A New Technique for Insertion of the Colonoscope Through the Ileocaecal Valve N. Gabrielsson, S. Granqvist Dept. of Diagnostic Radiology, Huddinge University Hospital, Sweden
Summary
At colonoscopy it is important to examine the distal part of ileum in inflammatory diseases particularly. Different techniques for insertion of
the colonoscope into the ileum have been described. In our experience these methods require considerable skill and practice. We have therefore worked out a technique for easier access to the ileum with a colonoscope. A closed biopsy forceps is used for identification of the ileocaecal valve by dislodging the upper lip. The
forceps is manoeuvred through the ostium and then the colonoscope can be inserted into the ileum with the forceps as a guide.
Key-Words: Peranal ileoscopy, technique, ileocaecal valve.
Eine neue Methode zur Insertion des Koloskops durdi die Ileozökalklappe Besonders bei entzündlichen Dickdarmerkrankungen ist eine Untersuchung des terminalen Ileums von Bedeutung. Für die Einführung des Koloskops durch die Ileozökalklappe sind verschiedene Ver-
fahren beschrieben worden. Unserer Erfahrung nach erfordern diese eine erhebliche Geschicklich-
keit und einige °bung. Aus diesem Grund wurde eine neue Technik entwickelt, bei der mit der geschlossenen Biopsiezange zunächst die obere Lippe der Ileozökalklappe dargestellt wird. Dann wird die Zange durch das Ostium vorgeschoben und das Instrument über die Zange als Leitschiene ins Ileum eingeführt.
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Endoscopy 9 (1977) 38-41
@ Georg Thieme Verlag, Stuttgart
A new Technique for Insertion of the Colonoscope
39
Fig. 1 ac Techniques for insertion of the colonoscope into the distal ileum according- to previous methods.
Endoscopic examination of the entire small
intestine requires access to a special fiberscope, an enteroscope. The principle for the technique is that the instrument follows a probe which, prior to the endoscopy, passes through the gastrointestinal canal, which usually takes 2-5 days (1, 3, 4). An altogether different technique for total enteroscopy has been reported in which, during laparotomy,
the surgeon guides a long colonoscope, introduced perorally, through the small intestine (6). Both of these methods are rather complicated and the examination is performed only at a few endoscopic centres. An additional reason for this is that pathologic
disorders in the small intestine are sited chiefly in the proximal and distal parts, to which endoscopic access can be more easily
obtained by other means. The proximal part of the small intestine above Treitz's ligament, which can be examined with a duodenoscope, is the site of disorder in most diseases affecting the entire small intestine. The distal part, which can be reached with a long
colonoscope, is the most common location for inflammatory diseases. Crohn's disease usually occurs in the distal ileum, and backwash ileitis in cases of ulcerous colitis is always restricted to the most distal part of the small intestine. At colonoscopy on the suspicion of these diseases, therefore, it is im-
portant to be able to inspect and take biopsies from the distal ileum. The sometimes difficult differential diagnosis between inflammatory diseases can thus be simplified. Equivocal radiologic findings and occult intestinal haemorrhage are other rare indications for endoscopy of this part of the intestine.
The technique for access to the ileum at colonoscopy has been described by several authors (2, 4, 5, 7-9). The instrument is passed into the small intestine by inclining the tip medially in the caecum towards the ileocaecal valve. Under air inflation the ileo-
caecal valve can be passed in favourable cases (Fig. 1 a). If this fails, the instrument can be inverted at the bottom of the caecum with the tip directed medially. The colonoscope can then either be further advanced making a U-turn in the caecum until the tip has reached the entrance of the ileum (Fig. lb) or drawn back in inverted position to the level of the valve (Fig. 1 c). With both techniques
the tip can hook into the valve and by bending it medially the instrument can be made to slide out into the ileum. The rate of success is reported to have been between 30 and 97°/o of those cases where examination of the ileum was attempted. From our experience, however, these methods involve fairly considerable difficulties and we have not suc-
Downloaded by: Chinese University of Hong Kong. Copyrighted material.
A
N. Gabrielsson, S. Gran qvist
40
Fig. 2 ad Ncw technique for insertion into the ileum using the biopsy forceps as a guide.
ceeded in attaining ileum in a reasonably high percentage of cases. The recognition of the ileo-caecal valve is not always simple. The semilunar lips may protrude only insignificantly into the lumen of the caecum and the upper lip usually conceals the entrance of the
ileum seen from above. The ostium in the ileo-caecal valve is often difficult to pass directly, as it is usually directed cranially from caecum and the transmitted force in the instrument works in the opposite direction. On inversion of the instrument the vision is often very restricted as the lens is pressed against the intestinal wall rendering it hard to locate
the ileo-caecal ostium. In the event of reduced distensibility of the caecum, furthermore, inversion is difficult or impossible.
(Fig. 2 a). By inclining the tip of the instrument medially the upper lip is dislodged; if the spot is the correct one the ostium of the valve, often made open by this procedure, can be safely identified (Fig. 2 b).
The forceps can then be manoeuvred through the ostium and advanced without visual control a decimetre or so into the distal ileum (Fig. 2 c). With the biopsy forceps the ostium is held open and the colonoscope intro-
duced into the ileum with the forceps as a guide (Fig. 2 d). During this latter manoeuvre it is important that the biopsy forceps is drawn back into the instrument as much as the colonoscope is inserted, as otherwise the tip of
the forceps may injure the mucosa of the small intestine. Once the valve has been pass-
ed, between 20 and 50 cm of the ileum can New Technique
We have therefore worked out a new tech-
nique for easier access to the ileum with a colonoscope. After reaching the ascending colon with the colonoscope, the ileo-caecal valve is first looked for; it is usually seen as a haustrum with a local elevation medially in the caecum. Should difficulties arise to localize the valve which not seldom occurs, TV fluoroscopy may aid. When an elevation suggestive of being the valve is discovered it is approached with a closed biopsy forceps
usually be inspected.
Different factors may prevent passage of the instrument to the ileum. Thus, even if the biopsy forceps could easily be passed into the distal ileum and biopsies taken, occasionally the angle between the ileum and the colonoscope was too acute for the instrument to be inserted into the small intestine. The ostium may be too oedematous and narrow to admit passage of the instrument in certain diseases, especially Crohn's disease or the valve cannot be located owing to obscuring scybala.
Downloaded by: Chinese University of Hong Kong. Copyrighted material.
A
A new Technique for Insertion of the Colonoscope
The ileo-caecal valve is identified and
the biopsy forceps has been inserted into the
Fig. 3c The tip of the instrument in the distal ileum with the forceps withdrawn.
ileum.
It is our experience that earlier reported methods require considerable skill and practice. By contrast, the new technique should provide a relatively easy means for inspection of the small intestine on colonoscopy. References 1
Classen, M., P. Frühmorgen, H. Koch, L. Demling: Peroral enteroscopy of the small and the large intestine. Endoscopy 4 (1972) 157
2 Deriding, L., M. Giessen, P. Frühmorgen: Atlas der Enteroskopie. Springer, Berlin 1974
3 Deyhle, P., S. Jenny, J. Furnagalli, E. Linder, R. Ammann: Endoscopy of whole small intestine. Endoscopy 4 (1972) 155
4 Friihmorgen, P., M. Classen: Enteroscopy (Small intestine - Large intestine). Acta hepato-gastroent. 21 (1974) 5 Gaisford, W. D.: Symposium; Fiberoptic colonoscopy. Total colonoscopy an office procedure. Dis. Col. Rect. 1
5 (1976) 388
Fig. 3b The valve is opened with the biopsy
6 Meyers, R. T.: Diagnosis and management of occult gastrointestinal bleeding: Visualization of the small bowel lumen by fiberoptic colonoscope. Amer. Surg. 42
forceps before the colonoscope is introduced.
7 Nagasako, K., C. Yuzawa, T. Takemoto: Observation of
(1976) 92
the terminal ileum. Endoscopy 3 (1971) 45
Since we introduced this technique, we have
been able to examine the distal ileum in a far greater number of cases than previously. No complications have been encountered.
8 Ottenjann, R., W. Barthelheimer: A special method for peranal ileoscopy. In: Endoscopy of the small intestine with retrograde pancreato-cholangiography. Demling, M. Classen.) Thieme, Stuttgart 1972
(Ed.:
L.
9 Watanabe, H., T. Narasuka, S. Yarnagata: Studies on the fibercolonoscopy: with special reference to the latest procedures. Tohoku J. Exp. Med. 117 (1975) 385
Dr. N. Gabrielsson, Dr. S. Granqvist, Dept. of Diagnostic Radiology, Huddinge Univ. Hospital, S-I4186 Huddinge
Downloaded by: Chinese University of Hong Kong. Copyrighted material.
Fig. 3 a
41
Summary
At colonoscopy it is important to examine the distal part of ileum in inflammatory diseases particularly. Different techniques for insertion of
the colonoscope into the ileum have been described. In our experience these methods require considerable skill and practice. We have therefore worked out a technique for easier access to the ileum with a colonoscope. A closed biopsy forceps is used for identification of the ileocaecal valve by dislodging the upper lip. The
forceps is manoeuvred through the ostium and then the colonoscope can be inserted into the ileum with the forceps as a guide.
Key-Words: Peranal ileoscopy, technique, ileocaecal valve.
Eine neue Methode zur Insertion des Koloskops durdi die Ileozökalklappe Besonders bei entzündlichen Dickdarmerkrankungen ist eine Untersuchung des terminalen Ileums von Bedeutung. Für die Einführung des Koloskops durch die Ileozökalklappe sind verschiedene Ver-
fahren beschrieben worden. Unserer Erfahrung nach erfordern diese eine erhebliche Geschicklich-
keit und einige °bung. Aus diesem Grund wurde eine neue Technik entwickelt, bei der mit der geschlossenen Biopsiezange zunächst die obere Lippe der Ileozökalklappe dargestellt wird. Dann wird die Zange durch das Ostium vorgeschoben und das Instrument über die Zange als Leitschiene ins Ileum eingeführt.
Downloaded by: Chinese University of Hong Kong. Copyrighted material.
Endoscopy 9 (1977) 38-41
@ Georg Thieme Verlag, Stuttgart
A new Technique for Insertion of the Colonoscope
39
Fig. 1 ac Techniques for insertion of the colonoscope into the distal ileum according- to previous methods.
Endoscopic examination of the entire small
intestine requires access to a special fiberscope, an enteroscope. The principle for the technique is that the instrument follows a probe which, prior to the endoscopy, passes through the gastrointestinal canal, which usually takes 2-5 days (1, 3, 4). An altogether different technique for total enteroscopy has been reported in which, during laparotomy,
the surgeon guides a long colonoscope, introduced perorally, through the small intestine (6). Both of these methods are rather complicated and the examination is performed only at a few endoscopic centres. An additional reason for this is that pathologic
disorders in the small intestine are sited chiefly in the proximal and distal parts, to which endoscopic access can be more easily
obtained by other means. The proximal part of the small intestine above Treitz's ligament, which can be examined with a duodenoscope, is the site of disorder in most diseases affecting the entire small intestine. The distal part, which can be reached with a long
colonoscope, is the most common location for inflammatory diseases. Crohn's disease usually occurs in the distal ileum, and backwash ileitis in cases of ulcerous colitis is always restricted to the most distal part of the small intestine. At colonoscopy on the suspicion of these diseases, therefore, it is im-
portant to be able to inspect and take biopsies from the distal ileum. The sometimes difficult differential diagnosis between inflammatory diseases can thus be simplified. Equivocal radiologic findings and occult intestinal haemorrhage are other rare indications for endoscopy of this part of the intestine.
The technique for access to the ileum at colonoscopy has been described by several authors (2, 4, 5, 7-9). The instrument is passed into the small intestine by inclining the tip medially in the caecum towards the ileocaecal valve. Under air inflation the ileo-
caecal valve can be passed in favourable cases (Fig. 1 a). If this fails, the instrument can be inverted at the bottom of the caecum with the tip directed medially. The colonoscope can then either be further advanced making a U-turn in the caecum until the tip has reached the entrance of the ileum (Fig. lb) or drawn back in inverted position to the level of the valve (Fig. 1 c). With both techniques
the tip can hook into the valve and by bending it medially the instrument can be made to slide out into the ileum. The rate of success is reported to have been between 30 and 97°/o of those cases where examination of the ileum was attempted. From our experience, however, these methods involve fairly considerable difficulties and we have not suc-
Downloaded by: Chinese University of Hong Kong. Copyrighted material.
A
N. Gabrielsson, S. Gran qvist
40
Fig. 2 ad Ncw technique for insertion into the ileum using the biopsy forceps as a guide.
ceeded in attaining ileum in a reasonably high percentage of cases. The recognition of the ileo-caecal valve is not always simple. The semilunar lips may protrude only insignificantly into the lumen of the caecum and the upper lip usually conceals the entrance of the
ileum seen from above. The ostium in the ileo-caecal valve is often difficult to pass directly, as it is usually directed cranially from caecum and the transmitted force in the instrument works in the opposite direction. On inversion of the instrument the vision is often very restricted as the lens is pressed against the intestinal wall rendering it hard to locate
the ileo-caecal ostium. In the event of reduced distensibility of the caecum, furthermore, inversion is difficult or impossible.
(Fig. 2 a). By inclining the tip of the instrument medially the upper lip is dislodged; if the spot is the correct one the ostium of the valve, often made open by this procedure, can be safely identified (Fig. 2 b).
The forceps can then be manoeuvred through the ostium and advanced without visual control a decimetre or so into the distal ileum (Fig. 2 c). With the biopsy forceps the ostium is held open and the colonoscope intro-
duced into the ileum with the forceps as a guide (Fig. 2 d). During this latter manoeuvre it is important that the biopsy forceps is drawn back into the instrument as much as the colonoscope is inserted, as otherwise the tip of
the forceps may injure the mucosa of the small intestine. Once the valve has been pass-
ed, between 20 and 50 cm of the ileum can New Technique
We have therefore worked out a new tech-
nique for easier access to the ileum with a colonoscope. After reaching the ascending colon with the colonoscope, the ileo-caecal valve is first looked for; it is usually seen as a haustrum with a local elevation medially in the caecum. Should difficulties arise to localize the valve which not seldom occurs, TV fluoroscopy may aid. When an elevation suggestive of being the valve is discovered it is approached with a closed biopsy forceps
usually be inspected.
Different factors may prevent passage of the instrument to the ileum. Thus, even if the biopsy forceps could easily be passed into the distal ileum and biopsies taken, occasionally the angle between the ileum and the colonoscope was too acute for the instrument to be inserted into the small intestine. The ostium may be too oedematous and narrow to admit passage of the instrument in certain diseases, especially Crohn's disease or the valve cannot be located owing to obscuring scybala.
Downloaded by: Chinese University of Hong Kong. Copyrighted material.
A
A new Technique for Insertion of the Colonoscope
The ileo-caecal valve is identified and
the biopsy forceps has been inserted into the
Fig. 3c The tip of the instrument in the distal ileum with the forceps withdrawn.
ileum.
It is our experience that earlier reported methods require considerable skill and practice. By contrast, the new technique should provide a relatively easy means for inspection of the small intestine on colonoscopy. References 1
Classen, M., P. Frühmorgen, H. Koch, L. Demling: Peroral enteroscopy of the small and the large intestine. Endoscopy 4 (1972) 157
2 Deriding, L., M. Giessen, P. Frühmorgen: Atlas der Enteroskopie. Springer, Berlin 1974
3 Deyhle, P., S. Jenny, J. Furnagalli, E. Linder, R. Ammann: Endoscopy of whole small intestine. Endoscopy 4 (1972) 155
4 Friihmorgen, P., M. Classen: Enteroscopy (Small intestine - Large intestine). Acta hepato-gastroent. 21 (1974) 5 Gaisford, W. D.: Symposium; Fiberoptic colonoscopy. Total colonoscopy an office procedure. Dis. Col. Rect. 1
5 (1976) 388
Fig. 3b The valve is opened with the biopsy
6 Meyers, R. T.: Diagnosis and management of occult gastrointestinal bleeding: Visualization of the small bowel lumen by fiberoptic colonoscope. Amer. Surg. 42
forceps before the colonoscope is introduced.
7 Nagasako, K., C. Yuzawa, T. Takemoto: Observation of
(1976) 92
the terminal ileum. Endoscopy 3 (1971) 45
Since we introduced this technique, we have
been able to examine the distal ileum in a far greater number of cases than previously. No complications have been encountered.
8 Ottenjann, R., W. Barthelheimer: A special method for peranal ileoscopy. In: Endoscopy of the small intestine with retrograde pancreato-cholangiography. Demling, M. Classen.) Thieme, Stuttgart 1972
(Ed.:
L.
9 Watanabe, H., T. Narasuka, S. Yarnagata: Studies on the fibercolonoscopy: with special reference to the latest procedures. Tohoku J. Exp. Med. 117 (1975) 385
Dr. N. Gabrielsson, Dr. S. Granqvist, Dept. of Diagnostic Radiology, Huddinge Univ. Hospital, S-I4186 Huddinge
Downloaded by: Chinese University of Hong Kong. Copyrighted material.
Fig. 3 a
41
