CT Colonography
Tomy Setyawan
CT Application Specialist
July 16, 2024
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CT Colonography
Background and Indication
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Rational Background of CT Colonography
CT Colonography atau Virtual colonoscopy merupakan pemeriksaan non-invansive yang menggunakan data citra CT
irisan tipis, serta dilengkapi aplikasi yang software yang mampu menampilkan citra 2D/ 3D dari usus besar guna
mendiagnosa kelainan/ penyakit pada usus besar.
Aplikasi software CT Colonography ini memungkinkan mensimulasikan citra 3D dan manipulasi jalur navigasi real-
time didalam usus besar yang mirip dengan prosedur tradisional endoskopi yang dimasukan melalui rectum.
CT Colonography telah berkembang pesat dari penelitian kedalam penyebaran klinis yang luas, saat ini telah
menjadi metode yang menjanjikan untuk mendeteksi polip, divertikel, dan kanker kolorektal.
Source: Debrabrata Mukherjee & Sanjay Rajagopalan ; CT and MR Angiography of Peripheral Circulation
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Anatomy of Colon
WHAT IS THE COLON?
The colon is also known as the large bowel or large intestine. It is an organ that is part of the
digestive system (also called the digestive tract) in the human body. The digestive system is the
group of organs that allow us to eat and to use the food we eat to fuel our bodies.
WHAT DOES THE COLON DO ?
The colon plays a very important role in how our bodies use the food we eat,
[Link] begins in the mouth where it is chewed by the teeth into smaller pieces. Once swallowed the
food travels into the esophagus which connects to the stomach.
[Link] the stomach food is further broken down to liquid and passed on to the small bowel (intestine).
[Link] the small bowel, the food breakdown continues with the assistance of the pancreas, liver and
gallbladder. Here is where all the important vitamins and nutrients in food are absorbed.
[Link] is left over, which is mostly liquid, then moves into the colon. The water is absorbed in the
colon. Bacteria in the colon break down the remaining material. Then the colon moves the leftover
material into the rectum.
[Link] rectum is like a storage-holder for this waste. Muscles in the rectum move the waste, called
stool, out of the body through the anus.
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Anatomy of Colon
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Clinical Indications
CT Colonography can be employed as a full morphological examination of the bowels and abdominal structures
for the following indications:
￭ After incomplete endoscopy that may be due to a proximal obstruction
￭ Search for proximal synchronous polyps and cancers in patients with occlusive colorectal cancer.
￭ Symptomatic patients at increased risk of endoscopy and sedation, generally the elderly and frail patients
￭ Follow-up evaluation of patients with known colorectal polyps/cancers
￭ Search for a primary neoplasm in patients with widespread metastatic disease
￭ Evaluation of chronic inflammatory bowel disease
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Other Tests
There are several tests for detecting and monitoring of colorectal cancers.
o Digital rectal exam (DRE), insertion of a lubricated, gloved finger into the rectum to feel for abnormal
areas
o Fecal occult blood test (FOBT), a lab test for minute blood trace in a fecal sample
o Sigmoidoscopy: endoscopic procedure using a probe (sigmoidoscope) inserted into the rectum and distal
colon to check for abnormalities or source of bleeding, diarrhea, abdominal pain, or constipation
o Colonoscopy: endoscopic procedure using a longer colonoscope for examining the entire colon, biopsy
and removal of polyps; also useful for diseases, e.g., Cohn’s disease and ulcerative colitis.
o Double contrast barium enema (DCBE): x-ray fluoroscopic examination of the lower gastrointestinal (GI)
tract after bowel cleansing, distending and coating the colon with air and barium.
Author | Department 7
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Clinical value of CT Colonography
Recent studies from the ESGAR committee have suggested that CT Colonography is superior to barium enema.
CT Colonography Traditional Colonoscopy
Less invasive, no sedation and insertion of Invasive, sedation and insertion of endoscope
endoscope required, no risk of perforation required
Fast and reproducible examination Longer procedure and dependent on the skills of
the gastroenterologists
Able to evaluate the complete large colon Examination may be incomplete because of
including examining behind the colonic folds by patient not being able to compliant or if there is
reversing the endoscopic view or via image a obstruction in the distal colon. Difficult to
manipulation examine behind colonic folds
Able to detect and evaluate extra-colonic Not able detect extra-colonic lesions
findings, e.g., lesions in the lungs, liver and
abdomen
Not able to provide pathological information on Able to evaluate tissue samples by performing a
the type of lesions biopsy during the procedure
Non-therapeutic procedure Therapeutic procedure, polyps can be removed
during the procedure
Author | Department 8
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Diagnostic accuracy of CT Colonography
Polyps size Sensitivity
CT colonoscopy has proven its diagnostic validity, especially in
Virtual Conventional
patients with incomplete conventional colonoscopy or with colonoscopy colonoscopy
occlusive lesions in the distal colon.
For screening purposes, guidelines must be set to stratify 10 mm 94 % 93 %
patients to undergo an immediate colonoscopy for 8 mm 94 % 92 %
polypectomy, short-term follow-up, or routine follow-up.
6 mm 89 % 88 %
Source: Pickhardt et al, New England Journal of Medicine, 2003 Author | Department 9
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Patient Preparation
General Preparation
❑ Laboratory test for Ureum and Creatinin Serum, with Maximum burden 1.5 mg/dL
❑ Colon Cleansing; 1 – 2 day before exam (Lower fiber diet, Bowel cleansing agent)
❑ Calculation GFR or eGFR for Further Renal Investigation, minimum 60mL/min/1.73m2
❑ Patients with Daily Medication, e.g Metformin for Diabetes Mellitus patient, Medication Should be
Stopped (H-1) to (H+1) of Examination.
❑ Allergic Test (Skin or Intravenous Test) Should be Performed
❑ Scanning Procedure (Breathing Technique)
❑ Using bowel relaxation agent if accepatable
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CT Colonography
Contrast Administration &
Injection Strategy
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Contrast Negative
- Untuk menggembungkan usus besar, agen gas dimasukkan melalui kateter rektal yang dimasukkan
melalui anus ( baik kateter balon tiup atau tabung enema rektal tipis standar dapat digunakan).
- Untuk pasien geriatri dan inkontinensia, kateter balon mungkin lebih baik dipertahankan.
- (Terlepas dari biayanya) karbon dioksida adalah agen distensi pilihan terbaik, meskipun udara ruangan –
juga merupakan alternatif yang dapat diterima.
- Karbon dioksida menawarkan keuntungan sebagai berikut:
1. Mudah diserap dan dengan demikian meminimalkan ketidaknyamanan pasca-prosedur
2. Difusi cepat melalui dinding kolon, mengurangi adanya refluks katup ileosekal
3. sekitar 1,5 hingga 2,0 liter karbon dioksida dapat dimasukkan menggunakan insufflator otomatis yang
dapat mempertahankan tekanan intraluminal konstan (25 mm Hg) selama insuflasi dan secara
optimal meregangkan usus besar.
4. Udara ruangan adalah alternatif yang lebih murah dan distensi yang memadai dapat dicapai dengan-
menerapkan 40-60x tiupan secara manual melalui pompa tangan.
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Contrast Negative
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IV Injection
Material Flowrate Volume
NaCl 4 ml/ sec 15 ml
Test Injection
Contrast 3-4 ml/ 80-100 ml
Media sec
3-4 ml/
NaCl sec 50 ml
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When Contrast IV is needed?
(1) (2)
The use of intravenous contrast agent in CT
Colonography is expected to further improve the
accuracy and diagnostic confidence in lesion
detection. Administration of intravenous contrast
material can sometimes be helpful in the
characterization of detected lesions and
visualization of extracolonic structures.
Contrast enhancement is generally indicated in the
search for primary cancer, the exclusion of cancer
in case of symptoms as well as the staging and
surveillance of known neoplasm.
Non-enhanced study Contrast enhanced study
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CT Colonography
Examination Workflow
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CT Colonography Examination Workflow
PROSEDUR
▪ Pasien tidur terlentang di atas meja pemeriksaan( head first atau feet
first )
▪ Selanjutnya pasien tidur miring “Lateral Position”
▪ Catheter rectal (canula) yang sudah terkoneksi pada plastic insuflator
bulb dipasangkan pada rectum.
▪ Pasien diinstruksikan agar jangan flatus, dan menahan rasa kembung.
▪ Lakukan distending (mengembungkan) colon dengan udara, dengan
menggunakan “plastic insuflator bulb” selama periode 1-2 menit. (+-40
kali pompa)
▪ Hentikan pompa jika pasien sudah merasa tidak nyaman atau
kembung sekali.
▪ Pasien kembali diposisikan Supine
▪ Lakukan Scanning Pertama untuk area abdominal atas dan bawah
▪ Pasien di posisikan Prone
▪ Lakukan Scanning Kedua untuk area yang sama.
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Supine Position; Scanning Protocol
Scan Parameter 16 Slice 64 Slice Low Dose
Kilo Voltage (kV) 130 kV 130 kV 110 kV
Reference mAs 150 150 90
Dose Modulation On On On
Collimation 16 x 0.6 64 x 0.6 64 x 0.6
Pitch 0.8 0.6 0.6
Iterative Reconstruction No No Yes (2-3)
Recon Slice 5 mm 5 mm 5 mm
Increment 5 mm 5 mm 5 mm
Kernel B20s B20s B20s
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Prone Position; Scanning Protocol
Scan Parameter 16 Slice 64 Slice Low Dose
Kilo Voltage (kV) 130 kV 130 kV 110 kV
Reference mAs 50 50 30
Dose Modulation On On On
Collimation 16 x 0.6 64 x 0.6 64 x 0.6
Pitch 0.8 0.6 0.6
Iterative Reconstruction No No Yes (2-3)
Recon Slice 5 mm 5 mm 5 mm
Increment 5 mm 5 mm 5 mm
Kernel B10s B10s B10s
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CT Colonography; Post Processing
• Axial MPR Slices can be added for comprehensive evaluation of anatomy
• 3D Endoluminal View ( Global View, Pano View, Dissection View)
• Movie Fly Through Endoluminal View if available.
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Reconstruction for Image Evaluation
syngo Extracolonic Evaluations
Colonography syngo CT Oncology
Lymph
Liver Lung
nodes
Slice width 1.0 mm 1- 3 mm 1.0 mm 1- 3 mm
30-50% 30-50%
Increment 0.7 mm 0.7 mm
overlap overlap
Routine Routine
B20f (supine)
Kernel Kernel, B60f Kernel,
B10f (prone)
e.g., B30f e.g., B30f
Width 400 Width 200 Width 1200 Width 300
Window
Level 40 Level 40 Level 600 Level 50
Author | Department 21
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Clinical Findings
First tumor in the sigmoid Second synchronous tumor in the hepatic flexure
Author | Department 22
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Flat lesions
Author | Department 23
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Diverticulosis Lesion morphology; Polyp vs fecal matter
Author | Department 24
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Ulcerative colitis. The contrast-enhanced axial CT image shows continuous wall thickening
of the sigmoid colon with mural stratification (arrow). Note that the outer contour of the
colon is regular and smooth
Author | Department 25
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Author | Department 26
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TERIMAKASIH
Author | Department 27
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