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The necessity of routine terminal ileum intubation in patients undergoing routine colonoscopy: Is it a must?
Abstract
Objectives Terminal ileal intubation (TIE) is a useful procedure during colonoscopy, but its clinical value is controversial in the literature. The aim of this study is to investigate the necessity of terminal ileal intubation during colonoscopy in patients not suspected of having inflammatory bowel disease. Methods This study was conducted by retrospectively reviewing data from 872 colonoscopies. Patients with inflammatory bowel disease and those with inadequate bowel preparation were excluded from the study. The demographic data of the patients, colonoscopy results, macroscopic and microscopic findings, and complications were recorded. Results The average age of the 763 patients included in the study was 53.26±23.82 years, with 429 (56.22%) male and 334 (43.78%) female patients. A total of 107 patients (14.02%) underwent TIE. Of the 107 patients who underwent TIE, 56 (52.33%) were female, and 51 (47.67%) were male, with an average age of 49.52±21.69 years. The colonoscopy indications for patients who underwent TIE were diarrhea in 46 patients, rectal bleeding in 38 patients, and abdominal pain in 23 patients. Macroscopic pathological findings were observed in 8 patients (7.46%), and microscopic pathological findings in 3 patients (2.80%). The proportion of patients with microscopic pathological findings accounted for 0.39% of all colonoscopies. Conclusions Our study suggests that while TIE, which requires experience and extends the duration of colonoscopy, may be beneficial for the diagnosis of selected patients, it may not be necessary in routine colonoscopies given its very low diagnostic value.
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Objective
The population‐based colorectal cancer screening guidelines in Japan recommend an annual fecal immunochemical test (FIT). However, there is no consensus on the need for annual FIT screening for patients who recently performed a total colonoscopy (TCS). Therefore, we evaluated the repeated TCS results for patients with positive FIT after a recent TCS to assess the necessity of an annual FIT.
Methods
We reviewed patients with positive FIT in opportunistic screening from April 2017 to March 2022. The patients were divided into two groups: those who had undergone TCS within the previous 5 years (previous TCS group) and those who had not (non‐previous TCS group). We compared the detection rates of advanced neoplasia and colorectal cancer between the two groups.
Results
Of 671 patients, 151 had received TCS within 5 years and 520 had not. The detection rates of advanced neoplasia in the previous TCS and non‐previous TCS groups were 4.6% and 12.1%, respectively (p < 0.01), and the colorectal cancer detection rates were 0.7% and 1.5%, respectively (no significant difference). The adenoma detection rates were 33.8% in the previous TCS group and 40.0% in the non‐previous TCS group (no significant difference).
Conclusions
Only a few patients were diagnosed with advanced neoplasia among the patients with FIT positive after a recent TCS. For patients with adenomatous lesions on previous TCS, repeated TCS should be performed according to the surveillance program without an annual FIT. The need for an annual FIT for patients without adenomatous lesions on previous TCS should be prospectively assessed in the future.
Objective
This meta‐analysis aimed to comprehensively explore the risk factors for inadequate bowel preparation (IBP).
Methods
We searched the Embase, PubMed, Web of Science, and The Cochrane Library databases up to August 24, 2023, to identify observational studies and randomized controlled trials (RCTs) that examined risk factors for IBP. A random effects model was used to pool the adjusted odds ratios and 95% confidence intervals.
Results
A total of 125 studies (91 observational studies, 34 RCTs) were included. Meta‐analyses of observational studies revealed that three preparation‐related factors, namely, characteristics of last stool (solid or brown liquid), incomplete preparation intake, and incorrect diet restriction, were strong predictors of IBP. The other factors were moderately correlated with IBP incidence, including demographic variables (age, body mass index, male sex, Medicaid insurance, and current smoking), comorbidities (diabetes, liver cirrhosis, psychiatric disease, Parkinson's disease, previous IBP, poor mobility, inpatient, and Bristol stool form 1/2), medications (tricyclic antidepressants, opioids, antidepressants, narcotics, antipsychotics, and calcium channel blockers), and preparation‐related factors (preparation‐to‐colonoscopy interval not within 3 to 5/6 h, nonsplit preparation, and preparation instructions not followed). No colonoscopy indications were found to be related to IBP. Meta‐analyses of RCTs showed that education, constipation, stroke/dementia, and discomfort during preparation were also moderately associated with IBP. Most of the other findings were consistent with the pooled results of observational studies. However, primarily due to imprecision and inconsistency, the certainty of evidence for most factors was very low to moderate.
Conclusions
We summarized five categories of risk factors for IBP. Compared to demographic variables, comorbidities, medications, and colonoscopy indications, preparation‐related elements were more strongly associated with IBP. These findings may help clinicians identify high‐risk individuals and provide guidance for IBP prevention.
Introduction
In the UK, endoscopy certification is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for colonoscopy training and certification.
Methods
Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted between 2019 and 2020 with multisociety expert representation. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on colonoscopy training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer reviewed by JAG and relevant stakeholders for incorporation into the updated colonoscopy certification pathway.
Results
In total, 45 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (20), assessment of competence (8) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (1) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, unassisted caecal intubation rate >90%, rectal retroversion >90%, polyp detection rate >15%+, polyp retrieval rate >90%, patient comfort <10% with moderate–severe discomfort); (2) minimum procedure count 280+; (3) performing 15+ procedures over the preceding 3 months; (4) attendance of the JAG Basic Skills in Colonoscopy course; (5) terminal ileal intubation rates of 60%+ in inflammatory bowel disease; (6) satisfying requirements for formative direct observation of procedure skills (DOPS) and direct observation of polypectomy skills (Size, Morphology, Site, Access (SMSA) level 2); (7) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool; (8) successful performance in summative DOPS.
Conclusion
The UK standards for training and certification in colonoscopy have been updated, culminating in a single-stage certification process with emphasis on polypectomy competency (SMSA Level 2+). These standards are intended to support training, improve standards of colonoscopy and polypectomy, and provide support to the newly independent practitioner.
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 ileum showed 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 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.
Objectives
Ileal intubation during screening colonoscopy can serve as supportive evidence of complete examination. However, most studies conducted in Western countries showed a limited value of ileal inspection in asymptomatic patients undergoing colonoscopy. Therefore, our aim is to determine the clinical yield of routine ileal examination during the performance of screening colonoscopy in a cohort of patients in the Middle East and identify factors associated with successful ileal intubation in this setting.
Methods
A retrospective review of a prospectively collected database of all screening colonoscopies was performed at a single endoscopy unit. The patients were divided into two groups; group A included patients in whom the extent of examination was the cecum and group B comprised of those who underwent ileal intubation as well. We summarized the endoscopic and pathological findings of the ileoscopic examinations and their clinical impact. Univariate and multivariate analyses were used to compare both groups and to identify factors predictive of ileal intubation in the setting of screening colonoscopy.
Results
Two thousand four hundred seventy-three unique completed screening colonoscopies were analyzed (group A=1465 patients, group B=1008 patients). Overall Ileal intubation rate was 40.8%. Of the patients in group B, 3.7% were noted to have findings on ileoscopy, which were deemed to be clinically significant in almost half (1.8% overall). Univariate analysis identified the following factors as being predictive of ileal intubation during screening colonoscopy: patients' age (51.7 vs. 53.5 years, p<0.001), short cecal insertion time, endoscopists' specialty (gastroenterology 42.3% vs. surgery 24.3%, p<0.001), type of colonoscope (pediatric 47.1% vs. adult 33.5% colonoscope, p<0.001), and quality of preparation in the right colon (poor vs. adequate/good : (25.6% vs. 42.5%, p<0.001). Mixed-effects logistic regression identified patients' age, endoscopist specialty, quality of right colon preparation, and cases with short insertion time as independent variables predicting ileal intubation during SC
Conclusion
The clinical yield of routine ileal intubation during screening colonoscopy is low. Ileal intubation during screening colonoscopy in our cohort was more likely in younger patients with adequate/good right colon preparation and when the exam is performed by a gastroenterologist, in cases with short insertion time. Prospective studies are needed to assess our research findings and to determine the clinical value of routinely intubating terminal ileum during screening colonoscopy in the population of the Middle East.
Several organizations worldwide have developed procedure-based guidelines and/or position statements regarding various aspects of quality and safety indicators, and credentialing for endoscopy. Although important, they do not specifically address patient needs or provide a framework for their adoption in the context of endoscopy services. The consensus guidelines reported in this article, however, aimed to identify processes and indicators relevant to the provision of high-quality endoscopy services that will support ongoing quality improvement across many jurisdictions, specifically in the areas of ethics, facility standards and policies, quality assurance, training and education, reporting standards and patient perceptions.
The authors report the case of a primary small bowel lymphoma discovered incidentally in a 33-year-old male following ileal intubation at colonoscopy. The patient subsequently underwent curative treatment with chemotherapy. This case not only highlights the importance of routine ileoscopy but also the successful use of chemotherapy in a disease for which the optimal treatment modality has not been well characterized.
It remains controversial whether ileoscopy should be attempted in all patients. Although the ease of ileoscopy and the diagnostic yield have been well described, there have been no studies describing the value of the diagnostic yield in altering clinical management. We carried out a study to ascertain whether it is worthwhile to perform ileoscopy in all patients having a colonoscopy.
We carried out a retrospective study of all patients who had a colonoscopy between January 1, 2002, and December 31, 2003. The patient details, indications, findings, and complications of the procedure were recorded, together with the histopathology reports of colonic and terminal ileal biopsies. Clinical case note of patients with a positive diagnosis was reviewed to ascertain whether there was a change to the patient's management following an abnormal biopsy result.
A total of 2,149 colonoscopies were performed. In 346 patients (16.1%), the terminal ileum was intubated. There were 16 abnormal findings on histology, which gave a diagnostic yield of 4.6% of all ileoscopies. A change to management occurred in only half of these patients.
Ileoscopy should only be attempted in situations in which the indication is warranted and that would alter management. It is not cost-effective to carry out ileoscopy on all patients.
Aim
The aim of this work was to evaluate the safety and feasibility of performing colonoscopy in patients aged 90 years or over.
Method
In compliance with PRISMA statement standards, a systematic review of studies reporting the outcomes of colonoscopy in patients aged ≥90 years was conducted. A proportional meta‐analysis model was constructed to quantify the risk of outcomes and a direct comparison meta‐analysis model was constructed to compare outcomes between nonagenarians and patients aged between 50 and 89 years via random‐effects models.
Results
Seven studies enrolling 1304 patients (1342 colonoscopies) were included. Analyses showed that complications related to bowel preparation occurred in 0.7% (95% CI 0.1%–1.6%), procedural complications in 0.6% (0.00%–1.7%), 30‐day complications in 1.5% (0.6%–2.7%), procedural mortality in 0.3% (0.0%–1.1%) and 30‐day mortality in 1.1% (0.3%–2.2%). Adequate bowel preparation and colonoscopy completion were achieved in 81.3% (73.8%–87.9%) and 92.1% (86.7%–96.3%), respectively. No difference was found in bowel preparation‐related complications [risk difference (RD) 0.00, p = 0.78], procedural complications (RD 0.00, p = 0.60), 30‐day complications (RD 0.01, p = 0.20), procedural mortality (RD 0.00, p = 1.00) or 30‐day mortality (RD 0.01, p = 0.34) between nonagenarians and patients aged between 50 and 89 years. The colorectal cancer detection rate was 14.3% (9.8%–19.5%), resulting in therapeutic intervention in 65.9% (54.5%–76.6%).
Conclusions
Although the evidence is limited to a selected group of nonagenarians, it may be fair to conclude that if a colonoscopy is indicated in a nonagenarian with good performance status (based on initial less‐invasive investigations), the level 2 evidence supports its safety and feasibility. Age on its own should not be a reason for failing to offer colonoscopy to a nonagenarian.
BACKGROUND: Although the most common cause of performing colonoscopy worldwide is screening for colon cancer, there are many indications including chronic diarrhea, anemia, and suspicion of bowel diseases. The colonoscopy procedure’s success was first defined as terminal ileum intubation. As the procedure’s morbidity risks and the difficulty of the learning curve of full colonoscopy are well-defined, a question of the necessity of cecal and terminal ileal (TI) intubation was led.The aim of this study is to evaluate the necessity of TI intubation during routine colonoscopy in patients who are considered not to have inflammatory bowel diseases (IBD).
METHODS: In this study, the records of patients who underwent colonoscopy in our hospital between 2014 January-2020 January were evaluated retrospectively.The cohort constituted of 5355 patients between 18 years and 82 years old.The demographic data of all patients, the parts that have been examined during the colonoscopy, the detected findings and the complications were noted.
RESULTS: The mean age of the patients was 56.5±24.3 years; 3213 were male and 2142 were female. TIE was performed in 511 (9.5%) patients and was not performed in remaining 4844 (90.5%) patients. The rate of patients with
macroscopic pathological findings detected in patients done TIE was 3.52%. The rate of pathological findings was 0.09%
in all patients underwent colonoscopy.
CONCLUSIONS: The results show that there is no reason for routine TIE during colonoscopy especially for cancer screening because the procedure extends the colonoscopy duration, requires experience, and its diagnostic value is low.
Key words: Colonoscopy; Colorectal neoplasms; Ileum.
Background and aims:
Ileo-colonoscopy is the procedure of choice for chronic nonbloody diarrhea (CNBD) of unknown origin. Histological evaluation at different colonic sites is mandatory to assess the presence of microscopic colitis. However, the value of routine ileal biopsy on normal-appearing mucosa as assessed by means of standard-resolution white-light ileoscopy is controversial given its reported low diagnostic yield. Hence, we have assessed for the first time the accuracy of retrograde ileoscopy using high-definition and dyeless chromoendoscopy (HD + DLC), thereby calculating the impact and cost of routine ileal biopsy in CNBD.
Methods:
Patients with CNBD of unknown origin were prospectively enrolled for ileo-colonoscopy with HD + DLC at five referral centers. Multiple biopsies were systematically performed on each colorectal segment and in the terminal ileum for histopathological analysis.
Results:
Between 2014 and 2017, 546 consecutive patients were recruited. Retrograde ileoscopy success rate was 97.6%. A total of 492 patients (mean age: 53 ± 18 years) fulfilled all the inclusion criteria: Following endoscopic and histopathological work-up, 7% had lymphoid nodular hyperplasia and 3% had isolated ileitis. Compared to the histopathology as the gold standard, retrograde ileoscopy with HD + DLC showed 93% sensitivity, 98% specificity and 99.8% negative predictive value. In patients with normal ileo-colonoscopy, ileum histology had no diagnostic gain and resulted in a cost of US $26.5 per patient.
Conclusions:
Retrograde ileoscopy with HD + DLC predicts the presence of ileitis in CNBD with excellent performance. The histopathological evaluation of the terminal ileum is the gold standard for the diagnostic assessment of visible lesions but has no added diagnostic value in CNBD patients with negative ileo-colonoscopy inspection using modern endoscopic imaging techniques.
This special report focuses on the current literature regarding the utility of terminal ileal (TI) intubation and biopsy. The authors reviewed the literature regarding the clinical benefit of TI intubation at the time of colonoscopy and also the evidence for TI intubation as a colonoscopy quality indicator. TI intubation is useful to identify ileal diseases such as Crohn's disease and additionally as a means of confirming colonoscopy completion when classical caecal landmarks are not confidently seen. Previous studies have demonstrated that TI intubation has variable yield but may be more useful in patients presenting with diarrhea. Reported rates of TI intubation at colonoscopy vary. The authors demonstrate that terminal ileoscopy is feasible in clinical practice and sometimes yields additional clinical information. Additionally it may be used as an indicator of colonoscopy completion. It may be particularly helpful when investigating patients with diarrhea, abnormalities seen on other imaging modalities and patients with suspected Crohn's disease. TIs reported as normal at endoscopy have a low yield when biopsied; however, biopsies from abnormal-looking TIs demonstrate a higher yield and have greater diagnostic value.
Intubation of the ileum during colonoscopy, although well described, is not routinely performed. It can establish the completeness of colonoscopic examinations and is useful in the diagnosis of inflammatory bowel disease. However, the diagnostic utility of routine ileoscopy during all colonoscopic procedures has not been well studied. We prospectively evaluated ileal intubations in 138 patients undergoing colonoscopy. The incidence of a positive diagnosis from ileoscopy was 2.7% in asymptomatic patients undergoing surveillance colonoscopy, and 29% of patients complained of diarrhea (18% in non-HIV patients, 67% in HIV-positive patients). We feel ileal intubation is an important adjunct to colonoscopy, especially in patients with diarrhea.
Since the diagnostic value of ileoscopy is not well documented, it is uncertain if terminal ileum intubation should be performed routinely in patients undergoing colonoscopy. We aimed to assess the diagnostic yield of terminal ileum intubation during colonoscopy according to indications for colonoscopy.
We routinely performed terminal ileum intubation in subjects who underwent colonoscopy at Ajou University Hospital between 1 January 2005 and 31 December 2005. Demographic data, indications for colonoscopy, endoscopic, and histopathologic findings of the terminal ileum were assessed.
A total of 3921 subjects underwent colonoscopy. The terminal ileum was successfully intubated in 3417 cases (87.1%). Macroscopic abnormality on terminal ileum was present in 125 cases (3.7%), and biopsies were taken for all of them. Clinically significant histopathology was observed in 11 cases, giving a 0.3% diagnostic yield in all ileoscopies. Seven out of 11 cases were diagnosed as Crohn's disease. The rate of diagnostic yield was 1.8% in patients with right lower quadrant (RLQ) abdominal pain and 0.4% in patients with diarrhea. This rate in cases with RLQ pain was significantly greater compared with the indications for medical check-ups.
Terminal ileum intubation during colonoscopy identifies significant pathology in 1.8% of cases who have RLQ abdominal pain, suggesting diagnostic value in this setting. However, its diagnostic yield is very low in other indications for colonoscopy. Thus the decision to perform ileoscopy or not during colonoscopy needs to be made on a case-by-case basis.
The utility of routine ileoscopy as a component of screening colonoscopy is unclear. Many endoscopists believe that routine intubation of the terminal ileum is a requirement for a full-screening colonoscopy. The authors have hypothesized that routine ileal intubation during screening colonoscopy is of little diagnostic value.
A retrospective analysis was performed using a prospectively maintained colonoscopy database of patients identified as undergoing a screening colonoscopy. All had undergone intubation of the terminal ileum at a tertiary referral center. Those who had undergone screening colonoscopy at the Mayo Clinic (Rochester, MN) were entered prospectively into a database. The study identified 6,408 patients who met the criteria of having terminal ileal intubation at the time of screening colonoscopy. The main outcome measured was abnormality of the terminal ileum at ileal intubation.
Ileoscopy showed grossly abnormal findings for only 1% of the patients, and pathologic abnormalities were identified for only 0.3% of all the patients.
The findings support the conclusion that intubation of the terminal ileum should not be a required part of screening colonoscopy.