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. 1999 Oct;45(4):537–541. doi: 10.1136/gut.45.4.537

Endoscopic mucosal biopsies are useful in distinguishing granulomatous colitis due to Crohn's disease from tuberculosis

A Pulimood 1, B Ramakrishna 1, G Kurian 1, S Peter 1, S Patra 1, V Mathan 1, M Mathan 1
PMCID: PMC1727684  PMID: 10486361

Abstract

BACKGROUND—Intestinal tuberculosis and Crohn's disease are chronic granulomatous disorders that are difficult to differentiate histologically.
AIMS—To characterise distinctive diagnostic features of tuberculosis and Crohn's disease in mucosal biopsy specimens obtained at colonoscopy.
METHODS—Selected histological parameters were evaluated retrospectively in a total of 61 biopsy sites from 20 patients with tuberculosis and 112 biopsy sites from 20 patients with Crohn's disease. The patients were chosen on the basis of clinical history, colonoscopic findings, diagnostic histology, and response to treatment.
RESULTS—The histological parameters characteristic of tuberculosis were multiple (mean number of granulomas per section: 5.35), large (mean widest diameter: 193 µm), confluent granulomas often with caseating necrosis. Other features were ulcers lined by conglomerate epithelioid histiocytes and disproportionate submucosal inflammation. The features characteristic of Crohn's disease were infrequent (mean number of granulomas per section: 0.75), small (mean widest diameter: 95 µm) granulomas, microgranulomas (defined as poorly organised collections of epithelioid histiocytes), focally enhanced colitis, and a high prevalence of chronic inflammation, even in endoscopically normal appearing areas.
CONCLUSIONS—The type and frequency of granulomas, presence or absence of ulcers lined by epithelioid histiocytes and microgranulomas, and the distribution of chronic inflammation have been identified as histological parameters that can be used to differentiate tuberculosis and Crohn's disease in mucosal biopsy specimens obtained at colonoscopy.


Keywords: tuberculosis; Crohn's disease; mucosal biopsy; histology

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Figure 1  .

Figure 1  

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(A) Colonic mucosal biopsy of a patient with tuberculosis showing multiple, large, confluent granulomas (maximum diameter of largest granuloma: 438 µm). (B) Colonic mucosal biopsy of a patient with Crohn's disease showing a single, small, naked granuloma in the mucosa (maximum diameter: 65 µm).

Figure 2  .

Figure 2  

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Colonic mucosa of a patient with Crohn's disease, showing an ill formed microgranuloma over a lymphoid follicle (maximum diameter: 75 µm).

Figure 3  .

Figure 3  

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Mucosal biopsy specimen from a patient with Crohn's disease, showing inflammatory granulation tissue from a site of deep ulceration.

Figure 4  .

Figure 4  

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Mucosal biopsy of a patient with tuberculosis, showing a conglomerate band of epithelioid histiocytes at a site of ulceration.

Figure 5  .

Figure 5  

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Ileal mucosal biopsy specimen from a patient with tuberculosis, showing disproportionate submucosal inflammation.

Figure 6  .

Figure 6  

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Colonic mucosal biopsy specimen of a patient with Crohn's disease, showing focal overrunning of crypts by neutrophils associated with increased chronic inflammatory cells in the adjacent lamina propria (focally enhanced colitis).

Selected References

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