eMedicine Specialties > Emergency Medicine > Gastrointestinal

Inflammatory Bowel Disease: Differential Diagnoses & Workup

Author: William Shapiro, MD, Consulting Staff, Department of Urgent Care and Emergency Medicine, Scripps Clinic and Research Foundation
Contributor Information and Disclosures

Updated: Apr 25, 2008

Differential Diagnoses

Appendicitis, Acute
Diverticular Disease
Endometriosis
Pelvic Inflammatory Disease

Other Problems to Be Considered

AIDS (The chronic diarrhea and diffuse colonic involvement of Kaposi sarcoma may mimic chronic UC.)
Antibiotic-associated colitis
Arteriovenous malformations
Collagenous colitis
Colon cancer
Fever of unknown origin
Infectious colitis (if confined to the rectum, rule out "gay bowel syndrome")
Intestinal lymphoma
Irritable bowel syndrome (can be present along with IBD): In IBS, diarrhea often alternates with constipation. In contrast to IBD, IBS is not associated with blood in the stool, nocturnal diarrhea, weight loss, or other inflammatory sequelae (eg, fever, arthritis, skin or eye lesions, perianal disease). Fecal WBCs are not observed in IBS.
Ischemic colitis
Pseudomembranous colitis
Radiation-induced colitis

Workup

Laboratory Studies

  • CBC with differential
    • Anemia may result from acute or chronic blood loss or malabsorption (iron, folate, vitamin B-12) or may reflect the chronic disease state.
    • Leukocytosis, anemia, and thrombocytosis are common. A modestly elevated WBC is observed in active disease, but a marked elevation suggests the presence of an abscess or other suppurative complication.
  • Erythrocyte sedimentation rate: The sedimentation rate is typically elevated and has been used to monitor disease activity.
  • Serum chemistry
    • Hypokalemia reflects the severity of the diarrhea.
    • Abnormal liver function test results may represent pericholangitis or sclerosing cholangitis.
    • Hypoalbuminemia, resulting from protein-losing enteropathy, suggests extensive colitis.
    • Decreased serum calcium may reflect reduced serum albumin.
  • Type and cross-match: Consider obtaining a type and cross-match.
  • Stool examination: Send stool for fecal leukocytes, ova and parasite studies, bacterial pathogens culture, and Clostridium difficile titer.
    • Amebiasis can be difficult to identify from the stool. Consider serologic testing in this regard.
    • As many as 50-80% of cases of acute terminal ileitis are due to Yersinia enterocolitis infections. This produces a picture of pseudoappendicitis. Yersiniosis also has a high frequency of secondary manifestations, such as erythema nodosum and monarticular arthritis, similar to IBD.
  • Blood culture: Cultures may be positive if peritonitis or fulminant colitis is present.
  • New serologic tests: Recently, new serologic tests have become available to aid in the diagnosis of IBD and differentiate between CD and UC. Perinuclear antineutrophil cytoplasmic antibodies (pANCA) have been identified in some patients with UC, and anti-Saccharomyces cerevisiae antibodies (ASCA) have been found in patients with CD. Furthermore, those patients with IBD who are seronegative appear to have a lower incidence of resistant disease. Currently, these markers are not sensitive enough to be used as screening tests for IBD.

Imaging Studies

  • Upright chest radiography and abdominal series
    • Evaluate for an edematous irregular colon with "thumb printing." Occasionally, there may be pneumatosis coli (air in the colonic wall).
    • Look for free air and especially for evidence of toxic megacolon, which appears as a long continuous segment of air-filled colon greater than 6 cm in diameter (see Image 2).
    • In the supine position, dilatation is predominantly noted in the transverse colon secondary to air collection.
    • Repeat radiographs at 12- to 24-hour intervals to monitor the course of dilatation and to assess the need for emergency colectomy.
    • Associated findings include nephrolithiasis, cholelithiasis, or arthritis of the spine or the sacroiliac joints.
  • Barium enema
    • In UC, a barium enema (BE) may reveal a shortened colon, with loss of haustrations and destruction of the mucosal pattern (ie, lead pipe colon).
    • Skip areas and rectal sparing are noted in CD.
    • BE is contraindicated in patients with moderate-to-severe colitis because it risks perforation or precipitation of a toxic megacolon.
  • Upper GI with small bowel follow-through
    • In CD, areas of segmental narrowing with loss of normal mucosa, fistula formation, and the string sign (a narrow band of barium flowing through an inflamed or scarred area) in the terminal ileum are typically observed.
    • Some patients with UC also demonstrate inflammatory changes in the terminal ileum (ileitis), but they lack the skip pattern characteristic of CD.
    • CT scanning and ultrasonography: CT scanning and ultrasonography are best for demonstrating intra-abdominal abscesses, mesenteric inflammation, and fistulas.
  • More recently, wireless capsule endoscopy, used most often to investigate the source of GI bleeding, has been found useful in diagnosing mucosal lesions in CD.

Procedures

  • Findings on sigmoidoscopy may be diagnostic in UC because the rectum is always involved.
  • The mucosal surface becomes irregular and friable, bleeds easily when touched, and may have pseudopolyps.
  • Because of the degree of sensitivity, a colonoscopy is recommended for making the diagnosis and for evaluating the extent and severity of disease.
  • Avoid procedures in acutely ill patients.

More on Inflammatory Bowel Disease

Overview: Inflammatory Bowel Disease
Differential Diagnoses & Workup: Inflammatory Bowel Disease
Treatment & Medication: Inflammatory Bowel Disease
Follow-up: Inflammatory Bowel Disease
Multimedia: Inflammatory Bowel Disease
References
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Further Reading

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Keywords

IBD, ulcerative colitis, UC, Crohn disease, Crohn's disease, CD, regional enteritis, terminal ileitis, granulomatous ileocolitis, inflammation of the colon, colitis, irritable bowel syndrome, mucous colitis, rubor, spastic colon, chronic inflammatory diseases of the GI tract, pancolitis, backwash ileitis

perianal fistulas, perianal abscesses, strictures, gallstones, calcium oxalate kidney stones, fat malabsorption, enteric hyperoxaluria, iritis, episcleritis, arthritis, pericholangitis, sclerosing cholangitis, peritonitis with sepsis, thromboembolic disease, toxic megacolon, chronic anemia, malnutrition

growth retardation, bloody diarrhea, nonbloody diarrhea, rectal urgency, tenesmus, arthralgias, grossly bloody stools, gastric outlet obstruction, irregular bowel habits, uveitis, liver disease, perianal fissures, rectal prolapse

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Contributor Information and Disclosures

Author

William Shapiro, MD, Consulting Staff, Department of Urgent Care and Emergency Medicine, Scripps Clinic and Research Foundation
William Shapiro, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

William K Chiang, MD, Associate Professor, Department of Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine; Consulting Staff, 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eugene Hardin, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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