What to know about ulcerative colitis

Ulcerative colitis is a relatively common long-term condition that causes inflammation in the colon. It is a form of inflammatory bowel disease (IBD) that is similar to Crohn’s disease.

The colon removes nutrients from undigested food and eliminates waste products through the rectum and anus as feces.

In severe cases, ulcers form on the lining of the colon. These ulcers may bleed, which produces pus and mucus.

Various medication options are available, and doctors can tailor treatment to meet individual needs.

Symptoms

The first symptom of ulcerative colitis is usually diarrhea.

Stools become progressively looser, and some people may experience abdominal pain with cramps and a severe urge to go to the bathroom.

Diarrhea may begin slowly or suddenly. Symptoms depend on the extent and spread of inflammation.

The most common symptoms of ulcerative colitis include:

• abdominal pain
• bloody diarrhea with mucus

Some people may also experience:

• fatigue or tiredness
• weight loss
• loss of appetite
• anemia
• elevated temperature
• dehydration
• a constant urge to pass stools

Symptoms are often worse early in the morning.

Symptoms may be mild or absent for months or years at a time. However, they will usually return without treatment and vary depending on the affected part of the colon.

What causes red diarrhea?

Types

Symptoms may vary depending on the area of inflammation.

The sections below discuss the various types of ulcerative colitis, many of which affect different parts of the colon:

Ulcerative proctitis

This type affects only the end of the colon, or the rectum. Symptoms tend to include:

• rectal bleeding, which may be the only symptom
• rectal pain
• an inability to pass stools despite frequent urges

Ulcerative proctitis is usually the mildest type of ulcerative colitis.

Proctosigmoiditis

This involves the rectum and the sigmoid colon, which is the lower end of the colon.

Symptoms include:

• bloody diarrhea
• abdominal cramps
• abdominal pain
• a constant urge to pass stool

Left-sided colitis

This affects the rectum and the left side of the sigmoid and descending colon.

Symptoms usually include:

• bloody diarrhea
• abdominal cramping on the left side
• weight loss

Pancolitis

This affects the whole colon. Symptoms include:

• occasionally severe, bloody diarrhea
• abdominal pain and cramps
• fatigue
• considerable weight loss

Fulminant colitis

This is a rare, potentially life threatening form of colitis that affects the whole colon.

Symptoms tend to include severe pain and diarrhea, which can lead to dehydration and shock.

Fulminant colitis can present a risk of colon rupture and toxic megacolon, which causes the colon to become severely distended.

Diet

According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), some dietary measures may help relieve symptoms, including:

• eating smaller, more regular meals, such as five or six small meals per day
• drinking plenty of fluids, especially water, to prevent dehydration
• avoiding caffeine and alcohol, which can both increase diarrhea
• avoiding sodas, which can increase gas
• keeping a food diary to identify which foods make symptoms worse

A doctor may suggest temporarily following a specific diet depending on symptoms, such as:

• a low fiber diet
• a lactose-free diet
• a low fat diet
• a low salt diet

It may help to take supplements or eliminate particular foods from the diet. However, a person should discuss any complementary or alternative measures with a doctor before trying them.

Here, find out more about what to eat and avoid with ulcerative colitis.

Causes

The exact causes of ulcerative colitis are unclear. However, they may involve the following:

Genetic factors

ResearchTrusted Source suggests that people with ulcerative colitis are more likely to have certain genetic features. The specific genetic feature that a person has may affect the age at which the disease appears.

Environment

The following environmental factors might affect the onset of ulcerative colitis:

• diet
• air pollution
• cigarette smoke

Immune system

The body might respond to a viral or bacterial infection in a way that causes the inflammation associated with ulcerative colitis.

Once the infection resolves, the immune system continues to respond, which leads to ongoing inflammation.

Another theory suggests that ulcerative colitis may be an autoimmune condition. A fault in the immune system may cause it to fight nonexistent infections, leading to inflammation in the colon.

Risk factors

Some known risk factors for ulcerative colitis include:

• Age: Ulcerative colitis can affect people at any age but is more common at 15–30 years of age.
• Ethnicity: White people and those of Ashkenazi Jewish descent have a higher risk of developing the condition.
• Genetics: Although recent studies have identified specific genes that may play a role in ulcerative colitis, the link is unclear due to the role of environmental factors.

Diagnosis

A doctor will ask about a person’s symptoms and medical history. They will also ask whether any close relatives have had ulcerative colitis, IBD, or Crohn’s disease.

They will also check for signs of anemia, or low iron levels in the blood, and tenderness around the abdomen.

Several tests can help rule out other possible conditions and diseases, including Crohn’s disease, infection, and irritable bowel syndrome.

These include:

• blood tests
• stool tests
• X-ray
• barium enema, during which a healthcare professional passes a fluid called barium through the colon to show any changes or anomalies in a scan
• sigmoidoscopy, in which a healthcare professional inserts a flexible tube with a camera at the end, called an endoscope, into the rectum
• colonoscopy, wherein a doctor examines the whole colon using an endoscope
• a CT scan of the abdomen or pelvis

A person with ulcerative colitis will need to see a doctor who specializes in treating conditions of the digestive system, or a gastroenterologist.

They will assess the type and severity of the condition and create a treatment plan.

Treatment

Ulcerative colitis symptoms can range from mild to severe, but it needs treatment. Without treatment, the symptoms may go away, but there is a higher chance of them coming back.

Most people will receive outpatient treatment. However, around 15% of people with the disease have a severe form. Of these, 1 in 5 may need to spend time in the hospital.

Treatment will focus on:

• maintaining remission to prevent further symptoms
• managing a flare until symptoms go into remission

Various medications are available, and a doctor will make a treatment plan that takes individual needs and wishes into account. Natural approaches can support medical treatment, but they cannot replace it. 

Long-term treatment to maintain remission

The first aim of treatment is to reduce the risk of a flare and its severity if a flare does occur. Long-term therapy can help achieve this.

There are several types of medication, and a doctor will make a treatment plan to suit the individual.

Ulcerative colitis results from a problem with the immune system. Three types of drugs that can help are biologics, immunomodulators, and small molecules. These target the way the immune system works.

They include: 

• TNF-α antagonists, such as infliximab (Remicade) or adalimumab (Humira)
• anti-integrin agents, such as vedolizumab (Entyvio)
• Janus kinase inhibitors, such as tofacitinib (Xeljanz)
• interleukin 12/23 antagonists, such as ustekinumab (Stelara)
• immunomodulators, for instance, thiopurines (azathioprines) and methotrexate

These drugs can help people with moderate to severe symptoms, but they may have adverse effects. People should talk to their doctor about the options available and the benefits and risks of each drug.

However, for mild to moderate symptoms, guidelines suggest 5-aminosalicylic acid, or aminosalicylates (5-ASA), as a first-line treatment.

Examples include:

• mesalamine
• balsalazide
• sulfasalazine

Other options

Aminosalicylates: In the past, 5-ASA played a key role in treating the symptoms of ulcerative colitis. These are still an option, but current guidelines recommend focusing on long-term treatment to prevent symptoms from occurring in the first place.

Steroids: These can help manage inflammation if aminosalicylates do not help. However, long-term use can have adverse effects, and experts recommend minimizing their use.

Managing severe active ulcerative colitis

A person with severe symptoms may need to spend time in the hospital. Hospital treatment can reduce the risk of malnutrition, dehydration, and life threatening complications, such as colon rupture. Treatment will include intravenous fluids and medications.

Surgery

If other treatments do not provide relief, surgery may be an option.

Some surgical options include:

• Colectomy: A surgeon removes part or all of the colon.
• Ileostomy: A surgeon makes an incision in the stomach, extracts the end of the small intestine, and connects it to an external pouch, called a Kock pouch. The pouch then collects waste material from the intestine.
• Ileoanal pouch: A surgeon constructs a pouch from the small intestine and connects it to the muscles surrounding the anus. The ileoanal pouch is not an external pouch. Sometimes it is called a J-pouch.

According to the American Gastroenterological Association, around 10–15% of people with ulcerative colitis will need a colectomy.

Lifestyle and natural remedies

Some home care strategies and remedies may help manage the symptoms of ulcerative colitis. 

Natural medicine

Here are some options that people may use:

• Probiotics: A 2019 review suggests that some probiotics may help manage IBD.
• Herbal remedies: Other researchTrusted Source from 2019 found that some herbal remedies may help reduce symptoms and manage the condition. Examples include aloe vera gel and wheatgrass juice. 
• Fruits and other plant-based foods: Some earlier research shows that ingredients naturally present in blueberries, black raspberries, cocoa, Indian quince, green tea, grapes, olive oil, and Indian gooseberries may have a beneficial effect.
• Spices: Garlic, ginger, fenugreek, saffron, turmeric, and Malabar tamarind may help with IBD symptoms.

Research has not yet confirmed the possible benefits of the options above, but moderate amounts appear safe to add to the diet. However, it is worth checking with a healthcare professional first.

Lifestyle options

Scientists have also found that the following may help:

Education: The more a person knows about a health condition, the more in control they tend to feel. Learning about ulcerative colitis can help ease anxiety and lead to effective coping and management techniques, research from 2017Trusted Source shows.

Exercise: Some research suggests that aerobic exercise may have an anti-inflammatory effect, which could benefit people with ulcerative colitis. One 2019 studyTrusted Source, for example, found that combining exercise with an anti-inflammatory diet could have a positive effect. Check with a healthcare professional before changing an exercise routine, however, as 20% of participants with ulcerative colitis in a 2016 study experienced a worsening of symptoms after doing intense exercise.

Mindfulness: In a 2020 study, 37 people with ulcerative colitis engaged in a mindfulness-based intervention that involved four online therapy and four face-to-face sessions. After 6 months, the participants had lower markers of inflammation than 20 participants who did not have the sessions. 

Complications

The possible complications of ulcerative colitis can range from a lack of nutrients to potentially fatal bleeding from the rectum. 

Possible complications include:

Colorectal cancer

Ulcerative colitis, especially if symptoms are severe or extensive, increases the risk of developing colon cancer.

According to the NIDDK, colon cancer risk is highest when ulcerative colitis affects the entire colon for longer than 8 years.

Toxic megacolon

This complication occurs in a few cases of severe ulcerative colitis.

In toxic megacolon, gas becomes trapped, causing the colon to swell. When this occurs, there is a risk of colon rupture, septicemia, and shock.

Other complications

Other possible complications of ulcerative colitis include:

• inflammation of the skin, joints, and eyes
• liver disease
• osteoporosis
• perforated colon
• severe bleeding
• severe dehydration

To prevent bone density loss, a doctor may prescribe vitamin D supplements, calcium, or other medications.

Attending regular medical appointments, closely following a doctor’s advice, and being aware of symptoms can help prevent these complications.