Symptoms of Ulcerative Colitis
Ulcerative colitis always affects the rectum, and extends proximally, in a diffuse, symmetrical, and contiguous pattern for a distance that varies between individuals. Patients may develop proctitis, proctosigmoiditis, left-sided colitis (inflammation up to the splenic flexure), extensive colitis (inflammation extending proximal to the splenic flexure), or pancolitis (inflammation involving the entire colon). The location of inflammation tends to remain constant throughout the course in patients and the combination of disease extent and mucosal severity influence disease presentation and prognosis.
Because the rectum is inflamed in virtually all patients with
ulcerative colitis, the
hallmark symptoms are rectal bleeding, passage of mucopus, and urgency
to evacuate. Diarrhea, in contrast, is related to the extent of colonic
inflammation such that many patients with proctitis present with constipation
and hematochezia. Other symptoms include tenesmus (a sensation of
needing to evacuate stool, or “dry heaves of the rectum,” that often is nonproductive)
and abdominal cramping. Abdominal pain, per se, is uncommon
as ulcerative
colitis most commonly is limited to the mucosa, whereas pain receptors
in the gut are present on the serosa and peritoneum. More seriously ill
patients can present with accompanying anorexia, nausea, emesis (typically
associated with bowel movements), and possible toxic manifestations of
orthostasis, tachycardia, and fevers. Disease severity is assessed by the
clinical criteria of Truelove and Witts.
Patients with fulminant UC present with fever and continuous bloody
diarrhea, consisting of greater than 10 bowel movements daily. Toxic
megacolon, defined by fulminant colitis and radiographic evidence of
colonic dilatation, is not unique to
ulcerative colitis, and can also occur with Crohn’s
colitis or infectious colitides.
The clinician should elicit any extraintestinal manifestations, previous
or concomitant medication history, smoking history, and family history of IBD.