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What is ulcerative colitis?
Ulcerative colitis is a disease that causes inflammation and sores (ulcers) in the lining of the large intestine (colon). It usually affects the lower section (sigmoid colon) and the rectum. But it can affect the entire colon. In general, the more of the colon that's affected, the worse the symptoms will be.
The disease can affect people of any age. But most people who have it are diagnosed before the age of 30.
What causes ulcerative colitis?
Experts aren't sure what causes it. They think it might be caused by the immune system overreacting to normal bacteria in the digestive tract. Or other kinds of bacteria and viruses may cause it.
You are more likely to get ulcerative colitis if other people in your family have it.
What are the symptoms?
The main symptoms are:
- Belly pain or cramps.
- Bleeding from the rectum.
Some people also may have a fever, may not feel hungry, and may lose weight. In severe cases, people may have diarrhea 10 to 20 times a day.
The disease can also cause other problems, such as joint pain, eye problems, or liver disease.
In most people, the symptoms come and go. Some people go for months or years without symptoms (remission). Then they will have a flare-up. About 5 to 10 out of 100 people with ulcerative colitis have symptoms all the time.footnote 1
How is ulcerative colitis diagnosed?
Doctors ask about the symptoms, do a physical exam, and do a number of tests. Testing can help the doctor rule out other problems that can cause similar symptoms, such as Crohn's disease, irritable bowel syndrome, and diverticulitis.
Tests that may be done include:
- A colonoscopy. In this test, a doctor uses a thin, lighted tool to look at the inside of your entire colon. At the same time, the doctor may take a sample (biopsy) of the lining of the colon.
- Blood tests, which look for infection or inflammation.
- Stool sample testing to look for blood, infection, and white blood cells.
How is it treated?
Ulcerative colitis affects everyone differently. Your doctor will help you find treatments that reduce your symptoms and help you avoid new flare-ups.
If your symptoms are mild, you may only need to use over-the-counter medicines for diarrhea (such as Imodium). Talk to your doctor before you take these medicines.
Many people need prescription medicines, such as aminosalicylates, steroid medicines, or other medicines that reduce the body's immune response. These medicines can stop or reduce symptoms and prevent flare-ups.
Some people find that certain foods make their symptoms worse. If this happens to you, it makes sense to not eat those foods. But be sure to eat a healthy, varied diet to keep your weight up and to stay strong.
If you have severe symptoms and medicines don't help, you may need surgery to remove your colon. Removing the colon cures ulcerative colitis. It also prevents colon cancer.
How will ulcerative colitis affect your life?
People who have ulcerative colitis for 8 years or longer also have a greater chance of getting colon cancer. The longer you have had ulcerative colitis, the greater your risk.footnote 2 Talk to your doctor about your need for cancer screening. These tests help find cancer early, when it is easier to treat.footnote 3
Ulcerative colitis can be hard to live with. During a flare-up, it may seem like you are always running to the bathroom. This can be embarrassing. And it can take a toll on how you feel about yourself. Not knowing when the disease will strike next can be stressful.
If you are having a hard time, seek support from family, friends, or a counselor. Or look for a support group. It can be a big help to talk to others who are coping with this disease.
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The cause of ulcerative colitis is unknown. It may be caused by an abnormal response by the body's immune system to normal intestinal bacteria. Disease-causing bacteria and viruses also may play a role.
Ulcerative colitis can run in families.
The symptoms of ulcerative colitis may include:
- Diarrhea or rectal urgency. Some people may have diarrhea 10 to 20 times a day. The urge to go to the bathroom may wake you up at night.
- Rectal bleeding. The disease usually causes bloody diarrhea and mucus. You also may have rectal pain and an urgent need to empty your bowels.
- Belly pain, often described as cramping. Your belly may be sore when touched.
- Constipation. This symptom may develop depending on what part of the colon is affected. Constipation is much less common than diarrhea.
- Loss of appetite.
- Fever. In severe cases, fever or other symptoms that affect the entire body may develop.
- Weight loss. Ongoing symptoms, such as diarrhea, can lead to weight loss.
- Too few red blood cells (anemia). Some people get anemia because of low iron levels caused by bloody stools or intestinal inflammation.
Ulcerative colitis may be mild, moderate, or severe.
Most people have periods of remission (when the condition is not active) that may last up to several years. These periods are interrupted by occasional flare-ups of moderate symptoms. About 5 to 10 out of 100 people who have ulcerative colitis have symptoms all the time.footnote 1
Children may have the same symptoms that adults have. Also, children with the disease may grow more slowly than normal and go through puberty later than expected.
Complications and long-term effects
Problems from ulcerative colitis can include:
- Narrowed areas of the intestine (strictures). They can make it hard to pass stools.
- Increased risk of cancer of the colon and rectum. This risk is higher than average if you have had ulcerative colitis for 8 years or longer.
- Complications outside the digestive tract. These include joint pain, skin problems, and eye problems.
- The colon swelling to many times its normal size. This is called toxic megacolon. It's rare, but it needs treatment right away.
- Other rare complications, such as scarring of the bile ducts and the pancreas.
- Inflammatory bowel disease, which also increases the risk of melanoma, a serious type of skin cancer. Your doctor may recommend regular screening by a dermatologist.footnote 4
Irritable bowel syndrome
Some people who have ulcerative colitis also have irritable bowel syndrome (IBS). It isn't as serious as ulcerative colitis. IBS causes belly pain along with diarrhea or constipation.
Pregnancy and ulcerative colitis
Most women with ulcerative colitis can have a normal pregnancy and deliver a healthy baby. Symptoms may be worse during the first 3 months of pregnancy. Some medicines to treat the disease can be used during pregnancy.
What Increases Your Risk
You have an increased risk of ulcerative colitis if you:
- Have a family history of the disease. Your risk increases if an immediate family member such as a parent, brother, or sister has the disease.
- Are of Ashkenazi Jewish ancestry. To learn more about genetic diseases in this group, see the topic Ashkenazi Jewish Genetic Panel (AJGP).
When should you call your doctor?
Call a doctor immediately if you have been diagnosed with ulcerative colitis and you have:
- Fever over 101°F (38.3°C) or shaking chills.
- Lightheadedness, passing out, or rapid heart rate.
- Stools that are almost always bloody.
- Severe dehydration, such as passing little or no urine for 12 or more hours.
- Severe belly pain with or without bloating.
- Pus draining from the area around the anus or pain and swelling in the anal area.
- Repeated vomiting.
- Not passing any stools or gas.
If you have any of these symptoms and you have been diagnosed with ulcerative colitis, your disease may have become significantly worse. Some of these symptoms also may be signs of toxic megacolon. This is a condition in which the colon swells to many times its normal size. Toxic megacolon requires emergency treatment. Left untreated, it can cause the colon to leak or rupture. This can be fatal.
People with ulcerative colitis usually know their normal pattern of symptoms. Call your doctor if there is a change in your usual symptoms or if:
- Your symptoms become significantly worse than usual.
- You have persistent diarrhea for more than 2 weeks.
- You have lost weight.
Watchful waiting is not appropriate when you have any of the above symptoms. If your symptoms are caused by ulcerative colitis, delaying the diagnosis and treatment may make the disease worse. And it can increase your risk of other problems.
Even when the disease is in remission, your doctor will want to see you regularly to check for complications. Some of these problems can be hard to detect. It is always a good idea to call your doctor's office for advice.
Who to see
Health professionals who can diagnose ulcerative colitis include:
For the treatment and management of ulcerative colitis, you are likely to be referred to a gastroenterologist.
To be evaluated for surgery, you may be referred to a:
Exams and Tests
Ulcerative colitis can be fairly easy to diagnose, because it normally affects only the colon and rectum. And it usually causes an obvious change in daily bowel habits, such as frequent stools with blood or mucus.
Your doctor may:
- Conduct a medical history and physical exam.
- Look inside your colon and rectum with flexible sigmoidoscopy or colonoscopy. The doctor uses a small, lighted scope to look inside the intestine. In general, colonoscopy is preferred, because it can be used to see the entire colon. Both procedures can be used to take a sample (biopsy) of intestinal tissue. Biopsies are collected during sigmoidoscopy or colonoscopy to see if you have ulcerative colitis. A biopsy also may be done to look for cancer.
Other exams and tests that may be used include:
- Abdominal X-ray. It provides a picture of the inside of the abdomen.
- Barium enema. It allows the doctor to examine the colon.
- Computed tomography (CT) scan or MRI. These provide detailed pictures of the inside of the body.
- Stool analysis (including a test for blood in the stool). This test looks for blood, signs of bacterial infection, parasites, or white blood cells.
- Blood and urine tests to check for anemia, inflammation, or malnutrition. An erythrocyte sedimentation rate (ESR, or sed rate) or a C-reactive protein (CRP) blood test may be done to look for infection or inflammation.
Some people have symptoms of inflammatory bowel disease (IBD), but neither Crohn's disease nor ulcerative colitis can be diagnosed. These people have a form of IBD called indeterminate colitis. Doctors believe that it has features of both Crohn's disease and ulcerative colitis.
Treatment for ulcerative colitis depends mainly on how bad the disease is. It usually includes medicines and changes in diet. A few people have symptoms that are long-lasting and severe, in some cases requiring more medicines or surgery.
You may need to treat other problems, such as anemia or infection. Treatment in children and teens may include taking nutritional supplements to restore normal growth and sexual development.
If you don't have any symptoms or if your disease is not active (in remission), you may not need treatment. But your doctor may suggest that you take medicines to keep the disease in remission.
If you do have symptoms, they usually can be managed with medicines to put the disease in remission. It often is easier to keep the disease in remission than to treat a flare-up.
Mild symptoms may respond to:
- Antidiarrheal medicines.
- Enemas or suppositories that contain medicine.
- Aminosalicylates. These medicines relieve inflammation in the intestines. They are also taken to keep the disease in remission.
- Steroid medicines. Your doctor may prescribe these for a few weeks to control active disease.
- Changes in your diet.
Moderate to severe symptoms
These symptoms usually require steroid medicines to control inflammation. The dose you need may be higher than that needed to treat mild symptoms. When inflammation goes away, you will take aminosalicylates to keep the condition in remission.
Severe symptoms also may be treated with:
- Immunomodulator medicines or cyclosporine. These strong medicines suppress the immune system to prevent inflammation.
- Biologics. They block the inflammatory response in your body and help reduce the inflammation in your colon. They may be used if other medicines don't control your symptoms.
- Surgery. Removal of the large intestine (colon) cures ulcerative colitis. But surgery may not cure all of the problems that the condition can cause in other areas of the body, such as the liver and joints. Surgery also is done to treat problems such as bleeding or toxic megacolon.
Treatment in the hospital
You may need treatment in the hospital if you have severe ulcerative colitis with symptoms outside the digestive tract, such as fever or anemia. Treatment includes replacing fluids and electrolytes lost because of severe diarrhea.
Your doctor will want to see you for a follow-up visit about every 6 months while your condition is stable. You'll need to see the doctor more often if you are having problems. Many people are so familiar with their condition that they can handle minor flare-ups on their own. In some cases, you may be able to talk with your doctor on the phone for minor problems.
If you are taking medicines, you may need to have lab tests regularly.
You cannot prevent ulcerative colitis, because the cause is unknown.
You can take steps at home to reduce symptoms of ulcerative colitis.
Medicines to treat your condition: If you have only mild symptoms, antidiarrheal medicines may help. For disease in the rectum alone, you can try medicines given in a suppository, enema, or foam.
Medicines to avoid: In general, doctors recommend that you don't use nonsteroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen or naproxen). These medicines may cause flare-ups. But some people may be more likely to have flare-ups from NSAIDs than other people. Talk to your doctor about whether to avoid these medicines.
A change in your diet may help reduce symptoms. Keep a food diary to find out which foods make your symptoms worse. During a flare-up, avoid or reduce these foods. But instead of cutting out a whole group of high-nutrient foods, try replacing them with healthy choices.
If you have had or are planning to have surgery that will create an ostomy, you may feel self-conscious or embarrassed. After a period of adjustment, most people are able to resume all of their usual activities. In fact, you may feel better than before surgery because you may no longer have painful symptoms. Support groups are available for people with ostomies.
Ulcerative colitis can affect every aspect of your life. You may want to seek counseling or social support from family, friends, or clergy.
Helping a child
Children tend to have a harder time than adults in managing the disease. So your support is very important.
Children may feel self-conscious if they don't grow as fast as other children their age. Encourage your child to take medicine as prescribed. Offer your help with the treatment so that your child can feel better, start growing again, and lead a more normal life.
Medicines usually are the main treatment for ulcerative colitis. They control or prevent inflammation in the intestines and help to:
- Relieve symptoms.
- Promote healing of damaged tissues.
- Put the disease into remission and keep it from flaring up again.
- Postpone or prevent the need for surgery.
The choice of medicine usually depends on how bad the disease is, the part of the colon affected, and any complications you may have.
- Treatment of mild to moderate disease often begins with aminosalicylates. These are a type of disease-modifying antirheumatic drug (DMARD). They relieve inflammation in the intestines and help the disease go into remission. They may also keep the disease from becoming active again.
- Steroid medicines may be added if symptoms continue. They relieve inflammation in the intestines.
- For severe cases, you may have stronger treatment with another DMARD or intravenous (IV) corticosteroids.
If you're pregnant or breastfeeding
If you are pregnant or are planning to become pregnant, talk to your doctor about which medicines might be okay for you to use. Sometimes severe ulcerative colitis can harm your baby more than the medicines you take to keep it under control. Some medicines, though, should never be taken when you are pregnant. Your doctor can tell you which medicines are okay while you are pregnant or breastfeeding.
Ulcerative colitis affects only the large intestine. So surgery that removes the entire large intestine can cure the disease. Some people who have the disease in the entire colon eventually need surgery to remove the colon. Surgery also can often cure the rare problems that the disease causes outside of the colon, such as skin and eye problems. But it may not cure liver problems and some joint problems.
People may need surgery for ulcerative colitis in several situations, such as when other treatment fails to manage symptoms, when holes form in the large intestine, or if dysplasia is found during colonoscopy or biopsy.
Removal of the colon to cure ulcerative colitis involves one of these surgeries:
- In ileoanal anastomosis, the surgeon removes some or all of the large intestine (colon) and the diseased lining of the rectum. Then the end of the small intestine (the ileum) is connected to the anal canal. This allows you to have bowel movements without an ostomy.
- In proctocolectomy and ileostomy, the large intestine and rectum are removed, leaving the lower end of the small intestine (the ileum). The surgeon sews the anus closed and makes a small opening called a stoma in the skin of the lower belly. The ileum is connected to the stoma, creating an opening to the outside of the body.
What to think about
Ileoanal anastomosis is done most often. Proctocolectomy with ileostomy is preferred for people who cannot tolerate anesthesia for a long period of time because of illness or age.
In most cases, surgery can be scheduled at your convenience. Emergency surgery usually isn't needed unless an acute attack causes toxic megacolon, severe uncontrolled bleeding, or a rupture in the intestine. The risk of problems after surgery can be high if surgery is done during a severe or rapidly worsening attack or if emergency surgery is needed.
Even though there is little scientific proof that it works, many people who have ulcerative colitis consider nontraditional or complementary medicine in addition to prescription medicines. They may turn to these other treatments because there is no cure other than removal of the colon.
Other treatment choices
- Special diets or nutritional supplements, such as probiotics.
- Fatty acids found in oily fish, such as salmon and tuna.
- Vitamin supplements, such as vitamins D and B12.
- Herbs, such as aloe and ginseng.
- Stimulation of the feet, hands, and ears to try to affect parts of the body (reflexology).
- Chiropractic therapy.
Probiotics and fatty acids are the most promising complementary therapies being studied for ulcerative colitis. But there is still not much known about their value. As with any treatment, talk with your doctor before using any of these treatments.
Several studies have shown that the nicotine patch may help treat active ulcerative colitis. It is not yet known how long the benefits of the nicotine patch last or if the patch can help prevent flare-ups. If the patch works, it most likely benefits people whose symptoms began or became worse after quitting smoking.
But because of the addictive power and other harmful effects of nicotine, most doctors still prefer to use traditional medicines to treat ulcerative colitis before trying the nicotine patch.
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- American Gastroenterological Association (2010). AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology, 138(2): 738–745. Available online: http://www.gastro.org/practice/medical-position-statements.
- Kornbluth A, Sachar DB (2010). Ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee. American Journal of Gastroenterology, 105(3): 501–523. Available online: http://www.nature.com/ajg/journal/v105/n3/full/ajg2009727a.html.
- Singh S, et al. (2014). Inflammatory bowel disease is associated with an increased risk of melanoma: A systematic review and meta-analysis. Clinical Gastroenterology Hepatology, 12(2): 210–218. DOI: 10.1016/j.cgh.2013.04.033. Accessed March 25, 2015.
Current as of: April 15, 2020
Author: Healthwise Staff
E. Gregory Thompson MD - Internal Medicine
Adam Husney MD - Family Medicine
Peter J. Kahrilas MD - Gastroenterology
Current as of: April 15, 2020
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