4th Yogyakarta Digestive Week

2018

Fistula in Ano :
Imaging Challenge
Bambang P Utomo

1
 Outline
• Background
• Theory, diagnosis and ordering examination
• Classification
• Modalities availability, advantage and paucity
• X-Ray Fistulography
• Endoanal Ultrasonography
• MR Imaging
• CT Imaging
 Background
• High effort to visualized narrow structure and it’s
circumstance

• Modalities imaging validity and it’s sensitivities

and spesifitivies

• Communication between radiologists and

surgeons

• Reporting format assessment of preperioperative

imaging fistulography
Theory
 Definition and Symptom
• Definition :
Is the presence chronic granulation track, connects
the epithelial lining of the anus or rectum and the
perianal skin

• Symptom
1. Discharge which soils the under clothes.
2. Irritation and itching of the skin around the anus.
3. Anal discomfort.
 What are radiologist looking
for?
What classification is the fistula?

Where is it?

Where is the internal opening?

Are there any extensions?

Is there an/ any abcess?

 Fenomena
Who is ordering fistulography ?
1. General practitioner
2. Internist
3. General surgeon
4. Digestive surgeon

Some of patient with no inspection assessment

Lack of ordering with EAUS, CT Scan and MRI

 Modalities Decision

• X-Ray fistulography: Very low validity, approx 16 %

• MRI : Sensitivity 0.9 Specificity 0.6

• EAUS : Sensitivity 0.9 Specificity 0.4

• CT-Scan : Sensitivity ? Specificity ?

X-Ray Contras Fistulography
• Earliest primary method
• Acute tracks may not have a patent lumen
• Can’t through by plug/ debris in the fistulas tract
• Failure to asses relationship between fistula and the sphincter
complex
• Difficult
to decide whether an extension has a supra or an
infralevator location
• Often impossible the exact level of the internal opening
• Fail to know the integrity of the sphincters
X-Ray Fistulography

Dr. Ahmed Easy

 X-Ray Fistulography

Useful if extra
sphincteric fistula
suspected

Dr. Ahmed Easy

Endoanal Ultrasonography(EAUS)
with H2O2
• Beneficial in detecting the course of primary tract.
• Cost effective and superior in diagnosing trans-sphincteric
fistula
• Detect the site & number of internal opening
• Comparing MRI has certain advantages: cheap, simple,
quick and portable, can be performed in the operating
room.
• High enough reliability to be considered the study of
complex anal fistula.
 Fistula classification based on
ultrasonography
Submucosal
Subcutaneous

Intersphincteric

Low transsphincteric

Medium transsphincteric

High transsphincteric

Suprasphichteric

Extrasphincteric
EAUS level low anal canal
Subcutaneous EAS

External anal sphincter/ subcuteus

Anococcygeal ligament
EAUS level medial anal canal
IAS & EAS

IAS darker homogenous ring

EAS white heterogeneous ring around IAS

EAUS level high anal canal
puborectalis muscle

Female

Man
Simple transsphincteric fistula

Man
Transsphincteric fistula with
abcess
Extrasphincteric fistula with
abcess
Vertical submucosal and
intersphinteric extension
 MR Imaging
Provide more information anatomy of the anal
canal, anal spinchter complex and the relationship
of the fistula to pelvic floor structures.

The ability to demonstrate hidden areas of sepsis

and secondary extensions
Type of perianal fistula and degree of involvement
of surrounding pelvic structure are individualised
 MRI Classification Perianal
Fistula in Ano
• Any anatomic system of classification of
perianal fistulas must be based on the
relationship between the primary track and the
anal spinchter complex and puborectal muscle

• St James’s Hospital, related Park surgical

classification to anatomic MR imaging findings
in axial and coronal planes (proposed by
radiologist), a MRI descriptive and accurate
finding reports based.
 Grade 1. Simple linier
interspincteric fistula, axial plane

radiographics.rsna.org2012
Grade1. Simple linier interspincteric
fistula, coronal plane

radiographics.rsna.org2012
Grade 2. Interspincteric fistula
with abcess, axial plane

radiographics.rsna.org2012
Grade III. Transsphincteric
fistula, coronal plane

radiographics.rsna.org2012
Grade III. Transsphincteric
fistula, coronal plane

radiographics.rsna.org2012
 Grade IV. Transsphincteric
fistula with abcess, axial plane

radiographics.rsna.org2012
Grade IV. Transsphincteric fistula
with abcess, coronal plane

radiographics.rsna.org2012
Grade V. Supralevator and translevator
disease with fistula, coronal plane

radiographics.rsna.org2012
Horseshoe abcess, axial and
coronal plane

radiographics.rsna.org2012
 CT Scan Imaging

• Now still poor resolution of softisue for small/

micro complex structure.

• Developing the technique and post-processing

software.
radiographics.rsna.org2012
Terima Kasih