The symptoms of ulcerative colitis — stomach cramps, abdominal pain, and diarrhea that's frequently bloody — come and go. While serious complications from ulcerative colitis are rare, they can occur and, as a caregiver, you need to know what symptoms warrant emergency medical care.

Roughly 20 to 30 percent of patients with ulcerative colitis are hospitalized at some point because of their disease, according to a study published in April 2021 in the journal Lancet Gastroenterology and Hepatology.

In general, any increase in the severity of a loved one's ulcerative colitis symptoms should prompt a call to their doctor. This can indicate a flare-up, and it may be necessary to adjust the current treatment plan in order to reduce any inflammation quickly.

Severe symptoms, like excessive bleeding or intense abdominal pain, can indicate a serious complication of ulcerative colitis, such as acute severe ulcerative colitis or a perforated colon, that could become life-threatening if not treated right away.

Recognizing Acute Severe Ulcerative Colitis

Also known as fulminant colitis, this complication affects less than 10 percent of people with ulcerative colitis and involves damage to the entire thickness of the intestinal wall, according to the Crohn's and Colitis Foundation.

In fulminant colitis, the whole lining of the colon becomes inflamed, causing severe symptoms like bloody diarrhea and belly pain. Unless the inflammation is brought under control, patients with fulminant colitis are at risk of developing toxic megacolon, the most severe form of colitis.

Call your healthcare provider immediately if you notice your loved one is having more than six bowel movements per day that include a lot of blood, accompanied by any one of the following: a fast heart rate, a fever, a low temperature, and signs of anemia (such as feeling tired and shortness of breath). These are signs that their ulcerative colitis has become severe, according to the American Gastroenterological Association.

It's essential for acute severe ulcerative colitis to be recognized early and that the patient’s condition is monitored closely while they receive intravenous corticosteroids, according to a review published in January 2019 in the BMJ Postgraduate Medical Journal. Patients will also need to receive fluids intravenously to replenish electrolytes.

What You Need to Know About Toxic Megacolon

Considered the most serious complication of ulcerative colitis, toxic megacolon is the most extreme (and potentially life-threatening) form of fulminant colitis, notes the Crohn's and Colitis Foundation.

In toxic megacolon, a portion of the large intestine becomes paralyzed, stops working, and swells to many times its normal size. If left untreated, a portion of the intestine could be so severely damaged that it develops a hole, or perforates, possibly leading to a severe, and potentially fatal, infection.

Signs of toxic megacolon include:

Worsening abdominal pain
A visibly distended or bloated abdomen
Abdominal tenderness
Rapid heart rate
High fever
Dehydration
Vomiting

“Fortunately, with our current, effective therapies, toxic megacolon is not common," says Stephen B. Hanauer, MD, a professor of medicine at Northwestern University Feinberg School of Medicine and medical director of the Northwestern Medicine Digestive Health Center in Chicago. “The presence of severe or worsening abdominal pain associated with fever, vomiting, or dehydration requires urgent evaluation."

To prevent toxic megacolon, Dr. Hanauer recommends avoiding the following during a flare:

Narcotics
Non-steroidal anti-inflammatory drugs (NSAIDs) (like aspirin, ibuprofen, or naproxen)
Anti-diarrheal medication

Warning Signs of Perforated Bowel and Hemorrhaging

A perforated bowel is a hole in the wall of the intestine which can occur as a consequence of toxic megacolon, but can also be caused by intestinal infections, and certain types of medication.

A full colonoscopy during acute severe ulcerative colitis may also increase the risk of perforation, according to the January 2019 review in the BMJ Postgraduate Medical Journal.

This perforation is so dangerous because the contents of the intestine, which contain a large number of bacteria, can spill into the abdomen and cause a serious infection called peritonitis, notes the Crohn's and Colitis Foundation.

Signs of bowel perforation include severe abdominal pain, a high fever, and heavy rectal bleeding or hemorrhaging. As a caregiver, look for, or ask about, sudden and dramatic increases in the amount of blood in your loved one's stool.

If you suspect perforation, call 911 or go to the emergency room. Massive hemorrhaging in a patient with ulcerative colitis is an emergency condition that requires immediate medical attention and possibly surgical care to repair the hole in the colon wall.

Ways to Reduce the Risk of an Ulcerative Colitis Emergency

While many patients with ulcerative colitis may experience only mild or occasional symptoms, emergency situations can develop suddenly in both the newly diagnosed and in people who have had ulcerative colitis for a long time.

Keep in mind that the duration of flare-ups can be unpredictable and that remissions can vary in length, which means you always need to be on alert for any new or different symptoms.

“The most important control patients have to prevent flare-ups is to continue their maintenance medications, as directed," says Hanauer. “Antibiotics can also trigger flares, so they should only be used when appropriate — not for colds or viral infections. Quitting smoking can also trigger flare-ups, so patients should discuss smoking cessation with their gastroenterologists.”

Hanauer also recommends that patients with ulcerative colitis eat a healthy diet when they’re in remission to help ensure they’re meeting their nutritional requirements.

As the caregiver, you're in a unique position to notice changes in the nature and intensity of your loved one's ulcerative colitis symptoms. Always contact their medical team if you have any questions or suspect that the person with ulcerative colitis is experiencing an emergency. Your prompt action could save a life.

Additional reporting by Jordan M. Davidson.

Caregiver Tips: Knowing the Warning Signs of a Colitis Emergency

Recognizing Acute Severe Ulcerative Colitis

What You Need to Know About Toxic Megacolon

Warning Signs of Perforated Bowel and Hemorrhaging

Ways to Reduce the Risk of an Ulcerative Colitis Emergency