REVIEW ARTICLE

Colitis Tuberculosis
Budi Tan Oto*, Achmad Fauzi**, Ari Fahrial Syam**,
Marcellus Simadibrata**, Murdani Abdullah**, Dadang Makmun**,
Chudahman Manan**, Abdul Aziz Rani**, Daldiyono**
*Department of Internal Medicine, Faculty of Medicine, University of Indonesia
Dr. Cipto Mangunkusumo General National Hospital, Jakarta
**Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine
University of Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta

ABSTRACT

Tuberculosis (TB) is a significant public health problem worldwide. Indonesia is a country with the third
highest prevalence of TB in the world after China and India. TB infection can attack all organs of the human
body. TB in digestive system is one of the extrapulmonary TB manifestations and comprises of 3-16% of all
extrapulmonary TB cases. This type of TB may affect digestive system, peritoneum, mesentery lymphatic glands,
liver, and spleen. Digestive system is affected in 66-75% of patients with abdominal TB. The ileocaecal region
is most commonly affected. The manifestation of abdominal TB is not specific. Precise diagnostic approach and
supporting results are needed to determine final diagnosis. However, there is no single examination adequate
enough to diagnose abdominal TB. If the diagnosis can be established early, this disease could then be managed
with conventional anti-TB drugs. Treatment for both 6-9 months period and 18-24 months period has been proven
effective in management of extrapulmonary TB.
In countries with high abdominal TB prevalence, initiation of anti-TB therapy is allowed if there are the
clinical features present. Diagnosis can be determined when the patient has therapeutic response against the
the anti-TB treatment.
Keywords: tuberculosis, colitis, extrapulmonary, antituberculosis drugs
INTRODUCTION

Tuberculosis (TB) is an important public health

problem worldwide. Indonesia is a country with the
third highest prevalence of TB in the world, right
after China and India. Based on the 1985 Household
Health Survey and the 2001 National Health Survey,
TB is positioned as the third highest cause of death in
Indonesia.1,2,3
TB in digestive system is one of the manifestation
of extrapulmonary TB and comprises of 3-16% of
all extrapulmonary TB cases. The digestive system
is involved in 66-75% of patients with abdominal
TB. The gastrointestinal region that most commonly
affected is the ileocaecal region.3,4 TB in digestive
system also has unclear or hidden clinical features with
Correspondence:
Achmad Fauzi
Division of Gastroenterology, Department of Internal Medicine
Dr. Cipto Mangunkusumo General National Hospital
Jl. Diponegoro No. 71 Jakarta 10430 Indonesia
Phone: +62-21-3153957 Fax: +62-21-3142454
E-mail: ppfauzidr@yahoo.com

Volume 11, Number 3, December 2010

no specific laboratory results or radiologic features.

Clinical evaluation is required for early diagnosis
and correct treatment.4,5,6 Treatment with the standard
regimen of drugs for TB in the digestive system is quite
effective. Steroid as an additional treatment remains
arguable.1,6,7,8
MORPHOLOGY AND STRUCTURE OF THE BACTERIA

TB is a disease caused by the infection of

Mycobacterium tuberculosis (M. tuberculosis)
complex.3 M. tuberculosis has the shape of straight
or slightly curved rod, no spores, no capsule, and is
0.30.6 m in width and 14 m in length. Bacterial
wall is very complex, comprising of relatively high
fat layers (60%) which main components are mycolic
acids, complex waxes, dimycolic trephalose called cord
factor and mycobacterial sulpholipids which plays a
role in virulence. Other components of the bacterial
cell wall are polysaccharides, such as arabinogalactan
and arabinomannan. The complex structure of the cell
wall allows the bacteria to be acid-fast in nature.1,2,3
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Budi Tan Oto, Achmad Fauzi, Ari Fahrial Syam, Marcellus Simadibrata, Murdani Abdullah, et al
TRANSMISSION

The process of M. tuberculosis infection is commonly

transmitted by inhalation leading to pulmonary TB,
which is the most common clinical manifestation
compared to other organs. The transmission of this
disease is mostly achieved by inhaling bacilli which
contains droplet nuclei specifically from pulmonary
TB patients with productive cough or hemaptoe which
contains acid fast bacilli (AFB). Infections caused by
Mycobacterium bovis might be transmitted through
milk which is not adequately sterilized or has been
contaminated.1,2
Figure 2. Outcomes of primary infection9

Secondary Tuberculosis (Post Primary Tuberculosis)

Figure 1. Dissemination of tuberculosis2

PATHOGENESIS OF TUBERCULOSIS
Primary Tuberculosis

TB bacteria which enter respiratory tract will nest

in lung tissue to form a pneumonic nest called primary
nest or primary complex or Ghons focus. The primary
complex may emerge in any parts of the lungs, unlike
the reactivation focus. From the primary complex,
lymphatic vessels inflammation towards the hilus
(local lymphangitis) shall occur. The inflammation
is followed by the enlargement of hillar lymph nodes
(regional lymphadenitis). Primary complex, together
with local lymphangitis and regional lymphadenitis, is
known as the primary complex of Ranke.1,2,3

144

Dormant microorganisms in primary TB will emerge

years later as endogenous infection in adults, usually
occurring in the age of 15-40 years. The majority of
reinfection is mounting up to 90%. Post primary TB
starts with a complex commonly located in posteriorapical segment of either superior or inferior lobes.
Its invasion is directed to the parenchyma of lungs. This
early complex is at first shaped as a small pneumonia
complex. Within 3-10 weeks, it will then become
a tubercle, a granuloma which consists of histiocytes
and Datia Langhans cells (giant cells with multiple
nuclei) which are surrounded with lymphocytes
and various connective tissues. Depending on
the number of agents, virulence, and patients
immunity, this pneumonic complex will then follow
a certain pathway: gets reabsorbed back and heals
without leaving any marks, spreads and healing process
begins quickly along with the forming of fibrotic tissue,
or pneumonic complex spreads widely to form caseous
tissue. Cavity will emerge as the caseous tissue gets
coughed out. The cavity will then spread and create
new pneumonic affect. This pneumonic complex shall
follow one pattern of pathways as mentioned above,
get condensed and encapsulates itself and known as
tuberculoma. It is clear and heals to produce what is
called open healed cavity, or heals by encapsulating
itself and finally shrink down.1,2,3

DEFINITION OF COLITIS TUBERCULOSIS

Colitis is an acute or chronic inflamation in colon

which, based on the etiology, can be classified as
follows:3,4,5 (1) Infective colitis, such as: shigellosis,
colitis TB, amebic colitis, pseudomembrane colitis,
colitis of other viral/bacterial/parasite etiologies;
(2) Non-infective colitis, such as: ulcerative colitis,
Crohns disease, radiative colitis, non-specific colitis.

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Colitis Tuberculosis
Table 1. Post primary tuberculosis9
Extrapulmonary tuberculosis

Pulmonary tuberculosis

Common

Less common

Cavities

Pleural effusion

Empyema

Upper lobe infiltrates

Lymphadenophaty (usually cervical)

Male genital tract (epididymitis, orchitis)

Fibrosis

Central nervous system (meningitis, Female genital tract (tubo-ovarian, endometrium)

cerebral tuberculoma)

Progressive pneumonia

Pericaditis (effusion/constrictive)

Kidney

Endobronchial

Gastrointestinal (ileocaecal, peritoneal)

Adrenal gland

Spine, other bone and joint

Skin (lupus vulgaris, tuberculids, miliary)

TB in the digestive system is one of the

manifestations of extrapulmonary TB and comprises
of 3-16% of all extrapulmonary TB cases. This type
of TB can affect the digestive system, peritoneum,
mesenteric lymph nodes, liver, as well as spleen.
The digestive system is affected in 66-75% of patients
with abdominal TB. Guts and peritoneum can be
infected through mesenteric lymph nodes, infected
tuba falopii, direct spread from an infected organ, and
hematogenous spread. Direct infection from the wall of
the guts is highly possible after drinking unpasteurized
milk or swallowing a large number of bacilli from the
pulmonary cavity. Reactivation from the body within
few years of time after hematogenous spread is highly
possible.7,8

Figure 3. Distribution of tuberculosis cases by anatomical site in

HIV negative patients10
PTB

: pulmonary
tuberculosis
EPTB : extrapulmonary
tuberculosis
LNTB : lymph node
tuberculosis

Figure 4. Distribution of tuberculosis cases by anatomical site in

HIV positive patients10

In colitis TB, caecum and ascending colon are two

areas most frequently affected, followed by transverse
colon and descending colon. Based on several
references, 6-90% of patients with pulmonary TB
Volume 11, Number 3, December 2010

have enteric involvement. This big interval is caused

by the severity of pulmonary TB, where the degree
of severity of pulmonary TB is directly proportional
to the incidence of concurrent enteric involvement.7,8
Table 2. Anatomic distribution of tuberculosis of the
intestine (from clinical and necropy series)8
Site

Cases (%)

Duodenum

2-3

Jejunum

7-25

Ileum

70-80

Ileocecal area

55-85

Appendix

5-25

Colon

25-50

Rectum

5-10

Anal canal

0-4

On the other side, 7-75% of patients with enteritis

TB have no history of concurrent pulmonary TB based
on various reports in Canada, USA, and England.
Studies in India reported that 60-75% of patients with
enteritis TB have no association with active pulmonary
TB, 0-20% have association with active pulmonary TB,
and 5-40% have association with inactive pulmonary
TB.7,8,11
PATHOGENESIS OF COLITIS TUBERCULOSIS

The pathogenesis of abdominal TB can be divided

into 4 mechanisms are swallowing infected sputum,
hematogenous spread from an active pulmonary
process or miliary TB, consuming contaminated milk
or food and direct spread from the adjacent organs.
Infection may occur primarily in the gastrointestinal
tract or secondary from other focuses in the body.7,8,11
In the case of ingested tubercle bacilli, intestinal
TB might be caused by consuming contaminated
food and milk. Secondary infection can happen
due to swallowing infectious sputum in patients
with pulmonary or laryngeal TB. After ingestion,
bacteria shall pass the stomach and head to the small
intestine. The lipid capsule protects bacteria from
digestion process such as the stomach acid secretions.
In the intestines, germination process takes place in
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areas containing many lymphoid tissues, excessively

static in physiology, areas with high rate of water and
electrolyte absorption, as well as areas with minimal
digestive activity.1,7,8,11
While the hematogenous spread from extraintestinal
focuses of infection involves spreading through blood
which can occur in primary phase of pulmonary TB
and in miliary TB. In these conditions, early lesions
are found in submucosa area, with normal mucosa
appearance.8,11
The most frequently affected location is the
ileocaecal region. The affinity of TB bacilli in this
region might be due to the presence of many lymphoid
tissues with relatively slower stream. Microorganisms
penetrate the mucosa to settle in submucosal lymphoid
tissues, where they would start inflammatory reactions
which lead to the emergence of lymphangitis,
endarteritis, granuloma, caseous necrosis, mucosal
ulcerations, and fibrotic tissue.3,8,11
Macroscopic feature of intestinal lesions can
be categorized as follows: ulcerative (60%),
hypertrophic (10%), and ulcerous-hypertrophic (30%).
The ulcerous-hypertrophic feature is most frequently
found in illeocaecal TB in comparison to the TB
affecting other segments of gastrointestinal tracts. 8,11,12

Table 3. Symptoms and signs of tuberculosis17

Symptoms

n (%)

Signs

n (%)

Weight loss

49 (57)

Fever

40 (46.5)

Abdominal pain

43 (50)

Ascites

23 (27)

Pyrexia of
unknown origin

36 (42)

Abdominal tenderness

23 (27)

Abdominal
distension

19 (22)

Abdominal mass

Vomiting

13 (15)

Peritonitis

Night sweats

CLINICAL MANIFESTATIONS

The signs and symptoms are blurry and not specific.

The clinical manifestations might be acute, chronic,
or acute in chronic process. As a result, the diagnosis
of ileocaecal TB is hard to establish and requires high
clinical suspicion rate, especially in the high-risk
group.1,7,8,11,12,13
In literatures, it is mentioned that TB of the
digestive system occurs more frequently in young
adult. Two thirds of the patients are 21-40 years old
and in several studies it was shown that the incidence
in women is higher than that in men (2 : 1).3,4,14
In a study conducted by Khan et al the average
age was 33 15 years old with 59% of the patients
were women. The most frequent symptoms found
subsequently were abdominal pain, fever, night sweat,
weight loss, nausea, vomiting, ascites, constipation,
and diarrhea. Subacute and acute intestinal obstruction
was found in 13% and 11% of all patients, respectively.
The length of time the symptoms had been experienced
before the patients received their medication for the
first time was 265 150 days. History of previous TB
treatment was found in 6,2% of patients and a history
of TB among family members was found in 2.9% of
patients.7,14,15
In history of illness, the symptoms found were
abdominal pain, night sweats, weight loss, loss of
appetite, nausea, vomiting, and chronic diarrhea.
Most patients have constitutional symptoms
146

such as fever (40-70%), pain (80-95%), diarrhea

(11-20%), constipation, alteration between constipation
and diarrhea, weight loss (40-90%), anorexia and
weakness. Unspecific chronic abdominal pain was the
chief complaint in 80 to 90 percent of all patients. Pain
might be colic or continuous if the mesenteric lymph
nodes were involved.1,5,6
Mass in lower right quadrant was palpable in
25-50% of all patients. Intestinal obstruction and colon
perforation were reported. Abdominal distention due
to ascites was various between 10-65%. The presence
of ascites could help to differentiate ileocaecal TB and
Crohns disease considering that ascites is rarely found
in Crohns disease. The proportion of the occurrence of
this case along with abdominal TB is varied between
30-40%.7,8,14,16

Anorexia

7 (8)

3 (3.5)

Acute bowel
obstruction

2 (2)

Jaundice

1 (1)

3 (3.5)

Fistula-in-ano

1 (1)

Dysphagia

2 (2)

Perianal mass

1 (1)

Shortness of
breath

1 (1)

Post-cholecystectomy

1 (1)

PR bleed + mass
at anal margin

1 (1)

Neck mass

1 (1)

Fistula-in-ano

1 (1)

Cough

7 (8)

10 (11.5)

In laboratory examination, routine laboratory result

can indicate mild anemia and increased erythrocyte
sedimentary rate in 50-80% of patients. Leukocyte
count is usually within normal range. Positive
tuberculin test in most of the patients with intestinal
TB has limited diagnostic value since it cannot differ
between active disease and previous sensitization due
to contact or vaccination. Furthermore, purified protein
derivative (PPD) skin test might give negative result
in immune-compromised patients.12,13,14,16
The examination of acid-fast bacilli (AFB) of
sputum, stools, and tissue AFB as well as the result
of tissue AFB culture often give negative results. In
a study conducted by Wells, Northoven and Howard,
positive result of sputum and tissue AFB test were
achieved only in less than 50% of all cases. A Canadian
study, AFB culture from tissue specimen collected
through surgical procedures only gives positive results
in 8 out of 17 patients with abdominal TB and direct
tissue-AFB examination gives positive results in

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Colitis Tuberculosis

5 out of 17 patients. Khan et al showed positive results

for mycobacterium tissue culture only in 7% of patients
with abdominal TB and the sensitivity of acid-fast
bacilli examination was 24.3%.8,11,12,14,16
Radiology findings are not specific. Patients chest
X-ray often shows no abnormalities. This condition
is not a wonder, considering less than 50% of patients
show pulmonary abnormalities. The image of specific
process in roentgen photo leads to the diagnosis, but it
was also mentioned that a normal chest X-ray does not
exclude abnormalities. Sharma et al found coincidence
with pulmonary TB as much as 46%.12,13,14,16
Table 4. Diagnostic yield of various investigations in patients with
abdominal tuberculosis17
n (patients
in which
investigations
performed)

Yield of
diagnostic test
n/%

Barium meal and follow

trough

70

58/83

Barium enema

34

15/44

Ultra sound

93

82/88

CT scan abdomen

35

28/80

Histopathology of

35

35/100

Histopathology of surgical
specimen

35

29/83

Histopathology of
colonoscopic biopsy

28

14/50

Histopathology of ultrasound
and CT guided biopsy

5/100

Histopathology of upper GI
endoscopic biopsy

10

4/40

Acid fast bacilli culture

87

6/7

Investigations

Barium enema and follow-through can show

mucosal ulceration and stricture, caecal deformity
and gaping, or incompetent ileocaecal valve. CT is an
imaging modality which helps in judging intraluminal
and extraluminal pathology as well as the distribution
of the disease.12,14,16,15,18
Eventhough colonoscopy nowadays has largely
replaced the role of past radiologic examination,
double-contrast barium enema examination can
provide a more detailed information on mucosal
pattern and early images of intestinal TB. With a better
understanding of early radiologic features of colitis
TB, an earlier diagnosis using double-contrast barium
enema is made possible.14,15,18
DIAGNOSIS

The main problem in abdominal TB is diagnostic

and management issues. The symptoms and signs of
abdominal TB are usually not specific and resembles
to other diseases.1,2,3
Abdominal TB is established based on history of
the disease, physical examination, lab examination and
other diagnostic examination as well as good response
Volume 11, Number 3, December 2010

after TB treatment. Abdominal TB can occur with or

without pulmonary TB.1,2,3,12,13
Presumptive diagnosis can be made if an active
pulmonary TB is found and/or accompanied with
clinical or radiologic findings that are consistent to
intestinal TB. It is essential to remember that positive
chest X-ray findings were found in less than 50% of
patients.2,3,13,19,20
The definite diagnosis is based on histological
findings, Ziehl-Neelsen staining of the acid-fast
bacilli, and culture, although the sensitivity of each
examination was reported to be various. Colonoscopy
with biopsy is one of the non-operative diagnostic
approach which is useful for acknowledging ileocaecal
TB.19,20,21 The combination of histological examination
and culturing biopsy material can establish the
diagnosis in more than 80% of patients.11,21,22,23
Deep biopsy per endoscopy is best performed
on the margin and the base of the ulcer, considering
granuloma of TB are often located in submucosal area.
This situation is different with the granuloma found
in Crohns disease, which are usually located in the
mucosa.19,20,22,23
PCR examination from biopsy specimens can help
in establishing the diagnosis with higher sensitivity
and specificity in comparison to urine culture and
the result can be obtained in a relatively short period
of time.19,20,23,24,25 Anti-cord factor antibodies with
ELISA is also regarded as being useful in establishing
intestinal TB fast and in helping to differ it from
Crohns disease.23,24
In gastrointestinal TB, endoscopy finding is not
pathognomonic. Finding granuloma and positive acidfast bacilli from the biopsy of tissue obtained through
endoscopy are also rare occasions. TB can happen in
all segments of the gastrointestinal tract. The region
most commonly affected is the ileocaecal region and
the caecum.18,22,23,26
Through colonoscopy, features can be found
including hyperemic mucosa with erosion and
edema, some with bleeding, visible multiple polypoid
mass in ileocaecal valve and terminal ileus (giving
the differentials of TB, Crohns, and malignancy)
with multiple ulcerations in the rectum, ascending
colon, and caecum. Segmental or isolated colonic TB
comprises of 9.2% of all abdominal TB cases, and it
usually affects sigmoid colon, ascending colon, and
transversal colon. Multifocal involvement was seen
in 28-44% of patients with colitis TB.22,23,26
Lee et al in a prospective analysis of endoscopic
findings, created a scoring system in measuring
the probability of Crohns disease as well as intestinal
TB with positive prediction values of 94.9% and
88.9%, respectively.27 Endoscopic findings supporting
Crohns disease include anorectal lesion, longitudinal
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ulcer, aphtose ulcer, and cobblestone appearance,

whereas endoscopic findings supporting intestinal
tuberculosis include transversal ulcer, polypoid mass,
the involvement of less than four segments, and
ileocaecal-valve lesion.18,26
Histological features of the result of colon
biopsy often show active chronic colitis with cryptic
destruction giving the differentials of inflammatory
bowel diseases (IBD) and chronic bacterial/parasitic
infection. Pulimoid et al in a study on the result of
colonoscopic biopsy, concluded that the histologic
features of mucosal biopsy might aid in separating
cases of intestinal TB and Crohns disease, but multiple
biopsy from different segments are required.28 It was
also said that the accuracy of diagnosis is directly
proportional to the amount of biopsy performed from
rectum to the ileus.21,22,24
DIFFERENTIAL DIAGNOSIS

The differential diagnosis of ileocaecal TB includes

actinomycosis, amebiasis, Yersinia enterocolitis,
Crohns disease, lymphoma, dan adenocarcinoma.
Biopsy helps in identifying lymphoma or carcinoma
cell. Amebiasis is usually acute in nature even though
some patients may experience chronic colitis or colon
ameboma. Biopsy obtained from the ulcers found in
mostly normal mucosa may contain the trophozoic
phase of Entamoeba histolytica. The microorganism is
usually found in patients stools and amoeba serology
shall give positive result.21,24,29
Table 5. Differential diagnosis of abdominal tuberculosis17
Symptom

Differential diagnosis

Malabsorption

Coeliac disease
Lymphoma
Immunoproliferative small intestinal disease

Mass

Caecal carcinoma
Appendicular mass
Crohns disease

Ascites

Cardiac disease
Renal disease
Hepatic disease
Malignancy

that if a strong clinical suspicion is found in an endemic

area, empirical therapy using anti-tuberculosis is
allowed. Another study conducted by Ramanathan
et al concluded that justifying the initiation of antituberculosis drugs therapy in an endemic area based
on clinical suspicion and adequate response should
be acceptable as a diagnostic basis of abdominal
TB although histopathological or microbiology
confirmation was not possible.12
Marshall JB, in a study on the length of TB
treatment, mentioned that a therapy regimen of 6,
9, or 18 to 24 months all were proven effective in
the management of extrapulmonary TB. Systemic
symptoms such as fever, anorexia, and weight loss
can decline in 4 to 6 weeks, whereas gastrointestinal
symptoms require a longer time.7
In a study conducted in Saudi Arabia, it was
reported that corticosteroid reduce the frequency of
recurrent abdominal pain, intestinal obstruction, and
surgical procedure as well as mortality rate. It was then
suggested also to give corticosteroid especially in the
case of peritonitis TB.8,9,28
CONCLUSION

Clinical manifestations of abdominal TB are not

specific. In a way, detailed diagnostic approaches
and supporting results are needed to determine
the final diagnosis. On the other side, there is
no single examination, be it clinical symptoms,
laboratory, radiology, endoscopy, microbiology
or histopathological examinations are adequate to
diagnose abdominal TB. Diagnostic approach to
abdominal TB remains a challenge for clinicians;
aside from the need of strong clinical judgment.
If the diagnosis can be quickly established, this
disease would then be able to be treated with
conventional anti-tuberculosis drugs. Therapy for 6,
9 and 18 to 24 months are all proven to be effective in
the management of extrapulmonary TB.
In countries with high prevalence of abdominal
TB, initiating a trial of anti-tuberculosis treatment
is allowed if it is accompanied by consistent clinical
features. Diagnosis can be established when the patient
responds to anti-TB treatment.

MANAGEMENT

REFERENCES

Therapy with standard anti-tuberculosis drugs

has a high efficacy on intestinal TB. Compliance is
the main point which determines the success of
therapy.27,30
Khan et al reported a small group of patients whose
diagnosis of abdominal TB was hard to establish and
the therapy trial using anti-tuberculosis drugs can be
taken into consideration within tight monitoring.24
A study on abdominal TB in India also mentioned

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