Differential diagnosis of Crohn's disease and intestinal tuberculosis in patients with spontaneous small-bowel perforation

Surgical Management of Complicated Abdominal Tuberculosis: The First Systematic Review-New Treatments for an Ancient Disease and the State of the Art

Background: Abdominal tuberculosis comprises all forms of tuberculosis that involve the gastrointestinal tract. Controversies exist regarding the surgical approach and timing and type of intervention for complicated forms of abdominal tuberculosis. The aim of this systematic review is to define the rate of surgical treatment, the type of surgical procedures performed and the role of minimally invasive surgery in the management of abdominal tuberculosis. Methods: The literature in MEDLINE, Scopus and Google Scholar and forward and backward citations for studies published between database inception and July 2022 were searched without language restrictions. All prospective and retrospective studies were included. The electronic database search yielded 2440 records. Additionally, eight records were identified through snowball searching. Following duplicate removal (45 duplicates found), 2403 records were screened for titles and abstracts. After screening for titles and abstracts and exclusion criteria, 38 reports were included for systematic review, 27 retrospective studies and 11 prospective studies. Data extracted included the general and demographic characteristics of the studies, diagnostic methods used, clinical presentation, site of involvement and details on surgical treatment. Results: In total, 2870 patients with a diagnosis of abdominal tuberculosis were included, and 1803 (63%) underwent a surgical procedure. The majority of patients underwent an open surgical procedure (95%). The most commonly performed procedures were adhesiolysis (21%) and small bowel resection with primary anastomosis (21%). Conclusions: The results of this review suggest that whenever surgery is required, there is a tendency to perform open surgical procedures in patients with complicated abdominal tuberculosis, both in emergency and elective settings, despite advances in minimally invasive surgery. The study protocol was registered on PROSPERO (CRD42022354322).

Treatment of intestinal tuberculosis with small bowel perforation: a case report

Background

Diagnosis of intestinal tuberculosis poses a dilemma to physicians due to nonspecific symptoms like abdominal pain, fever, nausea, and a change in bowel habit. In particular, the distinction between inflammatory bowel disease and intestinal tuberculosis remains challenging.

Case presentation

A 27-year-old man from Colombia presented with fever, night sweats, and progressive lower abdominal pain. Computed tomography revealed a thickening of the bowel wall with a mesenterial lymphadenopathy, ascites ,and a pleural tumor mass. Histology of intestinal and pleural biopsy specimens showed a granulomatous inflammation. Although microscopy and polymerase chain reaction (PCR) for Mycobacterium tuberculosis (MTB) were negative, empirical MTB treatment was initiated on suspicion. Due to a massive post-stenotic atrophied intestinal bowel, MTB medications were administered parenterally in the initial phase of treatment to guarantee adequate systemic resorption. The complicated and critical further course included an intra-abdominal abscess and bowel perforation requiring a split stoma, before the patient could be discharged in good condition after 3 months of in-hospital care.

Conclusions

This case highlights the clinical complexity and diagnostic challenges of intestinal MTB infection. A multidisciplinary team of physicians should be sensitized to a timely diagnosis of this disease, which often mimics inflammation similar to inflammatory bowel disease, other infections, or malignancies. In our case, radiological findings, histological results, and migratory background underpinned the suspected diagnosis and allowed early initiation of tuberculostatic treatment.

Intestinal tuberculosis and Crohn's disease: the importance and difficulty of a differential diagnosis

Tuberculosis (TB) is the most prevalent infection worldwide and affects one third of the population, predominantly in developing countries. Intestinal TB (ITB) is the sixth most frequent extra-pulmonary TB infection. Crohn's disease (CD) is a chronic inflammatory bowel disease that arises from the interaction of immunological, environmental and genetic factors. Due to changes in the epidemiology of both diseases, distinguishing CD from ITB is a challenge, particularly in immunocompromised patients and those from areas where TB is endemic. Furthermore, both TB and CD have a predilection for the ileocecal area. In addition, they share very similar clinical, radiological and endoscopic findings. An incorrect diagnosis and treatment may increase morbidity and mortality. Thus, a great degree of caution is required as well as a familiarity with certain characteristics of the diseases, which will aid the differentiation between the two diseases.

Ulcerative intestinal tuberculosis case as a complication of treatment by infliximab for intestinal Behçet's disease: A case report

RATIONALE

Intestinal Behçet's disease (BD) is characterized by intestinal ulcerations and gastrointestinal symptoms. Ulcerative intestinal tuberculosis (TB) is usually with dyspepsia, abdominal pain, vomiting, and weight loss. The 2 diseases exhibit similar clinical manifestations, but the most critical aspects of their clinical courses and required treatments are not at all similar.

PATIENT CONCERNS

We present a case in which a patient with intestinal Behçet's disease developed a de novo ulcerative intestinal TB infection after the start of anti-tumor necrosis factor-α treatment. This was despite histopathologic examination without caseous necrosis granuloma and negative for acid-fast staining and latent TB screen.

DIAGNOSES

Intestinal Behçet's disease and intestinal TB.

INTERVENTIONS

The patient was treated with quadruple antituberculous chemotherapy, comprising rifapentine, isoniazid, ethambutol, and pyrazinamide.

OUTCOMES

At follow-up about 3 months, the therapy of oral antituberculous drugs and thalidomide was continued and the patient's condition had stabilized.

LESSONS

This case illustrates the importance of closely monitoring patients who are on infliximab for possible onset of TB, even without abdominal symptoms, and with negative screening results for latent TB.

The potential role of CT enterography and gastrointestinal ultrasound in the evaluation of anti-tubercular therapy response of intestinal tuberculosis: a retrospective study

Background

Accurate evaluation of anti-tubercular therapy (ATT) responses is crucial for both diagnosis and treatment of intestinal tuberculosis (ITB). Little is known about the role of cross-sectional imaging techniques in ITB follow-up assessment. We aimed to investigate the accuracy of cross-sectional imaging modalities, CT enterography (CTE) and gastrointestinal ultrasound (GIUS), in the evaluation of ATT responses in ITB patients.

Methods

Patients diagnosed with ITB and followed up by CTE and/or GIUS were retrospectively searched in the databases. Clinical, imaging, laboratory and endoscopic data were collected at baseline and the first follow-up visit. Responses were graded as good, partial and no response based on protocols described in the literature and by our institution. CTE evaluation was based on changes in the lesion area, mural thickness, enhancement patterns and lymph nodes, while GIUS evaluation was based on changes in bowel wall morphology and the Limberg score. Clinical evaluation was used as the gold-standard evaluation method, which was determined by a comprehensive impression of endoscopic changes along with symptomatic improvement and laboratory tests, with imaging results masked.

Results

Twenty patients with ITB were enrolled in our study. The first follow-up time was from 2 to 12 months (average 6 months). According to the gold standard evaluation, 11 patients were evaluated as having a good ATT response, while 9 had a partial response. A total of 18 patients were followed up by CTE, while 7 were followed up by GIUS, depending on medical and/or financial considerations. The accuracy of CTE and GIUS was 83% (15/18) and 85.7% (6/7), respectively. The sensitivity, specificity, PPV and NPV of CTE were 88.9, 77.8, 80 and 87.5%, respectively. Moreover, the sensitivity, specificity, PPV and NPV of GIUS were 100, 50, 83.3 and 100%, respectively. By combining the results of CTE and GIUS results, the overall accuracy was 90%, with sensitivity and specificity of 91.7 and 87.5%, respectively.

Conclusion

To our knowledge, this is the first study exploring the accuracy of the cross-sectional imaging modalities CTE/GIUS in the evaluation of ATT responses. Our results indicated their promising application prospect in clinical practice as a non-invasive and cost-effective approach.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-1030-0) contains supplementary material, which is available to authorized users.

Atypical serious hematochezia and rare imaging feature in gastrointestinal tuberculosis

A young patient had serious hematochezia for nearly 2 months without obvious cause. Abdominal CT images showed rare features such as serious hemorrhage and multiple miliary nodules in the small bowel. The colonoscopy showed multiple lymphoid follicles in the terminal ileum. The laparotomy showed adverse adhesion in the abdominal cavity and multiple miliary noduli in the surfaces of small bowel wall. The pathology suggested tuberculosis. This patient received anti-TB therapy and the condition improved gradually. There are many variants of GI tuberculosis demonstrating uncommon and rare imaging features. It turned to be difficult in diagnosis when it showed the rare appearance, such as the great amount of intestinal bleeding and multiple noduli in our case. The reason why gastrointestinal bleeding might be attributed to the invasiveness of submucosal vessels by the tuberculosis bacteria. And the multiple noduli on the bowel wall might be the granuloma formation. Therefore, from the experience of our case, gastrointestinal tract might also be the first and only involved site, and it may cause great amount of bleeding to a life danger, even in young people.

Intestinal tuberculosis: a diagnostic challenge

OBJECTIVE

To describe characteristics, presentation, time to diagnosis and diagnostic findings of patients with intestinal tuberculosis (ITB) in a low-burden country.

METHOD

Retrospective study of 61 consecutive ITB patients diagnosed between 2008 and 2014 at a large East London hospital.

RESULTS

Forty of sixty-one patients were male. Mean age was 34.6 years. 93% of patients were born abroad, mostly from TB-endemic areas (Indian subcontinent: 88%, Africa: 9%). 25% had concomitant pulmonary TB. Median time from symptom onset to ITB diagnosis was 13 weeks (IQR 3-26 weeks). Ten patients were initially treated for IBD, although patients had ITB. The main sites of ITB involvement were the ileocaecum (44%) or small bowel (34%). Five patients had isolated perianal disease. Colonoscopy confirmed a diagnosis of ITB in 77% of those performed. 42 of 61 patients had a diagnosis of ITB confirmed on positive histology and/or microbiology.

CONCLUSION

Diagnosis of ITB is often delayed, which may result in significant morbidity. ITB should be excluded in patients with abdominal complaints who come from TB-endemic areas to establish prompt diagnosis and treatment. Diagnosis is challenging but aided by axial imaging, colonoscopy and tissue biopsy for TB culture and histology.

Meta-Analytic Bayesian Model For Differentiating Intestinal Tuberculosis from Crohn's Disease

OBJECTIVES

Distinguishing intestinal tuberculosis (ITB) from Crohn's disease (CD) is difficult, although studies have reported clinical, endoscopic, imaging, and laboratory findings that help to differentiate these two diseases. We aimed to produce estimates of the predictive power of these findings and construct a comprehensive model to predict the probability of ITB vs. CD.

METHODS

A systematic literature search for studies differentiating ITB from CD was conducted in MEDLINE, PUBMED, and EMBASE from inception until September 2015. Fifty-five distinct meta-analyses were performed to estimate the odds ratio of each predictive finding. Estimates with a significant difference between CD and ITB and low to moderate heterogeneity (I²<50%) were incorporated into a Bayesian prediction model incorporating the local pretest probability.

RESULTS

Thirty-eight studies comprising 2,117 CD and 1,589 ITB patients were included in the analyses. Findings in the model that significantly favored CD included male gender, hematochezia, perianal disease, intestinal obstruction, and extraintestinal manifestations; endoscopic findings of longitudinal ulcers, cobblestone appearance, luminal stricture, mucosal bridge, and rectal involvement; pathological findings of focally enhanced colitis; and computed tomographic enterography (CTE) findings of asymmetrical wall thickening, intestinal wall stratification, comb sign, and fibrofatty proliferation. Findings that significantly favored ITB included fever, night sweats, lung involvement, and ascites; endoscopic findings of transverse ulcers, patulous ileocecal valve, and cecal involvement; pathological findings of confluent or submucosal granulomas, lymphocyte cuffing, and ulcers lined by histiocytes; a CTE finding of short segmental involvement; and a positive interferon-γ release assay. The model was validated by gender, clinical manifestations, endoscopic, and pathological findings in 49 patients (27 CD, 22 ITB). The sensitivity, specificity, and accuracy for diagnosis of ITB were 90.9%, 92.6%, and 91.8%, respectively.

CONCLUSIONS

A Bayesian model based on the meta-analytic results is presented to estimate the probability of ITB and CD calibrated to local prevalence. This model can be applied to patients using a publicly available web application.

Perforation of the Peptic Ulcer Localized in the Proximal Jejunum - Case Report

Non-traumatic perforation of the digestive tract occurs most often in the duodenum and stomach (peptic ulcer), as well as the colon (diverticulitis, cancer or ischemic lesions). Perforation of the small bowel is very rare. The Authors of the study presented a case of proximal jejunum perforation, which occurred in a patient with a history of duodenal peptic ulcer disease. Diagnosis posed no difficulties, and treatment included the excision of the ulceration and suturing of the bowel. The patient recovered without complications and the histological examination failed to reveal the nature of the ulcer. However, based on the medical history, one may suppose that it might be of peptic etiology, which makes this case exceptional.

Patients with perianal Crohn's disease have poor disease outcomes after primary bowel resection

BACKGROUND AND AIM

The presence of perianal disease in Crohn's disease patients is one of the factors of postoperative recurrence. The aim of this study is to evaluate long-term prognosis of perianal Crohn's disease patients in Asian.

METHODS

Patients with Crohn's disease who had undergone surgical bowel resection were divided into two groups according to the presence of perianal lesion. We monitored the occurrences of abdominal and/or perianal reoperation and readmission due to disease flare-up.

RESULTS

The 132 patients included in the study were divided into 2 groups, those with perianal disease (45 patients, 34.1%) and those without perianal disease (87 patients, 65.9%). Patients with perianal disease was younger in age (33.8 years versus 39.8 years, p = 0.015) and had been diagnosed as CD at a younger age (21.9 years versus 28.6 years, p = 0.005) than patients without perianal disease. Patients with perianal disease showed more extra-intestinal manifestation than patients without perianal disease (8 versus 3, p = 0.008). Reoperation was required in 46 (44.8%) patients during the follow-up period. The presence of perianal disease independently increased the risk of reoperation [hazard ratio (HR), 3.112; confidence interval (CI), 1.707-5.675]. Furthermore, patients with perianal disease had increasing risks of abdominal reoperation (HR 1.978; 95% CI, 1.034-3.784).

CONCLUSIONS

Patients with Crohn's disease and perianal lesions had a higher risk of reoperation. Considering these findings, physicians should consider aggressive and early top down therapy for patients with perianal Crohn's disease.

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.

Intraperitoneal tuberculous abscess: Computed tomography features

AIM: To evaluate the computed tomography (CT) features of intraperitoneal tuberculous abscess (IPTA).

METHODS: Eight patients with IPTA confirmed by pathology were analyzed retrospectively. The clinical symptoms, medical images, and surgical findings were evaluated. Involvement of the intestine, peritoneum, viscera, and lymph nodes was also assessed.

RESULTS: All 8 patients had a history of abdominal discomfort for 1 to 6 mo. Physical examination revealed a palpable abdominal mass in 6 patients. Three patients had no evidence of pulmonary tuberculosis (TB). All IPTAs (11 abscesses) were seen as a multiseptated, peripherally enhanced, hypodense mass with enlarged, rim-enhanced lymph nodes. The largest abscess diameter ranged from 4.5 cm to 12.2 cm. CT showed 2 types of IPTA: Lymph node fusion and encapsulation. Of the 8 patients, one had liver tuberculosis and one had splenic and ovarian tuberculosis. Two cases showed involvement of the terminal ileum and ileocecal junction. Ascites were found in 4 cases. Three patients had peritonitis and mesenteritis. Three patients showed involvement of the omentum. Three patients had histological evidence of caseating granuloma, and 5 had histological evidence of acid-fast bacilli.

CONCLUSION: CT is crucial in the detection and characterization of IPTA. Certain CT findings are necessary for correct diagnosis.