Can you lose blood via the colon with a history of ulcerative colitis and elevated C-Reactive Protein (CRP)?

From the Guidelines

Yes, you can lose blood via the colon with a history of ulcerative colitis and elevated C-Reactive Protein (CRP). Ulcerative colitis is an inflammatory bowel disease that causes inflammation and ulcers in the colon and rectum, which can bleed and lead to blood in the stool. An elevated CRP level indicates active inflammation in the body, which often correlates with disease activity in ulcerative colitis. During flare-ups, the inflamed intestinal lining becomes more fragile and ulcerated, making it prone to bleeding. The blood loss can range from microscopic amounts only detectable through testing to visible blood in the stool, which may appear bright red, maroon, or black depending on where the bleeding occurs in the colon.

According to the AGA clinical practice guideline on the role of biomarkers for the management of ulcerative colitis 1, in patients with UC with moderate to severe symptoms suggestive of flare, the AGA suggests using fecal calprotectin >150 mg/g, elevated fecal lactoferrin, or elevated CRP to rule in active inflammation and inform treatment adjustment. This guideline also suggests that patients with UC in symptomatic remission but elevated biomarkers of inflammation should undergo endoscopic assessment of disease activity rather than empiric treatment adjustment.

If you have ulcerative colitis and notice blood in your stool, especially with other symptoms like increased bowel movements, abdominal pain, or fatigue, you should contact your healthcare provider promptly as this likely indicates active disease requiring treatment adjustment. Medications commonly used to control ulcerative colitis flares include mesalamine preparations, corticosteroids like prednisone, immunomodulators such as azathioprine, and biologics like infliximab or adalimumab, depending on the severity of your condition. In severe cases, such as massive colorectal hemorrhage or non-responders to medical treatment, subtotal colectomy with ileostomy may be the surgical treatment of choice 1.

Key points to consider:

• Ulcerative colitis can cause bleeding in the colon, especially during flare-ups.
• Elevated CRP levels indicate active inflammation and may correlate with disease activity.
• Biomarkers such as fecal calprotectin, fecal lactoferrin, and CRP can be used to monitor disease activity and inform treatment decisions.
• Endoscopic assessment may be necessary to evaluate disease activity, especially in patients with elevated biomarkers or severe symptoms.
• Treatment options include medications such as mesalamine, corticosteroids, immunomodulators, and biologics, as well as surgery in severe cases.

From the Research

Ulcerative Colitis and Blood Loss

• Ulcerative colitis (UC) is a chronic inflammatory bowel disease that can cause bleeding in the colon, as indicated by the presence of bloody diarrhea, which is one of the classic presentations of the disease 2.
• The inflammation in UC can lead to erosion and ulceration of the colonic mucosa, resulting in bleeding, as noted in the study that describes the pathognomonic findings of UC, including bleeding and ulcerations 2.
• Elevated C-Reactive Protein (CRP) levels are often associated with active UC, and studies have shown that CRP levels correlate with clinical and endoscopic activity in UC patients 3, 4.
• A study found that an increased CRP level was observed in patients with active disease, and the disease activity index (DAI) was higher in patients with increased CRP 4.
• Another study determined that a CRP cut-off of ≥12 mg/L generated an 85% positive predictive value for having a paired erythrocyte sedimentation rate (ESR) of >30 mm/h, indicating severe colitis 3.

Relationship Between CRP and Ulcerative Colitis

• CRP levels have been shown to correlate with clinical and endoscopic activity in UC patients, with higher CRP levels indicating more severe disease 4, 5.
• A study found that the CRP/albumin ratio (CAR) is a practical marker for determining acute severe ulcerative colitis, with a cut-off value of 0.6 having a sensitivity of 88.9% and a specificity of 90.3% 6.
• The correlation between CRP and clinical score in UC is linear, except for proctitis, as noted in a study that evaluated the correlation between clinical scoring systems and CRP in inflammatory bowel disease 5.

Blood Loss via the Colon

• The studies suggest that patients with a history of ulcerative colitis and elevated CRP levels are at risk of bleeding in the colon, due to the inflammation and erosion of the colonic mucosa associated with active UC 2, 4.
• The presence of bloody diarrhea and the correlation between CRP levels and clinical activity in UC patients support the idea that blood can be lost via the colon in patients with a history of ulcerative colitis and elevated CRP 2, 4.