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Ulcerative Colitis

The Facts

Ulcerative colitis is a type of inflammatory bowel disease (IBD) that causes inflammation and sores in the lining of the rectum and large intestine (colon). It's a chronic condition, although symptoms can disappear for months at a time only to flare up again. It typically first appears in men or women between the ages of 15 and 40, but occasionally this condition first occurs in people in their 60s.


Researchers believe ulcerative colitis happens when the immune system overreacts in defending the body against a virus, bacteria, or dietary or environmental substance in the intestinal wall. It's still not clear what the exact trigger might be, but it's thought to vary from person to person.

Ulcerative colitis is an autoimmune disease that tends to occur in people with a family history of the condition. It is related to other autoimmune conditions, in which the immune system mistakenly attacks the body's own tissues instead of only fighting infections. Ulcerative colitis occurs most commonly in Caucasians, and particularly in people of Jewish heritage.

Certain environmental triggers can also lead to colitis. For example, people who live in cities are more at risk of developing the disease than those in rural areas.

Symptoms and Complications

Bloody diarrhea is the main symptom of ulcerative colitis, caused by the inflammation in the bowel. People with colitis can have anywhere from less than 4 to more than 10 bowel movements daily, even losing control of their bowels and having diarrhea during sleep, in severe cases.

Other signs and symptoms of ulcerative colitis include:

  • lower abdominal pain and cramps (especially during defecation)
  • rectal bleeding
  • anemia (iron deficiency) due to blood loss in diarrhea
  • urgency to defecate (urgent bowel movements) or incontinence (loss of bowel control)
  • weight loss or other signs of malnutrition (e.g., tiredness or malaise)
  • fever over 37.5°C, especially when disease symptoms are severe

Some people with colitis develop arthritis, skin rashes, inflammation of the eye, or liver disease. In children, ulcerative colitis can lead to limited growth. There are also acute complications like bleeding and potentially severe inflammation of the intestinal wall (toxic megacolon).

People with ulcerative colitis are also at increased risk of developing colorectal cancer. The risk of colorectal cancer increases over time, but regular examination by your doctor can help to reduce the risk.

Making the Diagnosis

A doctor can diagnose ulcerative colitis based on your family and medical history, and your symptoms. The doctor will also collect a stool sample to ensure there isn't a bacterial infection in your colon. You'll also have to give a blood sample to check for high numbers of white blood cells, which is a sign of immune system activity and might mean that you have an immune disease such as colitis.

Your doctor is likely to recommend that you have a colonoscopy or perhaps a barium enema.

Colonoscopy allows your doctor to look at the intestinal walls by inserting a colonoscope (a flexible lighted tube with a tiny camera in the tip) up the rectum and into the colon. The test is important to determine how much inflammation is present. If the inflammation extends beyond the colon, it may indicate Crohn's disease.

During a barium enema, barium (a contrast dye) is placed into the bowel in an enema form and sometimes air is added. The barium fills and coats the lining of the bowel, creating a picture of the rectum, colon, and a portion of the small intestine. This test usually takes about 20 minutes and can be somewhat uncomfortable.

Treatment and Prevention

Certain dietary restrictions can help control flare-ups in people with ulcerative colitis, although treatment with medications is also required. For example, some people find that milk triggers their symptoms, so they exclude it from their diet. Eating smaller, more frequent meals that are low in fat and dairy products can help manage symptoms. During a flare-up, avoiding bran, fruit, and raw vegetables can help manage symptoms, because these foods may worsen diarrhea. Your doctor may also recommend increasing your calcium and vitamin D intake to help prevent deficiencies related to poor nutrient absorption.

Aminosalicylates are anti-inflammatory medications. Examples include mesalamine (5-ASA or 5 aminosalicylic acid), olsalazine, and sulfasalazine.* Aminosalicylates often control symptoms completely. Side effects include nausea, vomiting, heartburn, headaches, orange-coloured urine, and gastrointestinal bleeding (in rare cases).Loperamide may be used to relieve general symptoms of cramping and diarrhea, but should not be used during severe attacks.

Corticosteroids work to reduce inflammation, especially when there is a flare-up of ulcerative colitis. They can be used as suppositories or enemas, but are often taken in pill form. Examples of corticosteroids include budesonide, hydrocortisone, and prednisone. The side effects of steroid medication include weight gain, acne, high blood pressure, increased risk of infections, increased risk of abnormally high blood sugar levels (diabetes mellitus). Osteoporosis and other health complications can occur with long-term steroid treatment.

Immune-suppressing medications, such as azathioprine or methotrexate, help suppress the immune system so that the body stops attacking its own tissues. These may be tried if the medications listed above do not control symptoms.

Biologic response modifiers, or biologics, are a type of medication that work by blocking some of the pathways involved in causing inflammation of the colon. These medications are often used in people with moderate-to-severe symptoms when other treatments are not effective. They are usually given by injection. Examples include adalimumab, infliximab, golimumab, and vedolizumab.

Tofacitinib is a newer oral medication, which belongs to a class of medications called  janus kinase (JAK) inhibitors. It is used for moderate-to-severe symptoms, and usually reserved for those who have not seen good results from a biologic response modifier.

About one-third of people with ulcerative colitis eventually need surgery because of bleeding, or to prevent colorectal cancer. Surgery is the only permanent cure for ulcerative colitis, and people who have their colon removed can still lead normal lives with proper diet and treatment.

Normally, contents flow from the stomach through the small intestine to the large intestine (colon) and finally to the rectum, where it passes from the body. Until recently, surgery involved removing the colon and rectum and creating a small opening in the side of the abdomen around the belt line. The surgeon connected the free end of the small intestine (the part called the ileum) to the opening, and a pouch was worn over the hole to collect waste and be emptied as needed (usually 3 or 4 times a day).

A newer procedure called an ileoanal anastomosis allows people to have more normal bowel movements after their surgery. The surgeon removes the colon but leaves the outer muscles of the rectum intact, attaching the ileum to the inside of the rectum and the anus. This creates an internal pouch of intestinal tissue. The pouch can occasionally become inflamed (pouchitis), but this can be treated with antibiotics.

Routine check-ups, cancer screenings, and immunizations are important for people with ulcerative colitis.

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