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

Intestinal lesions of 212 cases presenting with symptoms of intestinal obstruction were studied. Of these, 159 cases were diagnosed as tuberculosis and 10 as Crohn's disease. Forty-three cases could not be classified into any of these entities and are excluded from this account. The amount of chemotherapeutic drugs received by each patient preoperatively was recorded. Cases proved as tuberculosis at the first operation were put on antituberculosis chemotherapy. Thirteen of these cases were operated on a second time, and tissue reactions under the influence of chemotherapy were studied. Fresh diseased tissue was studied for acid-fast organisms by culture and animal inoculation.Morphological features of the tuberculosis group are described in detail. Although the cases were broadly classified into the ulcerative and ulcerohypertrophic varieties, a distinction was not always sharp and the two types of lesions were at times found to coexist. The macroscopic features presented a very wide range, and at times distinction from Crohn's disease, especially in the ulcerohypertrophic variety, was difficult. Microscopically, however, they could be distinguished without much difficulty. Caseation, although a characteristic feature of tuberculous granulomas may, albeit rarely, be absent. Granulomas which are characteristically confluent may be present only in the mesenteric lymph nodes. Acid-fast organisms are not grown consistently from diseased tissues; where grown, they are of human type. Reparative changes during chemotherapy are described in detail; these follow a non-specific pattern. In the group of Crohn's disease, transmural cracks and fissures were consistently observed in all cases. Distinguishing features between the two diseases are discussed in detail.

Colonoscopic study of 50 patients with colonic tuberculosis

Fifty patients with colonic tuberculosis are reported in whom a colonoscopic diagnosis confirmed by histological examination was possible in 40. Bacteriological studies did not increase the diagnostic yield. Abdominal pain was the most common symptom (90%) and an abdominal mass the most common abnormal physical finding (58%). A nodular mucosa with areas of ulceration was the usual colonoscopic finding. Ileocaecal disease was found in 16, ileocaecal and contiguous ascending colon disease in 14, segmental colonic tuberculosis in 13, ileocaecal disease and non-confluent involvement of another part of the colon in five, and pancolitis in two patients. This report emphasises that colonoscopy is a useful procedure for diagnosing colonic tuberculosis and that segmental colonic tuberculosis is not uncommon.

Differentiating Crohn’s disease from intestinal tuberculosis

Differentiating Crohn’s disease (CD) and intestinal tuberculosis (ITB) has remained a dilemma for most of the clinicians in the developing world, which are endemic for ITB, and where the disease burden of inflammatory bowel disease is on the rise. Although, there are certain clinical (diarrhea/hematochezia/perianal disease common in CD; fever/night sweats common in ITB), endoscopic (longitudinal/aphthous ulcers common in CD; transverse ulcers/patulous ileocaecal valve common in ITB), histologic (caseating/confluent/large granuloma common in ITB; microgranuloma common in CD), microbiologic (positive stain/culture for acid fast-bacillus in ITB), radiologic (long segment involvement/comb sign/skip lesions common in CD; necrotic lymph node/contiguous ileocaecal involvement common in ITB), and serologic differences between CD and ITB, the only exclusive features are caseation necrosis on biopsy, positive smear for acid-fast bacillus (AFB) and/or AFB culture, and necrotic lymph node on cross-sectional imaging in ITB. However, these exclusive features are limited by poor sensitivity, and this has led to the development of multiple multi-parametric predictive models. These models are also limited by complex formulae, small sample size and lack of validation across other populations. Several new parameters have come up including the latest Bayesian meta-analysis, enumeration of peripheral blood T-regulatory cells, and updated computed tomography based predictive score. However, therapeutic anti-tubercular therapy (ATT) trial, and subsequent clinical and endoscopic response to ATT is still required in a significant proportion of patients to establish the diagnosis. Therapeutic ATT trial is associated with a delay in the diagnosis of CD, and there is a need for better modalities for improved differentiation and reduction in the need for ATT trial.

Electron microscopy of the intestine and rectum in acquired immunodeficiency syndrome

To provide a better understanding of the morphologic changes that take place in the intestine and colon in acquired immunodeficiency syndrome (AIDS), electron microscopy was performed on intestinal or colonic biopsy specimens obtained from 6 patients with AIDS and from 2 patients with AIDS-related lymphadenopathy syndrome. Cryptosporidia were attached to the plasma membrane of epithelial cells in 2 patients and were noninvasive. An invasive protozoan organism identified as Microsporidia was found in 1 patient. Evidence for epithelial cell injury was limited. Unusually prominent secretory granules in colonic epithelial cells (a morphologic counterpart of secretion) was found in 2 patients. Tubuloreticular structures were observed in 7 patients. The structures were found in endothelial cells, lymphocytes, monocytes, intraepithelial lymphocytes, and free in the capillary lumen. Tube- and ring-shaped forms were observed in 2 patients, prominent intraepithelial mast cells in 4 patients, rectal spirochetosis in 1 patient, and pseudomembranous colitis in 1 patient with intestinal and systemic shigellosis. Vesicular rosettes, retroviruses, other viruses, and Mycobacterium avium-intracellulare were not observed. These observations expand our knowledge of morphologic changes in the colonic and intestinal mucosa in patients with AIDS. Tubuloreticular structures are so prominent, in contrast to our previous electron-microscopic observations in other disease and normal states of the intestine and colon, that their finding (though clearly nonspecific) may be a clue to the diagnosis of AIDS in an otherwise equivocal situation.

Diagnostic dilemma of abdominal tuberculosis in non-HIV patients: An ongoing challenge for physicians

AIM: To assess the clinical features, yield of the diagnostic tests and outcome of abdominal tuberculosis in non-HIV patients.

METHODS: Adult patients with discharge diagnosis of abdominal tuberculosis (based upon; positive microbiology, histo-pathology, imaging or response to trial of anti TB drugs) during the period 1999 to 2004 were analyzed. Patient’s characteristics, laboratory investigations, radiological, endoscopic and surgical findings were evaluated. Abdominal site involved (intestinal, peritoneal, visceral, and nodal) and response to treatment was also noted.

RESULTS: There were 209 patients enrolled. One hundred and twenty-three (59%) were females. Symptoms were abdominal pain 194 (93%), fever 134 (64%), night sweats 99 (48%), weight loss 98 (47%), vomiting 75 (36%), ascites 74 (35%), constipation 64 (31%), and diarrhea 25 (12%). Sub-acute and acute intestinal obstruction was seen in 28 (13%) and 12 (11%) respectively. Radiological evidence of pulmonary tuberculosis was found in 134 (64%) patients. Basis of diagnosis of abdominal tuberculosis were radiology (Chest and barium X-Rays, Ultrasound and CT scan abdomen) in 111 (53%) and histo-pathology (tissue obtained during surgery, colonoscopy, CT or ultrasound guided biopsy, laparoscopy and upper gastro intestinal endoscopy) in 87 (42%) patients. Mycobacterium culture was positive in 6/87 (7%) patients and response to therapeutic trial of anti tubercular drugs was the basis of diagnosis in 5 (2.3%) patients. Predominant site of involvement by abdominal TB was intestinal in 103 (49%) patients, peritoneal in 87 (42%) patients, solid viscera in 10 (5%) and nodal in 9 (4%) patients. Response to medical treatment was found in 158 (76%) patients and additionally 35 (17%) patients also underwent surgery. In a 425 ± 120 d follow-up period 12 patients died (eight post operative) and no case of relapse was noted.

CONCLUSION: Abdominal TB has diverse and non- specific symptomatology. No single test is adequate for diagnosis of abdominal tuberculosis in all patients. Abdominal TB in non-HIV patients remains an ongoing diagnostic dilemma requiring a high index of clinical suspicion.

Abdominal tuberculosis in urban Britain--a common disease

Between 1973 and 1983 abdominal tuberculosis was responsible for the admission of 90 patients to a west London district general hospital. Over the same period Crohn's disease was newly diagnosed in 102 hospitalised patients. In contrast with Crohn's disease, the majority (75) of tuberculous patients were Asian immigrants. Mean duration of residence in the United Kingdom was 4 +/- 0.9 (SD) years, and mean age at presentation was 34.9 +/- 1.1 years. Forty per cent of tuberculosis patients presented as an acute emergency to physicians, surgeons, or gynaecologists while the remainder presented a more insidious, chronic picture. Five groups of tuberculous patients were recognised. Forty two subjects had intestinal tuberculosis characterised by pain (100%), abdominal mass (43%) and abnormal contrast radiology (100%). Ten of these underwent emergency laparotomy for intestinal obstruction or perforation. Twenty seven patients had tuberculous peritonitis although only 16 had ascites. Eight patients presented with pyrexia and granulomatous hepatitis. Five had pulmonary and abdominal tuberculosis. The remaining eight patients represented a miscellaneous group. The diagnosis of abdominal tuberculosis was established histologically (60 cases), bacteriologically (six cases) or radiologically (24 cases). Chest radiograph, tuberculin skin testing and paracentesis were usually unhelpful. Five severely ill patients died. The remainder recovered completely after specific triple chemotherapy and response to treatment was usually evident within 14 days. In urban Britain tuberculosis is an important cause of abdominal disease. Prognosis is excellent following specific therapy.

Endoscopic mucosal biopsies are useful in distinguishing granulomatous colitis due to Crohn's disease from tuberculosis

BACKGROUND

Intestinal tuberculosis and Crohn's disease are chronic granulomatous disorders that are difficult to differentiate histologically.

AIMS

To characterise distinctive diagnostic features of tuberculosis and Crohn's disease in mucosal biopsy specimens obtained at colonoscopy.

METHODS

Selected histological parameters were evaluated retrospectively in a total of 61 biopsy sites from 20 patients with tuberculosis and 112 biopsy sites from 20 patients with Crohn's disease. The patients were chosen on the basis of clinical history, colonoscopic findings, diagnostic histology, and response to treatment.

RESULTS

The histological parameters characteristic of tuberculosis were multiple (mean number of granulomas per section: 5.35), large (mean widest diameter: 193 microm), confluent granulomas often with caseating necrosis. Other features were ulcers lined by conglomerate epithelioid histiocytes and disproportionate submucosal inflammation. The features characteristic of Crohn's disease were infrequent (mean number of granulomas per section: 0.75), small (mean widest diameter: 95 microm) granulomas, microgranulomas (defined as poorly organised collections of epithelioid histiocytes), focally enhanced colitis, and a high prevalence of chronic inflammation, even in endoscopically normal appearing areas.

CONCLUSIONS

The type and frequency of granulomas, presence or absence of ulcers lined by epithelioid histiocytes and microgranulomas, and the distribution of chronic inflammation have been identified as histological parameters that can be used to differentiate tuberculosis and Crohn's disease in mucosal biopsy specimens obtained at colonoscopy.

Role of colonoscopic biopsy in distinguishing between Crohn's disease and intestinal tuberculosis

BACKGROUND

The histological differential diagnosis of Crohn's disease and intestinal tuberculosis can be very challenging, as both are chronic granulomatous disorders with overlapping histological features.

AIM

To evaluate selected clinical and histological parameters in colonic biopsy specimens for their ability to discriminate between Crohn's disease and intestinal tuberculosis.

METHODS

25 patients with Crohn's disease and 18 patients with intestinal tuberculosis were selected for this study on the basis of established clinical, radiological and histological criteria. Clinical data and selected histological parameters in colonoscopic biopsy specimens were assessed retrospectively. A total of 103 and 41 biopsy sites were evaluated in patients with Crohn's disease and intestinal tuberculosis, respectively.

RESULTS

Clinical parameters helpful in differentiating intestinal tuberculosis from Crohn's disease included chest radiographic features of tuberculosis (56% v 0%), perianal fistulae (0% v 40%) and extraintestinal manifestations of Crohn's disease (0% v 40%). Histopathological features that seemed to reliably differentiate between intestinal tuberculosis and Crohn's disease included confluent granulomas, > or =10 granulomas per biopsy site and caseous necrosis (in biopsy samples of 50%, 33% and 22% of patients with intestinal tuberculosis, respectively, v 0% of patients with Crohn's disease). Features that were observed more often in patients with intestinal tuberculosis than in those with Crohn's disease included granulomas exceeding 0.05 mm(2) (67% v 8%), ulcers lined by conglomerate epithelioid histiocytes (61% v 8%) and disproportionate submucosal inflammation (67% v 10%).

CONCLUSION

Clinical features and selected histological parameters in colonoscopic biopsy specimens can help in differentiating between Crohn's disease and intestinal tuberculosis.

Segmental colonoscopic biopsies in the differentiation of ileocolic tuberculosis from Crohn's disease

BACKGROUND AND AIM

The differentiation between Crohn's disease (CD) and tuberculosis (TB) of the intestine can be difficult in areas where both diseases occur. The present study examined histological criteria that would enable the diagnosis in mucosal biopsies.

METHODS

Colonoscopic biopsies from 33 patients with TB and 31 patients with CD were examined for several specific histological features and their distribution.

RESULTS

The salient distinguishing features of TB were granulomas larger than 400 microm in maximum dimension, more than four sites of granulomatous inflammation per site, cessation, a band of epithelioid histiocytes in ulcer bases and location of granulomas in the caecum. The salient features of CD were granulomas not showing any of the above features, focally enhanced colitis, pericryptal granulomatous inflammation, and the presence of architectural alteration/activity/chronic inflammation/deep ulceration at sites that did not show granulomatous response in the same or adjacent segments. Although granulomas in CD were distributed throughout the colon, they were more frequent in the rectosigmoid than in TB. All biopsies from endoscopically abnormal sites did not show distinguishing features of TB or CD, emphasizing the need for multiple biopsies. There was an accrual in the number of diagnoses made with increasing numbers of biopsies from rectum to ileum.

CONCLUSIONS

Histology of mucosal biopsies can aid in the differentiation of TB from CD, but multiple biopsies from different colonic segments are important for complete evaluation.

Intestinal infection with Mycobacterium avium in acquired immune deficiency syndrome (AIDS). Histological and clinical comparison with Whipple's disease

At endoscopy, a 30-year-old man with acquired immune deficiency syndrome (AIDS), Kaposi's sarcoma, diarrhea, and unexplained malabsorption showed erythematous macular duodenal lesions consistent with Whipple's disease by histology and electron microscopy. Symptoms did not respond to tetracycline. Subsequent cultures revealed systemic Mycobacterium avium (M. avium) infection. Tissue from this patient, from patients with Whipple's disease and from a macaque with M. avium were compared. All contained PAS-positive macrophages but M. avium could be distinguished by positive acid-fast stains and a difference in pattern of indirect immunofluorescence staining with bacterial typing antisera. PAS-positive macrophages in the intestinal lamina propria are no longer pathognomonic of Whipple's disease. Ultrastructural and histological similarities between Whipple's disease and M. avium infection suggest that both are manifestations of immune deficits limiting macrophage destruction of particular bacteria after phagocytosis. M. avium must be considered in the differential diagnosis of diarrhea in patients with AIDS and other immunosuppressed conditions.

Diagnosis of ileocecal and colonic tuberculosis by colonoscopy

The colonoscopic findings in 11 proven cases of ileocecal tuberculosis consisted of deformed ileocecal valve in all 11 and contracted cecal lumen in 10. This was associated with mucosal nodules predominantly around the ileocecal valve, pseudopolypoid folds, and mucosal protuberance. Two patients had an isolated cecal ulcer. In three of the 11 patients the examination enabled a histologic diagnosis to be made on the basis of typical granuloma. In the other four patients Mycobacterium tuberculosis was isolated from the tissue obtained through biopsies.

Intestinal tuberculosis: clinicopathologic analysis and diagnosis by endoscopic biopsy

OBJECTIVES

Tuberculosis is still an important cause of granulomatous colitis in developing countries. If we can diagnose tuberculosis using endoscopic biopsy material, clinicians can avoid invasive diagnostic procedures and needless operations. For this purpose, we evaluated clinical manifestations, pathological findings, and diagnostic methods in endoscopically biopsied intestinal tuberculosis patients.

METHODS

From January 1991 to December 1996, 42 patients with intestinal tuberculosis were endoscopically examined and tissue culture, immunohistochemical stain, Ziehl-Neelsen stain, and polymerase chain reaction in fresh and fixed tissue were applied. The pathological findings were analyzed and compared with the results of the other diagnostic methods.

RESULTS

In tuberculosis patients, transverse ulcers with surrounding hypertrophic mucosa and multiple erosions were usual colonoscopic findings. The granulomas were found in 74% of the cases. The positivity ranged from 30-45%. There were no significant differences in the positivity among those diagnostic methods (p > 0.05). The positivity of Ziehl-Neelsen stain in fixed tissue was higher in the group having granulomas and it was reversed in PCR (p < 0.05). The increasing number of biopsy particles raised the positivity of Ziehl-Neelsen stain and PCR in fixed tissue (p < 0.05).

CONCLUSIONS

Transverse ulcers were the most characteristic colonoscopic finding and granulomas were frequent pathological findings in intestinal tuberculosis. Higher positivity and reliable results were found in tissue culture, Ziehl-Neelsen stain, and polymerase chain reaction. To increase the diagnostic rate, the endoscopist should take enough tissue and deep biopsy material from ulcer bases and diseased mucosae.

Clinical, colonoscopic, and histological profile of colonic tuberculosis in a tertiary hospital

BACKGROUND AND STUDY AIMS

Colonic tuberculosis is not uncommon in developing countries. As emigration to the West increases, it is worthwhile to recall the clinical, colonoscopic, and histopathological features of this condition.

PATIENTS AND METHODS

The clinical, colonoscopic and histopathological findings were evaluated in 43 patients with colonic tuberculosis.

RESULTS

Abdominal pain, weight loss, diarrhea, fever, and a lump in the abdomen were the commonest symptoms. Extraintestinal tuberculosis was present in 11 patients (26 %). Colonoscopy revealed ulcers in 30 patients (70 %), nodules in 24 (56 %), a deformed cecum and ileocecal valve in 17 (40 %), strictures in 10 (23 %), polypoid lesions in six (14 %), and fibrous bands forming mucosal bridges in three (7 %). The cecum and ascending colon were the commonest sites involved. Segmental tuberculosis was seen in six of the 32 patients (19 %) in whom full-length colonoscopy could be performed. Two or more sites were involved in 19 patients (44 %). Histopathology revealed well-formed granulomas in 23 patients (54 %). Fourteen of the above patients (61 %) had caseation and 11 (48 %) had confluence of the granulomas. Acid-fast bacilli were present in the biopsies from two patients (5 %). Ill-formed granulomas were seen in seven patients (16 %) and chronic inflammatory changes in 13 (30 %). Despite the various histopathological findings, all of the patients responded to antitubercular treatment and continued to remain asymptomatic during the follow-up period.

CONCLUSIONS

Colonoscopy with biopsy is a useful method for diagnosing colonic tuberculosis. Even in the absence of the classic histopathological features, a therapeutic trial may be indicated in a given clinical and colonoscopic setting. Follow-up is essential.

Pathology of tropical appendicitis

Over the past 25 years, 2921 appendicectomies were performed at this hospital. All were subjected to routine histopathological examination. In 95% of cases, histopathological examination did not add any further information but in 153 (5%) cases, clinically important pathological findings were detected for the first time. Seventy (2.3%) specimens showed typical evidence of tuberculosis. Parasitic infestation was detected in 75 (2.5%), including enterobiasis (1.4%), amoebiasis (0.5%), ascariasis (0.5%), ascariasis with trichuriasis (0.05%), and taeniasis (0.05%). Other lesions found were mucocele (0.1%) and carcinoid tumour (0.1%). It is concluded that routine histopathological examination of all appendicectomy specimens should be performed to avoid missing any clinically important and treatable condition.

Active tuberculosis unrecognised until necropsy

12 of the 24 cases of active tuberculosis which came to necropsy in Dundee hospitals from 1968 to 1975 were diagnosed after death. The overall distribution of anatomical types was similar to that in previous surveys, but in those diagnosed at necropsy there was an excess of psoas abscess and miliary, colonic, and adrenal lesions. Class-IV patients and a history of steroid therapy were also more common in cases diagnosed at necropsy. None of these differences is statistically significant.

The CT features of abdominal tuberculosis in children

BACKGROUND

The last decade has seen a resurgence in the incidence and clinical presentation of tuberculosis (TB). Little data exist in the paediatric age group regarding abdominal tuberculosis (ATB) and limited reports of its CT features have been published.

PURPOSE

To elucidate the CT features of ATB in children.

MATERIALS AND METHODS

The medical records of 22 patients with ATB were reviewed. Data were extracted regarding the methods of diagnosis and HIV status. The plain chest films were examined and the CT scans were assessed for adenopathy, solid organ involvement, ascites, bowel wall and omental thickening and inflammatory masses.

RESULTS

Ten patients had biopsy-proven ATB, 11 had extra-abdominal TB with clinical suspicion of ATB and 1 had a positive trial of therapy. Five patients were tested for HIV and one tested positive. Thirteen patients had abnormal chest radiographs. The commonest CT finding was lymphadenopathy ( n=17), followed by solid organ involvement ( n=12), ascites ( n=5), bowel wall thickening ( n=5), inflammatory masses ( n=2) and omental thickening ( n=1).

CONCLUSIONS

The clinical features of ATB are protean. This usually results in a delay in diagnosis and impacts negatively on patient morbidity and mortality. On CT, the constellation of findings is highly suggestive of the diagnosis of ATB and, used in conjunction with clinical and laboratory data, should narrow the differential considerably. Unique findings include histologically proven active TB in calcified lymph nodes and a pancreatic TB granuloma.

Gastric tuberculosis: a manifestation of acquired immunodeficiency syndrome

A Haitian man with acquired immunodeficiency syndrome (AIDS), fever, malaise, and diarrhea is described. A computed tomographic (CT) scan showed a retrogastric mass with an associated ulcer. An upper gastrointestinal tract study showed an ulcer with both benign and malignant features. Endoscopy revealed a malignant-appearing ulcer, but cultures and histologic examinations of surgical biopsy specimens indicated gastric tuberculosis. The relationship between tuberculosis and AIDS is discussed.

Intestinal tuberculosis: experience at a Canadian teaching institution

Thirteen cases of inflammatory bowel disease suspected to be intestinal tuberculosis are analyzed. In nine, the diagnosis was established from such criteria as caseation necrosis, positive acid-fast stains or cultures of the diseased tissue. In four others, enteric tuberculosis remained a diagnostic possibility as judged by the following criteria: coexistence of the bowel lesion with established tuberculosis elsewhere, a clear response to antituberculous chemotherapy, or typical features on roentgenographic, surgical or histologic examination. The patients with intestinal tuberculosis were not necessarily recent immigrants or poor, nor did they have coexistent active pulmonary disease. Although most exhibited classic features of intestinal tuberculosis, the diagnosis was rarely considered at first. A greater awareness of the entity is needed to avoid confusion between intestinal tuberculosis and Crohn's disease.

Intestinal tuberculosis with abdominal complications: radiologic and pathologic features

BACKGROUND

To investigate radiologic and pathological features of intestinal tuberculosis with abdominal complications.

METHODS

Twenty-two patients with 23 surgically proven complications (nine intestinal obstructions, eight perforations, three fistulae, and three intestinal bleeds) were analyzed. Medical records, radiologic studies, and pathologic examinations were reviewed with special emphasis on searching for the common features in each group of complication.

RESULTS

The most important single feature in seven of the nine patients with intestinal obstruction was the presence of stricture. In the remaining two patients, bowel adhesion was a primary cause of obstruction. In eight patients with intestinal perforation, both obstruction and ulcerations in the dilated proximal loop were the important features in six, and multiple deep ulcerations without obstruction was a primary cause in the remaining two. The common features in three patients with fistulae were focal or multiple strictures, severe adhesions, and fibrotic bowel wall. Intestinal bleeding originated from diffuse mucosal ulcerations. The abdominal complications occurred during antituberculous therapy in 10 of the 22 patients.

CONCLUSION

Understanding the radiologic and pathologic features of intestinal tuberculosis with complications help in making an appropriate clinical decision for the treatment strategy. Close observation is necessary, especially in those patients who are acutely ill during antituberculous medical therapy. Enteritis-Intestines, diseases-Intestines, infection-Intestines, perforation-Intestines, stenosis or obstruction.

Ultrasound guided fine needle aspiration cytology in abdominal tuberculosis

Although barium studies and CT are useful in assessing abdominal pathology in tuberculosis, imaging findings are not always specific and a histopathological or bacteriological confirmation is often required. The aim of the present study was to evaluate the role of ultrasound (US) guided fine needle aspiration cytology (FNAC) in the diagnosis of abdominal tuberculosis in patients with non-palpable lesions detected on US/CT. FNAC was performed on 31 sites in 30 patients. The sites included enlarged lymph nodes (n = 14), focal lesions in liver (n = 2) and spleen (n = 8), and thickened bowel in the ileocaecal region (n = 7). The results were classified cytomorphologically into four groups: (1) definite evidence of tuberculosis; (2) presumptive evidence of tuberculosis; (3) suggestive of tuberculosis; and (4) negative for tuberculosis. 18 of the 31 FNACs (58%) revealed a positive diagnosis of tuberculosis (definite evidence in nine patients and presumptive evidence in nine patients). 13 of the 31 FNACs (42%) showed either necrosis alone (n = 4) or negative results (n = 9). Zeihl-Neelson staining for acid-fast bacilli on direct smear was positive in only nine patients (29%). Splenic and lymph nodal FNAC had a high sensitivity (87.5% and 78.6%, respectively) in the diagnosis of tuberculosis. None of the bowel and liver FNACs was diagnostic. No complications were encountered. US guided FNAC offers a safe and accurate method of achieving a diagnosis in patients with suspected abdominal tuberculosis who present with radiologically demonstrable but non-palpable lesions, especially those involving lymph nodes and spleen.

Gastrointestinal tract tuberculosis: a study of 102 cases including 55 hemicolectomies

Tuberculosis continues to be a major health problem in India. Our experience of 102 cases of gastrointestinal tract tuberculosis is presented. Eighty-one of these patients experienced obstructive symptoms, 62 had radiographic evidence of intestinal obstruction, and four had bowel perforation. Lymphadenopathy was present in 16 patients and pulmonary tuberculosis in 28. The commonest sites of bowel involvement were ileo-caecal, ileum and ascending colon. Duodenal lesions were seen in three cases and in another three there was isolated appendicular involvement. Right hemicolectomy was necessary in 55 of the 74 patients who had surgical exploration. Histopathological reports were available in 88 subjects. The various radiographic manifestations of tuberculosis of the bowel are discussed. Radiologically and sometimes even on histopathology, differentiation of ileo-caecal tuberculosis from Crohn's ileo-colitis may prove impossible.

Intestinal tuberculosis

Intestinal tuberculosis is a disease with protective clinical manifestations. The radiographic changes in the bowel are similarly varied but often highly suggestive if not characteristic. The key radiologic changes in the bowel, with emphasis on the ileocecal area, are described and the clinical and pathologic features are reviewed.

Predictors of clinical and endoscopic findings in differentiating Crohn's disease from intestinal tuberculosis

BACKGROUND

There are many similarities and overlaps in clinical manifestations and ileocolonoscopic features between Crohn's disease (CD) and intestinal tuberculosis (ITB). Differentiation between CD and ITB is of great importance.

AIM

To investigate the values of clinical and endoscopic findings in differential diagnosis between CD and ITB.

METHODS

Clinical and endoscopic features of a cohort of 130 cases of CD and 122 cases of ITB from June 2003 to February 2009 were retrospectively reviewed following predetermined criteria. Parameters were screened by logistic regression analysis. Furthermore, the diagnostic efficacy of screened parameters was analyzed by regression equation (mathematical model) and receiver operating characteristic curve (ROC curve).

RESULTS

The clinical features helpful in differentiating CD from ITB are hematochezia, intestinal surgery, perianal diseases, pulmonary tuberculosis, ascites, and positive of PPD skin test; the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by clinical features were 90.3, 76.8, 83.8, 80.7, and 88.0%, respectively. The endoscopic features helpful in differentiating CD from ITB were rectum involved lesions, longitudinal ulcer, cobblestone appearance, fixed-open ileocecal valve, transverse ulcer, and rodent ulcer; the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by endoscopic features were 82.9, 82.0, 82.5, 82.9, and 82.0%, respectively.

CONCLUSIONS

It was proposed that a diagnostic algorithm based on available clinical and endoscopic regression equation could improve the current sensitivity, specificity, and accuracy in differentiating between CD from ITB.

Does Crohn's disease need differentiation from tuberculosis?

Crohn's disease (CD) and tuberculosis (TB) of the gastrointestinal tract pose major diagnostic problems for clinicians where these conditions coexist. Clinically and radiologically, the diseases are similar. In the West, TB is considered in the differential diagnosis of all suspected cases of CD, particularly among Asian migrants. Earlier age of presentation, perianal disease and enteric fistulae favour a diagnosis of CD. Aphthoid ulceration, pseudopolyps and filiform mucosa at endoscopy are suggestive of CD and a negative tuberculin test us useful. The final diagnosis depends largely on histopathology and the presence or absence of acid fast bacilli. Tuberculosis is more common in developing countries and intestinal TB frequently coexists with pulmonary tuberculosis. TB is known to affect all age groups and fistulous communication, although uncommon, does occur. In addition to radiology and endoscopy, laparotomy may be required to establish the diagnosis. In developing countries, CD is uncommon and remains largely a diagnosis of exclusion. A trial of anti-tuberculosis therapy may often be prescribed before definitely diagnosing CD. The development of molecular biology techniques had led to a revival of interest in mycobacteria as a possible aetiological agent in CD. DNA from Mycobacterium paratuberculosis and Mycobacterium kansaii have both been identified in CD cases but the significance of this finding has not been established. However, in the near future polymerase chain reaction will become increasingly useful in differentiating CD from intestinal TB because it allows the amplification and identification of very small quantities of mycobacterium DNA.