anatomia - diagnostica (pptshare)

8/7/2019 Anatomia - diagnostica (PPTshare)

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Prof. Filippo Pucciani

CLINICA CHIRURGICA GENERALE E DISCIPLINE CHIRURGICHEUniversit degli Studi di Firenze


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Test o - Ar ticoli

Riabilitazion e uro-gin e cologica - II ed izion ePaolo di Be nedett o E dizioni Min e rva M ed ica

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Pucciani F . et al. Mul timo dal r eh abili ta tion of fa e cal incon tine nc e: ex pe rie nc e of an i talian c e ntr e de vo ted to fa e cal dis or de r r eh abili ta tion. Te ch Coloproc tol 2003; 7 : 139-147.

Pucciani F . et al. : P e lvic floor dyssy ne rgia an d bimo dal r eh abili ta tion : r es ults of combin ed pe lvipe rine al kin es ithe rap y an d biof eed backtraining. In t J Color e ct Dis 1998; 13 : 124-130.


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Con tine nc e - De f e ca tion

S torag e an d e vacua tion of ga s an d st ool

Soma tovis ce ral in te gra ted ac tivity

Fa e cal con tine nc e De f e ca tion


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FAECAL CON TINENCE - DEFAECA TION

Pe lvic floor mu s cles Anal s phinc te r sNe ural in te grity (AN PN)Se ns or y an d mo tor ac tivity of the r e ctumAnal se ns a tion

Colonic mo tilityFae cal con s iste nc e

Coor dina te inte rac tion


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P e lviDist r ett o po ste rior e


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ANATOMIA

R ett o



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Ana tomia de l r ett o


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P e rine oPiano s up e rficiale

Fe mal e pe rine um


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Mus coli p e rine ali -Sfin te r e anal e este rno


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P e rine al mu s clesS training p e rine al r e flex

P e rine al mu s cle con trac tion on st raining po st ula tes a r e flex r e la tion sh ip tha t we callthe "st raining-p e rine al r e flex ." W e s ugg est tha t this r e flex, which r es ults in p e rine al mu s cle con trac tion , s uppor ts the pe rine um again st the incr e a sed intra-ab dominal pr ess ur e induc edby st raining an d the te nde nc y of the pe rine um to des ce nd.

S hafik A, El-Sibai O , S hafik AA, Ahmed I. Eff e c t of st raining on p e rine al mu s cles an d the ir role in p e rine al s uppor t: Ide ntification of the st raining-p e rine al r e flex . J Surg R es 2003; 112 : 162-167.

Po st -de f e ca tion r e flex?

Soma tic e le me nt


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Po st -de f e ca tion r e flex

As s oon a s the con te nts hav e pa ssed the r e is ash arp con trac tion of the s phinc te r s an d le va tor ani mu s cles s o tha t the pe lvic floor i s e le va ted toits original po s ition , the canal clo sed an d the valv e me chani s m r est or ed . Th is is call ed the po st -de f e ca tion r e flex .

Park s AG, Por te r NH , Har dca st le J. The sy ndrom e of des ce nd ing p e rine um. Proc R Soc M ed 1966; 59 : 477-482.

Soma tic e le me nt Vis ce ral e le me nt

Join ed longi tudinal mu s cle

?+


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Join ed Longi tudinal Mu s cleCorruga tor ani

Pubor ectalis mu s cle+

Longi tudinal mu s cle of the r e ctum

Lunni s S. Ana tom y an d func tion of the anal longi tud inal mu s cle.Br J Surg 1992;; 79 : 882-884.


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PERINEAL BODY

P e rine al bo dy is the s ite along w hich

the te ndine us fibr es of p e rine al mu s clesfrom the two s ides de cu ss a te with e ac h othe r acro ss the midline

S hafik A, Ahm ed I, S hafik AA, El-G hamraw y T A, El-Sibai O. Surgicalana tom y of the pe rine al mu s cles an d the ir role in p e rine al dis or de r s .

Ana t Sci In t 2005; 80 : 167-171.


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PERINEAL BODYOb stet ric trauma

Endoanal s onogra phy for ob stet ric traumaMar tine z HM et al. En doanal s onograp hy in a ssess me nt of f e cal incon tine nc e following ob stet ric trauma.Ultra s oun d Ob stet Gyne col 2003; 22 : 616-621

Pe rine al bo dy th ickn ess/s phinc te r de f e ctsOb e rwal de r M, Wex ne r SD et al. Anal ul tra s oun d an d e ndos onograp hic m e a s ur e me nt of p e rine al bo dy th ickness: ane w e valua tion for f e cal incon tine nc e in f e mal es . Surg En dos c 2004; 18 : 650-654.

Pe rine orrap hy : s urgical appro xima tion of bila te ral exte ns ion of p e rine al bo dy inste a d of le va tor ani

Soga H , Naga ta I et al. A hist otopograp hic st udy of the pe rine al bo dy in e lde rly wom e n: the s urgical applicabili ty of nov e l hist ological fin d ings . In t Urog yne col J P e lvic Floor D ys func t 2007; 18 : 1423-1430.


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Re ctovaginal se ptum

The r e ctovaginal se ptum (fa s cia) a ttac hes to the pe lvic s ide wall along awe ll de fined line . It exte nds from p e rine al bo dy towar d the arcu s te ndine us fa s cia e pe lvis with which it conv e rg es appro xima te ly midwa y bet wee n the

pubi s (3.75 cm) an d the is chial s pin e (4.8 cm).

Le ffle r KS et al: Attac hme nt of the r e c tovaginal se ptum to the pe lvic s ide wall. Am J Ob stet Gyne col 2001; 185 : 41-43.

The r e ctovaginal se ptum i s form ed of a n et work of collag e n, e last ic fibr es, s moo th mu s cle ce lls, ne rve fibr es e me rging from the au tonomic inf e rior hypoga st ric pl ex us, an d variabl e numb e r s of s mall v esse ls .

S te cco C et al: Hist otopograp hic st udy of the r e c tovaginal se ptum. I tal J Ana t Embr yol 2005; 110 : 247-254.


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Re ctovaginal e ndom et rios is

Re ctoc e le

Ente roc e le

Re ctovaginal fi st ula

Urethra

Vaginalcoil

Rectovaginalseptum

Anorectum

Re ctovaginal se ptum

Pa thologi es

P e lvic MNR


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En te roc e le

En te roc e le

Re ctal prolap se


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Cocc yx Anococc yge al ligam e nt

Cocc ygo dynia

Anococc yge al ligam e nt Po st anal s pac es


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De f e cograp hyCocc yge al trauma - D yssy ne rgia

Cocc yge altrauma

Dyssy ne rgia


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P e rine oPiano profon do

Diaframmapelvico


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PA VIMENTO PEL VICOProi e zioni cor ticali



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Fa s cia p e lvica

S tru ttur e comuni uro-gin e -proc tologic he

- F.P. Pari et ale Arco te ndine o de l m. e le va tor e de llano

- F .P . Vis ce ral e Lamina s acro-r ett o-g e nito-pubica


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Lamina s acro-r ett o-g e nito-pubicaCroc e di Ric har d

Le g . Pubo-ur et raliLe g . Ur et ro-p e lvici

Le g . Car dinali

Le g . Sacro-u te rini


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Strutture supporto utero-vagina



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S.J. Lewis, K.W. Heaton. Stool Form Scale as a Useful Guide to Intestinal Transit TimeScandinavian Journal of Gastroenterology 1997; 32 (9) : 920 924.

Fa e cal con s iste nc eS tool form s cal e



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S tool form

S e ve ral st udies hav e alr e a dy sh own tha t the st ool form s cal eis st rongl y corr e la ted with whole -gu t tran s it time by s cin tigrap hyor ra dio-opaqu e mark e r s

Choung RS , Lock e GR 3r d, Zins me iste r AR, Sc hle ck CD , Talley NJ .Epide miolog y of s low an d fast colonic tran s it us ing a s cal e of st ool form in a communi ty.

Alime nt P harmacol The r. 2007; 26 :1043-50.

Fa e cal impac tion Ov e rflow incon tine nc eType 1

Type 2



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ANATOMIA

R ett o



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SFIN TERI ANALISc he ma



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Th r ee loop s the or y



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SNPPless i s acral e e coccig e o



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Pullen AH, Tucker D, Martin JE. Morphological and morphometric characterization of Onufs nucleus in spinal cord in man.J Anat 1997; 191: 201-213.

Onufrowicz 1889 nucleus XCranial origin distal part S1

Caudal end proximal part S3

Onuf s nucl e us



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Ne rvo pu de ndo



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Ne rvo pu de ndo



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Supra s pinal con trol of anal s phinc te r PubM ed

V itton V , Grimaud JC, Bouvier M, Abysique A. Supraspinal control of external anal sphincter motility: effects of vesical distension in humans and cats.. Neurogastroenterol Motil. 2006 Nov;18(11):1031-40.

Nout YS, Leedy GM, Beattie MS, Bresnahan JC. Alterations in eliminative and sexual reflexes after spinal cord injury: defecatory function and development of spast icity in pelvic floor musculature.Prog Brain Res. 2006 ;152:359-72. Review.

Pierce LM, Reyes M, Thor KB, Dolber PC, Bremer RE, Kuehl TJ, Coates KW. Immunohistochemical evidence for the interaction between levator a ni and pudendal motor neurons in the coordination of pelvic

floor and visceral activity in the squirrel monkey. Am J Obstet Gynecol. 2005 May;192(5):1506-15.

Abysique A, Orsoni P, Bouvier M. Evidence for supraspinal nervous control of external anal sphincter motility in the cat. Brain Res. 1998 Jun 8;795(1-2):14 7-56.

MacDonagh R, Sun WM, Thomas DG, Smallwood R, Read NW. Anorectal function in patients with complete supraconal spinal cord lesions. Gut. 1992 Nov;33(11):1532-8.

Weber J, Beuret-Blanquart F, Ducrotte P, Touchais JY, Denis P. External anal sphincter function in spina l patients. Electromyographic and manometric study. Dis Colon Rectum. 1991 May;34(5):40 9-15.

Holstege G, Tan J. Supraspinal control of motoneurons innervating the striated muscles of the pelvic floor including urethral and anal sphincters in the cat. Brain. 1987 Oct;110 ( Pt 5):1323-44.

Weber J, Denis P, Mihout B, Muller JM, Blanquart F, Galmiche JP, Simon P, Pasquis P. Effect of brain-stem lesion on colonic and anorectal motility. Study of three patients. Dig Dis Sci. 1985 May;30(5):419-25.

Pu de ndal n e rveTonic EAS ac tivity Volun tar y EAS in hibitionCu tan e ou s -anal r e flex



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Colonic mo tilityManom et r y

HAPCSegmenting activity * - LAPC

*

Ba ss otti G et Al. Normal a s pe cts of color e c tal mo tility an d abnormali ties in s low tran s it con st ipa tion.Worl d J Ga st roe nte rol 2005; 11 : 2691-96



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Re ctal mo tor compl exes

The te mporal a ss ocia tion wi th mo tor e ve nts in the pro ximal colon s ugg ests tha t PRMA i s trigg e r ed by the arrival of st ool or ga s in the r e ctum. B e cau se mo st cycles ar e e ithe r se gm e ntal or ar e propaga ted r et rogra de ly, PRMA ma y se rve a s an in trins ic braking m e chani s m tha t pr e ve nts un time ly flow of coloniccon te nts, par ticularl y during s lee p.Rao SS , W elche r K. P eriodic r ec tal mo tor ac tivity: the intrins ic colonic ga te kee per ? Am J Ga st roe nte rol 1996; 91 : 890-897.

The on set of r e ctal con trac tion s wa s accompani ed by incr e a s ing r est ing pr ess ur e an d con trac tile ac tivity

of the anal canal , s uc h tha t pr ess ur e in the anal canal wa s alwa ys gr e a te r than pr ess ur e in the r e ctum .Ferrara A et al. R e lation sh ip b et wee n anal canal ton e an d r ectal mo tor ac tivity. Dis Colon R ec tum 1993; 36 : 337-342.

PRMA : P e riodic R e ctal Mo tor Ac tivity


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Dis or de r s of de f e ca tion Anor e ctal inv est iga tion s

Anor e ctal manom et r y

Ne uro-p hys iologic tests(EMG , pude ndo-anal r e flexes, PN TML, PN-S s EP)

Anal e ndos onograp hy

MNR

De f e cograp hy

Func tional Morp hologic

ENDOSCOPY


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ENDOSCOPIAColoproc tologia

Anos copiaRett os copiaRett o-s igmoi dos copiaPan-colo s copia

Indicazioni s pe cifiche pe r ogni te cnica st rum e ntale



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MALATTIA EMORROIDARIARett os copia



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Test Ve ri Fal s ipo s itivo po s itivi po s itivi

Test Ve ri Fal s ine ga tivo ne ga tivi ne ga tivi

Rappor to es ito test diagno st ico / mala ttia

S e ns ibilit: ve ri po s itivi s u tutti i mala tiSp e cificit: ve ri ne ga tivi s u tutti i s aniValor e pr ed ittivo po s itivo: ve ri po s itivi / tutti i po s itivi al testValor e pr ed ittivo n e ga tivo: ve ri ne ga tivi / tutti i ne ga tivi al test



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Clinical u se fulness of a ssess ing anor e ctal p hys iolog y

1. To provi de ne w informa tion tha t coul d influe nc e the manag e me nt of pa tie nts with dis or de r s of de f e ca tion.

2. To ide ntif y the pa tie nts who ma y mo st be ne fit from this a ssess me nt.Rao SS , Pa te l RS : How u se ful ar e manom et ric tests of anor e c tal func tion in the manag e me nt of de f e ca tion d is or de r s? Am J Ga st roe nte rol 1997; 92 : 469-475.



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To a ssess pa tie nts prior to an d to facili ta te biof eed back training of the e vacua tion an d con tine nc e me chani s m.

Rao SSC , Azpiroz F , Diaman t N, Enck P , Touga s G, Wal d A: Minimumst an dar ds of anor e ctal manom et r y. N e uroga st roe nte rol Mo til 2002; 14 : 553-559.



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Manometria anorettaleAmbulatorio - Strumentazione



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Anal r est ing pr ess ur eMaximal volun tar y con trac tionRe cto-Anal In hibitor y Re flexRe ctal se ns a tion sRe ctal complianc e

Se ns ibility: 92.2%Spe cificity: 86.6%Pos itive pr ed ictive fac tor : 0.90

Ne ga tive pr ed ictive fac tor : 0.64

Sun WM et al. : Utility of a combin ed test of anor ec tal manom et r y, electrom yograp hy, an d se ns ation in dete rmining the mechani s m of i diopa th ic faecal incon tine nc e . Gu t; 1992; 33 : 807-813.



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Manom et ria anor ett ale st azionariaFa s i di r e gist razion e

ARP : Anal R est ing Pr ess ur eMVC : Ma ximal volun tar y con trac tionRAIR: Re cto Anal In hibitor y Re flex

RECT AL SENSA TIONSCOMPLIANCE



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Manom et ria anor ett ale ARP

LD A LS P



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LD A LS PProf. Filippo Pucciani


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LD A LS P



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Manom et ria anor ett aleVolum e vett or e



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Manom et ria anor ett aleMVC



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Manom et ria anor ett aleMVC

LD A LS P



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Manom et ria anor ett aleRAIR



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Sampling r e flex



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Sampling r e flex

IAS

EAS

Sampling r e flex

RAIR

RAER


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Manom et ria anor ett aleRAIR



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Manom et ria anor ett aleComplianc e r ett ale R e ctal se ns a tion s

LD A LS P

+CRST : Con s ciou s Re c tal

S e ns itivity Th r esh old

CS : Con st an t S e ns a tion

MTV: Maximal Tole ra ted Volum e



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Manom et ria anor ett aleComplianc e r ett ale



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Fa e cal con tine nc eNe ural pa thwa ys R e flexes la te nc y

PN TML

PA r eflex

Pn-S s EP

Pu de ndalne rve



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Fa e cal incon tine nc eNe uro-p hys iologic tests

Clinical in dica tion s

1. S ymp toma tic pa tie nts with low ARP wi th no obviou s ex plana tion.

2. Incon tine nt pa tie nt with a n e ga tive workup.

3. Abnormal workup wi thou t ano-r e ctal ana tomical ex plana tion.

4. Fa e cal incon tine nc e in pa tie nts aff e cted by ne urological dise a ses .

Tests

A. Anal e le ctrom yograp hy.

B. Pu de ndo-anal r e flex (PA).

C. Pu de ndal n e rve te rminalmo tor la te nc y (PN TML).

D. Pu de ndal n e rve s oma to-se ns orial e vok ed po te ntials (PN-S s EP).

Col e J. , Go ttes man L. : Anal e le ctrop hys iological an d pu de ndal n e rve e vok ed po te ntials . In: Prac tical gui de to anor ectal test ing.

Igaku-S hoin E ds . N e w York 1995;207-220.


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Fa e cal incon tine nc eNe uro-p hys iologic tests

Test S timula tion M e a s ur e me nt Diagno s is

PA r e flex Aff e r e nt ne rve st imula tion La te nc y of s acralr e flex Pol yne uropa thiesP e lvic floor ne uropa th ies

PN TML * Eff e r e nt ne rve st imula tionLa te nc y of te rminal mo tor

fibr es st imula tion

Pu de ndal n e rve st r et ch injuries(ob stet ric trauma , des ce ndingpe rine um sy ndrom e )

PN-S s PE Mixed ne rve st imula tion Ampli tude of s calpr es pon se Mye lopa thies

Cole J. , Go ttes man L. : Anal e lec trop hys iological an d pu de ndal n erve evok ed pote ntials . In : Prac tical gui de to anor ec tal test ing. Igaku-S hoin E ds . N ew York 1995; 207-220.


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Ana tomia p e lviRMN



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MNR - D e f e cograp hyNormal s ubj e cts


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P e lvic MNRDPS - H yste r e ctom y



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MNR



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MNRFa e cal incon tine nc e



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DISTENSION RECTOCELEDe f e cograp hy



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P e lvic floor dyssy ne rgiaRe ctal In tuss us ce ption + An te rior diste ns ion r e ctoc e le

70%



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En dos onografia anal e con s on da ro tan te



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En dos onografia anal e con s on da ro tan teIncon tine nza f e cal e

anatomia - diagnostica (pptshare)

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