Dr Suman Sharma Associate Professor Department of Shalya Tantra National Institute of Ayurveda Emailsumanhp2006gmailcom Phone 9418159666 Definition Ultrasonography is study of internal organs structures or blood vessels using high frequency sound waves the actual test called u ID: 920185
Download Presentation The PPT/PDF document "rabiezahran@Gawab.com Ultrasonography in..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
rabiezahran@Gawab.com
Ultrasonography in Ano-rectal disorders
Dr.
Suman
Sharma
Associate Professor, Department of Shalya Tantra
National Institute of Ayurveda
E-mail-sumanhp2006@gmail.com
Phone- 9418159666
Slide2Definition
Ultrasonography is study of internal organs, structures or blood vessels using high frequency sound waves, the actual test called ultrasound scan or sonogram.
Ultrasonography
Slide3Definition (contd.)
Ultrasound are
sound waves of frequencies greater than audible to human ear i.e. greater than 20,000Hz
.
Slide4A sound waves travels in a pulse & when it is reflected back it becomes an echo. The pulse-echo principle is used for ultrasound imaging.
A pulse generated by one or more piezo-electric crystals in an ultrasound probe or transducer.
Ultrasound probe crystal is shocked by single extremely short pulse of electricity to vibrate at a frequency determined by its thickness.
Principles
Slide5Principle
Once
echo are converted into electrical signals, these are processed & transformed into a visual display of the measure of the amplitude of the echo this is echo quantification
.
The
transducer picks up the return echo & record any changes in the pitch or direction of the sound, the image is immediately visible on the screen.
sound waves travel faster in solids than liquids or gases. The major cause of attenuation in soft tissue is absorption,
Slide71. Ultrasound waves
They are waves of very high frequency ranging between 3.5 – 10 MHz and up to 20 MHz in endo-sonography.
When the frequency the resolution and penetration .
Slide8Slide9Slide10Different Patterns found in USG
Echo free
Hypo echoic
Hyper echoic
Heterogeneous
Slide11Echo pattern
Echofree :
When ultrasound waves pass through fluids ( ascites- simple cyst- blood vessels) no reflection occurs and these areas appears as black areas with posterior enhancement .
Slide12Slide13Echo
pattern
Echogenic :
When ultrasound waves pass through solids (bones – stone) all waves are reflected and appears as white color with posterior shadow .
Slide14Gall Bladder
Slide15Slide16Normal Anatomy of Gall bladder
Slide17Liver metastases
Heterogeneous
echogenicity
Slide18Slide19Trans Rectal Ultra-
sonography (TRUS)
or
(Endo-rectal Ultra-
sonography
)
Slide20Detection of ano-rectal and pelvic disorders.
Useful in detecting prostatic abnormalities.
Getting USG guided Biopsies
Uses of Endo-Rectal USG
This is becoming increasingly popular
Slide21Rectal and Pelvic disorders (Indications)
Benign diseases Faecal incontinence Inflammatory conditions
Slide22Rectal and Pelvic disorders (Indications)
Detection and staging of CA Rectum
(commonest indication)
Early detection
Staging
Guiding while chemotherapy or surgery alone is required
EUS can assess suitability for
transanal
excision
Peri
-rectal lesions in the pelvis
Retro-rectal masses can be visualized and assessed.
Diagnosis and management of
submucosal
lesions such as
submucosal
lipoma
,
carcinoid
tumour
and occasionally in gastro intestinal
tumours
[GIST] as well.
Slide23TRUS provides excellent visualization of the layers of the rectal wall.
Accurate /useful tool for staging primary rectal cancer and determining rectal wall integrity.
It is a fast and minimally invasive technique performed with portable equipment.
It accurately assesses the anal sphincter and provides critical information for planning the appropriate treatment of
peri
-anal fistulae and fecal incontinence.
TRUS is better than MRI for the evaluation of superficial tumors, whereas MRI provides a better visualization of locally advanced or stenosing cancers.
TRUS is comparable to MRI in the staging of
peri
-rectal lymph nodes.
Although TRUS is limited in the evaluation of the circumferential resection margin due to its small field of view, 3D TRUS can improve the accuracy of diagnosis of
anorectal
diseases and therefore should have an expanded role in the management of patients with
anorectal
diseases.
Advantages of TRUS
Slide24Fecal incontinence due to sphincter damage.
Peri
-anal inflammatory conditions and Abscesses.
Peri
-anal fluid collections
Submucus lesions like
Lipoma
, cysts etc.
Fistula in ano and detection of its tracks and internal openings.
Anal disorders (Indications)
Limited use than Rectum
Slide25Preparation of the patient
The patient must kept nil orally prior to examination.
The patient must be prepared with enemas to remove all air, stool and mucus from the rectum because they can create artifacts during the study.
Slide26Position
Left lateral decubitus position
( commonly used )
.
Knee-chest position.
Prone Position
Slide27Left Lateral Position
Slide28Prone Position
Slide29Technique
Digital rectal exam to evaluate the size, fixation, location and morphology of the rectal lesion.
Following
proctoscopy
and after estimating the tumor size and distance from the anal verge ERUS is prepared.
A
baloon
is placed over the crystal of the probe inserted into the rectum, past the proximal border of rectal mass
Then balloon is inflated with water (about 30-60 ml of water)
Imaging of rectum is initiated as the probe is withdrawn.
Slide30To evaluate the lesions of anal canal the balloon may be replaced with
sonolucent plastic cap and Rectum is filled with 150 cc of water.
Technique
Slide31Images are usually obtained by using an ultrasound frequency of 5-15MHz, depending on which part of rectum or anal canal is being examined.
Technique
Slide32The ERUS Rectal Anatomy
Fluid inter-space is essential
Images of rectal wall comprise three
hperechoic
and two
hypoechoic
layers alternatively
T
Slide33The ERUS Rectal Anatomy
Slide34The ERUS Rectal Anatomy
Slide35Slide36The ERUS Anal Anatomy
The anal ultrasonic image differs from the rectal image in having only four layers:
1
. Hyper echoic inner ring
2. Hypo echoic –internal anal sphincter
3. Hyper echoic-/
hypoechoic
outer ring longitudinal muscle/external anal sphincter and
4. Mixed pattern-
ischiorectal
fat.
Slide37Diagrams of anal sphincters. Coronal (A) and axial (B) views show the IAS and EAS and the other anal canal anatomic structures. A indicates anal canal; and R, rectum.
Slide38Upper anal canal level, identified by the horseshoe sling of the
puborectalis muscle posteriorly (arrows) and loss of the EAS in the midline anteriorly. The IAS is also shown by arrowheads.
Slide39Middle canal level, identified by the completion of the EAS ring anteriorly (black arrows) and maximum IAS thickness (white arrows).
Slide40Lower canal level, defined as that immediately caudal to the termination of the IAS and comprising the subcutaneous the EAS (arrows). The
anococcygeal ligament is also shown posteriorly
(arrowheads).
Slide41Common Diseases
Slide42Fecal incontinence
To identify sphincter damage, type of sphincter damages, fibrosis and atrophy .
To identify those patients with sphincter damage who may benefitted from surgical repair.
Slide43ESG of damaged EAS with scarring
Slide44Axial (left) and
sagittal (right) endoanal sonograms show
a
transsphincteric
fistula with an abscess
within
ischioanal
fossa
at the 2-o’clock position
Peri
-anal Abscesses and Fistulae
Slide45Axial and
sagittal magnified endoanal sonograms show the
intersphincteric
component of the abscess (a) at the 12-o’clock position
Peri
-anal Abscesses and Fistulae
Slide46The IAS is shown between black arrows, and the EAS is shown between white arrows
Peri
-anal Abscesses and Fistulae
Slide47Diagram of the coronal plane shows the extent of the trans-
sphincteric fistula
Peri
-anal Abscesses and Fistulae
Slide48Endoanal
sonogram shows an ischioanal abscess at the 3- to 6-o’clock position (black arrows) and its
transsphincteric
extension through both the markedly thinned EAS and IAS (white arrows) at the level of the middle anal canal
Peri
-anal Abscesses and Fistulae
Slide49After
cannulation of the fistula and injection of peroxide, on a subsequent endoanal sonogram through the high anal canal level, prompt visualization of the peroxide was noted in the abscess (black arrows) and fistula extending through both the markedly thinned IAS and
puborectalis
muscle (PRM), which extends into a small superficial
submucosal
abscess cavity (white arrows).
Peri
-anal Abscesses and Fistulae
Slide50Endoanal
sonogram through the supralevatoric level obtained before administration of peroxide reveals a horseshoe
supralevatoric
abscess cavity (black arrows) and a deficiency area in the rectal wall at the 6-o’clock position (white arrow).
Peri
-anal Abscesses and Fistulae
Slide51After peroxide injection, an
endoanal sonogram clearly depicts the suprasphincteric abscess cavity (black arrows) communicating with the anal lumen (white arrow). The internal opening is shown as a
subepithelial
breach connecting with the
intersphincteric
tract through an internal
sphincteric
defect.
Peri
-anal Abscesses and Fistulae
Slide52T1 primary rectal melanoma.
A, Axial endorectal
sonogram shows that the tumor (Tm) confined to the mucosa (white arrows) and
submucosa
is irregularly thinned (thick black arrow) at the 7-o’clock position. The normal adventitial layer is also shown with a thin black arrow.
B
, Diagram of the axial view shows the tumor confined to the first layer.
CA Rectum
Slide53T1
overstaging adenocarcinoma. Axial
endorectal
sonogram after endoscopic biopsy shows a mass confined with an adventitial layer (arrows) at the 6-o’clock position.
Overstaging
of the T1 tumor was caused by presence of hemorrhage in the biopsy area.
CA Rectum
Slide54T2
adenocarcinoma. Axial endorectal
sonogram shows a mass confined with the adventitial layer (arrows) at the 12-o’clock position. There is also a lymph node (4 mm in diameter; arrowhead) adjacent to the tumor (Tm).
CA Rectum
Slide55T2
overstaging adenocarcinoma
.
A
, Axial
endorectal
sonogram shows extension of the tumor (large arrows) through the
muscularis
propria
(small arrow) into the
perirectal
tissue at the 3-o’clock position.
B
, Continuity of the
muscularis
propria
layer (arrows) with probe rotation; the T2 tumor can be seen.
CA Rectum
Slide56T3
adenocarcinoma. Axial endorectal
sonogram shows that the thin and
echogenic
fifth (adventitial) layer is focally disrupted at the 10-o’clock position (arrows).
CA Rectum
Slide57T4
adenocarcinoma. A, Axial
endorectal
sonogram shows a fatty tissue plane between the tumor (Tm) and the right seminal
vesicula
(S). There is no invasion to the seminal
vesicula
.
B
, Axial
endorectal
sonogram from the same patient at another plane. There is considerable invasion of the left seminal
vesicula
.
CA Rectum
Slide58Villous adenoma.
A and B
,
pedunculated
polypoid
tumor (Tm; arrows) -3 to6-o’clock position. The rectal
submucosa
(small arrowhead) and adventitia (large arrowhead) are shown in
B
.
C
and
D
, Magnified
endorectal
sonogram and diagram show the polyp stalk (
C
, white arrows) and its relationship to the rectal
submucosal
(
C
, long black arrow) and adventitial (
C
, short black arrow) layers. SV indicates seminal
vesicula
.
Slide59Pathologic lymph node in rectal non-Hodgkin malignant lymphoma. Axial endorectal
sonogram shows a pathologic lymph node (arrow) with a diameter of 10 mm, round and hypoechoic adjacent to the tumor (Tm).
CA Rectum
Slide60Treatment Options in Ayurveda
Improvement of status of AgniRasayan SevanSnehanaBasti ChikitsaAushadh Prayoga
Vyayama
Ahara Vyavastha
Avoidance of vata prakopaka Ahara Vihara
THANKS