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Does the endoscopic appearance of the ileocecal valve suggest the severity of Crohn's disease in the terminal ileum?
Journal of Crohn's and Colitis (2009) 3, 287–290
available at www.sciencedirect.com
Does the endoscopic appearance of the ileocecal valve suggest the severity of Crohn's disease in the terminal ileum? Tamás Molnár a,⁎, Klaudia Farkas a , Ferenc Nagy a , Zoltán Szepes a , László Tiszlavicz b , István Németh b , Tibor Nyári c , Tibor Wittmann a a
First Department of Medicine, University of Szeged, H-6720, Korányi fasor 8, Szeged, Hungary Department of Pathology, University of Szeged, Szeged, Hungary c Department of Medical Informatics, University of Szeged, Szeged, Hungary b
Received 5 May 2009; received in revised form 11 June 2009; accepted 3 August 2009
KEYWORDS Ileocecal valve; Ileoscopy; Crohn's disease
Abstract Despite ileoscopy being the only procedure, which can accurately detect mucosal abnormalities in the ileum, it is performed only in 5–15% of the colonoscopies. Aim: The aim of this study was to retrospectively determine the predictive value of the endoscopic findings of the ileocecal valve (ICV) in patients with CD. Methods: Data of 100 ileal or ileocolonic CD patients (45 females, 55 males, mean age 27.6 years, range 5–66), who underwent ileocolonoscopy between 2004 and 2008, were reviewed. Macroscopic appearance of the ICV and the endoscopic severity of the ileum evaluated by the Simple Endoscopic Score for Crohn's Disease were determined by re-evaluating the examinations recorded on DVDs in all cases. Histological scoring was performed in 56 cases. Statistical analyses were performed to assess relationships between the normal-looking ICV and the histological and endoscopic scores of the ileum and the correlation between the severity of the ileal inflammation and the macroscopic appearance of the ICV. Results: A macroscopically normal appearance of the ICV was detected in 30 patients. 60% of these patients were diagnosed with mild, 26.7% with moderate and 13.3% with severe endoscopic ileal inflammation. ICV was affected by CD in 70 patients, in whom significantly more severe ileal inflammation (p = 0.005) was detected than in patients with normal-looking ICV. Discussion: Our results suggest that ileal exploration should be attempted in every suspected CD patients, because, although the appearance of the ICV correlates with the severity of the ileal inflammation, a normal-looking ICV does not correspond to normal ileal mucosa in almost one third of the cases. © 2009 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.
⁎ Corresponding author. Tel.: +36 62 545186; fax: +36 62 545185. E-mail address: [email protected] (T. Molnár). 1873-9946/$ - see front matter © 2009 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.crohns.2009.08.001
288
T. Molnár et al.
1. Introduction Since 1972, when the first report of a successful ileoscopy was published,1 endoscopic observation of the ileal mucosa has become the gold standard procedure for the detection of mucosal abnormalities in the terminal ileum. Despite this, ileal intubation has not been mandatory over the last decades, and ileoscopy is performed only in an average of 5–15% of the colonoscopies in the daily routine, varying among endoscopy centers.2 Patients in Veterans Affairs and academic sites were more likely to undergo terminal ileum endoscopy compared with community sites.3 The lack of timing and competency, as well as the low diagnostic yield in unselected patients are the main limitations of routine ileal intubation.4 Suspicion of Crohn's disease (CD) and the presence of diarrhoea are those conditions, in which the examination of ileum with biopsy is the most helpful in the clinical setting.5 Although the rate of ileal intubation in patients with inflammatory bowel disease (IBD) can be as high as 94.6% in an experienced academic center with a mean procedure time of 21 min,6 we have no doubt that this rate is rather a dream than a reality in most IBD centres. In about 30% of CD patients there is isolated ileum involvement, thus its endoscopic examination is important for the accurate diagnosis. The endoscopic findings of the large bowel usually have no predictive value regarding the subsequent ileal involvement, although a healthy cecum and ileocecal valve (ICV) may suggest no mucosal lesion in the ileum based on the daily routine. The predictive and timesaving yield of a healthy or ulcerated ICV is somewhat overestimated in the daily clinical practice in patients with known or suspected CD. Furthermore, a normal-looking ileal mucosa may reveal significant pathological findings on biopsy.
Table 1
The aim of this study was to accurately determine the predictive value of the endoscopic findings of the ICV in patients with ileal or ilecolonic CD, compared with the endoscopic and histological findings; or to determine as gastroenterologist mythbusters, whether it is true that in case of a normal-looking ICV, there is no ileal CD and intubation is not necessary.
2. Patients and method Ileocolonoscopic findings of 100 CD patients (45 females, 55 males, mean age 27.6 years, range 5–66) examined between 2004 and 2008 have been reviewed retrospectively. All of the examinations were performed by one experienced endoscopist. Patients with endoscopically confirmed CD in the terminal ileum were enrolled in the study. 51 CD patients were diagnosed with ileal, 33 with ileocolonic locations, 3 patients with the combination of ileal and upper gastrointestinal, 6 with ileocolonic and upper gastrointestinal, and 7 with ileal and anal involvement. On the basis of the Montreal classification,7 60 patients were classified into the nonstricturing, non-penetrating subgroup (B1), 20 into the stricturing (B2), 14 into the penetrating (B3) and 6 into the stricturing-penetrating subgroup (B4) (Table 1). The macroscopic appearance of the ICV was assessed and the endoscopic severity of the ileum was determined based on the Simple Endoscopic Score for Crohn's Disease (SES-CD) in all cases.8 We considered edematous and erythematous, ulcerated, destroyed or opened ileocecal valves as abnormal. All of the colonoscopic findings recorded on DVDs were re-evaluated by the endoscopist, who performed the examinations previously.
Demographic and clinical characteristics of CD patients underwent ileocolonoscopy. CD patients undergoing ileoscopy CD patients with normal ICV (n = 100) (n = 30)
Mean present age (years) Mean age at the diagnosis (years) Sex (M/F) Mean duration of the disease (years) Mean duration of the disease at the time of ileoscopy (years) Localization of the disease Ileal Ileocolonic Ileal + upper GI Ileocolonic + upper GI Ileal + anal Behaviour of the disease Non-stricturing–non-penetrating Stricturing Penetrating Stricturing–penetrating Endoscopic severity of the inflammation in the terminal ileum (SES-CD) Mild Moderate Severe
32 27.6 55/45 4.4 2.2
36.2 32.6 20/10 3.5 1.3
51 33 3 6 7
19 8 1 1 1
60 20 14 6
23 3 4 0
25 53 22
14 12 4
T Molnar Predictive value of the endoscopic appearance of the ileocecal valve Ileal biopsy samples could be obtained in 56 cases. All of these histological specimens were scored on the scale of 1– 13 for epithelial damage (0–2 points), architectural changes (0–2 points), mononuclear cells in lamina propria (0–2 points), granulocytes in lamina propria (0–2 points), granulocytes in epithelium (0–3 points), erosions or ulcers (0–1 point) and granulomas (0–1 point) according to the daily routine of our Pathology Department. Statistical analysis was carried out using logistic regression to confirm relationships between the normal-looking ICV and the histological and endoscopic scores of the ileum and Chi square test to evaluate whether there is a correlation between the severity of the ileal inflammation and the macroscopic appearance of the ICV.
3. Results During ileocolonoscopy, mild ileal activity (granularity and hyperaemia) without ulceration (0 point) and with some aphtous ulcers (1 point) was detected in 14 and 23, moderate (2 points) in 36 and severe (3 points) in 27 cases. Activity of the inflammatory process was confirmed by histological examination in 56 patients, in whom biopsy was taken. The mildest activity with 3 points was revealed in 3; the most severe activity with 13 points in 5 cases. A macroscopically normal appearance of the ICV was detected in 30 cases (20 females and 10 males, mean age 32.6 years, range 5–66). In all but two cases, cecum was also normal-looking. Based on the SES-CD, the inflammatory process of the ileum proved to be mild in 60%, moderate in 26.7% and severe in 13.3% of these cases. The histological examination of 22 ileal biopsies of patients with a normallooking ICV revealed more severe inflammatory activity in 31.8% and milder activity in 18.2% of the cases, when compared with the endoscopic findings (Fig. 1). Logistic regression analysis examining the association of the normallooking ICV and the histological scores of the ileal samples revealed an Odds ratio (OR) of 1.2, 95% confidence interval 1–1.5 (p = 0.05). Logistic regression analysis examining the relation between the normal-looking ICV and the endoscopic scores of the ileum revealed an Odds ratio of 1.7, 95% confidence interval 0.97–3.07 (p = 0.06). CD was localized to the ileum with or without upper GI or anal manifestations in 21 and to the ileocolon in 9 cases. 23 patients were classified into group B1, 3 into group B2 and 4 into group B3 (Table 1).
289
ICV was affected by CD in 70 patients (25 females and 45 males, mean age 25.4 years, range 9–65 years) with the involvement of the cecum in 32 cases. The ileal inflammation proved to be mild in 27.1%, moderate in 40% and severe in 32.9% of these cases. CD was localized to the ileum with or without upper GI or anal manifestations in 40 and to the ileocolon in 30 cases. 37 patients were classified into group B1, 17 into group B2, 10 into group B3 and 6 into group B4. Moderate and severe inflammation of the ileum were detected significantly more frequently (p = 0.05) in case of the inflammation of the ICV.
4. Discussion Examination of the terminal ileum is the gold standard investigation in patients with suspected CD, chronic ileal infections and in case of diarrhoea with unknown origin. According to previous studies on the value of ileoscopy, the diagnostic yield may be as high as 2–7% in unselected and even higher in selected patients in the Western countries, where CD is more frequent than in the East.9,10 The diagnostic value of ileoscopy is lower in Asian countries, where no benefit of ileoscopy has been reported for unselected patients.10 Right quadrant abdominal pain and diarrhoea are the main symptoms indicating ileal intubation. Histological examination can confirm the suspected diagnosis after the terminal ileum was successfully intubated. According to a prospective study of a tertiary center, 55 s are needed to pass through the ICV after reaching the cecum,11 although this procedure time seems to be very idealistic in the majority of the cases. However, the rate of ileal intubations increases with the improvement of endoscopic technology and with the increasing experience of the endoscopists. Most cases showing clinically significant findings on ileoscopy are isolated Crohn's ileitis. Since the macroscopically normal appearance of the ICV suggests the normality of the ileal mucosa in suspected CD, ileal intubation is not always attempted in difficult cases. On examination significant (p= 0.005) correlation was detected between the severity of the ileal inflammation and the macroscopic appearance of the ICV. Although the appearance of the ICV indicates the endoscopic (OR: 1.7) and histological (OR: 1.2) severity of the ileal inflammation, the ileum was affected in 30% of our CD patients despite a normal ICV and some strictures were also observed behind the normal ICV. A macroscopically mild inflammation was detected in more than half of the patients, and ileal localization alone was detected in 70% of the cases. In patients with mild activity, the sensitivity of the other diagnostic modalities is not high enough to make the accurate diagnosis and subsequently to initiate the appropriate treatment. According to our results, although the appearance of the ICV correlates with the severity of the ileal inflammation and its normal appearance seems to indicate a healthy ileal mucosa in the vast majority of cases, it does not completely rule out the presence of different severity of ileal inflammation, therefore, ileal exploration should be attempted in every suspected CD patients.
References Figure 1 Distribution of the patients on the basis of the endoscopic and histological severity of the ileal inflammation in case of normal-looking ICV.
1. Nagasako K, Yazawa C, Takemoto C. Biopsy of the terminal ileum. Gastrointest Endosc 1972;19:7–10.
290 2. Sultan S, Mitchell RM. The importance of ileoscopy in suspected small bowel disease. Eur J Gastroenterol Hepatol 2004;16:359. 3. Harewood GC, Mattek NC, Holub JL, Peters D, Lieberman DA. Variation in practice of ileal intubation among diverse endoscopy settings: results from a national endoscopic database. Aliment Pharmacol Ther 2005;22:571–8. 4. Iacopini G, Frontespezi S, Vitale MA, Villotti G, Bella A, d'Alba L, De Cesare A, Iacopini F. Routine ileoscopy at colonoscopy: a prospective evaluation of learning curve and skill-keeping line. Gastrointest Endosc 2006;63:250–6. 5. Geboes K. The strategy for biopsies of the terminal ileum should be evidence based. Am J Gastroenterol 2007;102:1090–2. 6. Terheggen G, Lanyi B, Schanz S, et al. Safety, feasibility, and tolerability of ileocolonoscopy in inflammatory bowel disease. Endoscopy 2008;40:656–63.
T. Molnár et al. 7. Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classification of inflammatory bowel disease: controversies, consensus and implications. Gut 2006;55:749–53. 8. Daperno M, D'Haens G, Van Assche G, et al. Development and validation of a new, simplified endoscopic activity score for Crohn's disease: the SES-CD. Gastrointest Endosc 2004;60: 505–12. 9. Al-Sohaily S, Leong RWL. The yield of ileoscopy at colonoscopy. J Gastroenterol Hepatol 2008;23:4–5. 10. Jeong SH, Lee KJ, Kim YB, et al. Diagnostic value of terminal ileum intubation during colonoscopy. J Gastroenterol Hepatol 2008;23:51–5. 11. Ansari A, Soon SY, Saunders BP, et al. A prospective study of the technical feasibility of ileoscopy at colonoscopy. Scand J Gastroenterol, 2003;38:1184–6.
available at www.sciencedirect.com
Does the endoscopic appearance of the ileocecal valve suggest the severity of Crohn's disease in the terminal ileum? Tamás Molnár a,⁎, Klaudia Farkas a , Ferenc Nagy a , Zoltán Szepes a , László Tiszlavicz b , István Németh b , Tibor Nyári c , Tibor Wittmann a a
First Department of Medicine, University of Szeged, H-6720, Korányi fasor 8, Szeged, Hungary Department of Pathology, University of Szeged, Szeged, Hungary c Department of Medical Informatics, University of Szeged, Szeged, Hungary b
Received 5 May 2009; received in revised form 11 June 2009; accepted 3 August 2009
KEYWORDS Ileocecal valve; Ileoscopy; Crohn's disease
Abstract Despite ileoscopy being the only procedure, which can accurately detect mucosal abnormalities in the ileum, it is performed only in 5–15% of the colonoscopies. Aim: The aim of this study was to retrospectively determine the predictive value of the endoscopic findings of the ileocecal valve (ICV) in patients with CD. Methods: Data of 100 ileal or ileocolonic CD patients (45 females, 55 males, mean age 27.6 years, range 5–66), who underwent ileocolonoscopy between 2004 and 2008, were reviewed. Macroscopic appearance of the ICV and the endoscopic severity of the ileum evaluated by the Simple Endoscopic Score for Crohn's Disease were determined by re-evaluating the examinations recorded on DVDs in all cases. Histological scoring was performed in 56 cases. Statistical analyses were performed to assess relationships between the normal-looking ICV and the histological and endoscopic scores of the ileum and the correlation between the severity of the ileal inflammation and the macroscopic appearance of the ICV. Results: A macroscopically normal appearance of the ICV was detected in 30 patients. 60% of these patients were diagnosed with mild, 26.7% with moderate and 13.3% with severe endoscopic ileal inflammation. ICV was affected by CD in 70 patients, in whom significantly more severe ileal inflammation (p = 0.005) was detected than in patients with normal-looking ICV. Discussion: Our results suggest that ileal exploration should be attempted in every suspected CD patients, because, although the appearance of the ICV correlates with the severity of the ileal inflammation, a normal-looking ICV does not correspond to normal ileal mucosa in almost one third of the cases. © 2009 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.
⁎ Corresponding author. Tel.: +36 62 545186; fax: +36 62 545185. E-mail address: [email protected] (T. Molnár). 1873-9946/$ - see front matter © 2009 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.crohns.2009.08.001
288
T. Molnár et al.
1. Introduction Since 1972, when the first report of a successful ileoscopy was published,1 endoscopic observation of the ileal mucosa has become the gold standard procedure for the detection of mucosal abnormalities in the terminal ileum. Despite this, ileal intubation has not been mandatory over the last decades, and ileoscopy is performed only in an average of 5–15% of the colonoscopies in the daily routine, varying among endoscopy centers.2 Patients in Veterans Affairs and academic sites were more likely to undergo terminal ileum endoscopy compared with community sites.3 The lack of timing and competency, as well as the low diagnostic yield in unselected patients are the main limitations of routine ileal intubation.4 Suspicion of Crohn's disease (CD) and the presence of diarrhoea are those conditions, in which the examination of ileum with biopsy is the most helpful in the clinical setting.5 Although the rate of ileal intubation in patients with inflammatory bowel disease (IBD) can be as high as 94.6% in an experienced academic center with a mean procedure time of 21 min,6 we have no doubt that this rate is rather a dream than a reality in most IBD centres. In about 30% of CD patients there is isolated ileum involvement, thus its endoscopic examination is important for the accurate diagnosis. The endoscopic findings of the large bowel usually have no predictive value regarding the subsequent ileal involvement, although a healthy cecum and ileocecal valve (ICV) may suggest no mucosal lesion in the ileum based on the daily routine. The predictive and timesaving yield of a healthy or ulcerated ICV is somewhat overestimated in the daily clinical practice in patients with known or suspected CD. Furthermore, a normal-looking ileal mucosa may reveal significant pathological findings on biopsy.
Table 1
The aim of this study was to accurately determine the predictive value of the endoscopic findings of the ICV in patients with ileal or ilecolonic CD, compared with the endoscopic and histological findings; or to determine as gastroenterologist mythbusters, whether it is true that in case of a normal-looking ICV, there is no ileal CD and intubation is not necessary.
2. Patients and method Ileocolonoscopic findings of 100 CD patients (45 females, 55 males, mean age 27.6 years, range 5–66) examined between 2004 and 2008 have been reviewed retrospectively. All of the examinations were performed by one experienced endoscopist. Patients with endoscopically confirmed CD in the terminal ileum were enrolled in the study. 51 CD patients were diagnosed with ileal, 33 with ileocolonic locations, 3 patients with the combination of ileal and upper gastrointestinal, 6 with ileocolonic and upper gastrointestinal, and 7 with ileal and anal involvement. On the basis of the Montreal classification,7 60 patients were classified into the nonstricturing, non-penetrating subgroup (B1), 20 into the stricturing (B2), 14 into the penetrating (B3) and 6 into the stricturing-penetrating subgroup (B4) (Table 1). The macroscopic appearance of the ICV was assessed and the endoscopic severity of the ileum was determined based on the Simple Endoscopic Score for Crohn's Disease (SES-CD) in all cases.8 We considered edematous and erythematous, ulcerated, destroyed or opened ileocecal valves as abnormal. All of the colonoscopic findings recorded on DVDs were re-evaluated by the endoscopist, who performed the examinations previously.
Demographic and clinical characteristics of CD patients underwent ileocolonoscopy. CD patients undergoing ileoscopy CD patients with normal ICV (n = 100) (n = 30)
Mean present age (years) Mean age at the diagnosis (years) Sex (M/F) Mean duration of the disease (years) Mean duration of the disease at the time of ileoscopy (years) Localization of the disease Ileal Ileocolonic Ileal + upper GI Ileocolonic + upper GI Ileal + anal Behaviour of the disease Non-stricturing–non-penetrating Stricturing Penetrating Stricturing–penetrating Endoscopic severity of the inflammation in the terminal ileum (SES-CD) Mild Moderate Severe
32 27.6 55/45 4.4 2.2
36.2 32.6 20/10 3.5 1.3
51 33 3 6 7
19 8 1 1 1
60 20 14 6
23 3 4 0
25 53 22
14 12 4
T Molnar Predictive value of the endoscopic appearance of the ileocecal valve Ileal biopsy samples could be obtained in 56 cases. All of these histological specimens were scored on the scale of 1– 13 for epithelial damage (0–2 points), architectural changes (0–2 points), mononuclear cells in lamina propria (0–2 points), granulocytes in lamina propria (0–2 points), granulocytes in epithelium (0–3 points), erosions or ulcers (0–1 point) and granulomas (0–1 point) according to the daily routine of our Pathology Department. Statistical analysis was carried out using logistic regression to confirm relationships between the normal-looking ICV and the histological and endoscopic scores of the ileum and Chi square test to evaluate whether there is a correlation between the severity of the ileal inflammation and the macroscopic appearance of the ICV.
3. Results During ileocolonoscopy, mild ileal activity (granularity and hyperaemia) without ulceration (0 point) and with some aphtous ulcers (1 point) was detected in 14 and 23, moderate (2 points) in 36 and severe (3 points) in 27 cases. Activity of the inflammatory process was confirmed by histological examination in 56 patients, in whom biopsy was taken. The mildest activity with 3 points was revealed in 3; the most severe activity with 13 points in 5 cases. A macroscopically normal appearance of the ICV was detected in 30 cases (20 females and 10 males, mean age 32.6 years, range 5–66). In all but two cases, cecum was also normal-looking. Based on the SES-CD, the inflammatory process of the ileum proved to be mild in 60%, moderate in 26.7% and severe in 13.3% of these cases. The histological examination of 22 ileal biopsies of patients with a normallooking ICV revealed more severe inflammatory activity in 31.8% and milder activity in 18.2% of the cases, when compared with the endoscopic findings (Fig. 1). Logistic regression analysis examining the association of the normallooking ICV and the histological scores of the ileal samples revealed an Odds ratio (OR) of 1.2, 95% confidence interval 1–1.5 (p = 0.05). Logistic regression analysis examining the relation between the normal-looking ICV and the endoscopic scores of the ileum revealed an Odds ratio of 1.7, 95% confidence interval 0.97–3.07 (p = 0.06). CD was localized to the ileum with or without upper GI or anal manifestations in 21 and to the ileocolon in 9 cases. 23 patients were classified into group B1, 3 into group B2 and 4 into group B3 (Table 1).
289
ICV was affected by CD in 70 patients (25 females and 45 males, mean age 25.4 years, range 9–65 years) with the involvement of the cecum in 32 cases. The ileal inflammation proved to be mild in 27.1%, moderate in 40% and severe in 32.9% of these cases. CD was localized to the ileum with or without upper GI or anal manifestations in 40 and to the ileocolon in 30 cases. 37 patients were classified into group B1, 17 into group B2, 10 into group B3 and 6 into group B4. Moderate and severe inflammation of the ileum were detected significantly more frequently (p = 0.05) in case of the inflammation of the ICV.
4. Discussion Examination of the terminal ileum is the gold standard investigation in patients with suspected CD, chronic ileal infections and in case of diarrhoea with unknown origin. According to previous studies on the value of ileoscopy, the diagnostic yield may be as high as 2–7% in unselected and even higher in selected patients in the Western countries, where CD is more frequent than in the East.9,10 The diagnostic value of ileoscopy is lower in Asian countries, where no benefit of ileoscopy has been reported for unselected patients.10 Right quadrant abdominal pain and diarrhoea are the main symptoms indicating ileal intubation. Histological examination can confirm the suspected diagnosis after the terminal ileum was successfully intubated. According to a prospective study of a tertiary center, 55 s are needed to pass through the ICV after reaching the cecum,11 although this procedure time seems to be very idealistic in the majority of the cases. However, the rate of ileal intubations increases with the improvement of endoscopic technology and with the increasing experience of the endoscopists. Most cases showing clinically significant findings on ileoscopy are isolated Crohn's ileitis. Since the macroscopically normal appearance of the ICV suggests the normality of the ileal mucosa in suspected CD, ileal intubation is not always attempted in difficult cases. On examination significant (p= 0.005) correlation was detected between the severity of the ileal inflammation and the macroscopic appearance of the ICV. Although the appearance of the ICV indicates the endoscopic (OR: 1.7) and histological (OR: 1.2) severity of the ileal inflammation, the ileum was affected in 30% of our CD patients despite a normal ICV and some strictures were also observed behind the normal ICV. A macroscopically mild inflammation was detected in more than half of the patients, and ileal localization alone was detected in 70% of the cases. In patients with mild activity, the sensitivity of the other diagnostic modalities is not high enough to make the accurate diagnosis and subsequently to initiate the appropriate treatment. According to our results, although the appearance of the ICV correlates with the severity of the ileal inflammation and its normal appearance seems to indicate a healthy ileal mucosa in the vast majority of cases, it does not completely rule out the presence of different severity of ileal inflammation, therefore, ileal exploration should be attempted in every suspected CD patients.
References Figure 1 Distribution of the patients on the basis of the endoscopic and histological severity of the ileal inflammation in case of normal-looking ICV.
1. Nagasako K, Yazawa C, Takemoto C. Biopsy of the terminal ileum. Gastrointest Endosc 1972;19:7–10.
290 2. Sultan S, Mitchell RM. The importance of ileoscopy in suspected small bowel disease. Eur J Gastroenterol Hepatol 2004;16:359. 3. Harewood GC, Mattek NC, Holub JL, Peters D, Lieberman DA. Variation in practice of ileal intubation among diverse endoscopy settings: results from a national endoscopic database. Aliment Pharmacol Ther 2005;22:571–8. 4. Iacopini G, Frontespezi S, Vitale MA, Villotti G, Bella A, d'Alba L, De Cesare A, Iacopini F. Routine ileoscopy at colonoscopy: a prospective evaluation of learning curve and skill-keeping line. Gastrointest Endosc 2006;63:250–6. 5. Geboes K. The strategy for biopsies of the terminal ileum should be evidence based. Am J Gastroenterol 2007;102:1090–2. 6. Terheggen G, Lanyi B, Schanz S, et al. Safety, feasibility, and tolerability of ileocolonoscopy in inflammatory bowel disease. Endoscopy 2008;40:656–63.
T. Molnár et al. 7. Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classification of inflammatory bowel disease: controversies, consensus and implications. Gut 2006;55:749–53. 8. Daperno M, D'Haens G, Van Assche G, et al. Development and validation of a new, simplified endoscopic activity score for Crohn's disease: the SES-CD. Gastrointest Endosc 2004;60: 505–12. 9. Al-Sohaily S, Leong RWL. The yield of ileoscopy at colonoscopy. J Gastroenterol Hepatol 2008;23:4–5. 10. Jeong SH, Lee KJ, Kim YB, et al. Diagnostic value of terminal ileum intubation during colonoscopy. J Gastroenterol Hepatol 2008;23:51–5. 11. Ansari A, Soon SY, Saunders BP, et al. A prospective study of the technical feasibility of ileoscopy at colonoscopy. Scand J Gastroenterol, 2003;38:1184–6.