Describe types of bowel wall thickening on enhanced CT scan and the diagnostic signs to differentiate inflammatory , neoplastic , ischemic and other causes of bowel wall thickening .
Describe types of bowel wall thickening on enhanced CT scan and the diagnostic signs to differentiate inflammatory , neoplastic , ischemic and other causes of bowel wall thickening .
Emergency x ray films dr ahmed esawy
include different cases for oral radiodiagnosis examination all over the world
CT /MRI Plain X ray images
PNEUMOTHORAX
AIR FLUID LEVEL
FOREIGN BODY CION SWALLOWONG
ATELECTASIS
COLLAPSE
PNEUMOMEDIASTINUM
PNEUMOPERITONEUM
RETROPNEUMOPERITONEUM
INTESTINAL OBSTRUCTION
SMALL INTESTINAL OBSTRUCTION
LARGE INTESTINAL OBSTRUCTION
ILIEUS
STERNUM FRACTURES
OESOPHAGUS TEAR
Imaging vastitis differentitis funiculitis seminal vesiculitis Dr Ahmed EsawyAHMED ESAWY
Imaging vastitis differentitis funiculitis seminal vesiculitis dr ahmed esawy
IMAGING OF LOWER URINARY TRACT INFECTION LUTI
include different cases for oral radiodiagnosis examination all over the world
CT /MRI Plain X ray ultrasound TRANSRECTAL ULTRASOUND images
Cystitis
Prostatitis
urethritis
Orchitis
Epidydmitis
Epidydmo-orchitis
funiculitis
Vastitis/differentitis
Seminal vesiculitis
IMAGING OF LOWER URINARY TRACT INFECTION LUTI
include different cases for oral radiodiagnosis examination all over the world
CT /MRI Plain X ray ultrasound images
Cystitis
Prostatitis
urethritis
Orchitis
Epidydmitis
Epidydmo-orchitis
funiculitis
Vastitis/differentitis
Seminal vesiculitis
Imaging prostatitis ,urethritis Dr Ahmed EsawyAHMED ESAWY
Imaging prostatitis ,urethritis dr ahmed esawy
IMAGING OF LOWER URINARY TRACT INFECTION LUTI
include different cases for oral radiodiagnosis examination all over the world
CT /MRI Plain X ray ultrasound TRANSRECTAL ULTRASOUND images
Cystitis
Prostatitis
urethritis
Orchitis
Epidydmitis
Epidydmo-orchitis
funiculitis
Vastitis/differentitis
Seminal vesiculitis
Imaging orchitis epidydmitis epidydmo orchitis
IMAGING OF LOWER URINARY TRACT INFECTION LUTI
include different cases for oral radiodiagnosis examination all over the world
CT /MRI Plain X ray ultrasound TRANSRECTAL ULTRASOUND images
Cystitis
Prostatitis
urethritis
Orchitis
Epidydmitis
Epidydmo-orchitis
funiculitis
Vastitis/differentitis
Seminal vesiculitis
USMLE MSK L011 Lower 09 Anatomical regions of lower limb.pdfAHMED ASHOUR
The lower limb is divided into several anatomical regions, each with its own set of bones, muscles, nerves, and blood vessels. Understanding these regions is essential for studying the anatomy and function of the lower extremity. These anatomical regions collectively contribute to the overall structure and function of the lower limb, allowing for various movements, weight- bearing, and activities such as walking, running, and standing. Studying the anatomy of the lower limb is crucial for healthcare professionals, anatomists, and individuals in fields such as orthopedics, sports medicine, and physical therapy.
MRI TMJ temporo mandibular jiont Dr Ahmed EsawyAHMED ESAWY
Mri tmj temporo mandibular jiont dr ahmed esawy
include different cases for oral radiodiagnosis examination all over the world
CT /MRI Plain X ray images
Temporomandibular Disk
Disk Evaluation
Retrodiskal layers
Temporomandibular Joint Disk Position Assessed at Coronal MR Imaging
According to the degree of anterior disk displacment (ADD) our series was classified into 4 categories
Category 0 (Normal disc position)
Category I (Partial anterior disc displacement with reduction (PADDWR))
Category II (Partial anterior disc displacement without reduction (PADDWOR))
Category III (Complete anterior disc displacement with reduction (CADDWR))
Category IV (Complete anterior disc displacement without reduction (CADDWOR))
Disk Displacement
May be uni- or multidirectional
Unidirectional anterior and multidirectional anterolateral and anteromedial displacements are the most common type
Unidirectional transverse and posterior displacements are rare
Partial anterior disk displacement
Unidirectional complete anterior disk displacement
Posterior disc displacement
Disk Deformity
Lateral disc displacement
Recapture of Displaced Disk
LABRUM
pseudomeniscus sign,"
Degenerative (Osteoarthritis)
The cervical spine functions to provide mobility and stability to the head while connecting it to the relatively immobile thoracic spine. The movement of nodding the head takes place predominantly through flexion and extension at the joint between the atlas and the occipital bone, the atlanto-occipital joint.
USMLE RESP 05 thoracic wall anatomy medical chest .pdfAHMED ASHOUR
The thoracic wall refers to the skeletal and muscular structures that form the outer boundary of the thoracic cavity, providing protection to the organs within the chest in addition to running vessels and nerves.
The thoracic wall plays a crucial role in protecting the vital organs of the chest, including the heart and lungs. The coordinated action of the ribs, sternum, muscles, and diaphragm allows for the expansion and contraction of the thoracic cavity during respiration. The bony and muscular structures also contribute to the overall stability and integrity of the chest region.
Similar to Anal perianal imaging part 1 CT MRI anatomy Dr Ahmed Esawy (20)
Comparison between ct mri in ischemic stroke AHMED ESAWY
Comparison between ct MRI in ischemic stroke .1-Definition
2-Pathology
3-Vascular territory
4-Staging
5-hemorrhagic transformation of the infarct
Difference between simple hemorrhage and hemorrhagic neoplasm
difference between Hemorrhagic infarct and primary intracerebral hemorrhage
6-Comparison between CT/MRI
7-CTA, MRA
8-Fogging
9-Pseudonormalization
10-Protocol
11-Differential diagnosis
12-home message
All thing breast ultrasound breast mammography part 3AHMED ESAWY
All thing breast ultrasound breast mammography part 3
Breast mammogram ultrasound lipoma ,oil cyst ,galactocele intramammary lymph node in UOQ hamartoma Simple cyst (typical) calcification Surgical scar Breast implants, scirrhuc carcinoma lobular carcinoma Skin calcifications vascular calcifications Sutural Dystrophic popcorn Large Rod like rim Round/punctuate Fat necrosis Milk of calcium Fibrocystic FCC fibroadenosis Fat necrosis with oil cyst mastitis with Abscess Haematoma atypical ductal hyperplasia Intracystic papilloma ductal carcinoma in situ ,invasive ductal carcinoma BIRAD
All thing breast ultrasound breast mammography part 1AHMED ESAWY
All thing breast ultrasound breast mammography part 1
Breast mammogram ultrasound lipoma ,oil cyst ,galactocele intramammary lymph node in UOQ hamartoma Simple cyst (typical) calcification Surgical scar Breast implants, scirrhuc carcinoma lobular carcinoma Skin calcifications vascular calcifications Sutural Dystrophic popcorn Large Rod like rim Round/punctuate Fat necrosis Milk of calcium Fibrocystic FCC fibroadenosis Fat necrosis with oil cyst mastitis with Abscess Haematoma atypical ductal hyperplasia Intracystic papilloma ductal carcinoma in situ ,invasive ductal carcinoma BIRAD
Update secrets in plain x ray abdomen gases ,air fluid level .AHMED ESAWY
plain x-ray abdomen gas normal air fluid level in-the-abdomen gasless abdomen small bowel obstruction large intestinal obstruction ileus gastric dilatation extraluminal abdomen gas (pneumonpperitoneum) extraluminal abdomen gas(retropneumonpperitoneum gas in specific organs (hepatobiliary ,genitourinary) gasless abdomen ‘step-ladder apperance stretch/slit sign string of pearls sign coiled spring sign small-bowel feces sign disproportionate dilatation of sb gallstone ileus intussusception caecal volvulus sigmoid volvulus colonic pseudo obstruction ogilvie syndrome acute colitis toxic megacolon ischemic colitis sentinel loops intestinal pseudo-obstruction syndromes gastric volvulus organoaxial gastric volvulus mesenterico-axial right upper quadrant gas crescent sign: air beneath the diaphragm peri hepatic sub hepatic morrison’s pouch fissure for ligament teres doges cap sign rigler’s (double wall sign) ( both the serosal and the related mucosal walls of the bowel are delineated it means free air is at that serosal surface ) ligament visualization falciform ligament sign: air delineating the falciform ligament umbilical inverted ‘v’ sign triangular air cupola sign football sign or air dome (a large air collection beneath that does not confirm to any bowel loop) continous diaphragm sign scrotal air in children decubitus abdomen sign double bubble sign lesser sac sign peritonitis postoperative pelvic and spinal fractures
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
3. Dr Ahmed Esawy
ANAL ,PERIANAL IMAGING
(endovaginal ultrasound
endoanal ultrasound
perineal ultrasound
MRI)
FOR ANAL ,PERIANAL
DISEASE
4. Dr Ahmed Esawy
HOME MASSEGE
• ANAL ANATOMY
• ANAL PERIANAL FISTULA
• ANAL TEARS (OBSTETRIC)
• FAECAL INCONTINENCE
• OTHER DISEASES
5. Dr Ahmed Esawy
NATOMY ANORECTAL ANATOMY :
Anal Sphincter:
internal sphincter
external sphincter
Puborectalis muscle and levator ani
6. Dr Ahmed Esawy
Anatomical canal :
- extends from perineal skin to dentate line
Surgical canal :
- extends from perineal skin to anorectal ring ( 1-1.5cm abov e dentate line )
- total length 4-5 cm
7. Dr Ahmed Esawy
ANATOMY OF THE ANAL CANAL
• The surgical anal canal extends from the anal verge distally to the anorectal
ring proximally.
• The anatomical anal canal extends from the anal verge distally to the dentate
line proximally.
• The dentate line is the junction of the ectoderm and endoderm in the anal
canal.
• The muscles of the anal canal can be regarded as forming a tube within a
funnel :
-The sides of the funnel are the levator ani muscles.
- The stem of the funnel is the external anal sphincter.
- The tube inside the stem of the funnel is the internal sphincter.
8. Dr Ahmed Esawy
The total length of the surgical anal canal is about 4-5 cm.
The anal sphincter is comprised of three layers:
1-Internal sphincter: continuance of the circular smooth muscle
of the rectum, involuntary and contracted during rest, relaxes at
defecation.
2-Intersphincteric space.
3-External sphincter: voluntary striated muscle, divided in three
layers that function as one unit.
These three layers are continuous cranially with the puborectal
muscle and levator ani
9. Dr Ahmed Esawy
Schematic representation of the anal canal with the probe in situ.
Level 1, puborectalis.
Level 2,deep (proximal) external anal sphincter (EAS).
Level 3, superficial (mid) EAS.
Level 4, subcutaneous (distal) EAS.
12. Dr Ahmed Esawy
THE INTERNAL ANAL SPHINCTER
• Is a thickened continuation of the circular muscle coat of the rectum.
• The internal anal sphincter is 2.5 cm long and 2.5 mm thick.
13. Dr Ahmed Esawy
THE EXTERNAL ANAL SPHINCTER
• It was Formerly subdivided into a deep, superficial and
subcutaneous portions but now is considered to be one
muscle.
• The external sphincter muscle is composed of voluntary
muscles.
14. Dr Ahmed Esawy
THE LEVATOR ANI MUSCLE
• The anatomy of the levator ani muscle is important as it
constitutes part of the sphincter mechanism of the anal canal.
• The levator ani is a broad, thin muscle, attached to the side of
the pelvis and united medially with its fellow to form the
greater part of the floor of the pelvic cavity.
• It consists of the following parts:
The Ilio coccygeus.
The pubococcygeus.
The puborectalis.
16. Dr Ahmed Esawy
SURGICAL ANATOMY
Line diagram shows coronal-view of the anal canal
and perianal region.
17. Dr Ahmed Esawy
Diagrams of anal sphincters. Coronal (A) and axial (B) views show the IAS and
EAS and the other anal canal anatomic structures.
A indicates anal canal; and R, rectum.
18. Dr Ahmed Esawy
• Diagram shows the normal anatomy of the Anorecal region
in the coronal plane a = anal canal, IRF = ischiorectal
fossa, R = rectum (Quoted from John et al., 1999).
19. Dr Ahmed Esawy
The total length of the surgical anal canal is about 4-5 cm.
The anal sphincter is comprised of three layers:
1-Internal sphincter: continuance of the circular smooth muscle of the rectum,
involuntary and contracted during rest, relaxes at defecation.
2-Intersphincteric space.
3-External sphincter: voluntary striated muscle, divided in three layers that function as
one unit.
These three layers are continuous cranially with the puborectal muscle and levator ani
20. Dr Ahmed Esawy
The puborectal muscle is contracted at rest and accounts for the 80? angulation of
the anorectal junction. It relaxes during defecation.
21. Dr Ahmed Esawy
ENDOANAL ULTRASOUND (EUS)
• It is a simple technique that analyzes anatomy in real time.
• Peroxide-enhanced EUS was found to be a useful technique
for detection of the presence, number, types and internal
course of perianal fistulas.
22. Dr Ahmed Esawy
ANATOMY AT US
Four anatomical layers could be demonstrated on EUS:
• The Plastic Cone: produces an inner, well defined ring of high
reflectivity.
• The Submucosa : is moderately reflective.
• The Internal sphincter: a well-defined, circular, hypoechoic band.
• The External sphincter: seen as a circular ring with low or
intermediate echogenicity.
• The Intersphincteric space: round hyperechoic ring between the
hypoechoic internal & external sphincter.
23. Dr Ahmed Esawy
• The Puborectalis muscle is identified as a hypoechoic U-
shaped band at the level of the anorectal flexure.
• The appearance of the anal canal at ultrasound is dependent on
the height of the axial level being imaged.
• The lower end of the canal is identified by the loss of the
circumferential hypoechoic ring of the internal sphincter.
• The upper end of the canal is identified by the hypoechoic
horseshoe sling of the levator ani muscle posteriorly.
25. Dr Ahmed Esawy
• At the anal verge, the internal anal sphincter is typically
seen as an incomplete ring (arrows) that partially
encircles the canal.
26. Dr Ahmed Esawy
• The internal sphincter is seen as a continuous
hypoechoic ring (large arrows) that surrounds the
submucosal space (small arrows).
27. Dr Ahmed Esawy
• At the cranial end, the external sphincter muscle
becomes hypoechoic (arrow) and gives rise to the
levator ani sling above this level (arrows ).
28. Dr Ahmed Esawy
Normal appearance of the anal canal at US. Axial images of the anal canal show the normal anatomy from
the most caudal aspect of the anal verge (a) extending up to the level of the levator ani muscle (d). (a) At
the anal verge, the internal anal sphincter is typically seen as an incomplete ring (arrows) that partially
encircles the canal.
29. Dr Ahmed Esawy
Once the transducer is in the anal canal, the internal sphincter is seen as a continuous
hypoechoic ring (large arrows) that surrounds the submucosal space (small arrows). The
external anal sphincter appears as a less well-defined hyperechoic band immediately
outside the internal sphincter .
30. Dr Ahmed Esawy
At the cranial end of the anal canal, the external sphincter muscle becomes more
hypoechoic (arrow in c).
31. Dr Ahmed Esawy
The echogenicity of the internal anal sphincter increases
with age, with the replacement of smooth muscle by the
connective tissues. (Nielsen et al., 2001).
The thickness of the internal anal sphincter is measured
at the 3 O‟clock or 9 O‟clock position where the muscle
is symmetrical. The muscle thickness is age dependant,
increasing in thickness whilst become less distinct with
age. (Rottenberg & Williams, 2003 ).
In the adult; The measured thicknesses of the Internal
anal sphincter range from (0.5–3.7 mm), while for
External anal sphincter range from ( 5.8–9.8 mm).These
measurement is less in neonate: the internal anal
sphincter range from (0.8-1.9 mm), while external anal
sphincter range from (1.2-2.3 mm). ( Nielsen et al.,
2001).
32. Dr Ahmed Esawy
Transverse endoanal US image shows (a) normal sphincter complex. ES =
external sphincter, IS = internal sphincter
33. Dr Ahmed Esawy
Transverse endorectal US image shows M: mucosa SM: sub mucosa MP:
muscularis propria SS: sub serosa
34. Dr Ahmed Esawy
Transverse endoanal US scan of the anal sphincter complex shows the internal
sphincter muscle as a homogeneous hypoechoic circular band (curved arrows). 2-4 mm
The external sphincter (straight arrows) is shown with mixed echogenicity. Note that the
borders of the external sphincter are more difficult to define at endoanal US.
Between the internal and external sphincters, the intersphincteric space (arrowheads) is
depicted as a hyperechoic band. Within this band, the hypoechoic longitudinal muscle
can be identified
35. Dr Ahmed Esawy
Normal endoanal sonographic appearances of
anal sphincters at 3 different levels. A, Upper
anal canal level, identified by the horseshoe
sling of the puborectalis muscle posteriorly
(arrows) and loss of the EAS in the midline
anteriorly. The IAS is also shown by arrowheads.
B, Middle canal level, identified by the
completion of the EAS ring anteriorly (black
arrows) and maximum IAS thickness (white
arrows). C, Lower canal level, defined as that
immediately caudal to the termination of the IAS
and comprising the subcutaneous the EAS
(arrows). The anococcygeal ligament is also
shown posteriorly (arrowheads).
C
36. Dr Ahmed Esawy
Normal appearance of the anal canal at US: Axial images of the anal canal show the
normal anatomy of anal canal from the most caudal aspect of the anal verge at (a)
extending up to the level of the levator ani muscle at (d): (a) At the anal verge, the
internal anal sphincter is typically seen as an incomplete ring (arrows) that partially
encircles the canal. (b) Once the transducer is in the anal canal, the internal sphincter is
seen as a continuous hypoechoic ring (large arrows) that surrounds the submucosal
space (small arrows). The external anal sphincter appears as a less well-defined
hyperechoic band immediately outside the internal sphincter
37. Dr Ahmed Esawy
(c, d) At the cranial end of the anal canal, the external sphincter muscle
becomes more hypoechoic (arrow in c) and gives rise to the levator ani sling
above this level (arrows in d)
38. Dr Ahmed Esawy
Sphincter Muscle Thickness Measured at Endoanal Sonography, Endoanal MRI,
and Phased Array MRI
39. Dr Ahmed Esawy
Endovaginal sonography performed at the level of the bladder neck: the
intramural portion of the urethra (yellow arrow), the anal canal (red arrow) and the
pubovisceral muscle (short black arrow) are depicted.
40. Dr Ahmed Esawy
transanal scans obtained with biplane 9-MHz transducer
A, Axial image of healthy 20-year-old woman shows anterior portion of anal canal.
Internal anal sphincter (IS) is prominent hypoechoic layer. B, Long-axis view
corresponding to A shows internal sphincter (IS) in its entirety. Arrow marks
anorectal junction, where thin muscularis propria thickens and becomes more
round-appearing internal anal sphincter. There is no sphincter defect. Magnification
on two crystal arrays is never exactly same.
41. Dr Ahmed Esawy
curved transducer
A, Axial image of healthy 40-year-old woman shows prominent hypoechoic ring
of internal anal sphincter (IS). B, Rotating transducer by 90° from position in A
shows anal sphincter in longitudinal view. Anal verge is on right and anorectal
junction (arrow) on left of image.Internal anal sphincter (IS) appears as two
longitudinal substantial hypoechoic bands.
42. Dr Ahmed Esawy
anorectal junction with traditional end-fired transvaginal probe
A, Axial image of lower rectum of healthy 56-year-old woman shows prominence of
submucosa as broad echogenic layer. Muscularis propria (arrows) surrounds gut and
is thin and hypoechoic. B, At anorectal junction of same patient as in A, thin
muscularis propria thickens and becomes more roundappearing internal anal
sphincter (IS). External anal sphincter (arrowheads) appears at this level as
echogenic, rather poorly marginated sling-like structure around posterior aspect of
anal canal. There is no sphincter defect.
44. Dr Ahmed Esawy
FUNCTION OF ANAL SPHINCTER AND
PUBORECTALIS
• Puborectalis: control continence over
solid stool
• Internal sphincter: control of liquid
faeces
• External sphincter provide internal
sphincter in times of sudden need, such
as raised intra abdominal presures
• Anal cushion : the amount of blood
flowing through its arteriovenous
channels provide control over flatus
45. Dr Ahmed Esawy
(a) Endoanal scan demonstrating the „„U‟‟-shaped puborectalis muscle, which
attaches to the pubic rami anteriorly. (b) Endoanal scan demonstrating the internal
anal sphincter (white arrow) and the external anal sphincter (black arrow). (c)
Three dimensional endoanal ultrasound demonstrating the circumference/width as
well as length of the anal sphincter defect.
46. Dr Ahmed Esawy
Endoanal ultrasound of middle anal canal
demonstrating IAS ,EAS in healthy
asymptomatic female
49. Dr Ahmed Esawy
Normal perianal anatomy of 47-year-old
female volunteer imaged with CT
CT (A-C) of inner internal sphincter (+),
outer external sphincter (white dovetail
arrows), levator ani muscle (B, thick
arrows), and fat-containing ischioanal
fossa (*).
50. Dr Ahmed Esawy
Normal perianal anatomy of 45-year-old male
volunteer imaged with CT anal sphincter complex
is seen as two concentric rings. Inner internal
sphincter (+), outer external sphincter (white or
black dovetail arrows), levator ani muscle (thick
arrows), fat containing ischioanal fossa (*).
52. Dr Ahmed Esawy
Line diagram shows the normal
anatomy of the perianal region in the
axial plane
The puborectal muscle has
its origin on both sides of the
pubic symphysis, forming a
'sling' around the
anorectum.
53. Dr Ahmed Esawy
• On axial and coronal MR
images , the different
layers of anal sphincter
and the surrounding
structures can be
displayed perfectly
54. Dr Ahmed Esawy
Drawing illustrates the anal clock, which is the surgeon's view of the perianal region when the patient is
in the lithotomy position. The anterior perineum (p) is at the 12 o'clock position, and the natal cleft (n) is at
the 6 o'clock position; 3 o'clock refers to the left lateral aspect, and 9 o'clock, the right lateral aspect of the
anal canal. This schema exactly corresponds to the orientation of axial MR images of the perianal region.
55. Dr Ahmed Esawy
Normal perianal anatomy. axialT1-weighted (a)
and coronalT2-weighted (b) MR images show the normal
anatomy of the perianal region. a = anal canal, es =
external sphincter, iaf = ischioanal fossa, irf = ischiorectal
fossa, R = rectum, straight arrow in a = the levator plate.
57. Dr Ahmed Esawy
Normal perianal anatomy of 47-year-
old female volunteer imaged with MR
imaging.
Anal sphincter complex is seen as two
concentric rings. MR imaging: inner (+)
internal sphincter and outer external
sphincter (white dovetail arrows) appear
relatively hypointense on all T2-weighted
images without fat suppression (A-C).
Levator ani muscle (B, thick arrows)
forms superior boundary of fat-
containing ischioanal fossa (*) on either
side of anal canal.
58. Dr Ahmed Esawy
Normal perianal anatomy of 45-year-old
male volunteer imaged with MR
imaging.
MR imaging (T2-weighted without fat
suppression images; A-C)
anal sphincter complex is seen as two
concentric rings. Inner internal sphincter
(+), outer external sphincter (white or black
dovetail arrows), levator ani muscle (thick
arrows), fat containing ischioanal fossa (*).
61. Dr Ahmed Esawy
2D Transperineal
Functional Imaging
• Enterocele, Rectocele,
Cystocele,Mesh, Slings.
The patient position and the probe position
during transperineal scanning
62. Dr Ahmed Esawy
Describes the sample steps for performing transperineal 2D imaging using any
abdominal probe
transperineal imaging
Identify the suitable transducer
Identify the probe orientation
Press the button on the side of the probe to activate the probe
Set the depth at 6.7 cm
Set the resolution at 1/32 Hz
Place the transducer on the perineal area and obtain sagittal view of the bladder,
vagina, and the rectum (including the midsagittal view of pubic symphysis)
Adjust the gain
Ask the subject to cough or bear down to visualize the movement of anterior,
apical, and posterior compartments
Ask the subject to “squeeze vaginal muscles or perform Kegels” to visualize the
movement of the levator plate
Transperineal US
63. Dr Ahmed Esawy
This view demonstrates Incorrect positioning as the starting 2D field of view should
include pubic symphysis anteriorly and the anorectal angle posteriorly. The field of view
as demonstrated does not contain the pubic symphysis, and as such the distance from
the edge of the pubic symphysis to the edge of the levator plate that creates the
anorectal angle cannot be obtained. Depending on the patient‟s body habitus and pelvic
floor laxity, the field of view may need to be made larger
64. Dr Ahmed Esawy
This view demonstrates CORRECT positioning as the starting 2D field of view
includes the pubic symphysis (S) anteriorly and the levator plate (LP) posteriorly.
Also noted are the bladder (B), uterus (U), vagina (V), and anorectum (R)
2D Transperineal
65. Dr Ahmed Esawy
Perineal ultrasound
Axial images of the levator hiatus at rest (a), during contraction (b) and during
valsalva
manoeuvre (c). A) anal opening; U) urethra; V) vagina
66. Dr Ahmed Esawy
The appearance of the puborectalis muscle in a rendered volume in the axial
plane, using translabial 3D ultrasound with speckle reduction imaging.
The two arrows indicate the gap between urethra and puborectalis insertion
that can conveniently be palpated to determine muscle integrity
67. Dr Ahmed Esawy
(a) Transperineal scan demonstrating the puborectalis muscle. (b) Transperineal
scan demonstrating the internal anal sphincter (white arrow) and the external anal
sphincter (black arrow). Note that the external anal sphincter is circumferential at a
more distal level to the puborectalis.
68. Dr Ahmed Esawy
Transperineal US show intact EAS ,IAS,
with muscular atrophy in 75 y old female with
fecal incontinence
72. Dr Ahmed Esawy
The view of the left side of the anterior compartment:
( a ) histologic section, ( b ) drawing of the anterior
compartment structures, and ( c ) the left sagittal view
of the 3D EVUS cube with the structures marked.
BL bladder,
CU compressor urethra,
LCM longitudinal and circular layer,
P pubic bone, PCF pubocervical fascia,
SUG striated urogenital sphincter, TP trigonal plate,
TR trigonal ring, U urethra, UT uterus, V vagina,
VT vesical trigone
2D/3D Endovaginal
Anterior
Compartment Imaging
73. Dr Ahmed Esawy
The view of the left side of the posterior
compartment: ( a ) histologic section, ( b )
drawing of the posterior compartment structures,
and ( c ) the left sagittal
view of the 3D EVUS volume with the structures
marked. EAS - m external anal sphincter main
section,EAS - n external anal sphincter notch,
EAS - sq external
anal sphincter subcutaneous section, IAS
internal anal sphincter, IAS - L internal anal
sphincter length, IAS – T internal anal sphincter
thickness, R rectum, RS rectovaginal
septum, STP superfi cial transverse perinei, V
vagina.
2D/3D Endovaginal
posterior
Compartment Imaging
74. Dr Ahmed Esawy
view of the perineal area upon anal entry.
The external anal sphincter (EAS), internal anal sphincter (IAS), probe in the
anorectum (T), anal mucosa (AM),rectovaginal fascia (RVF), vaginal epithelium
(VE),urethra (U), and the vagina are marked (V)
75. Dr Ahmed Esawy
2D vaginal ultrasound visualising the anal mucosa, IAS (IS), EAS and the
ano-rectal junction. The vaginal transducer is placed in the posterior
vaginal fourchette.
A coronal section from the mid canal level (left) and a sagittal section
(right) where also rectum (R) visualise
76. Dr Ahmed Esawy
3D vaginal ultrasound acquisitions seen in a transverse section (right) and in a
sagittal section (left). VT: vaginal transducer. TPS: transversus perinei superficialis.
CTP: centrum tendineum perinei. M: Anal mucosa. IAS: internal anal sphincter.
EAS: external anal sphincter. PBR: puborectalis.
77. Dr Ahmed Esawy
(a) Endovaginal scan demonstrating the puborectalis muscle (white arrow). (b)
Endovaginal scan demonstrating the internal anal sphincter (white arrow) and the
external anal sphincter (black arrow).
78. Dr Ahmed Esawy
The perineal body (1) is hypoechogenic.
The perineal membrane (2) is anchored in the
perineal body and stretches towards the central
point (4), and is relatively hypoechogenic.
The hyperechogenic puboperineal muscles (3)
are positioned anterior to the external anal
sphincter (5).
The hypoechogenic central point (4) is located
dorsal to the vaginal introitus, gathering fibers
from the perineal membrane,
the superficial vaginal muscles, Colles‟ fascia and
the external anal sphincter.
Between the external (5) and the internal (7) anal
sphincters is the thin hyperechogenic conjoined
longitudinal muscle (6), which is interrupted by the
perineal body immediately cranial to the external
sphincter.
The rectovaginal septum (8) is seen cranial to the
perineal membrane. Inside the anal canal,
the rectal columns (9) fill the lumen of the anal
canal.
Transvaginal sagittal midline ultrasound image of the anal canal and the perineum
during pregnancy.
79. Dr Ahmed Esawy
Transvaginal sagittal midline ultrasound
image of the perineum, rectovaginal
septum and anal canal immediately after
delivery in a woman with a first-degree
perineal tear with all
perineal structures preserved. Marked
edema is seen in the perineal membrane
(2), rectovaginal septum (8) and perineal
body (1).
The fibers in the external anal sphincter
(5) are intact, but it has a different
appearance from that seen before
delivery.
3,puboperineal muscle;
4, central point;
6, conjoined longitudinal muscle;
7, internal anal sphincter;
9, rectal columns.
80. Dr Ahmed Esawy
Transvaginal semicircular transverse ultrasound image of the perineal body and
anal canal during pregnancy. The perineal membrane (2) and the puboperineal
muscle (3) meet in the midline in the perineal body (1).
5, external anal sphincter;
7, internal anal sphincter
81. Dr Ahmed Esawy
Transvaginal sagittal midline ultrasound image of the anal canal immediately after
delivery in a woman with a fourth-degree perineal tear. All structures in the perineum
including the rectovaginal septum are torn, and are missing from the image. The
following structures can be identified dorsal to the anal canal: external anal sphincter
(5), conjoined longitudinal muscle (6),internal anal sphincter (7) and puborectal
muscle (PR). Anterior to the anal canal, the cranial part of the internal anal sphincter
(7) remains intact.
9, rectal columns.
82. Dr Ahmed Esawy
4D/3D SONOGRAPHIC DESCRIPTION
OF THE SQUEEZE MECHANISM IN THE
ANAL SPHINCTER
83. Dr Ahmed Esawy
The anal squeeze mechanism in the external anal sphincter (EAS) has been
described as two (alternative three) slings with different insertions that when
contracting, pull different segments of the anal canal in anterior or posterior
directions thus closing the anal canal .
The function in the internal anal sphincter (IAS) is to maintain the resting
pressure in the anal canal and to relax, thus enabling rectal sensations and
evacuation.
The third component of the anal sphincter - the conjoined longitudinal muscle
(LM) - has not been discussed in relation to continence.
The aim of the present study was to describe the movements in the anal
sphincter during voluntary squeeze in healthy nulliparous women using a new
ultrasonographic technique.
84. Dr Ahmed Esawy
A ) At rest, the midsagittal external anal sphincter (EAS) (1) almost parallels the
perineum (5). The longitudinal muscle (LM) (2) is hypoechogeneic and the internal
anal sphincter (IAS) (3) is hyperechogeneic on transanal sonography.
B). During a contraction, the EAS (1) is elongated in a cranial direction. The IAS (3)
and the LM (2) are stretched and the walls of the IAS get thinner.
85. Dr Ahmed Esawy
C) At rest in a transverse projection the EAS (1) and the IAS (3) are hyperechogeneic
and the LM is hypoechogeneic.
D). During a squeeze the walls of the IAS (3) are compressed, while the thickness of the
LM (2) increases or remains unchanged. The EAS (1) compress the anal canal.
Vagina (5).
86. Dr Ahmed Esawy
During a squeeze of the anal sphincter complex, the EAS contracts by a
diameter reduction and by an elongation in cranial direction. The LM
moves in cranial direction along the anal canal and the walls of IAS are
compressed. Thus, the present study did not confirm the old sling theory
on anal continence
87. Dr Ahmed Esawy
translabial ultrasound of the anal sphincter using the VCI-static technique in a
patient with a IAS and EAS defect