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Kaneko M, Matsushima M, Ueda T, Sato H, Sano M, Teramura E, Fujisawa M, Suzuki H. Significance of Epidemiological Background in Preventing the Misdiagnosis of Intestinal Tuberculosis as Crohn's Disease. Intern Med 2024; 63:2391-2397. [PMID: 38296473 DOI: 10.2169/internalmedicine.3093-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2024] Open
Abstract
The misdiagnosis of intestinal tuberculosis (ITB), such as Crohn's disease (CD), and subsequent treatment with immunosuppressive therapies can lead to severe outcomes. However, the differential diagnosis between these two conditions can be challenging. We herein report a patient from Myanmar who was initially diagnosed with CD due to the presence of non-caseating granulomas. The patient's symptoms were aggravated with steroid treatment, eventually leading to a diagnosis of ITB. In the international medical community, we encounter patients from countries, such as Myanmar, where tuberculosis is endemic. Therefore, it is necessary to understand the epidemiological background of each country to accurately distinguish between CD and ITB.
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Affiliation(s)
- Motoki Kaneko
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Masashi Matsushima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Takashi Ueda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Hirohiko Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Masaya Sano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Erika Teramura
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Mia Fujisawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Japan
| | - Hidekazu Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Japan
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Li YP, Lu TY, Huang FR, Zhang WM, Chen ZQ, Guang PW, Deng LY, Yang XH. Differential diagnosis of Crohn's disease and intestinal tuberculosis based on ATR-FTIR spectroscopy combined with machine learning. World J Gastroenterol 2024; 30:1377-1392. [PMID: 38596500 PMCID: PMC11000079 DOI: 10.3748/wjg.v30.i10.1377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/02/2024] [Accepted: 02/06/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Crohn's disease (CD) is often misdiagnosed as intestinal tuberculosis (ITB). However, the treatment and prognosis of these two diseases are dramatically different. Therefore, it is important to develop a method to identify CD and ITB with high accuracy, specificity, and speed. AIM To develop a method to identify CD and ITB with high accuracy, specificity, and speed. METHODS A total of 72 paraffin wax-embedded tissue sections were pathologically and clinically diagnosed as CD or ITB. Paraffin wax-embedded tissue sections were attached to a metal coating and measured using attenuated total reflectance fourier transform infrared spectroscopy at mid-infrared wavelengths combined with XGBoost for differential diagnosis. RESULTS The results showed that the paraffin wax-embedded specimens of CD and ITB were significantly different in their spectral signals at 1074 cm-1 and 1234 cm-1 bands, and the differential diagnosis model based on spectral characteristics combined with machine learning showed accuracy, specificity, and sensitivity of 91.84%, 92.59%, and 90.90%, respectively, for the differential diagnosis of CD and ITB. CONCLUSION Information on the mid-infrared region can reveal the different histological components of CD and ITB at the molecular level, and spectral analysis combined with machine learning to establish a diagnostic model is expected to become a new method for the differential diagnosis of CD and ITB.
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Affiliation(s)
- Yuan-Peng Li
- College of Physical Science and Technology, Guangxi Normal University, Guilin, Guangxi 541004, China
| | - Tian-Yu Lu
- Department of Gastroenterology, The Affiliated Hospital of South University of Science and Technology, Shenzhen 518000, Guangdong Province, China
| | - Fu-Rong Huang
- Department of Optoelectronic Engineering, Jinan University, Guangzhou 510632, Guangdong Province, China
| | - Wei-Min Zhang
- Department of Gastroenterology, Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou 510632, Guangdong Province, China
| | - Zhen-Qiang Chen
- Department of Optoelectronic Engineering, Jinan University, Guangzhou 510632, Guangdong Province, China
| | - Pei-Wen Guang
- Department of Optoelectronic Engineering, Jinan University, Guangzhou 510632, Guangdong Province, China
| | - Liang-Yu Deng
- Department of Optoelectronic Engineering, Jinan University, Guangzhou 510632, Guangdong Province, China
| | - Xin-Hao Yang
- Department of Optoelectronic Engineering, Jinan University, Guangzhou 510632, Guangdong Province, China
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Dhoble P, Desai D, Abraham P. Is the rise in Crohn's disease in India accompanied by a fall in intestinal tuberculosis? A single-center experience. Indian J Tuberc 2020; 68:210-214. [PMID: 33845954 DOI: 10.1016/j.ijtb.2020.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/21/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The relationship between the incidence of intestinal tuberculosis (TB) and Crohn's disease (CD) is interesting, especially considering the striking similarity between the two conditions. Some studies from Asian populations suggested that the incidence of intestinal TB decreases when there is an increase in CD. AIM To compare the incidence trend between intestinal TB and CD over 15 years. METHODS Medical records of patients seen in the Division of Gastroenterology over 15 years (2005-2019) were reviewed. CD was diagnosed according to the Copenhagen criteria. Intestinal TB was diagnosed in the appropriate clinical situation if any one or more of the following was present: (1) positive TB MGIT culture; (2) positive Gene Xpert for TB; (3) suggestive histologic findings, with positive tissue acid-fast bacillus (AFB) on smear or with sustained response to anti-TB therapy. The incidence time trend of patients with CD and intestinal TB diagnosis was then studied year-wise. RESULTS 632 medical case records were accessed; 60 patients were excluded due to inadequate data or not fulfilling diagnostic criteria. The 572 patients included 224 with intestinal TB (median age 37 years, IQR 22; 125 [56%] females) and 348 with CD (median age 40 years, IQR 25; 159 [46%] females [p < 0.02 as compared to TB]). Thus, more patients with CD were seen during the study period, but there was no correlation between the incidence of the two conditions (r = 0.318; p = 0.25). CONCLUSION In Indian patients in a single private-sector center, there was no inverse correlation between the incidence of intestinal TB and CD over 15 years.
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Affiliation(s)
- Pavan Dhoble
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai 400016, India
| | - Devendra Desai
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai 400016, India.
| | - Philip Abraham
- Division of Gastroenterology, P D Hinduja Hospital, Mumbai 400016, India
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Arora U, Ananthakrishnan AN, Kedia S, Bopanna S, Mouli PV, Yadav DP, Makharia GK, Yajnik V, Ahuja V. Effect of oral tobacco use and smoking on outcomes of Crohn's disease in India. J Gastroenterol Hepatol 2018; 33:134-140. [PMID: 28475826 DOI: 10.1111/jgh.13815] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 04/24/2017] [Accepted: 05/02/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM Smoking has been linked with adverse outcomes in Crohn's disease (CD); however, it is not known whether oral tobacco (OT) use affects disease outcomes in these patients. The study aimed to assess the association between smoking or OT and outcomes in CD. METHODS Retrospective analysis was performed on prospectively maintained records of CD patients from 2004 to 2016. The parameters assessed included disease characteristics at baseline (location, behavior, age at onset, perianal disease, and extraintestinal manifestations), course pattern, and outcomes (surgery, hospitalizations, immunomodulator or biologics use, and steroid requirement). RESULTS A total of 426 patients were included (mean age: 39.9 years; 59.9% men; median follow up: 71 months). Forty patients were ever-OT users, and 59 were ever-smokers, ever-use being defined as daily use for at least 2 years. OT use was associated with male sex and smoking. Both OT use and smoking had no effect on baseline characteristics, but upper gastrointestinal disease was less common in ever-smokers. Both OT use and smoking did not have any effect on surgery, immunomodulator, and biologic use. Similarly, no association was found between these outcomes and duration, daily, and cumulative exposure to tobacco. Current but not former tobacco use in both smoked (adjusted odds ratio = 2.59 [1.22-5.49]) and OT (adjusted odds ratio = 2.97 [1.03-8.6]) forms increased risk of hospitalizations. CONCLUSION Oral tobacco use and smoking had no significant detrimental effect on disease phenotype or medical and surgical requirements in CD in Indian patients, affirming other non-Caucasian studies that found lack of effect of smoking. However, current tobacco use in any form was associated with hospitalization during follow up.
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Affiliation(s)
- Umang Arora
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Sawan Bopanna
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Pratap Venigalla Mouli
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Dawesh P Yadav
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Govind K Makharia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Yajnik
- Massaschusetts General Hospital Crohn's and Colitis Center, Boston, Massachusetts, USA
| | - Vineet Ahuja
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Herle K, Jehangir S. Retained Wireless Capsule Endoscope in a Girl with suspected Crohn's Disease. APSP J Case Rep 2016; 7:27. [PMID: 27672577 PMCID: PMC5027058 DOI: 10.21699/ajcr.v7i4.466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 07/21/2016] [Indexed: 12/22/2022] Open
Abstract
Wireless capsule endoscopy (WCE) is one of the great milestones in the field of gastroenterology. It is versatile in image acquisition, painless and can reach parts of the small bowel not amenable to conventional endoscopy. The commonest complication with WCE is retention of the capsule. We report a case of retained capsule in a child who was being investigated for obscure gastrointestinal bleeding (OGIB). Operative intervention was required for its retrieval after two weeks of expectant management.
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Affiliation(s)
- Koushik Herle
- Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, INDIA
| | - Susan Jehangir
- Department of Pediatric Surgery, Christian Medical College, Vellore, Tamil Nadu, INDIA
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Du J, Ma YY, Xiang H, Li YM. Confluent granulomas and ulcers lined by epithelioid histiocytes: new ideal method for differentiation of ITB and CD? A meta analysis. PLoS One 2014; 9:e103303. [PMID: 25299041 PMCID: PMC4191941 DOI: 10.1371/journal.pone.0103303] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 06/26/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There are few widely accepted criteria other than caseation, which has low sensitivity, for differentiating intestinal tuberculosis (ITB) and Crohn's disease (CD). OBJECTIVE We performed a meta-analysis to evaluate the use of confluent granulomas and ulcers lined by epithelioid histiocytes as histological methods for differentiating ITB and CD, compared with that of caseation. METHODS We searched PubMed, Medline, Embase, Web of Science, the Cochrane Library and Chinese Biomedicine Database for all relevant studies on the histological differentiation of ITB and CD. Sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated for each study. Study quality and heterogeneity were assessed. Meta-regression analysis and sensitivity analyses were performed. RESULTS Ten randomized trials involving 316 ITB and 376 CD patients were included. The results showed that analysis of caseation showed an overall weighted area under the curve (AUC) of 0.9966, overall sensitivity and specificity were 0.21 and 1.00, respectively, with a positive likelihood ratio (+LR) of 10.79, negative likelihood ratio(-LR) of 0.82 and DOR of 13.74. Confluent granulomas had a lower overall weighted AUC of 0.9381, sensitivity and specificity were 0.38 and 0.99, respectively, with a +LR of 16.29, -LR of 0.65 and DOR of 26.52. Overall weighted AUC for ulcers lined by epithelioid histiocytes was 0.9017, sensitivity and specificity were 0.41 and 0.94, respectively, with a +LR of 6.46, -LR of 0.54 and DOR of 13.17. Significant heterogeneity was noted for the studies. Meta-regression analysis showed that study source, publication year, size, design and quality did not affect heterogeneity. CONCLUSION Confluent granulomas and ulcers lined by epithelioid histiocytes are helpful in distinguishing ITB from CD, which may provide a new method, other than caseating granulomas and acid-fast bacilli, to differentiate ITB and CD in mucosal biopsies.
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Affiliation(s)
- Juan Du
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yan-Yan Ma
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Ha Xiang
- Department of Pathology, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - You-Ming Li
- Department of Gastroenterology, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
- * E-mail:
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Mathew G, Thambi M, Unnikrishnan MK. A multimodal Darwinian strategy for alleviating the atherosclerosis pandemic. Med Hypotheses 2013; 82:159-62. [PMID: 24355423 DOI: 10.1016/j.mehy.2013.11.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 11/24/2013] [Indexed: 01/15/2023]
Abstract
The conflict between our 'primitive' genes and 'modern' lifestyle probably lies at the root of several disorders that afflict modern man. Atherosclerosis, which is relatively unknown among contemporary hunter-gatherer populations, has reached pandemic proportions in recent times. Being an evolutionary problem with several inter-related pathologies, current therapeutic strategy for treating atherosclerosis has inherent limitations. Reviewing evolution-linked risk factors suggests that there are four aspects to the etiology of atherosclerosis namely, decreased intestinal parasitism, oversensitivity of evolutionarily redundant mast cells, chronic underactivation of AMPK (cellular energy sensor) and a deficiency of vitamin D. A combination of these four causes appear to have precipitated the atherosclerosis pandemic in modern times. Man and worms co-existed symbiotically in the past. Massive de-worming campaigns could have disrupted this symbiosis, increasing nutritional availability to man (pro-obesity) at the cost of decreased immunotolerance (pro-atherogenicity). A reduction in helminth-induced chronic TH2 activation could also have enhanced TH1 polarization, eventually disrupting the reciprocal regulation of TH1/TH2 balance and resulting in atherosclerosis. The riddance of helminth infestations may have rendered mast cells immunologically redundant, making them oversensitive to inflammatory stimuli, thereby playing a pro-atherogenic role. AMPK activation exerts pleiotropic anti-atherogenic effects, such as suppression of fatty acid, cholesterol, protein synthesis, reduction of vascular smooth muscle proliferation, etc. As energy deficit is the chief stimulus for AMPK activation, the over-nourished modern man appears to be suffering from chronic underactivation of AMPK, legitimising the unrivalled supremacy of metformin, the oldest prescribed antidiabetic drug. The fact that humans evolved in the sunny tropics suggests that humans are selected for high vitamin D levels. Vitamin D deficiency is now linked to several conditions including increased risk of CV disorders, diabetes, etc. The manifold decrease in vitamin D levels in modern man justifies a need for supplementation. We therefore hypothesize that a judicious combination of mast cell stabilization, AMPK activation, vitamin D supplementation, and moderation in hygiene practices could be an evolution-based multimodal strategy for both preventing and mitigating the pandemic of atherosclerosis.
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Affiliation(s)
- Geetha Mathew
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal 576104, India
| | - Magith Thambi
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal 576104, India
| | - M K Unnikrishnan
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal 576104, India.
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Banerjee R, Balaji M, Sasikala M, Anuradha S, Rao GV, Nageshwar Reddy D. Granulomas of intestinal tuberculosis and Crohn's disease can be differentiated by CD73 cell surface marker expression: a pilot study. Dig Dis Sci 2013; 58:2301-7. [PMID: 23625284 DOI: 10.1007/s10620-013-2667-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 03/27/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intestinal tuberculosis (ITB) and Crohn's disease are similar granulomatous disorders. Granulomas are present in both and difficult to differentiate on histopathology alone. A recent study demonstrated recruitment of mesenchymal cells (MSCs) at the periphery of granulomas in lymph node tuberculosis which suppressed T cell responses. We hypothesized that granulomas of ITB would also recruit MSCs to evade host immune response. AIM The purpose of this study was to demonstrate MSC markers in granulomas of ITB and evaluate whether distribution of MSC markers could differentiate between granulomas of Crohn's and ITB. METHODS We initially retrospectively enrolled 17 patients with confirmed ITB (8) or Crohn's (9) with granulomas on histopathology. Tissues were evaluated by immunofluorescence for MSC markers CD29, CD90, CD73 and absence of haematopoietic markers CD31, CD34, CD45 and CD14. Double-staining was done to confirm presence of MSCs. Subsequently, 23 postoperative specimens of Crohn's (18) and ITB (5) were analyzed for validation. RESULTS Overall, 27 Crohn's and 13 ITB cases were assessed. CD29 and CD90 positive cells were noted around both ITB and Crohn's granulomas. MSC marker CD73 was expressed around the granulomas of ITB alone and was completely absent in the Crohn's. The subsequent assessment of granulomas in postoperative specimens of Crohn's and ITB also showed similar results. CONCLUSION Granulomas of ITB and Crohn's disease can be differentiated by CD73 MSC surface marker expression. The differential CD73 expression around ITB granuloma indicates that Mycobacterium tuberculosis evades host immunity by recruiting MSCs with CD73 expression. MSCs with increased CD73 expression could be the future for therapeutic intervention in Crohn's.
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Affiliation(s)
- Rupa Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad, India
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The role of in vitro interferonγ-release assay in differentiating intestinal tuberculosis from Crohn's disease in China. J Crohns Colitis 2012; 6:317-23. [PMID: 22405168 DOI: 10.1016/j.crohns.2011.09.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 07/27/2011] [Accepted: 09/07/2011] [Indexed: 02/06/2023]
Abstract
AIM Intestinal tuberculosis (ITB) and Crohn's disease (CD) have overlapping clinical, radiographic, endoscopic and histologic features, which makes the distinction between these two disease entities a great challenge in tuberculosis-endemic countries. The aim of the study was to investigate the value of in vitro interferonγ release assay (T-SPOT.TB) in differentiating ITB from CD. METHODS From June 2008 to February 2010, a total of 93 consecutive patients with undetermined ITB or CD were prospectively recruited. Clinical, endoscopic, histologic and therapeutic responses were longitudinally monitored at follow-up evaluation until the final definite diagnosis has been reached. RESULTS After a median of 6 months' follow-up (interquartile range [IQR], 3.0 to 7.5 months), definitive diagnosis was achieved in 84 of the 93 patients (90%), with 19 having ITB and 65 having CD. On univariate analysis, a long duration of illness, chronic diarrhea, and anemia were significantly more common in CD (P<0.05). While night sweat, ascites, pulmonary lesions, circumferential ulcer on endoscopy, ileo-cecal valve involvement and epithelioid granulomas were significantly more common in ITB (P<0.05). On multivariate analysis, T-SPOT.TB (Hazard ratio 7.0, 95% confidence interval [CI] 1.9-25.7) was found to be a good predictor for ITB diagnosis. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of T-SPOT.TB were 84.2%, 75.4%, 50.0%, and 94.2%, respectively. CONCLUSIONS When differentiating ITB and CD in tuberculosis-endemic regions, T-SPOT.TB blood test may be a helpful and practical diagnostic tool for its high NPV to rule out ITB.
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Abstract
The epidemiology and phenotype of inflammatory bowel disease (IBD) in the Chinese population is not well-known. We performed a comprehensive search of the Chinese biomedical literature database from 1989 to 2007 using the following key words: inflammatory bowel disease (IBD), ulcerative colitis (UC), Crohn's disease (CD). The investigation of hospitalized IBD patients from 1990 to 2003 was also carried out in 23 medical centers of 11 cities over China. There are some notable epidemiological and phenotypical differences between Chinese IBD and Caucasian IBD, including a lack of familial clustering, male predominance, a relatively later onset of the illness with no second peak age occurrence after 50 years old, a milder clinical course, less extra-intestinal manifestations and complications, and less fistulous and peri-anal complications in Chinese CD. The data indicate an increased incidence of IBD in China with many complicated clinical problems, which offers potential opportunities to study the disease prospectively and identify the etiological factors, leading also to the better management of this disease in China.
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Affiliation(s)
- Yu Fang Wang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Niriella MA, De Silva AP, Dayaratne AHGK, Ariyasinghe MHADP, Navarathne MMN, Peiris RSK, Samarasekara DN, Satharasinghe RL, Rajindrajith S, Dassanayake AS, Wickramasinghe AR, de Silva HJ. Prevalence of inflammatory bowel disease in two districts of Sri Lanka: a hospital based survey. BMC Gastroenterol 2010; 10:32. [PMID: 20302651 PMCID: PMC2856522 DOI: 10.1186/1471-230x-10-32] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 03/19/2010] [Indexed: 02/06/2023] Open
Abstract
Background Inflammatory bowel disease (IBD) is being increasingly diagnosed in Asia. However there are few epidemiological data from the region. Methods To determine prevalence and clinical characteristics of IBD, a hospital-based survey was performed in the Colombo and Gampaha districts (combined population 4.5 million) in Sri Lanka. Patients with established ulcerative colitis (UC) and Crohn's disease (CD), who were permanent residents of these adjoining districts, were recruited from hospital registries and out-patient clinics. Clinical information was obtained from medical records and patient interviews. Results There were 295 cases of IBD (UC = 240, CD = 55), of which 34 (UC = 30, CD = 4) were newly diagnosed during the study year. The prevalence rate for UC was 5.3/100,000 (95% CI 5.0-5.6/100,000), and CD was 1.2/100,000 (95% CI 1.0-1.4/100,000). The incidence rates were 0.69/100,000 (95% CI 0.44-0.94/100,000) for UC and 0.09/100,000 (95% CI 0.002-0.18/100,000) for CD. Female:male ratios were 1.5 for UC and 1.0 for CD. Mean age at diagnosis was (males and females) 36.6 and 38.1y for UC and 33.4 and 36.2y for CD. Among UC patients, 51.1% had proctitis and at presentation 58.4% had mild disease. 80% of CD patients had only large bowel involvement. Few patients had undergone surgery. Conclusions The prevalence of IBD in this population was low compared to Western populations, but similar to some in Asia. There was a female preponderance for UC. UC was mainly mild, distal or left-sided, while CD mainly involved the large bowel.
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Affiliation(s)
- Madunil A Niriella
- University Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka
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Clinical, endoscopic, and histological differentiations between Crohn's disease and intestinal tuberculosis. Am J Gastroenterol 2010; 105:642-51. [PMID: 20087333 DOI: 10.1038/ajg.2009.585] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The clinical, endoscopic, and histological features of Crohn's disease (CD) and intestinal tuberculosis mimic each other so much that it becomes difficult to differentiate between them. The aim was to find out clinical, endoscopic, and histological predictor features for differentiation between CD and intestinal tuberculosis. METHODS We recruited 106 patients, 53 each with CD and intestinal tuberculosis, in this study. The clinical, histological, and endoscopic features were subjected to univariate, bivariate, and multivariate analyses. On the basis of regression coefficients of the final multivariate logistic model, a score to discriminate between CD and intestinal tuberculosis was devised. For the validation of the score, the same model was tested on 20 new patients, each with CD and intestinal tuberculosis. RESULTS On univariate analysis, although longer duration of disease, chronic diarrhea, blood in stool, perianal disease, extra-intestinal manifestations, involvement of left colon, skip lesions, aphthous ulcers, cobblestoning, longitudinal ulcers, focally enhanced colitis, and microgranulomas were significantly more common in CD, partial intestinal obstruction, constipation, presence of nodular lesions, higher number, and larger granulomas were significantly more common in intestinal tuberculosis. On multivariate analysis, blood in stool (odds ratio (OR) 0.1 (confidence interval (CI) 0.04-0.5)), weight loss (OR 9.8 (CI 2.2-43.9)), histologically focally enhanced colitis (OR 0.1 (CI 0.03-0.5)), and involvement of sigmoid colon (OR 0.07(0.01-0.3)) were independent predictors of intestinal tuberculosis. On the basis of regression coefficients of the final multivariate logistic model, a score that varied from 0.3 to 9.3 was devised. Higher score predicted more likelihood of intestinal tuberculosis. Once the cutoff was set at 5.1, then the sensitivity, specificity, and ability to correctly classify the two diseases were 83.0, 79.2, and 81.1%, respectively. Area under the curve for receiver-operating characteristic (ROC) to assess the ability of these features to discriminate between CD and intestinal tuberculosis was 0.9089. The area under ROC in the validation data set was 89.2% (95% CI 0.79-0.99). With a similar cutoff score of 5.1, sensitivity and specificity in the validation model were 90% (95% CI 66.9-98.2) and 60% (95% CI 36.4-80.0), respectively. CONCLUSIONS Blood in stool, weight loss, focally enhanced colitis, and involvement of the sigmoid colon were the most important features in differentiating CD from intestinal tuberculosis.
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Shankar H, Singh S, Singh P, Singh A, Sohal J, Greenstein R. Presence, characterization, and genotype profiles of Mycobacterium avium subspecies paratuberculosis from unpasteurized individual and pooled milk, commercial pasteurized milk, and milk products in India by culture, PCR, and PCR-REA methods. Int J Infect Dis 2010; 14:e121-6. [DOI: 10.1016/j.ijid.2009.03.031] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 03/31/2009] [Indexed: 11/30/2022] Open
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Cost-effectiveness of adalimumab for the maintenance of remission in patients with Crohn's disease. Eur J Gastroenterol Hepatol 2009; 21:1302-9. [PMID: 19465858 DOI: 10.1097/meg.0b013e32832a8d71] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Adalimumab is a fully human, monoclonal antibody clinically effective for the treatment of active Crohn's disease. The cost-effectiveness of adalimumab versus conventional, nonbiologic pharmacotherapies is unknown. This study evaluated the cost-effectiveness of adalimumab versus conventional, nonbiologic pharmacotherapies in the maintenance of Crohn's disease. METHODS Trial data from two randomized controlled studies [Crohn's Trial of the Fully Human Antibody Adalimumab for Remission Maintenance (CHARM) and CLinical Assessment of Adalimumab Safety and Efficacy Studied as Induction Therapy in Crohn's Disease (CLASSIC I)] were analyzed within a cost-utility framework using a 1-year horizon from the perspective of the National Health Service (UK). The treatment efficacy and use for the adalimumab arm were based on observations from CHARM. A regression model used data from CLASSIC I to predict efficacy in patients who received nonbiologic pharmacotherapy. Unit costs of drugs, hospitalization, and other medical resources were derived from the literature. Primary standard gamble-calculated data were used to derive health-utility estimates. RESULTS Compared with conventional, nonbiologic pharmacotherapy, adalimumab seemed to be cost-effective for the treatment of patients with severe disease and moderate-to-severe disease. The 56-week incremental cost-effectiveness ratio was 16 064 UK pounds/quality-adjusted life-year and 33 731 UK pounds/quality-adjusted life-year for severe and moderate-to-severe groups, respectively. Sensitivity analyses showed that the findings were robust. In the treatment of patients over their lifetimes, the incremental cost-effectiveness ratio was 6550 UK pounds/quality-adjusted life-year and 17 873 UK pounds/quality-adjusted life-year for patients with severe Crohn's disease and those with moderate-to-severe Crohn's disease, respectively. CONCLUSION Adalimumab maintenance therapy seems to be cost-effective versus conventional, nonbiologic therapies for the maintenance of remission in patients with active Crohn's disease.
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Das K, Ghoshal UC, Dhali GK, Benjamin J, Ahuja V, Makharia GK. Crohn's disease in India: a multicenter study from a country where tuberculosis is endemic. Dig Dis Sci 2009; 54:1099-107. [PMID: 18770037 DOI: 10.1007/s10620-008-0469-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2008] [Accepted: 07/16/2008] [Indexed: 12/19/2022]
Abstract
Although Crohn's disease is thought to be rare and intestinal tuberculosis common in India, Crohn's disease is being reported more often. However, there is a lack of systematic study on Crohn's disease from India. In this analysis of data from three inflammatory bowel disease clinics (two in northern India and one in eastern India), criteria for Crohn's disease were applied retrospectively: (1) World Health Organization (WHO) criteria; or (2) compatible histology (European Crohn's and Colitis Organization) or failure of response to 4-8 weeks of anti-tuberculosis therapy (Asia-Pacific guidelines); or (3) compatible macroscopic, radiologic, colonoscopic features (European Crohn's and Colitis Organization). Others were classified as probable Crohn's disease. The Montreal classification was used for disease phenotype. Age at onset and duration of symptoms (182 patients, 117 male) were 34.5 (+/-13.6; 7-73) years and 3.0 (+/-5.8; 0.1-36) years, respectively. Diarrhea (68%), abdominal pain (62%), and weight loss (57%) were common. The common intestinal complications were occult (27%) and overt (40%) gastrointestinal bleeding and obstruction (28%). There were 141 (78%) and 41 (22%) with definite and probable Crohn's disease respectively. Of 147 (81%) available histopathology specimens (endoscopic biopsy in 110; 75%), 31 (21%) had granuloma. Seventy-one out of 166 (43%) had received anti-tuberculosis therapy in the past. Results from the Montreal classification were as follows: age at onset, A1:A2:A3 6%:64%:30%; location of disease, L1:L2:L3:L4 32%:41%:23%:4%, and disease behavior, B1:B2:B3 51%:24%:25%. Twenty-six (15%) and 31 (17%) patients had upper gastrointestinal and perianal modifiers. The drugs used were: aminosalicylates (128, 70%), steroids (76, 42%), azathioprine (53, 29%), methotrexate (4, 2%), and salazopyrine (14, 8%). Sixty-six (36%) patients underwent surgical treatment. We concluded that the phenotype of Crohn's disease in India is very similar to that described in other regions of Asia and the West, except for a delay in diagnosis and a more complicated disease at diagnosis.
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Affiliation(s)
- Kshaunish Das
- Division of Gastroenterology, School of Digestive and Liver Diseases, Institute of Post-Graduate Medical Education & Research, Kolkata, India
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Abstract
AIM The aim of the study was to use hospitalization data for the analysis of inflammatory bowel disease time trends in the United States. METHODS US hospital utilization data were available for individual years from 1970 to 2004 through the National Hospital Discharge Survey. Age-specific rates of hospitalization were calculated for consecutive 5-year periods. RESULTS An increase in the rates of hospitalization for Crohn's disease was most pronounced in the age group 65+ followed by the age group 45 to 64. By contradistinction, the rates in the youngest age group 0 to 44 stayed largely unchanged. In ulcerative colitis, a significant increase in hospitalization rates was limited to the oldest age group, whereas the rates in the middle and young age group remained unchanged. CONCLUSIONS Extrapolation of the current trends suggests that in the future the hospitalization for inflammatory bowel disease may start to level off. This may occur earlier and be more pronounced in younger age groups and patients with ulcerative colitis than Crohn's disease.
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Thia KT, Loftus EV, Sandborn WJ, Yang SK. An update on the epidemiology of inflammatory bowel disease in Asia. Am J Gastroenterol 2008; 103:3167-82. [PMID: 19086963 DOI: 10.1111/j.1572-0241.2008.02158.x] [Citation(s) in RCA: 398] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A rising trend in the incidence and prevalence of inflammatory bowel disease (IBD) in Asia has been recognized for the past two decades. It has been postulated that this phenomenon may be related to the westernization of lifestyles, including changes in dietary habits and environmental changes such as improved sanitation and industrialization. Previously we reported that the incidence and prevalence rates of IBD in Asia were low compared with the West, but there was a notably rising secular trend. In this review, we summarize the recent epidemiological data in Asia, characterize the clinical features, risk factors and genetic susceptibility of Asian IBD patients, and compare these to those of Western IBD patients. In the past decade, the incidence and prevalence of IBD reported across Asia, particularly in East Asia, has continued to increase. Familial clustering is generally uncommon in East Asia but appears to be higher in West Asia. The genetic susceptibilities in Asian IBD patients differ from those of White patients, as NOD2/CARD15 mutations are much less common. The clinical phenotypes and complication rates of Asian IBD resemble the White population in general, but with some differences, including lower surgical rates, higher prevalence of males, and higher prevalence of ileocolonic involvement among East Asian Crohn's disease patients, and a low frequency of primary sclerosing cholangitis among IBD patients in East and Southeast Asia.
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Affiliation(s)
- Kelvin T Thia
- Miles & Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA
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de Silva H, de Silva N, de Silva A, Jewell D. Emergence of inflammatory bowel disease ‘beyond the West’: do prosperity and improved hygiene have a role? Trans R Soc Trop Med Hyg 2008; 102:857-60. [DOI: 10.1016/j.trstmh.2008.03.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Revised: 03/18/2008] [Accepted: 03/18/2008] [Indexed: 10/22/2022] Open
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Yu AP, Cabanilla LA, Wu EQ, Mulani PM, Chao J. The costs of Crohn's disease in the United States and other Western countries: a systematic review. Curr Med Res Opin 2008; 24:319-28. [PMID: 18067689 DOI: 10.1185/030079908x260790] [Citation(s) in RCA: 197] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To conduct a critical and systematic literature review of the costs of Crohn's disease (CD) in Western industrialized countries. RESEARCH DESIGN AND METHODS Studies published in English that described the cost of CD in Western industrialized countries were identified using three major databases (Medline, EMBASE, and ISI Web of Science). Studies were reviewed and rated based on their relevance to cost of illness and the reliability of the estimates. All costs were adjusted for inflation to 2006 values. RESULTS Estimated direct medical costs were $18,022-18,932 per patient with CD per year in the United States, and euro 2898-6960 in other Western countries. Hospitalizations accounted for 53-66% of direct medical costs, with an average cost-per-hospitalization of $37,459 in the United States. Estimated indirect costs accounted for 28% of the total cost in the United States and 64-69% in Europe. Costs differed greatly by disease severity. Costs of patients with severe disease were 3- to 9-fold higher than patients in remission. Direct medical costs in the United States for patients in the top 25% of total costs averaged $60,582 per year; costs of patients in the top 2% averaged more than $300,000 per year. Combining prevalence rates, the total economic burden of CD was $10.9-15.5 billion in the United States and euro 2.1-16.7 billion in Europe. LIMITATIONS This review is limited by the research quality and variations of the individual studies reviewed, and only includes English articles. CONCLUSIONS This updated literature synthesis demonstrated the substantial total cost burden of CD, of which hospitalizations accounted for more than half of direct medical costs.
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Jeong SH, Lee KJ, Kim YB, Kwon HC, Sin SJ, Chung JY. Diagnostic value of terminal ileum intubation during colonoscopy. J Gastroenterol Hepatol 2008; 23:51-5. [PMID: 18171342 DOI: 10.1111/j.1440-1746.2007.05151.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM Since the diagnostic value of ileoscopy is not well documented, it is uncertain if terminal ileum intubation should be performed routinely in patients undergoing colonoscopy. We aimed to assess the diagnostic yield of terminal ileum intubation during colonoscopy according to indications for colonoscopy. METHODS We routinely performed terminal ileum intubation in subjects who underwent colonoscopy at Ajou University Hospital between 1 January 2005 and 31 December 2005. Demographic data, indications for colonoscopy, endoscopic, and histopathologic findings of the terminal ileum were assessed. RESULTS A total of 3921 subjects underwent colonoscopy. The terminal ileum was successfully intubated in 3417 cases (87.1%). Macroscopic abnormality on terminal ileum was present in 125 cases (3.7%), and biopsies were taken for all of them. Clinically significant histopathology was observed in 11 cases, giving a 0.3% diagnostic yield in all ileoscopies. Seven out of 11 cases were diagnosed as Crohn's disease. The rate of diagnostic yield was 1.8% in patients with right lower quadrant (RLQ) abdominal pain and 0.4% in patients with diarrhea. This rate in cases with RLQ pain was significantly greater compared with the indications for medical check-ups. CONCLUSIONS Terminal ileum intubation during colonoscopy identifies significant pathology in 1.8% of cases who have RLQ abdominal pain, suggesting diagnostic value in this setting. However, its diagnostic yield is very low in other indications for colonoscopy. Thus the decision to perform ileoscopy or not during colonoscopy needs to be made on a case-by-case basis.
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Affiliation(s)
- Seong Hyun Jeong
- Department of Gastroenterology, Ajou University Hospital, Suwon, South Korea
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Babyatsky MW, Keroack MD, Blake MA, Rosenberg ES, Mino-Kenudson M. Case records of the Massachusetts General Hospital. Case 35-2007. A 30-year-old man with inflammatory bowel disease and recent onset of fever and bloody diarrhea. N Engl J Med 2007; 357:2068-76. [PMID: 18003964 DOI: 10.1056/nejmcpc079029] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Mark W Babyatsky
- Department of Medicine, Mount Sinai Medical Center and Mount Sinai School of Medicine, New York, USA
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Makharia GK, Sachdev V, Gupta R, Lal S, Pandey RM. Anti-Saccharomyces cerevisiae antibody does not differentiate between Crohn's disease and intestinal tuberculosis. Dig Dis Sci 2007; 52:33-9. [PMID: 17160471 DOI: 10.1007/s10620-006-9527-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2006] [Accepted: 07/17/2006] [Indexed: 01/12/2023]
Abstract
The clinical, morphological, and histological features of intestinal tuberculosis (IT) and Crohn's disease (CD) mimic so much, that it becomes difficult to differentiate between them. The sensitivity of anti-Saccharomyces cerevisiae antibody (ASCA) IgG and ASCA IgA in CD is 60%-80%, whereas the specificity is almost 90%. There are no reports of study of ASCA in patients with IT, nor has it ever been used to differentiate CD from IT. Patients with ulcerative colitis (UC; n=25), CD (n=59), and IT (n=30) and 21 healthy controls were included in this study. The location and behavior of CD were classified according to the Modified Montreal classification. Five milliliters of blood was taken from them and serum was stored at -70 degrees C. ASCA antibodies (both IgG and IgA) were estimated using commercially available ELISA kits (AESKU Diagnostics, Germany). Anti-neutrophilic cytoplasmic antibody was measured by indirect immunofluorescence test. ASCA IgA was positive in 4.7%, 28%, 33.9%, and 43.3% and ASCA IgG was positive in 4.7%, 24%, 50.8%, and 46.6% of healthy controls and patients with UC, CD, and IT, respectively. Either ASCA IgG or ASCA IgA was positive in 9.5%, 40%, 61% and 66.6% of healthy controls, UC, CD, and IT, respectively. ANCA was positive in 0%, 32%, 10.1%, and 6.6% of healthy controls, UC, CD, and IT, respectively. ASCA IgG was positive in a significantly higher number of patients with CD (P<0.0001) and IT (P<0.0001) in comparison to healthy controls. ASCA IgA was positive in a significantly higher number of patients with UC (P<0.04), CD (P<0.013), and IT (P<0.006) in comparison to healthy controls. In comparisons between diseases, ASCA IgG was positive in significantly more patients with CD (P<0.001) and IT (P<0.001) in comparison to UC. There was no significant difference in ASCA IgA (33.9% vs. 43.3%), ASCA IgG (50.86% vs. 46.6%), or ANCA (10.7%, 7.4%) in patients with CD and IT, respectively. There was no correlation between ASCA and duration, location and behavior of CD, and IT. We conclude that ASCA IgG and ASCA IgA do not help to differentiate between IT and CD.
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Affiliation(s)
- Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
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