History
The manifestations of inflammatory bowel disease (IBD) generally depend on the area of the intestinal tract involved. The commonly experienced symptoms of Crohn disease include recurrent abdominal pain and diarrhea. Sometimes, the diagnosis may be delayed by several months to a few years, as these symptoms are not specific for IBD. Patients with IBD may have symptoms of irritable bowel syndrome (IBS), with cramping, irregular bowel habits, and passage of mucus without blood or pus.
Systemic symptoms are common in IBD and include weight loss, fever, sweats, malaise, and arthralgias. A low-grade fever may be the first warning sign of a flare. Patients are commonly fatigued, which is often related to the pain, inflammation, and anemia that accompany disease activity. Recurrences may occur with emotional stress, infections or other acute illnesses, pregnancy, dietary problems, use of cathartics or antibiotics, or nonadherence to therapy. Children may present with growth retardation and delayed or failed sexual maturation. In 10%-20% of cases, patients present with extraintestinal manifestations, including arthritis, uveitis, or liver disease (see Complications).
Grossly bloody stools, occasionally with tenesmus, although typical of ulcerative colitis, are less common in Crohn disease. Stools may be formed, but loose stools predominate if the colon or the terminal ileum is involved extensively. Fifty percent of patients with Crohn disease may present with perianal disease (eg, fistulas, abscesses). Occasionally, acute right lower quadrant pain and fever, mimicking appendicitis or intestinal obstruction, may be noted. Weight loss is observed more commonly in Crohn disease than in ulcerative colitis because of the malabsorption associated with small bowel disease, or small bowel disease may act as an appetite deterrent. In addition, patients may reduce their food intake in an effort to control their symptoms.
The World Gastroenterology Organization (WGO) indicates the following symptoms may be associated with inflammatory damage in the digestive tract [1] :
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Diarrhea: mucus or blood may be present in the stool; can occur at night; incontinence may occur
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Constipation: this may be the primary symptom in ulcerative colitis, when the disease is limited to the rectum; obstipation may occur and may proceed to bowel obstruction
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Bowel movement abnormalities: pain or rectal bleeding may be present, as well as severe urgency and tenesmus
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Abdominal cramping and pain: commonly present in the right lower quadrant in Crohn disease; occur periumbilically or in the left lower quadrant in moderate to severe ulcerative colitis
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Nausea and vomiting: occurs more often in Crohn disease than in ulcerative colitis
Other considerations include a family history of IBD, celiac disease, or colorectal cancer; the use of medications such as antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs); the presence of mood disorders; the use of tobacco; and recent travel. [1]
Physical Examination
Fever, tachycardia, dehydration, and toxicity may occur in patients with inflammatory bowel disease (IBD). Pallor may also be noted, reflecting anemia. The prevalence of these factors is directly related to the severity of the attack.
Toxic megacolon is a medical emergency. Patients appear septic; have high fever, lethargy, chills, and tachycardia; and have increasing abdominal pain, tenderness, and distention.
Patients with Crohn disease may develop a mass in the right lower quadrant. Perianal complications (eg, perianal fissures or fistulas, abscesses, rectal prolapse) may be observed in up to 90% of patients with this disease. [2] Common presenting signs include occult blood loss and low-grade fever, weight loss, and anemia. The rectal examination often reveals bloody stool or a positive Hemoccult stool test.
Growth retardation may be the only presenting sign of IBD in young patients. The physical examination should also include a search for extraintestinal manifestations, such as iritis, episcleritis, arthritis, and dermatologic involvement. (see Complications.)
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Inflammatory bowel disease. Severe colitis noted during colonoscopy in a patient with inflammatory bowel disease. The mucosa is grossly denuded, with active bleeding noted. The patient had her colon resected very shortly after this view was obtained.
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Inflammatory bowel disease. Stricture in the terminal ileum noted during colonoscopy in a patient with inflammatory bowel disease. This image depicts a 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.
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Inflammatory bowel disease. Enteroenteric fistula noted on a small bowel series of x-ray films in a patient with inflammatory bowel disease. 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 the 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.
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Inflammatory bowel disease. The table distinguishes features of Crohn disease (CD) and ulcerative colitis (UC).
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Inflammatory bowel disease. Toxic megacolon. Courtesy of Dr. Pauline Chu.
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Inflammatory bowel disease. Early pyoderma gangrenosum, before skin breakdown. Medial aspect of the right ankle in a patient with inflammatory bowel disease. Same day and same patient as in the next image.
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Inflammatory bowel disease. Pyoderma gangrenosum. Courtesy of Dr. Gene Izuno.
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Inflammatory bowel disease. Severe advanced pyoderma gangrenosum of the medial aspect of the left ankle in a patient with inflammatory bowel disease.
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Inflammatory bowel disease. Crohn disease involving the terminal ileum. Note the "string sign" in the right lower quadrant (viewer's left).
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Inflammatory bowel disease. Increased postrectal space is a known feature of ulcerative colitis.
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Inflammatory bowel disease. Plain abdominal radiograph of a patient with known ulcerative colitis who presented with an acute exacerbation of his symptoms. This image shows thumbprinting in the region of the splenic flexure of the colon.
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Inflammatory bowel disease. Double-contrast barium enema study shows pseudopolyposis of the descending colon in a patient with ulcerative colitis.
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Inflammatory bowel disease. 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 (<i>arrow</i>). Note the pseudopolyposis in the descending colon.
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Inflammatory bowel disease. This 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 oriented.
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Inflammatory bowel disease. This 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.
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Inflammatory bowel disease. Inflamed colonic mucosa demonstrating pseudopolyps in a patient with ulcerative colitis.
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Inflammatory bowel disease. Chronic architectural changes in ulcerative colitis. Note the crypt branching and irregularity of size and shape, with an increase in chronic inflammatory cells in the lamina propria.
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Inflammatory bowel disease. High-power view of a crypt abscess in ulcerative colitis shows the crypt to be dilated and filled with neutrophils and debris.
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Inflammatory bowel disease. Chronic architectural changes in ulcerative colitis. Note the trifid crypt.
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Inflammatory bowel disease. Basal plasmacytosis in ulcerative colitis. Plasma cells separate the crypt bases from the muscularis mucosae.
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Inflammatory bowel disease. Low-power image of a colon biopsy specimen in a patient with ulcerative colitis illustrates changes limited to the mucosa. These changes include chronic alterations of the crypt architecture and an increase in chronic inflammatory cells in the lamina propria.
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Inflammatory bowel disease. Bowel-wall thickening and foreshortening are apparent in this specimen from a colectomy for ulcerative colitis. In addition, the mucosa is hyperemic, with focal nodularity and ulceration.
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Inflammatory bowel disease. Another gross specimen illustrating ulcerative colitis.
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Inflammatory bowel disease. This is an example of low-grade glandular dysplasia in a patient with longstanding ulcerative colitis. Note the loss of mucin, nuclear hyperchromasia, and nuclear pseudostratification. See the next image.
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Inflammatory bowel disease. High-grade dysplasia in the same patient as the previous image. There is significant cytologic atypia, with rounding of the nuclei and a greater degree of pseudostratification.
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Inflammatory bowel disease. Histologic section from another location in the same patient as described in the previous image. This field shows glands that are suspicious for invasive carcinoma.
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Inflammatory bowel disease. Computed tomography scan depicting Crohn disease in the fundus of the stomach.
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Inflammatory bowel disease. Double-contrast barium enema study demonstrates marked ulceration, inflammatory changes, and narrowing of the right colon in a patient with Crohn colitis.
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Inflammatory bowel disease. Cobblestoning in Crohn disease. Spot views of the terminal ileum from a small bowel follow-through study demonstrates linear longitudinal and transverse ulcerations that create a cobblestone appearance. Also, note the relatively greater involvement of the mesenteric side of the terminal ileum and the displacement of the involved loop away from the normal small bowel secondary to mesenteric inflammation and fibrofatty proliferation.
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Inflammatory bowel disease. Crohn disease involving the terminal ileum. Note the "string sign" in the right lower quadrant (viewer's left).
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Inflammatory bowel disease. This computed tomography scan from a patient with terminal ileal Crohn disease shows an enteroenteral fistula (arrow) between loops of diseased small intestine.
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Inflammatory bowel disease. A teenage patient with Crohn disease underwent a contrast-enhanced upper gastrointestinal computed tomography study with small-bowel follow-through. Several loops of small bowel are in the pelvis. Note there is a loop of distal bowel with a thickened wall (solid arrow), which is contrasted with a less involved loop of bowel in which the intestinal wall is not thickened at all (dotted arrow).
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Inflammatory bowel disease. Computed tomography scan depicting Crohn disease in the fundus of the stomach.
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Inflammatory bowel disease. This colonoscopic image of a large ulcer and inflammation of the descending colon in a 12-year-old boy with Crohn disease.
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Inflammatory bowel disease. This laparoscopic view depicts creeping fat along the mesentery of the terminal ileum in a patient with Crohn disease.
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Inflammatory bowel disease. Cobblestone change of the mucosa of the terminal ileum in a patient with Crohn disease. Communicating fissures and crevices in the mucosa separate islands of more intact, edematous epithelium.
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Inflammatory bowel disease. Fat wrapping on the serosal surface of the terminal ileum in Crohn disease. Fat wrapping often correlates directly with underlying strictures, stenosis, or areas of previous transmural inflammation.
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Inflammatory bowel disease. Colonic granuloma in a patient with Crohn disease (arrow). Hematoxylin-eosin staining. Courtesy of Dr E. Ruchelli.
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Inflammatory bowel disease. A deep knifelike, fissuring, transmural ulcer in Crohn disease is shown in this histologic image.
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Inflammatory bowel disease. Another example of a deep, fissuring ulcer in a patient with Crohn disease. Note the increase in submucosal inflammation and scattered lymphoid aggregates.
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Inflammatory bowel disease. Prominent lymphoid aggregates and granuloma in the muscularis propria and pericolic fat of patient with Crohn disease. The inflammation extends through the full thickness of the bowel wall.
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Inflammatory bowel disease. A crypt abscess demonstrating active, neutrophilic inflammation in Crohn disease.
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Inflammatory bowel disease. Granuloma in the mucosa in a Crohn disease patient.
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Inflammatory bowel disease. Double-contrast barium enema study shows changes of ulcerative colitis disease. Note the granular mucosa.
Tables
Complication |
Prevalence |
Scleritis |
18% |
Anterior uveitis |
17% |
Gall stones (particularly in Crohn disease) |
13%-34% |
Inflammatory arthritis |
10%-35% |
Anemia |
9%-74% |
Aphthous stomatitis |
4%-20% |
Osteoporosis |
2%-20% |
Erythema nodosum |
2%-20% |
Source: Larson S, Bendtzen K, Nielsen OH. Extraintestinal manifestations of inflammatory bowel disease: epidemiology, diagnosis and management. Ann Med. 2010;42:97-114. |
|
Complication |
Crohn Disease |
Ulcerative Colitis |
Arthritis |
33% |
4% |
Aphthous stomatitis |
10% |
4% |
Uveitis |
6% |
3% |
Erythema nodosum |
6% |
3% |
Ankylosing spondylitis |
6% |
2% |
Psoriasis |
2% |
1% |
Pyoderma gangrenosum |
2% |
2% |
Primary sclerosing cholangitis |
1% |
4% |
Source: Vavricka SR, Brun L, Ballabeni P, et al. Frequency and risk factors for extraintestinal manifestations in the Swiss inflammatory bowel disease cohort. Am J Gastroenterol. 2011;106:110-9. |
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