Computed Tomographic Enterography and Enteroclysis: Pearls and Pitfalls

doi:10.1067/j.cpradiol.2007.08.007

Current Problems in Diagnostic Radiology

Volume 37, Issue 6, November–December 2008, Pages 279-287

https://doi.org/10.1067/j.cpradiol.2007.08.007 Get rights and content

Computed tomographic (CT) enterography and enteroclysis improve visualization of the small bowel mucosa and wall in comparison with traditional CT and fluoroscopic studies by distending the small bowel through enteric hyperhydration with a negative contrast agent. Although CT enterography is performed with oral hyperhydration, CT enteroclysis requires the placement of an enteroclysis tube, often in patients who are unable to orally consume the amount of liquid. When tolerated, CT enterography is often preferred due to its lack of invasiveness. Magnetic resonance enterography and enteroclysis are other modalities that are still being studied and show promise in the imaging of small bowel. Unlike small bowel follow-through, conventional enteroclysis, or capsule endoscopy, extraenteric findings are best assessed on CT enterography. These include findings in the surrounding mesentery, perienteric fat, and the adjacent solid organs that may be associated with the small bowel process and include fistulas or abscesses, mural hyperenhancement, prominent vasa recta, and other inflammatory changes. CT enterography has developed into the first-line modality in the imaging of Crohn's disease and is considered the most appropriate imaging modality in patients with suspected Crohn's disease. It is also increasingly being used in the assessment of small bowel infections, neoplasms, adhesions, and polyps.

Section snippets

Protocol

The patient must be NPO for 4 hours before the CT enterography. Before the start of the procedure, the radiologist explains the examination in detail including the inherent risks involved and obtains informed consent. An IV access is established and 10 mg IV metoclopramide (Reglan; Pharmaceutical Associates, Greenville, SC) is administered. This is performed 60 minutes before the study to increase gastric emptying and promote small bowel peristalsis. Each patient is then given four 450-mL

Crohn's Disease and Other Small Bowel Pathologies

CT enterography is currently the most appropriate imaging modality per the American College of Radiology in adults and children presenting with symptoms of abdominal pain, fever, and diarrhea in which Crohn's disease is suspected. It is also the most appropriate imaging in monitoring Crohn's disease flare-up in patients presenting with symptoms such as abdominal pain, fever, and leukocytosis and who have a known history of Crohn's disease. In comparison to routine contrast-enhanced CT, CT

Current Status

In comparison with conventional imaging studies such as small bowel follow-through and contrast-enhanced CT scans, CT enterography has demonstrated improved visualization of the small bowel mucosa due to adequate luminal distention.15, 18 Although ileoscopy and capsule endoscopy still remain the most sensitive exams for the detection of small bowel mucosal abnormalities, they are unable to assess for extraenteric complications of Crohn's disease. Ileoscopy also provides a very limited

Conclusion

CT enterography is the most appropriate imaging modality for the assessment of Crohn's disease. CT enterography and enteroclysis have proven to be effective alternative imaging tools to conventional barium studies in demonstrating small bowel pathology and to conventional endoscopic studies in demonstrating small bowel pathology in conjunction with associated mesenteric abnormalities.

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Cited by (36)

Degree of colonic distension: Intrapatient comparison between CT colonography and CT with water enema
2016, Clinical Imaging
Citation Excerpt :
CTWE provided adequate lumen distension in all the colonic segments and was superior to CTC-S protocol for the visualization of sigmoid and descending lumen (P< .05). Luminal distension is a fundamental requirement for CT imaging of the bowel because collapsed segments may hide the presence of tumors or polypoid lesions and mimic wall thickening simulating pathologic conditions such as Crohn's disease [8]. A recent paper already focused on the comparison between CTC and CTWE, specifically concerning the incidence of hiatal hernia as an incidental and physiological consequence of the colonic distension [5]; however, to our knowledge, a detailed comparison between these two techniques regarding the degree of large-bowel distension has not been reported in literature so far.
Compare colonic distension using CT colonography (CTC) and CT with water enema (CTWE) in the same patients.
Twenty-seven patients who underwent both CTC and CTWE, considering separately supine (CTC-S) and prone (CTC-P) acquisition of CTC were included. The colon was divided into six segments, performing both a qualitative and quantitative analysis.
Adequate distension of sigmoid colon was more frequently achieved with CTC-P and CTWE compared to CTC-S (P< .05). CTC-P and CTWE showed better distension of the left colon compared to CTC-S (P< .01 and P= .03 regarding sigmoid colon, respectively; P= .01 and P= .03 regarding descending colon, respectively).
Computed tomography (CT) studies of the colon should be customized to fulfill the clinical query.
Evaluation and management of small-bowel tumors in the era of deep enteroscopy
2014, Gastrointestinal Endoscopy
Computed Tomography Enteroclysis
2014, Textbook of Gastrointestinal Radiology: Volumes 1-2, Fourth Edition
Computed tomography of the bowel: A prospective comparison study between four techniques
2013, European Journal of Radiology
Citation Excerpt :
Pairwise comparisons using the Bonferroni adjustment demonstrated a significant difference in the frequency of adverse effects between CTE and CT-WE techniques (p = 0.0012), but no difference was found among all the other CT protocols. As well as for conventional barium studies, luminal distention is also required for CT imaging of the bowel, because collapsed bowel loops can hide even large lesions and may falsely mimic wall thickening [2], and such a requisite is valid for both the small and large bowel. Macari et al. [14] have considered that appropriate luminal distension is achieved when the small bowel diameter corresponds to at least 2 cm, and intraluminal contrast material separates the intestinal walls and allows the identification of folds (valvulae conniventes), without collapsed loops.
The major objective was to prospectively compare the grade of bowel distension obtained with four different computed tomography (CT) techniques dedicated for the examination of the small intestine (CT enteroclysis [CTE] and enterography [CTe]), of the colon (CT with water enema [CT-WE]), or both (CTe with water enema [CTe-WE]). The secondary objective was to assess patients’ tolerance toward each CT protocol.
Recruitment was designed to obtain four groups of the same number of patients (30). Each group corresponded to a specific CT technique, for a total of 120 consecutive outpatients (65 male and 55 female, mean age 51.09 ± 13.36 years).
CTE was performed after injection of methylcellulose through a nasojejunal tube, while in the CTe protocol a polyethylene glycol electrolyte solution was orally administered to patients prior to the CT acquisition. In the CT-WE protocol intraluminal contrast (water) was administered only by a rectal enema, while CTe-WE technique included both a rectal water enema and oral ingestion of neutral contrast material to obtain a simultaneous distension of small and large bowel.
CT studies were reviewed in consensus by two gastrointestinal radiologists who performed a quantitative and qualitative analysis of bowel distension on a per segment basis. The presence and type of adverse effects were recorded.
CTE provided the best distension of jejunal loops (median diameter 27 mm, range 17–32 mm) when compared to all the other techniques (p < 0.0001). The frequency of patients with an adequate distension of the terminal ileum was not significantly different among the four groups (p = 0.0608). At both quantitative and qualitative analysis CT-WE and CTe-WE determined a greater and more consistent luminal filling of the large intestine than that provided by both CTE and CTe (p < 0.0001 for all colonic segments). Adverse effects were more frequent in patients belonging to the CTE group (p < 0.0028).
CTE allows an optimal distension of jejunal loops, but it is the most uncomfortable CT protocol. When performing CT-WE, an adequate retrograde distension of the terminal ileum was provided in a particularly high percentage of patients. CTe-WE provides a simultaneous optimal distension of both small and large bowel.
Fluoroscopic and CT Enteroclysis. Evidence-Based Clinical Update.
2013, Radiologic Clinics of North America
Errors in the Radiological Evaluation of the Alimentary Tract: Part II
2012, Seminars in Ultrasound, CT and MRI
Plain abdominal radiography and computed tomographic (CT) enteroclysis are 2 essential radiological investigations in the study of gastrointestinal tract. Errors in patient preparation, execution, and interpretation may lead to severe consequences in the diagnosis and thus in patient outcome. Abdominal radiography is one of the most frequently requested radiographic examinations, and has an established role in the assessment of the acute abdomen. CT enteroclysis has revolutionized the assessment of small-bowel pathology, especially in patients with inflammatory bowel. The purpose of this article is to describe the pitfalls in the execution and interpretation of plain abdominal film and CT enteroclysis.

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Original articleComputed Tomographic Enterography and Enteroclysis: Pearls and Pitfalls

Section snippets

Protocol

Crohn's Disease and Other Small Bowel Pathologies

Current Status

Conclusion

Radiol Clin North Am

Gastrointest Endosc

J Am Coll Surg

CT evaluation of Crohn's disease: Effect on patient management

AJR

Computed tomography vs. barium studies in the acutely symptomatic patient with Crohn's

J Comput Assist Tomogr

Assessment of small bowel Crohn disease: Noninvasive peroral CT enterography compared with other imaging methods and endoscopy—Feasibility study

Radiology

CT findings in ulcerative, granulomatous and indeterminate colitis

AJR

Spiral CT findings in active and remission phases in patients with Crohn's disease

J Comput Assist Tomogr

Spiral CT demonstration of hypervascularity in Crohn's disease: “Vascular jejunization of the ileum” or the “comb sign”

Abdom Imaging

Infliximab for the treatment of fistulas in patients with Crohn's disease

N Engl J Med

Original article
Computed Tomographic Enterography and Enteroclysis: Pearls and Pitfalls