Technique

Fistulography must be avoided in the presence of significant sepsis and should be delayed in high-output fistulas till the traffic decreases. No specific patient preparation is required in most cases.

• Choice of catheter is determined by the bore of the track, and catheters ranging from thin sialography cannulae to large Foley catheters may be used

• Ideally, either the catheter itself or catheter balloon should occlude fistula opening, avoid leakage and allow sufficient filling pressure

• A water-soluble contrast medium is injected under fluoroscopic control, although barium may be used if bowel opacification is desired

• Spot filming should include a minimum of two radiographs at right angles

• When examining complex tracks, a catheter with sideholes is advantageous

Fistulography can help—

• Determine the site of origin of fistula

• Demonstrate a communication into abscess

• Confirm the presence or absence of distal obstruction

A direct fistulogram may often be more appropriate in cases of renocutaneous fistulas, since contrast CT images are often compromised by a potentially non-functioning kidney. More recently, fistulography has been combined with CT to allow improved anatomical demonstration of the underlying pathology in complex disease. In addition, saline fistulography followed by MR imaging has been shown to give even better soft tissue resolution than CT due to the multiplanar capabilities of MRI. Recent studies using hydrogen peroxide ultrasound fistulography in bowel-related fistula have shown fistula tract visualization as good as that achieved with the direct contrast technique. In this method, 20-90 mL of the peroxide solution (30% hydrogen peroxide and 70% povidone/iodine) is slowly injected into the fistula and the production of gas bubbles aids USS localization.

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