Differential diagnosis

Condition Crohn's disease Differential Diagnosis table for Irritable bowel syndrome Differentiating signs/symptoms Differentiating tests

May present with fatigue, diarrhoea, abdominal pain, weight loss, fever and rectal bleeding. Other signs may include presence of oral ulcers, perianal skin tags, fistulae, abscesses and sinus tracts; abdominal exam may reveal a palpable mass in the ileocecal area; no mass present on digital rectal examination. May present with bloody diarrhea, hx lower abdominal pain, fecal urgency, presence of extraintestinal manifestations (e.g., erythema nodosum, acute arthropathy), hx of primary sclerosing cholangitis. No mass present on digital rectal examination.

• • • • • • • •

Stool culture, microscopy and antigen testing: negative. Upper GI and small bowel series: edema and ulceration of the mucosa with luminal narrowing and strictures. CT/MRI abdomen: skip lesions, bowel wall thickening, surrounding inflammation, abscess, fistulae. Colonoscopy: aphthous ulcers, hyperemia, edema, cobblestoning, skip lesions. Stool culture, microscopy and antigen testing: negative. Histology: continuous distal disease, mucin depletion, basal plasmacytosis, diffuse mucosal atrophy, absence of granulomata and anal sparing. Colonoscopy: rectal involvement, continuous uniform involvement, loss of vascular marking, diffuse erythema, mucosal granularity, fistulas (rarely seen), normal terminal ileum (or mild "backwash" ileitis in pancolitis). The basic laboratory tests may reveal azotaemia and hypokalaemia. Although the colon mucosa may look normal endoscopically, there will be abnormal changes histologically on colon biopsies. Although many patients with coeliac disease will have no routine laboratory abnormalities, basic laboratory tests in coeliac disease can reveal an irondeficiency anaemia, hypocalcaemia, or a prolonged prothrombin time. Antiendomysial antibodies and tissue transglutaminase antibodies may be detected in coeliac disease. Small bowel biopsy will be abnormal with partial villous atrophy in coeliac disease. Colon cancer can be diagnosed by colonoscopy, whereas cancers of the rectum, sigmoid, and lower descending colon can be seen with flexible sigmoidoscopy. Although less sensitive than endoscopy, many colon cancers can be seen on aircontrast barium enema. CT colography is accurate for colon neoplasms but is not yet widely available. Iron-deficiency anaemia may be present. Stool examination for ova and parasites can be used for screening. Multiple stools should be examined. The serum Giardia antigen is accurate for diagnosing Giardia lamblia.

Ulcerative colitis

Lymphocytic and collagenous colitis Coeliac disease

• •

The patient with lymphocytic or collagenous colitis will have soft to watery diarrhoea that often is not associated with pain and tends not to be episodic. Physical examination is normal. Patients with coeliac disease usually have weight loss. The physical examination is usually negative. Some patients with coeliac disease will have early osteoporosis.

Colon cancer

Colon cancer can sometimes cause a change in bowel habits with either constipation or more frequent, smaller calibre stools. Some, but not all, colon cancer patients will have blood in their stool, and a rectal cancer may be palpable on rectal examination. Most bacterial and viral infections in immunocompetent patients are acute. The parasite Giardia lamblia can be associated with diarrhoea, nausea, and bloating. Differentiating tests

Bowel infections

Condition Crohn's disease

• •

Stool culture, microscopy and antigen testing: negative. Upper GI and small bowel series: edema and ulceration of the mucosa with luminal narrowing and strictures. CT/MRI abdomen: skip lesions, bowel wall thickening, surrounding inflammation, abscess, fistulae. Colonoscopy: aphthous ulcers, hyperemia, edema, cobblestoning, skip lesions. Stool culture, microscopy and antigen testing: negative. Histology: continuous distal disease, mucin depletion, basal plasmacytosis, diffuse mucosal atrophy, absence of granulomata and anal sparing. Colonoscopy: rectal involvement, continuous uniform involvement, loss of vascular marking, diffuse erythema, mucosal granularity, fistulas (rarely seen), normal terminal ileum (or mild "backwash" ileitis in pancolitis). The basic laboratory tests may reveal azotaemia and hypokalaemia. Although the colon mucosa may look normal endoscopically, there will be abnormal changes histologically on colon biopsies. Although many patients with coeliac disease will have no routine laboratory abnormalities, basic laboratory tests in coeliac disease can reveal an iron-deficiency anaemia, hypocalcaemia, or a prolonged prothrombin time. Anti-endomysial antibodies and tissue transglutaminase antibodies may be detected in coeliac disease. Small bowel biopsy will be abnormal with partial villous atrophy in coeliac disease. Colon cancer can be diagnosed by colonoscopy, whereas cancers of the rectum, sigmoid, and lower descending colon can be seen with flexible sigmoidoscopy. Although less sensitive than endoscopy, many colon cancers can be seen on air-contrast barium enema. CT colography is accurate for colon neoplasms but is not yet widely available. Iron-deficiency anaemia may be present. Stool examination for ova and parasites can be used for screening. Multiple stools should be examined. The serum Giardia antigen is accurate for diagnosing Giardia lamblia.


Ulcerative colitis

• • •

Lymphocytic and collagenous colitis Coeliac disease

Colon cancer

Bowel infections

Sign up to vote on this title
UsefulNot useful