AJR 2000; 175:121-128
© American Roentgen Ray Society
Tuberculous Colitis
Radiologic-Colonoscopic Correlation
Seong Jin Park1,2,
Joon Koo Han1,
Tae Kyoung Kim1,
Joo Sung Kim3,
Hyun Chae Jung3,
In Sung Song3 and
Byung Ihn Choi1
1
Department of Radiology, Seoul National University College of Medicine, 28,
Yongon-dong, Chongno-gu, Seoul, 110-744, Korea.
2
Present address: Department of Diagnostic Radiology, Kyung Hee University
Hospital, 1, Hoeki-dong, Dongdaemun-ku, Seoul, 110-744, Korea.
3
Department of Internal Medicine, Seoul National University College of
Medicine, Seoul, 110-744, Korea.
Received September 13, 1999;
accepted after revision November 9, 1999.
Presented at the annual meeting of the Radiological Society of North
America, Chicago, November 1998.
Address correspondence to J. K. Han.
Introduction
Until recently, intestinal tuberculosis was considered a rare chronic
disease, occurring mainly in people of Third World countries. However,
researchers have noted a sharp increase in incidence of tuberculosis in young
adults in association with recent epidemics of AIDS
[1]. Compared with
immunocompetent patients, patients with AIDS frequently have a greater
incidence of extrapulmonary tuberculosis. Therefore, it is necessary for
radiologists to recognize the colonoscopic findings of various colonic
diseases, including inflammatory bowel diseases and tumorous conditions.
Diagnosis of Tuberculous Colitis
In the past, the radiologic diagnosis of intestinal tuberculosis was made
with barium contrast studies. Although colonoscopy and colonoscopic biopsy
have gained wide popularity and have supplanted the primary diagnostic role of
radiologic studies [2], the
double-contrast barium enema can provide detailed information on the mucosal
pattern and early staging features of intestinal tuberculosis
[3]. With a better
understanding of the early features of tuberculous colitis, early diagnosis
with double-contrast barium enema might be possible.
Intestinal tuberculosis is diagnosed when histologic tests reveal caseating
granulomas or acid-fast bacilli. However, the sensitivity of revealing
acid-fast bacilli or granulomas with caseating necrosis is low (approximately
32% and 50%, respectively) [4].
Therefore, the clinical diagnosis of intestinal tuberculosis depends on the
presence of colonic mucosal lesions that are suggestive of intestinal
tuberculosis on double-contrast barium enema or endoscopy. A clinical
diagnosis of intestinal tuberculosis can also be made with a therapeutic trial
of antituberculous treatment, especially in endemic areas.
Early Features of Tuberculous Colitis
The early features of intestinal tuberculosis are spasm, hypersecretion,
increased motility, lymphoid hyperplasia, thickened folds, and shallow
ulcers.
Aphthous Ulcerations
The ulcer in a patient with tuberculosis colitis is not considered an
important finding because it does not appear on single-contrast barium enema
[5]. On double-contrast barium
enema, multifocally scattered shallow ulcers are frequently revealed on the
ascending and transverse colon, correlating colonic aphthous ulcers with
surrounding mucosal edema on colonoscopy (Fig.
1A,1B,1C).
Small aphthous ulcers are considered specific for Crohn's disease. However,
although uncommon, small aphthous ulcers have been described in tuberculous
colitis [6].
Spasm and Increased Motility
Most of the radiologic findings of colonic tuberculosis described in the
literature are from single-contrast barium enema. However, because of the
inherent limitations of this technique, the radiologic signs include only the
splitting of the barium meal or spasm and hypermotility of the ileocecal
region (Stierlin's sign). In the early stage, in which only small and shallow
ulcers are present, this sign is probably caused by inflammatory edema around
the nerve plexus of the wall
[7]. However, the incidence of
early features, such as spasm, hypersecretion, or increased motility, is low
on double-contrast barium enema. Because spasm can be assessed only on
fluoroscopy, the low incidence of this finding is probably caused by the
forceful dilation by air in the spastic segment during double-contrast barium
enema and colonoscopy [5].
Advanced Features of Tuberculous Colitis
Findings of advanced tuberculous colitis on double-contrast barium enema
include transverse ulcers, nodularities, thickened folds, inflammatory or
postinflammatory polyposis, and luminal narrowing and deformity in the
ileocecal region [3,
7]. A nodular mucosa with areas
of ulceration is the usual colonoscopic finding of advanced tuberculous
colitis [6].
Transverse or Circumferential Ulceration and Nodularities
The double-contrast barium enema permits the evaluation of the contour and
intraluminal surface of the colon; therefore, polypoid lesions and the
characteristic transversally oriented ulcers of tuberculous colitis are more
evident on the barium enema than on colonoscopy
[7]. In the colon, lymph
follicles are oriented transversally, so ulcers frequently adopt this axis
[8]. A whole-girdle ulcer
develops when transverse ulcers are fused. The areas of ulceration are
superficial and generally have well-defined but irregular margins. On
colonoscopy, the ulceration is superficial with thickening of surrounding
mucosal folds (Fig.
2A,2B,2C).
The surrounding mucosa is nodular and hyperemic and blended imperceptibly with
normal mucosa [6]. Rose-thorn
ulcers (deep-penetrating ulcers) or fistulas that appear on double-contrast
barium enema may not appear on colonoscopy (Fig.
3A,3B).
The ulcer bed is covered with necrotic slough and appears coarsely granular on
colonoscopy [3].
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Fig. 2B. —22-year-old woman with advanced tuberculous colitis. Single-contrast
barium enema shows thickened circumferential and transverse folds in shortened
and narrowed ascending colon (arrowheads) and terminal ileum
(arrows).
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Fig. 2C. —22-year-old woman with advanced tuberculous colitis. Colonoscopic
image shows transversally oriented ulcerations covered with necrotic slough
and intervening nodular and circumferential elevations of thickened folds.
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Fig. 3B. —21-year-old man with rose-thorn ulcers. Colonoscopic image shows
shallow ulceration and fold thickening. Colonoscopy has limitations in
revealing deep ulcers with small orifices (rose-thorn ulcers).
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Inflammatory Pseudopolyps and Postinflammatory Polyps
Inflammatory pseudopolyps or postinflammatory polyps are common in
tuberculous colitis and inflammatory bowel disease. Inflammatory pseudopolyps
are hypertrophied tabs of mucous membrane that resemble a polyp; they are
caused by ulceration surrounding and sometimes undermining a portion of intact
mucosa. Postinflammatory polyps comprise excessively regenerated mucosa that
develop from a previously inflamed area. Therefore, the background of
inflammatory pseudopolyps is coarse and granular, and the background of
postinflammatory polyps is smooth. The simultaneous presence of inflammatory
and postinflammatory polyps is possible in tuberculous colitis. In most
patients, the findings of polyps on double-contrast barium enema directly
correlate with those on colonoscopy (Fig.
4A,4B).
However, a small proportion of patients with suspected postinflammatory polyps
on double-contrast barium enema have multiple inflammatory pseudopolyps with
active transverse ulceration on colonoscopy (Fig.
5A,5B,5C).
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Fig. 4A. —24-year-old woman with inflammatory pseudopolyps and circumferential
ulcers involving ileocecal region and ascending colon. Double-contrast barium
enema shows multiple inflammatory pseudopolyps (arrowheads) with
background of ulcers in the cecum and ascending colon and patulous ileocecal
valve (arrow).
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Fig. 4B. —24-year-old woman with inflammatory pseudopolyps and circumferential
ulcers involving ileocecal region and ascending colon. Colonoscopic image
reveals widespread ulcerations and remnant islands of normal mucosa
(inflammatory pseudopolyps), directly corresponding with A.
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Fig. 5A. —41-year-old woman with discrepancy between double-contrast barium
enema and colonoscopic findings. Double-contrast barium enema shows luminal
narrowing and deformity of ileocecal area and ascending colon without evidence
of active mucosal lesion.
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Fig. 5C. —41-year-old woman with discrepancy between double-contrast barium
enema and colonoscopic findings. Colonoscopic image shows areas of active
ulcerations with inflammatory pseudopolyposis (arrows).
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Deformity of Ileocecal Valve
When the ileocecal valve is involved in tuberculous colitis, it can be
edematous, deformed, and usually has an area of superficial ulceration
[6]. As a consequence of
fibrotic change, the ileocecal valve appears patent on double-contrast barium
enema and colonoscopy (Fig.
6A,6B).
In general, colonoscopy is superior to double-contrast barium enema in the
visualization of hyperemic inflamed mucosa or ileocecal valves. However, in
some patients, colonoscopy cannot reveal the ileocecal valve; in this case,
the colonoscope cannot show parts of the colon because of severe stenosis or
redundant colon.
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Fig. 6A. —42-year-old woman with patulous ilececal valve. Double-contrast
barium enema shows opened ileocecal valve with cecal deformity (open
arrow). Note inflammatory polyps (solid arrows) seen as filling
defect at ileocecal valve.
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Mass Effect and Stenosis
Occasionally, researchers report focal stenosis or mass effect that mimics
colonic malignancies [8].
Tuberculous stricture shows smooth transition to the normal area, and a
focally preserved haustral pattern in the stenotic area, changing shape as the
degree of colonic distention varies with different amounts of air. Also, at
the transition area, thickened folds and occasional mucosal irregularity
occur, suggestive of inflammatory stricture (Fig.
7A,7B).
In patients with severe luminal stenosis, double-contrast barium enema can
reveal proximal bowel loops, and colonoscopy cannot because the colonoscope
cannot pass through narrow segments (Fig.
8A,8B).
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Fig. 7A. —66-year-old woman with ileocecal deformity with mass formation.
Double-contrast barium enema shows cecal contraction and polypoid mass
(solid arrows) with shouldering. Note deformed ileocecal valve and
deep-penetrating ulcerations (open arrow) in terminal ileum. This
image was used to diagnose inflammatory bowel disease.
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Fig. 7B. —66-year-old woman with ileocecal deformity with mass formation.
Colonoscopic image reveals mulberry-shaped polypoid mass (arrows) in
ileocecal valve area. Because colonoscope could not pass into terminal ileum,
this patient's condition was misdiagnosed as villous tumor on colonoscopy.
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Fig. 8A. —50-year-old man with luminal narrowing of ascending colon.
Double-contrast barium enema reveals distal and proximal loops of ascending
colon to stenosis (arrowheads). Double-contrast barium enema can
reveal ulcerations and deformities of cecum and ascending colon proximal to
stenotic segment.
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Pouch Formation
Pouches are formed by postinflammation fibrosis. Pouches are well depicted
on double-contrast barium enema and colonoscopy (Fig.
9A,9B).
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Fig. 9A. —69-year-old woman with pouch formation in ascending colon and cecum.
Double-contrast barium enema reveals pouches (arrows) resulting from
postinflammatory fibrosis in ascending colon and cecal deformity.
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Introduction
Diagnosis of Tuberculous Colitis
