MRI of pouch-related fistulas in ulcerative colitis after restorative proctocolectomy

Purpose: Our purpose was to determine the value of MRI in diagnosing pouch-related fistulas in patients with ulcerative colitis and to compare pulse sequences with and without contrast enhancement in their performance of visualization. Method: Forty-four patients with pelvic symptoms after restorative proctocolectomy underwent MRI. All 26 patients with pouch-related fistulas were treated surgically; 18 patients with pouchitis were treated conservatively. MRI was performed at 1.0 T with T1-weighted FLASH sequences before and after administration of Gd-DTPA, T2-weighted and proton density-weighted turbo SE sequences, and a T2-weighted fat saturation sequence. Images were analyzed for the presence of fistula; pulse sequences were additionally compared for best visualization on a four point scale of diagnostic confidence. Results: MRI detected 23 of 26 cases of fistulas; there were no false-positive diagnoses. Surgery revealed fistulas in three cases in which Ilo pathology was found on MRI. Two patients had a short sinus tract at the pouch-anal anastomosis, and a third patient had a pouch-vaginal fistula. The Gd-enhanced FLASH sequence obtained the highest score, and second best was the T2-weighted fat saturation technique, Conclusion: MRI is a valuable technique for diagnosing pouch-related fistulas. However, there are limitations in detection of short sinus tracts and pouch-vaginal fistulas. Highest diagnostic confidence is obtained with a Gd-enhanced FLASH sequence, which might be helpful after pelvic surgery or if the fat saturation technique is equivocal.