G a s t r o i n t e s t i n a l I m a g i n g • C l i n i c a l Pe r s p e c t i ve

Pickhardt
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Positive Oral Contrast Material for Abdominal CT

Gastrointestinal Imaging
Clinical Perspective

Positive Oral Contrast Material for

FOCUS ON:

Abdominal CT: Current Clinical

Indications and Areas of Controversy
Perry J. Pickhardt 1 OBJECTIVE. The use of positive oral contrast material for abdominal CT is a frequent
protocol issue. Confusion abounds regarding its use, and practice patterns often appear ar-
Pickhardt PJ bitrary. Turning to the existing literature for answers is unrewarding, because most studies
are underpowered or not designed to address key endpoints. Even worse, many decisions are
now being driven by nonradiologists for throughput gains rather than patient-specific consid-
erations. Herein, the current indications for positive oral contrast material are discussed, in-
cluding areas of controversy.
CONCLUSION. As radiologists, we owe it to our patients to drive the appropriate use
of positive oral contrast material. At the very least, we should not allow nonradiologists to re-
strict its use solely on the basis of throughput concerns; rather, we should allow considerations
of image quality and diagnostic confidence to enter into the decision process. Based on dif-
ferences in prior training and practice patterns, some radiologists will prefer to limit the use
of positive oral contrast material more than others. However, for those who believe (as I do)
that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably)
make a major impact on diagnosis, it behooves us to keep fighting for its use.

he use of positive oral contrast believes that positive oral contrast material

T material for abdominal CT dates

Keywords: abdominal CT, CT contrast material,
oral contrast material
doi.org/10.2214/AJR.19.21989
Received July 10, 2019; accepted after revision
August 13, 2019.
P. J. Pickhardt is an advisor to Bracco and a shareholder
in SHINE, Elucent, and Cellectar Biosciences.
Supported by Bracco.
1
Department of Radiology, University of Wisconsin
School of Medicine & Public Health, E3/311 Clinical
Science Center, 600 Highland Ave, Madison, WI
53792-3252. Address correspondence to P. J. Pickhardt
(ppickhardt2@uwhealth.org).
AJR 2020; 215:69–78
ISSN-L 0361–803X/20/2151–78
© American Roentgen Ray Society
back to the earliest days of scan-
ning [1–3]. Initially, long scan-
ning times leading to motion artifact, as well
as thick sections with noncontiguous inter-
vals, made positive oral contrast material a
valuable asset for abdominal assessment.
With the many subsequent advancements in
CT technology, the role of enteric contrast
material has since evolved and been further
refined over time. Substantial practice-specif-
ic variations now exist among radiologists,
with some branding positive oral contrast ma-
terial as largely old-fashioned and rarely us-
ing it for routine scanning, whereas others
continue to rely on it for a wide variety of in-
dications. A disturbing recent trend, however,
is the increasing decision to forego positive
oral contrast material largely (or solely) for
increased patient throughput, typically driven
by nonradiologists such as emergency depart-
ment (ED) physicians, surgeons, and even
health system administrators [4, 5]. As radi-
ologists, we need to ensure that such finan-
cially driven nonmedical justifications are in
the best interest of our patients. This issue ul-
timately circles back to whether or not one
adds enough clinical benefit to offset relative-
ly small temporal increases in turnaround
time and ED length of stay, which are typi-
cally on the order of 30–40 minutes [4, 5].
However, objectively measuring the true clin-
ical value of positive oral contrast material is
difficult. Simply comparing overall diagnos-
tic rates or recall rates fails to consider the
more subjective but critical issue of diagnos-
tic confidence or certainty. The existing med-
ical literature is largely devoid of properly de-
signed and powered studies to fairly and
adequately address the key questions. Fur-
thermore, many underpowered studies (n <
500 patients) allow the possibility of unin-
tended bias related to preconceived hypothe-
ses relating to positive oral contrast material
use [6–8]. On the other hand, although anec-
dotal cases in which the use of positive oral
contrast material made a positive diagnostic
impact are readily available (Figs. 1–10),
there are few if any landmark clinical studies
to date that clearly show the benefit of posi-
tive oral contrast material. Thus, expert opin-
ion may represent the best available alterna-
tive, but this source also unavoidably reflects
personal preferences [9–11].

AJR:215, July 2020 69

 Pickhardt
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This article will review the current role of of agents used for fluoroscopy. In general, wa-
positive oral contrast material for abdominal ter-soluble iodinated agents are now favored
CT in adults, including clinical indications in by many over barium for most routine CT in-
which its use is generally accepted as well as dications [12, 13]. However, barium contrast
those indications in which positive oral con- material still accounts for a greater total vol-
trast material is best avoided. From there, ume of abdominal CT studies compared with
the focus will turn toward areas of contro- the water-soluble iodinated agents for positive
versy in which wider variations in practice oral contrast material. Furthermore, the low-
patterns exist. Beyond patient-specific indi- osmolar nonionic iodinated agents are gener-
cations and throughput concerns, many ad- ally preferred over older high-osmolar ionic
ditional factors may further influence the de- contrast agents because of improved palatabil-
cision to use positive oral contrast material, ity and safety index as well as the now com-
which will also be considered. parable cost [12–16]. Neutral enteric contrast
agents have a waterlike attenuation and also
Categories of Enteric Contrast include water. Most nonwater neutral agents
Material for Abdominal CT have a nonabsorbable component to promote
There are several classes of enteric contrast luminal distention for CT enterography [17]. It
material for CT, which can be broadly cate- should be emphasized that not providing any
gorized according to their attenuation values enteric contrast material is not equivalent to
relative to the intrinsic waterlike succus of the neutral agent approach, because the lack
the gastrointestinal tract. Higher-attenuation of distention will limit bowel evaluation and
positive contrast agents that are used for both potentially create pseudolesions [10, 18]. Hy-
fluoroscopy and CT include barium sulfate brid approaches include the so-called “ED
and iodinated water-soluble agents. For CT, appy cocktail” used at my institution, which
the concentration of these agents is of course combines a positive iodinated agent for opaci-
markedly diluted relative to the concentration fication and neutral agents (i.e., polyethylene
TABLE 1: Positive Oral Contrast Material Use at Abdominal CT: Indications,
Contraindications, and Areas of Controversy
Positive Oral Contrast Material Use Indication
Is generally indicated Suspected postoperative bowel leaka
Suspected gastrointestinal fistulaa
Suspected interloop abscess or other fluid collectiona
Oncologic staging and surveillancea
CT colonographyb
Nonspecific abdominal pain or other symptoms (subacute)a
Is not helpful, is best avoided, or is CT enterographyc
contraindicated
Suspected mesenteric ischemia
Suspected intraabdominal hemorrhage or gastrointestinal bleeding
CT angiography
Blunt abdominal trauma (acute)
High risk for aspiration
Hepatobiliary and pancreatic indications
Genitourinary indications (urography, urolithiasis, renal and adrenal
lesions)
Is an area of controversy Nontraumatic abdominal pain (acute)
Suspected appendicitis
Suspected small-bowel obstruction
Crohn disease (acute)
Penetrating abdominal trauma
aWater-soluble nonionic contrast material is generally preferred.
bBoth iodinated contrast material and barium contrast material are often combined for CT colonography.
cNeutral enteric contrast material is indicated.
70
glycol [PEG]–water mix) for increased lumi-
nal distention and transit [19]. Finally, nega-
tive air or carbon dioxide gas can serve as an
effective enteric contrast agent, most notably
for routine CT colonography (CTC) [20], but
also for problem-solving in gastric and small-
bowel evaluations [21, 22].
Specifics related to oral contrast protocols
in terms of timing and volume regimens will
not be covered in detail in this article. In ad-
dition, enteric contrast material can also be
administered by nonoral routes, including per
rectum and via enteric catheters. This article
will focus on oral contrast administration—
specifically, positive oral contrast material.
Generally Accepted Indications for
Positive Oral Contrast Material Use
at Abdominal CT
There are certain indications for which
positive oral contrast material is clearly ben-
eficial (Table 1). Obvious examples include
confirmation of suspected postoperative
bowel leak and suspected fistula formation
involving the gastrointestinal tract [23, 24]
(Fig. 1). Although the use of positive oral con-
trast material in evaluating for extraluminal
abdominal fluid collections is less essential in
the modern MDCT era because of increased
spatial resolution and soft-copy review, it can
still be valuable in the setting of interloop ab-
scesses (Fig. 2). In general, the conspicuity of
extraluminal fluid collections is greatly im-
proved by opacified adjacent bowel loops.
CTC represents another obvious indica-
tion for positive oral contrast material, pref-
erably with both dilute barium sulfate (for
tagging of solid residual fecal material and
for surface coating of flat lesions) and wa-
ter-soluble iodinated contrast material (for
opacifying residual luminal fluid and for
providing and additional catharticlike effect)
[25–27]. This regimen is particularly rele-
vant for the detection of flat, right-sided ses-
sile serrated lesions [28, 29].
Another indication for positive oral con-
trast material is oncologic staging and sur-
veillance, particularly for tumors prone to
peritoneum- and bowel-based involvement
(Figs. 3 and 4). In this nonurgent and con-
trolled outpatient setting, patient throughput
is less of a concern, and oral contrast proto-
cols can be planned for ahead of time. Cer-
tain studies have argued that positive oral
contrast material may be unnecessary in this
setting [7], but limitations of these studies
include inadequate and underpowered end-
points and lack of control groups. Further-
AJR:215, July 2020
 Positive Oral Contrast Material for Abdominal CT
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more, the editorial tone of some publication
titles may suggest a preconceived bias.
Abdominal CT for nonspecific abdominal
pain or other vague symptoms in the subacute
outpatient setting often represents a hunt for
the unknown. Even if the pretest probability
for serious disease is relatively low, the goal
of excluding an unlikely but relevant disease
process remains. Lacking a specific target,
the comprehensive nature of an abdominal
CT evaluation when performed with both
oral and IV contrast media makes it an ide-
al test for this common scenario. Again, pa-
tient throughput is less of an issue relative to
achieving an optimal examination.
Indications for Which Positive Oral
Contrast Material Is Best Avoided or
Contraindicated
Table 1 also lists typical clinical indica-
tions for which positive oral contrast materi-
al is generally not needed, is best avoided, or
is clearly contraindicated. For CT enterogra-
phy, neutral enteric contrast material is used,
whereas for suspected gastrointestinal bleed-
ing, positive oral contrast material could ob-
scure active luminal extravasation. Some of
the other entities represent relative contrain-
dications in which the presence of positive
oral contrast material is likely of no direct
benefit but would not negatively impact di-
agnosis (e.g., for genitourinary indications).
In cases of bowel wall thickening, includ-
ing mesenteric ischemia, enteritis, and angio-
edema, the negative impact of positive oral
contrast material on the assessment of muco-
sal enhancement is often cited, but the ability
to assess for low-attenuation intramural ede-
ma is generally not affected and is more vi-
tal to diagnosis (Fig. 5). One CT enteroclysis
study found that positive oral contrast mate-
rial allowed improved ileocecal evaluation
over neutral enteric contrast material [30].
For CT angiography, positive oral contrast
material would impact the appearance of 3D
volume-rendered vascular images but would
likely not affect diagnostic evaluation of the
more important 2D source images.
For some cases for which positive oral
contrast material is often considered detri-
mental, it may actually help delineate key
findings (Fig. 6). In the past, positive oral
contrast material was used by some in the
setting of blunt abdominal trauma [31], but
numerous subsequent studies have shown
that its omission saves time, decreases costs,
and decreases the risk of aspiration without
AJR:215, July 2020
impacting accuracy [32, 33]. Regarding po-
tential aspiration risk, my colleagues and I
have noticed in our ED practice that this rea-
son is often abused and exaggerated in the
setting of acute nontraumatic abdominal
pain to circumvent the use of positive oral
contrast material. This inappropriate avoid-
ance of positive oral contrast material use re-
sults in limited bowel assessment, which may
impact both diagnostic confidence and over-
all accuracy.
Areas of Controversy for Positive
Oral Contrast Material Use
Although positive oral contrast material
practice patterns may vary widely for even
the relatively straightforward indications and
contraindications discussed earlier, the true
controversy primarily centers around the
acute indications listed in the third section
of Table 1. CT has revolutionized the evalu-
ation of acute nontraumatic abdominal pain
and is now an indispensable tool in this set-
ting [34–38]. Numerous studies using a vast
array of protocol variations have investigat-
ed the performance of CT for appendicitis,
and direct comparison of older, disparate ap-
proaches is fraught with uncertainty [39].
However, I believe that the highest accuracy
can be achieved with both oral and IV con-
trast media over unenhanced techniques [40,
41] (Fig. 7). Perhaps even more importantly,
although attention is often focused solely on
acute appendicitis [39], approximately 75%
of adults with suspected appendicitis will in
fact be experiencing symptoms from some-
thing else [40, 42]. Considering only a mi-
nority of patients who undergo appendecto-
my misses the point that, in actual practice,
CT evaluation must broadly assess for alter-
native conditions in the majority of patients.
Although positive oral contrast material al-
lows assessment of luminal opacification
of the appendix (highly specific for exclud-
ing appendicitis) [43], it can contribute even
more to the wide array of potential alterna-
tive diagnoses, whether appendiceal in na-
ture (Fig. 8) or more likely something else
[42, 44] (Fig. 9). This is true regardless of
whether abdominal symptoms are diffuse or
specific to a quadrant [38].
Before imaging, it is difficult or impossi-
ble to predict in advance which patient scans
will truly benefit from positive oral contrast
material in terms of diagnostic assessment
(Fig. 9), but the same can be said of IV con-
trast material. Therefore, it seems prudent to
optimize the diagnostic evaluation for this
important clinical setting by using both oral
and IV contrast media whenever feasible. In
a recent study, my colleague and I analyzed
IV contrast-enhanced CT scans of 1000 pa-
tients presenting to the ED with pain focused
on a specific abdominal quadrant (250 con-
secutive patients for each quadrant) [38] and
found that more than 90% of patients re-
ceived positive oral contrast material.
The existing literature includes many un-
derpowered cohorts attempting to address
the issue of positive oral contrast material for
acute nontraumatic abdominal pain. Study
endpoints including overall positive rates, re-
call rates, and simple agreement rates [6, 8,
45] likely require much larger cohorts and
fail to effectively measure the effect on diag-
nostic confidence. In our prospective experi-
ence involving more than 1400 ED patients
undergoing CT for nontraumatic abdominal
pain, diagnostic confidence was significantly
higher for cases in which positive oral con-
trast material was used (Triche BL, et al.,
presented at the Society of Abdominal Ra-
diology 2019 annual meeting). Another large
study found that both diagnostic ability and
confidence improved with enteric contrast
material (positive or neutral) compared with
no contrast material [18]. Of course, these re-
sults may in part reflect the comfort level of
a given practice with positive oral contrast
material. Similar to other large studies [4,
5], my colleagues and I have found that posi-
tive oral contrast material use in more than
10,000 patients added approximately 30–40
minutes on average to the ED length of stay
(Pickhardt PJ, unpublished data). What it re-
ally boils down to is whether the increased
diagnostic confidence related to positive oral
contrast material use justifies this relatively
small increase in time; in our practice, we
believe that it generally does.
Some may consider suspected small-bow-
el obstruction (SBO) to be a contraindica-
tion for positive oral contrast material [46],
but my colleagues and I have found it to be
quite useful in our practice [47]. As with sus-
pected appendicitis, CT in a significant sub-
set of patients with suspected SBO will ac-
tually prove to have no clinically significant
mechanical obstruction, so a more general
assessment of these patients is needed. In the
setting of SBO, however, the ­functional infor-
mation and even the therapeutic effect pro-
vided by positive oral contrast material make
it a valuable asset and may offset any added
71

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patient discomfort. Even when the transition
point is not reached at the time of scanning,
which is common, the water-soluble iodin-
ated contrast material provides a contrast
challenge nevertheless. This contrast chal-
lenge is effective in predicting the need for
surgery in patients with adhesive SBO and
can shorten hospital stays [48]. Even beyond
patients with SBO, the therapeutic effect of
administered water-soluble contrast materi-
al will also benefit patients presenting to the
ED with constipation from opioid use or oth-
er causes, which is a common scenario [49].
For more routine outpatient evaluation of
Crohn disease, including assessment of re-
sponse to treatment or mild disease flares, CT
and MR enterography are generally the pre-
ferred imaging tests. However, in the acute
ED setting of severe disease, my colleagues
and I typically perform standard abdomi-
nal CT with oral and IV contrast media. The
use of both oral and IV contrast media allows
better delineation of phlegmon, interloop ab-
scesses, and fistulous communications (Figs.
1 and 2). In addition, patients with severe
Crohn disease may have more difficulty tol-
erating the larger volumes and luminal disten-
tion associated with enterography protocols.
Although there is now general agree-
ment that positive oral contrast material is
best avoided in the setting of serious blunt
abdominal trauma [32, 33], controversy sur-
rounds its use in penetrating trauma. Some
argue that the increased specificity provid-
ed by showing extraluminal contrast mate-
rial may justify its use. However, contrast
leakage is seen in only 15–30% of cases, and
positive oral contrast material will not de-
tect partial-thickness serosal injuries in need
of repair [50]. Comparable performance has
been shown with IV contrast material–only
protocols [50]. Thus, the use of positive oral
contrast material for penetrating trauma in
the acute setting does not appear to justify
the delay in initial imaging related to its use,
except perhaps on a case-by-case basis.
Other Issues to Consider
Beyond the patient-specific indications
and throughput concerns discussed, many
additional factors may further influence the
decision about whether to use positive oral
contrast material. The issue of diagnostic
confidence has already been mentioned, but
it deserves further consideration. Unlike call-
back rates and other metrics, confidence in
diagnosis is somewhat subjective and there-
72
Pickhardt
fore is more difficult to measure. However,
the critical difference between a definite CT
diagnosis versus less confident levels such
as “likely,” “possible,” or “cannot exclude”
is worthy of emphasis and is generally not
reflected in accuracy calculations. Among
some practice groups who have abruptly
abandoned positive oral contrast material
use, increased hedging in reports related to
limited bowel evaluation has reportedly led
to repeat scanning and other negative devel-
opments [51]. This effect is of course prac-
tice-specific, because comfort levels without
positive oral contrast material will vary relat-
ed to training and experience, but the impact
can be particularly strong in academic cen-
ters where trainees are on call or practices
where nonspecialist coverage is provided.
Many practices have instituted body mass
index (BMI)-based protocols for which only
thinner patients routinely receive positive
oral contrast material. Although the rationale
is that large patients with increased amounts
of visceral fat will benefit less from positive
oral contrast material, studies have failed to
show a BMI-dependent difference related to
positive oral contrast material use [52, 53].
Therefore, these approaches add complex-
ity to the protocol process without a clear-
cut benefit. In the end, individual practices
should probably decide whether or not they
believe the net gain from positive oral con-
trast material administration justifies its use
without consideration of BMI.
Delayed transit of positive oral contrast ma-
terial at the time of scanning will diminish its
diagnostic yield in some cases. For example,
if appendicitis is the leading clinical concern,
cecal opacification is required for positive oral
contrast material to make an effective contri-
bution (although it may still contribute to al-
ternative diagnoses). Some studies have shown
that contrast material may not reach the co-
lon in a substantial minority of patients [54].
As I mentioned earlier, adding nonabsorbable
agents such as PEG will hasten transit [19].
Other studies have shown delayed gastric emp-
tying [46], which may reflect adynamic ileus
from the acute process, or underlying gastro-
paresis or gastric outlet obstruction (and there-
fore contribute to the diagnosis).
Issues related to patient acceptance have
been briefly discussed earlier. Although oral
contrast regimens add some burden for pa-
tients, one study found that nearly 90% would
be willing to do it assuming there was some
associated potential benefit [55]. In general,
positive oral contrast material is remarkably
safe and serious side effects are exceeding-
ly rare. For low-energy scanning (low-kilo-
volt), including low-kiloelectron-volt images
for dual-energy CT, the concentration of the
positive oral contrast material can be further
reduced [56, 57]. Finally, a small increase in
radiation dose (on the order of 10%) may be
associated with the use of positive oral con-
trast material with automated exposure con-
trol [58], but this factor is likely negligible in
the overall decision process.
Conclusion
The role of positive oral contrast material
for abdominal CT in everyday practice con-
tinues to evolve. Many factors influence the
decision on its use, and there is often no sim-
ple answer, but indication-specific consider-
ations should generally hold sway. Oral con-
trast material (whether positive or neutral)
can reduce diagnostic error and can increase
diagnostic confidence. I believe that there is
definitely still a role for positive oral contrast
material in modern state-of-the-art abdomi-
nal CT. As radiologists, we owe it to our pa-
tients to drive the appropriate use of positive
oral contrast material. At the very least, we
should not allow nonradiologists to restrict
its use solely on the basis of throughput con-
cerns; rather, we should allow considerations
of image quality and diagnostic confidence
to enter into the decision process. Based on
differences in prior training and practice pat-
terns, some radiologists will prefer to lim-
it the use of positive oral contrast material
more than others. However, for those who
believe (as I do) that positive oral contrast
material can genuinely increase diagnostic
confidence and can sometimes (rather unpre-
dictably) make a major impact on diagnosis,
it behooves us to keep fighting for its use.
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Fig. 1—Positive oral contrast material for confirming
gastrointestinal leak and fistula. (Reprinted with
permission from Pickhardt PJ, Bhalla S, Balfe DM.
Radiology, 2002, vol. 224, 9–23 © Radiological
Society of North America)
A, Oral and IV contrast-enhanced CT image of
78-year-old man who had previously undergone
surgery for abdominal wall abscess related to
diverticular disease shows enteric contrast agent
(arrow) leaking via colocutaneous fistula from
sigmoid colon into abdominal wall defect.
B, Oral and IV contrast-enhanced CT scan of
24-year-old man with Crohn disease shows marked
bowel wall thickening and surrounding mesenteric
infiltration, with luminal contrast material outlining
multiple ileocolic and colocolic fistulous tracts
(arrows).
AJR:215, July 2020
 Positive Oral Contrast Material for Abdominal CT
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Fig. 2—Interloop abscesses in setting of active

Crohn disease.
A and B, Transverse (axial) (A) and coronal (B) oral
and IV contrast-enhanced CT images of 24-year-
old man show marked bowel wall thickening and
mesenteric inflammation, including complex air- and
fluid-filled mesenteric abscess (arrows). Positive
luminal contrast material within adjacent bowel loops
allows confident diagnosis of extraluminal interloop
abscess.
C and D, Transverse (axial) (C) and coronal (D) IV
contrast-enhanced CT images obtained without
oral contrast material of 24-year-old woman show
phlegmonous changes in right lower quadrant,
but differentiation between thickened bowel and
surrounding mesenteric inflammation is poor
because of lack of positive oral contrast material.
Multiple complex air- and fluid-filled mesenteric
abscesses (arrows) were missed at initial
interpretation of these images. These collections had
increased in size on follow-up imaging (not shown).

A B

C D

Fig. 3—Positive oral contrast material for increasing

conspicuity of peritoneal metastatic disease.
A and B, Oral and IV contrast-enhanced CT images
of 49-year-old woman with history of small-bowel
gastrointestinal stromal tumor show multiple small
peritoneum-based soft-tissue implants (arrows),
consistent with development of metastatic disease.
These tumors would likely be much more difficult
to detect without positive oral contrast material
throughout adjacent bowel.
A B

AJR:215, July 2020 75

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A B C
Fig. 4—Positive oral contrast material for depicting typical malignancies involving small bowel.
A, Oral and IV contrast-enhanced CT image of 69-year-old man shows multiple foci of hematogenous metastases from melanoma on this single image. Oral contrast
material improves conspicuity of these lesions, some of which are partially intussuscepting.
B, Oral and IV contrast-enhanced CT image of 68-year-old man shows large cavitary mass in central pelvis. Presence of oral contrast material centrally confirms
communication with gastrointestinal tract, clue to diagnosis of malignant small-bowel gastrointestinal stromal tumor, which was proven after surgery.
C, Oral and IV contrast-enhanced CT image of 52-year-old man shows multifocal areas of marked eccentric small-bowel wall thickening. Presence of positive oral
contrast material allows confident localization of abnormal soft tissue that, along with lack of obstruction and associated mesenteric lymphadenopathy, is highly
suggestive of lymphoma. This case proved to be mantle cell lymphoma.

Fig. 5—Positive oral contrast material in setting of

small-bowel wall thickening from angioedema.
A and B, Oral and IV contrast-enhanced CT images
of 47-year-old woman (A) and 35-year-old woman
(B) presenting with acute nontraumatic abdominal
pain show multiple thickened small-bowel loops.
Presence of positive oral contrast material in
involved segments may impact assessment of
mucosal enhancement but does not diminish visibility
of low-attenuation intramural thickening or serosal
enhancement. Pattern of small-bowel wall thickening
is compatible with nonneoplastic edema, which can
be seen in inflammatory, infectious, and ischemic
causes. However, both cases proved to be due to
angioedema related to angiotensin-converting
enzyme inhibitor therapy, another important cause to
consider in this setting.
A B

Fig. 6—Positive oral contrast material showing

gastroduodenal fistulas in setting of malignant
intraductal papillary mucinous neoplasia (IPMN) of
pancreas.
A and B, Coronal oral and IV contrast-enhanced CT
images of 76-year-old man show bizarre, branching
low-attenuation process (asterisks) centered in
pancreas that massively expands ductal system. In
addition, fistulization with stomach (arrows, A) and
broad communication with duodenum (arrows, B) are
nicely depicted by oral contrast material interface.
Findings are compatible with IPMN, which proved to
have malignant component at surgery.
A B

76 AJR:215, July 2020

 Fig. 7—Positive oral contrast material in diagnosis of
Positive Oral Contrast Material for Abdominal acute
CT appendicitis.
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A, Coronal oral and IV contrast-enhanced CT image

of 32-year-old man shows dilated fluid-filled appendix
(arrowhead) that fails to opacify with positive oral
contrast material. Given absence of thickened or
enhancing appendiceal wall, lack of contrast filling of
appendiceal lumen is useful clue to diagnosis.
B, Coronal oral and IV contrast-enhanced CT image
of 40-year-old man shows thickened enhancing
appendiceal wall (arrowhead) as well as unopacified
luminal fluid that fails to communicate with adjacent
cecal contrast material. In general, use of both oral
and IV contrast media can allow more confident
diagnosis.

A B

Fig. 8—Positive oral contrast material in diagnosis of

other acute appendiceal conditions.
A, Curved reformatted coronal oral and IV contrast-
enhanced CT image of 31-year-old man presenting
with right lower quadrant pain shows appendiceal
mucocele (arrow) intussuscepting into ascending
colon. Good opacification of surrounding bowel
allows confident diagnosis. Low-grade mucinous
neoplasm was confirmed after surgery.
B, Curved reformatted coronal oral and IV contrast-
enhanced CT image of 59-year-old man presenting
with right lower quadrant pain shows another
mucocele of appendix (asterisk). Symptoms were
related to acute torsion about appendiceal base
(arrowheads). Good opacification of surrounding
bowel again allows confident diagnosis. Low-grade
mucinous neoplasm was confirmed after surgery.
(Reprinted from [44])

A B

Fig. 9—Positive oral contrast material in setting of

acute nontraumatic abdominal pain (nonappendiceal
causes).
A, Coronal oral and IV contrast-enhanced CT
image of 21-year-old man with right lower quadrant
pain shows mildly inflamed, blind-ending loop of
unopacified small bowel (arrow), extending off distal
ileum. Confident detection of Meckel diverticulitis
might have been much more challenging without
positive oral contrast material opacifying adjacent
normal small-bowel loops. Note also normal air-filled
appendix (arrowhead).
B, Coronal oral and IV contrast-enhanced CT image
of 68-year-old woman shows perforated benign
peptic ulcer (arrowheads) in pyloric channel region
that is outlined by positive oral contrast material.
Extraluminal contrast material in lesser sac (arrow)
surrounds undersurface of left hepatic lobe. Marked
low-attenuation gastroduodenal wall thickening
surrounds native lumen (asterisk), but other bowel
loops appear thickened from associated peritonitis.
Scan was obtained as CT angiogram to evaluate for
aortic dissection after oral contrast material had
already been administered. However, without use
of positive oral contrast material in this case, the
inadvertent diagnosis might have been quite difficult.
A B

AJR:215, July 2020 77

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Fig. 10—Positive oral contrast material in setting of

small-bowel obstruction (SBO). Patient is 57-year-
old man who presented with abdominal pain and
distention.
A, Coronal oral and IV contrast-enhanced CT image
shows multiple dilated fluid-filled loops of small
bowel with transition point at surgical anastomosis
(arrow); these findings are compatible with SBO.
B, Although positive oral contrast material does not
directly contribute to CT-based diagnosis, supine
frontal abdominal radiograph obtained 2 days after
A shows contrast material in colon, indicating
successful nonoperative management of SBO.
This approach of water-soluble contrast challenge
benefits from diagnostic CT evaluation, which
confirms initial diagnosis, identifies transition point,
and can be used to assess for signs of early vascular
compromise, among other abnormal findings.

A B

78 AJR:215, July 2020