Subscribe to RSS
![](/products/assets/desktop/img/oa-logo.png)
DOI: 10.1055/s-0042-1742576
Magnetic Resonance Defecography in Obstructive Defecation Syndrome: A Pictorial Review Imaging Findings and Impact on Surgical Management
- Abstract
- Introduction
- Magnetic Resonance Defecography Procedure and Imaging Technique
- Pathological Conditions
- Anterior Compartment Abnormalities
- Middle Compartment Abnormalities
- Posterior Compartment Abnormalities
- References
Abstract
Pelvic floor, a funnel-shaped muscular structure plays a significant role in bowel and bladder activities. Defecatory disorders result from the structural changes and functional disorders. Pelvic floor dysfunction affects 15% of multiparous women. It is being expected that after 30 years, there would be 45% rise in demand of pelvic floor imaging. After ruling out primary and secondary causes of constipation, diagnosis of obstructed defecation syndrome (ODS) is made. ODS is emerging as one of the important causes of constipation. As the symptoms are nonspecific and examination findings are frequently inaccurate, the clinical evaluation becomes a difficult task. Hence, various imaging modalities are becoming popular as an adjunct tool for the assessment of these disorders. Clinical management of ODS is based on the Constipation and Bowel Activity Score (CABA) and delineation of the pelvic floor anatomy. After defining the pelvic floor anatomy–based structural abnormality, day care ambulatory surgical procedure, that is, stapled transanal resection rectopexy (STARR), is offered to the patients of ODS. It provides significant relief to patients suffering from constipation and reduction in postoperative CABA score. This review discusses the role of magnetic resonance defecography imaging in ODS its impact on subsequent management.
#
Keywords
magnetic resonance defecography - obstructed defecation syndrome - constipation and bowel activity scoreIntroduction
The pelvic floor supports anterior, middle, and posterior compartments. Any disorder in any compartment leads to pelvic floor dysfunction (PFD). Posterior compartment is clinically considered an index compartment of pelvic floor. Constipation is an index symptom of posterior pelvic floor compartment and thus has become an important clinical parameter for evaluation of PFD.[1] After ruling out primary and secondary causes of constipation, diagnosis of obstructed defecation syndrome (ODS) is made. ODS is emerging as one of the important causes of constipation.[2] [3]
According to the National Institute for health and Clinical Excellence (NICE) guidelines 2010, ODS is characterized by the urge to defecate but an impaired ability to expel the focal bolus.[4]
ODS can be graded by various scoring systems, that is, the Longo Score, Wexner, and Constipation and Bowel Activity Score (CABA; [Table 1]).[3] Clinical management of ODS is based on CABA score and delineation of the pelvic floor anatomy (PFA). The rectal intussusception is detected on pelvic imaging after its suspicion on clinical examination in patients of CABA score being more than 10. After definition of PFA-based structural abnormality, surgical correction is offered to the patients of ODS. The surgical procedure, that is, stapled transanal resection rectopexy (STARR) is done after confirmation of rectal intussusceptions during examination under anesthesia.[5] It is a day-care ambulatory surgery that provides significant relief to patients suffering from constipation and reduction in postoperative CABA score.[6]
CABA score questionnaires |
|||||
---|---|---|---|---|---|
Frequency |
|||||
Symptoms |
Never |
Rarely |
Sometimes |
Usually |
Always |
Excessive straining |
0 |
1 |
2 |
3 |
4 |
Incomplete evacuation |
0 |
1 |
2 |
3 |
4 |
Use of laxatives |
0 |
1 |
2 |
3 |
4 |
Digital pressure |
0 |
1 |
2 |
3 |
4 |
Constipation |
0 |
1 |
2 |
3 |
4 |
Score_______ |
|||||
never, 0; rarely <1/month; sometimes <1/week, ≥1/month, usually <1/day, ≥1/week; always ≥1/day |
|||||
Score: >5, suspicious; >10, indicative; >15, diagnostic of ODS |
#
Magnetic Resonance Defecography Procedure and Imaging Technique
Bowel preparation is recommended 2 to 8 hours before the examination. Before imaging, patients are instructed regarding the maneuvers they will be asked to perform as a part of the procedure (squeezing, straining, and defecation), using easy to understand language/patient's vernacular language.
Finally, 150 to 200 mL of warm ultrasound jelly is instilled in the patient's rectum using rectal tube in left lateral decubitus position and patients are made to wear an adult diaper and lie down in supine position with hips and knees bent at 45 degrees.
The entire scan acquisition phase is divided into two phases which include static images of pelvic floor (high-resolution T2-weighted [W] coronal and transverse images) and dynamic phase imaging with the True Fast Imaging with Steady State Precession (FISP) in sagittal plane over 55 seconds at a frequency of one shot per 1.1 seconds (TR: 5.8 ms and TE: 2.8 ms), slice thickness: 7 mm (field of view: 270 mm × 270 mm and matrix 256 × 256) at rest, squeezing and defecating, followed by postvoiding.
Normal Anatomy of the Pelvic Floor and Imaging Findings
The pelvic floor is divided into three compartments: anterior compartment (urinary bladder and urethra), middle compartment (uterus, cervix, and vagina), and posterior compartment (includes rectum and anal canal) as shown in [Fig. 1].
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-1.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
The endopelvic fascia is a layer of connective tissue which attaches the pelvic organs to the pelvic side walls. A tear in its anterior portion results in bladder descent (cystocele) while a tear in its posterior aspect results into anterior rectocele/enterocele. Perineal body is another passive structure into which many structures insert. These include: external anal sphincter, endopelvic fascia, muscles of urogenital diaphragm (superficial and deep transverse perinei), levator ani, and puborectalis muscles.
Levator ani muscle consists of three different muscle groups: iliococcygeus, pubococcygeus, and ischiococcygeus. The pubococcygeus and ileococcygeus are horizontal sheet like structures which fan out to insert at the pelvic side wall. These are assessed well on coronal images. The puborectalis arises from the pubic bone and forms a sling around the rectum. It is easily imaged in the axial plane ([Figs. 2] and [3]).
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-2.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-3.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
The anorectal junction is the point of taper of the distal part of the rectum as it meets the anal canal ([Fig. 4]). It is the point of reference for posterior compartment descent. The anorectal angle is the angle between the posterior border of the distal part of the rectum and the central axis of the anal canal. At rest, it usually measures between 108 to 127 degrees. It changes depending on contraction or relaxation of puborectalis muscle. Normally, the angle becomes more acute during squeezing and becomes more obtuse on defecation ([Fig. 5]).
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-4.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-5.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Subsequently, few lines are drawn on the sagittal magnetic resonance (MR) resting and defecation phase images. The pubococcygeal (PC) line is drawn from the inferior border of the pubic symphysis to the last coccygeal articulation ([Fig. 6]). It represents the level of pelvic floor and is the landmark for measuring pelvic organ prolapse. PC line is reproducible and is independent of pelvic tilt. The perpendicular distances of the bladder neck, uterocervical junction, and the anorectal junction from the PC line are measured during the rest and defecation phases.
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-6.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Following these measurements, the puborectal hiatus line and M lines are measured. The H line is drawn from the inferior margin of symphysis pubis up to the posterior wall of rectum at the level of anorectal junction. It represents the anteroposterior width of the levator hiatus.
M line is a perpendicular line drawn from PC line to the most posterior aspect of the H line ([Fig. 6]). It represents the vertical descent of the levator hiatus. Normally, the H and M lines should not exceed 5 and 2 cm, respectively. Pelvic floor weakening will result in widening of the levator hiatus and descent of the levator plate resulting into elongation of the H and M lines on pelvic floor relaxation respectively ([Fig. 7]; [Table 2]).
Grade |
H line (cm) |
M line (cm) |
---|---|---|
Normal |
<6 |
0–2 |
Mild |
6–8 |
2–4 |
Moderate |
8–10 |
4–6 |
Severe |
>10 |
6–8 |
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-7.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
#
#
Pathological Conditions
Pelvic floor abnormalities have been classified topographically which involve anterior, middle or posterior compartments or their combinations. Prolapse is graded according to the rule of three: prolapse of a pelvic organ below the PC line by 3 cm is mild, between 3 to 6 cm is moderate, and more than 6 cm is severe ([Table 3]).[7]
Abnormality |
Mild (cm) |
Moderate (cm) |
Severe (cm) |
---|---|---|---|
Cystocoele: bladder neck below pubococcygeal (PC) line |
0–3 |
3–6 |
>6 |
Vaginal vault descent: posterior margin of vault below PC line |
0–3 |
3–6 |
>6 |
Rectal descent: anorectal junction below PC line |
0–3 |
3–6 |
>6 |
Peritoneocele |
0–3 |
3–6 |
>6 |
#
Anterior Compartment Abnormalities
Cystocoele: it is defined as descent of the bladder base below the PC line ([Fig. 8]). The perpendicular distance of bladder base from the PC line is measured. Normally, it should lie above the PC line. Cystocoeles are graded as mild, moderate, or severe. The repair is done by retropubic urethropexy.
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-8.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Urethral hypermobility: it indicates a loss of urethral sphincter integrity when there has been loss of urethral sphincter and fascial support. Increase of abdominal pressure leads to rotation of the urethral axis into the horizontal plane. Dynamic MR imaging can depict urethral hypermobility. It requires a pubovaginal sling procedure for repair ([Fig. 9]).
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-9.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
#
Middle Compartment Abnormalities
Vaginal vault or cervical prolapse is defined as descent of the vaginal vault or cervix below the PC line ([Fig. 10]). The degree of prolapse is graded as mild, moderate, or severe. In cases of uterine prolapse, the cervix is located abnormally low through the vagina which may thus appear shortened. If isolated organ prolapse is present, pelvic organ prolapse (POP) surgery is performed ([Fig. 11]). In case it is associated with intussusception, pelvic organ prolapse and stapled transanal resection of rectum (POPSTARR) procedure is performed which is a combination of POP surgery along with STARR procedure ([Fig. 12]).
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-10.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-11.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-12.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
#
Posterior Compartment Abnormalities
Rectocele: they can arise from anterior, posterior, or lateral walls and are measured as the depth of wall protrusion beyond the expected margin of the normal anorectal wall ([Fig. 13]).[8] They are clinically significant when the bulge exceeds 2 cm during evacuation. Rectoceles are graded as small, moderate, and large if they measure less than 2, 2 to 4, and 4 cm or more, respectively. The advantage of MR defecography is that it provides information about the size, as well as dynamics, of rectocele emptying, as well as any residual contrast retention, within the rectocele postevacuation, along with any coexistent abnormalities.[8]
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-13.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Rectal invagination and prolapse: it includes prolapse of the mucosa alone ([Fig. 14]), or a full-thickness rectal wall prolapse involving both the mucosa and muscular layer which is referred to as intussusception ([Fig. 15]). When evaluating intussusception, the distance of parietal inversion from the anal verge is assessed. Further, it is classified into intrarectal, intra-anal, or extra-anal. Extension beyond the anal verge is referred as rectal prolapse ([Fig. 16]).[9] Intussusception is classified as low-grade (rectal mucosa infolding but not entering the anal canal) and high-grade intussusceptions (full-thickness prolapse that penetrates the anal canal).[8] Simple mucosal prolapse is treated with transanal excision of the prolapsed mucosa. Rectopexy might be required for full-thickness rectal intussusception.
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-14.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-15.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-16.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Peritoneocele/enterocele: defined as herniation of the pelvic peritoneal sac into the rectogenital space, the rectovaginal septum in women, passing below the proximal one-third of the vagina. It may contain fat (referred to as peritoneocele as shown in [Fig. 17]), small bowel, or sigmoid colon (enterocele). MR imaging criteria for enterocele diagnosis include: bowel loops seen between the vagina and rectum, bowel below the PCL, rectovaginal space widening, and abnormal deepening of the cul-de-sac. Enteroceles are usually not visualized at rest phase, as a filled rectum does not provide a sufficient space for small bowel loop to descend into the pelvis.[8] These are usually seen at the end of defecation as a consequence of increased intra-abdominal pressure. Descent of small-bowel loops more than 2 cm into the rectovaginal space indicates a torn rectovaginal fascia that should be treated with culdoplasty.
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-17.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Descending perineal syndrome: it refers to a condition in which the pelvic muscles lose tone which results into excessive descent of the entire pelvic floor at rest or during evacuation. On dynamic images, perineal descent is quantified by measuring the descent of the anorectal junction from the PCL ([Fig. 18]). It is considered abnormal if the descent exceeds 2.5 cm. The H and M lines will be longer as the width of the pelvic hiatus is greater in descending perineal syndrome. This syndrome can involve not only the posterior but, frequently, the anterior and middle compartments thereby classified as uni-, bi-, or tri-compartmental.
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-18.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Spastic pelvic floor syndrome (also referred as pelvic floor uncoordination or anismus) is a functional abnormality that affects some constipated patients who experience evacuation failure associated with involuntary, inappropriate, and paradoxical contraction of striated pelvic floor musculature ([Fig. 19]). Its etiology is unclear and can include both abnormal muscle activity and psychologic or cognitive factors.
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-19.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
The impact of MR imaging findings on the management has been depicted in a flow chart in [Fig. 20].
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-20.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
#
#
Conflict of Interest
None declared.
-
References
- 1 Agarwal BB, Chintamani C, Mahajan K. Pelvic floor dysfunction: reinventing the spokes of the wheel. JIMSA 2012; 25: 13
- 2 Agarwal BB, Chintamani C, Mahajan K. Derriere distress-defecation-defication. JIMSA 2013; 26: 155
- 3 Sharma S, Agarwal B. Scoring system in evaluation of constipation and ODS. JIMSA 2012; 25: 57-59
- 4 National Institute for Clinical Excellence.. Interventional Procedures Programme: interventional procedures overview of double stapled transanal rectal resection procedure for obstructed defaecation syndrome. Accessed January 11, 2021 at: https://www.nice.org.uk/guidance/ipg351/evidence/overview-315775549
- 5 Dindo D, Weishaupt D, Lehmann K, Hetzer FH, Clavien PA, Hahnloser D. Clinical and morphologic correlation after stapled transanal rectal resection for obstructed defecation syndrome. Dis Colon Rectum 2008; 51 (12) 1768-1774
- 6 Agarwal BB, Manish K, Pandey H, Doda R, Agarwal V, Saxena KK. Stapled transanal rectal resection (STARR): results of the first Asian experience. The Gangaram Journal. 2011; 1: 118-122
- 7 Kelvin FM, Maglinte DD, Hale DS, Benson JT. Female pelvic organ prolapse: a comparison of triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctography. AJR Am J Roentgenol 2000; 174 (01) 81-88
- 8 Colaiacomo MC, Masselli G, Polettini E. et al. Dynamic MR imaging of the pelvic floor: a pictorial review. Radiographics 2009; 29 (03) e35
- 9 Thapar RB, Patankar RV, Kamat RD, Thapar RR, Chemburkar V. MR defecography for obstructed defecation syndrome. Indian J Radiol Imaging 2015; 25 (01) 25-30
Address for correspondence
Publication History
Article published online:
19 September 2023
© 2022. Indographics. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
-
References
- 1 Agarwal BB, Chintamani C, Mahajan K. Pelvic floor dysfunction: reinventing the spokes of the wheel. JIMSA 2012; 25: 13
- 2 Agarwal BB, Chintamani C, Mahajan K. Derriere distress-defecation-defication. JIMSA 2013; 26: 155
- 3 Sharma S, Agarwal B. Scoring system in evaluation of constipation and ODS. JIMSA 2012; 25: 57-59
- 4 National Institute for Clinical Excellence.. Interventional Procedures Programme: interventional procedures overview of double stapled transanal rectal resection procedure for obstructed defaecation syndrome. Accessed January 11, 2021 at: https://www.nice.org.uk/guidance/ipg351/evidence/overview-315775549
- 5 Dindo D, Weishaupt D, Lehmann K, Hetzer FH, Clavien PA, Hahnloser D. Clinical and morphologic correlation after stapled transanal rectal resection for obstructed defecation syndrome. Dis Colon Rectum 2008; 51 (12) 1768-1774
- 6 Agarwal BB, Manish K, Pandey H, Doda R, Agarwal V, Saxena KK. Stapled transanal rectal resection (STARR): results of the first Asian experience. The Gangaram Journal. 2011; 1: 118-122
- 7 Kelvin FM, Maglinte DD, Hale DS, Benson JT. Female pelvic organ prolapse: a comparison of triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctography. AJR Am J Roentgenol 2000; 174 (01) 81-88
- 8 Colaiacomo MC, Masselli G, Polettini E. et al. Dynamic MR imaging of the pelvic floor: a pictorial review. Radiographics 2009; 29 (03) e35
- 9 Thapar RB, Patankar RV, Kamat RD, Thapar RR, Chemburkar V. MR defecography for obstructed defecation syndrome. Indian J Radiol Imaging 2015; 25 (01) 25-30
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-1.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-2.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-3.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-4.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-5.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-6.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-7.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-8.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-9.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-10.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-11.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-12.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-13.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-14.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-15.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-16.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-17.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-18.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-19.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/10.1055-s-00058257/202201/thumbnails/10-1055-s-0042-1742576-i0006-20.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)