klinikinspraktins apvalgos

COMPUTED TOMOGRAPHY COLONOGRAPHY THE PROCEDURE IN OUR

DAYS. LITERATURE REVIEW
KOMPIUTERINS TOMOGRAFIJOS KOLONOGRAFIJA IANDIEN. LITERATROS
APVALGA
Dileta Rutkauskait1, Kstutis Strupas2, Algirdas Edvardas Tamoinas1
Vilniaus universiteto Medicinos fakulteto Radiologijos, branduolins medicinos ir medicinos fizikos katedra
Vilniaus universiteto Medicinos fakulteto Gastroenterologijos, nefrourologijos ir chirurgijos klinika

1
2

Department of Radiology, Nuclear Medicine and Medical Physics, Faculty of Medicine, Vilnius University
Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Vilnius University

1
2

ABSTRACT
Key words: virtual colonoscopy, CT colonography, colon cancer, colon polyps.
Colorectal cancer is a common malignancy that results in significant morbidity and mortality. It is a curable disease if
detected early and may be prevented if precursor adenomas are detected and removed. One of noninvasive examination
methods of the colon is computed tomography colonography. Computed tomography colonography has been shown to be
sufficiently accurate in detecting colorectal neoplasia. Recent data about examination was collected from MEDLINE and
Pubmed databases. This article reviews current indications, contraindications and methodology of computed tomography
colonography. We describe computed tomography colonography Reporting and Data System and discuss the accuracy
of computed tomography colonography based on recent reports and literature data. We conclude that computed tomography colonography is safe and effective colon examination method, especially when carried out properly. Probability of
complications of this procedure is very low with minimal discomfort for the patient. The noninvasive nature of computed
tomography colonography may be attractive to patients, and the use of this modality may improve screening compliance
and diagnostic rates.

SANTRAUKA
Reikminiai odiai: virtuali kolonoskopija, KT kolonografija, storosios arnos vys, storosios arnos polipai.
Storosios arnos vys yra danai pasitaikantis piktybinis navikas su auktais sergamumo ir mirtingumo rodikliais. Anksti nustaius v, jis yra pagydomas, taip pat jo galima ivengti paalinus jo pirmtakus adenomas. Vienas i neinvazini storosios
arnos tyrimo metod yra kompiuterins tomografijos kolonografija. I literatros altini inoma, kad kompiuterins tomografijos kolonografija yra gana tikslus diagnostikos metodas ir gali aptikti gaubtins bei tiesiosios arnos neoplazijas. iame
straipsnyje pateikiami Medline ir PubMed duomen bazse surinkti naujausi duomenys apie kompiuterins tomografijos
kolonografij. Taip pat straipsnyje apvelgiamos dabartins indikacijos, kontraindikacijos ir kompiuterins tomografijos
kolonografijos metodikos. Apraoma kompiuterins tomografijos kolonografijos ataskait teikimo ir duomen sistema,
naujausi literatros altiniai apie tyrimo tikslum. Tinkamai atliekama kompiuterins tomografijos kolonografija yra saugus
ir veiksmingas storosios arnos tyrimo metodas. ios procedros komplikacij tikimyb yra labai maa, diskomfortas pacientui bna minimalus. Neinvazin kompiuterins tomografijos kolonografija gali bti pacientams patraukli ir galt pagerinti
storosios arnos vio atrank bei diagnostikos rodiklius.

Dileta Rutkauskait
Radiologijos ir branduolins medicinos centras
Santariki g. 2, Vilnius
dileta.rutkauskaite@santa.lt
teorija ir praktika 2013 - T. 19 (Nr. 2),
2) 195201 p.

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INTRODUCTION
Colorectal cancer is the second leading cause of cancer
mortality in Europe. Each year approximately 435 000 people are newly diagnosed with colorectal carcinoma (CRC)
[1] . It is a curable disease if detected early and may be
prevented if precursor adenomas are detected and removed.
Computed tomography colonography (CTC), also called
virtual colonoscopy, has made great progress over the years,
and is becoming more and more popular. With the advent
of faster computed tomography scanners and powerfull
computer software, examinations are performed more quickly with less patient radiation exposure providing the
radiologist data that allow accurate polyp detection using
two- and three-dimensional imaging [2].
In the article we review the literature data about CTC
methodology, indications and contraindications, complications and CTC accuracy for detection colon cancer and
polyps.
OBJECTIVE
CT colonography, also known as virtual colonoscopy,
is a technique that uses data generated from CT imaging of
the fully cleaned and gas-distended colon to generate twodimensional (2D) and three-dimensional (3D) images of
the colon. It was first reported by Vining et al. in 1994 as a
rapid, noninvasive imaging method to investigate the colon
and rectum [2].
CTC is an alternative diagnostic test to colonoscopy
diagnosing colorectal cancer and polyps [3]. Up to now,
on-going debate continues on CTC suitability of the screening. Despite the evidence that it can be as sensitive as
optical colonoscopy for large polyps and cancer detection
it is not yet recommended as a routine screening tool by
all organizations. To date, no studies have been published
assessing reduction in CRC incidence or mortality. The majority of studies have focused on comparing the characteristics of this method with colonoscopy [4]. A number of
meta-analyzes to determine the accuracy of this study were
carried out. CTC is a potential screening test, with an estimated sensitivity of 88 % for advanced neoplasia 10 mm
[5]. In recent systematic review and meta-analysis CTC was
mostly an effective diagnostic technique for lesions > 6 mm
with an average sensitivity of 68.35 % for lesions of all sizes.
Sensitivity for detection of lesions >6mm was calculated at
76.24 %, increasing to 77.55 % for lesions > 10 mm. It
follows that the results of CTC improves with large size
lesions and shows that CTC compares favorably with optical colonoscopy for detection of larger polyps (> 6 mm) [6].
Barium enema examination accurately identifies latestage cancer, but it is a poor test for important cancer-precursor lesions [7] and is rarely used for colorectal-cancer
screening today.
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PATIENT PREPARATION
The purpose of the bowel preparation for CTC is to
minimize or eliminate the negative effect of stool on the
interpretation of the examination. Three major approaches
have been undertaken: cathartic-only, tagging-only, and
complete cathartic/tagging strategies. Whereas the first two
approaches have demonstrated adequate polyp sensitivities
in high-prevalence cohorts, only the complete cathartic/tagging strategy has demonstrated effective polyp detection
rates in the intended cohorts of low-prevalence or screening populations [8]. Fecal and fluid tagging is a promising technique being evaluated to replace standard bowel
cleansing. It may be performed with or without electronic
bowel cleansing. The patient ingests small amounts of barium or iodinated oral contrast medium with meals prior
to CTC. The high attenuation contrast medium incorporates within the residual stool facilitating differentiation
from polyps. When electronic bowel cleansing techniques
are used (digital cleansing), the high attenuation tagged
stool is segmented from the data leaving only the colonic
mucosa and filling defects which are attributed to polyps
and cancerous masses [2].

Figure 1. CT colonoscopy: distension of the colon: after

room air insufflation, verification of correct distension in
CT scout mode
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EXAMINATION TECHNIQUE
Adequate colon distension should be obtained to visualize the complete colonic lumen and optimal scan parameters should be used to prevent unnecessary radiation burden. For optimal distension, automatic carbon dioxide or
manual room air insufflation should be performed, preferably via a thin, flexible catheter [2, 9] (Figure 1). If we use
automatic insufflator for colon distention, usually about 3
liters of carbon dioxide is used. Manualy we insufflate room
air untill the patient indicates discomfort.
Hyoscine butylbromide or glucagone (when available)
are the spasmolytic agents because of the positive effect
on insufflation and pain/burden [10]. Scans in two positions prone and supine are required for adequate distension and high polyp sensitivity and decubitus position may
be used as an alternative for patients unable to lie in prone
position. The great intrinsic contrast between air or tagging
and polyps allows the use of low radiation dose. The lowdose protocol without intravenous contrast agent should be
used when extracolonic findings are deemed unimportant.
The normal abdominal CT scan protocols with intravenous
enhancement should be used in supine position for the evaluation of extracolonic findings in patients suspected for
colorectal cancer [9]. If we perform CTC study with intravenous contrast agent, the native scan is performed in
prone patient position and a scan with contrast agent in
supine position. Only portovenous contrast phase is usually recommended. The amount of contrast agent is chosen
depending on the body weight of the patient.
DATA VISUALIZATION AND INTERPRETATION
(C-RADS)
After scaning acquired CT data are transferred onto a
dedicated postprocessing work station equipped with navigator software, permitting the radiologist to obtain multiplanar reformations as well as to construct an endoluminal model of the air-distended colon, allowing fly-through
capabilities in the distended colon in both the antegrade
and retrograde directions. Workstations allow simultaneous
viewing of the 3D and 2D images and also provide a 3D

map of the colon indicating the position along the colon of

the area being viewed [2] (Figure 2).
All colonic findings are described according to C-RADS (CT Colonography Reporting and Data System) [11]
(Table 1).
CTC INDICATIONS, DIAGNOSTIC ADVANTAGE
AND DISCUSSION
Laghi A. (2012) in recent article summarise indications
for CTC [12]. Incomplete colonoscopy is the most important and accepted indication. It completely replace barium
enema and is recommended by AGA (American Gastroenterological Association) since 2006 [13]. CTC we can choose for elderly patients unfit for colonoscopy (CC) for the
purpose of avoiding excessive risk at CC; in such case this
procedure achievable with reduced preparation since target
lesions are cancers and not polyps.
CT colonography is suitable in case of asymptomatic
diverticular disease for extension and severity assessment of
diverticulosis. Colon mapping are similar to barium enema
(BE), in addition CTC is more accurate than BE, preferred
by patients, with a shorter room time, fewer complications,
lower radiation exposure [14].

Figure 2. Virtual colonoscopy, 3D analysis: endoluminal

flythrough mode: virtual CT

Table 1. CT Colonography Reporting and Data System: CT colonography findings and follow-up recommendation (our
adapted from [11])
Score
C0
C1
C2
C3
C4

Description
Inadequate study/Awaiting Prior Comparison
Normal Colon or Benign Lesion;Continue Routine Screening
Intermediate Polyp or Indeterminate Finding;Surveillance
or Colonoscopy Recommended
Polyp, Possibly Advanced Adenoma; Follow-up Colonoscopy Recommended
Colonic Mass, Likely Malignant; Surgical Consultation
Recommended
teorija ir praktika 2013 - T. 19 (Nr. 2)

Examples
Inadequate preparation or insufflation
No polyp6 mm:lipoma or diverticula
Intermediate polyp 6-9mm, <3 in number
Polyp 10mm;3 polyps, each 6-9mm
Lesion compromises bowel lumen, demonstrates extracolonic invasion
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Colonoscopy has a considerable error rate for localization of colorectal cancer, especially when previous colorectal procedures have been performed. Without accurate
localization and definitions of margins, the surgeon may
resect the wrong segment or incompletely remove the tumor, and this is especially important with the advent of
laparoscopic surgery and the loss of the ability to palpate
the colon [15]. So with the help of CTC we can accurately
detect localization of the tumor and synchronous lesions
and/or polypectomy site before a laparoscopic surgery.
CTC is a potential technique for colorectal carcinoma
screening. Studies on the impact of CTC screening on CRC
incidence or mortality have not yet been conducted. Seven
systematic reviews and metaanalyses on CTC performance
characteristics in comparison to colonoscopy [1622] reported that sensitivity was low for small polyps and increased with polyp size (Table 2 and Table 3).
In accordance with European guidelines for quality assurance in colorectal cancer screening and diagnosis (2010) New technologies under evaluation are not
recommended for CRC screening by the EU.
Virtual colonoscopy is recommended in the United
States for first-line screening in high- and medium-risk
patients. Only the patients with one or more polyps measuring more than 9 mm detected by that procedure are
referred for optical colonoscopy. In this strategy, polyps me-

asuring less than 6 mm are deliberately disregarded, while

for polyps measuring 6-9 mm, the patient has the choice
between monitoring with future colonography procedures
or undergoing colonoscopy to remove the polyp [23]. At
the moment CC should be recommended as the first choice, whereas CTC to be offered in those who refuse or are
unwilling to undergo CC [12].
When used for surveillance after surgery for CRC cancer, CTC with intravenous contrast enhancement combines
the ability of detecting polyps and cancer with an accuracy
that is similar to CC, and, at the same time, it offers the
evaluation of extra-colonic findings (regional and distant
lymphadenopathies and liver metastases) [12].
During the CTC we can determine or suspect any
changes, however, it is not possible to take a biopsy as we
would do during CC. CTC is very sensitive to small changes, but is not as specific in assessing the nature of changes
as CC is.
CTC CONTRAINDICATIONS
Contraindications are: intestinal obstruction syndrome, acute abdomen syndrome, recent abdominal surgery
and pregnancy. Difficulties insufflating the colon or positioning the patient may be encountered with obese patients
[23]. Absolute contraindications are diverticulitis and acute
phase of irritable bowel diseases (IBDs). In the case of sus-

Table 2. Meta-analyses and systematic reviews targeted on CTC founded polyps according their size in mixed population
of patients

Pickard et al.(2011) [21]

Chaparro et al (2009) [43]
Rosman et al. (2007) [19]
Mulhall et al. (2005) [18]
Halligan et al. (2005) [17]
Sosna et al. (2003) [16]

Pickard et al.(2011) [21]

Chaparro et al (2009) [43]
Rosman et al. (2007) [19]
Mulhall et al. (2005) [18]
Halligan et al. (2005) [17]
Sosna et al. (2003) [16]

CTC founded polyps according their size per-patient sensitivity

Number of patients
<6 mm
6-9 mm
11 151 (49 studies)
10 546 (47 studies)
60%
30 studies
56%
63%
6393 (33 studies)
48%
70%
2610 (24 studies)
86%
1324 (14 studies)
65%
84%
CTC founded polyps according their size per-patient specificity
Number of patients
11 151 (49 studies)
10 546 (47 studies)
90%
30 studies
6393 (33 studies)
92%
93%
2610 (24 studies)
86%
1324 (14 studies)
-

>9 mm
83%
82%
85%
93%
88%

Overall
96,1%
69%
70%
-

92%
97%
97%
95%

83%
86%
-

Table 3. Meta-analysis targeted on nonscreening population with positive fecal occult blood test (Walleser et al. 2007)
[20]
Per patient analysis
Polyps 10 mm
Cancers
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Number of patients
5 studies

Sensitivity (% )
63%
89%

Specificity ( %)
95%
97%
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pected diverticulitis and in patients with IBDs presenting

with acute symptoms, CTC should be avoided because of
the risk of complications. In these conditions, contrast-enhanced multidetector computed tomography is the preferable examination to provide all the necessary information to
the clinician [12].
INCIDENTAL FINDINGS IN CT
COLONOGRAPHY
In addition to intracolonic findings, CTC examines the
entire abdomen and pelvis similarly to a CT scan [24]. Incidental extracolonic findings are classified according CTC
reporting and data system [11], it helps to classify significant versus insignificant extracolonic lesions (Table 4).
Veerappan GR. et al. (2010) retrospective study of 2,277
patients undergoing CTC, extracolonic findings were identified in 1,037 (46 %) patients, with 787 (34.5 %) insignificant and 240 (11.0 %) significant findings [25]. Extracolonic incidental findings are more frequent with increasing age
and although they are common, only a minority are of high
significance [26]. Pickhardt PJ. et al. (2011) study results
suggest very interesting findings that small sliding hiatal hernias are commonly induced by colonic distention at CTC
and should probably not be reported to avoid inappropriate
diagnosis, workup, or treatment [27]. O'Connor examined
that renal mases in unenhanced CTC are very common finding, but imaging criteria can be used for reliable identification of most of these lesions as benign without further
workup. Mean attenuation alone appears reliable for determining which renal masses need further evaluation [28].
PATIENT PREFERENCE, ACCEPTANCE AND
TOLERANCE OF CTC
Von Wagner et al. (2012) the randomized controlled
study found that symptomatic patients consider CT colonography as more acceptable than colonoscopy [29]. Patients have also significantly less physical discomfort after
CT colonography than after colonoscopy (median colonoscopy score of 39 vs median CT colonography score of 35,
P = .001) and experience significantly fewer adverse events.
Thomeer M. and colleagues (2002) found that factors ot-

her than the discomfort related to the examination play an

important role in the patient's preference for virtual CT colonography, namely the faster procedure, the lower physical
challenge, and the absence of sedation [29].
In the studies, when the patients indicated CT colonography as more painful examination, bowel relaxants were
not used, and sedatives and analgesics were administered
during colonoscopy in all patients [30-33]. In the studies
when the patients indicated that CT colonography was a
less painful examination, bowel relaxants were routinely
administered, and sedatives and analgesics were administered during colonoscopy in a lower proportion of the study
population [29, 30, 34, 35].
In a recent study [10], which compare colonic distension and perceived burden of CT colonography between
participants receiving hyoscine butylbromide (buscopan)
and glucagon hydrochloride as bowel relaxant most frequently reported side effects were a dry mouth in the buscopan group (15 %) and nausea in the glucagon group (13
%). Compared to glucagon, premedication with buscopan
results in significantly more adequately distended colons
and a less burdensome procedure. When buscopan can be
used, it is the preferred bowel relaxant. The patients experience during both examinations mainly depends on the
technique of the procedure.
COMPLICATIONS
Adequate colonic distention is critical for effective performance of CT colonography. Optimal colonic distention
(which is distinct from maximal distention) is achieved
when diagnostic quality is properly balanced against patient comfort and safety [36]. Perforation of the colon is an
exceedingly uncommon complication of CT colonography.
An advantage of CT colonography is that unlike colonoscopy it does not require the insertion and maneuvering of an
endoscope to the cecum [37]. The first time CTC related
perforation was described and published in 2004 by Kamar
M. [38]. Therefore, perforation rates for diagnostic colonoscopy are significantly higher than for CT colonography.
Colonic perforation is a known risk of conventional colonoscopy screening and ranges between 0.060.19 % of cases

Table 4. CT Colonography Reporting and Data System: Radiologic Metod of Categorizing Extracolonic Findings
According to Clinical Significance (our adapted from [11])
Score
E0
E1
E2
E3
E4

Description
Limited examination: compromised by artifact; evaluation of extracolonic soft tissues is severely limited
Normal exam or anatomic variant
Clinically unimportant findings; no work-up indicated
Likely unimportant findings, incompletely characterized;
work-up may be indicated
Potentially important findings; communicate to referring physician as per accepted practice guidelines
teorija ir praktika 2013 - T. 19 (Nr. 2)

Examples
Not applicable
Retroaortic left renal vein
Simple liver or kidney cysts
Complex kidney cyst
Aortic aneurysm, lymfadenopathy
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[37]. Perforation of the colon and rectum is a relatively rare,

but potentially morbid complication of CTC, especially in
symptomatic patients [39]. In large multicentric study with
total of 11 870 CT colonographic studies perforation rate
was of 0.059 %. Six (84 %) of seven cases of perforation
occurred in symptomatic patients at high risk for colorectal
neoplasia, and one (16 %) occurred in an asymptomatic
average-risk patient [40]. To summarise older age and underlying concomitant colon pathology increase the risk of
perforation. In largest Pickhardts PJ. (2006) study according CTC risk of perforation includes 21 923 studies in 16
centers [36]. There were no cases of colonic perforation at
CT colonography among the 11 707 patients being screened, and there were two cases of perforation among patients
who underwent 10 216 diagnostic studies.
We can conclude that the CTC is safe procedure with
minimum risk of perforation in symptomatic and elderly
patients.
CONCLUSION
The noninvasive nature of CTC may be attractive to
patients, and the use of this modality can improve screening
compliance and diagnostic rates. Many people are reluctant
to undergo colonoscopy because of its inconvenience or
discomfort, or because of embarrassment [41]. Adequate
preparation and colon distension should be obtained to visualize the complete colonic lumen for best results.
One of the main disadvantages of CTC is ionising radiation, but we can apply the low dose protocols when carrying out the scan. If possible, it is recommended to use
CTC instead of BE because the CTC is much more sensitive and produces less radiation.
In everyday practice, in Lithuania, we would recommend to start applying this method when CC is incompleted and the whole colon is not inspected. CTC can be
prescribed for elderly patients when CC is contraindicated
for any side effects. We would recommend the CTC as an
alternative for colon cancer screening, especially when the
patient refuses the CC.
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Gautas 2013 m. kovo 8 d., aprobuotas 2013 m. balandio 14 d.

Submitted March 8, 2013, accepted April 14, 2013.

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