The Value of Terminal Ileum Intubation During Colonoscopy

Nawal Alkhalidi Abdulhadi Alrubaie Raed Esttaifan Rezqallah Maitham Kenber About the authors

Abstract

It is uncertain whether terminal ileum intubation should be performed routinely during colonoscopy, as there is uncertainty regarding its diagnostic value. The aim of the present study is to assess the diagnostic yield of terminal ileum intubation during colonoscopy according to indications for colonoscopy. This is a cross-sectional study in which the results of 294 total colonoscopy procedures were reviewed; ileal intubation was performed in 269 (91.49%) patients. The indications for colonoscopy, the results of ileoscopy, and the histopathological results of ileal biopsies were evaluated. A total of 54 (20%) out of 269 patients who had successful intubation into the terminal ileumshowed macroscopic abnormalities on the terminal ileum. Biopsies were positive in 4 out of 54 (7.4%); all were of Crohn disease. Two were erosions (9.5%.) and 2 were ulcers (18.8%). The two erosions were presented as abdominal pain, abdominal pain and alternating bowel motion. Those with ulcers were presented with diarrhea and perianal disease.

Conclusions

Considering the low diagnostic yield of ileal intubation during colonoscopy, the decision to performileoscopy or not during colonoscopy needs to bemade on a case-by-case basis. However, routine ileal intubation, brief attempts should be considered despite low diagnostic yield.

Keywords:
colonoscopy; terminal ileum; ileocecal intubation; Crohn’s disease

Introduction

It is dubious whether terminal ileum intubation ought to be performed routinely during colonoscopy as there is uncertainty regarding its diagnostic value.11 Jeong SH, LeeKJ,KimYB,Kwon HC, Sin SJ, Chung JY.Diagnostic value of terminal ileumintubationduringcolonoscopy. JGastroenterolHepatol 2008;23(01):51-55. Doi: 10.1111/j.1440-1746.2007.05151.x
https://doi.org/10.1111/j.1440-1746.2007...
Concerns regarding complete colonoscopy dictates that cecal landmarks such as the ileocecal valve and the appendiceal opening during colonoscopy are largely accepted, although some regard ileal intubation as the evidence of a complete procedure.22 Börsch G, Schmidt G. Endoscopy of the terminal ileum. Diagnostic yield in 400 consecutive examinations. Dis Colon Rectum1985;28 (07):499-501 33 Farrar WD, Sawhney MS, Nelson DB, Lederle FA, Bond JH. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol 2006;4(10):1259-1264 44 Abadie SN, HaqueM. Documentation of complete colonoscopy; can we do it better? Gastrointest Endosc 2008;67(05):AB247-AB248 Although ileoscopy is not practiced routinely, it may be beneficial in some patients with right lower quadrant pain, diarrhea of unknown cause, inflammatory bowel disease, hematochezia, and suspected ileocecal tuberculosis.55 Cherian S, Singh P. Is routine ileoscopy useful? An observational study of procedure times, diagnostic yield, and learning curve. Am J Gastroenterol 2004;99(12):2324-2329 66 Yoong KK, Heymann T. It is not worthwhile to perform ileoscopy on all patients. Surg Endosc 2006;20(05):809-811 77 Kennedy G, Larson D, Wolff B, Winter D, Petersen B, Larson M. Routine ileal intubation during screening colonoscopy: a useful maneuver? Surg Endosc 2008;22(12):2606-2608 88 Bhasin DK, Goenka MK, Dhavan S, Dass K, Singh K. Diagnostic value of ileoscopy: a report fromIndia. J Clin Gastroenterol 2000; 31(02):144-146 99 Misra SP, Dwivedi M, Misra V. Ileoscopy in 39 hematochezia patients with normal colonoscopy. World J Gastroenterol 2006; 12(19):3101-3104 1010 Zwas FR, Bonheim NA, Berken CA, Gray S. Diagnostic yield of routine ileoscopy. Am J Gastroenterol 1995;90(09):1441-1443 Most studies on ileoscopy were done Western countries, and less in Asian countries.88 Bhasin DK, Goenka MK, Dhavan S, Dass K, Singh K. Diagnostic value of ileoscopy: a report fromIndia. J Clin Gastroenterol 2000; 31(02):144-146 1111 Niriella MA, De Silva AP, Dayaratne AH, et al. Prevalence of inflammatory bowel disease in two districts of Sri Lanka: a hospital based survey. BMC Gastroenterol 2010;10:32 Ileocolonoscopy is the procedure of choice for chronic nonbloody diarrhea of unknown origin. A histopathological examination of multiple sites is crucial to diagnose microscopic colitis. The routine ileal biopsy of normally appearing mucosa assessed by standard-resolution white-light ileoscopy is controversial because of the reported low diagnostic yield.1212 Borsotti E, Barberio B, D'Incà R, et al. Terminal ileumileoscopy and histology in patients undergoing high-definition colonoscopy with virtual chromoendoscopy for chronic nonbloody diarrhea: A prospective, multicenter study. United European Gastroenterol J 2019;7(07):974-981 Currently, the position employed to intubate the ileum is with the patient in the left lateral position and entering the valve at the 6 o'clock position. However, we have sometimes encountered difficulty when performing ileoscopy in this position, leading to extra time being consumed during busy endoscopy lists. During such difficult procedures, placing the patient in the prone position using A ‘down and left’ technique facilitated ileal intubation.1313 De Silva AP, Kumarasena RS, Perera Keragala SD, et al. The prone 12 o'clock position reduces ileal intubation time during colonoscopy compared to the left lateral 6 o'clock (standard) position. BMC Gastroenterol 2011;11:89 1414 Ansari A, Soon SY, Saunders BP, Sanderson JD. A prospective study of the technical feasibility of ileoscopy at colonoscopy. Scand J Gastroenterol 2003;38(11):1184-1186 As performing a biopsy of an endoscopically normal terminal ileum is controversial.1515 Byrne MF, Power DG, Keeling AN, Kay E, Murray FE, Patchett SE. Combined terminal ileoscopy and biopsy is superior to small bowel follow-through in detecting terminal ileal pathology. Dig Liver Dis 2004;36(02):147-152 1616 McHugh JB, Appelman HD, McKenna BJ. The diagnostic value of endoscopic terminal ileumbiopsies.AmJ Gastroenterol 2007;102 (05):1084-1089 1717 Melton SD, Feagins LA, Saboorian MH, Genta RM. Ileal biopsy: Clinical indications, endoscopic and histopathologic findings in 10,000 patients. Dig Liver Dis 2011;43(03):199-203 1818 Powell N, Hayee BH, Yeoh DP, Rowbotham DS, Saxena V,McNair A. Terminal ileal photography or biopsy to verify total colonoscopy: does the endoscope agree with the microscope? Gastrointest Endosc 2007;66(02):320-325 The aim of the present study is to assess the diagnostic yield of terminal ileum intubation during colonoscopy according to indications for colonoscopy.

Methods

This is a cross-sectional study in which the results of 294 total colonoscopy procedures were reviewed; ileal intubations were performed in 269 patients

All procedures at Gastroenterology and Hepatology Center were performed at the gastroenterology and hepatology center in Baghdad from April 2018 to September 2020 using Olympus, Lucera CF-H260AL.

The degree of bowel preparation was reasonable in all patients. Midazolam and pethidine were used for conscious sedation with doses according to the needs of each individual patient.

The indications for colonoscopy, the results of ileoscopy, and the histopathological results of ileal biopsies were evaluated.

Biopsy was taken in all macroscopic abnormalities of the terminal ileum.

An abnormality was considered as being clinically significant if it raised a new diagnosis or if it led to specific investigations or management, such as inflammatory bowel disease, intestinal tuberculosis, Behcet's disease, and tumors; otherwise they were considered as nonspecific.

Inclusion Criteria

Indications for Colonoscopy:

  1. 1–Abdominal pain: abdominal pain only or with diarrhea, constipation, alternating bowel motion, persistent or recurrent abdominal pain, and hematochezia with or without fever.

  2. 2–Without abdominal pain: including constipation, alternating bowel motion, diarrhea, and bleeding from rectum only.

Exclusion Criteria

Asymptomatic medical check-up. Follow-up of known surgical or medical gastrointestinal conditions.

Statistical Analysis

Statistical analysis was performed with IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, NY, USA).

Results

A total of 54 (20%) out of 269 patients who underwent successful terminal ileum intubation showed macroscopic abnormalities on the terminal ileum, which included ulcers, erosions, congestion, and nodular mucosa.

In 22 out of 269 patients (8%), there was mucosal nodularity. In 21 (7.8%) patients, there was congestion and/or erosions. In 11 (4%) patients, the abnormalities were ulcers. A total of 65 (24.16%) patients presented with haematochesia; 10(3%) of them associated with abdominal pain; 30 (11.1%) without abdominal pain; and 25 (9.2%) without abdominal pain but with abnormal bowel motion. Tables 1,2,3

Table 1
indications and findings in abdominal pain with other symptoms

Table 2
Indications and findings in patients without abdominal pain

Table 3
Miscellaneous indications

Biopsy Results

Biopsies of the 54 patients with macroscopical abnormalities of the terminal ileum were positive in 4 (7.4%) patients, which corresponded to 1.4% of all ileal intubations. All were of Crohn's disease; 2 were erosions (9.5%) out of 21 patients with congestion/erosions; and 2 were ulcers (18.1%) out of 11 ulcer patients.

Diagnostic Biopsies According to Clinical Indications for Colonoscopy (Table 4)

Table 4
Relation of clinical indications endoscopic findings and histopathological biopsy results

The two patients with erosions presented with abdominal pain or with abdominal pain and alternating bowel motion.

Those with ulcers presented with diarrhea and perianal disease.

Discussion

In the present study, the most common indication for ileal intubation was abdominal pain (51.6%) followed by haematochezia (24.16%), constipation (10%), diarrhea (5.9%), and suspected irritable bowel syndrome (4%). There were 91% successful ileal intubations. There were 20% abnormal macroscopical findings in the terminal ileum, which were mucosal nodularity (8%), congestion and/or erosions (7.8%), and ulcers (4%). Positive biopsies were 7.4%, all corresponding to Crohn's disease.

Compared with Akere et al.,1919 Akere A, Otegbayo JA, Tejan EA. Terminal ileum intubation during colonoscopy: Should it be routinely performed on all patients? Trop J Med Res 2017;20(01):66-69 the indication for intubation was abdominal pain (26.2%), haematochezia (25%), constipation (14.2%), and diarrhea (14.2%); the rate of successful ileal intubation was 30.9%; abnormal macroscopical findings were 2.4%, including ulcers, polypoid lesions, and cobblestone appearance, which may be attributed to the wide disparity in successful intubations. The rate of positive biopsies was 93.7%, including chronic nonspecific ileitis, acute chronic ileitis, and tuberculous ileitis, which can be attributed to differences in the diets of the patients.

Velidedeoğlu et al.2020 Velidedeoglu M, Enes Arikan A, Kagan Zengin A. Diagnostic value of terminal ileum biopsies in patients with abnormal terminal ileum mucosal appearance. Ulus Cerrahi Derg 2015;31(03): 152-156 showed the most common indications for intubation are diarrhea (39%), haematochezia (28%), abdominal pain (26%), abdominal bloating (18%), constipation (5%), and mucoid rectal discharge (5%). Macroscopical abnormalities were ulcers and/or erosions (39%), mucosal nodularity 18%, and erythema was 42%.

A study by Wijewantha et al.2121 Wijewantha HS, de Silva AP, Niriella MA, et al. Usefulness of Routine Terminal Ileoscopy and Biopsy during Colonoscopy in a Tropical Setting: A Retrospective Record-Based Study. Gastroenterol Res Pract 2014;2014:343849 showed a successful intubation rate of 90.15% and 47/81 (58%) positive biopsies. This high percent because ileal intubation done for only indicated intubation as this will be (6.15%) from the overall. From those, 28/47 (59.5%) were Crohn's disease, 6/47 (12.7%) were tuberculosis, 8/47 (17%) were ileitis due to resolving infection, and 5/47 (10.6%) were drug-induced ileitis. There were macroscopical abnormalities in 34/47 (72.3%), of which 21/34 (61.7%) were mild inflammation or erosions, and 13/34 (38.3%) were few aphthous ulcers. The most common indications of terminal ileoscopy were diarrhea in 29.31%, abdominal pain in 15.83%, suspected irritable bowel syndrome in 10.6%, and anemia in 9.81%.

Conclusion

High ileal intubation rates may be achieved without complications.

The diagnostic yield of the procedure is very low; therefore, the decision to perform ileoscopy or not during colonoscopy needs to be made on a case-by-case basis.

However, routine ileal intubation, brief attempts should be considered despite low diagnostic yield, it may be useful to improve or maintain endoscopic skills, especially in a training setting.

Acknowledgments

We thank all the nursing and supportmembers of the staff of the Endoscopy Unit and members of staff of the Department of Pathology, Hepatology and Gastrointestinal disease Center, Baghdad, Iraq, for their assistance toward the success of the present research work.

References

  • 1
    Jeong SH, LeeKJ,KimYB,Kwon HC, Sin SJ, Chung JY.Diagnostic value of terminal ileumintubationduringcolonoscopy. JGastroenterolHepatol 2008;23(01):51-55. Doi: 10.1111/j.1440-1746.2007.05151.x
    » https://doi.org/10.1111/j.1440-1746.2007.05151.x
  • 2
    Börsch G, Schmidt G. Endoscopy of the terminal ileum. Diagnostic yield in 400 consecutive examinations. Dis Colon Rectum1985;28 (07):499-501
  • 3
    Farrar WD, Sawhney MS, Nelson DB, Lederle FA, Bond JH. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol 2006;4(10):1259-1264
  • 4
    Abadie SN, HaqueM. Documentation of complete colonoscopy; can we do it better? Gastrointest Endosc 2008;67(05):AB247-AB248
  • 5
    Cherian S, Singh P. Is routine ileoscopy useful? An observational study of procedure times, diagnostic yield, and learning curve. Am J Gastroenterol 2004;99(12):2324-2329
  • 6
    Yoong KK, Heymann T. It is not worthwhile to perform ileoscopy on all patients. Surg Endosc 2006;20(05):809-811
  • 7
    Kennedy G, Larson D, Wolff B, Winter D, Petersen B, Larson M. Routine ileal intubation during screening colonoscopy: a useful maneuver? Surg Endosc 2008;22(12):2606-2608
  • 8
    Bhasin DK, Goenka MK, Dhavan S, Dass K, Singh K. Diagnostic value of ileoscopy: a report fromIndia. J Clin Gastroenterol 2000; 31(02):144-146
  • 9
    Misra SP, Dwivedi M, Misra V. Ileoscopy in 39 hematochezia patients with normal colonoscopy. World J Gastroenterol 2006; 12(19):3101-3104
  • 10
    Zwas FR, Bonheim NA, Berken CA, Gray S. Diagnostic yield of routine ileoscopy. Am J Gastroenterol 1995;90(09):1441-1443
  • 11
    Niriella MA, De Silva AP, Dayaratne AH, et al. Prevalence of inflammatory bowel disease in two districts of Sri Lanka: a hospital based survey. BMC Gastroenterol 2010;10:32
  • 12
    Borsotti E, Barberio B, D'Incà R, et al. Terminal ileumileoscopy and histology in patients undergoing high-definition colonoscopy with virtual chromoendoscopy for chronic nonbloody diarrhea: A prospective, multicenter study. United European Gastroenterol J 2019;7(07):974-981
  • 13
    De Silva AP, Kumarasena RS, Perera Keragala SD, et al. The prone 12 o'clock position reduces ileal intubation time during colonoscopy compared to the left lateral 6 o'clock (standard) position. BMC Gastroenterol 2011;11:89
  • 14
    Ansari A, Soon SY, Saunders BP, Sanderson JD. A prospective study of the technical feasibility of ileoscopy at colonoscopy. Scand J Gastroenterol 2003;38(11):1184-1186
  • 15
    Byrne MF, Power DG, Keeling AN, Kay E, Murray FE, Patchett SE. Combined terminal ileoscopy and biopsy is superior to small bowel follow-through in detecting terminal ileal pathology. Dig Liver Dis 2004;36(02):147-152
  • 16
    McHugh JB, Appelman HD, McKenna BJ. The diagnostic value of endoscopic terminal ileumbiopsies.AmJ Gastroenterol 2007;102 (05):1084-1089
  • 17
    Melton SD, Feagins LA, Saboorian MH, Genta RM. Ileal biopsy: Clinical indications, endoscopic and histopathologic findings in 10,000 patients. Dig Liver Dis 2011;43(03):199-203
  • 18
    Powell N, Hayee BH, Yeoh DP, Rowbotham DS, Saxena V,McNair A. Terminal ileal photography or biopsy to verify total colonoscopy: does the endoscope agree with the microscope? Gastrointest Endosc 2007;66(02):320-325
  • 19
    Akere A, Otegbayo JA, Tejan EA. Terminal ileum intubation during colonoscopy: Should it be routinely performed on all patients? Trop J Med Res 2017;20(01):66-69
  • 20
    Velidedeoglu M, Enes Arikan A, Kagan Zengin A. Diagnostic value of terminal ileum biopsies in patients with abnormal terminal ileum mucosal appearance. Ulus Cerrahi Derg 2015;31(03): 152-156
  • 21
    Wijewantha HS, de Silva AP, Niriella MA, et al. Usefulness of Routine Terminal Ileoscopy and Biopsy during Colonoscopy in a Tropical Setting: A Retrospective Record-Based Study. Gastroenterol Res Pract 2014;2014:343849

  • Ethical Approval and Permission

    Ethical permission was granted by the scientific committee in Gastroenterology and Hepatology Center.
  • Financial Support and Scholarship

    None to declare

Publication Dates

  • Publication in this collection
    03 June 2022
  • Date of issue
    Jan-Mar 2022

History

  • Received
    13 June 2021
  • Accepted
    06 Aug 2021
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