Ulcerative Colitis: Symptoms, Treatment and Nursing Care

ULCERATIVE COLITIS

Ulcerative colitis (UC) is a chronic inflammatory bowel disease that causes inflammation and ulceration of the lining of the colon and rectum. It commonly follows a course of relapses, called flares, and periods of remission. The disease usually starts in the rectum and extends proximally in a continuous pattern for a variable distance.

Ulcerative colitis can range from limited rectal disease to extensive, life-threatening colitis. It requires continuing assessment and treatment even when symptoms improve. These notes explain its clinical features, diagnosis, medical treatment, surgical indications and nursing management for diploma nursing revision.

Learning objectives

1. Define ulcerative colitis and describe its distribution.
2. Explain factors involved in its development and pathophysiology.
3. Identify intestinal and extraintestinal manifestations.
4. Differentiate UC from Crohn's disease and infectious colitis.
5. Outline investigations and assessment of disease severity.
6. Explain medicines, acute severe colitis management and surgery.
7. Develop nursing care plans with rationales and measurable evaluation.
8. Teach nutrition, medicine adherence, danger signs and follow-up.

Relevant anatomy and physiology

The large intestine consists of the caecum, ascending, transverse, descending and sigmoid colon, followed by the rectum and anal canal. Its functions include absorption of water and electrolytes, storage of stool and controlled elimination. The mucosal lining provides a barrier between luminal contents and underlying tissues.

• Mucosa: contains the epithelial surface and crypts. In UC, inflammation principally involves this lining.
• Submucosa: contains vessels, nerves and connective tissue.
• Muscular layers: coordinate movement of intestinal contents.
• Rectum: stores stool and participates in the sensation of the need to defecate.
• Anal sphincters: help control stool passage.

Inflamed mucosa bleeds easily and cannot absorb normally. Rectal inflammation contributes to urgency and tenesmus. Severe inflammation can impair colonic movement and lead to dangerous dilatation.

Classification

By extent

Extent and severity are different. Limited disease can cause substantial distress, while extensive disease may be in remission. Treatment can change the visible pattern, so endoscopic findings must be interpreted with the history and biopsy results.

By disease activity

• Remission: symptoms and objective inflammatory activity are controlled according to the treatment target.
• Mild or moderate active disease: symptoms vary in frequency and impact; assessment includes bleeding, stool frequency, vital signs, laboratory results and endoscopy.
• Acute severe UC: a serious flare with frequent bloody stools and systemic toxicity, requiring hospital management.
• Steroid-dependent or refractory disease: describes difficulty maintaining control during steroid reduction or failure to respond adequately to treatment.

Causes and contributing factors

The exact cause is not fully established. UC is thought to arise from interaction between genetic susceptibility, altered immune responses, the intestinal microbiome and environmental factors.

• Genetic susceptibility: a family history of inflammatory bowel disease increases risk.
• Immune dysregulation: inappropriate inflammatory responses damage the intestinal mucosa.
• Microbiome: changes in intestinal microorganisms may interact with barrier and immune function.
• Environment: exposures and lifestyle factors may influence risk and disease course.

UC is not simply caused by eating a particular food, and it is not spread through ordinary contact. Stress can worsen coping and perceived symptoms but should not be presented as the sole cause. Infection, medicine interruption or other factors may accompany apparent relapse and need assessment. Smoking is harmful and should not be recommended as treatment.

Pathophysiology

1. Susceptibility and immune dysregulation contribute to persistent mucosal inflammation.
2. Inflammatory cells and mediators injure the epithelial surface and crypts.
3. The lining becomes friable and develops ulcers, resulting in blood and mucus in stool.
4. Impaired water absorption and altered motility contribute to frequent diarrhoea.
5. Rectal inflammation produces urgency and tenesmus.
6. Repeated blood loss, inflammation and reduced intake contribute to anaemia, fatigue and nutritional problems.
7. Severe disease can cause systemic toxicity, colonic dilatation, major bleeding or perforation.

Healing between ulcerated areas can form inflammatory pseudopolyps. These differ from ordinary adenomatous polyps, but long-standing colonic inflammation still requires a cancer-surveillance plan.

Clinical manifestations

Intestinal symptoms

• Diarrhoea, often containing blood and mucus.
• Rectal bleeding, which can occur even without frequent loose stools in proctitis.
• Urgency and inability to delay defecation.
• Tenesmus: a persistent sensation of needing to pass stool despite incomplete or little evacuation.
• Cramping abdominal pain, often associated with bowel movements.
• Nocturnal bowel movements and disturbed sleep.
• Reduced appetite, nausea or weight loss during active illness.

Systemic features

• Fatigue, weakness and pallor from anaemia or inflammation.
• Fever and tachycardia in more severe illness.
• Dehydration, dizziness and reduced urine output.
• Weight loss and reduced functional ability.
• Impaired growth or delayed development in children with inadequately controlled disease.

Extraintestinal manifestations

Ulcerative colitis versus Crohn's disease

These are general patterns, not sufficient criteria for self-diagnosis. Treated UC, severe disease and selected associated inflammation can alter typical appearances. Some patients initially have inflammatory bowel disease that cannot be confidently classified.

Differential diagnoses

• Infectious colitis, including bacterial dysentery and Clostridioides difficile infection.
• Amoebic colitis where epidemiologically relevant.
• Crohn's disease.
• Ischaemic colitis.
• Drug-related or radiation-related colitis.
• Colorectal malignancy or other causes of bleeding.
• Haemorrhoids or anal disease, which should not be assumed to explain persistent bloody diarrhoea.

In Uganda, stool infection assessment is especially relevant when evaluating bloody diarrhoea. Avoid starting immunosuppression on the assumption that all persistent diarrhoea is UC without appropriate clinical assessment. Infection can also coexist with established inflammatory bowel disease.

History taking and examination

History

1. Document stool frequency over 24 hours, consistency, blood, mucus and nocturnal episodes.
2. Ask about urgency, tenesmus, incontinence and access to a toilet.
3. Assess abdominal pain, distension, nausea and vomiting.
4. Record appetite, recent weight change, intake and urine output.
5. Ask about fever, dizziness, fatigue and extraintestinal symptoms.
6. Review previous diagnoses, endoscopy, admissions, operations and treatment response.
7. Check prescribed medicines, adherence, steroid exposure, NSAIDs and recent antibiotics.
8. Ask about travel, unsafe food or water, infectious contacts and family history.
9. Assess smoking, stress, work or school disruption, sleep and available support.
10. Explore concerns about medicines, fertility, body image, stomas and cost of care.

Examination

Assess temperature, pulse, blood pressure, respiratory rate, hydration, pallor, nutritional state and mental status. Examine the abdomen for distension and tenderness, watching for guarding or other signs of peritonitis. Assess skin, eyes and joints when indicated. Intimate assessment requires explanation, consent, privacy and an appropriate trained practitioner. In a severely ill patient, avoid repeated painful examination that delays urgent management.

Investigations and diagnosis

Diagnosis combines symptoms, endoscopic findings, histology and exclusion of important alternatives. In acute severe colitis, a carefully performed limited sigmoidoscopy may be safer and more appropriate than routine full colonoscopy with standard bowel preparation.

Acute severe ulcerative colitis

A commonly used adult definition is six or more bloody stools daily plus at least one sign of systemic toxicity: pulse above 90 beats/minute, temperature above 37.8°C, haemoglobin below 10.5 g/dL or ESR above 30 mm/hour. Modified assessment may use CRP. This is a hospital emergency, not a routine outpatient flare. Children require paediatric assessment tools and management.

Urgent warning signs: increasing distension, severe or changing pain, persistent vomiting, marked bleeding, fever, tachycardia, reduced urine, hypotension or confusion. A sudden reduction in stool output with worsening distension may indicate deterioration rather than recovery.

Initial hospital management

1. Arrange urgent gastroenterology and early surgical assessment.
2. Monitor vital signs, fluid balance, stool frequency, bleeding and abdominal findings.
3. Obtain ordered blood tests, stool studies, imaging and appropriate endoscopic assessment.
4. Correct fluid and electrolyte deficits as prescribed.
5. Administer prescribed intravenous corticosteroids while the specialist team evaluates infection and complications.
6. Provide appropriate nutritional support; routine prolonged bowel rest is not a substitute for treatment.
7. Implement prescribed venous-thromboembolism prophylaxis after assessment of contraindications.
8. Avoid unreviewed antidiarrhoeals, anticholinergics, opioids or other medicines that may worsen colonic dilatation in severe disease.

Response is reassessed early, including around the third day of intravenous treatment. Failure to improve requires a timely decision about rescue therapy, such as infliximab or ciclosporin in appropriate patients, or surgery. Perforation, uncontrolled major bleeding and other life-threatening complications can require immediate surgery; do not wait for a predetermined treatment period.

Toxic megacolon

Toxic megacolon is acute, non-obstructive colonic dilatation with systemic toxicity. It can complicate severe colitis. The patient may have distension, tenderness, fever, tachycardia and deterioration. It requires urgent specialist care, close monitoring, correction of physiological disturbance and treatment of the underlying process, with surgery when indicated. Do not give routine bowel preparation or assume fewer bowel movements mean the flare has resolved.

Medical management

Treatment aims to induce remission, maintain control, improve quality of life and prevent complications. Selection depends on disease extent, severity, previous response, risks, access and patient preferences. An induction medicine is not necessarily suitable for long-term maintenance.

Some patients with moderate-to-severe disease benefit from early advanced therapy rather than repeated ineffective courses of older medicines. Treatment availability and monitoring capacity must be considered. Antibiotics are used when indicated for infection or complications; they are not a universal maintenance treatment for UC.

Medicine education

• Explain why maintenance treatment continues when symptoms improve.
• Teach rectal preparations privately and respectfully; their local delivery can be important in distal disease.
• Do not abruptly stop prolonged systemic steroids without the prescribed plan.
• Discuss infection screening and vaccine review before immunosuppression. Live vaccines need specialist assessment.
• Review non-prescription drugs, NSAIDs and herbal products before use.
• Provide a clear contact route for side effects, poor response or difficulty obtaining medicines.

Surgical management

Indications

• Perforation or peritonitis.
• Life-threatening haemorrhage.
• Toxic megacolon or severe deterioration requiring operative treatment.
• Failure of appropriate medical or rescue treatment.
• Chronic active disease despite optimised treatment or unacceptable treatment effects.
• Selected dysplasia or colorectal cancer.

Operations

• Subtotal colectomy with end ileostomy: commonly used for urgent severe disease, leaving the rectum for a later management plan.
• Proctocolectomy with ileostomy: removes colon and rectum and diverts stool through an abdominal stoma.
• Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA): creates an ileal reservoir connected to the anus in suitable patients, often through staged operations.

Surgery removes the diseased colon and rectum when both are resected, but the patient still needs postoperative care and follow-up. Pouchitis, altered bowel function, dehydration, fertility concerns or extraintestinal problems may remain relevant. Explain the actual operation planned rather than promising that every patient will avoid a permanent stoma.

Nursing management during a flare

Nursing care plan

Perioperative and stoma care

Before surgery, confirm understanding and consent, support fluid and nutritional optimisation, review steroid and immunosuppressant exposure and arrange stoma counselling and site assessment. Explain likely postoperative tubes, pain management and mobility.

After surgery, monitor airway, breathing, circulation, bleeding, wound, pain, urine and drain output. Assess ileostomy colour, moisture, swelling, output and surrounding skin. Record losses carefully because ileostomy output can cause dehydration and salt depletion. Follow the prescribed feeding and thromboprophylaxis plan.

• Teach appliance emptying and changing through demonstration and supervised practice.
• Fit the appliance to protect skin without constricting the stoma.
• Report a dusky or black stoma, severe pain, persistent vomiting, absent output with obstructive symptoms or unusually high output.
• Discuss body image, intimacy, work, supplies and caregiver support.
• For an ileal pouch, explain expected bowel changes and report increased frequency, bleeding, fever or pelvic discomfort that could indicate a complication.

Nutrition

No single diet cures UC. Assess food tolerance, nutrient intake, anaemia and weight change. A balanced diet tailored to symptoms and treatment is preferable to broad avoidance lists. Small frequent meals can help when appetite is poor. During a flare, temporary texture or fibre changes may be advised for comfort; prolonged restriction needs review.

• Encourage fluids and prescribed replacement appropriate to losses.
• Consider a food and symptom diary to identify individual difficulties.
• Do not exclude dairy routinely unless there is a relevant intolerance or specific advice.
• Address iron and other deficiencies through assessment and prescribed treatment.
• Review calcium, vitamin D and bone health when relevant, especially with steroid exposure.
• Use supplements or enteral support when indicated. Parenteral nutrition is reserved for appropriate clinical circumstances, not routine “bowel rest”.

Complications

• Anaemia from bleeding, inflammation or deficiency.
• Dehydration and electrolyte disturbance.
• Malnutrition and impaired growth in children.
• Severe bleeding, toxic megacolon, perforation and sepsis.
• Venous thromboembolism.
• Long-term colorectal cancer risk in relevant colonic disease.
• Eye, joint, skin and hepatobiliary disease.
• Bone loss and medicine-related adverse effects.
• Psychological distress, disturbed sleep and disruption of work or education.

Discharge education and long-term follow-up

1. Explain relapse and remission and the purpose of the maintenance plan.
2. Give the exact medicine schedule, monitoring requirements and contact details.
3. Teach urgent review for marked bleeding, fever, severe pain, distension, persistent vomiting, dehydration or worsening weakness.
4. Keep a symptom record when useful and attend planned review rather than adjusting immunosuppression independently.
5. Discuss balanced nutrition, safe food handling and practical toilet access.
6. Arrange cancer surveillance according to duration, extent, inflammatory burden, family history and associated primary sclerosing cholangitis; intervals are individualised.
7. Review bone health, vaccination and infection prevention.
8. Discuss pregnancy planning and medicines with the specialist team; uncontrolled disease and abrupt treatment changes can both create problems.
9. Support smoking cessation and avoid recommending tobacco for UC.
10. Provide stoma or pouch follow-up where relevant, with access to supplies and advice.

Revision questions and clinical case

1. Define UC and classify it by extent.
2. Explain how mucosal inflammation produces blood, diarrhoea and tenesmus.
3. Compare UC with Crohn's disease.
4. List investigations and their purposes.
5. Define acute severe UC and explain why it requires admission.
6. Describe corticosteroid use and why steroids are unsuitable for routine maintenance.
7. Outline surgical indications and common operations.
8. Give nursing interventions for fluid loss, nutrition and perianal skin care with rationales.

Clinical case: A patient with established UC reports eight bloody stools daily, pulse 110/minute, fever and increasing distension. Arrange urgent admission and specialist review, assess circulation and hydration, document stool and abdominal findings and implement ordered investigations and treatment. Do not give an unreviewed antidiarrhoeal or wait for the next routine appointment.

References and further reading

• NIDDK: Definition and Facts of Ulcerative Colitis. Symptoms and Causes.
• NIDDK: Diagnosis. Treatment. Eating, Diet and Nutrition.
• AGA: Mild-to-Moderate UC Guideline. Living Guideline for Moderate-to-Severe UC.
• BSG: Inflammatory Bowel Disease in Adults Guideline (2025).
• NICE NG130: Ulcerative Colitis Management.

Return to the Diploma in Nursing Direct Curriculum. Related notes: Abdominal Cancers.