rabiezahran@Gawab.com Ultrasonography in Ano-rectal disorders - PowerPoint Presentation

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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

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Definition

Ultrasonography is study of internal organs, structures or blood vessels using high frequency sound waves, the actual test called ultrasound scan or sonogram.

Ultrasonography

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Definition (contd.)

Ultrasound are

sound waves of frequencies greater than audible to human ear i.e. greater than 20,000Hz

.

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A 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

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Principle

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.

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sound waves travel faster in solids than liquids or gases. The major cause of attenuation in soft tissue is absorption,

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1. 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 .

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Different Patterns found in USG

Echo free

Hypo echoic

Hyper echoic

Heterogeneous

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Echo 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 .

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Echo

pattern

Echogenic :

  When ultrasound waves pass through solids (bones – stone) all waves are reflected and appears as white color with posterior shadow .

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Gall Bladder

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Normal Anatomy of Gall bladder

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Liver metastases

Heterogeneous

echogenicity

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Trans Rectal Ultra-

sonography (TRUS)

or

(Endo-rectal Ultra-

sonography

)

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Detection 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

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Rectal and Pelvic disorders (Indications)

Benign diseases Faecal incontinence Inflammatory conditions

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Rectal 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.

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TRUS 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

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Fecal 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

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Preparation 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.

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Position

Left lateral decubitus position

( commonly used )

.

Knee-chest position.

Prone Position

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Left Lateral Position

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Prone Position

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Technique

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.

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To 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

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Images are usually obtained by using an ultrasound frequency of 5-15MHz, depending on which part of rectum or anal canal is being examined.

Technique

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The ERUS Rectal Anatomy

Fluid inter-space is essential

Images of rectal wall comprise three

hperechoic

and two

hypoechoic

layers alternatively

T

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The ERUS Rectal Anatomy

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The ERUS Rectal Anatomy

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The 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.

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Diagrams 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.

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Upper 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.

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Middle canal level, identified by the completion of the EAS ring anteriorly (black arrows) and maximum IAS thickness (white arrows). 

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 Lower 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).

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Common Diseases

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Fecal 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.

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ESG of damaged EAS with scarring

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Axial (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

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Axial and

sagittal magnified endoanal sonograms show the

intersphincteric

component of the abscess (a) at the 12-o’clock position

Peri

-anal Abscesses and Fistulae

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The IAS is shown between black arrows, and the EAS is shown between white arrows

Peri

-anal Abscesses and Fistulae

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Diagram of the coronal plane shows the extent of the trans-

sphincteric fistula

Peri

-anal Abscesses and Fistulae

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Endoanal

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

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After

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

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Endoanal

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

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After 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

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T1 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

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T1

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

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T2

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

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T2

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

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T3

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

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T4

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

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Villous 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

.

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Pathologic 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

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Treatment Options in Ayurveda

Improvement of status of AgniRasayan SevanSnehanaBasti ChikitsaAushadh Prayoga

Vyayama

Ahara Vyavastha

Avoidance of vata prakopaka Ahara Vihara

THANKS