Terminal ileal intubation and biopsy in routine colonoscopy practice

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.

Importance of biopsies and histological evaluation in patients with chronic diarrhea and normal colonoscopies

BACKGROUND

In patients with chronic diarrhea, colonoscopy may identify inflammatory causes or some occult disease, and also can show a normal mucosa. Serial biopsies of intestinal mucosa can be useful for a differential diagnosis, and to modify the treatment.

AIM

To evaluate whether the biopsies performed in patients with chronic diarrhea and a normal colonoscopy contribute to the differential diagnosis and alter the therapeutic approach.

METHODS

A descriptive, retrospective and cross-sectional study using a computerized database was done. Patients with chronic diarrhea and a normal colonoscopy underwent serial biopsies of the terminal ileum, ascending colon and rectum.

RESULTS

From 398 records, 214 were excluded. Of the 184 patients enrolled, 91 showed histological changes: 40% nonspecific inflammation; 5.18% lymphocytic inflammation, 10.37% eosinophilic inflammation; 39.26% lymphoid hyperplasia; 2.22% collagenous colitis; 2.22% melanosis; and 0.74% pseudomelanose. The sites with the largest number of changes were the terminal ileum and right colon.

CONCLUSIONS

Serial biopsies in patients with chronic diarrhea and normal colonoscopy identified changes in almost 50% of cases and 22% of these cases may had modified the treatment after identification of collagenous, lymphocytic and eosinophilic colitis.

Examinations and procedures for licensure (competency assurance)

Patients with inflammatory bowel disease (IBD) are at higher risk of venous thromboembolism (VTE), though physicians may be unaware of this risk or hesitant to start pharmacologic VTE prophylaxis in the presence of active gastrointestinal bleeding. We report a case of a 38-year-old patient hospitalized with acute severe ulcerative colitis (UC) who was not placed on pharmacologic VTE prophylaxis and developed bilateral pulmonary embolism (PE). The patient's UC did not respond to medical therapy. Due to his PE, the patient’s total proctocolectomy was delayed six months. He also developed a large pelvic hematoma after colectomy requiring further surgical intervention. Hospitalized inflammatory bowel disease (IBD) patients require pharmacologic VTE prophylaxis unless they have life-threatening bleeding.