Preston et al.'6 introduced the balloon ... taken as the contents of the rectum were expelled. Each frame .... balloon expulsion test a valid measure of the pelvic.
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Techniques in evacuation proctography in the diagnosis of intractable constipation and related disorders
A M Roe FRcs
D C C Bartolo MS FRCS
N J McC Mortensen MD FRCS
University Department of Surgery, Bristol Royal Infirmary, Bristol BS2 8HW
Summary A technique of evacuation proctography using a simple barium and air mixture is described. The study can be easily combined with a bariu'm enema examination. A series of 35 patients with intractable constipation have been studied and compared with 7 controls. Most of the abnormalities seen using more elaborate methods of defaecography were identified. Variants of rectal intussusception were found in 16 patients. Other diagnoses included rectocele, mucosal and full rectal prolapse, accentuation of puborectalis impression and solitary rectal ulcer. The technique should prove useful in the management of patients with disorders of defaecation.
Introduction Patients with constipation and defaecatory disorders who do not respond to the usual therapeutic measures present problems in diagnosis and management. They may have slow colonic transit"2 with a pelvic floor disorder3'4, or may complain of obstructed defaecation symptoms with chronic straining at stool, a feeling of incomplete evacuation and rectal bleeding. These symptoms of obstructed defaecation are common to a number of disorders including descending perineum syndrome5'6, irritable bowel syndrome7, solitary rectal ulcer8, mucosal prolapse5 and rectal intussusception9. Various radiological techniques have been used in the diagnosis of these anorectal disorders. Hurst'0, in 1919, opacified the stool with bismuth carbonate taken the night before the study and observed, on X-ray, mass movements in the colon in response to a meal and normal and abnormal emptying of the sigmoid colon and rectum after defaecation. Brown" employed a solution of barium for studies of anorectal mechanisms in children. Phillips and Edwards'2 opacified the rectum using 20 g of barium sulphate mixed with sodium carboxy-methyl-cellulose taken at each meal for 3 days beforehand together with coating the anal canal with barium sulphate. Kerremans"13used a contrast medium to simulate the normal consistency of faecal matter and observed anorectal function using cineradiography. Broden and Snellman'4 used cineradiography in their studies of procidentia of the rectum. Cineradiography has also been used in the investigation of motor activity in the sigmoid colon"5. Bartolo and colleagues6 employed a barium solution to outline the rectum and a small beaded chain to outline the anal canal; this technique allowed accurate measurements of anorectal angle and perineal
descent. Preston et al.'6 introduced the balloon proctogram, a simple method of proctography also enabling accurate measurements of anorectal dynamics. Mahieu and colleagues'7 '9 reported a large series of 200 defaecograms, the contrast medium used being a mixture of 150 cm' of barium sulphate mixed with 100 g of potato starch. A number of different disorders were identified, including variants of rectal intussusception, prolapse, rectocele and accentuation of the impression of puborectalis sling. In the present series the technique employed to obtain a standard proctogram was that of Bartolo et al.6. In those patients with abnormal descent or changes in rectal morphology, we proceeded to evacuation proctography using a new technique to elucidate the underlying pathology.
Based on paper read to Section of Colo-Proctology, 23 January 1985
Patients and methods Thirty-five patients (11 men, 24 women) have been studied. They all complained of troublesome constipation or obstructed defaecation which had proved resistant to treatment. All underwent clinical investigations, sigmoidoscopy and, where appropriate, barium enema. Control studies of evacuation proctography were carried out in 7 patients undergoing barium enemas for other bowel disorders but who had no anorectal abnormalities. Informed consent was obtained from each patient. The study was approved by the Ethical Committee of the Bristol and Weston Health district. Evacuation proctography: No bowel preparation was used since it was deemed more physiological to observe how anorectal morphology altered during defaecation without preparation. Liquid barium sulphate (50 ml) was instilled into the rectum, which was then insufflated with air to drive the contrast material proximally and outline the rectal mucosa. X-rays were taken by ampliphotography using a 100 mm camera (Sircam 106, Siemans) 0.6 mm focus and a voltage of 125 kV from a 100 mA generator to give a short exposure at a rate of one frame per second. The patient was positioned prone and a fast-film sequence was obtained during straining. The patient was then seated on a bedpan and radiographs were taken as the contents of the rectum were expelled. Each frame was numbered automatically, enabling the sequence to be studied in detail. In the latter part of the study a commode with water-filled surround was used and this enhanced the quality of the X-rays (see Figure 2).
0141-0768/86/ 060331-03/$02.00/0 i 1986 The Royal Society of
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Joumal of the Royal Society of Medicine Volume 79 June 1986
Results Of 35 studies performed, 4 demonstrated delayed large bowel transit and 31 normal transit'. The' findings were compared with those in 7 normal subjects. A number of abnormalities were diagnosed in these patients (Table 1). Rectal intussusception was a common finding (Figures 1 and 2), variations of the
-D.
Table 1. Diagnosis in 35 evacuation proctograph studies Recto-rectal intussusception Rectocele and intussusception Rectocele Full rectal prolapse Anterior mucosal prolapse Accentuation of puborectalis impression Solitary rectal ulcer Normal or no definite diagnosis
1
,1
13 3 4 1 4 3 3 4
re s a 8mall rectocele a tst. As the Figure 1'rStt&vaeA.zh anal canal fills (small arrows), d large anteriwr rectocele fills with barium (large arrows)
Figure 1. Postersanterwrd view of dtal' intusception. There is abnormal perineal descent and lateral muco#al folds (small arrows) as the anal canal fills (large arrows)
Figure-2.^ elt viw of inttssuseeptMi6 showing flattening of the lower rectum with tipping up of the anterior portion (small arrows) and a narrowing above forming the intussusception (large arrows)
Fie 4. Normal ptotam at rest. On strainng a small hooked anterior rectocele is produced (arrow)
Figure 5. Accentuation'ofpuborectalis sling. As the-patient strains down the posterior impression made by puborectalis becomes more pronounced (arrows)
Journal of the Royal Society of Medicine Volume 79 June 1986
disorder being demonstrated in 16 patients. It was possible to identify 4 criteria for making the diagnosis of intussusception: (1) abnormal perineal descent; (2) indenting mucosal folds on posteroanterior view; (3) flattening of the lower rectum with tipping up of the anterior portion; (4) a narrowing above the flattened lower rectum where the upper rectum intussuscepts into the lower rectum. Figure 3 is the proctogram of a patient with a very large rectocele. Three patients had small 'hooked' anterior rectoceles, Figure 4 being one example. Figure 5 demonstrates accentuation of puborectalis sling. In only 4 patients was there no discernible abnormality. None of these abnormalities was seen in control subjects.
Discussion Most researchers who have performed proctography have tried to use a radio-opaque medium of similar consistency to that of normal faeces13 17-9. Consequently these studies have involved prior bowel preparation and reconstitution of the contrast medium. In the present study a simple liquid barium/ air mixture was used. The main disadvantages of such a liquid medium are that it may not be physiologically equivalent to faeces and patients with weak sphincter muscles, particularly those with incontinence, may be unable to retain the contrast. We found that the barium and air contrast method for evacuation proctography requires little preparation and is easy to administer. Many patients who complained of obstructed defaecation symptoms were found to have small, hard stools in the rectum on examination. We consider that, by using no bowel preparation but simply outlining the anorectum with barium and air, our technique is as physiological as artificially emptying the rectum and instilling a medium of homogeneous consistency - in this particular group of patients, at least. The doublecontrast technique gives excellent mucosal detail and is able to demonstrate all the pathologies seen by Mahieu in his large series17i 9. Many patients with constipation and obstructed defaecation will require barium enemas as part of their investigations, and a further advantage of our technique is that it can be simply added to the end of a barium enema study. Our present policy in the investigation of patients with intractable constipation is first to perform standard proctograms, and in those patients with abnormal descent or other changes in rectal morphology to proceed to evacuation proctography. We consider the technique described to be a simple and useful method of proctography, and many of the disorders thus identified may be amenable to surgical correction.
References 1 Hinton JM, Lennard-Jones JE, Young AC. A new method for.studying gut transit times using radioopaque markers. Gut 1969;10:842-7 2 Preston DM, Hawley PR; Lenrd-Jones JE, et al. Results of colectomy for severe idiopathic constipation in women (Arbuttnot Lane's disease). Br J Surg 1984;71:547-52 3 Preston DM, Lennard-Jones JE. Is there a pelvic floor disorder in slow transit constipation. Gut 1981;22:A890 4 Roe AM, Bartolo DCC, Virjee J, Mortensen NJ. Is the balloon expulsion test a valid measure of the pelvic floor abnormality in slow transit constipation? Gut 1984;25:A1149-50 5 Parks AG, Porter NH, Hardcastle J. The syndrome of the descending perineum. Proc R Soc Med 1966;59:477-82 6 Bartolo DCC, Read NW, Jarralt JA, Read MG, Donnelly TC, Johnson AG. Differences in anal sphincter function and' clinical presentation in patients with pelvic floor descent. 'Gastroenterology 1983;85:68-75 7 Lennard-Jones JE. Functional gastrointestinal disorders. N Engl J Med 1983;308:431-5 8 Rutter KRP. Electromyographic changes in certain pelvic floor abnormalities. Proc R Soc Med 1974;67:53-6 9 Thre T, Seligson U. Intussusception of the rectum internal procidentia: treatment and results in 90 patients. Dis Colon Rectum 1975;18.391-6 10 Hurst AF. Constipation and allied intestinal disorders. London: Hodder & Stoughton; Oxford: Oxford University Press, 1919 11 Brown B. Defecography or anorectal studies in children including cinefluorographic observation. J Can Assoc Radiol 1965;16:66-76 12 Phillips SF, Edwards DAW. Some aspects of anal continence and defaecation. Gut 1965;6:396-405 13 Kerremans R. Morphological and physiological aspects of anal continence and defaecation. Brussels: Editions Arscia S A, 1969 14 Broden B, Snellman B. Procidentia of the rectum studies with cineradiography: a contribution to the discussion of causative mechanism. Dis Colon Rectum 1968;11;330-49 15 Ritchie JA, Ardran GM, Truelove SC. Motor activity of the sigmoid colon of humans, a combined study by intraluminal pressure recordings and cineradiography. Gastroenterology 1962;43:642-68 16 Preston DM, Lennard-Jones JE, Parks AG. The balloon proctogram. Br J Surg 1984;71:29-32 17 Mahieu P. La defecographie. Description d'une technique simplifice et apport diagnostique. Ann Gastroenterol Hepatol 1983;19:345-50 18 Mahieu P, Pringot J, Bechart P. Defecography: I. Description of a new procedure and results in normal subjects. Gastrointest Radiol 1984;9-.247-51 19 Mahieu P, Pringot J, Bechart P. Defecography: II. Contribution to the diagnosis of defaecation disorders. Gastrointest Radiol 1984,9:253-61
(Accepted 19 December 1985)
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