Rectal stenosis. A rare complication of chronic salpingitis caused by an intrauterine device

The authors describe one case of rectal stenosis complicating chronic salpingitis in a patient carrying an intrauterine device. This observation is peculiar in that the inflammatory fibrous reaction is very intense, spreading all over the pelvis and forming a pseudotumoral mass sheathing the rectum. The clinical signs were mainly digestive, including a rectal syndrome: cramplike pelvic pain before defecation, tenesmus, constipation, abdominal pain and induration of the anterior aspect of the rectum observed during the clinical examination. Radiological examinations (barium enema, ultrasound, CT) show a tissue mass within the pelvis, with considerable thickening of the rectal wall. Ultrasound-guided biopsy in the pelvis yielded only nonspecific inflammatory signs with dominant fibrosis. The diagnosis of rectal stenosis caused by chronic salpingitis complicating the presence of an IUD was made only during surgery.     

小儿推拿联合益生菌治疗儿童功能性便秘疗效观察

目的探讨小儿推拿联合益生菌对儿童功能性便秘的临床疗效。方法选择105例符合功能性便秘诊断标准的儿童,年龄2岁11个月～8岁2个月,随机分为两组,A组为对照组（n=54）使用双歧杆菌三联活菌胶囊口服治疗,B组为联合治疗组（n=51）使用小儿推拿联合双歧杆菌三联活菌胶囊口服治疗,观察治疗后两组的大便性状评分和每周排便次数。结果 B组14～28d大便性状评分优于对照组,每周排便次数多于对照组。结论小儿推拿联合益生菌治疗儿童功能性便秘可明显改善患者大便性状,增加每周排便次数,临床疗效优于单用益生菌口服治疗。     

Metastatic rectal gastrointestinal stromal tumor with intestinal obstruction: A rare case report

Gastrointestinal stromal tumors (GISTs) arising from the rectum are rare. We report the case of an aggressive rectal gastrointestinal stromal tumor (GIST) in a 60-year-old female that presented for symptoms of constipation and lower gastrointestinal bleeding. Upon rectal examination, a hard mass was found at 6cm from the anal marge. An MRI was indicated that shows a well-demarcated lesion originates from the distal rectum with exophytic growth and central necrosis. The diagnosis of rectal gist was confirmed by colonoscopy with biopsy and immunohistochemical analyses of bioptic material. Liver metastases were seen on computerized tomography (CT). She was referred for palliative chemotherapy. The patient had suffered from intestinal obstruction three weeks after his initial presentation and passed away shortly thereafter. We aimed to report this case as an aggressive and rare GIST localization.     

排粪造影在功能性出口梗阻诊断中的临床意义

目的探讨排粪造影在诊断与治疗功能性出口梗阻性便秘中的应用。方法对186例排便障碍者进行排粪造影检查与治疗。结果 7例X线无异常,179例有异常X线表现。其中直肠前突113例,直肠黏膜脱垂、内套叠92例,会阴下降64例,盆底痉挛综合征11例,耻骨直肠肌综合征7例,内脏下垂7例,乙状结肠疝3例。其中多种异常表现并存69例。结论排粪造影对功能性出口梗阻性便秘的诊断与治疗具有重要价值。     

Assessment of chronic constipation: colon transit time versus defecography

OBJECTIVE: The aim of this study was to determine the value of radiological colon transit time (CTT) measurements in relation to defecography (DFG) in chronically constipated patients. MATERIALS AND METHODS: In 30 patients with chronic constipation, total and segmental CTT was determined using radiopaque markers. In all of these patients defecography (DFG) was obtained. The patients were divided into three groups: In group I, 11 patients were classified with idiopathic constipation based on low stool frequency, normal DFG, or absence of symptoms of abnormal defecation. In group II, ten patients with rectal intussusception were diagnosed by DFG. In group III, there were nine patients with rectal prolapse or spastic pelvic floor syndrome, based on results of DFG. RESULTS: Group I, idiopathic constipation (n = 11), showed increased total CTT (mean, 93 h) and segmental CTT (right colon, 33 h (36%), left colon, 31 h (33%), rectosigmoid, 29 h (31%)). In group II, intussusception (n = 10), patients had normal mean total CTT (54 h) and a relative decrease in rectosigmoid CTT (mean, 13 h (24%)). In group III (n =9), rectal prolapse (n = 5) or spastic pelvic floor syndrome (n = 4), patients showed elevated total (mean, 167 h) and rectosigmoidal CTT (mean, 95 h (57%)). Mean total CTT was significantly different between groups I and II and between groups II and III, and mean rectosigmoidal CTT was significantly different between all three groups (P < 0.05). CONCLUSION: The use of total and rectosigmoidal CTT helps to identify the underlying pathophysiology of chronic constipation. Furthermore CTT helps to identify patients, who may benefit from DFG.     

Ultrasound imaging of the anorectal malformation during the neonatal period: a comprehensive review

Anorectal malformation (ARM) is classified as low, intermediate, or high; accurate diagnosis of the type during the early neonatal period is important to determine the appropriate initial surgical approach. This review assesses the role of ultrasound examination in the classification of ARM during the neonatal period, with a focus on landmarks on the sonogram, the approach used for sonography, and the optimal examination timing. The following three factors on the sonogram are used for the classification: location of the fistula, the distance between the distal rectal pouch and the anal dimple (perineum) (P–P distance), and the relationship between the puborectalis muscle and the distal rectal pouch. Three approaches can be used to evaluate ARM by ultrasonography, namely, suprapubic, perineal, and infracoccygeal approaches. Each approach has its own advantages and disadvantages. Optimal timing of the ultrasound examination is also important with respect to each factor to classify ARM. We have described the pitfalls of ultrasound in diagnosis of cases, namely ARM with Down syndrome (which tends to be without fistula), ARM with low birth weight, ARM with unusual location of fistula, ARM with opened fistula (where the P–P distance is unreliable), and cloacal malformation (variation of the high-type ARM).     

Small bowel hydro‐MR imaging for optimized ileocecal distension in Crohn's disease: Should an additional rectal enema filling be performed?

PURPOSE: To assess the impact of an additional rectal enema filling in small bowel hydro-MRI in patients with Crohn's disease. MATERIALS AND METHODS: A total of 40 patients with known Crohn's disease were analyzed retrospectively: 20 patients only ingested an oral contrast agent (group A), the other 20 subjects obtained an additional rectal water enema (group B). For small bowel distension, a solution containing 0.2% locust bean gum (LBG) and 2.5% mannitol was used. In all patients, a breathhold contrast-enhanced T1w three-dimensional volumetric interpolated breathhold examination (VIBE) sequence was acquired. Comparative analysis was based on image quality and bowel distension as well as signal-to-noise ratio (SNR) measurements. MR findings were compared with those of conventional colonoscopy, as available (N = 25). RESULTS: The terminal ileum and rectum showed a significantly higher distension following the rectal administration of water. Furthermore, fewer artifacts were seen within group B. This resulted in a higher reader confidence for the diagnosis of bowel disease, not only in the colon, but also in the ileocecal region. Diagnostic accuracy in diagnosing inflammation of the terminal ileum was 100% in group B; in the nonenema group there were three false-negative diagnoses of terminal ileitis. CONCLUSION: Our data show that the additional administration of a rectal enema is useful in small bowel MRI for the visualization of the terminal ileum. The additional time needed for the enema administration was minimal, and small and large bowel pathologies could be diagnosed with high accuracy. Thus, we suggest that a rectal enema in small bowel MR imaging be considered.     

Echographic study with high-frequency and high-spatial resolution transducer in the evaluation of renal transplant in pediatric age

PURPOSE: We investigated the role of power Doppler US with a high-frequency and high-resolution transducer (13 MHz) in the visualization of interlobular arterioles in patients with normally functioning renal transplants or with chronic rejection. MATERIAL AND METHODS: We examined 15 patients (mean age 15 years; range 10-18 years) with a General Electric 500 MD unit using 7.5 and 13 MHz linear transducers. In all the patients serum creatinine and diuresis were evaluated; 4 patients underwent US-guided biopsy that resulted in the diagnosis of chronic rejection. RESULTS: Normally functioning renal transplants were found in 11 patients and chronic rejection was seen in 4. In normally functioning renal transplants, interlobular vessels could be depicted as "cortical blush" with the 7.5 MHz transducer; in the same patients power Doppler US with the 13 MHz transducer permitted a correct evaluation of interlobular vessels that were arranged in series like a palisade. In chronic rejection power Doppler US with the 13 MHz transducer better depicted cortical vascularity and showed irregular, narrow arteries. CONCLUSION: Power Doppler US with a 13 MHz transducer is particularly useful in children after renal transplants due to their reduced tissutal thickness. The lateral resolution of 13 MHz transducers (< 0.3 mm) allows to separate interlobular vessels from each other and the high frequency of the probe can depict interlobular vessels in the peripheral cortex. The optimal visualization of cortical vascularity with a 13 MHz transducer allows early detection of chronic rejection.     

MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value

Objectives

We describe the spectrum of findings and the diagnostic value of MR defecography in patients referred with suspicion of dyssynergic defecation.

Methods

48 patients (34 females, 14 males; mean age 48 years) with constipation and clinically suspected dyssynergic defecation underwent MR defecography. Patients were divided into patients with dyssynergic defecation (n = 18) and constipated patients without dyssynergic defecation (control group, n = 30). MRIs were analysed for evacuation ability, time to initiate evacuation, time of evacuation, changes in the anorectal angle (ARA-change), presence of paradoxical sphincter contraction and presence of additional pelvic floor abnormalities. Sensitivity, specificity, positive and negative predictive values and accuracy for the diagnosis of dyssynergic defecation were calculated.

Results

The most frequent finding was impaired evacuation, which was seen in 100% of patients with dyssynergic defecation and in 83% of the control group, yielding a sensitivity for MR defecography for the diagnosis of dyssynergic defecation of 100% (95% confidence interval (CI) 97–100%), but a specificity of only 23% (95% CI 7–40%). A lower sensitivity (50%; 95% CI 24–76%) and a high specificity (97%; 95% CI 89–100%) were seen with abnormal ARA-change. The sensitivity of paradoxical sphincter contraction was relatively high (83%; 95% CI 63–100%). A combined analysis of abnormal ARA-change and paradoxical sphincter contraction allowed for the detection of 94% (95% CI 81–100%) of the patients with dyssynergic defecation.

Conclusion

MR defecography detects functional and structural abnormal findings in patients with clinically suspected dyssynergic defecation. Impaired evacuation is seen in patients with functional constipation owing to other pelvic floor abnormalities than dyssynergic defecation.Dyssynergic defecation, which produces functional outlet obstruction during defecation, is one of the causes of chronic constipation. Dyssynergic defecation is a functional disorder characterised by either paradoxical contraction, an inability to relax the anal sphincter and/or puborectalis muscle, or impaired abdominal and rectal pushing forces. In the literature, many other terms such as anismus [1], dyskinetic puborectalis muscle [2], non-relaxing puborectalis syndrome [3], spastic pelvic floor syndrome [4, 5] and pelvic floor dyssynergia [6] have been used. An expert group (Rome III) [7] recently proposed the term “dyssynergic defecation” to appropriately describe the failure of co-ordination or dyssynergia of the abdominal and pelvic floor muscles involved in defecation. Different physiological tests can be used to investigate this functional disorder, including the balloon expulsion test, electromyography (EMG) of the puborectalis muscle and anorectal manometry. Defecography can be performed to rule out structural rectal abnormalities and provide an estimate of the degree of rectal emptying. As false-positive and false-negative results are common with these different tests, none can be used by itself as a gold standard for identifying patients with dyssynergic defecation.Most authorities recommend using a combination of diagnostic tests and clinical history. The Rome III expert group defined the criteria for the diagnosis of dyssynergic defecation based on clinical history, anorectal manometry, balloon expulsion test, EMG and conventional defecography (evacuation proctography) [7]. Functional imaging with conventional defecography is considered to be a useful adjunct in establishing the diagnosis of dyssynergic defecation. Delayed initiation of evacuation and impaired evacuation in particular, as seen on conventional defecography, are highly predicitive for the presence of dyssynergic defecation [8, 9]. Different structural imaging findings in conventional defecography have been described in patients with dyssynergic defecation; however, the usefulness of these findings is discussed controversially [8, 10, 11].The experience with MR defecography, which has shown to be a valuable alternative to evacuation proctography [12–15], is limited in dyssynergic defecation patients. There is only one study which has focused on the MR defecography findings in a study setting in patients with dyssynergic defecation [16]. Hence, the purpose of this study was to describe the spectrum of findings in MR defecography in patients referred with the suspicion of dyssynergic defecation and to assess the value of MR defecography in establishing this diagnosis. For the latter, the patients with dyssynergic defecation were compared with a group of constipated patients without dyssynergic defecation.     

仿真排粪造影剂的研制及其临床应用研究

目的 :研制用于排粪造影的仿真排粪造影剂及配套用的注推器和专用软肛管 ,为临床提供诊断和治疗的依据。方法 :选择无便秘症状的健康志愿者 35例 (简称正常组 ) ,男 14例 ,女 2 1例 ,平均年龄 44岁。采用了钡悬液排粪造影检查 (简称 1法 )及仿真排粪造影检查 (简称 2法 )双法对比观察。便秘病人 6 7例 (简称便秘组 ) ,男 19例 ,女 48例 ,平均年龄 47岁。也进行了双法对比观察。 1法造影剂的配方为 2 0 0 %的硫酸钡悬液 40 0 ml。 2法配方 :包括硫酸钡粉剂、麦麸及白芨粉。结果 :正常组经 1法、2法观察 18例女性有轻度直肠前凸 ,占 5 1% ,余未见异常。1法、2法对比力排状态下肛直角有显著性差异。便秘组中 5例无异常发现 ,有异常发现的 6 2例病人中盆底痉挛异常者 2 3例 (简称痉挛组 ) ,占 34% ,其中男 10例 ,女 13例。盆底松驰异常者 39例 (简称松驰组 ) ,占5 8% ,其中男 5例 ,女 34例。痉挛组 :肛直角静息状态下 1法、2法测量结果相同 ,力排状态下不同。肛门上距静息状态下 1法、2法相同 ,力排状态下不同。松驰组 :肛直角静息状态下 1法、2法测量结果相同 ,力排状态下不同。肛门上距静息状态下 1法、2法相同 ,力排状态下相同。结论 :本造影方法可准确区别直肠粘膜脱垂和全套叠 ,正确诊断耻骨直肠肌痉挛     

Barium studies and ileoscopy compared in children with suspected Crohn's disease

The findings on barium follow through, ileoscopy and biopsy of the terminal ileum in 46 children with suspected chronic inflammatory bowel disease have been compared to the final clinical diagnosis. Ileoscopy and barium follow through agreed in 91%, barium follow through and biopsy in 80% and barium follow through, ileoscopy and biopsy in 76% of cases. A pronounced lymphoid hyperplasia pattern was present radiologically in 24%, and was a source of error in two cases. Barium follow through compared favourably to ileoscopy or biopsy individually, detecting 18 of 20 and 17 of 20 cases respectively; however, ileoscopy combined with biopsy diagnosed every case. The sensitivity of the barium follow through was 0.90 with a specificity 0.96 for the diagnosis of Crohn's disease in the terminal ileum.     

Videodefaecography combined with measurement of the anorectal angle and of perineal descent

Cineradiographic defaecography combined with measurement of the anorectal angle and descent of the pelvic floor is proposed. The method used in 73 women gave valuable information in 48 patients who complained of anal incompetence, rectal tenesmus, and chronic constipation. In these patients, high and low rectal intussusception, rectocele, and pathologic movement of the pelvic floor were detected. Some of these phenomena could only be diagnosed by the radiologic method here described. Quantitations of the anorectal angle and descent of the pelvic floor placed the group with constipation halfway between normal individuals and those with anal incompetence. The value of this finding is discussed. Recent improvements in anorectal surgery often make videodefaecography decisive for the choice of the optimal operative method. Therefore, videodefaecography together with measurement of the anorectal angle and pelvic floor descent is recommended whenever anorectal surgery for correction of functional disturbances is contemplated.     

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。     

Radiological diagnosis of constipation and anal incontinence caused by changes in the pelvic floor and anal sphincter. Our experience with 38 patients with constipation with or without incontinence

Rectal constipation, anal incontinence and constipation combined with incontinence, are often caused by organic or simply functional changes in the pelvic floor and sphincteric apparatus. Therefore morphological as well as manometric and electromyographic studies of these anatomical parts are required. This is possible by combining two techniques: Intestinal Transit Time (ITT) and Defecatory Proctogram with Balloon (DPB). Personal experience of 38 patients with constipation with or without incontinence is reported. The results lead to the following conclusions: 1) ITT is a simple and non-invasive radiological technique that provides us with objective evidence of an impairment, i.e. constipation, whose symptoms are often only subjective; especially it allows us to identify rectal constipation, that can be caused by impairment of the anal sphincteric apparatus. 2) Using an uroprophylactic with a collar that adapts to the size of the anal duct, DPB always permits visualisation of the duct with good representation of the recto-anal angle, whose changes may be the expression of organic or only functional impairments of the anal sphincteric apparatus. Increasing use of the two radiological techniques is therefore recommended in the diagnosis of alterations of the pelvic floor or anal sphincter.     

Altered gastric emptying in patients with irritable bowel syndrome

Irritable bowel syndrome is the most frequent functional disorder of the digestive system. Patients with irritable bowel syndrome have motor disorders not only in the colon, but also in other parts of the digestive tract such as the oesophagus and small intestine; however, it is not known whether the stomach is also involved. We used a radiolabelled mixed solid-liquid meal (technetium-99m for the solid component, indium-111 for the liquid component) to study gastric emptying of solids (GES), liquids (GEL) and indigestible solids (GER) in 50 patients diagnosed as having irritable bowel syndrome (30 with predominant constipation and 20 with predominant diarrhoea). GER was measured by counting the number of indigestible solids remaining in the stomach 4 h after they were swallowed. In patients with irritable bowel syndrome, GES and GEL were slower than in control subjects (P<0.05). GER was normal in all patients except for two women. Thirty-two patients (64%) showed delayed GES, 29 (58%) delayed GEL, and 2 (4%) delayed GER. Among patients with irritable bowel syndrome, GES was slower in those with predominant constipation than in those with predominant diarrhoea (P<0.05); GEL and GER were similar in both groups. Gastroparesis was found in a large proportion of patients with irritable bowel syndrome, suggesting the presence of a more generalised motor disorder of the gut.     

潜艇艇员慢性便秘的心理因素研究

目的 通过对潜艇艇员中便秘患者进行心理测试来研究功能性便秘与心理因素之间的关系,以期为便秘的诊断和治疗提供依据.方法 对26名符合罗马Ⅲ标准的功能性便秘患者(实验组)和30名健康者(对照组)进行对照研究,采用生活事件量表、症状自评量表进行心理测试,分析心理状况.结果 在生活事件量表评定中,在负性生活事件得分上,实验组高于对照组;在症状自评量表评定中,总分、总均分、阳性项目数,实验组均明显高于对照组;另外,躯体化、强迫、抑郁、焦虑等因子分实验组也都高于对照组.结论 精神心理因素在便秘的发病中起了一定作用,因此在对潜艇艇员便秘进行药物治疗的同时,进行心理测试和心理治疗是必要的.     

Patient navigation: improving timeliness in the diagnosis of breast abnormalities.

OBJECTIVE: Patient navigation is a process that provides assistance to referring physicians in arranging further investigations and consultation for defined patient groups. This can facilitate timely investigations and potentially minimize delays. The purpose of this study was to determine the impact of patient navigation on timeliness in the diagnosis of breast abnormalities. METHODS: We retrospectively studied a cohort of 536 women who underwent breast core biopsy at our institution during comparable 6-month periods in 1999 and 2000 to determine the effects of patient navigation, age, and biopsy result on the wait for a biopsy after diagnostic imaging. Patient navigation was used for all women referred through the provincial breast cancer screening program. Navigation was unavailable to patients directly referred by physicians in 1999. In 2000, the program was expanded to encompass all patients. RESULTS: From 1999 to 2000, the median wait for a biopsy remained relatively stable for "navigated" screening patients at 12 days (n = 97) and 13 days (n = 133), respectively. The introduction of patient navigation for directly referred patients resulted in a statistically significant decrease in waiting times, from 20 days (n = 144) in 1999 to 14 days (n = 162) in 2000. Age and biopsy results were statistically significant variables, but their effect on the group data was negligible relative to that of navigation. CONCLUSIONS: Patient navigation significantly improves timeliness in the diagnosis of breast abnormalities and can potentially improve quality of life with more timely reassurance for women with benign conditions and earlier treatment for those with malignancy.     

Evaluation of chronic infectious interstitial pulmonary disease in children by low-dose CT-guided transthoracic lung biopsy

Background Children with chronic infectious interstitial lung disease often have to undergo open lung biopsy to establish a final diagnosis. Open lung biopsy is an invasive procedure with major potential complications. Transthoracic lung biopsy (TLB) guided by computed tomography (CT) is a less-invasive well-established procedure in adults.Objective Detailing the role of low-dose CT-guided TLB in the enhanced diagnosis of chronic lung diseases related to infection in children.Materials and methods A group of 11 children (age 8 months to 16 years) underwent CT-guided TLB with a 20-gauge biopsy device. All investigations were done under general anaesthesia on a multidetector CT scanner (SOMATOM Volume Zoom, Siemens, Erlangen, Germany) using a low-dose protocol (single slices, 120 kV, 20 mAs). Specimens were processed by histopathological, bacteriological, and virological techniques.Results All biopsies were performed without major complications; one child developed a small pneumothorax that resolved spontaneously. A diagnosis could be obtained in 10 of the 11 patients. Biopsy specimens revealed chronic interstitial alveolitis in ten patients. In five patients Chlamydia pneumoniae PCR was positive, in three Mycoplasma pneumoniae PCR was positive, and in two Cytomegalovirus PCR was positive. The average effective dose was 0.83 mSv.Conclusion Low-dose CT-guided TLB can be a helpful tool in investigating chronic infectious inflammatory processes in children with minimal radiation exposure. It should be considered prior to any open surgical procedure performed for biopsy alone. In our patient group no significant complication occurred. A disadvantage of the method is that it does not allow smaller airways and vessels to be assessed.     

Functional gastrointestinal disorders among soldiers in peacetime versus out-of-area missions

Functional gastrointestinal syndromes are chronic disorders of the abdomen with an absence of organic findings. The aim of this study was to compare the frequency and symptomatology of functional abdominal syndromes in soldiers during an out-of-area mission versus during peacetime at home. We examined 124 soldiers who sought medical care for abdominal symptoms at the German Field Hospital Trogir, Croatia. The control group consisted of 113 soldiers who were referred with abdominal symptoms to the Central Hospital of German Armed Forces Koblenz, Germany. After excluding an organic disease, the diagnosis of a functional disorder was made. Fourteen percent of the Implementation Force soldiers had symptoms of a functional syndrome. At home, the frequency of functional gastrointestinal disorders was 50%, significantly greater than the rate during the out-of-area mission (p < 0.0001). We conclude that functional gastrointestinal disorders are more rare during out-of-area missions than during peacetime. They are probably as frequent away from home as at home, but "health care seeking" is less frequent under the stressful conditions of out-of-area missions.     

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。