Sunday, 16 March 2014

Pelvic floor imaging part 5: what is an enterocoele?

It's been a few weeks but my pelvic floor imaging series is back! So far, the posts have covered whether you need a proctogram, what is involved in having a proctogram, and looking at two of the most common findings on a proctogram test: rectocoele and rectal prolapse. This link will take you to all of my pelvic floor articles. This post focusses on another finding occasionally seen, an enterocoele (or enterocele for North American readers).

An enterocoele (pronounced enter-o-seal) is a prolapse of the small bowel into the pelvis. The bowel is divided into small bowel, which is usually located in the centre of the abdomen, and the large bowel which is located around the edge of the abdomen and ending in the rectum or back passage. The small bowel can sometimes drop down into the pelvis and press on the bladder or rectum, and this is seen particularly after a hysterectomy. In order to see this, all women undergoing a proctogram in my clinic are given a barium drink before the test and this then shows up the small bowel during the test. Without the barium drink, enterocoeles are very difficult to detect. Only women get the drink because enterocoeles are extremely rare in men, due to differences in the pelvic anatomy.

This is an xray image from the end of a proctogram test, showing loops of small bowel containing barium lying directly on top of the rectum:

This is a movie clip from the same test, showing how the enterocoele develops during evacuation. This study also shows a rectal prolapse, which I described in more detail in a previous post:

One of the major advantages of MRI proctograms over xray proctograms is that enterocoeles can be seen without having to drink a barium drink beforehand. Other findings such as bladder or vaginal prolapses can also be seen without any additional xray dye or contrast, making the test far less invasive and more tolerable. I will describe MRI proctograms in more detail in a future post. Remember, if you have an xray proctogram without the barium drink, it is unlikely an enterocoele will be detected.

In my next pelvic floor post, I will describe another proctogram finding called anismus, also known as anorectal dyssynergy.

Dr Vikas Shah
Consultant Radiologist