Inflammatory Bowel Disease

Aka: Inflammatory Bowel Disease, Autoimmune Bowel Disorder

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II. Epidemiology

  1. Age: 10 to 40 years old
  2. First degree relative with Inflammatory Bowel Disease increases risk 10 fold

III. Differential Diagnosis

  1. Lower GI Bleeding
    1. Diverticulitis (most common cause)
    2. Angiodysplasia (Arteriovenous Malformation)
    3. Neoplasm
    4. Ulcerative Colitis (Blood Diarrhea distinguishes from Crohn's Disease)
    5. Ischemic Colitis (Older patients with sudden onset pain)
    6. Anorectal Disease
      1. Hemorrhoids
      2. Anal Fissures
  2. Diarrhea
    1. Non-Infectious Osmotic Diarrhea
    2. Non-Infectious Secretory Diarrhea
    3. Ulcerative Colitis (bloody Diarrhea)
    4. Crohn's Disease
    5. Irritable Bowel Syndrome (diagnosis of exclusion)
    6. Fecal Impaction (with leakage)
    7. Infectious Diarrhea (Sudden onset and often painful)
      1. Pseudomembranous colitis of Clostridium difficile (recent antibiotic use)
      2. Entamoeba histolytica
      3. Tuberculosis
      4. Cytomegalovirus
      5. Yersinia
      6. Strongyloides

IV. History

  1. Travel
  2. Contaminated intake
    1. Foodborne Illness
    2. Waterborne Illness
  3. Immunodeficiency risk
  4. High risk sexual behavior
  5. Family History of Gastrointestinal disease
  6. Medications in the last 6 months (e.g. antibiotics)

V. Symptoms

  1. Chronic Inflammatory Diarrhea
    1. Crohn Disease may also cause Secretory Diarrhea (Chronic Watery Diarrhea)
  2. Pain
    1. Ulcerative Colitis
      1. Lower abdominal cramps
      2. Relieved with Bowel Movement
    2. Crohn's Disease
      1. Constant pain often in right lower quadrant
      2. Not relieved with Bowel Movement
  3. Stool Blood
    1. Grossly bloody stool in Ulcerative Colitis

VI. Signs

  1. Abdominal Mass
    1. Ulcerative Colitis: No abdominal mass
    2. Crohn's Disease: Mass often at Right lower quadrant
  2. Gastrointestinal Tract Affected
    1. Ulcerative Colitis
      1. Affects only colon
      2. Continuous from Rectum
    2. Crohn's Disease
      1. Mouth to anus potentially affected
      2. Discontinuous, "Skip" lesions
  3. Bowel Tissue affected
    1. Ulcerative Colitis: Mucosal disease (no Granuloma)
    2. Crohn's Disease: Transmural disease (Granulomas)

VII. Associated Conditions: Extraintestinal

  1. See Gynecologic Manifestations of Crohn's Disease
  2. See Spondyloarthropathy due to Inflammatory Bowel Disease
  3. Crohns Disease and Ulcerative Colitis are associated with similar extraintestinal disorders (more common in Crohns Disease)
  4. Musculoskeletal (Osteoporosis, Colitic Arthritis, Ankylosing Spondylitis)
  5. Ocular (Episcleritis, Uveitis, Recurrent Iritis)
  6. Dermatologic (Digital Clubbing, Erythema Nodosum, Pyoderma Gangrenosum, Lichen Planus, Aphthous Stomatitis, Psoriasis)
  7. Hepatobiliary (Hepatic Steatosis, Primary Sclerosing Cholangitis, Cholelithiasis, Pericholangitis)
  8. Nephrolithiasis
  9. Hypercoagulable state (Deep Vein Thrombosis, Pulmonary Embolism)

VIII. Labs: Stool Studies

  1. Fecal Calprotectin
    1. Newer test with high Test Sensitivity and Test Specificity for Inflammatory Bowel Disease
    2. Fecal Calprotectin <40 mcg/g and CRP <0.5 reduce Inflammatory Bowel Disease likelihood to<1%
      1. Menees (2015) Am J Gastroenterol 110(3):444-54 [PubMed]
  2. General Stool studies
    1. Stool Culture
    2. Stool for Ova and Parasites
    3. GiardiaAntigen
    4. Clostridium difficile Toxin and culture
    5. Fecal Leukocytes
  3. Additional Stool studies
    1. Yersinia enterocolitica culture
    2. Toxigenic Escherichia coli isolation
    3. Entamoeba histolytica serologic titers

IX. Labs: Immunocompromised Patient Evaluation

  1. Chlamydia trachomatis
  2. Cryptosporidium Antigen
  3. Neisseria gonorrhoeae
  4. Herpes Simplex Virus (HSV)
  5. Cytomegalovirus (CMV)
  6. Isospora belli
  7. Mycobacterium tuberculosis

X. Labs: Underlying Nutrition and Disease Severity

  1. Complete Blood Count
  2. C-Reactive Protein or Erythrocyte Sedimentation Rate
    1. Correlates with severity
  3. Serum Protein level
    1. Serum Albumin
    2. Serum Transferrin
    3. Serum Prealbumin
  4. Iron Indices
    1. Serum Ferritin
    2. Serum Iron
    3. Total Iron Binding Capacity

XI. Differential Diagnosis: Distinguishing Crohn's Disease from Ulcerative Colitis

  1. Location
    1. Crohn's Disease can involve any area of Gastrointestinal Tract (most common in ileocolic region)
    2. Ulcerative Colitis is typically limited to colon, and has onset at the Rectum
  2. Thickness
    1. Crohn's Disease involves the entire bowel wall
    2. Ulcerative Colitis is limited to the mucosa and submucosa
  3. Colonoscopy
    1. Crohn's Disease demonstrates skip lesions, cobblestoning, ulcerations and strictures
    2. Ulcerative Colitis demonstrates pseudopolyps, continuous areas of inflammation
  4. Other discriminating factors
    1. Anemia is more common in Ulcerative Colitis
    2. Abdominal Pain is more common in Crohn's Disease
    3. Anorexia and weight loss is common in Crohn's Disease
    4. Rectal Bleeding is more common in Ulcerative Colitis (bloody Diarrhea is a common presentation)
    5. Colon Cancer is much more common in Ulcerative Colitis

XII. Diagnosis

  1. Colonoscopy with mucosal biopsy

XIII. Imaging

  1. CT Abdomen and Pelvis (or MRI Abdomen)
    1. Undifferentiated Inflammatory Bowel Disease (prior to diagnosis)
    2. Known Inflammatory Bowel Disease with complication
      1. Small Bowel Obstruction
      2. Sepsis with suspected intraabdominal source
      3. Perianal Sepsis
  2. Abdominal XRay findings (if done for other reasons)
    1. Perforation signs (i.e. Free air in peritoneum)
    2. Toxic Megacolon
    3. Thumb-printing
      1. Pattern of multiple locations where bowel wall appears indented (as if by a thumbs)

XIV. Management

  1. See Ulcerative Colitis (bloody Diarrhea)
  2. See Crohn's Disease
  3. See Microscopic Colitis
  4. Precautions
    1. Consult gastroenterology in acute presentations prior to diagnosis and in exacerbations
    2. Avoid management (e.g. Corticosteroids) that interfere with diagnosis prior to definitive study (e.g. Colonoscopy)
    3. Exclude infection (e.g. C. difficile and other enteric Bacterial Infection) pre-diagnosis and with exacerbations
  5. Symptom management in formally diagnosed Inflammatory Bowel Disease (e.g. prior Colonoscopy with biopsy)
    1. Avoid starting Corticosteroids unless infection has been excluded, IBD cause is known and GI consultant agrees
    2. Ongoing Inflammatory Bowel Disease management may be adjusted
      1. Patients with increased symptoms on a Corticosteroid taper could return to the prior dose
      2. Patients on 5-Aminosalicylic Acid could have dosing maximized or add rectal enema (4 g)

XV. Resources

  1. Crohn's and Colitis Foundation of America
    1. http://www.ccfa.org
  2. Cedars-Sinai Inflammatory Bowel Disease Center
    1. http://www.csmc.edu/ibd

XVI. References

  1. Cardy and Williams in Swadron (2022) EM:Rap 22(7): 15-7
  2. McDowell (2022) Inflammatory Bowel Disease, StatPearls, Treasure Island
    1. https://www.ncbi.nlm.nih.gov/books/NBK470312/

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Related Studies

Ontology: Inflammatory Bowel Diseases (C0021390)

Definition (NCI) A spectrum of small and large bowel inflammatory diseases of unknown etiology. It includes Crohn's disease, ulcerative colitis, and colitis of indeterminate type.
Definition (NCI_NCI-GLOSS) A general term that refers to the inflammation of the colon and rectum. Inflammatory bowel disease includes ulcerative colitis and Crohn's disease.
Definition (MSH) Chronic, non-specific inflammation of the GASTROINTESTINAL TRACT. Etiology may be genetic or environmental. This term includes CROHN DISEASE and ULCERATIVE COLITIS.
Definition (CSP) chronic, non-specific inflammation of the gastrointestinal tract; etiology may be genetic or environmental.
Concepts Disease or Syndrome (T047)
MSH D015212
SnomedCT 155759008, 196974002, 266516008, 24526004
LNC LP36210-0, LA15162-3
English Bowel Diseases, Inflammatory, Inflammatory Bowel Diseases, IBD, IBD - Inflam bowel disease, BOWEL DIS INFLAMM, INFLAMM BOWEL DIS, Inflammatory bowel disease NOS, Inflammatory Bowel Diseases [Disease/Finding], Disease;inflammatory bowel, bowel disease inflammatory, disease inflammatory bowel, inflammatory bowel diseases, bowel diseases inflammatory, inflammatory bowel disease, Autoimmune Bowel Disorder, Inflammatory bowel diseases, inflammatory bowel disease (diagnosis), Inflammatory bowel disease, IBD - Inflammatory bowel disease, Inflammatory bowel disease (disorder), Inflammatory bowel disease, NOS, Inflammatory Bowel Disease
Italian Malattia infiammatoria intestinale, Malattia infiammatoria intestinale NAS, Malattie infiammatorie dell'intestino
Dutch inflammatoire darmziekte NAO, inflammatoire darmziekte, Darmziekte, inflammatoire, Darmziekten, inflammatoire, Inflammatoire darmziekte, Inflammatoire darmziekten, Ziekte, inflammatoire darm-, Ziekten, darm-, inflammatoire
French Maladie inflammatoire intestinale SAI, Syndrome de l'intestin irritable (SII), Maladie entérique inflammatoire, Maladies inflammatoires intestinales, Maladies inflammatoires de l'intestin, MICI, Maladies inflammatoires chroniques de l'intestin, Maladies inflammatoires des intestins
German IBD, entzuendliche Darmerkrankung NNB, entzuendliche Darmerkrankung, Entzündliche Darmkrankheiten
Portuguese Doença intestinal inflamatória, Doença intestinal inflamatória NE, Doenças Inflamatórias Intestinais, Doenças Intestinais Inflamatórias, Enteropatias Inflamatórias, Doenças Inflamatórias do Intestino, Doença entérica inflamatória
Spanish EII, Enfermedad intestinal inflamatoria NEOM, Enfermedades Inflamatorias Intestinales, Enfermedades Intestinales Inflamatorias, enfermedad inflamatoria intestinal (trastorno), enfermedad inflamatoria intestinal, Enfermedad intestinal inflamatoria, Enfermedades Inflamatorias del Intestino
Japanese 炎症性腸疾患ＮＯＳ, ｴﾝｼｮｳｾｲﾁｮｳｼｯｶﾝ, ｴﾝｼｮｳｾｲﾁｮｳｼｯｶﾝNOS, 炎症性腸疾患, 腸疾患-炎症性
Swedish Inflammatoriska tarmsjukdomar
Czech záněty střev nespecifické, Zánětlivé střevní onemocnění, Zánětlivé střevní onemocnění NOS, idiopatické střevní záněty, střeva - nemoci zánětlivé, nespecifické střevní záněty, IBD
Finnish Tulehdukselliset suolistosairaudet
Russian KISHECHNIKA VOSPALITEL'NYE BOLEZNI, КИШЕЧНИКА ВОСПАЛИТЕЛЬНЫЕ БОЛЕЗНИ
Croatian UPALNE BOLESTI CRIJEVA
Polish Choroby jelit zapalne, Zapalenie jelit nieswoiste
Hungarian Gyulladásos bélbetegség, Gyulladásos bél betegség k.m.n., IBD
Norwegian Inflammatorisk tarmsykdom, Tarmsykdom, inflammatorisk
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: IBD5 gene (C1415836)

Concepts Gene or Genome (T028)
English IBD5, inflammatory bowel disease 5, IBD5 gene
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Inflammatory Bowel Disease

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