Ulcerative Colitis

A long term condition that causes hot, red, swelling (inflammation) and in serious conditions ulcers (sores that bleed, produce mucus and pus) on the lining of the large intestine colon.

• It usually begins in the rectum, then worsens to involve some or all of the large intestine colon.
• It usually affects person of any gender age 15- 30 years of age and  second peak of incidence of persons of age  50 – 70 years.

Examples of ulcerative colitis include:

The different forms of ulcerative colitis and their most common symptoms include:

• Ulcerative proctitis – Inflammation located in the rectum
• Proctosigmoiditis – Inflammation located in the rectum and sigmoid colon
• Left-sided colitis (also limited or distal colitis) – Inflammation in the left side of the colon (rectum, sigmoid colon, descending colon)
• Pancolitis – Inflammation throughout the whole colon

Other types of colitis include:

• Crohn’s disease
• Intermediate colitis (mainly in children- difficult to tell what form of IBD it is)
• Microscopic colitis
  • Lymphocytic colitis or Collagenous colitis (main symptoms are diarrhoea, watery diarrhoea in the presence of a normal colonoscopy, and long term inflammation in the absence of crypt architectural distortion on mucosal biopsies)- main cause due to medication anti-inflammatory medication (NSAID’s) and stomach ulcer and heartburn medication (PPI’s).
• Diversion colitis – inflamed and dysfunctioning colon.
• Pseudomembranous colitis is caused by Clostridioides difficile (caused by antibiotics use).

The clinical similarities and differences between Crohn’s disease and Ulcerative colitis are highlighted in Table 1.

Ng WK, Wong SH, Ng SC. Changing epidemiological trends of inflammatory bowel disease in Asia. Intest Res 2016;14:111. doi:10.5217/ir.2016.14.2.111

Diagnosis tests

Truelove and Witts’ criteria is a useful tool in defining the severity of ulcerative colitis in adults.

Acute severe colitis is defined by more than six bloody stools a day plus one or more of the following markers of systemic upset:

• Pulse >90 beats/min;
• Temperature >37.8°C;
• Haemoglobin <10.5g/dL;
• Erythrocyte sedimentation rate (ESR) >30mm/h

This condition is a medical emergency and requires inpatient management for intensive therapy.

In such instances, pharmacists should refer patients to their GP or an acute walk-in centre.

The Pharmaceutical Journal, PJ, August 2021, Vol 307, No 7952;307(7952)::DOI:10.1211/
PJ.2021.1.101504

Other diagnosis tools for grading disease activity and severity of ulcerative colitis

Mayo Score

The Mayo Score for ulcerative colitis activity is a commonly used tool that grades stool frequency (0-3), rectal bleeding (0-3), findings on endoscopy (0-3), and physician’s global assessment (0-3). Endoscopy findings are graded as:

• Mayo 0: normal or inactive disease
• Mayo 1: mild disease (erythema, decreased vascular pattern, and mild friability)
• Mayo 2: moderate disease (marked erythema, lack of vascular pattern, friability, and erosions)
• Mayo 3: severe disease (spontaneous bleeding and ulcerations)

Rubin DT, Ananthakrishnan AN, Siegel CA, Barnes EL, Long MD. ACG Clinical Guideline Update: Ulcerative Colitis in Adults. Am J Gastroenterol. 2025;120:1187-1224. Source

Ulcerative Colitis Endoscopic Index of Severity (UCEIS)

A tool that determines severity solely on the basis of ranking certain endoscopic descriptors, including vascular pattern (0-2), bleeding (0-3), and erosions and ulcers (0-3).

• Vascular patterns are classified as: 0, normal; 1, patchy obliteration; 2, obliterated.
• Bleeding is ranked as: 0, none; 1, mucosal; 2, luminal mild; 3, luminal moderate or severe.
• Erosions and ulcers are classified as: 0, none; 1, erosions; 2, superficial ulcer; 3, deep ulcer.

The ACG Ulcerative Colitis Activity Index

An extensive tool to help determine disease severity. It includes stool frequency, presence of blood in stool, frequency of faecal urgency, haemoglobin level, ESR, CRP level, faecal calprotectin level, endoscopy Mayo sub score, endoscopy UCEIS score, and intestinal ultrasound.

Diagnosis to differentiate Crohn’s disease from Ulcerative colitis

Serologic markers for Inflammatory bowel disease include most notably Positive perinuclear antineutrophil cytoplasmic antibodies (pANCA) and positive anti–saccharomyces cerevisiae antibodies (ASCA) are associated with Ulcerative colitis and Crohn’s disease.

• Specifically, pANCA is highly associated with Ulcerative colitis.
• Positive pANCA and negative ASCA findings suggest Ulcerative colitis.
• Negative pANCA and positive ASCA suggest Crohn’s disease.

A colonoscopy confirms the diagnosis of suspected Ulcerative colitis, and it is the technique of choice to assess disease activity in patients with symptomatic Ulcerative colitis.

• In acute-onset (sudden onset) cases of Ulcerative colitis, plain abdominal radiographs are a useful adjunct to imaging.
• Such images may reveal colonic dilatation in severe cases, evidence of perforation (tear or hole in intestine), which suggests toxic megacolon, ileus, or obstruction.
• An MRI is useful in the differentiation of Ulcerative colitis from Crohn’s disease, in that fistulae or the presence of small bowel disease are present only in Crohn’s disease.

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