Imaging
Rectovaginal Fistulas
- Preliminary Diagnosis: Rectovaginal Fistulas
-
I. What imaging technique is first-line for this diagnosis?
- II. Describe the advantages and disadvantages of this technique for diagnosing rectovaginal fistulas.
-
III. What are the contraindications for the first-line imaging technique?
-
IV. What alternative imaging techniques are available?
- V. Describe the advantages and disadvantages of the alternative techniques for diagnosing rectovaginal fistulas.
- VI. What are the contraindications for the alternative imaging techniques?
Preliminary Diagnosis: Rectovaginal Fistulas
I. What imaging technique is first-line for this diagnosis?
Contrast enema with barium or water-soluble contrast.
II. Describe the advantages and disadvantages of this technique for diagnosing rectovaginal fistulas.
Advantages
Specific examination as entry point with contrast near the diseased segment of bowel. Can easily and quickly identify the location, length, and quality of the fistula.
Inexpensive, quick examination.
Disadvantages
Takes a great deal of patient cooperation and maneuverability to conduct the exam successfully. Can be uncomfortable for the patient.
Radiation level is low overall, but variable based on the operator.
May not see the abnormality, as there are contrast filled loops of bowel overlying the region of abnormality.
Can be messy, as there is leakage of contrast on the patient and the fluoroscopic table.
III. What are the contraindications for the first-line imaging technique?
Relative contraindications in pregnant women.
IV. What alternative imaging techniques are available?
CT with oral and/or rectal contrast and with intravenous contrast.
Vaginography.
Radiographs.
MRI.
V. Describe the advantages and disadvantages of the alternative techniques for diagnosing rectovaginal fistulas.
CT with IV contrast with additional oral and/or rectal contrast
Advantages
Specific, quick examination that allows one to obtain multiplanar reformats to better visualize the scanned structures.
Can visualize and identify fistulas (length, location, etc.)
Can appreciate enhanced characteristics of diseased segments of bowel (perifistular inflammation).
Disadvantages
Exposure to ionizing radiation.
Vaginography
Advantages
Inexpensive and can specifically isolate and identify the fistula tract with barium or water soluble oral contrast.
Disadvantages
Takes a great deal of patient cooperation and maneuverability to conduct the exam successfully. Most times uncomfortable for the patient.
Radiation level is overall low but variable based on the operator.
Can be messy, as there is leakage of contrast on the patient and the fluoroscopic table.
Radiographs
Advantages
Inexpensive.
May show ectopic gas.
Disadvantages
Very nonspecific.
Difficult to identify and characterize a fistula using this imaging modality.
Only beneficial if oral/rectal or vaginal contrast is administered prior to the study.
MRI
Advantages
Provides excellent detail regarding fistulas.
Disadvantages
Expensive.
May be time consuming.
Requires significant patient cooperation to minimize motion artifact.
Abundance of bowel gas limits resolution when interpreting MR images.
VI. What are the contraindications for the alternative imaging techniques?
CT with IV contrast with additional oral and/or rectal contrast
Relative contraindication in pregnant patients.
Vaginography
Relative contraindication in pregnant patients.
Radiographs
No significant contraindication. Some institutions may require consent in pregnant patients.
MRI
Contraindicated in patients with non-MR compatible hardware.
Relative contraindication to administer gadolinium-based contrast agent during pregnancy or in patients with renal failure.
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