Radiographic Special Procedures PDF

RADIOGRAPHIC SPECIAL PROCEDURES MR.JOEY D. PARIS, RRT,RSO,RHSO X-RAY SECTION HEAD WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER DIAGNOSTIC IMAGING DEPARTMENT  DEFINITION OF CONTRAST MEDIA  CM are diagnostic agents that are instilled...

RADIOGRAPHIC SPECIAL PROCEDURES MR.JOEY D. PARIS, RRT,RSO,RHSO X-RAY SECTION HEAD WEST VISAYAS STATE UNIVERSITY MEDICAL CENTER DIAGNOSTIC IMAGING DEPARTMENT  DEFINITION OF CONTRAST MEDIA  CM are diagnostic agents that are instilled into body orifice or injected into the vascular system, joints and ducts to enhance subject contrast in anatomic areas where there is low subject contrast.  A material that is being ingested or injected into the body for visualization of the organ.  Substance having either a higher or lower atomic number than the surrounding tissues which are used to represent organs of the body which are not visualized in a plain radiography.  DEFINITION OF CONTRAST MEDIA  Serves as a diagnostic and therapeutic aid to physician to visualize certain tissues/ organ  The ability of the CM to enhance subject contrast depends on: 1. Atomic number of CM. 2. Atoms concentration of the element/volume of the medium.  TYPES OF CONTRAST MEDIA Radiopaque  Appears white (decreased density) on the radiograph (ex. Barium sulfate, iodine).  Also known as positive contrast media.  Composed of elements with high atomic number. Radiolucent  Appears black (increased density) on the radiograph (air, nitrogen, carbon dioxide).  Also known as negative contrast media.  Composed of elements with low atomic number.  FOUR PHYSICAL STATES OF CONTRAST MEDIA 1. OIL Example: Pantopaque, Dionosil - Used in Myelogram and Bronchogram Studies 2. TABLETS Example: Biloptin (Iopodate), Telepaque, (Iopanoic Acid) Cholebrine (iocetamic acid) Bilisectan (Iodoalphanoic acid) and Cistobil - Used in Gall Bladder Studies 3.Powder- Barium Sulphate (Baryntgen) 4.Liquid – all iodinated and non-ionic contrast medium  FOUR PHYSICAL STATES OF CONTRAST MEDIA 3.POWDER Example: Barium Sulfate (Baryntgen) - Used in GIT, Esophogram, Barium Enema, and Small Intestinal Studies. 4.LIQUID Example – all iodinated and non-ionic contrast medium.  POSITIVE CONTRAST MEDIA 1. BASO4 (BARIUM SULFATE)  For examination of the esophagus  For small intestine  For upper GI series 2. IODINATED FORM  Are used in the examinations of the GI, kidneys, gallbladder, pancreas, heart, brain, uterus, spinal column, arteries, veins and joints.  Atomic number of 53.  IMPORTANT FACTORS IN SELECTING CONTRAST MEDIUM  It must be non toxic and must be safe both locally where administered.  It must procedure adequate contrast  It must have a suitable viscosity  It must have a suitable persistence  It must have miscibility or immiscibility as appropriate  PHYSIOCHEMICAL PROPERTIES Water solubility  in vascular applications an immediate dilution with blood. Viscosity  is a measure of the fluidity of solutions  measured in millipascals (mPa) per second.  The higher the viscosity of the solution, the longer it will take for the contrast medium to be diluted by blood. Osmolality-  Adverse reactions to CM have been related to osmolality.  A measure of the total number of particles in a solution/kg of water.  BARIUM SULFATE  BaSO4 – 1 atom of barium, 1 atom of sulfur and 4 atoms of oxygen thus it is a compound.  The most common type of contrast used in imaging of the GI system.  Inert powder composed of crystals (colloidal suspension) that has a tendency to clump and come out of suspension (flocculation).  Stabilizing agents such as sodium carbonate or sodium citrate are used to prevent flocculation.  Atomic number of 56.  BARIUM SULFATE  It absorbs water  Has a high atomic number  It is insoluble in water  It cannot be absorbed by GIT  It is non toxic  It has a relative contraindication in the GIT  TYPES OF BARIUM SULFATE 1. COMMERCIAL  It has flavoring and additives BARODENSE BAROSPERSE BARYTGEN 2. PLAIN BaSo4  Has a very unpalatable taste but its advantage lies in the fact that it adheres well on the mucosa of the organ  BARIUM SULFATE  It is generally recommended that barium sulfate is mixed with cold tap water (40°-45° F) to reduce irritation to the colon and aid the patient in holding the enema (increase retention of CM) during the examination. The cold water reduces spasm and cramping and reported to have anesthetic effect on the colon.  Room temperature water (85°-90° F) is recommended by most experts to produce a more successful examination with maximal patient comfort.  The RT should never use hot water because it may scald (burn) the mucosal lining of the colon. INTRODUCTION TO CONTRAST MEDIA  IONIC CM  are contrast agent salts of electrically negatively charged acids containing iodine that ionizes in solution and causes more patient discomfort.  Urovision  Urografin  Angiografin  Hypaque  Cardio-conray  Conray  Uromiro  Urovist  Telebrix  NON-IONIC CM  a contrast agent that does not ionize in solution and is safer, less painful, and better tolerated by the patient.  Trade name - Generic name  Ultravist - Iopromide  Iopamiro - Iopamidol  Omnipaque - Iohexol  Amipaque - Metrizamide  Isovist - Iotrolan  SENSITIVITY TEST  TEST DONE TO CHECK PATIENT TOLERANCE TO CM.  TO SERVE AS TEST DOSE  1cc OF CONTRAST MEDIUM  ANTIHISTAMINE INJECTED TO PATIENT FOR ANY ALLERGIC REACTION.  SENSITIVITY TEST 1. Scleral Method- one drop of contrast medium is put into the sclera (white part of the eyeball) 2. Sublingual Method- one drop of contrast medium is deposited into the inferior base of the tongue. 3. Intradermal Method- one cc. of contrast medium is just beneath the skin 4. Intravenous Method – One cc. of contrast medium is injected into the vein. METHODS OF ADMINESTERING CM 1. DIRECT METHOD  Barium enema; Retrograde pylography; Cystoscopy 2. INDIRECT METHOD  ORAL: CM introduced through mouth  PARENTHERAL: CM introduced via injection  SIALOGRAPHY  Term applied for the radiologic examination of the salivary gland & ducts with the use of contrast medium  Radiopaque medium injected into the main duct and flows into the intra-glandular ductules  Use to demonstrate inflammatory lesions & tumor to determine the extent of salivary fistulae & to localize diverticulae, strictures and calculi  Examination done one at a time (per gland)  SIALOGRAPHY  2 – 3 minutes before the procedure; patient is given a secretory stimulant to open the duct for ready identification of its orifice & for easier passage of a cannula or catheter  Suck a wedge of fresh lemon and is repeated on completion of the examination to stimulate rapid evaluation of the contrast medium  Radiograph may be taken 10 minutes later to verify clearance of the medium SIALOGRAPHY  SIALOGRAPHY CONTRAST MEDIA INTRODUCTION  Manual pressure with a syringe attached to the cannula or catheter or by hydrostatic pressure  Hydrostatic pressure: Syringe barrel with plunger removed attached to a drip stand & set at a distance of 28 inches (70 cm) above the level of the patient’s mouth  Filling procedure done under fluoroscopic guidance & obtain spot radiograph  PAROTID GLAND TANGENTIAL PROJECTION - SUPINE  Rotate head towards the side being examined.,  CR perpendicular to lateral surface of the mandibular ramus  PAROTID GLAND TANGENTIAL PROJECTION PRONE  Head resting on chin  Rotate head away from the side being examined  When the Parotid (Stensen’s) duct does not have to be demonstrated, rest the patient’s head on forehead and nose.  CR perpendicular to lateral surface of the mandibular ramus PAROTID GLAND  SIALOGRAPHY PAROTID GLAND  To study the parotid gland, better detail can be obtained particularly for demonstration of calculi, by having the patient fill the mouth with air & then puff the cheeks out as much as possible or if not let the patient suspend respiration during exposure.  SIALOGRAPHY PAROTID GLAND STRUCTURE SHOWN:  Parotid gland and duct well demonstrated lateral to and clear of mandibular ramus  LATERAL PROJECTION PAROTID AND SUBMANDIBULAR GLAND PAROTID SUBMANDIBULAR  Extend the patient neck so  Head in true lateral. that space between cervical  CR perpendicular to and rami is cleared. inferior margin of the  MSP is 15 degrees to IR. angle of the mandible.  CR perpendicular to 1 inch (2.5 cm) superior to mandibular angle. IGLAUER METHOD – Simple manuever to increase visibility of salivary calculus by having the index finger place on the back of the tongue.  LATERAL PROJECTION PAROTID AND SUBMANDIBULAR GLAND Demonstrates bony structures, calcific deposit, swelling of the parotid and submandibular glands. OBLIQUE PROJECTION Deeper portions of the parotid and submandibular glands.  AXIAL PROJECTION INTRAORAL METHOD Rest the vertex to the plane of film  CR: intersection of the MSP & CR passing through the second molar.  VSM: for submandibular gland region to demonstrate tumor masses of lesions that lies posterior or lateral to the floor of the oral cavity  AXIAL PROJECTION INTRAORAL METHOD  AXIAL PROJECTION INTRAORAL METHOD STRUCTURES SHOWN  Axial image of the floor of the mouth.  Entire sublingual gland and ducts.  Anteromedial part of the submandibular gland.  The only projection that gives an unobstructed view of the sublingual gland.  PALATOGRAPHY  SRE using positive contrast technique to investigate suspected tumors of the soft palate.  Patient in sitting lateral position with the nasopharynx centered to IR.  1st palatogram swallow small amount of thick creamy barium sulfate to coat inferior surface of the soft palate and uvula.  2nd lateral image, 0.5 ml of creamy barium is injected into each nasal cavity to coat superior surface of soft palate and posterior wall of the nasopharynx.  Make exposure during phonation to demonstrate the range of movement of the soft palate and position of tongue.  NASOPHARYNGOGRAPHY  SRE of the nasopharynx using negative and positive CM. Upright Lateral projection – negative CM  Demonstrate hypertrophy of the pharyngeal tonsil or adenoids.  CR directed to ¾ inch (1.9 cm) anterior to EAM.  PM – intake of deep breath thru the nose to ensure filling of the nasopharynx with air.  POSITIVE CM NASOPHARYNGOGRAPHY  Performed to assess extent of nasopharyngeal tumors. 1. Iodized oil 2. Finely ground barium sulfate  Preliminary radiographs are SMV and upright lateral.  Upon completion of examination have the patient sit up and blow thru the nose to evacuate CM. SMV  Elevate shoulders to extend neck.  OML 40°-45° to horizontal plane.  CR 15°-20° cephalad. UPRIGHT LATERAL  CR horizontally directed to nasopharynx.  PHARYNGOGRAPHY  Opaque study of the pharynx made with an ingestible contrast medium  Thick, creamy mixture of water & barium sulfate  Use of fluoroscopy with spot radiograph made during deglutition  DEGLUTITION: the act of swallowing & done in rapid & highly coordinated action of many muscles.  PHARYNGOGRAPHY  Bolus CM must be projected into the pharynx at the height of the anterior movement of the larynx.  Shortest exposure time must be selected.  For mucosal phase patient is refrain from swallowing again the barium sulfate.  Take the mucosal study during the modified Valsalva’s maneuver for double contrast delineation.  GUNSON METHOD  A practical technique for synchronizing the exposure with the height of swallowing act in deglutition studies of the pharynx and superior esophagus.  Tying a dark-colored shoestring around the patient’s throat above the thyroid cartilage.  LARYNGOPHARYNGOGRAPHY  Stationary or tomographic negative contrast studies of the air-containing laryngopharyneal structures.  Studies of the larygo-pharyngeal structures are made in both frontal & lateral directions  Done on respiratory & stress maneuvers  Done in 5 maneuvers 1. Quiet inspiration 2. Normal (expiratory)phonation 3. Inspiratoty phonation 4. Valsalva maneuver 5. Modified Valsalva maneuver  LARYNGOPHARYNGOGRAPHY NORMAL (EXPIRATORY) QUIET INSPIRATION PHONATION Test abduction of the Expiratory phonation test vocal cords adduction of the vocal cords Show open (abducted) Take a deep breath and vocal cords. then exhaling slowly To phonate: a high “eee” or low pitched “aah” Show close (adducted) vocal cords.  LARYNGOPHARYNGOGRAPHY INSPIRATORY PHONATION VALSALVA’S MANEUVER  Reverse phonation & aspirate  Take a deep breath & while or aspirant maneuver for the holding the breath in; to bear demonstration of the laryngeal down as if trying to move the ventricle bowels  Instructed to exhale completely  This act forces the breath & then slowly inhaling to make against the closed glottis & a harsh; stridulous sound with increases both intra-thoracic & phonation of “e” intra-abdominal pressure  Adducts the vocal cords;  Show complete closure of moves them inferiorly & the glottis balloons the ventricle for clear  Test the elasticity & delineation functional integrity of the glottis  MODIFIED VALSALVA’S MANEUVER  Asked the patient to pitch the nostril together with the thumb & forefinger of one hand & the mouth closed to make & sustain a slight effort to blow the nose  Test the elasticity of the hypo-pharynx & the piriform recesses  Show the glottis closed & the hypopharynx & piriform recesses distended with air  TOMOLARYNGOGRAPHY Tomographic studies of the laryngopharyngeal structures either before or after the introduction of radiopaque CM. Uses rapid-travel lnear sweep and exposures are made during the first half of the arc (40-50 degrees) to prevent overlap streaking by facial bones and teeth.  BILIARY SYSTEM  SRE of the biliary system involves studying the manufacture, transport and storage of bile.  Bile is manufactured by the liver.  GB is the temporary storage area for bile.  The liver is the largest solid organ in the human body and occupies most of the RUQ and Right Hypochondrium.  Right and Left lobe of the liver is separated by the falciform ligament.  The liver secretes 800-1,000 ml or 1 quart of bile per day.  The major of function of bile is to aid in digestion of fats by emulsifying or breaking down fat globules.  BILIARY SYSTEM  Bile is formed in the small lobules in the liver and travels through the right or left hepatic ducts.  The right and left hepatic ducts continue to join the common hepatic duct..  Bile is carried to the GB via the cystic duct.  Bile can also be carried directly to the duodenum via the common bile duct which is then joined by the pancreatic duct (duct of Wirsung). BILIARY SYSTEM  GALL BLADDER  Pear shaped sac composed of three parts. 1. Fundus – distal end and the broadest part of GB. 2. Body – main section of GB 3. Neck – narrow proximal end which continues as the cystic duct.  The cystic duct is 3-4 cm long.  The GB is 7-10 cm long, 3 cm wide and holds 30-40 cc of bile.  The three primary functions of the GB is: 1. Store 2. Concentrate 3. Contract when stimulated.  GALL BLADDER Fish scale GB Strawberry GB Fish scale appearance Strawberry appearance due to presence of due to the presence of multiple cyst of the cholesterol/cholesterol mucosa. gallstone. Sandpaper GB Courvoisier GB Roughened condition of Enlarged and palpable GB the mucous membrane of in patient with carcinoma the GB associated with of the head of the the presence of pancreas. gallstones. Associated with jaundice due to obstruction of the CBD.  GALL BLADDER HYPERSTHENIC ASTHENIC GB moves laterally and GB moves medially and superiorly I to 3 inches inferiorly I to 3 inches (2.5 to 7.6 cm) on full (2.5 to 7.6 cm) on full expiration. inspiration.  COMMON BILE DUCT  The common hepatic duct draining the liver joins with the cystic duct to form the common bile duct.  7.5 cm in length and has an internal diameter of a drinking straw.  The CBD descends behind the superior portion of the duodenum and head of the pancreas to enter the second or descending portion of the duodenum.  COMMON BILE DUCT  The CBD and Pancreatic duct forms into a common passageway called the Hepatopancreatic Ampulla or the Ampulla of Vater.This is the narrowest part of the passageway and common site of impaction of gallstones.  At the terminal opening of the passageway into the duodenum is a circular muscle fiber called the Hepatopancreatic sphincter or Sphincter of Oddi. This sphincter relaxes when levels of CCK increases in the bloodstream. BILIARY TREE  GB LOCATION VS BODY HABITUS HYPERSTHENIC  GB located higher and more lateral.  15-20 degrees LAO body rotation to separate GB from the vertebral spine. STHENIC/HYPOSTHENIC  GB located halfway between the xiphoid tip and lower lateral rib margin.  20-25 degrees LAO body rotation to separate GB from the vertebral spine. ASTHENIC  GB is lower and medial at the level of the iliac crest.  35-40 degrees LAO body rotation to separate GB from the vertebral spine.  BILIARY SYSTEM CHOLEGRAPHY  General term for a radiographic study of the biliary system. CHOLECYSTOGRAPHY  SRE of the gallbladder.  ALSO CALLED CHOLECYSTOGRAM CHOLANGIOGRAPHY  SRE of the biliary ducts.  ALSO CALLED CHOLANGIOGRAM CHOLECYSTANGIOGRAPHY  SRE of gallbladder and biliary ducts.  ALSO KNOWN AS CHOLECYSTOCHOLANGIOGRAPHY  CHOLECYSTOCHOLANGIOGRAM.  BILIARY SYSTEM CHOLELITHS  Gallstones CHOLELITHIASIS  Condition of having gallstones. CHOLECYSTITIS  Inflammation of the GB CHOLECYSTECTOMY  Surgical removal of the GB.  BILIARY SYSTEM ADMINISTRATION 1. By mouth  Absorb through the intestines and carried to the liver through the portal vein. 2. By injection into a vein – (single bolus or by drip infusion) intravenous.  Most commonly injected at the antecubital veins and passes through the heart into the arterial circulation. The CM enters the liver via the hepatic artery and portal vein. 3. Direct injection into the ducts – during biliary tract surgery or through an indwelling tube. BILIARY SYSTEM  ORAL CHOLECYSTOGRAM (OCG)  The most common SRE  Sodium ipodate to study the GB. (Biloptin); 6 capsules  The purpose of OCG is to each containing 500 mg. study radiographically the This is the most widely anatomy and function of used agent. the biliary system.  Iopanoic acid (Telepaque);  CM is ingested orally. 6 capsules each containing  Ingestion of 4-6 tablets or 500 mg. capsules during the  The oral CM use for evening before the visualization of the GB is examination. called cholecystopaques.  BILIARY SYSTEM INDICATIONS:  Function of the liver – ability to remove the CM from the bloodstream and excrete it with the bile.  Patency and condition of the biliary ducts.  Concentrating and emptying power of the GB.  Gallstones, calculi  Pure cholesterol stones – appear as negative filling defects.  Calcium containing stones – radiopaque stones  Cholelithiasis – gallstones/calculi in the GB, most common abnormalities diagnosed during OCG  Choledocholithiasis – calculi in the CBD  Cholecystitis – acute or chronic inflammation of the GB, common complication of cholelithiasis.  Biliary neoplasia, mass, biliary stenosis – narrowing of the CBD.  BILIARY SYSTEM INDICATIONS: CHOLELITHIASIS  stones/calculi in the GB  most common abnormalities diagnosed during OCG.  Increased levels of calcium, bilirubin and cholesterol may lead to formation of gallstones. CHOLEDOCHOLITHIASIS  calculi in the CBD  BILIARY SYSTEM INDICATIONS: CHOLECYSTITIS  acute or chronic inflammation of the GB,  common complication of cholelithiasis.  Blockage of the cystic duct restricts flow of bile from the GB into the CBD, the blockage is due to a stone lodged in the neck of the GB.  Symptoms of acute cholecystitis include abdominal pain, tenderness in the RUQ and fever.  In chronic cholecystitis the symptoms include RUQ pain, heartburn and nausea following a meal.  Pancreatitis and carcinoma of the GB is associated with chronic cholecystitis.  Radionuclide scan and UTZ may also demonstrate stone in the GB.  BILIARY SYSTEM BILIARY NEOPLASM  GB carcinoma are rare however it is aggressive and spread to the liver, pancreas and GI tract.  80% of the patients with carcinoma of the GB have stones.  CT and UTZ are the best modalities to demonstrate neoplasm of the GB. BILIARY STENOSIS  narrowing of the CBD.  Cholecystitis and jaundice may result form biliary stenosis.  ORAL CHOLECYSTOGRAM (OCG) CONTRAINDICATIONS: 1. Advanced hepatorenal disease 2. Active gastrointestinal disease 3. Hypersensitivity to iodinated CM 4. Pregnancy  ORAL CHOLECYSTOGRAM (OCG) PRELIMINARY DIET  Avoidance of laxative 24 hours before ingestion of CM.  Avoidance of all food after receiving the CM.  Noon meal that is rich in simple fats & a light evening meal that is fat free (oral media is administered 3 hours after the evening meals)  CM given 10 – 12 hours prior to the procedure – most effective (CM reach the GB).  Evening meal that is fat free to prevent the possibility of continued emptying of the GB and release of radiopaque bile.  ORAL CHOLECYSTOGRAM (OCG) PRELIMINARY DIET  CM is given 2-3 hours after evening meal.  Absorption time is 10-12 hours.  Ipodate calcium rapidly absorbed and allows visualization of the biliary ducts in 1.5 hours and visualization of the GB in 3-4 hours.  Patient must refrain form chewing gum and smoking until after exams.  70-80 kVp should be used.  Non-visualization on the first day may result in a 2- day study with a second dose of CM.  ORAL CHOLECYSTOGRAM (OCG) FATTY MEAL - (POST MOTOR MEAL)  Given after the satisfactory visualization of the GB  Consist of commercially available bars or eggs & milk or eggnog.  Cause GB to contract & additional diagnostic information can be obtained - functional / contracting ability of GB.  Study of the extrahepatic ducts.  Patient is placed in an RPO position so that GB can best drain.  Radiographs are obtain in the RPO position every 15 minutes.  ORAL CHOLECYSTOGRAM (OCG) Additional techniques  For better visualization of the ducts, manufacturers make the following recommendations: 1. Biloptin  12 capsules at the usual time or  6 capsules 10-12 hours before the examination plus another 6 capsules 3 hours before. 2. Telepaque  3-6 tablets are taken 4 hours after a fatty lunch on the day preceding the examination, and then a full dose of 6 tablets after a fat-free meal in the evening.  ORAL CHOLECYSTOGRAM (OCG) PA PROJECTION - SCOUT Sthenic CR perpendicular to level of L2 (1/2 – 1 inch above lowest margin of rib cage) and 2 inches to right of MSP.  ORAL CHOLECYSTOGRAM (OCG) PA PROJECTION  Determine presence and location of opacified GB.  Choleliths  Correctness of exposure factors.  Best demonstrate milk calcium bile.  ORAL CHOLECYSTOGRAM (OCG) LAO POSITION  Rotate the patient 15°-40°.  Greater obliquity (40◦) for asthenic patients than for hypersthenic (15◦)  Best demonstrates opacified GB away from vertebral column.  Ideal projection to delineate between gas in the bowel and radiolucent stones in the GB.  The most common basic position of the GB.  Oblique GB, with less foreshortening and self- superimposition than in PA.  ORAL CHOLECYSTOGRAM (OCG) RIGHT LATERAL POSITION  Used to differentiate gallstones from renal stones or calcified mesenteric lymph nodes  Demonstrates opacified GB away from vertebral column and bowel loops.  ORAL CHOLECYSTOGRAM (OCG) RIGHT LATERAL DECUBITUS  Was developed by Whelan.  Fluid and calculi level of the GB.  Opacified GB away from the vertebral column.  Demonstrate multiple small stones that cannot be detected in other projections.  Demonstrate stratification or layering of gallstones.  Alternative to PA upright.  ORAL CHOLECYSTOGRAM (OCG) PA UPRIGHT PROJECTION Upright PA center the IR 2-4 inches below the prone level to allow change in the GB position.  Demonstrate stratification or layering of gallstones.  Axial representation of the opacified GB.  Demonstrate mobility of the GB to detect presence of stone that are too small to cast individual shadows & to differentiate papiloma or other tumor shadow from cholesterol calculi shadow  GB inferior and medial. ORAL CHOLECYSTOGRAM (OCG)  ORAL CHOLECYSTOGRAM (OCG)  The right lateral decubitus and upright positions are used to demonstrate stones that are heavier than bile and that are too small to be visible other than when accumulated in the dependent portion of the gallbladder. These positions are also used to demonstrate stones that are lighter than bile and that are visualized only by stratification.  The right lateral decubitus position has the further advantage of permitting the gallbladder to gravitate toward the dependent right side, where it will lie below any adjacent gas containing loops of the intestine and away from bony superimposition when it occupies a low and/or medial position.  The decubitus position is also used when patients cannot stand for an upright PA or AP projection.  Upright/ decubitus: small stone layer gravitate on fundus of GB  INTRAVENOUS CHOLANGIOGRAPHY  Employed to investigate the biliary ducts of cholecystectomized patients.  It is also used to investigate the biliary ducts and gallbladder of non-cholecystectomized patients when these structures are not visualized by OCG and when, because of vomiting or diarrhea, a patient cannot retain the orally administered medium long enough for its absorption.  INTRAVENOUS CHOLANGIOGRAPHY  Place the patient in the supine position for a preliminary radiograph of the abdomen.  Place the patient in the RPO position (15 to 40 degrees) for an AP oblique projection of the biliary ducts.  Timed from the completion of the injection, duct studies are ordinarily obtained at 10-minute intervals until satisfactory visualization is obtained.  CM is supplied in an isotonic saline or glucose solution by slow IV infusion.  Maximum opacification usually requires 30 to 40 minutes.  Intravenous cholangiography is not generally indicated for patients who have liver disease or for those whose biliary ducts are not intact.  In cases of obstructive jaundice and post-cholecystectomy, ultrasonography has become the preferred technique for demonstrating the biliary system. INTRAVENOUS CHOLANGIOGRAPHY  PERCUTANEUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)  Technique employed for pre-operative radiologic examination of the biliary tract.  More invasive than other forms of cholangiography.  It involves a direct puncture of the biliary ducts.  This technique is used for patients with jaundice when the ductal system has been shown to be dilated by CT or ultrasonography but the cause of the obstruction is unclear.  The performance of this examination has greatly increased because of the availability of the Chiba ("skinny") needle.  Often used to place a drainage catheter for treatment of obstructive jaundice  INDICATION : obstructive jaundice, stone extraction & biliary drainage.  RISK: liver hemorrhage, pneumothorax and escape of bile.  PERCUTANEUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)  PTC is performed by placing the patient in supine position on radiographic table  R side is surgically prepared & appropriately draped  Following local anesthesia, skinny needle is held parallel to the floor & inserted through the right lateral intercostal space & advanced towards the liver hilum  Stylet of the needle is withdrawn & syringe filled with CM is attached to the needle  Under fluoroscopic control the needle is slowly withdrawn until CM is seen to be filled the biliary ducts  Following filling of biliary ducts, needle maybe completely withdrawn & serial or spot radiograph taken  OPERATIVE – IMMEDIATE CHOLANGIOGRAPHY  Performed during cholecystectomy.  Use to investigate the: 1. patency of the bile ducts 2. functional status of the sphincter of the hepato- pancreatic ampulla 3. reveal the presence of previously undetected biliary tract calculi.  CM (6-8 cc) is introduced into the CBD; small catheter is inserted into the remaining portion of the cystic duct.  OPERATIVE – IMMEDIATE CHOLANGIOGRAPHY  The 15-20 degress RPO is helpful in projecting the biliary ducts away from the spine, especially in hyposthenic patient.  An iodinated contrast agent is introduced into the common bile duct to evaluate biliary patency and that of the hepatopancreatic ampulla.  Any calculi can be detected and removed before completion of surgery.  POST-OPERATIVE CHOLANGIOGRAPHY  Post –operative “delayed” & T-tube cholangiography are radiologic terms applied to the biliary tract examination that is performed by way of the t-shaped tube left in the common bile duct for post operative drainage.  Use to demonstrate the caliber & patency of the ducts; status of the sphincter of the hepato-pancreatic ampulla & the presence of residual or previously undetected stones or other pathologic condition.  Water soluble CM is used (25% – 30%) concentration.  POST-OPERATIVE CHOLANGIOGRAPHY  Scout film  Fluoro guided or overhead projection  15-20 degrees RPO  Lateral : to demonstrate anatomic branching of the hepatic duct & to detect any abnormalities not demonstrated in RPO  Clamped is not removed from the t-tube before completion of the examination  T-shaped tube is left in the common bile duct for postsurgical drainage.  ENDOSCOPIC RETROGRADE CHOLANGIOPANCREOTOGRAPHY (ERCP)  SRE of the biliary and main pancreatic ducts.  ERCP is a useful diagnostic method when the biliary ducts are not dilated and when no obstruction exists at the ampulla.  ERCP is performed by passing a fiberoptic endoscope through the mouth into the duodenum under fluoroscopic control. To ease passage of the endoscope, the patient's throat is sprayed with a local anesthetic. Because this causes temporary pharyngeal paresis, food and drink are usually prohibited for at least I hour after the examination.  ENDOSCOPIC RETROGRADE CHOLANGIOPANCREOTOGRAPHY (ERCP)  Food may be withheld for up to 10 hours after the procedure to minimize irritation to the stomach and small bowel.  After the endoscopist locates the hepatopancreatic ampulla (ampulla of Vater), a small cannula is passed through the endoscope and directed into the ampulla  Once the cannula is properly placed, the contrast medium is injected into the common bile duct.  Oblique spot radiographs may be taken to prevent overlap of the common bile duct and the pancreatic duct.  Injected CM must be drain from the normal ducts within approximately 5 minutes.  ENDOSCOPIC RETROGRADE CHOLANGIOPANCREOTOGRAPHY (ERCP)  ERCP is often indicated when both clinical and radiographic findings indicate abnormalities in the biliary system or pancreas.  OCG, ultrasound examination, or IVC is usually performed before ERCP.  Trendelenburg position – CM fills the intrahepatic ducts.  Semi-erect - CM fills the lower end of the CBD.  ENDOSCOPIC RETROGRADE CHOLANGIOPANCREOTOGRAPHY (ERCP)  OPERATIVE PANCREATOGRAPHY  Surgico radiologic procedure wherein a soluble- iodinated CM is introduced into the main pancreatic duct (duct of Wirsung).  Perform to rule-out abnormalities of the pancreas.  May be done via: 1. Reflux filling from an injection to the CBD. 2. Direct injection through the transduodenal catherization of the duct.  DIGESTIVE SYSTEM  Radiolucent and radiopaque CM are used to visualize the GI tract.  Radiolucent or negative CM nclude swallowed air, carbon dioxide, gas crystals and gas bubbles in the stomach.  Calcium and magnesium citrate carbonate crystals are most commonly used to produce carbon dioxide gas.  The most common positive or radiopaque CM used in the GI system is barium sulfate.  DIGESTIVE SYSTEM THICK BARIUM  3-4 parts barium sulfate and 1 part water.  2-3 spoonfuls should be ingested.  More difficult to swallow and descends slowly and use to coat the mucosal lining.  Well suited for use in the esophagus. THIN BARIUM  1 part barium sulfate and 1 part water.  3-4 continuous swallow.  Well suited for study of the entire GI tract.  DIGESTIVE SYSTEM DOUBLE CONTRAST  Enhance the diagnosis of certain disease and conditions of the upper GI’s.  Was 1st developed in Japan where a high incidence of stomach carcinoma exist.  High density barium sulfate is used to provide coating of the stomach mucosa.  Calcium and magnesium citrate are the two common forms of crystals used as negative CM.  The gas mixes with the barium sulfate and forces it against the stomach mucosa providing better coating and visibility of the mucosa and its patterns.  Polyps, diverticulum and ulcers are best seen in double CM technique.  ABDOMINAL FISTULAE AND SINUSES  Fistulae (abnormal passages between two internal organs).  Sinuses (abnormal channels leading to abscesses).  To explore fistulae and sinuses in the abdominal region, have the intestinal tract as free of gas and fecal material as possible. Oblique projections  demonstrate the full extent of a sinus tract. Modified gastrointestinal procedure  detect the origin of colonic fistulae.  Iodized oil is frequently used in conjunction with a thin suspension of barium sulfate.  For demonstration of a colonic fistula, the colon is filled with an enema consisting of the full amount of water but only about one-third the amount of barium ordinarily used.  ABDOMINAL FISTULAE AND SINUSES  For demonstration of a fistula of the small intestine, the patient ingests a thin barium suspension.  The fistulous tract is then injected with the iodized oil.  ESOPHAGOGRAM  Special radiographic examination of the esophagus and pharynx with the used of single/double CM.  Also called barium swallow.  No preparation is needed  For full column, single CM technique, a 30% - 50% weight/ volume suspension is useful  If double CM: barium or carbon dioxide crystal is used  For double CM: a low viscosity, high density barium developed for double contrast gastric examination is used.  Esophagogram generally uses thin and thick barium.  ESOPHAGOGRAM SINGLE CM  Scout film: upright of the esophagus  Patient is instructed to take a cup of barium suspension in the left hand & drink it on request.  Fluoroscopist asked patient to swallow several mouthful of barium so that the act of deglutition can be observed to determined the abnormality.  Various breathing maneuvers under fluoroscopic observation is done to demonstrate lesion.  ESOPHAGOGRAM DOUBLE CM  A free flowing, high density barium is used.  A gas producing substance usually carbon dioxide crystal is added to the barium mixture or can be given by mouth immediately before the barium suspension is given.  Same procedure is done & delayed images maybe taken on request.  ESOPHAGOGRAM FILLING PHASE  Use to distend the lumen of the esophagus to demonstrate the entire length.  2:1 or 3:1 barium preparation. MUCOSAL PHASE  Use to demonstrate the mucosal pattern of the esophagus.  4:1 barium preparation  ESOPHAGOGRAM  Barium passes through the esophagus fairly slowly if it is swallowed at the end of full inspiration.  Barium is delayed in the lower part for several seconds if it is swallowed at the end of full expiration.  ESOPHAGOGRAM INDICATIONS: Achalasia  Motor disorder of the esophagus in which peristalsis is reduced on the distal 2/3 of the esophagus.  Also called cardiospasm. Barrett’s Esophagus  The replacement of the normal squamous epithelium with columnar-lined epithelium ulcer tissue in the lower esophagus.  NM (Tc-99m pertechnetate) is the modality of choice to rule out this pathology.  ESOPHAGOGRAM INDICATIONS: Carcinoma  Adenocarcinoma is the most common form of cancer of the esophagus.  Carcinosarcoma – large irregular polyp.  Esophagogram and endoscopy are modality of choice to detect these tumors.  CT-Scan is performed in staging of the tumor and whether it has metastasize beyond the inner layer of the mucosa of the esophagus.  ESOPHAGOGRAM INDICATIONS: Dysphagia  Difficulty in swallowing.  Video and digital fluoroscopy are the modality of choice. Esophageal Reflux  Reported as heartburn by patients.  It is the entry of gastric contents to the esophagus.  Excessive intake of aspirin, alcohol, caffeine and smoking increases the incidence of reflux.  ESOPHAGOGRAM INDICATIONS: Esophageal Varices  Dilation of the veins in the distal esophagus.  Has the radiographic appearance of wormlike or cobblestone.  BEST SEEN IN RECUMBENT POSITION. Foreign Bodies  Bolus of food, metallic objects may lodge in the esophagus. Zenker’s Diverticulum  Large out-pouching of the esophagus just above the esophageal sphincter.  ESOPHAGOGRAM RECUMBENT POSITION  The recumbent position is used to obtain more complete contrast filling of the esophagus (especially filling of the proximal part) by having the barium column flow against gravity.  The recumbent position is routinely used for the demonstration of esophageal varices.  ESOPHAGOGRAM TECHNIQUES FOR THE DEMONSTRATION OF ESOPHAGEAL REFLUX 1. Breathing Exercise Valsalva maneuver - is the most common breathing exercise. Mueller maneuver – patient exhales and tries to inhale against a clossed glottis. 2. Water Test Done with the patient in supine position and turned slightly to the left side (LPO) position. The barium fills the fundus, then the patient is asked to swallow a mouthful of water through a straw. A positive water test occurs when significant amount of barium regurgitate into the esophagus from the stomach.  ESOPHAGOGRAM TECHNIQUES FOR THE DEMONSTRATION OF ESOPHAGEAL REFLUX 3. Compression Paddle Technique Placed under the patient in the prone position, the paddle is inflated to provide pressure to the stomach region. 4. Toe-touch maneuver Performed to study possible regurgitation into the esophagus from the stomach. The cardiac orifice is observed fluoroscopically. Esophageal reflux and hiatal hernias are demonstrated in this technique.  ESOPHAGOGRAM RAO POSITION  MSP 35 to 40 degrees to IR.  CR perpendicular to T5- T6 (2-3 inches below jugular notch).  Demonstrate the entire contrast filled esophagus free from superimposition of the heart and vertebra.  Best single projection of barium-filled esophagus  ESOPHAGOGRAM LATERAL POSITION  Place the patient in the  2 – 3 exposure in rapid lateral position facing the succession before the CM radiographer. passes into the stomach  CR perpendicular to T5-T6 if it is swallowed at the (2-3 inches below jugular end of full inhalation notch).  For demonstration of  Entire esophagus entire esophagus; between thoracic spine exposure is made while and heart. patient is drinking the CM Swimmer’s lateral through a straw in a rapid & continuous swallow.  Allows better demonstration of the upper esophagus without superimposition of the arms and shoulders.  ESOPHAGOGRAM LATERAL POSITION  ESOPHAGOGRAM AP/PAPROJECTION  CR 1 inch inferior to sternal angle (T5-T6).  Esophagus must be adequately demonstrated through the superimposed thoracic vertebrae.  UPPER GASTRO-INTESTINAL  The stomach must be empty for an examination of the upper gastrointestinal tract (the stomach and small intestine).  It is also desirable to have the colon free of gas and fecal material.  Preparation usually consists of a soft, low-residue diet for 2 days to prevent gas formation from excessive fermentation of the intestinal contents.  Cleansing enemas may be given to ensure a properly prepared colon.  UPPER GASTRO-INTESTINAL  An empty stomach is ensured by withholding both food and water after midnight for a period of 8 to 9 hours before the examination.  When a small intestine study is to be made, food and fluid are withheld after the evening meal.  Because it is believed that nicotine and chewing gum stimulate gastric secretion and salivation, some physicians tell patients not to smoke or chew gum after midnight on the night before the examination. This restriction is made to prevent excessive fluid from accumulating in the stomach and diluting the barium suspension enough to interfere with its coating property.  UPPER GASTRO-INTESTINAL  Two general procedures are routinely used to examine the stomach:  The single-contrast method and the double-contrast method.  A biphasic examination is a combination of the single- contrast and double-contrast methods on the same day.  Barium meal" normally reaches the ileocecal valve in 2 to 3 hours and the last portion in 4 to 5 hours.  The barium usually reaches the rectum within 24 hours.  UPPER GASTRO-INTESTINAL SINGLE CM  In the single-contrast method - 30% to 50% weight/volume range.  Begin the examination with the patient in the upright position.  The radiologist may first examine the heart and lungs fluoroscopically and observe the abdomen to determine whether food or fluid is in the stomach.  The radiologist asks the patient to swallow two or three mouthfuls of the barium. During this time, examine and expose any indicated spot films of the esophagus.  By manual manipulation of the stomach through the abdominal wall , the radiologist then coats the gastric mucosa.  After studying the rugae and as the patient drinks the remainder of the barium suspension, observe the filling of the stomach and further examine the duodenum.  UPPER GASTRO-INTESTINAL SINGLE CM 1. Determine the size, shape, and position of the stomach. 2. Examine the changing contour of the stomach during peristalsis. 3. Observe the filling and emptying of the duodenal bulb. 4. Detect any abnormal alteration in the function o r contour o f the esophagus,stomach, and duodenum.  Fluoroscopy is performed with the patient in the upright and recumbent positions while the body is rotated and the table is angled so that all aspects of the esophagus, stomach, and duodenum are demonstrated.  If esophageal involvement is suspected, a study is usually made with a thick barium suspension.  UPPER GASTRO-INTESTINAL DOUBLE CM  The principal advantages of this method over the single- contrast method are that small lesions are less easily obscured and the mucosal lining of the stomach can be more clearly visualized.  To begin the examination, place the patient on the fluoroscopic table in the upright position.  Give the patient a gas-producing substance in the form of a powder, crystals, pills, or a carbonated beverage.  Give the patient a small amount of high-density barium suspension.  For even coating of the stomach walls, the barium must flow freely and have a low viscosity.  Barium suspensions have weight/volume ratios of up to 250%.  UPPER GASTRO-INTESTINAL DOUBLE CM  Place the patient in the recumbent position, and instruct him or her to turn from side to side or to roll over a few times.  This movement serves to coat the mucosal lining of the stomach as the carbon dioxide continues to expand.  Just before the examination the patient may be given glucagon or other anticholinergic medications intravenously or intramuscularly to relax the gastrointestinal tract.  These medications improve visualization by inducing greater distention of the stomach and intestines.  UPPER GASTRO-INTESTINAL BIPHASIC EXAMINATION  The biphasic gastrointestinal examination incorporates the advantages of both the single-contrast and double- contrast upper gastrointestinal examinations, with both examinations performed on the same day.  The patient first undergoes a double contrast examination of the upper gastrointestinal tract.  When this study is completed, the patient is given an approximately 15% weight/volume barium suspension and a single-contrast examination is performed.  This biphasic approach increases the accuracy of diagnosis without significantly increasing the cost of the examination.  BODY HABITUS HYPERSTHENIC Stomach is high and transverse level of T9-T12. Pyloric portion level of T11-T12, at midline. Duodenal bulb is at the level of T11-T12 to right of midline.  BODY HABITUS HYPOSTHENIC,ASTHENIC J-shaped stomach, low and vertical, T11-L4. Pyloric portion level of L3- L4 to left of midline. Duodenal bulb at the level of L3-L4.  BODY HABITUS STHENIC Stomach T10-L2. Pyloric portion level of L2 near midline. Duodenal bulb L2 near midline.  AIR-BARIUM IN THE STOMACH SUPINE PRONE The fundus which is the The fundus is in the most posterior part of highest position. the stomach is at the Barium – Pylorus lowest part. Air - Fundus Barium fills the fundus part. ERECT Barium – Fundus Air – Fundus Air – Pylorus Barium – Pylorus Air-Barium in a straight line AIR-BARIUM IN THE STOMACH  STOMACH Upright Right lateral recumbent Stomach moves Stomach moves forward. downward 3-6 inches. Pylorus closer to lumbar Supine spine. Stomach moves Left lateral upright superiorly. Stomach moves Prone backward. Stomach moves slightly Pylorus closer to downward. abdominal wall.  UGIS  SRE distal esophagus, Food & drinks are stomach, duodenum & withheld after midnight 8 proximal jejunum – 9 hours before the  Soft residue diet for 2 examination. days to prevent gas When the small intestine formation as a result of study is to be made, food excessive fermentation of & drinks are withheld the intestinal content after evening meals.  Cleansing enema is given 1 full cup (2 ounces) of to assure a properly BaSO4 prepared colon  UGIS PA PROJECTION PA recumbent position. PA upright position  For radiographic studies Demonstrates the size, of the stomach and shape and relative duodenum. position of the  CR to L1. stomach, but it does not  Stomach moves give an adequate superiorly I ½ to 4 inches demonstration of the ( 3.8 to 10 cm). unfilled fundic portion of the organ.  CR to 3-6 inches below L1-L2.  UGIS PA PROJECTION  The greatest visceral movement between the prone and the upright positions occurs in asthenic patients.  Do not apply an immobilization band for standard radiographic projections of the stomach and intestines because the pressure is likely to cause filling defects and because it interferes with emptying and filling of the duodenal bulb, factors that are important in serial studies.  UGIS PA PROJECTION Sthenic CR to L1 and 1 inch left of vertebral column. Asthenic CR 2 inches below L1. Hypersthenic 2 inches above L1.  UGIS PA PROJECTION Body and pylorus filled with Hypersthenic barium and air in the fundus. Pyloric canal and duodenal Polyps, diverticulum, bulb completely bezoars and gastritis in the superimposed by prepyloric body and pylorus. portion of stomach. Asthenic/Hyposthenic pyloric canal and duodenal bulb in profile. Sthenic Pyloric canal and duodenal bulb partially superimposed by prepyloric portion of stomach.  UGIS PA AXIAL PROJECTION GORDON METHOD  CR 35 to 45 degrees cephalad.  Best demonstrates and open up high transverse stomach for hypersthenic patients.  Greater and lesser curvatures in profile. GUGLIANTINI  20 to 25 degrees cephalad for demonstration of the stomach in infants.  UGIS RAO POSITION  40-70 degrees body C-loop in profile but rotation. superimposed on lumbar  Hypersthenic patients vertebra. require a greater degree of Air in the fundus. rotation than do sthenic Barium in the body, and asthenic patients. pylorus and duodenum.  Best demonstrates Polyps, ulcers of the pyloric canal and the duodenal bulb free of pylorus. superimposition of the serial studies must be pylorus because gastric taken at an interval of peristalsis is usually more 30 – 40 seconds. active when the patient is in this position.  UGIS RAO POSITION  UGIS LPO POSITION  Body rotated 30 to 60 degrees (45 degrees).  Demonstrates the fundic portion of the stomach filled with barium.  Good position for double contrast of body, pylorus, and duodenal bulb.  UGIS RIGHT LATERAL POSITION Upright left lateral  Best image of the  Demonstration of the left pyloric canal and the retrogastric space. duodenal bulb in Recumbent right lateral patients with a hypersthenic habitus.  Demonstration of the right retrogastric space,  C-loop. duodenal loop, and  Stomach located higher duodenojejunal junction. in this position than in PA  Demonstrates anterior and RAO. and posterior aspects of  CR to L1 1-1 ½ inches the stomach, the pyloric anterior to MCP. canal, and the duodenal bulb  UGIS RIGHT LATERAL POSITION  UGIS AP PROJECTION  The stomach moves Partial Trendelenburg superiorly and to the left  Helps fills fundus with in this position. barium on thin asthenic  Tilt the table to full or patient. partial Trendelenburg for Full Trendelenburg the demonstration of  Demonstration of hiatal hiatal hernia. hernia.  The best AP projection of the retrogastric portion of the duodenum and jejunum.  UGIS AP PROJECTION  UGIS WOLF METHOD  The Wolf method' is a modification of the Trendelenburg position  The technique was developed for the purpose of applying greater intraabdominal pressure than is provided by body angulation alone and thereby ensuring more consistent results in the radiographic demonstration of small, sliding gastroesophageal herniations through the esophageal hiatus.  The Wolf method requires the use of a semicylindrical radiolucent compression device measuring 22 inches (55 cm) in length, 10 inches (24 cm) in width, and 8 inches (20 cm) in height.  UGIS WOLF METHOD  A further advantage of the device is that it does not require angulation of the table; thus the patient is able to hold the barium container and ingest the barium suspension through a straw with comparative ease.  Patient in a 40- to 45-degree RAO position.  To allow for complete filling of the esophagus, make the exposure during the third or fourth swallow.  CR Perpendicular to the long axis of the patient's back and centered at the level of either T6-T7.  This position usually results in a 10-20-degree caudad angulation of the central ray.  UGIS WOLF METHOD  UGIS RAO SERIAL AND MUCOSAL STUDIES  The use of a pneumatic paddle for the demonstration of the gastric mucosa after the fluoroscopic examination.  The paddle is placed under pyloric sphincter and duodenal bulb.  A radiograph is obtained with the pneumatic paddle inflated, and additional radiographs are taken as the paddle is deflated.  The fluoroscopic portion of this examination is performed by the radiologist.  This method demonstrates a compression and a non compression study of the pyloric end of the stomach and the duodenal bulb at different stages of filling and emptying.  A compression study of the mucosa of a localized area of the gastrointestinal tract  UGIS RAO SERIAL AND MUCOSAL STUDIES  HYPOTONIC DUODENOGRAPHY Examination that uses intubation for the evaluation of post bulbar duodenal lesion & for detection of pancreatic diseases. The tubeless technique requires temporary drug induce duodenal paralysis so that a double contrast examination can be performed without interference from peristaltic activity.  SMALL INTESTINAL SERIES  SRE of the small intestine by administering the barium sulfate by: 1. mouth 2. by complete reflux filling with a large volume of barium enema 3. by direct injection into the bowel through an intestinal tube which is called the electrolysis  Patient preparation: same as UGIS.  SMALL INTESTINAL SERIES INDICATIONS:  Low-residue diet for 2 1. Study the form and function days before the small of the 3 components of the intestine study. small bowel.  NPO 8 hours before the 2. Detect abnormal conditions. exam. CONTRAINDICATIONS:  No cigarette or chewing 1. Pre-surgical patient gum. 2. Perforated hollow viscus 3. Large bowel obstruction.  Patient is asked to Use iodinated CM. empty the bladder to prevent displacement of ileum to the distended bladder.  UGI-SMALL BOWEL COMBINATION  1st cup (8 ounces) of barium – time noted.  Routine stomach study.  2nd cup of barium is given.  30 minutes after initial barium intake a PA projection of the proximal small bowel is perform.  The 1st radiograph of the SIS (30 minutes) is perform 15 minutes after UGIS.  For the first 2 hours of the SIS radiographs are obtained in 15- to 30-minute intervals.  After 2 hours radiographs are obtained every hour until it reaches the ileo-cecal valve.  SMALL BOWEL ONLY SERIES  2 cups of BaSO4 ingested.  1st radiograph taken 15 or 30 minutes after ingestion.  Half-hour radiographs for for 2 hours time frame.  After 2 hours radiographs are taken at 1 hour intervals.  ENTEROCLYSIS DOUBLE CM SMALL BOWEL PROCEDURE  CM is injected into the INDICATIONS: duodenum to examine 1. Bowel ileus the small bowel.  CM injected through a 2. Regional enteritis BILBAO or SELLINK tube 3. Malabsorption syndrome into the terminal (sprue). duodenum.  Barium is given at a rate DISADVANTAGES: of 100 ml/min  Air or Methylcellulose is 1. Increased patient injected to distend and discomfort. provides double contrast 2. Bowel perforation. effect.  INTUBATION METHOD SINGLE CM  Also known as small bowel enema.  Uses NGT for introduction of CM for therapeutic and diagnostic purposes.  Therapeutic - (Miller-Abbott tube) to relieve post- operative distention and small bowel obstruction.  COMPLETE REFLUX EXAMINATION Complete reflux filling of the small bowel Glucagon is administered to relax the intestine Diazepam (valium) may also be given to diminish discomfort during initial portion of the filling of the bowel 15% weight volume barium suspension is often used and a large amount of suspension (about 4500ml) is required to fill the colon & small intestine Retention enema tip is used & the patient is place in supine position Barium is allowed to flow until it is observed in duodenal bulb The enema bag is then lowered to the floor to drain the colon before filming of the small intestine.  SIS METHOD OF IMAGING PRONE POSITION SUPINE POSITION 1. Allows abdominal 1. To take advantage of the compression to superior and lateral shift separate various bowel of the barium-filled loops. stomach for visualization 2. Higher degree of of the retrogastric visibility. portions of the TRENDELENBURG duodenum and jejunum 1. Separate overlapping 2. To prevent possible loops of ileum. compression overlapping of loops of the intestine.  LARGE INTESTINE  There are two basic radiologic methods of examining the large intestine by means of diagnostic or contrast enemas the: 1. single-contrast method - colon is examined with a barium sulfate suspension only. 2. double-contrast method - two-stage or single-stage procedure.  In the two-stage double-contrast procedure, the colon is examined with a barium sulfate suspension and then, immediately after evacuation of the barium suspension, with an air enema or another gaseous enema. LARGE INTESTINE  LARGE INTESTINE  Barium demonstrates the anatomy and tonus of the colon and most of the abnormalities to which it is subject.  The gaseous medium serves to distend the lumen of the bowel and to render visible through the through the transparency of its shadow.  Most enema bags have a capacity of 3 quarts (3000 m l ) when fully distended  The tubing is approximately 6 feet long.  For single-contrast 12% to 25% for weight/volume.  For double contrast examinations, a relatively high density barium product is used.  75% to 95% weight/volume ratio is common.  LARGE INTESTINE  Barium sulfate temperature should be below body temperature about 85°to 90° F (29° to 30° C).  An enema that is too warm is injurious to intestinal tissues and produces so much irritation that it is difficult, if not impossible, for the patient to retain the enema long enough for a satisfactory examination.  Cold barium enema suspensions about 41°F (5°C) have been recommended on the basis that the colder temperature 1. produces less irritation, 2. has a mild anesthetic effect that relaxes the colon, 3. stimulates tonic contraction of the anal sphincter.  BARIUM ENEMA SRE of the large Height of barium content intestine. at 18-24 inches (45-60 Insertion of enema tip – cm) above the level of the sims’ position – 35 to 40 anus degrees lean forward on Tube is inserted for a left side total distance of 3 ½ to 4 This position relaxes the inches (8.7 to 10 cm) abdominal muscle , Inserted during which decreases Intra- exhalation: directed abdominal pressure on anteriorly 1 – 1 ½ inch the rectum and makes following curve of relaxation of the anal rectum then slightly sphincter less difficult. superiorly BARIUM ENEMA SUPINE Air rises to the most anterior portion of the large intestine. 1. Transverse colon 2. Sigmoid colon Barium fills the: 1. Ascending colon 2. Descending colon BARIUM ENEMA PRONE Air fills the: 1. Rectum 2. Ascending colon 3. Descending colon BARIUM 1. Transverse colon  BARIUM ENEMA LATERAL (RECTUM) ROBIN’S MODIFICATION  True lateral position. The most important  CR to MCP between modification in barium ASIS and posterior enema. sacrum. Demonstrates a direct  Best demonstrates lateral view of the recto- polyps, strictures and sigmoid colon without fistula between the superimposition. bladder and uterus.  Best demonstrates the rectum and rectosigmoid portion.  BARIUM ENEMA LATERAL (RECTUM) ROBIN’S MODIFICATION  BARIUM ENEMA RPO POSITION  35- 45 degree rotation from the table.  Best demonstrates the left colic flexure and the descending colon.  Similar image can also be seen in LAO position.  BARIUM ENEMA LPO POSITION  35- 45 degree rotation from the table.  Best demonstrates the right colic flexure and the ascending and sigmoid portions of the colon.  Similar image can also be seen in RAO position.  BARIUM ENEMA AP PROJECTION  Air filled transverse colon filled.  Opacified colon including flexures and rectum. TRENDELENBURG  Separates redundant and overlapping loops of the bowel.  BARIUM ENEMA PA PROJECTION  Barium filled transverse colon filled.  Opacified colon including flexures and rectum.  BARIUM ENEMA AP AXIAL /AP AXIAL OBLIQUE PROJECTION BUTTERFLY POSITION AP AXIAL PROJECTION  CR 30- 40 degrees cephalad to 2 inches inferior to ASIS. AP AXIAL OBLIQUE PROJECTION  LPO position (30°-40°) body rotation.  CR 30°- 40° cephalad to 2 inches inferior and 2 inches medial to right Best demonstrates an ASIS elongated view of the rectosigmoid area than on other views  BARIUM ENEMA PA AXIAL/PA AXIAL OBLIQUE PROJECTION BUTTERFLY POSITION PA AXIAL Best demonstrates an  CR 30◦-40° caudad to level elongated view of the of ASIS rectosigmoid area PA AXIAL OBLIQUE than on other views PROJECTION  RAO position (35°-45°) body rotation.  CR 30°- 40° caudad to ASIS and 2 inches to left of lumbar spinous process.  BARIUM ENEMA RIGHT LATERAL DECUBITUS  CR horizontal to level of the iliac crests.  Best demonstrates the "up" medial side of the ascending colon and the lateral side of the descending colon when the colon is inflated with air.  Air inflated portion of the colon is of primary importance.  BARIUM ENEMA LEFT LATERAL DECUBITUS  CR horizontal to level of the iliac crests.  Best demonstrates the "up" lateral side of the ascending colon and the medial side of the descending colon when the colon is inflated with air  Air inflated portion of the colon is of primary importance.  BARIUM ENEMA VENTRAL DECUBITUS  CR to level of the iliac crests.  Best demonstrates the "up" posterior portions of the colon and is most valuable in double- contrast examinations.  BARIUM ENEMA AXIAL PROJECTION CHASSARD-LAPINE METHOD  Demonstrates an axial projection of the rectum, rectosigmoid junction, and sigmoid.  A right angle view to the AP projection,  Demonstrates the anterior and posterior surfaces of the lower portion of the bowel and permits the coils of the sigmoid to b e projected free from overlapping.  BARIUM ENEMA BILLING’S Supine CR 35-45 degrees midway between ASIS. Prevent overlapping loop and separates sigmoid colon. Demonstrates recto- sigmoid area.  BARIUM ENEMA OPPENHEIMERS FLETCHERS MODIFICATION  Supine LAO position (30°-35°)  CR 12 degrees caudad to CR 30°-35° cephalad. 1 inch proximal to the upper border of the symphysis pubis.  COLOSTOMY General term applied to Post operative contrast the surgical procedure of studies to determine forming an artificial the efficacy of opening to the intestine, treatment in case of usually through the diverticulitis, ulcerative abdominal wall for fecal colitis, & to detect any passage. new or recurrent lesion. The regional term are coLostomy, cecostomy, iLeostomy, and jejunostomy.  DEFECOGRAPHY Functional study of the anus and rectum during evacuation and rest phase of defecation. Performed for the patient with a defecation dysfunction. Also known as evacuation proctography, dynamic rectal examination. 100% weight/volume barium sulfate paste with a special injector mechanism is use to instill the barium directly into the rectum. Lateral projections are obtained during defecation by spot filming. This evaluation includes measurements of the anorectal angle and the angle between the long axis of the anal canal and rectum. DEFECOGRAPHY  URINARY SYSTEM The kidneys normally The adult bladder can hold excrete I to 2 L of urine per approximately 500 ml of day. fluid when completely full. The kidneys normally The desire for micturition extend from the level of the (urination) occurs when superior border of T12 to about 250 ml of urine is in the level of the transverse the bladder. processes of L3 in persons Urography – radiographic of sthenic build. examination of the urinary Respiratory movement of system 1 inch and normally drop 1. CM introduced to no more than 2 inches (5 bloodstream by cm) in the change from intravenous injection (IVU). supine to upright position. 2. Catheterization (RGP).  URINARY SYSTEM Ionic and non-ionic are the Glucophage (metformin) two CM used in urology. should not be given Temporary hot flash and iodinated CM 48 hours metallic taste in the mouth before the procedure and are the common side withheld for another 48 effects occurring after IV hours after the procedure. injection of iodinated CM. Patient should never be RT must check the BUN left alone after IV injection and Creatinine (diagnostic of CM. indicators of the kidneys). Physician must be Normal BUN – 8-25 mg/100 summoned immediately ml. for any moderate or Normal Creatinine 0.6-1.5 severe reaction. mg/dl.  PREPARATION OF CM Before withdrawing the CM from the vial. 1. Confirm the correct contents. 2. Expiration date 3. Read the label very carefully. 4. empty bottles should be shown to the radiologist. For 50-100 ml of CM use 18-20 gauge butterfly needle. 23-25 gauge needle for pediatric patients. Most reactions to contrast media occur within the first 5 minutes after administration. 2-8 minutes CM appears at the pelvocalyceal system. 15-20 minutes after injection is the greatest concentration of CM in the kidneys. PREPARATION OF CM  INTRAVENOUS UROGRAPHY Most common SRE of the urinary system. also referred to as IVP (refers only to renal pelpes). Commonly referred to as IVU or excretory urography. True functional test of the urinary system. PURPOSE: 1. Visualize collectiong portion of the urinary system. 2. Assessed the functional ability of the kidneys. Empty bladder before examination: 1. Bladder that is full could rupture. 2. Urine dilutes the CM.  INTRAVENOUS UROGRAPHY PROCEDURE URETERAL COMPRESSION Method to enhanced filling of the pelvocalyceal system and proximal ureters. Applied over the distal ends of the ureters. This is done to retard flow of the opacified urine into the bladder and thus ensure adequate filling of the renal pelves and calyces. Compression is generally contraindicated if a patient has urinary stones, an abdominal mass or aneurysm, a colostomy, a suprapubic catheter, or traumatic injury. INTRAVENOUS UROGRAPHY PROCEDURE  INTRAVENOUS UROGRAPHY PROCEDURE RESPIRATION TRENDELENBURG All exposures are made Same result to at the end of the end of compression device expiration. without risk to the Normal respiratory patient whose excursion of the symptoms kidneys varies from 1-1 contraindicate ureteric ½ inches. compresion.  BASIC IVU PROTOCOL 1. Nephrogram 4. 20 minute obliques 1 minute after start of LPO and RPO position injection. Ureters away from the 2. 5 minute spine. Full KUB 5. Post-void Supine is the preferred Taken after patient has position. void. 3. 15 minute PA, erect AP Full KUB Bladder should be Supine is the preferred included. position.  IVU AP PROJECTION NEPHROGRAM  CR midway between xiphoid tip and iliac crets.  Single AP projection of the kidney taken 60 minutes after injection. NEPHROTOMOGRAPHY  Primarily performed to rule out renal hypertension.  IVU RPO AND LPO POSITIONS  CR perpendicular to iliac crets.  30 degrees body rotation.  Kidney farthest from IR in profile.  Ureter nearest IR projected away from the vertebral spine.  IVU POST VOID  CR perpendicular to iliac crets.  Demonstrate enlarged prostate or prolapse bladder.  Ureteral reflux ERECT POST VOID  Best demonstrates nephroptosis (positional change of kidneys).  IVU AP PROJECTION URETERIC COMPRESSION  CR midway between xiphoid tip and iliac crets.  Best demonstrates pyelonephritis.  RETROGRADE UROGRAPHY Non functional Considered to be an examination of the operative procedure urinary system. combining urologic – CM introduce directly radiologic under careful retrograde ( backward aseptic condition against the flow) into The examination is the pelvicalyceal performed in a specially system. equipped cystoscopic Requires radiologic examination catheterization of the room. ureter for the injection of CM to the pelvicalyceal system.  RETROGRADE UROGRAPHY The patient is place on a Frequently performed to cystoscopic table & the determined the localization of urinary calculi or other knees are flex over the type of obstruction. stirrups of the adjustable Sodium iodide and sodium leg support (modified bromide first used for RGU. lithotomy position) Patient drink a large amount of Catheterization of the water (4 or 5 cups) for several ureter is performed hours before the examination to ensure excretion of urine in through a an amount sufficient for ureterocystoscope & the bilateral catheterized catheter is inserted into specimens and renal function the vesicoureteral orifices tests.  RETROGRADE UROGRAPHY The retrograde urogram is indicated for evaluation of the collecting system in patients who have renal insufficiency or who are allergic to iodinated contrast media. 1. Preliminary radiograph showing the urethral catheter in position 2. Pyelogram 3. Urethrogram PYELOGRAM : some radiologist recommends that the head of the table to be lowered 10 – 15 degrees for the pyelogram to prevent the CM from escaping into the ureter 3 – 5 ml of solution will fill the average normal renal pelvis.  RETROGRADE UROGRAPHY URETHROGRAM : patient is instructed to inhale deeply & then to suspend respiration at the end of full expiration RPO or LPO as an additional view LATERAL – patient turn lateral on affected side is taken to demonstrate anterior displacement of the kidney or ureter to delineate a perinephritic abscess CROSS TABLE LATERAL – supine or prone; useful for demonstration of ureteropelvic region in patient with hydronephrosis. RETROGRADE UROGRAPHY  RETROGRADE CYSTOGRAPHY CYSTOGRAM Non functional radiographic examination of the urinary bladder after instillation of an iodinated CM via a urethral catheter Cystogram : is a common procedure to rule out trauma, calculi, tumor & inflammatory disease of the urinary bladder No patient preparation but prior to catheterization procedure, the patient should empty the bladder After catheterization under aseptic condition, the bladder is drain of any residual urine The bladder is then filled with dilute CM (150-500 cc) in allowed to flow in by gravity ( never attempt to introduce pressure which will result to rupture of the bladder ).  RETROGRADE CYSTOGRAPHY CYSTOGRAM AP BLADDER & PROXIMAL PART OF URETHRA CR 15 degrees caudad. RPO : 40 – 60 degrees rotation CR perpendicular or 10 degrees caudad PA BLADDER : CR to bladder neck at 10 – 15 degrees cephalad Use to project the shadow of prostate above that of the pubic bone.  RETROGRADE CYSTOGRAPHY CYSTOGRAM LATERAL Use for demonstration of the anterior & posterior bladder wall & the base of the bladder. CHASSARD LAPINE Squat shot use to obtain axial image of the posterior surface of the bladder & of the lower end of the ureter when they are opacified AP OF DISTAL URETER Lowering the head of the table 15 – 20 degrees to permit the filled bladder to stretch superiorly RETROGRADE CYSTOGRAPHY CYSTOGRAM  VOIDING CYSTOURETHROGRAM A functional study of The voiding face of the the bladder & the examination is best urethra; evaluates the done with fluoroscopy ability of the patient to with image acquisition urinate capability. Maybe taken after the MALE : patient in routine cystogram supine or upright 30-40 Common pathologic degrees RPO position. indication are trauma or FEMALE : in supine incontinence slight oblique position After voiding shot is complete; a voiding AP must be done VOIDING CYSTOURETHROGRAM  METALLIC BEAD CHAIN CYSTOURETHROGRAPHY Investigates anatomic abnormalities responsible for stress incontinence in women.  HYSTEROSALPINGOGRAPHY SRE of the fallopian tube, ovaries & uterus using positive CM Demonstrate patency of oviduct in cases of infertility Scheduled about 10 days after start of menstruation. CM: liopodol, skiodan, kayopaque, salpix AP, PA, OBLIQUE & LATERAL PELVIC PNEUMOGRAPHY VAGINOGRAPHY Pelvic pneumography, Used in the investigation gynecography, and of congenital pangynecography are malformations and the terms used to denote pathologic conditions radiologic examinations such as vesicovaginal of the female pelvic and enterovaginal organs by means of fistulas. intraperitoneal gas insufflation.  FETOGRAPHY The demonstration Confirm suspected of the fetus in utero. fetal death, to Avoided until after the determine the eighteenth week of presentation and gestation because of position of the fetus, the danger of Determine whether radiation induced fetal the pregnancy is malformations. single or multiple. Detect suspected abnormalities of development, FETOGRAPHY  PLACENTOGRAPHY DISKOGRAPHY Radiographic SRE of the examination in which the intervertebral disk walls of the uterus are injected into the center investigated to locate the of the disk with a placenta in cases of double entry needle. suspected placenta previa.  CEREBRAL MYELOGRAPHY ANGIOGRAPHY SRE of the blood vessel SRE of the central of the brain by means nervous system, of injecting the CM in spinal cord the carotid artery Introduction of CM in sub-arachnoid space INDICATION: intracranial at level of L3 – L4 aneurysm, vascular CM: Iopaniro (iodized lesion, tumor, oil) AP, PA, R & L OBLIQUE & CROSS TABLE LATERAL  COLCHERR-SUSSMAN AP and lateral employed Center the horizontal in this method of ruler to the gluteal fold at pelvimetry requirethe use the level of the ischial of the Colcher-Sussman tuberosities (10 cm pelvimeter. below superior border This device consists of a of symphysis pubis). metal ruler perforated at centimeter intervals and mounted on a small stand. COLCHERR-SUSSMAN ANGIOGRAPHY  Radiographic examination of the vessels after injection of CM. LYMPHOGRAPHY  Radiographic examination of the lymphatic vessels.  1 hour of injection – lymph vessel.  24 hours after injection – lymph nodes.