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بنام خدا Defecography

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بنام خدا Defecography 1/15/2019 بنام خدا Defecography 1 1/15/2019 Overview: • Definition • Anatomy • Method of assessment • Indication • Preparation • Instrument • Contrast media • Technique • Recording • Other technique • Technique pitfalls • Parameters • Abnormalities Findings Definition: Dynamic rectal examination (DRE) or defecography or proctography. • DRE provides a dynamic assessment of the act of defecation by recording the rectal expulsion of a barium paste. • DRE provides qualitative and quantitative information on the function of anorectal and pelvic floor function, and the effectiveness of the anal sphincter and rectal evacuation. 2 1/15/2019 Anatomy 3 1/15/2019 4 1/15/2019 5 1/15/2019 Method of assessment • Barium enema • Colon transit time • MR defecography Indications for dynamic rectal examination are: 1. Outlet obstruction (disorder of defecatory or rectal evacuation), caused by intussusception, enterocele or spastic pelvic floor syndrome. 2. To distinguish between anterior rectocele and enterocele. 3. Fecal incontinence combined with outlet obstruction in intra-anal intussusception. 6 1/15/2019 Preparation • No bowel preparation was used • It was deemed more physiological to observe how anorectal morphology altered during defaecation without preparation. • Two hours prior to the examination the patient ingests 135 ml of liquid barium contrast to opacify the small bowel. • In females the vagina is coated with 30 ml amidotrizoic acid 50% solution gel. • The use of tampons and gauzes soaked in barium should be avoided, because they can impaire pelvic-function. LEFT: Pathology is suspected because of a great distance between rectum and vagina. No oral contrast had been given. RIGHT: After ingestion of liquid barium contrast a large enterocele is seen. 7 1/15/2019 Instrument: 8 1/15/2019 9 1/15/2019 10 1/15/2019 Contrast media • The ideal rectal contrast has to simulate stool in weight and consistency. • Barium paste approximates to the consistency of feces • (Evacu-Paste 100) is a convenient paste. Recording • The fluoroscopic screening of the rectum (one frame per second) and the function of the pelvic musculature and the continence mechanism is assessed. • The whole procedure of DRE should be recorded on video or DVD. • Dynamic recording enables the examiner to follow the movements of the rectum, facilitating the diagnosis of rectocele, enterocele and intussusception, as well as to evaluate the function of the anal sphincter. • The duration of examination is about 15 minutes. 11 1/15/2019 Technique (The four dynamic phases) • images are obtained with the patient at: 1. Rest 2. maximal sphincter contraction (squeezing) 3. maximal strain certain muscles (straining) 4. defecation (push the barium paste) Procedure: 1. The barium paste is injected until the patient experiences discomfort due to rectal distension or until about 250 ml has been instilled. (Liquid barium sulphate (50 ml) was instilled into the rectum, which was then insufflated with air to drive the contrast material proximally and outline the rectal mucosa.) 2. Then, the patient is asked to sit on a special commode. It is important that the patient is sitting during the procedure, since much of physiological nature of defecation is lost when the patient is lying down. 12 1/15/2019 X-ray: 1. Initially the patient is screened in left lateral projection at rest without consciously contracting any pelvic muscles and a spot film is taken. 2. The patient then maximally contracts the pelvic floor muscles ('squeeze') which results in a more tense muscular diaphragm and in elevation of the entire pelvic floor a spot film or video is taken. 3. Then, a fast-film sequence was obtained during straining with closed sphincters . defecation: 1. Finally the patient is asked to empty the rectum as completely as possible. 2. An estimate of the completeness of defecation and measurement of pelvic floor descent can be made. 13 1/15/2019 Rest, start of defecation and end of defecation Additional x-ray: • Additional oblique or anteroposterior (AP) views should be taken of any unexplained radiographic feature seen on the lateral views. • An S-shaped rectum may simulate an intussusception in lateral projection. • Some patients give a history of various unusual maneuvers (digital support of vagina or perineum) to aid defecation. (Allowing the patients to demonstrate the maneuvers). 14 1/15/2019 On the left lateral and an AP-view of a patient with an intussuseption on both views. On the left lateral and an AP-view of a patient with an S-shaped rectum which simulates an intussuseption on the lateral view. 15 1/15/2019 Normal defecography. • (A) At rest. • (B) Note the deeper impression exerted by the puborectal sling (arrow) and the cranial migration of the distal rectum during forced contraction. • (C) During straining with closed sphincters, caudal migration of the anorectal junction is seen (asterisk). • (D) During evacuation, the anal canal opens with loss of puborectalis impression. 16 1/15/2019 Interpretation Parameters 17 1/15/2019 Anorectal angle • The anorectal angle (ARA) is measured between the anal canal longitudinal axis and the posterior rectal line, parallel to the longitudinal axis of the rectum. • At rest = 90 - 100°. • maximal sphincter contraction (squeezing) = (70 - 90°) • maximal strain certain muscles (straining) = >100) • during defecation = (110 - 180°) • ARA is an indirect indicator of the puborectal muscle activity. 18 1/15/2019 • Normal pelvic floor movements. • (A) Mid-sagittal T1- weighted SPGR image obtained at rest after IV administration show normal position of the bladder B, vaginal vault V, and rectum in relationship to the pubococcygeal line (white line). The black lines make the anorectal angle (ARA) and their crosspoint represents the anorectal junction (ARJ). • (B) Mid-sagittal T1- weighted SPGR image obtained during squeezing in the same patient show normal minimal elevation of the pelvic floor and sharpening of the ARA. • (C) Mid-sagittal T1- weighted SPGR image obtained during straining in the same patient show normal minimal descend of the pelvic floor and widening of the ARA. 19 1/15/2019 Perineal descent • This is "the caudad movement of the pelvic floor (anorectal junction) straining". • Defecation normally involves a relaxation of the pelvic floor (levator ani), leading to descent of the perineum. • Normal perineal descent or elevation is less than 4 cm from the pubococcygeal line in either direction (superior or inferior). • less than 3.5 cm relative to the resting position, when the bony landmarks (bis-ischiatic line and tip of the coccyx). • Indirectly represents the elevation and descent of pelvic floor. • Its clinical significance is still controversial 20 1/15/2019 Findings of rectal descent: • Horizontal rectum during push • Delayed or incomplete rectal emptying • Delayed or incomplete rectocele emptying • Rectum protruding into anal canal • Long rectum in the bottom three inches of the pelvis Efficiency of emptying/evacuation • Normally, there is 90-100% evacutaion of rectal contents. 21 1/15/2019 Anal canal width • Again measured during maximal evacuation, this is usually less than 2.5 cm. Anal canal length This is measured during maximal evacuation. 22 1/15/2019 Abnormalities Findings • Rectocele • Rectal prolapse • Sigmoidocele • Intussusception • Spastic pelvic floor syndrome (Paradoxical puborectalis contraction) Abnormal perineal descent 23 1/15/2019 24 1/15/2019 Rectocele • This is the most common finding with this type of imaging. • A rectocele can be defined as an anterior or posterior bulge of the rectal wall beyond the extrapolated line of the wall. • Significantly more anterior rectoceles were found in female patients in males. • Almost always in females, this is an anterior rectoceles where the anteiror rectal wall bulges forward, into the vagina. • In males, the prostate gland gives more support in this area compared to the vaginal cavity, so rectoceles, especially anterior rectoceles are uncommon in males. Less commonly and in males, there may be posterior rectoceles, where the rectum bulges posteriorly. • Anterior rectoceles may occur in individuals without complaints of the anorectal region as a posiible normal phenomenon. This may only be a significant finding if there are symptoms of obstructed defecation. • Usually rectoceles greater than 3 cm and those that do not empty are clinically significant. 25 1/15/2019 Rectocele seen during straining (right) Rectal prolapse/Internal rectal intussusception • The rectum may be seen to prolapse, whether internally or externally. • Intussusception of the rectum is an invagination of the rectal wall, which begins as a circular fold 6 to 8 cm up in the rectum and develops into a condition in which the entire rectal wall folds in towards the rectal lumen. • There can be difficulty differentiating between internal intussusception and a normal rectal fold. • The thickness of the intussusception is half the width of the intussusception (the intussusception is a doubled over layer of rectal wall). • The intussusception can be intra-rectal, intra-anal or finally extra-anal as a rectal. 1 : Intra-rectal intussusception, 2 : Intra-anal intussusception, 3 : Extra-anal intussusception (rectal prolapse) 26 1/15/2019 Enterocele and Sigmoidocele • Enterocele is a prolapse of peritoneum that contains a section of small intestine. Sigmoidocele is a prolapse of peritoneum that contains a section of sigmoid colon. • In females, these prolapses usually descend between the rectum and the vagina. • An enterocele is a peritoneal sac that has herniated downwards along the ventral rectal wall. As DRE is routinely performed with small bowel and vaginal contrast, loops of small bowel are then seen to fill the gap between the vagina and the rectum. • Grade 1 is maximally reaching down to the distal half of the vagina, and partial or complete reduction of the rectal lumen. Grade 2 is as grade 1, but reaching down to the perineum. Grade 3 is protruding out of the anal canal to form a rectal prolapse. 27 1/15/2019 Normal findings at rest (left); during defecation there is a rectocele, that is pushed downward by an enterocele .
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