Limsrivilai Julajak, Shreiner Andrew B, Pongpaibul Ananya, Laohapand Charlie, Boonanuwat Rewat, Pausawasdi Nonthalee, Pongprasobchai Supot, Manatsathit Sathaporn, Higgins Peter D R
Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA.
Division of Gastroenterology, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Am J Gastroenterol. 2017 Mar;112(3):415-427. doi: 10.1038/ajg.2016.529. Epub 2017 Jan 3.
Distinguishing intestinal tuberculosis (ITB) from Crohn's disease (CD) is difficult, although studies have reported clinical, endoscopic, imaging, and laboratory findings that help to differentiate these two diseases. We aimed to produce estimates of the predictive power of these findings and construct a comprehensive model to predict the probability of ITB vs. CD.
A systematic literature search for studies differentiating ITB from CD was conducted in MEDLINE, PUBMED, and EMBASE from inception until September 2015. Fifty-five distinct meta-analyses were performed to estimate the odds ratio of each predictive finding. Estimates with a significant difference between CD and ITB and low to moderate heterogeneity (I<50%) were incorporated into a Bayesian prediction model incorporating the local pretest probability.
Thirty-eight studies comprising 2,117 CD and 1,589 ITB patients were included in the analyses. Findings in the model that significantly favored CD included male gender, hematochezia, perianal disease, intestinal obstruction, and extraintestinal manifestations; endoscopic findings of longitudinal ulcers, cobblestone appearance, luminal stricture, mucosal bridge, and rectal involvement; pathological findings of focally enhanced colitis; and computed tomographic enterography (CTE) findings of asymmetrical wall thickening, intestinal wall stratification, comb sign, and fibrofatty proliferation. Findings that significantly favored ITB included fever, night sweats, lung involvement, and ascites; endoscopic findings of transverse ulcers, patulous ileocecal valve, and cecal involvement; pathological findings of confluent or submucosal granulomas, lymphocyte cuffing, and ulcers lined by histiocytes; a CTE finding of short segmental involvement; and a positive interferon-γ release assay. The model was validated by gender, clinical manifestations, endoscopic, and pathological findings in 49 patients (27 CD, 22 ITB). The sensitivity, specificity, and accuracy for diagnosis of ITB were 90.9%, 92.6%, and 91.8%, respectively.
A Bayesian model based on the meta-analytic results is presented to estimate the probability of ITB and CD calibrated to local prevalence. This model can be applied to patients using a publicly available web application.
尽管已有研究报道了有助于区分肠结核（ITB）和克罗恩病（CD）的临床、内镜、影像学及实验室检查结果，但鉴别这两种疾病仍存在困难。我们旨在评估这些检查结果的预测能力，并构建一个综合模型来预测ITB与CD的发病概率。
在MEDLINE、PUBMED和EMBASE数据库中进行系统的文献检索，检索时间从数据库建立至2015年9月，纳入区分ITB和CD的研究。进行了55项不同的荟萃分析，以评估每个预测性检查结果的比值比。将CD与ITB之间存在显著差异且异质性低至中度（I<50%）的评估结果纳入结合了局部检验前概率的贝叶斯预测模型。
分析纳入了38项研究，共2117例CD患者和1589例ITB患者。模型中显著支持CD的检查结果包括男性、便血、肛周疾病、肠梗阻及肠外表现；内镜检查发现纵行溃疡、鹅卵石样外观、管腔狭窄、黏膜桥及直肠受累；病理检查发现局灶性增强性结肠炎；计算机断层扫描小肠造影（CTE）发现不对称性肠壁增厚、肠壁分层、梳征及纤维脂肪增生。显著支持ITB的检查结果包括发热、盗汗、肺部受累及腹水；内镜检查发现横行溃疡、回盲瓣松弛及盲肠受累；病理检查发现融合性或黏膜下肉芽肿、淋巴细胞套袖样浸润及组织细胞内衬的溃疡；CTE发现短节段受累；以及γ-干扰素释放试验阳性。该模型通过49例患者（27例CD，22例ITB）的性别、临床表现、内镜及病理检查结果进行验证。诊断ITB的敏感性、特异性及准确性分别为90.9%、92.6%和91.8%。
基于荟萃分析结果提出了一个贝叶斯模型，用于根据当地患病率估计ITB和CD的发病概率。该模型可通过一个公开可用的网络应用程序应用于患者。
