直肠前突手术前后的动态X线和MR排粪造影

目的:评价动态X线和磁共振排粪造影在直肠前突自动痔疮套扎术(RPH)治疗前后的应用价值.方法:中重度直肠前突患者16例纳入研究,年龄25～68岁,平均51岁,均为经产妇;全部完成RPH术前和术后的动态X线和MRI排粪造影检查.在两种检查图像上分别分析直肠前突的程度和并发症,并进行对比分析.结果:X线排粪造影显示术前重度直肠前突10例(58％)和中度直肠前突6例(42％),术后仅见中度直肠前突2例;直肠前壁黏膜脱垂、直肠内套叠和痔疮的显示术后(3例次)明显少于术前(33例次)(x2=14.933,P＜0.001).MR排粪造影显示术前重度直肠前突7例(43％)和中度直肠前突9例(57％),术后仅显示中度直肠前突1例;结直肠并发症显示(13例次)明显少于X线排粪造影(42例次)(x2=15.291,P＜0.001),但显示了更多的结直肠外合并症.结论:X线和MRI排粪造影评价直肠前突各有优缺点,综合评价更完整,并对RPH治疗后评估有良好应用价值.     

经阴道后壁双重修补法治疗直肠前突60例

我院自1993年6月采用经阴道后壁双重修补直肠前壁和阴道直肠隔的方法，治疗直肠前突60例，效果显著。回临床资料1．1一般情况本组60例，年龄36～61岁，平均41·45岁；生育卫～6胎；病程3～20年；平均每天排便6．85次。排便困难56例，占93．3％；腹胀34例，占56．7％；需辅助排便（口服泻剂、灌肠、手挖等）48例，占80％。X线排粪造影诊断：测量静息位，力排强忍，力排时前突的深度和长度，根据力排的直肠前突的深度“’“分为：轻度前突的深度为7～15mm，中度为16～30mm，重度为＞31mm，＜6mm为正常。本组病例全部为中、重度。1．2方法1．2…     

便秘的病因与排粪造影诊断价值的探讨

目的：分析便秘的原因并评价排粪造影对出口梗阻型便秘的诊断价值。方法：对１００例便秘患者作排粪造影分析。结果：出口梗阻者９６例,其中单纯性直肠前突１９例（１９．７９％）,直肠前突伴有其他异常４０例（４１．６７％）,直肠粘膜脱垂及其合并症３７例（３８．５４％）。结论：由于出口梗阻结肠无力常合并存在并相互作用导致便秘的发生。作者强调排粪造影能对出口梗阻做出准确的病因学诊断。排粪造影的正确应用为肛肠外科医     

排粪造影对功能性肛门直肠梗阻的诊断价值及临床应用(附156例分析)

目的：分析功能性肛门直肠梗阻的病因及X线表现。方法：156例女性患者接受了检查。采用浓度为180％。200％硫酸钡行常规排粪性造影，透视下动态观察并连续摄片。结果：156例患者中，直肠前突96例。会阴下降107例。直肠内套叠59例，盆底痉挛综合征45例，盆底疝7例，内括约肌失弛缓症3例。正常3例，直肠前突常合并会阴下降、直肠内套叠及盆底痉挛综合症。本组病例中，46例直肠前突、29例直肠内套叠、2例内括约肌失弛缓症经临床手术治疗。均获得了良好的效果。结论：排粪性造影较传统的肛直肠部检查更敏感可靠。它能直接显示功能性出口梗阻的原因及发病程度。为临床治疗提供了可靠依据。     

直肠前突的X线和磁共振排粪造影研究

目的:比较显示直肠前突的X线和MRI排粪造影两种方法,进一步探讨直肠前突排粪造影技术.方法:中重度直肠前突患者32例纳入研究,年龄22～77岁,平均48岁,均为女性;全部X线和MRI排粪造影检查.比较两种图像显示直肠前突及其程度和并发症的情况.结果:两种技术均良好显示了全部的直肠前突,X线排粪造影直肠前突程度高于MRI排粪造影.X线排粪造影显示肠并发症(84例次)明显高于MRI排粪造影(26例次,P＜0.01);其它肠外并发症则X线排粪造影显示(12例次)不如MRI排粪造影(40例次,P＜0.01).结论:X线和磁共振排粪造影各有优缺点,前者在显示直肠前突本身和肠并发症更佳,后者则有利于显示肠外并发症.     

排粪造影检查在诊断功能性出口梗阻型便秘中的价值

对53例临床初步诊断便秘患者进行排粪造影检查。检查前均行结肠运输试验除外结肠型便秘。结果：直肠前突35例，直肠粘膜内套叠44例，会阴下降24例，盆底肌肉痉挛综合症14例，仅1例未见异常。粪造影检查诊断的敏感性为98．1％，由此表明，应用排粪造影检查诊断功能性出口梗阻型便秘具有极高的敏感性和应用价值。     

排粪X线造影在肠易激综合征诊断中的应用

为了解排粪X线造影在肠易激综合征患者中的应用价值，对12例便秘为主型、10例便秘和腹泻交替型、14例腹泻型肠易激综合征患者进行排粪X线造影。结果排粪造影阳性的例数为13例（36.11％），排便过程中的异常有多种，包括直肠前突、直肠粘膜脱垂、内脏下垂、会阴下降和盆底痉挛综合征等。说明排粪X线造影对肠易激综合征的诊断和治疗有一定的价值。     

直肠排粪造影在便秘患者病因诊断中的意义

目的评价直肠排粪造影在便秘原因诊断中的意义。方法56例临床怀疑由于肛肠疾病引起的便秘患者（女51例,男5例,年龄33～72岁,平均41岁）均在经肛门——直肠灌注对比剂为160％（W／V）的硫酸钡250mL后接受了直肠排粪造影。结果在56例便秘患者中,直肠前突见于42例。耻骨直肠肌肥厚4例,直肠前壁黏膜脱垂3例,直肠内套叠3例,乙状结肠疝2例,直肠息肉1例,以及经病理证实的直肠癌1例。结论直肠排粪造粪造影在便秘的病因学诊断中具有高度准确性。     

排粪造影X线测量在功能性便秘诊断中的应用价值

目的探讨排粪造影X线测量在功能性便秘病因诊断中的应用价值。方法对35例出现临床症状的功能性便秘患者,进行排粪造影检查,显示直肠病变程度和并发症情况,进行图像采集和后处理,分别测量肛直角(ARA)、肛上距(DUAC)、直肠前突深度、乙耻距(DSPC)、骶直距(DSR)。结果 X线良好的显示了全部直肠功能性病变,本组35例患者中,直肠前突26例,直肠前壁黏膜脱垂18例,直肠内套叠3例,耻骨直肠肌肥厚2例,乙状结肠冗长1例。结论排粪造影X线测量在功能性便秘的病因诊断中具有较高的应用价值。     

动态直肠排粪造影在出口梗阻型便秘中的应用价值(附1055例分析)

目的分析出口梗阻型便秘的主要病因及其直肠排粪造影表现,探讨动态直肠排粪造影对出口梗阻型便秘的价值。方法 1174例便秘患者行直肠排粪造影检查,透视下动态观察并摄片;其中阳性1055例(男性170例,女性885例)。结果出口梗阻型便秘男性患者的主要病因为盆底痉挛综合征,而女性患者的主要病因为直肠前突、直肠粘膜脱垂。出口梗阻型便秘患者常多种病因共存。结论动态直肠排粪造影能显示出口梗阻型便秘的直接原因,为出口梗阻型便秘的诊疗提供可靠依据。     

直肠黏膜脱垂患者排粪造影的X线表现分级研究

目的 探讨X线排粪造影在诊断直肠黏膜脱垂病变中的影像学分级方法.方法 对38例通过X线排粪造影诊断为直肠黏膜脱垂的病例进行影像表现分析,并参考国内外学者的文献进行细化分级.结果 按照笔者研究的分级方法,38例直肠黏膜脱垂病例X线排粪造影诊断为1级的8例;2级27例,其中2a级15例,2b级12例;3级3例.部分患者同时合并直肠前突等其他征象.结论 直肠黏膜脱垂病变X线排粪造影的细化分级,可能有助于临床治疗方案的设计.     

Functional evaluation of the anorectal region

Defecography is a method allowing the morphodynamic evaluation of the anorectal region. The technique we employed needs two complementary times: "phase" defecography and dynamic defecography. In our series of patients affected with severe constipation, 2 groups could be identified. Group A included those patients (mean age: 38.7 years) in whom no significant changes were observed in anorectal angle and in the distance of anorectal angle from pubococcygeal line in comparison with normal subjects (Student's t-test). Group B included those patients (mean age: 63.3 years) in whom significant reduction was observed in anorectal angle on straining, together with increased distance of anorectal angle from pubococcygeal line on squeezing in comparison with normal subjects (Student's t-test). In constipated patients narrowed anal canal was observed (60%), together with rectocele (42.6%), mucosal prolapse (27.8%), rectal prolapse (18%) and solitary ulcer (14.7%). In idiopathic incontinence patients (mean age: 63.3 years), increased distance was observed of anorectal angle from pubococcygeal line on squeezing and, in the most severe cases, even at rest, with the patient sitting (Student's t-test). In incontinent patients larger anal canal was observed (67.6%), together with rectocele (36.7%), mucosal prolapse (14.7%), and rectal prolapse (11.7%).     

Radiologic investigation of external rectal prolapse. Assessment in 48 patients with defecography, seven of them also with dynamic CT of the pelvis

PURPOSE: To report our personal experience in 48 patients with external rectal prolapse examined with defecography, evaluating radiological signs and the indications for surgical treatment. We also report the results of 7 patients with severe prolapse submitted to dynamic CT of pelvis. MATERIAL AND METHODS: The findings relative to 48 patients suffering from external prolapse, 27 women and 21 men, (mean age 58 years), were retrospectively reviewed. In our study protocol the patient is made to sit on a defecographic commode with the pelvis in lateral projection and radiographic images are acquired at rest, on contraction and on evacuation. Dynamic CT of pelvis with axial and coronal scans of the pelvic floor was carried out in 7 patients with severe prolapses. Twenty-six of 48 patients underwent rectopexy. RESULTS: The main symptoms were anorectal and perineal weight sensation (93%), perineal disturbance in the sitting position (91%) and anorectal pain extended to sacral area (83%). Manometry, which was performed in 36 cases, showed a rectoanal inhibitory reflex evokable at high volumes of air, especially in incontinent subjects. Defecography demonstrated external rectal prolapse in all cases; rectal intussusception in 32, mucosal prolapse in 30, abnormal widening of the anorectal angle in 24 (16 of them were incontinent), rectocele in 22 and perineal descent syndrome in 16 cases. DISCUSSION AND CONCLUSIONS: External rectal prolapse is sometimes a dynamic progression of a rectal intussusception. In anorectal intussusceptions, the invaginatum involves the anal canal, thus causing the external prolapse. Defecography clearly shows the continuation of invagination out of the anus, with the formation of prolapse. Dynamic CT proved accurate in detecting the rectum morphology, but added no further information to defecography, except for the diastasis of anosphincterial muscles. Therefore, we conclude that defecography is the method of choice, though complementary to other instrumental techniques such as manometry, electromyography and endoscopy, in the diagnostic workup of these patients. Moreover, it can recognize other alterations, such as incontinence and rectocele, which can be submitted to surgical correction with rectopexy.     

蹲姿排粪造影的临床应用

目的：探讨具有长期蹲姿排粪习惯的病人取蹲姿排粪造影的临床应用价值。方法：对130例有不同程度长期排粪障碍者，先后进行坐姿和蹲姿的排粪造影检查。结果：两种姿势检查的结果对比证实，对于长期取蹲姿排粪习惯的病人，蹲姿检查较坐姿检查疾病的检出率高，特别对直肠前突及会阴下降者，蹲姿比坐姿检出率更高，经统计学处理有显著意义。结论：对长期取蹲姿排粪习惯的病人，在行该项检查时应取蹲姿。     

Defecography in rectal wall prolapse conditions]

INTRODUCTION: Pelvic floor and rectal prolapse conditions have greatly benefitted by new imaging and instrumental diagnostic approaches, and especially defecography, for both pathophysiological interpretation and differential diagnosis. We investigated the efficacy of defecography in the assessment of rectal prolapse, and in particular the role of videoproctography in diagnosing such dynamic disorders. MATERIAL AND METHODS: We selected 224 patients with rectal prolapse from a series of 1,190 consecutive subjects with evacuation disturbances examined in the last 5 years with defecography combined with videoproctography. The patients were 176 women and 48 men ranging in age 32-79 years (mean: 48). Defecography was carried out with Mahieu's technique, but we changed the filter position slightly. Sixty-seven per cent of our patients had been submitted to sigmoidoscopy, but this examination does not usually show rectal intussusception. Occult blood test in feces and double contrast barium enema were carried out in 42% and 38% of cases, respectively, to exclude any organic conditions of colon. RESULTS: Mucosal prolapse was more frequent than intussusception (71% and 34%, respectively); rectal walls went out through the anus in 12 cases of anorectal intussusception and thus caused external rectal prolapse. Rectal prolapse was associated with other anorectal alterations, such as rectocele, perineal descent and puborectalis muscle syndrome, in 96 cases. DISCUSSION AND CONCLUSIONS: The dynamic changes of ampulla are well depicted by videoproctography, which showed anorectum normalization and spontaneous reduction of invagination after intussusception. Defecography exhibited good capabilities in showing rectal wall function abnormalities. Finally, some features of videoproctography such as low radiation dose, noninvasiveness and ease of execution, make the examination acceptable to patients with anorectal disorders and for the follow-up of rectal prolapse.     

Prospective assessment of interobserver agreement for defecography in fecal incontinence

OBJECTIVE: The primary aim of our study was to determine the interobserver agreement of defecography in diagnosing enterocele, anterior rectocele, intussusception, and anismus in fecal-incontinent patients. The subsidiary aim was to evaluate the influence of level of experience on interpreting defecography. SUBJECTS AND METHODS: Defecography was performed in 105 consecutive fecal-incontinent patients. Observers were classified by level of experience and their findings were compared with the findings of an expert radiologist. The quality of the expert radiologist's findings was evaluated by an intraobserver agreement procedure. RESULTS: Intraobserver agreement was good to very good except for anismus: incomplete evacuation after 30 sec (kappa, 0.55) and puborectalis impression (kappa, 0.54). Interobserver agreement for enterocele and rectocele was good (kappa, 0.66 for both) and for intussusception, fair (kappa, 0.29). Interobserver agreement for anismus: incomplete evacuation after 30 sec was moderate (kappa, 0.47), and for anismus: puborectalis impression was fair (kappa, 0.24). Agreement in grading of enterocele and rectocele was good (kappa, 0.64 and 0.72, respectively) and for intussusception, fair (kappa, 0.39). Agreement separated by experience level was very good for rectocele (kappa, 0.83) and grading of rectoceles (kappa, 0.83) and moderate for intussusception (kappa, 0.44) at the most experienced level. For enterocele and grading, experience level did not influence the reproducibility. CONCLUSION: Reproducibility for enterocele, anterior rectocele, and severity grading is good, but for intussusception is fair to moderate. For anismus, the diagnosis of incomplete evacuation after 30 sec is more reproducible than puborectalis impression. The level of experience seems to play a role in diagnosing anterior rectocele and its grading and in diagnosing intussusception.     

Defecography by spiral computed tomography

PURPOSE: We investigated the possible role of helical CT defecography in pelvic floor disorders by comparing our results with those of conventional defecography. MATERIAL AND METHODS: Our series consisted of 90 patients, namely 62 women and 28 men, ranging in age 24-82 years. They were all submitted to conventional defecography, and 18 questionable cases were also studied with helical CT defecography. The conventional examination was performed during the 4 standard phases of resting, squeezing, Valsalva and straining; we used a remote-control unit. The parameters for helical CT defecography were: 5 mm beam collimation, pitch 2, 120 KV, 250 mAs and 18-20 degrees gantry inclination to acquire coronal images of the pelvic floor. The rectal ampulla was distended with a bolus of 300 mL nonionic iodinated contrast agent (dilution: 3 g/cc). The patient wore a napkin and was seated on the table, except for those who could not hold the position and were thus examined supine. Twenty-second helical scans were performed at rest and during evacuation; multiplanar reconstructions were obtained especially on the sagittal plane for comparison with conventional defecographic images. RESULTS: An unquestionable diagnosis could be made in all the 18 patients submitted to helical CT defecography. The diagnosis was in agreement with proctology results and added new information in all cases. Sixteen patients had constipation and 2 fecal incontinence--one from rectal prolapse and the other from a rectovaginal fistula. In this latter case helical CT defecography permitted to confirm the fistula and suggest its course. One patient had a previously undetected ovarian cancer metastatic to the anterior rectal wall. DISCUSSION AND CONCLUSIONS: Coronal helical CT defecography images permitted to map the perineal floor muscles, while sagittal reconstructions provided information on the ampulla and the levator ani. To conclude, helical CT defecography performed well in the study of pelvic floor disorders and can follow conventional defecography especially in questionable cases.