Clin Endosc.  2012 Sep;45(3):254-262.

Differential Diagnosis of Inflammatory Bowel Disease: What Is the Role of Colonoscopy?

• Jung SA

Abstract

Colonoscopy plays a crucial role in the diagnosis, treatment and follow-up monitoring of inflammatory bowel disease (IBD). Practitioners should be well informed of the colonoscopic findings of IBD to prevent the misdiagnosis, overtreatment or delayed treatment. Distinguishing between Crohn's disease and ulcerative colitis is essential in terms of pharmacological treatment, surgical decision-making, and prognosis. But there are still lesions with difficulty in differentiation that approximately 10% of the patients fall into the category of indeterminate colitis. Efforts are needed to carefully select treatment approach appropriate for each patient by providing a precise diagnosis on the extent and degree of lesions as well as to accurately delineate the lesions to assure that they are compared in subsequent rounds of follow-up monitoring in order to allow redetermination and adjustment of the treatment.

Keyword

Inflammatory bowel disease; Colonoscopy; Differential diagnosis

MeSH Terms

Colitis
Colitis, Ulcerative
Colonoscopy
Crohn Disease
Diagnosis, Differential
Diagnostic Errors
Follow-Up Studies
Humans
Inflammatory Bowel Diseases
Prognosis

Figure

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  Fig. 1 Chronographic alteration in endoscopic findings of typical Crohn's disease. A 37-year-old female had colonoscopy with complaints of diarrhea. At initial diagnosis, multiple aphthous erosion and linear ulcer with normal surrounding mucosa were noted (A, B). She was diagnosed as Crohn's disease. After 2 years, colonoscopy revealed the ulcers were deeper with typical cobblestone appearance caused by numerous, confluent ulcerations (C, D). She had been treated with combination of steroid and immunosuppressants. Five months after the treatment, ulcers were healed with fibrotic change (E, F) with resolution of symptoms, and complete remission was achieved. Four years after the initial diagnosis, symptoms were exacerbated and follow-up colonoscopy showed deep ulcers with recurrent cobble stone appearance (G, H) that biologic agent was initiated. Even though the ulcerative lesions in the mucosa improved, stenosis followed, eventually leading to balloon dilation (I, J). Since the patient clearly showed natural progression during the treatment of Crohn's disease, there was no confusion in the diagnosis of Crohn's disease.

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  Fig. 2 Confusing endoscopic findings of ulcerative colitis. A 22-year-old male had colonoscopy with complaints of loose stool. At initial diagnosis, diffuse erythema with friable and granular mucosal change was noted from the rectum to the descending colon without involvement of the right colon (A, B, C). He was diagnosed as ulcerative colitis and had been treated for 1 year, and complete remission was achieved (D, E, F). Four years after the diagnosis, during the follow-up colonoscopy, multiple longitudinal ulcers without involvement of rectum were noted which could have been confused with Crohn's disese if the patient did not have colonoscopy previously (G, H, I). Colonoscopic findings were more compatible with ulcerative colitis 8 months later compared with the latest exam (J, K, L).

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  Fig. 3 Confusing endoscopic findings of Crohn's disease. A 22-year-old male had colonoscopy with complaints of mucoid stool. Initial findings showed friable mucosal change with granularity noted in the rectum without any involvement of the rest of the colon (A, B, C). The patient was diagnosed as ulcerative proctitis. One year later, disease was extended to the entire colon and the patient had systemic treatment with consideration of the extensive ulcerative colitis (D, E, F). Six months after the treatment, follow-up colonoscopy revealed that the rectum was spared with multiple linear skipped ulcer (G, H, I). Four years after the initial diagnosis, the rectum was involved again confusing the diagnosis. One year after the latest exam, cobblestone appearance was found (J, K, L). Final diagnosis was adjusted to Crohn's disease since he was initially diagnosed as ulcerative colitis 4 years ago

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