MRI imaging of Perianal fistula
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Transcript MRI imaging of Perianal fistula
Dr. Ahmed Refaey , FRCR
Consultant Radiologist
Riyadh Military Hospital
Format of the lecture
Anatomy
Pathogenesis
Imaging techniques
Scanning protocoles
Classification
Examples
ANATOMY
Anatomy
Anatomical canal :
- extends from perineal skin
to dentate line
Surgical canal :
- extends from perineal skin
to anorectal ring ( 1-1.5cm
abov e dentate line )
- total length 4-5 cm
Anal sphincter
comprised of 3 layers
Internal sphincter
- continuance of circular smooth
muscle of rectum, involuntary,
contracts at rest & relaxes at
defecation
Intersphincteric space
External sphincter
- voluntary striated muscle ,
continuous cranially with
puborectal muscle &levator ani
Puborectal muscle has its origin on both sides of the symphysis
pubis, forming a sling around the anorectum
The puborectal
muscle is contracted
at rest and accounts
for the 8O0
angulation of the
anorectal junction . It
relaxes during
defecation
On axial and
coronal MR
images , the
different
layers of anal
sphincter and
the
surrounding
structures can
be displayed
perfectly
Coronal
Axial
PATHOGENESIS
Perianal fistula
Abnormal connection between the
epithilialised surface of the anal canal and
the skin.
Causes
1ry
- obstruction of anal gland which leads to stasis &
infection with abscess & fistula formation ( most
common cause )
2ry
- iatrogenic ( post hemorrhoiedal surgury )
- inflammatory bowel dis. ( crohn’s disease )
- infections ( viral , fungal or TB )
- malignancy
IMAGING TECHNIQUES
Imaging techniques
Fistulography
Endosonography
CT
MRI
Perianal fistulography
Anal endosonography
CT
MRI protocol
T1W &T2W fse axial and coronal
T2W with fat sat
T1W + CM
FOV 200
T2W
----- anatomy
T2W with fat sat ---- fistula
The anal clock
P: anterior
perineum
n: natal cleft
The anal
clock
The surgeon’s view
of the perianal region
when the patient is in
the supine lithotomy
position ,
corresponds to the
orientation of axial
MRI of the perianal
region
Reporting
Position of the
mucosal opening
on axial images
using anal clock
Distance of
mucosal defect to
perianal skin on
coronal images
2ry fistulas or
abscess
CLASSIFICATION
Classification
Parks classification
1- intersphincteric
2- transsphincteric
3- extrasphincterisc
4-suprasphincteric
Intersphincteric & transsphincteric are the most common
Intersphincteric --> 70 %
Transsphincteric -->20%
St. James university hospital
classification
MR imaging Grading of
perianal fistulas
MRI Grading of perianal fistulas
Grade 1 :
simple linear intersphincteric fistula
Grade 2 :
intersphincteric fistula with abscess or 2ry track
Grade 3 :
transsphincteric fistula
Grade 4:
transsphinteric fistula with abscess or2ry track
within ischeorectal fossa
Grade 5 :
supralevator & translevator fistula
Grade 1 :
simple linear intersphincteric fistula
Intersphincteric fistula
Axial T2W with and without fat
saturation
The intersphincteric fistula
located at 6 o’clock
Intersphincteric fistula
Perianal fistula with an abscess
Grade 2 :
intersphincteric fistula with
abscess or 2ry track
Grade 3 :
transspincteric fistula
Transsphincteric fistula
The defect through internal & external
sphincter at 6 o’clock is clearly visible
Transsphincteric fistula at 11 o’clock
Grade 4:
transsphinteric fistula with
abscess or2ry track within
ischeorectal fossa
Grade 5 :
supralevator & translevator
fistula
Suprasphincteric fistula
Two tracts in
ischeorectal
region
The right sided
tract runs over
the puborectal
muscle (asterisc)
& the mucosal
opening lies at
the level of
dentate line
(black arrow)
Extrasphincteric fistula
A small abscess in
left ischeoanal
fossa , the fistula
runs through
levator ani , it is
therefore above the
sphincter complex
and
extrasphincteric
Complex fistula
2 tracts in left buttock
form single tract
The fistula breaks through
the external sphincter
In intersphincteric space it
divides again into 2 tracts
One ends blindly in the
intersphincteric space
The other breaks through
the internal sphincter with
mucosal defect at 1 o’clock
Differential diagnosis
Pielonidal sinus
Small abscess just above the nates
No relation with sphincter complex
Proctitis
No fistula was seen
Diffuse thickening of rectal mucosa due to proctitis
Ischiorectal space abscess
An abscess in ischiorectal space with no
connection to the sphincter complex
REFERENCES
Goodsall DH, Miles WE. Diseases of the anus and rectum.
London, England: Longmans, Green, 1900.
↵ Parks AG, Gordon PH, Hardcastle JD. A classification of
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↵ Spencer JA, Ward J, Beckingham IJ, Adams C, Ambrose NS.
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↵ Haggett PJ, Moore NM, Shearman JD, Travis SPL, Jewell DP,
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↵ Hussain SM, Stoker J, Schouten WR, Hop WCJ, Lameris JS. Fistula-inano: endoanal sonography versus endoanal MR imaging in
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↵ Spencer JA, Chapple K, Wilson D, Ward J, Windsor ACJ, Ambrose NS.
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imaging. AJR Am J Roentgenol 1998;