Sonographic appearance of anal cushions of hemorrhoids

AIM To evaluate the diagnostic value of different sonographic methods in hemorrhoids.METHODSForty-two healthy volunteers and sixty-two patients with gradesⅠ-Ⅳhemorrhoids received two different sonographic examinations from January 2013 to January2016 at the First and Second Hospitals of Xinjiang Medical University in a prospective way.We analyzed the ultrasonographic findings of these participants and evaluated the outcomes.Resected gradesⅢandⅣhemorrhoid tissues were pathologically examined.The concordance of ultrasonographic results with pathologyresults was assessed with the Cohen’s kappa coefficient.RESULTS All healthy volunteers and all patients had no particular complications related to sonography.There were no statistically significant differences between the participants regarding age(P=0.5919),gender(P=0.4183),and persistent symptoms(P>0.8692).All healthy control participants had nospecial findings.However,30 patients with hemorrhoids showed blood signals around the dentate line on ultrasonography.When gradesⅠandⅡhemorrhoids were analyzed,there were no significant differences between transrectal ultrasound(TRUS),transperianal ultrasound(TPUS),and transvaginal ultrasound(TVUS)(P>0.05).GradesⅢandⅣhemorrhoids revealed blood flow with different directions which could be observed as a"mosaic pattern".In patients with gradesⅢandⅣhemorrhoids,the number of patients with"mosaic pattern"as revealed by TRUS,TPUS and TVUS was 22,12,and 4,respectively.Patients with gradesⅢandⅣdisease presented with a pathologically abnormal cushion which usually appeared as a"mosaic pattern"in TPUS and an arteriovenous fistula in pathology.Subepithelial vessels of resected gradesⅢandⅣhemorrhoid tissues were manifested by obvious structural impairment and retrograde and ruptured changes of internal elastic lamina.Some parts of the Trietz’s muscle showed hypertrophy and distortion.Arteriovenous fistulas and venous dilatation were obvious in the anal cushion of hemorhoidal tissues.After pathological results with arteriovenous fistulas were taken as the standard reference,we evaluated the compatibility between the two methods according to the Cohen’s kappa coefficiency calculation.The compatibility(Cohein kappa co-efficiency value)between"mosaic pattern"in the TPUS and arteriovenous fistula in pathology was very good(?=0.8939).When compared between different groups,TRUS presented the advantage that the mosaic pattern could be confirmed in more patients,especially for group A.There was a statistical difference when comparing group A with group B or C(P<0.05 for both).There were obvious statistical differences between group A and group B with regard to the vessel diameter and blood flow velocity measured by TRUS(P<0.05).CONCLUSION Patients with gradesⅢandⅣhemorrhoids present with a pathologically abnormal cushion which usually appears as a"mosaic pattern"in sonography,which is in accord with an arteriovenous fistula in pathology.There are clearly different hemorrhoid structures shown by sonography."Mosaic pattern"may be a parameter for surgical indication of gradesⅢandⅣhemorrhoids.