The Evaluation and Treatment of Crohn Perianal Fistulae: EUA, EUS, MRI, and Other Imaging Modalities

Wise, Paul E.; Schwartz, David L.

doi:10.1016/j.gtc.2012.01.009

Cited by 36 publications

(21 citation statements)

References 68 publications

(64 reference statements)

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“…Magnetic resonance imaging (MRI) is the single best imaging modality for this purpose, although sometimes the addition of other tests such as endoanal ultrasound (EUS) is required. During recent years, the focus of MRI research on fistula-in-ano has been two-fold; most previous research focused on comparing MRI with EUS or examination under anesthesia (EUA) [6][7][8] , but during more recent years, as efficacy of MRI has been more established, the focus of research has shifted to assessment of inflammatory activity. However, when it comes to choosing the right sequences, there has only been one published original study (by Halligan et al [9] ), which was performed back in 1998.…”

Section: Introductionmentioning

confidence: 99%

Comparison of different magnetic resonance imaging sequences for assessment of fistula-in-ano

Torkzad¹,

Åhlström²,

Karlbom³

2014

WJR

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AIM:To assess agreement between different forms of T2 weighted imaging (T2WI), and post-contrast T1WI in the depiction of fistula tracts, inflammation, and internal openings with that of a reference test. METHODS:Thirty-nine consecutive prospective cases were enrolled. The following sequences were used for T2WI: 2D turbo-spin-echo (2D T2 TSE); 3D T2 TSE; short tau inversion recovery (STIR); 2D T2 TSE with fat saturation performed in all patients. T1WI were either a 3D T1-weighted prepared gradient echo sequence with fat saturation or a 2D T1 fat saturation [Spectral presaturation with inversion (SPIR)]. Agreement for each sequence for determination of fistula extension, internal openings, and the presence of active inflammation was assessed separately and blindly against a reference test comprised of follow-up, surgery, endoscopic ultrasound, and assessment by an independent experienced radiologist with access to all images. RESULTS:Fifty-six fistula tracts were found: 2 intersphincteric, 13 trans-sphincteric, and 24 with additional tracts. The best T2 weighted sequence for depiction of fistula tracts was 2D T2 TSE (Cohen's kappa = 1.0), followed by 3D T2 TSE (0.88), T2 with fat saturation (0.54), and STIR (0.19). Internal openings were best seen on 2D T2 TSE (Cohen's kappa = 0.88), followed by 3D T2 TSE (0.70), T2 with fat saturation (0.54), and STIR (0.31). Detection of inflammation showed Cohen's kappa of 0.88 with 2D T2 TSE, 0.62 with 3D T2 TSE, 0.63 with STIR, and 0.54 with T2 with fat saturation. STIR, 3D T2 TSE, and T2 with fat saturation did not make any contributions compared to 2D T2 TSE. Post-contrast 3D T1 weighted prepared gradient echo sequence with fat saturation showed better agreement in the depiction of fistulae (Cohen's kappa = 0.94), finding internal openings (Cohen's kappa = 0.97), and evaluating inflammation (Cohen's kappa = 0.94) compared to post-contrast 2D T1 fat saturation or SPIR where the corresponding figures were 0.71, 0.66, and 0.87, respectively. Comparing the best T1 and T2 sequences showed that, for best results, both sequences were necessary. CONCLUSION: 3D T1 weighted sequences were best for the depiction of internal openings and active inflammatory components, while 2D T2 TSE provided the best assessment of fistula extension. Key words: Fistula; Magnetic resonance imaging; Diagnosis Core tip: Both T1 (post-contrast) and T2 weighted sequences are needed for the best assessment of fistulain-ano; T2 weighted imaging: 2D turbo-spin-echo (2D T2 TSE) is most useful for depiction in relation to sphincter muscles. 3D T2 TSE cannot replace 2D T2 TSE. Post-contrast 3D T1 weighted prepared gradient echo sequence with fat saturation is necessary for the CASE CONTROL STUDY

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Section: Introductionmentioning

confidence: 99%

Comparison of different magnetic resonance imaging sequences for assessment of fistula-in-ano

Torkzad¹,

Åhlström²,

Karlbom³

2014

WJR

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“…MDCT techniques are highly accurate for the detection of extraintestinal manifestations, especially for abscesses and fistulae (level A) [68,81]. MRI is the gold standard to image perianal lesions of patients with suspicion of CD (level A) [82,83,84,85]. Anorectal US is helpful to evaluate perianal abscesses (level B).…”

Section: Assessment At Diagnosismentioning

confidence: 99%

“…Transdermal perianal US might enhance the diagnostic accuracy regarding perianal fistulae and abscesses (level C) [82,83,84,85,86,87,88,89,90,91,92]. Imaging should be performed in combination with examination under anaesthesia (level D).…”

Section: Monitoring In Symptomatic Patientsmentioning

confidence: 99%

Monitoring Disease Activity and Progression in Crohn's Disease. A Swiss Perspective on the IBD Ahead ‘Optimised Monitoring' Recommendations

Sauter

Beglinger²,

Girardin³

et al. 2014

Digestion

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Background and Aims: The structured IBD Ahead ‘Optimised Monitoring' programme was designed to obtain the opinion, insight and advice of gastroenterologists on optimising the monitoring of Crohn's disease activity in four settings: (1) assessment at diagnosis, (2) monitoring in symptomatic patients, (3) monitoring in asymptomatic patients, and (4) the postoperative follow-up. For each of these settings, four monitoring methods were discussed: (a) symptom assessment, (b) endoscopy, (c) laboratory markers, and (d) imaging. Based on literature search and expert opinion compiled during an international consensus meeting, recommendations were given to answer the question ‘which diagnostic method, when, and how often'. The International IBD Ahead Expert Panel advised to tailor this guidance to the healthcare system and the special prerequisites of each country. The IBD Ahead Swiss National Steering Committee proposes best-practice recommendations adapted for Switzerland. Methods: The IBD Ahead Steering Committee identified key questions and provided the Swiss Expert Panel with a structured literature research. The expert panel agreed on a set of statements. During an international expert meeting the consolidated outcome of the national meetings was merged into final statements agreed by the participating International and National Steering Committee members - the IBD Ahead ‘Optimized Monitoring' Consensus. Results: A systematic assessment of symptoms, endoscopy findings, and laboratory markers with special emphasis on faecal calprotectin is deemed necessary even in symptom-free patients. The choice of recommended imaging methods is adapted to the specific situation in Switzerland and highlights the importance of ultrasonography and magnetic resonance imaging besides endoscopy. Conclusion: The recommendations stress the importance of monitoring disease activity on a regular basis and by objective parameters, such as faecal calprotectin and endoscopy with detailed documentation of findings. Physicians should not rely on symptoms only and adapt the monitoring schedule and choice of options to individual situations.

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“…Other investigations that may provide useful information include transperineal ultrasonography, endorectal endoscopic ultrasonography and flexible sigmoidoscopy to assess the inflammation in the rectum [6]. Healing of a perianal fistula is often slow, and therefore repeated frequent imaging is generally unnecessary, unless there is suspicion of a new fistula developing.…”

Section: Perianal Crohn's Diseasementioning

confidence: 99%

Role of Immunosuppressives in Special Situations: Perianal Disease and Postoperative Period

Ghosh

Iacucci

2014

Dig Dis

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Complex perianal disease is associated with poor outcome and requires early effective therapy. Corticosteroids are not effective in perianal fistulising Crohn's disease, and antibiotics, immunosuppressants and anti-TNF therapy are required. It is important to consider combined medical surgical therapy after accurate imaging using an MRI scan of the pelvis. Drainage of any abscess at examination under anaesthesia and seton insertion are important before introduction of immunosuppressants and anti-TNF therapy. Long-term follow up of patients in a single centre reported responders to azathioprine having a reduced risk of perianal surgery (OR = 0.36; 95% CI: 0.27-0.46), but complex perianal fistulising Crohn's disease generally requires combination therapy with anti-TNF and azathioprine. Patients with recent perianal disease without fistulae and aged 40 years or older respond better to azathioprine monotherapy. Response to monotherapy with azathioprine is often slow and incomplete. In the recent GETAID study of early administration of azathioprine versus conventional management in patients at high risk of disabling disease, a higher cumulative proportion of patients in the azathioprine group were free of perianal surgery. In patients not responding to anti-TNF therapy, thalidomide or tacrolimus may be considered. Hyperbaric oxygen may be used as adjunctive therapy where available. The role of adipose-derived stem cell injection requires further long-term studies. In prevention of post-operative recurrence of Crohn's disease, azathioprine or 6-mercaptopurine had a favourable incremental cost-effectiveness ratio compared with no prophylactic therapy up to 1 year. In a Cochrane systematic review, azathioprine/6-mercaptopurine was associated with a significantly reduced risk of clinical recurrence [RR = 0.59, 95% CI: 0.38-0.92, number needed to treat (NNT) = 7] and severe endoscopic recurrence (RR = 0.6, 95% CI: 0.44-0.92, NNT = 4). Individual studies of prevention of post-operative recurrence using azathioprine/6-mercaptopurine have shown only modest benefit. In patients at high risk of relapse after surgical resection, anti-TNF therapy may be beneficial, but more data is required from ongoing studies. Strategies to prevent post-operative recurrence in Crohn's disease are evolving but need further refinement.

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The Evaluation and Treatment of Crohn Perianal Fistulae: EUA, EUS, MRI, and Other Imaging Modalities

Cited by 36 publications

References 68 publications

Comparison of different magnetic resonance imaging sequences for assessment of fistula-in-ano

Comparison of different magnetic resonance imaging sequences for assessment of fistula-in-ano

Monitoring Disease Activity and Progression in Crohn's Disease. A Swiss Perspective on the IBD Ahead ‘Optimised Monitoring' Recommendations

Role of Immunosuppressives in Special Situations: Perianal Disease and Postoperative Period

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