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World J Gastroenterol. Jan 28, 2019; 25(4): 418-432
Published online Jan 28, 2019. doi: 10.3748/wjg.v25.i4.418
Differentiating Crohn’s disease from intestinal tuberculosis
Saurabh Kedia, Prasenjit Das, Kumble Seetharama Madhusudhan, Siddhartha Dattagupta, Raju Sharma, Peush Sahni, Govind Makharia, Vineet Ahuja
Saurabh Kedia, Govind Makharia, Vineet Ahuja, Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
Prasenjit Das, Siddhartha Dattagupta, Department of Pathology, All India Institute of Medical Sciences, New Delhi 110029, India
Kumble Seetharama Madhusudhan, Raju Sharma, Department of Radiology, All India Institute of Medical Sciences, New Delhi 110029, India
Peush Sahni, Department of GI Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
Author contributions: All authors equally contributed to this paper with conception and design of the study, literature review and analysis, drafting and critical revision and editing, and final approval of the final version.
Conflict-of-interest statement: The authors declare no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Saurabh Kedia, MD, Assistant Professor, Department of Gastroenterology, All India Institute of Medical Sciences, Room No 3066, Third Floor, Teaching Block, New Delhi 110029, India. dr.saurabhkedia@aiims.edu
Telephone: +91-11-26546575 Fax: +91-11-26588663
Received: July 26, 2018
Peer-review started: July 26, 2018
First decision: October 8, 2018
Revised: December 7, 2018
Accepted: December 14, 2018
Article in press: December 14, 2018
Published online: January 28, 2019
Processing time: 184 Days and 8.2 Hours
Abstract

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

Keywords: Crohn's disease; Intestinal tuberculosis; Endoscopy; Computed tomographic enterography; Granuloma

Core tip: There is a constant challenge of differentiating Crohn’s disease (CD) from intestinal tuberculosis, especially with the increasing burden of inflammatory bowel disease in tuberculosis-endemic areas. Caseation necrosis on biopsy, positive acid-fast bacillus smear/culture, and necrotic lymph node on computed tomography (CT) are the only differentiating features with 100% specificity, though are limited by poor sensitivity. Multi-parametric models have their own limitations and a therapeutic trial of anti-tubercular therapy is often required. Upcoming markers include the latest Bayesian meta-analysis, enumeration of peripheral blood T-regulatory cells, and updated CT based predictive score. Therapeutic trial is associated with a delay in CD diagnosis, and better modalities/biomarkers are required for improved differentiation and reduction in the need for anti-tubercular therapy trial.