Ulcerative Colitis Differential Diagnoses

  • Author: Marc D Basson, MD, PhD, MBA, FACS; Chief Editor: Julian Katz, MD   more...
 
Updated: May 21, 2012
 
 

Diagnostic Considerations

Differentiation between ulcerative colitis and Crohn disease is critical to developing a treatment plan. In addition, prolonged use of cathartics, especially cascara, over many years may lead to a condition known as cathartic colon. Other problems to be considered include collagenous colitis and lymphocytic colitis (rarely requires surgery, low risk for malignancy), infectious colitis, ischemic colitis in elderly patients, and radiation colitis.

Radiologic findings in cases of acute infective enterocolitis from infection caused by Entamoeba histolytica (amebiasis), cytomegaloviral colitis, and Isospora, Salmonella, Shigella, or Yersinia may be similar to the findings seen in cases of ulcerative colitis; this is especially true with CT scans.

Ulcerative colitis versus Crohn disease

Grossly, Crohn disease is characteristically noncontiguous, with intervening, or skipped, areas of normal mucosa. The ulcerations in Crohn disease tend to be linear and often lead to the classic cobblestone appearance of the mucosa. Crohn disease may involve the entire GI tract, whereas ulcerative colitis involves only the large bowel.

Microscopically, the inflammation in ulcerative colitis and Crohn disease can appear the same, but noncaseating granulomas are present only in Crohn disease. Granulomas are present in 60% of Crohn disease specimens but are never present in ulcerative colitis specimens; therefore, their presence is specific for Crohn disease. The inflammation of Crohn disease may be transmural, whereas it is confined to the mucosa and submucosa in ulcerative colitis. Unfortunately, the differentiation is not always possible preoperatively. All large series of proctocolectomies include a subset of patients (approximately 10%) who were preoperatively thought to have ulcerative colitis but were subsequently diagnosed with Crohn disease.

The traditional idea that ulcerative colitis involves only the large bowel has been challenged. Significant gastroduodenal inflammation in children with ulcerative colitis has been reported. However, aphthous ulceration is considered unique to Crohn disease.[2] In addition, patchiness of the colonic mucosa suggestive of skip lesions may occur during the treatment phase of ulcerative colitis, leading one to question the diagnosis. These patchy areas may be seen endoscopically in as many as 38% of patients with ulcerative colitis who undergo medical therapy. Rectal sparing may also occur at some point during medical treatment of ulcerative colitis in as many as 44% of cases.[33] Proximal disease may be seen even after proctocolectomy. Capsule endoscopy has demonstrated patchy inflammation in the proximal bowel in patients with chronic pouchitis following proctocolectomy with ileal pouch reconstruction.[34]

Distinguishing ulcerative colitis from Crohn disease is important. See the table below.

Table 1. Distinguishing Ulcerative Colitis from Crohn Disease (Open Table in a new window)

Ulcerative ColitisCrohn Disease
Only colon involvedPanintestinal
Continuous inflammation extending proximally from rectumSkip-lesions with intervening normal mucosa
Inflammation in mucosa and submucosa onlyTransmural inflammation
No granulomasNoncaseating granulomas
Perinuclear ANCA (pANCA) positiveASCA positive
Bleeding (common)Bleeding (uncommon)
Fistulae (rare)Fistulae (common)

Cathartic colon

The radiologic appearance of cathartic colon is similar to that of ulcerative colitis. In cathartic colon, the changes are more marked in the right hemicolon than in the left. The bowel is distensible, and there are inconstant areas of bowel narrowing and loss of haustra.

Other diagnostic considerations

In addition to excluding Crohn disease, guidelines from the World Gastroenterology Organization recommend ruling out the following in the differential diagnosis of ulcerative colitis[21] :

  • Chronic schistosomiasis
  • Amebiasis
  • Intestinal tuberculosis
  • Ischemic colitis
  • Radiation colitis

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Marc D Basson, MD, PhD, MBA, FACS  Professor, Chair, Department of Surgery, Assistant Dean for Faculty Development in Research, Michigan State University College of Human Medicine

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

E Stanton Adkins III, MD  Clinical Associate Professor, Departments of Pediatrics and Surgery, University of South Carolina School of Medicine

E Stanton Adkins III, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, and American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Kenneth Azarow, MD  Program Director, Pediatric Surgery, Children's Hospital and University of Nebraska Medical Center; Professor, Department of Surgery, Uniformed Services University of the Health Sciences

Kenneth Azarow, MD is a member of the following medical societies: American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Iman Bayat, MBBS, MRCS  Principal House Officer in Surgery, Department of Surgery, Mater Health Services, Australia

Iman Bayat, MBBS, MRCS is a member of the following medical societies: Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Jennifer Lynn Bonheur, MD  Attending Physician, Division of Gastroenterology, Lenox Hill Hospital

Jennifer Lynn Bonheur, MD is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, New York Academy of Sciences, New York Society for Gastrointestinal Endoscopy, and Sigma Xi

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; Ardelyx Ownership interest Board membership

Peter W Gourlas, MD  Consulting Staff, Colorectal Unit, Princess Alexandre Hospital, Mater Adults Hospital and Greenslopes Private Hospital

Peter W Gourlas, MD is a member of the following medical societies: Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Michael A Grosso, MD  Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Andre Hebra, MD  Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children's Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Jodi Hirst, MBBS  Specialist Registrar in General Surgery, Mater Misericordiae Adult Hospital

Disclosure: Nothing to disclose.

Emma Igras, MBBS, FRACS  Clinical Research Fellow, Department of Surgical Oncology, Princess Alexandra Hospital, Australia

Emma Igras, MBBS, FRACS is a member of the following medical societies: Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Alex Jacocks, MD  Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine

Disclosure: Nothing to disclose.

Judith R Kelsen, MD  Clinical Instructor in Pediatrics, University of Pennsylvania School of Medicine; Attending Physician, Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia

Judith R Kelsen, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Study of Liver Diseases, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Tri H Le, MD  Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center

Tri H Le, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America

Disclosure: Nothing to disclose.

Luis M Lovato, MD  Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Petar Mamula, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine

Petar Mamula, MD, is a member of the following medical societies: American Academy of Pediatrics, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Brian J Miller, MBBS, LRCP, MRCS, FRCSC, FRACS  Associate Professor in General Surgery and Colorectal Surgery, Department of Surgery, University of Queensland, Princess Alexandra Hospital

Brian J Miller, MBBS, LRCP, MRCS, FRCSC, FRACS is a member of the following medical societies: Colorectal Surgical Society of Australia and New Zealand, Gastroenterological Society of Australia, Royal Australasian College of Surgeons, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

David A Piccoli, MD  Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine

David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Jorge H Vargas, MD  Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, University of California, Los Angeles, David Geffen School of Medicine; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System

Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Specialty Editor Board

Anil Minocha, MD, FACP, FACG  Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center; Clinical Professor, University of Mississippi School of Pharmacy

Anil Minocha, MD, FACP, FACG is a member of the following medical societies: American Academy of Clinical Toxicology, American Association for the Study of Liver Diseases, American College of Forensic Examiners, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy

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

Harsh Grewal, MD, FACS, FAAP  Clinical Professor of Surgery, Temple University School of Medicine; Chief, Division of Pediatric Surgery, Cooper University Hospital

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, and Southwestern Surgical Congress

Disclosure: Nothing to disclose.

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

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.

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Increased postrectal space is a known feature of ulcerative colitis.
Plain abdominal radiograph on a patient with known ulcerative colitis who presented with an acute exacerbation of his symptoms. Image shows thumbprinting in the region of the splenic flexure of the colon.
Double-contrast barium enema study shows pseudopolyposis of the descending colon.
Single-contrast enema study in a patient with known ulcerative colitis in remission shows a benign stricture of the sigmoid colon.
Plain abdominal radiograph in a 26-year-old with a 10-year history of ulcerative colitis shows a long stricture/spasm of the ascending colon/cecum. Note the pseudopolyposis in the descending colon.
Single-contrast enema study in a patient with total colitis shows mucosal ulcers with a variety of shapes, including collar-button ulcers, in which undermining of the ulcers occurs, and double-tracking ulcers, in which the ulcers are longitudinally orientated.
Double-contrast barium enema study shows total colitis. Note the granular mucosa in the cecum/ascending colon and multiple strictures in the transverse and descending colon in a patient with a more than a 20-year history of ulcerative colitis.
Single-contrast barium enema study shows burnt-out ulcerative colitis.
Intravenous urogram in the same patient as in Image 11 shows features of ankylosing spondylitis.
Lateral radiograph of the lumbar spine in the same patient as in Images 10-11 shows a bamboo spine.
Single-contrast barium enema study in a patient with Shigella colitis.
Postevacuation image obtained after a single-contrast barium enema study shows extensive mucosal ulceration resulting from Shigella colitis.
Double-contrast barium enema studies show granular mucosa associated with Campylobacter colitis.
Ulcerative colitis as visualized with a colonoscope.
Inflamed colonic mucosa demonstrating pseudopolyps.
Table 1. Distinguishing Ulcerative Colitis from Crohn Disease
Ulcerative ColitisCrohn Disease
Only colon involvedPanintestinal
Continuous inflammation extending proximally from rectumSkip-lesions with intervening normal mucosa
Inflammation in mucosa and submucosa onlyTransmural inflammation
No granulomasNoncaseating granulomas
Perinuclear ANCA (pANCA) positiveASCA positive
Bleeding (common)Bleeding (uncommon)
Fistulae (rare)Fistulae (common)
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