Professional Documents
Culture Documents
2009;53:177-186
*, , ,
,
* IBD
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).
178 : 53 3, 2009
IBD
.
,
.
(evidence level) (recommendation grade)
.
.
.
,
.
3.
1)
,
. 2004 WHO
890
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.
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1965 5.1% 1995 1.0% .
10-15% 5 HIV
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.
2)
. 6
7
17%
8
.
1.
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2.
9
4.8% .
,
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10
46% ,
11
54%
12
.
1)
4.
5-10% ,
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2)
, M. tuberculosis
. ,
4. 179
(Table 1).7
14
. 93
(Table 2).
(76%),
, ,
(60.8%), (54%) , ,
1)
15
20-50
14
, , ,
. 30%
,
. .
(1) :
29.8% 9.3%,
16
4.0%, 2.6% .
13
17,18
. 95
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% ,
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.
, HIV
6
.
HIV 0%
21
HIV
.
(3)
.
(acid fast bacilli)
. ,
14
73%
. , , ,
14
, ,
PCR
PCR ,
25,26
(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
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),
(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
(induration) .
PCR ,
2 TU
PCR
RT-23 5 TU PPD-S .
25
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%
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
.
(1) :
T (T SPOT-
M. tuberculosis
TST .
QFT
. QFT
TST
29 27(93%) 3
, cut-off
. 2 1
1 .
9 15
(http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a4.htm).
4.3 6 82.5%
, .
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
. 4
29 5 isoniazid , 1 ethambutol
16
,
.
.
73 8 2
50
20,46
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