Computed Tomography

Scout image
General abdominal scanning methods

• CT evaluation of the abdomen and pelvis requires

greater attention to patient preparation than CT
evaluation of any other area of the body.

• Most CT scans of the abdomen require the

administration of an oral contrast agent to demonstrate
the intestinal lumen and to distend the GIT.

• The use of oral contrast is important to differentiate a

fluid-filled loop of bowel from a mass or an abnormal
fluid collection.
•Either dilute barium suspension or a dilute water-
soluble agent (gastrograffin) may be used with equal
effectiveness.
•In general, the greater volume of oral CM, the better
the bowel opacification.
•Although 600 ml is the minimum requirement,
patient compliance may be a limiting factor.
•Patient should be given only clear fluids or at least 2-
4 hours before scanning to ensure that food in the
stomach is not mistaken for pathologic tissue.
•Air and water are excellent as low-attenuation
contrast agents.
Gastrograffin vs water contrast
•Air or CO2 is frequently used to insufflate the
colon producing a very high negative contrast.
•Water or a low-HU oral barium suspension is
sometimes used in place of positive contrast
agents.
•These low-HU agents do not obscure mucosal
surfaces or superimpose abdominal vessels on
post-processed images.
•The use of a low-HU oral contrast has an added
advantage in that it does not mask radiopaque
stones in the CBD or urinary tract.
• Few institutions routinely administer rectal contrast material.
Normally it is used for colon cancer staging.

• The bladder is best appreciated on CT when filled with urine or

contrast agent.

• The vagina is seen in cross section as a flattened ellipse of soft

tissue between the bladder and rectum.

• An inserted tampon will outline the cavity of vagina. With air

density and is useful in identification of vaginal canal.

• The appropriate timing, rate and dose of IV CM is essential. Image

acquisition must be completed before IV contrast medium reaches
the equilibrium phase.
• Pre-CE scans are now seldom obtained in routine
abdominal study but may be used in specific indication
such as diagnosis of fatty infiltration or other alteration
of parenchymal attenuation.

• Multiphasic imaging is frequently used for specialized

studies of the pancreas, liver and kidney as well as in
many abdominal CTA protocols.

• CT of the abdomen and pelvis is used for the evaluation of

virtually all organs and most vessels.

• A routine soft tissue window setting (WW:450; WL:50)

will adequately display most abdominal anatomy.
• The liver may also be examined using ‘liver windows’ which
are narrower (WW:150; WL:70) and intended to improve
the visibility of subtle liver lesions.

• The lung bases are contained in slices of the upper

abdomen and must be viewed using ‘lung windows’
(WW:1500;WL:-600)

• Bone windows (WW:2000; WL:600) may help to reveal

abnormalities of the bones.

• If previous studies are available, it is advisable to use the

same DFOV allows easy visual comparison of any changes
in size of lesions or structures when both studies are
displayed side by side on PACS monitor or illuminator.
•Although landmark easily visible on the scout
images are often used to guide technologists as
to where cross sectional slices should begin and
end, technologists must verify that the anatomy
of interest has indeed been scanned.

•Similarly, scanning should not start or stop in the

middle of obvious abnormality.

•Protocols are performed while patient lies in a

supine position on the scan table with the arm
elevated above the head.
• Patients are asked to hold their breath during scan acquisition to
reduce movement and decrease motion artifacts.

• Patient movement during scanning will cause anatomic structures

to be displaced, distorted or blurred.

• There is a wide range in the number of protocols used at different

institutions for CT of the abdomen and pelvis or they can be
designed to address a particular clinical question or to evaluate a
specific abdomen or pelvic organ.

• Technologists are encouraged to carefully review images and call a

radiologist whenever they suspect abnormal results could
necessitate additional imaging.
 Liver
• The normal CT attenuation of the liver unenhanced CT
ranging from 38-70 HU.

• In healthy subject, the attenuation of the liver is at least

10 HU greater than that of the spleen.

• Fatty infiltration of the liver is one of the common

indications for CT liver which results from variety causes
including alcoholism, diabetes, obesity, chemotherapy,
corticosteroid therapy, hyper alimentation and
malnutrition.
• Fatty infiltration reduces CT attenuation of the involved
liver with 10 HU less than that of the spleen.

• This is accurately assessed on non-contrast CT.

• Many operators include ROI comparisons between liver

and spleen.

• Another common finding in the liver is that of cavernous

hemangiomas. This benign tumors are often discovered
incidentally during hepatic imaging by either
ultrasonography or CT.

• Although majority cases hemangiomas are solitary, some

patients have multiple lesions.
•Most hemangiomas have characteristic
appearance on CT

• On unenhanced CT: it appears as well-defined

hypodense mass of the same density as other blood-
filled spaces, such as IVC.

• Post CE: lesion shows progressive filling in

enhancement from periphery; eventually the lesion
becomes uniformly enhanced.
•Because the liver derives approximately 25% of
its blood supply from the hepatic artery and the
remaining 75% from the portal vein, there are
several phases of enhancement after the IV
administration of a bolus of CM.

• The first is the hepatic arterial phase (typically 15-25 s

post bolus)
• Portal venous phase (60-70s post CE)

•For routine abdominal CT, liver is scanned in

portal venous phase.
• Some indications such as hyper vascular liver lesion or
hepatic vascular anatomy, scanning in more than one
phase may improve examination’s sensitivity.

• In some practices, scans are obtained during 3 phases of

liver enhancement for hyper vascular hepatocellular
carcinoma:
• Early arterial phase (24 s)
• Late arterial phase (40s )
• Portal venous phase (70 s)

• Some practices using 4 phases technique: pre contrast,

arterial phase, portal venous phase, and delayed
phase.
•Multiphase liver CT is used to detect and
characterize liver lesions as different types of
tumors enhance differently during each phase
depending on whether they are hyper-vascular or
hypo-vascular lesions.

• Pre-contrast liver scans are used to detect calcifications, visualize

hemorrhage from trauma, and demonstrate hyper-vascular
lesions which appear hypodense compared to the surrounding
liver parenchyma.

• The arterial phase of scanning is performed approximately 30-40

seconds after the contrast injection is initiated and is most
accurately determined by using bolus tracking (monitor: aorta at
120HU).
 • The portal venous phase is performed 70-90 seconds
post contrast and hypovascular lesions appear
hypodense and hypervascular lesions appear isodense
(same density as surrounding liver).

• The delayed phase is performed 5-10 minutes post

contrast and is used to further characterize lesions.

• Hemangiomas are slow to enhance, and some

Hepatocellular ca (HCC) can appear hypodense due to
rapid washout and Cholangiocellular ca (CCC) can
appear hyperdense due to delayed washout.
Multiphase liver
Hemangioma
Pancreas
• The pancreas differs in size, shape and location
depending on individual patient.

• A technique that use thin slices and IV CE

improves visualization the main pancreatic
duct.

• In jaundice patient, non-CE scan at the area of

CBD may help in visualization of CBD calculi.
• Water or low-attenuation oral contrast agents are preferred
because dense contrast may obscure small stones.

• Multiphasic protocols are common for pancreatic indications.

• Commonly, data acquisition is timed to coincide with the late

arterial phase (30-40 s after bolus injection).

• The exact time of these phases is patient-dependent, bolus

tracking software is often used.

• Two-phase are commonly done:

• Arterial (20-30 s)
• Venous (70s)
Pancreatic CT
 Kidney and ureters
• Most renal abnormalities are best seen on CT after IV CM.
• Unenhanced CT is generally reserved to demonstrate
calcification and calculi.
• Unenhanced CT also used as a baseline for attenuation
measurements when enhancement is calculated as a feature of
renal mass characterization.
• Then performing CT for renal mass evaluation, scans are typically
taken before the contrast bolus and at 1 or more phases post-CE.

• In general,:
• Corticomedullary phase (30-70 s)
• Nephrogram phase (80-120 s)
• Excretory phase (3 mins)~also can last 15 mins or longer.
• 2D and 3D reformations may help in defining certain
types of renal abnormalities such as renal cell
carcinoma and ureteropelvic junction (UPJ)
obstruction.

• CTU is an examination optimized for imaging the

kidneys, ureters and bladder. Protocols vary, but all
include the use of MDCT with thin-slice imaging, IV
administration of CM and imaging in the excretory
phase
•CTU protocols:
• Unenhanced
• Corticomedullary (60 s)
• Nephrographic (110 s)
• Excretory (3-16 mins)

•CM administration is accomplished by using 2

different approach:
• A single bolus injection: 100-150 ml LOCM at 2-3 ml/s
• Split bolus injection: split the bolus with interval of 2-
15 mins to image a combined nephrographic-
excretory phase.
• Other technique might be used in CTU to
optimize the visualization of the urinary tract
including:
• Abdominal compression bands
• IV saline hydration (~250 ml saline)
• Low-dose of furosemide (Lasix)

• Multiphase CTU is associated with a relatively

high radiation dose.

• Split bolus technique has been gaining popularity

because of combining 2 phases~ reduces
radiation dose.
 Non-contrast CT of urinary tract
calculi
• Also called as unenhanced helical CT (UHCT).
• It has become the standard technique for evaluation of
suspected renal colic.
• The advantages of UHCT compared to other technique
are:
• High diagnostic accuracy >99%
• Can be performed and interpreted rapidly.
• It provides most of the information required for the management
of ureteral calculi including the size measurements of the calculi.
Stones of > 1000HU appear to respond less well in ESWL
• The presence of associated urinary tract obstruction can also be
identified.
• The data acquisition required from the top of the
kidney to the base of the bladder.
• Collimation is typically at 2.5-3.0 mm and thinner slices
are required for better diagnosis.
• The major drawback is radiation dose.