Imaging alternatives to colonoscopy: CT colonography and colon capsule. European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline - Update 2020.

1: ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia.Strong recommendation, high quality evidence.ESGE/ESGAR do not recommend barium enema in this setting.Strong recommendation, high quality evidence. 2: ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. The timing depends on an interdisciplinary decision including endoscopic and radiological factors.Strong recommendation, low quality evidence.ESGE/ESGAR suggests that, in centers with expertise in and availability of colon capsule endoscopy (CCE), CCE preferably the same or the next day may be considered if colonoscopy is incomplete.Weak recommendation, low quality evidence. 3: When colonoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with alarm symptoms.Strong recommendation, high quality evidence.Because of lack of direct evidence, ESGE/ESGAR do not recommend CCE in this situation.Very low quality evidence.ESGE/ESGAR recommend CTC as an acceptable alternative to colonoscopy for patients with non-alarm symptoms.Strong recommendation, high quality evidence.In centers with availability, ESGE/ESGAR suggests that CCE may be considered in patients with non-alarm symptoms.Weak recommendation, low quality evidence. 4: Where there is no organized fecal immunochemical test (FIT)-based population colorectal screening program, ESGE/ESGAR recommend CTC as an option for colorectal cancer screening, providing the screenee is adequately informed about test characteristics, benefits, and risks, and depending on local service- and patient-related factors.Strong recommendation, high quality evidence.ESGE/ESGAR do not suggest CCE as a first-line screening test for colorectal cancer.Weak recommendation, low quality evidence. 5: ESGE/ESGAR recommend CTC in the case of a positive fecal occult blood test (FOBT) or FIT with incomplete or unfeasible colonoscopy, within organized population screening programs.Strong recommendation, moderate quality evidence.ESGE/ESGAR also suggest the use of CCE in this setting based on availability.Weak recommendation, moderate quality evidence. 6: ESGE/ESGAR suggest CTC with intravenous contrast medium injection for surveillance after curative-intent resection of colorectal cancer only in patients in whom colonoscopy is contraindicated or unfeasibleWeak recommendation, low quality evidence.There is insufficient evidence to recommend CCE in this setting.Very low quality evidence. 7: ESGE/ESGAR suggest CTC in patients with high risk polyps undergoing surveillance after polypectomy only when colonoscopy is unfeasible.Weak recommendation, low quality evidence.There is insufficient evidence to recommend CCE in post-polypectomy surveillance.Very low quality evidence. 8: ESGE/ESGAR recommend against CTC in patients with acute colonic inflammation and in those who have recently undergone colorectal surgery, pending a multidisciplinary evaluation.Strong recommendation, low quality evidence. 9: ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp ≥ 6 mm detected at CTC or CCE.Follow-up CTC may be clinically considered for 6 - 9-mm CTC-detected lesions if patients do not undergo polypectomy because of patient choice, comorbidity, and/or low risk profile for advanced neoplasia.Strong recommendation, moderate quality evidence.
Competing Interests: D. Burling provides unpaid support to the colon cancer charity, 40tude (not as trustee or officer). E. Dekker has received consultancy honoraria from Fujifilm, Olympus, Tillots, GI Supply, and CPP-FAP, and speakers’ fees from Olympus, Roche and GI Supply; she has endoscopic equipment on loan and receives a research grant from Fujifilm; she is on the supervisory board for eNose. R. Eliakim receives a lecture fee and grant support from Medtronic (from 2018 ongoing). I. Fernandez-Urien has provided paid consultancy to Medtronic (2019 – 2020). J.E. van Hooft has received lecture fees from Medtronics (from 2014 to 2015 and 2019) and Cook Medical (2019), and consultancy fees from Boston Scientific (2014 – 2017); her department has received research grants from Cook Medical (2014 – 2019) and Abbott (2014 – 2017). M.F. Kaminski provides speaking, teaching, and consultancy services to Olympus (from 2017 ongoing), and speaking and teaching services to Fujifilm, from whom he has equipment on loan (from 2019 ongoing). A. Koulaouzidis received travel support for CEGS meetings from the Jinshan Group (2018, 2019); his department was supported by Ankon with an advisory meeting (June 2019); he has received research support from Given Imaging (2010 – 2011). M.C.W. Spaander receives research support from Medtronic (from 2016 ongoing). C. Spada provides consultancy to Medtronic (from 2016 ongoing). D. Bellini, G. Cappello, C. Carretero, M. de Haan, C. Hassan, A. Laghi, P. Lefere, D. McNamara, T. Mang, S.M. Milluzzo, M. Morrin, E. Neri, S. Pecere, M. Pioche, A. Plumb, D. Regge, E. Rondonotti, J. Stoker, and S. Taylor declare that they have no conflicts of interest. ESGAR and ESGE covered costs for travel expenses. ESGAR and ESGE did not influence the content of this Guideline.
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