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Ulcerative Colitis, Signs & Symptoms, ACG (2025): Evidence-based…
Ulcerative Colitis
Clinical Reasoning
Bloody diarrhea: Mucosal ulceration and inflammation cause rectal bleeding and frequent loose stools.
Abdominal pain and urgency: Colonic inflammation increases bowel motility and causes cramping, urgency, and tenesmus.
Fatigue and anemia: Chronic intestinal blood loss and inflammation may contribute to iron deficiency anemia and fatigue.
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Disease severity: Evaluate stool frequency, bleeding, vital signs, inflammatory markers, hemoglobin, and endoscopic findings to determine severity.
Complications: Severe inflammation may cause acute severe colitis, toxic megacolon, perforation, or significant hemorrhage. Long-standing extensive colitis increases colorectal cancer risk.
APRN decision-making: Assess for disease flares, exclude infectious causes such as Clostridioides difficile, monitor complications, and coordinate treatment or gastroenterology referral based on disease severity.
Patho
Genetic and Environmental Factors: Genetic susceptibility, alterations in gut microbiota, and environmental exposures contribute to intestinal inflammation.
Mucosal Involvement: Inflammation primarily affects the mucosa and may extend into the superficial submucosa, unlike Crohn's disease, which involves transmural inflammation.
Continuous Inflammation: Inflammation typically begins in the rectum and extends proximally through the colon in a continuous pattern.
Epithelial Barrier Disruption: Damage to the intestinal epithelial barrier contributes to increased permeability, mucosal ulceration, bleeding, and mucus production.
Crypt Abscesses: Neutrophils accumulate within intestinal crypts, contributing to mucosal injury and serving as a characteristic histologic finding of active inflammation. Crypt abscesses are characteristic of active UC but are not exclusive to UC, so they should not be presented as diagnostic on their own.
Chronic Immune-Mediated Inflammation: Dysregulated intestinal immune responses cause chronic inflammation of the colon and rectum.
Assessment
History: bleeding, stool frequency and characteristics, urgency
Medication, allergies, medical history, and family history
Vitals, weight, and hydration status
Abdominal exam, palpation, assessing overall severity and patient stability
Nutrition status, fluid intake
Diagnosis & Testing
Stool Studies: exclude infection/ C. difficile
Fecal Calprotectin: intestinal inflammation
GI: colonoscopy with biopsies
CBC, CMP, Albumin, CRP, Vitamin D, ESR
Specialty Resources
Gastroenterologist: Referral for colonoscopy, disease management, advanced therapies, and persistent symptoms.
Registered Dietitian: Nutritional counseling, dietary modifications, and management of nutritional deficiencies.
Colorectal Surgeon: Referral for refractory disease, colorectal dysplasia or cancer, or severe complications.
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APRN Scope of Practice
Assessment: Evaluate symptoms, risk factors, nutritional status, and disease severity.
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Management: Manage appropriate medications, monitor adverse effects, and coordinate specialty care.
Prevention: Promote vaccinations, nutritional health, medication adherence, and colorectal cancer surveillance.
Follow-Up: Monitor symptoms, inflammatory markers, and treatment response to maintain remission.
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Prevelance
Prevalence: Approximately 3.1 million U.S. adults (1.2%) reported a history of ulcerative colitis (Dahlhamer & Terlizzi, 2026).
Screening Prevention
Primary Prevention: No proven way to prevent UC. Healthy eating and avoiding unnecessary antibiotic use may help support gut health.
Early Detection: Evaluate patients with persistent bloody diarrhea, abdominal pain, or rectal urgency.
Colorectal Cancer Screening: Surveillance colonoscopy typically begins 8 years after symptom onset, depending on disease extent and risk factors.
Tertiary Prevention: Maintenance medications, such as 5-ASA and biologics, help control inflammation, prevent flares, and reduce complications.
Morbidity & Mortality
Morbidity
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Complications include anemia, malnutrition, and colorectal cancer.
Mortality
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Long-standing, extensive UC increases the risk of death from colorectal cancer.
Signs & Symptoms
Abdominal cramps, fatigue
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Bloody diarrhea, mucous in stool, urgency
Possible joint, skin, or eye symptoms
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ACG (2025): Evidence-based guidelines for UC diagnosis, treatment, monitoring, and maintenance of remission.
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AGA (2023): Recommends using fecal calprotectin and CRP alongside clinical symptoms to evaluate disease activity and treatment response.
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