Diagnosis: Left-sided (Mayo 2 severity) Ulcerative colitis
Case Summary:
Chronic diarrhea with inflammatory features (blood in stool, urgency, nocturnal bowel movements, rectal pain) has a broad differential including inflammatory bowel disease, radiation colopathy, ischemic colitis, drug induced colitis and amoebic colitis. While peak age of IBD onset is between 15-35 years, a second small peak can occur between 50-70 years of age. Cessation of tobacco use may trigger disease flares in ulcerative colitis (UC). Crohn’s disease (CD) often presents with non bloody diarrhea, abdominal pain, cramping, weight loss, and may also have symptoms of perianal involvement. Ulcerative colitis and Crohns colitis may present as bloody diarrhea.
Laboratory findings of iron deficiency anemia, thrombocytosis and hypoalbuminemia maybe seen in IBD, due to ongoing chronic blood loss, inflammation and malnutrition. Fecal leucocytes can be detected and fecal calprotectin maybe elevated in IBD, however these findings are non-specific and are associated with all causes of inflammatory diarrhea. Similarly inflammatory markers like ESR and CRP can be elevated, but these are non-specific, and have a greater role in monitoring disease response to therapy rather than in diagnosis. Serologic markers like pANCA and ASCA are not recommended for establishing a diagnosis of IBD. Stool tests should be sent to rule out infectious etiologies, including testing for ova & parasites and Clostridiodes difficile infection.
Colonoscopy is the most appropriate step to obtain tissue biopsy to confirm diagnosis, as well as to characterize disease extent and severity. The Mayo sub score helps grade endoscopic disease severity in UC. Classic histopathologic findings on colonic mucosal biopsies include cryptitis, crypt abscesses, lamina propria plasmacytosis, crypt branching, and crypt shortfall.
Case authored by: Bhavana Bhagya Rao MD
References:
- Rubin, David T. MD, FACG1; Ananthakrishnan, Ashwin N. MD, MPH2; Siegel, Corey A. MD, MS3; Sauer, Bryan G. MD, MSc (Clin Res), FACG (GRADE Methodologist)4; Long, Millie D. MD, MPH, FACG5 ACG Clinical Guideline: Ulcerative Colitis in Adults, The American Journal of Gastroenterology: March 2019 – Volume 114 – Issue 3 – p 384-413 doi: 10.14309/ajg.0000000000000152
https://pubmed.ncbi.nlm.nih.gov/30840605/ - Dassopoulos T, Cohen RD, Scherl EJ, Schwartz RM, Kosinski L, Regueiro MD. Ulcerative Colitis Care Pathway. Gastroenterology. 2015;149(1):238-https://pubmed.ncbi.nlm.nih.gov/26025078/
- Peyrin-Biroulet L, Sandborn W, Sands BE, et al. Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE): Determining Therapeutic Goals for Treat-to-Target. Am J Gastroenterol. 2015;110(9):1324-1338.
https://pubmed.ncbi.nlm.nih.gov/26303131/
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Case 1 Index
Introduction
Physical Exam
Differential Diagnosis
Diagnostic Testing
Colonoscopy Findings
Endoscopic Findings
Pathology 1
Pathology 2
GI SIM 