1983, The British Journal of Radiology, 56, 715-719

OCTOBER 1983

Gastrointestinal fluoroscopy: patient dose and methods for its reduction

By 'Stephen J. Leibovic, M.S. and tWilliam J. H. Caldicott, M.B., B.S. Department of Radiology, Children's Hospital and Harvard Medical School, Boston, Mass.
(Received September 1982 and in revised form March 1983)

ABSTRACT

The aim of this study was to demonstrate a method which could be used to identify factors which contribute to the radiation exposure to patients from fluoroscopy during contrast examinations of the gastro-intestinal tract. Measurements of exposure made at the level of the X-ray tube collimator were extrapolated to obtain entrance exposure at the centre of the field and used as an index of the integral dose to the patient. Such data have heretofore been unavailable. The population studied included 65 patients ranging in age from 1 month to 21 years. In an initial study, median entrance exposure at the field centre for barium swallow examinations ranged from 0.98 to 1.7 mC/kg (3.8 to 6.6 R); barium meal: 1.9-5.7 mC/kg (7.4-22 R); barium meal with small bowel: 1.4-7.7 mC/kg (5.3-30 R); barium enema: 0.93-7.7 mC/kg (3.6-41 R). Gonadal dose, measured in males, ranged from undetectable to 0.71 mGy (71 mrad). The presence of contrast medium in thefluoroscopicfieldincreased the exposure from a single 100 mm spot film, taken with automatic exposure control, by a factor of up to 16, and fluoroscopic exposure rate, using automatic brightness control, by a factor of 2 or more. We recommend modifications in the operation and design of fluoroscopic equipment, especially when fitted with brightness and exposure controls, for the reduction of patient exposure. Implementation of two modifications, a high/low dose switch, and a variable aperture iris diaphragm, reduced patient exposure from 1.4 to 3.4 times.

dosimeter applied to the patient can be used to measure the total dose to an organ, such as the testes, but since the fluoroscopic field is rarely stationary, the total dose to the patient cannot be measured in this way. One approach is to estimate the entrance exposure at the centre of the field (ECF) and use this as an index of the integral dose to the patient. We have used this method to monitor fluoroscopy equipment and modifications to equipment and operator technique, with the aim of reducing patient exposure. The values we are reporting cannot be used to assess the dose absorbed by any one region or organ of the body because no attempt was made to record the scanning patterns of the moving field, or the exposure times, or the exposure rates for each region in the total area exposed.
MATERIALS AND METHODS

A great deal of effort is being spent on minimising patient dose during radiographic procedures, as radiation from medical procedures is a source of increasing concern amongst health care professionals and the public alike. Fluoroscopy contributes a significant proportion of the total radiation received by patients and staff during radiological examinations of the gastro-intestinal tract. However, fluoroscopic exposures and factors that determine them have received little attention in the literature and available data are often not comparable since different measuring techniques have been employed (Hertz & Werner, 1973; Kaude et al, 1969; Leibovic & Fellows, 1983; Leibovic & Lebowitz, 1980; Pratt et al, 1973; Saenger et al, 1976; Seppanen et al, 1979; Vogel et al, 1978; Webster et al, 1974). A

Present address: Stanford Medical School, Stanford, California 94305, USA fAddress for reprints: W. J. H. Caldicott, Department of Radiology, Children's Hospital Medical Center, 300 Longwood Avenue, Boston, Massachusetts 02115, USA

Exposures were measured with lithium fluoride TLD100 extruded ribbon (Harshaw Chemical Co.). The dosimeters were individually calibrated and checked for reproducibility against a Keithley ion chamber/dosimeter during the course of the study. The energy dependence of this ion chamber in the diagnostic range is well known (Morgan et al, 1978) and corrections were applied as necessary. Calibration of the thermoluminescent dosimeters was performed at energies and dose levels similar to those measured on patients in order to minimise their known energy and dose dependence. Dosimeters were read in a Harshaw model 2000 thermoluminescence analyser run with carbon dioxide gas. Dosimeters were individually packaged in black plastic, and applied, two at a time, to the exit surface of the undercouch tube collimator. The patient exposure was determined from the collimator exposure by using a ratio of collimator exposure to patient exposure, established in a pilot phantom study using the techniques employed in a standard fluoroscopic examination with a phantom in the beam. The exposure estimated in this way (extrapolated patient ECF) is an estimate of the total exposure at skin level in the centre of the entrance field, ignoring back-scatter. In a separate study of exposure during voiding cystourethrography, during which the fluoroscopic unit does remain relatively stationary, it was found that patient entrance exposure estimated from measured collimator exit

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exposure compared well with measurements of ECF by dosimeters applied directly to the skin, when backscatter is accounted for. The X-ray equipment used consisted of a Philips modular three phase generator with a Machlett tube (0.6/1.2 mm focal spot, 2.5 mm Al total filtration) coupled to a Philips Medical TV chain (6 inch, 600 G, image intensifier and plumbicon camera). Fluoroscopic kVp and mA are continuously varied by the generator to maintain a pre-set average brightness of the television image. The TV chain integrates light output from the image intensifier over the central 60% of the area of the image field. As the patient moves or as contrast medium fills the field, the kVp and mA fluctuate. The kVp typically ranges from 50 to 100, and mA from 0.5 to 3 during fluoroscopy. Spot filming kVp is pre-set by the radiographer, usually between 70 and 85, depending on the size of the patient. The mA is then determined by the generator, and the exposure automatically timed. Kodak Lanex Regular rare earth screens and OG1 film are used in the cassettes for the spot film device and DuPont Cronex SF2-2W film is used in the 100 mm camera. Overhead plain films are also taken during some examinations, using Kodak Lanex Regular screens and OG1 film. All films are processed in a Kodak RP X-omat with 90-second processing. No attempt was made to monitor fluoroscopic field size, which, by common practice, was limited as much as possible. Patient population Measurements were made on 48 patients during gastro-intestinal examinations in the first trials. Table I shows the ages of the patients, the types of examinations performed, fluoroscopy time, and the number of spot films. Standard procedures were followed, using barium sulphate as the contrast medium. On days when dosimetry was performed, sequential examinations were monitored and no cases were excluded from the study. Examinations were either performed by, or supervised by, experienced paediatric radiologists who were aware that dosimetry was being performed. In 23 male patients gonadal dose was monitored by applying a dosimeter to the thigh adjacent to the scrotum, in a manner similar to the technique used by Kaude et al (1969). Because of the large variation in exposure demonstrated during the examinations we sought to investigate the influence of contrast media on total fluoroscopic exposure. A comparison of patient exposure with and without contrast medium was made in three patients undergoing voiding cystourethrography. In these three patients, exposures from spot films of the pelvis with and without contrast medium in the bladder were compared. For each film, kVp was manually selected (mA became automatically fixed by kVp selection) and photo-timed exposure time was read from a readout on the control panel. Exposures were
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calculated from technique factors and previously prepared exposure curves. Repeat studies using modifiedfluoroscopicequipment As a direct result of the above study, two modifications were made to the fluoroscope to reduce exposure rate. (1) A two-position, maximum table-top exposure switch was readjusted to provide a low setting of 0.65 mC kg" 1 min" 1 (2.5 R min"1) and a high setting of 1.3 mC kg" 1 min" 1 (5 R min"1). The low setting was then used except when not adequate for a large patient. (2) The fixed aperture iris of the TV camera was replaced by a variable aperture iris diaphragm as suggested by Rossi et al (1978). The aperture can be altered from a minimum diameter of 21 mm to a maximum of 70 mm by the fluoroscopist. A small number of patients was monitored for entrance exposure during examinations after the modifications were made. A different dose measurement system, developed for use during cardiac catheterisation, was used, and is described in detail elsewhere (Leibovic & Fellows, 1983). It makes use of a pancake style ionisation chamber mounted at the collimator face, which allows direct measurement of the product of exposure and area (R.cm2). In this series of trials, collimation was set at the outset of an examination and remained fixed for its duration. Measurement of the size of the entrance field on the patient at the conclusion of the examination then allows calculation of ECF from: ECF [mC/kg (R)] = Exposure area product [(mC/kg) cm2 (R cm2)] Field size [cm2] Therefore, these results are directly comparable with the measurements obtained by TLD dosimetry. Comparison of the two dosimetry systems in single examinations yielded comparable results (6%).
RESULTS

Table I shows median exposures and exposure ranges, by age, for the four types of examinations monitored prior to equipment modification. As can be seen from the table, a large quantity of radiation is directed at (and absorbed by) the patient during these studies. ECFs during fluoroscopy were up to one hundred times greater than exposures typically encountered in plain film examinations of patients of similar age because of the very much longer total exposure time from fluoroscopy. However, the skin area exposed to make a plain film of the gastro-intestinal tract is from 250-1000 cm2, about six times as large as thefluoroscopyfield. Although there was a general trend towards increasing exposure with age, a direct relationship could not be shown, probably because of the many uncontrolled variables in this study, including fluoroscopic time, kVp and mA fluctuations, distance of the

OCTOBER 1983

Gastrointestinal fluoroscopy: patient dose and methods for its reduction

TABLE I
ENTRANCE EXPOSURES AT THE CENTRE OF THE FIELD (ECF) FROM GASTROINTESTINAL EXAMINATIONS

Type of examination and age range Ba swallow 12d-15mo 16mo-10y ll-20y Upper GI <2y 6y 10-20y Upper GI and SBFT <2y 10-20y Ba enema 15, 18y Enema-air contrast 8, lly

Time (seconds)

Number of spot films

ECF (mCkg" 1 ) (R) 1.5-8.1 (3.8) 4.1-15 (6.6) 2.8-34 (6.5) 4.5-11 (7.4) 11 17-26 (22) 3.7-9.9 (6.3) 17-65 (30) 31,41 3.6, 9.6

9 7 5 6 1 6 4 6 2 2

65-314 (161) 151-363 (225) 27-163 (97) 154-300 (196) 147 107-252 (188) 80^68 (265) 180-409 (281) 190, 223 42, 120

3-12 5-16 2-7 8-11 4 6-10 6 6-14 2,6 0, 1

0.4-2.1 (1.0) 1.1-3.9 (1.7) 0.7-8.8 (1.7) 1.2-2.8 (1.9) 2.8 4.4-6.7 (5.7) 1.0-2.6 (1.6) 4.4-17 (7.7) 8.0, 11 1.0, 2.5

Fluoroscopy time, number of spot films, and exposure expressed as ranges, with mean exposure time and median exposure shown in brackets. SBFT = Small bowel follow-through.

image intensifier from the exit surface of the patient, number of spot films taken and spot film technique factors. It should be noted, however, that in ten cases when ECF was computed for spot films and fluoroscopy independently, spot filming was responsible for only about 10% of the ECF from the complete examination. The presence of contrast agents in the fiuoroscopic field, as expected, seemed greatly to increase the exposure from the examination. ECF and fiuoroscopic time were greater in patients over ten years of age in upper gastro-intestinal studies with small bowel examination than in those patients who only had the upper gastro-intestinal study. We could not independently assess the influence of barium in the small bowel on exposure. However, a greater average exposure rate was measured in patients who had a conventional barium enema with a solid column of barium (0.041 mC kg" 1 s" 1 (0.16 R s"1) than in patients with a double contrast enema (0.021 mC kg" 1 s" 1 (0.083 R s"1)). Patients having an air contrast enema were younger, but age differences alone could not account for the large difference in average exposure rates. To investigate the exposure differences associated with the introduction of contrast agents, we compared spot films of the pelvis with and without contrast material in the bladder. The presence of contrast medium increased exposure by up to sixteen times. The magnitude of the difference depended on the area of the field covered by the contrast material in the bladder. Male gonadal doses during barium swallow examinations ranged from undetectable (less than 0.02 mGy (2 mrad)) to 0.12 mGy (12 mrad). For upper gastrointestinal examinations, gonadal dose ranged from 0.02

to 0.12 mGy (2 to 12 mrad), but when small bowel follow-through was included, the male gonadal dose was 0.05 to 0.71 mGy (5 to 71 mrad). Enema patients received from 0.34 to 0.48 mGy (34 to 48 mrad) [using 2.25 mGy (mC kg" 1 ), or 0.88 rad R" 1 in soft tissue for X rays of effective energy 35 keV]. Gonadal dose was monitored only prior to equipment modification. Table II shows median exposures and exposure ranges by age, after equipment modifications. In every examination monitored, and in every age group, patient exposure was significantly less after the modifications. These figures cannot be compared on a case-by-case basis, due to uncontrolled variables in the study. However, they do show an approximately 1.5 to 3-fold reduction in exposure. We cannot independently assess the contribution to the reduction in exposure from the individual modifications made, as use of the variable iris diaphragm was left to thefluoroscopist,the number of patients monitored was small, and there were variations in patient age, size, number of spotfilms,and in the duration of fluoroscopy.
DISCUSSION

The present study has demonstrated (a) the efficacy of using the ECF method as an index of integral dose during fluoroscopy, and (b) the application of this method for the assessment of the effect on exposure of changes to fluoroscopy equipment and operator technique. It must be stressed that the exposures measured by this method cannot be extrapolated to give patient dose, or dose to a particular region or organ because of the moving field during fluoroscopy. However, apart from scattered radiation, most of the exposure is absorbed by the patient, as the transmitted

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56, No. 670 Stephen J. Leibovic and William J. H. Caldicott

TABLE II
E C F S FROM GASTROINTESTINAL EXAMINATIONS AFTER EQUIPMENT MODIFICATIONS

Type of examination and age range Ba swallow <15mo 16mo-10y ll-20y Upper GI <2y

n 1 3 1 2 1 5 1 1 2

Time (seconds) 119 133-193 (163) 137 189, 214 136 202-321 (239) 165 189 108,413

Number of spot films

ECF (mCkg"1) 0.4 0.4-1.1 (0.8) 1.7 0.4, 0.7 1.1 1.2-3.9 (2.4) 0.75 3.5 2.2, 3.8 (R) 1.6 1.7-4.2 (3.2) 6.4 1.7, 2.7 4.2 4.7-15 (9.3) 2.9 13.6 8.5, 14.6

9 10 4 4-7 9 10 6, 11

4iy
10-21y Upper GI and SBFT <5y 9y 10-20y

Values expressed as ranges with mean exposure times and median exposures (in brackets).

radiation is only that small fraction of the total which is required to produce an image with modern imaging systems. Therefore, the integral exposure is presumably a factor in determining the overall risk to the patient, but not the sole factor because dose distribution is nonuniform, organ sensitivities to the effects of radiation differ, and risk is probably not a linear function of dose. Male gonadal doses in our patients were in the normal range for gastro-intestinal fluoroscopic procedures suggesting that the exposures were not excessive by usual standards. Several lines of evidence show that patient exposure is increased by the presence of contrast material in the fluoroscopicfield.(1) Exposure of a single 100 mm spot film of the pelvis was increased by up to 16 times when contrast medium was introduced into the bladder. (2) The use of automatic exposure controls for overhead films of the abdomen and fluoroscopic spot films when there is a large quantity of barium in the bowel frequently results in overexposed films. (3) Exposure factors during fluoroscopy increase markedly when contrast material in the abdomen occupies a large part of the fluoroscopic field, as during fluoroscopy of the terminal ileum when the small bowel is filled with barium. (4) The exposure rate during barium enema examinations was markedly less in the patients who had an air contrast study than in the patients who had an enema with a solid column of barium. The increase in exposure caused by the contrast medium is attributable to both the design and operation of equipment with automatic brightness and exposure control devices. The sensing device for automatic exposure control for 100 mm spot filming on our equipment occupies a very small discrete area in the centre of the field. If this area is covered by contrast medium, a marked increase in exposure occurs. The small size of the sensor makes this device extremely sensitive. The device for exposure

control for large format cassette spot filming has a larger, three-part, ionisation chamber: a weighted average of exposure to each part of the chamber is used to determine film exposure. Because of its larger size, this device is less sensitive than the one for 100 mm filming, but overexposure may still occur, especially when many loops of barium-filled small bowel occupy much of the field. Automatic brightness control for the television system integrates brightness over a predetermined area of the field (60% in our case), and exposure increases with increase in the fraction of the field covered by high density material such as contrast medium. The TV chain controls the output of the X-ray generator through a negative feedback loopif the camera sees less light, it increases generator output and vice versa. Generator output and patient exposure increase when dense contrast material is in the field. The camera also receives less light if the size of the aperture on the camera is reduced. Smaller apertures result in increased exposure and better quality television images, whereas larger apertures decrease exposure and image quality, which becomes progressively more "grainy" with increasing aperture size. Radiation exposure from gastro-intestinal fluoroscopy cannot be considered inconsequential, and modifications in both operator technique and equipment design are warranted. We propose the following: (1) As well as following the time-honoured principles of limitation of both fluoroscopy time and the distance from the patient to the image intensifier, all fluoroscopists must be aware of the influence of contrast medium on automatic brightness and exposure controls. When examining a discrete section of the contrast agent-filled organ, an efficient diagnosis can usually be made with only a small fraction of the fluoroscopic field occupied by

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Gastrointestinal fluoroscopy: patient dose and methods for its reduction

an opacified organ. Spot films should not be made fitting of a variable aperture iris diaphragm on the TV with exposure sensors covered with contrast camera on the fluoroscopic equipment used for this medium. The considerable increase in exposure study has shown that even these simple steps can required to penetrate contrast material rarely significantly reduce entrance exposures at the centre of provides additional information, and in view of the the field. present data cannot be justified. (2) To make the operator aware of the position and size ACKNOWLEDGMENTS We wish to thank Ms. Joan McDonagh, R.T. for her of automatic exposure control sensors, their size and location should be visible on the television assistance in the preparation of the manuscript, and Mr. V. monitor. This could be achieved with backlighting Eloranta, Polaroid Corporation, Cambridge, Massachusetts, on the TV screen which changed with the selection for assistance in obtaining the iris diaphragm. of the filming format. (3) The setting of maximum exposure rate during REFERENCES fluoroscopy should be reduced. The object of this HERTZ, M. & WERNER, A., 1973. Radiation dose to the gonads control is to put an upper limit on the exposure rate during cystourethrography in children. Israel Journal of which can occur during fluoroscopy, especially Medical Sciences, 13, 614-616. when there is contrast medium in the field. On our KAUDE, J. V., LORENZ, E. & REID, J. M., 1969. Gonad dose to children in voiding urethrocystography performed with equipment, the maximum table top exposures 70 mm image intensifier fluorography. Radiology, 92, allowed were 1.3 mC kg" 1 , and 2.6 mC kg" 1 (5 R 111-114. and 10 R) per minute in the low and high dose SOURKES, A. & REED, positions, respectively. Our experience with the low LEE, D., Performance M., HOLLOWAY, A. F. intensifier M. H., 1981. evaluation of image tubes. exposure setting showed that it was always Radiology, 138, 455^59. sufficient. Consequently, it was readjusted so that LEIBOVIC, S. J. & FELLOWS, K. E., 1983. Patient dose during the low exposure setting is 0.65 mC kg" 1 min" 1 cardiac catheterization procedures, with some suggestions (2.5 R min"1) and the high setting is 1.3 mC kg" 1 for its reduction. Cardiovascular and Interventional Radiology, (in press). min~l (5 R min"1). The low setting is adequate for LEIBOVIC, S. J. & LEBOWITZ, R. L., 1980. Reducing patient most patients. dose in voiding cystourethrography. Urological Radiology, 2, (4) The fixed aperture iris of the television camera 103-107. should be replaced with a variable aperture iris L. & Energy diaphragm. Using this extra level of control, the MORGAN, T. J., BRAITEMAN,factors DIRKSE, J., 1978. Keithley dependence of correction for 2 models of radiologist is able to decrease the exposure to the diagnostic ion chambers. Medical Physics, 5, 162-163. patient by up to a factor of 3 by opening the PRATT, A. D., GALBRAITH, R. H. & KEREIAKES, J. G., 1973. aperture. This produces a more "grainy" image Evaluation of 16 mm cine cystourethrography in children: which is adequate much of the time. The aperture Method and dosimetry. Radiology, 106, 183-185. can be reduced in size when a more detailed image Rossi, R. P., WESENBERG, R. L. & HENDEE, W. R., 1978. A variable aperture fluoroscopic unit for reduced patient is required. On our camera, aperture diameters exposure. Radiology, 129, 799-802. range from a minimum of 21 mm to a maximum of 70 mm. If the light intensity was uniform across the SAENGER, E. L., KEREIAKES, J. G., CAVANAUGH, D. J., HALL, J. L. & EISEMAN, W., 1976. Cystourethrography procedures in opening of the diaphragm, the larger opening should reduce exposure by a factor of 11. In children, evaluation of benefits vs. dose. Radiology, 118, 123-128. practice only a three-fold reduction occurs, SEPPANEN, U., TORNIAINEN, P. & KIVINIITTY, K., 1979. probably due to inhomogeneity in the light beam Radiation gonad doses received by children in intravenous profile across the aperture. urography and micturition cystourethrography. Pediatric Radiology, 8, 169-172. (5) Image intensifier efficiency should be monitored routinely to prevent increased patient exposure VOGEL, H., LOHR, H. & WALLBAUM, F., 1978. Strahlenexposition und Risiko bei der Rontgendiagnostik des from an inefficient image intensifier. Film exposure kindlichen Verdauungstraktes. Klinische Pddiatrie, 190, and brightness control remain adequate when 560-565. automatically controlled and thus give no indica- WEBSTER, E. W., ALPERT, N. M. & BROWNELL, G. L., 1974. tion that exposure rates are increasing. Lee et al Radiation doses in pediatric nuclear medicine and diagnostic (1981) documented a 15% drop in efficiency in an x-ray procedures. In Pediatric Nuclear Medicine. Ed. by A. E. image intensifier over a two-year period. James, H. N. Wagner & R. L. Cooke (WB Saunders, Limitation of the maximum exposure rate and the Philadelphia).

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