Combination of increased visceral fat and long segment involvement: Development and validation of an updated imaging marker for differentiating Crohn's disease from intestinal tuberculosis

Background and Aim Computed tomographic (CT) features (long segment, ileocaecal area involvement, and lymph nodes > 1 cm) have demonstrated good specificity but poor sensitivity, while visceral to subcutaneous fat ratio on CT (VF/SC > 0.63) has moderate sensitivity and specificity in differentiating Crohn's disease (CD) and intestinal tuberculosis (ITB). This study aims to develop and validate an updated model incorporating CT features and VF/SC to improve the diagnostic accuracy of imaging in differentiating CD/ITB. Methods Computed tomographic features and VF/SC were documented in two cohorts (development [ n  = 59, follow‐up: January 2012 to November 2014] and validation [ n  = 69, follow‐up: December 2014 to December 2015]) of CD/ITB patients diagnosed by standard criteria. Patients with normal CT were excluded. Features significantly different between CD/ITB were incorporated into a model. Results In both the cohorts, necrotic lymph nodes were exclusive for ITB (23.1% vs 0% and 43.3% vs 0%), while long segment involvement (57.6% vs 7.7%, P  < 0.001, and 52.6% vs 16.1%, P  < 0.001) and VF/SC ratio > 0.63 (72.7% vs 19.2%, P  < 0.001, and 81.6% vs 25.8%, P  < 0.001) were significantly more common in CD. A risk score of 2, based upon long segment involvement and VF/SC ratio > 0.63, had an excellent specificity of 100% and 100% and sensitivity of 54% and 50% for CD in development and validation cohorts, respectively. Based upon these features, in 43% patients with the diagnostic dilemma of CD/ITB, a definite diagnosis based only on imaging could be made. Conclusion Necrotic lymph nodes are exclusive for ITB, and the combination of long segment involvement and VF/SC ratio > 0.63 is exclusive for CD, and these features can make a definite diagnosis in 43% patients with a CD/ITB dilemma.