Ulcerative colitis

Ulcerative colitis is a long-term condition that inflames the inner lining of the large bowel. The large bowel includes the colon and rectum. Small open sores, called ulcers, may form and bleed.

Inflammation usually begins in the rectum and spreads upwards through the colon without leaving healthy gaps. It may affect only the rectum, the left side of the colon, or most of the colon. This pattern helps distinguish ulcerative colitis from Crohn’s disease, another type of inflammatory bowel disease, or IBD.

Symptoms often come and go. An active period is called a flare-up. A period with few or no symptoms is called remission. Treatment aims to settle inflammation, keep you in remission and protect the bowel from long-term damage.

Ulcerative colitis can also affect areas outside the bowel, including the joints, skin, eyes and liver. Regular follow-up matters even when you feel well because inflammation can sometimes continue without obvious symptoms.

The symptoms depend on how much of the colon is inflamed and how active the inflammation is. They may develop gradually or begin more suddenly.

Common symptoms include:

• Diarrhoea, often containing blood or mucus
• An urgent or frequent need to open your bowels
• Abdominal cramps or pain
• Feeling that you still need to pass stool after going
• Tiredness, reduced appetite or unplanned weight loss
• Fever during a more severe flare

Blood loss and ongoing inflammation may cause anaemia, meaning too few healthy red blood cells. This can make you tired, short of breath or light-headed.

Inflammation outside the bowel may cause painful or swollen joints, tender skin lumps, mouth ulcers or red, painful eyes. Some liver and bile duct problems cause itching or yellowing of the skin and eyes.

Symptoms can resemble infections, haemorrhoids, irritable bowel syndrome and other bowel conditions. Having blood in your stool does not by itself mean that you have ulcerative colitis, but it should be medically assessed.

The exact cause is not known. Ulcerative colitis appears to develop when the immune system reacts in an abnormal and lasting way in someone who is susceptible. Genes, gut microbes and environmental exposures may all contribute.

You are more likely to develop it if a close family member has ulcerative colitis or Crohn’s disease. However, many people with the condition have no affected relatives, and most relatives of someone with ulcerative colitis never develop it.

Ulcerative colitis is not caused by stress or by a particular food. Stress and certain foods may make symptoms harder to manage, but they do not create the underlying inflammation.

Smoking has a complicated association with ulcerative colitis, but it is not a safe treatment or prevention method. Smoking causes serious harm to the heart, lungs and blood vessels. If symptoms change after you stop smoking, discuss them with your healthcare team rather than restarting.

Diagnosis usually begins with a review of your symptoms, medicines, family history and general health. An abdominal and rectal examination may be offered.

Blood tests can look for anaemia, inflammation and changes in liver or kidney function. Stool tests help rule out infections. A stool test called faecal calprotectin measures a protein released during bowel inflammation. It can support the assessment and may later help monitor treatment, but it does not confirm ulcerative colitis on its own.

Endoscopy is used to examine the bowel lining. During a colonoscopy, a thin flexible camera is passed through the anus to inspect the rectum and colon. Small tissue samples, called biopsies, are removed and examined under a microscope. The procedure is usually done with medicine to make it more comfortable.

A shorter examination called flexible sigmoidoscopy may be used, especially during a severe flare when a full colonoscopy may not be appropriate. Scans or abdominal X-rays may be needed if complications are suspected.

Other causes of bowel inflammation must be considered before the diagnosis is confirmed. These include bacterial or parasitic infections and inflammation caused by certain medicines.

Treatment is based on where the inflammation is, how active it is, previous treatments and your general health. The immediate goal is to control a flare. Long-term treatment aims to maintain remission without ongoing steroid use.

Aminosalicylates, also called 5-ASAs, reduce inflammation in the bowel lining. They may be taken by mouth or delivered directly into the rectum as a suppository or enema. Rectal treatment can be particularly useful when inflammation is limited to the lower bowel.

Corticosteroids like prednisone or hydrocortisone may be used for a flare that does not respond to initial treatment. They work quickly but can cause important side effects when used repeatedly or for long periods. They are not intended as routine maintenance treatment.

For moderate or severe inflammation, treatment may include medicines that alter parts of the immune response. These include immunomodulators, biologic medicines and targeted tablets known as small-molecule medicines. The choices differ in how they are taken, how quickly they work and what monitoring they require.

Some immune treatments increase the chance of certain infections. Before treatment, you may need screening for infections and a review of vaccinations. Blood tests or other monitoring may continue during treatment. Do not stop a prescribed medicine suddenly without medical advice, even if you feel well.

Hospital care may be needed for a severe flare. Treatment can include fluids, medicines given through a vein and close monitoring for complications.

Surgery is considered when medicines do not control inflammation, side effects are unacceptable, abnormal precancerous cells are found, or an urgent complication develops. Surgery removes the colon and rectum. Waste can then leave through an opening in the abdomen into a bag, called an ileostomy, or the small bowel may be shaped into an internal pouch connected to the anus.

Removing the colon eliminates ulcerative colitis from the bowel, but surgery has its own possible complications. An internal pouch can become inflamed, and some symptoms outside the bowel may continue.

Medicines commonly used for this include adalimumab. Which one suits you, if any, is a decision for you and your doctor.

Severe inflammation can cause substantial bleeding, dehydration or a hole in the bowel. A rare complication called toxic megacolon happens when the colon becomes severely inflamed and enlarged. It needs urgent hospital treatment.

Ulcerative colitis also increases the risk of blood clots, particularly during a severe flare or hospital admission.

Long-standing inflammation affecting much of the colon raises the risk of colorectal cancer. The level of risk is influenced by how long you have had the condition, how much bowel is involved, inflammation over time, family history and certain bile duct conditions. Your follow-up plan may include surveillance colonoscopies to look for early cell changes before cancer develops.

Other possible complications include anaemia, reduced bone strength and poor nutrition. Some people develop primary sclerosing cholangitis, or PSC, which causes inflammation and scarring in the bile ducts that carry bile from the liver.

Treatment can also have side effects. Your care team should explain the main risks and the monitoring needed for the medicine you use.

There is no proven way to prevent ulcerative colitis. It is not caused by something you did, and no specific diet, supplement or lifestyle change can guarantee that it will not develop.

If you have the condition, taking maintenance treatment as agreed can reduce the chance of some flare-ups. Keeping follow-up appointments and reporting a return of symptoms can help inflammation be treated earlier.

Avoid smoking as a prevention or treatment strategy. Before using non-steroidal anti-inflammatory drugs, such as ibuprofen or naproxen, ask whether they are suitable for you because they may worsen bowel symptoms in some people.

Ulcerative colitis usually continues throughout life unless the colon and rectum are removed. Its course is not fully predictable. Some people have long remissions with occasional mild flares. Others have frequent or severe inflammation and need several treatment changes or surgery.

Most people can continue work, education, exercise, relationships and travel. During a flare, urgency, fatigue and access to toilets can affect daily plans. Practical steps may include carrying spare supplies, locating toilets before travel and discussing temporary adjustments at work or school.

No single ulcerative colitis diet works for everyone. During a flare, some foods may increase diarrhoea or discomfort without causing the inflammation itself. A food and symptom record can help identify personal patterns. Avoid cutting out whole food groups without support, as restrictive diets can lead to weight loss or nutrient shortages. A dietitian familiar with IBD can help if eating is difficult.

Emotional health also matters. Unpredictable symptoms can cause embarrassment, low mood or anxiety. Support from an IBD nurse, counsellor, peer group or trusted people may help.

Pregnancy is possible for most people with ulcerative colitis. Good control of inflammation before and during pregnancy is important. Some medicines can be continued, while others need advance planning. Discuss pregnancy plans before changing treatment.

Routine follow-up may include symptom reviews, blood or stool tests, medicine monitoring and colonoscopy. Keep attending even during remission.

Arrange a routine medical appointment if you have persistent diarrhoea, repeated urgency, blood or mucus in your stool, unexplained weight loss, or symptoms that regularly wake you at night.

If you already have ulcerative colitis, contact your IBD team promptly when symptoms return or become more frequent. An agreed flare plan may explain which tests are needed and whether treatment should change.

Seek urgent medical advice if you have:

• Increasing bloody diarrhoea or difficulty keeping fluids down
• Fever with worsening bowel symptoms
• New severe weakness, dizziness or signs of dehydration
• A painful, red eye or a sudden change in vision
• Yellow skin or eyes

Get emergency help for heavy or continuous bleeding, fainting, severe abdominal pain with a swollen or rigid abdomen, confusion, breathing difficulty or chest pain. These symptoms can indicate major blood loss, toxic megacolon, a bowel perforation or a blood clot.

Is ulcerative colitis the same as Crohn’s disease?

No. Both are forms of IBD, but ulcerative colitis affects the inner lining of the colon and rectum in a continuous pattern. Crohn’s disease can affect any part of the digestive tract and may involve deeper layers of the bowel wall.

Can ulcerative colitis be cured?

Medicines can control inflammation but do not permanently remove the condition. Surgery to remove the colon and rectum eliminates ulcerative colitis from the bowel. Surgery may still require long-term care, particularly for an ileostomy or internal pouch.

What foods should I avoid with ulcerative colitis?

There is no universal list. During a flare, high-fibre, fatty, spicy or dairy foods may worsen symptoms for some people, but responses differ. Food does not replace anti-inflammatory treatment. Seek dietetic support before making major restrictions.

Does stress cause ulcerative colitis flare-ups?

Stress does not cause ulcerative colitis. It can affect sleep, appetite and bowel function, and some people notice worse symptoms during stressful periods. Stress management may support wellbeing but does not treat active inflammation by itself.

Will I need a stoma?

Many people never need surgery. A stoma may be temporary or permanent if the colon is removed, depending on the operation and your circumstances. Some people instead have an internal pouch connected to the anus.

Can I drink alcohol with ulcerative colitis?

Alcohol can worsen diarrhoea or interact with some medicines. Whether it is suitable depends on your symptoms, liver health and treatment. Check the advice for your medicine and discuss concerns with your care team.