SYB: Defecogram

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SYB Defecogram

• By Borko Kereshi, MSIII

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The Case

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

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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

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The 7 Steps of a Defecogram

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

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Rest
6
Cough
no incontinence during coughing
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Squeeze
appropriate motion of the anorectal angle during
the squeeze
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Valsalva
appropriate motion of the anorectal angle during
the valsalva maneuver
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Evacuation
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Evacuation
Any abnormalities noted?
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Evacuation
Any abnormalities noted?
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Anterior Rectocele
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Evacuation
Any other abnormalities noted?
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Evacuation
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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)

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Post-evacuation valsalva
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Post-evacuation rest
Small post void residual
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• 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

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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