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

The differential diagnosis of Irritable bowel Syndrome based on predominant symptoms 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 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

Differential Diagnosis for Pain predominant symptoms	Clinical Features	Diagnosis
Aerophagia, bloating	Anxiety may cause air swallowing	Abdominal radiograph
Intermittent small bowel obstruction	More likely with a history of previous abdominal surgeries	Abdominal radiograph, small bowel barium radiograph, CT scan
Ischemia	Intestinal angina especially in patients with atherosclerosis, weight loss, aversion to food, pain half an hour after meals	Mesentric angiography, Doppler USG, CT angiography
Chronic pancreatitis	Epigastric pain	Abdominal radiograph to assess for calcifications, endoscopic USG, CT scan
Endometriosis	Menstrual associated symptoms, pelvic symptoms	Diagnostic laproscopy
Acute Intermittent Porphyria	Rare, may have elevated liver enzymes and neurologic symptoms	Seum and urine porphyrins, especially porphobilinogen and amino levulinic acid

The table below summarizes the findings that differentiate watery causes of chronic diarrhea

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 whenpalpated 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	Abdominal tenderness 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 blockerslike 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 enzyme lactase
		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/IV criteria Pharmacologic studies based criteria	High dietary fiber Osmotic laxatives such as polyethylene glycol, sorbitol, and lactulose Antispasmodicdrugs (e.g. anticholinergicssuch as hyoscyamineor dicyclomine)

Differential Diagnosis of Irritable Bowel Syndrome

The differential diagnosis of Irritable bowel Syndrome based on predominant symptoms 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 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

Differential Diagnosis for Pain predominant symptoms	Clinical Features	Diagnosis
Aerophagia, bloating	Anxiety may cause air swallowing	Abdominal radiograph
Intermittent small bowel obstruction	More likely with a history of previous abdominal surgeries	Abdominal radiograph, small bowel barium radiograph, CT scan
Ischemia	Intestinal angina especially in patients with atherosclerosis, weight loss, aversion to food, pain half an hour after meals	Mesentric angiography, Doppler USG, CT angiography
Chronic pancreatitis	Epigastric pain	Abdominal radiograph to assess for calcifications, endoscopic USG, CT scan
Endometriosis	Menstrual associated symptoms, pelvic symptoms	Diagnostic laproscopy
Acute Intermittent Porphyria	Rare, may have elevated liver enzymes and neurologic symptoms	Seum and urine porphyrins, especially porphobilinogen and amino levulinic acid

References