Enterocutaneous fistulas: a primer for radiologists with emphasis
on CT and MRI
Received: 29 June 2017 /Revised: 22 August 2017 /Accepted: 24 August 2017 / Published online: 29 September 2017
The Author(s) 2017. This article is an open access publication
Enterocutaneous fistulas (ECFs) represent abnormal com-
munications between the gastrointestinal tract and the skin.
Nowadays, the majority (~80%) of ECFs develops second-
ary to abdominal surgeries; alternative, less common
causes include chronic inflammatory bowel diseases
(IBD) such as Crohn’s disease, tumours, and radiation en-
teritis in descending order of frequency. These rare disor-
ders require thorough patient assessment and multidisci-
plinary management to limit the associated morbidity and
mortality. This pictorial review includes an overview of
causes, clinical manifestations, complications and manage-
ment of ECFs. Afterwards, the imaging appearances, dif-
ferential diagnoses, and therapeutic options of post-surgi-
cal, IBD-related, and malignant ECFs are presented with
case examples. Most of the emphasis is placed on the cur-
rent pivotal role of CT and MRI, which comprehensively
depict ECFs providing cross-sectional information on
the underlying postsurgical, neoplastic, infectious, or in-
flammatory conditions. Radiographic fistulography re-
mains a valid technique, which rapidly depicts the ECF
anatomy and confirms communication with the
bowel. The aim of this paper is to increase radiologists’
familiarity with ECF imaging, thus allowing an appropriate
choice between medical, interventional, or surgical treat-
ment, ultimately resulting in higher likelihood of therapeu-
• Enterocutaneous fistulas may complicate abdominal sur-
gery, sometimes Crohn’s disease and tumours.
• The high associated morbidity and mortality result from
sepsis, malnutrition and metabolic imbalance.
• The multidisciplinary management of ECFs requires thor-
ough imaging for correct therapeutic choice.
• Radiographic fistulography rapidly depicts fistulas and
communicating bowel loops in real-time.
• Multidetector CT and MRI provide cross-sectional informa-
tion on fistulas and underlying diseases.
Keywords Enterocutaneous fistula
Computed tomography (CT)
resonance imaging (MRI)
Enterocutaneous fistulas (ECFs) are defined as abnormal
communications between the gastrointestinal (GI) tract and
the skin. Albeit relatively rare compared to past decades,
ECFs still represent one of the most challenging conditions
encountered in surgical practice, burdened with severe mor-
bidity, impaired quality of life, and substantial mortality [1–3].
In recent years, specialised centres developed a robust
management approach, which combines experience from sur-
geons, interventional radiologists, intensive care physicians,
nutritionists, wound care specialists and nurses. Summarised
in Table 1, this multidisciplinary treatment relies on thorough
diagnostic imaging for correct patient selection and therapeu-
tic choice: unfortunately, very limited literature exists on
cross-sectional imaging of ECFs [4, 5].
This pictorial review relies upon experience at a tertiary
referral hospital where oncologic and chronic inflammatory
* Massimo Tonolini
Department of Radiology, BLuigi Sacco^ University Hospital, Via
G.B. Grassi 74, 20157 Milan, Italy
Insights Imaging (2017) 8:537–548