Beyond the gut: Extraintestinal manifestations of ulcerative colitis

Ulcerative colitis (UC) is a disease that primarily affects the colon. However, as many as one in four people with UC experience something called extraintestinal manifestations (EIMs). These are health conditions that affect parts of the body outside the gastrointestinal tract. They can occur in people who have inflammatory bowel disease (IBD), such as ulcerative colitis or Crohn's disease.

EIMs can significantly affect your quality of life. Recognizing the symptoms early and discussing them with your healthcare professional is crucial to getting proper treatment.

Extraintestinal manifestations happen because inflammatory bowel disease causes inflammation throughout the body. That means the immune system isn't just overactive in the gut — it also can trigger inflammation in other parts of the body, affecting organs and tissues beyond the gastrointestinal tract. Some extraintestinal manifestations occur during disease flares, when symptoms of a condition return or worsen, while others develop when intestinal symptoms seem under control.

The most common EIM in people with ulcerative colitis is joint issues. People with IBD may experience aching or painful joints without swelling, called arthralgia. Some people also may develop arthritis, which is pain and swelling or warmth in the joints. There's no damage to joints with IBD-associated arthralgia. The pain can be in large joints — knees, shoulders and hips — or smaller joints — hands, knees and ankles — and usually occurs during a flare. Controlling gut inflammation usually helps improve pain from arthralgia and arthritis. Joint pain also can be triggered by certain medicines or withdrawal from steroids.

A small number of people with IBD might develop ankylosing spondylitis or sacroiliitis — two arthritic conditions that cause hip and back pain. Both conditions can damage joints and develop when ulcerative colitis symptoms seem under control. Treatment uses medicines that are similar to those used for rheumatoid arthritis to relieve pain and swelling.

Ulcerative colitis is linked to some liver diseases, most notably primary sclerosing cholangitis (PSC) and autoimmune hepatitis. PSC causes inflammation and scarring of the bile ducts that may lead to permanent scarring of the liver, called cirrhosis, or liver failure or cancer. It can develop even when UC seems well controlled. Autoimmune hepatitis occurs when the immune system attacks the liver, causing mild to severe inflammation. Treatment for both conditions usually includes anti-inflammatory medications or immunomodulators, medications that help manage the immune system's response.

Some liver conditions can be side effects of specific medicines, including certain immunosuppressants. Long-term IV nutrition can lead to fat buildup in the liver. You may have regular blood tests to check your liver and to catch problems early.

Uveitis and iritis are eye conditions most often linked to ulcerative colitis. Uveitis affects the middle layer of the eye, while iritis affects the iris, the colored part of the eye. Both conditions may occur during periods of active gut inflammation and cause pain, redness and blurred vision, usually in one eye. Early diagnosis by an eye doctor, called an ophthalmologist, is important. Treatment typically involves prescription eye drops.

Some UC medications also might affect the eyes. Long-term steroid use can increase the risk of cataracts, and immunosuppressants can raise the risk of infections such as conjunctivitis, commonly called pink eye.

Skin problems are less common with UC, but some issues can be serious. Rashes, lesions and ulcers can occur during a flare or happen independently. Ulcerative colitis medications also can affect the skin — steroids may thin the skin or cause bruising, and some treatments can make acne worse. Treatments include medications to control inflammation and targeted topical therapies to heal the skin. Some medications that treat ulcerative colitis increase the risk of developing nonmelanoma skin cancer. Regular skin exams are recommended for people with longstanding ulcerative colitis and those who receive certain immunosuppressive therapies.

Ulcerative colitis is associated with weaker bones and a higher chance of fractures. Inflammation from UC itself and steroid medications used to treat the disease can reduce bone density and strength. In addition, the condition can negatively affect how the body absorbs some nutrients that usually help keep bones healthy.

Your healthcare professional might recommend occasional bone density scans to check the strength of your bones. You also might need to increase your intake of calcium, vitamin D and other nutrients that help support bone health. Your healthcare professional also may recommend prescription medications that can help slow bone loss. Healthy lifestyle habits such as not smoking, making sure you get enough nutrients, walking, lifting weights, and doing pushups and other weight-bearing exercises can help keep bones strong.

Hair thinning or loss can result from iron deficiency, poor nutrition, some medications or the effects of ulcerative colitis flares. Nails might grow slowly, become brittle or show discoloration if nutrient deficiencies or inflammation is present. Oral health can be affected, too, with gum disease and dental erosion more common in people with UC. Proper nutrition, addressing nutrient deficiencies, not smoking, regular dental checkups and good oral hygiene are habits that help support healthy hair, nails and teeth.

Kidney issues are less common in UC, but they can occur. Chronic inflammation or diarrhea can increase the risk of kidney stones. Symptoms of kidney stones include one-sided back or flank pain and blood in your urine. Treatment might involve increasing hydration, prescription medications, and procedures to remove or break up stones.

Early recognition is key. Some EIMs, such as eye inflammation or liver disease, can progress silently. It's important to quickly communicate new or ongoing symptoms to your healthcare professional. Your care team will work with other specialists to properly treat your symptoms and help you feel better.