European Radiology

, Volume 24, Issue 7, pp 1487–1496 | Cite as

Perforation rate in CT colonography: a systematic review of the literature and meta-analysis

  • Davide Bellini
  • Marco Rengo
  • Carlo Nicola De Cecco
  • Franco Iafrate
  • Cesare Hassan
  • Andrea Laghi



The primary aim was to assess the perforation rate of CTC; the secondary aim was to identify potential clinical/technical predictors of this complication.


Methods for analysis were based on PRISMA (preferred reporting items for systematic reviews and meta-analyses). From the selected studies, the rate of CTC perforation and patient/technical characteristics potentially associated with this event were extracted. Forest plots showing individual and pooled estimates of the perforation rate were obtained for all analyses. I2 was used to evaluate heterogeneity between studies.


Eleven articles out of the 187 initially identified were selected for the analysis (103,399 patients). There were 29,048 (28 %) asymptomatic individuals and 30,773 (30 %) symptomatic patients; this characteristic was not reported in the remaining subjects (42 %). Colon distension was obtained manually in 69,222 (67 %) and using an automated carbon dioxide insufflator in 26,479 (26 %) patients; in the remaining 7 % of patients, this information was missing. Twenty-eight colonic perforations were reported, with the CTC perforation rate estimated to be 0.04 % (95 % CI. 0.00-0.10), 19-fold higher in symptomatic than in screening subjects (OR: 19.2, CI 3.3-108 and P = 0.001). The surgical rate was 0.008 %. No CTC-related deaths were reported.


The perforation rate in CTC is very low, particularly considering asymptomatic individuals.

Key Points

This is the first meta-analysis on this topic, based on 100,000 patients.

The CTC-related colorectal perforation rate is 0.04 %, 0.02 % in asymptomatic subjects.

The CTC-induced surgery rate is 0.008 % (1:12,500).

The perforation rate in CTC is low, particularly in average-risk, asymptomatic individuals.


Computed tomographic colonography Intestinal perforation Mass screening Insufflation General surgery 

Abbreviations and acronyms


Computed tomographic colonography


Colorectal cancer


Conventional colonoscopy


Effect size


Odds ratio


Perforation rate


Double-contrast barium enema



The scientific guarantor of this publication is Andrea Laghi. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. One of the authors has significant statistical expertise. Institutional Review Board approval was not required because this is a meta-analysis. Written informed consent was not required for this study because this is a meta-analysis. Methodology: Systematic review with meta-analysis.


  1. 1.
    Chaparro M, Gisbert JP, Del Campo L, Cantero J, Maté J (2009) Accuracy of computed tomographic colonography for the detection of polyps and colorectal tumors: a systematic review and meta-analysis. Digestion 80:1–17PubMedCrossRefGoogle Scholar
  2. 2.
    Regge D, Laudi C, Galatola G et al (2009) Diagnostic accuracy of computed tomographic colonography for the detection of advanced neoplasia in individuals at increased risk of colorectal cancer. JAMA 301:2453–2461PubMedCrossRefGoogle Scholar
  3. 3.
    Lefere P, Dachman AH, Gryspeerdt S (2007) Computed tomographic colonography: clinical value. Abdom Imaging 32:541–551PubMedCrossRefGoogle Scholar
  4. 4.
    Nicholson FB, Barro JL, Bartram CI et al (2005) The role of CT colonography in colorectal cancer screening. Am J Gastroenterol 100:2315–2323PubMedCrossRefGoogle Scholar
  5. 5.
    Hassan C, Di Giulio E, Marmo R, Zullo A, Annibale B (2011) Appropriateness of the indication for colonoscopy: systematic review and meta-analysis. J Gastrointest Liver Dis 20:279–286Google Scholar
  6. 6.
    A. C. P. a. E. Committee (2006) Position of the American Gastroenterological Association (AGA) Institute on computed tomographic colonography. Gastroenterology 131:1627–1628CrossRefGoogle Scholar
  7. 7.
    Taylor SA, Laghi A, Lefere P, Halligan S, Stoker J (2007) European Society of Gastrointestinal and Abdominal Radiology (ESGAR): consensus statement on CT colonography. Eur Radiol 17:575–579PubMedCrossRefGoogle Scholar
  8. 8.
    Levin B, Lieberman DA, McFarland B et al (2008) Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 134:1570–1595PubMedCrossRefGoogle Scholar
  9. 9.
    Rockey DC, Paulson E, Niedzwiecki D et al (2005) Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet 365:305–311PubMedCrossRefGoogle Scholar
  10. 10.
    Pickhardt PJ, Hassan C, Halligan S, Marmo R (2011) Colorectal cancer: CT colonography and colonoscopy for detection–systematic review and meta-analysis. Radiology 259:393–405PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Jensch S, Bipat S, Peringa J et al (2010) CT colonography with limited bowel preparation: prospective assessment of patient experience and preference in comparison to optical colonoscopy with cathartic bowel preparation. Eur Radiol 20:146–156PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    van Gelder RE, Birnie E, Florie J et al (2004) CT colonography and colonoscopy: assessment of patient preference in a 5-week follow-up study. Radiology 233:328–337PubMedCrossRefGoogle Scholar
  13. 13.
    Siewert B, Kruskal JB, Eisenberg R, Hall F, Sosna J (2010) Quality initiatives quality improvement grand rounds at Beth Israel Deaconess Medical Center: CT colonography performance review after an adverse event. Radiographics 30:23–U37PubMedCrossRefGoogle Scholar
  14. 14.
    Neri E, Caramella D, Vannozzi F, Turini F, Cerri F, Bartolozzi C (2007) Vasovagal reactions in CT colonography. Abdom Imaging 32:552–555PubMedCrossRefGoogle Scholar
  15. 15.
    Neri E, Halligan S, Hellström M et al (2013) The second ESGAR consensus statement on CT colonography. Eur Radiol 23:720–729PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Khan JSKJS, Moran BJ (2011) Iatrogenic perforation at colonic imaging. Color Dis 13:481–493CrossRefGoogle Scholar
  17. 17.
    Berrington de Gonzalez A, Kim KP, Yee J (2010) CT colonography: perforation rates and potential radiation risks. Gastrointest Endosc Clin N Am 20:279–291PubMedCrossRefGoogle Scholar
  18. 18.
    Atalla MA, Rozen WM, Master M, McLaughlin S (2009) Education and imaging. Colonic perforation during 'virtual' CT colonography. J Gastroenterol Hepatol 24:1800PubMedCrossRefGoogle Scholar
  19. 19.
    Atalla MA, Rozen WM, Niewiadomski OD, Croxford MA, Cheung W, Ho YH (2010) Risk factors for colonic perforation after screening computed tomographic colonography: a multicentre analysis and review of the literature. J Med Screen 17:99–102PubMedCrossRefGoogle Scholar
  20. 20.
    Pickhardt PJ (2006) Incidence of colonic perforation at CT colonography: review of existing data and implications for screening of asymptomatic adults. Radiology 239:313–316PubMedCrossRefGoogle Scholar
  21. 21.
    Burling D, Halligan S, Slater A, Noakes MJ, Taylor SA (2006) Potentially serious adverse events at CT colonography in symptomatic patients: National survey of the United Kingdom. Radiology 239:464–471PubMedCrossRefGoogle Scholar
  22. 22.
    Belo-Oliveira P, Curvo-Semedo L, Rodrigues H, Belo-Soares P, Caseiro-Alves F (2007) Sigmoid colon perforation at CT colonography secondary to a possible obstructive mechanism: report of a case. Dis Colon Rectum 50:1478–1480PubMedCrossRefGoogle Scholar
  23. 23.
    Coady-Fariborzian L, Angel LP, Procaccino JA (2004) Perforated colon secondary to virtual colonoscopy: report of a case. Dis Colon Rectum 47:1247–1249PubMedCrossRefGoogle Scholar
  24. 24.
    Debugne G, Gillet B, Pierard S et al (2006) Colonic perforation after virtual colonoscopy. Gastroenterol Clin Biol 30:1103–1105PubMedCrossRefGoogle Scholar
  25. 25.
    Kamar M, Portnoy O, Bar-Dayan A et al (2004) Actual colonic perforation in virtual colonoscopy: report of a case. Dis Colon Rectum 47:1242–1244PubMedCrossRefGoogle Scholar
  26. 26.
    Triester SL, Hara AK, Young-Fadok TM, Heigh RI (2006) Colonic perforation after computed tomographic colonography in a patient with fibrostenosing Crohn's disease. Am J Gastroenterol 101:189–192PubMedCrossRefGoogle Scholar
  27. 27.
    Wong SH, Wong VWS, Sung JJY (2007) Virtual colonoscopy-induced perforation in a patient with Crohn's disease. World J Gastroenterol 13:978–979PubMedGoogle Scholar
  28. 28.
    Liberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med 151:W65–W94PubMedCrossRefGoogle Scholar
  29. 29.
    Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J (2003) The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 3:25PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Sosna J, Blachar A, Amitai M, Barmeir E, Peled N, Goldberg SN, Bar-Ziv J (2006) Colonic perforation at CT colonography: assessment of risk in a multicenter large cohort. Radiology 239:457–463PubMedCrossRefGoogle Scholar
  31. 31.
    Kim DH, Pickhardt PJ, Taylor AJ et al (2007) CT colonography versus colonoscopy for the detection of advanced neoplasia. N Engl J Med 357:1403–1412PubMedCrossRefGoogle Scholar
  32. 32.
    Iafrate F, Iussich G, Correale L et al (2013) Adverse events of computed tomography colonography: an Italian National Survey. Dig Liver Dis 45:645–650PubMedCrossRefGoogle Scholar
  33. 33.
    Johnson CD, Chen MH, Toledano AY et al (2008) Accuracy of CT colonography for detection of large adenomas and cancers. N Engl J Med 359:1207–1217PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Atkin W, Dadswell E, Wooldrage K et al (2013) Computed tomographic colonography versus colonoscopy for investigation of patients with symptoms suggestive of colorectal cancer (SIGGAR): a multicentre randomised trial. Lancet 381:1194–1202PubMedCrossRefGoogle Scholar
  35. 35.
    Zalis ME, Blake MA, Cai W et al (2012) Diagnostic accuracy of laxative-free computed tomographic colonography for detection of adenomatous polyps in asymptomatic adults: a prospective evaluation. Ann Intern Med 156:692–702PubMedCrossRefGoogle Scholar
  36. 36.
    Halligan S, Wooldrage K, Dadswell E et al (2013) Computed tomographic colonography versus barium enema for diagnosis of colorectal cancer or large polyps in symptomatic patients (SIGGAR): a multicentre randomised trial. Lancet 381:185–1193CrossRefGoogle Scholar
  37. 37.
    Stoop EM, de Haan MC, de Wijkerslooth TR et al (2012) Participation and yield of colonoscopy versus non-cathartic CT colonography in population-based screening for colorectal cancer: a randomised controlled trial. Lancet Oncol 13:55–64PubMedCrossRefGoogle Scholar
  38. 38.
    Burling D, Patnick J (2012) Guidelines for the use of imaging in the NHS Bowel cancer Screening Program. 2nd edn. NHSBSCP. Pubblication No. 5. Department of Health, LondonGoogle Scholar
  39. 39.
    Iqbal CW, Cullinane DC, Schiller HJ, Sawye MD, Zietlow SP, Farley DR (2008) Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg 143:701–706PubMedCrossRefGoogle Scholar
  40. 40.
    Cho SB, Lee WS, Joo YE et al (2012) Therapeutic options for iatrogenic colon perforation: feasibility of endoscopic clip closure and predictors of the need for early surgery. Surg Endosc 26:473–479PubMedCrossRefGoogle Scholar
  41. 41.
    Hamdani U, Naeem R, Haider F et al (2013) Risk factors for colonoscopic perforation: a population-based study of 80118 cases. World J Gastroenterol 19:3596–3601PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Davey J, Turner RM, Clarke MJ, Higgins JP (2011) Characteristics of meta-analyses and their component studies in the Cochrane Database of Systematic Reviews: a cross-sectional, descriptive analysis. BMC Med Res Methodol 11:160PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2014

Authors and Affiliations

  • Davide Bellini
    • 1
  • Marco Rengo
    • 1
  • Carlo Nicola De Cecco
    • 1
  • Franco Iafrate
    • 2
  • Cesare Hassan
    • 3
  • Andrea Laghi
    • 1
  1. 1.Department of Radiological Sciences, Oncology and Pathology“Sapienza” University of Rome, ICOT HospitalLatinaItaly
  2. 2.Department of Radiological Sciences, Oncology and Pathology“Sapienza” University of Rome, Policlinico Umberto I HospitalRomeItaly
  3. 3.Gastroenterology and Digestive Endoscopy UnitNuovo Regina Margherita HospitalRomeItaly

Personalised recommendations