Abstract
Background
Successful anal fistula care in complex cases can be assisted by specialized imaging which accurately defines the site of the internal fistula opening and the fistula type. There are currently limited data concerning the clinical indications for and accuracy of transperineal ultrasound (TP-US) in acute perianal sepsis. The aims of this study were to compare the anatomical interpretation of TP-US images with magnetic resonance imaging (MRI) and surgical findings in an unselected patient cohort presenting with acute perianal sepsis.
Methods
Sixty-seven consecutive patients with acute anorectal sepsis referred from the surgical department were examined using TP-US and Gadolinium-enhanced MRI with both examiners blinded to the surgical results. Fistulae were categorized by the Parks’ classification of fistula type.
Results
Thirty-six abscesses were detected by MRI, 38 by TP-US and 30 by surgical examination. Operatively discordant cases showed only ischiorectal panniculitis. TP-US was more accurate in the diagnosis of superficial sepsis and MRI in the diagnosis of deep-seated perirectal infection. TP-US and MRI show concordance with operative findings in fistula diagnosis with a tendency for TP-US to overdiagnose trans-sphincteric fistulae and MRI to over diagnose extra-sphincteric fistulae. Comparison of TP-US with MRI showed good agreement for perianal abscess diagnosis (τ = 0.82) and for fistula diagnosis (τ = 0.68). For fistulae, TP-US showed moderate agreement with surgery (τ = 0.43) with only fair agreement between MRI and surgery (τ = 0.29).
Conclusions
Transperineal ultrasound complements other imaging modalities in the anatomical diagnosis of acute perianal abscesses and fistulae. It has specific advantages over other techniques and is accurate in the detection of superficially located perirectal sepsis showing concordance with MRI and surgical findings.
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References
Sangwan YP, Rosen L, Riether RD, Stasik JJ, Sheets JA, Khubchandani IT (1994) Is simple fistula-in-ano simple? Dis Colon Rectum 37:885–889
O’Malley RB, Al-Hawary MM, Kaza RK, Wasnik AP, Liu PS, Hussain HK (2012) Rectal imaging: part 2, perianal fistula evaluation on pelvic MRI–what the radiologist needs to know. AJR Am J Roentgenol 199:W43–W53
Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD (1996) Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum 39:723–729
Vermeire S, Van Assche G, Rutgeerts P (2007) Perianal Crohn’s disease: classification and clinical evaluation. Dig Liver Dis 39:959–962
Strong SA (2007) Perianal Crohn’s disease. Semin Pediatr Surg 16:185–193
Chapple KS, Spencer JA, Windsor AC, Wilson D, Ward J, Ambrose NS (2000) Prognostic value of magnetic resonance imaging in the management of fistula-in-ano. Dis Colon Rectum 43:511–516
Toyonaga T, Tanaka Y, Song JF et al (2008) Comparison of accuracy of physical examination and endoanal ultrasonography for preoperative assessment in patients with acute and chronic anal fistula. Tech Coloproctol 12:217–223
Fields S, Rosainz L, Korelitz BI, Panagopoulos G, Schneider J (2008) Rectal strictures in Crohn’s disease and coexisting perirectal complications. Inflamm Bowel Dis 14:29–31
Kim Y, Park YJ (2009) Three-dimensional endoanal ultrasonographic assessment of an anal fistula with and without H(2)O(2) enhancement. World J Gastroenterol 15:4810–4815
Stewart LK, McGee J, Wilson SR (2001) Transperineal and transvaginal sonography of perianal inflammatory disease. AJR Am J Roentgenol 177:627–632
Bonatti H, Lugger P, Hechenleitner P et al (2004) Transperineal sonography in anorectal disorders. Ultraschall Med 25:111–115
Wedemeyer J, Kirchhoff T, Manns MP, Gebel MJ, Bleck JS (2004) Transcutaneous perianal ultrasound (PAUS) for the imaging of fistulas and abscesses in Crohn’s disease. Z Gastroenterol 42:1315–1320
Zbar AP, Oyetunji RO, Gill R (2006) Transperineal versus hydrogen peroxide-enhanced endoanal ultrasonography in never operated and recurrent cryptogenic fistula-in-ano: a pilot study. Tech Coloproctol 10:297–302
Domkundwar SV, Shinagare AB (2007) Role of transcutaneous perianal ultrasonography in evaluation of fistulas in ano. J Ultrasound Med 26:29–36
Maconi G, Ardizzone S, Greco S, Radice E, Bezzio C, Bianchi Porro G (2007) Transperineal ultrasound in the detection of perianal and rectovaginal fistulae in Crohn’s disease. Am J Gastroenterol 102:2214–2219
Morris J, Spencer JA, Ambrose NS (2000) MR imaging classification of perianal fistulas and its implications for patient management. Radiographics 20:623–637
Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63:1–12
Cho DY (1999) Endosonographic criteria for an internal opening of fistula-in-ano. Dis Colon Rectum 42:515–518
Altman DG (1991) Statistics in medical journals: developments in the 1980s. Stat Med 10:1897–1913
Grouven U, Bender R, Ziegler A, Lange S (2007) The kappa coefficient. Dtsch Med Wochenschr 132(Suppl 1):e65–e68
Zbar AP, de Souza NM, Puni R, Kmiot WA (1998) Comparison of endoanal magnetic resonance imaging with surgical findings in perirectal sepsis. Br J Surg 85:111–114
Berman L, Israel GM, McCarthy SM, Weinreb JC, Longo WE (2007) Utility of magnetic resonance imaging in anorectal disease. World J Gastroenterol 13:3153–3158
Chew SS, Yang JL, Newstead GL, Douglas PR (2003) Anal fistula: levovist-enhanced endoanal ultrasound: a pilot study. Dis Colon Rectum 46:377–384
Dietrich CF, Barreiros AP, Nuernberg D, Schreiber-Dietrich DG, Ignee A (2008) Perianal ultrasound. Z Gastroenterol 46:625–630
Berger T, Garrido F, Green J, Lema PC, Gupta J (2012) Bedside ultrasound performed by novices for the detection of abscess in ED patients with soft tissue infections. Am J Emerg Med 30:1569–1573
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Plaikner, M., Loizides, A., Peer, S. et al. Transperineal ultrasonography as a complementary diagnostic tool in identifying acute perianal sepsis. Tech Coloproctol 18, 165–171 (2014). https://doi.org/10.1007/s10151-013-1031-x
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DOI: https://doi.org/10.1007/s10151-013-1031-x