Ulcerative colitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 20 Aug 2025

Last updated: 29 Jul 2025

Ulcerative colitis (UC) is a type of inflammatory bowel disease characterized by diffuse inflammation of the colonic mucosa and a relapsing, remitting course.

Patients commonly experience bloody diarrhea, chronic diarrhea (or both), lower abdominal pain, fecal urgency, and extraintestinal manifestations, particularly those related to activity of the colitis.

Diagnosis requires endoscopy with biopsy and negative stool culture.

Relapses are often associated with pathogens; therefore, stool should be obtained for culture in all cases of disease flare-up.

Treatment aims to induce and maintain remission. Drug choice and formulation depends on the severity and extent of disease.

Toxic megacolon can occur with associated risk of perforation. Bowel adenocarcinoma is a complication in 3% to 5% of patients.

Definition

UC is a type of inflammatory bowel disease that characteristically involves the rectum and extends proximally to affect a variable length of the colon. It is recognized as a multifactorial polygenic disease, as the exact etiology is still unknown. Included in the etiologic theories are environmental factors, immune dysfunction, and a likely genetic predisposition.[1][2][3]

This topic covers the diagnosis and treatment of ulcerative colitis in adults.

History and exam

Key diagnostic factors

rectal bleeding
diarrhea
blood in stool

Full details

Other diagnostic factors

abdominal pain
arthritis and spondylitis
malnutrition
abdominal tenderness
fever
weight loss
constipation
skin rash
uveitis and episcleritis
pallor

Full details

Risk factors

family history of inflammatory bowel disease
human leukocyte antigen-B27
infection
use of nonsteroidal anti-inflammatory drugs (NSAIDs)
not smoking or former smoker

Full details

Diagnostic investigations

1st investigations to order

stool studies for infective pathogens
fecal calprotectin (FC)
CBC
comprehensive metabolic panel (including LFTs)
erythrocyte sedimentation rate (ESR)
CRP
plain abdominal radiograph
flexible sigmoidoscopy
colonoscopy
biopsies

Full details

Tests to avoid

serologic antibody testing

Full details

Investigations to consider

CT scan
intestinal ultrasound

Full details

Treatment algorithm

ACUTE

acute severe ulcerative colitis

moderate-to-severe disease

mild disease

ONGOING

disease in remission

Contributors

Authors

Andrew Poullis, BSc, MBBS, MD, FRCP

Consultant Gastroenterologist

Department of Gastroenterology

St George’s Hospital

London

Disclosures

AP is an author of a reference cited in this topic.

Sailish Honap, MBChB (Hons), MRes, MRCP (UK)

Consultant Gastroenterologist

Department of Gastroenterology

St George’s Hospital

London

Disclosures

SH has received honoraria from Pfizer (speaker, consultant, advisory board member, and received travel grants), Janssen (speaker fees, travel grants), AbbVie (speaker fees, consultant, travel grants), Takeda (speaker fees), Ferring (travel grants), Pharmacosmos (travel grants), Galapagos (travel grants).

Kamal Patel,

Disclosures

all disclosures

Aaron Bhakta, BMedSci (Hons), BMBS, MSc, MRCP

Clinical Fellow in Gastroenterology

Department of Gastroenterology

St George’s Hospital

London

Disclosures

AB declares that he has no competing interests.

Acknowledgements

Dr Hesam A. Nooredinvand, and Dr Andrew Poullis would like to gratefully acknowledge Dr Ben Shandro, Dr Anet Soubieres, Dr Rhys Hewett, Dr Willem J.S. de Villiers, and Dr Houssam Mardini, previous contributors to this topic.

Disclosures

BS, AS, RH, WJSD, and HM declare that they have no competing interests.

Revisores

Trevor Winter, MD, PhD

Associate Professor of Medicine

Division of Digestive Diseases and Nutrition

University of Kentucky

Lexington

Declarações

TW declares that he has no competing interests.

Sharon Stein, MD

Assistant Professor of Surgery

Division of Colon and Rectal Surgery

University Hospital Case Medical Center

Cleveland

Declarações

SS received a fee for educational courses on laparoscopic surgery, paid for in part by Covidien, Olympus, and Applied Medical.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

Referências

Nossas equipes internas de editoria e de evidências trabalham em conjunto com colaboradores internacionais especializados e pares revisores para garantir que forneçamos acesso às informações o mais clinicamente relevantes possível.

Principais artigos

World Gastroenterology Organisation. Global guidelines: inflammatory bowel disease. Aug 2015 [internet publication].Texto completo

Rubin DT, Ananthakrishnan AN, Siegel CA, et al. ACG clinical guideline: ulcerative colitis in adults. Am J Gastroenterol. 2019 Mar;114(3):384-413. Resumo

Feuerstein JD, Isaacs KL, Schneider Y, et al. AGA clinical practice guidelines on the management of moderate to severe ulcerative colitis. Gastroenterology. 2020 Apr;158(5):1450-61.Texto completo Resumo

Harbord M, Eliakim R, Bettenworth D, et al. Third European evidence-based consensus on diagnosis and management of ulcerative colitis. Part 2: current management. J Crohns Colitis. 2017 Jul 1;11(7):769-84.Texto completo Resumo

National Institute for Health and Care Excellence (UK). Ulcerative colitis: management. May 2019 [internet publication].Texto completo

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

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Ulcerative colitis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Tests to avoid

Investigations to consider

Treatment algorithm

acute severe ulcerative colitis

moderate-to-severe disease

mild disease

disease in remission

Contributors

Authors

Andrew Poullis, BSc, MBBS, MD, FRCP

Disclosures

Sailish Honap, MBChB (Hons), MRes, MRCP (UK)

Disclosures

Kamal Patel,

Disclosures

Aaron Bhakta, BMedSci (Hons), BMBS, MSc, MRCP

Disclosures

Acknowledgements

Disclosures

Revisores

Trevor Winter, MD, PhD

Declarações

Sharon Stein, MD

Declarações

Peer reviewer acknowledgements

Disclosures

Referências

Principais artigos

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Diagnósticos diferenciais

Diretrizes

Folhetos informativos para os pacientes

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice