What Bowel Symptoms Suggest IBD with Pyoderma Gangrenosum?

It is important for anyone diagnosed with pyoderma gangrenosum (PG) to monitor their digestive health. PG is associated with inflammatory bowel disease (IBD)—such as Crohn’s disease or ulcerative colitis—with a meta-analysis estimating that about 17.6% of people with PG also have IBD ^[1]. However, most people with PG will not necessarily develop IBD. Since early detection can improve your care, being aware of which bowel symptoms to report can help you and your doctor decide if further evaluation is needed ^[2][3].

When to Seek Urgent Medical Care

Not all digestive symptoms require a trip to the emergency room, but some signs indicate a potential emergency. Seek immediate medical attention if you experience:

• Heavy or ongoing rectal bleeding, or black, tarry stools (which can be a sign of internal bleeding)
• Severe, sudden, or worsening abdominal pain
• Fainting, severe dizziness, or confusion
• Persistent vomiting or an inability to keep fluids down
• A painful swelling around your anus, especially if accompanied by a fever or pus (which could be an abscess)

Key Bowel Symptoms to Discuss with Your Care Team

Many common issues, like infections, dietary changes, or certain medications, can cause temporary stomach upset. However, you should contact your care team soon if you notice persistent or unexplained changes, as these can be clues for underlying IBD:

• Changes in Bowel Habits: Persistent or recurrent diarrhea, an urgent need to have a bowel movement, or frequently waking up during the night to use the bathroom ^[2].
• Blood or Mucus: Seeing bright red blood or mucus in your bowel movements ^[2]. Note that while this can be a sign of IBD, it can also be caused by hemorrhoids or infections.
• Abdominal Discomfort: Ongoing abdominal pain or cramping ^[2].
• Perianal Issues: Draining openings (fistulae), fissures, or new skin tags around the anus ^[4][5]. While these can be caused by other conditions like hemorrhoids or hidradenitis, they are particularly relevant clues for Crohn’s disease ^[5].
• Systemic Signs: Unexplained weight loss, fever, or extreme fatigue ^[2]. Your doctor may also detect anemia (a low red blood cell count) through routine blood work, which can sometimes accompany IBD ^[6][7].

Tip: Keep a symptom log noting how often you have bowel movements, what they look like, and any pain, fever, or medication use to share with your doctor.

Do Skin and Bowel Symptoms Flare Together?

It is a common misconception that your skin and your bowel will always flare at the same time. While they often do—for example, one specific study of PG patients with IBD found that 93% of them had active bowel disease at the time their PG was diagnosed—this is not universally true for everyone ^[8].

Sometimes, PG skin ulcers worsen while IBD is completely quiet or in remission ^[9][8]. In other cases, the skin lesions appear before a formal IBD diagnosis is made ^[10]. In fact, mild or completely absent bowel symptoms do not entirely rule out IBD; doctors have occasionally discovered underlying colitis in PG patients who had no noticeable digestive complaints ^[11][3]. However, this does not mean every person with PG needs invasive testing if they have no bowel symptoms.

Getting Evaluated

Because of the link between these conditions, your dermatologist or primary care doctor may recommend a referral to a gastroenterologist (a doctor specializing in the digestive system) ^[12]. A referral does not automatically mean you will need a colonoscopy; it simply means an expert can help determine if testing is appropriate based on your symptoms, family history, and risk factors.

If your doctor suspects IBD or wants to rule out other causes (like infections), they may start with non-invasive testing:

• Blood tests: To check for anemia, white blood cell counts, and inflammatory markers like CRP or ESR ^[13][6]. Keep in mind that these markers can sometimes be normal even if you have IBD.
• Stool tests: To rule out bacterial infections and measure fecal calprotectin (a marker of inflammation in the intestines) ^[14][15]. Elevated calprotectin suggests inflammation, but it is not specific to IBD and can also rise due to infections or certain pain relievers (NSAIDs).

While these initial tests provide helpful clues, they cannot confirm IBD on their own. If your symptoms or test results raise suspicion, a gastroenterologist may recommend an endoscopy/colonoscopy ^[16] or imaging (like an MRI or CT scan) ^[11]. A colonoscopy allows the doctor to look directly at the lining of your colon and take small tissue samples (biopsies). While a colonoscopy often provides critical diagnostic evidence, it may not see isolated inflammation higher up in the small intestine, which is why imaging is sometimes needed as well ^[17][16].

(Note: Never stop taking your PG medications without speaking to your doctor, even if you are concerned they might be masking bowel symptoms).