Brief Article
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World J Gastroenterol. May 7, 2014; 20(17): 5017-5024
Published online May 7, 2014. doi: 10.3748/wjg.v20.i17.5017
Routine diagnosis of intestinal tuberculosis and Crohn's disease in Southern India
Geir Larsson, Thrivikrama Shenoy, Ramalingom Ramasubramanian, Leena Kondarappassery Balakumaran, Milada Cvancarova Småstuen, Gunnar Aksel Bjune, Bjørn Allan Moum
Geir Larsson, Department of Medicine, Unger-Vetlesen Institute, Lovisenberg Diaconal Hospital, NO-0440 Oslo, Norway
Thrivikrama Shenoy, Population Health and Research Institute, Medical College PO, Trivandrum 695011, Kerala, India
Ramalingom Ramasubramanian, Thoothukudi Government Medical College, Thoothukudi 628002, Tamil Nadu, India
Leena Kondarappassery Balakumaran, Population Health and Research Institute, Medical College PO, Trivandrum 695011, Kerala, India
Milada Cvancarova Småstuen, Department of Biostatistics, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, NO-0318 Oslo, Norway
Gunnar Aksel Bjune, Institute of Health and Society, Faculty of Medicine, University of Oslo, NO-0318 Oslo, Norway
Bjørn Allan Moum, Department of Gastroenterology and Hepatology, Institute of Clinical Medicine, Oslo University Hospital Ullevål, NO-0424 Oslo, Norway
Author contributions: Larsson G designed and performed the research and wrote the paper; Shenoy T designed the research, advised on the research methods, served as a centre investigator and edited the paper; Ramasubramanian R served as a centre investigator and edited the paper; Balakumaran LK organised the research and sample collection and edited the paper; Småstuen MC supervised on the statistical analyses and edited the paper; Bjune GA advised on tuberculosis aspects and edited the paper; Moum BA advised on the research design, methods and gastroenterological aspects and edited the paper.
Supported by The South-Eastern Norwegian Regional Health Authority, No. 2011132, Lovisenberg Diaconal Hospital’s Research Fund and The Unger-Vetlesen Medical Fund
Correspondence to: Dr. Geir Larsson, Department of Medicine, Unger-Vetlesen Institute, Lovisenberg Diaconal Hospital, NO-0440 Oslo, Norway. larsson.geir@gmail.com
Telephone: +47-23-225140 Fax: +47-23-225139
Received: October 11, 2013
Revised: December 31, 2013
Accepted: March 5, 2014
Published online: May 7, 2014
Processing time: 207 Days and 16.3 Hours
Abstract

AIM: To investigate whether routinely measured clinical variables could aid in differentiating intestinal tuberculosis (ITB) from Crohn’s disease (CD).

METHODS: ITB and CD patients were prospectively included at four South Indian medical centres from October 2009 to July 2012. Routine investigations included case history, physical examination, blood biochemistry, ileocolonoscopy and histopathological examination of biopsies. Patients were followed-up after 2 and 6 mo of treatment. The diagnosis of ITB or CD was re-evaluated after 2 mo of antituberculous chemotherapy or immune suppressive therapy respectively, based on improvement in signs, symptoms and laboratory variables. This study was considered to be an exploratory analysis. Clinical, endoscopic and histopathological features recorded at the time of inclusion were subject to univariate analyses. Disease variables with sufficient number of recordings and P < 0.05 were entered into logistic regression models, adjusted for known confounders. Finally, we calculated the odds ratios with respective confidence intervals for variables associated with either ITB or CD.

RESULTS: This study included 38 ITB and 37 CD patients. Overall, ITB patients had the lowest body mass index (19.6 vs 22.7, P = 0.01) and more commonly reported weight loss (73% vs 38%, P < 0.01), watery diarrhoea (64% vs 33%, P = 0.01) and rural domicile (58% vs 35%, P < 0.05). Endoscopy typically showed mucosal nodularity (17/31 vs 2/37, P < 0.01) and histopathology more frequently showed granulomas (10/30 vs 2/35, P < 0.01). The CD patients more frequently reported malaise (87% vs 64%, P = 0.03), nausea (84% vs 56%, P = 0.01), pain in the right lower abdominal quadrant on examination (90% vs 54%, P < 0.01) and urban domicile (65% vs 42%, P < 0.05). In CD, endoscopy typically showed involvement of multiple intestinal segments (27/37 vs 9/31, P < 0.01). Using logistic regression analysis we found weight loss and nodularity of the mucosa were independently associated with ITB, with adjusted odds ratios of 8.6 (95%CI: 2.1-35.6) and 18.9 (95%CI: 3.5-102.8) respectively. Right lower abdominal quadrant pain on examination and involvement of ≥ 3 intestinal segments were independently associated with CD with adjusted odds ratios of 10.1 (95%CI: 2.0-51.3) and 5.9 (95%CI: 1.7-20.6), respectively.

CONCLUSION: Weight loss and mucosal nodularity were associated with ITB. Abdominal pain and excessive intestinal involvement were associated with CD. ITB and CD were equally common.

Keywords: Diagnosis; Differential; Tuberculosis; Gastrointestinal; Crohn’s disease; India; Signs and symptoms; Endoscopy; Histopathology

Core tip: Intestinal tuberculosis (ITB) and Crohn’s disease (CD) may easily be confused with one another in terms of clinical, laboratory, endoscopic and histopathological features. In this prospective multi-centre study from Southern India, we found weight loss and mucosal nodularity were associated with ITB. Furthermore, right lower abdominal pain and multi-segment intestinal involvement were associated with CD. The random inclusion of as many CD as ITB patients suggests that CD may be increasing in the region. Current diagnostic modalities for differentiating ITB from CD are imperfect and simple inexpensive tools for diagnosis are needed.