Feeling tired and fatigued may be more than just the result of another long day if you have ulcerative colitis. It could be a warning sign of iron deficiency.

The blood loss and internal damage to the intestine associated with ulcerative colitis can frequently lead to iron deficiency, when your body is not getting enough iron to function properly. In fact, anemia is the most common complication associated with inflammatory bowel diseases, according to a review published in May 2019 in the Swiss medical journal Acta Haematologica.

But it’s not as simple as taking iron supplements. Some iron-deficiency treatments, especially oral supplements, may actually make your ulcerative colitis symptoms worse. That’s why it’s important to know what's causing iron deficiency issues before starting treatment.

Once iron deficiency is treated properly, energy levels can improve dramatically, as can overall health and disease status.

Doctor Turned Patient

Peeyush Bhargava, MD, a radiologist with the University of Texas Medical Branch at Galveston, was a medical resident when he began experiencing severe constipation, abdominal pain, and then bloody diarrhea. A colonoscopy confirmed a diagnosis of ulcerative colitis.

“I was frequently passing blood with my bowel movements, and I found myself getting increasingly tired,” Dr. Bhargava says. “I wasn’t surprised at all to find that I had iron deficiency anemia.”

His doctor put him on oral iron tablets to treat the iron deficiency, but Bhargava’s symptoms worsened. So he stopped taking them after a week. His colitis later worsened to the point that he was hospitalized and given nutrition intravenously.

Although the hospital treatment helped his ulcerative colitis symptoms, Bhargava continued to have iron deficiency. “It was challenging just to get up in the morning and go to work,” he says. “And because the tiredness was getting worse, the frequency of bowel movements would get worse, and I’d lose more blood with every bowel movement.”

After speaking with an oncologist at the hospital in New York City where he worked, Bhargava tried intravenous iron infusions and vitamin B12 injections, treatments commonly used to counteract chemotherapy side effects.

“It almost instantaneously helped my energy levels,” he says. “And it also helped my colitis symptoms.”

Bhargava also changed his lifestyle. He became a vegetarian and started practicing pranayama, a form of yoga breathing. With these lifestyle modifications alongside Ayurvedic herbal supplements, Bhargava remains symptom free of both ulcerative colitis and iron deficiency. As his body healed and ulcerative colitis symptoms eased, he lost less blood, and his body regained its ability to absorb iron from his diet.

He has since started helping patients with colitis and Crohn’s through his website, where he recommends lifestyle changes, yoga, and Ayurvedic herbal supplements.

Treat Ulcerative Colitis, Then Iron Deficiency

Bhargava says the key to successfully treating his iron deficiency was to first get his ulcerative colitis under control so his body could absorb iron properly.

Gastroenterologist David T. Rubin, MD, a professor of medicine and the director of the Digestive Disease Center at University of Chicago Medicine, agrees. “You have to address the underlying reason for iron deficiency,” Dr. Rubin says. “If it’s because you have active colitis and bleeding, then you need to fix the colitis.”

Rubin says that iron deficiency occurs in about 20 to 30 percent of people with ulcerative colitis. According to the 2019 review in Acta Haematologica, patients in remission or with mild disease should be screened for anemia every 6 to 12 months, while people with active disease should be screened every three months. It also recommends that patients receive an annual screening for vitamin B12 and folic acid.

Chronic blood loss in the colon is a common cause and leads to symptoms like Bhargava experienced, such as bloody diarrhea and stools.

Another cause of iron deficiency may be that people with ulcerative colitis can be too restrictive in their diets because of fears of aggravating their condition, Rubin says. This can lead to malnutrition and iron deficiency.

Sometimes patients will have a combination of iron deficiency and a form of anemia called anemia of chronic disease or chronic inflammation. This form of anemia can be from chronic inflammation from colitis, which disrupts the body’s ability to use stored iron and to absorb iron from food.

Recognizing Symptoms and Treating Iron Deficiency

Fatigue is one of the most common symptoms of iron deficiency, but other symptoms may include having pale or yellowish skin, shortness of breath or chest pain, unexplained weakness, and rapid heartbeat. Iron deficiency is diagnosed through a blood test that includes a complete blood count.

Once iron deficiency is diagnosed and ulcerative colitis symptoms are under control, you can treat iron deficiency. A review published in March 2021 in Expert Review of Gastroenterology & Hepatology recommended oral iron supplements only for asymptomatic patients and those with mild symptoms. It said that intravenous iron supplementation should be the mainstay treatment for active anemia, since it's easily tolerated and absorbed. It’s also highly effective at replenishing iron stores.

After your body’s iron stores are back up, eating a diet rich in foods containing iron can help maintain healthy iron levels in the blood. Iron-rich foods include these choices: