Imaging of Anal Fistula

Dr Sue Roach

Introduction
Pre-operative confirmation of fistula
complexity has been shown to facilitate
surgical planning of sphincter saving
techniques[1] and to reduce the incidence of
unidentified sepsis, which is the leading
cause of fistula recurrence [2].

Imaging Objectives
Determine relationship of fistula to
sphincter complex
Identify any secondary fistulous tracks

Imaging Modalities
Fistulography
Endoanal ultrasound
Magnetic resonance

Fistulography
Acute tracks may not have a patent lumen
Difficult to relate the track to the sphincter
and levator ani
Shown to be accurate in only 16% [3]
Helpful for chronic fistulae with an external
opening distant from the anus

Endoanal ultrasound
Operator dependent
Highly accurate at identifying the internal
opening [4]
Depicts fewer secondary extensions than
MR
Difficulty differentiating active track from
fibrosis

Magnetic Resonance
Most accurate technique for evaluation of
the primary track and any extensions [4].
More accurate predictor of patient outcome
than surgical findings at EUA[5].

Beets-Tan RGH, Beets GL, Gerritsen van der Hoop A. et al. Preoperative
MR Imaging of Anal Fistulas: Does it Really Help the Surgeon?
Radiology 2001; 218:75-84

Prospective study 56 patients

MR prior to surgery but result witheld from
surgeon until end of surgery while patient
still anaesthetised
Important additional information in 21%.
Benefit greatest in crohns (40%), recurrent
fistulas (24%), primary fistulas (8%)

Spencer JA, Chapple K, Wilson D et al. Outcome After Surgery for

Perianal Fistula: Predictive Value of MR Imaging. AJR 1998; 171:403406

Prospective study 48 patients

MR and then surgical exploration blinded to MR
MR categorised 41% complex. Surgery 38%.
Only agreed in 8 cases
19 patients required further surgery. 13 of these
considered complex on MR, 9 by surgery
MR better at predicting outcome than surgery

Gadolinium?
Post operative problems
Complex cases such as crohns disease[6]

Endoanal coil?
Endocoils give superior anatomical
resolution of fistula disease within the
sphincter
Resolution falls off rapidly outside the
sphincter
Complex tracks outside the sphincter are
not well seen

MR Technique
Phased array pelvic coil
Axial and coronal imaging of the perineum
T1 and short T1 inversion recovery (STIR)
images obtained
Additional saggital high resolution T2
images occasionally helpful
IV gadolinium rarely administered

Morris J, Spencer JA, Ambrose S. MR Imaging

Classification of Perianal Fistulas and Its implications
for Patient Management. Radiographics 2000;
20:623-635

Grade 1 Simple Intersphincteric

Fistula

Grade 2 Intersphincteric track with

secondary track or abscess

Grade 3 Trans-sphincteric Fistula

Grade 4 Trans-sphincteric Fistula

With Abscess or Secondary Track

Grade 5 Supralevator and

Translevator Disease

Aims
To establish the common MR patterns of
idiopathic peri-anal fistulation in Hope
Hospital patients.

Methods
Retrospective review
24 consecutive MR scans performed for
idiopathic anal fistulation
Scans performed on a 1 Tesla MR scanner
with phased array pelvic coil technique

Results

% of patients

Discussion
Majority (50%) of patients with idiopathic
peri-anal fistulation have uncomplicated
disease
25% have trans-sphincteric fistulae
complicated by secondary tracks or
ischiorectal abscess
Supra-levator or trans-levator disease is
relatively rare in this patient group (8%).

Grade 1- Intersphincteric fistula

Grade 2- Intersphincteric fistula with

collection

Grade 3- Trans-sphincteric fistula

Grade 4- Trans-sphincteric fistula

with secondary track

Grade 5- Translevator disease

Summary
MR is a valuable modality in the
assessment of peri-anal fistula
Accurately identifies disease complexity

References

1: Beets-Tan RGH, Beets GL, Gerritsen van der Hoop A. et al. Preoperative MR
Imaging of Anal Fistulas: Does it Really Help the Surgeon? Radiology 2001;
218:75-84
2: Bartram C, Buchanan G. Imaging anal fistula. Radiol Clin N Am 41 (2003) 443457
3: Kuijpers HC, Schulpern T. Fistulography for fistula-in-ano: is it useful? Dis
Colon Rectum 1985;28:103-4
4: Buchanan GN, Halligan S, Bartram CI et al. Clinical Examination,
Endosonography, and MR Imaging in Preoperative Assessment of Fistula in Ano:
Comparison with Outcome-based Reference Standard. Radiology 2004; 233:674681
5: Spencer JA, Chapple K, Wilson D et al. Outcome After Surgery for Perianal
Fistula: Predictive Value of MR Imaging. AJR 1998; 171:403-406
6: Horsthius K, Stoker J. MRI of perianal crohns disease. AJR 2004; 183:13091315
7: Morris J, Spencer JA, Ambrose S. MR Imaging Classification of Perianal Fistulas
and Its implications for Patient Management. Radiographics 2000; 20:623-635