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Imaging alternatives to colonoscopy: CT colonography and colon capsule. European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline – Update 2020

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Main recommendations

1. ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia. Strong recommendation, high quality evidence. ESGE/ESGAR do not recommend barium enema in this setting. Strong recommendation, high quality evidence.

2. ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. The timing depends on an interdisciplinary decision including endoscopic and radiological factors. Strong recommendation, low quality evidence. ESGE/ESGAR suggests that, in centers with expertise in and availability of colon capsule endoscopy (CCE), CCE preferably the same or the next day may be considered if colonoscopy is incomplete. Weak recommendation, low quality evidence.

3. When colonoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with alarm symptoms. Strong recommendation, high quality evidence. Because of lack of direct evidence, ESGE/ESGAR do not recommend CCE in this situation. Very low quality evidence. ESGE/ESGAR recommend CTC as an acceptable alternative to colonoscopy for patients with non-alarm symptoms. Strong recommendation, high quality evidence. In centers with availability, ESGE/ESGAR suggests that CCE may be considered in patients with non-alarm symptoms. Weak recommendation, low quality evidence.

4. Where there is no organized fecal immunochemical test (FIT)-based population colorectal screening program, ESGE/ESGAR recommend CTC as an option for colorectal cancer screening, providing the screenee is adequately informed about test characteristics, benefits, and risks, and depending on local service- and patient-related factors. Strong recommendation, high quality evidence. ESGE/ESGAR do not suggest CCE as a first-line screening test for colorectal cancer. Weak recommendation, low quality evidence.

5. ESGE/ESGAR recommend CTC in the case of a positive fecal occult blood test (FOBT) or FIT with incomplete or unfeasible colonoscopy, within organized population screening programs. Strong recommendation, moderate quality evidence. ESGE/ESGAR also suggest the use of CCE in this setting based on availability. Weak recommendation, moderate quality evidence.

6. ESGE/ESGAR suggest CTC with intravenous contrast medium injection for surveillance after curative-intent resection of colorectal cancer only in patients in whom colonoscopy is contraindicated or unfeasible. Weak recommendation, low quality evidence. There is insufficient evidence to recommend CCE in this setting. Very low quality evidence.

7. ESGE/ESGAR suggest CTC in patients with high risk polyps undergoing surveillance after polypectomy only when colonoscopy is unfeasible. Weak recommendation, low quality evidence. There is insufficient evidence to recommend CCE in post-polypectomy surveillance. Very low quality evidence.

8. ESGE/ESGAR recommend against CTC in patients with acute colonic inflammation and in those who have recently undergone colorectal surgery, pending a multidisciplinary evaluation. Strong recommendation, low quality evidence.

9. ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp ≥6 mm detected at CTC or CCE. Follow-up CTC may be clinically considered for 6–9-mm CTC-detected lesions if patients do not undergo polypectomy because of patient choice, comorbidity, and/or low risk profile for advanced neoplasia. Strong recommendation, moderate quality evidence.

Source and scope

This is an update of the 2014–15 Guideline of the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR). It addresses the clinical indications for the use of imaging alternatives to standard colonoscopy. A targeted literature search was performed to evaluate the evidence supporting the use of computed tomographic colonography (CTC) or colon capsule endoscopy (CCE). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence.

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Abbreviations

ANDR:

advanced neoplasia detection rate

CCE:

colon capsule endoscopy (CCE-1, first generation; CCE-2, second generation)

CT:

computed tomography

CTC:

computed tomographic colonography

DCBE:

double-contrast barium enema

ECCO:

European Cancer Organization

ECF:

extracolonic finding

ESGAR:

European Society of Gastrointestinal and Abdominal Radiology

ESGE:

European Society of Gastrointestinal Endoscopy

FIT:

fecal immunochemical test

FOBT:

fecal occult blood test

GRADE:

Grading of Recommendations Assessment, Development and Evaluation

IBD:

inflammatory bowel disease

NPV:

negative predictive value

OR:

odds ratio

PEG:

polyethylene glycol

PICO:

population, intervention, comparison/control, outcome

PPV:

positive predictive value

RCT:

randomized controlled trial

SIGGAR:

Special Interest Group in Gastrointestinal and Abdominal Radiology

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Acknowledgments

The authors would like to thank Dr Maria Pellisé, Gastroenterology Department (ICMDiM), Hospital Clinic de Barcelona, Spain, and Professor Konstantinos Triantafyllou, Hepatogastroenterology Unit, Attikon University General Hospital, Athens, Greece, for their review of this Guideline.

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Authors and Affiliations

  1. Digestive Endoscopy Unit and Gastronenterology, Fondazione Poliambulanza, Brescia, Italy

    Cristiano Spada & Sebastian Manuel Milluzzo

  2. Department of Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy

    Cristiano Spada, Sebastian Manuel Milluzzo & Silvia Pecere

  3. Gastroenterology Unit, Nuovo Regina Margherita Hospital, Rome, Italy

    Cesare Hassan

  4. Department of Radiological Sciences, Oncology and Pathology, Diagnostic Imaging Unit, La Sapienza University of Rome, I.C.O.T. Hospital, Latina, Italy

    Davide Bellini

  5. St. Mark’s Hospital, Harrow, London, UK

    David Burling

  6. Radiology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Turin, Italy

    Giovanni Cappello & Daniele Regge

  7. Department of Gastroenterology, University of Navarre Clinic, Healthcare Research Institute of Navarre, Pamplona, Spain

    Cristina Carretero

  8. Department of Gastroenterology and Hepatology, Amsterdam University Medical Center location AMC, Amsterdam, The Netherlands

    Evelien Dekker

  9. Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv, Israel

    Rami Eliakim

  10. Department of Radiology, University Medical Center, Utrecht, The Netherlands

    Margriet de Haan

  11. Departments of Gastroenterological Oncology and Cancer Prevention, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland

    Michal F. Kaminski

  12. Endoscopy Unit, Centre for Liver and Digestive Disorders, University Hospitals, NHS Lothian, Edinburgh, UK

    Anastasios Koulaouzidis

  13. Department of Surgical-Medical Sciences and Translational Medicine, La Sapienza University of Rome, Rome, Italy

    Andrea Laghi

  14. Department of Radiology, Stedelijk Ziekenhuis, Roeselare, Belgium

    Philippe Lefere

  15. Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria

    Thomas Mang

  16. RCSI Radiology, Royal College of Surgeons in Ireland, Dublin, Ireland

    Martina Morrin

  17. TAGG Research Centre, Department of Clinical Medicine, Trinity Centre, Tallaght Hospital, Dublin, Ireland

    Deirdre McNamara

  18. Diagnostic Radiology 3, Department of Translational Research, University of Pisa, Pisa, Italy

    Emanuele Neri

  19. Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France

    Mathieu Pioche

  20. Centre for Medical Imaging, University College London, London, UK

    Andrew Plumb & Stuart Taylor

  21. Gastroenterology Unit, Ospedale Valduce, Como, Italy

    Emanuele Rondonotti

  22. Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands

    Manon CW Spaander

  23. Gastroenterology, Hospital de Navarra, Pamplona, Spain

    Ignacio Fernandez-Urien

  24. Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands

    Jeanin E. van Hooft

  25. Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands

    Jaap Stoker

  26. University of Turin Medical School, Turin, Italy

    Daniele Regge

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  1. Cristiano Spada
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  2. Cesare Hassan
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  3. Davide Bellini
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  28. Daniele Regge
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Corresponding author

Correspondence to Cristiano Spada.

Ethics declarations

Competing interests

D. Burling provides unpaid support to the colon cancer charity, 40tude (not as trustee or officer). E. Dekker has received consultancy honoraria from Fujifilm, Olympus, Tillots, GI Supply, and CPP-FAP, and speakers’ fees from Olympus, Roche and GI Supply; she has endoscopic equipment on loan and receives a research grant from Fujifilm; she is on the supervisory board for eNose. R. Eliakim receives a lecture fee and grant support from Medtronic (from 2018 ongoing). I. Fernandez-Urien has provided paid consultancy to Medtronic (2019–2020). J.E. van Hooft has received lecture fees from Medtronics (from 2014 to 2015 and 2019) and Cook Medical (2019), and consultancy fees from Boston Scientific (2014–2017); her department has received research grants from Cook Medical (2014–2019) and Abbott (2014–2017). M.F. Kaminski provides speaking, teaching, and consultancy services to Olympus (from 2017 ongoing), and speaking and teaching services to Fujifilm, from whom he has equipment on loan (from 2019 ongoing). A. Koulaouzidis received travel support for CEGS meetings from the Jinshan Group (2018, 2019); his department was supported by Ankon with an advisory meeting (June 2019); he has received research support from Given Imaging (2010–2011). M.C.W. Spaander receives research support from Medtronic (from 2016 ongoing). C. Spada provides consultancy to Medtronic (from 2016 ongoing). D. Bellini, G. Cappello, C. Carretero, M. de Haan, C. Hassan, A. Laghi, P. Lefere, D. McNamara, T. Mang, S.M. Milluzzo, M. Morrin, E. neri, S. Pecere, M. Pioche, A. Plumb, D. Regge, E. Rondonotti, J. Stoker, and S. Taylor declare that they have no conflicts of interest.

ESGAR and ESGE covered costs for travel expenses. ESGAR and ESGE did not influence the content of this Guideline.

Disclaimer

ESGE/ESGAR Guidelines represent a consensus of best practice based on the available evidence at the time of preparation. They may not apply to all situations and should be interpreted in the setting of specific clinical situations and resource availability. They are intended to be an educational tool to provide information that may support endoscopists in providing care to patients. They are not rules and should not be utilized to establish a legal standard of care.

This Guideline was reviewed internally by both ESGE and ESGAR, and distributed to ESGE individual members and member societies for comments.

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This article is published simultaneously in the journals Endoscopy (https://doi.org/10.1055/a-1258-4819) and European Radiology (https://doi.org/10.1007/s00330-020-07413-4).

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Spada, C., Hassan, C., Bellini, D. et al. Imaging alternatives to colonoscopy: CT colonography and colon capsule. European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline – Update 2020. Eur Radiol 31, 2967–2982 (2021). https://doi.org/10.1007/s00330-020-07413-4

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