SAR_Oral Contrast_FINAL.pptx - Society of Abdominal Radiology
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Lisa L. Chu, M.D. Z. Jane Wang, M.D. Eleanor L. Ormsby, M.D. Antonio C. Westphalen, M.D. Benjamin M. Yeh, M.D. Department of Radiology & Biomedical Imaging University of California, San Francisco Disclosures § ZhenJaneWang,M.D. ü Nextrast,Inc.shareholder § BenjaminM.Yeh,M.D. ü GeneralElectricHealthcareresearch agreement ü Nextrast,Inc.shareholder ü OxfordUniversityPressbookroyalties § Otherauthorshavenodisclosures Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions LearningObjectives § Understandmeritsandpitfallsofpositiveand neutraloralcontrastagents § Assessevidence-baseduseofdifferentoral contrastagentsinspecificsettings § Discussfuturedirectionsoforalcontrastagents § Targetaudience:generalandabdominal radiologists Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Introduction § Useofsometypeoforalcontrast(positiveor neutral)isbetterthannooralcontrastfor optimalevaluationofabdomen § Historically,positiveoralcontrastconsidered standardofcare § Recentpublicationsfocusonneutralornooral contrast ü Fewhead-to-headpaperssupportpositiveoral contrastuse,likelybiasedbyhistoricalcontext Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Introduction § ConspicuityofCTfindingsdependsontypeof oralcontrastand“color”ofunderlyingdisease CartoonillustrationofCTwithneutral oralcontrast.Itmaybedifficultto discernextraluminalmassesgivensimilar attenuationtothatofneutralcontrast. CartoonillustrationofCTwithpositive oralcontrastshowsextraluminal massesmorevividly. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Introduction § ConspicuityofCTfindingsdependsontypeof oralcontrastand“color”ofunderlyingdisease CartoonillustrationofCTwithpositive oralcontrast.Itmaybedifficultto discernhyperemiainthedistalilealwall. CartoonillustrationofCTwithneutral oralcontrastshowsthedistalilealwall hyperemiamorevividly. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Anyoralcontrastbetterthannone § MoreintestinalCT IntestinalFindingsonCT ü Neutralcontrastà Percent(%) findingsmadewith anykindoforalagent thannooralagent moreintestinal findingsdetected ü N=716barium&576 water(neutral)oral contrastCTscans,and 716CTscanswithout oralcontrast Source:Kammereretal.,EurRad2015. 18 16 14 12 10 16% 8 6 11% Nooral contrastà fewerbowel findings detected 4 5% 2 0 Barium Water None Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions OralContrast&DiseaseConspicuity § Positiveandneutraloralcontrastagentseach havebenefitsanddrawbackstoconsider Positive Abscess Bowel fistula Bowel leak Extraluminal hematoma Extraluminal tumor Bowel wall inflammation Bowel wall ischemia Intraluminal tumor GI bleeding Neutral Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Neutraloralcontrasthelpsinthe evaluationof… § Bowelwalldisease ü Inflammatorybowel Terminal ileitisfrom Crohn’sdz disease ü Bowelwallischemia ü Shockbowel § Intraluminalhypervascular tumors § Extraluminalcalcifications Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Meritsofneutraloralcontrast:Crohn’sdisease Clinicalhistory:51yearoldwoman withCrohn’sdiseasepresentswith abdominalpain,nauseaand vomiting. Imagingfindings:OnCTwithIV andpositiveoralcontrast,the positivecontrastobscuresbowel wallhyperenhancement(arrow). CTenterographywithIVand neutraloralcontrastperformedsix monthspriorclearlyshowsbowel wallhyperenhancement(arrow) consistentwithactivedisease. Teachingpoint:CTenterographywhichusesneutraloralcontrastis superiortopositiveoralcontrastinevaluatingforbowelwallhyperemiain activeCrohn’sdisease. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Meritsofneutraloralcontrast:Bowelwallischemia Clinicalhistory:51yearoldwoman statuspostCABGpresentswith abdominalpain. Imagingfindings:CTwithIVand positiveoralcontrastshows pneumatosisofileum(arrow)but wallenhancementispoorly evaluated.SubsequentCTwithIV andneutralcontrastshows pneumatosisANDlackofwall enhancementofthesameilealloop duetoinfarction(arrow).RLQrenal transplant(arrows). Teachingpoint:Acutemesentericischemiaisalife-threateningcondition (mortalityrateof50-90%)thatrequirespromptdiagnosisandtreatment. Bewarythatpositiveoralcontrastcanobscurewallhypoenhancement. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Meritsofneutraloralcontrast:Hypervascularmass(#1) Clinicalhistory:71yearoldman withhistoryofcoloncancer. Imagingfindings:CTwithIVand positiveoralcontrastobscuresan enhancingmassatthefourth portionoftheduodenum(arrow), notseenfor5consecutiveCTscans withpositiveoralcontrast. SubsequentCTwithIVandneutral oralcontrastclearlyshowsthe stableduodenalmass(arrow),in retrospectpresentonallprior scans,andwhichwasproventobe aGISTonsurgicalpathology. Teachingpoint:Positiveoralcontrastcanobscureenhancingintraluminal tumorsduetosimilarhyperattenuation.Considerneutraloralcontrast insteadwhenevaluatingforintraluminalhypervascularmasses. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Meritsofneutraloralcontrast:Intraluminalmass(#2) Clinicalhistory:45yearoldwoman withunintentionalweightlossfor evaluationformalignancy. Imagingfindings:CTwithIVand positiveoralcontrastobscuresan enhancingintraluminalmassinthe stomach(arrow)whichwasmissed. Yearslater,upperendoscopy revealsagastricsubmucosalmass. SubsequentCTwithIVandneutral oralcontrastrevealsthemass (arrow).Masslatershowntobe ectopicpancreaticrest. Teachingpoint:Positiveoralcontrastcanobscureenhancingintraluminal tumorsduetosimilarhyperattenuation.Neutraloralcontrastbetter visualizesintraluminalhypervascularmasses. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Meritsofneutraloralcontrast:Extraluminalcalcification Clinicalhistory:86yearoldwoman withserousovariancarcinoma. Imagingfindings:Atfirstglanceon CTwithpositiveoralcontrast,right posteriorhyperdenselesion(arrow) appearstobepositiveoral contrast.ComparisonwithCTwith IVandneutraloralcontrastshows thatitisactuallycalcifiedserous ovariancarcinoma(arrow)andnot withinabowelsegment. Teachingpoint:Positiveoralcontrastmakesitmoredifficultto confidentlydiagnosecertainextraluminalcalcifications. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Pitfallsofneutraloralcontrast:Peritonealmetastasis Clinicalhistory:78yearoldman withcoloncancer. Imagingfindings:AtinitialCTwith withIVandneutraloralcontrast, leftpelvicmetastasis(arrow)was notdetected,eventhoughaPET scanshowedFDGuptakeinthat region.SubsequentCT1weeklater withIVandpositiveoralcontrast clearlyshowsthemesentericmass (arrow). Teachingpoint:CTsensitivityforperitonealmetastasesisreportedtobe 28to70%inmultiplepublications.Peritonealmetastasesmaybeless conspicuouswithneutralthanwithpositiveoralcontrast. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Positiveoralcontrasthelpsinthe evaluationof… § Extraluminaltumors § Abscesses § Fistulas/leaks Peritoneal implant Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Meritsofpositiveoralcontrast:Extraluminaltumors(#1) Clinicalhistory:55yearoldman withhistoryoflivertransplant presentswithabdominalpain. Imagingfindings:CTwithIVand neutraloralcontrastobscurestwo hypoattenuatingmesenteric masses(arrows).WithCTwith positiveoralcontrast,the mesentericmasses(arrows)are muchmorediscrete.Theywere proventobedesmoidtumorson pathology. Teachingpoint:Hypoattenuatingmesentericmassesmayhavesimilar densitytoneutraloralcontrast.Positiveoralcontrastissuperiorinthe evaluationforextraluminaltumors. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Meritsofpositiveoralcontrast:Extraluminaltumors(#2) Clinicalhistory:35yearoldwoman withmetastaticovariancancer. Imagingfindings:CTwithIVand neutraloralcontrastobscures multiplemesentericmasses (arrows).OnCTwithIVandpositive oralcontrast,themesenteric masses(arrows)canbeeasily differentiatedfromadjacentbowel. Teachingpoint:Evenwhenmesentericmasseshavedensityslightly differenttothatofneutraloralcontrast,theycanbeeasilymissed. Positiveoralcontrastissuperiorintheevaluationofsuchmasses. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Meritsofpositiveoralcontrast:Extraluminaltumor(#3) Clinicalhistory:57yearoldwoman withmetastaticovariancancer. Imagingfindings:OnCTwithIV andneutraloralcontrast,the paracolicmetastasiswasmissed (arrows).OnsubsequentCTwithIV andpositiveoralcontrast,the paracolicmetastasis(arrows)was moreeasilydifferentiatedfromthe adjacentdescendingcolon. Teachingpoint:Besuretoinclude“running”thecoloninyourCTsearch pattern.Atfirstglance,theparacolicmasscanbemistakenforcolon. However,positiveoralcontrastclearlyshowsthatitisextraluminal. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Meritsofpositiveoralcontrast:Intra-abdominalabscesses Clinicalhistory:27yearoldman withfeverandabdominalpain. Imagingfindings:OnCTwith neutraloralcontrastandwithoutIV contrast,itisdifficulttodistinguish multipleinterloopabscesses (arrows)fromadjacentbowel loops.OnCTwithIVandpositive oralcontrast,theinterloop abscesses(arrows)canbemore easilydistinguishedfrombowel loops. Teachingpoint:Theintra-abdominalabscessesmayhavesimilardensity toneutraloralcontrast.Positiveoralcontrastprovideshigherconspicuity andconfidenceforthedetectionofintra-abdominalabscesses. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Meritsofpositiveoralcontrast:Gastrogastricfistula Clinicalhistory:54yearoldwoman withhistoryofRoux-en-Ygastric bypasswithabdominalpain. Imagingfindings:CTwithpositive oralcontrastshowsoralcontrast flowingfromthegastricpouch (arrow)intothegastricremnant (arrow),suggestinga communicationbetweenthetwo cavities. Teachingpoint:Gastrogastricfistulaoccursinupto6%ofRoux-en-Y gastricbypasses.Twotheoriesforfistulaformationexists:(1)incomplete stomachdivisionduringcreationofpouch,and(2)staple-linefailure. Positiveoralcontrastcanbeusedtoevaluateforfistulasanywhereinthe GItract.Neutraloralcontrastisoflimitedvalueinthesescenarios. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Mimicsofpositiveoralcontrast:Colonicvarices Clinicalhistory:54yearoldman withabdominalpain. Imagingfindings:CTwithIVand positiveoralcontrastshows extensivecolonicvaricesfroma colonicvascularmalformation (arrow).Atfirstglance,thecolonic varicescanbemistakenforpositive oralcontrast.However,further reviewshowsthatpositiveoral contrasthasnotyetreachedthe colon. Teachingpoint:Besureto determinehowfartheoralcontrast hasgonebeforeassuming intraluminalhyperdensematerialis positiveoralcontrast. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Pitfallsofpositiveoralcontrast:Serosalcalcifications Clinicalhistory:78yearoldwoman withserousadenocarcinoma omentalmetastasesofunknown primary. Imagingfindings:CTwithIVand positiveoralcontrastshows extraluminalhyperdensematerial (arrows).Thesewereinitially mistakenforleakageofpositive oralcontrast.However,comparison withpriorstudiesshowedthatthe extraluminalcalcificationswere unchangedandconsistentwith serosalcalcifications. T eachingpoint:ComparisonwithpriorCTscans,particularlythose withoutpositiveoralcontrast,iskeytoavoidingthispotentialpitfall. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Pitfallsofpositiveoralcontrast:Pseudo-wallthickening Clinicalhistory:59yearoldman withlymphomapresentswith abdominalpain. Imagingfindings:CTwithIVand positiveoralcontrastshows pseudo-wallthickeningatthe cecum(arrow)duetopoormixing ofthepositiveoralcontrastand bowelcontents.Thereisincidental noteofsplenomegaly(arrow), ascites(arrow),andrightpleural effusion(arrow). Teachingpoint:Bewaryofmixing artifacts,apitfallwhichcanoccur anywhereintheGItract. Pseudolesionsaremorecommon withpositivethanneutralcontrast. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Pitfallsofpositiveoralcontrast:Pseudolesions&poormixing Clinicalhistory:78yearoldwoman withlowerabdominalpain. Imagingfindings:CTwithIVand positiveoralcontrastshowsa pseudolesioninthesmallbowel (arrow)duetopoormixingoforal contrastandbowelcontents. RepeatCTwithIVandneutraloral contrastshowsnomassinthat region(arrow)butinsteadshows realcecalnodularfoldthickening (arrow)whichwasmissedonCT withpositiveoralcontrast(arrow). Cecalbiopsyrevealedtubulovillous adenoma. Teachingpoint:Positiveoralcontrastmayshowheterogeneousmixing thatresemblesintraluminalmassorhiderealintraluminalmasses. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Meritsofnooralcontrast:Emergencyroomsetting Numerouspublicationsreportonpotentialbenefits ofnooralcontrastforabdominalCTtriageinthe emergencyroomsetting. Caveats: § Mostpublicationsfocusonrapidthroughputandrelated overallcostsavings. § DataonCTsensitivityforactualdiseaseislimitedbysmall samplesizesforpublicationswherenooralcontrastwas comparedwithoralcontrastuseintheemergencyroom setting. § Noneofthepublicationsareadequatelypoweredtoassess costofmisdiagnosiswhennooralcontrastisadministered. Clancy1993;Shreve1999;Stafford1999;Huynh2004;Anderson2005; Lee2006;Schuur2010;Laituri2011;Kepner2012;Levenson2012; Razavi2014;Alabousi2015;Uyeda2015. Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Inpractice: § Majorityofpracticesusepositiveoralcontrastformost abdominalscans § Thereisnoconsensusonwhichoralcontrasttouse(positive, neutral,nooralcontrast)formostindications Recommendations: § Positiveoralcontrastisprobablybestwhenthereisconcernfor peritonealtumorsorextraluminalfluidcollections § Neutraloralcontrastisbestwhenfocusisonbowelwall inflammationorischemia § Eachagenthaspitfalls.Patientsmayhaveconcurrentfindings onthesameCTscan,somethatwouldbemoreconspicuous withpositiveandotherswithneutraloralcontrast ü Example:Abdominalpainpatientsmayhavebothbowel wallinflammation(seenbestwithneutralagent)and abscesses(seenbestwithpositiveagent) Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions FutureDirections § “Biphasic”dualenergyCToralagentletscontrast signalbedigitallysubtractedasneeded Mouse click 70keVCTimage (Positiveoralcontrastimage) Iodinedensityreconstruction (“Neutraloralcontrastimage”) Disclaimer:NobiphasicCTcontrastagentsareFDAapprovedyetforclinicaluse. Rathnayakeetal,insubmission Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions Conclusion § ConspicuityofCTfindingsdependsontypeoforal contrastand“color”ofunderlyingdisease. Positiveandneutraloralcontrastagentseach havestrengthsandweaknesses § Practicalapproach ü Protocolbasedonleadingsuspecteddiagnosis ü RepeatexamasneededwithCT,MRIorPETwhen clinicalfindingsdonotmatchradiologicfindings § Future–“biphasic”dualenergyCTagents? Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. AlabousiA,PatlasMN,SneN,KatzDS.IsOralContrastNecessaryforMultidetectorComputedTomographyImagingofPatientsWith AcuteAbdominalPain?CanadianAssociationofRadiologistsjournal=Journall'Associationcanadiennedesradiologistes.2015;66(4): 318-22. 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