Ulcerative Colitis.

Ulcerative colitis is not curable with medication; the underlying immune dysregulation persists. However, modern therapies induce durable remission in most patients, and total proctocolectomy with ileal pouch-anal anastomosis is curative for the disease itself, though it brings its own long-term considerations such as pouchitis. With consistent treat-to-target management, lifetime colectomy rates are 10-15%.

Ulcerative colitis affects only the colon with continuous mucosal inflammation starting at the rectum, while Crohn's disease can affect any part of the gut from mouth to anus, with skip lesions, transmural inflammation, and a tendency to form fistulas and strictures. UC produces bloody diarrhea; Crohn's more often causes abdominal pain, weight loss, and perianal disease. Smoking worsens Crohn's but is protective in UC.

A flare typically brings bloody loose stools several times per day, urgency that disrupts work and sleep, lower abdominal cramping that eases briefly after passing stool, and persistent fatigue. In severe flares, fever, racing heart, and weight loss develop, signaling acute severe colitis that needs hospital admission. Most flares build over days to a few weeks.

Diagnosis combines history of bloody diarrhea, blood tests showing inflammation or anemia, stool tests to exclude infection, fecal calprotectin, and an ileocolonoscopy with biopsies that demonstrates continuous mucosal inflammation starting in the rectum. Histology confirms crypt distortion, crypt abscesses, and basal plasmacytosis confined to the mucosa.

Mild proctitis usually responds to a 1 g mesalamine suppository at bedtime, sometimes combined with a mesalamine enema. Mild left-sided or extensive disease is treated with oral mesalamine at 2.4-4.8 g/day plus topical mesalamine. Once-daily dosing is as effective as divided doses. Treatment is continued long-term to maintain remission.

Biologics are injectable or infused antibodies that block specific inflammatory pathways. Options include anti-TNF agents (infliximab, adalimumab, golimumab), anti-integrin vedolizumab, IL-12/23 ustekinumab, and IL-23p19 agents mirikizumab and risankizumab. They are used for moderate-to-severe disease or steroid-dependent or steroid-refractory disease, with remission rates ranging from 15-35% at week 8 across trials.

Long-standing extensive ulcerative colitis increases colorectal cancer risk, with cumulative incidence rising roughly 1% per year of disease beyond the first decade. Risk is higher with extensive disease, primary sclerosing cholangitis, family history, and persistent inflammation. Surveillance colonoscopy starting 8 years after diagnosis, with chromoendoscopy or high-definition white light, substantially reduces cancer mortality.

Lifetime colectomy rates have fallen to 10-15% with modern medical therapy. Surgery is recommended for medically refractory disease, severe flares unresponsive to rescue therapy, dysplasia or cancer, and selected complications such as toxic megacolon or perforation. The most common operation is total proctocolectomy with ileal pouch-anal anastomosis (J-pouch), usually in two or three stages.

A J-pouch is a reservoir created from the terminal ileum after total proctocolectomy that is connected to the anal canal, allowing bowel movements through the natural anus rather than a permanent stoma. Most patients pass stool 4-6 times per day once the pouch adapts over 6-12 months. Pouchitis develops in roughly 50% over time and is usually treatable with antibiotics.

No single diet treats ulcerative colitis. A Mediterranean-style pattern with fish, olive oil, whole grains, and cooked vegetables is supported by observational and trial data. Limit ultra-processed foods, sugar-sweetened beverages, and excess red meat. During flares, soft low-residue foods are usually better tolerated. A registered dietitian familiar with IBD can personalize the plan.

There is a clear genetic component. First-degree relatives have a 3-15% lifetime risk compared with around 0.3% in the general population. Over 200 risk loci have been identified, but no single test predicts disease. Most patients have no affected family member at the time of diagnosis.

Yes. About 20% of UC patients are diagnosed before age 18, with peak pediatric incidence around 10-15 years. Children more often present with extensive colitis, growth failure, and delayed puberty, and pediatric guidelines support earlier escalation to biologic therapy. Long-term outcomes are excellent with specialist pediatric IBD care.

Yes. Conception during remission gives the best pregnancy outcomes; most maintenance therapies (mesalamine, thiopurines, anti-TNF agents, ustekinumab, vedolizumab) are continued through pregnancy. JAK inhibitors and methotrexate are avoided. Flares during pregnancy are riskier than treatment exposure. Preconception counseling with the IBD team is the most important step.

Topical and oral 5-ASA work over 2-4 weeks. Oral steroids show meaningful symptom improvement within 5-7 days. JAK inhibitors and S1P modulators respond within 1-2 weeks. Anti-TNF and ustekinumab work over 4-8 weeks; vedolizumab and IL-23 agents over 8-14 weeks. Endoscopic healing typically lags behind symptomatic response.

Acute severe ulcerative colitis (ASUC) is defined by Truelove-Witts criteria — more than six bloody stools per day plus tachycardia, fever, anemia, or elevated ESR. It requires same-day hospital admission, IV methylprednisolone, prophylactic anticoagulation, and structured rescue planning with infliximab or cyclosporine at day 3-5 if steroids fail. Roughly 30% require colectomy during the admission.

Yes. Although active smoking is statistically associated with milder UC, the cardiovascular, cancer, and respiratory harms of smoking far outweigh any potential benefit. Smokers should quit while their IBD team optimizes maintenance therapy to offset any short-term flare risk after cessation.

Surveillance colonoscopy is recommended starting 8 years after diagnosis for left-sided or extensive disease, then every 1-3 years depending on risk factors. Patients with primary sclerosing cholangitis need annual colonoscopy from the time both diagnoses are established. Surveillance is usually performed with chromoendoscopy or high-definition white light with targeted biopsies.

Yes. Extraintestinal manifestations occur in 25-40% of patients and include peripheral arthritis, axial spondyloarthritis, episcleritis or uveitis, erythema nodosum, pyoderma gangrenosum, and primary sclerosing cholangitis (PSC, ~5%). Some, such as peripheral arthritis, track with bowel activity; others, such as PSC and axial spondyloarthritis, have an independent course.

Yes. Before starting biologics, JAK inhibitors, or steroids, vaccinations should be updated: pneumococcal (PPSV23/PCV20), recombinant zoster, annual influenza, COVID-19, hepatitis B, and HPV where age-appropriate. Live vaccines must be completed before immunosuppression begins. Latent tuberculosis and hepatitis B screening are mandatory prior to anti-TNF therapy.

Generic mesalamine and corticosteroids are inexpensive and widely available, often a few US dollars per month. Biologics and small molecules vary widely — list prices range from several hundred to several thousand dollars per dose, but most patients access them through insurance, biosimilars, or manufacturer support programs. In India and other emerging markets, biosimilar infliximab and adalimumab have substantially lowered access barriers.

Yes, the underlying immune tendency persists for life, though most patients spend most of their time in remission with appropriate maintenance therapy. Colectomy removes the colon and eliminates UC-specific inflammation, although the pouch and rectal cuff can still become inflamed. With modern treat-to-target care, life expectancy and quality of life are close to that of the general population.