Surg Radiol Anat (2011) 33:249–256

DOI 10.1007/s00276-010-0762-x

ORIGINAL ARTICLE

Ileocecal junction: anatomic, histologic, radiologic and endoscopic

studies with special reference to its antireflux mechanism
Ali A. Shafik • Ismail A. Ahmed • Ahmed Shafik •

Mohamed Wahdan • Soheir Asaad •

Essam El Neizamy

Received: 22 August 2010 / Accepted: 3 December 2010 / Published online: 24 December 2010
Ó Springer-Verlag 2010

Abstract surrounded by two lips: upper and lower. A mucosal fold

Aim The aim of the study was to perform histomorpho- started at both angles of the stoma and extended along the
logic, endoscopic, and radiologic studies of the ileocecal cecal circumference. It was marked on the outer cecal
junction (ICJ). A clearer understanding of the anatomical aspect by a groove.
structure of the ICJ may shed some light on its function. Conclusion The ileocecal nipple is a muscular tube with a
Methods Histomorphologic studies were performed in 18 transversely lying stoma and is suspended to the cecal wall
cadavers and radiologic in 22 and endoscopic in 10 healthy by a ‘‘suspensory ligament’’. The morphologic structure of
volunteers. Morphologic studies were done with the help of the ileocecal nipple was confirmed endoscopically and
a magnifying loupe: histologic sections were stained with radiologically. The ileocecal nipple was closed at rest and
hematoxylin and eosin and Masson’s trichrome. The ICJ opened upon terminal ileal contraction to deliver ileal
was studied radiologically using the method of small bowel contents to the cecum. It evacuated the barium periodically
meal. Endoscopic study was done under controlled air into the cecum. The ileocecal nipple structure seems to be
inflation using a video endoscope. adapted to serve the function of cecoileal antireflux.
Results A nipple (1.5–2 cm long) with transversely lying
stoma protruded from the medial wall of the cecum. A Keywords Cecum
Nipple
Stoma
Fornix
Reflux

fornix was found on each side. The nipple stoma was Ligament

Abbreviations
A. A. Shafik
I. A. Ahmed
A. Shafik
Department of Surgery and Experimental Research, ICJ Ileocecal junction
Faculty of Medicine, Cairo University, Cairo, Egypt ICN Ileocecal nipple
IC Ileocecal
M. Wahdan SD Standard deviation
Department of Anatomy, Faculty of Medicine,
Cairo University, Cairo, Egypt

S. Asaad
Department of Histology, Faculty of Medicine,
Cairo University, Cairo, Egypt Introduction

E. El Neizamy
The ileocecal junction (ICJ) has remained a controversial
Department of Tropical Medicine, Faculty of Medicine,
Cairo University, Cairo, Egypt region of the gut [1, 7, 12]. A lot of questions concerning
its anatomical structure and function still need to be
A. A. Shafik (&) answered. The ICJ is the site where the chyme passes from
Ahmed Shafik Hospital, 7, Gamal Salem St., of Mossadek St.,
the ileum to the colon [16]. It is our well-known notion that
Dokki-Giza 12311, Egypt
e-mail: [email protected] the passage of chyme from the ileum to the colon is under
URL: http://www.ahmedshafik.com neuronal and hormonal control [3, 13]. It seems that the ICJ

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has an influence on the transit of chyme from the ileum to bright light, and fine surgical instruments. Following naked
the colon. The human colon absorbs up to 1,500 ml of eye examination, the specimen was photographed.
chyme daily; this amount can be doubled or tripled and
could then overload the colon and impair the colonic Histologic study
motility [9]. Furthermore, the ICJ serves to separate the
abundant colonic flora from the ileum [4]. The ICJs of the 18 cadavers were examined histologically.
The use of the term of ICJ rather than ileocecal valve or Each specimen was cut longitudinally along the terminal
sphincter reflects our uncertainty regarding the physio- ileum, ICJ, and cecum at three sites: mesenteric, antimes-
anatomy of this region [2, 5, 8, 10]. The concept of an enteric, and midway between the mesenteric and antimes-
ileocecal valve is based on the existence of two horizontal enteric sites. The specimens were fixed in buffered
folds of mucous membrane that project around the orifice formalin, processed for paraffin sections of 5-lm thickness,
of the ileum [14]. On the other hand, the ileocecal sphincter and stained with Masson’s trichrome stain.
concept (ICS) stems from the fact that there is a high-
pressure zone at the ICJ [1, 2, 5, 6, 8, 10] which reacts to Radiologic study
changes in ileal or colonic distension. Also a thickening of
the muscle coat at the ICJ could be demonstrated [11, 14]. The ICJ was studied radiologically in 22 healthy volunteers
In view of the above-mentioned controversies, we per- (mean age 42.3 ± 14.2 years, range 21–55 years; 14 men,
formed a histomorphologic, endoscopic, and radiologic 8 women). The subjects had no gastrointestinal complaints
study of the ICJ. A clearer understanding of the anatomical in the past or at the time of enrolment. They had a mean
structure of the ICJ may shed some light on its function. stool frequency of 7.6 ± 1.2 per week (range 6–9), which
The knowledge of such structural–functional relationship matched with that of the normal volunteers in our labora-
seems necessary to clarify the mechanism of chyme tory. The ICJ was studied by oral administration of barium
delivery through the ICJ and the functional and pathologic sulfate using the method of small bowel meal described by
disorders that affect this area. The current communication Sutton [15].
embodies the results of our study.
Endoscopic study

Materials and methods The endoscopic study comprised colonoscopic examination

of ten healthy volunteers (6 men, 4 women, mean age
Histomorphologic studies were carried out in 18 cadavers. 38.6 ± 7.9 years, range 29–52 years). The endoscope used
Radiologic studies were performed in 22 and endoscopic in was a video endoscope EC-200-LR (Fujinon, Osaka,
10 healthy volunteers. Japan). The colon was prepared using 20% mannitol given
orally, followed by repeated saline enemas. Under con-
Cadaveric study trolled air inflation, the cecum, ileocecal region, and the
terminal ileum were examined. The colonoscopy was
Eighteen cadavers [mean age 36.6 ± 14.2 (SD) years, performed under no pharmacological treatment (sedation,
range 8–52 years; 10 men, 8 women] were studied. They analgesia, and antispasmodics). The pancolonoscopy
had a normal gastro-intestinal tract. They were studied showed normal colon, cecum, and terminal ileum.
after being fixed in 10% formalin. For macroscopic All participants of the different sections of our study
examination, every ileocecal specimen was opened by gave an informed consent before enrolment, and our Fac-
cutting its wall at different planes. At first, the ascending ulty Review Board and Ethical Committee approved the
colon was transversely cut approximately 5 cm from the study.
ICJ to have an overview of the ICJ with the intact cecum,
ileum, and ascending colon. Subsequently, the lateral wall
of the cecum was opened, and the cut extended for 3–5 cm Results
so that the ICJ could be clearly viewed and photographed
from inside the cecum. The terminal ileum was then Cadaveric specimens
incised through its antimesenteric border so that the rela-
tion of the ICJ to the terminal ileum could be clearly The terminal ileum approached the upper part of the medial
examined. The incision started approximately 5–6 cm wall of the cecum. When the cecum was opened, a nipple
proximal to the ICJ and was extended to open the junction. was identified protruding from the medial wall as a con-
The ICJ was studied with the help of a magnifying loupe, tinuation of the terminal ileum.

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The ileocecal nipple

The nipple was 1.5–2 cm long and 1.5–2 cm in diameter

and ended by a transversely lying ileocecal opening
(Fig. 1). On palpation, the nipple wall was thicker in the
proximal than in the distal part. It was covered with
mucosa, which was continuous with the cecal mucosa,
while the lining mucosa was an extension of the ileal
mucosa (Fig. 2). The covering mucosa showed mild rugae
while the lining mucosa was smooth (Fig. 2).
The nipple had a superior and an inferior wall, which
were collapsed so that the ileocecal opening showed as a
transversely lying narrow slit (Figs. 1, 3). At the proximal
end of the nipple, there was an oval opening, which rep- Fig. 2 Cadaveric specimen showing a the terminal ileum, b the
resented the end of the terminal ileum in the cecal wall ileocecal nipple slit open, c fornix, and d cecum
(Fig. 4). On slitting open the nipple and the distal 2 in. of
the terminal ileum, we found that the ileal mucosa was
continuous into the nipple (Fig. 5). A cecal recess or fornix
was revealed on each side of the nipple and extended along
its whole length (Fig. 5). It was lined with the cecal
mucosa.
In one cadaveric specimen, the ileum opened flush with
the cecal wall (Fig. 6), with no nipple formation. The ile-
ocecal opening was oval, and no fornices were identified.

Fig. 3 Cadaveric specimen showing a the transversely lying ileoce-

cal stoma, b suspensory sling, c terminal ileum, d cecum, and
e ascending colon

The ileocecal stoma

It lay at the end of the ileocecal nipple as a transversely

lying slit of 1–2 cm in width. The opening was surrounded
by two lips: an upper and a lower (Figs. 1, 3). The lower lip
was thinner, longer, and more redundant than the upper
Fig. 1 Cadaveric specimen showing a the ileocecal stoma, b the one, and both were convex to the outer aspect of the
suspensory ligament, c the cecum, and d the ascending colon opening (Figs. 1, 3).

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Fig. 6 Cadaveric specimen showing a the terminal ileum slit open; it

opened flush with the cecal wall with no nipple formation, b the
cecum

the cecal cavity. It had a falciform shape of 1 cm width at

its start close to the ileocecal opening and diminished
gradually to a few millimeters at its distal end. The ileo-
cecal opening was narrowed or closed when we manually
pulled the mucosal fold on either of its two sides in lateral
direction.
The mucosal fold was marked on the outer surface of the
Fig. 4 Cadaveric specimen showing a the upper lip of the ileocecal cecum by a transversely lying groove. The cecal groove
nipple slit open to show d the opening at the proximal end of the was more prominent in the mucosal folds, which extended
nipple, b suspensory sling, and c lower lip of the ileocecal nipple
around the whole cecal circumference, than in the incom-
plete folds. When we distended the cecum by filling it with
water, the cecal groove became more apparent.

Histologic structure of the ileocecal nipple

Examination of the longitudinal section of the ileocecal

nipple (ICN) revealed a thin outer longitudinal and a thick
inner circular muscle layer in the terminal ileum (Figs. 7,
8). The ileal musculosa extended into the nipple where it
became thin. The smooth muscle bundles in the nipple
consisted mainly of circular fibers with a few longitudinal
ones which existed at the base of the nipple (Figs. 7, 8).
The circular muscle layers on either side of the nipple
wall were separated from each other by a distance at the
nipple base and gradually came closer together until they
Fig. 5 Cadaveric specimen showing a the terminal ileum and
b ileocecal nipple slit open. The ileal mucosa extended into the fused into one layer of smooth muscle bundles slightly
nipple. A fornix (c) exists on each side of the nipple above the middle of the nipple (Fig. 7). The muscle fibers
did not reach the tip of the nipple; they occupied
Suspensory ligament of the ileocecal nipple approximately the lower three quarters of the nipple,
leaving the upper quarter which consisted of mucosa only,
Starting at each corner of the ileocecal opening, a mucosal free of muscle and full of adipose connective tissue
fold arose which extended along the whole cecal circum- (Fig. 7). The muscle layer in the nipple was also sur-
ference in eight cadavers and to approximately half the rounded by adipose tissue, which occurred in the nipple
circumference in nine (Figs. 1, 3). It consisted of a folded, submucosa, too. The muscle layer of the nipple extended
horizontally lying mucosa and formed a sort of shelf inside into the cecum.

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Radiologic findings

On examination of the serial barium films, the terminal

ileum presented at one time empty, and the ICN appeared
as a filling defect in the cecum (Fig. 9a). In subsequent
photographs, it was seen gradually filling with barium. The
barium continued to flow, filling the nipple until it became
distended while the ileocecal stoma remained closed; the
filled nipple took the shape of a hen’s beak (Fig. 9b). Upon
full distension, the closed nipple opened and evacuated its
content of barium into the cecum (Fig. 9c). After evacua-
tion, the terminal ileum and the nipple walls were col-
lapsed, and the nipple appeared as a filling defect in the
barium-filled cecum (Fig. 9d). After a few seconds (mean
6.6 ± 1.4 s, range 5–8), another gush of barium from the
ileum was pushed into the nipple, and the above-mentioned
cycle was repeated; the barium was periodically expelled
from the ileum to the cecum. When the cecum replenished
with barium, it contracted pushing its contents toward the
cecocolonic junction.
During videoscopic examination, the ileum showed
peristaltic activity, which stopped short of the terminal
7–9 cm of the ileum. This terminal segment lacked the
peristaltic movement and contracted as one segment
pushing the barium into the nipple and cecum.

Endoscopic examination
Fig. 7 a Photomicrograph of a longitudinal section at the region of
the ileocecal nipple at its mesenteric side, showing thick circular When the cecum was reached, the ICN could be seen
muscle layer in the ileum (I) that extends inside the nipple (N) and 4–5 cm proximal to the cecal floor. Viewed from the
becomes thin at its root in the cecal part (C) (Masson’s trichrome 94).
b Higher magnification of the encircled area in a showing the root of ascending colon, the ICN was seen in seven subjects as a
the nipple enclosing smooth muscles in its center and covered with crescent-shaped fold, which projected into the cecal lumen
mucosa (arrow) (Masson’s trichrome 925) for approximately 1 cm (Fig. 10). In three subjects, the
fold showed as two wings emerging from a small globular
swelling which represented the upper lip of the ICN
(Fig. 11); the fold occupied nearly one-third of the cecal
circumference.
After repeated attempts, the endoscope could be intro-
duced through the ICN into the terminal ileum, which was
evident with its villi and peristaltic waves. At slow with-
drawal of the endoscope from the terminal ileum out of the
ICN, the nipple mucosa unlike the ileal mucosa was
smooth, and the lower lip of the ICN was longer, thinner,
and more redundant than the upper one. When the tip of the
endoscope emerged from the ICN, both lips approached
each other and shut the ICN.

Discussion
Fig. 8 Photomicrograph of a longitudinal section at the region of
the ileocecal nipple at its antimesenteric side, showing thick inner
circular and thin outer longitudinal muscle layers in the ileum The current study may shed some light on the structural–
that extends inside the leaflet of the nipple (N) (Masson’s functional relationship of the ICJ. It seems that the ICJ is
trichrome 96) structurally adapted to serve the function of preventing

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Fig. 9 Barium follow-through

showing serial films of the
functional activity of the
terminal ileum and ileocecal
junction. a Empty terminal
ileum. The ileocecal nipple
appears as a filling defect in the
medial wall of the cecum.
b Barium filled the terminal
ileum and entered the ileocecal
nipple which appeared as a
narrow canal passing through
the medial wall of the cecum.
c The barium filled the ileocecal
nipple which appeared as a wide
canal. d The terminal ileum
emptied its contents of barium.
The empty ileocecal nipple
appeared as a filling defect in
the medial wall of the cecum

Fig. 10 Endoscopic view of the ileocecal nipple seen from the Fig. 11 Endoscopic view showing the suspensory sling (a) extending
ascending colon showing the upper (a) and the lower (b) lips from the upper lip of the ileocecal nipple (b)

cecoileal reflux, i.e. it constitutes (Fig. 12) an antireflux fibers. The ICN had a proximal oval-shaped opening at the
mechanism which needs to be discussed. termination of the ileum and a distal one in the form of a
transverse slit at the tip of the nipple. The difference in the
The ICJ antireflux mechanism orientation of the two openings located at either end of the
ICN appears to be a contributing factor to the prevention of
The ICN, protruding into the cecum for 1.5–2 cm, seems to cecoileal reflux.
provide, in itself, an antireflux mechanism. It can be Endoscopic evidence obtained during our studies sug-
directly compressed during cecal contraction, especially so gests that the ICN is sealed at rest, probably as an effect of
as the distal part of the ICN wall consisted of only mucosa its muscular structure. The stoma was closed after with-
and, in contrast to its proximal part, contained no muscle drawal of the endoscope from the ileum. Meanwhile, the

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probably compresses the ICN during passage of the nipple

through the cecal wall.
In the case in which the ileum opened directly into the
cecum, no nipple was encountered. The IC opening was
vertically oval, lay flush with the cecal wall, and its his-
tologic structure was similar to that of the terminal ileum.
There were no mucosal folds or fornices related to the IC
opening. Obviously, all factors involved in the cecoileal
antireflux mechanism seem to be absent, and we believe
that cecal contractions would cause cecoileal reflux.

Mucosal folds

We assume that the mucosal folds connected to the IC

stoma have other functions in addition to assisting in the
closure of the IC stoma. When stretched upon cecal dis-
tension with chyme, they may act to support the ICN, as it
protrudes inside the cecum, by slinging it to the cecal wall.
In view of this function and being encountered in all the
studied specimens, the mucosal folds are better termed the
Fig. 12 A diagram illustrates the ileocecal junction (ICJ). a The ‘‘suspensory ligament’’ of the ICN. With the cecum empty,
transversely lying ileocecal stoma, b suspensory sling, c cecum, the mucosal folds are presumably redundant. When the
d ascending colon, and e appendix
cecum fills and becomes distended, the mucosal folds
assumably become stretched and pull on the IC stoma
ICN opens intermittently under the contractile activity of resulting in its firm closure. Moreover, the mucosal folds,
the terminal ileum in order to evacuate its contents and lying horizontally, appear to act as shelves that compart-
then closes again. mentalize the cecum.
Closure of the IC stoma appears to be assisted by the The mucosal folds could be identified on the outer
mucosal folds attached to its lips because manual lateral aspect of the cecum by a groove which deepened on cecal
stretch of these folds affected closure of the aperture. We distension. The groove might act as a landmark denoting
believe that, under normal physiologic conditions, closure the level of the ICN on the cecal wall. This finding may be
of the stoma, which probably halts further filling of the of significance during surgical or laparoscopic exploration
cecum, occurs by stretch of the mucosal folds at maximal of the gut.
cecal distension, as well as by cecal contraction exerting The above-mentioned anatomical findings and the anti-
direct compression on the ICN. Both nipple compression reflux mechanism could be confirmed radiologically with
and closure of the IC stoma seem to be facilitated by the the small bowel barium meal. The ICN appeared protrud-
transverse arrangement of the slit and further by the ing as a filling defect in the barium-filled cecum. When the
mucosal, muscle-fiber-free lips boarding the ICN. Mean- barium reached the terminal ileum, the ICN was empty. On
while, the presence of a fornix on either side of the ICN contraction of the terminal ileum, the ICN opened gradu-
may assist in nipple compression during cecal filling. ally receiving the barium and passing it to the cecum. The
A radiological study has shown that barium was stored absence of peristaltic movements in the terminal ileum
in the terminal ileum for a few seconds. When distended, suggests that it contracts by the mass movement as is the
the ileum contracted and pushed its contents distending the case in the large gut. This movement might be necessary to
ICN, which opened to evacuate. It is thus suggested that the push the ileal contents through the closed ICN. When the
terminal ileum expels its contents periodically through the cecum became full and contracted pushing its contents to
ICN into the cecum. After intermittent gushes of ileal the ascending colon, the absence of barium in the ICN
contents had filled the cecum, it contracted pushing its appears to indicate closure of the ICN by the aforemen-
contents toward the ceco-colic junction. tioned antireflux mechanism.
There may be other factors of significance in the
cecoileal antireflux mechanism. The high location of Motility and reflex action of the ileocecal nipple
the ICN in the upper part of the cecum, very likely above
the contractile part of the cecum, may also share in pre- From the histologic point of view, the ICN seems to be a
venting cecoileal reflux. Moreover, cecal contraction contractile structure as its muscle bundles are a

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