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© Borgis - New Medicine 3/2011, s. 90-92
Małgorzata Kołodziejczak1, *Iwona Sudoł-Szopińska2, Paweł Grochowicz1, Krzysztof Wagiel1
Utility of fistulography in diagnosing a post-traumatic rectal fistula – a case report
1Proctology Department, Hospital at Solec, Poland
Head of Department: dr hab. med. Małgorzata Kołodziejczak
2Department of Diagnostic Imaging, Institute of Rheumatology and Department of Diagnostic Imaging, Medical University of Warsaw, Poland
Head of Department: prof. dr hab. med. Iwona Sudoł-Szopińska
Summary
Background. Classical fistulography in most coloproctological centers has been replaced by anorectal ultrasound and magnetic resonance fistulography which are considered the „gold standards” in preoperative diagnosis of perianal fistulas. However, in case of a non-cryptogenic fistula, there still is a place for standard fistulography.
Aim. To present the role of standard fistulography in the preoperative assessment of a recurrent, post-traumatic fistula-in-ano.
Material and Methods. A 47-year-old man was admitted to the proctology department. Five years previously he had experienced an impalement injury to the perineum upon a ladder. At that time, the perineal wound was checked and the bleeding controlled. Since then he had been operated on four times due to recurrent anal fistulas. Anorectal ultrasound, followed by fistulography and computed tomography were performed.
Results. Anorectal ultrasound demonstrated an extrasphincteric fistula not communicating with the rectum. Fistulography revealed the fistula to be running parallel to the rectal wall, and confirmed the lack of an internal opening. Additionally, approximately 30 cm from the anal verge, the fistula came to an end with an outline of a non-contrasting foreign body. Computer tomography showed this foreign body to be located within the right iliopsoas muscle, with its lower margin against the right iliac artery. Laparotomy was performed, and a 10 cm long piece of wood was removed.
Conclusions. 1. In the preoperative diagnostics of a perirectal fistula, whose etiology is not cryptogenic, fistulography serves as an accurate yet simple, fast, and minimally-invasive diagnostic method. 2. Computer tomography allows for the precise localization of a foreign body with respect to its surrounding structures.
Introduction
The preoperative diagnostic algorithm for cyptogenic perirectal fistulas is generally known and accepted. Magnetic resonance imaging (MRI) and anorectal ultrasound (AUS) are considered the „gold standards” (1, 2). The use of multiplanar imaging, sequences like fat suppression, and contrast enhancement in MRI, plus three dimensional techniques with hydrogen peroxide enhancement in AUS, have made it possible to delineate primary and secondary fistulous tracts and fluid collections with respect to the external anal sphincter and puborectalis muscle, and identify the internal opening site (1, 3).
Herein we report a rare case of a post-traumatic fistula around a foreign body in the retroperitoneal space, which was diagnosed by classical anal fistulography – an imaging method considered by and large obsolete.
Case report
A 47-year-old man was admitted to the proctology department due to recurrence of an anal fistula. Five years previously he had experienced an impalement injury to the perineum upon a ladder. At that time, the perineal wound was checked and the bleeding controlled. Since then he had been operated on four times due to recurrent anal fistulas.
In the proctological examination, the active and passive tone of the sphincters was appropriate. On the right side, 2 cm from the anal verge the external opening of the fistula was localized. Anoscopy and rectoscopy did not reveal an internal opening of the fistula. The patients was sent for AUS, and was examined in the left lateral position using the BK Medical scanner, Profocus 2202, with a 2050 type 3D mechanical volumetric endoprobe of 6-16 MHz frequency. A suprasphincteric fistula without an internal opening was demonstrated (fig. 1).
Fig. 1. Anorectal ultrasound demonstrates an extrasphincteric fistula in perirectal tissue, on the right side.

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Piśmiennictwo
1. Sun MR, Smith MP, Kane RA: Current techniques in imaging of fistula in ano: three-dimensional endoanal ultrasound and magnetic resonance imaging. Semin Ultrasound CT MR 2008; 29: 454-71. 2. Bartram C, Buchanan G: Imaging anal fistula. Radiol Clin N Am 2003; 41: 443-457. 3. Zbar AP, Armitage NC: Complex perirectal sepsis: clinical classification and imaging. Tech Coloproctol 2006; 10: 83-93. 4. Seow-Choen F, Nicholls RJ: Anal fistula. Br J Surg 1992; 79: 197-205. 5. Law PJ, Bartram CI: Anal Endosonography: Technique and normal anatomy. Gastrointestinal Radiol 1989; 14: 349-535. 6. Elangovan S, Bhuvaneswary V, Nadarajan S, Kannan RR, Velmurugan S: Comparative study of fistulography and anal endosonography in fistula-in-ano. Indian J Radiol Imaging 2002; 12: 343-6. 7. Weisman RI, Orsay CP, Pearl RK, Abcarian H: The role of fistulography in fistula-in-ano. Dis Colon Rectum 1991; 34: 181-184. 8. Kuijpers HC, Schulpen T: Fistulography for fistulo-in-ano. Dis Colon Rectum 1985; 28: 103-104. 9. Halligan S: Review: imaging fistula-in-ano. Clinical Radiol 1998; 53: 85-95. 10. Tapes B, Cerni I: The use of different diagnostic modalities in diagnosing fistula-in-ano. Hepatogastroenterology 2008; 55: 912-5. 11. Pomarri F, Pittarello F, Dodi G, Pianon P, Muzzio PC: Radiologic diagnosis of anal fistulae with radio-opaque markers. Radiol Med 1988; 75: 632-7. 12. Pomerri F, Dodi G, Pintacuda G et al.: Anal endosonography nas fistulography for fistula-in-ano. Radiol Med 2010; 22 [Epub ahead of print] 13. Choen S, Burnett S, Bartram CI, Nicholls RJ: Comparison between anal endosonography and digital examination in the evaluation of anal fistulae. Br J Surg 1991; 78: 445-447. 14. Law PJ, Talbot RW, Bartram CI, Northover JMA: Anal endosonography in the evaluation of perianal sepsis and fistula in ano. Br J Surg 1989; 76: 752-755. 15. Shahid M Hussain, Stoker J, Schouter WR et al.: Fistula-in-ano: Endoanal sonography versus endoanal MR Imaging in classification: Radiology 1996; 200: 475-481. 16. Cho DY: Endosoniographic criteria for an internal opening of fistula-in-ano. Dis Colon Rectum 1999; 42: 515-518. 17. Lunnis PJ, Barker PG, Sultan AH: Magnetic resonance imaging of fistula-in-ano. Dis Colon Rectum 1994; 37: 708-718.
otrzymano: 2011-07-11
zaakceptowano do druku: 2011-08-23

Adres do korespondencji:
*Iwona Sudoł-Szopińska
Department of Diagnostic Imaging, Medical University of Warsaw
Kondratowicza St. 8, 03-242 Warsaw
tel./fax: 48 22 3265991
e-mail: sudolszopinska@gmail.com

New Medicine 3/2011
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