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Comparative Evaluation of the Fecal-Tagging Quality in CT Colonography

Posted Oct 31, 2009 Updated Apr 7, 2023
By Koichi Nagata MD PhD , An Kumar Singh MD , Minal Jagtiani Sangwaiya MBBS MRCS MD , Janne Näppi PhD , Michael E. Zalis MD , Wenli Cai PhD , Hiroyuki Yoshida PhD
9 min read

Rationale and Objectives

The purpose of this evaluation was to compare the tagging quality of a barium-based regimen with that of iodine-based regimens for computed tomographic (CT) colonography.

Materials and Methods

Tagging quality was assessed retrospectively in three different types of fecal-tagging CT colonographic cases: 24 barium-based cases, 22 nonionic iodine-based cases, and 24 ionic iodine-based cases. For the purpose of evaluation, the large intestine was divided into six segments, and the tagging homogeneity of a total of 420 segments (70 patients) was graded by three blinded readers from 0 (heterogeneous) to 4 (homogeneous).

Results

For barium-based cases, the average score for the three readers was 2.4, whereas it was 3.4 for nonionic iodine and 3.6 for ionic iodine. The percentages of segments that were assigned scores of 4 (excellent tagging [100%]) were 11.6%, 61.9%, and 72.9% for the barium-based, nonionic iodine-based, and ionic iodine-based regimens, respectively. The homogeneity scores of iodine-based fecal-tagging regimens were significantly higher than those of the barium-based fecal-tagging regimen ( P < .001). The CT attenuation values of tagging in the cases were also assessed: the minimum and maximum values were significantly higher for the iodine-based regimens than for the barium-based regimen ( P < .001).

Conclusions

The iodine-based fecal-tagging regimens provide significantly greater homogeneity in oral-tagging fecal material than the barium-based fecal-tagging regimen. Iodine-based fecal-tagging regimens can provide an appropriate method for use in nonlaxative or minimum-laxative CT colonography.

Thorough bowel cleansing and adequate distension are necessary for successful computed tomographic (CT) colonographic (CTC) examinations. However, patients often perceive these two procedures as the most unpleasant aspects of CTC examinations . Fecal tagging by orally administered positive-contrast agents can be used for the effective differentiation of fecal material from polyps by enhancing residual stool and fluid, thus increasing the specificity of polyps . For distinguishing tagged fecal contents reliably from soft tissue lesions in the large intestine, the tagging of fecal material should be homogeneous . In general, three contrast agents are suitable for fecal-tagging CT colonography: barium sulfate, ionic iodine, and nonionic iodine . However, to our knowledge, the quality of tagging using these three contrast agents has never been compared in fecal-tagging CT colonography.

In this study, we retrospectively compared the quality of tagging using three contrast agents with either nonlaxative or minimum-laxative regimens. The quality of tagging was assessed in terms of homogeneity and CT attenuation values (in Hounsfield units [HU]) of the residual fecal material. We also evaluated the observed presence of residual stool and fluid for each regimen.

Materials and methods

Study Group

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Fecal-Tagging Regimens

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CT Colonography

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Evaluation of Residual Stool and Fluid and Tagging Quality

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Figure 1, Examples of the scoring of the presence of residual stool and fluid and their tagging quality. (a) In the transverse colon (circle) , residual stool and fluid were scored 3 (large stool) and 0 (no fluid), respectively. Tagging homogeneity was scored 1 (poor tagging) by two of three readers. In the descending colon (arrow) , residual stool and fluid were scored 3 and 0, respectively. Tagging homogeneity was scored 2 (inhomogeneous tagging) by two of three readers. (b) In the cecum (circle) , sigmoid colon (arrow) , and rectum (broken arrow) , residual stool were scored 3 (large stool), 3, and 2 (moderate-size stool), respectively. Scores for residual fluid were all 0 (no fluid). Tagging homogeneities were all scored 4 (excellent tagging) by all three readers.

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Statistical Analysis

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Results

Bowel Preparation

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Figure 2, Percentages of the residual stool scores in all colon segments for the barium group, nonionic iodine group, and ionic iodine group. Scoring: 0=no stool, 1=small stool (maximum diameter<6mm), 2 = moderate-size stool (6–9mm), 3 = large stool (≥10mm).

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Figure 3, Percentages of the residual fluid scores in all colon segments for the barium group, nonionic iodine group, and ionic iodine group. Scoring: 0=no fluid, 1=minimal fluid (depth or width<6mm), 2 = moderate fluid (depth or width≥6mm, depth<50% of the luminal circumference), and 3 = substantial fluid (depth≥50% of the luminal circumference).

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Tagging Quality

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Figure 4, Tagging homogeneity scores of each reader and the average tagging homogeneity scores for the barium group, nonionic iodine group, and ionic iodine group. Distal colon=rectum, sigmoid colon, and descending colon. Proximal colon=transverse colon, ascending colon, and cecum. Scoring: 0=no tagging (tagging<25%), 1 = poor tagging (25% ≤ tagging<50%), 2 = inhomogeneous tagging (50% ≤ tagging<75%), 3 = good tagging (75% ≤ tagging<100%), and 4 = excellent tagging (100%).

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Figure 5, Maximum attenuation values of each reader and the average maximum attenuation values for the barium group, nonionic iodine group, and ionic iodine group. Distal colon=rectum, sigmoid colon, and descending colon. Proximal colon=transverse colon, ascending colon, and cecum. HU, Hounsfield units.

Figure 6, Minimum attenuation values of each reader and the average minimum attenuation values for the barium group, nonionic iodine group, and ionic iodine group. Distal colon=rectum, sigmoid colon, and descending colon. Proximal colon=transverse colon, ascending colon, and cecum. HU, Hounsfield units.

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Discussion

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Acknowledgments

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Academic Radiology, Volume 16, Issue 11
Journals General Radiology
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