Studies of ulcerative colitis I. Clinical data bearing on the nature of the somatic process.

Abstract

Summary Ulcerative colitis is a disease which may begin at any age, from early infancy to old age. Abnormal bowel symptoms, notably constipation, are present in the majority of patients for many years before the onset of what is identified as ulcerative colitis. In this series of 32 patients it was found that bleeding was the earliest symptom in the majority of patients (68 per cent), whereas diarrhea was a presenting symptom in only 37 per cent. Forty four per cent of the patients were moderately to severely constipated at the onset. Among 17 patients who had complete remissions, relapses were ushered in with bleeding in 14 cases (76 per cent), a total of 43 occasions. Correlation with radiologic findings suggests that when the disease is restricted to the terminal segments of the large bowel constipation or normal stools are the rule, whereas when the disease extends caudad or involves proximal segments, diarrhea is the rule. Palmer and Cullinan have reached a similar conclusion. Further, it was observed that when the diseased colon was bypassed by short-circuiting operations, active colitis, with bleeding, could persist or recur in the bypassed segments. Finally an identical ulcerative process was observed to develop in the ileum of 3 patients who had ileostomy and colectomy, where the ileum was proven to be normal at the time of operation. No final conclusions can be drawn from these data, but certain clues are given. The prominence of bleeding as the earliest symptom directs attention to processes affecting the vascular status of the mucosa or submucosa of the colon. The dependence of fecal consistency on the location and extent of the colitic process also suggests that this process primarily involves the mucosa or submucosa rather than the colon as a total functioning unit. The clinical data suggest that, when enough of the colon is involved, diarrhea results from hastened peristalsis and diminished absorption of water as well as exudation of fluid into the lumen. On the other hand, when the process is confined to rectum or lower sigmoid, there may actually be a protective spasm so that feces do not enter the involved area, and constipated stools result, with tenesmus, rectal spasm, and the passage of mucus, blood, or pus. Bargen also has pointed out that constipation may result under these circumstances. This means that neither diarrhea nor constipation can be interpreted in psychologic terms alone in ulcerative colitis, at least not after the active colitic process has begun, since the location of the somatic process as noted before is a major determinant of which symptom will predominate. The recurrence of activity in a bypassed colon is further evidence that the process is not dependent on the contents of the small intestine, which now no longer reach the colon. And the development of ulcerative ileitis following ileostomy and colectomy indicates that the disease process is not bound by the specific functional activity of the large bowel as an excretory organ. These findings point up the need for caution in psychosomatic correlations, since the primary pathophysiologic variable in ulcerative colitis has obviously not yet been identified. The observations just reported provide evidence that diarrhea cannot be considered a basic process, and that therefore psychosomatic formulations of ulcerative colitis based on mechanisms of diarrhea must be re-examined. The prominence of bleeding provides a lead for further investigation of what is the primary process in bowel. A critical evaluation of previous hypotheses and an attempt to relate present knowledge of both somatic and psychic processes is forthcoming.6