227

Prone
View:

Cross-Table
An Alternative

Invertogram

American Journal of Roentgenology 1983.140:227-229.

K. L. Narasimharao1
G. R. Prasad1
S. Katariya2
K. Yadav1
S. K. Mitra1
I. C. Pathak1

Lateral
to the

in Imperforate

Anus

The prone cross-table

lateral radiograph
provides
equal or sometimes
better information, compared
to the invertogram,
for demonstration
of the level of rectal atresia in
neonates.
Easy positioning,
better cooperation
of the patient, elimination
of the effect
of gravity, and better delineation
of the rectal gas shadow are the advantages
of the
prone lateral view. Among the 45 cases compared,
equal findings were noted in 37, but
in eight babies the level of rectal atresia was more caudal in the prone radiograph
than
in the invertogram.

In the
togram,
The

radiologic
first

evaluation

described

precautions

in the

of the

neonates

by Wangensteen

and

technique

and

the

with
Rice

[1

pitfalls

imperforate

anus,

],

the

has

stood

in its interpretation

the
test

inverof time.

have

been

well documented
[2, 3]. Since
the rectum
is the highest
part of the bowel
in the
prone
position
[4], the evaluation
of the rectal
gas shadow
in a prone
cross-table
lateral
view should
help in distinguishing
the supralevator
from the translevator
lesions.
Our study was conducted
to test this hypothesis
the prone lateral
radiograph,
which
has certain
advantages
invertogram,

can

Subjects
Our

and

replace

study

to the

Education

and

Research,

radiologically

with

views

(figs.

obtained

consisted

Department

1 B and
from

latter

in the

diagnosis

to consider
whether
over the conventional

of anorectal

malformations.

Methods

prospective

admitted
ated

the

and

the

of 45 consecutive

of Pediatric

Surgery

Chandigarh

(India),

invertograms

2B),

(figs.

obtained

parents.

We

from
1 A and

simultaneously
did

not

use

neonates

of the

1 981

2A)

also

prone

and

patient.

markers

of

imperforate
Institute

January
in each

skin

with

Postgraduate
The

babies

type.

were

cross-table

Informed

any

anus,

of Medical
evalulateral

consent
The

well

was
known

precautions
of allowing
enough time after birth for the air to reach
the inverted
position
were followed
routinely
for the invertograms.
face down with their hips flexed and were kept in this genupectoral
obtaining

the

prone

lateral

like in the invertogram.

The

films

the rectal

Received
June 28, 1982:
sion September
14. 1982.

accepted

after

revi-

Department
of Pediatric
Surgery,
Postgraduate Institute
of Medical Education
and Research,
Chandigarh
160 012, India. Address
reprint
requests to I. C. Pathak.
2 Department
of Radiodiagnosis,
Postgraduate
Institute
Chandigarh

of

Medical
160 012,

Education

AJR 140:227-229,
February
0361 -803X/83/1402-0227
American

Roentgen

and

India.

Ray

1983
$00.00
Society

Research,

were

radiographs

Pressure

reviewed

which

were

over the abdomen

in a blind

fashion

the rectum and 3 mm in

The babies were held
position for 3 mm for
centered
over the greater
trochanters
was avoided during this procedure.

by a consultant

radiologist,

and

the

level

of

gas shadow

was evaluated
according
to the bony landmarks
of the pubococcygeal
line and the ischial
point [2]. The distance
of the rectal gas shadow from the pubococcygeal
line was also measured.
In high and intermediate
anomalies,
the ultimate proof of the level
of the rectal gas shadow was the barium examination
of the distal loop of the colon, after
the neonatal
colostomy.

Results
In terms
interpretation
intermediate

of high,
intermediate,
and low
of the level of rectal
atresia
in 18,

and

low

anomaly

types,
in 43

in four).

there
was no difference
sets of radiographs
(high

Two

other

cases

were

in the
in 21,

interpreted

NARASIMHARAO

228

ET

AL.

AJR:140

February

1983

Fig. 1 -A,
Invertogram.
Rectal gas
shadow
at the pubococcygeal
line (high
anomaly).
B, Prone cross-table
lateral
view of same case shows level of gas
shadow
between
pubococcygeal
line
and ischial line (intermediate
anomaly).

American Journal of Roentgenology 1983.140:227-229.

Fig. 2.-A.
tal anomaly.
ischial
line.
shows
low
shadow
is 4
invertogram.

as high
mediate
When

and intermediate
on the invertogram,
but as interand low, respectively,
on the prone
lateral
films.
the measurements
were made on the radiographs

in relation
of the
view,

to the pubococcygeal
rectal

gas

in none

of

shadow
the

line to judge
in the

patients

prone

was

the termination

cross-table

it more

lateral

cephalic

than

shown
in the invertogram.
On the contrary,
the gas shadow
on the prone lateral
view was more caudal
(1-4
mm) in eight
of the 45 cases.
The most impressive
difference
was in the delineation
of
the

rectum.

In 15 of 45

cases,

the

rectum

was

more

dis-

tended,
giving
better
delineation
of the gas shadow
in the
prone
lateral
films,
compared
to the inverted
radiographs.
Nine of these
15 babies
had clinically
evident
rectourinary
communication
per

urethra

as indicated
before

by

the

passage

of meconium

decompression.

above
the levator
ani and those
in which
it extends
below
this level is of paramount
importance
in planning
the type of
surgical

treatment.

in accordance
cygeal
line,
the

level

obtained
instead
found
1.
and

of

In the

management
between

of neonates

with

the lesions

in which

imperforate
the rectum

anus,
ends

evaluation

is the most

the

anomaly.

in the prone
The positioning
genupectoral

of the

useful
The

compared

hence

causes

position

deceptive

contraction
obliteration

in deriving

information

can

in the prone,
easier
required

togram
with splints
and adhesive
tapes.
This
advantage
over the traditional
invertogram.
2. Most of the time, the baby keeps
crying
which

shadow

be

lateral
view
radiograph
are certain
advantages
we

is much

to the

gas

like the pubococ line

of Cremin
[5]

investigation

same

lateral
position:
of the patient
position

rectal

landmarks,
and the M

by a prone
cross-table
of an invertogram.
There

consuming,

and

the distinction

The

with the bony

the ischial
point,

on an invertogram

tography
Discussion

Invertogram.
Low anorecRectal gas shadow distal to
B, Prone lateral view also
anomaly,
but level of gas
mm caudal to that shown in

hips-flexed

and

less

is the
during

of the puborectalis
of the

lower

time

for an inver-

rectum,

major
inversling
re-

sulting
in fallacious
assessment
of the type of malformation
[2]. The babies
are usually
calm and relaxed
in the genupectoral
position,
and the full extent
of the rectal gas shadow

AJR:140

February

PRONE

1983

LATERAL

VIEW

OF

IMPERFORATE

ANUS

229

American Journal of Roentgenology 1983.140:227-229.

Fig. 3.-A,
Invertogram.
Poorly delineated rectal gas shadow.
This baby had
clinically
evident
rectourethral
fistula
and high anomaly.
B, Prone lateral view
better delineates
rectal gas shadow than
inverted
radiograph.

would
be shown
of the rectal
gas
our

cases
3. The
to gravity

on the
shadow

radiograph.
The better
appearance
in the prone
lateral
view in some

of

may be due to this factor.

rectum
may be pulled
in a cephalic
direction
due
in the inverted
position,
depicting
a higher
level of

gas shadow
in relation
to the bony landmarks
(Rhoads
cited
in [2]). This is avoided
in a prone
lateral
position.
4. In those
anomalies
where
there
is a fistula
with the
urinary
of the
resulting

or genital
tract,
this fistula
becomes
the highest
part
rectum
in an invertogram
and gas
may escape,
in less distension
of the rectum
[3]. In the prone

lateral

position,

the

chances
for better
better
delineation
supported
rectourinary
rectal
gas

fistula

is

lowest

in position

and

the

distension
of the rectum
are high, causing
of the rectal
gas shadow
(fig. 3). This is

by

the fact that nine of the babies

with evident
communication
have shown
better
delineated
shadow
in the prone
lateral
film.

Our results
indicate
that in about
1 8#{176}/o
(8/45)
of cases,
the level of the rectal
gas shadow
was 1-4 mm lower on the
prone
lateral
view than on the invertogram.
In our series,
the therapeutic
anomaly

appeared

decisions

were

intermediate

altered

in only

one

on the invertogram

case:

The

and

was

to be managed
on the prone

with
lateral

This

is proof

types

certainly

a colostomy,
but
film so anoplasty
of

of radiographs

at

least

the

the

anomaly
was done

equal

for day-to-day

value

practice

was low
instead.
of

and

the

the

two

occa-

sional
superiority
of the prone
film.
We recommend
the
routine
use of the prone
cross-table
lateral
view
in the
evaluation
of the babies
with imperforate
anus,
because
it
provides
equivalent
or sometimes
better
information
than an
invertog
ram.

REFERENCES
1.

Wangensteen

OH,

determining

the

2. Stephens
Chicago:

FD, Smith
Year

Book

3.

Gordon

IRS,

4.

London:
Berdon

Butterworths,
WE,
Baker

positioning
5.

Ross

studies

in infants
BJ.
Clin

CO.

The

Radio!

Imperforate

approach.

Ann

ED. Anorectal
Medical,

FGM.

and

a method

1930:92:77-81

malformations

Diagnostic

in children.

radiology

1977
OH,
Leonidas
and

children.

radiological

anus:
Surg

1971

in gastrointestinal

Cremin
lies.

Rice

surgical

J.

pediatrics.
of

prone

roentgenologic

1968:103:444-455

assessment

1971 :22:239-244

Advantages

genitourinary

AJR

in

of anorectal

anoma-

of