Inflammatory Bowel Disease Differential Diagnoses

  • Author: William A Rowe, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Oct 26, 2011
 
 

Diagnostic Considerations

Ninety percent of patients with Crohn disease have involvement of the terminal ileum and/or right colon. Pediatric patients are more likely (about 20%) to present with disease limited to the small intestine. Occasionally, gastric or duodenal Crohn disease manifests as seemingly refractory ulcer disease.

Other problems that should be considered include the following:

Acquired immunodeficiency syndrome (AIDS) - The chronic diarrhea and diffuse colonic involvement of Kaposi sarcoma may mimic chronic ulcerative colitis

  • Antibiotic-associated colitis
  • Arteriovenous malformations
  • Backwash ileitis
  • C1 esterase deficiency
  • Collagenous colitis
  • Colon cancer
  • Fever of unknown origin
  • Infectious colitis (if confined to the rectum, rule out "gay bowel syndrome")
  • Intestinal lymphoma
  • Intestinal tuberculosis
  • Irritable bowel syndrome (can be present along with IBD)
  • Ischemic colitis
  • Pseudomembranous colitis
  • Radiation-induced colitis

In addition, 2010 guidelines from the World Gastroenterology Organization recommend ruling out chronic schistosomiasis and amebiasis in the differential diagnosis of ulcerative colitis.[7] In the differential diagnosis of Crohn disease, the following should also be ruled out[7] :

  • Chronic amebiasis
  • Chronic Yersinia infection
  • Lymphogranuloma venereum
  • Actinomycosis
  • Chronic diverticulitis
  • Behçet disease
  • Nonsteroidal anti-inflammatory drug (NSAID) enteropathy

Differential Diagnoses

Proceed to Workup
 
 
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.

References

  1. Lashner B. Inflammatory bowel disease. In: Carey WD, ed. Cleveland Clinic: Current Clinical Medicine -- 2009. Philadelphia, Pa: Saunders; 2009.

  2. Jantchou P, Morois S, Clavel-Chapelon F, Boutron-Ruault MC, Carbonnel F. Animal protein intake and risk of inflammatory bowel disease: The E3N prospective study. Am J Gastroenterol. Oct 2010;105(10):2195-201. [Medline].

  3. Bengtson MB, Solberg IC, Aamodt G, Jahnsen J, Moum B, Vatn MH. Relationships between inflammatory bowel disease and perinatal factors: both maternal and paternal disease are related to preterm birth of offspring. Inflamm Bowel Dis. May 2010;16(5):847-55. [Medline].

  4. Loftus EV Jr, Silverstein MD, Sandborn WJ, Tremaine WJ, Harmsen WS, Zinsmeister AR. Ulcerative colitis in Olmsted County, Minnesota, 1940-1993: incidence, prevalence, and survival. Gut. Mar 2000;46(3):336-43. [Medline]. [Full Text].

  5. Loftus EV Jr, Silverstein MD, Sandborn WJ, Tremaine WJ, Harmsen WS, Zinsmeister AR. Crohn's disease in Olmsted County, Minnesota, 1940-1993: incidence, prevalence, and survival. Gastroenterology. Jun 1998;114(6):1161-8. [Medline].

  6. Vavricka SR, Brun L, Ballabeni P, Pittet V, Prinz Vavricka BM, Zeitz J, et al. Frequency and risk factors for extraintestinal manifestations in the Swiss inflammatory bowel disease cohort. Am J Gastroenterol. 2011;106:110-119.

  7. [Guideline] Bernstein CN, Fried M, Krabshuis JH, Cohen H, Eliakim R, Fedail S, et al. World Gastroenterology Organization Practice Guidelines for the diagnosis and management of IBD in 2010. Inflamm Bowel Dis. Jan 2010;16(1):112-24. [Medline].

  8. Mokrowiecka A, Daniel P, Slomka M, Majak P, Malecka-Panas E. Clinical utility of serological markers in inflammatory bowel disease. Hepatogastroenterology. Jan-Feb 2009;56(89):162-6. [Medline].

  9. Leighton JA, Shen B, Baron TH, Adler DG, Davila R, Egan JV, et al. ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease. Gastrointest Endosc. Apr 2006;63(4):558-65. [Medline]. [Full Text].

  10. Li CY, Zhang BL, Chen CX, Li YM. OMOM capsule endoscopy in diagnosis of small bowel disease. J Zhejiang Univ Sci B. Nov 2008;9(11):857-62. [Medline]. [Full Text].

  11. Ardizzone S, Cassinotti A, Duca P, et al. Mucosal healing predicts late outcomes after the first course of corticosteroids for newly diagnosed ulcerative colitis. Clin Gastroenterol Hepatol. Jun 2011;9(6):483-489.e3. [Medline].

  12. Gordon M, Naidoo K, Thomas AG, Akobeng AK. Oral 5-aminosalicylic acid for maintenance of surgically-induced remission in Crohn's disease. Cochrane Database Syst Rev. 2011;(1):CD008414. [Medline].

  13. Tursi A, Brandimarte G, Papa A, et al. Treatment of relapsing mild-to-moderate ulcerative colitis with the probiotic VSL#3 as adjunctive to a standard pharmaceutical treatment: a double-blind, randomized, placebo-controlled study. Am J Gastroenterol. Oct 2010;105(10):2218-27. [Medline].

  14. Hedin C, Whelan K, Lindsay JO. Evidence for the use of probiotics and prebiotics in inflammatory bowel disease: a review of clinical trials. Proc Nutr Soc. Aug 2007;66(3):307-15. [Medline].

  15. Mach T. Clinical usefulness of probiotics in inflammatory bowel diseases. J Physiol Pharmacol. Nov 2006;57 Suppl 9:23-33. [Medline].

  16. Khan KJ, Ullman TA, Ford AC, et al. Antibiotic therapy in inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterol. Apr 2011;106(4):661-73. [Medline].

  17. [Guideline] Lichtenstein GR, Abreu MT, Cohen R, Tremaine W. American Gastroenterological Association Institute medical position statement on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. Gastroenterology. Mar 2006;130(3):935-9. [Medline]. [Full Text].

  18. Ford AC, Sandborn WJ, Khan KJ, et al. Efficacy of biological therapies in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol. Apr 2011;106(4):644-59, quiz 660. [Medline].

  19. Kiran RP, Nisar PJ, Church JM, Fazio VW. The role of primary surgical procedure in maintaining intestinal continuity for patients with Crohn's colitis. Ann Surg. Jun 2011;253(6):1130-5. [Medline].

  20. de Silva S, Ma C, Proulx MC, et al. Postoperative complications and mortality following colectomy for ulcerative colitis. Clin Gastroenterol Hepatol. Nov 2011;9(11):972-80. [Medline].

  21. Lazarev M, Ullman T, Schraut WH, Kip KE, Saul M, Regueiro M. Small bowel resection rates in Crohn's disease and the indication for surgery over time: experience from a large tertiary care center. Inflamm Bowel Dis. May 2010;16(5):830-5. [Medline].

  22. Yamamoto T, Nakahigashi M, Umegae S, Matsumoto K. Prospective clinical trial: enteral nutrition during maintenance infliximab in Crohn's disease. J Gastroenterol. 2010;45(1):24-9. [Medline].

  23. Johannesson E, Simren M, Strid H, Bajor A, Sadik R. Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial. Am J Gastroenterol. May 2011;106(5):915-22. [Medline].

  24. Gisbert JP. Safety of immunomodulators and biologics for the treatment of inflammatory bowel disease during pregnancy and breast-feeding. Inflamm Bowel Dis. May 2010;16(5):881-95. [Medline].

  25. Brooklyn TN, Dunnill MG, Shetty A, Bowden JJ, Williams JD, Griffiths CE, et al. Infliximab for the treatment of pyoderma gangrenosum: a randomised, double blind, placebo controlled trial. Gut. Apr 2006;55(4):505-9. [Medline]. [Full Text].

  26. Agrawal D, Rukkannagari S, Kethu S. Pathogenesis and clinical approach to extraintestinal manifestations of inflammatory bowel disease. Minerva Gastroenterol Dietol. Sep 2007;53(3):233-48. [Medline].

  27. Ford AC, Bernstein CN, Khan KJ, et al. Glucocorticosteroid therapy in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol. Apr 2011;106(4):590-9; quiz 600. [Medline].

  28. García-Erce JA, Gomollón F, Muñoz M. Blood transfusion for the treatment of acute anaemia in inflammatory bowel disease and other digestive diseases. World J Gastroenterol. Oct 7 2009;15(37):4686-94. [Medline]. [Full Text].

 
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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
FeaturesCrohn DiseaseUlcerative Colitis
Skip areasCommonNever
Cobblestone mucosaCommonRare
Transmural involvementCommonOccasional
Rectal sparingCommonNever
Perianal involvementCommonNever
FistulasCommonNever
StricturesCommonOccasional
GranulomasCommonOccasional
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