Intestinal Research

Original Articles

Infection

Interferon-gamma release assay has poor diagnostic accuracy in differentiating intestinal tuberculosis from Crohn’s disease in tuberculosis endemic areas: Karan Sachdeva, Peeyush Kumar, Bhaskar Kante, Sudheer K. Vuyyuru, Srikant Mohta, Mukesh K. Ranjan, Mukesh K. Singh, Mahak Verma, Govind Makharia, Saurabh Kedia, Vineet Ahuja; Intest Res 2023;21(2):226-234. Published online June 13, 2022; DOI: https://doi.org/10.5217/ir.2022.00010

Background/Aims
Intestinal tuberculosis (ITB) and Crohn’s disease (CD) frequently present with a diagnostic dilemma because of similar presentation. Interferon-gamma release assay (IGRA) has been used in differentiating ITB from CD, but with sparse reports on its diagnostic accuracy in tuberculosis endemic regions and this study evaluated the same.
Methods
Patients with definitive diagnosis of ITB (n=59) or CD (n=49) who underwent IGRA testing (n=307) were retrospectively included at All India Institute of Medical Sciences, New Delhi (July 2014 to September 2021). CD or ITB was diagnosed as per standard criteria. IGRA was considered positive at >0.35 IU/mL. Relevant data was collected and IGRA results were compared between ITB and CD to determine its accuracy.
Results
Among 59 ITB patients (mean age, 32.6±13.1 years; median disease duration, 1 year; male, 59.3%), 24 were positive and 35 tested negative for IGRA. Among 49 CD patients (mean age, 37.8±14.0; median disease duration, 4 years; male, 61.2%), 12 were positive and 37 tested negative for IGRA. Hence, for diagnosing ITB, IGRA showed a sensitivity, specificity, positive and negative predictive values of 40.68%, 75.51%, 66.67%, and 51.39%, respectively. The area under the curve of IGRA for ITB diagnosis was 0.66 (95% confidence interval, 0.55–0.75). In a subset (n=64), tuberculin skin test (TST) showed sensitivity, specificity, positive and negative predictive values of 64.7%, 73.3%, 73.3%, and 64.71%, respectively. IGRA and TST were concordant in 38 (59.4%) patients with κ=0.17.
Conclusions
In a tuberculosis endemic region, IGRA had poor diagnostic accuracy for differentiating ITB from CD, suggesting a limited value of IGRA in this setting.

Citations

Citations to this article as recorded by

Mistakes to avoid in the management of abdominal tuberculosis
Abhirup Chatterjee, Daya Krishna Jha, Aravind Sekar, Vishal Sharma
Expert Review of Anti-infective Therapy.2025; 23(2-4): 197. CrossRef
New diagnostic strategies to distinguish Crohn's disease and gastrointestinal tuberculosis
Himanshu Narang, Saurabh Kedia, Vineet Ahuja
Current Opinion in Infectious Diseases.2024; 37(5): 392. CrossRef
Interferon-gamma release assays as a tool for differential diagnosis of gastrointestinal tuberculosis
Tsvetelina Velikova, Anita Aleksandrova
World Journal of Clinical Cases.2024; 12(27): 6015. CrossRef
Diagnostic yield and technical performance of the novel motorized spiral enteroscopy compared with single-balloon enteroscopy in suspected Crohn's disease: a prospective study (with video)
Partha Pal, Piyush Vishwakarma, Aniruddha Pratap Singh, Palle Manohar Reddy, Mohan Ramchandani, Rupa Banerjee, Anuradha Sekaran, Polina Vijayalaxmi, Hardik Rughwani, Pradev Inavolu, Santosh Darishetty, Pradeep Rebala, Guduru Venkat Rao, Manu Tandan, D. Na
Gastrointestinal Endoscopy.2023; 97(3): 493. CrossRef
Evidence-based approach to diagnosis and management of abdominal tuberculosis
Daya Krishna Jha, Mythili Menon Pathiyil, Vishal Sharma
Indian Journal of Gastroenterology.2023; 42(1): 17. CrossRef
Technical performance and diagnostic yield of motorised spiral enteroscopy compared with single-balloon enteroscopy in suspected Crohn’s disease: a randomised controlled, open-label study (the MOTOR-CD trial)
Partha Pal, Mohan Ramchandani, Rupa Banerjee, Piyush Viswakarma, Aniruddha Pratap Singh, Manohar Reddy, Hardik Rughwani, Rajendra Patel, Anuradha Sekaran, Swathi Kanaganti, Santosh Darisetty, Zaheer Nabi, Jagadish Singh, Rajesh Gupta, Sundeep Lakhtakia, R
Gut.2023; 72(10): 1866. CrossRef

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Miscellaneous

Addition of computed tomography chest increases the diagnosis rate in patients with suspected intestinal tuberculosis: Saurabh Kedia, Raju Sharma, Sudheer Kumar Vuyyuru, Deepak Madhu, Pabitra Sahu, Bhaskar Kante, Prasenjit Das, Ankur Goyal, Karan Madan, Govind Makharia, Vineet Ahuja; Intest Res 2022;20(2):184-191. Published online May 4, 2021; DOI: https://doi.org/10.5217/ir.2020.00104

Abstract PDF PubReader ePub

Background/Aims
Intestinal tuberculosis (ITB) is difficult to diagnose due to poor sensitivity of definitive diagnostic tests. ITB may be associated with concomitant pulmonary tuberculosis (PTB) which may remain undetected on chest X-ray. We assessed the role of contrast enhanced computed tomography (CECT) chest in detecting the prevalence of active PTB, and increasing the diagnostic yield in patients with suspected ITB.
Methods
Consecutive treatment naïve patients with suspected ITB (n=200) who underwent CECT chest (n=88) and had follow-up duration>1 year were recruited in this retrospective study (February 2016 to October 2018). ITB was diagnosed in the presence of caseating granuloma, positive acid fast stain or culture for Mycobacterium tuberculosis on biopsy, presence of necrotic lymph nodes (LNs) on CT enterography or positive response to anti-tubercular therapy. Evidence of active tuberculosis on CECT-chest was defined as presence of centrilobular nodules with or without consolidation/miliary nodules/thick-walled cavity/enlarged necrotic mediastinal LNs.
Results
Sixty-five of eighty-eight patients (mean age, 33.8±12.8 years; 47.7% of females) were finally diagnosed as ITB (4-caseating granuloma on biopsy, 12-necrotic LNs on CT enterography, 1-both, and 48-response to anti-tubercular therapy) and 23 were diagnosed as Crohn’s disease. Findings of active TB on CECT chest with or without necrotic abdominal LNs were demonstrated in 5 and 20 patients, respectively. No patient with Crohn’s disease had necrotic abdominal LNs or active PTB. Addition of CECT chest in the diagnostic algorithm improved the sensitivity of ITB diagnosis from 26.2% to 56.9%.
Conclusions
Addition of CECT chest significantly improves the sensitivity for definite diagnosis in a patient with suspected ITB.

Citations

Citations to this article as recorded by

Imaging in Abdominal Tuberculosis
Anuradha Sharma, Ankur Goyal, Devasenathipathy Kandasamy, Saurabh Kedia, Vineet Ahuja, Raju Sharma
Indographics.2024; 03(02): 045. CrossRef
Evidence-based approach to diagnosis and management of abdominal tuberculosis
Daya Krishna Jha, Mythili Menon Pathiyil, Vishal Sharma
Indian Journal of Gastroenterology.2023; 42(1): 17. CrossRef
Risk factors identification of COVID‐19 patients with chronic obstructive pulmonary disease: A retrospective study in Punjab‐Pakistan
Muhammad Muneeb Hassan, M. H. Tahir, Muhammad Ameeq, Farrukh Jamal, John T. Mendy, Christophe Chesneau
Immunity, Inflammation and Disease.2023;[Epub] CrossRef
Strengthening Tuberculosis Services for Children and Adolescents in Low Endemic Settings
Jeffrey R. Starke, Connie Erkens, Nicole Ritz, Ian Kitai
Pathogens.2022; 11(2): 158. CrossRef
Stringent screening strategy significantly reduces reactivation rates of tuberculosis in patients with inflammatory bowel disease on anti‐TNF therapy in tuberculosis endemic region
Peeyush Kumar, Sudheer K. Vuyyuru, Bhaskar Kante, Pabitra Sahu, Sandeep Goyal, Deepak Madhu, Saransh Jain, Mukesh Kumar Ranjan, Sandeep Mundhra, Rithvik Golla, Mukesh Singh, Shubi Virmani, Anvita Gupta, Nidhi Yadav, Mani Kalaivani, Raju Sharma, Prasenjit
Alimentary Pharmacology & Therapeutics.2022; 55(11): 1431. CrossRef

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Inflammatory Bowel Diseases

Prospective validation of CD4⁺CD25⁺FOXP3⁺ T-regulatory cells as an immunological marker to differentiate intestinal tuberculosis from Crohn’s disease: Ritika Rampal, Saurabh Kedia, Mohamad Nahidul Wari, Deepak Madhu, Amit Kumar Singh, Veena Tiwari, V. Pratap Mouli, Srikant Mohta, Govind Makharia, Vineet Ahuja; Intest Res 2021;19(2):232-238. Published online May 8, 2020; DOI: https://doi.org/10.5217/ir.2019.09181

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Background/Aims
Crohn’s disease (CD) and intestinal tuberculosis (ITB) remain “difficult-to-differentiate” diseases. We have previously documented peripheral blood frequency of CD4⁺CD25⁺FOXP3⁺ T-regulatory cells (Treg) as a biomarker to differentiate CD and ITB. We tried to validate these results in a larger cohort of CD and ITB patients.
Methods
Seventy treatment naïve patients of CD (n = 23) and ITB (n = 47) (diagnosed by standard criteria) were recruited prospectively from October 2016 to May 2017. Patients with history of antitubercular therapy in the past were excluded. The frequency of Treg cells in peripheral blood was determined by flow cytometry, and compared between CD and ITB patients.
Results
Similar to our previous study, frequency of Treg cells in peripheral blood was significantly increased in ITB as compared to CD patients (40.9 [interquartile range, 33–50] vs. 24.9 [interquartile range, 14.4–29.6], P< 0.001). Further, the receiver operating characteristics curve also showed good diagnostic accuracy with an area under the curve (AUC) of 0.77 (95% confidence interval, 0.65–0.89) and a FOXP3⁺ cutoff value of > 31.3% had a sensitivity and specificity of 83% and 82.6% respectively, to differentiate ITB from CD. Even for the indeterminate cases (n = 33), Treg cell frequency had similar diagnostic accuracy with an AUC of 0.85 (95% confidence interval, 0.68–0.95) and a cutoff of 32.37% had sensitivity and specificity of 87% and 95% respectively, to differentiate ITB from CD.
Conclusions
The current findings validate that the increased frequency of CD4⁺CD25⁺FOXP3⁺ Treg in the peripheral blood can be used as a biomarker with high diagnostic accuracy to differentiate ITB from CD.

Citations

Citations to this article as recorded by

New diagnostic strategies to distinguish Crohn's disease and gastrointestinal tuberculosis
Himanshu Narang, Saurabh Kedia, Vineet Ahuja
Current Opinion in Infectious Diseases.2024; 37(5): 392. CrossRef
Evidence-based approach to diagnosis and management of abdominal tuberculosis
Daya Krishna Jha, Mythili Menon Pathiyil, Vishal Sharma
Indian Journal of Gastroenterology.2023; 42(1): 17. CrossRef
Gut Microbiome in Probable Intestinal Tuberculosis and Changes following Anti-Tuberculosis Treatment
Hyuk Yoon, Young Soo Park, Cheol Min Shin, Nayoung Kim, Dong Ho Lee
Yonsei Medical Journal.2022; 63(1): 34. CrossRef
Single-nucleotide polymorphisms and activities of indoleamine 2,3-dioxygenase isoforms, IDO1 and IDO2, in tuberculosis patients
Tingming Cao, Guangming Dai, Hongqian Chu, Chengcheng Kong, Huijuan Duan, Na Tian, Zhaogang Sun
Hereditas.2022;[Epub] CrossRef
Recent advances in the diagnosis of intestinal tuberculosis
Hasan Maulahela, Marcellus Simadibrata, Erni Juwita Nelwan, Nur Rahadiani, Editha Renesteen, S. W. T. Suwarti, Yunita Windi Anggraini
BMC Gastroenterology.2022;[Epub] CrossRef
Addition of computed tomography chest increases the diagnosis rate in patients with suspected intestinal tuberculosis
Saurabh Kedia, Raju Sharma, Sudheer Kumar Vuyyuru, Deepak Madhu, Pabitra Sahu, Bhaskar Kante, Prasenjit Das, Ankur Goyal, Karan Madan, Govind Makharia, Vineet Ahuja
Intestinal Research.2022; 20(2): 184. CrossRef
Inflammatory bowel disease in Korea: epidemiology and pathophysiology
Jung Won Lee, Chang Soo Eun
The Korean Journal of Internal Medicine.2022; 37(5): 885. CrossRef
Intestinal tuberculosis or Crohn's disease: Illusion or delusion or allusion
Saurabh Kedia, Vineet Ahuja
JGH Open.2021; 5(2): 177. CrossRef
Deep‐learning system for real‐time differentiation between Crohn's disease, intestinal Behçet's disease, and intestinal tuberculosis
Jung Min Kim, Jun Gu Kang, Sungwon Kim, Jae Hee Cheon
Journal of Gastroenterology and Hepatology.2021; 36(8): 2141. CrossRef
Mycobacterium tuberculosis (MTB) antigen-induced upregulation of interleukin-35 expression in patients with MTB infection: In vitro blockade of the effects of interleukin-35 on T lymphocyte subsets
Hongbin Jiang, Beinian Cui, Jun Zhang
Pathogens and Disease.2021;[Epub] CrossRef

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Review

IBD

Intestinal tuberculosis or Crohn’s disease: a review of the diagnostic models designed to differentiate between these two gastrointestinal diseases: Julajak Limsrivilai, Nonthalee Pausawasdi; Intest Res 2021;19(1):21-32. Published online April 22, 2020; DOI: https://doi.org/10.5217/ir.2019.09142

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Differentiating Crohn’s disease (CD) from intestinal tuberculosis (ITB) is a diagnostic dilemma, particularly in regions where ITB is prevalent and CD incidence is increasing, because both diseases can present quite similarly, and diagnostic tests to identify Mycobacterium tuberculosis in tissue samples have rather poor sensitivity. Studies that were conducted to determine the factors that differentiate CD from ITB identified some significant characteristics, but none of those characteristics are exclusive to either ITB or CD. Many diagnostic models or scoring systems that use one to several diagnostic parameters have been proposed to help distinguish these two intestinal diseases. Early models consisted of parameters common to routine clinical practice, such as clinical features, and endoscopic and pathologic findings. The later models also include more advanced diagnostic parameters like high-resolution imaging and serological testing. However, the number and types of parameters differ among diagnostic models, and the systems used to calculate scoring also vary from model to model. Enhanced awareness and understanding of the currently available diagnostic models will help physicians determine which model(s) is/are most suitable for differentiating CD from ITB in their clinical practice.

Citations

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Interferon-gamma release assay has poor diagnostic accuracy in differentiating intestinal tuberculosis from Crohn’s disease in tuberculosis endemic areas
Karan Sachdeva, Peeyush Kumar, Bhaskar Kante, Sudheer K. Vuyyuru, Srikant Mohta, Mukesh K. Ranjan, Mukesh K. Singh, Mahak Verma, Govind Makharia, Saurabh Kedia, Vineet Ahuja
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Systematic Review

Accuracy of computed tomographic features in differentiating intestinal tuberculosis from Crohn's disease: a systematic review with meta-analysis: Saurabh Kedia, Raju Sharma, Vishnubhatla Sreenivas, Kumble Seetharama Madhusudhan, Vishal Sharma, Sawan Bopanna, Venigalla Pratap Mouli, Rajan Dhingra, Dawesh Prakash Yadav, Govind Makharia, Vineet Ahuja; Intest Res 2017;15(2):149-159. Published online April 27, 2017; DOI: https://doi.org/10.5217/ir.2017.15.2.149

Abstract PDF PubReader ePub

Abdominal computed tomography (CT) can noninvasively image the entire gastrointestinal tract and assess extraintestinal features that are important in differentiating Crohn's disease (CD) and intestinal tuberculosis (ITB). The present meta-analysis pooled the results of all studies on the role of CT abdomen in differentiating between CD and ITB. We searched PubMed and Embase for all publications in English that analyzed the features differentiating between CD and ITB on abdominal CT. The features included comb sign, necrotic lymph nodes, asymmetric bowel wall thickening, skip lesions, fibrofatty proliferation, mural stratification, ileocaecal area, long segment, and left colonic involvements. Sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio (DOR) were calculated for all the features. Symmetric receiver operating characteristic curve was plotted for features present in >3 studies. Heterogeneity and publication bias was assessed and sensitivity analysis was performed by excluding studies that compared features on conventional abdominal CT instead of CT enterography (CTE). We included 6 studies (4 CTE, 1 conventional abdominal CT, and 1 CTE+conventional abdominal CT) involving 417 and 195 patients with CD and ITB, respectively. Necrotic lymph nodes had the highest diagnostic accuracy (sensitivity, 23%; specificity, 100%; DOR, 30.2) for ITB diagnosis, and comb sign (sensitivity, 82%; specificity, 81%; DOR, 21.5) followed by skip lesions (sensitivity, 86%; specificity, 74%; DOR, 16.5) had the highest diagnostic accuracy for CD diagnosis. On sensitivity analysis, the diagnostic accuracy of other features excluding asymmetric bowel wall thickening remained similar. Necrotic lymph nodes and comb sign on abdominal CT had the best diagnostic accuracy in differentiating CD and ITB.

Citations

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Differentiation of Crohn's disease, ulcerative colitis, and intestinal tuberculosis by dual-layer spectral detector CT enterography
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New diagnostic strategies to distinguish Crohn's disease and gastrointestinal tuberculosis
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Evidence-based approach to diagnosis and management of abdominal tuberculosis
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Addition of computed tomography chest increases the diagnosis rate in patients with suspected intestinal tuberculosis
Saurabh Kedia, Raju Sharma, Sudheer Kumar Vuyyuru, Deepak Madhu, Pabitra Sahu, Bhaskar Kante, Prasenjit Das, Ankur Goyal, Karan Madan, Govind Makharia, Vineet Ahuja
Intestinal Research.2022; 20(2): 184. CrossRef
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Intestinal tuberculosis or Crohn's disease: Illusion or delusion or allusion
Saurabh Kedia, Vineet Ahuja
JGH Open.2021; 5(2): 177. CrossRef
Deep‐learning system for real‐time differentiation between Crohn's disease, intestinal Behçet's disease, and intestinal tuberculosis
Jung Min Kim, Jun Gu Kang, Sungwon Kim, Jae Hee Cheon
Journal of Gastroenterology and Hepatology.2021; 36(8): 2141. CrossRef
Prospective validation of CD4+CD25+FOXP3+ T-regulatory cells as an immunological marker to differentiate intestinal tuberculosis from Crohn’s disease
Ritika Rampal, Saurabh Kedia, Mohamad Nahidul Wari, Deepak Madhu, Amit Kumar Singh, Veena Tiwari, V. Pratap Mouli, Srikant Mohta, Govind Makharia, Vineet Ahuja
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Differentiating Crohn’s disease from intestinal tuberculosis
Saurabh Kedia, Prasenjit Das, Kumble Seetharama Madhusudhan, Siddhartha Dattagupta, Raju Sharma, Peush Sahni, Govind Makharia, Vineet Ahuja
World Journal of Gastroenterology.2019; 25(4): 418. CrossRef
The potential role of CT enterography and gastrointestinal ultrasound in the evaluation of anti-tubercular therapy response of intestinal tuberculosis: a retrospective study
Li Ma, Qingli Zhu, Yue Li, Wenbo Li, Xuan Wang, Wei Liu, Jianchu Li, Yuxin Jiang
BMC Gastroenterology.2019;[Epub] CrossRef
Indian guidelines on imaging of the small intestine in Crohn’s disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement
Saurabh Kedia, Raju Sharma, Govind Makharia, Vineet Ahuja, Devendra Desai, Devasenathipathy Kandasamy, Anu Eapen, Karthik Ganesan, Uday C Ghosha, Naveen Kalra, R Karthikeyan, Kumble Seetharama Madhusudhan, Mathew Philip, Amarender Puri, Sunil Puri, Saroj
Indian Journal of Radiology and Imaging.2019; 29(02): 111. CrossRef
Imaging in discriminating intestinal tuberculosis and Crohn’s disease: past, present and the future
Pradeep Goyal, Jimil Shah, Sonali Gupta, Pankaj Gupta, Vishal Sharma
Expert Review of Gastroenterology & Hepatology.2019; 13(10): 995. CrossRef
Combination of increased visceral fat and long segment involvement: Development and validation of an updated imaging marker for differentiating Crohn's disease from intestinal tuberculosis
Saurabh Kedia, Kumble S Madhusudhan, Raju Sharma, Sawan Bopanna, Dawesh P Yadav, Sandeep Goyal, Saransh Jain, Prasenjit Das, Siddhartha Dattagupta, Govind Makharia, Vineet Ahuja
Journal of Gastroenterology and Hepatology.2018; 33(6): 1234. CrossRef
Computed Tomography Enterography: Quantitative Evaluation on Crohn’s Disease Activity
Jingyun Cheng, Hui Xie, Hao Yang, Ke Wang, Guobin Xu, Guangyao Wu
Gastroenterology Research and Practice.2018; 2018: 1. CrossRef
Gastrointestinal Tuberculosis Presenting as Malnutrition and Distal Colonic Bowel Obstruction
Raja Chandra Chakinala, Zahava C. Farkas, Benjamin Barbash, Khwaja F. Haq, Shantanu Solanki, Muhammad Ali Khan, Edward Esses, Taliya Farooq, Brad Dworkin
Case Reports in Gastrointestinal Medicine.2018; 2018: 1. CrossRef
Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced
Fikri M Abu-Zidan, Arif Alper Cevik
World Journal of Emergency Surgery.2018;[Epub] CrossRef
Enfermedad de Crohn vs tuberculosis intestinal: un diagnóstico diferencial desafiante. Revisión de tema
Gabriel Alonso Mosquera-Klinger, Andrea Ucroz Benavides
Revista Colombiana de Gastroenterología.2018; 33(4): 423. CrossRef
Imaging of the small intestine in Crohn’s disease: Joint position statement of the Indian Society of Gastroenterology and Indian Radiological and Imaging Association
Saurabh Kedia, Raju Sharma, Govind K. Makharia, Vineet Ahuja, Devendra Desai, Devasenathipathy Kandasamy, Anu Eapen, Karthik Ganesan, Uday C. Ghoshal, Naveen Kalra, D. Karthikeyan, Kumble Seetharama Madhusudhan, Mathew Philip, Amarender Singh Puri, Sunil
Indian Journal of Gastroenterology.2017; 36(6): 487. CrossRef
Editor’s Pick: Recent Advances in the Diagnosis and Management of Abdominal Tuberculosis
Harshal S. Mandavdhare, Harjeet Singh, Vishal Sharma
EMJ Gastroenterology.2017; : 52. CrossRef

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