CTC Bulletin spring 2010:Layout 1 03/06/10 09:27 Pagina 1

Fall 2009 Winter 2009 Spring 2010 Summer 2010 Fall 2010

CT Colonography Bulletin
Highlighting a new noninvasive technique
for colorectal cancer screening
CTC Bulletin spring 2010:Layout 1 03/06/10 09:27 Pagina 2
Colonic distension
David Burling, Janice Muckian
Intestinal Imaging Centre, St. Mark’s Hospital, London, UK
With routine use of faecal tagging in CT colonography practice,
optimising colonic distension becomes the most important and
challenging determinant of examination quality. A well distended
colon is easy to navigate (either by 2D or 3D review) and thin
haustral folds are rapidly discriminated from polyps or cancer. The
combination of excellent preparation and distension enhances in-
terpretative experience (particularly welcome when several exam-
inations are read in succession). As a result, the accuracy and
confidence of the radiologist’s interpretation are increased, thereby
reducing ambiguity in CT colonography reports.
What factors improve distension?
There are a number of evidence based strategies for increasing
quality of colonic distension, including use of automated carbon
dioxide insufflation, multislice CT platforms, dual patient positioning
and intravenous administration of hyoscine butylbromide (Busco-
pan, Boehringer Ingelheim, Germany). Unlike glucagon, Buscopan
has been shown to significantly improve colonic distension[1].
We have used an automated insufflator (PROTOCO2L, Bracco, Italy)
continuously for over six years at St. Mark’s Hospital (>3000 pa-
tients) following an initial study which showed automated insuffla-
tion significantly improved quality of colonic distension compared
to a manual method[2]. We found improvement was greatest in the
sigmoid colon, a notorious site for diverticulosis (and associated
luminal narrowing). In addition, carbon dioxide is more comfortable
for patients than air as it is more rapidly absorbed by the colonic
mucosa after examination.The automated insufflation device is con-
siderably more convenient to use than manual methods of carbon
dioxide insufflation. According to protocol, the device initially deliv-
ers carbon dioxide at one litre/min but this rate increases in 1
litre/minute increments over two minutes to 3 litres per minute.
This approach helps avoid colonic spasm, which may occur if gas
Fig. 1
77 year old female, presenting with diarrhoea and anaemia underwent a standard CT colonography
examination (Table 1) as conventional colonoscopy was considered to be contraindicated by the re-
ferring clinician due to patient frailty. Sigmoid colonic perforation (yellow arrow shows retroperi-
toneal gas, confined to mesentery) was detected on the second scan acquisition (right lateral
decubitus patient position), with background severe sigmoid diverticulosis. Notably Buscopan was
not given due to past history of cardiac arrhythmia. The patient had no significant symptoms asso-
ciated with perforation and was managed conservatively with no secondary complications.
References
1. Taylor SA, Halligan S, Goh V et al (2003) Optimizing colonic distention for multi-detector row CT
colonography: effect of hyoscine butylbromide and rectal balloon catheter. Radiology 229(1):99-108
2. Burling D, Taylor SA, Halligan S et al (2006) Automated insufflation of carbon dioxide for MDCT
colonography: distension and patient experience compared with manual insufflation. AJR Am J Roentgenol
186(1):96-103
Introduction
delivery is too rapid at the beginning of insufflation. If intra-rectal
pressure (continuously measured at the rectal catheter tip) ex-
ceeds 25mm Hg, then insufflation is halted. If pressure exceeds
50mmHg, gas is actively vented by the device from the rectum.
These effects combine to improve safety and patient experience
and potentially help to reduce risk of perforation if a luminal ob-
struction is present.
Distension technique
Colonic distension technique using the automated insufflator is
well described in the literature[3] and is summarised in Table 1
(see Clinical Cases 1 and 2). Practical tips to improve distension
include propping the chest up with a folded pillow on the prone
examination (to avoid compression of transverse colon by the
abdominal wall) and using an additional lateral decubitus exami-
nation when distension is suboptimal.
Risk of perforation
Colonic perforation is a rare complication of CT colonography,
occurring in approximately 1 in 3000 diagnostic examinations[4],
and occurs even less commonly in asymptomatic patients[5].Whilst
many perforations are asymptomatic with the majority managed
conservatively (Fig. 1), CT colonography teams should minimise
risk by ensuring that practitioners undertaking the examination
are suitably trained and experienced. Notably true perforation
should be distinguished from pneumatosis coli, in which gas accu-
mulates within the colonic wall, usually prior to examination[6]
(Fig. 2). Finally, we recommend that practitioners provide clear in-
formation to patients about the likelihood of them encountering
some discomfort during colonic insufflation. This approach avoids
unrealistic patient expectations and anecdotally enhances patient
co-operation and experience by decreasing anxiety.
Fig. 2
Pneumatosis coli demonstrated by a small volume of gas within the ascending colonic wall (yellow ar-
rows) in a 71 year old woman undergoing CT colonography following positive faecal occult blood test
and incomplete colonoscopy. The volume and distribution of intramural gas was unchanged between
supine and prone examinations.
3. Tolan DJ, Armstrong EM, Burling D et al (2007) Optimization of CT colonography technique: a practical
guide. Clin Radiol 62(9):819-827
4. Burling D, Halligan S, Slater A et al (2006) Potentially serious adverse events at CT colonography in
symptomatic patients: national survey of the United Kingdom. Radiology 239(2):464-471
5. Pickhardt PJ (2006) Incidence of colonic perforation at CT colonography: review of existing data and
implications for screening of asymptomatic adults. Radiology 239(2):313-316
6. Pickhardt PJ, Kim DH, Taylor AJ (2008) Asymptomatic pneumatosis at CT colonography: a benign self-
limited imaging finding distinct from perforation. AJR Am J Roentgenol 190(2):W112-W117
CTC Bulletin spring 2010:Layout 1 03/06/10 09:27 Pagina 3

Clinical Case I

Dual pathology only detectable by CT colonography

David Burling, Janice Muckian
Intestinal Imaging Centre, St. Mark’s Hospital, London, UK

Presentation
87 year old woman with history of iron deficiency anaemia. Gastroscopy showed mild duodenitis but was otherwise normal.

CT colonography technique
See Table 1. Minimal laxative regimen utilised.

Table 1 - CT colonography technique

Bowel preparation – standard
• 50 ml of Gastrografin orally on each of the 2 evenings prior to examination
• 2 sachets Picolax (sodium picosulphate and magnesium citrate; Ferring Pharmaceuticals) the day before the examination, one at 8 am one at 2 pm
• Low residue diet for 2 days prior to examination with fluid diet only the day before
Bowel preparation – minimal laxative regimen
• As above but excluding Picolax
Examination protocol including colonic distension
• Smooth muscle relaxation: Intravenous injection of hyoscine butylbromide (Buscopan, Boehringer Ingelheim, Germany)
• Colonic insufflation with carbon dioxide using an automated CO2 injector (PROTOCO2L, Bracco, Italy)
• Supine and prone acquisitions
• Multislice CT: 64x1 mm, 80 mAs supine, 30 mAs prone, 120 kV (Siemens Healthcare, Germany)
• Prone dose increased to approx. 200 mAs if intravenously administered contrast – used routinely in patients at our institution with anaemia

Findings
The combination of excellent distension and preparation facilitated a confident diagnosis of a ‘minimally elevated’ polyp of 35 mm diameter in the caecum
(Fig. 3a-c).This diagnosis was confirmed when colonoscopic submucosal dissection and subsequent histopathological examination showed the polyp to be
a benign granular type, laterally spreading tumour. In addition, extra-colonic review revealed a localised renal mass of 8 cm diameter (Fig. 4), subsequently
confirmed after sugery to be a renal cell carcinoma.

c
Fig. 4
Same patient as in Fig. 3. An 8-cm renal cell carcino-
ma (arrow) was found in the upper pole of left kid-
ney on this coronal CT display (abdominal CT
Fig. 3a-c windows)
Case 1: an 87-year old woman with iron deficiency
anaemia and mild duodenitis. CT colonography re-
vealed a ‘minimally elevated’ polyp of 35 mm diame-
ter in the caecum. a. Supine 2D axial image (colon
b CT windows) b. prone 2D axial image (colon CT win-
dows) and c. 3D ‘endoluminal’ display.

Comment
High quality CT colonography permitted an accurate and efficient patient assessment of two important co-existent pathologies in this patient and thus fa-
cilitated the planning for subsequent (curative) management. No other single colonic investigation could have achieved this.
CTC Bulletin spring 2010:Layout 1 03/06/10 09:27 Pagina 4

Clinical Case II

Persistent colonic spasm mimicking cancer

David Burling, Janice Muckian
Intestinal Imaging Centre, St. Mark’s Hospital, London, UK

Presentation
76 year old woman presenting with anaemia and incomplete colonoscopy due to inadequate bowel preparation. A large rectal polyp had been removed at
endoscopy.

Technique
See Table 1. Minimal laxative regimen

Table 1 - CT colonography technique

Bowel preparation – standard
• 50 ml of Gastrografin orally on each of the 2 evenings prior to examination
• 2 sachets Picolax (sodium picosulphate and magnesium citrate; Ferring Pharmaceuticals) the day before the examination, one at 8 am one at 2 pm
• Low residue diet for 2 days prior to examination with fluid diet only the day before
Bowel preparation – minimal laxative regimen
• As above but excluding Picolax
Examination protocol including colonic distension
• Smooth muscle relaxation: Intravenous injection of hyoscine butylbromide (Buscopan, Boehringer Ingelheim, Germany)
• Colonic insufflation with carbon dioxide using an automated CO2 injector (PROTOCO2L, Bracco, Italy)
• Supine and prone acquisitions
• Multislice CT: 64x1 mm, 80 mAs supine, 30 mAs prone, 120 kV (Siemens Healthcare, Germany)
• Prone dose increased to approx. 200 mAs if intravenously administered contrast – used routinely in patients at our institution with anaemia

Findings
CT colonography examination with the patient in supine position revealed a short segment of persistent narrowing in the sigmoid colon, which we
suspected to be a focal spasm but which had an appearance indistinguishable from cancer (Fig. 5a,b).The prone scan confirmed diagnosis of spasm as this
segment ‘opened up’ but it also revealed in the same colonic segment a 5-mm sessile polyp (albeit clinically insignificant in this patient) (Fig. 5c,d).

a b

Fig. 5a-d
A 76-year old woman with a history of a large rectal polyp removed at endoscopy
and in whom colonoscopy was incomplete due to inadequate bowel preparation. CT
colonography revealed a focal spasm (yellow arrows) in the sigmoid colon indistin-
guishable from cancer: this was seen on the supine axial scan using modified lung
‘colon’ CT windows (a) and abdominal CT windows (b). On the prone scan, the
spasm ‘opened up’ revealing a 5-mm sessile polyp: this was seen on the axial 2D
c d display using modified lung ‘colon’ CT windows (c) and 3D ‘endoluminal’ display (d).

Comment
Despite the use of spasmolytic, persistent spasm may cause diagnostic uncertainty and mimic a cancer. Whilst referral for endoscopic evaluation may be
considered, radiologists can frequently resolve this uncertainty by reviewing the prone scan or undertaking an additional lateral decubitus examination. Use
of an automated insufflator makes additional scans more convenient and more comfortable for patients.

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