Imaging Pearls ❯ Small Bowel ❯ Oral Contrast
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- “In conclusion, enteric contrast continues to play an important role in the imaging assessment of patients presenting to the emergency department. Although it may no longer be required to ensure diagnostic accuracy on a routine basis, enteric contrast remains valuable, particularly when used in a targeted fashion to address specific clinical questions on a case-by-case basis. Enteric contrast is safe and well-tolerated by most patients with a low risk of serious side effects.”
The Use of Enteric Contrast in the Emergency Setting
Mohamed Z. Rajput et al.
Radiol Clin N Am - (2023) (in press) - “A recent survey revealed that most patients (89%) would prefer to drink oral contrast, even with only the slightest likelihood that this will improve diagnostic accuracy, rather than accepting a risk of a missed finding. Radiologists report increased diagnostic confidence and reader reliability in cases in which any type of enteric contrast is used for CT imaging.83 This can be particularly important in the emergency setting, where one encounters critical, life-threatening pathologies requiring confident and accurate diagnoses on a routine basis.”
The Use of Enteric Contrast in the Emergency Setting
Mohamed Z. Rajput et al.
Radiol Clin N Am - (2023) (in press) - “Targeted use of enteric contrast for CT imagingin patients presenting to the emergency department is helpful in specific clinical scenarios, especially when assessing for gastrointestinal tract perforation or complications following abdominal surgery.”
The Use of Enteric Contrast in the Emergency Setting
Mohamed Z. Rajput et al.
Radiol Clin N Am - (2023) (in press) - “Enteric contrast continues to play an important role in the imaging assessment of patients presenting to the emergency department, especially when combined with computed tomography in specific clinical situations to improve diagnostic accuracy. Enteric contrast is particularly helpful in assessing postoperative complications of abdominal surgeries such as anastomotic leaks and fistulas. Although not always administered routinely, enteric contrast can be useful to confirm bowel injuries in the setting of penetrating trauma. Enteric contrast can assist in the identification of the appendix in cases of suspected acute appendicitis. Enteric contrast is also effective at guiding operative versus nonoperative management of patients with small-bowel obstruction. Although enteric contrast is overall safe and well-tolerated, the benefits of using it should be weighed against potential risks to the patient, including the time required to administer enteric contrast potentially resulting in a delay in diagnosis.”
The Use of Enteric Contrast in the Emergency Setting
Mohamed Z. Rajput et al.
Radiol Clin N Am - (2023) (in press)
- “The purpose of this retrospective medical audit was to evaluate the effect of discontinuing routine administration of oral contrast material to oncology patients undergoing follow-up multidetector computed tomography (CT) on reader evaluation of study adequacy. Analysis of 100 patients' experience of CT shows that positive oral contrast material was their least pleasant experience (P < .0001). Abandoning the routine use of positive oral contrast material for follow-up scans in general oncology patients undergoing multidetector CT, with section reconstruction thickness of 2.5 mm, was audited for 447 patents and included 5-13-month follow-up. The patient satisfaction study and clinical audit were performed according to local institutional audit guidelines. Since this was a clinical audit project, ethical approval was not required under UK National Health Service research governance arrangements. No patient needed to be recalled, no related diagnostic error has been reported, and follow-up CT, available in 285 of 447 cases (64%), revealed no error on the audited scan. We conclude that the routine use of positive oral contrast material is unnecessary for follow-up multidetector CT for general oncology indications.”
Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
Harieaswar S et al.
Radiology. 2009 Jan;250(1):246-53 - “The purpose of this retrospective medical audit was to evaluate the effect of discontinuing routine administration of oral contrast material to oncology patients undergoing follow-up multidetector computed tomography (CT) on reader evaluation of study adequacy. Analysis of 100 patients' experience of CT shows that positive oral contrast material was their least pleasant experience (P < .0001). Abandoning the routine use of positive oral contrast material for follow-up scans in general oncology patients undergoing multidetector CT, with section reconstruction thickness of 2.5 mm, was audited for 447 patents and included 5-13-month follow-up. The patient satisfaction study and clinical audit were performed according to local institutional audit guidelines. No patient needed to be recalled, no related diagnostic error has been reported, and follow-up CT, available in 285 of 447 cases (64%), revealed no error on the audited scan. We conclude that the routine use of positive oral contrast material is unnecessary for follow-up multidetector CT for general oncology indications.”
Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
Harieaswar S et al.
Radiology. 2009 Jan;250(1):246-53 - "The standard contrast material was barium sulfate suspension (4.9% wt/vol in 225 mL, E-Z-CAT; E-Z-Em, Lake Success, NY) diluted in 1000 mL of water, making a suspension of 1.1% wt/vol. In a previous study, this contrast agent was found to be tolerated similarly to Gastromiro (Bracco, Milan, Italy) and better than Gastrografin (Bayer Schering Pharma, Berlin, Germany).”
Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
Harieaswar S et al.
Radiology. 2009 Jan;250(1):246-53 - "In our study, difficulties were encountered with thin patients (although not formally measured), peritoneal disease close to bowel loops, and in patients examined without the use of intravenous contrast material. Oral contrast material may be justified in some of these situations, although we do not routinely use oral contrast material in any of these groups. During the study, we also found positive oral contrast material may mask certain findings such as subtle mucosal deposits seen in carcinoid or melanoma and calcified peritoneal deposits, although a direct comparison of bowel delineation with and that without oral contrast material was not tested in this study.”
Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
Harieaswar S et al.
Radiology. 2009 Jan;250(1):246-53 - "On the basis of our findings, we suggest that if multidetector CT is available, positive oral contrast material should not be a routine requirement for follow-up abdominal pelvic scans in oncology patients. The requirement for routine positive oral contrast material should also be removed from research protocols (such as RECIST protocols) in these patients unless there is a specific indication for their use, such as known peritoneal disease or stage 3 ovarian tumors. This recommendation should not preclude using positive oral contrast material in certain situations, such as in patients who are very thin or are unable to have intravenous contrast material.”
Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
Harieaswar S et al.
Radiology. 2009 Jan;250(1):246-53 - OBJECTIVES: To evaluate the diagnostic efficacy of different oral contrast media (OCM) for abdominopelvic CT examinations performed for follow-up general oncological indications. The objectives were to establish anatomical image quality criteria for abdominopelvic CT; use these criteria to evaluate and compare image quality using positive OCM, neutral OCM and no OCM; and evaluate possible benefits for the medical imaging department. quality by grading the fulfilment of 24 anatomical image quality criteria.
RESULTS: Visual grading characteristics (VGC) analysis of the data showed comparable image quality with regards to reproduction of abdominal structures, bowel discrimination, presence of artefacts, and visualization of the amount of intra-abdominal fat for the three OCM protocols.
CONCLUSION: All three OCM protocols provided similar image quality for follow-up abdominopelvic CT for general oncological indications.
KEY POINTS: • Positive oral contrast media are routinely used for abdominopelvic multidetector computed tomography • Experimental study comparing image quality using three different oral contrast materials • Three different oral contrast materials result in comparable CT image quality • Benefits for patients and medical imaging department.
Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
Harieaswar S et al.
Radiology. 2009 Jan;250(1):246-53 - CONCLUSION: All three OCM protocols provided similar image quality for follow-up abdominopelvic CT for general oncological indications.
KEY POINTS: • Positive oral contrast media are routinely used for abdominopelvic multidetector computed tomography • Experimental study comparing image quality using three different oral contrast materials • Three different oral contrast materials result in comparable CT image quality • Benefits for patients and medical imaging department.
Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
Harieaswar S et al.
Radiology. 2009 Jan;250(1):246-53 - OBJECTIVE: The objective of our study was to compare the quality of bowel opacification from three different positive oral contrast agents-barium sulfate, diatrizoate, and iohexol-at abdominopelvic CT.
CONCLUSION: The frequency of inhomogeneous bowel opacification was lower for iohexol than for diatrizoate or barium sulfate. Barium showed the highest frequency of bowel lumen heterogeneity. The iodinated agents showed greater increases in mean CT attenuation from the proximal bowel segments to the distal bowel segments than barium sulfate.
Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
AJR Am J Roentgenol. 2019 Mar 5:1-7. - RESULTS: Fewer artifacts were detected with iohexol (4.3%) as the oral contrast agent than with diatrizoate (13.0%) and barium sulfate (14.3%) (each, p < 0.05). Barium showed a greater frequency of bowel lumen heterogeneity (388/831 segments, 47%) than iohexol (155/679, 23%) and diatrizoate (185/763, 24% segments) (p < 0.001). Barium showed higher CT attenuation than iohexol and diatrizoate in the stomach but lower CT attenuation in the ileum (each, p < 0.05).
Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
AJR Am J Roentgenol. 2019 Mar 5:1-7. - “We found that the frequency of nonuni- form opacification of bowel was higher with oral diatrizoate and barium sulfate than with iohexol at CT. The CT attenuation of all three types of positive oral contrast agents is lowest in the stomach and highest in the ileum, and the increase in CT attenuation from proximal to distal bowel is greater for diatrizoate and iohexol than for barium sulfate.”
Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
AJR Am J Roentgenol. 2019 Mar 5:1-7. - “There is a surprising paucity of published data on the comparative value of positive oral contrast material versus neutral or no oral contrast material for most general indications for abdominal CT. Nevertheless, in a consensus expert statement by the American College of Radiology and Society for Pediatric Radiology, positive oral contrast material is recognized to improve the delineation of bowel disease, such as abscesses or hypovascular tumors, from nonbowel disease and is also recognized to improve the delineation of bowel leaks.”
Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
AJR Am J Roentgenol. 2019 Mar 5:1-7. - “Although multiple studies of emergency department patients with relatively small sample sizes suggest that avoid- ance of oral contrast material may improve cost efficiency in that niche scenario, extrapolation of these narrowly staged studies to broader patient populations is not founded on solid evidence. Larger prospective multiinstitution studies that compare the value of positive, neutral, and no oral contrast material for the speed, accuracy, and confidence in diag- nosis of critical abdominal disease diagnoses in outpatients, oncology patients, and patients undergoing postoperative evaluations and in other scenarios are clearly needed.”
Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
AJR Am J Roentgenol. 2019 Mar 5:1-7. - "In conclusion, we found that inhomoge- neous opacification of the bowel lumen was more frequently seen with oral diatrizoate or barium sulfate than with oral iohexol at CT of the abdomen and pelvis. The iodinated agents showed a greater progressive increase in CT attenuation in more distal bowel segments than the more proximal bowel segments than was seen with barium sulfate. Further study is warranted to assess for the effects of these differences in bowel opacification on disease detection.”
Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
AJR Am J Roentgenol. 2019 Mar 5:1-7. - OBJECTIVE. The use of positive oral contrast material for abdominal CT is a frequent protocol issue. Confusion abounds regarding its use, and practice patterns often appear arbitrary. Turning to the existing literature for answers is unrewarding, because most studies are underpowered or not designed to address key endpoints. Even worse, many decisions are now being driven by nonradiologists for throughput gains rather than patient-specific consid- erations. Herein, the current indications for positive oral contrast material are discussed, including areas of controversy.
CONCLUSION. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process. Based on differences in prior training and practice patterns, some radiologists will prefer to limit the use of positive oral contrast material more than others. However, for those who believe (as I do) that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably) make a major impact on diagnosis, it behooves us to keep fighting for its use.
Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
Perry J. Pickhardt
AJR 2020; 215:1–10 - OBJECTIVE. The use of positive oral contrast material for abdominal CT is a frequent protocol issue. Confusion abounds regarding its use, and practice patterns often appear arbitrary. Turning to the existing literature for answers is unrewarding, because most studies are underpowered or not designed to address key endpoints. Even worse, many decisions are now being driven by nonradiologists for throughput gains rather than patient-specific consid- erations. Herein, the current indications for positive oral contrast material are discussed, including areas of controversy. , it behooves us to keep fighting for its use.
Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
Perry J. Pickhardt
AJR 2020; 215:1–10 - CONCLUSION. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process. Based on differences in prior training and practice patterns, some radiologists will prefer to limit the use of positive oral contrast material more than others. However, for those who believe (as I do) that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably) make a major impact on diagnosis, it behooves us to keep fighting for its use.
Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
Perry J. Pickhardt
AJR 2020; 215:1–10 - “A disturbing recent trend, however, is the increasing decision to forego positive oral contrast material largely (or solely) for increased patient throughput, typically driven by nonradiologists such as emergency department (ED) physicians, surgeons, and even health system administrators. As radiologists, we need to ensure that such financially driven nonmedical justifications are in the best interest of our patients.”
Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
Perry J. Pickhardt
AJR 2020; 215:1–10 
Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
Perry J. Pickhardt
AJR 2020; 215:1–10- Indications for Positive Oral Contrast
- Suspected postoperative bowel leak
- Suspected gastrointestinal fistula
- Suspected interloop abscess or other fluid collection
- Oncologic staging and surveillance
- Nonspecific abdominal pain or other symptoms (subacute) - "I believe that there is definitely still a role for positive oral contrast material in modern state-of-the-art abdominal CT. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process.”
Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
Perry J. Pickhardt
AJR 2020; 215:1–10 - “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
- OBJECTIVE. The objective of this study was to determine whether body fat percentage, measured using a portable handheld bioelectric impedance analysis (BIA) device, and body mass index (BMI, weight in kilograms divided by the square of height in meters) can estimate the amount of intraabdominal and intrapelvic fat and thereby predict the need for oral contrast material before abdominopelvic CT.
CONCLUSION. Using BIA in addition to BMI accurately predicts amount of intraabdominal and intrapelvic fat. This information may help guide the decision to use oral contrast material in patients presenting for abdominopelvic CT.
Using Body Mass Index and Bioelectric Impedance Analysis to Assess the Need for Positive Oral Contrast Agents Before Abdominopelvic CT
Wu Y et al.
AJR 2018; 211:340–346 - "We also did not directly examine whether the use of oral contrast material would alter clinical diagnosis. Thus, we cannot conclusively state that patients with a fat score of 3 or more could forgo oral contrast material without compromising diagnostic accuracy. In some circumstances, oral contrast material can aid in the diagnostic process regardless of the amount of intraabdominal and intrapelvic fat.”
Using Body Mass Index and Bioelectric Impedance Analysis to Assess the Need for Positive Oral Contrast Agents Before Abdominopelvic CT
Wu Y et al.
AJR 2018; 211:340–346 - “Despite these limitations, our results show that using BMI with the addition of BIA-determined body fat percentage in appropriate cases provides a rapid and refined approach for estimating the amount of intraabdominal and intrapelvic fat in patients presenting to the ED with nontraumatic abdominal pain. Using these criteria may help optimize use of oral contrast material, which would improve workflow and reduce wait times in the ED.”
Using Body Mass Index and Bioelectric Impedance Analysis to Assess the Need for Positive Oral Contrast Agents Before Abdominopelvic CT
Wu Y et al.
AJR 2018; 211:340–346 - “There were no statistically significant differences in sensitivity or specificity for CT scans performed in groups A and B. In patients with a BMI of less than 25, an intravenous contrast-enhanced CT protocol without oral contrast demonstrates similar accuracy to an intravenous contrast-enhanced protocol with oral contrast for diagnosing acute appendicitis.”
Diagnosing acute appendicitis using a nonoral contrast CT protocol in patients with a BMI of less than 25
Ramalingam V et al.
Emerg Radiol (2016) 23:455–462 - "A consideration in the use of oral contrast material is the rate of bowel opacification; notably, even with a standard 2-h preparatory time, in nearly a third of patients in this study, the oral contrast material did not opacify any portion of the colon. This finding is sim- ilar to our prior results, which reported an absence of colonic opacification in 32 % of patients.”
Diagnosing acute appendicitis using a nonoral contrast CT protocol in patients with a BMI of less than 25
Ramalingam V et al.
Emerg Radiol (2016) 23:455–462 - “In the assessment of Crohn’s disease, neutral or low attenuation agents provide the benefit of increasing conspicuity of diseased segments due to the striking contrast between the lower luminal density and the mucosal/mural hyperenhancement and stratification that is produced following intravenous contrast media administration. Also, hypervascular bowel lesions and active bleeding can be detected much more easily on studies performed with neutral oral contrast media as well, since the high attenuation of enhancing lesions or active extravasation of contrast material into bowel lumen stands out when surrounded by the lower attenuation distended bowel lumen. Positive oral contrast media, including both dilute barium and dilute water soluble iodinated contrast media can obscure such abnormalities and is problematic for creating three- dimensional images.”
ACR Manual On Contrast Media
Version 10.3 (2018) - Rationale and Objectives: This study aims to compare the diagnostic performance of abdominal computed tomography (CT) performed with and without oral contrast in patients presenting to the emergency department (ED) with acute nontraumatic abdominal pain.
Conclusions: Our study shows that oral contrast is noncontributory to radiological diagnosis in most patients presenting to the ED with acute nontraumatic abdominal pain. These patients can therefore undergo abdominal CT scanning without oral contrast, with no effect on radiological diagnostic performance.
CT for Acute Nontraumatic Abdominal Pain—Is Oral Contrast Really Required?
Kessner R et al.
Acad Radiol 2017; 24:840–845 - Conclusions: Our study shows that oral contrast is noncontributory to radiological diagnosis in most patients presenting to the ED with acute nontraumatic abdominal pain. These patients can therefore undergo abdominal CT scanning without oral contrast, with no effect on radiological diagnostic performance.
CT for Acute Nontraumatic Abdominal Pain—Is Oral Contrast Really Required?
Kessner R et al.
Acad Radiol 2017; 24:840–845 - “In conclusion, patients presenting to the ED with acute nontraumatic abdominal pain can be evaluated with abdominal CT with IV contrast material and without oral contrast material. Oral contrast material should be considered in very thin patients and in patients with history of inflammatory bowel disease or recent operation. We hope that the results of our study, along with other large studies, will pave the way to the formulation of new medical guidelines.”
CT for Acute Nontraumatic Abdominal Pain—Is Oral Contrast Really Required?
Kessner R et al.
Acad Radiol 2017; 24:840–845 - "A major disadvantage of administration of oral contrast material for abdominal CT in the ED is prolonged stay and delay in diagnosis and treatment. Levenson et al. showed that eliminating routine oral contrast use for abdominal CT in the ED may result in reducing both the mean ED length of stay and the turnaround time from CT request to completion, without compromise of patients’ diagnosis. Razavi et al. showed that when oral contrast was not used, there was a statistically significant decrease in the time from CT order to examination completion, the time from CT order to final in- terpretation, and also in the ED length of stay.”
CT for Acute Nontraumatic Abdominal Pain—Is Oral Contrast Really Required?
Kessner R et al.
Acad Radiol 2017; 24:840–845 - What do you do now?
- Focus on what has not been addressed-What about gastric pathology?
- Focus on positioning the oral contrast in areas to prevent delay in administrating the oral contrast
- Rethink the process from the perspective of the “Reading Physician (the radiologist)”