GPAtlas🧭 When to suspect
Inflammatory bowel disease (IBD) describes chronic, immune-mediated inflammation of the gastrointestinal tract, encompassing ulcerative colitis (UC), Crohn's disease and microscopic colitis.
Suspect it in any patient with persistent (> 4–6 weeks):
• Diarrhoea
• Abdominal pain
• Rectal bleeding
• Fatigue
• Unintentional weight loss
The principal differentials in primary care are irritable bowel syndrome (IBS), coeliac disease, infective colitis and colorectal cancer (CRC), so the two core tasks are to exclude cancer and to distinguish inflammatory from functional disease using objective stool testing before referral.
Onset is typically in the teens to thirties for UC and Crohn's, whereas microscopic colitis characteristically presents in those over 60. The symptom pattern points to the subtype:
| Subtype | Typical presentation | Distinguishing features |
|---|---|---|
| Ulcerative colitis | Bloody diarrhoea, urgency, tenesmus, mucus | • Continuous inflammation extending proximally from the rectum • Confined to the colon |
| Crohn's disease | Abdominal pain, diarrhoea, weight loss, mouth ulcers | • Any site mouth to anus • Skip lesions • Transmural • Perianal disease, fistulae, abscesses and strictures |
| Microscopic colitis | • Chronic, non-bloody, watery diarrhoea • Nocturnal stools • Urgency |
• Older adults (median age ~60) • Endoscopically normal mucosa, diagnosed on biopsy • Linked to NSAIDs, PPIs and SSRIs |
Source: NICE NG129 · NICE NG130
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