Differential Diagnosis of Inflammatory Bowel Disease:
Clostridium difficile infection
Irritable bowel syndrome
Hx: Extraintestinal Manifestations of Inflammatory Bowel Disease
Primary sclerosing cholangitis
Ankylosing spondylitis (see Spondyloarthritis)
Rare complication; seen more in CD than UC.
Small ulcers between gums and lower lip or along tongue; related to IBD disease activity.
Frequently classified as one of two types: type 1 affects large joints of arms and legs (elbows, wrists, knees, ankles); symptoms often acute and migratory; correlate with active bowel disease. Type 2 is symmetric, affects small joints, and is often chronic; unrelated to bowel disease activity.
Primary sclerosing cholangitis (see Hepatitis)
Severe inflammation and scarring of bile ducts; more common in UC and men,
Hx: Jaundice, nausea, pruritus, weight loss.
May be complicated by cholangiocarcinoma or colon cancer.
Pain and stiffness in lower spine and sacroiliac joints; may present before IBD symptoms.
Deep pain, redness of sclera. An ophthalmologic emergency.
Pain, blurry vision, photosensitivity, redness of eye. An ophthalmologic emergency.
More common in women with CD; related to IBD and therapy. Periodic screening important.
Tender, red nodules over shins and ankles; more common in UC and women; related to IBD disease activity.
Papules and pustules coalesce to form deep, chronic ulcers, often on shins and ankles; more common in UC; related to IBD disease activity.
Tx: Medical Therapy for Inflammatory Bowel Disease
Sulfasalazine, olsalazine, balsalazide, mesalamine: oral, rectal
Antibiotics (metronidazole, ciprofloxacin)
Oral, intravenous, rectal
Anti–TNF-α (adalimumab, certolizumab pegol, infliximab)
Acute-onset diarrhea with fever, chills, hematochezia, and/or pus in stool; positive stool culture (Escherichia coli or Campylobacter, Shigella, Salmonella, or Yersinia spp.)
Acute diarrhea caused by Entamoeba or Giardia spp.; Entamoeba spp. may cause hepatic abscess and RUQ pain; history of travel or drinking untreated water; stool antigens detected by ELISA
Clostridium difficile infection
Watery stool, lower abdominal cramping, fever, leukocytosis; recent antibiotic use, hospitalization, or stay in long term-care facility; C. difficile toxin in stool
*Irritable bowel syndrome
Hx: Patients meeting the Rome III (IBS) diagnostic criteria have recurrent abdominal pain or discomfort at least 3 days each month in the past 3 months (12 weeks) (with onset more than 6 months earlier) [not necessarily consecutive] associated with two or more of the following:
- Improvement with defecation;
- Onset associated with change in frequency of stool;
- Onset associated with change in form (appearance) of stool.
Dx: Normal colonoscopy
Alarm symptoms (not present) include onset after age 50 years, brief history of symptoms, weight loss, nocturnal symptoms, family history of colon cancer, rectal bleeding, and recent antibiotic use.
Tx: FODMAP diet
Celiac disease occurs in genetically predisposed persons with haplotype HLA-DQ2 or HLA-DQ8
Hx: Abdominal pain, bloating, diarrhea triggered by ingestion of gluten that is present in wheat, rye, and barley. Malabsorption, malnutru=ition, and iron deficiency anemia may be present.
Dx: Tissue transglutaminase antibody
Tx: Avoidance of gluten-containing foods is curative
Hx: Abdominal pain, bloating, chronic watery diarrhea; chronic NSAID use implicated in >50% of cases
Dx: Normal colonoscopy but abnormal biopsy with two subtypes (lymphocytic, collagenous);
Abdominal pain, bloating, diarrhea after lactose ingestion
LLQ pain, fever, diarrhea; abdominal CT shows inflamed diverticula
Abdominal pain, diarrhea, hematochezia; elderly patients with vascular disease; imaging of mesenteric vessels confirms diagnosis
Tenesmus, diarrhea, hematochezia; history of receptive anal intercourse; positive bacterial or viral cultures (Neisseria, Chlamydia, or Treponema spp.; HSV)