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Acquired Gastrointestinal Fistulas: Classification, Etiologies, and Imaging Evaluation¹

¹ From the Department of Radiology, National Naval Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889-5600 (P.J.P.); Department of Radiology, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (P.J.P.); and the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.B., D.M.B.). Received July 12, 2001; revision requested August 20; revision received September 14; accepted October 16. Address correspondence to P.J.P. (e-mail: pjpik@hotmail.com).

	ABSTRACT

TOP ABSTRACT INTRODUCTION CLASSIFICATION OF GI FISTULAS CAUSES OF ACQUIRED GI... OVERVIEW OF IMAGING TECHNIQUES INTERNAL GI FISTULAS EXTERNAL (CUTANEOUS) FISTULAS CONCLUSION REFERENCES

 
Fistulas are abnormal communications between two epithelial-lined surfaces. Gastrointestinal fistulas encompass all such connections that involve the alimentary tract, and they can be congenital or acquired in nature. This review focuses on acquired gastrointestinal fistulas. Development of an acquired gastrointestinal fistula can greatly affect patient outcome, yet the clinical manifestations are often protean in nature and the etiology, elusive. Imaging plays an important role in the detection and management of acquired gastrointestinal fistulas. The more routine use of cross-sectional imaging (especially computed tomography and magnetic resonance imaging) has altered the standard sequence of radiologic evaluation for possible fistulas, but fluoroscopic studies remain a valuable complement, especially for confirming and defining the anomalous communications. In this review, a classification scheme for gastrointestinal fistulas is provided, major causes are discussed, and individual fistula types are elaborated with an emphasis on contemporary imaging approaches.

© RSNA, 2002

Index terms: Barium enema examination, 70.1231, 70.1232, 80.123 • Fistula, gastrointestinal tract, 70.245, 70.25, 70.26, 70.27 • Fistula, genitourinary system, 80.23, 80.245 • Gastrointestinal tract, CT, 70.12111, 70.12112 • Gastrointestinal tract, radiography, 70.123 • Genitourinary system, CT, 80.12111, 80.12112 • Review

	INTRODUCTION

TOP ABSTRACT INTRODUCTION CLASSIFICATION OF GI FISTULAS CAUSES OF ACQUIRED GI... OVERVIEW OF IMAGING TECHNIQUES INTERNAL GI FISTULAS EXTERNAL (CUTANEOUS) FISTULAS CONCLUSION REFERENCES

 
Gastrointestinal (GI) fistulas represent abnormal ductlike communications between the gut and another epithelial-lined surface, such as another organ system, the skin surface, or elsewhere along the GI tract itself. A GI sinus tract, in comparison, is a similar ductlike passage that communicates with the gut at one end but ends blindly at the other. The development of a GI fistula can markedly increase patient morbidity and mortality, rendering detection of the fistula critical. Imaging often plays a pivotal role in the diagnosis and management of GI fistula, with fluoroscopic contrast agent–enhanced studies serving as the traditional standard bearer. The emergence of cross-sectional imaging techniques, however, has modified the radiologic approach to GI fistulas. Instead of replacing fluoroscopic contrast-enhanced studies, cross-sectional methods complement their conventional counterparts in the evaluation of GI fistulas.

In this review, we will provide an organ-system approach to classifying GI fistulas. A brief discussion of the major causes of acquired GI fistulas will follow. Last, a systematic review of GI fistulas according to our classification scheme will be provided, with an emphasis on contemporary imaging evaluation. The relative contribution and effectiveness of the various imaging modalities will be discussed for individual fistula types, because many unique features and challenges exist. The salient clinical features of specific GI fistulas, including management, will also be covered.

	CLASSIFICATION OF GI FISTULAS

TOP ABSTRACT INTRODUCTION CLASSIFICATION OF GI FISTULAS CAUSES OF ACQUIRED GI... OVERVIEW OF IMAGING TECHNIQUES INTERNAL GI FISTULAS EXTERNAL (CUTANEOUS) FISTULAS CONCLUSION REFERENCES

 
GI fistulas are generally named according to their participating anatomic components, and virtually every imaginable combination has been reported in the medical literature. Rather than recite all possible permutations, a more general approach is presented here (Fig 1). Because the terminology can be somewhat variable, we have attempted to use fistula names that prevail in the literature, regardless of underlying etiology. To begin, it is useful to separate congenital and acquired causes, since their clinical settings and implications obviously differ greatly. Congenital GI fistulas are best understood by realizing their embryologic origin and include such entities as branchial, tracheoesophageal, and omphalomesenteric fistulas. Congenital fistulas, however, are beyond the scope of this review and will not be considered further.

View larger version (38K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Classification of GI fistulas.

	CAUSES OF ACQUIRED GI FISTULAS

TOP ABSTRACT INTRODUCTION CLASSIFICATION OF GI FISTULAS CAUSES OF ACQUIRED GI... OVERVIEW OF IMAGING TECHNIQUES INTERNAL GI FISTULAS EXTERNAL (CUTANEOUS) FISTULAS CONCLUSION REFERENCES

 
The underlying causes of acquired GI fistulas are diverse and can include virtually any process resulting in bowel perforation from within or bowel penetration from an extraintestinal process (Fig 2). The majority of external (cutaneous) fistulas represent a complication of recent abdominal surgery (1). The leading causes of internal fistulas in the industrialized world are Crohn disease, diverticulitis, malignancy, or a complication of treatment of these entities. Not surprisingly, many cases are the result of multiple contributing factors; common examples include cancer patients who have undergone radiation therapy and patients with Crohn disease who have undergone prior bowel surgery. The specific location and type of fistula can often suggest certain causes, as will be seen when individual GI fistulas are covered more in depth. Some general features of the more common inflammatory causes will briefly discussed in the following paragraphs. Most of the remaining noninflammatory causes listed in Figure 2 will be covered in more detail in upcoming sections.

View larger version (38K): [in this window] [in a new window] [Download PPT slide]   Figure 2. Major causes of acquired GI fistulas.

Diverticulitis is a common cause of colonic fistula formation, with the fistula most often communicating with the urinary bladder (9). Colovaginal fistulas are also relatively common in women with sigmoid colon diverticulitis, particularly after hysterectomy. Fistulas are seen in up to 20% of cases of surgically treated diverticular disease (9,10). Another relatively common finding in diverticulitis is a fistulous tract that parallels the colonic lumen, representing a localized form of colocolic fistula that has been termed "double tracking." Not surprisingly, fistula formation of the sigmoid colon predominates in diverticular disease, but other colonic segments are occasionally involved.

Other than Crohn disease and diverticulitis, other less common inflammatory causes of GI fistulas include atypical infections, cholecystitis, pancreatitis, and appendicitis (11,12). Among the various atypical infectious causes that have been reported are tuberculosis, histoplasmosis, actinomycosis, xanthogranulomatous pyelonephritis, amebiasis, echinococcosis, and lymphogranuloma venereum (13–19).

	OVERVIEW OF IMAGING TECHNIQUES

TOP ABSTRACT INTRODUCTION CLASSIFICATION OF GI FISTULAS CAUSES OF ACQUIRED GI... OVERVIEW OF IMAGING TECHNIQUES INTERNAL GI FISTULAS EXTERNAL (CUTANEOUS) FISTULAS CONCLUSION REFERENCES

 
Fluoroscopic contrast-enhanced studies and conventional radiographic studies have traditionally served as the cornerstone for imaging of spontaneous GI fistulas. However, technical advances and the increased availability of cross-sectional imaging modalities have challenged this paradigm. The result has been a more flexible hybrid approach that utilizes the strengths of the various complementary imaging modalities now available. The preferred imaging approach will vary according to fistula type and the specific clinical scenario. Furthermore, even individual fistula types often elude generalization and must be treated on a case-by-case basis. This underscores the importance of the radiologist in determining the most appropriate sequence of imaging studies for a given case. Because many fistulas may be detected incidentally on cross-sectional images obtained because of other indications, familiarity with the direct and indirect signs of fistulas is essential for this unsuspected diagnosis.

Despite this wide variability, some broad comments can be made with regard to the imaging approach. Once the selection is made between conventional and cross-sectional imaging as the initial study, other technical considerations follow. Contrast-enhanced fluoroscopic examinations often remain the initial study of choice and are generally superior to endoscopy in demonstrating the presence and extent of a GI fistula (4). Fistulography is adequate for diagnosis of most external (cutaneous) fistulas and is also useful for follow-up in these cases (20). On occasion, enteric contrast-enhanced studies, such as a small-bowel study or enema, will provide as much or more diagnostic information. For extraintestinal internal fistulas, one must decide between pursuing a primary bowel study and a study that directly opacifies the communicating organ system, such as urography, vaginography, cholangiography, and others. For intestinal (gut-to-gut) fistulas, enteric contrast-enhanced studies are superior and may be the only noninvasive method able to demonstrate these fistulas in some cases.

The choice of contrast agent is another important factor in the performance of conventional GI studies. A water-soluble iodinated contrast agent is generally used, at least initially, for abdominal fistulography and enteric studies when frank perforation is suspected or pneumoperitoneum is present. This is predicated on the potential for extravasated barium to incite an inflammatory reaction in the peritoneum, which can be followed by the formation of dense fibrous adhesions (21–23). The risk of clinically important chemical peritonitis, however, is minimal unless a relatively large amount of barium has leaked, especially with the newer barium preparations. A similar but more localized and less severe foreign body reaction can occur with retroperitoneal and extraperitoneal barium extravasation (24). Despite these caveats, it is important to remember that barium is more sensitive than aqueous contrast agents for demonstrating GI fistulas due to the tendency of the latter to dilute, resulting in lower radiographic opacity (1). This dilution of water-soluble contrast agents is especially limiting for small-bowel examination, and initial evaluation with barium should be strongly considered in patients without pneumoperitoneum, particularly for intestinal (gut-to-gut) fistulas (22). When a water-soluble contrast agent is used initially, a negative study should be followed by a barium study when the index of suspicion remains high.

For imaging of most internal GI fistulas with extraintestinal communication, an aqueous contrast agent is generally preferred. This is obviously the case when the extraenteric component is primarily opacified, as with urographic and cholangiographic contrast-enhanced studies. A water-soluble agent should also be used when there is a possibility of vascular communication, due to the potentially life-threatening complication of barium embolization (25). An exception to this rule of using an aqueous contrast agent for imaging of extraintestinal involvement involves GI fistulas communicating with the tracheobronchial tree, where barium is indicated and generally well tolerated. A water-soluble agent in this setting can lead to potentially lethal pulmonary edema due to their relatively high osmolarity, although the risk is lower with nonionic agents (26,27). Furthermore, unless a large esophageal leak is suspected, barium remains the contrast agent of choice for esophagography, since the risk of clinically important mediastinitis or granuloma formation appears to be negligible with small amounts of barium extravasation (27).

Cross-sectional imaging, particularly computed tomography (CT), has further strengthened the radiologist’s armamentarium for evaluating GI fistulas. CT effectively complements conventional radiography with its ability to demonstrate extraluminal disease, including associated abscesses, tumor, or other coexisting processes. Although CT may be less sensitive for direct detection of some GI fistulas, there are instances where it may be more sensitive than conventional studies, such as with enterovesical fistulas (4,28,29).

Regardless of whether the fistula is directly detected at CT, CT often yields more valuable information overall with respect to patient care. Furthermore, it is important to at least consider the need for obtaining a CT scan prior to performing a conventional barium examination, because residual barium can produce troubling artifacts on CT. Technical advances such as multi–detector row CT allow for effective multiplanar reformations and volume-rendering techniques to directly display fistulas not oriented in the traditional transverse plane. Often, CT directly or indirectly demonstrates the presence of a GI fistula, elucidates the underlying cause, and obviates further imaging. An additional advantage of CT is its utility in guiding percutaneous drainage of associated abscesses.

Magnetic resonance (MR) imaging holds similar promise for the evaluation of certain forms of possible GI fistulas, but the application of MR imaging has been most visible in the evaluation of enterocutaneous fistulas, especially in the perianal region (30–32). Faster imaging sequences and the use of oral contrast agents may further expand the role of MR imaging in the future, but CT remains the primary cross-sectional modality for fistula evaluation because it is rapid, generally available, and less costly than MR imaging. Sonography plays a much more limited role in the evaluation of most GI fistulas and typically requires a corroborative study for confirmation (28,33).

The remainder of this review will focus on the specific forms of GI fistulas.

	INTERNAL GI FISTULAS

TOP ABSTRACT INTRODUCTION CLASSIFICATION OF GI FISTULAS CAUSES OF ACQUIRED GI... OVERVIEW OF IMAGING TECHNIQUES INTERNAL GI FISTULAS EXTERNAL (CUTANEOUS) FISTULAS CONCLUSION REFERENCES

 
Internal GI fistulas include both intestinal and extraintestinal types. Although some of these fistulas may be suspected on clinical grounds, their presence is often first discovered at imaging, sometimes quite unexpectedly. Complex GI fistulas (Fig 1) may consist of virtually any combination of internal and external communication, but for the purpose of this review each component will be considered separately.

Intestinal Fistulas
Intestinal (gut-to-gut) fistulas may involve any or all combinations of the small bowel, colon, and stomach. The clinical manifestation of this subset may be subtle, since only the alimentary tract is involved. Diarrhea, with or without abdominal pain, is the most common symptom overall (9). There are several factors that influence which segments of bowel are involved in the fistulous communication. In cases where a primary bowel abnormality is the underlying cause, the segment of diseased bowel will obviously be at highest risk. Proximity to the pathologic process, be it intestinal or extraintestinal, is also important. Finally, a preexisting or preferred pathway between certain portions of the gut, as with a connecting ligament or mesentery, explains the predisposition for some intestinal fistulas to form (see discussion of gastrocolic fistula later).

Enteroenteric and enterocolic fistulas are common complications of Crohn disease, where fistulas are often multiple and favor the ileocecal region (Fig 3). Enterocolic fistulas in Crohn disease are usually due to primary small-bowel disease, whereas the opposite is true for colonic diverticulitis. Overall, coloenteric fistulas constitute fewer than 10% of fistulas complicating diverticulitis (9). A more common form of intestinal fistula from diverticulitis is the so-called double-tracking colocolic fistula (Fig 4). This intraloop form of intestinal fistula results from localized perforation and paracolic extension that parallels the bowel lumen. A similar appearance can be seen with Crohn disease and perforated adenocarcinoma of the colon. Intestinal fistulas can also be seen in cases of other abdominal malignancies, radiation therapy, surgery, and foreign bodies (Fig 5) (34–36).

View larger version (164K): [in this window] [in a new window] [Download PPT slide]   Figure 3a. Enteroenteric and enterocolic fistulas. (a) Frontal radiograph from barium-enhanced small-bowel study in a 25-year-old man with Crohn disease shows multiple fistulous tracts extending from the terminal ileum (arrowheads), converging to a small mesenteric cavity (*), and communicating with the cecum and more proximal ileum (arrows). (b) Transverse contrast-enhanced CT scan in a 24-year-old man with Crohn disease shows irregular bowel wall thickening, mesenteric infiltration, and contrast agent-filled extraluminal tracts (arrows) centered in the ileocecal region. This complex enterocolic fistula involved distal ileum, cecum, ascending colon, and sigmoid colon.

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Figure 3b. Enteroenteric and enterocolic fistulas. (a) Frontal radiograph from barium-enhanced small-bowel study in a 25-year-old man with Crohn disease shows multiple fistulous tracts extending from the terminal ileum (arrowheads), converging to a small mesenteric cavity (*), and communicating with the cecum and more proximal ileum (arrows). (b) Transverse contrast-enhanced CT scan in a 24-year-old man with Crohn disease shows irregular bowel wall thickening, mesenteric infiltration, and contrast agent-filled extraluminal tracts (arrows) centered in the ileocecal region. This complex enterocolic fistula involved distal ileum, cecum, ascending colon, and sigmoid colon.

View larger version (166K): [in this window] [in a new window] [Download PPT slide]   Figure 4a. Colocolic (double-tracking) fistula. (a) Frontal radiograph from air-contrast barium enema examination in a 50-year-old man 1 month after an episode of acute diverticulitis shows a long-segment narrowing (arrowheads) involving the sigmoid colon. At the distal aspect of the stricture, a second channel (arrow) parallels the colonic lumen, the so-called double-tracking sign. Note additional scattered diverticula. (b) Transverse contrast-enhanced CT scan obtained 1 month earlier than a during an acute episode shows pericolonic inflammatory changes and a small peridiverticular abscess (arrow). Adjacent large diverticulum (arrowhead) may represent the point of eventual fistula reentry. Perforation with a localized fistula was confirmed at surgery and pathologic examination.

View larger version (177K): [in this window] [in a new window] [Download PPT slide]   Figure 4b. Colocolic (double-tracking) fistula. (a) Frontal radiograph from air-contrast barium enema examination in a 50-year-old man 1 month after an episode of acute diverticulitis shows a long-segment narrowing (arrowheads) involving the sigmoid colon. At the distal aspect of the stricture, a second channel (arrow) parallels the colonic lumen, the so-called double-tracking sign. Note additional scattered diverticula. (b) Transverse contrast-enhanced CT scan obtained 1 month earlier than a during an acute episode shows pericolonic inflammatory changes and a small peridiverticular abscess (arrow). Adjacent large diverticulum (arrowhead) may represent the point of eventual fistula reentry. Perforation with a localized fistula was confirmed at surgery and pathologic examination.

View larger version (167K): [in this window] [in a new window] [Download PPT slide]   Figure 5. Enterocolic fistula. Spot radiograph obtained during air insufflation for air-contrast barium enema examination in a 58-year-old man shows unsuspected communication between sigmoid colon and small bowel (arrowheads). The patient had undergone successful surgical removal of an infected abdominal aortic graft 6 months earlier. Note also faint contrast agent (arrow) extending along aortic region.

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Figure 6a. Gastrocolic fistulas. (a) Frontal radiograph from solid-column barium enema examination in a 57-year-old man shows fistulous communication between the transverse colon and stomach via a large benign gastric ulcer (*) extending into the gastrocolic ligament. Note smooth folds radiating from the ulcer crater and absence of a gastric or colonic mass. (b) Contiguous transverse contrast-enhanced CT scans in a 59-year-old woman with abdominal pain and vomiting show pericolonic inflammatory changes surrounding a large transverse colonic diverticulum (arrows) in the gastrocolic region. The process blends imperceptibly with thickened gastric antrum (arrowheads). (c) Image from contrast-enhanced enema examination in the same patient as in b shows gastrocolic fistula (arrowhead), which proved to be secondary to diverticulitis at surgery and pathologic examination.

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 6b. Gastrocolic fistulas. (a) Frontal radiograph from solid-column barium enema examination in a 57-year-old man shows fistulous communication between the transverse colon and stomach via a large benign gastric ulcer (*) extending into the gastrocolic ligament. Note smooth folds radiating from the ulcer crater and absence of a gastric or colonic mass. (b) Contiguous transverse contrast-enhanced CT scans in a 59-year-old woman with abdominal pain and vomiting show pericolonic inflammatory changes surrounding a large transverse colonic diverticulum (arrows) in the gastrocolic region. The process blends imperceptibly with thickened gastric antrum (arrowheads). (c) Image from contrast-enhanced enema examination in the same patient as in b shows gastrocolic fistula (arrowhead), which proved to be secondary to diverticulitis at surgery and pathologic examination.

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 6c. Gastrocolic fistulas. (a) Frontal radiograph from solid-column barium enema examination in a 57-year-old man shows fistulous communication between the transverse colon and stomach via a large benign gastric ulcer (*) extending into the gastrocolic ligament. Note smooth folds radiating from the ulcer crater and absence of a gastric or colonic mass. (b) Contiguous transverse contrast-enhanced CT scans in a 59-year-old woman with abdominal pain and vomiting show pericolonic inflammatory changes surrounding a large transverse colonic diverticulum (arrows) in the gastrocolic region. The process blends imperceptibly with thickened gastric antrum (arrowheads). (c) Image from contrast-enhanced enema examination in the same patient as in b shows gastrocolic fistula (arrowhead), which proved to be secondary to diverticulitis at surgery and pathologic examination.

Extraintestinal Fistulas
The extraintestinal fistulas constitute a diverse and intriguing collection of acquired GI fistulas since they can connect the gut with virtually any other organ system. Extraintestinal fistulas involving the genitourinary, biliary, vascular, and respiratory systems are considered below.

Genitourinary tract.—Communication between the GI and genitourinary tracts represents a major subset of extraintestinal internal fistulas. The bladder and vagina are most often affected, but involvement of the upper collecting system, urethra, or uterus is occasionally seen. Available diagnostic modalities for evaluating these lesions include urographic studies, contrast-enhanced GI studies, cross-sectional imaging, and endoscopic procedures. The most appropriate initial study varies according to fistula type, and the management approach continues to evolve. Both CT and MR imaging have proved to be useful for noninvasive evaluation of pelvic fistulas (30,31).

The term enterovesical fistula is often generally applied for bladder communication with the colon, small bowel, rectum, or appendix (28,40). Sigmoid diverticulitis is the single most common cause of enterovesical (specifically, colovesical) fistula (9). Furthermore, fistulas to the urinary bladder account for over half of all internal fistulas encountered in diverticular disease (Fig 7). Crohn disease accounts for most small-bowel–to-bladder fistulas and may be present in up to 3%–4% of patients with this disease (Fig 8) (29). Pelvic malignancy, especially colorectal adenocarcinoma, is the other major cause of a GI fistula to the bladder, followed by radiation- and surgically induced fistulas. Approximately 20% of all enterovesical fistulas are rectovesical, and fewer than 5% are appendicovesical (Fig 9). Specific clinical symptoms (fecaluria and pneumaturia) are present in 40%–70% of patients, but nonspecific symptoms such as cystitis are invariably present (9,28,40–42).

View larger version (93K): [in this window] [in a new window] [Download PPT slide]   Figure 7. Colovesical fistula. Transverse contrast-enhanced CT scans in a 56-year-old-man with pneumaturia and prior diverticulitis show air (arrowhead) in the bladder and the site of fistulous communication (arrow) between sigmoid colon and bladder. Note diverticulosis of the sigmoid colon.

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 8a. Enterovesical fistula. (a) Contiguous transverse CT scans obtained with intravenous and oral contrast agents in a 69-year-old woman with longstanding Crohn disease show a heterogeneous soft-tissue mass (M) associated with thickened ileal loops and adjacent bladder wall thickening (arrowhead). A small gas bubble (arrow) is present in the bladder lumen. (b) Fluoroscopic image shows contrast agent injection through a communicating enterocutaneous fistula and demonstrates the fistula (arrowhead) between the ileal segment and bladder. Small-bowel adenocarcinoma complicating Crohn disease was proved at surgery.

View larger version (146K): [in this window] [in a new window] [Download PPT slide]   Figure 8b. Enterovesical fistula. (a) Contiguous transverse CT scans obtained with intravenous and oral contrast agents in a 69-year-old woman with longstanding Crohn disease show a heterogeneous soft-tissue mass (M) associated with thickened ileal loops and adjacent bladder wall thickening (arrowhead). A small gas bubble (arrow) is present in the bladder lumen. (b) Fluoroscopic image shows contrast agent injection through a communicating enterocutaneous fistula and demonstrates the fistula (arrowhead) between the ileal segment and bladder. Small-bowel adenocarcinoma complicating Crohn disease was proved at surgery.

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 9. Rectovesical fistula. Transverse contrast-enhanced CT scan in a 65-year-old-man with ulcerative colitis shows air in a fistulous tract (arrow) between inflamed rectum and bladder. Note also air (arrowheads) in bladder lumen.

GI fistulas to the kidney or upper urinary tract are much less common than bladder fistulas and are more often due to urologic disease rather than a primary GI process (17,43,44). The "retroperitonealized" portions of the colon and duodenum are most often involved. Communication of the colon with the pelvicaliceal system (renocolic fistula) or the ureter (ureterocolic fistula) typically occurs secondary to chronic suppurative renal infection in the setting of urolithiasis and/or obstruction, as seen with xanthogranulomatous pyelonephritis (17,43,45). Less common causes include tuberculosis, trauma, surgery, radiation therapy, Crohn disease, diverticulitis, and malignancy (Fig 10) (46–48). Although fecaluria and pneumaturia may be present, the clinical picture more often is nonspecific and related to chronic or recurrent urinary tract infection (44).

View larger version (163K): [in this window] [in a new window] [Download PPT slide]   Figure 10a. Ureteroduodenal fistula. (a) Frontal radiograph obtained after retrograde contrast agent injection of right upper urinary collecting system in a 67-year-old man shows contrast agent within the duodenum (arrows) from an unsuspected fistula. Note wire (black arrowheads) and small amount of retained contrast agent (white arrowhead) in the collecting system. (b) Contrast-enhanced CT scan performed after a shows site of contact (white arrowhead) between duodenum and right ureter. The fistula likely resulted from injury during previous aortofemoral bypass surgery. Note vascular graft (black arrowhead) and right ureteral stent (arrow).

View larger version (169K): [in this window] [in a new window] [Download PPT slide]   Figure 10b. Ureteroduodenal fistula. (a) Frontal radiograph obtained after retrograde contrast agent injection of right upper urinary collecting system in a 67-year-old man shows contrast agent within the duodenum (arrows) from an unsuspected fistula. Note wire (black arrowheads) and small amount of retained contrast agent (white arrowhead) in the collecting system. (b) Contrast-enhanced CT scan performed after a shows site of contact (white arrowhead) between duodenum and right ureter. The fistula likely resulted from injury during previous aortofemoral bypass surgery. Note vascular graft (black arrowhead) and right ureteral stent (arrow).

The acquired rectovaginal fistula is the most common GI fistula involving the genital tract in women. Most cases are related to obstetric complications, inflammatory bowel disease, or some combination of gynecologic malignancy (particularly cervical cancer), surgery, and radiation therapy (7,50). Although the clinical symptoms, particularly the passage of feces through the vagina, usually indicate the presence of a fistula, its detection is often difficult on conventional GI studies unless a relatively large communication is present (Fig 11). Vaginography may demonstrate the fistula more clearly in subtle cases (51). More recently, CT and MR imaging have been shown to be useful for detection of rectovaginal and enterovaginal fistulas, whereas endorectal sonography appears to be relatively insensitive (30,33,52). An enteric contrast agent and/or air within the vagina can be demonstrated on CT scans in the majority of cases (52). Simple excision is often not adequate in these complex cases, and at least temporary colonic diversion is usually necessary. GI fistulas involving the uterine body and fallopian tubes are rare, compared with vaginal fistulas, and most often involve the left side of the colon (53). Most colouterine and colotubal (salpingocolic) fistulas result from diverticulitis, but a variety of other GI and genitourinary causes are possible, especially in younger women (9,53). Actinomycosis should be considered in the setting of an intrauterine device. A combination of hysterosalpingography and CT will provide a comprehensive preoperative assessment in most cases (Fig 12). Acquired rectourethral fistulas in males are also rare, with the majority of cases related to treatment for prostate cancer (Fig 13) (54).

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 11. Rectovaginal fistula. Lateral radiograph from air-contrast barium enema examination in a 38-year-old woman with ulcerative colitis shows air and contrast agent within the vagina (V). The site of communication (arrow) is visible inferiorly. The rectosigmoid region appears somewhat foreshortened and featureless.

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 12. Salpingocolic (colotubal) fistula. Frontal pelvic radiograph from hysterosalpingogram in a 28-year-old woman with a history of pelvic inflammatory disease shows left hydrosalpinx and contrast agent filling a tubo-ovarian abscess cavity (A), with extension superiorly into the left side of the colon (arrowheads).

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 13. Rectourethral fistula. Oblique radiograph from retrograde urethrogram in a 64-year-old man with a history of brachytherapy for prostate cancer shows contrast agent in the rectum (arrowheads). Contrast agent entered the rectum via a large communication with the prostatic urethra (arrow). As expected, contrast agent is also present in the anterior urethra and bladder (B). Note radiopaque brachytherapy implants in prostatic region.

Pneumobilia seen on imaging studies strongly suggests the presence of an internal biliary fistula in the absence of prior sphincterotomy, surgical bypass procedure, recent endoscopic retrograde cholangiopancreatography, or passed common duct stone. The Rigler triad of small-bowel obstruction, pneumobilia, and ectopic gallstone(s) is virtually pathognomonic for gallstone ileus but is present on conventional radiographs in only 30%–35% of cases (Fig 14a) (58). This triad of findings, however, is more readily apparent on CT scans (Fig 14b) (59). CT can also provide important information on the degree of bowel obstruction and suggest the likely site of fistula formation. Endoscopic retrograde cholangiopancreatography is a sensitive technique for direct demonstration of enterobiliary fistulas, especially those of the choledochoduodenal type. Conventional contrast-enhanced GI studies are somewhat less direct for direct demonstration but nonetheless are relatively noninvasive and may help detect an unsuspected communication with the biliary tree (Fig 15). Compared with CT, sonography is less accurate for detection of cholecystoenteric fistulas, but suggestive findings include an irregular contracted gallbladder, nonvisualization of the gallbladder, and pneumobilia (56).

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 14a. Gallstone ileus from cholecystoduodenal fistula. (a) Supine radiograph in a 76-year-old woman shows bowel gas pattern suggestive of small-bowel obstruction, two ectopic calcified gallstones (arrowheads), and air in the biliary tree (arrows). These findings constitute the Rigler triad. (b) Transverse CT scans obtained without intravenous contrast agent in an 85-year-old woman show pneumobilia (arrowheads) and high-grade small-bowel obstruction from an ectopic gallstone (short arrow). Note also orthotopic gallstones (long arrow) with a similar appearance.

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 14b. Gallstone ileus from cholecystoduodenal fistula. (a) Supine radiograph in a 76-year-old woman shows bowel gas pattern suggestive of small-bowel obstruction, two ectopic calcified gallstones (arrowheads), and air in the biliary tree (arrows). These findings constitute the Rigler triad. (b) Transverse CT scans obtained without intravenous contrast agent in an 85-year-old woman show pneumobilia (arrowheads) and high-grade small-bowel obstruction from an ectopic gallstone (short arrow). Note also orthotopic gallstones (long arrow) with a similar appearance.

View larger version (145K): [in this window] [in a new window] [Download PPT slide]   Figure 15. Cholecystocolic fistula. Spot radiograph from barium enema examination in an 81-year-old man with nonspecific abdominal complaints shows contrast agent within the gallbladder (*) from communication with the hepatic flexure. Air (arrowheads) is present within the biliary tree.

The aorta lies in proximity with the GI tract for much of its thoracic and abdominal course. Aortoenteric fistulas, therefore, can potentially involve the gut anywhere from the esophagus to the colon (60–62). The majority of cases occur in the presence of aortic aneurysm disease, either as a primary event or a secondary complication following surgical repair (60). Aortic fistulas involving the duodenum and esophagus warrant further consideration.

The duodenum participates in the majority of aortoenteric fistulas, owing to the proximity between its third portion and the underlying abdominal aorta. Primary aortoduodenal fistula is a rare life-threatening cause of gastrointestinal bleeding that results most commonly from an atherosclerotic aortic aneurysm (60,63). Unusual causes of a primary fistula include aortitis, radiation therapy, malignancy, and peptic ulcer disease (64,65). Most patients have upper or lower GI bleeding, but the classic triad of abdominal pain, GI bleeding, and pulsatile mass is present in fewer than 25% of cases (60,66). A "herald bleed" frequently precedes lethal exsanguination, and patient survival hinges on prompt diagnosis and emergent therapeutic laparotomy. Unfortunately, a correct preoperative diagnosis is determined in only a minority of cases, underscoring the importance of heightened clinical suspicion (60). Endoscopy is often the initial diagnostic study performed, but blood pooling may impair luminal visibility, and an alternate presumed source of bleeding is frequently identified, acting as a "red herring" (60). Conventional upper GI study, sonography, aortography, and tagged red blood cell scintigraphy all have marked limitations for diagnosis (67). CT, however, provides rapid and effective evaluation in hemodynamically stable patients suspected of having an aortoenteric fistula. CT findings such as perianeurysmal hematoma, pseudoaneurysm, contrast agent extravasation, periaortic or intraluminal gas, and focal duodenal wall thickening are highly suggestive of a fistula in the appropriate clinical setting (Fig 16a) (63,67,68).

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 16a. Primary and secondary aortoduodenal fistulas. (a) Primary aortoduodenal fistula. Transverse nonenhanced CT scan in an 80-year-old woman with GI bleeding shows a calcified abdominal aortic aneurysm (A) with intraluminal gas (arrow). Massive high-attenuation retroperitoneal hemorrhage (H) surrounds the aorta. (b) Secondary aortoduodenal fistula. Contiguous transverse contrast-enhanced CT scans in a 71-year-old man with GI bleeding and history of aortic repair shows air (black arrow) in the lumen of the aortic graft and tethering (white arrow) of overlying duodenum associated with periaortic inflammatory changes.

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 16b. Primary and secondary aortoduodenal fistulas. (a) Primary aortoduodenal fistula. Transverse nonenhanced CT scan in an 80-year-old woman with GI bleeding shows a calcified abdominal aortic aneurysm (A) with intraluminal gas (arrow). Massive high-attenuation retroperitoneal hemorrhage (H) surrounds the aorta. (b) Secondary aortoduodenal fistula. Contiguous transverse contrast-enhanced CT scans in a 71-year-old man with GI bleeding and history of aortic repair shows air (black arrow) in the lumen of the aortic graft and tethering (white arrow) of overlying duodenum associated with periaortic inflammatory changes.

Aortoesophageal fistulas are rare; in the majority of cases, they are caused by localized rupture of a thoracic aortic aneurysm (72,73). Unusual reported causes include esophageal carcinoma, foreign body ingestion, syphilis, and infected aortic graft (73–76). The clinical manifestation is fairly characteristic and is described by the Chiari triad: midthoracic pain or dysphagia, a sentinel episode of hematemesis, and a symptom-free interval that gives way to massive upper GI bleeding (73,76). Diagnosis prior to exsanguination is obviously imperative for successful surgical repair. The chest radiograph will typically demonstrate the presence of an enlarged or tortuous thoracic aorta (72). In stable patients, the combination of CT and contrast-enhanced esophagography will usually be diagnostic. The esophagogram will usually demonstrate deviation of the esophagus due to the aneurysm, with or without ulceration (Fig 17b) (72). The CT findings are analogous to those seen with aortoduodenal fistulas (Fig 17a). Aortography was performed in the past but provides less information than does chest CT and only rarely will show the fistula directly (72,77).

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 17a. Aortoesophageal fistula. (a) Transverse contrast-enhanced CT scan in a 52-year-old man with hematemesis and prior repair of thoracic aortic aneurysm with an endoluminal stent-graft shows air (arrowhead) in the aortic lumen adjacent to the stent-graft. Irregular air collection is also present in the expected region of the esophagus (arrow). (b) Oblique radiograph from contrast-enhanced esophagogram directly demonstrates aortoesophageal fistula (arrows), which was confirmed at surgery.

View larger version (173K): [in this window] [in a new window] [Download PPT slide]   Figure 17b. Aortoesophageal fistula. (a) Transverse contrast-enhanced CT scan in a 52-year-old man with hematemesis and prior repair of thoracic aortic aneurysm with an endoluminal stent-graft shows air (arrowhead) in the aortic lumen adjacent to the stent-graft. Irregular air collection is also present in the expected region of the esophagus (arrow). (b) Oblique radiograph from contrast-enhanced esophagogram directly demonstrates aortoesophageal fistula (arrows), which was confirmed at surgery.

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 18. Colovenous fistula. Postevacuation radiograph from barium enema examination shows contrast agent throughout the inferior mesenteric venous system (arrowheads). Colovenous fistula was due to diverticulitis. Note extensive sigmoid diverticulosis in this region. (Case courtesy of Charles A. Rohrmann, MD, Seattle, Wash.)

Direct invasion by esophageal carcinoma is the most common cause of acquired tracheoesophageal and bronchoesophageal fistulas, seen in approximately 5% of cases (88,89). Fistulas are especially common following radiation therapy in these patients. Other causes of tracheo- and bronchoesophageal fistulas include primary lung and tracheal carcinoma, esophageal instrumentation, tracheal intubation, trauma, presence of foreign bodies, and granulomatous infection (89–91). Patients typically present with dysphagia and symptoms suggestive of aspiration. The barium esophagogram remains the study of choice, because it effectively differentiates fistula from aspiration (Fig 19a, 19b). The lateral projection will generally best define tracheoesophageal fistulas, whereas bronchoesophageal fistulas may require a slightly different obliquity. As previously mentioned, aqueous contrast agents should be avoided because of the risk of potentially lethal pulmonary edema. CT can be a useful adjunct in selected cases for evaluation of the underlying cause or assessment of tumor burden (Fig 19c). Treatment options for malignant fistulas include palliation with gastrostomy or jejunostomy, surgical bypass or correction, and endoprosthetic stent placement (88,92). For benign fistulas, the goal of treatment is generally to achieve definitive repair (89).

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 19a. Tracheoesophageal and bronchoesophageal fistulas. (a) Lateral radiograph from barium esophagogram in a 61-year-old man with esophageal cancer shows contrast agent delineating tracheoesophageal communication (arrowhead). Note widening of tracheoesophageal stripe (*) and mass effect on the trachea from tumor. (b) Lateral radiograph from barium esophagogram in a 61-year-old man with recurrent pneumonia shows fistula (arrow) between esophagus and airway that was secondary to histoplasmosis. (c) Reformatted oblique transverse multi-detector row helical CT scan in a 47-year-old man with bronchogenic carcinoma shows irregular fistulous tract extending from the left bronchial tree (black arrowhead) to the esophagus (black arrow). Five standard transverse CT images (not shown) were needed to sequentially demonstrate the oblique course displayed on this single reformatted image. Note oral contrast agent (white arrow) in segmental bronchus and peripheral airspace consolidation (white arrowhead). The patient was treated with a covered esophageal stent.

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 19b. Tracheoesophageal and bronchoesophageal fistulas. (a) Lateral radiograph from barium esophagogram in a 61-year-old man with esophageal cancer shows contrast agent delineating tracheoesophageal communication (arrowhead). Note widening of tracheoesophageal stripe (*) and mass effect on the trachea from tumor. (b) Lateral radiograph from barium esophagogram in a 61-year-old man with recurrent pneumonia shows fistula (arrow) between esophagus and airway that was secondary to histoplasmosis. (c) Reformatted oblique transverse multi-detector row helical CT scan in a 47-year-old man with bronchogenic carcinoma shows irregular fistulous tract extending from the left bronchial tree (black arrowhead) to the esophagus (black arrow). Five standard transverse CT images (not shown) were needed to sequentially demonstrate the oblique course displayed on this single reformatted image. Note oral contrast agent (white arrow) in segmental bronchus and peripheral airspace consolidation (white arrowhead). The patient was treated with a covered esophageal stent.

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 19c. Tracheoesophageal and bronchoesophageal fistulas. (a) Lateral radiograph from barium esophagogram in a 61-year-old man with esophageal cancer shows contrast agent delineating tracheoesophageal communication (arrowhead). Note widening of tracheoesophageal stripe (*) and mass effect on the trachea from tumor. (b) Lateral radiograph from barium esophagogram in a 61-year-old man with recurrent pneumonia shows fistula (arrow) between esophagus and airway that was secondary to histoplasmosis. (c) Reformatted oblique transverse multi-detector row helical CT scan in a 47-year-old man with bronchogenic carcinoma shows irregular fistulous tract extending from the left bronchial tree (black arrowhead) to the esophagus (black arrow). Five standard transverse CT images (not shown) were needed to sequentially demonstrate the oblique course displayed on this single reformatted image. Note oral contrast agent (white arrow) in segmental bronchus and peripheral airspace consolidation (white arrowhead). The patient was treated with a covered esophageal stent.

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 20a. Esophagopleural fistulas. (a) Transverse nonenhanced CT scan in a 43-year-old woman shows large air-fluid collection in left pleural space (P) that encroaches on the esophagus (arrow). (b) Subsequent esophagogram shows contrast agent leak (arrowheads) from the distal esophagus into empyema. (c) Transverse contrast-enhanced CT scan in a 29-year-old man with a history of radiation therapy for Hodgkin disease shows communication (arrow) between esophagus and apical hydropneumothorax (P). L = aerated right upper lobe.

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 20b. Esophagopleural fistulas. (a) Transverse nonenhanced CT scan in a 43-year-old woman shows large air-fluid collection in left pleural space (P) that encroaches on the esophagus (arrow). (b) Subsequent esophagogram shows contrast agent leak (arrowheads) from the distal esophagus into empyema. (c) Transverse contrast-enhanced CT scan in a 29-year-old man with a history of radiation therapy for Hodgkin disease shows communication (arrow) between esophagus and apical hydropneumothorax (P). L = aerated right upper lobe.

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 20c. Esophagopleural fistulas. (a) Transverse nonenhanced CT scan in a 43-year-old woman shows large air-fluid collection in left pleural space (P) that encroaches on the esophagus (arrow). (b) Subsequent esophagogram shows contrast agent leak (arrowheads) from the distal esophagus into empyema. (c) Transverse contrast-enhanced CT scan in a 29-year-old man with a history of radiation therapy for Hodgkin disease shows communication (arrow) between esophagus and apical hydropneumothorax (P). L = aerated right upper lobe.

View larger version (175K): [in this window] [in a new window] [Download PPT slide]   Figure 21a. Gastropericardial and esophagopericardial fistulas. (a) Transverse contrast-enhanced CT scan in an 82-year-old woman with spontaneous pneumopericardium (P) shows hiatal hernia with inflammatory changes (arrowheads) adjacent to the pericardium. Gastropericardial communication (arrow) is suggested and was confirmed at fluoroscopic examination with water-soluble contrast agent (not shown). A penetrating benign gastric ulcer was the underlying cause. (b) Oblique esophagogram in a 73-year-old man with spontaneous pneumopericardium after distal esophagectomy for cancer shows contrast agent filling the pericardial space (arrowheads) via the esophagopericardial fistula. (Case courtesy of Charles A. Rohrmann, MD, Seattle, Wash.)

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 21b. Gastropericardial and esophagopericardial fistulas. (a) Transverse contrast-enhanced CT scan in an 82-year-old woman with spontaneous pneumopericardium (P) shows hiatal hernia with inflammatory changes (arrowheads) adjacent to the pericardium. Gastropericardial communication (arrow) is suggested and was confirmed at fluoroscopic examination with water-soluble contrast agent (not shown). A penetrating benign gastric ulcer was the underlying cause. (b) Oblique esophagogram in a 73-year-old man with spontaneous pneumopericardium after distal esophagectomy for cancer shows contrast agent filling the pericardial space (arrowheads) via the esophagopericardial fistula. (Case courtesy of Charles A. Rohrmann, MD, Seattle, Wash.)

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 22. Pancreaticocolocutaneous fistula. Frontal radiograph from barium enema examination in a 55-year-old man with severe pancreatitis shows contrast agent filling an irregular retroperitoneal collection (*) extending from the region of the pancreatic tail. Communication with the pancreatic ductal system is not apparent. Note also colocutaneous fistula (arrowheads).

	EXTERNAL (CUTANEOUS) FISTULAS

TOP ABSTRACT INTRODUCTION CLASSIFICATION OF GI FISTULAS CAUSES OF ACQUIRED GI... OVERVIEW OF IMAGING TECHNIQUES INTERNAL GI FISTULAS EXTERNAL (CUTANEOUS) FISTULAS CONCLUSION REFERENCES

 
Notwithstanding the deliberate creation of a gastrostomy, jejunostomy, or colostomy, the majority of unintended enterocutaneous fistulas represent a complication of prior surgery. Diverticulitis, appendicitis, Crohn disease, and other causes listed in Figure 2 may also manifest with a spontaneous external fistula on occasion (1). Perianal fistulas are somewhat unusual in that most appear to be idiopathic in nature or due to Crohn disease; these will be considered separately at the end of this section (103).

Factors that predispose to postoperative enterocutaneous fistula formation include anastomotic failure (eg, due to inadequate blood supply, diseased bowel, undue tension), adjacent abscess formation, distal obstruction, and certain underlying disease processes (12,104). Many of these same factors will also influence the likelihood of spontaneous closure of such fistulas. Enterocutaneous fistulas are further categorized according to their degree of fluid production. High-output fistulas drain more than 100–200 mL/day and generally originate in the upper GI tract, whereas low-output fistulas drain less than this amount and are typically more distal. Clinical management issues beyond diagnosis and treatment of the fistula itself include addressing potential electrolyte imbalances, sepsis, malnutrition, and wound care (105).

Enterocutaneous fistulas can be adequately delineated and followed with fistulography in the majority of cases (Fig 23) (20). In some instances, the fistulous tract may be shown to equal or better advantage with use of an intraluminal enteric contrast agent (Fig 22). The most common approach for fistulography is to gently insert a soft-tipped catheter and inject a water-soluble contrast agent with fluoroscopic guidance to opacify the tract. Contrast agent injection into an existing surgical drain can also yield informative findings. In addition to a variety of occlusive adaptors and balloons to obturate the skin site, it is often useful to have the able patient hold the catheter firmly in place during contrast agent injection. Although fistulography will usually demonstrate the bowel connection and any large communicating abscess, CT is usually performed in conjunction not only to help identify all abscess cavities but also to guide percutaneous drainage of any abscesses found (106,107). In current practice, external fistulas and associated abscesses are often first discovered or evaluated on CT scans, especially if the fistulous tract extends only to the subcutaneous tissue (Fig 24). Hydrogen peroxide–enhanced sonography has been used recently at some centers to delineate enterocutaneous fistulas (108).

View larger version (168K): [in this window] [in a new window] [Download PPT slide]   Figure 23. Enterocutaneous fistula. Oblique radiograph from pelvic fistulogram in a 29-year-old man with abdominal tuberculosis shows enterocutaneous fistula (arrowheads). Note second cutaneous fistula (arrow) that communicates with injection site.

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 24a. Gastrocutaneous and colocutaneous fistulas. (a) Transverse contrast-enhanced CT scan in a 65-year-old woman with Crohn disease shows unsuspected gastrocutaneous fistula (F). Note soft-tissue thickening (arrowheads) of the abdominal wall and stomach. A focal abdominal bulge was initially thought at clinical examination to be a ventral hernia because overlying skin was still intact at that time. (b) Transverse contrast-enhanced CT scan in a 78-year-old man who had previously undergone surgery for abdominal wall abscess shows enteric contrast agent (arrow) outlining a colocutaneous fistula involving the sigmoid colon (S) and an abdominal wound. Diverticulitis was the underlying cause for both the original abscess and recurrent fistula.

View larger version (167K): [in this window] [in a new window] [Download PPT slide]   Figure 24b. Gastrocutaneous and colocutaneous fistulas. (a) Transverse contrast-enhanced CT scan in a 65-year-old woman with Crohn disease shows unsuspected gastrocutaneous fistula (F). Note soft-tissue thickening (arrowheads) of the abdominal wall and stomach. A focal abdominal bulge was initially thought at clinical examination to be a ventral hernia because overlying skin was still intact at that time. (b) Transverse contrast-enhanced CT scan in a 78-year-old man who had previously undergone surgery for abdominal wall abscess shows enteric contrast agent (arrow) outlining a colocutaneous fistula involving the sigmoid colon (S) and an abdominal wound. Diverticulitis was the underlying cause for both the original abscess and recurrent fistula.

As mentioned earlier, perianal fistulas represent a unique subset of external fistulas. In the majority of cases, preoperative imaging is not necessary and patients generally do well with simple fistulotomy (103). In a minority of complex cases, however, preoperative imaging will be necessary to provide a road map for surgery. The primary goals of imaging are to determine if the fistula traverses the external sphincter (transsphincteric) or levator ani muscles and to identify any secondary fistulous tracts or abscess cavities that could lead to treatment failure (32). Most attempts at preoperative imaging with conventional fistulography, endoscopic sonography, and CT have failed to surpass the accuracy of the clinical examination (112–114). MR imaging, however, has shown notable promise and appears to be of most value in patients with Crohn disease and recurrent fistulas (Fig 25) (115). Hydrogen peroxide–enhanced sonography has also been used successfully for the evaluation of perianal fistulas (116).

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 25. Transsphincteric perianal fistula. Coronal dynamic contrast-enhanced gradient-echo MR image obtained with fat suppression in 34-year-old man without a history of Crohn disease shows a left-sided fistula (arrow) that pierces both sphincteric layers to exit the middle third of the anus. The fistula tracks inferiorly within the ischiorectal fossa. Note conspicuity of high-signal-intensity lesion due to inflammatory enhancement. (Case courtesy of John A. Spencer, MD, Leeds, England.)

	CONCLUSION

TOP ABSTRACT INTRODUCTION CLASSIFICATION OF GI FISTULAS CAUSES OF ACQUIRED GI... OVERVIEW OF IMAGING TECHNIQUES INTERNAL GI FISTULAS EXTERNAL (CUTANEOUS) FISTULAS CONCLUSION REFERENCES

	FOOTNOTES

 
Abbreviation: GI = gastrointestinal

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Navy or Defense.

	REFERENCES

TOP ABSTRACT INTRODUCTION CLASSIFICATION OF GI FISTULAS CAUSES OF ACQUIRED GI... OVERVIEW OF IMAGING TECHNIQUES INTERNAL GI FISTULAS EXTERNAL (CUTANEOUS) FISTULAS CONCLUSION REFERENCES

 

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