Distinguishing Crohn’s Disease from Intestinal Tuberculosis in Nepal: A Prospective Observational Study

Abstract

BACKGROUND AND AIMS Crohn’s disease (CD) and intestinal tuberculosis (ITB) are chronic granulomatous disorders with substantial overlap in clinical, endoscopic and histopathological features, posing significant diagnostic challenges. We aimed to compare demographic characteristics, clinical presentation, endoscopic and histological finding and treatment outcomes of CD and ITB and to identify distinguishing features in a Nepalese cohort.

METHODS This prospective observational study (2017–2024) included adults diagnosed with CD or ITB. CD was diagnosed via standard criteria; ITB was established by histopathology, GeneXpert MTB/PCR, or clinicoradiological response to anti-tubercular therapy (ATT). Patients failing to improve after one month of ATT were re-evaluated. Multivariate logistic regression identified independent predictors of diagnosis.

RESULTS Six of 75 patients (8.0%) initially treated as presumed ITB failed to respond to ATT at one month and were subsequently reclassified as CD, yielding a final cohort of 263 CD and 69 ITB patients. CD demonstrated male predominance (61.6%), whereas ITB was more common in females (59.4%) (p=0.003). Mean age at diagnosis was similar between CD (31.8 ± 6.7 years) and ITB (32.7 ± 12.9 years). Abdominal pain was reported in 87.5% of CD and 88.4% of ITB patients. Fever was more frequent in ITB (49.3% vs 24.7%), while rectal bleeding (41.8% vs 14.5%) and perianal disease (24.7% vs 0%) favored CD. Ileocecal involvement predominated in both groups. Histopathological confirmation of ITB was achieved in 58.0%. All confirmed ITB and CD patients achieved sustained clinical and endoscopic remission at six months follow-up. Female sex (aOR 2.48) and fever (aOR 2.12) independently predicted ITB, whereas rectal bleeding (aOR 0.18) and perianal disease (aOR 0.12) favored CD.

CONCLUSION CD and ITB frequently overlap, limiting the utility of disease location and histopathology alone. Accurate differentiation requires an integrated approach combining demographics, clinical markers, endoscopic findings, and microbiological testing. Prompt reassessment of patients failing to respond to anti-tubercular therapy within one month is critical to prevent misdiagnosis and ensure appropriate management as IBD incidence rises.