Terminal ileal biopsies should not be used to document extent of colonoscopic examination

We commend the British Society of Gastroenterology and the authors for the excellent publication of guidelines for the management of inflammatory bowel disease in adults (Gut 2004;53(suppl V):v1–v16). However, we feel that their recommendation for routine terminal ileal biopsying is inappropriate. Although it is important to biopsy the terminal ileum if there is macroscopic evidence of an abnormality, their statement that “a terminal ileal biopsy performed at colonoscopy documents the extent of examination” is not recommended practice, due to the potential risk of variant Creutzfeld-Jacob disease transmission from prion proteins which are prevalent in the lymphoid tissue of Peyer’s patches in the ileum. Although the use of disposable forceps may reduce the risk of transmission, there could still be contamination of the intubation channel of the colonoscope and prion protein is resistant to the standard endoscopic cleaning process.¹ If the extent of examination needs to be documented, then a photograph of the ileocaecal valve or ileal mucosa is preferable.

It is worth emphasising that prion protein may be present in any part of the gastrointestinal tract² and random biopsy of gastrointestinal mucosa for reasons other than confirming an endoscopic abnormality or excluding microscopic colitis is not acceptable. Similarly, for surveillance colonoscopy where multiple biopsy is recommended, the risk benefit ratio of this policy must be supported by the clinical indications.