Inflammatory bowel disease.

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Ulcerative colitis (UC) is a diffuse inflammation of the colon. A third of patients have a pan-colitis, a third have only the rectum (proctitis) or sigmoid colon involved, and the rest have inflammation up to the splenic flexure or transverse colon. Crohn's disease, by contrast, has patchy inflammation through the wall of the bowel, and can affect any part of the gut from the mouth to the anus. The most common site is the terminal ileum with or without the caecal region, but the colon, small intestine, perianal area, or any combination, can be affected, and there are often areas of inflammation with normal bowel between. It is known that there are strong genetic factors for both diseases, so some patients will give a family history, and a gene for Crohn's has been identified. There are clearly environmental factors too, such as smoking. The peak age for an inflammatory bowel disease (IBD) diagnosis is young adult, but it is increasingly being diagnosed in children and teenagers, and it can present occasionally in patients up to the age of 70. Crohn's is more common in young women, but there is no sex difference for UC. A GP practice with 6,000 patients is likely at any one time to have 12 known patients with UC, and 12 with Crohn's, and can expect to diagnose one or two new cases of UC, and one of Crohn's, each year.

Presentation -- UC UC presents in a standard way, with rectal bleeding, urgency of defecation, diarrhoea, and mild abdominal pain when needing to open bowels. Proctitis presents with blood and mucus separate from the stool, and patients are often constipated. More extensive disease will present bloody diarrhoea and patients become anaemic and unwell.

Diagnostic tips * Proctitis: note the presentation with blood per rectum and urgency in a young adult who may be constipated. Do not dismiss this as haemorrhoids, which do not cause urgency of defaecation. * Colitis: there are several weeks of bloody diarrhoea. The natural history is for attacks to come and go, so the patient may have had previous milder attacks in the past year or two. Up to a quarter of patients will give a history of having given up smoking. Smoking suppresses colitis and so patients may present within a few months of stopping. When to refer The diagnosis is easy to make by sigmoidoscopy,...

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