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explained. The benets that these applications offer to CT scanning are
described.
Chapter 27 is a new chapter focused on the application of audit principles
and offers good practice guidance for planning and conducting CTC audits
and using audit data to implement changes in practice.
In keeping with the ethos of learning and applying knowledge and understanding of the information presented within the text, Chap. 28 provides an
opportunity for readers to self-assess their knowledge and engage their critical thinking abilities by writing a preliminary report based on case samples.
Recommended answers are provided for you to check your responses. Use
this exercise as a learning activity to draw comparisons, learn from them and
develop a deep approach to learning.
Lastly, a brief glossary is provided at the end for terms that may appear
confusing within the text.
We wish you well in your extended scope of practice as a GI radiographer
undertaking CTC, and we hope you nd this revised edition a helpful and
useful resource in your continued learning and practice.
Los Angeles, CA JoelH.Bortz
Buckinghamshire, UK AarthiRamlaul
Durban, South Africa LeonieMunro
November 2023
Preface
Acknowledgements
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Professor Perry Pickhardt and Professor David Kim, Department of
Radiology, University of Wisconsin Medical School, are thanked for their
support and sharing their knowledge with Joel Bortz. Their advice and guidance for many years, as well as always being available for ‘second opinions’,
provided the foundation for this book to be written. Professor PJ Pickhardt,
Wisconsin University is thanked for the NAFLD hepatic steatosis image, and
the NAFLD [MAFLD] ultrasound scan. Professor D Kim is thanked for the
carpet lesion example, colo-vesical stula images, images of rectal varices,
the colo-vesical CTC images, and examples of a femoral hernia.
Clinton Bopp is thanked for the diagrams illustrating internal and external
haemorrhoids and the target drawing.
Viatronix Stony Brook, NewYork, is thanked for providing the electronic
cleansing images of the colon, and examples of the Viatronix 3D workstation
image.
Vimap Technologies is thanked for the cross-sectional illustration of their
CO2 warming mechanism in the VMX 1020 A insufator and the close-up
view of the Vimap gauge insufator.
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Contents
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1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Joel H. Bortz
2 Patient-Centred Communication in Imaging . . . . . . . . . . . . . . . . 11
Leonie Munro
3 Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Aarthi Ramlaul and Tracey Gregory
4 Principles of CT and Hybrid Imaging . . . . . . . . . . . . . . . . . . . . . 29
Christoph J. Trauernicht
5 Principles of Radiation Dose in CT and CT Colonography . . . . 41
Christoph J. Trauernicht
6 Dose Optimisation in CT Colonography . . . . . . . . . . . . . . . . . . . . 51
Christoph J. Trauernicht
7 Overview of CTC in Imaging the Colon . . . . . . . . . . . . . . . . . . . . 63
Rachel Baldwin-Cleland and Stephen Wilson
8 The Role of Contrast Media in CTC: Types,
Usage, Allergic Reactions, and Patient Safety . . . . . . . . . . . . . . . 81
Rachel Baldwin-Cleland and Stephen Wilson
9 Preparation of CTC Patient: Diet, Bowel Preparation,
the Role of Tagging, and Methods of Colonic Insufflation . . . . . 97
Joel H. Bortz
10 CTC Technique and Image Interpretation Methods . . . . . . . . . . 109
Joel H. Bortz
11 Anatomy of the Colon: Rectum to Ileocaecal Valve . . . . . . . . . . . 129
Joel H. Bortz
12 CTC Traps and Artefacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Joel H. Bortz
13 Internal Haemorrhoids, Anal Papilla, and Other
Anorectal Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Joel H. Bortz
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14 Polyps: Types and Sizes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Joel H. Bortz
15 The Adenoma-Carcinoma Sequence, Management,
and Treatment of Colon Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Joel H. Bortz and Hesta Friedrich-Nel
16 Colonic Diverticular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Joel H. Bortz
17 Lipomas of the Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Joel H. Bortz
18 Extracolonic Findings, Their Clinical Significance,
and the Role of Opportunistic Screening
. . . . . . . . . . . . . . . . . . . 241
Joel H. Bortz
19 Metabolic-Associated Fatty Liver Disease: Opportunistic
Screening at CT Colonography . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Joel H. Bortz
20 CTC for Incomplete and Failed Colonoscopy Cases . . . . . . . . . . 291
Joel H. Bortz
21 Good Practice Reporting in CTC . . . . . . . . . . . . . . . . . . . . . . . . . 301
Joel H. Bortz
Contents
22 The Role of Ultrasound and Magnetic Resonance
Imaging in the Evaluation of Colon Cancer . . . . . . . . . . . . . . . . . 313
Kalpesh Mody
23 Role of Nuclear Medicine in the Evaluation
of Colon Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Fozy Peer
24 Legal and Professional Requirements:
A Framework for Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Richard Price
25 Artificial Intelligence and Machine Learning
in Cross-Sectional Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Riaan van de Venter
26 Dual-Energy CT and Photon Counting CT . . . . . . . . . . . . . . . . . 345
Christoph J. Trauernicht
27 Application of Clinical Audit Principles for Good
Practice in CT Colonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Leonie Munro and Aarthi Ramlaul
28 Self-Assessment of CT Colonography Images . . . . . . . . . . . . . . . 359
Joel H. Bortz, Aarthi Ramlaul, and Leonie Munro
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
About the Authors
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RachelBaldwin-Cleland Rachel has been undertaking CTCs since 2005. She was a GI
superintendent and research radiographer at St Mark’s Hospital, London. She is currently
a clinical research fellow completing a PhD focused on education, training, and sustainability in CTC. She is also involved in setting up the National CTC Training and
Accreditation Programme in the UK.She is a faculty tutor for radiographer and radiologist
CTC courses, and CTC ‘Train the Trainer’ courses. She is Chair of the Gastrointestinal
Radiographer Specialist Interest Group (GIRSG) and is the radiographer representative on
the UK BCSP Quality Assurance Committee. Her other research areas involve small bowel
imaging and sarcopenia effects on surgical outcomes in GI patients.
JoelH.Bortz, MBChB, DMRD, FRCR, FFRRCS Joel is a South African trained radiologist with three radiology degrees. He served as an examiner and convenor for the
Colleges of Medicine of South Africa and was an examiner at several South African universities. He is based at LSG Imaging in Los Angeles, United States, and has vast experience
in CTC.He is the author of numerous peer- reviewed CTC publications and other imaging
topics.
HestaFriedrich-Nel Hesta is the acting Dean of the Faculty of Health and Environmental
Sciences at the Central University of Technology, Free State, South Africa. She has a master’s degree in Radiography (Therapy), a PhD in Health Professions Education, and a
Postgraduate Diploma in Higher Education.
TraceyGregory Tracey is an associate lecturer in diagnostic imaging at the University of
Derby. She is also the business manager and co-owner of a private dental practice in
Cumbria and an external speaker in dental radiography. She is currently an SCoR assessor
in dental radiography.
KalpeshGirishMody Kalpesh is a specialist radiologist/lecturer at Inkosi Albert Luthuli
Central Hospital in afliation with the University of KwaZulu-Natal (UKZN) in Durban,
South Africa. At the hospital, he provides a general radiological service to the population
of KwaZulu-Natal covering multiple imaging modalities including CT, ultrasound, and
MRI.He also has an interest in hepatobiliary and gastrointestinal imaging with a focus on
oncologic imaging. He is also involved in the administration and performance of the postgraduate programme in radiology at UKZN, as well as contributing to the undergraduate
medical syllabus.
LeonieMunro, ND Rad(D), MA Leonie is a retired diagnostic radiographer. She has a
national diploma in diagnostic radiography, a master’s degree in communication, a postgraduate diploma in public administration, and a certicate for trainers. She has authored
and co-authored several peer-reviewed journal publications, and chapters in books, which
focused on radiography and professional communication. She is the co-editor of the peerreviewed journal The South African Radiographer.
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FozyPeer Fozy is the past-president of the ISRRT and retired manager of the Nuclear
Medicine Department at the Inkosi Albert Luthuli Central Hospital in KwaZulu-Natal,
South Africa. She has published papers in both peer-reviewed and accredited journals. She
is now an executive member of the Society of Radiographers of South Africa.
Richard Price Richard is a diagnostic radiographer and Emeritus Professor of
Radiography at the University of Hertfordshire, UK.He is the immediate past Dean of the
School of Health and Social Work at the University. He is a co-author of the history of The
Society of Radiographers: 100years 1920–2020. From 2008 to 2014 he was editor-in-chief
of Radiography, the peer-reviewed journal of the Society of Radiographers. He is a past
president of the Society and College of Radiographers and was awarded the Society’s Gold
Medal in 1995.
AarthiRamlaul, EdD, MA, B.Tech(DRad), ND Rad(D) Aarthi is a diagnostic radiographer and Associate Professor of Diagnostic Radiography at Buckinghamshire New
University, UK. Her primary research focused on the development of critical thinking in
diagnostic radiography education and its impact on autonomous clinical decision-making.
She has a keen interest in the ethico-legal aspects of professional practice and the implementation of articial intelligence in clinical decision- making. Aarthi has edited and
authored numerous publications, including four textbooks in medical imaging.
Christoph J. Trauernicht Christoph is the Director of Medical Physics at Tygerberg
Hospital and Associate Professor at Stellenbosch University. He is the current president of
the Federation of African Medical Physics Organisations. He has also worked as an IAEA
expert on numerous occasions, including international training courses on CT quality
assurance and dosimetry, as well as dose optimisation. He serves on the Accreditation
Board of the International Organisation for Medical Physics. He has served as examiner
and convenor for the Colleges of Medicine of South Africa and has helped evaluate medical
physics interns as part of the National Board Assessment for the Health Professions Council
of South Africa. Chris was one of the founding members of the South African chapter of
AFROSAFE in 2018.
About the Authors
Riaan van de Venter Riaan is a lecturer and research associate in the Department of
Radiography at the Nelson Mandela University. They are an associate editor of the Journal
of Medical Imaging and Radiation Sciences and the co-editor of The South African
Radiographer. They are also the current president of the Society of Radiographers of South
Africa (SORSA). Riaan’s research interests span workforce development, health professions education, role extension, advanced practice, image interpretation, trauma, wellbeing, patient care, image interpretation as well as sexual and gender minorities.
StephenWilson Stephen has been undertaking CTC since 2007 and reporting CTC since
2009, with an advanced practice role at Peterborough City Hospital. Stephen obtained his
Pg. Cert in CT Colonography in 2015 from Keele University and completed his masters at
Salford University in 2017, specialising in upper GI.He is course administrator for the
University of Suffolk Pg. Cert in CT Colonography and a clinical lead for the National
CTC Training and Accreditation programme.
Abbreviations
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2D 2-Dimensional
3D 3-Dimensional
AAA Abdominal aortic aneurysm
AAC Abdominal aortic calcication
AC Adaptive child
ACG American College of Gastroenterologists
AGA American Gastroenterological Association
AI Articial intelligence
AIDR Adaptive iterative dose reconstruction
ALARA As low as reasonably achievable
ANN Articial neural network
Apps Applications (software)
ASIR Adaptive statistical iterative reconstruction
AUC Area under curve
BE Barium enema
BI-RADS Breast imaging reporting and data system
BLMRC Bright lumen magnetic resonance colonography
BMD Bone mineral density
BSCP Bowel cancer screening programmes
BSGAR British Society of Gastrointestinal and Abdominal Radiology
CAD Computer-aided diagnosis
CCE Colon capsule endoscopy
CCE Cryptogenic cirrhosis
CEA Carcinoembryonic antigen
ceCT Contrast-enhanced computed tomography
CEUS Contrast-enhanced ultrasonography
CNN Convolutional neural networks
CO2 Carbon dioxide
CP Controlling parent
C-Rads CT colonography reporting and data system
CRC Colorectal cancer
CTA Computed tomography angiography
CTC Computed tomographic colonography
CTDI Computed tomography dose index
CVD Cardiovascular disease
DCBE Double contrast barium enema
DD Diverticular disease
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DDSS Diverticular disease severity score
DECT Dual-energy computed tomography
DL Deep learning
DLMRC Dark lumen magnetic resonance colonography
DLP Dose-length product
DNA Deoxyribonucleic acid
DNN Deep Neural Network
DVD Digital versatile disc
DXA Dual-energy X-ray absorptiometry
E1 Not of clinical importance
E2 Low clinical importance
E3 Moderate clinical importance
E4 High clinical importance
EBCT Electron beam computerized tomography
EC Electronic cleansing
ECF Extracolonic ndings
eGFR Estimated glomerular ltration rate
ESGAR The European Society of Gastrointestinal and Abdominal
Radiology
ESGE European Society of Gastrointestinal Endoscopy
EUS Endoscopic ultrasonography
FAP Familial adenomatous polyposis
FC Free child
FDA Food and Drug Administration
FDG-PET F-18-Fluoro-deoxy-glucose positron emission tomography
FOV Field of view
FRAX Fracture risk assessment tool
GAN Generative adversarial network
gFOBt Guaiac faecal occult blood test
GIST Gastrointestinal stromal tumour
GIT Gastrointestinal tract
GRE Gradient echo
HASTE Half-Fourier acquisition single-shot turbo spin-echo
HCC Hepatocellular carcinoma
HCP Healthcare practitioners
HCPC Health and Care Professions Council
HCV Hepatitis C virus
HDL Low high-density lipoprotein
HP Hyperplastic polyp
HU Hounseld units
IV Intravenous
IAEA International Atomic Energy Agency
ICRP International Commission on Radiological Protection
ICRU International Commission on Radiation Units and
Measurements
ICV Ileocaecal valve
IEC International Electrotechnical Commission
IMA Inferior mesentery artery
Abbreviations
Abbreviations
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IO Iterative optimisation
IVC Inferior vena cava
Kerma Kinetic energy released in matter
keV Kiloelectronvolts
L Level (window)
LDL Low-density lipoprotein
LLD Left lateral decubitus
MAFLD Metabolic-associated fatty liver disease
MASH Metabolic-associated steatohepatitis
MDCT Multi-detector computed tomography
MERCURY Magnetic Resonance Imaging and Rectal Cancer European
Equivalence
MinIP Minimum intensity projection
MIP Maximum intensity projection
ML Machine learning
MPR Multiplanar reformations/reconstructions
MRC Magnetic resonance colonography
MRE MR elastography
MRF Mesorectal fascia
MRI Magnetic resonance imaging
MRS MR spectroscopy
MSAD Multiple scan average dose
MSI Microsatellite instability
NAFDL Non-alcoholic fatty liver disease
NASH Non-alcoholic steatohepatitis
NHS National Health Service
NHSBCSP National Health Service Bowel Cancer Screening Programme
NICE National Institute for Health and Clinical Excellence
NN Neural network
NP Nurturing parent
NPSA National Patient Safety Agency
NSF Nephrogenic systemic brosis
OP Optical colonoscopy
PACS Picture archiving and communication system
PET Positron emission tomography
PGD Patient Group Directive
PPE Personal protective equipment
PPV Positive predictive value
PVR Perspective volume rendering
QA Quality assurance
RCR Royal College of Radiologists
RECIST Response evaluation criteria in solid tumours
RLD Right lateral decubitus
RNN Recurrent neural networks
ROI Region of interest
SAFIRE Sinogram-afrmed iterative reconstruction
SCoR Society and College of Radiographers
SMA Superior mesentery artery
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SSCT Single-slice computed tomography
SSP Sessile serrated polyp
TA Transactional analysis
TBS Trabecular bone score
TD Translucent display
TDSN Tensor deep stack network
TNM Tumour node metastases
TRUS Transrectal ultrasound
TSA Traditional serrated adenoma
UICC Union for International Cancer Control
UK United Kingdom
US Ultrasound
USA United States of America
USE Ultrasound elastography
VC Virtual colonoscopy
VLDL Very low-density lipoprotein
W Width (window)
WHO World Health Organisation
Abbreviations
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