Irritable bowel syndrome differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Irritable bowel syndrome must be differentiated from other diseases that cause diarrhea, constipation, and abdominal pain, such as Celiac disease, Inflammatory bowel disease(Crohn's disease and Ulcerative colitis) Thyroid disease (Hyper or Hypothyroidism), strictures due to ischemia, diverticulitis or ischemia, among others.

The differential diagnosis for Irritable bowel syndrome can be listed based on predominant symptoms, such as constipation predominant, diarrhea predominant and pain predominant diseases.

Differentiating Irritable Bowel Syndrome from other Diseases

Diseases with similar symptoms

• Celiac disease
• Crohn's disease
• Zollinger-Ellison syndrome
• VIPoma
• Diverticulitis
• Endometriosis
• Gallstones
• Gastroesophageal reflux disease (GERD)
• Inflammatory bowel disease
• Lactose intolerance
• Thyroid disease- Hyperthyroidism/Hypothyroidism
• Chronic pancreatitis
• Small bacterial overgrowth
• Intermittent small bowel obstruction

Differential Diagnosis of Irritable Bowel Syndrome on the basis of Constipation:

The differential diagnosis of Irritable bowel Syndrome based on constipation is as follows:

Differential Diagnosis for Constipation predominant symptoms	Clinical features	Diagnosis
Strictures due to diverticultis,inflammatory bowel disease, ischemia or cancer	Obstipation, constipation	Barium enema, flexible sigmoidoscopy, colonoscopy, CT scan
Hypothyroidism	Fatigue, increased sensitivity to cold, dry skin, constipation, weight gain, puffy face, muscle weakness, hoarseness	Serum Thyroid Stimulating Hormone levels
Medication	Opiates, cholestyramine, Calcium-channel blockers, Anticholinergic medications	Medication history.
Neurologic disease	Concurrent multiple sclerosis, Parkinson disease, autonomic dysfunction(Shy-Drager)	History and neurologic examination
Pelvic floor dysfunction	Straining, self digitation	Rectal examination, defecography, anorectal manometry, balloon expulsion study
Colonic inertia	Infrequent bowel movements	Radiopaque markers, scintigraphy, wireless pH and motility capsule

Differential Diagnosis of Irritable Bowel Syndrome on the basis of Diarrhea:

The differential diagnosis of Irritable Bowel Syndrome based on diarrhea is as follows:

Differential Diagnosis for Diarrhea predominant symptoms	Clinical features	Diagnosis
Crohn's disease	Diarrhea, abdominal pain	Colonoscopy, small bowel barium radiograph, CT enterography, magnetic resonance enterography
Ulcerative colitis	Present with abdominal pain, tenesmus, have diarrhea and rectal bleeding	Colonoscopy
Microscopic colitis	Watery diarrhea with nocturnal symptoms	Colonoscopy, flexible sigmoidoscopy and biopsy
Celiac disease	Diarrhea, steatorrhea, anemia	Endoscopy with small bowel biopsy, Tissue transglutaminase antibody
Neuroendocrine tumor	Gastrinoma, Carcinoid and VIP producing tumor	Urine 5HIAA, fasting gastritis(followed by secretin stimulation test), serum VIP
Hyperthyroidism	Increased appetite, insomnia, diarrhea, palpitations, heat intolerance, increased sweating	Serum TSH levels
Lactose intolerance	Flatulence, bloating with lactose consumption	Avoidance trial, lactose breath test
Infectious causes	Abdominal discomfort, diarrhea especially in the setting of recent travel	Stool for ova and parasites, stool Giardia antigen, stool culture, trial of metronidazole
Small bowel bacterial overgrowth	Bloating, diarrhea, abdominal distension	Jejunal aspirate, lactulose breath hydrogen test, antibiotic trial
Clostridium difficile infection(Psuedomembranous colitis)	Recent antibiotic treatment	Stool Polymerase Chain reaction

The diffrentials of chronic watery diarrhea are as follows:

Cause			Osmotic gap		History	Physical exam	Gold standard	Treatment
			< 50 mOsm per kg	> 50 mOsm per kg*
Watery	Secretory	Crohns	+	-	Abdominal pain followed by diarrhea	Abdominal tenderness when palpated in severe disease Blood seen on rectal exam Fever Tachycardia Hypotension	Colonoscopy with biopsy	Topical mucosamine and corticosteroids are preferred Mesalamineand sulfasalazine are used for remission
		Zollinger-Ellison syndrome	+	-	Abdominal pain and diarrhea Dyspepsia Upper or lower GI bleeding	Abdominaltenderness whenpalpated in severe disease Blood seen on rectal exam, Hematochezia Hematemesis Tachycardia Hypotension	Gastrin levels	Proton pump inhibitors Octreotide
		Hyperthyroidism	+	-	Abdominal pain and diarrhea Dyspepsia Upper or lower GI bleeding	Lump in the neck Proptosis Tremors Increased DTR	TSH with T3 and T4	Carbimazole and methimazole Beta blockers like propylthiouracil Iodine-131
		VIPoma	+	-	Watery diarrhea Dehydration(thirst, dry skin, dry mouth, tiredness, headaches, and dizziness) Lethargy, muscle weakness Nausea, vomiting Crampy abdominal pain Weight loss Flushing	Lump in the neck Proptosis Tremors Increased DTR	Elevated VIPlevels Followed by imaging	Sandostatin or chemotherapy for malignant tumors Surgical removal of the tumor
	Osmotic	Lactose intolerance	-	+	Abdominal pain Bloating Diarrhea Flatulence	Abdominal tenderness	Intestinal biopsy	Avoidance of dietary lactose Substitution to maintain nutrient intake Regulation of calcium intake Use of enzymelactase
		Celiac disease	-	+	May be asymptomatic Vague abdominal pain Diarrhea Weight loss Malabsorption/ steatorrhea Bloatedness	Abdominal pain and cramping Abdominal distention Tetany Mouth ulcers Dermatitis herpetiformis Signs of the fat-soluble vitamins A, D, E, and K deficiency	IgA tissue transglutaminaseAb	Gluten-free diet
	Functional	Irritable bowel syndrome	-	-	Abdominal pain or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following: Improves with defecation Onset associated with change in frequency of stool Onset associated with change in appearance of stool 25% of bowel movements are loose stools History of straining is also common	Abdominal tenderness Hard stool in the rectal vault	Clinical diagnosis ROME III criteria Pharmacologicstudies based criteria	High dietary fiber Osmotic laxatives such as polyethylene glycol, sorbitol, and lactulose Antispasmodicdrugs (e.g. anticholinergics such as hyoscyamine or dicyclomine)

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Differential diagnosis of abdominal pain

The differential diagnosis based on abdominal pain are as follows:

Classification of acute abdomen based on etiology Presentation Clinical findings Diagnosis Comments Fever Rigors and Chills Abdominal Pain Jaundice Hypotension Guarding Rebound Tenderness Bowel sounds Other findings Lab Findings Imaging Common causes of Peritonitis Spontaneous bacterial peritonitis + Diffuse − − − − Hypoactive Ascitic fluid PMN>250 cells/mm³ Culture: Positive for single organism Ultrasound for evaluation of liver cirrhosis - Perforated gastric and duodenal ulcer + Diffuse − + + + N Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis Acute suppurative cholangitis + + RUQ + + + + ± Acute cholangitis + − RUQ + − − − N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + IV antibiotics Acute cholecystitis + RUQ + − − Hypoactive Hyperbilirubinemia Leukocytosis Ultrasound shows gallstone and evidence of inflammation Murphy’s sign Acute pancreatitis + Epigastric ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back Acute appendicitis + RLQ − + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite Acute diverticulitis + LLQ ± + − Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation Hollow Viscous Obstruction Small intestine obstruction − Diffuse − + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Gall stone disease/Cholelithiasis ± − Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination Acute ischemic colitis ± Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma Gynaecological Causes Fallopian tube Acute salpingitis + LLQ/ RLQ − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge Ovarian cyst complications Torsion of the cyst - RLQ / LLQ - ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding Functional Irritable Bowel Syndrome - Diffuse - - - - N Clinical diagnosis ROME III/IV criteria Pharmacologic studies based criteria - High dietary fiber,Osmotic laxatives and Antispasmodicdrugs The following is a list of diseases that present with acute onset severe lower abdominal pain: Disease Findings Ectopic pregnancy History of missed menses, positive pregnancy test, ultrasound reveals an empty uterus and may show a mass in the fallopian tubes. Appendicitis Pain localized to the right iliac fossa, vomiting, abdominal ultrasound sensitivity for diagnosis of acute appendicitis is 75% to 90%. Rupturedovarian cyst Usually spontaneous, can follow history of trauma, mild chronic lower abdominal discomfort may suddenly intensify, ultrasound is diagnostic. Ovarian cyst torsion Presents with acute severe unilateral lower quadrant abdominal pain, nausea and vomiting, tender adnexal mass palpated in 90%, ultrasound is diagnostic. Hemorrhagic ovarian cyst Presents with localized abdominal pain, nausea and vomiting. Hypovolemic shock may be present, abdominal tenderness and guarding are physical exam findings, ultrasound is diagnostic. Endometriosis Presents with cyclic pain that is exacerbated by onset of menses, dyspareunia. laparoscopic exploration is diagnostic. Acute cystitis Presents with features of increased urinary frequency, urgency, dysuria, and suprapubic pain. References