Radiological Procedures - A Guideline DR Bhushan Lakhkar

Dr.
Bhushan N Lakhkar
· A GUIDELINE
Radiological
Procedures
{A Guideline)
Dr Bhushan N. Lakhkar
Professor and Head Department of Radiodiagnosis & Imaging
Shri BMPatil Medical College, BLDE University, Bijapur, Kamataka
Assisted by
Dr Bhushita Lakhkar Guru
Asst. Professor, and Department of Radiodiagnosis & Imaging
ARYA PUBLICATIONS
(AVICHAL PUBLISHING COMPANY)
INDUSTRIAL AREA, TRILOKPUR ROAD, KALA AMB 173 030, DISTT. SIRMOUR (HP)
Delhi Office: 1002 Faiz Road (opp. Hanuman Murti), Karol Bagh, New Delhi 110 005
The book has been published in good faith that the views and opinions expressed in this book are solely
those of the original contri.butor(s)/ author.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means [graphic, electronic or mechanical, including photocopying, recording, taping or information retrieval
system] without the written permission of the copyright holder, application for which should be addressed
to the publisher. Such written permission must also be obtained before any part of this publication is stored
in a retrieval system of any nature. Breach of this condition is liable for legal action.
Exhaustive efforts have been made to ensure accuracy and correctness of contents of the book at the time
of going to press. However, in view of possibility of human error or changes in medical science, neither
the author, publisher nor any other person who has been involved in preparation of this work accepts any
responsibility for any errors or omissions or results obtained from use of information given in the book.
The publisher shall not be liable for any direct, consequential, or incidental damages arising out of the use
of the book.
In case of binding mistake, misprints, or missing pages etc, the publisher's entire liability, and your
exclusive remedy, is replacement of the book within one month of purchase by similar edition/reprint of
the book. In case of any dispute, all legal matters are to be settled under Delhi Jurisdiction only.
NOTICE
Published by: Information contained in this
ARYA PUBLICATIONS book is uptodate, believed to be
reliable when checked with the
(Avichal Publishing Company)
sources and is in accordance with
7, Industrial Area, Trilokpur Road the accepted standard, at the time
Kala Amb-173030, Distt. Sirmour (HP) of publication. However, with
ongoing research and passage of
time, new knowledge may modify
Delhi Office: some of it. The reader should,
1002 Faiz Road (opp. Hanuman Murti), therefore, approach the book with
Karol Bagh, New Delhi-110 005 (India) a realistic attitude (particularly the
drugs and doses) and should carry
Phone: 011-28752745, 28752604, 28755383 the professional responsibility. The
Fax: 011-28756921 readers are requested to verify the
Email: info@apcbooks.co.in information contained herein from
other sources. Neither the publisher
Website: www.apcbooks.co.in nor the author(s)/editor(s) assumes
any liability for any injury and/
or damage to persons or property
arising from the use of material in
ISBN-978-81-7855-565-2
this book.
© Author
First Edition: 2002

Reprint: 2008
Second Edition: 2010
Reprint: 2014
Third Edition: 2016
Reprint: 2017
Price: � �0.00
Laser Typesetting at:

Eltee Printmaster (P)
Printed at:
Deepak Offset Printers
Bawana Ind. Area, Delhi
Radiological
Procedures
{A Guideline)
Dr Bhushan N. Lakhkar
Professor and Head Department of Radiodiagnosis & Imaging
Assisted by
Dr Bhushita Lakhkar Guru
Asst. Professor, and Department of Radiodiagnosis & Imaging
ARYA PUBLICATIONS
INDUSTRIAL AREA, TRILOKPUR ROAD, KALA AMB 173 030, DISTT. SIRMOUR (HP)
Delhi Office: I 002 Faiz Road (opp. Hanuman Murti), Karol Bagh, New Delhi 110 005
The book has been published in good faith that the views and opinions expressed in this book are solely
those of the original contributor(s)/author.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means [graphic, electronic or mechanical, including photocopying, recording, taping or information retrieval
system) without the written permission of the copyright holder, application for which should be addressed
to the publisher. Such written permission must also be obtained before any part of this publication is stored
in a retrieval system of any nature. Breach of this condition is liable for legal action.
Exhaustive efforts have been made to ensure accuracy and correctness of contents of the book at the time
of going to press. However, in view of possibility of human error or changes in medical science, neither
the author, publisher nor any other person who has been involved in preparation of this work accepts any
responsibility for any errors or omissions or results obtained from use of information given in the book.
The publisher shall not be liable for any direct, consequential, or incidental damages arising out of the use
of the book.
In case of binding mistake, misprints, or missing pages etc, the publisher's entire liability, and your
exclusive remedy, is replacement of the book within one month of purchase by similar edition/reprint of
the book. In case of any dispute, all legal matters are to be settled under Delhi Jurisdiction only.
NOTICE
Published by: Information contained in this
ARYA PUBLICATIONS book is uptodate, believed to be
reliable when checked with the
(Avichal Publishing Company)
sources and is in accordance with
7, Industrial Area, Trilokpur Road the accepted standard, at the time
Kala Amb-173030, Distt. Sirmour (HP) of publication. However, with
ongoing research and passage of
time, new knowledge may modify
Delhi Office: some of it. The reader should,
1002 Faiz Road (opp. Hanuman Murti), therefore, approach the book with
Karol Bagh, New Delhi-110 005 (India) a realistic attitude (particularly the
drugs and doses) and should carry
Phone: 011-28752745, 28752604, 28755383 the professional responsibility. The
Fax: 011-28756921 readers are requested to verify the
Email: info@apcbooks.co.in information contained herein from
other sources. Neither the publisher
Website: www.apcbooks.co.in nor the author(s)/editor(s) assumes
any liability for any injury and/
or damage to persons or property
ISBN-978-81-7855-565-2 arising from the use of material in
this book .
© Author
First Edition: 2002

Reprint: 2008
Second Edition: 2010
Reprint: 2014
T hird Edition: 2016
Reprint: 2017
Price: t '.!">0.00
Laser Typesetting at:

Eltee Printmaster (P)
Printed at:
Deepak Offset Printers
Bawana Ind. Area, Delhi
I would like to thank my wife Bhavana for
standing beside me throughout my career and
helping me in writing this book. She has been
my inspiration and motivation for continuing
to improve my knowledge and move my career
forward. She is my rock, and I dedicate this
book to her.
Preface to Third Edition
Prime facea, I am grateful to the God for the good health and
wellbeing that were necessary to complete this book. Since the last
edition of this book was published in the year 2010 I have received
numerous email messages and letters from students commenting on
the book and suggesting how it could be improved. Based on my
own experiences in editing and in examining and supervising theses.
I have revised the book and added a few new chapters. My daughter
Bhushita provides the perfect blend of knowledge and skills that went
into authoring this book. She has added the new chapters and tried to
update the procedures. Words can not express my sincere appreciation
for her assistance to broaden the perspectives of this book.
The most obvious changes in this edition are the new chapters
on intervention, Doppler, CT and MR guided procedure. They are
assembled into an entirely new chapters which, I sincerely hope,
will help the residents. A few of the procedures like bronchography,
splenoportography, Myelography have become absolute with the
advances in CT and MRI and have been deleted. We have added
new chapters and updated some of the existing chapters. Because
the students are familiar with the layout of the first edition, we have
tried to change it as little as possible.
My main audience remain the students. I hope, they will find
the procedures presented in this book to be both inspirational and
instrumental in tackling new challenges in the field of imaging
sciences.
I would like to acknowledge the help of my students involved in
this project, without their support, this book would not have become
a reality.
Working with the Avichal staff was once again a pleasure. Their
collaboration is greatly appreciated. We thank Dr Vipin Gupta for his
patience in guiding us through this new edition.
Dr Bhushan N Lakhkar
Preface to Second Edition
Due to popularity and success of first edition of this book; it has been
decided to cease reprints and move immediately in to the production
of the second edition.
The aims and layout of this second edition are very similar to those
in the first, with improvement being made in each chapter. A new
chapter has been added on 'embolizing materials and interventional
procedures'. My major concern in this book is to help and encourage
the residents to perform all radiological procedures of diagnostic
quality and to help the clinicians in reaching the proper diagnosis.
I have received a lot of encouragement to prepare this second edition

from many residents, who have used this book during their residency
training period. I want to thank all my students who had helped me
patiently as the book progressed from the crude notes to its present
form.
Special thanks to Dr. Vipin Gupta, who constantly reminded me to

complete this book in time.
Finally I must thank may publisher, M/S Avichal Publishing Company,

without their support this edition would not have been possible.
Dr. Bhushan N. Lakhkar

Contents
1. Contrast Media 1
2. Intravenous Urogram-1.V.U. 27
3. Micturating Cystourethrogram (MCU) 42
4. Retrograde Pyeloureterography 47
5. Contrast Media in GIT 51
6. Barium Swallow 60
7. Barium Meal 66
8. Barium Meal Follow Through 76
9. Enteroclysis (Small Bowel Enema) 85
10. Barium Enema 97
11. Hysterosalpingography 110
12. Fallopian Tube Recanalisation 117
13. Sialography 121
14. T-Tube Cholangiography 124
15. Percutaneous Transhepatic Cholangiography 128
16. Catheters 134
17. Angiography 142
18. Phlebography 156
19. Dacrocystography 162
20. Interventional Radiology 167
21. New trends in Radiography 198
22. Mammography and Sono-Elastography 212
23. Doppler in Obstetrics and Peripheral Vessels 231
24. Advances in Interventions 246
25. CT Procedures 262
26. MR Procedures 272
27. Positron Emission Tomography (PET) 282
Chapter 1
Contrast Media
• Classification
• Chemistry
• Physiology
• Toxicity
• Treatment
• Contrast Media Used in Ultrasound
• Contrast Media Used in MRI
L__ • References
CLASSIFICATION
i
Contrast Media (CM)
t t
X-Ray & CT Ultra-sound MRI
_
Negative CM Air, CO2
__,
Positive CM
t t
Oily CM Iodinated CM Water soluble
Hepatic excretion lopanoic Renal excretion

acid Calcium lopadate
High osmolar Low osmolar _J
t t t t
Ionic monomers Ionic dimers loxaglic Non-ionic monomers Non-ionic dimers
lothalamate Diatrizoate acid locamic acid Metrizamide lohexol lotrol lotrolan
2 • Radiological Procedures
Iodine
1. Most of the i.v. contrast media contain iodine which has an atomic
number 53 and atomic weight 127.
2. Total iodine content in the body is 50 mg.
3. It's preferred because
• High contrast density due to high atomic number
• Allows firm binding to highly variable benzene ring
• Low toxicity.
4. It's not suitable for MRI.
Water Soluble Iodinated Contrast Media

Classification
I. Conventional Contrast Media/High Osmolarnonic Monomers
salts of
• Diatrizoic acid (Urovedeo, Trazograff, Urograffin, Angiograffin
and Contrastin)
• Iodamic acid
• Ioglicic acid
• Iothalamic acid (Conray, Triovideo)
• Ioxithalamic acid
II. Ionic Dimer
salts of
• Ioxaglic acid (Hexabrix)
• Iocarmic acid
III. Non-Ionic Monomer
• Iohexol-(omnipaque)
• Iopamidol -(Iopamiro)
• Ioversol -(optiray)
• Iopromide-(Ultravist)
• Iopentol
IV. Non Ionic Dimer
• Iotrol
• Iotrolan (Isovist)
• Iodixanol
Class II, III and IV are collectively known as low osmolar contrast
media.
Contrast Media •3
CHEMISTRY
I. Conventional Contrast Media/High Osmolar C.M./Ionic
Monomers
These are salts consisting of a sodium or meglumine cation and a
triodinated benzoate anion.
• Anions consisting of a benzoic acid molecule with three atoms of
iodine firmly attached at C 2, C4 and C6 .
• The C3 and Cs are connected to radicals CR3 and Rs, which are
amines E-NH2, and greatly reduce toxicity and increase solubility
of the molecules.
• Iodine particle ratio is 3:2.
• Sodium or meglumine act as cations.
• Differences between meglumine salts and sodium salts.
Meglumine salts Sodium salts
Solubility Better Same, less in some
L
I Viscosity High
acids
Low
I Tolerance Better Less, causes nausea
-
and vomiting
Blood brain barrier No effect Crosses (BBB)
Vascular effects Less Marked
Diuretic effect Strong Less
Opacification Poor Better
Bronchospasm Causes, so No
contraindicated in
bronchial asthma
Examples
1. Diatrizoic Acid
• The two side chains, R 3 and Rs in diatrizoic acid are replaced
by (NHCOCH3). This
- Increases solubility
- Decreases plasma protein binding thereby increasing its
ability to be filtered in glomerulus
- Improves patient tolerance
E.g.: Urograffin, Trazograff, Urovision, Urovideo, Angiograf
fin
2. lothalamic Acid
It is obtained by substitution of one of the two nitrogen atoms
of the benzene ring by a carboxyl group. It has better neural
tolerance but decreased cardiovascular tolerance.
E.g.: Conray, Triovideo
Disadvantages of Conventional Contrast Media

1. Osmolar concentration (osmolality) is extremely high upto 8 times
the physiological level of 300 m osm/kg water.
2. Osmolar challenge to every cell, tissue and fluid in the body is
responsible for their adverse effects.
3. The very high osmolarity is due to the fact that the non-radiopaque
cations (Na/meg) exert just as great as an osmolar load as do the
radiopaque anions. The cation is merely a carrier and serves no
radiological function. It would make an excellent sense to have
a contrast media with fewer or no non-radiopaque cation.
Useful Facts to Remember

• Osmolality is dependent on number of particles of solute in solution.
• Radiopacity is dependent on the iodine concentration of the solution
and is therefore dependent on the number of iodine atoms in each
molecule of the contrast medium.
• High radiopacity and low osmolality are desirable requirements.
• The ratio of the number of iodine atoms per molecule to the
number of particles per molecule of solute in solution is therefore
a fundamental criterion.
• Iodine particle ratio for all conventional high osmolar monomeric
contrast media salts is 3:2.
• Non-ionicity is essential for myelography and reduces the reactions
to LV. injection.
II. Low Osmolar Contrast Media

Ionic Dimers
• Two benzene rings (each with three iodine atoms) are linked by a
bridge to form a large compound, e.g., Hexabrix.
• This group carries only one carboxyl group. So known as monoacid
dimers.
• Iodine particles ratio is 6:2.
Contrast Media • 5
Non-Ionic Monomers (NIM)

• Carboxyl group (-COOH) at C-1, of monomeric salts is replaced by
a nonionizing radical and CONH2 producing an iodine : particle
ratio of 3:1.
• Metrizamide (Amipaque) was the earliest non-ionic monomer and
proved as an excellent contrast media but was very expensive,
impossible to autoclave and unstable in solution, so second
generation of NIM were included later such as :
- Iohexol (omnipaque)
- lopamidol (Iopamiro)
- loversol (optiray)
- lopromide (Ultravist)
• Iodine: particle ratio is 3:1.
• Osmolality is around 600 mosmols/kg whereas normal osmolality
of plasma is 280-303 mosmols/kg.
Non-Ionic Dimers
Iodine: particle ratio is 6:1.
E.g. Iotrol; Iotrolan (lsovist).
Osmolality is around 300 mosmols/kg which is nearly iso-osmolar
to plasma osmolality that is 280-303 mosmols/kg.
Additives Used in Contrast Media

1. Stabilizer-Ca or Na EDTA.
2 . Buffers-stabilizes pH during storage-Na acid phosphates.
3. Preservatives-generally not disclosed by manufacturers.
Ideal Contrast Media should have

1. High water solubility.
2. Heat and chemical stability (Shelf life). Ideally-3-5 years.
3. Biological inertness (non-antigenic).
4. Low viscosity.
5. Low or iso-osmolar to plasma.
6. Selective excretion, like excretion by kidney is favourable.
7. Safety : LD50 (lethal dose) should be high.
8. Reasonable cost.
Ionic Contrast Media Available in India are:

German Remedies
Diatrizoic-Acid group w/v Iodine Viscosity
(g/100 ml) mg/ml at 37° C
I
Urograffin
292
l 4
I 76% meg+Na
60% meg+Na 52 +8
I
66 +10 370 8.9
Angiograffin 65 306 5
Meglumine diatrizoate
Urovision
Na: Me 40:18 325 3.3
Bracco
I
WV Iod"me v·lSCOSl" ty at
(g/100 ml) mg/ml 37° c �-
Iothalamic acid group - -
Triovideo 280 60 280 4
Me Iothalamate -
Triovideo 400 66.8 400 4.5
Na Iothalamate -
Diatrizoic acid group
Urovideo 75% 68 + 8.3 370 8.4
meg + Na -
Urovideo 60% 54.4 + 6.7 296 4.1
meg+N _ a_ __ I
Unique (JB Chemicals)

w/v Iodine Viscosity at
Diatrizoic acid group
(g/100 ml) mg/ml 31° c
Trazograff
Trazogmff 76% 110+66 370 8.9
Na+meg +
Trazograff 60% 66 282 5.0
Meg
Trazograff plus 41.5+18.5 334 3.4
Na+meg
Contrast Media •7
Non-ionic contrast media available in India are:

Bracco
lopamidol (Iopamiro) w/v (g/100 ml) mg Uml Viscosity at
37°c
lopamidol 150 30.6 150 1.5
Iopamidol 200 40.8 200 2.0
Iopamidol 300 61.2 300 4.7
Iopamidol 370 75.5 370 9.4
Nycomed-Now GE Healthcare
Omnipaque (lohexol) mg Uml Viscosity at 37°C
Omnipaque 140 140 1.5
Mallinckrodt International Corporation

Optiray (Ioversol) mg Uml Viscosity at 37°C
Optiray 160 160 1.9
Optiray 240 240 3.0
Optiray 300 300 5.5
Optiray 320 320 5.8
Optiray 350 350 6.0
German Remedies
Ultravist (Iopromide) w/v (g/100 ml) mg Uml
Ultravist 150 31.2 150
PHYSIOLOGY
Concentration and excretion of these contrast media are predominantly
by passive glomerular filtration. Net tubular excretion and protein
binding is negligible in the dose used. Liver and Intestine excrete 1 %
of these compounds.
After intravascular administration, first it diffuses into the ex

travascular space (whole body opacification) and is simultaneously
excreted. Then equilibrium is reached between intra and extravascular
space in 10 min. Continued excretion and reentry of contrast media
from E.C.F. to I.CF. lead to decrease in plasma level. Plasma half life
is 30-60 min.
Contrast media are filtered from blood into Bowman's capsule
by passive glomerular filtration. In the Bowman's capsule, plasma
concentration of contrast media is the same as in blood. In PCT,
resorption of Na and H2O causes 5-10 times concentration of contrast
media. If the patient is on diuretics, the concentration does not occur.
Further increase in concentration of contrast media occurs by counter
current mechanism in the loop of Henle. In OCT by the action of
ADH, the concentration of contrast media further increases.
Points to Remember
1. Contrast media used for myelography are non-ionic contrast media.
2. Contrast media used for cerebral Angiography, are contrast media
containing only meglumine cation.
3. Contrast media containing only meglumine are - Conray 280,
Triovideo 280, Trazograff 60% and Angiograffin.
4. Contrast media containing only sodium are - Conray 420, Triovideo
420.
5. Contrast media containing sodium more than meglumine are -
Urovision and Trazograff plus.
6. Contrast media with least osmolarity are maximum Hexabrix.
7. Contrast media which cause maximum nausea and vomiting are
- Hexabrix.
8. Meglumine salts cause bronchospasm, so contra-indicated in
bronchial asthma.
9. LD50 - increased LD50 mean more safety:
- Iohexol is safest contrast media.
E.g.:
LD50 (mouse, I.V. lml/kg)
Conray 420 8
Hexabrix 12.5
Iohexol 24.2
Iopamidol 21.8
10. In newer contrast media, Iohexol is the most hyperosmolar.
Contrast Media •9
11. Viscosity influences the ease with which contrast media can be
injected. Viscosity increases as concentration increases and tends
to be higher for big size molecules (Dimers). High viscosity
interferes with mixing of contrast media with plasma and body
fluids.
�
Viscosity at
Contrast media �
I
20 c
°
37°c
Conray 420 8.1 5.4
Hexabrix 320 15.7 7.5
/ Omnipaque 240 5.6 3.3
�paque 300 11.6 6.1
Ornnipaque 240 has least viscosity.

12. Incidence of thrombo embolic phenomenon is fairly high when
contrast media is mixed with blood. This is higher with Low
Osmolar Contrast Media (LOCM). So, meticulous heparinization
is required during angiography.
TOXICITY
I. Reactions unrelated to contrast media.
II. Hyperosmolality.
III. Chemotoxic.
IV. Immunological.
I. Reactions Unrelated to Contrast Media

(i) Pyrogenic (Unsterile injection).
Management
• Stop injection.
• Reassure the patient.
• Cover the patient with Blanket.
• Once chills occur-change the syringe, contrast and scalp
vein set.
• No need for medication.
(ii) Vasovagal especially in anxious or psychosomatic patient.
(iii) Hypertensive attacks in patient with pheochromocytoma.
(iv) Excessive dehydration, hypoglycaemia.
"
II. Hyper Osmolarity

This is due to the high osmolarity of contrast media than plasma.
More with conventional contrast media. These reactions include
• Erythrocyte damage.
• Capillary endothelial damage.
• Vasodilatation.
• Hypervolemia.
• Cardiovascular effects.
• Vascular pain.
• Disturbance of BBB.
• Thrombosis and thrombophlebitis.
Erythrocyte Damage
Injection of hyperosmolar contrast media � Loss of H20 from RBC
� Dehydrated shrunken RBC � Increased internal viscosity with loss
of ability of RBC to deform to traverse capillaries � Obstruction of
important capillary beds (cerebral, coronary, renal, pulmonary).
Capillary Endothelial Damage
Hyp erosmolar Contrast media � Shrinkage of endothelial cells �
Widening of intercellular gaps � Capillary permeability.
Vasodilatation
Vasodilatation of arteriolar beds, is a direct result of perfusion with
any hyperosmolar solution. Clinically, this is evident by marked
vasodilatation produced on peripheral arteriography. This produces a
sensation of heat, which may be uncomfortable and often accompanied
by pain, especially in hand and external carotid artery territory.
Hypervolemia
This is due to diffusion of extracellular fluid through capillary walls
into blood which occurs whenever large volumes of hyperosmolar
fluid are injected intravascularly. The extravascular fluid is drawn
in so much that the blood volume may increase by 10% within a
few seconds. The increased capillary permeability due to endothelial
damage, permits intravascular fluid to escape from the capillaries and
soon reduces the blood volume towards its original level.
Cardiovascular Effects
• Peripheral vasodilatation.
• Decreased systemic blood pressure.
• Tachycardia.
• Cardiovascular insufficiency.
• Acute hypervolemia � Left ventricular stress.
• Selective arteriography induces bradycardia and moderate reduction
in cardiac output.
• Na edetate and Na citrate which are used as preservatives in
the contrast media chelate Ca2+, therefore leading to transient
hypocalcaemia. This causes negative ionotropic effect on heart.
Disturbance of Blood Brain Barrier
The blood tissue barrier in all non-neurological tissues allows molecules
to pass freely through the endothelium so that their concentration in
both the intra and extravascular fluids becomes equalized within few
minutes of injection.
The BBB is different. In healthy nervous tissue, the normal capillary
endothelium prevents contrast media molecules from free diffusion
into extravascular fluid. If the barrier is damaged, the permeability
across the barriers is increased and the sensitive neurological cells
are directly exposed to potentially neurotoxic substances including
contrast media molecules.
III. Chemotoxic Action

Chemotoxic effects are usually due to the cations. Especially Na+.
The effects are seen in
• Neurons.
• Myocardial cells.
• Capillary endothelium.
• RBC.
• Kidney.
Nephrotoxicity of contrast media is due to
- Decreased renal perfusion. (low B.P., peripheral vasodilatation).
- Glomerular injury - manifest as proteinuria.
- Tubular injury - due to osmolarity, chemotoxicity, ischaemia.
- Contrast media precipitation of Tamm Horsfall proteins that
block tubules.
- Swelling of renal tubular cells causing obstruction.
IV. Immunological (Allergic) Toxicity

Mechanisms
• Deactivation of angiotensin converting enzyme.
Incidence of adverse contrast media reactions to intra-arterial
injection is about l/3rd of incidence following intravenous injection

because the latter stimulate release of vasoactive substances from
mast cells or deactivates ACE in lung.
ACE deactivates bradykinin, the concentration of which rises with
IV injection of Contrast media.
• Due to damage to the endothelium which initiates the activation
system which inturn may be responsible for many adverse
anaphylactoid reactions.
• Activation of complement, kinins, coagulation and fibrinolytic
systems.
• Inhibition of cholinesterase with consequent vagal over stimulation�
acetylcholine release � collapse, bradycardia, bronchospasm.
• Release of vasoactive substances like histamine, bradykinin,
serotonin.
Anaphylactic Reaction
• Occurs in previously sensitized individual.
Anaphylactoid Reaction
• Occurs in nonsensitised individual.
Allergic reaction
Reactions may be allergic. However some workers do not accept this
hypothesis.
Reasons for Reasons against
• Not dose related. • May not occur first time.
• Common in patients with • No antibodies against contrast
bronchial asthma. media detected.
• Liberation of histamine from • Prior antihistamine does not
mast cells was experimentally totally prevent reactions.
shown. • Cardiac arrhythmias and arrest
do not occur in allergy.
High Risk Group Persons

1. Prior reactions to contrast media - 11 times more prone.
2. History of allergy - 4 times more prone.
3. Cardiac disease - 4 times more prone.
4. Asthma - 5 times more prone.
5. Diabetes - 4 times more prone.
6. Old age - 4 times more prone.
7. Neonates - 4 times more prone.

8. Myelomatosis, polycythemia.
9. Sickle cell anaemia, pheochromocytoma, homocystinuria.
Premedication for High Risk Group

1. Tab. Wysolone (10 mg) q.i.d. for 2-3 days (Prednisolone).
2. Tab Rantac (150 mg) b.d. for 2 days.
3. On the day of procedure, if necessary. Injection 1 ampoule of
Hydrocortisone.
Severity of reactions
• Minor : 1 in 20 cases - 5%.
Nausea, vomiting, mild rash, light headache and mild dyspnoea.
Needs no treatment, but requires assurance.
• Intermediate l in 100 - 1%.
Extensive urticaria, facial edema, bronchospasm, laryngeal oedema,
dyspnoea, mild chest pain or hypotension. Requires treatment but
generally there is no need for hospitalization.
• Severe reactions (l in 2000 - 0.05%).
Circulatory collapse, pulmonary oedema, severe angina, myocardial
infarction, convulsions, coma, cardiac or respiratory arrest. Requires
hospitalization and intensive care.
• Mortality - (l in 40,000 - 0.0025%).
Incidence of Reactions with Ionic Contrast Media (ICM) and

Non-Ionic Contrast Media (NICM) in General Population.
I
Contrast media reactions ICM NICM
Incidence I 3.8 to 12.7% 0.6 to 3.1%
Mortality 1/30,418 1/207,488
In high risk groups serious side 0.25% 0.045%
effects
Fatality rates 1/40,000 1/100000-200000
In patients known to have prior 18-20% 5-6%
reaction, reaction rate. I
With premedication steroids, Lower Lower I
reaction rate. -j
Treatment
Whenever contrast medium is being injected, the radiologist must
make sure that appropriate equipment for initial treatment of contrast
reactions, is kept ready.
Two basic rules to be remembered are
1. Make sure that the drugs for allergic reactions are available
before injecting the contrast.
2. Never leave the patient unattended after contrast has been
injected until examination is complete. No patient will have
a serious reaction after 60 min. of contrast administration.
General principles in the use of:
1. Oxygen.
2. Epinephrine.
3. Corticosteroids.
Oxygen
• Oxygen and equipment for assisting ventilation should be readily
available.
• Current recommendation for use of high dose oxygen is at the rate
of 10-12 L/min via face mask.
• 02 can be provided at up to 100% concentration.
• Currently it is recommended that high concentration of 02 should
be administered to any patient in respiratory distress, regardless of
his or her pre-existing condition.
Epinephrine
The most important single medication in treatment of anaphylactoid
reaction is epinephrine.
• It is a powerful sympathomimetic agent, activates both a and �
adrenergic receptors, thereby producing peripheral vasocontric
tion (a effects), increased cardiac contractility and cardiac rate (�1
effects) and smooth muscle bronchodilatation (�2 effects).
• Epinephrine is available in 2 dilutions :
- 1 in 1000-consists 1 mg epinephrine in 1 ml of fluid. This is
intended for s.c. or i.m. administration.
- 1 in 10,000-consists 1 mg epinephrine in 10 ml of fluid. This is
intended for i. v. administration.
• Epinephrine is administered
- s.c. in a dose of 0.1-0.3 ml (0.1-0.3 mg). It can be repeated every
10-15 min. until a total dose of 1 mg is administered.
- i.v. in the same dose of 0.1-0.3 mg, so due to greater dilution 1-3
ml is injected.
• Life threatening complications of epinephrine are hypertensive
crisis, myocardial ischaemia and infarction.
• It has to be administered carefully in the following patients:
1. with cardiac disease.
2. with hypertension.
3. on �-blockers.
Corticosteroids
They do not play a significant role in acute reactions, they may be
effective in reducing late reactions, which can be observed as long as
48 hours. after contrast injection. If steroids are to be administered,
intravenous doses of 100-1000 mg of hydrocortisone have been
recommended. The initial dose can be followed by continuous
infusion of 300-500 mg in a 250 ml solution of saline at rate of 60
ml/hr.
Assessment of the patients with reactions
Responsive Unresponsive
Check pulse and BP, look at skin for Start basic life support
erythema. Auscultate heart and lungs
Mild Moderate
Assure the patient Start I.V. line-isotonic fluid
infusion Oxygen
• Some of the symptoms which can precede severe reactions include.

Nausea, emesis, chills, sneezing, red or watery eyes, nasal con
gestion, feeling of confusion, disorientation or heightened anxiety.
• Each of the reactions that occurs has to be identified and treated
on its merit.
Mild Reactions
Reassure the patient and tell him the reaction will go away. Loosen
tight clothing if any. Tell the patient to take a few deep breaths in and
out to relax. Stay with the patient and watch until symptoms subside.
Moderate Reactions
Skin Reactions
• They can occur any where in the body commonly face, neck and
chest.
• They are usually pruritic.
• Usually no treatment is needed.
• If pruritus is severe use Diphenhydramine (50 mg)
• If patient develops severe diffuse erythema or angioedema use both
H 1 and H2 receptor blockers. (Cirnetidine-300 mg in 20 ml). If no
response use Epinephrine 0.1-0.3 ml (1 in 1000).
Respiratory Reactions
• Causes of respiratory decompensation
- Airway and laryngeal oedema
- Bronchospasm
- Pulmonary oedema
Laryngeal oedema management
- 02
- Epinephrine
- Intubation may be necessary
Bronchospasm
Mild - 02 10 L/min face mask
- metered dose inhaler Albuterol 2-3 inhalation.
Moderate
- Epinephrine (1 in 1000) 0.1-.3 ml S.C. repeat 10-15 min
- Aminophylline - 5 mg/kg LV. slowly over 10-20 min.
Severe
- Epinephrine - LV.
Pulmonary oedema
- Elevate head end of bed
- 02 10 L/min
- Furosernide 40 mg LV. slowly
- Morphine, 1-3 mg LV.
- Hydrocortisone 100 mg I.V. slowly
- Shift to ICU.
Contrast Media •17
Hypotension
Mild
1. Release any abdominal compression
2. Elevate legs
3. 02 10 L/min
4. Isotonic I.V. fluids - administer rapidly
Severe ------
With bradycardia
Atropine 0.6-1 mg I.V., slowly
Tachycardia
Epinephrine - 1-3 ml
--�
Repeat 3-5 ----
min (110,000) I.V.
Maximum up to 3 mg ---- up to 10 ml or Dopamine -1
Seizures or Convulsions
Mild
1. Tum the patient to one side to avoid aspiration. Be sure airway
is clear and open.
2. 02 10 L/min.
Severe
1. Diazepam, 5 mg I.V. slowly
Hypertensive Crises
1. 02- 10 L/min
2. Nitroglycerine, 0.4 mg tablet sublingually.
3. If no response, Nifedipine - 10 mg capsule, puncture end of
capsule and drop sublingually. Monitor B.P. closely.
4. Consider Stat. ECG.
5. If pheochromocytoma, Phentolamine 5 mg I.V.
6. Frusemide 40 mg I.V. slowly.
Extravasation of Contrast Material

1. Elevation of affected extremity above the heart level.
2. Ice packs (20 min t.i.d. for 2-3 days)
3. Plastic surgery consultation if
• Large volume extravasation (>30 ml ionic or > 100 ml non-ionic)
• Skin ulceration or blistering
• Worsening symptoms after 2-4 hours.
4. Close follow-up until resolution.
CONTRAST MEDIA USED IN ULTRASOUND

(Contrast agents boost echogenicity of blood)
On account of its ubiquity and low cost, ultrasound may soon
become the "diagnostic gatekeeper" for other modalities. Its ability
to visualize arterial and venous ischaemia, deep pulmonary emboli,
the microvascularity of tumors, make it well suited for 21st century
medicine.
A new wave of U.S. contrast agents make these and other studies
possible by increasing the echogenicity of blood, which can heighten
the tissue contrast and better delineate body cavities.
The parenteral U.S. echo enhancers consist of microscopic gas
filled bubbles whose surfaces reflect sound waves. These bubbles are
smaller than red blood cells, at less than 8 microns in size.
The backscattering effect they create due to the different impedances
of gas and liquid increases the echogenicity of blood.
The ingredients are not intrinsically toxic. Safety concerns on
avoiding gases with a tendency to coalesce and form emboli.
Generations of Echo Enhancers

First-Unstabilised bubbles in indocyanine green (can't survive
pulmonary passage, therefore used only for cardiac and large veins
studies).
Second-Longer lasting bubbles coated with shells of protein, lipids
or synthetic polymers.
Third-Encapsulated emulsions or bubbles, offer high reflectivity.
Ultrasound Contrast Agents

Ideal Qualities of Ultrasound Contrast Agents
• High echogenicity.
• Low attenuation
• Low blood solubility
• Low diffusivity
• Ability to pass through pulmonary capillary bed
• Lack of biological effects with repeated doses.
• Current generation of microbubbles have a diameter from 1 - 5
micrometer.The success of agents depends on the small size and
on the stability of their shell.
• Also newer ultrasound contrast agent have prolonged persistence
in the vascular bed which provides consistent enhancement of the
arterial Doppler signal.
• Also it is possible to perform dynamic & perfusion studies.

• The main mechanism for signal enhancement are backscattering,
bubble resonance, and bubble rupture that is highly dependent on
the acoustic power of the transmitted ultrasound also known as
MECHANICAL INDEX.
Different Types of Ultrasound Contrast Agents
(A) Tissue specific ultrasound contrast agents
Improves the assessment of certain organs like liver, kidney, pancreas,
prostate, and ovary by improving the acoustic differences between
normal & abnormal portions of organs.
• Levovist
• Sonovist [Schering]
• Sonozoid [Nycomed-Amersham]
The bubbles rupture produces a transient pressure wave, resulting
in characteristic mosaic pattern from the tissues, which is termed as
induced acoustic emission.
(1) Levovist
• First generation ultrasound contrast agent consisting of galactose
(milk sugar) ground into crystals whose irregular surface acts as
nidation sites on which air pockets form when suspended in water.
• Used in echocardiography in left ventricle functional assessment.
• In vascular phase also it can exhibit a tissue or organ specific action.
Gets accumulated in liver & spleen & improves detection of focal
liver lesion.
• Levovist has been developed by SCHERING-AG. The shell
stabilizer is galactose/palmitic acid and the gas used is air.
(2) Sonovist (From Schering Ag)
• A biodegradable synthetic capsule filled with sulphurhexa fluoride.
• It is a stable contrast media.
• It has an additional hepatosplenic parenchymal phase following
the pool phase.Microbubbles are stationary in this phase.
• Sonovist has been developed by SCHERING-AG. The shell stabilizer
is cyanoacrylate and the gas used is sulphur hexaflouride.
(B) Vascular Ultrasound Contrast Agent:

• These are gas microbubbles with a diameter less than 5 to 10
micrometer to pass through lung capillaries and into the systemic
circulation.
• These are most likely to be used in imaging of malignant tumours

in liver, kidney, ovary, pancreas & prostate.
• It is also used in cardiac evaluation.
Example:-Albunex & infosan.
• Albunex has been developed by MALLINCNODT INC. The shell
stabilizer is albumin and the gas used is air.
(C) Contrast Agents For Targeted Imaging:

• Improve the image contrast resolution through differential uptake.
• High sensitivity & specificity
• These agents permit noninvasive detection of thrombus, carcinoma,
inflammation& other sites where specific integrins or adhesion
molecules are expanded.
• Possible targets are molecular makers on thrombus, endothelial
cells & leucocytes.
NEWER APPLICATIONS
• HSG contrast sonography for evaluation of fallopian tube patency
-ECHOVIST
• Reflux sonography as an alternative to MCU, detect or excludes
VUR - LEVOVIST
• Administration of oral contrast agent - KnoRX facilitates uniform
echogenicity of contrast filled stomach & adequate visualization of
pancreas.
Types of Agents
Schering produces three parenteral agents:
1. Echovist-First one to be used and contains galactose based
microbubbles.
2. Levovist-More stable. Alongwith galactose based micro bubbles.
These are coated with a thin layer of palmitic acid.
3. Cavisomes--Gas filled cyanoacrylate microspheres for liver,
spleen and lymph node imaging.
Clinical Applications
• Contrast media can make vascular studies of perfusion and flow in
tiny vessels preferable even in machines lacking doppler capability.
• Contrast can also define vascular architecture surrounding malignant
stuctures, highlighting abnormal vessels.
• Can be used to study the fallopian tube patency.
CONTRAST MEDIA USED IN M.R.I.

MRI is the modality of choice for study of the central nervous sy stem
with its extension into imaging of abdomen, pelvis and musculoskeletal
sy stem because of its high spatial resolution, soft tissue contrast and
multiplanar imaging.
Concurrent development of contrast media has aided the rapid
expansion of this technique with increased clinical efficacy.
Requirements of an Ideal Contrast Media

1. Image contrast.
2. Tissue specific
3. Low toxicity and stability in vivo
4. Suitable shelf life.
5. Rapid clearance from the target tissue and safe excretion through
renal /hepatobiliary routes.
MR is unique in that there are multiple parameters responsible
for signal intensity. So the contrast agent must have the ability to
influence these parameters at low concentration to minimize dose
and potential toxicity.
Commercial Brands of Contrast Available in India

Name of brands Ionicity Osmolality Viscosity
(mosm/kg (mPa.s at 37°c)
)
OMNISCAN _j Non-i� -�
ProHance Non-ionic �:: - 1
::� +
Gadovist I Non ionic - --+- 1,603 4.96 -7
--- -
f Name of
brands
Ionicity Osmolality
(mosm/kg H2O)
Viscosity
(mPa.s at 37°c)
Magnevist Ionic 1,960 2.9---
--�
Dotarem Ionic 1,35 2
+-
MultiHance Ionic 1,970 L 5.3
Mechanism
In conventional and CT scanning, image contrast is generated by
different attenuation of the X ray beam by the tissues of the body.
-
The parameters determining MR signal intensity and contrast are:

1. Spin density
2. Relaxivity.
3. Magnetic susceptibility.
4. Diffusion and perfusion.
1. Spin Density
This cannot be significantly altered by a contrast agent, hence has
received less attention.
2. Relaxivity
The two relaxivity parameters that are unique to each tissue are Tl
and T2.
Tl is the longitudinal/ spin lattice relaxation time.
T2 is the transverse/ spin relaxation time.
Contrast enhancement depends upon the alteration of these two
relaxivity parameters. They can be categorised on the basis of relative
change each impart on either Tl and T2.
(a) Contrast agent that predominantly affects Tl relaxation is
referred to as a positive relaxation agent because enhanced Tl
shortening leads to increased signal intensity on Tl weighted
image .
(b) Contrast agent that predominantly affects T2 relaxation is
referred to as a negative relaxation agent because T2 shortening
causes decreased signal intensity on T2 weighted images.
3. Magnetic Susceptibility
Susceptibility describes the ability of a substance to become magnetised
in an external magnetic field.
(a) Diamagnetic-negligible effect.
(b) Paramagnetic
(c) Super paramagnetic-Very large positive susceptibility effect
(d) Ferromagnetic
Tl Relaxation Agents
Most commonly used Tl relaxation agents are paramagnetic
substances. Of these Gadolinium is the most frequently used.
Gadolinium is complexed with various ligands that act as chelating
agents. It belongs to the lanthanide metal group. It has a high spin
contrast number which produces a desirable relaxivity contrast agent.
Three agents have been approved by FDA. They are:

1. Gd-HP-D03A : (Gadoteridol/ProHance) - Non ionic
2. Gd-DTPA : (Gadopentetate dimeglurnine/
Magnavist) - Ionic
3. Gd-DTPA-BMA: (Gadodiamide/Ornniscan) - Non ionic
• These function as extracellular contrast agents.
• They are rapidly excreted by glomerular filtration with half
lives between 1-2 hours.
• Agents are distributed only when there is a break in the
blood-brain barrier/in the slowly flowing veins.
• These agents also cause T2 shortening but only at higher
doses.
• As these compounds are excreted by renal excretion, caution
should be exercised in renal impaired patients.
• 3-5% of adverse reactions in the form of nausea.
Dose---0.1-0.3 rnrnol/kg body weight
T2 relaxation agents
Eg. SPIO-Ferrite particles incorporated by super-para magnetic agents.
Of the Ferrite particles, Magnetite(Fe304) is used commonly. These are
crystalline oxides with particle size ranges from 0.5 to 1 micron and
are used in the study of the liver, spleen and GIT studies.
4. Diffusion and Perfusion

Mechanism of action
Ferrite particles are taken up by phagocytes of liver and spleen where
they cause rapid dephasing and hence decreased signal intensity.
Therefore, any metastatic deposit can be seen as higher signal intensity.
Hepatobiliary chelates
2 gadolinium chelates with hepatobiliary excretion are
• Gd-BOPTA & Gd-EOB-DTPA
• MnDPDP (Mangafodipir trisodium)
Both dynamic and delayed scans can be done
Blood pool chelates eg. AMI-227
Reversibly binds to plasma albumin achieving a substantial
improvement in magnitude and duration of blood pool enhancement.
Particulate agents/susceptibility agents

• SPIO
• USPIO
• Magnetite
Predominantly have T2 effects.
Newer applications
1. Spin density contrast agents like Perfluoroctyl bromide (PFOB)
can be used as negative contrast enhancement agents.
2. Using magnetisation transfer, enhancement caused by gadolinium
can be better appreciated.
3. First pass studies with 1.5 T or Echoplanar units by observing the
T2/ T2* effects of a contrast agent can make assessment of blood
flow and brain perfusion.
4. High dose applications-around O.3mmol/kg. body wt for better
detection of lesions.
5. Dysprosium chelates for T2/T2* effects of contrast medium is
observed during bolus transit.
Ionic (Gd-DTPA)
Intravenous
Non ionic (Gadodiamide)
Gd-Labeled Albumin
�
1
lntravascu.:.::::.._i Chromium-Labeled Red Blood Cells
Chromium-Labeled Red Blood Cells
Hepatobiliary 1� Manganese Chloride

Chelates:
MRI
Contrast
AGents Tumor Specific - Monoclonal Antibodies/Metalloporphyrins/
Nitroxides/Ferrioxamine
Gadolinium Oxide
Reticuloendoth Superparamagnetic Iron Oxide
Liposomes
Gastrointestinal I Positive Contrast Agents: Paramagnetic Agents/Short

H-relaxation Agents/Combination Contrast Agents
Negative GI Contrast Agents: Diamagnetic Contrast
Agents/Superparamagnetic Contrast Agents/
Perfluorochemicals
Short Answer Questions

1. Give examples of few ionic monomers and dimers used in diagnostic
radiology.
2. Give examples of few non ionic monomers and dimers used in
diagnostic radiology.
3. Why low osmolar contrast media is preferred for imtravenous
urography studies?
4. Enumerate the features of an ideal contrast media?
5. How will you treat a patient who developed shivering following
intravenous injection of a contrast media?
6. Why do we get reactions when the same contrast media is injected
by intravenous route as compared to intra-arterial route?
7. In which patients non ionic contrast media are preferred as compared
to ionic?
8. What drugs should be available in the emergency tray when you
perform intravenous urography examination?
9. Discuss in brief about commercially available ultrasound contrast
media.
10. Enumerate different contrast media used during the Magnetic
resonance evaluation. What are the organ specific contrast media?
REFERENCES
1. Larser EC. Contrast media for urography. In: Pollack HM (ed).
Clinical urography-An atlas and textbook of urological imaging,
pt edition. Philadelphia: WB Saunders, 1990: 23-26.
2. Stanley Baum, Michael J Pantecost, eds. Abram's angiography:
Interventional Radiology, vol.I, 4 th ed. Boston: Little, Brown, 1997:
13-48.
3. Bettrnann MA. Ionic versus non-ionic contrast agents for intravenous
use: Are all answers in Radiology 1990; 175: 616.
4. Cohan RH, Leder RA. Treatment of adverse reaction to radiographic
contrast media in adults. Radial Clin North Am 1996; 34: 1055-1076.
5. Cohan RH and Dunnick NR. Intravascular contrast media: Adverse
reactions. AJR 1987; 149: 665.
6. Siegle RL and Liebieman P. A review of untoward reaction to
iodinated contrast material. J Urol 1978; 119: 581.
7. Buem NP. Contrast agents for ultrasound imaging and Doppler. In:
Rumack CM, Wilson SR (eds). Diagnostic ultrasound, 2nd edn. St.
Louis: Mosby, 1998: 57-82.
8. David D Stark, William G Bradley, Jr-MRI Vol. 1, 3rd edition, Mosby

1999, Pg No. 257-275
9. RCNA-Hepatic imaging-Liver specific MR Imaging contrast
agents -March 1998:36-2,287-298
10. Robert E Edelman , Micheal B Zlatkin, John R Hesselink Clinical
MRI Vol 1. 2nd edition WB Saunders Company 1996:177-191.
11. Scott W Atlas-MRI of Brain and Spine , 2nd edition, Lippincott
Raven 1996-page 89-108.
Chapter 2
Intravenous Urogram-1.V.U.
• Indications
• Contraindications
• Risk Factors
• Contrast Media
• Preparation
• Procedure
• Filming Technique
• Nephrotomogram
• Modifications of Urogram
• Complications
• After Care
• Ct Urography
• Mr Urography
• References
It is the radiographic examination of urinary tract including renal

parenchyma, calyces and pelvis after intravenous injection of contrast
media. Intravenous pyelogram (IVP) is a misnomer as it implies
visualisation of the pelvis and calyces without the parenchyma. The
term pyelogram is reserved for retrograde studies visualising only the
collecting system.
There has been a decline in the intravenous urograms done over
the last 10 years. This is because of
1. Development of newer imaging modalities like CT Scan,
Ultrasound etc.
2. Cost--containment.
3. Adverse effects of contrast media.
27
INDICATIONS
In Adults
1. Screening of entire urinary tract especially in cases of haematuria
or pyuria.
2. Diseases of renal collecting system and renal pelvis.
3. Differentiation of function of both kidneys.
4. Abnormalities of the ureter.
5. Obstructive uropathy-IVU is the gold standard.
6. TB of the urinary tract.
7. Calculus disease.
8. Potential Renal Donors.
9. Prior to endo-urological procedures and surgery of urinary tract.
10. Suspected renal injury.
11. Renal colic or flank pain.
In Children
Besides the indications mentioned above other indications are
1. VATER anomalies: These patients have vertebral, anal, tracheo
oesophageal, and renal anomalies. Renal anomalies are seen in
about 90% of patients.
2. Malformation of urinary tract, e.g., polycystic disease, PUJ
obstruction etc.
3. Neurological disorders affecting urinary tract.
4. Malformation of genitalia like bilateral cryptorchidism, III degree
hypospadiasis, family history of urinary tract anomalies, urinary
tract infection.
5. Enuresis in the presence of bacteriuria, abnormal urinary sediment,
adolescents, diurnal/ nocturnal incontinence and history of
recurrent urinary tract infection.
6. In girls with constant or intermittent dampness which suggests
an ectopically inserted ureter, IVU is mandatory.
7. Anorectal anomalies.
8. Not recommended for evaluation of UTI unless preliminary voiding
cystourethrogram reveals reflux or some other compelling
indication.
CONTRAINDICATIONS (RELATIVE)
1. Iodine sensitivity.
2. Pregnancy.
Intravenous Urogram-I.V.U. • 29
3. Severe history of anaphylaxis previously carries 30% risk of

similar reaction on a subsequent occasion. The risk is lower with
low osmolar contrast media.
RISK FACTORS
l. Cardiac failure: For patients in cardiac decompensation,
hyperosmolar contrast should not be used as the media intensify
the congestive cardiac failure. Low osmolar contrast media like
Iohexol should be used.
2. Dehydration : Renal shut down may be precipitated especially in
infants, diabetics and in multiple myeloma patients as it causes
protein precipitation (Tamm Horsfall and Bence Jones Protein)
in renal tubules and results in anuria. Dehydration can cause
thrombosis of renal vein and renal failure in children.
3. Diabetes with Azotemia: These patients are prone to nephrotoxic
contrast media effects. 1 in 2000 patients can develop renal shut
down.
4. Previous allergic reaction: In these cases, non-ionic agents should
be used and injectable steroids should be given 12 and 4 hours
before procedure.
5. History of Pheochromocytoma: Contrast media can precipitate
hypertensive crisis.
CONTRAST MEDIA
Doses
In adults I
In children
Non-ionic contrast media
Iohexol-Omnipaque 240 mg I/ml 300mg I/ml
300 mg I/ml-40-80 ml or < 7 kg 4 ml/kg 3 ml/kg
350 mg I/ ml 40-80ml > 7 Kg 3 ml/kg 2 ml/kg
Ionic media
300 to 600 mg Iodine Meglumine iothalamate or diatrizoate
equivalent/kg body weight. 60% containing equivalent of 280 mg I/ I
Maximum of 40 gm of Iodine. ml of iodine. Dose is 1-2 ml /kg body
weight
< 6 months 10 ml
6 months-2 yrs 20 ml
2-10 yrs 20-40 ml.
Mode of injection
Contrast media is usually given as a LV. bolus injection within 30-60
seconds. The density of the nephrogram is directly proportional to
the plasma concentration of contrast media. More iodine increases
the density of the nephrogram. Large doses of contrast media increase
diuresis which distends the collecting system thus increasing the
diagnostic information from the urogram.
PREPARATION
For Adults
1. Ask for any history of Diabetes mellitus, Pheochromocytoma,
Renal disease, or allergy to drugs and any specific foods.
2. Fasting for 4 hours.
3. Do not dehydrate the patient.
4. Bowel preparation:
• Low residue diet like Dal-chapati/Non-vegetation food and
plenty of oral fluids.
• Bowel wash is given till bowel is clear of faecal matter on the
previous night. Conventional enema is not desirable because
it is inadequate for colon cleansing and leave residual air and
fluid in the bowel. However, distal colon enemas can be used
to clean the distal bowel and can be utilised in the place of 'he
suppository.
• Laxatives is recommended to eliminate faecal matter from the
colon and to reduce amount of gas in the bowel.
Dulcolax (Biscodyl) is given 2-4 tablets at bedtime for 2 days prior
to the I.V.U. If this does not cause adequate bowel cleansing then
give castor oil.
Castor oil is an effective catharsis when administered in the dose
of 30-60 ml. Castor oil is contraindicated in cases of abdominal
pain of unknown cause, old and debilitated patients.
In older patients it is advisable to use a suppository in the morning
in addition to oral laxatives.
For Children
1. No paediatric patient should ever be purposely dehydrated as it
is hazardous to do so.
2. Colon should be empty for I.V.U. For this, laxatives can be given.
However, results of laxatives are unpredictable and the compliance
Intravenous Urogram-1.V.U. • 31
in their administration by parents is erratic. Suppositories are

better for this purpose. Cleansing enemas are used in children
older than 2 years. A preliminary film is taken. If it shows undue
gas or faeces in colon the nurse can administer a cleansing enema
using soap suds.
3. The child posted for urography must not have a full stomach to
avoid vomiting. So the child should not be given anything by
mouth for 3-4 hours prior to the procedure.
PROCEDURE
• Patient is placed in supine position with pelvis at cathode side of
the tube.
• A support is placed under patient's knees to reduce lordotic
curvature of lumbosacral spine and provide comfort.
• A scout film is taken including the kidneys, ureters, bladder and
urethral regions on a large size film.
Contrast media is injected intravenously into a prominent vein
in the arm. Test injection of 1ml of contrast is given and patient is
observed for 1 min to look for any contrast reactions. Then the rest
of the contrast is rapidly injected within 30-60 seconds.
Cortical nephrogram is seen within 20 seconds of contrast injection.
This depicts the renal parenchyma opacified by contrast. The
nephrogram is made up of cortical phase due to vascular filling and
a tubular phase due to contrast within the lumen of renal tubule.
Density of the nephrogram depends on the dose of contrast and the
peak plasma level.
The appearance of pyelogram (contrast in calyces) is seen 2 minutes
after contrast injection. During its transit, it may be concentrated as
much as 50 times producing a dense pyelogram.
If a kidney fails to excrete detectable amount of contrast media
into collecting system, it is termed as non-visualising kidney. This
does not necessarily mean that the kidney is not functioning.
In Children
• Equipment should be capable of short exposures to avoid motion
blurring.
• Usually a moving grid is used.
• Source to image distance- 40 inches or 1 metre.
• Contrast - non-ionic best.
• Dose 1-2 ml/kg.

• Filming: The concentrating ability of the kidney is not fully
developed in neonates, so delay is given for initial films. First film
is taken 15 min after. Adequate collimation should be used so as
to reduce total absorbed dose and effect of scattered radiation on
film quality. Fast film-screen combinations and minimum number
of films should be taken.
• Gonadal protective shields should be used.
• If bowel gas obscures the renal region, either paddle compression
technique should be used or place the child in prone position as it
displaces bowel away from the kidneys or use post compression
release technique.
FILMING TECHNIQUE
Low KV (65-75) high mA (600-1000) and short exposure should be
used to get optimum image contrast.
Standard Films Taken

• Plain X-ray KUB /Scout film-14" x 17"
• 1 minute film-10" x 12"
• Post void film-10" x 8"
Plain X-ray KUB /Scout film provides valuable information and
sometimes indicates probable diagnosis. Useful in assessing
• Calculus
• Intestinal abnormalities
• Intestinal gas pattern
• Calcification
• Abdominal mass
• Foreign body
1 minute film shows nephrogram. This radiograph is often omitted
as the renal outlines are usually adequately visualised on 5 minute
film.
5 minutefilm shows nephrogram, renal pelvis, upper part of ureter.
Compression band is now applied on patient's abdomen and the
balloon is positioned on anterior superior iliac spine where ureters

cross pelvic brim. This is to produce better pelvicalyceal distension.
Compression contraindicated in:

1. Renal trauma
2. Large abdominal mass
3. Abdominal aneurysm
4. After abdominal surgery
5. If 5 minute film shows dilated calyces or if calyces and pelvis
are not adequately opacified, obstruction exists and compression
band should not be applied
If compression is applied, a film is taken after 5 minutes of
compression i.e. 10 minute film, centred on kidneys to demonstrate
distended collecting system and proximal ureters.
15 minute film: Visualisation of ureter is better in prone position as
they fill better. This position reverses the curve of the inferior course
of the ureters making it anti-dependent to gravity. Another method
to see ureter is modified trendelenberg technique with 15-20 degrees
head low tilt with the patient supine.
35 minute film: It gives complete overview of the urinary tract ;
kidney, ureter, bladder. Bladder distension can be evaluated.
Post void film: Taken immediately after voiding. It is used to assess
for
1. Residual urine; 2. Bladder mucosa! lesions; 3. Diverticula; 4.
Bladder tumour; 5. Outlet obstruction; and 6. VUR.
Note: All films are taken in full expiratory phase only.
Special films in IVU

l. Oblique view: To project the ureter away from spine and to separate
overlying radio opaque shadows mimicking calculi. Oblique
views are also used for visualisation of posterolateral aspects of
bladder; differentiation of extrinsic or intrinsic renal, ureteral or
bladder masses and for doubtful urethral masses.
2. Erect film is used to
• Provoke emptying of urinary tract;
• Demonstrate layering of calculi in cysts and abscesses;
• Detect urinary tract gas not seen in other films;
• Have optimum demonstration of renal ptosis, bladder hernia,
cystocele and areas of obstruction in ureter.
3. Prone film is used for

• Viewing of ureteral areas not seen in supine films,
• Demonstration of renal ptosis and bladder hernia.
4. Delayed films in IVU are taken 1-24 hours after injection. Patients
should always be instructed to void prior to delayed films so that
a calculus in the distal ureter is seen well.
Usual sequence of delayed films is after 1 hr, 3hrs, 6 hrs, 12 hrs
and 24 hrs.
Delayed films are used in
• Cases of obstruction where early nephrogram is seen but
collecting system is not seen.
• Long standing hydronephrosis in which renal parenchyma is
seen but collecting system is not visualised until many hours
later.
• Congenital lesions like non-visualised upper calyceal system
with ectopic or obstructed ureter.
Filming in Children
• Films are taken at 2min. (supine) and 7 min. (prone) after contrast
administration. Further films are taken depending on the case.
• To improve visualisation of left kidney, child can be given a
carbonated beverage as gas filled stomach displaces bowel. If not
adequate, right posterior oblique view is taken to show the left
kidney.
• The right kidney can be well seen through the liver in a 15-20
degree caudal tilted view.
• In most of the cases one preliminary and two post contrast films
will be sufficient.
In neonates, excretion of contrast media is delayed and prolonged
in the first month of life due to immaturity of the tissue. The
concentration of the contrast is also relatively poor.
NEPHROTOMOGRAM
This consists of rapid injection of contrast media followed by
tomography.
Indications
1. Mass lesion of renal parenchyma--cysts/tumours.
Intravenous Urograrn-1.V.U. • 35
2. Demonstrate damage to renal parenchy ma from infection or

infarct.
3. Exact localization of the mass.
4. Detection of parenchy mal scars.
5. Adrenal tumours.
6. Anomalies-horse shoe kidney, pelvic kidney.
7. Poor contrast concentration.
8. Renal trauma.
Technique
Patient is placed supine on X-ray table. Preliminary tomograms are
taken 6 cm and 9 cm from table top and contrast is injected rapidly.
For nephrotomogram body sections are taken at 1cm intervals, 60-90
seconds after end of injection. The tomograms should be taken at the
period of maximum intensity of nephrogram.
Tomogram levels
8, 9, 10 cm from table top for normal adult.
9, 10, 11 cm in heavier patient.
7, 8, 9 cm in thin patient.
5, 6, 7 cm for children.
• Linear tomogram is superior to complex motion tomography. 40-
50 tube arc gives the best tomographic effect.
• Since upper poles of the kidneys are located more posteriorly
than the lower poles, upper poles are seen better in posterior
tomograms and lower poles on anterior tomograms.
• A nephrotomogram at 12-20 seconds after commencement of
contrast injection (Arm-Kidney time) may demonstrate a
vascular phase with delineation of renal vascularity.
• A tomogram at 30-45 seconds shows dense parenchymal
opacification, delineation of cortex, medulla, corticomedullary
junction and also lobar anatomy of kidney.
• A series of tomograms (1-4 minute) shows homogeneous uniform,
increased density of parenchyma and no delineation of cortex
and medulla.
For obliteration of bowel gas, 8-10 degrees tube arc (Zonogram)
is used.
MODIFICATIONS OF UROGRAM
1. Diuretic urogram
• It is useful when intermittent obstruction is suspected but
cannot be confirmed by standard urogram. Therefore the use
of diuretics shows an acutely developing hydronephrosis if true
intermittent hydronephrosis is present.
• I.V. frusemide is used to induce diuresis which distends the
renal pelvis. The dose of Lasix is 0 .3-1 mg/kg in adults and
0.5 mg/kg in children.
• The film is taken 5-10 minutes after administering the diuretic.
2. Tailored urogram
• It modifies the urogram to provide the information needed to
include or exclude the clinical problem and tailor the urogram
for that. The study is terminated as soon as the desired
information is available.
3. Hypertensive urogram
• It is also called minute sequence urogram. Films are taken 1, 2, 3, 5
minutes after injection of contrast media. Although the findings
are of value, IVU cannot be used for screening of hypertensives
as there are many false positive and false negative results.
4. Drip infusion urography

• Contrast is given in 500 ml normal saline. Now, this procedure
is not widely used.
Advantages
• Nephrogram persists for longer time.
• Enhanced diuresis from the additional contrast media and water
volume will distend the collecting system and ureters more fully.
• Collecting system is visualised for longer times.
• No significant increase in contrast reactions.
• Ureteral compression need not be used because excellent ureteral
visualization is usually obtained.
• Administration is easy.
Disadvantages
• Overloads the patient with more Iodine than necessary.
• Calyceal blunting may be produced, suggesting abnormal dilatation.
• May lead to pyelosinus extravasation and pain in patients with

partial obstruction.
• Increased diuresis may decrease visualization if there is low fixed
specific gravity.
• May cause CCF in patients with borderline cardiac complaints.
• An initial vascular nephrogram is not obtained.
5. Limited urography
• The procedure is useful for follow up of earlier pathology. Films
taken : KUB; 15 min; Post void
6. Emergency urography
• It is done in cases of urinary colic. Films taken : KUB; 15 min
7. High dose urography

Indications
- Renal failure
- Ureteric Obstruction
- Emergency Urography
- Cystourethrography
- Suprarenal tumors
- Inadequate bowel preparation
- Retrocaval ureter
- Vesical fistula
- Percutaneous Nephrostomy
- Poor bowel preparation
• Used in mild renal impairment, it provides more information about
calyces than on US/CT.
• If US/CT cannot exclude obstruction (e.g., in presence of multiple
cysts).
• The unfavourable effect on urogram of decreased GFR and
impaired renal concentration in renal failure, can be counteracted
by increasing contrast medium dose to 600 mg I /kg, i.e., double
the normal dose.
• Patient should be well hydrated with normal metabolic and CVS
function at the time of the procedure. In some with impaired renal
function, there is an increase in serum creatinine following IV
contrast.
• Low osmolality non-ionic contrast media are preferred because of

less nephrotoxicity.
• IVU can be attempted up to a serum creatinine level of 5 mg%
(preferably using non-ionic contrast).
• Risk factors for the development of ARF after HDU :
- Diabetes
- Dehydration or fluid restriction before urogram
- Myxedema
- Repeated contrast procedures in a short period of time.
- Large doses of contrast
- Age > 60 yrs.
COMPLICATIONS
Due to Contrast
• Minor reactions (5%): Nausea, vomiting, mild rash, light headache,
mild dyspnoea.
• Intermediate reactions (1 %): Extensive urticaria, facial oedema,
bronchospasm, laryngeal oedema, dyspnoea, hypotension.
• Severe reactions (0.05%): Circulatory collapse, pulmonary oedema,
severe angina, myocardial infarction, convulsions, coma, cardiac or
respiratory arrest.
Due to Technique
• Upper arm or shoulder pain.
• Extravasation of contrast at the injection site.
Initial treatment
• Elevation of affected extremity above the heart.
• Ice packs (15-60 minute applications three times
per day for 1-3 days).
• Close observation for 2-4 hours (if volume exceeds 5 ml).
• Call referring physician (for any extravasation over 5 ml).
• Local injection of hyaluronidase (15-250 IU)-controversial.
Immediate plastic surgery consultation for the following

indications:
• Extravasated volume exceeds 30 ml of conventional ionic or 100 ml
of non-ionic contrast material.
• Skin blistering.
• Altered tissue perfusion (decreased capillary refill over or distal to
injection site).
• Increasing pain after 2-4 hours.
• Change in sensation distal to site of extravastion.
Daily phone calls by nurse or radiologist until manifestations

resolve to assess for the following:
• Residual pain.
• Blistering.
• Redness or other skin color change.
• Hardness.
• Increased or decreased temperature of skin at extravasation site
(compared with temperature of skin elsewhere).
• Change in sensation.
Documentation
• Contrast material extravasation form (for departmental monitoring
and quality assurance).
• Progress note (for medical record).
• Abdominal compression may cause hypotension/ syncope, forniceal
rupture of the calyces.
• Rarely extravasation of contrast in perinephric retroperitoneal space
may occur as a consequence of which, a perinephric abscess and
phlegmon may form if the urine is infected.
AFTER CARE
1. Observation for 6 hours.
2. Watch for late contrast reactions.
3. Prevention of dehydration.
4. In high risk patients-renal function tests should be done to
watch for deterioration.
MR OROGRAPHY
MR Urography techniques for visualizing urinary tract are mainly
divided into 2 categories:
1. Static fluid urography: Here
heavily T2-weighted sequences
are obtained to image the
urinary tract. It is most useful
in patients with dilated or
obstructed collecting systems
2. Excretory MR Urography: It is
performed during the excretory
phase of enhancement after IV
administration of Gadolinium
based contrast material. For
this technique, the patient must
have sufficient renal function to MR Urography
allow the excretion of contrast
material. Diuretic administration is an important factor in MR
Urography for better demonstration of non- dilated systems.
Advantages of MR Urography:
1. Useful in pediatric and pregnant patients as ionizing radiation is
avoided
2. Evaluation of the renal vasculature (artery and vein) is possible
Disadvantages of MR Urography:
1. Cost factor
2. The results are not encouraging in evaluation of the renal calculi.
Long Answer Questions-----------------

1. Define intravenous urography. What are the indications,
contraindications and preparation required for intravenous
urography? Describe the procedure in brief.
Short Answer Questions---- - - - - -- --- -

1. What are the indications for intravenous urography in adults and
in children?
2. What precautions will you take while performing intravenous

urography in patients with cardiac failure and multiple myeloma?
3. What contrast media are used in adults and children while
performing intravenous urography? What is the dose of contrast
media injected?
4. How will you prepare a patient for intravenous urography?
5. What is compression band? what is its use in intravenous urography?
state the contraindications for using compression bands.
6. What are the special views taken in intravenous urography for
• visualizing ureter
• calculi in cyst
• renal ptosis
7. How will you modify intravenous urography in following conditions
• hypertension
• intermittent obstruction
• urinary colic
8. State the complications of intravenous urography due to contrast
and due to technique.
REFERENCES
1. Nicholae Papanicolau. Urinary tract imaging and intervention : Basic
principles. In : Walsh PC, Retik AB, Varghan ED, Wein AJ (eds) :
Campbell's Urology, 7th ed. Philadelphia : WB Saunders, 1998: 172-188.
2. JS Dunbar. Excretory urography. In : Pollack HM (ed). Clinical
urography-An atlas and textbook of urological imaging, 1st edition.
Philadelphia : WB Saunders, 1990 : 101-202.
3. Radiological investigation of the urinary tract. In : Elkin M (ed).
Radiology of the urinary sy stem, 1st ed. Boston: Little, Brown, 1980 :
2-22.
4. Diagnostic uroradiologic techniques. In : Alan J. Davidson, David S.
Hartman DS (eds). Radiology of the kidney and urinary tract, 2nd ed.
Philadelphia : WB Saunders, 1994 : 3-19.
5. Williamson B Jr., Hartman GW. Intravenous urographic technique.
Radiology 1988; 167 : 593-599.
6. M Noroozian, RH Cohan etal: Multislice CT Orography: state of the
art. British Journal of Radiology (2004) 77, S74-S86.
7. Akira Kawashima, Terri J Vrtiska etal: CT Urography. Radio Graphics
2004; 24: S35-S54.
8. Verswijvel Geert, Oyen R: Magnetic Resonance Imaging in the
Detection and Characterization of Renal Diseases. Saudi Journal of
Kidney Diseases and Transplantation. Year 2004. Volume 15. Issue
3. Page 283-299 .
..
Chapter 3
Micturating Cystourethrogram (MCU)

• Indications
• Contrast Media
• Procedure
• Complications
• Other Techniques
• References
Urethrography is of 2 types:
1. Asending - where contrast is injected into the urethra. It is
mainly used to demonstrate anterior urethra.
2. Desending - Similar to MCU
- used to demonstrate Posterior urethra
Voiding cystourethrogram demonstrates the lower urinary tract
and helps to detect the existence of any vesico-ureteral reflux, bladder
pathology and congenital or acquired anomalies of bladder outflow
tract.
INDICATIONS
Children
1. UTI-Usually done after some weeks after acute stage or may be
done under antibiotic coverage. MCU is indicated after the 1st
occurrence of UTI in boys or girls.
2. Voiding difficulties like dysuria, thin stream, dribbling, frequency,
urgency.
3. Vesico ureteric reflux.
4. Other congenital anomalies : Meningomyelocele, Sacral agenesis,
Rectal anomalies.
5. Baseline study prior to lower UT surgery.
6. For post operative evaluation of ureteric abnormalities.
7. Pelvic Trauma.
Micturating Cystourethrograrn (MCU) • 43
8. In renal failure to exclude reflux.

9. Boys with hematuria-MCU can demonstrate posterior uretheral
valve or polyp.
Adults
Main indications
1. Trauma to urethra.
2. Urethral stricture.
3. Suspected urethral diverticula.
Other indications
1. UTI.
2. Reflux nephropathy prior to renal transplant of one/both
kidneys.
3. Follow up of patients with spinal cord injury.
CONTRAST MEDIA
Water soluble constrast media like Conray 280, Trivideo 400 mg,
Urograffin 60% are used which is diluted with normal saline in 1
3 ratio.
PROCEDURE
Using sterile technique, a catheter is introduced into the bladder. A
SF feeding tube with side holes are used for children and in older
children SF or lOF polyethylene or soft rubber catheters with end
holes are suitable.
In girls after an initial inspection of the perineum to identity any
local genital abnormalities (like cystoceles, or labial fusion etc.,) the
urethral catheter is inserted. W hen it enters the bladder a varying
amount of urine will flow through it. If there is no flow the catheter
is advanced until urine is obtained. Suprapubic pressure is sometimes
helpful in expressing a small amount of urine in the near empty
bladder. If no urine is obtained the catheter may have been inserted
into the vagina.
In males, the foreskin is retracted and catheter is introduced. The
catheter should be lubricated with an anaesthetic jelly and inserted
slowly and gently into the urethra holding the penis in a vertical
position.
The normal bladder capacity in children is estimated in ounces
,.
(1 ounce = 29 cc) as age (in years) x 2. In the bladder of newborns,

30-50 cc can be instilled with ease. From about 3 years, girls can hold
upto 200-250 cc and from 12 years even more. The capacity in boys is,
100-150 cc upto 5-6 years of age and 250 cc in older boys. Adequate
capacity is reached when the child becomes uncomfortable and begins
voiding around the catheter.
Filming
In children
In children up to the age of 2 yrs bladder is filled by hand injection.
For older children contrast medium is instilled from a bottle elevated
one metre above examination table.
During filling, fluoroscopic screening is performed at short intervals
to see if vesicoureteral reflux, diverticuli or other abnormalities are
present. The child is turned oblique on both sides to ensure that
minimal reflux is not overlooked.
If reflux appears, films are taken in the appropriate oblique
projection. If the bladder appears normal, one film is taken in the
frontal projection at the end of filling.
Voiding starts in infants the moment the catheter is removed. At
the end of voiding, a frontal film is made of the entire abdomen
including the kidney region in order to prevent overlooking the
vesicoureteral reflux which is apparent only on termination of voiding
and may reach the upper collecting system.
In adult male
Bladder is filled in the usual way as in a older child and voiding
filming is done in both oblique projection. The voiding study in male
adults can be modified by getting the patient to void against resistance,
i.e., either by compression of the distal part of penis or by using a
penile clamp. This is known as CHOKE CYSTOURETHROGRAPHY
which enhances visualization of urethera by the artificial distension.
In adult female
The procedure is essentially the same as in girls.
In addition to the standard exposures, a double exposed film
taken at rest and during straining demonstrates the degree of bladder
descent if any.
...
Micturating Cystourethrogram (MCU) • 45
COMPLICATIONS
1. Danger of attendant infection due to catheterization of bladder.
2. Adverse reactions may result from absorption of contrast medium
by bladder mucosa.
3. Due to technique:
• Acute urinary tract infection.
• Catheter trauma causing dysuria, frequency hematuria and
urinary retention.
• Complications of bladder filling, e.g. perforation by the catheter
or from over distention.
• Catheterization of vagina or ectopic ureteral orifice.
• Retention of a Foley's catheter.
• Radiation effect: VCU is a diagnostic procedure that inevitably
exposes gonads to some radiation. It should be kept to a
minimum. Careful attention to ensure very short screening
periods. Tightly collimated X-ray beam.
4. Autonomic dysreflexia: In paraplegic patients due to spinal cord
injury at or above T 6 level, forceful injection of contrast causes
severe headache, sweating and hypertension with bradycardia
due to forceful opening of the bladder neck. Treat by promptly
relieving vesical distension or give diazoxide 3-5 mg/kg.
OTHER TECHNIQUES
Excretion MCU (MCU followed by IVU)
• This method makes use of contrast media accumulated m the
urinary blader during intravenous urography.
Advantages
• Avoidance of physical and psychological trauma of catheterization.
• Avoidance of possible infection by uretheral catheterization.
• More physiological procedure hence can be more reliable.
Disadvantages
• Visualization is not usually adequate.
• Takes longer time.
• Vesico ureteric reflux cannot be visualized properly.
,.
Long Answer Questions----------------

1. Discuss micturating cystourethrography. under the following
headings:
(a) Indications in children and adults
(b) Contrast media
(c) Procedure
(d) Complications
Short Answer Questions----------------

1. What do you mean by micturating cystourethrography? What are
the indications for performing this procedure in children and adults.
2. Describe in brief the complications of micturating cystourethrography.
3. Write a short note on descending cysto urethrography.
REFERENCES
1. Marjorie Hertz. Cystourethrography. In : Pollack HM (ed). Clinical
urography-An atlas and textbook of urological imaging, 1st edition.
Philadelphia: WB Saunders, 1990 : 256-275.
2. Walsh PC, Retik AB, Varghan ED, Wein AJ (eds.) : Campbell's
Urology, 7th ed. Philadelphia : WB Saunders, 1998 : 188-192.
3. Radiological investigation of the urinary tract. In : Elkin M (ed).
Radiology of the urinary system, 1st ed. Boston : Little, Brown, 1980
: 25-32.
4. Papanicolaou N, Yoder IC. Diagnostic morphologic and urodynamic
antegrade pyelography. Radiol Clin North Am 1986; 24 : 561-571.
Chapter 4
Retrograde Pyeloureterography
• Definition
• Indications
• Contrast Medium
• Procedure
• After Care
• Complications
• Comparison of MCU & RGU
With Newer Modalities
• References
�-:" ....., --r-
Ii
...::....�- _ - --,·----
_._....
DEFINITION
It is the roentgenographic demonstration of the renal pelvis and
ureter by the retrograde injection of radio-opaque material through
the ureters.
INDICATIONS
1. Absent or unsatisfactory visualisation of the collecting system on
IVU.
2. Unexplained hematuria, when the ureters have not been completely
visualised by IVU.
3. Evaluating persistent intraureteral or intrapelvic filling defects on
IVU.
4. Demonstrating the exact site of ureteral fistula.
5. Brushing and/ or biopsy of suspected lesions.
6. Evaluating the collecting system in patients who cannot receive
intravenous contrast medium
CONTRAINDICATIONS
• Acute urinary tract infection.
• 47
CONTRAST MEDIUM
• Ionic contrast media can be used safely, however if there is any
specific contraindication like known hypersensitivity etc., Non ionic
contrast media may be used. The Ionic contrast media is preferred
due to its low cost. The strength of contrast media should be
150-200 mg I/ml.
• Contrast media should not be too dense as it will obscure small
lesions in the ureters and the pelvis.
PROCEDURE
Patient Preparation
• Bowel preparation with cathartics is not routinely performed.
Preliminary Film
• Full length supine AP abdomen before the examination is started.
Anaesthesia
• May be performed under local anaesthesia although general
anesthesia is often required. Sterile precautions are mandatory.
Technique
In the Operation theatre
• The surgeon catheterizes the ureter via a cystoscope and advances
the ureteric catheter to the desired level. Contrast medium is
injected under fluoroscopic control and spot films are exposed.
In the X-Ray Department

• With ureteric catheter(s) in situ, the patient is transferred from the
operation theatre to the X-ray department if necessary.
• Urine is aspirated and under fluoroscopic control contrast medium
is slowly injected. About 3-5 ml is usually enough to fill the pelvis
but the injection should be terminated before this if the patient
complains of pain or fullness in the loin.
Films
Using the undercouch tube
(a) Supine PA film of the kidney
(b) Both 35° anterior obliques of the kidneys. Low kVp (65-75 kVp)
technique is used to visualise calculi and contrast medium.
Retrograde Pyeloureterography • 49
(c) If there is pelvi-ureteric junction obstruction, the contrast medium

in the pelvis is aspirated. The films are examined and if satisfactory,
the catheter is withdrawn, first to 10 cm below the renal pelvis
and then to lie above the ureteric orifice. About 2ml of contrast
medium is injected at each of these levels and films taken.
AFTER CARE
1. Postanaesthetic observation.
2. Prophylatic antibiotics may be used.
COMPLICATIONS
1. Due to anaesthetic
• Complications of general anaesthesia.
2. Due to the contrast medium

• Contrast medium can be absorbed from the renal pelvis, giving
rise to adverse reactions. However, the risks are much less than
with excretory urography.
• Chemical pyelitis-if there is stasis of contrast medium.
• Extravasation due to overdistension of the pelvis.
3. Due to technique
• Introduction of infection
• Mucosal damage to the ureter
• Perforation of the ureter or pelvis by the catheter
COMPARISON OF MRMCU AND RGU

WITH NEWER MODALITIES
Advantages of MR - MCU and RGU
1. These studies are most valuable to detect congenital anomalies,
posterior urethral injuries, and with urethral and periurethral
tumours.
2. It is a better imaging modality for assessing the post traumatic
pelvic anatomy & non-invasive method for measuring stricture
length.
3. It clearly shows the extent of scar tissue as well as prostatic
displacement.
4. MR uretherography is more accurate in estimating the length of

obliterative urethral stricture than RGU combined with Voiding
cystouretherography
Limitations of conventional RGU combined with voiding

cystouretherography:
1. It does not provide accurate length of the defect because of poor
prostatic urethral filling.
2. It does not provide information regarding extent of fibrosis of
corpora spongiosa or prostatic displacement.
3. The stricture length is overestimated if bladder neck does not
relax.
Advantages of CT urethrography
1. C.T. voiding uretherography is more comfortable to the patient
because it requires adaptation only in one position.
2. Less time consuming; takes only few seconds
3. Comparison of lurninal size & stricture length for follow up is
possible.
4. Extralurninal pathology can be detected
5. Good patient compliance
6. Ability to survey whole urinary tract from kidney to urethra.

1.What is retrograde pyelography? State its indications and
contraindications.
2.Mention the complications of retrograde pyelography .
3.Draw a figure of normal urethra in males.
4.Draw a section prostatic urethra.
REFERENCES
1. Retrograde pyelography. In : Pollack HM (ed.). Clinical urography
An atlas and textbook of urological imaging, 1st edition. Philadelphia
: WB Saunders, 1990 : 101-202.
2. Walsh PC, Retik AB, Varghan ED, Wein AJ (eds) : Campbell's
Urology, 5th ed. Philadelphia: WB Saunders, 1986: 325-327.
Chapter 5
Contrast Media in GIT

• Introduction
• Properties of An Ideal Barium Preparation
• Advantages of Barium Sulphate Preparation
• Manufacture
• Characteristics Influencing Coating
• Adverse Effects
• Other Contrast Media Used
• Contrast Media For CT in GIT
• Contrast Media For MRI in GIT
• References
INTRODUCTION
The earliest contrast medium used in the GIT was iodised oil
(lipiodol). However, due to its oily nature, it did not coat the mucosa.
Hence, later, Bismuth sulphate came to be used.
At present the contrast medium of choice is Barium sulphate. The
reasons for using Barium sulphate for GI studies are
(a) Ba has a high atomic number 56. Therefore, it is highly
radioopaque
(b) Non absorbable, non-toxic.
(c) Insoluble in water/lipid.
(d) Inert to tissues.
(e) Can be used for double contrast studies.
PROPERTIES OF AN IDEAL BARIUM PREPARATION

1. High density for optimum study being performed.
2. Stable suspension which does not settle.
3. Should not flocculate with secretions.
4. Low melting characteristics to give a good and stable mucosal
coating.
51
ADVANTAGES OF BARIUM SULPHATE PREPARATION

1. Non-absorbable. Therefore Barium does not get degraded
throughout the bowel.
2. Suitable for double contrast studies as it coats the mucosa in a
thin layer, thus allows the introduction of 2nd or negative contrast
agent without significant degradation.
MANUFACTURE
Barium sulphate is obtained from the mines by chemical precipitation
in order to remove the impurities.
Steps
1. Mined Barium sulphate is reduced to Barium sulphide (soluble).
2. Barium sulphide + Sodium carbonate � Barium carbonate
(Poisonous).
3. Barium carbonate + Sulphuric acid � Insoluble Barium sulphate.
The particle size can be reduced by processing the powder in a
high speed pounding, machine.
Average particle size of precipitated barium sulphate ranges from
0.3 µm to � 12 µm .
0.3 µm particles are used along with large particles to enhance
coating and suspending properties of large particles. By themselves
small particles resist wetting. Particles towards the size of 12 µm are
generaly used for low viscosity, high density barium.
High density barium contains, a mixture of different sized particles,
that also results in increased viscosity. Viscosity can be reduced by the
addition of additives and suspending agents, which are proprietary,
e.g., microbar H.D. 200% w/v _for double contrast studies of upper
G.I. Tract.
BaSO4, being insoluble in water, is used in the form of a suspension.
The concentration of the suspension is indicated by weight/volume.
E.g.: 100% suspension contains 100 gm of BaSO4 in 100 ml of
prepared suspension.
Dilution
There are 3 systems to describe a particular dilution.
Weight by weight - wlw suspension

Specified weight of Barium sulphate is used and enough water is
then added to obtain a certain total weight.
Contrast Media in GIT • 53
E.g.: 30% w/w suspension is to weigh 30 g of Barium sulphate

and add 70 g of water to it for a total wt. of 100 g.
(1 gm of water = 1 ml of water).
Weight by volume - w/v suspension

Here a specified weight of Barium sulphate is determined and enough
water is added to obtain a certain total volume.
E.g.: 80% w/v suspension is to weigh 80gm Barium sulphate
and to add enough water to make the total volume upto 100 ml
suspension.
Volume by Volume - vlv suspension.

This system is possible but not recommended. A unit volume of dry
barium sulphate can vary considerably, depending on the degree of
packing.
Thick and thin barium are meaningless terms.
Specific gravity:
Weight of 1 litre of Barium solution
S.G. = ---'------------
Weight of 1 litre of water
Mixing
This is a very important step to assure a stable suspension. Use
of a high speed and high shear mixer ensures melting of the
Barium sulphate particles and also mixes the particles evenly in the
suspension. This ensures that the suspension is stable. It should be
mixed for atleast 15 min. continuously, to assure stability just before
the suspension is administered.
Commercially prepared Barium formulations in India are
manufactured by M/s. Eskayef Fine Chemicals Ltd. under the brand
name of 'MICROBAR' in the following specifications.
1. Microbar paste: 100% high viscosity paste in collapsible tubes.
This is a high density, high viscosity preparation used for
conventional studies of the pharynx and oesophagus.
2. Microbar suspension: 95% moderate density and viscosity
suspension for oesophagus, stomach and small intestinal
studies. Marketed in one litre bottles.
3. Microbar HD: 200% high density, low viscosity preparation,
supplied in a powder form in a tumbler pack. By adding 70 ml
of water to this and shaking the tumbler the desired amount
of suspension is formed which is ideal for double contrast
studies for oesophagus, stomach and duodenum. Sachets of
gas producing powder are supplied with the pack.
4. Microbar for enema : One and five kg packs of powder are

available. Desired suspension can be prepared.
How to prepare your own Barium suspension?

To prepare one litre of 50% suspension, take a small amount of water
(about 200 ml) and add 5 gm of Carboxy Methyl cellulose (C.M.C) to
it and mix well. Take 500 gm of Barium sulphate powder and add a
little of it at a time to the water, mixing continuously till a thick paste
is formed. This will prevent formation of clumps of the barium. To
this paste, add enough water to make up the volume of the mixture
to one litre and mix it well.
Then add the preservatives, antifoarning agents and antacids. The
whole mixture should then be mixed for 15 minutes, using a high
speed mixer to form a good suspension. This type of preparation
should not be diluted, otherwise it will tend to settle. The preparation
should also not be stored for a long time.
CHARACTERIS TICS INFLUENCING COATING

Additives
Additives are added to influence the rate of settling, viscosity, charge,
mucosal coating, thickness and flocculation. If too much of an additive
is used, the viscosity will be so high that the suspension flows only
with difficulty. Exact additives added by the manufacturers are kept
as a trade secret, but a varied range of additives can be used when we
prepare our own Barium sulphate suspension to achieve the required
properties.
Density
The appropriate density is achieved by making the suspension using
the required weight of Barium sulphate powder. Measuring Barium
powder using cups cannot be a standard preparation because the
compactness of filling the cup will vary. In addition the powder at
the top of the packet is made up of larger particles and hence will
have lesser weight as compared to the powder at the bottom which
is finer and more compact.
Stability
It indicates that the suspension will not settle down when allowed to
stand. Suspending agents like Gum acacia or carboxyrnethyl cellulose
(CMC) are used to prevent settling. These agents increase the viscosity
of the suspension, hence should be used in minimum amount to

attain the required stability. T he suspension is considered to be of
adequate stability, if it does not settle at the rate of more than 1/10
at the end of 3 hours.
CMC is hygroscopic, therefore retains water and prevents settling
of the particles. Hence it prevents sedimentation and size of the
particle remains the same.
Flocculation
Flocculation is the reduction in the number of particles by the
formation of larger masses. When the suspension comes in contact
with ionic solutions like intestinal or gastric secretion, the suspension
will form clumps. To prevent this, antacids are added which will
neutralise the gastric acid and prevent flocculation. They will also
make the suspension alkaline so that the intestinal secretions which
are alkaline will not cause flocculation.
Antacids used are
• Sodium citrate (commonly used).
• Aluminium hydroxide.
• Magnesium sulphate.
Preservatives
Plain Barium sulphate is inert. Since additives are added to it, we
get fungal growth. So preservatives are needed. Previously Methyl
paraben was used. Now Sodium metabisulphate is used.
Antifoaming agents
Simethicone or Melthylpolysiloxone are added to prevent formation
of air bubbles which mimic polyps (artifacts). They act by reducing
the surface tension of the gas bubbles enabling them to coalesce thus
facilitating gaseous release.
Coloring agent
Erythrocin is used.
Sweetening agent
Saccharine or fruit essences are used to mask the unpleasant chalky
taste of barium and produce less nausea. Chocolate is not commonly
used because of possible allergic reaction.
ADVERSE EFFECTS
1. Chemical peritonitis due to extravasation of additives of Barium
sulphate.
2. Extravasation into bronchial tree, urinary tract and other body
cavities will produce inflammation.
3. Barium inspissation in cases of colonic obstruction to form hard
stones.
4. Intravascular entry of Barium can cause embolism.
5. Appendicitis-not proved.
6. Barium Encephalopathy.
Small amount of Barium can absorbed from the peritoneum in
case of perforation
j,
Circulation
j,
Concentrates in CSF with detectable levels
j,
Encephalopathy
7. Previous contrast media extravasated may mimic cancer due to
inflammation. Longstanding barium deposits are carcinogenic.
OTHER CONTRAST MEDIA USED

Gastrograffin
20 ml of Urograffin 76% + 20 ml of Normal Saline + 2 drops of
Sorbitol (melting agent) which gives a better mucosal coating. Mix
thorough!y.
Indications
1. Suspected perforation.
2. Suspected fistula.
3. History of recent biopsy.
4. Suspected Lower Intestinal obstruction.
5. Corrosive poisoning.
6. Meconium ileus/plug syndrome.
7. Immediate post operation status.
Non-ionic Contrast Media

Low osmolar contrast media give better opacification of the GIT and
due to low osmolarity because less electrolyte imbalance and can

delineate small intestine better than ionic media due to less dilution.
But they are expensive.
Oral Cocktail
Mixture of Barium sulphate, Magnesium sulphate and a low osmolar
non-ionic contrast media. The latter two absorb water into the bowel
and dissolve Barium sulphate. Therefore, barium moves very fast in
the GIT.
Air/CO2
To diagnose intussusception.
Water
To diagnose Lipomatosis of colon which appears more lucent
compared to the water column.
CONTRAST MEDIA FOR CT IN GIT

Techniques employed in CT are chosen to maximize delineation of
normal anatomic structures, accurately identify pathologic processes
and ensure optimal utilization and operational efficiency.
For Stomach and Small Bowel

To a large extent, the sensitivity of CT in diagnosing pathology
depends on adequate bowel opacification and distension, as the basic
radiopathologic finding in a variety of diseases is thickening of the
intestinal wall. Therefore, the gut in question must be distended and
filled with a contrast agent. That permits the wall of the bowel to be
assessed accurately.
The ideal gut contrast agent

• Should fill the entire bowel lumen
• Should be palatable
• Non-irritating to the intestinal mucosa
• Should pass rapidly through the GI tract without producing artifacts
or stimulating vigorous intestinal peristalsis.
• Preferably the contrast media should coat the gut mucosa so that the
presence of bowel lesion is detectable when the lumen is not
distended.
A positive contrast material must increase the CT attenuation
value of bowel lumen atleast by 40HU. This can be done by using

dilute solutions of water soluble media or dilute suspensions of
Barium sulphate.
Conventional BaSO4 suspension are too dense resulting in streak
artifacts when administered. The commercial introduction of dilute
1-2% BaSO4 solutions containing special suspending agents has
permitted dilute barium to remain homogeneously suspended as it
passes through the GI tract.
A solution of 2-3% Meglumine diatrazoate increases the CT
attenuation value of the gut enough to permit a reliable differentiation
from the surrounding tissues. Although water soluble contrast agents
pass rapidly through the gut, they do not coat the gut wall and have
a poor taste. They tend to become diluted as they reach the terminal
ileum and thus the distal small bowel may be poorly demarcated.
Special Techniques
• Glucagon injection (0.1 mg iv /im) can be used for reducing gut
motility and motion artifacts.
• Octapeptide injections to briefly stimulate small bowel peristalsis.
• Metaclopramide 10 mg orally, 45 minutes before CT study rapidly
empties the stomach and improves opacification of ileum.
For Colon
Colon and rectum may be opacified using dilute iodinated solutions
1-2% as a 200-600 ml enema. Air contrast studies have been recently
advocated as the method of choice to evaluate the colon. This is
contraindicated in acute diverticulitis, inflammatory bowel disease
or radiation proctitis.
CONTRAST MEDIA FOR MRI IN GIT

GI contrast agents for MRI are being developed with the dual aims
of improving anatomic delineation and permitting better diagnosis
of functional disorders.
Ideal Characteristics for MRI are

Relatively strong with respect to its paramagnetic or super magnetic
properties so that small doses are effective.
• Chemically stable.
• Preferably non-metabolisable and rapidly eliminated.
• Inexpensive and easily synthesized.
• Non-toxic in doses appropriate for contrast enhancement.
Positive Contrast Agents

Water soluble:
• Ferric ammonium citrate.
• Manganese chloride. [e.g., Lumentlance-Bracco]
• Metal chelates including Gd-DTPA.
Water immiscible:
• Olive oil
Negative Contrast Agents

Water soluble:
• CO2 tablets
• Perfluorocarbons
• Magnetites
• Side effects-Relatively safe Castro intestinal side effects are the
commonest among the minimal side effects.
Short Answer Questions - - - - -----------

1. How will you prepare your own barium preparation for examination
of
(a) Esophagus
(b) Stomach
(c) Small intestine.
2. What are the Indications for the water soluble contrast media in
gastro-intestinal tract?
3. Write a short note on computed tomography oral contrast media.
REFERENCES
1. Jovitac Skucas, Albert A Moss. Contrast media. In : Freeny PC,
Stevenson GW (eds). Marguilis and Burhenne's Alimentary Tract
Radiology, 4th edn. St. Louis : Mosby, 1989 : 83-87.
2. Jovitac Skucas. Barium sulphate for gastrointestinal use. In: Richard
W Katzberg (ed). The contrast media manual. Baltimore : Williams
and Wilkins, 1992 : 187-199.
3. Small W.C. ef al. A multisite phase III study of the safety and efficacy
of a new manganese chloride-based gastrointestinal contrast agent
for MRI of the abdomen and pelvis.
Journal of Magnetic Resonance Imaging, July 1999; lO(i): 15-24.
Chapter 6
Barium Swallow
• Indications
• Relative Contraindications
• Contrast
• Technique
• Specific Conditions
• Complication
• References
Barium swallow is the contrast study from oral cavity upto the fundus
of the stomach.
INDICATIONS
1. Dysphagia and obstruction.
2. Pain during swallowing.
3. Assessment of mediastinal masses.
4. Assessment of left atrial enlargement.
5. Pre-op assessment of carcinoma bronchus and oesophagus.
6. Motility disorders of oesophagus, E.g.: Achalasia and diffuse
oesophageal spasm, scleroderma.
7. Assessment of site of perforation.
8. Zenker's diverticulum and cricoid webs. In these cases water
soluble contrast media are used. E.g. : Gastrograffin or dionosil
aqueous.
RELATIVE CONTRAINDICATIONS
• Tracheo oesophageal fistula.
• Perforation.
CONTRAST
• 100% Barium sulphate paste.
• 80% Barium sulphate suspension.
- 60
Barium Swallow • 61
• 30% Barium sulphate suspension for high kV technique.

• 200-250% high density, low viscosity for double contrast study.
TECHNIQUE
Pharynx
One mouthful (about 10-15 ml) of contrast media (Barium sulphate
paste) is given and fluoroscopic observation of the act of deglutition
is observed in frontal and lateral view with the patient erect. To get
optimum distension of the pharynx, exposure is triggered at the time
when the hyoid bone is at the highest point during swallowing. For
this, a string is tied just above the level of the larynx. The rotor is
kept running and patient is asked to swallow. Exposure is released
when the larynx comes above the string. Lateral film is taken in erect
and frontal film in supine position.
To Get Optimum Mucosal Coating
One mouthful of contrast media (Barium sulphate paste) is given to
the patient and the patient is instructed to swallow once and stop
swallowing there after. Spot films are taken in frontal and lateral
projections (better way is to ask patient to keep mouth open or
say eee .... eee .... after one swallow) or patient performs valsalva
maneuver in erect position with nose closed. Frontal and lateral spots
are taken to show distended pyriform sinuses and valecullae.
Oesophagus
Single Contrast
Multiple mouthfuls of 80% w /v Barium suspension are given. Follow
the barium bolus down the oesophagus and observe the peristalsis
always in supine position. Films are exposed in erect position
RAO, LAO, frontal and lateral views when the oesophagus is well
distended. In RAO position esophagus is projected clear of the spine.
The escape of contrast at the level of the diaphragmatic hiatus
should not be confused for reflux. Mucosal film is taken in RAO after
the oesophagus is empty. Then the fundus of the stomach, & G-0
junction are assessed with spot films in different obliquities in erect
and recumbent positions.
Double Contrast
Barium contrast should be high density, low viscosity (200 to 250%).
15-20 ml Barium is given in the mouth and the patient is asked to
swallow. Then effervescent powder is given with another mouthful of
barium. In erect position, gas tends to stay up, resulting in adequate
distension which stays for longer time as compared to supine position.

Prone position also retains more gas within the oesophagus and gives
adequate distension.
Hypotonia using Buscopan or Glucagon keeps the esophagus
distended for a longer time (Inj. Buscopan 2ml LV. given just before
the procedure). Filming is done in frontal, lateral, RAO and LAO.
Introduction of gas for double contrast studies can also be done
through a tube passed into the upper oesophagus.
SPECIFIC CONDITIONS
1. Severe dysphagia for both solids and liquids: A little dilute
Barium is given initially-5ml. Further filming and contrast
depends on the abnormality observed.
2. Pharyngeal Web: Video fluorography in frontal and lateral
projection is the best technique for investigating disorders of
swallowing. 50/50 dilution of standard high density barium will
show webs more readily. Films in supine for frontal, and erect for
lateral views are taken at maximum distension of the pharynx.
3. Foreign body impaction: To detect the level of obstruction in case
of radio-lucent foreign body in the oesophagus, a marsh mallow
coated with barium is swallowed whole. The passage of marsh
mallow will be hindered at the level of obstruction. Similarly,
cotton soaked with barium can be swallowed, but advantage of
the marsh mallow is that it dissolves spontaneously.
4. In Carcinoma: High viscosity, normal density liquid barium is
given.
5. Motility disorders: A minimum of 5 mouthfuls of contrast should
be given to study the motility disorders of the oesophagus, out of
which more than 2 mouthfuls should be abnormal for a positive
diagnosis. For motility disorders, a prone swallow is essential to
assess oesophageal contraction in the absence of gravity.
Disorders are either of peristalsis or sphincter abnormalities
(lower and upper oesophageal sphincters).
6. Achalasia: The oesophagus should be cleansed thoroughly (aspirate
and wash) so that secondary achlasia due to Ca oesophagus may
not be missed. Barium 80% w/v is used and the patient should
be studied in erect position. To differentiate achalasia from other
conditions showing abnormal peris-talsis, mecholyl test is done.
On administration of mecholyl, there will be hyperperistalsis,
pain and streaks of contrast entering the stomach confirming the
diagnosis of achalasia.
Or
Amyl Nitrate given orally will cause mild relaxation of the
narrowed portion of the oesophagus, thus causing small streaks
of contrast to enter the stomach.
7. Tracheo Oesophageal fistula
• Congenital
• Acquired
Ideal contrast is non-ionic water soluble contrast media.
When barium is used it should be fluid-like and patient should
be lying lateral. Do not forget to put the patient prone if a fistula
is not identifiable in the lateral position. If the fistula is seen, stop
the procedure, since barium aspiration may result in inflammation
and granuloma formation in the lung.
To demonstrate Tracheo-oesophagal fistula in infants, a Ryle's
tube is introduced to the level of mid oesophagus and contrast
is injected while withdrawing the tube slowl y. This will force the
contrast through any small fistula. Both lateral and prone views
to be assessed.
8. Hiatus hernia: High abdominal pressure is required to demonstrate
hiatus hernia. For this
• Patient has to strain.
• Patient is asked to lie down, straighten the legs and then raise
them up.
• Manual compression of the abdomen.
• Patient stands upright, ask him to bend downwards with legs
straight.
Stomach should be well distended, otherwise the hiatus hernia
may not be demonstrated.
9. Gastro oesophageal reflux: Siphon test. Fill the stomach with 50%
Barium (150-200 ml). Follow this with 1-2 mouthfuls of water to
remove traces of barium in the oesophagus. Make the patient
supine with left side raised 15 ° up. Keep one mouthful of water
in the patients mouth. Ask the patient to swallow the water-a
jet of barium will shoot into the water column as it enters the
G.O. junction. Alternatively with full stomach, ask the patient to
roll from side to side on the table. Reflux will be seen.
To promote reflux, abdominal pressure can be raised by straight
leg raising or putting patient prone with the bolster under the
abdomen at the level of the umbilicus, but these are unphysiological.
10. Oesophageal Varices : Supine right side up position, high density

thin barium should be used. Varices are best demonstrated in
mucosa! relief study after using Buscopan and valsalva maneuver.
COMPLICATION
1. Leakage of barium from an unsuspected perforation-granuloma
formation.
2. Aspiration.
Present status of Ba. Swallow in comparison with the following:

Oesophageal Endoscopy
• It is a gold standard for diagnosis of oesophagitis, Barret's
oesophagus & varices.
• It is also useful to take biopsy for confirmation.
Ultrasound
• At present, endoscopic ultrasound provides the most accurate
estimation of the depth of penetration in malignancy, the length
of esophagus affected, and the extent of lymph node involvement
in a patient of ca. esophagus.
• Fine needle aspiration of suspicious lymph nodes can also be taken.
• It is also useful in a patient of esophageal tear.
Computed Tomography
• Computed tomography is the standard tool for regional and distant
staging of esophageal cancer.
• It may detect thickened esophagus, enlarged lymph nodes, and
involvement of the mediastinum, lung or liver.
Long Answer Questions----------------

1. Discuss barium swallow under the following headings
(a) Indications
(b) Contraindications
(c) Choice of contrast
(d) Technique
(e) Complications
2. Discuss barium swallow examination in following conditions

(a) Dysphagia for both solids and liquids
(b) Pharyngeal web
(c) Foreign body impaction
(d) Carcinoma oesophagus
(e) Oesophageal varices
(f)Hiatus hernia
Short Answer Questions------------- - -

�
1. Enumerate in brief Siphon test carried out to demonstrate gastro
oesophageal reflux.
2. How will you carry out barium swallow examination in cases of
trachea-esophageal fistula ?
3. How will you perform barium swallow examination to demonstrate
motility disorders of oesophagus. How will you differentiate
Achalasia cardia from other motility disorders of oesophagus.
REFERENCES
1. Cunningham TE Jr., Joner G. Normal anatomy and techniques of
examination of the pharynx. In : Freeny PC, Stevenson GW (eds).
Marguilis and Burhenne's Alimentary Tract Radiology, 5th edn. St.
Louis : Mosby, 1994 : 101-106.
2. Freeny PC, Stevenson GW (eds). Marguilis and Burhenne's Alimentary
Tract Radiology, 5th edn. St. Louis : Mosby, 1994 : 176-184.
3. Freeman AH. Oesophagus. In : Graham H Whitehouse (ed).
Techniques in diagnostic imaging, 3rd edn. Oxford : Blackwell
Science, 1996 : 13-20.
Chapter 7
Barium Meal
• Indications
• Preparation
• Contrast Media
• Standard Views
• Conventional Single Contrast Study
• Double Contrast Barium Study
• Biphasic Study Of Upper Git
• Hypotonic Duodenography
• After Care
• Complications
• References
Barium meal is the radiological study of oesophagus, stomach,

duodenum and proximal jejunum. It is done by oral administration
of c ontrast media (Barium sulphate).
INDICATIONS
1. Symptoms which prompts Barium meal study are :
(a) Epigastric pain suggestive of peptic ulceration.
(b) Anorexia.
(c) Weight loss.
(d) Vomiting.
(e) Anaemia.
(f) H eart burn.
(g) Dyspepsia.
2. Upper abdominal mass.
3. Castro-intestinal haemorrhage.
4. Gastric or duodenal obstruction.
66
Barium Meal • 67
5. Malignancies of oesophago-gastric junction, stomach and

duodenum.
6. Systemic diseases like Tuberculosis affecting the upper gastro
intestinal tract.
7. Motility disorders of gastro-intestinal tract.
8. In children to identify a cause for vomiting due to : (i) Castro
oesophageal reflux; (ii) Pyloric obstruction; (iii) Malrotation.
CONTRAINDICATIONS
• Suspected cases of gastro-duodenal perforation
• History or suspicion of aspiration, where alternative contrast
medium should be considered.
• Large bowel obstruction (Barium inspissation occurs in these cases)
• Fistulous communication with any organs other than parts of G.I.T.
• Recent biopsy from GIT, as barium granuloma may form at biopsy
site.
PREPARATION
• Patient should not eat or drink for atleast 6 hours before examination.
Patients who are undergoing a routine study during a morning
session are usually told to fast overnight.
• As cigarette smoking may interfere with optimum coating of the
mucosa, patients should restrain from smoking.
• As prolonged fasting is harmful for patients with diabetes, early
morning appointment should be arranged.
• In patients with gastric outlet obstruction, prolonged fasting or
intravenous Metacloprarnide and sometimes nasogastric intubation
and aspiration of the contents may be necessary.
CONTRAST MEDIA
Single Contrast Study
Low density barium suspension (80-100% w /v) is used. 30% w /v
suspension is used for high kV single contrast study. Water soluble
contrast media are indicated when a gastro-duodenal perforation is
suspected. Use of newer non-ionic water soluble contrast media have
to advocated for the detection of upper GI perforation, when there
is risk of aspiration.
Double Contrast Study

A high density (approximately 250% w/v), low viscosity barium
suspension produces best mucosal coating and hence detail. Between
100 and 150 ml of barium suspension is usually necessary to achieve
adequate double contrast studies.
STANDARD VIEWS
Single Contrast (SC) Double Contrast (DC)
Fundus Supine Erect with two views 90°
to each other or Prone
right side down
Body Erect or Prone Supine with 60° head
end elevation
Antrum and Prone right side down Supine right side up
Pylorus
D1 and C loop Prone right side down Supine right side up
of duodenum
D4 of duodenum Supine Prone right side down
CONVENTIONAL SINGLE CONTRAST STUDY

In conventional study, radiography is done at 80-90 kV. In erect
position, fluoroscopy is done to visualise both domes of the diaphragm
and lung bases to detect any pathology. The stomach and intestines
are seen for fluid levels.
10-15 ml of 80-100% w/v barium suspension is given and patient
is made to swallow while esophagus is seen under fluoroscopy. The
table is made horizontal, and the patient lying supine is rotated
with the right side going up. In this way the patient is rotated in a
continuous clockwise manner as seen from the foot end of the patient.
A good coating of the entire stomach mucosa is thus obtained and
radiography is done to show the mucosal relief. If the coating is
inadequate, the patient is rolled again in the same direction before
taking the film.
The patient is kept supine and about 100-250 ml of barium is
given. Spot films of the filled fundus in varying obliquity may be
taken if any abnormality is detected. With the table horizontal, patient
is turned prone oblique right side dependent. In this position, barium
enters the duodenum through the pylorus. Spot films for duodenal
Barium Meal • 69
bulb and C loop can be taken after adjusting the obliquity to avoid
overlap. Spot films should be taken, both in distended and empty
states. Patient is then turned supine and the table is made erect. The
spot films for duodenal bulb and C loop are taken in right anterior
oblique position. Compression spot films of duodenum may be taken
if required.
More barium is given to distend the stomach wall. Standard filming
of esophagus may be done now while giving the barium. Graded
compression is given to see the mucosa! folds, and spot films may be
taken if required. The gastric peristalsis and rate of emptying through
the pylorus is observed. The patient is rotated under fluoroscopy to
observe all margins of the stomach so that anteriorly or posteriorly
placed lesions are not missed.
In erect position, right anterior oblique view of stomach shows
incisura angularis. Proximal jejunum is also seen well in this view.
To evaluate the retrogastric space, about 200-250 ml of barium is
given. In supine position, translateral film is taken to demonstrate
the retrogastric space. The disadvantage of the conventional single
contrast study is that small mucosa! lesions like polyps or early
carcinoma may not be demonstrated. This can be partly overcome
by a single high kV technique.
Single Contrast High kV Technique

Barium sulphate 30% w /v is used. Radiography is done at 120-130
kV. This permits visualisation through the barium column so that
lesions will not be drowned by the low density barium. Adequate
mucosa! relief study is not possible with such low density barium.
Remaining aspects of barium meal are similar to conventional single
contrast study.
Advantages of single contrast studies

• It is optimal for patients who are immobile or unable to swallow
gas forming tablets.
• Pylorospasm, fistulae and enlarged gastric rugae are best seen.
• Filling defects due to large masses in pyloric and duodenal region
are more easily identifiable by single contrast study. These are less
obviously identifiable on double contrast.
• It is the procedure of choice to examine patients with suspected
gastric or duodenal obstruction.
Disadvantages of single contrast study

• Lack of sensitivity in detecting small erosion/linear ulceration,
superficial gastric carcinomas and subtle mucosal abnormalities.
DOUBLE CONTRAST BARIUM STUDY

This technique was perfected in Japan where there is a high incidence
of gastric malignancy. Main purpose was for mass screening of the
gastric tumours for early detection. This technique relies much less on
fluoroscopy and more on filming which is done overcouch for better
image quality. This was subsequently found very useful for small
mucosal lesions like polyps, mucosal erosions and ulcers, recurrent
tumours and post operative studies.
Preparation
A 'dry' fluid free stomach is essential. Double contrast study should
not be done if secretions exist in the stomach. The secretions will
prevent adequate mucosal coating and may mimic tumours.
Contrast Media
High density (200-250% w/v) low viscosity barium sulphate is
essential. High viscosity barium does not flow well and does not
coat mucosa well, hence can produce apparent mucosal lesions.
Antifoaming agents which are added to barium suspension prevent
air bubble formation. Air bubbles can mimic polyps.
Gas Forming Agents

To produce gas in the stomach, Sodium bicarbonate and Citric acid
are given orally. When they come in contact in the stomach, carbon
dioxide is produced which acts as negative contrast. Commercially
available powders like gastrovision, eno, fruit salt etc. give good and
rapid gas release for double contrast studies. When Ryle' s tube is
placed in the stomach, this can be used to inject air.
Smooth Muscle Relaxants

Hyoscine (as n-butyl bromide, trade name : Buscopan) when given
intravenously produces good distension of the stomach and bowel
by smooth muscle relaxation and produces effacement of the mucosal
folds. Dosage of Buscopan is 1 ml (20 mg) through intravenous route.
Barium Meal • 71
LV. Buscopan is contraindicated in patients with :

• Glaucoma
• Urinary retention
• Tachycardia
• Cardiac diseases
• Poor general condition
• Haemodynamic imbalance.
Technique of Double Contrast

Injection Buscopan IV should be given just before giving barium to
study the stomach. To study the stomach and duodenum, injection
Buscopan is given when barium enters the duodenum.
About 100-150 ml of high density low viscosity barium is given.
Injection Buscopan is given as described before. Gas forming agents
are given. Then patient is rotated slowly for mucosal coating,
beginning from supine to right lateral to prone to left lateral and
back to supine.
Filming for various parts of stomach and duodenum is done with
standard views as stated before. The table may have to be tilted 30 °
headup /head low to attain maximum distension of the part to be
filmed. The study can be done without buscopan, rest of the procedure
remains the same.
Advantages of double contrast study

• Highly accurate method of detecting abnormalities following
gastric surgery, bile reflux gastritis, marginal ulceration, recurrent
carcinomas and abnormalities of the efferent loop.
Disadvantages of double contrast study

• Probably misses some polyps, ulcers, erosions, superficial carcinoma.
• Biphasic study overcomes all these problems and is the best and
most accurate method of evaluation of upper GIT. If meticulously
performed, it gives very good anatomic, as well as physiologic
information and has an accuracy which is comparable to endoscopy.
BIPHASIC STUDY OF UPPER GIT

Introduction
• Gives good anatomic & physiologic information & has accuracy
comparable to endoscopy.
Goal
• To have both mucosal delineation in double contrast phase & full
column distention in single contrast phase.
Contrast Medium
• 60-100% low viscosity, 200-250 ml of Barium is given orally with
gas forming powder in the last few mouthfuls.
Filming
• Duodenal spot filming is done first to
avoid flooding of the bowel
(a) Prone oblique Rt.side down Duodenal cap, C-loop
(b) Supine with Rt. side up oblique : Duodenum
(c) Erect Gastric fundus
(d) Supine with 60° head up Upper body of Stomach
(e) Supine Lower body of Stomach,
Pyloric antrum
(f) Supine with Rt. side up oblique : Pyloric antrum & Canal.
Note: Biphasic examination has to be performed quickly, without
wasting time. More gas and barium may be given as required.
HYPOTONIC DUODENOGRAPHY
Tubeless hypotonic duodenography can be performed as part of
routine double contrast barium meal or as a specific examination of
the duodenum. Rarely, persistent pylorospasm, poor coating, poor
distension or an unusual position of the duodenal loop can lead to
failure. With I.V. line fixed, about 100 ml of high density low viscosity
barium is administered by mouth. The patient is turned prone with
right side down position. As soon as the fully distended duodenal
cap is seen, Buscopan is injected I.V. Gas producing powder is then
given after turning the patient supine with right side up position.
First and second part of duodenum is seen now in double contrast
and the barium enters the third and fourth part. Filming is done same
as in double contrast barium meal to demonstrate various parts of
the duodenum.
Tube Method: The Bilbao-Dotter tube is passed into the first part of
the duodenum. I.V. line is fixed. With the patient in supine position,
Barium Meal • 73
50 ml of barium is injected through the tube and injection Buscopan

is given I.V.
The patient is turned so that the right side is up and air is injected
through the tube. Films are taken in RAO position (first and second
part of duodenum). Then the patient is turned prone and more air
is injected till air reaches the third part and a film is taken. Then the
patient is turned left side down lateral and a film for double contrast
of second part of duodenum is taken. Patient is then turned supine
and a film is taken for overview of duodenum on a large film.
Advantages of hypotonic duodenography

• Reliable results are obtained.
• Duodenal lumen is separable easily
• There is no overlap of stomach
Disadvantages of hypotonic duodenography

• Pylorus is not assessed
• Uncomfortable to patient
• Amount of barium entering cannot be controlled.
AFTER CARE
• The patient should be warned that his bowel motion will be white
for few days after the examination and to keep his bowel open with
laxative to avoid barium impaction which can be painful.
• The patient must not leave the department until any blurring of
vision produced by Buscopan has resolved.
COMPLICATIONS
1. Leakage of barium from an unsuspected perforation-peritonitis.
2. Aspiration pneumonia.
3. Barium impaction-converts a partial large bowel obstruction into
a complete obstruction.
4. Side effects from the pharmacological agents used alongwith
barium.
5. Acute gastric dilatation.
6. Barium embolisation if a bleeding ulcer is present.
Comparison of barium studies with other modalities like

Endoscopy �-� Barium Meal
1. Procedure of choice as diagnostic It has low diagnostic accuracy
accuracy is very high (Around (Around 83 %). Hence it is
100%) done when endoscopy is
2.1
contraindicated.
Ideal for erosive ulcers, smai 1 Ideal when endoscopy is
i
recurrent ulcers & early detection I contraindicated (in severe acute

of tumour & biopsy can also be cardiac or pulmonary diseases.)
I taken from the lesion. It is the modality to study the
physiology i.e. peristalsis &
emptying time.
Endoscopic Ultrasound
1. It is,..ideal to assess the extent of growth & its extension into the
wall of oesophagus.
2. It is useful in early detection of lymph nodes.
3. Biopsy can also be taken for confirmation of diagnosis.
Computed Tomography
1. Main role of C.T. is in staging the malignant disease process.
2. It is the modality of choice to assess the structure outside stomach
wall.
Long Answer Questions-----------------

1. Discuss barium meal examination under the following heading
(a) Contrast media
(b) Indications
(c) Contraindications
(d) Preparation of patient
(e) Radiographic positioning
(f) Complications and after care
2. Describe the contrast media used in barium meal study . Describe
the technique, advantage and disadvantage of
(a) Single contrast barium meal study
(b) Double contrast barium meal study
Barium Meal • 75
Short Answer Questions --- - -- - - - - - - --

1. Mention the indications and contraindications of barium meal study.
2. Mention the variations in barium preparation used for
(a) Single contrast study
(b) Double contrast study
(c) Biphasic study
3. Mention the indications and contraindications of Single contrast
study.
4. Mention the contraindications of Double contrast study.
5. Discuss the complications of barium meal study.
6. Briefly describe the biphasic study of upper gastrointestinal tract.
7. Describe briefly Hypotonic duodenography.
8. What are the advantages and disadvantages of barium meal study
as compared to endoscopy ?
9. What is the role of computer tomography in stomach lesions ?
REFERENCES
l. Harrie KM, Robert GM, Laurie BW. Normal anatomy and techniques
of examination of stomach and duodenum. In : Freeny PC, Stevenson
GW (edn). Marguilis and Burhenne's Alimentary Tract Radiology,
5th edn. St. Louis : Mosby, 1994 : 286-296.
2. Nolan DJ. Stomach and duodenum. In: Graham H Whitehouse
(ed). Techniques in diagnostic imaging, 3rd edn. Oxford : Blackwell
Science, 1996 : 22-33.
Chapter 8
Barium Meal Follow Through

• Indications
• Contrast Medium
• Preparation
• Small Bowel Follow Through
• Dedicated Small Bowel Follow Through
• Peroral Pneumocolon
• Retrograde Small Bowel Examination
• Advantages of BMFT
• Disadvantages of BMFT
• Complications
• Interpretation
• References
Bari um studies are still the mainstay for evaluating patients with
suspected small bowel abnormalities.
The major methods used for the barium examination of the small
bowel are:
1. Small bowel follow through examination.
2. Dedicated small bowel follow through examination.
3. Enteroclysis (or) small bowel enema.
4. Peroral pneumocolon.
5. Retrograde small bowel examination.
It is the radiographic examination of the GIT-oesophagus,
stomach, duodenum, small bowel and ileocaecal junction by oral
administration of contrast media. It is so called because it is performed
followin g a barium meal examination of the oesophagus, stomach and
duodenum.
76
Barium Meal Follow Through • 77
INDICATIONS
1. Patients who have low suspzcwn of small bowel disease -
abdominal pain and diarrhoea.
2. Patients with suspected complete (or) near complete small bowel
obstruction.
3. Patients who are suspected of suffering from Crohn's disease.
4. Patients who refuse placement of nasogastric tube/failed
intubation.
If enteroclysis is the routine method, the barium follow through
will only be used for
1. Elderly patients with suspected jejunal diverticulosis who
present with malabsorption.
2. In patients who are unwilling or in whom it is not possible
to perform intubation.
CONTRAINDICATIONS
1. Colonic obstruction.
3. Paralytic Ileus.
CONTRAST MEDIUM
Medium density barium suspension (50-60% w/v) contalIUilg a
suspending agent (to maintain its stability and prevent flocculation)
is used. High density barium (200-250% w/v) may produce an
appearance of fold thickening and clumping in the small bowel.
Acid barium sulphate suspension produces spasm, enlarged folds
and dilatation in duodenum and jejunum. Alkaline barium sulphate
suspension may improve coating of the valvulae conniventes which
increases diagnostic accuracy.
A water soluble Iodine contrast agent such as gastrograffin is of
limited value as it will be diluted and lose density in the small bowel.
If they are used in cases of small intestinal obstruction, they may
be so diluted by bowel content and their own osmotic action that
they would fail to demonstrate either the site or the cause of the
obstruction. In the old and frail patient or in young infants, there is
additional hazard that their osmotic action can seriously diminish
blood volume. It is safe to use barium if small bowel obstruction
is suspected and colonic obstruction is ruled out, to find the cause
and site of the lesion. Therefore, the principal value of water soluble
media is in the demonstration of leaks from the bowel.
PREPARATION
Before any small intestinal study
1. The colon should be cleaned by the administration of a suitable
purgative. (Purgative should be avoided in patients with
suspected obstruction, acute exacerbation of Crohn's disease or
an Ileostomy).
2. A low roughage diet and a high fluid intake is also maintained
for 48 hours prior to the investigation
3. No food or fluid should be taken for 12 hours before the
investigation. If the patient is taking tranquilizers, antispasmodics
and codeine, they should be stopped for 24-48 hours before the
examination.
SMALL BOWEL FOLLOW THROUGH

Initially 150 ml of high density barium and effervescent agents are
used to evaluate oesophagus, stomach and duodenum by means of
double contrast examination. Later 200 ml of barium (20-25%) (to
decrease the high density effect from double contrast study of Upper
GI study) followed by 250 ml of barium (40-45%) is given. Once this
is completed, a series of overhead radiographs are obtained at half
hourly intervals till terminal ileum is reached.
DEDICATED SMALL BOWEL FOLLOW THROUGH

• Single contrast technique.
• Double contrast technique.
Single Contrast Technique

Single contrast technique is employed routinely in our department.
Barium (600-900 ml) 50-60% is administered. Patient is asked to drink
this as rapidly as possible. He is then put in the right side dependent
position to aid rapid gastric emptying. After 15 to 20 minutes, a film
is taken with the patient prone to separate the bowel loops, using
high kV to demonstrate jejunum and proximal ileum. Subsequent
films are taken at 15-30 minute intervals till ileocaecal junction is
opacified. To demonstrate ileocaecal junction, supine right side up is
the best position since ileum enters caecum in the posteromedial part.
Advantages of Prone Position

• Better separation & less overlap of bowel loops.
• In this position the center of the abdomen is compressed making

entire abdomen more uniform and thus more uniform x-ray
penetration can be achieved.
• In this position loops of ileum tends to migrate cephalad and
becomes less compacted in the pelvis which is often a common
problem during procedure.
Positioning Purpose
First
�
Right side down dependent To aid gastric emptying I
Second Prone To separate bowel --�
loops
Third
--- Right side up To visualise IC junction
• Always empty the bladder prior to these spot films.

• Each overhead radiograph should be examined as soon as it is
processed. Any suspected abnormalities should be evaluated with
fluoroscopy and compression spot films.
• Many authorities recommend, that even in the absence of any
abnormality, periodic fluoroscopic examination and compression
spot images have to be taken.
Four spots of the ileo caecal junction should be taken with varying
degrees of compression. Compression should be applied on the bowel
loops to avoid overlap and to efface the mucosa so that the small
lesions may not be missed and mobility of the loops can be well
assessed. Spot films should be taken if required. The abnormalities
must be shown atleast in two spot films taken at different times to
demonstrate the persistence of the lesion.
Overlap of contrast filled bowel loops in the pelvis is often a
problem.
* Overlap of Contrast Filled Bowel Loops in the Pelvis Can

Beovercome by:
• Table head down.
• 30 ° caudal angled view of pelvis.
• Emptying of urinary bladder prior to filming the ileal loops.
* If Desired, Gastric and Bowel Peristalsis may be Increased by

various methods
1. Drugs Metaclopramide, Neostigmine, Glucagon,
Cholecystokinin. Of these, metaclopramide is most frequently
used. This promotes bowel motility and can decrease the
transit time of barium.
Metaclopromide hydrochloride is available as:

• Injection Perinorm or Injection Maxeron 5 mg/ml-2ml
Ampoule.
Dose: 2ml Injection given I.M 10-15 minutes after giving
Barium suspension following stomach, duodenal study.
• Tab. Perinorm or Maxeron-10 mg tabs.
Dose: 2 tabs given with the barium after stomach, duodenal
study.
Caution : In some patients it may lead to drowsiness (or) a
Parkinsonian like state. (Extra pyramidal reactions.)
2. 20-40 ml of sodium/meglumine diatrizoate to the barium also
reduces transit time.
3. Use of cold water to dilute barium and intermittent ice cold
water sips.
• Cooling makes the barium more palatable.
• More importantly cold barium speeds the gastric emptying
and passes more rapidly through the intestine than does the
room-temperature barium.
4. Preliminary cleansing of the colon and placing the patient in
right lateral recumbent position.
Note:
l. Polyposis: Films taken with collapsed loops show the polyps to
best advantage.
2. Diverticulosis: Delayed films may show persistence of barium in
the diverticulae. Erect position will reveal any fluid levels caused
by contrast media retained within the diverticulae.
3. Large ulcers: Large collection of barium may be seen in the delayed
film after the bowel loops have emptied the barium.
4. The transit time through the small bowel can vary greatly ranging
between 15 minutes and 5 hours
PERORAL PNEUMOCOLON
It is done at the end of B.M.F.T. when terminal ileum is suspicious
and needs clarification.
It is used mainly to evaluate distal ileum.
Preparation
Colonic preparation is similar to barium enema.
Technique
• Barium is administered orally.
• When barium has reached the right and proximal transverse colon,
air is insufflated into the rectum and refluxed into distal ileum.
• Glucagon can be used to relax the ileocaecal valve.
• It is usually employed at the end of barium meal follow through,
when the appearance of terminal ileum is suspicious and needs
clarification.
Advantages
• A routine overhead radiograph following use of the pneumocolon
technique for SBM examination can yield unsuspected & clinically
significant colonic findings.
RETROGRADE SMALL BOWEL EXAMINATION

Barium and air refluxed through the ileocaecal valve during a barium
enema examination may be used to examine the small bowel. This is
replaced nowadays by enteroclysis.
Advantages of BMFT
1. Easily performed.
2. No discomfort/intubation to the patient unlike in enteroclysis.
3. It is a physiological process. Hence transit time can be assessed.
Disadvantages of BMFT
1. Overlapping of barium filled bowel loops in the pelvis.
2. Poor distension of bowel loops.
3. Inappropriate timing for visualization of partial (or) intermittent
small bowel obstruction.
4. Operator dependence.
5. Time consuming.
COMPLICATIONS
1. Leakage of barium from an unsuspected perforation.
2. Aspiration.
3. Conversion of partial large bowel obstruction into a complete
obstruction by the impaction of barium.
4. Barium appendicitis, if barium impacts in the appendix.
5. Side effects of pharmacological agents used.
What to do in suspected cases of perforation?

Water soluble contrast media are indicated when perforation is
suspected. Using a Ryles tube, aspirate the stomach contents and then
give about 100 ml of water soluble contrast media (76% w /v) through
the Ryle's tube. Tilt the patient's head up to promote emptying and
look for evidence of leak through stomach or duodenum. If the patient
is erect, the contrast media may be seen to collect in the pelvis if
perforation is present.
If patient is supine, contrast leak through anterior wall perforation
may not be identifiable. If no leak is identifiable, opacification of the
urinary bladder or kidneys is an indirect evidence of a perforation
because contrast media is not absorbed from the GIT. The contrast
media in the above case is absorbed from the peritoneum and is
excreted by the kidneys.
INTERPRETATION
Small intestine extends from duodenojejunal flexure (ligament of
treitz) to the ileocaecal valve.
• Length - 6-7 metres.
• Calibre gradually diminishes.
Anatomical Differences Between Jejunum and Ileum

Jejunum Ileum
1. Proximal 2/5th of small intestine
Distal 3/5 of small intestine
th
(100-110 cm) (150-160 cm)

2. Thicker and more vascular wall Thinner and less vascular wall
3. Wider and often empty lumen Narrower and often loaded
lumen
4. Larger and closely set circular Smaller and few circular folds
folds
5. Villi are larger in number Very few villi
6. Peyer's patches are absent Peyer's patches are present.
Appearance of Jejunum and Ileum On Barium Study

Jejunum Ileum
Upper left & periumbilical region Lower right hypogastric and
pelvic region
Feathery appearance Featureless
Jejunum Ileum
Constitutes proximal Three-fifths
two-fifths of small
intestine
Position Upper left and Lower right hypogastric
periumblical region and pelvic region
Max. Diameter 4 cm 3cm
Number of folds 4-7 per cm 3-5 per cm
• Fold thickness 1.5-2 mm.

• Measurement of approximated bowel wall gives a wall depth of
1-1.5 mm.
• The collapsed bowel shows a feathery mucosal pattern in the
jejunum on BMFT due to valvulae conniventes.
• The pattern in ileum is less feathery and may be absent.
Long Answer Questions ---------- - - - - --

1. Discuss barium meal follow through under following headings:
(a) Definition
(b) Indications
(d) Contrast medium used in barium meal follow through
(e) Preparation of patient
(f) Describe the procedure & filming done in dedicated small bowel
follow through
(g) Advantages & disadvantages of barium meal follow through
(h) Complications of barium meal follow through
Short Answer Questions ------ - - - - -----

1. Discuss the difference between the jejunum & ileum anatomically
and on barium study.
2. What are the indications & contraindications of barium meal follow
through.
3. Discuss the contrast medium used in barium meal follow through.
4. What are the advantages of prone position during filming in barium
meal follow through study?
5. What are the various methods used to increase gastric and bowel
peristalsis during barium meal follow through study?
6. What is the role of cold water barium during barium meal follow
through study?
7. Describe briefly Peroral pneumocolon.
8. How do you diagnose perforation by barium study?
9. Shortly describe capsule endoscopy.
REFERENCES
2. S. Chou, S,J. Skehan, A.L. Brown, J. Rawlinson, S. Somevs. Detection
of unsuspected colonic abnormality using the pneumocolon technique
during small bowel meal examination Clinical Radiology, June 2000,
Vol. 55 No. 6 : 454-458.
Chapter 9
Enteroclysis (Small Bowel Enema)

• Indications
• Equipment
• Contrast Medium
• Preparation
• Technique
• Single Contrast Enteroclysis
• Double Contrast Enteroclysis
• Air Double Contrast Enteroclysis
• Comparison
• Advantages
• Disadvantages
• After Care
• Complications
• CT Enteroclysis
• MR Enteroclysis
• Refer ences
T his is the radiological study of small bowel from jejunum to the

ileocaecal junction by intubation of the jejunum and instillation of
contrast through the tub e.
INDICATIONS
1. Partial small bowel obstruction.
2. Cro hn' s disease-to know its extent.
3. Suspected M eckel' s div erticulum.
4. Malabsorption.
5. Tumor s of small intestine.
6. Occult GIT bleeding.
7. Equivocal BMFT but strong clinical suspicion.
85
CONTRAINDICATIONS
1. Complete colonic obstruction.
3. Massive dilatation of the small bowel.
4. Duodenal obstruction and
gastrojejunostomy.
5. Paralytic ileus.
EQUIPMENT
Bilbao Dotter tube: This is a 22F polyethylene tube which is 150 cm
long. The tube is 5 cm longer than the guide wire in order to eliminate
the risk of perforation by the wire protruding beyond the tip. The tip
has multiple side holes with or without an end hole. Usually there
are 8 holes. The guide wire is teflon coated to reduce friction.
CONTRAST MEDIUM
The contrast medium used for small bowel study is Barium sulphate.
This contrast medium should not flocculate, precipitate or settle down
in the presence of intestinal secretions. The above characteristics can
be accomplished by micro pulverisation of barium and addition of a
suspending agent. An acid Barium sulphate suspension can produce
spasm, enlarged folds, dilatation in the duodenum and jejunum and
also hypersecretion, hence this should not be used. On the other
hand, an alkaline Barium suspension improves the coating of valvulae
conniventes and hence should be used.
1. For single contrast enteroclysis: 20% w /v suspension of Barium
sulphate is used.
2. For double contrast enteroclysis: high density low viscosity Barium
sulphate suspension is ideal which is 200-250% w /v. We can
use 95% Microbar which can be diluted to 70% to decrease
the viscosity. Another important constituent is carboxy-Methyl
cellulose (CMC). To prepare this, add 10 gm of C.M.C. to 2 litres of
warm water and mix well. Then refrigerate the mixture overnight.
Shake this mixture well before use.
PREPARATION
1. The patient is subjected to liquid diet (2-3 litres) for a full day
before the examination and is called after overnight fasting for
the procedure.
Enteroclysis (Small Bowel Enema) • 87
2. Two to four Dulcolax tablets in the evening preceding the

enteroclysis are given. The above said preparation is very
important because a full caecum or a food filled ileum seriously
retards intestinal flow and produces artifacts and more fluid is
needed to reach the caecum quickly.
3. No rectal enema should be given because the enema fluid may
reflux into the small bowel and create confusing small bowel
patterns when it mixes with the Barium suspension.
4. Drugs such as Tranquilisers, Sedatives and Antispasmodics should
be discontinued the day before the examination. Anticholinergics
and Ganglion blocking drugs tend to cause dilatation of the small
bowel mimicking the sprue pattern. Narcotics affect both the
motility and appearance of folds of the small bowel.
5. Immediately before the examination, the pharynx is anaesthetised
with lignocaine jelly.
For Infant
1. 4 hours fasting.
2. To enhance gastric emptying, turn the baby to his right side.
3. Sedation.
4. Decreased peristalsis-compensated by 3-5 ml of metaclopromide.
Contrast Dose
Age I Dose
3-5 Months 200 ml
5-8 Months 300 ml
8-11 Months 400 ml
1-3 Years 500 ml
TECHNIQUE
Preliminary Plain Radiographs of the Abdomen
• They are useful to determine whether the patient is adequately
prepared and to exclude the presence of barium from previous
examinations. They also help in deciding the best radiographic
method for evaluating a patient with suspected small bowel disease.
For example, a patient with distension of only the proximal small
bowel loops would be best examined with enteroclysis whereas
a patient with distension of the entire small bowel would benefit
from barium enema.
• An upright film is useful to determine whether a large amount of

fluid is present in the stomach or small bowel loops, which needs
to be aspirated before the study can be performed.
• Free intraperitoneal air, displacement of bowel loops by a mass,
calcification and abnormality of bowel loops other than distension
can be observed in the preliminary film.
Procedure
The patient sits upright on a chair placed against the wall so that
he cannot move away from the advanced tube. Alternatively, in a
patient who cannot sit up, the tube can be placed with patient supine
or right lateral on the fluoroscopy table. 2-3 cc of 2% Xylocaine jelly
is introduced into the nostril through which the tube is to be placed
after ensuring that there is no nasal block or mass. Patients' neck is
hyper-extended. After this, the Bilbao-Dotter tube without the guide
wire is inserted through one of the nostrils and advanced with the
swallowing action of the patient till the tip reaches the stomach.
About 5-7 cm of tube is passed in stomach and then neck is flexed.
The guide wire may be used to stiffen the tube to assist
advancement through the oesophagus into the stomach. Make sure
the tube is in the oesophagus and not in the trachea by asking the
patient to cough and by observing under fluoroscopy. After 2/3rd of
the tube is passed, tip must be in the stomach. Under fluoroscopic
control, the tube is then advanced through the antrum of the stomach
into the pyloric canal. Now, with the guide wire 5 cm proximal to the
tube tip, the tube is slowly advanced till the tip enters the duodenal
cap. This may be facilitated by turning the patient supine with right
side up so that the location of the pyloric canal and duodenal cap
can be seen outlined by air. If this fails, turning the patient prone
with right side down oblique may help the tube to reach pyloric
canal by gravity.
Once the tube tip enters the first part of the duodenum, advance
the tube slowly keeping the guide wire 2-3 cm proximal to the
Pyloric sphincter. Withdraw the guidewire after each advancement.
At the end, the tube will be beyond duodeno-jejunal flexure and
the guidewire in the pyloric canal. Finally, the tube tip should be
approximately 4-5 cm distal to Trietz ligament. Such a placement
prevents reflux of Barium and carboxymethyl cellulose into proximal
parts of duodenum and stomach.
Note:
1. If the stomach is collapsed or has very little gas, injecting 100-150
ml of air will help the above manipulation.
2. If the stomach is over distended with gas, aspirate out air to
reduce distension.
3. If stomach contains residual fluid, it should be sucked out prior
to manipulation
4. While advancing the tube it will tend to hold up at the following
places due to acute angulation of the intestine.
• Junction of the first and second part of the duodenum.
• Junction of the second and third part of the duodenum.
• Duodeno jejunal fluxure.
Gentle pressure on the tube assisted by deep breathing by the
patient will help to negotiate these bends.
Problems
Prolonged Examination
It is due to improper flow rates. Too high infusion rates should not
be used. To restore peristalsis, injection metoclopramide 10 mg. I.V.
is useful.
Incomplete Distension of Small Bowel

It is due to slow infusion rates, or due to excessive dose or response
of metaclopramide. Increasing the rate of flow of contrast will solve
the problem.
Prolapse of Small Bowel into the Pelvis

Few loops of ileum may dip into the pelvis. When no adhesions
are present: angled compression allows lifting of pelvic segments. If
cecum obscures the pelvic ileum, patient is turned prone and the table
is tilted head down. This allows the caecum to empty and terminal
ileum becomes visible.
Faecal Material in the Terminal Ileum

This may be seen due to an incompetent ileo caecal valve or in
patients who are chronic users of laxatives or are taking long-term
mild sedation. Infusion of an adequate amount of methylcellulose
will push the debris into the colon.
Reflux into Duodenum and Stomach

This is due to too fast infusion rate or small bowel
obstruction. Incidence can be reduced by the use
of balloon enterocly sis catheter. In patients with
obstruction, preliminary decompression of the
stomach and proximal jejunum decreases reflux.
SINGLE CONTRAST ENTEROCLYSIS

This is performed in a patient with high grade partial small bowel
obstruction, especially if significantly dilated bowel loops are present.
Barium suspension 20% w/v. is injected at the rate of 75 to 120 ml/
minute.
Care should be taken to ensure that no air goes in during the
injection. An average of one to one and half litres of barium sulfate is
injected without any interruption. The average time taken to reach the
ileo caecal junction is about 15 minutes. Use interrupted fluoroscopy
to follow the head of the Barium column. Stenotic lesions are best
identifiable at the head of the barium column.
Filming: Take one 10 x 12 spot film for the jejunal loops. Another
film is taken for the entire small bowel. Spot films are taken with
or without compression wherever necessary. Spots of the ileo caecal
junction are included with and without compression. All the filming
is done with high kV technique (120-140 kV).
DOUBLE CONTRAST ENTEROCLYSIS

150 to 500 ml of barium suspension (high density and low viscosity)
is injected at the rate of 80-lO0ml/minute, till the proximal ileum is
reached. The head of the barium column is followed with intermittent
fluoroscopy and films are exposed wherever necessary. After this,
0.5% suspension of CMC is injected at a rate of around 75-120 ml/
min using a mechanical injector. Very rapid injection may result in
atonia. Ileocaecal spot films should be taken initially when the barium
column reaches the ileo caecal junction and then again when the ileo
caecal junction is in double contrast. If the patient has an urge to
defecate, he may be permitted to do so. The ileo caecal junction will
be seen well with double contrast immediately after he defecates and
spot films may be taken at this time.
Filming:
• Upper abdomen when jejunum is seen in double contrast.
• Full abdomen when entire small bowel is in double contrast.

• Ileocaecal spots in single and double contrast.
• Spot films as required.
Note:
• Filming has to be completed within 20-25 minutes for good double
contrast effect.
• Erect films do not give any additional information of small bowel
study.
AIR DOUBLE CONTRAST ENTEROCLYSIS

Preparation
Laxatives are given the night before the examination. Nothing is to
be taken by mouth after 7 pm the night before the examination.
Procedure
Barium: A 50% to 70% w/v Barium sulphate.
At a rate of approximately 60 ml/min, using a 100 ml syringe, 150
to 200 ml of barium suspension is injected slowly. The progress of the
barium column is observed by interval fluoroscopy. When the head
of the barium column reaches the distal ileum, air should be injected.
Initially, 200 ml of air is injected slowly at a rate of approximately
100 ml/min. After observing the progression of barium distally, inject
100-200 ml of air. About 600 to 1000 ml of air is necessary for double
contrast views of the whole small bowel. When the air reaches the
distal ileum, an antispasmodic agent is injected intravenously or
intramuscularly.
Procedure
150-200 ml of Barium. (60 ml/min)
j,
When barium reaches distal ileum
j,
600 - 1000 ml of AIK (100 ml/min)
j,
When AIR reaches distal ileum
j,
ANTISPASMODIC agent is given.
Advantages
The mucosal detail seen on the air double contrast study of the small
intestine is superior to any other examination. Aphthoid ulcer and
minute scar can be picked up easily.
Disadvantages
1. Difficult to reproduce
2. Uncomfortable to the patient
3. Air may pass through the minimal narrowing and mild narrowing
may be missed.
COMPARISON
Methyl Cellulose DC Enteroclysis Air DC Enteroclysis
1 Less information compared to air More clear detail
2 Simple procedure, can be done by Operator dependent
inexperienced radiologist
3 Less time (20 minutes) More time
Advantages
1. Contrast material is administered at a desired rate and not
influenced by the action of pyloric sphincter.
2. Direct infusion at a rate that produces hypotonia, completely
dilates the entire small intestine and therefore the fold patterns
and mucosal abnormality can be easily assesed. The frequent
intermittent flucroscopic monitoring during the enteroclysis
examination, together with the volume challenge induced by
the infusion, facilitates the recognition of fixed & non distensible
segments.
3. Because the distensibility of bowel lumen is challenged by
enteroclysis, the bowel proximal to stenosis dilates-thus
facilitating recognition of even a minimal narrowing.
4. Sinuses and fistulous tracts can be demonstrated by enteroclysis.
5. The time taken for the examination is not more than 20-30 minutes.
6. Enteroclysis tube may be left in place in patients with obstruction
to achieve better decompression.
7. Enteroclysis permits better delineation of the small bowel than
that achieved by Barium meal follow through. Segmentation of
the barium column and flocculation is avoided.
Disadvantages
1. Placement of Nasogastric tube for enteroclysis causes discomfort
which can be minimized by tranquillisers.
2. Extrapyramidal symptoms of Metaclopramide can be made to
subside by giving benadryl (or Atropine).
3. Nausea and vomiting due to inadequate tube placement proximal
to treitz ligament.
- Treatment: Aspiration of contents by withdrawing the tube into
the stomach.
4. Rapid colonic emptying.
5. Use of Barium as primary contrast agent.
6. Operator dependent.
7. Failure to depict extra-intestinal changes.
AFTER CARE
The patient should be warned that diarrhoea may occur as a result of
the large volume of fluid given. Patient can take full diet following
the procedure.
COMPLICATIONS
1. Aspiration.
2. Perforation of the bowel.
Anatomical differences between small bowel and large bowel

Small bowel Large bowel
Valvulae conniventes Present Absent
Numbe, of loops Many Few
�
Distribution
---- of loops- - Central Peripheral
t-
Haustra - -Absent
- - Present
Diameter
Solid faeces
3-5 cm
Absent
-1 5 Cm
Present
Present status of barium studies versus capsule endoscopy,
iloescopy, CT and MR enteroclysis.
Capsule Endoscopy
• Capsule endoscope offers high diagnostic results in IBD, ulcers,
polyp, erosions.
Advantages
• No radiation exposure.
• Minimal patient discomfort.
• Less operator dependant.
Disadvantages
• Inability to control the camera.
• Biopsy can not be taken.
• Capsule may not reach caecum in cases of stricture hence incomplete
examination.
Ileoscopy
Endoscopy examination limited to distal ileum.
Advantages
• Biopsy can be taken.
Disadvantages
• Inability to reach caecum.
• Inability to intubate ileum during colonoscopy.
CT ENTEROCLYSIS
• An 8-F nasojejunal tube is positioned in the duodenojejunal
junction. Diastilled water is infused with a pressure controlled
pump. Patient is given intravenous antispasmodic to reduce the
motion artefact caused by bowel peristalsis. C.T. enteroclysis is
many times combined with LV. contrast study. Helical scanning is
started 70 seconds after the administration of I.V. contrast whenever
indicated. Reformatted images are obtained in sagittal and oblique
planes.
Advantages of CT Enteroclysis over Conventional Enteroclysis

• CT Enteroclysis allows better detection of intraluminal, intramural
or extramural pathologies e.g.polyps, mass, liver, metastasis, lymph
nodes.
• Lesions as small as 5-35mm can also be detected.
• Bowel wall thickness can also be measured.
• Detection of enteric fisulous tract, stenosis is possible.
MR ENTEROCLYSIS
• The basic procedure is same.
• MR Enteroclysis can be performed with both iron based and
positive gadolinium contrast agents.The use of methylcellulose in
water as enteric contrast agent with Gd-DTPA is preffered because
it acts as biphasic enteric contrast agent with low signal intensity
on Tl WI & high signal intensity on T2WI.
Advantages of MR Enteroclysis
• High sensitivity for high grade small bowel obstruction for eg:
ulcerative colitis, crohn's disease.
• Bowel wall enhancement provided by gadolinium allows assessment
of inflammatory disease activity eg: ulcerative colitis, crohn's
disease.
• Real time functional information provided by MR is definitely an
advantage over other modalities as we get a 3D image reconstruction.
• No radiation involved hence can be useful for paediatric age group
& pregnant patients.
Long Answer Questions -----------------

1. Discuss enteroclysis under following headings:
(a) Definition
(b) Indications & contraindications
(c) Contrast medium used in enteroclysis
(d) Preparation of patient before enteroclysis
(e) Equipments used during procedure
(f) Describe the technique of double contrast enteroclysis
(g) Advantages & disadvantages of enteroclysis
Short Answer Questions-----------------

1. What are the indications & contraindications of enteroclysis?
2. Mention the variations in barium preparations used for
(a) Single contrast enteroclysis
(b) Double contrast enteroclysis
(c) Air double contrast enteroclysis
3. Which drugs are to be discontinued before enteroclysis examination?
why?
4. What is the role of preliminary plain radiograph of the Abdomen

before enteroclysis examination?
5. Describe bilbao-dotter tube. Describe the procedure of tube placement.
6. What is treitz ligament? Describe shortly its role in enteroclysis.
7. What are the problems encountered during enteroclysis procedure?
How do you overcome these problems?
8. Compare methyl cellulose DC with air DC enteroclysis.
9. Describe briefly - CT enteroclysis/MR enteroclysis
REFERENCES
1. Freeny PC, Stevenson GW (eds). Marguilis and Burhenne'sAlimentary
2. Nolan DJ. Small intestine. In: Graham H Whitehouse (ed). Techniques
in diagnostic imaging, 3rd edn. Oxford : Blackwell Science, 1996
35-44.
3. Dean D.T. Maglinte, Frederic M. Kelvin, Micheal obstruction :
optimizing Radiologic investigation and Non-surgical management.
Radiology, Jan 2001, Vol. 218. Number 1 : 39-46.
Chapter 10
Barium Enema
• Definition
• Contrast
• Preparation
• Positions
• Double Contrast Barium Enema (DCBE)
• Single Contrast Barium Enema (SCBE)
• Special Barium Enema Studies
• Aftercare
• Complications
• Virtual Colonoscopy
• CT Colonoscopy
• MR Colonography
• References
DEFINITION
It is the radiographic study of the large bowel by administration of
the contrast medium through the rectum.
CONTRAST
Pure crystals of Barium sulphate are formed by milling of the mined
raw mineral barytes, precipitation with sulphuric acid, followed by
washing and drying. Particle size varies from 0.6-1.4 microns (fine and
uniform) to 4-50 microns (large crystal in more heterogeneous form).
Particles are coated with various agents to achieve rapid flow, good
mucosa! adhesion, adequate radiographic density, an even coating
which is plastic and does not crack and absence of artifact or foaming.
Additives - Carboxy Methyl Cellulose
- Simethicone, Gum acaeeae, Pectin
- Dimethyl Polysilicone (anti foaming agent)
97
PREPARATION
There are different regimes of bowel preparation and most regimes rely
on a combination of dietary restriction, purgation and overhydration
with the possible addition of cleansing water enema.
Diet
Patient should be given a low residue (low fibre) diet for 2 days prior
to the examination. Patient should not have any fatty fried foods. He
should not have vegetables and fruits. Patient can have egg, meat,
dal and soups. Patient should drink plenty of clear fluids on the
day preceding the examination. Iron containing medication should
be stopped 2 days before the examination because they make stools
adhere to mucosa.
Laxatives
(For removal of most solid material)
Castor Oil (30 ml)

• irritant cathartic.
• cheap, though unpleasant to take, is gentle in effect.
• has dual action, being broken down in the small bowel into : (i)
Ricinoleic acid, which inhibits water reabsorption; (ii) Mineral oil
residue that probably has a direct motor action causing contractions
in the distal small bowel and proximal colon.
Bisacodyl (15-20 mg)

• irritant cathartic
• contact laxative belonging to polyphenolic group of compounds
• hydrolysed by intestinal enzymes in the small and large bowel into
desacetyl bisacodyl which has a direct motor action on the bowel
and also a slight secretory effect.
E.g.: Dulcolax.
Magnesium Citrate (5-10 mg)
• saline type cathartic is more pleasant to take than magnesium
sulphate.
• magnesium and the sulphate or citrate radicals are poorly absorbed
from the gut, leading to osmotic retention of fluid and increased
peristalsis.
E.g.: Picolax (one sachet contains 10 mg of sodium picosulphate,
3.5 g of magnesium oxide and 12 g of citric acid).
Barium Enema • 99
• It is a contact and osmotic laxative.

• Headache is its most common side effect.
E.g.: Citramag (Magnesium citrate equivalent to 5 g of Mg Oxide).
Bowel Wash
• Previous night.
• In the morning, 2 hours prior to the procedure.
• Pass the tube beyond the rectosigmoid junction and infuse about
1.5-2 litres of fluid allowing evacuation. Repeat this till efflux is
clear of any faecal matter. T his is done for removal of smaller
particles.
• Patient lies: Left lateral position-receiving first 500 ml.
Prone position-receiving second 500 ml.
Right lateral position-receiving third 500 ml.
Preparation of Patient in our Department

1. Tab. dulcolax 2 HS - 2 Days.
2. Tap water enema on previous night and 7 a.m. on the day of
investigation.
3. Low residue diet - 2 Days.
4. To come on empty stomach on the of investigation.
Preparation of the Patient should not be done in

1. Diarrhoea.
2. Total obstruction.
3. Paralytic ileus.
4. Children less than 8 yrs. of age.
POSITIONS
Part of the bowel SCBE
Rectum and presacral space Left lateral Frontal-prone
Rectosigmoid Prone right side down oblique
Splenic flexure Prone left side down oblique
Hepatic flexure Prone right side down oblique
Entire colon Supine
DOUBLE CONTRAST BARIUM ENEMA (DCBE)

First modern double contrast barium enema with air insufflation wus
performed by Fischer in 1923 and later popularized by Welin in 1960s.
Preliminary Films
Plain radiograph of the abdomen is essential and helps in assessing
any abnormalities of gas filled bowel loops. In the presence of residual
faecal matter, double contrast examination should be cancelled. In
many centres, barium enemas are performed after an excretory
urogram. This not only reduces the time of hospitalization but also
gives relationship of the urinary system to the colon. It also helps in
visualization of the bladder in frontal and lateral projections and this
permits the study of the space between bladder and rectum.
Indications
1. Preferred method for routine examination.
2. High risk patients - rectal bleeding, previous H/o carcinoma or
polyp, family H/o colorectal cancer or polyposis.
3. Demonstration of sinuses or fistulas.
4. Patient with severe diverticulosis, polyposis or diarrhoea.
5. Presence of obstruction.
6. Reduction of an intussusception.
Contraindication
1. Allergy to barium suspension.
2. Peritonitis.
3. Acute or fulminating inflammatory colon disease.
4. Debilitated, unconscious, inability to cooperate.
5. History of recent rectal/colonic biopsy.
Procedure
Barium suspension : High density (slower flowing, better coating) 75%
to 95% w/v.
The patient is in prone position with left side down oblique and
high density low viscosity barium suspension is allowed to flow upto
splenic flexure. Now air is introduced with patient prone. Air should
push the barium column and never pass beyond the column. The role
of IV muscle relaxant before or after the double contrast barium study
had found to have no effect on the mucosa! coating. Frontal view
of rectum is taken in prone position and then the patient is turned
left lateral to take the lateral view. Then oblique right side down
view for rectosigmoid junction is taken. The patient is taken back
in prone position with right side dependent and air is pumped into
Barium Enema• 101
left sided colon. Once barium comes into transverse colon tum the
patient left side up - barium enters right sided colon and reaches the
ileocaecal junction. Now with the right side up, more air is pumped
till air outlines the ileocaecal junction. Take spot films for flexures
and ileocaecal junction. Now proceed with full films in supine, both
decubitus and erect as required.
Advantages of Double Contrast Over Single Contrast

• Better surface details.
• Surface lesions can be demontrated to the best effect.
• Easy unraveling of the colon as it is possible to look through loops.
Disadvantages of Double Contrast Over Single Contrast

• Difficult in uncooperative patients.
• Fistulae/sinuses can be missed.
• Effacement of submucosal detail of the colon and overlooking of
annular /polypoid lesion is possible.
Note:
1. If colon repeatedly gives contraction, Buscopan 1ml i.v. can be
given.
2. If patient does not retain barium, then for better retention :
• make patient prone.
• distend the colon slowly.
• reassure the patient.
• if there is sphincter incompetence, then strap the buttocks with
sticking plaster.
• use Foley's catheter with big balloons. The balloon is inflated in
mid rectum and then gently pulled back till there is resistance
do not use balloon in acute inflammation.
3. In patients who have total obstruction, let patient evacuate part
of the barium and then pump air. The froth goes through the
obstruction and proximal limit of obstruction can be demonstrated.
SINGLE CONTRAST BARIUM ENEMA (SCBE)

Indications
1. Uncooperative, very debilitated or immobile patient.
2. Evaluation of acute obstruction or volvulus.
3. Reduction of intussusception.
4. Show configuration of colon.

5. Where only gross pathology is to be excluded.
Contraindications
1. Allergy to barium suspension.
2. Risk of perforation.
3. Peritonitis.
4. Suspicion of acute/fulminating ulcerative colitis.
5. Following a recent deep biopsy.
Procedure
Barium suspension : Low density (to promote see through effect with
a high kV or compression) 15% to 20% w/v.
Tube is placed in the rectum with the patient in left lateral position.
The height of the enema should not be more than 1 metre above the
table top. In case there is gas in the rectum, the patient is kept supine
and infusion is started. Otherwise the patient is kept in left lateral
position. As soon as the entire rectum is full, the tube is clamped
and a lateral view is taken. Then the patient is put prone and with
the infusion running, the frontal view film of the rectum is exposed.
In the prone position, pelvis tilts forward, sacrum lies parallel to
the film and foreshortening of rectum is prevented. The patient is
kept prone with right side down oblique position. This position helps
in the opening up the curve of rectosigmoid junction. Spot views of
rectosigmoid junctions with barium flowing are taken.
Now the patient is kept prone oblique with left side down.
Splenic flexure opens out and spot view of splenic flexure is taken.
As barium flows towards hepatic flexure, patient is turned right side
down oblique and spot films of hepatic flexure. With continuous flow
of barium caecum fills up. As soon as the reflux across ileocaecal
junction takes place, the tube is clamped and ileocaecal spot films
are exposed. A full film is now exposed to show entire colon. After
evacuation, mucosal relief film is exposed. Polyposis and diverticulo
sis can be better visualized on post-evacuation films.
Pelvic outlet view for rectum : Give 30° cranial angulation to the
tube with the patient supine so that pubic symphysis and sacral
promontory overlap.
Pelvic inlet view for sigmoid : Should be taken before the transverse
colon is filled with barium. 30° caudal tilt is given to the X-ray tube
with patient supine.
Barium Enema• 103
Note: During the entire study, the head of the barium column
should be followed under flouroscopy.
A limited double contrast study can be done following conventional
study but it is technically inferior to a direct DCBE. (Our department
follows this technique)
• Patient evacuates after SCBE.
• Adequacy of evacuation is checked. If the evacuation is near
total, about 300-400 ml of barium is again filled.
• Now air is pumped in from the rectum under fluoroscopy and
double contrast filming is done.
• If there is a large amount of residual barium, then supine, right
and left decubitus, frontal films, and if required, erect films
should be taken.
Absolute Contraindications for Both DCBE and SCBE

• Toxic megacolon.
• Pseudomembranous colitis.
• If rectal biopsy has been done in the previous 5 days, it is preferable
to wait for 7 days.
• Paralytic ileus.
• Difficulty to pass tube in rectum. For example, inflammed piles,
growth etc.
Relative Contraindication
• Incomplete bowel preparation.
SPECIAL BARIUM ENEMA STUDIES

Sigmoid Flush
It is used in patients with severe diverticular disease to improve
visualization of affected bowel. 500-700 ml of dilute barium suspension
is run in at the end of standard DCBE and spot radiographs are
taken of the filled sigmoid and descending colon. The numerous rings
formed in DCBE are easier to interpret in SCBE. The dense barium
adheres to the mucosa while the dilute suspension gives a see through
effect.
Colostomy Enema
A non-wash out bowel preparation is strongly advised in patients
with a colostomy. Standard barium suspension may be used. Cut
the balloon of a Foley's catheter and then fit an infant bottle feeding
nipple over this after having cut a suitably sized hole in the end.
Catheter is advanced for about 15 cm through the nipple and is then
inserted into the stoma until nipple acts as a bung in the stoma.
Some guaze swabs with a central cut are placed around the nipple
and the patient's hand is used to hold this in place. The suspension
is run through the main tube and gas is introduced through the side
arm. Alternative techniques include using a Foley's catheter with
its balloon inflated to seal the stoma or with a hole made in the
colostomy bag itself.
Colon is filled till mid-transverse colon. Then patient is turned to
right side and gas is insufflated. Rotate the patient to manipulate the
column around the hepatic flexure and bring the barium to ascending
colon. It is important to turn the patient prone. Spot radiographs
taken are supplemented by two decubitus views.
Instant Barium Enema

It is done to show the extent and severity of known colitis. No
bowel preparation is required as residue does not accumulate in a
segment of active colitis. Technique works best in ulcerative colitis
where disease is continuous but gives acceptable results in Crohn's
disease. A preliminary plain radiograph is recommended to exclude
toxic megacolon or perforation which are absolute contraindications
to an instant barium enema. Colon should be filled until residue is
encountered or the transverse colon is reached. Rectum is drained and
gas is very gently insufflated turning the patient as required. A prone
radiograph is all that is required. Lateral pelvic view will show size
of rectum and an erect radiograph, the flexures and transverse colon
in double contrast. Balloon catheters are contraindicated.
Water-Soluble Contrast Enema

Gastrografffin (meglumine diatrizoate) or similar products are used
as enema contrast media for certain conditions. Normally it is used
as 1:3 dilution with water.
Indications
1. Intestinal perforation due to diverticulosis, perforated carcinoma,
leaking anastomosis and abdominal stab wounds communicating
with colon.
2. Fistulas (vesicocolonic, vaginocolonic)
Barium Enema • 105
3. Softening of meconium in newborns and to relieve faecal impaction

in adults.
Hyperosmolar nature of gastrograffin may produce severe
dehydration, shock and death in:
• hypovolemic infants.
• sick children.
• very old and very ill.
AFTERCARE
1. The patient should be warned that his bowel motion will be white
for a few days after the examination.
2. Laxatives should be used to avoid barium impaction in patients
with constipation.
COMPLICATIONS
Can result from:
• Preparation of patient
• Pharmacological agents
• Procedure
Perforation
• balloon catheters may cause local trauma to rectum.
• patients with colitis, radiation therapy and where there is low
anastomosis are more prone for perforation.
• perforation may be intraperitoneal or extraperitoneal.
• in intraperitoneal-massive serosal fluid exudate with hypovolaemia
will occur which may be compounded by Gram negative endotoxic
shock.
• barium sulphate particles in peritoneal cavity will cause foreign
body reaction with formation of dense adhesions.
• barium granuloma - due to barium retention within bowel wall
from intramural perforation
• rarely venous intravasation
• if barium enters systemic circulation, pulmonary embolism will
result.
Treatment: antibiotics, fluid replacement and peritoneal lavage.
Inspissation of Barium
• Causing severe constipation to the patient.
• It is seen in elderly patients with obstructive lesion or if barium is
given in large amount and infused beyond the lesion.
• Usually results from residue impacting in a stricture and high
intracolonic pressures generated by the purgative exceeding the
integrity of the bowel wall.
Prevention: Fluid should be forced and laxatives should be used
after the procedure.
Water Intoxication and Electrolyte Imbalance

• Due to preparation with cleansing water enema.
Caustic Colitis
• Due to detergent or soap enemas being used, as these interfere with
mucosal coating.
Transient Bacteremia
• Following instrumentation/ dilatation of the colon.
Pharmacological Agents Causing Complications

• Buscopan: ctry mouth and in 10% of patients there is blurring of
near vision, which lasts for about 20 minutes.
• Sensitivity to barium suspension is very rare.
• Anaphylactic reactions to latex balloon catheters have been reported
(silicon rubber catheters are the alternative).
Colonoscopy
• This exam involves placing a flexible endoscope into the colon.
• Intervention is possible, biopsies can be taken and polyps can be
removed.
• Colonoscopy is generally considered the procedure of choice for
colon cancer screening.
Computed Tomography
• It offers better density discrimination.
• It allows visualization of the wall of the gut.
• It permits demonstration of structures beyond the alimentary tube,
thus allowing assessment of extent of disease.
Barium Enema• 107
• It provides reconstruction of images in various planes.

• It is an excellent method for needle biopsy of lesions of colon.
VIRTUAL COLONOSCOPY
Virtual colonoscopy, also known as CT colonography, refers to using
spiral CT scanning or multidetector CT and computers to simulate
colonoscopy by generating high-resolution multidimensional views
of the colon.
Advantages
1. It is less invasive.
2. It offers greater safety, less discomfort, and greater patient
acceptance.
Disadvantages
1. Main disadvantage is increased cost and is inability to take biopsy.
2. It has poor sensitivity for small polyp.
CT COLONOSCOPY
In this procedure entire colon is visualized by C.T. examination with
3 D reconstruction.
Indications
1. When colonoscopy could not be performed ( eg. In case narrowed
bowel, In a case of colonic obstruction to see the part distal to
obstruction.)
2. Elderly and sick patients.
3. Patients who are at increased risk of complication, due to
colonoscopy such as patient on oral anti coagulant.
4. Poor patient compliance during conventional colonoscopy.
Advantages
1. No anaesthesia, sedation required and high patient compliance.
2. Minimally invasive procedure with clear detection of polyp and
other lesions.
3. Markedly lower risk of perforating the colon.
4. Abnormalities outside colon can also be well visualized.
MR COLONOGRAPHY
Currently three different liquid enema techniques are used for MR
colonography:
1. Bright lumen. Water gadolinium enema is used.
2. Black lumen. Water enema for luminal distension and intravenous
infusion of gadolinium for enhancement of the colonic wall.
3. Fecal tagging. Based on die that contains barium to give stools
the same signal intensity as water on TlWt GRE image.
Advantages
1. For detection of crohn's disease, sensitivity and specificity is very
high.
2. MR colonography with fecal tagging can detect smaller lesions
from 6 mm in size.
3. No radiation involved.
Long Answer Questions- �

- - - --------- -
1. Discuss barium enema under following headings:
(a) Definition
(b) Preparation of patient
(c) Contrast media used during procedure
(d) Indications & contraindications of S.C.B.E.
(e) Indications & contraindications of D.C.B.E.
(f) Complications of barium enema.
2. Describe S.C.B.E. and D.C.B.E. under following headings:
(a) Preparation
(b) Contrast media used during each procedure
(c) Indications & contraindications
(d) Procedure
(e) Complications
Short Answer Questions--------- - - - ----

1. Write a short note on water soluble contrast media.
2. What is barium enema? How will you prepare a patient for this
procedure?
Barium Enema • 109
3. Discuss in brief complications of barium enema.

4. Mention the indications & contraindications of D.C.B.E.
5. What is the role of preliminary film before D.C.B.E.?
6. Mention the advantages & disadavantages of D.CB.E. over S.C.B.E.
What are the absolute contraindications for both?
REFERENCES
2. Bartram Cl. Colon. In : Graham H Whitehouse (ed). Techniques in
diagnostic imaging, 3rd edn. Oxford : Blackwell Science, 1996 : 50-
724.
3. E.M. Elson, D.M. Campbell, S. Halligan, I.Shaikh, S. Davitt, Cl.
Bartram. The effect of timing of LV. Muscle relaxant on the quality
of Double contrast Barium enema. Clinical Radiology, May 2000; Vol.
55. No. 5 : 395-397.
Chapter 11
Hysterosalpingography
• Indications
• Equipment
• Procedure
• Technique
• After Care
• Complications
• Falloposcopy
• Sono Salpingography (Sion Test)
• References
It is the procedure in which the contrast is injected into the uterus to

study the uterine cavity and fallopian tubes.
INDICATIONS
1. Infertility:
• To demonstrate patency of the fallopian tubes and their
communication with the peritoneal cavity. The causes of
tubal blockage are obstruction following tubal infection,
fimbrial adhesions, tubal pregnancy, tumour and sterilization
procedures. Poor operative technique and tubal spasm may
give false appearance of tubal blockage.
• Prior to artificial insemination.
2. Recurrent abortions: To demonstrate congenital abnormalities of the
uterus or incompetence of the internal os of the uterus.
3. Following tubal surgery: To monitor the effect of tubal surgery. For
example, to confirm tubal occlusion in a sterilization procedure or
to demonstrate patency and length of falloplan tubes after surgical
intervention to restore patency of pathologically obstructed tubes.
4. Migrated IUCD.
110
Hysterosalpingography • 111
5. Uterine and tubal lesions like tuberculosis, submucous fibroids,

polyps, synechiae.
CONTRAINDICATIONS
• Active Pelvic Sepsis.
• Sensitivity to contrast media.
• Recent dilatation and currettage.
• Pregnancy.
• The week prior to and the week following onset of menstruation.
• Severe renal or cardiac disease.
• Cervicitis/purulent vaginal discharge.
EQUIPMENT
• Contrast Media: Water soluble. For example, Urograffin 60%, Conray
280, Trivideo 280. Volume 10-20 ml. (Average volume 5-6 ml, in
nulliparous women 3-4 ml, if there is hydrosalphyx > 10 ml).
• 20 cc syringe.
• Canula: Leech Wilkinson, Jarcho type, Spackman.
• Uterine sound and dilator.
• Sims speculum.
• Tenaculum: Trauma is less, so ideal for nulliparous women.
(Vulsellum forceps can also be used but trauma is more).
• Fluoroscopy unit with spot film devices.
PROCEDURE
Ideal Time of Procedure: Between 8th and 10th day of menstrual
cycle, i.e., 2-3 days after stoppage of menstruation so that menstruation
tissue or fluid is not carried either into the oviduct or the peritoneal
cavity and the incidence of intravasation of contrast is low. Done
before 12th day because oocyte undergoes meiosis during this time
and is radiosensitive. Thus radiation exposure during this time should
be avoided.
Patient Preparation: The patient should be advised to abstain
from intercourse between booking the appointment and the time
of examination unless a reliable method of contraception is used to
avoid the possibility of irradiating an early pregnancy. Patient should
be fasting 4 hours prior to the procedure.
Premedication: Premedication is not required in majority of the

cases. When the patient is very anxious, 5-10 mg of I.V. diazeparn
30 minutes before procedure is helpful to prevent the tubal spasm
which can be provoked by anxiety. Morphine and Pethidine should
not be given as they stimulate the contraction of the fallopian tubes.
However Baralgan, which contains analgin and pitafemone HCl in
2 ml ampoule or 0.6 mg atropine sulphate in 1 ml ampoule can be
given I.V. 10 to 15 minutes before starting the procedure.
The bladder should be emptied prior to HSG. A full bladder will
elevate the fallopian tubes and may cause apparent tubal blockage
with the spurious radiological appearance of a hydrosalpinx.
TECHNIQUE
• Using a canula.
• Using Foley's catheter.
Using a Canula
The patient is placed in lithotomy position at the edge of the X-ray
table. A speculum is introduced into the vagina and the anterior lip
of the cervix is held with tenaculurn and gentle traction is applied.
The canula is inserted into the cervical canal under direct vision.
The speculum is then removed and patient is carefully moved up
the X-ray table in supine position. Care must be taken to remove all
the air bubbles from the syringe and canula before injecting, as these
may mimic polyps or fibroids.
Under fluoroscopic control, 2 ml of the contrast media is injected
to outline the uterine cavity. To prevent leak from the cervix, a
downward traction should be kept on the tenaculurn while keeping
an upward pressure to the canula.
The injection is then continued slowly governed by the patient's
tolerance until the oviducts have been outlined and free intraperitoneal
spill of the dye is visualised.
Filming:
• As the tubes begin to fill.
• When peritoneal spill has occurred.
Maximum X-ray screening time must not exceed 30 seconds using
an image intensifier and only two X-ray plate exposures are permitted
in order to minimize radiation to female gonads. (70-90 kV range)
Using Foley's Catheter

Cameron et al have described a method using 8 F Foley's catheter.
The cervix is exposed with a vaginal speculum and swabbed with
an antiseptic solution with the patient in lithotomy position. After
the lumen of the catheter is filled with the contrast (to prevent air
bubbles) the catheter is inserted through the cervical os using a
cervical forceps to guide it when the ballon lies within the uterine
cavity, it is gently inflated with water (2-3 ml). Before the injection of
contrast, the ballon is pulled downwards against the internal os. The
speculum is withdrawn and the catheter is attached to the syringe.
The patient assumes a more relaxed supine position. Contrast injection
and filming is same as with using a canula.
Advantages
1. No need for tenaculum thus avoiding possible cervical trauma
and bleeding.
2. Ability of a single operator to control both the injection and
exposure of spot films on a conventional fluoroscopic machine.
3. Much easier to obtain spot radiographs because the patient is in
more comfortable position and there is no chance of obscuring
anatomy with metal artefacts.
4. A "drainage" radiograph can be obtained at the end of the
procedure to demonstrate the uterine cavity without the catheter
creating artefacts.
5. Avoids false passage formation.
6. Avoids potential uterine perforation.
Disadvantages
1. The tip of the catheter sometimes blocks the tube on one side. This
can be avoided by applying downward traction on the catheter
while injecting the contrast.
2. The part of the uterus adjacent to the bulb cannot be studied. For
visualization of the lower uterine segment and the cervical canal
which are obliterated by balloon catheter, the balloon may be
deflated gradually while simultaneously injecting the radioopaque
dye.
False positive result is seen in hydrosalpinx. False negative
result is due to tubal spasm. Tubal spasm is seen in response to
anxiety or injecting the contrast with pressure. To eliminate tubal
spasm, sublingual nitroglycerine, general anaesthesia, narcotics,
tranquillizers and adrenalin or glucagons may be given.
For peritubal adhesions HSG has high false positive rates.

Note: Lack of tubal fitting in a patient with no known tubal
surgery (or) infection is a non-specific finding on HSG.
Differential Diagnosis
- Anatomic obstruction
- Technical problem
- Cornual spasm.
- Possibly mucosal plugging.
Contrast may loculate around fimbrial adhesions and mimic a
hydrosalphinx.
AF TER CARE
• It must be ensured that patient is in no serious discomfort before
she leaves.
• She must be cautioned that there may be mild bleeding per vagina
for 1-2 days.
• For mild pain analgesics may be given.
COMPLICATIONS
1. Pain may occur at the following times :
• Using the vulsellum forceps.
• During insertion of canula.
• With tubal distension and distension of uterus.
• Generalised lower abdominal pain due to peritoneal irritation
by the contrast media.
2. Venous intravasation due to: (0.6 to 3.7%)
• Excessive injection pressure.
• Traumatization of the endometrium by the tip of the cannula.
• The examination performed when the endometrium is deficient
as after curettage (or) menstruation.
3. Trauma to the uterus due to canula causing perforation.
4. Exacerbation of Pelvic Infection. [over all infection rate 0.25 to 3%
after procedure]
FALLOPOSCOPY
Falloposcopy is a recent development, pioneered by Dr. Kerin of USA.
In this method, a very fine flexible fiberoptic tube is guided through
the cervix and uterus into each fallopian tube, thus allowing the
visualization of the inner lining of the entire length of the fallopian
tube. This can provide useful information about the extent of tubal
damage, and the possibility for successful repair.
SONO SALPINGOGRAPHY (Sion test)

Premedication - same as above
Technique
Foley's catheter (SF) is introduced into uterine cavity with the patient
in supine position. The bulb of the catheter is inflated with 2 ml of
normal saline. Transvaginal sonography of uterus with catheter insitu
is performed in sagittal and coronal planes. After scanning the uterus
and ovaries, the area between the comua of uterus and the ovary
on one side is focused upon. A mixture of normal saline and air is
pushed with moderate force into uterine cavity using a 20 cc syringe
fixed to the metallic adaptor. A slight traction is given to the catheter
while injecting to occlude internal os with the bulb. If the fallopian
tube is patent the flow can be seen as a gush of fluid cascading
past the 'surprised' ovary and this phenomenon is called the 'Water
Fall Sign'. Then the same procedure is repeated with the other side
focussed. When the tubes are blocked, the patient complains of acute
pain in the suprapubic region and , the reflux of fluid and air is seen
in the stem of the catheter. Also uterine cavity can be seen distending
in case of tubal block.
Advantages
• Can demonstrate the tubal block, its site and extent with higher
accuracy and reliability.
• No radiation exposure.
Disadvantages
• Individual tube evaluation sometimes become difficult.
Other Techniques
1. Harris uterine injector (HUI)
2. Angiodilator techniques
3. Jarcho type canula
4. Sheath needle catheters
5. Malmstrom vaccum apparatus
6. Spackman canula
Long Answer Questions------ ---- - --

1. Discuss hysterosalpingography under following headings:
(a) Definition
(b) Indications
(d) Equipment required
(e) Preparation of patient
(f) Various techniques used
(g) After care & Complications
Short Answer Questions ----------.-------

1. Mention indications of hysterosalpingography.
2. What are the contraindications of H.S.G.?
3. Describe briefly the techniques used in H.S.G.
4. Enumerate advantages and disadvantages of using foley's catheter
over canula.
5. Describe briefly about sonosalpingography.
REFERENCES
1. Whitehouse GH. Female genital tract. In : Graham H Whitehouse
(ed). Techniques in diagnostic imaging, 3rd edn. Oxford : Blackwell
Science, 1996 : 300-311.
2. Whitehouse GH. Imaging in gynaecology. In: RG Grainger, DJ Allison
(eds). Diagnostic Radiology, vol.II, 3rd edition. New York: Churchill
Livingstone, 1997 : 1956-1957.
3. Maguiness SD, 0 Djahanbakhch and G Grudzinskas. 'Assessment of
fallopian tube'. Obs. and Gynaec. Survey, 1991, vol. 47, No. 7 page
589.
Chapter 12
Fallopian Tube Recanalisation

Indications
Contraindications
Timing of Study
Instrumentation
Preparation
Premedication
Technique
Other Methods
Post Procedure Follow Up
Complications
References
Tubal factors account for 30-40% of female infertility. Obstruction to

the uterine end of the fallopian tube is noted in 20% of HSG's. In
FTR, a guide wire is passed through a catheter to recannulate the tube
and to restore its potency. It is preceded usually by selective osteal
salpingography to confirm the presence of block.
INDICATIONS
• Unilateral/bilateral cornual block proved by conventional HSG,
and/or laparoscopy with chromotubation. Blocks distal to the
cornua are not an indication for FTR.
CONTRAINDICATIONS
1. Tubal blocks distal to the cornual end.
2. Patients with tubal pathology like hydrosalpinx and abnormal
fimbriae.
3 . Patients with history of tubal surgery.
4. Patients with history of PIO causing dense adhesions and scarring .
117
TIMING OF THE STUDY

• As for HSG, the follicular phase between 8th and 10th day after
the onset of menstruation is selected
INSTRUMENTATION
• 850mAs X-ray machine with fluoroscopic facility.
• Fallopian tube catheterization set:
- Double Balloon canula (Bard's/Mencini's)
- Catheter
- 0.0028 F Terumo guide wire
• Contrast media-Triovideo 280/Conray 280
PREPARATION
• Patient should be advised to abstain from intercourse between
booking of the appointment and time of examination unless a
reliable method of contraception is used to avoid the possibility of
irradiating an early pregnancy. Bladder should be emptied before
the procedure. (ovarian dose in FTR-0.2-2.15 CGY).
PREMEDICATION
• 25 mg Phenergan injection i.m., 0.6 mg Atropine should be given
half an hour before the procedure.
• Suitable Antibiotic cover is also provided e.g., Doxycyclin.
• If patient is still restless, 5-10 mg i.v. of diazepam is given to remove
the anxiety.
TECHNIQUE
• T he canula is inserted through the cervix into the uterus and is made
to stay in position by inflation of the two bulbs, one at the level of
the internal os and other at the level of the cervical canal (Fig.l).
Contrast media is injected into the canula to confirm the findings
of comual end block. Under fluor-oscopic guidance, a catheter
(usually 6 F) is advanced through the canula into the opening
of the fallopian tube (Fig. 2). A guide wire is introduced through
the catheter till it comes at the fimbrial end thereby dislodging
the obstruction (Fig.3). A simplified technique of fallopian tube
catheterization is described in which the tube is recanalised with
a guidewire alone.
Fallopian Tube Recanalisation • 119
• 2-3 ml of contrast media is injected into the fallopian tube to verify

the recanalisation.
• The procedure is done on the opposite side in cases of bilateral
block.
• A peritoneal spill on both sides verifies bilateral tubal recanalisation.
OTHER METHODS
• Hysteroscopic placement of catheters with laparoscopic guidance.
• Sonographically guided transvaginal fallopian tube catheterization.
POST PROCEDURE FOLLOW UP

• Admit the patient and observe for 12 hours for signs of perforation
leading to peritonitis.
• Antibiotic cover.
COMPLICATIONS
• Ectopic pregnancy (10%) in history of tubal disease.
• Early tubal reocclusion and strictures.
• Perforation and fistula formation.
Note: Transcervical recanalization can be used in the management of
patients with post operative strictures with underlying inflammatory
obstruction and strictures technique is a failure in case of fistulae
complicating reversal surgery.

1. What are the indications and contraindications of fallopian tube
recanalisation? How do y ou prepare patient for this procedure?
2. What are the pre-medications and complications of fallopian tube
recanalisation? Describe in brief the technique of fallopian tube
recanalisation.
REFERENCES
1. Thurmond AS, Rosch J. Non-surgical FTR for the treatment of
infertility. Radiology 1990; 174 : 371-374.
2. Thurmond AS. Selective salpingography and FTR. AJR 1991; 156 :

33-38.
3. Novy M , Thurmond AS. Patton P, Uchida. Diagnosis of comal
obstruction by transcervical FTR. Fertility and Sterility 1988; 50 : 434.
4. Millward S.F., Claman P., Leader A., Spence J.E. Technical report
: fallopian tube recanalization - a simplified technique. Clinical
Radiology July 1994; 49(7) : 496-497.
5. Lang E.K. The efficacy of transcervical recanalization of obstructed
post operative fallopian tubes. Eur- Radiology 1998; 8(3) : 461-465.
6. Nikolic B , spies J. B., Lundsten M. J., Abbara S. Patient radiation
dose associated with uterine artery embolization Radiology. January
2000; 214(1) : 121-125.
Chapter 13
Sialography
• Indications
• Equipment
• Preparation of the Patient
• Procedure
• References
This is the study to demonstrate the parotid or submandibular glands

by injection of contrast medium into the duct system.
INDICATIONS
1. Calculi.
2. Chronic inflammatory disease.
3. Mass lesion.
4. Obstructive lesion.
5. Penetrating trauma.
6. Strictures.
7. Fistula.
8. Prior to CT evaluation of salivary glands.
CONTRAINDICATIONS
1. Allergy to iodine.
2. Acute Sialadenitis.
EQUIPMENT
1. Contrast medium-water soluble, ionic contrast media like
Triovideo 280,Conray 280 or non-ionic contrast medium such as
omnipaque-350.
2. Lacrimal cannula or disposable 22 G (Gelco/Venflon).
3. Lacrimal dilator. Liebreich's double ended lacrimal probe.
121
4. 2 cc syringe. Four grades (00/0, 1/2, 3/4 & 5/6) 00/0 and ½
are required for sialography. Outer diametre of cannula 1.02 mm.
Rabinov sialography catheter obtainable in a sterile pack and is
recommonded.
5. Lemon/vitamin C tablet.
PREPARATION OF THE PATIENT

Removal of false teeth, if any.
PROCEDURE
l. Preliminary radiograph
Plain radiograph should be taken before embarking on sialography
because a considerable pathology is associated with opaque calculi
within the glands themselves or their ducts, particularly in the
submandibular gland.
2. Locating duct openings
(a) Parotid duct opens opposite 2nd upper molar tooth on the
buccal surface of the cheek.
(b) Submandibular duct opens at the base of the frenulum of the
tongue.
(c) In case the ostium is not visible, apply pressure on the gland
or give a sialogogue like lime. Then saliva will be seen pouring
through the punctum.
3. Dilate the punctum with lacrimal dilator.
4. Technique
Two techniques for cannulating the ducts are by using:
(a) Intracath technique.
(b) Lacrimal cannula technique.
• If we are using an intracath, we should cut enough plastic
tubing from the tip of intracath with fine scissors such that
2 mm of the inner wire stilette is still protruding. Now the
punctum is cannulated for 5 mm. Now withdraw the stilette
such that it no longer protrudes the outer tube.
• The inner stilette produces stiffness during introduction of
catheter. The stilette is removed and outer tube is attached to
polythene tube.
• Now the contrast is injected.
• In the lacrimal cannula method, contrast is injected into the
cannula which is introduced through the duct opening.
Sialography • 123
• Contrast is injected till the patient complains of pain by a

prearranged signal.
• About 0.5-1.0 cc of contrast is required.
5. Film exposure
Positioning for parotids:
• Frontal view is taken with face rotated 5-10 degrees towards
the side of study.
• Lateral view is taken with 15-20 degrees cranial tube tilt.
Positioning for submandibular gland
• Lateral view is taken with 15-20 degrees cranial tube tilt.
Films are taken during injection. The catheter is left in place
till the adequacy of films is ensured.
6. Aftercare: none
If sialadenitis occurs after the procedure, it should be treated with
antibiotics and anti-inflammatory drugs.
7. Complications
• Sialadenitis and abscess
• Stricture of the ducts.
8. Disadvantages of sialogram
• Masses less than 1cm may not be detected.
• Contrast does not always penetrate the deep lobe of parotid
gland.
Short Answer Questions ----------------�

1. What is sialography? Enumerate indications and contraindication of
sialography.
2. Describe the procedure of sialography in brief.
REFERENCES
1. Smith NJD. Salivary glands. In : Graham H. Whitehouse (ed).
Techniques in diagnostic imaging, 3rd edn. Oxford : Blackwell
Science, 1996 : 3-12.
2. Chapman AH. Salivary glands. In : David Sutton. Textbook of
radiology and imaging, 6th edn. New York : Churchill Livingstone,
1998 : 789-792.
Chapter 14
T-Tube Cholangiography
• Indications
• Technique
• Pitfalls
• Interpretation
• References
A type of direct cholangiography, which allows study of the CBD

in the post-operative period prior to removal of T-tube, determining
the patency of CBD. If there are no post-operative complications, a
T-tube cholangiogram should be obtained 8-10 days after operation.
It is estimated that approximately 5% of post-operative T-tube
cholangiograms will show retained calculi (Glenn, 1974). If retained
stones are detected, percutaneous removal through T-tube tract,
as popularized by Mazzariello (1978) and Bushenne (1980) is the
treatment of choice.
INDICATIONS
1. Exploration of the bile ducts at operation.
2. Poor or absent drainage of bile from the T-tube after operation to
determine whether the T-tube is blocked or is no longer present
in the CBD.
3. Haemorrhage from the T-tube.
4. Demonstration of residual hematoma or abscess formation within
the liver parenchyma after partial hepatectomy or liver laceration.
TECHNIQUE
• No patient preparation is required. The examination is done on
fluoroscopy unit with image intensifier and a tilting table, 7-10
days after operation/earlier if there is indication for this such as
haemorrhage from T-tube/failure of T-tube drainage.
-124
I-Tube Cholangiography • 125
The patient is placed supine on the X-ray table with the left side
slightly raised. All dressings and metal objects are removed from the
liver area.
A preliminary film of right upper quadrant should be obtained
before injection to establish the position of tube and identify unusual
air collections. Sterile technique is used, and a syringe connected to
a No. 21 or No. 23 scalp vein needle is filled with contrast material
and closely scrutinized to eliminate air bubbles. The I-tube is then
punctured and gently aspirated to withdraw air bubbles lodged in
the tube. The I-tube should then be clamped just beyond the point
of insertion of the needle to prevent distal air bubbles from being
mobilized during injection.
Dilute contrast medium should be used so that stones are not
obscured. If bile ducts are markedly dilated, more dilute contrast
medium (CM) should be injected, but overdistension should be
avoided. Care should be taken not to introduce air bubbles into biliary
tree as they may mimic stones on cholangiogram.
Approximately 5 cc of CM is injected under fluoroscopic control
and a spot film is obtained in AP projection. Patient is then rotated
into the left posterior oblique position and the procedure repeated
with an additional 5 cc injection.
A further injection is made when the patient is placed in RPO
and finally a film is taken with patient supine once again in straight
AP. Normally a total of 20-25 cc of CM is sufficient to obtain these
special views.
After final injection, a right lateral film may be obtained if
required. If desired, films are taken at 15min / 30 min intervals
depending upon degree of delay in emptying of biliary tract until
patency of biliary tract is determined. If obstruction is encountered,
it is best to withdraw as much of contrast media as possible prior to
removal of the syringe.
With a slow injection rate, the patient should experience no pain.
A sense of fullness will occasionally be noted. Marked discomfort
indicates that either the I-tube is malpositioned or the normal flow
of bile is obstructed. If explanation is not evident fluoroscopically,
it is best to pause and review the available films before proceeding.
PITFALLS
Differentiation between air bubbles and calculi may be made by
placing the patient in Trendelenburg and Semierect positions. Not
everything that is round and rises to float is an air bubble. Gall stones
do not have to be faceted and cholesterol stones may float in CM.
Elseny and Jacobs showed that specific gravity of cholesterol stone
is 1.04, which is the greatest specific gravity that native bile reaches,
which means stones can hardly float in native bile, but may float after
the dilution by contrast. Air bubbles fortunately are never faceted,
never sink in bile/contrast medium and typically appear as tiny,
perfectly round, smooth, and often multiple lucent defects.
INTERPRETATION
Normal T-tube cholangiogram
Normally there is free drainage of the CM into the duodenum and
there may be reflux of CM into the pancreatic duct. Using this
technique, the entire biliary tract is outlined, including any cystic duct
remnant. Oblique/lateral views or both are necessary to demonstrate
the latter.
Abnormal T-tube cholangiogram

1. Failure of CM to enter the duodenum may be due to :
(a) Rapid injection of CM resulting in the spasm of sphincter of
Oddi.
(b) Organic obstructive lesion such as tumor or calculus. When
obstructive lesion is encountered, spot films of the area should
be taken.
2. Failure of CM to pass into the IHD may result either from
concretions obstructing the lumen or orifice of proximal limb of
T-tube or CM following the path of least resistance distally.
3. Failure of T-tube drainage after operation may be due to :
(a) Occlusion of T-tube by debris. This is sometimes overcome by
injection of CM.
(b) Malposition of T-tube in CBD. This happens when upper
limb of T-tube lies against wall of right or left hepatic duct,
usually because the upper limb is too long, which may lead
to obstruction of bile flow leading to jaundice.
(c) Kinking of the T-tube within the abdomen.
(d) One or both limbs of T-tube may lie outside the CBD. Clinically
this is suspected when there is failure of drainage, leakage of
bile around the tube or a biliary fistula.
T-Tube Cholangiography • 127
4. Haemorrhage from a I-tube post-operatively

It may be due to
(a) Erosion of small vessel by the tube.
(b) Vitamin K deficiency in patient with obstructive jaundice of
long duration.
5. Residual calculi in CBD
These usually pass down from the intrahepatic ducts more
commonly from the left hepatic duct and are found in the upper
CBD or rarely at its lower end.
6. Lower CBD obstruction at I-tube cholangiography
This is most commonly due to spasm of sphincter of Oddi, owing
to rapid injection of CM. It may also be due to :
1. A neoplasm at head of pancreas.
2. Chronic pancreatitis with fibrosis of the lower CBD.
3. A benign stricture after passage of a calculus.
4. Primary carcinoma of the papilla or CBD.
5. A calculus impacted at the sphincter of Oddi.

1. What are the indications and contraindications of T-Tube
cholangiography? Describe the technique in brief.
2. How will you interpret T-Tube cholangiogram? What are the pitfalls
of the procedure?
REFERENCES
1. Radiology of the liver. McNulty, 1977, p. 122- 123.
2. Radiology of the gall bladder and bile ducts. Philip M Hatfield,
Robert E Wise, p.103-109.
3. An atlas of anatomy basis to radiology. Isadore Meschan, 1975, p.
911-912.
4. White house Techniques is diagnostic Radiology 3rd (edn.) Blackwell
Scientific Publications (1996).
Chapter 15
Percutaneous Transhepatic
Cholangiography
• Indications
• Prerequisites
• Technique
• After Care
• Comparison of PTC and ERC
• References
It is a method of direct cholangiography and provides the most

complete and detailed radiographic demonstration of biliary duct
system.
INDICATIONS
• In presence of bile duct obstruction which has been demonstrated by
US/CT where information provided by these studies is insufficient
for diagnostic purposes/for planning treatment.
• Prior to biliary drainage procedures/stenting.
• Undiagnosed jaundice.
• Extrahepatic bile duct obstruction due to calculi, strictures and
malignancies.
• Biliary diseases.
• Sclerosing cholangitis.
• Chronic pancreatitis.
• Post operative fistula.
CONTRAINDICATIONS
• Ascites-difficulty in puncturing and applying compression,
possibility of haemorrhage is high.
128
Percutaneous Transhepatic Cholangiography • 129
• Biliary sepsis-appropriate antibiotic cover, use small volume

contrast and establish drainage.
• Hydatid disease.
• Bleeding diathesis.
• Contrast hypersensitivity.
PREREQUISITES
Patient Preparation
1. US /CT must be performed prior to PTC, which provides useful
information regarding not only to the level of obstruction but also
to the assessment of tumor resectability and planning of the most
appropriate approach to biliary decompression.
2. Check clotting profile and platelet count.
3. Xylocaine sensitivity test.
4. HIV and HBsAg be tested for.
5. Fasting 4 hours prior to procedure.
6. Start I.V. line and broad spectrum antibiotics (in view of high
incidence of bacterial colonization of obstructed biliary system).
7. Premedication 30 minutes prior to procedure.
8. Informed consent.
Equipment
1. Fluoroscopy unit with image intensifier and a tilting table
2. Chiba needle-22/23 G, 15-20 cm long with short bevel, stainless
steel needle.
TECHNIQUE
PTC is performed as a sterile procedure with the patient on a
fluoroscopic table which preferably is able to tilt. This is done under
local anaesthesia with i.v. sedation and analgesia with appropriate
patient monitoring.
Two approaches: Right flank approach (Lateral) and epigastric
approach.
Right Flank Approach

A flexible chiba needle is inserted, usually from the right side. The
puncture site is slightly anterior to midway between the tabletop and
the xiphisternurn; inferior to the right lateral costophrenic angle on
fluoroscopy on full inspiration and superior to the hepatic flexure of

the colon on full expiration. The needle is inserted medially through
the liver while screening, angulated slightly anteriorly to the coronal
plane and directed craniad towards a point midway between the right
cardiophrenic angle and the first part of the duodenum which can
usually be identified by luminal gas.
• Specific vertebral bodies are not appropriate for guidance as their
relationship to the liver is variable. Needle movement should be
during suspended respiration, end-expiration or end-inspiration,
and the different phases of respiration can be used to help direct
the needle.
• Needle tip is advanced to approximately over the right margin
of the spine and then withdrawn incrementally with intermittent
suction applied with a syringe connected via a short tubing.
• Needle entry into a bile duct is identified by aspiration of bile or
injection of contrast medium.
• It is important to inject only sufficient contrast media to establish
diagnosis, as injecting more in high-grade obstruction will increase
risk of septic shock.
• Injection of contrast media outside bile ducts should be minimum
as it tends to obscure the region of interest, may be painful and
can produce pseudo-obstruction of IHBD.
• Injection into portal or hepatic veins is recognised by rapid flow of
contrast media away from the needle tip.
• Injection into lymphatics - narrow irregular channels passing
downwards and medially but without typical branching of bile
ducts. These have a characteristic fine beaded appearance.
• Injection into liver parenchyma - persistent amorphous stain.
• Injecting periportally - static branching stain.
• Injection into bile ducts - slow 'oil like' flow of contrast medium
away from needle tip. With multiple needle passes it is common to
produce haemobilia, when this occurs blood stained bile is aspirated
which is more viscous than frank venous blood and drips like oil
rather than water.
• If biliary radicle is punctured in first pass, repeated attempts are
made with slight variation in craniocaudal angulation but without
withdrawing tip from liver substance.
• If gall bladder is punctured accidentally, continue by injecting contrast
till gall bladder lumen and CBD are opacified and appropriate
films are taken (frontal, 45 degrees, LPO, lateral, Trendelenberg).
After filming, contrast and bile are aspirated out of gall bladder to
decompress system.
• The success rate using fine needle PTC increases with number
of passes and increase in number of passes does not increase the
incidence of serious complications.
• As movement in biliary radicles is gravity dependent, various
positional manoeuvres are done. LPO and Prone positions are used
to opacify left lobe ducts.
• Following successful duct entry, bile samples should be obtained
for bacteriological and if malignant obstruction is suspected for
cytological examination.
• Water-soluble contrast medium (200-300 mg I/ml) is then injected
in sufficient quantities to obtain as much filling as possible of the
intrahepatic and extra hepatic duct system without using undue
pressure. As much bile as possible is aspirated, but if aspiration
is difficult without loosing needle position then undiluted CM is
used (bile itself produces some dilution).
• In very dilated systems or if stones are suspected more dilute CM
is needed so that stones or ductal anatomy is not obscured.
• With needle in position, patient can be carefully moved into a LPO
position, which helps to fill the more anterior left lobe ducts and
feet down table tilt us used to fill the EHBD completely. Films are
checked prior to needle withdrawal and then further films are taken
in different projections to ensure complete visualization of biliary
system. A prone film may be needed to fill left ducts
Epigastric Approach
It is preferred when:
1. If only left lobe cholangiogram is required or if right sided PTC
has failed to produce left lobe cholangiogram.
2. If there is right lobe atrophy or previous right hepatectomy which
results in gall bladder or bowel lying deep to right lateral wall
where they are at risk of puncture with a right flank approach.
Pitfalls
l. Fnlsc locnlizntion of level of obstruction: Failure to inject sufficient
CM or use table tilt and patient positioning can lead to false
localization of obstruction rt'cognizcd by presence of hazy margin
at level of appc1rent obstruction.
2. l11complctc c/10/i111g1osra111. Opacificatim1 of only right ducts i-; oftL 11
mistaken for a complete cholangiogram. The left ducts lie usually

over spine if not opacified even with patient rotation and table
tilt then direct epigastric approach is used.
AFfER CARE
1. Ask the patient to lie down on right lateral position, as this gives
compression to puncture site.
2. Check pulse and BP ½ hourly for 12-24 hours.
3. Observe for increase in abdominal girth.
4. Observe for signs and symptoms of peritonitis and intraperitoneal
haemorrhage.
COMPARISON OF PTC AND ERC

PTC ERC
Advantages Less expertise needed, Visualization of stomach
good duct filling above and duodenum.
an obstruction
Biopsy of periampullary
lesions possible.
Simultaneous
pancreatogram.
Note: Both may be followed by catheter or endoprosthesis insertion
for biliary drainage.
Contraindications Significant Unfavourable anatomy.
coagulopathy.
Marked ascites* Pseudocyst*
Recent acute
pancreatitis*
Success rates 98%-dilated ducts Upto 90% (Cotton 1977)
70%-undilated ducts
(Harbin et al. 1980)
Major 4.1% (Gibson 1988) 2-3% (Cotton 1977)
complications
Mortality 0.13% (Gibson 1988) 0.1-0.2% (Cotton 1977)
* Relative
Short Answer Questions - - - ---------- -

�
1. What are the pre-requisite for percutaneous transhepatic
cholangiography?
2. Enumerate the indications and contraindications of percutaneous
transhepatic cholangiography.
3. Compare in brief percutaneous transhepatic cholangiography and
endoscopic retrograde cholangiography.
4. Describe the technique of percutaneous transhepatic cholangiography.
What are the pitfalls of the procedure?
REFERENCES
1. RG Grainger, DJ Allison (eds). Diagnostic Radiology, vol.II, 3rd
edition. New York: Churchill Livingstone, 1997: 1209-1211.
2. J.P. Owen. Biliary tract. In : Graham H Whitehouse (ed).Techniques
in diagnostic imaging, 3rd edition. Oxford : Blackwell Science; 1996
: 90-95.
Chapter 16
Catheters
I
• Classification :
• Catheters Used For Different Studies

- For Global Injection (Aortogram)
- Cerebral Catheters
- Visceral Catheters
- Coronary Catheters
- Renal Catheters
- Balloon Angioplasty Catheters
• Sterilization Of Catheters
• References
Modern catheters are made of polyethylene, polyurethane nylon

or other plastic tubing to obtain better torque control and superior
strength. A high quality catheter in addition to having good torque
response and radio opacity should have flexible atraumatic tip and
a low surface frictional resistance for good trackability over a guide
wire.
Recently, catheters with lubricious hydromer coating have been
introduced and may perhaps set a new standard of efficacy for
selective and super selective catheterization.
CLASSIFICATION
Catheters can be classified as:
1. Diagnostic angiographic catheters.
2. Microcatheters.
3. Drainage catheters.
4. Balloon catheters.
5. Central venous catheters.
134
Catheters • 135
1. Diagnostic Angiographic Catheters

Side Holes
• Single hole (or 'port') at the end (for very selective injection).
• End hole with side holes.
• Blocked end with side holes only.
Advantages of having side holes are

• Holes clustered near the tip of the catheter helps to concentrate the
bolus of contrast medium delivered.
• They increase the rate at which the contrast medium can be injected
through the catheter.
• By dispersing the direction of exit of contrast medium from the
catheter they reduce the jet effect of the injection, there by reducing
the recoil of the catheter tip.
• They minimize the dissection of the artery, for if one or more of
the parts are not lying freely in lumen of the vessel, the contrast
medium can still escape through the exposed parts.
Sizes
Catheters intended principally for abdominal use are usually 6-80 cm
in length and thoracic or carotid arteries are usually 100-120 cm in
length. Size of the external diameter of the catheters depends on the
age of the patients, selective or super selective study and size of the
vessels. Catheter size is numbered in Fr. Gauge. (Outer Diameter).
1 F = 0.0131 inch = 0.033 mm
1 inch = 254 mm
1 mm= 0.394 inch
Most commonly in adult diagnostic work 5-7 French Catheters
are used. All these catheters come with certain numbers on them.
As the number keeps on increasing the catheter can be used in more
dilated and tortous aortic arch. These numbers denote the curves,
e.g., for Hilal catheters.
H-1-for young patient
H-3-for mild tortousity of aortic arch
H-5-for moderate tortousity of aortic arch
H-7-for markedly unfolded & dilated arch of aorta
In general it is good practice to use the smallest diameter catheter
feasible for any particular study to minimize the risk of arterial
damage by the procedure.
Shapes (Fig. 1)
Examples:
1. Straight catheter
2. Pigtailed catheter*
3. Cobra shaped catheter*
4. Side winder catheters* etc.
(Shepherd)
Note: *Represents catheters
commonly used in most of the Fig. 1
radiology departments.
CATHETERS USED FOR DIFFERENT STUDIES

For Global Injection (Aortogram)
1. Straight catheters
2. Pigtail catheters
These catheters are used for injecting a large volume of contrast
at a high rate of injection. Thus they have multiple holes.
1. Straight Catheters
Straight catheter with multiholes throws a jet from the tip and tends
to whip around and thus it may cause arterial wall damage. This can
be avoided with pigtail catheter.
2. Pigtail Catheters
In ventricles and arch of aorta only pigtail catheter should be used.
More the number of holes, more are the chances of distal thrombus
formation. Moreover clot may form at the distal end which cannot be
detected because the backflow occurs through the side holes. Pressure
injections or passage of a guide wire through the catheter may push
this clot into the artery.
Precaution: Thrombus formation can be avoided by frequent and
vigorous flushing. Harwood-Nash
DHN1
?
Cerebral Catheters
Hinck-Hilal catheter (Head hunter)* DHN2
Head hunter catheter is mainly used for
4 vessel cerebral angiogram. ====D=H=N3== ==::,
FOR MORE TORTUOUS AND ?
ELONGATED ARCH
Fig. 2
Catheters • 137
Hinck Headhunter
Bentson-Hanafee
Wilson
Hinck Headhunter
H1P _I)
H3P
Fig. 3 Fig. 4
S1M1
Kerber
Bentson-Hanafee-Wilson
Fig. 5
4. Bentson Hanafee Wilson OB2, JB3)

5. Simmons (SIM2)*
Note: Simmons catheter can also be used for selective visceral
angiography.
Visceral Catheters (Fig.7)

1. Shepherd's hook/hockey stick catheter*
2. Cobra head catheter*
H3
Hinck Headhunter
Hilal Modified Headhunter
SHK 0.8
?
Fig. 6
SHK 1.0
Fig. 7
)
Coronary Catheters (Fig. 8)
1. Judkins catheter 0L4, JLSAND JL6)
2. Arnplatz catheters (AL 1-AL 4)
3. Sones coronary catheter
Fig. 8
Catheters • 139
Renal Catheters (Fig. 9)

Selective -Simmons or sidewinder
-RDC (Renal double curved
selective catheter)*
Semiselective: Catheter has 6 side holes
just proximal to the tapered part.
2. Microcatheters
• 3 F or smaller.
• Designed for distal catheterization. Fig. 9
• Placed over .010-.018 guide wire.
• Used mostly for neuro intervention.
• Helpful in pheripheral intervention to select smaller vessels for
embolization or infusion.
• They have distal platinum marker but otherwise not very
radiopaque.
3. Drainage catheters
• Used for drainage of fluid collection including nephrostomy,
abscess, biliary gall bladder, pleural fluid, ascites, lymphoceles.
4. Balloon catheters
• Either very soft and pliable as occlusion balloon or forgarty
balloon to clear thrombosis or can be rigid and used for
dilatation (angioplasty).
• Balloon for diltation can be divided into 2 main categories
regarding the size of guide wire over which they are placed.
• The balloon used for coronary angiography and also in peripheral
and neuro-radiologic procedures are amaller ones mounted on
0.018 -0.024 size guide wire.
• Most peripheral interventions are performed with 0.035 wire
balloon system.
Balloon Angioplasty Catheters (Fig. 10)

1. Porst Mann's Korsetts balloon catheter
2. Dotter' s coaxial catheter
3. Caged balloon catheter
4. PVC balloon catheters-Recent*
Fig. 10
5. Central Venous Catheter

There are three basic categories of catheters
1. Non-tunnelled catheters
• These catheters are placed via central veins (Subclavian and
Internal Jugular) by blinded percutaneus technique.
• They are used for short term access.
2. Tunnelled catheters.
• They can be accessed externally and are designed for long term
home use.
3. Implanted subcutaneous port.

• These are attached to the port that is buried subcutaneously for
stabilization.
• They can be used for long term .
• Subcutaneous ports are available in single and dual port
configuration and may be placed either on chest wall or the
upper arm.
STERILIZATION OF CATHETERS
Before giving for sterilization, catheter should be washed in water and
with air jets so that clots in the catheter lumen will come out. Because
the rigidity and elasticity of polyethylene disappears above 75 degree
C, catheters are sterilized in solutions of quarternary ammonium
Catheters • 141
compounds or by gas. Some germicidal solutions require only 10-15

min. of soaking. Gas sterilization may take several hours. There is
some evidence that catheters should not be used for several days
after gas sterilization.
Teflon, Nylon and Dacron catheters may be autoclaved if
temperature does not exceed 121 °C and the pressure is not greater
than 15 pounds for 15 minutes. W hen catheters are autoclaved, they
should not be coiled in a circle less than 8 inches (20 ems) in diameter
because if the coil is too tight, under the heat of steam pressure, the
coating may crack or split at stress points.
Short Answer Questions--- ----- ----�

-
1. Classify Catheters. Write a short note on their sterilization.
2. Descibe the diagnostic angiographic catheters.
3. Write in brief about
• Micro catheters
• Drainage catheters
• Balloon catheters
• central venous catheter.
REFERENCES
1. Stanley Baum, Michael J Pantecost, eds. Abram's angiography
lnterventional Radiology, vol. I, 4th ed. Boston : Little, Brown, 1997
: 155-175.
2. David Allison. Arteriography. In : RG Grainger, DJ Allison (eds).
Diagnostic Radiology, vol. III, 3rd edition. New York : Churchill
Livingstone, 1997 : 2437-2457.
Chapter 17
Angiography
• Indications
• Patient Preparation And Precautions
• Local Anaesthesia
• Direct Needle Puncture + Injection of
Contrast with Needle in Situ
• Catheter Angiography
• Percutaneous Transluminal Angioplasty
• CT-Angiography
• MR-Angiography
• References
It is the study of the blood vessels by injection of a contrast medium

into the vessel.
This can be done in two ways:
• Direct injection of contrast with needle insitu
• Injection of contrast with catheter insitu (catheter angiograrn)
INDICATIONS
1. Primary vascular diseases like :
(a) Vasa-occlusive deseases.
(b) Vasospastic disease.
(c) Aneurysms.
(d) AVM Arteriovenous Malformations.
(e) AVF Arteriovenous Fistulas.
2. Vascularity assessment of a tumour.
3. Investigating source of haemorrhage.
4. Congenital vascular condition.
E.g.: coarctation, abnormal origin of vessels etc.
142
Angiography• 143
5. Pre-operative definition of vascular anatomy.

E.g. : Organ transplantation, Vascular tumour excision.
6. Percutaneous interventional vascular procedures.
CONTRAINDICATIONS
1. Bleeding tendencies or anticoagulant therapy leading to a
prothrombin time above 30% of the control values.
2. Pulse not palpable at the vascular access site .
3. Thrombogenic tendency.
4. Skin infections or swelling at site of entry. In case of this, alternate
entry site is selected.
5. Abnormal renal function. If patient is in CRF then it is better to
put the patient on dialysis after doing the angiogram.
6. Cardio Vascular diseases like recent MI, overt CCF. Contrast
injection may exacerbate cardiac failure.
7. Hepatic failure .
8. History of allergy, skin rashes or asthma.
9. Pregnancy.
10. Residual barium from previous studies.
PATIENT PREPARATION AND PRECAUTIONS

1. Careful history and clinical examination.
2. Informed consent.
3. Patient should be well hydrated.
4. Fasting 4 hours prior to procedure.
5. Shave and clean the arterial puncture !':>ite.
6. Xylocaine sensitivity test.
7. Following investigations to be done :
• Hb% and Haematocrit and platelet count
• ESR
• PT, PTT, BT and CT
• HBsAg and HN
• Pulse chart
• General examination and bruits, if any, should be noted
• If patient is on Warfarin, it should be stopped 4-6 days before
procedure
• If any H/ o heparinization, heparin should be stopped 4-6 hours

before procedure
• PTT 1.2 x control, is acceptable
• Any history of drug intake
• History of diabetes mellitus
• History of coronary heart disease
LOCAL ANAESTHESIA
1%-2% xylocaine without adrenaline is used.
After intradermal and subcutaneous infiltration, needle is advanced
at 45 degree angle to the skin surface, with the femoral artery fixed
with 3 fingers, 3-4 ml is infiltrated medial to the artery. Care should
be taken not to inject in the femoral vessels, by aspirating prior to
the injection. Then 3-4 ml of xylocaine is injected lateral to the artery.
This large quantity of local anaesthesia helps in stabilising the artery
and to minimise local vasospasm.
DIRECT NEEDLE PUNCTURE + INJECTION OF

CONTRAST WITH NEEDLE IN SITU
For the Femoral Artery
• Feel the inguinal ligament.
• Feel the artery and fix it with three fingers of left hand below the
inguinal ligament.
• Inject the local anaesthetic agent at the site of the puncture as
described above.
• Make a hole in skin using a thick needle 2½ cm (1 inch) below the
inguinal ligament or give a stab incision.
Various anatomical descriptions are given regarding the site of

puncture:
• In the author's experience the best place is where the artery can be
most easily palpated, irrespective of the relationship of this point
to the inguinal skin crease. Since this is usually the point where
the artery crosses the head of the femur it is also the easiest point
to achieve haemostasis afterwards.
• Introduce the needle through the skin hole maintaining an angle
of 45 degrees to the skin surface and go along the course of artery.
After traversing the subcutaneous tissue, feel the pulsations of the
artery with the needle tip and puncture the artery with a sharp jab
at 45 degrees to the skin surface and stop.
Angiography • 145
• If needle moves side to side it means that artery has not been
punctured. Needle should move up and down to be quite certain
about arterial puncture.
• Remove the stillete and slowly withdraw the needle till blood freely
spurts out.
• To stabilise the needle, the needle is advanced about 1 to 2 cm into
the vessel with the help of a short guide wire.
• Connect the tubing to the hub of the needle through a 2 way stop
cock making sure that there is no air inside it.
• Suck and withdraw blood in the syringe and discard it and flush
with another syringe. Then inject contrast and do filming.
• Flush the system once every minute. The stopcock should be closed
during flushing and not after stopping the injection to prevent
reflux of blood into the needle tip where a thrombus may form.
• Post procedure hemostasis is achieved by compression using 3
fingers; most distal finger on puncture site on the wall of the artery,
other 2 fingers to compress the proximal vessel and pull out the
needle. Do not allow spurting of blood after withdrawing needle
if catheter is not used. Compress just enough till a bruit is felt on
the finger and distal pulsations are just felt. Hold for 10 minutes,
release in a graded manner (never leave suddenly as a thrombus
may get washed away) and watch for rebleeding.
Complications of Direct Arterial Puncture

Technique Using Needle
1. Due to local anaesthesia
(a) Allergic
(b) Toxic-due to injection in the vein, e.g., convulsions and cardiac
arrhythmias.
2. Due to contrast media

(a) Allergic and idiosyncratic reactions are much less common
with intra arterial injections than with intravenous injections.
(b) Feeling of warmth localised to the region supplied by the
injected artery.
(c) Pain may follow injection of contrast material into the vessel.
(d) Chemotoxic effects: If contrast media containing pure sodium
ions is used, the chances of these reactions are high. Meglumine
salts are less toxic.
3. Due to technique
(a) Haemorrhage/haematoma formation at puncture site.
(b) Arterial thrombosis and embolization due to trauma to the
vessel wall or if the puncture is made on an atherosclerotic
plaque.
(c) Sub intimal dissection.
(d) Infection at puncture site (late).
(e) Damage to local structures: For example, Brachia! plexus
damage during axillary artery puncture.
4. Distant complications
(a) Peripheral embolism can result from atherosclerotic plaque
damage or dislodgement of a thrombus formed at puncture
site.
(b) Air embolism can be prevented by :
• ensuring that all taps and connectors are tight.
• always sucking back when a new syringe is connected.
• ensuring that all bubbles are excluded from the syringe
before injecting.
(c) Cotton fibre embolus occurs when syringes are filled from
bowls containing cotton swabs. This can be prevented by :
• Using separate bowls for flushing and for wet swabs.
• A closed system of perfusion.
CATHETER ANGIOGRAPHY (Injection of contrast media

with catheter in situ)
Site of Entry
1. Femoral artery : Most common and preferred route of entry.
2. Axillary artery : Site of entry, in case of femorals are not palpable.
3. Brachial: Midarm is preferred for the catheterisation. Antecubital
fossa is not the first choice because the artery is smaller than at
the midarm.
4. Direct carotid : Percutaneous entry into the common carotid
artery is done at the lower border of the thyroid cartilage.
5. Direct vertebral : Only historical now. The vertebral artery was
punctured by a special needle which had only a side hole without
any end hole.
6. Radial artery : The advantage is that if the artery is thrombosed
Angiography • 147
the limb still survives because of the palmar and dorsal arches.
4F or smaller caliber catheters have to be used.
7. Popliteal artery : This artery is punctured in the popliteal fossa
and has been used primarily for angioplasty.
Seldinger Needle for Arterial Puncture

• The classic Seldinger's needle is a 3 piece needle, outer one is the
16G cannula, middle is the needle with a lumen inside which is a
stillete.
• The length is 7 ems. This needle now is no longer in use.
• The recent needle consists 2 parts, outer is the lumen (18 gauge)
inside is the stillete (diameter more than 1 mm).
• The needles of this type are modified COOK' s and modified POTT' s
needles.
/ �
Technique for Catheter Angiography
Cathete,
Catheter
e
Neece G,id wi
7
7
( A<te,y#rx ��-------- ,--------or-.

(a ) (b) (c) (d) (e)
Seldinger technique for catheterizing blood vessels.
• After injecting local anaesthetic, with all aseptic precautions as

described earlier, a stab incision is made 2.5 cm below the inguinal
ligament. The fascia is separated using fine artery forceps to make
a track for passing the catheter.
• Artery is punctured using the above needle by the usual technique
of transfixing the vessel.
• The guide wire is advanced gently for 20-25 cm. Do not advance,
if there is resistance. Do not use force for any maneuver. The
needle is removed while holding the guide wire in place and firm
compression is applied to the puncture site to prevent bleeding.
• The guide wire is cleaned of all blood by a wet gauze piece while
maintaining compression at puncture site to prevent blood loss.
• Now the catheter is threaded over guide wire till end of guide wire
should come outside catheter. Then catheter is advanced holding
guide wire firmly.
• The guide wire is removed and immediately suction is applied with
a syringe to which a stopcock has already been fitted. This syringe

is then discarded and a fresh syringe filled with heparinised saline.
(1000 units of Heparin in 540 ml of normal saline) is used to flush
the catheter.
• Once the catheter is in the vessel, Heparin may be injected in a
bolus.
• Some give low dose, i.e., 3000 units in adults. Some give high
doses, i.e., 10,000 units, in which case, before catheter withdrawal
appropriate dose of protamine sulfate is given to reverse the
heparization.
• In our institution we do not give bolus dose of Heparin as a routine.
• Flushing of the catheter should be done every one minute. While
flushing always check for the backflow into the syringe so that
injection of any thrombus formed within the catheter can be
avoided.
• All air must always be excluded from the system.
• In certain cases, continuous flushing of the catheter is done with the
help of a pump. T his, however, could give rise to fluid overload.
Contrast Used for Angiography

3 basic types of contrast material are used:
(a) High density (more than 70%)-e.g., Conray 420, Trivideo 400,
Urograffin 76%, Trazograf 76%, Urovideo 370)
(b) Medium Density (60%)-e.g., Conray 280, Urograffin 60%,
Trazograf 60%, Triovideo 280, Angiograffin 65%.
(c) Low density (30%)-e.g., No preparation available in India. For
this, dilute medium density contrast by 50%.
• High density contrast (76%) is used for Global injections.
• All selective angiographies need medium density (60%) contrast
material.
• Low density contrast material can be used wherever Digital
Subtraction Angiography is available and for test injections.
Special points for contrast injection

• In the ventricle and in the aortic root we do not inject a pure sodium
contrast as high concentration of Sodium in coronary arteries can
lead to arrythmias. Sodium concentration should be isotonic to the
plasma sodium. These conditions are met by Sodium meglumine
combinations like Urograffin, Trazograff and Urovideo.
Angiography • 149
• Pure meglumine salts should also not be injected as they do not

contain any sodium.
• Pure Sodium salts are more painful than meglumine salts.
• Pure Sodium salts should not be used for any selective angiograms.
• Pure Sodium salts can cause damage to spinal cord if large volumes
are injected in the descending thoracic aorta close to the artery of
Adamkiewicz.
• Sodium salts are never used in cerebral circulation. Use pure
meglumine for cerebral angiograms. Avoid sodium and meglumine
combinations for cerebral studies.
• Injection in the aorta away from the root can be done by any
contrast agent.
Rates of Contrast Injection and Volume of Contrast Media

(a) Heart and Arch of aorta:
20-25ml/sec.
Total volume 30-40 ml in heart and 40-80 ml in arch.
(b) Abdominal aorta:
15-20 ml/sec (with occlusive disease)
20-25 ml/sec (without occlusive disease)
Total volume: 40-80 ml.
(c) Infrarenal segment:
8-10 ml/sec
Total volume 40 ml
In step motion angios the volume increases to 80-100 ml.
(d) Innominate:
8-10 ml/sec
Total volume 20 ml.
(e) Other arteries:
(i) Carotids: 10 ml rapidly with hand
(ii) Internal carotid: 8 ml rapidly with hand
(iii) Vertebral: 6 ml rapidly with hand
(iv) External carotid: 5 ml rapidly with hand
(v) Coeliac axis: 6-8 ml/s (total of 40 ml)
(vi) S.M.A.: 6-8 ml/s (total of 40 ml)
] too h'1gh vo1umes
(vii) I.M.A: 4 ml/s (20 ml total)
(viii) Renal: 8-10 rapid injection with hand.
(ix) Femorals : 20-40 ml (hand injection with static serial)

: 50 ml (6-8 ml/s in step motion angio)
* Before removal of catheter assure that peripheral pulses are
palpable. If peripheral pulses are not palpable then do a
pull out Angio. Withdraw the catheter to a point 10 cm
above the puncture site and do an angiogram to see if any
thrombus is present or if vasospasm exists. If it does, then
the vascular surgeon should be consulted before removing
the catheter.
* If no complications exist, pull out the catheter.
* When withdrawing feel the artery proximal to the catheter
and the entry site. After removing the catheter let the blood
spurt out three times and then compress the artery at and
proximal to the puncture site with 3 fingers.
* Also suck with a syringe as the catheter is being withdrawn
to remove any microemboli.
* Compress with just enough force so as to feel a bruit
under the fingers and ensure that the distal pulses are just
felt without any local bleeding. Grade the compression
accordingly.
More complications occur due to over compression than the
procedure itself
Post Procedure Care

• Bed rest
• Keep the puncture part without moving for atleast 6-8 hrs.
• Watch for any recurrence of bleeding.
• Peripheral pulses should be monitored/Vitals monitored.
• Hydrate the patient well.
• Deterioration of renal function should be watched for.
Complications of Femoral artery catheterisation

(A) Due to contrast medium
Most of them have been dealt with earlier. A few extra and important
ones are:
1. Allergic and Idiosyncratic: Non-fatal reactions are much less
common with intra-arterial injections than with intravenous
injections.
Angiography • 151
2. Chemotoxic effect
• Coronary arteries:
Pure sodium or pure meglumine salts produce impaired
myocardial contractility and ECG changes.
Addition of calcium improves the contractility.
• Cerebral arteries:
Sodium salts are highly neurotoxic
• Spinal cord:
Direct injection into a lumbar or an intercostal artery which feeds
the artery of ADAMKIEWICZ or diversion of large volume of
contrast into the spinal vascular bed can result in spinal cord
damage. Large volume contrast injection in thoracic aorta can
also cause spinal cord damage. Treatment is by replacing CSF
with (N) isotonic saline in 10 ml aliqouts.
• Kidneys:
Acute renal failure is a rare complication
(B) Due to the technique

(a) Local
1. Haemorrhage/Haematoma.
2. Arterial thrombus: This can be minimised by Heparin
bonded catheters and guide wires and meticulous flushing
with heparinised saline.
3. Infection at puncture site.
4. Damage to local structures, i.e., brachia! plexus in axillary
artery puncture.
5. False aneurysm.
6. A.V. fistula.
(b) Distant
1. Peripheral embolus
2. Atheroembolism-J tip guide wires should be preferred to
minimise this possibility.
3. Air embolus: Prevented by ensuring
• All taps and connectors are tight
• Always sucking back when a new syringe is attached
• Ensuring all bubbles are removed before injecting
• Keeping the syringe vertical with plunger up while
injecting
4. Cotton fibre embolus : prevented by

• separate bowls of saline for flushing and wet swabs
• closed system of perfusion
5. Artery dissection : Ri"sk is reduced by
• floppy, J shaped guide wires
• Pigtail catheters
• Test injection prior to pressure injection
• Careful and gentle manipulation of catheters and guide
wires.
6. Catheter knotting
7. Catheter impaction
8. Catheter and guide wire breakage
9. Bacteremia/Septicaemia
PERCUTANEOUS TRANSLUMIN,AL .ANGIOPLASTY

Definition
Encompasses both dilatation of stenotic lesions and the recanalisation
of occluded vessels.
Technique
• Basic method consists
of passing a guiding
catheter to a site from
which a guidewire can Narrowed lumen of the vessel
be negotiated through
the region to be dilated.
·�
• An injection of contrast 8 Guidewire
Ls
delineates the exact
length and position of the
(
lesion and its proximal
and distal limits.
C ,:
-�Balk>o" Catl>ete,
• The guidewire and
catheter are manipulated
through the stenosis, the
wire is withdrawn and
D
C Increased luminal diameter
Balloon catheter angioplasty
an injection of contrast is
made to show that the lesion has been safely negotiated and that
runoff remains intact.
• The guidewire is then replaced so that its tip lies well distal to the
Angiography • 153
abnormal segment and the original catheter is replaced by a balloon

catheter of appropriate dimensions without altering the position of
the wire.
• The balloon is then manipulated into the area of stenosis and
inflated.
• The balloon should be fully deflated before any attempt is made
to alter its position.
• The balloon is inflated manually with a 10cc syringe loaded with
dilute contrast medium.
Precautions and Preparations

Anticoagulant, fibrinolytic and antispasmodic drugs are essential in
the preparation of the patient before the procedure.
COMPLICATIONS
(1) Puncture site
haemorrhage
thrombosis
pseudoaneurysms
(2) Target vessel and its distribution territory

embolisation
thrombosis
dissection
perforation
occlusion
(3) Catheter related

balloon rupture
\ embolisation
CT-ANGIOGRAPHY
CT angiography is a three-dimensional technique that provides
information about the imaged vessels and adjacent structures.
Advantages of CT angiography
• It is a non invasive, outpatient examination with minimal risk.
'\ It can demonstrate eccentric stenosis, which can be missed on
, conventional an�iography.
\'
• It can also demonstrate retrograde filling of vessels distal to an

occlusion by collaterals with high origin.
• Aneurysms can be best diagnosed by CT angiography.
Disadvantages of CT angiography
• Short segment stenoses may be missed.
• Differentiation between tight stenosis and occlusion can be difficult
in patients with heavy vascular calcification.
• Radiation exposure.
• Risk of contrast reaction.
MR-ANGIOGRAPHY
• MR- angiography is defined as the MR technique that selectively
displays the flowing blood in the vessels.
• There are different techniques based on either the flow effect or on
the use of contrast agent.
• MRI technique creates soft tissue contrast between blood vessels
and surrounding tissues.
The three main types of MR-ANGIOGRAPHY

1. Time of flight angiography (TOF).
2. Phase contrast angiography (PCA).
3. Contrast enhanced magnetic resonance angiography (CE-MRA).
All angiography techniques differentially enhance vascular MR
signal. TOF and PCA reflect the physical properties of flowing blood
that were exploited to make the vessels appear bright. CE-MR
Angiography creates the angiographic effect by using an intravenously
administered MR contrast agent which selectively shorten the Tl Wt
images. MR- Angiography images optimally display area of contrast
blood-flow-velocity. Loss of streamline flow occurs at all vessel
junctions and stenosis, and in regions of mural thrombosis resulting
in a loss of signal.
Disadvantages of MR-ANGIOGRAPHY
1. Overestimation of stenosis.
2. Low flow velocity can create regions with signal loss and the
wrong diagnosis of a stenosis of a vessel.
3. Ghost images which can be overcome by changing the phase
encoding direction.
Angiography • 155
Short Answer Questions - - - - - - - - - - ---�

1. What are the indications and contraindications of angiography ?
2. How will y ou prepare a patient for angiography ? What precautions
will y ou take before the procedure?
3. Write a short note on direct needle puncture.
4. What are the complications of direct needle puncture technique?
5. Write short note on catheter angiography.
6. What are the contrast media used for angiography?
7. What are the complications of femoral artery catherisation?
8. Describe in short Percutaneous transluminal angioplasty.
REFERENCES
1. Stanley Baum, Michael J Pantecost, eds. Abram's angiography :
Interventional Radiology, vol. I, 4th ed. Boston : Little, Brown, 1997:
242-249.
2. John M Jacobs. Diagnostic neuroangiography-Basic techniques. In:
Anne G Osborn (ed). Diagnostic Cerebral Angiography, 2nd edition.
Philadelphia : Williams and Wilkins, 1999 : 421-431.
3. David Allison. Arteriography. In : RG Grainger, DJ Allison (eds).
Diagnostic Radiology, vol. III, 3rd edition. New York : Churchill
Livingstone, 1997: 2346-2368.
4. Gary J Becker. Balloon angioplasty. In : Stanley Baum, Michael J
Pantecost, eds. Abram's angiography : Interventional Radiology, vol.
III, 4th ed. Boston : Little, Brown, 1997 : 3-43.
5. Donald E Schwarten. Aortic, iliac and peripheral angioplasty.
In : Castaneda-Zuniga WR, Todavarthy SM (eds). Interventional
Radiology, vol. I, 2nd edition. Baltimore : Williams and Wilkins, 1992
: 378-422.
6. David Allison. Interventional Radiology. In: RG Grainger, DJ Allison
(eds). Diagnostic Radiology, vol. III, 3rd edition. New York : Churchill
Livingstone, 1997 : 2514-2520.
7. Olbert F, Kamel F. Techniques of percutaneous transluminal
angioplasty. In : Dondelinger RF, Rossi P (eds). Interventional
Radiology. Thieme, New York, 1990 : 550-563.
8. Colapinto RF, Stronell RD, Johnston WK. 1986. Transluminal
angioplasty of complete iliac obstructions : AJR 146 : 859-862.
Chapter 18
Phlebography
• Phlebography of Lower Limb
• Indications
• Equipment
• Patient Preparation
• Procedure
• After Care
• Complications
• Interpretation
• Inferior Venacavography
• Capnocavography
• References
PHLEBOGRAPHY OF LOWER LIMB

It is the study of the deep veins of the p elvis, thigh and calf following
intravenous administration of contrast media.
INDICATIONS
1. Deep vein thrombosis of the lower limb.
2. Suspected venous obstruction by tumor or extrinsic pressure.
3. Secondary or recurrent varicose veins especially in whom surgery
is contempl ated.
4. Patients with swollen legs where the differential diagnosis is
between venous incompetence, lymphedema and cellulitis.
5. Outlining venous malformation.
6. Investigation of varicose ulcers in the post thrombotic syndrome.
CONTRAINDICATIONS
1. Allergy to iodine
2. Local sepsis
3. Obvious acute deep vein thrombosis
- 156
Phlebography • 157
EQUIPMENT
• Contrast media-low osmolar contrast media, volume 50-150 ml.
• Butterfly needle (23 G).
• Fluoroscopy unit with spot film device and tilting radiography
table.
PATIENT PREPARATION
• Check recent serum creatinine level.
• Elevate the leg overnight if oedema is severe
• Informed consent
PROCEDURE
1. Patient is placed supine on the X-ray table with all elastic
wrappings removed from the leg.
2. Preliminary radiographs of leg and thigh taken m order to
ascertain optimum exposure.
3. Technique:
(a) Ascending phlebography

• Tourniquets applied just above the ankle and below the knee
in order to occlude the superficial system and direct flow into
the deep veins.
• Table tilted 65 ° from the horizontal feet down position in order
to prevent layering of contrast medium.
• Leg should be internally rotated in order to separate the tibia
and fibula and the deep veins of the calf.
• Weight should not be borne by the foot being injected so that
the calf muscles remain relaxed and the veins can be filled with
contrast.
• 23G butterfly needle is inserted into peripheral vein on the
dorsum of foot.
• 40 cc contrast medium is injected into the extremity either by
hand or pressure injector.
• First exposure made about 2 minutes after the beginning of
injection focusing the legs.
• If stereoscopic views are required, exposure of legs taken in
second or stereo position.
• 3rd film is taken exposing the thigh.
• The table is lowered again and another film taken of the legs
to determine the degree of stasis present.
• Lastly, a separate exposure of the pelvis done by tilting the table
back to horizontal position as this position favours the filling of
the pelvic veins with contrast material.
• At the end of the procedure, needle should be flushed with 0.9%
saline to avoid the risk of phlebitis.
(b) Descending phlebography

• Less frequently done procedure.
• Patient supine with feet against foot rest.
• Femoral vein is punctured at the groin and with the needle
insitu, patient is put in erect or near erect position and contrast
injected.
• If the patient performs valsalva maneuver, contrast will reflux
down an incompetent femoral vein into the popliteal vein.
AFTER CARE
The limb should be exercised.
COMPLICATIONS
Due to Contrast Medium
• General complications of intravascular contrast media.
• Thrombophlebitis
• Tissue necrosis
• Cardiac arrhythmia
Due to Technique
• Haematoma
• Extravasation
• Pulmonary embolus due to dislodged clot/ air.
INTERPRE TATION
Normal venogram as the result of phlebographic technique is defined
as follows:
1. Contrast filling has occurred in the normal fashion.
2. All deep and superficial veins are opacified except for profunda
femoris vein which is demonstrated only in 50%.
3. All veins are normal in appearance and free of filling defects .

The criteria for positivity is as follows
• Only a filling defect or vessel cut-off associated with collateral
and minimal proximal filling is considered positive.
• The intraluminal filling defect should be detected on more than
one view.
INFERIOR VENACAVOGRAPHY
Indications
1. To demonstrate the site of venous obstruction, displacement or
infiltration.
2. To detect caval and renal anomalies.
3. To evaluate the status of the cava and its collaterals before ligation
of the inferior vena cava.
Relative Contraindications
1. Sensitivity to contrast media
2. Active spreading thrombophlebitis
3. Severe concurrent hepatic and renal dysfunction
Equipment
• Contrast media-low osmolar contrast media 40 ml
• Rapid serial radiography unit
• Catheter SF with side holes
• Pump injector
Technique
• With the patient supine, the catheter is inserted into the femoral
vein using the Seldinger technique.
• An injection of 40ml of contrast medium is made in 2 seconds by
the pump injector and recorded by rapid serial radiography.
• Better and more prolonged filling seen if patient performs valsalva
maneuver.
• Films-rapid serial radiography is performed (two films per second
for 5 seconds and one film per second for 5-10 seconds in AP and
lateral projections).
After Care
• Pressure at the venepuncture site
• Monitoring the patient
Complicatons
• Due to contrast media
• Due to technique
CAPNOCAVOGRAPHY
Visualisation of inferior vena cava by injection of CO2 into the vein. It
is ideal in patients who are allergic to iodinated contrast media. The
buoyancy of CO2 makes it necessary for the procedure to be done in
the left lateral position for optimal visualisation of the NC. The main
limitation of the technique is the possibility of neurotoxicity.
Intraosseus Phlebograhy
If intravenous route is not accessible Intraosseus phlebography can be
done. In this technique a cannula is directly inserted into the medullary
space of the greater trochanter of femur or lateral malleolus, in order
to visualize the pelvic veins or lower limb veins. The procedure
requires general anaesthesia, and is rarely used now a days.
Ultrasound Indications of Duplex Ultrasound

• Deep venous thrombosis.
• Suspected or proven pulmonary emboli.
• Unexplained leg swelling after orthopaedic, pelvic or vascular
surgery.
• Unexplained, chronic leg swelling.
Method
Ultrasound imaging is the non- invasive examination of veins and
their surrounding tissues. Low frequency transducers (2.3 Mr{z) are
used to examine the iliac veins and inferior vena cava and high
frequency transducers (7 .5-10 MHz) are used for superficial veins.
Other veins are interrogated by midrange transducers of 5-7.5
MHz . Colour-Doppler is used to diagnose venous back-flow and
valvular incompetence. It is preferable to start in the groin and
move sequentially down to the posterior tibial veins at the ankle.
The external iliac to the popliteal veins, normal venous flow should be
spontaneous and vary with respiration. The posterior tibial veins may
be undetectable. Compression of the foot should then be employed,
resulting in an easily detectable surge.
Short Answer Questions- - ------------�

1. What are the indications, contraindications of Phlebography?
2. What is Intraosseous Phlebography?
3. Write a short note on inferior vena cavagraphy.
4. Describe in brief the procedure for Phlebography.
5. How do y ou interpret Phlebography in case of varicose veins?
6. What are the complications of peripheral phlebography?
REFERENCES
1. Stanley Baum, Michael J Pantecost, eds. Abram's angiography :
Interventional Radiology, vol. I, 4th ed. Boston : Little, Brown, 1997:
443-450.
2. RG Grainger, DJ Allison (eds). Diagnostic Radiology, vol. III, 3rd
edition. New York : Churchill Livingstone, 1997: 2425-2457.
3. Scott R Kerns, Irvin F Hawkins and Frank W Sabatelli: Current status
of carbon dioxide angiography. RCNA, Jan 1995; 33 : 25-26.
4. Frederich L Kramer, George Teitelbaum and Geno J Merli : Pan
venography and pulm angiography in diagnosis of DVT and
pulmonary thrombo-embolism. RCNA, Sept 1986; 24 : 397-399.
5. David Sutton. Textbook of radiology and imaging, 6th edn. New
York : Churchill Livingstone, 1998 : 743-768.
Chapter 19
Dacrocystography
• Anatomy of Nasolacrimal Duct
• Definition
• Indications
• Materials
• Technique
• Complications
• Other Techniques
• References
ANATOMY OF NASOLACRIMAL DUCT

There is one lacrimal canaliculus in each lid, about 10 mm long,
which commences at the puncta lacrimala. The Superior canaliculus
is smaller and shorter than the inferior canaliculus. At their angles
they are dilated to form ampullae. Lacrimal sac is 12 mm long; its
closed upper end is laterally flattened and its lower part rounded
and merging into the duct. The lacrimal canalculi open into its lateral
wall near its upper end. Nasolacrimal duct is about 18 mm long,
descends from lacrimal sac to open anteriorly in the inferior meatus
at an expanded orifice. A mucosal lacrimal fold forms an imperfect
valve just above this opening.
DEFINITION
Dacrocystography is a procedure by which nasolacrimal duct system
is opacified by injecting contrast media into it.
INDICATIONS
1. Epiphoria
2. Obstruction-Canalicular, Nasolacrimal duct
3. Chronic dacrocystitis
4. Fistula
162
Dacrocystography • 163
5. Tumors
6. Diverticula
7. Dacrolith
8. Before any intervention to nasolacrimal tract
MATERIALS
• Lacrimal canula or 18G blunt needle with polythene catheter.
[outside diametre 0.63 mm]
• Contrast
- Lipiodol (Better opacification but more chances of granuloma
formation)
- Ionic/Non-ionic contrast media.
• 2cc syringe
• Local anaesthetic drops-Lignocaine 4%
• Punctum dilator (Nettleship dilator)
• Cotton tipped applicator
TECHNIQUE
Preliminary anteroposterior, lateral and oblique views are obtained
to exclude radio-opacities that might interfere with interpretation.
Local anaesthetic drops are instilled. Lower end of lid is everted to
locate lower canaliculus at the medial end of lid. Inferior punctum is
dilated and inferior canaliculus canulated with lacrimal canula. Upper
punctum is occluded with cotton tipped applicator. 2-3ml of contrast
is gently injected to opacify the entire nasolacrimal apparatus.
It is essential not to advance the catheter more than 3-4 mm into
the canaliculus.
Films
• Anteroposterior
• Lateral
• Oblique views
Films are taken during contrast injection (distension
dacrocystography). 5 to 30 minute late films are obtained to evaluate
the dye retention.
Normal dacrocystogram shows complete filling of superior and
inferior punctal ampullae, ascending and descending canaliculi,
common duct, lacrimal sac and nasolacrimal duct.
During procedure patient experiences mild local irritation, pain

and bad taste in the mouth._
Bilateral injections are· advised as the abnormalities are usually
bilateral.
COMPLICATIONS
• Contrast extravasation
• Granuloma formation (with lipiodol)
• Injury to canalic.ulus (perforation)
• Infection
OTHER TECHNIQUES
• Macro Dacro Cystography (0.3 mm focal spot for enlarging the
image).
• Digital subtraction dacrocystography
• CT dacrocystography

1. Discuss anatomy of Nasolacrimal duct along with a diagram.
2. Define dacrocystography. What are the indications of
dacrocystography?
3. Describe in brief the technique of dacrocystography.
M R DA CRYOCYSTOGRAPHY
Mr Dacryocystography is MRI mediated non invasive technique of
evaluation of lacrimal apparatus with draining system using normal
saline or gadolinium based contrast agents. Traditionally, lacrimal
apparatus has been evaluated using x-rays or gamma rays, however,
this lead to exposure of the�lens to radiation. MR Dacryocystography
has distinct advantage to save the lens from ionising radiation
exposure.
Structure of Lacrimal Gland

The lacrimal drainage system consists of the upper and lower
canaliculi which lie in the medial aspect of eye and drain into the
lacrimal sac. The lacrimal sac empties into lacrimal duct which opens
into the inferior nasal conchae. There are three normal narrowings in
the drainage system called valves. These are-
• Rosenmuller valve: between common canaliculus and lacrimal sac.
Dacrocystography • 165
• Krause's valve: at the neck of the sac.

• Hasner's valve: at the opening into the nasal cavity.
History of Lacrimal Evaluation

Dacryocystography has been done using different techniques.
These include macro-dacryocystography using magnification, distension
dacryocystography using radiography during pressure injection of the contrast
media, kinematic dacryocystography using cinematography to evaluate the
function (flow) in the nasolacrimal duct, tomographic dacryocystography and
digital subtraction dacryocystography with videotape recording.
Indications for MR Dacryocystography

• Strictures in the lacrimal apparatus.
• Sialolithiasis.
• Any unknown cause of epiphora.
Technique of MR Dacryocystography
MR Dacryocystography has been done using different contrast
combinations. It can be done using high viscous agents like iodinated
contrast agents, low viscosity agents like normal saline combination
with lidocaine or using gadolinium chelates. However, low viscosity
agents offer distinct advantages as they allow use of narrow cannula,
flow smoothly and the patient himself can manage the pressure
according to requirement.
• First, the cannulation is done with the help of the ophthamologist.
Narrow tip cannula is used having an inner diameter of 0.2-0.3
mm.
• The proximal end of the catheter is threaded over a 23-gauge
butterfly-shaped hypodermic needle.
• The microcannulas are connected with a Y-shaped tube system
so that the patients could inject contrast media in both lacrimal
pathways simultaneously by manually compressing the piston of
a single syringe.
• The imaging is done using standard head coil.
• Heavily T2 weighted images are taken (TR/TE range 4000/600-
1000).
• During injection, imaging is repeated for 3min with interval of 4-5
seconds.
• Conventional Tl and T2 weighted images are also taken.
Advantages of MR Dacryocystography
• It avoids the ionising radiation exposure to the lens.
• It has high temporal resolution and allows dynamic evaluation of
fluid flow in the nasolacrimal drainage system.
• MR Dacryocystography can be used interactively; therefore, the
operator observing the cathode ray tube monitor can also ask the
patient to increase the injection rate when filling is incomplete or
delayed.
Drawbacks of MR Dacryocystography
• It does not reflect any soft tissue contrast. So, in practical settings,
it requires normal TlW and T2W imaging.
REFERENCES
1. AL Millman, A Licbeskind and AM Putterman : Radiological Clinics
of North America-Dacrocystography : The technique and its role
in practice of ophthalmology. Vol. 25, No . 4, July 1987.
2. Peter L Munk, Linda Warren Burhenne, Frank V Buffam, Robert
Nugent, David T Lin. Dacrocystography : comparison of water
soluble and oil based contrast agents. Radiology 1989; 173 : 827-830.
Chapter 20
lnterventional Radiology
• Embolization Material and Substances
• Angioplasty
• Intracranial Aneurysms
• Intracranial Avm's
• Uterine Artery Embolization
• Bronchial Artery Embolization (BAE)
• Vertebroplasty
EMBOLIZATION
It is defined as the "therapeutic introduction of various substances
into the circulation to occlude vessels, either to arrest or prevent
haemorrhage, to devitalize a structure, tumor or organ by occluding
its blood supply. "
Embolization may have 3 therapeutic goals:
1. An adjuctive goal, e.g., preoperative, adjuct to chemotherapy
or radiotherapy
2. A curative goal, e.g., definitive treatment such as that performed
in cases of aneurysm, AVFs, AVMs and traumatic bleeding
3. A palliative goal, e.g., relieving symptoms, such as large
AVMs.
Embolization Material and Substances

History
1 st agent used was
Autologous blood clot
• Easily and quickly obtained
• Biocompatible
Disadvantage
• Recanalization recurs within hours to days due to body's natural
clot lysis.
167
Modern Embolic Agents
I Temporary I
Gel foam
particles Coils Others liquid Agents
Collagen
PVA Pushable Amplatzer plugs Glue
T hrombin
Embospheres Injectable GGVOD Onyx
Detectable Detectable Alcohol
- Mechanical Balloons ALGEL
- Electrolytic
- Hydrolytic
Next Agents
• Facial strips harvested from dura and tensor fascia lata.
Gelfoam (Gelatin Foam)

• It is biological substance made form purified skin gelatin.
• It was first used in 1964 for Carotico-Cavemous fistule.
• It is available in sterile sheets & powder form (40 to 60 particles).
• Gel foam is cut into 1 - 2 mm pieces
Mixed with dilute contrast
l
Injected as pledgets or
Prepared as slurry
• MECHANISM OF ACTION
- It aggregates or swells on hydration into larger particles
Mechanical obstruction
l
Slowing of blood flow
Hastening thrombus formation

Interventional Radiology • 169
• It also provides scaffold for clot formation

• Advantage
- Temporary nature is advantageous in case of haemoptysis and
trauma.
- Low cost
- Extensive clinical experience
• Disadvantage
- Can cause infection due to the trapped air bubbles.
- Can lead to ischemia due to small size ( <70 µm) following
distal embolization.
Polyvinyl Alcohol Particles

• It was first used in 1974
• Permanent
- Particles are made form PVA sheets that is vaccum dried and
rasped into particles.
- Particles are filtered with sieves and are available in size ranging
from 100 µm to ll0µm .
- Because of the method of preparation particles, they are of
irregular size.
Mechanism of Action
• PVA particles are irregular in shape with (oblong, oval, irregular,
shape, Angulated) promotes aggregation.
• PVA particles - Adherent to vessel wall
- Stagnation of flow
- Inflammatory reaction & focal angionecrosis
- Vessel fibrosis
- Permanent occlusion
• Disadvantage
1. Occludes vessels from proximally due to irregular size
2. Can cause catheter occlusion which can lead to non- targeted
embolization when catheter is flushed.
Tris - Acryl Gelatin Microspheres

• It was approved by the U.S. FDA in 2000.
• Embospheres are available in six size ranges.
40 to 120 µm
100 to 300 µm
300 to 500 µrn

500 to 700 µrn
700 to 900 µrn
900 to 1200 µrn
• Ernbolizations are packed in 20 ml prefilled syringes containing
2 ml of spheres in saline.
• Ernbospheres gold are colored for visibility.
• T.A. gelatin rnicrospheres are made from on acrylic polymer
matrix impregnated and embedded with porcine gelatin .
• They are non resorbable hydrophilic particles
• They are smooth and spherical in shape unlike PVA particles.
MECHANISM OF ACTION
Sarne as PVA
• Advantage
o Particle accumulation in catheter tube is uncommon.
• Disadvantages
1. Need for intermittent agitation to prevent sedimentation.
2. Ernbospheres are composed of porcine gelatin which has
allergic potential.
3. Careful attention in sizing is required because same size
ernbosphere will penetrate more deeply compared with PVA
which could cause unintended ischernia .
Coils (Permanent)
Mechanism of Action
• Coils in the blood vessel ------------,
t
Slowing of blood flow Vessel wall damage
i
Thrornbogenesis Release of thrornbogenic factors
i i
Clot formation Thrornbogenesis
i i
Thrombus occurs within 5mins Clot formation
• Coils - Steels
- Platinum - Expensive
- More malleable
- Radio-opaque easy to see under
fluoroscopy
• Size - 0.008 to 0.052 inches
• Length - 1 to 300 mm
• Diameter - 1 to 27 mm
• Shape - J or C shaped, helical, conical , tornado, straight,
complex 3D shapes.
• Coils may be bare or fibered with material such as Dacrum, nylon
fiber , polyester, wool, silk, PVA embedded within them to increase
the thermogenicity.
• Advantage - Easy to see, control and display
- Causes complete occlusion of vessels
• Disadvantage - Occlusion of non target vessels
- Coil migration
- Vessel dissection
- Vessel perforation
- Vessel rupture (to reduce rupture , soft detectable
coils are used)
- Infection Uncommon
- Allergic reaction
• In general, coils should be sized 20 to 30 °/4> larger then what the
vessel measures on predeployment angiogram to prevent distal
embolization/ migration.
Methods of Coil Delivery

1. Pushing
2. Injection
3. Commercial detachment system
1. Pushable Coils
- Most commonly used
- Special guide - wire with bulbous tip is used to physically push
the coil through an end- hole catheter into a desired position.
Advantage - Ready availability, relative cost & easy to use.
Disadvantage - Reposition is not possible once deployed.
- Can be trapped at sharp curves of vessels.
2. Injectable Coils
- Injection through a catheter via a small syringe filled with saline.
- Quicker method
3. Liquid Coils
- Liquid coils are deployed by forceful injection of contrast
through the catheter after loading the coil.
- Soft, non fibered platinum coils of 0.008 to 0.016 inch diameter.
Advantage - Tight coil compaction ,
- Ability to accommodate to tortuous anatomy
- Ability to flow to a target distal to the catheter if
desired.
4. Detachable Coils
- Shape - 3 D basket type
- 2D helical type
- Not routinely used
Disadvantage - Expensive
- Large setup time
- GDC - Guglielmi detechable coils
Designed for embolizatoin of Intracranial

saccular aneurysms.
- It is non fibered, extremely soft.
- Uncoated platinum coil fixed to a stainless steel delivery wire.
- Used in AVM and Aneurysms.
5. Hydrogel Coil
- It is a detachable platinum coils coated with an expandable
polymer
- When detached in the vasculature
Polymer expands
Coil diameter increases from 0.014 to 0.027 inches

Complete expansion occurs within 20 minutes
lnterventional Radiology • 173
- Advantage - Greater volume expansion and occlusion than

regular coil.
- Do not depend on thrombus formation.
- Disadvantage - Coil can get stuck in the catheter if the coil is not
compatible with the delivery system.
Others - (Permanent)
1. Detachable Balloon
- It was first used in 1974
- Balloon is made of latex of size 6 to 14 mm and silicon size 6
to 10 mm.
- Use in - Carotico canvenous fistula, Pulmonary AVM's,
Large - vessel occlusion.
Advantage - Ability to occlude large vessel.
- Possible to reposition.
Disadvantage - Rupture risk, deflation, migration, premature
detachment .
2. Amplatzer Vascular Plugs
- It is a new device (expandable nitinol mesh vascular occlusion
device . )
- Amplatzer I - Simple thick disk 4 to 16 mm
- Amplatzer II - Thin disk 3 to 22 mm
- They have stainless steel screw attachment to delivery wire &
radio-opaque marker bands at both ends.
Advantage - Reduces need for a multiple coil. Hence saves
money and time.
Disadvantage - 1. Used in straight segment of vessel which
dose not taper.
2. Does not cause immediate thrombosis.
3. They are non fibered and depend on patient
ability to form thrombus (limited use in
patient coagullopathic diseases)
- Uses - Internal Iliac Artery, mesenteric A, Renal A,
Portal vein, Splenic A, TIPS.
Permanent Liquid Agents

• Glue
• Onyx
• Alcohol
• ALGEL
1. Glue (N-Butyl-2-Cyanoacrylate)
Trufill, Cordis, Miami lakes, Glubran 2, GEM
t
Preparation
lg. of tubes of NBCA free monomer, when exposed to
anionic environment (blood and
water), polymerization occurs.
10 ml of ethiodized oil Vehicle and acts as a polymerization
retardant
lg. of tantalum powder Provides radiographic opacification
and intiates polymerization.
• MECHANISM OF ACTION
• Glue adherent to vessel wall
i Causes
Inflammatory reaction
i Progresses to
Chronic inflammation
i Fibrosis
• Polymerization of glue starts immediately on contact with anions.
• To avoid unintended polymerization by premature contact with
anions catheter should be flushed with 5 % Dextrose in water
intermittently.
• That is why it requires special set up i.e. 3 way stopcock ( syringe
for NBCA and 5% dextrose)
• Immediately after glue injection, catheter tip is retracted to avoid
catheter adherence to the vessel lumen.
Advantage - 1. Permanent
2. completely occludes the vessels
3. Works instantly
Disadvantage-1. Catheter can get entrapped in the occluded

vessel
2. Requires expertise
3. Polymerization can spread distally or reflux
proximally to the intended location
2. Ethylene Vinyl Alcohol Copolymer (Unyx) (Evoh)

- First used as embolic agent by Dr. Taki in 1990
- Copolymer of ethylene vinyl alcohol
- Prepared with dimethyl sulfoxide (DMSO)
- Opacification material used is - Tantalum powder
Mechanism of Action
t
- EVOH + on contact with blood
DMSO diffuses away
t
Polymerization of EVOH
Forms a cast
- Procedure - Onyx comes with separate vial of DMSO and DMSO
compatible catheters must be used for procedure.
Catheter is placed in position
DMSO is injected to fill the catheter dead space
t
Which inhibits in catheter polymerization of onyx.
Onyx is injected under fluoroscopy guidance.

- Advantage - Non - adhesive- allows longer injection times and
ability to temporally suspend embolization which
allows further procedure during angiography.
- Disadvantage - Need DMSO compatible catheter
- DMSO is toxic and rapid injection causes
vasospasm and neurosis
- Injection rate < 0.3ml/ >40 seconds.

- Used: in cerebral AVM.
3. Absolute Alcohol
- Mechanism of Action
Ethanol
Denaturation of proteins
t
Thrombosis
Fibrosis
Infarction
Disadvantage- 1. Difficulty to control placement.
2. Lack of opacity
3. Rapid dilution by vascular inflow.
4. Calcium Alginate Gel

- Polymer of alginic acid.
- Procedure - Calcium alginate
t
Liquid alginate (premixed with
contrast for visibility)
t
Calcium chloride
Forms a non adhesive gel foam.

Advantage - Unlike coils, gel fills the entire structure to be
occluded
- Catheter occlusion is less likely because two
components are injected separately.
Disadvantage - Requires expertise
ANGIOPLASTY
Angioplasty is the technique of mechanically widening a narrowed
or obstructed blood vessel; as a result of atherosclerosis.
In an angioplasty procedure, under fluoroscopic guidance a
balloon-tipped catheter, is passed into an artery and advanced to
the site of the narrowed vessel. The balloon is then inflated to open
the vessel, deflated and removed.
Angioplasty with or without vascular stenting is a minimally
invasive procedure performed to improve blood flow in the arteries.
During angioplasty, a small wire mesh tube called a stent may
be permanently placed in the newly opened artery to help it remain
open. There are two types of stents: bare stents (wire mesh) and
covered stents (also commonly called stent grafts).
Types of angioplasty
• Peripheral angioplasty
In Peripheral angioplasty mechanical widening and opening of
blood vessels other than the coronary arteries is achieved. It is
called percutaneous transluminal angioplasty or PTA. PTA is done
to treat stenotic leg arteries, especially the common iliac, external
iliac, superficial femoral and popliteal arteries.
• Coronary angioplasty
Percutaneous coronary intervention (PCI), known as coronary
angioplasty is a therapeutic procedure to treat the stenotic coronary
arteries of the heart found in coronary heart disease. The stenotic
segments are due to the deposition of cholesterol-laden plaques
formed due to atherosclerosis.
• Renal angioplasty
Atherosclerotic obstruction of the renal artery is treated with
angioplasty of the renal artery (percutaneous transluminal renal
angioplasty, PTRA). Renal artery stenosis can lead to hypertension
and loss of renal function.
• Carotid angioplasty
It consists of a stent along with an embolic capture device designed
to reduce or trap emboli and clot debris. Angioplasty and stenting
have success rates similar to carotid endarterectomy surgery. Simple
angioplasty is not preferred in this vessel due to complication.
• Cerebral arteries angiography
Transluminal balloon angioplasty for vasospasm after aneurysmal
SAH.
Intracranial atherosclerosis.
Pre-Requisites and Preparation of Patient

• Patient identification
• Laboratory investigations (X-rays, ECG, blood tests)
• Any allergies
•Nil by mouth (6 hours prior to the procedure).
Procedure
• An area in the arm or groin is cleaned and prepared by applying
local antiseptics. Under local anesthesia a small incision is made
in the area. Under the guidance of X-ray monitor, the catheter is
inserted through the incision, until it reaches the blocked artery.
Contrast is injected into the vessel through the catheter, so as to
determine the site of arterial blockage or narrowing. An angiogram
is taken to capture the images of the blocked arteries. Once, the
narrowed arteries are identified, a guide wire (for guiding placement
of balloon catheter) followed by a balloon catheter are introduced
gently through the skin puncture. As balloon catheter is placed
in the blocked artery, it is inflated for a few seconds. Inflation of
balloon at the same site may be repeated if required. After the
completion of angioplasty, the imaging tests are conducted to check
for the blood flow. If blood circulation to the heart or peripheral
narrowed vessel is improved, then remove the catheter, balloon
catheter and guide wire. Bleeding at the insertion site is prevented
by applying pressure. Proper dressing of the incision is done to
avoid any infection. After the angioplasty procedure, the patient
is hospitalized for observation.
• How does the procedure work?
Angioplasty uses an inflatable balloon which is passed to the site
of the blockage where it is inflated and deflated. In this process,
the balloon expands the artery wall, increasing the flow through
the artery. The stent is placed at the site to hold the artery open;
this helps in allowing the artery to heal in an open position.
What are the benefits vs. risks?

Benefits
• Less invasive and relatively low-risk, low-cost procedures.
• No general anaesthesia.
• No surgical incision is needed.
• Able to return to normal activities shortly after the procedure.
Risks
• Major complications are uncommon. However, catheter can lead to
injury of the artery. The balloon also poses a risk of blood clots or
tearing the artery.
• When angioplasty is performed alone, blockages can recur, although
most of these arteries can be opened again successfully. This can
also occur when a stent is placed in the artery at the time of the
angioplasty.
• Heavy bleeding from the catheter insertion site may require special
medication or a blood transfusion.
• There is a risk of stroke in carotid angioplasty and stenting.
• A rare complication with balloon angioplasty is abrupt vessel
closure, or occlusion within 24 hours of procedure. If it happens,
treatment with medication into the artery to dissolve clots followed
by angioplasty or stenting may be appropriate. Emergency bypass
surgery may be needed in few cases.
• Other rare complications include heart attack and sudden cardiac
death.
• There 1s risk of an allergic reaction due to contrast material
injection.
• Damage to the blood vessel, bruising or bleeding at the puncture
site, and infection.
• Contrast material used during these procedures may cause renal
failure, a decrease in kidney function, particularly if there is already
some degree of decreased kidney function.
What are the limitations of Angioplasty and Vascular Stenting?

Angioplasty does not reverse or cure the underlying disease of
atherosclerosis.
Angioplasty may have to be repeated if the same artery becomes
blocked again, a condition called restenosis. If a stent is placed at
the time of the angioplasty, the chance of restenosis may be reduced
but can still occur.
Only about half of patients with renal vascular hypertension
caused by atherosclerosis have their blood pressure successfully treated
or improved by angioplasty/ stenting. By the time the procedure is
done, many of these patients have disease in small arteries within
the kidney that does not respond to angioplasty.
Angioplasty and vascular stenting for peripheral artery disease
(PAD) affecting arteries in the pelvis and legs are less successful when
there are multiple leg vessels that are narrowed or when small vessels
have to be opened.
Angioplasty and stent placement in the carotid artery is associated
with potential complications that can develop from stents being
placed in the carotid arteries. A dedicated filter device may be used
during stent placement to try and help keep blood clots and other
plaques from passing into the brain during the procedure, thereby
lowering the risk of stroke.
Recent Advances
The more recent developments in coated stents, are available which
would further enhance the effectiveness of the procedure. For example,
the stainless steel tubes coated with substances such as rapamicin
(sirolumus) on BX velocity stent have been proved to eliminate the
recurrence of the heart problem
There is risk of narrowing of the stented segment because of
tissue growth in 10 to 20 per cent of the patients depending on the
complexity of the disease and the length of the stent used.
INTRACRANIAL ANEURYSMS
An aneurysm is a focal weakening in vessel wall layers.
As an aneurysm grows, its potential to cause significant side
effects and/ or rupture increases.
Subarachnoid hemorrhage is the commonest presentation where
the patient complains of the 'worst headache of my life'. It may be,
associated with features of raised intracranial pressure.
Management
Endovascular embolisation
Surgery
Both in combination
Indications for Embolisation:

To prevent re-rupture of aneurysm.
To alleviate mass effect
Contraindication
Coagulopathy
Local infection at puncture site
Systemic illness - Renal derangement.
Materials Used
Puncture system
Guide catheters (7 F)
Microcatheters and delivery system
'Y' Connectors-tuhoy Borst
Pressure infusion
GDC coils
Detachment system
Drugs
Non ionic contrast
Heparin
Nitro glycerin - To release the spasm
Mannitol - To reduce the oedema
Protamine - Heparin reversal
GDC Coils
GDC is a platinum coil
Soldered at the end of an insulated stainless steel guidewire
A low voltage current employs electrolysis to detach the coil
Before detachment, the coil can be repositioned to achieve optimal
placement
GDC System has three main components:
- 10 or 18 system microcatheter with two tip markers (Markers
are placed at 3 cm distance)
- Power supply with two connecting cables
- GDC coils
10 system - soft coils
18 system - larger coils.
B.___ Tracker Micro-Catheter

with 2 Tip Marker
Mechanism of Action of GDC

• After embolization of the CDC coils, following changes occur in
the aneurysm:
• Thrombus formation
• Deposition of proteinaceous material - cellular component
• Fibroblast infiltration 4 days after coiling
• After 14 days, thin membrane develops covering the aneurysm
orifice. This membrane consists of endothelium like cells covering
the coils across the border of the aneurysm
• Three months after the coiling, aneurysm orifice is covered by a
thick membrane resembling vascular media
• Neointima organized in three layers
Superficial Layer - Endothelium continuous with parent artery
Middle Layer - Smooth muscle aligned parallel to long axis of
the artery
Deep Layer - Smooth muscle cells are haphazardly arranged
and separated by abundant ground substance.
Multiple neocapillaries are seen
• Endothelial layer covering the orifice of aneurysm adhere tightly to
the underlying coil and invests itself within the crevasses present
between them
Procedure
After -injecting local anesthetic and making a small incision at the
groin, the radiologist will thread a small catheter into the femoral
artery. While Swatching the fluoroscope images on a computer screen,
the radiologist will maneuver the catheter through the arteries until it
is near the brain aneurysm. At this point, a micro-catheter (a very tiny
tube) will be advanced through the original catheter to the opening of
the aneurysm. A CDC coil will be pushed through the micro-catheter
into the aneurysm. The coil will bend and conform to the shape of
the aneurysm. After the coil is deposited, a very small electric current
is applied to the wire to make it detach from the micro-catheter. The
radiologist will insert as many coils as are necessary to completely
fill the aneurysm.
If the neck of the aneurysm is wide enough to require a stent,
the stent will be deployed through the catheter first. After the stent
is in place, the coils will be deposited in the aneurysm through the
stent. Here Stent acts as supporter for the coil to prevent prolapse of
coil into the parent artery through wide neck(> 4 mm). Check angio
should be done and there should be no filling of contrast in aneurysm.

After the aneurysm is completely filled, the micro-catheter
and guiding catheter will be withdrawn, the sheath removed and
hemostasis achieved.
Never stop coiling if intra-procedural aneurysm ruptures. Coil
itself will obliterate the perforation site.
Advantage
Minimally invasive coil embolization allows treatment of cerebral
aneurysms that previously were considered inoperable.
This procedure is less invasive
Requires significantly less recovery time than open surgery for
aneurysm repair.
Disadvatage
Expensive
Need to follow up for recurrence/regrowth
Complications
A. Contrast reactions
B. Local
1. Puncture site
(a) Haemorrhage and haematoma
(b) False aneurysm
(c) Arteriovenous fistula
(d) Perivascular or subintimal contrast injection
(e) Local thrombosis
(f) Local infection
(g) Damage to adjacent nerves
(h) Arterial dissection at puncture site.
2. Intraprocedural rupture of aneurysm

3. Damage to target or other organs due to
(a) Excess of contrast
(b) Catheter clot embolus distally.
4. Fracture and loss of guide-wire tip
5. Knot formation in catheters
6. Occlusion of intracranial vessels
Follow up
To see the regrowth/residue.
With CT Angio, MRA or DSA as per hospital protocol.
Never do invasive procedure for follow up.
INTRACRANIAL AVM'S
An Arterio-Venous Malformation, or AVM, is a complex network of
abnormal vascular channels that consist of arterial feeders, arterial
collaterals, the AVM nidus and enlarged venous channels. The
capillary component is absent with resultant direct communication
between the arterial and venous component.
An AVM is congenital in origin and develops between 45th & 65th
day of embryogenesis.
The patient presents with intracranial hemorrhage, seizures or
headache as the commonest presentation.
Management of AVM
Is multimodality.
Endovascular embolisation,
surgical excision
radiosurgery
all aid treatment as an individual modality or in conjunction with
each
other.
Contraindication
Coagulopathy
Local Infection at puncture site
Systemic illness - Cardiac abnormality
Renal derangement.
PREPARATION
Materials Used
Puncture system
Guide catheters (7 F)
Microcatheters and delivery system
'Y' Connectors-Tuhoy Borst
Pressure infusion
Onyx/Glue (embolising material).
Prodedure
After injecting local anesthetic and making a small incision at the
groin, the radiologist will thread a small catheter into the femoral
artery. While watching the fluoroscope images on a TV screen, the
radiologist will maneuver the catheter through the arteries until it is
near the brain AVM. At this point, a micro-catheter (a very tiny tube)
will be advanced. The nidua is then embolised with Onyx or glue
depending on the angioarchitechture.
Complications
A. Contrast reactions
B. Local
1. Puncture site
(a) Haemorrhage and haematoma
(b) False aneurysm
(c) Arteriovenous fistula
(d) Perivascular or subintimal contrast injection
(e) Local thrombosis
(f) Local infection
(g) Damage to adjacent nerves
(h) Arterial dissection at puncture site.
2. Damage to target or other organs due to
(a) Excess of contrast
(b) Catheter clot embolus
3. Fracture and loss of guide-wire tip
4. Knot formation in catheters
5. Intra procedural rupture of vessel/nidus leading to ICH.
Follow up
To plan re-embolisation.
Prognosis
Embolization of brain AVMs can be performed with a high degree of
technical success and a low rate of permanent neurologic complications.
UTERINE ARTERY EMBOLIZATION

Uterine artery embolization has become an extremely valuable therapy
for patients with gynaecological and obstetrical diseases.
INDICATIONS
1. In uterine leiomyoma
2. Ateriovenous malformations
3. Postpartum and post-operative haemorrhage
4. Malignant gyanecological tumours.
Contraindication
1. Primary vascular diseases like :
(a) Severe anaphylactoid reactions to radiographic contrast
media.
(b) Uncorrectable coagulopathy.
(c) Severe renal insufficiency.
2. Active pelvic inflammatory disease.
3. Endometritis
Pre-Procedure Preparation
1. Pelvic ultrasound, including recording of uterus volume and of
size and position of individual fibroid.
2. Pelvic MRI ( optional but recommended):- Allows assessment of
fibroids and presence of adenomyosis.
3. Laboratory studies including Complete blood count and Follicular
stimulating hormonal assay.
4. Endometrial biopsy if there is intermenstural bleeding.
Patient Preparation
1. Fasting overnight
2. Preparation of puncture site
3. Pre-procedure medication
4. Foleys catheter for bladder catheterisation.
5. I.V line to be put.
6. Prophylactic antibiotics
Procedure
1. Local anaesthesia infiltrated into the groin.
2. Bilateral percutaneous catheterization of femoral arteries to be
done ,one by one .
3. First a pigtail cathter is advanced into the abdominal aorta at the
level of renal artery and pelvic arteriography cione. Then selective
internal iliac artery catheterization is done.
4. Then Robert's uterine catheter is advanced into the uterine artery
and selective angiogram should be performed. The vascular blush
is embolised with polyvinyl alcohol particles ( 350-500µ) until
vascular blush is obliterated.
5. Check angiogram is done to assess the effectiveness of embolization.
Post-Procedure Management
1. Proper hydration.
2. I.V morphine 1 to 4 mg/hrly
3. Antiemetics therapy if required.
4. Patient is discharged as soon as general condition is alright.
Complication
1. Non-target embolisation
2. Post -embolisation syndrome
3. Amenorrhea and premature menopause.
4. Vaginal discharge of fibroid i.e fibroid expulsion.
BRONCHIAL ARTERY EMBOLIZATION (BAE)

Bronchial artery embolization (BAE) has become an established
procedure in the management of massive and recurrent hemoptysis.
Because of poor pulmonary reserve most patients with massive
hemoptysis are not surgical candidates. Immediate control of
hemorrhage is achieved in around 85% of patients by embolization,
although 20% of these patients rebleed within next 6 months. The
long-term success rate is around 50%.
Indications
• Bronchial artery embolization is mainly performed for control of
life-threatening massive haemoptysis (expectoration of blood).
• Patients with recurrent episodes of smaller volume haemoptysis,
who are not fit for surgery.
Pathophysiologic Features
The source of massive hemoptysis is usually the bronchial circulation
(90% of cases). In many acute and chronic lung diseases, pulmonary
circulation is reduced or occluded at the level of the pulmonary arterioles
because of hypoxic vasoconstriction, intravascular thrombosis, and
vasculitis. As a result, bronchial arteries proliferate and enlarge to
replace the pulmonary circulation. The enlarged bronchial vessels,
which exist in an area of active or chronic inflammation, may be
ruptured due to erosion by a bacterial agent or due to elevated
regional blood pressure. The arterial blood under systemic arterial
pressure subsequently extravasates into the respiratory tree, resulting
in massive hemoptysis
Anatomy of the Bronchial Artery

The bronchial arteries have variable anatomy in terms of ongm,
branching pattern, and course. The bronchial arteries originate
directly from the descending thoracic aorta, most commonly between
the levels of the TS and T6 vertebrae.
Four classic bronchial artery branching patterns have been reported:
1. Two on the left and one on the right that presents as an
intercostobronchial trunk (ICBT) (40% of cases);
Descending
------------- Aorta
Right Bronchial Left Bronchial

--'
Arteries A. �-t---- Arteries
2. One on the left and one ICBT on the right (21 %);
Descending
------------ Aorta
Right Bronchial ---- A.��-1---- Left Bronchial

Arteries Arteries
3. Two on the left and two on the right (one ICBT and one
bronchial artery) (20%); and
I
Right Bronchial ---- A:-'---.---- Left Bronchial

Arteries Arteries
4. One on the left and two on the right (one ICBT and one
bronchial artery) (9.7%).
Right Bronchial -----2'�1.I-"""' 11---.--1----- Left Bronchial

Arteries Arteries
The right ICBT is the most consistently seen vessel at angiography

(80% of individuals). The right ICBT usually arises from the right
posterolateral aspect of the thoracic aorta and the normal right and
left bronchial arteries from the anterolateral aspect of the aorta.
Procedure
• Before the procedure, chest X-ray, computed tomography (CT) and
bronchoscopy is performed to locate the bleeding site.
• Under X-ray fluoroscopic guidance, angiography with DSA is
performed for delineation of vascular structures. The arterial access
is usually via the common femoral artery at the groin region.
• The bronchial artery and the other arteries supplying the bleeding
sites are identified and selectively cannulated with catheter.
Although cobra-type curved catheters are most commonly used
for catheterization of the bronchial artery, several different types
of catheters (e.g., Simmons-1, headhunter, Yashiro-type) should be
prepared for optimal selection of bronchial arteries
• After catheterization of the bronchial artery, bronchial angiography
is performed with manual injection of contrast medium.
• Angiographic findings in massive hemoptysis include hypertrophic
and tortuous bronchial arteries, neovascularity, hyp ervascularity,
shunting into the pulmonary artery or vein, extravasation of
contrast medium, and bronchial artery aneurysm.
• Particles are then injected through the catheter to block the arteries.
Polyv inyl alcohol particles are commonly used.
• The procedure usually requires 2-4 hours.
• After the procedure, vital signs (e.g., blood pressure and pulse rate)
should be monitored.
Potential Complications
1. With the use of non-ionic contrast medium, coaxial catheters and
digital subtraction angiographic technique, serious complications
arising from bronchial artery embolization is not common. The
overall adverse reactions related to iodine-base contrast medium
is below 0.7%.The mortality due to reaction to non-ionic contrast
medium is below 1 in 250000.
2. Particles flowing to the spinal artery, causes spinal artery occlusion
, resulting in paralysis of the legs and lower part of the body.
3. Injury of bronchial artery with life-threatening bleeding.
4. Non-target embolization of branches of subclavian artery causes
injury to other organs i.e brainstem, fingers.
5. Chest p�in and difficulty in swallowing: These may occur 2-7
days after embolization and are usually self-limiting.
6. Vascular damage due to arterial puncture or manipulation of
guidewire and catheter
7. Transverse myelitis (inflammation of the spinal cord).

8. Fistula formation between the bronchus and esophagus.
9. Death of bronchial tissue.
Embolic Materials
• A variety of embolic materials are used for BAE. Absorbable gelatin
sponge is widely used because it is inexpensive, easy to handle,
and has a controllable embolic size. However, disadvantages of
absorbable gelatin sponge are its resolvability and lack of radiopacity.
Its use may lead to recanalization of the embolized artery and
may sometimes be responsible for recurrent bleeding. Polyvinyl
alcohol particles are nonabsorbable embolic materials, and particles
350-500 µm in diameter are the most frequently used worldwide.
T heir use may prevent the early recurrence of hemoptysis due to
recanalization of the embolized artery, as might be anticipated with
absorbable gelatin sponge.
• It is essential to avoid the use of embolic materials that can pass
through the bronchopulmonary anastomosis. Experimental study has
demonstrated a bronchopulmonary anastomosis of 325 µm in the
human lung. Pulmonary infarction via bronchial artery-pulmonary
artery shunts or systemic artery embolization via bronchial artery
pulmonary vein shunts may occur when embolic agents less than
325 µm in diameter are used. In addition, it is important to avoid
using embolic agents that produce distal occlusion to such an
extent that normal peripheral branches that supply the bronchi,
esophagus, or vasa vasorum of the pulmonary artery or aorta
become occluded, possibly leading to disastrous complications (eg,
bronchial, esophageal, pulmonary arterial, or aortic wall necrosis).
To avoid the complications indicated earlier, we recommend the
use of polyvinyl alcohol particles with a diameter of 350-500 µm
for BAE.
• Liquid embolic agents (eg, isobutyl-2 cyanoacrylate, absolute
ethanol) are not currently used because of the high risk of severe
complications such as tissue necrosis. Stainless steel platinum
coils are generally not used for BAE because they tend to occlude
more proximal vessels and may preclude repeat embolization
if hemoptysis recurs. However, they may be used to occlude a
pulmonary artery aneurysm and may occasionally be used in the
internal mammary artery to prevent embolization of a normal
vascular territory and development of collateral vessels.
Technique
• Prior to BAE, the number and ongm sites of bronchial arteries
from the aorta should be carefully evaluated to determine the
optimal angiographic approach. This can be accomplished with a
preliminary descending thoracic aortogram. Abnormal bronchial
arteries are visualized on an initial thoracic aortogram in the majority
of affected patients. Although cobra-type curved catheters are most
commonly used for catheterization of the bronchial artery, several
different types of catheters (eg, Simmons-1, headhunter, Yashiro
type) should be prepared for optimal selection of bronchial arteries.
This superselective catheterization permits stabilization of the
catheter position within the bronchial artery and safe positioning in
the bronchial circulation beyond the origin of spinal cord branches,
which prevents severe complications. After catheterization of the
bronchial artery, bronchial angiography is performed with manual
injection of contrast medium.
• Angiographic findings in massive hemoptysis include hypertrophic
and tortuous bronchial arteries, neovascularity, hypervascularity,
shunting into the pulmonary artery or vein, extravasation of contrast
medium, and bronchial artery aneurysm. Although extravasation of
contrast medium is considered a specific sign of bronchial bleeding,
this finding is rarely seen, and its reported prevalence ranges from
3.6% to 10.7%. Thus, the determination of which arteries are to be
embolized should be based on a combination of CT, bronchoscopic,
and angiographic findings with clinical correlation. All angiograms,
including intercostal arteriograms, must be carefully scrutinized for
opacification of spinal arteries to avoid inadvertent embolization.
Results
• Previous studies have shown that BAE is very effective in
controlling acute massive hemoptysis. The initial nonrecurrence
rates for BAE have been reported to be 73%-98%, with a mean
follow-up period ranging from 1 day to 1 month. Immediate
success rates have increased recently because of the introduction
of superselective embolization and the refinement of embolic agents
and techniques. However, the long-term success rate of BAE in
hemoptysis is unfavorable. Long-term recurrence rates have been
reported to be 10%-52%, with a mean follow-up period ranging
from 1 to 46 months. However, the long-term success rate can be
improved with repeat BAE. Hemoptysis may recur after successful
BAE if the disease process is not controlled with drug therapy or
surgery because embolization does not address the underlying
lnterventional Radiology • 193
disease but rather treats the symptom. In this sense, BAE is a

palliative procedure that prepares the patient for elective surgery
for localized disease or continued antimicrobial therapy.
• Recurrent bleeding may be caused by recanalization of embolized
vessels, incomplete embolization, revascularization by the collateral
circulation, inadequate treatment of the underlying disease,
progression of basic lung disease, or nonbronchial systemic arterial
supply. Recurrence rate may also be influenced by the cause of the
hemoptysis. Recurrent bleeding is more common in patients with
chronic tuberculosis, aspergilloma, or neoplasm. In one study of 103
patients who underwent BAE, 16 patients (15.5%) required repeat
embolization; all 16 had hemoptysis due to chronic tuberculosis. It
is believed that this was due mainly to hypertrophy of the collateral
nonbronchial systemic arteries. In a series by Katoh et al, 75% of
patients with aspergilloma experienced recurrence of hemoptysis
after undergoing initial embolization. Hayakawa et al reported that
BAE failed within 1 month in 42% of patients with neoplasm. A
neoplasm receives its blood supply from multiple feeder vessels
other than the bronchial artery and invades the vascular structure
aggressively.
COMPUCATIONS
• Several complications of BAE have been reported in the literature.
Chest pain is the most common complication, with a reported
prevalence of 24%-91%. Chest pain is likely related to an ischemic
phenomenon caused by embolization and is usually transient. In
addition, dysphagia due to embolization of esophageal branches
may be encountered, with a reported prevalence of 0.7%-18.2%.
Dysphagia also regresses spontaneously. Subintimal dissection of
the aorta or the bronchial artery during BAE is the other minor
complication, with a reported prevalence of 1 %-6.3%. There
are usually no symptoms or problems related to the subintimal
dissection.
• The most disastrous complication of BAE is spinal cord ischemia
due to the inadvertent occlusion of spinal arteries. The prevalence
of spinal cord ischemia after BAE is reported to be 1.4%-6.5%. As
discussed earlier, the visualization of radicular branches on bronchial
or intercostal angiograms is not an absolute contraindication for
BAE. However, when the anterior medullary artery (artery of
Adamkiewicz) is visualized at angiography, embolization should
not be performed.
• Other rare complications that have been reported in the literature

include aortic and bronchial necrosis, bronchoesophageal fistula,
non-target organ embolization (e.g., ischernic colitis), pulmonary
infarction, referred pain to the ipsilateral forehead and orbit, and
transient cortical blindness. It is hypothesized that cortical blindness
develops because of embolism to the occipital cortex, either via
a bronchial artery-pulmonary vein shunt or via collateral vessels
between the bronchial and vertebral arteries.
VERTEBROPLASTY
Vertebroplsty is a procedure performed to treat spinal compression
fracture. In this procedure medical-grade bone cement is injected
directly into the fractured vertebra. This cement hardens quickly and
acts like an internal cast.
Kyphoplasty is a procedure in which balloon is inserted into the
vertebral body to expand the space before the cement is added .
This may help to restore the vertebral to somewhat closer to its pre
fractured height.
Indications
• Painful vertebra from:
- Osteoporotic fracture
- Neoplastic fractures
- Tumor infiltration
Contraindications
Uncorrected coagulopathy
Infection-Spine/ elsewhere
Objectivies of Vertebroplasty
• Pain relief
- Osteoporotic fracture
- Neoplasm
• To provide stability
• To prevent further vertebral collapse at adjacent levels
Patient Selection
Patients ideal for vertebroplasty
- Single level or only a couple of levels
- Focal pain , tenderness corresponding to level of edema by MRI

- Fracture present < 2 months or recent worsening of fracture
- Fracture limits activity
- No sclerosis of fractured vertebra
Patients Not Ideal For Vertebroplasty

- Fracture present for > 1 year
- Other causes for back pain if present
- Disc herniation, spinal stenosis, facet or sacroiliac joint disease
Pre-procedure imaging
• Radiographs
• Compare with prior studies
CT. spine
To evaluate the integrity of posterior vertebral margin.
• Magnetic resonance imaging
- Tl,T2,STIR sequences
- Assess for vertebral body marrow edema
- Exclude stenosis due to disc and/ or facet disease
Day of procedure
• NPO after midnight
• Informed consent
• Antibiotics : 1 gm cefazolin IV or vancomycin
Sedation : Midazolam
- Analgesia: Fentanyl
• Local
- 1 % Lidocaine
- 0.5% Bupivicaine on bone
• General anesthesia Rarely required
Procedure : Cement Mixture - Acrylic Cement

Polymethylmethacrylate (PMMA)
Polymer powder
• Liquid monomer
• Opacifying agent
- Barium sulfate powder, Tungsten, Tantalum
• Option additive : Antibiotic powder
Procedure: Cement Injection

• Meticulous fluoroscopic monitoring during the injection process
• Liquefied cement is injected into vertebral body
• Termination of injection
- Cement in posterior 1/4 of vertebral body on lateral projection
- Cement extending outside vertebra
This procedure takes about 1-2 hours ( depending on how
many vertebrae are treated). Patients will be required to remain for
observation for two hours. They are permitted to go home and resume
normal activities within 24-48 hours.
In of N@opl tie Comp ion Fr du

• Treat to alleviate pain
• Stabilize vulnerable vertebrae
• Opportunity to obtain biopsy
• Amount of pain reduction may be less than what is achieved in
the treatment of osteoporotic compression fractures
• Greater risk for complications
C@tnent Inf ettlon Complle4tlon5

1. Cement extravasation
2. Infection, pulmonary , embolism, fracture - lamina - pedicle
3. Increased pain
4. Spinal cord or nerve root injury
Vertebroplasty is a palliative procedure and does not correct the

underlying cause of the vertebral fracture.
• Appropriate management of osteoporosis or malignancy must
therefore be initiated and continued
• Vertebroplasty can be combined with other therapies.
Chapter 21
New trends in Radiography

• Digital Radiography
• Computed Radiography
• PACS
Digital projection radiography consists of CR (computed radiography)

and DR (direct radiography).
Both CR an� DR use a medium to capture x-ray energy and both
procedure a digital image.
11\tUtAl Atlltlct APl-t\'

Digital radiography emerged first in experimental form in 1990. Unlike
CR imaging, DR systems use built-in image plates (for combined
image captures readout) and no cassettes are required. This eliminates
the manual steps required in manipulating the cassette and the time
needed for photo-stimulable storage phosphor (PSP) read-out and
processing. Thus, it is faster than CR.
DR System
198
New Trends in Radiography • 199
PRINCIPLE AND WORl<ING

DR works on the principle of conversion of one form of energy into
other, i.e., x-ray into electrical energy. DR uses detectors which have
inbuilt capacity to detect the x-ray signal and simultaneously convert
it into electric signal. DR is classified into two sub types:
1. DR with direct conversion
2. DR with indirect conversion
Direct conversion involves single step conversion of x-ray into
electric energy; however, indirect conversion involves multiple steps
before giving final electric signal for image formation.
Direct
Phosphor Based
J
Scintillator
---�-
Visible Light i Visible Light
J
Photodiocfus
TFT
Oii"e'ct Col\ve�itlh Detectors

These detectors use x-ray photoconductors such as amorphous
selenium, lead oxide that directly convert x-ray photons into electric
charge.
Selenium based direct conversion DR systems are equipped with
either,
(a) Selenium drum
(b) Flat panel detectors
Selenium IJmm 4'ased :SY5ftem of Direct Cott�rsto«:

This system uses rotating selenium dotted drum as photoconductor.
The selenium drum is positively charged and when exposed to
x-rays, it produces a charge proportional to incidental x-rays. This
charge is further recorded during rotation by an analog to digital

converter. However, selenium drum detectors are dedicated thorax
stand systems with no mobility because of their bulky design.
X-Rays
Photoconductor
(Amorphous Selenium)
Analog to digital
converter
Thin film transistor-Direct conversion:

In this, an x-ray photoconductor (amorphous selenium) is added
as the top layer of thin film transistor. It is connected to a high
voltage source through two electrodes. When x-rays falls, electron
and holes are produced. The applied voltage separates the electron
and holes. The electronic charge is stored in capacitors and is read
our sequentially. Therefore, x-rays are directly converted to electronic
signal.
The advantage of amorphous selenium TFT array over selenium
drum is that these detectors can be mounted on thorax stands and
Bucky tables.
Indirect conversion detectors

Indirect convertors were the first to come in practice; however, they
are now replaced by direct conversion detectors.
It is a two step process:
(a) When x-rays strike the scintillator (cesium iodide or gadolinium
oxysulphide), the x-ray energy is converted to visible light.
(b) Visible light is converted into electric charge by means of
silicon photodiode arrays and charge collected at photodiode
is converted into a digital signal by using the underlying
readout electronics.
Indirect conversion can be done either by using charged coupled
devices (CCD) or with a flat panel detector.
Indirect conversion using CCD

Charged coupled devices are the light sensitive devices used for
recording images.
CCD arrays are used to record the visible light emitted by a
scintillation crystal that has absorbed the energy. CCD can be used in
radiography as lens-coupled CCD system or a slot scan CCD system.
In a lens coupled CCD, optical lens is used to reduce the area of
projected light to fit into CCD array. This system demagnetizes the
light and sends it to the CCD array. Slot scan CCD, on the other hand,
uses special x-ray tube with a tungsten anode. It uses a combination
of small collimated beam and concordant detector and reduces the
impact of scattered radiation. Slot scan CCD needs fixed installation,
so they are dedicated to chest radiography, mammography or dental
radiography.
[ X-Rays
Scintillator
Optical Lens
CCD
Indirect conversion usiug Flat Panel Detector (FPD)

Indirect conversion have now been done through flat panel detectors.
An FPD has a triple layer structure consisting of scintillator layer,
amorphous silicon photo iodide circuit layer and a TFT array. Here,
the visible light energy produced by the scintillators is further
converted by photodiodes into electrical charge. The electrical charge
is read out by TFT array for image formation.
Difference between Direct and Indirect type of Flat Panel Digital
detectors
l fudirect Digital conversion
Direct Digital conversion .,. L
Direct conversion of X-ray s to
Indirect conversion of X-ray s to
electrical signal. electrical signal.
X-rays------ light ------ electric
X-rays --------- electric signal
---�--�---�----
Uses photoconductor.
_signal
Uses s cintillator which converts
x-rays to light and photodiode
array converts light into electrical
-----------��-s ��_l. __
Detector material u sed Scintillator material used - Cesium
Amorphous selenium iodide
Photodiode material - silicon
Resolution maintained as Poorer resolution with increasing

thickness of photoconductor is scintillator thickness (due to light
increased scatter)
Advantage: no light divergence Advantage: High quantum
detective efficiency (DQE)
Disadvantage: light divergence
ADVANTAGE OF DR SYSTEM
• Filmless department (No film costs, darkroom space, processor to
maintain, films to search for or file (Digital department).
• Saves expenditure on the films
• Immediate read out.
• Cassette free operation.
• Good for high volume Radiography.
• Can be used for Mammography.
• Detectors can be re-exposed immediately.
• Computer aided diagnosis.
• Better contrast resolution.
• Image manipulation.
• Directly used in PACS.
• Increased productivity.
• Decreased retakes and exposure.
DISADVANTAGES OR DR SYSTEM
• Detector places are fragile, heavy and fixed so cannot be used for
mobile radiography.
• It is expensive.
• Not compatible with existing tables.
Monitors in DR
lK 1000 x 1000 pixels
2K 2000 x 1000 pixels
4K 4000 x 4000 pixels
4k monitors are used in mammography and chest radiography
CR VS DR SYSTEM
CR I DR
Cost Moderate Very expensive
Size Portable/Fixed Fixed
Processing Time From 55 seconds From 8 seconds
Image available on Only if reader located Yes
site on site
Plate Phosphor screen in No cassette
cassette
Amorphous selenium,
silicon detector plate
connected to computer
Archiving to Images Archiving to P.C., Archiving to PC,
external hard-device external hard-drive or
or DVD DVD
Advantage 1. Better quality 1. Small decrease
2. Less radiation dose in technique
time/time to
development when
compared to CR
Relative Image Quality with CR and DR

• When equivalent radiation doses were used, the images obtained
with DR were judged as superior in quality to those obtained with
CR (Gruber et al).
• Image noise scores were significantly lower with DR compared
with CR.
• Dose reduction with DR was likely feasible in radiography without
sacrificing image quality or diagnostic information.
• Digital imaging with DR further has the potential to reduce
radiation exposure due to better image quality with lower radiation
exposure.
Assessing Image Capture Efficiency

Detective quantum efficiency (DQE) is a value used to describe
a detector's efficiency in capturing images. This includes signal
absorption efficiency, as well as conversion efficiency in indirect
systems that require a scintillator for translating x-ray to light.
As DQE values increase, less radiation exposure is required to

achieve a target signal-to-noise ratio.
CR systems achieve lower DQE values than DR flat-panel
detectors.
Achieving better DQE is an important goal so that facilities can
reduce the radiation doses needed to obtain diagnostic quality images,
especially in pediatric patients.
COMPUTED RADIOGRAPHY
Computed radiography was first introduced in 1980-81. It uses
the same radiographic equipment as conventional system with no
additional changes in X-ray machine. However, it uses an imaging
plate that contains a photostimulable phosphor (replacing conventional
film screen combination) and needs a cassette reader. Images can be
sent to PACs. This digitalized image can be stored on a hard disk of
computer or in printed form.
CR system consists of x-ray receptor plate, CR scanner and
computer for processing data.
CR System
STRUCTURE OF CR CASSETTE
The most important component of the CR system is the CR cassette.
It consists of multiple layers:
1. Protective layer - fluorinated polymer layer
2. Phosphor layer (0.1 mm) - BaFX: Eu +2 (Europium doped Baaium
flourohalid)
3. Anti-halo layer - prevents laser from passing through
4. Reflective layer - reflected light from phosphor is allowed to pass.
5. Base - polyethylene tetraphtalate.
6. Backing layer-protect base from damage.
These layers of the film are inserted into a light tight cassette.
The Cassette has carbon fibre in front and aluminium at the back
that prevents damage to phosphor plate. Back panel contains lead foil
to protect the plate from back-scatter.
I_ Protective L�:r
1
Phosphor Layer (Approx 0.1 mm)
Anti-Halo And Reflective Layer

I_ ---- - -
-�
L Ba�ki� Layer J
_
Cross Section of CR Plate
PRINCIPLE OF CR SYSTEM
The CR plates use semiconductors as its working material.
Concept of electron transfer in semiconductors:
• aa111-1.�1 Conduction band
Hole Forbidden gap

--·-
Electrons Valence band
Electric field direction
Conduction via electrons and holes in a semiconductor
In semiconductors, there is a small forbidden gap between the

valence band and the conduction band as shown in diagram. At
absolute zero, the valence band is completely full with electrons and
the material acts as an insulator. As the temperature increases, some
electrons gain sufficient thermal energy to escape from the valence
band and cross the forbidden gap into the conduction band. Once
sufficient electrons have crossed the gap, conduction of electric current
becomes possible and conductivity increases with temperature.
When x-rays fall on CR cassette, X-ray photons falling on phosphor
plate produce a latent image by promoting electrons to meta-stable
traps of higher energy level present in the Europium doped Barium
flourahalide - BaFBr and BaFI compound phosphor plate. Impurities
in the crystal lattice are responsible for luminescence. With the
increase in the concentration of impurity ions, the intensity of the
luminescence becomes greater. CR screens use barium fluorohalides
doped with europium (europium is the impurity in the crystal).
When these are stimulated by laser beam, there is release of
energy of meta stable traps which trigger a process called photo
stimulated luminescence (PSL) resulting in the emission of shorter
wavelength (blue) light in an amount proportional to the original
x-ray irradiation. The blue PSL light is collected with a light guide
and detected with a photomultiplier tube (PMT). The PMT signal is
digitized to form the image on a point-by-point basis.
The process of latent image formation is done in the CR cassette
which is directly exposed to the x-rays. The second step, reading the
cassette is done separately with the help of the scanner.
Unrecorded imaging plate

-ilafBr ..... .
Support
X-ray Photons
Second image
Scan ,,,,_,,,_,._..,......,,_..._
Erasing
Phosphosphor plate and mechanism for image formation
e MDU.
The CR reader is used in the second step of the image generation
which works on the principle of photo stimulated luminescence

guided by lasers.
The CR reader has multiple steps:

• First the cassette is opened with release of plate.
• Then, the plate is moved by the roller for scanning by the laser.
• Laser then stimulates the trapped electrons to come back to
lower energy state and release energy in the form of light
photons. These light photons are of high energy and low
wavelength.
• Further, the released light photons strike a PMT (photomultiplier
tube) and electric signal is generated.
Imaging plates can theoretically be re-used thousands of times
if they are handled carefully. An image can be erased by simply
exposing the plate to a room-level fluorescent light. Helium-neon
(633 nm) laser beam sweeps the plate in faster fashion.
Most laser scanners automatically erase the image plate after laser
scanning is complete. The imaging plate can then be re-used. In CR
system, only the collimated part forms the image and residual signals
from plate are erased by heating it with laser. The total time for
processing the image is 30-45 seconds.
Advantages
1. Image quality is better in CR than conventional radiography and
various parameters such as brightness, contrast, sharpness etc.
can be compensated automatically without re-exposure.
2. Significant reduction in the exposure factor without loss of density.
3. Faster and better processing.
4. Image data is already in digital form so easily linked to PACS.
5. Can be used for mobile radiography.
Disadvantages
1. High initial cost.
2. Radiographers do not get feedback of accuracy of their exposure
factors and skills.
3. Spatial resolution is less than the conventional radiography and
factors responsible for it are pixel size, thickness of phosphor
layer and size of phosphor grains.
PICTURE ARCHIVING AND COMMUNICATION

SYSTEM (PACS)
PACS is the medical imaging technology which allows storage and
easy access for the images from multiple modalities in a digital
format. It eliminates the need for manual storage, transport and helps
in making film free departments.
History
PACS was discussed at the meeting of radiologists in 1982. Dr. Glass
has been one of the pioneers in this field. The first large scale PACS
installation was in the University of Kansas, Kansas city.
Components of PACS
PACS has four major components:
1. Imaging modalities like x-ray, MRI, CT scan (source of data).
2. Secured network for transport of patient information.
3. Workstations for viewing and analysing images.
4. Archieves for storage and retrieval of image and reports.
I Modalities (CT, MRI, USG) I

Scanning and Capture Ris/His
Working of PACS
The PACS works in a very complex fashion with integration of
different components. However, entire process can be simplified in
few steps. First step involves the image acquisition. It is done at
different modalities like X-ray, CT scan, MRI, USG etc. These images
are then securely transferred to quality assurance (QA) workstation

sometimes called PACS gateway. The person controlling the QA
workstation checks whether the patient details and other important
attributes of study are correct. If the data and the quality of the images
meet the required parameters of QA workstation, images are then
transferred to the archive for storage. The archive can store images
and in some cases, can store reports and measurements.
The next step in the workflow are the reading stations where
the radiologists can analyse the images to prepare the reports. The
reading workstations are attached with the reporting package. Other
facilities available at working stations are CD /DVD softwares to burn
the images. The various subpart of the PACS are connected by the
high speed optic fibre cables to manage the data transfer.
The PACS system can be integrated with the radiology information
system (RIS) and hospital information system (HIS). In more developed
form of PACS, the lossy images require less data space, however, they
have included web based interfaces to use the internet or wide area
network as their means of communication (usually via VPN or SSL).
IMAGES IN PACS
Images in PACS are of two types: lossy and loss less.
• Lossy - Lesser clarity than the non lossy images, they are more
useful where multiple viewing is required, e.g. Inward viewing.
• Loss less - These require more space for storage and have higher
level of clarity, so are more useful in reporting areas, e.g. radiological
purposes.
WORKSTATIONS
• It is the interactive component of the PACS where the radiologist
or the physician interact to generate the reports.
• A workstation comprises of:
- Display monitors
- Computers
- Local storage which is connected by network cables.
• The computer should have enough computing power of 3 MHz
and greater RAM.
• Display monitors are of 2 types-cathode ray tube (CRT) monitors
or liquid crystal display (LCD) monitors.
• LCD monitors are expensive but have less weight and are thin with
better brightness of display but they have narrow viewing angles.

• The minimum resolution for the USG, MRI and CT SCAN image
viewing has to be two megapixel.
• Mammography requires minimum resolution of 5 megapixel to
view finer details like fine calcifications.
B ACKUP FOR PACS

The data in PACS can be stored either online or offline. The medical
images are normally stored locally in the PACS for retrieval.
However, it is very important to have backup storage to deal with
the circumstances of disaster. Ideally, the images should be moved
off site as and when they are created. However, alternate options of
removable media (hard drives, DVD's) can be used for storage and
transfer to off site location.
COMMUNICATION BETWEEN PACS SERVER AND

WORKING STATION
The communication with the PACS server is done through the DICOM
messages. The communication process is as follows:
Establishing connection with the PACS server
Preparing of request with dicom attributes (e.g. c-find)
Typing the request in docom format
Sending request to server
Server sends back response to request and

required response selected for analysing
INTEGRATION OF PACS WITH OTHER SYSTEMS

PACS can be integrated with other systems like hospital information
system (HIS) so that it support all modalities in all departments
throughout the institution. This allows all the data related to one
patient to be available at single place. However, till now, mini-PACS
system have been working which involve local islands of PACS.
Integration has multiple advantages in the form of less errors in
patient related data and improved data storage.
Advantage of PACS System

• It makes paper free and film free departments.
• Simultaneous availability of images at multiple places.
• Provides option of image manipulation tools for optimal information
extraction.
• Remote access with option of e-reporting.
• Provides option for integration with other systems (e.g. HIS, RIS).
• No fear of image loss.
• Increases efficiency with better patient care.
• Teleradiology possible.
• Saves film cost
Disadvantages of PACS System

• Highly technical and requires skilled workforce.
• High initial cost.
• Requires continuous updates and maintenance.
• In case of PACS failure, no backup.
REFERENCES
Pacs
• Strickland, N. "PACS (picture Archiving and Communicating
System): Filmless Radiology.' Archives of Disease in Childhood 83.l
(2000): 82-86. PMC. Web. 31 May 2016
• Jorwekar GJ, Dandekar KN, Baviskar PK, Picture Archiving and
Communicating System (PACS): Clinician's Perspective About
Filmless Imaging; Indian J Surge. 2015 Dec; 77 (Suppl 3) : 774-7.
• Aldosari B; User acceptance of a picture archiving and communication
system (PACS) in a Saudi Arabian hospital radiology department;
BMC Med Inform Decis Mak. 2012 May 28; 12 : 44.
CR/DR
• Bansal GJ. Digital radiography. A comparison with modern
conventional imaging. Postgraduate Medical Journal. 2006; 82(969):
425-428. doi:10.1136 / pgmj.2005.038448.
• ACR. Practice Guideline for Digital Radiography. (Res. 42) October
1, 2007. Reston, VA: American College of Radiology. 2007:23-35.
Chapter 22
Mammography and Sono-Elastography

• Mammography
• Ultrasound of Breast
• MRI Breast
• MR Ductography
• Elastography
MAMMOGRAPHY
Screening Mammography
Screening mammography is a radiological examination performed to
detect unsuspected breast lesions in asymptomatic women.
Diagnostic Mammography
Diagnostic mammography is a radiographic examination performed
to evaluate patients who have signs and/or symptoms of breast
disease or imaging findings of concern requiring specific follow-up.
Indications
Screening
1. Asymptomatic women aged 40 years and over.
2. Asymptomatic women aged 35 years and over who have a high
risk* of developing breast cancer.
* First degree relatives diagnosed with premenopausal breast
cancer and histological risk factors (ADH, ALH).
Diagnostic
1. Symptomatic women aged 35 years and over with a breast lump
or other clinical evidence of breast cancer.
2. Radiographic abnormality detected on screening mammography
(Screening call back).
3. Recommended for short-interval follow-up (BIRADS 3).
4. Surveillance of the breast following local excision of breast
carcinoma.
- 212
Mammography and Sono-Elastography • 213
5. Evaluation of a breast lump in women following augmentation

mammoplasty.
6. Suspicious breast lump in a man.
Standard Views
These are those that are performed on routine screening mammograms:
Cranio-caudal and Medio-Lateral oblique.
1. Cranio-caudal view
It is used for the medial aspect of the breast. X-ray tube is kept at
90°. Patient is facing straight, head turned away. Technician stands
at medial aspect. The breast is positioned in a Sandwich technique.
• Include patients' opposite medial breast if possible.
• Lateral pull: retro mammary fat.
• Nipple is centered.
• Apply taut compression: pull gently forward.
• Smoothen out folds and wrinkles (Finger roll).
• Ipsilateral arm relaxed.
Assessment criteria: All medial tissues should be visualized with
following pre-requisites for good film:
• Pectoral muscle visible.
• Nipple in center and profile.
• Symmetrical.
• No movement, no artifacts.
• Tissue thickness evenly distributed.
• Limitations: Poor visualization of lateral breast tissue.
2. Medio-lateral oblique (MLO) view

Medio-lateral Oblique view is taken from the middle of the chest,
out to side of the body with the x-ray tube at an angle. This is the
only view in which maximum amount of breast tissue is visualized.
• Positioning: Cassette holder parallel to pectoralis muscle in axilla.
• 40°- 60° tube angulation.
• Steep angle is use for tall slim females. Lesser angle is used for
short heavy females.
• Patient faces the unit straight with arm resting over and on to the
back of the cassette holder.
• Elbow flexed and hand on bar. Shoulders pushed down.
�--�------------=--=-====----=---=-=--�==-=c=-c=--=,----:-==-
• Breast pulled up and out and centered on Bucky. Taut compression
is applied.
• Top of the compression plate is just below the clavicle and inner
edge alongside the sternum.
• Nipple in profile.
• Pull abdominal tissue down to open infra-mammary fold.
Assessment criteria: Pectoral muscle is wide superiorly with a convex
anterior border.
• Pectoral muscle viewed to nipple line.
• Nipple should be in profile.
• Visualization of infra-mammary fold.
Supplementary/Additional Views
These views are used in diagnostic breast workups in addition to the
standard views.
• True lateral view - 90° view: ML and LM.
• Spot compression view
• Magnification view
• Exaggerated cranio-caudal views
- XCCL view
- XCCM view
• Axillary tail view
• Cleavage/valley view
• Tangential view
• Implant displaced
Significance of Compression
• Separates glandular tissue.
• Decreases superimposition of tissues.
• Improves resolution of the image.
• Increases contrast.
• Reduces scatter radiation.
• Decreases radiation dose.
Tmtlng of Mammography
It is usually done during the week after the menstrual period. T he
breasts are most likely to be tender the week before and the week
during the menstrual cycle.
Mammog raphy and Sono-Elastography • 215
Preparation
Avoid using deodorants, anti-perspirants, powders, lotions, creams
or perfumes under the arms or on the breasts. Metallic particles in
powders and deodorants could be visible on mammogram and cause
confusion.
Mammography
• First of all, it is important to identify the mammographic pattern.
It is named as the principal breast tissue:
1. Predominant fat (less 25% fibroglandular densities)
2. Heterogeneous (25-50 fibroglandular densities)
3. Heterogeneously dense (51-75%)
4. Extremely dense (more)
Predominantly Predominantly Heterogenously Extremely

fatty heterogenous dense dense
Morphology: Round, oval, lobulated, irregular or architectural

distortion.
Margin: Circumscribed, partially obscured, micro-lobulated, ill

defined, speculated.
0 CJOO �
Circumscribed Partially
obscured
Microlo
bultaed
Ill defined Spiculated
Benign and Malignant Calcifications on Mammography

Benign - They are diffuse and scattered in distribution. These are of
following types:
• Skin calcifications (tattoo like).
• Vascular (linear and parallel tracts).
• Coarse or chunky - fibro adenoma.
• Large rod-like - plasma cell mastitis.
• Round and punctate - fibrocystic changes or adenosis.
• Lucent centered - fat necrosis, calcified debris in ducts.
• Egg- shell or rim like - fat necrosis and cyst walls.
• Milk of calcium - in cystic hyperplasia.
• Sutural calcification along the knots.
• Dystrophic calcification - irradiated breast or following trauma.
Suspicious Malignancy - Clustered distribution. Usually these
calcifications are biopsied to determine their exact nature.
• Amorphous.
• Coarse heterogeneous.
Malignant - Linear and segmental distribution suggests high
probability of malignancy.
• Fine pleomorphic.
• Fine linear branching.
CALCIFICATION
It is important to see distribution, morfology, size and number of
calcifications to give a BIRADS categorization.
I Calcifications
I Egg shell or rim like
- - - - - -------Mammography and Sono-Elastography • 217
Lucent centered
Coarse or pop corn
Vascular
Large rod like
Dystrophic
Milk of calcium or tea in cup

calcification
@@
Skin
@
Round and punctate 00
ooo
Fine linear branching

Distribution of calcification
Size
• < 0 .5 mm: suspicious
• 0.5-2 mm: can be benign or malign
• > 2 mm: benign
Architectual Distortion: The normal architecture is distorted and

there is no definite mass visible.
This finding includes fine line or spiculations radiating from a
point, focal retraction or distortion of the edge of the parenhyma. If
there is no traumatic or surgery history, biopsy is always indicated.
BIRADS
The BIRADS acronym stands for Breast Imaging-Reporting and
Data System which is a widely accepted risk assessment and quality
assurance tool in mammography, ultrasound or MRI.
• BIRADS 0: Incomplete, further imaging or information is required.
• BIRADS I: Negative, symmetrical and no masses, architectural
disturbances or suspicious calcifications present.
• BIRADS II: Benign findings, interpreter may wish to describe a
benign-appearing finding.
• BIRADS III: Probably benign, short interval follow-up of 6 months
suggested.
• BIRADS IV: Suspicious abnormality.
- There is a mammographic appearance which is suspicious for
malignancy.
- Biopsy should be considered for such a lesion.

- These can be further divided as,
) BIRADS IVa: low level of suspicion for malignancy.
) BIRADS IVb: intermediate suspicion for malignancy.
) BIRADS IV c: moderate suspicion for malignancy.
• BIRADS V: There is a mammographic appearance which is highly
suggestive of malignancy and action should be taken.
• BIRADS VI: Known biopsy proven malignancy
ULTRASOUND OF BREAST
Indication of Sonomammography
1. Evaluate young ( < 30 years) or pregnant or lactating patients who
are symptomatic
2. Evaluate palpable lump with negative mammographic finding
3. Helps in guiding biopsy
4. Evaluate breast implants for rupture
5. Screening of high density breast
6. Differentiate between cystic and solid lesion
Technique
For Medial lesions- The patient is placed supine. lpsilateral arm is
placed over the patient's head.
For Lateral lesions - Patient is placed in opposite posterior oblique
position. lpsilateral arm is placed over the patient's head.
For Superior lesions - The patient is sitting with ipsilateral arm placed
over the patient's head.
• Scanning the nipple and subareolar region is challenging because
the nipple pushes into the breast substance, appearing as a vaguely
shadowing nodule in the subcutaneous area. The tightly packed
ducts in the breast are parallel to the ultrasound beam, making
these difficult to see in case of pathology.
• With nipple lesions, it is helpful to "roll" the nipple, using the
probe to scan it along its side. This improves the angle of the ducts
to the ultrasound beam making for easier and better visualization.
Heeling or toeing of the transducer may be necessary to improve
the angle.
• Use Coupling Gel in liberal quantity and use gel warmer.
• Apply gentle uniform pressure with the ultrasound transducer.
• Increase transducer pressure for greater penetration and scanning

the subareolar region.
Fig. 22.1: Radial scanning pattern

along the direction of lobes and ducts
Fig. 22.2: Scanning in whole organ Fig. 22.3: Another pattern is the
has been seen vertical pattern.
Difference between benign and malignant breast masses on

ultrasound:
S. No. Benign Malignant
1. Wider than taller Taller than wider -
2. Well circumscribed Spiculated margins
3. Post acoustic enhancement I Posterior shadowing
4. No secondary signs Nipple retraction, skin
thickening, retraction of ulcer
5. PSV and RI are reduced PSV >15m/sec2 , RI> 0.75
6. Multiple Single lesion except metastasis
7. Normal vascularity Increased vascularity
I (neovascularity)
-- - -_1. --- -
MRI BREAST
Breast MRI is a rapidly growing field, especially in the assessment
of high risk women.
Indications of breast MRI

ACR guidelines:
1. High risk screening-
(a) Personal and family history.
(b) High risk lesions: ADH/ALH/LCIS.
(c) BRCA1/BRCA2 gene positivity.
(d) Mantle radiotherapy.
2. Extent of disease.
3. Insufficient characterization on mammography and USG.
4. Neo-adjuvant chemotherapy.
5. Metastatic axillary lymphadenopathy in patient with unknown
pnmary.
6. Posterior lesion to assess chest wall invasion.
7. Complete or partial breast reconstruction.
8. Breast Implants (detection of cancer in implant patient).
9. High individual cancer risk.
10. Recurrent breast cancer.
Sequences used
Tl, T2, Tl +C (gadolinium): Dynamic and kinetic analysis.
Basic MRI breast Technique:-

1. Coils and patient positioning: Patient is placed in the prone
position with the breast in the 'cups' of the coil (hanging down
in the plastic cup coils).
(a) Padding done to minimize patient motion.
(b) Prone position minimizes the effects of respiratory motion and
helps breast to move away from the chest wall, resulting in
reduction of cardiac and respiratory motion.
2. MRI field strength: Can be performed at 1.Stesla or higher. The
high field strength enables the acquisition of high resolution
imaging with adequate SNR and enables better SNR and faster
imaging.
3. Imaging protocols: Pre-contrast TlWI should be checked carefully

to ensure adequate breast coverage and lack of severe artifacts.
(a) 0.2 mmol/kg gadolinium DTPA injected i.v. with a power
injector at a rate of 3ml/sec followed by 20ml saline push.
4. Plane of imaging: Sagittal or axial planes of acquisition are
preferred. Thin section (thickness <4mm) and pixel size of <lmm.
5. Fat suppression: On contrast images, many times lesion enhances
and becomes isointense to surrounding fatty tissue. Active fat
suppression images helps in eliminating surrounding fat.
Kinetic Analysis Curves

Type I - There is a slow rise and a continued rise with time. Seen in
benign lesions.
Type II - A slow or rapid initial rise followed by a plateau in the
delayed phase. These lesions require biopsy.
Type III - The type 3 curve shows a rapid initial rise, followed by a
drop-off with time (washout) in the delayed phase. Seen in malignant
lesions.
MRI KINETIC CURVE

It involves evaluation of lesion after contrast injection.
Enhancement rate (wash in): amount of increased intensity at the
area of concern. It is measured 1 minute after contrast injection.
Q)
E
Q)
(.)
C
ctl
.c
C
Q)
iii
�
c
0
(.)
0
c
:J
0
E
<{
Time
Fig. 22.4: Type 1 progressive enhancement
cQ)
E
Q)
(.)
C
Cll
.r:::
C
Q)
en
�
c0
(.)
0
c
:::,
0
E
<(
Time
Fig. 22.5: Type 2 - Plateau pattern
(Benign lesions)
cQ)
E
Q)
(.)
C
Cll
.r:::
C
Q)
en
�
c0
(.)
0
c:::,
0
E
<(
Time
Fig. 22.6: Type 3 - washout enhancement
(malignant lesions)
Enhancing lesions are divided into three main categories: focus/

foci, masses and areas of non-mass ehancement.
Mass
A masis a three-dimensional lesion that occupies a space within the
breast.
Shape
It can be round, oval, lobulated or irregular.
Lobulated masses have undulating contours.
Irregular masses have an uneven shape that cannot be characterized
as round, oval or lobulated.
If a mass is irregularly shaped, it has a 32% chance of being
malignant.
Margin
Margin can be described as smooth, irregular or spiculated.
Spiculated margin are frequently a feature of malignant breast
lesions and radial scars. If a mass has spiculated margins, it has an
80% chance of being malignant.
Enhancement pattern in mass

1. Homogeneous enhancement is uniform and confluent enhancement
throughout the mass.
2. Heterogeneous enhancement is nonuniform enhancement, which
varies within the mass.
3. Rim enhancement is enhancement mainly concentrated at the
periphery of the mass. This type of enhancement is frequently
a feature of high-grade invasive ductal cancer, fat necrosis, and
inflammatory cysts. A lesion with rim enhancement that is not a
typical cyst has a 40% chance of malignancy.
4. Dark internal septations refers to non-enhancing septations in an
enhancing mass. These are typical for fibroadenomas, especially
when the lesion has smooth or lobulated margins.
5. Enhancing internal septations are usually a feature of malignancy.
6. Central enhancement is pronounced enhancement of a nidus within
an enhancing mass. Central enhancement has been associated
with high-grade ductal cancer. Central enhancement has been
associated with high-grade ductal cancer.
Non-mass enhancement
Non-mass enhancement is enhancement without three-dimensional
characteristics. It is important because it occurs in a significant number
of cancers. Its important to look at its distribution, its enhancement
pattern and its symmetry or asymmetry.
Distribution - Non-mass Enhancement

Focal < 25% of quadran!
Ductal 60% cancer
Linear Not ductal orientation (31 % cancer)
Segmental Multiple ducts (78% cancer)
Regional Non ductal or segmental (21 %
cancer)
Diffuse
Focus and Foci

These foci are enhancing areas of less than 5 mm in diameter and are
too small to characterize.
They have persistent type 1 curves.
These lesions are typically stable on follow-up and are considered
to be a part of the normal background enhancement pattern in the
breast.
Internal Enhancement Pattern - Non-mass

Non-mass enhancement can be termed homogeneous and
heterogeneous, just as mass enhancement can.
As mentioned earlier, punctate enhancement is usually benign,
but it can occur focally. In that case there is a 25% chance of cancer.
Clumped enhancement is the most important non-mass enhancing
pattern to recognize. It has a 60 c¼, chance of cancer (typically DCIS).
For non-mass enhancement, kinetics are not very useful.
MR DUCTOGRAPHY EVALUATION OF DISCHARGING

NIPPLE
Nipple discharge is a relatively common symptom. Most nipple
discharges are physiologic and are not associated with underlying
benign and malignant neoplasm.
Procedure of MR Ductography:
MR Ductography can depict fluid filled tubular structures non
invasively by using heavily T2 weighted images in which no contrast
is required. It accentuates the structures that contain fluid with long
T2 relaxation time. The dilated ducts are imaged as tubular structures
with high signal intensity. Any intraductal lesion is visualized as
signal defect in the duct, an irregular duct wall or ductal obstruction.
Advantages of MR Ductography:
• Non-invasive.
• Radiation free.
• Useful for follow up.
• No contrast material required.
• It is 3 dimensional and it can show the distal part of the duct.
Disadvantages:
• Costlier than conventional ductography.
• Contraindicated in some patients with metallic implants, pacemakers.
• Non-dilated ducts are not visualized.
SONO-ELASTOGRAPHY
Elastography is a non invasive technique of imaging which includes
measuring tissue hardness/elasticity in response to the applied
pressure. It is virtual palpation to assess the tissue characteristics.
BASIC TERMINOLOGY IN ELASTOGRAPHY

Stress
It is defined as force per unit area and measured in pounds per square
inch (psi). Stress can be due to compression which acts perpendicular
to the surface and leads to decrease in size. Shear stress is the force
applied parallel to the surface which leads to deformation. Stress can
be applied exogenously using probe or effect of endogenous pressure
and can be studied by motion of vessels, cardiac or respiratory
movements. However, endogenous pressure is preferred due to better
control and measurement.
Strain
It is defined as change in the measurements/angles of the tissue in
response to stress. It is defined as change in the length per unit length
and is u_-rut less.
Elasticity
It is the ability of a tissue to come back to its original dimensions
once the stress is removed.
Viscosity
It is the measurement of resistance of fluid to stress.
Hooke's Law
It states that stress is directly proportional to the strain within the
elastic limits. It is true mainly for the homogeneous solids.
Poison's Ratio
When a tissue is exposed to stress, its' one dimension decreases.
However, the other dimension increases. It is defined as lateral
contraction per unit breadth or longitudinal extension per unit length.
For normal tissues, value is 0.5.
ELASTOGRAPHIC TECHNIQUES:-
Elastography can be divided into multiple types using different
methods:
• Based on the method used for applying stress (mechanical or
ultrasonic force).
• Based on the type of response of tissue to the applied stress (static
or quasi-static).
COMPRESSION ELASTOGRAPHY:
It is the most widely used technique in ultrasonography. This
technique tries to evaluate the elastic properties of tissue in response
to external compression. Radio-frequency signals are the response
received from the tissues. The amount of shift of the signal received
equals the amount of tissue displacement. Three methods have been
used to measure the tissue strain-
• Spatial correlation method
• Phase shift tracking method
• Combined correlation method
Hard or stiff substances generally move as a whole with all points
moving in the same amount in response to compression which results
in small rate of change of compression. However, soft tissues have
high rate of change of compression. The stiffer areas are shown as
darker on elastography.
Limitation: The amount of tissue displacement and the rate of
displacement change depend upon the applied stress. So with change
in compression force, these parameters change and true elastic
property of the tissue may not come.
VIBRATION ELSATOGRAPHY
Vibration elastography, on the other hand, generates tissue
displacement through the use of an independent external vibration
source. Relative displacement is measured by using a variant of
Doppler imaging that depicts differential motion of tissue types.
This technique provides good correlation for tissue that have a large
difference in stiffness. However, the heterogeneity of breast tissue
may limit the use of vibration elastography for whole-breast imaging
or for lesion detection. Elastographic imaging of the prostate gland
can be performed with manual compression strain imaging (two
dimensional) or with external vibration with Doppler imaging, which
permits two- and three-dimensional imaging.
A COUSTIC RADIATION FORCE IMPULSE METHOD

This method includes short duration acoustic impulses which provide
the necessary stress for producing strain in the tissues. These are called
pushing pulses and can be produced by ultrasound transducer array.
Ultrasound pulses can track these displacements by locating change
in the peak along multiple tracking lines. Peak displacement, time
taken to reach the peak and recovery time are used to characterise the
tissues. Tissue recoil also produces shear waves and speed of shear
waves is proportional to the tissue stiffness.
QUALITATIVE VERSUS QUANTITATIVE MEA SUREMENTS

Qualitative measurements are generally used for lesion identification
and monitoring ablation procedures. However, quantitative methods
are more useful to evaluate the diffuse pathologies e.g. liver fibrosis.
EL ASTOGRAPHY APPLICATIONS
Elastography has its utility in different organs. However, the major
organs of application involve the breast and liver.
Breast
In breast, elastography plays an important role in differentiating
benign from malignant lesions. In general, benign lesions have
less stiffness in comparison to the malignant lesions due to higher
desmoplastic reaction in the malignant lesions.
• Cancerous tissues appear darker on elastography as compared to
benign lesions and normal tissues.
• Malignant tissues generally appear larger on elastography then on
grey scale imaging. However, this is not seen in the benign lesions.
Elastographic Score
Score 1: presence of homogeneous strain in the lesion (green).
Score 2: prevalence of green colour with few blue spots.
Score 3: mainly green with central blue colour.
Score 4: almost completely green with peripheral green areas.
Score 5: completely blue with peripheral glow around the lesion.
In elastography, scoring the cut-off between benign and malignant
is taken between 3 to 4.
A semi-quantitative method of strain ratio between the lesion and
adjacent normal tissue is measured.
Examples:
• Simple bone cyst shows bull's eye appearance on elastography
with central bright area and peripheral dark areas.
• Breast carcinoma appears darker than the normal tissue.
Liver
In liver, sono-elastography has more role in diffuse liver disease
like fibrosis, cirrhosis where the B-mode imaging has limited role.
Elastography provides a non-invasive diagnostic alternative to biopsy
in fibrotic diseases.
TECHNIQUE-
Transient elastography apparatus has been widely used to evaluate
liver stiffness. It uses single cycle of low amplitude low frequency
(50 Hz) vibration to produce shear wave. The velocity of the shear
wave is faster in the dense fibrotic tissue. Tip of the probe is placed
in the intercostal space with the patient lying supine with arms in
abduction. Under control time motion and A -mode , the region of
interest is chosen in the liver. Stiffness is measured on a cylinder of
hepatic tissue of 1cm diameter and 2-4cm length. Median value of
10 successful values expressed in kilopascal is taken as liver stiffness.
The normal values stand around 5.5 kpa, with cirrhotic values ranging
between 13-75 kpa.
Similarly, liver elastography can be used to measure stiffness
in post treatment evaluation in viral hepatitis, assessment of portal
hypertension, TIPS and assessment of the liver transplant patients.
Prostate
Two main types of US elastography have been applied for imaging
the prostate: compression and vibration. Compression imaging is
similar to that demonstrated in the breast cases already described.
Prostatic carcinoma
At B-mode US, most prostate cancers are hypoechoic, but many are
isoechoic and a few are hyperechoic. As a result, the overall sensitivity
of endorectal US for prostate cancer detection is about 50%. The
added use of Doppler imaging increases the detectin rate by only 5%.
In contrast, endorectal real-time elastography enables the diagnosis
of prostate cancer with a reported accuracy of 76%. However, the
major role of elastography is to improve the results of image-directed
biopsy and therapy, compared with the use of endorectal US alone.
Prostate cancers have a higher elastic modulus (stiffness) than that
of surrounding normal prostate tissue. Consequently, prostate cancers
will appear dark on elastograms.
Sonoelastography-guided prostate biopsies yield detection rates
that are nearly threefold higher than those for systematic biopsy
techniques while requiring fewer core samples.
Benign prostatic hyperplasia

In general, foci of benign prostatic hyperplasia have elastic moduli
(stiffness) that are an order of magnitude greater than those of normal
prostate tissues but are less than those of prostate carcinomas.
As a result, on elastograms, benign prostatic hyperplasia will
appear darker than normal prostate tissue. However, the difference
between benign prostatic hyperplasia and prostate carcinoma can be
difficult to discern because benign prostatic hyperplasia also appears
darker than the background tissues. Consequently, benign prostatic
hyperplasia can represent a false-positive finding for cancer.
REFERENCES
1. Paredes ES. Atlas of mammography. Lippicott Williams & Wilkins.
(2007) ISBN:0781764335.
2. Neal L, Tortorelli CL, Nassar A. Clinician's Guide to Imaging
and Pathologic Findings in Benign Breast Disease. Mayo Clinic
Proceedings. 2010;85(3):274-279. doi:10.4065/mcp.2009.0656.
3. Masciadri N, Ferranti C. Benign breast lesions: Ultrasound. Journal
of Ultrasound. 2011;14(2):55-65. doi:10.1016/j.jus.2011.03.002.
4. Kornecki A; Current status of breast ultrasound; Can Assoc Radiol
J. 2011 Feb;62(1):31-40.
5. Kuhl. C; The Current Status of Breast MR Imaging * Part I. Choice
of Technique, Image Interpretation, Diagnostic Accurancy and
Transfer to Clinical Practice; Radiology, August 1, 2007; 244(2):
356-378.
Chapter 23
Doppler in Obstetrics and Peripheral Vessels

• Obstetric Doppler
• Peripheral arterial doppler
Doppler ultrasound is a non-invasive test that can be used to

estimate blood flow through blood vessels by using high-frequency
sound waves (ultrasound). One of the important utilities of Doppler
ultrasound is in antenatal phase.
OBSTETRIC DOPPLER
Indications
• Investigation of the uterine and umbilical arteries gives information
on the perfusion of the utero-placental and feta-placental circulations
respectively.
• IUGR assessment in second and third trimesters.
• In fetal distress and fetal insufficiency.
• Doppler studies of selected fetal organs are valuable in assessment
of the hemodynamic responses to fetal hypoxia and anemia.
• Color Doppler plays a vital role in the diagnosis of fetal cardiac
and non-cardiac malformations.
Indications for the assessment of the uterine artery doppler

ultrasound:
1. Previous history of pre-eclampsia.
2. Previous child with IUGR.
3. Unexplained high maternal serum alpha-fetoprotein levels.
4. High human chorionic gonadotropin levels.
Timing of Doppler
• As and when clinician suspects.
• As and when growth of fetus is not proportional to weeks of
gestation.
231
Position of Patient
Examination is performed with mother in a recumbent position.
Probe used
3.5-5 MHz curvilinear probe.
Technique of Fetal Doppler

The fetal Doppler is carried out on both arterial and venous flows. 3
sets of readings are taken before final values are given. Each sample
must have atleast 3 wave cycles.
Doppler ultrasound waveforms reflect the blood velocity.
Assessment of true velocity depends on the angle between the
ultrasound beam and the direction of the blood flow, ideally which
should be as close to O degrees.
The angle-independent indices used for measurement are-
1. Systolic-to-diastolic (S/D) ratio = Peak systolic velocity/End
diastolic velocity (PSV/EDV).
2. Resistive index (RI) = (PSV - EDV)/PSV.
3. Pulsatility index (PI) = (PSV - EDV)/Mean velocity.
Uterine Artery
Location of Uterine Artery
Uterine artery arises from the ascending branch of internal iliac artery.
It travels to the uterus, crossing the ureter anteriorly. There are two
uterine arteries, one on each side. Each uterine artery should be
sampled soon after the crossing of the iliac vessels.
Normal Waveforms
Fig. 23.1: Normal Flow Pattern
• The PI of each uterine artery should be obtained independently, using

a PI value of 1.41 to differentiate between normal and abnormal
Doppler in Obstetrics and Peripheral Vessels • 233
values. Diastolic notch 1s seen

normally in second trimester;
however, notch is not present
normally in third trimester.
• Uterine artery changes seen
unilaterally are not significant.
However, if difference between
the indices is more than 1, follow Fig. 23.2: First Trimester
up should be done.
Fig. 23.3: Second Trimester Fig. 23.4: Third Trimester
Abnormal Waveforms:
1. If the end diastolic flow does not increase throughout pregnancy
or if a small notch is detected at the beginning of diastole, the
fetus is at high risk for developing IUGR.
Fig. 23.5: Abnormal UTA with Fig. 23.6: Normal

early diastolic notch.
2. Diastolic blood flow may be absent or even reversed with extreme

degrees of placental dysfunction. Such findings may result into
fetal death.
• An abnormal PI and uterine artery notching in the second
trimester best predicted pre-eclampsia, whereas the best
predictor of IUGR in high-risk patients was an increased RI.
Umbilical Artery
• Umbilical artery is the branch of the anterior division of internal
iliac artery.
• Placental blood is assessed by studying the umbilical artery.
Factors affecting the results of umbilical artery doppler

• Umbilical artery is best examined in a segment of free floating
umbilical cord.
• Umbilical artery waveforms should be obtained during periods of
fetal apnea because fetal breathing affects the waveforms.
• Fetal cardiac arrhythmia, particularly periods of bradycardia, can
also lead to abnormal Doppler ultrasound indices.
Normal Waveforms
End diastolic flow is often absent in the first trimester and the diastolic
component increases with advancing gestation (decrease in placental
vascular resistance).
Fig. 23.7: First Trimester
Fig. 23.8: Second Trimester
Fig. 23.9: Third Trimester

Abnonnal Wave/onns:
• Decreased diastolic component and angle-independent indices
become abnormal (values above their reference ranges). This occurs
secondary to increase in vascular resistance, noted in conditions like
IUGR.
• Worsening of placental insufficiency result in decrease in diastolic
velocity which then becomes absent and later is reversed.
• The values of various indices are variable with age and should be
correlated with established charts.
Fig. 23.10: Absent, but not Fig. 23.11: Reversal of diastolic flow.
reversed diastolic flow UA Doppler waveforms obtained in
fetus with severe IUGR.
Middle Cerebral Artery

Color Doppler is used to evaluate the main cerebral arteries such as
internal carotid artery, the middle cerebral artery, anterior and the
posterior cerebral arteries and to evaluate the vascular resistance in
different areas supplied by these vessels.
MCA is the vessel of choice to assess the fetal cerebral circulation
because it is easy to identify, is highly reproducible and provides
information on the brain-sparing effect. It is responsible for almost
80% of blood supply to brain.
Location and Technique

• Obtain an axial section of the head at the level of the sphenoid
bones.
• Identify circle of Willis with MCA.
• The MCA should be sampled soon after its origin from the !CA.-
Normal Variations in MCA

• MCA PI (pulsatility index) changes throughout gestation.
• The lower PI values early and late in gestation may result from the
increased metabolic requirements of the brain during these periods.
• Reversed flow of the MCA velocity waveforms can be observed

with head compression in normal pregnancies.
Abnormal Findings
• IUGR is associated with increased blood flow to the fetal brain. This
is visualized as increased blood flow during diastole on Doppler.
This effect is termed the brain-sparing effect and is demonstrated
by a lower value of the MCA Pl.
• The MCA PI is below the normal range when oxygen tension (P02)
is reduced.
• When the 02 deficit is greater, the PI tends to rise, suggesting the
development of brain edema.
• In IUGR fetuses, the disappearance of the brain-sparing effect or
presence of reversed MCA flow is a critical event for the fetus and
precedes fetal death.
• The middle cerebral artery peak systolic velocity (MCA PSV) is
increased in IUGR fetuses. Increase predicts perinatal mortality
more accurately than does the MCA Pl.
• In anemic fetuses, the high MCA PSV is related to a decreased fetal
hemoglobin that can decrease blood viscosity; therefore cardiac
output increases. In IUGR fetuses, however, the MCA PSV increases
significantly related to hypoxemia and hypercapnia and thus to
brain autoregulation.
Fig. 23.12: Normal waveform in middle cerebral artery (third trimester)
Other Arteries
Descending Aorta
• Measured at the level of the diaphragm.
• The PI of the fetal descending aorta is 1.96 + /- 0.30 (SD) at the
diaphragm and 1.68 + /- 0.28 after the origin of the renal arteries.
The PI of the fetal descending aorta remains relatively constant
throughout gestation.
• Waveforms represent the summation of flow to the kidneys, bowel,
placenta, and lower extremities.
• In severe IUGR fetuses, there is reversed flow in the descending
aorta.
Fig. 23.13: Color Doppler showing descending aorta
Fig. 23.14: Normal waveform in descending aorta (third trimester)
Other Vessels
• Splenic Artery
• Superior Mesenteric Artery
• Adrenal Artery
• Renal Artery
• Femoral Arteries
• Internal Iliac And External Iliac Arteries
• Superior Cerebellar Artery
Factors Affecting Flow Velocity Waveform

Maternal position
During Doppler studies, the mother should lie in a semi-recumbent
position with a slight lateral tilt. This minimizes the risk of developing
supine hypotension syndrome due to caval compression.
Fetal Heart Rate

There is an inverse relation between fetal heart rate and length of
cardiac cycle and therefore, fetal heart rate influences the configuration
of the arterial Doppler waveform. When the heart rate drops, the
diastolic phase of the cardiac cycle is prolonged and the end-diastolic
frequency shift declines. Although the Doppler indices are affected
by the fetal heart rate, the change is of no clinical significance when
the rate is within the normal range.
Fetal breathing movements

During fetal breathing movements, there are variations in the shape
of the flow velocity waveforms from fetal vessels and, therefore,
Doppler examinations should be conducted only during fetal apnea
and in the absence of fetal hiccup or excessive movement.
Blood viscosity
Animal studies have demonstrated that increased blood viscosity
is associated with reduced cardiac output and increased peripheral
resistance and vice versa. However, Giles et al were unable to
demonstrate a significant association between blood viscosity
(measured in post-delivery umbilical cord blood) and impedance to
flow in the umbilical artery.
PERIPHERAL ARTERIAL DOPPLER

Anatomy of Lower Limb
The lower limb gets its arterial supply from external iliac artery
divison of the aorta. After crossing the groin crease, the external
artery is named as common femoral artery which divides into 2 major
branches. The deeper branch is called profunda femoral artery and
the superficial branch is called superficial femoral artery, which is
the main artery for evaluation in sonography. The superficial femoral
artery continues as popliteal artery at the knee crease region. The
popliteal artery further divides into 3 major branches namely, anterior
tibial, posterior tibial and peroneal arteries. Anterior tibial artery
continues as the dorsalis pedis artery.
Common iliac artery
Internal iliac artery .,...____ External iliac artery

on al
Grain crease---�,.____ Comm femor artery
1-+-->r-- - Profunda femoris artery
Superficial femoral artery
Popliteal artery
Anterior tibial artery

Peroneal artery
Posterior tibial artery �
Fig. 23.15
Normal Diameters of the Arteries

S. No. Artery Diameter (in mm)
---
_,
1. Sub-diaphragmatic aorta 21-24
2. Infra-d�phragmatic aorta +
--�20
3. Common iliac artery I 10-12
4. External iliac artery 8-10
1
5. Common femoral artery 7-9
6. Superficial femoral artery 6-8
-j - -'"'------
7. Popliteal �r!ery � _ 4-6
Arteries Scanned in Lower Limb Doppler

Arteries scanned in Doppler US of lower limbs:
Aorta and the following arteries on both sides
• Common iliac artery
• External iliac artery
• Common femoral artery
• Profunda femoris artery
• Superficial femoral artery

• Popliteal artery
• Tibio-peroneal trunk
• Posterior tibial artery
• Anterior tibial artery
• Peroneal artery
• Dorsalis pedis artery
Indications For Lower Limb Arterial Doppler:-

• Atherosclerosis
• Thrombo-embolism
• Aneurysm
• Intimal dissection
• Pseudo-aneurysm
• A-V fistula
• Entrapment syndrome
• Cystic adventitial disease
Examination Protocol and Technique

Probe Selection
The superficial course of the leg arteries makes it possible to use
higher-frequency transducers of 5-7.5 MHz, depending on the
thickness of the soft-tissues.
Patient Position
The femoral and anterior tibial arteries are examined in the supine
position and all other lower leg arteries and the popliteal artery in
the prone position with slight elevation of the distal lower leg by a
support placed under the ankles.
Technique
In general, vessels are visualized in two planes. First, the vessel
is identified in the transverse plane. The pulse repetition frequency
and gain are set so as to ensure good color filling of the arterial
lumen while avoiding aliasing. A survey in the transverse plane has
the advantage of enabling rapid identification of vessel dilatations,
stenoses that produce aliasing and occlusions, once adequate setting
has been achieved. Abnormal findings need to be confirmed and
quantified in the longitudinal plane.
With the patient in the supine position, the common femoral

artery is identified in the transverse plane and traced along its course
to the bifurcation . The transducer is positioned (in most cases on the
inner thigh) to view the bifurcation in such a way that the profunda
femoris artery, which typically arises from the posterolateral aspect,
comes to lie exactly behind the superficial femoral artery. In this way,
the bifurcation is depicted as a fork in longitudinal orientation, which
facilitates vessel identification and proper angle setting for evaluation
of a stenosis at the origin of the profunda femoris.
The superficial femoral artery is traced in longitudinal orientation
down the inner thigh. The vessel course inside the adductor canal is
easier to follow with the leg turned outwardly and the knee slightly bent.
The popliteal artery and vein are best examined with thepatient
lying prone. The vein runs superficial to the artery. As the anterior
tibial artery arises from the anterolateral aspect of the popliteal artery,
its origin is seen farther away from the transducer when scanning
from the popliteal fossa.
After having penetrated the interosseous membrane, the anterior
tibial artery is traced distally along its anterolateral course in
longitudinal orientation. The tibiofibular trunk varies in length from
1-5 cm, depending on the level of origin of the anterior tibial artery.
Its division into the posterior tibial and fibular arteries is identified
in the transverse plane. In the longitudinal view, the vessels are
continuously scanned for stenosis or occlusion by following their
courses distally. If a vessel disappears from the scanning plane, it
can easily be identified again by changing to a transverse view. The
tibia and fibula cast acoustic shadows and can serve as landmarks.
The dorsalis pedis artery and the posterior tibial artery behind
the medial malleolus of ankle are examined in the supine position
using a high-frequency transducer (7.5-10 MHz). These vessels are
first identified in the transverse plane to then obtain the Doppler
spectrum in the longitudinal plane. From there, the course of the
plantar artery can be tracked in transverse orientation and its patency
determined down into the interdigital arteries.
Common Doppler Findings

Normal Flow Pattern
The spectral waveform in the lower limb arteries is triphasic in
nature. The initial high velocity forward flow phase results from the
cardiac systole. It is followed by brief reverse flow which signifies
the peripheral resistance. The final component is the small forward
flow seen in the late phase of the diastole.
Fig. 23.16: Normal spectrum in superficial femoral artery
Fig. 23.17: Normal spectrum in popliteal artery
Fig. 23.18: Normal spectrum in anterior tibial artery

Arterial Occlusive Disease

The most common pathology in the peripheral arteries is the
thrombo-embolism phenomenon which leads to luminal narrowing
and ischaemic changes in distal limb. However, the effects of the
vascular compromise depends on the extent of the narrowing. On
Doppler ultrasound, the extent of the narrowing can be quantified.
1. Normal
• Triphasic waveform, no spectral broadening.
2. 1-19% narrowing
• Triphasic waveform with minimal spectral broadening.
• Peak systolic velocity (PSV) increased < 30% relative to the
adjacent proximal segment.
• Proximal and distal waveforms remain normal.
3. 20-49% narrowing
• Triphasic pattern maintained, however, reverse flow component
may be diminished.
• Broadening of spectrum.
• PSV is increased 30-100% relative to adjacent proximal segment.
• Proximal and distal waveforms are normal.
4. 50-99%narrowing
• Monophasic waveform with loss of reverse flow and forward
flow components.
• Extensive spectral broadening.
• PSV is increased > 100% relative to adjacent proximal segment.
• Distal waveform is monophasic with reduced systolic velocity.
5. Complete occlusion
• No arterial flow in the occluded segment.
• Pre-occlusive thump.
• Monophasic distal waveform.
l
At the site of stenosis: Spectral broadening
Post stenotic turbulent flow

In short segment stenosis, there can be return to triphasic flow
l
Post stenotic - dampened and biphasic flow
Fig. 23.19
REFERENCES
1. A Kubilay Ertan, H Alper Taniverdi. Donald School Journal of
Ultrasound in Obstetrics and Gynecology, April-June 2013;7(2):128-
148
2. Rurnack CM, Wilson SR, William Charboneau J, Johnson
JM.Diagnostic Ultrasound, 4th ed. Vol. 1. Uttar Pradesh, India:
Elsevier; 2011 .p.1472
3. Giles WB, Trudinger BJ, Pairner AA. Umbilical cord whole blood
viscosity and the umbilical artery flow velocity time waveforms:
a correlation. Br J Obstet Gynaecol 1986;93:466
4. Arduini D, Rizzo G, Boccolini MR, Romanini C, Mancuso S.
Functional assessment of uteroplacental and fetal circulations
by means of color Doppler ultrasonography. J Ultrasound Med
1990;9: 249-53
5. Maulik D, Yarlagadda P, Downing G. Doppler velocirnetry in
obstetrics. Obstet Gynecol Clin North Arn 1990;17:163-86
6. Mari G, Abuharnad AZ, Cosrni E, et al. Middle cerebral artery
peaksystolic velocity: technique and variability. J Ultrasound Med
2005; 24:425-430.
Chapter 24
Advances in Interventions
• Endovenous Laser Ablation of Varicose Veins
• HIFU
• Peacutaneous nephrostorny
• Non-Invasive Tissue Ablation Therapy
ENDOVENOUS LASER ABLATION OF VARICOSE VEINS

Introduction
Lower extremity venous insufficiency is a common medical condition
and Great saphenous vein (GSV) reflux is the most common underlying
cause of symptomatic varicose veins. Till now, surgery was considered
the standard therapy for varicose veins, especially when the GSV
is involved. However, it is observed that the clinical results are not
always satisfactory and severe side effects such as infection or nerve
damage are common.
Minimally invasive procedures using endovenous laser ablation
techniques [EVLA] are safe and effective ways of eliminating reflux
with less morbidity, faster recovery and improved cosmetic results.
Etiology
Venous disease resulting from valve reflux appears to be the underlying
pathophysiology for the formation of varicose veins. Venous blood
normally flows from distal to proximal and superficial to deep.
When these valves fail, the affected vein becomes incompetent.
Incompetent valves in the venous system allow blood to reflux and
flow in both directions. As a consequence, venous hypertension
develops in the vein and its associated tributaries fail. The affected
veins eventually get dilated and become varicose.
- 246
Advances in Interventions • 247
Normal Flow direction should always be

• Cephalad.
• Superficial to deep.
An incompetent vein allows blood to flow from the deep to surface
veins. This causes varicosites & perforators leading to venous reflux.
Superficial vein
Fat
----
-------: Normal perforator
-�
?
Muscle Deep vein Venous blood flows

upwards against gravity
<== and any backflow is

prevented by valves that
shut against the flow
Fig. 24.1
Superficial vein
Fat ---,
- - ' lncompitent
-------------,l�I S perforator
r i
r r ,--
Muscle Deep vein

Damage and don't function
properly. Backflow of
==> blood is not prevented and
pooling of blood stretches
and balloons the walls
Fig. 24.2
Endovenous laser ablation indications

• Insufficiency of the GSV or SSV visualized using CDUS (Colour
Doppler Ultrasound). The superficial system has valves which
prevent the backflow of the blood. However, when the valves
become incompetent, the backflow starts and vessel becomes
incompetent.
Contraindications
• Pregnancy
• Peripheral Artery Disease
• Allergies to Local Anesthetic Agents
• Severe hypercoagulability
• DVT or concomitant deep vein insufficiency
Mechanism of endovenous laser ablation

Laser generators generally use a 600nm laser fiber to deliver the
energy.
Laser generates high-energy, bundled light that is monochromatic
(same wavelength), coherent (in phase), and collimated (photons run
parallel). The thermal reaction after the laser exposure is mechanism
of action in laser treatment. The produced heat may reach up to 800 °C
at the tip of the fiber and results in the formation of steam bubbles.
The bubbles cause the blood to boil and induce thermal injuries to
the venous endothelium. The intravascular heat decreases to 90 °C
at 4mm from the laser tip. Steam bubbles that form at the tip of
the fiber dissipate quickly and pose no systemic risk of tissue bums
around the vein.
Histological studies show that EVLA (endovenous laser ablation)
damages the endothelial and intimal layers, the internal elastic lamina
and the media to some degree. The adventitia is rarely affected. Using
the pulse mode or continuous mode usually does not influence the
effectiveness of the outcome. The major advantage of the continuous
mode is that the duration of treatment is shorter. The pulse mode
is considered to have a higher risk of adverse events such as
microperforation.
Technique
EVLA can be performed under local tumescent anesthesia in an
outpatient setting. The most commonly used technique is to identify
the vein using ultrasound from the ankle to the SFJ. The saphenous
nerve is distant from the GSV above the knee compared to below the
Vein Vein
heated closed
Catheter
entry point
Vericose
veins
Laser
turned off
turned on
Fig. 24.3: Endovenous laser treatment of vericose veins

knee. Some radiologists prefer to cannulate the GSV at the level of

the knee so as not to harm the saphenous nerve, which is prone to
injury with ablations below the knee. Venous access is obtained by a
needle puncture under ultrasound guidance.
After entering the vein, a guide wire (mostly J tip or a straight
tip) is inserted. If the varicose vein is tortuous, has a small diameter,
has a large dilated branch emerging from it or contains thrombotic,
sclerotic segments, advancing the wire can be difficult. In such case,
under ultrasound examination of the area to visualize the tip of the
wire, rotating the wire or exchanging the wire for a hydrophilic one
usually solves the problem.
After the guide wire is in place; the needle is removed, a small
incision is made at the skin and a long introducer sheath is inserted.
The tip of the sheath is located at the SFJ (sapheno-femoral junction),
the laser fiber is inserted through the sheath so that the tip of the laser
fiber is positioned 1-2 cm distal to the SFJ and 1-2 cm away from the
tip of the plastic introducer sheath using ultrasound guidance. One
should ensure that the laser tip lies beyond the end of the catheter
before activating the laser energy.
Local tumescent anesthesia (5 mL epinephrine, 5 mL bicarbonate
and 35 mL 1 % lidocaine diluted in 500 mL saline or prilocaine 2%
without bicarbonate, diluted in 500 mL saline) is then injected along
the entire course of the saphenous vein from the cannulation site up
to the SFJ. The tumescent anesthesia has three functions:
1. It protects the perivenous tissue from the effects of laser
energy via a cooling effect.
2. It removes the blood from the lumen by collapsing the vein
and increasing the effectiveness of the laser ablation.
3. It increases the surface area contact between laser tip and the
vein wall.
Tumescent anaethesia surrounding laser fibre:

The act of forcing the blood from the vein prior to ablation is
important because it allows for ablation of the vein wall and does not
cause a thrombosis within the lumen. The parameters used, including
the power, the wavelength and the speed at which the laser fiber is
pulled back are variable.
Patients are usually discharged with an anti-inflammatory
medication, such as diclofenac 50 mg taken three times daily for one
or two weeks or as needed. Elastic bandages or class II (20-30 mmHg)
graduated supporting stockings are recommended for one to three
weeks. Compressive stockings not only compress the vein and help
to increase the effectiveness of the treatment, but they also decrease
the patient's post-procedural discomfort.
Complications
• Bruising, soreness, tenderness and indurations along the treated vein
segment.
• Mild post procedural pain.
HIGH INTENSITY FOCUSSED ULTRASOUND (HIFU)

High intensity focussed ultrasound is a non-invasive therapeutic
technique for tissue ablation using focussed high intensity ultrasound
waves. Traditionally, ultrasound has been used mainly for diagnostic
purposes. HIFU is primarily used for treatment of certain tumors.
Unlike cryoablation and radio-ablation, it is totally non invasive.
History of development
Fry and colleagues were the first to use HIFU in humans by
producing elevated acoustic intensities. However, the use of HIFU
in tumor treatment has come into picture more in 1990s with better
understanding of its ability to cause cell necrosis.
Difference between diagnostic ultrasound and HIFU

• Diagnostic ultrasound works on low intensity ultrasound waves.
However, HIFU works using high intensity ultrasound waves in
the focus area of the probe.
• The diagnostic ultrasound delivers time averaged intensity
of approximately 1-100 mW/ crn.2 with peak pressure of
0.001-0.003MPa,however, intensity values in HIFU ranges around
100-10000 W/ crn.2 with peak pressure of 10-30MPa.
Effects of HIFU and Principle of Working

HIFU produces mainly 3 types of effects in tissues with variable role
in tissue necrosis.
1. Thermal effects of HIFU

Major effect in the tissues is heat energy production by the absorption
of the ultrasound waves. The heat raises the temperature to around
60 degrees in the tissues and causes coagulation necrosis within few
seconds. Since this effect is produced only in the region of focus point
(where the rays converge), the superficial tissue survives the effects
of HIFU as they don't receive focussed ultrasound waves. Focussing
is done in small volume regions (e.g. 1mm diameter and length up
to 6 mm).
2. Mechanical effects of HIFU

Mechanical effects are due to ability of HIFU to interact with the
matter causing rarefaction and compression. The various mechanical
effects are as follows,
• Cavitation - It is the formation or movement of gas filled bubble
within the acoustic zone. It is because of the rarefaction and
compression effect of HIFU that the gas is extracted from the
tissues and bubble is formed. This bubble can interact with the
acoustic field to produce the mechanical effects. There can be stable
cavitation or inertial cavitation. In both types, there is change in
the size of bubble in different ways producing pressure effect on
surrounding tissues to damage them.
• Micro streaming - It is the rapid movement of the fluid around
the bubble created in cavitation (mainly stable cavitation). It can
produce the shear effects to damage the tissue. This happens mainly
in the liquid tissues.
• Radiation Forces - These are produced due to reflection or
absorption of ultrasound waves. The returned waves are of greater
force and cause tissue damage. This happens mainly in the solid
medium.
3. Biological Effect
The mechanism involved in the biological effects of HIFU is mainly
the thermal effects and the cavitation effects. What so-ever is the effect
produced by HIFU, the mechanism of tissue damage is through cell
necrosis and cell apoptosis. The intensity of HIFU and its effects do
not follow the linear relation.
Clinical uses of HIFU

• Treatment of benign and malignant solid tumours - It is mainly used
in the treatment of HCC, renal cell carcinoma, bladder carcinoma
and prostate cancer.
• HIFU has been used in thrombolysis with variable success rate..
• Arterial occlusion for tumor therapy and bleeding.
• Homeostasis for bleeding vessels and organs.
• Drug and gene delivery.
Imaging guidance and monitoring of HIFU therapy

Two important things control the success of HIFU therapy:
• Whether focus of HIFU lies in region of interest.
• Temperature monitoring.
Monitoring can be done using MRI, sonography and CT scan.
MRI offers distinct advantage of temperature monitoring which is not
available in other modalities, however, it is expensive. USG provides
better spatial resolution for location of target tissue but there is no
temperature monitoring.
Limitations of HIFU
• HIFU being ultrasound suffers from all of its major artifacts and
drawbacks. E.g. acoustic shadowing, reverberation artifact etc.
• Gas in the bowel cannot be penetrated by HIFU so less useful in
bowel tumours.
• In HIFU, the reflected waves are of very high energy so these can
damage normal tissue between lesion and transducer.
• HIFU is more useful where acoustic window is available.
• HIFU can produce damage to surrounding normal tissues.
• Shear effect can cause dissemination of malignant cells.
PERCUTANEOUS NEPHROSTOMY
Introduction
First described in 1955 by Goodwin et al as a minimally invasive
treatment for urinary ob.struction causing marked hydronephrosis,
Percutaneous nephrostomy (PCN) is a well-established therapy for
urinary drainage in patients with supravesical urinary tract obstruction
and for urinary diversion, as in patients with urinary fistulae, leaks or
hemorrhagic cystitis. T he procedure is also performed to gain access
to the urinary tract for ureteral stent placement, percutaneous stone
removal and other endoscopic procedures. T he collecting system can
be located with fluoroscopy or by using cross-sectional techniques
such as ultrasonography or computed tomography. Fluoroscopic
localization is especially useful if a radio-opaque stone, indwelling
ureteral stent or contrast opacified collecting system can serve as a
target.
Definition
Percutaneous nephrostomy: Image-guided percutaneous placement
of a catheter into the renal collecting system.
Technical success for percutaneous nephrostomy: Placement

of a catheter of sufficient size to provide adequate drainage of the
collecting system or to allow successful tract dilatation so that the
planned interventional procedure can be successfully completed
through the nephrostomy tract.
Indications and Contraindications

A. Indications
1. Relief of urinary obstruction
• Urosepsis or suspected infection.
• Acute renal failure.
• Intractable pain.
2. Urinary diversion
• Traumatic or iatrogenic ureteral injury.
• Inflammatory or malignant urinary fistula.
3. Access for end-urologic procedure
• Stone removal.
• Dilatation or stenting of a ureteral stricture.
• Endopyelotomy.
• Foreign body retrieval (e.g. fractured stent).
• Ureteral occlusion for urinary fistula.
• Tumor fulguration.
• Delivery of medications and chemotherapy.
• Biopsy of an urothelial lesion.
4. Diagnostic testing
• Antegrade pyelography.
• Ureteral perfusion (Whitaker test).
B. Absolute Contraindications:
• There are no absolute contraindications.
C. Relative Contraindications:
• Uncorrectable severe coagulopathy or bleeding diathesis (e.g.
thrombocytopenia, patient with liver or multisystem failure).
• Terminally ill patient.
• Fluoroscopically guided procedures are best avoided in
pregnancy, particularly in the first trimester. Ultrasound guided
procedures are preferred in such patients.
Anatomy relevant to percutaneous renal entry

Renal anatomy is necessary for selection of safe route through the
kidney for percutaneous nephrostomy.
The renal artery divides into major ventral and dorsal branches,
which creates ·a zone of relative avascularity between the divisions.
This zone (known as the Brodel bloodless line of incision) lies
just posterior to the lateral convex border of the kidney. Bleeding
complications related to percutaneous nephrostomy can be minimized
by traversing this avascular region.
Fig. 24.4: Avascular zone of Brodels
• The optimal entry plane lies posterolaterally at the junction

of the anterior two-thirds and posterior one-third of the renal
parenchyma. Because of the normal renal re:tation about its
horizontal axis, the posterior calyces are usually oriented
with their long axis pointing to this watershed territory. The
anteriorly and posteriorly directed calyces can be identified
fluoroscopically by using iodinated contrast material and air.
• With the patient prone, urine containing iodinated contrast
material opacifies anteriorly directed (dependent) calyces, which
are usually seen tangentially. Air introduced into the collecting
system accumulates in the posteriorly directed (non-dependent)
calyces. Oblique fluoroscopy with the image intensifier angled
20°-30° from the vertical towards the side of the kidney to be
punctured, can be used for entry into the collecting system, along
the fluoroscopic axis. Alternatively, when vertical fluoroscopy
is used, the patient may be placed in an oblique position with

the side of the kidney to be punctured elevated to 20°-30 °.
Fig. 24.5: Urogram shows simultaneous opacification of

anteriorly and posteriorly oriented calyces. Anteriorly
directed calyces are seen tangentially and posteriorly
directed calyces are seen en face due to the renal axis.
Puncture Site Selection

The site of renal entry is dictated by the indication for access with
consideration of the anatomic constraints. A lower pole posterior calyx
accessed via a subcostal approach is usually best for simple urinary
drainage. A posterior calyx of the upper or middle collecting system
offers the easiest access to the uretero-pelvic junction for potential
ureteral negotiation. A puncture behind a stone may be the most
expedient for uncomplicated stone disease, whereas puncture of a
posterior calyx in the upper pole (which may require a supracostal
approach with a slightly increased frequency of complications) often
provides the opportunity for visualization of a greater portion of the
collecting system for removal of complex stones. In some difficult
cases, a single access may not be sufficient and additional entry sites
may need to be created (e.g., treatment of stag horn calculi).
Basic Nephrostomy Technique

Patient Preparation
• Patient should be duly explained about the procedure and consent
should be obtained.
• Patient should be screened for bleeding diathesis and any urinary

infection. Prophylactic antibiotics should be given in case of any
suspected infection.
• Successful nephrostomy tube placement requires visualization of the
collecting system for appropriate entry site selection. Fluoroscopic
imaging after intravenous injection of iodinated contrast material is
commonly used to locate the renal pelvis for puncture. In certain
cases, opacification of the renal collecting system can be achieved
by retrograde injection of contrast material via a ureteral stent. This
method may be especially helpful in a patient with a non-dilated
collecting system. Direct needle puncture can also be performed
onto a visible stone or internal stent, if present. Direct antegrade
needle pyelography performed from a posterior approach by using
fluoroscopy and anatomic landmarks or with the assistance of other
imaging guidance is the method most commonly used.
Standard Procedure for Initial Entry

The patient is placed on the fluoroscopy table in the prone position.
The back and flank are cleansed and draped under sterile conditions.
An entry site into the collecting system is selected based on anatomic
landmarks determined from prior imaging or by using other imaging
techniques as previously outlined. After infiltration of the skin
and subcutaneous tissues with 1 % lidocaine over the selected site,
respiration is suspended and a 22- gauge needle is passed from a
direct posterior approach into the collecting system during vertical
postero-anterior fluoroscopy. During passage, two tactile "pops" can
be appreciated. The first occurs as the needle traverses the renal
capsule and the second occurs as the needle enters the collecting
system.
Renal entry is suggested by movement of the needle tip in concert
with the renal outline during respiratory excursion. Aspiration
is performed as the needle is withdrawn, until urine is observed.
Contrast material and air are injected for calyceal definition. Some
operators prefer carbon dioxide to air as a contrast material to avoid
the unlikely possibility of air embolism. A point above the selected
renal entry site is identified, ideally from a subcostal approach and
lateral to the paraspinous musculature. A skin incision appropriate to
the anticipated nephrostomy tube size is made with a no. 11 blade,
taking care to avoid the neurovascular bundle beneath the inferior
aspect of the adjacent rib. Under continuous fluoroscopy, an 18-gauge
diamond-tipped needle is advanced along the axis of the fluoroscopy
tube from the skin site to the selected renal entry site. After entry into
the renal parenchyma, puncture of the selected calyx is monitored
fluoroscopically. Only the posterolateral margin of the collecting

system should be punctured. Through-and-through puncture of the
anterior margin of the collecting system (and potentially the large
anterior arterial branches) is to be avoided. The stylet of the needle
is removed.
Track Dilation and Nephrostomy Tube Placement:

Small-bore (up to 14F) tracks can be created over a guide wire coiled
in the renal pelvis. Sequential dilation is performed over this guide
wire. Tubes coated with hydrophilic material are usually easily placed
through tracks dilated to an identical French size. At initial placement,
a metal stiffening cannula is used to support the tube for passage
through the soft tissues. The metal cannula, contained within the
nephrostomy tube, is passed over the guide wire to a point just
beyond the edge of the collecting system. The tube is advanced off the
metal stiffener into the collecting system over the guide wire. Tubes
of 8-10 F are usually sufficient for drainage of non-infected urine.
Larger tubes (12-14 F) may be necessary for drainage of infected
urine or to ensure appropriate urine flow in procedures complicated
by gross hematuria. Once placed, the position of the catheter should
be confirmed with an injection of contrast material with prompt
decompression of the collecting system anticipated following optimal
catheter positioning. Overdistension of the collecting system at initial
Air in 22G Wire Wire Drainage

posterior Needle catherter
Calyx
Wire
(a ) (b) (c) ( d) (e)
Fig. 24.6: Radiographs show the basic technique of percutaneous nephrostomy.
(in different patients)
(a) With the patient in the prone position, 22-gauge needle passed into renal
pelvis. After a urine sample is collected, contrast material is injected to confirm
the intrapelvic position and a small amount of room air is introduced to identify
posteriorly directed calices.
(b) From a 25 ° posterolateral oblique approach, a 18-20 g needle is passed into
the pelvis
(c) A wire passes easily into the ureter via the selected approach.
(d) After dilation of track a self-retaining catheter (in this case a Cope loop
catheter) is advanced over the wire, and the loop is formed in the renal pelvis
tube placement should be avoided, especially in patients with infected

urine, to prevent bacteremia.
Post-operative Care
• Frequent vital signs should be obtained to evaluate for the potential
of ongoing blood loss or for the development of septic complications
in those at risk.
• Careful charting of the nephrostomy tube output to assess adequacy
of drainage should also be performed.
• Hematuria, which is initially present in virtually all patients in
whom percutaneous renal entry is performed, should diminish
gradually over 24--48 hours.
• Narcotics may be required for pain relief, especially in patients with
intercostal entries.
• Arrangements should be made for ongoing tube care and
maintenance if long-term drainage is anticipated.
Complications
1. Septic shock
2. Hemorrhage
3. Bowel transgression
4. Pleural complications (pneumothorax, empyema, hydrothorax,
hemothorax)
NON-INVASIVE TISSUE ABLATION THERAPY

Non-invasive tissue ablation is a therapeutic technique of abnormal
tissue destruction using different mediums. Tissue ablation can be
done by 3 major ways:
• Radiofrequency ablation.
• Cryo-ablation.
• High intensity focussed ultrasound ablation.
Tissue ablation is mainly used to destroy tumour cells.
Traditionally, surgery has been the mainstay treatment for the tumour
resection. However, in recent times, tumour ablation has emerged as
an important alternative as well as complementary treatment to the
surgical approach.
Need for ablation therapy:

Traditionally, surgical resection has been the mainstay for tumour
treatment where there is resection of normal tissue together with the
abnormal tissue. However, with growing effort towards tissue sparing
therapies, effort has been towards localised treatment. E.g. nephron
sparing treatment in renal cell carcinoma. Ablation therapies have

been a step in this direction. Initially, localised therapy has been given
using open or laparoscopic route, however now percutaneous route
has come into picture.
Cryo-Ablation
Cryo-ablation is a technique of tissue destruction by creating very
low temperatures.
Uses of Cryoablation
Cryo-ablation is used mainly in destruction of tumour tissue. It is
commonly used where multiplicity of lesion with high chances of
recurrence is there. It is also used in cases where need for organ
sparing is required.
Principle and Technique
Cryo-ablation causes rapid decrease in the temperature of the tissue
and leads to ice formation at the target site. Two mechanisms work
in causing cell death. Firstly, the ice formation with decrease in
temperature is directly cytotoxic together with intracellular dehydration
which causes rupture of cell membrane and death. Secondarily, there
occurs clotting in the vessels when the temperature is reduced which
causes cell death by hypoxia.
Cryo-ablation is mediated through a cryoprobe which is generally
a metallic shaft. Metallic shaft is inserted into the site of lesion.
Further, the liquid gas like argon is used to rapidly cool the probe.
This leads to ice ball formation around the probe. Cell death is time
and temperature dependent. The critical temperature for the cell death
° ° °
is between -19 to -40 C. The probe itself reaches to around -19 C. The
ice ball must extend 3 cm beyond the tumor margins for achieving
°
a temperature of -20 C at the margins. Studies have shown that the
double freezing cycle (i.e.-freezing-thawing-freezing) produces better
efficacy. A variation in the normal single probe procedure is by using
multiple probe cryoablation. The probes are available in various sizes
(1.4-8 mm).
The important aspect of cryoablation is intra-operative monitoring.
It can be done through CT, MRI AND USG.
Risks of Cryo Ablation
• Pain around the area of discomfort.
• Risk of infection.
• Bleeding.
• If near liver, it can damage bile ducts and blood vessels.
• In kidney, it can damage collecting system.
• In lungs, it can cause collapse with pneumothorax.

• If near nerves, it can cause numbness and motor paralysis.
Radio frequency-ablation (RFA)
Radio frequency ablation is a process of tissue destruction using high
frequency alternating current. RFA is the most commonly used method
of localised tissue ablation. It is mostly done through percutaneous
route presently.
Uses
• It is mainly used presently where surgical resection is not possible
like in diffuse and recurrent tumours.
• It is also used as a palliative treatment.
• It is useful where normal tissue sparing is important for patient
e.g. nephron sparing in person with solitary kidney.
Principle and Technique
RFA works by using high frequency alternating current. This current
produces a lot of heat energy at the site of application due to agitation
of the ions around the electrode. This causes the coagulation necrosis
of the tissue. It can cause damage to both normal and abnormal tissue.
RFA can be done as an outpatient procedure with minimal hospital
stay. It is generally combined with pre and post procedure imaging.
E.g. CT to evaluate success of the procedure. The procedure is done
using small electrodes which deliver the current to the site of interest.
Needle can be placed under guidance of USG, MRI or CT. It can be
done through the percutaneous, laparoscopic route or at laparotomy.
With currently available devices, the largest focus of necrosis that
can be induced with a single application is approximately 4-5 cm
in greatest diameter. Thus, the diameter of suitable lesions must
be less than 3- 4 cm unless placement of multiple probes is done.
Simultaneous decrease of the arterial supply to the tumour with
balloon occlusion or embolization or at laparotomy with temporary
occlusion of the hepatic inflow (Pringle manoeuvre) increases necrosis.
The proximity of the tumors to large vessels may prevent adequate
heating, as well as proximity to central bile ducts, which predisposes
the patient to a risk of biliary complications. RFA is commonly used
for liver kidney and pancreatic tumours.
COMPLICATIONS OF RFA:
• Related to thermal effects: Surrounding normal tissue can be
damaged. E.g. in hepatic tumour RFA, diaphragmatic damage,
cholecystitis and bile strictures are common.
• Related to electrode insertion: It can cause tumour seeding, infection,

pneumothorax (in lung RFA), and haemorrhage.
• Post ablation syndrome; flu like symptoms.
• RFA can interfere w ith the functioning of other electronic devices
in body. E.g. pacemakers, defibrillators.
• RFA is a painful procedure so done under sedation and may suffer
from complications of sedation.
REFERENCES
HIFU
1. Kim Y, Rhim H, Choi MJ, Lim HK, Choi D. High-Intensity Focused
Ultrasound Therapy: an Overview for Radiologists. Korean Journal
of Radiology. 2008;9(4):291-302. doi:10.3348/kjr.2008.9.4.291.
2. Enne JW, Preusser T, Gunther M.Z; High-intensity focused ultrasound:
principles, therapy guidance, simulations and applications; Med
Phys. 2012 Dec; 22(4):311-22. Epub 2012 Aug 10.
3. Cheun VY.; Sonographically guided high-intensity focused ultrasound
for the management of uterine fibroids; J Ultrasound Med. 2013 Aug;
32(8):1353-8. doi:10.7863/ultra.32.8.1353.
PCN
4. Siddiqi Nasir H, Percutaneous Nephrostomy Technique, Medscape,
Nov 11, 2014
5. Regalado SP. Emergency Percutaneous Nephrostomy.
Seminars in Interventional Radiology. 2006;23(3):287-294.
doi:10.1055/s-2006-948768.
Non invasive tissue ablation
1. Foster RCB, Stavas JM. Bone and Soft Tissue Ablation. Seminars
in lnterventional Radiology. 2014; 31(2):167-179. doi: 10.1055/s-0034-
1373791.
2. Tatli Servet, Tapan -Omit,. Morrison Paul R, Silverman Stuart.
G; Radiofrequency ablation: technique and clinical applications;
Diagn Interv Radial 2012; 18:508-516.
Endovenous Laser ablation of Varicose Veins
1. Oguzkurt L. Endovenous laser ablation for the treatment of
varicose veins.; Diagn Interv Radial. 2012 Jul-Aug; 18(4):417-22. doi:
10.4261/1305-3825.DIR.5248-ll.0. Epub 2011 Dec 28. Review.
2. Ash JL, Moore CJ. Laser treatment of varicose veins: order out of
chaos; Semin Vase Surg. 2010 Jun; 23(2):101-6.
Chapter 25
CT Procedures
• HRCT
• CT Enteroclysis
• CT Urography
HIGH RESOLUTION COMPUTED TOMOGRAPHY (HRCT)

HRCT is the imaging technique where thin slice cuts are used with
high-spatial-frequency reconstruction algorithm to view lung details
and characterise the diseases.
The term HRCT was coined by Toda. Nakata et al published
first report on HRCT.
Technical aspects
HRCT has a role in evaluating fine details at the level of lung lobules,
thus, separate factors are required. HRCT mediated fine details cannot
be achieved in normal lung CT even after reconstruction. Technical
aspects in HRCT can be divided into 2 parts -major and minor.
Major factors
1. Slice thickness - HRCT is done using thin slice, of thickness
less than 1 mm. Thin slice minimises volume averaging within
the plane of scan. The normal slice thickness of 2.5-Scm is not
adequate for HRCT.
2. Reconstruction algorithm- HRCT involves using high spatial
frequency algorithm. This algorithm reduces image smoothening
and increases spatial resolution making structures appear sharper.
High spatial frequency simply means that frequency of information
recorded in final image is relatively high.
3. HRCT has to be done in full inspiration with breath hold.
Expiratory scans may lead to mis-interpretation.
Important hints to confirm non inspiratory scans-
• Concave posterior margin of trachea hints at expiratory scan.
• Gradient of increasing lung opacity from anterior to posterior
-
hints towards expiratory scan.
262
CT Procedures • 263
4. Expiratory scans have a role in obstructive airway diseases as

they help in proving air trapping.
5. Role of prone imaging - It can be useful in confirming sub pleural
pathologies e.g. Sub pleural reticulation.
Less Important Factors:

• Kilovolts (Peak), Milliamperes and Scan Time
High frequency algorithm increases noise together with increasing
image details. These three parameters play an important role in
minimising this noise.
Noise is inversely related to the photons absorbed and to the
product of milli-ampere and scan time. By increasing the mA/
kV and ms, noise can be minimised. However, these cannot be
increased beyond a certain level as to avoid excessive exposure to
radiation. The routine optimal values of kV (peak) are kept at 120
and mA at 100-200. Scan time is kept as short as possible (0.5-1
sec).
• Window setting: One consistent lung window setting is important
with window mean/width values of 600-700 HU/1000-1500 HU.
Soft tissue window kept at 50/350 HU is used for mediastinum,
hila and pleura.
• Image display: Workstation of lung window 12 on 1.
• Reconstruction: Trans-axial, entire thorax.
• Matrix size is kept at 512x 512 with FOV encompassing entire
thorax. Interslice gap is kept at 10-20 mm.
Indications of HRCT
• Evaluation of diffuse pulmonary disease discovered on chest
radiographs, conventional CT of the chest or other CT examinations
that include portions of the chest, including selection of the
appropriate site for biopsy of diffuse lung disease.
• Evaluation of the lungs in patients with clinically suspected
pulmonary disorders with normal or equivocal chest radiographs.
• Evaluation of suspected small and/or large airway disease.
• Quantification of the extent of diffuse lung disease for evaluating
effectiveness of treatment.
Lung anatomy on HRCT

Normal lung anatomy as well pathologies can be understood in terms
of its basic unit, secondary pulmonary lobule.
Components of secondary pulmonary lobule: There are 3

components
1. Interlobular Septa
Anatomically, secondary lobules are bounded by connective
tissue septa which extend inward from pleural surface.
The septa are part of peripheral interstitial fiber system.
Interlobular septa are thicker in the periphery as compared
to the central part of lung. The sepal thickness (0.1mm) lies
at lower HRCT resolution limit, so septa are seen occasionally
in the periphery. They contain lymphatics and veins.
2. Centrilobular Structures
Central portion of the lobule contains pulmonary artery and
its bronchiolar branches which supply the lobule and some
connective tissues. In HRCT generally, a solitary dot is seen
as bronchiole wall thickness is below resolution of HRCT.
The pulmonary artery in the lobule can be seen as a dot like
structure, branching or linear structure.
3. Lobular Parenchyma and Lung Acini
Lobular parenchyma consists of alveoli and associated
pulmonary bed. The parenchyma is supported by connective
tissue stroma called intralobular interstitium. It is difficult to
see these structures unless they have increased density than
air.
• Secondary lobules are well defined, regular with thicker and
better defined interlobular septa. However, the lobules are
irregular with thin interlobular septa in the central part.
Normal Secondary Lobule Anatomy
Bronchioles
Pulmonary veins and

Lymphatics
�
Visceral Pleura
Fig. 25.1
CT ENTEROCLYSIS
Definition. It is a hybrid technique that combines the methods of
fluoroscopic intubation and infusion of fluid for examination of small
bowel with CT.
Indications
1. Partial small bowel obstruction.
2. Crohn's disease and Ulcerative colitis.
3. Suspected Meckel's diverticulum.
4. Malabsorption.
5. Small bowel tumors.
6. Unexplained gastrointestinal bleeding.
7. Complete colonic obstruction.
8. Paralytic ileus.
9. Massive small bowel dilatation.
Contraindications
1. Pregnancy
2. Gastric outlet obstruction
Technique
CT Enteroclysis can be done in two ways-
1. CT enteroclysis with neutral enteral plus IV contrast.
2. CT enteroclysis with only enteral contrast agents.
Patient Preparation
These are common to both techniques,
• Low residue diet and good hydration.
• Laxatives a day prior to the procedure and no oral dose on the day
of procedure.
Sedation can be used optionally if required.
CT Enteroclysis with Neutral Enteral plus IV contrast (using

Neutral contrast agents)
Fluoroscopic Phase
• The various neutral enteral agents are methylcellulose, water or
0.1 % barium sulfate.
• 13F enteroclysis catheter is used with balloon positioned to the left

of the spine in the horizontal part of duodenum.
• 60 ml of air is infused under fluoroscopy following balloon inflation
to check the position of the catheter.
• 0.3mg of Glucagon is administered intravenously.
• 1.SL of water is infused initially at the rate of 130 ml/min.
• Patient is then shifted to the CT table.
CT Phase
• 0.3 mg of Glucagon is administered intravenously.
• 150L of water is infused at the rate of 100-150 ml/min.
• I/V contrast agents are administered at 4 ml/sec (total 150 ml). CT
is obtained at a delay of 50sec for optimal mucosal enhancement.
• Balloon is deflated and refluxed water from stomach is aspirated.
• These agents allow better assessment of mucosal enhancement,
mural thickness as well as mesenteric vasculature.
• Better used in unexplained sub acute gastrointestinal bleeding due
to vascular malformation and assessment of inflammatory activity
and complications of small bowel Crohn's disease.
CT Enterodysis with Enteral contrast agents

(using Positive contrast agents)
Fluoroscopic Phase
• 13-14F enteroclysis catheter is used with balloon positioned in the
descending part of duodenum.
• 60 ml of air is infused under fluoroscopy following balloon inflation
to check the position of the catheter.
• 12% of the water soluble contrast agent (total> 2 Ltrs) is infused in
the small intestine
at the rate of
55-100 ml/min.
CT Phase
• 550-1000 ml of
water soluble
contrast material
is infused on
CT table before
and during CT
examination.
Fig. 25.2: Enteroclysis Catheter
• Enteroclysis tube is withdrawn from the stomach and contrast

material is suctioned.
• No intravenous contrast is used with these agents.
• Mainly used to detect lower grades of small bowel obstruction and
internal fistulas.
Disadvantages
1. Increased cost and increased radiation dose.
2. Long timing of procedure.
3. The invasiveness of the procedure raises concern for complications
such as bowel perforation, enteral contrast material aspiration or
respiratory depression from sedation.
CT Enteroclysis versus MR Enteroclysis

• Magnetic resonance (MR) enteroclysis has the advantage of lack
of radiation exposure and safe contrast agents but appears less
accurate than CT enteroclysis.
• In patients allergic to iodinated contrast, MRI is used.
• In patients with impaired renal function, MRI is used.
• Direct evaluation of diseased wall, extension and involvement to
other abdominal structures are well delineated.
• Small bowel lesions of pelvis are easier to detect.
• Large bowel is simultaneously evaluated.
COMPUTED TOMOGRAPHIC UROGRAPHY

Intravenous Urography (IVU) has been traditionally used as an imaging
modality of choice to evaluate the urinary tract. However, with the
introduction of multidetector technology, Computed Tomographic
Urography (CTU) has been preferred in imaging the urinary tract.
CT urography is temporal and spatial evaluation of the urinary
tract involving non contrast phase and post contrast multiphase
examination (cortico-medullary, nephrogenic and excretory phases).
CTU offers the advantage of imaging the urinary tract in a single
breath hold along with image reconstruction.
Indications
Conditions commonly referred for CTU:
1. Urinary calculus disease
2. Evaluation of Hematuria
3. Suspected pelvis or ureteral obstruction

4. Inflammatory conditions of kidney and ureter
5. Congenital anomalies of kidney and ureter
6. Urinary tract trauma
Contraindications
The patients in whom this procedure is contraindicated are as follows:
1. Allergy to contrast agents.
2. Asthmatic patients.
3. Patients with cardiac diseases.
4. Renal insufficiency.
5. Diabetic patients.
6. Pregnant patients.
Procedure
Most CTU protocols are triphasic examinations. Oral contrast is not
required.
Patient Preparation: Patients should be told to avoid food intake
6 hours before the examination. However, they should maintain good
hydration prior to the examination.
Technique: Patient is made to lie supine with arms over the head.
CTU is performed by adjusting a tube voltage of 120kVp and a tube
current of 250mAs, with a pitch of 1.5:1 and collimation of 2.5mm.
Non contrast images are obtained with a slice thickness of 5mm and
contrast enhanced images are obtained with a slice thickness of 3mm.
After the scan has been completed, the images are reconstructed as
required.
Imaging Protocol: A
typical protocol consists of the
following:
(a) Non-contrast
(b) Contrast enhanced
- Cortico-medullary
- Nephrographic
- Excretory or delayed
Unenhanced scans exten
ding from the top of the Cortico-rnedullary
kidneys through the bladder
Nephrographic Phase Excretory Phase
are useful for evaluation of calculi, fat containing lesions and

parenchymal calcifications and to provide baseline attenuation for
assessment of lesion enhancement.
For contrast enhanced images, a non-ionic iodinated contrast
agent (containing 30-42 g of iodine) is administered intravenously at
a dose of 100-150 ml at the rate of 2-4 ml/ sec.
Cortico-medullary phase images are obtained 30-70 seconds after
start of contrast administration, which provide information about the
renal vasculature and perfusion.
Nephrographic phase images obtained after 90-180 seconds
are sensitive for characterization and detection of renal masses.
Homogeneous enhancement of the kidneys during this phase
optimizes detection of small renal masses.
Excretory phase images are obtained 8-lOminutes after contrast
administration when there is opacification of the collecting systems,
ureters and bladder. Excretory images allow for evaluation of the
urothelium.
SPLIT BOLUS TECHNIQUE

CT Urography can also be performed by the Split bolus technique,
whereby the contrast is given as 2 boluses before a single enhanced
scan is acquired. With this technique, after the unenhanced CT scan,
a fractionated dose of contrast material (30-S0mL) is administered
followed by a delay of 8-10 minutes before the remaining (80-100
mL) contrast material is given. A subsequent scan is obtained 100
seconds after the second dose of contrast material. The earlier smaller
bolus provides excretory information, while the second, larger bolus
provides information on vascular anatomy and renal parenchyma.
Disadvantages
1. Sub-optimal opacification of the ureters and intermittent peristaltic
waves may result in limited visualization of one or more segments.
2. High radiation exposure.
3. Expensive procedure.
A variety of techniques have been proposed to achieve adequate
opacification and distension of the pelvicalyceal system and ureters.
These are,
• abdominal compression
• saline infusion
• diuretic administration
• prone patient positioning
However, compression is not recommended in patients with
abdominal pain or in patients with history of urinary tract obstruction,
recent surgery and aortic aneurysm.
To limit radiation dose, upper abdomen superior to the kidneys
is excluded during unenhanced and excretory acquisitions.
The split bolus technique has the advantage of elimination of an
additional acquisition resulting in decreased radiation dose.
Also, radiation reduction techniques such as automated current
modulation can be helpful to limit overexposure.
REFERENCES
1. Lalitha P, Reddy MCh, Reddy KJ, Kumari MV. CT Enteroclysis; Jpn
J Radiol. 2011 Dec; 29(10):673-81. Epub 2011 Oct 19.
2. van der Merwe BSl, Ackermann C, Els H; CT enteroclysis in the
developing world: how we do it, and the pathology we see; Eur
J Radiol. 2013 Aug;82(8):e317-25. doi: 10.1016/j.ejrad.2013.03.018.
Epub ?013 May 8.
3. Sundaram B, Chughtai AR, Kazerooni EA; Multidetector high
resolution computed tomography of the lungs: protocols and
applications; J Thorac Imaging. 2010 May; 25(2):125-41. doi:10.1097/
RTI.0b013e3181d9ca37.
4. ACT-STR P ractice parameter for the performance of highresolution
computed tomography (HRCT) of the lungs of adults; ACR, revised
2015.
5. Silverman G. Stuart, Leyendecker R. John and Amis Stephens E.
What Is The Current Role of CT Urography and MR Urography
in the Evaluation of the Urinary Tract? Radiology 2009; 250
309-323
6. Alderson M. Skip, Susan Hilton, Papanicoloau Nicholas. CT

Urography: Review of Technique and Specrum of Diseases.
Applied Radiology. 2011; 40: 6-13.
7. O'Connor J.Owen, Maher M. Michael. CT Urography. AJR 2010;
195 : 5.
8. Joffe A. Sander, Servaes Sabah, Okon Stephen, Horowitz Mitchell.
Multidetector Row CT Urography in the Evaluation of Haematuria.
Radiographies 2003; 23 : 1441-1455.
9. Kawashima Akira et al. CT Urography. Radiographies 2004;
24 : S35-S54.
10. [Guideline] ACR Practice Guideline for the Performance of
Excretory Urography, Accessed December 14 2010
11. Wang LJ, Wong YC, Huang CC, Wu CH, Hung SC, Chen HW.
Multidetector computerized tomography urography is more
accurate than excretory urography for diagnosing transitional cell
carcinoma of the upper urinary tract in adults with hematuria.
J Ural. Jan 2010;183(1):48-55.
12. Katayama H, Yamaguchi K, Kozuka T, Takashima T, Seez P,
Matsura K. Adverse reactions to ionic and nonionic contrast
media. A report from the Japanese Committee on the Safety of
Contrast Media. Radiology. Jun 1990; 175(3) : 621-8.
Chapter 26
MR Procedures
1. • MR Arthrography 2. MRCP Magnetic Resonance
• Shoulder Arthrography Cholangio - Pancreatography
• MRI Protocol in Arthrography • Technique
• Knee Arthrography • Clinical applications
• Wrist Arthrography • Pitfalls in interpretations
• Recent advances -
comparision with ERCP
MR ARTHROGRAPHY
MR arthrography is a semi-invasive imaging technique used to
evaluate the intracapsular part of joint with the help of capsular
distension using contrast agents.
History of Arthrography
Intracapsular contrast injection and imaging have undergone several
developments over a period of time. In earlier days, pneumoathrograms
were done where air was used to distend the joint capsule. It was later
replaced by positive contrast based joint athrography. With further
development, double contrast based arthrography came into use
where both air and positive contrast agents were used to evaluate the
joint but in lower amounts. However, in the present time, the most
commonly used agent is gadolinium dimeglumine in mixture with
normal saline or positive contrast agent. MRI is the modality used in
viewing the details after contrast injection.
Joints for MR Arthrography

MR arthrography is mainly done in the synovial joints. Major joints
where MR arthrography is done are,
• Shoulder(gleno-hurneral joint) • Knee joint
• Ankle joint • Wrist joint
• Temporo-mandibular joint
272
MR Procedures• 273
MR ARTHROGRAPHY SHOULDER JOINT

Indications
• To evaluate the articular cartilage.
• To evaluate the biceps-labral complex.
• To evaluate capsular ligamentous complex.
Contraindications
• Infection over the superficial tissue.
Technique
MR Arthrography includes contrast injection into the joint capsule
followed by MRI. It can be done using direct or indirect approach.
Indirect approach includes intravenous injection of the contrast. It is
more useful for synovial evaluation. Direct approach includes direct
injection of contrast into the joint space. It is the preferred approach
for evaluation.
MR arthrography can be done as an isolated procedure or it can
be combined with plain MRI images prior to the contrast injection.
Preparation of the Contrast Agent

Different contrast mixture combinations are used for injection.
However, most commonly used combination consists of the following-
• Iodinated contrast agent: 5 ml
• Anaesthetic agent : 10 ml
• Normal saline: 5 ml
• Gadopentatae dimeglumine: 0.1-0.2 ml
How to inject the contrast:

Contrast can be injected under fluoroscopic or ultrasound guidance.
It helps in correct placement of the needle tip into the joint space
which in turn prevents the extracapsular spillage.
The contrast can be injected using the anterior or the posterior
approach. The anterior approach is generally preferred.
• The patient is placed in the supine position on the fluoroscopic
table with the arm externally rotated.
• The shoulder is prepared under aseptic conditions.
• The injection site is localised over the medial margin of the
humeral head at the junction of upper two-thirds and lower
one-third.
• Local anaesthetic agent is injected into the superficial tissues.

• Needle is placed into the joint space and confirmed
fluoroscopically.
• Contrast is injected into the joint space.
• The MRI is done within one hour of contrast injection.
Posterior approach can also be used in selective cases where
distortion of the anterior anatomy is to be avoided.
MRI .PROTOCOL IN MR ARTHROGRAPHY

Various sequences taken are-
• Plain Scout in different planes.
• Sagittal Oblique Tl WI with fat Suppression.
• Coronal Oblique Tl WI with fat Suppression.
• Axial Oblique Tl WI with fat Suppression.
• Coronal PD Image.
• Coronal T2WI with fat Suppression.
Common labral injuries-
• Bankart's lesion
• Perthe's lesion
• ALPSA
• GLAD
• Reverse Bankart's lesion
• Kim's lesion
MR arthrography can be helpful in assessing the gleno-humeral
ligaments and capsule status.
Fig. 26.1: Mr arthrography sagittal image

showing normal gleno-humeral ligaments
MR Procedures• 275
MR ARTHROGRAPHY KNEE JOINT

Indications
• Evaluation of recurrent meniscal injuries.
• Osteo-chondral injuries.
• Articular loose bodies.
Technique
Different approaches can be used for contrast injection. However,
lateral approach is the most commonly used.
1. Patient is positioned over the table with the fluoroscopic tube
over the patella.
2. Mid-portion of the patella is palpated.
3. Patient is asked to relax the quadriceps and sublux the patella
laterally. The posterior edge of the lateral margin is palpated and
the mid-portion is marked.
4. Standard sterile conditions should be followed.
5. Anaesthetize the skin.
6. Advance a 1½" 25G needle under the patella from a lateral
approach while subluxing it laterally. The needle should come to
rest against the patellar cartilage near the centre of the patella.
7. Contrast solution is injected taking care not to inject bubbles.
8. The contrast solution should flow easily. This can be monitored
fluoroscopically. Some experienced individuals routinely perform
this procedure without fluoroscopic guidance.
Contrast Solution
1. Inject 40 cc standard MR Arthrogram diluted gadolinium solution
(20 cc normal saline, 10 cc Omnipaque 300, 10 cc 1% lidocaine,
and 1.0 cc gadolinium).
2. If the patient has a joint effusion, aspirate off as much as possible
and inject the above 40 cc plus whatever volume was aspirated.
MR ARTHROGRAPHY WRIST /HAND

It can be done by 2 ways:
• Direct MR Arthrography.
• Indirect MR Arthrography.
Direct is more useful.
• Patient is positioned in supine position with hand on side and palm
facing downwards.
• The wrist is prepared under aseptic conditions.

• The entry site is subjected to local anaesthesia.
• The radio-carpal joint is entered dorsally using 25G needle with
the needle directed proximally to avoid dorsal lip of radius.
• Injection into the intercarpal and distal radio-ulnar joints is done.
• Multiple injection sites can be chosen as per requirement.
• A total of 3-4 ml contrast mixture is injected.
• Patient is then shifted to MRI gantry for imaging using standard
protocol.
MAGNETIC RESONANCE CHOLANGIO

PANCREATOGRAPHY (MRCP)
• Technique
• Clinical Applications
• Pitfalls in interpretation
• Recent advances
• Comparision of MRCP vs ERCP.
Magnetic Resonance Cholangio-Pancreatography (MRCP) is used
for non-invasive work-up of patients with pancreatico-biliary diseases.
Technique
Preparation: Patient should be empty stomach for 8-12 hours to
avoid any fluid in GI tract especially in stomach. If fluid is present
in stomach, it can be suppressed by intake of blue-berry juice.
MRCP is usually performed with heavily T2-weighted sequences
by using fast spin-echo or single-shot fast spin-echo software and both
thick collimation (single-seciton) and thin-collimation (multi-section)
techniques with a torso phased array coil. The coronal plane is used
to provide a cholangiographic display and the axial plane is used
to evaluate the pancreatic duct and distal common bile duct. 3-D
reconstruction can be done by using a maximum-intensity projection
(MIP) algorithm on the thin-collimation source image. Although
the thick-collimation and 3-D MIP images more closely resemble
conventional cholangiograms and are familiar to may clinicians,
spatial resolution is degraded because of volume-averaging effects.
A number of techniques have been employed to achieve heavy T2-
weighting, however, two techniques commonly used include-RARE
and HASTE.
RARE: Rapid Acquisition and Relaxation Enhancement (RARE) is
MR Procedures • 277
a fast spin echo (FSE) or Turbo spin echo (TSE) single shot technique
acquired as thick slab of 3-7 centimetres with acquisition time of 2-3
seconds. RARE uses long TE in the range of 900 ms so that fluid
which has long T2 shows bright signal. Signal from background is
decayed. RARE is generally acquired as thin slice acquisition for small
intraductal calculi or other filling defects.
HASTE: Half Fourier Single Shot Turbo Spin Echo (HASTE) is FSE
or TSE acquired as single shot in which only half of K-space is filled.
TE used in HASTE is in the range of 80-100 ms so background tissues
are not suppressed. Post processing in the form of MIP is needed to
get cholangiopancreatogram.
MRCP should also include, depending on the case, other MR
sequences to evaluate extraductal structures and pathologies.
Clinical Applications of MRCP

1. Cystic Diseases of the Bile duct: Choledochal cyst, Choledochocele
and Caroli's disease.
2. Congenital Anomalies:
• Pancreatic divisum - MRCP is useful in detecting pancreatic
divisum. Congenital variations like low cystic duct insertion,
medial cystic duct insertion, parallel course fo the cytic and
hepatic ducts and aberrant right hepatic duct are visualised on
MRCP.
• Biliary atresia - MRCP can non-invasively establish the diagnosis
of biliary atresia.
3. Choledocholithiasis:
MRCP is an excellent method to detect CBD stones. They appear
as dark filling defects within the high-signal-intensity fluid on
MRCP.
4. Primary Sclerosing Cholangitis:
Findings on MRCP include-
(i) String-on-beads appearance/Pruned-tree appearance.
(ii) Pruning of peripheral ducts.
(iii) Thickned duct wall.
(iv) Intraluminal web.
(v) Obtuse angle between central and peripheral ducts (Normally
angle is acute).
5. Post-surgical Complications:
Post-surgical complications like benign strictures, retained stones,
biliary leak and biliary fistula are effectively evaluated with

MRCP.
6. Chronic Pancreatitis:
Findings in alcoholic pancreatitis include-
(i) Irregular/beaded enlargement of pancreatic duct.
(ii) String of pearls appearance.
(iii) Intraductal filling defect due to calculi/protein plugs.
(iv) Loss of normal tapering of main pancreatic duct.
(v) Stenosis of MPD is shorter, smoother and more symmetrical
in chronic pancreatitis.
7. Pancreatic pseudocysts:
MRCP is more sensitive than ERCP in detection of pseudocysts.
However, MRCP is less sensitive in demonstrating the site of
communicaiton with the pancreatic duct.
8. Neoplastic Lesions:
Features of malignant stricture in CBD-
(i) Short segment stricture with irregular margin.
(ii) Asymmetrical narrowing.
(iii) Rat tail appearance.
(iv) Stricture with shouldering.
(v) Ductal encasement with lymph node enlargement.
9. Biliary Cystadenoma and Cystadenocarcinoma:
ERCP has a limited role in demonstrating the presence and extent
of disease because the mucin secreted by these tumors causes
filling defects and partial obstruction of contrast material. MRCP
is potentially more accurate in demonstrating the extent of these
tumors.
Pitfalls in interpretation
1. Filling defect: Pneumobilia, blood clot, sludge and susceptibility
artifacts from metallic clips may be misinterpreted as small stones.
2. Non pathological bile duct narrowing from vascular pulsation
(Hepatic artery & Gastroduodenal artery): Most common sites
are common hepatic duct, left hepatic duct and mid portion of
CBD.
3. Misinterpretation Related to the Cystic Duct: When the cystic duct
runs parallel to the common hepatic duct for some distance, the
two structures together may be mistaken for a dilated common bile
duct. This pitfall is most likely to occur on an MIP reconstructed
image. Therefore, the source images should be evaluated carefully.
4. Pitfalls Related to the Peri-ampullary Region: Contraction of the

choledochal sphincter may be misinterpreted as an impacted
stone or stricture in the distal bile duct. When this defect is seen
on direct cholangiography, it is known as the pseudocalculus
sign. Unlike with an impacted stone, only the superior margin
of the defect is outlined by the high-signal intensity bile. A more
important difference is that the presence of the defect is transient.
Recent advances in MRCP

(1) Functional/Contrast Enhanced MRCP
Although conventional fluid-based T2-weighted MRCP is excellent for
demonstrating morphological details, there is still pack of functional
information concerning bile production and excretion through the
biliary tree. MR contrast agents with hepatobiliary excretion such as
mangafodipir strisodium, gadopentate dimeglumine or Gd-BOPtA
are now being used for this purpose.
The optimum timing for biliary excretion of these contrast agents
ranges from 10-60 minutes. The preferred acquisition sequence for
Tl-weighted MRCP is a fat-saturated, spoiled gradient recall (SPGR)
sequence.
Indications and current role of Functional/Contrast Enhanced
MRCP:
1. Defining biliary anatomy for pre-surgical planning prior to
major hepatectomies and living donor liver transplantation.
2. Evaluating integrity of bile ducts.
3. Differentiating true obstruction from pseudo-obstruction.
(2) Secretin - f.jfhanced MRCP

Secretin is a gastrointestinal peptide which stimulates pancreatic duct
epithelial cells to produce a bicarbonate rich fluid with resultant
increase in diameter of pancreatic duct. It also increases the tone of
sphincter of Oddi with increase in volume of stationary fluid within
the duct. The adverse effects of secretin are mainly nausea, flushing,
abdominal pain, and vomiting which can be seen in up to 5% of
patients.
Advantages
1. Better delineation of full length of main pancreatic duct.
2. Enhances detection of pancreatic variations such as pancreatic
divisum.
3. Reduces frequency of false positive findings of stricture.
4. Assess sphincter of Oddi function.
r��;;-
Comparison of MRCP and ERCP
I --
MRCP ERCP �
l:
invasive, radiation- Involves contrast injection and
radiation.
--
1MRc P produces images ERCP, ducts are distended with
of ducts in their natural ontrast.
physiological state.
1
3. MRc·P can be combined Extraductal pathology or structures
with conventional MR cannot be assessed.
I imaging to evaluate
extraductal disease.
��
1-J;.c:b
s beyond obstruction Contrast may not pass beyond the
e visualized. obstruction. Hence, proximal ducts
-- are not seen.
5. MRCP can be performed It may not be possible technically to
in post surgical patients perform ERCP in such patients.
I
in whom biliary-enteric
anastomosis has been
performed
6. Non-operator dependent. Operator dependent.
7. MRCP is useful in Upto 10% technical failures are
patients after incomplete reported in ERCP.
or unsuccessful
_ ERCP.
8. I Safe. ERCP involves morbidity and
L
mortality. Complications include
pancreatitis, haemorrhage,
perforation and sepsis.
9. Major limitation of Therapeutic options like
MRCP is its therapeutic sphincterotomy, endoscopic
incapability. lithotomy, brush cytology, collection
of pancreatic juice, stricture
dilatation, stent placement and
biopsy are possible with ERCP.
10. Second limitation of High spatial resolution achievable
MRCP is its lesser spatial with ERCP may be important in
resolution as compared precise delineation of pancreatic
to ERCP. side branches. This is of significance
with availability of newer less
L
invasive pancreatic surgeries-
segmental pancreatic resection, cyst
enucleation. -
REFERENCES
1. Chung, C. B., Gigena, L.M. and Resnick, D. 2002. MR Arthrography
of Shoulder. Current Protocols in Magnetic Resonance Imaging.
A:A22:A22.2.
2. Ogul H, Bayraktutan U, Yildirim OS, et al. Magnetic Resonance
ARthrography of the Glenohumeral Joint: Ultrasonography-Guided
Technique Using a Posterior Approach. T he Eurasian Journal of
Medicine. 2012; 44(2):73-78. doi: 10.5152/eajm.2012.18.
3. Lee MJ, Motamedi K, Chow K, Seeger LL. Gradient-recalled echo
sequences in direct shoulder MR arthrography for evaluating the
labrum. Skeletal Radiol. 2008;37:19-25.
4. Choudur HN, Ellins ML. Ultrasound-guided gadolinium joint
injections for magnetic resonance arthrography. J Clin Ultrasound.
2011; 39:6-11.
5. MR Cholangiopancreatography of Bile and Pancreatic Duct
Abnormalities with Emphasis on the Single-Shot Fast Spin-Echo
Technique, RadioGraphics 2000; 20:939-957.
6. Fulcher AS, Turner MA. MR pancreatography: a useful tool for
evaluating pancreatic disorder. RadioGraphics 1999; 19:5-24.
7. Ernst 0, Asselah T, Sergent G et al. MR Cholangiography in primary
sclerosing cholangitis. AJR Am J Roentgenol 1998; 171:1027-1030.
8. Pitfalls in MR Cholangiopancreatographic Interpretation.
RadioGraphic 2001; 21:23-37.
9. Advances in magnetic resonance cholangiopancreatography: From
morphology to functional imaging. Indian J Radiol Imaging/
November 2007/Vol. 17/Issue 4.
Cha ter 27
Positron Emission Tomography (PET)

• Principle of PET
• Interpretation
• Fusion with CT & MRl
• Uses of PET
• Limitation of PET
Positron em.Iss1on tomography is a diagnostic imaging technique

which evaluates the metabolic activity in any tissue using radiotracers
to isolate high activity zones (physiological or pathological) from low
activity zones. Traditionally, PET was used alone to give high activity
zone, however, it suffered major drawback of organ localisation.
Hence, recently PET has been used in combination with CT (PET
CT) or MRI (PET MRI).
Principle of Pet
PET is a functional imaging technique which locates the high
functional zones in body, physiological or pathological (malignant
tumors). A high activity zone in the body has increased glucose
uptake and metabolism. In malignant tumors which have fast
growth rate and division, requiring more glucose and amino acids.
PET scan uses radio tracers based on these compounds to judge the
metabolic activity. Most commonly used radiotracers are the glucose
based compounds e.g. FDG (F-fluro-2-deoxy-D-glocose). Cells with
increased metabolism show increased uptake of FDG. FDG enters
into metabolism cycle and is converted into FDG-6-phosphate by
hexokinase enzyme. However, the further enzymes cannot metabolise
phosphorylated glucose which gets trapped within the cell.
The trapped FDG releases positrons which combines electrons from
the surroundings and undergoes annihilation. This process releases
°
two photons moving at approximately 180 to each other. These
positrons are detected by scintillators and then data is interpreted.
282
Positron Emission Tomography (PET) • 283
Detection of Emission
The emissions in PET consist of high energy photons (512 KeV). These
photons are detected using high power scintillators. Most common
scintillators are made of bismuth germinate (BGO) or cerium- doped
lutetium oxyortho silicate (LSO). These scintillators are further
coupled with photo multiplier tubes (PMT).
Interpretation
The interpretation of the radiotracer activity can be assessed using
qualitative and quantitative methods. However, before interpretation,
the values need to be corrected for the attenuation they suffer because
of passage through the body.
Qualitative method: It is based on the visual impression of the
uptake based on the provided images. Intensity of the colour in
comparison to the surrounding helps to differentiate normal from
abnormal. However, it is highly subjective.
Quantitative methods: These are the semi-quantitative values
given by the software.
Standard uptake value: It is defined as tracer activity in the
tissues divided by injected radiotracer dose/patient weight where
radiotracer dose is in milli-curie and patient weight is in kilograms.
The SUV value cut -off to differentiate benign from the malignant
is 2.5-3. However, it is important to differentiate between normal
physiological uptake and pathological values.
The other less commonly used methods are glucose metabolic
rate, tumour burden.
Pet Fusion with CT and MRI

PET was used in isolation initially to evaluate the lesions. However,
PET suffered a major drawback of lesion localisation with respect to
body parts. This lead to the simultaneous use of PET with CT and
MRI. Presently, the hybrid PET and CT scanners are mostly used
where both PET and CT are first done separately and then interlinked
in different planes. MRI fusion with PET is still in the experimental
stage.
Uses of PET/PET-CT
Most common use of PET scan is in oncology.
DIAGNOSIS
• PET is the modality of choice in characterising of lung nodules
especially less than 10 mm.
• PET is very helpful in locating the primary tumour where multiple
secondaries exist.
• PET is useful in breast cancer, thymic tumours.
• However, the FDG -PET has limited application in brain tumours
due to inherent high uptake of glucose in brain tissue.
Initial Staging
PET has role in the initial staging of the tumours as it is helpful in
localisation of the metastasis in the distant sites and has an impact
on the treatment. In lung cancers, it is mainly used in non-small
cell cancers. PET can better determine the staging in comparison to
contrast enhanced CT. However, certain tumours like mucinuous
adeno-carcinoma are not FDG avid so can give false negative results.
Treatment Response
Most of the drugs used in chemotherapy are cytostatic and not
cytocidal, so do not produce much change in the size of the tumour,
however, there is decrease in the metabolic activity of the cells. This
leads to decreased glucose utilisation by the cells. This makes PET
as the modality of choice to judge the initial response to therapy as
compared to other modalities like contrast enhanced CT. However,
there is not much difference in the end stage evaluation for treatment.
It is very useful to separate the responders from non-responders after
2 cycles of chemotherapy in lymphoma.
Restaging/Recurrence/Prognosis
Many cancers re-occur after the initial treatment. This is one of the
most acceptable indications of PET CT. PET has a proven role in
assessing the prognosis of colorectal carcinoma.
Limitations of PET
• Patient motion can interfere with the site localisation.
• Attenuation (transmission) corrections artifacts can occur where
there are highly attenuating objects in the path of the CT beam,
such as hip prostheses, pacemakers, dental devices and contrast
enhanced vessels.
Positron Emission Tomography (PET) • 285
• If the patient has undergone strenuous activity, false positive results

can come due to increased FDG uptake by the muscles.
• PET does not differentiate between physiological and pathological
uptake areas.
• PET can show enhancement even in non tumourous lesions like
infections, etc.
The new edition of "Radiological Procedures" has been
thoroughly revised and updated in simple and lucid language.
The new methods and tools that are now available in the field
of radiology for the diagnosis of disease conditions have been
added. Several chapters reflect the rapid pace of advancement
in the field of radiology and the book concludes. with a series
of chapters that summarizes the newer trends in radiography,
CT, MR guided procedures & PET scan. The book has been
written keeping in mind the basic requirements for both
radiologists & radiographers. This book will enlighten students
and contribute to a healthier future.
Dr. Bhushan N Lakhkar, is a well known faculty in the

field of Radiodiagnosis. He has a teaching experience of over
35 years in various teaching institutions in India and Abroad.
He was Professor and H.O.D. at KMC, Manipal for 15 years.
He was a visiting professor at Agakhan University, Nairobi.
He is an author of two books in radiodiagnosis. He has many
publications to his credit in national and international scientific
journals. He is very popular amongst the students for his
innovative approach and simple method of teaching. During
his distinguished career he has been recognized for his
academic excellence by learned authorities.
ARYA PUBLICATIONS
Industrial Area, Trilokpur Road, Kala Amb-173 030, Distt. Sirmour (H.P)
Delhi Office: 1002 Faiz Road (opp. Hanuman Murti), Karol Bagh, New Delhi - 110 005
Phone: 011-28752604, 28752745 Fax: 011-28756921
Website: www.apcbooks.co.in E-mail : info@apcbooks.co.in

Radiological Procedures - A Guideline DR Bhushan Lakhkar

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Radiological Procedures - A Guideline DR Bhushan Lakhkar

Uploaded by

Copyright:

Available Formats

Dr.

First Edition: 2002

Laser Typesetting at:

First Edition: 2002

Laser Typesetting at:

I have received a lot of encouragement to prepare this second edition

Special thanks to Dr. Vipin Gupta, who constantly reminded me to

Finally I must thank may publisher, M/S Avichal Publishing Company,

Dr. Bhushan N. Lakhkar

Hepatic excretion lopanoic Renal excretion

High osmolar Low osmolar _J

Water Soluble Iodinated Contrast Media

Disadvantages of Conventional Contrast Media

Useful Facts to Remember

II. Low Osmolar Contrast Media

Non-Ionic Monomers (NIM)

Additives Used in Contrast Media

Ideal Contrast Media should have

Ionic Contrast Media Available in India are:

Unique (JB Chemicals)

Non-ionic contrast media available in India are:

Mallinckrodt International Corporation

After intravascular administration, first it diffuses into the ex­

Ornnipaque 240 has least viscosity.

I. Reactions Unrelated to Contrast Media

II. Hyper Osmolarity

III. Chemotoxic Action

IV. Immunological (Allergic) Toxicity

injection is about l/3rd of incidence following intravenous injection

High Risk Group Persons

7. Neonates - 4 times more prone.

Premedication for High Risk Group

Incidence of Reactions with Ionic Contrast Media (ICM) and

Assessment of the patients with reactions

• Some of the symptoms which can precede severe reactions include.

Extravasation of Contrast Material

CONTRAST MEDIA USED IN ULTRASOUND

Generations of Echo Enhancers

Ultrasound Contrast Agents

• Also it is possible to perform dynamic & perfusion studies.

(B) Vascular Ultrasound Contrast Agent:

• These are most likely to be used in imaging of malignant tumours

(C) Contrast Agents For Targeted Imaging:

CONTRAST MEDIA USED IN M.R.I.

Requirements of an Ideal Contrast Media

Commercial Brands of Contrast Available in India

The parameters determining MR signal intensity and contrast are:

Three agents have been approved by FDA. They are:

4. Diffusion and Perfusion

Particulate agents/susceptibility agents

Hepatobiliary 1� Manganese Chloride

Gastrointestinal I Positive Contrast Agents: Paramagnetic Agents/Short

Short Answer Questions

8. David D Stark, William G Bradley, Jr-MRI Vol. 1, 3rd edition, Mosby

It is the radiographic examination of urinary tract including renal

3. Severe history of anaphylaxis previously carries 30% risk of

in their administration by parents is erratic. Suppositories are

• Dose 1-2 ml/kg.

Standard Films Taken

balloon is positioned on anterior superior iliac spine where ureters

Compression contraindicated in:

Special films in IVU

3. Prone film is used for

After intravascular administration, first it diffuses into the ex