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Ulcerative Colitis

Practice Essentials

Ulcerative colitis (UC) is one of the two major types of inflammatory bowel disease (IBD), along with Crohn disease (CD). Unlike Crohn disease, which can affect any part of the gastrointestinal tract, ulcerative colitis characteristically involves the large bowel (see the image below). Ulcerative colitis is a lifelong illness that has a profound emotional and social impact on the affected patients.

Ulcerative colitis. Ulcerative colitis as visualiz

Ulcerative colitis. Ulcerative colitis as visualized with a colonoscope.

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Signs and symptoms

Patients with UC predominantly complain of the following:

Rectal bleeding

Frequent stools

Mucous discharge from the rectum

Tenesmus (occasionally)

Lower abdominal pain and severe dehydration from purulent rectal discharge (in severe cases, especially in the elderly)

In some cases, UC has a fulminant course marked by the following:

Severe diarrhea and cramps



Abdominal distention

UC is associated with various extracolonic manifestations, as follows:


Pyoderma gangrenosum


Erythema nodosum

Ankylosing spondylitis


Other conditions associated with UC include the following:

Primary sclerosing cholangitis (PSC)

Recurrent subcutaneous abscesses unrelated to pyoderma gangrenosum

Multiple sclerosis

Immunobullous disease of the skin

Physical findings are typically normal in mild disease, except for mild tenderness in the lower left abdominal quadrant (tenderness or cramps are generally present in moderate to severe disease
). In severe disease, the following may be observed:



Significant abdominal tenderness

Weight loss

The severity of UC can be graded as follows:

Mild: Bleeding per rectum, fewer than four bowel motions per day

Moderate: Bleeding per rectum, more than four bowel motions per day

Severe: Bleeding per rectum, more than four bowel motions per day, and a systemic illness with hypoalbuminemia (< 30 g/L)

See Presentation for more detail.


Laboratory studies are useful principally in determining the extent of the disease, excluding other diagnoses, and in assessing the patient’s nutritional status. They may include the following:

Serologic markers (eg, antineutrophil cytoplasmic antibodies [ANCA], anti– Saccharomyces cerevisiae antibodies [ASCA])

Complete blood cell (CBC) count

Comprehensive metabolic panel

Inflammation markers (eg, erythrocyte sedimentation rate [ESR], C-reactive protein [CRP])

Stool assays

Diagnosis is best made with endoscopy and biopsy, on which the following are characteristic findings:

Abnormal erythematous mucosa, with or without ulceration, extending from the rectum to a part or all of the colon

Uniform inflammation, without intervening areas of normal mucosa (skip lesions tend to characterize Crohn disease)

Contact bleeding may also be observed, with mucus identified in the lumen of the bowel

The extent of disease is defined by the following findings on endoscopy:

Extensive disease: Evidence of UC proximal to the splenic flexure

Left-side disease: UC present in the descending colon up to, but not proximal to, the splenic flexure

Proctosigmoiditis: Disease limited to the rectum with or without sigmoid involvement

Imaging modalities that may be considered include the following:

Plain abdominal radiography

Double-contrast barium enema examination

Cross-sectional imaging studies (eg, ultrasonography, magnetic resonance imaging, computed tomography scanning)

Radionuclide studies


See Workup for more detail.


Medical treatment of mild UC includes the following:

Mild disease confined to the rectum: Topical mesalazine via suppository (preferred) or budesonide rectal foam

Left-side colonic disease: Mesalazine suppository and oral aminosalicylate (oral mesalazine is preferred to oral sulfasalazine)

Systemic steroids, when disease does not quickly respond to aminosalicylates

Oral budesonide

After remission, long-term maintenance therapy (eg, once-daily mesalazine)

Medical treatment of acute, severe UC may include the following:


Intravenous high-dose corticosteroids

Alternative induction medications: Cyclosporine, tacrolimus, infliximab, adalimumab, golimumab

Indications for urgent surgery include the following:

Toxic megacolon refractory to medical management

Fulminant attack refractory to medical management

Uncontrolled colonic bleeding

Indications for elective surgery include the following:

Long-term steroid dependence

Dysplasia or adenocarcinoma found on screening biopsy

Disease being present for 7-10 years

Surgical options include the following

Total colectomy (panproctocolectomy) and ileostomy

Total colectomy

Ileoanal pouch reconstruction or ileorectal anastomosis

In an emergency, subtotal colectomy with end-ileostomy

See Treatment and Medication for more detail.

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