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Deka UJ, Sarkar R, Dasgupta JK, Bhattacharyya A, Ray S, Basu K, Dhali GK, Das K. Endoscopic Monitoring of Treatment of Indeterminate Intestinal Lesions in a Prospective "Real-Life" Cohort in Eastern India Where Tuberculosis Remains Endemic: Distinguishing Intestinal Tuberculosis From Crohn's Disease. Cureus 2024; 16:e75663. [PMID: 39677998 PMCID: PMC11642180 DOI: 10.7759/cureus.75663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2024] [Indexed: 12/17/2024] Open
Abstract
Introduction It is sometimes difficult to differentiate between intestinal tuberculosis (ITB) and Crohn's disease (CD) in India, as both conditions may mimic each other. The aim was to differentiate ITB from CD in indeterminate intestinal lesions with a therapeutic trial of anti-tubercular therapy (ATT) and follow-up to find out the clinical, endoscopic, radiological, and histological predictors for differentiation between ITB and CD. Methods A prospective observational cohort study of patients diagnosed with ITB and CD according to the Asia-Pacific Guidelines in a "real-life" clinical setting was conducted. ITB was diagnosed by Paustian criteria with Logan's modification. CD was diagnosed according to European Crohn's and Colitis Organization (ECCO) guidelines. We put the patients with a definite diagnosis of ITB and those with an indeterminate diagnosis on ATT and followed them up clinically, endoscopically, and radiologically. Patients were reassessed clinically, endoscopically, and histologically eight weeks after the start of therapy. They were again evaluated endoscopically and radiologically after completion of six months of ATT. The CD patients continued anti-inflammatory, immunomodulator, biological, and/or steroid treatments. Results We conducted this prospective study on consecutive Indian patients who had 21 definite diagnoses of ITB, 26 definite diagnoses of CD, and 42 indeterminate diagnoses. We diagnosed 49 with ITB and 28 (57%) after a therapeutic trial. Ultimately, 40 patients received a CD diagnosis, with 14 (35%) not responding to the ATT therapeutic trial. In patients with ITB, symptomatic improvement after eight weeks of ATT is correlated with endoscopic healing, especially for ulcers but not necessarily for nodularity or strictures. In 50% of these patients, minimal nodularity/pseudopolypii as well as residual scarring was seen on endoscopy even after completion of therapy. Strictures in ITB patients persisted on endoscopy in 40% despite six months of ATT. GI bleeding (64% vs. 10%; p < 0.0001), chronic diarrhea (71% vs. 35%; P = 0.02), fistula or sinuses (21% vs. 0%; p < 0.01), and multiple site involvement of the intestine (73% vs. 6%; p < 0.0001) were significantly more common in CD than in patients with ITB. Fever (82% vs. 50%; p < 0.01) and positive tuberculin tests were more common in ITB patients. PCR positivity and the presence of AFB in smear and culture could be demonstrated in only a small percentage of ITB patients. Conclusion Therapeutic trials in indeterminate intestinal lesions can distinguish ITB from CD without significant adverse effects. Strictures in patients with ITB do not resolve in all patients. GI bleeding, chronic diarrhea, fistulas or sinuses, multiple sites of involvement, and fever have the highest accuracy in differentiating ITB from CD.
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Affiliation(s)
| | - Rajib Sarkar
- Gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, IND
| | - Jayanta Kumar Dasgupta
- Gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, IND
| | - Avik Bhattacharyya
- Radiology, Institute of Postgraduate Medical Education and Research, Kolkata, IND
| | - Sukanta Ray
- Surgical Gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, IND
| | - Keya Basu
- Oncopathology, Institute of Post Graduate Medical Education and Research, Kolkata, IND
| | - Gopal K Dhali
- Gastroenterology, Institute of Post Graduate Medical Education and Research, Kolkata, IND
| | - Kshaunish Das
- Gastroenterology, Institute of Post Graduate Medical Education and Research, Kolkata, IND
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Koulali H, Azzmouri S, Tajir M, Zerrouki K, Haloui A, Elmqaddem O, Zazour A, Ismaili Z, Kharrasse G. Granulomatous Colitis Due to Hermansky-Pudlak Syndrome. ACG Case Rep J 2024; 11:e01477. [PMID: 39493955 PMCID: PMC11527421 DOI: 10.14309/crj.0000000000001477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 06/28/2024] [Indexed: 11/05/2024] Open
Abstract
Hermansky-Pudlak syndrome (HPS) is a rare genetic disorder characterized by oculocutaneous albinism, bleeding diathesis, and multiorgan involvement. Granulomatous enterocolitis may occur in a subset of patients. Distinguishing HPS from other diseases such as Crohn's disease can be challenging, and managing HPS-associated colitis is complex. Recent reports suggest potential efficacy of infliximab in treating HPS-related granulomatous colitis. Here, we document the case of a 27-year-old patient with genetically confirmed HPS type 1, presenting with granulomatous colitis and successfully treated with corticosteroids and infliximab.
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Affiliation(s)
- Hajar Koulali
- Department of Hepato-Gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
- Digestive Diseases Research Laboratory (DSRL), Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Samira Azzmouri
- Department of Hepato-Gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
- Digestive Diseases Research Laboratory (DSRL), Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Mariam Tajir
- Laboratoire de Génétique Médicale, Laboratoire Central, Centre Hospitalo-Universitaire Mohammed VI, Faculté de Médecine et de Pharmacie d’Oujda, Université Mohammed Premier, Oujda, Morocco
| | - Khawla Zerrouki
- Laboratoire de Génétique Médicale, Laboratoire Central, Centre Hospitalo-Universitaire Mohammed VI, Faculté de Médecine et de Pharmacie d’Oujda, Université Mohammed Premier, Oujda, Morocco
| | - Anass Haloui
- Department of Pathology, Mohammed VI University Hospital/Faculty of Medicine, Mohammed 1st University, Oujda, Morocco
| | - Ouiam Elmqaddem
- Department of Hepato-Gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
- Digestive Diseases Research Laboratory (DSRL), Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Abdelkrim Zazour
- Department of Hepato-Gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
- Digestive Diseases Research Laboratory (DSRL), Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Zahi Ismaili
- Department of Hepato-Gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
- Digestive Diseases Research Laboratory (DSRL), Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
| | - Ghizlane Kharrasse
- Department of Hepato-Gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
- Digestive Diseases Research Laboratory (DSRL), Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, Morocco
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Cheng M, Zhang H, Huang W, Li F, Gao J. Deep Learning Radiomics Analysis of CT Imaging for Differentiating Between Crohn's Disease and Intestinal Tuberculosis. JOURNAL OF IMAGING INFORMATICS IN MEDICINE 2024; 37:1516-1528. [PMID: 38424279 PMCID: PMC11300798 DOI: 10.1007/s10278-024-01059-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/17/2024] [Accepted: 02/21/2024] [Indexed: 03/02/2024]
Abstract
This study aimed to develop and evaluate a CT-based deep learning radiomics model for differentiating between Crohn's disease (CD) and intestinal tuberculosis (ITB). A total of 330 patients with pathologically confirmed as CD or ITB from the First Affiliated Hospital of Zhengzhou University were divided into the validation dataset one (CD: 167; ITB: 57) and validation dataset two (CD: 78; ITB: 28). Based on the validation dataset one, the synthetic minority oversampling technique (SMOTE) was adopted to create balanced dataset as training data for feature selection and model construction. The handcrafted and deep learning (DL) radiomics features were extracted from the arterial and venous phases images, respectively. The interobserver consistency analysis, Spearman's correlation, univariate analysis, and the least absolute shrinkage and selection operator (LASSO) regression were used to select features. Based on extracted multi-phase radiomics features, six logistic regression models were finally constructed. The diagnostic performances of different models were compared using ROC analysis and Delong test. The arterial-venous combined deep learning radiomics model for differentiating between CD and ITB showed a high prediction quality with AUCs of 0.885, 0.877, and 0.800 in SMOTE dataset, validation dataset one, and validation dataset two, respectively. Moreover, the deep learning radiomics model outperformed the handcrafted radiomics model in same phase images. In validation dataset one, the Delong test results indicated that there was a significant difference in the AUC of the arterial models (p = 0.037), while not in venous and arterial-venous combined models (p = 0.398 and p = 0.265) as comparing deep learning radiomics models and handcrafted radiomics models. In our study, the arterial-venous combined model based on deep learning radiomics analysis exhibited good performance in differentiating between CD and ITB.
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Affiliation(s)
- Ming Cheng
- Department of Medical Information, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
- Henan Key Laboratory of Image Diagnosis and Treatment for Digestive System Tumor, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
| | - Hanyue Zhang
- Henan Key Laboratory of Image Diagnosis and Treatment for Digestive System Tumor, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Wenpeng Huang
- Department of Nuclear Medicine, Peking University First Hospital, Beijing, 100034, China
| | - Fei Li
- School of Cyber Science and Engineering, Wuhan University, Wuhan, 430072, China
| | - Jianbo Gao
- Henan Key Laboratory of Image Diagnosis and Treatment for Digestive System Tumor, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
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Lu B, Huang Z, Lin J, Zhang R, Shen X, Huang L, Wang X, He W, Huang Q, Fang J, Mao R, Li Z, Huang B, Feng ST, Ye Z, Zhang J, Wang Y. A novel multidisciplinary machine learning approach based on clinical, imaging, colonoscopy, and pathology features for distinguishing intestinal tuberculosis from Crohn's disease. Abdom Radiol (NY) 2024; 49:2187-2197. [PMID: 38703189 DOI: 10.1007/s00261-024-04307-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/19/2024] [Accepted: 03/20/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVES Differentiating intestinal tuberculosis (ITB) from Crohn's disease (CD) remains a diagnostic dilemma. Misdiagnosis carries potential grave implications. We aim to establish a multidisciplinary-based model using machine learning approach for distinguishing ITB from CD. METHODS Eighty-two patients including 25 patients with ITB and 57 patients with CD were retrospectively recruited (54 in training cohort and 28 in testing cohort). The region of interest (ROI) for the lesion was delineated on magnetic resonance enterography (MRE) and colonoscopy images. Radiomic features were extracted by least absolute shrinkage and selection operator regression. Pathological feature was extracted automatically by deep-learning method. Clinical features were filtered by logistic regression analysis. Diagnostic performance was evaluated by receiver operating characteristic (ROC) curve and decision curve analysis (DCA). Delong's test was applied to compare the efficiency between the multidisciplinary-based model and the other four single-disciplinary-based models. RESULTS The radiomics model based on MRE features yielded an AUC of 0.87 (95% confidence interval [CI] 0.68-0.96) on the test data set, which was similar to the clinical model (AUC, 0.90 [95% CI 0.71-0.98]) and higher than the colonoscopy radiomics model (AUC, 0.68 [95% CI 0.48-0.84]) and pathology deep-learning model (AUC, 0.70 [95% CI 0.49-0.85]). Multidisciplinary model, integrating 3 clinical, 21 MRE radiomic, 5 colonoscopy radiomic, and 4 pathology deep-learning features, could significantly improve the diagnostic performance (AUC of 0.94, 95% CI 0.78-1.00) on the bases of single-disciplinary-based models. DCA confirmed the clinical utility. CONCLUSIONS Multidisciplinary-based model integrating clinical, MRE, colonoscopy, and pathology features was useful in distinguishing ITB from CD.
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Affiliation(s)
- Baolan Lu
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Zengan Huang
- Medical AI Lab, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, People's Republic of China
| | - Jinjiang Lin
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Ruonan Zhang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Xiaodi Shen
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Lili Huang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Xinyue Wang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Weitao He
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Qiapeng Huang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, Guangdong, People's Republic of China
| | - Jiayu Fang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, Guangdong, People's Republic of China
| | - Zhoulei Li
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Bingsheng Huang
- Medical AI Lab, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, People's Republic of China
| | - Shi-Ting Feng
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Ziying Ye
- Department of Pathology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan Road 2nd, Guangzhou, 510080, People's Republic of China.
| | - Jian Zhang
- Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, Shenzhen, Guangdong, People's Republic of China.
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Guangdong, People's Republic of China.
| | - Yangdi Wang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou, 510080, Guangdong, People's Republic of China.
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Yu ZQ, Bai XY, Ruan GC, Han W, Xu TM, Zhang MY, Wang BM, Zhang YJ, Guo MY, Yang H. Autoimmune pancreatitis associated with inflammatory bowel diseases: A retrospectively bidirectional case-control study in China. J Dig Dis 2023; 24:452-460. [PMID: 37503771 DOI: 10.1111/1751-2980.13209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVES Autoimmune pancreatitis (AIP) is a rare and enigmatic immune-mediated inflammatory disease. We aimed to investigate the prevalence, characteristics, and associated factors of AIP-inflammatory bowel disease (IBD) in China. METHODS A retrospective bidirectional case-control study was performed. The diagnoses of IBD and AIP were made based on the European Crohn's and Colitis Organization guidelines and the International Consensus Diagnostic Criteria. IBD controls were matched by age, sex, and IBD type at a ratio of 1:4, while AIP controls were matched by AIP types. RESULTS The age-standardized prevalence of AIP-IBD patients in the IBD and AIP population were 292.0 and 8151.93 per 100 000 population, respectively. IBD patients had a higher risk of AIP compared to non-IBD patients (odds ratio 8.4, 95% confidence interval 4.7-14.9, P < 0.0001), and AIP patients had a higher risk of developing IBD compared to the general population in China. The mean age at diagnosis of IBD and AIP was 34.83 years and 40.42 years. IBD was diagnosed before AIP in seven cases. The median total IBD and AIP duration was 43.5 months and 13.5 months. Use of mesalamine and tuberculosis were associated with AIP in IBD patients (P = 0.031). And fecal occult blood test was associated with IBD in AIP patients (P = 0.008). CONCLUSIONS Most AIP-IBD patients had ulcerative colitis and type 2 AIP. IBD patients are more likely to develop AIP compared to the general population, and vice versa. Use of mesalamine and tuberculosis infection were associated with AIP, and fecal occult blood test was associated with IBD.
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Affiliation(s)
- Zi Qing Yu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiao Yin Bai
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ge Chong Ruan
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wei Han
- Department of Epidemiology and Biostatistics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Tian Ming Xu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Meng Yuan Zhang
- Department of Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bei Ming Wang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yu Jia Zhang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ming Yue Guo
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hong Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Choudhury A, Dhillon J, Sekar A, Gupta P, Singh H, Sharma V. Differentiating gastrointestinal tuberculosis and Crohn's disease- a comprehensive review. BMC Gastroenterol 2023; 23:246. [PMID: 37468869 DOI: 10.1186/s12876-023-02887-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/13/2023] [Indexed: 07/21/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Aravind Sekar
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Pankaj Gupta
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Harjeet Singh
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Vishal Sharma
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Watermeyer G, Katsidzira L, Nsokolo B, Isaac Alatise O, Duduyemi BM, Kassianides C, Hodges P. Challenges in the diagnosis and management of IBD: a sub-Saharan African perspective. Therap Adv Gastroenterol 2023; 16:17562848231184986. [PMID: 37457138 PMCID: PMC10345935 DOI: 10.1177/17562848231184986] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
With the exception of South Africa, inflammatory bowel disease (IBD) has long been considered uncommon in sub-Saharan Africa (SSA) with a dearth of peer-reviewed publications from the subcontinent. This most likely reflects underreporting as some cases may be missed due to the high burden of infectious diseases which may closely mimic IBD. In addition, many countries in SSA have limited endoscopic capacity, inadequate access to diagnostic imaging and a notable scarcity of histopathologists, radiologists and gastroenterologists. Beyond these obstacles, which significantly impact patient care, there are many other challenges in SSA, particularly the unavailability of key IBD therapies. In this review, we discuss barriers in diagnosing and managing IBD in SSA, as well as some of the initiatives currently in place to address these short comings.
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Affiliation(s)
| | - Leolin Katsidzira
- Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Bright Nsokolo
- School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia
| | - Olusegun Isaac Alatise
- Division of Gastrointestinal/Surgical Oncology, Department of Surgery, Obafemi Awolowo University/Teaching Hospitals Complex, Ile-Ife, Osun, Nigeria
| | - Babatunde M. Duduyemi
- Department of Pathology, College of Medicine and Allied Health Sciences/Teaching Hospitals Complex Highest University of Sierra Leone, Freetown, Sierra Leone
| | - Chris Kassianides
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Phoebe Hodges
- Barts and the London School of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London, UK
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8
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KC P, Bhattarai M, Adhikari S, Parajuli P, Bhandari S, Bhattarai HB, Sharma NK, Karki S, Acharya S, Basnet B. Intestinal tuberculosis can masquerade as Crohn's disease: A teachable moment. SAGE Open Med Case Rep 2023; 11:2050313X231184342. [PMID: 37425137 PMCID: PMC10328157 DOI: 10.1177/2050313x231184342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 06/08/2023] [Indexed: 07/11/2023] Open
Abstract
Intestinal tuberculosis and Crohn's disease are chronic granulomatous diseases with similar clinical presentations and can mimic one another. Their treatment modalities are completely different; however, sometimes it is challenging to differentiate them. We report a case of a 51-year-old female presenting with abdominal pain and on-and-off diarrhea for 4 years with weight loss. Clinical symptoms along with multiple aphthous ulcers in the terminal ileum and negative tuberculin test favored the diagnosis of Crohn's disease. The patient did not respond to steroids. A repeat colonoscopy with acid-fast bacilli stain showed Mycobacterium tuberculosis. This case highlights that acid-fast bacilli culture and tuberculosis polymerase chain reaction to confirm or rule out the diagnosis of intestinal tuberculosis in all patients suspected of Crohn's disease.
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Affiliation(s)
- Pooja KC
- Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
| | | | - Subodh Adhikari
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Prakriti Parajuli
- Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
| | | | | | | | - Shailendra Karki
- Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Suryakiran Acharya
- Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
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Watermeyer G, Awuku Y, Fredericks E, Epstein D, Setshedi M, Devani S, Mudombi W, Kassianides C, Katsidzira L. Challenges in the management of inflammatory bowel disease in sub-Saharan Africa. Lancet Gastroenterol Hepatol 2022; 7:962-972. [PMID: 35779534 DOI: 10.1016/s2468-1253(22)00048-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 06/15/2023]
Abstract
Inflammatory bowel disease (IBD) is generally considered a disease of high-income countries and is regarded as rare in sub-Saharan Africa. However, this assumption is almost certainly an underestimate, and the high burden of communicable diseases makes IBD in sub-Saharan Africa difficult to detect. Furthermore, some gastrointestinal infections can closely mimic IBD, contributing to delays in diagnosis and complicating therapeutic decision making. Constraints in endoscopic capacity alongside a scarcity of qualified diagnostic pathologists add to the difficulties. Implementing evidence-based guidelines recommended by international societies is challenging, mostly due to high costs and unavailability of medication. However, cost-effective approaches can still be implemented to manage IBD in sub-Saharan Africa as the predominant disease phenotype is mild-to-moderate ulcerative colitis, which often responds to treatment with basic medication. In this Series paper, we summarise the current management of IBD in sub-Saharan Africa and propose how it can be tailored to suit the epidemiological and socioeconomic specificities of the region. We also discuss measures required to address existing challenges, such as educating health-care workers about the diagnosis and management of IBD or improving endoscopic capacity.
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Affiliation(s)
- Gillian Watermeyer
- Department of Medicine, University of Cape Town Groote Schuur Hospital, Cape Town, South Africa.
| | - Yaw Awuku
- Department of Medicine, University of Health and Allied Sciences, Ho, Ghana
| | - Ernst Fredericks
- Department of Medicine, University of Stellenbosch, Cape Town, South Africa
| | | | - Mashiko Setshedi
- Department of Medicine, University of Cape Town Groote Schuur Hospital, Cape Town, South Africa
| | - Smita Devani
- Department of Medicine, Aga Khan University Hospital, Nairobi, Kenya
| | - Wisdom Mudombi
- Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Leolin Katsidzira
- Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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10
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Watermeyer G, Katsidzira L, Setshedi M, Devani S, Mudombi W, Kassianides C. Inflammatory bowel disease in sub-Saharan Africa: epidemiology, risk factors, and challenges in diagnosis. Lancet Gastroenterol Hepatol 2022; 7:952-961. [DOI: 10.1016/s2468-1253(22)00047-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 02/07/2023]
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11
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Weng F, Meng Y, Lu F, Wang Y, Wang W, Xu L, Cheng D, Zhu J. Differentiation of intestinal tuberculosis and Crohn's disease through an explainable machine learning method. Sci Rep 2022; 12:1714. [PMID: 35110611 PMCID: PMC8810833 DOI: 10.1038/s41598-022-05571-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 01/13/2022] [Indexed: 12/16/2022] Open
Abstract
Differentiation between Crohn’s disease and intestinal tuberculosis is difficult but crucial for medical decisions. This study aims to develop an effective framework to distinguish these two diseases through an explainable machine learning (ML) model. After feature selection, a total of nine variables are extracted, including intestinal surgery, abdominal, bloody stool, PPD, knot, ESAT-6, CFP-10, intestinal dilatation and comb sign. Besides, we compared the predictive performance of the ML methods with traditional statistical methods. This work also provides insights into the ML model’s outcome through the SHAP method for the first time. A cohort consisting of 200 patients’ data (CD = 160, ITB = 40) is used in training and validating models. Results illustrate that the XGBoost algorithm outperforms other classifiers in terms of area under the receiver operating characteristic curve (AUC), sensitivity, specificity, precision and Matthews correlation coefficient (MCC), yielding values of 0.891, 0.813, 0.969, 0.867 and 0.801 respectively. More importantly, the prediction outcomes of XGBoost can be effectively explained through the SHAP method. The proposed framework proves that the effectiveness of distinguishing CD from ITB through interpretable machine learning, which can obtain a global explanation but also an explanation for individual patients.
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Affiliation(s)
- Futian Weng
- School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China.,National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, 361005, Fujian, China.,Data Mining Research Center, Xiamen University, Xiamen, 361005, Fujian, China
| | - Yu Meng
- Department of Gastroenterology and Hepatology, Shenzhen University General Hospital, Shenzhen, 518055, China.,Shenzhen University Clinical Medical Academy, Shenzhen University, Shenzhen, 518037, China
| | - Fanggen Lu
- The Gastroenterology Department of Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Yuying Wang
- Data Mining Research Center, Xiamen University, Xiamen, 361005, Fujian, China.,School of Management, Xiamen University, Xiamen, 361005, Futian, China
| | - Weiwei Wang
- School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China.,National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, 361005, Fujian, China.,Data Mining Research Center, Xiamen University, Xiamen, 361005, Fujian, China
| | - Long Xu
- Department of Gastroenterology and Hepatology, Shenzhen University General Hospital, Shenzhen, 518055, China.,Shenzhen University Clinical Medical Academy, Shenzhen University, Shenzhen, 518037, China
| | - Dongsheng Cheng
- School of Software Engineering, Shenzhen Institute of Information Technology, Shenzhen, 518172, China
| | - Jianping Zhu
- National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, 361005, Fujian, China. .,Data Mining Research Center, Xiamen University, Xiamen, 361005, Fujian, China. .,School of Management, Xiamen University, Xiamen, 361005, Futian, China.
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12
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Weinberg SE, Mughal AM. A Case of Intestinal Tuberculosis Mimicking Crohn's Disease: A Clinical and Diagnostic Dilemma. Eur J Case Rep Intern Med 2021; 8:002699. [PMID: 34912732 PMCID: PMC8668007 DOI: 10.12890/2021_002699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/05/2021] [Indexed: 11/05/2022] Open
Abstract
This case highlights the importance of differentiating between Crohn's disease and intestinal tuberculosis. The rates of misdiagnosis of Crohn's disease and intestinal tuberculosis range from 50% to 70% because of their non-specific and clinically similar manifestations.If intestinal tuberculosis is misdiagnosed as Crohn's disease, use of immunomodulatory drugs commonly used for Crohn's disease can increase the risk of disseminated tuberculosis. Here we present a case highlighting the clinical similarity between these two distinct medical conditions and suggest how a similar scenario can be approached, which can help to differentiate between the two otherwise very similar conditions. LEARNING POINTS Given the similarities, it is key to differentiate Crohn's disease from intestinal tuberculosis as early as possible.Patients undergoing colonoscopy for possible Crohn's disease should have colonic biopsy samples sent for AFB culture.Consider investigations for intestinal tuberculosis in uncontrolled Crohn's disease where intestinal tuberculosis has not been worked up previously.
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Affiliation(s)
- Sharon Esther Weinberg
- Department of Respiratory Medicine, Morriston Hospital, Swansea Bay University Health Board, Swansea, Wales, UK
| | - Ahsan M Mughal
- Department of Respiratory Medicine, Morriston Hospital, Swansea Bay University Health Board, Swansea, Wales, UK
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13
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Ionescu S, Nicolescu AC, Madge OL, Marincas M, Radu M, Simion L. Differential Diagnosis of Abdominal Tuberculosis in the Adult-Literature Review. Diagnostics (Basel) 2021; 11:2362. [PMID: 34943598 PMCID: PMC8700228 DOI: 10.3390/diagnostics11122362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 11/18/2022] Open
Abstract
Tuberculosis (TB) is a public health issue that affects mostly, but not exclusively, developing countries. Abdominal TB is difficult to detect at first, with the incidence ranging from 10% to 30% of individuals with lung TB. Symptoms are non-specific, examinations can be misleading, and biomarkers commonly linked with other diseases can also make appropriate diagnosis difficult. As a background for this literature review, the method used was to look into the main characteristics and features of abdominal tuberculosis that could help with differentiation on the PubMed, Science Direct, and Academic Oxford Journals databases. The results were grouped into three categories: A. general features (the five forms of abdominal tuberculosis: wet and dry peritonitis, lymphadenopathy, lesions at the level of the cavitary organs, lesions at the level of the solid organs), B. different intra-abdominal organs and patterns of involvement (oesophageal, gastro-duodenal, jejunal, ileal, colorectal, hepatosplenic, and pancreatic TB with calcified lymphadenopathy, also with description of extraperitoneal forms), and C. special challenges of the differential diagnosis in abdominal TB (such as diagnostic overlap, the disease in transplant candidates and transplant recipients, and zoonotic TB). The study concluded that, particularly in endemic countries, any disease manifesting with peritonitis, lymphadenopathy, or lesions at the level of the intestines or solid organs should have workups and protocols applied that can confirm/dismiss the suspicion of abdominal tuberculosis.
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Affiliation(s)
- Sinziana Ionescu
- 1st Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (S.I.); (L.S.)
- Department of Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | | | - Octavia Luciana Madge
- 1st Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (S.I.); (L.S.)
| | - Marian Marincas
- 1st Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (S.I.); (L.S.)
- Department of Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Madalina Radu
- Pathology Department, Bucharest Oncology Institute, 022328 Bucharest, Romania;
| | - Laurentiu Simion
- 1st Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (S.I.); (L.S.)
- Department of Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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14
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A combination of circulating microRNA-375-3p and chemokines CCL11, CXCL12, and G-CSF differentiate Crohn's disease and intestinal tuberculosis. Sci Rep 2021; 11:23303. [PMID: 34857759 PMCID: PMC8639680 DOI: 10.1038/s41598-021-02383-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022] Open
Abstract
Differentiation of Crohn’s disease (CD) from intestinal tuberculosis (ITB) is a big challenge to gastroenterologists because of their indistinguishable features and insensitive diagnostic tools. A non-invasive biomarker is urgently required to distinguish ITB/CD patients particularly in India, a TB endemic region, where CD frequency is increasing rapidly due to urbanization. Among the three differentially expressed miRNAs obtained from small RNA transcriptomic profiling of ileocaecal/terminal ileal tissue of ITB/CD patients (n = 3), only two down-regulated miRNAs, miR-31-5p, and miR-215-5p showed comparable data in qRT-PCR. Out of which, only miR-215-5p was detectable in the patient’s plasma, but there was no significant difference in expression between ITB/CD. On the other hand, miR-375-3p, the pulmonary TB specific marker was found in higher amount in the plasma of ITB patients than CD while reverse expression was observed in the ileocaecal/terminal ileal tissues of the same patients. Next, using Bioplex pro-human cytokine 48-plex screening panel, only three chemokines, Eotaxin-1/CCL11, SDF-1α/CXCL12, and G-CSF have noted significantly different levels in the serum of ITB/CD patients. ROC analysis has revealed that compared to a single molecule, a combination of miR-375-3p + Eotaxin-1/CCL11 + SDF-1α /CXCL12 + G-CSF showed a better AUC of 0.83, 95% CI (0.69–0.96) with 100% specificity and positive predictive value while sensitivity, negative predictive value, and accuracy were 56%, 69%, and 78% respectively in distinguishing ITB from CD. This study suggests that a combination of plasma markers shows better potential in differentiating ITB from CD than a single marker and this panel of markers may be used for clinical management of ITB/CD patients.
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15
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Lee JH, Tey TT, Foo FJ, Koh F. Perforated viscus as first presentation of Crohn's disease: a case report. J Surg Case Rep 2021; 2021:rjab415. [PMID: 34603683 PMCID: PMC8480525 DOI: 10.1093/jscr/rjab415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/27/2021] [Indexed: 12/03/2022] Open
Abstract
Bowel perforation as the first presentation of inflammatory bowel disease is rare and unusual in young patients. A previously asymptomatic 21-year-old Asian male presented with perforated small bowel secondary to previously undiagnosed Crohn’s disease. He underwent an exploratory laparotomy and subsequent small bowel resection and was commenced on mesalazine post-operation. He recovered well with subsequent regular follow-up with gastroenterology. The main management of Crohn’s disease is multidisciplinary in nature, and collaboration between different disciplines is inherent with the aim of reducing symptoms and maximizing patient quality of life.
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Affiliation(s)
- Jia Hui Lee
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Tze Tong Tey
- Department of Gastroenterology, Sengkang General Hospital, Singapore, Singapore
| | - Fung Joon Foo
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Frederick Koh
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
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16
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Razafindrazoto CI, Randriamifidy NH, Rakotomalala JA, Ralaizanaka BM, Rakotomaharo M, Hasina Laingonirina DH, Maherison S, Rasolonjatovo AS, Rakotozafindrabe ALR, Rabenjanahary TH, Razafimahefa SH, Ramanampamonjy RM. Inappropriate prescription of corticosteroid therapy during inflammatory ileo-colitis revealing disseminated tuberculosis with digestive involvement: Two case reports. Clin Case Rep 2021; 9:e04215. [PMID: 34136233 PMCID: PMC8190683 DOI: 10.1002/ccr3.4215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 11/10/2022] Open
Abstract
It is essential to differentiate intestinal tuberculosis from Crohn's disease because of the therapeutic implications of Crohn's disease, which can exacerbate the symptoms of tuberculosis.
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Affiliation(s)
- Chantelli Iamblaudiot Razafindrazoto
- Department of GastroenterologyUniversity Hospital Joseph Raseta BefelatananaAntananarivoMadagascar
- Faculty of MedicineUniversity of AntananarivoAntananarivoMadagascar
| | | | | | - Behoavy Mahafaly Ralaizanaka
- Faculty of MedicineUniversity of AntananarivoAntananarivoMadagascar
- Department of Hepato‐GastroenterologyUniversity Hospital AndrainjatoFianarantsoaMadagascar
| | - Mialitiana Rakotomaharo
- Department of GastroenterologyUniversity Hospital Joseph Raseta BefelatananaAntananarivoMadagascar
- Faculty of MedicineUniversity of AntananarivoAntananarivoMadagascar
| | - Domoina Harivonjy Hasina Laingonirina
- Department of GastroenterologyUniversity Hospital Joseph Raseta BefelatananaAntananarivoMadagascar
- Faculty of MedicineUniversity of AntananarivoAntananarivoMadagascar
| | - Sonny Maherison
- Department of GastroenterologyUniversity Hospital Joseph Raseta BefelatananaAntananarivoMadagascar
- Faculty of MedicineUniversity of AntananarivoAntananarivoMadagascar
| | - Anjaramalala Sitraka Rasolonjatovo
- Department of GastroenterologyUniversity Hospital Joseph Raseta BefelatananaAntananarivoMadagascar
- Faculty of MedicineUniversity of AntananarivoAntananarivoMadagascar
| | - Andry Lalaina Rinà Rakotozafindrabe
- Department of GastroenterologyUniversity Hospital Joseph Raseta BefelatananaAntananarivoMadagascar
- Faculty of MedicineUniversity of AntananarivoAntananarivoMadagascar
| | - Tovo Harimanana Rabenjanahary
- Department of GastroenterologyUniversity Hospital Joseph Raseta BefelatananaAntananarivoMadagascar
- Faculty of MedicineUniversity of AntananarivoAntananarivoMadagascar
| | - Soloniaina Hélio Razafimahefa
- Department of Hepato‐GastroenterologyUniversity Hospital AndrainjatoFianarantsoaMadagascar
- Faculty of MedicineUniversity of FianarantsoaFianarantsoaMadagascar
| | - Rado Manitrala Ramanampamonjy
- Department of GastroenterologyUniversity Hospital Joseph Raseta BefelatananaAntananarivoMadagascar
- Faculty of MedicineUniversity of AntananarivoAntananarivoMadagascar
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17
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Israrahmed A, Yadav RR, Yadav G, Alpana, Helavar RV, Rai P, Jain MK, Gupta A. 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. JGH OPEN 2020; 5:180-189. [PMID: 33553653 PMCID: PMC7857287 DOI: 10.1002/jgh3.12478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/25/2020] [Accepted: 12/05/2020] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Amrin Israrahmed
- Department of Radiodiagnosis Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow India
| | - Rajanikant R Yadav
- Department of Radiodiagnosis Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow India
| | - Geeta Yadav
- Department of Pathology Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow India.,Department of Pathology King George's Medical University Lucknow India
| | - Alpana
- Department of Radiodiagnosis Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow India
| | - Rajesh V Helavar
- Department of Radiodiagnosis Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow India.,Department of Radiology Columbia Asia Hospitals Bengaluru India
| | - Praveer Rai
- Department of Gastroenterology Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow India
| | - Manoj Kumar Jain
- Department of Pathology Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow India
| | - Archna Gupta
- Department of Radiodiagnosis Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow India
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18
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Banerjee R, Pal P, Mak JWY, Ng SC. Challenges in the diagnosis and management of inflammatory bowel disease in resource-limited settings in Asia. Lancet Gastroenterol Hepatol 2020; 5:1076-1088. [PMID: 33181087 DOI: 10.1016/s2468-1253(20)30299-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 12/14/2022]
Abstract
Inflammatory bowel disease (IBD) is increasing in prevalence in resource-limited settings in Asia. Although the prevalence of IBD is lower in these settings than in high-income countries, the high disease burden due to large population size is projected to overtake that of high-income countries in the near future. Unique challenges exist for diagnosing and managing IBD in Asia. On one hand, the inadequate disease awareness in physicians and the general population, the scarcity of diagnostic services, the infectious mimics of IBD (specifically intestinal tuberculosis), and the widespread use of empirical antibiotics and antitubercular therapy pose diagnostic challenges. On the other hand, the absence of a centralised health-care delivery system or universal health insurance, the high cost of therapy, limited access to biologics, and the high risk of opportunistic infections with immunosuppressive therapy present therapeutic challenges. The high probability of tuberculosis reactivation often precludes biological therapy because Asia is highly endemic for tuberculosis and has a high prevalence of latent tuberculosis. Current screening strategies are often ineffective in ruling out latent tuberculosis. Hence, management strategies are often modified according to these challenges. This Series paper discusses the challenges in the diagnosis and management of IBD in resource-limited settings in Asia.
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Affiliation(s)
- Rupa Banerjee
- IBD Centre, Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India.
| | - Partha Pal
- IBD Centre, Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Joyce Wing Yan Mak
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, LKS Institute of Health Science, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Diseases, LKS Institute of Health Science, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
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19
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Nayak SS, Shetty MV, Pai CG, Guruprasad KP, Satyamoorthy K. Apoptosis in peripheral blood lymphocytes in intestinal tuberculosis and Crohn's disease: Implications to diagnostic differentiation. Indian J Gastroenterol 2020; 39:338-345. [PMID: 32803718 DOI: 10.1007/s12664-019-01011-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 12/24/2019] [Indexed: 02/04/2023]
Abstract
AIM Intestinal tuberculosis (ITb) and Crohn's disease (CD) mimic each other often leading to misdiagnosis. We evaluated the difference between ITb and CD using the extent of apoptosis in peripheral blood lymphocytes. METHODS CD4+ cells as a percentage of the lymphocytes and viable, dead, total apoptotic, early apoptotic, and late apoptotic CD4+ cells were assessed in the peripheral blood by flow cytometry in healthy controls and patients with confirmed active ITb and CD prior to initiating therapy. Early apoptotic and total apoptotic cells were further expressed as a proportion of the percentage of CD4+ cells. RESULTS The percentages of CD4+ cells (6.5 [3.0, 8.7] vs. 13.40 [10.15, 13.40]; p < 0.001), total apoptotic cells (0.13 [0.0, 0.22] vs. 0.08 [0.0, 0.21]; p = 0.045), early apoptotic (1.24 [0.55, 2.54] vs. 0.71 [0.40, 1.30]; p = 0.037), and the proportion of the latter two parameters (17.18 [5.61, 57.33] vs. 4.84 [2.71, 9.83]; p-value 0.039) and (17.18 [7.4, 67.50] vs. 5.51 [3.10, 11.03]; p-value 0.036) were significantly different between patients with ITb and CD. The best sensitivity, specificity, and positive and negative predictive values for the diagnosis of ITb were seen with the CD4+ cell percentage (82.6%, 82.4%, 86.4%, 77.8%, respectively) and the proportion of early apoptotic cells (73.9%, 70.6%, 77.3%, 66.7%, respectively). CONCLUSION CD4+ cells as a percentage of peripheral blood lymphocytes and the proportion of early apoptotic CD4+ cells show promise to diagnostic differentiation between ITb and CD.
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Affiliation(s)
- Suprabha Suresh Nayak
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576 104, India
| | - Mamatha Vishwanatha Shetty
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576 104, India
| | - Cannanore Ganesh Pai
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576 104, India.
| | - Kanive Parashiva Guruprasad
- School of Life Sciences, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576 104, India
| | - Kapaettu Satyamoorthy
- School of Life Sciences, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576 104, India
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20
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Zhao Y, Xu M, Chen L, Liu Z, Sun X. Levels of TB-IGRA may help to differentiate between intestinal tuberculosis and Crohn's disease in patients with positive results. Therap Adv Gastroenterol 2020; 13:1756284820922003. [PMID: 32523624 PMCID: PMC7235651 DOI: 10.1177/1756284820922003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 03/17/2020] [Indexed: 02/04/2023] Open
Abstract
AIM The aim of this study was to investigate the significance of positive tuberculosis interferon gamma release assay (TB-IGRA) in the differential diagnosis of intestinal tuberculosis (ITB) and Crohn's disease (CD) patients, and to find a suitable threshold to help distinguishing CD from tuberculosis (TB), so as to provide better recommendations for clinical treatment. METHODS A retrospective study was performed including 484 patients who underwent TB-IGRA testing for suspected CD or ITB treated in the Shanghai Tenth People's Hospital of Tongji University between January 2015 and May 2018. According to the diagnostic criteria, 307 patients, including 272 CD and 35 ITB patients, were recruited for the final analysis. We comprehensively and systematically collected their clinical manifestations, and analyzed the influence of TB-IGRA values referring to diagnosis criteria, and the possible causes of false positives. The receiver operator characteristic (ROC) curve and the cut-off value were applied to distinguish between ITB and CD patients. RESULTS Of the 56 patients with suspected CD enrolled, 23 were finally diagnosed with CD and 33 with ITB. In patients with TB-IGRA ⩾ 100 pg/ml, 4 cases were CD and 29 cases were ITB, while 19 cases were CD and 4 cases were ITB in patients with TB-IGRA < 100 pg/ml (p < 0.05). TB-IGRA ⩾ 100 pg/ml indicated a high possibility of TB infection, with a sensitivity of 88% and a specificity of 74%. Three out of the four CD patients with TB-IGRA ⩾ 100 pg/ml had a history of tuberculosis, while only 1 of the 19 CD patients with TB-IGRA < 100 pg/ml had a history of tuberculosis (p < 0.05). The average duration of ITB was 7 months, and that of CD was 46.8 months, thus a significant difference (p < 0.05) was observed. Perianal lesions such as anal fistula or abscess were found in all CD patients. Among ITB patients, 8 out of 15 patients with TB-IGRA ⩾ 400 pg/ml experienced weight loss, while only 1 out of 18 patients with TB-IGRA < 400 pg/ml underwent weight loss (p < 0.05). CONCLUSION Patients with CD have longer duration of disease, and perianal lesions are more common in CD. ITB patients with TB-IGRA ⩾ 400 pg/ml experience weight loss more readily, which indicates that TB-IGRA value may be correlated positively with the severity of ITB. In patients with CD and ITB, TB-IGRA = 100 pg/ml may be a cut-off value of TB-IGRA. For patients with TB-IGRA ⩾ 100 pg/ml, it is recommended to use diagnostic anti-TB treatment first. Comprehensive analysis and judgment are required for patients with TB-IGRA from 14 pg/ml to 99 pg/ml. TB-IGRA false positivity may occur in patients with a history of TB infection.
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Affiliation(s)
- Yujie Zhao
- Gastroenterology Department, Tenth People’s Hospital of Tongji University, Shanghai, China
| | - Meilin Xu
- Gastroenterology Department, Shanghai Renhe Hospital, Shanghai, China
| | - Liang Chen
- Gastroenterology Department, Tenth People’s Hospital of Tongji University, Shanghai, China
| | - Zhanju Liu
- Gastroenterology Department, Tenth People’s Hospital of Tongji University, Shanghai, China
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21
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Tan J, Porter D, Guo J, Pan L, Yang G, Zhang Z. A Neglected Case of Colonic Tuberculosis With Thoracolumbar Enterocutaneous Fecal Fistulae. J Med Cases 2020; 11:111-114. [PMID: 34434378 PMCID: PMC8383560 DOI: 10.14740/jmc3463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/09/2020] [Indexed: 11/11/2022] Open
Abstract
Although intestinal tuberculosis (ITB) typically affects ileocecal segments, the complication of tubercular enterocutaneous fistula is very rare. As an isolated phenomenon, primary intestinal manifestation without extraintestinal tuberculosis (TB) is exceptional and rarely reported. We present a patient with isolated ITB with six spontaneous thoracolumbar tubercular enterocutaneous fistulae. A 37-year-old Chinese woman was admitted to our institution complaining of escape of fecal matter through several openings in her back over the previous 20 years. She had nonspecific abdominal symptoms (occasional abdominal pain and alteration in bowel habit). External physical examination confirmed the presence of external thoracolumbar fecal fistulae in association with a scoliosis. Abdominal examination was unremarkable. Diagnostic colonoscopy with biopsy did not definitively confirm a diagnosis of TB. Microscopic examination in both microbiology and histopathology labs failed to identify acid-fast bacilli; however, gastrointestinal TB (GITB) was considered high on the differential diagnosis list. It was elected to perform open laparotomy with resection of the left hemi-colon. Postoperatively, she was treated with standard anti-tuberculous treatment for 6 months. The patient had an uneventful postoperative course, during which the fistulae gradually closed over the next year. This case with several low-output fistulas exiting the patient’s back was successfully treated by a combination of surgery and antimicrobial therapy. The aim of this rare case report is to raise the awareness of atypical presentation of tubercular colonic enterocutaneous fistula so that timely diagnosis and intervention can salvage patient quality of life.
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Affiliation(s)
- Jie Tan
- School of Clinical Medicine, Tsinghua University, Beijing 100084, China
| | - Daniel Porter
- Department of Orthopaedics, The First Hospital of Tsinghua University (Beijing Huaxin Hospital), Beijing 100016, China
| | - Jinxing Guo
- Department of General Surgery, The First Hospital of Tsinghua University (Beijing Huaxin Hospital), Beijing 100016, China
| | - Lijie Pan
- Department of General Surgery, The First Hospital of Tsinghua University (Beijing Huaxin Hospital), Beijing 100016, China
| | - Guoshan Yang
- Department of General Surgery, The First Hospital of Tsinghua University (Beijing Huaxin Hospital), Beijing 100016, China
| | - Zichao Zhang
- Department of General Surgery, The First Hospital of Tsinghua University (Beijing Huaxin Hospital), Beijing 100016, China
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Merino Gallego E, Gallardo Sánchez F, Gallego Rojo FJ. Intestinal tuberculosis and Crohn's disease: the importance and difficulty of a differential diagnosis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 110:650-657. [PMID: 30168341 DOI: 10.17235/reed.2018.5184/2017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Watermeyer GA, Locketz M. CD73 expression in tissue granulomas in distinguishing intestinal tuberculosis from Crohn's disease in a South African cohort. Scand J Gastroenterol 2019; 53:1217-1221. [PMID: 30295112 DOI: 10.1080/00365521.2018.1503326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Overlap of clinical, endoscopic and radiographic features, coupled with a poor microbiological yield makes differentiating Crohn's disease (CD) from intestinal tuberculosis (ITB) challenging. A potential histological differentiating mechanism is the use of immunohistochemical staining for the mesenchymal stem cell marker CD73, as a pilot study showed ITB but not CD granulomas stained positive for this marker. The aim of this study was to assess the value of CD73 in differentiating ITB from CD granulomas in a South African cohort. METHODS Patients with confirmed CD or ITB were identified from a pathology database. Tissue sections were reviewed by a pathologist to confirm the presence of granulomas. These were then stained with a mouse monoclonal anti-CD73 antibody. The slides were examined together by a pathologist and gastroenterologist in a blinded manner for anti-CD73 staining around granulomas. RESULTS Ninety six cases were available for analysis; 50 cases of ITB and 46 cases of CD. Thirty percent of CD granulomas (14/46) stained positive for CD73, whereas CD73 positivity was seen in 52% (26/50) of cases of ITB. This was statistically significant (OR 2.48, 95% CI 1.1-5.72, p = .03). The area under the curve (AUC) was 0.61. Sensitivity of CD73 in predicting ITB was 52% and specificity was 70%. Overall CD73 staining of granulomas correctly classified only 60% of cases. CONCLUSIONS In our study we have shown that significantly more patients with ITB express CD73 in their granulomas than those with CD. However the relatively poor sensitivity, specificity and AUC make this test unlikely to be of value in our clinical practice.
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Affiliation(s)
- Gillian A Watermeyer
- a Division of Gastroenterology, Department of Medicine , Groote Schuur Hospital and University of Cape Town , Cape Town , South Africa
| | - Michael Locketz
- b Division of Anatomical Pathology , National Health Laboratory Service and University of Cape Town , Cape Town , South Africa
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Alegbeleye BJ. Crohn's disease in a developing African mission hospital: a case report. J Med Case Rep 2019; 13:80. [PMID: 30846003 PMCID: PMC6407268 DOI: 10.1186/s13256-019-1971-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/03/2019] [Indexed: 12/31/2022] Open
Abstract
Background A case is reported of innocuous intestinal obstruction requiring surgical intervention that was confirmed to be Crohn’s disease histopathologically in a resource-constrained rural mission hospital in Cameroon. Case presentation A 70-year man of Kumbo origin from Northwest region of Cameroon with a history of crampy right lower-quadrant abdominal pain, non-bloody, non-mucoid diarrhea alternating with constipation presented to my institution. Abdominal examination of the patient revealed an ill-defined mass in the right iliac fossa and visible peristalsis. An abdominal computed tomographic scan and barium enema study confirmed a complex ascending colonic and cecal tumor. The patient underwent exploratory laparotomy. The intraoperative finding was a huge complex inflammatory mass involving the cecum, terminal ileum, and sigmoid colon. He subsequently had sigmoidectomy with end–to-end sigmoidorectal anastomosis and a cecal resection, and the proximal ascending colon was exteriorized because end mucoid fistula and terminal ileostomy were performed. The histopathological diagnosis confirmed Crohn’s disease. The patient subsequently received five courses of adjuvant chemotherapy consisting of azathioprine, methotrexate, mesalamine, and methylprednisolone. He had complete disease remission and subsequently had closure of ileostomy with satisfactory postoperative status. The most recent follow-up abdominal computed tomographic scan and colonoscopy revealed disease-free status. The patient is also currently receiving a maintenance dose of rectal mesalamine and oral omeprazole treatment. He has been followed every 2 months in the surgical outpatient clinic over the last 16 months with satisfactory clinical outcome. Conclusions Crohn’s disease is uncommon in Africa, and this entity is encountered sparingly. The signs and symptoms of Crohn’s disease overlap with many other abdominal disorders, such as tuberculosis, ulcerative colitis, irritable bowel syndrome, and others. Several publications in the literature describe that it is difficult to make an accurate diagnosis of this disease, despite the fact that many diagnostic armamentaria are available to suggest its presence. Most of the patients with Crohn’s disease are treated conservatively, and a few may require surgical intervention, especially those presenting with complications such as intestinal obstruction, perforations, and abscess as well as fistula formations, as seen in this index patient. Crohn’s disease is considered by many to be a very rare disease in Africa. It is interesting to know that Crohn’s disease, which affects mainly young adults, may debut at any age. The rarity and clinical curiosity of this entity suggested reporting of my patient’s case. Evidence-based up-to-date information on Crohn’s disease is also documented.
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Affiliation(s)
- Bamidele Johnson Alegbeleye
- Department of Surgery, St Elizabeth Catholic General Hospital, Shisong, P.O Box 8, Kumbo - Nso, Bui Division, Northwestern Region, Cameroon.
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25
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Development and Validation of a Novel Diagnostic Nomogram to Differentiate Between Intestinal Tuberculosis and Crohn's Disease: A 6-year Prospective Multicenter Study. Am J Gastroenterol 2019; 114:490-499. [PMID: 30741735 DOI: 10.14309/ajg.0000000000000064] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Differentiating Crohn's disease (CD) from intestinal tuberculosis (ITB) remains a diagnostic challenge. Misdiagnosis carries potential grave implications. We aimed to develop and validate a novel diagnostic nomogram for differentiating them. METHODS In total, 310 eligible patients were recruited from 6 tertiary inflammatory bowel disease centers. Among them, 212 consecutive patients (143 CD and 69 ITB) were used in the derivation cohort for the establishment of diagnostic equation and nomogram; 7 investigative modalities including clinical manifestations, laboratory results, endoscopic findings, computed tomography enterography features, and histology results were used to derive the diagnostic model and nomogram. Ninety-eight consecutive patients (76 CD and 22 ITB) were included for validation of the diagnostic model. RESULTS Eight out of total 79 parameters were identified as valuable parameters used for establishing diagnostic equations. Two regression models were built based on 7 differential variables: age, transverse ulcer, rectum involvement, skipped involvement of the small bowel, target sign, comb sign, and interferon-gamma release assays (for model 1) or purified protein derivative (for model 2), respectively. Accordingly, 2 nomograms of the above 2 models were developed for clinical practical use, respectively. Further validation test verified the efficacy of the nomogram 1 with 90.9% specificity, 86.8% sensitivity, 97.1% PPV, 66.7% negative predictive value (NPV), and 87.8% accuracy for identifying CD, and the efficacy of the nomogram 2 with 100% specificity, 84.2% sensitivity, 100% positive predictive value, 64.7% NPV, and 87.8% accuracy for diagnosing CD. CONCLUSIONS The derivation and validation cohorts identified and validated 2 highly accurate and practical diagnostic nomograms for differentiating CD from ITB. These diagnostic nomograms can be conveniently used to identify some difficult CD or ITB cases, allowing for decision-making in a clinical setting.
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26
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Wu X, Huang H, Hou H, Shen G, Yu J, Zhou Y, Bosco MJ, Mao L, Wang F, Sun Z. Diagnostic Performance of a 5-Marker Predictive Model for Differential Diagnosis Between Intestinal Tuberculosis and Crohn's Disease. Inflamm Bowel Dis 2018; 24:2452-2460. [PMID: 29860270 DOI: 10.1093/ibd/izy154] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The differentiation between intestinal tuberculosis (ITB) and Crohn's disease (CD) is a challenge. The aim of this study was to investigate a predictive model for differential diagnosis between ITB and CD. METHODS A total of 268 patients who were suspected of having ITB or CD were prospectively recruited between January 2013 and September 2016. The clinical, laboratory, radiological, endoscopic, and histological features were investigated and subjected to univariate and multivariate analyses. The final predictive model was developed based on the regression coefficients of multivariate logistic regression. To validate the model, the same regression equation was tested on the other group. RESULTS A total of 239 patients had a final diagnosis, including 86 ITB and 153 CD. Five variables (perianal disease, pulmonary involvement, longitudinal ulcer, left colon, and ratio of tuberculosis-specific antigen to phytohaemagglutinin) were selected for the predictive model to discriminate between ITB and CD. In the predictive model of the training data set, the area under the receiver operating characteristic (ROC) curve, sensitivity, specificity, and accuracy, with a cutoff level of 0.29, were 0.975 (95% confidence interval [CI], 0.939-0.993), 96.7%, 90.7%, and 92.8%, respectively. Application of the predictive model to the validation data set showed similar performance in distinguishing ITB from CD. The area under the ROC curve, sensitivity, specificity, and accuracy were 0.950 (95% CI, 0.871-0.987), 88.5%, 93.5%, and 91.7%, respectively. CONCLUSIONS This 5-marker predictive model could be conveniently used by clinicians to draw a reliable differential diagnosis between ITB and CD in clinical practice. 10.1093/ibd/izy154_video1izy154.video15790725497001.
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Affiliation(s)
- Xiaohui Wu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Huanjun Huang
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Hongyan Hou
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Guanxin Shen
- Department of Immunology, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Yu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Yu Zhou
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Munyemana Jean Bosco
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Lie Mao
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Feng Wang
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
| | - Ziyong Sun
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, China
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27
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Atypical serious hematochezia and rare imaging feature in gastrointestinal tuberculosis. Clin J Gastroenterol 2018; 12:182-188. [PMID: 30232704 DOI: 10.1007/s12328-018-0910-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 09/16/2018] [Indexed: 10/28/2022]
Abstract
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.
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28
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Banerjee R, Pal P, Girish BG, Reddy DN. Risk factors for diagnostic delay in Crohn's disease and their impact on long-term complications: how do they differ in a tuberculosis endemic region? Aliment Pharmacol Ther 2018; 47:1367-1374. [PMID: 29572889 DOI: 10.1111/apt.14617] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/30/2017] [Accepted: 02/26/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND The diagnosis of Crohn's disease (CD) can be delayed in clinical practice. In tuberculosis endemic areas, empirical anti-tubercular therapy further delays treatment. AIM(S) To assess risk factors for diagnostic delay and its impact on the long-term complications of Crohn's disease in India where tuberculosis is endemic. METHODS Data from a large prospectively established inflammatory bowel disease registry were analysed retrospectively. The time from onset of symptoms to diagnosis (diagnostic delay) was calculated and categorised into two groups based on median diagnostic delay. The risk factors for delay including anti-tubercular therapy were analysed. Logistic regression analysis was done to assess impact of diagnostic delay on development of stenotic and fistular complications including need for surgery. RESULTS Seven hundred and twenty Crohn's disease patients (60.3% male, median: 28 years) were included. Main outcome measures were stenosis, fistula and need for surgery. Subjects with diagnostic delay >18 months (median) developed significantly higher stenotic complications and surgery (OR 4.12; 95% CI: 2.74-6.33, P < 0.001 and OR 2.41, 95% CI: 1.68-3.42, P < 0.001), respectively, compared to those ≤18 months. There was no difference in the development of fistulous complications. 193/720 (27%) received anti-tubercular therapy which significantly contributed to diagnostic delay (OR: 2.47; 95% CI: 1.76-3.47, P < 0.001) with 47% showing initial clinical response (Crohn's disease activity index- CDAI decrease >100). Moreover, the incidence of stenotic complications was significantly higher in patients who had received prior anti-tubercular therapy (55/193 (28.49%) vs 78/527 (14.8%), P < 0.001, OR: 2.60, 95% CI: 1.64-4.12). CONCLUSIONS Diagnostic delay in Crohn's disease is associated with significantly higher stenotic complications and need for surgery. Empirical anti-tubercular therapy is the single largest contributor to diagnostic delay in tuberculosis endemic areas. Despite initial clinical response to anti-tubercular therapy, long-term stenotic complications are higher.
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Affiliation(s)
- R Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - P Pal
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - B G Girish
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D N Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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29
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Guri A, Kori M, Herskovitz P, Zimhony O. Intestinal granulomatous disease: what is the first call. BMJ Case Rep 2018; 2018:bcr-2017-223094. [PMID: 29674398 DOI: 10.1136/bcr-2017-223094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 15-year-old girl presented with erythema nodosum and mild abdominal complaints. Her intestinal granulomatous disease was erroneously diagnosed as Crohn's disease despite the fact that the possibility of tuberculosis was considered. The final diagnosis of tuberculosis was made only when an anti-tumour necrosis factor therapy resulted in further deterioration. The patient was treated with isoniazid, rifampin, pyrazinamide and ethambutol, with slow and steady clinical improvement until complete recovery was achieved.
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Affiliation(s)
- Alex Guri
- Department of Pediatrics, Kaplan Medical Center, Rehovot, Israel
| | - Michal Kori
- Department of Pediatrics, Kaplan Medical Center, Rehovot, Israel
| | | | - Oren Zimhony
- Infectious Diseases Unit, Kaplan Medical Center, Rehovot, Israel
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30
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Lin WC, Chang CW, Wang TE, Wang HY, Shih SC, Chu CH, Hsu TC. Endoscopic features and treatment response have better prediction rate than clinical symptoms/signs in distinguishing Crohn's disease and intestinal tuberculosis. ADVANCES IN DIGESTIVE MEDICINE 2017. [DOI: 10.1002/aid2.12121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Wei-Chen Lin
- Division of Gastroenterology; Department of Internal Medicine, Mackay Memorial Hospital; Taipei Taiwan
- Mackay Medicine; Nursing and Management College; Taipei Taiwan
| | - Chen-Wang Chang
- Division of Gastroenterology; Department of Internal Medicine, Mackay Memorial Hospital; Taipei Taiwan
- Mackay Medicine; Nursing and Management College; Taipei Taiwan
| | - Tsang-En Wang
- Division of Gastroenterology; Department of Internal Medicine, Mackay Memorial Hospital; Taipei Taiwan
- Mackay Medicine; Nursing and Management College; Taipei Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology; Department of Internal Medicine, Mackay Memorial Hospital; Taipei Taiwan
- Mackay Medicine; Nursing and Management College; Taipei Taiwan
| | - Shou-Chuan Shih
- Division of Gastroenterology; Department of Internal Medicine, Mackay Memorial Hospital; Taipei Taiwan
- Mackay Medicine; Nursing and Management College; Taipei Taiwan
| | - Cheng-Hsin Chu
- Division of Gastroenterology; Department of Internal Medicine, Mackay Memorial Hospital; Taipei Taiwan
- Mackay Medicine; Nursing and Management College; Taipei Taiwan
| | - Tzu-Chi Hsu
- Division of Colon and Rectal Surgery; Department of Surgery, Mackay Memorial Hospital; Taipei Taiwan
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31
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Wang L, Hong Y, Wu J, Leung YK, Huang Y. Efficacy of thalidomide therapy in pediatric Crohn’s disease with evidence of tuberculosis. World J Gastroenterol 2017; 23:7727-7734. [PMID: 29209113 PMCID: PMC5703932 DOI: 10.3748/wjg.v23.i43.7727] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/28/2017] [Accepted: 09/13/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To evaluate the efficacy of thalidomide for treating troublesome cases of pediatric Crohn’s disease (CD) with tuberculosis infection.
METHODS A retrospective study of clinical outcome among children treated with thalidomide was conducted. All patients had evidence of tuberculosis infection with a failure of anti-tuberculosis treatment for more than one year, and were subsequently diagnosed with CD. All the patients received thalidomide treatment with a starting dose of 1.2-2.5 mg/kg per day. Remission was defined as pediatric CD activity index less than or equal to 10.
RESULTS Ten patients with CD were treated with thalidomide at an average age of 7.2 years and followed up for a median of 22.2 mo. Clinical remission rate was 60% after 9-12 mo of thalidomide treatment. One patient with no response had an interleukin-10 receptor alpha gene mutation. Erythrocyte sedimentation rate, C-reactive protein and platelet count showed a dramatic decrease; hemoglobin level and weight improved significantly after thalidomide treatment when compared with the baseline values.
CONCLUSION Thalidomide is an effective and safe drug for remission of CD in pediatric patients who have been treated for tuberculosis.
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Affiliation(s)
- Lin Wang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, Shanghai 201102, China
| | - Yan Hong
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, Shanghai 201102, China
- Department of Pediatrics, Taizhou Women’s and Children’s Hospital of Wenzhou Medical University, Taizhou 318000, Zhejiang Province, China
| | - Jie Wu
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, Shanghai 201102, China
| | - Ying-Kit Leung
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, Shanghai 201102, China
| | - Ying Huang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, Shanghai 201102, China
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Seo H, Lee S, So H, Kim D, Kim SO, Soh JS, Bae JH, Lee SH, Hwang SW, Park SH, Yang DH, Kim KJ, Byeon JS, Myung SJ, Yang SK, Ye BD. Temporal trends in the misdiagnosis rates between Crohn's disease and intestinal tuberculosis. World J Gastroenterol 2017; 23:6306-6314. [PMID: 28974897 PMCID: PMC5603497 DOI: 10.3748/wjg.v23.i34.6306] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/30/2017] [Accepted: 08/15/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the temporal trends in the misdiagnosis rate between Crohn's disease (CD) and intestinal tuberculosis (ITB) in South Korea. METHODS We retrospectively reviewed the medical records of patients managed for CD or ITB at Asan Medical Center, a tertiary referral hospital, Seoul, Korea between 1996 and 2014. The temporal trends in the misdiagnosis rates between the two diseases were analyzed. The demographic and clinical characteristics were compared between CD patients who were initially misdiagnosed as ITB (final CD group) and vice versa (final ITB group). Final diagnostic criteria for ITB and medication for CD before definite diagnosis of TB were also analyzed in final ITB group. RESULTS In total, 2760 patients were managed for CD and 772 patients for ITB between 1996 and 2014. As well, 494 of the 2760 CD patients (17.9%) were initially misdiagnosed as ITB and 83 of the 772 ITB patients (10.8%) as CD. The temporal trend in misdiagnosing CD as ITB showed a decrease (OR = 0.89, 95%CI: 0.87-0.91, P < 0.001), whereas the temporal trend in misdiagnosing ITB as CD showed an increase (OR = 1.06, 95%CI: 1.01-1.11, P = 0.013). Age at diagnosis, presenting symptoms, and proportion of patients with active/past perianal fistula and active/inactive pulmonary tuberculosis (TB) were significantly different between final CD group and final ITB group. Forty patients (48.2%) in final ITB group were diagnosed by favorable response to empirical anti-TB treatment. Seventeen patients (20.5%) in final ITB group had inappropriately received corticosteroids and/or thiopurines due to misdiagnosis as CD. However, there were no mortalities in both groups. CONCLUSION Cases of CD misdiagnosed as ITB have been decreasing, whereas cases of ITB misdiagnosed as CD have been increasing over the past two decades.
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Affiliation(s)
- Hyungil Seo
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Seohyun Lee
- Division of Gastroenterology, Department of Internal Medicine, Center for Health Promotion, Seoul National University Hospital, Seoul 03080, South Korea
| | - Hoonsub So
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Donghoi Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Seon-Ok Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Jae Seung Soh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University College of Medicine Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do 14068, South Korea
| | - Jung Ho Bae
- Department of Gastroenterology, Seoul National University College of Medicine, Seoul National University Hospital Gangnam Center, Seoul 06236, South Korea
| | - Sun-Ho Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
- Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
- Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Kyung-Jo Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
- Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
- Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
- Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
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Rana SS, Sharma V, Sharma R, Nada R, Gupta R, Bhasin DK. Capsule endoscopy in small bowel Crohn’s disease and Tuberculosis. Trop Doct 2017; 47:113-118. [PMID: 28058980 DOI: 10.1177/0049475516686542] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Differentiation of small bowel tuberculosis (SBTB) from Crohn’s disease (CD) is a diagnostic challenge. We studied 52 patients with suspected SBTB or CD with terminal ileal involvement, who were prospectively enrolled. After confirming patency of the gastrointestinal tract, 26 patients underwent capsule endoscopy (CE). A final diagnosis of CD was found in 18 patients and SBTB in eight patients. All SBTB patients had involvment of the ileocecal valve (ICV) with large (n = 6) and aphthous (n = 2) ulcers in the ileal segment. In CD, ICV involvement was seen in five (33%) patients. Large and aphthous ulcers were observed in seven (47%) and 15 (100%) patients, respectively. On comparison with CD, patients with SBTB had increased frequency of ICV involvement ( P = 0.002) and lesser frequency of aphthous ulcers ( P = 0.007). CE can help in differentiating CD from SBTB by the position of its involvement and the type of ulcers present.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ravi Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Gupta
- Department of Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deepak Kumar Bhasin
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Sabe VT, Basson AR, Jordaan E, Mazinu M. The association between environmental exposures during childhood and the subsequent development of Crohn's disease: A score analysis approach. PLoS One 2017; 12:e0171742. [PMID: 28170439 PMCID: PMC5295693 DOI: 10.1371/journal.pone.0171742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 01/25/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Environmental factors during childhood are thought to play a role in the aetiology of Crohn's Disease (CD). In South Africa, recently published work based on an investigation of 14 childhood environmental exposures during 3 age intervals (0-5, 6-10 and 11-18 years) has provided insight into the role of timing of exposure in the future development of CD. The 'overlapping' contribution of the investigated variables however, remains unclear. The aim of this study was to perform a post hoc analysis using this data and investigate the extent to which each variable contributes to the subsequent development of CD relative to each aforementioned age interval, based on a score analysis approach. METHODS Three methods were used for the score analysis. Two methods employed the subgrouping of one or more (similar) variables (methods A and B), with each subgroup assigned a score value weighting equal to one. For comparison, the third approach (method 0) involved no grouping of the 14 variables. Thus, each variable held a score value of one. RESULTS Results of the score analysis (Method 0) for the environmental exposures during 3 age intervals (0-5, 6-10 and 11-18 years) revealed no significant difference between the case and control groups. By contrast, results from Method A and Method B revealed a significant difference during all 3 age intervals between the case and control groups, with cases having significantly lower exposure scores (approximately 30% and 40% lower, respectively). CONCLUSION Results from the score analysis provide insight into the 'compound' effects from multiple environmental exposures in the aetiology of CD.
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Affiliation(s)
- Victor Tinashe Sabe
- Medical BioScience Department, University of the Western Cape, Bellville, Western Cape, South Africa
- * E-mail:
| | - Abigail Raffner Basson
- Medical BioScience Department, University of the Western Cape, Bellville, Western Cape, South Africa
- Division of Gastroenterology and Liver Disease, Cominelli Laboratory, School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Esme Jordaan
- Biostatistics Unit, Medical Research Council of South Africa, Parow, Western Cape, South Africa
| | - Mikateko Mazinu
- Biostatistics Unit, Medical Research Council of South Africa, Parow, Western Cape, South Africa and the Statistics and Population Studies Department, University of the Western Cape, Bellville, Western Cape, South Africa
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Pratap Mouli V, Munot K, Ananthakrishnan A, Kedia S, Addagalla S, Garg SK, Benjamin J, Singla V, Dhingra R, Tiwari V, Bopanna S, Hutfless S, Makharia G, Ahuja V. Endoscopic and clinical responses to anti-tubercular therapy can differentiate intestinal tuberculosis from Crohn's disease. Aliment Pharmacol Ther 2017; 45:27-36. [PMID: 27813111 DOI: 10.1111/apt.13840] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 07/15/2016] [Accepted: 10/03/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Differentiation between intestinal tuberculosis and Crohn's disease is difficult and may require therapeutic trial with anti-tubercular therapy in tuberculosis-endemic regions. AIM To evaluate the role of therapeutic trial with anti-tubercular therapy in patients with diagnostic confusion between intestinal tuberculosis and Crohn's disease. METHODS We performed retrospective-comparative (n = 288: 131 patients who received anti-tubercular therapy before being diagnosed as Crohn's disease and 157 intestinal tuberculosis patients) and prospective-validation study (n = 55 patients with diagnostic confusion of intestinal tuberculosis/Crohn's disease). Outcomes assessed were global symptomatic response and endoscopic mucosal healing. RESULTS In the derivation cohort, among those eventually diagnosed as Crohn's disease, global symptomatic response with anti-tubercular therapy was seen in 38% at 3 months and in 37% who completed 6 months of anti-tubercular therapy. Ninety-four per cent of intestinal tuberculosis patients showed global symptomatic response by 3 months. Endoscopic mucosal healing was seen in only 5% of patients with Crohn's disease compared with 100% of intestinal tuberculosis patients. In the validation cohort, all the patients with intestinal tuberculosis had symptomatic response and endoscopic mucosal healing after 6 months of anti-tubercular therapy. Among the patients with an eventual diagnosis of Crohn's disease, symptomatic response was seen in 64% at 2 months and in 31% who completed 6 months of anti-tubercular therapy, none had mucosal healing. CONCLUSIONS Disproportionately lower mucosal healing rate despite an overall symptom response with 6 months of anti-tubercular therapy in patients with Crohn's disease suggests a need for repeat colonoscopy for diagnosing Crohn's disease. Patients with intestinal tuberculosis showing significant symptomatic response after 2-3 months of anti-tubercular therapy, suggest that symptom persistence after a therapeutic trial of 3 months of anti-tubercular therapy may indicate the diagnosis of Crohn's disease.
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Affiliation(s)
- V Pratap Mouli
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - K Munot
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - A Ananthakrishnan
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA
| | - S Kedia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - S Addagalla
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - S K Garg
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - J Benjamin
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - V Singla
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - R Dhingra
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - V Tiwari
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - S Bopanna
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - S Hutfless
- Division of Gastroenterology, Johns Hopkins University, Baltimore, MA, USA
| | - G Makharia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - V Ahuja
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
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Jin T, Fei B, Zhang Y, He X. The diagnostic value of polymerase chain reaction for Mycobacterium tuberculosis to distinguish intestinal tuberculosis from crohn's disease: A meta-analysis. Saudi J Gastroenterol 2017; 23:3-10. [PMID: 28139494 PMCID: PMC5329974 DOI: 10.4103/1319-3767.199135] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIM Intestinal tuberculosis (ITB) and Crohn's disease (CD) are important differential diagnoses that can be difficult to distinguish. Polymerase chain reaction (PCR) for Mycobacterium tuberculosis (MTB) is an efficient and promising tool. This meta-analysis was performed to systematically and objectively assess the potential diagnostic accuracy and clinical value of PCR for MTB in distinguishing ITB from CD. MATERIALS AND METHODS We searched PubMed, Embase, Web of Science, Science Direct, and the Cochrane Library for eligible studies, and nine articles with 12 groups of data were identified. The included studies were subjected to quality assessment using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS The summary estimates were as follows: sensitivity 0.47 (95% CI: 0.42-0.51); specificity 0.95 (95% CI: 0.93-0.97); the positive likelihood ratio (PLR) 10.68 (95% CI: 6.98-16.35); the negative likelihood ratio (NLR) 0.49 (95% CI: 0.33-0.71); and diagnostic odds ratio (DOR) 21.92 (95% CI: 13.17-36.48). The area under the curve (AUC) was 0.9311, with a Q* value of 0.8664. Heterogeneity was found in the NLR. The heterogeneity of the studies was evaluated by meta-regression analysis and subgroup analysis. CONCLUSIONS The current evidence suggests that PCR for MTB is a promising and highly specific diagnostic method to distinguish ITB from CD. However, physicians should also keep in mind that negative results cannot exclude ITB for its low sensitivity. Additional prospective studies are needed to further evaluate the diagnostic accuracy of PCR.
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Affiliation(s)
- Ting Jin
- The First People's Hospital of Xiaoshan District, Hangzhou, Zhejiang, China
| | - Baoying Fei
- Department of Gastroenterology, Tongde, Hospital of Zhejiang Province, Zhejiang, China,Address for correspondence: Prof. Baoying Fei, Department of Gastroenterology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China. E-mail:
| | - Yu Zhang
- First School of Clinical Medicine Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xujun He
- Department of Gastroenterological Laboratory, Zhejiang Province People's Hospital, Zhejiang, China
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Zhang F, Xu C, Ning L, Hu F, Shan G, Chen H, Yang M, Chen W, Yu J, Xu G. Exploration of Serum Proteomic Profiling and Diagnostic Model That Differentiate Crohn's Disease and Intestinal Tuberculosis. PLoS One 2016; 11:e0167109. [PMID: 27997555 PMCID: PMC5173341 DOI: 10.1371/journal.pone.0167109] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 11/07/2016] [Indexed: 01/30/2023] Open
Abstract
AIM To explore the diagnostic models of Crohn's disease (CD), Intestinal tuberculosis (ITB) and the differential diagnostic model between CD and ITB by analyzing serum proteome profiles. METHODS Serum proteome profiles from 30 CD patients, 21 ITB patients and 30 healthy controls (HCs) were analyzed by using weak cationic magnetic beads combined with MALDI-TOF-MS technique to detect the differentially expressed proteins of serum samples. Three groups were made and compared accordingly: group of CD patients and HCs, group of ITB patients and HCs, group of CD patients and ITB patients. Wilcoxon rank sum test was used to screen the ten most differentiated protein peaks (P < 0.05). Genetic algorithm combining with support vector machine (SVM) was utilized to establish the optimal diagnostic models for CD, ITB and the optimal differential diagnostic model between CD and ITB. The predictive effects of these models were evaluated by Leave one out (LOO) cross validation method. RESULTS There were 236 protein peaks differently expressed between group of CD patients and HCs, 305 protein peaks differently expressed between group of ITB patients and HCs, 332 protein peaks differently expressed between group of CD patients and ITB patients. Ten most differentially expressed peaks were screened out between three groups respectively (P < 0.05) to establish diagnostic models and differential diagnostic model. A diagnostic model comprising of four protein peaks (M/Z 4964, 3029, 2833, 2900) can well distinguish CD patients and HCs, with a specificity and sensitivity of 96.7% and 96.7% respectively. A diagnostic model comprising four protein peaks (M/Z 3030, 2105, 2545, 4210) can well distinguish ITB patients and HCs, with a specificity and sensitivity of 93.3% and 95.2% respectively. A differential diagnostic model comprising three potential biomarkers protein peaks (M/Z 4267, 4223, 1541) can well distinguish CD patients and ITB patients, with a specificity and sensitivity of 76.2% and 80.0% respectively. Among the eleven protein peaks from the diagnostic models and differential diagnostic model, two have been successfully purified and identified, Those two peaks were M/Z 2900 from the diagnostic model between CD and HCs and M/Z 1541 from the differential diagnostic model between CD and ITB. M/Z 2900 was identified as appetite peptide, M/Z 1541 was identified as Lysyl oxidase-like 2 (LOXL-2). CONCLUSION The differently expressed protein peaks analyzed by serum proteome with weak cationic magnetic beads combined MALDI-TOF-MS technique can effectively distinguish CD patients and HCs, ITB patients and HCs, CD patients and ITB patients. The diagnostic model between CD patients and HCs consisting of four protein peaks (M/Z 4964, 3029, 2833, 2900), the diagnostic model between ITB patients and HCs comprising four protein peaks (M/Z 3030, 2105, 2545, 4210) and the differential diagnostic model between CD patients and ITB patients comprising three protein peaks (M/Z 4267, 4223, 1541) had high specificity and sensitivity and can contribute to diagnoses of CD, ITB and the differential diagnosis between CD and ITB. Two proteins from the diagnostic model of CD and the differential diagnostic model between CD and ITB were identified. Further experiments are required using a larger cohort of samples.
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Affiliation(s)
- Fenming Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Chengfu Xu
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Longgui Ning
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Fengling Hu
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Guodong Shan
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Hongtan Chen
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Ming Yang
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Wenguo Chen
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Jiekai Yu
- Department of Tumor Research Institute, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Guoqiang Xu
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
- * E-mail:
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Predictive Factors for Differentiating Between Crohn's Disease and Intestinal Tuberculosis in Koreans. Am J Gastroenterol 2016; 111:1156-64. [PMID: 27296940 DOI: 10.1038/ajg.2016.212] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 04/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES A differential diagnosis between intestinal tuberculosis (ITB) and Crohn's disease (CD) is challenging. The aim of this study was to investigate the clinical, endoscopic, and histological features and to create a predictive score model for differentiating CD and ITB. METHODS In total, 261 patients, 99 with ITB and 162 with CD, were recruited from seven tertiary centers from 2005 to 2013 and reviewed retrospectively. For the creation of a validated model, parameters were selected by univariate logistic regression and receiver operating characteristic curve analyses. Then, the prediction model was established on the basis of β-coefficients of the multivariate logistic regression. For the validation of the model, the same regression equation was tested on the other group. RESULTS Age, diarrhea, ring-shaped ulcer, longitudinal ulcer, sigmoid involvement, suspicious radiological pulmonary tuberculosis, and gender were selected as the factors for a seven-marker model. In the seven-marker model of the validation data set, the sensitivity, specificity, positive predictive value, and negative predictive value with a cutoff level of 0.35 were 98.0, 92.4, 88.9, and 98.6, respectively. CONCLUSIONS The seven-marker model seems to be highly reliable for differentiating between ITB and CD and could be conveniently used by clinicians to obtain results.
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Lee HS, Choe J, Lee HJ, Hwang SW, Park SH, Yang DH, Kim KJ, Ye BD, Byeon JS, Myung SJ, Yoon YS, Yu CS, Kim JH, Yang SK. Change in the diagnosis of inflammatory bowel disease: a hospital-based cohort study from Korea. Intest Res 2016; 14:258-63. [PMID: 27433148 PMCID: PMC4945530 DOI: 10.5217/ir.2016.14.3.258] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/02/2016] [Accepted: 05/09/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS Accurately diagnosing inflammatory bowel disease (IBD) remains a challenge, but is crucial for providing proper management for affected patients. The aim of the present study was to evaluate the frequency of change in diagnosis in Korean patients who were referred to our institution with a diagnosis of IBD. METHODS We enrolled 1,444 patients diagnosed with ulcerative colitis (UC) and 1,452 diagnosed with Crohn's disease (CD), who had been referred to the Asan Medical Center between January 2010 and December 2014. These patients were assessed and subsequently classified as having UC, CD, indeterminate colitis, possible IBD, or non-IBD. RESULTS During a median follow-up of 15.9 months, 400 of the 2,896 patients (13.8%) analyzed in this study experienced a change in diagnosis. A change in diagnosis from UC to CD, or vice-versa, was made in 24 of 1,444 patients (1.7%) and 23 of 1,452 patients (1.6%), respectively. A change to a non-IBD diagnosis was the most common modification; 7.5% (108 of 1444) and 12.7% (184 of 1452) of the patients with a referral diagnosis of UC and CD, respectively, were reclassified as having non-IBD. Among the 292 patients who were ultimately determined not to have IBD, 135 (55 UC and 80 CD cases) had received IBD-related medication. CONCLUSIONS There are diagnostic uncertainties and difficulties in relation to IBD. Therefore, precise assessment and systematic follow-up are essential in the management of this condition.
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Affiliation(s)
- Ho-Su Lee
- Health Screening and Promotion Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jaewon Choe
- Health Screening and Promotion Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hyo Jeong Lee
- Health Screening and Promotion Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyung-Jo Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yong Sik Yoon
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin-Ho Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Miot J, Smith S, Bhimsan N. Resource use and cost of care with biologicals in Crohn's disease in South Africa: a retrospective analysis from a payer perspective. Int J Clin Pharm 2016; 38:880-7. [PMID: 27118462 DOI: 10.1007/s11096-016-0304-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 04/13/2016] [Indexed: 12/30/2022]
Abstract
Background Crohn's disease is a relapsing remitting inflammatory disease of the gastrointestinal tract. Treatment may require expensive biological therapy in severe patients. Affordability of the high cost anti-TNF-α agents has raised concern although evidence suggests cost-offsets can be achieved. There is little information on the resource utilisation of Crohn's patients in low and middle income countries. Objective The objective of this study is to investigate the resource utilisation and costs associated with biologicals treatment of Crohn's disease. Setting The setting for this study is in private healthcare in South Africa from a payer perspective. Method A retrospective longitudinal analysis of an administrative claims database from a large private healthcare insurer of patients who had at least 1 year claims exposure prior to starting biologicals and 2 years follow-up thereafter. Resource utilisation and costs including total Crohn's costs, hospital admissions and surgery, out of hospital costs, biologicals and chronic medicines were analysed. Main outcome measure The primary objective was to compare the change in resource utilisation and costs for Crohn's related conditions before and after starting biological treatment. Results A cohort of 72 patients was identified with a 35% (p = 0.005) reduction in Crohn's related costs (excluding the cost of biologicals) from ZAR 55,925 (U$5369) 1 year before compared to ZAR 36,293 (U$3484) 2 years after starting biological medicines. However, inclusion of the cost of biologicals more than doubled the total costs to ZAR 150,915 (±91,642) U$14,488 (±8798) in Year 2. Significant reductions in out-of hospital Crohn's related spend was also observed. Conclusions A reduction in healthcare costs is seen following starting biologicals in patients with moderate to severe Crohn's disease. However, the high cost of biological therapy outweighs any possible savings achieved in other areas of healthcare utilisation.
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Affiliation(s)
- Jacqui Miot
- Department of Pharmacy and Pharmacology, Faculty of Health Sciences, School of Therapeutic Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2196, South Africa. .,Clinical Policy Unit, Discovery Health, Sandton, South Africa.
| | - Susan Smith
- Clinical Policy Unit, Discovery Health, Sandton, South Africa
| | - Niri Bhimsan
- Clinical Policy Unit, Discovery Health, Sandton, South Africa
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Proteome analysis of the macroscopically affected colonic mucosa of Crohn's disease and intestinal tuberculosis. Sci Rep 2016; 6:23162. [PMID: 26988818 PMCID: PMC4796817 DOI: 10.1038/srep23162] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 02/25/2016] [Indexed: 12/17/2022] Open
Abstract
Differentiation between intestinal tuberculosis (ITB) and Crohn’s disease (CD) is challenging in geographical regions where both these diseases are prevalent. There is a need of biomarkers for differentiation between these two disorders. Colonic biopsies from inflamed mucosa of treatment-naive patients with ITB, CD and controls were used for analysis. Protein extracted from biopsies was digested with trypsin and resulting peptides were labeled with iTRAQ reagents. The peptides were subsequently analyzed using LC-MS/MS for identification and quantification. Gene ontology annotation for proteins was analyzed in PANTHER. Validation experiments were done for six differentially expressed proteins using immunohistochemistry. 533 proteins were identified and 241 proteins were quantified from 5 sets of iTRAQ experiments. While 63 were differentially expressed in colonic mucosa of patients with CD and ITB in at least one set of iTRAQ experiment, 11 proteins were differentially expressed in more than one set of experiments. Six proteins used for validation using immunohistochemistry in a larger cohort of patients; none of them however was differentially expressed in patients with ITB and CD. There are differentially expressed proteins in tissue proteome of CD and ITB. Further experiments are required using a larger cohort of homogeneous tissue samples.
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Ma JY, Tong JL, Ran ZH. Intestinal tuberculosis and Crohn's disease: challenging differential diagnosis. J Dig Dis 2016; 17:155-61. [PMID: 26854750 DOI: 10.1111/1751-2980.12324] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 02/02/2016] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
| | | | - Zhi Hua Ran
- Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Division of Gastroenterology and Hepatology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai Inflammatory Bowel Disease Research Center, Shanghai, China
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Wei JP, Wu XY, Gao SY, Chen QY, Liu T, Liu G. Misdiagnosis and Mistherapy of Crohn's Disease as Intestinal Tuberculosis: Case Report and Literature Review. Medicine (Baltimore) 2016; 95:e2436. [PMID: 26735549 PMCID: PMC4706269 DOI: 10.1097/md.0000000000002436] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The differential diagnosis of Crohn's disease (CD) and intestinal tuberculosis (ITB) remains difficult as the clinical symptoms of the 2 digestive diseases are so similar. Here we report a case where a patient was initially misdiagnosed with ITB prior to the correct CD diagnosis. The 46-year-old male patient was hospitalized elsewhere for pain in the right lower abdomen and underwent an appendectomy. The pathological diagnosis was ITB and the patient was administered antituberculosis therapy for 1 year. Afterward, the patient was readmitted to the hospital for a right lower abdominal mass. A computed tomography scan revealed intestinal gas, fistula, and abdominal mass. We performed a right hemicolectomy on the patient. Postoperatively, we diagnosed the patient with CD, based on patient history and pathological examination. According to the CD active index (CDAI), the patient was at high risk and began treatment with infliximab. The patient has remained in complete remission and made a good recovery after 8-months follow-up. We compared this case with the results of a literature review on the misdiagnosis between CD and ITB (26 previously reported cases) to determine the characteristics of misdiagnosed cases. We found that distinguishing between ITB and CD is difficult because of their varied clinical presentation, nonspecific investigative tools, and profound similarities even in pathological specimens. Although a CT scan to determine the morphology of the bowel wall is a key for correct diagnosis, each case still poses challenges for diagnosis and administrating the appropriate treatment.
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Affiliation(s)
- Jiang-Peng Wei
- From the Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
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Choi YS, Kim DS, Lee JB, Kim JK, Jung HJ, Lee SD, Song KH, Lee DH, Kim MJ. Clinical Features of Tuberculous Versus Crohn's Anal Fistulas, in Korea. J Crohns Colitis 2015; 9:1132-7. [PMID: 26374663 DOI: 10.1093/ecco-jcc/jjv164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/07/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS In Western countries, tuberculous anal fistula may not be an issue because tuberculosis [TB] is not common, and this is a very rare form of extrapulmonary manifestation of TB. However in TB-endemic countries, careful diagnostic differentiation is required because the clinical features of TB anal fistula and Crohn's disease [CD] anal fistula are similar, with distinguishing features remaining unclear. We aimed to analyse the clinical features of TB versus CD anal fistulas. METHOD Among 13872 patients who underwent anal fistula surgery from 2003 to 2014, 87 patients with TB fistulas and 116 patients with CD fistulas were included. Data on the annual incidence of TB and CD, as well as the clinical, pathological, ultrasonographic, colonoscopic and surgical data were analysed. RESULTS Compared with CD, the TB group was older [median: 37 vs 22 years] and underlying chronic illness was more common [20.3% vs 2.6%]. In the TB group, 46 patients [59.7%] showed active or inactive pulmonary TB, and acid-fast bacilli and caseating granuloma were found in 56.3% and 62.1%, respectively. During colonoscopy, mucosal lesions were observed more frequently in CD [96.9% vs 16.9%]. CONCLUSIONS TB anal fistula is clinically very similar to CD anal fistula. In Korea, the incidence of CD anal fistula has recently increased in prevalence, whereas the prevalence of TB anal fistula is decreasing but is still persistent. We recommend that clinicians should prepare for a possibility of TB as well as CD anal fistula in TB-endemic countries including Korea.
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Affiliation(s)
- Yong-Sung Choi
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Do-Sun Kim
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Jae-Bum Lee
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Jong-Kyu Kim
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | | | - Seong-Dae Lee
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Kee-Ho Song
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Doo-Han Lee
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Mi-Jung Kim
- Department of Pathology, Daehang Hospital, Seoul, Korea
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Ye Z, Lin Y, Cao Q, He Y, Xue L. Granulomas as the Most Useful Histopathological Feature in Distinguishing between Crohn's Disease and Intestinal Tuberculosis in Endoscopic Biopsy Specimens. Medicine (Baltimore) 2015; 94:e2157. [PMID: 26656343 PMCID: PMC5008488 DOI: 10.1097/md.0000000000002157] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Ziyin Ye
- From the Department of Pathology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China (ZY, YL, QC, LX); and Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China (YH)
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Raffner Basson A, Swart R, Jordaan E, Mazinu M, Watermeyer G. Vitamin D Deficiency Increases the Risk for Moderate to Severe Disease Activity in Crohn's Disease Patients in South Africa, Measured by the Harvey Bradshaw Index. J Am Coll Nutr 2015; 35:163-74. [PMID: 26430776 DOI: 10.1080/07315724.2015.1039665] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Vitamin D has immunoregulatory properties and appears to influence disease outcomes in patients with Crohn's disease (CD). The primary aim of this study was to evaluate the association between vitamin D status and CD activity in South Africa. METHODS In a cross-sectional study performed between September 2011 and January 2013, serum 25-hydroxyvitamin D (25(OH)D) was measured in 186 consecutive patients with CD seen at 2 inflammatory bowel disease (IBD) centers and 199 healthy controls in the Western Cape, South Africa. Lifestyle and clinical variables were identified using an investigator-administered questionnaire, as well as clinical examination and patient case notes. Vitamin D status was evaluated in 2 ways: ≤ 20 ng/mL vs ≥ 21 ng/mL and ≤ 29 ng/mL vs ≥ 30 ng/mL. Disease activity was measured by the Harvey Bradshaw Index (HBI). Various 25(OH)D threshold concentrations for predicting a higher HBI score were also investigated. RESULTS On multiple log-binomial regression analysis, higher HBI scores and not having taken vitamin D supplementation in the 6 months prior to enrollment were identified as risk factors for vitamin D deficiency in patients with CD, defined either as ≤ 20 ng/mL or as ≤ 29 ng/mL (p < 0.03). Compared to patients with HBI < 5, those with HBI ≥ 8 were 2.5 times more likely to have 25(OH)D concentrations ≤ 21 ng/mL (prevalence risk [PR] = 2.5; 95% confidence interval [CI], 1.21-6.30). The risk was similar, though not as high, when defined as ≤ 29 ng/mL (PR = 2.0; 95% CI, 1.13-3.51). When vitamin D deficiency was defined as <20, <30, <40, and <50 ng/mL, the sensitivity and specificity obtained were 44.9% and 78.8%; 75.5% and 62.4%; 86.7% and 44.7%; and 92.9% and 23.5%, respectively (area under the curve = 0.71; p < 0.0001). CONCLUSION Low serum 25(OH)D was associated with increased CD activity in a South African cohort.
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Affiliation(s)
| | | | - Esme Jordaan
- b Statistics and Population Studies Department.,c University of the Western Cape, Bellville, Western Cape, SOUTH AFRICA; Biostatistics Unit, Medical Research Council of South Africa , Parow , Western Cape , SOUTH AFRICA
| | - Mikatako Mazinu
- c University of the Western Cape, Bellville, Western Cape, SOUTH AFRICA; Biostatistics Unit, Medical Research Council of South Africa , Parow , Western Cape , SOUTH AFRICA
| | - Gillian Watermeyer
- d Department of Gastroenterology , Groote Schuur Hospital , Cape Town , Western Cape , SOUTH AFRICA.,e Department of Medicine , University of Cape Town , Cape Town , Western Cape , SOUTH AFRICA
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Kim EY, Choi IJ, Kwon KA, Ryu JK, Hahm KB. Highlights from the 52nd Seminar of the Korean Society of Gastrointestinal Endoscopy. Clin Endosc 2015; 48:269-78. [PMID: 26240798 PMCID: PMC4522416 DOI: 10.5946/ce.2015.48.4.269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/02/2015] [Indexed: 11/14/2022] Open
Abstract
In this July issue of Clinical Endoscopy, state-of-the-art articles selected from the lectures delivered during the 52nd Seminar of the Korean Society of Gastrointestinal Endoscopy (KSGE) on March 29, 2015 are covered, focusing on highlighted educational contents relevant to either diagnostic or therapeutic gastrointestinal (GI) endoscopy. Our society, the KSGE, has continued to host this opportunity for annual seminars twice a year over the last 26 years and it has become a large-scale prestigious seminar accommodating over 4,000 participants. Definitely, the KSGE seminar is considered as one of the premier state-of-the-art seminars dealing with GI endoscopy, appealing to both the beginner and advanced experts. Lectures, live demonstrations, hands-on courses, as well as an editor school, which was an important consensus meeting on how to upgrade our society journal, Clinical Endoscopy, to a Science Citation Index (Expanded) designation were included in this seminar. The 52nd KSGE seminar consisted of more than 20 sessions, including special lectures, concurrent sessions for GI endoscopy nurses, and sessions exploring new technologies. This is a very special omnibus article to highlight the core contents divided into four sessions: upper GI tract, lower GI tract, pancreatobiliary system, and other specialized sessions.
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Affiliation(s)
- Eun Young Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Il Ju Choi
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Kwang An Kwon
- Department of Gastroenterology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ki Baik Hahm
- Department of Gastroenterology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Wu YF, Ho CM, Yuan CT, Chen CN. Intestinal tuberculosis previously mistreated as Crohn's disease and complicated with perforation: a case report and literature review. SPRINGERPLUS 2015; 4:326. [PMID: 26180746 PMCID: PMC4493258 DOI: 10.1186/s40064-015-1129-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 06/30/2015] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Tuberculosis is known as a notorious mimicker and distinguishing between intestinal tuberculosis and Crohn's disease is a huge diagnostic challenge. CASE DESCRIPTION Here, we report a case of hollow organ perforation due to intestinal tuberculosis that was previously mistreated as Crohn's disease. Staged operation with emergency resection of the diseased small bowel and temporary ileostomy was performed for the perforation, followed by 6-month standard treatment for miliary tuberculosis, which was diagnosed on the basis of the presence of acid-fast bacilli in the diseased bowel and positive culture of Mycobacterium tuberculosis from sputum, ascites, and stool samples. Ileostomy takedown was performed, and the continuity of the gastrointestinal tract was restored 6 months after the first surgery. The patient recovered well thereafter. CONCLUSION Timely surgical intervention can help establish the finial diagnosis of tuberculosis, rescue the patient from abdominal emergency, and provide a chance for cure.
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Affiliation(s)
- Yu-Feng Wu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Cheng-Maw Ho
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Tsu Yuan
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiung-Nien Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
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Sekine K, Nagata N, Shindo T, Morino E, Shimbo T, Akiyama J, Mizokami M, Uemura N. Combined identifying granuloma and biopsy culture is useful for diagnosing intestinal tuberculosis. Int J Colorectal Dis 2015; 30:939-45. [PMID: 25868516 DOI: 10.1007/s00384-015-2208-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2015] [Indexed: 02/04/2023]
Abstract
PURPOSES Differential diagnosis of intestinal tuberculosis (ITB) and inflammatory bowel disease (IBD) can be difficult, but many gastroenterologists may only perform biopsy for pathology and their own experience. This study aimed to identify optimal sample collection and pathogen detection methods for diagnosing ITB. METHODS A cohort of 182 patients (50 had ITB and 132 had IBD or other colonic diseases) who underwent colonoscopy was analyzed. Sensitivity of acid-fast bacilli (AFB), culture, polymerase chain reaction (PCR), and granuloma pathology on hematoxylin and eosin stain for diagnosing ITB were compared in relation to biopsy, endoscopic aspirated intestinal fluid, or standard stool evaluations. We also evaluated which combination offered the highest yield to diagnose intestinal tuberculosis in addition to granuloma pathology. RESULTS Between ITB and non-ITB, no significant differences were observed in age, sex, and nationality. In biopsy analysis, sensitivity was as follows: culture (50%), AFB (38%), PCR (25%), granuloma pathology (51%), and caseous granuloma (8.2%), while specificity of granuloma pathology was low (80%), compared to other tests. In intestinal fluid analysis, sensitivity was as follows: culture (46%), AFB (42%), and PCR (35%). In standard stool analysis, sensitivity was as follows: culture (47%), AFB (37%), and PCR (23%). Granuloma pathology plus biopsy culture offered the highest combination sensitivity (77 %), significantly (P < 0.01) higher than that for granuloma pathology alone (51%). CONCLUSIONS When encountering suspected intestinal tuberculosis or IBD on colonoscopy, biopsy culture is recommended in addition to pathological assessment of granuloma. This diagnostic strategy will lead to accurate differential diagnosis of colonic disease, facilitating appropriate treatment.
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Affiliation(s)
- Katsunori Sekine
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
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Sood A, Midha V, Singh A. Differential diagnosis of Crohn's disease versus ileal tuberculosis. Curr Gastroenterol Rep 2015; 16:418. [PMID: 25277043 DOI: 10.1007/s11894-014-0418-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Both intestinal tuberculosis and Crohn's disease are chronic granulomatous inflammatory diseases of the bowel having overlap of clinical, endoscopic, radiological, and histological features. Differentiating between the two disorders is relevant not only in Asian countries but also in the West. In spite of diagnostic criteria for both diseases being available, still the dilemma of segregating the two diseases remains. Nearly one third of the patients with Crohn's disease may receive anti-tuberculosis treatment also. Diagnosis should be based on the combination of all disease-specific and corroborative evidences.
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Affiliation(s)
- Ajit Sood
- Department of Gastroenterology, DMC&H, Ludhiana, 141001, India,
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