Ulcerative colitis

Ulcerative colitis is a chronic inflammatory bowel disease that is believed to involve an immune system reaction. This causes inflammation and ulceration (pitting or erosion) of the inner layer of the large intestine’s lining, also called the mucosa.

The large intestine is the lower part of the digestive tract, coming after the stomach and small intestine. It includes the colon, rectum, and anus. Inflammation often starts in the rectum and lower colon, but ulcerative colitis can affect the entire colon. Symptoms may include bouts of bloody diarrhea, abdominal cramps, and fever.

Ordinarily, the colon absorbs salt and excess water from waste material moving through the GI tract after food has been digested. Bacteria in the colon help break down this waste, helping it move through the colon, rectum, and anus.

When ulcers (sores) form on the intestinal mucosa due to ulcerative colitis, however, the colon has a harder time absorbing water, resulting in loose stools and persistent diarrhea.

How common is ulcerative colitis?

The rates of both ulcerative colitis and Crohn’s disease are highest in North America and Northern Europe. For every 100,000 people, 156 to 291 people around the world have UC. Each year, another 9 to 20 people out of 100,00 are diagnosed. In the U.S., around 600,000 people have UC.

What's the difference between ulcerative colitis and Crohn's disease?

Because both these IBD types can cause inflammation in the GI tract and have overlapping symptoms, it’s easy to confuse them. Three key differences between ulcerative colitis and Crohn’s disease involve the areas affected.

Ulcerative colitis affects the colon and rectum, whereas Crohn’s disease can affect all areas of the GI tract, from the mouth to the anus.

The damage to the large intestine that occurs with ulcerative colitis is continuous, typically starting in the rectum and spreading through the colon. In contrast, Crohn’s disease leaves patchy areas of damaged tissue throughout the GI tract, which are mixed in with healthy, undamaged tissue.

UC inflames the innermost layer of the wall of the large intestine, whereas Crohn’s disease can penetrate multiple layers of the GI tract, including the connective tissue that supports and surrounds it.

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Ulcerative colitis most often affects the large intestine, although other areas may be affected. Common ulcerative colitis symptoms include:

• Abdominal pain and cramping
• Bloody stool
• Bowel movement (BM) urgency
• Diarrhea or constipation
• Mucus or pus in the stool
• Rectal bleeding
• Tenesmus (urgent or frequent need to have a BM, despite the bowels being empty)

Some ulcerative colitis symptoms are more likely to occur when the disease is severe or affects more of the large intestine. These might include symptoms such as:

• Fatigue
• Fever
• Nausea
• Vomiting
• Weight loss (sometimes significant)

Ulcerative colitis symptom flare-ups

Ulcerative colitis alternates between symptom flare-ups and remission (periods when symptoms aren’t present). Although the condition is chronic, symptoms can come and go. Weeks, months, or years can pass between flare-ups, as the condition doesn’t follow a predictable pattern.

In most cases, flare-ups start gradually, producing symptoms such as an urgent need to have a BM, mild cramps in the lower abdomen, and stool that’s bloody and contains mucus. But flare-ups can sometimes come on suddenly and severely, leading to symptoms such as intense abdominal pain, explosive diarrhea (which may contain blood, mucus, and pus), high fever, and peritonitis (inflammation of the abdominal cavity lining). Severe ulcerative colitis flare-ups can cause profound illness.

Ulcerative colitis staging

Ulcerative colitis staging (grading) is mainly based on rectal bleeding, as follows:

• Mild ulcerative colitis: Less than four episodes of rectal bleeding per day
• Moderate ulcerative colitis: More than four episodes of rectal bleeding per day
• Severe ulcerative colitis: More than four episodes of rectal bleeding per day along with systemic symptoms (those that affect the entire body, such as fever) and hypoalbuminemia (low levels of the albumin protein in the blood)

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UC is thought to be an autoimmune disease in which the immune system mistakenly attacks healthy intestinal cells and tissues. Although the exact cause of ulcerative colitis remains unknown, some health experts believe one or more of the following factors contribute to the development of the disease:

Ulcerative colitis may be due to genetic mutations

Scientists have identified hundreds of gene mutations (changes or variants) that raise the risk for ulcerative colitis. Many of these genes usually help control the immune system. Mutations in these genes can change the way the immune system responds to bacteria in the gut, which can lead to chronic inflammation.

Ulcerative colitis may be due to an overactive immune response

Ordinarily, the gut barrier facilitates the transportation of nutrients into the gut while keeping harmful agents out. If cracks form in this layer of protection, the immune system responds by unleashing white blood cells (WBCs) to attack certain bacteria or viruses in the gut, resulting in inflammation.

Research also suggests that ulcerative colitis might be triggered by the body’s overactive immune response to a virus or bacterial infection. The inflammatory response by the immune system is usually temporary and tends to go away once the body recovers from illness.

In people with ulcerative colitis, however, inflammation may persist long after the body heals from an illness or infection. In these cases, the immune system may keep sending WBCs to the lining of the large intestine, leading to chronic inflammation.

Ulcerative colitis may be due to an imbalance in gut flora

Also referred to as gut microbiota, gut flora consists of the billions of tiny organisms (called microbes, including bacteria, viruses, and fungi) that live within the digestive tract. For the most part, these microbes are symbiotic, meaning both the body and the microbes benefit from their presence in the gut. Helpful microbes provide immune support and aid digestion, among other benefits.

A smaller number of gut microbes, however, are pathogenic, meaning they can cause disease. People with ulcerative colitis tend to have fewer symbiotic microbes in the gut compared to people without the disease. This can lead to dysbiosis, an imbalance in gut flora that can increase susceptibility to diseases such as UC.

Ulcerative colitis may be due to environmental triggers

A range of environmental factors have been linked to the development of ulcerative colitis. These include exposure to bacteria (such as those influenced by diet), viruses, stress, and long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen.

Ulcerative colitis seems to be more common in people who don’t smoke, and it appears that some people develop the disease after quitting smoking. That said, smoking can still cause other serious health issues, and continuing or starting to smoke in the hopes of lowering the risk for ulcerative colitis isn’t advisable.

It’s important to note that neither these environmental factors nor any other factors have been definitively shown to cause (or prevent) ulcerative colitis.

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Certain risk factors may raise the risk for ulcerative colitis. These include:

Age: Most people first develop ulcerative colitis between 15 and 30 years old, although some may not develop the disease until they’re between the ages of 50 and 70.

Family history: Around 8 to 14 percent of people with ulcerative colitis have a family history of the disease. In fact, people with a first-degree blood relative (such as a sibling or parent) with UC are four times more likely to develop the disease themselves.

Race/ethnicity: Ulcerative colitis is more common in white people compared to other races. In particular, Jewish people of Ashkenazi descent (from central and eastern Europe) have a higher risk of developing the disease compared to other ethnicities.

Sex assigned at birth: Some studies show that people assigned male at birth (AMAB) are slightly more likely to develop ulcerative colitis compared to people assigned female at birth (AFAB), but most studies show that people AMAB and AFAB are equally likely to be affected. Older adults AMAB, however, are more likely to be diagnosed with UC than older adults AFAB.

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Ulcerative colitis is often classified based on its location. UC subtypes include:

Ulcerative proctitis

Inflammation is limited to the rectum with ulcerative proctitis. It usually affects fewer than six inches of the rectum and is often considered less severe than other types of UC. Still, the condition can cause ulcerative colitis symptoms such as rectal bleeding and pain along with an urgent need to defecate (have a BM), which may include both diarrhea and constipation.

Left-sided colitis

Sometimes referred to as distal or limited colitis, left-sided colitis causes continuous inflammation in the large intestine that starts at the rectum and extends as far into the colon as the splenic flexure, a bend in the colon close to the spleen. The condition can cause ulcerative colitis symptoms such as bloody diarrhea, loss of appetite, weight loss, and pain on the left side of the abdomen.

Proctosigmoiditis

Left-sided colitis also includes proctosigmoiditis, which causes inflammation in the rectum and lower segment of the colon located just above the rectum called the sigmoid or descending colon. It can cause ulcerative colitis symptoms such as bloody diarrhea and left-sided abdominal pain and cramping.

Proctosigmoiditis can also cause tenesmus. This can lead to abdominal pain, cramping, and an urgent need to have a BM, despite the bowels being empty.

Pancolitis

Also referred to as extensive or total colitis, pancolitis causes inflammation across the entire colon. It can cause ulcerative colitis symptoms such as severe abdominal pain and cramping; bloody, sometimes severe and persistent diarrhea; fatigue; and substantial weight loss. Some with this extensive type may also experience fevers.

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Over time, ulcerative colitis can cause complications. For instance, blood loss due to UC can cause the amount of red blood cells and iron in the blood to drop too low. Heavy or persistent bleeding can result in various types of anemia such as iron-deficiency anemia, which can produce symptoms such as fatigue and shortness of breath.

Malnutrition from ulcerative colitis

People with ulcerative colitis may experience malnutrition due to malabsorption (inability of the intestines to absorb nutrients). This can be a result of bleeding or diarrhea or a side effect of certain ulcerative colitis treatments such as medications or surgery. Compared to UC, Crohn’s disease tends to produce more malnutrition and malabsorption issues, but these complications may also occur with UC.

Growth issues from ulcerative colitis

Children with ulcerative colitis may also experience issues with growth and development. For example, they may be underweight and have trouble gaining weight. They may also be shorter in stature and grow slowly. Puberty may also be delayed.

Colon cancer and ulcerative colitis

People with long-standing ulcerative colitis (lasting seven to eight years or more) that involves a third or more of the colon are at higher risk for colorectal cancer (also referred to as colon cancer). In people with pancolitis, cancer may start around seven or more years after UC symptoms first manifest, with roughly 0.5 to 1 percent of people with this severe form of UC developing colon cancer every year after this point.

After 20 years of living with UC, around 7 to 10 percent of people develop colon cancer. The risk of colon cancer may be as high as 30 percent for a person who has lived with ulcerative colitis for 35 years, compared to someone without UC.

Life-threatening complications from ulcerative colitis

Other serious and potentially life-threatening complications of UC that require emergency treatment at a hospital include:

Ileus: Ulcerative colitis can damage the nerves and muscles of the bowel, which may result in an ileus. This is a condition that halts or greatly slows down peristalsis, the series of wave-like muscle contractions that move fluid, food, and gas through the digestive tract. In addition to abdominal distention (enlarged and swollen abdomen due to trapped gas or fluid, digestive content, or tissue buildup), an ileus can cause symptoms such as severe abdominal pain and cramping, nausea, vomiting, and the inability to have a bowel movement or to pass gas.

Perforation: Ulcerative colitis can lead to tears or ruptures of the wall of the large intestine.

Fulminant ulcerative colitis (also called toxic colitis): Ulcerative colitis symptoms can quickly grow severe and become fulminant ulcerative colitis. This condition can cause symptoms such as more than 10 bloody BMs per day, high fever, rapid heart rate, severe anemia, perforation of the colon, massive bleeding, widespread infection, and ileus.

Toxic megacolon: This occurs when fulminant ulcerative colitis grows worse, spreading to the deep tissue layers of the large intestine. Toxic megacolon occurs when the colon loses muscle tone. Within hours or days, extreme dilatation (inflammation and distention) and paralysis of the colon sets in. An ileus then occurs, as the large intestine can no longer function properly.

Toxic megacolon is the most common cause of death in people with ulcerative colitis. It can cause symptoms such as:

• Dehydration
• High fever
• Perforation (rupture or tearing) of the large intestine
• Peritonitis (inflammation of the abdominal cavity lining)
• Rapid heart rate
• Severe abdominal pain
• Weakness

Extraintestinal manifestations of ulcerative colitis

In some cases, ulcerative colitis can cause issues outside of the GI tract known as extraintestinal manifestations (EIMs). These can lead to significant complications that can adversely impact quality of life.

EIMs associated with ulcerative colitis can affect the:

Bones: Ulcerative colitis and corticosteroids used to treat the disease can lead to low bone mass, which raises the risk for conditions that cause weak and brittle bones such as osteoporosis and a milder form of this bone disease known as osteopenia.

Eyes: UC complications may include inflammation of the whites of the eyes (known as episcleritis) and the inside of the eye (referred to as uveitis).

Joints: Ulcerative colitis can lead to arthritis (joint pain and swelling), as well as a condition that causes inflammation of the pelvic joints called sacroiliitis.

Skin: UC complications can include a condition called erythema nodosum, which causes inflamed skin nodules (small lumps or growths that occur just underneath the skin). Pyoderma gangrenosum may also occur. This condition causes purple sores to form on the skin.

Spine: UC complications may include a condition known as ankylosing spondylitis, which causes inflammation in the spine.

Liver: People with ulcerative colitis commonly experience minor issues that affect liver health, with about 1 to 3 percent experiencing mild to severe liver disease such as hepatitis (inflammation of the liver) and cirrhosis (a condition that causes liver damage and scarring).

Bile ducts: Primary sclerosing cholangitis may also occur. This condition causes inflammation, narrowing, and eventual closing of the bile ducts, which are thin tubes that channel an important chemical from the liver to the small intestine to help with the digestive process.

Bile duct inflammation may occur years before any ulcerative colitis symptoms that affect the large intestine. The condition greatly increases the risk of bile duct cancer and possibly colon cancer.

Emotional and mental health complications of ulcerative colitis

People with ulcerative colitis must also navigate many emotional challenges. Although research hasn’t shown that stress and other mental health factors cause IBD, ulcerative colitis can greatly impact people’s mental and emotional health.

The condition can wear down their self-esteem, as contending with the disease for many years can produce feelings of frustration, humiliation, and loss of control. Many also feel socially stigmatized because of their condition, which can raise the risk for or worsen mood disorders such as anxiety and depression.

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To help diagnose ulcerative colitis, your healthcare provider (HCP) will discuss your symptoms and personal and family medical history. They might ask about lifestyle factors, such as whether you currently or have ever smoked tobacco. And they’ll ask about any medicines, herbs, or supplements you take.

Next, your HCP will perform a physical exam. Along with checking your blood pressure, heart rate, and temperature, they may also:

• Look at your abdomen to see if it’s distended (swollen and bloated)
• Listen for bowel sounds with a stethoscope
• Feel and press your abdomen to see if you have pain, tenderness, or masses in specific areas
• If necessary, perform a digital rectal exam with a gloved and lubricated finger to examine your rectum and collect and check your stool for blood

Your HCP may also order certain tests to determine whether ulcerative colitis is the cause of your symptoms. If UC is determined to be the cause, these tests can also show to what extent the large intestine has been affected.

Various tests can also help rule out other health conditions that produce GI symptoms similar to ulcerative colitis. In addition to Crohn’s disease and colorectal cancer, these include conditions such as:

• Appendicitis: Inflammation and infection of the appendix, a tiny organ that projects from the large intestine
• Celiac disease (also called celiac sprue): An immune reaction caused by eating gluten, a protein found in grains including wheat, rye, and barley
• Clostridioides difficile (C. diff, formerly called Clostridium difficile): Bacteria that causes inflammation and infection of the colon
• Gastroenteritis (“stomach flu”): Inflammation of the lining of the stomach and small and large intestines due to an infection, typically bacterial or viral
• Irritable bowel syndrome (IBS): A condition that affects how the brain and gut interact that causes abdominal pain and changes in bowel habits without visible signs of damage to the digestive tract

Certain tests can also help confirm or rule out other types of colitis (inflammation of the colon) such as:

Bacterial colitis: Inflammation in the colon caused by bacteria such as Escherichia coli, more commonly known as E​. coli

Ischemic colitis: Inflammation and injury to the colon caused by ischemia (reduced blood flow to the area)

Microscopic colitis: Inflammation of the colon that can only be seen by examining tissue under a microscope. This includes:

• Lymphocytic colitis: Inflammation occurs when the lining of the colon contains higher levels of white blood cells (WBCs) called lymphocytes.
• Collagenous colitis: Inflammation occurs when the layer of collagen under the lining of the colon is thicker than usual, and sometimes contains more WBCs than normal. (Collagen is a protein that is the building block of connective tissue in the body.)

Endoscopy to diagnose or rule out ulcerative colitis

HCPs may suspect ulcerative colitis when people have symptoms such as recurring bloody diarrhea, abdominal cramps, and a compelling urge to defecate along with associated complications and a history of similar flare-ups. An HCP may recommend an endoscopic test to confirm the diagnosis. (An endoscope is a thin, flexible tube equipped with a light and camera used to examine the esophagus, stomach, and small intestine.)

Flexible sigmoidoscopy to diagnose ulcerative colitis

This involves insertion of an endoscope known as a sigmoidoscope into the rectum and lower part of the colon (called the sigmoid or descending colon) to observe and assess the severity of inflammation in these areas. It may also entail taking samples of stool or mucus for testing and removing small samples of affected tissue for further assessment under a microscope, a procedure known as a biopsy.

In people with ulcerative colitis, these tissue samples usually show chronic inflammation. Even during remission periods, there are usually abnormalities of the large intestine that can be seen with the sigmoidoscope in people with UC.

Colonoscopy to diagnose ulcerative colitis

The entire length of the colon is examined with a colonoscope during this procedure. This scope can reach deeper into the colon when inflammation extends beyond the reach of a sigmoidoscope.

Other types of endoscopy for ulcerative colitis

Other endoscopic tests might include:

Capsule endoscopy (CE): This noninvasive procedure involves swallowing a capsule equipped with a tiny camera that takes and transmits pictures of the intestines. It’s used more often as a tool for diagnosing Crohn’s disease and may be ordered to rule out this IBD type as the cause of symptoms. A specific type of CE called colon capsule endoscopy can help diagnose and monitor ulcerative colitis, especially if a biopsy isn’t required.

Chromoendoscopy: During an endoscopic procedure such as a colonoscopy, the HCP performing the procedure may opt to spray a blue liquid dye into the colon to detect and highlight minor changes in the lining of the large intestine.

Imaging scans for ulcerative colitis

These might include one or more of the following:

Barium X-ray: After a contrast dye is given by enema (called a barium enema), an X-ray of the abdomen is taken to view the lining of the large intestine. This may help pinpoint the extent and severity of ulcerative colitis. The test isn’t done when the disease is active (such as during a flare-up) due to the risk of causing a perforation or tear in the intestine.

Although barium X-rays may still be done to evaluate digestive issues, the test has been mostly replaced by endoscopy and more advanced imaging studies such as computed tomography (CT) enterography, CT colonography, and magnetic resonance imaging (MRI) enterography, due to the superior image quality produced by these tests.

CT or CT enterography: CT scans of the GI tract may show an obstruction or stricture (inflammation and narrowing) of the small or large intestine. But because regular CTs may not clearly depict the lining of the intestines, a variation of this imaging test called CT enterography may be ordered to provide a clearer picture of the intestinal lining. It involves using barium contrast to widen the intestine for better viewing.

CT colonography: This CT scan generates two-dimensional (2D) and three-dimensional (3D) images of the rectum and colon. It also involves using contrast dye and inflating the colon with gas from a tube inserted into the rectum to provide sharper details of the large intestine.

MRI or MRI enterography: MRI scans can provide 2D and 3D images of the lining of the intestines, which may show tears, ulcers, inflammation, irritation, or bleeding. Like CT enterography, MRI enterography involves the use of contrast to provide more detailed images.

Lab tests to support the diagnosis or rule out ulcerative colitis

Although lab tests can’t confirm an ulcerative colitis diagnosis on their own, some may be ordered to rule out conditions that cause similar symptoms or to look for telltale signs of the disease and associated complications. These include lab tests such as a/an:

Albumin test: This test measures the level of a protein produced by the liver called albumin. Albumin levels may be lower in people with ulcerative colitis due to malnutrition and malabsorption.

Antibody and antigen testing: Around 60 to 70 percent of people with ulcerative colitis test positive for perinuclear antineutrophil cytoplasmic antibodies (P-ANCA). Anti-saccharomyces cerevisiae antibodies (ASCA) are also found in people with Crohn’s disease and ulcerative colitis.

But because ASCA is more commonly found in people with Crohn’s, testing for both P-ANCA and ASCA may help distinguish between these IBD types. Testing for carcinoembryonic antigen (CEA) may also help with diagnosing ulcerative colitis, as higher CEA levels may occur during UC flare-ups. A CEA test may also be used to help diagnose colon cancer.

Complete blood count (CBC): A low red blood cell (RBC) count may be due to anemia, while a high WBC count may be a general sign of inflammation or infection.

C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): These blood tests check for elevated CRP and ESR levels, which may point to inflammation in the body.

Electrolyte panel: Also called a serum electrolyte test, this blood test can measure and monitor the levels of the body’s main electrolytes (electrically charged minerals) such as sodium, chloride, potassium, and bicarbonate. Diarrhea can deplete these electrolytes.

Fecal calprotectin or lactoferrin test: Calprotectin is a protein made by a type of WBC called a neutrophil. Higher levels in the stool result from neutrophils moving to the area of inflammation in the GI tract and releasing this protein.

Lactoferrin is another protein made and released by neutrophils in response to inflammation in the GI tract. High levels of lactoferrin may indicate IBD.

Liver function tests (LFTs): Also referred to as a hepatic function test or liver panel, LFTs measure various liver proteins and enzymes. In addition to albumin, these include alkaline phosphatase (ALP), aspartate transaminase (AST), alanine aminotransferase (ALT), bilirubin, gamma-glutamyl transferase (GGT), prothrombin time (PT), international normalized ratio (INR), and total protein.

LFT values reflect how well the liver is functioning and may be used to help diagnose and monitor liver disease, infection, or injury. Inflammation due to ulcerative colitis can affect the liver’s ability to break down nutrients and eliminate waste.

Various types of liver disease are among the most common UC complications. Therefore, checking LFTs at regular intervals is an essential part of routine IBD management.

Stool culture: A fecal occult blood test (FOBT) or fecal immunochemical test (FIT) involves examining a stool sample under a microscope to look for the presence of infectious organisms (such as bacteria or parasites) and blood. A stool test can help rule out certain infections and determine the severity of inflammation.

Vitamin and mineral panel: These blood tests can check for deficiencies in nutrients such as iron, folate, and vitamins B12 and D. Low levels of these nutrients may be due to malabsorption caused by damage to the intestines.

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Although scientists have yet to find a cure for the disease (that doesn’t involve surgical removal of the colon and rectum), various ulcerative colitis treatments can help alleviate symptoms, maintain remission for longer, and improve quality of life. Medications, lifestyle interventions (including dietary), and surgery may all play a role in treating and managing the disease.

Your HCP will work with you to develop an effective ulcerative colitis treatment plan based on current clinical guidelines for the disease and your needs. Your UC treatment plan might include:

Medication for ulcerative colitis

One or more ulcerative colitis medications may be prescribed, depending on factors such as the extent and severity of the disease and type of symptoms you have. These might include:

Aminosalicylates for mild to moderate ulcerative colitis

Aminosalicylates (such as sulfasalazine, olsalazine, mesalamine, and balsalazide) can help reduce inflammation, prevent flare-ups, or help you stay in remission. Although most are oral medicines, mesalamine also comes in enema and suppository forms.

Corticosteroids for moderate to severe ulcerative colitis

Also called glucocorticoids or steroids, corticosteroids such as prednisone or budesonide may be an option if aminosalicylates don’t work well enough alone.

Because corticosteroids can have serious side effects, especially since fairly high doses are often needed to induce remission, they’re usually only prescribed for short-term use. Treatment with corticosteroids is gradually reduced and then discontinued altogether over the course of a few weeks. Another type of ulcerative colitis medicine (such as an aminosalicylate) may be used to maintain symptom improvement, as can a biologic or an immunomodulator (see more below).

Immunomodulators for moderate to severe ulcerative colitis

Also called immunosuppressants (or immunosuppressive drugs), immunomodulators decrease or suppress immune system activity such as the inflammation that occurs with moderate to severe ulcerative colitis. Azathioprine, 6-mercaptopurine, and methotrexate (more commonly used to treat Crohn’s disease) may be prescribed to maintain disease remission and allow for safe withdrawal of corticosteroids. As such, they’re sometimes referred to as steroid-sparing drugs.

They work by inhibiting the function of T cells, one of the two main types of white blood cells called lymphocytes. (The other main type of white blood cells are B cells.) It may take around one to three months of taking one of these immunomodulators before ulcerative colitis symptoms improve, as these medicines tend to work slowly.

They may also cause serious side effects such as a higher risk of infection, liver or pancreatic inflammation, and a type of cancer that starts in lymphocytes called lymphoma. Therefore, close monitoring of liver function and white blood cells are needed while using this treatment.

Cyclosporine may be another option for people with severe UC whose symptoms haven’t been relieved with corticosteroids. For most people, this medicine initially helps control severe flare-ups, although some may eventually require surgery.

Tacrolimus may also help maintain remission. It’s prescribed to people with severe ulcerative colitis whose symptoms are hard to manage. A short course of tacrolimus is usually prescribed when starting a regimen of aminosalicylates such as azathioprine and mercaptopurine.

Biologics for moderate to severe ulcerative colitis

Biologics for IBD are genetically engineered medicines derived from living sources that can help induce and maintain remission. They work by targeting specific proteins involved in the body’s inflammatory response.

Biologics approved for treatment of moderate to severe ulcerative colitis in people whose symptoms haven’t been sufficiently relieved by other medicines include adalimumab, golimumab, infliximab, ustekinumab, and vedolizumab. These are given by intravenous (IV) infusion or injection.

Sphingosine-1-phosphate receptor modulator for moderate to severe ulcerative colitis

Ozanimod is the first sphingosine-1-phosphate receptor (S1PR) modulator approved by the U.S. Food and Drug Administration (FDA) to treat moderate to severe ulcerative colitis, including in people whose symptoms aren’t adequately relieved with other treatments or who experience severe side effects with other medicines. This S1PR modulator is also an FDA-approved multiple sclerosis treatment.

The drug works by reducing the movement of lymphocytes from lymph nodes to sites of inflammation. This, in turn, reduces inflammation within the intestines.

Ozanimod may decrease the number of white blood cells, thereby raising the risk of infection. It can also slow the heart rate and cause liver damage, among other side effects. It isn’t indicated for people who’ve had a heart attack (without pain caused by unstable angina), stroke or a mini-stroke called a transient ischemic attack, or various types of heart failure within the previous six months.

It’s also not recommended for people:

• With a history of certain types of arrhythmias (irregular or abnormal heart rhythms) that haven’t been corrected with a pacemaker
• With severe, untreated sleep apnea
• Who take antidepressants called monoamine oxidase inhibitors (such as linezolid, phenelzine, and selegiline)

Janus kinase (JAK) inhibitors for moderate to severe ulcerative colitis

By blocking the action of the JAK enzyme, these drugs interfere with communication between cells that coordinate and cause inflammation.

Tofacitinib is a JAK inhibitor approved by the FDA for long-term treatment of moderate to severe ulcerative colitis and in cases in which other therapies, including biologics, have failed to induce and maintain remission. The drug also carries a risk of serious side effects, including higher risk of infection and pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung).

Hospitalization for severe ulcerative colitis

At times, people may be admitted to the hospital for treatment of severe flare-ups, especially when ulcerative colitis causes serious and sometimes life-threatening complications such as an ileus, perforation, fulminant ulcerative colitis, or toxic megacolon. In some cases, emergency surgery is required to treat these complications.

Symptom-specific treatments such as corticosteroids to treat severe inflammation are given by IV infusion. Heavy rectal bleeding may call for blood transfusions, while dehydration may require IV fluids to replenish fluids and balance electrolytes, as hypokalemia (low potassium levels in the blood) and hypomagnesemia (low magnesium levels in the blood) may lead to toxic dilatation (inflammation and distention) of the colon.

People who are malnourished or who have issues with malabsorption may also receive nutritional support. This often involves enteral nutrition, which entails delivering liquid food containing the proper blend of macronutrients (protein, carbohydrates, and fats) and micronutrients (such as vitamins and minerals) through a tube that goes directly into the stomach or small intestine.

Ulcerative colitis surgery

Around 30 percent of people with extensive ulcerative colitis may need surgery. Emergency surgery may be required for sudden, life-threatening flare-ups involving complications such as massive bleeding, perforation, fulminant colitis, or toxic megacolon.

In some cases, surgery may also be performed for serious cases that aren’t considered immediate emergencies. This might include colon cancer, narrowing of the large intestine, or when high corticosteroid doses are needed to control the disease. Surgery may also be considered for children experiencing delayed or stunted growth due to UC.

Total proctocolectomy can cure ulcerative colitis

Total proctocolectomy involves complete removal of the large intestine, including the colon, rectum, and anus (which includes the sphincter muscles that allow stool to pass through during bowel movements). The procedure effectively and permanently cures UC, but it’s often reserved for cases in which other treatments, including various types of ulcerative colitis medicine, have failed to help. Around a quarter of people experience inflammation in the small intestine after surgery, even if this wasn’t the case prior to surgery.

Ileostomy may be placed during ulcerative colitis surgery

Because the rectum and anus are removed during a proctocolectomy, an ileostomy may be placed. In this procedure, the surgeon brings the end of the ileum (lowest part of the small intestine) out through an opening created in the abdominal wall called a stoma. A detachable and replaceable plastic ileostomy bag is placed over the stoma to allow for collection and disposal of stool.

Proctocolectomy with ileal pouch-anal anastomosis (IPAA)

Also referred to as J-pouch surgery (or ileoanal anastomosis or ileoanal reservoir surgery), proctocolectomy with IPAA is the procedure of choice when surgery is needed to treat severe ulcerative colitis. It involves surgical removal of the large intestine and most of the rectum along with creation of a small reservoir (pouch) made from the ileum (end portion of the small intestine) and attached to the remaining rectum just above the anus.

Stool will collect in this internal pouch and pass through the anus during bowel movements. However, stools are watery and BMs occur frequently (around five to six times per day). A temporary ileostomy is often needed, but this opening will be closed during a second surgery several months later.

The risk of rectal cancer goes down substantially with this procedure, but it isn’t completely gone since a small amount of rectal tissue may remain. One benefit of J-pouch surgery is that it allows people to stay continent (have control of their bowels) since the muscles of the anal sphincter remain intact.

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Be sure to get prompt medical care from your healthcare provider (HCP) if you suspect you have ulcerative colitis or if symptoms persist or become severe. These include symptoms such as:

• Bloody stool
• Blood leaking from your anus
• Dehydration
• Fever that persists for more than a day or two or doesn’t respond to fever-lowering medications
• Heavy, persistent diarrhea

If you suspect you’re having symptoms of fulminant ulcerative colitis or toxic megacolon, go to your local hospital emergency room for immediate medical evaluation and care. These include symptoms such as:

• 10 or more bloody BMs per day or massive rectal bleeding
• High fever
• Ileus
• Rapid heart rate
• Severe abdominal cramping, pain, or bloating

What questions should you ask your healthcare provider?

Be sure to discuss any questions or concerns you might have about ulcerative colitis with your HCP. These questions from the Crohn’s & Colitis Foundation can help you get the conversation started:

• What type of ulcerative colitis do I have, and what likely caused it?
• What are the signs and symptoms of ulcerative colitis, including the type that I have?
• Which ulcerative colitis symptoms require urgent medical care?
• How do I monitor my condition and how will I know if my condition is getting worse?
• How will I know if I’m having an ulcerative colitis flare-up?
• How will I know if my ulcerative colitis is in remission?
• How can ulcerative colitis affect my ability to work, travel, exercise, and perform my usual daily activities?
• Can ulcerative colitis affect family planning and pregnancy?
• How will people possibly react to my illness?
• What’s the best way to explain ulcerative colitis to others? Are there any resources you can recommend?
• What are my ulcerative colitis treatment options, and what are the potential risks, side effects, and benefits of each?
• Can I lower my risk for flare-ups with lifestyle interventions? If so, which lifestyle interventions would you recommend and why?
• What can I do to ease my ulcerative colitis symptoms at home?
• Can you refer me to an online or in-person support group for people living with ulcerative colitis?
• Are there any clinical trials for ulcerative colitis you would recommend?

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Scientists are still looking for a way to prevent and cure the disease without the need for surgery to remove the colon and rectum. For now, the best way to decrease the frequency and severity of flare-ups is to follow your ulcerative colitis treatment plan, adjusting it as needed with guidance from your HCP.

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For most people, ulcerative colitis alternates between flare-up and remission periods for the rest of their lives. But although UC is a lifelong disease, it’s usually not life-threatening and the life expectancy for people with the disease tends to be on par with the general population. Most people with the disease can also continue to live full and active lives.

That said, complications associated with ulcerative colitis can sometimes be severe and life-threatening. For instance, the long-term survival rate for UC-related colon cancer is about 50 percent, which is comparable to the survival rate in the general population. People with ulcerative proctitis (when the disease is limited to the rectum) tend to have the best prognosis and are less likely to experience severe complications or need surgery.

For about 10 percent of people who experience an ulcerative colitis flare-up for the first time, the disease progresses quickly and results in serious complications. In contrast, around 10 percent of people recover fully from the disease after one bout of UC. For the rest, ulcerative colitis recurs to some degree over time unless they have a proctocolectomy.

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Ulcerative colitis can disrupt your life physically, emotionally, and mentally. But there are things you can do to help lessen the impact the disease has on your life and to live better with ulcerative colitis.

Below are some healthy lifestyle practices that can complement your ulcerative colitis treatment plan:

Maintain close relationships. Share what you’re going through and what your needs are with trusted friends and family members. Be honest about your experiences and needs, and find meaningful ways to talk about your ulcerative colitis so you feel understood and so others can better understand how to help and support you.

Lean on members of your support circle. Confirm who’s able and willing to support you in different areas of your life. From daily or weekly tasks such as picking up groceries or kids from school to helping with work assignments, knowing who you can trust to help you with these and other tasks and responsibilities can give you peace of mind and lower your stress level.

Consider joining an online or in-person support group for people with ulcerative colitis or IBD. If needed, seek help from a licensed mental health provider for support with mental or emotional health issues you might be having, especially if you’ve already been diagnosed with a mental health disorder and you feel the stress of living with a chronic illness is making it worse.

Adjust your daily work or school routine. For instance, you can pack your lunch with foods that are less likely to aggravate your symptoms (see below). Request work or school accommodations such as relocating your office or desk closer to the restroom, working remotely, or seeking extra time to complete school or work assignments when your symptoms flare up.

Try taking short breaks from your tasks when symptoms take hold at work or school. Take a moment to bring your tension level down with stress-management techniques such as breathing exercises, meditation, or simply getting a bit of low-key exercise such as walking outdoors or even around the building a few times.

Rein in stress. Although stress doesn’t cause ulcerative colitis, it can make certain symptoms (such as pain) feel worse. Find meaningful ways to reduce your stress. This might include techniques as mentioned above, as well as other healthy ways to ease stress such as listening to music to soothe your senses or partaking in easy, lighthearted activities by yourself or with others such as singing karaoke to boost your mood.

Cope with intimacy challenges. When you have ulcerative colitis, being physically intimate with others can feel daunting at times. Have an open dialogue with your spouse or partner about these challenges, including how UC can sometimes limit your desire for physical intimacy.

You may want to speak with your HCP about how ulcerative colitis may be contributing to sexual dysfunction. This might include speaking with a licensed mental health provider, such as a sex therapist, about these issues and learning strategies that might help.

Get on the family plan. For people assigned female at birth (AFAB), ulcerative colitis doesn’t usually affect their chances of getting pregnant. But infertility may be a complication of J-pouch surgery in people AFAB, with this risk being much lower with an ileostomy.

Although most people AFAB with ulcerative colitis have healthy pregnancies and babies, the risk of giving birth prematurely or to a baby with low birthweight may be higher in those AFAB who conceive during a flare-up or have a flare-up while pregnant. For these reasons, HCPs usually recommend that people AFAB get UC under control before trying to conceive.

Most types of ulcerative colitis medicine can be taken during pregnancy, but some (such as certain immunosuppressants) may need to be discontinued as they may raise the risk of congenital differences. In some cases, your HCP may prescribe a medicine that’s not usually taken during pregnancy. This may be the case if the risks of having a flare-up during pregnancy outweigh the risks associated with the medicine.

If you’re wanting to get pregnant or already are, be sure to consult with your HCP right away. Together, you can modify your ulcerative colitis treatment plan to achieve a healthy pregnancy while keeping UC symptoms at bay.

Modify your ulcerative colitis treatment plan, if needed. Sticking to your UC treatment plan is vital for staying in remission. If you’re sticking to the program but still experiencing frequent flare-ups, however, reach out to your HCP about changing your treatment strategy.

Prepare practical supplies. Ulcerative colitis symptoms, including those that affect bowel habits, are often unpredictable. As such, it’s important to plan as best you can and to carry practical supplies in your bag or backpack. These might include items such as:

• Clean underwear and a change of clothing (such as shorts or pants)
• Disposable bags for soiled clothes
• Disposable gloves to handle soiled clothes or clean the toilet
• Hand sanitizer
• Toilet paper or wet wipes
• Air freshener drops or spray

Disability benefits for ulcerative colitis

Some people with ulcerative colitis may be eligible for disability benefits. The U.S. Social Security Administration (SSA) allots these benefits to people who can’t work due to severe complications caused by the disease.

The following conditions are considered by SSA when determining benefits eligibility for people with ulcerative colitis:

• Anemia
• Bowel obstruction (blockage of intestinal contents)
• Daily enteral (tube) or parenteral (IV) nutrition
• Extreme weight loss
• Hypoalbuminemia (low albumin levels)
• Painful abdominal mass

Access the SSA website for more information on how to apply for SSA disability benefits.

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In general, most health experts recommend that people with ulcerative colitis engage in low-to-moderate-intensity exercise. These include cardio activities such as walking, jogging, cycling, and swimming along with strength-training exercises, stretching, and yoga.

Some people with ulcerative colitis find that being physically active helps them alleviate tension and stress, lift their mood, and feel better overall. In addition, exercise can confer long-term benefits that counter various UC complications, including strengthening bones and potentially lowering the risk of colon cancer.

Lower impact exercise is generally recommended for people with ulcerative colitis because strenuous workouts may trigger certain GI symptoms such as abdominal pain, diarrhea, GI bleeding, and ischemic colitis.

Intense exercise may cause these symptoms because of changes associated with:

• Intestinal inflammation
• Motility (movement of food through the digestive tract)
• Hormones
• Intestinal blood flow
• Intestinal permeability (absorption of nutrients and fluids through the intestinal lining)

That said, a 2023 review of studies published in Gastroenterology Report found the benefits associated with strenuous exercise in people with IBD are at least equal to those seen with moderate-intensity exercise, particularly as it relates to disease activity, exercise enjoyment, fatigue, sleep, and quality of life. According to the review:

Low-intensity exercise such as walking and calisthenics (strength-training that uses one’s body weight to work large muscle groups) improved quality of life and reduced IBD disease activity along with inflammatory markers.

Moderate-intensity exercise such as light jogging, cycling, swimming, and low-impact sports provided the same benefits as low-intensity workouts, plus it improved cardiorespiratory fitness (the capacity of the heart and lungs to deliver oxygen to the body’s muscles and organs during physical activity).

High-intensity exercise such as high-impact sports and prolonged strenuous activities (like marathons and triathlons) enhanced people’s balance of gut microbes, quality of life, and physical functioning while reducing fatigue. These activities also increased intestinal inflammation and permeability while decreasing intestinal blood flow, however.

For those engaging in any form of exercise, monitoring disease activity is essential. When ulcerative colitis symptoms flare up, it’s best to avoid activities that can place additional stress on the intestines. This means it’s best to rest during disease flare-ups.

All in all, follow these tips to exercise safely:

Consult with your HCP beforehand. This is key, especially when starting or making significant changes to your exercise routine. Be sure you ask your HCP which symptoms and complications to look out for when you’re active, and which ones call for you to ease off your activity or stop altogether.

Consult with an exercise expert. This may include working with a clinical exercise physiologist with specialized training and expertise in designing, implementing, and supervising exercise programs for people with ulcerative colitis and associated complications.

Consult with a registered dietitian nutritionist (RDN): It’s important to know which foods to eat and when to eat them, as well as how many calories you need daily based on the type, duration, and intensity of your workouts and how active you are in general. An RDN can help you create an eating plan that helps you reach your exercise goals without causing your ulcerative colitis symptoms to get worse.

Keep tabs on the nearest restroom facilities. If you’re exercising outdoors, find routes that allow for bathroom breaks when needed.

Know your capabilities and limits. If you’re looking to build endurance and increase the intensity of your workouts, do so gradually and with caution. Scientists haven’t determined physiological thresholds, limitations, or parameters for exercise in people with IBD. It’s therefore important to listen to your body and not overexert yourself, as doing so can make certain ulcerative colitis symptoms worse.

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Ulcerative colitis isn’t caused by any specific food or diet, and there isn’t a particular diet that can cure or prevent the disease. That said, certain foods may trigger or worsen ulcerative colitis symptoms such as inflammation, whereas others seem to ease various symptoms and can be eaten without causing any digestive issues.

Which foods fit on which list can vary, as there’s no single dietary approach that works the same way for all people. In fact, most people find that some trial and error is needed to find which foods to place on their “go” and “no” lists.

Bear in mind that such food lists may change depending on whether you’re in remission or experiencing a flare-up. A good starting point would be to consult with an RDN to develop an eating plan that helps control flare-ups while allowing you to enjoy many delicious meals, despite having ulcerative colitis.

Although tracking your diet can help with weight loss, it may also help you identify which foods cause which ulcerative colitis symptoms. Keeping a food journal involves recording every food or drink you consume, and then noting each time a certain food or drink causes a particular symptom. This can help you identify food trigger patterns. Also be sure to jot down any stressful events or times when you’re anxious in your food diary, as stress can make certain UC symptoms worse.

Tips for eating during ulcerative colitis flares

When ulcerative colitis symptoms flare up, it’s often best to stick with bland foods that are easy to digest. This is known as a bland or low-residue diet (LRD), which limits dietary fiber to less than 10 to 15 grams daily and restricts other foods that may stimulate bowel activity. LRD aims to reduce ulcerative colitis symptoms such as abdominal cramping and pain by decreasing the size and frequency of bowel movements.

Foods to avoid on a low residue diet for ulcerative colitis flares

Foods to avoid typically include:

• Crunchy peanut butter
• Dried beans, lentils, and peas
• Dried fruit, berries, and other fruit with skin or seeds
• Raw vegetables generally, plus these vegetables, either cooked or raw: broccoli, cauliflower, Brussels sprouts, cabbage, kale, and Swiss chard
• Tough meats with gristle
• Seeds and nuts
• Whole grain breads (such those made with buckwheat, flax, and oatmeal), cereals, pastas, and popcorn

Foods allowed on a low residue diet for ulcerative colitis flares

Foods that may be safe to eat include:

• Butter, margarine, mayonnaise, oil, and salad dressings
• Eggs, meats, and fish
• Fruit without peels or seeds and some canned or well-cooked fruit (such as peeled apples, banana, cantaloupe, and seedless peeled grapes)
• Juices without pulp or seeds
• Refined grain products such as white breads, cereals, and pastas (aim for fewer than two grams of fiber per serving)
• Milk, puddings, yogurt, and cream-based soups (limit to two cups daily)
• Some cooked, soft vegetables (such as beans, beets, carrots, cucumber, mushrooms, and eggplant)
• White rice

Following a bland diet as instructed by your HCP or RDN can also help you identify specific food triggers. Your HCP or RDN will work with you to slowly and safely reintroduce your usual foods back into your diet. If ulcerative symptoms come back after reintroducing a certain food, you’ll have a good idea this food is the likely cause.

Other dietary strategies to employ during ulcerative colitis flares

Other dietary strategies you may want to try during an ulcerative colitis flare include:

• Avoiding foods that may increase stool output such as prunes, caffeinated drinks like coffee, and various fresh fruits and vegetables (see above)
• Boosting intake of omega-3 fatty acids found in fatty fish (such as salmon, herring, mackerel, and sardines), which may help lessen inflammation
• Decreasing alcohol consumption
• Decreasing intake of concentrated sweets (such as candy, soda, and juices) to help decrease the amount of fluids that flow into your intestine, which may contribute to watery stools
• Eating smaller meals more frequently, which may be better tolerated and help your body absorb more of the nutrients it needs
• Talking with your HCP about taking certain dietary supplements (such as iron, calcium, and vitamin D) or meal-replacement products (such as shakes) if you’re experiencing issues with malnutrition or malabsorption or have a poor appetite and solid foods aren’t well-tolerated

Advancing your diet after an ulcerative colitis flare-up

Resuming your ordinary eating habits after a flare-up might entail:

• Slowly adding back various foods.
• If you’re mostly having clear liquids (such as water, apple juice, or gelatin), try progressing to soft foods (such as eggs and applesauce) before gradually moving on to solid foods.
• Introduce one or two different foods every few days, staying away from foods that cause symptoms.
• Gradually add fiber sources (such as tender, cooked vegetables, canned or cooked fruits, and cooked cereals).
• Boost the amount of calories and protein you get following a flare, as you may have gotten less of these due to symptoms such as abdominal pain, diarrhea, or decreased appetite or because of corticosteroid use.

Initial foods to try following an ulcerative colitis flare

Foods to try introducing after a flare-up may include:

• Applesauce
• Cooked eggs
• Diluted juices
• Canned fruit
• Mashed potatoes, rice, or noodles
• Oatmeal
• Plain chicken, turkey, or fish
• Sourdough or white bread

Between flares, follow a balanced diet and eat a wide variety of nourishing foods as tolerated, focusing on whole foods such as fruits, vegetables, whole grains, lean proteins, and low- and nonfat dairy products.

Also be sure to hydrate well with healthy fluids such as water. A good rule of thumb in general is to drink 0.5 fluid ounces per pound of body weight daily.

Note that your fluid needs may go up during episodes of diarrhea and with exercise. It’s also important to replenish lost electrolytes by drinking electrolyte beverages with sodium, potassium, and chloride. Try to stick to drinks with no added sugars or artificial sweeteners such as aspartame, sucralose, and saccharin.

Finally, it’s important to get enough protein following an ulcerative colitis flare and while you’re in remission. Between flares, aim to eat roughly 1 gram of protein for each kilogram (about 2.2 pounds) of body weight each day.

To gain weight back and to restore lost protein, you may need to increase your protein intake by 50 percent. Your protein needs may also go up if you’re taking corticosteroids. Be sure to talk with your HCP or RDN to determine your exact protein needs following a flare.

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• What It's Really Like Living With Ulcerative Colitis
• Can Mindful Eating Help You Manage Ulcerative Colitis?
• Coping with the Mental and Emotional Burden of Ulcerative Colitis