Variation in practice of ileal intubation among diverse endoscopy settings: results from a national endoscopic database

Background: Terminal ileum intubation rates at colonoscopy are variable. One of the major indications for terminal ileum intubation is to identify Crohn's disease. Signs and symptoms which raise a suspicion of Crohn's include abdominal pain/ bloating, anaemia and diarrhoea. Aim: To determine the proportion of terminal ileal intubation in patients undergoing evaluation of abdominal pain/ bloating, anaemia or diarrhoea with normal endoscopic findings at colonoscopy. Methods: The Clinical Outcomes Research Initiative national endoscopic database was analysed to determine the proportion of terminal ileum intubation in patients undergoing evaluation of either abdominal pain/ bloating, anaemia or diarrhoea with normal endoscopic findings at colonoscopy and to characterize this population of patients. Patients with known or suspected inflammatory bowel disease were excluded from the analysis. Results: Between January 2000 and December 2003, 21 638 patients underwent complete colonoscopy for evaluation of either abdominal pain/ bloating, anaemia or diarrhoea with normal colon findings. Overall, 3858 patients ( 18%) underwent terminal ileum evaluation. Intubation rates differed according to procedure indication: abdominal pain ( 13%), anaemia ( 13%), diarrhoea ( 28%). Terminal ileum assessment declined with advancing patient age and was least frequent in Black patients ( 12% vs. 18% in non- Blacks, P < 0.0001). Ileal intubation rates also varied among endoscopy site types: community ( 17%), academic ( 21%), Veterans Affairs Medical Centres ( 17%), P < 0.0001. Multiple logistic regression identified patients with the indication of diarrhoea ( OR: 2.58) as more likely to undergo terminal ileum intubation when compared with those with abdominal pain/ bloating. Patients in Veterans Affairs ( OR: 1.26) and academic ( OR: 1.29) sites were more likely to undergo terminal ileum intubation compared with community sites. Conclusion: Less than one- fifth of patients with either abdominal pain/ bloating, anaemia or diarrhoea underwent ileal intubation in the setting of a normal colonoscopy. Significant practice variation was observed in rates of terminal ileum evaluation. Further study is required to determine whether terminal ileum examination impacts patient management or outcome.