Inflammatory Bowel Disease Clinical Presentation

Updated: Apr 10, 2020
  • Author: William A Rowe, MD; Chief Editor: BS Anand, MD  more...
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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] :

  • Diarrhea: mucus or blood may be present in the stool; can occur at night; incontinence may occur

  • 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

  • Bowel movement abnormalities: pain or rectal bleeding may be present, as well as severe urgency and tenesmus

  • 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

  • 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.)