Journal of Radiology Nursing xxx (2020) 1e9

Contents lists available at ScienceDirect

Journal of Radiology Nursing

journal homepage: www.sciencedirect.com/journal/
journal-of-radiology-nursing

CT Colonography for Colorectal Cancer Screening

Zina Ricci, MD *, Mariya Kobi, MD, Judy Yee, MD
Department of Radiology, Montefiore Medical Center, Bronx, NY

a b s t r a c t

Keywords: CT colonography (CTC), also known as “virtual colonoscopy,” is a minimally invasive complementary
CT colonography screening method to optical colonoscopy (OC) that is growing in its availability and utilization. As a
Colorectal cancer screening screening test, it is typically performed in outpatient radiology sites. Examinations are monitored by a
CT colonography bowel preparation
radiologist trained in its performance. CTC is selectively performed in a hospital setting for patients with
Fecal tagging
comorbidities that render them at a high risk for OC, such as cardiac disease or screening before organ
Fluid tagging
transplantation. In cases where OC is unsuccessful for at complete colonic inspection, CTC can be per-
formed the same day after OC or planned at a later date to evaluate the remainder of the colon. Can-
didates for CTC must be able to follow instructions and tolerate colonic insufflation. Patients who have
fecal incontinence or significant rectal prolapse are not candidates for CTC because of limited ability to
maintain colonic distension. Finally, strict adherence to the recommended colonic preparation before
CTC is critical to the examination's success.
© 2020 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.

Introduction screening with either a high-sensitivity stool-based test or a direct

Excluding skin cancer, colorectal cancer is the third most
commonly diagnosed cancer each in men and women in the United
States and is the second overall leading cause of cancer death.
Colorectal cancer affects all racial groups but has the highest inci-
dence and mortality rate among African Americans, American In-
dians, and Alaska Natives. Lifestyle risk factors associated with a
higher colorectal cancer risk include cigarette smoking, obesity,
physical inactivity, high dietary intake of alcohol and red meat, and
low dietary intake of fruits, vegetables, fiber, and calcium. Patients
with hereditary polyposis syndromes, family history of colorectal
cancer, inflammatory bowel disease (ulcerative colitis and Crohn's
disease), type 2 diabetes or a history of abdominopelvic radiation
are at higher risk for colorectal cancer (Wolf et al., 2018).
CTC is a nationally recognized colorectal cancer screening test
supported by the American Cancer Society (ACS) and the United States
Preventive Services Task Force (Bibbins-Domingo et al., 2016; Wolf
et al., 2018). The ACS recommends that patients aged 45 years and
older with an average risk of colorectal cancer undergo regular
No financial assistance was obtained.
Not presented at a meeting.
Conflict of interest: The authors have no conflict of interest.
* Corresponding author: Zina Ricci, Montefiore Medical Center, 111 East 210th
Street, Bronx, NY 10467.
E-mail address: zricci@montefiore.org (Z. Ricci).
visual examination with OC or CTC depending on patient preference
and test availability. They recommend that all patients with positive
result on CTC should be followed up with timely colonoscopy in the
event of potential biopsy. Stool-based tests include annual fecal
immunochemical test, guaiac-based fecal occult blood test, and mul-
titarget stool DNA test every 3 years. OC screening is recommended
every 10 years and CTC screening every 5 years (Wolf et al., 2018).
OC is the reference standard test for screening and has the
unique advantage of same-day tissue sampling of detected colonic
pathology. However, it requires sedation and caries a low risk of
colonic perforation (4 per 10,000 colonoscopies) and bleeding (8
per 10,000 colonoscopies), both of which are more common when
polypectomy is performed. CTC is a minimally invasive alternative
to OC that has the advantage of not requiring sedation, not causing
bleeding, and carrying a lower risk of colonic perforation (2 per
10,000 exams) (Wolf et al., 2018). It does not carry the low risk of
infection of OC incurred by an improperly cleansed colonoscope.
However, it precludes tissue sampling and requires subsequent OC
if colonic pathology is detected. CTC is readily used to complete
colonic screening after incomplete OC and is the only direct visu-
alization screening alternative in patients with complex medical
disease that places them at high risk for sedation or who have a
higher risk of procedural bleeding or perforation. OC and CTC have
equivalent sensitivity for colorectal cancer detection (96% for CTC;
95% for OC) (Pickhardt et al., 2011).
The goal of visual screening with OC or CTC is to detect and
remove polyps and detect colon cancer at an earlier stage. Although

https://doi.org/10.1016/j.jradnu.2020.04.005
1546-0843/$36.00/© 2020 Association for Radiologic & Imaging Nursing. Published by Elsevier Inc. All rights reserved.

Please cite this article in press as: Ricci Z et al., CT Colonography for Colorectal Cancer Screening, Journal of Radiology Nursing, https://doi.org/
10.1016/j.jradnu.2020.04.005
2 Z. Ricci et al. / Journal of Radiology Nursing xxx (2020) 1e9
most polyps are benign, those which are of the adenomatous va-
riety are precursors of most colon cancers via the well-established
“adenoma-carcinoma” sequence. Therefore, the goal is to remove
adenomatous polyps before they become cancerous.
Patient preparation (colonic preparation)
Colonic preparation for CTC is based on three components: di-
etary restriction, fecal and fluid tagging, and colonic catharsis. The
diagnostic success of CTC depends on adherence to and adequacy of
colonic preparation. Fecal and fluid tagging is unique to CTC and is
not necessary for optical colonoscopy preparation. Our bowel
preparation instructions are presented in Tables 1 and 2.
Dietary Restriction
A 24-hour low-fiber diet starts 2 days before CTC followed by a
clear-liquid diet 1 day before CTC. A high-fiber diet consists of
varying amounts of fruits, vegetables, and grains, which, although it
improves regularity of bowel movements, adds residue, and bulk in
the colon that is more difficult to eliminate when cleansing is
desired. Hence, a low-fiber diet aids subsequent cathartic colonic
cleansing (Vanhauwaert et al., 2015) and also improves stool
tagging with oral contrast (Liedenbaum et al., 2010). The patient
must be NPO after midnight on the day before the examination.
Drinking 6-8 glasses of water is required on the day before CTC to
prevent dehydration caused by cathartic fluid shifts and to decrease
cathartic gastrointestinal side-effects such as nausea, bloating,
vomiting, and abdominal pain (Lichtenstein et al., 2007).
Fecal and Fluid Tagging
The goal of tagging is to allow oral contrast to be passively
incorporated into retained stool and fluid, resulting in a higher CT
density. Stool is tagged with 450 ml of dilute barium sulfate (2%
weight/volume; Readi-Cat2 (R)), which is ingested in the morning
the day before CTC. Stool tagging prevents mistaking retained solid
stool fragments for polyps by rendering them hyperdense
(Figure 1). The contrast also coats the surface of some polyps
improving their conspicuity and detection (Kim et al., 2014;
Table 1
CTC bowel preparation with magnesium citrate
2 days before CTC: follow a low-fiber diet
1 day before CTC:
8 AM Drink Readi-Cat2 (R) (barium sulfate oral
suspension, Bracco)- 450 mL
Breakfast Hara, Blevins, Clear-liquid diet; drink 2 glasses of water in the
& Chen, 2011 morning
9 AM Bisacodyl 4 tablets (5 mg each) with 8 oz glass of
water
11 AM Drink 1 bottle (10 0z) of chilled magnesium citrate
oral solution
Lunch Clear-liquid diet; drink at least 4 glasses of water in
the afternoon
Dinner Clear-liquid diet; drink at least 2 glasses of water in
the evening
6 PM Drink 1 bottle (10 oz) of chilled magnesium citrate
oral solution
10 PM Drink Gastrografin (R) diatrizoate meglumine and
diatrizoate sodium solution USP, Bracco (30 mL)
diluted in 8 oz water
Midnight Drink more water until midnight but remain NPO
after midnight
CTC ¼ CT colonography.
The day of CTC 7 AM: Take your regular prescription medications with a small
amount of water (take your other medications 2 hours before or 2 hours after taking
the laxative).
Please cite this article in press as: Ricci Z et al., CT Colonography for Colorectal Cancer Screening, Journal of Radiology Nursing, https://doi.org/
10.1016/j.jradnu.2020.04.005
Table 2
CTC bowel preparation with polyethylene glycol
2 days before CTC: follow a low-fiber diet
1 day before CTC:
8 AM Drink Readi-Cat2 (R) (barium sulfate oral suspension, Bracco)-
450 mL
Breakfast Clear-liquid diet; drink 2 glasses of water in the morning
12 PM Start the prepared bottle of chilled GoLYTELY (finish by 5 PM)
Lunch Clear-liquid diet; drink at least 4 glasses of water in the
afternoon
Dinner Clear-liquid diet; drink at least 2 glasses of water in the evening
10 PM Drink Gastrografin (R) (30 mL) diluted in 8 oz water
Midnight Drink more water until midnight but remain NPO after
midnight
CTC ¼ CT colonography.
The day of CTC 7 AM: Take your regular prescription medications with a small
amount of water (take your other medications 2 hours before the laxative).
O’Connor et al., 2006). Fluid is tagged with 30 mL of diatrizoate
meglumine and diatrizoate sodium solution (Gastrografin (R),
Bracco), an ionic water-soluble contrast agent, diluted in 8 oz of
water. Iohexol (Omnipaque, GE Healthcare), a nonionic contrast
agent, is an alternative agent (Johnson et al., 2016). Fluid tagging
agents have a cathartic effect helping to decrease any retained stool
and can unmask colonic lesions submerged in dependent fluid
pools by rendering the fluid hyperdense (Figure 2). When patients
are referred for same-day CTC after incomplete colonoscopy, fluid
tagging is achieved by administering 30 ml of Gastrografin (R)
diluted in 8 oz of water 2 hours before the CTC (Chang et al., 2011).
Colonic Catharsis
Bowel catharsis can be achieved with a variety of orally ingested
laxatives. Magnesium citrate and sodium phosphate are “dry-
preparation” saline cathartic agents that cause less residual colonic
fluid and are ideal for CTC because unlike in OC, it is difficult to
remove fluid from the colon during CTC. Polyethylene glycol (PEG)
is an alternative “wet-preparation” agent that causes more residual
colonic fluid and is a second-choice agent for CTC (Macari et al.,
2001). PEG has the unique advantage of not causing electrolyte
disturbance that may occur with the dry agents.
Magnesium citrate is a saline cathartic with osmotic action that
increases intraluminal fluid and induces colonic peristalsis. One
bottle (10 oz) is ingested the morning before CTC and a second
bottle in the evening before CTC. It is administered in conjunction
with the oral laxative bisacodyl (Neri et al., 2013). Magnesium cit-
rate is the preferred dry-preparation agent although it is used with
caution in patients with renal impairment, heart disease, patients
on diuretics, and in elderly or debilitated patients (Adamcewicz,
Bearelly, & Porat, 2011; ACReSAReSCBT-MR Practice parameter
for the performance of computed tomography (CT) colonography
in adults, 2019) because it may cause electrolyte imbalance.
PEG is a water-soluble osmotically active polymer that causes
diarrhea and may be administered as a 2 L volume dose (Scalise
et al., 2016). It can be given safely to patients with renal dysfunc-
tion, hepatic failure, or congestive heart failure (Lee et al., 2015).
Indications for CTC
The accepted clinical indications for CTC are listed in Table 3
(ACReSAReSCBT-MR Practice parameter for the performance of
computed tomography (CT) colonography in adults, 2019). Most
patients referred for CTC in our practice are those who have un-
dergone incomplete colonoscopy or those who have a contraindi-
cation to optical colonoscopy. The incomplete colonoscopy rate is
reported between 4% and 25% and increases with age up to a rate of
 Z. Ricci et al. / Journal of Radiology Nursing xxx (2020) 1e9 3

Figure 1. Retained stool fragment. (A) Stool fragment (black arrow) mimicking a polypoid lesion on the endoluminal view. Corresponding axial 2D images with colon (B and C) soft
tissue windows reveal the structure to be homogeneously hyperdense (white arrow) c/w tagged stool. The irregular shape on 3D images also supports the diagnosis of a stool
fragment.

22e33%. Reasons for incomplete colonoscopy include failure to
reach the cecum, poor bowl preparation, colonic redundancy or
tortuosity (most often sigmoid colon), severe diverticular disease,
acute angle flexures or fixated loops, adhesions, colonic spasm,
female sex or older age, a low body mass index, and colonic
obstruction due to malignancy or benign stenosis (Brahmania et al.,
2012).
CTC should not be performed in patients with active bowel disease
such as acute colitis, acute diarrhea, acute diverticulitis, recent colo-
rectal surgery, suspected colonic perforation or small bowel
obstruction. Although many broad-necked hernias do not interfere
with CTC, patients with symptomatic colon-containing abdominal
wall hernias should not undergo CTC. Patients with recent endoscopic
biopsy or polypectomy/mucosectomy during colonoscopy cannot
undergo CTC until at least 1 week later. CTC is contraindicated in
pregnancy or potential pregnancy, in routine follow-up of
inflammatory bowel disease, in patients with hereditary polyposis or
nonpolyposis cancer syndromes, and in patients with anal canal
disease (ACReSAReSCBT-MR Practice parameter for the performance
of computed tomography (CT) colonography in adults, 2019).
CTC technique
Before beginning the examination, the performing radiologist,
technologist, or physician's assistant needs to confirm that the
patient completed all aspects of colonic preparation. The patient
should describe yellow or mustard-colored watery colonic output
only. If they are still passing stool or brown fluid, the examination
needs to be rescheduled the next day after an additional prep or at
another date after a new prep is completed.
The patient is directed to use the restroom just before the ex-
amination to evacuate any residual colonic secretions. After

Figure 2. Axial 2D images in the right decubitus position of a patient who failed to ingest Gastrografin before examination with colon (A and B) soft tissue windowing show the low
attenuation-dependent fluid level (white arrow) in the ascending colon that lacks fluid tagging. Underlying colonic pathology cannot be excluded in this segment. (C) Axial 2D
images in another patient who received Gastrografin to tag the colonic fluid in the left decubitus position shows a 7 mm polypoid defect (white arrowhead) in the medial ascending
colon wall outlined by the fluid level (white arrow); it is more conspicuous with soft tissue windowing (D). (E) Corresponding endoluminal 3D view shows a subtle flat polypoid
defect (black arrow). A tubular adenoma was removed on subsequent colonoscopy.

Please cite this article in press as: Ricci Z et al., CT Colonography for Colorectal Cancer Screening, Journal of Radiology Nursing, https://doi.org/
10.1016/j.jradnu.2020.04.005
4 Z. Ricci et al. / Journal of Radiology Nursing xxx (2020) 1e9
Table 3
Clinical indications for CTC*
 Screening examination of patients at average or moderate risk for developing
colorectal carcinoma
 Surveillance examination of patients with a history of colonic neoplasm
 Diagnostic examination of symptomatic patients who have abdominal pain,
anemia, weight loss, or another relevant gastrointestinal symptom
 Follow-up examination after incomplete screening, surveillance, or diagnostic
colonoscopy
 Follow-up examination for characterization of colorectal lesions
indeterminate on colonoscopy
 Examination of patients at increased risk for complications of colonoscopy
(advance age, anticoagulant usage, sedation risk)
 Examination of patients with a colonic stoma
 Exam before surgery for colorectal cancer to better localize tumor and screen
for synchronous lesions
CTC ¼ CT colonography.
*
ACR-SAR-SCBT-MR Practice parameter 2019.
removing underwear and putting on a gown, the patient is placed
feet first on the CT scan table and right side down with their knees
bent 90 . Visual inspection of the anal area and a preprocedural
rectal examination are advised to avoid bleeding or trauma if un-
derlying anorectal pathology exists (Yee, 2008). Multiple pieces of
tape are prepared, and the standard CTC catheter (PROTOCO2L
Administration Set, E-Z-EM, Inc, Bracco) is attached to an electronic
CO2 insufflator (E-Z-EM Bracco ProtoCO2L 6400 insufflator)
(Figure 3). The thin flexible catheter tip is lubricated and placed into
the rectum to the demarcated blue indicator line. Insertion of the
rectal tube is performed by the radiologist or a trained radiology
technologist, nurse, or physician assistant. The catheter rectal
balloon can be inflated with the included syringe. Tape is used to
surround the tube and adhere it to the buttocks and to pull the
buttocks together to prevent tube dislodgement during the
examination.
Automated insufflation of CO2 is performed with an electronic
insufflator that continually monitors colonic pressure at the rectal
catheter tip and records the total volume administered using a fixed
flow rate of 3 L per minute. The adjustable pressure setting should
be set at 20e25 mm Hg, which is well tolerated by most patients
and can be lowered if the patient reports discomfort. The first 1.5 to
2 L of CO2 administered should be with the patient remaining in the
right side down position to optimize rectosigmoid and descending
colonic distention. Then, the patient should be turned supine to
allow another 1e2 L of CO2 to fill the transverse and right colon
(Yee, 2008).
Figure 3. (A) A standard CTC catheter (PROTOCO2L Administration Set, E-Z-EM, Inc, Bracco) has a soft flexible tip (black arrowhead) shown with the balloon inflated, a small port for
a syringe to inflate the balloon (black arrow), a retention bag (white arrow), and an insertion site (white arrowhead) that is attached to the CO2 insufflator. (B) The PROTOCO2L
colonic insufflator has a tubing with a metal attachment (black arrow) that is linked at sealed to the CO2 tank (not shown).
Please cite this article in press as: Ricci Z et al., CT Colonography for Colorectal Cancer Screening, Journal of Radiology Nursing, https://doi.org/
10.1016/j.jradnu.2020.04.005
If insufflation ceases and the volume administered stops rising,
it is important to exclude the possibility that the tubing is kinked or
that the rectal tube dislodged. Another common cause of insuffla-
tion failure is the presence of fluid pockets in the colon or the
tubing, in which case, shifting the patient's position or emptying
fluid into the catheter effluent collection container to clear the tube
can be helpful. Occasionally, if a large amount of fluid builds up in
the tube, the tube should be removed and a new one placed.
Another cause of insufflation failure is bowel kinking or blockage,
which may completely prevent insufflation.
Once sufficient colonic distension has been achieved, a CT scout
view of the abdomen and pelvis in the supine position is obtained
(Figure 4). Assessment of colonic distension is based on the patient
reporting a sense of fullness or discomfort, physical examination
demonstrating mild abdominal distention, a volume of about 3e4 L
has been administered or if the intracolonic pressure remains
elevated to a level of up to 40 mm Hg without decreasing. The
volume required for full colonic distension varies among patients
from 3 to 10 L (Pickhardt, 2007), with most patients requiring a
minimum of 4 L in our experience. Based on a volumetric analysis,
the mean retained gas volume of diagnostically adequate CTC ex-
aminations was found to be 3.5 L (McLaughlin, Murphy, & Crush,
2013). If a patient has had prior colonic resection, the insufflated
volume required will be less. If the patient has an incompetent
ileocecal valve or has poor anorectal sphincter control leading to
gas leakage, the insufflated volume will be much greater. If the
scout reveals adequate colonic distension (Figure 5), the first set of
axial images is obtained in the supine position. The images are
immediately reviewed to determine if colonic distension has been
achieved, and if not, repeat coaching of the patient is attempted.
Then, the examination is repeated in a second position, which
improves the chance to adequately distend all colonic segments and
to shift residual fluid levels that may obscure segments of colon
(Yee et al., 2003). The second examination is typically performed in
the right decubitus position, which has been found to achieve the
best overall all colonic volume (Pickhardt et al., 2014; Takahashi
et al., 2019). The rectal balloon is deflated in the second scanning
position to prevent a rectal lesion from being obscured. Finally,
these two data sets are quickly reviewed by the radiologist to
ensure that all segments of the colon have been adequately dis-
tended in at least one position and to exclude any signs of perfo-
ration before examination termination. If necessary, a third
complete or focused data set can be planned after further insuf-
flation in the left decubitus position if needed. Morbidly obese
patients are more amenable to being scanned in the right and left
 Z. Ricci et al. / Journal of Radiology Nursing xxx (2020) 1e9 5

Figure 4. A CT scan scout view obtained in the supine position after colonic insuf-
flation with 4 L CO2 and the patient reporting feeling distended. The examination show
demonstrates sufficient colonic distension and axial 2D images could be obtained
immediately afterward. Note the rectal tube in place (white arrow).
Figure 6. A 3D volume-rendered image generated by dedicated CTC software program
created from the set of axial 2D images obtained after colonic insufflation in the supine
position. The red and yellow line reflects a computer-generated centerline that will
become the navigation flight path when 3D images of the colonic lumen are reviewed.

Figure 5. (A, B) Initial set of images in the supine position revealed that the patient failed to maintain colonic distension. (A) 3D endoluminal view in the supine position shows a
smooth area of narrowing of the descending colon (black arrow) which precludes visualization of the colonic lumen mucosa in this segment. (B) Corresponding coronal 2D view
shows the segment of descending colon which is inadequately distended (black arrow). (C, D) After further colonic insufflation and coaching of the patient, subsequent images in the
right decubitus position show adequate colonic distension and of the descending colon (white arrow). Note the normal appearance of distended semilunar colonic folds of the colon
on the 3D image.

Please cite this article in press as: Ricci Z et al., CT Colonography for Colorectal Cancer Screening, Journal of Radiology Nursing, https://doi.org/
10.1016/j.jradnu.2020.04.005
6 Z. Ricci et al. / Journal of Radiology Nursing xxx (2020) 1e9

lateral decubitus positioning, which removes pressure from the
anterior abdominal wall pannus.
When CTC is performed on the same day after incomplete co-
lonoscopy, a limited low-dose CT scan of the abdomen and pelvis
consisting of select axial scans spaced several centimeters apart
may be performed before rectal tube insertion to exclude any evi-
dence of pneumoperitoneum due to colonoscopic perforation. CTC
is typically postponed for at least 1 week after OC if biopsy was
performed.
Screening CTC is performed without intravenous contrast and
with low-dose multidetector CT technique with an average dose
length product at or lower than 3 mSv, which is a dose similar to
annual background radiation exposure (Yee & McFarland, 2018).
The radiation dose, however, needs to be increased in obese pa-
tients to maintain diagnostic image quality (McCollough et al.,
2006).
How CTC is interpreted
CTC is interpreted using a dedicated software program that
creates 3-dimensional volume-rendered images of the distended
colon (Figure 6). Two data sets are available, one for each position
the patient was scanned in (i.e., supine and right decubitus), which
may be analyzed separately but can also be viewed simultaneously
as needed for problem solving. The CTC viewer allows simultaneous
visualization of the 2D data in 3 planes (axial, coronal, and sagittal)
along with the 3D volume-rendered endoluminal data on a display
with 4 windows (Figure 7). The reader places a crosshair on a
colonic abnormality and can simultaneously localize and inspect
the potential lesion in other planes while comparing the 2D with
3D appearances. Extracolonic findings are interpreted from the
axial supine 2D data set with routine abdominal windows typically
after the colonic interpretation.
There are two primary methods of CTC interpretation: 2D and
3D review. When analyzing 2D data, the radiologist systematically
tracks magnified axial images of the distended colon from the
anorectum to the cecum. The display is periodically panned to
recenter the colonic segment of interest in the field of view. The
data are viewed with dedicated high-contrast colon windowing
(widths ranging from 1,400 to 1,500 and levels ranging from 200
to 400) that increases the conspicuity of polyps and colonic le-
sions that interface with the gas-filled colonic lumen. Multiplanar
reformats in the sagittal and coronal plane are readily available as
needed to aid tracking a tortuous colonic segment and for problem
solving of abnormalities seen on the axial images. Axial images are
also viewed using abdominal soft tissue windowing (width of 400
and levels ranging from 10 to 40) to characterize colonic lesions
based on their attenuation (Figure 8). When analyzing 3D data, the
radiologist systematically tracks the endoluminal images of the
colon, known as the “fly-through,” at a chosen navigation speed.

Figure 7. The typical screen available on CTC software allows simultaneous visualization of 3D endoluminal tracking (lower right) with coordinated 2D images in the coronal (upper
left), sagittal (upper right), and axial (lower right) planes. The visible crosshair can be readily moved to the area of interest. The purple arrow on 2D images is on the normal ileocecal
valve which has a typical inverted dimple appearance on 3D images (black arrow).

Please cite this article in press as: Ricci Z et al., CT Colonography for Colorectal Cancer Screening, Journal of Radiology Nursing, https://doi.org/
10.1016/j.jradnu.2020.04.005
 Z. Ricci et al. / Journal of Radiology Nursing xxx (2020) 1e9 7

Figure 8. A polypoid lesion in the ascending colon whose nature is revealed based on its attenuation. (A) Endoluminal 3D view shows a polypoid structure (black arrow) arising
from a fold. (B) Corresponding axial 2D image in right decubitus position shows the polypoid lesion (black arrow) arising from a fold (white arrowhead) and indenting the tagged
fluid level. (C) Corresponding axial 2D image with soft tissue windows confirms the fatty attenuation (black arrow) of the lesion, consistent with a benign lipoma.

Figure 9. A 62-year-old woman referred for screening CTC found to have a sigmoid polyp. (A) Endoluminal 3D view shows a 1 cm polyp (black arrow). (B) Corresponding 2D image
in right decubitus position with soft tissue windows confirms a polyp (white arrow) by revealing its central soft tissue core. It was fixed in position on supine images (not shown). Its
conspicuity is increased because its surface is coated with contrast. A tubular adenoma was removed on subsequent colonoscopy.

Figure 10. A 49-year-old woman referred for CTC after incomplete colonoscopy due to constricting sigmoid neoplasm. (A) Endoluminal 3D view of the sigmoid shows a nodular
irregular mass (black asterisk) constricting the lumen. (B) Corresponding axial 2D image shows the eccentric nodular soft tissue mass (black arrow) compressing the sigmoid lumen.
(C) Corresponding coronal 2D image shows the mass in its longitudinal plane and reveals its segmental annular constricting nature (white arrow) analogous to an “apple-core,” and
reveals some mildly enlarged lymph nodes in the sigmoid mesentery (white arrowheads). CTC was successful at visualizing the remainder of the colon and found no additional
pathology. The patient underwent left hemicolectomy revealing invasive sigmoid adenocarcinoma with 3/28 lymph nodes positive for tumor.

Please cite this article in press as: Ricci Z et al., CT Colonography for Colorectal Cancer Screening, Journal of Radiology Nursing, https://doi.org/
10.1016/j.jradnu.2020.04.005
8 Z. Ricci et al. / Journal of Radiology Nursing xxx (2020) 1e9

Figure 11. A 64-year-old man referred for CTC after incomplete colonoscopy due to a constricting rectosigmoid neoplasm. (A) 3D endoluminal view shows a lobulated irregular
sigmoid mass (black arrow). (B) Corresponding axial 2D image shows the sigmoid mass (black arrow) bulging into the superior rectal lumen (white asterisk). CTC was able to
visualize the remainder of the colon above the malignant stricture not seen on optical colonoscopy and found an additional lobulated polypoid mass (white arrow) in the
descending colon (C). The patient underwent left hemicolectomy and low anterior resection revealing invasive rectosigmoid moderate to poorly differentiated adenocarcinoma with
no nodal involvement. The additional descending colon mass was found to represent a tubulovillous adenoma with focal high-grade dysplasia.

Figure 12. A 69-year-old woman having high risk for optical colonoscopy because of anticoagulation therapy for antiphospholipid antibody syndrome was referred for CTC after a
positive Cologuard (R) and (Exact Sciences Corporation, Madison, WI) result. (A) 3D endoluminal view shows a large broad irregular sessile polypoid lesion in the ascending colon
(black arrow). (B) Corresponding axial 2D image in the left decubitus position shows the carpet-like growth pattern of this lesion (black arrowheads) spanning the lateral margin of
the ascending colon. (C) Axial 2D image in the right decubitus position with soft tissue windowing shows the lesion (white arrowhead) outlined by the dependent tagged fluid level.
Subsequent colonoscopy was performed and biopsy revealed a large benign tubulovillous adenoma. The patient underwent right partial colectomy.

Four fly-throughs are performed, which includes retrograde
tracking from the anorectum to the cecum and subsequent anter-
ograde tracking from the cecum to the anorectum in each position
scanned. It is necessary to view the data in both directions because
a lesion may hide behind a fold and only be visible in one direction
(Yee, 2008). The method of interpretation is based on the radiol-
ogist's preference and has been shown to have minimal effect on
CTC diagnostic performance.
Case examples of colorectal pathology on CTC
The main screening target of CTC are polyps, including benign
and premalignant polyps, which are indistinguishable on CTC. A
polyp appears as a round or ovoid soft tissue structure that can be
sessile (Figure 9) or pedunculated and is often easily visualized on
3D images where they have a classic protuberant appearance. Some
polyps are rendered more conspicuous on 2D images when their
surface is coated with a thin rim of contrast alerting the radiologist
to their presence. In contrast, colonic carcinoma typically appears as
an irregular nodular luminal mass and may cause circumferential
luminal narrowing (apple-core appearance) (Figure 10). Three-
dimensional images readily depict an irregular protuberant struc-
ture that often narrows the lumen. Strictured segments can only be
assessed on 2D images because luminal distension is not sufficient
to visualize the colonic mucosal surface on 3D images. In addition to
detecting focal colonic neoplasm, CTC is able to detect additional
coexisting colonic lesions (synchronous cancer) or polyps
(Figure 11), which may harbor malignancy or be premalignant in
nature, guiding surgical management. CTC can also detect a set of
less-common colonic lesions known as “carpet lesions” (Pickhardt
et al., 2014), which typically measure at least 3 cm and have a
unique broad-based flat shape with minimally raised edges and
typically located in the rectum or cecum (Figure 12). Although they
are usually benign, they can harbor aggressive histologic features
and less often be malignant. Therefore, they require surgical
management.
Conclusion
CTC is becoming progressively more available and is now
considered a reliable visual screening tool for colorectal cancer. It
matches OC in its ability to detect both colonic malignancy and
precursor lesions of malignancy. It is critical in completing
screening of those patients who had incomplete OC and is vital in
giving opportunity to screen those who have any medical condition
that precludes them from or places them at high risk for sedation
needed for OC. It also serves as an alternative screening examina-
tion to OC based on patient preference. A key advantage of CTC is its
minimal and lower risk of colonic perforation than OC.

Please cite this article in press as: Ricci Z et al., CT Colonography for Colorectal Cancer Screening, Journal of Radiology Nursing, https://doi.org/
10.1016/j.jradnu.2020.04.005
 Z. Ricci et al. / Journal of Radiology Nursing xxx (2020) 1e9
The success of CTC rests on many factors that involve both patient
participation and performing staff skill. Patients must strictly follow
CTC colonic preparation including dietary restriction, fecal and fluid
tagging, and colonic catharsis and must be able to tolerate and
maintain colonic insufflation for the examination duration. Per-
forming staff must be trained in CTC performance, maintain appro-
priate technical parameters, and understand how to optimize
examination performance. Performing staff should maintain a pro-
fessional and supportive environment for patients undergoing CTC to
improve the patient's overall experience and comfort, which is vital
to examination success. Finally, interpreting radiologists must be
specifically trained in CTC interpretation and be able to analyze both
2D and 3D data sets aimed to detect significant colonic pathology.
References
Adamcewicz, M., Bearelly, D., Porat, G., et al. (2011). Mechanism of action and
toxicities of purgatives used for colonoscopy preparation. Expert Opinion on
Drug Metabolism & Toxicology, 7, 89-101.
American College of Radiology. (2019) ACReSAReSCBT-MR Practice parameter for
the performance of computed tomography (CT) colonography in adults.
Retrieved from https://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/
CT_Colonography.pdf.
Brahmania, M., Park, J., Svarta, S., Tong, J., Kwok, R., & Enns, R. (2012). Incomplete
colonoscopy: maximizing completion rates of gastroenterologists. Canadian
Journal of Gastroenterology and Hepatology, 26(9), 589-592.
Bibbins-Domingo, K., Grossman, D.C., Curry, S.J., et al. (2016). Screening for colo-
rectal cancer: US Preventive Services Task Force recommendation statement.
JAMA, 315, 2564-2575.
Chang, K.J., Rekhi, S.S., Jr., Anderson, S.W., et al. (2011). Fluid tagging for CT colo-
nography: effectiveness of a 2-hour iodinated oral preparation after incomplete
optical colonoscopy. Journal of Computer Assisted Tomography, 35, 91-95.
Hara, A.K., Blevins, M., Chen, M.H., et al. (2011). ACRIN CT colonography trial: does
reader’s preference for primary two-dimensional versus primary three-
dimensional interpretation affect performance? Radiology, 259, 435-441.
Johnson, B., Hinshaw, J.L., Pickhardt, P.J., et al. (2016). Objective and subjective
intrapatient comparison of Iohexol versus Diatrizoate for bowel preparation
quality at CT Colonography. American Journal of Roentgenology, 206, 1202-1207.
Kim, D.H., Hinshaw, J.L., Lubner, M.G., et al. (2014). Contrast coating for the surface
of flat polyps at CT colonography: a marker for detection. European Radiology,
24, 940-946.
Lee, K.J., Park, H.J., Kim, H.S., et al. (2015). Electrolyte changes after bowel prepa-
ration for colonoscopy: a randomized controlled multicenter trial. World Journal
of Gastroenterology, 21(10), 3041-3048.
Please cite this article in press as: Ricci Z et al., CT Colonography for Colorectal Cancer Screening, Journal of Radiology Nursing, https://doi.org/
10.1016/j.jradnu.2020.04.005
9
Lichtenstein, G.R., Cohen, L.B., & Uribarri, J. (2007). Bowel preparation for CT colo-
nography: the importance of adequate hydration. Alimentary Pharmacology &
Therapeutics, 26, 633-641.
Liedenbaum, M.H., Denters, M.J., de Vries, A.H., et al. (2010). Low-fiber diet in
limited bowel preparation for CT colonography: Influence on image quality and
patient acceptance. American Journal of Roentgenology, 195, W31-W37.
Macari, M., Lavelle, M., Pedrosa, I., et al. (2001). Effect of different bowel prepara-
tions on residual fluid at CT colonography. Radiology, 218, 274-277.
McCollough, C.H., Bruesewitz, M.R., & Kofler, J.M., Jr. (2006). CT dose reduction and
dose management tools: overview of available options. Radiographics, 26(2),
503-512.
McLaughlin, P.D., Murphy, K.P., Crush, L., et al. (2013). Computed tomography
colonography technique: the role of Intracolonic gas volume. Radiology Research
and Practice, 2013, 1-12. https://doi.org/10.1155/2013/517246.
Neri, E., Lefere, P., Gryspeerdt, S., et al. (2013). Bowel preparation or CT colonog-
raphy. European Journal of Radiology, 82, 1137-1143.
O’Connor, S.D., Summers, R.M., Choi, J.R., et al. (2006). Oral contrast adherence to
polyps on CT colonography. Journal of Computer Assisted Tomographyr, 30, 51-57.
Pickhardt, P.J., Bakke, J., Kuo, J., et al. (2014). Volumetric analysis of colonic disten-
tion according to patient position at CTC: diagnostic value of the right lateral
decubitus series. AJR. American Journal of Roentgenology, 203, W623-W628.
Pickhardt, P.J., Hassan, C., Halligan, S., & Marmo, R. (2011). Colorectal cancer: CT
colonography and colonoscopy for detection-systematic review and meta-
analysis. Radiology, 259(2), 393-405.
Pickhardt, P.J., Lam, V.P., Weiss, J.M., Kennedy, G.D., & Kim, D.H. (2014). Carpet le-
sions detected at CT colonography: clinical, imaging, and pathologic features.
Radiology, 270(2), 435-443.
Pickhardt, P.J. (2007). Screening CT colonography: how I do it. AJR. American Journal
of Roentgenology, 189, 290-298.
Scalise, P., Mantarro, A., Pancrazi, F., et al. (2016). Computed tomography colo-
nography for the practicing radiologist: a review of current recommendations
on methodology and clinical indications. World Journal of Radiology, 8, 472-
483.
Takahashi, N., Nagata, K., Iyama, A., Mikami, T., Kanazawa, H., & Saito, H. (2019).
Colonic distention and patient acceptance of CT colonography: supine/prone vs
left/right lateral scanning. The British journal of Radiology, 92, 20180538.
Vanhauwaert, E., Matthys, C., Verdonck, L., et al. (2015). Low-residue and low-
fiber diets in gastrointestinal disease management. Advances in Nutrition, 6,
820-827.
Wolf, A.M.D., Fontham, E.T.H., Church, T.R., et al. (2018). Colorectal cancer screening
for average-risk adults: 2018 guideline update from the American Cancer So-
ciety. CA: A Cancer Journal for Clinicians, 68, 250-281.
Yee, J., Kumar, N.N., Hung, R.K., et al. (2003). Comparison of supine and prone
scanning separately and in combination at CT colonography. Radiology, 226,
653-661.
Yee, J., & McFarland, E. (2018). Extracolonic findings and radiation: what the
referring provider needs to know. Abdominal Radiology, 43, 554-565.
Yee, J. (2008). Virtual colonoscopy. Philadelphia, PA: Lippincott Williams & Wilkins.