Ulcerative colitis bloody stool

Cases report: severe colonic bleeding in ulcerative colitis is refractory to selective transcatheter arterial embolization

Ulcerative colitis (UC) is a chronic inflammatory condition affecting the mucosal layer of the colon. Up to 3% of UC patients, mainly those with pancolonic disease and in the setting of an acute flare , may develop acute severe lower gastrointestinal bleeding – usually attributed to diffuse mucosal ulceration – during the course of their disease. According to guidelines, it represents an indication of urgent colectomy ; indeed, this life-threatening complication accounts for up to 10% of all urgent colectomies for UC . However, morbidity and even mortality following urgent colectomy in this setting are not negligible . Improvements in interventional radiology techniques treating lower gastrointestinal bleeding have increased the expectancy of conservative treatments in this complication. In this sense, several studies show excellent results concerning technical and clinical success of superselective transcatheter embolization in lower gastrointestinal bleeding, avoiding surgery in more than two-thirds of patients . However, patients with inflammatory bowel disease (IBD) are generally excluded from these series; to our knowledge, only one case of a patient diagnosed with long-standing UC and a massive haemorrhage successfully treated with transcatheter arterial embolization has been published up to date . However, the authors could not demonstrate that the colonic haemorrhage was due to a UC exacerbation, as colonoscopy did not show any mucosal ulceration. Hereby, we present a single centre experience of all three cases of massive haemorrhage in UC patients treated with transcatheter arterial embolization since 2011. Written informed consent was obtained from all patients.

Case reports

Case report #1, January 2011

A 27-year-old Caucasian woman was admitted to the Emergency Department of our Institution because of bloody diarrhoea – up to 10 bowel movements per day – during the last month, 3 weeks after quitting smoking. Physical examination showed no abnormalities but confirmed haematochezia on digital rectal examination. Colonoscopy showed continuous severe colonic inflammation with small ulcers from the anus to the descendent colon, classified as grade 3 in Mayo endoscopic sub-score and 3 points in Ulcerative Colitis Endoscopic Index of Severity (UCEIS); complete examination was not performed because of the risk of perforation. Empirical antibiotic treatment with ciprofloxacin and metronidazole, as well as oral and rectal mesalamine were started and partial symptomatic improvement was achieved. Venous thrombosis prophylaxis with subcutaneous enoxaparin, 40 mg per day, was started. At admittance, haemoglobin, white cell count, platelets, fibrinogen and C reactive protein (CRP) were within the reference range. Stool cultures were negative. Cytomegalovirus (CMV) infection was also ruled out in colonic biopsies (polymerase chain reaction – PCR – and, later, immunohistochemistry). As bloody diarrhoea persisted 48 h later, and histopathological examination of colonic biopsies showed crypt distortion, a mixed inflammatory infiltrate of the lamina propria and crypt abscesses suggesting the diagnosis of UC, intravenous methylprednisolone (1 mg per kg of weight, daily) was started. After 3 days of corticosteroids the patient achieved partial clinical response (6 bowel movements per day, Edinburgh index 2 points, CRP within the normal range); nevertheless, 2 weeks later infliximab therapy (5 mg/kg of weight) was started due to sustained clinical activity, with 10 bloody bowel movements per day and a progressive increase of CRP levels, up to 10 mg/dL. Three days after the first dose of infliximab, the patient presented a massive lower bleeding with haemodynamic instability and severe anaemia; CT scan showed active arterial haemorrhage from ascendant colon; a subsequent arteriography demonstrated active arterial bleeding from a colic branch of the superior mesenteric artery; selective transcatheter embolization with platinum microcoils (MicroNester©, Cook Medical) was performed with immediate technical success; nevertheless, the patient persisted with rectal bleeding 2 days after embolization, requiring laparoscopic subtotal colectomy and ileostomy. Pathological evaluation of the colon confirmed the diagnosis of UC. Eight days after surgery the patient was discharged.

Case report #2, December 2016

A 39-year-old Caucasian women diagnosed with pancolonic UC 3 months earlier was admitted into our department because of a severe flare of the disease and an associated Clostridium difficile infection. She had started treatment with 160 mg of adalimumab due to steroid-dependent disease 9 days before, after performing a rectosigmoidoscopy which showed erythema, lack of vascular pattern, friability, erosions and aphtae (grade 2 of Mayo endoscopic sub-score, 3 points in the UCEIS index); complete examination was not performed because of the risk of perforation. CMV infection was ruled out in rectal biopsies. Laboratory findings showed haemoglobin of 12.3 g/dL, 14.500 leucocytes per mL, fibrinogen of 873 mg/dL, serum creatinine of 1.18 mg/dL, and CRP of 9.2 mg/dL. Metronidazole was started and a second dose of adalimumab was administered. Venous thrombosis prophylaxis with subcutaneous enoxaparin, 40 mg per day, was started. As fever, bloody diarrhoea and abdominal pain persisted, intravenous corticosteroids at 1 mg per kg of weight dosage were started; the patient was also switched to intravenous infliximab at 10 mg per kg of weight. CMV PCR in blood samples was negative, and faecal samples ruled out Clostridium difficile persistence. After 3 days partial response was observed – 3 bloody stools per day, no colonic dilation on abdominal X-ray (Edinburgh index 0 points), CRP 5.6 mg/dL – and a second infliximab infusion at 10 mg per kg of weight was administered 4 days later. After 12 h she presented massive lower haemorrhage, hypotension, tachycardia and severe anaemia needing supportive intervention with intravenous fluids and packed red blood cells transfusion. A CT scan showed active arterial bleeding in the ascendant colon; subsequent arteriography showed active arterial bleeding from a colic branch of the superior mesenteric artery that could be embolized with polyvinyl alcohol particles (Contour TM, Boston Scientific), with immediate technical success. Although clinical situation became steady, 6 days later she developed a massive haemorrhage; finally, urgent laparoscopic subtotal colectomy and terminal ileostomy were done. Clinical evolution was favourable, and the patient was discharged with corticosteroid tapering. Pathological evaluation of the colon confirmed the diagnosis of UC without infectious complications or dysplasia.

Case report #3, January 2018

A 42-year-old Hispanic woman with history of autoimmune hypothyroidism and uncomplicated Caesarean section 6 weeks before, was admitted to our hospital because of fever, abdominal pain and bloody diarrhoea – confirmed after digital rectal examination – with up to 8 bloody bowel movements per day for the last 4 days. Physical examination also showed diffuse abdominal tenderness without signs of peritonitis. Laboratory exam showed haemoglobin of 9.2 g/dL, leucocytes 11.610 per mL, fibrinogen of 828 mg/dL, CRP of 4.4 mg/dL and ALT of 127 UI/mL, with no other significant alterations. A CT-scan ruled out obstetric complications, showing marked oedema of rectum and sigmoid colon; rectosigmoidoscopy showed severe inflammation (grade 3 in Mayo endoscopic sub-score; 5 points in UCEIS index) with deep and large ulcers affecting the whole circumference from rectum to 45 cm from anus, erythema and erosions; complete examination was not performed because of the risk of perforation. Despite negative stool cultures, ciprofloxacin and metronidazole was initiated, as well as oral (4 g per day) and topical mesalamine (1 g per day), with favourable response. Histopathological examination of colonic biopsy specimens showed crypt distortion, a mixed inflammatory infiltrate of the lamina propria and crypt abscesses, suggesting UC. After 6 days of therapy, she presented a lower massive gastrointestinal bleeding, with haemodynamic instability and severe anaemia needing supportive intervention with intravenous fluids and packed red blood cells transfusion. Corticosteroids at 1 mg per kg of weight dosage were started. Urgent CT-scan showed active arterial bleeding in the sigmoid colon; subsequent arteriography performed 16 h from the beginning of symptoms showed active bleeding from a branch of the inferior mesenteric artery. After selective catheterization, embolization with polyvinyl alcohol particles (Contour TM, Boston Scientific) was performed with immediate technical success, as demonstrated by complete occlusion of the bleeding vessel confirmed by a control radiographic series with the injection of contrast in the inferior mesenteric artery. However, 5 h after the procedure she restarted with persistent bleeding, abdominal pain, need for additional packed red blood cells transfusion and, finally, urgent open subtotal colectomy and terminal ileostomy was performed. Pathological evaluation of the colon showed signs of UC without infectious complication or dysplasia.

Ulcerative colitis stool: A visual guide

The following treatments for UC reduce inflammation that leads to stool symptoms:

  • Aminosalicylates, which are drugs that target inflammation in the lining of the colon.
  • Corticosteroids, which are powerful, fast-acting anti-inflammatories used to treat UC flare-ups.
  • Immunomodulators, which are drugs that regulate the immune system.
  • Biologics, which target inflammation in the gut.

Treating diarrhea

People with IBD should avoid taking antidiarrheal medications.

Antidiarrheal drugs can increase the risk of a complication called megacolon, in which digestive gases become trapped in the colon, causing it to swell. In some cases, this can be fatal.

The safest way to treat diarrhea is to make dietary changes. Many people with UC experience diarrhea after eating specific foods.

Keeping a food diary along with a daily record of stool symptoms can help people identify and eliminate these trigger foods.

Reducing blood in stools

A recent study suggests that a prebiotic supplement may help reduce bloody stools and other symptoms of UC.

Participants taking the prebiotics supplement experienced significantly decreased abdominal pain and cramping. They also reported reduced nausea, vomiting, diarrhea, and blood in stools, although these effects were not statistically significant.

The study was small, so more research is needed to determine the best way to reduce blood in stools.

If a person frequently has bloody stools, a doctor may prescribe iron supplements to help prevent anemia.

Treating constipation

Share on PinterestKeeping a food diary can help identify the cause of the symptoms.

The International Foundation for Gastrointestinal Disorders (IFFGG) recommend the following treatments for mild constipation:

  • drinking plenty of fluids
  • eating fibrous foods, such as uncooked fruits and vegetables
  • eating whole-grain bread and cereals

However, many people with UC find that fibrous foods and whole grains trigger other symptoms, so keeping a food diary can help people identify which foods cause which symptoms.

Other methods for relieving constipation include:

  • Squatting while having a bowel movement: Sitting with the knees higher than the hips when using the toilet can help align the rectum, making stools easier to pass.
  • Exercising: Exercise helps speed up the movement of stools through the colon.
  • Taking laxatives: Doctors may recommend osmotic laxatives for people with IBD. These increase water availability in the colon, which helps to soften stools.

However, people with UC should talk to a doctor before taking laxatives, as these medications can increase wind and stomach cramps.

Managing bowel incontinence

Many people who experience bowel incontinence find it difficult to discuss the issue with a doctor.

However, a doctor may be able to identify the underlying cause of a leaky bowel and can offer advice on how to control and manage this symptom.

Some suggestions for managing bowel incontinence include:

Bowel retraining

People who experience a sense of urgency may benefit from delaying bowel movements. This technique is called bowel retraining.

Although bowel retraining may be difficult at first. Over time, however, it will help build up strength and control over the rectum and sphincter muscles.

Pelvic floor exercises

The pelvic floor muscles support the pelvic organs, which include the bladder and bowel, as well as the uterus in women.

Pelvic floor exercises can help strengthen the muscles around the anus, reducing incontinence. To find the pelvic floor muscles, imagine stopping a urine stream or practice while urinating.

To perform pelvic floor exercises, contract and hold the pelvic floor muscles for a count of 3, and then relax the muscles, while slowly counting to 3. Avoid pushing out the muscle during the relaxation stage.

Repeat this 15 times to complete one set of exercises. Aim to complete three sets each day.

An ulcerative colitis (UC) diagnosis can bring about changes you never thought you’d face. But, if you’re newly diagnosed, or even if you’ve had your diagnosis for a while, how do you know what’s normal and what’s cause for alarm when it comes to UC?

What UC Symptoms Are Considered ‘Normal?’

The Crohn’s and Colitis Foundation describes the symptoms of UC as:

  • Loose bowel movements
  • Persistent diarrhea accompanied by blood in the stool
  • Abdominal pain
  • Generally bloody stool
  • Crampy abdominal pain

Not the most fun list, but it leaves a lot to be interpreted by you, the patient. For instance, how “bloody” is too bloody? How much pain is too much pain? What if you’re not having bowel movements at all?

There’s a variety of symptoms that are considered either indicative of UC or “normal.” Some symptoms of UC that may be a new normal, but not necessarily a flare. How can you determine what’s normal and what’s a sign of trouble?

Define Your Normal With UC

“Normal” when you have UC is completely subjective to you. That’s probably not the answer you’re looking for, but I’ll share my experience to help you determine your normal.

My normal with UC is:

  • Constipation. There are days I really struggle to have a bowel movement due to constipation. I usually cycle on and off with Miralax when I need it.
  • Fatigue. I’m tired most days, but I’m not so fatigued that I can’t perform at my job or take care of other responsibilities.
  • Hemorrhoids. I can’t seem to shake them. My hemorrhoids are concentrated around my rectum, and I usually wind up breaking them open when I have a bowel movement. So, bright-red blood in my stool is normal.
  • Mild cramps. After eating a trigger food, I get mild cramps that mimic the cramps you get right before diarrhea, but they subside after a few minutes or so.

This is my version of normal, and it may not be the same for you. I determined that these symptoms were “normal” for me by doing the following:

  • Asking my gastroenterologist (GI) about it. I asked about seeing blood in my stool, about the cramps, and about the fatigue. She found the hemorrhoids, which answered the blood question, but I keep an open line of communication with her in case things go haywire.
  • Looking at my stool. This might sound gross, but I do it every time I have a bowel movement. That way I know how much blood came out, if there’s any mucous, and how formed my stools are. You can even find apps to help you keep track of these types of symptoms.
  • Rating my days. On particularly good and bad days, I make sure to give the day a rating on my own scale (mine’s a basic 1 – 10, with 10 being awesome). If I have a lot of bad days (2-3) in a row, I check in with my GI.

What UC Symptoms Are Cause for Concern?

What’s not normal for UC, again, depends on the person. My abnormal symptoms have included:

  • Severely painful stomach spasms. So painful that I cried out and spent hours wrestling with the cramps to no avail.
  • Lots of blood in my stool. I saw tablespoons of blood with each bowel movement — or in place of a bowel movement, only blood.
  • More than three watery bowel movements in a day. If I have more than three and they’re starting to become loose and watery, I know that’s not normal.

In these cases, I seek medical attention.

If you’re experiencing not-so-normal symptoms, I recommend avoid Googling your symptoms and visiting WebMD if a symptom is worth going to a hospital over. You’ll likely only see horror stories or hear about someone’s near-death experience, which isn’t typically indicative of what you’re experiencing.

What to Do When UC Symptoms Are Abnormal or Severe

What do you do once you’ve determined that the symptoms you’re experiencing don’t fit into your realm of “normal?” If your abnormal symptoms are manageable, meaning that you might feel icky, but can still somewhat function, call your GI doctor.

If your particular doctor is unavailable, call the on-call GI doctor. Let them know what you’re experiencing and ask them to get back to you as your symptom isn’t normal. You can always leave a message with a nurse or contact your GI through an online portal if you can’t get ahold of them on the phone.

In cases when your symptoms are severe (e.g., my severe stomach spasms), go to the emergency room. That means if you’re unable to walk, move, or speak due to pain or cramping, or if you’re incoherent, the emergency room is your best bet. However, in cases where you might be seeing more blood than usual, or your pain level is slightly elevated, there’s not much an emergency room can do for you, and, more often than not, they may send you home. Always defer to your GI doctor, unless what you’re experiencing is causing severe dehydration, bleeding, or pain.

The Crohn’s and Colitis Foundation says you should seek immediate medical attention if you have:

  • Heavy, persistent diarrhea
  • Bleeding from the rectum and blood clots in your stool
  • Constant pain
  • A high fever

The Bottom Line

Living with UC means dealing with a variety of symptoms, which can often be confusing and induce anxiety. When in doubt, talk to your doctor if you’re worried something isn’t normal.

See more helpful articles:

10 Questions to Ask Your Doctor About Your Ulcerative Colitis

Sick and Tired: How to Deal With Fatigue When You Have Ulcerative Colitis

When Food Attacks: How I Roll With the Gut Punches of Ulcerative Colitis

Symptoms of Ulcerative Colitis

UC can cause a variety of symptoms. Weight loss is common. People with UC typically experience one or more of the following:

  • abdominal pain and cramping
  • diarrhea or constipation
  • bleeding or discharge from your rectum
  • anemia and fatigue
  • joint pain or clubbing of fingers

Cramps and abdominal pain

If you have UC, you may experience abdominal pain with cramping. It can range from mild to severe.

Anti-spasmodic medications might help relieve your pain. Heating pads and rest may also provide relief. Sometimes, your cramping may be severe enough that you need prescription medications to manage it.

Diarrhea

Another common symptom of UC is diarrhea. In some cases, it may contain blood, pus, or mucus.

You may experience sudden urges to defecate that are difficult to control. Incontinence can happen as well. These urges may occur up to 10 times per day and sometimes at night. This may compel you to plan your days around your bathroom breaks. In some cases, it may even lead you to become homebound.

Medications may help you control diarrhea, but it’s important to talk to your doctor before taking any over-the-counter drugs. Some common anti-diarrheal medications may make your condition worse.

Constipation and tenesmus

It’s also possible to experience constipation as a result of UC but it’s significantly less common than diarrhea.

You might also experience tenesmus. This is a feeling of incomplete evacuation, or the need to have a bowel movement even when you’ve recently emptied your colon. It may cause you to strain and cramp up.

Stool bulking drugs, such as psyllium husk (Metamucil, Fiberall), may help control these symptoms.

Rectal bleeding and discharge

UC often causes bleeding or mucus discharge from your rectum. You may find spots of blood or mucus in your toilet or on your clothing. Your stool may also become very soft and bloody or contain red streaks or mucus. You may also experience pain in your rectal area, as well as a persistent feeling of needing to have a bowel movement.

Anemia and fatigue

If you experience frequent bleeding in your gastrointestinal tract, you may develop anemia. This complication of UC can result in fatigue. Even without anemia, fatigue is a common symptom among people with UC.

Anemia-related fatigue is different than just being tired. If you develop significant anemia, you won’t feel refreshed after resting. Your breathing may become labored. Even simple activities may seem challenging. Other potential symptoms of anemia include:

  • dizziness
  • headaches
  • pale skin

To diagnose anemia, your doctor will likely order a blood test. They may encourage you to take over-the-counter iron supplements or prescribe other treatments.

Joint pain and clubbing of fingers

If you have UC, you may develop aching joints that commonly involve your low back, hips and knees, but can affect other joints as well. UC can also affect your skin, eyes, liver and lungs. In some cases, clubbing of your fingers may occur. Potential symptoms of clubbing include:

  • downward curving of your nails
  • increased roundness and widening of your nails
  • increased angle between your nails and cuticles
  • bulging of the tips of your fingers
  • warmth or redness of the tips of your fingers

Mucus colitis: A common gastrointestinal disorder involving an abnormal condition of gut contractions (motility) and gut sensation (hypersensitivity) characterized by abdominal pain, bloating, mucous in stools, and irregular bowel habits with diarrhea or constipation or alternating diarrhea and constipation, symptoms that tend to be chronic and to wax and wane over the years. Although the disorder can cause chronic recurrent discomfort, it does not lead to any serious organ problems.

Making the diagnosis usually involves suspecting and making a positive diagnosis and excluding other illnesses. Treatment is directed toward relief of symptoms and includes changes in diet (eating high fiber and avoiding caffeine, milk products and sweeteners), exercise, relaxation techniques, and medications.

Alternative names include irritable bowel syndrome (IBS), nervous colon syndrome, and spastic colitis.

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Causes

Many types of digestive problems can make more mucus show up in your poop. Some are serious and long-lasting. Others, like food poisoning, can clear up quickly. A few examples:

Irritable bowel syndrome (IBS). The main symptoms may be constipation (IBS-C), diarrhea (IBS-D), or alternating diarrhea and constipation (IBS-M). It’s typical to see mucus in your poop if you have this condition.

Ulcerative colitis. This type of inflammatory bowel disease (IBD) causes sores in the intestines. They can bleed and make pus and mucus, which you might see when you go to the bathroom. It also often causes diarrhea, belly pain, and cramping.

Proctitis. This is inflammation of the lower part of your large intestine, called the rectum. Sexually transmitted infections, foodborne illnesses, and IBD can cause it.

C. difficile (c. diff ). Infection with this type of bacteria can cause severe, even life-threatening diarrhea. It smells very bad and often has mucus.

Food poisoning. If you get flu-like symptoms and your poop has blood or mucus in it, you may have food poisoning.

Other infections. An infection with other bacteria or parasites can also cause the problem. Dysentery is one example.

Rectal cancer. One of the main signs of rectal cancer is bleeding, but you may also have mucus.

Inflammatory Bowel Disease Clinic

Ulcerative colitis

Ulcerative Colitis (UC) is one of the two main forms of Inflammatory Bowel Disease (IBD).

Ulcerative Colitis (UC) is a condition that causes inflammation and ulceration of the inner lining of the rectum and colon (the large bowel). Inflammation is the body’s reaction to injury or irritation, and can cause redness, swelling and pain. In UC, tiny ulcers develop on the surface of the lining and these may bleed and produce pus.

The inflammation usually begins in the rectum and lower colon, but it may affect the entire colon.

WHAT ARE THE SYMPTOMS?

UC may range from mild to severe, and will vary from person to person. Please refer to Clinical Presentation for the list of the most common symptoms.

WHAT ARE THE DIFFERENT TYPES OF ULCERATIVE COLITIS?

Ulcerative Colitis (UC) is generally categorized according to how much of the colon is affected.

Proctitis

In proctitis, only the rectum is inflamed. This means that the rest of the colon is unaffected and can still function normally. For many people with proctitis the main symptom is passing fresh blood, or blood stained mucus. You may get diarrhea, or you may have normal stools or even constipation. You may also feel an urgent need to rush to the toilet. Some people with proctitis often feel that they have an urge to pass a stool, but cannot pass anything because the bowel is actually empty. This is called tenesmus.

Proctosigmoiditis

In some people, the sigmoid colon (the short curving piece of colon nearest the rectum) may also be inflamed – a form of UC sometimes known as proctosigmoiditis. The symptoms are similar to those of proctitis, although you are less likely to have constipation with proctosigmoiditis.

Left-sided (distal) colitis

In this type of UC the inflammation starts at the rectum and continues up the left side of the colon (also known as the distal or descending colon). Symptoms include diarrhea with blood and mucus, pain on the left hand side of the abdomen, urgency, and tenesmus.

Pancolitis (extensive, total colitis)

Pancolitis extends along most of the colon. Extensive or total colitis can cause very frequent diarrhea with blood, mucus, and sometimes pus. You may also have severe abdominal cramps and pain, tenesmus, and weight loss. In milder flare-ups the main symptom may be diarrhea or looser stools without blood.

Very rarely, when the inflammation is severe, digestive gases may get trapped in the colon, making it swell up. This is known as toxic megacolon and it can cause a high fever as well as pain and tenderness in the abdomen. It is essential to get treatment quickly for this condition, as it may need surgery.

CAN ULCERATIVE COLITIS AFFECT OTHER PARTS OF THE BODY?

Ulcerative colitis (UC) can cause complications (extra problems) outside the digestive system. Over a third of people with ulcerative colitis develop other conditions, mainly affecting the joints, eyes and skin. Refer to the Extraintestinal Manifestations section for more information.

You may find helpful information available in the IBD diagnostics, IBD treatment and IBD and lifestyle sections.

Is This Normal? Ulcerative Colitis Symptoms, Explained

This overview can help you better understand your ulcerative colitis symptoms and know when it’s time to check in with your medical team.

  • Bloody stools “This is the hallmark symptom of ulcerative colitis,” Swaminath says. The disease causes open sores in the large intestine, which can become irritated to the point of bleeding. “It’s important to recognize that there is a difference between hemorrhoidal bleeding, which is a little blood on the toilet paper when you wipe, and the bleeding of ulcerative colitis, which tends to be more dramatic, with blood actually in the stool,” he explains. Whenever you experience bloody diarrhea with mucus or pus, or if the bleeding seems to be coming directly from your rectum, you should discuss it with your doctor.
  • Urgency The average person might form stools anywhere from three times a week to three times a day, with a reasonable amount of time between awareness of stool in the rectum and needing to get to the bathroom, Dr. Raymond says. With ulcerative colitis, you may have little time to reach a toilet. “Inflammation in the rectum associated with ulcerative colitis is very uncomfortable, so when the stool hits that area, most people with ulcerative colitis have to find a bathroom right away,” Swaminath says. And this can really affect quality of life. In fact, urgency is so prevalent among people with ulcerative colitis that many map out restroom locations before they leave the house or use smartphone apps to locate bathrooms when they’re out on the town. But that doesn’t mean the symptom should be ignored. Urgency warrants a call to your doctor when you can no longer make a socially appropriate bathroom visit, Raymond says.
  • Loose stools People with ulcerative colitis also tend to have intermittent diarrhea. This may progress from an episode now and then to experiencing loose stools almost every time you go.
  • Abdominal pain “Ulcerative colitis tends to cause low abdominal cramping,” Raymond says. If that cramping becomes severe or suddenly worse, call your doctor.
  • Worsening symptoms “People with a more slowly developing course of ulcerative colitis usually notice their symptoms gradually getting worse,” Swaminath says. “You may first see a little blood in your stool and then notice you are going to the bathroom a little more frequently. Over time, you may go from twice a day to three to four times a day to waking up in the middle of the night to go.” If you see a noticeable change in your symptoms, you could be experiencing a flare; always check in with your doctor.
  • Weight loss People with ulcerative colitis often experience loss of appetite and have trouble absorbing nutrients from the foods they eat — and that means they may lose weight, the CCFA explains. This can lead to fatigue and low energy as well. Some weight loss with ulcerative colitis can be expected, but you should still address any weight loss with your doctor to make sure you’re getting the nutrients you need.
  • Inflammation elsewhere in the body As an autoimmune disease, ulcerative colitis can cause inflammation beyond the intestines. “These extra-intestinal manifestations, as we call them, can include painful welts typically on the shins, inflamed joints, or aphthous ulcers: painful little white sores on the inside of your cheeks or on your tongue,” Swaminath says. If you have these symptoms, even without bowel issues, let your doctor know, he adds.
  • Periods of time without symptoms Ulcerative colitis symptoms tend to come and go, with periods of flares followed by remission. When you’re in remission, it’s perfectly normal to be symptom-free for months or even years, according to the CCFA. To try to stay in remission and avoid an ulcerative colitis flare, keep taking your medication as prescribed.

The best strategy for understanding your ulcerative colitis symptoms is to have an open, honest conversation with your doctor. “Bloody diarrhea, urgency, weight loss, and fatigue associated with ulcerative colitis can take a real toll on your quality of life,” Swaminath says. To get the most targeted, appropriate treatment for you, be as honest and as clear as possible in your communications with your healthcare team.

Types of Ulcerative Colitis

Becoming well-informed about your chronic illness is a helpful part of your journey. It is important to learn all you can about your diagnosis and how it may affect you. We can help you understand the different types of ulcerative colitis, as well as the common symptoms and complications.

Ulcerative colitis is a chronic illness that can affect different parts of the colon and rectum. There is a wide array of symptoms and complications depending on the extent of your disease and the type of ulcerative colitis you have.

Getting diagnosed with a chronic, lifelong disease is overwhelming. It is important to learn all you can about your diagnosis and how it may affect you. We can help you understand the different types of ulcerative colitis, as well as the common symptoms and complications.

Ulcerative Proctitis

In ulcerative proctitis, bowel inflammation is limited to the rectum. This condition typically affects less than six inches of the rectum, and it is not associated with an increased risk of cancer.

Symptoms may include:

  • Rectal bleeding

  • Rectal pain

  • Urgency in your bowel movements

Left-Sided Colitis

In this form of ulcerative colitis, continuous inflammation begins at the rectum and extends as far into the colon as the splenic flexure, which is a bend in the colon near the spleen. Left-sided colitis also includes proctosigmoiditis, which affects rectum and the lower segment of colon located right above the rectum known as the sigmoid colon.

Symptoms may include:

  • Loss of appetite

  • Weight loss

  • Bloody diarrhea

  • Pain on the left side of the abdomen

Extensive Colitis

This type of ulcerative colitis affects the entire colon. Continuous inflammation begins at the rectum and extends beyond the splenic flexure.

Symptoms may include:

  • Loss of appetite

  • Bloody diarrhea

  • Abdominal pain

  • Weight loss

These contractions help move food through your digestive tract, but if they’re too strong and long-lasting, you might wind up with IBS-D, which stands for irritable bowel syndrome with diarrhea. If your muscle contractions are too weak, you may deal with IBS-C, which is IBS that causes constipation. If it’s really a toss-up depending on the day, welcome to life with IBS-M, or IBS involving a mix of both constipation and diarrhea. No matter your kind of IBS, you may also experience abdominal cramping, gas, and mucus in your stool.

If you have IBS-D or IBS-M, you might get diarrhea and have other symptoms during flare-ups, which can be triggered by stress, foods including wheat, dairy, and citrus, or hormonal changes like being on your period. As with many of the other issues on this list, if IBS is forcing your stool to rush through your body too quickly, you can wind up with green diarrhea.

If you’ve been diagnosed with IBS-D or IBS-M and you pretty much have things under control, you don’t need to freak out over the occasional green poop. But if you’re regularly having green diarrhea, and it seems to be linked with things like eating certain foods or feeling overwhelmed with stress, it’s a good idea to check in with your doctor. Together, you may be able to figure out if there’s more you can do to avoid flare-ups.

5. You have Crohn’s disease or ulcerative colitis.

Though these inflammatory bowel diseases have various differences, they can both make you more prone to diarrhea that might look green.

Crohn’s disease causes irritation in your digestive system, usually in your small intestine and the beginning of your large intestine, according to the National Institute of Diabetes and Digestive Kidney Diseases. Diarrhea is a major symptom, and it can be green because of undigested bile, Dr. Shen says. If you have Crohn’s, you might also experience other symptoms like stomach pain, fatigue, fever, weight loss, bloody poop, reduced appetite, and malnutrition, according to the Mayo Clinic.

Ulcerative colitis happens when you have inflammation and sores in your digestive tract, usually in your large intestine and rectum, according to the Mayo Clinic. In addition to diarrhea, you might experience abdominal cramping, rectal pain, a sensation of really needing to poop, bleeding when you do actually poop, weight loss, fatigue, fever, and other unpleasant symptoms.

Much like with IBS, doctors aren’t exactly sure of what causes inflammatory bowel diseases. And, unfortunately, treating these conditions may require some trial and error. If you’re dealing with persistent poop problems, stomach pain, and anything else that seems concerning, see your doctor to see if you have an inflammatory bowel disease.

6. You’re taking iron supplements.

First things first: You should only take iron supplements if your doctor says they’re necessary due to an issue like iron deficiency anemia. This happens when you lack enough iron for your body to create hemoglobin, a protein that’s essential for healthy red blood cells. If you start taking iron supplements without a doctor’s guidance, you might accidentally ingest too much and wind up with symptoms like nausea and vomiting, so you shouldn’t just decide to take them out of nowhere.

Now that you know that, if you do need to take iron supplements, keep in mind that they can cause green or black poop, Dr. Bedford says. If your poop is black, it actually may be a sign that your body is absorbing the iron properly, according to the U.S. National Library of Medicine. On the other hand, green poop when you’re taking iron supplements may be a sign your body isn’t absorbing the nutrient properly, Dr. Bedford explains, in which case you should talk to a doctor to see if you need to adjust your formulation or dosage.

7. You recently had your gallbladder removed.

Now, for the last stop on the bile train: Removal of your gallbladder, which stores bile, can result in green poop. This pear-shaped organ might need to be removed if you have gallstones, which are hard deposits of material that can block the flow of bile and cause a world of hurt. Also known as a cholecystectomy, this is one of the most common surgeries in the United States.

The Scoop on Poop

Answers to 7 FAQs

From diet to disease, many things affect your poop. If you have any concerns that your stool is abnormal, then visit your physician.

1. What is poop made of?

In a typical bowel movement, about 75% of the stool volume is water. The other 25% is a mixture of things, primarily dead and living bacteria, food waste, as well as undigested parts of foods, typically fibrous foods such as seeds, nuts, corn, and beans, and substances contributed by the intestines and liver, such as mucus and bile (a dark green to yellowish-brown fluid). Many things can affect the balance of stool content, including diet, medications, supplements, and the presence of a GI disease, disorder, or infection.

2. What is a healthy bowel movement?

An ideal stool is medium-brown, long, smooth, and soft, which passes easily from the body with little straining or effort. Healthy individuals typically have bowel movements anywhere between three per day and three per week. More than three per day is often associated with diarrhea, and fewer than three per week typically suggests constipation, although there must be other symptoms present before the stool strictly qualifies as either diarrhea or constipation. Ideal stool requires little effort and no straining for elimination.

3. What does the colour of my poop mean?

Brown: Healthy bowel movements tend to be brown, due to the presences of bile and bilirubin, which is a product resulting from dead red blood cells being broken down in the intestine.

Black: If your stool is black, it is important to see your doctor, as it could be a sign of internal bleeding from higher in the digestive tract, especially if it smells foul and is tarry. However, there are many benign causes of black stool, including ingesting something with bismuth subsalicylate such as Pepto-Bismol® (which can also turn your tongue black), iron supplements, black liquorice, blueberries, or other darkly coloured foods.

Red or Maroon: If you are bleeding in the lower portion of the digestive tract, then this could cause bright red stool. Bleeding could be a result of inflammatory bowel disease, diverticulitis, hemorrhoids, fissures, polyps, or colorectal cancer. However, a red stool might be unrelated to bleeding, since consuming large amounts of foods with red colouring, such as cakes or colourful packaged breakfast cereals, tomato-based sauce and soup, and beets can also colour your stool red.

Orange: If you consume excess beta-carotene from supplements or produce, such as carrots, sweet potato, squash, some leafy greens, and some herbs, then your stool can appear orange.

Yellow/Pale Brown/Grey: Bright yellow diarrhea can signify a condition known as Giardiasis (see sidebar). Stool that is yellow or pale can also result from reduced production of bile salts, since a normal, brown-coloured stool acquires its hue from breaking down bile. Pale stool (yellow or grey) can signify a problem with the liver or gallbladder, so if you have persistently light-coloured stool, then you should see your physician.

Green: Most often, green stool is the result of ingesting large quantities of green foods, such as leafy greens or foods with green colouring added. Iron supplements may also cause the stool to become green. However, green stool could also signify a colonic transit time that is too fast. Bile usually becomes darker as it passes through the large intestine but stays green if it moves through too quickly.

Giardiasis

Giardiasis is an infection caused by the most commonly reported (5-10% of Canadians and their pets) intestinal parasite in North America and the world, Giardia lamblia. Individuals most often contract it through consumption of contaminated water or exposure to an infected person. Its symptoms include abdominal pain, diarrhea, nausea or vomiting, loss of appetite, swollen abdomen, gas, headache, and fever. If you experience some of these symptoms, visit your doctor, as effective treatment is readily available.

4. Is the texture of my bowel movement normal?

The Bristol Stool Chart is the most useful tool developed for assessing the texture and shape of your stool. On a scale of 1-7, you rate your stool on how solid or liquid it is. For instance, small, hard lumps that are difficult to pass would be a 1, and entirely liquid would be a 7. On this scale, 1-2 could signify constipation, 3-5 are healthy stools, and 6-7 point to diarrhea.

5. Why do some stools float and others sink?

Most stool sinks because the contents of feces tend to be denser than water. However, some stool just floats and, generally, this is nothing of concern, as it is usually the result of gas within the fecal matter, or a high fibre intake. Excess fat in the stool (steatorrhea) can also cause feces to float. This is especially common in individuals who have GI conditions that affect fat absorption, such as celiac disease or Crohn’s disease, but can also happen in healthy individuals who consume large quantities of fat, which is likely the cause if the stool is also oily and foul smelling.

6. Why does it hurt when I have a bowel movement?

There are many reasons why defecation might cause pain. Depending on the type and severity of the pain, it could be anything from what you ate to an irritated hemorrhoid. In rare cases, a tumour in the intestine could make bowel movements painful. If you have any concerns about persistent pain, see your physician. Here are some common causes:

  • Constipation is the most common cause of pain; if your stools are hard and difficult to pass, this could be the culprit
  • Diarrhea can also cause cramping, leading up to elimination
  • If you eat too much spicy food, the oils can stay in your stool and cause burning upon defecation, in the same way that they can make your mouth burn when you eat them
  • Hemorrhoids, anal fissures (tears in the anus), and abscesses can cause pain and bleeding
  • Bowel conditions, such as irritable bowel syndrome, celiac disease, inflammatory bowel disease (Crohn’s disease and ulcerative colitis), and colorectal cancer can also cause pain
  • Severe pain while experiencing bowel movements could signify a tumour obstructing the rectum or anus

7. Why does my poop smell so bad?

The first thing to remember is that what goes in also comes out, so if you had a spicy meal, chances are you’ll smell it strongly when it exits. Meat produces more smell than vegetables and intestinal bacteria produce several sulphur-containing compounds that are the primary smelly culprits along with fatty acids and skatole, a product resulting from the naturally-occurring process of amino acids being broken down in the intestine. The human nose can detect hydrogen sulphide in concentrations as low as one-half part per billion, making it easy for us to smell stool! Malabsorption, particularly of fats (see FAQ 5), can cause a stronger odour, so talk to your doctor if this persists.

Animals and Poop

  • The white part of bird stool is actually the bird’s version of urine. Birds have only one hole for defecation and “urination”. The white part is uric acid, which is not very soluble in water, as opposed to the urea that mammals excrete, which is why the “urine” from birds is white.
  • Adult African elephants eat 200-250kg of food a day and poop about 50kg daily. Some ingenious individuals in Thailand make paper from elephant dung – an astounding 115 sheets per day from one elephant’s deposits – which is primarily composed of fibre. They claim the paper does not smell and is bacteria-free.
  • Both the Adélie penguin and silver-spotted skipper butterfly – in its caterpillar stage – projectile poop; the caterpillar ejects its stool as far away as 1.4 meters!
  • A rabbit produces two types of digestion bi-products, leading some folks to believe they eat their poop. However, its fecal pellet is brown, hard, and spherical, with little odour, as it is composed mostly of undigested fibre (rabbits don’t generally eat these). However, rabbits also pass cecotropes, composed of nutrients from the rabbit’s digestion, which the rabbit needs to eat a second time to extract the necessary nutrition. These pellets consist of small, soft, shiny globs, each coated with a layer of rubbery mucus, and pass from the body in an elongate mass. As it contains a large mass of beneficial cecal bacteria, it has a strong odour, which the rabbit appears to enjoy. The mucosal coating protects the bacteria as they re-enter the stomach en route to the intestines.
First published in the Inside Tract® newsletter issue 182 – 2012
Image: Rasulov | Bigstockphoto.com

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