Marc Beer-Gabel

Dynamic Transperineal Ultrasound in the Diagnosis of Pelvic Floor Disorders

AbstractPURPOSE: Defecating proctography and more recently, magnetic resonance imaging have both been used for diagnosis in patients with pelvic floor dysfunction. This pilot study assessed the feasibility of dynamic transperineal ultrasound in a range of specific disorders affecting evacuation. METHODS: A protocol of sagittal and transverse transperineal imaging was established defining the infralevator viscera and soft tissues and the margins of the puborectalis muscle. Dynamic measurements were possible for the extent of puborectalis shortening, the anorectal angle, and the movement during straining of the anorectal junction. Calculations were made of the depth of demonstrated rectoceles, the posterior urethrovesical angle, and the movement of the urethrovesical junction. Diagnoses were confirmed by proctography (where appropriate) and clinical examination. RESULTS: Transverse images of the anal sphincter were comparable with those obtained using endoanal ultrasonography. Sagittal images permitted the measurement of puborectalis contraction and the anorectal angle comparable with those obtained during defecography. Cystoceles were able to be diagnosed during closure of the posterior urethrovesical angle and abnormal urethrovesical junction descent during straining. Rectoceles, peritoneoceles, enteroceles, and rectoanal intussusception were readily identified using dynamic transperineal ultrasonography. CONCLUSION: Dynamic transperineal ultrasound is a simple, noninvasive way to assess dynamically the interaction of the pelvic viscera and their relationship to the pelvic floor musculature in patients with evacuatory disorders and pelvic floor dysfunction.

Dynamic transperineal ultrasound vs. defecography in patients with evacuatory difficulty: a pilot study

Background and aimsDefecating proctography has been traditionally used to assess patients with evacuatory dysfunction. More recently, dynamic transperineal ultrasound has been described, defining the interaction between the infralevator viscera and the pelvic floor at rest and during straining. This study compared qualitative diagnosis and quantitative measurement obtained by defecography and dynamic transperineal ultrasonography in patients with evacuatory difficulty.Patients and methodsThirty-three women were examined using both techniques with both examiners blinded to the results of the other method. Quantitative measurement was made of rectocele depth, anorectal angle (at rest and during maximal straining) and anorectal junction position at rest and movement during straining.ResultsThere was good agreement for the diagnoses of rectocele, rectoanal intususseption, and rectal prolapse. Dynamic transperineal ultrasound was more likely than defecography to make multiple diagnoses or to diagnose an enterocele when a rectocele was present. There was no difference noted between the two techniques for the measurement of anorectal angle at rest, anorectal junction position at rest, or anorectal junction movement during straining. The mean anorectal angle during straining was 123.3±4.3° as measured by defecography and 116.4±3.3° as measured by dynamic transperineal ultrasound, nearly reaching statistical significance.ConclusionDynamic transperineal ultrasound is a simple and accurate technique for assessment of the pelvic floor and soft-tissues in patients with evacuatory dysfunction.

Acute hepatitis E virus infection presenting as a prolonged cholestatic jaundice.

Hepatitis E virus (HEV) is an enteric virus that usually causes a self-resolving hepatitis; although, it may be fatal, especially in pregnant women. Although HEV is endemic in Israel, there have been no recent local outbreaks. We report the case of a 70-year-old man who presented with painless jaundice. Ultrasound and abdominal computed tomography scan revealed gallstones, with no evidence of cholecystitis and no dilatation of the intra-or extrahepatic bile ducts. An open cholecystectomy was performed with intraoperative cholangiography. There was no evidence of choledocholithiasis. A subsequent endoscopic retrograde cholangiopancreatography was normal. His bilirubin level subsequently increased to a maximum of 25 mg/dL, and his gamma-glutamyl-transferase level reached 1,400 U/L. There was no evidence of any autoimmune or metabolic disease, and routine viral serology was normal except for immunoglobulin G to hepatitis A virus. A liver biopsy revealed an acute cholestatic picture. The jaundice resolved slowly after a period of 6 months. Hepatitis E virus RNA was isolated from the acute-phase serum and was not detectable in the convalescent serum. This case is a unique example of chronic cholestatic jaundice that we think is caused by acute HEV infection.

Treatment of Chronic Hepatitis C Virus Infection

OBJECTIVE: To review the literature on the treatment of chronic hepatitis C virus (HCV) infection. DATA SOURCES: MEDLINE search (1986–December 1999) using key words such as HCV, hepatitis, non-A and non-B hepatitis, as well as terms regarding treatment during that time period. DATA SYNTHESIS: HCV infection was initially treated with interferon monotherapy, but only a minority of patients responded to long-term therapy. A higher rate of response in both interferon-naïve patients and interferon-relapsers has been achieved by using the combination of interferon and ribavarin. Other treatment regimens including high-dose interferon protocols, ursodeoxycholic acid, amantadine, and nonsteroidal antiinflammatory drugs have been less promising. Many alternative therapies are being investigated. CONCLUSIONS: HCV infection is a major public health problem. It is now possible to achieve a cure in nearly 50% of the patients with this infection. Many additional therapies are being evaluated in order to achieve a higher cure rate.

Predictive Factors for the Diagnosis of Irritable Bowel Syndrome in a Large Cohort of 440,822 Young Adults

Background: The prevalence of irritable bowel syndrome (IBS) in the community has been reported in numerous cross-sectional surveys. However, little is known about the incidence and predictive factors for the clinical diagnosis of IBS. Methods: We examined the association of socioeconomic, anthropometric, and occupational factors with the incidence of IBS in a cohort of 440,822 young Israeli adults aged 18 to 39 who served in active military service during the years 2005 to 2011. Results: During the follow-up of 1,925,003 person-years, IBS was diagnosed de novo in 976 patients, giving an incidence rate of 221:100,000 (0.2%) person-years for the diagnosis of IBS. On multivariable Cox analysis, higher socioeconomic status [hazard ratio (HR) 1.629; 95% confidence interval (CI), 1.328-1.999; P<0.0001], Israeli birth (HR 1.362; 95% CI, 1.084-1.712; P=0.008), Jewish ethnicity (HR 2.089; 95% CI, 1.344-3.248; P=0.001), education ≥than 11 years (HR 1.674; 95% CI, 1.019-2.751; P=0.042), and a noncombat military position (HR 1.196; 95% CI, 1.024-1.397; P=0.024) were found to be risk factors for the diagnosis or for the worsening of IBS. Overweight (HR 0.744; 95% CI, 0.589-0.941; P=0.014), obesity (HR 0.698; 95% CI, 0.510-0.95; P=0.025), living in a rural settlement (HR 0.705; 95% CI, 0.561-0.886; P=0.003), and Middle Eastern (HR 0.739; 95% CI, 0.617-0.884; P=0.001,) or North African and Ethiopian origin (HR 0.702; 95% CI, 0.585-0.842; P<0.001) were found to be protective for the diagnosis or the worsening of IBS. Conclusions: This study provides novel data on the socioeconomic, anthropometric, and occupational factors predictive for IBS development. The predictive factors for IBS diagnosis may point to the fact that stress had a lower impact on IBS incidence in our study cohort.

Dynamic Transperineal Ultrasonography

In assessing patients who present as the final common pathway with the symptom complex of evacuatory dysfunction, there is general recognition that the vast majority of them have a multiplicity of pelvic-floor and perineal soft-tissue abnormalities across compartments. A dynamic imaging modality is required to define the real-time integration of these anomalies and to highlight their significance in each case, particularly when there is clinical or radiographic evidence of a dominant pathology and where corrective surgery is contemplated. Dynamic transperineal ultrasound (DTP-US) is a simple, radiation-free, inexpensive, and learnable technique that highlights pathology in each pelvic compartment and the interplay between compartments during straining and simulated bolus defecation. Another significant advantage of the technique is its ability to demonstrate tissues that lie well beyond the focal distance of an endoanal probe. Studies on selected patient subgroups with complex evacuatory difficulty are awaited that compare DTP-US with its counterpart, dynamic magnetic resonance (MR) imaging. We suggest that using DTP-US for realtime assessment of pelvic-floor function is best performed by the clinician managing the case or in close collaboration with the radiologist for the best potential clinical outcome. Consideration should be given to its formal accreditation by coloproctologists, gastroenterologists, radiologists, gynecologists, and biofeedback therapists.

Ultasound in Coloproctologic Practice: Dynamic Transperineal Ultrasound and Transvaginal Sonography

Dynamic transperineal ultrasonography (DTP-US) is a recently developed and studied novel and simple means for the real-time assessment of component parts of the anterior, middle, and posterior pelvic compartments and their interaction during provocative maneuvers such as straining and simulated defecation. Although it potentially rivals axial endoanal ultrasonography in the quality and resolution of images that it provides statically for the assessment of the integrity of the internal and external anal sphincters, it also may be most useful in dynamic mode for the assessment of patients primarily presenting with evacuatory dysfunction or those with defecation difficulty following pelvic surgery. There is generally a poor correlation between the symptoms attributed to pelvic floor dysfunction and radiologically demonstrated anatomical findings (1), and studies have shown that the vast majority of patients presenting with evacuatory disorders have a multiplicity of pathology (2). The traditional assessment of these patients often involves a fairly poorly tolerated “extended” defecographic technique requiring opacification of the small bowel, bladder, vagina, and even the peritoneal cavity to determine pathology of the pelvic floor compartments (3) with a presumptive decision-making process to define what represents the dominant pathology in such patients (4). Recently, static DTP-US has been used to assess the morphology and integrity of the anal sphincter components in nullipara (particularly where expensive endoluminal probes are not available), producing images that are as accurate as axial endoanal ultrasonography (5,6). Dynamic real-time TP-US is a new noninvasive technique simply performed (and learned) that assesses the anterior, middle, and posterior per-

Surgeon-Performed Ultrasound in Proctologic Practice

Since the introduction of endoanal and endorectal ultrasound by Law and Bartram in 1989, (Law and Bartram 1989) there has been an accelerated use of this technique for the preoperative assessment and management of rectal and anal cancers, (Beynon et al. 1991; Garcia-Aguilar et al. 2002) delineation of the anatomy of complex cryptogenic and inflammatory bowel disease-related perirectal sepsis (Zbar and Armitage 2006; Regadas and Regadas 2008) and for the definition of potentially reparable or augmentable external and internal sphincter defects (Martinez Hernandez Magro et al. 2003; Gravanta and Giordano 2008). Modifications of this technique with hydrogen peroxide enhancement for assessment of fistula-in-ano, (Cheong et al. 1993) Duplex supplementation for detection of perirectal blood flow, (Mallouhi et al. 2004) contrast enhancement (Chew et al. 2003), and 3-dimensional reconstruction with stacked, close interval interpolation (Zimmerman 2003; West et al. 2003; Buchanan et al. 2004) have been recent developments as has been endorectal-guided biopsy of locally recurrent rectal and anal cancers and for perirectal lymph node biopsy particularly following radiotherapy (Gavioli et al. 2000; Liersch et al. 2003). Coronal reconstruction has attempted to resolve some of the limitations inherent in endoanal sonography to provide a multiplanar interpretation of complex fistulous disease and its relationship to the main sphincter complex (Gold et al. 1999; Williams et al. 2001) and has offered useful information about staging of anal cancers prior to definitive chemoradiation (Christensen et al. 2004).

A high prevalence of NAFL in an octogenerian population

demonstrated that ~le prevalence of latty liver was pnsinvely correlated to several risk factors, including male sex, aged, hypertriglycernemia and/or hypercholesterolemia, impaired glucose tolerance or diabetes mellitns, hypertension, overweight or obesity(body mass index>24kg/m2),central obesity(mailes:waist to hip ratio>0.85;females:waist to hip ratio>0~85), and hy~ramintransterasemia. Conclusions There is a high prevalence of nonalcoholic fatty, liver among certain populations in Shanghai, of which, metabolic syndrome are closely relevant.