Colorectal cancer differential diagnosis

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To view the differential diagnosis of familial adenomatous polyposis (FAP), click here
To view the differential diagnosis of hereditary nonpolyposis colorectal cancer (HNPCC), click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Saarah T. Alkhairy, M.D.

Overview

Colorectal cancer must be differentiated from other diseases that cause unexplained weight loss, unexplained loss of appetite, nausea, vomiting, diarrhea, anemia, jaundice, and fatigue, such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), hemorrhoids, anal fissures, and diverticular disease. There are less common conditions that may be confused as colorectal cancer such as infectious colitis and gastrointestinal lymphoma.

Colorectal Cancer Differential Diagnosis

• Colorectal cancer must be differentiated from other diseases that cause lower abdominal pain and fever like appendicitis, diverticulitis, inflammatory bowel disease, cystitis, and endometritis.

Diseases		Symptoms		Signs			Diagnosis		Comments
		Abdominal pain	Bowel habits	Rebound tenderness	Guarding	Genitourinary signs	Lab findings	Imaging
GI diseases	Colorectal cancer	LLQ	Constipation	-	-	-	Serum carcino-embryogenic antigen  Low Vit b12 Hypercalcemia	CT scan, x-ray and MRI used to show metastasis	-
	Inflammatory bowel disease	LLQ	Bloody diarrhea	-	-	-	Leukocytosis	-	Colonoscopy and tissue sampling are recommended for differentiating between Crohn's disease and ulcerative colitis
	Diverticulitis	LLQ	Constipation Or Diarrhea	-	+	+	Leukocytosis	CT scan shows evidence of inflammation and out-pouchings of the colonic wall
	Appendicitis	LLQ / RRQ	Constipation	+	+	-	Leukocytosis	Ultrasound shows evidence of inflammation Ct scan shows acute gangrenous appendix with calcified appendicolith	Nausea & vomiting,decreased appetite
	Strangulated hernia	LLQ	-	-	-	-	No specific tests	CT scan used to detect the hernia and to show if it is single or multiple
Gentiourinary diseases	Cystitis	LLQ	-	+	-	Suprapubic tenderness	Pyuria Presence of nitrites and leukocyte estrase	X ray is done to probe the suspicion of emphysematous cystitis. CT scan shows gas in the bladder in cases of emphysematous cystitis.
	Prostatitis	LLQ Groin pain	-	-	-	Tender and enlarged	Serum PSA elevated Leukocytosis Elevated CRP	CT scan shows edema and enlarged prostate Abscess may be observed
	Pelvic inflammatory disease	Bilateral	-	+	-	Purulent vaginal discharge	Nucleic acid amplification tests is the best laboratory test for PID.	Transvaginal utrasonography
Gynecological diseases	Endometritis	LLQ	-	+	-	+	No specific tests	Ultrasound is helpful to rule out other differential diagnosis such as pelvic abscess, thrombosis and masses	Vaginal discharge Vaginal bleeding
	Salpingitis	LLQ/ RLQ		+/-	+/-		Leukocytosis	Pelvic ultrasound	Vaginal discharge

• The table below summarizes the findings that differentiate colorectal from the most common other conditions that cause unexplained weight loss, unexplained loss of appetite, nausea, vomiting, diarrhea, anemia, jaundice, and fatigue.

Condition	Differentiating Signs/Symptoms	Differentiating Tests
Irritable Bowel Syndrome (IBS)	A clinical diagnosis is based on either Rome I, II, or III Criteria. Rome I is continuous or recurrent symptoms for at least 3 months; abdominal pain or discomfort, relieved with defecation and/or associated with change in frequency and/or consistency of stool; and an irregular pattern of defecation with at least 25% of the time with two or more of the following: altered stool frequency, altered stool form, altered stool passage, passage of mucus, bloating or feeling of abdominal distention Rome II is at least 12 weeks of abdominal discomfort or pain, which need not be consecutive, in the preceding 12 months with two or more of the following: relieved with defecation, onset associated with a change in frequency of stool, onset associated with a change in form of stool Rome III is recurrent abdominal pain or discomfort 3 days per month in the last 3 months, associated with two or more of the following: improvement of abdominal pain with defecation, change in frequency of stool, change in appearance of stool; with onset at least 6 months prior to diagnosis	There is no specific diagnostic test for IBS; patients who fulfill the clinical criteria for IBS and have no alarm features have a very low probability of organic disease; colonoscopy or colonic imaging is recommended for patients older than 50 years of age due to higher pre-test probability of colorectal cancer
Ulcerative Colitis	The average age of onset of inflammatory bowel disease (20 to 40 years) is younger than with colorectal cancer; patients with inflammatory bowel disease frequently have watery diarrhea; patients with colitis are at higher risk of colorectal cancer and may need reassessment if symptoms are atypical or do not respond to treatment	Colonoscopy will show rectal involvement, continuous uniform involvement, loss of vascular marking, diffuse erythema, mucosal granularity, and a normal terminal ileum (or mild 'backwash' ileitis in pancolitis)
Crohn's Disease	Patients with colitis are at higher risk of colorectal cancer and need reassessment if symptoms are atypical or do not respond to treatment	Colonoscopy with intubation of the ileum is the definitive test to diagnose Crohn's disease and will show mucosal inflammation and discrete deep superficial ulcers located transversely and longitudinally, creating a cobblestone appearance; the lesions are discontinuous, with intermittent areas of normal-appearing bowel (skip lesions)
Hemorrhoids	Bright red rectal bleeding that is separate from the stool; there is no abdominal discomfort or pain, altered bowel habits, or weight loss	Colonoscopy or colonic imaging is recommended in patients with abdominal symptoms in addition to rectal bleeding and in those older than 50 years of age
Anal Fissure	Severe pain on defecation; blood is usually present on wiping, there is no abdominal discomfort or pain, altered bowel habits, or weight loss	Colonoscopy or colonic imaging is recommended in patients with abdominal symptoms in addition to rectal bleeding and in those older than 50 years of age
Diverticular disease	Diverticular stricture or inflammatory mass may be clinically indistinguishable from colorectal cancer	Colonoscopy with biopsies and CT imaging will usually differentiate diverticular disease from colorectal cancer

Other conditions that can be mistaken for colorectal cancer including the following:

• Benign colon polyps
• Ischemic colitis
• Infectious colitis
• Arteriovenous malformation (AVM)
• Carcinoid/neuroendocrine tumors
• Small intestine carcinomas
• Gastrointestinal lymphoma
• Ileus
• Pregnancy
• Appendicitis
• Hernia
• Lactose intolerance
• Flatulence
• Ulcer
• Cholecystitis

References

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