Physical and rectal examinations are often sufficient for diagnosing and staging most perianal conditions in patients with Crohn's disease. Some patients must be examined under general anaesthesia, especially if perianal suppuration and tenderness are present. In addition, examination under general anaesthesia is considered an extension of the physical examination in patients with painful anorectal disease. For more complex presentations, additional modalities are needed including CT scanning with rectal contrast, endorectal sonography, endoscopies and MR imaging. Each test has specific advantages as already described in a previous chapter.
Endorectal ultrasonography is the easiest test for detection of abscesses and fistulae. Anal-wall thickness may be measured as an indicator of disease activity . MR imaging greatly facilitates the detection of fistulous tracts that extend into the supraleva-tor space. Rectal-wall thickening and perirectal inflammation are clearly shown . In a prospective study from St. Mark's Hospital in which 35 patients with fistula-in-ano were evaluated by examination under anaesthesia and MR imaging, four patients had occult fistulae identified on MR imaging that were not seen during the physical examination . Overall, studies suggest that 4-9% of cases may benefit from the increased diagnostic accuracy offered by MR imaging .
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