Do You Know the Different Types of UC?

Ulcerative colitis (UC), a type of inflammatory bowel disease (IBD) in which the lining of the colon becomes inflamed, causes symptoms that include urgent bowel movements, bloody stools, and cramping. UC has four subtypes, each of which is diagnosed based on the extent of colon involvement and other factors.

Here’s what to know about the four main types of UC and how they are diagnosed and treated.

• Ulcerative proctitis
• Left-sided colitis
• Proctosigmoiditis (a type of left-sided colitis)
• Extensive colitis (Pancolitis)

Ulcerative Proctitis

• Pain in the rectum, anus, or left side of the abdomen
• Rectal bleeding
• An increased sense of urgency in your bowel movements
• A constant urge to have a bowel movement even though your bowel may be empty (tenesmus)
• Diarrhea or constipation

Left-Sided Colitis

Common symptoms include:

• Diarrhea
• Bleeding
• Loss of appetite
• Weight loss
• Severe left-sided abdominal pain

Proctosigmoiditis

Extensive Colitis (Pancolitis)

Symptoms often include:

• Severe diarrhea
• Bleeding
• Cramps
• Abdominal pain
• Unintended weight loss

A colonoscopy is the only way to definitively diagnose UC and its subtypes. This procedure is performed under general anesthesia and involves inserting a colonoscope (a long, lighted tube with an attached camera) into your rectum and then into your colon.

A colonoscopy can help doctors see the amount of ulceration and bleeding that has occurred in the mucosa (the lining of the colon).

Lab Tests

Lab tests can include blood work to check for nutrients, antibodies, or signs of infection.

They may also use the stool sample to rule out other possible conditions.

X-rays

Sigmoidoscopy

A flexible sigmoidoscopy is similar to a colonoscopy, but it is less intrusive. This procedure uses a flexible tube with a light to view just the lower portion of the colon, which consists of the two areas leading up to your rectum: the descending colon and the sigmoid colon. A sigmoidoscopy is typically used to evaluate the severity of UC after it’s been diagnosed.

Chromoendoscopy

A chromoendoscopy is a type of colonoscopy that involves injecting a blue dye into the colon. The blue dye helps to highlight possible precancerous lesions and polyps in the colon.

Your doctor may then take a small sample of colon tissue (biopsy) or remove any polyps they find.

Biopsy

If your doctor removes a small tissue sample or a polyp from your colon, they will send it to a lab for examination. The lab can help screen for worsening UC as well as colorectal cancer.

CT Scan

UC is a chronic condition associated with periods of relapse and remission. Remission refers to periods when no signs of disease are present or are significantly reduced. Severity of the disease and type can influence your risk of complications related to UC, says Daniel Stein, MD, associate professor and director of the inflammatory bowel disease program at Froedtert & the Medical College of Wisconsin in Milwaukee.

While Dr. Stein notes that greater involvement of the colon usually means more severe UC, that doesn’t always hold true. “You could have somebody with very limited disease, just in the rectum, but very severe disease, with deep ulceration and marked swelling and bleeding,” he says. On the other hand, “You can also see somebody whose entire colon is involved, but with very mild disease.”

In general, Stein says, the level of inflammation in the rectum, rather than higher areas of the colon, accounts for the greatest share of UC symptoms that people report.

• Anemia
• Primary sclerosing cholangitis (scarring in the bile duct and liver)
• Diarrhea with fever
• Toxic megacolon (extremely enlarged colon that leads to systemic toxicity)

How much of your colon is affected probably won’t have an enormous impact on how your doctor recommends treating the condition, says Stein. “The anatomic features do have a factor in it,” he says, adding that they are just one element among several. “The whole clinical picture, from symptoms to laboratory abnormalities to how inflamed the colon looks, will guide us to which clinical therapies we choose.”

Regardless of the extent or severity of the UC, Stein emphasizes the importance of receiving proper treatment. “Ulcerative colitis, if left untreated, will progress over time,” he says.

That includes many people with milder UC, who often let their condition “smolder for a while before they come and see a doctor,” Stein says.

“If the rectum is relatively healthy compared with the rest of the colon,” he says, “people can often control their symptoms a little bit better.”

• Biologics Biologics target specific parts of the immune system. Examples include infliximab, adalimumab, golimumab, vedolizumab, ustekinumab, mirikizumab, and risankizumab.
• Small Molecules Oral medications that may help treat UC directly include tofacitinib, upadacitinib, filgotinib, and tzanimod.
• Immunomodulators These medications help to suppress the immune system. Examples include azathioprine, mercaptopurine, and cyclosporine.
• Steroids Corticosteroids like prednisone and budesonide can reduce inflammation and potentially induce remission.
• Anti-Inflammatory Drugs Both sulfasalazine and 5-aminosalicylates can be used during remission maintenance.
• Surgery In ulcerative colitis, surgery involves removing the entire large intestine (rectum and colon). Surgeons can preserve bowel continence and avoid an ileostomy (a bag) by performing a surgery called a J-pouch, where part of the small intestine is expanded so the body can use it to store waste. In some cases, a permanent ileostomy is required.

Your doctor may also prescribe medications to help control different symptoms. These can include antidiarrheal medicines, pain relievers, iron supplements, and antispasmodics (to help with cramping).

Lifestyle Factors and UC

Steps you can take include:

• Learning mindfulness
• Managing stress
• Staying active with regular exercise or physical activities
• Eating a healthy, balanced diet to help prevent malnutrition or maintain weight (though you may want to avoid high-fiber foods because they are harder to digest)
• Avoiding smoking
• Avoiding caffeinated beverages
• Staying hydrated

You may also want to ask your doctor about taking supplements, such as iron, to help prevent malnutrition.