Inflammatory Bowel Disease Clinical Presentation

Author: William A Rowe, MD; Chief Editor: Julian Katz, MD more...

Updated: Oct 26, 2011

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History
Physical Examination
Complications of Disease
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History

The manifestations of inflammatory bowel disease (IBD) generally depend on the area of the intestinal tract involved. Some patients with IBD also have irritable bowel syndrome (IBS), which can produce occasional cramping, irregular bowel habits, and passage of mucus without blood or pus.

Systemic symptoms are common in IBD and include fever, sweats, malaise, and arthralgias. A low-grade fever may be the first warning sign of a flare. Patients are commonly fatigued, which is often related to the pain, inflammation, and anemia that accompany disease activity. Recurrences may occur with emotional stress, infections or other acute illnesses, pregnancy, dietary indiscretions, use of cathartics or antibiotics, or withdrawal of anti-inflammatory or steroid medications. Children may present with growth retardation and delayed or failed sexual maturation. In 10-20% of cases, patients present with extraintestinal manifestations, including arthritis, uveitis, or liver disease (see Complications).

Grossly bloody stools, occasionally with tenesmus, although typical of ulcerative colitis, are less common in Crohn disease. Stools may be formed, but loose stools predominate if the colon or the terminal ileum is involved extensively. One half of patients with Crohn disease present with perianal disease (eg, fistulas, abscesses). Occasionally, acute right lower quadrant pain and fever, mimicking appendicitis or intestinal obstruction, may be noted. Not uncommonly, patients have been diagnosed with irritable bowel syndrome before being diagnosed with IBD. Various intestinal and extraintestinal manifestations of IBD also may be observed in conjunction with either ulcerative colitis or Crohn disease (see Complications).

Weight loss is observed more commonly in Crohn disease than in ulcerative colitis because of the malabsorption associated with small bowel disease. Patients may reduce their food intake in an effort to control their symptoms. Commonly, the diagnosis is established only after several years of recurrent abdominal pain, fever, and diarrhea.

Physical Examination

Fever, tachycardia, dehydration, and toxicity may occur in patients with IBD. Pallor may be noted, reflecting anemia. The magnitude of these factors is directly related to the severity of the attack.

Evaluate for signs of localized peritonitis, although abdominal tenderness is common. Patients with toxic megacolon appear septic. These individuals have high fever; lethargy; chills; tachycardia; and increasing abdominal pain, tenderness, and distention. (See the Table below.)

Patients with Crohn disease may develop a mass in the right lower quadrant. Complications (eg, perianal fissures or fistulas, abscesses, rectal prolapse) may be observed in up to 90% of patients with this disease, and common presenting signs include occult blood loss and low-grade fever, weight loss, and anemia. Growth retardation is seen in children and may be the only presenting sign in young patients.

The rectal examination often reveals bloody stool on gross or Hemoccult examination.

The physical examination should include a search for extraintestinal manifestations, such as iritis, episcleritis, arthritis, and dermatologic involvement. (see Complications.)

Table. Distinguishing Features of Crohn Disease Versus Ulcerative Colitis (Open Table in a new window)

Features	Crohn Disease	Ulcerative Colitis
Skip areas	Common	Never
Cobblestone mucosa	Common	Rare
Transmural involvement	Common	Occasional
Rectal sparing	Common	Never
Perianal involvement	Common	Never
Fistulas	Common	Never
Strictures	Common	Occasional
Granulomas	Common	Occasional

Complications of Disease

Many complications associated with IBD can occur with either ulcerative colitis or Crohn disease. Extraintestinal complications occur in approximately 20% of patients with IBD. In some cases, they may be more problematic than the bowel disease itself. Intestinal complications can include strictures, fistulas and abscesses, perforation and toxic megacolon, and malignancy.

Extraintestinal complications can include crippling osteoporosis, a hypercoagulable state can occur in IBD, anemia, gallstones occur, primary sclerosing cholangitis, aphthous ulcers, iritis (uveitis) and episcleritis, and skin complications (pyoderma gangrenosum, erythema nodosum).

The Swiss National IBD Cohort Study demonstrated the risks of extraintestinal complications of IBD as follows:^[6]

Arthritis – Crohn disease, 33%; ulcerative colitis, 4%
Aphthous stomatitis – Crohn disease, 10%; ulcerative colitis, 4%
Uveitis – Crohn disease, 6%; ulcerative colitis, 3%
Erythema nodosum – Crohn disease, 6%; ulcerative colitis, 3%
Ankylosing spondylitis – Crohn disease, 6%; ulcerative colitis, 2%
Psoriasis – Crohn disease, 2%; ulcerative colitis, 1%
Pyoderma gangrenosum – Crohn disease and ulcerative colitis, 2%
Primary sclerosing cholangitis – Crohn disease, 1%; ulcerative colitis, 4%

Many patients had more than one extraintestinal complication. The risk factors for having complications included family history and active disease for Crohn disease only; no significant risk factors were noted in patients with ulcerative colitis.

Proceed to Differential Diagnoses

Contributor Information and Disclosures

Author

William A Rowe, MD President, Gastroenterology Associates of Central Pennsylvania, PC; Manager, Endoscopy Center of Central Pennsylvania, LLC; Clinical Associate Professor of Surgery, Division of Colon and Rectal Surgery, Milton S Hershey Medical Center, Pennsylvania State University College of Medicine

William A Rowe, MD is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association,Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

William K Chiang, MD Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center

William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Andrew A Dahl, MD Director of Ophthalmology Teaching, Mid-Hudson Family Practice Institute, The Institute for Family Health; Assistant Professor of Surgery (Ophthalmology), New York College of Medicine

Andrew A Dahl, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Sarvotham Kini, MD Assistant Professor of Emergency Medicine, Emory University School of Medicine, Atlanta, GA

Sarvotham Kini, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Surgeons, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Hampton Roy Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

William Shapiro, MD Consulting Staff, Department of Urgent Care and Emergency Medicine, Scripps Clinic and Research Foundation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Rajeev Vasudeva, MD, FACG Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine

Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Columbia Medical Society, South Carolina Gastroenterology Association, and South Carolina Medical Association

Disclosure: Pricara Honoraria Speaking and teaching; UCB Consulting fee Consulting

R Christopher Walton, MD Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

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Inflammatory bowel disease. Severe colitis noted during colonoscopy. The mucosa is grossly denuded, with active bleeding noted. This patient had her colon resected very shortly after this view was obtained.

Inflammatory bowel disease. Stricture in the terminal ileum noted during colonoscopy. Narrowed segment visible upon intubation of the terminal ileum with the colonoscope. Relatively little active inflammation is present, indicating that this is a cicatrix stricture.

Inflammatory bowel disease. Enteroenteric fistula noted on small bowel series of x-ray films. The narrow-appearing segments filled out relatively normally on subsequent films. Note that barium is just starting to enter the cecum in the right lower quadrant (viewer's left), but that barium has also started to enter the sigmoid colon toward the bottom of the picture, thus indicating the presence of a fistula from the small bowel to the sigmoid colon.

Distinguishing features of Crohn disease (CD) and ulcerative colitis (UC). IBD = inflammatory bowel disease.

Toxic megacolon. Courtesy of Dr. Pauline Chu

Pyoderma gangrenosum. Courtesy of Dr. Gene Izuno.

Inflammatory bowel disease. Crohn disease involving the terminal ileum. Note the "string sign" in the right lower quadrant (viewer's left).

Inflammatory bowel disease. Inflammation in the terminal ileum noted during colonoscopy. Areas of inflammation, friability, and ulceration in the terminal ileum are consistent with mild-to-moderate Crohn disease.

Inflammatory bowel disease. Severe advanced pyoderma gangrenosum of the medial aspect of the left ankle.

Inflammatory bowel disease. Early pyoderma gangrenosum, before skin breakdown. Medial aspect of the right ankle. Same day and same patient as in Media file 6.

Table. Distinguishing Features of Crohn Disease Versus Ulcerative Colitis

Table. Distinguishing Features of Crohn Disease Versus Ulcerative Colitis

Features	Crohn Disease	Ulcerative Colitis
Skip areas	Common	Never
Cobblestone mucosa	Common	Rare
Transmural involvement	Common	Occasional
Rectal sparing	Common	Never
Perianal involvement	Common	Never
Fistulas	Common	Never
Strictures	Common	Occasional
Granulomas	Common	Occasional

View Table List

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