Ulcerative colitis

Ulcerative colitis (UC) is part of a large category of diseases referred to as inflammatory bowel disease (IBD). Ulcerative colitis causes inflammation and ulcers (open sores) to develop on the inner lining of your large intestine and rectum. These ulcers can bleed and secrete pus or mucus, creating uncomfortable and sometimes debilitating symptoms.

A gradual onset of symptoms

Ulcerative colitis usually starts in the lower part of your large intestine (the rectum) and then spreads slowly to the entire colon. Because of this, UC symptoms tend to develop gradually rather than appear suddenly. Left untreated, these symptoms can lead to severe complications.

UC is a chronic disease

Ulcerative colitis is a chronic disease, meaning it lasts a long time and cannot be cured. There may be times when your symptoms go away for several months or even years, but your symptoms will eventually come back during a flare-up event.

However, with the treatment and support, you can greatly reduce your symptoms and bring about long-term remission.

Symptoms of ulcerative colitis

Symptoms can vary

Ulcerative colitis symptoms tend to develop over time, and they vary from person to person. The most common symptoms include:

  • Abdominal pain and cramping, especially on the left side.
  • Constipation, which may occur if you have inflammation on the rectum.
  • Diarrhea, often with blood, mucus, or pus.
  • Extreme tiredness (fatigue).
  • Fever.
  • Feeling like you can’t completely empty your bowel (tenesmus).
  • Frequently needing to use the restroom.
  • Loss of appetite.
  • Rectal pain.
  • Rectal bleeding (passing small amounts of bright red blood with stool).
  • Weight loss.

In children, ulcerative colitis can lead to stunted growth.

UC symptoms in women

Women may experience additional symptoms related to ulcerative colitis. These include:

  • Anemia. Women are more likely to experience anemia, a condition in which your blood can’t carry enough oxygen to meet your body’s needs. This can lead to fatigue and make it hard to do day-to-day physical activities.
  • Irregular periods.
  • More intense abdominal pain or diarrhea during menstruation.

Advanced symptoms and complications

As the disease progresses, other symptoms may develop. These include:

  • Joint pain.
  • Kidney stones.
  • Liver disorders.
  • Rashes
    • Ulcerative colitis rash: ulcerative colitis may lead to the development of a rash or skin sores, especially on the arms and legs.
  • Redness and swelling (inflammation) of the eyes.
  • Weak and brittle bones (osteoporosis).

Provider and patient having a discussion

Ulcerative colitis: causes and risk factors

Causes

Experts don’t know what causes ulcerative colitis, but it may be related to your immune system. Normally, your immune system attacks bacteria and viruses that could make you sick. However, with UC, the immune system mistakes the cells of your large intestine for a threat and attacks. When your immune system attacks your own healthy cells, it is referred to as an autoimmune condition. This causes inflammation and ulcers.

Why some people develop ulcerative colitis and not others is still being studied. It may have to do with genetic factors. You are more likely to develop UC if a family member has it. However, most cases develop in people without a family history.

Environmental factors, like exposure to certain viruses or bacteria, may also play a role. Your body may try to fight this infection and then overreact.

Doctors used to think that excess stress and certain foods cause ulcerative colitis, but we now know this isn’t true. Diet and stress can make symptoms worse, but they don’t cause them.

Risk factors

A risk factor is anything that increases your chance of developing a certain disease. Some risk factors for ulcerative colitis include:

  • Age. Ulcerative colitis usually develops between the ages of 15 and 30 years old. However, children and older adults can develop UC as well.
  • Family history. Having a family member with ulcerative colitis raises your risk of the disease.
  • Race and ethnicity. White people and people of Ashkenazi Jewish descent are more likely to develop UC than other populations.

Woman hiker with backpack facing the sun

How is ulcerative colitis diagnosed?

If you have symptoms of ulcerative colitis, you should reach out to your healthcare professional. They will start by asking you about your symptoms, your family and medical history, and your lifestyle. They will also perform a physical exam.

Your doctor may also order one or more of the following tests to rule out other diseases and confirm your diagnosis.

Lab tests

  • Blood tests. A small blood sample can be checked in a lab for signs of infection or anemia.
  • Stool sample tests. A stool sample can be checked in a lab for the presence of white blood cells or certain proteins, which can both be signs of ulcerative colitis. The sample can also be checked for other problems, like bacteria, viruses, or parasites.

Endoscopic procedures

The only way to know for sure if you have UC is to do an endoscopic procedure. This involves using a special tool, called an endoscope, to see inside your large intestine or other parts of your digestive tract. There are several possible types of this procedure.

  • Upper endoscopy. In this procedure, your doctor will use an endoscope with a light and camera at the end to look into your esophagus, which connects your mouth and stomach. They will look for signs of inflammation, and they may take a small sample of tissue (a biopsy) for further testing.
  • Colonoscopy. In this procedure, your doctor looks inside your large intestine using a colonoscope. They will check for any abnormal growths, tissue that is red or swollen, sores (ulcers), or bleeding. Your doctor may take a biopsy of any suspicious tissue, or they may try to treat areas that are bleeding.
  • Sigmoidoscopy. This procedure is similar to a colonoscopy, but your doctor will only look at the left side of your large intestine (referred to as the sigmoid colon). Sigmoidoscopies can be helpful in cases of severe intestinal inflammation or blockages.

Medical imaging

If you have severe inflammation or severe symptoms, your doctor may recommend doing a medical imaging test instead of an endoscopic procedure. These tests are non-invasive but still allow your doctor to look for serious complications. They include:

  • CT scan. A CT scan takes many pictures of your organs from different angles to create a detailed 3D representation. Your doctor can look at these images for signs of complications or inflammation.
  • Lower GI (gastrointestinal) series. For this procedure, you will swallow a chalky liquid (barium) that will coat the inside of your digestive tract and make it easy to see on an x-ray. Your doctor can then take an x-ray of your large intestine to look for blockages, ruptures, or other complications. However, they may not be able to see inflammation.

Female patient and CT imaging technician

Treatments for ulcerative colitis

Ulcerative colitis is a chronic condition, which means you will have to manage it for the rest of your life. There is no cure for ulcerative colitis.

However, there are a variety of treatment options that can help you manage your symptoms and have long-term remission. Your treatment will depend on the severity of your condition, your symptoms, your overall health, and your goals. UCHealth specialists will work closely with you to formulate the right treatment plan.

UC medications

Medications are usually the first treatment for ulcerative colitis. There are many different types to help you manage different symptoms.

Anti-inflammatory medications

  • 5-aminosalicylates: These medications work by blocking the chemicals that trigger inflammation. They can be taken by mouth or as a suppository.
  • Corticosteroids: Corticosteroids are powerful medications that reduce inflammation and immune system activity. They are usually used in moderate or severe cases of UC that don’t respond to other treatments. Long-term use of corticosteroids can have negative side effects.

Immunosuppressants

Ulcerative colitis is an autoimmune condition. So, if anti-inflammatory medications aren’t working, your doctor may prescribe medications to suppress your immune system to stop UC from attacking your large intestine. Certain commonly prescribed immunosuppressants for UC can affect your liver and pancreas, however, so you will need to have regular follow-ups with your doctor.

Biologics

Biologics are a group of medications that target specific proteins made by your immune system. These include drugs like Infliximab (Remicade), adalimumab (Humira) and golimumab (Simponi). Biologics are most often used in cases of UC that don’t respond well to other treatments.

Other UC medications

Anti-diarrheal medications like loperamide help relieve diarrhea by slowing down how fast your body absorbs water. It does not cure ulcerative colitis, but it can reduce the number of times you need to go to the bathroom during the day. Other medications:

  • Iron supplements: These can help reduce symptoms of anemia caused by ulcerative colitis.
  • Pain medications: Your doctor may recommend that you take pain relievers like acetaminophen (Tylenol). Avoid medications like ibuprofen or sodium naproxen, however, which can can make symptoms of UC worse.

Symptoms may go away for a time, especially with the right treatment. This is referred to as remission.

However, symptoms may gradually come back or “flare-up.” You may have to try different combinations of medications or treatments to get ulcerative colitis back under control.

For severe cases: ulcerative colitis surgery

If your ulcerative colitis is severe and does not respond to medication, your doctor may recommend surgery. Surgery eliminates ulcerative colitis by removing part or all of your colon and rectum.

  • Hemicolectomy. Your surgeon removes the right or left side of your large intestine, developing on which part is affected by ulcerative colitis. They will then reconnect the remaining colon to the rest of the digestive tract.
  • Ileoanal anastomosis (J-pouch) surgery. Your surgeon removes all of your large intestine and rectum. Then, they create a pouch out of your small intestine and connect it to your anus. This allows you to pass stool like normal and control your bowel movements.
  • Permanent ileostomy. If your surgeon is not able to perform a J-pouch surgery, they will create an opening in your abdomen wall (an ileal stoma) and attach a plastic pouch. Stool will pass into this pouch, which must be worn at all times.

Ulcerative colitis: diet and management

After you have been diagnosed with ulcerative colitis, you might be asking what you should and shouldn’t eat to best take care of your body. Eating well is especially important with ulcerative colitis, since symptoms can lead to weight loss and malnutrition. Unfortunately, there are no hard-and-fast rules when it comes to UC and diet.

Your healthcare team may recommend that you go on an elimination diet. This is a temporary diet that involves avoiding, and then slowly reintroducing, certain foods to see what foods trigger your symptoms. Only follow this diet under our doctor’s supervision to make sure you are getting adequate nutrition.

Other tips you can try include:

  • Eating small meals throughout the day. Rather than eating 3 large meals, consider eating four to six smaller meals throughout the day.
  • Staying hydrated. Diarrhea can quickly dehydrate you. Drink lots of clear fluids, like water, tea, broth, and rehydration solutions.
  • Using simple cooking techniques. Try boiling, steaming, and poaching your foods. Avoid greasy or heavy cooking methods, as these can complicate digestion.
  • Keeping a food journal. Track what you eat and how it makes you feel. You can talk about these with your healthcare team. Keeping a food journal is also a good way for you to make sure you are eating enough throughout the day.
  • Consider talking to a registered dietician or nutritionist. These professionals can help you come up with a customized nutrition plan, recommend supplements, and help you navigate a new relationship with food.

Man sampling food from spoon

Diet and ulcerative colitis flare-ups

If you are dealing with a flare-up, you may not have an appetite or know what you can safely eat. Here are some general guidelines.

Avoid potential trigger foods:

  • Alcohol and caffeine.
  • High-fat foods.
  • Insoluble fiber, which is contained in foods like fruits with skins, raw green vegetables (broccoli, cauliflower, veggies with peels), whole nuts, and whole grains.
  • Lactose, a sugar that can be found in dairy products.
  • Spicy foods.
  • Sugary foods.
    • Non-absorbable sugars: Sorbitol, mannitol, and other sugar alcohols that can be found in low- or no-sugar products.

Try eating easily-digested foods:

  • Low-fiber fruits, like bananas, cantaloupe, honeydew melon, and cooked fruits.
  • Lean protein like fish, lean cuts of pork, white meat poultry, soy, and eggs.
  • Refined grains found in sourdough or white bread, potato or gluten-free bread, white pasta, white rice, and oatmeal.
  • Peeled, low fiber vegetables, like potatoes, cucumbers (without seeds), and squash.

If you are having a flare-up, be sure to talk to your healthcare team. They can help you come up with both a diet and a treatment plan.

Ulcerative colitis vs Crohn’s disease

Ulcerative colitis and Crohn’s disease are both inflammatory bowel diseases (IBDs). They can have similar symptoms, like abdominal pain, diarrhea, blood in stool, loss of appetite, and more.

However, ulcerative colitis only affects the large intestine. Meanwhile, Crohn’s disease can affect any part of the digestive tract, from the mouth to the anus. Additionally, UC only affects the inner lining of the large intestine, while Crohn’s disease can affect any layer. The best way to tell whether you have UC, Crohn’s disease, or something else is to talk to your doctor. They can do medical imaging procedures to see which parts of your digestive tract are affected.

Ulcerative colitis vs colitis

Colitis is a general term for inflammation of the large intestine. This can be the result of an infection with a virus or bacteria. Ulcerative colitis is a severe and life-long form of colitis.

Ulcerative colitis vs IBS

Irritable bowel syndrome (IBS) is a group of symptoms that often occur together, usually changes in bowel habits, uncomfortable bloating, and abdominal pain. Unlike UC, IBS does not cause any inflammation or other visible signs of disease. Additionally, UC can raise your risk for colon cancer, but IBS cannot.

Ulcerative colitis vs diverticulitis

Diverticulitis occurs when weak spots in the intestinal wall bulge outwards under pressure and become infected. This is different from ulcerative colitis, which is an autoimmune condition that causes inflammation. Both can lead to cramping, abdominal pain, and blood in stool. However, diverticulitis is more likely to cause sudden-onset diarrhea or constipation.

The only way to know for sure which condition you have is to talk to your doctor.