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: Sudarshana Datta, MD [2]



Differentiating Irritable Bowel Syndrome from other Diseases

Differential diagnosis based on the predominant symptom(s)



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

Differential diagnosis based on predominant symptom(s)

Differential diagnosis based on abdominal pain

The differential diagnosis of IBS based on abdominal pain is as follows:

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Fever Rigors and chills Abdominal Pain Jaundice Diarrhea Melena/ hematochezia/ hemtemesis Hypo-


Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis + + RUQ + + + + N
  • Abnormal LFT
  • WBC >10,000
Ultrasound shows biliary dilatation/stents/tumor Septic shock occurs with features of SIRS
Acute cholangitis + RUQ + N Ultrasound shows biliary dilatation/stents/tumor Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis + RUQ + Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis + Epigastric ± ± N Ultrasound shows evidence of inflammation Pain radiation to back
Primary biliary cirrhosis RUQ/Epigastric + N
  • Increased AMA level, abnormal LFTs
Primary sclerosing cholangitis + RUQ + N ERCP and MRCP shows
  • Multiple segmental strictures
  • Mural irregularities
  • Biliary dilatation and diverticula
  • Distortion of biliary tree
The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Cholelithiasis ± RUQ/Epigastric ± + + N to hyperactive for dislodged stone Ultrasound shows gallstone Murphy’s sign
Gastric causes Peptic ulcer disease ± Diffuse + in perforated + + N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis
Gastritis ± Epigastric + in chronic gastritis
Gastroesophageal reflux disease Epigastric
Gastric outlet obstruction Epigastric ± Hyperactive
Gastrointestinal perforation + ± Diffuse ± +, depends on site + + ±
  • WBC> 10,000
Air under diaphragm in upright CXR
Dumping syndrome Lower and then diffuse
Intestinal causes Acute appendicitis + +in pyogenic appendicitis Starts in epigastrium, migrates to RLQ + in perforated appendicitis + + Hypoactive Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Acute diverticulitis + ± LLQ Hematochezia + Hypoactive CT scan and ultrasound shows evidence of inflammation
Inflammatory bowel disease ± Diffuse ± Hematochezia
Irritable bowel syndrome ± Diffuse + N Tests done to exclude other diseases as it diagnosis of exclusion Tests done to exclude other diseases as it diagnosis of exclusion Symptomatic treatment
Whipple's disease ± Diffuse ± ± N *Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Toxic megacolon + Diffuse + + ± Hypoactive CT scan shows:

Ultrasound shows:

  • Loss of haustra coli of the colon
  • Hypoechoic and thickened bowel walls with irregular internal margins in the sigmoid and descending colon
  • Prominent dilation of the transverse colon (>6 cm)
  • Insignificant dilation of ileal bowel loops (diameter >18 mm) with increased intraluminal gas and fluid
Tropical sprue + Diffuse +
Celiac disease Diffuse ±, also dermatitis herpetiformis + Hyperactive (increased sounds)
Infective colitis +
Hepatic causes Viral hepatitis + RUQ + +
Liver masses + + in Liver abscess RUQ ± + in sepsis
Budd-Chiari syndrome ± RUQ ± + in liver failure leading to varices N
Findings on CT scan suggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Hemochromatosis RUQ Dull / aching + with infections and GI involvement + in cirrhotic patients may be in cardicmyopathy
  • >60% TS
  • >240 μg/L SF
  • Raised LFT
Ultrasound shows evidence of cirrhosis Extra intestinal findings:
  • hyperpigmentation
  • Diabetes mellitus
  • Arthralgia
  • Impotence in males
  • Cardiomyopathy
  • Atherosclerosis
  • Hypopituitarism
  • Hypothyroidism
  • Extrahepatic cancer
  • Prone to specific infections
Cirrhosis + RUQ + varices
Peritoneal causes Spontaneous bacterial peritonitis + Diffuse + in cirrhotic patients ± Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
Ultrasound for evaluation of liver cirrhosis
Hollow Viscous Obstruction Small intestine obstruction Diffuse + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
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 + Hematochezia ± Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination
Acute ischemic colitis ± ± Diffuse + Massive + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting
Hemorrhagic causes Ruptured abdominal aortic aneurysm Diffuse Massive + N Normal CT scan Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage Diffuse Massive + N Anemia CT scan History of trauma
Gynaecological Causes Tubal causes Torsion of the cyst RLQ / LLQ ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Acute salpingitis + ± RLQ / LLQ ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge
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
Extra-abdominal causes Pulmonary disorders Pleural empyema + ± RUQ/Epigastric N
Cardiovascular disorders Myocardial Infarction Epigastric + in cardiogenic shock N

Differential diagnosis based on constipation

The differential diagnosis of irritable bowel syndrome based on constipation as the predominant symptom is as follows:[1][2][3][4][5][6][7][8][9][10]

Differential Diagnosis for Constipation predominant symptoms Clinical features Diagnosis
Strictures due to diverticultis,inflammatory bowel disease, ischemia or cancer
  • Medication history.
Neurologic disease
Pelvic floor dysfunction
  • Straining, self digitation
Colonic inertia

Differential Diagnosis based on abdominal pain and diarrhea

Below is a table that overviews the differential based on type of diarrhea. A more detailed table follows.

Diarrhea with abdominal pain/cramping may be caused by infectious diseases, celiac disease,[11] parasites,[12] food allergies[13] and lactose intolerance.[14] See the list of causes of diarrhea for other conditions which can cause diarrhea. Celiac disease in particular is most often misdiagnosed as IBS.[15] The differential diagnosis of irritable bowel syndrome based on abdominal pain and diarrhea is as follows:[16][17][18][19][20][21][22][23][24][25]

Overview based on type of diarrhea

Cause Osmotic gap History Physical exam Gold standard Treatment
< 50 mOsm per kg > 50 mOsm per kg*
Watery Secretory Crohns + -
Zollinger-Ellison syndrome + -
  • Gastrin levels
  • Proton pump inhibitors
  • Octreotide
Hyperthyroidism + -
VIPoma + -
  • Elevated VIPlevels
  • Followed by imaging
Osmotic Lactose intolerance - +
Celiac disease - +
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:
  • Onset associated with change in frequency of stool
Clinical diagnosis
  • ROME IV criteria
  • Exclusion of organic causes based on laboratory investigations and imaging

Details based on pathology

Irritable bowel syndrome must be diifferentiated from other causes of abdominal pain and diarrhea.

Diseases Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging Histopathology
Abdominal pain Diarrhea Flushing Dyspnea Palpitations Other symptoms Wheezing Telangiectasia Hypotension Tachycardia Systolic murmur of tricuspid regurgitation Other physical findings Urinary 5-hydroxyindoleacetic acid (5-HIAA) Serum Chromogranin A (CgA) Other markers Abdominal computed tomography (CT) Abdominal MRI Somatostatin receptor scintigraphy [SRS], or Octreoscan Metaiodobenzylguanidine (MIBG) scintigraphy Other diagnostic studies Transthoracic echocardiography
Carcinoid Syndrome[26][27][28][29][30][31][32][33][34] Neuroendocrine tumor of midgut [35][36][37][38] +


+ + + +




Metastatic tumors in the liver: Right upper quadrant pain, hepatomegaly, and early satiety

+ +/- +/- + + - + + + +
  • Valve thickening with retraction and reduction in the mobility of the tricuspid valve

Pathognomonic radiological sign of midgut NET.

Neuroendocrine tumor of lung[39][40][41][42] + + + + +
+ +/- +/- + + - + + Sensitive for detection of liver metastases if present + + - Typical low-grade:bland cells containing regular round nuclei with finely dispersed chromatin and inconspicuous small nucleoli.Mitotic figures are scarce and necrosis is absent.

Intermediate-grade atypical: presence of Neuroendocrine morphology and either necrosis or 2 to 10 mitoses per 10 HPF

Irritable Bowel Syndrome[43][44][45][46] +


- - - - - - - - - - - - - - - - Rome IV criteria
  • Recurrent abdominal pain, at least 1day/week in the last 3 months, a/s with 2 or more of the following criteria:

•Related to defecation

•Associated with a change in stool frequency

•Associated with a change in stool form (appearance)

Malignant neoplasms of small intestine[47][48][49] +/- +/- - - +/- - - +/- - * Abdominal mass - + Abdominal CT scan may be diagnostic of small intestine cancer. Findings on CT scan suggestive of small intestine cancer include intrinsic mass with a short segment of bowel wall thickening MRI and MRI enteroscopy are other advance modalities to diagnose and stage small intestinal cancers - - Enteroscopy, capsule endoscopy and double balloon enteroscopy Biopsy and histopathology
Crohn disease[50][51][52][53] +/- - - - - - - - - - - - - -
  • Focal ulcerations and acute and chronic inflammation
Benign cutaneous flushing[54] - - + - - - - - - - - - - - - - - - - - - -
Systemic mastocytosis[55][56][57][58][59] + + + + - +/- +/- + - - - - - -
Asthma exacerbation[60][61][62][63] - - - + + + - - + -
  • Tachypnea
  • Prolonged expiratory phase of respiration (decreased I:E ratio)
  • Seated position with use of extended arms to support the upper chest (tripod position)
  • +/- Pulsus paradoxus
- - - -- - - - Chest X ray -
  • Loss of the normal pseudostratified structure of airway epithelium
  • Increase in the proportion of goblet cells
  • Fibrotic thickening of the sub-epithelial reticular basement membrane
  • Increased numbers of myofibroblasts
  • Increased vascularity
  • Increased airway smooth muscle mass
  • Increased extracellular matrix
Anaphylaxis[64][65][66][67][68] + -/+ + + + +/- - + + - - - - - - - - - - History of exposure to insect stings,food alllergy,rubber latex,food additives,,allergy to medications,physical factors such s excercise and cold
Histaminergic Angioedema[69][70][71][72][73] +/- +/- + + + + - + + - - - - - - - - - -
  • Take proper clinical history of previous similar episodes
  • Medication history
  • Any allergy to insects stings , foods or any ingestion within previous 24 hours
Medullary Thyroid Carcinoma[74][75][76][77] - +/- +/- +/- - - - - - - - - - - - -

For metastasis


Differential diagnosis based on diarrhea

The following table outlines the major differential diagnoses based on diarrhea as the major presenting symptom

Differential Diagnosis for Diarrhea predominant symptoms Clinical features Diagnosis
Crohn's disease
Ulcerative colitis
Microscopic colitis
Celiac disease
Neuroendocrine tumor
  • Serum TSH levels
Lactose intolerance
  • Avoidance trial, lactose breath test
Infectious causes
  • Abdominal discomfort, diarrhea especially in the setting of recent travel
Small bowel bacterial overgrowth
Clostridium difficile infection(Psuedomembranous colitis)


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