Crohn Disease Differential Diagnoses

Updated: Jan 06, 2017
  • Author: Leyla J Ghazi, MD; Chief Editor: Praveen K Roy, MD, AGAF  more...
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Diagnostic Considerations

Patients with Crohn disease frequently present with abdominal pain, nonbloody diarrhea, weight loss, fever, and, sometimes, obstructive symptoms such as nausea, early satiety, and vomiting. A variety of intestinal manifestations and extraintestinal manifestations (EIMs) also may be observed in conjunction with either Crohn disease or ulcerative colitis. Features differentiating the 2 forms of inflammatory bowel disease (IBD) are summarized in Table 1, below.

Table 1. Characteristics Differentiating Crohn Disease and Ulcerative Colitis (Open Table in a new window)

  Crohn Disease Ulcerative Colitis
Distribution Entire gastrointestinal tract Colon only, though gastritis is recognized
Skip lesions Continuous involvement proximally from rectum
Pathology Full thickness Mucosa only
Granulomas (15-30% in biopsy specimens; 40-60% in surgically resected bowel) No granulomas
Radiology Entire gastrointestinal tract Colon only
Skip lesions Continuous involvement proximally from rectum
Fistulae, abscesses, fibrotic strictures Mucosal disease only
Cancer risk Increased Estimated to be 3% at 10 years, 8% at 30 years, and 18% at 30 years after diagnosis [46] ; risk is higher in patients with primary sclerosing cholangitis and long-standing colitis (> 8-10 y); may be lower in subsequent studies (see Intestinal Manifestations).
  Crohn Disease Ulcerative Colitis
Bleeding Occasional Very common
Obstruction Common Uncommon
Fistulae Common None
Weight loss Common Uncommon
Perianal disease Common Rare

Despite extensive workup, 15% of patients with isolated colitis have an undetermined type of IBD that shows features of both Crohn disease and ulcerative colitis. The distinction is often difficult to make, especially if the patient meets all diagnostic criteria for ulcerative colitis but is a smoker or has rectal sparing—features that suggest the possibility of Crohn disease or IBD of undetermined type.

In addition, there is a subpopulation of patients with Crohn colitis who will not develop small bowel disease in their lifetime. This group represents approximately 20% of the colitis patients.

Differential Diagnoses