Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD) that affects nearly 2 million Americans and millions more worldwide. This chronic condition causes inflammation and ulcers in the colon (large intestine) and rectum, with the immune system mistakenly attacking the lining of these organs. Most people with UC have unpredictable flare-ups that can be challenging to manage, followed by periods of remission with no symptoms. Others never achieve remission.

Ulcerative colitis can greatly affect quality of life, causing fatigue and stress. Severe cases may require surgery to remove the colon.

Knowing the symptoms of UC is important so you can be diagnosed and treated early. Ignoring symptoms can make the condition worse and require more aggressive treatment.

Common Symptoms

In UC, symptoms are closely linked to the level of inflammation in the body. The classic symptoms of UC typically include:

• Diarrhea with blood or mucus
• Frequent bowel movements, often more than four per day
• A constant urgent need to have a bowel movement, or feeling incomplete after having one
• Abdominal pain

Other Signs and Symptoms

In addition to these, other signs and symptoms that may be experienced are:

• Constipation
• Anemia
• Weight loss
• Fever
• Fatigue
• Abdominal cramping
• Nausea
• Loss of appetite

Early Signs of Inflammation 

Given that UC is a systemic disease with inflammation spreading throughout the body, symptoms can extend beyond the intestinal tract. These are known as extraintestinal manifestations (EIMS). They may occur in up to 24 percent of people with IBD before bowel symptoms ever develop, and are common in UC. Eventually, over 40 percent of patients will develop EIMs during the lifetime of their disease. A few of these manifestations include:

• Joint pain and arthritis
• Inflammatory eye conditions
• Certain skin rashes and lesions
• Mouth ulcers

While the exact cause of UC is complicated and not well understood. Researchers predominately believe a susceptible individual’s genetics interact with various environmental exposures to trigger the disease. It is believed that only about 8.2 percent of those specific gene variations have been discovered so far.

Environmental factors, problems with the gut barrier and the immune system, and gut bacteria interact to cause and sustain the inflammation seen in UC.

1. Autoimmunity and Environment

In UC, the immune system mistakenly attacks healthy colon tissues, causing long-lasting inflammation and ulcers. Alongside this autoimmune response, other factors can harm the gut’s protective barrier, creating a “leaky gut” and reduced thickness in the mucus layer.

Some of the more common factors that contribute to initially developing UC include:

• Poor sleep
• Dysbiosis (imbalanced gut bacteria)
• Vitamin D deficiency
• Toxins, including air pollution
• Medications, including some non-steroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitors (PPIs)
• Food allergens and gluten
• Infections

Stress and diet also play significant roles in gut health, and any of these factors can impact gene expression, the immune system, gut health, and inflammation. They may also trigger a flare-up or relapse. Exposure to viruses, infections, food additives, or antibiotics early in life can also influence the development of UC.

Moreover, a damaged barrier can impair the absorption of essential nutrients like vitamins and minerals. In turn, this lack of nutrients can make UC symptoms worse and make the body more prone to infections, continuing the cycle of gut damage and immune reactions.

2. Gut Microbiome

The gut microbiome, which includes various bacteria, interacts with the mucus barrier in the intestines to maintain a healthy balance between harmful and beneficial bacteria. An imbalance, known as dysbiosis, can trigger inflammation and damage the gut lining.

Researchers have discovered that people with UC have a different mix of microbes than healthy people. Specifically, UC patients have more of several opportunistic pathogens and less beneficial species such as Bacteroides species, Akkermansia muciniphila, and Faecalibacterium prausnitzii. This dysbiosis can result in inflammation and gut lining damage, contributing to the onset of UC and potentially colorectal cancer.

What Happens in the Body?

The colon plays a vital role in water absorption and waste elimination. In UC, it becomes inflamed, leading to the development of ulcers in its lining. Typically, inflammation begins in the rectum before spreading upward through different sections of the colon.

Ulcerative colitis is characterized by chronic inflammation of the colon and rectum, and is typically divided into four types based on the severity and location of the inflammation.

These types influence the treatment approach and include:

1. Ulcerative proctitis: limited to the rectum
2. Proctosigmoiditis: affecting the rectum and rectosigmoid colon
3. Left-sided colitis: extending from the rectum to the left upper abdomen near the spleen, called the splenic flexure of the colon
4. Pancolitis: also known as extensive colitis, affecting the entire colon

Acute severe ulcerative colitis may be considered an additional type or a complication of ulcerative colitis. Like pancolitis, it affects the entire colon, but involves more severe pain, heavy diarrhea, bleeding, and fever. It can be life-threatening, requiring prompt treatment.

In addition to the factors that can damage the gut barrier, other factors have been found to make someone more likely to develop UC including:

• Age: UC can occur at any age, but typically begins between the ages of 15 and 30, with another peak between 50 and 70 years old.
• Ethnicity: Although anyone can get UC, ethnicity plays a role in risk. The majority of UC patients are white people with European ancestry. The Ashkenazi Jewish population has the highest innate risk of UC. In the United States, non-white Americans, particularly black people, are seeing a significant rise in the prevalence of UC cases with more serious outcomes, possibly due to delayed diagnosis and treatment. Asians have the lowest prevalence of UC in the U.S.
• Family history: Having a first-degree family member with UC increases the likelihood four times.
• Diet: Diets rich in processed, fried, or sugary foods can trigger inflammation and exacerbate symptoms. Researchers have also linked higher levels of red and processed meat, eggs, protein, soft drinks, and alcohol consumption to a higher risk of relapse in UC.
• Lifestyle: Living in an urban area, using oral contraceptives, and experiencing obesity elevate risk.

Factors that are protective against developing UC include being breastfed, living near farm animals, having access to hot water and a personal toilet, and having a high folate level.

The diagnosis of ulcerative colitis (UC) typically involves several steps, starting with an initial evaluation.

Moreover, it is important to distinguish between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). They share some symptoms like abdominal pain and changes in bowel habits, but IBD involves chronic inflammation of the digestive tract, while IBS does not. This means treatments differ for each, so getting the right diagnosis is key.

Diagnostic Tests

• Blood tests: These can show if you have anemia, which might mean bleeding in your colon or rectum. A high erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) could indicate severe UC. Certain autoantibodies associated with UC are not reliable for diagnosis. Low albumin levels (a type of protein) may signal how serious the disease is and predict the need for colectomy or a limited response to certain biological medications.
• Stool samples: Tests on stool samples check for infections, inflammation, and UC-specific markers like fecal calprotectin. A low stool lactoferrin level can rule out UC. Stool testing for lactoferrin may be a less invasive option than imaging or a colonoscopy for children and pregnant women.
• Colonoscopy with biopsies: A colonoscopy lets doctors see the entire colon, take tissue samples for biopsies, check for inflammation, and determine how severe the disease is. It can also help rule out other conditions like Crohn’s disease and colorectal cancer, as well as find any complications.
• Sigmoidoscopy: Similar to a colonoscopy but focusing on the lower left colon (sigmoid) and rectum, this procedure is less invasive and preferred for mild cases or monitoring healing.
• Imaging tests: While not used for diagnosis, computed tomography (CT) scans and magnetic resonance imaging (MRI) can assess how severe the disease is, check for complications and EIMs, and rule out other conditions.

In some cases, specialized X-rays like barium enemas may also be used to detect inflammation or complications. These tests offer important information to guide treatment choices and track disease progress.

Complications of UC can occur in the intestine or elsewhere in the body and include:

• Anemia: Severe bleeding from the colon in UC can result in anemia due to a reduced number of red blood cells.
• Osteoporosis: Both UC and corticosteroids used in its treatment can impact bone health. Steroids, even in low doses, can reduce calcium absorption and sex hormones crucial for bone strength, and induce bone cell death. These effects can lead to osteopenia, osteoporosis, and a risk of fractures.
• Growth and development issues in children: Children with UC may experience growth and development issues due to malabsorption of essential nutrients and chronic inflammation.
• Primary sclerosing cholangitis: This rare complication involves inflammation and scarring of the bile ducts, which can damage the liver.
• Ankylosing spondylitis and arthritis: Inflammation from UC can affect joints, leading to conditions like ankylosing spondylitis (spinal joint inflammation) and arthritis of other joints, causing pain and stiffness.
• Uveitis: UC can cause eye inflammation, resulting in conditions like uveitis, which can lead to eye pain, redness, and severe vision problems, including blindness.
• Colorectal cancer: Chronic inflammation and cellular changes in UC affecting a large part of the colon increase the risk of colorectal cancer.
• Incontinence or sexual dysfunction: Apart from the psychological and emotional effects, incontinence and sexual dysfunction can arise due to physical reasons or as side effects of treatments like corticosteroids.
• Perianal diseases: Anal fissures, abscesses, and rarely, fistulas, can occur with pain, swelling, discharge, and difficulty with bowel movements. Bleeding associated with these complications might be mistaken for a UC flare-up, potentially leading to incorrect treatment when urgent surgery is necessary.
• Clostridium difficile infection: Clostridium difficile infection is a common complication, often triggered by antibiotic use and resulting in severe diarrhea and abdominal pain.
• Emergency complications: Immediate medical attention is needed for severe rectal bleeding, blood clots, dehydration, fulminant colitis, colon dilation (toxic megacolon), and perforation of the colon.

Treatment for ulcerative colitis varies based on disease severity and extent. Mild or moderate conditions are typically treated at home, but more severe flare-ups may require hospitalization. Treatment options are tailored to the individual’s condition, with the goals of inducing and maintaining remission, along with optimizing nutrition and quality of life. Treatments may range from nutritional therapy to medications, surgery, or more novel therapies.

Nutritional Therapy

Nutritional therapy, including the elemental diet, may be necessary in severe cases to support digestive health and prevent malnutrition. The elemental diet is a liquid therapy that provides easily absorbable, essential nutrients, while the colon heals. This diet is provided either orally or with enteral nutrition through a feeding tube directly into the digestive tract. While other diets are being explored, more research is needed before they are widely adopted as standard treatments.

Medications

• 5-ASA (Aminosalicylates): Aminosalicylates (mesalamine and sulfasalazine) are commonly used for mild cases of ulcerative colitis to target inflammation in the gastrointestinal tract and induce remission. They are most effective when administered rectally as suppositories or enemas, but can also be taken orally.
• Antibiotics: Antibiotics such as fluoroquinolones or metronidazole may be prescribed if an infection or certain complications are present. It is important to have a conversation with your prescriber about the potential serious side effects and alternative treatment options.
• Steroids: Steroids (prednisone and budesonide) are typically used for moderate to severe cases of UC to suppress the immune response, rapidly gaining control of the disease. However, due to potential side effects, they are not recommended for long-term use.
• Immunomodulators: These medications, including azathioprine, work by suppressing the immune system to prevent inflammation and damage. They are considered when other medications are ineffective or not tolerated, but may take several months to work.
• Biologics: Biologics like infliximab, adalimumab, and vedolizumab are protein-based antibodies administered via infusion or injection that target specific proteins to reduce inflammation. They are particularly beneficial for moderate to severe cases of UC.
• Targeted synthetic small molecules: This relatively new class of oral medication targets specific parts of the immune system by inhibiting Janus kinase (JAK) enzymes, thereby halting inflammation from within the cells. Examples include tofacitinib and upadacitinib. The FDA has also approved the use of ozanimod, a phingosine-1-phosphate receptor (S1PR) modulator that targets inflammation, for the treatment of moderate to severe UC.

Suppressing the immune system may be necessary under certain circumstances, but it is important to know that doing so increases the risk of infections, osteoporosis, and certain cancers like colon, cervical, and skin cancer.

Surgery

Surgery becomes necessary when medications fail to control symptoms. A colectomy to remove all or part of the colon will be necessary for up to 15 percent of those with UC, especially those under 40 and those with severe symptoms, high CRP, or low albumin levels.

While a colectomy can cure UC by removing the inflamed tissue causing symptoms, there is a high rate of complications after colorectal surgery, with nearly 30 percent experiencing post-surgery issues.

Complications include:

• Pelvic sepsis or infection
• Leakage
• Small bowel obstruction
• Sexual dysfunction
• Pouchitis with potential abdominal pain, diarrhea, or urgency
• Urinary or fecal incontinence

Some of these symptoms can be long-term and require medical management.

There is no one-size-fits-all therapy for UC, and in patients with severe disease, the newer advanced treatments only work 50 percent of the time, at best, necessitating colectomy. This underscores the need for more effective therapies. Ongoing research is actively exploring novel therapies and targets within the microbiome and immune system to address the unmet need. Emerging treatments offer promising avenues for improving UC management and outcomes.

Fecal Microbiota Transplantation

The link between gut microbial imbalance and IBD has led to research on fecal microbiota transplantation (FMT). Initially used for recurrent Clostridioides difficile infections, FMT is showing promise in treating IBD, obesity, and allergic diseases. FMT involves transferring stool from a healthy donor into the gastrointestinal tract of a recipient to restore a healthy balance of gut bacteria.

Low-Dose Naltrexone (LDN)

Low-dose naltrexone (LDN) is a potential therapeutic option in the management of UC. Although there are no peer-reviewed studies on LDN for UC, there have been some case studies of possible effectiveness in various gastrointestinal and autoimmune diseases including Crohn’s disease, Type 1 diabetes, and multiple sclerosis, as well as conditions like fibromyalgia, AIDS, and cancer.

LDN helps regulate the immune system by promoting T regulatory cell function and temporarily blocking opioid receptors in the brain. This action can help reduce inflammation and balance immune responses. While not a standard conventional treatment, functional medicine practitioners prescribe LDN for its immune-modulating effects in managing UC and other autoimmune conditions.

A Functional Medicine Approach to Ulcerative Colitis

Functional medicine (FM) investigates the underlying causes of bodily dysfunction and customizes treatments to individual patients, earning it the nickname “personalized medicine.” It is a holistic approach focused on identifying causes and connections, and restoring balance.

Here is how the 5R approach might be applied to treat UC:

1. Remove: Identify and eliminate factors contributing to inflammation, leaky gut, and dysbiosis, such as specific food sensitivities, stressors, or environmental toxins. Use drugs or herbs to treat any underlying infections.
2. Replace: Replenish essential elements like digestive enzymes or bile acids necessary for digestion and absorption.
3. Reinoculate: Introduce beneficial bacteria through probiotics and fermented foods to restore a healthy gut microbiota crucial for immune function.
4. Repair: Support gut healing by providing nutrients like l-glutamine, zinc, and quercetin, known to reduce leaky gut and promote intestinal repair.
5. Rebalance: Optimize nutrition, manage stress, and promote healthy lifestyle habits to rebalance the body and keep inflammation at bay to prevent disease recurrence.

Limited research exists on FM due to the newness and personalized nature of the approach. However, in a case report, a 23-year-old woman with UC saw her symptoms disappear after following the 5Rs program:

• The removal phase targeted parasites, toxins, infections, and inflammatory foods that could damage the gut lining.
• Supplements like digestive enzymes, bile acids, and vitamins replaced what she lacked and helped repair her gut lining.
• Probiotics helped re-inoculate and rebalance her microbiome.
• Stress reduction helped lower her inflammation and rebalance her lifestyle, with the goal of preventing recurrence.

Living with ulcerative colitis (UC) poses various challenges, including the unpredictable nature of flare-ups, symptoms like diarrhea, abdominal pain, and fatigue, and the need for ongoing medical care. Treatment can also be difficult due to side effects and the potential for surgery with lasting life changes. Apart from physical challenges, thoughts and attitudes related to the illness, disability, and social limitations significantly impact well-being.

Individuals with UC often experience anxiety and depression, which studies suggest can worsen disease activity and contribute to flare-ups. The gut-brain connection highlights how the microbiome and neurotransmitters influence mood and physical health. Addressing the physical, mental, and emotional aspects of UC is vital to break this cycle.

Practices like mindfulness, meditation, therapy, exercise, yoga, and social support have been effective in helping individuals with UC manage stress and enhance mental well-being. Approaching UC management proactively and positively can empower individuals to follow treatment plans diligently and adopt lifestyle changes that boost overall health.

When approaching UC naturally, there are a few options to consider for helping your gut heal and reducing inflammation. Although these methods are supported by science, everyone responds differently, so it is important to work with a health care professional.

Nutrition

When dealing with inflammation, what you eat matters. An anti-inflammatory diet can help ease inflammation that causes flare-ups. However, what triggers inflammation can be different for each person due to food sensitivities. Keeping track of what you eat in a food journal or working with a nutritionist can help you identify foods that are causing problems. Here are some dietary approaches with evidence supporting their effectiveness:

• Anti-inflammatory diet: A diet rich in peeled fruits, cooked vegetables, healthy fats, and lean proteins, and low in dairy and processed foods, like the Mediterranean diet, can help reduce inflammation and promote gut health. Lactose from dairy products can trigger symptoms like bloating, gas, and diarrhea in about 40 percent of those with UC who have lactose malabsorption.
• Fiber-rich foods: A high-fiber diet aids digestion, promotes beneficial gut bacteria growth, and may lower the risk of colorectal cancer. Aim for 14 grams of fiber for every 1,000 calories you eat.
• Prebiotic foods and SCFAs: Foods like cooked garlic, cooked onions, and bananas promote the growth of beneficial gut bacteria and the production of SCFAs like butyrate. These SCFAs are crucial for maintaining a healthy gut lining, managing UC, and regulating the immune system. Fermented vegetables like sauerkraut offer probiotics as well as prebiotics to feed beneficial bacteria.
• Omega-3 fatty acids: The typical Western diet today provides an omega-3 to omega-6 ratio of about 1:20, which can contribute to increased inflammation in the body and raise the risk of chronic diseases. Research indicates that achieving a balanced ratio closer to 1:1 can enhance the chances of remission in ulcerative colitis (UC). In one study, UC patients who consumed about 21 ounces of Atlantic salmon per week had lower disease activity and inflammation compared to those with a diet high in omega-6 fatty acids.

Other diets, including a plant-based diet and restrictive diets like the low FODMAP diet, specific carbohydrate diet, and autoimmune diet show promise in reducing inflammation and easing symptoms in UC. However, there is a lack of large-scale studies on their effectiveness. It is important to note that restrictive diets are not intended for long-term use because they have the potential to disrupt gut bacterial balance and cause nutritional deficiencies.

Supplements

• Vitamin D: An adequate level of vitamin D supports your immune function, reduces inflammation, and might lower the chance of UC relapse. You can get vitamin D from sunlight, fatty fish, and supplements.
• Fish oil: Fish oil supplements contain important omega-3 fatty acids like eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). They can supplement your diet, especially if you do not eat fish much. Studies on fish oil for UC show mixed results, which might depend on factors like study design, dosage, and the quality of the oil. Still, these supplements can help balance your fatty acids to prevent UC and ease inflammation.
• Sea algae omega-3s for vegans: Sea algae provides a plant-based omega-3 alternative for supplemental DHA and EPA.
• Probiotics: The effects of probiotics are strain-specific and cannot be generalized to other strains within the same species. Specifically, Escherichia coli Nissle 1917 and Lactobacillus rhamnosus GG are two strains studied for their potential to modulate gut inflammation and improve symptoms in UC patients.
• Curcumin: Studies have found curcumin inhibits inflammation in UC and helps induce remission.
• Boswellic acid: Boswellic acid shows promise in reducing UC ulcers and inflammation.
• Cannabis: Some small studies suggest that cannabis might help with symptom relief and remission in UC, but reviews of larger studies with varying doses, formulations, and methods of using cannabis show uncertain results. Of note, some individuals in the general population may develop cannabis hyperemesis syndrome with chronic cannabis use, with the potential for worsening abdominal pain and vomiting in susceptible patients.
• Aloe vera: Known for its anti-inflammatory and antioxidant properties, aloe vera is widely used for IBD. In a small study of patients with mild to moderately active UC, aloe vera significantly decreased disease activity and improved tissue health. Rat studies have also demonstrated a protective and therapeutic effect on UC. However, the evidence is not yet sufficient to recommend aloe vera as an alternative therapy.
• Psyllium husk: Psyllium husk or seed can help relieve constipation.
• Bromelain: Taken between meals, this enzyme combination from pineapple acts as an anti-inflammatory and has been shown to improve intestinal inflammation and barrier dysfunction in UC.

Lifestyle

• Regular exercise: Exercise can help you manage stress, feel less tired, and keep your bones healthy. Exercise has been shown to result in an overall reduction in inflammatory processes in the body. It can also aid normal gut motility.
• Restful sleep: Sleep disturbances are common with UC, especially during a flare-up. But having a regular sleep schedule, avoiding caffeine at night, and creating a relaxing bedtime routine and space can help you sleep better.

While you cannot change your age and genetics, you have a lot of control over environmental factors and things that affect gut health and contribute to leaky gut. Focusing on what you can control empowers you to take proactive steps in preventing UC, flare-ups, and complications.

While some people may experience UC only once and never face it again, others can suffer severe complications. As the disease progresses, it can affect the large intestine, increasing the risk of colon cancer. Early detection and timely colon removal can greatly improve survival rates.

Prevention Tips

• Follow an anti-inflammatory diet such as the Mediterranean diet or one that works for you.
• Consider incorporating omega-3-rich foods into your diet, such as anchovies and sardines, while reducing your intake of omega-6-rich oils found in refined vegetable oils.
• Avoid or limit foods that increase the risk of colorectal cancer, including red meats, processed meats, and processed foods.
• Get regular screening for colorectal cancer.
• Maintain a healthy weight.
• Exercise regularly, including weight-bearing exercises to prevent osteoporosis, and consider regular DEXA scans to monitor bone health.
• Stay hydrated to counter fluid loss from diarrhea and prevent dehydration.
• Markedly limit alcohol consumption.
• Nurture a healthy gut by addressing leaky gut issues and promoting a balanced microbiome.