Clinical Bottom Line

Question	2026 practical answer
Is TI intubation a screening quality metric?	No. ACG/ASGE 2024 tracks cecal intubation with landmark photos, ADR, SSLDR, prep adequacy, and surveillance intervals. Terminal-ileum intubation rate is not on that list.
When should I enter the ileum?	Suspected Crohn's, chronic diarrhea, abnormal ileal imaging, obscure bleeding after a negative EGD, and IBD assessment. Also when cecal landmarks are uncertain and you need proof of completion.
First technique	Confirm cecum (appendiceal orifice plus ileocecal valve). Aspirate gas. Put the valve at 6 or 9 o'clock. Hook the inferior lip, withdraw, and suction so the ileum sleeves over the tip. Do not push.
Water	Water immersion or exchange makes the valve buoyant and often easier after air has ballooned the cecum.
If the valve will not open	Change position, drop to a pediatric colonoscope, add a distal cap, then try retroflexed ileocecal-valve entry. A closed forceps can probe a slit-like posterior orifice.
Biopsy a normal-looking TI?	Usually no on a screening exam. Yield is low when the mucosa looks normal. Biopsy when the ileum looks abnormal or the indication is diarrhea, suspected IBD, or imaging-defined ileitis.

When does ileal intubation change management?

Cecal intubation with photographs of the appendiceal orifice and ileocecal valve is how you prove a complete colonoscopy. Entering the terminal ileum is a separate decision. It pays off when the question is ileal disease, not when the question is average-risk colorectal cancer screening.

Intubate with intent in:

Suspected or known Crohn's disease, including postoperative ileal assessment. See the Rutgeerts score page.
Chronic unexplained diarrhea.
Right-lower-quadrant pain or abnormal ileal imaging.
Obscure bleeding after a negative EGD, when you are already in the cecum.
IBD surveillance when the ileum is part of the disease map. Chromoendoscopy details live on the IBD surveillance page.

Neilson and colleagues reviewed the same split: ileoscopy helps you find Crohn's and confirm completion when cecal landmarks are unconvincing. It is not a routine add-on for every screening list.

Is TI intubation a quality metric?

The 2024 ACG/ASGE quality indicators for colonoscopy keep cecal intubation (target at least 95%, with photo documentation of landmarks) on the dashboard. Priority measures are now adenoma detection rate, sessile serrated lesion detection rate, bowel-prep adequacy, and recommended-interval adherence. Terminal-ileum intubation rate is not a quality indicator.

Leiman's 2020 screening cohort (7,799 exams, 28 endoscopists) is the practical number: median TIIR 37%, range 2% to 93%, and no correlation with polyp, adenoma, or serrated detection. Ileal entry lengthened withdrawal. A 10% sample of intubated cases found no clinically important ileal pathology. Use that paper when someone argues that a high TIIR is a quality badge.

Insertion mechanics still matter. Torque, loop reduction, and a straight scope in the cecum are what make the valve reachable. That lives on the colonoscopy insertion page.

How do I intubate the valve?

Frontline Gastroenterology's ileocolonoscopy primer is still the cleanest sequence:

Prove you are in the cecum. Identify the appendiceal orifice and the ileocecal valve. The tri-radiate fold is the least reliable landmark.
If the orifice looks bow-shaped, the "arrow" at the apex points toward the ileal opening.
Orient the valve at 6 or 9 o'clock. That is the most neutral vector for the instrument.
With the tip in the cecal pole, aspirate gas. A ballooned cecum tents the valve shut.
Slowly withdraw and move the tip onto the inferior lip. Hook with up-angulation. A short corrective push as the valve opens, plus a burst of water or air, seats the tip.
Suction as you enter so the ileum sleeves over the scope. Pushing against a closed valve retroflexes you in the cecum or drops you back into the ascending colon.

Iacopini's prospective series put a number on the learning curve: about 50 supervised ileoscopies to reach an 80% intubation rate and 16 cm of ileal inspection. Thin-lipped valves were the hardest. Volcanic morphology was the easiest. Once competent, intubation was fast (about 1 minute) with a 97% success rate.

What if the valve will not open?

Water. Under water the valve is buoyant. Water exchange or immersion after a gas-filled cecum is often the difference between a miss and a 5 to 10 cm ileal look. Cadoni and Leung's VideoGIE demonstration is the technique source, not a quality-indicator paper.
Scope and cap. A pediatric colonoscope or a distal cap helps when the adult instrument will not turn into a posterior slit.
Position. Left-lateral to supine (or the reverse) changes how the valve hangs.
Retroflexed entry. In the cecum, max up-angle and a gentle push can bring the valve to 6 o'clock. Pull back and the tip can fall into the ileum. Straighten the dials before you push proximal. This is salvage, not the default.
Closed forceps. For a slit-like posterior orifice, a closed biopsy forceps can act as a probe. Do not treat this as first-line.

Should I biopsy a normal-looking ileum?

Biopsy an abnormal TI. Lymphoid hyperplasia, aphthae, ulcers, strictures, and denuded mucosa are the pictures that change management.

A normal-looking TI on a screening colonoscopy has a low histologic yield. Neilson's review and McHugh's surgical-pathology series both say the same thing: random biopsy of endoscopically normal ileum rarely pays. In chronic diarrhea the calculus is different. Yusoff showed that ileoscopy plus colonic biopsies raise diagnostic yield in that indication. Match the biopsy to the question, not to a habit of "I got in, so I took six."

Selected references

Last reviewed September 20, 2026. Written for clinicians deciding whether to enter the ileum on today's list, and how to do it when the valve is not facing them.

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Colonoscopy

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