直肠内脱垂病人直肠形态研究及临床意义

目的 评价直肠内脱垂病人直肠形态结构变化及其临床意义.方法 31例功能性便秘患者及10例正常对照组行排粪造影评估直肠内脱垂的直肠形态学改变.数据采用Mann-Whitney U非参数法及Fisher's精确检验.结果 病人组与对照组直肠全层内套叠分别为23/31例、2/10例,Fisher's精确检验P=0.007,差别有显著统计学意义;病人组与对照组直肠前壁折叠厚度分别为(13.51±9.42)mm及(3.68±2.34)mm,后壁折叠厚度(5.36±3.92)mm及(2.82±0.99)mm,套叠鞘部直径(37.19±11.79)mm及(25.32±9.25)mm、套入部内口径(14.91±4.74)mm及(19.73±6.36)mm、套叠鞘部直径与套入部内口径之比2.82±1.64及1.28±0.12、静息时直肠最大直径(48.97±9.55)mm及(39.84±8.45)mm,各项差异均有统计学意义(P＜0.05).结论排粪造影可正确区分直肠全层内套叠或直肠黏膜内脱垂,为选择合理的治疗方案提供依据,但基于排粪造影而行治疗干预必须谨慎.     

Rectal intussusception and rectal prolapse: detection and postoperative evaluation with defecography

The authors studied pre- and post-operative defecograms in 20 patients with rectal intussusception and three with rectal prolapse to assess the value of defecography in detection of these conditions. Eleven patients also had solitary rectal ulcers. Two to 3 months after surgery, patients underwent defecography, and results were correlated with postoperative symptoms. In all three patients with rectal prolapse, and 13 of 20 with intussusception, findings on postoperative defecograms were normal and symptoms were gone. Abnormalities and symptoms persisted in two patients and recurred in another two. In five patients, symptoms persisted despite normal defecographic findings. In 11 patients with solitary rectal ulcers, rectal lesions were cured in nine; in two, intussusception and rectal lesions recurred. Thus, presence or absence of solitary rectal ulcer corresponded to postoperative symptoms in all cases. Symptoms and postoperative defecographic findings corresponded in 20. This study suggests that rectal intussusception and prolapse most likely lead to defecation disorders and that defecography is useful in detecting them.     

Barium findings in retrograde intussusception.

Four instances of antiperistaltic intussusception are presented. These serve to depict the varied roentgen appearances in both types of intussusception on barium study and emphasize two simple interpretational principles: (1) when contrast material is administered orad to an antegrade or caudad to a retrograde intussusception, it must first enter the intussusceptum; and (2) when barium is administered orad to a retrograde or caudad to an antegrade intussusception, it must first enter the intussuscipiens. Attention is also directed to tube related intussusceptions and to potential difficulty in their identification.     

The dissection sign of nonreducible ileocolic intussusception

A retrospective study of 90 cases of ileocolic intussusception seen over a 5-year period was undertaken to identify features of failed hydrostatic reductions. A new, reliable sign of nonreducible intussusception was found: the dissection sign. Of the 90 cases, 23 demonstrated barium dissecting between the intussusceptum and intussuscipiens ; of those, nine had necrotic bowel found at surgery. All of the 23 cases with dissection failed hydrostatic reduction. Of the 23 patients, 22 were below age 2 years. None of those reduced by barium enema had dissection. The dissection sign on barium enema for ileocolic intussusception is an indication to discontinue hydrostatic reduction and to institute surgical treatment, especially in patients under age 2 years.     

Ultrasonographic findings of small bowel intussusception, focusing on differentiation from ileocolic intussusception

The purpose of this study was to evaluate the typical ultrasonographic findings of transient small bowel intussusception (SBI) and to differentiate it from ileocolic intussusception (ICI) in paediatrics. 22 transient SBI (male:female = 13:9, age: 7-132 months (mean 38 months)) and 27 ICI (male:female = 19:8, age: 1-60 months (mean 13 months)) patients diagnosed on ultrasonography were retrospectively evaluated. The findings of location, diameter, thickness of outer rim, and inclusion of mesenteric lymph nodes within intussuscipiens were compared. In the transient SBI, the head of intussusception was located in the right lower quadrant (RLQ) in 11 (50%), the right upper quadrant (RUQ) in 2 (9.1%) and the periumbilical area in 9 (40.9%) cases. The anteroposterior (AP) diameter ranged from 0.84-2.4 cm (mean 1.38 cm), and thickness of outer rim ranged from 0.10-0.34 cm (mean 0.26 cm). No mesenteric lymph nodes were contained within the intussuscipiens. In the ICI, the head was located in the RUQ in 17 (63%), the epigastrium in 7 (25.9%) and the left upper quadrant in 3 (11.1%) cases. The AP diameter ranged from 1.89-3.32 cm (mean 2.53 cm), and the thickness of the outer rim ranged from 0.30-0.86 cm (mean 0.53 cm). Mesenteric lymph nodes were contained within the intussuscipiens in 26 (96.3%) cases. In conclusion, when compared with ICI, the transient SBI occurs predominantly in the RLQ or periumbilical region, has a smaller AP diameter, a thinner outer rim, and dose not contain mesenteric lymph nodes.     

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.     

排粪造影结合盆腔造影诊断直肠内脱垂

目的：设计一种盆腔造影结合排粪造影的方法，以期区分直肠粘膜脱垂与直肠全层套叠，指导直肠内脱垂的治疗。材料与方法：８２例直肠内脱垂和３６例对照者行排粪造影结合盆腔造影。结果：在８２例患者中，５０例有直肠内脱垂征象、而盆底腹膜正常者为直肠粘膜脱垂，其中２６例伴异常会阴下降；３２例有直肠内脱垂征象、盆底腹膜随直肠前壁降入套叠鞘部、并构成直肠壁内疝疝囊者为直肠全层套叠，６例疝囊上口敞开者术中证实有内容物疝入，２０例伴异常会阴下降。结论：排粪造影结合盆腔造影是区分粘膜脱垂与全层套叠、诊断直肠内脱垂伴发的直肠壁内疝等盆底疝等直观、可靠的方法。     

The diagnostic role of abdominal CT imaging findings in adults intussusception: focused on the vascular compromise

Intussusception is defined as telescoping of one segment of the gastrointestinal tract into an adjacent one. Unlike that in children, adult intussusception is a relatively rare condition. More than 90% of patients with adult intussusception have been reported to have an organic cause, with benign or malignant tumors for accounting for approximately 65% of the cases. In general, the diagnosis is easily made by means of computed tomography (CT) or magnetic resonance (MR) imaging. The imaging appearance of a bowel-within-bowel configuration with or without contained fat and mesenteric vessels, is pathognomonic. As the intussusceptum enters into the intussuscipiens, the mesentery is carried forward and trapped between the overlapping layers of bowel. The twisting or severe constriction of the mesenteric vessels may result in vascular compromise with subsequent edematous thickening of the involved bowel. In these circumstances, ischemic necrosis may develop if timely intervention is not undertaken. Therefore, determination of the presence or absence of intestinal necrosis in intussusception is important in patient management. On CT, the presence of well-known diagnostic CT criteria for strangulated obstruction (especially severe engorgement or twisting of the mesenteric vessels) as well as evidence of loss of the layered pattern, accumulation of extraluminal fluid collection, and bowel perforation, may suggest the diagnosis of intestinal necrosis. CT and MR imaging are limited in determining the primary disease causing intussusception. However, CT and MR provide excellent pre-operative evaluation, including the possible extension and/or dissemination of a malignant tumor. CT and MR imaging may also be useful in suggesting the presence of vascular compromise.     

Anorectal function in patients with defecation disorders and asymptomatic subjects: evaluation with defecography

A controlled radiologic study of anorectal function was performed with the use of defecography in 19 patients with constipation and 13 with incontinence. All patients were age and sex matched to control subjects who were referred for barium enema study and who had no defecation disorder. There were no statistically significant differences between either patient group and the control group in anorectal angle and excursion of the anorectal junction. In the 32 patients and 155 consecutive patients referred for defecography because of a variety of defecation disturbances, approximately twice as many rectal wall abnormalities were seen compared with findings in the control group. These findings included intussusception, rectal prolapse, rectocele, mucosal prolapse, spastic pelvic floor, descending perineum syndrome, and solitary rectal ulcer syndrome. In conclusion, the main role of defecography is to document rectal wall changes during defecation straining as possible causes of evacuation difficulties. Clinical symptoms should also be taken into account when treatment is contemplated.     

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.     

Anorectal function: defecographic measurement in asymptomatic subjects

A study of anorectal function during fluoroscopically monitored defecation was conducted in 32 asymptomatic subjects. Two observers independently measured various parameters on defecograms and reviewed video recordings during the subjects' squeezing, rest, and straining. There was a wide range of measurements for the anorectal angle, the position of the anorectal junction, perineal motility, and anal canal width. Interobserver variation of these measurements was large. In 17 subjects, both observers agreed that rectal emptying was incomplete. In 10 patients, there was agreement on the presence of rectal wall changes such as intussusception, rectocele, and mucosal prolapse. Defecographic measurements should be interpreted with caution and should not be used as the only criteria for treatment. Anatomic changes of the anorectal region during straining at defecation do not necessarily cause symptoms but may be a precursor of clinical disorders. Defecography is useful in the detection of these abnormalities.     

Bronchoarterial ratio and bronchial wall thickness on high-resolution CT in asymptomatic subjects: correlation with age and smoking

OBJECTIVE: The purpose of this study was to determine whether the values of the bronchoarterial ratio and bronchial wall thickness, as viewed during high-resolution CT, relate to age and smoking status in asymptomatic healthy subjects. SUBJECTS AND METHODS: High-resolution CT was performed prospectively in 85 subjects without cardiopulmonary disease. The subjects were divided into three groups according to age: 29 subjects were 21-40 years old; 29 subjects, 41-64 years old; and 27 subjects, 65 years or older. Both bronchoarterial ratios, defined as the diameter of the bronchial lumen divided by the diameter of its accompanying artery, and the T/D ratio, defined as wall thickness (T) divided by the total diameter of the bronchus (D), were measured at the segmental and subsegmental levels of the apical and posterior basal segments. Each calculated ratio was evaluated according to age and smoking status. RESULTS: Significant correlation was found between the bronchoarterial ratio and age (r = 0.768, p < 0.0001), with the bronchoarterial ratio increasing with age and exceeding 1 in 41% of subjects older than 65 years. No significant correlation was seen between the T/D ratio and age. No significant differences in bronchoarterial ratio and T/D ratio were seen between smokers and nonsmokers in subjects overall; but in the elderly group, the T/D ratio was significantly higher in smokers than in nonsmokers (p = 0.021). CONCLUSION: The bronchoarterial ratio is influenced by aging. The normal bronchoarterial ratio in a substantial number of subjects older than 65 years overlaps with the ratio considered to represent bronchiectasis. Thus, when this ratio is used for the quantitative analysis of pulmonary and cardiovascular disease, the influence of age should be considered.     

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。     

Solitary rectal ulcer syndrome: findings at barium enema study and defecography

Sixteen cases of histopathologically proved solitary rectal ulcer syndrome were encountered. Fifteen patients underwent barium enema study; in nine cases the findings--including rectal stricture, granularity of the mucosa, and thickened rectal folds-were nonspecific. In six cases the study was normal. All patients had a long history of defecation disorders, and defecography was performed in all. In seven cases, intussusception of the rectal wall was seen; in another case the intussusception was accompanied by a rectocele. One case showed rectal prolapse. In four cases, failed relaxation of the puborectalis occurred and prevented the passage of the bolus; in another case there was abnormal perineal descent. In two patients studies were normal. In patients with defecation disorders, the possibility of this syndrome should be considered. Defecography is the method of choice for establishing the diagnosis.     

The value of ultrasound in children with suspected intussusception

The purpose of this study was to verify the reliability of ultrasound for the diagnosis and exclusion of intussusception and to assess the usefulness of various clinical and imaging findings for determining when ultrasound should be used as a diagnostic screen. We reviewed the medical records and radiologic examinations of 151 pediatric patients referred for possible intussusception. Clinical, radiographic, and ultrasound findings were compared in children with and without intussusception and correlated with diagnosis and reducibility of intussusception. The patients were placed in risk groups on the basis of certain combinations of clinical or radiographic findings. These groups were used to test alterations of the types of radiologic studies performed if high-risk patients were to undergo enema procedure only, without preliminary ultrasound. Intussusception was present in 49 patients (32.5%) and absent in 102 patients (67.5%). Symptoms and physical findings such as abdominal pain, vomiting, and bloody stools were common in both groups. Empty right lower quadrant and palpable mass were strongly associated with intussusception Omitting a screening ultrasound in high-risk patients decreased the number of patients who underwent both ultrasound and enema examinations, but the number of unnecessary enemas increased with all risk factors used. Palpable mass as a risk factor allowed reduction of double studies with the least increase in unnecessary enemas. Ultrasound provided supportive evidence findings in intussusception such as intussusceptum thickness greater than 10 mm or a large amount of trapped fluid indicate poor reducibility, and thinner, more echogenic outer rings with no trapped lymph nodes suggest the possibility of spontaneous resolution. Our findings support the use of ultrasound as a screening examination for children with possible intussusception in all cases, except those with high-risk factors such as a palpable abdominal mass.     

Evacuation proctography in normal volunteers

Constipated patients evaluated by evacuation proctography may be subjected to vigorous medical therapy or surgery, even colectomy, based on radiographic findings that have been called "abnormal" in the literature. Criteria for normal defecography are not uniformly established, nor has correlation of structural or functional findings with symptoms been clearly documented. We prospectively studied 21 asymptomatic volunteers to assess the frequency of findings in a control population, and to establish a quantitative measure of normal rectal emptying. Standard defecography technique demonstrated rectocele, intussusception, pelvic descent, or puborectalis spasm in 14/21 volunteers (67%). The range of rectal emptying was 12.5% to 100%, with four subjects (19%) evacuating less than or equal to 40% of the barium paste. There was no correlation between severity of radiographic findings and degree of evacuation. Defecography results in patients being considered for symptomatic intervention should be interpreted cautiously, given the wide range of normal variation in a control population.     

Serial change in airway lumen and wall thickness at thin-section CT in asymptomatic subjects

PURPOSE: To retrospectively analyze serial changes in airway lumen and wall thickness (WT) at multi-detector row computed tomography (CT) in asymptomatic subjects. MATERIALS AND METHODS: Institutional review board did not require its approval or informed patient consent. Airway dimensions were analyzed in 52 patients (30 men and 22 women) without known cardiopulmonary disease. Contiguous 2-mm CT sections were obtained after reconstruction, extending from origin of right posterior basal segmental bronchi to posterior subsegmental bronchi. Following parameters were determined with semiautomatic image-processing program: luminal area (LA), total airway area (TA), short axis of lumen (LSD), and short axis of total airway (TSD). In airways in which adjacent vessel or branching of small bronchus abutted boundary of airway, extrapolated line was traced by one radiologist. Airway wall area (WA) was calculated as TA - LA, and WT was calculated as (TSD - LSD)/2. Relative WA (WA% = [WA/TA] . 100) and ratio of airway WT to total diameter (D) (WT/D = WT/TSD) were calculated. Linear regression analysis and Spearman rank correlation were used to evaluate relationship between airway parameters (LA, WA%, and WT/D ratio) and distance from origin of segmental bronchi. RESULTS: LA decreased as CT proceeded from hilum to periphery (r = -0.765, P < .001). In 308 (32.7%) of 943 bronchi, however, LA increased as CT proceeded from hilum to periphery. LA increased by 10% or more in 101 (10.7%) of 943 bronchi. Mean changes in WA% and WT/D ratio between two contiguous sections were 0.66 +/- 5.05 (standard deviation) and 0.003 +/- 0.024, respectively. WA% changed by more than 5% between two contiguous sections in 274 (29.0%) of 943 bronchi. WT/D ratio changed by more than 0.02 between two contiguous sections in 338 (35.8%) of 943 bronchi. CONCLUSION: Variation of airway lumen and WT is found in asymptomatic subjects without known cardiopulmonary disease.     

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。     

Defecography

Defecography is a technique of examining the rectum and anal canal in which the patient is studied while sitting down rather than recumbent and recordings are obtained both at rest and during straining. The authors describe their findings in 83 patients with dyschezia. Defecation was normal in 28 patients. Prolapse of the anal mucosa was seen in 13 patients and internal procidentia in 23, 12 of whom also had intussusception manifested as rectal prolapse. A deep rectogenital fossa associated with an enterocele was seen in 16 patients; 13 had a proctocele, while fecal retention was seen in 5. Descent of the pelvic floor and changes in the angle between the rectum and anal canal were assessed. The authors recommend defecography as a more physiological means of assessing rectal dysfunction.     

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.