Problems with Defecation

Checklist:

Disturbances of Defecation

Is the patient constipated?

Is the patient incontinent of stool?

Did the rectal digital examination reveal bleeding or a rectal prolapse?

An Embarrassing Problem

Samantha Pamper (68) has come to the department with a problem she does not really want to brag about: She has been stool incontinent for a few years and needs diapers when she leaves her home. She has given birth to three children and is grossly overweight. Her social life has suffered quite a bit. Finally she has found a female surgeon she trusts who specializes in incontinence and other rectoanal problems. For proper preoperative planning the surgeon needs to have functional information about the defecation process: she has ordered a defecography for Mrs. Pamper. Llewellyn is the specialist for this type of problem in the radiology department—he has all the utensils for it stowed away in a little cabinet: a camping toilet made of plastic and a large ruler with lead markings. He fixes the toilet to the footstand of the fluoroscopy unit and elevates it to a comfortable sitting position. After the rectal examination he cautiously introduces a large-lumen tube into Mrs. Pamper's rectum and injects a rather thick barium paste. The vagina is also lined with just a little contrast using a smaller tube. Mrs. Pamper is asked to squat on the toilet, ready to be fluoroscoped in a lateral projection with the lead ruler held tight between her thighs.

I The Ultimate Bleed d

Rectal Exam Squatting Position Rectal Exam Squatting Position

ANTERIOR

Fig. 9.37 d A blood pool scan after administration of techne-tium-99-labeled red cell in another patient with a less intense bleed shows no abnormality in the first 45 minutes. Kidneys, bladder, liver, spleen, and heart show a homogeneously high radiotracer uptake, as expected. Another scan 20 hours later (e) not only indicates the location of the primary bleeding source (arrow) in the cecum but also proves its intraintestinal location because the radiotracer activity is spread out over the colon by the ongoing peristalsis.

I Problems of Defecation a Normal finding b Enterocele or sigmoidocele a Normal finding

Anterior Rectocele

B b c Anterior rectocele

Anterior Rectocele
Anterior rectocele

b Enterocele or sigmoidocele

Sigmoidocele

Enterocele or sigmoidocele

Rectum

Enterocele or sigmoidocele

Rectum d Rectal invagination and rectal prolapse d Rectal invagination and rectal prolapse

Cecum Problems

Invagination

Prolapse

Invagination

Prolapse

Fig. 9.38 These are the typical findings during defeco-graphy. a This is a normal situation. b In the case of an enterocele, a more proximal segment of bowel prolapses down between the rectum and the vagina during defecation. c A rectocele is a significant outpouching of the rectal wall either posteriorly or anteriorly during defecation. The content of this out-pouching is not emptied, causing a constant and unsuccessful urge. d If the rectum has lost its mooring in the pelvic floor, it invagi-nates or prolapses during defecation.

"With no other procedure," Llewellyn says to Hannah, "can we evaluate the defecation so well. It may not be as complex as the swallowing act but quite a few things can definitely go wrong. We make a video during the rest, the push, and the emptying phases; we measure the length of the anal canal and the change of its angle during pushing and expulsion." After the procedure is finished, Hannah and he review the video together. Mrs. Pamper's anterior rectal wall bulges toward the vagina quite a bit while she is straining—there is a definite anterior rectocele (Fig. 9.38c, Fig. 9.39), which makes a regular evacuation impossible. The surgeon can now go ahead and plan her therapy.

I Anterior Rectocele

I Anterior Rectocele

Rectocele Radiographs

Fig. 9.39 This radiograph doneduring the straining phaseof the defecogram demonstrates an obvious outpouching of the anterior rectal wall that can only be evacuated with great difficulty: This is an anterior rectocele.

Defecography is a significant intrusion into the privacy of the patient. The setting and the ambiance during the examination must take this into account.

Fig. 9.39 This radiograph doneduring the straining phaseof the defecogram demonstrates an obvious outpouching of the anterior rectal wall that can only be evacuated with great difficulty: This is an anterior rectocele.

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