Investigation of Anorectal Functional Disorders: With Special Emphasis on Defaecography

221 Pages·1993·10.054 MB·English

by  M. A. Kamm (auth.), Professor Dr. med. Peter Buchmann, Professor Dr. med. Werner Brühlmann (eds.)

P. Buchmann W. Briihlmann (Eds.)
Investigation of
Anorectal
Functional Disorders
With Special Emphasis on Defaecography
With 130 Figures, Some in Colour,
and 38 Tables
Springer-Verlag
Berlin Heidelberg New York London Paris
Tokyo Hong Kong Barcelona Budapest
Professor Dr. Peter Buchmann
Chirurgische Klinik, Stadtspital Waid
Tiechestrasse 99, 8037 Zurich, Switzerland
Professor Dr. Werner Briihlmann
Institut fUr Rontgendiagnostik
Stadtspital Triemli
Birmensdorferstrasse 497, 8063 Zurich, Switzerland
ISBN-13:978-3-642-77404-1 e-ISBN-13:978-3-642-77402-7
DOl: 10.1007/978-3-642-77402-7
Library of Congress Cataloging-in-Publication Data
Investigation of anorectal functional disorders: with special emphasis
on defaecographylP. Buchmann, W. Briihlmann, eds. P.cm.
Includes bibliographical references and index.
ISBN-13:978-3-642-77404-l
1. Defecation disorders - Diagnosis - Congresses. 2. Anorectal
function tests - Congresses. 3. Defecography - Congresses.
I. Buchmann, P. (Peter) II. Briihlmann, W. (Werner)
RC866.D43I59 1993 616.3'5 - dc20 92-26472
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Preface
Medical examination of the anus and lower rectum has a
very long tradition. The first instrument utilized was the
doctor's finger, and digital examination is still the most
important step after a precise case history. Endoscopy,
first with a short tube, then with a rigid sigmoidoscope,
enabled physicians to look inside the large intestine
as far as 25 cm ab ano.
In 1919, Holzknecht introduced X-ray examination of the
colon with contrast enema, but research concentrating on
the physiology and pathophysiology of the anorectum
and pelvic floor did not start until the second half of
this century.
Many of the newly developed investigations have the
disadvantage of influencing their own result (e.g. balloon
size in manometry) or interfering with physiology (e.g.
bowel preparation for endoscopy or double-contrast
examination). Defaecography and scintigraphy are de
signed to investigate bowel motility. Defaecography in
particular demonstrates the phase of rectal emptying, yet
the value and range of indications for this new method
have not been clearly defined. We therefore organized a
workshop, held in May 1991, the results of which are
presented in this book. We hope, that this volume will
help the physician in selecting the appropriate investi
gations and in performing and interpreting them.
We warmly thank the firms that supported our work
shop: Auto Suture (Swiss) AG, Hoeri; Blendax
Richardson AG, Geneva; Eli Lilly S.A., Geneva;
Hofmann-La Roche, Basel; Johnson & Johnson AG,
Spreitenbach; Kali-Duphar Pharma AG, Berh; Kodak,
Lausanne; Medichemie AG, Ettlingen; Phardi AG,
Basel; Philips Medical Systems AG, Zurich; Sandoz
Wander Pharma AG, Bern; Schering (Swiss) AG,
Schlieren; Searle S.A., Lausanne.
VI Preface
Our thanks go to all the contributors, to Mrs. Dovian for
the workshop administration, to Mrs. Fluckiger for the
manuscript management and, last but not least, to
Springer-Verlag Heidelberg for publishing the book.
Zurich, autumn 1992 w. Bruhlmann
P. Buchmann
Contents
1 Physiology and Pathophysiology
of Defaecation
M.A. Kamm ............................. 1
2 Ultrasound Anatomy of the Pelvic Floor
U. Hildebrandt . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3 Pelvic Floor Stability and the Uterus
R. Hauck................................ 23
4 Case History and Clinical Examination
P. Buchmann. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5 Defaecography:
Technique and Radiation Exposure
W. Briihlmann and W. Miiller-Duysing 42
6 Defaecographic Parameters
in Asymptomatic Subjects
R. Goei.................................. 50
7 Indications for Defaecography
A. Riihl, J.F. Erckenbrecht, M.-C. Marti,
and J. Hirsig ............................. 61
8 The Value of Defaecography
for Treatment Decisions
D. Geile, R. Stahl, and M.-C. Marti ...... .'. . 73
9 Conventional Radiography,
Computed Tomography
and Magnetic Resonance Imaging
G. Stuckmann . . ... . . . . ... . . . . . . . . . . . . . . . . 90
VIII Contents
10 Balloon Proctography
M.-C. Marti......................... ..... 103
11 Endoscopy and Histological Findings
J.F. Erckenbrecht and A. Ruhl ............. 106
12 Scintigraphy
M.A. Kamm ............................. 111
13 Transit Time Measurement
J.H.C. Kuijpers.......... ........... . ..... 115
14 Manometry, Electromyography
and Other Functional Pelvic Floor Tests
M.A. Kamm ............................. 119
15 Rectal Prolapse
P.H.G. Mahieu and J.H.C. Kuijpers......... 127
16 Rectal Outpocketing
R. Hauck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
17 Enterocele
R. Hauck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
18 Assessment of Functional Constipation
J.H.C. Kuijpers.... . ............... . ...... 189
19 Defaecography and Incontinence
M.-C. Marti. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
20 Anal Sphincter Dysplasia
J. Hirsig .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
List of Senior Authors
Buchmann, Peter, Prof. Dr. med.
Chirurgische Klinik, Stadtspital Waid
Tiechestrasse 99, 8037 Zurich, Switzerland
Briihlmann, Werner, Prof. Dr. med.
Institut flir Rontgendiagnostik, Stadtspital Triemli
Birmensdorferstrasse 497, 8063 Zurich, Switzerland
Erckenbrecht, J.F., Prof. Dr. med.
Medizinische Klinik, Krankenanstalten
"Florence Nightingale", Kreuzbergstrasse 79
W-4000 Dusseldorf 31 (Kaiserswerth), FRG
Geile, Dorothee, Dr. med.
Einsteinstrasse 127, W-8000 Munchen 80, FRG
Goei, Reginald, Dr. med.
Department of Radiology, De Wever Hospital
PO Box 4446, 6401 CX Heerlen, The Netherlands
Hauck, Reiner, Dr. med.
Maximilianstrasse 14, W-8000 Munchen 22, FRG
Hildebrandt, D., PO Dr. med.
Chirurgische Klinik, Dniversitatskliniken des Saarlandes
W-6650 Homburg/Saar, FRG
Hirsig, Johannes, Dr. med.
FMH flir Kinderchirurgie
Zurichstrasse 63,8424 Embrach, Switzerland
Kamm, Michael A., Dr. med.
St. Mark's Hospital, City Road
London EC1 V 2PS, United Kingdom
X List of Senior Authors
Kuijpers, H.C., Dr. med.
Allgemene Chirurgie, Academisch Ziekenhuis Nijmegen
Geert Grooteplein 14, Postbus 9101
6500 HB Nijmegen, The Netherlands
Mahieu, P.H.G., Dr. med.
Department of Radiology UCL
Surgical Institute of Brussels
59, Square Marie-Louise, 1040 Brussels, Belgium
Marti, M.-C., Prof. Dr. med.
Hopital Cantonal Universitaire, 24, rue Michelin-du-Crest
1211 Geneve 4, Switzerland
Riihl, A., Dr.
Medizinische Klinik, Krankenanstalten
"Florence Nightingale", Kreuzbergstrasse 79
W-4000 Dusseldorf 31 (Kaiserswerth), FRG
Stuckmann, G., Dr. med.
Rontgendiagnostik, Kantonsspital
Brauerstrasse 15,8401 Winterthur, Switzerland
1 Physiology and Pathophysiology of Defaecation
M.A. Kamm
The process of defaecation is complex and depends on the integration of
neurological information from the brain, spinal cord, pelvic floor and colon
itself. Once this information has been processed the act of defaecation relies
on intact colonic and pelvic floor function. Other factors which contribute to
this process include the colonic contents (bile acids, fatty acids, water and
fibre content), gender, age, personality and hormonal status.
1.1 Extrinsic Control of Colonic Motor Function
Our knowledge about the cerebral control of large bowel function remains
rudimentary, yet it is likely that many disorders of defaecation derive from
an abnormality of this regulation. Recent animal studies have revealed
specific cerebral control sites and neurotransmitters [1]. The hypothalamus
directly affects colonic activity: the intracerebroventricular injection of
thyrotropin-releasing hormone produces an increase in motility [2]. Experi
mental work in animals has also demonstrated an important central role
of thyrotropin-releasing hormone and corticotropin-releasing hormone in
influencing gastrointestinal transit and faecal output. Changes in colonic
motility associated with stress can be shown to be related to intracerebral
release of corticotropin-releasing hormone [3]. Opioids also influence
colonic activity, some of them by their central action in the brain or spinal
cord [4, 5]. Undoubtedly other neurotransmitters of importance will
emerge.
It is possible that disturbances of colonic motility and defaecation in some
patients derive from abnormal cerebral control. Evidence in support of this
comes from the disturbed colonic function and constipation observed after a
cerebrovascular accident, including subarachnoid haemorrhage, although
the changes may be due in part to altered peripheral autonomic function and
are usually not permanent. Colonic transit can be delayed after an anterior
or posterior pontine lesion [6]. In multiple sclerosis, constipation affects
more than 40% of patients [7], although the exact relationship of cerebral or
spinal plaques to altered motility remains to be determined.
Perhaps the most interesting association is that between psychological dis
turbance and altered defaecation. Normal individuals can slow their colonic