special procedure of sinus and fistula

1. SINOGRAM AND
FISTULOGRAM
Soni Nagarkoti
B.Sc.MIT 2nd Year
NAMS, Bir Hospital

2. Overview
Fistula
Types of fistula
sinus
Indications of sinogram and fistulogram
Contraindications
Equipments needed
Additional accessories and drugs
Patient preparations and positioning
Filming

3. What is fistula?
• A fistula is an abnormal pathway between two
anatomic spaces or a pathway that leads from an
internal cavity or organ to the surface of the body.
• Is an abnormal connection between two hollow
spaces(such as blood vessels, intestines)
• Can develop in various parts of body
• Is caused by injury or surgery but can result from
infection or inflammation

4. Types of fistula on the basis of location
• Internal fistula
(connection between lumen of one vicious and another)
for eg :-vesicovaginal fistula, enterorectal, rectovaginal,
etc.
• External fistula
(connection between one hollow vicious to the exterior)
for eg :- enterocutaneous fistula
• Fistula joining two vessels
for eg :- arteriovenous fistula

5. Types of fistula on the basis of openings
1. Blind fistula
with only one open end could be a sinus tract
2. Complete fistula
with both external and internal openings
3. Incomplete fistula
fistula with external skin opening which doesn’t
connect to any internal organs

6. Common fistulas
Fistulas Abnormal connection between:-
1. Perilymph fistula Air filled middle ear and fluid filled inner
ear
2. Vesicovaginal fistula Urinary bladder and vagina
3. Rectovaginal fistula Lower part of large intestine/rectum and
vagina
4.Anorectal fistula End of bowel/rectum and anus
5. Enterorectal fistula Small intestine and rectum
6.Enterocutaneous
fistula
Intestinal tract and stomach and skin
7. Rectovesical fistula Rectum and urinary bladder

7. Cause of fistula
1. Congenital (fistula present due to birth defect)
2. Acquired (fistula developed in later stage of life)
• Traumatic
• Inflamatory
• Post medcal treatment
• Malignancy
• Diseases
• Iatrogenic

8. Some common congenital fistulas
1. Branchial fistula(developed in the upper part of neck
anterior to sternocleidomastoid to skin surface)
2. Tracheo-esophageal (between trachea nad
oesophagus)
3. Congenital AV fistula (between artery and vein)
4. Thyroglossal fistula(formed by the rupture of the
thyroglossal duct)

9. Common acquired traumatic fistulas
• Head trauma can lead to perilymph fistulas,
• trauma to other parts of the body can cause
arteriovenous fistulas.
• Obstructed labor can lead to vesicovaginal and
rectovaginal fistulas.
• An obstetric fistula develops when blood supply to the
tissues of the vagina and the bladder (and/or rectum) is
cut off during prolonged obstructed labor.
• Vesicovaginal and rectovaginal fistulas may also be
caused by rape, in particular gang rape, and rape with
foreign objects,

10. Common acquired fistulas
1. Post medical treatment
(Complications from gallbladder surgery can lead to
biliary fistula. Radiation therapy can lead to
vesicovaginal fistula.)
2. Diseases
(Inflammatory bowel disease, more often in the form
of Crohn's disease than ulcerative colitis, is the leading
cause of anorectal, enteroenteral, and enterocutaneous
fistulas.)

11. Cond……
3. Inflammatory
caused by inflammation for eg:-enterovesical hernia
4. Malignancy
when growth of one organ penetrates into the nearby
organ. e.g., Rectovesical fistula in carcinoma rectum
4.iatrogenic (caused by the health care provider)
• Cimino fistula - AVF for hemodialysis
• ECK fistula - to treat esophageal varices in portal HTN

13. Sinus
• A sinus tract is an abnormal channel that originates or
ends in one opening.
• Blind track lined by granulation tissue leading from
epithelial surface down into the tissues
• Could be congenital or acquired
1. Congeninal = preauricular sinus
2. Acquired = TB sinus
Pilonidal sinus
Actinomycosis
Median mental sinus

14. • A pilonidal sinus (PNS) is a small hole or tunnel in the skin. It
may fill with fluid or pus, causing the formation of a cyst or
abscess. It occurs in the cleft at the top of the buttocks.
• Actinomycosis is a rare bacterial disease characterized by
abscess formation on mouth breast or GI tract. the abscess may
grow larger and penetrate the surrounding bone and muscle to
the skin, where they break open and leak large amounts of pus
forming sinus.
• Median mental sinus is the sinus on the chin can be the result
of a chronic apical abscess due to pulp necrosis of a mandibular
anterior tooth.

15. What is sinogram or fistulogram?
• A Sinogram or Fistulogram is an special x-ray
procedure that is perform to visualize any abnormal
passage (fistula/sinus) in the body, following the
injection of contrast media (x-ray dye) into the
opening between two or more organs.
• Is usually a painless procedure
• Is usually completed within half an hour
• The examination may be performed under fluroscopic
control and may include full size plain film
radiography

16. Indications
• Development of a sinus or a fistula
• Route or extent of the sinus or fistula
• In order to fig out which organs are involved

17. Contraindications
• Patient suffering from severe pyrexia (fever).
• Severe localized infection.

18. Equipments required
 High power x-ray generator.
 X-ray tube
 Floating/tilting type of x-ray table
 Fluoroscopic unit with II TV system
 Resuscitative apparatus

19. Accessories and drugs required
• Iv cannula (18G, 20G, 22G)
• Dressing material (sterile towels, gauzes, cotton swabs,
scissors, gloves).
• Skin antiseptic solutions: povidone iodine, spirit,
savlon.
• Local anaesthetic injection: lignocaine
• A low osmolar contrast medium should be used.
• LOCM – 150-280 mgI/ml.
• Disposable syringe ( 10ml ,20 ml)

20. Patient preparations
There are no diet restrictions before the procedure.
 The medical history and allergies should be checked.
 It is better to check serology report prior to procedure
 The procedure is explained to the patient
A consent form is signed.
The metallic objects is removed and patient is made to
change into a hospital gown

21. Technique
A preliminary film is taken of the fistula/sinus area to
exclude the presence of a radio-opaque foreign body.
The patient lies supine on the fluoroscopic table, with the
opening of the sinus or fistula uppermost, and is made as
comfortable as possible.
The skin surrounding the area is prepared using a suitable
antiseptic preparation and sterile towels are placed around
the opening.

22. • If there is discharge of pus or mucus from the opening,
then only the contrast is injected to the sinus if not the
whole procedure is avoided
• If a drainage tube is in situ, the control agent may be
introduced through it
• If not then, a cannula of the appropriate size is inserted into
the orifice of the sinus/fistula, a gauze pad is firmly placed
around the site of entry to discourage reflux.
• The sufficient quantity of a water soluble contrast agent is
injected under fluoroscopic control to outline the extent of
the lesion.
• Depending upon the departmental protocols and patient
situation, the spots films are taken.

23. Filming
• Generally, two images are normally taken at right angles to each
other.i.e.
1. AP or PA
2. Lateral
• Erect views using a horizontal beam may also be taken.

24. What to do after the procedure?
If the fistula/sinus is inside the back passage or
vagina, patient should go to the toilet to pass any left
over contrast.
If the fistula/sinus is outside the body, wound site will
be cleaned and dressed.

25. Aftercare
• There is no special things to care of after the procedure
still some things is needed to be taken in consideration
• If the patient experience headache, nausea, vomiting or
dyspnea or chest pain should immediately inform the
technologist
• We should take care of the sinus or fistula to avoid
bacterial infections and further complication of the
wound

26. Complications
• Common risks and complications include:
• Perforation of the fistula/sinus opening (minor pain)
• Bruising and/or infection from the tube insertion.
• May require treatment with antibiotics.
• Less common risks and complications include:
• Allergic reaction to the Contrast.
• Rash, hives, itching, nausea, fainting or shortness of
breath.
• Medication may be given to relieve this.

27. Congenital fistula (branchial fistula)

28. Tracheoesophageal fistula
• Note
• Thin barium is used
incase of TEF as the
ionic contrast if
inhaled in trachea can
cause chemotoxicity
i.e.
chemopneumonitis/
intractable chest
infections

29. Vesicovaginal fistula

30. Rectovaginal fistula

31. Perianal fistula

32. Fitulogram connecting the
skin surface(near rectum) to
the urinary bladder

33. Fistulogram showing skin
surface and the oesophagus

34. Sinogram

35. Radiograph showing contrast material in the
subperiosteal area and within the medullary cavity

37. References
Clark’s Special Procedures in Diagnostic Imaging,
A.S.Whitly et. all, 1st edition
A Guide to Radiological Procedures, S. Chapman & R.
Nikelny, 4 and 5th ediditon
Radiological Procedures: a guideline, Dr. B.N. Lakhar, 1st
edition
Various internet sites

38. Questions
1. Despite of having a sinus or fistula, in which
condition we don’t perform sinogram or
fistulogram?
2. Which contrast medium is used in case of suspected
TEF? Why?
3. Can ionic contrast media be given for fistulogram or
sinogram?
4. What is the filming pattern of sinogram or
fistulogram?
5. Explain about iatrogenic fistulas.