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Digestive Disorders > IBD > Ulcerative Colitis

Ulcerative Colitis Symptoms: The Complete Guide

Laura Fouquette

Laura Fouquette

Ulcerative colitis is a recurrent, chronic inflammatory bowel disease (IBD) that typically is onset between ages 20 and 35. In contrast to Crohn's disease, which mainly involves the small intestine, ulcerative colitis mainly affects the large intestine (colon).

Symptoms outside the large intestine are possible, such as skin changes, for example. Because there are other conditions that can occur alongside ulcerative colitis, it is important to know the possible symptoms and associated conditions to identify disease early and to avoid misdiagnosis.

What are the symptoms of ulcerative colitis?

The main symptom of ulcerative colitis is diarrhea containing blood or pus. The frequency of bowel movements is high. The following symptoms can also occur:

  • Painful bowel movements
  • Feeling of incomplete bowel emptying (rectal tenesmus)
  • Urgency to pass bowel movements
  • Lower abdominal pain
  • Weight loss

Serious cases with a sudden, potentially life-threatening evolution can manifest with the following symptoms:

  • Severe diarrhea with significant fluid loss
  • Severe abdominal cramping
  • Significant bulging of the belly with swelling and bloating (abdominal distension)
  • Fever and an increase of inflammatory cells and markers in the blood

What are the first signs of ulcerative colitis?

Typically, the first sign and cardinal symptom of ulcerative colitis is bloody diarrhea with pus. This leads physicians to suspect ulcerative colitis as a possible diagnosis. After the diagnosis, less intense symptoms, such as lower abdominal pain and painful bowel urgency, can retrospectively be assigned to the disease.

For some patients, ulcerative colitis may initially manifest with infrequent bowel movements and mild abdominal pain that gradually worsen over time. For others, a flare-up may be the first manifestation with severe diarrhea, abdominal pain, fever, and weight loss. Symptomatic periods then usually alternate with symptom-free periods.

Because ulcerative colitis may appear alongside associated conditions or appear after, patients with associated conditions should also be assessed for ulcerative colitis symptoms. The presence of some associated conditions may indicate active ulcerative colitis.

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What symptoms and conditions can occur alongside ulcerative colitis?

In many cases, ulcerative colitis occurs together with conditions of the skin, liver and bile ducts, joints, and eyes. This is important to know to identify associated conditions as early as possible. If any of these conditions occur, physicians should be vigilant and check for ulcerative colitis. This table summarizes commonly associated conditions:

Condition Description Possible symptoms
Primary sclerosing cholangitis (PSC) Long-term, progressive inflammation and destruction of bile ducts inside and outside of the liver; reorganization (remodeling) of the liver tissue; increased risk of bile duct cancer (cholangiocarcinoma) Depends on condition’s progression: \ Early-stage: extreme tiredness (fatigue), fever, itching (pruritus), yellowing of the skin and eyes (jaundice), weight loss, feeling of sickness, abdominal pain

Advanced stage: jaundice, enlarged liver and spleen

Late-stage: liver scarring (cirrhosis) and liver failure

Ankylosing spondylitis Long-term inflammatory condition, which mainly affects the backbone (vertebral column) and the sacroiliac joints (SI joints); may lead to their complete stiffening Lower back and hip pain and stiffness, which may improve with physical activity; neck pain, fatigue, pain and swelling of other body parts, painful bone-tendon transitions (e.g. where the Achilles tendon joins the heel bone); weight loss, fever, eye inflammation, appetite loss
Erythema nodosum Inflammation of the fatty tissue under the skin (subcutaneous fat) Painful, red lumps mostly located on the front side of the lower legs
Pyoderma gangrenosum Rare inflammatory disease of the skin characterized by sores Small red bumps or blisters evolve into deep skin sores (ulcers), often with purple edges; mostly located on the lower legs
Pyostomatitis vegetans Rare condition with lesions on the inner lining of the mouth (oral mucosa) Redness of the oral mucosa with little yellow pimples; those can turn into canker sores (aphthous ulcers)
Iritis, episcleritis, uveitis Types of eye inflammation Depend on which part is inflamed; eye discomfort or pain due to light (photophobia), red eye, (dull) eye pain, blurred or cloudy vision

Can constipation be a symptom of ulcerative colitis?

Ulcerative colitis mainly manifests with diarrhea containing blood or pus. However, some people may experience constipation, especially when the condition only affects the last section of the large intestine. Inflammation of the intestinal mucosa in ulcerative colitis can, in rare cases, lead to narrowing of the large intestine (stenosis). This constriction can also 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 clinical symptom of ulcerative colitis, diarrhea with blood or pus, can also occur in other diseases. Diagnostics are, therefore, important in order to confirm the diagnosis and to rule out diseases with similar symptoms (differential diagnosis).

After a physical examination and a thorough medical history (anamnesis) are taken, diagnostic procedures in the following list can be completed when ulcerative colitis is suspected:

  • Blood tests: inflammation marker, liver function tests, pANCA (a type of antibody)
  • Colonoscopy (endoscopy): test to determine if there are characteristic inflammatory lesions on the inner lining (mucosa) of the large intestine
  • Stool tests: performed to rule out infection and to assess inflammatory markers of the large intestinal mucosa (calprotectin and lactoferrin)
  • Medical imaging: ultrasound, contrast enema (x-ray examination with the large intestine being filled with a contrast agent), and special MRI exams

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

Is an ulcerative colitis flare-up possible without diarrhea?

Because diarrhea is the main clinical symptom of ulcerative colitis, a flare-up without diarrhea would be very atypical. Stool frequency is usually one criterion assessed to determine flare-up severity.

A flare-up may be conceivable if the affected person has increasing abdominal pain, cramping, and bloody stool. If other symptoms, like fever or fatigue, occur without diarrhea, your healthcare provider should investigate other possible conditions.

If the disease activity is unclear, a control colonoscopy may help: If there are no signs of inflammation on the inner lining of the large intestine, this is called endoscopic remission. Even if there are no visible signs, however, there may still be ongoing microscopic inflammation, especially in mild cases. Examining tissue samples (biopsy) under a microscope can assess if there is inflammation.

How long does an ulcerative colitis flare-up last?

Typically, a single flare-up lasts one to two months, but it can be shorter with quick and effective treatment. The duration of a flare-up (relapse) varies and depends on how quickly an effective medication is found.

What should you do when a flare-up occurs?

Report to your doctor to discuss treatment plans if a flare-up occurs, meaning symptoms reappear or worsen. The aim is to quickly contain the flare-up and de-escalate it without serious complications.

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Laura Fouquette

Laura Fouquette

Laura Fouquette is a digital health enthusiast from California. She completed a Master of Public Health (MPH) in Epidemiology/Biostatistics and a Bachelor's of Public Health at the University of California, Berkeley. She currently works as a freelance writer/researcher in Berlin.

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