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Establishing intubation of the cecum can be a laborious, frustrating, and sometimes erroneous endeavor. Following confirmed colonoscopic intubation of the cecum, the presence of three anatomic landmarks (alone and in combination) were evaluated to precisely define their reliability.Between February 1991 and January 1992, 771 of 904 consecutive colonoscopic examinations were completed to the cecum as confirmed by fluoroscopy.All three cecal landmarks studied (ileocecal valve, appendiceal orifice, and transillumination) were present in 64 percent of patients, and two landmarks were seen in 32 percent (96 percent of patients had multiple landmarks). The ileocecal valve was the most reliable cecal landmark (98 percent), followed by the appendiceal orifice (87 percent) and transillumination through the abdominal wall (75 percent).The ileocecal valve is the most reliable cecal landmark and is invariably visualized, even when all other cecal landmarks are obscure. Although other cecal landmarks are usually identifiable, they are most valuable when found in association with the ileocecal valve.