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We have a dedicated site for Germany. This practical volume is intended for all radiologists, gastroenterologists, and surgeons who are responsible for, or interested in, the diagnosis and care of patients with diseases of the anal and perianal region. Physical and surgical examination is carefully discussed, with consideration of limitations, results, clinical needs, and the questions likely to be posed of imaging. The subsequent three sections provide detailed information on the different imaging modalities: transanal and transperineal ultrasound, contrast-enhanced MRI, and CT.
Covers all imaging procedures for the investigation of perianal inflammatory diseases Provides detailed practical information relevant to diagnosis and management Proposes a diagnostic algorithm with integration of the different imaging modalities Written by radiologists, surgeons, and gastroenterologists with a multidisciplinary perspective see more benefits. Hyperechoic foci correspond to air bubbles arrows. Intravenous injection of gadolinium was administered at the discretion of the radiologist.
The EUA was conducted in the operating room, with the patient in lithotomy position and under spinal anesthesia. The surgeon was initially blinded to the MRI and EU results, and assessed the anatomy of the fistula with the aid of a stylet. After the complete evaluation of the fistulous trajectory, the findings of MRI and EU were informed to the surgeon before the surgical treatment was performed. For the three examination modalities, the fistulous trajectory was classified according to the Parks 13 and the American Gastroenterological Association AGA classifications 5.
Parks's classification distinguishes fistulas in five types: superficial, intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. The AGA classification distinguishes fistulas in "simple" and "complex".
The simple one is defined as low superficial, intersphincteric or transsphincteric , has a single external orifice, and no perianal complications. The complex fistula, on its turn, is high intersphincteric, transsphincteric, extrasphincteric or suprasphincteric and may present several external orifices or be associated with perianal abscess, anal stricture, proctitis or communication with the vagina or bladder.
Secondary pathways, rectovaginal fistula and presence of proctitis have also been reported. For statistical analysis, we described the number of perianal fistulae identified in terms of frequency and percentage. For each two exams, we considered the null hypothesis as zero Kappa coefficient absence of agreement. We used the Friedman's non-parametric test to compare the number of fistulous trajectories identified in each exam.
We excluded one patient because of anal stenosis that prevented the introduction of the EU transducer.
Evaluation of Perianal Fistulas in Patients With Crohn's Disease
Patients had a diagnosis of Crohn's disease between one and 28 years mean All patients were on drug treatment. The main symptoms were anal secretion 11 patients , pain 9 , pruritus 8 , bleeding 6 and fecal incontinence 6. The average Harvey-Bradshaw scale was 2. Seven patients had proctitis. As to the fistulous trajectories, ten patients had only one, six had two, three had three, and one patient had four, totaling 35 detected perianal fistulouspaths Tables 1 and 2.
MRI failed to identify two rectovaginal fistulas and one transsphincteric pathway in the anterior midline. EU did not identify a supraelevator abscess and two transsphincteric pathways - one lateral and one posterior. Both the MRI and the EU of one patient were not able to show the horseshoe transsphincteric fistulous trajectory in the posterior midline, which was diagnosed only under examination under anesthesia. In the other 18 cases, all the fistulous pathways detected by MRI and EU were also identified by the surgeon, who was not aware of the results of the imaging tests.
There were no conflicts in the findings regarding the fistulous trajectories erroneously diagnosed in the three exams. When comparing the three exams in patients with a single fistulous trajectory, there was agreement in seven of the ten patients; in those with more than one fistulous path, agreement occurred in only four of the ten individuals.
The estimated Kappa coefficient was 0. The estimated Kappa coefficient of agreement was 0. Each point corresponds to one fistulous path. The evaluation of perianal fistulizing Crohn's disease is challenging, even for experienced surgeons. Accurate diagnosis is essential for effective treatment. The anatomy of the fistulous path, its relationship with the sphincter muscles, and the identification of collections are key components for treatment planning. Failure to detect any of these components results in improper handling and fistula recurrence.
The management of perianal fistulizing Crohn's disease has changed considerably in the last decades after the spread of the use of biological therapy, such as infliximab and adalimumab. Although these medications cause closure of the external orifice and help in the resolution of drainage of purulent secretion through the anus, the fistulous pathway remains inflammatory and leads to fistula recurrence 16 - Therefore, to plan the best treatment, it is recommended to perform imaging in the evaluation of patients, especially those with complex perianal fistula 4 , 5. For the other ten patients who had more than one fistulous trajectory, there was agreement between the three exams in only four cases.
The high incidence of complex fistulas and the low agreement in the findings between different methods reinforce the importance of imaging tests in patients with perianal fistulizing Crohn's disease.
Imaging of Perianal Inflammatory Diseases
Pelvic MRI is recommended as an initial examination to evaluate fistulizing perianal disease, as it is an accurate and non-invasive method 4. In this study, MRI was able to detect seven cases of suprasphincteric fistulas, including one that was not detected by EUA.
The phenotype of rectal and perianal involvement in CD is predictive of a poor outcome, poses a significant psychological burden, and impacts on quality of life. Patients have a lot to lose if their disease is not controlled adequately and promptly. The disease course can ultimately culminate in the need for surgery, which might be a proctectomy and permanent ileostomy. There is still a lot to learn about this phenotype of disease and various needs are unmet:. Tozer et al. For patients with pCD, ensure a prompt diagnosis is made so that patients can start appropriate therapy in a timely manner.
The Radiology Assistant : Rectum - Perianal Fistulas
Also ensure that optimum assessment is achieved by using a combination of clinical assessment, imaging, and examination under anaesthesia. Psychological support can be helpful for many patients with pCD who are struggling with a difficult burden of symptoms.
Combined medical and surgical approaches are needed for disease management, and the pathway should include monitoring and optimisation of therapy. Patients need to be educated about their disease and, importantly, how to access the system if they have intercurrent issues.