Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) that causes inflammation in the large intestine (colon), and it can be difficult to differentiate early UC symptoms from those of other IBDs and gastrointestinal conditions. The variety of early signs that people report can make it difficult to diagnose UC, says Jamil Alexis, MD, a gastroenterologist at Stamford Health in Connecticut.
Inflammation from UC can worsen over time, and symptoms may be mild at first. About 50 percent of people with ulcerative colitis have early symptoms, which often come and go, or are mild enough not to prompt medical attention.
“My ulcerative colitis patients have often had symptoms for several months,” says Robert Fearn, MD, a gastroenterologist at the University of California, Irvine Medical Center in Orange. “They often tell me their symptoms were initially dismissed as a passing bug or irritable bowel syndrome.” But it’s important to recognize early signs of ulcerative colitis so you can get diagnosed, start treatment, and prevent complications.
1. Blood in Your Stool
Blood in the stool is an important early symptom of ulcerative colitis, says Adam Pont, MD, a gastroenterologist in private practice in New York City. According to research, bloody diarrhea is the most common symptom that prompts people with UC to seek medical attention for the condition. In general, blood in the stool is abnormal and needs medical attention to assess the cause.
Along with blood, some people notice mucus in their stool. Passing the mucus that acts as a protective lining in your gastrointestinal tract can be normal if you’re not experiencing inflammation or seeing blood alongside it. But passing blood is typically caused by the effects of inflammation in the colon and rectum. “Ulcerative colitis causes inflammation and swelling of the bowel wall,” says Dr. Fearn.
2. Loose, Watery Stools
Diarrhea with or without visible blood is another common early symptom of ulcerative colitis. “One of the signs we look for is bloody diarrhea — where the blood is mixed in with the unformed stool, indicating a larger section of bowel is significantly inflamed,” says Fearn.
Passing loose, watery stools three or more times per day qualifies as diarrhea, but any loose stools that aren’t usual for you also counts. Diarrhea in UC happens because inflammation affects the colon in ways that prevent fluid absorption while letting extra fluid in, making stools themselves more liquid.
3. Cramping and Abdominal Pain
Cramping and abdominal pain with ulcerative colitis are typically due to irritation of the muscles in your colon wall, says Dr. Alexis, and over 70 percent of people with an IBD report abdominal pain.
This inflammation also triggers the stretch receptors of bowel nerves, which sense the presence of stool in the colon and can cause waves of cramping pain, says Fearn. At first, cramping and tenderness may feel mild and easily be passed off as gas or a pulled muscle. But if it continues, your healthcare provider may want to test for another cause, such as IBD.
4. Bloating
Bloating happens when gas gets trapped in your stomach and intestines, and it’s common in ulcerative colitis. Excess gas can build up because UC-related inflammation makes it difficult for your body to digest certain foods, like sugars and starches.
When these undigested foods get to your large intestine, bacteria break them down and create gas as a by-product. Besides poor digestion, excess gas and bloating in UC can also occur due to constipation, unbalanced gut bacteria (microbiome), heightened intestinal sensitivity, and food intolerances.
5. Bowel Habit Changes
Bowel movements follow a broad schedule that looks different for everyone. Some people poop every day, while others go only three times per week. But when you have ulcerative colitis, bowel movements can feel unpredictable and urgent.
“In healthy adults, the rectum can expand to hold just over 1 cup of stool,” says Alexis. “In ulcerative colitis, inflammation causes the rectum to become stiff and less able to accommodate stool over time, which leads to a more urgent need to pass stools and, in some cases, fecal incontinence.”
According to one research review, international surveys reveal that over 80 percent of people with UC report bowel urgency. Urgency is more common in people with active inflammation, but it can occur even when symptoms such as increased frequency and rectal bleeding have resolved.
Besides a more pressing need to visit the bathroom, UC can cause tenesmus, which describes feeling like you need to poop even when you don’t. This happens in up to 30 percent of people with UC or Crohn’s disease because the swelling in the large intestine irritates nerves that tell the brain you need to have a bowel movement.
“Even though ulcerative colitis is probably not the most common cause of any of these symptoms, you should definitely speak to your doctor should you experience any of them,” says Dr. Pont.
The Takeaway
Early signs of ulcerative colitis can be subtle and easily blamed on other causes, but early detection and treatment can protect against future complications.
The first symptoms of ulcerative colitis can include blood in the stool, diarrhea, abdominal pain or cramping, bloating, and bowel habit changes.
If you experience these symptoms, tell your healthcare provider, who can assess the likely cause and refer you to a gastroenterologist.
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Resources
Demase K et al. Mimics of Inflammatory Bowel Disease: Commonly Encountered Differentials of an Uncommon Condition. The Medical Journal of Australia. July 22, 2024.
AWARE-IBD Diagnostic Delay Working Group. Sources of Diagnostic Delay for People With Crohn’s Disease and Ulcerative Colitis: Qualitative Research Study Author. PLoS One. June 10, 2024.
Capobianco I et al. Adverse Food Reactions in Inflammatory Bowel Disease: State of the Art and Future Perspectives. Nutrients. January 25, 2024.
How Often and How Long Should It Take You to Poop? Cleveland Clinic. May 11, 2022.
Van Meegdenburg MM et al. Dyssynergic Defecation May Aggravate Constipation: Results of Mostly Pediatric Cases With Congenital Anorectal Malformation. The American Journal of Surgery. January 2015.
Ira Daniel Breite, MD, is a board-certified internist and gastroenterologist. He is an associate professor at the Icahn School of Medicine at Mount Sinai, where he also sees patients and helps run an ambulatory surgery center.
Dr. Breite divides his time between technical procedures, reading about new topics, and helping patients with some of their most intimate problems. He finds the deepest fulfillment in the long-term relationships he develops and is thrilled when a patient with irritable bowel syndrome or inflammatory bowel disease improves on the regimen he worked with them to create.
Breite went to Albert Einstein College of Medicine for medical school, followed by a residency at NYU and Bellevue Hospital and a gastroenterology fellowship at Memorial Sloan Kettering Cancer Center. Working in city hospitals helped him become resourceful and taught him how to interact with people from different backgrounds.
Abby McCoy is an experienced registered nurse who has worked with adults and pediatric patients encompassing trauma, orthopedics, home care, transplant, and case management. She is a married mother of four and loves the circus — that is her home! She has family all over the world, and loves to travel as much as possible.
McCoy has written for publications like Remedy Health Media, Sleepopolis, and Expectful. She is passionate about health education and loves using her experience and knowledge in her writing.
