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Ulcerative Colitis: Symptoms, Modern Treatment & Living with IBD
At a glance
FrequencyAlongside Crohn's disease, the second major inflammatory bowel disease (IBD) - several hundred thousand people in Germany are affected by an IBD, with comparable rates across other Western countries
Age at onsetOften first appears between the ages of 20 and 40; but can occur at any age
Curable?Not curable with medication - surgical removal of the large intestine (colectomy) can usually cure the disease
Pattern of involvementAffects only the large intestine, always starts at the rectum, and can spread upward
Ulcerative colitis is an inflammatory bowel disease (IBD) in which the mucosa of the large intestine (colon) and the rectum is inflamed. The inflammation always starts at the rectum and can spread from there continuously upward - in contrast to Crohn's disease, where the inflammation can affect the entire digestive tract and usually occurs segmentally.1
The disease usually runs in flares: phases of active inflammation alternate with symptom-free or low-symptom phases (remission). The treatment goal is the longest possible remission - ideally with healing of the bowel lining (mucosal healing).1,3
A surgical cure is possible - unlike with Crohn's disease
In contrast to Crohn's disease, there is a surgical option for cure with ulcerative colitis: removing the entire large intestine (colectomy) can usually eliminate the disease. This procedure is, however, a major step and is mostly only considered when medication treatments do not work well enough.
2. Difference from Crohn's disease
Ulcerative colitis and Crohn's disease are grouped under the umbrella term IBD, but they differ in important respects.1
Feature
Ulcerative colitis
Crohn's disease
Pattern of involvement
Large intestine only, ascending continuously from the rectum
Entire digestive tract possible, often segmental with healthy sections
Depth of inflammation
Mostly only the mucosa
Can affect all wall layers (transmural)
Main symptom
Bloody diarrhea
Chronic diarrhea (often without blood), abdominal pain, fistulas
Surgical cure
Possible (colectomy)
Not possible according to current knowledge
3. Symptoms
The symptoms depend on the extent of the inflammation and the disease activity.1
Main symptoms
Bloody diarrhea - the main symptom; often with admixtures of mucus and pus
Urgency (tenesmus) - frequent, painful urge to pass stool, often with a small stool amount
Abdominal pain - often in the lower left abdomen, cramping
Increased stool frequency - during a flare often markedly more than normal, including 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 heavy bloody diarrhea, high fever, severe abdominal pain, or a massive sense of being unwell, medical help should be sought immediately. A severe flare can lead to complications such as toxic megacolon and usually requires inpatient treatment. In an emergency, call the emergency number - 112 across the EU, or 999 or 112 in the UK.
4. Causes and risk factors
The exact cause is, according to current knowledge, not fully understood. As with Crohn's disease, an interplay of several factors is assumed.1
Genetics: a family 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 the body's own gut flora leads to chronic inflammation of the large-intestine mucosa.
Gut microbiome: changes in the composition of the gut flora (dysbiosis) are discussed as a contributing cause.
Smoking: interestingly, smoking appears to have a certain protective effect in ulcerative colitis - in contrast to Crohn's disease, where smoking worsens the course. This expressly does not mean, however, that smoking is recommended - the health harms far outweigh 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 staged biopsies: the most important examination. Shows the typical continuous inflammation that starts at the rectum. Staged biopsies from various bowel 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
Lab: CRP, ESR, complete blood count, iron/ferritin. Fecal calprotectin is a sensitive marker of inflammatory activity in the bowel and is very well suited for monitoring the course and for distinguishing from irritable bowel syndrome.1
Stool test: to rule out infectious causes - above all Clostridioides difficile, campylobacter, salmonella.
Abdominal ultrasound: can show wall thickening non-invasively. Often used for monitoring the course.
Treatment depends on the extent, the disease activity (mild, moderate, severe), and the course so far. The current DGVS S3 guideline (fully updated November 2025, AWMF 021-009) emphasizes mucosal healing as a treatment goal. The decision is usually made by your treating gastroenterology team.1,3
Basis5-ASA / mesalazine - first line
5-aminosalicylic acid (mesalazine, sulfasalazine) is usually the first-line treatment for ulcerative colitis - both during a flare and for maintaining remission.1
Mesalazine - the right form depending on the involvement
Proctitis / left-sided colitis: suppository, foam, or enema (local). Extensive colitis: oral as tablets / granules.
Often also combined use (oral plus local). A favorable side-effect profile, usually well tolerated.
FlareCorticosteroids - short-term, then taper
Systemic corticosteroids (e.g. prednisolone)
Used for moderate to severe flares when 5-ASA is not enough. Corticosteroids should usually be given as briefly as possible and then tapered off - they are not a long-term medication. More: discontinuing corticosteroids.
Budesonide MMX
Can be an alternative for milder to moderate cases - less systemic effect than classic corticosteroids.
MaintenanceImmunosuppressants
Azathioprine / 6-mercaptopurine
For maintaining remission when 5-ASA is not enough. The onset of effect usually takes several months. Regular lab monitoring is necessary.
EscalationBiologics, JAK inhibitors & S1P modulator
For 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
Acts gut-selectively. Advantage: less systemic immunosuppression. Often used for ulcerative colitis.
Anti-IL-12/23 - ustekinumab
Inhibits interleukins 12 and 23. Approved for ulcerative colitis.
JAK inhibitors - tofacitinib, upadacitinib, filgotinib
Taken orally (tablets instead of injections). Inhibit the Janus kinases. A special feature: a fast onset of effect. Regular lab monitoring and individual risk assessment are necessary (including 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
Corticosteroids are not a long-term medication for ulcerative colitis. Steroid-free remission is the treatment goal. When corticosteroids are needed repeatedly or over a longer time, escalating treatment should be discussed - the options are considerably broader today than just a few years ago.
7. Surgery: colectomy and pouch
In some of those affected with severe ulcerative colitis that cannot be controlled with medication, or when dysplasia/carcinoma appears, surgical removal of the large intestine (colectomy) can be considered. In contrast to Crohn's disease, this operation can usually cure the disease.1
Proctocolectomy with a pouch - the standard procedure
The entire large intestine and the rectum are removed. A reservoir is formed from the small intestine (an ileoanal pouch, J-pouch) and connected to the anus. This usually preserves natural bowel emptying - without a permanent stoma. Stool frequency is usually increased after the operation.
Pouchitis
Inflammation of the pouch occurs in a relevant proportion of those operated on. Usually treated with antibiotics.
Stoma
A temporary or, in rare cases, permanent stoma (an artificial bowel outlet) may be necessary - many of those affected report that quality of life with a stoma is often better than with a severe, uncontrolled flare.
8. Everyday life with ulcerative colitis
Medications: regular intake even in remission is crucial - especially with 5-ASA, which is often given as long-term treatment. Stopping it on your own increases the risk of a flare. More: discontinuing medication.
Diet: there is no special ulcerative colitis diet. During 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, folate) regularly.
Bowel cancer surveillance: with long-standing ulcerative colitis and extensive involvement, the risk of bowel cancer is increased. Regular surveillance colonoscopies with biopsies are usually recommended - the exact intervals are set by your treating gastroenterology team.1
Vaccinations: under immunosuppression, special vaccination recommendations apply. Live vaccines are usually contraindicated. Vaccination status should be checked and updated before starting treatment.
Psychological burden: fear of flares, urgency in public, fatigue, and shame can considerably affect quality of life. Psychological support is part of guideline-based care. Patient organizations (for example, in Germany the DCCV) offer counseling and peer support; in your own country, look for the national IBD patient organization.
How brite helps you with ulcerative colitis
Mesalazine in the morning and evening, an enema before bed, azathioprine with breakfast, a corticosteroid tapering schedule, and the next vedolizumab appointment in two weeks - IBD treatment is detail work. brite makes it clear.
Intake reminders - 5-ASA daily, biologic appointments, corticosteroid tapering schedule, enemas in the evening: brite reminds you on time. With maintenance medication in particular, consistency is crucial for the course. Set up a reminder
Interaction check - azathioprine plus allopurinol? Mesalazine plus NSAIDs? brite warns you about combinations that are particularly critical with IBD - spotting flare triggers early. Check now
Health journal - document flares, calprotectin, stool frequency, symptoms, and weight over time. Helps at your next gastroenterology appointment and makes your own course visible. Track your progress
Digital medication plan - all your IBD medications clearly laid out for gastroenterology, your GP, and the emergency department - especially important during an acute flare, when decisions have to be made quickly. Go to the medication plan
Ulcerative colitis affects only the large intestine and the mucosa; Crohn's disease can affect the entire digestive tract and all wall layers. Ulcerative colitis always starts at the rectum and spreads continuously; Crohn's disease often shows a segmental pattern. Only with ulcerative colitis is a surgical cure possible (colectomy).1
Not with medication - but surgical removal of the large intestine (colectomy with a pouch) can usually cure the disease. This procedure is mostly only considered when medication treatment does not work well enough. Many of those affected achieve long-term remission without surgery using modern treatment.1
5-aminosalicylic acid (mesalazine) is usually the first-line treatment for ulcerative colitis - both for treating a flare and for maintaining remission. It is used as a suppository, foam, enema, or tablet, depending on the extent. It has a favorable side-effect profile and is mostly given as long-term treatment.1
Medications taken orally (tablets) that inhibit the Janus kinases - enzymes involved in relaying inflammation signals. For ulcerative colitis, tofacitinib, upadacitinib, and filgotinib are approved. Advantage: a fast onset of effect and oral intake (no injections). Regular lab monitoring is necessary.3
Usually yes - mesalazine is often recommended as long-term treatment for maintaining remission in ulcerative colitis. Studies show that stopping mesalazine markedly increases the risk of a flare. The decision should always be discussed with your gastroenterology team.1
With long-standing ulcerative colitis and extensive involvement of the large intestine, the risk of bowel cancer is slightly increased over the long term. Regular surveillance colonoscopies allow early detection. 5-ASA as long-term treatment may possibly further lower the cancer risk (the evidence is debated).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 quality of life and are part of guideline-based care.
After removal of the large intestine and rectum, a reservoir is formed from the small intestine (an ileoanal pouch, J-pouch) and connected to the anus. This usually preserves natural bowel emptying. Stool frequency is mostly increased after the operation. Pouchitis (inflammation of the pouch) can occur and is usually treated with antibiotics.
Blumenstein I, Kucharzik T et al. Updated S3 Guideline Ulcerative Colitis, Version 7.0. Z Gastroenterol 2025. Full text (PDF)
German Crohn's Disease / Ulcerative Colitis Association (DCCV). dccv.de
Competence Network for Inflammatory Bowel Diseases (Germany). kompetenznetz-ced.de
Medical disclaimer: This article is for general information and does not replace medical advice, diagnosis, or treatment. IBD medications should usually not be stopped or changed in dose on your own. With signs of a severe flare (heavy bloody diarrhea, high fever, severe abdominal pain), seek medical help immediately. The choice of medication and dosing is always determined individually by your treating gastroenterology team. Last updated: April 2026.
