Multi Detector Computed Tomography Fistulography In Patients of Fistula-in-Ano: An Imaging Collage

Fistula-in-ano, or perianal fistula, is a challenging clinical condition for both diagnosis and treatment. Imaging modalities such as fistulography, anal endosonography, perineal sonography, magnetic resonance imaging (MRI), and computed tomography (CT) are available for its evaluation. MRI is considered as the modality of choice for an accurate delineation of the tract in relation to the sphincter complex and for the detection of associated complications. However, its availability and affordability is always an issue. Moreover, the requirement to obtain multiple sequences to depict the fistula in detail is cumbersome and confusing for the clinicians to interpret. The inability to show the fistula in relation to normal anatomical structures in a single image is also a limitation. Multi detector computed tomography fistulography (MDCTF) is an underutilized technique for defining perianal fistulas. Acquisition of iso-volumetric data sets with instillation of contrast into the fistula delineates the tract and its components. Post-processing with thin sections allows for a generation of good quality images for presentation in various planes (multi-planar reconstructions) and formats (volume rendered technique, maximum intensity projection). MDCTF demonstrates the type of fistula, its extent, whether it is simple or complex, and shows the site of internal opening and associated complications; all in easy to understand images that can be used by the surgeons. Its capability to represent the entire pathology in relation to normal anatomical structures in few images is a definite advantage. MDCTF can be utilized when MRI is contraindicated or not feasible. This pictorial review shares our initial experience with MDCT fistulography in evaluating fistula-in-ano, demonstrates various components of fistulas, and discusses the types of fistulas according to the standard Parks classification.