Ulcerative colitis (UC) is a chronic inflammatory bowel disease that affects the large intestine.¹ Because of an overactive response of the immune system, either a part of or the entire innermost lining of the rectum and colon become inflamed and ulcers form. UC affects nearly 1 million people in the United States and Europe. It can occur at any age, but initial presentation typically occurs between the ages of 15 and 35.² The peak incidence is between 50 and 80 years of age.³ Symptoms can range from mild to severe. People with UC can also develop gastrointestinal tract-disease-related symptoms in other areas of the body such as the eyes, skin, and joints.⁴

The exact etiology of UC is unknown. Factors like an abnormal immune response, genetics, microbiome, and the environment all contribute to UC.¹ Other potential causes include smoking cessation, non-steroidal anti-inflammatory (NSAID) use, and enteric infections like Clostridioides difficile (C. diff).² In fact, infection with nontyphoid Salmonella or Campylobacter is associated with an 8 to 10 times higher risk for developing UC in the following year compared with those who have not been infected.⁵ Further, a C. diff infection ranges from 5% to 47% among patients with newly diagnosed or relapsing irritable bowel disease.² Genetic factors also play a role in UC.⁵ Up to 20% of people with UC have a blood relative with irritable bowel disease, and having a sibling with UC increases the risk of developing the disease 4.6-fold.^4,5 A diet high in refined sugar, fat, and meat also increase the risk.5

Clinicians should consider an UC diagnosis if a patient has symptoms of bloody diarrhea, mucous, urgency, tenesmus, and abdominal cramping and other causes of these symptoms are absent. Clinicians should assess the severity of disease, triggers causing onset, and potential alternate etiologies during a full clinical history. Symptoms assessed during a diagnosis include frequency of bowel movements, bleeding, urgency, abdominal pain, cramping, and weight loss, which is a marker of disease severity. Since enteric infections can mimic UC, an infectious etiology should always be suspected. An infectious etiology should be excluded during diagnosis by performing pathogen testing through PCR-based assays.²

To look for signs of disease inside the colon and rectum, a complete colonoscopy including examination of the terminal ileum should be performed. In individuals with severe disease, a sigmoidoscopy with biopsies is appropriate since a colonoscopy introduces a risk of perforation. The severity of disease should be determined by incorporating both patient-reported outcomes and laboratory- and endoscopy-based values after a diagnosis is made.²

In 2019, the American College of Gastroenterology (ACG) and in 2019 and 2020, the American Gastroenterological Association (AGA) published clinical guidelines for UC.^2,6,7 The overall goal of treatment for UC is achieving remission, maintaining remission, and controlling inflammation. No standard treatment works for every patient, so personalized treatment plans depending on disease severity, location of the disease in the body, past responses to medications, side effects of medications, and comorbidities dictate the treatment approach.⁴ Treatment often includes medication, diet and nutrition modifications, or surgical procedures that remove the affected part of the intestine.¹ Prescription medications for UC suppress the immune system’s abnormal inflammatory response. Categories of medications include 5-ASAs, antibiotics, biologics, corticosteroids, and immunomodulators.

The AGA recommends that patients with mild to moderate UC are treated using a standard dose of mesalamine (2-3 grams/d) or diazo-bonded 5-aminosalizylate (5-ASA).⁷ For patients with moderate to severe UC, the AGA recommends using infliximab, adalimumab, golimumab, vedolizumab, tofacitinib, or ustekinumab over no treatment. In hospitalized adult patients with acute severe UC (ASUC), the AGA suggests using intravenous methylprednisolone dose of 40 to 60 mg/d rather than a high dose of intravenous corticosteroids.⁶

The ACG categorizes recommendations into therapeutic decisions for induction and maintenance. For patients with mildly active UC, the ACG recommends rectal 5-aminosalicylate therapies at a dose of 1 g/d for induction and maintenance of remission. For patients with moderate to severe UC, they recommend oral systemic corticosteroids and adalimumab, golimumab, or infliximab for induction of remission. The ACG recommends methylprednisolone 60 mg/d or hydrocortisone 100 mg 3 or 4 times per day to induce remission in hospitalized patients with ASUC.²

People with UC find that a diet of soft and bland foods decreases discomfort compared with spicy or high-fiber foods. In addition, frequent diarrhea reduces the body’s ability to absorb essential nutrients, so it is essential to maintain good nutrition.¹

In 25% to 30% of patients with UC, medical therapy is unsuccessful.¹ Therefore, surgery is considered. One surgical procedure performed in patients with UC involves removal of the colon and rectum, or proctocolectomy. In a total proctocolectomy with end ileostomy, the anus is surgically removed along with the colon and rectum. The other surgical procedure used is a proctocolectomy with ileal pouch-anal anastomosis where the colon and rectum are removed, but the anus and anal sphincter muscles remain intact.⁴  

The goal of ulcerative colitis management is to achieve a sustained and durable period of steroid-free remission that is accompanied by psychosocial support, normal health-related quality of life, prevention of morbidity that includes hospitalization and surgery, and cancer prevention. To achieve this goal, management must involve a quick and precise diagnosis, assessment of the patient’s poor risk outcome, and administration of the correct therapy for that patient.²

The goal of ulcerative colitis management is to achieve a sustained and durable period of steroid-free remission that is accompanied by psychosocial support, normal health-related quality of life, prevention of morbidity that includes hospitalization and surgery, and cancer prevention. To achieve this goal, management must involve a quick and precise diagnosis, assessment of the patient’s poor risk outcome, and administration of the correct therapy for that patient.²

1.      What is Ulcerative Colitis? Crohn’s & Colitis Foundation. Accessed April 11, 2022. https://www.crohnscolitisfoundation.org/what-is-ulcerative-colitis

2.      Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol. 2019;114(3):384-413. doi:10.14309/ajg.0000000000000152

3.      Langan RC, Gotsch PB, Krafczyk MA, Skillinge DD. Ulcerative Colitis: Diagnosis and Treatment. AFP. 2007;76(9):1323-1330.

4.      What Is Ulcerative Colitis? Crohn’s and Colitis. Accessed April 11, 2022. https://www.crohnsandcolitis.com/ulcerative-colitis

5.      Adams SM, Bornemann PH. Ulcerative Colitis. AFP. 2013;87(10):699-705.

6.      Feuerstein JD, Isaacs KL, Schneider Y, et al. AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis. Gastroenterology. 2020;158(5):1450-1461. doi:10.1053/j.gastro.2020.01.006

7.      Ko CW, Singh S, Feuerstein JD, et al. AGA Clinical Practice Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis. Gastroenterology. 2019;156(3):748-764. doi:10.1053/j.gastro.2018.12.009

8.      Sandborn WJ, Feagan BG, Hanauer SB, Lichtenstein GR. The Guide to Guidelines in Ulcerative Colitis: Interpretation and Appropriate Use in Clinical Practice. Gastroenterol Hepatol (N Y). 2021;17(suppl 4):3-13.