eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Ulcerative Colitis: Differential Diagnoses & Workup

Author: Jonathan E Markowitz, MD, Associate Professor of Clinical Pediatrics, University of South Carolina School of Medicine; Attending Pediatric Gastroenterologist, Associate Director of Pediatric Residency Program, Greenville Hospital System
Coauthor(s): Petar Mamula, MD, Assistant Professor, Department of Pediatrics, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine; Robert Baldassano, MD, Director, Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology and Nutrition, Associate Professor, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania; David A Piccoli, MD, Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine; Liz D Dancel, MD, Resident, Department of Pediatrics, Greenville Hospital System University Medical Center
Contributor Information and Disclosures

Updated: Sep 11, 2009

Differential Diagnoses

Amebiasis
Hemolytic-Uremic Syndrome
Henoch-Schoenlein Purpura
Irritable Bowel Syndrome
Salmonella Infection

Other Problems to Be Considered

Pseudomembranous (Clostridium difficile) colitis
Infectious colitis (due to Escherichia coli or Yersinia, Salmonella, or Shigella species)

Workup

Laboratory Studies

  • CBC count commonly reveals a mild anemia, which can be due to chronic blood loss (ie, microcytic, hypochromic) or may represent chronic disease (ie, normocytic). In cases of fulminant colitis, severe anemia may be present.
  • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level are frequently elevated during active disease.
  • Result for antineutrophil cytoplasmic antibody with a perinuclear staining pattern (p-ANCA) are positive in up to 80% of patients with ulcerative colitis (UC) and in up to 20% of patients with Crohn disease (CD).
  • Serum albumin levels may be low in fulminant colitis.
  • Fecal calprotectin may be elevated during times of active inflammation.
    • Calprotectin is a calcium-binding S-100 protein found in the neutrophil cytosol that is released with cell activation or death.
    • An assay for calprotectin is now commercially available and may be useful to differentiate a disease flare from other causes of abdominal pain or diarrhea.
  • Micronutrient and vitamin levels are typically low in CD but less commonly so in UC.
  • Obtain stool cultures to rule out infectious colitis. Obtain an assay for E coli H7:0157 if the patient's symptoms are consistent with hemolytic uremic syndrome.
  • Obtain a stool assay for C difficile toxins A and B because C difficile colitis can mimic UC or it may be responsible for a flare. Evaluation for toxin A or toxin B alone is inadequate for an accurate diagnosis of C difficile infection.
  • Liver dysfunction may indicate sclerosing cholangitis or autoimmune hepatitis.

Imaging Studies

  • An abdominal obstruction series (ie, supine and upright abdominal radiography) is useful to evaluate for air-fluid levels, dilated loops of bowel, evidence of obstruction, or possible toxic megacolon. No pathognomonic findings for UC on this type of study are reported.
  • Barium enema study is useful to evaluate the colon for stricture and for mucosal abnormalities, especially when colonoscopy cannot be performed. Barium enema studies may also demonstrate source of bleeding other than UC, such as a polyp.
  • An upper GI series with small-bowel follow-through is used to evaluate for small-bowel inflammation that would support a diagnosis of CD rather than UC.
  • CT scanning of the abdomen is useful to evaluate for bowel-wall thickening and obstruction. If present, abscesses and fistulae imply a diagnosis of CD rather than UC.
  • Radionuclide-tagged WBC scanning can be used to demonstrate small-bowel inflammation that differentiates CD from UC.
  • MRI of the abdomen is increasingly used to evaluate the large and small bowel for inflammatory changes and to look for transmural versus mucosal inflammation.
  • Wireless video capsule endoscopy, also known as the Pillcam, is an increasingly used imaging technology that may reveal small bowel involvement in inflammatory bowel disease (IBD) that differentiates CD from UC.

Procedures

  • Colonoscopy with biopsy is the most valuable procedure in the evaluation of the patient with IBD.
    • Typical findings in someone with UC are inflammation first evident in the rectum that proximally extends in a contiguous fashion. The mucosa typically appears erythematous, friable, and granular, and it has lost the normally visible vascular markings.
    • Findings more consistent with CD than with UC are sparing of the rectal mucosa, aphthous ulceration, and noncontiguous or skip lesions.
  • When possible, visualizing the entire colon and the last portion of the ileum (terminal ileum) is best because the terminal ileum is not actively involved in UC but is commonly involved in CD. However, patients with pancolitis occasionally have microscopic inflammation in the terminal ileum, which is thought to be secondary to reflux of colonic contents through an inflamed ileocecal valve (ie, backwash ileitis).

Histologic Findings

  • Biopsy findings consistent with UC are polymorphonuclear leukocytes near the base of the crypts.
  • Cryptitis describes aggregation of polys in the crypt epithelium, and the term crypt abscess is used when polys have accumulated in the lumen of the crypt.
  • Lymphocytes, eosinophils, and mast cells may also be observed in the lamina propria in acute UC. However, no pathognomonic biopsy findings have been described for UC.
  • Noncaseating granulomas are diagnostic of CD.

More on Ulcerative Colitis

Overview: Ulcerative Colitis
Differential Diagnoses & Workup: Ulcerative Colitis
Treatment & Medication: Ulcerative Colitis
Follow-up: Ulcerative Colitis
Multimedia: Ulcerative Colitis
References
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References

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Further Reading

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Keywords

ulcerative colitis, UC, fulminant colitis, ulcerative proctitis, ulcerative proctocolitis, inflammatory bowel disease, IBD, Crohn disease, Crohn's disease, CD, cryptitis, abdominal cramping, bloody stool, diarrhea, rectal bleeding, anorexia, weight loss, leukocytosis, hypoalbuminemia, severe hemorrhage, toxic megacolon, intestinal perforation, growth failure, arthropathy, tachycardia, tachypnea, anemia, hypokalemia, hypomagnesemia, hypoproteinemia, pancolitis, sclerosing cholangitis, carcinoma, pyoderma gangrenosum, uveitis, arthritis, chronic active hepatitis, granulomatous hepatitis, amyloidosis, fatty liver, pericholangitis, thromboembolic disease, factor V, factor VIII, deep venous thrombosis, pulmonary emboli, neurovascular disease

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Contributor Information and Disclosures

Author

Jonathan E Markowitz, MD, Associate Professor of Clinical Pediatrics, University of South Carolina School of Medicine; Attending Pediatric Gastroenterologist, Associate Director of Pediatric Residency Program, Greenville Hospital System
Jonathan E Markowitz, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, Crohns and Colitis Foundation of America, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Coauthor(s)

Petar Mamula, MD, Assistant 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.

Robert Baldassano, MD, Director, Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology and Nutrition, Associate Professor, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania
Robert Baldassano, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
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.

Liz D Dancel, MD, Resident, Department of Pediatrics, Greenville Hospital System University Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Jorge H Vargas, MD, Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, David Geffen School of Medicine, University of California at Los Angeles; 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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

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.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Chief Editor

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.

 
 
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