Contrast and Special Radiological Procedures PDF

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/382367833 Contrast and Special Radiological Procedures Book · July 2024 CITATIONS READS 0 493 3 authors, including: Ayush Kumar Mewar University 4 PUBLICATIONS 0 CITATIONS SEE PROFILE All content following this page was uploaded by Ayush Kumar on 19 July 2024. The user has requested enhancement of the downloaded file. !"#$ % " & ' ' ( ($ $ )* +) ,-.+/$ ! # 012(342(3'56&7!12$&8$(37#1 0 -.-- % " & ' ' ( ($ CONTENTS - S.No. Topic Name Page No. 1. RADIOLOGICAL CONTRAST MEDIA 2-11 Gastrointestinal Tract Investigations 2. BARIUM SWALLOW 12-14 3. BARIUM MEAL 15-17 4. BARIUM MEAL FOLLOW THROUGH 18-20 5. BARIUM ENEMA 21-23 6. SMALL BOWEL ENEMA 24-25 Renal System Investigations 7. IVP 26-29 8. RGU 30-32 9. MCU 33-36 10. NEPHROSTOGRAM 37-38 11. INFUSION PYELOGRAM 39-42 Other Special Investigations 12. SIALOGRAPHY 43-46 13. DACROCYSTOGRAPHY 47-49 14. BRONCHOGRAPHY 50-52 15. ARTHROGRAPHY 53-55 16. HSG 56-59 17. MYELOGRAPHY 60-63 18. ORAL CHOLECYSTOGRAPHY 64-66 1 Radiological Contrast Media Contrast media are substances used to highlight areas of the body in radiographic contrast to their surrounding tissues. Contrast media enhance the optical density of the area under investigation so that the tissue/structure absorption differentials are sufficient to produce adequate contrast with adjacent structures, enabling imaging to take place. There are numerous types of radiographic contrast media used in medical imaging, which have different applications depending on their chemical and physical properties. When used for imaging purposes contrast media can be administered by injection, insertion or ingestion. History of radiographic contrast media Radiographic contrast has been used for over a century to enhance the contrast of radiographic images. In 1896, in the year after X-rays were discovered, inspired air became the first recognized contrast agent in radiographic examinations of the chest. In 1898, the first contrast studies were carried out on the upper gastrointestinal tract of a cat using bismuth salts. These salts were very toxic, and by 1910 barium sulphate and bismuth solutions were being used in conjunction with the fluoroscope, barium sulphate having been used with differing additives ever since for imaging of the gastrointestinal tract. Images of the urinary system were achieved in the early 1920s. In the early 1920s, syphilis was treated with high doses of sodium iodide. During this treatment the urine in the bladder was observed to be radio-opaque owing to its iodine content. In 1923 the first angiogram and opacification of the urinary tract was performed using sodium iodide. Sodium iodide was too toxic for satisfactory intravenous use, necessitating a need to find a less toxic iodinated compound. The first iodine-based contrast used was a derivative of the chemical ring pyridine, to which a single iodine atom could be bound in order to render it radio-opaque. Iodine-based contrast media have been used ever since. These media, however, produced varying adverse reactions, and it was realized that a contrast agent was needed that was both safe to administer and enhanced the contrast of the radiographic image. Modern ionic contrast agents were introduced in 1950 and were derivatives of tri-iodo benzoic acid; this structure enabled three atoms of iodine to be carried, rendering it more radio-opaque. However, the agents still caused adverse effects, as they were still of high osmolarity; the term is explained below. Ionic media dissociate in water; their injection into the blood plasma results in a great increase in the number of particles present in the plasma. This has the effect of displacing water. Water moves from an area of greater concentration to an area of lesser concentration by the process of osmosis, the physical process that occurs whenever there is a concentration difference across a membrane and that membrane is permeable to the diffusing substance. Osmolality (which is generally considered interchangeable with the term ‘osmolarity’) is defined as the number of solute particles, i.e. the contrast medium molecules, dissolved in 1 L (1000 g) of water. These media exert tremendous osmotic activity on the body. The 2 osmolality of normal human blood is given as around 290–300 mOsm/kg (milliosmoles per kilogram). There remained a need to find a water-soluble iodine-based contrast agent with reduced toxicity but which still produced satisfactory radio-opacity on images. In the 1970s and 1980s non-ionic low-osmolality contrast media became widely available, with the first non-ionic contrast medium being introduced in 1974, representing a major advancement in diagnostic imaging. Most recently the non-ionic dimers have emerged. These media are highly hydrophilic, resulting in lower chemotoxicity, and they are iso-osmolar with the respective body fluids, meaning they can be used for examinations such as angiography and computed tomography (CT) arteriography, which require high doses of contrast media to be administered and where low toxicity is essential. Requirements of ‘the ideal’ contrast medium and types of contrast agent There is currently no contrast medium on the market that is considered to be ideal, but the ideal contrast medium should fulfill certain requirements for safe and effective application. It should be: Easy to administer Non-toxic A stable compound concentrated in the required area when injected Rapidly eliminated when necessary Non-carcinogenic Of appropriate viscosity for administration tolerated by the patient Cost-effective. Contrast media are divided into two main categories. The first is negative contrast media, which are radiolucent and of low atomic number, causing the part in which they are placed to be more readily penetrated by X-rays than the surrounding tissue; as they attenuate the X-ray beam less effectively than body tissue, they appear darker on the X-ray image. Gases are commonly used to produce negative contrast on radiographic images. The second type is positive contrast media; these are radio-opaque and of a high atomic number, causing the part in which they are placed to be less readily penetrated by X-rays than the surrounding tissue. Consequently, this contrast agent-filled area appears denser than body tissue. Barium- and iodine-based solutions are used in medical imaging to produce positive contrast. Both positive and negative contrast can be used together in double-contrast examinations to produce a radiographic image. Double contrast is used primarily in the alimentary tract, but is 3 also used in arthrography of joints. The positive contrast medium is used to coat the walls of the cavity and the negative contrast, in the form of a gas, is used to distend the area being imaged. Double-contrast examinations permit optimum visualization by producing a high inherent contrast while allowing adequate penetration of the area under examination. Use of a small amount of contrast agent in conjunction with the distended cavity allows coating of the structures in the cavity (or in the case of the alimentary tract, the mucosal lining), which provides better detail of the area when the thin coating is shown in contrast to the gas-filled area, rather than using large amounts which may be dense enough to mask important information. Negative contrast media The following gases create negative contrast on radiographic images: Air: Introduced by the patient during a radiographic examination, e.g. inspiration during chest radiography, or can be introduced by the radiographer as part of the examination in a double-contrast barium enema Oxygen: Introduced into cavities of the body, for example in the knee during arthrography to demonstrate the knee joint Carbon dioxide: Introduced into the gastrointestinal tract in conjunction with a barium sulphate solution to demonstrate the mucosal pattern, e.g. double-contrast barium meal. For the barium meal it is formulated as effervescent powder (e.g. ‘Carbex’ granules) or ready- mixed carbonated barium sulphate (e.g. ‘Baritop’). Carbon dioxide can also be introduced into the colon when performing a double-contrast barium enema. It has been recommended that carbon dioxide be used as the negative contrast agent in a double-contrast barium enema, rather than air, as it causes less immediate abdominal pain1 as well as less post-procedural pain and discomfort.2 However, some studies have shown that carbon dioxide produces inferior distension and additional insufflations are required to maintain adequate quality distension.3 Carbon dioxide can also be used as an alternative contrast to iodinated contrast for diagnostic angiography and vascular interventions in both the arterial and the venous circulation. The gas produces negative contrast owing to its low atomic number and low density compared with adjacent tissues. Positive contrast media Barium and iodine solutions are used to create positive contrast on radiographic images. Barium sulphate solutions (BaSO4) used in gastrointestinal imaging Barium solutions are the universal contrast media used for radiographic examinations of the gastrointestinal tract. The following characteristics make barium solutions suitable for imaging of the gastrointestinal tract: High atomic number (56) producing good radiographic contrast Insoluble 4 Stable Relatively inexpensive Excellent coating properties of the gastrointestinal mucosa Barium suspensions are composed from pure barium sulphate mixed with additives and dispersing agents, held in suspension in water. Compounds to stabilize the suspension are added; these act on the surface tension and increase the viscosity of the solution. A dispersing agent is added to prevent sedimentation, ensuring an even distribution of particles within the suspension. Also added to the suspension is a deforming agent, used to prevent bubbles that may mimic pathology in the gastrointestinal tract. Flavorings are usually added to oral solutions, making them more palatable for patients. The concentration of barium in the solution is normally stated as a percentage weight to volume ratio (w/v). A 100% w/v solution contains 1 g of barium sulphate per 100 mL of water; the density of the barium solution is therefore dependent upon the weight/volume. There are many varieties of barium suspension available and the type used depends on the area of the gastrointestinal tract being imaged. It also depends greatly upon the individual preferences of the practitioner. Patients rarely have allergic reactions to barium sulphate but may react to the preservatives or additives in the solutions. Barium sulphate preparations are usually safe as long as the gastrointestinal tract is patent and intact. A severe inflammatory reaction may develop if it is extravasated outside the gastrointestinal tract; this is most likely to occur when there is perforation of the tract. If barium sulphate escapes into the peritoneal cavity, inflammation and peritonitis may occur. Escaped barium in the peritoneum causes pain and hypovolaemic shock and, despite treatment which includes fluid replacement therapy, steroids and antibiotics, there is still a 50% mortality rate; of those who survive, 30% will develop peritoneal adhesions and granulomas.4 Aspiration of barium solutions during upper gastrointestinal tract imaging is considered to be relatively harmless, most frequently affecting the elderly patient. Physiotherapy is usually required to drain the aspirated barium and should be performed before the patient leaves the department. Oral barium sulphate should not be administered in cases of obstruction as it may inspissate behind an obstruction, compounding the patient’s condition. Sedated patients should not undergo radiological examinations of the upper gastrointestinal tract as their swallowing reflex may be diminished, increasing the risk of aspiration. When preparing barium solutions for administration it is important to check expiry dates and ensure the packaging is intact. Solutions administered rectally should be administered at body temperature to improve patient tolerability and also reduce spasm of the colon. It is important that the administrator knows the patient’s full medical history and checks for any contraindications prior to administration. Barium sulphate solutions are contraindicated for the following pathologies: Suspected perforation 5 Suspected fistula Suspected partial or complete stenosis Paralytic ileus Haemorrhage in the gastrointestinal tract Toxic megacolon Prior to surgery or endoscopy If the patient has had a recent gastrointestinal wide bore biopsy (usually within 3–5 days) or a recent anastomosis When barium sulphate solutions are contraindicated for gastrointestinal imaging, a water- soluble iodine-based contrast medium (e.g. Gastrografin or Gastromiro) should be used. These can be administered orally, rectally or mechanically, e.g. via stomas. The iodine concentration of Gastrografin is 370 mg/mL and of Gastromiro 300 mg/mL. When used for imaging the gastrointestinal tract, water-soluble contrast produces a lower-contrast image than barium owing to its lower atomic number. The patient’s consent must be given prior to the administration of barium contrast solutions. The patient should be given a full explanation, be reassured about the examination and given the opportunity to ask questions. It is important when using barium sulphate solutions that associated pharmacological agents such as buscopan and glucagon are fully understood and the indications and contraindications ensuring their safe application adhered to. Iodine-based contrast media used in medical imaging and their development The largest group of contrast media used in imaging departments is the water-soluble organic preparations in which molecules of iodine are the opaque agent. These compounds contain iodine atoms (iodine has an atomic number of 53) bound to a carrier molecule. This holds the iodine in a stable compound and carries it to the organ under examination. The carrier molecules are organic, containing carbon, and are of low toxicity and high stability. Iodine is used as it is relatively safe and the K edge = 32 keV (binding edge of iodine K-shell electron), thus being close to the mean energy of diagnostic X-rays. Selection of kVp for imaging examinations using iodine-based contrast plays a part in providing optimum attenuation. The absorption edge of iodine (35 keV) predicts that 63–77 kVp is the optimal range. The iodine-based compounds are divided into four groups (Fig. 1.1) depending on their molecular structure, as follows: 1. Ionic monomers 2. Ionic dimers 3. Non-ionic monomers 4. Non-ionic dimers 6 Figure: - 1.1. Classification of contrast media Ionic monomers – high osmolar contrast media (HOCM) (Fig. 1.2) The basic molecule of all water-soluble iodine-containing contrast media is the benzene ring. Benzene itself is not water soluble; to make it soluble, carboxyl acid (COOH) is added. Three of the hydrogens in this molecule are replaced by iodine, rendering it radio-opaque, but it still remains quite toxic. The remaining two hydrogens (R1 and R2 in Fig. 28.2) are replaced by a short chain of hydrocarbons, making the compound less toxic and more acceptable to the body. The exact nature of these compounds differs between different contrast media, but they are usually prepared as sodium or meglumine salts as these help to provide solubility. Figure: -1.2. Molecular structure of an Ionic Monomer (HOCM) Ionic compounds dissociate (dissolve) into charged particles when entering a solution. They dissociate into positively charged cations and negatively charged anions. For every three iodine molecules present in ionic media, one cation and one anion are produced when it enters a solution. Their ‘effect’ ratio is therefore 3:2. These solutions are highly hypertonic, with an osmolality approximately five times higher than human plasma (1500–2000 mOsm/kg H2O compared with 300 mOsm/kg H2O for plasma). Ionic dimers – low osmolar contrast media (LOCM) (Fig. 1.3) As contrast agents developed in the 20th century, it was acknowledged that a contrast medium with reduced osmotic effects was needed. As previously stated, the higher the ‘effect’ ratio the lower the osmolarity of the contrast media. An attempt was made to increase the ‘effect’ ratio and produce a contrast medium with lower osmolarity. This was achieved by linking together two conventional ionic contrast media molecules. The resulting dimeric ionic contrast medium was an improvement on the HOCM. Reduced osmolality (600 mOsm/kg 7 H2O) made the contrast more tolerable for patients. The ionic molecule still dissociates into two particles, a positive cation and a negative anion. However, there are now twice as many particles in solution with twice the osmolarity. Each molecule carried six iodines (as opposed to three in the HOCM), hence there is an iodine atom-to-particle ratio of 6:2; so only half the number of molecules are needed to achieve the same iodine concentration. This means a lower volume of contrast medium is therefore required for an examination. Figure: - 1.3 Molecular structure of Ionic Dimer (LOCM) Non-ionic monomers (LOCM) (Fig. 1.4) These are low osmolar agents and do not dissociate into two particles in a solution, making them more tolerable and safer to use than ionic contrast. For every three iodine molecules in a non-ionic solution, one neutral molecule is produced. Non-ionic contrast media are therefore referred to as 3 : 1 compounds. They substitute the sodium and meglumine side chains with non-ionising radicals (OH)n. Two major advantages arise through the change in chemical structure: the first is that the negative carboxyl group is eliminated, thereby reducing the neurotoxicity; and the second is that the elimination of the positive ion reduces osmolality to 600–700 mOsm/kg H2O. Non-ionic LOCM is recommended for intrathecal and vascular radiological procedures. Figure: - 1.4 Molecular structure of non-ionic monomer Non-ionic dimers (isotonic) – the gold standard (Fig. 1.5) Clearly, the closer the osmolality of a contrast agent is to that of blood plasma, and the better an isotonic solution, i.e. that the contrast solution has similar osmolality to blood plasma 8 (approximately 300 mOsm/kg H2O), is a most ideal option. Non-ionic dimers are dimeric non-dissociating molecules; for every one molecule there are six iodine atoms. The ratio is therefore 6:1; double that of the non-ionic monomers. An important feature of these is that they are isotonic. Their iso-osmolality, combined with a slower diffusion of the larger molecules across vessel walls from the vascular space, plays a significant role in imaging venous phase images following arterial injections (and arterial phase images following venous injections). These compounds represent a gold standard water-soluble iodine contrast medium. Figure:1.5 - Molecular structure of non-ionic dimers The percentage solution The percentage solution indicates the amount of solute in the solvent. The percentage solution does not indicate the percentage iodine content, as demonstrated in the following table. Percentage iodine content in contrast media Contrast media Percentage solution Iodine conc. of solution Urografin150 30 146 mg/mL Urografin370 76 370 mg/mL Gastrografin 76 370 mg/mL Niopam370 75.5 370 mg/mL The solvent affects the viscosity of the contrast agent. Viscosity is the resistance to flow of a contrast medium and relates to the concentration, molecular size and temperature of the contrast. The volume and density of contrast used is dependent upon the examination being undertaken, the pathology being investigated, the age of the patient and the patient’s medical status. Essential criteria for the ‘ideal’ intravenous contrast agent Water soluble Heat/chemical/storage stability Non-antigenic 9 Available at the right viscosity and density Low viscosity, making them easy to administer Persistent enough in the area of interest to allow its visualisation Selective excretion by the patient when the examination is complete Same osmolarity as plasma or lower Non-toxic, both locally and systemically Low cost Possible side-effects of ionic-based contrast media Any water-soluble ionic contrast introduced into the vascular system can potentially cause physiological adverse effects. These effects are caused by the high osmolarity and chemotoxic effects of the medium. Although both ionic and non-ionic iodine media have physiological effects on the body, ionic media are of higher osmolarity and potentially cause more side effects in the patient. An ionic contrast has approximately five times the osmolarity of human plasma. Water-soluble organic iodine contrast media have two effects: the desirable primary effect of attenuating X-rays and providing the radiographic image with adequate contrast, and the unwanted secondary effect of inducing potential side effects in patients. Primary effect – image contrast Optimum attenuation is achieved by selecting the appropriate concentration of iodine in solution for the planned examination. Two solutions with the same iodine content should provide the same iodine concentration in blood after intravenous injection. This is not the case, however, and the concentration may be affected by small molecules diffusing out of the blood vessel lumen, or by solutions of high concentration within the blood vessel drawing water out of adjacent cells by osmosis (therefore diluting the solution), as mentioned in the introduction to this chapter. To illustrate this, remembering that osmolality is defined as the number of solute particles (e.g. the contrast media molecules) dissolved in 1 L (1000 g) of water; a comparison between normal blood plasma osmolality and different contrast agents is shown below: Normal blood plasma ~300 mOsm/kg water Ionic monomer ~1200–2400 mOsm/kg water, making it very hypertonic Ionic dimers, and non-ionic monomers and dimers (LOCM) are still hypertonic but to a much lesser degree, reducing the osmotic activity. They are, however, more expensive. Isotonic iodixanol (Visipaque) has approximately a third the osmolality of the non-ionic media and a sixth of that of the monomeric ionic media. When comparing two contrast media with the same iodine concentration, a higher venous concentration of iodine is obtained when diffusion of contrast medium is slowed down by 10 using large molecules (dimers) and osmotic effects are reduced by reducing the number of molecules/ions in solution (monomers). Secondary effect – adverse events Contrast media are specifically designed to minimise secondary effects or adverse reactions. The ‘perfect’ contrast agent would cause no adverse effects at all. Although reactions to contrast media are rare, it is essential that every effort is made to minimise the risk. Acute adverse reactions do occur and are defined as reactions that occur within 1 hour after administration of a contrast medium. Adverse reactions to contrast media or drugs are generally classified into two categories: 1. Idiosyncratic reactions are dose dependent and usually anaphylactoid in nature. These are unpredictable, having a prevalence of 1–2% (0.04–0.22% severe), and are fatal in 1 in 170 000.5 2. Non-idiosyncratic reactions are divided into chemotoxic and osmotoxic. Chemotoxic effects can be minimized through the use of LOCM. As LOCM are available at a reasonable cost the use of higher-toxicity substances could be challenged medicolegally.6 REFRENCES https://radiologykey.com/wp- content/uploads/2016/03/B9780702039331000281_f028-001-9780702039331.jpg https://radiologykey.com/wp- content/uploads/2016/03/B9780702039331000281_f028-002-9780702039331.jpg https://radiologykey.com/wp- content/uploads/2016/03/B9780702039331000281_f028-003-9780702039331.jpg https://radiologykey.com/wp- content/uploads/2016/03/B9780702039331000281_f028-004-9780702039331.jpg https://radiologykey.com/wp- content/uploads/2016/03/B9780702039331000281_f028-005-9780702039331.jpg https://radiologykey.com/contrast-media-2 , Susan Cutler 11 Barium Swallow Introduction-: It is the study of oesophagus up to cardio-oesophageal junction, gastro-oesophageal junction. So it is also known as ESOPHAGOGRAPHY. It is used of examine upper GI tract which includes oesophagus to the lower sphincter of oesophagus. It is a radiological investigation of oesophagus in which contrast media (BaSO 4) paste is given to patient and during swallowing; various spot films are taken of oesophagus. Indications-: Dysphagia Achalasia Hiatus hernia Retro-sternal pain Stricture Partial obstruction Diverticula Tracheo-oesophageal fistulae Perforation Carcinoma of oesophagus Regurgitation Esophagitis Frequent vomiting Contra-Indications-: Complete oesophageal obstruction Suspected leakage from oesophagus into the mediastinum , pleura and peritoneal cavity Pregnant lady Not done just after any type of oesophageal surgery Contrast Media-: BaSO4 (water insoluble, white chalky powder) Gastrografin (water soluble, iodinated) BaSO4 is not used in any type case of perforation then we use Gastrografin. Gastrografin is not used in any type case of trachea-oesophageal fistulae then we use BaSO4. 250% w/v in 100 ml 12 Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Sterile bowl Sterile spoon Distilled water Surgical gloves Lead apron Gauge piece spirit Patient preparation-: Nothing by mouth (NBM) before 2 hours prior of examination Ask patient not to smoke on the day of examination Explain whole procedure to patient Procedure-: Prepare the paste of BaSO4 in a sterile bowl. Patient is asked to lie down in supine position or erect (RAO) to avoid the overlapping of oesophagus by spine. A spoonful paste of BaSO4 is given to the patient and asked to swallow and upper. AP & LAT radiographs of oesophagus are taken. This is to get mucosal coating. Again a spoonful paste of BaSO4 is given to patient and to swallow and during swallowing necessary radiograph (lower oesophagus AP&LAT) is taken. A full length of oesophagus filled with Barium should also be taken to see the leakage into the mediastinum from a perforation or fistulae. Filming-: Upper oesophagus AP & LAT Lower oesophagus AP & LAT Complications-: Sometime constipation may occur. After care-: Patient is asked to take or to drink adequate amount of water to remove the barium from GI tract. 13 X-ray Images-: AP LAT Figure-: Barium Swallow study 14 Barium Meal Introduction-: It is the investigation of upper GI Tract including stomach, duodenum & duodenum- jejunum junction. CM is given to patient orally & various radiographs are taken. It may be done either with single CM or double contrast study. Indications-: Dyspepsia Gastric or duodenal obstruction Ca of gastro oesophageal junction, stomach & duodenum. Abdominal mass Weight loss, low apatite Vomiting Ulcer Contra-Indications-: Complete large bowel obstruction Suspected perforation Pregnant lady Allergy with CM Any type of Barium study is done with in 7 days. Contrast Media-: BaSO4 (water insoluble, white chalky powder) Gastrografin (water soluble, iodinated) Carbex granules for double contrast 135% w/v in 150 ml Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media(BaSO4) & Carbex granules Sterile bowl Sterile spoon Distilled water Surgical gloves Lead apron Gauge piece spirit 15 Patient preparation-: Nothing by mouth (NBM) before 6 hours prior of examination Laxative tablets are given to patient for clear visualization of bowel. Procedure-: Patient is asked to lie down on the fluoro table in supine position. For single contrast study, only BaSO4 mixture (135% w/v in 150 ml) is given to patient. For double contrast, the Carbex granules are given to patient after Barium mixture. It makes a barium coating on the mucosa and provides better mucosal information. After giving of Barium mixture, patient is asked to lie on the left side to prevent Barium from reaching in the duodenum too early. Patient is asked to roll on for sometime up to 2-4 rounds, it provides coating of BaSO4 over the mucosa. Filming-: Spot films are taken which are as follows:- Films Part visualization Supine RAO Antrum and greater curve Supine Antrum and body Supine LAO Lesser curve Left lateral Fundus Prone Duodenal loops Prone RAO/LAO Duodenal cap series When Barium enters duodenum turned RAO, fills duodenum with gas & duodenal cap films are taken. Complications-: Sometime constipation may occur. After care-: Patient is asked to take or to drink adequate amount of water to remove the barium from GI tract. 16 X-ray Images-: Figure-: Barium meal study 17 Barium Meal Follow Through (BMFT) Introduction-: It is called BMFT because it is performed following Barium Meal. A fluoroscopic examination of small bowel including from DJ junction to Ileocaecal junction (I-C junction). It is a no-invasive procedure in which CM is given to patient orally. Indications-: Crohn’s disease G.I. bleeding Abdominal pain Small bowel partial obstruction Meta absorption Abdominal mass Diarrhoea Carcinoma of small bowel Recurrent vomiting Contra-Indications-: Allergy to CM Pregnancy Complete bowel obstruction Paralytic injury Suspected perforation Contrast Media-: E-Z Microbar HD 100% W/V (300ml) Gastrografin (Iodinated water-soluble CM) Carbex granules (Double contrast) When BaSO4is contra indicated then iodinated water soluble contrast is used. Equipment-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Surgical gloves Lead apron Gauge piece spirit 18 Patient preparation-: Patient is asked for fasting before the night of examination. Laxative tablets are given to patient to empty bowel. Confirm any contra indications to contrast media being use. Metaclopramide (20mg) is given to patient 20 min. before the examination to avoid vomiting. Procedure-: Patient is asked to remove clothing and wear a hospital gown. Patient is asked to lie down in supine position on fluoro table. BUSCOPAN (20mg) IV injection is given to patient orally (no Carbex granules used) For double contrast, instead of giving barium first Carbex granules are given to patient who produces gas. After Carbex granules barium mix is given. It provides the coating of Barium on mucosal layer and provide better assessment of mucosal disease. After giving CM patient is asked to lie on his right side and this allow the mixing of barium into small bowel. Metaclopramide increases the rate of gastric emptying. Filming-: PA prone films are taken at the time interval of 20 minutes up to contrast reached IC junction. Compression films are taken to avoid overlapping of the loops of small bowel. After care-: Patient should be warned that his bowel motions will be white for few days. Advised to take adequate amount of water. Some laxatives may help to avoid constipation. 19 X-ray Images-: Figure-: BMFT 20 Barium Enema Introduction-: It is the radiological examination study of large intestine to evaluate the large bowel disease. Contrast media is introduced into the large bowel through anus with the help of catheter (Foley’s balloon catheter). Indications-: Crohn’s disease Blood in stool Chronic diarrhoea Polyps Ulcerative colitis Constipation Melaena Contra-Indications-: Allergy to CM Pregnancy Toxic megacolon Pseudo-membranous colitis Incomplete bowel preparation Complete obstruction Contrast Media-: BaSO4 (case of false passage) Gastrografin (case of perforation) Microbar/Polybar 115% w/v (500ml) or as required. Air (for double contrast) Equipment-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Foley’s catheter Syringe Enema cone Lignocaine jelly Surgical gloves 21 Lead apron Gauge piece spirit Patient preparation-: Advise to take low residual & high fiber diet before 3 days of examination. On the day of examination, patient is given some laxative tablets (Dulcolax, Flatulax). If patient do not have allergy from penicillin’s- (amoxicillin 1gm + gentamycin 120mg I.V. 15 minute before the procedure & following by amoxicillin 500mg tablet orally 6 hours later.) If patient have allergy from penicillin then- (vanomycin 1gm + gentamycin 120 mg prior to the start of examination) Sometime plane enema is given to the patient prior 1-2 hours of investigation to remove any residue in colon. Procedure-: Patient is asked to remove clothing and wear a hospital gown. Patient is asked to lie down in supine position on fluoro table. KUB x-ray is taken to make sure that the colon is clear. Then a lubricated enema tube with local anaesthesia is inserted into the rectum through anus. Patient is advised to tighten his/her anus sphincter muscle. BUSCOPAN 20 mg or Glucagon 1mg IV injection is given to the patient for muscle relaxant. Barium solution is introduced through the catheter with help of syringe (Accepto- syringe). Procedure can be done in 2 methods-: Single contrast: -only Barium mix is given to patient Double contrast: - firstly, Barium mix is inserted then air blows into the rectum. The air expands the colon and improves the quality of image because of thin coating of Barium over the mucosal layer. Patient is asked to roll from RAO to LAO position for better coating of Barium over the mucosal layer. Filming-: A series of radiographs are taken of Rectum-sigmoid colon, Hepatic flexure, spleen flexure of colon and IC junction – RAO, LAO, PRONE, LEFT & RIGHT LATERAL. After care-: Patient is asked to take or to drink adequate amount of water. Some laxatives are given to avoid constipation. Patient may have white stool for few days. 22 X-ray Images-: (A) (B) Figure-: (A) Single Contrast (B) Double Contrast 23 Small Bowel Enema (Eneteroclysis) Introduction-: It is the radiological study of small bowel from jejunum to the ileocaecal junction using the contrast media under the fluoroscopic guidance. Contrast media is instilled through the tube. Indications-: Diarrhea Abdominal pain Crohn’s disease Malabsorption GIT bleeding Suspected Meckel’s diverticulum Tumors of small intestine Partial small bowel obstruction Contra-Indications-: Complete colonic obstruction Suspected perforation Pregnant lady Allergy with CM Any type of Barium study is done with in 7 days. Paralytic ileus Recent surgery Contrast Media-: BaSO4 (water insoluble, white chalky powder) Gastrografin (water soluble, iodinated) 70% w/v in 1500 ml and add 600 ml of 0.5% carboxy-methyl-cellulose (CMC) after 500 ml of 70% w/v barium. Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media(BaSO4) & Carbex granules Sterile bowl Sterile spoon Distilled water Surgical gloves Lead apron Gauge piece spirit 24 Patient preparation-: Patient is asked for fasting before the night of examination. Laxative tablets are given to patient to empty bowel. Confirm any contra indications to contrast media being use. Metaclopramide (20mg) is given to patient 20 min. before the examination to avoid vomiting. Procedure-: Patient is asked to lie down on the fluoro table in supine position. After that a plain abdominal film (KUB) is taken. A plastic catheter with guide wire is inserted in GIT through mouth or nose. Lignocaine spray is lubricated on catheter and inserted to first part (nasal cavity) then small bowel. Catheter provides the prevention of Barium back reflux into stomach. After that spot films are taken. Filming-: x Prone film x Supine film Complications-: Sometime constipation may occur. After care-: Patient is asked to take or to drink adequate amount of water to remove the barium from GI tract. REFERENCE - ¾ https://images.emedicinehealth.com/images/article/main_image/barium-swallow- 1.jpg ¾ http://1.bp.blogspot.com/e1y7t3Ophig/UFankm0DD0I/AAAAAAAAAD0/GNWJ G8K7U2I/s640/Barium+swallow.jpg ¾ https://2.bp.blogspot.com/Kao8hXyx_U0/XDljOgALgMI/AAAAAAAAB5c/fUOb YIkE6rgTQ5RjDskFyXbBPHrB8HNpQCEwYBhgL/s320/bmft.jpg ¾ https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcTSB 4WW82iWXzFt2ptSEZgZYRTJCK2efi9uUxC7kaNBs4-X6hRkcyUf3uMsQ&s ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 25 Intra Venous Pyelography Introduction-: It is also known as – 1.) IVU (Intra Venous Urography) 2.) EU (Excretory Urography) It is a special radiological contrast media investigation of Kidneys, Bladder & Ureter. It is a Renal Function Test (RFT). Indications-: Check for normal function of kidney Check for shape, size & position of kidney Ectopic kidney Haematuria Hydronephrosis Bladder Diverticula Enlarged prostate Ureteric obstruction Urolithiasis Kidney donor patient Abdominal injury Bladder & Kidney infection Tumors Contra-Indications-: Contrast allergy ( AST + ve ) RFT abnormal Pregnant lady Poor patient preparation Acute trauma patient Fever Acute abdominal pain Hepatorenal syndrome Thyrotoxicosis Raised serum creatinin Multiple myeloma Contrast Media-: LOCM (low osmolar contrast media) Non – ionic Iohexol = Urografin Adult dose – 50ml Pediatric dose – 1ml/kg body weight Double dose IVP – 2ml/kg body weight 26 Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Abdominal compressor Metallic markers Immobilization aids IV administration equipments (50ml syringe, filling needle) Emergency drugs & equipments Surgical gloves Lead apron Gauge piece spirit Patient preparation-: Nothing by mouth (NBM) before 8-12 hours prior of examination Tell about to take low diet & light meal before 2-3 days of test Explain whole procedure to patient Give laxative tablets (a type of medicine that helps a person to empty their bowels) like – Dulcolax (2time) and Flatulax (3time) Advise AST ( Allergy sensitivity test ) and RFT ( Renal function test ) Suspend diabetic patient Procedure-: Patient comes to the room and checks the AST & RFT results and other old investigations. A plain film is taken to see the state of bowel preparation. IV set is introduced in the median anti cubical vein. Abdominal compression is applied. Contrast media is injected. A series of x-ray films are taken as follows – 27 FILM TIMING POSITION FILM SIZE INDICATIONS Plain film Before starting Supine 11”*14” Ensure patient (preliminary) the procedure preparation Nephrogram 5 min. after Supine 11”*14” Image of upper phase contrast media collecting system Nephrogram Show renal parenchyma Secretory phase 15 min. after Supine 11”*14” Both kidney see CM Upper ureter see Ureterogram 25 min. after Prone 11”*14” To see the UV phase CM junction and lower ureter Cystogram 45 min. after Supine 11”*14” To see the phase ( prevoid ) CM bladder capacity & any type of bladder diverticula Post void Supine 11”*14” To see the bladder residual volume After care-: Patient is asked to take or to drink adequate amount of water. Take healthy food properly. Anti histamine tablets for allergic reaction. X-ray Images-: 28 Figure -: Intravenous Pyelography Reference – ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 29 Retrograde Urethrography (RGU) Introduction-: It is a routine radiologic procedure (most typically in males) used to image the integrity of the urethra by using iodinated contrast media. It is a radiographic study of urethra using iodinated contrast media. Anatomy of Urethra-: It extends from bladder neck till the meatal opening at penis. 4-5 cm long in females 18-20 cm long in males Parts of Urethra-: Penile/Spongy urethra Anterior Urethra Bulbar urethra Urethra Membranous urethra Posterior Urethra Prostatic urethra Indications-: Stricture Pelvic trauma Urethral tear Urethral obstruction Urethral foreign body Urethral diverticula Prostatic abscess Fistula/false passage Urethral mucosal tumors Post operative evaluation Congenital abnormalities Contra-Indications-: Acute UTI Recently surgery of urethra 30 Iodine sensitivity/contrast allergy Contrast Media-: LOCM(Low osmolar contrast media) – Iopamidol Urograffin 76% ( trazograff 76% ) Ratio between contrast media and normal saline ( 4:1 ) Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Foley catheter no.8 Syringe Surgical gloves Lead apron Gauge piece spirit Patient preparation-: Patient micturates prior to the examination Procedure-: Ask to patient remove the clothes and wear a hospital gown. Now the patient lies on the fluoroscopic table in coned supine AP position and take a x-ray film (preliminary film) to see the base of bladder & urethra. Now patient is made to lie supine with slightly oblique position that provides best visualization of urethra. Foley’s catheter lubricated with lignocaine up to 2-4 cm inserted in the urethra through urethral orifice. Pressure is applied over the glans penis to avoid expulsion of the catheter. Contrast media is injected slowly under fluoroscopic guidance. Contrast images are taken. Filming-: 30 degree LAO(left anterior oblique) 30 degree RAO(right anterior oblique) Supine AP Complications-: Contrast reaction (due to absorption through absorption through bladder mucosa) UTI Urethral trauma/rupture Intravasation of contrast due to use of excessive pressure in stricture 31 After care-: Patient is asked to take or to drink adequate amount of water to remove the contrast media. X-ray Images-: Figure -: RGU Study Reference – ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 32 Micturating Urethrography (MCU) Introduction-: It is a fluoroscopic examination in which bladder is filled with contrast via supra pubic or retrograde catheterization & the urethra is assessed during voiding. Note-: mostly used to visualize & evaluate a) prostatic urethra b) changes in the bladder neck Indications-: A) Children-: o UTI o Voiding difficulties o Vesico-ureteric Reflux o Baseline study prior to urinary tract surgery o Post operative evaluation of ureteric abnormalities o Trauma o Suspected anatomic abnormalities of bladder neck & urethra B) Adults-: o Functional disorder of bladder & urethra o Suspected Vesico-vaginal/Vesico-colic fistula o Suspected bladder/urethral trauma o Urethral diverticula Contra-Indications-: Acute UTI Contrast Hypersensitivity Contrast Media-: LOCM, Iopamidol Water soluble CM – Urografin76% with dilution of 1:3 in NS Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Foley catheter No. 10F Infant feeding tube – 6No. Syringe Surgical gloves Lead apron Gauge piece spirit 33 Patient preparation-: Patient is asked to micturate prior to the examination. Procedure-: Patient micturates prior to the examination. Preliminary film – coned view of bladder using under couch table. Under aseptic conditions, catheterize the urinary bladder with patient in supine position. Residual urine is drained. Push the diluted CM slowly under fluoroscopic guidance. Ask the patient to inform you when he has urged to micturate. Catheter should not be removed until the radiologist is convinced that patient will micturate or until no more contrast medium drips into the bladder. Ask the patient to micturate in a urine receiver in an erect oblique position. Spot images are taken during micturition in right & left oblique projection & reflux is recorded. Finally, a full length view of the abdomen is taken to demonstrate any undetected reflux of the contrast medium that might have occurred in the kidneys & to record the post micturition residue. Filming-: Preliminary film Filling phase – full bladder in supine position Voiding phase – LAO & RAO Post void or A full length film – to show reflux & post void residual volume Vesico-vaginal / Vesico-rectal fistula – Lateral, Oblique Complications-: Contrast reaction Contrast induced cystitis UTI Catheter trauma Bladder perforation Retention of Foley’s catheter Catheterization of vagina/ectopic ureter After care-: Warned of rare dysuria & retention. Reflux – antibiotics are to be prescribed. 34 X-ray Images-: Figure-: MCU 35 Figure-: kidney reflux shows in mcu image Reference – ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 36 Nephrostogram Indications-: To evaluate the site of ureter obstruction To evaluate for urine leak To evaluate residual stones Ureteral fistula To evaluate the condition of kidney Placing, checking position or removing a nephrostomy tube Contra-Indications-: Contrast hypersensitivity Pregnancy UTI (urinary tract infection) Contrast Media-: Urografin 60% dilute in NS (normal saline) Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Normal saline Lead apron spirit Patient preparation-: Nothing by mouth (NBM) before 6 hours prior of examination Routine test - BT, CT, Blood pressure Explain whole procedure to patient Suspension of blood thinners & diabetic medication Patient must have a nephrostomy tube already positioned in the kidney. Procedure-: Ask patient to wear hospital gown. Patient positioning (supine with slightly tilted). Contrast will be injected through the nephrostomy tube by the radiologist. Spot images will be taken. Nephrostomy tube may be removed after the procedure. Note-: you will have a nephrostomy catheter to relieve a blockage in your urinary system. The catheter will be inserted through your skin into your kidneys. It will allow urine to drain into a bag outside your body. In some cases, it may also drain into your bladder. 37 Filming-: Oblique Lateral After care-: Patient monitored by physician in recovery room. X-ray Images-: Figure -: Nephrostogram 38 Infusion Pyelogram Introduction-: It has two types of study – 1) Antegrade pyelography 2) Retrograde pyelography 1) Antegrade Pyelography Definition-: It is a diagnostic test that uses contrast agent to produce detailed x-ray pictures of the upper urinary tract (kidney&ureter). Indications -: To diagnose 1) Hydronephrosis 2) Ureteropelvic junction obstruction 3) Obstruction of the ureters When retrograde pyelogram is impossible to perform or contra-indicated Contra-Indications-: Patient’s single functional kidney Bleeding diathesis Pregnancy Allergy to contrast media Contrast Media-: LOCM (low osmolar CM) Urografin 60% Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Ultrasound/CT scan 22G Chiba needle Surgical gloves Lead apron Gauge piece spirit Patient preparation-: 39 Explain whole procedure to patient Routine test = BT, CT, Serum creatinine If patient has bleeding disorder then inform to his/her doctor. Sedatives Antibiotics Procedure-: The kidney will initially be examined with an US probe or a CT scan. After they are located, the overlying skin will be anesthetized & a needle will be passed directly into the kidney. This needle is used to inject dye to outline the renal collection system (part of the urinary tract draining urine between the kidney & bladder) on x-ray images & detect any blockages or obstructions. X-ray image -: Figure – Antegrade Pyelogram 40 2) Retrograde Pyelography Definition-: It is a diagnostic test that uses contrast agent to produce detailed x-ray pictures of the upper urinary tract (kidney & ureter). Difference-: Dye is injected directly into the ureters rather than in a vein.( via-cystoscope) Indications-: When IVP produces an inadequate image. Haematuria Recurrent and suspected cancer Contra-Indications-: Patient’s single functional kidney Bleeding diathesis Pregnancy Allergy to contrast media UTI Contrast Media-: LOCM (low osmolar CM) Urografin 60% Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Disposable syringe Cystoscope catheter Surgical gloves Lead apron Gauge piece spirit Patient preparation-: None by mouth 12 hours prior to the exam. Bladder empty before exam. Sedative & analgesics is given. 41 Procedure-: Cystoscopy is performed and the small catheter is inserted into the opening of the ureter in the bladder. Dye is injected & fluoroscopy is performed to visualize the ureters & kidneys. The entire study can take 15 to 30 minutes and is done on a outpatient basis. X-ray image-: Figure -: Retrograde pyelogram Reference – ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 42 Sialography Introduction-: It is a radiological examination to demonstrate salivary gland & their ducts using contrast media. Sialography of sub-lingual gland is not possible because cannulation of sub-lingual duct is impossible. Anatomy-: 3 pair of major salivary gland-: (1) Parotid (2)Sub-mandibular (3) Sub-lingual Largest salivary Smallest salivary gland Whartson's duct gland Stenson's duct opens into mouth on Duct of Rivinus parotid duct side of frenulum opens into floor opens into oral of mouth vestibule opposite 2nd upper molar Indications-: Sialolithiasis Sicca syndrome Xerostomia Obstruction Stricture Pain & swelling Infection Tumor Trauma Assess the extend of ductal & glandular destruction Contra-Indications-: Contrast allergy Recent surgery Severe inflammation of salivary gland 43 Acute infections Calculus close to the ductal opening Contrast Media-: Diatrizoate(Urografin) Note-: Oil based contrast media may obstruct Metrizoate the duct so that do not used. (Eg: - Lipiodol) Iohexol 1-2 ml Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Polythene catheter Syringe Lemon juice(stimulation of saliva secretion) Cannula Cotton swab Tongue depressor Lachrymal dilators Skull unit Anesthesia Surgical gloves Lead apron Spirit Patient preparation-: Any radiopaque artifacts are removed from the area of interest(Eg:- duplicate teeth, hairpin, earrings, etc) Ensure that no contra-indication to the pharmacological agent used. Check pregnancy state. Procedure should be explained to the patient before undergoing to the procedure. Procedure-: Preliminary radiographs i.e. to detect conditions that do not require contrast. Give secretory stimulant to patient (Eg-: lemon juice 2-3 min. before contrast administration). It helps to open duct for easy identification. Duct orifice is sprayed with topical anesthetic. Orifice of duct is dilated with the lachrymal dilator & the cannula or polythene catheter introduced into the duct & it is connected to the syringe. Up to 2ml of CM is injected. The injection is terminated when patient feels discomfort. Image taken immediately after contrast injection. 44 After that patient sucks on a lemon wedge again to evacuate contrast. Take post procedure radiographs after 5 min. to confirm evacuation of contrast/demonstrate any residual contrast. Filming-: Parotid gland – AP view, Lateral, Lateral Oblique Sub-mandibular – Occlusal view, Lateral, Lateral Oblique After care-: Take proper rest. X-ray Images-: Figure-: Salivary Gland Figure-: 1) Parotid Gland (A- right & B- left) 45 Figure-: 2) Sub-mandibular Gland Reference – ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 46 Dacrocystography (DCG) Introduction-: It is a radiological examination of the naso-lacrimal apparatus using contrast media. It consists of lacrimal canaliculi, lacrimal sac and naso-lacrimal duct. Anatomy-: Lacrimal system = lacrimal gland + naso-lacrimal apparatus Lacrimal gland-: Located at the superior-lateral aspect of the orbit. It produces tears/lacrimal fluid. Lacrimal sac Lacrimal puncta Canaliculi Excretory lacrimal duct Figure-: lacrimal gland and apparatus Indications-: Epiphora Dacrocystitis Canaliculitis Stricture NLD obstruction Contra-Indications-: Non consent by patient to procedure Contrast media allergy Pregnancy Recent instrumentation Acute Dacrocystitis Contrast Media-: Oil soluble Lipiodol(1-2ml) 47 Sometimes it may obstruct the duct Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Syringe Cannula Cotton swab Lachrymal dilators Skull unit Surgical gloves Lead apron Spirit Patient preparation-: Patient identification i.e. 3c’s (correct patient, correct site, correct procedure). Complete consent form. No diet restrictions. Any radiopaque artifacts are removed from the area of interest(Eg:- duplicate teeth, hairpin, earrings, etc) Ensure that no contra-indication to the pharmacological agent used. Check pregnancy state. Procedure should be explained to the patient before undergoing to the procedure. Procedure-: The superior or inferior puncta are dilated. Plastic catheters are inserted into the respective canaliculi. CM, usually 1-2 ml of Lipiodol is simultaneously injected on both sides & PA radiographs are taken. 10 minutes later an erect oblique film is taken to assess the effect of gravity on tear drainage. Digital subtraction provides a higher quality image capture than conventional. Filming-: Preliminary film-: occipito-mental view , lateral view Contrast film-: PA, erect oblique After care-: Take proper rest. 48 X-ray Images-: Figure -: Dacrocystography Reference – ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 49 Bronchography Introduction-: It is the radiological study of the tracheo-bronchial tree following introduction of contrast media. Indications-: To demonstrate the site & extent of bronchial obstruction Bronchiectasis Haemoptysis Bronchitis Chronic pneumonia Asthma Emphysema Tumors (ca lung) Contra-Indications-: Acute Respiratory infection Poor Respiratory reserve CM allergy Massive Haemoptysis Contrast Media-: LOCM, Non-Ionic, Dimer agent {Eg-: Iotrolan300 has been used (2-3ml per lung segment). Maximum 25ml per patient} Iohexol Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Syringe Bronchoscope Catheter Surgical gloves Lead apron Gauge piece spirit 50 Patient preparation-: Chest physiotherapy NBM for 6 hrs prior to exam Premedication = Atropine 0.6mg + Morphine 10mg Sedatives may be given to the patients. Procedure-: Patient is asked to remove clothing & wear a patient gown & lie on the couch. An IV line may insert into hand for emergency medication. Anesthetic is sprayed into the bore of the throat. A Bronchoscope or catheter may introduce into the trachea through nose or mouth. Commence the installation of contrast under fluoroscopic guidance. Filming-: Preliminary film – chest PA & Lateral Spot film – chest PA, Lateral & Oblique After care-: Chest physiotherapy Vital signs are measured after exam A chest x-ray may be performed 24 to 48 hrs after the procedure to assess the removal of contrast dye from airway. X-ray Images-: Figure-: Bronchoscope 51 PA OBL Figure -: Bronchoscopy Reference – ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 52 Arthrography Introduction-: A radiological examination which is performed to demonstrate & assess the joint & associated soft tissue structures for pathologic processes after the injection of contrast media into the joint capsule. Indications-: Fine abnormal growth Fluid filled cyst Loss of motion (difficulty in movement) Loose body Tear in the soft tissue of the joint (Eg.- arthritis) Cartilage, capsular or ligamentous injuries Trauma Persistent pain Dislocation Contra-Indications-: Local sepsis Avascular necrosis of bones Reflex sympathetic dystrophy (RFD) i.e. a group of symptoms including pain ,tenderness, warmth or coolness. Contrast Media-: Contrast Media Radiopaque Radiolucent (+ve contrast) (-ve contrast) Ionic Non-ionic Air(40ml) (urografin) (Iohexol) Contrast media introduction :- 1) Directly into the joint space 2) Indirectly into the bloodstream & eventually absorbed into the joint 53 Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Long & thin sharp needle Surgical gloves Lead apron Spirit Patient preparation-: Any radiopaque artifacts are removed from the area of interest(Eg:- duplicate teeth, hairpin, earrings, etc) Ensure that no contra-indication to the pharmacological agent used. Check pregnancy state. Procedure should be explained to the patient before undergoing to the procedure. Advice the patient of any complications involved with doing the procedure. Patient must sign an informed consent form before the procedure is done. Procedure-: Patient wears a hospital gown. Ready the positioning of patient. Preliminary film takes without contrast. Skin around the joint is cleaned by antiseptic solution. Contrast is injected into joint using long thin needle. Patient is asked to move the joint which allows the spread of contrast throughout the joint. Spot film imaging For double contrast study, air is introduced into joint & this provides better visualization. Filming-: Preliminary film :- 1. AP 2. Lateral 3. Additional film (acc. to the joint to be assess i.e. for knee – skyline, tunnel view) After care-: Rest the joint that was injected for at least 12 hrs. after the procedure. Ice packs or over the counter pain relief medication is recommended to decrease pain & swelling. Symptoms of pain, red skin or fever 3 or more days following the procedure should be reported to your physician. 54 Risk-: A risk of infection Possibility of vessel or nerve injury Contrast allergy reactions Chance of cancer from excessive exposure to radiation X-ray Images-: Figure-: Arthrogram of shoulder joint Reference – ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 55 Hysterosalpingography (HSG) Introduction-: Hystero = uterus, salpingo = fallopian tube (FT) It is the radiographic examination of uterus & FT under fluoroscopic guidance following introduction of contrast media. Anatomy-: Figure-: Female Reproductive System Indications-: Infertility To detect a blockage in FT FT obstruction Stricture/Stenosis in FT To detect uterine abnormalities such as – Uterine anomalies Endometrial polyps Fibroids Intrauterine adhesions Genital tuberculosis To evaluate the result of tubal surgeries Recurrent spontaneous abortions Prior to the artificial insemination (to check whether the uterus & FT is blocked or not) Contra-Indications-: Suspected pregnancy Pelvic infections Vaginal bleeding 56 Contrast allergy Dilation & curettage/abortion (removal of the part of lining of uterus) Week prior to & week following onset of menstruation Contrast Media-: Water soluble HOCM or LOCM , 10-20ml (Eg.- Urografin 60%, Iohexol) Lipid soluble CM (Lipiodol) is no longer recommended due to delayed absorption, leave residue & oil embolism. Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Syringe Vulsellum forceps Uterine/Wilkinson cannula 8-F Foley catheter Surgical gloves Vaginal speculum Local anesthesia Antiseptic solution Lead apron Spirit Ideal time for procedure-: Between 8th & 10th day of menstrual cycle & 2-3 days after the stoppage of menstruation. Before 12th day because oocyte undergoes meiosis during this time & is radiosensitive. Patient preparation-: Patient must abstain from sexual intercourse between booking the appointment & the time of examination. Patient should be fasting 4 hours prior to the procedure. Bladder should be emptied prior to HSG. Apprehensive patient may need premedication. If the patient has irregular or absent menses, a pregnancy test before performing HSG is recommended. On the night before the procedure, you may ask to take a laxative or an enema to empty your bowels, so that the uterus & surrounding structures can be seen clearly. Procedure-: Patient is asked to remove clothing & lie supine in lithotomy position (knees flexed, legs abducted & heels together). Antispasmodic medicine may give to patient. Perineum is cleaned with Betadine antiseptic solution. 57 Radiologist inserts vaginal speculum & cleans the vagina with povidone-iodine solution. Anterior lip of the cervix is grasped by Vulsellum forceps & cannula is inserted into cervical canal. If 8 No. Foley catheter is used then no need to hold vaginal tip. Cannula & syringe is made air bubble free. Contrast media is injected slowly under fluoroscopic guidance. Spot films are taken. Filming-: Preliminary film-: coned PA view of pelvic cavity Spot film-: AP, Oblique After care-: It must be ensured that the patient is in no serious discomfort & nor has significant bleeding before she leaves. The patient must be advised that she may have bleeding before for 1-2 days & pain may persist for up to 2 weeks. Complications-: Pain Pelvic infection Bleeding Lymphatic intravasation Pregnancy irradiation Allergic reaction Uterine perforation 58 X-ray Image-: Figure-: HSG investigation Reference – ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 59 Myelography Introduction-: It is aradiological examinationthat uses a CM to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts & tumors. Anatomy-: Spinal cord begins at the occipital bone & extends down to the space between the 1 st & 2nd lumber vertebra. It is about 45cm long. The brain and spinal cord are enclosed in 3 continuous protective membranes called as meninges i.e. a) durameter b) arachnoid c) piameter. Sub-arachnoid space is located between arachnoid and piameter. It is filled with CSF (total adult CSF volume -150ml). It bathes brain & spinal cord with nutrients. It cushion against shock. It is that place where contrast is injected for myelogram. Figure-: Anatomy of vertebra Indications-: Arm or leg numbness, weakness or pain Spinal stenosis Tumor or infection Herniated disc Inflammation of meninges Problems with the blood vessels to the spine Arthritis disc Pain in spine Scoliosis Spondylitis Arachidonitis Contra-Indications-: Contrast allergy Blood in CSF 60 Severe Arachidonitis Increased intracranial pressure Recent lumber puncture Contrast Media-: Dosage (9-10ml) Non-ionic, water soluble, iodine based CM (eg.-: Iohexol, Iotrolan) Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Syringe Puncture needle Surgical gloves Lead apron Spirit Patient preparation-: Avoid solid foods for several hours before the exam. Fluids may be continued. Patient should be well hydrated before exam. Patient wears a gown. Some drugs should be stopped one or 2 days before myelogram i.e. a) antipsychotic medications b) antidepressants c) blood thinners/anticoagulants Premedication-: injectablesedative/muscle relaxant is administrated 1 hour before the exam to reduce anxiety & relax the patient atropine & morphine. Needle placement & Injection process-: Contrast introduction accomplished via puncture of subarachnoid Step-1 -: puncture sites a} lumber (L3-L4) b} cervical (C1-C2) Note-: lumber site is safer, easier on the patient and used most often for the procedure. Step-2-: needle placement using fluoroscopy ; Body position for lumber puncture -: a) prone position b) left lateral position with the spine flexed to wider the interspinous space. Body position for cervical puncture -: a) erect position b) prone position with the head flexed to open the interspinous space. Procedure-: Lumber site is cleaned. Local anesthetic is applied. Lumber puncture needle is inserted generally at the level of L3-L4. 61 The needle is slowly advanced until spinal fluid flows from the lumen of the needle (after withdrawal of stylet) The stylet is returned & the needle advanced an additional 2mm to ensure that the entire level of the needle is with in the subarachnoid space. A small amount of spinal fluid is withdrawn to maintain stasis & to provide a sample. Contrast media is injected using fluoroscopic guidance. Spot films are taken. Filming-: Preliminary film-: A) AP B) Lateral Spot film-: A) PA B) Lateral C) oblique D) Prone decubitus spine, E) Lateral flexion & extension. After care-: Take bed rest of 8-24 hrs. With the head slightly elevated. Patient should drink plenty of fluids. Patient should be instructed to notify the physician or medical staff if he or she examined severe headache or nausea or vomiting. Patient should/will be monitored with vital signs. 62 X-ray Images-: Figure-: myelogram of lumber spine Figure-: Lumber puncture needle Reference – ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 63 Oral Cholecystography (OCG) Introduction-: It is the radiographic study of gall bladder by the oral administration contrast media. Anatomy-: It is pear shaped hollow viscous acts as reservoir of bile situated on the inferior surface of the right lobe of liver. Length-: 7-10cm Width-: 3cm Capacity-: 30-50ml Colour-: state blue Indications-: Inflammation of the GB Other abnormalities like polyps Tumors Gallstones To demonstrate suspected pathology in the gall bladder Contra-Indications-: Severe hepatorenal disease Acute cholecysititis Iodine sensitivity (AST+ve) & Pregnancy Dehydration Contrast Media-: Biloptin Telepaque Chloebrin Solu-biloptin Equipments-: Fluoroscopic unit with spot film device Radiographic cassette Contrast media Surgical gloves Lead apron Gauge piece spirit 64 Patient preparation-: Prone 20 degree LAO preliminary film is taken when appointment is made. A laxative 2 days prior to the examination. A fat-containing evening meal on the evening prior to the examination. The CM is taken with water 14 hours prior to the patient’s appointment. Food is forbidden until the examination is completed. Procedure-: 6 tablets of Telepaque or Solu-biloptin orally night before the examination. A prone oblique view with right side raised to 20 degree is taken after 12-16 hours for GB visualization. After the preliminary film, the patient usually lies in the supine position and appropriate spot film of the GB are taken. Ask the patient to eat fatty meal. After 30-40 minute films are taken to assess the contractibility of the GB and small filling defect (stones or polyps). Cystic and CBD also visualized in post fatty meal films. If the GB is not visualized a “double dose” OCG may have to be performed where the patient takes in all 12 tablets of CM, 6 tablets being taken on each of the two nights prior of examination. Filming-: Prone 20 degree LAO Supine 20 degree RPO Erect 20 degree LAO Fatty meal provided Prone 20 degree LAO 30 min. after the fatty meal Complications-: Mild gastrointestinal disturbances Skin reactions Uricosuric action Impaired renal function Abnormal thyroid function tests Increased effect of protein bound drugs because of shared binding with albumin After care-: Patient is asked to take or to drink adequate amount of water to remove the CM. Check vital signs properly. 65 X-ray Images-: Figure-: Oral Cholecystography Reference – ¾ Radiological Procedure, 3rd Edition – Dr. Bhushan N Lakhkar ¾ A guide on special radiographic investigations & techniques – Dr. Kushal Gehlot, lalit agarwal ¾ A guide to radiological procedure, 4th Edition – Stephen Chapman 66 Buy your books fast and straightforward online - at one of world’s fastest growing online book stores! Environmentally sound due to Print-on-Demand technologies. Buy your books online at www.morebooks.shop Kaufen Sie Ihre Bücher schnell und unkompliziert online – auf einer der am schnellsten wachsenden Buchhandelsplattformen weltweit! Dank Print-On-Demand umwelt- und ressourcenschonend produzi ert. Bücher schneller online kaufen www.morebooks.shop KS OmniScriptum Publishing Brivibas gatve 197 LV-1039 Riga, Latvia [email protected] Telefax: +371 686 204 55 www.omniscriptum.com View publication stats

Contrast and Special Radiological Procedures PDF

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