Terminal ileum of patients who underwent colonoscopy: endoscopic, histologic and clinical aspects

Abstract

-Context -For the diagnosis of the diseases which affect the terminal ileum, the colonoscopy allows macroscopic evaluation and the performing of biopsies. Studies with criteria for the endoscopic and histological characterization of this segment are scarce and there are still some doubts about the need of biopsies in patients with normal ileoscopy. Objective -Study the terminal ileum of patients who underwent colonoscopy considering: endoscopic and histological correlation; agreement between results of the initial histological evaluation and slides review, and the chance of subjects with normal ileoscopy with abdominal pain and/or chronic diarrhea to show histological alterations.Methods -In a prospective study, 111 patients who presented smooth mucosa without enanthema in the endoscopic exam of the terminal ileum were selected. Biopsies of the ileal mucosa of such patients were performed, being the slides routinely examined and reviewed afterwards. Results -The correlation between patients with normal ileoscopy and ileum with preserved histological architecture was of 99.1%. The agreement between initial histological evaluation and slides review calculated by the Kappa test was 0.21. In patients with abdominal pain and/or chronic diarrhea, the chance of showing histological alterations was 2.5 times higher than the others. Conclusions -The correlation between endoscopic and histological findings was high. The agreement between the initial histologic evaluation and slides review was not satisfactory. The chance of subjects with normal ileoscopy with abdominal pain and/or chronic diarrhea, showing histological alterations was higher in relation to the asymptomatic ones or with other symptoms, although the clinical importance of this datum was not evaluated.

How does a biopsy of endoscopically normal terminal ileum contribute to the diagnosis? Which patients should undergo biopsy?

“…In a study by Melo et al (1) performed in 2009, biopsy results of 111 cases with a normal-appearing terminal ileum were assessed. The comparison of a group with chronic diarrhea and/or abdominal pain to a group of asymptomatic patients or patients with other symptoms showed that the possibility of having mild to moderate ileitis was 2.5-fold higher.…”

“…Therefore, it is lined by a specialized lymphoid tissue of the immune system. Increases in lymphocytes, macrophages, and mast cells in response to luminal antigens are observed physiologically (1, 2). Diseases involving the terminal ileum may be classified as the inflammatory bowel diseases (IBD), infectious and parasitic diseases, and more rarely, neoplasia.…”

Aspectos endoscópicos no diagnóstico de doenças que acometem o íleo terminal

“…Em estudo prospectivo de 111 pacientes que apresentaram ao exame endoscópico do íleo terminal normal (mucosa lisa e sem enantema), Melo et al 35 constataram que a chance de indivíduos com ileoscopia normal, portadores de dor abdominal e ou diarréia crônica, apresentar alterações histológicas foi 2,5 vezes maior em relação aos demais.…”

“…Diversos autores sugerem a realização de biópsias do íleo terminal de aspecto endoscópico normal em pacientes com diarréia crônica e ou dor abdominal 5,31,[33][34][35][36] , pois a partir do estudo histológico desses casos foi possível o diagnóstico de enfermidades como doença de Crohn 34,36 , tuberculose intestinal 31 , citomegalovirose 33 e microsporidíase 34 . Por outro lado, Yusoff et al 37 e Silva et al 38 verificaram que a avaliação microscópica de pacientes com diarréia crônica e ileoscopia normal não contribuiu para o diagnóstico de seus pacientes.…”

Can microscopic ileitis in patients with clinically suspected inflammatory bowel disease predict the future?

“…However, the clinical setting and the indication for the procedure is of paramount importance and may be correlated with the diagnostic yield when performing biopsies in a suitable setting [9][10][11]. Thus, TI biopsies may be of greatest value for patients who undergo endoscopy for known or strongly suspected Crohn's disease [12][13][14].…”