FLUORSOSCOPIC PROCEDURES LECTURE BY MR PR-2024.pptx

FLUOROSCOPIC PROCEDURES BY PRINCE ROCKSON (RADIOLOGY MANAGER- THE BANK HOSPITAL) 1  Objectives Discuss the following fluoroscopic procedures and techniques: Barium studies Intravenous urogram (IVU) Hysterosalpinogra...

FLUOROSCOPIC PROCEDURES BY PRINCE ROCKSON (RADIOLOGY MANAGER- THE BANK HOSPITAL) 1  Objectives Discuss the following fluoroscopic procedures and techniques: Barium studies Intravenous urogram (IVU) Hysterosalpinography (HSG) Retrograde urethrogram/ Micturating Cystourethrogram 2  Fluoroscopy Equipment Under-couch X-ray tube fluoroscopy (C-arm) Over-couch X-ray tube fluoroscopy 3 BARIUM SWALLOW  A barium swallow is a radiological study that employs a contrast agent/ medium to determine pathologies of the oesophagus.  It is also referred to as esophagram in USA.  Adult & children  Uses barium sulphate, Gastrografin, Ominipaque (Iohexol) 4  Indications for barium swallow:  Odynophagia (painful swallowing)  Dysphagia (difficulty with swallowing)  Narrowing or irritation of the esophagus  Hiatal hernia  Gastroesophageal reflux disease (GERD) or GORD  Anaemia  Blood stained vomitus  Assessment of tracheo-oesophageal fistula  Unexplained weight loss Contraindications  Complete Obstruction  Perforation (especially after recent surgery)  Recent gastric or oesophageal surgery 5 Complications A barium swallow is generally a safe test, but like any procedure, there are complications.  Leakage of barium from an unsuspected perforation can lead to peritonitis Allergic reaction or anaphylaxis may occur in people who are allergic to the barium drink.  Constipation may develop.  Aspiration of barium 6  Major complications for all barium examinations Barium peritonitis: Leakage of barium from an unsuspected perforation Contrast examination of the gastrointestinal tract is rarely complicated by perforation. The colon and rectum are most affected, with many perforations limited to the retroperitoneum. Generalised peritonitis is therefore rare, but it is life- threatening and difficult to treat. The incidence of peritonitis following barium studies is in the order of 2-8 per 10 000 investigations Proper clinical assessments of patients prior to barium studies are important to prevent Barium peritonitis. 7  To avoid barium peritonitis patients with suspected perforations should not undergo barium examinations.  Note if there is any suspicion of a fistula in the abdomen, water soluble contrast agent (eg. Gastrografin,Iohexol/Ominipaque should be used. Thus, water soluble contrast agents can be absorbed in the peritoneum with limited effects unlike barium which will not be absorbed.  However, If there is any suspicion of a fistula between the oesophagus and the trachea, or when aspiration is a possibility, it not recommended to use gastrografin. Gastrografin, Iohexol/Ominipaque in the lungs can cause some fibrosis (Barium is even safer than gastrografin). 8  Management and Prognosis The management of barium peritonitis includes vigorous fluid resuscitation, broad-spectrum antibiotics, and early surgical intervention to remove barium and deal with perforation. The prognosis of barium peritonitis has long been held to be poor, with the mortality in early series being as high as 53%. However, more recent reviews have documented mortality rates in the region of 20%. Such improvements can be ascribed to better understanding of the pathophysiology of this condition. 9 Preparation for Barium swallow If the interest is on just the oesophagus, then no special preparation is required. However, if the stomach is involved then: 1. No food 6-8 hours prior to the examination 2. The patient is advised not to smoke on the day of the examination, as it increases gastric motility. 3. Check patient identification 4. Check for pregnancy 5. The procedure should be explained to the patient prior to the examination 6. The patient must sign a consent form for the examination 7. Medical history should be taken 8. Appropriate laboratory results and other examinations must be reviewed prior to the examination ANATOMY OF THE UPPER GIT 10 Examination Technique Examination Technique A chest x-ray may be taken initially prior to Barium Swallow procedure. 1. Single Contrast Barium Swallow In single contrast, only barium solution is used as radio-opaque material The picture must be exposed at the minimum of two dimensions for better evaluation (A.P and lateral views).The entire esophagus must be visualized in AP, Lateral and both. The Esophagus must be demonstrated to be barium filled. Mucosal relief films should also be taken. The gastroesophageal junction should demonstrate its relaxation with flow of barium from the esophagus to the stomach. The esophagus is assessed for reflux and motility disorders. Erect: AP, RAO, AP Stomach, AP Trendelenburg with Valsalva 11 12  AP position RAO position RAO image 13 AP image 14 To demonstrate a tracheo-oesophageal fistula in infants, a nasogastric tube (NG Tube) is introduced to the level of the mid oesophagus, and the contrast agent is syringed in to examine the oesophagus. Aftercare Patients must drink a lot of water to get the barium out to prevent constipation. Patients are informed that the stool may be white for the first 2 or three days 15 Normal images LT RT 16 17 18 19 BARIUM MEAL Barium meal is a diagnostic test used to detect abnormalities of mainly the stomach and the duodenum. Method 1. Double contrast: the method of choice to demonstrate mucosal pattern and abnormality. 2. Single contrast: i. children- since it usually is not necessary to demonstrate mucosal pattern. ii. Very ill adults- to demonstrate gross pathology only. 20 Indications Unexplained Weight loss abdominal mass Gastrointestinal haemorrhage Unexplained iron-deficiency and anaemia Partial duodenal obstruction Assessment of site of perforation: It is essential that a water soluble contrast medium is used. Gastrointestinal reflux 21 Contraindications, Anatomy & Preparation of patient Large bowel obstruction Immediate or impending gastric/abdominal surgery ANATOMY OF THE STOMACH Preparation Check patient identification Check for pregnancy Patient must be fasted for 6-8hours Medical history should be taken Appropriate laboratory results and other examinations must be reviewed prior to the examination The procedure should be explained to the patient prior to the examination The patient must sign a consent form for the examination 22  Technique The patient takes the gas producing agent (Citric Acid + Sodium Bicarbonate: Andrew's liver salts). The patient then takes the barium mixture. The patient is made to roll to 2 full turns counterclockwise so that barium can coat the stomach. Series of fluoroscopically guided films are taken in a variety of positions to demonstrate the stomach, duodenal cap and first part of duodenum. Typical Film Series Position Demonstrates LPO Antrum and greater curve Supine Antrum and body RPO Lesser curve Supine Left Lateral Fundus Prone Duodenal loop RAO, LAO Duodenal Cap series Erect LAO , RAO Esophagus Supine Abdomen AP Stomach and small intestine Trendelenburg Fundus to rule out reflux 23  Aftercare Patients must drink a lot of water to get the barium out to prevent constipation. Patients are informed that the stool may be white for the first 2 or three days 24 Areae gastricae in the antrium 25 LPO LPO 26 RAO RAO 27 Erect Aspiration 28 Ca Duodenal ulcer Peptic ulcer stomach 29 Complications 1. Leakage of barium from an unsuspected perforation.. 2. Aspiration. 3. Conversion of partial large bowel obstruction into a complete obstruction by the impaction of barium. 4. Barium appendicitis, if barium impacts in the appendix 30  Barium follow through Barium Follow Through demonstrates the small bowel from the duodenum to the ileoceacal region encompassing the duodenum, jejunum and ileum including the junctions superiorly with the stomach and inferiorly with the ascending colon. 31  Barium follow through - Indications ? Partial obstruction Abdominal masses failed small bowel enema Ulcer Post-operative ileus (use of gastrografin) Crohn’s disease Suspected small bowel neoplasm Suspected small bowel obstruction that has been managed conservatively 32  Barium follow through - Technique Aim is to deliver a single column of barium into the small bowel If this examination is performed in conjunction with a barium meal, then it continues after the meal procedure. Prone abdomen taken every 20 minutes during the first hour of patient drinking solution. Subsequent radiographs taken at 30 minutes until the colon is reached Spot films of the terminal ileum in supine position (compression pad is used to separate any overlying loops of small bowel that are obscuring 33 Example Barium F. Through 34 Small bowel obstruction 35 Large Intestine Barium Enema 36  Indications The indications for barium enema examination include, but are not limited to the following: Ulcerative colitis - ulcerations and inflammation of the large intestine Crohn’s disease - ulcerations and inflammation occurring in any part of the GI tract (mouth to anus) Infection or inflammation, such as diverticulitis (inflammation of pouches of the colon wall) Obstructions and polyps (growths) Cancer Unusual bloating or lower abdominal pain Changes in bowel movements, such as chronic diarrhea or constipation, or passing of blood, mucus, and/or pus 37 Contraindications Suspected bowel perforation Severe ulcerative colitis Pregnancy Toxic megacolon Acute abdominal pain 38  Preparation During the preparation patient must be on light diet prior to exam: 1st day: Koko without bread and milk Agidi/plain rice and light soup, no fish or meat; Castor oil / Mist Sennco in the evening after the last meal. 2nd day: Repeat 3rd day: Fasting ANATOMY OF THE LARGE INTESTINE 39 40 41 Technique Single Contrast Study The colon is filled with barium, and a series of x-rays are taken to demonstrate the entire colon. The radiologist/ Radiographer will then insert a small tube into the rectum and begin to instill, using gravity, a mixture of barium and water into the colon in the left lateral position. A series of x-rays are taken as the barium flows from the rectum to the cecum. When the entire colon is coated, an AP abdominal film is taken. Double Contrast Study In a Double Contrast Study, the barium solution is evacuated and air is pumped through the tube to distend the colon. Serial x-rays are then taken to demonstrate the rectum, sigmoid, descending, transverse and ascending colon and the cecum. All views should demonstrate the colonic loops barium coated, unfolded and air – filled. 42 Routine projections for over couch procedures Single contrast Double contrast Lateral and AP rectum PA /AP shows entire large PA /AP shows entire large intestine in PA or AP mode intestine in PA or AP mode RPO/LAO opens splenic flexure RPO/LAO opens splenic LPO/RAO opens hepatic flexure flexure Right and Left lateral LPO/RAO opens hepatic decubitus to show fluid levels flexure PA/AP post evacuation Lateral rectum / ventral decubitus lateral This projection is significant in the detection of recto-vesical and recto- vaginal fistulae. Patient position: The Patient is placed in a lateral recumbent, with a pillow for the head. Align mid-axillary plane to midline of table or IR. Flex and superimpose knees; place arms up in front of the head. Ensure that no rotation occurs; superimpose shoulders and hips they are to be parallel to the short axis of the table. Lateral rectum / ventral decubitus lateral ii  Lateral rectum / ventral decubitus lateral Anatomy demonstrated: Contrast-filled recto-sigmoid region  Rt and lt lateral decubitus projections Central ray: Direct CR horizontal, perpendicular to IR. Center CR to level of iliac crest and MSP.  Rt and lt lateral decubitus projections Anatomy demonstrated: Entire large intestine is demonstrated to include air-filled left colic flexure and descending colon for a right lateral and an air-filled right colic flexure, ascending colon, and cecum for a left lateral.  PA/ AP POST EVACUATION PROJECTION ii Anatomy demonstrated: Entire large intestine should be To visualized only a residual amount of contrast media. This is to ensure that the bowel is cleared of barium suspension before the patient goes home. Diverticulosis/itis Ca colon 50 Hirschsprung's disease in Children INTRAVENOUS UROGRAPHY (IVU) IVU is a radiological procedure used to visualize abnormalities of the urinary system, including the kidneys, ureters and bladder. 52 An injection of x-ray contrast media (water-soluble non-ionic iodinated contrast media) is given to a patient via a needle or cannula into the vein, typically in the arm. The contrast is excreted from the bloodstream via the kidneys, and the contrast media becomes visible on x- rays almost immediately after injection. X-rays are taken at specific time intervals to capture the contrast as it travels through the different parts of the urinary system. 53 REASONS FOR IVU IVU is performed to demonstrate the size, shape and parenchyma of the kidneys, ureters and bladder. It is also used to evaluate kidney function To evaluate any urinary system disorders such as kidney disease, ureteral or bladder stones, enlarged prostate and trauma/injury or tumour. 54 SPECIFIC INDICATIONS Repeated infections Renal colic Flank pain Trauma Retention and decreased urinary output Kidney Stones Renal cell carcinoma Polycystic Kidneys 55 CONTRAINDICATIONS ❑General contraindications to contrast agent ❑Hepato renal syndrome ❑Pregnancy ❑Blood urea raised above a certain defined or normal level ❑Anuria, or absence of urine excretion ❑ Diabetes, especially diabetes mellitus ❑ Severe hepatic or renal disease ❑Patients taking drugs such as metformin, Glucophage, Fortamet, Glumetza, Glucovance, Diabex, Riomet, Actoplus Met, Avandamet, 56 PATIENT PREPARATION Abdominal preparation 57 PROJECTIONS The projections required for an IVU differ according to departmental requirements. However, the basic projections are A. Control B. Immediate C. 5 minutes D. 10 minutes/15minutes E. 20 Minutes F. Post-void 58 A Control Film 5 minutes Film 59 Ureteric Compression 1 60 AN IMAGE TAKEN AFTER 10-15MINS OF An image showing the CONTRAST An Image showing the kidneys, ureters and bladder on a Post INJECTION bladder at 20-25 mins Micturation film 61 SOME PATHOLOGIES 62 HYSTEROSALPINOGRAPHY (HSG) 63 WHAT IS HSG?  It refers to the radiographic examination of portions of the female reproductive system, Particularly the Uterus and the Uterine tubes (Fallopian tubes).  Hence the name Hystero-(Uterus) and Salpinx-(Fallopian tube)  HSG’s are done by injecting contrast material into the uterus under fluoroscopic guidance. 64 CLINICAL INDICATIONS  HSG’s are primarily carried out to assess female infertility (Either primary or secondary infertility)  Recurrent spontaneous abortions  Congenital uterine anomalies  Post operative evaluation of tubal ligation  Investigation of uterine pathologies e.g: pelvic masses, fistulas etc. NB: HSG’s may also prove therapeutic as they restore tubal patency. 65 CONTRA INDICATIONS  Pregnancy  Acute pelvic inflammatory or infectious conditions  Active vaginal bleeding  Recent cervical dilation and curettage  Recent tubal or uterine surgery (usually within 6weeks)  Sensitivity to contrast. 66 CONTRAST MEDIA  Currently water-soluble non-ionic iodinated contrast media (Omipaque- Iohexol, Iopamiro-lopamidol, ultravist-iopromide) are preferred and widely used.  However oil-based contrast such as lipidol may also be used. Advantages of water-soluble iodinated contrast over oil-based contrast:  Relatively rapid absorption without leaving residue  Rarely causes granuloma formation  Prompt demonstration of tubal patency without the need for delay films NB: Oil based contrast are however twice as likely to induce tubal patency and allow pregnancy. 67  EQUIPMENT AND ACCESSORIES REQUIRED SPECULUM:  Used to open up vaginal wall to allow easy visualization of the cervix. CANNULA:  Inserted into the uterus to instill contrast material. 68 EQUIPMENT AND ACCESSORIES REQUIRED TENACULUM  Used to pick up small pieces of tissue in this case the anterior lip of the cervix UTERINE SOUND  Used to probe the uterus, some may also be used to dilate the cervix 69 PATIENT PREPARATION  The procedure is done during the proliferative phase of the menstrual cycle between the 7th -10th day or 8th -12day  The patient must be advised to avoid sexual intercourse from the onset of her period to the day of the exam  As an additional measure rule out pregnancy or for patient with irregular menstrual cycles  ß-HCG test (Beta human chorionic gonadotropin tests) should be carried out.  Explanation of procedure to the patient and consent form also signed. 70 PATIENT PREPARATION II  40mg Buscopan start is given to the patient an hour prior to the exams  Mild analgesics and prophylactic antibiotics may be given to reduce pain from cramps and any potential infections  The patient may also be asked to empty their bladder to prevent the displacement of the uterus and uterine tubes 71 PROCEDURE  Always ensure to obtain informed consent before the procedure starts.  The patient is then placed in lithotomy position with the legs bent at the knee or supported with stirrups if available.  The patient is draped with sterile towels and the perineum is cleaned with antiseptic solution  A vaginal speculum is inserted and the cervix is localized and cleaned with antiseptic solution eg: povidine-iodine solution 72 POSITION FOR HSG PROCEDURE LITHOTOMY POSITION 73 PROCEDURE II  The cervix is cannulated, dilation with a balloon catheter helps to occlude the cervix, preventing contrast media from flowing out of the uterine cavity during the injection phase.  A tenaculum may be necessary to aid in insertion and fixation of the cannula or catheter.  When cervical placement of the cannula or catheter has been obtained, the physician may remove the speculum and place the patient in a slight Trendelenburg position.  This position facilitates the flow of contrast media into the uterine cavity.  A syringe filled with contrast media is attached to the cannula or balloon catheter. 74 PROCEDURE III  Using fluoroscopy, the Radioloist/Radiographer slowly injects contrast media into the uterine cavity.  If the uterine tubes are patent (open), contrast media flows from the distal ends of the tubes into the peritoneal cavity.  In most cases about 10-20ml of contrast is used to fill the uterine cavity 75 FILM SERIES  An initial collimated scout image is taken with the patient in Lithotomy position  During injection of the contrast media, a series of collimated images may be obtained while the uterine cavity and uterine tube are filling.  4 spot films may be taken (as below), however, may depend on departmental protocols: Early filling phase Fully distended uterus Tubal filling phase Peritoneal spillage 76 FILM SERIES II EARLY FILLING PHASE FULLY DISTENDED UTERUS TUBAL FILLING PHASE PERITONEAL SPILLAGE 77 COMPLICATIONS  Pain from uterus dilation and peritoneal spillage.  Infection  Bleeding  Vascular intravasation  Uterine perforation  Contrast reactions 78 AFTER CARE Antibiotics: This medicine is given to fight or prevent an infection caused by bacteria. Pain medicine: This may be needed to take away or decrease pain. Vaginal care: Vaginal pads will be needed for 1 to 2 days, if the patient have some vaginal spotting. Some leftover contrast after the procedure may also come out of your vagina. Patients should also carefully wash their vagina with soap and water and should change vaginal pad any time it gets wet or dirty. 79 PATHOLOGIES 80 CYSTOGRAPHY AND URETHROGRAPHY  Cystography and urethrography consist of imaging the bladder and/or urethra before, during and after administration of contrast via urethral or cystostomy catheter. Alternative terms for these studies include cystourethrography, voiding cystourethrography, and retrograde urethrography  The goal of cystography and/or urethrography is to detect the presence or absence of anatomic and/or functional abnormalities of the lower urinary tract by producing a series of diagnostic quality images 81  INDICATIONS  Indications for cystography include, but are not limited to, evaluation of: 1. Recurrent urinary tract infections. 2. Vesicoureteral reflux. 3. Baldder contour. 4. Bladder diverticula. 5. Suspected rupture. 6. Fistulae. 7. Integrity of postoperative anastomoses or suture lines. 8. Bladder outlet obstruction. 9. Incontinence. 10. Hematuria. 82 11. Neoplasia. Indications for urethrography include, but are not limited to, evaluation of: 1. Urethral diverticula. 2. Urethral strictures 3. Bladder outlet or urethral obstruction. 4. Trauma. 5. Recurrent urinary tract infection. 83  If a urinary catheter is not in place, the urethra or bladder should be catheterized using aseptic technique.  An appropriate volume of contrast should be administered to demonstrate the anatomic structures of interest.  The examination should be tailored to the needs of the individual patient.  Fluoroscopy can optimize diagnostic yield, especially during voiding studies.  Clinical judgement should guide decisions about contrast quantity and use of infusion or injection technique.  Appropriate images should be produced to demonstrate normal and abnormal findings with the minimum radiation dose necessary to achieve an optimal study. 84 THANK YOU 85