Lisa L. Chu, M.D.

Z. Jane Wang, M.D.

Eleanor L. Ormsby, M.D.
Antonio C. Westphalen, M.D.
Benjamin M. Yeh, M.D.

Department of Radiology & Biomedical Imaging

University of California, San Francisco
Disclosures
§  Zhen Jane Wang, M.D.
ü  Nextrast, Inc. shareholder
§  Benjamin M. Yeh, M.D.
ü  General Electric Healthcare research
agreement
ü  Nextrast, Inc. shareholder
ü  Oxford University Press book royalties
§  Other authors have no disclosures

Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Learning Objectives
§  Understand merits and pitfalls of positive and
neutral oral contrast agents

§  Assess evidence-based use of different oral

contrast agents in specific settings

§  Discuss future directions of oral contrast agents

§  Target audience: general and abdominal

radiologists
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Introduction
§  Use of some type of oral contrast (positive or
neutral) is better than no oral contrast for
optimal evaluation of abdomen

§  Historically, positive oral contrast considered

standard of care

§  Recent publications focus on neutral or no oral

contrast
ü  Few head-to-head papers support positive oral
contrast use, likely biased by historical context
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Introduction
§  Conspicuity of CT findings depends on type of
oral contrast and “color” of underlying disease

Cartoon illustration of CT with neutral Cartoon illustration of CT with positive

oral contrast. It may be difficult to oral contrast shows extraluminal
discern extraluminal masses given similar masses more vividly.
attenuation to that of neutral contrast.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Introduction
§  Conspicuity of CT findings depends on type of
oral contrast and “color” of underlying disease

Cartoon illustration of CT with positive Cartoon illustration of CT with neutral

oral contrast. It may be difficult to oral contrast shows the distal ileal wall
discern hyperemia in the distal ileal wall. hyperemia more vividly.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Any oral contrast better than none

§  More intestinal CT Intestinal Findings on CT
findings made with 18

16
any kind of oral agent
14
than no oral agent

Percent (%)
12
ü  Neutral contrast à No oral
10 contrast à
more intestinal fewer bowel
16%
findings detected 8 findings
6 detected
ü  N = 716 barium & 576 11%
water (neutral) oral 4
5%
contrast CT scans, and 2
716 CT scans without 0
oral contrast Barium Water None

Source: Kammerer et al., Eur Rad 2015.

Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Oral Contrast & Disease Conspicuity

§  Positive and neutral oral contrast agents each
have benefits and drawbacks to consider
Positive Neutral
Abscess
Bowel fistula
Bowel leak
Extraluminal hematoma
Extraluminal tumor
Bowel wall inflammation
Bowel wall ischemia
Intraluminal tumor
GI bleeding
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Neutral oral contrast helps in the

evaluation of…
§  Bowel wall disease
ü  Inflammatory bowel Terminal
ileitis from
disease Crohn’s dz

ü  Bowel wall ischemia

ü  Shock bowel
§  Intraluminal hypervascular
tumors
§  Extraluminal calcifications
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Merits of neutral oral contrast: Crohn’s disease

Clinical history: 51 year old woman
with Crohn’s disease presents with
abdominal pain, nausea and
vomiting.
Imaging findings: On CT with IV
and positive oral contrast, the
positive contrast obscures bowel
wall hyperenhancement (arrow).
CT enterography with IV and
neutral oral contrast performed six
months prior clearly shows bowel
wall hyperenhancement (arrow)
consistent with active disease.

Teaching point: CT enterography which uses neutral oral contrast is

superior to positive oral contrast in evaluating for bowel wall hyperemia in
active Crohn’s disease.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Merits of neutral oral contrast: Bowel wall ischemia

Clinical history: 51 year old woman
status post CABG presents with
abdominal pain.
Imaging findings: CT with IV and
positive oral contrast shows
pneumatosis of ileum (arrow) but
wall enhancement is poorly
evaluated. Subsequent CT with IV
and neutral contrast shows
pneumatosis AND lack of wall
enhancement of the same ileal loop
due to infarction (arrow). RLQ renal
transplant (arrows).

Teaching point: Acute mesenteric ischemia is a life-threatening condition

(mortality rate of 50-90%) that requires prompt diagnosis and treatment.
Be wary that positive oral contrast can obscure wall hypoenhancement.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Merits of neutral oral contrast: Hypervascular mass (#1)

Clinical history: 71 year old man
with history of colon cancer.
Imaging findings: CT with IV and
positive oral contrast obscures an
enhancing mass at the fourth
portion of the duodenum (arrow),
not seen for 5 consecutive CT scans
with positive oral contrast.
Subsequent CT with IV and neutral
oral contrast clearly shows the
stable duodenal mass (arrow), in
retrospect present on all prior
scans, and which was proven to be
a GIST on surgical pathology.

Teaching point: Positive oral contrast can obscure enhancing intraluminal

tumors due to similar hyperattenuation. Consider neutral oral contrast
instead when evaluating for intraluminal hypervascular masses.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Merits of neutral oral contrast: Intraluminal mass (#2)

Clinical history: 45 year old woman
with unintentional weight loss for
evaluation for malignancy.
Imaging findings: CT with IV and
positive oral contrast obscures an
enhancing intraluminal mass in the
stomach (arrow) which was missed.
Years later, upper endoscopy
reveals a gastric submucosal mass.
Subsequent CT with IV and neutral
oral contrast reveals the mass
(arrow). Mass later shown to be
ectopic pancreatic rest.

Teaching point: Positive oral contrast can obscure enhancing intraluminal

tumors due to similar hyperattenuation. Neutral oral contrast better
visualizes intraluminal hypervascular masses.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Merits of neutral oral contrast: Extraluminal calcification

Clinical history: 86 year old woman
with serous ovarian carcinoma.

Imaging findings: At first glance on
CT with positive oral contrast, right
posterior hyperdense lesion (arrow)
appears to be positive oral
contrast. Comparison with CT with
IV and neutral oral contrast shows
that it is actually calcified serous
ovarian carcinoma (arrow) and not
within a bowel segment.

Teaching point: Positive oral contrast makes it more difficult to

confidently diagnose certain extraluminal calcifications.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Pitfalls of neutral oral contrast: Peritoneal metastasis

Clinical history: 78 year old man
with colon cancer.

Imaging findings: At initial CT with
with IV and neutral oral contrast ,
left pelvic metastasis (arrow) was
not detected, even though a PET
scan showed FDG uptake in that
region. Subsequent CT 1 week later
with IV and positive oral contrast
clearly shows the mesenteric mass
(arrow).

Teaching point: CT sensitivity for peritoneal metastases is reported to be

28 to 70% in multiple publications. Peritoneal metastases may be less
conspicuous with neutral than with positive oral contrast.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Positive oral contrast helps in the

evaluation of…
§  Extraluminal tumors
§  Abscesses
§  Fistulas / leaks

Peritoneal
implant
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Merits of positive oral contrast: Extraluminal tumors (#1)

Clinical history: 55 year old man
with history of liver transplant
presents with abdominal pain.

Imaging findings: CT with IV and
neutral oral contrast obscures two
hypoattenuating mesenteric
masses (arrows). With CT with
positive oral contrast, the
mesenteric masses (arrows) are
much more discrete. They were
proven to be desmoid tumors on
pathology.

Teaching point: Hypoattenuating mesenteric masses may have similar

density to neutral oral contrast. Positive oral contrast is superior in the
evaluation for extraluminal tumors.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Merits of positive oral contrast: Extraluminal tumors (#2)

Clinical history: 35 year old woman
with metastatic ovarian cancer.

Imaging findings: CT with IV and
neutral oral contrast obscures
multiple mesenteric masses
(arrows). On CT with IV and positive
oral contrast, the mesenteric
masses (arrows) can be easily
differentiated from adjacent bowel.

Teaching point: Even when mesenteric masses have density slightly

different to that of neutral oral contrast, they can be easily missed.
Positive oral contrast is superior in the evaluation of such masses.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Merits of positive oral contrast: Extraluminal tumor (#3)

Clinical history: 57 year old woman
with metastatic ovarian cancer.

Imaging findings: On CT with IV
and neutral oral contrast, the
paracolic metastasis was missed
(arrows). On subsequent CT with IV
and positive oral contrast, the
paracolic metastasis (arrows) was
more easily differentiated from the
adjacent descending colon.

Teaching point: Be sure to include “running” the colon in your CT search

pattern. At first glance, the paracolic mass can be mistaken for colon.
However, positive oral contrast clearly shows that it is extraluminal.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Merits of positive oral contrast: Intra-abdominal abscesses

Clinical history: 27 year old man
with fever and abdominal pain.

Imaging findings: On CT with
neutral oral contrast and without IV
contrast, it is difficult to distinguish
multiple interloop abscesses
(arrows) from adjacent bowel
loops. On CT with IV and positive
oral contrast, the interloop
abscesses (arrows) can be more
easily distinguished from bowel
loops.

Teaching point: The intra-abdominal abscesses may have similar density

to neutral oral contrast. Positive oral contrast provides higher conspicuity
and confidence for the detection of intra-abdominal abscesses.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Merits of positive oral contrast: Gastrogastric fistula

Clinical history: 54 year old woman
with history of Roux-en-Y gastric
bypass with abdominal pain.

Imaging findings: CT with positive
oral contrast shows oral contrast
flowing from the gastric pouch
(arrow) into the gastric remnant
(arrow), suggesting a
communication between the two
cavities.

Teaching point: Gastrogastric fistula occurs in up to 6% of Roux-en-Y
gastric bypasses. Two theories for fistula formation exists: (1) incomplete
stomach division during creation of pouch, and (2) staple-line failure.
Positive oral contrast can be used to evaluate for fistulas anywhere in the
GI tract. Neutral oral contrast is of limited value in these scenarios.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Mimics of positive oral contrast: Colonic varices

Clinical history: 54 year old man
with abdominal pain.
Imaging findings: CT with IV and
positive oral contrast shows
extensive colonic varices from a
colonic vascular malformation
(arrow). At first glance, the colonic
varices can be mistaken for positive
oral contrast. However, further
review shows that positive oral
contrast has not yet reached the
colon.
Teaching point: Be sure to
determine how far the oral contrast
has gone before assuming
intraluminal hyperdense material is
positive oral contrast.

Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Pitfalls of positive oral contrast: Serosal calcifications

Clinical history: 78 year old woman
with serous adenocarcinoma
omental metastases of unknown
primary.

Imaging findings: CT with IV and

positive oral contrast shows
extraluminal hyperdense material
(arrows). These were initially
mistaken for leakage of positive
oral contrast. However, comparison
with prior studies showed that the
extraluminal calcifications were
unchanged and consistent with
serosal calcifications.

T
eaching point: Comparison with prior CT scans, particularly those
without positive oral contrast, is key to avoiding this potential pitfall.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Pitfalls of positive oral contrast: Pseudo-wall thickening

Clinical history: 59 year old man
with lymphoma presents with
abdominal pain.
Imaging findings: CT with IV and
positive oral contrast shows
pseudo-wall thickening at the
cecum (arrow) due to poor mixing
of the positive oral contrast and
bowel contents. There is incidental
note of splenomegaly (arrow),
ascites (arrow), and right pleural
effusion (arrow).
Teaching point: Be wary of mixing
artifacts, a pitfall which can occur
anywhere in the GI tract.
Pseudolesions are more common
with positive than neutral contrast.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Pitfalls of positive oral contrast: Pseudolesions & poor mixing

Clinical history: 78 year old woman
with lower abdominal pain.
Imaging findings: CT with IV and
positive oral contrast shows a
pseudolesion in the small bowel
(arrow) due to poor mixing of oral
contrast and bowel contents.
Repeat CT with IV and neutral oral
contrast shows no mass in that
region (arrow) but instead shows
real cecal nodular fold thickening
(arrow) which was missed on CT
with positive oral contrast (arrow).
Cecal biopsy revealed tubulovillous
adenoma.

Teaching point: Positive oral contrast may show heterogeneous mixing

that resembles intraluminal mass or hide real intraluminal masses.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Merits of no oral contrast: Emergency room setting

Numerous publications report on potential benefits
of no oral contrast for abdominal CT triage in the
emergency room setting.

Caveats:
§  Most publications focus on rapid throughput and related
overall cost savings.
§  Data on CT sensitivity for actual disease is limited by small
sample sizes for publications where no oral contrast was
compared with oral contrast use in the emergency room
setting.
§  None of the publications are adequately powered to assess
cost of misdiagnosis when no oral contrast is administered.

Clancy 1993; Shreve 1999; Stafford 1999; Huynh 2004; Anderson 2005;
Lee 2006; Schuur 2010; Laituri 2011; Kepner 2012; Levenson 2012;
Razavi 2014; Alabousi 2015; Uyeda 2015.
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

In practice:
§  Majority of practices use positive oral contrast for most
abdominal scans
§  There is no consensus on which oral contrast to use (positive,
neutral, no oral contrast) for most indications
Recommendations:

§  Positive oral contrast is probably best when there is concern for
peritoneal tumors or extraluminal fluid collections
§  Neutral oral contrast is best when focus is on bowel wall
inflammation or ischemia
§  Each agent has pitfalls. Patients may have concurrent findings
on the same CT scan, some that would be more conspicuous
with positive and others with neutral oral contrast
ü  Example: Abdominal pain patients may have both bowel
wall inflammation (seen best with neutral agent) and
abscesses (seen best with positive agent)
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Future Directions
§  “Biphasic” dual energy CT oral agent lets contrast
signal be digitally subtracted as needed

Mouse
click

70 keV CT image Iodine density reconstruction

(Positive oral contrast image) (“Neutral oral contrast image”)
Disclaimer: No biphasic CT contrast agents are FDA approved yet for clinical use.
Rathnayake et al, in submission
Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

Conclusion
§  Conspicuity of CT findings depends on type of oral
contrast and “color” of underlying disease.
Positive and neutral oral contrast agents each
have strengths and weaknesses

§  Practical approach
ü  Protocol based on leading suspected diagnosis
ü  Repeat exam as needed with CT, MRI or PET when
clinical findings do not match radiologic findings

§  Future – “biphasic” dual energy CT agents?

Introduction – Neutral Contrast – Positive Contrast – Recommendations – Future - Conclusions

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Acute Abdominal Pain? Canadian Association of Radiologists journal = Journal l'Association canadienne des radiologistes. 2015;66(4):
318-22.
2.  Anderson BA, Salem L, Flum DR. A systematic review of whether oral contrast is necessary for the computed tomography diagnosis of
appendicitis in adults. American journal of surgery. 2005;190(3):474-8.
3.  Clancy TV, Ragozzino MW, Ramshaw D, Churchill MP, Covington DL, Maxwell JG. Oral contrast is not necessary in the evaluation of blunt
abdominal trauma by computed tomography. American journal of surgery. 1993;166(6):680-4; discussion 4-5.
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observational study. European radiology. 2015;25(3):669-78.
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diagnosis of appendicitis in adult ED patients. The American journal of emergency medicine. 2012;30(9):1765-73.
7.  Laituri CA, Fraser JD, Aguayo P, et al. The lack of efficacy for oral contrast in the diagnosis of appendicitis by computed tomography. The
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department: impact on patient throughput and diagnosis. Emergency radiology. 2012;19(6):513-7.
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pathway on radiology turn around times, emergency department length of stay, and patient safety. Emergency radiology. 2014;21(6):
605-13.
11.  Schuur JD, Chu G, Sucov A. Effect of oral contrast for abdominal computed tomography on emergency department length of stay.
Emergency radiology. 2010;17(4):267-73.
12.  Shreve WS, Knotts FB, Siders RW, Culler A, Fenn-Buderer N, Black C. Retrospective analysis of the adequacy of oral contrast material for
computed tomography scans in trauma patients. American journal of surgery. 1999;178(1):14-7.
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Contact information: Lisa L. Chu, M.D. Lisa.Chu@ucsf.edu