Ulcerative colitis
Ulcerative colitis is long-term inflammation of the lining of the colon and rectum. For reasons that are still not fully understood, the immune system starts…
On this page
- How the illness shows itself
- Flare-ups, remission and what sets them off
- Signs of a severe flare-up: this needs hospital
- How the diagnosis is confirmed
- What brings a flare-up under control
- The key point: maintenance treatment is taken when you are well, too
- About food, honestly
- Bowel cancer risk and why the colonoscopy keeps coming round
- Online consultation
Medicines commonly prescribed for Ulcerative colitis
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: INJECTABLE PERFUSION, 100 mgActive substance: infliximabManufacturer: Pfizer Europe Ma EeigPrescription requiredDosage form: INJECTABLE, 25 mg/ml (2ml, 20ml and 40ml)Active substance: methotrexate, methotrexateManufacturer: Accord Healthcare S.L.U.Prescription requiredDosage form: INJECTABLE, 20 mgActive substance: methotrexateManufacturer: Medac Gesellschaft Für Klinische Spezialpräparate GmbhPrescription required
Ulcerative colitis is long-term inflammation of the lining of the colon and rectum. For reasons that are still not fully understood, the immune system starts working against a person's own bowel: the lining reddens, swells and develops small ulcers that bleed. The condition does not go away by itself and is not cured by a course of tablets, but it is very manageable — most people with ulcerative colitis spend years with no symptoms at all. The difference between "this illness runs my life" and "I barely notice it" usually comes down to one thing, and we say it plainly further down.
How the illness shows itself
The main sign is loose stool containing blood, mucus or pus, day after day. Alongside it come sudden urgent trips to the toilet, the feeling of never quite finishing, false alarms that produce only mucus, and cramping pain low in the abdomen, more often on the left. If only the rectum is inflamed, stools may still be formed — and there can be quite enough blood to frighten anyone.
Plenty of people put it down to piles or something they ate, for months on end. The rule of thumb is simple: a one-off upset settles within days, whereas ulcerative colitis drags on for weeks and keeps coming back. Blood in the stool is always a reason to see a doctor, whatever your age.
The illness rarely stays inside the bowel. In roughly one person in three the inflammation reaches other organs too: large joints ache and swell, eyes turn red and sore, ulcers appear in the mouth, and firm painful lumps come up on the shins. Fatigue deserves a separate mention: it is not laziness but a direct result of inflammation and blood loss, and it should be reported to a doctor just as the bowel symptoms are.
Flare-ups, remission and what sets them off
The course comes in waves. For weeks, months and sometimes years there are almost no symptoms — that is remission. Then the inflammation flares again. The exact moment cannot be predicted, but the circumstances that make a flare more likely are known, and some of them are within our control.
The commonest cause of a flare-up is maintenance treatment that has been stopped. There is a whole section on this below, but it is the first thing a gastroenterologist thinks of when someone in remission suddenly turns up with blood in the stool.
The second is non-steroidal anti-inflammatory painkillers. Ibuprofen, diclofenac, naproxen and their relatives — sold over the counter and taken by almost everyone for headache or toothache — can stir up bowel inflammation in people with ulcerative colitis. This is not a ban on pain relief: it means the painkiller should be chosen together with a doctor, and that the familiar ibuprofen in the bathroom cupboard stops being harmless once you have this condition.
The third is gut infections and antibiotics. Ordinary food poisoning can tip the illness into a flare, and a course of antibiotics prescribed for something else alters the gut flora and can open the door to a clostridial infection. That is why, when things get suddenly worse, the first thing a doctor arranges is a stool test for Clostridioides difficile and the usual gut infections — the treatment for that is quite different, and stepping up immune suppression here would be a mistake. Stress does not cause the illness, but flare-ups do happen more often during stressful periods.
Signs of a severe flare-up: this needs hospital
Mild and moderate flare-ups are treated at home. A severe one is treated as an inpatient, and it is not something to sit out until Monday or until it settles on its own: it develops over a few days, sometimes over hours.
Get urgent medical help the same day if any one of these appears:
- bloody stools six or more times a day, particularly if they wake you at night;
- a temperature alongside the bowel symptoms;
- a fast pulse, weakness, dizziness on standing, fainting;
- severe unremitting abdominal pain, quite unlike the usual cramps before opening the bowels;
- a visibly swollen abdomen, especially if the stools have suddenly stopped;
- persistent vomiting and being unable to keep fluids down.
Swelling of the abdomen together with pain, fever and a racing pulse is particularly worrying: this is how acute toxic dilatation of the colon (toxic megacolon) presents — a rare but life-threatening complication in which the distended, inflamed bowel can rupture. It develops quickly and needs hospital care with a surgeon involved. If someone deteriorates sharply with severe abdominal pain, pallor and confusion, call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single number 112 is in use). One trap is worth spelling out: during a severe flare-up you should not take medicines that stop diarrhoea — by holding the contents inside an inflamed bowel they can bring on exactly this kind of distension.
How the diagnosis is confirmed
The diagnosis is not made from a description of symptoms, because far too many conditions produce the same ones. It starts with tests: a full blood count shows anaemia and inflammation, and a stool sample rules out gut infection. One particularly useful test is faecal calprotectin, which separates inflammation in the bowel wall from functional disorders such as irritable bowel syndrome, where the bowel is not inflamed at all.
The decisive investigation is endoscopy. A flexible tube with a camera is passed through the rectum, the lining is inspected and small tissue samples are taken. For a first diagnosis a full colonoscopy is usually needed: it matters how far up the inflammation reaches, because both treatment and later monitoring depend on it. It is done with pain relief or light sedation, and the bowel is cleared the day before with a special preparation.
As the assessment goes on, the doctor separates ulcerative colitis from Crohn's disease, the other inflammatory bowel disease. They look alike, but in Crohn's disease the inflammation can sit anywhere in the digestive tract and goes through the full thickness of the wall, whereas in ulcerative colitis only the lining of the colon is affected, continuously, starting from the rectum. The distinction is not academic: treatment and outlook differ.
What brings a flare-up under control
No medicine here removes the cause — they all damp down an excessive immune reaction so that the lining can heal. A gastroenterologist leads the choice, which depends on how widespread the inflammation is and how severe the flare is.
In mild and moderate flare-ups the mainstay is aminosalicylates (5-ASA drugs). They are taken by mouth and, where the rectum and left side of the colon are involved, locally as well: suppositories, foam or enemas. The local forms deserve a word of their own, because many people dismiss them as awkward — yet in low-lying disease they work better than tablets, since they deliver the drug straight to the inflamed area.
If that is not enough, corticosteroids are added as a short course with the dose tapered down. They settle a flare well but are no good for continuous use: taken long term they thin the bones and bring on cataracts, raised blood sugar and raised blood pressure. When they cannot be avoided, treatment moves on to immunosuppressants and, in moderate to severe disease, to biological drugs or targeted molecules in tablet form. These treatments call for regular blood tests and caution around infections.
In a severe flare-up the medicines are given into a vein in hospital. If even that fails, the colon is removed. Surgery sounds alarming, but it should be understood properly: removing the colon frees a person from ulcerative colitis for good, and modern techniques mean a permanent stoma bag can be avoided in most cases.
The key point: maintenance treatment is taken when you are well, too
Maintenance treatment means the medicines taken during remission, when nothing hurts. It is precisely the treatment people abandon most often, and that abandonment is the leading cause of flare-ups. The reasoning is easy to follow: no symptoms, feeling normal, the box untouched for months — why would a healthy person take tablets? But remission in ulcerative colitis is not self-sustaining; it rests on the medicine. Take the medicine away and the inflammation returns, sometimes within a month, sometimes within six.
The second argument is far less widely known: taking aminosalicylates continuously not only holds remission but, on the available evidence, also lowers the risk of bowel cancer. The tablet taken in the quiet periods is doing two jobs at once.
In practice this means the following. Do not stop your maintenance drug on your own initiative, even after a year of feeling perfectly well. If taking it is a burden — too many tablets, side effects, cost, an inconvenient form — say so out loud to your doctor: there is almost always something to swap it for or a way to simplify the regimen. A missed dose is not doubled up; you simply carry on.
About food, honestly
There is no universal diet for ulcerative colitis, and diet is not the cause of the illness. This is worth saying plainly, because the subject attracts a great deal of confident advice, and because of it some people spend years eating five foods and arrive at the clinic short of iron and vitamins.
What is known for certain is something else: in remission the great majority eat ordinary, full meals without restrictions. During a flare-up it makes sense to switch temporarily to something gentler — smaller meals more often, less coarse fibre, less spice and fat, limited coffee and alcohol, and plenty of fluids, because frequent loose stools dehydrate you quickly.
Individual intolerance to particular foods does occur, and a food diary helps to find it: write down what you ate and how you felt, and after a few weeks a pattern emerges. But whole food groups — dairy, all grains, all vegetables — should not be cut out without discussing it with a doctor: that costs you calcium, vitamin D, iron and protein, and the illness does not retreat in return. In long-standing disease and in anyone on steroids, the doctor keeps an eye on bone health and iron levels and prescribes supplements where needed.
Bowel cancer risk and why the colonoscopy keeps coming round
This part usually comes as news, and it should not. Long-standing inflammation of the colon lining raises the risk of cancer developing there. The risk is not the same for everyone: it is higher if the illness has lasted many years, if the inflammation covers much of the colon, if flare-ups are severe and frequent, if close relatives have had bowel cancer, or if primary sclerosing cholangitis is present alongside it.
That is why people with ulcerative colitis have colonoscopies at regular intervals — not because anything has been suspected, but as a planned schedule. It usually begins some years after the first symptoms, and is then repeated at an interval the doctor sets for each individual. The point is to catch changes in the lining at the stage where they are not yet cancer and can simply be removed.
There is one conclusion: do not skip a scheduled colonoscopy, however well you feel. Early changes give no warning of themselves, and the symptoms that might otherwise raise suspicion of bowel cancer — blood in the stool, diarrhoea, abdominal pain — are already there in ulcerative colitis, so they are useless as an alarm signal here.
Online consultation
With ulcerative colitis, questions keep coming up between appointments with the gastroenterologist, and most of them are settled by talking. An online consultation is a good place to go through early symptoms and work out which tests are worth having before you see a specialist, to discuss a diagnosis already made and the results of investigations, and to make sense of the prescribed regimen: how to take it, what to expect, what to do about side effects and why you should not stop at the first sign of improvement.
Remotely it is also convenient to cover what there is never time to ask in the clinic: which painkiller you can use instead of your usual one, what to do if you have been prescribed an antibiotic for something unrelated, when it is time to chase up the scheduled colonoscopy, how to plan a pregnancy and what to adjust in the treatment beforehand. If your description points to a severe flare-up, the doctor will say so straight away and direct you to hospital.
This material is for information only and does not replace medical advice.
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