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Ulcerative colitis: symptoms, modern therapy & living with IBD
At a glance
FrequencyAlongside Crohn's disease the second major inflammatory bowel disease (IBD) — in Germany several hundred thousand people are affected by an IBD
Age at onsetOften first occurs between the ages of 20 and 40; can, however, occur at any age
Curable?Not curable with medication — a surgical removal of the colon (colectomy) can generally cure the disease
Pattern of involvementAffects exclusively the colon, always begins at the rectum and can spread upward
Ulcerative colitis is an inflammatory bowel disease (IBD) in which the mucous membrane of the colon and the rectum is inflamed. The inflammation always begins at the rectum and can spread from there continuously upward — in contrast to Crohn's disease, in which the inflammation can affect the entire digestive tract and generally occurs segmentally.¹
The disease generally runs in flares: phases of active inflammation alternate with symptom-free or low-symptom phases (remission). The therapy goal is the longest possible remission — ideally with healing of the intestinal mucosa (mucosal healing).¹˒³
Surgical cure possible — unlike with Crohn's disease
In contrast to Crohn's disease, with ulcerative colitis there is a surgical possibility of cure: the removal of the entire colon (colectomy) can generally eliminate the disease. This procedure is, however, a major step and is mostly only considered when drug therapies do not work sufficiently.
2. Difference from Crohn's disease
Ulcerative colitis and Crohn's disease are grouped together under the umbrella term IBD, but differ in important points.¹
Feature
Ulcerative colitis
Crohn's disease
Pattern of involvement
Colon only, ascending continuously from the rectum
Entire digestive tract possible, often segmental with healthy sections
Depth of inflammation
Usually only the mucous membrane (mucosa)
Can affect all wall layers (transmural)
Leading symptom
Bloody diarrhea
Chronic diarrhea (often without blood), abdominal pain, fistulas
Surgical cure
Possible (colectomy)
Not possible according to current knowledge
3. Symptoms
The complaints depend on the extent of the inflammation and the disease activity.¹
Leading symptoms
Bloody diarrhea — the leading symptom; often with admixtures of mucus and pus
Urge to defecate (tenesmus) — frequent, painful urge to defecate, often with a small amount of stool
Abdominal pain — often in the left lower abdomen, cramp-like
increased stool frequency — in a flare often considerably more than normal, also at night
Primary sclerosing cholangitis (PSC) — a chronic inflammation of the bile ducts that occurs more often with ulcerative colitis than with Crohn's disease
Severe flare: seek medical help immediately
With severe bloody diarrhea, high fever, severe abdominal pain or a massive sense of illness, medical help should be sought immediately. A severe flare can lead to complications such as a toxic megacolon and generally requires inpatient treatment.
4. Causes and risk factors
The exact cause is, according to current knowledge, not fully clarified. As with Crohn's disease, an interplay of several factors is assumed.¹
Genetics: A familial clustering is known. The risk for first-degree relatives is increased, but lower than with Crohn's disease.
Immune system: A misdirected immune response against one's own intestinal flora leads to a chronic inflammation of the colon mucosa.
Gut microbiome: Changes in the composition of the intestinal flora (dysbiosis) are discussed as a contributing cause.
Smoking: Interestingly, smoking appears to have a certain protective effect with ulcerative colitis — in contrast to Crohn's disease, where smoking worsens the course. That, however, expressly does not mean that smoking is recommended — the health damage far outweighs it.
Other factors: An appendectomy (removal of the appendix) in childhood appears to lower the risk of ulcerative colitis. NSAIDs (e.g. ibuprofen) can trigger or worsen flares.
5. Diagnosis
Colonoscopy with step biopsies: The most important examination. Shows the typical continuous inflammation that begins at the rectum. Step biopsies from various intestinal sections confirm the diagnosis histologically. The extent is classified: proctitis (rectum only), left-sided colitis (up to the left flexure) or extensive colitis (beyond that).¹
Laboratory: CRP, ESR, blood count, iron/ferritin. Fecal calprotectin is a sensitive marker for the inflammatory activity in the bowel and is very well suited for monitoring the course and for distinguishing from an irritable bowel syndrome.¹
Stool examination: To rule out infectious causes — above all Clostridioides difficile, Campylobacter, Salmonella.
Abdominal ultrasound: Can show wall thickening non-invasively. Is often used for monitoring the course.
The therapy is guided by the extent, the disease activity (mild, moderate, severe) and the course so far. The current S3 guideline of the DGVS (fully updated November 2025, AWMF 021-009) emphasizes mucosal healing as the therapy goal. The decision is generally made by the treating gastroenterology.¹˒³
Base5-ASA / mesalazine — first line
5-aminosalicylic acid (mesalazine, sulfasalazine) is generally the first-line therapy with ulcerative colitis — both in a flare and for maintaining remission.¹
Mesalazine — the right dosage form depending on the involvement
Proctitis / left-sided colitis: suppositories, foam or enema (local). Extensive colitis: orally as tablets / granules.
Often also combined application (oral plus local). Favorable side-effect profile, generally well tolerated.
FlareCortisone — short-term, then taper
Systemic cortisone (e.g. prednisolone)
Is used with moderate to severe flares when 5-ASA is not sufficient. Cortisone should generally be given for as short a time as possible and then tapered — it is not a long-term medication. More: Stopping cortisone.
Budesonide MMX
Can be an alternative with milder to moderate courses — lower systemic effect than classic cortisone.
MaintenanceImmunosuppressants
Azathioprine / 6-mercaptopurine
For maintaining remission when 5-ASA is not sufficient. The onset of effect generally takes a few months. Regular laboratory checks necessary.
EscalationBiologics, JAK inhibitors & S1P modulator
With moderate to severe ulcerative colitis, when immunosuppressants do not work or are not tolerated, considerably more options are available today than just a few years ago.¹˒³
Anti-TNF — infliximab, adalimumab
Classic first-generation biologics. Biosimilars are available.
Anti-integrin — vedolizumab
Gut-selective in its effect. Advantage: less systemic immunosuppression. Is often used with ulcerative colitis.
Anti-IL-12/23 — ustekinumab
Inhibits the interleukins 12 and 23. Approved for ulcerative colitis.
JAK inhibitors — tofacitinib, upadacitinib, filgotinib
Taken orally (tablets instead of injections). Inhibit the Janus kinases. Special feature: rapid onset of effect. Regular laboratory checks and an individual risk assessment necessary (among other things cardiovascular risks, herpes zoster).³
S1P modulator — ozanimod
A new active ingredient that inhibits the migration of immune cells into the bowel. Taken orally. Approved for moderate to severe ulcerative colitis.
Steroid-free remission as the goal
Cortisone is not a long-term medication with ulcerative colitis. A steroid-free remission is the therapy goal. When cortisone is needed repeatedly or over a longer period, a therapy escalation should be discussed — the options are considerably broader today than just a few years ago.
7. Surgery: colectomy and pouch
With a portion of those affected with severe ulcerative colitis that cannot be controlled with medication or with the occurrence of dysplasia/carcinoma, a surgical removal of the colon (colectomy) can be considered. In contrast to Crohn's disease, this operation can generally cure the disease.¹
Proctocolectomy with a pouch — the standard procedure
The entire colon and the rectum are removed. From the small intestine a reservoir (ileoanal pouch, J-pouch) is formed, which is connected to the anus. This generally preserves the natural emptying of stool — without a permanent artificial bowel outlet. The stool frequency is generally increased after the operation.
Pouchitis
An inflammation of the pouch occurs in a relevant proportion of those operated on. Is generally treated with antibiotics.
Stoma
A temporary or, in rare cases, permanent stoma (artificial bowel outlet) can be necessary — many of those affected report that the quality of life with a stoma is often better than with a severe, uncontrolled flare.
8. Living with ulcerative colitis
Medications: regular intake even in remission is decisive — especially with 5-ASA, which is often given as a long-term therapy. Stopping on one's own increases the flare risk. More: Stopping medications.
Nutrition: There is no special ulcerative-colitis diet. In a flare, easily digestible, low-fiber food is often recommended. In remission: a balanced diet, identifying individual intolerances. Check for deficiencies (iron, vitamin D, vitamin B12, folic acid) regularly.
Colorectal cancer screening: With long-standing ulcerative colitis with extensive involvement, the risk of colorectal cancer is increased. Regular surveillance colonoscopies with biopsies are generally recommended — the exact intervals are determined by the treating gastroenterology.¹
Vaccinations: Under immunosuppression, special vaccination recommendations apply. Live vaccines are generally contraindicated. The vaccination status should be checked and updated before the start of therapy.
Psychological burden: Fear of flares, the urge to defecate in public, fatigue and shame can considerably impair the quality of life. Psychological support is part of guideline-compliant care. The DCCV e. V. offers advice and self-help.
How brite helps you with ulcerative colitis
Mesalazine in the morning and evening, plus an enema before going to bed, azathioprine with breakfast, a cortisone tapering schedule and the next vedolizumab appointment in two weeks — IBD therapy is detailed work. brite makes it clear.
Intake reminder — 5-ASA daily, biologics appointments, a cortisone tapering schedule, enemas in the evening: brite reminds you punctually. Especially with maintenance medication, consistency is decisive for the course. Set up a reminder
Interaction check — azathioprine plus allopurinol? Mesalazine plus NSAIDs? brite warns about combinations that are particularly critical with IBD — recognize flare triggers early. Check now
Health history — document flares, calprotectin, stool frequency, symptoms and weight over time. Helps at the next appointment in gastroenterology and makes your own course visible. Track your history
Digital medication plan — all IBD medications clearly organized for gastroenterology, the GP and the emergency room — especially important during an acute flare, when decisions have to be made quickly. Go to medication plan
Ulcerative colitis affects only the colon and the mucous membrane; Crohn's disease can affect the entire digestive tract and all wall layers. Ulcerative colitis always begins at the rectum and spreads continuously; Crohn's disease often shows a segmental involvement. Only with ulcerative colitis is a surgical cure possible (colectomy).¹
Not with medication — but a surgical removal of the colon (colectomy with a pouch) can generally cure the disease. This procedure is mostly only considered when drug therapy does not work sufficiently. Many of those affected achieve a long-term remission without surgery with modern therapy.¹
5-aminosalicylic acid (mesalazine) is generally the first-line therapy with ulcerative colitis — both for treating a flare and for maintaining remission. It is applied as a suppository, foam, enema or tablet, depending on the extent. It has a favorable side-effect profile and is mostly given as a long-term therapy.¹
Orally taken medications (tablets) that inhibit the Janus kinases — enzymes that are involved in the transmission of inflammation signals. With ulcerative colitis, tofacitinib, upadacitinib and filgotinib are approved. Advantage: a rapid onset of effect and oral intake (no injections). Regular laboratory checks are necessary.³
Generally yes — mesalazine is often recommended as a long-term therapy for maintaining remission with ulcerative colitis. Studies show that stopping mesalazine considerably increases the flare risk. The decision should always be discussed with the gastroenterology.¹
With long-standing ulcerative colitis with extensive colon involvement, the risk of colorectal cancer is slightly increased in the long term. Regular surveillance colonoscopies allow early detection. 5-ASA as a long-term therapy can possibly additionally lower the cancer risk (the evidence is being discussed).¹
Stress does not cause ulcerative colitis — but it can favor flares and intensify the perception of symptoms. Stress management and psychological support can improve the quality of life and are part of guideline-compliant care.
After removal of the colon and rectum, a reservoir (ileoanal pouch, J-pouch) is formed from the small intestine, which is connected to the anus. This generally preserves the natural emptying of stool. The stool frequency is mostly increased after the operation. A pouchitis (inflammation of the pouch) can occur and is generally treated with antibiotics.
Medical disclaimer: This article is for general information and does not replace medical advice, diagnosis or therapy. IBD medications should generally not be stopped on one's own or changed in dose. With signs of a severe flare (severe bloody diarrhea, high fever, severe abdominal pain), seek medical help immediately. The choice of medication and dosage is always determined individually by the treating gastroenterology. Last updated: April 2026.
