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.

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.

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.

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.

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.

Endoscopy plays an integral role in the diagnosis, management, and surveillance of inflammatory bowel disease (IBD). Because there is no single pathognomonic test that establishes the diagnosis of IBD, endoscopy is useful in establishing the diagnosis, excluding other etiologies, distinguishing Crohn's disease from ulcerative colitis, defining the patterns, extent, and activity of mucosal inflammation, and obtaining mucosal tissue for histologic evaluation. In established IBD, endoscopy helps define the extent and severity of involvement, which in turn influences medical and surgical decisions, aids in targeting medical therapies, and allows for the management of IBD-related complications. Furthermore, endoscopy plays a key role in the surveillance of patients with long-standing colitis who are at increased risk for dysplasia and the development of colorectal cancer.

Epithelioid granulomas with transmural inflammation are a characteristic histological feature in Crohn's disease (CD). However, these are not frequently detected by histopathological examination in the biopsy specimens. Here, we demonstrated unique structures with T-lymphocyte aggregates (TLAs) that were specifically found in ileal villi of CD. We characterized the histological and phenotypical features of these structures and assessed the diagnostic value of TLAs for CD.

Tissue samples were obtained from the inflamed and uninflamed areas of ileal and colonic mucosa of 32 patients with CD. For controls, mucosal samples were obtained from unaffected areas of 18 patients with colon cancer and inflamed and uninflamed areas of 12 patients with ulcerative colitis (UC).

1) In 21 of 32 cases of CD (66%), we found unique structures with lymphoid cell aggregates that were localized in villi of ileum. These structures were not detected in any normal or UC intestine. 2) These structures were composed mainly of T cells, and CD4+ CD45RO+ cells dominated. Neither B cells nor c-kit positive immature lymphocytes were found. Moreover, CD68 positive macrophages were demonstrated in these aggregates, and cells positive for interleukin 18, a pivotal cytokine for Th1 differentiation, were expressed. 3) The aggregates were detected in seven of 13 patients with CD in whom granuloma was not detected by precise histopathological examination. Furthermore, we detected TLAs even in the ilea of two of four CD patients (50%) whose affected lesions were limited to the colon.

We demonstrated TLAs in intestinal villi that may contribute to the pathogenesis of CD. Detection of these lymphocyte aggregates is helpful for diagnosis of CD when granuloma is not found.

Spontaneous ruptures of the esophagus are rare, but may lead to deleterious courses, even if diagnosed early.

We report a case of Boerhaave's syndrome-mimicking esophageal perforation due to a stricture of the distal esophagus as the primary manifestation of Crohn's disease. Diagnosis was delayed resulting in a complicated clinical course. The presented patient is the first case in the literature with esophageal perforation related to a previously undiagnosed Crohn's disease that lead to stenosis of the distal esophagus before becoming clinically apparent.

Difficulties in differential diagnosis, problems related to initial misdiagnosis and consecutive mismanagment of spontaneous esophageal perforation, and treatment options including nonsurgical approaches are discussed.

Serial sections of 1047 colonic and rectal biopsies from 385 children and adolescents suffering from Crohn's disease were studied histologically. Inflammatory alterations were seen in 76% of the biopsies and 84% of the patients. Incidence of inflammatory infiltration, of crypt abscesses, of erosions, and of ulcers decrease from caecum to rectum were studied. The incidence of granulomas falls along the colon but rises in the rectum. The occurrence of granuloma depends rather on the severity of the inflammation than on the biopsy site. Granulomas are present in 26% of the biopsies and 42% of the patients. Compared to adults, the incidence was twofold in children. Discontinuous type of infiltration, density of infiltration, crypt abscesses, rectal erosions prevail in children, diffuse type of infiltration, and colonic ulcers in adults. Incidence of granulomas is reduced after the second year of illness and after the 16th year of life. The number of granulomas per mm3 biopsy is increased in children, their average size in adults.

HLA-DR antigens in small and large intestinal epithelia were examined in Crohn's disease (CD). Seventy-two biopsy specimens (10 from the duodenum, 18 from the terminal ileum, and 44 from various sites of the large intestine) were obtained from 5 patients with CD chronologically; before treatment, during elemental diet (ED) treatment, and during home elemental enteral hyperalimentation (HEEH). HLA-DR antigens on the intestinal epithelia were identified by the indirect immunoperoxidase staining method using two mouse anti-HLA-DR monoclonal antibodies. In the small intestine, HLA-DR antigens were expressed differently from normal controls in macroscopically or microscopically pathological areas, but not in macro- or microscopically normal areas. In the large intestine, when the disease was in full vigor before treatment, HLA-DR antigens were always aberrantly expressed even in the macroscopically uninvolved areas, as well as in macroscopically involved areas. However, when the disease was suppressed after ED followed by HEEH treatment, the antigens were not always expressed in the macroscopically uninvolved areas, or in the macroscopically involved areas. These findings suggest that HLA-DR antigens are not merely expressed as a non-specific response to inflammation, but may be expressed as a primary change which results in macroscopic lesions. The possible role of HLA-DR antigens in the immunological mechanism in CD is proposed.

Serial sections of 1434 colonic and rectal biopsies of 347 patients with Crohn's disease were performed. The relationship between the incidence of granulomas and the inflammatory alterations of the mucosa and some clinical parameters was studied. The presence of granulomas depends on the severity of inflammatory alterations and not on the site of the biopsy. The number of granulomas per mm3 increases from caecum to rectum. The incidence of granulomas decreases with age, duration of illness and under a conservative therapy. If several biopsies, taken at the same or at different times, are studied, granulomas can be found in 40-50% of these patients.