Ulcerative Colitis Clinical Presentation

Updated: Oct 31, 2023
  • Author: Marc D Basson, MD, PhD, MBA, FACS; Chief Editor: BS Anand, MD  more...
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Patients with ulcerative colitis (UC) predominantly complain of rectal bleeding, with frequent stools and mucous discharge from the rectum. [31] Some patients also describe tenesmus. The onset is typically insidious. In severe cases, purulent rectal discharge causes lower abdominal pain and severe dehydration, especially in the elderly population.

Ulcerative colitis manifests as an intense inflammatory reaction in the large intestine. Rarely, patients have persistence of small intestinal inflammation following proctocolectomy and pull-through. [32, 33] Constipation may be the main symptom when the inflammation is limited to the rectum (proctitis). [4]

Fulminant disease

In some cases, ulcerative colitis has a fulminant course marked by severe diarrhea and cramps, fever, leukocytosis, and abdominal distention. Fulminant disease occurs more often in children than in adults. [34] An estimated 15% of patients present with an attack severe enough to require hospitalization and steroid therapy. [35, 36] Children may also present with systemic complaints, including fatigue, arthritis, failure to gain weight, and delayed puberty. The differential diagnosis of these symptoms in the pediatric population includes many entities, and definitive diagnosis may be delayed.

Extracolonic manifestations

Extraintestinal manifestations of inflammatory bowel disease include the following [4] :

  • Musculoskeletal conditions: Peripheral or axial arthropathy
  • Cutaneous conditions: Erythema nodosum, pyoderma gangrenosum
  • Ocular conditions: Scleritis, episcleritis uveitis
  • Hepatobiliary conditions: Primary sclerosing cholangitis (PSC)

Ulcerative colitis is associated with various extracolonic manifestations. These include uveitis, pyoderma gangrenosum, pleuritis, erythema nodosum, ankylosing spondylitis, and spondyloarthropathies. Reportedly, 6.2% of patients with inflammatory bowel disease have a major extraintestinal manifestation. Uveitis is the most common, with an incidence of 3.8%, followed by PSC at 3%, ankylosing spondylitis at 2.7%, erythema nodosum at 1.9%, and pyoderma gangrenosum at 1.2%. [37] However, reports vary, and some have stated that the incidence of ankylosing spondylitis is as high as 10%. Arthropathies occur in as many as 39% of patients with inflammatory bowel disease. About 30% of such patients have inflammatory back pain, 10% have synovitis, and as many as 40% have radiologic findings of sacroiliitis. [38]

Primary sclerosing cholangitis

PSC is a potentially serious condition associated with ulcerative colitis, often resulting in cholestatic jaundice and liver failure that requires liver transplantation. Of patients with PSC, 75% have inflammatory bowel disease. Of patients with ulcerative colitis, 5% have cholestatic liver disease, and 40% of those have PSC. One interesting hypothesis about the etiology of PSC in patients with ulcerative colitis involves the release of proinflammatory agents in the colon and their absorption into the enterohepatic circulation; they are then concentrated in the biliary system, leading to bile duct damage. [39, 40]

Additional manifestations of disease

Anecdotal reports of recurrent subcutaneous abscesses unrelated to pyoderma gangrenosum exist, [1] and multiple sclerosis also has been weakly associated with ulcerative colitis. [2]

Immunobullous disease of the skin has been associated with ulcerative colitis. One theory regarding this association is the concept of epitope spread. Colonic inflammation leads to mucosal damage, which exposes otherwise hidden antigens. Antibodies to these antigens are then formed; these most likely are cell adhesion molecules, which cross-react with similar antigens in other tissues. [3]


Physical Examination

Findings from abdominal examination are usually unremarkable in ulcerative colitis (UC). Physical findings are typically normal in mild disease, except for mild tenderness in the lower left abdominal quadrant (tenderness or cramps are generally present in moderate to severe disease [4] ). The extent and/or the severity of the disease may be reflected by abdominal tenderness, and digital rectal examination may yield mucus and bloody stools. [10]

Patients with severe disease can have signs of volume depletion and toxicity, including the following:

  • Fever

  • Tachycardia

  • Significant abdominal tenderness

  • Weight loss



The severity of ulcerative colitis can be graded as follows:

  • Mild: Bleeding per rectum and fewer than four bowel motions per day

  • Moderate: Bleeding per rectum with more than four bowel motions per day

  • Severe: Bleeding per rectum, more than four bowel motions per day, and a systemic illness with hypoalbuminemia (< 30 g/L)