Why “Feeling Fine” Isn’t Enough: The Hidden Dangers of Undertreated UC

Every year on World IBD Day, the global community comes together to raise awareness about the realities of living with inflammatory bowel disease (IBD). For the millions navigating conditions like ulcerative colitis (UC), managing the physical symptoms is only half the battle; understanding what is happening beneath the surface is where true long-term health begins. Far too often, patients fall into the trap of normalizing chronic discomfort, mistaking temporary symptom relief for actual disease control. To bridge this gap, patients need both advanced clinical strategies and reliable educational tools to better understand their diagnosis.

To dive deeper into the clinical realities of disease monitoring and the dangers of silent inflammation, The Educated Patient sat down with Monika Fischer, M.D., a professor of medicine in the Department of Gastroenterology and Internal Medicine at Indiana University. In this exclusive Q&A, Fischer breaks down why relying solely on how a patient feels is no longer an acceptable standard of care in 2026, and how a proactive, “treat-to-target” approach can help patients reclaim a life uninterrupted by UC.

From a clinical standpoint, why do so many patients with IBD normalize ongoing symptoms instead of recognizing them as signs of active disease?

Monika Fischer, M.D.: Because we are human. We adapt, and that is what we are trained to do from infancy. We naturally want to live a normal life, so we gradually get used to the discomfort. Surveys actually show that over 90% of IBD patients adapt to their symptoms, and 70% believe they are living a normal life even while actively flaring.

Another major factor is therapeutic disappointment. Some patients lose hope after hearing from their first or second gastroenterologist that their current state is “the best it can get,” especially if they have already cycled through several therapies. They essentially make peace with their symptoms out of frustration.

What are some of the most common red flags that patients, and perhaps even providers, overlook when it comes to worsening UC?

MF: Blood in the stool is never a good sign. Developing a sudden sense of urgency — especially for patients who haven’t experienced that symptom before — and worsening diarrhea are clear warning signs.

However, fatigue is perhaps the most widely overlooked systemic symptom. In our medical field, it is now recognized as a distinct extraintestinal manifestation of UC. We often treat the bowel symptoms successfully, but the profound fatigue and low energy persist. Depression is another critical, often unspoken factor. In a standard, rushed clinic visit, providers tend to focus strictly on: “Do you have blood in your stool? Do you have diarrhea? Do you have pain?” If the patient answers no, the provider assumes they are fine, completely missing these systemic flags.

We often hear that symptom control does not equal disease control. A patient I recently interviewed noted that while he felt better, he knew his body wasn’t completely healed inside. Can you explain why underlying inflammation still matters?

MF: Symptom control is our most immediate goal because patients want to feel better, but it is just the tip of the iceberg. Clinical trials consistently show that roughly 25% of patients who feel entirely well still have active, ongoing inflammation when we look through a scope or evaluate biopsies.

This matters because extensive evidence proves that patients with residual, silent inflammation are far more likely to experience early clinical flares, steroid dependency, hospitalizations and an elevated risk of colon cancer.

Furthermore, ulcerative colitis is a progressive disease. Ongoing, uncontrolled inflammation eventually leads to irreversible structural damage and scarring of the bowel wall. When the rectum becomes chronically scarred, it loses its capacity to expand, which leads to permanent urgency and incontinence. Similarly, the sigmoid colon can become rigid and narrow like a lead pipe, causing chronic pain and severe bowel dysfunction.

Finally, uncontrolled inflammation remains the single most critical risk factor for developing precancerous lesions and colon cancer over time.

How exactly do delayed treatment or undertreatment impact these long-term patient outcomes?

MF: Ignoring mild symptoms allows silent inflammation to cause structural damage. Additionally, untreated inflammation can spread. What begins as limited proctitis or left-sided colitis can extend to involve the entire colon (pancolitis). Full-colon inflammation carries much higher rates of hospitalization and often becomes more refractory to standard treatments.

Beyond the physical damage, undertreatment takes a massive psychosocial toll. Patients adapt to being chronically lethargic, withdraw from social functions and experience high rates of absenteeism at work. It is our job as health care providers to look deeper and ensure the patient is biologically, endoscopically and histologically healed.

What advice do you give patients about when to revisit treatment conversations or consider adjusting their care path, even if their symptoms seem manageable?

MF: Continuous, objective monitoring is the most crucial aspect of managing IBD. Merely picking the right drug is not enough. We cannot rely solely on patient-reported symptoms; in 2026, managing IBD by symptoms alone is an unacceptable approach.

In my practice, I utilize a “treat-to-target” strategy. We monitor objective biomarkers of inflammation, primarily fecal calprotectin (a stool test). On a patient’s very first visit, we provide a specialized toolkit, and my nursing staff educates them on how to use it. It is a highly effective, noninvasive home test. I have patients submit a stool sample monthly after starting a new therapy until we confirm healing, and every three to six months thereafter.

While colonoscopies remain the gold standard for confirming true endoscopic and histologic healing, utilizing stool biomarkers allows us to closely track disease activity and adjust therapies proactively without relying on invasive procedures alone.

Is there anything else you would like our audience to know before we wrap up?

MF: I want patients to know that while UC is a chronic condition without a cure, we have an incredible luxury of treatment options and drug classes today. It is incredibly rare that we cannot find a successful therapeutic combination.

Our ultimate goal is complete mucosal healing so that the disease does not interfere with any domain of your life. You should only have to think about your UC when it is time to take your medication, submit a stool sample or see your provider. If you do not feel completely well, or if your provider is satisfied with a soft bar of clinical improvement while your endoscopy still shows active disease, do not settle. Seek a second opinion, or partner with a tertiary IBD center to get your disease under complete control.

This transcript was edited for clarity.