Aims: Dyschesia can be provoked by inappropriate defecation movements. The aim of this prospective study was to demonstrate dysfunction of the anal sphincter and/or the musculus (m.) puborectalis in patients with dyschesia using anorectal endosonography. Methods: Twenty consecutive patients with a medical history of dyschesia and a control group of 20 healthy subjects underwent linear anorectal endosonography (Toshiba models IUV 5060 and PVL-625 RT). In both groups, the dimensions of the anal sphincter and the m. puborectalis were measured at rest, and during voluntary squeezing and straining. Statistical analysis was performed within and between the two groups. Results: The anal sphincter became paradoxically shorter and/or thicker during straining (versus the resting state) in 85% of patients but in only 35% of control subjects. Changes in sphincter length were statistically significantly different (p<0.01, χ 2 test) in patients compared with control subjects. The m. puborectalis became paradoxically shorter and/or thicker during straining in 80% of patients but in only 30% of controls. Both the changes in length and thickness of the m. puborectalis were significantly different (p<0.01, χ 2 test) in patients versus control subjects. Conclusions: Linear anorectal endosonography demonstrated incomplete or even absent relaxation of the anal sphincter and the m. puborectalis during a defecation movement in the majority of our patients with dyschesia. This study highlights the value of this elegant ultrasonographic technique in the diagnosis of "pelvic floor dyssynergia" or "anismus". C onstipation is one of the most common gastrointestinal problems in Western Europe. Among other criteria, constipation is defined as less than three bowel movements per week for at least 12 weeks over one year.1 Dyschesia is an entity characterised mainly by difficult evacuation of stools, forced straining during defecation, and a sensation of incomplete evacuation after defecation. Although not specific for dyssynergia, a need for manual disimpaction or support of the pelvic floor can exist during defecation. Defecation frequency can be normal.The aetiology of dyschesia can be divided into two groups. Organic aetiological factors (tumours, etc.) need to be differentiated from functional disorders. The most prevalent functional cause of dyschesia is pelvic floor dyssynergia where the patient does not sufficiently relax and sometimes even paradoxically contracts the pelvic floor muscles (anal sphincter and musculus (m.) puborectalis) during straining to defecate. 2-8To demonstrate insufficient relaxation of the anal sphincter and m. puborectalis during defecation, a manometric and/or electromyographic study of these pelvic floor muscles can be performed.Anorectal endosonography was introduced by John Wild in 1949. 9 The technique has continuously been improved since then. Flexible as well as rigid echoprobes can now be used to visualise the rectal wall and other pelvic floor structures. Two types of acoustic windows are used. Accurate...
A 71-year-old male patient with a superficial transitional cell carcinoma of the urinary bladder developed high fever and jaundice, accompanied by progressively increasing serum aminotransferase activities, 2 weeks after the fourth local instillation with an attenuated live strain of Mycobacterium bovis [bacillus Calmette-Guérin (BCG)]. A liver biopsy showed non-caseating granulomatous hepatitis. Cultures for mycobacteria were negative. Mycobacterial DNA was not detected in liver tissue using the polymerase chain reaction. Empirical treatment with rifampicin and isoniazid was started, resulting in partial recovery. After 6 months of therapy, however, serum aminotransferase activities were still twice the upper limit of normal. A second liver biopsy still demonstrated several granulomas. Only after addition of prednisolone, liver tests completely normalized. Also histologically the lesions improved dramatically. This suggests that the BCG hepatitis was at least partially caused by a hypersensitivity reaction. Our patient is the first reported case of BCG hepatitis with histological follow-up under therapy.
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