Ulcerative colitis

Causes

The exact cause of ulcerative colitis is unknown.

A combination of factors may be responsible, including:

• problems with your immune system – where the immune system mistakenly attacks the lining of your large bowel, making it inflamed
• genetics – genes you inherit from your family
• environmental factors – like air pollution, medication and viruses or bacteria in your gut

Your GP will start by asking about your health and habits to get a clearer picture of what is going on. Expect questions about the pattern of your symptoms, your diet, and any recent travel, since this could point to travellers' diarrhoea instead. They will also want to know about any medicines you are taking, including over the counter ones, whether a bowel condition runs in your family, and any past health problems you have had.

Your GP may also examine your abdomen by hand. They are likely to ask for a stool sample, which can be checked with a qFIT test for blood and mucus, and with a faecal calprotectin test for infection or inflammation. Blood tests may also be arranged to look for signs of inflammation or anaemia.

Additional tests for ulcerative colitis

If your GP suspects ulcerative colitis, you may be referred to a hospital for further tests. These can include a colonoscopy, where a thin, flexible tube with a camera is passed into your bottom to examine the whole of your large bowel, or a sigmoidoscopy, which looks at just the end of your large bowel in the same way. An X-ray, MRI scan, or CT scan may also be used.

You will be told exactly which tests you need and how to prepare for them.

Treatment

Treatment for ulcerative colitis aims to relieve and prevent symptoms.

Your treatment will depend on how severe your symptoms are and how often they flare up. Mild flare-ups can be usually be treated at home. But severe flare-ups usually need treatment in hospital to reduce the risk of complications.

Treatment will usually be provided by a range of healthcare professionals.

Medication

Most people will get medication to treat symptoms of ulcerative colitis. This includes medications like:

• aminosalicylates (ASAs) – often the first treatment option, used to get and keep inflammation under control and can be given rectally as well as orally
• corticosteroids – used to get inflammation under control quickly, but not suitable for long-term use

If you have lots of flare-ups or aminosalicylates do not keep your inflammation under control, you may need other treatments, such as:

• immunosuppressants like azathioprine or mercaptopurine – used to reduce the activity of the immune system
• biologic medicines, like adalimumab, infliximab, golimumab, ustekinumab or vedolizumab
• other advanced medicines like filgotinib, ozanimod, tofacitinib and upadacitinib

Surgery

Surgery to treat ulcerative colitis may be an option if:

• you choose to have surgery instead of taking medications that may cause side effects
• medications don’t control your symptoms
• your quality of life is severely affected by your condition
• you have serious complications of ulcerative colitis

Surgery for ulcerative colitis involves removing part or all of your large bowel (known as a colectomy). This means the small intestine must be used to pass waste products out of your body instead.

During the surgery, your small intestine will either be:

• joined to the surface of your tummy (known as an ileostomy or a colostomy) – after this type of surgery, poo comes out of the opening on your tummy and is collected in special bags that you wear
• joined directly to your rectum (the end of your large bowel), so your poo comes out of your bottom as usual
• used to create an internal pouch that’s connected to your bottom (known as an ileo-anal pouch or J-pouch) – this means your poo can pass through your bottom as usual

Diet

There’s no evidence that a particular diet causes ulcerative colitis. But alongside medications, some changes to your diet may help control symptoms for some people.

You could:

• eat 5 to 6 small meals rather than 3 main meals
• try to eat a healthy, varied diet that includes a wide variety of fruit, vegetables, nuts, seeds, proteins and wholegrains
• drink plenty of water

You could also speak to your IBD team about:

• keeping a food diary to find out if any particular foods affect your symptoms
• removing trigger foods from your diet – but do not make major changes to your diet without talking to your IBD team and make sure you are still getting all the nutrients you need
• taking a food supplement if you are struggling to get enough nutrients from your diet
• being referred to a dietitian

Managing stress

Stress doesn’t cause ulcerative colitis. But, managing stress may reduce how often you get symptoms.

To help manage stress, you could:

• exercise – speak to your IBD team about a suitable exercise plan
• try relaxation techniques like yoga, medication and breathing exercises
• talk to others – Crohn’s & Colitis UK has details of local support groups
• speak to your GP if you think you may have depression

Fertility and pregnancy

A woman’s chance of becoming pregnant isn’t usually affected by ulcerative colitis.

However, surgery for ulcerative colitis might affect your fertility, especially pouch surgery.

Most women with ulcerative colitis will have a normal pregnancy and a healthy baby. But if you’re pregnant or planning a pregnancy you should discuss it with your IBD team. This is because they may need to change your medication.

If you’re having a flare-up of ulcerative colitis you may also be advised to avoid getting pregnant until it’s under control.

If you have ulcerative colitis, you may face a higher risk of certain other problems, including:

• osteoporosis
• poor growth and development in children and young people

More serious and rare complications can include:

• primary sclerosing cholangitis (PSC), inflammation of the bile ducts that can lead to liver damage
• narrowing in the bowel (strictures) that may become blocked or make it hard for stool to pass
• toxic megacolon, where severe inflammation traps gas in the colon, causing it to swell greatly and possibly rupture
• a higher risk of bowel cancer
• a higher risk of blood clots in the legs or lungs