Photoelectric Dominant Imaging in Dual-Energy CT: Clinical Potential for Mucosal Enhancement in the Abdomen

INTRODUCTION: CT photoelectric-dominant imaging (PED) offers the potential to enhance contrast between tissues of similar electron density and improve lesion conspicuity. Despite this promise, PED is not yet clinically implemented. This study aimed to evaluate the diagnostic performance of PED compared with the commonly used DECT reconstructions for mucosal enhancement assessment in acute abdominal pathologies. METHODS: This retrospective single-center study included 38 patients with acute abdominal pathology (cystitis, appendicitis, colitis, cholecystitis) who underwent contrast-enhanced DECT in the venous phase. For each case, conventional, 40 keV, and 50 keV images, iodine maps, and PED images were generated. Six radiologists graded mucosal enhancement using a 4-point Likert scale. Scores were compared using repeated-measures ANOVA with post hoc testing, and interobserver agreement was assessed. RESULTS: PED images consistently outperformed conventional and 50 keV images across all evaluated pathologies (4/4, P<0.01). Compared to 40 keV images, PED images showed superior performance in 3/4 conditions (P<0.01), with the exception of cholecystitis, where 40 keV achieved the highest overall score (P<0.01). When compared with iodine maps, PED received slightly higher-but not statistically significant-scores, indicating near-equivalent diagnostic performance; however, it received the highest agreement among all reviewers (0.84, 0.77). CONCLUSIONS: PED images demonstrate a promising diagnostic potential for mucosal enhancement assessment in acute abdominal inflammatory conditions. Their superior performance compared to conventional and 50 keV DECT images-and even marginally to iodine maps-supports further research in larger cohorts to better clarify organ- and pathology-specific advantages and to define their diagnostic role.