(17) Radiologic Contrast Examinations .pdf

RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila LESSON 1 - PRELIM Topic Outline: Radiographic Positioning and Terminology Anatomical Position Body Planes and Special Planes...

RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila LESSON 1 - PRELIM Topic Outline: Radiographic Positioning and Terminology Anatomical Position Body Planes and Special Planes Surface Landmarks Anatomic Relationship Terms Projection Position View and Method Body Movement Terminology B. SPECIAL PLANES 1. Interiliac plane RADIOGRAPHIC POSITIONING Transects the pelvis at the top of the iliac AND TERMINOLOGY crest Level: L4 spinous process ANATOMICAL POSITION Used in positioning: Standing upright/erect ○ Lumbar spine Face and eyes ○ Sacrum directed forward ○ Соссух forward Arms extended by the sides Palms turned forward Heels together Toes pointing anteriorly BODY PLANES AND SPECIAL PLANES A. BODY PLANES 2. Occlusal plane 1. Sagittal Formed by biting surfaces of the upper and Right and left lower teeth with jaws closed Midsagittal: equal right and left Used in positioning: Parasagittal: unequal right and left ○ Odontoid process 2. Coronal ○ Some head projections Anterior and posterior Midcoronal/Midaxillary plane: equal anterior and posterior 3. Horizontal Right angle to the long axis of the body Cross-sectional/Transverse/Axial plane 4. Oblique At any angle among the three. Shaina Baula | 1 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila SURFACE LANDMARKS Caudad ○ Parts away from the head of the body. Cephalad ○ Parts toward the head of the body. III. SUPERIOR VS INFERIOR Superior ○ Nearer to the head or situated above. Inferior ○ Nearer to the feet or situated below. ANATOMIC RELATIONSHIP TERMS I. ANTERIOR VS POSTERIOR Anterior/Ventral ○ Forward or front part of the body or organ. IV. CENTRAL VS PERIPHERAL Posterior/Dorsal Central ○ Back part of the body or organ. ○ Mid area or main part of an organ. Peripheral ○ Parts at or near the surface, edge or outside of the body part. II. CAUDAD VS CEPHALAD Shaina Baula | 2 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila V. MEDIAL VS LATERAL VIII. SUPERFICIAL VS DEEP Medial Superficial ○ Parts toward the median plane or ○ Parts near the skin or surface. toward the middle of the body. Deep Lateral ○ Parts far from the surface. ○ Parts away from the median plane or away from the middle part of the body. IX. PARIETAL VS VISCERAL Parietal ○ Wall or lining of a body cavity. Visceral ○ Covering of an organ. VI. PROXIMAL VS DISTAL Proximal ○ Parts nearest the point of attachment/origin. Distal X. IPSILATERAL VS CONTRALATERAL ○ Parts farthest from the point of Ipsilateral attachment/origin. ○ Parts on the same side of the body. Contralateral ○ Parts on the opposite side of the body. VII. EXTERNAL VS INTERNAL External ○ Parts outside of an organ/body. Internal ○ Parts inside of an organ/body. Shaina Baula | 3 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila XI. PALMAR VS DORSUM (HAND) ANTEROPOSTERIOR (AP) PROJECTION Palmar/Volar A perpendicular CR enters the front ○ Palm of the hand. (anterior) body surface and exits the back Dorsum (posterior) body surface. ○ Back or posterior surface of the hand. XII. PLANTAR VS DORSUM (FEET) POSTEROANTERIOR (PA) PROJECTION Plantar A perpendicular CR enters the back ○ Sole of the foot. (posterior) body surface and exits the front Dorsum (anterior) body surface. ○ Top or anterior surface of the foot. AP AXIAL PROJECTION There is a longitudinal angulation of CR with the long axis of the body. 10 degrees or more. PROJECTION Path of the central ray as it goes through the patient to the IR. ○ e.g. AP or PA projection The entrance and exit points in the body. Based on anatomical position. Relationships formed between the central ray and the body. ○ e.g. Axial & Tangential Projection TANGENTIAL PROJECTION CR is directed toward the outer margin of a curve. CR skims the surface of the body. To project the part free of superimposition. Shaina Baula | 4 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila AP OBLIQUE PROJECTION CR enters the anterior surface and exits posteriorly. LATERAL PROJECTION CR enters one side of the body and exits the opposite side. PA OBLIQUE PROJECTION LATEROMEDIAL AND MEDIOLATERAL CR enters the posterior surface and exits PROJECTION anteriorly. Lateromedial and mediolateral to indicate the sides entered and exited by the central ray. OBLIQUE PROJECTION CR enters the body from a side angle following an oblique plane. ○ e.g. AP or PA oblique projection POSITION Identifies the overall posture or the general body position. The specific placement of the body part in relation to the radiographic table/image receptor. ○ e.g. upright, supine, seated Shaina Baula | 5 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila Upright position Sims position Erect or marked by a vertical position. A recumbent position with the patient lying Seated-upright position on the left anterior side (semiprone) and the Sitting on a chair or stool. right knee and thigh partially fixed. Recumbent position General term referring to lying down in any position. Lithotomy position A supine position with knees and hip flexed and thighs abducted and rotated externally. Supine position Lying on the back. Lateral position Prone position Always named according to the side closest Lying face down. to the IR. Trendelenburg position Supine position with head lower than feet. Oblique position Achieved when the entire body is rotated so that the coral plane is not parallel with the radiographic table or IR. Right anterior oblique (RAO) or Left anterior oblique (LAO) Fowler’s position Supine position with head higher than feet Right posterior oblique (RPO) or Left posterior oblique (LPO) Shaina Baula | 6 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila BODY MOVEMENT TERMINOLOGY ABDUCTION VS ADDUCTION Abduct/Abduction Movement of a part away from the central axis of the body. Adduct/Adduction Decubitus position Movement of a part toward the central axis Indicates that the patient is lying down CR of the body. horizontal and parallel with the floor. ○ e.g. ventral, dorsal or lateral decubitus Used to demonstrate air-fluid levels or free-air in the chest and abdomen. EXTENSION VS FLEXION Extension Straightening a joint. The normal position of a joint. Flexion Act of bending a joint. Lordotic position Opposite of extension. Achieved by having the patient lean backward while in upright position so that shoulders are in contact with the IR. Used for visualization of pulmonary apices. HYPEREXTENSION, EXTENSION, AND HYPERFLEXION VIEW AND METHOD Extension View Straightening of a joint; when both elements Used to describe the body part as seen by of the joint are in the anatomic position; the IR. normal position of a joint. Exact opposite of projection. Hyperextension Method Forced or excessive extension of a limb or Named after individuals in recognition of joints. their development of a method to Hyperflexion demonstrate a specific atomic part. Forced overflexion of a limb or joints. ○ e.g. water, Caldwell, Townes Shaina Baula | 7 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila ROTATE/ROTATION Rotate/Rotation Turning or rotating of the body or a body part around its axis; rotation of a limb can be medial (toward the midline of the body from the anatomic position or lateral (away from the midline of the body from the anatomic position. EVERSION VS INVERSION ○ e.g. medial or lateral rotation Evert/Eversion Outward turning of the foot at the ankle. Invert/Inversion Inward turning of the foot at the ankle. CIRCUMDUCTION Circumduction Circular movement of a limb. SUPINATION VS PRONATION Supinate/Supination Rotation of the forearm so that the palm is up. Pronate/Pronation Rotation of the forearm so that the palm is down. Shaina Baula | 8 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila TILT VS DEVIATION PROTRACTION VS RETRACTION Tilt Protraction Tipping or slanting a body part slightly. A movement of parts of the body anteriorly Related to the long axis of the body. in a transverse plane. Retraction A movement of part of the body posteriorly in a transverse plane. ELEVATION VS DEPRESSION Elevation Deviation Upward movement of a part of the body. Turning away from the regular standard or Depression course. Download movement of a part of the body. DORSIFLEXION VS PLANTAR FLEXION Dorsiflexion Flexion or bending of the foot toward the leg. Plantar flexion Flexion or bending of the foot downward toward the sole. Shaina Baula | 9 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila LESSON 2 - PRELIM position, size, shape and internal structure of the organ that was not apparent on the Topic Outline: original radiograph. Special Radiographic Procedures with TYPES OF CONTRAST MEDIA Contrast Media 1. POSITIVE CONTRAST MEDIA Contrast Media Substances having a higher atomic number Types of Contrast Media than the surrounding tissues and they ○ Positive Contrast Media usually appear white/radiopaque in the ○ Negative contrast Media radiograph. They achieve this difference by ○ Double Contrast Studies absorbing less or more respectively of the Physical State of Contrast Media incident radiation than do the surrounding Container of Liquid Contrast Medium tissues. Characteristics of Contrast Media Barium sulfate is the inorganic compound. Important Factors in Selecting Contrast It is a white crystalline solid that is odorless Medium and insoluble in water. It occurs as the Physiochemical Properties mineral barite, which is the main Mode of Administrations commercial source of barium and materials Contraindications prepared from it. The white opaque appearance and its high density are SPECIAL RADIOGRAPHIC PROCEDURES exploited in its main applications. WITH CONTRAST MEDIA Barium and iodine preparations are the most common positive contrast media, CONTRAST MEDIA appearing radiopaque due to their high Are substances having a higher or lower atomic numbers. atomic number than the surrounding tissues Barium is presented as barium sulfate and which are used to opacity organs of the iodine as complex organic molecules. body to x-rays, which are not visualized in a Barium sulfate - Is an opaque medium that plain radiograph. opacity the alimentary tract and that this A chemical substance applied to the was likely to be a high density salt which anatomical or functional region being would not be absorbed and which would be imaged, to increase the differences between excreted unchanged at the end of the different tissues or between normal and procedure. abnormal tissue. There are naturally occurring minerals Radiocontrast agents are a type of medical commonly known as "barites". Barium contrast medium used to improve the minerals, chiefly barites and witherite, are visibility of internal bodily structures in x-ray very abundant, occupying approximately based imaging techniques such as 0.05% of the earth crust. Computed tomography (CT) or Barium sulfate is mainly used in the imaging of Radiography. Radiocontrast agents are the digestive system: typically iodine or barium compounds. Barium Enema (Large Bowel Investigation) A substance that is administered to the and DCBE (Double Contrast Barium patient that is either more radiopaque or Enema) more radiolucent than the surrounding Barium Swallow (Esophageal Investigation) tissue that allows assessment of the Shaina Baula | 10 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila Barium Meal (Stomach Investigation) and 4. Barium given orally in suspected distal large Double Contrast Barium Meal bowel obstruction. Barium Follow Through (Stomach and Small Forms of Barium Sulphate: Bowel Investigation) 1. Powder- Berntgen, E-Z Paque Barium sulfate is ideal contrast for GIT for 2. Liquid/suspension - Baritop with carbon several reasons: dioxide 1. Barium is an ideal radiographic contrast. a. E-Z-M with flavoring 2. Barium sulfate is non-absorbable and b. Lafayette Flo-coat barium sulfate non-toxic. suspension 3. Barium sulfate can be prepared as a stable c. E-Z-HD Barium Sulfate suspension. 2. NEGATIVE CONTRAST MEDIA Different properties of barium sulfate: Are substances having a lower atomic 1. Concentration. This is the most Important number than the surrounding tissues that variable of a barium suspension, it is appear black or radiolucent in the expressed in wt/vol. and represents the radiograph. Examples: Gastroluft, E-Z-Gas, weight of barium sulfate in grams in 100 ml (Air, Carbon Dioxide, Oxygen) of suspension. DOUBLE CONTRAST STUDIES 2. Particle size. Larger sized particles are Double contrast studies use a small amount preferred in double contrast studies. of positive contrast medium to coat the 3. Viscosity. It is dependent partly on mucosal surface of a hollow organ such as concentration but it is not synonymous with the stomach, intestines, bladder followed by it. distention with air. 4. Thixotropy. This refers to shear stress with PHYSICAL STATE OF CONTRAST MEDIA the different rates of stretchability of barium 1. Oil - Pantopaque, Dionosil, Lipiodol ultra sulfate coated on bowel lumen. fluid and Ethiodol - Myelogram, 5. Additives. Stabilizing, anti-caking, Bronchogram, Hysterosalpingography. anti-flocculation (such as carboxyl- methyl 2. Tablets - Telepaque (iopanoic Acid), cellulose) and anti foaming agents (such as Biloptin (lopodate), Cholebrine (iocetamic dimethylpolysiloxane) are usually added as acid), Bilisectan (lodoalphanoic acid) - commercial preparation. Hepatobiliary Side effects of barium sulfate: 3. Powder - Barium Sulfate (Baryntgen) also 1. Bloating sulphate in British English) is a salt of 2. Constipation (severe, continuing) sulfuric acid. 3. Cramping (severe) 4. Liquid - all iodinated and non-ionic contrast 4. Nausea or vomiting medium 5. Stomach or lower abdominal pain lodine based or iodinated contrast media may 6. Tightness In chest or troubled breathing be divided into: 7. Wheezing 1. Water-soluble-iodinated contrast media Hazards and Complications: excreted by the kidneys are used for many 1. Leakage Into the pleural or peritoneal procedures, including all types of spaces. angiography and for intravenous and 2. Leakage Into the mediastinum. retrograde. 3. Possible pulmonary aspiration. 2. Water-insoluble contrast media Include aqueous suspension of propyliodone Shaina Baula | 11 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila (Dionsil), used in bronchography. Oily Isovue Iopamidol contrast media Include Lipiodol. 3. Oily contrast media Vesipaque Iodixanol 1. Ionic Contrast media - are contrast agent CONTAINER OF LIQUID CONTRAST MEDIUM salts of electrically negatively charged acids 1. Ampoules - made or glass with a constricted containing iodine that ionizes in solution and neck indicated by a colored ring that is causes more patient discomfort. snapped off in order to open it. BRAND NAME GENERIC NAME 2. Vials - single or multi-dose glass container with a rubber seal at the top containing Urovison Sodium and meglumine liquid or powder forms of a drug. diatrizoate CHARACTERISTICS OF CONTRAST MEDIA Hypaque Sodium diatrizoate 1. Different absorptive power from tissue, thereby producing effective radiographic Uromiro Meglumine iodamide contrast; 2. No irritant or toxic side effects; Telebrix loxitalamic acid 3. Accurate delineation of the organ; 4. Persistence for sufficient time to take Conray Sodium iothalamate radiographs; IMPORTANT FACTORS IN Angiografin Meglumine diatrizoate SELECTING CONTRAST MEDIUM Ureografin Sodium and meglumine 1. It must be non-toxic and must be safe both locally where administered. 2. Non-ionic Contrast media - are contrast 2. It must procedure adequate contrast agents that do not ionize in solution and are 3. It must have a suitable viscosity safer, less painful, and better tolerated by 4. It must have a suitable persistence the patient. 5. It must have miscibility or immiscibility as BRAND NAME GENERIC NAME appropriate PHYSIOCHEMICAL PROPERTIES Ultravist Iopromide 1. Water solubility - also known as aqueous solubility, is the maximum amount of a Iopamiro Iopamidol substance that can dissolve in water at Omnipaque Iohexol equilibrium at a given temperature and pressure. Amipaque Metrizamide 2. Viscosity - is a measure of the fluidity of solutions and it is measured in millipascals Isovist Iotrolan (mPa) per second. The higher the viscosity of the solution, the longer it will take for the Iopamidol 370 Iopamidol contrast medium to be diluted by blood to diagnostically useful concentrations. Optiray Ioversol 3. Osmolality - the concentration of Oxillan Ioxilan osmotically active particles in a solution, expressed as the number of osmoles per kilogram (Osm. kg.) of solution. Osmolality Shaina Baula | 12 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila of a solution is directly proportional to the number of dissolved particles (molecules, ions) the osmolality of CM can be decreased by Increasing the number of iodine atoms per dissolved particle. MODE OF ADMINISTRATIONS 1. Injected intra - vascularly 2. Administered and then concentrated or excreted 3. Ingested 4. Injected directly into the site of interest 5. Injected and then caused to move to the site of interest (postural means) as in pneumography Methods of introducing Sensitivity test: 1. Scleral Method - drop into the lower conjunctival sac. 2. Buccal/Sublingual Method - placed under the tongue to dissolve and is most often readily absorbed. 3. Intradermal Method - needle is almost against patient skin is being it slowly at 5-15 angles until resistance is felt. 4. Intra-venal Method - introduction of 1-5 c of bolus directly into systemic circulation. CONTRAINDICATIONS 1. A previous severe adverse reaction 2. Heart disease 3. Hepatic failure 4. Oliguria renal failure 5. Thyrotoxicosis 6. Pregnancy Shaina Baula | 13 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila LESSON 3 - PRELIM Gastromiro - a low osmolarity contrast agent containing iopamidol, is a more Topic Outline: palatable orange-flavored alternative. Methods of Imaging the Gastric Tract Indications: Water-Soluble Contrast Agents 1. Suspected perforation. Gases 2. Meconium ileus. Barium 3. To identify bowel lumen and Pharmacological Agents communications with bowel lumen on CT. A ○ Hyoscine-N-Butylbromide dilute (c. 3%) solution of water-soluble (Buscopan) contrast medium (e.g. 30 mL of Gastrografin ○ Glucagon in 1 Lof flavored drink) is used to minimize ○ Metoclopramide (Maxolon) beam hardening artifacts. Contrast Swallow 4. Low osmolar contrast media (LOCM) is ○ Contrast Medium advised if the patient is vulnerable to Barium Meal aspiration. ○ Contrast Medium Modification of Technique for Young Children METHODS OF IMAGING THE GASTRIC TRACT 1. Plain film 2. Barium swallow 3. Barium meal 4. Barium follow-through 5. Small bowel enema 6. Barium enema Complications: WATER-SOLUBLE CONTRAST AGENTS 1. Hyper osmolar Contrast media (HOCM) can Gastrografin - is an aniseed-tasting, high precipitate pulmonary oedema if aspirated osmolarity contrast agent (sodium (not LOCM). amidotrizoate and meglumine 2. HOCM can cause hypovolemia and amidotrizoate), containing a wetting agent electrolyte disturbance due to the for oral or rectal use. Although primarily hyperosmolality of the contrast media used in diagnosis, its high osmolarity is drawing fluid into the bowel (not LOCM). exploited to help achieve bowel catharsis in 3. May precipitate in hyperchlorhydric gastric CT colonography, and to diagnose and treat acid (i.e. 0.1 M HCI). meconium ileus and adhesive small bowel GASSES obstruction. Its use should be monitored in 1. Oesophagus, stomach and duodenum - The the frail and the very young, who are at risk contrast agent should be palatable, produce of profound fluid and electrolyte an adequate volume of gas (200-400 mL), disturbance. It is diluted from one part and not compromise the barium coating with Gastrografin to four parts water for rectal bubbles or residue, or by dilution. Carbon administration. Low osmolar contrast agents dioxide used in conjunction with barium may be given orally but the taste is achieves a 'double contrast' effect. For the unpleasant. upper gastrointestinal tract, CO, is Shaina Baula | 14 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila administered orally in the form of 1. Barium swallow (e.g. Baritop 100% w/v or gas-producing granules/powder (sodium E-Z HD 200%-250% 100-150 mL, as bicarbonate) mixed with fluid (citric acid) required). Carbex. Alternative CO2 producing drinks 2. Barium meal (e.g. E-Z HD 250% w/v). such as tonic water or ginger ale deliver High-density, low-viscosity barium delivers a less-predictable volumes of gas and dilute thin coating which is still sufficiently dense the barium, but may be used for functional for satisfactory pacification in double studies where barium coating and fine contrast studies. Simethicone and sorbitol mucosal detail is not essential. provide antifoaming and coating properties. 2. Large bowel - Pressure-regulated CO, 3. Barium follow-through (e.g. E-Z Paque insufflating pumps for the large bowel are 60%-100% w/v 300 mL; can be reduced to widely available and produce optimal 150 mL if performed after a barium meal). distension with continuous delivery of CO2 Sorbitol induces osmotic hyperperistalsis, at 15-25 mmHg. Carbon dioxide can also be especially when combined with administered by hand pump, but this tends Metoclopramide and Gastrografin, and is to resorb quickly and produces inferior partially resistant to flocculation. bowel distension when compared with air. 4. Small bowel enema (e.g. either a 300 mL Room air administered per rectum via a can of Baritop 100% w/v or two tubs of E-Z hand pump attached to the enema tube is Paque, made up to 1500 mL; 60% w/v). less desirable. Peaks and troughs in 5. Barium enema (e.g. Polibar 115% w/v 500 pressure associated with manual insufflation mL or more, as required). Reduced density are more likely to cause discomfort and be between 20% and 40% w/v for single associated with perforation. contrast examinations. BARIUM Advantages: Barium suspension is made up of finely 1. The main advantage of barium over ground barium sulphate particles in the water-soluble contrast agents is better range of 0.3-1.0 µm. A non-ionic suspension coating resulting in better mucosal detail. maintains a stable suspension and prevents 2. Low cost. clumping. The resulting solution has a pH of Disadvantages: 5.3, which makes it stable in gastric acid. 1. Precludes accurate subsequent abdominal CT interpretation with potential delays of up to 2 weeks to allow satisfactory clearance of the barium. 2. High morbidity associated with barium entering the peritoneal cavity. Complications: 1. Perforation. Water-soluble contrast medium should be the initial agent used for any investigation in which there is a risk or suspicion of perforation. Barium leak into the peritoneal cavity is rare but extremely serious, resulting in pain and severe hypovolemic shock. Treatment consists of intravenous fluid resuscitation, emergency Shaina Baula | 15 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila surgery and washout with antibiotics. Contraindications: Mortality is in the order of 50%; of those that 1. Cardiac, unstable angina or survive, 30% will develop granulomata and tachyarrhythmias peritoneal adhesions. Mediastinal and 2. Untreated closed angle glaucoma pleural cavity barium also has a significant 3. Severe prostatism mortality rate. Aftercare: 2. Aspiration. Aspirated barium is relatively 1. Patients should not drive until blurred vision harmless. Sequelae include pneumonitis has resolved. and granuloma formation. Physiotherapy is 2. A post procedure patient information leaflet required (for both aspirated barium and should explicitly state that in the rare event LOCM) if the patient is unable to voluntarily of sudden onset of a painful or painless red clear the barium before the patient leaves eye, the patient must attend A&E hospital. immediately. 3. Intravasation. This very rare complication GLUCAGON may result in a barium pulmonary embolism, This polypeptide hormone produced by the which carries a mortality of 80%. alpha cells of the islets of Langerhans in the PHARMACOLOGICAL AGENTS pancreas has a predominantly HYOSCINE-N-BUTYLBROMIDE (BUSCOPAN) hyperglycaemic effect but also causes This is an antimuscarinic agent, thus smooth muscle relaxation. It is used in the inhibiting both intestinal motility and gastric USA as an alternative to hyoscine, which is secretion. It is not recommended for not licensed there. children. Indications: Indications: To decrease bowel motility as a diagnostic 1. Visual observation of bowel spasm, causing aid for GI studies. diagnostic difficulty. Adult dose: 2. To improve diagnostic accuracy in CT and 0.2-0.5 mg i.v. over 1 min (or 1 mg i.m.) for MRI. barium meal 3. Patient distress of discomfort following 0.5-0.75 mg i.v. over 1 min (1.0-2.0 mg i.m.) bowel insufflation. for barium enema Adult dose: 1mg i.m. for CT or MRI small bowel imaging 20 mg i.v. may be repeated at 15 min Bolus doses >1 mg administered via i.v. intervals up to a dose of 40 mg in 1 h. may cause nausea and vomiting and are Advantages: not recommended. 1. Its immediate onset of action Advantages: 2. Short duration of action (approx. 5-10 min) 1. More potent smooth muscle relaxant than 3. Low cost hyoscine. Arrests small bowel peristalsis Side effects: more reliably and lasts longer compared 1. Antimuscarinic blurring of vision, dry mouth, with hyoscine. transient bradycardia followed by 2. Short duration of action (approximately tachycardia, and rare side effects of urinary 15-20 min) similar in length to hyoscine. retention and acute gastric dilatation. 3. Does not interfere with small-bowel transit 2. Precipitation of closed angle glaucoma time (SBTT). through pupillary dilation, which is an ophthalmological emergency. Shaina Baula | 16 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila Side effects: CONTRAST SWALLOW 1. Nausea (common), vomiting (uncommon) Indications: Suspected Esophageal Pathology and abdominal pain (rare) 1. Endoscopy negative dysphagia or 2. Paradoxically causes hypoglycemia, odynophagia (painful swallow) especially in those who have fasted 2. Motility disorders 3. Hypersensitivity reactions (rare) 3. Globus sensation 4. Relatively long onset of action 1( min), 4. Assessment of tracheo-oesophageal similar to hyoscine 5. Relatively high cost fistulae compared with hyoscine 5. Failed upper Gl endoscopy Contraindications: 6. Timed barium swallow to monitor achalasia 1. Pheochromocytoma, precipitating a therapies catecholamine crisis Contraindications: 2. Insulinoma (reactive hypoglycemia) None. 3. Glucagonoma CONTRAST MEDIUM Aftercare: 1. E-Z HD 200%-250% or Baritop 100% w/v, No specific instructions. 100 mL (or more, as required) METOCLOPRAMIDE (MAXOLON) 2. Water-soluble contrast agent if perforation is Indications: suspected (e.g. Conray, Gastrografin) As a dopamine antagonist, metoclopramide 3. LOCM (approx. 300 mg | mL-1) si safest if stimulates gastric emptying, aids duodenal there is a risk of aspiration intubation and accelerates small-intestinal 4. Gastrografin should NOT be used for the transit by coordinating peristalsis and investigation of a tracheo-oesophageal dilating the duodenal bulb. fistula or when aspiration is a possibility. Adult dose: Use LOCM instead. 10-20 mg oral or 10 mg i.m. or 10 mg by 5. Barium should NOT be used initially if slow i.v. injection. perforation is suspected. if perforation is not Advantages: identified with a water-soluble contrast 1. Produces rapid gastric emptying and agent, then a barium examination should be therefore increased jejunal peristalsis considered. 2. Antiemetic Equipment: Side effects: Rapid fluoroscopy images, rapid exposures Dystonic side effects with doses exceeding (6 frames s-1) or video recording may be 0.5 mg kg^-1. This is more common in required for assessment of the children and young adults. Intramuscular laryngopharynx and upper esophagus administration of an anticholinergic drug, for during deglutition. example, biperiden 5 mg or procyclidine 5 Patient Preparation: mg, i s usually effective within 20 min. None (but as for barium meal if the stomach Contraindications: is also to be examined). Parkinson's disease, epilepsy. Technique: Aftercare: 1. Start with the patient in the erect position, No specific instructions. right anterior oblique (RAO) position to project the esophagus clear of the spine. An ample mouthful of barium is swallowed and this bolus is observed under fluoroscopy for Shaina Baula | 17 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila dynamic assessment to assess the function under lateral screening guidance. 10 of the esophagus. Then further mouthfuls to 20 mL of LOCM is syringed in to with spot exposure(s) to include the whole distend the esophagus, which will esophagus with dedicated anterior posterior force the contrast medium through (AP) views of the gastro-oesophageal any small fistula which may be junction. present. The process is repeated for 2. Dynamic coned views of the hypopharynx the upper and mid esophagus. It is with a frame rate of 3-4 s^1, in AP and important to actively monitor for lateral, and views during patient swallowing. aspiration into the airway from 3. The patient is placed semi prone in a overspill, which can lead to 'recovery position' in a left posterior oblique diagnostic confusion. (LPO) position. A distended single-contrast Aftercare: view while drinking identifies hernias, subtle Eat and drink as normal but with extra mucosal rings and varices. Modifications fluids. may be required depending on the clinical Complications: indication. 1. Leakage of barium from an unsuspected a. If dysmotility is suspected, barium perforation should be mixed with bread or 2. Aspiration marshmallow bolus and observed BARIUM MEAL under fluoroscopy correlating Methods: symptoms with the passage of the 1. Double contrast. The method of choice to bolus in the erect position. demonstrate mucosal pattern. b. If perforation is suspected, a CT with 2. Single contrast. Uses include the following: quadruple strength oral contrast a. Children-since it usually is not (100 mL Omnipaque 300 made up to necessary to demonstrate mucosal 1 L with water) is more sensitive and pattern provides improved anatomical b. To demonstrate gross pathology location of perforation. only, typically very frail patients c. To demonstrate a unable to swallow gas granules tracheo-oesophageal fistula in Indications: infants, a 'pull back' nasogastric tube 1. Failed upper gastrointestinal endoscopy or esophagogram may be performed if patient unwilling to undergo endoscopy the standard esophagogram is 2. Gastro-oesophageal reflux disease where negative. This technique is lifestyle changes and empirical therapies particularly useful in patients known are ineffective to aspirate or who are ventilated. 3. Partial obstruction Suction and nursing support should Contraindications: be available should aspiration occur. Complete large-bowel obstruction. The patient is positioned prone with CONTRAST MEDIUM the arms up and the table may be 1. E-Z HD 250% w/v 135 mL tilted slightly head down. A 2. Carbex granules (double contrast nasogastric tube is introduced into technique) the stomach and then withdrawn to Patient Preparation: the level of the lower esophagus 1. Nil orally for 6 h prior to the examination Shaina Baula | 18 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila 2. Assess contraindications to the Comprehensive documentation of the examination pharmacological agents used is provided by the following: Preliminary Image: 1. Spot exposures of the stomach (lying): None. a. RAO - to demonstrate the antrum Technique: and greater curve The double contrast method b. Supine - demonstrate the antrum 1. Gas-producing agent is swallowed. and body 2. The patient then drinks the barium while c. LAO - to demonstrate the lesser lying on the left side, supported by their curve en face elbow. This position prevents the barium d. Left lateral tilted, head up 45 from reaching the duodenum too quickly, degrees - to demonstrate the fundus thus obscuring the greater curve of the From the left lateral position, the stomach. patient returns to a supine posi- tion 3. The patient then lies supine and slightly on and then rolls onto the left side and the right side, to bring the barium up against over into a prone position. This the gastro-oesophageal junction. This sequence of movements is required maneuver is screened to check for reflux, to avoid barium flooding into the which may be revealed by asking the duodenal loop, which would occur if patient to cough or to swallow water while in the patient were to roll onto the right this position (the 'water siphon' test). side to achieve a prone position. Extreme provocation testing with the patient 2. Spot image of the duodenal loop (lying): in a head down position during swallowing a. Prone - The patient lies on a is non physiological. Clinically relevant compression pad to prevent barium reflux is assessed by 24 h pH probe from flooding into the duodenum. monitoring and by endoscopic evidence of An additional view to demonstrate oesophagitis. If reflux is observed, images the anterior wall of the duo- denal are taken to record the level to which it loop may be taken in an RAO ascends. position. 4. An i.v. injection of a smooth muscle relaxant 3. Spot images of the duodenal cap (lying): (Buscopan 20 mg or glucagon 0.3 mg) may a. Prone be given to better distend the stomach and b. RAO - The patient attains this to slow down the emptying of contrast into position from the prone position by duodenum. The administration of Buscopan rolling first onto the left side, for the has been shown to not affect the detection reasons mentioned previously. of gastro-oesophageal reflux or hiatus c. Supine hernia. d. LAO 5. The patient is asked to roll onto the right 4. Additional views of the fundus in an erect side and then quickly over in a complete position may be taken at this stage, if there circle, to finish in an RAO position. This roll is suspicion of a fundal lesion. is performed to coat the gastric mucosa with 5. Spot images of the esophagus are taken, barium. Good coating has been achieved if while barium is being swallowed, to the area gastrice in the antrum is visible. complete the examination. Images: Shaina Baula | 19 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila In newborn infants with upper intestinal obstruction (e.g. duo- denal atresia), the diagnosis may be confirmed if 20 mL of air is injected down the nasogastric tube (which will almost certainly have already been introduced by the medical staff). If the diagnosis remains in doubt, it can be replaced by a positive contrast agent (dilute barium or LOCM if MODIFICATION OF TECHNIQUE the risk of aspiration is high). FOR YOUNG CHILDREN Aftercare: The main indication will be to identify a cause for 1. The patient must not drive until any blurring vomiting. The examination is modified to identify of vision produced by the Buscopan has the three major causes of vomiting resolved. This usually occurs within 30 gastro-oesophageal reflux, pyloric obstruction and minutes. malrotation, and it is essential that the position of 2. The patient should be warned that their the duodeno-jejunal flexure is demonstrated: bowel motions will be white for a few days 1. Single-contrast technique using 30% w/v after the examination and may be difficult to barium sulphate and no paralytic agent. flush away. 2. A relatively small volume of barium-enough 3. The patient should be advised to eat and to just fill the fundus—is given to the infant drink normally but with extra fluids to avoid in the supine position. An image of the barium impaction. Occasionally laxatives distended oesophagus is exposed. may also be required. 3. The child is turned semiprone into a LPO or Complications: RAO position. An image is taken as barium 1. Leakage of barium from an unsuspected passes through the pylorus. The pylorus is perforation shown to be an even better advantage if 2. Aspiration 20-40 degrees caudocranial angulation can 3. Conversion of a partial large bowel be employed with an overhead screening obstruction into a complete obstruction by unit. Gastric emptying is prolonged if the the impaction of barium child is upset. Adummy coated with 4. Barium appendicitis, if barium impacts in the glycerine is a useful pacifier. appendix (exceedingly rare) 4. Once barium enters the duodenum, the 5. Side effects of the pharmacological agents infant is returned to the supine position, and used. with the child perfectly straight, a second image is taken as barium passes around the duodenojejunal flexure. This image should just include the lower chest, to verify that the child is straight. 5. Once marotation has been diagnosed or excluded, a further volume of barium is administered until the stomach is reasonably full and barium lies against the gastro-oesophageal junction. The child is gently rotated through 180 degrees in an attempt to elicit gastro-oesophageal reflux. Shaina Baula | 20 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila LESSON 4 - PRELIM slender build, a modification of the more extreme asthenic. The stomach is Topic Outline: elongated, J-shaped and extends to the iliac Barium Meal crest or below. The gallbladder is lower and ○ Habitus more toward the midline compared to the ○ Movement and Position of the sthenic type of build. Stomach in Different Body Positions 4. ASTHENIC HABITUS ○ Modifications Employed in Ugis This represents the slender build type, often ○ Radiographic Demonstration of very frail and has a poor muscle tone; the Minimal Hiatal Hernias stomach is almost vertical in position with ○ Kinds Of Operation in the the gallbladder very near the midline. Stomach Small Bowel Follow-Through Small Bowel Enema Barium Enema Contrast Enema in Neonatal Low Intestinal Obstruction BARIUM MEAL HABITUS 1. HYPERSTHENIC HABITUS Excessive strength or tonicity of the body or any part: The type of bodily habitus is characterized by massive proportions. The MOVEMENT AND POSITION OF THE STOMACH stomach is very high in position and almost IN DIFFERENT BODY POSITIONS horizontal and the gallbladder is away from 1. ERECT the midline and the emptying of the stomach The stomach moves inferiorly in the erect is rather fast. position especially the distal and pyloric portion with the pylorus moving from high as 2. STHENIC HABITUS T12 to as low as the sacrum. In this position A bodily type characterized by strong build, the barium mixture tends to gravitate and a modification of the more massive fills up the distal end of the stomach, the hypersthenic type. The stomach is more pylorus, the valve and the duodenum and a J-shaped and is located lower than in the portion of the body of the stomach massive body type. The gallbladder is less depending upon the amount of barium being transverse and lies midway between the ingested by the patient. Air contrast is lateral and abdominal wall and the midline. achieved in the fundus. The left lateral erect The large bowel lies mainly within the position offers the best depiction of the abdominal cavity. relationship of the stomach and to the spine which menstruation indicates the depth of 3. HYPOSTHENIC HABITUS the retrogastric space. Lack of strength and tonicity; the type of bodily habitus characterized by a more Shaina Baula | 21 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila 2. SUPINE POSITION 4. RIGHT LATERAL RECUMBENT This offers the most superior displacement In this position the stomach duodenum of the stomach. In this position the gastric swings forward from its 2 areas of fixation contents tends to flow to the fundus with thereby changing its relationship to the retro some air within the stomach while fluid gastric structures. Hence, this projection gravitates to the most dependent portion of provides an excellent method of separating the stomach. This is the best position to the various anatomic parts of the stomach, demonstrate double contrast study of the at the same time this does not provide for body of the stomach and the pylorus. an accurate detection of the relationship of the retro-gastric structures to the stomach. In this projection the pylorus antrum and the gastric body falls anteriorly away from the level of the duodenum producing a clear cut depiction of the pylor-bulbar area. The fundus lies posterior to the liver and is in a position with the diaphragm above and 3. PRONE POSITION behind. The body is anteriorly located under In this position there is a greater tendency the inferior abdominal wall. The pyloric for a lower position of the stomach than in antrum extends obliquely posteriorly, supine and to fall obliquely forward and superiorly and to the right. The pyloric is downward. In this case the barium mixture situated just above the head of the tends to gravitate and fills up the distal end pancreas in the posterior part of the of the body of the stomach. The pylorus, abdomen. valve and the stomach, and the c-loop while there is usually a mixture of air and barium coated in the mucosa of the fundus, thus a double contrast study is achieved in the fundus. 5. OBLIQUES (RAO/LAO) These projections are designed to project the different surfaces of the stomach and are primarily for evaluation of the stomach walls as well as the duodenum. The LAO is Shaina Baula | 22 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila designed to demonstrate double contrast Note: study of the body of the stomach, the This modification is designed for an infant pylorus, bulb and the duodenum, while patient’s stomach. filling of the fundus is achieved. 3. HAMPTON’S MODIFICATION Patient first assume supine position Elevate the right side of the body approx. 45 degrees or in such a way that the bulb is separated from the vertebrae Place the support in the elevated side MSP centered to the midline of the table and the midaxillary plane to the midline of the table. RP along the level of the pylorus CR is directed perpendicular Note: This is the best modification to demonstrate a leaf-like pattern of the pylorus and the MODIFICATIONS EMPLOYED IN UGIS bulb. 1. GORDON’S MODIFICATION (PA AXIAL PROJECTION) 4. POPPEL'S METHOD (RIGHT ANGLE VIEW OF Adjust the body and center a plane that THE STOMACH) passes 4 inches to the left of the pylorus to This is used to demonstrate the retrogastric the midline of the table. space and to evaluate pancreatic mass. RP: 4 inches to the left of the pylorus Central Ray is projected 45 degrees Note: cranially through the RP In this the patient should be positioned right Use 10x12 film placed lengthwise after the ingestion of the contrast media. Exposure as taken at the end of Two exposures are taken, first with the full-suspended respiration central ray directed horizontally and second with the central ray directed vertically. Note: This is the best projection to demonstrate A. Positioning : FIRST EXPOSURE the pylorus and the bulb for hypersthenic With the central ray directed horizontally, patients, in this case filling of the distal half place the patient in the supine position. of the stomach is achieved and double Adjust the cassette placed vertically at the contrast study in the fundus. right side and center it to a plane that passes midway between the midaxillary 2. GUGLIANTINI’S MODIFICATION (PA AXIAL plane and the anterior aspect of the body, at PROJECTION) the level of the pylorus. The position of patient is the same as the Adjust the central Ray and direct it to the Gordon's modification only the central ray is midpoint of the film. directed at an angle of 35 degrees cranially Use 10x12 films placed lengthwise Shaina Baula | 23 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila Exposure is taken at the end of exhalation maximum distension of the entire esophagus B. Positioning: SECOND EXPOSURE C. No angulation of the table, thus the patient Shift the tube and direct the central ray is able to hold the barium container and to vertically passing through the R.P. which is digest the barium mixture through a tube 4 inches to the left of the pylorus, centered with a comparative case. to the midline of the table Adjust 10x12 film placed lengthwise and Position: center it to the direction of the central ray Patent is placed on the examining table is Ask the patient to suspend respiration for asked to assume a modified-knee-chest exposure position during the placement of the compression device. Structure Shown: Place the device transversely under the This is used to demonstrate right angle view abdomen, below the costal margin of the stomach and that retrogastric space, Patient is then adjusted in a 40-45 degrees and at the same time for the evaluation of RPO position, with the thorax centered to the pancreatic pathology, such as the midline of the table. pancreatic mass, pancreatic CA, and Adjust 14x17 films with the angulation of the pancreatitis. tube Central ray is directed at right angles to the RADIOGRAPHIC DEMONSTRATION OF long axis of the film reference point at the MINIMAL HIATAL HERNIAS level of either 6 or 8th thoracic vertebra. The modifications or procedures described on this are the modification of trendelenburg Instruction: position. These techniques were evolved for A container holding the barium mixture and the purpose of applying greater a drinking tube is placed to the left hand of intra-abdominal pressure than is provided the patient. Then instruct to ingest the by the body angulations, alone and thereby barium in rapid continuous swallows. To ensuring more consistent results in the allow complete filling of the esophagus, the radiographic demonstration of small sliding exposure is made the third or fourth gastro-esophageal herniation through the swallow. esophageal hiatus. 2. SOMMER-FOEGELLE METHOD 1. WOLF METHOD This requires the use of a specially This requires the use of a semi cylindrical constructed 34 degree angle board over radio parent compression device measuring which the patient is flexed to place his 22 inches in length, 10 inches in width, and trunks in a Trendelenburg position. The 8 inches in height upper edge of the board is thickly padded to exert pressure on the lower abdomen and to This device provides: further increase intra-abdominal pressure. A. Trendelenburg angulation of the patient's trunks Positioning: B. Increase intra-abdominal pressure enough Angle board is placed on the examining to permit adequate contrast filling and table with the film and assists the patient in Shaina Baula | 24 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila getting onto the table in kneeling position. Water-soluble small bowel contrast studies Both thighs are placed against the board are rarely diagnostic, as contrast becomes MSP centered to the midline of the device diluted in small bowel fluid resulting in poor and asked the patient to lean straight mucosal and anatomic detail. An exception forward and rest his full weight on the is in adhesional small bowel obstruction, board. Central ray is directed at right angles where conservative investigation and in relation to the film. Reference point 'treatment' with water-soluble contrast xiphoid process exposure is made during agents (frequently Gastrografin) may reduce the Muller Maneuver. the need for surgical intervention. In this case limited images are usually acquired at KINDS OF OPERATION IN THE STOMACH 1, 4 and 24 h, stopping once contrast is Partial Gastrectomy seen in the colon. Subtotal gastrectomy Total Gastrectomy Patient Preparation: Gastro-jejunostomy Metoclopramide 20 mg orally may be given before or during the examination to enhance SMALL BOWEL FOLLOW-THROUGH gastric emptying. Methods: 1. Single contrast Preliminary Image: 2. With the addition of an effervescent agent If vomiting, a plain abdominal film should be 3. With the addition of a pneumocolon performed to exclude high-grade small technique bowel obstruction. Indications: Technique: 1. Pain with weight loss The aim is to deliver a single continuous 2. Diarrhea column of barium into the small bowel. This 3. Transfusion dependent is achieved by the addition of 10 mL of anemia/gastrointestinal bleeding Gastrografin to the barium solution and the unexplained by colonic or gastric patient lying on their right to enhance gastric investigation emptying. If a follow-through examination is 4. Partial obstruction combined with a barium meal, glucagon can 5. Malabsorption be used for the duodenal cap views rather 6. Small bowel adhesive obstruction (water than Buscopan, because it has a short soluble contrast) length of action and does not interfere with the SBTT. Contrast Medium: E-Z Paque 100% w/v 300 mL usually given Images: divided over 20 min. The transit time 1. Prone PA images of the abdomen are taken through the small bowel is reduced by the every 15-20 min during the first hour, and addition of 10 mL of Gastrografin to the subsequently every 20-30 min until the barium, improving distension and reducing colon is reached. The prone position is used flocculation. In children, 3-4 mL kg is a because the pressure on the abdomen suitable volume. helps separate the loops of the small bowel. Shaina Baula | 25 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila 2. Each image should be reviewed and spot directly into the jejunum. However, the supine fluoroscopic views, using a degree of distal small bowel distension by compression device or pad if appropriate, small bowel enema and small bowel may be considered. follow-through methods is usually fairly 3. Dedicated spot views of the terminal ileum similar. are routinely acquired. Disadvantages: Additional Images: 1. Per-nasal/oral intubation may be unpleasant 1. To separate loops of the small bowel: for the patient, and may prove difficult. a. compression with fluoroscopy 2. Longer room time and greater staff b. with x-ray tube angled into the pelvis resources required. c. obliques—in particular with the right side 3. Potentially higher radiation dose to the raised for terminal ileum views, or patient (screening the tube into position). d. occasionally with the patient tilted head down Indications and Contraindications: e. pneumocolon—gaseous insufflation of the These are the same as for a barium colon via a rectal tube after barium arrives follow-through. In some departments it is in the caecum, which often results in only performed in the case of an equivocal good-quality double-contrast views of the follow-through. terminal ileum 2. Erect image—Occasionally used to reveal any Contrast Medium: fluid levels caused by contrast medium retained 1. Single contrast—e.g. E-Z Paque 70% w/v within diverticula. diluted; or Baritop 100% w/v (one 300 mL can made up to 1500 mL with water) 2. 600 mL of 0.5% methylcellulose after 500 mL of 70% w/v barium What is required for the procedure? Bilbao Dotter Tube ○ 22 F polyethylene tube ○ 150 cm long Aftercare: ○ Multiple side(8) holes at the tip with As for barium meal. or without end hole Complications: As for barium meal. SMALL-BOWEL ENEMA Advantage: This procedure gives better distension and visualization of the proximal small bowel than that achieved by a barium follow-through because rapid infusion of a large continuous column of contrast medium Shaina Baula | 26 RADIOLOGIC CONTRAST EXAMINATIONS Name of Professor: Dr. Emerlinda Reyes | 3rd year, 1st semester | BSRadTech 3-1 A.Y. 2024-2025 | EAC-Manila Silk tube with tungsten filled guide tip. prelubricated and fully within the tube, ○ It is made up of polyurethane & the whereas for the Bilbao-Dotter tube, the stylet & internal lumen of the tube guidewire is introduced after the tube tip is are coated with water. in the stomach. ○ Activated lubricant to facilitate the 2. The tube is then passed through the nose or smooth removal of the stylet after the mouth, and brief lateral screening of the insertion. neck may be helpful in negotiating the epiglottic region. The patient is asked to swallow with the neck flexed, as the tube i