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J. H. Bortz
Table 19.5 MAFLD
Diagnosis Detection of liver steatosis (histology,
Management The following are recommended
a
Adapted from text of Eslam etal. [1]
a
non-invasive biomarkers)
In addition, at least one of three
criteria: obesity, type 2 diabetes
mellitus, clinical evident of metabolic
dysfunction (e.g. ↑ waist
circumference and abnormal lipid or
glycaemic prole)
Imaging study (e.g. US, CT) with
evidence of fatty content
• Change in lifestyle and exercise,
reduce dietary fat intake
• Metabolic risk management (e.g.
hypertension and dyslipidaemia)
• Pioglitazone, vitamin E
[52, 53]. The author personally informs patients
with MAFLD seen at screening CTC of its
potential risks so that they can then discuss
future management with their physicians [10].
Literature underscores that colonic ndings and
ECFs must be reported on [10, 28, 50]; hence,
the reporting template in Chap. 21 includes
MAFLD.
Key Messages
• 70% of patients with MAFLD may have normal liver enzymes.
• Ultrasound can only detect steatosis when
>30% of the liver is affected.
• Liver attenuation in steatosis is always lower
than the HU of spleen.
• Magnetic resonance spectroscopy (MRS) has
excellent sensitivity in both detecting and
accurately quantifying hepatic steatosis.
• Liver biopsy remains the gold standard for
diagnosing MAFLD, staging the degree of
MASH, and assessing histological brosis.
• Increased incidence of adverse CV events in
patients with MAFLD compared to the general population.
• MAFLD is characterised by an atherogenic
lipid prole, namely
– High triglyceride (TG) levels.
– Low high-density lipoprotein (HDL)
levels.
– An increased level of low-density lipopro-
tein (LDL).
– Increased very low-density lipoprotein
(VLDL) particles.
– Increase levels of lipoprotein B100
concentration.
• MAFLD diagnosis includes elevated serum
liver enzymes (ALT, AST, GGT)
• Cryptogenic cirrhosis is the end stage of a
chronic liver disease.
• MAFDL may induce HCC.
• Fatty sparing may be present.
19.12 Summary
In recent years, the presence of MAFLD in
asymptomatic individuals has increased signicantly, especially in those who are obese or have
type 2 diabetes. While most will remain asymptomatic in the presence of MAFLD, a small percentage will progress to non-alcoholic
steatohepatitis (NASH), and, with inammatory
and necrotic changes will then progress to cirrhosis, and nally hepatocellular carcinoma.
The diagnosis of MAFLD at CTC is easily
made on unenhanced abdominal CT scans. The
ROI tool is placed over the right lobe of the liver
to measure the HU readings. The liver normally
has a HU value of approximately 60. MAFLD is
diagnosed when the value drops below 45 HU;
lower readings mean more fatty inltration in the
liver. MAFLD liver is an ECF of moderate clinical importance (E3), but some radiologists classify it as E2 (low clinical importance).
Acknowledgements Prof PJ Pickhardt, Wisconsin
University for the NAFLD hepatic steatosis image, and
the NAFLD [MAFLD] ultrasound scan.
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CTC forIncomplete andFailed
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Colonoscopy Cases
JoelH.Bortz
20
20.1 Introduction
Colorectal cancer (CRC) is a leading cause of
death worldwide [1]. Over the past few years,
colon cancer has been diagnosed in younger
adults [2–7]. The American Cancer Society [6],
as well as the US Preventive Services Task Force
[7], recommend CRC screening should commence at age 45years and not at age 50 years.
Screening begins at age 40years if there is a family history of CRC.Both computed tomography
colonoscopy (CTC) and optical colonoscopy
(OC) are used in screening of patients; OC is
used for therapeutic and diagnostic procedures.
There are a range of reasons for an incomplete or
failed OC [8, 9]. The 2020 guideline update of
the European Society of Gastrointestinal
Endoscopy (ESGE) and the European Society of
Gastrointestinal and Abdominal Radiology
(ESGAR) includes CTC and colon capsule
endoscopy (CCE) as alternative imaging procedures in incomplete or failed OC [10]. Double
contrast barium enema (DCBE) is not listed in
current literature [9, 10] thus will not be discussed in this chapter (see also Chap. 1). The
focus of this chapter is the role of CTC and its
advantages compared to CCE. Reasons for
incomplete or failed OC are provided. CTC
J. H. Bortz (*)
LSG Imaging, Los Angeles, CA, USA
images are presented to illustrate some of these
reasons.
The following abbreviations are used in this
chapter.
• CCE: colon capsule endoscopy
• CRC: colorectal cancer
• DCBE: double contrast barium enema
• ECFs: extracolonic ndings
• ESGAR: European Society of Gastrointestinal
and Abdominal Radiology
• ESGE: European Society of Gastrointestinal
Endoscopy
• 3D: three-dimensional
• 2D: two-dimensional
• OC: optical colonoscopy
20.2 Colon Capsule Endoscopy (CCE)
Spada et al. [11] compared CCE and CTC in
patients with incomplete colonoscopy (IC). They
concluded that the two tools were of comparable
efcacy in terms of colon evaluation. Patients
who had undergone an OC and a CCE study indicated they preferred the latter [12]. A disadvantage of CCE is its battery life; video compression
could be a possible solution [13]. It is not feasible
to visualise organs and structures outside of the
colon in a CCE procedure. In terms of the respective average costs of CCE and CTC, the latter is
almost half that of CCE [14].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. H. Bortz et al. (eds.), CT Colonography for Radiographers,
https://doi.org/10.1007/978-3-031-30866-6_20
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20.3 Reasons forIncomplete
andFailed Optical
Colonoscopy
Reasons for incomplete or failed OC: operator
factors (e.g., endoscopists’ experience, caecal
intubation rate); patient factors (e.g., inadequate
bowel preparation, low body mass index); technical factors (e.g., diverticular disease, previous
surgery, previous radiotherapy in the pelvis
region) [9]; and anatomic factors. The latter
include tortuous or exceedingly long colon, looping of the colon especially in the sigmoid colon,
acute exure angle, and xation of colon loops
[9]. According to CTC literature, predictive factors on incomplete OC include total colon length,
number of exures, and advanced diverticular
disease [15, 16].
20.4 Advantages ofCTC
CTC is a fast, safe, socially distanced, minimally
invasive, low-dose examination which does not
require sedation [10, 17–21]. A CT scanner with
special software produces a reconstruction of the
carbon dioxide (CO2) lled colon. The software
produces two-dimensional (2D) images and
three-dimensional (3D) endoluminal views [18,
20, 21]. The software allows video viewing of a
3D virtual y-through of the colon from the rec-
tum to the caecum (retrograde navigation) and
back to the rectum (antegrade navigation). This
process takes approximately 2 min to perform;
one is able to stop the y-through at any stage for
careful scrutiny of any part of the colon that may
have a lesion [22]. In a routine supine and prone
CTC examination, a virtual y-through is performed four times.
The software also has a tool to produce a 3D
surface-rendered image (colon-map) of the
entire colon as shown in Fig.20.1a–c. The software generates an automated centreline for
endoluminal navigation. The automated centreline may be used for invivo length measurements. Figure 20.1d, e shows an automated
green line.
Redundancy of colon segments is a reason for
incomplete or failed OC [9, 15, 23]. Examples of
redundant segments of the colon at CTC are presented in Fig.20.1f, g. Figure20.1h shows redun-
dancy and an acute exural fold. Examples of
colon pathologies seen at CTC are presented in
Fig.20.1i–n.
Another advantage of a CTC is that a scan
covers the entire abdomen from the lung bases to
below the pelvis allowing for visualisation of
extracolonic organs and structures [24–28]. It is
not feasible to visualise organs and structures
outside of the colon in CCE and OC.Examples of
extracolonic ndings (ECFs) at CTC are presented in Fig.20.2a–f.
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293
cd
Fig. 20.1 (a) 3D surface-rendered image (colon-map)
showing sigmoid in a normal appearing colon. (b) An
oblique colon-map showing an ischaemic stricture (black
arrow). (c) Colon-map showing extensive diverticular dis-
ease involving the sigmoid and distal descending colon
(white circle). The rest of the colon is normal. (d) Normal
colon-map with automated centreline (green line) which
allows for measurement of length of the colon.
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J. H. Bortz
Fig. 20.1
the caecum indicates the site of a lesion observed in the
CTC y-through. (f) Grossly redundant transverse colon
(TC) with loops lying low in the pelvis. (g) Colon-map
showing a grossly redundant sigmoid colon (SC), and nor-
(e) Colon-map with green centreline. Red dot in
mal descending colon (DC), transverse colon (TC), and
ascending colon (white arrow). R rectum. (h) Colon-map
showing an acute exural fold (white arrow) and
redundancy.
mn
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ij
kl
295
Fig. 20.1
patient slightly oblique. Red arrow indicates stricture in
sigmoid colon due to previous attacks of diverticulitis. R
rectum, TC transverse colon, AC ascending colon, C caecum. (j) 2D left lateral decubitus view of patient in (i).
Sigmoid colon (red square). Thickening of colon with multiple diverticula throughout the sigmoid colon (red arrows).
(i) Colon-map of left lateral decubitus with the
Yellow arrow=presence of an intramural sinus tract which
indicates a linear collection of uid within the thickened
wall. (k) 3D of annular carcinoma in the sigmoid colon. (l)
2D axial view of patient in (k). Red hexagon=‘apple-core’
appearance of underlying cancer. (m) 3D showing mass at
CTC. (n) 2D coronal view of patient in (m). A=enlarged
mesenteric nodes. B=mass in jejunum
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Fig. 20.2 (a) Axial 2D view showing 5.3cm abdominal
aortic aneurysm. Scattered calcication in wall of aorta
(red arrows). The aneurysm constitutes an urgent referral
for a stenting procedure. (b) 2D sagittal view showing
large mass (red arrows) anterior to spleen and left kidney
with partial calcication of wall. Adenocarcinoma of the
pancreas proven on biopsy. (c) 2D axial view showing
cyst lower pole of right kidney. An incidental nding of no
clinical importance. (d) 2D axial view showing multiple
gallstones containing air (red square). There is no evidence of cholecystitis. (e) 2D axial view showing umbilical hernia (green and white arrows) lled with fat. An
incidental nding. (f) 2D axial view showing destruction
of posterior margin of the vertebral body (red circle). An
important nding indicating metastasis
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20.5 Incomplete Optical
Colonoscopy: Role
ofRadiology Imaging
and uid. A patient is given 250mL of 2% barium and 50mL of non-ionic iohexol (Omnipaque)
to drink when fully recovered after incomplete
OC. On average, it takes 3–4 h for the tagging
Literature underscores that CTC should be performed on patients with incomplete OC [9, 29–
33]. The percentage of incomplete OC studies is
reported to range from 0.4 to 15% [34, 35]. The
ESGE and ESGAR 2020 guideline includes CTC
in incomplete OC; DCBE as an imaging alternative to colonoscopy is not included [10]. The
guideline does not list DCBE as an imaging alternative to colonoscopy. The diagnostic performance
of CTC in symptomatic and asymptomatic patients
for the detection of CRC and large polyps is similar to OC and superior to barium enema thus the
latter examination should be discouraged [3].
ESGE and ESGAR [10] recommend a same
day or next day CTC for incomplete OC.A same
day CTC requires tagging of any residual stool
agents to reach the colon. Before insufation of
CO2 commences a pre-procedure low-dose CT
scan is performed to exclude the possibility of an
OC caused colonic perforation [10]. Examples of
colonic perforation in a patient referred for CTC
following an incomplete OC are shown in
Fig.20.3a, b.
If free air is visualised, a CTC is not performed: the referring gastroenterologist is
informed of this complication. If a CTC is to
be performed the next day, then the patient is
kept on uids only overnight and the taggingagents are taken orally that night. If free
air has been excluded on the pre-procedure CT
scan, a CTC examination is performed the next
day.
ab
Fig. 20.3 (a) 2D CTC coronal image shows extensive
gas (red arrows) extending along the sigmoid mesentery
and superiorly along the retroperitoneal fascial planes.
Incomplete optical colonoscopy earlier on the same day
was difcult and included sigmoid polypectomy. (b) 2D
sagittal view of patient in (a). Red arrows show extraluminal gas extending along the sigmoid mesentery and superiorly along the retroperitoneal fascial planes
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