Ulcerative Colitis

Ulcerative colitis is a chronic inflammatory bowel disease in which abnormal immune reactions cause inflammation and ulcers on the inner lining of the large intestine.

Overview

Ulcerative colitis is a chronic disease in which abnormal reactions of the immune system cause inflammation and ulcers on the inner lining of the large intestine. Ulcerative colitis is a type of inflammatory bowel disease. Crohn’s disease and microscopic colitis are other common types of inflammatory bowel disease.

The disease can begin gradually and become worse over time, or it can start suddenly. Symptoms range from mild to severe. Most people have periods of flares (times when symptoms appear) followed by periods of remission, when symptoms disappear. Remission can last for weeks or years. The goal of treatment is to keep people in remission long term. The disease is more likely to develop in people between the ages of 15 and 30, although it may develop at any age.

Signs and Symptoms

Symptoms of ulcerative colitis vary from person to person. Common symptoms include:

  • Diarrhea
  • Passing blood with your stool or rectal bleeding
  • Cramping and pain in the abdomen
  • Passing mucus or pus with your stool
  • Tenesmus, which is feeling a constant urge to have a bowel movement even though your bowel may be empty
  • An urgent need to have a bowel movement

Symptoms vary in severity. Mild symptoms may include fewer than four bowel movements a day and sometimes passing blood with stool. Severe symptoms may include more than six bowel movements a day and passing blood with stool most of the time. In extremely severe (fulminant) ulcerative colitis, a person may have more than ten bloody bowel movements in a day.

Some symptoms are more likely when ulcerative colitis is more severe or affects more of the large intestine. These symptoms include:

  • Fatigue, or feeling tired
  • Fever
  • Nausea or vomiting
  • Weight loss

You may have periods of remission that last for weeks or years. After a period of remission, you may have a relapse, or a return of symptoms.

Complications from Ulcerative Colitis

In some cases, ulcerative colitis may lead to serious, life-threatening complications that develop quickly. These require treatment at a hospital or emergency surgery. Serious complications include:

  • Fulminant ulcerative colitis is marked by extremely severe symptoms, such as more than ten bloody bowel movements in a day, often with fever, rapid heart rate, and severe anemia. People with fulminant ulcerative colitis have a higher chance of developing toxic megacolon and perforation.
  • Perforation is a hole in the wall of the large intestine.
  • Severe rectal bleeding is passing a large amount of blood from the rectum, which may require emergency surgery.
  • Toxic megacolon occurs when inflammation spreads to the deep tissue layers of the large intestine, causing it to swell and stop working.

Some people with ulcerative colitis also have inflammation in parts of the body other than the large intestine, including:

  • Joints, causing certain types of arthritis
  • Skin
  • Eyes
  • Liver and bile ducts, causing conditions such as primary sclerosing cholangitis

Ulcerative colitis may lead to complications that develop over time. These include:

  • Anemia: A condition in which you have fewer red blood cells than normal. Ulcerative colitis may lead to more than one type of anemia, including iron-deficiency anemia and anemia of inflammation or chronic disease.
  • Dehydration: Severe ulcerative colitis may require treatment at a hospital with intravenous (IV) fluids and electrolytes
  • Blood Clots: People with ulcerative colitis also have a higher risk of blood clots.
  • Bone problems: Ulcerative colitis and corticosteroids used to treat the disease can affect the bones, leading to low bone mass, such as osteopenia or osteoporosis.
  • Growth and development problems in children: These include gaining less weight than normal, slowed growth, short stature, or delayed puberty.
  • Colorectal cancer: People with long-standing ulcerative colitis that involves a third or more of the colon are at increased risk and require closer screening.

Causes and Risk Factors

Doctors are not sure what causes ulcerative colitis. Experts think the following factors may play a role:

  • Genes: Ulcerative colitis sometimes runs in families. Research suggests that certain genes increase the chance that a person will develop ulcerative colitis.
  • Abnormal reactions of the immune system may lead to inflammation in the large intestine.
  • Microbiome: The microbes in your digestive tract, including bacteria, viruses, and fungi, are called the microbiome. Studies have found differences between the microbiomes of people who have inflammatory bowel disease and those who do not. Researchers are still studying this relationship.
  • Environment: Experts think a person’s surroundings and factors outside the body may play a role. Researchers are still studying how the environment interacts with genes, the immune system, and the microbiome to affect the chance of developing ulcerative colitis.

Ulcerative colitis is more likely to develop in people who:

  • Are between the ages of 15 and 30, although the disease may develop at any age
  • Have a first-degree relative, such as a parent, sibling, or child, with inflammatory bowel disease
  • Are of Jewish descent

Prevention Guidance

Researchers have not found that specific foods cause ulcerative colitis symptoms, although healthier diets appear to be associated with less risk of developing inflammatory bowel disease. If you have ulcerative colitis, your doctor may recommend a colonoscopy to screen for colorectal cancer. Screening can check for dysplasia (precancerous cells) or colorectal cancer. Diagnosing cancer early can improve chances for recovery.

For people with ulcerative colitis, doctors typically recommend colonoscopies every 1 to 3 years, starting 8 years after ulcerative colitis started.

Diagnosis

To diagnose ulcerative colitis, doctors review medical and family history, perform a physical exam, and order medical tests. Doctors order tests to:

  • Confirm the diagnosis of ulcerative colitis
  • Find out how severe ulcerative colitis is and how much of the large intestine is affected
  • Rule out other health problems, such as infections, irritable bowel syndrome, or Crohn’s disease, that may cause similar symptoms

Medical and Family History

Your doctor will ask about your symptoms, your medical history, and any medicines you take. Your doctor will also ask about lifestyle factors, such as smoking, and about your family medical history.

Physical Exam

During a physical exam, your doctor may check your blood pressure, heart rate, and temperature. Doctors may use these measures, along with your symptoms and test results, to find out how severe the disease is. Your doctor may also use a stethoscope to listen to sounds within your abdomen and press on your abdomen to feel for tenderness or masses. The physical exam may include a digital rectal exam to check for blood in your stool.

Blood Tests

A healthcare professional will take a blood sample and send it to a lab. Doctors use blood tests to check for signs of ulcerative colitis and complications, such as anemia. Blood tests can also show signs of infection or other digestive diseases.

Stool Tests

A healthcare professional will give you a container for catching and storing stool. Doctors may use stool tests to check for conditions other than ulcerative colitis, such as infections that could be causing your symptoms. Doctors may also use stool tests to check for signs of inflammation in the intestines.

Endoscopy of the Large Intestine

Doctors order endoscopy of the large intestine with biopsies to diagnose ulcerative colitis and rule out other digestive conditions. During an endoscopy, doctors use an endoscope — a long, flexible, narrow tube with a light and a tiny camera on one end — to view the lining of the large intestine. Doctors obtain biopsies by passing an instrument through the endoscope to take small pieces of tissue from the lining of the rectum and colon. A pathologist then examines the tissue under a microscope.

Two types of endoscopy can diagnose ulcerative colitis:

  • Colonoscopy is when a doctor uses a colonoscope to view the lining of the rectum and the entire colon.
  • Flexible sigmoidoscopy is when a doctor uses a sigmoidoscope to view the lining of the rectum and lower colon.

Treatment and Management

Doctors treat ulcerative colitis with medicines and surgery. Each person experiences ulcerative colitis differently. Doctors recommend treatments based on how severe the disease is and how much of the large intestine is affected. Doctors most often treat severe and fulminant ulcerative colitis in a hospital.

Medicines

Doctors prescribe medicines to reduce inflammation in the large intestine and to help bring on and maintain remission. People with ulcerative colitis typically need lifelong treatment with medicines unless they have surgery to remove the colon and rectum.

Which medicines your doctor prescribes depends on how severe ulcerative colitis is. Medicines that reduce inflammation in the large intestine include:

  • Aminosalicylates: Doctors prescribe these to treat mild or moderate ulcerative colitis or to help people stay in remission.
  • Corticosteroids, also called steroids: Doctors prescribe these to treat moderate to severe ulcerative colitis and to treat mild to moderate ulcerative colitis in people who do not respond to aminosalicylates. Doctors typically do not prescribe corticosteroids for long-term use or to maintain remission, since long-term use may cause serious side effects.
  • Immunosuppressants: Doctors may prescribe these to treat moderate to severe ulcerative colitis and help people stay in remission. Doctors may also prescribe immunosuppressants to treat severe ulcerative colitis in people who are hospitalized and do not respond to other medicines.
  • Biologics: Doctors prescribe these to treat moderate to severe ulcerative colitis and help people stay in remission.
  • Small molecule medicines: Doctors may prescribe these for adults with moderate to severe ulcerative colitis who do not respond to other medicines or who have severe side effects with other medicines.

Surgery

Your doctor may recommend surgery if you have:

  • Colorectal cancer
  • Dysplasia, or precancerous cells that increase the risk for developing colorectal cancer
  • Life-threatening complications, such as severe rectal bleeding, toxic megacolon, or perforation of the large intestine
  • Symptoms that do not improve or stop after treatment with medicines
  • Symptoms that only improve with continuous treatment with corticosteroids, which may cause serious side effects when used long term

To treat ulcerative colitis, surgeons typically remove the colon and rectum and change how the body stores and passes stool. The most common types of surgery are:

  • Ileoanal reservoir surgery, in which surgeons create an internal pouch from the end part of the small intestine, called the ileum, and attach it to the anus. This surgery most often requires two or three operations. After the operations, stool collects in the internal pouch and passes through the anus during bowel movements.
  • Ileostomy, in which surgeons attach the end of the ileum to an opening in the abdomen called a stoma. Stool passes through the stoma and is collected in an ostomy pouch (a bag attached to the stoma and worn outside the body).

Surgery may be laparoscopic or open. In laparoscopic surgery, surgeons make small cuts in the abdomen and insert special tools to view, remove, or repair organs and tissues. In open surgery, surgeons make a larger cut to open the abdomen.

Treating Symptoms and Complications

Doctors may recommend or prescribe other treatments for symptoms or complications. Talk with your doctor before taking any over-the-counter medicines.

To treat mild pain, doctors may recommend acetaminophen instead of nonsteroidal anti-inflammatory drugs (NSAIDs). People with ulcerative colitis should avoid nonsteroidal anti-inflammatory drugs for pain because these medicines can make symptoms worse.

To prevent or slow loss of bone mass and osteoporosis, doctors may recommend calcium and vitamin D supplements or medicines, if needed. Talk with your doctor before using dietary supplements or any other complementary or alternative medicines or practices.

For severe complications treated in a hospital, doctors may give:

  • Antibiotics if severe ulcerative colitis or complications lead to infection
  • Blood transfusions to treat severe anemia
  • Intravenous (IV) fluids and electrolytes to prevent and treat dehydration

Living With Ulcerative Colitis

If you have ulcerative colitis, you should eat a healthy, well-balanced diet. Talk with your doctor about a healthy eating plan.

Ulcerative colitis symptoms may cause some people to lose their appetite and eat less, and they may not get enough nutrients. In children, a lack of nutrients may play a role in problems with growth and development.

Researchers have not found that specific foods cause or worsen ulcerative colitis symptoms. Talk with your doctor about any foods that seem related to your symptoms. Your doctor may suggest keeping a food diary to help identify foods that seem to make your symptoms worse.

Depending on your symptoms and the medicines you take, your doctor may recommend changes to your diet or dietary supplements.

Managing Cancer Risk

Due to the increased risk of certain cancers in people with ulcerative colitis, doctors may recommend starting colorectal cancer screening 8 to 10 years after diagnosis, with repeat screening every 1 to 5 years. People with Crohn's disease and primary sclerosing cholangitis may need screening every year, starting at diagnosis.

Find Clinical Trials

Clinical trials uncover better ways to prevent, diagnose, treat, and understand diseases and conditions. To ensure results apply to everyone, volunteers of all ages, sexes, and backgrounds, including both healthy individuals and those with specific medical conditions, are needed. Find clinical trials on ulcerative colitis.

Community Support

The following resources offer information and support for people with ulcerative colitis and their families:

Note: This resource list is for informational purposes only. It is not comprehensive, and an organization's inclusion does not constitute an endorsement by NIH.

Research Information

The National Institutes of Health (NIH) is the largest public funder of biomedical research in the world. NIH invests most of its budget in medical research seeking to enhance life and to reduce illness and disability. NIH-funded research has led to breakthroughs and new treatments helping people live longer, healthier lives, and building the research foundation that drives discovery.

NIH conducts and supports clinical trials in many diseases and conditions, including digestive diseases. These trials look to find new ways to prevent, detect, or treat disease and improve quality of life.

Researchers are currently studying many aspects of ulcerative colitis and other types of inflammatory bowel disease, such as:

  • Genes associated with disease in African Americans
  • Whether a special diet can alter the bacteria in the large intestine and induce remission in children with ulcerative colitis
  • How the immune system controls inflammation in the digestive tract in people with inflammatory bowel disease
  • New treatments for ulcerative colitis

Other research efforts include:

Find NIH-funded research projects using NIH RePORTER, a searchable database of current and past research projects supported by NIH and other federal agencies.