肠结核与克罗恩病的鉴别诊断

在诸多肠道炎症性病变中,肠结核和克罗恩病是两大重要的疾病,近年来两者的发病率均呈上升趋势。肠结核与克罗恩病的临床、影像学、内镜和病理学表现均十分相似。肺结核的存在和结核杆菌的发现有利于肠结核的诊断,但克罗恩病误诊为肠结核的概率仍很高。本文就这两种疾病的诊断和鉴别诊断作一综述。 一、诊断标准 1.肠结核:符合以下任何一项标准即可确诊:①肠壁或肠系膜淋巴结找到干酪样坏死性肉芽肿;②病变组织病理检查找到结核杆菌;③病变处取材培养结核杆菌阳性;④病变处取材动物接种有结核改变。一般病例根据临床症状、体征以及X线检查有典型结核改变、肠外找到结核灶和抗痨试验治疗6周病情有改善,便可作出临床诊断。     

克罗恩病与肠结核临床及内镜特征的鉴别分析

目的 探讨克罗恩病(CD)与肠结核(ITB)的临床及内镜特点,为两者的临别诊断提供依据.方法 回顾性分析2003年6月-2009年2月168例CD患者和156例ITB患者的临床及内镜资料.结果 CD以男性为主(男;女为108:60),肠道手术率较ITB高[(33.3%比10.9%,P<0.01)];CD的腹泻、便血、肛周疾病、肠梗阻的发生率分别为66.1%、32.1%、16.1%和28.0%.明显高于ITB组(分别为47.0%、7.7%、3.4%和9.4%,P值<0.05或<0.01);而ITB的发热、盗汗多于CD组(P值均<0.05),且伴肺结核、腹水发生率明显高于CD组(P值均<0.01);ITB的球蛋白升高、红细胞沉降率增快、结核菌素纯蛋白衍化物试验阳性率、结核抗体阳性率均高于CD组;CD患者内镜下纵行溃疡、网格状溃疡、卵石征、肠腔狭窄均多于ITB组(P值<0.01或<0.05),而ITB的环行溃疡、同盲瓣受累多见(P值<0.01或<0.05),且受累的回盲瓣常变形和开口固定.结论 CD与ITB各有其临床特点,临床特点结合内镜下卵石征、纵行溃疡、网格状溃疡、环行溃疡出现的概率、回盲瓣受累情况及形态变化是鉴别两者的重要特征.     

克罗恩病与肠结核鉴别诊断研究进展

克罗恩病与肠结核的鉴别诊断一直是临床医师面临的一个难题,本文分析了克罗恩病与肠结核鉴别诊断研究的现状及存在的问题,对现有的诊断措施做了相应的评价,旨在帮助临床医师提高鉴别诊断的水平。     

肠结核与克罗恩病鉴别诊断的临床评价

肠结核(ITB)是结核分枝杆菌引起的慢性特异性肠道感染.近年来,结核病的流行在世界范围呈上升趋势[1-3],我国作为结核病的高发区,肺结核和肺外结核的发病率也在不断增加.在消化专业的临床就诊中,肠结核并不少见.由于其在临床、内镜、病理、影像等多方面与克罗恩病(CD)相似,而且缺乏特异性的鉴别指标,误诊率很高.至今,肠结核与克罗恩病的鉴别诊断依然是我们临床面临的一大难题[4].我们对近年来国内外学者关于肠结核和克罗恩病鉴别诊断的研究进展进行述评.     

克罗恩病和肠结核的组织病理学研究

目的：明确克罗恩病和肠结核的组织病理学特征，找出异同点。方法：利用手术切除的肠结核和克罗恩病理标本，观察其组织病理学特征并比较。结果：克罗恩病的特征为裂隙性溃疡、非干酪样坏死性肉芽肿、肿膜下层增宽；肠结核的特征为干酪样坏死、粘膜下层闭锁，肉芽肿融合，组织切片有许多相似之处，如微肉芽肿，全层炎症等，结论：典型的肠结核和克罗恩病易于鉴别，但二者组织病理学的相似性，给部分病例的鉴别诊断带来困难。     

克罗恩病与肠结核鉴别诊断方法的评价

目的　对克罗恩病与肠结核的鉴别诊断方法进行评价 ,寻找更好的鉴别诊断策略。方法　采用回顾性方法 ,将 1990～ 2 0 0 4年武汉大学人民医院既往确诊的克罗恩病与肠结核病例资料各 30例进行复习 ,分析其临床表现、放射影像学、内镜和组织病理学特征的异同之处 ,其结果行Pearson相关分析。结果　克罗恩病的内镜表现以铺路石样改变、节段性病变及非对称性的纵行溃疡为主 ,其病理表现主要是裂隙样溃疡、非干酪样肉芽肿、淋巴细胞聚集。肠结核的内镜表现以溃疡和假息肉为主 ,其病理表现主要是肠壁和淋巴结的干酪样坏死、黏膜肌层的破坏。两组病例的主要临床表现、系统钡餐和 (或 )钡剂灌肠检查和内窥镜表现呈正相关 ,γ分别为 0 .976、0. 975和 0 .96 1。两组病例的病理学特征无相关性 ,γ为 0. 12 9。两组病例在确诊前容易相互误诊 ,误诊率分别为 36. 7%和 5 0 . 0 %。结论　内镜和病理检查对于CD和肠结核的鉴别作用较大 ,临床表现和放射影像学检查可起到协助鉴别作用。     

结核杆菌DNA检测在肠结核与克罗恩病鉴别诊断中的价值

目的：探讨聚合酶链反应（PCR）技术对肠结核和克罗恩病（Crohn's disease,CD)的鉴别诊断价值。并对其内镜活检组织的病理改变进行比较,方法：C地38例肠结核和30例CD活检组织进行病理分析、抗酸染色镜检和PCR技术检测结核杆菌DNA。结果：（1）淋巴细胞聚集在CD远较肠结核多见（P＜0．05）;而肉芽肿,尤其是干酪样肉芽肿和肉芽肿的融合在肠结核却更多见（P＜0．05）。两者其他病理特点的差异在活检组织中不明显或难以发现;（2）PCR技术检测结核杆菌DNA总阳性率为63．2％（24／38例）;在与CD肉芽肿形态相同的肠结核组中阳性率为71．4％（10／14例）;在无肉芽肿瘤变的肠结核组中阳性率为64．7（11／17例）。而该技术在CD组无1例阳性。抗酸染色镜检总阳性率为21．1％（8／38例）。结论：内镜活检病理对肠结核与CD的鉴别诊断有一定局限。PCR技术是鉴别肠结核和CD极有价值的一种新方法。     

肠结核类似克罗恩病1例并文献分析

克罗恩病是一种病因未明的慢性非特异性肠道炎症性疾病,肠结核是结核分枝杆菌引起的肠道慢性特异性感染疾病,为常见的肺外结核病之一.二者临床表现及内镜下表现有许多相似之处,临床误诊率高,本文通过1例误诊为克罗恩病的肠结核病例,对二者进行文献回顾并分析,从而更好的对二者在临床上进行诊断与鉴别诊断.     

肠结核与克罗恩病的鉴别诊断分析

近年来肠结核（ITB）和克罗恩病（CD）的发病率呈逐年升高趋势,因两者的临床、内镜以及病理学检查结果均有很大的相似性,因此两者间的鉴别诊断一直是临床医师面临的难题。本研究采用回顾性分析方法,对本院最近6年来确诊的 ITB 患者和 CD 患者的资料进行分析,总结其临床、内镜、病理学特点及抗酸杆菌染色检查结果,为寻求更好的鉴别诊断方法提供参考。     

克罗恩病与肠结核临床及内镜表现的比较

目的通过对克罗恩病(CD)与肠结核(IT)的临床及内镜表现进行回顾性分析,找出对鉴别诊断有帮助的要点。方法对我院1981年12月至2005年12月收治的32例CD和12例IT住院患者的临床症状、并发症、内镜检查进行分析。结果CD患者平均年龄低于IT患者(P<0.05)。肠外结核IT常见(P<0.01)。CD结肠纵行溃疡及铺路石样改变明显高于IT患者(P<0.01),而IT以环形溃疡为主(P<0.05)。肠镜病理示CD有大量淋巴细胞聚集,IT可见干酪样肉芽肿及找到抗酸杆菌(P<0.01)。而临床症状、并发症CD与IT相似(P>0.05)。结论内镜及其病理检查对鉴别CD和IT起到重要作用。     

克罗恩病与肠结核的临床分析与比较

目的对克罗恩病(CD)与肠结核(IT)进行临床分析和比较,找出对鉴别诊断有帮助的要点。方法回顾性分析我院1983年~2004年间住院的62例CD患者和21例IT患者的临床资料。结果CD男性多见。临床表现、各种并发症的出现、实验室检查、腹部B超/CT以及消化道造影均对鉴别诊断帮助不大,CD的肠黏膜活检诊断率低。CD与IT的常见部位都是回肠及回盲部,但CD可累及直肠,吻合口病变为77.4%。CD纵行溃疡仅占13.6%,而环形溃疡却占26.7%,回盲瓣受累22.2%,IT瘘管形成并不罕见(14.3%)。CD肠系膜淋巴结最大直径为(10±3)mm,均无上皮样肉芽肿,而IT肠系膜淋巴结最大直径为(18±5)mm,P<0.01,均有上皮样肉芽肿,41.2%有干酪样坏死。CD裂隙溃疡多于IT(P<0.01)。CD中全层炎、淋巴组织增生、黏膜下层水肿均比IT多(P<0.05)。结论CD与IT的鉴别需要多方面综合判断,手术标本的病理对鉴别有重要意义。     

Histopathology and TB-PCR kit analysis in differentiating the diagnosis of intestinal tuberculosis and Crohn’s disease

AIM: To compare the histopathologic features of intestinal tuberculosis (ITB) and Crohn’s disease (CD) and to identify whether polymerase chain reaction for Mycobacterium tuberculosis (TB-PCR) would be helpful for differential diagnosis between ITB and CD.METHODS: We selected 97 patients with established diagnoses (55 cases of ITB and 42 cases of CD) who underwent colonoscopic biopsies.Microscopic features of ITB and CD were reviewed,and eight pathologic parameters were evaluated.Nine cases of acid fast bac...     

Differentiating Crohn's disease from intestinal tuberculosis

Differentiating Crohn's disease(CD) and intestinal tuberculosis(ITB) has remained a dilemma for most of the clinicians in the developing world, which are endemic for ITB, and where the disease burden of inflammatory bowel disease is on the rise. Although, there are certain clinical(diarrhea/hematochezia/perianal disease common in CD; fever/night sweats common in ITB), endoscopic(longitudinal/aphthous ulcers common in CD; transverse ulcers/patulous ileocaecal valve common in ITB), histologic(caseating/confluent/large granuloma common in ITB; microgranuloma common in CD), microbiologic(positive stain/culture for acid fast-bacillus in ITB), radiologic(long segment involvement/comb sign/skip lesions common in CD; necrotic lymph node/contiguous ileocaecal involvement common in ITB), and serologic differences between CD and ITB, the only exclusive features are caseation necrosis on biopsy, positive smear for acid-fast bacillus(AFB) and/or AFB culture, and necrotic lymph node on cross-sectional imaging in ITB. However,these exclusive features are limited by poor sensitivity, and this has led to the development of multiple multi-parametric predictive models. These models are also limited by complex formulae, small sample size and lack of validation across other populations. Several new parameters have come up including the latest Bayesian meta-analysis, enumeration of peripheral blood T-regulatory cells, and updated computed tomography based predictive score. However, therapeutic anti-tubercular therapy(ATT) trial, and subsequent clinical and endoscopic response to ATT is still required in a significant proportion of patients to establish the diagnosis. Therapeutic ATT trial is associated with a delay in the diagnosis of CD, and there is a need for better modalities for improved differentiation and reduction in the need for ATT trial.     

试验性抗结核治疗鉴别肠结核与克罗恩病的临床与内镜分析

目的探讨试验性抗结核治疗鉴别诊断肠结核与克罗恩病的评估标准及合适的判断时间点。方法回顾分析接受试验性抗结核治疗且最后得以确诊的28例肠结核（ITB）和11例克罗恩病（CD）患者在治疗过程中临床表现及肠镜下的改变。结果2组患者基线时较特异的临床特征包括活动性肺结核、PPD强阳性、肛瘘或肛周脓肿等差异均无统计学意义。抗结核治疗后2组临床症状均有改善,但3个月后ITB组无好转率为0,CD组为27．3％（P=0．004）。抗结核治疗3个月及6个月,ITB组活动性溃疡消失率＋明显好转率分别为90．9％（20／22）＋9．1％（2／22）及100％（28／28）＋0;结节样病变消失率＋明显好转率为58．8％（10／17）＋41．2％（7／17）及76．5％（13／17）＋23．5％（4／17）。而CD组在各时点活动性溃疡、结节样病变均无明显好转（P均〈0．01）。结论ITB和CD的鉴别因缺乏特异性指标,部分鉴别困难的病例仍需采用试验性抗结核治疗。试验性抗结核治疗后3个月,回结肠镜复查见活动性溃疡及结节样病变消失或明显好转,伴临床症状痊愈或明显好转可评定为试验治疗有效。     

Differentiation between intestinal tuberculosis and Crohn's disease in endoscopic biopsy specimens by polymerase chain reaction

OBJECTIVES: It is difficult to differentiate intestinal tuberculosis from Crohn's disease because of similar clinical, pathological, radiological, and endoscopic findings. The purpose of this study was to investigate the value of polymerase chain reaction (PCR) assay in the differentiation intestinal tuberculosis from Crohn's disease, and compare the histopathological features of endoscopic biopsy of the two disorders. METHODS: A total of 39 endoscopic biopsy specimens from patients with intestinal tuberculosis and 30 specimens from patients with Crohn's disease were subjected to pathological analysis retrospectively, Ziehl-Neelsen stain, and PCR assay. RESULTS: Except for granuloma with caseation and confluence, which was the characteristic of intestinal tuberculosis, other pathological features of intestinal tuberculosis and Crohn's disease were very similar or were difficult to find in endoscopic biopsy specimens. The positivity rate by PCR in 39 intestinal tuberculosis specimens was 64.1% (25/39), but was zero by PCR in 30 Crohn's disease specimens. Moreover, in the tissues of intestinal tuberculosis with granulomas similar to those of Crohn's disease, there were 71.4% (10/14) positive by PCR, and there were 61.1% (11/18) positive in intestinal tuberculosis tissues without granulomas. CONCLUSIONS: Biopsy is of limited diagnostic value in the differentiation intestinal tuberculosis from Crohn's disease, and PCR is valuable in the differentiation between intestinal tuberculosis and Crohn's disease.     

Pathology of intestinal tuberculosis and its distinction from Crohn's disease

Intestinal lesions of 212 cases presenting with symptoms of intestinal obstruction were studied. Of these, 159 cases were diagnosed as tuberculosis and 10 as Crohn's disease. Forty-three cases could not be classified into any of these entities and are excluded from this account. The amount of chemotherapeutic drugs received by each patient preoperatively was recorded. Cases proved as tuberculosis at the first operation were put on antituberculosis chemotherapy. Thirteen of these cases were operated on a second time, and tissue reactions under the influence of chemotherapy were studied. Fresh diseased tissue was studied for acid-fast organisms by culture and animal inoculation.Morphological features of the tuberculosis group are described in detail. Although the cases were broadly classified into the ulcerative and ulcerohypertrophic varieties, a distinction was not always sharp and the two types of lesions were at times found to coexist. The macroscopic features presented a very wide range, and at times distinction from Crohn's disease, especially in the ulcerohypertrophic variety, was difficult. Microscopically, however, they could be distinguished without much difficulty. Caseation, although a characteristic feature of tuberculous granulomas may, albeit rarely, be absent. Granulomas which are characteristically confluent may be present only in the mesenteric lymph nodes. Acid-fast organisms are not grown consistently from diseased tissues; where grown, they are of human type. Reparative changes during chemotherapy are described in detail; these follow a non-specific pattern.In the group of Crohn's disease, transmural cracks and fissures were consistently observed in all cases. Distinguishing features between the two diseases are discussed in detail.     

The role of in vitro interferonγ-release assay in differentiating intestinal tuberculosis from Crohn's disease in China

AimIntestinal tuberculosis (ITB) and Crohn's disease (CD) have overlapping clinical, radiographic, endoscopic and histologic features, which makes the distinction between these two disease entities a great challenge in tuberculosis-endemic countries. The aim of the study was to investigate the value of in vitro interferonγ release assay (T-SPOT.TB) in differentiating ITB from CD.MethodsFrom June 2008 to February 2010, a total of 93 consecutive patients with undetermined ITB or CD were prospectively recruited. Clinical, endoscopic, histologic and therapeutic responses were longitudinally monitored at follow-up evaluation until the final definite diagnosis has been reached.ResultsAfter a median of 6 months' follow-up (interquartile range [IQR], 3.0 to 7.5 months), definitive diagnosis was achieved in 84 of the 93 patients (90%), with 19 having ITB and 65 having CD. On univariate analysis, a long duration of illness, chronic diarrhea, and anemia were significantly more common in CD (P < 0.05). While night sweat, ascites, pulmonary lesions, circumferential ulcer on endoscopy, ileo-cecal valve involvement and epithelioid granulomas were significantly more common in ITB (P < 0.05). On multivariate analysis, T-SPOT.TB (Hazard ratio 7.0, 95% confidence interval [CI] 1.9–25.7) was found to be a good predictor for ITB diagnosis. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of T-SPOT.TB were 84.2%, 75.4%, 50.0%, and 94.2%, respectively.ConclusionsWhen differentiating ITB and CD in tuberculosis-endemic regions, T-SPOT.TB blood test may be a helpful and practical diagnostic tool for its high NPV to rule out ITB.