Ileocaecal disease: TB, Crohn’s or malignancy?: a lecture

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Ileocaecal disease: TB, Crohn’s or malignancy?

PUNJ SURG 2026 · Ludhiana · 31 October 2026

Ileocaecal disease

TB,

Crohn’s

or malignancy?

Dr Prateek Gupta Assistant Professor, Department of General Surgery Dayanand Medical College & Hospital, Ludhiana prateekguptasurgery.com

02 / 15

17.3%

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

Sources: Cai 2007, Dig Dis Sci · Limsrivilai 2017, Am J Gastroenterol · Keighley & Williams, 4th ed · Bailey & Love, 28th ed · Drawing: original

2

Three diseases share one junction

of clinical diagnoses made before colonoscopy matched the final diagnosis

52 hospitalised patients with ileocaecal ulcers, China

03 / 15

45% vs 76% retrospective, matched free of surgery at 14 years, prior ATT vs none

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

A wrong guess costs the patient

Sources: Gupta 2020, J Crohns Colitis · Choudhury 2023, BMC Gastroenterol · Lin 2009, Int J Colorectal Dis

3

Crohn’s treated as TB

TB treated as Crohn’s

Steroids can spread TB dissemination, surgery and death are reported

TB operated on as cancer

2 of 14 operated, in one series had a right hemicolectomy for presumed cancer, with no histology before or during surgery

ATT: anti-tubercular therapy

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favours TB

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

History and scope tilt the odds; no single sign settles it

Sources: Limsrivilai 2017, Am J Gastroenterol (38 studies) · Du et al, cited in Jha 2023, Indian J Gastroenterol · Keighley & Williams, 4th ed

4

History

Scope

Fever, night sweats

Transverse ulcers specificity 88%, sensitivity 43% Patulous ileocaecal valve specificity 91%, sensitivity 38%

Haematochezia, perianal disease

Longitudinal ulcers, cobblestoning, rectal involvement

favours Crohn’s

The limit: with ulcers only in the terminal ileum, the scope alone often cannot tell them apart. Histology and PCR for TB remain essential.

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On CT, necrotic nodes favour TB; comb sign and skip lesions favour Crohn’s

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

Sources: Kedia 2017, Intest Res (6 studies, 417 Crohn’s, 195 TB) · Essential Surgical Practice, 5th ed · Keighley & Williams, 4th ed · Node drawings: original schematic

5

TB against Crohn’s, pooled from 6 CT studies

Schematic drawings

Necrotic nodes specificity 100%, sensitivity 23%

TB

Comb sign specificity 81%, sensitivity 82%

Crohn’s

Skip lesions specificity 74%, sensitivity 86%

Crohn’s

TB: often rim-enhancing, multilocular

Lymphoma: typically homogeneous

Where it misleads: lymphoma can be confused with TB when nodes enlarge fast with central necrosis.

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A negative biopsy does not exclude TB

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

Sources: Weeranawin 2026, Intest Res (meta-analysis) · Jha 2023, Indian J Gastroenterol (ICMR workflow)

6

Endoscopic biopsy for TB: pooled sensitivity 55 studies, 6,072 participants

AFB

12%

Caseating granuloma

18%

Culture

23%

Xpert MTB/RIF

29%

PCR

58%

So raise the yield At least six pieces, in sterile saline, for microbiology ICMR workflow

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Exclude cancer with reasonable certainty before an ATT trial

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

Sources: Essential Surgical Practice, 5th ed · Keighley & Williams, 4th ed · SRB’s Manual of Surgery, 6th ed · Sabiston, 21st ed

7

Caecal cancer

Hyperplastic caecal TB may mimic it, and the two can coexist

Lymphoma

Fast-growing nodes with central necrosis can pass for TB

Ileal NET

The larger mesenteric mass is often mistaken for the primary

If it cannot be excluded, operate to diagnose: laparoscopy or laparotomy, frozen section, and a mesenteric node for culture and histology.

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64%

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

Feeling better on ATT is not healing

Sources: Pratap Mouli 2016, Aliment Pharmacol Ther · Jha 2023, Indian J Gastroenterol · Choudhury 2023, BMC Gastroenterol (authors’ suggestion)

8

felt better at two months

None

had mucosal healing on ATT

Crohn’s patients given ATT, AIIMS validation cohort. TB patients in the same cohort: all healed after six months of ATT.

Judge the trial at the mucosa: colonoscopy at two months, whatever the symptoms.

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Stable patient: tissue first, the ATT trial last

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

Synthesis, not a published algorithm: Jha 2023 · Essential Surgical Practice · Keighley & Williams · Bailey & Love · Sabiston · Pratap Mouli 2016 · Choudhury 2023

9

Perforation or complete obstruction: emergency surgery first (slide 12).

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Operate for complications; in limited Crohn’s, resection is a reasonable alternative to infliximab

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

Sources: Jha 2023, Indian J Gastroenterol · Keighley & Williams, 4th ed · Bailey & Love, 28th ed · Ponsioen 2017, Lancet Gastroenterol Hepatol (LIR!C)

10

TB

Perforation, complete or recurrent obstruction, massive bleeding

Operate

Crohn’s

Its complications

Operate resection does not cure Crohn’s

Limited, non-stricturing ileocaecal disease (under 40 cm); conventional therapy failed

Laparoscopic resection a reasonable alternative to infliximab

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TB strictures, no emergency: ATT first, then choose by the stricture

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

Sources: Jena 2023, BMC Gastroenterol · Jha 2023, Indian J Gastroenterol · Keighley & Williams, 4th ed · SRB’s Manual of Surgery, 6th ed

11

ATT first Strictures respond in 66%

If symptoms persist:

Dilate scope can reach it

Strictureplasty over 50% of the lumen lost, or dilatation fails or cannot reach

Resect closely spaced; within 10 cm of the valve or over 12 cm; friable bowel

At operation: examine the whole small bowel and treat every stricture at one sitting.

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TB in the emergency: operate, and let the patient and peritoneum decide: join or stoma

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

Sources: Essential Surgical Practice, 5th ed · Keighley & Williams, 4th ed · Bailey & Love, 28th ed · Schein, 3rd ed · SRB, 6th ed

12

Full-blown obstruction with gross distension, or perforation peritonitis

Emergency surgery

In TB, a perforation frequently lies proximal to a stricture

Resect usually safer than oversewing or strictureplasty

Then: join or exteriorise? Primary anastomosis whenever feasible; exteriorise the sick

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At operation, do not resect uncomplicated acute ileitis; when TB is suspected, take tissue every time

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

Sources: Sabiston, 21st ed · Schwartz, 11th ed · Essential Surgical Practice, 5th ed · Schein’s Common Sense Emergency Abdominal Surgery, 3rd ed

13

Normal appendix, acute terminal ileitis

Do not resect the ileum: acute ileitis settles by itself Remove the appendix, unless the caecum or the appendix base is inflamed, leave the appendix, as removing it may lead to a fistula About one in eight cases of acute terminal ileitis is Crohn’s

Caseating nodes, tubercles, small-bowel strictures

Think TB, and take tissue every time to confirm TB, and to look for a cancer that mimics it

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The operation follows the diagnosis

What is it?

Why it matters

The clues

The trial

When to operate

Which operation

Sources: Schwartz · Sabiston · Bailey & Love · Keighley & Williams · SRB · Essential Surgical Practice · Roy · PubMed search, 15 Oct 2026 · Drawing: original schematic

14

Curable carcinoma, proven or suspected

Right hemicolectomy high tie; to the proximal third of the transverse colon

Crohn’s

Limited resection grossly diseased bowel only

TB

Limited resection: unless extensive disease precludes it

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Take-home: tissue first

Sources: as on slides 2–14

15

1

Tissue before the big operation: histology, and at least six pieces in saline for microbiology.

2

A negative biopsy does not exclude TB, and feeling better on ATT does not prove it.

3

Start an ATT trial only when TB is strongly suspected and cancer is excluded with reasonable certainty; judge it at the mucosa at two months.

4

Operate for complications, taking tissue every time. If cancer cannot be excluded, operate to diagnose; if a curable carcinoma is still suspected, do a right hemicolectomy.

What is it?