What are the symptoms and treatment options for ulcerative colitis?

Symptoms of Ulcerative Colitis

Ulcerative colitis presents with rectal bleeding, increased stool frequency/diarrhea, and urgency as the cardinal symptoms, with rectal bleeding ranked as the most important symptom by gastroenterologists. 1

Core Gastrointestinal Symptoms

Primary Symptoms

• Rectal bleeding is the most important symptom, ranging from streaks of blood in stool to obvious bleeding or mostly blood 1
• Urgency to pass stools was rated as very important by 55% of patients who experienced it and impacts 72% of patients' quality of life 1
• Increased stool frequency/diarrhea affects 56% of patients and was rated important by 70% of those experiencing it 1
• Abdominal pain occurs in 56% of patients, typically presenting as cramping or discomfort in the lower abdomen 1, 2

Disease Severity Classification by Symptoms

• Mild-to-moderate disease: fewer than 4-6 bowel movements per day above baseline, mild-moderate rectal bleeding, absence of constitutional symptoms 1
• Moderate disease: 4-6 bowel movements per day above baseline with mild-to-moderate abdominal pain and blood in stool 2
• Severe disease: more than 6 bowel movements per day, severe abdominal pain, significant bleeding, and may include fever and hemodynamic instability 2, 3

Systemic and Extraintestinal Symptoms

Constitutional Symptoms

• Fatigue is experienced by 83% of patients with UC and was rated as having large impact on quality of life by 59% of patients 1
• Weight loss may indicate severe disease activity 1
• Fever suggests more severe inflammation or potential infectious complications 2, 3

Extraintestinal Manifestations

• Joint symptoms occur in 39% of patients and were rated as very important by 57% of those experiencing them 1
• Skin symptoms affect 22% of patients 1
• Eye symptoms (uveitis) occur in 17% of patients 1
• Primary sclerosing cholangitis occurs in approximately 27% of patients with UC 4

Additional Important Symptoms

Sleep and Quality of Life Impact

• Sleep disturbance affects 22% of patients and should be assessed using numerical scales like PROMIS Sleep Disturbance Item Bank 1
• Nocturnal diarrhea indicates more severe disease activity 1
• Tenesmus (painful straining with bowel movements) is a characteristic symptom 1
• Fecal incontinence may occur with severe urgency 1

Endoscopic Features Corresponding to Symptoms

The severity of symptoms correlates with endoscopic findings:

• Mild endoscopic activity: granularity, decreased vascular pattern, mild friability 1
• Moderate endoscopic activity: moderate friability, obvious bleeding 1
• Severe endoscopic activity: spontaneous bleeding, deep ulcerations, mucosal detachment, well-like ulceration 1, 3

Clinical Pitfalls

Patients and gastroenterologists have significant discrepancies in acceptable symptom levels for remission: patients most commonly accept no symptoms (no rectal bleeding, no urgency, no increased stool frequency), while gastroenterologists often accept mild symptoms occurring occasionally (less than 2 days per week) 1. This gap highlights the importance of patient-centered symptom assessment rather than relying solely on physician global assessment.