TB or CD?

A Aljebreen, MD, Assistant

Professor, department of
Medicine, KKUH
Colrectum Forum
2007

Overview

TB and CD epidemiology
How to diagnose?

Introduction

In geographical regions where both intestinal

tuberculosis (TB) and Crohns disease (CD)
coexist, the differential diagnosis of these two
conditions poses a challenge to clinicians.
The ultimate course of these two disorders is
different.
Intestinal TB is entirely curable, provided that
the diagnosis is made early enough and
appropriate treatment is instituted.
In contrast, CD is a progressive relapsing
illness.
Unfortunately, it is difficult to differentiate
intestinal TB from CD because of similar
clinical, pathological, radiological, and
endoscopic findings.

Epidemiology of TB

Annual incidence rates of

extrapulmonary tuberculosis have been
increasing to 4.7 cases per 100,000
population in 1997 in Saudi Arabia.
Extrapulmonary TB represented 28.2%
of all reported TB cases.
Abdominal TB accounted for 16% of all
extrapulmonary TB in 2 large series
from Riyadh and Jeddah.

Ministry of Health. Tuberculosis. Annual Health Report, 1997. p. 4

Epidemiology of TB

Gastrointestinal TB was the 2nd

most common type of TB after
pulmonary disease among 820
patients with TB between 1982 and
1990 (small bowel involvement in
34% of them)

Al-Karawi. J Clin Gastroenterol 1995; 20:

225-232.

CD in Saudi Arabia

Very scarce data

It was considered an area without IBD
1982, the first 2 cases reported.
In 2003, Al-Ghamdi reported the first study
about CD where they collected 77 cases from
1983-2002.
Concluded there was a definite increase in
the incidence of CD
At KKUH we have collected 79 new IBD cases
within the last 2 years
So, there is a definite surge of IBD
Al-Ghamdi et al, WJG
2003

Extrapulmonary TB:
difficult to diagnose??

Several forms of extrapulmonary TB

lack any of the localizing symptoms
or signs.
Cutaneous anergy to PPD was noted
in 35-50% of patients.
No clinical or radiological evidence
of pulmonary TB could be found in
up to one 3rd of these patients.

Diagnosis: intestinal TB
or CD

They can present exactly with same

clinical pictures (same age group,
symptoms and signs)
Same radiological findings and same
endoscopic findings
Mostly with same pathological
findings
So how can we make the diagnosis?

? Other features

History of previous TB
CXR findings of TB
The tuberculin skin test is less
helpful, because a positive test does
not necessarily mean active disease.
Perianal fistulae and extraintesitnal
manifestations of CD
If all negative: any other clues??

Multiple attempts!!

Endoscopic findings?
Laproscopic findings?
Histological findings?
PCR?
Empirical TB?

Endoscopic diagnosis?

CD (4 parameters)

Anorectal lesions,
longitudinal ulcers,
aphthous ulcers, and
cobblestone appearance

Intestinal TB (4 parameters)

involvement of fewer than four segments,

a patulous ileocecal valve,
transverse ulcers, and
scars or pseudopolyps

Endoscopy. 2006 Jun;38(6):592-

Endoscopic diagnosis?

Lee et al hypothesized that a diagnosis of Crohn's

disease could be made when the number of
parameters characteristic of Crohn's disease was
higher than the number of parameters
characteristic of intestinal tuberculosis, and vice
versa.
Making these assumptions, the diagnosis of either
intestinal tuberculosis or Crohn's disease would
have been made made correctly in 77 of our 88
patients (87.5 %), incorrectly in seven patients
(8.0 %), and would not have been made in four
patients (4.5 %).

Endoscopy. 2006 Jun;38(6):592-

Endoscopic findings: TB

In tuberculosis patients,
transverse ulcers with
surrounding hypertrophic
mucosa and multiple erosions
were usual colonoscopic findings.

Am J Gastroenterol 1998;93: 606609.

Gastrointest Endosc 2004;59:362-8.

Typical transverse ulcer

Gastrointest Endosc 2004;59:362-8.

Radiology

SBFT reveals a thickened bowel wall with

distortion of the mucosal folds and
ulcerations.
CT may show preferential thickening of the
ileocecal valve and medial wall of the cecum
and massive lymphadenopathy with central
necrosis.
Calcified mesenteric lymph nodes and an
abnormal chest film are other findings that aid
in the diagnosis of intestinal tuberculosis.

At surgery: TB

Reduced largely since introduction of

colonoscopy
Indications:

Mass lesions associated with the hypertrophic form,

because they can lead to luminal compromise with
complete obstruction.
Surgery also may be necessary when free
perforation, confined perforation with abscess
formation, or massive hemorrhage occur.

Findings:

The bowel wall appears thickened with an

inflammatory mass surrounding the ileocecal region.
The serosal surface is covered with multiple
tubercles.
The mesenteric lymph nodes frequently are enlarged
and thickened.

Histologically

Intestinal TB: granulomas are

Large,
multiple,
confluent with
caseation
Ulcers lined by epitheliod histiocytes

CD
Fissuring ulcer,
lymphoid aggregates,
transmural inflammation, and
Infrequent, small, noncaseating
granulomas.

Am J Gastroenterol
2002;97:1446 1451.
Pulimood et al. Gut 1999

Multiple
confluent
granulomas,
one of which
exhibits
necrosis.
There is almost
no infiltration of
neutrophils.

PCR: rapid and accurate?

The positivity rate by PCR in 39 intestinal

tuberculosis specimens was 64.1%
(25/39), but was zero by PCR in 30
Crohns disease specimens.
Moreover, in the tissues of intestinal
tuberculosis with granulomas similar to
those of Crohns disease, there were
71.4% (10/14) positive by PCR, and there
were 61.1% (11/18) positive in intestinal
tuberculosis tissues without granulomas.
Am J Gastroenterol
2002;97:1446 1451.

Empirical anti-TB

If intestinal TB still possibility, give

4-6 weeks of anti-TB
30% of CD patietns at China
receives anti-TB before final
diagnosis
? Saudi

ASCA?

ASCA (IgG and IgA) does not

differentiate between CD and
intestinal TB
No correlation between ASCA and
duration, location and behaviour of
CD and intestinal TB

Makhania et al. Digestive disease & Science. Jan 200

Microbiology

Finding Acid-fast bacilli in one third

of patients.
The organism also can be recovered
in a culture of the involved tissues
(up to 50% of pts but need 8 weeks)

Horvath et al, AJG 1998

Intestinal TB: when to

call?

The definitive diagnosis of

intestinal tuberculosis is made by
identification of the organism in tissue,
either by direct visualization with an
acid-fast stain,
by culture of the excised tissue, or
by a PCR assay.

Presumptive diagnosis

can be established in
A patient with active pulmonary
tuberculosis and radiologic and
clinical findings that suggest intestinal
involvement.
Response to anti-TB

Summary

In geographical regions where both intestinal tuberculosis

(TB) and Crohns disease (CD) coexist, the differential
diagnosis of these two conditions poses a challenge to
clinicians.
Unfortunately, it is difficult to differentiate intestinal TB
from CD because of similar clinical, pathological,
radiological, and endoscopic findings.
Although attempts have been made to distinguish them,
there are still no specific differential diagnostic methods
up to now.
Polymerase chain reaction (PCR) assay, which allows
highly specific and sensitive detection of Mycobacterium
tuberculosis has been developed (9 11), and may provide
a novel means for differentiating between these two
conditions.