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Crohn
Disease Differential
Diagnoses
Updated: Jul 26, 2019 | Author: Leyla J Ghazi, MD; Chief
Editor: Praveen K Roy, MD, AGAF more...

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Diagnostic Considerations
Patients with Crohn disease frequently present with
abdominal pain, nonbloody diarrhea, weight loss,
fever, and, sometimes, obstructive symptoms such as
nausea, early satiety, and vomiting. World Health
Organization diagnostic criteria for Crohn disease
include the following [57] :

Discontinuous or segmental lesions as well as a

cobblestone appearance or longitudinal
ulcer noted on radiologic studies, endoscopy,
and resected specimens
Transmural inflammation, as evidenced by
clinical evaluation, radiologic studies, biopsy
findings, and resected specimens
Noncaseating granulomas, as revealed on
biopsy findings and resected specimens
Fissures and fistulas, as evidenced by clinical
evaluation, radiologic studies, and resected
specimens
Perianal disorders on clinical evaluation

A variety of intestinal manifestations and

extraintestinal manifestations (EIMs) also may be
observed in conjunction with either Crohn disease or
ulcerative colitis. Features differentiating the two
forms of inflammatory bowel disease (IBD) are
summarized in Table 1, below.

Table 1. Characteristics Differentiating Crohn Disease

and Ulcerative Colitis (Open Table in a new window)

Characteristic

Ulcerative
Crohn Disease
Colitis

Entire Colon only,

gastrointestinal though gastritis
tract is recognized

Distribution
Continuous
involvement
Skip lesions
proximally from
rectum

Full thickness Mucosa only

Granulomas (15-
Pathology
30% in biopsy
specimens; 40- No granulomas
60% in surgically
resected bowel)

Entire
gastrointestinal Colon only
tract

Continuous
involvement
Radiology Skip lesions
proximally from
rectum

Fistulae,
Mucosal
abscesses,
disease only
fibrotic strictures

Estimated to
be 3% at 10
years, 8% at 30
years, and 18%
at 30 years
after diagnosis
[47] ; risk is
higher in
patients with
Cancer risk Increased primary
sclerosing
cholangitis and
long-standing
colitis (> 8-10 y);
may be lower
in subsequent
studies (see
Intestinal
Manifestations).

Presentation

Ulcerative
Crohn Disease
Colitis

Bleeding Occasional Very common

Obstruction Common Uncommon

Fistulae Common None

Weight loss Common Uncommon

Perianal
Common Rare
disease

Other diagnostic considerations

Despite extensive workup, 15% of patients with
isolated colitis have an undetermined type of IBD
that shows features of both Crohn disease and
ulcerative colitis. The distinction is often difficult to
make, especially if the patient meets all diagnostic
criteria for ulcerative colitis but is a smoker or has
rectal sparing—features that suggest the possibility
of Crohn disease or IBD of undetermined type.

In addition, there is a subpopulation of patients with

Crohn colitis who will not develop small bowel
disease in their lifetime. This group represents
approximately 20% of the colitis patients.

Tuberculosis is also in the differential diagnosis of

Crohn disease. Simple clinical findings (eg, fever,
rectal bleeding, diarrhea, symptomatic duration)
appear to be most accurate for differentiating Crohn
disease from intestinal tuberculosis. [57]
Anti–Saccharomyces cerevisiae antibodies (ASCA)
do not help in differentiating small bowel
tuberculosis from small bowel Crohn disease, but if
both ASCA and interferon-gamma release assays are
available and the ASCA result is positive, while the
interferon gamma release assay result is negative,
the specificity for Crohn disease is high, particularly
in Asian populations. [57] Endoscopy in combination
with radiologic and laboratory findings are also
useful for differentiating between Crohn disease and
intestinal tuberculosis.

In addition to excluding ulcerative colitis and

intestinal tuberculosis, guidelines from the World
Gastroenterology Organization recommend ruling
out the following in the differential diagnoses of
Crohn disease [58, 57] :

Behςet disease

Celiac disease

Irritable bowel syndrome (IBS) (if inflammatory

changes are present, it is not IBS)

Nonsteroidal anti-inflammatory drug (NSAID)

enteropathy

Differential Diagnoses
Amebiasis

Appendicitis

Bacterial Gastroenteritis

Behcet Disease

Celiac Disease and HLA-DQ2/DQ8

Diverticulitis

Giardiasis

Intestinal Carcinoid Tumor

Intestinal Tuberculosis

Irritable Bowel Syndrome (IBS)

Ischemia

Tuberculosis

Ulcerative Colitis

Viral Gastroenteritis

Workup

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