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

Callahan et al.
Enteric Contrast Media in Pediatric Patients

Pediatric Imaging
Clinical Perspective

The Use of Enteric Contrast

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Media for Diagnostic CT, MRI, and

FOCUS ON:

Ultrasound in Infants and Children:

A Practical Approach
Michael J. Callahan1 OBJECTIVE. Enteric contrast media are commonly administered for diagnostic cross-
Jennifer M. Talmadge2 sectional imaging studies in the pediatric population. The purpose of this manuscript is to re-
Robert MacDougall1 view the use of enteric contrast media for CT, MRI, and ultrasound in infants, children, and
Carlo Buonomo1 adolescents and to share our experiences at a large tertiary care pediatric teaching hospital.
George A. Taylor 1 CONCLUSION. The use of enteric contrast material for diagnostic imaging in infants
and children continues to evolve with advances in imaging technology and available enteric
Callahan MJ, Talmadge JM, MacDougall R, contrast media. Many principles of enteric contrast use in pediatric imaging are similar to
Buonomo C, Taylor GA those in adult imaging, but important differences must be kept in mind when imaging the gas-
trointestinal tract in infants and children, and practical ways to optimize the imaging exami-
nation and the patient experience should be employed where possible.

he American College of Radiol-

T
Radiation Dose Considerations
ogy (ACR) manual on contrast Iodine and barium have relatively large
media provides an excellent re- atomic numbers of 53 and 56, respectively,
view of the use of enteric con- which result in an increase in the photoelectric
trast media for diagnostic imaging of adults effect when imaging with CT, substantially in-
[1]. However, few guidelines exist for the creasing the linear attenuation coefficient of the
use of enteric contrast media for cross-sec- target tissues. As a result, studies have shown
tional imaging in the pediatric population. that the presence of attenuating enteric contrast
We review the use of enteric contrast media media can cause a nominal increase in pre-
for CT, MRI, and ultrasound in infants, scribed tube current compared with an unen-
children, and adolescents and share our ex- hanced scan when automated exposure control
periences at a large tertiary care pediatric (AEC) is used [2]. However, the resulting mod-
teaching hospital. est radiation dose increase is similar to other
sources of variation in AEC algorithms, such
CT as patient positioning, number of localizer im-
Keywords: adolescents, children, CT, enteric contrast Enteric contrast media improve visualiza- ages, and localizer technical factors [3].
media, infants, MRI, pediatric, ultrasound tion of bowel for abdominal CT and can in- The presence of enteric contrast media in-
crease the conspicuity of surrounding anat- herently increases subject contrast due to in-
DOI:10.2214/AJR.15.15437
omy and pathology. Enteric contrast media creased overlap of the CT energy spectrum
Received August 11, 2015; accepted after revision used for CT can be positive (i.e., hyperatten- and the k edge of iodine and barium. This im-
December 13, 2015. uating) or neutral (i.e., relatively similar in proved contrast potentially affords a decrease
attenuation to water). Positive contrast media in patient radiation dose because image noise
are typically iodine-based or dilute barium- can be increased while maintaining the con-
1
Department of Radiology, Boston Children’s Hospital,
300 Longwood Ave, Boston, MA 02115. Address
correspondence to M. J. Callahan
based (i.e., 2.0%). Commercially available trast-to-noise ratio. Image contrast can be im-
(michael.callahan@childrens.harvard.edu). neutral contrast media are typically barium- proved further with low-kilovoltage imaging
based but are diluted to a greater extent than (e.g., 80–100 kV), particularly in smaller pa-
positive CT contrast media (i.e., 0.1%). Water tients [4]. This approach comes with several
2
Maine Medical Center, Portland, ME.
or other ingestible fluids can also be used as important caveats. First, a noise limit exists
AJR 2016; 206:973–979 neutral enteric contrast media in certain sit- where improvements in image contrast do not
0361–803X/16/2065–973
uations. Bowel gas serves as a naturally oc- improve image quality for small structures,
curring negative enteric contrast medium for which can be masked by image noise [5]. Sec-
© American Roentgen Ray Society abdominal CT studies. ond, images obtained at low-kilovoltage set-

AJR:206, May 2016 973

 Callahan et al.

(Gastrografin, Bracco Diagnostics; Gastro- threatening reactions can occur unpredict-

view, Covidien) are approved by the U.S. ably. Iodinated enteric contrast media should
Food and Drug Administration for enteric be administered only when properly trained
use and are commonly used in adults for ab- caregivers equipped to provide treatment of
dominal CT. However, if these contrast me- such reactions are available.
dia are not diluted appropriately, their high
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osmolar content can result in dangerous flu- Positive CT Contrast Media

id shifts and electrolyte disturbances in neo­ Opinions vary regarding the need for enter-
nates and small children because patients in ic contrast media for pediatric abdominal CT
those age groups have relatively low plas- studies [9, 10]. Although advances in CT spa-
ma volume. Risks of aspiration pneumonia tial resolution and multiplanar reformations
have also been described [6, 7], although have rendered enteric contrast media less crit-
the reported risks of adverse events includ- ical for certain CT diagnoses, it remains an
ing aspiration pneumonia are extremely low, important adjunct for abdominal CT. Positive
Fig. 1—Polyvinyl chloride tubes (approximate wall even when an HOCM is administered. enteric contrast media can be particularly use-
thickness, 0.2 cm; approximate inside diameter, 1.5 Dilute iodine-based low-osmolar contrast ful in small children, who tend to have a pau-
cm) filled with air (A), ioversol 320 (B), and diluted media (LOCM) can be substituted for dilute di- city of retroperitoneal and intraperitoneal fat,
ioversol 320 according to our institution’s oral
preparation guidelines (C). Axial CT images obtained atrizoate meglumine as enteric contrast media limiting intrinsic subject contrast between the
with abdomen and bone window settings show streak for CT studies. Virtually any HOCM or LOCM bowel and solid organs [11].
artifact from undiluted ioversol 320 (arrows). Note used as IV contrast material can be diluted and Iodine-based enteric contrast media used
apparently similar density of ioversol 320 and dilute
ioversol with abdomen window setting, and relative
used for contrast-enhanced CT. A comprehen- for fluoroscopic imaging must be diluted to
difference in density with bone window setting. sive list of similar water-soluble iodinated con- avoid streak artifact on CT (Fig. 1). Barium
trast media can be found in Appendix A of the sulfate suspensions routinely used for fluo-
tings are more susceptible to streak and beam ACR Manual on Contrast Media [1]. Dilute io- roscopy will cause streak artifact on diagnos-
hardening artifact and should be limited to dine-based LOCM have a substantially lower tic CT images (Fig. 2), potentially obscuring
small patients to avoid tube-peaking. osmolality than dilute diatrizoate meglumine disease or abnormality. However, certain di-
In our opinion, enteric contrast media at the concentrations typically used for CT, and lute barium-based enteric contrast media are
can facilitate certain image diagnoses while the risks of aspiration pneumonia and pulmo- commercially available at appropriate con-
maintaining lower radiation doses for pediat- nary edema from dilute iodine-based LOCM centrations for CT [1]. In the setting of bowel
ric patients. As such, the potential benefit of are likely as low, if not lower, than risks asso- perforation, dilute barium sulfate suspension
enteric contrast media for pediatric abdomi- ciated with oral administration of dilute diatri- is relatively contraindicated and dilute water-
nal CT studies generally outweighs the small zoate meglumine. However, even LOCM are soluble iodine-based contrast media are gen-
potential risk from any marginal increase in hyperosmolar relative to normal serum and erally thought to be safer [1].
radiation dose. should be administered with some caution. We use dilute iodine-based LOCM for CT
The risks of anaphylactoid reactions from evaluation of generalized abdominal pain,
CT Contrast Media Risks enteric administration of water-soluble io- suspected intraabdominal abscesses or fluid
Dilute high-osmolar contrast media dinated contrast media have been described collections, abdominal or pelvic masses, on-
(HOCM) such as diatrizoate meglumine [8]. Although infrequent, severe and life- cology follow-up, or complications of abdom-

Fig. 2—Streak
artifact on CT caused
by barium sulfate
suspension.
A and B, Scout
image (A) and axial
CT image (B) in
10-year-old girl with
right lower quadrant
pain, vomiting, and
leukocytosis who
ingested barium
sulfate 12 hours
earlier for upper
gastrointestinal
examination. Retained
barium sulfate in
colon resulted in
streak artifact on
CT image (B), which
obscured appendix.
A B

974 AJR:206, May 2016

 Enteric Contrast Media in Pediatric Patients

administered such that the first dose is given based contrast media remain within the bowel
90 minutes before the examination, the sec- lumen, decrease water absorption, and help
ond dose 30 minutes before the examination, distend the entire small bowel, which is a dis-
and the third dose just before the CT exami- tinct advantage over the use of water. Neutral
nation if the patient can tolerate it. Our oral CT contrast media allows for improved vi-
contrast mixture can be safely administered sualization of enhancing bowel wall (Fig. 3)
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orally, via a transesophageal catheter, or even compared with positive intraluminal enter-
through an ostomy catheter. ic contrast media, which often decreases the
We do not restrict oral intake for unsedat- conspicuity of bowel wall enhancement.
ed patients before abdominal CT studies. Because patients with inflammatory bow-
Guidelines for oral intake restrictions for el disease often require numerous cross-sec-
patients who require sedation are based on tional imaging studies during their lifetime,
aspiration risk and are determined by anes- we prefer MR enterography when evaluat-
thesiologists at our institution (Table 2). ing inflammatory bowel disease in the non-
The need for rectal contrast media for CT emergent setting to minimize long-term ex-
in children has decreased significantly with posure to ionizing radiation [17, 18]. When
the widespread use of MDCT and multipla- CT enterography is deemed clinically ap-
nar reformats, and we believe that rectal con- propriate, we administer water mixed with
trast material is rarely, if ever, necessary for polyethylene glycol 3350 (PEG) (MiraLAX,
routine diagnostic CT studies when using ­Schering-Plough) in a fashion similar to our
Fig. 3—15-year-old boy with newly diagnosed
Crohn disease and anemia. Patient was unable to modern CT scanner technology. MR enterography protocol, which is detailed
tolerate MRI because of claustrophobia. Study was in the MRI section of this article.
performed with standard departmental mixture Neutral CT Contrast Media Some authors have described the use of
and dosing of polyethylene glycol 3350 and water
45 minutes before CT examination. IV ioversol 320 Neutral contrast media can be used for CT milk as inexpensive neutral oral contrast
was also administered. Coronal reformatted image to distend the lumen of the bowel and to im- material for CT [19, 20]. Milk contains fat,
shows distention of small bowel loops and excellent prove evaluation of the bowel wall. Water is which slows intestinal peristalsis and transit,
visualization of bowel wall (arrow).
the least expensive, safest, and most accessi- making it a somewhat more desirable neu-
ble neutral contrast medium [16]. Water will tral enteric contrast material than water. Koo
inal surgery. We do not use enteric contrast effectively distend the lumen of the stomach and colleagues [19] compared whole milk to
media in the setting of suspected appendici- and proximal duodenum; however, as wa- VoLumen in 215 adult patients and found no
tis, abdominal trauma, suspected acute small- ter passes through the bowel, it will be ab- significant difference with respect to bowel
bowel obstruction, or CT angiography of the sorbed, which limits distention of the more distention and bowel wall visualization but
abdomen and pelvis. In these clinical set- distal small bowel and colon. reported better patient acceptance of milk.
tings, we have found that CT with IV contrast Barium sulfate suspension 0.1% (­VoLumen,
material only can be performed more quickly, Bracco) is a commercially available neutral to MRI
with a similar level of efficacy [12–14]. slightly hyperdense enteric contrast medium Enteric contrast material can be con-
Our routine enteric contrast medium for CT enterography or MR enterography in sidered as positive on MRI, if it results in
for CT is dilute ioversol 320 (Optiray 320, the setting of inflammatory bowel disease
Mallinckrodt). It is also our primary iodine- [17]. VoLumen contains sorbitol, which re- TABLE 2: Oral Intake Restriction
based IV contrast material for our contrast- duces water absorption and increases the vis- Guidelines for Sedation
enhanced CT studies. Dilute ioversol 320 cosity of the intraluminal contents. Sorbitol-
Duration of Intake
is essentially tasteless, which is particular- Restriction Before
ly helpful when administering it to pediat- TABLE 1: Oral Bowel Preparation Type of Liquid or Food Sedation
ric patients. Flavor additives can be used to Doses for CT
Clear liquidsa 2 hr
make dilute iodinated contrast media even Patient Age Oral Preparation Dose (mL)a
more palatable for children. Water-soluble Breast milk 4 hr
iodinated contrast media can be mixed and < 1 mo 45 Formula and fortified 6 hr
diluted with water, juice, soda, or a special 1 mo–1 y 90 breast milk
beverage provided from home by the child’s 1–6 y 120 Solid food From 12 am
parents. Adult studies have concluded that Note—Gastrostomy tube feeding should be stopped
6–12 y 180
low-osmolar iodinated contrast media such after 12 am except for children under 1 year old who
as iohexol and ioversol tend to be more palat- 12–16 y 240 may continue gastrostomy tube formula up to 6
hours before time of sedation. For emergency
able than diatrizoate meglumine, which has a > 16 y 300
procedures or sedation, appropriate oral intake
bitter taste even when diluted [15]. aThree doses of the listed amounts are given with a restriction status may be determined by the
Our routine oral contrast mixture involves ratio of 1 mL of ioversol 320 diluted for each 30 mL of attending anesthesiologist or emergency medicine
diluting 1 mL of ioversol 320 for every 30 mL clear liquid. The first dose is provided 90 minutes physician in consideration of patient acuity and the
before the examination, the second 30 minutes urgency of the procedure.
of liquid. The volume of liquid administered before the examination, and the third at the time of aExamples include water, apple juice, electrolyte

is based on the child’s age (­Table 1). Doses are the examination if the patient can tolerate it. solution.

AJR:206, May 2016 975

 Callahan et al.
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A B
Fig. 4—Two polyvinyl chloride tubes (approximate wall thickness, 0.2 cm; approximate inside diameter, 1.5 cm) filled with acai juice (AJ) and tap water (W).
A, On axial HASTE sequence (TR/TE, 500/70; slice thickness, 4 mm; number of signals acquired, 1; matrix, 256 × 256), both AJ and W are bright.
B, Axial 3D MRCP sequence (TR/TE, 2000/711; slice thickness, 1.5 mm; number of signals acquired, 1; matrix, 256 × 256) shows significant loss of signal intensity of AJ,
likely from paramagnetic effects of manganese in acai juice at high TR and TE values.

Fig. 5—7-year-old boy with recurrent pancreatitis.

A, Coronal 3D MRCP maximum-intensity-projection
image (TR/TE, 4373/716; number of signals averaged,
1; matrix, 256 × 256) obtained after oral administration
of acai juice shows excellent visualization of common
bile duct (straight arrow) and pancreatic duct
(curved arrow). Note suppression of signal within
gastrointestinal tract.
B, Coronal fat-suppressed T2-weighted image
(TR/TE, 4178/100; number of signals averaged, 2; slice
thickness, 5 mm; matrix, 256 × 256) during same study
shows increased signal intensity from fluid within
stomach and duodenum (arrows).

A B

A B
Fig. 6—Two patients with suspected inflammatory bowel disease.
A, 16-year-old girl who could not tolerate oral intake of polyethylene glycol 3350. Axial fat-suppressed volumetric interpolated breath-hold examination image (TR/TE, 138/4.76;
slice thickness, 6 mm; number of signals averaged, 1; matrix, 256 × 256) after administration of gadolinium-based IV contrast material shows lack of distention of bowel.
B, 18-year-old boy who underwent standard polyethylene glycol 3350 preparation. Axial fat-suppressed VIBE image (TR/TE, 138/4.76; slice thickness, 6 mm; number of
signals averaged, 1; matrix, 256 × 256) shows optimal distention of multiple normal loops of bowel.

976 AJR:206, May 2016

 Enteric Contrast Media in Pediatric Patients

i­ ncreased signal intensity on certain pulse se- ume given to an adolescent patient is 400 suspension 30–60 minutes before the MR en-
quences, or negative if it results in decreased mL. Contraindications to administration of terography examination begins. Our dosing is
signal on certain pulse sequences. Notably, acai, blueberry, or pineapple juice are type 1 typically 24 oz total for children greater than
many contrast media are biphasic, which re- diabetes or allergy. 50 kg, 16 oz for children 25–50 kg, and 8 oz for
sults in a positive or negative signal, depend- Commercially available negative oral con- children less than 25 kg. Patients lie on their
ing on the pulse sequence [21]. We describe trast media such as ferumoxsil (GastroMARK, right side after drinking the mixture to facil-
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the use of negative and positive MR enteric Mallinckrodt), in addition to manganese chlo- itate gastric emptying, and more distal small
contrast media at our institution. ride, barium sulfate suspension, and fer- opacification. Diarrhea is a common side effect
ric particles, can render bowel contents dark but is generally well tolerated and typically oc-
Negative MRI Enteric Contrast Media on T2-weighted images. However, in con- curs after the MR enterography study is com-
Negative enteric contrast media is most trast to acai juice, most commercial negative pleted [28]. Before the MR enterography study,
frequently used for MRCP, which uses heavi- oral contrast media are expensive, not always we provide a patient information sheet warning
ly T2-weighted 3D and 2D imaging sequenc- available, and not particularly palatable, mak- of the potential side effects of PEG.
es to image bile within the pancreaticobili- ing them less suited for use in children. Rectal contrast material is not routinely
ary tree. Bile is inherently hyperintense on administered for MRI at our institution, al-
fluid-sensitive sequences, but the signal in- Positive MRI Enteric Contrast Media though some authors have described the use
tensity of the fluid material in the adjacent MRI is an established diagnostic tool for of rectal contrast material for staging rectal
stomach, duodenum, and jejunum is similar the evaluation of known or suspected inflam- cancer with MRI in adults [37, 38].
to bile, potentially resulting in partial obscu- matory bowel disease in children [26–29]. A
ration of the biliary tree [22]. Certain brands comprehensive MR enterography examina- Ultrasound
of acai juice, blueberry juice, and pineapple tion uses enteric contrast material to distend Air tends to attenuate or reflect sound
juice contain relatively high levels of man- the small bowel lumen and improve visu- waves. Attenuation is caused by the rela-
ganese, resulting in paramagnetic effects on alization of the bowel wall (Fig. 6). Exam- tively high attenuation coefficient of air
bowel contents that make them hypointense ples of positive enteric contrast media used compared with soft tissue, whereas reflec-
on heavily T2-weighted 3D sequences [23, for MR enterography include ingestible flu- tion occurs at a boundary of two materials
24] (Fig. 4). Opacification of the lumen of id mixed with PEG, psyllium (Metamucil, with different acoustic impedances such as
the stomach and duodenum with acai, blue- Proctor and Gamble), and dilute barium sul- an air–soft tissue or air-fluid interface (Fig.
berry, or pineapple juice immediately before fate suspension 0.1% (VoLumen) [30–36]. 7). Conversely, fluids have relatively low at-
an MRCP study can significantly diminish We use PEG powder for solution (MiraLAX) tenuation coefficients and thus more easi-
or eliminate the high signal-intensity fluid mixed with water as our routine enteric contrast ly transmit sound waves than surrounding
within the bowel lumen adjacent to the com- media for abdominal MRI studies. PEG aids soft-tissue structures, potentially improving
mon bile duct and pancreatic duct, improving in diagnosis by distending the lumen of small visualization of deeper structures. As a re-
visualization of the biliary system (Fig. 5). bowel. We dilute 17 g of PEG in 8 oz (237 mL) sult, fluid can be administered as oral con-
Date syrup has also been used as an enter- of water, Hawaiian Punch (Dr Pepper Snapple trast material in conjunction with real-time
ic contrast medium with similar results [25]. Group), or Crystal Light (Kraft Foods). After sonography to answer specific clinical ques-
When performing MRCP studies, we rou- patients have fasted for at least 6 hours, they tions and facilitate visualization of certain
tinely administer age-adjusted volumes of receive a weight-adjusted dose of PEG fluid abdominal structures [39–43].
acai juice to patients about 15–30 minutes
before the examination [22]. The typical vol-

Fig. 7—Ultrasound phantoms consisting of two Fig. 8—Ultrasound image of 5-week-old boy shows Fig. 9—Ultrasound image of 7-week-old boy shows
cylindric plastic ultrasound covers submerged in hypertrophic pyloric stenosis (arrows). Patient normal pylorus (arrow). Patient was given 5% glucose
water, one containing water (A) and one containing air was given 5% glucose water via bottle during water via bottle during examination, which fills lumen
(B). Note posterior wall of water-filled cylinder (A) is examination, which fills lumen of stomach (antrum) of stomach (antrum) and passes through normal
visible, but cylinder filled with air (B) shows posterior and improves conspicuity of pylorus. pylorus into duodenal bulb (DB).
acoustic shadowing, obscuring posterior wall.

AJR:206, May 2016 977

 Callahan et al.

Fig. 10—4-day-old boy with

soft-tissue mass.
A, Ultrasound image
shows mass (black arrows)
surrounding gastric antrum
and proximal duodenum.
Relationship to proximal
gastrointestinal tract was
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augmented with 5% glucose

water administered via bottle
during examination, which fills
lumen of stomach and duodenal
bulb (white arrows).
B, Abdominal CT image
obtained after oral and
enteric contrast material
administration also shows mass
(arrows). Pathology revealed
benign myofibroblastic lesion.
A B

We administer 5% glucose water (­Enfamil, rectally administered saline to reduce an intus- control: what is the effect on patient radiation ex-
Mead Johnson) via a bottle to some infants un- susception using ultrasound guidance has also posure? Eur J Radiol 2011; 79:e58–e62
dergoing sonography for suspected hypertro- been described [46–48]. 3. Cody DD. Management of auto exposure control
phic pyloric stenosis (HPS) (Fig. 8). Glucose during pediatric computed tomography. Pediatr
water is not always necessary for the sono- Conclusion Radiol 2014; 44(suppl 3):427–430
graphic diagnosis of HPS, but can be a useful The use of enteric contrast material for diag- 4. Guimarães LS, Fletcher JG, Yu L, et al. Feasibility
adjunct to exclude HPS in certain clinical situ- nostic imaging in infants and children contin- of dose reduction using novel denoising tech-
ations, particularly if the gastric antrum is un- ues to evolve with advances in imaging tech- niques for low kV (80 kV) CT enterography: opti-
derdistended or contains air. Using a bottle to nology and available enteric contrast media. As mization and validation. Acad Radiol 2010;
administer glucose water orally is preferable to outlined in this article, commercially available 17:1203–1210
a nasoenteric tube because the physiologic pro- contrast media, certain beverages, and over- 5. Yu L, Li H, Fletcher JG, McCollough CH. Auto-
cess of swallowing facilitates gastric emptying the-counter medications can be used as enter- matic selection of tube potential for radiation dose
[39]. In the setting of suspected HPS, the infant ic contrast media for children undergoing CT, reduction in CT: a general strategy. Med Phys
is given 20–30 mL of glucose water via a bot- MRI, and ultrasound imaging. Although many 2010; 37:234–243
tle, typically in the right lateral decubitus posi- of the principles of enteric contrast use for pe- 6. Donnelly LF, Frush DP, Frush KS. Aspirated con-
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pylorus (Fig. 9) can help exclude the diagno- gastrointestinal tract is different in infants and 7. Lim-DunhAm JE, Narra J, Benya EC, Donaldson
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978 AJR:206, May 2016

 Enteric Contrast Media in Pediatric Patients

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