Small bowel tuberculosis

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

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.

Imaging in discriminating intestinal tuberculosis and Crohn's disease: past, present and the future

Introduction: Intestinal tuberculosis (ITB) and Crohn's disease (CD) have similar clinical presentation, but require different treatment approaches. Despite advances in various endoscopic, imaging, microbiological, and histological techniques, the differentiation of these two entities is often difficult. Newer radiological and image acquisition modalities have now become indispensable tools for evaluation of these two diseases.Areas covered: This review summarizes the currently available literature on various radiological investigations to differentiate ITB from CD. This review also enumerates the newer modalities in image acquisition techniques and their potential role for differentiating these two diseases. At present abdominal computed tomography (CT) scan is used as a first line investigation for differentiating ITB from CD. Magnetic resonance imaging (MRI) is preferred in pediatric patients and for follow-up studies.Expert opinion: Role of newer modalities like contrast enhanced abdominal ultrasound, perfusion CT, advanced MRI and positron emission tomography (PET) is evolving and requires further exploration. Till further robust studies are available, differentiation between ITB and CD requires use of a combination of clinical, endoscopic, serological, histological, and radiological parameters rather than relying on a single test.

Gastrointestinal Tuberculosis

Gastrointestinal tuberculosis (TB) is a fascinating disease which can be observed both in the clinical context of active pulmonary disease and as a primary infection with no pulmonary involvement. It represents a significant clinical challenge because of the resurgence of TB as well as the diagnostic challenges it poses. A high clinical suspicion remains the most powerful tool in an era of medicine when reliance on diagnostic technology increases. Antimicrobial therapy is the mainstay of therapy, but surgical and endoscopic interventions are frequently required for intestinal TB. Gastrointestinal TB is truly the "great mimic" and continues to require the astute clinical acumen of skillful clinicians to diagnose and treat.

Capsule endoscopy in small bowel Crohn’s disease and Tuberculosis

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.

Intestinal tuberculosis versus crohn's disease: Clinical and radiological recommendations

Intestinal tuberculosis is a common clinical problem in India. The clinical features of this disease are nonspecific and can be very similar to Crohn's disease. Radiological evaluation of the small bowel has undergone a paradigm shift in the last decade. This long tubular organ that has traditionally been difficult to evaluate can now be well-visualized by some innovative imaging and endoscopic techniques. This article highlights the state-of-the-art evaluation of ulceroconstrictive diseases of the bowel and provides recommendations for the differentiation of intestinal tuberculosis from Crohn's disease.

Evaluation of intestinal tuberculosis by multi-slice computed tomography enterography

BACKGROUND

Multi-slice computed tomography enterography (MSCTE) is now widely used to diagnose and monitor intestinal disease. Preliminary studies suggest that MSCTE may be useful in detecting intestinal tuberculosis (ITB). We sought to assess the use of MSCTE for the diagnosis of ITB in our medical center.

METHODS

In this retrospective study, 15 patients (11 males and 4 females, 6 to 65 years old) were enrolled and diagnosed with ITB by MSCTE. Diagnosis were confirmed by pathology or clinical criteria. Two experienced abdominal radiologists evaluated the images and defined the location, number, shape, edge, surrounding tissue alterations of ITB and other associated changes in the peritoneum, mesentery and solid abdominal organs.

RESULTS

The interval between the onset of symptoms and diagnosis varied from 20 days to 10 years. The most common symptom was abdominal pain (80 %). The ileocecum was the most common site affected by ITB (87 %). Morphological MSCTE findings were variable and included multi-segmental symmetric intestinal mural thickening found in 6 patients (40 %), solid masses found in 9 patients (60 %), and enlarged lymph nodes (LNs) found in 13 (87 %) patients. Non-enhancing central necrosis and rim enhancement were noted in 10 patients (67 %).

CONCLUSIONS

Characteristic MSCTE findings of ITB include solid mass or multi-segmental symmetric mural thickening involving the ileocecal area and rim enhanced LNs. Knowledge of these features in combination with a high index of suspicion can be useful in early diagnosis of ITB.

Computerized tomography-based predictive model for differentiation of Crohn's disease from intestinal tuberculosis

BACKGROUND

Intestinal tuberculosis (ITB) and Crohn's disease (CD) have clinical, radiological, endoscopic, and histological resemblance. There is paucity of literature regarding differentiation of CD and ITB based on radiology using computed tomography (CT).

AIMS

The present study was designed to compare CT features of ITB and CD and develop a predictive model to differentiate ITB and CD.

METHODS

Patients with ITB and CD, who underwent CT enteroclysis/CT enterography/CT abdomen before starting treatment, were recruited. Specific findings were noted by a radiologist who was blinded to the diagnosis. A predictive model was developed based on the features which were significantly different in these diseases.

RESULTS

Fifty-four patients with CD and 50 patients with ITB were compared. On univariate analysis, left colonic involvement, ileocecal involvement, long-segment involvement, comb sign, presence of skip lesions, involvement of ≥3 segments and ≥1-cm sized lymph nodes were significantly different between CD and ITB. On multivariate analysis, ileocecal involvement, long-segment involvement and the presence of lymph node ≥1 cm were statistically significant. Based upon the latter three variables, a risk score (with values ranging from 0 to 3) was generated, with scores 0 and 1 having specificity of 100 % and 87 %, respectively, and positive predictive values (PPV) of 100 % and 76 %, respectively, for ITB and scores 2 and 3 having specificity of 68 % and 90 %, respectively, and PPV of 63 % and 80 %, respectively, for CD.

CONCLUSIONS

A predictive model based on the presence of long-segment involvement, ileocecal involvement and lymph nodes sized ≥1 cm on CT could differentiate ITB and CD with good specificity and PPV.

Tuberculosis--the great mimicker

Tuberculosis is an immense health problem in the developing world, and it remains a health care challenge in the developed world. It can affect virtually any organ system in the body. Diagnosis of tuberculosis is often difficult. Many patients with tuberculosis present with nonspecific symptoms, negative purified protein derivative skin test result, and negative findings on culture specimens. Cross-sectional imaging with ultrasound, multidetector computed tomography, and magnetic resonance imaging plays an important role in the diagnosis of tuberculosis. Tuberculosis demonstrates a variety of radiologic features depending on the organ involved and can mimic a number of other disease entities. Cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis. Tuberculosis is a great mimicker as its radiologic manifestations can simulate numerous other diseases across the body systems. However, recognition and understanding of the common and uncommon radiologic manifestations of tuberculosis should alert considering tuberculosis in the high-risk population and correct clinical setting to enable appropriate treatment.

Spectrum of imaging findings on MDCT enterography in patients with small bowel tuberculosis

Abdominal tuberculosis (TB) is the sixth most common extrapulmonary site of involvement. The sites of involvement in abdominal tuberculosis, in descending order of frequency, are lymph nodes, genitourinary tract, peritoneal cavity, and gastrointestinal tract. The radiological armamentarium for evaluating tuberculosis of the small bowel (SBTB) includes barium studies (small bowel follow-through, SBFT), CT (multidetector CT, CT enterography, and CT enteroclysis), ultrasound (sonoenteroclysis), and magnetic resonance imaging (MRI; enterography and enteroclysis). In this review, we illustrate the abnormalities at MDCT enterography in 20 consecutive patients with SB TB and also describe extraluminal findings in these patients. MDCT enterography allows non-invasive good-quality assessment of well-distended bowel loops and the adjacent soft tissues. It displays the thickness and enhancement of the entire bowel wall in all three planes and allows examination of all bowel loops, especially the ileal loops, which are mostly superimposed. The terminal ileum and ileocaecal junction are the most common sites of small bowel involvement in intestinal TB. The most common abnormality is short-segment strictures with symmetrical concentric mural thickening and homogeneous mural enhancement. Other findings include lymphadenopathy, ascites, enteroliths, peritoneal thickening, and enhancement. In conclusion, MDCT enterography is a comprehensive technique for the evaluation of SB TB.

Small-bowel obstruction associated with Crohn's enterolith

One of the lesser known clinical manifestations of Crohn's disease is the formation of small-bowel enteroliths. These concretions precipitate in the setting of small-bowel stasis within the alimentary tract and are associated with a variety of disease states causing strictures or diverticula. In the acute setting, patients typically present with signs of intestinal obstruction due to stone impaction. The case we report involves a 67-year-old female with long-standing Crohn's disease who presented with a 6-day history of worsening abdominal pain. Plain abdominal radiographs demonstrated dilated bowel loops consistent with intestinal obstruction. Computed tomography revealed a 2.5-cm calcified density at the transition point in the distal ileum, and two additional stones were present in the proximal ileum. At surgery, multiple ileal strictures were found, and ileocolic resection with primary anastomoses was performed. The accurate diagnosis of enterolithiasis in the setting of Crohn's disease has significant clinical implications for management and is a harbinger of underlying bowel stenosis.

CT appearances of abdominal tuberculosis

The purpose of this article is to review and illustrate the spectrum of computed tomography (CT) appearances of abdominal tuberculosis. Tuberculosis can affect any organ or tissue in the abdomen, and can be mistaken for other inflammatory or neoplastic conditions. The most common sites of tuberculosis in the abdomen include lymph nodes, genitourinary tract, peritoneal cavity and gastrointestinal tract. The liver, spleen, biliary tract, pancreas and adrenals are rarely affected, but are more likely in HIV-seropositive patients and in miliary tuberculosis. This article should alert the radiologist to consider abdominal tuberculosis in the correct clinical setting to ensure timely diagnosis and enable appropriate treatment.

Computed tomography enteroclysis: a review

Computed tomography (CT) enteroclysis is being performed routinely for evaluation of suspected small bowel diseases. The availability of multidetector CT scanners has further increased the diagnostic yield of enteroclysis. There is excellent depiction of small bowel wall pathology on CT enteroclysis especially with use of negative enteric contrast. We discuss the CT enteroclysis technique and procedure along with the imaging spectrum of some common small bowel pathologies.

Differentiation of Crohn’s disease from intestinal tuberculosis in India in 2010

Differentiating intestinal tuberculosis from Crohn’s disease (CD) is an important clinical challenge of considerable therapeutic significance. The problem is of greatest magnitude in countries where tuberculosis continues to be highly prevalent, and where the incidence of CD is increasing. The final clinical diagnosis is based on a combination of the clinical history with endoscopic studies, culture and polymerase chain reaction for Mycobacterium tuberculosis, biopsy pathology, radiological investigations and response to therapy. In a subset of patients, surgery is required and intraoperative findings with pathological study of the resected bowel provide a definitive diagnosis. Awareness of the parameters useful in distinguishing these two disorders in each of the different diagnostic modalities is crucial to accurate decision making. Newer techniques, such as capsule endoscopy, small bowel enteroscopy and immunological assays for Mycobacterium tuberculosis, have a role to play in the differentiation of intestinal tuberculosis and CD. This review presents currently available evidence regarding the usefulness and limitations of all these different modalities available for the evaluation of these two disorders.

Small bowel tuberculosis diagnosed by the combination of video capsule endoscopy and double balloon enteroscopy

Small bowel tuberculosis is sometimes encountered in oriental countries, and because its symptoms are vague and present a nonspecific pattern, confirmative diagnosis is difficult to achieve. In 2001, two new innovative endoscopic techniques for the small bowel, video capsule endoscopy and double balloon enteroscopy, were introduced, thus advancing the diagnostic technology for small bowel disorders. Our asymptomatic patient with small bowel tuberculosis was diagnosed definitively using the combination of video capsule endoscopy and double balloon enteroscopy. The number of such cases will increase when those procedures become more widely used. At present, the endoscopic view of small bowel tuberculosis is difficult to differentiate from Crohn's disease and drug-induced enteropathy, but from now on it will be possible to distinguish them utilizing endoscopic and fluoroscopic images. On the basis of the characteristics of small bowel tuberculosis with its endoscopic images, referring to our case report and previous literature, we report a topical diagnostic procedure, the combination of video capsule endoscopy and double balloon enteroscopy.

Review article: the diagnosis and management of Crohn's disease in populations with high-risk rates for tuberculosis

BACKGROUND

Distinguishing Crohn's disease from intestinal tuberculosis in endemic areas is challenging as both conditions have overlapping clinical, radiological, endoscopic and histological characteristics. Furthermore, high rates of latent tuberculosis confer a considerable risk of reactivation once therapy for established Crohn's disease is started.

AIM

To review current strategies in differentiating these two conditions, and in managing Crohn's disease, in populations with high rates of tuberculosis.

METHODS

Literature review and clinical experience.

RESULTS

While various clinical, radiological, endoscopic and histological parameters may aid in differentiating Crohn's disease from intestinal tuberculosis, these remain imperfect and as treatment options differ misdiagnosis has grave consequences. We propose a diagnostic algorithm, based on currently available evidence and experience, to aid in this dilemma. We also discuss approaches to the management of Crohn's disease, including agents targeting tumour necrosis factor-alpha, in patients at risk of developing tuberculosis.

CONCLUSIONS

A diagnosis of Crohn's disease in individuals at risk for tuberculosis should only be made after careful interpretation of clinical signs, abdominal imaging and systematic endoscopic and histological assessment. Newer techniques for the diagnosis of latent tuberculosis still need to be validated in this environment, and guidelines on the treatment of latent tuberculosis in this setting require clarification.