Endoscopic Diagnosis of IBD

Endoscopic diagnosis of inflammatory bowel disease - UpToDate Page 1 of 23
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Endoscopic diagnosis of inflammatory bowel disease

Author: Michael A Roy, MD
Section Editors: Paul Rutgeerts, MD, PhD, FRCP, John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor: Kristen M Robson, MD, MBA, FACG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2020. | This topic last updated: Jun 04, 2018.
INTRODUCTION
Gastrointestinal (GI) endoscopy has a pivotal role in the diagnosis of suspected

inflammatory bowel disease (IBD) [1-6]. Colonoscopy with ileoscopy,
esophagogastroduodenoscopy (EGD), and enteroscopy can usually differentiate between
IBD and its mimics, particularly when augmented by results of histopathology. In addition,
other modalities such as endoscopic ultrasonography have considerable utility in the
diagnosis and evaluation of complicated anorectal Crohn disease and in the differentiation
of ulcerative colitis from Crohn’s colitis [7]. Beyond its diagnostic utility, GI endoscopy has
an important role in the staging of severity of disease, evaluation and treatment of strictures,
detection of postoperative recurrence, assessment of the efficacy of medical therapy,
surveillance for neoplasms, and preoperative assessment, particularly in Crohn disease.
This topic will review the diagnostic accuracy of GI endoscopy, the major endoscopic
findings that may be seen in patients with IBD, and some practical considerations regarding
endoscopy in patients with suspected IBD. The current challenge is to select patients who
will benefit from endoscopy, and to decide when to use other diagnostic modalities either in
combination with or instead of endoscopy. The clinical manifestations and treatment of the
different forms of this disorder are discussed separately.
● (See "Clinical manifestations, diagnosis, and prognosis of Crohn’s disease in adults".)
https://www.uptodate.com/contents/endoscopic-diagnosis-of-inflammatory-bowel-disease/... 3/11/2020
● (See "Overview of the medical management of mild (low risk) Crohn disease in adults".)
● (See "Overview of medical management of high-risk, adult patients with moderate to
severe Crohn disease".)
● (See "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults".)
● (See "Medical management of low-risk adult patients with mild to moderate ulcerative
colitis".)
● (See "Management of the hospitalized adult patient with severe ulcerative colitis".)
ILEOCOLONIC DISEASE
Endoscopic findings in ulcerative colitis — Endoscopy in ulcerative colitis (UC) typically

reveals the following:
● Erythema
● Edema/loss of the usual fine vascular pattern
● Granularity of the mucosa
● Friability/spontaneous bleeding
● Pseudopolyps
● Erosions
● Ulcers
The granular appearance is manifested by changes in light reflection during colonoscopy.

Instead of reflecting light in large patches, the granular mucosa reflects a multitude of small
points of light, giving the appearance of "wet sandpaper" [4]. Many different scores have
been used to assess the severity of the endoscopic lesions used in therapeutic studies. The
score used in most drug studies is the Mayo endoscopic score of activity (calculator 1) [8].
The Mayo score ranges from 0 to 12, with higher scores corresponding with more severe
disease. The endoscopic subscore ranges from 0 to 3.
The endoscopic findings in UC begin at the anal verge and extend proximally. The
involvement is almost always continuous and circumferential, with inflammation beginning
from the point of origin and continuing to a gradual transition to normal mucosa (picture 1)
[4]. A progressive increase in chronic inflammation in a proximal to distal pattern supports
the diagnosis of UC [9]. Occasional patients with treated UC or newly diagnosed UC
demonstrate rectal sparing or patchiness of distribution of inflammatory changes [10,11].
However, the prevalence of these findings is likely overestimated by standard evaluation
with colonoscopy and endoscopic biopsy when compared with colectomy specimens [12]. In
addition, a subset of patients with UC has focal inflammation around the appendiceal orifice
that is not contiguous with disease elsewhere in the colon (a "cecal patch") [13,14]. The
distribution may also become patchy as a result of therapy.
Pseudopolyps are not specific for UC but are more common in this disorder, occurring in
approximately 20 percent of cases (picture 2). They can range from a few millimeters in
diameter to a centimeter or more. They tend to be taller than they are wide and can mimic
neoplasms; biopsy confirms that they are not neoplastic [4]. Pseudopolyps are associated
with increased severity and more extensive involvement in UC. However, the outcome in
patients with pseudopolyps is better than in those with similar disease extent and severity
who do not have pseudopolyps [15].
Backwash ileitis — Backwash ileitis refers to the presence of inflammation in the distal
ileum in patients with ulcerative colitis. The term "backwash" evolved from a belief that the
inflammation arose from exposure of the ileal mucosa to cecal contents, although the
precise pathogenesis is not well understood. A detailed review of ileocolonic resection
specimens in 200 patients in whom Crohn disease was definitively excluded found a
prevalence of 17 percent [16].
In most reports, the severity of ileal inflammation paralleled the severity of colonic
inflammation and was more common in patients with pancolitis compared with those with
only distal disease [16-18]. An association with an aggressive disease course, primary
sclerosing cholangitis, and an increase risk of development of pouchitis following restorative
proctocolectomy has also been reported [19]. One study suggested that the presence of
backwash ileitis may predict an increased risk of development of dysplasia and colorectal
cancer [17], although this observation has not been confirmed in other reports.
When faced with endoscopic findings of pancolitis and distal ileal inflammatory changes, it is
important to obtain adequate mucosal biopsies to help distinguish Crohn ileocolitis from
pan-ulcerative colitis with backwash ileitis. The presence of granulomatous inflammation on
histology can help make this distinction, but when granulomata are absent, upper
gastrointestinal and small bowel imaging may be useful.
Endoscopic findings in Crohn disease — There are three major endoscopic findings that
are specific for the diagnosis of Crohn disease and help to distinguish it from UC [1]:
● Aphthous ulcers – Small discrete aphthous ulcers can be seen in early lesions (picture
3) [9]. Deeper ulcers involve the entire wall of the colon, in contrast to the ulcers in
patients with UC, which involve only the mucosa.
● Cobblestoning – Serpiginous and linear ulcers can course for several centimeters along
the longitudinal axis of the colon in Crohn disease (picture 4) [4]. This type of ulceration
results in the typical cobblestoning lesions; the deep linear ulcers are the "cracks"
between the stones, while areas of inflamed or normal tissue form the "stones".
● Discontinuous lesions – Crohn disease lesions are typically discontinuous. They can be
adjacent to normal tissue, resulting in "skip areas" (picture 5). In contrast, UC tends to
be continuous and taper out gradually. If a biopsy taken from endoscopically normal
tissue adjacent to an ulcer shows normal histology, the ulcer is probably due to Crohn
disease [4].
Other endoscopic findings that support the diagnosis of Crohn disease, but are not specific,
include the following:
● A normal rectum supports the diagnosis of Crohn disease, since UC always involves
the rectum. On the other hand, involvement of the left side of the colon in general is
less common in Crohn disease than in ulcerative colitis.
● The presence of normal vasculature adjacent to affected tissue is seen in Crohn

disease, while loss of vascularity and friability is more typical of UC.
● Isolated involvement of the terminal ileum is highly suggestive of Crohn disease.

Terminal ileitis or "backwash ileitis" can occur in UC, but is only seen in the setting of
pancolitis, allowing the distinction from Crohn disease [3]. Ileoscopy should always be
attempted in patients with suspected Crohn disease; it adds little or no risk to a
diagnostic colonoscopy [20]. (See 'Backwash ileitis' above.)
The relationship between endoscopic and clinical severity is relatively weak, but statistically
significant in Crohn disease [21].
Two scores have been developed (the CDEIS and the SES-CD score) for the assessment
of the severity of endoscopic lesions in Crohn disease. These scores are used mostly in
clinical drug trials in Crohn disease, in which mucosal healing has become one of the major
endpoints [22,23].
ENDOSCOPY VERSUS RADIOGRAPHY IN ILEOCOLONIC IBD
Ulcerative colitis and Crohn disease (CD) were traditionally diagnosed using clinical
characteristics, radiologic studies, and proctosigmoidoscopy. However, radiographic studies
are now considered an adjunctive rather than a primary diagnostic tool due to the nearly
universal availability of colonoscopy.
Barium studies — The use of barium enema as an imaging modality in the diagnosis of
IBD has practically disappeared from clinical practice. When additional imaging is required
to supplement the diagnostic yield of endoscopic procedures, it is obtained from more
precise imaging studies.
Other radiologic tests — Several other radiologic tests have been used in the diagnosis of
IBD. These include ultrasonography, magnetic resonance imaging (MRI), scintigraphy, and
computed tomography (CT) [24-30]. A meta-analysis of prospective studies that used these
modalities in the diagnosis of IBD found relatively good levels of diagnostic accuracy [31].
Little difference in accuracy was found among these modalities and the authors stressed the
need to limit the exposure to ionizing radiation given the chronic nature of IBD and the need
for repeated re-evaluation.
The use of MRI for assessment of Crohn disease is expanding, and a number of studies are
attempting to validate predictors of aggressive CD. Several groups are developing a
Magnetic Resonance Index of Activity [32]. An advantage of MRI over CT is the lack of
radiation exposure. Because of this, it is the preferred study in some centers. (See "Clinical
manifestations, diagnosis, and prognosis of Crohn’s disease in adults", section on 'Imaging'
and "Radiation-related risks of imaging".)
ROLE IN DIFFERENTIAL DIAGNOSIS
The clinical and radiographic presentation of inflammatory bowel disease (IBD) can be
mimicked by a host of other disorders. As a result, gastrointestinal (GI) endoscopy has an
indispensable role in the differential diagnosis of IBD.
Infectious colitis and/or ileitis — Several infectious agents can cause mucosal
inflammation and look identical to either Crohn disease or ulcerative colitis (UC) at
colonoscopy (table 1 and picture 6). In one study of patients with mucoid bloody diarrhea
and suspected inflammatory bowel disease, 38 percent were found to have an infectious
colitis [33]. As noted below, histologic findings may help to distinguish these disorders, with
crypt distortion favoring the diagnosis of inflammatory bowel disease [34].
In patients with ulcerative colitis, infection with cytomegalovirus (CMV) can pose major
diagnostic and therapeutic dilemmas. Early diagnosis is essential and prior to the
widespread use of ganciclovir, patient outcomes were frequently quite poor. One
retrospective study suggested that certain endoscopic findings (wide mucosal defects,
"punched out" ulcerations, linear ulcerations) may highly correlate with CMV colitis in
patients with concomitant ulcerative colitis [35].
The self-limited nature of most episodes of infectious colitis often differentiates it from IBD
without the need for endoscopy. Examination of the stool for ova and parasites, and aerobic
and anaerobic culture are required for confusing cases.
Tuberculosis of the terminal ileum and cecum can mimic Crohn disease by producing a
narrowed lumen and nodularity. The presence of caseating granulomas, positive culture, or
acid fast bacilli on colonoscopic biopsy specimens establishes the diagnosis of tuberculosis
[36]. Other endoscopic findings suggestive of tuberculosis are grouped ulcers, nodules, and
destruction of the ileocecal valve. Other authors have reported the association of certain
clinical features (blood in the stool, weight loss, sigmoid colon involvement, and focally
enhanced colitis) with intestinal tuberculosis [37]. It may be difficult to detect granulomas
due to their deep location; thus, their absence does not rule out tuberculosis. Biopsies
should be taken from the raised edematous margins and sent for histologic as well as
bacteriologic tests [36]. (See "Abdominal tuberculosis".)
Other infectious agents can cause terminal ileitis and confusion with Crohn disease. In one
prospective study, for example, 7 percent of 110 patients with suspected IBD based upon
radiography had an eventual diagnosis of infectious colitis [3]. In addition to tuberculosis,
other causative agents included Yersinia enterocolitica, Campylobacter, Shigella, and
Salmonella caused ileitis (table 1).
Pseudomembranous colitis — Pseudomembranous colitis may resemble IBD. Small

groups of pseudomembranes can look grossly like the aphthous ulcers of Crohn disease
(picture 7A-B). However, the pseudomembranes are present on top of the mucosa, and do
not result in ulceration of the underlying tissue. (See "Clostridioides (formerly Clostridium)
difficile infection in adults: Clinical manifestations and diagnosis", section on 'Endoscopy'.)
NSAID ileitis — Chronic use of nonsteroidal antiinflammatory drugs (NSAIDs) has been
associated with a variety of pathologic changes throughout the GI tract. Thus, NSAID use
should be considered in the differential diagnosis of ulcerations and/or inflammatory
changes. (See "NSAIDs: Adverse effects on the distal small bowel and colon".)
Radiation colitis — Radiation can cause mucosal inflammation that resembles ulcerative
colitis. It tends to be continuous, friable, and left-sided. A history of abdominal radiation,
even if temporally distant, should differentiate the two diagnoses. (See "Clinical
manifestations, diagnosis, and treatment of radiation proctitis", section on 'Endoscopy and
biopsy'.)
Ischemic colitis — Ischemic colitis tends to be continuous, left-sided, and associated with
mucosal friability, findings that resemble ulcerative colitis (picture 8). The keys to proper
diagnosis are sparing of the rectum in ischemic colitis and the presence of risk factors for
ischemic colitis (eg, atherosclerotic disease, congestive heart failure, recent hypotension).
(See "Colonic ischemia".)
Colitis associated with diverticular disease — Infrequently, patients with diverticular

disease develop a segmental colitis, most commonly in the sigmoid colon. The clinical,
endoscopic, and histologic features vary but can resemble IBD. (See "Segmental colitis
associated with diverticulosis".)
Role of ileoscopy — Visualization and biopsy of the terminal ileum can be routinely
accomplished by an experienced endoscopist in most patients (80 to 97 percent) [38,39].
While this area may also be visualized by barium enema, colonoscopy with ileoscopy has
improved accuracy. As an example, in a study of 110 patients with suspected Crohn
disease based upon involvement of the terminal ileum on barium examination, only 48 (44
percent) had a final diagnosis of Crohn disease [3]. The positive predictive value of
ileoscopy was 96 percent; there was only one false positive result on colonoscopy (due to
Y. enterocolitica infection). Biopsies of the terminal ileum appear to have their greatest
value in patients undergoing colonoscopy who are known to have or are strongly suspected
of having Crohn disease or those with an abnormal imaging study of the terminal ileum [40].
However, some patients with evidence of active small bowel Crohn disease on CT
enterography may have normal ileoscopy. This can occur if the distal ileum is not involved,
or if the inflammation is confined to the intramural portion of the bowel wall and mesentery
[41].
SMALL BOWEL DISEASE
Wireless capsule endoscopy — Experience with wireless capsule endoscopy in the

diagnosis of Crohn disease is discussed separately. (See "Wireless video capsule
endoscopy", section on 'Crohn disease'.)
Radiography — Historically, small bowel radiography has played a key role in the
diagnostic evaluation of patients with suspected Crohn disease. However, other imaging
modalities such as computed tomographic enterography, wireless capsule endoscopy,
magnetic resonance enteroclysis, and magnetic resonance enterography have
demonstrated diagnostic accuracy equivalent to or better than that of standard small bowel
follow-through or enteroclysis [29,42-46]. In addition, the MRI-based modalities avoid
radiation exposure in patients requiring serial small bowel imaging over time.
Enteroscopy — Push enteroscopy can be used to evaluate suspected Crohn disease of

the proximal to mid-small bowel. Its major limitations include the inability to examine all or
most of the small intestine, patient discomfort, and the potential for complications related to
the instrument itself or the associated overtube. The major utility of enteroscopy is for
evaluation and biopsy of lesions seen radiographically or by capsule endoscopy.
Device-assisted enteroscopy (eg, double balloon and single balloon enteroscopy)

represents a major advance in the direct endoscopic inspection of the small bowel. The
instruments can be inserted orally or rectally and complete small bowel visualization can be
achieved in up to 86 percent of cases [47]. Disadvantages include patient discomfort and
very long procedure times. (See "Overview of deep small bowel enteroscopy".)
UPPER GASTROINTESTINAL DISEASE
Up to 4 percent of patients with Crohn disease have gastroduodenal involvement, which is

most effectively diagnosed with esophagogastroduodenoscopy (EGD). Gastroduodenal
disease can present simultaneously with distal disease or at some time after the diagnosis
of distal disease [48]. Gastroduodenal disease is occasionally discovered prior to the
development of distal disease or may occur in isolation.
The differential diagnosis of inflammatory disease isolated to the upper gastrointestinal tract
includes sarcoidosis, peptic ulcer disease, nonspecific duodenitis, eosinophilic
gastroenteritis, tuberculosis, and Brunner's gland hyperplasia.
The endoscopic findings of gastroduodenal Crohn disease are similar to those of distal
disease and include mucosal granularity, nodularity and friability. Stellate, linear, or
serpiginous ulcers may be seen. Aphthous ulcers also occur. Histopathologic examination
has an important role in confirming the diagnosis, particularly in isolated gastroduodenal
disease.
PERIRECTAL DISEASE
Role of endosonography — The use of endoscopic ultrasonography (EUS) to measure

bowel wall thickness and extent of inflammatory changes can help distinguish ulcerative
colitis from Crohn colitis [7]. EUS is also valuable in the diagnosis of perirectal complications
of Crohn disease. A study comparing EUS and MRI with exam under anesthesia (EUA)
found that EUS and MRI had similar accuracy [49]. Combining EUS with either MRI or EUA
yielded optimal results. Rectal endosonography with a linear array probe may be more
accurate than MRI in the diagnosis of complex anorectal Crohn fistulae [50]. (See "The role
of imaging tests in the evaluation of anal abscesses and fistulas", section on
'Endosonography'.)
GENERAL CONSIDERATIONS
Indications — When feasible and safe, direct endoscopic visualization of the

gastrointestinal (GI) tract mucosa is of major value in the diagnosis of suspected
inflammatory bowel disease. This benefit is especially related to the ability to obtain targeted
mucosal biopsy specimens, which can often definitively establish the diagnosis. Patients
should be carefully selected and previously evaluated with appropriate laboratory studies
(including stool cultures) and, when indicated, imaging studies. As a general rule,
endoscopy should be reserved for patients with apparently mild to moderate disease by
history and clinical examination.
When there is diagnostic uncertainty, repeat colonoscopy can confirm or refute the initial
diagnosis of either Crohn disease or ulcerative colitis. In one large series, repeat
colonoscopy one to two years after the initial diagnosis (527 with ulcerative colitis and 228
Crohn disease) resulted in reclassification of the diagnosis in 10 percent [51].
In patients with established chronic colitis, colonoscopy can assist in the evaluation of acute
exacerbations and rule out other diagnostic considerations such as ischemia, diverticulitis,
Clostridioides (formerly Clostridium) difficile, or cytomegalovirus (CMV) colitis [52].
Endoscopy can also provide prognostic information [53].
In the case of patients presenting with acute colitis, limited examination with a flexible
sigmoidoscopy may be all that is needed to establish a diagnosis. Depending upon the
endoscopic appearance, many endoscopists may choose to extend the examination to a full
colonoscopy, the primary benefit of which is to establish the extent of disease within the
colon and to determine whether there is involvement of the terminal ileum.
Bowel preparation — A typical colonoscopy bowel preparation may be too aggressive for
patients with active inflammatory bowel disease (IBD), leading to increased diarrhea and
bleeding. The preparation should be tailored to the individual patient. Clear liquids by mouth
for several days and gentle tap water enemas, for example, may be all that is necessary in
acutely ill patients [4]. Some experts recommend limited colonoscopy without preparation in
this setting. (See "Bowel preparation before colonoscopy in adults".)
Bowel preparations containing sodium phosphate and non-steroidal anti-inflammatory drugs

can also result in endoscopic and histologic artifactual changes. These changes are
occasionally misinterpreted as representing active disease.
Contraindications — In addition to the usual contraindications (such as a perforated

viscus, recent myocardial infarction, and severe diverticulitis), patients with severe acute
colitis, toxic megacolon, or an inability to undergo adequate bowel preparation are not
candidates for colonoscopy. Examining the distal colon with a flexible sigmoidoscope,
particularly in suspected ulcerative colitis (UC), may provide sufficient diagnostic information
with considerably less risk than a full colonoscopy [4].
Biopsy — The specimens should be labeled according to segments from where they were
obtained, since an intermittent pattern of inflammation can be helpful in differentiating Crohn
disease from ulcerative colitis [9]. Biopsies should be obtained at multiple levels, even if the
mucosa appears normal, since up to 40 percent of specimens obtained from grossly normal
appearing tissue in patients with suspected IBD show inflammation on microscopic
evaluation. This is particularly relevant in patients with presumed ulcerative colitis treated
medically prior to undergoing diagnostic colonoscopy or those with primarily distal UC and
findings of periappendiceal inflammation [13,54]. Close attention to details of the clinical
presentation, imaging studies and serologic results, and clear communication with the
pathologist are necessary in bringing clarity to these diagnostic dilemmas.
Biopsy of the terminal ileum further increases the diagnostic accuracy [3]. Abnormal
appearing tissue, polyps and masses should also be sampled to rule out concomitant
neoplastic changes, and brushings and stool samples should be obtained if an infectious
etiology is suspected.
Biopsy of micro-ulcers (less than 5 mm in size) has the highest diagnostic yield, followed by
the edge of larger ulcers [55]. Findings of chronic inflammation support the diagnosis of IBD.
Granulomas are highly suggestive of Crohn disease, but are found in only 5 to 24 percent of
biopsy specimens [3,55].
Histology from a rectal biopsy is useful for differentiating IBD from self-limited (infectious)
colitis. Crypt distortion with forked glands, crypt atrophy, and a villiform surface appearance
support the diagnosis of IBD and are not usually seen with infectious colitis [34]. A mixed
inflammatory infiltrate in the lamina propria is also associated with IBD, but can be more
subjective than crypt distortion. Changes in crypt architecture occur early in the course of
the disease, being seen as soon as seven days after the onset of symptoms in patients with
acute onset IBD [56].
A number of endoscopic features are common to both Crohn disease and ulcerative colitis,
including pseudopolyps, loss of haustral folds, fibrotic strictures, and linear superficial scars
[9]. The ability of histologic examination to differentiate these two inflammatory lesions is
somewhat limited since the mucosa is only able to respond to inflammation in a limited
number of ways [9].
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces
are longer, more sophisticated, and more detailed. These articles are written at the 10th to
12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Crohn disease in adults (The Basics)" and
"Patient education: Ulcerative colitis in adults (The Basics)")
● Beyond the Basics topics (see "Patient education: Crohn disease (Beyond the Basics)"
and "Patient education: Ulcerative colitis (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Gastrointestinal endoscopy has a pivotal role in the diagnosis of suspected

inflammatory bowel disease (IBD) and can differentiate between IBD and its mimics,
particularly when augmented by results of histopathology. (See 'Role in differential
diagnosis' above.)
● Patients should be carefully selected and previously evaluated with appropriate

laboratory studies (including stool cultures) and, when indicated, imaging studies. As a
general rule, endoscopy should be reserved for patients with apparently mild to
moderate disease by history and clinical examination. (See 'Indications' above.)
● Obtaining biopsies at the time of colonoscopy adds little to the risk or duration of the
procedure and should always be performed. The specimens should be labeled
according to segments from where they were obtained. (See 'Biopsy' above.)
● Endoscopy in ulcerative colitis (UC) typically reveals the following (see 'Endoscopic
findings in ulcerative colitis' above):
• Erythema
• Edema/loss of the usual fine vascular pattern
• Granularity of the mucosa
• Friability/spontaneous bleeding
• Pseudopolyps
• Erosions
• Ulcers
● There are three major endoscopic findings that are specific for the diagnosis of Crohn
disease and help to distinguish it from UC: aphthous ulcers, cobblestoning, and
discontinuous lesions. (See 'Endoscopic findings in Crohn disease' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
Topic 4072 Version 16.0
GRAPHICS
Continuous involvement of colonic lesions in ulcerative colitis
In contrast to Crohn disease, lower endoscopy in ulcerative colitis shows continuous and
circumferential involvement, with no normal areas of mucosa.
Courtesy of James B McGee, MD.
Graphic 76332 Version 3.0
Colonic pseudopolyps in inflammatory bowel disease
Endoscopy of pseudopolyps; these lesions are not specific to ulcerative colitis,

although they are more common in this disorder than in Crohn disease.
Aphthous lesions in Crohn disease
Colonoscopy demonstrates small discreet aphthous lesions (superficial

ulcerations) that are characteristic of early lesions in Crohn disease.
Linear ulcerations in Crohn disease
Colonoscopy shows linear ulcers that can course for several centimeters along
the longitudinal axis of the colon in Crohn disease.
Asymmetric distribution of lesions in Crohn disease
Colonoscopy in Crohn disease demonstrates the characteristic patchy erythema

(left panel) and ulceration (right panel) that occur next to areas of normal
mucosa.
Infectious mimics of inflammatory bowel disease
Infectious agents causing colitis and/or ileitis
Bacteria
Shigella species
Enterohemorrhagic Escherichia coli
Enteroinvasive E. coli
Campylobacter jejuni
Salmonella species (gastroenteritis and typhoid fever)
Yersinia enterocolitica
Mycobacterium tuberculosis
Clostridioides (formerly Clostridium) difficile
Vibrio parahaemolyticus
Chlamydia trachomatis (lymphogranuloma venereum serotypes)
Parasites
Entamoeba histolytica
Schistosoma species
Balantidium coli
Trichinella spiralis
Viruses
Cytomegalovirus
Infectious agents causing proctitis

Neisseria gonorrhoeae
Herpes simplex virus
C. trachomatis
Treponema pallidum
Cytomegalovirus
Adapted from: Guerrant RL, Lima AA. Inflammtory enteritides. In: Principles and Practice of Infectious Diseases,
5th ed, Mandell GL, Bennett JE, Dolin R (Eds), Churchill Livingstone, Philadelphia 2000. p.1127.
Infectious colitis
Endoscopy of infectious colitis can look identical to either Crohn's disease or

ulcerative colitis.
Pseudomembranous colitis
Endsocopy of pseudomembranous colitis reveals small groups of

pseudomembranes (left panel) that may be confused grossly with the aphthous
ulcers of Crohn's disease (right panel). These lesions can be distinguished since
pseudomembranes are present on top of the mucosa and do not result in
ulceration of the underlying tissue.
Pseudomembranous colitis
Endoscopic appearance of Clostridioides (formerly Clostridium) difficile-induced

pseudomembranous colitis.
(Left panel) Scattered pseudomembranes are visible on top of the mucosa,
being separated by areas of relatively normal mucosa. Some of the lesions have
a red halo (arrows).
(Right panel) Yellow pseudomembrane circumferentially covering the entire
colonic mucosa.
Normal sigmoid colon
Endoscopic appearance of the normal sigmoid colonic mucosa. The fine

vasculature is easily visible, and the surface is shiny and smooth. The folds
are of normal thickness.
Ischemic colitis on colonoscopy
Endoscopy of ischemic colitis may reveal continuous necrosis and mucosal

friability that resembles ulcerative colitis (left panel); discrete ulcers with
surrounding edema may also be seen (right panel).
Normal sigmoid colon
Endoscopic appearance of the normal sigmoid colonic mucosa. The fine

vasculature is easily visible, and the surface is shiny and smooth. The folds
are of normal thickness.

Endoscopic Diagnosis of IBD

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Endoscopic diagnosis of inflammatory bowel disease - UpToDate Page 1 of 23

Official reprint from UpToDate®

Endoscopic diagnosis of inflammatory bowel disease

Gastrointestinal (GI) endoscopy has a pivotal role in the diagnosis of suspected

● (See "Clinical manifestations, diagnosis, and prognosis of Crohn’s disease in adults".)

Endoscopic findings in ulcerative colitis — Endoscopy in ulcerative colitis (UC) typically

The granular appearance is manifested by changes in light reflection during colonoscopy.

● The presence of normal vasculature adjacent to affected tissue is seen in Crohn

● Isolated involvement of the terminal ileum is highly suggestive of Crohn disease.

ENDOSCOPY VERSUS RADIOGRAPHY IN ILEOCOLONIC IBD

ROLE IN DIFFERENTIAL DIAGNOSIS

Pseudomembranous colitis — Pseudomembranous colitis may resemble IBD. Small

Colitis associated with diverticular disease — Infrequently, patients with diverticular

SMALL BOWEL DISEASE

Wireless capsule endoscopy — Experience with wireless capsule endoscopy in the

Enteroscopy — Push enteroscopy can be used to evaluate suspected Crohn disease of

Device-assisted enteroscopy (eg, double balloon and single balloon enteroscopy)

UPPER GASTROINTESTINAL DISEASE

Up to 4 percent of patients with Crohn disease have gastroduodenal involvement, which is

Role of endosonography — The use of endoscopic ultrasonography (EUS) to measure

Indications — When feasible and safe, direct endoscopic visualization of the

Bowel preparations containing sodium phosphate and non-steroidal anti-inflammatory drugs

Contraindications — In addition to the usual contraindications (such as a perforated

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● Gastrointestinal endoscopy has a pivotal role in the diagnosis of suspected

● Patients should be carefully selected and previously evaluated with appropriate

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 4072 Version 16.0

Continuous involvement of colonic lesions in ulcerative colitis

Courtesy of James B McGee, MD.

Graphic 76332 Version 3.0

Colonic pseudopolyps in inflammatory bowel disease

Endoscopy of pseudopolyps; these lesions are not specific to ulcerative colitis,

Courtesy of James B McGee, MD.

Graphic 76729 Version 3.0

Aphthous lesions in Crohn disease

Colonoscopy demonstrates small discreet aphthous lesions (superficial

Courtesy of James B McGee, MD.

Graphic 78561 Version 9.0

Linear ulcerations in Crohn disease

Courtesy of James B McGee, MD.

Graphic 68093 Version 4.0

Asymmetric distribution of lesions in Crohn disease

Colonoscopy in Crohn disease demonstrates the characteristic patchy erythema

Courtesy of James B McGee, MD.

Graphic 71769 Version 4.0

Infectious mimics of inflammatory bowel disease

Infectious agents causing colitis and/or ileitis

Enterohemorrhagic Escherichia coli

Salmonella species (gastroenteritis and typhoid fever)

Clostridioides (formerly Clostridium) difficile

Chlamydia trachomatis (lymphogranuloma venereum serotypes)

Infectious agents causing proctitis

Herpes simplex virus

Graphic 67648 Version 4.0

Endoscopy of infectious colitis can look identical to either Crohn's disease or

Courtesy of James B McGee, MD.

Graphic 51993 Version 1.0

Endsocopy of pseudomembranous colitis reveals small groups of

Courtesy of James B McGee, MD.

Graphic 60237 Version 2.0

Endoscopic appearance of Clostridioides (formerly Clostridium) difficile-induced