Ulcerative colitis: symptoms, treatment, diet, and more

What Is Ulcerative Colitis?

Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD) that causes inflammation and ulcers in the innermost lining of the large intestine (also known as the colon) and rectum.

If you have ulcerative colitis, you may experience symptoms such as diarrhea, blood in your stool, fatigue, abdominal pain, cramping, and weight loss.

Ulcerative colitis is thought to be a chronic relapsing-remitting disease in which people experience periods of active disease, where there is active inflammation, followed by periods of inactive disease, also known as remission.^ There's no cure for ulcerative colitis, but treatment can help manage symptoms and prevent complications.

How common is ulcerative colitis?

It's estimated that ulcerative colitis affects up to 944,000 people in the United States^, with 39,600 newly diagnosed cases each year.^

Who gets ulcerative colitis?

Ulcerative colitis can affect anyone, but it’s most commonly diagnosed when you’re between the ages of 10 and 30 and less commonly between the ages of 50 and 80.^ Ulcerative colitis affects both men and women equally, and is more common in those of Jewish descent ^ and those with a family history of ulcerative colitis.^

Ulcerative colitis in children

Approximately 15-20% of all ulcerative colitis cases occur in children.^ Children tend to have a more severe type of ulcerative colitis and are twice as likely to have extensive disease (inflammation throughout the large intestine) compared to adults.

Children diagnosed with ulcerative colitis are also more likely to require hospitalization and surgery compared to those diagnosed as adults, though treatment can help reduce these risks.^

Types of ulcerative colitis

The type of ulcerative colitis you have depends on the location of the inflammation in your GI tract. 

• Ulcerative proctitis - With ulcerative proctitis, inflammation is present only in the rectum (the last part of your GI tract before your anus). 
• Proctosigmoiditis - With proctosigmoiditis, inflammation is present in the rectum and the last part of the large intestine (called the sigmoid colon). 
• Left-sided colitis - If you have left-sided colitis, your doctor saw inflammation in the left side of your large intestine (called the descending colon), but not across the colon, or on the right side. With left-sided colitis, inflammation extends from the left-side of the colon to the rectum.
• Pancolitis - With pancolitis, also known as extensive colitis, inflammation is present throughout the large intestine from the rectum to the parts of your colon closest to the small intestine. 

It’s possible for your type of ulcerative colitis to change over time. Your doctor can help determine your specific type of ulcerative colitis.

What is mild, moderate, and severe ulcerative colitis?

When you’re initially diagnosed, your doctor will determine the severity of your ulcerative colitis. Your UC may be considered mild, moderate, or severe depending on your symptoms, colonoscopy or sigmoidoscopy results, and lab test results.

The severity of your UC will help your doctor determine the right treatment plan for you. 

Ulcerative colitis vs Crohn’s disease vs IBS

Ulcerative colitis and Crohn’s disease are both inflammatory bowel diseases in which inflammation occurs in different parts of the GI tract while IBS is a functional disorder.

• Ulcerative colitis - Inflammation occurs in the rectum and large intestine (colon) and affects the innermost lining of the GI tract.
• Crohn’s disease - Inflammation can occur anywhere throughout the GI tract but is most commonly seen in the small intestine. Crohn’s disease often shows up as patches of inflammation surrounded by healthy tissue and may affect the entire thickness of your GI tract. 
• Irritable bowel syndrome (IBS) - While people with IBS may have similar symptoms to those with IBD, IBS does not cause inflammation and is considered a functional disorder in which the function of the bowel is disrupted. The exact cause of IBS is currently unknown.

Signs & Symptoms

The signs and symptoms of ulcerative colitis can vary from person to person and may differ depending on the location and severity of inflammation in the colon and rectum. Common symptoms may include:

• Diarrhea
• Blood or mucus in your stools
• Bowel urgency
• Stomach cramping or pain
• Fatigue
• Loss of appetite
• Weight loss
• Anemia
• Joint pain
• Skin or eye irritation
• Fever
• Feelings of incomplete evacuation of your bowels
• Constipation
• Acid reflux 

Extraintestinal manifestations of ulcerative colitis

When symptoms of ulcerative colitis occur outside of the gastrointestinal tract, they are called extraintestinal manifestations (EIMs). EIMs occur in 25-40% of people with inflammatory bowel disease^ and can significantly impact your quality of life. Common EIMs of ulcerative colitis include:^

• Peripheral arthritis - Inflammation of the joints in the arms and legs may occur in up to 14% of people with ulcerative colitis. Arthritis is more common in people with pancolitis than those with left-sided colitis.
• Skin and mouth - Approximately 2-10% of people with ulcerative colitis may develop erythema nodosum (red, painful bumps under the skin). Pyoderma gangrenosum (large, painful sores) may occur in up to 2.6% of cases.
• Eyes - Inflammation of the middle layer of the eye (anterior uveitis) may occur in 3-4% of people with UC.
• Liver - Primary sclerosing cholangitis (PSC) is a rare liver condition in which the bile ducts in and around the liver become inflamed. This inflammation leads to scarring and narrowing of the bile ducts and in some cases may require a liver transplant. It’s estimated that up to 5% of people with UC may develop PSC.

What is an ulcerative colitis flare?

An ulcerative colitis flare, or flare-up, is when you experience symptoms of the disease. Flare-ups can be triggered by a variety of factors, including stress^{ }, missing, skipping, or taking the wrong dose of your medication,^ or consuming certain foods.

During a flare, you may experience abdominal pain, bowel urgency, diarrhea, or constipation. You may also notice increased fatigue, loss of appetite, or weight loss. An ulcerative colitis flare can last for a few days to several months or years.

Does a flare mean you have inflammation?

Inflammation in the GI tract, also referred to as active disease, is poorly correlated with symptoms.

It's possible to have no noticeable symptoms while still having inflammation. Likewise, it's possible to experience symptoms without having active disease. As a result, it's important to have your doctor continue to check your labs and scopes for inflammation, even if you're feeling symptom-free.

The absence of inflammation can only be confirmed by your doctor after looking at the lining of your GI tract during a colonoscopy or endoscopy, or by a doctor in a lab using a microscope.

Causes

The exact cause of ulcerative colitis is unknown. However, researchers believe that, in genetically susceptible individuals, certain environmental factors may contribute to microbiome changes and lead to an inappropriate immune system response.^

Risk Factors

Ulcerative colitis can affect anyone at any age. However, certain factors may increase your risk of developing UC including:^{     }

• Age - You may be more likely to develop UC if you’re between the ages of 10-30 or 50-80 years old
• Family history - If you have a family history of inflammatory bowel disease, you’re more likely to develop it yourself 
• Race - If you are white or of Ashkenazi Jewish descent, you are at an increased risk for developing ulcerative colitis
• Stress - Stressful life events and high perceived stress may increase your risk of developing UC
• Lifestyle - Former smoker, and alcohol use
• Personality type - Neuroticism
• Nutrient deficiencies - Vitamin D deficiency 
• Certain types of birth control - Oral contraceptive use 
• Antibiotic exposure - Excessive antibiotic use in early childhood 
• Certain dietary factors - Dietary factors such as frequent soda consumption and a high fat diet may increase your risk

Diagnosis

If your doctor suspects you might have ulcerative colitis, they will perform a number of tests and procedures to confirm or rule out a diagnosis. 

Lab tests

• Blood tests - Your gastroenterologist may order blood tests to check for anemia (a lower-than-normal number of red blood cells) or signs of an active or inactive infection. They may also check for vitamin and nutrient deficiencies and signs of inflammation, such as your c-reactive protein levels (CRP) or erythrocyte sedimentation rate (ESR).
• Stool tests - In certain cases, your doctor may request a stool sample to measure your fecal calprotectin levels (a measure of bowel inflammation), or fecal PCR to check for bacterial infections.

Procedures

• Colonoscopy - A colonoscopy is a procedure in which your doctor, typically your gastroenterologist, uses a small, flexible camera to look inside your rectum and large intestine. During your colonoscopy, your doctor will examine the inner lining of your entire colon to look for signs of inflammation. Your doctor may also take small samples of your intestine - called biopsies - to check for microscopic levels of inflammation and make a diagnosis. If you undergo a colonoscopy, you’ll likely be sedated to avoid discomfort. 
• Flexible sigmoidoscopy - During this procedure, your doctor will insert a small flexible camera into your rectum to examine the lower part of your large intestine, called the sigmoid colon and rectum. Unlike a colonoscopy, many people undergo a sigmoidoscopy without sedation. 

Imaging

Imaging is not always required for people with ulcerative colitis but your doctor may recommend certain procedures to identify certain complications of the disease. Imaging can also be used to look for the presence of inflammation in the small intestine which may be indicative of Crohn’s disease. The most common imaging procedures include:

• MRI Scan - An MRI (magnetic resonance imaging) scan uses a strong magnetic field and radio waves to take detailed images of the intestines and surrounding area. During an MRI scan, you lay on a table inside a large, cylindrical machine. Since MRI scans do not use x-rays, they may be used instead of a CT scan to avoid radiation exposure.
• CT Scan - a CT (computed tomography) scan is a type of x-ray that doctors use to create detailed images of the inside of the body. Your doctor may order a CT scan to look at your intestines and surrounding organs to diagnose potential complications of the disease such as primary sclerosing cholangitis or toxic megacolon. 

Treatment Options

There is no cure for ulcerative colitis. However, there are many treatment options available that are used to reduce inflammation, symptoms, and complications.

In the best-case scenario, treatment may lead to periods of deep remission and few, if any, symptoms. While no single treatment works for everyone, your doctor will be able to help find the best option for you.

Anti-inflammatory medications

These medications are used to reduce inflammation in the lining of your intestines. There are two types of anti-inflammatory drugs commonly used in ulcerative colitis.

• Steroids - Steroids, such as prednisone and budesonide, are typically used for a short period of time to reduce inflammation. They may be used with other medications, and the dosage is typically tapered down over time.
• 5-ASAs (5-Aminosalicylates) - 5-ASA drugs are often used as the first line treatment for mild to moderate ulcerative colitis. In these patients, mesalamine can help reduce symptoms, induce and maintain remission, and help you improve your quality of life. 5-ASAs may be taken orally or delivered directly to the colon through a suppository, enema, or foam. The most common 5-ASAs include mesalamine (Asacol, Lialda, Pentasa, Apriso, Delzicol), sulfasalazine (Azulfidine, Sulfazine), balsalazide (Colazal, Giazo), and olsalazine (Dipentum).^

Immune system suppressors (immunomodulators)

These types of drugs help to reduce inflammation by decreasing the activity of your immune system. They may be used in combination with other medications, such as biologics. Immune system suppressors used in ulcerative colitis include 

• 6-mercaptopurine (Purixan, Purinethol)
• Azathioprine (Azasan, Imuran)

Biologics

Biologics prevent and reduce inflammation in the digestive system by targeting and blocking certain parts of your immune system that cause inflammation.

Common biologics used for ulcerative colitis include:

• Infliximab (Remicade)
• Adalimumab (Humira)
• Golimumab (Simponi)
• Vedolizumab (Entyvio)
• Ustekinumab (Stelara)
• Risankizumab-rzaa (Skyrizi)

Depending on the severity of your inflammation and which other medications you’ve tried, your doctor may recommend a biologic to treat your inflammation. 

Small molecule medications

Small molecule medications are a type of medication that is taken by mouth and may help reduce inflammation in people with moderate-to-severe ulcerative colitis when other medications have failed. 

Common small molecule medications used to treat ulcerative colitis include:

• Tofacitinib (Xeljanz)
• Upadacitinib (Rinvoq)
• Ozanimod (Zeposia)

Anti-diarrheal medications

Your doctor may recommend a fiber supplement to bulk up your stools and reduce mild to moderate diarrhea. For severe cases of diarrhea, loperamide (Imodium) is sometimes recommended.

It's important to note that anti-diarrheal medications may not be appropriate and could be potentially harmful, so you should only take them under the supervision of your doctor. Certain medications, such as cholestyramine, may also be prescribed if bile acid malabsorption is contributing to your diarrhea.^

Pain relievers

If you experience mild pain, your doctor may recommend acetaminophen (Tylenol).

Research is currently inconclusive about the safety of NSAIDS, such as aspirin, ibuprofen (Advil, Motrin) and naproxen (Aleve) for people with ulcerative colitis, with a recent review finding that NSAID use was associated with increased complications in Crohn’s disease but not ulcerative colitis.^

Antispasmodics, such as dicyclomine, neuropathic-directed agents, such as amitriptyline or gabapentin, and antidepressants, such as tricyclic antidepressants or selective serotonin re-uptake inhibitors (SSRIs), may also be helpful for reducing pain.^

Antibiotics

There are certain instances where antibiotics may be prescribed for individuals with UC.

People with ulcerative colitis are at an increased risk for fecal infections and small intestinal bacterial overgrowth (SIBO).^{ } If you have a fecal infection, your doctor may prescribe antibiotics, such as vancomycin, metronidazole, or Ciproflofloxacin to treat it.^

If you have SIBO, an antibiotic, such as Rifaximin, may be prescribed to treat it.^

Individuals with ulcerative colitis who have undergone ileal pouch anal anastomosis surgery (IPAA), may also be prescribed antibiotics if they have pouchitis, or inflammation of the pouch.^

Supplements

Curcumin/turmeric supplementation - Curcumin supplementation has been suggested to increase the chances of inducing remission in those with mild to moderate ulcerative colitis.^ Recent reports of liver injury from high bioavailable curcumin supplements have been reported.^{ } If you and your doctor decide you want to try curcumin supplementation, it may be a good idea to regularly monitor liver functioning tests and stop supplementation if liver injury occurs. This is of particular concern to those on certain medications that are processed in the liver, as it would be difficult to know whether it’s the curcumin or medication that is causing the liver injury. 

Fish oil/Omega 3 fatty acid supplements - Guidelines say there’s insufficient evidence that supports the use of fish oil supplementation for induction or maintenance of remission in IBD.^

Probiotics - In patients with mild to moderate ulcerative colitis, taking certain probiotics along with 5-ASA’s, or alone may increase the chances of induction of remission.^{ }

Glutamine - A meta-analysis found that glutamine supplementation did not encourage induction or maintenance of remission, nor did it help with nutritional status, intestinal permeability, or symptoms.^

Surgery

Surgery for ulcerative colitis is typically considered when medical therapy fails to manage your inflammation, when you experience complications of the disease, or when you’re at a risk of developing cancer such as colorectal cancer.

About 20-30% of people with ulcerative colitis may need surgery within 25 years of diagnosis.^

The most common form of surgery for ulcerative colitis is called a proctocolectomy which involves removing your colon and rectum. There are two types of proctocolectomy surgeries:

• Proctocolectomy with ileal pouch-anal anastomosis surgery (IPAA, or J-pouch, surgery) - This procedure may require multiple surgeries to complete and involves the removal of your colon and rectum followed by the creation of a j-pouch. A j-pouch is when your small intestine is formed into a “J” which functions as your new rectum and is attached to your anus, allowing you to pass stool in the way you previously did . 
• Proctocolectomy with end ileostomy - This procedure involves the removal of your colon, rectum, and anus. Your surgeon will then create an opening, or stoma, in your abdomen, and your ileum (the last part of your small intestine) will stick out of this stoma. This is known as an ileostomy. With an ileostomy, stool passes out of your body through the stoma and into an ostomy bag which is worn outside of your body and needs to be emptied throughout the day.

Diet

Diet plays an important role in managing ulcerative colitis. Diet can help decrease symptoms and prevent and manage malnutrition.

It's important to work with a registered dietitian with experience working with people with ulcerative colitis to develop a personalized nutrition plan. Your dietitian will help you prevent or correct malnutrition and avoid restrictive eating habits which may negatively impact your symptoms and relationship with food.

Lifestyle factors

Certain lifestyle factors, such as stress and poor sleep quality, may lead to more severe symptoms of ulcerative colitis.

• ‍Stress - Research suggests that people who experience higher levels of stress, new sources of stress, or a recent life event are more likely to experience a flare.^{ }
• ‍Sleep quality - 47-72% of people with ulcerative colitis suffer from poor sleep quality, which may be associated with increased risk for disease activity.^{ }

Mental health care

People with ulcerative colitis are more likely to experience anxiety and depression than healthy individuals. Anxiety and depression are also more common when you have active disease compared to remission.^ It may be helpful to consult with a GI-specific psychologist to process a new diagnosis or cope with the symptoms and worries that people with Crohn’s disease often experience. 

Is ulcerative colitis curable?

There is no cure for ulcerative colitis. However, with proper treatment and management, people with ulcerative colitis can often lead normal, active lives.

Diet & Nutrition

Diet guidelines for ulcerative colitis

A recent study from the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) suggested general diet guidelines for people with ulcerative colitis.^

The guidelines recommend increasing your intake of:

• Omega-3 fatty acids from fish (but not from supplements)

The guidelines recommend no changes to your intake of:

• Fruits and vegetables
• Refined sugars and carbohydrates
• Wheat/gluten
• Chicken or poultry
• Alcoholic beverages

The guidelines recommend reducing your intake of:

• Red and processed meats
• Unpasteurized dairy products
• Dietary fats including palm oil, coconut oil, dairy fats, and trans fats
• Maltodextrin-containing foods
• Artificial sweeteners
• Carboxymethylcellulose
• Polysorbate-80
• Carrageenan
• Titanium dioxide
• Sulfites

The guidelines were not able to come to a consensus on the intake of:

• Pasteurized dairy products

Diets for ulcerative colitis

Your diet can play an important role in helping to manage your symptoms and needs to be  individualized in order to be effective and reduce your risk for symptoms, malnutrition, and disordered eating.

Everyone’s trigger foods (foods that cause symptoms when consumed) are unique and it’s important to find what works for you in particular in order to keep your diet as broad and sustainable as possible. 

Unlike in Crohn’s disease, there is no specific diet that has been shown in research studies to be effective at helping people with ulcerative colitis get into and stay in remission.^

While there are several diets that have been popularized on the internet and social media for the treatment of ulcerative colitis, none of the following diets have sufficient evidence to support the use of these diets for the induction or maintenance of remission.^ Some diets commonly considered by people with ulcerative colitis include:

• Mediterranean diet
• Specific carbohydrate diet (SCD)
• IBD anti-inflammatory diet (IBD-AID)
• Autoimmune Protocol Diet (AIP)
• Low FODMAP diet
• Gluten free diet

Complications

Anemia - Anemia is a complication of ulcerative colitis in which your body does not produce enough healthy red blood cells which carry oxygen. Anemia due to an iron deficiency is common in people with IBD and is caused by blood loss and poor iron absorption due to inflammation.^ A common symptom  of iron deficiency anemia is chronic fatigue.

Blood clots - People with ulcerative colitis are at a 1.5-3.5x greater risk of blood clots in their veins compared to the general population.^

Cervical cancer - Although individuals with ulcerative colitis may not be at an increased risk for cervical cancer, they do appear to be at an increased risk for cervical lesions that could be precancerous, therefore, annual PAP smears are often recommended.^{ }

Colorectal cancer - People with ulcerative colitis are 2.4 times more likely to develop colorectal cancer than the general population. Male sex, young age at diagnosis, and extensive colitis (pancolitis) are all associated with increased risk of colorectal cancer.^

Dehydration - Dehydration can occur in UC patients, especially when they have frequent loose bowel movements, toxic megacolon, or have recently had surgery.^{ }

Fulminant colitis - Fulminant colitis occurs when you have more than 10 stools a day, have continuous rectal bleeding, abdominal pain, distention, a fever and decreased appetite.^

Malnutrition - When your body isn't receiving or absorbing the nutrients it needs, you may experience malnutrition. Common symptoms of ulcerative colitis, such as diarrhea, cramping, and abdominal pain, may make it harder to eat enough to nourish your body and harder for your body to absorb the nutrients you consume. Malnutrition is associated with worse outcomes, loss of response to medications, and decreased quality of life.^ You should always work with a registered dietitian to address malnutrition.

Osteoporosis - Studies have suggested that people with IBD may have lower bone mineral density and a higher risk of fractures than the general population.^ It's estimated that 2-9% of people with UC  may have osteoporosis.^ Factors increasing the risk for osteoporosis include lower body mass index (BMI), lower body weight, and an older age.^ 

Perforated colon - This is where there’s an injury somewhere in the colon wall.^ This may occur during colonoscopies or during surgeries.^

Pouchitis - pouchitis is when there’s inflammation of the pouch.^ Up to 48% of J-pouch patients may experience pouchitis within the first two years after IPAA surgery.^ Factors that may increase the risk for pouchitis include a history of primary sclerosing cholangitis, and need for biologic therapy prior to colectomy.^

Primary sclerosing cholangitis - Primary sclerosing cholangitis (PSC) is a rare, progressive bile duct and liver disease that may occur in individuals with IBD.^ Although only 2-5% of individuals with IBD may have PSC, about 70% of those with PSC also have or develop IBD.^{ } PSC is more common in males and in UC patients with pancolitis.^ 

Skin cancer - Individuals with IBD have an increased risk for melanoma, or skin cancer.^

Skin disorders - Skin disorders are one of the most common complications of IBD.^ You may experience red bumps or blisters on your skin, fistulas or fissures around your rectum, or canker sores in and around your mouth.

Surgical complications - Ileal-anal separation, anal stricture, pouchitis, pouch prolapse, pelvic sepsis, and small bowel obstructions are all possible complications of an IPAA surgery.^{ }

Toxic megacolon - Toxic megacolon is a life threatening complication of Ulcerative colitis.^ Symptoms can include enlarged colon (found by CT scan), a fever, elevated heart rate, anemia, and/or elevated neutrophils and dehydration, altered electrolytes, low blood pressure, and/or confusion or unusual behavior.^

Prognosis

Your prognosis with ulcerative colitis is highly individualized and depends on the severity of your disease, treatment, and the presence of any complications. It’s essential to work closely with your healthcare team to manage your disease effectively and minimize potential complications.