ABSTRACT SUBMISSION FORM

Abstract submission deadline :

ABSTRACT TITLE:
A LOCAL CASE OF MRI-DIAGNOSED HORSESHOE PERIANAL FISTULA IN A 38 YEAR OLD
MALE

Presenting Author

Title  Prof  DrX Mr Ms

Last Name CAHANAP First Name & MARY KATHRINA V.

Initials

Department DDIRS

Telephone 09293629521 Facsimile

E-mail Cahanapkay22@gmail.com

Co-Author(s)

Last Name First Name & Initials

Last Name First Name & Initials

Last Name First Name & Initials

Last Name First Name & Initials

Abstract Format for Case Report

A LOCAL CASE OF MRI-DIAGNOSED HORSESHOE PERIANAL FISTULA IN A 38 YEAR OLD

MALE

CASE REPORT (200-250 words)

BACKGROUND/RARITY OF THE CASE

Perianal fistula is a heterogenous disease entity resulting from inflammation secondary to
inflammatory bowel disease, sequelae of perianal abscess, or other conditions such as anal or rectal cancer
and trauma. As a complex disorder, it is associated with significant morbidity and challenging treatment.
The incidence of perianal fistula ranges from approximately 1 to 2 per 10,000 individuals with an
approximate 2:1 male to female predominance1-3. Until recently, radiologic imaging modalities played a
limited role in evaluating perianal fistula. With the advent of MR imaging, clinicians can be provided with
more precise information on the anatomy of the anal canal, the anal sphincter complex, and the
relationships of the fistula to the pelvic floor structures and the plane of the levatorani muscle4. It also
helps in the identification of secondary extensions, particularly horseshoe tracts and abscesses resulting in
complete evaluation and highest possible diagnostic accuracy aiding successful surgical interventions,
aiming to reduce complications and recurrences5.

DIAGNOSTICS:
Fistulogram was performed as seen which revealed opacification of a tract which bifurcates into
two other separate tracts.
MR imaging of the pelvis was also done as shown in Figure 2. The result revealed a
transsphincteric fistula at the 6 o'clock position with the anal opening about 2.1 cm above the anal verge
with two tracts extending posteriorly into external openings, one on each side. The result was signed-out as
horseshoe perianal fistula.

INTERVENTION/OUTCOME:
The management of most fistulas requires surgical intervention and its success necessitate accurate
pre-operative assessment of the course of the primary fistulous track and the site of any secondary
extension or abscesses7. The lack of accurate pre-operative is associated with a significant prevalence of
recurrence rate ranging between 7% to 50% tomography and endoanal ultrasound imaging.
CONCLUSION/SIGNIFICANCE:
In patients presenting with fistula in ano, MRI is a useful technique for successful management. It
has the ability to provide information about the fistula with great anatomic detail with respect to secondary
tracks and abscesses as well as the surrounding pelvic organs aiming to reduce complications and
recurrences.

KEYWORDS: (at least 3, using terms from the Medical Subject Headings or MeSH list)
Fistula in-ano, horsehoe perianal fistula, MRI diagnosed case fistula

POSTER LAYOUT FOR CASE REPORT AND ANALYTICAL STUDIES

 CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL

TITLE: A LOCAL CASE OF MRI-DIAGNOSED HORSESHOE PERIANAL FISTULA IN A 38 YEAR OLD

MALE

AUTHOR/S: CAHANAP, MARY KATHRINA VALENCIA

ABSTRACT:

Perianal fistula is a complex disease with significant patient morbidity and challenging treatment.
As a heterogenous clinical entity, it requires multiple surgical techniques for management. Therefore, it is
necessary to have precise radiologic information about the location of the fistulous track to adopt the best
surgical strategy and avoid recurrences. Currently, magnetic resonance (MR) imaging is the technique of
choice for preoperative evaluation of perianal fistulas to improve patient outcome.
This is a case report of a 38 year old male who presented with a recurrent fistulous opening at
the left buttocks and right proximal thigh after a local surgery for perianal fistula. MR imaging was
performed and revealed horseshoe perianal fistula.

FULL TEXT:
A LOCAL CASE OF MRI-DIAGNOSED HORSESHOE PERIANAL FISTULA IN A 38 YEAR OLD
MALE

A Case Report
Submitted to the Department of Diagnostic Imaging and Radiologic Sciences,
Corazon LocsinMontelibano Memorial Regional Hospital

By
Mary Kathrina V. Cahanap, MD
First Year, Radiology Resident
cahanapkay22@gmail.com
09293629521
ABSTRACT

Perianal fistula is a complex disease with significant patient morbidity and challenging treatment.
As a heterogenous clinical entity, it requires multiple surgical techniques for management. Therefore, it is
necessary to have precise radiologic information about the location of the fistulous track to adopt the best
surgical strategy and avoid recurrences. Currently, magnetic resonance (MR) imaging is the technique of
choice for preoperative evaluation of perianal fistulas to improve patient outcome.
This is a case report of a 38 year old male who presented with a recurrent fistulous opening at the
left buttocks and right proximal thigh after a local surgery for perianal fistula. MR imaging was performed
and revealed horseshoe perianal fistula.

\
INTRODUCTION
Perianal fistula is a heterogenous disease entity resulting from inflammation secondary to
inflammatory bowel disease, sequelae of perianal abscess, or other conditions such as anal or rectal cancer
and trauma. As a complex disorder, it is associated with significant morbidity and challenging treatment.
The incidence of perianal fistula ranges from approximately 1 to 2 per 10,000 individuals with an
approximate 2:1 male to female predominance1-3. Until recently, radiologic imaging modalities played a
limited role in evaluating perianal fistula. With the advent of MR imaging, clinicians can be provided with
more precise information on the anatomy of the anal canal, the anal sphincter complex, and the
relationships of the fistula to the pelvic floor structures and the plane of the levatorani muscle4. It also
helps in the identification of secondary extensions, particularly horseshoe tracts and abscesses resulting in
complete evaluation and highest possible diagnostic accuracy aiding successful surgical interventions,
aiming to reduce complications and recurrences5.

CASE REPORT
A thirty eight year old male presented with recurrent perianal fistula. He reported a four-year
history of perianal pain due to perianal abscess in his right medial thigh and fistula in ano which were not
responsive to culture-guided antibiotic regimen. Due to persistence of symptoms, surgical management
through fistulotomy was done two years prior.
With the current presentation, patient reported fistulous opening at the right buttocks and right
proximal thigh associated with foul smelling discharges. He was referred to our institution and managed as
a case of recurrent fistula in ano.
Fistulogram was performed as seen in Figure 1 which revealed opacification of a tract which
bifurcates into two other separate tracts.
Figure 1- A Figure 2- B

Figure 1.Fistulogram dated

02/22/2019. (A) Scout image reveals
locules of air along the medial aspect
of right proximal thigh. (B)Subsequent
introduction of contrast material shows
opacification of a tract which bifurcates
into two other separated tracts. (C-red
arrow) The first tract is a blind-ended
tract directed postero-superiorly in the
left buttock up to the level of S5 while
Figure 3- C the other tract(blue arrow) is directed
anteriorly crossing the midline and
inferiorly towards the medial aspect of
the right proximal thigh. Further
introduction of the contrast shows
continuity above tract with the
anorectal region.

MR imaging of the pelvis was also done as shown in Figure 2. The result revealed a
transsphincteric fistula at the 6 o'clock position with the anal opening about 2.1 cm above the anal verge
with two tracts extending posteriorly into external openings, one on each side. The result was signed-out as
horseshoe perianal fistula.
 FIGURE 2-A FIGURE 2 B
1 1

FIGURE 2 D
FIGURE 2 C
1
1

Figure 2.Magnetic resonance imaging report of the patient's pelvis

taken 03/14/2019.Multiplanar and multisequence images of the
pelvis were obtained without intravenous contrast. (figure 2 B) The
fistula was injected with sterile KY jelly. (figure 2 C) Result reveals
a transsphincteric fistula at the 6 o'clock position with the anal
opening about 2.1 cm above the anal verge (green arrow). There
are two tracts extending posteriorly into external openings, one on
each side. The opening in the in the left is located in the medial
gluteal region (Figure 2 C – orange arrow) while the opening in
the right along the posteromedial aspect of the right proximal thigh
just below the gluteal region (Figure 2 D - red arrow). The result
was signed-out as horseshoe perianal fistula.

DISCUSSION
Horseshoe-shaped perianal fistulas do not occur often. According to a 15-year observational study,
it has an incidence of 2%, mostly developing from a cryptoglandular infection and the common region of
development is at 6 o'clock position6. This is consistent with this patient who presented previously with a
perianal abscess and the recent MR imaging revealed a horseshoe fistula at the6 o'clock position with the
anal opening about 2.1 cm above the anal verge.
The management of most fistulas requires surgical intervention and its success necessitate accurate
pre-operative assessment of the course of the primary fistulous track and the site of any secondary
extension or abscesses7. The lack of accurate pre-operative is associated with a significant prevalence of
16-18
recurrence rate ranging between 7% to 50% .Despite limited early use, various imaging methods and
modalities have been developed in diagnosing evaluating perianal fistula, including traditional
fistulography, computed tomography and endoanal ultrasound imaging8.
Although imaging techniques played a limited role in evaluation of perianal fistulas in the past, it is
now increasingly recognized that imaging techniques, especially magnetic resonance imaging, play a
crucial role4. MR imaging allows identification of infected tracks and abscesses that would otherwise
remain undetected. Furthermore, radiologists can provide detailed anatomic descriptions of the relationship
between the fistula and the anal sphincter complex, thereby allowing surgeons to choose the best surgical
treatment, such as the ligation of the intersphincteric fistula tract (LIFT), significantly reducing recurrence
of the disease or possible secondary effects of surgery, such as fecal incontinence9-10.
In the case presented, the diagnosis of horseshoe fistula was not established without an MR
imaging. The advantages of MR imaging include multiplanar imaging and a high degree of soft-tissue
differentiation, which show the fistulous track in relation to the underlying anatomy in a projection relevant
to surgical exploration11. The use of MRI for the identification and classification of perianal fistulae can
provide essential information that has been shown to have both preoperative and prognostic value. Correct
identification of perianal fistulae and an appreciation for common management approaches are useful for
effective radiological-surgical communication12.

CONCLUSION
In patients presenting with fistula in ano, MRI is a useful technique for successful management. It
has the ability to provide information about the fistula with great anatomic detail with respect to secondary
tracks and abscesses as well as the surrounding pelvic organs aiming to reduce complications and
recurrences.
REFERENCES
1. Zanotti, C., et al. (2007). An assessment of the incidence of fistula-in-ano in four countries of the
European Union. International Journal of Colorectal Disease, 22(12):1459-1462.
2. Sainio, P. (1984). Fistula-in-ano in a defined population: incidence and epidemiological aspects.
AnnalesChirurgiaeetGynaecologiae, 73(4): 219-224.
3. Morris, J., Spencer J.A., & Ambrose, N.S. (2000). MR imaging classification of perianal fistulas
and its implications for patient management. Radiographics, 20(2): 623-635.
4. Criado, J.M., et al. (2011). MR imaging evaluation of perianal fistulas: spectrum of imaging
features. Radiographics, 32(1).
5. Daabis, N., et al. (2004). Magnetic resonance imaging evaluation of perianal fistula. The Egyptian
Journal of Radiology, 44(4): 705–711.
6. Koehler, A., Risse-Schaaf, A., &Athanasiadis, S. (2004). Treatment for horseshoe fistulas-in-ano
with primary closure of the internal fistula opening: a clinical and manometric study. Diseases of
the Colon & Rectum, 47(11): 1874–1882.
7. Seow-Choen , Phillips RK (1991). Insights gained from the management of problematical anal
fistulae at St. Mark's Hospital, 1984-88. Br J Surg, 78(5): 539–541.
8. Halligan, S. & Stoker, J. (2006). Imaging of fistula in ano. Radiology, 239(1): 18–33.
9. Beckingham, I.J., et al. (1996). Prospective evaluation of dynamic contrast enhanced magnetic
resonance imaging in the evaluation of fistula in ano. Br J Surg, 83(10): 1396–1398.
10. Buchanan, G., et al. (2002). Effect of mri on clinical outcome of recurrent fistula-in-ano. Lancet,
360(9346): 1661–1662.
11. Bartram, C. & Buchanan, G. (2003). Imaging anal fistula. RadiolClin North Am, 41(2): 443–457.
12. Gage, K., et al. (2013). MRI of perianal fistulas: bridging the radiologic-surgical divide. Abdom
Imaging, 38(5): 1033–1042.
Your department’s logo
may be placed at the
bottom right corner of
the poster