Ulcerative colitis

Ulcerative colitis is a type of inflammatory bowel disease (IBD) that causes inflammation and sores, called ulcers, in part of the digestive tract. Ulcerative colitis (UL-sur-uh-tiv koe-LIE-tis) affects the innermost lining of the large intestine, called the colon, and rectum. Symptoms usually develop over time, rather than coming on suddenly.

Ulcerative colitis can weaken the body and can sometimes lead to life-threatening complications. While it has no known cure, treatment can greatly reduce and relieve symptoms of the disease. It also may bring about long-term remission.

Ulcerative colitis symptoms can vary, depending on how serious the inflammation is and where it happens. Symptoms may include:

• Diarrhea, often with blood or pus.
• Rectal bleeding — passing a small amount of blood with stool.
• Belly pain and cramping.
• Rectal pain.
• Urgency to pass stool.
• Not being able to pass stool despite urgency.
• Weight loss.
• Fatigue.
• Fever.
• In children, failure to grow.

About half of the people with ulcerative colitis have mild to moderate symptoms. The course of ulcerative colitis may vary, with some people having long periods of remission.

Types

Healthcare professionals often classify ulcerative colitis according to its location. Types of ulcerative colitis include:

• Ulcerative proctitis. Inflammation is confined to the area closest to the anus, called the rectum. Rectal bleeding that sometimes happens with difficulty having bowel movements may be the only sign of the disease.
• Left-sided colitis. Inflammation extends from the rectum up through the sigmoid and descending colon. Proctosigmoiditis is a type of left-sided colitis. Inflammation involves the rectum and sigmoid colon — the lower end of the colon. Symptoms include bloody diarrhea, belly cramps and pain, and not being able to move the bowels despite the urge to do so, called tenesmus.
• Widespread colitis. This is sometimes called pancolitis. This type often affects the entire colon and causes bouts of bloody diarrhea that may be severe, belly cramps and pain, fatigue, and significant weight loss.

When to see a doctor

See a healthcare professional if you notice a lasting change in your bowel habits or if you have symptoms such as:

• Belly pain.
• Blood in the stool.
• Ongoing diarrhea that doesn't respond to nonprescription medicines.
• Diarrhea that awakens you from sleep.
• An unexplained fever lasting more than a day or two.

Although ulcerative colitis usually isn't fatal, it's a serious disease that, in some cases, may cause life-threatening complications.

The exact cause of ulcerative colitis isn't known. Previously, diet and stress were suspected, but now healthcare professionals know that these factors may worsen but don't cause ulcerative colitis. Possible causes may include:

• Immune system issue. One possible cause is an immune system malfunction. When the immune system tries to fight off an invading virus or bacterium, an irregular immune response causes the immune system to attack the cells in the digestive tract too.
• Genetic traits. Several genetic markers have been associated with ulcerative colitis. Heredity also seems to play a role in that the condition is more common in people who have family members with the disease.

Ulcerative colitis affects about the same number of women and men. Risk factors may include:

• Age. Ulcerative colitis usually begins before the age of 30. But it can occur at any age, and some people may not develop the disease until after age 60.
• Race or ethnicity. Although white people have the highest risk of the disease, ulcerative colitis can happen in any race. The risk is even higher for those of Ashkenazi Jewish descent.
• Family history. You're at higher risk if you have a close relative, such as a parent, sibling or child, with the disease.

Possible complications of ulcerative colitis include:

• Severe bleeding.
• A hole in the colon, known as a perforated colon.
• Severe dehydration.
• Loss of red blood cells, known as anemia.
• Bone loss, called osteoporosis.
• Inflammation of the skin, joints and eyes.
• An increased risk of colon cancer.
• A rapidly swelling colon, called toxic megacolon.
• Increased risk of blood clots in veins and arteries.
• Delayed growth and development in children.

Endoscopic procedures with tissue biopsy are the only way to definitively diagnose ulcerative colitis. Other types of tests can help rule out complications or other forms of inflammatory bowel disease, such as Crohn's disease.

To help confirm a diagnosis of ulcerative colitis, one or more of the following tests and procedures may be recommended:

Lab tests

• Blood tests. A healthcare professional may suggest blood tests to check for anemia — a condition in which there aren't enough red blood cells to carry oxygen to the tissues — or to check for signs of infection. Markers of inflammation are also sometimes checked.
• Stool studies. White blood cells or certain proteins in stool can suggest ulcerative colitis. A stool sample also can help rule out other conditions, such as infections caused by bacteria, viruses or parasites.

Endoscopic procedures

• Colonoscopy. This exam allows a healthcare professional to view the entire colon using a thin, flexible, lighted tube with a camera on the end. During the procedure, the healthcare professional takes samples of tissue for testing in a lab. This is called a biopsy. A tissue sample is necessary to make the diagnosis.
• Flexible sigmoidoscopy. A medical professional uses a slender, flexible, lighted tube to examine the rectum and sigmoid colon — the lower end of the colon. If the colon is severely inflamed, this test may be done instead of a full colonoscopy.

Imaging procedures

• X-ray. If symptoms are severe, a standard X-ray of the abdominal area may be done to rule out serious complications, such as a perforated colon.
• CT scan. A CT scan of the abdomen or pelvis may be performed if a complication is suspected. A CT scan also may reveal how much of the colon is inflamed.
• CT enterography and magnetic resonance (MR) enterography. A healthcare professional may recommend one of these noninvasive tests to exclude any inflammation in the small intestine. These tests are more sensitive for finding inflammation in the bowel than are conventional imaging tests. MR enterography is a radiation-free alternative.

Ulcerative colitis treatment usually involves either drug therapy or surgery.

Several categories of medicines may be effective in treating ulcerative colitis. The type you take depends on the severity of your condition. The medicines that work well for some people may not work for others, so it may take time to find a medicine that helps you.

In addition, because some medicines have serious side effects, you need to weigh the benefits and risks of any treatment.

Anti-inflammatory drugs

Anti-inflammatory medicines are often the first step in the treatment of ulcerative colitis and are appropriate for many people with this condition. These medicines include:

• Oral 5-aminosalicylates. Examples of this type of medicine include sulfasalazine (Azulfidine), mesalamine (Delzicol, Lialda, others), balsalazide (Colazal) and olsalazine (Dipentum). Which one is recommended, and whether it is taken by mouth or as an enema or suppository, depends on the area of the colon that's affected.
• Corticosteroids. These medicines, which include prednisone and budesonide, are generally reserved for moderate to severe ulcerative colitis that doesn't respond to other treatments. Due to the side effects, they are not usually given long term.

Immunomodulators

These medicines also reduce inflammation, but they do so by suppressing the immune system response that starts the process of inflammation. For some people, a combination of these medicines works better than one medicine alone.

Immunomodulators include:

• Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol, Purixan). These are the most widely used immunomodulators for the treatment of inflammatory bowel disease. Taking them requires that you follow up closely with your healthcare team and have your blood checked regularly to look for side effects, including effects on the liver and pancreas.
• Cyclosporine (Gengraf, Neoral, Sandimmune). This medicine is usually reserved for people who haven't responded well to other medicines. Cyclosporine has the potential for serious side effects and is not for long-term use.

Biologics

This class of therapies targets proteins made by the immune system. Types of biologics used to treat ulcerative colitis include:

• Infliximab (Remicade), adalimumab (Humira) and golimumab (Simponi). These medicines, called tumor necrosis factor (TNF) inhibitors, work by neutralizing a protein produced by the immune system. They are for people with severe ulcerative colitis who don't respond to or can't tolerate other treatments.
• Vedolizumab (Entyvio). This medicine is approved for treatment of ulcerative colitis for people who don't respond to or can't tolerate other treatments. It works by blocking inflammatory cells from getting to the site of inflammation.
• Ustekinumab (Stelara). This medicine is approved for treatment of ulcerative colitis for people who don't respond to or can't tolerate other treatments. It works by blocking a protein that causes inflammation.
• Mirikizumab (Omvoh). Mirikizumab is a biologic medicine recently approved to treat ulcerative colitis.
• Risankizumab (Skyrizi). Risankizumab is another biologic medicine recently approved to treat ulcerative colitis.

Small molecules

More recently, orally delivered agents also known as "small molecules" have become available for ulcerative colitis treatment. Types of small molecule medicines include:

• Tofacitinib (Xeljanz), upadacitinib (Rinvoq) and filgotinib (Jyseleca). These medicines are known as Janus kinase (JAK) inhibitors. JAK inhibitors are small molecule medicines that help reduce inflammation by targeting parts of the immune system that cause inflammation in the intestines.
• Ozanimod (Zeposia). Ozanimod is another type of small molecule medicine available for ulcerative colitis. Ozanimod is a class of medicine known as a sphingosine-1-phosphate (S1P) receptor modulator.

The U.S. Food and Drug Administration (FDA) recently issued a warning about tofacitinib, stating that preliminary studies show an increased risk of serious heart-related problems and cancer from taking this medicine. If you're taking tofacitinib for ulcerative colitis, don't stop taking the medicine without first talking with a healthcare professional.

Other medicines

You may need additional medicines to manage specific symptoms of ulcerative colitis. Always talk with your healthcare team before using nonprescription medicines. One or more of the following medicines may be recommended:

• Antidiarrheal medicines. For severe diarrhea, loperamide (Imodium A-D) may be effective. Use antidiarrheal medicines with great caution and after talking with your healthcare team, because they may increase the risk of an enlarged colon, called toxic megacolon.
• Pain relievers. For mild pain, your care team may recommend acetaminophen (Tylenol, others) — but not ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) and diclofenac sodium, which can worsen symptoms and increase the severity of disease.
• Antispasmodics. Sometimes care professionals prescribe antispasmodic therapies to help with cramps.
• Iron supplements. If you have ongoing intestinal bleeding, you may develop iron deficiency anemia and be given iron supplements.

Surgery

Surgery can eliminate ulcerative colitis and involves removing your entire colon and rectum. This procedure is called a proctocolectomy.

In most cases, proctocolectomy involves another procedure called ileoanal anastomosis (J-pouch) surgery. A J-pouch eliminates the need to wear a bag to collect stool. The surgeon constructs a pouch from the end of the small intestine. The pouch is then attached directly to the anus, allowing for a relatively typical way to expel waste.

In some cases, a pouch is not possible. Instead, surgeons create a permanent opening in the belly, called an ileal stoma, through which stool is passed for collection in an attached bag.

In another type of procedure known as a continent ileostomy, also called a Koch pouch, the surgeon creates an ileal stoma opening in the belly, then places a one-way valve in the opening. A continent ileostomy does not collect stool in a bag. Instead, a tube is placed into the valve when stool needs to be emptied. This allows for control over the timing of bowel elimination.

Cancer surveillance

You will likely need more-frequent screening for colon cancer because of your increased risk. The recommended schedule will depend on the location of your disease and how long you have had it. People with proctitis are not at increased risk of colon cancer.

If your disease involves more than your rectum, you will require a surveillance colonoscopy every 1 to 2 years, beginning as soon as eight years after diagnosis. The frequency depends on how much inflammation there is and how much of the colon is involved.

Sometimes you may feel helpless when facing ulcerative colitis. But changes in your diet and lifestyle may help control your symptoms and lengthen the time between flare-ups.

There's no firm evidence that what you eat actually causes inflammatory bowel disease. But certain foods and beverages can worsen your symptoms, especially during a flare-up.

It can be helpful to keep a food diary to keep track of what you're eating, as well as how you feel. If you discover that some foods are causing your symptoms to flare, you can try removing them from your diet.

Here are some general dietary suggestions that may help you manage your condition:

• Limit dairy products. Many people with inflammatory bowel disease find that problems such as diarrhea, belly pain and gas improve by limiting or removing dairy products. You may be lactose intolerant — that is, your body can't digest the milk sugar, called lactose, in dairy foods. Using an enzyme product such as Lactaid may help as well.
• Eat small meals. You may find that you feel better eating five or six small meals a day rather than two or three larger ones.
• Drink plenty of liquids. Try to drink plenty of liquids daily. Water is best. Alcohol and beverages that contain caffeine stimulate your intestines and can make diarrhea worse, while carbonated drinks frequently produce gas.
• Talk to a dietitian. If you begin to lose weight or your diet becomes very limited, talk to a registered dietitian.

Stress

Although stress doesn't cause inflammatory bowel disease, it can make your symptoms worse and may trigger flare-ups.

To help control stress, try:

• Exercise. Even mild exercise can help reduce stress, relieve depression and stabilize bowel function. Talk to your healthcare team about an exercise plan that's right for you.
• Relaxation and meditation exercises. One way to cope with stress is to regularly relax and use techniques such as deep, slow breathing to calm down. Many helpful books and online videos are available to help with relaxation and meditation.

Many people with digestive disorders have used some form of complementary and alternative medicine. However, there are few well-designed studies showing the safety and effectiveness of complementary and alternative medicine.

Although research is limited, there is some evidence that adding probiotics along with other medicines may be helpful, but this has not been proved.

Symptoms of ulcerative colitis may first prompt you to visit your primary healthcare professional. Your healthcare professional may recommend that you see a specialist who treats digestive diseases, called a gastroenterologist.

Because appointments can be brief, and there's often a lot of information to discuss, it's a good idea to be well prepared. Here's some information to help you get ready, and what to expect from your appointment.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.
• Write down any symptoms you're experiencing, including any that may not seem to be related to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medicines, vitamins or supplements that you're taking. Be sure to let your healthcare professional know if you're taking any herbal preparations as well.
• Ask a family member or friend to come with you. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who goes with you may remember something that you missed or forgot.
• Write down questions to ask your healthcare professional.

Your time with your healthcare professional is limited, so preparing a list of questions ahead of time can help you make the most of your time. List your questions from most important to least important in case time runs out. For ulcerative colitis, some basic questions to ask your health professional include:

• What's the most likely cause of my symptoms?
• Are there other possible causes for my symptoms?
• What kinds of tests do I need? Do these tests require any special preparation?
• Is this condition temporary or long lasting?
• What treatments are available, and which do you recommend?
• What types of side effects can I expect from treatment?
• Are there any prescription or over-the-counter medicines I need to avoid?
• What sort of follow-up care do I need? How often do I need a colonoscopy?
• Are there any alternatives to the primary approach that you're suggesting?
• I have other health conditions. How can I best manage them together?
• Are there certain foods I can't eat anymore?
• Will I be able to keep working?
• Can I have children?
• Is there a generic alternative to the medicine you're prescribing?
• Are there any brochures or other printed material that I can take with me? What websites do you recommend?

What to expect from your doctor

Your healthcare professional is likely to ask you some questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your healthcare professional may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• Do you have abdominal pain?
• Have you had diarrhea? How often?
• Have you recently lost any weight without trying?
• Does anything seem to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Have you ever had liver problems, hepatitis or jaundice?
• Have you had any problems with your joints or eyes, had skin rashes or sores, or had sores in your mouth?
• Do you awaken from sleep during the night because of diarrhea?
• Have you recently traveled? If so, where?
• Is anyone else in your home sick with diarrhea?
• Have you taken antibiotics recently?
• Do you regularly take nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve)?