Radiographic Contrast Procedures

and Radiation Safety

D.A. Feeney, DVM, MS, Diplomate, ACVR
Professor of Radiology, College of Veterinary Medicine
University Of Minnesota, St. Paul, MN 55108

INTRODUCTION:

This discussion is a guide to special, but relevant radiographic procedures that can be used in almost any
private practice situation. No specialized equipment is required, except the option to direct the x-ray beam
away from the floor [but don’t aim it at any occupied area when using the proposed horizontal-beam
techniques]. Properly performed imaging procedures minimize surprises at laparotomy or necropsy and
foster accurate diagnosis and prognosis with minimal patient discomfort and client expense.

A. HORIZONTAL-BEAM RADIOGRAPHY

The object of horizontal-beam radiography [ x-ray beam directed parallel to the floor] is to use the
influence of gravity on fluid [or the lack of gravitational influence on air] to clarify findings suspected on
routine [recumbent lateral or VD/DV views made with the x-ray beam directed toward the floor] without
the use of contrast media. The most common uses of horizontal-beam radiography are:
a) to position the patient so this fluid, if it is
"free"[movable] in a cavity [i.e. pleural space], may be moved away from the area of
interest so regional pathology can be visualized
b) to position the patient so "free" fluid may be serially
quantitated to determine if it is increasing of decreasing with less confusion than routine
views.
NOTE: if you see a "flat" [parallel to ground] fluid line, there must be free air as well as
free!!!
c) to position the patient to permit differentiation of "free"
fluid from "trapped" fluid [which is usually associated with inflammatory or possibly
neoplastic processes] or a mass.
d) to position the patient to determine if air seen in a cavity
is "free" or within normal viscera.

B. CARDIOVASCULAR RADIOGRAPHY
1. Non-selective Angiogram/Venogram
A. Contraindications:dehydrated patient, oliguric patient,
patient with history of contrast media reactions
Considerations: ? worthwhile considering use of meglumine rather than sodium cation,
if restricted sodium intake.
? worthwhile using nonionic contrast media, if high risk patient (e.g.
old cat, critically ill patient of any species)

B. Patient Preparation: SURVEY RADIOGRAPHS!!!

No special preparation, but the less stool and ingesta present, the better. Use sedation
as necessary for adequate patient restraint within risk-benefit judgment of patient's
presenting problem.

C. Contrast Media Dose/Route of Administration:

 Give 200 up to 400 mg of Iodine [as sterile sodium diatrizoate or sterile
sodium iothalamate(CONRAY 400®)] per lb of body weight as a rapid intravenous
[bolus] injection through a preplaced catheter in the cephalic vein (for cranial vena cava)
or lateral saphenous vein (for caudal vena cava). Catheter should remain usable for at
least 15 minutes in case of reaction to contrast media requiring venous access for
fluid/drug administration. If you use the nonionic contrast media [iohexol or iopamidol],
use the same mg of Iodine/lb as for ionic agents. Watch for thrombus formation
with nonionics!!

D. Radiographic Views & Filming Sequence:

AFTER SURVEY RADIOGRAPHS!!! Expose radiograph (usually lateral view) 2-4
seconds after injection for best vena caval opacification from the respective catheter
placement sites. Expose radiograph 3-5 seconds after cephalic vein injection for best right
heart or pulmonary artery opacification. Expose radiograph 4-8 seconds after cephalic
vein injection for best left heart or intrathoracic aorta opacification. Wait 8+ seconds for
abdominal aortic studies.

C. URINARY TRACT RADIOGRAPHY

1. Excretory Urography
A. Contraindications: dehydrated patient, oliguric patient,
patient with history of contrast media reactions
Considerations: ? worthwhile considering use of meglumine
rather than sodium cation, if sodium intake. ? worthwhile using
nonionic contrast media, if high risk patient e.g. old cat, critically ill
patient of any species)

B. Patient Preparation: SURVEY RADIOGRAPHS!!

-withhold food NOT water for 24 hours unless emergency
-cleansing enema at least 2 hours before radiography unless emergency
-don't sedate unless necessary-may delay excretion phases 2° to hypotension
C. Contrast Media Dose/Route of Administration:
Give 400 mg of Iodine [as sterile sodium diatrizoate or
sterile sodium iothalamate] per lb body weight as a rapid intravenous [bolus] injection
through a preplaced cephalic vein catheter. Can use meglumine or eglumine + sodium
cation mixtures, but pyelographic won't be as good. Catheter should remain usable for at
least 15 minutes in case of reaction to contrast for fluid/drug administration. If you use
the nonionic contrast media [iohexol or iopamidol], use the same mg of Iodine/lb as for
ionic agents.

D. Radiographic Views & Filming Sequence:

AFTER SURVEY RADIOGRAPHS!! Expose a VD view @ 15-20
seconds after bolus injection, expose a Lateral and VD view @ 5 minutes after injection,
expose VD oblique views also @ 5 minutes [ectopic ureter suspects only], expose a VD
[lateral optional] @ 20 minutes after injection, and expose a VD [lateral optional] @ 40
minutes after injection.

2. Cystography [positive / negative / double contrast]

A. Contraindications: Don’t use room air in the presence of gross hematuria carbon dioxide
or nitrous oxide instead.

B. Patient Preparation: SURVEY RADIOGRAPHS!!

-withhold food NOT water for 24 hours unless emergency
 -cleansing enema at least 2 hours before radiography unless emergency
-sedate as necessary

C. Contrast Media Dose/Route of Administration:

After emptying the bladder, distend urinary bladder [via
aseptic retrograde catheterization of the urethra-bladder] until "palpably turgid" [usually
3-5 ml/lb-body wt.]. This applies to either positive [use solution
containing approximately 100 mg/ml of Iodine (as sterile diatrizoate or iothalamate)] or
negative [usually use room air-see contraindications] contrast studies. For double
contrast "puddleogram" studies, perform negative contrast study as above, but follow air,
etc with 1-3 ml of positive contrast media [use solution containing approximately 100-
150 mg/ml of Iodine (as sterile diatrizoate or iothalamate)].

D. Radiographic Views & Filming Sequence:

AFTER SURVEY RADIOGRAPHS!! Expose a lateral & VD view immediately after
administration, expose oblique or DV/opposite lateral views to clarify "attached" filling
defects.

3. Retrograde Urethrography & Distension Retrograde Urethrocystography

A. Contraindications: Don’t use room air in the presence of gross hematuria because it can
cause fatal air embolism! Use either carbon dioxide or nitrous
oxide instead. Don’t use distension technique if recent bladder
wall/urethral injury or surgery.

B. Patient Preparation: SURVEY RADIOGRAPHS!!

-withhold food NOT water for 24 hours unless emergency
-cleansing enema at least 2 hours before radiography unless emergency
-sedate as necessary

C. Contrast Media Dose/Route of Administration:

Routine Retrograde Urethrogram:
After emptying the bladder via aseptic retrograde
catheterization, place tip of catheter in the distal urethra [often much easier with
a 4-7 French balloon (SWAN-GANZ) catheter]. Administer 5-20 ml
[depending on size of patient] of a solution containing approximately 150-
200mg/ml of Iodine (as sterile diatrizoate or iothalamate)].

Distension retrograde urethrocystography:

After emptying the bladder via aseptic retrograde catheterization, distend
urinary bladder [via aseptic retrograde catheterization of the urethra Æ bladder]
until "palpably turgid" [usually 3-5 ml/lb-body wt.] of a solution containing
approximately 150-200mg/ml of Iodine (as sterile diatrizoate or iothalamate)].
Then, catheterize the distal urethra with a 4-7 French balloon (SWAN-GANZ)
catheter and administer 5-20 ml [depending on size of patient] of a solution
containing approximately 150-200mg/ml of Iodine (as sterile diatrizoate or
iothalamate)].
Note: bladder can be filled via the balloon catheter, but the infusion is more rapid
using more standard types of urethral catheters.

*Beware of overdistending balloon which can cause urethral pressure necrosis!!

*Beware of overdistending bladder with balloon catheter in place because you can rupture
the bladder easier than with simple(nonballoon) catheter because there is no exit
for the pressure!!
 D. Radiographic Views & Filming Sequence:
AFTER SURVEY RADIOGRAPHS!! Expose a lateral view during administration of
last 2-3 ml of contrast media. Expose VD [VD oblique in males] view during
administration of last 2-3 ml of subsequent injection of similar volume of contrast media.

4. Voiding Urethrography
A. Contraindications Don’t perform if bladder wall/urethral injuries including recent
previous surgery

B. Patient Preparation: SURVEY RADIOGRAPHS!!

-withhold food NOT water for 24 hours unless emergency
-cleansing enema at least 2 hours before radiography
-usually requires sedation unless patient extremely
depressed

C. Contrast Media Dose/Route of Administration:

After emptying the bladder via aseptic retrograde catheterization, distend urinary bladder
[via aseptic retrograde catheterization of the urethra-->bladder] until "palpably turgid"
[usually 3-5 ml/lb-body wt.] of a solution containing approximately 150-200mg/ml of
Iodine (as sterile diatrizoate or iothalamate)].

D. Radiographic Views & Filming Sequence:

AFTER SURVEY RADIOGRAPHS!! Apply pressure to bladder via wooden/plastic
spoon or equivalent until voiding is observed. Expose during active voiding. Keep hands
out of primary x-ray beam!!! EASIER SAID THAN DONE!!!

D. ALIMENTARY TRACT RADIOGRAPHY

1. Esophogram
A. Contraindications:
BEWARE of dyspneic animals-they may aspirate contrast
media during administration!!
B. Patient Preparation: SURVEY RADIOGRAPHS!!
No special patient prep necessary. Don’t use sedation,
anesthesia or parasympatholytic (i.e. atropine) drugs. If patient impossible to
handle, use very light dose of acepromazine maleate with no other drugs!!
C. Contrast Media Dose/Route of Administration:
Determine the Intent of the Study and proceed:

1. Look for leaks: If suspected leak potentially communicates with the lung or airways [i.e.
bronchoesophageal or esophagopulmonary fistula], use liquid barium or optimally a
nonionic iodinated contrast agent [iohexol or iopamidol]. Otherwise, use 1/2 strength
water, ionic iodinated contrast media[e.g. Oral Hypaque®, or any angiographic or
urographic iodinated contrast agent]. If iodinated study is negative, follow with liquid
barium since some leaks cannot be found with iodinated preparations. Give either type of
contrast media via buccal pouch infusion of 5-15 ml.

2. Observe esophageal mucosa:

Use either barium paste (expensive and not useful for anything else) or liquid barium [>
30% w/v (or > 25% w/w) suspension]. Administer via "pasting" the roof of the mouth or
via buccal pouch infusion (liquid).

3. Assess efficacy of esophageal peristalsis:

Mix any kind of barium with food [best if use both canned or semi-moist and dry chow
 in sequence] & allow o eat or force feed, if necessary this is not necessary if you
can unequivocally see a dilated esophagus on the survey radiographs. In that case, pass
a stomach tube to rule out the unlikely presence of obstruction at the
gastroesophageal junction.

D. Radiographic Views & Filming Sequence:

AFTER SURVEY RADIOGRAPHS!! Give the contrast media with the patient in the
position [usually lateral recumbency] you wish to view the patient on the radiograph.
Expose the view within 10-15 seconds of administration. BEST if expose within 5-10
seconds of observing the act (? attempt) of swallowing if looking for leaks or coating the
mucosa (barium only). It trying to assess esophageal function, position & expose the
views you need within 15-30 seconds of observed act of swallowing. Solid food will
normally be evacuated from the cervical & intrathoracic esophagus in less than one
minute by effective peristalsis [> 2 minutes grossly abnormal]. Repeat radiographs as
needed to determine how effective emptying actually is or if it occurs at all.

2. Upper Gastrointestinal Study

A. Contraindications: None specifically, but you don't need a G.I. series to make the
diagnosis of complete obstruction. This should be obvious on the
survey radiographs.
NOTE: -if it is obvious that there is a leak, don't use barium!!!
-beware of ionic (hypertonic) iodinated compounds in dehydrated and
pediatric patients!!!

B. Patient Preparation: SURVEY RADIOGRAPHS!!

Withhold food for 24 hours, give cleansing enema at least 1 hour before beginning study
[including the survey films]. Remember, a colon full of stool will impede gastric
emptying and may lead to false positive dx. Use NO sedation, anesthesia or
parasympatholytic (i.e. atropine) drugs. If patient impossible to handle, use very light
dose of acepromazine maleate with no other drugs!!

C. Contrast Media Dose/Route of Administration:

Administer via stomach tube approximately 1 oz. (30 ml)/5lbs of body wt. of a 30-60%
w/v [approximately 25-40% w/w]preparation of a micropulverized barium sulfate
suspension packaged as a liquid-not a powder. However, you can readily adjust the
concentration of the packaged liquids by adding tap water so don't hesitate to buy liquid
barium preparations labeled "HIGH-DENSITY". Powdered barium preparations which
require reconstitution commonly "flocculate or agglomerate" in animals limiting their
specificity in the assessment of hemorrhagic or inflammatory disorders. The only
indication for ionic, iodinated compounds is if you suspect a leak. In those cases,
substitute 1/2 strength dilution of an iodinated compound in equal volume to the dose of
barium suggested above. Nonionic agents are better, but expensive for large volumes!

D. Radiographic Views & Filming Sequence:

AFTER SURVEY RADIOGRAPHS!! If stomach is likely the site of abnormality,
film immediately after administration of contrast media but use Right and Left lateral as
well as VD and DV views. If small bowel is the likely site of abnormality, use Right
lateral and either a DV or a VD immediately after contrast administration. There after for
either stomach or small intestinal lesions film at least every 30 minutes until the
contrast media is in the colon and the stomach is empty. NOTE: in patients with apparent
rapid onset of gastric emptying [as indicated by duodenal opacification] film every 15
minutes during the small intestinal transit to the colon so you don't miss something!
3. Barium Enema

A. Contraindications:
If it is obvious that there is a leak, don't use barium!!!
If it is likely the intestinal wall may be friable, don't be over zealous with
distension!!!

B. Patient Preparation: SURVEY RADIOGRAPHS!!

See "Upper Gastrointestinal Study".
Use deep narcotic sedation or light general anesthesia.
Use moderate temperature [i.e. not cold or hot] water for cleansing enema preceding this
study to prevent artifactual "spasms" of the colon which may persist for several
hours after a cold water enema!

C. Contrast Media Dose/Route of Administration:

Administer via gravity approximately 10 ml/lb of body wt.of a 30% w/v [approximately
25% w/w] preparation of a micropulverized barium sulfate suspension. Use IV stand and
hanging bucket with delivery tube (or commercially available "barium enema kits"
designed for use with IV stand)] connected to a Foley catheter (use a big balloon since
even sedated dogs push the catheters out-obviously messy) placed just inside the anal
sphincter.
NOTE: -this a strictly a "ball park" dose and range is from as little as 5 ml/lb to as much
as 20(or more)ml/lb]
- the barium product used may be packaged either as a liquid or a powder since
flocculation in the colon is nonspecific.

D. Radiographic Views & Filming Sequence:

AFTER SURVEY RADIOGRAPHS!! Expose VD and both Left and Right lateral
views immediately after complete filling is achieved. However, it may be necessary to
make an occasional lateral view before "ball park" dose has been given if patient shows
undue discomfort!! In addition, it may be necessary to give more than the "ball park"
dose to achieve complete filling so take 1 lateral view after "ball park" dose has been
given to determine if all parts of the colon and cecum have been distended. Continue
distension until questionable areas are either distended or are no longer questionable as
truly being narrowed or having a filling defect!!

E. RADIATION SAFETY
The following are reminders tainted with my opinion about general radiation safety considerations
for diagnostic X-ray facilities:
-Radiation safety should be a daily occurrence and should include personnel body monitors
(usually film badges) worn in locations (e.g. under the apron at gonad level; outside the
apron at collar level) specified by state/provincial ionizing radiation rules.
-Always wear your personnel (body) monitor when near any potential radiation exposure situation
-However, regardless of whether the radiation rules require personnel monitors to be used, I
recommend them for all individuals (e.g. kennel help, receptionist/technician in adjacent
room [unless the room itself is monitored]) potentially exposed to ionizing radiation
(consult local radiation expert on isotopes).
-Don’t hold the patient unless absolutely necessary (check state or provincial guidelines about
specific regulations and violations because of variations; some states prohibit holding
animals or being in the room)
-Always wear aprons with 0.5 mm lead equivalent shielding if in the X-ray room
-Always wear gloves with at least 0.5 mm lead equivalent shielding if holding the patient
-Never have any part of your body (shielded or otherwise) in the primary X-ray beam
-Consider wearing thyroid shields and shielded glasses (seek advice of local radiation expert and
check your state or provincial rules because these may be required)
-Consider wearing ring monitor if your work, although shielded, involves repeated close proximity
 to the primary X-ray beam

REMEMBER, KEEP POTENTIAL RADIATION EXPOSURE (including scatter as well as primary

beam) AS LOW AS IS REASONABLE ACHIEVABLE!!!!!!

If there are any questions about compliance, contact the state or provincial radiation safety officer.