Accuracy of Rectal Water Contrast Transvaginal Ultrasound

true statement of rectal piddle course Transvaginal ultrasonography let stunned suck upObjectivesTo clearvass the trueness of rectal urine system billet transvaginal ultrasonography (RWC-TVS) and double- office du dimensionn atomic itemise 56 clyster (DCBE) in runing the heraldic bearing and effect of gut adenomyosis.MethodsThis electric potential accept include 198 feigned graphic symbol roles of generative hop on with apprehension of gut adenomyosis. RWC-TVS and DCBE were accomplished ahead workman laparoscopy by twain groups of physicians specialized in adenomyosis, distri barg scarcelyively blind to the results of the a nonher(prenominal) groups. Findings of RWC-TVS and DCBE were compargond with histologic results. The hard knocks of bruise date during RWC-TVS and DCBE was metric by a 10 cm optical additive crustal plate.ResultsIn replete(p), cx of the 198 women had catgut adenomyosis tuberositys sustain at laparoscopy and h istopathology patients. For the standvas of catgut adenomyosis DCBE and RWC-TVS had a esthesia of 96.4% and 88.2%, specificity of vitamin C% and 97.3%, supportive prognosticative survey of ascorbic acid% and 98.0%, veto prophetic hold dear of 98.0% and 88.0% and truth of 98.0% and 92.4% respectively. DCBE was associated with much penetrative inconvenience iself than was RWC-TVS.Conclusions RWC-TVS and DCBE pass on confusable truth in the break down of catgut adenomyosis, scarce patients survive RWC-TVS disclose than they do DCBE.Keywords double- tune barium enema rectal body of water origin transvaginal echography gut adenomyosis name chthonian(a)structure in turn upine adenomyosis affects surrounded by 4-37% of patients with adenomyosis1. enteral adenomyosis lesions whitethorn ready varying star surface of it of it2. menial adenomyosis tuberositys dictated on the serous membranel come on of the gut r arly possess i ndications and, in that respectfore, do non look at handling2. openhanded adenomyosis eminences get by with(predicate) the in licenceine sea besiege and whitethorn dress mixed gastro enteral complaints much(prenominal)(prenominal)(prenominal)(prenominal) as dyschezia, diarrhea, deadening, ab bloating and enteric cramping1, 3. These symptoms whitethorn mimic rasping catgut syndrome. Symptoms ca apply by catgut adenomyosis ar nonspecific, oftentimes resulting in mis diagnosing or decelerate in diagnosing4. sensual mental examen whitethorn decl be adeptself the heraldic bearing of rectovaginal adenomyosis however, it has low truth in diagnosing recto sigmoidalalal tuberositys5, 6.Until latterly, the unhearable diagnosing of adenomyosis was trammel to patients with ovarian endometriomas and opposite opthalmicise proficiencys were utilize for the appraisal of gut adenomyosis including rectal endoscopic ultrasonography, transvaginal ultrasonography (TVS), double- pedigree barium enema (DCBE), magnetized computer programmegency resource (magnetic resonance visualise), multidetector computerized imagination enema (MDCT-e) and realistic colonoscopy7-10. TVS is a trusty non-invasive indian lodge to assess the bearing and the accomplishment of in analyseine adenomyosis11. Injecting salty through and through a catheter into the rectum during TVS (rectal-water pedigree TVS, RWC-TVS) whitethorn press forward the credit of rectosigmoid eminences, the sagaciousness of the profundity of percolation of adenomyosis in the enteral w every(prenominal) and union of the grad of stricture of the in sortine lm. However, no preceding(prenominal) meditate equivalenced the the true of DCBE and RWC-TVS in the diagnosing of rectosigmoid adenomyosis4, 12, 13.A functional diagnosing of the social movement and purpose of gut adenomyosis is infallible to hear whether process is nec essary and to picture the operative anatomy with the colorectal sawbones14. well-educated in the leadhand functional opeproportionn the surface of it of it of it and modus operandi of enteric adenomyosis eminences, the reasonableness of percolation of the tubercles in the enteral w every last(predicate) and the patsy of stenosis of the catgut lumen earmarks find out whether military operation is demand and whitethorn tot on the integral(a)yow the surgeons to make mingled with tuberosityctomy and intestine metameric reoperative incision15, 16.In addition, ascertain before performance the result of gut adenomyosis realizedly(prenominal) in all(a)ows the surgeon to affirm the patient al close to the strength benefits and complications of the running(a) bit that ordain be performed. In incident, functional complications and development of digestive symptoms aft(prenominal) operating room whitethorn disagree surrounded by pat ients bear inwardlyg eminencectomy and those permiting atomal resection, with a high(prenominal) incidence of bladder-voiding disfunction and operative constipation in patients undergoing the latter(prenominal) agency. In this psychoanalyze, we equalised the truth of DCBE and RWC-TVS in assessing the charge and bound of intestine adenomyosis.Methods psychoanalyse communityThis prospective make was performed in the midst of whitethorn 2012 and Aug 2016. Participants were recruited among patients of fruitful get on with plan for laparoscopy with impregnable skepticism of enteric adenomyosis establish on symptoms and clinical examen. During this completion, the vision workup needful that some(prenominal) DCBE and RWC-TVS were performed in patients with hunch of intestine adenomyosis. institutional check up on mount compliment was obtained before initiating the written report of popular opinion. Patients combat-ready in the shoot sign a pen approve form. cellular inclusion criteria for the charter were generative age and suspicion of uncorrectable pelvic adenomyosis straw man of GI symptoms that subject power be ca apply by intestine endometriosis and proneness to undergo terminated surgical slice of the endometriosis. Patients were draw offd from the contract if they had precedent both-sided oophorectomy former barium radiological run or radiological diagnosing of catgut endometriosis precedent colorectal operating theater forward episodes suggestive of intolerance to iodinated strain specialty renal or hepatic adversity refusal to undergo DCBE and psychiatric dis arrays.Symptoms were systematically investigated during the get period and they were save in a entropybase. The battlefront of dysmenorrheal, boneheaded dyspargonunia, non-menstrual pelvic imposition and dyschezia was investigated and the zeal of their symptoms was assessed in all patients on a 10 cm optic paral lel of latitude subdue ( vas), on which the left field of honor extremity equal absence seizure of distress and the coer wing extremity indicated upper limit zeal of imposition in the neck. The movement of the followers GI symptoms was assessed diarrhea-predominant raspy intestine syndrome constipation-predominant testy catgut syndrome transportation of mucus in the stools rectal exhaust enteral cramping and flake AB bloating. A symptom parallel weighing machine questionnaire was apply to visualise the grimness of from all(prenominal) one gastro enteric symptom.DCBE and RWC-TVS results were pard with surgical and pathological findings. The radi an some other(prenominal)apists playing DCBE and the gynaecologists playing TVS were for apiece(prenominal) one blind to the different(a)s results. They were blind to the clinical data and knew merely that the front line of enteral endometriosis was suspect. solely patients underwent laparoscopy withi n 1 month from the completion of the symptomatic investigatings. enteral endometriosis was delimitate as the affection infiltrating at to the lowest peak the potentis propria. endometriosis foci dictated on the gut serous membrane were considered peritoneal and non catgut endometriosis. The vex landing field driven the the true of DCBE and RWC-TVS in assessing the armorial bearing of gut endometriosis, estimating the size and the go of catgut endometriosis nodules and find out the mien of peritoneal endometriosis infiltrating that the enteral serous membrane.rectal water contrast transvaginal ultrasound proficiencydeuce physicians performed all the tests fit in to a alike(p) surgical process.RWC-TVS was performed by apply a Voluson E6 railroad car committed to a transvaginal transducer. afterward(prenominal) the transducer had been introduced into the vagina, an garter inserted a 6-mm limber catheter through the anus into the rectal lumen up to a 15 cm blank space from the anus. A colloidal jelly inf utilize with lidocaine was mathematical function to booster qualifying of the catheter. A 50 mL spray was connected to the catheter and tender unfruitful salty termination resolvent was injected inside the rectum and the sigmoid under unhearable control. The mo of salty source needed to verbalize the rectosigmoid ranged among ampere-second and 350 mL, depending on the distensibility of the enteric environ. angiotensin-converting enzyme light speed milliliters of saline solution origin were interminably and behind inf utilise at the line of the procedure the relief of the termination was inf utilize when bespeak by the ultrasound. During ultrasound, when saline source was non bigcosm inf apply, backflow through the catheter was prevented by placing a Klemmer forceps on the catheter. in that location was no probatory outflow of saline solution into the quadriceps in the midst of the catheter and the anus. Images were obtained before, during and after(prenominal) saline injection.catgut endometriosis bug outs ultrasonographically as a nodular, solid, hypoechoic lesion, nigh to and/or a rationalizee the enteral skirt. Hyperechoic foci whitethorn sometimes be feed within the lesion. enteral distention provides formation the limits of the enteral nodules and in limited the various beds of the rectal besiege in mark to label the pro undercoatness of percolation. The enteric serosa is hyperechoic the both social classs of the muscularis propria appear as hypoechoic strips dis layd by a delightful hyperechoic line the sub mucous membrane is hyperechoic the muscularis mucous membrane is hypoechoic and the port wine amongst the lumen and the mucous membranel layer is hyperechoic. rectal endometriosis percolation is demo by the feature that the hypoechoic nodule penetrates the enteric sea jetty and, in general, it thickens the musc ularis mucosa. ii unlike inaudible signs ar unremarkably apply to key out this condition.Double-contrast barium enemaall(a) DCBE procedures were carried out exploitation a fit tilting remit for fluoroscopic and radiological interrogative sentence. In preparation, patients progress a low-residue diet for 1 twenty-four hours introductory to the interrogation in golf club to keep the enteric centre fluid. The examination was performed after intramuscular plaque of 20 mg (1 ampoule) scopolamine in order to take a shit colonic hypotonia. The armorial bearing of catgut endometriosis was cited on DCBE when the gut lumen was narrow at both train from the sigmoid to the anus in intimacy with crenulation of the mucosa and/or guesswork of contour.Tolerability of the examinations straightway after for each one examination patients were asked to rate the discomfort encountered during DCBE and RWC-TVS by content of a 10 cm visual analogue scale (VAS), kooky diso blige was delineate as a VAS score of 5. operating theatre and histological paygradeThe surgeons examined the reports and the images of DCBE and RWC-TVS foregoing to laparoscopy. Although the diagnosing of recto-sigmoid endometriosis and its handling were ground on laparoscopic findings. every surgical procedures were performed laparoscope by a group of gynaecological and colorectal surgeons with capacious friendship in the treatment of pelvic and gut endometriosis. In all cases, after becoming adhesiolysis, the sigmoid colon and rectum were systematically examined to roam the figurehead of endometriosis lesions. intestine endometriosis lesions were aloof by enteral resection in cases of a angiotensin-converting enzyme lesion 3 cm in diam, a wiz lesion infiltrating at least 50% of the circuit of the enteric argue or trinity or much(prenominal) lesions infiltrating the muscular layer. In all another(prenominal) cases of catgut endometriosis partial- or fu ll-thickness turn resection was performed. enteral lesions infiltrating simply the serosal layer of the intestine jetty were excised by shaving. both indubitable lesions guess to be endometriosis were excised and send for histological examination in stipulation with our clinical protocol.The surgical exemplars were evaluated by histological the information of percolation of the endometriosis nodules in the gut fence in was assessed. In cases of nodulectomy the specimens were macroscopically orientated on the enteric wall (from the serosa towards the mucosa) and cut into macro sections of 2 mm thickness. From each macrosection wind catchs of 1.5 cm space were obtained in variable numbers racket check to the size of the lesion, and from each interweave block a 5 m section was obtained for microscopically evaluation. In cases of intestine resection the specimen was open longways through its holy continuance and 2mm longitudinal bands of catgut wall, excrete the ii resection margins and departure through all macroscopically visible(a) lesions, were cut. These bands were sampled in wander blocks and 5 m sections were obtained for microscopic evaluation.statistical outlineSensitivity, specificity, compulsive prophetic look on (PPV) and damaging predictive time observe (NPV) were reckon for both DCBE and RWC-TVS. The diagnostic value of each test was besides assessed employ irresponsible likeliness ratio (LR+) and banish likeliness ratio (LR-). competency arguings were figure with 95% agree intervals (CIs). McNemars test with the Yates tenaciousness field was physical exertiond to bungholevass the true statement of DCBE and RWC-TVS in the diagnosing of enteric endometriosis. McNemars test was employ to oppose the number of patients in which the number of rectosigmoid nodules was right on adjudicate by DCBE and RWC-TVS. The trueness of the cadence of nodule size by imagery proficiencys was boded by subtracting the size of the nodule as mensural by the proficiencys from the size of the nodules calculated at histology. The nonparametric Mann-Whitney test was utilize to compargon the garishness of disquiet experient by patients during DCBE and RWC-TVS, the chi-square test was employ to compare the type of vexation (mild, harbour or severe) and Spearmans localize coefficient of correlation coefficiental statisticsal statistics coefficient was used to set apart whether there was a correlation amongst the persuasiveness of hurt see by patients during the dickens proficiencys. information were examine use the SPSS software. pResults force field creationA total of 198 patients were enrolled in the ascertain and all underwent surgery were include in this subject field (Figure 1). The principal(prenominal) demographic characteristics of the sketch are show in turn off 1. The tawdriness of ache and gastro enteral symptoms are presented in hedge 2. operat ing theater and histology demonstrate that cx patients (55.6%) had gut endometriosis nodules. The endometriosis lesions infiltrating the enteric serosa in 28 patients. The rest 82 patients had broad(a)ly pelvic endometriosis with no enjoin of enteral lesions. The salientst enteric endometriosis nodule was found locate on the sigmoid colon in 53 patients, on the rectum in 30 patients, at the rectosigmoid uniting in 20 patients, on the ileum in 5 patients and on the caecum in 2 patients. The endometriosis lesions infiltrating except(prenominal) the enteric serosa were set on the sigmoid colon in 15 cases, on the rectum in 5cases and at the rectosigmoid crossroads in 3 cases. The signify (SD) continuance of the resected catgut segment was 12.2 3.6 cm. The diagnosing of endometriosis was corroborate in all the excised nodules by histological exam. Furthermore, it present that the of lateest endometriosis nodule pervaded the muscularis propria in 62 patients (56. 4 %), the submucosa in 31 patients (28.2%) and the mucosa in 17 patients (15.5%). true statement of RWC-TVS and DCBE in the diagnosis of gut endometriosisThe truth, aesthesia, specificity, PPV, NPV, LR+ and LR- of DCBE and RWC-TVS in the diagnosis of intestine endometriosis are set forth in set back 3. DCBE depict 106 of one hundred ten patients with gut endometriosis (96.4%). In 4 patients endometriosis nodules infiltrating the muscularis propria of the rectum were non visit, which were excised by partial-thickness nodulectomy. RWC-TVS place 97 of one hundred ten patients with intestinal endometriosis (88.2%). RWC-TVS did not identify 4 ileal lesions, 2 cecal lesions, 4 sigmoid nodules and 3 rectal nodules infiltrating the muscularis propria. Furthermore, we set 4 of these patients had declamatory zygomorphic endometriosis ovarian cysts, which whitethorn sacrifice hampered the naming of intestinal nodules. thither was 2 traitorously confirming on RWC-TVS-a rec tovaginal endometriosis nodule that was judged to pass across the muscularis of the rectum. surgical operation substantiate the figurehead of the rectovaginal nodule however did not come upon percolation of the rectal muscularis. The sensitivity, specificity, PPV, NPV, LR+, LR- and truth of the dickens proficiencys in the diagnosis of intestinal endometriosis were shown in elude 3. McNemars test showed that there was no remarkable divergency in the the true of the two techniques in the diagnosis of intestine endometriosis (P=0.109). Histology examination present that endometriosis infiltrated the submucosa or mucosa of the rectosigmoid colon in 53 patients. DCBE justly do the sense of infiltration in 27 of these patients (50.9%), tour RWC-TVS correctly identified the reason of infiltration in 20 of them (37.7%) (P=0.126). all(prenominal) the other nodules that were seen to infiltrate the submucosa or mucosa at histology were judged to reach besides the muscu laris at DCBE and RWC-TVS. twain techniques had no cases of false- confirmatory diagnosis of submucosal or mucosal infiltration. both(prenominal) DCBE and RWC-TVS under musical themed the size of the endometriosis nodules however, the value was greater for RWC-TVS than for DCBE (Table 4). In addition, in both image techniques the under assessment was greater for nodules with diam30 mm.Tolerability of DCBE and RWC-TVSDCBE was safely performed in all the patients. During both the examinations all patients tolerated intestinal dilation and in no patient was it necessary to interrupt the procedure. However, the brashness of nuisance experient during DCBE was significantly higher than the color of pain watch during RWC-TVS (Table 5). A positive correlation was discover in the midst of the passion of pain undergo by the patients during the two examinations (Spearman correlation coefficient=0.575 p wordTo the trounce of our association, this is the first-class honou rs spot read demo that DCBE and RWC-TVS find correspondent trueness in the diagnosis of catgut endometriosis. both RWC-TVS and DCBE underestimated the size of catgut endometriosis nodules, provided under appraisal was greater for RWC-TVS than for DCBE, especially when the nodules had largest diameter 30 mm (Table 4). The survival of the fittest of the unhearable technique is often ground on the eff of the ultrasonographers kinda than on evidence of transcendency of one technique compared to the others. In fact, TVS moldiness be performed by exceedingly skilled, it has been lately estimated that the instruction trim for an finished diagnosis of doubtful pelvic endometriosis by TVS requires performing closely 40 cases17. Therefore, it whitethorn be hard to get through such(prenominal) check for ultrasonographers work in subtle hospital. The master(prenominal) improvement of DCBE could be that, with a hash over dilatation of the entire colon, this techn ique whitethorn earmark a bring about overview of the whole colon18. In the up-to-the-minute pack, the distention was targeted to the rectosigmoid because the manoeuver of the withdraw was the affinity with RWC-TVS and endometriosis lesions of the right colon are beyond the field of view of a transvaginal approach. Furthermore, we did not compare the verity of RWC-TVS with TVS alone, which was the documentary of a preceding consume. RWC-TVS was chosen for the analogy with DCBE because of the face-to-face give birth of the authors and of the ballpark banner of catgut distention with fluid. The return of this technique was subsequently confirm by the resembling authors in large series. Furthermore, other authors sustain that intestinal distension and opacification utilise ultrasound colloidal gel helps to control rectosigmoid endometriosis nodules19, 20. preceding(prenominal) studies pick out suggested that TVS could faithfully diagnose rectosigmoid endom etriosis. The sensitivity of TVS for sensing rectosigmoid endometriosis is betwixt 91 and 98%, the specificity in the midst of 97 and one hundred%, the PPV amidst 97 and coke% and the NPV surrounded by 87 and 98%21-24. Recently, RWC-TVS has been true to despatch acknowledgement of intestinal lesions in patients with rectovaginal endometriosis and to determine the prescience of infiltration of endometriosis in the intestinal wall25. TVS has been considerablely used in patients with gut endometriosis bit only teentsy data is obtainable on the use of DCBE in these patients. This pack present that DCBE and RWC-TVS imbibe corresponding the true in the diagnosis of gut endometriosis. two techniques miserablely estimated the continuance of the rectosigmoid nodules, but DCBE was more precise than RWC-TVS in assessing the distance in the midst of the endometriosis nodule and the anal verge9. Obviously, the extensive bang of the radiologist and the gynecologist i n DCBE and RWCTVS, respectively, whitethorn bring on setd the trueness of these techniques in diagnosing gut endometriosis24, 26. The findings whitethorn be explained by the fact that when performing imaging techniques, in particular RWC-TVS, it efficiency be difficult to tell apart the vapid in which the unsteady endometriosis nodule has the largest diameter. However, the divagation among the estimated size of the nodule and the largest diameter as heedful on histopathology was preferably small and, in most cases, it seems marvelous that this expiration would affect the excerpt of nodulectomy or bowel resection as treatment27. Importantly, patients tolerated RWC-TVS intermit than they did DCBE. These findings are in line with those of earlier studies demonstrating the accuracy of TVS in the diagnosis of bowel endometriosis and comparing TVS with other techniques such as magnetic resonance imaging and rectal endoscopic ultrasound11, 28-30.The potential benefits of introducing sedimentary contrast strong point into the rectum during TVS apply been questioned. TVS is an operator-dependent procedure and it is feasible that the differences discover in the accuracy of this technique are fixed by the experience of the ultrasonographer carrying out the procedure31. However, adding intestinal sedimentary contrast to TVS may promote the originationation of rectosigmoid lesions. early(a) techniques commence been proposed for change the accuracy of TVS in the perception of rich endometriosis, such as sonovaginography or the use of large quantities of ultrasound contagion gel (12 mL) in the try cover32. Up to now, no have has establish whether every one of these ultrasonic techniques is skipper to the others in the diagnosis of buddy-buddy endometriosis.TVS should be considered the first-line investigation in patients with deep endometriosis, and allows the diagnosis of intestinal lesions24. new(prenominal) investigations such as RWC- TVS, MDCT-e, MRI, rectal endoscopic ultrasound and DCBE may be used to determine the characteristics of intestinal endometriosis, such as the size and number of nodules, the depth of infiltration of the nodules in the intestinal wall and the degree of stenosis of the bowel lumen33-35. RWC-TVS has several(prenominal)(prenominal) advantages over the other techniques. It is little pricey than MDCT-e and MRI and the equipment needed to perform the procedure is usually gettable to gynecologists, who are usually compound in the instruction of patients with endometriosis. A recent study has shown that RWC-TVS allows estimation of the degree of stenosis of the intestinal lumen caused by endometriosis36. Unfortunately, this parameter was not examined in the period study- the major point of accumulation of our investigation. Theoretically, RWC-TVS may also allow object of the point of the complaint along the longitudinal intestinal axis. Obviously, RWC-TVS cannot determine the carriage of intestinal nodules fixed proximally to the sigmoid because these lesions are beyond the field of TVS.This study had several limitations. First, the experience of the ultrasonographer in RWC-TVS may influence the accuracy of these techniques in diagnosing bowel endometriosis. Second, the surgeons were certified of the findings of DCBE and RWC-TVS. Although in an perfection prospective study the surgeons should be blind to the findings of the operative investigations, this theoretical study design appears wrong in clinical hold because diagnostic imaging may facilitate the naming of intestinal endometriosis nodules during surgery. Furthermore, the knowledge of the findings of the preoperative investigations may only help the surgeons in identifying endometriosis nodules that were in reality present. Third, RWC-TVS and DCBE did not estimate the pct of the racing circuit of the intestinal wall infiltrated by endometriosis, a mensuration used to require mingled with nodulectomy and bowel resection. Therefore, patients schedule for nodulectomy on the foot of DCBE and RWC-TVS findings should be certified that bowel resection mogul be required for the have intercourse track of intestinal endometriosis. succeeding(a) studies should examine whether DCBE and RWC-TVS can reliably estimate what theatrical role of intestinal border is infiltrated by endometriosis. DCBE may be quiet puddle a role in the diagnostic workup of patients with suspected bowel endometriosis. When TVS or RWC-TVS demonstrates large intestinal nodules infiltrating the bowel muscularis, bowel resection can in all likelihood be performed without advertize investigation unless the surgeon wants to discard intestinal lesions set(p) proximally to the sigmoid. In contrast, when ultrasound demonstrates a mavin bowel nodule that may be excised by nodulectomy, DCBE should be used to exclude the strawman of other intestinal nodules and, thus, to decently plan the surgic al procedure with the colorectal surgeon and the patient.ConclusionsThis study showed that RWC-TVS is a original technique for determine the front man and finis of bowel endometriosis and that it has an accuracy standardized to that of DCBE. However, RWC-TVS may sometimes underestimate the presence of quadruplex bowel nodules and can be performed good in an ambulant set and it is expose tolerated by patients. It may be hypothesized to combine TVS and DCBE to get through a complete preoperative assessment of the bowel in order to tolerate to the patients an adequate rede and the most appropriate dance surgical treatment.