BILIARY SYSTEM 3.
The Emptying Mechanism
CHOLECYSTOGRAPHY
CM
- Biloptin (Sodium Ipodate)
- Telepaque (Iopanoic Acid)
Contraindication
- Patients who are allergic to iodine
dye
- Patient in early pregnancy
- If the serum bilirubin level is greater
than 1.8mg/dl
BILIARY CALCULI
- Orally
- Intravenously
- By retrograde cannulation of the
papilla of water (?)
- Percutaneously into the hepatic
ducts
- By direct inject at operation
- Through a drainage tube after
operation
Functions of GB
1. The reservoir function
2. The Concentration function
■ Water and salts are absorbed
in the gallbladder whereas
the bile pigments are not and
as a result, bilirubin is
concentrated about 20 times,
cholesterol, bile salts and
calcium about 5-10 times.
■ In disease of the gallbladder,
this concentration function is
readily impaired
■ It is claimed by some that
there is reciprocal innervation
of the gallbladder and
relaxation of the sphincter.
■ There is also a hormonal
influence as follows: when
practically any acid or any
food substance particularly
fats and fatty acids comes
into contact with the
duodenal mucosa,
cholecystokinin is formed,
which is absorbed into the
bloodstream and causes the
gallbladder to empty
4. The Secretory Function
■ The gallbladder apparently
secretes constituents of the
bile, such as cholesterol
mucin
Methods of Study Employed in GB
● Oral Method
In this case the contrast medium
is ingested and it is absorbed
through the intestinal mucosa by the
portal blood stream, and enters
through the portal vein. From the
hepatic cells, the contrast substance
is excreted with the biled and
conveyed to the gallbladder, which
after concentrating and storing
sufficient amount of the specified
bile becomes radiopaque, it takes
approx 20 - 12 hours for the contrast
medium to reach the gallbladder.
The contrast medium is telepaque,
biloptin, cholebrine and cistobil
tablets
 ● Intravenous Method
In this case the contrast medium
Biligrafin forte or plain biligrafin is injected
into the vein and the opaque passes
through the blood circulation and enters the
liver through the hepatic artery. From the
hepatic cells the contrast substance is
excreted with the bile and conveyed to the
gallbladder, which after concentrating and
storing sufficient amounts of the specified
bile becomes radiopaque. It takes the
contrast medium to reach the gallbladder
around 10 minutes after injection
Indication in doing Cholecystography
1. To determine the function of the liver,
its ability to remove the contrast
medium from the bloodstream and
excrete it with the bile
2. To determine the patency of the
biliary ducts
3. To evaluate the concentrating and
emptying power of the gallbladder
4. To detect such conditions as biliary
calculi (stones and papillomas-small
tumors
PREPARATION OF PATIENT
POSITIONING
● Reason why general survey film first
of the abdomen preceding
1. AP or PA proj - Localizing film
preparation for a cholecystography
examination is being taken first.
1. First if the intestinal tract is
found to be clean, and if the
contrast medium is to be
administered orally, the
examination can be
shortened by one day.
2. The large film demonstrates
the location of the liver and
thus the possibility of failure
to detect transposition of the
organ
3. It frequently terminates the
examination through the
demonstration of a
gallbladder filled with
radiopaque stones.
● Fatty meals for lunch are eggs
butter, cream and milk in order to
empty the gallbladder and thus to
have it ready to receive the specified
bile.
● An evening meal that is free of fats
to prevent the possibility of
continued emptying of the
gallbladder during the time the liver
is excreting the specified bile.
● Oral media are usually administered
about 3 hours after the light evening
meal, with a little amount of water as
desired. One tablet for every 5
minutes interval or 2 tablets for
double dose.
● NPO at 12 midnights for better
intensification of the contrast media
● Breakfast is usually withheld
● Patient is told to report to the x-ray
department on time.
● Place the patient in the supine
position of comfort • Adjust the body
and center the right side to the
midline of the table
● Adjust 10x12 film places lengthwise
so that its lower border is approx. 1
inch below the iliac crest
● CR is directed perpendicular to the
mid point of the film Palpate the last
rib as the RP
 ● Exposure is taken at the end of full
exhalation
2. RAO
● Ask the patient to assume supine
position
● Oblique the body to separate
superimposition between the
gallbladder and the vertebra
● Body obliquity: for hypersthenic
patient - 15-25 degrees
● Asthenic patient - 25-45 degrees
● RP: gallbladder previously located
from the localization film
● Central ray Perpendicular
● Take the exposure at the end of the
exhalation
3. LPO
● Patient assumes in PA position
● Oblique the body in order to
separate the gallbladder from the
column RP
● CR is perpendicular to the film
4. Upright Projection: PA
● Patient is placed in the PA standing
position
● Physiologic maneuver have the
patient raised both upper extremities
with the hands holding the upper
border of the VCH.
● RP-gallbladder that is 2 to 4 inches
lower than in the recumbent
● Use 10x12 films placed lengthwise
and center it to the RP
● CR is directed horizontally passing
through the RP.
● Exposure is taken at the end of
exhalation
5. RLAT decubitus
● Have the patient assumes the right
lateral position of comfort that is
lying on his right side
● Adjust the cassette 10x12 placed
vertically on either the anterior or
posterior aspect of the body and
immobilize it with sandbags
● Elevate the body in such way as to
center the gallbladder to the center
of the cassette. Reference point -
gallbladder
● CR is directed horizontally passing
through the RP and the midpoint of
the film
● Exposure is taken at the end of
exhalation
6. RLAT recumbent
● is in the same position as the Rlat
decub
● Center a plane that passes midway
between the mid-axillary and the
anterior aspect of the abdomen
along the gallbladder to the midline
of the film
● CR is directed vertically to the mid
point of the film • Respiration is
suspended for the exposure
● Use 10x12 film placed lengthwise
centered to the direction of the CR.
MODIFICATION
A. TRENDELENBURG MANEUVER
● Place the patient in the supine or
oblique as required •Center the right
side of the body to the midline of the
table
 ● Tilt the table in such way that the
head is lower than the feet approx.
15-20°
● RP- gallbladder
● Use 10x12 films placed length wise
and centered the film; the gas is the
reference point.
● CR is directed to the midpoint of the
film vertically
● Exposure is taken at the end of
exhalation
B. FLEISCHNER'S MODIFICATION
● This is a reverse Lindblom position
that the patient stands in the PA
position t feet away From the VCH
● Dorsiflex the body with the bands
grasping the upper border of the
VCH and the abdomen against it.
● RP-T4
● Use 14x17 film placed lengthwise
and centered to the reference point.
● CR is directed to the midpoint of the
film vertically.
● Exposure is taken at the end
exhalation
POST MOTOR MEAL
This consists of giving the patient
fatty foods to eat such as: 2 eggs, 1
glassful of milk and toasted bread
with butter. The purpose of the fatty
meal is to evaluate the concentrating
and emptying power of the
gallbladder. This allows the sphincter
of oddi to relax there by allowing the
gallbladder to empty its contents into
the small intestine.
PROJECTION:AP or PA recumbent
upright
● Patient maybe placed in the PA
position.
● Center the Right side to the midline
of the table.
● RP- gallbladder
● Use 8x10 film placed lengthwise and
centered to the RP CR is directed
vertically to the mid point of the film
● Exposure at the end of exhalation.
INTRAVENOUS CHOLANGIOGRAPHY
(IVC)
Contraindications
● Patients with an allergy to lodine
dye. Patients with a bilirubin level
greater than 3.5 mg/dl
Indication
● To demonstrate the biliary ducts
of cholecystectomized subject.
● To investigate the biliary ducts
and gallbladder of non subject.
● In cases of non-visualization of
the gallbladder by the oral
method In cases where due to or
diarrhea, the cannot retain the
orally administered long enough
for its absorption.
Preliminary Preparation
● The preparation of the patient in
this examination is the same as
that in the oral method
Contrast Medium
● Biligrafin (meglumine iodipamide)
or logycamide) Biliscopin (iotroxic
acid) Biligram (Meglumine
● One hundred (100) ml bottles for
infusion are obtainable.
Alternatively, ampoules of
contrast medium are used, mixed
with suitable diluents, the
quantities being from 10 ml to 1
ml/kg body weight and mixed with
250-ml normal saline.
Things to be prepared for the
injection
● Basic trolley containing sterilized
5 to 15 cc syringes and needles.
● A sterilized 30-50 cc syringe and
disposable needle gauge 20 or
21
● Cotton balls with alcohol
● Tourniquet
● Ampoules of contrast medium
and infusion bottle of saline
Scout films, Supine position
● Place the patient in the supine
position of comfort. Center the
right side to the midline of the
body.
● Adjust a 10x12 film placed
lengthwise so that its border is
approx. One inch below the iliac
crest
● CR is directed vertically to the
midpoint of the film
● Exposure is taken at the end of
exhalation
Purpose
● To determine if the patient well
prepared for the examination
● To detect any incidental findings
● To check technical factor
Injection Phase
A. SENSITIVITY TEST - 5 cc of the
C.M. Is injected intravenously by the
attending physician or the radiologist.
Then the patient will observe untoward
reactions, such as nausea and vomiting,
and cold.
B. DOSE - (25cc) this is injected 15-30
minutes after the test dose, if no
reaction occurs.
IMMEDIATE OR OPERATIVE
CHOLANGIOGRAM BILIARY
SURGERY
Indications
● This is used in the investigation
of the patency of the bile ducts
and the status of the sphincter of
of oddi
● To reveal the presence of calculi
that cannot be detected by
palpation
● To demonstrate conditions such
as tumor, stricture or dilation of
the passages.
Things to be prepared for the OR.
● The necessary number of films
and cassettes, use 10x12
● Hangers and lead apron
Procedures
1. Before entering the operating
room, change your shoes with
slippers (rubber) er) and wear OR
gown, cap and mask.
2. Following the removal of the
gallbladder the surgeon inserts
the T-tube into the common duct.
3. Before the C.M. is to be injected
(Urovison or Hypaque) position
the tube and the film (use
stationary grid) and set the
factors.
4. First injection-10cc. Take 2
exposures. Then process the
films immediately bring the
processed films and show it to
the surgeon for confirmation
5. If satisfied, the end of the
examination. If not, another 10cc
of the C.M. is injected through the
in lying tube then another 2
exposures, till the examination is
finished.
DELAYED, POST OPERATIVE OR
T-TUBE CHOLANGIOGRAPHY
Procedure
● The drainage tube is clipped off
by means of artery forceps. The .
tube is wiped with an antiseptic
impregnated swab and the
injection of contrast medium is
made directly into the tube care
must be taken to ensure that no
bubbles are injected (as these
may stimulate calculi) and that
contrast medium does not leak
out on to the skin the injection is
watched on the television monitor
and continued until the entire
biliary tree has been satisfactorily
demonstrated series radiographs
are taken as required. When all
necessary radiographs have
been taken, the clip is from the
drainage tube.
Projections
A. SCOUT FILM
● Patient is in the supine position of
comfort
● Adjust the body and center the in
lying tube to the midline of the
table or RP-in lying tube cassette
● Use 10x12 film placed lengthwise
and centered to the RP
● CR is directed vertically to the
midpoint of the film
● Suspend respiration for
exposure
Purpose
● To be able to determine the exact
location of the T-tube
● To demonstrate any remaining
stone or calculi
● To check technical factor
B. INJECTION PHASE
● Before the C.M. is to be injected,
aspirate the bile contents of the
ducts thru the in lying tube for
better visualization of the ducts.
Then the attending physician or
the radiologist injects 10 cc. of
the via the tube and right after the
injection takes 2 exposures
simultaneously.
Positioning
AP proj
● Patient is placed in supine
position
● RP in lying tube, which is
centered to the midline of the
table
● CR is directed vertically to the
film
● Use10x12 films placed
lengthwise
RAO
● From the supine position oblique
the body approx. 45 degrees.
● The left side is being elevated
● RP in lying tube.
● CR is directed vertically to the
film
● Ask the patient to suspend
respiration for exposure. If the
examination is not satisfactory,
the procedure is to be repeated.
PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY (PTC)
CONTRAINDICATION
● Who have a tendency to bleeding
or prolong clotting times Patient
with the biliary tract infection
● Who have a history of sensitivity
to contrast media
PATIENT PREPARATION
● The prothrombin time is tested
and must be corrected if found to
be abnormal
● Prophylactic antibiotic cover is
given
● The patient must have nothing to
eat or drink for five hours
Premedication: Omnopon and
Scopolamine, or Diazepam Contrast
Media: Conray 280 or its equivalent, 20
to 60 ml
PRELIMINARY FILM
● The patient lies supine on the
fluoroscopy table, with his right
band behind his hand. An
anteroposterior view of the right
side of the abdomen is taken,
using 10x12 cassettes with its
lower border at the level of the
right iliac crest. Center the
midclavicular 1-2 inches above
the level of the lower costal
margin.
TECHNIQUE
● The patient lies supine on the
fluoroscopy table, with his right
behind his head. Blood pressure,
puise, temperature and
respiration are recorded. Under
fluoroscopic control, the puncture
site is chosen and marked on the
patient's skin. The examination is
performed under strict aseptic
conditions. is prepared with a
suitable antiseptic and draped
with sterile towels. determined
puncture site. The patient is
asked stop to The patient's Local
anaesthetic is injected at the
breathing in mid-respiration and
the Chiba needle is Inserted into
the liver. The stylet is removed
and the needle is connector, to a
syringe containing contrast
medium. Under withdrawn while
contrast medium is gently
injected, until a is connected via a
flexible polythene fluoroscopic
control, bile duct the needle is
located, Contrast Into the bile
ducts radiographs are taken
using the under-couch tube. If
aspirated from the ducts the
contrast medium slowly medium
is injected If the bile ducts are
dilated, bile is is injected. If a bile
duct is not entered during the first
withdrawal of the needle, it can
be re-inserted up to 10 times
before the examination is
abandoned. The quantity of
contrast medium injected will vary
with the calibre of the ducts. If the
ducts are dilated, bile and
contrast medium are aspirated
from the ducts before the needle
is removed. After the needle has
been removed, further
radiographs are taken with the
patient in the supine, oblique,
lateral, erect and Trendelenburg
positions.
● If the examination has revealed a
dilated or obstructed room for
laparotomy to be performed.
biliary tree, the patient will I go
straight to the operating If bile
was not aspirated from the liver,
and therefore no injection was
made, the implication may be that
the jaundice is not of obstructive
origin and the patient is usually
returned
● In suspected extra hepatic biliary
obstruction, delayed films-taken 2
hours after the Injection are of
value.
AFTER CARE OF THE PATIENT
1. The patient must be under
constant observation for 48 hours
for any sign of hemorrhages,
leakage of bile or peritonitis.
2. Temperature, pulse and blood
pressure are recorded every 10
minutes for 1 hour, then 2hourly
for 4 hours, then 4 hourly for 24
hours.
 ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
(ERCP)
INDICATIONS
1. In the investigation of recurrent
jaundice or other biliary tract
problems.
2. In the investigation of pancreatic
disease.
3. Patients with ascites or tendency
to bleeding when PTC is
contraindicated.
4. Patients who have obstructive
jaundice. 5. If the serum bilirubin
is greater than 3mg%.
CONTRAINDICATION
● Patient with a positive serological
test for Australia antigen (surface
antigen of the hepatitis B virus
(HBV) because it is not possible
to sterile the instrument.
● With a history of sensitivity to CM
or other drugs
● With a pyloric stenosis, it would
be impossible to pass the
endoscope.
● With acute pancreatitis
● With and anticholinergic drugs is
inadvisable
● Patients with acute cholangitis
Preparations
1. NPO for at least five hours
2. Recent radiographs of the
abdomen
PREMEDICATION
● 30 minutes before the
examination, the patient is given
an Amethocaine lozenge (30mg)
to suck, and 10 minutes before
he is given 20 mg
hyocine-N-butyl bromide
(buscopan) intramuscularly, to
produce duodenal anatomy.
CONTRAST MEDIA
1. Pancreatic duct. Meglumine
diatrizoate (angiografin) or CM
that have high iodine content.
2. Biliary duct. Meglumine
jothalamate (conray 280) not be
too dense as otherwise small
opacities, such as caused by
papilloma or radiolucent biliary
calculi, may be obscured.
Technique
● The patient lies on his left side,
on the fluoroscopy table.
Diazepam (Valium) is given
intravenously at the rate of 5 mg
per minute until dysarthria or
ptosis occurs. The endoscope is
then introduced into the
esophagus and passed through
the stomach and into the
duodenal bulb. Duodenal juice
instilled to suppress frothing. is
aspirated and a silicone
preparation is
 ● The endoscope is positioned in
the second part of the duodenum
and the papilla of Vater is located.
A polythene catheter is filled with
a contrast medium and is
inserted down the central channel
of the endoscope. Care must be
taken to ensure that there are no
air bubbles in the catheter or in
the syringe, as these can
stimulate calculi. A stage, bile is
usually aspirated as further
safeguard against introducing air
into the duct system. Just before
the papilla is cannulated, the
patient is gently turned into the
prone position. To demonstrate
the pancreatic duct, 2-4 ml of CM
is injected under fluoroscopic
control. As soon as the larger
radicles of the pancreas have
been filled, the injection is
stopped. As the finer radicles
without with our further injection.
Under the couch radiographs are
taken
1. Patient in prone position
2. Lateral position
3. Both posterior and oblique
positions.
Over the couch radiographs are
taken
1. Patient in prone position
2. Both oblique
3. Lateral position
AFTER CARE OF THE PATIENT
1. NPO for about an hour after the
examination
2. Serum amylase level should be
estimated on the following day at
intervals for about 3 weeks
INTRAVENOUS PYELOGRAPHY(IVP)
Indications
● Abdominal or pelvic mass
● Renal or ureteral calculi
● Kidney trauma
● Flank pain
● Hematuria
● Hypertensions Renal failure
● UTI
Contraindications
● Hypersensitivity to iodinated
contrast media Anuria or absence
of urine excretion
● Multiple myeloma
● Diabetes mellitus
● Severe hepatic or renal disease
● Congestive heart failure
Two methods of study employed
● Functional Method or Descending
or Excretory Pyelography- CM is
injected intravenously.
● Instrumental Method or
Retrograde or Ascending
Pyelography- CM is injected
 directly into the renal pelvis or
other parts of the canals by
means cystoscopy.
PREPARATION OF THE PATIENT
1. Take 2 Dulcolax tablets after
lunch prior to examination
2. Take light evening meals.
3. Provide oral castor oil 30 cc.or
perform cleansing enema before
bedtime until the return flow is
clear.
4. NPO at 12 midnight to ensure
total emptying of stomach
5. Insert Dulcolax suppository
rectally at 4:00 A.M. to cleanse
the distal end of the colon, or
cleansing enema again
6. No breakfast. no smoking.
Procedure
● Take plain KUB before injecting
the contrast medium.
Purposes:
1. To demonstrate the contour of the
kidneys and their location in the
supine position.
2. To reveal the presence of any
renal or calculi
3. To check the technical factor
4. To check the patients is well
prepared for the examination.
Positioning of plain KUB
AP
● Patient is placed in the supine
position of comfort
● Adjust the body and center the
MSP to the midline of the table.
otherwise umbilicus
● RP midway between the ASIC
otherwise umbilicus
● Adjust the film placed
lengthwise
● CR is directed vertically to the
center of the film.
● Ask the patient to suspend
respiration for exposure.
• STRUCTURE SHOWN:
● A faint of the kidneys. The psoas
should be clearly visualized.
Technique and time interval exposure
1. Nephrogram or Nephrotogram - taken
immediately after completion of injection
to capture the early stages of the
contrast medium entering the collecting
system.
2. Five minutes - (for kidneys) after the
completion of the injection.
● Patient in supine position of
comfort.
● MSP centered to the midline of
the table.
● RP midway between the ASIC
otherwise umbilicus
● Center the 10x12 film to the RP
 ● Central ray is directed to the RP
● Respiration is suspended for
exposure.
3. Fifteen minutes - views for the
kidneys and ureters with the
compression
● Patient in supine position of
comfort.
● MSP centered to the midline of
the table.
● RP midpoint between the ASIC
● Center the 10x12 film to the RP
● Central ray is vertically directed
to the RP
● Respiration is suspended for
exposure
4. Thirty minutes - views for the kidneys,
ureters and urinary bladder. Positioning
is the same as the plain KUB exposure
5. Additional time interval - exposure
such as 5 minutes and 1 hour maybe
taken upon the discretion of the
radiologist.
Right and left anterior Oblique-
projection may also taken.
6. Post Voiding or Post Micturation Film
view of the gallbladder is taken - This is
to be done after the radiologist has
confirmed the time Interval.
Exposure films. This is being achieved
by simply telling the patient to urinate as
much as he can.
Purposes:
● To demonstrate the mobility of
the organ, nephrotosis (positional
change of kidneys).
● To evaluate the amount of urine
left in the urinary bladder.
● To detect the presence of turnor.
● In case of male patient to detect
any enlargement of the prostate
gland pushing up on the floor of
the gallbladder.
Positioning
● Anteroposterior - Upright or
Recumbent - Preferably Upright -
to detect Ptotic kidneys
● Place the patient in the AP
position
● Ad just the body and center the
MSP to the midline of the
cassette
● RP point of umbilicus
● Adjust the 14x17 cassette
lengthwise and center it to the
ASIC
● CR horizontally directed to the
umbilicus
● Suspend respiration for exposure
HYPERTENSIVE INTRAVENOUS
PYELOGRAPHY
PREPARATION OF THE PATIENT
1. Take 2 Dulcolax tablets after
lunch prior to examination
2. Take light evening meals.
 3. Provide oral castor oil 30 cc.or
perform cleansing enema before
bedtime until the return flow is
clear.
4. NPO at 12 midnight to ensure
total emptying of stomach
5. Insert Dulcolax suppository
rectally at 4:00 A.M. to cleanse
the distal end of the colon, or
cleansing enema again
6. No breakfast. no smoking.
● Scout film before injection of
contrast medium intravenously
● Injection phase
● Sensitivity test - 1 cc of iodinated
CM Is injected intravenously with
15-30 minutes observation for
any reactions.
Full dose
Time Interval Exposures
1. Takes 1,2,3 minutes film after the
completion of the injection using 10x12
films for adults, centered to the region of
the kidneys.
2. Five minutes - take exposure for the
entire urinary systems centered to the
level of the ASIC with the in AP position.
CR Is directed vertically to the RP.
3. Fifteen minutes - applied ureteric
compression or take PA projection
4. Thirty minutes - AP projection for the
entire urinary systems.
5. Post vold or Micturation film after
emptying the bladder with the urine
and contrast media.
6. Upright position or AP projection.
DRIP INFUSION or GRAVITY METHOD
IVP
PREPARATION OF THE PATIENT
1. Take 2 Dulcolax tablets after lunch
prior to examination
2. Take light evening meals
3. Provide oral castor oil 30 cc.or
perform cleansing enema before
bedtime until the return flow is clear.
4. NPO at 12 midnight to ensure total
emptying of stomach
5. Dulcolax suppository rectally at 4:00
A.M. to cleanse the distal end of the
colon, or enema again
6. No breakfast. no smoking.
● Scout film AP projection.
● Sensitivity test 1cc CM
Full dose
● This is administered 30 minutes
after sensitivity test. In these
case, 2 ampoules of CM
(Telebrix, Anglografin, Conray,
 Hypaque, etc.) It is being
incorporated with a 200 cc or 5%
dextrose water. Prepare IV set
and IV stand, and then adjust the
height of the dextrose bottle in
such way that the fluid will flow as
fast as possible by opening it full
blast the tubing of the dextrose.
After the amount has been
consumed proceed in taking the
time interval exposure.
● Time Interval Exposures
- 5 minutes, 15 minutes, 30
minutes, 45 minutes, 1
hour, 2 hours or even up to
24 hours, depending on
the opacification of the
systems.
CYSTOGRAPHY
Preliminary procedure of the patient:
● The patient is instructed to void
before being placed to the x- ray
table.
Technique:
● Scout film- to check whether the
lower bowels are free from gases
and fecal material.
● If fecal matters are present the
patient is given cleansing enema.
● For gas, urologist inserts a
catheter to dislodge the air while
the abdomen is being massage.
Positioning
● The patient is requested to empty
his bladder.
● Position the patient in supine
position with the MSP centered to
the midline of the table.
● RP midway between the ASIC
● CR is directed vertically to the RP
● Use 10x12 film Placed lengthwise
and centered to the direction of
the CR
3 Proj taken after after the filling of
the urinary bladder:
1. Anteroposterior projection - Position
as doing the scout film
2. Right and left oblique Projection
● From the supine position the
body approx. 60 degrees.
● RP is 1 inch distal to the elevated
ASIS
● CR is vertically to the RP
● Use 10x12 film placed
crosswise.
3. Lateral projection
● Assume left or right lateral
position
● RP upper ASIS
● CR is directed vertically
Chassard-Lapine Position
4. This is the same in doing barium
enema examination.
MICTURATING CYSTOGRAPHY
● This examination is used mainly
to demonstrate vesico-ureteric
reflux, especially in children. It is
also used in the investigation of
stress incontinence and of
outflow tract obstruction. It is
performed under fluoroscopic
control, preferably with image
intensification and television.
Contraindication
● The examination is contra
indicated if there is acute infect of
the bladder and urethra.
PREPARATION OF THE PATIENT
● The patient micturates
immediately before the
examination
CM
● Dilute water soluble contrast
medium is used, such as
Hypaque 10-15% on its
equivalent
Technique
● The patient lies supine in the
fluoroscopy table. Under strict
aseptic conditions, a catheter is
introduced into the bladder.
Reducing risk of catheterization
A. The catheter is lubricated with a
cream containing Hibitine
B. Rigid asepsis is observed
C. time during which the catheter is in
position is kept to the minimum possible.
● Any residual urine is drained,
measure and sent to the
laboratory for examination. The
contrast medium is run into the
bladder using a drip technique. A
relatively slow infusion is
necessary, usually with the bottle
about 90cc. (36 in) above the
table and with tap in the full "ON"
position. The infusion is
controlled by intermittent
fluoroscopy of the abdomen. If
reflux is seen, appropriate
radiographs are taken; usually on
10x12 cassettes, using the couch
tube. When the bladder is full the
catheter is withdrawn. The table
is then tilted to vertical position
and the patient stands firmly on
the step.
● Under couch films are taken
during micturition. Some form of
receiver is required during the
micturition series.
The patient in emptying the bladder
at this time may experience difficulty.
This can be overcome by:
1. By affording the patient as
much privacy as possible.
2. Ensuring that the bladder is
filled to its maximum capacity.
3. Reducing to a minimum the
time interval between removing
the catheter and being ready to
examine micturition.
Positioning
● For small children, the
examination is best demonstrated
in the supine position and
oblique. It is useful to continue
the infusion until the micturition is
initiated, before the catheter is
removed. It is sometimes
advocated that the contrast
media be introduced into the
bladder through a supra-pubic
needle.
● When the examination on the
radiographs taken during
micturition, so that any reflux
occurring is demonstrated. Stress
Incontinence: Lateral projections
are taken in erect position of the
bladder.
1. At rest
2. Straining with the catheter
in situ
3. With the patient
micturating
DOUBLE CONTRAST
CYSTOGRAPHY
● For negative contrast
cystography, simply catheterize
the bladder, drain all the urine
from the bladder and through a
three stop cock, instil air or gas
into the bladder until it becomes
slightly turgid. This examination is
usually carried out to localize and
grade a bladder tumor before
radiotherapy. It is particular value
when the neoplasm lies in
diverticulum.
Patient preparation
1. Patient should have not more than
one pint of fluid during the preceding 24
hours and nothing to drink for 8 hours.
2. Patient micturates immediately before
examination.
CM
• Sterile barium sulphate, such as
steripaque 120 ml.
Technique
• The patient lies supine on a foam
mattress on the x-ray table. Under strict
aseptic condition, the bladder is
catheterized and emptied and the
steripaque is run under fluoroscopic
control, preferably with image
intensification and television. The
catheter is left in position and the
over-couch views will be taken.
POSITION
AP
● The patient lies supine. A 10x12
cassette is used with its upper
border at the level of the ASIC.
Center 1 inch below the anterior
iliac spines, with the tube angled
15 degrees caudad.
PAO
● From the supine position the
patient is rotated 35 degrees to
each side in turn. Foam pads
support the raised side of the
pelvis. A 10x12 cassette is
placed transversely, with its upper
border at the level of the iliac
crests A is taken in each position.
Center 2.5 cm. below the anterior
superior iliac supine of the raised
side. After the radiographs have
been inspected, most of the
contrast medium is drained off,
leaving only about 20 ml. Under
fluoroscopic control the bladder is
then distended with 60-to 80 ml.
Carbon dioxide. The barium
remaining in the bladder will coat
any tumor or ulcer but will not
adhere to normal mucosa. A
series of projections is taken
using a horizontal beams as
follows:
1. AP The patient lies on his side, facing
the tube with the knees extended. A grid
cassette is supported vertically behind
the pelvis with Its cauda border at the
level of the symphysis pubis.
2. Supine lat-The patient lies supine,
with the hands on the chest. The
cassette is supported vertically at the
side of the pelvis.
3. Prone lat - The patient lies prone, with
the hands under his chin. The cassette
is supported vertically at the side of the
pelvis.
4. AP - The position of the patient is
reversed so that he can lie on the
opposite side from the first antero
posterior projection. The cassette is
supported vertically behind the pelvis.
5. Erect AP-From the horizontal position
the table is tilted until the patient is erect
and standing comfortably on the
footrest. The bucky is used for this
projection. The lower border of the
cassette

URETHROGRAPHY
Preparation of the patient
● The patient should micturate
immediately before the
examination.
Contrast medium
● Usually 30 to 40 ml. of viscous
contrast medium such as
umbradil viscous is used. But in
cases of suspected urethral
rupture, a water soluble contrast
medium such as Urografin 60%
or its equivalent may be
preferred.
Equipment
● One method of introducing the
contrast medium is by means
Knutson clamp, but some
authorities recommend the use of
a Foley catheter. The
examination is performed using
either fluoroscopic or
conventional methods.
Preliminary film
● The patient lies supine on the
x-ray table and an antero
posterior projection of the bladder
base and the urethra is taken. A
10x12 cassette is with its upper
border at the level of the anterior
superior iliac spines. Center in
the midline 2.5 cm. Below the
anterior superior iliac spines with
the tube angled 15 degrees
caudad.
Technique
● The catheter or cannula is
inserted into the urethra under
strict aseptic conditions. If a
cannula is used, it is firmly fixed
in position by adjustment of the
arms of the clamp. If a catheter is
used, the balloon is inflated.
● The patient is rotated into the
right anterior oblique projection
with the right hip a knee flexed
and with the raised side of the
pelvis supported on foam pads.
The contrast is injected and serial
films are taken as acquired. A
typical series of films would be
antero-posterior and oblique of
the posterior urethra and bladder
neck. The injection is continued
until the base of the bladder is
outlined by the contrast medium.
At the end of injection, an over
couch projection is taken, as for
the preliminary film. The cannula
or catheter is then removed and
the patient allowed emptying the
bladder.
Modifications
1.The bladder may be distended with 10
to 25%. Hypaque before the viscous is
and projections during micturition are
then both obtained after the standard
projection taken.
2. An entirely over-ouch technique can
be used after infusion or approx. 200 ml.
Of contrast medium. Three radiographs
are taken with the patient lying in the
right posterior oblique position.
a. At the end of the infusion when
the patient urgently requires
voiding the bladder.
b. During micturition
c. After abruptly arresting
micturition.
3. Double contrast technique is
sometimes used, with air as the
negative contrast in the investigation of
urethral diverticula.
The nasopharynx lies posteriorly above
the soft and hard palates.
The oropharynx Is the portion
extending from the soft palate to the
level of the hyoid bone.
The laryngeal pharynx lies posterior to
the larynx, its anterior wall being formed
by the posterior surface of the larynx.
The laryngeal pharynx extends inferiorly
and is continuous with the esophagus.
TRACHEA
● The trachea is a fibrous,
muscular tube with 16 to 20
C-shaped cartilaginous rings
embedded in its walls for greater
rigidity
● It measures approximately 1/2
inch (1.3 cm) in diameter and 4
1/2 inches (11 cm) in length, and
its posterior aspect The last
tracheal cartilage is tis flat
elongated and has a hook like
process, the carina, which
extends posteriorly on its inferior
surface.
● At the carina, the trachea divides,
or bifurcates, into two lesser
tubes-the primary bronchi. One of
these bronchi enters the right
lung, and the other enters the left
lung
● The primary bronchi slant
obliquely Inferiorly to their
entrance into the lungs, where
they branch out to form the right
and left bronchial branches.
● The right primary bronchus is
shorter, wider, and more vertical
than the left primary bronchus.
LOBES OF THE LUNG
● three to the right lung
● two to the left lung.
The secondary bronchi divide further
and decrease in caliber. The bronchi
continue dividing into tertiary bronchi,
then Into smaller bronchioles, and end
in minute tubes called the terminal
bronchioles. The extensive branching of
the trachea is commonly referred to as
the bronchial tree because it resembles
a tree trunk
Alveoli
● The terminal bronchioles
communicate with alveolar ducts.
● Each duct ends in several
alveolar sacs. The walls of the
alveolar sacs are lined with
alveoli.
● Each lung contains millions of
alveoli. and carbon dioxide is
exchanged by diffusion within the
walls of alveoli.
Lungs
● The lungs are the organs of
respiration.
● They provide the mechanism for
introducing oxygen into the blood
and removing carbon dioxide
from the blood.
● The lungs are composed of a
light, spongy, highly elastic
substance, the parenchyma, and
they are covered by a layer of
serous membrane.
● Each lung presents a rounded
apex that reaches above the level
of the clavicles Into the root of the
neck and a broad base that,
resting on the obliquely placed
diaphragm, reaches lower in back
and at the sides than in front.
● The right lung is about 1 Inch (2.5
cm) shorter than the left lung
because of the large space
occupied by the liver, and It is
broader than the left lung
because of the position of the
heart.
● The lateral surface of each lung
conforms with the shape of the
chest wall. The inferior surface of
the lung is concave, fitting over
the diaphragm, and the lateral
margins are thin.
● During respiration, the lungs
move inferiorly for Inspiration and
superiorly for expiration.
● During inspiration, the lateral
margins descend into the deep
recesses of the parietal pleura; in
radiology, this recess is called the
costophrenic angle.
● The mediastinal surface is
concave with a depression called
the hilum that accommodates the
bronchi, pulmonary blood
vessels, lymph vessels, and
nerves.
● The inferior mediastinal surface
of the left lung contains a
concavity called the cardiac
notch. This notch conforms to the
shape of the heart.
● Each lung is enclosed in a
double-walled, serous membrane
sac called the pleura.
● The Inner layer of the pleural sac,
called the visceral pleura, closely
adheres to the surface of the
lung, extends into the Interlobar
fissures, and is contiguous with
the outer layer at the hilum.
● The outer layer, called the
parietal pleura, lines the wall of
the thoracic cavity occupied by
the lung and closely adheres to
the upper surface of the
diaphragm.
● The two layers are moistened by
serous fluid so that move easily
on each other. The serous fluid
prevents friction between the
lungs and chest walls during
respiration.
● The space between the two
pleural walls is called the pleural
cavity.
● Each lung is divided into lobes by
deep fissures. The fissures lie in
an oblique plane inferiorly and
anteriorly from above, so that the
lobes overlap each other in the
AP direction.
● The oblique fissures divide the
lungs into superior and inferior
lobes.
● The superior lobes lle above and
are anterior to the inferior lobes. -
● The right superior lobe is divided
further by a horizontal fissure,
creating a right middle lobe.
● The left lung has no horizontal
fissure and no middle lobe.
● The portion of the left lobe that
corresponds in position to the
right middle lobe is called the
lingula.
● The lingula is a tongue-shaped
process on the anteromedial
border of the left lung. It fills the
space between the chest wall
and the heart.
● Each of the five lobes divides into
bronchopulmonary segments and
subdivides into smaller units
called primary lobules.
● The primary lobule is the
anatomic unit of lung structure
and consists of a terminal
bronchiole with its expanded
alveolar duct and alveolar sac
BRONCHOGRAPHY
Bronchography is a contrast study for
demonstration of the
broncho-pulmonary tree/segments
Initially, it was the definitive diagnosis for
bronchiectasis, however the advent of
CT-high resolution CT (HRCT) almost
push bronchography out of use
 ● Dribbling contrast over the back
Indications of the tongue-not reliable and
already abandoned

● Bronchiectasis Patient Prep

● Bronchial obstruction-site &
extent
● Other possible indications-when
other Imaging modalities are
negative includes:
○ Recurrent
○ Haemoptysis
○ Broncho-pleural fistula
○ Congenital
lesions-agenesis &
sequestration
● Chest physiotherapy postural
drainage and percussion)
● NPO for 6 hrs prior to procedure
● Pre-medications-0.6mg Atropine
& 10mg Morphine or omnopron
● Asthmatics should have steroid
prophylaxis & salbutamol
pre-procedure
Preliminary Films

Contraindications ● AP and Lat

I. Acute respiratory infection Technique

II. Poor respiratory reserve
III. Others-massive hemoptysis, ● Trans-nasal method
active PTB & hx of allergy ● Cricothyroid method

Materials Trans-nasal method

● Fluoroscopic unit with overcouch ● If the examination is being

tube performed under local
● Catheter anaesthesia, the patient is given
● Contrast media-LOCM and anaesthetic lozenge to suck.
(lotrolan-300) 2-3ml per lung The nose, throat, nasopharynx
segment; ≤25ml/patient and trachea sprayed with topical
anaesthetic. A catheter is passed
Methods through the nose into the
nasopharynx and into the
● Catheter trachea. The proximal end of the
● Cricothyroid puncture-not for catheter is attached to the cheek
<12yr old by means of adhesive tape.
● Bronchoscope
● Others prefer to pass the catheter
into the trachea through the
mouth, using direct laryngoscopy.
When the examination is
performed under general
anaesthesia, the catheter is
passed down the endotracheal
tube, which is already in situ.
● Contrast Medium is injected
down the catheter, usually in 3 to
4 equal amounts, the first 2 or 3
portion being used to
demonstrate the lower and
middle lobes and the lingula, the
last portion being used to fill the
upper lobe. To fill the middle and
lower lobes, the patient leans
towards the side being examined,
and then bends forwards, then
sideways, then backwards,
contrast medium being injected in
each position. To fill the upper
lobe, the patient lies in the side
being examined, with the head
raised and the feet lowered.
Following injection of the contrast
medium, he is then turned
half-way on the face and then
half way on to the back, and
during these manoeuvres', the
head of the table is lowered
slightly.
● In each position the contrast
medium is injected quite quickly.
The patient is held in position for
about 5 seconds during which he
is to take in deep breath slowly,
so as to draw contrast medium
out to the periphery of the lung.
He is then moved into the next
position. All breathing should be
calm and slow, so as to coughing.
● If both sides are being examined
at one time, the right lung is
usually filled first but some
radiologists prefer to fill the of the
suspected lesion first.
Cricothyroid Method
The lies supine or sits on chair. Local
anaesthetic is injected into the skin over
the cricothyroid area and into the
trachea through the crico-thyroid
membrane. The patient leans toward the
side being examined and is supported
by a nurse. A crico-thyroid needle is
inserted into the trachea and when it is
correctly sited contrast medium is
injected. The needle is then withdrawn
and the patient placed in the positions
previously described for the trans- nasal
method of filling the various parts of the
lung.
Films
● Anteroposterior and lateral views
are taken after the first side has
been filled with CM as for the
preliminary films.
● Antero-posterior and right and left
posterior oblique views are taken,
after the first side has been filled.
● For posterior oblique views
patient is rotated 45 degrees from
the supine position towards each
 side in turn. The upper border of
the cassette should be 1 Inch
above level of the shoulders and
the whole chest must be
included. Each exposure is made
on arrested inspiration.
Satisfactory views of the first side
must be obtained before the
second side is filled.
Aftercare
1. As soon as the examination is
completed, the patient is encouraged to
cough in order to remove as much of the
contrast medium as possible.
2. The patient must have nothing to eat
or drink for at least 3 hours until the
effect of the anaesthetic have worn off.
This is to avoid accidental aspiration of
food or drink
3. Physiotherapy (postural coughing and
percussion) is required to remove
further contrast medium
4. If the examination has been
performed on an outpatient, the patient
must not be allowed to leave the
department before he has completely
recovered from the sedation and local
anaesthetic.
5. Radiography of the chest is often
carried out 24 hours after the
examination, to see how much contrast
medium remains
Selective Bronchography
May be carried out during bronchoscopy
if a fibre optic bronchoscope is being
used. Samples of lung tissue are
obtained by cytology forceps, which are
introduced down one of the channels of
the endoscope. The same channel is
used for Injecting contrast medium
DIONOSIL OILY via a 100cm long
disposable catheter to the part of the
lung being examined. The contrast
medium is injected under fluoroscopic
control. The Anteroposterior and oblique
views of the chest are taken.
Percutaneous Lung Biopsy
● The purpose of this examination
is to obtain specimens of lung
tissue for bacteriological and
histological analysis.
● It is performed under fluoroscopic
control using image
intensification and television if
possible a C arm intensifier is
used.
● The examination is
contra-indicated in patients with
sever generalized lung disease
with pulmonary hypertension on
artificial ventilators.
PATIENT PREP
● Full radiographic examination of
the chest, including tomography
to localize the lesion must have
been carried out within the
 previous 24-48 hours. The patient
must have nothing to eat or drink
for 4-6 hours
PRE MEDICATION
● Diazepam
TECHNIQUE
● Patient lies supine on the
fluoroscopy table and is made as
comfortable as possible.
● Under control, the optimum site
for puncture is located and its
position marked on the patient's
skin.
● The skin is cleansed and local
anaesthetic is infiltrated. The
biopsy needle is inserted through
the lung tissue, the patient is
asked to stop breathing so as to
minimize the risk of air embolism.
● Specimens of lung tissue are
sent to the pathology department
of analysis
● A radiograph of the chest, on
expiration, is taken 30 minutes to
one hour after the end of the
examination, to demonstrate
whether a pneumothorax is
present.
AFTER CARE OF PATIENT
1. The patient must stay in bed for 6
hours and be observed frequently for
signs of pneumothorax
2. Radiograph of the chest may be
required during this time but a
pneumothorax is unlikely to occur later
than 5 hours after the examination. The
patient must remain in the ward, under
observation for 24 hours.
Pre-sacral Pneumography
● It is used to demonstrate
retroperitoneal structures,
particularly the supra-renal
glands.
PATIENT PREPARATION
1. The patient should take a suitable
apparent on each of the preceding two
nights
2. The patient should have nothing to
eat or drink for five hours
3. Local preparation of the injection,
including shaving of the peer- anal area,
should be carried out.
4. The patient should micturate
immediately before the examination.
PREMEDICATION
● Omnopon
CM
● 300-600 ml of carbon dioxide
each side.
APPARATUS
● tilting table with image intensifier

Pre-sacral Pneumography
Preliminary Film
Patient lays supine position using 14x17
film with the lower border at the level of
the illac crest. The diaphragm must be
included on the radiograph. This
radiograph is used to asses bowel
clearance and to establish exposure
factors.
TECHNIQUE
● Patient lies on his left side on the
tilting table
● The peri-anal area is cleansed
with a mild antiseptic and local
anaesthetic is infiltrated between
the anus and the coccyx
● A needle catheter or needle
cannula is then introduced
● When the needle is correctly
positioned, 20 ml of saline are
injected to expand the pre sacral
space and to render it relatively
more vascular
● The needle is then withdrawn so
that the injection of gas can be
given through the catheter or
cannula, thus diminishing the risk
of embolism.
● The catheter is attached to the
patient by adhesive tape and
remains in situ until the
● The injection of carbon dioxide is
given, half the gas being injected
on each side.
● This is actually carried out under
fluoroscopic control by the
radiologist, using image
intensification and television.
● The patient is gently turned into
the position, and the foot of the
couch is lowered about 15
degrees.
● AP and OBLIQUE views are then
taken using the under couch tube
● The patient is then turned into the
AP position and AP view is taken
Cassette is placed transversely,
with its lowered border at the
level of the iliac crests RP renal
areas
● Note: the patient remains in bed
for 24 hours
Upper Abdominal Pneumography
● Is used to demonstrate the
inferior surface of the diaphragm
and thus to evaluate masses in
the upper abdomen or chest
base.
● It is also used to distinguish
between intrinsic and extrinsic
filling defects in the stomach and
between benign and malignant
gastric ulcers.
PATIENT PREP
1. Patient should take suitable aperients
on each of the nights preceding the
examination.
2. Patient must have nothing to eat or
drink for at least four hours.
3. Patient should micturate immediately
before the examination.
PREMEDICATION ● Lower border of cassette is
● Omnopon and Scopolamine placed at the of the ASIS
● CR perpendicular
CM
● 1000 to 1500ml carbon dioxide LATERAL DECUBITUS

PRELIMINARY FILM ● Patient lies on the side not under

examination
● The bowel should be free from ● Grid cassette, supported
fecal shadows and the bladder vertically
must be empty but as this ● CR directed horizontally
preparation is not as critical as in
pelvic pneumography SUPINE LATERAL
●
● Patient lies in supine position on ● Patient lies supine on foam pads
the tilting table with lower border to raise him from the table top
of cassette at the level of the ● Grid cassette, supported
anterior superior iliac spines. vertically at the side of the patient
● CR directed horizontally
TECHNIQUE ● Erect or Supine views may also
be required
The procedure is the as the examination
of the pelvic viscera except that the Mediastinal Pneumography
patient is not tilted head downwards and a. in case of Myasthenia gravis or of
therefore a myelography harness is not primary or tertiary
necessary After instillation of the gas, hyperthyroidism where a
the patient is placed in whatever suspected tumour has not been
position will maneuver the gas into the demonstrated on plain films or by
appropriate region. If the diaphragm is tomography
being examined the table is brought b. in cases or esophageal
slowly into the vertical position so that carcinoma where the examination
the gas will rise under the diaphragm. If can be used to asses the extent
one of the abdomen is being examined, and operability of the tumour
the patient lies on the opposite side for a c. in the demonstration of
few minutes. mediastinal lymph nodes.

POSITIONING This examination is contra-indicated in

patients with impaired respiratory
● PRONE function
● Patient into the prone position
Patient Preparation
1. Recent plain films of the chest
including penetrated views and lateral
tomograms of the anterior mediastinum
are taken, usually the day before the
examination.
2. Patient must have nothing to eat or
drink for five hours
3. Patient is on anti-cholenergic drugs,
these must come to the department with
him and must be given at the set times
even if this during the examination
4. Patients should micturate immediately
before the examination.
PRE MEDICATION
Sodium Amytal but respiratory
depressants such as Morphine or
Pethidine must be avoided.
CM
● Oxygen or Air 350 ml
PRELIMINARY FILM
● A preliminary tomogram is taken
to determine exposure factors
and depth of "cut required.
Patient placed in a lateral position
and a midline tomogram of the
anterior mediastinum is taken.
● Center over the anterior
mediastinum at the level of the
manubrio-sternal angle 2 inch
posterior to the anterior surface of the
sternum.
TECHNIQUE:
● The procedure is explained to the
patient
● Patient lies supine in tomography
table, with the neck extended
● The skin and tissues immediately
behind the manubrium sterni are
infiltrated with local anaesthetic.
● Punctured is made above the
suprasternal notch and the
needle, with stillete, is inserted in
the midline, in line with the
manubrio-sternal joint.
● Gas is then injected, the quantity
usually between 100 to 500 ml.
● When the gas has been injected,
the patient sits up for one or two
minutes, and is then placed in
lateral position and tomograms
are taken in the midline and at
1cm. Intervals up to 4 cm on
either side of the midline
● A multi section cassette is of
advantage
AFTER CARE
1. Pulse, temperature, respiration and
blood pressure are recorded every 15
mins. For 2 hours and then 4 hourly for
the next 24 hours.
2. Patient remains in bed for 24 hours
and must remain under observation in
the ward for a further 24 hours.