Case report form
Differential Diagnosis between Crohn’s disease and Intestinal Tuberculosis
Date of visit: YYYY-MM-DD ____________
Patient enrollment number____________
Date of birth: YYYY-MM-DD ____________
Sex: Male / Female
1. Final diagnosis: 1) Crohn’s disease 2) Intestinal tuberculosis 3) Others: ____________
Date of final diagnosis: YYYY-MM-DD ____________
Diagnostic criteria in case of ITB:
1) AFB 2) Positive culture 3) Positive caseating granuloma 4) Clinical suspicion with response to anti- TB therapy
2. Past history
1) Previous history of TB: Yes / No If yes, date of diagnosis: YYYY-MM-DD ____________
1 Site: lung / abdomen / lymph node / articular joint / other sites ____________
2 History of TB therapy: Yes / No 3 Duration of TB medication: ( ) month 4 Cure of TB: Yes / No
2) History of perianal abscess/fistula: Yes / No If yes, date of diagnosis: YYYY-MM-DD ____________
Type of therapy for perianal abscess/fistula ____________
3) Comorbidities:
Hypertension ( ) Diabetes ( ) Chronic liver disease ( ) Others ____________
4) Current medication ____________
3. Clinical symptoms and signs
1) Date of first symptom development: YYYY-MM-DD____________
2) Symptoms
1 Fever (tympanic temperature > 37.8℃): Yes / No 2 Abdominal pain: Yes / No
3 Diarrhea (liquid or loose stool 3 or more times per day ): Yes / No 4 Hematochezia: Yes / No
5 Body weight: previous: ( ) kg, current ( ) kg, Interval between previous and current weight measurement ( ) months
6 Night sweat: Yes / No
7 Arthralgia: Yes / No If yes: site ____________
8 Oral ulcers: Yes / No
9 Erythema nodosum: Yes / No If yes: site ____________
10 Pyoderma gangrenosum: Yes / No If yes: site ____________
3) Signs
1 Abdominal mass: Yes / Suspected / No 2 Perianal fistula: Active / Scar / No
4. Laboratory evaluation
Tests Date: YYYY-MM-DD
____________
Results
WBC (/µL) Hb (g/dL) Platelet (/µL) ESR (mm/hr) Albumin (g/dL)
QuantiFERON®-TB Gold In-Tube Positive / Negative / Indeterminate
ASCA IgA Positive / Negative / Indeterminate
ASCA IgG Positive / Negative / Indeterminate
5. Radiologic evaluation
Tests Date: YYYY-MM-DD
____________
Results
Chest PA/Left lateral Normal / Active TB/ TB scars
Small-bowel follow-through
Presence of lesions Yes/ No
If lesions (+): sites Jejunum / Proximal ileum / Terminal ileum Type of lesions
Ulcers Longitudinal ulcers / Transverse ulcers /
No
Cobblestone appearance Yes / No
Stricture Yes / No
Entero-enteric fistula Yes / No
Others Please describe:
6. Colonoscopic evaluation: YYYY-MM-DD____________
1) Endoscopist:
2) Colonoscopic findings
Parameters Result Colonoscopic scoring
Involvement Select all the involved site:
Ileocecum: Yes / No Ascending colon: Yes / No
If yes < 4 ―1:
Transverse colon: Yes / No Descending colon: Yes / No Sigmoid colon: Yes / No
Anorectum: Yes / No
A patulous ileocecal valve Yes / No If yes ―1:
Transverse ulcers Yes / No If yes ―1:
Scar or pseudopolyps Yes / No If yes ―1:
Anorectal lesions Yes / No If yes +1:
Longitudinal ulcers Yes / No If yes +1:
Aphthous ulcers Yes / No If yes +1:
Cobblestone appearance Yes / No If yes +1:
Total score:
3) Biopsy (Biopsy should be performed from more than one lesion per segment and more than 2 pieces from one lesion)
Serial number Biopsy site Describe the lesion Number of tissue
TB PCR test
1 Done / Not done
2 Done / Not done
3 Done / Not done
4 Done / Not done
5 Done / Not done
6 Done / Not done
More
4) Intestinal tissue culture for
Mycobacterium tuberculosis
(Culture should be requested using 3 or more biopsy tissues)Serial number Biopsy site Describe the lesion Number of tissue 1
2 3 4 5 6 More
