The document discusses the difficulties in differentiating between Crohn's disease (CD) and intestinal tuberculosis (ITB) given their similar clinical, endoscopic, and histological features. Both are granulomatous diseases that can affect the intestine. While ITB is more common in India, rates of CD are increasing worldwide and also in developing countries. Making an accurate diagnosis is important as treatment approaches differ between the two conditions. Several clinical, endoscopic, radiological, and histological features are discussed that may suggest one condition over the other, but differences are often subtle. A high index of suspicion is needed to diagnose ITB in areas where it is endemic to ensure appropriate treatment.

2.  Crohn ’ s disease (CD) and intestinal
tuberculosis are granulomatous diseases of the
intestine.
 The clinical, morphological,radiologic
,endoscopic and histological features of CD
and intestinal tuberculosis are so similar that it
becomes difficult to differentiate between
these two entities.
Epstein D.Review article: the diagnosis and management of Crohn’s disease in
populations with high-risk rates for tuberculosis . Aliment Pharmacol h er
2007 ; 25 : 1373 – 88 .

4.  In India,intestinal tuberculosis is very
common, but CD is also being increasingly
reported from all over the country.
 The natural history and response to
treatment differ.

5.  Intestinal TB if wrongly treated with
immunosuppresant could flare up and
disseminate.
 Empirical treatment with ATT may delay the
diagnosis of CD and may result in
complications.
 ATT hepatotoxicity also possible.

6.  High rates of latent tuberculosis confer a risk of
reactivation once therapy for established Crohn’s
disease is started.

7.  Worldwide there is a resurgence of TB.
 80 % of all new cases in 2014 occurred in
Africa, South-East Asia and Western Pacific
regions.
 Increasing incidence in developed nations
since mid-1980s due to immigration,HIV
and the development of MDR TB.
Global Tuberculosis Control Report WHO 2017

9.  Incidence of both CD and ulcerative colitis
(UC) is increasing in the Asian Pacific
region, India, Eastern Europe and South
Africa.
 In Saudi Arabia,mean annual incidence of
CD over two decades changed from 0.32 /
100,000 to 1.66 / 100,000, representing
more than a fivefold increase.
Ouyang Q,Ta n d o n R G ohK L et al. emergence of inflammatory bowel disease in
the Asian Pacific region . Curr Opin Gastroenterol
2015;21:408 – 1 3 .

11. Spread occurs via
 Swallowing infected sputum in cases with active
PTB.
 Ingestion of contaminated milk causing bovine TB.
 Hematogenous spread from active PTB, miliary TB
or silent bacteremia during the primary phase of
TB.
 Direct extension from adjacent organs is very rare.
 ONLY 20 – 25 % OF PATIENTS HAVE
CONCOMITANT ACTIVE PULMONARY TB

12.  Abdominal tuberculosis
A l K a r a w i MA,Mo h a m e d A E,Yaswy MI et al.Protean manifestation of
gastrointestinal tuberculosis: report on 130 patient.J Clin Gastroenterol 1995;20:2 5–3 2 .

13.  In a study of ITB from Hong Kong, the
ileocecal region was involved in 86 % of
patients.
 Ileocecal area preferred because of
 Abundant lymphoid aggregates.
 Prolonged contact between bacilli and mucosa due
to physiologic stasis.
 Absence of digestive activity
Article in Hong Kong medical journal =
Xianggang yi xue za zhi / Hong Kong Academy of
Medicine · September 2006 Source: PubMed

14.  Crohn's disease has a predilection for the
Distal small intestine and proximal colon.
 One third to one half of all patients have
disease affecting both ileum and colon.
 Another one third have disease confined to
the small intestine, primarily the terminal
ileum.
 There may be an increasing group with
isolated colonic disease.
 Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition

15.  ITB usually present with symptoms
ranging from 1 month to 1 year.
 Crohn’s :from the onset of symptoms to
diagnosis is 3.3 yrs.

16.  ICTB
 Pain most common – 85%
 weight loss in 66 %
 fever in 35 – 50 %
 diarrhea in only 20 % of
patients
 abdominal tenderness is found
in most patients
 abdominal mass, usually inthe
right lower quadrant, in 25 to
50 % of patients.
 Intestinal obstruction,
perforation,abscess
 CROHN’S
 Abdominal pain
 Weight loss, fever,growth
retardation in children
 Diarrhoea
 Bleeding per rectum
 Perianal disease
 Extraintestinal
manifestations
 Abdominal mass
 Intestinal obstruction,
perforation,abscess

17. Demographic features
 Mean ages ( ± s.d.) of patients with CD and
intestinal tuberculosis were 36.5 ± 12.9 years and
32.8 ± 14 years P=0.1), respectively.
 Both diseases have an insidious onset which may
go undiagnosed for many years.
 Median duration of the disease was significantly
longer in patients with CD (53.3 P < 0.001) than in
patients with intestinal tuberculosis (23.4 months).
Clinical, endoscopic, and histological differentiations between crohn ’ s disease and intestinal
tuberculosis .Govind k.makharia.The american journal of gastroenterology volume 105 |
march 2010

19.  Chronic diarrhoea,bleeding PR,perianal
disease,extraintestinal involvement more seen
in Crohn’s patients.
 Fever is seen in both CD and ITB, but a high-
swinging fever (>38.5 C) favours ITB in the
absence of any intra-abdominal abscess.
 Abdominal pain,constipation and partial bowel
obstruction seen more in ITB pts.
 Peritoneal involvement with ascites favour a
diagnosis of ITB but as it is often absent it is
not very discriminatory.

20.  Routine blood counts and biochemical tests do
not help.
 ESR and CRP, are too nonspecific.
 Serological markers, such as (p-ANCA and c-
ANCA), and the IgA and IgG subtypes of ASCA,
had no significant diagnostic value in
discriminating between ITB and CD.These tests
should not therefore be relied upon for
distinguishing ITB from CD.
Ghoshal U C et al.Anti - Saccharomyces cerevisiae antibody is not useful to dfferentiate
between Crohn’s disease and intestinal tuberculosis in India . J Postgrad Med
2007;53:166–70 .

22.  The involvement of rectum,sigmoid colon ,
descending colon,ascending colon, and
jejunum was significantly more common in
patients with CD than in patients with
intestinal tuberculosis.
 There was no significant difference in the
involvement of the ileocecal region, ileum
stomach, and duodenum in patients with
CD and intestinal tuberculosis.
 Clinical, endoscopic, and histological differentiations between crohn ’ s
disease and intestinal tuberculosis .Govind k.makharia.The american journal
of gastroenterology volume 105 | march 2010

24.  Skip lesions,aphthous ulcers,linear ulcers,
superficial ulcers,cobblestoning favour
crohns disease.
 Nodularity of the colonic mucosa was seen
significantly more in patients with intestinal
tuberculosis
Clinical, endoscopic, and histological differentiations between crohn ’ s disease
and intestinal tuberculosis .Govind k.makharia.The american journal of
gastroenterology volume 105 | march 2010

26.  Lee YJ et al. Analysis of colonoscopic findings in the differential diagnosis between
intestinal tuberculosis and Crohn’s disease. Endoscopy 2006; 38: 592–7

27.  Four endoscopic features of CD
 Anorectal lesions
 Longitudinal ulcers
 Apthous ulcers
 Cobblestone appearance.
 Four endoscopic features of ITB
 Transverse ulcers
 Pseudopolyps and scarring
 Involvement of fewer than four segments
 Patulous ileo-caecal valve
Positive predictive value for CD of 94.9%
and 88.9% for ITB was achieved.

28. longitudinal
ulcers
And
cobblestonin
g in crohns
trans-
verse ulcer
encir-
cling the
entirelu-
men in a
patient
with ITB.

29. Aphthous
ulcers in
rectum in CD
Patulous IC
valve,scarrin
g ,ulcers in
ITB

30.  Both conditions are characterized by
granulomatous inflammation with overlapping
histologic features.
 In ITB, the classical and pathognomonic
features of caseating granulomatous
Inflammation and acid fast bacilli are present in
<30% of cases.
 A positive TB culture has a poor yield of <20%
and the diagnosis is often delayed by several
weeks.

31.  The importance of taking multiple biopsies
in cases of suspected ITB significantly
increases the diagnostic yield.
 Biopsies should be taken from all segments
of the bowel including both endoscopically
normal and abnormal areas.
 Ulcerated areas should be thoroughly
sampled (including multiple biopsies from
both the base and the edge of the ulcer)

33. solitary
AFB
In ITB
multiple,
confluent
granulomas with
caseous necrosis
in ITB

34. multiple,
confluent
granulomas with
caseous necrosis
ITB with
large
granuloma
.

35. aphthous ulcer in
CD
moderate
disarray of crypt
architecture in CD

36. Cryptitis in CD Crypt abscess in
CD

37. Small single
granuloma in CD

38. Barium studies in ITB
 Fleischner sign (a thickened patulous ICV combined
with a narrowed terminal ileum).
 Stierlin’s sign (a rapid emptying of contrast
through a gaping ileo-ceacal valve into a shrunken
or ‘amputated’ caecum).

44. ileo-cae-
cal ulcers with
destroyed caecum
and bladder
fistula in ITB
retraction of
the caecum out of
the pelvis in ITB

45. Barium studies in CD
 A long segment of involvement, with skip
lesions and preservation of the valve and
caecum was considered typical of CD

46. Numerous
aphthous ulcers
in CD
extensive
'cobblestoning'
due to linear
ulceration and
mucosal oedema
in CD

48. Concentric bowel
wall thickening in
CD
Asymmetrical wall
thickening with
mucosal tethering
in ITB

49. large
lymphadenopathy
with necrotic
centers displacing
bowel loops in ITB
minimal concentric bowel wall
thickening (open arrow)
involving a long segment of
small bowel+ Ascites and
thickening of
the parietal peritoneum in ITB

50. mesenteric fibrofatty
Change+ prominent
mesenteric vascular pattern
simulating the ‘comb-
Sign+ A thickened bowel loop
in CD

52. THANK YOU