Intestinal tuberculosis and Crohn's disease: challenging differential diagnosis

Differential diagnosis of Crohn's disease and intestinal tuberculosis based on ATR-FTIR spectroscopy combined with machine learning

BACKGROUND

Crohn's disease (CD) is often misdiagnosed as intestinal tuberculosis (ITB). However, the treatment and prognosis of these two diseases are dramatically different. Therefore, it is important to develop a method to identify CD and ITB with high accuracy, specificity, and speed.

AIM

To develop a method to identify CD and ITB with high accuracy, specificity, and speed.

METHODS

A total of 72 paraffin wax-embedded tissue sections were pathologically and clinically diagnosed as CD or ITB. Paraffin wax-embedded tissue sections were attached to a metal coating and measured using attenuated total reflectance fourier transform infrared spectroscopy at mid-infrared wavelengths combined with XGBoost for differential diagnosis.

RESULTS

The results showed that the paraffin wax-embedded specimens of CD and ITB were significantly different in their spectral signals at 1074 cm-1 and 1234 cm-1 bands, and the differential diagnosis model based on spectral characteristics combined with machine learning showed accuracy, specificity, and sensitivity of 91.84%, 92.59%, and 90.90%, respectively, for the differential diagnosis of CD and ITB.

CONCLUSION

Information on the mid-infrared region can reveal the different histological components of CD and ITB at the molecular level, and spectral analysis combined with machine learning to establish a diagnostic model is expected to become a new method for the differential diagnosis of CD and ITB.

Differentiation of Crohn's disease, ulcerative colitis, and intestinal tuberculosis by dual-layer spectral detector CT enterography

AIM

To investigate the value of radiological features and energy spectrum quantitative parameters in the differential diagnosis of Crohn's disease (CD), ulcerative colitis (UC), and intestinal tuberculosis (ITB) by dual-layer spectral detector computed tomography (CT) enterography (CTE).

MATERIALS AND METHODS

Clinical and CTE data were collected from 182 patients with CD, 29 with UC, and 51 with ITB. CT images were obtained at the enteric phases and portal phases. The quantitative energy spectrum parameters were iodine density (ID), normalised ID (NID), virtual non-contrast (VNC) value, and effective atomic number (Z-eff). The area under curve (AUC) of the receiver operating characteristic curve (ROC) was calculated.

RESULTS

The vascular comb sign (p=0.009) and enlarged lymph nodes (p=0.001) were more common in patients with CD than UC or ITB. In the differentiation of moderate-severe active CD from UC, enteric phase NID (AUC, 0.938; p<0.001) and portal phase Z-eff (AUC, 0.925; p<0.001) had the highest accuracy, which were compared separately. In the differentiation of moderate-severe active CD from ITB, enteric phase NID (AUC, 0.906; p<0.001) and portal phase Z-eff (AUC, 0.947; p<0.001) had the highest accuracy; however, the AUC value was highest when the four parameters are combined (AUC, 0.989; p<0.001; AUC, 0.986; p<0.001; AUC, 0.936; p<0.001; and AUC, 0.986; p<0.001).

CONCLUSION

The present study shows that the combined strategies of four parameters have higher sensitivity and specificity in differentiating CD, UC, and ITB, and may play a key role in guiding treatment.

Deep Learning Radiomics Analysis of CT Imaging for Differentiating Between Crohn's Disease and Intestinal Tuberculosis

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.

Intestinal tuberculosis with small bowel stricture and hemorrhage as the predominant manifestation: Three case reports

BACKGROUND

Intestinal tuberculosis is a chronic disease caused by Mycobacterium tuberculosis that mainly affects the ileum and cecum. Small bowel tuberculosis, characterized by predominant involvement of the small intestine, is an extremely rare condition with highly atypical clinical presentations, making diagnosis even more challenging.

CASE SUMMARY

We report three cases of small intestinal tuberculosis, two of the patients presented primarily with abdominal pain, and one presented with gastrointestinal bleeding. All patients underwent blood tests and imaging examinations. Small bowel endoscopy (SBE) revealed that the main lesions in these patients were intestinal stenosis or gastrointestinal bleeding caused by small intestinal ulcers. One patient ultimately underwent surgical treatment. Following a complex diagnostic process and comprehensive analysis, all patients were confirmed to have small intestinal tuberculosis and received standard antituberculosis treatment, leading to an improvement in their condition.

CONCLUSION

Patients with SBTs present with nonspecific symptoms such as abdominal pain, weight loss, and occasional gastrointestinal bleeding. Accurate diagnosis requires a thorough evaluation of clinical symptoms and various tests to avoid misdiagnosis and complications.

Crohn's disease and intestinal tuberculosis: challenging from every angle

A woman in her 20s with a recent diagnosis of Crohn's disease (CD) affecting the ileocaecal valve was started on adalimumab, after routine tuberculosis (TB) tests were negative. Her abdominal symptoms got worse and she started presenting respiratory distress and fever. Tomography revealed a left pleural effusion, pneumonia and peritonitis with pelvic abscess. The diagnosis of disseminated TB with digestive involvement was suggested and sputum cultures were positive for Mycobacterium tuberculosis Treatment for TB was started and immunosuppressants discontinued, leading to respiratory improvement. Abdominal imaging was repeated, showing worsening signs of multisegmental ileal wall thickening, ileocaecal valve obstruction and a persistent pelvic abscess. She was then submitted to a laparoscopic ileocaecal resection for suspicion of worsening CD. Histopathology showed chronic ileocolitis compatible with CD and ganglionic tuberculosis, revealing the diagnosis of intestinal tuberculosis superimposed in CD. Recovery was uneventful.

IBD barriers across the continents - East Asia

Inflammatory bowel diseases (IBDs) are chronic illnesses with significant morbidities and impact on patients' quality of life. There has been a rapid increase in the incidence of IBD in East Asia in recent decades. However, there is a huge unmet need in the diagnosis and management of IBD in this region. With the increasing awareness of IBD in East Asia and a persistently high rate of tuberculosis in this region, this poses a significant challenge in the diagnosis and management of IBD. In this review, we will explore the barriers to the diagnosis and management of IBD in the East Asia, hoping to provide an insight on how to improve the healthcare system in the management of this complex disease.

A Novel Serum Metabolomic Panel for the Diagnosis of Crohn's Disease

BACKGROUND

A distinctive metabolic phenotype provides the opportunity to discover noninvasive biomarkers for the diagnosis of Crohn's disease (CD) and for differentiating it from other intestinal inflammatory diseases. The study sought to identify new biomarkers for CD diagnosis.

METHODS

Serum metabolites from 68 newly diagnosed and treatment-naïve patients with CD and 56 healthy control (HC) subjects were profiled using targeted liquid chromatography-mass spectrometry. Five metabolic biomarkers were identified to distinguish patients with CD from the HC subjects and validated in a separate cohort consisting of 110 patients with CD and 90 HC subjects using a combination of univariate analysis, orthogonal partial least-squares discriminant analysis, and receiver-operating characteristic curve analysis. Differences in the 5 metabolites were evaluated among patients with CD and patients with ulcerative colitis (n = 62), intestinal tuberculosis (n = 48), and Behçet's disease (n = 31).

RESULTS

Among the 185 quantified metabolites, a panel of 5 (pyruvate, phenylacetylglutamine, isolithocholic acid, taurodeoxycholic acid, and glycolithocholic acid) were found to distinguish patients with CD with high accuracy from HC subjects, with an area under the curve of 0.861 (P < .001). The performance of the model in assessing clinical disease activity was comparable to that of the present biomarkers: C-reactive protein and erythrocyte sedimentation rate. The 5 metabolites were significantly different among the patients and were valuable in the differentiation between CD and other chronic intestinal inflammatory diseases.

CONCLUSIONS

The combination of 5 serum metabolite biomarkers for the diagnosis of CD has the potential to provide an accurate, noninvasive, and inexpensive alternative to conventional tests and might be valuable for the differentiation from other diagnostically challenging intestinal inflammatory diseases.

Factors associated with delayed diagnosis of Crohn's disease: A systematic review and meta-analysis

Background

Delayed diagnosis is a major barrier to the effective management of Crohn's disease (CD). Several studies have investigated factors responsible for delays in diagnosis, but no meta-analyses have systematically assessed the impact of these factors.

Aim

To assess the impact of various factors on the delayed diagnosis of CD.

Methods

PubMed, EMBASE, and Web of Science databases were searched to identify observational studies published before April 2022 that assessed factors associated with delays in CD diagnosis. Further, we excluded review articles, case reports, or commentaries without original data. We pooled effect siee distinct samples. The assessment of study quality was performed utilizing the Newcastle-Ottawa Scale, while the presence of between-study heterogeneity was investigated. For a visual appraisal of potential publication bias, a funnel plot was employed. The study protocol was registered with PROSPERO, CRD42022322251.

Results

A total of 18 studies were included in the paper, covering 13 countries. The study sample consisted of 9669 cases. Ileal CD (OR = 1.46, 95 % CI = 1.21-1.76), smoking at the time of diagnosis (OR = 1.19, 95 % CI = 1.02-1.38), and use of NSAIDs (OR = 1.34, 95 % CI = 1.04-1.72) were significantly associated with a delay in CD diagnosis. However, no significant associations were observed between diagnostic delay and sex, age, endoscopic ileocolonoscopy, or diarrhea. Funnel plot analysis, indicating potential risks of publication bias, suggested the existence of unpublished or unreported study findings.

Conclusion

The findings suggest that ileal CD, use of NSAIDs, and smoking are risk factors for the delayed diagnosis of CD. Enhancing education of patients and primary care providers about these factors is warranted.

Acute intestinal obstruction: What if it is instead colonic tuberculosis? What diagnostic and management dilemmas are there?

INTRODUCTION AND IMPORTANCE

Colonic tuberculosis is rare. Clinical, biologic endoscopic and radiological features are not unequivocal. A multitude of differential diagnoses interfere, including Crohn's disease and cancer.

CASE PRESENTATION

we present a case of a 48-year-old Tunisian female who complained from occlusive syndrome. For whom none of the various elements of the medical record, the clinical, endoscopic and radiological investigations had enabled a decision to be reached in favor of one diagnosis over the other. Several diagnoses were suggested, including Crohn's disease, neoplastic diseases and, ultimately, colonic tuberculosis, since our country was endemic for this pathology. The collegial decision of the medical staff involved in the management was to operate on the patient. Surgery was required with the intention to treat and mainly to provide histological proof of the disease. A right colectomy allowed histological examination and a diagnosis of colonic tuberculosis.

DISCUSSION

The diagnosis should be discussed in patient from endemic countries, who complain chronic abdominal pain, vesperal fever and weight loss for who endoscopy shows the presence of nodules or ulcers. The diagnosis is retained on the basis of pathological findings.

CONCLUSIONS

Because of a nonspecific clinical and endoscopic presentations, multiples biopsies even surgical resection are mandatory to rule out differential diagnosis and to confirm the diagnoses of colonic tuberculosis.

Intestinal tuberculosis can masquerade as Crohn's disease: A teachable moment

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.

Paediatric gastrointestinal endoscopy in the Asian-Pacific region: Recent advances in diagnostic and therapeutic techniques

There has been a rapid expansion in the knowledge of paediatric gastroenterology over the recent decade, with a fast-growing repertoire of diagnostic techniques and management strategies for a wide spectrum of childhood gastrointestinal (GI) diseases. Paediatric GI endoscopy is a core competency every paediatric gastroenterologist should possess, and represents one of the most common procedures performed in children for both diagnostic and therapeutic purposes. Yet there remains a dearth of literature on the utility and outcomes of paediatric GI endoscopy in the Asia-Pacific region. Data on the diagnostic value of paediatric GI endoscopy would be an important aspect of discussion, with the emergence of inflammatory bowel disease (IBD) and eosinophilic GI disease as increasingly common endoscopic diagnoses. Time-based trends in paediatric GI endoscopy do point towards more IBD and gastroesophageal reflux disease-related complications being diagnosed, with a declining incidence of GI bleeding. However, the real-world diagnostic value of endoscopy in Asia must be contextualised to the region-specific prevalence of paediatric GI diseases. Helicobacter pylori infection, particularly that of multidrug-resistant strains, remains a highly prevalent problem in specific regions. Paediatric functional GI disorders still account for the majority of childhood GI complaints in most centres, hence the diagnostic yield of endoscopy should be critically evaluated in the absence of alarm symptoms. GI therapeutic endoscopy is also occasionally required for children with ingested foreign bodies, intestinal polyposis or oesophageal strictures requiring dilation. Endoscopic haemostasis is a potentially life-saving skill in cases of massive GI bleeding typically from varices or peptic ulcers. Advanced endoscopic techniques such as capsule endoscopy and balloon-assisted enteroscopy have found traction, particularly in East Asian centres, as invaluable diagnostic and therapeutic tools in the management of IBD, obscure GI bleeding and intestinal polyposis. State of the art endoscopic diagnostics and therapeutics, including the use of artificial intelligence-aided endoscopy algorithms, real-time confocal laser endomicroscopy and peroral endoscopic myotomy, are expected to gain more utility in paediatrics. As paediatric gastroenterology matures as a subspecialty in Asia, it is essential current paediatric endoscopists and future trainees adhere to minimum practice standards, and keep abreast of the evolving trends in the diagnostic and therapeutic value of endoscopy. This review discusses the available published literature on the utility of paediatric GI endoscopy in Asia Pacific, with the relevant clinical outcomes.

Clinical Analysis of Intestinal Tuberculosis: A Retrospective Study

PURPOSE

This study aimed to summarize and analyze the clinical data of intestinal tuberculosis (ITB) in order to provide guidance for accurate diagnosis and treatment of ITB.

METHODS

This study consecutively included patients with ITB who were admitted to our hospital from 2008 to 2021 and retrospectively analyzed their clinical features.

RESULTS

Forty-six patients were included. The most common clinical symptom was weight loss (67.4%). Seventy percent of 20 patients were positive for tuberculin skin test; 57.1% of 14 patients were positive for mycobacterium tuberculosis specific cellular immune response test, while 84.6% of 26 patients were positive for tuberculosis infection T cell spot test. By chest computed tomography (CT) examination, 25% and 5.6% of 36 patients were diagnosed with active pulmonary tuberculosis and with inactive pulmonary tuberculosis, respectively. By abdominal CT examination, the most common sign was abdominal lymph node enlargement (43.2%). Forty-two patients underwent colonoscopy, and the most common endoscopic manifestation was ileocecal ulcer (59.5%), followed by colonic ulcer (35.7%) and ileocecal valve deformity (26.2%). ITB most frequently involved the terminal ileum/ileocecal region (76.1%). Granulomatous inflammation with multinucleated giant cells and caseous necrosis was found via endoscopic biopsies, the ultrasound-guided percutaneous biopsy of enlarged mesentery lymph nodes, and surgical interventions. The acid-fast bacilli were discovered in 53.1% of 32 samples. Twenty-one cases highly suspected of ITB were confirmed after responding to empiric anti-tuberculosis therapy.

CONCLUSIONS

It was necessary to comprehensively analyze clinical features to make an accurate diagnosis of ITB and aid in distinguishing ITB from diseases such as Crohn's disease and malignant tumors.

Challenges in the management of inflammatory bowel disease in sub-Saharan Africa

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.

Genome-wide DNA methylation profiling in differentiating Crohn's disease from intestinal tuberculosis

BACKGROUND

Differential diagnosis of Crohn's disease (CD) and intestinal tuberculosis (ITB) is still difficult in clinical pratice. DNA methylation has been considered as a favorable area for biomarker exploration and identification.

OBJECTIVE

The purpose of the current study was to evaluate DNA methylation changes between CD and ITB.

METHODS

We performed a genome-wide association study to identify differentially methylated positions (DMPs), including 8 CD patients (before the initial of biologics or immunomodulators), 6 ITB patients, and 8 healthy controls (HCs), in whole blood DNA using the Infinium HumanMethylation850 BeadChip.

RESULTS

Patients in the CD group and ITB group were all observed with hypo-methylated changes compared with HCs. However, the CD group overlaps with the ITB group in DNA methylation, suggesting a stable epigenetic profile between the two diseases. The pathway enrichment analysis showed the alternation in inflammation-related pathway, immune system, and signal transduction. Focused on the DMPs located in the promoter region, further analysis indicated hypermethylation of cg03122532 (5'UTR of KCNJ15) could be a potential CD-specific biomarker.

CONCLUSIONS

We identified specific differential methylation loci related to CD and ITB in blood DNA. DNA metylation as a important epigenetic modification could contribute to the pathogenesis study and biomarker exploration of the diseases.

Core indicators of an evaluation and guidance system for quality of care in inflammatory bowel disease centers: A critical review

The mission of the IBD Quality Care Evaluation Center (IBDQCC) is to establish indicators of quality of care (QoC), certify IBD units to generate a network of IBD quality care, and eventually improve the national level of IBD healthcare. The final list of 28 core and 13 secondary IBD QoC indicators suitable for the healthcare system in China were selected using a Delphi consensus methodology. Units that met all core indicators were qualified as "regional"; units that met all core indicators together with more than 50% of the secondary indicators received a rating of "excellence." Using the selected QoC core indicators for certifying IBD units, a network of IBD quality care units covering the majority of IBD patients in China was established.

FUNDING

This work was financially supported by Cultivation Funding for Clinical Scientific Research Innovation, Renji Hospital, School of Medicine, Shanghai Jiaotong University (RJPY-LX-004), National Natural Science Foundation of China (No. 81,770,545), Shanghai Science and Technology Innovation Initiative (21SQBS02302), and Cultivated Funding for Clinical Research Innovation, Renji Hospital, School of Medicine, Shanghai Jiaotong University (RJPY-LX-004).

A Case of Intestinal Tuberculosis Mimicking Crohn's Disease: A Clinical and Diagnostic Dilemma

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.

Very early onset inflammatory bowel disease in a South Asian country where inflammatory bowel disease is emerging: a distinct clinical phenotype from later onset disease

BACKGROUND/AIMS

Information on pediatric inflammatory bowel disease (PIBD) and very early onset IBD (VEOIBD) are sparse in India, where IBD is emerging. We aimed to evaluate characteristics of VEOIBD and later onset PIBD (LO-PIBD) in India.

METHODS

We performed retrospective analysis of a large, prospectively maintained IBD registry. PIBD was divided in to VEOIBD ( < 6 years) and LO-PIBD (6-17 years). Demographic data, disease characteristics and treatment were compared between the PIBD groups and with other Asian/Western studies as well as the adult patients of the registry.

RESULTS

Of 3,752 IBD patients, 292 (7.8%) had PIBD (0-17 years) (175 Crohn's disease [CD], 113 ulcerative colitis [UC], 4 IBD-undifferentiated; 22 VEOIBD [7.5%], and 270 LO-PIBD [92.5%]). VEOIBD patients had more severe disease compared to LO-PIBD in both UC (P= 0.003) and CD (P< 0.001). Familial IBD was more common in VEOIBD (13.6%) compared to LO-PIBD (9.2%). Ileal disease (L1) was an independent risk factor for diagnostic delay in pediatric CD. Diagnostic delay ( > 6 months) was significantly lower in VEOIBD (40.9%) than in LO-PIBD (78.8%) (P< 0.001). Compared to other Asian and Western studies, extensive UC (72.5%) and complicated CD (stricturing/penetrating: 42.7%) were relatively more common. Perianal CD was relatively less frequent (7.4%). PIBD had a significantly higher number of complicated and ileal CD and extensive UC comparison to adult cohort of the registry.

CONCLUSIONS

VEOIBD has more aggressive phenotype than LO-PIBD. Disease appears distinct from other Asian and Western studies and adult onset disease, with more complicated CD and extensive UC.

Application value of tissue tuberculosis antigen combined with Xpert MTB/RIF detection in differential diagnoses of intestinal tuberculosis and Crohn's disease

Background

The purpose of this study was to examine the value of Xpert MTB/RIF assay and detection of additional Mycobacterium tuberculosis complex (MTBC) species antigens from intestinal tissue samples in differentiating intestinal tuberculosis (ITB) from Crohn’s disease (CD).

Methods

Several clinical specimens of intestinal tissue obtained by either endoscopic biopsy or surgical excision were used for mycobacteriologic solid cultures,Xpert MTB/RIF assays, immunohistochemistry, and histological examinations. Four antigens (38KDa, ESAT-6, MPT64, and Ag85 complex) of MTBC in the intestinal tissue were detected by immunohistochemical analysis.

Results

The study included 42 patients with ITB and 46 with CD. Perianal lesions and longitudinal ulcers were more common in patients with CD, while caseating granuloma and annular ulcers were more common in patients with ITB. The positive rate of MTBC detected by Xpert MTB/RIF in intestinal tissues of patients with ITB was 33.33%, which was significantly higher than that in patients with CD and that detected using acid-fast staining smears. It was also higher than that detected by tissue MTBC culture, but the difference was not statistically significant. The positive MPT64 expression rate in patients with ITB was 40.48%, which was significantly higher than that observed in patients with CD. The sensitivity of parallelly combined detection of tuberculosis protein MPT64 and Xpert MTB/RIF in diagnosing ITB was 50.0%.

Conclusions

The detection of Xpert MTB/RIF in intestinal tissue is a rapid and useful method for establishing an early diagnosis of ITB. The detection of MTBC using Xpert MTB/RIF and MPT64 antigen in intestinal tissues has a definitive value in the differential diagnosis ofITB and CD. The combination of these two methods can improve the detection sensitivity.

Asian Organization for Crohn's and Colitis and Asia Pacific Association of Gastroenterology practice recommendations for medical management and monitoring of inflammatory bowel disease in Asia

Inflammatory bowel disease (IBD) has increased in incidence and prevalence in Asian countries since the end of the 20th century. Moreover, differences in the cause, phenotypes, and natural history of IBD between the East and West have been recognized. Therefore, the Asian Organization for Crohn's and Colitis and the Asia Pacific Association of Gastroenterology have established recommendations on medical management of IBD in Asia. Initially, the committee members drafted 40 recommendations, which were then assessed according to Grading of Recommendations Assessment, Development and Evaluation. Eight statements were rejected as this indicated that consensus had not been reached. The recommendations encompass pretreatment evaluation; medical management of active IBD; medical management of IBD in remission; management of IBD during the periconception period and pregnancy; surveillance strategies for colitis-associated cancer; monitoring side effects of thiopurines and methotrexate; and infections in IBD.

Case of Crohn's Disease Initially Misdiagnosed as Intestinal Tuberculosis Due to Active Pulmonary Tuberculosis

Differentiating Crohn's disease (CD) from intestinal tuberculosis (TB) is a challenge. In patients suspected of having CD or intestinal TB compounded with active pulmonary TB in its early stages, clinicians often lean towards a diagnosis of intestinal TB. A 14-year-old female patient was admitted with symptoms of abdominal pain and diarrhea with hematochezia. Colonoscopy revealed a stricture of the ileocecal valve and scattered longitudinal ulcers. Initial chest radiography showed consolidation in the left lower lobe of the lung. Chest CT revealed branching nodular opacities and consolidation. The TB PCR of the bronchial washing fluid was positive. The patient was diagnosed with pulmonary and intestinal TB. The colonoscopy findings favored CD. Despite this, anti-tubercular therapy was initiated based on the radiology findings and PCR test. After treatment with anti-tubercular therapy, the patient's diarrhea and abdominal pain worsened despite the improvement observed on her chest radiography. Follow-up colonoscopy revealed aggravation of her ulcers. The patient was diagnosed with CD and treated with prednisolone and mesalazine. Her clinical condition improved, and follow-up colonoscopy showed significant improvement of the ulcers. This case highlights the need for caution in diagnosis and suggests that clinicians consider reevaluation in similar cases.

Challenges in the diagnosis and management of inflammatory bowel disease in resource-limited settings in Asia

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.

Clinical diagnosis and endoscopic analysis of 10 cases of intestinal tuberculosis

To analyze the clinical characteristics of intestinal tuberculosis (ITB), pay attention to the diagnostic value of endoscopy and mucosal biopsy, improve the recognition of atypical manifestations of ITB under endoscopy, and reduce misdiagnosis and missed diagnosis.The clinical data of 10 patients who were hospitalized in Changzhou second people's Hospital and finally diagnosed as ITB from January 1, 2015 to present were analyzed retrospectively. The basic information, medical history, clinical manifestations and computed tomography (CT), endoscopy of the patients was analyzed retrospectively. The results of pathological examination were analyzed and sorted out.Among the 10 patients, the ratio of male to female was 7:3, 10 (100%) had abdominal pain, 3 (30%) had diarrhea and 2 (20%) had bloody stool. The positive rate of tuberculosis T cell test was 75% (6/8), the diagnostic rate of chest high resolution CT was 60%, and the abnormal rate of abdominal high-resolution CT was 66.7% (6/9). Colonoscopy showed that the lesions mainly involved ileocecum (70%) and ascending colon (60%). Most of the lesions were intestinal stenosis (60%) and circular ulcer (50%). In a few cases, cold abscess (20%) and scar diverticulum (10%). Most of the pathological manifestations were granuloma formation and multinucleated giant cells (60%). The detection rate of caseous granuloma was 20%.The general condition and clinical manifestations of patients with ITB are not specific. Endoscopy and mucosal biopsy are of great significance for its diagnosis. The clinical manifestations and endoscopy of some patients showed atypical signs. Therefore, the combination of multi-disciplinary team models and the enhancement of clinician's recognition of the characteristics of endoscopic examination of ITB can improve us the diagnosis level of ITB.

Levels of TB-IGRA may help to differentiate between intestinal tuberculosis and Crohn's disease in patients with positive results

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.

Environmental, Nutritional, and Socioeconomic Determinants of IBD Incidence: A Global Ecological Study

BACKGROUND AND AIMS

The wide variation in inflammatory bowel disease [IBD] incidence across countries entails an opportunity to recognise global disease determinants and hypothesise preventive policies.

METHODS

We fitted multivariable models to identify putative environmental, nutritional, and socioeconomic determinants associated with the incidence of IBD (i.e. ulcerative colitis [UC] and Crohn's disease [CD]). We used the latest available country-specific incidence rates, and aggregate data for 20 determinants, from over 50 countries accounting for more than half of the global population. We presented the associations with exponentiated beta coefficients (exp[β]) indicating the relative increase of disease incidence per unit increase in the predictor variables.

RESULTS

Country-specific incidence estimates demonstrate wide variability across the world, with a median of 4.8 new UC cases (interquartile range [IQR] 2.4-9.3), and 3.5 new CD cases [IQR 0.8-5.7] per 100 000 population per year. Latitude (exp[β] 1.05, 95% confidence interval [CI] 1.04‒1.06, per degree increase), prevalence of obesity [1.05, 1.02‒1.07, per 1% increase], and of tobacco smoking [0.97, 0.95‒0.99, per 1% increase] explained 71.5% of UC incidence variation across countries in the adjusted analysis. The model for CD included latitude [1.04, 1.02‒1.06], expenditure for health (1.03, 1.01‒1.05, per 100 purchasing power parity [PPP]/year per capita increase), and physical inactivity prevalence [1.03, 1.00‒1.06, per 1% increase], explaining 58.3% of incidence variation across countries. Besides expenditure for health, these associations were consistent in low/middle- and high-income countries.

CONCLUSIONS

Our analysis highlights factors able to explain a substantial portion of incidence variation across countries. Further high-quality research is warranted to develop global strategies for IBD prevention.

Gastrointestinal Tuberculosis Mimicking Crohn's Disease

We present the case of a 24-year-old woman with complaints of abdominal pain, bloody diarrhea, and weight loss for 3 months. An outpatient colonoscopy revealed scattered ulcers, suggestive of Crohn's disease (CD). Histopathology also favored the diagnosis of CD. However, after admission to our hospital for further investigation, a chest radiograph revealed pulmonary cavitations. A computed tomography scan suggested the diagnosis of active pulmonary tuberculosis (TB). Therefore, a bronchofibroscopy, a total colonoscopy with ileoscopy, and an upper endoscopy were performed. Not only were acid-fast bacilli present in both bronchoalveolar lavage fluid and gastric juice, but also in colonic biopsies. A complete resolution of gastrointestinal symptoms was achieved 2 weeks after starting anti-TB drugs.

Intestinal tuberculosis and Crohn's disease: the importance and difficulty of a differential diagnosis

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.

Analysis of Phenotypic Variables and Differentiation Between Untypical Crohn's Disease and Untypical Intestinal Tuberculosis

BACKGROUND

The differentiation between untypical intestinal tuberculosis (UITB) and untypical Crohn's disease (UCD) is a challenge.

AIMS

To analyze phenotypic variables and propose a novel prediction model for differential diagnosis of two conditions.

METHODS

A total of 192 patients were prospectively enrolled. The clinical, laboratory, endoscopic, and radiological features were investigated and subjected to univariable and multivariable analyses. The final prediction model for differentiation between UCD and UITB was developed by logistic regression analysis and Fisher discriminant analysis on the training set. The same discriminant function was tested on the validation set.

RESULTS

Twenty-five candidates were selected from 52 phenotypic variables of typical Crohn's disease (TCD), UCD, and UITB patients. UCD's variables overlapped with both TCD and UITB. The percentages of tuberculosis history, positive PPD, and positive T-SPOT result in UCD were all significantly higher than that in TCD (11.6% vs. 0.0%, 27.9% vs. 0.0%, 25.6% vs. 4.5%, respectively, P < 0.05). The regression equations and Fisher discriminant function for discrimination between UCD and UITB were developed. In the training data, the area under the receiver operating characteristic of equations was 0.834, 0.69, and 0.648 in the clinical-laboratory, endoscopic, and radiological model, respectively. The accuracy of Fisher discriminant function for discrimination was 86% in UCD and 73% in UITB in the validation data.

CONCLUSIONS

Phenotypes of UCD patients in TB-endemic countries may be associated with TB infection history. Fisher discriminant analysis is a good choice to differentiate UCD from UITB, which is worthy of verification in clinical practice.

The potential role of CT enterography and gastrointestinal ultrasound in the evaluation of anti-tubercular therapy response of intestinal tuberculosis: a retrospective study

Background

Accurate evaluation of anti-tubercular therapy (ATT) responses is crucial for both diagnosis and treatment of intestinal tuberculosis (ITB). Little is known about the role of cross-sectional imaging techniques in ITB follow-up assessment. We aimed to investigate the accuracy of cross-sectional imaging modalities, CT enterography (CTE) and gastrointestinal ultrasound (GIUS), in the evaluation of ATT responses in ITB patients.

Methods

Patients diagnosed with ITB and followed up by CTE and/or GIUS were retrospectively searched in the databases. Clinical, imaging, laboratory and endoscopic data were collected at baseline and the first follow-up visit. Responses were graded as good, partial and no response based on protocols described in the literature and by our institution. CTE evaluation was based on changes in the lesion area, mural thickness, enhancement patterns and lymph nodes, while GIUS evaluation was based on changes in bowel wall morphology and the Limberg score. Clinical evaluation was used as the gold-standard evaluation method, which was determined by a comprehensive impression of endoscopic changes along with symptomatic improvement and laboratory tests, with imaging results masked.

Results

Twenty patients with ITB were enrolled in our study. The first follow-up time was from 2 to 12 months (average 6 months). According to the gold standard evaluation, 11 patients were evaluated as having a good ATT response, while 9 had a partial response. A total of 18 patients were followed up by CTE, while 7 were followed up by GIUS, depending on medical and/or financial considerations. The accuracy of CTE and GIUS was 83% (15/18) and 85.7% (6/7), respectively. The sensitivity, specificity, PPV and NPV of CTE were 88.9, 77.8, 80 and 87.5%, respectively. Moreover, the sensitivity, specificity, PPV and NPV of GIUS were 100, 50, 83.3 and 100%, respectively. By combining the results of CTE and GIUS results, the overall accuracy was 90%, with sensitivity and specificity of 91.7 and 87.5%, respectively.

Conclusion

To our knowledge, this is the first study exploring the accuracy of the cross-sectional imaging modalities CTE/GIUS in the evaluation of ATT responses. Our results indicated their promising application prospect in clinical practice as a non-invasive and cost-effective approach.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-1030-0) contains supplementary material, which is available to authorized users.

Interleukin-22 receptor 1 is expressed in multinucleated giant cells: A study on intestinal tuberculosis and Crohn's disease

BACKGROUND

It is challenging to distinguish intestinal tuberculosis from Crohn's disease due to dynamic changes in epidemiology and similar clinical characteristics. Recent studies have shown that polymorphisms in genes involved in the interleukin (IL)-23/IL-17 axis may affect intestinal mucosal immunity by affecting the differentiation of Th17 cells.

AIM

To investigate the specific single-nucleotide polymorphisms (SNPs) in genes involved in the IL-23/IL-17 axis and possible pathways that affect susceptibility to intestinal tuberculosis and Crohn's disease.

METHODS

We analysed 133 patients with intestinal tuberculosis, 128 with Crohn's disease, and 500 normal controls. DNA was extracted from paraffin-embedded specimens or whole blood. Four SNPs in the IL23/Th17 axis (IL22 rs2227473, IL1β rs1143627, TGFβ rs4803455, and IL17 rs8193036) were genotyped with TaqMan assays. The transcriptional activity levels of different genotypes of rs2227473 were detected by dual luciferase reporter gene assay. The expression of IL-22R1 in different intestinal diseases was detected by immunohistochemistry.

RESULTS

The A allele frequency of rs2227473 (P = 0.030, odds ratio = 0.60, 95% confidence interval: 0.37-0.95) showed an abnormal distribution between intestinal tuberculosis and healthy controls. The presence of the A allele was associated with a higher IL-22 transcriptional activity (P < 0.05). In addition, IL-22R1 was expressed in intestinal lymphoid tissues, especially under conditions of intestinal tuberculosis, and highly expressed in macrophage-derived Langhans giant cells. The results of immunohistochemistry showed that the expression of IL-22R1 in patients with Crohn's disease and intestinal tuberculosis was significantly higher than that in patients with intestinal polyps and colon cancer (P < 0.01).

CONCLUSION

High IL-22 expression seems to be a protective factor for intestinal tuberculosis. IL-22R1 is expressed in Langhans giant cells, suggesting that the IL-22/IL-22R1 system links adaptive and innate immunity.

The Polymorphism rs17525495 of LTA4H Is Associated with Susceptibility of Crohn's Disease instead of Intestinal Tuberculosis in a Chinese Han Population

Background

Because of the similarity of intestinal tuberculosis and Crohn's disease in disease phenotype, differential diagnosis has always been a clinical problem. Arachidonic acid metabolites play an important role in the inflammatory response of intestinal tuberculosis and Crohn's disease. Recent studies have shown that the polymorphism locus in the promoter region of LTA4H gene affects LTB4 expression level and the susceptibility to extrapulmonary tuberculosis. Thus, we identified a total of 148 patients with intestinal tuberculosis, 145 with Crohn's disease, and 700 normal controls in this study.

Methods

All the study participants were local Han people from Jiangxi Province in the past eleven years. DNA was extracted from the paraffin-embedded specimens or the whole blood. The LTA4H promoter SNP (rs17525495) was genotyped with TaqMan assay.

Results

The T-alleles frequency was not significantly increased in patients with intestinal tuberculosis compared with healthy control group (p=0.630; OR=1.07; 95%CI=0.81-1.41), while patients with Crohn's disease have significantly increased T allele frequency compared with healthy population (p=0.032; OR=1.34; 95%CI=1.03-1.75). During treatment, the presence of the T allele significantly increased the proportion of Crohn's patients requiring glucocorticoids (p<0.05).

Conclusions

The T allele of LTA4H gene SNP (rs17525495) is a risk factor for Crohn's disease instead of intestinal tuberculosis. More importantly, there may be a potential association of the different genotypes of rs17525495 with the treatment efficacy of 5-ASA and glucocorticoids in patients with Crohn's disease. The association between LTA4H polymorphism and drugs therapeutic effects might contribute to the practice of precision medicine and the prediction of clinical outcomes.

Diagnostic Performance of a 5-Marker Predictive Model for Differential Diagnosis Between Intestinal Tuberculosis and Crohn's Disease

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.

Atypical serious hematochezia and rare imaging feature in gastrointestinal tuberculosis

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.

Temporal trends in the misdiagnosis rates between Crohn’s disease and intestinal tuberculosis

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.

The Challenge of Inflammatory Bowel Disease Diagnosis in Asia

Background

The current major clinical challenge relates to the accurate diagnosis of inflammatory bowel disease (IBD) in Asian countries with a high background prevalence of infections.

Summary

The diagnosis of Crohn's disease in geographical areas where tuberculosis is endemic poses a major diagnostic challenge.

Key Messages

Infections can mimic IBD and complicate the course of existing IBD. Limited availability of diagnostic modalities and health service may delay diagnosis. A multidisciplinary approach, continuous medical education, and academic activities may warrant an accurate diagnosis of IBD.