Skip to main content
SpringerLink
Log in

CT enterography for Crohn’s disease: optimal technique and imaging issues

  • Published:
Abdominal Imaging Aims and scope Submit manuscript

Abstract

CT enterography (CTE) is a common examination for patients with Crohn’s disease. In order to achieve high quality, diagnostic images, proper technique is required. The purpose of this treatise is to review the processes and techniques that can optimize CTE for patients with suspected or known Crohn’s disease. We will review the following: (1) how to start a CT enterography program; (2) workflow issues, including patient and ordering physician education and preparation; (3) oral contrast media options and administration regimens; (4) intravenous contrast media injection for uniphasic and multiphasic studies; (5) CTE radiation dose reduction strategies and the use of iterative reconstruction in lower dose examinations; (6) image reconstruction and interpretation; (7) imaging Crohn’s patients in the acute or emergency department setting; (8) limitations of CTE as well as alternatives such as MRE or barium fluoroscopic examinations; and (9) dictation templates and a common nomenclature for reporting findings of CTE in Crohn’s disease. Many of the issues discussed are summarized in the Abdominal Radiology Society Consensus MDCT Enterography Acquisition Protocol for Crohn’s Disease

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Raptopoulos V, Davis MA, Davidoff A, et al. (1987) Fat-density oral contrast agent for abdominal CT. Radiology 164:653–656

    Article  CAS  PubMed  Google Scholar 

  2. Thoeni RF, Filson RG (1988) Abdominal and pelvic CT: use of metoclopramide to enhance bowel opacification. Radiology 169:391–393

    Article  CAS  PubMed  Google Scholar 

  3. Raptopoulos V, Schwartz RK, McNicholas MM, et al. (1997) Multiplanar helical CT enterography in patients with Crohn’s disease. AJR 169:1545–1550

    CAS  PubMed  Google Scholar 

  4. Rosen MP, Siewart B, Sands DZ, et al. (2003) Value of abdominal CT in emergency department for patients with abdominal pain. Eur Radiol 13:418–424

    PubMed  Google Scholar 

  5. Mazzeo S, Caramella D, Battola L, et al. (2001) Crohn disease of the small bowel: spiral CT evaluation after oral hyperhydration with isotonic solution. J Comput Assist Tomogr 25:612–616

    CAS  PubMed  Google Scholar 

  6. Wold PB, Fletcher JG, Johnson CD, Sandborn WJ (2003) Assessment of small bowel Crohn disease: noninvasive peroral CT enterography compared with other imaging methods and endoscopy-feasibility study. Radiology 229:275–281

    Article  PubMed  Google Scholar 

  7. Megibow AJ, Babb JS, Hecht EM, et al. (2006) Evaluation of bowel distention and bowel wall appearance by using neutral oral contrast agent for multi-detector row CT. Radiology 238:87–95

    Article  PubMed  Google Scholar 

  8. Hara AK, Leighton JA, Heigh RI, et al. (2006) Crohn disease of the small bowel: preliminary comparison among CT enterography, capsule endoscopy, small-bowel follow-through and ileoscopy. Radiology 238:128–134

    Article  PubMed  Google Scholar 

  9. Bodily KD, Fletcher JG, Solem CA, et al. (2006) Crohn disease: mural attenuation and thickness at contrast-enhanced CT enterography- correlation with endoscopic and histologic findings of inflammation. Radiology 238:505–516

    Article  PubMed  Google Scholar 

  10. Booya F, Fletcher JG, Huprich JE, et al. (2006) Active Crohn disease: CT findings and interobserver agreement for enteric phase CT enterography. Radiology 241:787–795

    Article  PubMed  Google Scholar 

  11. Paulsen SR, Huprich JE, Fletcher JG, et al. (2006) CT enterography as a diagnostic tool in evaluating small bowel disorders: review of clinical experience in over 700 cases. Radiographics 26:641–662

    Article  PubMed  Google Scholar 

  12. Hara AK, Alam S, Heigh RI, et al. (2008) Using CT enterography to monitor Crohn’s disease activity: a preliminary study. AJR 190:1512–1516

    PubMed  Google Scholar 

  13. Baker ME, Walter J, Obuchowski NA, et al. (2009) Mural attenuation in normal small bowel and active inflammatory Crohn’s disease on CT enterography: location, absolute attenuation, relative attenuation and the effect of wall thickness. AJR 192:417–423

    PubMed  Google Scholar 

  14. Hara AK, Walker FB, Silva AC, Leighton JA (2009) Preliminary estimate of triphasic CT enterography performance in hemodynamically stable patients with suspected gastrointestinal bleeding. AJR 193:1252–1260

    PubMed  Google Scholar 

  15. Huprich JE, Fletcher JG, Fidler J, et al. (2011) Prospective blinded comparison of wireless capsule endoscopy and multiphase CT enterography in obscure gastrointestinal bleeding. Radiology 2011(260):744–751

    Article  Google Scholar 

  16. Lee SS, Oh TS, Kim HJ, et al. (2011) Obscure gastrointestinal bleeding: diagnostic performance of multidetector CT enterography. Radiology 259:739–748

    Article  PubMed  Google Scholar 

  17. Huprich JE, Barlow JM, Hansel SL, Alexander JA, Fidler JL (2013) Multiphase CT enterography evaluation of small-bowel vascular lesions. AJR 2013:65–72

    Google Scholar 

  18. Wang Z, Chen JG, Liu JL, Qin XG, Huang Y (2013) CT enterography in obscure gastrointestinal bleeding: a systematic review and meta-analysis. J Med Imaging Rad Oncol 57:263–273

    Google Scholar 

  19. Elsayes KM, Al-Hawary MM, Jagdish J, Ganesh HS, Platt JF (2010) CT enterography: principles, trends and interpretation of findings. Radiographics 30:1955–1974

    Article  PubMed  Google Scholar 

  20. Gourtsoyianni S, Zamboni GA, Romero JY, Raptopoulos VD (2009) Routine use of modified CT enterography in patients with acute abdominal pain. Eur J Radiol 69:388–392

    PubMed  Google Scholar 

  21. Panes J, Bouhnik Y, Reinisch W, et al. (2013) Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines. J Crohn’s Colitis 7:556–585. doi:10.1016/j.corhns.2013.02.020

    CAS  Google Scholar 

  22. Bruining DH (2010) CT enterography: is it the current state-of-the-art for small bowel diagnostics? Dig Dis 28:429–432

    PubMed  Google Scholar 

  23. National Council on Radiation Protection and Measurements (2009) Ionizing radiation exposure of the population of the United States. Report 160. Bethesda, MD: National Council on Radiation Protection and Measurements.

  24. Maglinte DDT, Applegate KE, Rajesh A, et al. (2009) Conscious sedation for patients undergoing enteroclysis: comparing the safety and patient-reported effectiveness of two protocols. Eur J Radiol 70:512–516

    PubMed  Google Scholar 

  25. Kuehle CA, Ajaj W, Ladd SC, et al. (2006) Hydro-MRI of the small bowel: effect of contrast volume, timing of contrast administration and data acquisition on bowel distension. AJR 187:W375–W385

    PubMed  Google Scholar 

  26. Rollandi GA, Curone PF, Biscaldi E, et al. (1999) Spiral CT of the abdomen after distention of small bowel loops with transparent enema in patients with Crohn’s disease. Abdom Imaging 24:544–549

    CAS  PubMed  Google Scholar 

  27. Fletcher JG (2008) CT enterography technique: theme and variations. Abdom Imaging 34:283–288

    Google Scholar 

  28. Huprich JE, Fletcher JG (2009) CT enterography: principles, technique and utility in Crohn’s disease. Eur J Radiol 69:393–397

    PubMed  Google Scholar 

  29. Ilangovan R, Burling D, George A, et al. (2012) CT enterography: review of technique and practical tips. Br J Radiol 85:876–886

    PubMed Central  CAS  PubMed  Google Scholar 

  30. Sood RR, Joubert I, Franklin H, Doyle T, Lomas DJ (2002) Small bowel MRI: comparison of polyethylene glycol preparation and water as oral contrast media. J Magn Reson Imaging 15:401–408

    PubMed  Google Scholar 

  31. Arslan H, Etlik O, Kayan M, et al. (2005) Peroral CT enterography with lactulose solution: preliminary observations. AJR 185:1173–1179

    PubMed  Google Scholar 

  32. Hebert JJ, Taylor AJ, Winter TC, Reichelderfer M, Weichert JP (2006) Low-attenuation oral GI contrast agents in abdominal-pelvic computed tomography. Abdom Imaging 31:48–53

    CAS  PubMed  Google Scholar 

  33. Young BM, Fletcher JG, Booya F, et al. (2008) Head-to-head comparison of oral contrast agents for cross-sectional enterography: small bowel distention, timing, and side-effects. J Comput Assist Tomogr 32:32–38

    PubMed  Google Scholar 

  34. Koo CW, Shah-Patel LR, Baer JW, Frager DH (2008) Cost-effectiveness and patient tolerance of low-attenuation oral contrast material: milk versus VoLumen. AJR 190:1307–1313

    PubMed  Google Scholar 

  35. Minordi LM, Vecchioli A, Mirk P, Bonomo L (2011) CT enterography with polyethylene glycol solution vs CT enteroclysis in small bowel disease. Br J Radiol 84:112–119

    PubMed Central  CAS  PubMed  Google Scholar 

  36. Schindera ST, Nelson RC, DeLong DM, et al. (2007) Multi-detector row CT of the small bowel: peak enhancement temporal window-initial experience. Radiology 243:438–444

    Article  PubMed  Google Scholar 

  37. Vandenbroucke F, Mortele KJ, Tatli S, et al. (2007) Noninvasive multidetector computed tomography enterography in patients with small bowel Crohn’s disease: is a 40-second delay better than 70 seconds? Acta Radiol 48(1052–1060):2007

    Google Scholar 

  38. Makanyanga J, Punwani S, Taylor SA (2012) Assessment of wall inflammation and fibrosis in Crohn’s disease: value of T1-weighted, gadolinium-enhanced MR imaging. Abdom Imaging 37:933–943

    PubMed  Google Scholar 

  39. Jaffe TA, Am Gaca, Delaney S, et al. (2007) Radiation dose from small-bowel follow-through and abdominopelvic MDCT in Crohn’s disease. AJR 189:1015–1022

    PubMed  Google Scholar 

  40. Peloquin JM, Pardi DS, Sandborn WJ, et al. (2008) Diagnostic ionizing radiation exposure in a population-based cohort of patients with inflammatory bowel disease. Am J Gastroenterol 103:2015–2022

    PubMed Central  PubMed  Google Scholar 

  41. Desmond AN, O’Regan K, Curran C, et al. (2008) Crohn’s disease: factors associated with exposure to high levels of diagnostic radiation. Gut 57:1524–1529

    Article  CAS  PubMed  Google Scholar 

  42. Brenner DJ (2008) Should computed tomography be the modality of choice for imaging Crohn’s disease in children? The radiation risk perspective. Gut 57:1489–1490

    Article  PubMed  Google Scholar 

  43. Palmer L, Herfarth H, Porter CQ, et al. (2009) Diagnostic ionizing radiation exposure in a population-based sample of children with inflammatory bowel diseases. Am J Gastroenterol 104:2816–2823

    PubMed Central  PubMed  Google Scholar 

  44. Kroeker KI, Lam S, Birchall I, Fedorak RN (2011) Patients with IBD are exposed to high levels of ionizing radiation through CT scan diagnostic imaging: a five-year study. J Clin Gastroenterol 45:34–39

    PubMed  Google Scholar 

  45. Chatu S, Subramanian V, Pollok RC (2012) Meta-analysis: diagnostic medical radiation exposure in inflammatory bowel disease. Aliment Pharmacol Ther 35:529–539

    CAS  PubMed  Google Scholar 

  46. Pearce MS, Salotti JA, Little MP, et al. (2012) Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumors: a retrospective cohort study. Lancet 380:499–505

    PubMed Central  PubMed  Google Scholar 

  47. Brenner DJ, Hall EJ (2012) Cancer risks from CT scans: now we have data, what next? Radiology 265:330–331

    Article  PubMed  Google Scholar 

  48. Kambadakone AR, Prakash P, Hahn PF, Sahani DV (2010) Low-dose CT examinations of Crohn’s disease: impact of image quality, diagnostic performance and radiation dose. AJR 195:78–88

    PubMed  Google Scholar 

  49. Allen BC, Baker ME, Einstein DM, et al. (2010) Effect of altering automatic exposure control settings and quality reference mAs on radiation dose, image quality, and diagnostic efficacy in MDCT enterography of active inflammatory Crohn’s disease. AJR 195:89–100

    PubMed  Google Scholar 

  50. Guimaraes LS, Fletcher JG, Yu L, et al. (2010) Feasibility of dose reduction using novel denoising techniques for low kV (80 kV) CT enterography: optimization and validation. Acad Radiol 17:1203–1210

    PubMed Central  PubMed  Google Scholar 

  51. Siddiki H, Fletcher JG, Hara AK, et al. (2011) Validation of lower radiation computed tomography enterography imaging protocol to detect Crohn’s disease in the small bowel. Inflamm Bowel Dis 17:778–786

    PubMed  Google Scholar 

  52. Kambadakone AR, Chaudhary NA, Desai GS, et al. (2011) Low-dose MDCT and CT enterography of patients with Crohn disease: feasibility of adaptive statistical iterative reconstruction. AJR 196:W743–W752

    PubMed  Google Scholar 

  53. Craig O, O’Neill S, O’Neill F, et al. (2012) Diagnostic accuracy of computed tomography using lower doses of radiation for patients with Crohn’s disease. Clin Gastroenterol Hepatol 10:886–892

    PubMed  Google Scholar 

  54. Kaza RK, Platt JF, Al-Hawary MM, et al. (2012) CT enterography at 80 kVp with adaptive statistical iterative reconstruction versus at 120 kVp with standard reconstruction: image quality, diagnostic adequacy and dose reduction. AJR 198:1084–1092

    PubMed  Google Scholar 

  55. Gonzalez-Guindalini FD, Botelho MPF, Huseyin GT, et al. (2013) MDCT of chest, abdomen, and pelvis using attenuation- based automated tube voltage selection in combination with iterative reconstruction: an intrapatient study of radiation dose and image quality. AJR 2013(201):1075–1082

    Google Scholar 

  56. Hough DM, Fletcher JG, Grant KL, et al. (2012) Lowering kilovoltage to reduce radiation dose in contrast-enhanced abdominal CT: initial assessment of a prototype automated kilovoltage selection tool. AJR 199:1070–1077

    PubMed  Google Scholar 

  57. Kanal KM, Chung JH, Wang J, et al. (2011) Image noise and liver lesion detection with MDCT: a phantom study. AJR 197:437–441

    PubMed  Google Scholar 

  58. Hernandez-Giron I, Geleijns J, Calzado A, Veldkamp WJH (2011) Automated assessment of low contrast sensitivity for CT systems using a model observer. Med Phys 38(S1):S25

    PubMed  Google Scholar 

  59. Baker ME, Dong F, Primak A, et al. (2012) Contrast-to-noise ratio and low-contrast object resolution on full-and low-dose MDCT: SAFIRE versus filtered back projection in a low-contrast object phantom and in the liver. AJR 199:8–18

    PubMed  Google Scholar 

  60. Pickhardt PJ, Lubner MG, Kim DH, et al. (2012) Abdominal CT with model-based iterative reconstruction (MBIR): initial results of a prospective trial comparing ultralow-dose with standard-dose imaging. AJR 199:1266–1274

    PubMed Central  PubMed  Google Scholar 

  61. Von Falck C, Bratanova V, Rodt T, et al. (2013) Influence of sonogram affirmed iterative reconstruction of CT data on image noise characteristics and low-contrast detectability: an objective approach. PLos One 8(2):e56875. doi:10.1371/journal.pone.0056875

    Article  Google Scholar 

  62. Schindera ST, Odedra D, Raza SA, et al. (2013) Iterative reconstruction algorithm for CT: can radiation dose be decreased while low contrast detectability is preserved? Radiology 269:511–518

    Article  PubMed  Google Scholar 

  63. Schindera ST, Odedra D, Mercer D, et al. (2014) Hybrid iterative reconstruction technique for abdominal CT protocols in obese patients: assessment of image quality, radiation dose, and low-contrast detectability in a phantom. AJR 202:W146–W152

    PubMed  Google Scholar 

  64. Husarik DB, Schindera ST, Morsbach F, et al. (2014) Combining automated attenuation-based tube voltage selection and iterative reconstruction: a liver phantom study. Eur Radiol 24:657–667

    PubMed  Google Scholar 

  65. Goenka AH, Herts BR, Dong F, Obuchowski NA, et al. (2014) Effect of reduced radiation exposure and iterative reconstruction on detection of low contrast attenuation lesions in an anthropomorphic liver phantom: an 18-reader study. Radiology 272:154–163

    Article  PubMed  Google Scholar 

  66. Herts B, Baker ME, Obuchowski N, et al. (2013) Dose reduction for abdominal and pelvic MDCT following a change to a graduated weight-based protocol for selecting quality reference mAs, kVp and slice collimation. AJR 200:1298–1303

    PubMed  Google Scholar 

  67. Baker, ME, Karim W, Bullen J, Primak A, Dong F, Herts BR (2014) Estimated radiation exposure using automatic tube voltage selection with both fixed and weight-based quality reference mAs, and with a fixed 120 kVp, weight-based quality reference mAs. Presented at the 2014 American Roentgen Ray Society Annual Meeting, May, 2014, San Diego, CA.

  68. Gandhi N, Baker, ME, Goenka AH, et al (2014) Diagnostic accuracy of sonogram affirmed iterative reconstruction and filtered back projection in CTE at half-dose for active inflammatory terminal ileal Crohn’s disease: a multireader study. Presented at the 2014 Radiologic Society of North America Scientific Assembly and Annual Meeting, December, 2014, Chicago, IL

  69. Bruining DH, Loftus EV, Ehman EC, et al. (2011) Computed tomography enterography detects intestinal wall changes and effects of treatment in patients with Crohn’s disease. Clin Gastroenterol Hepatol 9:679–683

    PubMed  Google Scholar 

  70. Bruining DH, Siddiki HA, Fletcher JG, et al. (2012) Benefit of computed tomography enterography in Crohn’s disease: effects on patient management and physician level of confidence. Inflamm Bowel Dis 18:219–225

    PubMed  Google Scholar 

  71. Kerner C, Carey K, Mills AM, et al. (2012) Use of computed tomography in emergency departments and rates of urgent diagnoses in Crohn’s disease. Clin Gastroenterol Hepatol 10:52–57

    PubMed Central  PubMed  Google Scholar 

  72. Isreali E, Ying S, Henderson B, et al. (2013) The impact of abdominal computed tomography in a tertiary referral centre emergency department on the management of patients with inflammatory bowel disease. Aliment Pharmacol Ther 38:513–521

    Google Scholar 

  73. Vogel J, Moreira A, Baker ME, et al. (2007) CT enterography for Crohn’s disease: accurate preoperative imaging. Dis Colon Rectum 50:1761–1769

    PubMed  Google Scholar 

  74. Kerner C, Carey K, Baillie C, et al. (2013) Clinical predictors of urgent findings on abdominopelvic CT in emergency department patients with Crohn’s disease. Inflamm Bowel Dis 19:1179–1185

    PubMed Central  PubMed  Google Scholar 

  75. Kohli MD, Maglinte DDT (2009) CT enteroclysis in incomplete small bowel obstruction. Abdom Imaging 34:321–327

    PubMed  Google Scholar 

  76. Pariente B, Cosnes J, Danese S, et al. (2011) Development of the Crohn disease digestive damage score, the Lemann score. Inflamm Bowel dis 17:1415–1422

    PubMed Central  PubMed  Google Scholar 

  77. Pariente B, Peyrin-Biroulet L, Cohen L, Zagdanski AM, Colombel JF (2011) Gastroenterology review and perspective: the role of cross-sectional imaging in evaluating bowel damage in Crohn disease. AJR 197:42–49

    PubMed  Google Scholar 

  78. Rimola J, Ordas I, Rodriguez S, Ricart E, Panes J (2012) Imaging indexes of activity and severity for Crohn’s disease: current status and future trends. Abdom Imaging 37:956–958

    Google Scholar 

  79. Al-Hawary MM, Kaza RK, Platt JF (2013) CT enterography: concepts and advances in Crohn’s disease imaging. Radiol Clin N Am 51:1–16

    PubMed  Google Scholar 

Download references

Acknowledgments

We would like to thank the many other members of the Crohn’s Disease Focus Group of the Society of Abdominal Radiology who contributed thoughts and ideas that are incorporated in this document: Mahmoud Al-Hawary, Suhda Anupindi, David Bruining, Kassa Darge, Jonathan Dillman, David Einstein, Jeff Fidler, Michael Gee, Flavius Gugliemo, Tracy Jaffe, Seong Ho Park, Daniel Podberesky, Jordi Rimola, Dushyant Sahani, Jorge Soto, Stuart Taylor, and last but not least Alec Megibow, whose foresight and leadership helped propel small bowel imaging into the 21st Century.

Conflict of interest

Dr. Baker receives support from Siemens Healthcare in the form of salary support, software, and hardware to investigate radiation dose reduction in CT and has informal consultations with Bracco. Dr. Fletcher receives support from Siemens Healthcare in the form of grant support. Dr. Maglinte is a consultant for Cook Inc. Drs. Hara and Platt has no conflicts of interest.

Author information

Authors and Affiliations

  1. Imaging Institute/L10, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA

    Mark E. Baker

  2. Mayo Clinic School of Medicine, Mayo Clinic, Scottsdale, AZ, USA

    Amy K. Hara

  3. University of Michigan School of Medicine University of Michigan Health System, Ann Arbor, MI, USA

    Joel F. Platt

  4. Indiana University School of Medicine Indiana University Health, Indianapolis, IN, USA

    Dean D. T. Maglinte

  5. Mayo Clinic School of Medicine, Rochester, MN, USA

    Joel G. Fletcher

Authors
  1. Mark E. Baker
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Amy K. Hara
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Joel F. Platt
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dean D. T. Maglinte
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joel G. Fletcher
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mark E. Baker.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Baker, M.E., Hara, A.K., Platt, J.F. et al. CT enterography for Crohn’s disease: optimal technique and imaging issues. Abdom Imaging 40, 938–952 (2015). https://doi.org/10.1007/s00261-015-0357-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00261-015-0357-4

Keywords

Search

Navigation