Ulcerative colitis

Ulcerative colitis (UC) is defined as a chronic, relapsing-remitting, non-infectious disease affecting the colon and/or rectum (National Institute for Health and Care Excellence (NICE), 2020). Ulcerative colitis causes continuous, diffuse and superficial inflammation of varying intensity, affecting different areas of the colon and rectum (large intestine). The inflammation leads to ulceration of the large intestine which in turn causes its characteristic signs and symptoms (Davis et al, 2018).

Ulcerative colitis has a prevalence of approximately 156–291 people per 100,000 of the population in Europe and North America, where its high prevalence is thought to relate to diet and an industrialised lifestyle (Ordás et al, 2012). Ulcerative colitis affects more females than males (King et al, 2020) and is commonly diagnosed in people aged 15–25 years old (NICE, 2023).  

The symptoms of ulcerative colitis come in waves lasting from a few days to a few weeks, varying in degrees of severity and seemingly random. Although the severity of the signs and symptoms of ulcerative colitis varies between individuals, the characteristic symptoms include: 

• bloody diarrhoea (with and without mucus and/or pus)
• rectal urgency
• tenesmus (cramping pain around the rectum associated with a sensation of wanting to pass stools)
• abdominal pain (Davis et al, 2018; Gajendran et al, 2019)

Other signs and symptoms of ulcerative colitis include:

• anaemia
• weight loss (often more than 5 kg in the previous year)
• frequency of bowel movements, i.e. more than four times daily

A few people present to healthcare facilities with constipation, although this is the minority (Gajendran et al, 2019).

People living with ulcerative colitis are at higher risk of some other extraintestinal manifestations of disease, some of which are iatrogenic, e.g. caused by repeated

The cause of ulcerative colitis is not known but it is likely that it has multiple causes which gives rise to different symptoms and different levels of intensity of the disease. It is thought that there is a genetic component to the disease, as the risk in first degree relatives of someone affected is approximately 6–16% higher than the general population (Ordás et al, 2012). The genetic predisposition to ulcerative colitis in some people is thought to make them more susceptible to having an abnormal mucosal immune response to gut bacteria causing the characteristic large intestine inflammation (Ordás et al, 2012).

There are some environmental and lifestyle factors known to contribute to or protect people from ulcerative colitis. Smoking is known to be protective against ulcerative colitis and, where it is present, leads to a milder form of the disease (Ordás et al, 2012). Exposure to food poisoning, e.g. salmonella

A suspicion of ulcerative colitis arises from the clinical presentation of symptoms and the gold standard for diagnosis is endoscopy and subsequent histological examination of biopsies taken (Davis et al, 2018). The British Society of Gastroenterology guidelines (Lamb et al, 2019) identify that infectious disease should be excluded first by taking stool cultures and a clostridium difficile toxin test.

Diagnosis also includes identifying the extent and severity of the inflammation. While an initial diagnosis of ulcerative colitis may be made by carrying out a sigmoidoscopy, an ileocolonoscopy is needed in the first year after diagnosis to understand the extent and severity (Lamb et al, 2019).

NICE (2019) identify the use of Truelove and Witts severity index for categorising the severity of ulcerative colitis (Table 1).

It is important that the patient is part of the decision making about the treatment of ulcerative colitis and that they should be aware of the side-effects of the treatment as well as the risk of developing colorectal cancer as a result of the ulcerative colitis (NICE, 2019). NICE (2022) guidelines recommend lifetime colonoscopic surveillance for colorectal cancer in people with inflammatory bowel disease whose symptoms started 10 years ago and who also have ulcerative colitis. Colonoscopy is offered either annually, 3 or 5-yearly depending on whether the colorectal cancer risk is high, intermediate or low.

Management of ulcerative colitis requires a multidisciplinary team and depends on the severity of the disease and the parts of the bowel affected (NICE, 2019). As no cure currently exists, treatment is aimed at inducing remission from the disease and attempting to maintain this.

Antidiarrhoeals, e.g. loperamide and codeine phosphate, should only be used under

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