Transperineal ultrasound in the assessment of haemorrhoids and haemorrhoidectomy: a pilot study

EFSUMB Recommendations for Gastrointestinal Ultrasound Part 3: Endorectal, Endoanal and Perineal Ultrasound

This article represents part 3 of the EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound (GIUS). It provides an overview of the examination techniques recommended by experts in the field of endorectal/endoanal ultrasound (ERUS/EAUS), as well as perineal ultrasound (PNUS). The most important indications are rectal tumors and inflammatory diseases like fistula and abscesses in patients with or without inflammatory bowel disease (IBD). PNUS sometimes is more flexible and convenient compared to ERUS. However, the technique of ERUS is quite well established, especially for the staging of rectal cancer. EAUS also gained ground in the evaluation of perianal diseases like fistulas, abscesses and incontinence. For the staging of perirectal tumors, the use of PNUS in addition to conventional ERUS could be recommended. For the staging of anal carcinomas, PNUS can be a good option because of the higher resolution. Both ERUS and PNUS are considered excellent guidance methods for invasive interventions, such as the drainage of fluids or targeted biopsy of tissue lesions. For abscess detection and evaluation, contrast-enhanced ultrasound (CEUS) also helps in therapy planning.

Sonographic appearance of anal cushions of hemorrhoids

AIM

To evaluate the diagnostic value of different sonographic methods in hemorrhoids.

METHODS

Forty-two healthy volunteers and sixty-two patients with grades I-IV hemorrhoids received two different sonographic examinations from January 2013 to January 2016 at the First and Second Hospitals of Xinjiang Medical University in a prospective way. We analyzed the ultrasonographic findings of these participants and evaluated the outcomes. Resected grades III and IV hemorrhoid tissues were pathologically examined. The concordance of ultrasonographic results with pathology results was assessed with the Cohen’s kappa coefficient.

RESULTS

All healthy volunteers and all patients had no particular complications related to sonography. There were no statistically significant differences between the participants regarding age (P = 0.5919), gender (P = 0.4183), and persistent symptoms (P > 0.8692). All healthy control participants had no special findings. However, 30 patients with hemorrhoids showed blood signals around the dentate line on ultrasonography. When grades I and II hemorrhoids were analyzed, there were no significant differences between transrectal ultrasound (TRUS), transperianal ultrasound (TPUS), and transvaginal ultrasound (TVUS) (P > 0.05). Grades III and IV hemorrhoids revealed blood flow with different directions which could be observed as a “mosaic pattern”. In patients with grades III and IV hemorrhoids, the number of patients with “mosaic pattern” as revealed by TRUS, TPUS and TVUS was 22, 12, and 4, respectively. Patients with grades III and IV disease presented with a pathologically abnormal cushion which usually appeared as a “mosaic pattern” in TPUS and an arteriovenous fistula in pathology. Subepithelial vessels of resected grades III and IV hemorrhoid tissues were manifested by obvious structural impairment and retrograde and ruptured changes of internal elastic lamina. Some parts of the Trietz’s muscle showed hypertrophy and distortion. Arteriovenous fistulas and venous dilatation were obvious in the anal cushion of hemorhoidal tissues. After pathological results with arteriovenous fistulas were taken as the standard reference, we evaluated the compatibility between the two methods according to the Cohen’s kappa co-efficiency calculation. The compatibility (Cohein kappa co-efficiency value) between “mosaic pattern” in the TPUS and arteriovenous fistula in pathology was very good (ĸ = 0.8939). When compared between different groups, TRUS presented the advantage that the mosaic pattern could be confirmed in more patients, especially for group A. There was a statistical difference when comparing group A with group B or C (P < 0.05 for both). There were obvious statistical differences between group A and group B with regard to the vessel diameter and blood flow velocity measured by TRUS (P < 0.05).

CONCLUSION

Patients with grades III and IV hemorrhoids present with a pathologically abnormal cushion which usually appears as a “mosaic pattern” in sonography, which is in accord with an arteriovenous fistula in pathology. There are clearly different hemorrhoid structures shown by sonography. “Mosaic pattern” may be a parameter for surgical indication of grades III and IV hemorrhoids.

Current applications of transperineal ultrasound in gastroenterology

Transperineal ultrasound is an inexpensive, safe and painless technique that dynamically and non-invasively evaluates the anorectal area. It has multiple indications, mainly in urology, gynaecology, surgery and gastroenterology, with increased use in the last decade. It is performed with conventional probes, positioned directly above the anus, and may capture images of the anal canal, rectum, puborectalis muscle (posterior compartment), vagina, uterus, (central compartment), urethra and urinary bladder (anterior compartment). Evacuatory disorders and pelvic floor dysfunction, like rectoceles, enteroceles, rectoanal intussusception, pelvic floor dyssynergy can be diagnosed using this technique. It makes a dynamic evaluation of the interaction between pelvic viscera and pelvic floor musculature, with images obtained at rest, straining and sustained squeezing. This technique is an accurate examination for detecting, classifying and following of perianal inflammatory disease. It can also be used to sonographically guide drainage of deep pelvic abscesses, mainly in patients who cannot undergo conventional drainage. Transperineal ultrasound correctly evaluates sphincters in patients with fecal incontinence, postpartum and also following surgical repair of obstetric tears. There are also some studies referring to its role in anal stenosis, for the measurement of the anal cushions in haemorrhoids and in chronic anal pain.

Three-dimensional power Doppler transanal ultrasonography, to monitor haemorrhoidal blood flow after Doppler-guided ALTA sclerosing therapy

AIM

The study aimed to use power Doppler imaging (PDI) transanal ultrasonography to produce three-dimensional power Doppler angiography images of haemorrhoidal tissue and to monitor the effects of Doppler-guided aluminium potassium sulfate and tannic acid (DGALTA) sclerotherapy.

METHOD

Ninety-six haemorrhoids in 43 patients were examined using PDI transanal ultrasonography, and DGALTA sclerotherapy was performed from April 2011 to April 2012. DGALTA sclerotherapy was conducted using a four-step injection process with pulse wave Doppler ultrasound under perianal local anaesthesia.

RESULTS

A three-dimensional power Doppler angiography image of the blood flow in haemorrhoidal tissue was produced using PDI transanal ultrasonography. The cross-sectional area of blood flow in the haemorrhoidal tissue (PDI area) significantly decreased after DGALTA sclerotherapy. The PDI areas in the preoperative state and 1 and 3 months after treatment were 0.35±0.27, 0.03±0.05 and 0.04±0.05 cm(2) (P<0.0001).

CONCLUSION

A three-dimensional power Doppler angiography image of the haemorrhoidal tissue was technically possible and showed blood flow in the haemorrhoidal tissue to be significantly decreased after DGALTA sclerotherapy.