SYB: Defecogram

By Borko Kereshi, MSIII

The Case

• 32 year old female with a history of:– Chronic constipation– Straining– Irritable Bowel Syndrome

Defecogram: The Technique

• Approximately 1 hour before the study the patient ingests one bottle of thin barium to visualize the small bowel for possible enterocele.

• Barium paste is instilled into the rectum. • A small metallic marker is placed on the skin

near the anus. • The patient is imaged in the lateral projection

during the following maneuvers…

The 7 Steps of a Defecogram

• 1: Rest• 2: Cough• 3: Squeeze• 4: Valsalva• 5: Evacuation• 6: Post-evacuation valsalva• 7: Post-evacuation rest

Rest

Cough

no incontinence during coughing

Squeeze

appropriate motion of the anorectal angle during the squeeze

Valsalva

appropriate motion of the anorectal angle during the valsalva maneuver

Evacuation

Evacuation

Any abnormalities noted?

Evacuation

Any abnormalities noted?

Anterior Rectocele

Evacuation

Any other abnormalities noted?

Evacuation

Puborectalis Dyskinesia

• contraction of the puborectalis during evacuation (left arrow in preceding image)

• Additionally, there is contraction of the anal sphincter during evacuation consistent with sphincter dyskinesia (right arrow)

Post-evacuation valsalva

Post-evacuation rest

Small post void residual

• The patient required multiple efforts of Valsalva and squeeze to evacuate the barium.

• This impaired contraction is highly predictive of anismus– Anismus: malfunction of the external anal

sphincter and puborectalis muscle during defecation

– More common in women– Sometimes associated with sexual abuse

References

• LEROI A.-M. ; BERKELMANS I. ; DENIS P. ; HEMOND M. ; DEVROEDE G. Anismus as marker of sexual abuse : consequences of abuse on anorectal motility. Digestive diseases and sciences. ISSN 0163-2116. vol. 40, no7, pp. 1411-1416, 1995

• healthlibrary.epnet.com• www.aboutincontinence.org