title: Images of the terminal ileum are more convincing than cecal images for verifying the extent of colonoscopy.
abstract: OBJECTIVE
  Independent verification of colonoscopy completion is important for quality assurance. Cecal photographs aimed at showing key landmarks, including the ileocecal valve (ICV) and appendiceal orifice are the currently recommended standard, but are often perceived as unreliable. Images of the terminal ileum demonstrating villi may provide more robust evidence of completion. We sought to prospectively evaluate the ease of routine intubation of the terminal ileum and to compare the effectiveness of terminal ileum and cecal photographs in convincing independent reviewers that total colonoscopy had been accomplished.
  
  
  METHODS
  A prospective, observational study evaluated 216 consecutively completed colonoscopies performed in routine clinical practice. Cecal and terminal ileum photographs were evaluated and scored by independent reviewers. Frequency of terminal ileum intubation, time required, and safety parameters were recorded.
  
  
  RESULTS
  The terminal ileum was intubated and photographed in 188/216 (87%) of cases. Median time taken to intubate, or attempt to intubate the terminal ileum was 1 min 24 s, and was achieved without complications or requirement for additional sedation. Terminal ileum images were significantly more likely to be considered convincing than cecal images ( P<0.0001 for all reviewers). There was excellent interobserver agreement amongst the opinion of reviewers regarding terminal ileum photographs (kappa=0.91).
  
  
  CONCLUSIONS
  Terminal ileum intubation is achievable rapidly and safely in the majority of patients undergoing colonoscopy. Terminal ileum images provide more convincing evidence of complete examination of the colon than cecal images, even when attempts to capture images specifically of the ICV and appendiceal orifice are made.
authors.affiliation: Imperial College Healthcare NHS Trust, Gastroenterology Department, St Mary's Campus, London, UK. nick.powell@nhs.net
authors.forename: N
authors.initials: N
authors.lastname: Powell
authors.forename: H
authors.initials: H
authors.lastname: Knight
authors.forename: J
authors.initials: J
authors.lastname: Dunn
authors.forename: V
authors.initials: V
authors.lastname: Saxena
authors.forename: J
authors.initials: J
authors.lastname: Mawdsley
authors.forename: C
authors.initials: C
authors.lastname: Murray
authors.forename: J
authors.initials: J
authors.lastname: Hoare
authors.forename: J
authors.initials: J
authors.lastname: Teare
authors.forename: A
authors.initials: A
authors.lastname: McNair
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002432:Cecum; D003113:Colonoscopy / Q000379:methods / Q000592:standards*; D004282:Documentation / Q000379:methods*; D005260:Female; D006801:Humans; D007082:Ileum; D007413:Intestinal Mucosa; D008297:Male; D008875:Middle Aged; D018024:Peer Review, Health Care; D010781:Photography; D011446:Prospective Studies; D011785:Quality Assurance, Health Care / Q000379:methods*; D055815:Young Adult