Fluoroscopy

What is Fluoroscopy?
Fluoroscopy is an imaging technique used by medical professionals to visualize internal organs
while they are in motion. If an X-ray is a still picture, fluoroscopy is like a movie. The images
are projected onto a monitor very similar to a television screen. This is very helpful for
healthcare providers because they can see exactly how an organ is functioning.
Fluoroscopy and X-rays are both imaging tests that use radiation to take images of your
internal tissues.
The difference is that X-rays take snapshots of internal tissues in a single moment, whereas
fluoroscopy can provide continuous, real-time images of your internal tissues using several
pulses (brief bursts) of radiation.
Equipment used for fluoroscopy

 In fluoroscopy, the X-ray tube is left on or pulsed rapidly, so that the physician can
view a live, continuously changing image, rather than a radiographic snapshot, frozen
in time.
 With some systems, the X-ray tube points upward from beneath the patient table, and
the image intensifier tube views downward from above.
 Alternatively, the X-ray tube and image intensifier can be at opposite ends of a rigid
"C-arm" support that can be rotated about one or more axes.
 Either way, the image intensifier tube faces directly into the X-ray beam, with the
patient in between.
The Image Intensifier

 An image intensifier is a marvelous device that can transform a body-sized pattern of X

rays into a small optical image, introducing little distortion or noise in the process.
 When detail is important, the tube's output screen can be photographed directly with a still
camera or, primarily for cardiac studies, with a cine (movie) camera.
 But for the immediacy and flexibility of real-time viewing, the image is fed into a video
camera.
Cont.

 The four principal components of an image intensifier tube are: the large (15-35
centimeters across) input fluorescent screen, the interior surface of which is covered with a
thin veneer of photosensitive metal (the photocathode), from which electrons can easily be
dislodged by visible light; the electron-focusing electrodes; the anode; and the small (3 cm
in diameter) output fluorescent screen.
 During an exposure, an X-ray photon that managed to pass through the patient strikes the
image intensifier tube's input screen, producing a tiny burst of light (X ray-stimulated
fluorescence). Light photons from the screen eject electrons from the adjacent
photocathode (photoelectric effect), and these newly liberated photoelectrons are drawn
immediately toward the anode.
Cont.

 That is, a life-size X-ray shadow produces a life-size visible-light image, which in turn,
gives rise to a life-size pattern of photoelectrons that begin moving toward the anode. The
X-ray image information is now carried in, and represented by the spatial configuration of
these electrons. As they accelerate toward the anode, the electrons are squeezed closer
together by the focusing electrodes, which shrinks the image they convey by a factor of
five to ten.
 On striking the small fluorescent output screen at high velocity, each electron produces a
bright point-flash of light (electron-stimulated fluorescence)
Cont.

 The net result is an optical image at the output screen with human anatomy appearing
much as it does in an ordinary developed X-ray film, only much smaller. But the image
intensifier tube's output image is thousands of times brighter than the one originally
produced on its input fluorescent screen, and of a size suitable for recording by a film or
television camera.
The Television Link

 A TV system usually consists of a video camera for acquiring the image; a monitor for
display; an information transmission channel connecting the camera to the monitor; and
possibly a videotape recorder for storage.
 With the closed-circuit television found in most imaging departments, the transmission
channel consists of electrical cables; the monitor may be in the same suite as the imaging
device, but it could also be elsewhere in the hospital, or even more distant.
 For wireless transmission, signals are sent from a microwave or radio frequency
transmitter, perhaps by way of earth-orbital satellite, to a receiver. Either way, an optical
image (such as from an image intensifier tube) is captured by the camera, transformed into
an electromagnetic signal, transmitted and received as such, and finally converted back
into a visual display at the viewing monitor.
Cont.

 A vacuum tube video camera is designed to convert a two-dimensional optical image into
an electrical voltage that varies with time, called the video signal. The visual image from
an image intensifier, say, is projected by glass lenses onto the front surface of the thin,
photosensitive "target" inside the camera tube.
 Meanwhile, a narrow beam of electrons rapidly and repeatedly traces out a raster pattern
(closely spaced parallel lines) on the back side of the target. The electrical properties of the
target material are sensitive to light, such that wherever on the back of the target the
scanning electron beam happens to be striking, the voltage coming from the target at that
instant is proportional to the amount of light focused at the corresponding point on the
illuminated) opposite side. As the electron beam scans a pattern of light that varies in two
spatial dimensions, in effect, the image is encoded in the form of a video signal voltage
that varies accordingly over time.
Cont.

 A vacuum tube display reverses the process, transforming the received video signal back
into an optical image. An electron beam within the tube scans its fluorescent display
screen, following the same raster pattern adopted by the video camera.
 At the same time, the video signal coming from the camera is being detected by the
receiver and applied to the display tube's grid; this electrode acts like an electron spigot,
regulating the number of electrons striking the fluorescent screen at that instant-hence the
level of brightness there.
 The video signal voltage, which varies with time, is thus translated back into a two-
dimensional spatial pattern of parallel lines of varying brightness, somewhat like an
engraving. The resolution of a system with a television link is limited mainly by the
electron beam scan pattern.
Cont.

 Some medical fluoro systems employ the raster pattern of American broadcast television,
in which a single frame (image) is made up of 525 parallel lines of spatially modulated
brightness.
 Modern fluoro TV systems, and good computer monitors, commonly use about 1,000 lines
per image as will commercial high definition television, HDTV), and some even achieve
2,000 lines per frame.
 In general, though, the resolution lies in the 1 to 0.3 mm range (i.e., objects any closer
together than that are not seen as being separate), depending on the equipment, and that is
about ten times poorer than for film radiography.
 Fortunately, the resolution of fluoroscopy is perfectly adequate for many tasks.
Cont.

 Recently developed solid-state optical devices such as the charge-coupled device (CCD)
camera used in camcorders, and the flat-panel liquid crystal displays (LCD) found in
virtually all laptop computers, work quite differently from the conventional vacuum tube
cameras and monitors described above, but they can produce pictures suitable for many
clinical applications.
 Because they tend to be much smaller and lighter, require no high voltages, waste less
energy as heat, do not emit electromagnetic radiation that could interfere with electronic
medical equipment, and are more rugged, they (or other solid-state devices) are likely to
displace their vacuum tube aunts and uncles in the clinic over time.
Cont.

 Solid-state X-ray image receptors are also being developed that can directly transform a
pattern of X rays into a voltage signal. Making use of the specially advantageous electrical
and mechanical properties of thin films of amorphous (glasslike, non-crystalline) silicon or
selenium, such devices would replace the combination of image intensifier tube plus video
camera,
THE NEED FOR QUALITY ASSURANCE

 X-ray tubes and generators, image intensifiers, video cameras, monitors, and all the other
bits and pieces that might go into a medical imaging unit are usually stable and reliable.
 As with any other complex machine, though, a tune-up or part replacement is occasionally
needed. So an essential aspect of the operation of any medical imaging facility is a
rigorously implemented quality assurance (QA) program, designed to ensure that the
images produced are diagnostically as useful as possible and that the risks to the patients
and staff are minimal.
 A QA program may be required by state and/or federal regulations, but whether voluntary
or man dated by law, adhering to it is wise and cost-effective, and works in every body's
best interest. QA programs are usually established and managed by specially trained Ph.D.
or M.S.-level physicists who have chosen to apply their skills in the medical setting.
Cont.

 Some elements of the program are carried out daily or weekly by the radiographers who
normally operate the imaging equipment in patient examinations, but the more complex
checks are performed by the medical physicists.
 Scheduled QA tests can catch many partial equipment failures before they become serious
difficulties. As an X-ray tube ages, for example, its anode becomes a bit cratered at points
where it was briefly overheated, causing its focal spot to enlarge and reducing radiograph
resolution and sharpness.
 Likewise, some links within the television chain can slowly deteriorate and subtly degrade
the signal, leading to slightly lower image contrast, or perhaps adding a pinch more visual
noise.
Cont.

 Such changes can add up and slowly diminish the system's ability to reveal clinically
important image patterns, unless staff can discern and correct the problems early.
 The radiation safety component of a QA program ensures that the amount of radiation
produced by an X-ray machine is sufficient to provide clinically useful images, but that the
dose to the patient does not exceed that amount.
 Similarly, it is important that the exposures borne by the staff, who work around patients
and the equipment day after day for years on end, be monitored and kept to a minimum.
Cont.

 Some exposure is inevitable, but following a few commonsense rules (stay as far as
possible from the source of radiation, while still being close enough to carry out the job
properly, minimize exposure time; use proper radiation shielding: always wear a film
badge radiation sensor) and adhering to the other elements of a standard radiation safety
program minimize risks to patients and staff.
How it helps in diagnosis?

 Healthcare providers use fluoroscopy for different parts of your body to diagnose several
conditions, including
 Barium swallow (esophagogram): A barium swallow is a fluoroscopy imaging test that
checks for problems in your upper gastrointestinal (GI) tract, which includes your mouth,
back of the throat, esophagus, stomach and the first part of your small intestine. The test
involves drinking a chalky-tasting liquid that contains barium, a safe substance that makes
parts of your body show up more clearly on X-ray imaging. These tests can help
diagnose esophageal disorders, ulcers, hiatal hernia, GERD (gastroesophageal reflux
disease), structural problems in the GI tract and tumors.
Cont.

 Barium enema: A barium enema, which is also called lower gastrointestinal tract
radiography, is a fluoroscopy imaging test that checks for problems in your colon and
rectum (parts of your large intestine). A healthcare provider pours a safe liquid containing
barium through a tube inserted into your anus. This liquid coats the inside of the large
intestine and clearly shows its outline on X-ray imaging. This test can help diagnose
inflammatory bowel disease (Crohn’s disease or ulcerative colitis), diverticulosis, colon
cancer, polyps and colonic volvulus (abnormal twisting of the bowel).
 Angiography: Angiography, or angiogram, uses fluoroscopy to identify and diagnose
narrowing or blockages in the arteries in your body. Sometimes, providers may perform an
angioplasty, a procedure used to open blocked coronary arteries, during a diagnostic
angiography, if necessary.
Cont.

 Cystography: Cystography is an imaging test that can use fluoroscopy to help diagnose
problems in your bladder. During cystography, a healthcare provider inserts a thin tube
called a urinary catheter into your urethra and injects contrast dye into your bladder. This
dye helps parts of your bladder show up more clearly on X-ray imaging. This test can help
your provider study your bladder emptying while you’re urinating (peeing). This is called a
voiding cystography. It can help show how well your bladder empties during urination and
whether any urine backs up into your kidneys (vesicoureteral reflux).
 Hysterosalpingogram: In this procedure, a provider uses fluoroscopy to provide images of
biologically female reproductive organs. It can help diagnose certain causes of infertility.
Cont.

 Myelography: Myelography uses fluoroscopy and an injection of contrast material to

evaluate your spinal cord, nerve roots and spinal lining (meninges). It’s particularly useful
for assessing your spine following surgery and for assessing disc issues in people who
cannot undergo MRI testing (usually due to having a medical device, such as a
cardiac pacemaker).
Indications and Contra indications

 For example, when fluoroscopy is used during a cardiac catheterization, the healthcare
provider can see how blood is moving through the blood vessels and where there are
blockages. Fluoroscopy can also be used to aid in the insertion of catheters into bile ducts
or the urinary system.
 Fluoroscopy can be used on many parts of the body. Sometimes a dye or contrast material
is used in conjunction with fluoroscopy to help medical experts visualize how the
substance is moving through the body. A good example would be barium, which is used
during a fluoroscopy of the intestines in order to see it moving through the bowels.
 Other examples of the use of fluoroscopy include its use during orthopedic surgeries where
it can aid the surgeon in the replacement of damaged joints or in the repair of bone
fractures.
Fluoroscopy for procedure guidance

 Cardiac catheterization: In this procedure, fluoroscopy shows blood flowing through your
arteries. It can help visually guide healthcare providers in performing angioplasties
 Placement of stents: Fluoroscopy can help ensure the proper placement of stents, which are
devices that help open narrow or blocked blood vessels.
 Orthopedic surgery: Your surgeon may use fluoroscopy to help guide orthopedic
procedures, such as joint replacement and fracture (broken bone) repair.
Cont.

 Catheter insertion and manipulation: Fluoroscopy can help ensure the proper placement of
catheters, which are thin, hollow tubes that help get fluids into your body or drain fluids
from your body. Providers can place catheters through your urethra, blood vessels and bile
ducts.
Benefits versus Risks

 Benefits:
 Fluoroscopy is used in a wide variety of examinations and procedures to diagnose or treat
patients. Some examples are:
 Barium X-rays and enemas (to view the gastrointestinal tract)
 Catheter insertion and manipulation (to direct the movement of a catheter through blood
vessels, bile ducts or the urinary system)Placement of devices within the body, such as
stents (to open narrowed or blocked blood vessels)
 Angiograms (to visualize blood vessels and organs)
 Orthopaedic surgery (to guide joint replacements and treatment of fractures)
Cont.

 Allows healthcare providers to see movement and function (like in a movie) that cannot be
seen in other fixed imaging studies (like a photograph).Guides sometimes life-saving
surgical treatments. 
 Risks:
 Radiation doses are usually higher than in common imaging like x-rays. This means these
procedures are slightly more likely to increase the possibility you may get cancer later in
life.
 Some fluoroscopy procedures are longer and use more radiation than others. These could
cause skin reddening and hair loss.
 Contrast dye, if used, can produce an allergic reaction in some people.