Endosonography in anorectal disease: an overview

Anorectal endosonography (AE), which was introduced 20 years ago, derives from the study of urology. It was first used to evaluate rectal tumours and later also to investigate benign disorders of the anal sphincters and pelvic floor. The technique is easy to perform, it has a short learning curve and causes no more discomfort than a routine digital examination. A rotating probe with a 360 degrees radius and a frequency between 5 and 16 MHz is introduced to the rectum and then slowly withdrawn so that the pelvic floor and subsequently the sphincter complex are seen. Recently, it has become possible to reconstruct three-dimensional images. AE has been used for almost every possible disorder in the anal region and has increased our insight into anal pathology. The clinical indications for AE are: 1. Faecal incontinence in patients when surgery is an option. AE can show sphincter defects with excellent precision. There is a perfect correlation with surgical findings. Studies comparing AE with endoanal magnetic resonance imaging (MRI) have shown that both methods are equally good for demonstrating defects in the external anal sphincter; the internal anal sphincter is better visualized with AE. After sphincter repair, the effect is directly related to the decrease in the sphincter defect. 2. Perianal fistulae. AE has been shown to be accurate in staging perianal cryptoglandular fistulae and fistulae in Crohn's disease. When there is an external fistula opening, H2O2 can be introduced with a plastic infusion catheter. The tract then becomes visible as a hyperechoic lesion ("white"). It has been shown that this corresponds well with surgical findings. It is equally sensitive as endoanal MRI. Since recurrent cryptoglandular fistulae are complex in 50% and Crohn's fistula in 75%, it is mandatory to perform AE preoperatively in these patients to avoid missed tracts during surgery and subsequent recurrences. 3. Rectal tumors. In low tubulovillous adenomas or malignant polyps considered removable locally, confirming the local resectability (T0 or T1) is mandatory. Although larger rectal and more advanced tumours can be evaluated with AE, MRI is more sensitive in staging nodal involvement. 4. Anal carcinoma for staging. AE has been shown to stage better than the classical TNM classification for both local extension and prognosis. In conclusion, AE images the internal and external anal sphincter with high accuracy. It is easy to perform and is of particular value in the diagnosis of anal incontinence and perianal fistulae. It is excellent in staging anal carcinoma and can also be used in staging rectal carcinoma, especially very low large malignant polyps.