排粪造影影像学诊断

Daniel Buckland PhD HMS III Gillian Lieberman, MD Defecograms Daniel Buckland PhD, Harvard Medical School Year III Gillian Lieberman, MD February 2012 Daniel Buckland PhD HMS III Gillian Lieberman, MD Daniel Buckland PhD HMS III Gillian Lieberman, MD Outline • Patient Presentation • Menu of Tests • Anatomy • Defecogram (Overview, Patient Prep, Procedure) • Reading a Defecogram • Normal Defecogram Video • Defecogram with Rectocele • Our Patient..Sigmoidocele • Differential Diagnoses • Drawbacks with Defecography • Other Findings with Defecography • MR Defecography • Our Patient..Outcome • Summary Daniel Buckland PhD HMS III Gillian Lieberman, MD Index Case..Radiology Requisition • F w/history of Prader-Willi* and rectal prolapse. • s/p rectoplexy ~1mo • Please eval for persistent rectal or pelvic floor prolapse *Prader-Willi associated with obesity, reduced muscle tone, lower IQ, hypogonadism 3 Daniel Buckland PhD HMS III Gillian Lieberman, MD Menu of Tests • Structure Information – Double Contrast Barium Enema – Endocavitary US – CT • Function Information – Fluoroscopic defecography – Anal manometry – Electromyography – MR defecography 4 Daniel Buckland PhD HMS III Gillian Lieberman, MD Anatomy Schematic representation of the puborectal sling, rectal bulb (RB), pubo- rectal muscle (PRM), and anal canal (AC). -Women have an anterior vaginal vault not shown in image 5 Image from Faccioli, N., A. Comai, et al. (2010). "Defecography: a practical approach." Diagn Interv Radiol 16(3): 209-216. Daniel Buckland PhD HMS III Gillian Lieberman, MD Defecogram Overview • Preferred Study for: – Intussusception – Prolapse – Rectocele • Enteroceles • Sigmoidoceles – Descending perineum syndrome – Dyskinetic puborectalis muscle syndrome • Indications – Constipation • Need for vaginal splinting – Incomplete evacuation – Incontinence • With or without rectal bleeding – Mucous discharge – Perineal pain or discomfort 6 Daniel Buckland PhD HMS III Gillian Lieberman, MD Defecogram Patient Preparation • Night Before – Bowel Prep • Prior to Imaging – Oral Barium – Patient Counseling • Patient Placed in Left Lateral Decubitus – Barium paste injected into rectum (also vagina if female) 7 Image from Faccioli, N., A. Comai, et al. (2010). "Defecography: a practical approach." Diagn Interv Radiol 16(3): 209-216. Syringe filled with barium paste attached to rectal probe Daniel Buckland PhD HMS III Gillian Lieberman, MD Defecogram Procedure • Patient placed upright on radio-transparent commode • Told to evacuate bowels • Fluoroscopic images taken of evacuation 8 Image from Faccioli, N., A. Comai, et al. (2010). "Defecography: a practical approach." Diagn Interv Radiol 16(3): 209-216. Commode in front of fluoroscopy sensor for defecographic imaging Daniel Buckland PhD HMS III Gillian Lieberman, MD Reading a Defecogram • Quality Control • Static – Anal Canal – Vaginal Vault – Sigmoid Colon • Dynamic – Compare pre-, peri-, and post-evacuation – Motion of structures • Physiologic motion – Complete evacuation of paste – Appropriate timing of contraction • Abnormal motion – Rectocele, sigmoidocele, enterocele – Mechanical obstruction – Dysmotility – Intusseseption 9 Daniel Buckland PhD HMS III Gillian Lieberman, MD Normal Defecogram Video • Can show entire straining sequence • Used to diagnose functional defects 10 Companion Patient 1 Fluoroscopic Image Sequence From BIDMC, PACS Play Cine Daniel Buckland PhD HMS III Gillian Lieberman, MD Defecogram with Rectocele • Sigmoid Colon (SC) • Anal Canal (AC) • Vaginal Vault (V) • Rectocele (R) 11 SC AC V R From BIDMC, PACS Companion Patient 2 Spot film taken during fluoroscopic evaluation Daniel Buckland PhD HMS III Gillian Lieberman, MD Our Patient..Sigmoidocele • Sigmoid Colon (SC) • Anal Canal (AC) • Site of rectoplexy (RP) Large sigmoidocele, and probable enterocele, with marked descent of opacified sigmoid colon anterior to the rectum to the level of the perineum. Lack of contrast in rectum probably due to reported incontinence Lack of contrast in vaginal vault due to sigmoidocele 12 SC AC From BIDMC, PACS RP Index Patient Spot film taken during fluoroscopic evaluation Daniel Buckland PhD HMS III Gillian Lieberman, MD Differential Diagnoses • Marked descent of sigmoid – Failure of sigmoidoplexy – Redundant sigmoid colon • Lack of contrast in bowel – Incontinence – Pelvic floor weakness 13 Daniel Buckland PhD HMS III Gillian Lieberman, MD Drawbacks with Defecography Contraindications • Patient non-compliance – Weakness – Balance • Non-communicating rectum • Suspected perforation – Can attempt thickened gastrografin Limitations • Fluoroscopy – Low resolution – Only single plane – Ionizing Radiation 14 Daniel Buckland PhD HMS III Gillian Lieberman, MD Intussusception • Anal Canal (AC) • Site of Intussusception (Arrows) 15 AC Images from Faccioli, N., A. Comai, et al. (2010). "Defecography: a practical approach." Diagn Interv Radiol 16(3): 209-216. and Ott, D. J., D. L. Donati, et al. (1994). "Defecography: results in 55 patients and impact on clinical management." Abdom Imaging 19(4): 349-354. AC Companion Patient 4 Companion Patient 3 Daniel Buckland PhD HMS III Gillian Lieberman, MD Descending Perineum Syndrome 16 Descent of the anorectal junction (asterisk) between resting position (a) and during evacuation (b). Bis-ischiatic line (BIL) is considered as the reference level. A large rectocele is also evident (arrowheads). This is two spot films taken during the same fluoroscopic evaluation Image from Faccioli, N., A. Comai, et al. (2010). "Defecography: a practical approach." Diagn Interv Radiol 16(3): 209-216. Companion Patient 5 Daniel Buckland PhD HMS III Gillian Lieberman, MD Dyskinetic puborectalis muscle 17 The arrow indicates an abnormally deep puborectal impression at the beginning of the evacuation phase. The anal canal is opening (arrowheads) and a small rectocele appears (asterisk). Image from Faccioli, N., A. Comai, et al. (2010). "Defecography: a practical approach." Diagn Interv Radiol 16(3): 209-216. Companion Patient 6 Daniel Buckland PhD HMS III Gillian Lieberman, MD MR Defecography showing Intussusception • Higher Cost • Technically more complex – Requires Open MR • More comfortable for patient – No enema or vaginal contrast • Circumferential mural intussusception (arrowheads) that extends into the rectal ampulla. An anterior rectocele is also evident (arrow) 18 Image from Roos, J. E., D. Weishaupt, et al. (2002). "Experience of 4 years with open MR defecography: pictorial review of anorectal anatomy and disease." Radiographics 22(4): 817-832. Companion Patient 7 Sagittal MRI Daniel Buckland PhD HMS III Gillian Lieberman, MD Our Patient…Outcome • Follow-up with PCP for potential surgical revision of sacroplexy if symptoms continue. Daniel Buckland PhD HMS III Gillian Lieberman, MD Summary • Defecograpy is used for functional imaging of the muscles and tubular structures used in defecation • It can diagnose anatomic and functional defects. • The most common modality is fluoroscopy, but MRI can be used as well. • Physicians ordering defecograms should prepare patients to go through an experience that may violate their social taboos. Daniel Buckland PhD HMS III Gillian Lieberman, MD References • Bassotti, G. and V. Villanacci (2011). "A practical approach to diagnosis and management of functional constipation in adults." Intern Emerg Med. • Faccioli, N., A. Comai, et al. (2010). "Defecography: a practical approach." Diagn Interv Radiol 16(3): 209-216. • Ott, D. J., D. L. Donati, et al. (1994). "Defecography: results in 55 patients and impact on clinical management." Abdom Imaging 19(4): 349-354. • Roos, J. E., D. Weishaupt, et al. (2002). "Experience of 4 years with open MR defecography: pictorial review of anorectal anatomy and disease." Radiographics 22(4): 817-832. 21 Daniel Buckland PhD HMS III Gillian Lieberman, MD Acknowledgements • Michael Acord MD 22