Usefulness of 3D transperineal ultrasound in severe stenosis of the anal canal: preliminary experience in four cases

Management of Perianal Fistulas Associated with Crohn Disease: A Nurse's Perspective

Crohn disease perianal fistulas are associated with considerable morbidity and impaired quality of life. Nurses who specialize in inflammatory bowel disease (IBD) play a vital role in the management of Crohn disease perianal fistulas from diagnosis to long-term care; however, there is little evidence available to inform Crohn associated perianal fistula management strategies for nurses. This narrative review aims to provide IBD nurses with an up-to-date overview of Crohn perianal fistulas. It discusses the vital role IBD nurses play within the multidisciplinary team; the physical, social, and psychological impacts of Crohn perianal fistulas on patients; available treatment options; and how IBD nurses can support patients in their perianal fistula journey to enable optimum outcomes for patients. It also reviews diagnostic techniques and IBD nurses' involvement in Crohn perianal fistula diagnosis. While this article is aimed at IBD nurses, it is relevant to all nurses irrespective of their role (unit, clinic, community, and stoma) who interact with patients with Crohn perianal fistulas because awareness of the signs and symptoms of this condition will enable timely referrals and diagnosis.

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.

Transperineal Sonography of Anal Mass Status Post Total Colectomy: A Case Report

Transperineal sonography is a diagnostic tool for imaging the pelvic floor and lower pelvis. Because of the higher spatial resolution of pelvic sonography compared with other cross-sectional imaging techniques, transperineal sonography can provide detailed visualization of the lower pelvic organs, including the urethra, vagina, and anorectum. This case report describes the use of transperineal sonography for evaluation of an indeterminate lower pelvic process seen on computed tomography in a 53-year-old woman with progressive pelvic pain, dysuria, and dyspareunia. Because of severe dyspareunia, the patient declined transvaginal sonography. Transperineal sonography provided diagnostic imaging of the anal mass causing these symptoms.

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.

Diagnosis and treatment of iatrogenic anorectal stenosis

Iatrogenic anorectal stenosis is one of serious complications after anorectal surgery, and it is often caused by improper operation in surgical resection of hemorrhoids and anal fistula, procedure for prolapse and hemorrhoids (PPH), internal hemorrhoid agent injection and saving anal sphincter in low rectal cancer. Because of the difficulty of defecation, severe anal pain may occur. Stenotic ring can be directly touched in anal and low rectal stenosis. The degree and extent of the stenosis can be observed by colonoscopy in upper rectal stenosis. Mild stenosis can be temporarily treated with conservative therapy. If the degree of stenosis does not relieve or stenosis is more severe, we can choose different types of surgery according to the position, scope and the reasons of stenosis, which include scar closed procedure, longitudinal incision and transverse suture procedure, thread-drawing procedure, reconstruction of the anus by skin flap transposition or colostomy. Although only one procedure was adopted in the majority of cases, two or more procedures can be combined. This article reviews the diagnosis and treatment of anorectal stenosis.

Magnetic resonance imaging and endorectal ultrasound for diagnosis of rectal lesions

Endorectal ultrasonography (ERUS) and magnetic resonance imaging (MRI) allow exploring the morphology of the rectum in detail. Use of such data, especially assessment of the rectal wall, is an important tool for ascertaining the perianal fistula localization as well as stage of the cancer and planning it appropriate treatment, as stage T3 tumors are usually treated with neoadjuvant therapy, whereas T2 tumors are initially managed surgically. The only advantage of ERUS over MRI is the possibility of assessing T1 tumors that could be treated by transanal endoscopic microsurgery. However, MRI is better for visualizing most radiological prognostic features in rectal or anal cancer such as a circumferential resection margin less than 1 mm, T stage at T1-T2 or T3 tumors with extramural extension less than 5 mm, absence of extramural vascular invasion, N stage at N0/N1, and tumors located in the middle or upper third of the rectum. It can also evaluate the intersphincteric space or levator ani muscle involvement. Increased signal on diffusion weighted imaging (DWI) and low apparent diffusion coefficient (ADC) values as well as an irregular contour and heterogeneous internal signal intensity seem to predict the involvement of pelvic lymphatic nodes better than their size alone. Computed tomography as well as other examination techniques, including digital rectal examination, contrast edema, recto- and colonoscopy, are less useful in staging of rectal cancer but still are very important screening tools.