Radiographic Contrast Examination is the study of specialized radiographic

examinations with application of contrast media to enhance and/or visualize different

organs and body structures of interest.
Contrast Media
 Contrast Media or Contrast agents are substances which help in better
differentiation between adjacent tissues.
 It is a chemical substance of very high or very low atomic number or weight;
therefore, it increases or decreases the density of the organ under examination.
Qualities of Good Contrast Media (Ideas Contrast medium/media)
 Show structures not seen on plain films (proper demo of the organ system)
 Easy to administer
 Produces little toxicity
 Concentrates in the area of interest
 Rapid elimination
 Minimal stress to the patients
2 Types of Contrast Media
1. Negative – Air, oxygen, carbon dioxide
2. Positive – Barium, Iodine
Negative Contrast Media
 Negative Contrast agents reduce the atomic number of the area to be
demonstrated.
 These types of contrast media will have little attenuation of the x-ray beam.
Positive Contrast Media
 The positive contrast agents increase the atomic number of the area to be
demonstrated in relation to the surrounding tissue.
Properties of Contrast Media
 Miscibility – the ability of the medium to mix with other liquid.
 Viscosity – the resistance of fluid to movement.
 Toxicity – the lethality of the compound
 Osmolality – the measure of the number of dissolved particles, whether ions,
molecules, or compound, in a solution.
Note: To reduce the viscosity of the contrast media, the contrast is put in the warmer.
Indications
 Stones (calculi)
 Strictures
 Masses or Tumor
 When plain radiography is inconclusive
Note: Calculus (1 stone), Calculi (plural of calculus; more than 2 stones)
Contraindications
 Pregnancy
 History of contrast media allergies
 Elevated creatinine level
Note: Normal levels of creatinine in the blood are approximately 0.6 to 1.5 mg/100 ml
Question: Why do we check creatinine levels before CT scan?
The focus of this assessment is POC creatinine testing to assess kidney
function before people have intravenous contrast for CT imaging. Intravenous
iodine-based contrast agents used in CT scans can cause acute kidney injury (AKI),
particularly in people who are at high risk and those with known kidney dysfunction.
Question: Why Creatinine Tests Are Done
Doctors use creatinine and creatinine clearance tests to check how well your
kidneys work. This is called renal function. Testing the rate of creatinine clearance
shows the kidneys' ability to filter the blood. As renal function gets worse, creatinine
clearance also goes down.
Mode of Administration
Contrast Administration
1. Through oral – swallowed (taken by mouth or orally)
2. Through rectal – administered by enema (given rectally)
3. Through veins (intravenous) – Injected into a blood vessel (vein or artery; also
called given intravenously or intra-arterially)
4. Through inhalation (also known as Xenon CT) – very rare
Allergic Reactions
1. Mild
2. Moderate
3. Severe
Mild or Minor
 Nausea
 Vomiting
 Flushing
 Metallic taste
 Minor coughing
 Sweating
 Feeling of warmth
Note: Flushing side effects would be skin flushing or blushing describes feelings of
warmth and rapid reddening of your neck, upper chest, or face.
Moderate
 Urticaria/hives
 Asthma attack
 Erythema
 Facial edema
Note: Face swelling is the enlargement or distention of the face due to fluid buildup or
inflammation in the facial tissues.
Severe
 Convulsion
 Cyanosis
 Shock
 Cardiac arrest
 Renal failure
 Pulmonary edema
 Respiratory arrest
Note: The term "seizure" is often used interchangeably with "convulsion." During
convulsions a person has uncontrollable shaking that is rapid and rhythmic, with the
muscles contracting and relaxing repeatedly.
Note: The number of particles of contrast media (solute) per kilogram of water (solvent)
Why do we use contrast media?
 To increase the contrast between the organ of interest and its surroundings
Positive Contrast Media
 Water Insoluble Contrast Media
o Barium sulfate (sulphate)
 Exists in powder or semisolid suspension
 Not soluble in water
 Stay within the body cavity for a long period of time
 Used majority in Gastrointestinal (GIT)
 Barium Swallow – esophagogram, esophagram
 Barium Enema
 Small bowel
 Precaution
o Barium sulfate (sulphate) is not absorbed and excreted, it is not used in
suspected cases of perforation and obstruction
 When barium sulfate is used in suspected cases of perforation, it
could leak through the perforation and once it leaks to the
peritoneal cavity, this would cause irritation. Peritoneal cavity is
known as peritonitis
 In terms of the obstruction, the blockage makes the barium sulfate
unable to leave the body system, it can cause abdominal
distension.
Negative Contrast Media
 It has lower atomic weight than surrounding tissue. For example, air, oxygen,
carbon dioxide
 Water soluble contrast media
o Iodine
 Exist in liquid form
 Soluble in water
 Quickly absorbed and excreted by the body
 Does not stay within the body for long. Speed is important.
 Used in Urinary System, Biliary System, CNS (Central Nervous
System), CVS (Cardiovascular system) and some GIT Exams.
 Types
o High Osmolar Contrast Media (HOCM)
o Low Osmolar Contrast Media (LOCM)
Osmolality
 Concentration of dissolved particles in a solution.
 A solution with high concentration of dissolved particle will induce a greater
osmotic pressure
 When contrast media with an osmolality far greater than that of body fluid is
introduced to the body, the osmotic pressure causes water to move from low
body fluid to high osmolar contrast media
 This leads to dehydration and increases the likelihood of intolerance to the
contrast media – Contrast Media Reactions
o The greater the contrast media used, the greater the chances of contrast
media reaction but if the contrast media that has osmolality so there is low
chance of contrast media reactions.
Types of organic iodine contrast media
 High Osmolar Contrast Media
o Older, less expensive Iodine based contrast media
o Possess high concentration of dissolved particles
o When in solution, it dissociates into iodine and sodium or meglumine.
o More likely to cause contrast media reaction and has been largely
replaced by Low Osmolar Contrast Media (LOCM)
o When high Osmolar Contrast Media is introduced into a solution, it breaks
down into anion (iodine) and cation (sodium or meglumine)
o Example:
 Diatrozoate Sodium or meglumine (Urografin)
 Iothalamate Sodium or meglumine (Conray)
 Low Osmolar Contrast Media
o Advancement over High Osmolar Contrast Media
o More expensive
o Two methods reduce the concentration of dissolved particles.
 Ionic Low Osmolar Contrast Media (LOCM) – Contrast Media
dissociated in solution but into less particles.
 Example - Hexabrix
 Non-Ionic Low Osmolar Contrast Media (LOCM) – Contrast
Media does not dissociate in solution but into less particles; less
likely to cause Contrast Media Reactions (CMRs).
 Example – iopamidol (lopamiron)
Gastrointestinal tract
 The Gastrointestinal tract is the tract from the mouth to the anus which includes all
the organs of the digestive system.
 Accessory glands
o Salivary glands
o Liver
o Gallbladder
o Pancreas

Basic Anatomy
 Functions:
o Intake and/or digestion of food, water, vitamins and minerals
o Absorb digested good particles, along with water, vitamins and essential
elements,
o Eliminate any unused material in the form of semisolid water products.

Indications
 Achalasia
 Barrett’s esophagus
 Dysphagia
 Foreign bodies
 Hiatal Hernia
 Bezoar
 Stenosis
 Fistula
 Intussusception
 Volvulus
 Esophageal Varices
Contraindications
 Bowel Perforation
 Large Bowel Obstruction
 Appendicitis
Patient Preparation
 NPO (nothing by mouth) for 8 to 9 hours. NPO by midnight
 Low residue diet for 2 days
 No smoking and/or chewing gum
 Cathartics may be given
 o Contraindications to Cathartics
 Gross bleeding
 Severe diarrhea
 Obstruction
 Pregnancy
 Note: 2 types of cathartics are irritant cathartics (castor oil)
and saline cathartics (magnesium citrate)
Contrast Media
 Positive
 Negative
Types of Contrast Studies
 Single
 Double
Classification of Contrast Media
 Ionic
 Non ionic
 Oil based
 Water based
Types of Gastrointestinal Tract Examination
 Sialography
 Pharyngography
 Esophagography (Barium Swallow)
 UGIS/ Barium Meal
 Small intestinal series
 Barium Enema
 SIALOGRAPHY
SRE of the Salivary Glands
 Contrast Media – Oil-based, Iodine (denser image)
 Indications
o Calculus
o Strictures
o Stenosis
o Mass Lesion

The Salivary Glands

Parotid Glands
 Largest
 Wedge-like shape
Parotid Duct
 Stensen’s duct
Submandibular Glands
 Large
 Irregular in shape
Submandibular duct
 Wharton’s duct
Sublingual Glands
 Narrow
 Smallest
Sublingual ducts
 Ducts of Rivinus
Main Sublingual Duct
 Bartholin’s Duct
Patient preparations (Sialography)
 Patient to be aware of the discomfort of procedure
 Dentures and opaque items from head and neck are removed
 Consent
 PHARYNGOGRAPHY
SRE of the pharynx
 Anatomy of the Pharynx

Contrast Media for Pharyngography

 Thick, Creamy mixture of H2o and BaSO4
Indications for Pharyngography
 Tumor
 Foreign body
 Abscess
 ESOPHAGOGRAPHY
SRE of the esophagus

 Purpose – to study radiographically the form and function of the swallowing

aspects of the esophagus; aka Barium Swallow
 Anatomy and Physiology for Esophagography
o Pharynx
 Food passes from oropharynx to the laryngopharynx
o Esophagus
 Carries food and saliva to stomach
 10 inches and 0.75 inches in diameter

 Indications for Esophagography

o Achalasia
o Barrett’s Esophagus
o Dysphagia
o Foreign Bodies
o GERD (gastroesophageal reflux disease, or chronic acid reflux)
o Esophageal Cancer
o Esophageal varices
o Atresia
o Hiatal hernia
 Contrast for Esophagography
 o Single Contrast Study
 Full column
o Double Contrast Study
 Patient Preparation for Esophagography
o Patients need no preparation for an esophagram
o Unless an Upper GI Series is to follow
o All clothing and metallic B/N, the mouth and the waist should be removed.
 Structures shown (AP Projection)
o Esophagus superimposed by the thoracic vertebrae

 Structures shown (RAO or LPO Projection Projection)

o Esophagus between the vertebrae and the heart

 Structures shown (Lateral Projection)

o Esophagus free from superimposition of thoracic spine
 UPPER GASTROINTESTINAL SERIES (UGIS)
SRE of the stomach
Body Habitus

Hypersthenic
 Massive Body build
 Large Intestine Extends to periphery
 Stomach high and assumes transverse position
Hyposthenic/Asthenic
 More slender & narrow lung, low diaphragm
 J-Shaped Stomach
 Gallbladder near midline
Sthenic
 Average Body Built
 Somewhat J-shaped
 Gallbladder less transverse
 Left colic flexure of large intestine is quite high
Movement of BaSO4 according to Patient Position
 Prone fills the body and pylorus of stomach
 Supine fills the fundus
 RAO fills the pyloric and antrum
 LAO fills fundic area and body
Indications for Upper Gastrointestinal Series (UGIS)
 Gastric Ulcer
 Pyloric Stenosis
 Hiatal Hernia
 Diverticulum
 Gastritis
 Bezoar
Patients preparators for Upper Gastrointestinal Series (UGIS)
 Stomach and small intestines must be empty
 Colon should be free of gas and fecal material
 Low-residue diet for 2 days
 Cleansing enemas may be given
 NPO for 8 to 9 hours. NPO by midnight
 No smoking and/or chewing gum
 SMALL INTESTINAL SERIES
SRE of small intestine
 Contrast media for Small Intestinal Series
o BaSO4 or Iodinated
 Anatomy and Physiology for Small Intestinal Series
o Small Intestines
 Digestion and absorption occur in this portion
o 3 portions of the Small Intestine
 Duodenum – Widest portion of small intestine
 Jejunum
 Ileum
 Purpose for Small Intestinal Series
o Studies the form and function of the 3 components of the small bowel
 Indication for Small Intestinal Series
o Enteritis
o Neoplasm
o Fistula
 Contraindication for Small Intestinal Series
o Perforation
o Large bowel obstruction
 Patient Preparation for Small Intestinal Series
o Low residue diet for 2 days
o Cleansing enemas may be given but is not recommended
o NPO after evening meal and the morning after
o Patient’s bladder should be empty before and during the procedure
 Projections for Small Intestinal Series
o AP Projection – Prevents compression of overlapping loops of intestine
o AP Projection (Trendelenburg) – For Asthenic Patients
o Oblique Projections – To unfold or uncoil low lying superimposed loops of
ileum
o Lateral Projection – For tumors and masses
 LARGE BOWEL SERIES (BARIUM ENEMA)
SRE of large intestine
 Contrast media for large bowel series (barium enema)
o BaSO4 or water-soluble Contrast Media and Air
 Anatomy and Physiology for large bowel series (barium enema)
o Reabsorption of fluids and elimination of waste products
o 5 feet long
 Anatomy for large bowel series (barium enema); 4 main parts
o Cecum
o Colon
o Rectum
o Anal Canal
 Indications for large bowel series (barium enema)
o Colitis
o Diverticulum
o Intussusception
o Volvulus
o Polyps
 Contraindications large bowel series (barium enema)
o Perforation
o Large bowel obstruction
o Appendicitis
 2 types of Barium Enema
o Single Contrast Study
 Colon is filled with barium, which outlines the intestines and reveals
large abnormalities.
o Double Contrast Study
 Colon is first filled with barium
 Barium is drained out, leaving only a thin layer of barium on the wall
of colon
 Colon then filled with air. Provides detailed view of inner surface of
colon
 Biliary System
Liver
 Largest solid organ in the body
 3 to 4 lbs
 Manufactures bile
 Right upper quadrant
 Functions of the liver
o Produces large amounts of Bile
o Aid in the digestion of fats by emulsifying fat globules
o 800 to 1000 mL of Bile per day

Gallbladder
 Store Bile – If bile is not needed for digestive purposes, it is stored for future use
in the gallbladder.
 Concentrate bile – Bile is concentrated within the gallbladder as a result of
hydrolysis (removal of water)
 Contract when stimulated – Gallbladder contracts when food such as fats or fatty
acids are in duodenum.
 Clinical Indications
o Choledocholithiasis – Presence of stones in biliary ducts
 Symptoms
 Pain
 Tenderness in Right Upper Quadrant (RUQ)
 Jaundice
 Sometimes pancreatitis
o Cholelithiasis
 Condition of having abnormal calcifications or stones in Gallbladder
 Increased levels of bilirubin, calcium or cholesterol
 60% of gallstones are primarily composed of cholesterol
 25 to 30% are primarily cholesterol and crystalline salts
 10 to 15% crystalline calcium salts
 Symptoms
o Jaundice

Milk calcium Bile

 Emulsion of biliary stones in Gallbladder
 Seen as diffuse collection of sand-like calcifications
or sediment
 Cholecystectomy
Cholecystitis
 Inflammation of the gallbladder
 Acute and Chronic
o Acute Cholecystitis – develop over hours and usually because of
gallstone obstructs the cystic duct
 Signs and symptoms of Acute Cholecystitis
 Sudden sharp pain in Right Upper Quadrant (RUQ)
 Fever
 Nausea and Vomiting
o Chronic Cholecystitis – Caused by repeated attacks of acute (sudden)
cholecystitis
 Signs and symptoms of Chronic Cholecystitis
 Severe abdominal pains
 Pain that spreads to your back
 Nausea and Vomiting
Biliary Stenosis
 Narrowing of one of the Biliary ducts
 Filling defect with a small chance of Contrast Media passing
Cholegraphy
 It is the general term for radiographic study of the biliary system.
 Ultrasonography is now the primary imaging technique for the assessment of the
gallbladder and bile ducts and oral cholecystography is obsolete
 Check function of liver
 Check concentrating and emptying power of the Gallbladder
 Presence of Calculi
 Methods are named according to
o route of Contrast Media
o portion of Gallbladder and Biliary Tract to be examined.
 Method of Cholegraphy
o Methods are named according to the route of contrast media
 By mouth – Oral Cholecystography
 Venous – Intravenous Cholangiography
 Direct Injection to the ducts
 Percutaneous Transhepatic Cholangiography
 Operative or Immediate Cholangiography
 Post-Operative, Delayed, or T-Tube Cholangiography
Cholecystography – Examination of Gallbladder
Cholangiography – Examination of Biliary ducts
Cholecystoangiography/Cholecystocholoangiography – Examination of both the
Gallbladder and Biliary Ducts
Take note:
 Full Expiration – Gallbladder moves laterally and superiorly 1-3 inches
 Full inspiration – Gallbladder moves medially and inferiorly 1-3 inches
 Indications
o Biliary Calculi
o Cholecystitis
o Biliary Stenosis

Oral Cholecystography
 Examination of Gallbladder by administering contrast media by mouth
 Before Oral cholecystogram is performed, the patient’s allergic response to
iodine compound is determined
 Contraindications
o Vomiting
o Diarrhea
o Severe Jaundice
o Liver Dysfunction
o Pyloric Obstruction
o Malabsorption Syndrome
o Hypersensitivity to iodinated Contrast Media
o Cholecystectomized patient
 Instruction to patient for Oral Cholecystography
 o Explain the purpose of preliminary preparation and procedure.
o Tell patient the approximate time required for the examination.
o Avoid laxatives for 24 hours after the ingestion of Contrast Media.
o For oral technique, ask patient whether any reaction such as vomiting or
diarrhea occurred.
o Determine whether patient has remained NPO.
o Once the patient understands the procedure, have patient change into an
examination gown.
 Intestinal Tract Preparation
o Scout radiographs on the day before the examination
o Laxatives administered 24 hours before ingestion of the contrast media
 Preliminary Diet
o Fatty food is given a day before the procedure
o Fat-free evening meal
 Contrast media used for Oral Cholecystography
o Iodinated Contrast Medium
 Telepaque
 Urografin
 Capsules or Granules
 Contrast Media Administration for Oral Cholecystography
o Single dose (3 grams – 4-6 tablets) approximately 2 to 3 hours after
evening meal
o Absorption time – 10 to 12 hours for most present-day oral agents

Intravenous Cholangiography
 Seldom performed, because of higher reactions to contrast media.
 Investigate the biliary ducts of cholecystectomized patients.
 Also investigate biliary ducts and Gallbladder of noncholecystectomized patients.
 Contraindications of Intravenous Cholangiography
o Liver disease
o Biliary ducts not intact
o Bilirubin is increasing or exceeds 2mg/dl

Percutaneous Transhepatic Cholangiography

 Used for patients with Jaundice
 Performance of this examination has greatly increase because of availability of
Chiba (skinny) needle
 Contrast media used for Percutaneous Transhepatic Cholangiography
o Telebrix
o Conray
o Hypaque
  Indications for Percutaneous Transhepatic Cholangiography
o Obstructive Jaundice
o Stone extraction and Biliary Drainage

 Possible complications for Percutaneous Transhepatic Cholangiography

o Leakage of Bile into peritoneal cavity
o Hemorrhage
o Pneumothorax
o Sepsis/Infection

Postoperative Cholangiography or T-tube Cholangiography

 Postoperative, Delayed, and T-tube cholangiography - radiologic terms applied to
biliary tract examination
 Occurs 1-3 days after surgery
 Contrast Media used for Postoperative Cholangiography or T-tube
Cholangiography
o Water Soluble organic contrast media
 Purposes of Postoperative Cholangiography or T-tube Cholangiography
o Determine the patency of Bile duct
o Status of Sphincter of Oddi and Ampulla of Vater
o Determine dilation and contraction of Biliary Ducts

Endoscopic Retrograde Cholangiopancreatography (ERCP)

 It is used to diagnose biliary and pancreatic pathologic conditions
 ERCP useful method when the biliary ducts are not dilated
 Performed by passing a fiber optic endoscope through the mouth into the
duodenum under fluoroscopic control.
 Patient’s throat is sprayed with local anesthetic.
 Food and drink usually prohibited for 1 hour after the examination.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
 ERCP is a procedure used to investigate abnormalities of the bile duct,
pancreatic duct and ampulla using an endoscope.
 Endoscope features
 o Camera – allows physician to see inside duodenum, ampulla and ends of
ducts.
o Probe/instruments – perform biopsies, clear stones, dilate a narrowing or
place a stent
 Patients are placed under deep sedation or general anesthesia during the
procedure.

Special Radiographic Exams

Types of Examination
1. Sialography – Imaging of the Salivary Glands
2. Pharyngography – A special radiographic examination of the pharynx after the
ingestion of the contrast media
3. Esophagography – Also known as barium swallow
4. UGIS – Upper Gastrointestinal Series; also known as barium meal
5. Small Intestinal Series - A special radiographic examination of the small intestine
6. Barium Enema – Upper Gastrointestinal series; also known as barium meal
SRE of the Salivary Glands (Sialography)
Contrast Media
 Oil based, Iodinated contrast media (denser image)
 Water soluble iodinated contrast media (normal image)
Indications
 Calculus
 Strictures
 Obstruction
 Epiglottitis
 Foreign body
 Stenosis
 Diverticulum
 Fistula
 Tumors
Patient Preparation
 Patient should be aware of the discomfort of the procedure
 Dentures and opaques items from the head and neck are removed
 Patient consent must be signed.
Procedure
1. Scout film
 Scout or Plain film of the Ductular Parenchyma and System, Check Calculi
2. Secretory Stimuli
  Give patient Lemon Juice 2-3 minutes before Contrast Media is given
3. Introduction of Contrast Media
 Through Cannula to identified orifice
4. Filming
 Start taking radiographs
5. Secretory Stimuli
 Give patient additional Lemon Juice to evacuate Contrast Media
6. Continuation of Exam
 10 minutes after secretory stimuli is given to verify Contrast Media
evacuation
Manner of Introduction
 Injection by Manual pressure
o Rabinov – A special type of catheter specifically used during sialography
 Administration by Hydrostatic Pressure
o Water soluble Contrast Media
o Drip stand would be 28 degrees or 70 cm
o Above patients’ mouth
o Fluoroscopy Guided

Note: Hydrostatic pressure is the pressure exerted by a fluid at rest due to the force of
gravity.
Projection: Parotid Gland

Projection Position Central Ray Reference Point

Tangential Supine/Prone/Seated Perpendicular Lateral surface of

Projection mandibular ramus
(between EAM and
mandibular Ramus)
Note: Projection refers to the way the x-ray beam will pass while Position refers to the
placement or position of the patient's body
 Projection: Parotid and Submandibular

Projection Position Central Ray Reference Point

Lateral projection (R  Semi prone Perpendicular Parotid: 1st superior

and L position) or Seated to mandibular angle
 Parotid: MSP
15 degrees Submandibular: 1st
from True inferior gonion or
Lateral mandibular angle
position.

Projections: Submandibular and Sublingual

 Projection Position Central Ray Reference Point

Axial (Intraoral Recumbent with Perpendicular to Between

method) neck hyperextended plane of film intersection of MSP
and a coronal plane
passing through 2nd
molar

SRE of the Pharynx: Pharyngography

Contrast Media
 Thick, Cream Mixture of H2o and BaSO4 (50% - 50%)
Indication
 Tumor
 Foreign Body
 Abscess
Fluoroguided procedure with spot films
 Synchronized rapid exposure with shortest time possible or videotape

Anatomy of the Pharynx

Procedure
1. Scout films
 AP and Lateral
2. Introduce Contrast Media
 Instruct patient to hold BaSO4 in mouth
3. Exposure during deglutition
 Upward movement of tracheal cartilage
4. If Mucusal Study
 Patient is not allowed to swallow again
5. Take Mucosal Study
 During Modified Valsalva Maneuver

Projections: Pharyngography
 Projection Position Central Ray Reference Point

AP Projection Sitting in front of Perpendicular Laryngeal

VGD prominence (C4)
Lateral Projection Sitting or standing in Perpendicular 1 inch below EAM
front of VGD

SRE of the Digestive System: Esophagus (Esophagography)

Purpose
 Studies the form of function of the swallowing aspect of the area under
investigation
 Also known as Barium Swallow
Indications
 Achalasia
 Anatomic Anomalies
 Barret’s Esophagus
 Esophageal CA
 Dysphagia
 Esophageal Varices
 Foreign bodies
 Gerd
 Zenker’s Diverticulum
 Atresia
Methods of Esophagography
 Full-column, Single Contrast Study
 Double Contrast Study
Full Column, Single Contrast Study
 Contrast Media
o 30-50% weight per volume suspension
 Procedure
1. Spot radiographs in Upright Position
2. Use Horizontal and Trendelenburg as indicated
3. Take the cup of BA in the left hand and drink upon request
Projection

Projection Position Central Ray Reference

point
 AP or PA projection Upright or recumbent Perpendicular T5-T6
 RAO or LPO (35 to (Recumbent is preferred)
40 degrees)
 Lateral Projection
 SRE of the Digestive System – Stomach: UGIS (Upper Gastrointestinal Tract)

Indications
 Gastric Ulcer
 Gastritis
 Pyloric Stenosis
 Bezoar
 Hiatal Hernia
 Hypertrophic Pyloric Stenosis
 Parasites
 Gastric Carcinoma
  Diverticulum
 Emesis
Patient Preparations
 Stomach and Small Intestines must be empty
 Colon should be free of gas and fecal material
 Low-residue diet for 2 days
 Cleansing enemas may be given
 NPO for 8 to 9 hours/ NPO by midnight
 No smoking and/or chewing gum
Methods of UGIS
 Single Contrast Examination
o Contrast Media: 40 to 50% per volume BaSO4: 1 glass
o Esophageal involvement: thick barium
o Demonstrates the following
 Size, shape, position of stomach
 Changing contour of Stomach during peristalsis
 Abnormal alterations (extrinsic pathology)
 Double Contrast Examination
o Contrast Media
 High Density BaSO4 (250% WT/volume)
 Gas-producing substance
o Demonstrate the following
 Small lesions
 Mucosal lining
o 1 Glass given 1 hour prior to exam; 1 glass given during exam
 Biphasic Examination
o Contrast Media: 15% weight per volume BaSO4
o Single and double contrast taken at one time in a day
o If single phase is used with thin BaSO4, double contrast is done first
o Procedure:
 Scout film of upper abdomen – To calibrate factors and locate
magenblasse
 Scout film of lower abdomen (PA) – aka flat plate of the abdomen
(FPA)
 Different phases of the study
 Mucosal phase – Thick BaSO4 to demo mucosal lining. Partial
distention of stomach
 Filling or distention phase - Thin BaSO4 introduced to fully distend
the stomach
  Post filling or distension phase – BaSO4 allow to flow; whole GI
tract is demonstrated. Taken 1 hour after Contrast Media
introduction
o Procedure: Overhead technique
 Mucosal Phase
 PA Projection
 LPO Projection
 AP Projection
 RAO Projection
 Lateral Projection
 Filling or Distention phase
 PA projection
 LPO Projection
 AP Projection
 Post filling or distention phase
 AP projection of the Upper Abdomen
 PA projection of the Abdomen
Projection

Projection Position Central Ray Reference Structures shown

Point

Pa Projection Prone/upright
Perpendicular Between MSP Prone
and Left Lateral  Stomach
border of moves
abdomen at superiorly
level of L1-L2 1.5-4 inches
(Prone) and 6 accordingly.
inches at lower  To body
than L1-L2 habitus,
(upright) stomach
spread
horizontally
Upright
 Size, shape,
position of
stomach
Reference point according to Body Habitus
Reference point according to Body Habitus
Asthenic/Sthenic 2-3 fingerbreaths above LCA
Hyposthenic 4-5 fingerbreaths above LCA
Hypersthenic 5-6 fingerbreaths above LCA
Projections

Projection Position Central Ray Reference Structures shown

Point

LPO Semi prone Perpendicula Between  Duodenal

Projection  40-70 r MSP and loop (c-loop)
degrees Left Lateral inc.
obliquity (45 border of duodenal
degrees for abdomen at bulb and
normal build) level of L1- pyloric canal
RAO position L2  J-shaped
 Peristalsis is stomach
most active
Projection

Projection Position Central Ray Reference Structures shown

Point

RAO Semi supine Perpendicula Between Body and fundus

Projection  30-60 r MSP and filled with BaSO4
degrees Left Lateral and pylorus and
obliquity (45 border of antrum filled with
degrees for abdomen at air
normal build) level
between
xiphoid tip
and lower
rib margin
Projections

Projection Position Central Ray Reference Structures shown

Point

Lateral Upright Perpendicula Upright Upright

Projection  Left side r  L3  Left
dependent Recumbent retrogastric
Recumbent  L1-L2 space
 Right side Between Recumbent
dependent MCP and  Right
anterior retrogastric
surface of space,
the body duodenal
loop and
duodenojeju
nal junction
Anterior and
Posterior surface
Projection

Projection Position Central Ray Reference Structures shown

Point

AP Supine Perpendicula Between Stomach

projection r MCP and  Well-filled
left lateral fundic
border of portion,
abdomen at pyloric
level portion,
between duodenum,
xiphoid tip retrogastric
and lower portion of
rib margin duodenum
and jejunum
Diaphragm
 Hernial
protrusion
through
diaphragm
Projection

Projection Position Central Ray Reference Structures shown

Point

PA Axial Prone Gordon Level of L2 Gordon

projection  45-45 degrees (1-2 inches  Open up the
cephalad above LCA) high
Gugliantini horizontal
 20-25 degrees stomach of a
cephalad hypersthenic
patient
Gugliantini
 Infantile
stomach
 SRE of the Digestive System - Small Intestine (Small Intestinal Series [SIS])
Contrast Media
 BaSO4 or Iodinated
Purpose
 Studies the form and function of the 3 components of the small bowel
 Detect abnormal conditions
 Procedure must be timed to examine function of the small bowel
o Time should be noted when patient finished drinking the last of the
contrast media
Indications
 Enteritis
 Neoplasm
 Malabsorption syndrome
 Fistula
Contraindications
 Perforated, hollow viscus
 Large Bowel Obstruction
Patient Preparations
 Low-residue diet for 2 days
 Cleansing enemas may be given but is not recommended
 NPO after evening meal and the morning after
 Patient’s bladder should be empty before and during the procedure
Methods of Small Intestinal Series (SIS)
 UGI – Small bowel combination or barium follow through
 Oral Method – Small bowel only
UGI – Small bowel combination or barium follow through
1. Routine UGI done first
2. First cup of Contrast Media (8 Oz or ounces)
3. Second cup of Contrast Media
4. PA Projection of Proximal portion (30 minutes after BaSO4 ingestion)
5. Radiographs of 15-30 minutes interval (first 2 hours)
6. Radiographs of one hour interval if needed (after 2 hours)
7. Termination of Ileocecal valve
Oral Method – Small Bowel only
1. Scout film (FPA)
2. 2 cups of BaSO4 ingested
3. PA Projection of Proximal portion (15 minutes to 30 minutes)
4. Radiographs of 30 minutes interval (first 2 hours)
5. Radiographs of 1 hour interval if needed (If more time is needed)
6. Termination of ileocecal valve
Projections
 AP Projection – Prevents compression of overlapping loops of intestine
 AP Projection (Trendelenburg) – For Asthenic patients
 Oblique Projections – To unfold or uncoil low lying superimposed loops of Ileum
 Lateral Projection – For tumors and masses
Note: Upper Abdomen Landmark – L2; Flat plate of the abdomen – between iliac crest
or L4
 SRE of the digestive system – Large Intestine (Barium Enema)
Contrast Media
 BaSO4 or H2O soluble Contrast Media and Air
Anatomy and Physiology
 Large Intestines
o Begins at Right iliac region joining the ileum of Small Intestine
o Forms an arch surrounding the loops of Small Intestine and ends at the
anus
o 5 feet long and greater in diameter than the Small Intestine
o 4 main parts: Cecum, Colon, Rectum and Anal Canal

Indications
 Colitis
 Diverticulum
 Intussusception
 Neoplasm
 Adenocarcinoma
 Polyps
 Volvulus
Contraindications
 Bowel perforation
 Large bowel obstruction
 Appendicitis
Patient Preparations
 Cleansing enema 1 day before the examination
 Light Supper
 Give Laxative to Patient: Castor Oil (60cc – Adult; 30cc – children) or Dulcolax
 NPO at midnight
 Cleansing Enema in the morning
 No breakfast, No smoking
Equipment
 Enema bags (3 quartz or 300 mL)
o Filter may be used to prevent passage of mixed lumps of Barium
o Must be 18-24 inches above the rectum
 Tubing – 6 feet long
 Ky Jelly
 Forceps
Insertion of Enema Tip (Procedure)
1. Turn patient to left in SIMS Position- Lean forward around 35-40 degrees
2. Adjust intravenous pole (IV pole) – Not higher than 24 inches (61 cm) above the
level of the anus
3. Direct the tube anteriorly 1 to 1.5 inches – following the angle of the anus
4. Direct the tube slightly superiorly – following the curve of the rectum
5. Insert the tube for not more than 3.5 – 4 inches
Single Contrast Study (Procedure; Phases of the Study)
1. Filling Phase – Radiographs are taken
2. Evacuation phase – Remove enema tip and allow patient to evacuate contrast
media
3. Post-Evacuation Phase – Radiographs are taken
Single Contrast Study (Procedure; Overhead technique)
1. Filling phase
 PA or AP Projection
 Left Lateral
 RPO or LAO
 LPO or RAO
2. Evacuation phase – No imaging
3. Post-evacuation phase – AP Projection of lower abdomen
Projection

Projection Position Central Ray Reference Structures shown

Point

PA or AP Prone or Perpendicular Level of iliac Entire colon

Projection Supine crest at
MSP
Trendelenbur
g can help
separate
overlapping
loops of the
bowel
Projection: Single Contrast Study

Projection Position Central Ray Reference Structures shown

Point

PA or AP Prone or AP Axial AP Axial Rectosigmoid

Axial Supine  30-40  2 inches area with less
Projection degrees below superimposition
cephalad ASIS
PA Axial
 30-40 PA Axial
degrees  Level of
caudad ASIS
Projection: Single Contrast Study

Projection Position Central Ray Reference Structures shown

Point

RAO or Semi prone Perpendicular 1-2 inches Right colic flexure,

LPO or semi lateral to ascending colon,
Projection supine midline of body sigmoid portion
at level of iliac
35-45 crest
degrees
obliquity
Projections: Single Contrast Study

Projection Position Central Ray Reference Structures shown

Point

RPO or Semi prone Perpendicular 1-2 inches Left colic flexure

LAO or semi lateral to and descending
Projection supine midline of body colon
at level of iliac
35-45 crest
degrees
obliquity
Projections: Single Contrast Study

Projection Position Central Ray Reference Structures shown

Point

Lateral Lateral Perpendicular Level of ASIS Rectum, distal

Projection Recumbent sigmoid portion
Double Contrast Study (Procedure; Phases of the Study)
1. Evacuation Phase
o Patient evacuates contrast media
o Not all BaSO4 is evacuated
2. Post-evacuation phase
o Patient to lie in SIMS Position
o Introduce air via colonic insufflator (7 or 10-15 pumps)
3. Post-evacuation phase
o Radiographs are taken
Projections: Double Contrast Study

Projection Position Central Ray Reference Structures shown

Point

R Lateral Lateral Horizontal Level of iliac Up medial side of

Decubitus Recumbent crest at MSP ascending colon,
with R side lateral side of
dependent descending colon

Projections: Double Contrast Study

Projection Position Central Ray Reference Structures shown

Point

L Lateral Lateral Horizontal Level of iliac Up lateral side of

Decubitus Recumbent crest at MSP ascending colon,
with L side medial side of
dependent descending colon
Projections: Double Contrast Study

Projection Position Central Ray Reference Structures shown

Point

R or L Lateral Horizontal Level of iliac Up posterior

Ventral Recumbent crest at MSP portions of the
Decubitus with L side colon
dependent
Projections: Double Contrast Study; AP, PA, Oblique, Lateral Upright
 Identical to those in recumbent position
 Image Receptor (IR) is placed at the lower level to
compensate for the drop of the bowel due to the effect
of gravity
Single Stage Double Contrast (Projections)

PA PROJECTION RIGHT LATERAL DECUBITUS

LPO PROJECTION LEFT LATERAL DECUBITUS

RPO PROJECTION

R LATERAL PROJECTION
OF RECTUM

AP PROJECTION PA PROJECTION
LAO PROJECTION RPO PROJECTION

RAO PROJECTION LPO PROJECTION

 Biliary System
 Radiographic examination of the biliary system involves studying the
manufacture, transport and storage of bile.
 An understanding of radiographic examination of the biliary system requires
knowledge of the basic anatomy and physiology of the liver, gallbladder and
connecting ducts.
Radiographic Anatomy

Liver
 It is a complex organ that is absolutely essential to life. However, the on function
most appliable to radiographic study is the production of large amounts of bile.
Bile
 The major function of bile is to aid in the digestion of fats by emulsifying or
breaking down fat globules and the absorption of fat following its digestion.
Gallbladder is a pear shaped sac composed of fundus,
body and neck.
 3 primary functions of the gallbladder
o To store bile
o To concentrate bile
o To contract when stimulated
 Common Bile Duct (CBD) is a tube
that carries bile from the liver and the
gallbladder through the pancreas and
into the duodenum.
It is formed where the ducts from the
liver and gallbladder are joined.

Cholegraphy
 It is the general term for radiographic study of the biliary system.
 Ultrasonography is now the primary imaging technique for the assessment of the
gallbladder and bile ducts, and oral cholecystography is obsolete.

Methods of Cholegraphy
 Methods are named according to the route of contrast media
 By mouth
o Oral Cholecystography
 Venous
o Intravenous Cholangiography
 Direct Injections to the Ducts
o Percutaneous Transhepatic Cholangiography
o Operative Cholangiography
o Post-Operative, Delayed, Or T-Tube Cholangiography
 Cholecystography
 o SRE of the Gallbladder (GB)

 Cholangiography
o SRE of the Biliary Ducts
 Cholecystoangiography Cholecystocholangiography
o SRE of both the Gallbladder and the Biliary Ducts

Oral Cholecystography
 In the past, contrast medium was ingested orally for a cholecystogram, thus this
was terms an oral cholecystogram (OCG).
 Oral Cholecystography/cholecystogram is an examination of the Gallbladder by
administering contrast medium by mouth.
 However, oral contrast media for the OCg has been discontinued.
 Indications
o Biliary Calculi
o Cholecystitis
o Congenital Anomalies
o Neoplasms
o Biliary Stenosis
 Contraindications
o Vomiting
o Pyloric Obstruction
o Severe Jaundice
o Diarrhea
o Malabsorption Syndrome
o Liver Dysfunction
o Hepatocellular Disease
o Hypersensitivity to iodinated Contrast Media
o Cholecysectomized Patient
 Contrast media used
o Iodinated Contrast Medium
 Example:
 Telepaque
 Orografin
 Cholebion
 Biloptin
 Capsules/Granules
 Routine Positions (Reminder: Always start with scout film)
o Projection: PA Projection
 Position: Upright or prone
  Central ray: Perpendicular
 Reference Point: Centered to gallbladder according to bod habitus
 Structure Shon: Axial view of the opacified gallbladder

o Projection: PA Oblique (RPO) Projection

 Position: LAO Position 15-40 degrees obliquity
 Central Ray: Perpendicular
 Reference Point: Centered to Gallbladder according to Body Habitus
 Structure shown: Gallbladder free of superimposition.

o Projection: Lateral Projection

 Position: Ride side dependent
 Central Ray: Perpendicular
 Reference Point: Centered to Gallbladder according to Body Habitus
 Structure shown: Used to differentiate Gallbladder stones vs Renal
stones vs calcified mesenteric lymph nodes
Intravenous Cholangiography
 Investigate biliary tract of cholecystectomized patient.
 Investigate biliary tract of non-cholecystectomized patient.
 In cases of non-visualization by oral.
 For patient who cannot retain the orally administered contrast long enough for its
absorption due to diarrhea or vomiting.
 Contraindications
o Liver Disease
o Non-Intact Biliary Ducts
o Patient’s Bilirubin is Increasing or exceeds 2mg/dl
 Routine Projections and Positions
o Projection: PA Oblique (RPO) Projection
 Position: Semi prone, LAO position 15-40 degrees obliquity
 Central Ray: Perpendicular
 Reference Point: Centered to Gallbladder according to Body
Habitus
 Structure shown: Gallbladder free of superimposition
 10-minute intervals
Percutaneous Transhepatic Cholangiography
 Percutaneous transhepatic cholangiography is a minimally invasive diagnostic
and/or therapeutic procedure to evaluate and treat obstruction in the biliary tract.
 How?
o A thin needle is inserted through the skin below the ribs and into the liver
using x-ray (fluoroscopy) guidance.
 What Kind of Needle?
 Chiba Needle
o It is a two-part hollow needle with a beveled tip angled at 30 degrees.
o One of the most commonly used biopsy/percutaneous access needles.
 Contrast Media Used
o (20-40ML) of:
 Telebrix
  Conray
 Hypaque

Percutaneous Transhepatic Cholangiography

 Indications
o Obstructive Jaundice
o Stone Extraction and Biliary Drainage
 Possible Complications
o Leakage of Bile into peritoneal cavity
o hemorrhage
o pneumothorax
o Sepsis/Infection
 Flow
o Place patient in supine
o Patient’s right side is prepared and draped
o Local Anesthesia administered
o Chiba Needle held parallel to the floor
 Inserted through R lateral intercostal space and advanced toward
the liver hilum
o Stylet of needle withdraw
o Syringe of CM attached to needle
Postoperative Cholangiography or T-Tube Cholangiography
 Occurs 1-3 days after surgery
 Procedure that examines the biliary tract after surgery by a way of a T-shaped
tube left in the common bile duct for postoperative drainage and to demonstrate
the patency of the ducts and presence of stones
 Contrast media used:
o Water soluble organic contrast media:
 Concentration no more than 25-30%
 Purposes
o Determine patency of bile duct
o Status of sphincter of oddi and apulla of vater
o Demo residual calculi
o Determine dilatation and concentration of biliary ducts
 Flow
o Scout Film
 PA Projection of Upper Abdomen
o Patient’s right side is prepared and draped
 AP Oblique Projection (RPO Position)
o Local Anesthesia administered
 Under Fluoroscopic Control
o Spot Films
 AP Oblique Projection (RPO Position)
o Added Projection
 Lateral Projection to demonstrate branching of hepatic ducts
Operative/ Immediate Cholangiogram
 It is performed during biliary tract surgery to investigate the patency of the bile
ducts and to reveal the presence of stones
 Direct examination of the gallbladder and biliary duct done in the operating room
for aseptic reason.
 Surgeon exposed the biliary tract and injects contrast directly into the common
duct or following removal of the gallbladder through an in-lying tube.
 Exposure must be made at the end of full exhalation and must be as short as
possible.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
 Endoscopic retrograde cholangiopancreatography, or ERCP, is a procedure to
diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas.
 It combines X-ray and the use of an endoscope—a long, flexible, lighted tube.
 Procedure that examines the biliary tract after surgery by a way of a T-shaped
tube left in the common bile duct for postoperative drainage and to demonstrate
the patency of the ducts and presence of stones.
What does a Diagnostic ERCP accomplish?
 Demonstrates strictures, dilations, or lesions within the biliary or pancreatic ducts
 Checks the patency of the biliary and pancreatic ducts
 Visualizes stones not detected by other modalities
What does a Therapeutic ERCP accomplish?
 Remove Small Lesions
 Removes Choleliths
 Can dilate a blocked or narrowed duct
Technique (Procedure)
 Anesthesize throat
o Use buccal spray
 Fiber optic endoscope into the mouth
 Locate ampulla of vater
 Oblique Projection
o To demo bile duct and pancreatic duct
 Small cannula passed through
o Via the endoscope
 Contrast Media introduced to the CBD
o Upon reaching the ampulla of vater
 Spot radiographs
o Within 5 minutes only

Note:
 No food and drinks given to the patient due to the absence of the gag reflex
 No fluid intake 1 hour after procedure
 No solid food 10 hours after procedure
 Ultrasound of Upper Abdomen before ERCP
 Oral cholecystogram IV Cholecystography before ERCP