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Ulcerative Colitis

Disease Summary:

Ulcerative colitis (UC) is a chronic inflammatory disease of the lining of the rectum and colon (large intestine).  It always effects the rectum, which is the lowest part of the large intestine.  It can also progress to involve other segments or the entire colon.  It only involves the large intestine, whereas Crohn's disease can involve other segments of the intestinal tract including the stomach and small intestine.  Inflammation is limited to the innermost lining of the large intestine, while Crohn's disease effects all layers of the bowel wall.  UC is an immune-mediated disease in which there is a loss of control of normal bowel immune activity and the ongoing activity results in inflammation and damage to the bowel wall.


Symptoms vary depending on the severity of inflammation and the extent of the involvement.  Symptoms may include rectal bleeding, diarrhea, abdominal cramping, stool urgency, and rectal discomfort.


The cause of ulcerative colitis is not known.  One is more likely to develop UC if a parent or sibling has the disease.  However, most people with UC do not have a family history of the disease.  It is most often diagnosed before the age of 30, but can be diagnosed at any age.  When the diagnosis is suspected, a variety of tests may be performed including blood work, x-rays, and stool studies.  Everyone with symptoms consistent with ulcerative colitis should have a colonoscopy or flexible sigmoidoscopy to confirm the diagnosis, assuming the individual is healthy enough to undergo the procedure.  During the procedure, the gastroenterologist will directly examine the lining of the colon and rectum with the endoscope to look for evidence of inflammation.  The severity and extent of inflammation can be assessed, and biopsies can be taken to examine under the microscope.


Medical treatment involves healing the inflammation and maintaining remission, or preventing the inflammation from returning.  Medication choices include aminosalicylates, steroids, immunomodulators, and biologics.  There is no cure for ulcerative colitis, but these medications can significantly reduce symptoms and even bring about long-term remission.


Aminosalicylates (sulfasalazine and mesalamine) are antiinflammatory medications for the colon and can be used for induction and maintenance of remission in mild to moderate disease.  These medications are available in oral and rectal formulations and work to decrease the inflammation in the colon lining. Other anti inflammatory medications such as ibuprofen, naproxen, and diclofenac should be avoided because these may cause a worsening of the disease.


Corticosteroids (prednisone, methylprednisolone, and budesonide) are effective in inducing remission in moderate to severe ulcerative colitis, and are available in oral, rectal, and IV (intravenous) forms.  Corticosteroids have a number of significant side effects, and are not intended for chronic (long term) use to maintain remission in UC.  Budesonide has fewer side effects and may be used long-term.  Your doctor will discuss side effects associated with corticosteroids.


Immunomodulator medications include 6-mercaptopurine (6-MP) and azathioprine.  These medications are taken orally, but may take up to two to three months to reach their peak effect.  They are effective for maintenance of remission in moderate to severe disease.  These medications require periodic blood work because they may cause a low white blood cell count and liver test abnormalities.  Your doctor will discuss other potential side effects from these medications.


Biologic agents are given by injection to treat and maintain remission in moderate to severe UC.  The medication can be given IV (intravenous) or SQ (subcutaneous) depending upon the particular drug.  These medications suppress the immune system and one should be checked for tuberculosis and hepatitis B prior to starting therapy.  There are rare risks of serious infections with these medications.  Your doctor will discuss other potential side effects from these medications.  These medications are effective in maintaining long-term remission.


It does not matter which therapy you are taking, medication compliance is essential.  If medication is not taken properly, the result may be recurrence or worsening of symptoms and potential complications.  This may require escalation of therapy or possibly surgery.  Medication adherence and maintaining follow-up with your doctor will help minimize these risks.


At some point, surgery may be required.  This occurs when medications no longer control symptoms and inflammation.  The entire colon will be removed.  Removing the entire colon is a cure for ulcerative colitis.  The colorectal surgeon will use a portion of the small intestine to create a pouch, which is connected to the rectum.  This reques 2 or 3 operations over a period of several months.

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