Digestive Disorders > IBD > Ulcerative Colitis

Ulcerative colitis symptoms: The complete guide

Dr. med. Andre Sommer

Dr. med. Andre Sommer

Ulcerative colitis is a recurring chronic inflammatory bowel disease (IBD) that usually begins in young adults (between 20 and 35 years). In contrast to Crohn's disease, which also involves the small intestine, the colon is mainly affected in ulcerative colitis. Symptoms outside the colon are also possible, including some skin diseases. There are also other diseases that occur frequently with ulcerative colitis. Precise knowledge of the possible symptoms of ulcerative colitis and their associated diseases is important to identify ulcerative colitis early and to avoid misdiagnoses.

Which gastrointestinal complaints occur with ulcerative colitis?

The main symptom of ulcerative colitis is bloody-slimy diarrhea: The frequency of bowel movements is high and there is slimy secretion. The following symptoms also occur:

  • Painful urgency
  • Lower abdominal pains
  • Weight loss

Serious cases of illness with a sudden, threatening course can be accompanied by the following:

  • Severe diarrhea with high fluid loss
  • Severe abdominal cramps
  • Abdominal distension (the tummy bulges significantly and is therefore very bulky and bloated)
  • Additionally fever and an increase in inflammatory cells in the blood (leukocytosis)

What are the first signs of ulcerative colitis?

Bloody-slimy diarrhea directs the treating physicians to the suspected diagnosis of ulcerative colitis, making it the first symptom that leads to a diagnosis. When the diagnosis has been made, retrospectively less specific symptoms such as lower abdominal pain and painful stool urgency can be assigned to inflammatory bowel disease. Patients with diseases that are common with ulcerative colitis should have an accurate history of symptoms of ulcerative colitis taken. This can prevent the ulcerative colitis from being overlooked.

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What symptoms and diseases can still occur with ulcerative colitis?

Ulcerative colitis occurs in many cases together with diseases of the skin, liver and bile ducts, joints, and eyes. This knowledge is important to identify accompanying diseases as early as possible. Conversely, there should be increased vigilance for symptoms if diseases occur that often coexist with ulcerative colitis. The following table summarizes the common accompanying diseases and symptoms:

Disease Description of the disease Possible symptoms
Primary sclerosing cholangitis (PSC) Progressive inflammation and destruction of the bile ducts inside and outside the liver; in the course of connective tissue remodeling of the liver and destruction of the liver Fatigue, itching, yellowing of the skin and eyes (jaundice);

Acute bile duct inflammation with fever and upper abdominal pain; Late stage liver failure

Ankylosing spondylitis Chronic inflammatory disease, which mainly affects the axis skeleton (spine) and the sacroiliac joints (sacral-iliac joints) and leads to their complete stiffening Nocturnal back pain with improvement after exercise; tapping and displacement pain over the sacrum; painful bone-tendon transitions e.g. on the Achilles tendon; inflammation of the joints on the hip, shoulder or knee joint; fatigue, fever, weight loss
Erythema nodosum Inflammation of the subcutaneous fatty tissue Painful, reddened knots on the extensor sides of the lower legs
Pyoderma gangrenosum Ulcerations on the lower legs Painful focal blisters and redness; deep ulcerations (open spaces)
Pyostomatitis vegetans Formation of canker sores (open, inflamed areas Painful mucosal damage on the oral mucosa
Iritis, episcleritis, uveitis Inflammation of various parts of the eye Photophobia, "red eye", dull pain in the eye
Multiple sclerosis Chronic inflammatory disease of the central nervous system Emotional disorders, visual disturbances, pain during eye movements, movement disorders

Can constipation also be a symptom of ulcerative colitis?

The main symptom of ulcerative colitis is bloody-slimy diarrhea, so constipation is not a typical symptom of ulcerative colitis. Inflammation of the intestinal mucosa in ulcerative colitis can in rare cases lead to narrowing (stenosis) of the large intestine. These constrictions can cause constipation. Stenosis is much more common in Crohn's disease and is not a typical symptom of ulcerative colitis.

How is ulcerative colitis diagnosed?

The main symptom of ulcerative colitis, bloody-slimy diarrhea, also occurs in other diseases. Diagnostics are therefore important both to confirm the suspected diagnosis and to rule out competing diseases. The following list shows the examinations that are indicated after a thorough medical history for suspected ulcerative colitis:

  • Blood tests: Inflammation, liver, pANCA (certain antibodies)
  • Colonoscopy (endoscopy): characteristic inflammatory lesions
  • Stool tests: Marker for inflammation of the mucosa calprotectin and lactoferrin
  • Imaging examinations: Ultrasound, X-ray contrast enema and special MRI examinations

With a typical medical history and typical lesions of the intestinal mucosa, the diagnosis of ulcerative colitis is made. The laboratory values are used for orientation in diagnostics, for example if the patient's anamnesis is not clear or the symptoms are mild.

Is an ulcerative colitis flare-up possible without diarrhea?

Yes, but most patients also have diarrhea during relapses. A flare-up is also conceivable if the person affected has abdominal pain and blood in the stool, but no diarrhea. If the activity of the disease is questionable, a control endoscopy helps: If there are no signs of inflammation on the intestinal mucosa, this is called endoscopic remission.

How long does an ulcerative colitis flare-up last?

The duration of a colitis flare-up depends on how quickly an effective medication is found. The severity of a flare-up is standardized based on the symptoms, and the medication used is selected according to the severity. Usually, a single flare-up lasts for one to two months, but can also be shorter with quick and effective therapy.

What to do when a flare-up occurs?

Those affected should report to their doctor if a flare-up occurs. The patient should then discuss the medication plan with the doctor. The aim is to contain the flare-up quickly and help it subside without serious complications.

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Adler, G. (2013). Morbus Crohn-colitis ulcerosa. Springer-Verlag.

Dignass et al.: S3-Leitlinie Colitis ulcerosa: Diagnostik und Therapie. Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). As of September 2011, http://www.awmf.org/leitlinien/detail/ll/021-009.html, downloaded on 09/04/2018

Herold, G. (2014). Innere Medizin 2015. Eigenverlag.

Lecis, P., Germana, B., Papa, N., Bertiato, G., Doglioni, C., Galliani, E., & Biedo, F. C. (2002). p-ANCA and ASCA antibodies in the differential diagnosis between ulcerative rectocolitis and Crohn's disease. Recenti progressi in medicina, 93(5), 308-313, online: http://europepmc.org/abstract/med/12050913, downloaded 09/04/2018.

Dr. med. Andre Sommer

Dr. med. Andre Sommer

I’m André, a medical doctor from Berlin. Together with a team of medical doctors, nutritionists and data scientists we empower people to understand digestive issues with our app Cara.

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