Role of CT colonography in symptomatic assessment, surveillance and screening

Abstract

Introduction

When ‘whole colonic imaging’ is indicated, clinicians must decide between optical colonoscopy, barium enema and CT colonography (CTC). CTC is a relatively new technique which has become increasingly accessible in the UK over the past 5 years. As radiologists have gained experience and scanning parameters have standardised, there have been substantial improvements in both the accuracy and safety of CTC.

Methods

We review evidence from observational studies and randomised trials, and draw on expert opinion, to provide a comprehensive discussion of the current role of CTC in both symptomatic and asymptomatic individuals.

Conclusions

The emergence of CTC could soon entirely obviate the need for barium enema. CTC now has a complementary role alongside colonoscopy in symptomatic patients and a possible future role in colorectal cancer screening in the UK.

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References

  1. 1.

    Vining DJ, Shifrin RY et al (1994) Virtual colonoscopy. Radiology 193:446

    Google Scholar 

  2. 2.

    Johnson CD, Chen MS, Toledano AY et al (2008) Accuracy of CT colonography for colorectal cancer screening. NEJM 359(12):1207–1217

    PubMed  Article  CAS  Google Scholar 

  3. 3.

    Halligan S, Altman DG, Taylor SA, Mallett S, Deeks JJ, Bartram CI, Atkin W (2005) CT colonography in the detection of colorectal polyps and cancer: systematic review, meta-analysis, and proposed minimum data set for study level reporting. Radiology 237(3):893–904

    PubMed  Article  Google Scholar 

  4. 4.

    Sosna J, Morrin MM, Kruskal JB et al (2003) CT colonography of colorectal polyps: a meta-analysis. AJR Am J Roentgenol 181:1593–1598

    PubMed  Google Scholar 

  5. 5.

    Stevenson G (2008) Colon imaging in radiology departments in 2008: goodbye to the routine double contrast barium enema. Can Assoc Radiol J 59(4):174–182

    PubMed  Google Scholar 

  6. 6.

    Taylor SA, Halligan S, Saunders BP, Bassett P, Vance M, Bartram CI (2003) Acceptance by patients of multidetector CT colonography compared with barium enema examinations, flexible sigmoidoscopy, and colonoscopy. AJR Am J Roentgenol 181:913–921

    PubMed  Google Scholar 

  7. 7.

    East JE, Saunders BP, Boone D, Halligan S, Taylor SA (2006) Comprehensive mucosal visualization at optical colonoscopy. Gastroenterology 131(3):975–976

    PubMed  Article  Google Scholar 

  8. 8.

    Yee J, Sadda S, Aslam R, Yeh B (2010) Extracolonic findings at CT colonography. Gastrointest Endosc Clin N Am 20(2):305–322

    PubMed  Article  Google Scholar 

  9. 9.

    Hellström M, Svensson MH, Lasson A (2004) Extracolonic and incidental findings on CT colonography (virtual colonoscopy). AJR Am J Roentgenol 182:631–638

    PubMed  Google Scholar 

  10. 10.

    Tolan DJ, Armstrong EM, Chapman AH (2007) Replacing barium enema with CT colonography in patients older than 70 years: the importance of detecting extracolonic abnormalities. AJR Am J Roentgenol 189(5):1104–1111

    PubMed  Article  Google Scholar 

  11. 11.

    Macari M, Lavelle M et al (2001) Effect of different bowel preparations on residual fluid at CT colonography. Radiology 218:274–277

    PubMed  CAS  Google Scholar 

  12. 12.

    Lefere PA, Gryspeerdt SS et al (2002) Dietary fecal tagging as a cleansing method before CT colonography: initial results polyp detection and patient acceptance. Radiology 224:393–403

    PubMed  Article  Google Scholar 

  13. 13.

    Kim MJ, Seong HP et al (2009) Efficacy of barium-based fecal tagging for CT colonography: a comparison between the use of high and low density barium suspensions in a Korean population—a preliminary study. Korean J Radiol 10(1):25–33

    PubMed  Article  Google Scholar 

  14. 14.

    Bruzzi JF, Moss AC, Brennan DD et al (2003) Efficacy of IV Buscopan as a muscle relaxant in CT colonography. Eur Radiol 13:2264–2270

    PubMed  Article  Google Scholar 

  15. 15.

    Taylor SA, Halligan S, Goh V et al (2003) Optimizing colonic distension for multi-detector row CT colonography: effect of hyoscine butylbromide and rectal balloon catheter. Radiology 229:99–108

    PubMed  Article  Google Scholar 

  16. 16.

    Yee J (2002) CT colonography examination prerequisites. Abdom Imaging 27:244–252

    PubMed  CAS  Google Scholar 

  17. 17.

    Shinners TJ, Pickhardt PJ, Taylor AJ, Jones DA, Olsen CH (2006) Patient-controlled room air insufflation versus automated carbon dioxide delivery for CT colonography. AJR Am J Roentgenol 186:1491–1496

    PubMed  Article  Google Scholar 

  18. 18.

    Pickhardt PJ, Barish MA, Barlow DS, et al. (2005) Significant complications at CT colonography: survey results from the working group on virtual colonoscopy. Sixth international symposium on virtual colonoscopy, Boston, 17–18 October 2005

  19. 19.

    Neri E, Faggioni L, Cerri F et al (2010) CT colonography versus double-contrast barium enema for screening of colorectal cancer: comparison of radiation burden. Abdom Imaging 35(5):596–601

    PubMed  Article  Google Scholar 

  20. 20.

    Brenner DJ, Hall EJ (2007) Computed tomography—an increasing source of radiation exposure. N Engl J Med 357:2277–2284

    PubMed  Article  CAS  Google Scholar 

  21. 21.

    Taylor SA, Charman SC, Lefere P et al (2008) CT colonography: investigation of the optimum reader paradigm by using computer-aided detection software. Radiology 246:463–471

    PubMed  Article  Google Scholar 

  22. 22.

    Summers RM, Yao J, Pickhardt PJ et al (2005) Computed tomographic virtual colonoscopy computer-aided polyp detection in a screening population. Gastroenterology 129:1832–1844

    PubMed  Article  Google Scholar 

  23. 23.

    Halligan S, Altman DG, Mallett S et al (2006) Computed tomographic colonography: assessment of radiologist performance with and without computer-aided detection. Gastroenterology 131:1690–1699

    PubMed  Article  Google Scholar 

  24. 24.

    Petrick N, Haider M, Summers RM et al (2008) CT colonography with computer-aided detection as a second reader: observer performance study. Radiology 246:148–156

    PubMed  Article  Google Scholar 

  25. 25.

    Sabanli M, Balasingam A, Bailey W, Eglinton T, Hider P, Frizelle FA (2010) Computed tomographic colonography in the diagnosis of colorectal cancer. Br J Surg 97(8):1291–1294

    PubMed  Article  CAS  Google Scholar 

  26. 26.

    Johnson CD, Harmsen WS, Wilson LA et al (2003) Prospective blinded evaluation of computed tomographic colonography for screen detection of colorectal polyps. Gastroenterology 125:311–319

    PubMed  Article  Google Scholar 

  27. 27.

    Cotton PB, Durkalski VL, Pineau BC et al (2004) Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA 291:1713–1719

    PubMed  Article  CAS  Google Scholar 

  28. 28.

    Rockey DC, Paulsen EK, Niedzwiecki D et al (2005) Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet 365:305–311

    PubMed  CAS  Google Scholar 

  29. 29.

    Rockey DC (2009) Computed tomographic colonography: current perspectives and future directions. Gastroenterology 137(1):7–14

    PubMed  Article  Google Scholar 

  30. 30.

    Hoff G, Foerster A, Vatu MH et al (1986) Epidemiology of polyps in the rectum and colon. Recovery and evaluation of unresected polyps 2 years after detection. Scand J Gastroenterol 21:853–862

    PubMed  Article  CAS  Google Scholar 

  31. 31.

    Kulling D, Christ AD, Karaaslan N et al (2001) Is histological investigation of polyps always necessary? Endoscopy 33:428–432

    PubMed  Article  CAS  Google Scholar 

  32. 32.

    Ferrucci JT (2001) Colon cancer screening with virtual colonoscopy: promise, polyps, politics. AJR Am J Roentgenol 177:975–988

    PubMed  CAS  Google Scholar 

  33. 33.

    Macari M, Berman P, Dicker M et al (1999) Usefulness of CT colonography in patients with incomplete colonoscopy. AJR Am J Roentgenol 173:561–564

    PubMed  CAS  Google Scholar 

  34. 34.

    Morrin MM, Kruskal JB, Farrell RJ et al (1999) Endoluminal CT colonography after an incomplete endoscopic colonoscopy. AJR Am J Roentgenol 172:913–918

    PubMed  CAS  Google Scholar 

  35. 35.

    Copel L, Sosna J, Kruskal JB et al (2007) CT colonography in 546 patients with incomplete colonoscopy. Radiology 244:471–478

    PubMed  Article  Google Scholar 

  36. 36.

    Hanson ME, Pickhardt PJ, Kim DH, Pfau PR (2007) Anatomic factors predictive of incomplete colonoscopy based on findings at CT colonography. AJR Am J Roentgenol 189:774–779

    PubMed  Article  Google Scholar 

  37. 37.

    Pickhardt PJ, Kim DH, Menias CO et al (2007) Evaluation of submucosal lesions of the large intestine: part 1. Neoplasms. Radiographics 27:1681–1692

    PubMed  Article  Google Scholar 

  38. 38.

    Pickhardt PJ, Kim DH, Menias CO et al (2007) Evaluation of submucosal lesions of the large intestine: part 2. Nonneoplastic causes. Radiographics 27:1693–1703

    PubMed  Article  Google Scholar 

  39. 39.

    Johnson CD, Chen MH, Toledano A et al (2008) Accuracy of CT colonography for detection of large adenomas and cancer. N Engl J Med 359:1207–1217

    PubMed  Article  CAS  Google Scholar 

  40. 40.

    Beale AL, Penney MD, Allison MC (2005) The prevalence of iron deficiency among patients presenting with colorectal cancer. Colorectal Dis 7:398–402

    PubMed  Article  CAS  Google Scholar 

  41. 41.

    Raje D, Mukhtar H, Oshowo A, Ingham CC (2007) What proportion of patients referred to secondary care with iron deficiency anaemia have colon cancer? Dis Colon Rectum 50(8):1211–1214

    PubMed  Article  Google Scholar 

  42. 42.

    Choi YJ, Park SH, Lee SS et al (2007) CT colonography for follow-up after surgery for colorectal cancer. AJR Am J Roentgenol 189:283–289

    PubMed  Article  Google Scholar 

  43. 43.

    Kim HJ, Park SH, Pickhardt PJ, Yoon SN, Lee SS, Yee J, Kim DH, Kim AJ, Kim JC, Yu SC, Ha HK (2010) CT colonography for combined colonic and extracolonic surveillance after curative resection of colorectal cancer. Radiology 257(3):697–704

    PubMed  Article  Google Scholar 

  44. 44.

    Cancer Research UK website. http://info.cancerresearchuk.org/cancerstats/types/bowel/index.htm. Accessed 27 June 2010

  45. 45.

    Hewitson P, Glasziou P, Watson E, Towler B, Irwig L (2008) Cochrane systematic review of colorectal cancer screening using the faecal occult blood test (hemoccult): an update. Am J Gastroenterol 103:1541–1549

    PubMed  Article  Google Scholar 

  46. 46.

    Atkin WS, Edwards R, Kralj-Hans I et al (2010) Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 375(9726):1624–1633

    PubMed  Article  Google Scholar 

  47. 47.

    McFarland EG, Fletcher JG, Pickhardt PP et al (2009) ACR Colon Cancer Committee white paper: status of CT colonography 2009. AJR Am J Roentgenol 193:1242

    Google Scholar 

  48. 48.

    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 134:1570–1595

    PubMed  Article  CAS  Google Scholar 

  49. 49.

    Pickhardt PJ, Kim DH, Meiners RJ, Wyatt KS, Hanson ME, Barlow DS, Cullen PA, Remtulla RA, Cash BD (2010) Colorectal and extracolonic cancers detected at screening CT colonography in 10,286 asymptomatic adults. Radiology 255(1):83–88

    PubMed  Article  Google Scholar 

  50. 50.

    Pickhardt PJ, Hain KS, Kim DH, Hassan C (2010) Low rates of cancer or high-grade dysplasia in colorectal polyps collected from computed tomography colonography screening. Clin Gastroenterol Hepatol 8(7):610–615

    PubMed  Article  Google Scholar 

  51. 51.

    Pickhardt PJ, Hassan C, Laghi A, Zullo A, Kim DH, Iafrate F, Morini S (2008) Small and diminutive polyps detected at screening CT colonography: a decision analysis for referral to colonoscopy. AJR Am J Roentgenol 190:136–144

    PubMed  Article  Google Scholar 

  52. 52.

    Bond JH (2000) Clinical evidence for the adenoma-carcinoma sequence, and the management of patients with colorectal adenomas. Semin Gastrointest Dis 11:176–184

    PubMed  CAS  Google Scholar 

  53. 53.

    Lieberman D (2009) Debate: small (6–9 mm) and diminutive (1–5 mm) polyps noted on CTC: how should they be managed? Gastrointest Endosc Clin N Am 20(2):239–243

    Article  Google Scholar 

  54. 54.

    Lee D, Muston D, Sweet A, Cunningham C, Slater A, Lock K (2010) Cost effectiveness of CT Colonography for UK NHS colorectal cancer screening of asymptomatic adults aged 60–69 years. Appl Health Econ Health Policy 8(3):141–154

    PubMed  Article  Google Scholar 

  55. 55.

    Fisichella VA, Hellstrom M (2010) Survey update on implementation, indications, and technical performance of computed tomography colonography in Sweden. Acta Radiol 51(1):4–851

    PubMed  Article  Google Scholar 

  56. 56.

    Almond LM, Bowley D, Roy-Choudhury S, Hendrickse C, Karandikar SS (2010) Trends in whole colonic imaging. Acta Radiol 51(6):708

    PubMed  Article  Google Scholar 

  57. 57.

    Halligan S, Lilford RJ, Wardle J, Morton D, Rogers P, Wooldrage K, Edwards R, Kanani R, Shah U, Atkin W (2007) Design of a multicentre randomized trial to evaluate CT colonography versus colonoscopy or barium enema for diagnosis of colonic cancer in older symptomatic patients: the SIGGAR study. Trials 8:32

    PubMed  Article  Google Scholar 

  58. 58.

    Ozel B, Pickhardt PJ, Kim DH, Schumacher C, Bhargava N, Winter TC (2010) Accuracy of routine nontargeted CT without colonography technique for the detection of large colorectal polyps and cancer. Dis Colon Rectum 53(6):911–918

    PubMed  Article  Google Scholar 

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Conflict of interest

The authors declare that they have no conflicts of interest.

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Correspondence to L. Maximilian Almond.

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Almond, L.M., Bowley, D.M., Karandikar, S.S. et al. Role of CT colonography in symptomatic assessment, surveillance and screening. Int J Colorectal Dis 26, 959–966 (2011). https://doi.org/10.1007/s00384-011-1178-8

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Keywords

  • CT colonography
  • Barium enema
  • Colorectal cancer
  • Surveillance
  • Screening