World Gastroenterology Organisation Global Guidelines
Mohamed Tahiri (Chair, Morocco)
K.L. Goh (Co-Chair, Malaysia)
Zaigham Abbas (Pakistan)
David Epstein (South Africa)
Chen Min-Hu (China)
Chris Mulder (Netherlands)
Amarender Puri (India)
Michael Schultz (New Zealand)
Anton LeMair (Netherlands)
Funding and conflict of interest statement
All of the authors have stated that there were no conflicts of interest in relation to their authorship of this paper. Anton LeMair acted as guideline development consultant for WGO.
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“Diarrhea attacking a person affected with phthisis is a mortal symptom.”
— Hippocrates, Aphorisms 5.14
“It is impossible to diagnose abdominal tuberculosis with any degree of certainty, since the disease mimics many other abdominal conditions and histological confirmation may be equivocal.”
— Joseph Walsh, Transactions of the National Association for the Study and Prevention of Tuberculosis 1909;5:217–22
Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, typically causing pulmonary TB. TB is the ninth most frequent cause of death worldwide and is the leading cause due to a single infectious agent, ranking above human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS).
In 2017, 10 million people developed TB disease and 1.6 million died of it, including 0.3 million among people with HIV—TB is the leading killer of HIV-positive people .
Abdominal tuberculosis is uncommon in comparison with pulmonary TB. Gastrointestinal TB makes up 2.5% of extrapulmonary cases in the United States .
Early diagnosis remains difficult, due to the nonspecific clinical presentation of TB, which can mimic other gastrointestinal diseases and may vary from an acute to a chronic abdomen in areas endemic for TB. While some may benefit from antitubercular therapy, others may develop surgical problems such as strictures, obstruction, fistulas, or perforations, which may necessitate surgical intervention.
HIV infection is a major risk factor for the development of TB, and peritoneal tuberculosis is a real medical challenge in immunocompromised patients due to its insidious and nonspecific symptoms.
Although any area of the gut can be involved, tuberculous involvement of the gastrointestinal tract is most frequently seen in the ileocecal area, the ileum, and the colon. The ileocecal area is most commonly affected by TB. Explanations for this include its high density of lymphoid tissue, slowing of intestinal transit, and low concentration of bile acids .
Tuberculous peritonitis needs to be considered in all cases of unexplained exudative ascites. Other locations for abdominal TB infection are: spleen, liver, and lymph nodes [3–6].
WGO cascades: a hierarchical set of diagnostic, therapeutic, and management options for dealing with risk and disease, ranked by the resources available.
World Gastroenterology Organisation (WGO) guidelines and cascades are intended to highlight appropriate, context-sensitive and resource-sensitive management options for all geographical areas, regardless of whether they are “developing,” “semi-developed,” or “developed.” WGO cascades are context-sensitive, and the context is not necessarily defined solely by resource availability.
The cascade options presented here for both the diagnosis and management of gastrointestinal tuberculosis are key and represent the most important part of this document. Particular emphasis is placed on gold-standard, medium-resource, and low-resource categories.
For the “Cascades for diagnosing gastrointestinal TB,” see Section 3.1 below.
1.3.1 WHO 2018 global tuberculosis report [1,7]
The incidence of intestinal TB (ITB) has increased in parallel with the overall increase in the prevalence of tuberculosis. One in five TB patients in the European Union has extrapulmonary tuberculosis . The incidence of Crohn’s disease (CD) has also increased over the past several decades all over the world, including those areas where the disease has conventionally been reported to be rare .
Tuberculosis flourishes wherever there is poverty and overcrowding; 5–15% of the estimated 1.7 billion people infected with M. tuberculosis (MTB) will develop overt clinical TB disease during their lifetime .
The probability of developing TB disease is much higher among people infected with HIV, and it is also higher among people affected by risk factors  such as:
Extrapulmonary disease is more common in patients with HIV:
Abdominal tuberculosis may occur due to:
Reactivation of a latent TB focus may be caused by immune suppression due to advanced age, HIV/AIDS infection, anti-TNF therapy, malnutrition, weight loss, alcoholism, diabetes, chronic renal failure, and other conditions [12,14,15].
Pulmonary TB. Most cases of TB are pulmonary (Fig. 1). Among patients with extrapulmonary TB, only 15–20% have concomitant active pulmonary tuberculosis . Pulmonary TB is not covered by this guideline.
Extrapulmonary TB. Extrapulmonary TB can be found in the following locations: larynx, lymph nodes, pleura, brain, kidneys, bones and joints, peritoneum and intestines, meninges, skin, and pericardium. Clinicians will continue to see cases, due to the resurgence of tuberculosis that has been taking place since the mid-1980s in many countries. Extrapulmonary TB is found more often in HIV-infected or other immunosuppressed individuals, and young children. With the exception of abdominal TB, extrapulmonary TB is not covered by this guideline.
Miliary TB. A third, but rare, form of TB is miliary TB, in which tubercle particles are carried to all parts of the body through the bloodstream. Miliary TB is not covered by this guideline.
Abdominal TB. Tuberculosis can involve any part of the gastrointestinal tract, from the mouth to anus (49%), peritoneum (42%), mesenteric lymph nodes (4%), and the solid viscera, including the liver and pancreaticobiliary system (5%) [13,16]. The most common site of involvement in intestinal TB is the ileocecal region, followed by the colon and jejunum.
The symptoms and signs of gastrointestinal and peritoneal tuberculosis are nonspecific, and the diagnosis may be missed or delayed—resulting in increased morbidity and mortality.
Most patients with abdominal tuberculosis present with symptoms that have lasted from 1 month to 1 year. These patients may present with abdominal pain, wasting, weight loss in general, loss of appetite, fever, diarrhea, constipation, rectal bleeding, and edema . The symptoms are usually of moderate intensity.
The presence of coexistent pulmonary TB significantly increases the frequency of fever and night sweats, weight loss, and pulmonary symptoms.
TB may be associated with a number of immune-mediated manifestations such as erythema nodosum, erythema induratum, reactive arthritis (Poncet disease) and uveitis, all of which may mimic extraintestinal manifestations of Crohn’s disease [19–22].
The physical examination may reveal pallor, ascites or doughy abdomen, and generalized abdominal tenderness, especially in the right iliac fossa. Patients may have hepatomegaly and abdominal masses due to liver involvement, enlarged lymph nodes, adherent bowel loops, or a cold abscess .
The symptoms and signs of abdominal TB are nonspecific and may very much resemble CD and other gastrointestinal pathology. TB may be confused with cancers of the relevant areas. Intestinal TB has been identified in asymptomatic patients who undergo colonoscopies for other reasons.
Pain is the most common presentation in about 85%, weight loss in 66%, fever in 35–50%, and diarrhea in 20% of patients.
TB should always be considered in the differential diagnosis of unusual gastrointestinal presentations, especially in high TB-endemic areas.
Sources: [4,17,18,23] and other references mentioned in the text above.
Cascades of context-sensitive and resource-sensitive options/alternatives for countries and regions with different levels of resources and access, and with different cultures and epidemiology.
Currently, there is no gold standard for the diagnosis of latent TB infection and early detection of active TB; accordingly, no single test is adequate for the diagnosis of abdominal tuberculosis in all patients. Abdominal TB in non-HIV patients remains an ongoing diagnostic dilemma, requiring a high index of clinical suspicion .
Abdominal TB should always be considered as one of the differential diagnoses of an acute or chronic abdomen in endemic areas  and in specific situations in developed countries, such as in HIV patients and patients receiving treatment with immunosuppressive drugs or biologics.
A definitive diagnosis of gastrointestinal TB can be made if any of the following four criteria are present :
A diagnosis of peritoneal TB should be considered in the differential diagnosis of exudative ascites (protein > 2.5 g/dL) with a lymphocyte predominance and/or a serum-ascitic albumin gradient of < 1.1 mg/dL. Adenosine deaminase levels are elevated. Microbiological or pathological confirmation remains the gold standard for diagnosis .
A diagnosis of intestinal TB  should be based on:
Despite advances in diagnostic methods, a considerable proportion of the TB cases reported to the World Health Organization are still diagnosed clinically rather than being confirmed bacteriologically, due to a lack of funding or a lack of local expertise. In 2016, less than 60% of the pulmonary cases reported to the WHO were bacteriologically confirmed .
3.2.1 Routine lab tests
Routine laboratory tests reveal mild anemia and an increased sedimentation rate in 50–80% of patients. The white blood count is usually normal .
Computed tomography (CT) scanning with oral contrast is the most helpful imaging modality for assessing intraluminal and extraluminal pathology. It can show the location and extent of the inflammatory process and involvement of the intestine, mesentery, peritoneum, lymph nodes, and solid organs, as well as retroperitoneal disease [17,18,30]. It can discriminate between carcinomatous ascites and peritoneal tuberculosis. The presence of necrotic lymph nodes is diagnostic for peritoneal tuberculosis. If applicable, CT enterography can detect and map the involved small bowel.
Ultrasound. Endoscopic ultrasonography (EUS) can help with the imaging of various lesions close to the gastrointestinal lumen, and they can also be aspirated or biopsied using EUS-guided fine-needle aspiration or biopsy . Targeted biopsies from the lymph nodes, liver, and pancreas may be taken . EUS is useful for imaging peritoneal tuberculosis .
Magnetic resonance imaging (MRI) cannot detect small calcifications within nodes or masses and is not helpful for distinguishing between Crohn’s disease and intestinal TB.
Chest x-ray. A negative chest x-ray does not exclude abdominal TB.
Endoscopy with biopsy may be useful for diagnosing intestinal TB if the area of the affected gut is within reach of a flexible endoscope. Not infrequently, the disease is not considered until it is diagnosed at the time of surgery . Double-balloon enteroscopy may be helpful for obtaining biopsies. In case of duodenal infiltrate without clear ulcers, performing polypectomy after banding may be helpful for obtaining better biopsies .
Laparoscopy with a biopsy is used to diagnose peritoneal TB, but its role is less clear in intestinal TB . Laparoscopy with a directed biopsy allows rapid, specific diagnosis .
Biopsies show acid-fast bacilli or caseating granulomas in case of TB, but acid-fast bacilli staining lacks sensitivity and specificity. Distinguishing between Crohn’s disease (CD) and TB is never completely straightforward, and although it is rare, the two can coexist, especially during biological therapies.
Making a diagnosis of intestinal TB with endoscopy and mucosal biopsy is difficult, as the disease is submucosal and the diagnostic yield is poor (demonstrating AFB, positive TB PCR, caseating granulomas, or a positive TB culture). Pulimood and others have described a number of histological features on mucosal biopsy specimens which, in the absence of acid-fast bacilli and caseating granulomatous inflammation, are diagnostic of intestinal TB [35–37]. These include confluent granulomas, multiple granulomas in a given biopsy site, large granuloma size, bands of epithelioid histiocytes lining ulcers, submucosal granulomas, and disproportionate submucosal inflammation—i.e., submucosal inflammation that significantly exceeds mucosal inflammation.
Histopathological findings may include nonspecific inflammatory changes:
Acid-fast smear microscopy involves bacterial examination of biological fluids in patients with suspected abdominal TB.
Culture-based methods. These are the current reference standard. They require a more developed laboratory capacity; biopsy culture for MTB is time-consuming (from 3–8 weeks up to 12 weeks to provide results) , and the results are frequently negative (with an accuracy ranging from 25% to 35%  and even lower in other studies).
3.2.7 Serological testing results
Rapid molecular tests. The only rapid test for diagnosing TB currently recommended by the WHO is the Xpert® MTB/RIF assay (Cepheid, Sunnyvale, California, USA).
Interferon-gamma release assay (IGRA). IGRA is based on the stimulation of a cellular immune response by the immunodominant antigens ESAT-6 and CFP10 specific to MTB, and it provides a diagnostic alternative to the tuberculin skin test.
IGRA test options include:
Various studies have confirmed the informational value of these tests in diagnosing TB, and the emergence of IGRA tests may improve the identification of latent tuberculosis infection (LTBI) .
The main advantages of these tests are:
Although it is still difficult to determine superiority between the IGRAs and the tuberculin skin test (TST), both are negatively affected by immunosuppressive therapy. Screening before starting immunosuppressive therapy should therefore be considered. It is imperative for all patients to receive screening prior to anti-TNF therapy .
IGRA may be used as part of the overall risk assessment to identify individuals for preventive treatment (e.g., immunocompromised persons, children, close contacts, and recently-exposed individuals) , but due to the above-mentioned disadvantages, IGRA tests are not suitable for large-scale screening studies, particularly among children.
Determination of interferon-gamma levels in ascitic fluid may be a technique with future application in the diagnosis of peritoneal TB .
The European Centre for Disease Prevention and Control (ECDC) has published the following guidance on the use of interferon-gamma release assays to support the diagnosis of TB :
3.2.8 Polymerase chain reaction test
PCR. The TB PCR assay on either endoscopic or surgical biopsy specimens from patients with ITB has been found to have a high level of accuracy for diagnosing ITB, with a specificity of up to 95% and an accuracy of 82.6% .
3.2.9 Tuberculin skin test
PPD. Purified protein derivative (PPD) is an advanced version of the tuberculin skin test (TST). It is based on protein components from culture filtrates of MTB and is used to diagnose (latent) TB infection.
A false-negative PPD reaction may be secondary to:
The diagnostic value of the PPD skin test for ITB is uncertain, and results are influenced according to the prevalence of TB in the population that is being tested [13,15,17]:
3.2.10 Adenosine deaminase
Adenosine deaminase (ADA) is a reliable enzyme marker for tuberculous ascites. An ADA cut-off value of between 36 and 40 IU/L has a high sensitivity (100%) and specificity (97%) for diagnosing peritoneal tuberculosis [23,44].
3.2.11 TB diagnostic technologies endorsed by WHO
Molecular detection of TB and drug resistance
3.3.1 Peritoneal tuberculosis
Differential diagnosis based on lesion type :
3.3.2 Intestinal tuberculosis
Differential diagnosis based on lesion type :
3.3.3 TB and Crohn’s disease
Crohn’s disease (CD) is an idiopathic inflammatory disease with a definite genetic background and modified by multiple environmental factors . The diagnosis of CD is based on a combination of clinical features, endoscopic characteristics, and histological characteristics .
Along with the incidence of TB, the incidence of CD in areas that are endemic for TB has also increased [17,48,49].
IBD is an important differential diagnosis in both developed and developing countries. In developing countries with endemic TB with high rates of latent infection, testing otherwise healthy individuals for “exposure” is not appropriate.
3.3.4 Other diagnoses to consider
• Pseudomyxoma peritonei
• Peritoneal lymphomatosis
• Diffuse peritoneal leiomyomatosis
• Benign splenosis
Patients with abdominal TB should receive a full course of antitubercular therapy.
A 2-month course of treatment as detailed in Table 8 is currently recommended for uncomplicated ITB. Longer treatment should be avoided, as it is associated with poor compliance and an increased risk of side effects of potentially toxic drugs.
• Extrapulmonary TB should be treated using the same antituberculous drug regimens as pulmonary TB disease. Regimens of 6, 9, and 18–24 months are all effective for extrapulmonary tuberculosis.
• A Cochrane review found no evidence to suggest that 6-month treatment regimens are inadequate for treating people who have intestinal and peritoneal TB, but the numbers are small .
• Anti-TB treatment should be started immediately (irrespective of the CD4 count in case of HIV/TB co-infection).
• Standard therapy of at least 9 months’ duration is also effective in most AIDS patients who are started on appropriate treatment in a timely fashion and who are compliant.
• The potential for multidrug resistance needs to be kept in mind and accounted for.
• Treatment of tuberculosis in AIDS patients is the same as in patients without HIV infection, but multidrug-resistant tuberculosis is more common in patients with AIDS.
Hepatotoxicity may be caused by isoniazid (INH), rifampicin (RIF), or pyrazinamide (PZA)
Monitoring for drug-induced hepatotoxicity (DIH) or drug-induced liver injury (DILI) 
Other medication side effects include gastrointestinal symptoms, rash, and drug–drug interactions.
Multidrug resistance (MDR) has been observed in 2.4–13.2% of strains of MTB isolated from newly diagnosed pulmonary TB patients and in 17.4–25.5% of previously treated patients. Extensive drug resistance (XDR) is found almost exclusively in previously treated patients and accounts for about 6% of MDR-TB.
WHO shorter MDR-TB regimen:
Empirical antituberculous drug treatment for 2–3 months may be considered appropriate in countries with a high prevalence of abdominal TB and if the clinical features are compatible—i.e., the clinical, radiographic, and endoscopic data are consistent with the diagnosis of abdominal TB and if other common diseases such as cancer, nonspecific inflammatory bowel disease, and other specific infections can be adequately ruled out .
The diagnosis of tuberculous enteritis can be taken as highly probable if the patient responds to treatment and if no relapse occurs at the end of follow-up .
Monitoring of the response should be carried out weekly for 4–6 weeks:
However, it is recommended that a TB diagnosis should be established before commencing treatment, for the following reasons [11,17]:
When laparoscopy is not available or not affordable, and if patients are inoperable, ascitic ADA testing can be crucial for making a quick diagnosis of peritoneal tuberculosis and starting empirical anti-tuberculosis drugs.
In patients with a high index of suspicion of peritoneal tuberculosis and ADA > 30 IU, antituberculosis treatment can be started.
• If PCR is not available, consider empirical antitubercular therapy.
• If the culture is positive, continue treatment, if negative consider Crohn’s disease.
* Clinical risk assessment includes consideration of a history of previous TB originating from a high-prevalence area and high swinging fever, in the absence of an intra-abdominal abscess.
• If PCR is not available and there is no evidence of peritoneal tuberculosis in a biopsy, consider empirical antitubercular therapy and wait for the culture results.
• If the culture is positive, continue treatment; if negative, consider Crohn’s disease (although ascites is much less common in CD or any other cause of ascites).
• Adenosine deaminase (ADA) activity is increased in tuberculosis, liver disease, and certain malignancies (among other conditions).
Surgical intervention is reserved for complications—fibrosis, strictures, and acute abdomen—or when there is uncertainty in the diagnosis.
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