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REVIEW

2009;53:177-186

*, , ,
,

* IBD

Diagnostic Guideline of Intestinal Tuberculosis


You Sun Kim, M.D.*, Young-Ho Kim, M.D. , Kang-Moon Lee, M.D. ,
Joo Sung Kim, M.D., Young Sook Park, M.D. , and IBD Study Group of
the Korean Association of the Study of Intestinal Diseases
Department of Internal Medicine, Inje University College of Medicine*, Sungkyunkwan University School of Medicine,
The Catholic University of Korea College of Medicine, Seoul National University College of Medicine,
Eulji University School of Medicine, Seoul, Korea

Tuberculosis (TB) is a still prevalent and important disease entity in Korea. TB can involve any part of the gastrointestinal tract, and intestinal TB is an important disease of extra-pulmonary TB. The diagnosis of intestinal TB
remains a challenge because the signs and symptoms are nonspecific. It should be differentiated from the inflammatory bowel diseases and malignancies, especially Crohns disease. The diagnosis of intestinal TB should be
based on careful clinical evaluation, such as extra-intestinal signs, colonoscopic and histologic evaluation. Newer
techniques such as PCR method or test for the diagnosis of latent TB (Interferon- assay) may be helpful. In
addition, a high index of suspicion must be kept in mind to ensure a timely diagnosis. Herein, IBD Study Group
of the KASID proposes a diagnostic guideline based on currently available evidence and experience, especially
those of Korea. We also propose the test which may be helpful to establish the proper diagnosis of intestinal
TB. (Korean J Gastroenterol 2009;53:177-186)
Key Words: Tuberculosis, Gastrointestinal; Diagnosis; Guideline

20

1950

. , AIDS ,

. , ,

: , 139-872, 1 280-1

Tel: (02) 970-8207, Fax: (02) 970-8621
E-mail: pys1109@eulji.ac.kr
*
(A080588).

Correspondence to: Young Sook Park, M.D.


Department of Internal Medicine, Eulji University School of
Medicine, Eulji Medical Center, 280-1, Haggye 1-dong, Nowon-gu, Seoul 139-872, Korea
Tel: +82-2-970-8207, Fax: +82-2-970-8621
E-mail: pys1109@eulji.ac.kr

178 : 53 3, 2009

IBD

.
,

.
(evidence level) (recommendation grade)
.



.


.
,
.

3.
1)
,
. 2004 WHO
890
170 ,
3
.

X-
,
4
1965 5.1% 1995 1.0% .

10-15% 5 HIV
6

.
2)

. 6
7
17%
8
.

1.
, , , ,
.
, ,

. ,

1

.
2.

9
4.8% .

,
,
10

46% ,


11


54%
12

.
1)

4.

5-10% ,

. ,

2)

, M. tuberculosis

. ,

4. 179

(Table 1).7

14

. 93

(Table 2).

(76%),

, ,

(60.8%), (54%) , ,
1)

15

20-50

14

, , ,
. 30%
,
. .
(1) :

(2) (Extra-intestinal tuberculosis):



.

37.3%.

29.8% 9.3%,

16
4.0%, 2.6% .

13

17,18

. 95

(73%), (56%), (39%)


19

.
Table 1. Diagnosis of Intestinal Tuberculosis
Definite diagnosis (one of three)
Caseating granuloma on mucosal biopsy
Tissue acid-fast bacilli staining
Tissue culture positive for M. tuberculosis
Probable diagnosis
Clinical & endoscopic improvement after empiric anti-TB
treatment with following findings
Previous TB history, TB patient contact history
Characteristic colonoscopic findings
Suspected TB histology
Tissue TB PCR positive
Abnormal chest X-ray (active or inactive TB)
Abdominal imaging with features of TB
Positive tuberculin skin test or interferon- assay
TB, tuberculosis; PCR, polymerase chain reaction.

2)
ESR, CRP
, .
HIV
.
PCR
.
(1) :
57%, (ESR)
14
16%, 42% ,

43%, ESR 38%,


15

27% .

CRP
20

50% .
Table 2. Test for the Diagnosis of Intestinal Tuberculosis
Obligatory test
Colonoscopy with biopsy (AFB stain)
Tissue culture for M. tuberculosis
Chest X-ray
Laboratory test (CBC, ESR, Chemistry, CRP)
Optional test
Tissue TB PCR
Tuberculin skin test, interferon- assay
Small bowel follow-through (enteroclysis)
Abdominal CT
HIV antibody
AFB, acid-fast bacilli; TB, tuberculosis; PCR, polymerase
chain reaction; HIV, human immunodeficieny virus; CRP,
C-reactive protein; ESR, erythrocyte sedimentation rate.

(2) HIV : HIV


3
(CD4+200/mm )

, HIV

6
.

HIV 0%
21

HIV

.
(3)

.
(acid fast bacilli)
. ,

180 The Korean Journal of Gastroenterology: Vol. 53, No. 3, 2009

14

73%

. , , ,

14
, ,

PCR

44% .17,25 20%

PCR ,

88% (16/18), 0% (0/8),

25,26

0% (0/30) 88.8%, 100%,

(2) :

100%, 93.7%

22
.

, ,
23,25,26-28

,
3)

,
.
, .
4 4 , ,
, .

, 90%
.


21
,

4 4 (involvement of fewer
than four segments), (transverse ulcers),
(pseudopolyps, scars), (patulous
ileocecal value) (Fig. 1).
, ,
, ,
.

(1) : ,

(longitudinal ulcers), ,

, (cobblestone appearance)

23,24

Fig. 1. Characteristic colonoscopic findings of intestinal


tuberculosis. (A) Transverse ulcerations. (B) Ulcer scars with
pseudopolyps. (C) A patulous
ileocecal valve.

Kim YS, et al. Diagnostic Guideline of Intestinal Tuberculosis 181

5)

94.9%,
88.9% .
, 44

.


.

. ,

. PCR

4)

X-

. , ,

M. tuberculosis

3-4

, .

(1) X- :

29
15-20%

(1) :

50%

17,18,27


14-16,25

27- 67%


14,15,25

8-14% ,

X- .
(2) , : ,

.


32

, (margin) (base)
18

, ,

30

25

, 6
27

(2) :

(mesenteric border)

(caseating granulomatous

(pseudosacculation)

inflammation) . ,

30%

(confluent granulomas), ,

25,32,33

(3) , :

(10 m),

(bands of epithelioid histiocytes lining ulcers),

(submucosal granulomas)

32-34

(3) PCR

31

PCR

,

35
. insertion element IS6110 PCR

182 : 53 3, 2009

PCR
93.8%, 60.0% PCR
36

PCR

9.8%, PCR 0%

,
,
DNA
35

6)


.
BCG
.
(1) PPD (Tuberculin skin test, TST):

TST PPD

PCR 45%, PCR 30%

(induration) .

PCR ,

2 TU

PCR

RT-23 5 TU PPD-S .

25

PCR

33.3% real-time PCR

27 gauge PPD

37

66.7% .

. (wheal) 6-10 mm

PCR

. 48-72

PCR DNA

PCR

1-2 cm

o
1% NaOH 100 C 2-5

38

38

TST

(4)

10 mm .

100%

non-tuberculous mycobacterium (NTM) ,

15,16,25

BCG PPD

NTM BCG . ,

, ,

14-36%

3-4

38
.

39
.

TST

( )

40
69.4%, 55.2% .

. ,

BCG

TST

3-4 . ,

1997, 6 BCG

BCG

29

(3)

(2) TST :

TST

38

BCG

TST TST

. HIV
(primary TB), (disseminated TB)

4. 183

(anergy)

41

(3) Interferon- :
(EAST-6, CFP-10) T

interferon- (QuantiFERON -

. CRP

. ,
1
.

TB Gold, Celestis limited, St kilda, Australia; QFT) interferon-

(1) :

T (T SPOT-

TB , Oxford Imunotec Limited, Oxon, UK).

M. tuberculosis

EAST-6, CFP-10 BCG NTM

TST .

QFT TST boosting TST

QFT

. QFT

TST

29 27(93%) 3

, cut-off

. 2 1

2005, FDA QFT TST

1 .

9 15

(http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a4.htm).

4.3 6 82.5%

TST QFT 70%

TST 66%, QFT 97% QFT

, .

42

7,44

45

QFT TST

46
. CRP

(91.6% vs

2 84.6% CRP

43

QFT TST

. QFT

CRP

CRP

. TST

2, 4, 8 1 mg/dL

HIV ,

20
.

1 CRP

78.6%).

47

TST QFT

2-3

(2)

7)
,

.
2-3


.
(http://www.knta.or.kr/korea/study/study05_3.
asp)
48,49

184 The Korean Journal of Gastroenterology: Vol. 53, No. 3, 2009

. 4

29 5 isoniazid , 1 ethambutol
16

,

.


.
73 8 2


50

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