Endgames Case Review

A young woman with recurrent perianal sepsis

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1969 (Published 23 April 2015) Cite this as: BMJ 2015;350:h1969
  1. Tom L Kaye, radiology specialist registrar1,
  2. Anthony O’Connor, consultant gastroenterologist2,
  3. Dermot Burke, consultant in gastrointestinal surgery3,
  4. Damian J M Tolan, consultant radiologist4
  1. 1Department of Radiology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds LS9 7TF, UK
  2. 2Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital
  3. 3Department of Surgery, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital
  4. 4Department of Radiology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital
  1. Correspondence to: T Kaye thomas.kaye{at}nhs.net

A 23 year old woman had been experiencing cramping abdominal pain, alternating diarrhoea and constipation, and episodic blood per rectum for four months. An earlier colonoscopy showed proctitis, which was thought to be indicative of underlying inflammatory bowel disease, and she was started on oral and topical mesalazine. In the following months she was admitted twice with acute perianal sepsis, which required examinations under anaesthesia and drainage of an intersphincteric abscess. She later presented after feeling generally unwell for four days with “flu-like” symptoms and perianal pain. On examination she had tenderness and fluctuance in the region of the right ischial tuberosity, with an external fistula opening visibly in the perineum. Her blood tests show mild neutrophilia (9.40×109/L, reference range 2-7.5) and mildly raised C reactive protein (380.96 nmol/L (40 mg/L), 0-95.24 (0-10) only.

Questions

  • 1. What imaging modality should be used to investigate this clinical presentation?

  • 2. What is the underlying pathophysiology of perianal fistulation?

  • 3. What classification systems are used for perianal fistulas?

  • 4. What is the optimal management for a patient with a perianal fistula and abscess?

Answers

1. What imaging modality should be used to investigate this clinical presentation?

Answer

Magnetic resonance imaging (MRI) of the pelvis.

Discussion

Although a variety of techniques can be used to image perianal fistulas, MRI is widely accepted as the technique of choice for patients who present with recurrent perianal sepsis or signs of complex fistulation and for those with underlying Crohn’s disease.

Perianal fistulography, in which the external opening of the fistula is catheterised and a water soluble contrast agent injected, is now rarely used. This is because both the primary tract and extensions may fail to fill with contrast and the sphincter muscles are not directly visualised, which hinders anatomical assessment. The test is less accurate and reliable than modern techniques.1 2

Computed tomography may depict perianal fistulas and associated abscesses …

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