Ultrasound in Coloproctologic Practice: Endorectal/Endoanal Ultrasound

  • Ponnandai J. Arumugam
  • Bharat Patel
  • John Beynon


Endoanal ultrasound is gaining importance in staging, treatment, and follow-up of anal carcinomas, and with the new 3D reconstructions, it will be interesting to see the impact it will have on neoplastic and functional anorectal disorders. It also shares an important role in assessing complex fistula-in-ano with MRI and is indispensable in the management of fecal incontinence. Its value and its limitations have been discussed in this section of the chapter.


Rectal Cancer Fecal Incontinence Anal Sphincter External Anal Sphincter Internal Anal Sphincter 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Barrett MW. Chemoradiation for rectal cancer: current methods. Semin Surg Oncol. 1998;15:114–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345:638–46.PubMedCrossRefGoogle Scholar
  3. 3.
    Nicholls RJ, Mason AY, Morson BC, Dixon AK, and Fry IK. The clinical staging of rectal cancer. Br J Surg. 1982;69:404–9.PubMedGoogle Scholar
  4. 4.
    Brown G, Radcliffe AG, Newcombe RG, Dallimore NS, Bourne MW, and Williams GT. Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging. Br J Surg. 2003;90:355–64.PubMedCrossRefGoogle Scholar
  5. 5.
    Zbar AP, deSouza NM, Strickland N, Pignatelli M, and Kmiot WA. Comparison of endoanal magnetic resonance imaging and computed tomography in the preoperative staging of rectal cancer: a pilot study. Tech Coloproctol. 1998;2:61–6.Google Scholar
  6. 6.
    Drew PJ, Farouk R, Turnbull LW, Ward SC, Hartley JE, and Monson JR. Preoperative magnetic resonance staging of rectal cancer with an endorectal coil and dynamic gadolinium enhancement. Br J Surg. 1999;86:250–4.PubMedCrossRefGoogle Scholar
  7. 7.
    Beynon J, Mortenson NJMcC, Foy DMA, Channer JL, Virjee J, and Goddard P. Endorectal sonography: Laboratory and clinical experience in Bristol. Int J Colorectal Dis. 1986;1:212–5.PubMedCrossRefGoogle Scholar
  8. 8.
    Gavioli M, Bagni A, Piccagli I, Fundaro S, and Natalini G. Usefulness of endorectal ultrasound after preoperative radiotherapy in rectal cancer: comparison between sonographic and histopathologic changes. Dis Colon Rectum. 2000;43:1075–83.PubMedCrossRefGoogle Scholar
  9. 9.
    Wild JJ and Reid JM. Diagnostic use of ultrasound. Br J Phys Med. 1956;19:248–57.PubMedGoogle Scholar
  10. 10.
    Wild JJ and Foderick JW. The feasibility of echometric detection of cancer in the lower gastrointestinal tract. Am J Proct Gastro Col Rectal Surg. 1978;Jan–Feb:16–25.Google Scholar
  11. 11.
    Wild JJ and Foderick JW. The feasibility of echometric detection of cancer of the lower gastrointestinal tract II. Am J Proct Gastro Col Rectal Surg. 1978;Mar–Apr:11–20.Google Scholar
  12. 12.
    Dragsted J and Gamelgaard J. Endoluminal ultrasonic scanning in the evaluation of rectal cancer. Gastrointest Radiol. 1983;8:367–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Hildebrandt U and Fiefel G. Pre-operative staging of rectal cancer by intrarectal ultrasound. Dis Colon Rectum. 1985;28:42–6.PubMedGoogle Scholar
  14. 14.
    Hildebrandt U, Fiefel G, Schwarz HP, and Scherr O. Endorectal ultrasound: Instrumentation and clinical aspects. Int J Colorectal Dis. 1986;1:203–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Kim JC, Cho YK, Kim SY, Park SK, and Lee MG. Comparative study of three-dimensional and conventional endorectal ultrasonography used in rectal cancer staging. Surg Endosc. 2002;16(9):1280–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Steele SR, Martin MJ, and Place RJ. Flexible endorectal ultrasound for predicting pathologic stage of rectal cancers. Am J Surg. 2002;184(2):126–30.PubMedCrossRefGoogle Scholar
  17. 17.
    Poller DN. Method of specimen fixation and pathological dissection of colorectal cancer influences retrieval of lymph nodes and tumour nodal stage. Eur J Surg Oncol. 2000;26:758–62.PubMedCrossRefGoogle Scholar
  18. 18.
    Herrera-Ornelas L, Justiniano J, Castillo N, Petrelli NJ, Stule JP, and Nittelman A. Metastases in small lymph nodes from colon cancer. Arch Surg. 1987;122:1253–6.PubMedGoogle Scholar
  19. 19.
    Dworak O. Number and size of lymph nodes and node metastases in rectal carcinomas. Surg Endosc. 1989;3:96–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Catalano MF, Sivak MV, Rice T, Gragg LA, and Van Dam J. Endosonographic features predictive of lymph node metastasis. Gastrointest Endosc. 1994;40:442–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Hildebrandt U, Klein T, Feifel G, Schwarz HP, Koch B, and Schmitt RM. Endosonography of pararectal lymph nodes. In vitro and in vivo evaluation. Dis Colon Rectum. 1990;33:863–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Beynon J, Foy DMA, Channer JL, Temple LN, Virjee J, and Mortensen NJM. The endosonic appearances of normal colon and rectum. Dis Colon Rectum. 1986;29:810–3.PubMedGoogle Scholar
  23. 23.
    Hermanek, Hutter RVP, Sobin LH, Wagner G, Wittekind C, and Spiess B. TNM atlas: illustrated guide to the TNM/pTNM classification of malignant tumors. Berlin: Springer-Verlag; 1997.Google Scholar
  24. 24.
    Mackay SG, Pager CK, Joseph D, Stewart PJ, and Solomon MJ. Assessment of the accuracy of transrectal ultrasonography in anorectal neoplasia. Br J Surg. 2003;90:346–50.PubMedCrossRefGoogle Scholar
  25. 25.
    Rifkin MD and Marks GJ. Transrectal US as an adjunct in the diagnosis of rectal and extrarectal tumours. Radiology. 1985;157:499–502.PubMedGoogle Scholar
  26. 26.
    Rifkin M and Wechsler RJ. A comparison of computed tomography and endorectal ultrasound in staging rectal cancer. Int J Colorectal Dis. 1986;1:219–23.PubMedCrossRefGoogle Scholar
  27. 27.
    Romano G, De Rosa P, Vallone G, Rontando A, Grassi R, and Santangelo ML. Intrarectal ultrasound and computed tomography in the pre-and postoperative assessment of patients with rectal carcinoma. Br J Surg. 1985;72(Suppl):S117–19.PubMedGoogle Scholar
  28. 28.
    Glaser F, Schlag P, and Herfarth C. Endorectal ultrasonography for the assessment of invasion of rectal tumours and lymph node involvement. Br J Surg. 1990;77:883–7.PubMedGoogle Scholar
  29. 29.
    Holdsworth PJ, Johnston D, Chalmers AG, Chennels P, Dixon MF, Finan PJ, Primrose JN, and Quirke P. Endoluminal ultrasound and computed tomography in the staging of rectal cancer. Br J Surg. 1988;75:1019–22.PubMedGoogle Scholar
  30. 30.
    Detry R and Kartheuser A. Endorectal ultrasonography in staging small rectal tumours. Br J Surg. 1992;79(Suppl):S30.Google Scholar
  31. 31.
    Katsura Y, Yamada K, Ishizawa T, Yoshinaka H, and Shimazu H. Endorectal ultrasonography for the assessment of wall invasion and lymph node metastasis in rectal cancer. Dis Colon Rectum. 1992;35:362–68.PubMedCrossRefGoogle Scholar
  32. 32.
    Beynon J. An evaluation of the role of rectal endosonography in rectal cancer. Ann R Coll Surg Engl. 1989;71(2):131–9.PubMedGoogle Scholar
  33. 33.
    Orrom WJ, Wong WD, Rothenberger DA, Jensen LL, and Goldberg SM. Endorectal ultrasound in the preoperative staging of rectal tumours. A learning experience. Dis Colon Rectum. 1990;33:654–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Garciá-Aguilar J, Pollack J, Lee S, et al. Accuracy of endorectal ultrasound in preoperative staging of rectal tumours. Dis Colon Rectum. 2002;45:10–15.PubMedCrossRefGoogle Scholar
  35. 35.
    Adams WJ and Wong WD. Endorectal ultrasonic detection of malignancy within rectal villous lesions. Dis Colon Rectum. 1995;38:1093–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Sailer M, Leppert R, Bussen D, Fuchs KH, and Thiede A. Influence of tumour position on accuracy of endorectal ultrasound staging. Dis Colon Rectum. 1997;40:1180–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Beynon J, Mortensen NJM, Foy DMA, Channer JL, Rigby H, and Virjee J. Preoperative assessment of meso-rectal lymph node involvement in rectal cancer. Br J Surg. 1989;76:276–9.PubMedGoogle Scholar
  38. 38.
    Beynon J, Mortensen NJM, Foy DMA, Channer JL, Virjee J, and Goddard P. Preoperative assessment of local invasion in rectal cancer: digital examination, endoluminal sonography or computed tomography? Br J Surg. 1986;73:1015–17.PubMedGoogle Scholar
  39. 39.
    Milsom JW, Lavery IC, Stolfi VM, et al. The expanding utility of endoluminal ultrasonography in the management of rectal cancer. Surgery. 1992;112:832–41.PubMedGoogle Scholar
  40. 40.
    Lindmark G, Elvin A, Pahlman L, and Glimelius B. The value of endosonography in preoperative staging of rectal cancer. Int J Colorectal Dis. 1992:7:162–6.PubMedCrossRefGoogle Scholar
  41. 41.
    Gupta NC, Falk PM, Frank AL, Thorson AM, Frick MP, and Bowman B. Pre-operative staging of colorectal carcinoma using positron emission tomography. Nebr Med J. 1993;211:30–55.Google Scholar
  42. 42.
    Behr TM, Becker WS, Bair HJ, et al. Comparison of complete versus fragmented technetwin-99m-labeled anti-CEA monoclonal antibodies for immunoscintigraphy in colorectal cancer. J Nucl Med. 1995;36:430–41.PubMedGoogle Scholar
  43. 43.
    Sironi S, Ferrero C, Gainolli L, Landoni C, Del Maschio A, Fazio F, and Zbar AP. The role of imaging in the diagnosis and staging of primary and recurrent rectal cancer. In: Audisio RA, Geraghty JG, and Longo WE, editors. Modern management of cancer of the rectum. London: Springer-Verlag; 2001. p. 33–49.Google Scholar
  44. 44.
    Gualdi GF, Casciani E, Guadalaxara A, d’Orta C, Polettini E, and Pappalardo G. Local staging of rectal cancer with transrectal ultrasound and endorectal magnetic resonance imaging. Dis Colon Rectum. 2000;43:338–45.PubMedCrossRefGoogle Scholar
  45. 45.
    Kim NK, Kim MJ, Yun SH, Sohn SK, and Min JS. Comparative study of transrectal ultrasound, pelvic computerized tomography, and magnetic resonance imaging in preoperative staging of rectal cancer. Dis Colon Rectum. 1999;42:770–5.PubMedCrossRefGoogle Scholar
  46. 46.
    Brown G, Radcliffe AG, Newcombe RG, Dallimore NS, Bourne MW, and Williams GT. Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging. Br J Surg. 2003;90:355–64.PubMedCrossRefGoogle Scholar
  47. 47.
    Wood CB, Ratcliffe JG, Burt TW, Malcolm AJH, and Blumgart LH. Local tumour invasion as a prognostic factor in colorectal carcinoma. Br J Surg. 1981;68:326–8.PubMedGoogle Scholar
  48. 48.
    Beynon J, Mortensen NJM, Foy DMA, Rigby HS, Channer JL, and Virjee J. The detection and evaluation of locally recurrent rectal cancer with rectal endosonography. Dis Colon Rectum. 1989;32:509–17.PubMedGoogle Scholar
  49. 49.
    Mascagni D, Corellini L, Urciuoli P, and Di Matteo G. Endoluminal ultrasound for early detection of local recurrence of rectal cancer. Br J Surg. 1989;76:1176–80.PubMedGoogle Scholar
  50. 50.
    Wolpert A, Beer-Gabel M, Lifschitz O, and Zbar AP. The management of presacral masses in the adult. Tech Coloproctol. 2002;6:43–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Sultan AH, kamm MA, Hudson CN, Nicholas JR, and Bartram CI. Endosonography of the anal sphincters: normal anatomy and comparison with manometry. Clin Radiol. 1994;49:368–74.PubMedCrossRefGoogle Scholar
  52. 52.
    Schafer A, Erick P, Furst G, Kahn T, Frieling T, and Lubke HJ. Anatomy of the anal sphincter; comparison of anal endosonography to magnetic resonance imaging. Dis Colon Rectum. 1994;137:777–81.CrossRefGoogle Scholar
  53. 53.
    Sultan AH, Nicholls RJ, Kamm MA, Hudson CN, Beynon J, and Bartram CI. Anal endosonography and correlation with in vitro and in vivo anatomy. Br J Surg. 1993;80:508–11.PubMedGoogle Scholar
  54. 54.
    Bartram CI and Frudinger A. Handbook of anal endosonography. United Kingdom: Wrightson Biomedical Publishing Ltd; 1997.Google Scholar
  55. 55.
    Burnett SJ and Bartram CI. Endosonographic variations in the normal internal anal sphincter. Int J Colorectal Dis. 1991;6:2–4.PubMedCrossRefGoogle Scholar
  56. 56.
    Frudinger A, Halligan S, Bartram CI, Price AB, Kamm MA, and Winter R. Female anal sphincter: Age related differences in asymptomatic volunteers with high—frequency endoanal US. Radiology. 2002;224:417–23.PubMedGoogle Scholar
  57. 57.
    Kamm MA, Hoyle CH, Burleigh DE, Law PJ, Swash M, Martin JE, Nicholls RJ, and Northover JM. Hereditary internal anal sphincter myopathy causing proctalgia fugax and constipation. A newly identified condition. Gastroenterology. 1991;100:805–10.PubMedGoogle Scholar
  58. 58.
    Vaizey CJ, Kamm MA, and Bartram CI. Primary degeneration of the internal anal sphincter as a cause of passive faecal incontinence. Lancet. 1997;349(9052):612–15.PubMedCrossRefGoogle Scholar
  59. 59.
    Bartram CI. Anal endosonography. Alimentary tract radiology. 5th ed. St. Louis: Freeney and Stevenson; 1994.Google Scholar
  60. 60.
    Gold DM, Bartram CI, Halligan S, Humphries KN, Kamm MA, and Kmiot WA. Three dimensional endoanal sonography in assessing anal canal injury. Br J Surg. 1999;86:365–70.PubMedCrossRefGoogle Scholar
  61. 61.
    Pinedo G, Vaizey CJ, Nicholls RJ, Roach R, Halligan S, and Kamm MA. Result of repeat anal sphincter repair. Br J Surg. 1999;86:66–9.PubMedCrossRefGoogle Scholar
  62. 62.
    Speakman CTM, Burnett SJD, Kamm MA, and Bartram CI. Sphincter injury after anal dilatation demonstrated by anal endosonography. Br J Surg. 1991;78:1429–30.PubMedGoogle Scholar
  63. 63.
    Zbar AP and deSouza NM. The anal sphincter. In: deSouza NM, editor. Endocavitary MRI of the pelvis. London: Harwood Academic Publishers; 2001. p. 91–109.Google Scholar
  64. 64.
    Nielsen MB, Rasmussen OO, Pederson JF, and Chritiansen J. Risk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano. Dis Colon Rectum. 1993;36:677–80.PubMedCrossRefGoogle Scholar
  65. 65.
    Bartram CI and Sultan AH. Anal endosonography in faecal incontinenece. Gut. 1995;37:4–6.PubMedGoogle Scholar
  66. 66.
    Sultan AH, Kamm MA, Nicholls RJ, and Bartram CI. Prospective study of the extent of lateral anal sphincterotomy division during lateral sphinctertomy. Dis Colon Rectum. 1994;37:1031–3.PubMedCrossRefGoogle Scholar
  67. 67.
    Sultan AH, Kamm MA, Hudson CN, Thomas J, and Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993;329:1905–11.PubMedCrossRefGoogle Scholar
  68. 68.
    Ho YH, Tsang C, Tang CL, Nyam D, Eu KW, and Seow-Choen F. Anal sphincter injuries from stapling instruments introduced transanally. Dis Colon Rectum. 200;43:169–73.Google Scholar
  69. 69.
    Deen KI, Williams JG, Hutchinson R, Keighley MRB, and Kumar D. Fitulas in ano: endoanal ultrasongraphic assessment assists decision making for surgery. Gut. 1994;35:391–4.PubMedGoogle Scholar
  70. 70.
    Hussain SM, Stoker J, Schouten WR, Hop WC, and Lameris JS. Fistula in ano: Endoanal sonography versus endoanal MR imaging in classification. Radiology. 1996;200:475–81.PubMedGoogle Scholar
  71. 71.
    Laurence FY, Birnbaum EH, Read TE, Kodner IJ, and Fleshman JW. Use of endoanal ultrasound in patients with rectovaginal fistulas. Dis Colon Rectum. 1999;42:1057–64.CrossRefGoogle Scholar
  72. 72.
    Kruskal JB, Kane RA, and Morrin MM. Peroxide-enhanced anal endosonography; technique, image interpretation, and clinical applications. Radiographics. 2001;21;S173–89.PubMedGoogle Scholar
  73. 73.
    Lunniss PJ, Kamm MA, and Phillips RKS. Factors affecting continence after surgery for anal fistula. Br J Surg. 1994;81:1382–5.PubMedGoogle Scholar
  74. 74.
    Zbar AP and deSouza NM. Prospective comparison of endosonography, magnetic resonance imaging and surgical findings in anorectal fistula and abscess complicating Crohn’s disease. Br J Surg. 1999;86:1093–4.PubMedCrossRefGoogle Scholar
  75. 75.
    Zbar AP, deSouza NM, Puni R, and Kmiot WA. Comparison of endoanal magnetic resonance imaging with surgical findings in perirectal sepsis. Br J Surg. 1998;85:111–14.PubMedCrossRefGoogle Scholar
  76. 76.
    Zimmerman DDE. Diagnosis and treatment of transsphincteric perianal fistulas [thesis]. Rotterdam, The Netherlands: Erasmus University; 2003.Google Scholar
  77. 77.
    Zbar AP, Fenger C, Efron C, Beer-Gabel M, and Wexner SD. The pathology and molecular biology of anal intraepithelial neoplasia: comparisons with cervical and vulvar intraepithelial carcinoma. Int J Colorectal Dis. 2002;17:203–15.PubMedCrossRefGoogle Scholar
  78. 78.
    Tarantino D and Bernstein MA. Endoanal ultrasound in the staging and management of squamous-cell carcinoma of the anal canal. Potential implications of a new ultrasound staging system. Dis Colon Rectum. 2002;45:16–22.PubMedCrossRefGoogle Scholar
  79. 79.
    Giovannini M, Bardou VJ, Barclay R, et al. Anal carcinoma; prognostic value of endorectal ultrasound (ERUS). Results of a prospective multicenter study. Endoscopy. 2001;33(3):231–6.PubMedCrossRefGoogle Scholar
  80. 80.
    Lohnert M, Doniec JM, Kovacs G, Schroder J, and Dohrmann P. New method of radiotherapy for anal cancer with three-dimensional tumour reconstruction based on endoanal ultrasound and ultrasound-guided afterloading therapy. Dis Colon Rectum. 1998;41(2):169–76.PubMedCrossRefGoogle Scholar
  81. 81.
    Halligan S, Sultan AH, Rottenberg G, and Bartram CI. Endosonography of the anal sphincters in solitary rectal ulcer syndrome. Int J Colorectal Dis. 1995;10:79–82.PubMedCrossRefGoogle Scholar
  82. 82.
    Marshall M, Halligan S, Fotheringham T, Bartram C, and Nicholls RJ. Predictive value of internal anal sphincter thickness for diagnosis of rectal intussusception in patients with solitary rectal ulcer syndrome. Br J Surg. 2002;89:1281–5.PubMedCrossRefGoogle Scholar
  83. 83.
    Beer-Gabel M, Teshler M, Barzilai N, Lurie Y, Malnick S, Bass D, and Zbar A. Dynamic transperineal ultrasound in the diagnosis of pelvic floor disorders. Dis Colon Rectum. 2002;45:239–48.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2005

Authors and Affiliations

  • Ponnandai J. Arumugam
    • 1
  • Bharat Patel
    • 2
  • John Beynon
    • 3
  1. 1.Department of Colorectal SurgeryRoyal Cornwall HospitalTruroUK
  2. 2.Department of RadiologySingleton HospitalSwanseaUK
  3. 3.Department of Colorectal SurgerySingleton HospitalSwanseaUK

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