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More than 500,000 Americans have ulcerative colitis, an inflammatory bowel disease (IBD) that causes chronic inflammation of the digestive tract. Like Crohn's disease, another common IBD, ulcerative colitis can be painful and debilitating and sometimes can lead to life-threatening complications.

Ulcerative colitis and Crohn's disease are similar — so similar that they're often mistaken for one another. Both inflame the lining of your digestive tract, and both can cause severe bouts of watery or bloody diarrhea and abdominal pain. But ulcerative colitis usually affects only the innermost lining of your large intestine (colon) and rectum. Crohn's disease, on the other hand, can occur anywhere in your digestive tract, often spreading deep into the layers of affected tissues.

There's no known medical cure for ulcerative colitis, but therapies are available that may dramatically reduce the signs and symptoms of ulcerative colitis and even bring about a long-term remission.

The signs and symptoms of ulcerative colitis can vary widely, depending on the severity of inflammation and where it occurs. For that reason, doctors often classify ulcerative colitis according to its location. Here are the signs and symptoms that may accompany ulcerative colitis, depending on its classification:

• Ulcerative proctitis. In this form of ulcerative colitis, inflammation is confined to the rectum and for some people, rectal bleeding may be the only sign of the disease. Others may have rectal pain, a feeling of urgency or an inability to move the bowels in spite of the urge to do so (tenesmus).
• Left-sided colitis.   As the name suggests, inflammation extends from the rectum up the left side through the sigmoid and descending colon. Signs and symptoms include bloody diarrhea, abdominal cramping and pain, and weight loss.
• Pancolitis. Affecting the entire colon, pancolitis causes bouts of bloody diarrhea that may be severe, abdominal cramps and pain, fatigue, weight loss, and night sweats.
• Fulminant colitis. This rare, life-threatening form of colitis affects the entire colon and causes severe pain, profuse diarrhea, and sometimes, dehydration and shock. People with fulminant colitis are at risk of serious complications including colon rupture and toxic megacolon, which occurs when the colon becomes severely distended.

The course of ulcerative colitis varies, with periods of acute illness often alternating with periods of remission. But over time, the severity of the disease usually remains the same. Only a small percentage of people with a milder condition such as ulcerative proctitis go on to develop more severe signs and symptoms.

Like Crohn's disease, ulcerative colitis causes inflammation and ulcers in your intestine. But unlike Crohn's, which can occur in patches anywhere along the digestive tract, ulcerative colitis usually affects a continuous section of the inner lining of the colon beginning with the rectum.

No one is quite sure what triggers ulcerative colitis, but there's a consensus as to what doesn't. Researchers no longer believe that stress is the main culprit, although stress can often aggravate symptoms. Instead, current thinking focuses on the following possibilities:

• Immune system. Some scientists think a virus or bacterium may cause ulcerative colitis. The digestive tract becomes inflamed when the body's immune system tries to fight off the invading microorganism. It's also possible that inflammation may stem from the virus or bacterium itself or from an autoimmune reaction in which the body mounts an immune response even though no pathogen is present.
• Heredity. Because you're more likely to develop ulcerative colitis if you have a parent or sibling with the disease, scientists suspect that genetic makeup may play a contributing role. Research into which genetic mutations might increase susceptibility to ulcerative colitis is ongoing.
• Environment. Because ulcerative colitis occurs more often among people living in cities and industrial nations, it's possible that environmental factors, including a diet high in fat or refined foods, may play a role.
• Antibiotics. Antibiotic therapy can lead to acute colitis or to pseudomembranous colitis, a particularly serious disease. These problems occur because antibiotics disrupt the normal balance of bacteria in your intestinal tract. But researchers haven't found a clear link between antibiotics and ulcerative colitis.

Ulcerative colitis affects about the same number of women and men. Risk factors may include:

• Age. Ulcerative colitis can strike at any age, but you're most likely to develop the condition when you're young. Ulcerative colitis often strikes people in their 30s, although a small number of people may not develop the disease until the sixth or seventh decade of life.
• Ethnicity. Although whites have the highest risk of the disease, it can strike any ethnic group. If you're Jewish and of European descent, you're four to five times as likely to have ulcerative colitis.
• Family history. You're at higher risk if you have a close relative, such as a parent, sibling or child, with the disease.
• Where you live. If you live in an urban area or in an industrialized country, you're more likely to develop ulcerative colitis. People living in Northern climates also seem to have a greater risk of ulcerative colitis.

See your doctor if you experience a persistent change in your bowel habits or if you have any of the signs and symptoms of ulcerative colitis, such as abdominal pain, blood in your stool, ongoing bouts of diarrhea that don't respond to over-the-counter (OTC) medications or an unexplained fever lasting more than a day or two.

Although ulcerative colitis usually isn't fatal, it's a serious disease that, in some cases, may cause life-threatening complications.

Your doctor will likely diagnose ulcerative colitis only after ruling out other possible causes for your signs and symptoms, including irritable bowel syndrome (IBS), diverticulitis and colorectal cancer. To help confirm a diagnosis of ulcerative colitis, you may have one or more of the following tests and procedures:

• Blood tests. Your doctor may suggest blood tests to check for anemia or signs of infection. Two tests that look for the presence of certain antibodies can sometimes help diagnose which type of inflammatory bowel disease you have, but not everyone with ulcerative colitis or Crohn's disease has these antibodies. These tests are not sensitive enough for routine use but may be helpful in specific circumstances.
• Colonoscopy. This is the most sensitive test for diagnosing ulcerative colitis or Crohn's disease. It allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis. Sometimes a tissue sample can help confirm a diagnosis. If there are clusters of inflammatory cells called granulomas, for instance, it's likely you have Crohn's disease, because granulomas don't occur with ulcerative colitis. Risks of this procedure include perforation of the colon wall and bleeding, especially when a biopsy is taken.
• Flexible sigmoidoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the sigmoid, the last 2 feet of your colon. The test usually takes just a few minutes. It's somewhat uncomfortable, and there's a slight risk of perforating the colon wall. It may also miss problems higher up in your colon.
• Barium enema. This diagnostic test allows your doctor to evaluate your entire large intestine with an X-ray. Barium, a contrast dye, is placed into your bowel in an enema form. Sometimes, air is added as well. The barium fills and coats the lining of the bowel, creating a silhouette of your rectum, colon and a portion of your small intestine. Barium enema isn't as reliable as colonoscopy, it doesn't allow your doctor to take tissue samples, and it's not used in people with moderate to severe disease because of the risk of complications.
• Small bowel X-ray. This test looks at the part of the small bowel that can't be seen by colonoscopy. You drink a barium "shake" before the procedure, and X-rays are the taken of your small intestine. This test can be helpful in distinguishing between ulcerative colitis and Crohn's disease.

The most serious acute complication of ulcerative colitis is toxic megacolon. This occurs when your colon becomes paralyzed, preventing you from having a bowel movement or passing gas. Signs and symptoms include abdominal pain and swelling, fever and weakness. You might also become disoriented or groggy. If toxic megacolon isn't treated, your colon may rupture, causing peritonitis, a life-threatening condition requiring emergency surgery.

Other possible complications of ulcerative colitis include:

• Perforated colon
• Severe dehydration
• Liver disease
• Inflammation of the skin, joints and eyes

IBD and colon cancer
Both ulcerative colitis and Crohn's disease increase your risk of colon cancer. Despite this increased risk, however, more than 90 percent of people with inflammatory bowel disease never develop cancer. Your risk is greatest if you've had inflammatory bowel disease for at least eight to 10 years and if it has spread through your entire colon. You're less likely to develop cancer if only a small part of your colon is diseased.

Pregnancy
If you have ulcerative colitis, consult your doctor before becoming pregnant or fathering a child. Some medications used to treat IBD have the potential to cause birth defects or can be passed to the baby through breast milk. Active ulcerative colitis increases the risk of fetal death or preterm labor. If you're already pregnant, be sure you're cared for by a doctor who has experience with IBD and pregnancy.

The goal of medical treatment is to reduce the inflammation that triggers your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to long-term remission. Treatment for ulcerative colitis usually involves either drug therapy or surgery.

Doctors use several categories of drugs that control inflammation in different ways. But drugs that work well for some people may not work for others, so it may take time to find a medication that helps you. In addition, because some drugs have serious side effects, you'll need to weigh the benefits and risks of any treatment.

Anti-inflammatory drugs
Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:

• Sulfasalazine (Azulfidine). Doctors have used this drug for many years to treat ulcerative colitis. Although it can be effective in reducing symptoms of the disease, it has a number of side effects, including nausea, vomiting, heartburn and headache. Don't take this medication if you're allergic to sulfa medications.
• Mesalamine (Asacol, Rowasa) and olsalazine (Dipentum). These medications tend to have fewer side effects than sulfasalazine has. You take them in tablet form or use them rectally in the form of enemas or suppositories, depending on the area of your colon affected by ulcerative colitis. Mesalamine enemas can relieve signs and symptoms in more than 80 percent of people with ulcerative colitis in the lower left side of their colon and rectum. Olsalazine may cause or worsen existing diarrhea in some people.
• Balsalazide (Colazal). This is another formulation of mesalamine, the compound found in drugs such as Asacol and Rowasa. Colazal delivers anti-inflammatory medication directly to the colon. The drug is similar to sulfasalazine, but uses a less toxic carrier and may produce fewer side effects. Twenty percent of people with ulcerative colitis using this medication experience remission lasting longer than 12 weeks.
• Corticosteroids. Steroids can help reduce inflammation, but they have numerous side effects, including a puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. More serious side effects include high blood pressure, type 2 diabetes, osteoporosis, bone fractures, cataracts and an increased susceptibility to infections. Long-term use of these drugs in children can lead to stunted growth. Also, corticosteroids don't work for everyone who has ulcerative colitis. Doctors generally use corticosteroids only if you have moderate to severe inflammatory bowel disease that doesn't respond to other treatments. Corticosteroids aren't for long-term use and are generally prescribed for a period of three to four months. They may also be used in conjunction with other medications as a means to induce remission. For example, corticosteroids may be used with an immune system suppressor because the corticosteroids can induce remission, while the immune system suppressors can help maintain remission. Occasionally your doctor may also prescribe steroid enemas to treat disease in your lower colon or rectum. These, too, are only for short-term use.
• Fish oil. The omega-3 fatty acids in fish oil have been shown to reduce inflammation in people with ulcerative colitis. One experimental therapy uses a drink containing fatty acids from fish oil, antioxidants and soluble fiber. In studies, the supplement significantly reduced the need for corticosteroid therapy.

• Azathioprine (Imuran) and mercaptopurine (Purinethol). These drugs have been used to treat Crohn's disease for years, but their role in ulcerative colitis is only now being studied. Because azathioprine and mercaptopurine act slowly, they're sometimes initially combined with a corticosteroid, but in time, they seem to produce benefits on their own, with less long-term toxicity. Side effects are not minor, however, and can include allergic reactions, bone marrow suppression, infections, and inflammation of the liver and pancreas.
• Cyclosporine (Neoral, Sandimmune). This potent drug is normally reserved for people who don't respond well to other medications or who face surgery because of severe ulcerative colitis. In some cases, cyclosporine may be used to delay surgery until you're strong enough to undergo the procedure; in others, it's used to control signs and symptoms until less toxic drugs start working. Cyclosporine begins working in one to two weeks, but because it has the potential for severe side effects including kidney and liver damage, fatal infections and an increased risk of lymphoma, the risks and benefits of treatment must be carefully weighed.
• Infliximab (Remicade). This drug received Food and Drug Administration approval in September 2005 for use in ulcerative colitis. It works by neutralizing a protein produced by your immune system known as tumor necrosis factor (TNF). Infliximab finds TNF in your bloodstream and removes it before it causes inflammation in your intestinal tract. Some people with heart failure and people with multiple sclerosis and those with cancer or a history of cancer can't use infliximab. If you're currently taking infliximab, talk to your doctor about the potential risks. The drug has been linked to an increased risk of infection, especially tuberculosis, and may increase your risk of blood problems and cancer. What's more, because infliximab is partly a mouse protein, it can cause serious allergic reactions in some people — reactions that may be delayed for days to weeks after starting treatment. Once started, infliximab is often continued as long-term therapy, although its effectiveness may wear off over time.

Nicotine patches
These skin patches — the same kind smokers use — seem to provide short-term relief from flare-ups of ulcerative colitis for some people, especially people who formerly smoked. How nicotine patches work isn't exactly clear, and no one should take up smoking as a treatment for ulcerative colitis. The risks from smoking far outweigh any potential benefit.

Other medications
In addition to controlling inflammation, some medications may help relieve your signs and symptoms. Depending on the severity of your ulcerative colitis, your doctor may recommend one or more of the following:

• Anti-diarrheals. A fiber supplement such as psyllium powder (Metamucil) or methylcellulose (Citrucel) can help relieve signs and symptoms of mild to moderate diarrhea by adding bulk to your stool. For more severe diarrhea, loperamide (Imodium) may be effective. Use narcotics with great caution, however, because they increase the risk of toxic megacolon.
• Laxatives. In some cases, swelling may cause your intestines to narrow, leading to constipation. Talk to your doctor before taking any laxatives, because even those sold over-the-counter may be too harsh for your system.
• Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others). Don't use nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen (Aleve). These are likely to make your symptoms worse.
• Iron supplements. If you have chronic intestinal bleeding, you may develop iron deficiency anemia. Taking iron supplements may help restore your iron levels to normal and reduce this type of anemia once your bleeding has stopped or diminished.

New treatments
Researchers are testing the drug adalimumab (Humira), which is currently approved for treating arthritis, for use in ulcerative colitis. Like infliximab, it blocks tumor necrosis factor, but may have fewer side effects than infliximab does.

Surgery
If diet and lifestyle changes, drug therapy or other treatments don't relieve your signs and symptoms, your doctor may recommend surgery.

Surgery can often eliminate ulcerative colitis. But that usually means removing your entire colon and rectum (proctocolectomy). In the past, after this surgery you would wear a small bag over an opening in your abdomen to collect stool. But a procedure called ileoanal anastomosis eliminates the need to wear a bag. Instead, your surgeon constructs a pouch from the end of your small intestine. The pouch is then attached directly to your anus. This allows you to expel waste normally, although you may have as many as five to seven watery bowel movements a day because you no longer have your colon to absorb water. Between 25 percent and 40 percent of people with ulcerative colitis eventually need surgery.

Sometimes you may feel helpless when facing ulcerative colitis. But changes in your diet and lifestyle may help control your symptoms and lengthen the time between flare-ups.

Diet
There's no firm evidence that what you eat actually causes inflammatory bowel disease. But certain foods and beverages can aggravate your signs and symptoms, especially during a flare-up in your condition. It's a good idea to try eliminating from your diet anything that seems to make your signs and symptoms worse. Here are some suggestions that may help:

• Limit dairy products. Like many people with inflammatory bowel disease, you may find that problems such as diarrhea, abdominal pain and gas improve when you limit or eliminate diary products. You may be lactose intolerant — that is, your body can't digest the milk sugar (lactose) in dairy foods. If so, try substituting yogurt or low-lactose cheeses, such as Swiss and cheddar, for milk. Or use an enzyme product such as Lactaid to help break down lactose. In some cases, though, you may need to eliminate dairy foods completely. If you need help, a registered dietitian can help you design a healthy diet that's low in lactose.
• Experiment with fiber. For most people, high-fiber foods such as fresh fruits and vegetables and whole grains are the foundation of a healthy diet. But if you have inflammatory bowel disease, fiber may make diarrhea, pain and gas worse. If raw fruits and vegetables bother you, try steaming, baking or stewing them. You may also find that you can tolerate some fruits and vegetables, but not others. In general, you may have more problems with foods in the cabbage family, such as broccoli and cauliflower, and with very crunchy foods such as raw apples and carrots.
• Avoid problem foods. Eliminate any other foods that seem to make your symptoms worse. These may include "gassy" foods such as beans, cabbage and broccoli, raw fruit juices and fruits — especially citrus fruits — spicy food, popcorn, alcohol, caffeine, and foods and drinks that contain caffeine such as chocolate and soda.
• Eat small meals. You may find you feel better eating five or six small meals rather than two or three larger ones.
• Drink plenty of liquids. Try to drink plenty of fluids daily. Water is best. Alcohol and beverages that contain caffeine stimulate your intestines and can make diarrhea worse, while carbonated drinks frequently produce gas.
• Ask about multivitamins. Because ulcerative colitis can interfere with your ability to absorb nutrients and because your diet may be limited, vitamin and mineral supplements can play a key role in supplying missing nutrients. They don't provide essential protein and calories, however, and shouldn't be a substitute for meals.
• Talk to a dietitian. If you begin to lose weight or your diet has become very limited, talk to a registered dietitian.

Stress
Although stress doesn't cause inflammatory bowel disease, it can make your signs and symptoms much worse and may trigger flare-ups. Stressful events can range from minor annoyances to a move, job loss or the death of a loved one.

When you're under stress, your normal digestive process changes. Your stomach empties more slowly and secretes more acids. Stress can also speed or slow the passage of intestinal contents. It may also cause changes in intestinal tissue itself.

Although it's not always possible to avoid stress, you can learn ways to help manage it. Some of these include:

• Exercise. Even mild exercise can help reduce stress, relieve depression and normalize bowel function. Talk to your doctor about an exercise plan that's right for you.
• Biofeedback. This stress-reduction technique helps you reduce muscle tension and slow your heart rate with the help of a feedback machine. You're then taught how to produce these changes yourself. The goal is to help you enter a relaxed state so that you can cope more easily with stress. Biofeedback is usually taught in hospitals and medical centers.
• Regular exercise, yoga, massage or meditation. These can all be effective ways to relieve stress. You can take classes in yoga and meditation or practice at home using books or tapes.
• Progressive relaxation exercises. These help you relax the muscles in your body, one by one. Start by tightening the muscles in your feet, then concentrate on slowly letting all the tension go. Next, tighten and relax your calves. Continue until every muscle in your body, including those in your eyes and scalp, is completely relaxed.
• Deep breathing. Most adults breathe from their chests. But you become calmer when you breathe from your diaphragm — the muscle that separates your chest from your abdomen. When you inhale, allow your belly to expand with air; when you exhale, your abdomen naturally contracts. Deep breathing can also help relax your abdominal muscles, which may lead to more normal bowel activity.
• Hypnosis. Hypnosis may reduce abdominal pain and bloating. A trained professional teaches you how to enter a relaxed state and then guides you as you imagine your intestinal muscles becoming smooth and calm.
• Other techniques. Set aside at least 20 minutes a day for any activity you find relaxing — listening to music, reading, playing computer games or just soaking in a warm bath.

Ulcerative colitis doesn't just affect you physically — it takes an emotional toll as well. If signs and symptoms are severe, your life may revolve around a constant need to run to the toilet. In some cases, you may barely be able to leave the house. When you do, you might worry about an accident, and this anxiety only makes your symptoms worse.

Even if your symptoms are mild, gas and abdominal pain can make it difficult to be out in public. You may also feel hampered by dietary restrictions or embarrassed by the nature of your disease. All of these factors — isolation, embarrassment and anxiety — can severely alter your life. Sometimes they may lead to depression.

One of the best ways to feel more in control is to find out as much as possible about inflammatory bowel disease. In addition to talking to your doctor, look for information in books and on the Internet from sites such as the National Institutes of Health, Crohn's & Colitis Foundation of America (CCFA) and major medical centers or universities. You might find it especially helpful to talk to people who share your condition. In addition, organizations such as the CCFA have chapters set up across the country. Your doctor, nurse or dietitian can locate the chapter nearest you, or you can contact the organization directly. In many parts of the country, local newspapers also publish the times and locations of various support group meetings. If possible, take your family with you to meetings. The more they know about your disease, the better able they'll be to understand what you're going through.

Although support groups aren't for everyone, they can provide valuable information about your condition as well as emotional support. Group members frequently know about the latest medical treatments or integrative therapies. You may also find it reassuring to be among people who understand what you're going through.

Some people find it helpful to consult a psychologist or psychiatrist who's familiar with inflammatory bowel disease and the emotional difficulties it can cause. Although living with ulcerative colitis can be discouraging, the outlook is brighter than it was even just a few years ago.

Many people are interested in nontraditional approaches to healing, especially when standard treatments produce intolerable side effects or aren't able to provide an improvement. To address this interest, the National Institutes of Health established the National Center for Complementary and Alternative Medicine (NCCAM). The Center's mission is to explore nontraditional therapies in a scientifically rigorous way. In general, alternative medicine refers to therapies that may be used instead of conventional treatments. Complementary or integrative medicine, on the other hand, usually means therapies used in conjunction with traditional treatments. Complementary therapies may include acupuncture or acupressure, massage, music or art therapy, guided imagery, yoga, tai chi, and hypnosis. These definitions are often used interchangeably, however. Sometimes acupuncture might be used exclusively to treat a colon problem, for instance.

Most alternative and complementary therapies don't simply address a problem with the body. Instead, they focus on the entire person — body, mind and spirit. As a result, they can be especially effective at reducing stress, alleviating the side effects of conventional treatments and improving quality of life.

Studies have found that more than half the people with either ulcerative colitis or Crohn's disease have used some form of alternative or complementary therapy. The most common complementary therapies tried were nutritional supplements, probiotics and fish oil. Side effects and ineffectiveness of conventional therapies are primary reasons for seeking alternative care. Only about two-thirds report their alternative or complementary therapy use to their doctors, however. Because even natural herbs can have side effects and cause dangerous interactions, be sure to let your doctor know before you try any alternative or complementary therapies.

NCCAM's findings are available on its Web site. You can also talk to information specialists at the center's clearinghouse by calling (888) 644-6226 between 8:30 a.m. and 5 p.m. Eastern time.