Symptoms of Ulcerative Colitis
The cardinal symptom of ulcerative colitis is bloody diarrhea, typically accompanied by urgency, tenesmus, and colicky abdominal pain that is often relieved by defecation. 1, 2, 3
Primary Gastrointestinal Symptoms
Bloody diarrhea is the hallmark presenting symptom and occurs in the vast majority of patients with active disease 1, 3, 4. The blood is typically mixed with mucus 3, 4.
Increased stool frequency affects approximately 83% of patients with active colitis, with bowel movements often exceeding 4-8 times daily 1, 5.
Urgency occurs in 85% of patients with active disease and represents a critical symptom that significantly impacts quality of life 5, 6, 7.
Tenesmus (painful straining with a sensation of incomplete evacuation) is present in 63-78% of patients with active colitis 5, 8. This symptom is particularly prominent in distal disease and proctitis 9.
Colicky abdominal pain is frequently localized to the left lower quadrant in distal colitis and is often relieved by defecation 1, 3, 4.
Important Clinical Nuance: The Constipation Paradox
Approximately 27% of patients with active ulcerative colitis paradoxically void hard stools despite having inflammatory diarrhea 5. This occurs more commonly in active than quiescent disease and reflects proximal colonic stasis with distal irritability 5. Up to one-third of patients with ulcerative proctitis experience constipation alongside tenesmus 9.
Systemic and Constitutional Symptoms
Weight loss correlates with more severe disease activity and is a marker of significant inflammation 2, 3.
Fever is rare in uncomplicated ulcerative colitis but signals severe inflammatory activity or potential complications when present 1, 3.
Malaise, anorexia, and fatigue occur as systemic manifestations, though these are less prominent than in Crohn's disease 1, 3.
Extraintestinal Manifestations
Joint symptoms (arthritis or arthralgia) may accompany or even precede gastrointestinal symptoms 3, 6.
Dermatologic manifestations including erythema nodosum and pyoderma gangrenosum can occur 3.
Ocular symptoms such as uveitis or episcleritis are reported in some patients 3.
Red-Flag Symptoms Requiring Urgent Evaluation
Severe abdominal distension suggests toxic megacolon and warrants immediate assessment 3.
High fever combined with tachycardia signals possible systemic toxicity 3.
Profuse rectal bleeding is a critical warning sign requiring urgent intervention 3.
Clinical evidence of intestinal obstruction (vomiting, absent bowel sounds) demands immediate investigation 3.
Critical Clinical Pitfalls to Avoid
Do not assume absence of diarrhea means improvement—this may signal progression to fulminant infection in severe cases 3.
Do not overlook infectious causes, particularly C. difficile, which can mimic or coexist with ulcerative colitis flares 2.
Do not dismiss symptoms in patients with previous endoscopic documentation—approximately 27% of patients with both endoscopic and histologic healing may still have increased stool frequency 3.
Do not attribute all symptoms to active colitis in post-surgical patients—pouchitis develops in up to 50% of patients within 10 years after ileal pouch-anal anastomosis and presents with increased stool frequency, urgency, tenesmus, and pelvic discomfort 1, 9.