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CT Colonography
forRadiographers
AGuide toPerformance
and Image Interpretation
JoelH.Bortz
AarthiRamlaul
LeonieMunro
Editors
SecondEdition
Foreword by
Ingrid Britton
123
CT Colonography for Radiographers
Joel H. Bortz • Aarthi Ramlaul
Leonie Munro
Editors
CT Colonography for
Radiographers
A Guide toPerformance andImage
Interpretation
Second Edition
Foreword by
Ingrid Britton
Editors
Joel H. Bortz
Los Angeles, CA, USA
Leonie Munro
Morningside Durban, South Africa
Aarthi Ramlaul
Buckinghamshire New University
High Wycombe, UK
ISBN 978-3-031-30865-9 ISBN 978-3-031-30866-6 (eBook)
https://doi.org/10.1007/978-3-031-30866-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2016, 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
The editors collectively dedicate this book to all diagnostic
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radiographers (radiation technologists/medical radiation
technologists) who perform CT colonography or who will be
doing so in the future. Your professional approach to service
delivery to asymptomatic and symptomatic patients underpins
successful imaging of the colon for prevention and management
of colorectal cancer.
On a personal note…
Joel Bortz dedicates this to his children and seven
grandchildren.
Aarthi Ramlaul dedicates this to her husband and two sons.
Leonie Munro dedicates this to her family and two grandsons.
Joel H.Bortz, Aarthi Ramlaul, and Leonie Munro.
Foreword
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I am delighted to introduce this book which is written by leaders in the eld
of teaching and training of CT colonography. This is now established as a
mainstream investigation in all pathways aimed at detecting colorectal cancer
and its precursors.
Although colorectal cancer is one of the deadliest cancers, it remains
one of the most treatable if detected at an early stage. This requires the
expansion of necessary capacity, which is best facilitated by large radiographer provided services. Scrupulous attention to consistent high-quality
preparation, distention, and procedural modications, based on interpretation of the images during the scan, is required. When performed to the
highest standards, CTC performance has been validated as equivalent to
the previous gold standard of optical colonoscopy and has the potential to
save lives with its greater safety prole and patient acceptability. All these
facets are comprehensively addressed in this book. The technical and procedural aspects of CTC are discussed in consistent, standardised terms
within a methodical framework which will embed best practice in all students of this text.
This publication discusses the role of CTC in colorectal cancer diagnosis, other incidental colorectal diseases, extracolonic ndings and screening. Additionally, new chapters on the role of CTC for incomplete and
failed colonoscopy, and opportunistic screening broaden the remit of the
advanced practice radiographer with an encompassing view of the patient
pathway and extracolonic ndings. A new chapter on audit appropriately
underscores the importance of radiographer involvement in the quality
assurance of their service, and new chapters on PET, dual energy CT,
photon counting CT, and AI will equip the reader for current and future
developments.
Since the last edition radiology practice has evolved: an expanding
radiographer scope of practice has increased for those involved in the
reporting of CTC scans. The structure of this book should encourage even
greater numbers of the profession to take on this important responsibility.
By doing so, radiographers ensure one-stop staging with rapid escalation of
positive cases to endoscopy and multidisciplinary team meetings for the
benet of patients.
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Whether the reader of this book is responsible for delivering high-quality
examinations, the whole pathway, is a service lead, or is a healthcare professional within colorectal cancer services curious about the technology, this
book provides a comprehensive guide supporting the delivery of quality,
early diagnosis, and improved colorectal cancer survival.
IngridBritton
Royal Stoke University Hospital
Stoke-On-Trent, UK
Midlands Academy
London, UK
Foreword
Preface
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The increasing use of computed tomography colonography (CTC), also
known as virtual colonoscopy, as the preferred imaging modality, coupled
with an ongoing shortage of radiologists, adds to an already burdened radiology workload. Hence, diagnostic radiographers, who have a key role within
the imaging team in the United Kingdom’s National Health Service (NHS)
and are skilled in their practice, are becoming increasingly responsible for
patient pre-assessment, informed consent, and performing CTC examinations. Those radiographers who have received advanced training are providing a preliminary descriptive report of the images, thus being involved in
image interpretation and reporting of CTC images.
Following the success of the rst edition of this text, the editors are pleased
to offer this new, updated second edition of this textbook aimed at supporting
radiographers in this extended role, and once again lling the gap in this market. The aim of this new edition remains to provide radiographers with a
platform, on all aspects of CTC, in order to support them in their extended
scope of practice. When ‘radiographer’ is used within the text, we are referring to diagnostic radiographers/radiation technologists/medical radiation
technologists who practise within this extended role.
The editors and authors are leaders in the eld of radiography practice and
education. Dr. Joel H.Bortz, gastrointestinal (GI) radiologist and lead author,
has performed more than 10,000CTC examinations over the past 17years.
Collectively, the editors have put together these chapters, which serve as both
a learning package and a toolkit in CTC performance and image interpretation. All chapters have been updated to include current and future projected
developments within CTC performance and image interpretation and takes
into account the learning derived during the Covid-19 pandemic and the
increasing use of articial intelligence (AI) in radiography.
The text is suited to and aimed at radiographers globally, who wish to train
to take on this extended scope of practice, and those who are currently performing CTC examinations in practice. In addition, undergraduate and postgraduate radiography/radiation technology students will benet from using
this as a reference or core text in gastrointestinal imaging. Furthermore, the
scope of the text may appeal to trainee radiologists as well as nurses working
within medical imaging.
The overall strength of the text lies in the presentation and discussion of a
vast range of 2D and 3D images of normal anatomy as well as the most common pathologies seen in CTC.Each chapter includes helpful signposting and
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key take away messages that are focused on the essential elements that pertain to CTC. Each chapter includes a list of references which serves as a
source for further reading and adds to the learning experience for readers. The
text opens with an introduction which sets the scene and acts as a guide for
the chapters that follow.
There are two critical components to achieving a successful CTC examination: an adequately prepared bowel and good distension of the colon with
carbon dioxide (CO2). Patients must therefore fully understand their responsibilities for bowel preparation. This requires that oral and written instructions are clear, readable, and easily understood by all patients including those
with communication impairments. Communication is therefore pivotal, and
the chapter on communication gives guidance on patient-centred communication before, during, and following a CTC examination.
It is the responsibility of a radiographer performing CTC examinations to
ensure that patients have been provided with adequate, comprehensive information, including benets and related risks, to enable informed consent to be
established. The chapter on informed consent discusses duty of care and the
role and responsibilities of a radiographer in the information-giving and
consent- gaining process. The chapter also presents a current dilemma in the
consenting process relating to the use of AI in CTC procedures and subsequent decision-making regarding diagnosis and patient management.
A chapter on the principles of computed tomography is included again,
but this time there is discussion about the science of CT including hybrid
imaging and dual-energy CT.Student radiographers study this subject as part
of their undergraduate course of study and need to be familiar with the concepts discussed. Radiographers with years of experience would be gently
reminded about the science behind these technologies.
Due to the increasing number of CT examinations being performed, radiation doses associated with CT examinations have become a popular topic of
debate. Chapter 5 provides an insight into the principles of radiation dose and
explains the concepts of effective dose and diagnostic reference levels in CT
and CTC imaging.
Chapter 6 describes various options for dose optimisation in CTC in
response to the increased awareness of radiation dose contributed by radiological studies, especially CT examinations. The techniques discussed are not
unique to CTC, however, and can be applied for optimisation of various scan
protocols.
Chapter 7 reviews the development of CTC as a diagnostic tool, evaluates
current guidance, and discusses the future of CTC.As CTC is a minimally
invasive procedure, which involves the administration of air, intravenous
injections and contrast media, patient safety must be considered rst and
foremost throughout the examination.
Chapter 8 focuses on the role of contrast media in CTC including the types
of contrast media, the usage, allergic reactions, and issues of patient safety.
Cathartic bowel preparation and tagging agents are pivotal in CTC.For a successful study, it is important that a clean bowel is well distended and that
residual uid is tagged. Chapter 9 focuses on patient preparation, including
bowel preparation, the role of tagging and methods of colonic insufation.
Preface
Preface
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xi
Over the years, there have been several changes to the technique used in performing CTC examinations, and Chap. 10 is focused towards providing
detailed step-by-step guidance on conducting a CTC examination as seen
currently as best practice.
Chapter 11 teaches the normal anatomy of the colon as seen on 2D and 3D
CTC images to facilitate accurate image interpretation. In order to be able to
identify image appearances of pathologies, it is essential to know what normal anatomy looks like rst. Similarly, it is important to be knowledgeable of
normal image appearances as certain imaging artefacts or pitfalls in imaging
may produce images which may mimic a pathology. Commonly encountered
traps and artefacts are discussed in Chap. 12.
An extensive range of images demonstrating pathologies can be seen in
Chaps. 13–17 which cover internal haemorrhoids and other anorectal lesions;
the different types of polyps; the adenoma-carcinoma sequence; management
and treatment of colon cancer; diverticular disease and lipomas.
During CTC procedures, intra-abdominal and pelvic organs are visualised
and extracolonic lesions may be identied. While the majority of these lesions
are not considered to be of clinical importance, the potential benet of detecting an extracolonic lesion is of high clinical relevance which can benet the
patient through early detection and subsequent intervention. Chapter 18
explains the signicance of extracolonic ndings in CTC screening.
Chapter 19 is a new chapter which focuses on metabolic-associated fatty
liver disease, previously known as non-alcoholic fatty liver disease. This disease is of concern globally and CTC allows for visualisation of the liver, as an
extracolonic organ, during CTC imaging.
Chapter 20 is a new chapter which focuses on the role of CTC in incomplete or failed optical colonoscopy and the reasons for incomplete or failed
optical colonoscopy procedures are discussed.
Chapter 21 offers good practice guidance in CTC reporting. Reporting of
CTC must be undertaken by competently trained practitioners, i.e. either a
radiologist or trained radiographer.
With the increasing incidence of colorectal cancer, it is important to be
aware of the role of complementary imaging in supporting CTC.Chapters 22
and 23 evaluate, respectively, the role of ultrasound and magnetic resonance
imaging, and the role of nuclear medicine, in the management of colorectal
pathology.
Chapter 24 explores the responsibility and accountability of radiographers
within a practice framework and the possible consequences of failing to provide a duty of care, and practice, at the required standard.
Chapter 25 is a new chapter which focuses on AI and machine learning in
cross-sectional imaging. The use of AI in radiography practice is increasing
signicantly, and this chapter discusses the potential impact of AI in radiography and ethical considerations pertaining to the use of AI.The chapter also
provides an overview of AI-enabled image interpretation in cross-sectional
imaging, particularly in CTC.
Chapter 26 is a new chapter which focuses on the principles and dose,
related to the use of dual-energy CT.The science of dual-energy CT and photon counting, which are relatively recent advances in CT imaging, are
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