Intended for healthcare professionals

Practice Easily Missed

Inflammatory bowel disease

BMJ 2015; 351 doi: (Published 24 September 2015) Cite this as: BMJ 2015;351:h4416
  1. Ella Mozdiak, clinical research fellow in gastroenterology1,
  2. John O’Malley, general practitioner and clinical director2,
  3. Ramesh Arasaradnam, consultant gastroenterologist, senior lecturer3
  1. 1Gastroenterology Department, University Hospitals Coventry and Warwickshire, Coventry, UK
  2. 2Trafford Health Centre, Trafford, UK
  3. 3University of Warwick, Coventry CV2 2DX, UK
  1. Correspondence to: R Arasaradnam r.arasaradnam{at}

The bottom line

  • Inflammatory bowel disease can present with symptoms similar to irritable bowel syndrome

  • Diarrhoea of >6 weeks’ duration, especially with weight loss and where cancer is not suspected, warrants testing (such as full blood count, C reactive protein or erythrocyte sedimentation rate, coeliac antibodies, and thyroid function)

  • NICE guidelines recommend measuring faecal calprotectin in all patients with suspected inflammatory bowel disease, as it is useful in excluding the disease

  • Delayed diagnosis of inflammatory bowel disease is associated with reduced response to medical therapy and higher incidence of surgical intervention

A 21 year old woman presented to her general practitioner with tiredness and abdominal discomfort for the past year. She is treated for iron deficiency anaemia (attributed to menorrhagia) and for presumed irritable bowel syndrome. After hospital admission a few months later with suspected appendicitis, tests reveal vitamin B12 deficiency and raised inflammatory markers, prompting gastroenterology referral. Colonoscopy with terminal ileal biopsy confirms a diagnosis of Crohn’s disease.

What is inflammatory bowel disease?

Inflammatory bowel disease encompasses ulcerative colitis and Crohn’s disease, both idiopathic chronic diseases of the gastrointestinal tract. Ulcerative colitis is characterised by diffuse inflammation affecting the mucosa of the colon only. Crohn’s disease involves patchy transmural ulceration that can affect any part of the gastrointestinal tract. Around 5% of patients have features of both subtypes and are labelled inflammatory bowel disease “unclassified.”1

How common is inflammatory bowel disease?

  • A large systematic review showed the incidence and prevalence of inflammatory bowel disease are increasing with time,2 in particular among second generation Asian migrants in the UK

  • The incidence of ulcerative colitis is about 10-20/100 000/year, with a reported prevalence of 100-200/100 000 people3

  • The incidence of Crohn’s disease is around 5-10/100 000/year, with a prevalence of 50-100/100 000 people3

  • There is little gender difference in the prevalence of inflammatory bowel disease, …

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