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Ulcerative colitis

What's new

The American College of Gastroenterology (ACG) has released an updated guideline for the management of ulcerative colitis in adults. Achieving endoscopic improvement, defined as resolution of inflammatory changes with a Mayo endoscopic subscore of 0-1, is recommended as a treatment target. For moderately to severely active disease, options for induction and maintenance of remission include anti-TNF agents (infliximab, adalimumab, golimumab), other biologics (ustekinumab, vedolizumab, guselkumab, mirikizumab, risankizumab), S1P receptor modulators (ozanimod, etrasimod), and JAK inhibitors (upadacitinib, tofacitinib). Oral budesonide MMX is also recommended as an option for induction. For maintenance of remission achieved with corticosteroids, thiopurines are suggested over continued corticosteroid use. .

Background

Overview

Definition
UC is a chronic relapsing-remitting IBD characterized by superficial mucosal ulceration extending from the rectum to proximal colon.
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Pathophysiology
The pathogenesis of UC is multifactorial and involves mutations in susceptibility genes, abnormalities in gut microbiota composition and host-microbiome interactions, as well as abnormalities in humoral and cellular adaptive immunity.
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Epidemiology
The highest incidence and prevalence of IBD are seen in the populations of Northern Europe and North America and the lowest in continental Asia. In the US, the incidence of UC is estimated at 8.8 cases per 100,000 person-years, while the prevalence is estimated at 286.3 persons per 100,000 population.
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Disease course
Inflammation and ulceration of the colonic mucosa may result in clinical manifestations of proctitis, proctosigmoiditis, left-sided colitis, pancolitis, severe rectal bleeding, toxic megacolon, and CRC, in addition to extraintestinal complications.
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Prognosis and risk of recurrence
Over 10-years, 50-55% of patients remit, approximately 37% follow a chronic intermittent course, and 6% develop a chronic continuous course. An estimated 20-30% of patients require colectomy after 25 years of disease activity. The standardized mortality ratio of patients with UC, as compared with the general population, is estimated at 2.78 (95% CI, 1.48-4.75).
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of ulcerative colitis are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG 2025,2021,2019,2017,2010), the American Gastroenterological Association (AGA 2025,2024,2023,2020,2017), the British Society of Gastroenterology (BSG 2025), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES 2024), the European Society for Clinical Nutrition and Metabolism ...
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Screening and diagnosis

Clinical presentation: as per ACG 2019 guidelines, suspect the diagnosis of UC in patients with hematochezia and urgency.
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  • Diagnosis

Classification and risk stratification

Classification and severity assessment
As per ACG 2019 guidelines:
Categorize disease extent in patients with UC as:
Situation
Guidance
Proctitis
Within 18 cm of the anal verge, distal to the rectosigmoid junction
Left-sided colitis
Extending from the sigmoid to the splenic flexure
Extensive colitis
Beyond the splenic flexure
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Determine disease severity based on:
Situation
Guidance
Patient-reported outcomes
Bleeding and normalization of bowel habits
Inflammatory burden
Endoscopic assessment including extent and severity
Markers of inflammation
Disease course
Need for hospitalization
Need for corticosteroids
Failure to respond to medications
Disease impact
Functionality
QoL
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Diagnostic investigations

Infectious workup
As per ACG 2025 guidelines:
Obtain stool testing to rule out C. difficile in patients with suspected UC.
B
Obtain testing for C. difficile infection in patients with acute severe UC.
B
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  • Fecal calprotectin

  • Serologic testing

  • Diagnostic imaging

  • Assessment of disease activity

  • Assessment of acute abdomen

  • Nutritional assessment

  • Evaluation of anemia

  • Screening for osteoporosis

  • Screening for depression and anxiety

  • Hepatitis B evaluation

Diagnostic procedures

Flexible sigmoidoscopy: as per AAST/WSES 2021 guidelines, perform sigmoidoscopy for intra-luminal assessment of distal IBD activity, bleeding source identification and biopsies in an acute setting, if available.
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  • Lower gastrointestinal endoscopy

Medical management

General principles: as per ACG 2019 guidelines, UC is a chronic condition for which therapy is required to induce and maintain remission; therapeutic decisions should be categorized into those for (i) induction and (ii) maintenance, with a goal of obtaining and maintaining a steroid-free remission.
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  • Treatment targets

  • Induction of remission (mild-to-moderate disease, aminosalicylates)

  • Induction of remission (mild-to-moderate disease, corticosteroids)

  • Induction of remission (mild-to-moderate disease, thiopurines)

  • Induction of remission (moderate-to-severe disease, corticosteroids)

  • Induction of remission (moderate-to-severe disease, aminosalicylates)

  • Induction of remission (moderate-to-severe disease, thiopurines and methotrexate)

  • Induction of remission (moderate-to-severe disease, advanced therapy)

  • Induction of remission (moderate-to-severe disease, antibiotics)

  • Maintenance of remission (mild-to-moderate disease)

  • Maintenance of remission (moderate-to-severe disease, advanced therapy)

  • Maintenance of remission (moderate-to-severe disease, aminosalicylates)

  • Maintenance of remission (moderate-to-severe disease, thiopurines and methotrexate)

  • Maintenance of remission (moderate-to-severe disease, corticosteroids)

  • Maintenance of remission (antibiotics)

  • Management of inadequate treatment response (mild-to-moderate disease)

  • Management of inadequate treatment response (moderate-to-severe disease)

  • Management of acute severe UC (evaluation)

  • Management of acute severe UC (corticosteroids)

  • Management of acute severe UC (advanced therapy)

  • Management of acute severe UC (antibiotics)

  • Management of acute severe UC (supportive care)

  • Management of acute complications

  • Management of anemia (iron supplementation)

  • Management of anemia (RBC transfusion)

  • Management of anemia (monitoring of recurrence)

  • Management of anemia (management of recurrence)

  • Management of anemia (management of non-IDA anemia)

  • Management of pouchitis (prevention)

  • Management of pouchitis (antibiotics)

  • Management of pouchitis (probiotics)

  • Management of pouchitis (immunosuppressive therapy)

  • Management of pouchitis (mesalamine)

  • Management of pouchitis (fecal microbiota transplantation)

  • Management of pouchitis (management of Crohn's-like disease)

  • Management of pouchitis (management of cuffitis)

Nonpharmacologic interventions

Physical activity: as per ESPEN 2023 guidelines, encourage endurance training in all patients with IBD. Advise appropriate physical activity (mainly resistance training) in patients with IBD with decreased muscle mass and/or muscle performance.
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  • Dietary modifications

  • Nutritional support (counseling)

  • Nutritional support (general principles)

  • Nutritional support (oral nutritional supplements)

  • Nutritional support (enteral nutrition)

  • Nutritional support (parenteral nutrition)

  • Nutritional support (management of malnutrition)

  • Nutritional support (energy requirements)

  • Nutritional support (protein requirements)

  • Nutritional support (micronutrient requirements)

  • Nutritional support (vitamin supplements)

  • Nutritional support (avoidance of dehydration)

  • Nutritional support (avoidance of refeeding syndrome)

  • Probiotics

Therapeutic procedures

Fecal microbiota transplantation: as per BSG 2025 guidelines, avoid offering fecal microbiota transplantation for induction or maintenance of remission in patients with moderate-to-severe UC.
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Perioperative care

Preoperative counseling: as per ASCRS 2021 guidelines, counsel patients with UC undergoing proctectomy regarding possible effects on fertility, pregnancy, sexual function, and urinary function.
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  • Perioperative nutrition

  • Postoperative thromboprophylaxis

Surgical interventions

Indications for elective surgery: as per ACG 2019 guidelines, consider elective proctocolectomy in patients with UC failing maximal medical management.
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  • Indications for urgent surgery (acute severe UC)

  • Indications for urgent surgery (toxic megacolon)

  • Indications for urgent surgery (uncontrolled bleeding)

  • Indications for urgent surgery (perforation)

  • Indications for urgent surgery (intestinal obstruction)

  • Surgical approach

  • Surgical technique

Specific circumstances

Pregnant patients, nutritional support
As per ESPEN 2023 guidelines:
Monitor iron status and folate levels regularly in pregnant patients with IBD and supplement iron and folic acid in case of deficiencies.
B
Monitor nutritional status regularly in patients with IBD when breastfeeding and supplement in case of deficiencies.
B
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  • Pregnant patients (surgical management)

  • Elderly patients

  • Patients with obesity (evaluation)

  • Patients with obesity (nutrition)

  • Patients with obesity (weight loss)

  • Patients with obesity (anti-obesity medications)

  • Patients with obesity (bariatric surgery)

  • Patients with ostomy

  • Patients with C. difficile infection (antibiotic therapy)

  • Patients with C. difficile infection (withholding immunosuppressive therapy)

  • Patients with C. difficile infection (fecal microbiota transplantation)

Preventative measures

Healthy diet: as per AGA 2024 guidelines, recognize that a healthy, balanced, Mediterranean diet rich in a variety of fruits and vegetables and decreased intake of ultra-processed foods are associated with a lower risk of developing IBD.
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  • Breastfeeding

  • Routine immunizations (general principles)

  • Routine immunizations (influenza)

  • Routine immunizations (SARS-CoV-2)

  • Routine immunizations (RSV)

  • Routine immunizations (pneumococcal)

  • Routine immunizations (meningococcal)

  • Routine immunizations (herpes zoster)

  • Routine immunizations (varicella)

  • Routine immunizations (rotavirus)

  • Routine immunizations (yellow fever)

  • Routine immunizations (hepatitis B)

  • Routine immunizations (other vaccines)

Follow-up and surveillance

Follow-up: as per AGA 2023 guidelines, consider using a monitoring strategy combining biomarkers and symptoms in patients with UC in symptomatic remission.
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  • CRC surveillance

  • Cervical cancer surveillance

  • Skin cancer surveillance