CT Enterography & Multiphase CT, Do I Need these Exams for Abdominal Pain?

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Amanda Sharp
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1 CT Enterography & Multiphase CT, Do I Need these Exams for Abdominal Pain? Kristen Bishop, MD Assistant Professor UTSW Dept. of Radiology February 14, 2015

2 The most appropriate modality to work up a patient with abdominal pain is: A. X-ray B. Ultrasound 20% 20% 20% 20% 20% C. CT D. MRI E. Depends on additional details in the H&P A. B. C. D. E.

3 Computed Tomography Godfrey Hounsfield British electrical engineer Inventor of computed tomography Image an object in axial slices

4 Contrast Agents - Background Coating radiolucent structures with a metallic powders or pastes made the surface radio-opaque 1910 barium sulfate first used for GI imaging

contrast agent 1968 - first nonionic agent

5 Water soluble contrast agents Iodine opaque to x-rays 1928 First urographic iodinated contrast agent first nonionic agent was developed Some agents FDA approved for oral use

6 Example of CT without and with contrast

7 The Multiple Phase Exam (Liver Tumor Protocol)

8 CT Urography

9 CT Enterography

10 CT Protocol Variables IV contrast necessary? Some scans do not require Contraindications to contrast If IV contrast necessary Number of postcontrast phases and timing for each phase Radiology selects a protocol based on provided clinical history Use of oral contrast and type Standard barium, Volumen (CT enterography), or water soluble Portions of anatomy scanned or excluded Abdomen vs. pelvis Is CT even the best exam for the clinical question?

CPT Codes 74176 CT, abdomen and pelvis; without contrast material 74177 CT, abdomen and pelvis; with contrast material 74178 CT, abdomen and pelvis; without contrast material, followed by contrast

and further sections 72192 CT, pelvis; without contrast material 72193 CT, pelvis; with contrast material 72194 CT, pelvis; without contrast material, followed by contrast material(s) and further

11 CPT Codes CT, abdomen and pelvis; without contrast material CT, abdomen and pelvis; with contrast material CT, abdomen and pelvis; without contrast material, followed by contrast material(s) and further sections CT, abdomen; without contrast material CT, abdomen; with contrast material CT, abdomen; without contrast material, followed by contrast material(s) and further sections CT, pelvis; without contrast material CT, pelvis; with contrast material CT, pelvis; without contrast material, followed by contrast material(s) and further sections CT angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT colongraphy, diagnostic including image postprocessing; without contrast material CT colongraphy, diagnostic including image postprocessing; with contrast material CT colongraphy, screening including image postprocessing

12 CMS Measure (for outpatients)

13 CMS Measure (Abdominal CT Scans without and with contrast)

14 But is CT without and with contrast ever indicated? Yes! Exclusions from the CMS measure include ICD-9 codes for: Blunt abdominal trauma Hematuria, bladder cancer, urinary infection Adrenal mass Jaundice, liver lesion, liver or biliary cancer Pancreatic mass, hypoglycemic workup, pancreatitis Among others

15 How do I know which study is most appropriate?

16 ACR Appropriateness Criteria

17 Imaging Appropriateness Topics Breast Cardiac Gastrointestinal Musculoskeletal Neurologic Pediatric Thoracic Urologic Vascular Women s Imaging Interventional Radiation Oncology

Crohn s disease? Gastrointestinal LLQ pain suspected diverticulitis? RLQ pain suspected appendicitis?

18 Need to have targeted workup approach No generalized abdominal pain listed For example, your patient has abdominal pain But does he have: Fever and abdominal pain (or suspected abscess)? Acute pancreatitis? Blunt abdominal trauma? Crohn s disease? Gastrointestinal LLQ pain suspected diverticulitis? RLQ pain suspected appendicitis? Right upper quadrant pain? Suspected small bowel obstruction? Acute flank pain suspicion for stone? Urologic Acute pyelonephritis?

19 Example scenario 35 year old female with fever, dysuria, and unilateral flank pain CBC with elevated WBC UA with + bacteria, + WBC, + nitrite No significant PMH

20 Workup using ACR Appropriateness Criteria Acute pyelonephritis Uncomplicated patient Imaging not usually indicated Unless patient does not respond to therapy within 72 hours

21 Workup using ACR Appropriateness Criteria Contrast with the complicated patient Diabetes Immunocompromised, history of stones Urologic history Not responding to therapy Most appropriate is CT abdomen and pelvis without and with contrast

22 Example Scenario #2 35 year old male with long history of crampy abdominal pain and diarrhea Lab studies demonstrate iron deficiency anemia Family history of Crohn s disease

23 Workup using ACR Appropriateness Criteria Crohn s disease First presentation in an adult CT enterography highly preferred MR enterography also can be considered

24 Workup using ACR Appropriateness Criteria Other scenarios to consider Known Crohn s with worsening symptoms Standard CT with contrast and CT enterography equally good Known Crohn s with mild symptoms or surveillance CT enterography best Children or young adults Consider MR enterography

25 Example Scenario #3 45 year old female with right upper quadrant pain after eating Ultrasound demonstrates gallstones Also 2 cm echogenic lesion within the liver No history of liver disease or risk factors for liver disease No known primary malignancy

26 Workup using ACR Appropriateness Criteria Liver lesion > 1 cm, incompletely characterized Patient with no liver disease or known malignancy MRI without and with contrast best study CT without and with contrast slightly less preferred

27 Workup using ACR Appropriateness Criteria Other scenarios Patient with liver disease MRI without and with contrast best study CT without and with contrast less preferred Consider biopsy Patient with known primary malignancy MRI without and with contrast best study CT without and with contrast or CT with contrast slightly less preferred Consider biopsy

28 Try it out! ACR Appropriateness Criteria

CT abdomen with and without intravenous contrast is appropriate in which of the following situations: A. To evaluate a focal hepatic lesion 20% 20% 20% 20% 20% B.

29 CT abdomen with and without intravenous contrast is appropriate in which of the following situations: A. To evaluate a focal hepatic lesion 20% 20% 20% 20% 20% B. To evaluate a focal pancreatic lesion C. To evaluate a focal renal lesion D. To evaluate a focal adrenal lesion E. All of the above, but MRI may sometimes be more appropriate than CT A. B. C. D. E.

30 What is the name of the website which can be used to find the most appropriate radiologic workup for a given condition? A. ACR Practice Guidelines 20% 20% 20% 20% 20% B. ACR Consensus Statements C. ACR White Paper on the Management of Incidental Findings D. ACR Appropriateness Criteria E. ACR Decision Making Criteria A. B. C. D. E.

The Lewin Group undertook the following steps to identify the guidelines relevant to the 11 targeted procedures:

The Lewin Group undertook the following steps to identify the guidelines relevant to the 11 targeted procedures: Guidelines The following is a list of proposed medical specialty guidelines that have been found for the 11 targeted procedures to be included in the Medicare Imaging Demonstration. The list includes only