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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 20  |  Issue : 1  |  Page : 66-69

Terminal ileum intubation during colonoscopy: Should it be routinely performed on all patients?


1 Department of Medicine, College of Medicine, University of Ibadan, University College Hospital, Agodi, Ibadan, Nigeria
2 Department of Medicine, University College Hospital, Agodi, Ibadan, Nigeria

Date of Web Publication11-Jan-2017

Correspondence Address:
Dr. Adegboyega Akere
Department of Medicine, College of Medicine, University of Ibadan, University College Hospital, P. O. Box 28829, Agodi, Ibadan
Nigeria
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DOI: 10.4103/1119-0388.198125

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  Abstract 

Aim: The aim of this study was to evaluate the diagnostic yield and the usefulness of ileoscopy in a tropical setting. Patients and Methods: Colonoscopy was performed on consenting patients using Olympus Exera III Videocolonoscope (CF HQ190 L, Olympus UK). Terminal ileum intubation was attempted in all the patients who had cecal intubation. A pro forma was used to record information such as biodata of the patients, indications for the procedure, and the findings, including that of the intubated terminal ileum. Results: The colonoscopy results of 305 patients comprising 168 (55.1%) males and 137 (44.9%) females were analyzed. Cecum was reached in 272 (89.2%) patients and successful terminal ileum intubation was achieved in 84/272 (30.9%) patients. Macroscopically, 82 (97.6%) patients had normal ileum, while abnormal findings were recorded in two patients, giving a diagnostic yield of 2.4% (2/84). The various abnormalities were ulcers, polypoid lesions, and cobblestone appearance. Of the 16 (19%) patients who had a biopsy of the terminal ileum, microscopic abnormalities were seen in 15 (93.7%) patients while 1 (6.3%) patient had normal ileal histology. Conclusion: The diagnostic yield of ileoscopy in this study was very low, and hence, it may not be routinely necessary in all patients in our practice.

Keywords: Colonoscopy, ileocecal intubation, routine, terminal ileum


How to cite this article:
Akere A, Otegbayo JA, Tejan EA. Terminal ileum intubation during colonoscopy: Should it be routinely performed on all patients?. Trop J Med Res 2017;20:66-9

How to cite this URL:
Akere A, Otegbayo JA, Tejan EA. Terminal ileum intubation during colonoscopy: Should it be routinely performed on all patients?. Trop J Med Res [serial online] 2017 [cited 2019 Aug 22];20:66-9. Available from: http://www.tjmrjournal.org/text.asp?2017/20/1/66/198125


  Introduction Top


Identification of cecal landmarks such as appendiceal opening and ileocecal valve during colonoscopy is widely accepted as evidence of complete procedure. However, some regard ileal intubation as an evidence of complete colonoscopy.[1] Although ileoscopy is not routinely performed, it may however be of benefit in certain patients such as those with inflammatory bowel disease, diarrhea of unknown cause, hematochezia, suspected ileocecal tuberculosis, and right lower quadrant pain.[2],[3],[4],[5],[6],[7] Most of the studies on ileoscopy were conducted in Western populations and some in Asian countries.[6],[8] Therefore, the aim of this study was to evaluate the diagnostic yield and the usefulness of ileoscopy in a tropical setting.


  Patients and Methods Top


This was a prospective study at the Endoscopy Unit of the University College Hospital, Ibadan. All adult-consenting patients who were referred for colonoscopy were recruited in the study. A pro forma was used to record information such as biodata of the patients, indications for the procedure, and the findings of the procedure, including that of the terminal ileum where this was intubated.

All the patients underwent bowel preparation which commenced about 3 days before the procedure. The bowel preparation consisted of liquid diet, 10-30 mg of bisacodyl tablets in the morning, bisacodyl suppository nocte, as well as 1 l of normal saline taken orally twice daily, all for 3 days before the procedure. The bowel preparation was graded as good, satisfactory, or poor. Bowel preparation was adjudged as poor, if there was significant amount of semisolid/solid feces; satisfactory, if only clear liquid or small amount of semi-solid feces; good, if only a small amount of clear liquid was seen in the colonic lumen. Patients with poor bowel preparation were asked to take about a liter of normal saline orally, and the procedure was repeated after about 1-2 h on the same day.

Premedications were given to all the patients, which included intravenous midazolam 2.5-5 mg and pentazocine 15-30 mg in titrated doses. Before, during, and after the procedure, patients' vital signs were monitored using multiparameter monitor (Marathon Z, Health-care Equipment and Supplies Co. Ltd., UK).

Digital rectal examination was carried out on all the patients before the insertion of the colonoscope. Colonoscopy was thereafter performed using Olympus Exera III Videocolonoscope (CF HQ190 L, Olympus UK) with the patient in the left lateral position. Supine posture and abdominal pressure were applied where necessary. Terminal ileum intubation was attempted in all the patients who had cecal intubation.

After the procedure, all the patients were observed for 2 h before being discharged home with an assistant. They were also counseled with respect to resumption of oral intake and to report any observed complication immediately.

The data were analyzed using SPSS version 17.0 (SPSS Inc., Chicago, IL, USA). The means were used to express continuous variables and were compared where appropriate. P < 0.05 was considered statistically significant.


  Results Top


The 305 patients comprised 168 (55.1%) males and 137 (44.9%) females were analyzed. Cecum was reached in 272 (89.2%) patients and successful terminal ileum intubation was achieved in 84/272 (30.9%) patients. Analysis of the gender showed that 45 (53.6%) were male while 39 (46.4%) were female. There was no significant difference between the two groups (P = 0.74). The age range showed that 53 (63.1%) patients were < 58 years of age while 31 (36.9%) were older than 58 years. Again, there was no significant difference between these groups (P = 0.15).

Bowel preparation was good, satisfactory, and poor in 49 (58.3%), 28 (33.3%), and 7 (8.3%) patients, respectively, and there was a statistically significant difference among these groups (P = 0.00).

The most frequent indications in those patients who had ileal intubation were abdominal pain in 22 (26.2%), hematochezia in 21 (25%), constipation in 12 (14.2%), and diarrhea in 12 (14.2%) patients [Table 1].
Table 1: Indications in patients who had ileoscopy


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Macroscopically, 82 (97.6%) patients had normal ileum, while abnormal findings were recorded in two patients, giving a diagnostic yield of 2.4% (2/84). The various abnormalities were ulcers in one of the patients while the other had polypoid lesions and cobblestone appearance of the terminal ileum.

Only 16 (19%) of the patients had a biopsy of the terminal ileum taken, and out of these, microscopic abnormalities were seen in 15 (93.7%) patients while the remaining 1 (6.3%) patient had normal ileal histology. The histologic abnormalities were chronic nonspecific ileitis in 9 (56.2%), acute on chronic ileitis in 4 (25%), and tuberculous ileitis in 2 (12.5%) patients [Figure 1].
Figure 1: Histologic abnormalities of the ileum in the patients

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  Discussion Top


Routine terminal ileum intubation during colonoscopy is not widely performed in many clinical settings. In this study, we found a diagnostic yield of 2.4% for ileoscopy, which is higher than the 1% reported by Kennedy et al.[5] and the 1.9% reported by Kundrotas et al.[9] The sample size in their study was much larger than in our study, but more importantly, in contrast to our study, where most of our patients had an indication for the procedure, their study was carried out on asymptomatic patients who were just undergoing screening colonoscopy. The latter might explain the reason for the lower diagnostic yield recorded in those studies.

Yoong and Heymann[4] reported a diagnostic yield of 4.6%, which is higher than that in our study. In their study, diarrhea was the most frequent indication for colonoscopy, as well as in those patients who had ileal intubation, in contrast to our study, where abdominal pain was the most frequent indication. It has been observed that positive findings on ileoscopy often depend on the indications for the procedure. Although significantly higher abnormalities have been reported in patients with diarrhea and those with right lower quadrant pain,[2] Shah et al.[10] reported a diagnostic yield of 2% among 168 patients with chronic diarrhea and this is still lower than what was observed in our study. Furthermore, some other studies have reported significant histologic findings in patients with chronic diarrhea compared to other indications.[11],[12]

In our study, one of the patients with macroscopic abnormality had diarrhea as the indication for colonoscopy and eventually ileoscopy while the other patient had anorexia and weakness. Ileoscopy had to be performed on the latter patient because abdominal computed tomography scan suggested a lesion in the terminal ileum.

Another observation from our study was the abnormal histologic findings in macroscopically normal ileum. This underscores the importance of taking a biopsy of normally appearing mucosa although these findings did not alter the management of the patients concerned. Similar findings have been reported from some other studies.[3],[13]

Although the terminal ileum intubation rate in this present study (30.9%) is much lower compared to 72-97% reported in some other studies,[3],[6],[9],[14],[15],[16] the findings of this procedure were useful in a small percentage of patients while the findings did not alter the management of majority of the patients.


  Conclusion Top


The diagnostic yield of ileoscopy in this study was very low, and hence, it may not be routinely necessary in all patients. However, the decision to perform ileoscopy should be individualized on a case-by-case decision.

Acknowledgments

We thank all the nursing and support members of staff of the Endoscopy Unit and members of staff of the Department of Pathology, University College Hospital, Ibadan, Nigeria, for their assistance toward the success of this research work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Börsch G, Schmidt G. Endoscopy of the terminal ileum. Diagnostic yield in 400 consecutive examinations. Dis Colon Rectum 1985;28:499-501.  Back to cited text no. 1
    
2.
Jeong SH, Lee KJ, Kim YB, Kwon HC, Sin SJ, Chung JY. Diagnostic value of terminal ileum intubation during colonoscopy. J Gastroenterol Hepatol 2008;23:51-5.  Back to cited text no. 2
    
3.
Cherian S, Singh P. Is routine ileoscopy useful? An observational study of procedure times, diagnostic yield, and learning curve. Am J Gastroenterol 2004;99:2324-9.  Back to cited text no. 3
    
4.
Yoong KK, Heymann T. It is not worthwhile to perform ileoscopy on all patients. Surg Endosc 2006;20:809-11.  Back to cited text no. 4
    
5.
Kennedy G, Larson D, Wolff B, Winter D, Petersen B, Larson M. Routine ileal intubation during screening colonoscopy: A useful maneuver? Surg Endosc 2008;22:2606-8.  Back to cited text no. 5
    
6.
Bhasin DK, Goenka MK, Dhavan S, Dass K, Singh K. Diagnostic value of ileoscopy: A report from India. J Clin Gastroenterol 2000;31:144-6.  Back to cited text no. 6
    
7.
Misra SP, Dwivedi M, Misra V. Ileoscopy in 39 hematochezia patients with normal colonoscopy. World J Gastroenterol 2006;12:3101-4.  Back to cited text no. 7
    
8.
Niriella MA, De Silva AP, Dayaratne AH, Ariyasinghe MH, Navarathne MM, Peiris RS, et al. Prevalence of inflammatory bowel disease in two districts of Sri Lanka: A hospital based survey. BMC Gastroenterol 2010;10:32.  Back to cited text no. 8
    
9.
Kundrotas LW, Clement DJ, Kubik CM, Robinson AB, Wolfe PA. A prospective evaluation of successful terminal ileum intubation during routine colonoscopy. Gastrointest Endosc 1994;40:544-6.  Back to cited text no. 9
    
10.
Shah RJ, Fenoglio-Preiser C, Bleau BL, Giannella RA. Usefulness of colonoscopy with biopsy in the evaluation of patients with chronic diarrhea. Am J Gastroenterol 2001;96:1091-5.  Back to cited text no. 10
    
11.
Fine KD, Seidel RH, Do K. The prevalence, anatomic distribution, and diagnosis of colonic causes of chronic diarrhea. Gastrointest Endosc 2000;51:318-26.  Back to cited text no. 11
    
12.
Yusoff IF, Ormonde DG, Hoffman NE. Routine colonic mucosal biopsy and ileoscopy increases diagnostic yield in patients undergoing colonoscopy for diarrhea. J Gastroenterol Hepatol 2002;17:276-80.  Back to cited text no. 12
    
13.
Geboes K, Ectors N, D′Haens G, Rutgeerts P. Is ileoscopy with biopsy worthwhile in patients presenting with symptoms of inflammatory bowel disease? Am J Gastroenterol 1998;93:201-6.  Back to cited text no. 13
    
14.
Ansari A, Soon SY, Saunders BP, Sanderson JD. A prospective study of the technical feasibility of ileoscopy at colonoscopy. Scand J Gastroenterol 2003;38:1184-6.  Back to cited text no. 14
    
15.
Zwas FR, Bonheim NA, Berken CA, Gray S. Diagnostic yield of routine ileoscopy. Am J Gastroenterol 1995;90:1441-3.  Back to cited text no. 15
    
16.
Morini S, Lorenzetti R, Stella F, Martini MT, Hassan C, Zullo A. Retrograde ileoscopy in chronic nonbloody diarrhea: A prospective, case-control study. Am J Gastroenterol 2003;98:1512-5.  Back to cited text no. 16
    


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