The symptoms of ulcerative colitis vary between people, as well as the severity of these symptoms and additional complications. Roughly half of people diagnosed with ulcerative colitis experience relatively mild symptoms. Approximately 10% of affected individuals may have very severe symptoms, but this varies by how far the disease and the inflammation have progressed in their colon. In general, patients who have mild symptoms experience inflammation restricted to the rectum and a short colon segment adjacent to it. They often have a far better prognosis than patients with more widespread inflammation over their colon. 

Ulcerative colitis is a disease that manifests itself in cycles. Flare-ups are instances where symptoms are followed by periods of remission wherein the symptoms fade or disappear. Patients will go through these cycles for the rest of their lives. With proper treatment and medical care, these periods of remission can last longer before the next flare-up occurs. The period of remission could last months or even years. However, due to the lack a cure for this disease, eventually the symptoms will return in some form. The periods of flare-ups and remissions are still unpredictable for the most part. The disease’s unpredictability makes it difficult to evaluate whether or not the current treatment that a patient is on is working.

The disease can manifest at roughly any age, though the majority of people are diagnosed around their mid-30s. A small percentage of the affected population first experience their symptoms in their 60s or 70s. It’s essential to pay close attention to the presence of commonly recognized signs of ulcerative colitis and to make sure that you contact a healthcare provider if you experience them.

Some of the most frequent signs and symptoms include:

• Loose bowel movement or the urgent need to move your bowels. A related symptom is being unable to defecate despite the urgent need to do so.
• Rectal pain and bloody stool, or stool with pus. Rectal bleeding is another common symptom and may manifest by passing blood with stool.
• Abdominal cramps or pain.
• Persistent diarrhea accompanying the rest of the symptoms. 

Beyond gastrointestinal tract-related symptoms, other issues can appear as a result of the damage that the other symptoms have caused. The symptoms affect the quality of one’s life. These include:

• Weight loss and a loss of appetite
• Fatigue and low energy
• Nausea and vomiting
• Fever
• Anemia (low red blood cell count)
• Joint pain and swelling
• Eye irritation
• Rashes
• Failure to grow, malnutrition, or delayed development as a child

Complications may arise from ulcerative colitis, especially when symptoms go untreated or uncontrolled. Inflammation can permanently damage the colon lining itself. Some long-term complications of ulcerative colitis include:

• Severe bleeding – Bleeding occurs in the colon and blood appears in bowel movements, which is one of the most prominent symptoms of ulcerative colitis. The bleeding may become severe enough that the patient develops anemia or a significant drop in red blood cells throughout the body. 
• Swollen colon – Also known as toxic megacolon, this is a rare complication but a significant danger when it occurs. Gas is trapped in the colon, and the colon begins to swell to the point that it breaks. When the enlarged colon breaks, it releases bacteria into the body that can cause septicemia or blood poisoning.
• Perforated colon – A hole appears in the patient’s intestine due to severe inflammation and sores that have weakened the colon wall. A perforated colon often follows the toxic megacolon and is a medical emergency. Bacteria in the intestine can escape from the perforation and cause peritonitis, which is a severe infection.
• Risk for colorectal cancer – Patients with ulcerative colitis are twice as likely to get colorectal cancer than patients without the disease. While the threat remains low—most people who do have ulcerative colitis never get colorectal cancer—the likelihood still increases once you’ve had the disease for eight to ten years.
• Osteoporosis – Also known as bone loss, osteoporosis proves to be a significant risk for patients with ulcerative colitis. Up to 60% of the people with the disease end up having bones that are thinner than usual. This also increases the risk of fractures.
• Primary sclerosing cholangitis (PSC) – PSC causes inflammation and scarring in the body’s bile ducts, where digestive fluids travel from your liver to the small intestine. PSC itself is common among people with ulcerative colitis as the scars can make narrower bile ducts, causing a back up in the liver. If not treated, the liver can be damaged enough to need a transplant.

The lack of a specific cause, along with the symptoms and complications manifesting in patients in several ways, leads doctors to define different types of ulcerative colitis, which makes it even more important to diagnose and treat the disease correctly. The different types of ulcerative colitis are:

• Ulcerative proctitis – Bowel inflammation is limited to the rectum, and it affects roughly six inches or less of the rectum. This typically isn’t associated with increased cancer risks. Some primary symptoms are rectal bleeding, rectal pain, and urgent bowel movements.
• Left-sided Colitis – The inflammation in this type begins at the rectum and goes far into the colon, up to the splenic flexure, the bend in the colon near the spleen. One of the marks of left-sided colitis is proctosigmoiditis, which affects both the rectum and the sigmoid colon found on the lower area above the rectum. Symptoms include pain in the left side of the abdomen, appetite loss, weight loss, and bloody diarrhea.

Extensive Colitis – In this type of ulcerative colitis, the entire colon becomes affected with a continuous inflammation, beginning at the rectum beyond the splenic fixture. Symptoms include appetite loss, abdominal pain, weight loss, and bloody diarrhea.

The exact causes of ulcerative colitis remain largely unknown, although considerable medical research confirmed that it may be the result of several factors. To date, there has been no convincing evidence that the disease is caused by infection or is contagious.

• Overactive immune system – Doctors have considered that ulcerative colitis may be an immune disorder or an autoimmune disease. This is a disorder wherein the body’s immune systems and healthy white blood cells start attacking the body’s healthy tissues instead of foreign or intruding bacteria. In ulcerative colitis patients, this attack could be triggered by a virus. Inflammation continues even after the immune system should have killed the virus. However, if this was the cause, doctors are unsure why cells would cause inflammation only to the colon specifically and not anywhere else.
• Genetic factors – Roughly one-fifth of people who have ulcerative colitis have a close relative that has the same or another IBD, suggesting that genetic susceptibility is a risk factor. However, most people who do have ulcerative colitis still don’t have this type of family history. The risk of developing ulcerative colitis is between 1.6% to 30% if a person has a first-degree relative with the disease. Several genes that are associated with ulcerative colitis are also involved in how the intestines function. Since the inner surface of the intestines provides a barrier to protect the body tissues from bacteria, doctors suspect that the weakness or breakdown in this barrier causes contact between the tissue and the toxins. Ultimately, this triggers an immune reaction.
• Ethnicity – Ulcerative colitis can appear in every racial and ethnic group. However, some ethnicities may be more susceptible than others by a small margin. Studies have shown that Caucasian people, as well as people of Ashkenazi Jewish-descent, are more likely to get ulcerative colitis than others.
• Age and Gender – As mentioned earlier, people of just about any age are susceptible to ulcerative colitis. However, it often starts when someone is between the ages of 15- to 30-years-old, with the most people diagnosed around age 30. Both men and women alike are vulnerable to the disease, but older men are more likely to be diagnosed with the disease compared to older women. Individuals older than 60-years-old are also likely to get the disease.

Environmental factors – Because it’s been considered as a form of immune disorder, bacteria, viruses, and antigens are considered as risk factors for ulcerative colitis. Some studies suggest that certain things in the environment increase the likelihood of someone getting ulcerative colitis. However, the overall environmental risk is low. Some studies also indicate that nonsteroidal anti-inflammatory drugs or antibiotics could also increase the risk. A high-fat diet may also put people at risk of developing the disease. Certain foods, stress, and emotional distress are also said to be a trigger, but to date, doctors have not found conclusive evidence that proves this is true.

The different varieties of ulcerative colitis, along with the varying degrees of severity in the disease’s symptoms, make it necessary for doctors to make a correct diagnosis. Most healthcare providers should conduct a series of medical tests and exams, not just to make the diagnosis, but also to rule out other inflammatory bowel disorders or other causes of the symptoms.  

• Family and medical history – Because of the numerous risk factors in ulcerative colitis, doctors need to look at the comprehensive medical history of a patient to find any causes for the symptoms or any potential triggers for the disease. This includes whether any family members have had inflammatory bowel disorder or ulcerative colitis.
• Endoscopy and Colonoscopy – Additional testing may be recommended to spot signs of the disease inside the colon and rectum. An endoscopy enables doctors to see the inside of the colon through a lighted tube inserted through the anus. Chromoendoscopy can also help identify polyps or precancerous indications. 
• Biopsy – A small piece of colon tissue is removed from the inside of the intestine for doctors to test further and analyze. The tissue is sent to a pathology laboratory and screened for the disease.
• CT Scan – Another possible test for doctors to use is a CT scan, which is like an x-ray of the abdomen and the pelvis used to determine signs of inflammation. 

Blood tests – A blood test may be used to seek out signs of anemia or a low blood count. There also may be a need for specialized antibody tests or tests to determine a high level of C-reactive proteins.

Medications: 

The use of medication can suppress inflammation of the colon and give the body’s tissues more time to heal. They can also be used to suppress the severity of symptoms that cause diarrhea, bleeding, and abdominal pain. With proper administration, medications can also help decrease flare-ups of symptoms. Some of these medications include mesalamine, sulfasalazine, balsalazide, and olsalazine. Some doctors may also recommend corticosteroids, antibiotics, and biologics, but these will depend on each individual’s symptoms.

Diet & Lifestyle: 

No evidence supports treatment solely through dietary modification, but it’s still recommended for patients with ulcerative colitis to stay on a healthy, balanced diet. Food should be rich in fruits, vegetables, grains, beans, nuts, lean meats, fish, and eggs. It’s also recommended to eat four to six small meals a day and to remain hydrated. Drink slowly and avoid consuming products that may cause patients to ingest gas, including carbonated drinks.

Therapy and Procedures:

Living with a chronic illness such as ulcerative colitis may call for more specialized treatment, especially when symptoms get worse. Patients with more severe symptoms of ulcerative colitis may need to be hospitalized. A sudden and severe onset of acute symptoms of ulcerative colitis, such as uncontrolled bleeding, toxic megacolon, and perforation of the colon, may require emergency surgery.

These surgeries could be:

• Proctocolectomy with ileal pouch-anal anastomosis, which is the removal of the colon and rectum. An internal pouch is created to eliminate the need for an external ostomy.

Proctocolectomy with end ileostomy, which is the removal of the rectum, colon, and anus. An external ostomy is created.

To date, there is still no known cure for ulcerative colitis. Researchers are still conducting studies and clinical trials to test new treatments, interventions, and tests to detect and manage the disease.

In researching both causes and treatments for ulcerative colitis, it’s critically important to look into comprehensive patient medical histories. If doctors are more aware of what could be triggering symptoms internally, genetically, or environmentally, they may be able to take further steps towards finding a cure for the disease. Comprehensive digital medical records aid them greatly in this regard, allowing them to keep track of their patients and keep a close eye on the changes in their situations as well as what led them towards the diagnosis of the disease.

Doctors continue to seek out biological agents that are also potentially more effective in treating ulcerative colitis with fewer side effects. Today there remain many questions to be answered around the cause and the mechanism of ulcerative colitis inflammation. Development of newer and safer medications continues, as well as improvements in surgical procedures to improve the patient’s health and future quality of life.

People with ulcerative colitis who want to contribute to research can sign up for a PicnicHealth account to contribute their anonymized medical data to inflammatory bowel disease research.