Crohn's disease and ulcerative colitis: when is a diagnostic procedure necessary?

In the diagnosis and differential diagnosis of the inflammatory bowel diseases, Crohn's disease and ulcerative colitis, a simple but careful history and physical examination remain the keys. Routine screening laboratory tests are much less sensitive and almost totally non-specific, although microbiologic studies are often essential in order to rule out specific intestinal infections. The characteristics of the patient's history of abdominal pain and bowel pattern, and the physical findings of abdominal mass and perianal lesions, are most helpful in distinguishing Crohn's disease from ulcerative colitis. Similarly, clinical features, physical signs, and endoscopic appearances can tell us most of what we need to know about the severity of the disease. More advanced laboratory, radiologic, and histologic testing can clarify the nature and extent of the disease and identify complications, but we still treat patients, not blood tests or X-rays. With respect to treatment of inflammatory bowel disease, the mainstays are aminosalicylates, corticosteroids, immunomodulators, and antibiotics. Acute induction of remission is rarely difficult, but the greatest challenge in management is maintenance of long-term steroid-free remission throughout the entire course of these life-long diseases.