Normal-looking ileocecal valve does not exclude Crohn's disease in the terminal ileum

Introduction: Despite ileoscopy is the only procedure which can accurately detect mucosal abnormalities in the ileum, it is performed only in an average of 5–15% of the colonoscopies in the daily practice. Since ileum alone is affected in about 30% of CD patients, ileal intubation is very important in suspected ileal Crohn's disease (CD).

Aim: On the basis of the observation, that a normal-looking ileocecal valve (ICV) suggests the presence of normal ileal mucosa, the aim of this study was to retrospectively determine the predictive value of the endoscopic findings of ICV in patients with CD.

Patients and methods: Data of 100 CD patients (45 females, 55 males, mean age 27.6 years, range 5–66), who underwent ileocolonoscopy between 2003 and 2008, were reviewed. Macroscopic appearance of ICV and the endoscopic severity of the ileum evaluated by the Simple Endoscopic Score for Crohn's Disease (SES-CD) were determined in all cases. Histological scoring was performed in 56 cases.

Results: Macroscopically normal appearance of ICV was detected in 30 patients. 60% of these patients were diagnosed with mild, 26.7% with moderate and 13.3% with severe endoscopic ileal inflammation. CD was localized to the ileum alone in 70% of the patients. Histological examination of 22 ileal biopsies with normal-looking ICV revealed more severe inflammatory activity in 31.8% and milder activity in 18.2% of the cases than the endoscopic findings.

Conclusion: Our results suggest that normal-looking ICV does not indicate normal ileum mucosa almost in one third of the cases, therefore ileal exploration should be attempted to perform in every suspected CD patients.