Tb vs crohns clinical, histology, endoscopy

1. CROHN’S V/S TB
PRESENTER:DR.ABHINAV KUMAR

2. CLINICAL FEATURES THAT MAY HELP
TB CROHN’S
Duration of illness <12 months >12 months
Fever Evening fever with night
sweats
No specific pattern
Family history TB Crohn’s
Recurrence of disease after
surgery
Unlikely Yes
Perianal disease May occur Often present
Ascites exudate Uncommon, transudate
Extraintestinal
manifestations
Involvement of lung lymph
nodes
Arthropathy, PSC

3. CLINICAL FEATURES THAT MAY HELP
Govind K. Makharia et al Am J Gastroenterol 2010; 105:642–651

4. SEROLOGY/IMMUNOLOGY

5. ANTI SACCHAROMYCES CEREVISIAE ANTIBODY
Author TB CROHN’S
Makharia et al, 2007
14/30 30/59
Ghoshal et al, 2007 8/16 10/16
Amarapurkar et al, 2008 11/26 10/26
Dutta et al, 2011 3/30 9/30
TOTAL 36/102 59/131
35.2% 45.0%

6. TB ELISA
• Meta-analysis of 68 studies
– Poor sensitivity
• Sensitivity higher in smear positive patients
– Unreliable specificity
• Specificity higher when healthy individuals used for
comparison
Steingart et al. PLoS Med 2007

7. Inteferon-gamma release assay (IGRA)
• RD1-antigen (recombinant antigen from RD1 region of MTB)
based assays
– Diagnoses latent TB
– Usually positive in active TB, except miliary TB
– May be positive in some patients with untreated Crohn’s
disease

8. Tuberculin (PPD) skin test
• PPD reactivity rate in Crohn’s disease in India & other TB
endemic countries not known
• PPD testing advised by US FDA prior to infliximab therapy in
order to prevent TB reactivation

9. RADIOLOGY

10. BMFT in ITB
• Irregular and nodular narrowing of ileocecal junction with the
involvement of adjacent terminal ileum and cecum.
• Ulcers in ITB are linear, transverse, or stellate and often oval
• Involvement of cecum > ileum
• Cecum is contracted and pulled-up due to associated fibrosis
• Thickening of intestinal mucosal folds or occulation of barium caused by
malabsorption  Uncommon
• Multiple segments Infrequently
• Separation of bowel loops may be seen due to mesenteric adenopathy.
• Fistula and sinuses are uncommon.
• Enteroliths may also be seen in the dilated proximal segment in long
standing cases.

11. Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

12. Fleischner’s sign
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

13. STRING SIGN
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.
• String sign describes
persistently narrowed
segment of intestine due
to stricture.

14. PULLED UP CAECUM
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

15. Goose- Neck Deformity
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

16. Stierlin’s sign
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

17. String Sign
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

18. COMPUTED TOMOGRAPHY
ENTEROGRAPHY OF ITB
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

19. Magnetic resonance enterography of
intestinal tuberculosis
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

20. Computed Tomography Enterography
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

21. Barium Enteroclysis of Crohn’s disease
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

22. Computed tomography enterography of
Crohn’s disease
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

23. Magnetic resonance enterography of Crohn’s
disease
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

24. TB V/S CROHNS
ITB CROHNS
Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn’s disease: Clinical
and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72.

25. ENDOSCOPY/COLONOSCOPY

26. Colonoscopy in TB
• Superficial well defined ulcers with irregular margins
• Nodular mucosa
• Deformed IC valve with ulcers Ileocecal involvement
• Skip lesions in 10%
• Segmental involvement in 26%
• Pan-colitis in 4%
Shah S et al, Gut 1992

27. Colonoscopy in Crohn’s disease
• Aphthous ulcer
• Deep irregular ulcers
• Longitudinal ulcers
• Cobblestones
• Pseudopolyps
• Mucosal bridging
• Discontinuous involvement (Skip lesions)
• Luminal narrowing
• Fistulas

28. Types of involvement in patients with Crohn’s
disease & intestinal tuberculosis
Govind K. Makharia et al Am J Gastroenterol 2010; 105:642–651

29. Sites of involvement in patients with Crohn’s
disease & intestinal tuberculosis
Govind K. Makharia et al Am J Gastroenterol 2010; 105:642–651

30. HISTOPATHOLOGY

31. HPE OF RESECTED SPECIMENS
TB 159 CASES CROHN’S 10 CASES
Miliary nodules on serosa Common, conspicuous Rare
Length of strictures <3 cm Usually long
Internal fistulae Uncommon Rare
Perforation Uncommon Rare
Ulcers Circumferential. Usually
transverse.
Mesenteric attachment.
Longitudinal / serpiginous
Lymph nodes Large Small
Granulomas May be present in mesenteric
nodes when absent in
intestine
Not present in nodes when
absent in intestine
Tandon and Prakash, Gut 1972

32. CROHN’S VS TB:MUCOSAL BIOPSIES
TB CROHN’S
AFB seen 9 % -
Caseation 36% -
>4 granulomas/site 45% -
Granulomas >400μ 51% -
Confluent granulomas 42% 3%
Band of epithelioid
histiocytes
61% -
Single small granulomas 3% 26%
Mucosal changes distant to
granulomas
- 65%
Pulimood et al, Gut 1999; Pulimood et al, JGH 2004

33. Value of upper GI endoscopy and biopsy
• In 11% of children, the diagnosis of CD was based entirely on
UGI biopsy findings and granulomas on biopsy
• – Focal duodenal cryptitis
– Focally enhanced gastritis
– Sensitivity 99%, specificity 93%

34. MICROBIOLOGY

35. CONFIRMATION OF TB ON BIOPSY
TEST % POSITIVE AUTHORS
Caseous necrosis
23-36% Lee 2004, Pulimood 2005
AFB smear of biopsy 5-10%
AFB culture of
biopsy
7-40% Bhargava 1985, Lee 2004,
Khan 2006
AFB culture of
surgical tissue
70% Veeragandham 1996

36. TB PCR
TB CROHN’S
Moatter et al 1998 8/12 -
Gan et al 2002 25/39 0/30
Amarapurkar et al
2004
17/26 0/26
Pulimood et al 2008 6/20 1/20
Balamurugan et al
2008
21/26 5/46

37. TB versus Crohn’s Search for extraintestinal
tuberculosis
• Search for peripheral lymphadenopathy  FNAC, culture,
PCR, and biopsy
• Search for pulmonary lesion on chest x-ray, and do induced
sputum for AFB (x3), sputum PCR, bronchoalveolar lavage if
necessary
• Search for ascites, aspirate and send for cells, protein, culture,
PCR

38. Diagnosis of ITB
• Histology + Culture diagnostic in 60%
Bhargava DK et al, 1992
• Histology + Culture + Extra-intestinal TB diagnostic in 56% of
225 patients
Lee et al 2004
• Histology + culture diagnostic in 80%; addition of stool TB PCR
diagnosed 100% of 26 ITB patients
Balamurugan et al, 2011

39. Score for differentiation of CD & intestinal
tuberculosis.
• Score = –2.5 × involvement of sigmoid colon – 2.1 × blood in stool
+ 2.3 × weight loss – 2.1 × focally enhanced colitis + 7
• The score varied from 0.3 to 9.3
• Higher score predicted greater likelihood of intestinal tuberculosis.
• Once the cutoff was set at 5.1
• Sensitivity  83.0
• Specificity  79.2
• Ability to correctly classify the two diseases  81.1%
Govind K. Makharia et al Am J Gastroenterol 2010; 105:642–651