IBD Disguises:Diseases That May Mimic Crohn's Disease and Ulcerative Colitis

[NL]

Rather than a question, this is some information that may answer several questions here. My disclaimer is that I am not a professional or doctor but mom of a Ulcerative Colitis patient and family member of Colon Cancer surviver.

NL


http://www.ccfa.org/news/previous/news1201b.htm

IBD Disguises:
Diseases That May Mimic Crohn's Disease and Ulcerative Colitis

Ulcerative colitis and Crohn's disease are inflammatory conditions of
the intestinal tract. Each of these inflammatory bowel diseases (IBD) is
characterized by certain symptoms.

On the basis of your medical history and the physical examination, the
physician embarks on a series of investigations (endoscopy with
biopsies, x-ray tests, blood and stool tests) in order to determine the
cause of your illness.

No single symptom or test result "makes" the diagnosis of IBD. For
example, bloody diarrhea occurs not only in IBD, but also in certain
types of infectious colitis.

In fact, ulcerative colitis and Crohn's disease are sufficiently rare
that most patients will turn out to have something other than IBD.

Instead, it is the combination of all the elements of the history,
physical exam and the diagnostic tests that, together, exclude other
conditions and lead to a diagnosis of IBD. For example, when seeing a
patient with bloody diarrhea, the clinician raises the question of
possible IBD, rules out other conditions that may cause bloody diarrhea,
and finally concludes that the patient most likely has IBD.

Even in a person with a well-established diagnosis of Crohn's disease or
ulcerative colitis, any aggravation of symptoms does not necessarily
imply a flare-up of IBD.

An unrelated infection, a medication-related side effect, or an attack
of underlying irritable bowel syndrome (IBS), which can co-exist with
IBD, can all mimic the symptoms of IBD.

Very frequently, the patient "knows" whether the symptoms reflect an IBD
flare or not. Careful evaluation is nevertheless necessary in order to
determine the exact cause of the symptoms and institute the appropriate
treatment.

To complicate matters, infections and medications, such as aspirin and
non-steroidal anti-inflammatory drugs (NSAIDs), can sometimes "trigger"
the onset of IBD, or expose pre-existing but silent IBD. (NSAIDs include
many common over-the-counter pain medications, such as Advil®, Motrin®,
and Alleve®.)

Not surprisingly, the overlap between IBD and other conditions can lead
to an erroneous diagnosis.

Some IBD patients are told that they suffer from other conditions,
delaying the administration of proper treatment. Still other people
receive an incorrect diagnosis of IBD and are subject to wrong and
harmful treatments, such as corticosteroids and immunosuppressants.


Mimics of Ulcerative Colitis

The cardinal symptom of ulcerative colitis is rectal bleeding.

Other symptoms include diarrhea, the passage of mucus, and abdominal
pain.

Patients with disease involving only the rectum often report urgency and
tenesmus, a sensation of incomplete evacuation of stool.

Sicker patients have lack of appetite, nausea, fever and anemia.

In ulcerative colitis, endoscopy reveals widespread inflammation, which
extends from the rectum in a continuous fashion higher up to the sigmoid
colon or left colon, and which sometimes involves the entire colon.
Biopsies (tissue samples) obtained at endoscopy (examination of the
intestine with a lighted tube) are particularly useful, as they
frequently demonstrate specific chronic changes that reflect repeated
bouts of inflammation followed by healing.

In any patient who has a sudden onset of bloody diarrhea, an infectious
cause is most likely and needs to be excluded. In cases of infectious
diarrhea, patients often have had contact with other people who have a
history of diarrheal disease.

The physician orders stool cultures to exclude such organisms as
Salmonella, Shigella, Campylobacter, and Yersinia. The clinician also
tests for Clostridium difficile, an organism that commonly, but not
always, affects people who have received antibiotics.

Enterohemorrhagic Escherichia coli (E. coli O157:H7), a strain of the E.
coli bacterium, can cause diarrhea after a person ingests contaminated
water or food.

This can be complicated by hemolytic uremic syndrome, a condition
characterized by a low platelet count, anemia due to breakdown of red
blood cells, and kidney failure.

In cases of severe colitis, your doctor must be sure to exclude amoeba
(a kind of parasite), because treatment with corticosteroids, which are
standard IBD medications, can lead to dissemination of the infection
with catastrophic consequences.

People whose immune system has been compromised, such as patients who
have received immunosuppressants after organ transplantation or people
suffering from AIDS, are prone to specific opportunistic infections of
the intestine for which appropriate tests and treatments are available.
Individuals engaging in anal intercourse are at risk for gonorrhea,
syphilis, chlamydia and other sexually transmitted infections.

Ulcerative colitis is differentiated from infectious colitis on the
basis of the microbiologic studies and the results of biopsies from the
colon. If these studies are inconclusive, time provides the ultimate
test: infectious colitis resolves, frequently without treatment, whereas
ulcerative colitis declares itself as a chronic, relapsing disease.

Drugs, particularly aspirin and NSAIDs, are other important culprits of
intestinal inflammation. Physicians are increasingly recognizing the
fact that these agents cause inflammation and ulcers, not only in the
stomach and duodenum, but also in the lower small intestine and colon.

Since patients may not volunteer any history of using these drugs, the
clinician must obtain a very detailed medication history of prescription
and over-the-counter preparations. Stopping these drugs leads to
resolution of the symptoms.

Rectal bleeding can be a symptom of colon cancer, which may develop as a
complication of longstanding colitis. A patient who has a long history
of colitis that has been under control with anti-inflammatory
medications, and who suddenly develops rectal bleeding, needs a
colonoscopy to exclude colon cancer, among other possibilities.

People with diseased blood vessels or other conditions that impair
blood flow to the colon can develop ischemic colitis. The ulcers and
inflammation of ischemic colitis quickly heal, although in some cases
healing leads to scarring with narrowing of the lumen (the hollow
portion) of the colon. By analyzing the clinical circumstances and the
results of the endoscopy, the clinician can differentiate ischemic
colitis from ulcerative colitis.

Other patients who develop acute rectal bleeding may have colonic
diverticula (outpouchings of the colon) or arteriovenous malformations
(fragile, abnormal communications between veins and arteries that have a
tendency to rupture and bleed). At endoscopy, the diverticula or
arteriovenous malformations are seen, and there is no bowel
inflammation.

In people with long-standing symptoms, certain other conditions are
possible. Patients who have received radiation to the pelvis for
different cancers (uterine, cervical or prostate) can develop a
condition known as radiation colitis, which mainly affects the rectum
and sigmoid colon and leads to intermittent rectal bleeding. Patients
may develop radiation colitis several years after the administration of
the radiation. The diagnosis is usually obvious, and endoscopy and
biopsies clarify the picture.

People with microscopic colitis develop watery, non-bloody diarrhea.
This condition is most commonly seen in middle-aged women, but can be
present in women and men of all ages. Endoscopy shows no visible
inflammation; yet, as the name implies, examination of biopsies under
the microscope shows inflammation. The absence of rectal bleeding and
visible inflammation helps the physician in distinguishing microscopic
colitis from ulcerative colitis.

Mimics of Crohn's disease
The major symptoms of Crohn's disease are abdominal pain, diarrhea,
low-grade fever, and weight loss. Rectal bleeding is not as common as in
ulcerative colitis, and occurs predominantly in patients with Crohn's
disease of the colon. Patients sometimes develop perianal disease, with
fissures (cracks in the skin), fistulas, and abscesses.

As Crohn's disease progresses, the inflammation can lead to
complications such as bowel obstruction, abnormal channels (fistulas)
between the bowel and other organs, and abscesses (pockets of pus)
within the abdominal cavity. Endoscopy and imaging tests (barium x-rays,
CT scans and other tests) show patchy inflammation of the small bowel,
colon, or both. As with ulcerative colitis, biopsies obtained at
endoscopy are particularly useful, as they may demonstrate spotty
inflammation, chronic changes, and "granulomas," which are aggregates of
specific types of white cells (macrophages). The presence of perianal
disease or granulomas is very suggestive of CD.

Crohn's disease of the small bowel (inflammation of the ileum, or
"ileitis") typically causes acute or recurrent pain in the right lower
quadrant of the abdomen.

Many other diseases are characterized by similar pain. Acute
appendicitis is the most common and most dangerous diagnosis. The
physician will request a CT scan or ultrasound. If the clinical picture
remains unclear, surgical exploration may be necessary.

Other conditions that can mimic the right lower quadrant pain of Crohn's
include abnormalities of the ovaries and Fallopian tubes (cysts, tumors,
pelvic inflammatory disease), cancer of the cecum, lymphoma of the
ileum, radiation injury and inflammatory conditions of the blood vessels
that supply blood to the intestine.

Infections, such as tuberculosis and Yersinia, can affect the region of
the ileum and cecum and thus need to be considered among the diagnostic
possibilities.

The clinician obtains appropriate tests (endoscopy, biopsies, stool
cultures, antibodies in the blood) that help rule out these conditions.
In any patient with acute abdominal pain, such common conditions as
peptic ulcer disease, cholecystitis (inflammation of the gallbladder),
pancreatitis (inflammation of the pancreas), and intestinal obstruction
also need to be considered and ruled out with appropriate tests.

Patients with irritable bowel syndrome (IBS) have chronic abdominal
pain, sometimes with diarrhea and/or constipation. In IBS, blood and
stool tests, x-rays, endoscopy and biopsies all give normal results.

In Crohn's disease of the colon, the other diagnostic possibilities are
ulcerative colitis and its mimics--namely infections, medications,
radiation injury, and the other conditions discussed in the first half
of this article. Colonoscopy with biopsies and other laboratory studies
usually settle the issue.

Summary
In a patient whose symptoms suggest IBD, a systematic evaluation narrows
the range of diagnostic possibilities, excludes life-threatening
conditions, and leads the clinician to accept or reject the diagnosis of
IBD.

This evaluation consists of a detailed history,
a thorough physical examination,
and appropriate diagnostic tests.

Again, it is important to remember that the diagnosis of IBD is, in the
final analysis, a clinical diagnosis.

In our current state of knowledge, no single piece of information exists
that definitively makes the diagnosis of IBD. Rather, the collection of
all the available data is consistent (or not) with this diagnosis.

Finally, not every symptom in a person who is known to have Crohn's
disease or ulcerative colitis should be attributed to the IBD.

Following a careful evaluation, a complication or another intervening
disease needs to be excluded.

For this reason, it is important that you know about the various types
of tests that your doctor may recommend, and that you understand what
these exams may-and may not-reveal about your condition.

-- Themistocles Dassopoulos
Instructor of Medicine
University of Chicago

Date Posted: December 1, 2000
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-------- http://www.ccfa.org/news/previous/news1201b.htm

[MS]

I am a 35 year old marathon runner with a best time of 2 hours and 57 minutes. I have run 37 marathons during my recreational running career.

I recently discharged again from hospital and have been in and out since May 2000 with lower abdominal problems.

For any other sufferers out there who have had gut problems that mimic Crohn's or Ulcerative Colitis this may be a possible diagnosis.

As I mentioned I am a runner - specifically marathons and ultra races and since last year after lengthy training sessions in high humidity and heat I succumbed to severe lower left abdominal pain. Initially I used to "Knuckle" it out and like most endurance runners I'm used to the ups and downs of gut and stomach discomforts. However after experiencing sharp stabbing pain in my abdomen and passing explosive black diarrhea after one long hot and humid run session,which also showed indications of fresh streaks of blood, I knew all was not well.

On admission pain was relieved with analgesic injections and I was on an IV for 48 hours to rest the gut. A colonoscopy revealed about 30 small apthous ulcers in the sigmoid region of the colon.

A week later and after bed rest a further scope revealed no major changes. However 3-4 weeks after rest and reduced activity a further colonoscopy revealed that I had made a full recovery with all ulcers having disappeared.

Then again it happened this year again after a long run. This time There was explosive foul smelling black stool with traces of fresh blood. I also experienced abdominal distension and really bad gas. The pain and discomfort was horrible. On admission I was administered with IV and again intra muscular analgesic injections. 48 hours later I was colonoscopied and it revealed an almost complete colonic stricture in the same area  as before, accompanied by inflammation and several ulcers - the doctor said it was visibly like "classic Crohns disease".

However histology of biopsies revealed non specific inflammation which was not typical Crohns or Colitis. Further tests for amoeba were negative but I did test positive for aeromonas bacteria. Anyhow 5 days later pain subsided and about 7-8 days later so did the distension and general discomfort. A further colonscopy revealed I had made an astonishing full recovery and there was no evidence of inflammation, stricture or ulcers. The doctors were baffled somewhat, particularly with the speed of my recovery which is atypical of ulcerative colitis or Crohns.

After discussions the doctor decided to test for ischemic bowel. However this was then rejected when it was evident I had to have a Foley catheter inserted during the angio - no thanks I've had enough discomfort during one admission!!!

Anyhow a bit of research by the GI Doctor revealed that as a runner I could be suffering from endurance athlete's colonic ischemia. Read American Journal of Gastroenterology Vol. 93, No. 11, 1998 by Lucas . W and Schroy. P.

The cure - reduce running duration in high humidity and temperatures. Limit long runs of over 2 hours to once per week (especially summer). Spend more time in the summer on treadmills in the airconditioning. Hydrate well pre-exercise, during exercise and after exercise. Rest well at least once and possibly twice per week.

I hope that this input goes a step further in helping  doctors and patients also consider exercise habits as a factor when diagnosing gut complaints.

[MS]

I am a 35 year old marathon runner with a best time of 2 hours and 57 minutes. I have run 37 marathons during my recreational running career.

I recently discharged again from hospital and have been in and out since May 2000 with lower abdominal problems.

For any other sufferers out there who have had gut problems that mimic Crohn's or Ulcerative Colitis this may be a possible diagnosis.

As I mentioned I am a runner - specifically marathons and ultra races and since last year after lengthy training sessions in high humidity and heat I succumbed to severe lower left abdominal pain. Initially I used to "Knuckle" it out and like most endurance runners I'm used to the ups and downs of gut and stomach discomforts. However after experiencing sharp stabbing pain in my abdomen and passing explosive black diarrhea after one long hot and humid run session,which also showed indications of fresh streaks of blood, I knew all was not well.

On admission pain was relieved with analgesic injections and I was on an IV for 48 hours to rest the gut. A colonoscopy revealed about 30 small apthous ulcers in the sigmoid region of the colon.

A week later and after bed rest a further scope revealed no major changes. However 3-4 weeks after rest and reduced activity a further colonoscopy revealed that I had made a full recovery with all ulcers having disappeared.

Then again it happened this year again after a long run. This time There was explosive foul smelling black stool with traces of fresh blood. I also experienced abdominal distension and really bad gas. The pain and discomfort was horrible. On admission I was administered with IV and again intra muscular analgesic injections. 48 hours later I was colonoscopied and it revealed an almost complete colonic stricture in the same area  as before, accompanied by inflammation and several ulcers - the doctor said it was visibly like "classic Crohns disease".

However histology of biopsies revealed non specific inflammation which was not typical Crohns or Colitis. Further tests for amoeba were negative but I did test positive for aeromonas bacteria. Anyhow 5 days later pain subsided and about 7-8 days later so did the distension and general discomfort. A further colonscopy revealed I had made an astonishing full recovery and there was no evidence of inflammation, stricture or ulcers. The doctors were baffled somewhat, particularly with the speed of my recovery which is atypical of ulcerative colitis or Crohns.

After discussions the doctor decided to test for ischemic bowel. However this was then rejected when it was evident I had to have a Foley catheter inserted during the angio - no thanks I've had enough discomfort during one admission!!!

Anyhow a bit of research by the GI Doctor revealed that as a runner I could be suffering from endurance athlete's colonic ischemia. Read American Journal of Gastroenterology Vol. 93, No. 11, 1998 by Lucas . W and Schroy. P.

The cure - reduce running duration in high humidity and temperatures. Limit long runs of over 2 hours to once per week (especially summer). Spend more time in the summer on treadmills in the airconditioning. Hydrate well pre-exercise, during exercise and after exercise. Rest well at least once and possibly twice per week.

I hope that this input goes a step further in helping  doctors and patients also consider exercise habits as a factor when diagnosing gut complaints.