MSc.

Radiography (CT)
Clinical Applications of CT: Chest, Abdomen and Pelvis RAD5315

Do we need organ and pathology specific scan protocols for CT of the abdomen?

Terence Cesare

18786M
1. Introduction Multidetector computed tomography technology (MDCT) improved the diagnostic assessment of the abdomen. Nowadays, MDCT can cover larger anatomical volumes with increased spatial resolution along the z-axis, whilst decreasing the acquisition time. With a short acquisition time, the different phases of enhancement in the upper abdomen can be easily separated. Also images can be achieved with thin collimation therefore providing high-quality multiplanar and three-dimensional images representations (Marchal et al., 2005). With this technology at hand, customised protocols have been designed to maximise detection and characterisation of a wide variety of pathologic abnormalities. These protocols are modified according to both the anatomy being evaluated and the specific suspected pathologic abnormality, to image the organ or lesion during its maximum enhancement (Johnson et al., 2010). 2. Protocol The major differences in organ and pathologic specific protocols include the choice of oral contrast and slice thickness, and contrast phase timing. 2.1 Oral Contrast There are two types of oral contrast, the positive and the negative oral contrast. The positive oral contrast is a substance with a slightly radiopaque material such as diluted gastrografin of omnipaque. Positive oral contrast is given to the patients 1 hour before the start of the examination and its role is to mask and highlight the bowel. Positive oral contrast is very useful in defining the various segments of the duodenum from the pancreas, small bowel from mesenteric lesions as well as occasionally helping delineate intraperitoneal lesions from retroperitoneal one. However various studies suggest that with the introduction of MDCT, the utility of positive oral contrast has become uncertain (Lee et al., 2006).

The negative oral contrast medium which is usually mineral water has an added advantage since it does not mask radiopaque stones in the common bile duct. It also may aid in the evaluation of gastric and duodenal wall lesions. Before initiation of contrast-enhanced CT of the upper abdomen, administration of negative oral contrast medium is performed to distend the stomach and duodenum, which facilitates detection of abnormalities in the surrounding organs (Kalra et al., 2008). 2.2 Slice Thickness Studies have shown that thinner images with MDCT provide various benefits, such as reduced volume-averaging artefacts and increased detail (Kalra et al., 2008). Weg and coworkers, (1998) reported an increase in detection rates of 46% using thin slices. Also, Kopka et al. (2000) documented an overall increased detection rate of 96% and a characterisation of focal liver lesions with a specificity of 87% using sections of 2- to 4mm slice thickness. 2.3 Phases Detection of abdominal lesions is determined by its enhancement. Lesion characterisation is mainly based on the lesion contrast, therefore uptake during the different enhancement phases and scanning in sufficient phases is absolutely mandatory. The radiographer must make sure to achieve the exact phases according to the pathology or organ. When scanning for arterial phases, it is vital to start scanning in the exact time. Fixed time delays do not take into account the patient-to-patient variability in cardiac output or the contrast circulation time. A change in cardiac output affects aortic and hepatic enhancement therefore scanners are nowadays equipped with automated scanning trigger software wherein a threshold enhancement in a vessel or an organ is pre-selected to initiate manually or automatically a scan after injection of contrast (Marchal et al., 2005). The following are the most common phases encountered in different institutions: 2.3.1 Early Arterial Phase

In the early arterial phase at around 20 seconds after the start of injection, an ardent enhancement in the arterial vessels is visible. On the other hand there is a relatively little enhancement of the parenchyma or hypervascular lesions. CT angiography provides detailed information on the vessel architecture and vascular characteristics of hypervascular lesions such as arteries. This accurate definition of the vascular anatomy allows segmental localisation and assists in following surgical and non-surgical planning (Marchal et al., 2005).

Phases of scanning: Time-attenuation curves of different phases

2.3.2 Late Arterial Phase After the early arterial phase, approximately at 30-35 seconds after injection solid neoplasms will be maximally enhanced, whereas the parenchyma will be only minimally enhanced due to predominantly portal venous supply. This phase is referred to as the late arterial phase. This phase is optimal for detection of hypervascular lesions and hypervascular metastatic infiltration (Marchal et al., 2005). 2.3.3 Pancreatic Parenchymal Phase

At 40-45seconds from the start of the injection, the pancreatic parenchymal phase begins. The latter provides the highest rates of enhancement of the pancreatic parenchyma (Marchal et al., 2005).

2.3.4 Portal Venous Phase The portal venous phase which occurs at around 6070 seconds after the start of injection provides maximum enhancement of the hepatic parenchyma as well as a high enhancement rate in the pancreatic parenchyma. During this phase, the detection of relatively hypovascular lesions is possible. Hypovascular lesions include colorectal liver metastases or adenocarcinoma of the pancreas, which may be unsuspected and in some cases poorly imaged during the other two phases (Marchal et al., 2005). 2.3.5 Equilibrium Phase Finally, in certain cases a delayed-phase or equilibrium phase, of around 510 minutes after the start of injection is performed. The latter phase which is usually carried out to visualise liver or spleen lesions provide additional information for the characterisation of hypervascular lesions. Such lesions include hepatocellular and cholangiocellular carcinomas; and haemangiomas (Marchal et al., 2005). 3. Organ The standard abdomen and pelvis protocol involves scanning the patient from slightly above the diaphragm down to the iliac crest at the portal venous phase. Patients are also administered positive oral contrast, 1 hour prior to the examination. However in certain cases due to organ or pathological requirements, protocol alteration results. 3.1 Liver The liver can be investigated using various imaging modalities including ultrasound, computed tomography, positron emission tomography, magnetic resonance imaging, and other radiological interventional procedures (Sabouri et al., 2008). CT has always played a major role in liver imaging and is the most commonly modality used for the evaluation of

focal liver lesions after initial ultrasonography. Marchal et al. (2005) state that thin slices better visualised enhancement of the inner structures, boundary, and rim of the liver. Enhancement patterns such as homogeneous filling, abnormal internal vessels, peripheral puddles, and a complete ring are vital in the precise characterisation of lesions. These enhancements occur at different timed phases and therefore multiple phases scanning is essential in CT of the liver. Nino-Murcia and co-workers state that abnormal internal vessels are associated with hepatocellular carcinoma, peripheral puddles with haemangioma, and a complete ring with metastasis. For CT hepatic examination negative oral contrast is given 30 minutes before the examination. Unenhanced CT of the liver should be performed in cases of haemorrhage, calcifications and in parenchymal liver disease. When administering intravenous contrast medium, opacification of hepatic arteries is encountered at 1525 seconds (Kalra et al., 2008). This phase, the hepatic arterial phase is particularly important for evaluation of the liver. Some lesions are markedly vascular and are best seen on this phase. Also arterial phase imaging is excellent in evaluating the hepatic artery and to reveal pseudolesions (Urban et al., 2000). The hepatic arterial phase can be divided into an early arterial phase and a late arterial phase. The early phase presents opacification of the hepatic arterial system without much parenchymal enhancement, whilst the late phase, presents optimal opacification of the hepatic arteries and higher parenchymal enhancement. This knowledge is important in designing protocols, as hypervascular lesions are best visualised in the late arterial phase. The late phase is preferred and so because of additional concerns relating to excess radiation dose, the early phase is losing importance (Kalra et al., 2008). Liver enhancement in the portal venous system usually occurs between 45 and 55 seconds. This is followed by hepatic venous opacification at 6070 seconds after contrast injection, known as portal venous phase. In this phase most hypovascular lesions are evident. Studies

have demonstrated that the hepatic arterial phase reveal more numerous benign and malignant hypervascular liver lesions than the portal venous phase. Hence, triple-phase CT of the liver is performed in the unenhanced, late hepatic arterial and the portal venous phase (Kalra et al., 2008). In the delayed phase, the delay time greatly depends on the lesions size. For example in the case of a haemangioma, contrast material enters the extracellular space by diffusion, reducing the conspicuity of the liver lesion and its contrast with the surrounding parenchyma, causing obscuration of the lesion (Kalra et al., 2008). Hofer, (2005) said that hepatic lesions may be missed in the routine abdominal computed tomography scan protocol using the usual soft tissue window setting (WW 350; WL 50). By viewing the images in the liver window setting, normal parenchyma can be more clearly distinguished from lesions and the diagnosis can be improved. This window setting provides high image contrast (Sabouri et al., 2008). 3.2 Pancreas In pancreatic imaging the main aims are to assess tumour and to identify the complications of acute pancreatitis after the disease has been diagnosed from laboratory test results. The assessment of malignant tissue and the visualisation of organ as well as vessel infiltration, particularly in the superior mesenteric artery and vein is vital. The infiltration will determine whether a tumour is resectable or not. A good contrast-to-noise ratio is mandatory in imaging of the pancreas. Also to diagnose vessel infiltration, the optimal imaging phase must be timed (Kalra, 2008). The patient is given negative oral contrast 30 minutes before the examination to distend the stomach and duodenum so as to facilitate visualization of the pancreas. A triple-phase protocol including unenhanced, arterial and portal venous phases is generally used for imaging of the pancreas. Some studies suggest the inclusion of the parenchymal phase. This phase provides an optimal contrast-to noise ratio of pancreatic

tumours compared to the surrounding tissue. The tumours show up quite well in the portal venous phase and therefore the parenchymal phase can be excluded. Imaging in the arterial phase is required for CT angioram to depict the vascular anatomy for resection and diagnose disease (Kalra, 2008). 3.3 Spleen Evaluation of the spleen is most often done in combination with the liver and pancreas. The patient is given negative oral contrast 30 minutes before the examination. When CT is specifically ordered for imaging the spleen, images are obtained at the portal venous phase, in which homogenous parenchymal enhancement of the spleen occurs. When the splenic parenchyma is imaged in the arterial phase, a typical inhomogeneous sinusoidal or cordlike enhancement pattern is noted due to differential enhancement of the white and red pulp (Kalra et al., 2008). Urban et al., (2000) stated that obtaining an equilibrium phase may be helpful in confusing cases. 3.4 Adrenals In cases of adrenal enlargement and doubt exists whether the enlargement is benign or malignant, a densitometry process with determination of the enhancement pattern should be performed (Hofer, 2005). Whether the mass is being imaged incidentally or for further characterisation, there are several CT findings that contribute to the diagnosis including lesion size and attenuation values (Johnson et al., 2009). Hofer, (2005) stated that benign adenomas of the adrenal gland have a tendency of a more rapid wash-out of the contrast enhancement when compared to malignant lesions such as metastases and carcinomas. This method requires a scan before injection of contrast, a scan in the portal venous phase and a 15 minute delay scan after contrast injection. Eventually by histogram analysis of the washout of the lesion, the absolute or relative wash-out is calculated and the lesion is classified accordingly (Johnson et al., 2009). Negative oral contrast medium is given to the patient 30 minutes before the examination.

3.5 Kidneys 3.5.1 KUB Low dose unenhanced CT is the gold standard investigation to detect urinary-tract calculi due to its accuracy. At most institutions, the stone or KUB protocol scans patients in 3to 5-mm thick slices with a increase in the noise levels, so as to decrease the mA. Positive and negative oral contrast is not suggested (Tartari et al., 2010). Kalra et al., (2008) state that the administration of intravenous contrast media is rarely necessary in the investigation of patients with suspected urinary-tract calculi, however in suspicious cases; contrast media is administered to facilitate diagnosis. 3.5.2 Urography CTIVU protocol varies largely from one institution to another. The following protocol is the most common protocol used since it offers a low dose examination by limiting the number of phases. A low dose unenhanced CT is performed through the whole abdomen and pelvis. Afterwards, nephrographic and pyelographic phases are simultaneously acquired in a so called nephropyelographic phase (Chai et al., 2001). The nephropyelographic phase involves administering limited contrast medium, usually 30ml and after 10minutes the patient is injected with another 100ml contrast and scanned at the portal venous phase. In the resulting acquisition the renal parenchyma and the collecting system, ureters and bladder can be assessed (Kalra et al., 2008). Also maximum intensity projections reformations are very useful for the radiologist and urologist (Chai et al., 2001). 3.5.3 Renal Lesions Non-contrast CT scans are obtained initially to locate the kidneys; visualise anomalies; assess the presence of urinary-tract calculi; detect haematoma; and obtain baseline attenuation of renal masses (Kalra et al., 2008). Then in case of a renal tumour an arterial phase of the renal arteries is performed to aid in surgical and non-surgical planning. The portal venous phase is later carried out since renal parenchymal lesions are best recognised and characterised during this phase (Bruening et al., 2006).

3.6 Gastrointestinal When the gastrointestinal tract is assessed, adequate bowel distension, intravenous contrast administration and good contrast between the bowel lumen and the bowel wall is indispensable (Kalra et al., 2008). 3.6.1 CT Enterography Patients with small-intestinal disorders such as Crohns disease are best examined by CT enterography. CT enteroclysis improves the sensitivity and specificity in determining small bowel tumours, fistulas, abscesses or other inflammatory changes. This protocol involves administration of 1.5 litres of water to the patient, of which 500ml should be given immediately before scanning. Also buscopan is administered to reduce bowel movement 30minutes before the CT examination. The patient is scanned in the portal venous phase, the phase in which mural hyper-enhancement occurs (Bruening et al., 2006). 3.6.2 Mesenteric Ischemia In mesenteric ischemia, the role of CT is to detect the ischemic changes in the affected bowel loops and also to determine the cause of ischemia (Hong et al., 2006). Kalra et al., (2008) state that in cases of patients with mesenteric ischemia, a dual phase protocol is performed. The arterial and portal venous phase are acquired for adequate vessel and bowel-wall enhancement. 3.6.3 CT Colonography CT colonography is fast becoming the preferred screening tool for colonic polyps. The latter has a high sensitivity in the detection of small colon cancers and evaluates the pericolic spread of disease and the extent of mural involvement. (Kalra et al., 2008). In CT colonography, it is very important that is colon is clean. Buscopan is administered 30minutes before the examination to achieve bowel relaxation and afterwards air is carefully introduced through a rectal enema tube till the patient expresses discomfort. Two scans are acquired in the prone and supine positions. The prone scan is done without intravenous contrast whilst the supine scan is done with contrast media in the portal venous phase (Bruening et al., 2006).

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3.6.4 Appendicitis In case of appendicitis the normal abdomen and pelvis protocol is used, however several studies have promoted the use of CT protocols without oral contrast as a rapid and accurate method of establishing acute appendicitis. Although intravenous and oral contrast media facilitate diagnosis, it is well known that considerable time is required for oral contrast transit to the ileocaecal junction, thus delaying scan acquisition and increasing the risks to the patient (Mun et al., 2006). 4. Conclusion Whilst compiling this essay I could observe that there are various protocols for CT of the abdomen (O'Malley et al., 2000). The abdomen can be evaluated using other imaging modalities such as ultrasound, magnetic resonance imaging and fluoroscopy, however this also greatly depends on the availability and policies of the department. As I have already explained above, optimisation of the scanning technique and contrast material injection is important in the CT abdomen. The radiographer must prioritise the well being of the patient when choosing a protocol. This includes assessing the patients condition and safety, the radiation dose incurred, and contrast medium issues. The protocols will surely continue to evolve with the development of new technology in CT scanners and one should keep updated (Marchal et al., 2005).

5. Reference

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Bader TR, Prokesch RW, Grabenwoger F (2000) Timing of the hepatic arterial phase during contrast-enhanced computed tomography of the liver: assessment of normal values in 25 volunteers. Invest Radiol 35(8):486492. Bruening, R., Kuettner, A., & Flohr, T. (2006). Protocols for Multislice CT. (2nd ed.) Springer-Verlag Italia. Chai RY, Jhaveri K, Saini S et al (2001) Comprehensive evaluation of patients with haematuria on multi- slice computed tomography scanner: protocol design and preliminary observations. Australas Radiol 45:536-538. Hofer, M. (2005). CT Teaching Manual. (2nd ed.). New York: Thieme. Hong SS, Kim AY, Byun JH et al (2006) MDCT of small-bowel disease: value of 3D imaging. AJR Am J Roentgenol 187(5):1212-21. Johnson, P. T., Horton, K. M., & Fishman, E. K. (2009). Adrenal Imaging with Multidetector CT: Evidence-based Protocol Optimization and Interpretative Practice. Radiographics, 29(5), 1319-1331. Johnson, P. T., Horton, K. M., & Fishman, E. K. (2010). Optimizing Detectability of Renal Pathology With MDCT: Protocols, Pearls, and Pitfalls. AJR, 194, 1001-1012. Kalra, M.K., Saini, S. & Rubin, G.D. (2008). MDCT: From Protocols to Practice. Springer-Verlag Italia. Kopka L, Rodenwaldt J, Hamm B (2000) Biphasic multi-slice helical CT of the liver: intraindividual comparison of different slice thicknesses for the detection and characterization of focal liver lesions. Kopp AF, Heuschmid M, Claussen CD (2002) Multidetector helical CT of the liver for tumor detection and characterization. Eur Radiol 12:745-753.

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Lee, S. Y., Coughlin, B., Wolfe, J. M., Polino, J., Blank, F. S., & Smithline, H. A. (2006). Prospective comparison of helical CT of the abdomen and pelvis without and with oral contrast in assessing acute abdominal pain in adult Emergency Department patients. Emerg Radiol, 12, 150-157. Marchal., G., Vogl, T. J., Heiken, J. P., & Rubin, G. D. (2005). Multidetector-Row Computed Tomography Scanning and Contrast Protocols. Springer-Verlag Italia. Mun, S., Ernst, R. D., Chen, K., Oto, A., Shah, S., & Mileski, W. J. (2006). Rapid CT diagnosis of acute appendicitis with IV contrast material. Emerg Radiol, 12, 99-102. O'Malley, M. E., Halpern, E., Mueller, P. R., & Gazelle, G. S. (2000). Helical CT Protocols for the Abdomen and Pelvis: A Survey. AJR, 175, 109-113. Sabouri, S., Khatami, A., Azadeh, P., Ghoroubi, J., & Azimi, G. (2008). Adding Liver Window Setting to the Standard Abdominal CT Scan Protocol: Is It Useful?. Iran J Radiol, 5(2), 65-70. Schoellnast H, Tillich M, Deutschmann HA et al (2004) Improvement of parenchymal and vascular enhancement using saline flush and power injection for multiple-detector-row abdominal CT. Eur Radiol 14:659-664. Tartari, S., Rizzati, R., Righi, R., Deledda, A., Terrani, S., & Benea, G. (2010). Low-dose unenhanced CT protocols according to individual body size for evaluating suspected renal colic: cumulative radiation exposures. Springer, 115, 105-114. Urban, B. A., McGhie, P. A., & Fishman, E. K. (2000). Helical CT: Diagnostic Pitfalls of Arterial Phase Imaging of the Upper Abdomen. AJR, 174, 455-461. Weg N, Scheer MR, Gabor MP (1998) Liver lesions: improved detection with dualdetector-array CT and routine 2.5 mm thin collimation. Radiology 209(2):417426.

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