Ulcerative Colitis

What Is Ulcerative Colitis?

Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) that causes inflammation and ulceration of the innermost lining (mucosa) of the large intestine (colon) and rectum. Unlike Crohn's disease, which can affect any part of the gastrointestinal tract, ulcerative colitis is limited to the colon and always involves the rectum, extending continuously upward to varying extents.

UC affects approximately 900,000 people in the United States. The disease typically follows a relapsing and remitting course, with periods of active symptoms (flares) alternating with periods of remission. The extent of colonic involvement is classified as:

Ulcerative proctitis: Inflammation limited to the rectum
Left-sided colitis (distal colitis): Inflammation extending from the rectum up to the splenic flexure
Pancolitis: Inflammation involving the entire colon

Common Symptoms

Symptoms of ulcerative colitis vary depending on the severity and extent of inflammation. They may include:

Bloody diarrhea: The most characteristic symptom, often with mucus or pus
Rectal bleeding: Passing blood with or without stool
Urgency: A sudden, intense need to have a bowel movement
Tenesmus: A persistent feeling of needing to evacuate the bowels despite an empty rectum
Abdominal pain and cramping: Typically in the left lower abdomen
Increased frequency of bowel movements: Sometimes 10 to 20 or more times daily during severe flares
Fatigue: Related to chronic inflammation, anemia, and disrupted sleep
Weight loss and decreased appetite
Fever: During moderate to severe flares

Extraintestinal manifestations may also occur, affecting the joints (peripheral arthritis, sacroiliitis), skin (erythema nodosum, pyoderma gangrenosum), eyes (episcleritis, uveitis), and liver (primary sclerosing cholangitis).

Causes and Risk Factors

The precise cause of ulcerative colitis is not fully understood, but it is believed to result from an interplay of the following factors:

Immune system dysfunction: The immune system mistakenly attacks the cells of the colonic lining, leading to chronic inflammation. This may be triggered by an environmental factor in genetically susceptible individuals
Genetic predisposition: Having a first-degree relative with IBD increases your risk significantly. Over 200 gene loci have been associated with IBD susceptibility
Gut microbiome imbalance: Alterations in the diversity and composition of intestinal bacteria may play a role in triggering and perpetuating inflammation
Environmental factors: Urbanization, Western diet, antibiotic use, and stress may contribute to disease development
Age: Most commonly diagnosed between ages 15 and 30, with a second smaller peak between ages 50 and 70
Ethnicity: Higher prevalence in Caucasian and Ashkenazi Jewish populations, though it occurs across all ethnic groups

Notably, unlike Crohn's disease, smoking appears to have a protective effect against ulcerative colitis. However, smoking is not recommended due to its many other serious health risks. Former smokers have a higher risk of developing UC than people who have never smoked.

Diagnosis

Diagnosis of ulcerative colitis involves a combination of clinical evaluation, laboratory tests, and endoscopic assessment:

Blood tests: Complete blood count (to check for anemia), inflammatory markers (CRP, ESR), liver function tests, and albumin levels
Stool studies: Fecal calprotectin to quantify intestinal inflammation and stool cultures to rule out infectious causes of colitis
Colonoscopy with biopsies: The definitive diagnostic tool, allowing direct visualization of the colonic mucosa and collection of tissue samples. Typical findings include continuous mucosal inflammation starting from the rectum, with erythema, edema, friability, and ulceration
Flexible sigmoidoscopy: May be used during severe flares when a full colonoscopy carries higher risk
CT or MRI of the abdomen: To assess disease extent and rule out complications such as toxic megacolon

Treatment Options

The goal of UC treatment is to induce remission, maintain remission, and improve quality of life while minimizing medication side effects. Dr. Khan tailors treatment based on disease severity and extent.

Medications

5-Aminosalicylates (5-ASA): Mesalamine (oral and/or rectal formulations) is the first-line therapy for mild to moderate UC. Sulfasalazine is an alternative, particularly useful when joint symptoms are present
Corticosteroids: Prednisone, budesonide MMX, or intravenous methylprednisolone for moderate to severe flares. These are used short-term to induce remission but are not suitable for long-term maintenance
Immunomodulators: Azathioprine, 6-mercaptopurine, or methotrexate for patients who are steroid-dependent or do not maintain remission on 5-ASA alone
Biologic therapies: Anti-TNF agents (infliximab, adalimumab, golimumab), anti-integrin therapy (vedolizumab), and interleukin inhibitors (ustekinumab, mirikizumab) for moderate to severe disease
JAK inhibitors: Tofacitinib and upadacitinib are oral small-molecule therapies for moderate to severe UC that has not responded to conventional treatments
S1P receptor modulators: Ozanimod and etrasimod represent a newer class of oral therapies

Surgery

Approximately 15 to 20% of UC patients will eventually require surgery. Unlike Crohn's disease, surgery for UC can be curative:

Proctocolectomy with ileal pouch-anal anastomosis (IPAA or J-pouch): The most common surgical approach, removing the entire colon and rectum while creating an internal pouch from the small intestine to maintain bowel continuity
Proctocolectomy with ileostomy: Removal of the colon and rectum with creation of a permanent stoma

Surgery is considered for patients who do not respond to medical therapy, develop intolerable medication side effects, or have complications such as toxic megacolon, perforation, or dysplasia/cancer.

Colorectal Cancer Surveillance

Patients with long-standing ulcerative colitis have an increased risk of developing colorectal cancer. Current guidelines recommend surveillance colonoscopies beginning 8 years after the onset of symptoms, with repeat examinations every 1 to 3 years depending on risk factors. Dr. Khan performs chromoendoscopy or high-definition colonoscopy with targeted biopsies to detect early dysplastic changes.

When to See a Doctor

Seek prompt medical attention if you experience:

Persistent bloody diarrhea lasting more than a few days
Abdominal pain that progressively worsens
Unexplained weight loss or persistent fatigue
Fever along with GI symptoms
Symptoms of dehydration (dizziness, dark urine, excessive thirst)
Worsening symptoms despite current treatment
New joint pain, skin rashes, or eye inflammation accompanying bowel symptoms

Dr. Amber Khan at GastroCares offers comprehensive evaluation and management of ulcerative colitis, utilizing the latest evidence-based therapies to help patients achieve lasting remission and optimal quality of life.