International Atlas

by: Giancarlo Sarnelli M.D.

Sagittal perineal sonographic plane, obtained with high frequency superficial probe during straining, revealing enterocele (1) that emerges in the perineal space anterior to the rectum (4). The bowels are delimited by the peritoneal layer, well seen like an hyperechoic line (2) that encircle the mass. Is also well defined the anal canal (3) and a hypoechoic line (5) that divide the ano-rectal canal from the intestinal mass and give the certainty of diagnosis of enterocele.

Sagittal perineal sonographic plane, obtained with high frequency superficial probe during straining, revealing enterocele in peritoneal liquid (3) separating the intestinal loop (1) from the peritoneal wall (2). In the original image seen in real time one can observe the movements of the loops that seems to float in the liquid. It is not frequent to observe enterocele with liquid in peritoneal cavity and this aspect give total certainty of diagnosis.

Sagittal perineal sonographic plane, obtained with high frequency superficial probe during straining, revealing enterocele and rectocele. In the peritoneal cavity we can observe a little quantity of liquid between the intestinal loops (1) and the peritoneal wall (2). On the posterior side a protrusion of the anterior rectal wall (3) is clearly visible (associated rectocele). Enterocele and rectocele frequently coexist. 

Sonography represent a reliable tool for a rapid, economic and innocuous diagnosis of enterocele. The images that I show here prove that if peritoneal pouch content is bowel material the diagnosis is simple and reliable. When there is also peritoneal liquid the diagnosis is more reliable too.

However we must learn to differentiate enterocele pouch from rectocele bulging with ultrasound. In most part of the cases it is simple. We have to search the hypoechoic separation line localized between the peritoneal pouch and the rectum (Image 1 – Point 5) and observe it on real time during straining. Generally the bulging of rectocele is clearly seen in sonographic images like direct continuation of the anterior wall of the ano-rectal conduit. In other presentation the peritoneal pouch contents fat or nothing. In this cases the diagnosis, in my experience, is more complicated. 

About half of my patient with enterocele has had an hysterectomy. 

The presence of uterus doesn’t improve the diagnostic reliability of sonography. Same difficulty, sometimes, can exist in presence of high degree uterus prolapse.

I don’t know what is the range of diagnostic confidence of sonography in enterocele but I’m sure it is very high. I think ultrasound should be the first step when this defect is clinically suspected. In my experience sonography has sometime clearly demonstrated enterocele where clinical or colpo-cysto-defecograpy has failed. MRI should be the second step if the clinical or sonografic exploration has failed or leaved some doubt