Value of contrast enhanced spoiled gradient (SPGR) MR and MIP MR imaging in diagnosis of peri-anal fistula

Purpose

To assess the value of the combination of contrast enhanced T1 spoiled gradient (SPGR) MR and maximum intensity projection (MIP) MR imaging in the complete pre-operative evaluation of peri-anal fistula.

Patients and methods

This prospective study contained 28 patients with clinical diagnosis of peri-anal fistula, they were performed MRI using the following sequences in both axial and coronal planes: Pre contrast T2FSE, T1FSE and Post contrast SPGR. MIP reformated images were done using the SPGR sequence. Fistulas were classified according to Parks (6) classification, they were evaluated regarding site, type, extensions, complications and diagnostic accuracy of each sequence. Our findings were correlated with operative findings.

Results

Fourteen patients had inter-sphincteric fistulas (50%), 8 patients had trans-sphincteric fistulas (28.6%) and 6 patients had supra-sphincteric fistulas (21.4%). Simple non branching tracts were found in 22 patients, branching tracts in 6 patients, abscess cavity in 5 patients, horseshoe extension in 4 patients. Overall diagnostic accuracy of post contrast T1 SPGR was 97.3% and MIP MR imaging was 100%. Post contrast T1 SPGR accurately evaluated all patients but missed one faint horseshoe extension and other fine para anal branches. MIP imaging accurately evaluated all the extensions and ramifications but was poor in depth orientation.

Conclusion

MRI is a reliable diagnostic modality in the evaluation of peri-anal fistulas. Post contrast T1 SPGR sequence with its high resolution images and excellent anatomical orientation provides almost all the necessary details for accurate evaluation. Although MIP images lack depth orientation their high sensitivity, rotational 2D and 3D capabilities exquisitely depict all the fine ramifications and extensions. The combination of both provides complete evaluation and highest possible diagnostic accuracy aiding successful surgical interventions, aiming to reduce complications and recurrences.