Radiol Oncol 2006; 40(1): 7-15. The estimation of the value and mobility of Parks’ angle in case-series of patients with defecatory disorders - prospective clinical examination supplemented with the defecographic examination Małgorzata Kołodziejczak1, Iwona Sudoł-Szopińska2, Maciej Grochowicz1, Anna Bochenek3, Magdalena Światłowska3 1Proctology, Sub-Department of General Surgery, Hospital at Solec, Warsaw; 2Department of Diagnostic Imaging, Medical Academy Warsaw and Central Institute for Labour Protection-National Research Institute, Warsaw; 3Department of Radiology, Hospital at Solec, Warsaw, Poland Background. Defecography is used by a majority of colorectal surgeons for it is the only method for anatomic and dynamic studies of the act of defecation. The method provides information on different aspects of anorec-tal and pelvic floor function and offers the possibility of visualizing the development of anatomic abnormalities. Methods. We analyzed the defecography findings carried out at 56 patients (50 female and 6 male) from 24 to 83 years of age (the average age 58.3 years) with proctologic ailments such as: faecal incontinence, sensation of obstruction in the rectum, constipations, rectal prolapse, solitary ulceration of rectum. The values of Parks’ angle (ARA - the anorectal angle) were measured at rest, at strain and during defecation. Other parameters meas-ured included: duration of sphincter relaxation, overall duration of defecation, mobility of the pelvic diaphragm. Results. Abnormal values of Parks’ angle at rest and at strain were found in patients with the following problems: faecal incontinence, sensation of obstruction in rectum and constipation. However, they did not turn out to be characteristic for patients with rectal prolapse. Defecography has helped to detect concomitant rectocele in pa-tients suffering from constipation and sensation of obstruction in the rectum. Defecography has also proved to be effective in the evaluation of patients who suffered from solitary ulceration of rectum. During the examination of these patients it has been observed that Parks’ angle in various phases of defecation has flattened. The duration of sphincter relaxation in the studied group was changeable and did not depend on the kind of pathology. Conclusions. Defecography is one of the examinations which can be helpful in the evaluation of patient’s motor functions both before and after the operation. Key words: constipation; foecal incontinence; defecography Received 31 August 2005 Accepted 20 September 2005 Correspondence to: Assist. Prof. Iwona Sudol-Szopinska, MD, PhD, CIOP-PIB, ul. Czerniakowska 16, 00-701 Warsaw, Poland; Fax +48 2232 65991; E-mail: iwsud@ciop.pl 8 Kołodziejczak M et al. / Defecography Introduction The complex mechanism of defecation is con-trolled by both the central nervous system and the medullar centres. One of the steps of defecation reflex is the relaxation of sphincter muscles (puborectal and external anal sphincter) and the widening of the anorectal angle (ARA) of Parks’, caused by the activat-ed sensation of tenesmus of the central nerv-ous system. There are several factors which affect the defecation activity: volume and consistency of faeces, capacity of the rectal ampulla and susceptibility of the rectum wall, continence of sphincter muscles, sensory mechanism, mechanical factors such as: pelvis floor mus-cles, and value of the ARA of Parks’. Recognized as the necessary condition for normal human continence, Parks’ angle is formed between the longitudinal axis of the rectum and the axis of the anal canal and cre-ated by applying traction on the rectum by stretched puborectal muscle.1 Today, defecography is used by a majority of colorectal surgeons for it is the only method for anatomic and dynamic studies of the act of defecation.2 The method provides information on different aspects of anorectal and pelvic floor function and offers the possi-bility of visualizing the development of anatomic abnormalities.2 Although the number of investigations has questioned the significance of the ARA in the maintenance of faecal incontinence, the con-figurational changes of the ARA with volun-tary contraction or relaxation of the pelvic floor may be important.3 Furthermore, many clinicians continue to place credence in the ARA, and routine measurements are often taken.3 In this paper we present the application of defecography in the measurement of the ARA and the findings in defecography in patients with disturbed defecation. Radiol Oncol 2006; 40(1): 7-15. Methods A group of 56 consecutive patients (50 females and 6 males) from 24 to 83 years of age (the average age 58.3 years old) who suffered from defecation activity disorders in the form of: - constipation, - sensation of obstruction or incomplete defecation, - faecal incontinence, - rectal prolapse, - solitary ulcer of rectum were examined. Each patient was qualified for defecogra-phy by the surgeon. Prior to the examination the medical history of these patients was tak-en including information about past diseases, injuries and child-birth, in the case of the female patients. The patients’ continence for gas and faeces was evaluated with the Wexner scale. They also underwent the usual proctologic investigation and rectoscopy. Finally, the defecographic examination was performed be an experienced radiologist. Whole diagnostics were performed by one team of doctors. Informed consent was obtained after the nature of the procedures had been fully ex-plained to the patients, and the study was ap-proved by the Medical Academy authorities. The technique of defecographic examination The patients were prepared in a similar way as for the enema examination. The day before the investigation they took X-Prep or Fortrans. The contrast medium used for the examination was barium sulphate suspension concentrated with starch (solution of boiled potato flour) in order to obtain the thick con-sistency similar to the consistency of stool. The contrast medium was administered per rectum through Foley’s catheter in the amount enough to fill the splenic flexure of the colon. The examination was carried out in Kołodziejczak M et al. / Defecography 9 two stages. During the first stage, after the application of the contrast medium in the re-cumbent position, the patient was seated on a plastic bucket and then the catheter was withdrawn. The patient was asked to bear down as if to defecate. The examination was recorded on a mag-netic tape and the durations of the sphincter relaxation and the overall defecation were measured. The duration of sphincter relaxation is the time measured between the be-ginning and the end of widening of the anal canal. The overall duration of defecation is the time needed for passing stools.4 The recording was made in video technique with PANASONIC UCR/TV camera and XD PRO SUPER UMS 180 tape. During the second stage three x-ray films were taken: at rest, during the defecation and in the phase of maximum contraction. The x-ray films taken in 35 x 35 mm format were later used for measuring precisely the anorectal angle and evaluating the pelvis floor mobility. The films also allowed for the evaluation of the size of rectocele. During defecography the following parameters were estimated: ARA and its dynam-ics,3,5 duration of sphincter relaxation and overall duration of defecation. ARA was formed at intersection of the line running along the axis of the anal canal and the tan-gent line to the posterior wall of the rectum. The proper value of this triangle at rest is 95 -105°. During the defecation the angle should increase (up to about 150°) and during the contraction it should decrease up to about 80°. The mobility of pelvic diaphragm was es-timated on the basis of lowering of the anorectal junction in relation to the ischiadic tubers. The accepted standard was the lower-ing of anorectal junction not exceeding 3.5 cm during tenesmus.6 In addition, the dis-tance of the rectal posterior wall from the sacral bone was measured. The recording of the defecographic examination on the video tape allowed estimating individual stages of the defecation. Results Tables 1-6 show the results for six separate groups of patients depending on the ailment and the course of the disease. Thirteen patients with symptoms of gas and faecal incontinence were examined Table 1. Patients with faecal incontinence No. Age Sex No of births Parks’ angle at rest Parks’ angle at contraction Parks’ angle at defecation Rectocele Wexner Pelvic floor scale mobility (cm) Total defecation time/s/ 1 77 M- 110 90 115 - 3 <1 10 2 66 F2 110 110 145 - 12 >1 10 3 51 F2 150 100 120 Big 14 <5 8 4 73 F2 115 110 120 - 14 <5 20 5 49 M- 100 95 125 - 3 <5 17 6 69 F 4 85 80 90 - 4 <3 7 7 55 F1 115 105 125 - 17 <7 10 8 35 F1 120 110 118 - 14 <1 35 9 56 F1 110 110 120 - 8 <1 10 10 73 F- 117 108 123 Big 4 <5 30 11 57 F- 118 112 125 Small 10 1 32 12 72 F2 120 120 135 - 17 4 5 13 51 F1 115 98 132 Big 12 4 17 Radiol Oncol 2006; 40(1): 7-15. 10 Kołodziejczak M et al. / Defecography Table 2. The patients who felt sensation of obstruction or incomplete defecation No. Age Sex No of births Parks’ angle at rest Parks’ angle at contraction Parks’ angle at defecation Rectocele Wexner Pelvic floor scale mobility (cm) Total defecation time/s/ 1 55 F 2 110 80 120 little 0 ?1cm 20 2 59 F 3 115 95 125 - 0 ?2cm 110 3 55 F 1 95 95 105 little 0 ?10cm 10 4 46 F - 120 110 112 - 1 ?1,5cm 125 5 45 F 2 115 110 135 big 0 ?2cm 12 6 30 M 95 85 115 - 3 ?4cm 150 7 59 F 4 105 95 125 little 2 ?5cm 240 8 63 F - 105 95 110 - 1 ?5cm 45 9 73 F 2 95 86 115 big 2 ?4cm 25 10 69 F 1 133 120 130 little 0 ?3cm 32 11 65 F 2 90 80 180 14 ?1cm 3 12 35 M 115 105 122 0 ?3,5cm 41 13 60 F 1 95 90 115 little 8 ?4cm 6 (Table 1). In 1 case a small rectocele was de-tected which had not been discovered initial-ly by means of the proctologic examination. In 3 other cases a big rectocele was detected. Other 11 patients were characterized by too obtuse Park’s angle at rest and did not de-crease during contractions. Two patients had the right angle. In 9 out of 13 cases Parks’ angle did not decrease during the contraction. The lowering of pelvis floor mobility was de-tected in 7 cases. The overall duration of defe-cation did not turn out to be characteristic. The value of ARA in these cases was mostly incorrect. Thirteen patients, who felt sensation of ob-struction or incomplete defecation, were ex-amined (Table 2). In 8 cases ARA at rest was abnormally obtuse but in 9 cases it was prop-erly acute during contractions. Rectocele, not diagnosed initially during palpation, was de-tected at 6 patients; in 2 of them it was big. The overall duration of defecation length-ened; in 1 case it amounted to 2.5 minutes. Most of the patients in this group had abnor-mally obtuse Parks’ angle at rest and the overall duration of defecation was lengthened. Another group consisted of 2 female pa-tients with solitary ulcer of rectum (Table 3). These patients were characterized by “flatten-ing” of the value of Parks’ angle during vari-ous stages of defecation. In both cases ARA did not decrease during the contraction and the overall duration of defecation lengthened. The pelvis floor mobility was in both cases normal. Defecography turned out to be useful at examining patients with this rare disease. Values of Parks’ angle in various stages of the defecographic examination got flattened (the lack of dynamics of ARA during defecation) and the overall duration of defecation length-ened. There were 10 patients with rectal pro- Table 3. Patients with solitary rectal ulcer No. Age Sex No of Parks’ Parks’ births angle at angle at rest contraction Parks’ Rectocele angle at defecation Wexner Pelvic floor Total scale mobility defecation (cm) time/s/ 1 37 F - 108 110 118 - 0 1,5cm 40 2 66 F 1 155 125 155 - 0 1,5cm 14 Radiol Oncol 2006; 40(1): 7-15. Kołodziejczak M et al. / Defecography 11 Table 4. Patients with rectal prolapse No. Age Sex No of Parks’ Parks’ births angle at angle at rest contraction Parks’ Rectocele angle at defecation Wexner Pelvic floor Total scale mobility defecation (cm) time/s/ 1 81 F4 * * * 13 * * 2 80 F- * * * 14 * * 3 47 F4 * * * 16 * * 4 24 M - 95 80 115 - 0 4 7 5 72 F 3 95 120 140 Big 7-8 cm 2 7 10 6 50 M - 110 80 180 - 0 1 20 7 70 F 2 128 127 140 4cm 0 4 25 8 61 F 1 ?? ?? ? 8 4 15 9 74 F 1 120 107 140 - 16 * * 10 65 F 1 85 87 140 - 16 * 47 *Due to technical difficulties not all the parameters hale been measured. lapse (Table 4). Three of them could not un-dergo the examination due to technical rea-sons, i.e. the complete incontinence of con-trast medium. In 2 cases the examination helped to detect rectocele (1 was big). The overall duration of defecation was lengthened in 4 cases. The pelvis floor was abnormally lowered in 2 cases. In 3 cases abnormally ob-tuse ARA was detected. Values of ARA did not turn out to be characteristic for the group of patients with rectal prolapse. The group, who is characterized by symptoms of constipation, consisted of 12 patients (Table 5). The overall duration of defecation was lengthened in 4 cases and in the remain-ing 8 cases it was within the normal range. Rectocele was found in 9 patients: a small one in 2 cases, a medium one in 6 cases, and a big one in 1 case. In 5 cases ARA during contrac-tion did not decrease which was abnormal. In six cases abnormally obtuse ARA was detect-ed at rest. The last group consists of 2 female pa-tients who could not be assigned to any other group of proctologic ailments (Table 6). One of them had undergone rectopexy and the Table 5. The patients with obstruction No. Age Sex No of births Parks’ angle at rest Parks’ angle at contraction Parks’ angle at defecation Rectocele Wexner Pelvic floor scale mobility (cm) Total defecation time/s/ 1 79 F 2 135 95 135 - 0 ?4 10 2 69 F 3 120 90 135 - 0 ?2 15 3 77 F - 143 135 155 - 0 ?12 8 4 55 F - 103 95 118 little 6 ?2 22 5 66 F 1 123 129 148 middle 0 ?6,8 19 6 53 F 1 105 80 100 middle 0 ?3 10 7 47 F - 70 80 100 middle 0 ?2,4 20 8 31 F - 97 84 132 big 0 ?2 10 9 44 F 2 115 115 120 middle 2 ?4 10 10 26 F - 127 120 143 middle 0 ?2 18 11 57 F - 72 66 70 middle 0 ?5 15 12 72 F - 105 105 150 llittle 0 ?3 15 Radiol Oncol 2006; 40(1): 7-15. 12 Kołodziejczak M et al. / Defecography Table 6. Others disorders No. Age Sex No of births Kind of disorder Parks’ angle at rest Parks’ Parks’ Rectocele Wexner Pelvic floor angle at angle at scale mobility contraction defecation (cm) Total defecation time 1 48 F1 Following rectopexy 100 100 135 5 4 10 2 48 F 2 Following 95 burgery on recto-vaginal fistula 92 100 0 5 30 other post partum plastic operation of recto-vaginal fistula protected with transversosto-my. The former was characterized by low dynamics of ARA during defecation and the lack of decreasing the angle during contrac-tions. Unfortunately no examination was car-ried out due to the complete incontinence of contrast medium caused by the full wall rec-tal prolapse. The examination could not be comparative in relation to the pre-operative condition of the patient. In the case of the patient with post partum plastic operation of rectovaginal fistula pro-tected with transversostomy the fistula was not detected. ARA during defecation got flat-tened; there were very small differences be-tween the various stages of defecation. The overall duration of defecation lengthened more than twice. These disorders might have been caused with the temporary exclusion of the last segment of alimentary tract. Additionally to the above presented groups of patients, four underwent the exam-ination simultaneously in two groups. There were two patients with symptoms of rectal prolapse and faecal incontinence and another two patients with constipation and sensation of the obstruction. In each group the duration of sphincter relaxation was individually variable and did not depend on the pathology. Discussion Defecation activity disorders may occur on a different level and their causes are not always easy to diagnose. In order to evaluate the causes affecting the defecation a number of methods is used, such as: anorectal manome-try, transrectal ultrasound, electromyogra-phy, magnetic resonance and others. The sig-nificance of defecography and especially its value in measurements of the ARA is, howev-er, questioned by many authors. The main drawback of the method is inability to differ-entiate the effect of pelvic floor laxity from the incontinence on the basis of ARA result.3 Many clinicians continue, however, to place credence in the ARA, and routine meas-urements are often taken.3 This examination, apart from estimating ARA, allows physi-cians to evaluate the efficiency of rectal sphincters, pelvis floor muscles and suscepti-bility of the rectal ampulla. It is at this time probably the only objective means of meas-urement of anorectal anatomy and function because the sitting position for examination is not easily attainable with other methods.7 Defecography was first described in 1952 by Walden.8 In 1953 Ekengren and Snellman9 published an article in which they presented the application of defecography in diagnos-tics of constipation. In 1968 Broden and Snellman10 characterized and named the de-fecographic technique as well as indications for its application. In 1980s Mahieu el al.11,12 described the application of defecography as a new diagnostic procedure. Their work con-sisted of two parts and included an evaluation of anorectal functions using defecogra-phy. The investigation was carried out on healthy patients and patients suffering from proctologic diseases. We present results of defecography per- Radiol Oncol 2006; 40(1): 7-15. Kołodziejczak M et al. / Defecography 13 formed in several groups of patients with fol-lowing disorders: - constipation, - sensation of obstruction or incomplete defecation, - suspicion of rectocele, - faecal incontinence, - rectal prolapse. Defecography turned out to be a useful ex-amination and allowed for a very precise di-agnosis. In a group of patients with the sensation of incomplete defecation and sensation of obstruction, for example, six out of thirteen were diagnosed with rectocele. It was also possible to measure ARA fairly precisely and in this way to evaluate the function of the pelvic diaphragm what is impossible using other diagnostic methods. Abnormal values of ARA were detected in the group of patients characterized by constipations, faecal inconti-nence and the sensation of obstruction in the rectum. It could be related to defective func-tion of pelvic diaphragm and in some cases with the low contractility of puborectal mus-cle. Signs of nonrelaxing puborectalis muscle Agachan et al.13 found in 28.8% of the patients with defecatory disorders. He used manome-try, electromyography, and defecography. The latter in his opinion was probably the best for this purpose. This opinion is sup-ported by Karasics et al.,14 who claims that the value of the ARA is directly dependent on the puborectal muscle activity. Not effective con-traction of the puborectalis causes abnormal values of the ARA in each phases of defeca-tion. He adds that many patients have not evident functional diseases of the rectum which may be diagnosed by means of defecography. Also Jorge et al.,3 who compared defecogra-phy with proctography, found defecography reliable and superior, mostly because it is the only diagnostic test which provides anatomic details. In the majority of our patients suffering from incontinency value of the ARA was abnormal. Almost half of them had the exces- sive lowering of the pelvis floor, which might have led to incontinency. The latter factor is underlined by many authors.3 ARA did not turn out to be characteristic for patients with rectal prolapse. Although the defecographic examination was difficult to carry out in this group of patients, it showed the mechanism of rectal prolapse and was useful in choosing the right surgery tech-nique. Defecography is particularly useful in the diagnostics of early stages of the rectal prolapse when the upper part of the rectum becomes intussuscepted. In one case we ob-served acute ARA during the maximal sphincters contraction following the rectocele surgery because of the rectal prolapse, which was typical for the functional results of sur-gery of that type. Defecography has also proved to be effec-tive in the evaluation of patients who suffered from solitary ulcer of rectum. During the ex-amination of these patients it has been ob-served that ARA in various phases of defeca-tion has flattened. The duration of sphincter relaxation in the studied group was change-able and did not depend on the kind of pathology. Despite improvements in imaging tech-nique and better understanding of anorectal disorders, the exact role of defecography in defining anorectal disorders and its impact on therapy remains controversial.7,14 In spite of its undoubted diagnostic value we conclude that this examination should be an additional one to the clinical examination. The defecog-raphy is enable to visualise the peritoneal outline and its pouches, and may be of limited value in case of enterocele or rectal intusses-ception16 (although in the latter, defecography is necessary to sort out cases of intussescep-tion that might be clinical relevant whereas the clinical diagnosis of intussusception is re-lated only to long intussusception).17 The problem may also result from e.g. multifac-toral aetiology of obstructed defecation which makes it difficult to determine whether de-Radiol Oncol 2006; 40(1): 7-15. 14 Kołodziejczak M et al. / Defecography fecographic findings are the cause or result of excessive straining in patients with the ob-structed defecation.7 Additionally, there are scientific works which describe healthy vol-unteers who underwent this examination. Although they had not suffered from any proctological ailments, the defecographic ex-amination detected some disorders. Besides, not all the parameters which were used in our study appeared reliable for other researchers. Klauser18 tested reproducibility and agreement among three clinicians (a radiologist, a gastroenterologist, and a colorec-tal surgeon), all experienced in defecography, in evaluating defecographies, and did not in-clude in his study the measurement of the ARA. In his opinion, it has no clinical rele-vance. Dvorkin et al.19 compared magnetic resonance defecography and evacuation proctography. They confirmed the primary role of proctography for the diagnosis of in-tussusception, and the complementary role of magnetic resonance defecography by giving information on movements of the whole pelvic floor. Whereas Beer-Gabel et al.20 found no differences between dynamic transperineal ultrasound and defecating proctography for the measurement of the ARA, anorectal junction position at rest and during straining. Although defecography cannot be the only grounds for treating the patient,7 contempo-rary surgery of large intestine should be sup-plemented with a detailed evaluation of rec-tum functional functions. Our results in sev-eral case-series presented did not allow for any definitive data because of the hetero-geneity of the included group. They are pre-liminary, and some cases, e.g. solitaire rectal ulcer and rectal prolapse, were presented due to their rareness. The whole work will conti-nue but at this stage we are convinced that defecography is one of the examinations which can be helpful in the evaluation of pa-tient’s motor functions both before and after the operation. Conclusions 1. Abnormal values of Parks’ angle at rest and during constipation were detected at pa-tients who suffered from: faecal inconti-nence, sensation of obstruction in rectum and with constipation. 2. Values of Parks’ angle did not turn out to be characteristic for the examined group of patients with rectal prolapse. 3. Duration of sphincter relaxation was in-dividually variable and did not depend on the pathology. 4. Defecography enabled to detect con-comitant rectocele at patients with constipa-tions and the sensation of obstruction in rec-tum 5. Defecography was helpful at the evaluation of patients with solitary ulcer of rectum. In these cases ARA at various stages of defe-cation becomes “more flat”. References 1. Parks AG. Anorectal incontinence. J R Soc Med 1975; 68: 681-90. 2. Mellgren A, Bremmer S, Johansson C, Dolk A, Uden R, Ahlback SO, et al. Defecography. Results of investigations in 2,816 patients. Dis Colon Rectum 1994; 37: 1133-41. 3. Jorge JMN, Wexner SD, Marchetti F, Rosato GO, Sullivan ML, Jagelman DG. How reliable are cur-rently available methods of measuring the anorec-tal angle? Dis Colon Rectum 1992; 35: 332-8. 4. Selvaggi F, Pesce G, Scotto E, Carlo D, Mattefone V, Cannonio S. Evaluation of normal subject by defecographic technique. Dis Colon Rectum 1990; 33: 698-702. 5. Yoshioka K, Pinho M, Ortiz J, Oya M, Hyland G, Keyghley MRB. How reliable is measurement of the anorectal angle by videoproctography? Dis Colon Rectum 1991; 34: 1010-3. 6. Selvaggi F, Pesce G, Scotto Di Carlo E, Maffettone V, Canonico S. Evaluation of normal subject by de-fecographic technique. Dis Colon Rectum 1990; 33: 698-702. Radiol Oncol 2006; 40(1): 7-15. Kołodziejczak M et al. / Defecography 7. Dam JH, Ginai AZ, Gosselink MJ, Huisman WM, Bojer HJ, Hop WCJ, et al. Role of defecography in predicting clinical outcome of rectocele repair. Dis Colon Rectum 1997; 40: 201-7. 8. Walden L. Defecation block in cases of deep rec-togenital pouch. Acta Chir Scand 1952; 165(Suppl): 1-121. 9. Ekengren K, Snellman B. Roentgen appearances in mechanical rectal constipation. Acta Radiol 1953; 40: 447-56. 10. Broden B, Snellman B. Procidientia of the rectum studied with cineradiography: a contribution to the discussion of causative mechanism. Dis Colon Rectum 1968; 11: 330-47. 11. Mahieu P, Pringot J, Bodart P. Defecography I. Description of a new procedure and results in normal patients Gastrointest Radiol 1984; 9: 247-51. 12. Mahieu P, Pringot J Bodart P. Defecography II. Contribution to the diagnosis of defecation disorders. Gastrointest Radiol 1984; 9: 253-61. 13. Agachan F, Pfeifer J, Wexner SD. Defecography and proctography. Results of 744 patients. Dis Colon Rectum 1996; 39: 899-905. 14. Karasick S, Karasick D, Karasick SR. Functional disorders of the anus and rectum: findings on de-fecography. AJR Am J Roentgenol;1993; 160: 777-82. 15. Savoye-Collet C, Savoye G, Koning E, Leroi AM, Dacher JN. Defecography in symptomatic older women living at home. Age Ageing 2003; 32: 347-50. 16. Bremmer S, Ahlback SO, Uden R, Mellgren A. Simultaneous defecography and peritoneography in defecation disorders. Dis Colon Rectum 1995; 38: 969-73. 17. Karlbom U, Graf W, Nilsson S, Pahlman L. The ac-curacy of clinical examination in the diagnosis of recital intussusception. Dis Colon Rectum 2004; 47: 1533-38. 18. Kluser AG, Ting KH, Mangel E, Eibl-Eibesfeldt B, Muller-Lissner SA. Interobserver agreement in de-fecography. Dis Colon Rectum 1994; 37: 1310-16. 19. Dvorkin LS, Hetzer F, Scott SM, Williams NS, Gedroyc W, Lunniss PJ. Open-magnet MR de-fecography compared with evacuation proctogra-phy in the diagnosis and management of patients with rectal intussusception. Colorectal Dis 2004; 6: 45-53. 20. Beer-Gabel M, Teshler M, Schechtman E, Zbar AP. Dynamic transperineal ultrasound vs. defectogra-phy in patients with evacuatory difficulty: a pilot study. Int J Colorectal Dis 2004; 19: 60-7. Radiol Oncol 2006; 40(1): 7-15. Slovenian abstracts 57 Radiol Oncol 2005; 40(1): 1-5. Majhna količina proste plevralne tekočine. Drugi del - fiziološka plevralna tekočina Kocijančič I Izhodišča. V literaturi je le nekaj člankov, ki poročajo o možnostih rentgenskega in ultrazvočnega prikaza fiziološke plevralne tekočine pri zdravih. V zadnjem desetletju je napredek ultrazvočne tehnologije omogočil prikaz majhnih količin fiziološke plevralne tekočine pri približno 20 % zdrave populacije. Ob določenih fizioloških stanjih, kot je na primer nosečnost, je prikaz fiziološke plevralne tekočine z ultrazvokom bolj pogost. Zaključki. Pomembno je, da pozitivnega izvida brez spremljajočih kliničnih sprememb ne ocenimo za znak bolezni. Radiol Oncol 2006; 40(1): 7-15. Ocena Parksovega kota pri bolnikih z motnjami odvajanaja blata -prospektivna raziskava z defekografijo Kołodziejczak M, Sudoł-Szopińska I, Grochowicz M, Bochenek A, Światłowska M Izhodišča. Defekografijo uporablja veliko kolorektalnih kirurgov, ker lahko z njo anatomsko in dinamično proučujejo odvajanje blata. S preiskavo ugotovimo anorektalno funkcijo in delovanje medeničnega dna ter anatomske nepravilnosti. Metode. V prospektivni raziskavi smo z defekografijo proučili 58 bolnikov (50 žensk in 6 moških), ki so bili stari od 24 do 83 let (povprečno 58,3 leta) in so imeli proktološke težave. Bolniki so opisovali nezmožnost zadrževati blato, občutek obstrukcije v rektumu, zaprtost, zdrs rektuma in rektalno razjedo. Velikost Parksovega kota smo merili pred odvajanjem blata, med napenjanjem in med odvajanjem blata. Merili smo tudi trajanje sfinkterske relaksacije, trajanje odvajanja blata in gibljivost medenične prepone. Rezultati. Nenormalne vrednosti Parksovega kota smo ugotavljali pred odvajanjem blata in med napenjanjem pri bolnikih, ki niso uspeli zadrževati blato, ki so imeli občutek obstrukcije v rek-tumu ali so bili zaprti. Pri zdrsu rektuma pa omenjene nenormalne vrednosti nismo zasledili. Defekografija nam je pomagala odkriti rektokelo pri bolnikih, ki so tožili zaradi zaprtosti in občutka obstrukcije v rektumu. Koristna je bila tudi pri oceni bolnikov, ki so imeli rektalno razjedo. Parksov kot se je med odvajanja blata spreminjal, trajanje sfinkterske relaksacije pa je bilo spremenljivo ne glede na vrsto bolezni. Zaključki. Defekografija je koristna metoda pri motorični oceni odvajanja blata pred in po kirurškem zdravljenju. Radiol Oncol 2006; 40(1): 57-62.