Colitis: clinical findings may help distinguish inflammatory bowel disease from infectious colitis.

Clinical bottom line (level 4)

  1. Half of patients with a first attack of colitis had inflammatory bowel disease.
  2. In patients with a first attack of colitis (diarrhoea and rectal inflammation on sigmoidoscopy), inflammatory bowel disease was more likely with:
    • insidious onset, or acute deterioration with previous slight symptoms
    • < 4-6 bowel movements daily at onset
    • no fever or late onset fever > 38 C
    • macroscopically bloody stool
  3. Inflammatory bowel disease was less likely if:
    • acute onset
    • >10-12 bowel movements daily at onset
    • early fever
    • severe abdominal pain
    • vomiting
    • travel abroad
Schumacher et al: Scandinavian Journal of Gastroenterology 1994; 29: 265-274
Expires May 2003

The study

Setting: two acute hospitals, Sweden

105 patients (aged range 17 to 82 years, 57% male) first attack of colitis (inflammation extending above rectum diagnosed on sigmoidoscopy)

Excluded if
  • During second half of study, patients with obviously infected diarrhoea were excluded



    • ?independent ?blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
    • Combination of
      • stool culture, stool serology
      • histology from biopsy
      • follow-up for at least 3 years (mean 5.5 years)
    Diagnostic test: clinical findings on admission

    The evidence

    pre-test probability of inflammatory bowel disease: 50%, (95% CI: 40% to 58%)
    pre-test probability of infectious colitis: 31%, (95% CI: 22% to 39%)
    pre-test probability of non-specific colitis: 20%, (95% CI: 12% to 28%)

    diagnostic test IBD infectious colitis LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    insidious onset 29 1 18
    (2.6 to 120)     		95% 0.46
    (0.33 to 0.62)     		31%
    bowel movements < 4/24 hr at onset 25 1 15
    (2.2 to 110)     		94% 0.54
    (0.41 to 0.70)     		35%
    acute deterioration, previous slight symptoms 9 1 5.5
    (0.74 to 42)     		84% 0.85
    (0.74 to 0.98)     		45%
    no fever 27 4 4.2
    (1.6 to 11)     		80% 0.55
    (0.40 to 0.75)     		35%
    bowel movements 4-6/24 hr at onset 19 3 3.9
    (1.3 to 12)     		79% 0.70
    (0.55 to 0.89)     		41%
    late fever > 38 C 16 3 3.3
    (1.0 to 10)     		76% 0.76
    (0.62 to 0.95)     		43%
    macroscopically bloody stool 46 16 1.8
    (1.2 to 2.5)     		64% 0.23
    (0.10 to 0.53)     		18%
    bowel movements > 12/ 24 hr at onset 0 12 0.0
    (0.0 to 0.15)     		0% 1.6
    (1.2 to 2.1)     		61%
    early fever 3 24 0.077
    (0.025 to 0.24)     		7% 3.8
    (2.1 to 6.9)     		79%
    acute onset 4 26 0.095
    (0.036 to 0.25)     		9% 4.9
    (2.4 to 10)     		80%
    bowel movements 10-12/ 24 hr at onset 5 12 0.26
    (0.10 to 0.66)     		20% 1.4
    (1.1 to 1.9)     		58%
    severe abdominal pain 3 7 0.26
    (0.073 to 0.95)     		20% 1.2
    (0.99 to 1.5)     		54%
    vomiting 6 11 0.34
    (0.14 to 0.82)     		25% 1.5
    (1.0 to 1.8)     		60%
    travelling abroad 11 15 0.45
    (0.24 to 0.86)     		31% 1.5
    (1.0 to 2.1)     		60%
    subacute onset 10 4 1.5
    (0.53 to 4.5)     		58% 0.92
    (0.77 to 1.1)     		47%
    early fever, previous slight symptoms 6 1 3.7
    (0.47 to 29)     		78% 0.91
    (0.81 to 1.0)     		47%
    bowel movements 7-9/ 24 hr 3 5 0.37
    (0.095 to 1.4)     		27% 1.1
    (0.95 to 1.3)     		52%
    slight abdominal pain 28 17 1.0
    (0.67 to 1.5)     		50% 0.98
    (0.61 to 1.6)     		49%
    total

    Comments

    1. No data on the clinical findings in patients with non-specific colitis was given - by removing these patients from the analysis, this makes the likelihood ratios appear better than they are in reality. The exclusion of patients with obvious infective diarrhoea may decrease the magnitude of the LR, but this exclusion probably reflects the clinical situation in secondary care better.
    2. No additional information about the independence (or otherwise) of these findings.

    Citation

    1. Schumacher G, et al: a prospective study of first attacks of inflammatory bowel disease and infectious colitis: clinical findings and early diagnosis. Scandinavian Journal of Gastroenterology 1994; 29: 265-274
    Search Terms: colit* in Cochrane
    Contributor: Chris Ball and Bob Phillips, November 2000
    Reviewer: Zoltan Bodnar

    Clinical Question.
    Patient first attack of colitis
    Intervention or Exposure clinical findings
    Outcome inflammatory bowel disease