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Development and Validation of a Novel Diagnostic Nomogram to Differentiate Between Intestinal Tuberculosis and Crohn's Disease

A 6-year Prospective Multicenter Study

He, Yao, MD, PhD1; Zhu, Zhenhua, MD, PhD2; Chen, Yujun, MD1; Chen, Fang, MD1; Wang, Yufang, MD, PhD3; Ouyang, Chunhui, MD, PhD4; Yang, Hong, MD, PhD5; Huang, Meifang, MD, PhD6; Zhuang, Xiaodong, MD, PhD7; Mao, Ren, MD, PhD1; Ben-Horin, Shomron, MD1,8; Wu, Xiaoping, MD4; Ouyang, Qin, MD3; Qian, Jiaming, MD, PhD5; Lu, Nonghua, MD2; Hu, Pinjing, MD1; Chen, Minhu, MD, PhD1

American Journal of Gastroenterology: March 2019 - Volume 114 - Issue 3 - p 490–499
doi: 10.14309/ajg.0000000000000064

OBJECTIVES: Differentiating Crohn's disease (CD) from intestinal tuberculosis (ITB) remains a diagnostic challenge. Misdiagnosis carries potential grave implications. We aimed to develop and validate a novel diagnostic nomogram for differentiating them.

METHODS: In total, 310 eligible patients were recruited from 6 tertiary inflammatory bowel disease centers. Among them, 212 consecutive patients (143 CD and 69 ITB) were used in the derivation cohort for the establishment of diagnostic equation and nomogram; 7 investigative modalities including clinical manifestations, laboratory results, endoscopic findings, computed tomography enterography features, and histology results were used to derive the diagnostic model and nomogram. Ninety-eight consecutive patients (76 CD and 22 ITB) were included for validation of the diagnostic model.

RESULTS: Eight out of total 79 parameters were identified as valuable parameters used for establishing diagnostic equations. Two regression models were built based on 7 differential variables: age, transverse ulcer, rectum involvement, skipped involvement of the small bowel, target sign, comb sign, and interferon-gamma release assays (for model 1) or purified protein derivative (for model 2), respectively. Accordingly, 2 nomograms of the above 2 models were developed for clinical practical use, respectively. Further validation test verified the efficacy of the nomogram 1 with 90.9% specificity, 86.8% sensitivity, 97.1% PPV, 66.7% negative predictive value (NPV), and 87.8% accuracy for identifying CD, and the efficacy of the nomogram 2 with 100% specificity, 84.2% sensitivity, 100% positive predictive value, 64.7% NPV, and 87.8% accuracy for diagnosing CD.

CONCLUSIONS: The derivation and validation cohorts identified and validated 2 highly accurate and practical diagnostic nomograms for differentiating CD from ITB. These diagnostic nomograms can be conveniently used to identify some difficult CD or ITB cases, allowing for decision-making in a clinical setting.

1Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China;

2Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China;

3Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China;

4Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, People's Republic of China;

5Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China;

6Department of Gastroenterology, Zhongnan Hospital, Wuhan University School of Medicine, Wuhan, Hubei Province, People's Republic of China;

7Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China;

8Department of Gastroenterology, IBD Service, Sheba Medical Center and Sackler School of Medicine, Tel-Aviv University, Tel Hashomer, Israel.

Correspondence: Minhu Chen, MD, PhD. E-mail: Pinjing Hu, MD. E-mail:

SUPPLEMENTARY MATERIAL accompanies this paper at

Received May 08, 2018

Accepted November 08, 2018

© The American College of Gastroenterology 2019. All Rights Reserved.
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