Pediatr Radiol (2014) 44:1198–1208

DOI 10.1007/s00247-014-3085-y

REVIEW

Perianal disease in pediatric Crohn disease: a review

of MRI findings
Gregory L. Compton & Murray Bartlett

Received: 17 December 2013 / Revised: 7 May 2014 / Accepted: 12 June 2014

# Springer-Verlag Berlin Heidelberg 2014

Abstract Perianal complications of Crohn disease are a com- pediatric inflammatory bowel disease (IBD) is increasing
mon occurrence in children and can result in significant mor- worldwide [1–4, 6], making it important for radiologists to
bidity when not accurately characterized prior to surgical understand the anatomical and pathological findings in perianal
intervention. MRI is an excellent imaging modality for the fistulous IBD. Successful imaging evaluation of perianal fistu-
evaluation of perianal inflammatory bowel disease – allowing lous disease is essential in the assessment and management of
characterization and detailed description of perianal fistulas. perianal IBD. MRI is the modality of choice for children due to
MRI has many advantages over other imaging modalities for the lack of ionizing radiation, as pediatric patients with IBD are
the pediatric patient. Radiologists will benefit from a sophis- often subject to much higher radiation exposure from diagnos-
ticated understanding of perianal anatomy, the classification of tic studies during their lifetime [1–7]. The excellent soft-tissue
perianal fistulas, the advantages MRI offers in characteriza- resolution of MRI allows for the evaluation of the relationship
tion of perianal fistulas as well as the common and incidental between fistulous disease and the sphincter complex. Using the
findings that are important in the MRI evaluation of perianal Parks Classification [8], radiologists can effectively communi-
inflammatory bowel disease in children. Perianal fistulas are cate their findings to the surgical and medical teams to add
found at a high rate in pediatric referrals and are more com- value in the management of these patients.
monly found in male patients. In this article, we review the etiology and incidence of
perianal IBD, the relevant anatomy, the classification systems
Keywords Magnetic resonance imaging . Anatomy . used for fistula description, special considerations for imaging
Perianal . Crohn disease . Children . Fistula children, the techniques used in MRI evaluation of fistulous
disease and the imaging goals for the pediatric population.

Introduction
Etiology and incidence
Perianal disease is a common occurrence in children with
Crohn disease, affecting up to 38% [1–3] of this patient popu- Crohn disease is a chronic granulomatous inflammatory bow-
lation. In addition, 1 in 20 children with Crohn disease present el disease [1–5] of uncertain etiology, but it is thought to be
with fistulous disease in isolation [1–5]. The incidence of secondary to a combination of environmental, genetic/
immunological and gut flora interactions [4, 9]. It is more
common in people of European descent with an equal occur-
rence in males and females. The incidence of Crohn disease is
CME activity This article has been selected as the CME activity for the 3–7 per 100,000 individuals and is thought to be on the rise [1,
current month. Please visit the SPR Web site at http://www.pedrad.org on 3, 6]. Up to 38% of all individuals [3, 10] with Crohn disease
the Education page and follow the instructions to complete this CME
activity. will be affected by perianal disease involvement. Up to 4
times more male patients than female patients with the disease
G. L. Compton (*) : M. Bartlett
will have perianal disease [3, 10, 11] likely due to the in-
Medical Imaging Department, Royal Children’s Hospital,
Flemington Road, Parkville, Victoria 3052, Australia creased number of anal glands in males compared to females
e-mail: [email protected] [1, 12].
Pediatr Radiol (2014) 44:1198–1208 1199

It is important for the radiologist to be aware of perianal tone [11, 16] of the anal canal via involuntary contractions.
involvement in children as up to 25% of all cases of Crohn Superficial to the internal sphincter and separating it from the
disease occur in the pediatric or adolescent age group [1, 4, 5]. external sphincter is the intersphincteric space. This space of
Up to one-third of this patient group will develop perianal loose connective tissue contains predominantly areolar fat
inflammation during the course of the disease, which may lead [3, 7].
to fistula formation [1, 6]. In addition, perianal fistulous disease The external sphincter is composed of striated muscle and
can be the presenting complaint in 5% of children with previ- is responsible for ~15% of resting anal tone, but it is the strong
ously undiagnosed Crohn disease; these patients had no evi- voluntary contractions of the external sphincter that account
dence of intestinal involvement at the time of presentation [7]. for the preservation of continence [11, 14]. The external
sphincter is contiguous with the more superior puborectalis,
which is contiguous with the levator ani [1]. The external
Pathophysiology of perianal fistulae sphincter is connected to the perineal body anteriorly and the
anococcygeal ligament posteriorly [1].
The most commonly supported theory for the pathophysiological The external sphincter is the deep boundary of the
development of perianal fistulous disease is the “cryptoglandular ischioanal fossae, which is composed primarily of fat. The
hypothesis” [2, 13]. The suggestion that anal glands were in- superior border of the ischioanal fossae is levator ani and the
volved in the formation of perianal fistulas was first proposed by lateral border is obturator internus [1].
Chiari in 1878 [1, 7]. The anal glands lie at the dentate line and
have an unclear physiological purpose, but they may help to
lubricate the anus by secreting mucus into the anal crypts [7, 9]. Anatomy at MRI
Up to 90% of fistulas are thought to originate due to im-
paired drainage of the anal glands [14] but may also be sec- MRI lends itself well to the evaluation of the perianal anato-
ondary to surgical complications. Obstruction of these glands my. Non-contrast T1-weighted imaging (Fig. 2) gives an
leads to infection, which in turn leads to fistula and abscess
formation. The increased incidence of perianal fistulas in the
Crohn disease population is thought to be primarily due to the
presence of increased lymphoid aggregates, which surround the
anal glands [3, 7]. Less common causes of perianal fistulas
include tuberculosis, diverticulitis, pelvic infection, trauma,
anorectal carcinoma or previous radiotherapy [3, 10, 14].

Anatomy

The most important and relevant anatomical structures to be

familiar with, in order to report perianal fistula MRI cases, are
the internal and external sphincters, levator ani, the
intersphincteric plane and the ischioanal fossae (Fig. 1).
The anal canal connects the rectum to the anus and can be
divided into an upper two-thirds lined by columnar epithelium
and a lower one-third lined by squamous epithelium. The
junction between these two epithelial types occurs at the
dentate line, the location of the anal glands [3, 7] that open
into the anal canal via the anal sinuses (Crypts of Morgagni)
[14] that are located between the longitudinal mucosal col-
umns (Columns of Morgagni) [15]. The obstruction of these
glands and their subsequent infection is widely accepted to
promote the formation of perianal fistulas. The majority of the
anal glands lie posteriorly and are more numerous in males Fig. 1 Anatomy of the perianal region in coronal (a) and axial (b) planes.
[12]. Most anal glands are located in the subepithelium but can The most important structures are the external and internal sphincters with
the intersphincteric space placed between these muscle layers. Note the
also occur within the intersphincteric space [7]. levator ani is contiguous with the external sphincter in the anal canal and
The internal sphincter is continuous with the smooth muscle the rectal smooth muscle is contiguous with the internal sphincter. The
of the rectum [14] and is responsible for ~85% of the resting ischioanal fossa is located lateral to the external sphincter
1200 Pediatr Radiol (2014) 44:1198–1208

Fig. 2 Normal perianal anatomy of a 14-year old boy at MRI. (a) Axial sphincter (thick arrow), levator ani (asterisk) and ischioanal fossa (large
T1-weighted image at level of pubic symphysis and (b) coronal T2 fat- circle). (c) Axial T2-weighted fat-suppressed image: Note the normal
suppressed image demonstrate the anal canal (circle), internal anal hyperintense internal sphincter
sphincter (arrowhead), intersphincteric space (thin arrow), external anal

overview of the anatomy [11]; however, it is T2-weighted symphysis is in the 12 o’clock position and the natal cleft is in
sequences, including 3-D sequences such as T2 SPACE (sam- the 6 o’clock position. Three o’clock and 9 o’clock are left
pling perfection with application of optimized contrast using lateral and right lateral in position, respectively [16] (Fig. 3).
different flip angle evolution) that help to discriminate be- These positions also correspond well with the axial plane of
tween the tissue planes of the sphincter complex (Fig. 2). MRI imaging in perianal bowel disease. When describing the
The internal sphincter is most often hyperintense in com- origin of perianal fistulas it is important to use the anal clock to
parison to the external sphincter on T2-weighted images define the point at which the fistula communicates with the
(Fig. 2). In addition, the normal internal sphincter enhances anal canal, usually at the dentate line.
homogeneously on postcontrast imaging. The normal
intersphincteric space always follows fat signal. T2 fat-
saturated images are excellent in discriminating the internal Classification
sphincter from the intersphincteric space (Fig. 2).
Two classification systems for perianal fistulous disease have
been proposed – the Parks Classification [8] and the St.
The anal clock James’s University Classification [11].
The Parks Classification was first proposed in 1976 before
The anal clock is a visual aid for descriptive purposes used by the first use of a clinical MRI unit, and is based on surgical
surgeons to describe anal pathology relative to the circular findings in 400 patients. This descriptive classification system
anal canal as viewed in the lithotomy position [11]. The pubic is both simple and elegant and is well-applied to the use of
MRI in the evaluation of perianal fistulous IBD. The four
types of fistulas according to the Parks Classification are
intersphincteric, transsphincteric, suprasphincteric and
extrasphincteric. These four types of fistula are classified
according to the course of each fistula with relation to the
external sphincter in the coronal anatomical plane (Fig. 4).

Fig. 3 Axial T1-weighted image of a 13-year old female patient demon-

strates the concept of using the anal clock for describing perianal fistula.
The most anterior aspect of the anal canal is labeled 12 o’clock and the
most posterior aspect of the anal canal is labeled as 6 o’clock with
appropriate numerical labeling in between Fig. 4 Parks Classification of perianal fistulae
Pediatr Radiol (2014) 44:1198–1208 1201

Intersphincteric fistulas do not cross the external sphincter abscess or secondary tract. Similarly, both grades 3 and 4 are
and are limited to within the intersphincteric fat plane (Fig. 5). transsphincteric fistulas, but grade 4 has a secondary
The second type of fistula is the transsphincteric type. These extension or abscess. Grade 5 fistulas are termed
fistulae do cross the external sphincter to enter the ischiorectal/ supralevator and translevator disease, but are the same
ischioanal fossa (Fig. 6). Suprasphincteric fistulas, the third as the suprasphincteric and extrasphincteric classification
group, extend superiorly in the intersphincteric space to then types. The relationships between the two classification
turn 180o in a caudal direction and pierce the levator plate. The systems are compared in Table 1.
final and fourth type of fistula is the extrasphincteric, Though the St. James’s University Classification system is
which is the only type not to originate at the dentate more descriptive in its inclusion of secondary tracts and ab-
line in the anal canal but traverse the levator plate via scesses, we feel that the Parks Classification allows a simple
the ischiorectal fossa connecting the perianal skin to the means of communication of fistulous type to the surgical and
rectum directly. medical teams. The description of secondary tracts and ab-
The Parks Classification is well suited to the use of MRI for scesses as well as other ancillary findings is an impor-
the evaluation of perianal fistula disease as it is straightfor- tant component of the radiology report and should not
ward in application; each group is named after the course of be lost within the classification system. Identifying the
the fistula in relation to the external sphincter. Correctly fistula type and then describing its course in relation to
following the path of the fistula and identifying the anatomical the anal clock along with the presence/absence of sec-
structures it crosses allow the reporting radiologist to correctly ondary tracts and abscesses is an essential part of an
classify it. effective radiology report.
The St. James’s University Classification [11] is a MRI-based Another reason to use the Parks Classification, particularly
classification system that does not have a surgical reference. with reference to children is that it is based on the anatomy in
This system uses the nomenclature of the Parks Classification the coronal plane as opposed to the St. James’s University
(intersphincteric, transsphincteric, suprasphincteric or Classification, which is based on the anatomy in the axial
extrasphincteric) but takes into account the absence or presence planes. The dentate line, main site of the origin of fistulas
of secondary extensions or the formation of abscesses. The and distal region of the anal transition zone, is approximately
difference between grade 1 and grade 2 is that grade 2 has an 2 cm from the anal verge [16] in adults. The anal canal is much

Fig. 5 Axial T2-weighted fat-suppressed (a) and (b) axial T1 post- sphincter. (c) Coronal T2 fat suppressed image demonstrate this
gadolinium fat-suppressed images through the level of the anal canal in intersphincteric fistula (thin arrow) passing inferiorly confined by the
a 13-year-old girl demonstrate a high T2 signal intersphincteric fistula external sphincter (thick arrow). Diagram illustrates the path of the
with post-gadolinium enhancement passing through the internal sphincter intersphincteric fistula and its path along the intersphincteric space (red
at the 7 o’clock position (long arrow) into the intersphincteric space. It line) in both the coronal (d) and axial (e) planes
passes along this space (arrowheads) without perforating the external
1202 Pediatr Radiol (2014) 44:1198–1208

Fig. 6 Transsphincteric fistula in a 16-year-old boy with Crohn disease. enhancement of this active fistula (thin arrow) and the small ischioanal
Axial T2-weighted fat-suppressed image (a) demonstrates a high T2 signal collection (arrowhead). Coronal T2 fat-suppressed image (c) demonstrates
transsphincteric fistula passing from the 5 o’clock position through the the transsphincteric fistula passing through the external sphincter (thin
internal sphincter and the intersphincteric space, to cross the external arrow) and inferiorly through the ischioanal space (thick arrow).
sphincter (thin arrow) into the ischioanal space forming an abscess (large Diagrams in both coronal (d) and axial (e) planes illustrate the path of the
arrowhead). Note the low-signal inactive fistula (small arrowhead). Axial fistula (red line)
T1-weighted fat suppressed gadolinium-enhanced image (b) demonstrates

shorter in children, which can make assessment of fistulous 32-channel surface coil. Most examinations are performed
types in the axial plane difficult. We believe the coronal plane on the 1.5-T unit with no need for sedation or general anaes-
is very useful for pediatric patients as the entire anal canal can thetic. We do not routinely use anti-peristaltic agents to de-
be visualized on a single slice. crease gut motility, nor do we employ bowel preparation or
oral contrast to distend bowel. Fasting is also deemed unnec-
essary unless the MRI is performed with the patient under
Imaging parameters general anaesthetic. The majority of our studies take on
average less than 30 min. The T1 post-gadolinium effects
MRI scans for the evaluation of perianal fistulae can be are highlighted more [12, 17–19] on 3-T scanners, which
performed on 1.5-T or, ideally, 3-T equipment. At our institute, also gives the opportunity to decrease the scan time to
we utilize either 1.5 T (Aera; Siemens, Erlangen, Germany) obtain the same data set as a 1.5-T unit. This is a major
with a 12-channel phased-array body coil or 3 T advantage for children who may have trouble remaining
(MAGNETOM Trio; Siemens, Erlangen, Germany) with a still.

Table 1 A comparison of the relationship between the Parks and St. James’s Classification systems for perianal fistulas [8, 11]

Parks Classification St. James’s University Classification Description of St. James’s Grade

Intersphincteric Grade 1 Simple linear intersphincteric

Grade 2 Intersphincteric with abscess or secondary tract in the intersphincteric space
Transsphincteric Grade 3 Transsphincteric
Grade 4 Transsphincteric with abscess or secondary tract in the ischiorectal fossa
Suprasphincteric Grade 5 Supralevator & translevator disease
Extrasphincteric
Pediatr Radiol (2014) 44:1198–1208 1203

Table 2 Imaging parameters using a 1.5-T MRI with suggested protocol

Sagittal T2W FS Coronal T2W FS Axial Dixon TSE Axial T1W 3-D T1 VIBE+C SPACE T2 FS Diffusion

TR/TE (ms) 4,500/85 3,500/90 6,500/80 520/14 10.8/3.6 1,700/93 5,500/62

Number of slices 20 20 20 20 144 120 30
FOV (mm) 200 160 200 200 300 260 350
Slice/gap (mm) 3/0.5 4/0.5 4/0.5 4/0.5 0.7 iso 1 mm iso 4/0
Matrix 320x208 256 320/280 384/288 448 256 192/115
NEX 3 2 1 2 1 1.5
Fat suppression yes yes Dixon no water excite yes yes

+C with contrast, FS fat suppressed, FOV field of view, iso isotropic, NEX number of excitations, SPACE sampling perfection with application of
optimized contrast using different flip angle evolution, TE time to echo, TR time to repetition, TSE turbo spin echo, VIBE volume interpolated breathhold
examination

The standard protocol (Table 2) at our institution begins post processed into any plane [11, 22–24] and are therefore
with the acquisition of a sagittal T2 fast spin echo (FSE) also routinely performed. A disadvantage of the 3-D
sequence. The remainder of the examination is then planned sequences is that the volume of data acquisition requires
from this sagittal plane, so that the study is correctly oriented the patient to remain still for longer and is therefore
with respect to the anal canal. Axial and coronal images more susceptible to motion artifacts. SPACE also has
cannot be prescribed in the usual manner to give accurate loss of in-plane spatial resolution compared with T2 fat
depiction of the anal canal, as they will be oblique to the anal suppression.
canal and not profile disease processes accurately. As the anal Short tau inversion recovery (STIR) is a valuable
canal is tilted anteriorly by approximately 45o, the axial im- sequence for fat suppression; however, it has less signal
ages are prescribed so that they are perpendicular to the anal than T2 fat suppression TSE. STIR is often preferable if
canal (oblique axial) and the coronal images are prescribed the operator recognizes the need to minimize artifact.
parallel to the long axis of the anal canal (oblique coronal) [20] STIR should be considered if there is a need to de-
(Fig. 7). crease artifact from surgical material including silk su-
Gadolinium (0.1 mmol/kg) is administered and post gado- tures or metallic devices [20, 25, 26]. This may make
linium fat-saturation oblique axial and oblique coronal images STIR preferable to T2 fat-suppressed sequences when
are performed. In addition, we perform diffusion-weighted the operator recognizes the need to minimize artifact
imaging (DWI), using B values of 50, 400 and 800 to help from field inhomogeneities such as when gas or surgical
in the assessment of fistulous tracts and abscess formation [3, material is present. We have not found any significant
21] (Fig. 8). artifacts in our postoperative imaging such as large
Three-dimensional (3-D) T2-weighted fat-suppressed TSE areas of blooming artifact or issues due to the place-
sequences (e.g., SPACE) provide a volume of data that can be ment of fistula seton (Fig. 9).

Fig. 7 Demonstration of imaging planes in a 13-year-old girl. Sagittal of the anorectal junction resulting in distortion of the anatomy. Axial T2
T2-weighted fat-suppressed image (a) shows the plane of acquisition fat-suppressed image at a lower slice level in a male patient (c) shows the
(thin lines) required for axial images along the long axis of the anal canal. internal (arrowhead), external sphincters (large arrow) and
Coronal images are then acquired at 90o to this transverse plane. In this intersphincteric space (small arrow) are all apparently deficient posteri-
example study (b), the axial images (thin lines) are planned from the axis orly as a result of a poorly planned study
1204 Pediatr Radiol (2014) 44:1198–1208

Fig. 8 Abscess cavity in a 10-year-old boy. (a) Axial T2 fat-suppressed image shows an abscess cavity (arrow). (b) Initial diffusion image shows
restricted diffusion in the abscess cavity (arrow). (c) Matching low signal is seen on the apparent diffusion coefficient map (arrow)

Special imaging considerations for pediatric patients information regarding abscess formation laterally or
supralevator pelvic disease [2, 25, 30].
Obtaining the correct high-quality sequences in an acceptable Rectal contrast can be used to outline and distend the rectum
time frame is essential in imaging the child with Crohn disease in patients undergoing pelvic MRI for several diagnostic pur-
and suspected perianal disease. poses [1, 9, 31, 32]. Perianal abscess and fistulous disease can
When MRI, anal endosonography and clinical examination be quite a painful condition, and the insertion of an anal catheter
were compared, MRI was found to be more sensitive than and infusion of fluid with distension of the rectum would be
clinical examination and anal endosonography for discriminat- poorly tolerated in children, causing unneeded distress. It is
ing complex from simple disease with anal endosonography therefore not a recommended addition to pelvic MRI in this
noted to be superior to clinical examination [1, 27]. CT can subset of patients.
demonstrate some fistula and ischioanal/ischiorectal collec-
tions; however, it cannot adequately demonstrate the
anatomy that MRI does, and with the added radiation burden Advantages of MRI and clinical management
of CT, MRI offers an alternative, radiation-free imaging mo-
dality [4, 5, 28, 29]. MRI has come to replace all other imaging modalities in the
Endoanal coils are not routinely used in either children or evaluation of perianal fistulous disease due to its high speci-
adults even though they provide excellent depiction of sphinc- ficity and sensitivity – reported to be up to 81% sensitive and
teric fistulous disease [30]. They do not provide accurate 100% specific in a pediatric population [1, 11, 22–24, 33]. High
concordance rates between MRI findings and surgical findings
[1, 20, 25, 26, 34] are also an advantage to both the patient and
the treating medical team, as successful demonstration of primary
and secondary tracts as well as complications is essential for
surgical management [34, 35]. The use of the Parks
Classification for the description of perianal fistulae helps in
the communication of findings from the radiologist to
both the medical and surgical treating teams [1, 15, 27], which
is essential for guiding treatment algorithms and management
decisions.
Frequency selective fat saturation is used with T2-weighted
FSE to allow the fluid intensity tract/collection of a fistula/
abscess to stand out from the perianal/intersphincteric fat.
Active fistulae are high T2 signal and demonstrate enhance-
ment on post-gadolinium sequences. This is in comparison to
inactive fistulae, which are low signal and do not en-
hance. T1-weighted imaging of the pelvis is best suited
for anatomical outline as well as for the assessment of
Fig. 9 Seton placement in an 11-year-old boy. Sagittal T2-weighted fat-
suppressed image demonstrates a curved, low-signal seton tube passing
the presence/absence of lymphadenopathy and for reviewing
into the ischioanal tissue, placed for fistula drainage. This should not be bone marrow signal. The axial and coronal T2-weighted fat-
confused with an old fibrous fistula tract that is also low in signal saturated images are the most useful to identify and classify
Pediatr Radiol (2014) 44:1198–1208 1205

the fistula with sagittal used to plan the study as well as for
problem solving.
The key imaging goals are to correctly identify all
fistulas and to classify them by defining their relation-
ship to the sphincter complex [4, 5, 7, 28, 29, 36]. The
primary fistulous tract will be the tract with both internal
and external openings, most often at the skin. Secondary
tracts (Fig. 10) are either abscesses (undrained fluid
>3 mm in diameter) or extensions from the primary tract
[7, 13, 30]. Horseshoe fistulas (Fig. 11) are those that
extend in the clockwise and counterclockwise direction
from their internal opening at the dentate line [2, 7, 25,
30]. Secondary and horseshoe tracts are very important
to identify, as failure to do so is associated with a high
rate of recurrence after treatment [1, 7, 9, 31, 32, 36] of
up to 25% [37]. Up to 15% of fistulas have a compli-
cated course, including secondary and horseshoe tracts as
Fig. 11 Axial T2-weighted fat-suppressed image in an 11-year-old girl
well as abscesses [38] (Figs. 8, 12, 13). demonstrates a horseshoe fistula. This is an intersphincteric, high T2
Successful surgical management of perianal fistulous signal tract (arrows) that has a U-shaped course posteriorly located
disease in Crohn disease is dependent on the nature of between the internal and external anal sphincters
the primary fistulous tract and the presence or absence
of secondary tracts/abscesses – underlining the impor-
tance of correctly identifying these using MRI. Simple instead of surgical exploration to improve patient outcomes
fistulous tracts affecting the distal third of the anal [11]. To maintain continence in the management of high or
canal can usually be treated with fistulotomy, if more complex fistulae, by preventing the dividing of the external
conservative medical measures such as antibiotics and sphincter, a seton may be used as initial treatment. This
purine analogues (azathioprine and 6-mercaptopurine) is a surgical thread that is placed through the tract
are unsuccessful. The use of fibrin plugs and glue- instead of directly incising the tract to allow continuous drain-
like treatments for simple fistulas has also been trialed age of the tract. This can be used in conjunction with medical
[39]. therapy.
Simple abscesses can be directly incised and drained. The MRI also plays a role in both the prediction [35] and
location of the internal opening of the fistulous tract may be evaluation of response to treatment of perianal fistulous dis-
evident to the surgeon on examination under anesthetic; how- ease, for example, to assess if a fistulous tract has
ever, MRI demonstrates occult fistula not detected by exam- become inactive or if an abscess cavity has been suc-
ination under anaesthesia. Thus, MRI is better performed first cessfully drained. Clinical assessment of skin healing
may not be an accurate follow-up of fistulous disease
treated by infliximab as an active tract may still be
present, detectable by MRI, which is essential to iden-
tify in order to prevent recurrence [40, 41].
The radiologist should also assess the images for relevant
findings outside the perianal region and the sphincter com-
plex. These ancillary findings can have implications for both
prognosis and patient management. As an example, perianal
disease in the absence of rectal inflammation has a better
prognosis [42]. Ancillary findings are reported to be found
in up to 20% of patients [38]. In children, these ancillary
findings or extra-anal manifestations of IBD can include –
but are not limited to – enteritis, colitis, lymphadenop-
athy, fluid within the abdomen or pelvis, sacroiliitis,
Fig. 10 Secondary tract in a 15-year-old boy. Axial T2 fat-suppressed anal tags, complications from treatment or other extra-
image shows a high T2 signal fistula (arrows) passes from the anal region
to the right ischioanal fossa and then anteriorly into the posterior aspect of
intestinal manifestations of IBD (Figs. 14 and 15). A sug-
the right hemi-scrotum (secondary tract). Note the debris through the gested reporting approach to pelvic MRI assessment of
fistula from pus formation and the low signal foci of gas locules perianal IBD is outlined in Table 3.
1206 Pediatr Radiol (2014) 44:1198–1208

Fig. 12 Ischioanal abscess formation in a 10-year-old boy. Axial T2- image (b) demonstrates the ischioanal abscess (arrows) passes superiorly
weighted image with fat saturation (a) demonstrates a transsphincteric fistula to contact levator ani. Axial T1 fat suppressed image post-gadolinium (c)
(large arrow) in the 9 o’clock position passing into the ischioanal fossa shows enhancement of the abscess cavity (large arrow) and fistula tract.
forming an abscess (small arrow). Coronal T1-weighted fat-suppressed Note the enhancement of the rectal mucosa (small arrow)

Fig. 13 Transspincteric fistula and small ischioanal abscess. Axial T2- arrow). Image (b), slightly more superior to (a), shows this develops into
weighted fat suppressed image (a) demonstrates a transsphincteric fistula a larger collection (arrow)
(small arrow) at 10 o’clock passing into a small ischioanal abscess (large

Conclusion Perianal fistulous disease is a common occurrence in chil-

dren, especially in male patients, with known or suspected
Radiologists who evaluate perianal IBD should be familiar IBD. MRI is ideally suited to the evaluation of perianal
with perianal anatomy and the common pediatric pathological
findings to accurately classify them and convey this important
information to the treating teams.

Fig. 14 Axial T2-weighted fat-suppressed image of a 14-year-old with

known Crohn disease shows enteritis with small bowel wall thickening
(thin arrow) as well as proctitis (thick arrow) with a small amount of Fig. 15 Axial T2-weighted image of a 10-year-old boy with Crohn
adjacent free fluid disease and perianal fistula (not shown) and anal tags (arrow)
Pediatr Radiol (2014) 44:1198–1208 1207

Table 3 Suggested reporting approach* 8. Parks AG, Gordon PH, Hardcastle JD (1976) A classification of
fistula-in-ano. Br J Surg 63:1–12
Locate primary tract 9. Hendrickson BA, Gokhale R, Cho JH (2002) Clinical aspects and
pathophysiology of inflammatory bowel disease. Clin Microbiol Rev
Locate secondary tract (including horseshoe tracts) 15:79–94
Assess for abscess formation 10. Toma P, Granata C, Magnano G et al (2007) CT and MRI of
paediatric Crohn disease. Pediatr Radiol 37:1083–1092
Look for extension above the levator plate
11. Morris J, Spencer JA, Ambrose NS (2012) MR imaging classification
Assess for extra-anal inflammatory bowel disease of perianal fistulas and its implications for patient management.
Look for ancillary findings Radiographics 20:623–635, discussion 635–637
12. Hussain SM, Outwater EK, Joekes EC et al (2000) Clinical and MR
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Conflicts of interest None
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