Endorectal ultrasound

Definition

Ultrasound is a type of imaging technique that pain-lessly uses sound waves to produce an image of internal structures, organs, and masses. Endorectal ultrasound, also called transrectal ultrasound, is a special ultrasound technique in which the transducer is directly inserted through the anus and into the patient's rectum. The sound wave echoes detected by the transducer are converted by a computer into an image.

Purpose

Ultrasound technology has been used in medicine since World War II and is recognized as a non-invasive, non-radiative, real-time and inexpensive imaging capacity. It has become standard medical practice to produce fetal images and to identify and assess various anatomical features of the body.

Endorectal ultrasound is a specialized ultrasound application and it represents one of the most useful diagnostic tools for diseases of the anal and rectal regions of the body, especially for rectal, anal, and prostrate cancer screening and staging.

For rectal cancer , endorectal ultrasound is the most preferred method for staging both depth of tumor penetration and local lymph node metastatic status. Endorectal ultrasound:

• differentiates areas of invasion within large rectal adenomas that seem benign
• determines the depth of tumor penetration into the rectal wall
• determines the extent of regional lymph node invasion
• can be combined with other tests (chest x rays and computed tomography scans, or CT scans) to determine the extent of cancer spread to distant organs, such as the lungs or liver

The resulting rectal cancer staging allows physicians to determine the need for—and order of—radiation, surgery, and chemotherapy .

For patients diagnosed with anal cancer , endorectal ultrasound may help to stage the lesion and may be used as follow-up care to check for recurrence of cancer after treatment.

In the diagnosis of prostrate cancer, endorectal ultrasound has become a companion technique to digital rectal examination (DRE). It is also the most frequent method used to guide biopsy needle insertion. If surgery is indicated, endorectal ultrasound can also assist the pre-operative evaluation of the depth of cancer penetration and of the presence of metastases, as required to design appropriate surgical procedures.

Endorectal ultrasounds can also be used to check the overall treatment results.

Precautions

This is a very easy procedure. Unlike other imaging techniques, it uses no radiation and thus requires no special precautions.

Description

The instrumentation used for endorectal ultrasound consists of a hand-held probe, the transrectal transducer, a scanner, and an imaging screen. During the procedure, high-frequency acoustical (sound) waves are sent out by the small microphone-like transducer, which is inserted into the rectum. The waves bounce off the organ being examined and produce echoes sent by the transducer to a computer so as to generate a picture called a sonogram. Doctors examine the sonogram for echoes that may represent abnormal areas.

Usually, the patient lies on his side during the test. An endorectal probe is covered with a protective covering and inserted into the patient. The probe looks like a small enema tip and there is a minimal amount of discomfort associated with the procedure itself. Once inserted, the sonographer or radiologist gently moves the probe forward and backward to best evaluate the organ being examined. An endorectal ultrasound generally takes five to ten minutes. After the procedure, the radiologist interprets the results and sends a report to the referring physician.

Preparation

The patient requires no anesthetic or sedation, but needs an enema about two hours before the test in order to provide a clean rectal wall through which to scan. The evening before the procedure, it is recommended that the patient eat a small dinner, drinking only clear liquids and avoiding coffee, tea, or soft drinks after dinner.

Aftercare

The patient should enjoy a good meal and remember to keep a follow-up appointment if scheduled. In some cases, there may be some bleeding from the rectum, though this usually settles within a few days. Antibiotics may be prescribed in some cases.

Risks

Multiple studies have shown that the sound waves used with ultrasound imaging are harmless and may be directed at patients with complete safety. However, some patients may develop infections following the procedure, which could require further treatment. These may cause shivering and fever . Any manifestation of such symptoms should be immediately reported to the treating physician. Generally speaking, the entire procedure is well tolerated and there is usually minimal bleeding afterwards.

Normal results

Normal sonograms produce images that have the correct shape of the organ or tissue examined by the procedure, meaning that it corresponds to the true anatomy.

Abnormal results

Abnormal sonograms produce images which highlight abnormal features of the organ being scanned. In a tumor is present, it will show up as a distinct contrast feature on the sonogram.

See Also Imaging studies

Resources

BOOKS

Bankman, I. Handbook of Medical Imaging. Academic Press, 2000

Bushong, S. C. Diagnostic Ultrasound. New York: McGraw-Hill & Co., 1999.

Edelstein, Peter, M.D. Colon and Rectal Cancer. New York: Wiley-Liss, 2000.

PERIODICALS

Gavioli, M., A. Bagni, I. Piccagli, S. Fundaro, G. Natalini. "Usefulness of endorectal ultrasound after preoperative radiotherapy in rectal cancer: comparison between sono-graphic and histopathologic changes." Diseases of the Colon and Rectum 43 (August 2000):1075-83.

Hsieh, J.-S., C.-J. Huang, J.-Y. Wang, T.-J. Huang. "Benefits of Endorectal Ultrasound for Management of Smooth-Muscle Tumor of the Rectum." Diseases of the Colon and Rectum 42 (August 1999):322-8

Ott, D. J. "EUS and rectal cancer staging." American Journal of Gastroenterology 93 (April 1998):659-60.

Saclarides, T. J. "Endorectal ultrasound." Surgical Clinics of North America 78 (April 1998):237-49.

Sudhanshu, G. et al. "Staging of prostate cancer using 3-dimensional transrectal ultrasound images: a pilot study." Journal of Urology 162 (1999):1318-1321.

van den Berg, J. C., J. P. van Heesewijk, H. W. van Es. "Malignant stromal tumour of the rectum: findings at endorectal ultrasound and MRI." British Journal of Radiology 73 (September 2000):1010-12.

Monique Laberge, Ph.D.

KEY TERMS

Anal

—Pertaining to the anus, which is the terminal orifice of the digestive—or alimentary—canal.

Anatomy

—Structure of the body and of the relationship between its parts.

Biopsy

—Procedure that involves obtaining a tissue specimen for microscope analysis to establish a precise diagnosis.

Cancer screening

—Examination of people to detect early stages in the development of cancer even though they have no symptoms.

Colon

—Large intestine.

Digital rectal examination (DRE)

—Examination performed by a physician to detect rectal cancer. The physician inserts a gloved, lubricated finger into the rectum of the patient and feels for abnormal areas.

Endorectal probe

—Instrument which sends sound waves through the prostrate. Sound echoes are then recorded as an image.

Enema

—Injection of a liquid into the rectum.

Metastasis

—The transfer of cancer from one part of the body to another not directly connected with it.

Rectal

—Pertaining to the rectum, which is the last portion of the large intestine.

Sonogram —A computer picture of areas inside the body created by bouncing sound waves off organs and other tissues. Also called ultrasono-gram or ultrasound.

QUESTIONS TO ASK THE DOCTOR

• How many endorectal ultrasounds will I have to undergo?
• Are any other imaging tests indicated?
• How will this test help you diagnose my cancer?

Endorectal Ultrasound

Definition

Endorectal ultrasound (ERUS) is a procedure where a probe is inserted into the rectum and high frequency sound waves (ultrasound waves) are generated. The pattern of echoes as they bounce off tissues is converted into a picture (sonogram) on a television screen.

Purpose

ERUS is used as a diagnostic procedure in rectal cancer to determine stage of the tumor and as a post-radiation, presurgical examination to assess extent of tumor shrinkage. ERUS can also be used in cases of anal fistula (an abnormal passage) and problems with the anal sphincter muscles (muscles that control the opening and closing of the anus).

Precautions

Normal precautions should be taken with any diagnostic procedure. Since the population in which this procedure is normally done is elderly, the imaging staff should be extra cautious about stressing the patient. The procedure is invasive and may be embarrassing to some. Other patients may be anxious about their medical condition since endorectal ultrasounds are not routine. This places an added burden on already stressed hearts and nervous systems. Physicians, nurses, and technicians may need to be prepared for stress reactions that could include the heart, asthma, or anxious behaviors.

Description

ERUS has been used as a means to determine the depth of rectal cancers and to assess whether the tumor has affected surrounding tissues. This pre-treatment procedure has proven to be an accurate tool for tailoring surgery for patients.

Problems with interpretation of the sonograms after radiation and before surgery have resulted in tumors being identified that were merely the formation of fibrous tissues that remained after the tumors had been eliminated by the radiation. Yet, some of the fibrous areas actually hid residual tumors. Rectal anatomy itself can affect the accuracy of ultrasound reading. This makes ERUS problematic in determining the amount of tumor reduction a patient has after radiation therapy.

Preparation

The patient must evacuate the bowels completely before the procedure is done. This usually is assisted though the use of several enemas. The patient may be told to adhere to a liquid diet the day prior to doing this procedure. The probe is inserted, usually with little discomfort for the patient since it will only be examining the first few inches of the colon.

Aftercare

Since ERUS is a minor invasive procedure, there is no aftercare.

Risks

There are no risks to having an ultrasound.

Normal results

Normal results after an endorectal ultrasound are normal, healthy tissues.

Abnormal results

Abnormal results range from any number of congenital deformities in the lining of the rectum to serious rectal cancers.

Resources

BOOKS

Johnston, Lorraine. Colon and Rectal Cancer: A Comprehensive Guide for Patients and Families. Sebastopol, CA: O'Reilly, 2000.

Levin, Bernard. Colorectal Cancer: A Thorough and Compassionate Resource for Patients and Their Families. New York: Villard, 1999.

PERIODICALS

Gavioli, M. A. Bagni, I. Piccagli, S. Fundaro, and G. Natalini. "Usefulness of Endorectal Ultrasound after Preoperative Radiotherapy in Rectal Cancer: Comparison between Sonographic and Histopathologic Changes." Dis ColonRectum (August 2000): 1075-83.

OTHER

American Society of Colon and Rectal Surgeons."Practice Parameters for the Treatment of Rectal Carcinoma." May 9, 2001. 〈http://www.asco.org/prof/me/html/abstracts/gasc/m_969.htm〉.

National Cancer Institute. "NCI/PDQ Patient Statement:Rectal Cancer Updated 11/2000." OncoLink. May 9, 2001. 〈http://www.oncolink.upenn.edu/pdq_html/2/engl/200076.html〉.

KEY TERMS

Anal sphincter muscles— Muscles that control the opening and closing of the anus.

Fistula— An abnormal passage.

Sonogram— The picture formed by the pattern of echoes from an ultra sound.

Ultrasound waves— High frequency sound waves.