The main diagnostic investigations in colon proctology can be either instrumental or radiological.
Instrumental Investigations Anorectoscopy
Anorectoscopy represents the most common and immediate examination, and no proctological evaluation should proceed without the execution of anoscopy or, preferably, rectoscopy. It requires minimal preparation, typically using disposable anoscope or rectoscope. Connected to a fiber-optic light source, the anoscope is inserted into the patient's rectum. Insufflation of air allows the distension of rectal walls, enabling the specialist to have a clear view of the anal canal and rectum, up to 22 cm from the anus. It is an irreplaceable examination that allows visual analysis of the rectal mucosa and direct diagnosis of common conditions such as hemorrhoids, prolapses, fistulas, and less frequent conditions such as polyps, ulcers, and prolapses. Through anoscopy, the specialist can also perform biopsies for subsequent histological examinations.
Multifunctional Anoscope (MFA)
The MFA is a multifunctional anoscope that, during the initial examination, also allows the assessment of certain functional parameters of the rectum. It can perform a brief test of rectal functionality, the balloon expulsion test, assess the extent of any prolapse, and measure the length of the anal canal. If these data are altered, it may raise suspicion of concurrent pathologies during the initial examination. The specialist may then request further diagnostic tests. It also helps in selecting candidates for surgery and predicting potential postoperative complications.
Colonoscopy
Colonoscopy remains the best method for studying the morphology of the colon and rectum. After adequate intestinal preparation, a flexible colonoscope is introduced through the anus. Connected to a video system, it allows complete exploration of the colon and rectum. This procedure can reveal mucosal alterations or the presence of various types of neoplasms, for which biopsies can be performed to determine their histological nature. Due to the discomfort reported by patients undergoing this examination, sedation or, in specific cases, general anesthesia can be administered.
Capsule Endoscopy
Capsule endoscopy involves a transparent capsule approximately 1 cm in diameter and 2.5 cm in length, containing a miniature camera capable of transmitting images to a computerized system. After adequate preparation, the patient swallows the capsule, and as it travels through the gastrointestinal tract, images are captured. This method is primarily indicated for studying the small intestine and the ileum and is not yet widely used. There are situations where it is even contraindicated, such as in cases of intestinal strictures, stenosis, pregnancy, or in individuals with pacemakers.
Anorectal Manometry
Anorectal manometry is essential for studying anorectal function by assessing the pressures and volumes of the anal canal and rectum. This non-invasive examination allows the evaluation of potential dysfunctions of anal sphincters, rectal capacity, and the sensitivity of the anorectal tract. Acquiring this information is crucial in choosing both medical and surgical therapies. Alterations in pressure or volume parameters of the anorectal tract may indicate significant pathologies, such as fecal incontinence, constipation, and other intestinal conditions. Manometry is also indicated in the preoperative selection of patients when proper sphincter function is required or for postoperative checks following surgical procedures on the anorectal tract, such as sphincter reconstructions for fecal incontinence.
Electromyography (EMG) and Pudendal Nerve Terminal Motor Latency (PNTML)
EMG involves detecting electrical activity produced by muscle fibers and serves as an effective, though debated, neurophysiological study of the pelvic floor. Various methods of detection are used, such as electrodes or needles positioned in the perineum. It is useful for determining nerve impulse transmission dysfunctions, both centrally and peripherally, to identify perineal nerve lesions. PNTML is a method for studying the pudendal nerve, performed with an electrode on the specialist's examining finger. Its purpose is to determine...
Radiological Investigations Direct Abdominal X-ray
Primarily performed in emergencies, cases with suspected intestinal obstruction, or gastrointestinal perforation. This examination allows the observation of characteristic pathological signs in intestinal loops or the presence of free air in the abdomen, which is a characteristic sign of stomach perforation (perforated gastric ulcer) or of an intestinal segment (typical in cases of diverticulum rupture). Direct abdominal X-rays can also reveal radiopaque formations like kidney or urinary tract stones, vertebral body abnormalities, or foreign bodies in the gastrointestinal tract.
Double-Contrast Barium Enema
Today, this procedure is less commonly used, involving the introduction of a mixture of air and barium (double-contrast) into the colon through the anus. This preparation distends the colon and rectum. By taking a series of X-rays in various positions, it is possible to highlight large intestine abnormalities such as diverticula, neoplasms, stenotic segments, and extensive mucosal lesions. However, this procedure has the limitation of not being able to perform biopsies. The CT Colonography is now preferred.
CT Colonography
This method is increasingly performed as it allows for a thorough study of the colon and rectum while providing information about other abdominal and pelvic organs. A contrast medium is introduced through the anus, and a CT scan of the abdomen is performed immediately afterward. This method enables a precise evaluation of the intestinal wall and even small intestinal lesions. The possibility of obtaining 3D images makes this examination a reliable diagnostic tool for studying the colon and rectum.
Perineal Ultrasound
Perineal ultrasound is a sonographic study using a surface probe to assess the anatomy and functionality of the structures of the pelvic floor. It is indicated when rectal pathology is associated with urogynecological conditions. It can also be performed after colpoenterodefecography for a more detailed study of pelvic organs or to better identify a stable enterocele.
Transanal and Transrectal Ultrasound
Transanal and transrectal ultrasound is a very important, relatively non-invasive examination conducted using a rotating ultrasound probe introduced through the anus. This method is crucial for studying lesions of the sphincter apparatus, classifying perianal abscesses and fistulas, and for the study and staging of rectal tumors.
Pelvic Magnetic Resonance Imaging (MRI)
MRI is indicated for patients with both organic and functional pelvic floor pathologies. It is highly valuable for staging rectal tumors and diagnosing inflammatory pathologies such as abscesses. MRI can be performed in conjunction with defecography, referred to as Defeco-MRI, enabling the diagnosis of recto-rectal intussusception, rectocele, enterocele, and other potential causes of obstructed defecation. While this examination is very accurate, it still has limitations, particularly concerning the patient's position. New equipment is addressing this issue, and highly precise diagnostic MRIs will be available soon.
Colpocystoenterodefecography and Dynamic Cinedefecography
These examinations are the reference for studying obstructed defecation syndrome. After introducing different contrast media into the rectum, vagina, and bladder and having the patient drink another contrast fluid, the examination is conducted. The patient is asked to evacuate the contrast medium while static or dynamic images are recorded by a remote-controlled apparatus. This method studies the resting, pushing, and post-evacuation phases. With this technique, rectal prolapses, bladder prolapses, rectoceles, pelvic floor muscle dysfunctions, peritoneal and small intestine pathologies (enteroceles), and other significant conditions causing obstructed defecation, urinary incontinence, or other symptoms can be diagnosed.
Radiological Examination of Intestinal Transit with Markers
The validity of this examination is a subject of debate, but it finds utility in specific conditions like constipation due to slow intestinal transit. Various methods are used, and in our center, patients are instructed to ingest ten markers (small inert spheres) orally for six days (a total of 60 markers). On the seventh day, a direct abdominal X-ray is performed. Special formulas can calculate the actual intestinal transit times based on the quantity of markers retained in the colon, identifying various forms of constipation. When combined with other functional tests, it can still be crucial in determining the choice of therapy.
Instrumental Investigations Anorectoscopy
Anorectoscopy represents the most common and immediate examination, and no proctological evaluation should proceed without the execution of anoscopy or, preferably, rectoscopy. It requires minimal preparation, typically using disposable anoscope or rectoscope. Connected to a fiber-optic light source, the anoscope is inserted into the patient's rectum. Insufflation of air allows the distension of rectal walls, enabling the specialist to have a clear view of the anal canal and rectum, up to 22 cm from the anus. It is an irreplaceable examination that allows visual analysis of the rectal mucosa and direct diagnosis of common conditions such as hemorrhoids, prolapses, fistulas, and less frequent conditions such as polyps, ulcers, and prolapses. Through anoscopy, the specialist can also perform biopsies for subsequent histological examinations.
Multifunctional Anoscope (MFA)
The MFA is a multifunctional anoscope that, during the initial examination, also allows the assessment of certain functional parameters of the rectum. It can perform a brief test of rectal functionality, the balloon expulsion test, assess the extent of any prolapse, and measure the length of the anal canal. If these data are altered, it may raise suspicion of concurrent pathologies during the initial examination. The specialist may then request further diagnostic tests. It also helps in selecting candidates for surgery and predicting potential postoperative complications.
Colonoscopy
Colonoscopy remains the best method for studying the morphology of the colon and rectum. After adequate intestinal preparation, a flexible colonoscope is introduced through the anus. Connected to a video system, it allows complete exploration of the colon and rectum. This procedure can reveal mucosal alterations or the presence of various types of neoplasms, for which biopsies can be performed to determine their histological nature. Due to the discomfort reported by patients undergoing this examination, sedation or, in specific cases, general anesthesia can be administered.
Capsule Endoscopy
Capsule endoscopy involves a transparent capsule approximately 1 cm in diameter and 2.5 cm in length, containing a miniature camera capable of transmitting images to a computerized system. After adequate preparation, the patient swallows the capsule, and as it travels through the gastrointestinal tract, images are captured. This method is primarily indicated for studying the small intestine and the ileum and is not yet widely used. There are situations where it is even contraindicated, such as in cases of intestinal strictures, stenosis, pregnancy, or in individuals with pacemakers.
Anorectal Manometry
Anorectal manometry is essential for studying anorectal function by assessing the pressures and volumes of the anal canal and rectum. This non-invasive examination allows the evaluation of potential dysfunctions of anal sphincters, rectal capacity, and the sensitivity of the anorectal tract. Acquiring this information is crucial in choosing both medical and surgical therapies. Alterations in pressure or volume parameters of the anorectal tract may indicate significant pathologies, such as fecal incontinence, constipation, and other intestinal conditions. Manometry is also indicated in the preoperative selection of patients when proper sphincter function is required or for postoperative checks following surgical procedures on the anorectal tract, such as sphincter reconstructions for fecal incontinence.
Electromyography (EMG) and Pudendal Nerve Terminal Motor Latency (PNTML)
EMG involves detecting electrical activity produced by muscle fibers and serves as an effective, though debated, neurophysiological study of the pelvic floor. Various methods of detection are used, such as electrodes or needles positioned in the perineum. It is useful for determining nerve impulse transmission dysfunctions, both centrally and peripherally, to identify perineal nerve lesions. PNTML is a method for studying the pudendal nerve, performed with an electrode on the specialist's examining finger. Its purpose is to determine...
Radiological Investigations Direct Abdominal X-ray
Primarily performed in emergencies, cases with suspected intestinal obstruction, or gastrointestinal perforation. This examination allows the observation of characteristic pathological signs in intestinal loops or the presence of free air in the abdomen, which is a characteristic sign of stomach perforation (perforated gastric ulcer) or of an intestinal segment (typical in cases of diverticulum rupture). Direct abdominal X-rays can also reveal radiopaque formations like kidney or urinary tract stones, vertebral body abnormalities, or foreign bodies in the gastrointestinal tract.
Double-Contrast Barium Enema
Today, this procedure is less commonly used, involving the introduction of a mixture of air and barium (double-contrast) into the colon through the anus. This preparation distends the colon and rectum. By taking a series of X-rays in various positions, it is possible to highlight large intestine abnormalities such as diverticula, neoplasms, stenotic segments, and extensive mucosal lesions. However, this procedure has the limitation of not being able to perform biopsies. The CT Colonography is now preferred.
CT Colonography
This method is increasingly performed as it allows for a thorough study of the colon and rectum while providing information about other abdominal and pelvic organs. A contrast medium is introduced through the anus, and a CT scan of the abdomen is performed immediately afterward. This method enables a precise evaluation of the intestinal wall and even small intestinal lesions. The possibility of obtaining 3D images makes this examination a reliable diagnostic tool for studying the colon and rectum.
Perineal Ultrasound
Perineal ultrasound is a sonographic study using a surface probe to assess the anatomy and functionality of the structures of the pelvic floor. It is indicated when rectal pathology is associated with urogynecological conditions. It can also be performed after colpoenterodefecography for a more detailed study of pelvic organs or to better identify a stable enterocele.
Transanal and Transrectal Ultrasound
Transanal and transrectal ultrasound is a very important, relatively non-invasive examination conducted using a rotating ultrasound probe introduced through the anus. This method is crucial for studying lesions of the sphincter apparatus, classifying perianal abscesses and fistulas, and for the study and staging of rectal tumors.
Pelvic Magnetic Resonance Imaging (MRI)
MRI is indicated for patients with both organic and functional pelvic floor pathologies. It is highly valuable for staging rectal tumors and diagnosing inflammatory pathologies such as abscesses. MRI can be performed in conjunction with defecography, referred to as Defeco-MRI, enabling the diagnosis of recto-rectal intussusception, rectocele, enterocele, and other potential causes of obstructed defecation. While this examination is very accurate, it still has limitations, particularly concerning the patient's position. New equipment is addressing this issue, and highly precise diagnostic MRIs will be available soon.
Colpocystoenterodefecography and Dynamic Cinedefecography
These examinations are the reference for studying obstructed defecation syndrome. After introducing different contrast media into the rectum, vagina, and bladder and having the patient drink another contrast fluid, the examination is conducted. The patient is asked to evacuate the contrast medium while static or dynamic images are recorded by a remote-controlled apparatus. This method studies the resting, pushing, and post-evacuation phases. With this technique, rectal prolapses, bladder prolapses, rectoceles, pelvic floor muscle dysfunctions, peritoneal and small intestine pathologies (enteroceles), and other significant conditions causing obstructed defecation, urinary incontinence, or other symptoms can be diagnosed.
Radiological Examination of Intestinal Transit with Markers
The validity of this examination is a subject of debate, but it finds utility in specific conditions like constipation due to slow intestinal transit. Various methods are used, and in our center, patients are instructed to ingest ten markers (small inert spheres) orally for six days (a total of 60 markers). On the seventh day, a direct abdominal X-ray is performed. Special formulas can calculate the actual intestinal transit times based on the quantity of markers retained in the colon, identifying various forms of constipation. When combined with other functional tests, it can still be crucial in determining the choice of therapy.