Synopsis
Diagnose ulcerative colitis, describe its continuous colonic extent and activity, and deliver steroid-sparing medical care with timely surveillance and surgical discussion.
- Ulcerative colitis is chronic mucosal inflammation beginning in the rectum and extending proximally in a usually continuous pattern; extent can change over time or appear modified by treatment.
- Bloody diarrhoea, urgency, tenesmus and nocturnal stool are typical, but diagnosis still requires stool infection assessment, endoscopy and histology rather than symptoms alone.
- Record proctitis, left-sided or extensive disease and quantify activity because topical reach, systemic risk, surveillance and treatment selection all depend on them.
- For mild to moderate disease, mesalazine delivered to the involved mucosa is foundational; combined oral and rectal delivery is often more effective than ignoring distal treatment.
- Corticosteroids induce remission when 5-ASA is insufficient but should not maintain it; relapse during taper or repeated courses requires escalation to steroid-sparing therapy.
- Moderate to severe disease may require biologic or small-molecule therapy selected through current NICE and BSG guidance, individual safety assessment and shared decision-making.
- Increasing bloody stool frequency, tachycardia, fever, anaemia or raised inflammatory markers can indicate acute severe ulcerative colitis and requires hospital assessment, not an outpatient prescription change.
- Colectomy removes colitis and colorectal cancer risk from retained colon, but surgery creates new functional, fertility, stoma or pouch considerations and should be discussed before emergency circumstances.
Key red flags
Suspected acute severe colitis requires same-day hospital assessment with gastroenterology and colorectal surgery involvement from admission.
Abdominal distension, tenderness, systemic toxicity or reduced stool passage can indicate toxic megacolon or perforation and needs urgent imaging and surgical review.
Major haemorrhage, shock, severe electrolyte disturbance or venous thromboembolism is an emergency and should not await elective IBD clinic contact.
A painful red eye with photophobia or reduced vision suggests uveitis and requires urgent ophthalmology assessment rather than routine optometry alone.
Worsening symptoms during immunosuppression require infection testing and medicine-toxicity assessment before assuming uncontrolled UC.
Investigation priorities
Exclude treatable infection at diagnosis and during clinically important flares.
Management branches
Persistent bloody diarrhoea, urgency or tenesmus raises suspicion of new ulcerative colitis.
- Assess haemodynamic and systemic severity first, admitting suspected acute severe disease rather than progressing through a routine outpatient pathway.
- Obtain blood and stool tests, including infection assessment, medication and travel history, and examine for abdominal, perianal and extra-intestinal findings.
- Perform ileocolonoscopy with systematic biopsies when safe, using limited sigmoidoscopy instead if severe colitis makes full examination hazardous.
- Document activity, proctitis versus left-sided or extensive involvement, nutrition, extra-intestinal disease and individual cancer-surveillance factors.