Pathology of intestinal tuberculosis and its distinction from Crohn's disease

Mistakes to avoid in the management of abdominal tuberculosis

INTRODUCTION

The diagnosis and management of abdominal tuberculosis, i.e Gastrointestinal Tuberculosis (GITB) and tuberculous peritonitis (TBP) is challenging. Abdominal tuberculosis, presenting usually with abdominal pain, intestinal obstruction, and constitutional symptoms, is typically a paucibacillary condition. The diagnosis hinges on a correct interpretation of clinical, radiological, histological, biochemical, and microbiological findings as also appropriately assessing response to therapy.

AREAS COVERED

The authors review potential missteps that could occur in managing GITB and TBP sourced from published literature and clinical experience. These include avoiding excess use of tests with limited accuracy, understanding limitations of ascitic adenosine deaminase (ADA) and granulomas, avoiding empirical antitubercular therapy (ATT) where possible but also understanding that microbiological tests may not always be positive, and finally not to bank solely on subjective clinical responses but to use objective markers in assessing response to therapy. In addition, diagnosis of predisposing immunosuppressed states, attention to nutrition, appropriate management of sequelae with endoscopic dilatation/surgery, and early surgery when indicated are some of the additional issues discussed.

EXPERT OPINION

In future, a more secure diagnosis banking on the use of better microbiological tools, multiparameter-based models, artificial intelligence-based approaches, and use of advances in -omics-based approaches can improve diagnosis and avoid some missteps.

Immunohistochemistry and real-time Polymerase Chain Reaction: importance in the diagnosis of intestinal tuberculosis in a Peruvian population

INTRODUCTION

The diagnosis of intestinal tuberculosis is challenging even nowadays. This study aims to report the positivity rates of new diagnostic methods such as immunohistochemistry and Real-Time Polymerase Chain Reaction in patients with intestinal tuberculosis, as well as describe the pathological and endoscopic features of intestinal tuberculosis in our population.

METHODS

This was a retrospective observational study conducted in patients diagnosed with intestinal tuberculosis, between 2010 to 2023 from the Hospital Nacional Daniel Alcides Carrion and a Private Pathology Center, both located in Peru. Clinical data was obtained, histologic features were independently re-evaluated by three pathologists; and immunohistochemistry and real-time Polymerase Chain Reaction evaluation were performed. The 33 patients with intestinal tuberculosis who fulfilled the inclusion criteria were recruited.

RESULTS

Immunohistochemistry was positive in 90.9% of cases, while real-time Polymerase Chain Reaction was positive in 38.7%. The ileocecal region was the most affected area (33.3%), and the most frequent endoscopic appearance was an ulcer (63.6%). Most of the granulomas were composed solely of epithelioid histiocytes (75.8%). Crypt architectural disarray was the second most frequent histologic finding (78.8%) after granulomas, but most of them were mild.

CONCLUSION

Since immunohistochemistry does not require an intact cell wall, it demonstrates higher sensitivity compared to Ziehl-Neelsen staining. Therefore, it could be helpful for the diagnosis of paucibacillary tuberculosis.

Paralytic Ileus during Treatment of Pulmonary and Renal Tuberculosis in a Non-Human Immunodeficiency Virus Patient: An Unusual Presentation of Tuberculosis-immune Reconstitution Inflammatory Syndrome

Paralytic ileus as tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is extremely rare. We herein report a 44-year-old man with pulmonary and renal tuberculosis who developed paralytic ileus 14 days after starting antituberculosis therapy (ATT) despite an initial favorable response to ATT. Paralytic ileus was successfully managed with conservative care. He initially required hemodialysis because of obstructive uropathy due to renal tuberculosis, but he was able to withdraw from dialysis after placement of ureteral stents. TB-IRIS can affect organs other than the original sites of tuberculosis, and the combined use of steroids may be effective for its prevention and treatment.

Differentiating gastrointestinal tuberculosis and Crohn's disease- a comprehensive review

Gastrointestinal Tuberculosis (GITB) and Crohn's disease (CD) are both chronic granulomatous diseases with a predilection to involve primarily the terminal ileum. GITB is often considered a disease of the developing world, while CD and inflammatory bowel disease are considered a disease of the developed world. But in recent times, the epidemiology of both diseases has changed. Differentiating GITB from CD is of immense clinical importance as the management of both diseases differs. While GITB needs anti-tubercular therapy (ATT), CD needs immunosuppressive therapy. Misdiagnosis or a delay in diagnosis can lead to catastrophic consequences. Most of the clinical features, endoscopic findings, and imaging features are not pathognomonic for either of these two conditions. The definitive diagnosis of GITB can be clinched only in a fraction of cases with microbiological positivity (acid-fast bacilli, mycobacterial culture, or PCR-based tests). In most cases, the diagnosis is often based on consistent clinical, endoscopic, imaging, and histological findings. Similarly, no single finding can conclusively diagnose CD. Multiparametric-based predictive models incorporating clinical, endoscopy findings, histology, radiology, and serology have been used to differentiate GITB from CD with varied results. However, it is limited by the lack of validation studies for most such models. Many patients, especially in TB endemic regions, are initiated on a trial of ATT to see for an objective response to therapy. Early mucosal response assessed at two months is an objective marker of response to ATT. Prolonged ATT in CD is recognized to have a fibrotic effect. Therefore, early discrimination may be vital in preventing the delay in the diagnosis of CD and avoiding a complicated course.

Frequency, outcomes, and need for intervention in stricturing gastrointestinal tuberculosis: a systematic review and meta-analysis

BACKGROUND

Gastrointestinal strictures impact clinical presentation in abdominal tuberculosis and are associated with significant morbidity.

AIM

To conduct a systematic review of the prevalence of stricturing disease in abdominal and gastrointestinal tuberculosis and response to antitubercular therapy (ATT).

METHODS

We searched Pubmed and Embase on 13th January 2022, for papers reporting on the frequency and outcomes of stricturing gastrointestinal tuberculosis. The data were extracted, and pooled prevalence of stricturing disease was estimated in abdominal tuberculosis and gastrointestinal (intestinal) tuberculosis. The pooled clinical response and stricture resolution (endoscopic or radiologic) rates were also estimated. Publication bias was assessed using the Funnel plot and Egger test. The risk of bias assessment was done using a modified Newcastle Ottawa Scale.

RESULTS

Thirty-three studies reporting about 1969 patients were included. The pooled prevalence of intestinal strictures in abdominal tuberculosis and gastrointestinal TB was 0.12 (95%CI 0.07-0.20, I² = 89%) and 0.27 (95% CI 0.21-0.33, I² = 85%), respectively. The pooled clinical response of stricturing gastrointestinal tuberculosis to antitubercular therapy was 0.77 (95%CI 0.65-0.86, I² = 74%). The pooled stricture response rate (endoscopic or radiological) was 0.66 (95%CI 0.40-0.85, I² = 91%). The pooled rate of need for surgical intervention was 0.21 (95%CI 0.13-0.32, I² = 70%), while endoscopic dilatation was 0.14 (95%CI 0.09-0.21, I² = 0%).

CONCLUSION

Stricturing gastrointestinal tuberculosis occurs in around a quarter of patients with gastrointestinal tuberculosis, and around two-thirds of patients have a clinical response with antitubercular therapy. A subset of patients may need endoscopic or surgical intervention. The estimates for the pooled prevalence of stricturing disease and response to ATT had significant heterogeneity.

Totally laparoscopic treatment of intestinal tuberculosis complicated with bowel perforation: The first case report in worldwide literature with a brief review

Introduction

Bowel perforation is a relatively rare presentation of abdominal tuberculosis, whose diagnosis is challenging but fundamental to minimize morbidity and mortality. Laparoscopy is considered an effective modality for diagnosis, but its role in surgical treatment is still not established. We reported the first worldwide case of totally laparoscopic treatment of intestinal tuberculosis complicated with bowel perforation.

Case presentation

A 30-year-old man with a history of weight loss, preceded by 2 years of nonproductive cough, was admitted to the Infectious Disease Department with a presumed diagnosis of tuberculosis. A microbiological culture test confirmed the diagnosis, and the patient undertook quadruple antituberculous therapy. During hospitalization, he presented sudden abdominal pain, fever, and vomit. An abdominal CT scan showed small bowel perforation with granulomatous reaction. Laparoscopy was performed and revealed a 2 cm perforation on the medium ileum. Small bowel resection and totally intracorporeal side-to-side anastomosis were performed. No complication occurred until a clinical follow-up of 2 months.

Conclusion

In consideration of the increasing incidence of intestinal TB in both underdeveloped and Western countries, the diagnosis of this pathology should be taken into account in high-risk patients. Probably, the diagnostic challenges and emergency settings of intestinal TB with perforation and peritonitis, together with the lack of standardized guidelines regarding surgical management, make the use of laparoscopy apparently arduous, but the known advantages of laparoscopy and its technical feasibility should make it a conceivable option for the treatment of complicated cases.

Development and validation of a new algorithm model for differential diagnosis between Crohn's disease and intestinal tuberculosis: a combination of laboratory, imaging and endoscopic characteristics

Background

Sometimes in clinical practice, it is a great challenge to distinguish Crohn's disease (CD) and intestinal tuberculosis (ITB), we conducted this study to identify simple and useful algorithm for distinguishing them.

Methods

We retrospectively reviewed the medical history of the patients who were diagnosed as ITB or CD. We firstly identified ITB patients, and then the patients diagnosed with CD were matched by age, sex, and admission time in a 1:1 ratio. Patients who admitted between May 1, 2013 and April 30, 2019 were regarded as training cohort, and patients admitted between May 1, 2019 and May 1, 2020 were regarded as validation cohort. We used multivariate analysis to identify the potential variables, and then we used R package rpart to build the classification and regression tree (CART), and validated the newly developed model.

Results

In total, the training cohort included 84 ITB and 84 CD patients, the validation cohort included 22 ITB and 22 CD patients. Multivariate analysis showed that, positive interferon-gamma release assays (IGRAs), ≥ 4 segments involved, longitudinal ulcer, circular ulcer, and aphthous ulcer were confirmed as independent discriminating factors. Using these parameters to build the CART model made an overall accuracy rate was 88.64%, with sensitivity, specificity, NPV, and PPV being 90.91%, 86.36%, 90.48% and 86.96%, respectively.

Conclusion

We developed a simple and novel algorithm model covering laboratory, imaging, and endoscopy parameters with CART to differentiate ITB and CD with good accuracy. Positive IGRAs and circular ulcer were suggestive of ITB, while ≥ 4 segments involved, longitudinal ulcer, and aphthous ulcer were suggestive of CD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01838-x.

Pathology of Gastrointestinal Tuberculosis in Cattle

We describe the pathology of gastrointestinal tuberculosis in three cows. Gross lesions were found in the jejunum and ileum in all cases, and were characterized by button-shaped ulcers in the mucosa overlying Peyer's patches and adjacent mucosa. One case had similar changes in the pyloric region of the abomasum. In the affected intestinal segments, marked granulomatous inflammation effaced the lymphoid follicles of Peyer's patches and often extended transmurally. Transmural granulomatous inflammation was also found in the abomasum of one cow. Acid-fast bacilli were identified by the Ziehl-Neelsen method and the lesions were immunolabelled by an anti-Mycobacterium tuberculosis complex antibody. M. tuberculosis var. bovis was isolated in one case. Disseminated tuberculosis and marked lung lesions in all cows suggested that the gastrointestinal lesions were most likely secondary to pulmonary infection.

Systematic reporting of computed tomography enterography/enteroclysis as an aid to reduce diagnostic dilemma when differentiating between intestinal tuberculosis and Crohn's disease: A prospective study at a tertiary care hospital

Background and Aim

Crohn's disease (CD) and intestinal tuberculosis (ITB) have similar symptomatology and overlapping features on imaging, endoscopy, and histopathology. It is important to differentiate ITB from CD to initiate correct medical management. This prospective study aimed to characterize imaging features on computed tomography enteroclysis/enterography (CTE) that help in differentiating ITB from CD.

Methods

A total of 300 consecutive patients who underwent CTE with the suspicion of small bowel diseases were evaluated. CTE findings were documented on a detailed "CTE case record form" and were correlated with other investigations like endoscopy, histopathological and microbiological examination, and improvement on empirical therapy to arrive at a final diagnosis. Only confirmed cases of ITB/CD were included for further analysis.

Results

Final diagnoses revealed that 61 patients had ITB, 24 had CD, 90 patients had a final diagnosis not related to ITB/CD, and 125 had no bowel-related diseases. The sensitivity of CTE (ITB vs CD, 90.2 vs 91.6%) was higher than the sensitivity of ileocolonoscopy (ITB vs CD, 87 vs 83.3%). A homogenous pattern of bowel wall thickening and confluent bowel involvement were significantly more common in ITB. Stratified bowel wall thickening with mucosal hyperenhancement, skip lesions in the bowel, and a comb sign were significantly more common in CD. Stratified bowel wall enhancement with an intervening layer of fat was specifically (P < 0.001) seen in patients with CD, and necrotic (P = 0.002) and calcified (P = 0.055) lymph nodes were specifically seen in patients with ITB.

Conclusion

We propose a systematic approach to the radiological differentiation of ITB from CD.

IBD in India: Similar Phenotype but Different Demographics Than the West

BACKGROUND

Inflammatory bowel disease (IBD) is emerging in the developing world but phenotypic data are limited. We aimed to describe the phenotype, clinical presentation, disease behavior, and treatments of IBD in a large cohort in India.

METHODS

All persons presenting to the Asian Institute of Gastroenterology in Hyderabad, India since 2004 with a confirmed diagnosis of IBD were enrolled. The demographic profile at the first visit, family history of IBD, smoking history, time from first symptom onset to diagnosis, use of anti-tuberculousis treatment before IBD-specific treatment, disease phenotype, and medication history were collected by interview and chart review. Disease and family history and treatments used were updated at each follow-up visit.

RESULTS

Of 4006 persons enrolled, 59.9% had ulcerative colitis (UC) and the majority were male (60.3%). The median diagnostic delay in both UC and Crohn's disease (CD) was at least 2 years. At the time of diagnosis only 4.5% of CD were smokers and only 3.8% of UC were ex-smokers. Positive family history was uncommon (2.1%). The phenotype of persons with CD included 22.9% with stricturing disease and 9.4% with fistulizing disease. The most common site of disease was ileocolonic (40.9%) and only 2.5% had perineal fistulas. Among those with UC 18.7% had proctitis and 30.3% had pancolitis.

CONCLUSIONS

This is the largest cohort of persons with IBD reported from Asia. Although there are several demographic differences between persons with IBD from India compared with the West, the phenotypes of the disease are not highly different.

Histopathological Mimics of Inflammatory Bowel Disease

This review article discusses the challenges of making a firm histopathological diagnosis of inflammatory bowel disease (IBD) on biopsy and resection material and the importance of its distinction from a range of other inflammatory and infective conditions that may closely mimic IBD. In many cases, the diagnosis of ulcerative colitis or Crohn's disease is straightforward, especially when patients have a typical presentation and characteristic histopathological features. Knowledge of the full clinical history is very important, particularly past and recent medical history, drug history, foreign travel, or known contact with individuals with specific infection. Discussion of all cases of suspected IBD within a multidisciplinary team meeting is required to ensure that clinical, radiological, and pathological features can be correlated. Mimics of IBD can be divided into 4 categories: 1) those due to specific infection, 2) those due to a specific localized inflammatory process, 3) those due to iatrogenic causes, and 4) other rarer causes. Accurate diagnosis of IBD and exclusion of these mimics are crucial for patient management. Once a diagnosis of IBD has been proffered by a pathologist, it is very difficult to "undiagnose" the condition when an alternative diagnosis or "mimic" has been subsequently identified. The histological diagnosis of each of these IBD mimics is discussed in detail, with guidance on how to avoid the pitfall of missing these sometimes very subtle and "difficult to diagnose" conditions.

Intestinal tuberculosis or Crohn's disease: a review of the diagnostic models designed to differentiate between these two gastrointestinal diseases

Differentiating Crohn’s disease (CD) from intestinal tuberculosis (ITB) is a diagnostic dilemma, particularly in regions where ITB is prevalent and CD incidence is increasing, because both diseases can present quite similarly, and diagnostic tests to identify Mycobacterium tuberculosis in tissue samples have rather poor sensitivity. Studies that were conducted to determine the factors that differentiate CD from ITB identified some significant characteristics, but none of those characteristics are exclusive to either ITB or CD. Many diagnostic models or scoring systems that use one to several diagnostic parameters have been proposed to help distinguish these two intestinal diseases. Early models consisted of parameters common to routine clinical practice, such as clinical features, and endoscopic and pathologic findings. The later models also include more advanced diagnostic parameters like high-resolution imaging and serological testing. However, the number and types of parameters differ among diagnostic models, and the systems used to calculate scoring also vary from model to model. Enhanced awareness and understanding of the currently available diagnostic models will help physicians determine which model(s) is/are most suitable for differentiating CD from ITB in their clinical practice.

[Intestinal tuberculosis revealed by acute bowel obstruction during paradoxical reaction to antituberculosis treatment in an immunocompetent patient: about a case and literature review]

Abdominal tuberculosis accounts for 3 to 5% of all visceral diseases. Despite the demonstrated effectiveness of anti-tuberculosis treatments, some cases of exacerbation of the initial clinical presentation have been described during the initiation of treatment. However, these reactions also known as "paradoxical" have been rarely reported in immunocompetent patients and much less in the case of bowel obstruction. We report a case of intestinal tuberculosis revealed by acute bowel obstruction during paradoxical reaction to anti-tuberculosis treatment. The study included a 26-year old immunocompetent patient with occlusive syndrome after a month of treatment for pleuropulmonary tuberculosis. Abdominal computed tomography (CT) showed small bowel obstruction. Laparotomy objectified intraperitoneal mass with multiple adhesions. Anatomo-pathological examination of the surgical specimen showed intestinal tuberculosis. Patient's outcome was favorable after the continuation of initial antituberculosis treatment.

Gastroduodenal Tuberculosis: A Case Series and Review of Literature

Gastroduodenal tuberculosis is infrequently seen in day-to-day clinical practice with few cases reported in the literature. It is usually associated with features of gastric outlet obstruction. This is a case series of 4 patients with 2 of them having associated lower gastrointestinal involvement. One of them resembled a growth in the cardia of the stomach which responded to antitubercular drugs. Another had duodenal erosions with portal lymph node enlargement which responded to antitubercular drug treatment. None of the patients required surgical management. Gastroduodenal tuberculosis should be considered with a high degree of suspicion when patients present with gastric outlet obstruction or with endoscopic evidence of ulceronodular disease in areas endemic for tuberculosis.

Do additional colonoscopic biopsies increase the yield of Mycobacterium tuberculosis culture in suspected ileo-colonic tuberculosis?

BACKGROUND

Isolation of Mycobacterium tuberculosis on culture is vital for differentiating intestinal tuberculosis (ITB) from Crohn's disease (when histology is not diagnostic) and for diagnosis of multidrug-resistant tuberculosis. The current yield of TB culture (< 50%) from colonoscopic biopsy tissue is not satisfactory.

AIM

To determine whether more colonoscopic biopsies can increase the yield of TB culture in patients with ITB.

METHODS

In this prospective study, in patients who underwent colonoscopy for suspected ITB, four biopsies were taken (container 1) followed by an additional four biopsies (container 2) for TB culture, from involved regions. The culture was done using Mycobacterium Growth Indicator Tube (MGIT) 960. A final diagnosis of ITB was made if TB culture was positive, there was unequivocal histological evidence of TB, or there was unequivocal evidence of TB elsewhere in the body, in the absence of another diagnosis.

RESULTS

Of 182 patients enrolled (mean age 37.5 [SD 17.2] years; 93 [51.5%] women), 70 (38.4%) were finally diagnosed to have ITB. MGIT culture was positive in 29 (41.4%), 27 (38.5%), and 37 (52.8%) of 70 patients from containers 1, container 2, and combined eight biopsies, respectively. The incremental yield of eight biopsies was 11.4% (95% confidence interval [CI] 5.1 to 21.3%) as compared to container 1 and 14.3% (95% CI 7.1 to 24.7%) as compared to container 2.

CONCLUSION

Additional four (total eight) colonoscopic biopsies improved the yield of TB culture positivity over four biopsies by 11.4% to 14.3%, to 52.8%; this increase is clinically useful.

Drug resistance in intestinal tuberculosis: A reason to worry?

Background and Aim

Emergence of drug resistance in intestinal tuberculosis (ITB) makes the treatment of this condition challenging. While there is growing evidence of multiple and extensive drug resistance in pulmonary and glandular tuberculosis (TB), literature regarding susceptibility and resistance patterns in ITB is scarce. The aim of the current paper was to study the prevalence of drug resistance in patients with ITB.

Methods

Among patients presenting to a tertiary care hospital in Mumbai between 2008 and 2016, records of all patients with ITB, whose mucosal biopsy (obtained at ileocolonoscopy) tissue culture was positive for Mycobacterium tuberculosis and in whom drug sensitivity testing was performed, were retrospectively analyzed. Sensitivity and resistance to single or multiple anti-TB drugs were noted.

Results

A total of 43 patients were included, of whom 10 (23.2%) patients were diagnosed to have resistance to at least one first-line anti-TB drug. Resistance to isoniazid was the most common (nine patients), followed by rifampicin (six), pyrazinamide (five), streptomycin and ethionamide (four each), ethambutol, moxifloxacin and ofloxacin (three each), and p-amino salicylic acid (one). Six patients (13.9%) had multidrug-resistant TB and needed second-line anti-TB therapy as per drug sensitivity pattern. There was no patient with extensive drug-resistant TB.

Conclusion

Twenty-three percent of our patients with ITB tested for drug resistance had drug resistance, 13.9% being multidrug resistant and needing second-line anti-TB therapy.

Abdominal tuberculosis: Is there a role for surgery?

It is important that surgeons are familiar with the various manifestations of tuberculosis (TB). Although TB has been declining in incidence in the developed world, it remains an important problem in endemic areas of the developing world. The aim of the review was to elucidate the natural history and characteristics of abdominal TB and ascertain the indications for surgery. TB can affect the intestine as well as the peritoneum and the most important aspect of abdominal TB is to bear in mind the diagnosis and obtain histological evidence. Abdominal TB is generally responsive to medical treatment, and early diagnosis and management can prevent unnecessary surgical intervention. Due to the challenges of early diagnosis, patients should be managed in collaboration with a physician familiar with anti-tuberculous therapy. An international expert consensus should determine an algorithm for the diagnosis and multidisciplinary management of abdominal TB.

The use of Masson's trichrome staining, second harmonic imaging and two-photon excited fluorescence of collagen in distinguishing intestinal tuberculosis from Crohn's disease

AIM

Differentiation between Crohn's disease (CD) and intestinal tuberculosis (ITB) continues to be difficult. The present study investigated the collagen fibre characteristics of CD and ITB using Masson's trichrome staining, second harmonic generation (SHG) imaging and two-photon excited fluorescence (TPEF) imaging with the aim of distinguishing between them.

METHOD

The characteristics of collagen fibres in intestinal specimens from patients with CD, ITB and healthy controls were compared using Masson's trichrome staining and SHG and TPEF imaging.

RESULTS

Masson's trichrome staining showed that the content of collagen fibre (540.92 [139.61-1681.93] vs 236.17 [72.94-1108.32], P < 0.05) and fibre deposits (888.92 [315.89-3172.9] vs 498.98 [38.82-5802.31], P < 0.05) were both higher in ITB than in CD. The content of collagen fibre (594.677 [139.61-1681.93] vs 107.425 [4.66-988.7], P < 0.05) and fibre deposits (1118.4661 [315.89-5802.31] vs 340.575 [29.62-1188.87], P < 0.05) were significantly higher in lesions with granulomata than in those without. The SHG/TPEF images demonstrated that the percentage of fibrosis in ITB was also significantly higher than in CD (P < 0.05), in both surgical (13.363% ± 5.303% vs 8.322% ± 5.078%, P = 0.044) and endoscopic specimens (mean rank 13.5 vs 7.5, P = 0.023). The SHG/TPEF imaging described different distribution patterns of collagen between CD and ITB; in the former this was irregular in clumps while in ITB the collagen was arranged around caseating granulomata.

CONCLUSION

The evaluation of fibrosis in CD and ITB by Masson's trichrome staining and SHG and TPEF imaging appears to distinguish between these two diseases.

Abdominal tuberculosis: A retrospective analysis of 45 cases

Abdominal tuberculosis is defined as infection of the peritoneum, hollow or solid abdominal organs with Mycobacterium tuberculosis. The peritoneum and the ileocaecal region are the most likely sites of infection and are involved in the majority of the cases by haematogenous spread or through swallowing of infected sputum from primary pulmonary tuberculosis. Pulmonary tuberculosis is apparent in less than half of the patients. Patients usually present with abdominal pain, and the cause is usually identified through a combination of radiologic, endoscopic, microbiologic, histologic and molecular techniques. Anti-microbial treatment is the same as for pulmonary tuberculosis. Surgery is occasionally required.

Intestinal tuberculosis and Crohn's disease: challenging differential diagnosis

Along with epidemiological changes in tuberculosis (TB) and an increased incidence of Crohn's disease (CD), the differential diagnosis of intestinal TB (ITB) and CD is of vital importance and has become a clinical challenge because treatment based on misdiagnosis may lead to fatal outcomes. In this study, we reviewed the similarities and differences in clinical, endoscopic, radiological and histological features of these two diseases. Concomitant pulmonary TB, ascites, night sweats, involvement of fewer than four segments of the bowel, patulous ileocecal valve, transverse ulcers, scars or pseudopolyps strongly indicate ITB. Bloody stools, perianal signs, chronic diarrhea, extraintestinal manifestations, anorectal lesions, longitudinal ulcers and a cobblestone appearance are all suggestive of CD. Significant differences in the size, number, location and patterns of granulomas in ITB and CD with regard to their histopathologic features have been noted. Immune stain of cell surface markers is also helpful. Interferon-γ release assay and polymerase chain reaction analysis have achieved satisfactory sensitivity and specificity in the diagnosis of ITB. Computed tomography enterographic findings of segmental small bowel or left colon involvement, mural stratification, the comb sign and fibrofatty proliferation are significantly more common in CD, whereas mesenteric lymph node changes (calcification or central necrosis) and focal ileocecal lesions are more frequently seen in ITB. A diagnosis should be carefully established before the initiation of the therapy. In suspicious cases, short-term empirical anti-TB therapy is quite efficient to further confirm the diagnosis.

Granulomas as the Most Useful Histopathological Feature in Distinguishing between Crohn's Disease and Intestinal Tuberculosis in Endoscopic Biopsy Specimens

The incidence of Crohn's disease (CD) is increasing in Chinese populations in whom intestinal tuberculosis (ITB) is prevalent.This study aimed to identify differential diagnostic microscopic and endoscopic characteristics of CD from those of ITB.Patients with CD (N = 52) and patients with ITB (N = 16) diagnosed between 2010 and 2013 were identified. Specimens obtained via endoscopy were analyzed microscopically by a pathologist. The relationship between endoscopic appearance and histopathological features was analyzed. The χ test, Fisher's exact probability test, and the Mann-Whitney U test were used.Granulomas were present in 81.3% of ITB cases and in 67.3% of CD cases (P = 0.36). Granulomas in ITB cases were denser than those in CD cases (mean 5.29 ± 4.30 vs. 2.46 ± 3.50 granulomas per 10 low power fields; each low power field = 3.80 mm; P = 0.005). Granulomas in ITB cases were larger (mean widest diameter, 508 ± 314 μm; range, 100-1100 μm) than those in CD cases (mean widest diameter, 253 ± 197 μm; range, 50-800 μm). Basal plasmacytosis was more common in CD cases than in ITB cases (77.0% vs. 37.5%, P = 0.000). Endoscopy findings such as longitudinal ulcer, aphthous ulcer, and cobblestone appearance were only seen in CD cases (34.6%, 21.2%, and 23.1%, respectively). Granulomas were detected in the majority of cases with longitudinal ulcers (88.9%). Basal plasmacytosis was exclusively detected in cases with longitudinal ulcer and a cobblestone appearance.Characteristics of granulomas maybe the most important distinguishing features between CD and ITB. However, the histopathological characteristics of both diseases may overlap on endoscopic biopsy specimens. An accurate diagnosis should be made that considers clinical, endoscopic features, and pathologic findings.

Abdominal Tuberculosis: A Diagnostic Dilemma

BACKGROUND

Abdominal tuberculosis (TB) is the sixth most common form of extra-pulmonary site of infection after lymphatic, genitourinary, bone and joint, miliary and meningeal TB with a rising incidence in recent years. TB can affect any part of the gastro-intestinal (GI) tract including anus, peritoneum and hepato-biliary system. The clinical manifestations of abdominal tuberculosis are non-specific and mimic various GI disorders and cause delay in diagnosis and management.

AIM

To evaluate the various clinical, radiological and microbiological findings of abdominal tuberculosis and to define the role of histopathological examination in establishing the diagnosis in resource poor settings and to analyze the compliance and response to anti-tubercular treatment.

MATERIALS AND METHODS

A five year retrospective study (January 2010 to December 2014) was done in a tertiary teaching hospital in Northern India and all the cases diagnosed as abdominal tuberculosis during the study period, were included. The relevant clinical informations, laboratory results, microbiological and radiological investigations were recorded. Histopathological examination of all the resected / excised specimens was done and Ziehl-Neelsen (ZN) staining to detect the tubercular bacilli and Periodic acid-Schiff (PAS) stain to rule out fungal infection was done in all the cases.

RESULTS

Out of 48 cases with abdominal tuberculosis, the average age of presentation was 27.4 years with a slight male predominance (Male:Female=1.4:1). Abdominal pain (100%) was the most common presenting symptom followed by anorexia (98%), fever (88%) and intestinal obstruction (88%). The ileum was the most common site of involvement. All the 45 resected / excised tissue specimens (34 cases of intestinal resection and 11 cases of intesinal, omental and lymph nodes biopsies) showed epithelioid granulomas along with necrosis (in 38 cases) and Langhans giant cells (in 42 cases). Acid Fast Bacilli (AFB) positivity was seen in 5 tissue specimens only. All patients were put on anti-tubercular treatment and majority showed good response to therapy.

CONCLUSION

Abdominal tuberculosis should be considered as a differential diagnosis in patients with vague GI symptoms. Study of histopathological findings can aid in the diagnosis in the settings where advanced molecular methods of diagnosis are not available, leading to early diagnosis and management.

A rare case of perforation peritonitis with jejunal stricture in a patient recently treated for pulmonary tuberculosis

Abdominal tuberculosis (ATB) constitutes 12% of the extra pulmonary disease and is a rare but well-documented cause of perforation peritonitis, occasionally occurring in cases where the diagnosis has been delayed but may occur even after antituberculous therapy has been initiated. Most patients with tuberculosis strictures respond well to medical treatment and should be resorted to surgery only if drug therapy fails. Despite surgical intervention, tuberculosis perforation has a high complication and mortality rate. We present a case of 54-year-old male patient with a perforated jejunal stricture who had completed his treatment for pulmonary tuberculosis one month earlier. This case was unusual because of the age of patient at presentation (usually seen in young - 25 to 45 y), involvement of jejunum (commonly ileocaecal region), initial presentation with subacute obstruction followed by peritonitis (refused treatment at first instance) and patient having completed treatment for pulmonary tuberculosis recently.

Indian Society of Gastroenterology consensus statements on Crohn's disease in India

In 2012, the Indian Society of Gastroenterology's Task Force on Inflammatory Bowel Diseases undertook an exercise to produce consensus statements on Crohn's disease (CD). This consensus, produced through a modified Delphi process, reflects our current recommendations for the diagnosis and management of CD in India. The consensus statements are intended to serve as a reference point for teaching, clinical practice, and research in India.

High faecal calprotectin levels in intestinal tuberculosis are associated with granulomas in intestinal biopsies

BACKGROUND

The diagnosis of intestinal tuberculosis (ITB) is sometimes difficult to establish and requires endoscopic investigation with biopsies for histopathological examination. This study aimed to evaluate calprotectin as a marker of inflammation in ITB.

METHODS

Patients with ITB were prospectively recruited in Southern India from October 2009 until July 2012. Demographic, clinical, endoscopic and histological features were examined along with faecal calprotectin (FC), serum calprotectin (SC) and C-reactive protein (CRP).

RESULTS

Thirty patients (median age 34.5 years, 19 men) were included. Clinical features were abdominal pain (97%), weight loss (83%), cachexia (75%), fatigue (63%), watery diarrhoea (62%), nausea (55%) and fever (53%). Endoscopy showed transverse ulcers (61%), nodularity of mucosa (55%), aphthous ulcers (39%), strictures (10%) and fissures (10%). The terminal ileum and right colon harboured 81% of the lesions. Histology revealed granulomas in biopsies from 10 of the patients. FC and CRP levels showed a strong positive correlation (rs = 0.70, p < 0.01). FC, SC and CRP levels were higher in the granulomatous than the non-granulomatous patients, respectively (median FC 988 μg/g, interquartile range (IQR) 940 vs 87 μg/g, IQR 704, p < 0.01; median SC 8.2 μg/ml, IQR 7.3 vs 3.8 μg/ml, IQR 8.9, p = 0.23; median CRP 38.8 mg/L, IQR 42.9 vs 2.3 mg/L, IQR 13.5, p < 0.01). Higher median calprotectin and CRP levels were detected in patients with extensive than localized disease, but the differences did not reach statistical significance.

CONCLUSION

ITB patients with granulomas on histology have high levels of faecal calprotectin and CRP.

Acid-fast bacilli culture positivity and drug resistance in abdominal tuberculosis in Mumbai, India

BACKGROUND AND AIM

Culture positivity for Mycobacterium tuberculosis complex (MTB) in abdominal tuberculosis (TB) using Lowenstein Jensen medium and Bactec system varies from 25 % to 36 %. Data on the prevalence of drug resistance in primary abdominal TB is scant. Our aim was to study the acid-fast bacilli (AFB) culture positivity rate in primary abdominal TB using Bactec Mycobacterial Growth Indicator Tubes (MGIT) system and the prevalence of drug resistance in these patients.

METHOD

Records of patients with abdominal TB (diagnosed on clinical features, endoscopy, histology, microbiology) seen during the period 2008 to 2013 were retrieved from the Gastroenterology and Microbiology departments. Patients with extra-abdominal TB (five pulmonary, two nodal), adnexal (one), and HIV (one) were excluded from analysis.

RESULTS

Of 61 patients, 31 (50.8 %) had a positive AFB culture. In the 30 culture-negative patients, histology showed non-caseating granulomas in 25 patients. Drug sensitivity pattern was analyzed in 18 patients; resistance was detected in eight (14.3 % of all patients and 44.4 % of patients in whom drug sensitivity was done) including three (5.4 % of all subjects and 16.6 % in whom drug sensitivity was available) who were multidrug-resistant.

CONCLUSIONS

The rate of AFB culture positivity in primary abdominal TB was 50.8 % using Bactec MGIT. Likelihood of drug resistance was seen in 14.3 %, of whom 5.4 % were multidrug-resistant.

Visceral fat as a useful parameter in the differential diagnosis of Crohn's disease and intestinal tuberculosis

BACKGROUND/AIMS

Because of the similarities in the clinical presentations of Crohn's disease (CD) and intestinal tuberculosis (ITB), differential diagnosis is critical. Mesenteric adipose tissue hypertrophy and creeping fat are characteristic features of CD. The purpose of this study was to assess the usefulness of visceral fat for the differential diagnosis of CD and ITB.

METHODS

We conducted a retrospective review of 50 patients with findings of CD or ITB between January 2005 and July 2008. Abdominal computed tomography (CT) was performed on all subjects during their first evaluation. The abdominal fat area was assessed using quantitative abdominal CT.

RESULTS

The ratio of visceral fat to total fat (VF/TF) was significantly higher in male CD patients than in male ITB patients. The ratio of visceral fat to subcutaneous fat (VF/SF) was also higher in CD patients than in patients with ITB. For a VF/TF cut-off value of 0.46, the sensitivity and specificity for the diagnosis of CD were 42.1% and 93.3% respectively, with positive and negative predictive values of 88.9% and 56.0%, respectively.

CONCLUSION

Measurement of the abdominal fat area using CT can be clinically useful for the differential diagnosis of CD and ITB.

Multiplex PCR for rapid diagnosis of gastrointestinal tuberculosis

Background:

Rapid and specific diagnosis of gastrointestinal tuberculosis (GITB) is of utmost importance.

Aim:

To evaluate Multiplex PCR (MPCR) using MPB64 and IS6110 primers specific for M. tuberculosis for rapid diagnosis of GITB.

Materials and Methods:

MPCR was performed on colonoscopy biopsy specimens on 11 GITB confirmed (culture/AFB/histopathology was positive), 29 GITB suspected and 30 Non GITB (control group) patients.

Results:

MPB64 PCR had sensitivity and specificity of 90% and 100% for confirmed GITB cases. In 29 clinically diagnosed but unconfirmed GITB cases, MPCR was positive in 72.41%. MPCR was negative in all control group patients. The overall sensitivity and specificity of microscopy, culture, histopathology and MPCR was 5%, 2% 20% and 77.5% and 100%, 100%, 100% and 100% respectively.

Conclusion:

MPCR has good sensitivity and specificity in diagnosing gastrointestinal tuberculosis.

Abdominal tuberculosis: a histopathological study with special reference to intestinal perforation and mesenteric vasculopathy

BACKGROUND

Along with the increased incidence of pulmonary tuberculosis in parallel with the increase in population in various parts of the world, in recent years, the incidence of abdominal tuberculosis has also increased. The pathogenetic events in intestinal tuberculosis, which culminate in ulcer formation, perforation, and stricture, still have to be identified.

AIM

To correlate the gross and microscopic features in intestinal tuberculosis, in particular tuberculous perforation with changes in mesenteric vasculature.

PATIENTS AND METHODS

A one-year prospective study of excised/resected tissues from patients with abdominal tuberculosis requiring surgical intervention was conducted. Tissues from fifty-six patients were included in the study-of which 36 were resected intestinal segments and 20 were intestinal and lymph node biopsies. Hematoxylin and Eosin and Ziehl-Neelsen stains were used for histopathological examination.

RESULTS

Tuberculous enteritis was found to be present in 49 of the 56 patients (87.5%) (ileum being the site most commonly affected), while nodal involvement was seen in 39 (69.6%) patients. Perforations were present in 39 out of 49 (79.6%) intestinal tissues; most being solitary and ileum was the commonest site. Typical epithelioid cell granulomas were seen in the intestine and lymph nodes, with caseation being more prevalent in the latter. The mesenteric vasculature was frequently involved by granulomatous inflammation, with intravascular organizing thrombus being present in 30% of the resected specimens with perforation. Acid fast bacilli were demonstrated in the tissue sections of 37.5% of the patients. AFB positivity was higher in caseating granulomas.

CONCLUSION

Involvement of mesenteric vasculature by granulomatous inflammation was commonly associated with the ulcerative type with perforation, suggesting that ischemia caused by vascular thrombosis is responsible for tissue breakdown. This implies that vasculitis plays an important role in the natural history of abdominal tuberculosis.

Combined endoscopy, aspiration, and biopsy analysis for identifying infectious colitis in patients with ileocecal ulcers

BACKGROUND & AIMS

The ileocecal area is commonly involved in infection and inflammatory colonic diseases, but differential diagnosis can be difficult. We identified definitive endoscopic findings and a sample collection method for diagnosing infectious colitis.

METHODS

In a retrospective study, we analyzed data on 128 patients with ileocecal ulcer who underwent colonoscopy from 2007-2011 at the National Center for Global Health and Medicine in Tokyo, Japan. We collected information on location, size, number, and distinctive endoscopic findings and estimated diagnostic odds ratios (ORs). The sensitivities of microscopy, culture, polymerase chain reaction, and histologic methods in identifying patients with infection were compared with those of standard stool, endoscopic aspirated intestinal fluid, or biopsy analyses.

RESULTS

Of the 128 patients, 100 had infections, and 28 had Crohn's disease, Behçet's disease, or other inflammatory diseases. Predictive endoscopic findings were as follows: for amebiasis of the cecum (OR, 17.8), with exudates (OR, 13.9) and round-shaped ulcer (OR, 5.77); for tuberculosis (TB) with transverse-shaped ulcer (OR, 175), scar (OR, 34.6), linear-shaped ulcer (OR, 23.9), or ≥10 mm (OR, 14.0); for cytomegalovirus with round-shaped ulcer (OR, 4.09); and for Campylobacter with cecal valve lesion (OR, 58.3) or ≥10 mm (OR, 10.4). The sensitivity of endoscopic sample collection was significantly higher than that of standard stool sample collection for the diagnosis of amebiasis, TB, non-TB mycobacteria, and other bacteria (P < .05). The methods that detected infection with the highest levels of sensitivity were biopsy with histology for amebiasis, biopsy with culture for TB, biopsy with polymerase chain reaction for cytomegalovirus, and aspiration of intestinal fluid with culture for Campylobacter.

CONCLUSIONS

Combining results from endoscopic analysis with appropriate sample collection and pathogen detection methods enables infectious colitis to be differentiated from other noninfectious colonic diseases.

Gastrointestinal tuberculosis is not associated with proton pump inhibitors: A retrospective cohort study

AIM: To evaluate the effect of proton pump inhibitors (PPIs) on the development of gastrointestinal tuberculosis.

METHODS: All patients who were more than 20 years old and who had received a prescription for PPIs among those who visited Seoul National University Hospital from January 1, 2005 to December 31, 2009 were identified. Due to the low sensitivity of the microbiologic test and the nonspecific pathologic findings, the diagnosis of gastrointestinal tuberculosis was confirmed through the presence of active ulcerations and the responses to anti-tuberculosis medications. The patients were divided into two groups according to treatment duration (group 1: ≤ 3 mo; group 2: > 3 mo) and were followed up from the time they took the first prescription of PPIs until their last visit. Logistic regression analysis was used to calculate the relative risks (RR) and 95%CI, adjusting for covariates.

RESULTS: Among the 61  834 patients exposed to PPIs (50  534 in group 1; 11  300 in group 2), 21 patients were diagnosed with PPI-associated gastrointestinal tuberculosis during 124  274 person-years of follow-up. Of 21 patients, the 12 who revealed only scar changes in the colonoscopy were excluded from the statistical analyses. Of those who remained, 2 were excluded because they underwent gastrointestinal endoscopy within 4 wk of the first prescription for PPIs. Longer exposure to PPI was associated with a higher mean age (55.0 ± 14.5 in group 1 vs 58.2 ± 13.3 in group 2, P < 0.001) and a higher Charlson co-morbidity index (0.50 ± 0.93 in group 1 vs 0.77 ± 1.14 in group 2, P < 0.001). The true incidence of active gastrointestinal tuberculosis was 0.65 per 1000 person-years in group 1 and 0.03 per 1 000 person-years in group 2. Like the less-than-three-month PPI treatment period in group 1, the over-three-month PPI therapy period in group 2 was not associated with increased risk of acquiring gastrointestinal tuberculosis, after adjusting for age and co-morbidities, whereas the Charlson co-morbidity index was associated with increased risk of acquiring gastrointestinal tuberculosis based on the score [RR: (reference 1) in group 1 vs 1.518 in group 2; 95% CI: 1.040-2.216, P = 0.03].

CONCLUSION: Long-term PPI therapy does not seem to be associated with increased risk of acquiring gastrointestinal tuberculosis, but a higher Charlson co-morbidity index is associated with such.

Survey of inflammatory bowel diseases in India

INTRODUCTION

Inflammatory bowel disease (IBD), both ulcerative colitis (UC) and Crohn's disease (CD), once thought to be uncommon, is now seen commonly in India. The Indian Society of Gastroenterology (ISG) Task Force on IBD decided to collate data on the clinical spectrum of IBD currently prevailing in India.

METHODS

An open call to members of ISG was given through publication of a proforma questionnaire in the Indian Journal of Gastroenterology and the web portal of ISG. The proforma contained questions related with demographic features, family history, risk factors, clinical manifestations and characteristics, course of disease, and pattern of treatment of IBD.

RESULTS

Of 1,255 filled questionnaires received, 96 were rejected and 1,159 (92.3 %) were analyzed. This comprised data on 745 (64.3 %) patients with UC, 409 (35.3 %) with CD, and 5 with indeterminate colitis. The median duration of illness was longer in patients with CD (48 months) compared to those with UC (24 months) (p = 0.002). More than one half of patients (UC 51.6 %, CD 56.9 %) had one or more extraintestinal symptoms. A definite family history of IBD was present in 2.9 % (UC 2.3 % and CD 4.6 %; p = 0.12). The extent of disease in UC was pancolitis 42.8 %, left-sided colitis 38.8 %, and proctitis alone in 18.3 %. The extent of disease involvement in CD was both small and large intestine in 39.6 %, colon alone in 31.4 % and small intestine alone in 28.9 %. Stricturing and fistulizing disease were noted in 18.8 % and 4.4 % of patients with CD respectively. Chronic continuous and intermittent disease course were present in 35.5 % and 47.2 % of UC patients respectively, and in 23.1 % and 68.8 % of CD patients. Four percent of patients with UC had undergone colectomy, while 15.2 % of patients with CD underwent surgical intervention.

CONCLUSIONS

The present survey provides a reasonable picture of the demographic features and clinical manifestations of Indian patients with IBD, their risk factors, course of disease, and the treatment given to them.

Tuberculous lymphadenopathy mimicking pancreatic neoplasm

Abdominal tuberculosis (TB) is the sixth most common location of extrapulmonary TB involvement. Because its symptoms and signs are often nonspecific, laboratory and imaging findings mimic other diseases including carcinoma. Therefore, the diagnosis of abdominal TB is challenging. We herein report a case of 74-year-old woman who presented with abdominal pain, anorexia, and weight loss. She had been given a diagnosis of pancreatic head carcinoma. Laboratory data was unremarkable except for elevated erythrocyte sedimentation rate, CA125, and sIL-2R. CT scan revealed multiple enlarged peripancreatic lymph nodes and concentric thickening of the ileocecal wall. Colonoscopy demonstrated deformed ileocecal valve and erosions. Histological examination showed epithelioid granulomas. Laparoscopy revealed numerous white tubercles diffusely covering the parietal peritoneum. Histopathological images of peripancreatic lymph node revealed large multiple caseating granulomas surrounded by Langhans_giant cells and epithelioid cells. Polymerase chain reaction and culture of the specimens were positive for Mycobacterium tuberculosis. Tuberculous lymphadenopathy, colitis, and peritonitis were finally diagnosed. She responded well to the antitubercular treatment.

Case of intestinal tuberculosis mimicking Crohn's disease

BACKGROUND

Intestinal tuberculosis can closely mimic Crohn's disease and colon cancer. Presented here is a case of intestinal tuberculosis that closely mimicked both.

CASE REPORT

A 23 year old Hispanic female presented with several months of weight loss, recurrent fever, and emesis. The patient did not have pulmonary symptoms or radiographic evidence of tuberculosis. Colonoscopy evaluation with biopsy of the affected bowel segments were thought to be consistent with either colon cancer or Crohn's Disease. Acid fast bacilli staining and histological analysis did not display evidence of tuberculosis on two separate occasions. The patient developed colonic obstruction acutely during the course of treatment requiring resection of the affected bowel segment. Acid fast staining of the resected lymph nodes was positive and submucosal caseating granulomas were identified histologically, consistent with intestinal tuberculosis.

CONCLUSIONS

Intestinal tuberculosis remains a diagnostic challenge. Consideration of the disease should be maintained in equivocal cases.

Biopsy interpretation of colonic biopsies when inflammatory bowel disease is excluded

The interpretation of colonic biopsies related to inflammatory conditions can be challenging because the colorectal mucosa has a limited repertoire of morphologic responses to various injurious agents. Only few processes have specific diagnostic features, and many of the various histological patterns reflect severity and duration of the disease. Importantly the correlation with endoscopic and clinical information is often cardinal to arrive at a specific diagnosis in many cases.

CT appearances of abdominal tuberculosis

The purpose of this article is to review and illustrate the spectrum of computed tomography (CT) appearances of abdominal tuberculosis. Tuberculosis can affect any organ or tissue in the abdomen, and can be mistaken for other inflammatory or neoplastic conditions. The most common sites of tuberculosis in the abdomen include lymph nodes, genitourinary tract, peritoneal cavity and gastrointestinal tract. The liver, spleen, biliary tract, pancreas and adrenals are rarely affected, but are more likely in HIV-seropositive patients and in miliary tuberculosis. This article should alert the radiologist to consider abdominal tuberculosis in the correct clinical setting to ensure timely diagnosis and enable appropriate treatment.

Bowel obstruction caused by intestinal tuberculosis: an update

Tuberculosis is one of the most important communicable diseases worldwide, with an increasing incidence within the UK. The abdomen is involved in 11% of patients with extra-pulmonary tuberculosis, and can provide a diagnostic challenge if not suspected. The authors report the case of a 31-year-old Sudanese female who presented with intestinal obstruction due to a mass caused by abdominal tuberculosis. Imaging revealed evidence of multifocal tuberculosis involving the ileo-caecal region with abdominal and mediastinal lymphadenopathy. She went on to have a limited right hemicolectomy and completed antitubercular therapy. It is important to consider abdominal tuberculosis when conditions such as Crohn's disease or gastrointestinal malignancy are being entertained in those from a high-risk background. Since diagnosis can be difficult, if clinical suspicion is strong, surgery is a safe option. Recommended management combines up to 12 months of antitubercular therapy with conservative surgery.

Inflammatory bowel disease in India--changing paradigms

BACKGROUND

Inflammatory bowel disease is an emerging problem in Asia including India. Clinical data on this disease from eastern India and on its temporal trends in India is scarce.

MATERIALS AND METHODS

Existing Indian data on inflammatory bowel disease were retrieved using PubMed and a comparison of earlier data (up to 1980s) was made with more recent data (1990s and later) and our own data to find any significant differences. Our data included clinical data of 40 and ten consecutive patients with ulcerative colitis and Crohn's disease, respectively, collected prospectively from January 2003 to June 2009. For those whose symptoms started before 2003, data collection was partly retrospective. It included demography, symptoms and duration at presentation, follow-up findings, course, extraintestinal manifestations, treatment outcome and complications. Data were analysed by descriptive and analytical statistics.

RESULTS

Sixty-five percent of our ulcerative colitis patients presented with pancolitis, majority had severe clinical, endoscopic and histologic disease commensurate with other recent studies but in contrast to milder presentation in earlier studies. Of our patients, 27.5% developed pseudopolyposis of colon, two within 1 year of disease onset; 10% developed cancer colon for whom disease duration of 10 years or more was the only significant risk factor. Majority of our patients with Crohn's disease had mild inflammatory disease involving small gut which was controlled with aminosalicylates. Obscure lower GI bleed was an important mode of presentation.

CONCLUSIONS

Ulcerative colitis is presenting with increasing severity and extent in recent times. Rapid development of colonic pseudopolyposis was observed.

Differentiation of Crohn’s disease from intestinal tuberculosis in India in 2010

Differentiating intestinal tuberculosis from Crohn’s disease (CD) is an important clinical challenge of considerable therapeutic significance. The problem is of greatest magnitude in countries where tuberculosis continues to be highly prevalent, and where the incidence of CD is increasing. The final clinical diagnosis is based on a combination of the clinical history with endoscopic studies, culture and polymerase chain reaction for Mycobacterium tuberculosis, biopsy pathology, radiological investigations and response to therapy. In a subset of patients, surgery is required and intraoperative findings with pathological study of the resected bowel provide a definitive diagnosis. Awareness of the parameters useful in distinguishing these two disorders in each of the different diagnostic modalities is crucial to accurate decision making. Newer techniques, such as capsule endoscopy, small bowel enteroscopy and immunological assays for Mycobacterium tuberculosis, have a role to play in the differentiation of intestinal tuberculosis and CD. This review presents currently available evidence regarding the usefulness and limitations of all these different modalities available for the evaluation of these two disorders.

Histopathology and TB-PCR kit analysis in differentiating the diagnosis of intestinal tuberculosis and Crohn’s disease

AIM: To compare the histopathologic features of intestinal tuberculosis (ITB) and Crohn’s disease (CD) and to identify whether polymerase chain reaction for Mycobacterium tuberculosis (TB-PCR) would be helpful for differential diagnosis between ITB and CD.

METHODS: We selected 97 patients with established diagnoses (55 cases of ITB and 42 cases of CD) who underwent colonoscopic biopsies. Microscopic features of ITB and CD were reviewed, and eight pathologic parameters were evaluated. Nine cases of acid fast bacilli culture-positive specimens and 10 normal colonic tissue specimens were evaluated as the positive and negative control of the TB-PCR test, respectively. PCR assays were done using two commercial kits: kit <A> detected IS6110 and MPB64, and kit <B> detected IS6110 only; a manual in-house PCR method was also performed on formalin-fixed, paraffin-embedded colonoscopic biopsy specimens.

RESULTS: Statistically significant differences were noted between ITB and CD with regard histopathologic criteria: size of granulomas (P = 0.000), giant cells (P = 0.015), caseation necrosis (P = 0.003), confluent granulomas (P = 0.001), discrete granulomas (P = 0.000), and granulomas with lymphoid cuffs (P = 0.037). However, 29 cases (52.7%) of ITB showed less than five kinds of pathologic parameters, resulting in confusion with CD. The sensitivities and specificities of the TB-PCR test by kit <A>, kit <B>, and the in-house PCR method were 88.9% and 100%, 88.9% and 100%, and 66.7% and 100% in positive and negative controls, respectively. The PCR test done on endoscopic biopsy specimens of ITB and CD were significantly different with kit <A> (P = 0.000) and kit <B> (P = 0.000). The sensitivities and specificities of TB-PCR were 45.5% and 88.1%, 36.4% and 100%, and 5.8% and 100%, for kit <A> and kit <B> and in-house PCR method on endoscopic biopsy specimens. Among the 29 cases of histopathologically confusing CD, 10 cases assayed using kit <A> and 6 cases assayed using kit <B> were TB-PCR positive. A combination of histologic findings and TB-PCR testing led to an increase of diagnostic sensitivity and the increase (from 47.3% to 58.2) was statistically significant with kit <B> (P = 0.000).

CONCLUSION: The TB-PCR test combined with histopathologic factors appears to be a helpful technique in formulating the differential diagnosis of ITB and CD in endoscopic biopsy samples.

Clinical, endoscopic, and histological differentiations between Crohn's disease and intestinal tuberculosis

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.

Comparison of the pathologic characteristics of biopsy and operative specimens between Crohn's disease and intestinal tuberculosis: an analysis of 148 cases

AIM: To explore the distinctive diagnostic features of biopsy and operative specimens between Crohn's disease and intestinal tuberculosis.

METHODS: A retrospective study was performed to analyze the pathological features of 110 biopsy specimens (55 from patients with Crohn's disease, and 55 from patients with intestinal tuberculosis) and 38 operative specimens (29 from patients with Crohn's disease, and 9 from patients with intestinal tuberculosis). The value of these pathological features in differential diagnosis of the two diseases was analyzed.

RESULTS: Pathologic parameters of biopsy specimens helpful in differentiating Crohn's disease from intestinal tuberculosis included broadened submucosa, fissure-like ulcer, and granuloma (37.5% vs 14.0%, 10.9% vs 0%, and 10.9% vs 43.6%, respectively; all P < 0.05). Pathologic parameters of operative specimens helpful in differentiating Crohn's disease from intestinal tuberculosis included broadened submucosa, fissure-like ulcer, broadened muscularis propria, cobblestone appearance, and granuloma (51.7% vs 11.1%, 34.5% vs 0%, 62.1% vs 11.1%, 37.9% vs 0%, and 20.7% vs 77.8%, respectively; all P < 0.05).

CONCLUSION: The pathological features of biopsy specimens have limited value in differential diagnosis of Crohn's disease and intestinal tuberculosis. The pathological features of operative specimens have appreciable value in differentiating Crohn's disease from intestinal tuberculosis. It is essential to combine clinical, endoscopic and imageologic parameters to differentially diagnose the two diseases.