Ulcerative Colitis

Written by Dr. Brian Bressler on October 26, 2019

What is Ulcerative Colitis?

Ulcerative colitis is a type of inflammatory bowel disease (IBD) that causes chronic inflammation of the inner lining of the large intestine (colon). People with ulcerative colitis have small ulcers (sores) and abscesses (swollen areas filled with pus) in their colon and rectum that periodically flare up. The symptoms include bloody stools, diarrhea, abdominal pain and anemia (low levels of red blood cells).

Picture of large intestine showing ulcerative colitis.

What Causes Ulcerative Colitis?

There is no known cause of the disease. Researchers believe it’s a combination of nature (genetic factors) and nurture (environmental factors). Genetically, ulcerative colitis tends to run in families. Those with a first-degree relative with the disease are at higher risk for getting the disease.

There also appears to be an environmental component to the disease that creates an abnormal immune response. The immune system mistakenly treats normal intestinal matter – like food, bacteria, etc. – as foreign or invading substances. Because it identifies these things as “threatening”, the immune system sends white blood cells – which fight toxins and other foreign matter – into the lining of the colon. Here, the white blood cell activity causes inflammation and ulcerations, producing blood, pus and mucous. Both bacterial and environmental triggers – such as diet, antibiotic use and lifestyle – are points of interest for further study.

Is There a Cure for Ulcerative Colitis?

Because we haven’t clearly determined the cause of ulcerative colitis there is currently no cure. The basic goal of treatment is to decrease the inflammation in the colon, which then helps to control and manage the symptoms. Doctors typically use medications and nutrition to relieve symptoms, although sometimes surgery is also needed.

Though the disease is considered a chronic or life-long condition, proper treatment allows many to go long periods without symptoms or flare-ups. And it is possible to live a full and productive life with ulcerative colitis.

Who Is Likely to Get Ulcerative Colitis?

UC doesn’t discriminate. This means both men and women – of any age – can develop the disease, but most people are diagnosed in early adulthood. The disease tends to run in families, although no clear inheritance patterns have been established, and it’s more common in Caucasians of European decent—particularly among people of Jewish heritage.

Ulcerative Colitis Symptoms and Types

  • The symptoms of ulcerative colitis can vary from person to person, depending on the severity of inflammation and specifically where the inflammation occurs in the colon. Common symptoms of ulcerative colitis include:
  • Diarrhea
  • Bloody stools
  • Abdominal cramps
  • Rectal pain
  • Weight loss
  • Tenesmus (The feeling of being unable to completely empty the colon of stool, even if there is nothing left to expel.)

Additional symptoms of ulcerative colitis outside of the colon may include:

There are five types of the disease and each represents a different portion of the colon where inflammation occurs. Symptoms vary by the location that is inflamed. Here are the five forms of ulcerative colitis and the symptoms that accompany each.

Ulcerative proctitis.
In this type of the disease, which tends to be the mildest form, the inflammation is restricted to the area closest to the anus, near the end of the colon. In this form of the disease, the primary symptom is rectal bleeding. Some people may also have rectal pain and an accompanying feeling of urgency to have a bowel movement. These may be the first and only symptoms with this type of ulcerative colitis.

Proctosigmoiditis.
In this form of the disease, the rectum and lower end of the colon, identified as the sigmoid colon, are affected. Typical symptoms from this type of inflammation include bloody diarrhea, abdominal cramps and pain, and difficulty having a bowel movement, despite the urge to do so.

Left-sided colitis.
In this type of the disease the inflammation extends from the rectum up through the sigmoid colon and the descending colon. As the name suggests, this area is located in the upper left portion of the colon. Symptoms include bloody diarrhea, abdominal cramps and pain on the left side of the abdomen and weight loss due to fluid loss and poor absorption of nutrients.

Pancolitis.
This type of ulcerative colitis is more severe and inflammation can often be found in the entire length of the colon. Symptoms include bloody diarrhea that may be severe, abdominal cramps and pain, fatigue (from blood loss, which leads to anemia) and significant weight loss from fluid loss and poor nutrient absorption. Those with pancolitis are at greater risk of developing colon cancer.

Fulminant colitis.
This type of the disease is rare but severe enough to be life-threatening. It affects the entire length of the colon. Symptoms include severe pain, profuse bloody diarrhea, rapid weight loss and possible dehydration and shock. Those with this form of ulcerative colitis are at risk of serious complications that could include rupture of the colon.

Anatomy of colon to show what ulcerative colitis affects.

Ulcerative Colitis Diagnosis

Making an accurate diagnosis of ulcerative colitis often requires ruling out other possible causes (such as infection, Crohn’s disease, diverticulitis or colon cancer, among others) first before making a final determination. Since there is no single test that can make a definitive diagnosis of ulcerative colitis, your doctor will typically gather information from several sources to understand your symptoms. This information gathering may begin with a physical exam and a health history and be followed up with lab tests and scans. Here are some of the most common ways doctors go about making the diagnosis of ulcerative colitis.

Stool sample
One of the first lab tests your doctor may perform might be to collect a stool sample to check for the presence of white blood cells, which indicates an inflammatory disease. A stool that tests positive for inflammation is not enough to make a confirmed diagnosis of ulcerative colitis but it will prompt your doctor to investigate further with additional tests. A stool test can also rule out other similar disorders, such as those caused by parasites, viruses or bacteria.

Blood test
A blood test may be ordered to see if you have anemia (a condition where there are not enough red blood cells) and to look for signs of infection and inflammation of the intestine.

Colonoscopy
This test enables your doctor to look inside your entire colon (large intestine) using a thin, flexible, lighted tube equipped with a tiny camera. A colonoscopy reveals any inflammation in the intestine. During this procedure, a small sample of tissue from the intestine might be taken (called a biopsy) and sent to the lab for analysis to help confirm the diagnosis.

Flexible sigmoidoscopy
In this procedure, the doctor also uses a flexible, lighted tube with a small camera but the sigmoidoscopy only looks at the first third of your colon (called the sigmoid colon) located on the left side. A sigmoidoscopy may be ordered if the inflammation of your colon is severe. The potential downside of a sigmoidoscopy is that it can’t view potential problems higher in the colon.

X-ray
A standard X-ray may be performed on your abdominal area to rule out the existence of an enlarged and dilated colon (called toxic megacolon) or the possibility of a perforated colon.

Computerized tomography (CT)
You might also have a CT scan, which is a special type of X-ray that provides more detail than a standard X-ray. This test allows your doctor to see the entire colon and better understand the extent and location of the inflammation.

Magnetic resonance imaging (MRI)
Instead of a CT scan your doctor may order an MRI, which uses a magnetic field and radio waves to create highly defined images of the organs and tissues. The MRI can produce similar results as the CT scan. The advantage of MRI over the CT scan is that there is no radiation exposure.

Barium enema X-ray
In some instances, a barium enema X-ray may be recommended. During a barium enema X-ray a chalky liquid is injected into the colon through the rectum to outline the colon so it can be seen with an X-ray. In most cases, a colonoscopy or sigmoidoscopy will be preferred over the barium enema X-ray and serves as a more accurate means of viewing the colon. There is a very limited role for this test

Though most people will not have all of these tests performed in order to make a correct diagnosis, it may be necessary to have several of them to accurately confirm the diagnosis of ulcerative colitis.

Picture of the colon to show where a colonoscopy explores for ulcerative colitis.

Treatment of Ulcerative Colitis

The type of treatment you might receive for ulcerative colitis depends on the severity of the symptoms, the location of the inflammation and how much of the bowel is affected.

Because there is no cure for ulcerative colitis, treatment goals are designed to control the inflammation. Treatment is intended to put the disease into remission and to stop it from becoming active again. Remission can be defined in a few ways. The first way to define remission is when a patient’s bowel habit returns to normal, and no further blood is seen. Recent research suggests that a more reliable definition of remission is when there is no further evidence of inflammation seen in the bowel. This means to be certain a treatment has achieved remission, a physician may recommend a flexible sigmoidoscopy or colonoscopy to evaluate the colon.

Here are the established treatments for ulcerative colitis based on the severity of symptoms and their location. Depending on your unique situation, you may receive one or more of the drugs mentioned below. In more severe cases, surgery may be needed.

1. Mild to moderate left-sided (distal) colitis

For this type of colitis, there are three classes of anti-inflammatory medications:

  • Oral aminosalicylates. This class of medication is effective in treating inflammation in distal colitis. It includes medications by the names: Asacol, Pentasa, Mezavant, Salofalk, and Salazopyrin
  • Topical aminosalicylates. The aminosalicylate drug mesalazine (also known as mesalamine) works directly on the affected bowel wall when given as a suppository or enema. Salofalk and Pentasa are available as both suppositories and enemas.
  • Topical steroids. Steroids, also known as corticosteroids, are used for many different conditions that involve inflammation. For topical use in ulcerative colitis, steroids are given as an enema, suppositories or foam.

Each of these medications typically works well to reduce inflammation in mild to moderate ulcerative colitis. Topical mesalazine is the most effective form of therapy when the inflammation appears only on the left side of the colon. For inflammation that involves the entire colon, a combination of topical mesalazine and an oral aminosalicylate is used. Although aminosalicylates tend to work quickly (improvement may occur within a few weeks), the maximum effect may take up to 2 months.

If none of these three medications is enough to control the colitis, the next step is usually an oral steroid called prednisone. Prednisone attacks inflammation throughout the body and acts as an immune suppressant. Those taking prednisone typically only stay on it for is several weeks because it is known to have unpleasant side effects. However, other options might be available, such as biologic drugs (Remicade, Simponi, Humira and Entyvio) that act to neutralize your immune system.

Maintaining remission in mild to moderate left-sided colitis

Once you achieve remission, your treatment is reassessed. The guidelines recommend both topical mesalazine (suppositories or enemas) and oral aminosalicylates for maintenance of remission because they appear to have the strongest effect on keeping the inflammation at rest. Topical steroids are not recommended. If these treatments do not keep the disease in remission, other medications such as Imuran, mercaptopurine (both of which are immune suppressants), Remicade, Simponi, Humira or Entyvio may be considered.

2. Mild to moderate extensive colitis

If the inflammation has progressed in the bowel beyond what topical medications can treat effectively, it is called extensive colitis or pancolitis (inflammation of the entire colon). Extensive colitis is treated with anti-inflammatory agents, such as oral sulfasalazine or another aminosalicylate. Topical treatment may be added if it is assessed that this combined approach could be most effective.

Maintaining remission in mild to moderate extensive colitis

Oral aminosalicylates help to reduce relapses of inflammation. Long-term steroid treatment is not safe because of the side effects. Patients who need steroids to reach or maintain a state of remission are often prescribed Remicade, Inflectra, Renflexis, Simponi, Humira, Entyvio, Xeljanz, Imuran or mercaptopurine.

Ulcerative colitis not responding to aminosalicylates

Oral steroids (prednisone) can be used short-term if aminosalicylates fail to put the symptoms into remission or there is an acute need to provide relief from severe symptoms. Prednisone can typically be used for several weeks but must be slowly reduced thereafter. If oral steroids don’t work, Remicade, Inflectra, Renflexis, Simponi, Humira, Entyvio, Xeljanz, Imuran or mercaptopurine can be considered. Nicotine patches may also help with symptoms of ulcerative colitis but they are not a preferred treatment over mesalamine. Nicotine patches can cause headaches in some people and this limits the use of this therapy.

Cannabis is receiving a lot of interest as a treatment for ulcerative colitis. There are no easy answers to questions about how effective it is and how safe it is. But emerging results are intriguing, to say the least.

3. Severe colitis

Patients who have severe symptoms and are not helped by oral or topical aminosalicylates or prednisone should be treated with one of the immune suppressants Remicade, Inflectra, Renflexis, Simponi, Humira, Entyvio, Xeljanz, Imuran or mercaptopurine. However, those with symptoms indicating toxicity, such as fever, anemia or a fast heartbeat, may have to be admitted to the hospital for treatment with intravenous steroids. If no improvement occurs within a few days, treatment with intravenous cyclosporine or Remicade can be considered. The guidelines also recommend surgery as an option to remove the affected bowel in cases of severe colitis.

If a patient with severe colitis is suspected to also have an infection, they may be given an antibiotic. Some infections, particularly a bacterium called Clostridium difficile (C. difficile), make the inflammation more difficult to treat.

Surgery for Ulcerative Colitis

Better medical treatments in recent years have resulted in fewer people with ulcerative colitis needing surgery. About 20-30% of people with the disease will require surgery and it may be recommended for a number of reasons:

  • Surgery becomes an option if symptoms are not adequately controlled with medication or the side effects of treatment are severe enough to be dangerous to the patient’s health. If the colon begins showing signs of abnormal cell growth (dysplasia), surgery might be an option to reduce the risk of cancer. Some people also choose to have surgery if the symptoms of ulcerative colitis are significantly affecting their quality of life.
  • Surgery becomes necessary when emergency complications arise, such as tears in the colon, significant bleeding, a severe flare that does not subside within 3-4 days or when the muscles of the colon become dilated and are at risk of rupture (called toxic megacolon).

Surgical procedure to treat ulcerative colitis

Surgery can cure a person of ulcerative colitis but usually involves a number of surgical procedures. The first step is usually the removal of the entire colon (called a subtotal colectomy) up to and including most of the sigmoid colon (the last part of the large intestine) but leaving the rectum in place. The surgeon then creates an opening in the ileum (the last section of the small intestine) called an end ileostomy and may connect the ileum to the rectum. If the rectum is too diseased, the end ileostomy will extend out of the abdomen for the passage of mucous drainage.

The second step typically occurs a few months later when the remaining sigmoid colon and rectum are removed, leaving the anus and pelvic muscles in place so that voluntary control of bowel movements may still be possible. A pelvic pouch (also called a J-pouch) is constructed and connected to the anus. A temporary ileostomy is created (called a loop ileostomy) that allows the pelvic pouch to heal.

After a few weeks have passed to insure healing, the third, smaller procedure is performed to close or reverse the loop ileostomy. The procedure will then most likely allow you to have bowel movements without the need for an external ostomy bag.

All of these surgical procedures can be performed using standard (open) procedures or using minimally invasive (laparoscopic) procedures.

Possible complications

In general, surgery for ulcerative colitis is considered safe. But you do need to watch for the following acute and delayed complications, which could include:

  • Infection
  • Pelvic abscess
  • A painful obstruction of the ileum
  • Urinary incontinence
  • Impotence
  • Infertility
  • Pouchitis (inflammation of the ileal pouch)
  • Small bowel obstructions

Surgery for ulcerative colitis is an important decision. There are risks involved and not every person will be able to restore continuity. Those who are severely ill prior to surgery are more at risk for the above complications. Your need and desire for surgery must always be balanced with the possible complications you might encounter. The benefits and risks along with the best approach for you will be a decision you and your surgeon and other members of your healthcare team make together.

Examples of surgery for ulcerative colitis and Crohn's disease: end ileostomy, a loop ileostomy and a J-pouch.

Ulcerative Colitis Diet

Although there is no substantial evidence that diet alone can treat or cure ulcerative colitis, clinical practice and scientific evidence show that proper nutrition and specific dietary changes may help manage many challenges that come along with the disease. Amongst these challenges are dietary issues associated with ulcerative colitis, including: energy and nutrient deficiencies, weight loss, fatigue, and individual food intolerances that may worsen symptoms. In order to address these major issues, dietary management of ulcerative colitis should be focused on two major areas – meeting energy and nutrient needs, and symptom management.

The dietary strategies that may be used in conjunction with drug therapy for symptom management of ulcerative colitis are to avoid or limit foods that trigger symptoms, and to increase foods of benefit to overall health. Dietary intake may change quite a bit when experiencing a flare compared to remission. During a flare, individuals with ulcerative colitis often find relief by consuming a low fibre diet. Whereas when in remission, it is recommended that high fibre foods are gradually added back in for optimal health. Certain foods that may not cause symptoms during remission may trigger them during a flare.

One of the challenges with ulcerative colitis is that there is not one particular diet that works for everyone with the disease. Foods that worsen symptoms for one individual may be very different than foods that worsen symptoms for the next. It is important that each individual with ulcerative colitis find his/her own specific food intolerances.

Two of the more successful elimination diets that exist to date for individuals are:

  1. The Specific Carbohydrate Diet (SCD). The goal of the diet is to “starve out” harmful bacteria and restore the balance of bacteria in the gut. The diet proposes that complex carbohydrates are not easily digested and therefore feed harmful bacteria in our digestive tract causing them to overgrow producing by products and inflaming the bowel wall.
  2. The Low FODMAP diet. This diet eliminates foods that are high in short chain carbohydrates in order to decrease symptoms. This diet was developed by gastroenterologist Dr. Peter Gibson and registered dietitian Dr. Sue Shepherd to decrease functional gut symptoms such as gas, bloating, distention and diarrhea and/or constipation.

Risk Factors

The symptoms of UC vary by person and range from mild, with long periods between flare-up of symptoms (called remission), to severe symptoms that can result in frequent hospitalizations and have a major impact on peoples quality of life. In some individuals, poor prognostic factors are present that may indicate a more severe disease course. Identifying those with a high risk of severe disease course is important because it may allow the physician to consider a more proactive approach early in treatment to avoid or delay potential complications that may develop.

Some of these risk factors include:

  • Being diagnosed with UC at an early age. Ulcerative colitis diagnosed at an early age has been shown to be a reliable predictor of a more complicated disease course that might warrant an increased need for early immunosuppressive treatment. Approximately 20-30% of UC diagnoses occur in persons aged 20 years or younger. In most studies, UC incidence peaks between adolescence and early adulthood. In contrast, there is some research that indicates a later diagnosis is associated with worse outcomes. But, generally speaking, those diagnosed with UC at age 45 and older experience fewer relapses.
  • Early hospitalization. Patients that required hospitalization at diagnosis have been shown to be more likely to have a severe course of UC and need immunosuppressive therapy early in the treatment process. Early hospitalization is also a risk factor for a future colectomy (surgical removal of the colon).
  • Steroid use early in the course of treatment. Early use of corticosteroids (commonly called steroids) in treatment is also a predictor of severe disease. Corticosteroids are powerful anti-inflammatory drugs used for treating ulcerative colitis Because they carry significant side effects, steroids are typically reserved for those with moderate-to-severe disease or those who relapse after other therapies. They can be very effective short term therapies, but avoiding long or repeated treatments with corticosteroid is an important goal in treating UC. Other medications can help reduce the need for corticosteroids.

What Is the Difference Between Ulcerative Colitis and Other Inflammatory Bowel Diseases (IBDs)?

Ulcerative colitis is often assumed to be the same condition as Crohn’s disease, both of which are considered to be inflammatory bowel diseases (IBDs). Though there is some overlap in symptoms between ulcerative colitis and Crohn’s disease, different parts of the body are affected. Ulcerative colitis is limited to the colon while Crohn’s disease can affect any part of the GI tract, from the mouth to the anus.

The inflammation that accompanies ulcerative colitis is limited to the innermost lining of the colon. In contrast, the entire thickness of the bowel wall is affected with Crohn’s disease.

Another difference is that in Crohn’s disease, the inflammation of the intestine can be intermittent with spaces of normal, non-inflamed areas between the affected areas. In ulcerative colitis this spacing of inflammation does not occur.

In only about 10% of cases a person will have symptoms of both Crohn’s disease and ulcerative colitis.