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CT Colonography forRadiographers
AGuide toPerformance and Image Interpretation
JoelH.Bortz AarthiRamlaul LeonieMunro
SecondEdition
Foreword by Ingrid Britton
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CT Colonography for Radiographers
Joel H. Bortz • Aarthi Ramlaul Leonie Munro
Editors
CT Colonography for Radiographers
A Guide toPerformance andImage 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, specically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms 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 specic 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 afliations.
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 modications, 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 prole 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 benet 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.
IngridBritton
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 10,000CTC examinations over the past 17years. 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 articial 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 benet 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 benets 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 insufation.
Preface
Preface
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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. 1317 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 identied. While the majority of these lesions are not considered to be of clinical importance, the potential benet of detect­ing an extracolonic lesion is of high clinical relevance which can benet the patient through early detection and subsequent intervention. Chapter 18 explains the signicance 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 signicantly, 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