the quality of life. the removal of the entire large intestine, known as a proctocolectomy, results in a permanent ileostomy – where a stoma is created by pulling the terminal ileum through the abdomen. intestinal contents are emptied into a removable ostomy bag which is secured around the stoma using adhesive. another surgical option for ulcerative colitis that is affecting most of the large bowel is called the ileal pouch-anal anastomosis (ipaa). this is a two- or three-step procedure. in a three-step procedure, the first surgery is a sub-total colectomy, in which the large bowel is removed, but the rectum remains in situ, and a temporary ileostomy is made. the second step is a proctectomy and formation of the ileal pouch (commonly known as a "j-pouch"). this involves removing the large majority of the remaining rectal stump and creating a new "rectum" by fashioning the end of the small intestine into a pouch and attaching it to the anus. after this procedure, a new type of ileostomy is created (known as a loop ileostomy) to allow the anastomoses to heal. the final surgery is a take-down procedure where the ileostomy is reversed and there is no longer the need for an ostomy bag. when done in two steps, a proctocolectomy – removing both the colon and rectum – is performed alongside the pouch formation and loop ileostomy. the final step is the same take-down surgery as in the three-step procedure. time taken between each step can vary, but typically a six- to twelve-month interval is recommended between the first two steps, and a minimum of two to three months is required between the formation of the pouch and the ileostomy take-down. while the ileal pouch procedure removes the need for an ostomy bag, it does not restore normal bowel function. in the months following the final operation, patients typically experience 8–15 bowel movements a day. over time this number decreases, with many patients reporting four-six bowel movements after one year post-op. while many patients have success with this procedure, there are a number of known complications. pouchitis, inflammation of the ileal pouch resulting in symptoms similar to ulcerative colitis, is relatively common. pouchitis can be acute, remitting, or chronic however treatment using antibiotics, steroids, or biologics can be highly effective. other complications include fistulas, abscesses, and pouch failure. depending on the severity of the condition, pouch revision surgery may need to be performed. in some cased the pouch may need to be de-functioned or removed and an ileostomy recreated. the risk of cancer arising from a ileal pouch anal anastomosis is low. however, annual surveillance with pouchoscopy may be considered in individuals with risk factors for dysplasia, such as a history of dysplasia or colorectal cancer, a history of psc, refractory pouchitis, and severely inflamed atrophic pouch mucosa. bacterial recolonization in a number of randomized clinical trials, probiotics have demonstrated the potential to be helpful in the treatment of ulcerative colitis. specific types of probiotics such as escherichia coli nissle have been shown to induce remission in some people for up to a year. a probiotic named after its gastroenterologist medical doctor inventor, the de simone formulation, may be effective in inducing remission in active ulcerative colitis, and may be as effective as 5-asas in preventing relapse of quiescent uc. the de simone formulation was sold and researched under the brand name vsl#3 until 2016. since, it has been sold and researched under various regional brand names including visbiome in the united states and vivomixx in europe. a cochrane review of controlled trials using various probiotics found low-certainty evidence that probiotic supplements may increase the probability of clinical remission. people receiving probiotics were 73% more likely to experience disease remission and over 2x as likely to report improvement in symptoms compared to those receiving a placebo, with no clear difference in minor or serious adverse effects. although there was no clear evidence of greater remission when probiotic supplements were compared with 5‐aminosalicylic acid treatment as a monotherapy, the likelihood of remission was 22% higher if probiotics were used in combination with 5-aminosalicylic acid therapy. it is currently is unclear whether probiotics help to prevent future relapse in people with stable disease activity, either as a monotherapy or combination therapy. fecal microbiota transplant involves the infusion of human probiotics through fecal enemas. ulcerative colitis typically requires a more prolonged bacteriotherapy treatment than clostridium difficile infection to be successful, possibly due to the time needed to heal the ulcerated epithelium. the response of ulcerative colitis is potentially very favorable with one study reporting 67.7% of people experiencing complete remission. other studies found a benefit from using fecal microbiota transplantation. alternative medicine a variety of alternative medicine therapies have been used for ulcerative colitis, with inconsistent results. curcumin (turmeric) therapy, in conjunction with taking the medications mesalamine or sulfasalazine, may be effective and safe for maintaining remission in people with quiescent ulcerative colitis. the effect of curcumin therapy alone on quiescent ulcerative colitis is unknown. treatments using cannabis or cannabis oil are uncertain. so far, studies haven't determined its effectiveness and safety. abdominal pain management many interventions have been considered to manage abdominal pain in people with ulcerative colitis, including fodmaps diet, relaxation training, yoga, kefir diet and stellate ganglion block treatment. it is unclear whether any of these are safe or effective at improving pain or reducing anxiety and depression. nutrition diet can play a role in symptoms of patients with ulcerative colitis. the most avoided foods were spicy foods, dairy products, alcohol, fruits and vegetables and carbonated beverages; these foods were also avoided during remission and to prevent relapse. in some cases, especially in the flares period, the dietary restrictions of these patients can be very severe and can lead to a compromised nutritional state. some patients tend to eliminate gluten spontaneously, despite not having a definite diagnosis of coeliac disease, because they believe that gluten can exacerbate gastrointestinal symptoms. prognosis poor prognostic factors include: age < 40 years upon diagnosis, extensive colitis, severe colitis on endoscopy, prior hospitalization, elevated crp and low serum albumin. progression or remission people with ulcerative colitis usually have an intermittent course, with periods of disease inactivity alternating with "flares" of disease. people 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. a subset of people experience a course of disease progress rapidly. in these cases, there is usually a failure to respond to medication and surgery often is performed within the first few years of disease onset. people with more extensive disease are less likely to sustain remission, but the rate of remission is independent of the severity of the disease. several risk factors are associated with eventual need for colectomy, including: prior hospitalization for uc, extensive colitis, need for systemic steroids, young age at diagnosis, low serum albumin, elevated inflammatory markers (crp & esr), and severe inflammation seen during colonoscopy. surgical removal of the large intestine is necessary in some cases. colorectal cancer the risk of colorectal cancer is significantly increased in people with ulcerative colitis after ten years if involvement is beyond the splenic flexure. people with backwash ileitis might have an increased risk for colorectal carcinoma. those people with only proctitis usually have no increased risk. it is recommended that people have screening colonoscopies with random biopsies to look for dysplasia after eight years of disease activity, at one to two year intervals. mortality people with ulcerative colitis are at similar or perhaps slightly increased overall risk of death compared with the background population. however, the distribution of causes-of-death differs from the general population. specific risk factors may predict worse outcomes and a higher risk of mortality in people with ulcerative colitis, including: c. difficile infection and cytomegalovirus infection (due to reactivation). epidemiology together with crohn's disease, about 11.2 million people were affected as of 2015. each year, ulcerative colitis newly occurs in 1 to 20 per 100,000 people (incidence), and there are a total of 5-500 per 100,000 individuals with the disease (prevalence). in 2015, a worldwide total of 47,400 people died due to inflammatory bowel disease (uc and crohn's disease). the peak onset is between 30 and 40 years of age, with a second peak of onset occurring in the 6th decade of life. ulcerative colitis is equally common among men and women. with appropriate treatment the risk of death appears similar to that of the general population. uc has become more common since the 1950s. the geographic distribution of uc and crohn's disease is similar worldwide, with the highest number of new cases a year of uc found in canada, new zealand and the united kingdom. the disease is more common in north america and europe than other regions. in general, higher rates are seen in northern locations compared to southern locations in europe and the united states. uc is more common in western europe compared with eastern europe. worldwide, the prevalence of uc varies from 2 - 299 per 100,000 people. together, ulcerative colitis and crohn's disease affect about a million people in the united states. as with crohn's disease, the rates of uc are greater among ashkenazi jews and decreases progressively in other persons of jewish descent, non-jewish caucasians, africans, hispanics, and asians. appendectomy prior to age 20 for appendicitis and current tobacco use are protective against development of uc. however, former tobacco use is associated with a higher risk of developing the disease. united states as of 2004, the number of new cases of uc in the united states was between 2.2 and 14.3 per 100,000 per year. the number of people affected in the united states in 2004 was between 37 and 246 per 100,000. canada in canada, between 1998 and 2000, the number of new cases per year was 12.9 per 100,000 population or 4,500 new cases. the number of people affected was estimated to be 211 per 100,000 or 104,000. united kingdom in the united kingdom 10 per 100,000 people newly develop the condition a year while the number of people affected is 243 per 100,000. approximately 146,000 people in the united kingdom have been diagnosed with uc. history the first description of ulcerative colitis occurred around the 1850s. research helminthic therapy using the whipworm trichuris suis has been shown in a randomized control trial from iowa to show benefit in people with ulcerative colitis. the therapy tests the hygiene hypothesis which argues that the absence of helminths in the colons of people in the developed world may lead to inflammation. both helminthic therapy and fecal microbiota transplant induce a characteristic th2 white cell response in the diseased areas, which was unexpected given that ulcerative colitis was thought to involve th2 overproduction. alicaforsen is a first generation antisense oligodeoxynucleotide designed to bind specifically to the human icam-1 messenger rna through watson-crick base pair interactions in order to subdue expression of icam-1. icam-1 propagates an inflammatory response promoting the extravasation and activation of leukocytes (white blood cells) into inflamed tissue. increased expression of icam-1 has been observed within the inflamed intestinal mucosa of ulcerative colitis patients, where icam-1 over production correlated with disease activity. this suggests that icam-1 is a potential therapeutic target in the treatment of ulcerative colitis. gram positive bacteria present in the lumen could be associated with extending the time of relapse for ulcerative colitis. a series of drugs in development looks to disrupt the inflammation process by selectively targeting an ion channel in the inflammation signaling cascade known as kca3.1. in a preclinical study in rats and mice, inhibition of kca3.1 disrupted the production of th1 cytokines il-2 and tnf-∝ and decreased colon inflammation as effectively as sulfasalazine. neutrophil extracellular traps and the resulting degradation of the extracellular matrix have been reported in the colon mucosa in ulcerative colitis patients in clinical remission, indicating the involvement of the innate immune system in the etiology. fexofenadine, an antihistamine drug used in treatment of allergies, has shown promise in a combination therapy in some studies. opportunely, low gastrointestinal absorption (or high absorbed drug gastrointestinal secretion) of fexofenadine results in higher concentration at the site of inflammation. thus, the drug may locally decrease histamine secretion by involved gastrointestinal