Original Article: Clinical Endoscopy
Terminal ileal photography or biopsy to verify total colonoscopy: does the endoscope agree with the microscope?

https://doi.org/10.1016/j.gie.2007.02.039Get rights and content

Background

Various modalities exist to document the extent of colonoscopy, including a terminal ileum (TI) biopsy, which is considered the criterion standard by some authorities. A TI biopsy adds to procedure costs, is potentially hazardous, and the detection of pathology in routinely acquired biopsy specimens of a macroscopically normal TI is limited. A safer, less costly alternative for documenting total colonoscopy is desirable.

Objective

To evaluate the effectiveness of TI photography as a means of documenting total colonoscopy. We also assessed the diagnostic yield of TI biopsies in patients with a macroscopically normal TI.

Design

Prospective, observational study.

Setting

District general hospital in the United Kingdom.

Patients

A total of 232 unselected patients undergoing colonoscopy, TI intubation, photography, and biopsy.

Main Outcome Measurements

Independent, experienced endoscopists were asked to state whether villi (and, therefore, TI entry) were “definitely,” “probably,” or “definitely not” depicted in TI photographs. This was compared with TI histology as a means of verifying total colonoscopy. The diagnostic yield of biopsy specimens from a macroscopically normal TI was determined.

Results

Reviewers agreed that villi were “definitely present” in 93.8%, “probably present” in 5.9%, and “definitely not” present in 0.3% of cases, with excellent interobserver agreement (kappa value = 0.778, P < .0001). TI photographs “definitely” depicting villi (93.8%) did not differ significantly from histology confirming TI mucosa (96.1%, P = .285). Microscopic evidence of pathology was only detectable in 2.3% of patients with an endoscopically normal TI.

Conclusions

TI photography is an effective, safe, and cost-effective means of documenting total colonoscopy. Routine biopsy of a “normal” TI has a low diagnostic yield.

Section snippets

Patients and methods

A total of 232 unselected patients referred to our unit for colonoscopy, in whom TI intubation was achieved, were prospectively audited. All patients were aged 18 years or over. All patients underwent ileocolonoscopy while under conscious sedation with intravenous midazolam 2 to 4 mg (Hameln Pharmaceuticals, Gloucester, UK) and either fentanyl 75 to 100 mg (Martindale Pharmaceuticals, Romford, UK) or pethidine 25 to 50 mg (Auden McKenzie [Pharma division] Ltd, London, UK). Hyoscine butylbromide

Results

A total of 232 colonoscopies were performed with paired TI photograph and biopsy. The mean (standard deviation) age of patients was 52.0 ± 18.5 years (95% confidence interval 49.6-55.4), with an age range of 18-93 years. There were 131 women and 101 men. The most common indication was diarrhea, present in 43.5% of patients. Other indications included rectal bleeding (18.4%), assessment or surveillance of IBD (17.5%), and anemia (13.5%). Abdominal pain was a feature in 21.1%. Other indications,

Discussion

ASGE guidelines concerning quality indicators for colonoscopy suggest that visualization and photodocumentation of the cecum should be performed in all colonoscopies.1 However, the ASGE concedes that cecal photography “may not be convincing in all cases.” The unreliability of cecal landmarks to document the extent of colonic examination is corroborated by prospective studies.3, 4 We prospectively demonstrated that TI photography was an effective means of documenting total colonoscopy. It is a

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