Differential diagnosis

Differential Diagnosis table for Irritable bowel syndrome

Condition Differentiating signs/symptoms
Crohn's disease • 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.
Ulcerative colitis • 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.
Lymphocytic • The patient with lymphocytic or collagenous colitis will have
and collagenous soft to watery diarrhoea that often is not associated with pain
colitis and tends not to be episodic. Physical examination is normal.
Coeliac disease • 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.
Bowel infections • Most bacterial and viral infections in immunocompetent patients
are acute. The parasite Giardia lamblia can be associated with
diarrhoea, nausea, and bloating.
Differentiating tests
• 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.

Condition Differentiating tests

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.
Ulcerative • Stool culture, microscopy and antigen testing: negative.
colitis
• 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).
Lymphocytic • The basic laboratory tests may reveal azotaemia and
and collagenous hypokalaemia. Although the colon mucosa may look normal
colitis endoscopically, there will be abnormal changes histologically on
colon biopsies.
Coeliac disease • 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 • 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.
Bowel • Stool examination for ova and parasites can be used for
infections screening. Multiple stools should be examined. The serum
Giardia antigen is accurate for diagnosing Giardia lamblia.