Practical Gastrointestinal Endoscopy

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CHAPTER 6
Fig. 6.86–The ileo-cecal valve
is a bulge on the ileo-cecal fold
and can be a single bulge, double
bulge or ‘volcano’.
luminated tissue (Fig. 6.87c), typically with the tell-tale granular
appearance of the villous surface in close-up (as opposed to the
pale shine of colonic mucosa).
5–On seeing the ‘red-out’, freeze all movement, then
6–Insufflate air to open the lips (Fig. 6.87d) and wait—gently
twisting or angling the scope a few millimeters if necessary until
the direction of the ileal lumen becomes apparent; if considerable
angulation has been used to enter the valve de-angulation may be
needed to straighten things out and let the tip slide in.
7–Multiple attempts may be needed for success—both in locating
the valve and entering the ileum, if necessary rotating to slightly
different parts of the ileo-cecal fold, hooking over it and pulling
back to pass the area repeatedly. On each successive attempt try
to learn from the problems of the previous one, fining down tip
movements to a centimeter or two and a few degrees either way.
Change of position may also help.
The biopsy forceps can be used as a guide wire. If only a distant,
partial or uncertain view can be obtained of the ileal bulge or
opening, it is usually possible to use the biopsy forceps to locate
and then pass into the opening of the valve (Fig. 6.88), either to
obtain a blind biopsy or to act as an ‘anchor’. The forceps fix the
position of the tip relative to the valve and facilitate endoscope
passage through it on the guide-wire principle. Even if entry
into the ileum is not intended, the opened forceps can be used to
hook back the bulge of the upper lip of the valve to visualize the
ileal opening and make identification certain; suggestive bulges
or flattened areas can be identified misleadingly on more distal
folds.
Entry into the ileum can be in retroflexion. This ‘last ditch’ maneuver
is only likely to work in a huge colon and if the scope is completely
straightened and responsive. It is a useful option when
the ileo-cecal valve is slit-like and invisible from above (Fig. 6.89).
Retrovert the tip to visualize and then to enter the valve from
5cm
10cm
(a)
(b)
(c)
(d)
Fig. 6.87–(a) Locate the ileo-cecal valve (preferably at 6 o’clock) … (b)… pass in and angulate and deflate
slightly … (c)… pull back until the ‘red-out’ is seen … (d)… and insufflate to open the valve.