Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders

PURPOSE: Pelvic organ prolapse results in a spectrum of progressively disabling disorders. Despite attempts to standardize the clinical examination, a variety of imaging techniques are used. The purpose of this study was to evaluate dynamic pelvic magnetic resonance imaging and dynamic cystocolpoproctography in the surgical management of females with complex pelvic floor disorders. METHODS: Twenty-two patients were identified from The Johns Hopkins Pelvic Floor Disorders Center database who had symptoms of complex pelvic organ prolapse and underwent dynamic magnetic resonance, dynamic cystocolpoproctography, and subsequent multidisciplinary review and operative repair. RESULTS: The mean age of the study group was 58 ± 13 years, and all patients were Caucasian. Constipation (95.5 percent), urinary incontinence (77.3 percent), complaints of incomplete fecal evacuation (59.1 percent), and bulging vaginal tissues (54.4 percent) were the most common complaints on presentation. All patients had multiple complaints with a median number of 4 symptoms (range, 2–8). Physical examination, dynamic magnetic resonance imaging, and dynamic cystocolpoproctography were concordant for rectocele, enterocele, cystocele, and perineal descent in only 41 percent of patients. Dynamic imaging lead to changes in the initial operative plan in 41 percent of patients. Dynamic magnetic resonance was the only modality that identified levator ani hernias. Dynamic cystocolpoproctography identified sigmoidoceles and internal rectal prolapse more often than physical examination or dynamic magnetic resonance. CONCLUSIONS: Levator ani hernias are often missed by physical examination and traditional fluoroscopic imaging. Dynamic magnetic resonance and cystocolpoproctography are complementary studies to the physical examination that may alter the surgical management of females with complex pelvic floor disorders.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.No reprints are available.     

Pelvic Floor Imaging

The purpose of this paper is to describe the current modalities of pelvic floor imaging: pelvic floor and endoanal ultrasonography, cystourethrography, evacuation proctography, dynamic colpocystoproctography, magnetic resonance imaging and endoanal magnetic resonance imaging.As there are no set standards for prescribing imaging tests in pelvic floor disorders, we drew up a table of tests to be performed according to the anatomical abnormality observed on physical examination or functional sign reported by the patient.     

Phenotypic variation in functional disorders of defecation

BACKGROUND & AIMS: Although obstructed defecation is generally attributed to pelvic floor dyssynergia, clinical observations suggest a wider spectrum of anorectal disturbances. Our aim was to characterize phenotypic variability in constipated patients by anorectal assessments. METHODS: Anal pressures, rectal balloon expulsion, rectal sensation, and pelvic floor structure (by endoanal magnetic resonance imaging) and motion (by dynamic magnetic resonance imaging) were assessed in 52 constipated women and 41 age-matched asymptomatic women. Phenotypes were characterized in patients by principal components analysis of these measurements. RESULTS: Among patients, 16 had a hypertensive anal sphincter, 41 had an abnormal rectal balloon expulsion test, and 20 had abnormal rectal sensation. Forty-nine patients (94%) had abnormal pelvic floor motion during evacuation and/or squeeze. After correcting for age and body mass index, 3 principal components explained 71% of variance between patients. These factors were weighted most strongly by perineal descent during evacuation (factor 1), anorectal location at rest (factor 2), and anal resting pressure (factor 3). Factors 1 and 3 discriminated between controls and patients. Compared with patients with normal (n = 23) or reduced (n = 18) perineal descent, patients with increased (n = 11) descent were more likely (P < or = .01) to be obese, have an anal resting pressure >90 mm Hg, and have a normal rectal balloon expulsion test result. CONCLUSIONS: These observations demonstrate that functional defecation disorders comprise a heterogeneous entity that can be subcharacterized by perineal descent during defecation, perineal location at rest, and anal resting pressure. Further studies are needed to ascertain if the phenotypes reflect differences in the natural history of these disorders.     

Treatment of enterocele by obliteration of the pelvic inlet

PURPOSE: Enterocele is defined as a herniation of the peritoneal sac between the vagina and the rectum. This hernial sac contains either sigmoid colon or small bowel. It is well known that enteroceles are associated with symptoms of pelvic discomfort. It is unclear whether enteroceles contribute to evacuation difficulties. Controversies also exist regarding their treatment of choice. The aim of the present prospective study was to evaluate the impact of obliteration of the pelvic inlet on evacuation difficulties and on symptoms of pelvic discomfort. METHODS: From October 1994 to August 1996 20 females (median age, 53; range, 41–73 years) with symptomatic enterocele diagnosed on evacuation proctography underwent obliteration of the pelvic inlet with a nonabsorbable Mersilene® mesh. All patients presented with pelvic discomfort, characterized by feelings of prolapse (n=20), pelvic pressure (n=16), lower abdominal pain (n=13), and false urge to defecate (n=15). Symptoms of obstructed defecation were noted in 15 patients. Six months after repair, evacuation proctography with opacification of the small bowel and the vagina was repeated. RESULTS: The median duration of follow-up was 25 (range, 10–34) months. A persistent or recurrent enterocele was observed in none of the patients. All symptoms of pelvic discomfort disappeared except feelings of a false urge to defectate, which persisted in 27 percent of cases. Symptoms of obstructed defecation persisted in all patients with evacuation difficulties. CONCLUSIONS: In patients with pelvic discomfort enterocele should be considered as a possible causative factor. It is unlikely that this abnormality contributes to the problem of obstructed defecation. In patients with a symptomatic enterocele, obliteration of the pelvic inlet with a Mersilene® mesh is an adequate treatment.Read at the XVIIth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Malmö, Sweden, June 7 to 11, 1998.     

Dynamic magnetic resonance imaging defecography: a diagnostic alternative in the assessment of pelvic floor disorders in proctology

PURPOSE: Standard diagnostic proctologic procedures in the assessment of pelvic floor disorders include clinical evaluation and endoscopy. Particular aspects of combined pelvic floor disorders, especially those involving more than one pelvic compartment, may remain undetected without additional technical diagnostic procedures such as videoproctoscopy, cinedefecography, or colpocystodefecography. The aim of the study was to review the potentials of dynamic magnetic resonance imaging defecography to elucidate the underlying anatomic and pathophysiologic background of pelvic floor disorders in proctologic patients. PATIENTS AND METHODS: Dynamic magnetic resonance imaging defecography was performed in 20 Patients (13 females) with main diagnoses such as rectal prolapse or intussusception, rectocele, descending perineum, fecal incontinence, outlet obstruction, and dyskinetic puborectalis muscle after clinical evaluation. The investigation was performed on a 1.5 T-magnetic resonance imaging machine in supine position. The rectum was filled with Gd-DTPA enriched ultrasound gel. First a T1/T2 weighted investigation of the pelvis was performed, followed by defecography with evacuation of the rectum. Images were obtained in a sagittal plane in a frequency of 1 image/second (true FISP) at rest and during straining. The obtained magnetic resonance imaging video tapes were analyzed off-line with cinematographic evaluation of bladder base, uterus, and anal canal position in relation to the pubococcygeal line by a blinded radiologist. Investigation time was 20 minutes. RESULTS: In dynamic magnetic resonance imaging defecography of the pelvic floor, 12 patients with descending perineum, 10 rectoceles (10 females), 6 cystoceles (6 females), 4 enteroceles (4 females), 8 intussusceptions (5 females), and a dyskinetic puborectalis muscle in 3 males were detected. In 11 females and 3 males multifocal disorders were found, involving more than one compartment in females, whereas in males complex defects were restricted to the posterior compartment. Magnetic resonance imaging defecography revealed diagnoses consistent with clinical results in 77.3 percent and defects in addition to clinical diagnoses in combined pelvic floor disorders in 34 percent. CONCLUSIONS: In complex pelvic floor disorders, involving more than a single defect, dynamic magnetic resonance imaging represents a convenient diagnostic procedure in females and to a lesser extent in males, in particular in terms of dynamic imaging of pelvic floor organs during defecation. In addition to the clinical assessment, dynamic magnetic resonance imaging had clinical impact in proctologic and interdisciplinary treatment.Presented in part at the 116th German Congress of Surgery, 1999     

Dynamic Transperineal Ultrasound in the Diagnosis of Pelvic Floor Disorders

PURPOSE: Defecating proctography and more recently, magnetic resonance imaging have both been used for diagnosis in patients with pelvic floor dysfunction. This pilot study assessed the feasibility of dynamic transperineal ultrasound in a range of specific disorders affecting evacuation. METHODS: A protocol of sagittal and transverse transperineal imaging was established defining the infralevator viscera and soft tissues and the margins of the puborectalis muscle. Dynamic measurements were possible for the extent of puborectalis shortening, the anorectal angle, and the movement during straining of the anorectal junction. Calculations were made of the depth of demonstrated rectoceles, the posterior urethrovesical angle, and the movement of the urethrovesical junction. Diagnoses were confirmed by proctography (where appropriate) and clinical examination. RESULTS: Transverse images of the anal sphincter were comparable with those obtained using endoanal ultrasonography. Sagittal images permitted the measurement of puborectalis contraction and the anorectal angle comparable with those obtained during defecography. Cystoceles were able to be diagnosed during closure of the posterior urethrovesical angle and abnormal urethrovesical junction descent during straining. Rectoceles, peritoneoceles, enteroceles, and rectoanal intussusception were readily identified using dynamic transperineal ultrasonography. CONCLUSION: Dynamic transperineal ultrasound is a simple, noninvasive way to assess dynamically the interaction of the pelvic viscera and their relationship to the pelvic floor musculature in patients with evacuatory disorders and pelvic floor dysfunction.     

Simultaneous dynamic proctography and peritoneography for pelvic floor disorders

PURPOSE: We sought to evaluate a new diagnostic technique for the identification of rectal and pelvic floor pathology in patients with obstructed defecation, pelvic fullness/ prolapse, and/or chronic intermittent pelvic floor pain. METHODS: Thirteen symptomatic women with either a nondiagnostic physical examination or nondiagnostic dynamic proctography (DPG) were studied. After placement of intraperitoneal and intrarectal contrast material, resting and straining pelvic x-rays were obtained in all patients, and defecation was videotaped using fluoroscopy. RESULTS: Simultaneous DPG and peritoneography identified clinically suspected and unsuspected enteroceles in 10 of the 13 patients studied. An enterocele or other pelvic floor hernia was ruled out by the technique in three of the women studied. Rectoceles and rectal prolapse that were identified during physical examination were confirmed by DPG with peritoneography. Simultaneous DPG and peritoneography also gave a qualitative assessment of the severity and clinical significance of the identified pelvic floor disorders. Results of simultaneous DPG and peritoneography affected operative treatment planning in 85 percent of patients studied. CONCLUSION: Simultaneous DPG and peritoneography identifies both rectal and pelvic floor pathology and provides a qualitative assessment of pelvic floor pathology severity, which allows for better treatment planning in selected patients with obstructed defecation and pelvic prolapse.Video presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Perineal descent and levator ani hernia: a dynamic magnetic resonance imaging study

PURPOSE: Patients with symptomatic pelvic organ prolapse often have multifocal pelvic floor defects that are not always evident of physical examination. In this study, dynamic magnetic resonance imaging of symptomatic patients with pelvic floor prolapse demonstrated unsuspected levator ani hernia. This study was designed to identify any specific symptoms and/or physical findings associated with these hernias.METHODS: Eighty consecutive patients with pelvic organ prolapse, fecal and/or urinary incontinence, or chronic constipation received standardized questionnaires, physical examination, and dynamic magnetic resonance imaging. Fishers exact test was used to compare symptoms and examination findings between patients with or without levator ani hernia.RESULTS: Twelve patients (15 percent) were found to have unilateral (n = 8) or bilateral (n = 4) levator ani hernias on dynamic magnetic resonance imaging. No one specific symptom was directly associated with the presence of a levator ani hernia. Furthermore, levator ani hernias were not found more frequently in patients with previous pelvic floor surgery. Perineal descent on physical examination was associated with the finding of a levator ani hernia in nine patients (P = 0.02). Although not statistically significant, there was a trend toward a lower incidence of levator ani hernia in females using estrogen replacement therapy (P = 0.06).CONCLUSIONS: Patients with symptomatic pelvic organ prolapse and perineal descent on physical examination may have a levator ani hernia. Although the significance of levator ani hernia needs to be determined, the recurrence rate after the surgical management of pelvic organ prolapse remains unacceptably high, and ongoing investigation of all associated abnormalities is warranted.Data were obtained from the Johns Hopkins Pelvic Floor Database. Poster presentation at The American Society of Colon and Rectal Surgery Meeting, Boston, Massachusetts, June 24 to 29, 2000.     

Diagnosis of enteroceles by dynamic anorectal endosonography

PURPOSE: Enteroceles are herniations of the lining of the peritoneum and intestinal loops into the pouch of Douglas. They may accompany other pelvic and anorectal disorders or cause outlet obstruction. So far they are only diagnosed by defecography. We investigated the use of dynamic anorectal endosonography to detect this disorder. METHODS: Seventeen female patients with a defecation disorder were investigated by proctoscopy and endoluminal ultrasonography. In 14 patients defecography followed. Endosonography was performed using the curved array 7.5 MHz scanner directed to the ventral rectal wall. Dynamic studies were undertaken during rest and during maximal straining. The minimal distance between the inner verge of the anal canal and the peritoneal cavity was determined. RESULTS: Dynamic endosonography detected enteroceles in six patients in which the pouch of Douglas opened during straining and intestinal loops moved toward the anus. The diagnosis of enteroceles was confirmed in all patients by defecography giving a specificity of 100 percent. No enterocele was detected in the remaining eight patients with defecography, leading to a 100 percent sensitivity for endosonography. Comparing the 6 patients with enteroceles with the 11 patients without enterocele, the peritoneal-anal distances were at rest 3.9±0.5 and 3.3±0.5 cm (P<0.05) and during straining 3.6±0.5 and 1.3±0.2 cm (P<0.001), respectively. The change in peritoneal-anal distance was 2±0.5 cm in the enterocele group and 0.3±0.4 cm in the control group (P<0.001). Two patients with enteroceles had complete rectal prolapse. Four patients with enteroceles underwent surgery. Postsurgical endoluminal endosonography showed closure of the pouch of Douglas. CONCLUSIONS: Enteroceles may be diagnosed by dynamic anorectal endosonography. Compared with defecography dynamic anorectal endosonography is easier to perform, less cumbersome for the patient, and bears no radiation exposure. Therefore, this new diagnostic means may be useful in first-line search for enteroceles, but further studies are needed to prove its sensitivity for screening of this disorder.Presented at the 8th World Congress of the International Gastro-Surgical Club, Strasbourg, France, April 15 to 18, 1998, and at the Digestive Disease Week, New Orleans, Louisiana, May 16 to 22, 1998.     

盆腔器官脱垂的动态MRI研究进展

盆腔器官脱垂(pelvic organ prolapse,POP)是指由于盆底支持结构薄弱导致的盆腔器官疝出.动态MRI为无放射性、无创、快捷、全面、高分辨率的检查方法,其软组织对比性强,可清晰显示静息位及动态位时盆底肌肉和筋膜组织结构及功能上的变化,了解盆腔多组织器官的状况,为临床提供客观影像学数据.动态MRI常用于...     

Colpocystodefecography

PURPOSE: To assess, in one single procedure, a complete study of the female pelvis, including the Douglas pouch. METHODS: Colpocystodefecography (CCD) combines vaginal opacification, voiding cystography, and defecography. Three hundred examinations are reviewed. RESULTS: Thanks to the simultaneous visualization of the pelvic structures, CCD proved to be more useful than clinical evaluation to diagnose prolapses and particularly Douglas pouch hernias (enteroceles), the clinical diagnosis of which was missed in 93 of 111 cases. Moreover, in addition to morphologic and functional information, CCD brings about a new insight in the study of pelvic organs reciprocal influences, should they be positive (supporting function) or negative (external compression). Finally, significative pelvic surgery and particularly hysterectomy enhances greatly the risk of enteroceles. CONCLUSION: CCD is helpful in the preoperative staging, especially in the selection of the surgical procedure that will least likely predispose to possible late postoperative complications such as vaginal prolapses or enteroceles.     

A comparison of dynamic transperineal ultrasound (DTP-US) with dynamic evacuation proctography (DEP) in the diagnosis of cul de sac hernia (enterocele) in patients with evacuatory dysfunction

Background/Aims Cul-de-sac hernias (enterocele and peritoneocele) are difficult to diagnose in patients presenting with primary evacuatory difficulty. Failure to recognize their presence in patients undergoing surgery may lead to poor functional outcome. Accurate diagnosis requires specialized investigation including dynamic evacuation proctography (DEP) or dynamic magnetic resonance (MR) imaging. Recently, dynamic transperineal ultrasonography (DTP-US) has been used for this purpose. This study compares DEP with DTP-US for the diagnosis of cul-de-sac hernias in those patients presenting with evacuatory dysfunction. Materials and methods Sixty-two female patients with chronically obstructed defecation underwent blinded clinical, DEP, and DTP-US assessment to define the accuracy of diagnosis of cul-de-sac hernias. Results Both the DEP and the DTP-US techniques show concordance for the diagnosis of cul-de-sac hernias in an unselected patient cohort. Patients in both groups have the same duration of constipation with a greater likelihood of prior hysterectomy in those with cul-de-sac hernias. The diagnosis was established separately by DEP in 88% and in 82% of the cases by DTP-US. Transperineal sonography is discordant with DEP in 45% of cases once the diagnosis of cul-de-sac hernia is made, over the contents of the hernia and over the degree of transvaginal enterocele descent, where DTP-US tends to upgrade enterocele severity. Both techniques confirm the high incidence of concomitant pelvic floor compartment pathology. Conclusions Both methods have accuracy for the diagnosis of cul-de-sac hernias in those patients presenting with evacuatory difficulty. Transperineal sonography tends to more readily diagnose peritoneocele and to upgrade enterocele extent. As an office procedure, it is a valuable adjunct to the clinical examination in the diagnosis of cul-de-sac hernia.     

Four-contrast defecography: Pelvic “floor-oscopy”

PURPOSE: This study was designed to determine the accuracy of physical examination (as judged by four-contrast defecography) for women with pelvic floor relaxation disorders. METHODS: Sixty-two women (mean age, 59 years) who had obstructed defecation or constipation, vaginal prolapse, urinary difficulty, or pelvic pain underwent four-contrast defecography. Oral, vaginal, bladder, and rectal contrast were administered selectively and fluoroscopy was performed. Radiographic findings were compared with physical examination diagnosis. RESULTS: Four-contrast defecography changed the diagnosis in 46 patients (75 percent); 26 percent of presumed cystoceles, 36 percent of enteroceles, and 25 percent of rectoceles were not present on defecography. Defecography also revealed unsuspected coexisting defects in addition to known abnormalities detected on physical examination. In contrast, when physical examination was negative for these defects, 63 percent of patients were found to have cystoceles, 46 percent to have enteroceles, and 73 percent to have rectoceles on four-contrast defecography. The discovery of Grade 2 or 3 unsuspected abnormalities was significant, especially so for enteroceles. For posterior vaginal eversions extending to or past the introitus, physical examination was accurate in only 61 percent. Physical examination of large anterior defects was more accurate, with 74 percent of patients being correctly diagnosed. CONCLUSIONS: Physical examination diagnosis of pelvic floor relaxation disorders is frequently inaccurate, especially for large vaginal eversions. Four-contrast defecography improves diagnostic accuracy, helps to identify all pelvic floor defects before surgery, and can assist with planning the correct operative approach.     

Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders: pilot study

PURPOSE: Defecating proctography and more recently, magnetic resonance imaging have both been used for diagnosis in patients with pelvic floor dysfunction. This pilot study assessed the feasibility of dynamic transperineal ultrasound in a range of specific disorders affecting evacuation. METHODS: A protocol of sagittal and transverse transperineal imaging was established defining the infralevator viscera and soft tissues and the margins of the puborectalis muscle. Dynamic measurements were possible for the extent of puborectalis shortening, the anorectal angle, and the movement during straining of the anorectal junction. Calculations were made of the depth of demonstrated rectoceles, the posterior urethrovesical angle, and the movement of the urethrovesical junction. Diagnoses were confirmed by proctography (where appropriate) and clinical examination. RESULTS: Transverse images of the anal sphincter were comparable with those obtained using endoanal ultrasonography. Sagittal images permitted the measurement of puborectalis contraction and the anorectal angle comparable with those obtained during defecography. Cystoceles were able to be diagnosed during closure of the posterior urethrovesical angle and abnormal urethrovesical junction descent during straining. Rectoceles, peritoneoceles, enteroceles, and rectoanal intussusception were readily identified using dynamic transperineal ultrasonography. CONCLUSION: Dynamic transperineal ultrasound is a simple, noninvasive way to assess dynamically the interaction of the pelvic viscera and their relationship to the pelvic floor musculature in patients with evacuatory disorders and pelvic floor dysfunction.     

Dynamic magnetic resonance imaging evaluation of the structural and functional results of postanal repair for neuropathic fecal incontinence

PURPOSE: The aim of this study was to determine whether dynamic magnetic resonance imaging of the pelvic floor can discriminate between patients who improve after postanal repair for neurogenic fecal incontinence and those who remain symptomatic. METHODS: Pelvic floor measurements obtained during dynamic magnetic resonance imaging in eight females whose anal incontinence had improved after postanal repair were compared with those from nine females who remained symptomatic. All subjects also underwent standard anorectal physiology testing. RESULTS: There was no significant difference between groups with respect to any measurement of anterior or middle pelvic floor compartments. Additionally, there was no difference in posterior pelvic floor configuration when symptomatic patients were compared with those who had improved. However, dynamic magnetic resonance measurements revealed patients who remained symptomatic had significantly greater posterior pelvic floor weakness. Anorectal physiology was unable to differentiate between groups. CONCLUSIONS: There is no difference in static pelvic floor measurements when subjects remaining symptomatic after postanal repair are compared with those who have improved. In contrast, dynamic measurements may be able to predict failure in those who demonstrate excessive posterior pelvic floor mobility.     

Klassifikation der Beckenbodeninsuffizienz mit Hilfe der Magnetresonanztomographie (MRT) — ein Schritt zur rationalen Therapie

56 patients suffering from descending perineum syndrome (DPS) were investigated protocologically and by dynamic magnetic resonance imaging (dMRI), that was performed after filling the rectum with contrast media. Dynamic magnetic resonance imaging allowed the accurate evaluation of cystoceles, genital prolapses, rectoceles, enteroceles and external rectal prolapses. However, internal rectal prolapses and mucosal prolapses were diagnosed only in 2 of 10 patients. Based on the findings in dMRI, a new classification of descending perineum syndrome was developed dividing DPS in 4 disease stages. Each of these stages is characterized by a typical constellation of MRI results which facilitates the selection of the adequate treatment. In conclusion, dMRI of the pelvic floor is the most important imaging procedure in planning the correct therapy of DPS, thereby making cystography and defaecography dispensable.     

Imaging of primary sclerosing cholangitis: preliminary results by two new non-invasive techniques

BACKGROUND: Magnetic resonance cholangiography is a new technique which has already gained a role in primary sclerosing cholangitis. Computerised tomographic cholangiography is another non-invasive technique which has been used in assessing abnormal biliary tree, but has never been applied to evaluating primary sclerosing cholangitis. AIMS: To evaluate the ability of both magnetic resonance cholangiography and computerised tomographic cholangiography to detect bile duct changes in primary sclerosing cholangitis. PATIENTS AND METHODS: Magnetic resonance cholangiography and computerised tomographic cholangiography were performed in 16 primary sclerosing cholangitis patients. The computerised tomographic cholangiography data set was transferred to a processing workstation to obtain tridimensional reconstructions. Magnetic resonance cholangiography and computerised tomographic cholangiography images were analysed blind by two radiologists to assess: primary sclerosing cholangitis involvement, quality of imaging and the radiologist's certainty in determining the presence and location of the disease. RESULTS: Mean imaging quality was significantly better with computerised tomographic cholangiography compared with magnetic resonance cholangiography. Primary sclerosing cholangitis was identified in 15 cases with computerised tomographic cholangiography and 10 with magnetic resonance cholangiography (P < 0.05). Sensitivity in diagnosing primary sclerosing cholangitis was 94% with computerised tomographic cholangiography versus 63% with magnetic resonance cholangiography. Intrahepatic location was found in 14 cases, definitely present in 10 cases with computerised tomographic cholangiography and five with magnetic resonance cholangiography. Extrahepatic location was found in 13 cases, definitely present in 11 cases with computerised tomographic cholangiography and four with magnetic resonance cholangiography (P < 0.05). Computerised tomographic cholangiography also offered dynamic information about biliary excretion. CONCLUSIONS: Computerised tomographic cholangiography enables more accurate detection and location of primary sclerosing cholangitis than magnetic resonance cholangiography. Since computerised tomographic cholangiography offers additional information about biliary excretion, it may be proposed as an integrative technique in the diagnosis and follow-up of patients with primary sclerosing cholangitis.     

MRI facilitated a diagnosis of endometriosis of the rectum

A 51-year-old pre-menopausal Japanese woman suffering from chronic lower abdominal pain was referred to our hospital. A barium enema showed a stenotic lesion in the recto-sigmoid region, and a pelvic computed axial tomography (CAT) scan revealed a thickened rectal wall. A colonoscopic examination showed the rectum to be constrictive, but the mucosa appeared to be intact. Magnetic resonance imaging (MRI) with T1 high-intensity revealed a cystic lesion in the thickened wall of the rectum, which led us to suspect possible bowel endometriosis. Part of the biopsy specimen showed endometrial epithelium within the interstitial layer of histologically normal mucosa; finally, endometriosis of the rectum was diagnosed. The patient became asymptomatic after the initiation of hormonal treatment and later experienced spontaneous menopause. MRI was effective for diagnosis and the patient did not undergo unnecessary laparotomy. Although bowel endometriosis is generally diagnosed by means of resected specimens, in our patient, diagnosis was made using MRI and biopsy, and hormonal therapy had an effective role as a bridge to menopause. Received: July 12, 1999 / Accepted: January 28, 2000     

Value of navigator echo magnetic resonance angiography in detecting occlusion/patency of arterial and venous, single and sequential coronary bypass grafts

Aim of our work was to validate magnetic resonance angiography (MRA) in detecting occlusion/patency of coronary artery bypass grafts. Twenty patients with previous history of bypass surgery and recurrent episodes of chest pain were enrolled. Two patients could not be studied (claustrophobia, erratic breathing). Thus, 18 patients with 51 bypasses were examined using a navigator echo sequence: 21 arterial grafts (six sequential) and 30 saphenous vein grafts (five sequential). All patients had undergone contrast conventional angiography 3–15 days before MRA. The magnetic resonance (MR) data set was analyzed by two independent readers blinded to the results of conventional angiography (occlusion of 12 of 51 grafts). At magnetic resonance, two bypasses of the posterior descending artery, patent at conventional angiography, could not be visualized because of imaging slab malpositioning. Interobserver concordance was 96% (47/49). Magnetic resonance and conventional angiography provided identical answers in 47 out of 49 (96%) of the examined grafts. Eleven out of 12 occluded grafts and 36 out of 37 patent grafts were correctly identified with MR. As far as occlusion is concerned, the sensitivity of MR was 91%, the specificity 97%. To summarize, a 30 min outpatient MR examination is highly reliable in determining occlusion/patency of arterial and venous, single and sequential bypasses.     

Dynamic magnetic resonance defecography in 10 asymptomatic volunteers

AIM: Evaluation of the wide range of normal findings in asymptomatic women undergoing dynamic magnetic resonance (MR) defecography.METHODS: MR defecography of 10 healthy female volunteers (median age: 31 years) without previous pregnancies or history of surgery were evaluated. The rectum was filled with 180 mL gadolinium ultrasound gel mixture. MR defecography was performed in the supine position. The pelvic floor was visualized with a dynamic T2-weighted sagittal plane where all relevant pelvic floor organs were acquired during defecation. The volunteers were instructed to relax and then to perform straining maneuvers to empty the rectum. The pubococcygeal line (PCGL) was used as the line of reference. The movement of pelvic floor organs was measured as the vertical distance to this reference line. Data were recorded in the resting position as well as during the defecation process with maximal straining. Examinations were performed and evaluated by two experienced abdominal radiologists without knowledge of patient history.RESULTS: Average position of the anorectal junction was located at -5.3 mm at rest and -29.9 mm during straining. The anorectal angle widened significantly from 93° at rest to 109° during defecation. A rectocele was diagnosed in eight out of 10 volunteers showing an average diameter of 25.9 mm. The bladder base was located at a position of +23 mm at rest and descended to -8.1 mm during defecation in relation to the PCGL. The bladder base moved below the PCGL in six out of 10 volunteers, which was formally defined as a cystocele. The uterocervical junction was located at an average level of +43.1 mm at rest and at +7.9 mm during straining. The uterocervical junction of three volunteers fell below the PCGL; described formally as uterocervical prolapse.CONCLUSION: Based on the range of standard values in asymptomatic volunteers, MR defecography values for pathological changes have to be re-evaluated.