What are the signs and symptoms of inflammatory bowel disease and how is it managed?

Signs and Symptoms of Inflammatory Bowel Disease

IBD presents with a heterogeneous constellation of gastrointestinal symptoms including abdominal pain, diarrhea with increased stool frequency, rectal bleeding, weight loss, and anemia, along with potential extraintestinal manifestations affecting joints, skin, and eyes. 1

Core Gastrointestinal Symptoms

Primary Presenting Features

• Increased stool frequency and diarrhea are the hallmark findings in both Crohn's disease (CD) and ulcerative colitis (UC), with stool consistency varying from loose to watery depending on disease severity and location 2
• Rectal bleeding occurs commonly, particularly in UC where mucosal inflammation characteristically starts distally in the rectum and progresses proximally 1, 2
• Abdominal pain is a prominent feature, with left lower quadrant tenderness suggesting distal colitis or proctosigmoiditis, the most common initial presentation of UC 3
• Vomiting may occur, especially in more severe disease presentations 1

Systemic Manifestations

• Weight loss correlates with more severe disease activity and is characteristic of IBD, particularly in this age group 1, 3
• Anemia develops from chronic blood loss and chronic inflammation 1
• Fever, malaise, and anorexia are systemic symptoms more commonly seen in Crohn's disease 4

Extraintestinal Manifestations

Extraintestinal involvement can affect multiple organ systems and may precede or accompany gastrointestinal symptoms: 1

• Arthritis (joint inflammation) 1, 4
• Skin disorders including erythema nodosum and pyoderma gangrenosum 1, 4
• Uveitis (eye inflammation) 1, 4

Disease-Specific Patterns

Crohn's Disease Characteristics

• Transmural inflammation can occur anywhere in the entire gastrointestinal tract, with common localizations in the terminal ileum and colon 1
• Complications include abscesses and fistulas due to the transmural nature of inflammation 1
• Obstructive symptoms including abdominal distention, pain, nausea, vomiting, obstipation or constipation suggest anatomic abnormalities or structural complications 1

Ulcerative Colitis Characteristics

• Mucosal inflammation typically starts distally in the rectum with progression toward the more proximal colon 1
• Disease is limited to the colon with rare ileal involvement (backwash ileitis) 1
• The triad of abdominal pain, bloody diarrhea, and weight loss is particularly characteristic of UC in young adults 3

Critical Clinical Context

Symptom-Inflammation Disconnect

A crucial pitfall to recognize is that symptoms do not always correlate with disease activity: 1, 2

• Even after achieving endoscopic remission, only 29% and 41% of UC patients report normal stool frequency at 8 and 52 weeks respectively 2
• Up to 27% of UC patients with both endoscopic and histologic healing continue to have increased stool frequency 2
• Approximately 39% of IBD patients have overlapping functional gastrointestinal symptoms that persist despite mucosal healing 1, 2

Nocturnal Symptoms

• Nocturnal diarrhea and urgency are important distinguishing features that suggest organic disease rather than functional disorders 4, 2

Diagnostic Approach to Symptoms

Initial Assessment Algorithm

1. Document specific symptom patterns: stool frequency, consistency, urgency, rectal bleeding, and nocturnal symptoms to assess disease severity 4
2. Record systemic symptoms: fever, malaise, anorexia, weight loss, and abdominal pain (more common in CD) 4
3. Assess for extraintestinal manifestations affecting joints, skin, and eyes 4

Laboratory Correlation

• Fecal calprotectin provides objective evidence of intestinal inflammation: levels <100 μg/g suggest lower relapse probability, 100-200 μg/g warrant repeat testing, and >200 μg/g trigger endoscopic evaluation 1, 4
• Inflammatory markers including CRP (more sensitive than ESR) help detect active inflammation 4

Exclusion of Mimics

Before attributing symptoms to IBD, exclude infectious causes: 4, 3

• Obtain stool cultures for bacterial pathogens, Clostridium difficile toxin, and ova/parasites 4
• Consider alternative mechanisms including small intestinal bacterial overgrowth, bile acid diarrhea, carbohydrate intolerance, and chronic pancreatitis based on predominant symptom patterns 1

Management Framework

Treatment Goals

IBD management aims to achieve induction of remission followed by maintenance therapy to prevent recurrent disease flares. 1

Therapeutic Approach

• Conventional immunosuppressive therapies include azathioprine, 6-mercaptopurine, methotrexate, and 6-thioguanine for patients requiring long-term disease control 1
• Biologic therapy is indicated for insufficient response to immunosuppression or intolerance, with anti-TNF agents (infliximab, adalimumab, golimumab) typically used first-line 1, 5
• Next-line biologicals include vedolizumab (anti-integrin) and ustekinumab for CD (blocking IL-12/23 pathway) 1
• Small molecules such as tofacitinib (JAK inhibitor) are approved for UC treatment 1

Management of Functional Symptoms in IBD

When persistent GI symptoms occur despite controlled inflammation: 1

• Follow a stepwise approach to rule out ongoing inflammatory activity (fecal calprotectin, endoscopy with biopsy, cross-sectional imaging) 1
• Consider low FODMAP diet with attention to nutritional adequacy 1
• Offer psychological therapies (cognitive behavioral therapy, hypnotherapy, mindfulness therapy) 1
• Use osmotic and stimulant laxatives for chronic constipation 1
• Consider hypomotility agents or bile-acid sequestrants for chronic diarrhea in quiescent IBD 1
• Use antispasmodics, neuropathic-directed agents, and antidepressants for functional pain while avoiding opiates 1

Common Pitfalls to Avoid

• Do not rely solely on stool frequency to assess disease activity, as functional symptoms persist in many patients despite mucosal healing 1, 2
• Do not skip infectious stool studies even in known IBD patients, as superimposed infection is common and alters management 4, 3
• Do not delay reinitiation of therapy once infectious causes are excluded, as mucosal healing predicts better long-term outcomes 3
• Always exclude C. difficile infection before attributing symptoms to IBD flare, as this can mimic or coexist with IBD 3