What questions should I ask when evaluating a patient with suspected or known inflammatory bowel disease?

Essential Questions to Ask When Evaluating IBD Patients

Core Symptom Assessment

Document specific bowel symptoms systematically at every encounter, focusing on stool frequency, consistency, rectal bleeding, urgency, tenesmus, abdominal pain, incontinence, and nocturnal diarrhea. 1

• Stool characteristics: Ask about frequency (number per day), consistency (Bristol scale), presence and volume of blood, mucus, and pus 1, 2
• Urgency and incontinence: Specifically inquire about daytime and nighttime fecal incontinence, as these significantly impact quality of life 3, 1
• Pain patterns: Document location, character, timing relative to meals and bowel movements, and severity using a numeric scale 1
• Nocturnal symptoms: Ask if symptoms wake the patient from sleep, which indicates more severe disease 1, 2
• Perianal symptoms: In suspected or known Crohn's disease, ask about perianal pain, drainage, skin tags, fissures, and fistulas 3, 1
• Ostomy-related symptoms: For patients with ostomies, ask about output volume, consistency, appliance issues, and peristomal skin problems 3

Extraintestinal Manifestations

Systematically screen for extraintestinal manifestations at every visit, as they occur in up to 40% of IBD patients and may precede bowel symptoms. 1

• Musculoskeletal: Ask about joint pain, swelling, morning stiffness, and back pain (peripheral arthropathy and axial spondyloarthropathy) 1
• Dermatologic: Inquire about painful skin nodules (erythema nodosum) or ulcerating lesions (pyoderma gangrenosum) 1
• Ophthalmologic: Ask about eye redness, pain, photophobia, or vision changes (uveitis, episcleritis) 1
• Hepatobiliary: Document right upper quadrant pain, jaundice, or pruritus (primary sclerosing cholangitis) 1, 4

Disease Severity and Impact

Establish a complete symptom timeline including onset, duration, pattern, and progression to assess disease trajectory. 1

• Constitutional symptoms: Ask about fever, unintentional weight loss (quantify in kg/lbs), fatigue severity, and night sweats 1, 2
• Functional impact: Specifically ask how symptoms affect work, school, social activities, sleep, and sexual function 3, 1
• Subjective wellbeing: Ask patients to rate their overall health-related quality of life on a scale 3
• Self-management capacity: Inquire about the patient's ability to manage their disease independently and their sense of autonomy 3
• Disease acceptance: Ask how well the patient is coping with and accepting their diagnosis 3
• Information needs: Determine if the patient feels adequately informed about their condition and treatment options 3

Risk Factors and Disease Modifiers

Document family history of IBD or colorectal cancer, as first-degree relatives have a 4-fold increased risk of developing IBD. 1

• Smoking status: Record current, former, or never smoker status—current smoking is protective in UC but former smoking increases risk by 70% 1
• Appendectomy history: Ask about previous appendectomy, particularly if performed before adulthood, as this may be protective in UC 1
• Medication history: Document all current and past medications, especially NSAIDs (can trigger flares) and antibiotics (may alter microbiome) 1, 2
• Recent antibiotic use: Specifically ask about antibiotic exposure in the preceding 3 months 2

Infection Screening

Always screen for superimposed infections in patients with new or worsening symptoms, as infection can mimic or trigger IBD flares. 3

• Recent travel: Document destinations and timing relative to symptom onset, particularly travel to endemic areas for enteric pathogens 3, 1
• Infectious exposures: Ask about contact with individuals who have diarrheal illnesses 3, 1
• Sexual history: Obtain sexual behavior history when relevant for infectious differential diagnoses 1
• Prior C. difficile infection: Document any history of Clostridioides difficile infection, as recurrence is common in IBD 3, 2

Previous Disease History and Complications

Document all previous IBD-related surgeries, hospitalizations, and complications, as these predict future disease course and guide treatment intensity. 1

• Surgical history: Record type and date of any bowel resections, stricturoplasties, or ostomy creation 1
• Disease extent: Ask about previous endoscopic findings documenting disease location and extent (proctitis, left-sided, pancolitis for UC; ileal, colonic, ileocolonic for CD) 3, 1
• Previous complications: Inquire about history of strictures, fistulas, abscesses, perforations, or toxic megacolon 3, 5, 4
• Hospitalization history: Document frequency and reasons for previous IBD-related hospitalizations 1

Current Treatment and Adherence

Assess medication adherence at every visit, as non-adherence is a major cause of preventable disease flares. 3

• Current medications: List all IBD medications with doses, frequency, and duration of use 3, 1
• Medication adherence: Directly ask about missed doses, reasons for non-adherence, and barriers to taking medications 3
• Treatment response: Document whether current therapy is controlling symptoms adequately 3, 1
• Side effects: Ask about any medication-related adverse effects that might affect adherence 1
• Biologic therapy: For patients on biologics, ask about injection site reactions, infusion reactions, or delayed deliveries 3

Vaccination Status

Assess immunization status before initiating immunosuppressive therapy, as live vaccines are contraindicated once immunosuppression begins. 3, 1

• Routine vaccinations: Document status of influenza, pneumococcal, hepatitis B, HPV, and COVID-19 vaccines 3
• Live vaccines: Specifically ask about MMR, varicella, and zoster vaccine status before starting immunosuppression 3

Pregnancy and Reproductive Health (When Applicable)

For women of childbearing age, discuss pregnancy planning at every visit, as disease control before conception is critical for maternal and fetal outcomes. 3

• Pregnancy plans: Ask about current pregnancy status and plans for future pregnancy 3
• Contraception: Document contraceptive use and discuss safe options 3
• Disease activity: Emphasize the importance of achieving remission for at least 3 months before conception 3
• Teratogenic medications: Identify patients on methotrexate, JAK inhibitors, or S1P modulators who need medication changes before conception 3
• Folic acid supplementation: Confirm adequate folic acid intake (5 mg daily for those on sulfasalazine or with small bowel disease) 3

Psychosocial Assessment

Screen for mental health concerns at every visit, as IBD patients have significantly higher rates of anxiety and depression. 3

• Mental health symptoms: Ask about symptoms of depression, anxiety, and stress 3
• Social support: Inquire about family support, work situation, and financial concerns related to disease management 3
• Coping strategies: Assess how the patient is managing the psychological burden of chronic disease 3

Cancer Surveillance Needs

Determine colorectal cancer surveillance requirements based on disease duration, extent, and family history. 1

• Disease duration: Document years since diagnosis, as cancer risk increases after 8-10 years of disease 1
• Previous dysplasia: Ask about any history of dysplasia or polyps on prior colonoscopies 3
• Family history of colorectal cancer: Document first-degree relatives with colorectal cancer, as this increases surveillance intensity 1