Ulcerative Colitis

Causes

• Immune System Dysfunction: A leading theory suggests that the immune system mistakenly attacks harmless bacteria, food, and other substances in the gut, leading to chronic inflammation.
• Genetics: UC tends to run in families. People with a family history of UC are at higher risk. Specific gene mutations have been identified that increase susceptibility.
• Environmental Factors: While no specific environmental trigger has been definitively identified, factors like diet, stress, and certain infections may play a role in triggering flare-ups in genetically predisposed individuals. However, they are not considered direct causes.
• Gut Microbiome: Imbalances in the bacteria normally found in the gut may contribute to the inflammatory response.

Symptoms

• Diarrhea: Often with blood or pus. This is the most common symptom.
• Abdominal pain and cramping: Usually felt in the lower abdomen.
• Rectal pain.
• Rectal bleeding: Passing small amounts of blood with stool.
• Urgency to defecate (tenesmus): A strong, sudden urge to have a bowel movement.
• Inability to defecate despite urgency.
• Weight loss.
• Fatigue.
• Fever.
• Anemia: Due to chronic blood loss from the inflamed bowel.
• Extraintestinal manifestations: Inflammation can also affect other parts of the body, including:
  • Joint pain and swelling (arthritis)
  • Skin lesions (e.g., erythema nodosum, pyoderma gangrenosum)
  • Eye inflammation (e.g., uveitis, episcleritis)
  • Liver and bile duct inflammation (e.g., primary sclerosing cholangitis)

Diagnosis

• Blood Tests:
  • Complete Blood Count (CBC): To check for anemia (low red blood cells) and signs of inflammation.
  • C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR): Markers of inflammation in the body.
  • Liver function tests.
• Stool Tests:
  • To rule out infections (bacterial, viral, parasitic) that can cause similar symptoms.
  • To check for markers of inflammation in the stool (e.g., fecal calprotectin).
• Endoscopy with Biopsy:
  • Colonoscopy: A thin, flexible tube with a camera is inserted into the rectum and advanced through the entire colon to visualize the lining. Biopsies (small tissue samples) are taken to confirm inflammation and rule out other conditions.
  • Sigmoidoscopy: Similar to colonoscopy but examines only the rectum and lower part of the colon.
• Imaging Tests:
  • CT scan or MRI: May be used to assess the extent of inflammation, rule out complications, or differentiate UC from Crohn's disease.

Treatment

• Medications:
  • Aminosalicylates (5-ASAs): Often the first-line treatment for mild to moderate UC. They reduce inflammation in the colon (e.g., mesalamine, sulfasalazine). Available orally or as suppositories/enemas.
  • Corticosteroids: Used for short-term control of moderate to severe flare-ups due to their powerful anti-inflammatory effects (e.g., prednisone, budesonide). Not for long-term maintenance.
  • Immunomodulators: Suppress the immune system to reduce inflammation and maintain remission (e.g., azathioprine, mercaptopurine). They can take several weeks to months to become effective.
  • Biologic therapies: Target specific proteins in the immune system to reduce inflammation. Used for moderate to severe UC that hasn't responded to other treatments (e.g., infliximab, adalimumab, vedolizumab, ustekinumab). Administered by injection or infusion.
  • Janus kinase (JAK) inhibitors: Oral medications that block specific immune pathways (e.g., tofacitinib).
• Lifestyle and Dietary Management:
  • Dietary adjustments: While diet doesn't cause UC, certain foods can trigger symptoms during flare-ups. Identifying and avoiding personal trigger foods can help. A balanced, nutritious diet is important.
  • Stress management: Stress can exacerbate symptoms. Techniques like meditation, yoga, and exercise can be beneficial.
  • Avoid NSAIDs: These can worsen UC symptoms.
• Surgery:
  • Surgery (proctocolectomy, removal of the colon and rectum) is a curative option for UC. It is considered when medical therapy fails, for severe complications (e.g., toxic megacolon, severe bleeding), or if there is a high risk of colon cancer.
  • Often, a pouch (ileal pouch-anal anastomosis or J-pouch) is created from the small intestine to allow for stool passage, avoiding a permanent ostomy in many cases.

Living With Ulcerative Colitis

Ulcerative colitis is a lifelong condition with long stretches of normal life between flares, and how long those stretches last depends mostly on decisions made while you feel well. The most common mistakes are stopping maintenance treatment in remission and leaning on steroids instead of escalating.

Maintenance treatment continues when you feel fine

Mesalamine or sulfasalazine taken every day in remission roughly halves the chance of a flare, and for disease limited to the rectum a mesalamine suppository does more than any tablet. Stopping because symptoms are gone is the single most common reason for relapse, and it also forfeits the reduction in colon cancer risk that long-term mesalamine appears to provide.

Steroids treat a flare; they do not manage the disease

Prednisone or gut-targeted budesonide settles most flares within days, but needing steroids more than once a year, or being unable to taper off, means the maintenance plan is inadequate. That is the signal to move to a biologic such as infliximab or adalimumab, or an oral JAK inhibitor such as tofacitinib or upadacitinib, rather than to another round of prednisone.

Not every flare is colitis

A stool test for C. difficile is sent with every flare, because that infection mimics colitis, is more common in people with it, and is made worse by steroids. A stool calprotectin distinguishes active inflammation from irritable bowel symptoms, which many people with colitis also have. NSAIDs such as ibuprofen can trigger flares and are avoided. The Crohn's disease page covers the other form of inflammatory bowel disease, which is treated differently in places.

Colon cancer surveillance

Risk rises with the extent and duration of inflammation, so surveillance colonoscopy begins about eight years after symptoms started and repeats every one to three years, or annually from diagnosis when primary sclerosing cholangitis is also present. Keeping inflammation controlled is itself the most effective cancer prevention available.

Iron, bones, vaccines, and emergencies

Chronic blood loss makes iron deficiency common and often overlooked; intravenous iron works better than tablets during active disease. Repeated steroid courses call for a bone density check, since osteoporosis is more common in colitis. Before a biologic or JAK inhibitor, tuberculosis and hepatitis B are screened for and vaccines including shingles are brought current. Six or more bloody stools a day with fever, a racing pulse, or severe pain is acute severe colitis and needs hospital care the same day. Our gastrointestinal team coordinates care with gastroenterology, and the IBS versus IBD article explains how the two overlap. The Crohn's and Colitis Foundation and NIDDK publish patient guidance on treatment and living well.

If you have needed steroids more than once in the past year, or stopped your maintenance medication because you felt well, schedule a visit.