The ileocecal valve is located above the base of the cecum and is usually easily seen from the proximal ascending colon, though its morphology and orientation can vary greatly. In some instances the valve opening can be clearly identified from the ascending colon, but a protruding superior valve lip and an inverted cecum can make the identification of the valve opening from the ascending colon impossible. In such cases, the ileocecal valve can often only be identified as a yellowish, thickened and slightly raised fold in the lumen (Figs. 5.21-5.23).
Depending on the individual morphology of the valve, the position of the valve opening will also vary. This can present significant difficulties for intubation. Nevertheless, valve intubation and inspection of the terminal ileum should be attempted. Intubation of the valve and inspection of the terminal ileum is an important part of the endoscopic examination for b a
in difficult situations. If intubation of the valve is still not possible, in exceptional situations a closed biopsy forceps can be used to guide the endoscope through the clearly identified opening in the direction of the ileum (Fig. 5.24). The morphology of the small intestine mucosa makes the terminal ileum immediately recognizable. Compared with the smooth and shiny mucosa of the large intestine, the ileum mucosa has a velvety surface. Occasionally, the villi of the small intestine can be seen macroscopically; there is no haustration of the lumen. The ileum should normally be inspected until the instrument is used up, which can require > 20 cm (Fig. 5.25). In a small number of cases (< 5%) intubation of the ileocecal valve remains impossible despite every possible attempt.
E 5.1 illustrates the most important stages in examination procedure.
evaluating certain conditions (e.g., suspected Crohn disease, sonomorphological changes to the ileum). In emergencies involving bleeding in the lower gastrointestinal tract, inspection of the ileum helps localize the source of bleeding and often provides important information for the differentiation of ileal or colonic bleeding.
Valve intubation technique. Valve intubation technique depends on the morphology of the valve. Before intubation, the position of the valve opening must first be determined. If the valve is clearly visible, the endoscope can generally be advanced from the ascending colon into the ileum without a problem. If the valve opening is not readily identifiable, a careful inspection of the valve should first be made. Signs of the valve opening include secretion of small intestine contents (often foamy, bubbling; Fig. 5.23) or a visible indentation on the valve (Figs. 5.21 b, 5.22). Suctioning air out of the cecum can sometimes turn the valve opening around away from the base of the cecum and toward the ascending colon, making it visible. However, in some cases the valve opening remains difficult to identify and can only be seen from the base of the cecum. If this is the case, a complete retroflexion of the endoscope in the cecum may be required (Fig. 5.22).
After identifying a valve opening not passable from distal, the endoscope tip is placed in the cecum and slowly and carefully withdrawn in the direction of the already identified valve opening. As soon as the valve opening can be seen, the instrument tip can be advanced again toward the terminal ileum using air insufflation (in doses). Several attempts are often necessary
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