Proximal Colon

After passing the hepatic flexure, the view opens up to the proximal segments of the large intestine. In addition to the capacious ascending colon, the cecal pole and ileocecal valve are often visible at the end of the field of vision (Fig. 5.17). Often after passing the hepatic flexure, there can be a certain unnecessary advancement of the endoscope in the more distal colon segments. Thus, after positioning the endoscope tip securely in the ascending colon, it is recommended that the endoscope be carefully withdrawn and straightened. This alone can often further advance the instrument, in some cases even reaching the base of the cecum. If this does not succeed, active advancement of the endoscope is necessary. For passing the ascending colon,

Proximal Sigmoid Colon

Fig. 5.17 View into the ascending colon after passing the hepatic flexure. The ileocecal valve, seen as a yellowish, thickened fold, is on the lower edge of the lumen (arrow) in the distance.

Base Cecum
Fig. 5.18 View of the base of the cecum. Convergence of the three tenia originating at about the 3-o'clock, 11-o'clock, and 6-o'clock positions; appendix orifice in the center of the image.
Fig. 5.19 View of the ileocecal valve (thickened, yellowish semicircular fold on the left) and tilted cecum, obscured view into the cecum from this aspect.
Transillumination Caecum

Fig. 5.20 Transillumination of the endoscope tip through the abdominal wall of the lower right abdomen upon reaching the cecum.

Fig. 5.20 Transillumination of the endoscope tip through the abdominal wall of the lower right abdomen upon reaching the cecum.

advancing and withdrawing to straighten it, applying external hand pressure to prevent inefficient loss of instrument length in the flexible, more distal colon segments, or a combination of both procedures can be helpful. In some cases, the base of the cecum can ultimately be reached only by additionally repositioning the patient; especially for advancement in the right hemicolon, positioning the patient on his right side can make advancement easier.

Base of the cecum. Identifying the base of the cecum is usually unproblematic, given its characteristic morphology and the proximity of the ileocecal valve. The base of the cecum is characterized by a folded pattern produced by the three converging taenia; the appendix valve or invaginated appendiceal orifice is located at its center (Fig. 5.18). The ileocecal valve is located a few centimeters distally, and usually appears as a yellowish, thickened fold, separating the cecum from the ascending colon (Fig. 5.19). Position and flexibility of the cecum vary depending on its fixation to the dorsal abdominal wall. A broadly fixated cecum on the posterior wall of the abdominal cavity (as a continuation of the fixation of the ascending colon) results in a mostly immobile cecum. The range of normal anatomy encompasses all possible variations, including the complete lack of such a fixation, resulting in extreme cases in a highly mobile cecum and a possible inversion of the cecal pole or only the appendix. This explains why the base of the cecum can in some cases be completely visualized from the proximal ascending colon, but not in the case of an inverted or tilted cecum, which requires precise advancement in the cecum (Fig. 5.19). It is a good idea to document the images of the cecum (with or without the ileocecal valve) as a record of completion of colo-noscopy. Along with the typical endoluminal morphology, reaching the cecum can often also be confirmed by visible transillumination of the endoscope tip in the lower right abdomen (Fig. 5.20).

Intubating the Ileocecal Valve and Terminal Ileum a

Fig. 5.21 Ileocecal valve.

a The valve opening is easily identified from the ascending colon. b The valve is turned toward the cecal pole and not identifiable from the ascending colon. The indentation in the center of the valve could indicate the location of the valve opening.

Fig. 5.21 Ileocecal valve.

a The valve opening is easily identified from the ascending colon. b The valve is turned toward the cecal pole and not identifiable from the ascending colon. The indentation in the center of the valve could indicate the location of the valve opening.

Ileocecal Valve

Fig. 5.22 Ileocecal valve.

a The valve opening is presumably located at the indentation on the valve. b The endoscope tip must be almost completely inverted, as illustrated here.

Fig. 5.22 Ileocecal valve.

a The valve opening is presumably located at the indentation on the valve. b The endoscope tip must be almost completely inverted, as illustrated here.

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