ULTRASOUND EVALUATION OF CA RECTUM

CASE HISTORY - A 40 yrs female with recurrent bleeding per rectum & lower abd pain .

AT USG -   On trans abd ultrasound focal iso to hypo & hyperechoic rounded lesions of variable size noted in liver with hypoechoic halo around ,s/o mets . Rest of abd scan was normal for abd viscera . To evaluate ano-colorectal region a non gyne TVS applied . Non gyne TVS application showed irregular hypoechoic mural thickening in rectum just above anorectal junction involving about 55 mm long segment with mural thickness ranging 10 to 14 mm distorting layer & mucosal pattern. The lesion was hyperemic on color Doppler. A tiny hypoechoic mural nodule also noted adjacently & separately   likely s/o satellite metastatic lesion . Multiple rounded hypoechoic perirectal lymphadenopathy also noted  . In view of above findings the diagnosis of Ca rectum was made with adjacent satellite mural lesion , perirectal metastatic lymphadenopathy  & hepatic metastasis .

Fig 1 - Hepatic scan showing mets

Fig 2- TVS scan with rectal evaluation showing perirectal nodes .

Fig 3- TVS scan showing irregular hypoechoic rectal wall thickening distorting gut signature  & adjacent tiny mural satellite lesion.

Fig 4- On color Doppler the rectal thickening showed hyperemia .

 

  This is how ultrasound completed the diagnosis & TVS helped in rectal evaluation in proper . 

PS - Histopathology revealed adeno ca rectum .

ULTRASOUND IN NEONATAL HIRSCHSPRUNG DISEASE

CASE HISTORY 

A  20 days old neonate with distension of abdomen , at ultrasound showed  - slight narrowing of rectum ( dotted arrow )  & gross distension of sigmoid & descending colon ( arrow )  , & mild distension of entire colon. Rest of the abdomen was unremarkable  . On the basis of USG findings low (rectal) obstruction suspected with colonic distension , & possibility of Hirschsprung disease proposed .  On barium enema study classical findings of narrowing with coning ( zone of transition ) & distension of sigmoid noted , which supported further the diagnosis . The case underwent primary colostomy with rectal biopsy , which confirmed aganglionic nature Hirschsprung disease . 

Fig-1  suprapubic US scan shows rectal narrowing with coning ( dotted arrow ) , & distended sigmoid ( small arrow ) . UB seen empty . The image classically similar  to barium study .

Fig 2 - Quad US scan shows distended sigmoid , descending  & other parts of colon with rectal narrowing . 

Fig 3 - Lateral barium enema radiograph

Fig 4- AP barium enema radiograph 

Both fig 3 & 4 barium enema radiographs   

shows narrowing of rectum with coning / funnelling of zone of transition & distended sigmoid colon , classical for Hirschsprung  disease .  

Case 2-

Fig 5- Sono-Recto-sigmoidogram,showing rectal narrowing / stricture with sigmoid fullness-classically resembling with barium study consistent with possible diagnosis of "Hirschsprung disease " (story of a 30 days neonate with constipation & abdominal distension)

TAKE HOME- To diagnose Hirschsprung disease in neonatal period is quite feasible and rewarding. The liquid meconium in colon & recto-sigmoid region acts as a contrast ( echogenic liquid in bowel) during sonography & can delineate the rectal narrowing ( stricture as beak sign) with proximal sigmoid distension. In the late age the constipated & fecal matter loaded sigmoid obscures the stricture details due to fecal matter & gas shadowing .

PS - Barium enema radiographic images  & operative f/up courtesy : Dr Gaurav Bahety , M. Ch. pediatric surgeon , Bhilwara ( raj , India )