distinguishing long-term gastrointestinal conditions

There is significant overlap in presenting symptoms across different lower-GI conditions (Table 1).

Key similarities and distinctions include:

•

Blood with bowel motions and loose or watery bowel motions are the most common presenting symptoms with ulcerative colitis (UC).

•

Fatigue and abdominal pain are the most common presenting symptoms with Crohn’s disease (CD).

•

Coeliac disease rarely presents with blood or mucous in bowel motions.

•

Blood with bowel motions is not a feature of IBS.

•

Fatigue is very common across IBD, coeliac disease and IBS.

1/5

Blood with bowel motions and loose or watery bowel motions are the most common presenting symptoms with ulcerative colitis (UC)

Table 1. Symptom prevalence by disease (%)¹⁻⁵

Symptom

Blood with bowel motions

Urgency of bowel motions

Loose/watery bowel motions

Increased frequency of bowel motions

Tiredness/fatigue

Abdominal pain

Mucous with bowel motions

Blood from anus (fresh/not mixed with bowel motions)

Anxiety about distance to bathroom

Cramping with bowel motion

Sense of incomplete evacuation after bowel motion

Fissures, abscesses or fistulae

Not a feature

Very common

Universal

Very common

Not a feature

Common

Notes: Highlights show the five most reported symptoms in each condition. Average alarm symptoms for IBD are urgency, loose/watery bowel motions, increased frequency, tiredness/fatigue and abdominal pain. Blank cells do not imply absence of this symptom in this condition, only absence of data in the cited studies.

CoD=coeliac disease; CD=Crohn’s disease; IBS=irritable bowel syndrome; UC=ulcerative colitis.

Table 1. Symptom prevalence by disease (%)¹⁻⁵

Symptom

Blood with bowel motions

Urgency of bowel motions

Loose/watery bowel motions

Increased frequency of bowel motions

Tiredness/fatigue

Abdominal pain

Mucous with bowel motions

Blood from anus (fresh/not mixed with bowel motions)

Anxiety about distance to bathroom

Cramping with bowel motion

Sense of incomplete evacuation after bowel motion

Fissures, abscesses or fistulae

Not a feature

Very common

Universal

Very common

Not a feature

Common

CoD=coeliac disease; CD=Crohn’s disease; IBS=irritable bowel syndrome; UC=ulcerative colitis.

Table 1. Symptom prevalence by disease (%)^1-5

Symptom

Blood with bowel motions

Urgency of bowel motions

Loose/ watery bowel motions

Increased frequency of bowel motions

Tiredness/ fatigue

Abdominal pain

Mucous with bowel motions

Blood from anus (fresh/ not mixed with bowel motions)

Anxiety about distance to bathroom

Cramping with bowel motion

Sense of incomplete evacuation after bowel motion

Fissures, abscesses or fistulae

IBS

Not a feature

Very common

Universal

Very common

Not a feature

Common

Irritable bowel syndrome

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IBS is a longstanding illness with frequent abdominal discomfort and bowel symptoms that cannot be explained by any other disease. GI presentations include:

Abdominal pain or discomfort (present for at least 6 months) and relieved by defecation or associated with altered bowel frequency or stool form

Altered stool passage (straining, urgency, incomplete evacuation)

Abdominal bloating (more common in women than men)

Passage of mucus

IBS often also has extraintestinal features, including lethargy, nausea, back pain, headache or bladder symptoms. The condition rarely presents for the first time in people over 50 years old. The National Primary Care Diagnostic Pathway for Lower-GI Symptoms focuses on diarrhoea-predominant IBS (IBS-D).

The ROME criteria

A diagnosis of IBS can be supported by the ROME criteria.⁶ Recurrent abdominal pain on average at least 1 day a week in the past 3 months, associated with two or more of the following criteria:

•

Related to defecation

•

Associated with a change in stool frequency

•

Associated with a change in stool form (appearance)

These criteria need to be fulfilled for the past 3 months, with symptom onset at least 6 months prior to diagnosis.

Making a diagnosis

IBS is a positive clinical diagnosis based on characteristic symptoms and normal initial investigations, rather than a diagnosis made only after excluding all other conditions.^7,8 A confident diagnosis of IBS can be made according to following symptoms:⁹

•

Abdominal pain

•

Bowel dysfunction

•

Bloating

The diagnosis also requires exclusion of alarm symptoms, such as unintentional weight loss, rectal bleeding or recent change in bowel function, alongside normal haemoglobin (Hb), C-reactive protein (CRP), abdominal examination and digital rectal examination (DRE). Features not typical of IBS, such as nocturnal symptoms, iron deficiency anaemia, rectal bleeding or raised inflammatory markers, should prompt reconsideration of the diagnosis and further investigation.^7,8

For further information and resources, see Guts UK

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Coeliac disease

Coeliac disease occurs in 1-in-100 people and is undiagnosed in two-thirds of cases. It can present in non-specific ways, involving the common symptoms of lower-GI conditions described earlier, although potential distinguishing symptoms include:

Dermatitis herpetiformis

Tooth enamel problems

Reduced bone mineral density

Unexplained subfertility or repeated miscarriages

Neurological problems such as unexplained ataxia or peripheral neuropathy

Coeliac UK focuses on fatigue, abdominal pain, nausea, anaemia and neurological symptoms as common symptoms and signs of coeliac disease in adults.¹⁰ A 40-year single-centre analysis of 1547 found GI symptoms present in approximately half of coeliac patients, including:¹¹

24.3%

Diarrhoea

28%

Abdominal bloating

19.7%

Aphthous stomatitis

Risk factors for Coeliac disease include:

•

Family history, with a first-degree relative associated with a 1-in-10 risk

•

Down‘s or Turner syndrome

•

History of autoimmune conditions (e.g. type 1 diabetes or thyroid disease)

•

Iron-deficiency anemia or B12 or folate deficiency.

For further information and resources, see coeliac UK

Inflammatory bowel disease

IBD, which includes CD and UC, often presents with common lower-GI-symptoms, especially diarrhoea, abdominal pain, rectal bleeding or weight loss. Potential distinguishing symptoms include:

Nocturnal defecation

Fevers

Recurrent/persistent anal abscesses

Extra-intestinal manifestations (EIMs) in joints, skin, eyes or perianal area

Perianal symptoms, such as fissures, abscesses or fistulae, may present early in CD, sometimes before intestinal symptoms.^12-14

IBD is classically considered as a disease of young adulthood, usually presenting in people aged 18–35 years. However, there is a second spike at around 65 years, with a large Swedish study showing 23% of IBD patients to be at least 60 years old at point of diagnosis.¹⁵

Family history of IBD in a first-degree relative increases risk and should be considered during initial assessment.

Microscopic colitis

Microscopic colitis is a subset IBD distinct from CD or UD. The classical presentation is chronic watery non-bloody diarrhoea in older women (>60 years).¹⁶ Others follow a similar pattern to lower-GI CD, with faecal urgency, arthralgias, weight loss, abdominal pain, passage of stools at night and faecal incontinence.^17,18 Microscopic colitis is associated with:

•

Autoimmune conditions, including coeliac disease, thyroid disorders and polyarthritis¹⁶

•

Lifestyle factors, including smoking¹⁹

•

Medications, including statins, selective serotonin reuptake inhibitors (SSRIs), proton-pump inhibitors (PPIs) and non-steroidal anti-inflammatory drugs (NSAIDs), with the latter two also associated with a rise in faecal calprotectin (FCP).¹⁷

Microscopic colitis cannot be diagnosed in primary care.

Microscopic colitis is challenging to diagnose, as it appears macroscopically normal on endoscopy and requires histological confirmation by biopsy. A normal FCP result does not exclude a diagnosis (67% sensitivity; 75% specificity²⁰), so patients under high clinical suspicion should be referred for consideration of colonoscopy with biopsy. Many patients with undiagnosed microscopic colitis may have been through a diagnostic pathway with a colonoscopy already.¹⁸

Around 10%²¹ of microscopic colitis cases are self-limiting,²² but treatment with oral budesonide has been demonstrated to induce remission in between 54% to 84% of patients.²³ Loperamide may be suggested for symptomatic relief; however, there is a limited evidence base for this and other treatments.

Extra-intestinal manifestations

IBD may have EIM (Table 2)s:^24,25

Table 2. Extra-intestinal manifestations (%)^28,29

Manifestation

Peripheral arthritis

Axial arthritis

Anterior uveitis

Primary sclerosing cholangitis

Notes: Blank cells do not imply absence of this symptom in this condition, only absence of data in the cited studies.

•

Dependent on the definition, the prevalence of EIMs is reported to be between 6% and 47% of all patients.²⁶

•

Patients may be affected by more than one EIM, with over 20% of IBD patients reporting two EIMs and over 10% of patients reporting three or more.²⁶

•

EIMs may occur before or after IBD diagnosis, with 26% of all patients with EIMs report occurrence of EIMs up to 25 months (median 5 months) before IBD diagnosis.²⁶

•

EIMs can precede bowel symptoms, so new uveitis, inflammatory back pain, erythema nodosum or peripheral arthritis alongside GI symptoms should raise suspicion for IBD.²⁶

In 25.8% of cases, patients presented with their first EIM before IBD was diagnosed (median 5 months, range 0–25 months), while in 74.2% of cases, the first EIM manifested itself after IBD diagnosis (median 92 months, range 29–183 months).²⁷

First extra-intestinal manifestations of inflammatory bowel disease²⁷

Peripheral arthritis

First extra-intestinal manifestations of inflammatory bowel disease²⁷

•

70.0%

Peripheral arthritis

•

21.6%

Aphthous stomatitis

•

16.4%

Axial arthropathy/ ankylosing spondylitis

•

13.7%

Uveitis

•

12.6%

Erythema nodosum

•

4.9%

Pyoderma gangrenosum

•

2.7%

Psoriasis

For further information and resources, see Crohn’s & Colitis UK

HIV

HIV screening may be warranted in patients with GI symptoms, including chronic diarrhoea, depending on HIV stage:

Acute HIV infection in the first few weeks after exposure can include diarrhoea, nausea, fever, sore throat and muscle aches

Advanced HIV commonly includes persistent diarrhoea lasting more than a month, often linked to opportunistic infections

Patients continue to be diagnosed late with HIV. Review of late diagnoses showed 62% had missed opportunities for diagnosis, of which 62% were in primary care. Of these patients, 82% presented with indicator conditions, which can include chronic diarrhoea.³¹ GPs may miss opportunities to test for HIV due to:

•

Lack of knowledge of indicator conditions

•

Concern about causing offence to patient by suggesting an HIV test

•

Concern about consent required for test to be offered (minimum is seeking agreement to test and telling patient how result will be given).³²

Irritable bowel syndrome

IBS is a longstanding illness with frequent abdominal discomfort and bowel symptoms that cannot be explained by any other disease. GI presentations include:

Abdominal pain or discomfort (present for at least 6 months) and relieved by defecation or associated with altered bowel frequency or stool form
Altered stool passage (straining, urgency, incomplete evacuation)
Abdominal bloating (more common in women than men)
Passage of mucus

The ROME criteria

A diagnosis of IBS can be supported by the ROME criteria.²⁵ Recurrent abdominal pain on average at least 1 day a week in the past 3 months, associated with two or more of the following criteria:

Related to defecation
Associated with a change in stool frequency
Associated with a change in stool form (appearance)

These criteria need to be fulfilled for the past 3 months, with symptom onset at least 6 months prior to diagnosis.

Making a diagnosis

IBS is a positive clinical diagnosis based on characteristic symptoms and normal initial investigations, rather than a diagnosis made only after excluding all other conditions.²⁶ ²⁷ A confident diagnosis of IBS can be made according to following symptoms:²⁸

Abdominal pain
Bowel dysfunction
Bloating

For further information and resources, see Guts UK

Coeliac disease

Dermatitis herpetiformis
Tooth enamel problems
Reduced bone mineral density
Unexplained subfertility or repeated miscarriages
Neurological problems such as unexplained ataxia or peripheral neuropathy.

Coeliac UK focuses on fatigue, abdominal pain, nausea, anaemia and neurological symptoms as common symptoms and signs of coeliac disease in adults.²⁹ A 40-year single-centre analysis of 1547 found GI symptoms present in approximately half of coeliac patients, including:³⁰

Diarrhoea (24.3%)
Abdominal bloating (28%)
Aphthous stomatitis (19.7%)

Risk factors for Coeliac disease include:

Family history, with a first-degree relative associated with a 1-in-10 risk
Down's or Turner syndrome
History of autoimmune conditions (e.g. type 1 diabetes or thyroid disease)
Iron-deficiency anemia or B12 or folate deficiency.

For further information and resources, see coeliac UK

Inflammatory bowel disease

IBD, which includes CD and UC, often presents with common lower-GI-symptoms, especially diarrhoea, abdominal pain, rectal bleeding or weight loss. Potential distinguishing symptoms include:

Nocturnal defecation
Fevers
Recurrent/persistent anal abscesses
Extra-intestinal manifestations (EIMs) in joints, skin, eyes or perianal area.

Perianal symptoms, such as fissures, abscesses or fistulae, may present early in CD, sometimes before intestinal symptoms.³¹⁻³³

Family history of IBD in a first-degree relative increases risk and should be considered during initial assessment.

Microscopic colitis

Microscopic colitis is a subset IBD distinct from CD or UD. The classical presentation is chronic watery non-bloody diarrhoea in older women (>60 years).³⁵ Others follow a similar pattern to lower-GI CD, with faecal urgency, arthralgias, weight loss, abdominal pain, passage of stools at night and faecal incontinence.³⁶ ³⁷ Microscopic colitis is associated with:

Autoimmune conditions, including coeliac disease, thyroid disorders and polyarthritis³⁵
Lifestyle factors, including smoking³⁸
Medications, including statins, selective serotonin reuptake inhibitors (SSRIs), proton-pump inhibitors (PPIs) and non-steroidal anti-inflammatory drugs (NSAIDs), with the latter two also associated with a rise in faecal calprotectin (FCP).³⁶

Microscopic colitis cannot be diagnosed in primary care.

Microscopic colitis is challenging to diagnose, as it appears macroscopically normal on endoscopy and requires histological confirmation by biopsy. A normal FCP result does not exclude a diagnosis (67% sensitivity; 75% specificity³⁹), so patients under high clinical suspicion should be referred for consideration of colonoscopy with biopsy. Many patients with undiagnosed microscopic colitis may have been through a diagnostic pathway with a colonoscopy already.³⁷

Around 10%⁴⁰ of microscopic colitis cases are self-limiting,⁴¹ but treatment with oral budesonide has been demonstrated to induce remission in between 54% to 84% of patients.⁴² Loperamide may be suggested for symptomatic relief; however, there is a limited evidence base for this and other treatments.

For further information and resources, see Crohn’s & Colitis UK

Extra-intestinal manifestations

IBD may have EIM (Table 2)s:⁴³ ⁴⁴

Dependent on the definition, the prevalence of EIMs is reported to be between 6% and 47% of all patients.⁴⁵
Patients may be affected by more than one EIM, with over 20% of IBD patients reporting two EIMs and over 10% of patients reporting three or more.⁴⁵
EIMs may occur before or after IBD diagnosis, with 26% of all patients with EIMs report occurrence of EIMs up to 25 months (median 5 months) before IBD diagnosis.⁴⁵
EIMs can precede bowel symptoms, so new uveitis, inflammatory back pain, erythema nodosum or peripheral arthritis alongside GI symptoms should raise suspicion for IBD.⁴⁵

In 25.8% of cases, patients presented with their first EIM before IBD was diagnosed (median 5 months, range 0–25 months), while In 74.2% of cases, the first EIM manifested itself after IBD diagnosis (median 92 months, range 29–183 months).⁴⁶

Table 2. Extra-intestinal manifestations (%)⁴⁷ ⁴⁸

Manifestation

Peripheral arthritis

Axial arthritis

Anterior uveitis

Primary sclerosing cholangitis

Notes: Blank cells do not imply absence of this symptom in this condition, only absence of data in the cited studies.

HIV

HIV screening may be warranted in patients with GI symptoms, including chronic diarrhoea, depending on HIV stage:

Acute HIV infection in the first few weeks after exposure can include diarrhoea, nausea, fever, sore throat and muscle aches
Advanced HIV commonly includes persistent diarrhoea lasting more than a month, often linked to opportunistic infections.

Patients continue to be diagnosed late with HIV. Review of late diagnoses showed 62% had missed opportunities for diagnosis, of which 62% were in primary care. Of these patients, 82% presented with indicator conditions, which can include chronic diarrhoea.⁵⁰ GPs may miss opportunities to test for HIV due to:

Lack of knowledge of indicator conditions
Concern about causing offence to patient by suggesting an HIV test
Concern about consent required for test to be offered (minimum is seeking agreement to test and telling patient how result will be given).⁵¹

KNOWLEDGE CHECK

Question 1/4

Which statement about IBD in older adults is most accurate?

A – It is rare and usually long-standing from youth

B – It typically presents only with severe abdominal pain

C – It has a bimodal age distribution

D – It always causes raised FCP above 500

E – It is usually secondary to NSAID use

Question 2/4

Which feature most strongly suggests organic pathology rather than IBS?

A – Abdominal pain relieved by defecation

B – Bloating

C – Nocturnal diarrhoea

D – Symptom fluctuation

E – Association with stress

Question 3/4

Which combination most supports IBS diagnosis?

A – Weight loss and raised CRP

B – Nocturnal diarrhoea and anaemia

C – Abdominal pain relieved by defecation, normal CRP and low calprotectin

D – Rectal bleeding and raised calprotectin

E – Persistent fever

Question 4/4

Which statement about IBS is most accurate?

A – It is a diagnosis only after colonoscopy

B – It is a disorder of gut–brain interaction

C – It causes raised CRP

D – It requires lifelong laxatives

E – It is progressive

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A digital learning tool designed to support primary care professionals in diagnosing lower-gastrointestinal symptoms using the national pathway.

Pathway overview

Triage and red flags

Differential diagnosis

FIT and faecal calprotectin

Case studies

Ongoing care

distinguishing long-term gastrointestinal conditions

1/5

Blood with bowel motions and loose or watery bowel motions are the most common presenting symptoms with ulcerative colitis (UC)

2/5

3/5

4/5

5/5

Irritable bowel syndrome

Coeliac disease

24.3%

Diarrhoea

28%

Abdominal bloating

19.7%

Aphthous stomatitis

Yes, two-way sync keeps tasks aligned across platforms.

Inflammatory bowel disease

Peripheral arthritis

70.0%

HIV

Yes, two-way sync keeps tasks aligned across platforms.

Irritable bowel syndrome

Coeliac disease

Inflammatory bowel disease

Extra-intestinal manifestations

HIV

KNOWLEDGE CHECK

Which statement about IBD in older adults is most accurate?

Which combination most supports IBS diagnosis?

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