine

About 21% of inflammatory bowel disease patients use alternative treatments.[40] A variety of dietary treatments show promise, but they require further research before they can be recommended.[41] In vitro research, animal evidence, and limited human study suggest that melatonin may be beneficial.[42] Dietary fiber, meaning indigestible plant matter, has been recommended for decades in the maintenance of bowel function. Of peculiar note is fiber from brassica, which seems to contain soluble constituents capable of reversing ulcers along the entire human digestive tract before it is cooked.[43] Oatmeal is also commonly prescribed.[citation needed]

Fish oil. Eicosapentaenoic acid (EPA), derived from fish oil. This is an Eicosanoid that inhibits leukotriene activity, the latter which may be a key factor of inflammation. As an IBD therapy, there are no conclusive studies in support and no recommended dosage. But dosages of EPA between 180 to 1500 mg/day are recommended for other conditions, most commonly cardiac.[44]

Short chain fatty acid (butyrate) enema. The colon utilizes butyrate from the contents of the intestine as an energy source. The amount of butyrate available decreases toward the rectum. Inadequate butyrate levels in the lower intestine have been suggested as a contributing factor for the disease. This might be addressed through butyrate enemas. The results however are not conclusive.[citation needed]

Herbal medications are used by patients with ulcerative colitis. Compounds that contain sulphydryl may have an effect in ulcerative colitis (under a similar hypothesis that the sulpha moiety of sulfasalazine may have activity in addition to the active 5-ASA component).[45] One randomized control trial evaluated the over-the-counter medication methionine-methyl sulphonium chloride (abbreviated MMSC, but more commonly referred to as Vitamin U) and found a significant decreased rate of relapse when the medication was used in conjunction with oral sulfasalazine.[46]

Boswellia is an Ayurvedic (Indian traditional medicine) herb, used as a natural alternative to drugs. One study has found its effectiveness similar to sulfasalazine.[47]

[edit]Prognosis Complications of Crohn's disease vs. ulcerative colitis

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[edit]Progression

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remission
Nutrient deficiency Colon cancer risk
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Crohn's disease Ulcerative colitis Higher risk Slight Considerable

Prevalence of extraintestinal complications[48] Iritis/uveitis Females 2.2% Males 1.3% 3.2% 0.9% 1% 3% 0.8% 1.5% 0.8% 0.7% 2% 0.7%

Primary sclerosing Females 0.3% cholangitis Males 0.4% Ankylosing spondylitis Pyoderma gangrenosum Erythema nodosum Females 0.7% Males 2.7%

Females 1.2% Males 1.3%

Females 1.9% Males 0.6%

This section does not cite anyreferences or sources. Please help improve this section by adding citations toreliable sources. Unsourced material may be challenged and removed. (January 2012)
Patients with ulcerative colitis usually have an intermittent course, with periods of disease inactivity alternating with "flares" of disease. Patients with proctitis or left-sided colitis usually have a more benign course: only 15% progress proximally with their disease, and up to 20% can have sustained remission in the absence of any therapy. Patients with more extensive disease are less likely to sustain remission, but the rate of remission is independent of the severity of disease.

[edit]Ulcerative

colitis and colorectal cancer

There is a significantly increased risk of colorectal cancer in patients with ulcerative colitis after ten years if involvement is beyond the splenic flexure. Those with only proctitis or rectosigmoiditis usually have no increased risk.[5] It is recommended that patients have screeningcolonoscopies with random biopsies to look for dysplasia after eight years of disease activity.[49]

[edit]Primary

sclerosing cholangitis

Ulcerative colitis has a significant association with primary sclerosing cholangitis (PSC), a progressive inflammatory disorder of small and large bile ducts. As many as 5% of patients with ulcerative colitis may progress to develop primary sclerosing cholangitis.[50]

[edit]Mortality This section does not cite any references or sources. Please help improve this section by adding citations to reliable sources. Unsourced material may be challenged and removed. (January
2012)

The effect of ulcerative colitis on mortality is unclear, but it is thought that the disease primarily affects quality of life, and not lifespan.

[edit]Other

long-term features

Changes that can be seen in chronic ulcerative colitis include granularity, loss of the vascular pattern of the mucosa, loss of haustra, effacement of the ileocecal valve, mucosal bridging, strictures and pseudopolyps.[51]

[edit]Epidemiology
The incidence of ulcerative colitis in North America is 1012 cases per 100,000 per year, with a peak incidence of ulcerative colitis occurring between the ages of 15 and 25. Prevalence is 1 per 1000. There is thought to be a bimodal distribution in age of onset, with a second peak in incidence occurring in the 6th decade of life. The disease affects females more than males.[4] The geographic distribution of ulcerative colitis and Crohn's disease is similar worldwide,[52] with highest incidences in the United States,Canada, the United Kingdom, and Scandinavia. Higher incidences are seen in northern locations compared to southern locations inEurope[53] and the United States.[54] As with Crohn's disease, the prevalence of ulcerative colitis is greater among Ashkenazi Jews and decreases progressively in other persons of Jewish descent, non-Jewish Caucasians, Africans, Hispanics, and Asians.[19] Appendectomy prior to age 20 for appendicitis[55] and tobacco use[56] are protective against development of ulcerative colitis.