Ulcerative Colitis

Ulcerative colitis (UC) is a chronic condition that falls under the umbrella of inflammatory bowel diseases (IBDs). It is characterised by inflammation and the formation of ulcers in the lining of the large intestine (colon) and rectum. UC can cause significant discomfort and disruption to daily life, but with proper management, most people with the condition can lead full and active lives. Understanding the types and stages of ulcerative colitis is crucial for effective treatment and management.

What is Ulcerative Colitis?

Ulcerative colitis is a form of inflammatory bowel disease (IBD) that specifically affects the large intestine (colon) and rectum. The condition causes the inner lining of the colon to become inflamed and develop ulcers, leading to abdominal pain, diarrhoea, and rectal bleeding. The exact cause of ulcerative colitis remains unknown, but researchers believe that a combination of genetic predisposition, immune system dysfunction, environmental factors, and gut microbiome imbalances may contribute to its development. Recognising the various types and stages of ulcerative colitis is essential for proper diagnosis and treatment (Berre et al., 2023).

Ulcerative colitis can be classified into different types based on the extent and location of inflammation in the colon. The main types of ulcerative colitis include:

• Ulcerative proctitis: In this type, inflammation is limited to the rectum, which is the last part of the colon. Symptoms may include rectal bleeding, urgency to defecate, and tenesmus (a feeling of incomplete bowel movement).
• Proctosigmoiditis: This type involves inflammation of the rectum and the sigmoid colon, which is the lower end of the colon. Symptoms may include bloody diarrhoea, abdominal cramps, and tenesmus.
• Left-sided colitis: Also known as distal colitis, this type affects the rectum and the left side of the colon up to the splenic flexure. Symptoms may include abdominal pain, bloody diarrhoea, and weight loss.

Pancolitis: This type involves inflammation of the entire colon. Symptoms may include severe diarrhoea, abdominal pain, fatigue, and significant weight loss (Berre et al., 2023).

• Frequent and urgent bowel movements with loose and watery stools
• Presence of blood, pus, or mucus in the stool
• Cramping and pain in the abdomen
• Sudden and uncontrollable urge to have a bowel movement
• Unexplained weight loss due to chronic diarrhoea and inflammation

The symptoms of ulcerative colitis can vary widely depending on the severity of the inflammation and its location in the colon. Mild cases might present with occasional diarrhoea and abdominal discomfort, while more severe inflammation can lead to persistent diarrhoea, rectal bleeding, significant abdominal pain, and fatigue, leading to various symptoms, which include:

• Diarrhoea: Persistent diarrhoea, often accompanied by blood or pus, is a hallmark symptom of ulcerative colitis.
• Rectal bleeding: Due to the presence of ulcers in the rectum, people with ulcerative colitis may notice blood in their stool.
• Abdominal pain and cramping: Pain and cramping in the abdomen can range from mild to severe, depending on the extent of inflammation.
• Urgent bowel movements: Frequent and sudden urges to have a bowel movement are common in ulcerative colitis.
• Tenesmus: This refers to the feeling of a constant need to have a bowel movement, even when the bowel is empty.
• Weight loss: Inadequate nutrient absorption and frequent bowel movements can lead to unintended weight loss.
• Fatigue: Chronic inflammation and nutrient deficiency often result in feelings of tiredness and sluggishness.
• Nausea and vomiting: These symptoms may occur, especially during flare-ups of the disease.

The stages of ulcerative colitis are determined by the severity of symptoms and the degree of inflammation (Rubin et al., 2025). Disease severity is classified as follows:

• Mild: Characterised by fewer than four bowel movements per day, mild symptoms, and no systemic signs such as fever or weight loss.
• Moderate: Involves four to six bowel movements per day, more pronounced symptoms, and some systemic signs like low-grade fever and minor weight loss.
• Severe: Marked by more than six bowel movements per day, severe symptoms, and significant systemic signs, including high fever, considerable weight loss, and anaemia.
• Fulminant: A rare, life-threatening stage with extremely severe symptoms such as more than 10 bloody bowel movements daily, high fever, rapid heart rate, and severe anaemia.

While mild to moderate cases may be managed with medications and lifestyle modifications, severe and fulminant stages often require hospitalisation and more aggressive interventions.

The exact cause of ulcerative colitis remains unknown, but it is believed to result from an abnormal immune response. Some of the other causes include:

• Autoimmune response: In ulcerative colitis, the immune system mistakenly attacks the healthy tissues of the colon and rectum, leading to inflammation and ulceration.
• Genetic factors: Certain genes may increase an individual's susceptibility to developing ulcerative colitis, suggesting a genetic component to the disease.
• Environmental factors: Exposure to environmental triggers, such as infections or certain substances, may play a role in the onset of ulcerative colitis in genetically predisposed individuals.
• Microbiome imbalance: Differences in the composition and diversity of gut bacteria (microbiome) have been observed in people with ulcerative colitis, indicating a potential link between gut flora and the development of the disease.

Several risk factors may increase your likelihood of developing ulcerative colitis, including:

• Age (peaks at ages 15-30 and 50-70)
• Family history
• Ethnicity (Ashkenazi Jewish descent)
• Smoking status, as ulcerative colitis is more common in non-smokers.
• Use of nonsteroidal anti-inflammatory drugs (NSAIDs), which may exacerbate disease activity or trigger flares in individuals with ulcerative colitis
• Geographical location (more common in developed countries, urban areas, and northern climates)

Ulcerative colitis can lead to various complications that may affect different parts of the body. Some of the key complications associated with UC include:

• Extra-intestinal manifestations: Inflammation can spread beyond the intestines, causing joint pain and swelling, skin bumps, painful mouth ulcers, and eye irritation.
• Osteoporosis: Patients with UC have a higher risk of developing osteoporosis due to factors such as steroid medication side effects, poor nutritional absorption, and dietary changes.
• Growth and development issues: In children and young people, UC and its treatments can impact growth and development, leading to delayed puberty, short stature, or slowed weight gain.
• Primary sclerosing cholangitis (PSC): Some individuals with UC may develop PSC, a condition where the bile ducts become inflamed and damaged, potentially requiring a liver transplant in severe cases.
• Toxic megacolon: This rare but serious complication involves severe inflammation, causing the colon to become enlarged and swollen, potentially leading to colon rupture and sepsis.
• Bowel cancer: Patients with long-standing UC have an increased risk of developing colorectal cancer, necessitating regular colonoscopies for screening.
• Anaemia: UC can lead to various types of anaemia, including iron-deficiency anaemia and anaemia of chronic disease, due to factors such as inadequate nutrient absorption and intestinal bleeding.
• Blood clots: Chronic inflammation and certain medications can increase the risk of blood clots in people with UC.
• Fulminant ulcerative colitis: This acute and severe form of UC is characterised by frequent bloody bowel movements, fever, rapid heart rate, and severe anaemia, potentially leading to toxic megacolon and perforation of the colon.

Although ulcerative colitis cannot currently be prevented, appropriate monitoring and preventive care can reduce complications and improve long-term outcomes. including:

• Screening for skin malignancies, especially if biological agents are used in treatment.
• Bone mineral density assessment to monitor bone health and prevent osteoporosis.
• Vaccinations, including pneumococcal, influenza, and hepatitis B vaccines, to reduce the risk of infections.
• Maintaining a healthy diet and staying hydrated to support overall health and manage symptoms.
• Regular exercise, which can help reduce stress, improve mood, and maintain a healthy weight.
• Stress management techniques, such as relaxation exercises, deep breathing, and mindfulness, can help cope with the emotional impact of the disease.

Diagnosing ulcerative colitis typically involves a combination of tests and procedures to assess the extent and severity of the disease. Some of the main diagnostic tools include:

• Medical history and physical examination: Your doctor will ask about your symptoms, family history, and perform a physical exam to check for abdominal tenderness and other signs of UC.
• Blood tests: These may include a complete blood count (CBC) to check for anaemia and inflammation, and C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) to measure inflammation levels.
• Stool tests: Analysing stool samples can help rule out infections and detect the presence of blood or white blood cells, which may indicate inflammation.
• Colonoscopy: A flexible, lighted tube with a camera (colonoscope) is inserted through the rectum to examine the entire colon. During the procedure, your doctor may take tissue samples (biopsies) for further analysis.
• Sigmoidoscopy: Similar to a colonoscopy, but only examines the lower part of the colon (sigmoid colon) and rectum.
• Imaging tests: X-rays, computed tomography (CT) scans, or magnetic resonance imaging (MRI) may be used to assess the extent of inflammation and rule out complications such as toxic megacolon, perforation, or severe colonic inflammation.

Medications play a crucial role in managing ulcerative colitis by reducing inflammation and regulating the immune system. The choice of treatment depends on the severity of the condition and the patient's response to previous therapies.

1. Aminosalicylates (5-ASAs)

• Mesalazine, sulfasalazine, balsalazide, and olsalazine are commonly used as first-line treatments for mild to moderate ulcerative colitis (Rubin et al., 2025).
• These medications help reduce inflammation in the colon lining and are available in oral, enema, and suppository forms based on the affected area.

2. Corticosteroids

• Used for moderate to severe flare-ups, corticosteroids like prednisone and budesonide help suppress inflammation.
• These medications are intended for short-term use due to potential side effects such as weight gain, high blood pressure, and bone thinning.

3. Immunomodulators

• Azathioprine and mercaptopurine work by suppressing the immune response responsible for inflammation.
• These medicines are used for long-term management and require regular blood monitoring to detect potential side effects.

4. Biologic Therapies

• Infliximab and adalimumab are monoclonal antibodies that target specific proteins involved in inflammation.
• These biologics are effective in moderate to severe cases that do not respond to conventional treatments (Raine et al., 2022) .

5. Targeted Oral Small Molecules

• Tofacitinib and ozanimod help reduce inflammation by targeting immune system pathways.
• These are used in moderate to severe disease when other therapies fail.

6. Symptomatic Relief Medications

• Antidiarrhoeal agents, such as loperamide, may be prescribed for severe diarrhoea but should be used cautiously to avoid complications like toxic megacolon.
• Pain relievers, such as acetaminophen, are preferred over NSAIDs, which can worsen symptoms.
• Iron supplements may be recommended to treat iron deficiency anemia caused by chronic bleeding.

Living with ulcerative colitis can be challenging, but several strategies can help manage the condition and improve overall quality of life. These include:

• Develop a strong support system, including family, friends, and doctors.
• Learn stress management techniques, such as relaxation exercises, meditation, or yoga.
• Maintain a healthy lifestyle, including regular exercise and adequate sleep.
• Keep a food diary to identify potential trigger foods and adjust your diet accordingly.
• Stay hydrated and replenish lost fluids, especially during flare-ups.
• Be prepared for emergencies by carrying extra clothing, wipes, and any necessary medications.
• Consider joining a support group to connect with others who understand your experiences.
• Communicate openly with your healthcare team about your symptoms, concerns, and treatment options.

If you experience symptoms such as persistent diarrhoea, abdominal pain, rectal bleeding, or unexplained weight loss, it is essential to consult a doctor for a proper diagnosis. Additionally, if you have been diagnosed with ulcerative colitis and notice a worsening of symptoms, such as increased frequency or severity of diarrhoea, abdominal pain, or rectal bleeding, it is important to contact your doctor promptly. Timely intervention can help prevent complications and ensure that your treatment plan is adjusted as needed to manage your condition effectively.

• Ulcerative colitis is a chronic inflammatory bowel disease that affects the colon and rectum, causing symptoms such as diarrhoea, abdominal pain, and rectal bleeding.
• While the exact cause of ulcerative colitis is unknown, factors such as genetics, immune system dysfunction, and environmental triggers may play a role in its development.
• Treatment for ulcerative colitis typically involves a combination of medications, dietary modifications, and, in some cases, surgery.
• Living with ulcerative colitis can be challenging, but with proper management and support, it is possible to maintain a good quality of life.
• Recognising when to seek medical attention is crucial for effectively managing ulcerative colitis and preventing complications.