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Ulcerative colitis

Idiopathic Proctitis, Toxic Megacolon, Ulcerative Enterocolitis, Ulcerative Ileocolitis, Ulcerative Proctitis, Rectosigmoiditis

What is Ulcerative colitis?

Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD) that affects the large intestine.

The large intestine consists of the cecum, ascending/tranverse/descending/sigmoid colon and rectum. UC usually begins in the rectum and may continue up into the colon. When inflamed, the intestinal lining can become red, swollen, develop ulcers and bleed. This inflammation and irritation can prevent the large intestine from absorbing enough fluid and salt from stool, leading to diarrhea.

UC is a chronic, lifelong disease with alternating periods of activity and remission. Patients may experience intense symptoms followed by varying periods of time when the symptoms seem to disappear.

The cause of ulcerative colitis is unknown, but it appears to involve dysfunction of the immune system. Protective cells normally present in the gastrointestinal lining are triggered to attack when bacteria and viruses pass through the digestive tract. In patients with ulcerative colitis, this attack continues, even when harmful substances are no longer present – leading to chronic inflammation and irritation. It is not clear whether this immune dysfunction is a cause or result of UC.

UC appears most often in people between the ages of 15 and 35, but may also occur in older or younger populations. About 500,000 Americans have UC, according to the Crohn's & Colitis Foundation of America (CCFA). Another 500,000 have Crohn's disease (CD), the other major type of IBD.

Ulcerative colitis differs from Crohn's disease in a number of ways. In patients with ulcerative colitis, only the large intestine is affected whereas CD may occur anywhere throughout the digestive tract, including the small and large intestines. Inflammation caused by UC is usually continuous, without any normal tissue appearing between inflamed areas. In CD, there may be patches of normal tissue between inflamed areas. In addition, UC affects only the inner lining of the intestine, so ulcers are not likely to break through the innermost intestinal wall layer (mucosa), as may occur in patients with CD.

Inflammatory bowel diseases such as UC and Crohn's disease are sometimes confused with irritable bowel syndrome (IBS). However, IBS does not involve inflammation of the intestines, which is present in both UC and CD. Also, IBS does not include bloody diarrhea as a symptom and IBS tests reveal no abnormalities. IBS is not associated with either ulcerative colitis or Crohn's disease.

How is it diagnosed?

The first step in diagnosing ulcerative colitis (UC) is a visit to a physician for a medical history and physical examination. Individuals will present with the following complaints: rectal bleeding, having to strain to produce stools (tenesmus), repeated bouts of diarrhea then constipation, rectal urgency, abdominal cramping, fever, malaise, nausea and vomiting, joint pains (arthralgias), and night sweats. If individuals have a severe bout of ulcerative colitis, they will present to the physician with fever, body fluid loss (dehydration), increased heart rate (tachycardia), and abdominal tenderness.

Patients may be asked about the extent and duration of their symptoms, any family history of inflammatory bowel disease (IBD), as well as their eating, drinking or smoking habits.

Blood tests and stool samples may also be required. Blood tests can identify low red blood cell counts (anemia) and high white blood cell counts (which may indicate inflammation or infection). A stool sample analysis (fecal test) can identify bleeding or infection of the large intestine.

Various diagnostic tests may be used to determine if a patient has UC. They may also be used to rule out evidence of infections or other diseases (such as Crohn's disease, irritable bowel syndrome [IBS], colorectal cancer or diverticulitis) that may be causing the symptoms. These tests include:


Examination of the entire large intestine using a small, flexible tube (with a light and camera) inserted through the anus. This procedure allows physicians to identify the severity and extent of disease. Patients take a laxative prior to the procedure to cleanse the large intestine and are sedated during the procedure.

During colonoscopy, a tissue sample (biopsy) may be taken for evaluation under a microscope. This may help identify the type of IBD that is present. For example, if granulomas (clusters of inflamed cells) are found, a patient may be diagnosed with Crohn's disease (CD), since these cells do not occur with UC.


Similar to a colonoscopy, but used to examine the lower portion of the large intestine (the sigmoid colon and rectum).

Barium x-ray

X-rays of the gastrointestinal (GI) tract, after patients receive a dose of a contrast dye (barium) that allows organs to show up clearly on x-rays. Barium may be introduced to the body orally (upper GI barium tests) or via an enema (lower GI barium tests). X-rays can help identify what type of IBD is present (UC will only occur in the large intestine, whereas CD may affect any part of the digestive tract).

Barium x-rays are not considered as reliable as a colonoscopy or sigmoidoscopy for diagnosing UC because the x-rays may miss polyps and do not allow tissue samples to be taken for analysis under a microscope. They are not used in case of moderate to severe UC because of the risk of complications.

How is ulcerative colitis treated?

Individuals who have an acute exacerbation are initially stabilized on high dose steroids. Once their disease is under control, they are maintained on either a single medication or a combination of medications that can include sulfonamides, immunosuppressives, steroids, antibiotics, and antimetabolites.

If the individual has continuous exacerbations of the disease or is found to have changes in the colon wall consistent with cancer, a surgical resection of the colon (colectomy) may be necessary.


  • Aminosalicylates
  • Don't use aspirin. It increases the bleeding risk.
  • Antidiarrhea medication for minimal symptoms.
  • Sulfa drugs, such as sulfasalazine, for moderate symptoms.
  • Medicated enemas (usually with hydrocortisone).
  • Cortisone drugs for severe disease.
  • Immunosuppressive drugs in patients with chronic disease.

What might complicate it?

Individuals can have many complications including rectal bleeding, enlarged colon (toxic megacolon), cancer of the colon, inflammation of various parts of the eye (conjunctivitis, iritis, uveitis, episcleritis), bone loss (osteoporosis), and arthritis of the knees, ankles, elbows and wrists. Stress may aggravate the disease. After ten years of active disease, cancer of the colon may be found.

Predicted outcome

Individuals who undergo treatment for their disease can expect to be able to keep it under control by staying on their medications and keeping an eye on their stress levels. If the disease is not well controlled or the individual refuses therapy, the disease will progress. Non-compliance with medical regimens can also lead to dehydration, infection and possible sepsis (overwhelming systemic infection with a high mortality). If the disease is left to progress over a period, it may eventually lead to an enlarged colon (toxic megacolon) or colon cancer.


The different diseases that need to be excluded from consideration are gastroenteritis, infectious diarrhea, amebiasis (infection of the GI tract by amoeba), mesenteric adenitis (inflammation of the mesenteric lymph nodes), appendicitis, mesenteric ischemia (lack of blood supply to the small bowel and/or colon), diverticulitis (infection and inflammation of the colon), HIV, and colitis due to drug ingestion (NSAID induced).

Appropriate specialists

Gastroenterologist and general surgeon.

Notify your physician if

  • You or a family member has symptoms of ulcerative colitis.
  • Fever and chills develop.
  • Frequency of bowel movements or bleeding increases.
  • Abdomen becomes distended.
  • Jaundice (yellow eyes and skin and dark urine) develops.
  • Vomiting begins or abdominal pain increases.

Last updated 7 July 2015