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Akhoundi N, Bozchelouei JK, Abrishami A, Frootan M, Siami A, Alimadadi E, Saba GB, Rezazadeh E, Amerifar M, Eghdami E. Comparison of MRI and Endoanal Ultrasound in Assessing Intersphincteric, Transsphincteric, and Suprasphincteric Perianal Fistula. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2057-2064. [PMID: 37040280 DOI: 10.1002/jum.16225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES Perianal fistula is a common disorder characterized by an anomalous perianal track connecting two epithelialized surfaces, most commonly the anal canal and the perianal skin. Although each has its limitations, magnetic resonance imaging (MRI) and endoanal ultrasound are currently two acceptable modalities for assessing perianal fistula. This study aimed to evaluate the accuracy of MRI and endoanal ultrasonography in diagosing perianal fistula, considering the surgical results as the references. METHODS This prospective cohort study was performed on patients with symptomatic perianal fistulas. MRI results of patients reported by the radiologist were collected along with the findings of endoanal ultrasonography performed by a gastroenterologist. These results were compared with surgical findings as the reference standard. RESULTS The study enrolled 126 patients. Exactly 222 definitive fistulas were identified during surgery. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ultrasound for perianal fistula were 87.38, 38.46, 92.38, 26.31, and 82.25% respectively; and for MRI were 76.12, 57.69, 93.88, 22.05, and 74.19% respectively. The accuracy of endoanal ultrasound for detecting transsphincteric and intersphincteric fistulas was higher than MRI. In contrast, the diagnostic value of MRI for detecting suprasphincteric fistulas was higher than endoanal ultrasound. CONCLUSIONS Using endoanal ultrasonography to diagnose perianal fistulas is a relatively accurate method. This method may be more sensitive than MRI in detecting patients with perianal fistulas and abscesses.
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Affiliation(s)
- Neda Akhoundi
- Radiology Department, Hillcrest Hospital, University of California San Diego, San Diego, USA
| | - Javad Komijani Bozchelouei
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Alireza Abrishami
- Labbafinezhad Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Mojgan Frootan
- Gastroenterology Department, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Alireza Siami
- Biostatistical Analyzer, Amirkabir University of Technology, Tehran, Iran
| | - Elahe Alimadadi
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Research Institute For Gastroenterology And Liver Diseases, Tehran, Iran
| | - Gholamreza Bagherzadeh Saba
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Research Institute For Gastroenterology And Liver Diseases, Tehran, Iran
| | - Elmira Rezazadeh
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Maryam Amerifar
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Ebrahim Eghdami
- Radiology Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
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Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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Missing the Boat? Appreciating the Importance of the Pathophysiology of Perianal Crohn's Disease in Guiding Biological and Surgical Therapy. Dis Colon Rectum 2018; 61:529-531. [PMID: 29624546 DOI: 10.1097/dcr.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59:1117-1133. [PMID: 27824697 DOI: 10.1097/dcr.0000000000000733] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Bor R, Fábián A, Szepes Z. Role of ultrasound in colorectal diseases. World J Gastroenterol 2016; 22:9477-9487. [PMID: 27920469 PMCID: PMC5116592 DOI: 10.3748/wjg.v22.i43.9477] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/11/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023] Open
Abstract
Ultrasound is an undervalued non-invasive examination in the diagnosis of colonic diseases. It has been replaced by the considerably more expensive magnetic resonance imaging and computed tomography, despite the fact that, as first examination, it can usefully supplement the diagnostic process. Transabdominal ultrasound can provide quick information about bowel status and help in the choice of adequate further examinations and treatment. Ultrasonography, as a screening imaging modality in asymptomatic patients can identify several colonic diseases such as diverticulosis, inflammatory bowel disease or cancer. In addition, it is widely available, cheap, non-invasive technique without the use of ionizing radiation, therefore it is safe to use in childhood or during pregnancy, and can be repeated at any time. New ultrasound techniques such as elastography, contrast enhanced and Doppler ultrasound, mini-probes rectal and transperineal ultrasonography have broadened the indication. It gives an overview of the methodology of various ultrasound examinations, presents the morphology of normal bowel wall and the typical changes in different colonic diseases. We will pay particular attention to rectal and transperineal ultrasound because of their outstanding significance in the diagnosis of rectal and perineal disorders. This article seeks to overview the diagnostic impact and correct indications of bowel ultrasound.
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Bor R, Farkas K, Bálint A, Szűcs M, Ábrahám S, Milassin Á, Rutka M, Nagy F, Milassin P, Szepes Z, Molnár T. Prospective Comparison of Magnetic Resonance Imaging, Transrectal and Transperineal Sonography, and Surgical Findings in Complicated Perianal Crohn Disease. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:2367-2372. [PMID: 27629757 DOI: 10.7863/ultra.15.09043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/06/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Magnetic resonance imaging (MRI) and transrectal sonography are the two accepted imaging modalities for evaluation of perianal fistulas and abscesses. Transperineal sonography is a new technique that is easy to learn and can be performed at any time. The purpose of this study was to prospectively compare the diagnostic accuracy of MRI, transrectal sonography, and transperineal sonography with surgical findings in patients with perianal Crohn disease. METHODS All patients with perianal Crohn disease underwent MRI, transrectal sonography, and transperineal sonography within a few days before surgery. Fistulas were classified as simple (43.8%) or complex (52.2%) based on surgical findings. RESULTS Twenty-three patients with active perianal Crohn disease (12 women and 11 men; mean age, 29.9 years; current therapy: antibiotics, 69.6%; azathioprine, 56.5%; and biologics, 73.9%; previous surgery, 26.1%; and proportion of smokers, 39.1%) were included. Sensitivity values for MRI, transrectal sonography, and transperineal sonography for diagnosis of fistulas were 84.6%, 84.6%, and 100%, respectively. Transperineal sonography was more sensitive for diagnosis of perianal abscesses than MRI and transrectal sonography (100%, 58.8%, and 92.8%). CONCLUSIONS Transperineal sonography is a very accurate diagnostic method with outstanding sensitivity compared with MRI and transrectal sonography for evaluation of complicated perianal Crohn disease. Due to its simplicity and low cost, it is recommended that transperineal sonography be the first diagnostic modality in these cases.
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Affiliation(s)
- Renáta Bor
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Klaudia Farkas
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Anita Bálint
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Mónika Szűcs
- Departments of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | | | - Ágnes Milassin
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Mariann Rutka
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Ferenc Nagy
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Péter Milassin
- Department of Radiology, University of Szeged, Szeged, Hungary
| | - Zoltán Szepes
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Tamás Molnár
- First Department of Medicine, University of Szeged, Szeged, Hungary
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Grevenitis P, Thomas A, Lodhia N. Medical Therapy for Inflammatory Bowel Disease. Surg Clin North Am 2015; 95:1159-82, vi. [DOI: 10.1016/j.suc.2015.08.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Juncadella AC, Alame AM, Sands LR, Deshpande AR. Perianal Crohn’s disease: A review. Postgrad Med 2015; 127:266-72. [DOI: 10.1080/00325481.2015.1023160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Bor R, Farkas K, Bálint A, Szucs M, Ábrahám S, Baradnay G, Wittmann T, Szepes Z, Nagy F, Molnár T. Efficacy of combined anti-TNF-alpha and surgical therapy in perianal and enterocutaneous fistulizing Crohn's disease--clinical observations from a tertiary Eastern European center. Scand J Gastroenterol 2015; 50:182-7. [PMID: 25384713 DOI: 10.3109/00365521.2014.936033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Recently, anti-TNF-alpha therapy has increasingly been used in the treatment of perianal Crohn's disease (PCD), but there is only limited data regarding its short- and long-term efficacy. MATERIAL AND METHODS The medical records of 68 patients treated with anti-TNF-alpha for PCD were assessed retrospectively. Rate of complex fistulas was 75%. Every patient received induction therapy, but in 20 cases the treatment was discontinued before week 52 due to funding regulations, an allergic reaction, or compliance problems. On week 12, the luminal activity decreased in more than 80% of the cases and the complete remission (CR) rate was about 60%; by the end of the first year, this ratio did not change substantially. Complete fistula closure was achieved in 26 cases (38.3%) and 53 patients (51.5%) showed a partial response during the 1-year period. Regarding both perianal and luminal activities, CR rate was achieved in 23 cases (33.8%). However, after the biological therapy was discontinued, recurrence of fistulas could be detected in every second patient. Additional surgical intervention was performed in 45% of patients during the 1-year period (seton drainage of fistulas and abscess drainage). CONCLUSION The anti-TNF-alpha therapy combined with surgery is an effective treatment of PCD. Approximately every third patient revealed complete fistula closure, while half of the other cases showed a partial response. Due to the high rate of fistula recurrence after stopping the biological therapy, more than 1 year of anti-TNF-α treatment may be beneficial.
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Affiliation(s)
- Renáta Bor
- First Department of Medicine, University of Szeged , Szeged , Hungary
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Gu J, Valente MA, Remzi FH, Stocchi L. Factors affecting the fate of faecal diversion in patients with perianal Crohn's disease. Colorectal Dis 2015; 17:66-72. [PMID: 25306934 DOI: 10.1111/codi.12796] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 08/01/2014] [Indexed: 12/18/2022]
Abstract
AIM A study was carried out with the aim of identifying potential factors which might influence the fate of patients undergoing faecal diversion by stoma in perianal Crohn's disease. METHOD Patients with severe perianal Crohn's disease undergoing faecal diversion between 1994 and 2012 were identified and the factors associated with stoma closure were assessed using univariate and multivariate analysis. RESULTS Of 138 diverted patients, 30 (22%) achieved stoma closure, 45 (33%) had a stoma with the rectum left in situ and 63 (45%) underwent proctectomy with permanent stoma formation after a mean follow-up of 5.7 years. Univariate analysis demonstrated that synchronous colonic (P = 0.004) or rectal (P = 0.021) disease involvement and an increased frequency of loose seton placement (P = 0.001) adversely affected successful stoma closure rates. Multivariate analysis indicated a significant association between the inability to achieve stoma closure and persisting rectal involvement (OR 7.5, 95% CI 2.4-33.4), one or two placements of a loose seton (OR 3.3, 95% CI 1.4-8.8) and more than two placements (OR 6.9, 95% CI 1.2-132.5). No specific medical management was associated with an improved stoma closure rate, including biological agents when these were available (P = 0.25). CONCLUSION The fate of temporary faecal diversion in patients with perianal Crohn's disease is adversely affected by aggressive disease characteristics. No particular treatment, including biological therapy, was associated with an improved outcome.
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Affiliation(s)
- J Gu
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Lam TJ, van Bodegraven AA, Felt-Bersma RJF. Anorectal complications and function in patients suffering from inflammatory bowel disease: a series of patients with long-term follow-up. Int J Colorectal Dis 2014; 29:923-9. [PMID: 24965857 DOI: 10.1007/s00384-014-1926-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2014] [Indexed: 02/07/2023]
Abstract
AIM The aim of this study is to describe the long-term course of anorectal complains and function in a single centre cohort patients suffering from inflammatory bowel disease (IBD) with perianal lesions. METHODS Between 1993 and 2000, 56 IBD patients (43 Crohn's disease and 13 ulcerative colitis) with perianal complaints underwent anorectal function evaluation (AFE) (baseline). For follow-up, they were approached between 2010 and 2012 by sending questionnaires including Inflammatory Bowel Disease Quality of Life Questionnaire (IBDQ), Perianal Disease Activity Index (PDAI), faecal incontinence scale (Vaizey) and an invitation for AFE. RESULTS At follow-up, 46 patients (82 %) were available, 9 (16 %) were lost and 1 (2 %) had died. Thirty patients returned the questionnaires of which 17 also underwent AFE. The remaining 16 patients were interviewed by phone and were only willing to mention their anorectal complaints. Median follow-up was 14 year. In 25 of the 46 patients (54 %), perianal complaints persisted faecal incontinence (n = 7); soiling (n = 13) and active fistula (n = 5). Eighteen (39 %) patients had an active fistula at baseline and three persisted at follow-up. Two developed a new fistula. Mean IBDQ, Vaizey and PDAI were 178 (SD 29), 7 (SD 5) and 4.2 (SD 3.0), respectively. In 17 patients, who underwent AFE, anal endosonography showed healing in nine of the ten fistulas. Anal pressures as well as rectal capacity remained unaltered in the individual patient, but showed a large range within the group. CONCLUSION After 14 years, 54 % of the IBD patients with perianal lesions still have mild complaints. The quality of life remained moderate over a long period, which is concerning.
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Affiliation(s)
- Tze J Lam
- Department of Gastroenterology and Hepatology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands,
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MRI-based score helps in assessing the severity and in follow-up of pediatric patients with perianal Crohn disease. J Pediatr Gastroenterol Nutr 2014; 58:252-7. [PMID: 24121148 DOI: 10.1097/mpg.0000000000000199] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The radiologic healing of perianal fistulizing Crohn disease (PfCD) lags behind the clinical healing. Contrast-enhanced pelvic magnetic resonance imaging (MRI) is the radiologic study of choice used to diagnose PfCD in children. The aim was to study whether the various MRI-based radiologic parameters and score can help in staging and follow-up of patients with PfCD. METHODS We performed a retrospective chart review of children with PfCD who underwent contrast-enhanced MRI of the pelvis. The demographic profile, clinical status, and laboratory data of the patients at the time of each MRI examination were noted. Based on the clinical status of the patient at the time of MRI examinations, the MRIs were classified into 3 groups: severe disease, mild-to-moderate disease, and asymptomatic. Each MRI examination was reviewed by a radiologist, who was blinded to the clinical status of the patient. RESULTS Of the radiologic parameters, the number of fistulas, the complexity of fistulas, and the number of abscesses were significantly lower in the asymptomatic group compared with the mild-to-moderate and severe disease groups. The Van Assche MRI-based score was significantly lower in the asymptomatic group compared with the mild-to-moderate disease (P = 0.01) and the severe disease group (P = 0.002). The percentage increase in fistula activity after gadolinium administration was significantly lower in the asymptomatic group compared with the mild-to-moderate disease (P = 0.026) and severe disease (P = 0.019) groups. The MRI-based scores were significantly higher in the MRI examinations performed at diagnosis compared with those that were performed while the patients were receiving the treatment (P = 0.017). CONCLUSIONS The Van Assche MRI score and the percentage increase in fistula activity after gadolinium administration help in assessing the severity perianal Crohn disease. The Van Assche MRI score may be helpful in documenting healing during therapy of perianal Crohn disease.
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Imaging techniques and combined medical and surgical treatment of perianal Crohn's disease. J Ultrasound 2013; 18:19-35. [PMID: 25767636 DOI: 10.1007/s40477-013-0042-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 10/05/2013] [Indexed: 12/13/2022] Open
Abstract
Crohn's disease is a chronic inflammatory disease which may involve any segment of the gastrointestinal tract, most frequently the terminal ileum, the large intestine, and the perianal region. The symptoms of perianal Crohn's disease include skin disorders, hemorrhoids, anal ulcers, anorectal stenosis, perianal abscesses and fistulas, rectovaginal fistulas and carcinoma of the perianal region. The perianal manifestations of Crohn's disease cause great discomfort to the patient and are among the most difficult aspects to treat. Management of perianal disease requires a combination of different imaging modalities and a close cooperation between gastroenterologists and dedicated surgeons.
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