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Everything you need to know about Computed Tomography (CT) & CT Scanning

Contrast: Oral Contrast Imaging Pearls - Learning Modules | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Contrast ❯ Oral Contrast

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  • “Our Emergency physicians do not see that oral contrast administration for CT hampers operational efficiency; in fact, they have expressed gratitude to our department for care in diagnosis. They have stated that delays in patient turnaround are more frequently related to overall demand on the scanner and not to the oral contrast consumption period. They are all acutely aware of the serious consequences of missed or incorrect diagnoses (either leading to inappropriate hospital admission or discharge), and will always choose good medical care over time slashing, corner cutting methods that impress the dashboard monitors perhaps at the expense of excellence in patient care.”


    Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
 Megibow A.J. 
Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
  • “In summary, the Radiology department at NYU-Langone Medical Center has, through dialogue with our Emergency Medicine section, reaffirmed the benefits of oral contrast utilization for CT scanning of ED patients. We have found that stocking the oral contrast in the ED and allowing a 45-min period for oral contrast administration coordinated with obtaining clinical and laboratory information facilitate radiologic diagnosis with a high level of confidence and accuracy. As stated by JRD Tata, it is insistence on relentless attention to detail and insistence on highest standards of quality and performance that are the keys to productivity and efficiency, most certainly not through cutting corners.”


    Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
 Megibow A.J. 
Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
  • ”Utilizing a BMI threshold of 25 for adult men, and 30 for adult women, to administer oral contrast for abdominal and pelvic CT scan in ED patients appears to be a reasonable solution to facilitate shorter ED stays, while maintaining the diagnostic quality of CT scans, and reducing the need for repeat examination. While ED time constraints have certainly modified our current practice, taking action based on priorities has provided a reasonable approach based on demographics of our patient population.”


    Oral contrast administration for abdominal and pelvic CT scan in emergency setting: is there a happy medium?
Sokhandon, F. 
Abdom Radiol (2017) 42: 784. doi:10.1007/s00261-016-0969-3
  • OBJECTIVE. The purpose of this study is to objectively and subjectively compare nonionic iohexol and ionic diatrizoate iodinated oral contrast agents as part of a cathartic bowel regimen within the same CT colonography (CTC) cohort, with otherwise identical preparations.

    CONCLUSION. On the basis of this direct intrapatient comparison, we found that oral iohexol is a suitable alternative to diatrizoate for fluid tagging as part of a cathartic bowel preparation at CTC. Because this nonionic tagging agent is more palatable, less expensive, and likely safer than ionic diatrizoate, our CTC program now uses iohexol as the standard recommended regimen. 

    Objective and Subjective Intrapatient Comparison of Iohexol Versus Diatrizoate for Bowel Preparation Quality at CT Colonography 

    Johnson B et al. AJR 2016; 206:1202–1207
  • CONCLUSION. On the basis of this direct intrapatient comparison, we found that oral iohexol is a suitable alternative to diatrizoate for fluid tagging as part of a cathartic bowel preparation at CTC. Because this nonionic tagging agent is more palatable, less expensive, and likely safer than ionic diatrizoate, our CTC program now uses iohexol as the standard recommended regimen. 

    Objective and Subjective Intrapatient Comparison of Iohexol Versus Diatrizoate for Bowel Preparation Quality at CT Colonography 

    Johnson B et al. AJR 2016; 206:1202–1207 
  • “One important feature of high-quality CTC is adequate bowel preparation before the examination to ensure both removal of bulk stool and contrast tagging of any residual material remaining in the colon. Tagging of solid residual stool can be accomplished with dilute (2% weight/volume [w/v]) barium sulfate, whereas uniform tagging of residual luminal fluid requires iodinated water-soluble agents.”

    Objective and Subjective Intrapatient Comparison of Iohexol Versus Diatrizoate for Bowel Preparation Quality at CT Colonography 

    Johnson B et al. AJR 2016; 206:1202–1207 
  • “In conclusion, our initial experience with iohexol at CTC shows that it represents a suitable alternative to diatrizoate for fluid tagging as part of a cathartic bowel prepa- ration. On the basis of these results, in con- junction with iohexol being more palatable, less expensive, and presumably safer than diatrizoate, we think that iohexol can replace diatrizoate in routine clinical practice and have implemented this change in our program.”

    Objective and Subjective Intrapatient Comparison of Iohexol Versus Diatrizoate for Bowel Preparation Quality at CT Colonography 

    Johnson B et al. AJR 2016; 206:1202–1207
  • Delineation of the bowel was clearly practicable across all segments irrespective of the type of enteric contrast, though a slight impairment was observed without enteric contrast. Although delineation of intestinal pathologies was mostly classified "clearly delimitable" more difficulties occurred without oral contrast (neutral/positive/no contrast, 0.8 %/3.8 %/6.5 %). Compared to examinations without enteric contrast, there was a significant improvement in diagnosis that was even increased regarding the reader's diagnostic reliability. Positive opacification impaired detection of mucosal enhancement or intestinal bleeding.”


    Abdominal and pelvic CT: is positive enteric contrast still necessary? Results of a retrospective observational study.
Kammerer S et al.
Eur Radiol. 2015 Mar;25(3):669-78.
  • “Delineation of the bowel was clearly practicable across all segments irrespective of the type of enteric contrast, though a slight impairment was observed without enteric contrast.”


    Abdominal and pelvic CT: is positive enteric contrast still necessary? Results of a retrospective observational study.
Kammerer S et al.
Eur Radiol. 2015 Mar;25(3):669-78.
  • METHODS AND MATERIALS: Multislice CTs of 2,008 patients with different types of oral preparation (positive with barium, n = 576; neutral with water, n = 716; and no enteric contrast, n = 716) were retrospectively evaluated by two radiologists including delineation of intestinal segments and influence on diagnosis and diagnostic reliability exerted by the enteric contrast, using a three-point scale. Furthermore, diagnostic reliability of the delineation of selected enteric pathologies was noted. CT data were assigned into groups: oncology, inflammation, vascular, pathology, trauma and gastrointestinal pathology..”


    Abdominal and pelvic CT: is positive enteric contrast still necessary? Results of a retrospective observational study.
Kammerer S et al.
Eur Radiol. 2015 Mar;25(3):669-78.
  • “Water can replace positive enteric contrast agents in abdominal CTs. However, selected clinical questions require individual enteric contrast preparations. Pathology detection is noticeably impaired without any enteric contrast.”


    Abdominal and pelvic CT: is positive enteric contrast still necessary? Results of a retrospective observational study.
Kammerer S et al.
Eur Radiol. 2015 Mar;25(3):669-78.
  • In the ER setting do we need to use contrast agents?
    - Oral contrast
    - IV contrast
    - Rectal contrast
    - Any combination of the above
    - No contrast needed
  • “Omitting oral contrast for imaging patients with BMI >25 presenting with acute abdominal pain resulted in no delayed or missed diagnoses, in our retrospective study. The benefits of prompt imaging diagnosis outweigh the unlikely need for repeat imaging.”


    Is Oral Contrast Necessary for Multidetector Computed Tomography Imaging of Patients With Acute Abdominal Pain? Alabousi A, Patlas MN, Sne N, Katz DS
Can Assoc Radiol J. 2015 Jul 9. pii: S0846-5371(15)00038-8. [Epub ahead of print]
  • “We conducted a retrospective study to assess the effect of discontinuing oral contrast use for MDCT scans of the abdomen and pelvis for patients presenting with acute abdominal pain and body mass index (BMI) >25. Patients with BMI <25 continued to receive oral contrast. The medical records were reviewed to determine the rate of repeat imaging within 7 days from the initial CT scan, as well as delayed or missed diagnoses related to the absence of oral contrast. The study was approved by the research ethics board at our institution.”

    Is Oral Contrast Necessary for Multidetector Computed Tomography Imaging of Patients With Acute Abdominal Pain?
Alabousi A, Patlas MN, Sne N, Katz DS
Can Assoc Radiol J. 2015 Jul 9. [Epub ahead of print]
  • “A total of 1378 patients had an MDCT examination of the abdomen and pelvis between November 1, 2012, and October 31, 2013. 375 patients met the inclusion criteria (174 males and 201 females; mean age 57 years; range 18-97 years). Seven of 375 (1.9%) patients had a repeat CT examination with oral contrast within 7 days. Of these 7 patients, none had a change in the course of their management due to the utilization of oral contrast. No delayed or missed diagnoses related to the absence of oral contrast were identified.”

    Is Oral Contrast Necessary for Multidetector Computed Tomography Imaging of Patients With Acute Abdominal Pain?
Alabousi A, Patlas MN, Sne N, Katz DS
Can Assoc Radiol J. 2015 Jul 9. [Epub ahead of print]
  • PURPOSE: The purpose of our study was to validate the hypothesis that eliminating the use of oral contrast for multidetector computed tomography (MDCT) would not affect the detection of acute abdominal abnormalities in emergency room patients
    CONCLUSION: Omitting oral contrast for imaging patients with BMI >25 presenting with acute abdominal pain resulted in no delayed or missed diagnoses, in our retrospective study. The benefits of prompt imaging diagnosis outweigh the unlikely need for repeat imaging..”

    Is Oral Contrast Necessary for Multidetector Computed Tomography Imaging of Patients With Acute Abdominal Pain?
Alabousi A, Patlas MN, Sne N, Katz DS
Can Assoc Radiol J. 2015 Jul 9. [Epub ahead of print]
  • “In patients with body mass index greater than 25 presenting to the ED with acute abdominal pain, CT examinations can be acquired without oral contrast without compromising the clinical efficacy of CT.”


    Evaluation of Acute Abdominal Pain in the Emergency Setting Using Computed Tomography Without Oral Contrast in Patients With Body Mass Index Greater Than 25.
Uyeda JW et al.
J Comput Assist Tomogr. 2015 Aug 5. [Epub ahead of print]
  • “Of the 1992 patients included in this study, 4 patients (0.2%) underwent repeat CT studies directly related to the absence of oral contrast on the original examination. Of the 1992 CT scans, 1193(59.8%) were interpreted as negative, none of which required surgery or direct intervention. In patients with acute appendicitis, there was a sensitivity of CT in this patient population of 100% with a specificity of 99.5%.”

    Evaluation of Acute Abdominal Pain in the Emergency Setting Using Computed Tomography Without Oral Contrast in Patients With Body Mass Index Greater Than 25.
Uyeda JW et al.
J Comput Assist Tomogr. 2015 Aug 5. [Epub ahead of print]
  • PURPOSE: To evaluate the rate of delayed or missed diagnoses and need for additional computed tomography (CT) imaging in emergency department patients with abdominal pain who are imaged without oral contrast.

    CONCLUSIONS: In patients with body mass index greater than 25 presenting to the ED with acute abdominal pain, CT examinations can be acquired without oral contrast without compromising the clinical efficacy of CT.”


    Evaluation of Acute Abdominal Pain in the Emergency Setting Using Computed Tomography Without Oral Contrast in Patients With Body Mass Index Greater Than 25.
Uyeda JW et al.
J Comput Assist Tomogr. 2015 Aug 5. [Epub ahead of print]
  • “Abdominal CT scan without the use of oral contrast is accurate to allow for appropriate decision making by emergency physicians and general surgeons. In our series, no patients required repeat scanning. Further assessment by larger studies is appropriate.”


    Emergency department experience with nonoral contrast computed tomography in the evaluation of patients for appendicitis.
Glauser J, Siff J, Emerman C
J Patient Saf. 2014 Sep;10(3):154-8.
  • STUDY OBJECTIVES: The American College of Radiology lists oral contrast as an institution-specific option in the evaluation of right lower quadrant pain. Previous literature indicates that an accurate assessment for appendicitis can be made by CT using IV contrast alone, with significant time savings from withholding oral contrast. Before 2010, the protocol for CT use in the evaluation of possible appendicitis or undifferentiated abdominal pain routinely included oral contrast. The purpose of this study was to determine the incidence of repeat CT scans with oral contrast for the purpose of arriving at a final disposition in patients undergoing evaluation for abdominal pain. This analysis was also to determine if the general surgery service was willing and able to make accurate clinical determinations to operate without the use of oral contrast..”


    Emergency department experience with nonoral contrast computed tomography in the evaluation of patients for appendicitis.
Glauser J, Siff J, Emerman C
J Patient Saf. 2014 Sep;10(3):154-8.
  • RESULTS: A total of 311 CT scans met the study criteria. No cases of appendicitis were missed. Two patients were operated on based upon inflammatory findings in the right lower quadrant, one with typhlitis, the second with possible inflammatory bowel disease versus typhlitis. In each case, the diagnosis was made by CT, but the surgery service chose to operate based on clinical findings. Sixteen (5.14%; 95% CI, 3.2%-8.2%) cases of acute appendicitis were accurately identified. A normal appendix was visualized in 125 (40.2 %; 95% CI, 34.9-45.7) patients. No patients (0%; 95% CI, 0%-1.2%) required a repeat CT scan with oral contrast as part of the workup. On 30-day follow-up by chart review, no (0%; 95% CI, 0%-1.2%) significant surgical problems were identified, and no cases of missed appendicitis were identified.”


    Emergency department experience with nonoral contrast computed tomography in the evaluation of patients for appendicitis.
Glauser J, Siff J, Emerman C
J Patient Saf. 2014 Sep;10(3):154-8.
  • Do you need to be NPO for contrast enhanced CT scans?
    - Overnight fasting
    - 4-6 hours prior to the study
    - 2-3 hours prior to the study
    - Not needed at all
  • “ There is little evidence that ingestion of clear inert flluid prior to contrast enhanced CT is a cause of aspiration pneumonia; the length of fasting is variable in any country, being much long in some hospitals than in others.”
    Preparative Fasting for Contrast-Enhanced CT: Reconsideration
    Lee BY et al.
    Radiology 2012;263:444-450
  • “ The literature provides no direct evidence suggesting that ingestion of inert fluids prior to CT with intravenous contrast adminiastration causes aspiration pneumonia.”
    Preparative Fasting for Contrast-Enhanced CT: Reconsideration
    Lee BY et al.
    Radiology 2012;263:444-450
  • JHU Policy 2012
    - Do not eat 3 hours before the study
    - Drink lots of fluids though try to avoid coffee especially if you are scheduled for a cardiac CT scan
    - Drink lots of fluid for the 24 hours after the CT scan is completed
  • "Of 287 subjects who expressed a preference, 233 patients (81%) preferred dilute iohexol compared with 54 patients (19%) who preferred dilute diatrizoate sodium.ten patients had no preference and 3 did not complete the taste comparison study."

    Oral Contrast Media for Body CT: Comparison of Diatrizoate Sodium and Iohexol for Patient Acceptance and Bowel Opacification
    McNamara MM et al.
    AJR 2010;195:1137-11411

     

  • "Patients preferred dilute iohexol over dilute diatrizoate sodium for oral contrast for abdominal-pelvic CT. There was no significant difference in bowel opacification or adverse effect profile."

    Oral Contrast Media for Body CT: Comparison of Diatrizoate Sodium and Iohexol for Patient Acceptance and Bowel Opacification
    McNamara MM et al.
    AJR 2010;195:1137-11411

  • "We have recently switched completely to LOCM for our oral contrast during CT scanning. Iohexol is the only LOCM with Food and Drug Administration approval for use as an oral contrast at this time."

    The Use of Iohexol as Oral Contrast for Computed Tomography of the Abdomen and Pelvis
    Horton KM, Fishman EK, Gayler B
    J Comput Assist Tomogr 2008; 32:207-209
  • "Whole milk is comparable to VoLumen with respect to bowel distension and bowel wall visualization and has a lower cost, better patient acceptance, and fewer adverse symptoms. Milk is a cost effective alternative to VoLumen as a low attenuation oral contrast agent."

    Cost Effectiveness and Patient Tolerance of Low-Attenuation Oral Contrast Material: Milk Versus VoLumen
    Koo CW et al.
    AJR 2008; 190:1307-1313
  • Milk contains 4% fat and slows peristalsis and gives good distension of small bowel.

    Cost Effectiveness and Patient Tolerance of Low-Attenuation Oral Contrast Material: Milk Versus VoLumen
    Koo CW et al.
    AJR 2008; 190:1307-1313
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