Comparison of 64-slice CT colonography with conventional colonoscopy in patients with ulcerative colitis

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1 Comparison of 64-slice CT colonography with conventional colonoscopy in patients with ulcerative colitis Poster No.: B-0872 Congress: ECR 2012 Type: Scientific Paper Authors: N. Prabhakar, N. Kalra, D. Bhasin, S. S. Rana, R. Singh, N. Khandelwal; Chandigarh/IN Keywords: Gastrointestinal tract, CT-High Resolution, Colonography CT, Inflammation DOI: /ecr2012/B-0872 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 41

2 Purpose Ulcerative colitis (UC) is a chronic inflammatory disorder of the bowel of unknown etiology. Imaging studies in ulcerative colitis disease establish primary diagnosis and provide information for guiding management of patients with known disease. These patients require recurrent video colonoscopy to define the extent of the disease, to reconfirm the validity of diagnosis and for cancer surveillance. CT colonography (CTC) can be used as an alternative technique in these patients. In this technique volumetric data obtained by high resolution helical CT is analysed using specialized computer software to generate virtual colonoscopic images. Its advantage over conventional colonoscopy (CC) includes its non-invasive nature which leads to better patient compliance, ability to visualize entire colon, absence of blind areas and evaluation of extracolonic pathology. It allows simultaneous assessment of colonic mucosal surface, wall thickness, surrounding structures, local lymphadenopathy, fistulae and evaluation of proximal colon in patients with stricture. CTC is the only technique that is able to identify endoluminal, intramural and extracolonic findings. This is the first study which has evaluated the use of 64 slice multidetector CT (MDCT) colonography in patients of ulcerative colitis and has correlated between CTC and CC for granular appearance and pseudopolyps. Page 2 of 41

3 Fig. 1: CT colonography was done for a 57 year old man who had a history of long standing ulcerative colitis: This video shows the virtual colonoscopic images through the transverse colon showing the classical findings of granular appearance and pseudopolyps affecting his colon. References: - Chandigarh/IN Page 3 of 41

4 Images for this section: Fig. 1: CT colonography was done for a 57 year old man who had a history of long standing ulcerative colitis: This video shows the virtual colonoscopic images through the transverse colon showing the classical findings of granular appearance and pseudopolyps affecting his colon. - Chandigarh/IN Page 4 of 41

5 Methods and Materials 20 patients of either sex, presenting to the Gastroenterology Department, proven to have ulcerative colitis on colonoscopic or sigmoidoscopic biopsy and presently in clinically remission state, were enrolled in the study. The Institutional Ethics Committee approved the study protocol and a signed informed consent was obtained from each patient. The risks and possible benefits of the CTC procedure were fully explained to the patients. Three days prior to CTC, patients were asked to eat food with a low fibre content. Patients were given wet preparation. Wet preparation included 2 packets of polyethylene glycol electrolyte solution (peglec) dissolved in 2 liters of water. 40 ml of 76% iodinated contrast was added to the peglec solution, for the effective differentiation of faecal material from polyps. The tagging obtained was homogeneous and allowed us to differentiate polyps from residual faecal matter. Use of iodine based faecal tagging has been studied previously[1]. Page 5 of 41

6 Fig. 2: (A): Advantage of fecal tagging in a 45-year-old male who presented with history of ulcerative colitis for 2 months. (A) Endoluminal colonographic view showing an elevated lesion in descending colon. (B) coronal & (C) axial images show the same lesion to be tagged residual stool (showing high attenuation). References: - Chandigarh/IN Page 6 of 41

7 Fig. 3: (B):Advantage of fecal tagging in a 45-year-old male who presented with history of ulcerative colitis for 2 months. (A) Endoluminal colonographic view showing an elevated lesion in descending colon. (B) coronal & (C) axial images show the same lesion to be tagged residual stool (showing high attenuation). References: - Chandigarh/IN Page 7 of 41

8 Fig. 4: (C):Advantage of fecal tagging in a 45-year-old male who presented with history of ulcerative colitis for 2 months. (A) Endoluminal colonographic view showing an elevated lesion in descending colon. (B) coronal & (C) axial images show the same lesion to be tagged residual stool (showing high attenuation). References: - Chandigarh/IN To achieve adequate bowel distention, injection Buscopan (Hyosine Butylbromide) 20 mg iv(intravenous) was given to all patients who did not have glaucoma or urinary retention due to high grade prostate enlargement. Page 8 of 41

9 Fig. 5: (A) Prone and (B) Supine colonography images of a 25-yr-old female with 4 yr h/o ulcerative colitis showing optimal distention of the entire colon. (C) Prone colonography image of a 31-yr-old female with 4 yr history of ulcerative colitis showing inadequate distention of transverse colon with complete loss of haustral pattern in all segments of colon. References: - Chandigarh/IN CT was performed on 64 slice CT scanner. The patient was transferred to the CT table. The scanning protocol was as follows: kvp-120; ma-60 in prone and 200 in supine; section width-10 mm x 10 mm; reconstruction thickness- 0.5 mm. At the start of the procedure the patient was placed in left lateral decubitus position and the colon was insufflated through a rectal tube using room air. First unenhanced images were acquired with patient in prone position, then contrast enhanced images were acquired with patient in supine position. CT was performed after the administration of 100 ml of non-ionic contrast intravenously. Contrast enhanced CT was performed in portal venous phase. In addition intravenous contrast helped in better detection of submerged enhancing polyps that might otherwise be obscured by residual colonic fluid. The advantage of using iv contrast has also been reported previously [2]. Page 9 of 41

10 Post-processing of the acquired data was done on a workstation. 2D multiplanar reformatted saggital, coronal, oblique coronal and 3D virtual colonoscopy (endoluminal) images were generated. Axial and reformatted views were analyzed. Elevated lesions noted on colonography images were evaluated using cube views which helped in differentiation of elevated lesions from depressions. Fig. 6: Advantage of cube view: 20-yr-old male who presented with history of ulcerative colitis for five years showing (A) Endoluminal colonographic image with polyp like lesion. (B) Corresponding axial view shows no evidence of polyp. (C) Cube view demonstrates the lesion to be depression rather than an elevation (arrow). References: - Chandigarh/IN The findings of MDCT were recorded. Any complications during the procedure were recorded. CTC and conventional colonoscopy were done within one week of each other. The findings of conventional colonoscopy were considered as gold standard. The investigator reporting findings of CTC was blinded to the findings of CC and investigator performing CC was blinded to findings of CTC. Page 10 of 41

11 After completing CTC and CC, all patients were asked to complete questionnaires regarding abdominal pain, and loss of sense of dignity felt in both the procedures. A 7point Likert scale was used, with the highest score representing the most unfavorable feeling: 7, strongly dislike; 6, dislike; 5, somewhat dislike; 4, undecided; 3, somewhat like; 2, like; 1, strongly like, and the findings were compared. Questions about the preferred examination were asked. Page 11 of 41

12 Images for this section: Fig. 2: (A): Advantage of fecal tagging in a 45-year-old male who presented with history of ulcerative colitis for 2 months. (A) Endoluminal colonographic view showing an elevated lesion in descending colon. (B) coronal & (C) axial images show the same lesion to be tagged residual stool (showing high attenuation). - Chandigarh/IN Page 12 of 41

13 Fig. 3: (B):Advantage of fecal tagging in a 45-year-old male who presented with history of ulcerative colitis for 2 months. (A) Endoluminal colonographic view showing an elevated lesion in descending colon. (B) coronal & (C) axial images show the same lesion to be tagged residual stool (showing high attenuation). - Chandigarh/IN Page 13 of 41

14 Fig. 4: (C):Advantage of fecal tagging in a 45-year-old male who presented with history of ulcerative colitis for 2 months. (A) Endoluminal colonographic view showing an elevated lesion in descending colon. (B) coronal & (C) axial images show the same lesion to be tagged residual stool (showing high attenuation). - Chandigarh/IN Page 14 of 41

15 Fig. 5: (A) Prone and (B) Supine colonography images of a 25-yr-old female with 4 yr h/o ulcerative colitis showing optimal distention of the entire colon. (C) Prone colonography image of a 31-yr-old female with 4 yr history of ulcerative colitis showing inadequate distention of transverse colon with complete loss of haustral pattern in all segments of colon. - Chandigarh/IN Page 15 of 41

16 Fig. 6: Advantage of cube view: 20-yr-old male who presented with history of ulcerative colitis for five years showing (A) Endoluminal colonographic image with polyp like lesion. (B) Corresponding axial view shows no evidence of polyp. (C) Cube view demonstrates the lesion to be depression rather than an elevation (arrow). - Chandigarh/IN Page 16 of 41

17 Results In each patient the colon was divided into eight segments:1-rectum, 2 - sigmoid colon, 3 - descending colon, 4 - splenic flexure, 5 - transverse colon, 6 - hepatic flexure, 7 ascending colon and 8 - caecum. In 2 patients, conventional colonoscopy was incomplete due to tight strictures which were not negotiable. Therefore out of a total of 16 colonic segments in these 2 patients, 11 could not be evaluated. Also 5 segments in 5 different patients could not be evaluated on CTC due to the inadequate distension. Therefore out of total of 160 segments of colon in 20 patients, 144 were included in statistical analysis. Good correlation was seen between CTC and CC for detection of granular appearance. Fig. 7: 38-yr-old female with ulcerative colitis for 7 yrs (A) Endoluminal colonographic images, (B) & (C) Cube views and (D) Colonoscopic view of the patient showing granular appearance in the transverse colon. References: - Chandigarh/IN Page 17 of 41

18 56.1% segments showed granular appearance on CTC and 56.4% segments showed granular appearance on CC. The association was good with p value of.022 and kappa value of.353. Granular appearance on CTC and CC was also analyzed for the degree of association between the two modalities in all individual segments. Strong association was noted in the sigmoid colon and descending colon (Kappa value , and p value , respectively). Sensitivity and specificity on CTC for detecting granular appearance were 81% and 73.8% respectively. At low mas (60 ma) which was done in prone position, it was difficult to differentiate granular appearance from normal colonic mucosa. Fig. 8: False positive granular appearance at low ma in a 38-yr-old male with history of ulcerative colitis since 1 year (A) Colonographic image at low ma (60mA) showing artifactual granular appearance of rectum. (B) Colonoscopic image showing normal appearance of the rectum in the same patient. Granularity was not seen on conventional colonoscopy. References: - Chandigarh/IN Good correlation was also seen between CTC and CC for detection of pseudopolyps. Page 18 of 41

19 Fig. 10: (A), (B): Axial images in a 65-yr-old male presenting with 2 month history of ulcerative colitis showing evidence of pseudopolyps. References: - Chandigarh/IN Page 19 of 41

20 Fig. 9: 38-yr-old female with ulcerative colitis for 7 yrs. (A), (B) Normal ascending colon on colonoscopy and colonography. (C) Colonographic endoluminal view and (D) Colonoscopic view showing multiple elevated sessile lesions along the entire visualised circumference of the descending colon consistent with pseudopolyps. References: - Chandigarh/IN The association between the two investigations for pseudopolyps was better. 28.4% segments showed pseudopolyps on CTC and 22.1% segments showed pseudopolyps on CC. Overall, significant association was noted between CTC and CC (p value ). Pseudopolyps were also analyzed for the degree of association on CTC and CC in all individual segments. The p value was < 0.05 in segments 1, 2, 3 and 4 (rectum, sigmoid colon, descending colon and splenic flexure) suggesting significant association for the detection of pseudopolyps between CTC and CC in these segments. The Kappa value was >0.6 in the rectum, sigmoid and descending colon thus the strength of association is higher in these segments. Sensitivity and specificity on CTC for detecting pseudopolyps were 82.14% and 84.48% respectively. Page 20 of 41

21 Ulceration and loss of vascular pattern was seen in 54.4% and 53.7% of the 149 segments evaluated on colonoscopy. None of these findings could be correlated on CTC, which is one of the main drawbacks of CTC. Fig. 11: (A) Colonoscopy revealed superficial ulceration, erosions and loss of vascular pattern in the descending colon in a 35-yr-old male with 7 yr h/o ulcerative colitis. (B) Endoluminal colonographic images on the other hand show a normal appearance of same part of descending colon. References: - Chandigarh/IN Loss of haustral folds was seen in 78 (48.8%) of the 160 segments evaluated on CTC and in 15 out of 20 patients. Pericolonic vascularity and pericolonic lymph nodes were seen in 98 (61.3%) and 64 (40%) of the 160 segments evaluated on CTC. Pericolonic vascularity was not seen in 3 patients out of patients had evidence of pericolonic lymph nodes. Wall thickening was seen in 74 (46.3%) of 160 segments evaluated on CTC. None of the patients showed evidence of wall stratification on CTC. The loss of haustral folds on CTC showed significant association with granular appearance on conventional colonoscopy with a p value of Similarly pericolonic vascularity and wall thickness had significant association with loss of vascularity on CC Page 21 of 41

22 (Peripheral vascularity & CC-loss of vascular pattern p value of ; Wall thickening & CC- loss of vascular pattern p value of 0.002).These extraluminal findings can also be used as markers of disease extent and activity in addition to the intraluminal findings that are usually evaluated on CTC. Fig. 12: (A):31-yr-old female with ulcerative colitis for 4 yrs. (A) axial and (B) coronal MPR images showing typical extraluminal findings of ulcerative colitis: loss of haustral folds, wall thickening, increased pericolonic vascularity and pericolonoic lymph nodes and incidental extracolonic finding of hepatomegaly with fatty changes References: - Chandigarh/IN Page 22 of 41

23 Fig. 13: (B):31-yr-old female with ulcerative colitis for 4 yrs. (A) axial and (B) coronal MPR images showing typical extraluminal findings of ulcerative colitis: loss of haustral folds, wall thickening, increased pericolonic vascularity and pericolonoic lymph nodes and incidental extracolonic finding of hepatomegaly with fatty changes References: - Chandigarh/IN But in our study only 2 patients (10%) were seen to have presacral space more than 20 mm. Abdominal pain experienced on CTC was lesser as compared to colonoscopy. 30% of the patients had a Likert scale value of 4 in CTC whereas 75% of the cases had Likert scale value of 7 on conventional colonoscopy. The p value was 0.07 suggesting a significant difference between the amount of abdominal pain in CTC and CC. Similarly loss of sense Page 23 of 41

24 of dignity was more in CC with 55% of the cases having a Likert scale score of 7. There was a significant difference between loss of sense of dignity on CC and CTC. Concerning their preference regarding follow up examinations, 15 (75%) patients preferred CTC, 5 (25%) patients had no definitive opinion. None of the patients preferred colonoscopy. Page 24 of 41

25 Images for this section: Fig. 7: 38-yr-old female with ulcerative colitis for 7 yrs (A) Endoluminal colonographic images, (B) & (C) Cube views and (D) Colonoscopic view of the patient showing granular appearance in the transverse colon. - Chandigarh/IN Page 25 of 41

26 Fig. 8: False positive granular appearance at low ma in a 38-yr-old male with history of ulcerative colitis since 1 year (A) Colonographic image at low ma (60mA) showing artifactual granular appearance of rectum. (B) Colonoscopic image showing normal appearance of the rectum in the same patient. Granularity was not seen on conventional colonoscopy. - Chandigarh/IN Page 26 of 41

27 Fig. 9: 38-yr-old female with ulcerative colitis for 7 yrs. (A), (B) Normal ascending colon on colonoscopy and colonography. (C) Colonographic endoluminal view and (D) Colonoscopic view showing multiple elevated sessile lesions along the entire visualised circumference of the descending colon consistent with pseudopolyps. - Chandigarh/IN Page 27 of 41

28 Fig. 10: (A), (B): Axial images in a 65-yr-old male presenting with 2 month history of ulcerative colitis showing evidence of pseudopolyps. - Chandigarh/IN Page 28 of 41

29 Fig. 11: (A) Colonoscopy revealed superficial ulceration, erosions and loss of vascular pattern in the descending colon in a 35-yr-old male with 7 yr h/o ulcerative colitis. (B) Endoluminal colonographic images on the other hand show a normal appearance of same part of descending colon. - Chandigarh/IN Page 29 of 41

30 Fig. 12: (A):31-yr-old female with ulcerative colitis for 4 yrs. (A) axial and (B) coronal MPR images showing typical extraluminal findings of ulcerative colitis: loss of haustral folds, wall thickening, increased pericolonic vascularity and pericolonoic lymph nodes and incidental extracolonic finding of hepatomegaly with fatty changes - Chandigarh/IN Page 30 of 41

31 Fig. 13: (B):31-yr-old female with ulcerative colitis for 4 yrs. (A) axial and (B) coronal MPR images showing typical extraluminal findings of ulcerative colitis: loss of haustral folds, wall thickening, increased pericolonic vascularity and pericolonoic lymph nodes and incidental extracolonic finding of hepatomegaly with fatty changes - Chandigarh/IN Page 31 of 41

32 Conclusion MDCT colonography is a novel, promising, non-invasive, rapidly evolving technique. There have been many studies on the use of CT colonography in patients of colorectal cancer. But very few studies have evaluated the use of CT colonography in patients suffering from ulcerative colitis. Colonoscopy is considered the gold standard for patients of ulcerative colitis. Colonoscopy is used recurrently in patients of ulcerative coltitis as it gives information about both the extent and the severity of disease. CTC has shown good sensitivity for granular appearance and pseudopolyps seen in patients of ulcerative colitis. Hence can be used as an alternative to colonoscopy for determining the extent of disease. Carracosa et al [3] studied twenty patients of inflammatory bowel disease, out of which 12 were of ulcerative colitis. The authors concluded that, concerning endoluminal findings, virtual colonoscopy clearly depicted early and advanced changes in ulcerative colitis. The authors showed granular appearance of the colon mucosa in 4 patients and pseudopolyps in 7 patients on CT colonography. In another study by Andersen et al [4] in which twenty-one patients of inflammatory bowel disease were studied, out of which 6 patients were of ulcerative colitis, the authors found that the sensitivity to correctly diagnose chronic alterations of the bowel with multidetector CTC was very good and reached 100% for both Crohn's disease and ulcerative colitis. Speci#city was also 100%. The high sensitivity and specificity for diagnosing chronic changes of ulcerative colitis was also seen in our study. In addition, CTC shows the extraluminal and pericolonic findings. Loss of haustral folds, pericolonic lymph nodes, increased pericolonic vascularity and wall thickening are the major extraluminal findings in patients of ulcerative colitis.. In our study, good correlation was seen between the extraluminal findings seen on CTC with the luminal findings seen on CC. Extraluminal findings can be used to predict the disease extent in correlation with the intraluminal findings on colonography. CTC is most useful in patients who refuse to undergo colonoscopy or have incomplete colonoscopy due to the presence of narrowing or stricture. While colonoscope cannot go beyond the level of stricture and hence cannot evaluate areas proximal to the stricture, CTC has no such limitation and can evaluate areas proximal to a stricture. Page 32 of 41

33 Fig. 14: (A),(B),(C),(D):58-yr-old female patient of ulcerative colitis since 10 yrs. (A) Supine and (B) Prone axial images show stricture in sigmoid colon. (C) Supine and (D) Prone extracted colonographic images of colon show non-distensibility of part of sigmoid colon.(e) Colonographic endoluminal view demonstrating the stricture. (F) Colonoscopy showing a nonnegotiable narrowing with ulceration. References: - Chandigarh/IN Page 33 of 41

34 Fig. 15: (E),(F): 58-yr-old female patient of ulcerative colitis since 10 yrs. (A) Supine and (B) Prone axial images show stricture in sigmoid colon. (C) Supine and (D) Prone extracted colonographic images of colon show non-distensibility of part of sigmoid colon.(e) Colonographic endoluminal view demonstrating the stricture. (F) Colonoscopy showing a nonnegotiable narrowing with ulceration. References: - Chandigarh/IN Patients have shown better tolerance to CTC and feel less discomfort as compared to CC. This has been shown by many studies done previously also[5]. CTC is well tolerated in patients older than 60 years in whom colonoscopy is contraindicated or incomplete, despite the presence of sigmoid diverticular disease or colonic redundancy [6,7]. Another advantage of CTC is in cancer surveillance in patients of ulcerative colitis. Colorectal cancer is one of the most feared consequences of long standing ulcerative colitis and its prevention and treatment remain among the leading indications for proctocolectomy. The true incidence of cancer in ulcerative colitis is not defined but is almost certainly significantly increased. It appears to be in the range of 5% to 8% by 20 years after diagnosis [8]. Cancer prevention, by surveillance colonoscopies are performed every 1 to 2 years, beginning about 8 years after diagnosis in patients with extensive pancolitis and after 12 to 15 years in patients with left sided disease. CTC can Page 34 of 41

35 replace colonoscopy for cancer surveillance as it has shown senstivity and specificity equal to CC for detecting malignant masses in colon [2]. One of the interesting features of CT colonography is its ability to detect extracolonic lesions sometimes referred to as "incidental findings". In our study all incidentally detected extracolonic findings were documented. UC is associated with multiple extracolonic diseases like hepatobiliary disease which may be detected on CTC. Some findings may be previously known or lead to unnecessary work up, whereas others may be clinically important and must be taken into account when CT colonography is considered for routine diagnostic work up or screening. Fig. 16: Incidentally detected extracolonic findings. (A) Diverticulosis of sigmoid colon (B) Portal cavernoma with splenic capsular calcification (C) Cholelithiasis (D) Right hydronephrosis and left atrophic kidney. References: - Chandigarh/IN There have been few reports on severe CTC colonoscopy complications [9-10]. Colonic distension should be carried out carefully in patients of ulcerative colitis patients especially because of the presence of more fragile inflammed colonic wall. Page 35 of 41

36 The limitations of our study were the small sample size; all the cases evaluated were patients with chronic disease; and only known ulcerative colitis cases were studied. Therefore, no comment is possible on the accuracy of CTC in differentiating inflammatory bowel disease from other pathologies in patients with non-specific abdominal complaints. In conclusion, CTC may be used as a substitute for CC for evaluating patients of ulcerative colitis who are in remission. It is an `all-in-one' technique and provides information about the bowel lumen, bowel wall and extraluminal abnormalities in these patients. Page 36 of 41

37 Images for this section: Fig. 14: (A),(B),(C),(D):58-yr-old female patient of ulcerative colitis since 10 yrs. (A) Supine and (B) Prone axial images show stricture in sigmoid colon. (C) Supine and (D) Prone extracted colonographic images of colon show non-distensibility of part of sigmoid colon.(e) Colonographic endoluminal view demonstrating the stricture. (F) Colonoscopy showing a nonnegotiable narrowing with ulceration. - Chandigarh/IN Page 37 of 41

38 Fig. 15: (E),(F): 58-yr-old female patient of ulcerative colitis since 10 yrs. (A) Supine and (B) Prone axial images show stricture in sigmoid colon. (C) Supine and (D) Prone extracted colonographic images of colon show non-distensibility of part of sigmoid colon.(e) Colonographic endoluminal view demonstrating the stricture. (F) Colonoscopy showing a nonnegotiable narrowing with ulceration. - Chandigarh/IN Page 38 of 41

39 Fig. 16: Incidentally detected extracolonic findings. (A) Diverticulosis of sigmoid colon (B) Portal cavernoma with splenic capsular calcification (C) Cholelithiasis (D) Right hydronephrosis and left atrophic kidney. - Chandigarh/IN Page 39 of 41

40 References 1. Bielen D, Thomeer M, Vanbeckevoort D et al (2003) Dry preparation for virtual CT colonography with fecal tagging using water-soluble contrast medium: initial results. Eur Radiol 13: Kalra N, Suri S, Bhasin DK et al (2006) Comparison of multidetector computed tomographic colonography and conventional colonoscopy for detection of colorectal polyps and cancer. Indian J Gastroenterol 25: Carrascosa P, Castiglioni R, Capun ay C, Lo pez EB, Carrascosa J (2007) CT colonoscopy in inflammatory bowel disease. Abdom Imaging 32: Andersen K, Vogt C, Blondin D et al (2006) Multi-detector CT-colonography in inflammatory bowel disease: Prospective analysis of CT-findings to highresolution video colonoscopy. Eur J Radiol 58: Jung HS, Park DK, Kim MJ et al (2009) A comparison of patient acceptance and preferences between CT colonography and conventional colonoscopy in colorectal cancer screening. Korean J Intern Med 24: Yucel C, Lev-Toaff AS, Moussa N, Durrani H (2008) CT Colonography for Incomplete or Contraindicated Optical Colonoscopy in Older Patients. AJR Am J Roentgenol 190: Lefere P, Gryspeerdt S, Baekelandt, M Dewyspelaere, J Holsbeeck BV (2003) Diverticular disease in CT colonography. Eur Radiol 13:L62-L74 8. Gyde SN, Prior P, Allan RN et al (1988) Colorectal cancer in ulcerative colitis: A cohort study of primary referrals from three centres. Gut 29: Kamar M, Portnoy O, Bar-Dayan A et al (2004) Actual colonic perforation in virtual colonoscopy: report of a case. Dis Colon Rectum 47: Bettina S, Jonathan B, Eisenberg R, Hall F, Sosna J (2010) Quality improvement grand rounds at Beth Israel Deaconess Medical Center: CT colonography performance review after an adverse event. RadioGraphics 30: Page 40 of 41

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