RADIOGRAPHIC CONTRAST PROCEDURE

DEFINITION - Used in Myelogram and Bronchogram

Studies
CM are diagnostic agents that are instilled into body
orifice or injected into the vascular system, joints and 2.TABLETS
ducts to enhance subject contrast in anatomic areas
Example: Biloptin (Iopodate), Telepaque, (Iopanoic
where there is low subject contrast.
Acid) Cholebrine (iocetamic acid) Bilisectan
A material that is being ingested or injected into the (Iodoalphanoic acid) and Cistobil
body for visualization of the organ.
- Used in Gall Bladder Studies
Substance having either a higher or lower atomic
3. Powder- Barium Sulphate (Baryntgen)
number than the surrounding tissues which are used to
represent organs of the body which are not visualized 4. Liquid – all iodinated and non-ionic contrast
in a plain radiography. medium

POSITIVE CONTRAST MEDIA

Serves as a diagnostic and therapeutic aid to physician 1. BASO4 (BARIUM SULFATE)
to visualize certain tissues/ organ
• For examination of the esophagus
The ability of the CM to enhance subject contrast
depends on: • For small intestine

1. Atomic number of CM. • For upper GI series

2. Atoms concentration of the element/volume of 2. IODINATED FORM

the medium. • Are used in the examinations of the GI,
TYPES OF CONTRAST MEDIA kidneys, gallbladder, pancreas, heart, brain,
uterus, spinal column, arteries, veins and
Radiopaque joints.
• Appears white (decreased density) on the • Atomic number of 53.
radiograph (ex. Barium sulfate, iodine).
IMPORTANT FACTORS IN SELECTING CONTRAST
• Also known as positive contrast media. MEDIUM
• Composed of elements with high atomic  It must be non toxic and must be safe both
number. locally where administered.
Radiolucent  It must procedure adequate contrast
 It must have a suitable viscosity
• Appears black (increased density) on the  It must have a suitable persistence
radiograph (air, nitrogen, carbon dioxide).  It must have miscibility or immiscibility as
• Also known as negative contrast media. appropriate

• Composed of elements with low atomic PHYSIOCHEMICAL PROPERTIES

number. Water solubility
FOUR PHYSICAL STATES OF CONTRAST MEDIA in vascular applications an immediate dilution with
1. OIL blood.

Example: Pantopaque, Dionosil

Viscosity
• Room temperature water (85°-90° F) is
• is a measure of the fluidity of solutions recommended by most experts to produce a
• measured in millipascals (mPa) per second. more successful examination with maximal
• The higher the viscosity of the solution, the patient comfort.
longer it will take for the contrast medium to • The RT should never use hot water because it
be diluted by blood. may scald (burn) the mucosal lining of the
Osmolality colon.
• Adverse reactions to CM have been related to
osmolality. IONIC CM
• A measure of the total number of particles in a
are contrast agent salts of electrically negatively
solution/kg of water.
charged acids containing iodine that ionizes in solution
and causes more patient discomfort.
BARIUM SULFATE
• BaSO4 – 1 atom of barium, 1 atom of sulfur and 4 • Urovision
atoms of oxygen thus it is a compound. • Urografin
• The most common type of contrast used in • Angiografin
imaging of the GI system. • Hypaque
• Inert powder composed of crystals (colloidal • Cardio-conray
suspension) that has a tendency to clump and • Conray
come out of suspension (flocculation). • Uromiro
• Stabilizing agents such as sodium carbonate or • Urovist
sodium citrate are used to prevent flocculation. • Telebrix
• Atomic number of 56. NON-IONIC CM
• It absorbs water
a contrast agent that does not ionize in solution and is
• Has a high atomic number
safer, less painful, and better tolerated by the patient.
• It is insoluble in water
• It cannot be absorbed by GIT Trade name - Generic name
• It is non toxic
• It has a relative contraindication in the GIT • Ultravist - Iopromide
• Iopamiro - Iopamidol
TYPES OF BARIUM SULFATE • Omnipaque - Iohexol
1. COMMERCIAL • Amipaque - Metrizamide
• It has flavoring and additives BARODENSE • Isovist - Iotrolan
BAROSPERSE SENSITIVITY TEST
• BARYTGEN • TEST DONE TO CHECK PATIENT TOLERANCE TO
2. PLAIN BaSo4 CM.
Has a very unpalatable taste but its advantage lies in the • TO SERVE AS TEST DOSE
fact that it adheres well on the mucosa of the organ • 1cc OF CONTRAST MEDIUM
• ANTIHISTAMINE INJECTED TO PATIENT FOR ANY
• It is generally recommended that barium sulfate ALLERGIC REACTION
is mixed with cold tap water (40°-45° F) to
reduce irritation to the colon and aid the
patient in holding the enema (increase
retention of CM) during the examination. The
cold water reduces spasm and cramping and
reported to have anesthetic effect on the
colon.
Scleral Method- • 2 – 3 minutes before the procedure; patient is
one drop of contrast medium is put into the sclera given a secretory stimulant to open the duct for
(white part of the eyeball) ready identification of its orifice & for easier
Sublingual Method- passage of a cannula or catheter
one drop of contrast medium is deposited into the
• Suck a wedge of fresh lemon and is repeated on
inferior base of the tongue.
completion of the examination to stimulate
Intradermal Method-
rapid evaluation of the contrast medium
one cc. of contrast medium is just beneath the skin
Intravenous Method • Radiograph may be taken 10 minutes later to
One cc. of contrast medium is injected into the vein. verify clearance of the medium

METHODS OF ADMINESTERING CM

1. DIRECT METHOD

Barium enema; Retrograde pylography;Cystoscopy

2. INDIRECT METHOD

ORAL: CM introduced through mouth

PARENTHERAL: CM introduced via injection

SIALOGRAPHY

• Term applied for the radiologic examination of CONTRAST MEDIA INTRODUCTION

the salivary gland & ducts with the use of
• Manual pressure with a syringe attached to the
contrast medium
cannula or catheter or by hydrostatic pressure
• Radiopaque medium injected into the main
• Hydrostatic pressure: Syringe barrel with
duct and flows into the intra-glandular
plunger removed attached to a drip stand &
ductules
set at a distance of 28 inches (70 cm) above
• Use to demonstrate inflammatory lesions & the level of the patient’s mouth
tumor to determine the extent of salivary
• Filling procedure done under fluoroscopic
fistulae & to localize diverticulae, strictures
guidance & obtain spot radiograph
and calculi
PAROTID GLAND
• Examination done one at a time (per gland)
TANGENTIAL PROJECTION - SUPINE

• Rotate head towards the side being examined.,

• CR perpendicular to lateral surface of the

mandibular ramus

TANGENTIAL PROJECTION PRONE

• Head resting on chin

• Rotate head away from the side being

examined
 • When the Parotid (Stensen’s) duct does not VSM: for submandibular gland region to
have to be demonstrated, rest the patient’s demonstrate tumor masses of lesions that lies
head on forehead and nose. posterior or lateral to the floor of the oral cavity

• CR perpendicular to lateral surface of the STRUCTURES SHOWN

mandibular ramus
• Axial image of the floor of the mouth.
• To study the parotid gland, better detail can
• Entire sublingual gland and ducts.
be obtained particularly for demonstration of
calculi, by having the patient fill the mouth • Anteromedial part of the submandibular
with air & then puff the cheeks out as much as gland.
possible or if not let the patient suspend
respiration during exposure. • The only projection that gives an unobstructed
view of the sublingual gland.
STRUCTURE SHOWN:
PALATOGRAPHY
• Parotid gland and duct well demonstrated
lateral to and clear of mandibular ramus • SRE using positive contrast technique to
investigate suspected tumors of the soft
LATERAL PROJECTION PAROTID AND SUBMANDIBULAR palate.
GLAND
• Patient in sitting lateral position with the
PAROTID nasopharynx centered to IR.
• Extend the patient neck so that space between • 1st palatogram swallow small amount of thick
cervical and rami is cleared. creamy barium sulfate to coat inferior surface
of the soft palate and uvula.
• MSP is 15 degrees to IR.
• 2nd lateral image, 0.5 ml of creamy barium is
• CR perpendicular to 1 inch (2.5 cm) superior to
injected into each nasal cavity to coat superior
mandibular angle
surface of soft palate and posterior wall of the
SUBMANDIBULAR nasopharynx.

• Head in true lateral. • Make exposure during phonation to

demonstrate the range of movement of the
• CR perpendicular to inferior margin of the
soft palate and position of tongue.
angle of the mandible.
NASOPHARYNGOGRAPHY
LATERAL PROJECTION
• SRE of the nasopharynx using negative and
PAROTID AND SUBMANDIBULAR GLAND
positive CM.
• Demonstrates bony structures, calcific deposit,
• Upright Lateral projection – negative CM
swelling of the parotid and submandibular
glands. • Demonstrate hypertrophy of the pharyngeal
tonsil or adenoids.
OBLIQUE PROJECTION
• CR directed to ¾ inch (1.9 cm) anterior to EAM.
• Deeper portions of the parotid and
submandibular glands. • PM – intake of deep breath thru the nose to
ensure filling of the nasopharynx with air.
AXIAL PROJECTION INTRAORAL METHOD
POSITIVE CM NASOPHARYNGOGRAPHY
• Rest the vertex to the plane of film
N Performed to assess extent of nasopharyngeal
CR: intersection of the MSP & CR passing
tumors.
through the second molar.
 1. Iodized oil • Studies of the larygo-pharyngeal structures are
made in both frontal & lateral directions
2. Finely ground barium sulfate
• Done on respiratory & stress maneuvers
• Preliminary radiographs are SMV and upright • Done in 5 maneuvers
lateral.
1. Quiet inspiration
• Upon completion of examination have the
2. Normal (expiratory)phonation
patient sit up and blow thru the nose to
3. Inspiratoty phonation
evacuate CM.
4. Valsalva maneuver
SMV 5. Modified Valsalva maneuver

 Elevate shoulders to extend neck.

• Stationary or tomographic negative contrast
 OML 40°-45° to horizontal plane. studies of the air-containing laryngopharyneal
 CR 15°-20° cephalad. structures.
• Studies of the larygo-pharyngeal structures are
UPRIGHT LATERAL made in both frontal & lateral directions
 CR horizontally directed to nasopharynx. • Done on respiratory & stress maneuvers
• Done in 5 maneuvers
PHARYNGOGRAPHY
1. Quiet inspiration
• Opaque study of the pharynx made with an 2. Normal (expiratory)phonation
ingestible contrast medium 3. Inspiratoty phonation
• Thick, creamy mixture of water & barium 4. Valsalva maneuver
sulfate 5. Modified Valsalva maneuver
• Use of fluoroscopy with spot radiograph made
during deglutition LARYNGOPHARYNGOGRAPHY
• DEGLUTITION: the act of swallowing & done in QUIET INSPIRATION
rapid & highly coordinated action of many • Test abduction of the vocal cords
muscles. • Show open (abducted) vocal cords.
• Bolus CM must be projected into the pharynx NORMAL (EXPIRATORY) PHONATION
at the height of the anterior movement of the • Expiratory phonation test
larynx. adduction of the vocal cords
• Shortest exposure time must be selected. • Take a deep breath and then exhaling slowly
• For mucosal phase patient is refrain from • To phonate: a high “eee” or
swallowing again the barium sulfate. low pitched “aah”
• Take the mucosal study during the modified • Show close (adducted) vocal cords.
Valsalva’s maneuver for double contrast INSPIRATORY PHONATION
delineation.  Reverse phonation & aspirate or aspirant
maneuver for the demonstration of the
GUNSON METHOD
laryngeal ventricle
• A practical technique for synchronizing the  Instructed to exhale completely & then slowly
exposure with the height of swallowing act in inhaling to make a harsh; stridulous sound
deglutition studies of the pharynx and superior with phonation of “e”
esophagus.  Adducts the vocal cords; moves them
• Tying a dark-colored shoestring around the inferiorly & balloons the ventricle for clear
patient’s throat above the thyroid cartilage. delineation
LARYNGOPHARYNGOGRAPHY

Stationary or tomographic negative contrast studies of

the air-containing laryngopharyneal structures.
 • The right and left hepatic ducts continue to join
VALSALVA’S MANEUVER the common hepatic duct..
 Take a deep breath & while holding the breath • Bile is carried to the GB via the cystic duct.
in; to bear down as if trying to move the Bile can also be carried directly to the
bowels duodenum via the common bile duct which is
 This act forces the breath against the closed then joined by the pancreatic duct (duct of
glottis & increases both intra-thoracic & intra- Wirsung).
abdominal pressure
 Show complete closure of the glottis GALL BLADDER
 Test the elasticity & functional integrity of the Pear shaped sac composed of three parts.
glottis 1. Fundus – distal end and the broadest part of
GB.
MODIFIED VALSALVA’S MANEUVER 2. Body – main section of GB
• Asked the patient to pitch the nostril together 3. Neck – narrow proximal end which continues
with the thumb & forefinger of one hand & the as the cystic duct.
mouth closed to make & sustain a slight effort • The cystic duct is 3-4 cm long.
to blow the nose • The GB is 7-10 cm long, 3 cm wide and holds
• Test the elasticity of the hypo-pharynx & the 30-40 cc of bile.
piriform recesses • The three primary functions of the GB is:
• Show the glottis closed & the hypopharynx & 1. Store
piriform recesses distended with air 2. Concentrate
3. Contract when stimulated.
TOMOLARYNGOGRAPHY
• Tomographic studies of the laryngopharyngeal COMMON BILE DUCT
structures either before or after the • The common hepatic duct draining the liver
introduction of radiopaque CM. joins with the cystic duct to form the common
• Uses rapid-travel lnear sweep and exposures bile duct.
are made during the first half of the arc (40-50 • 7.5 cm in length and has an internal diameter of
degrees) to prevent overlap streaking by facial a drinking straw.
bones and teeth. • The CBD descends behind the superior portion
of the duodenum and head of the pancreas to
BILIARY SYSTEM enter the second or descending portion of the
• SRE of the biliary system involves studying the duodenum.
manufacture, transport and storage of bile. • The CBD and Pancreatic duct forms into a
• Bile is manufactured by the liver. common passageway called the
• GB is the temporary storage area for bile. Hepatopancreatic Ampulla or the Ampulla of
• The liver is the largest solid organ in the human Vater.This is the narrowest part of the
body and occupies most of the RUQ and Right passageway and common site of impaction of
Hypochondrium. gallstones.
• Right and Left lobe of the liver is separated by • At the terminal opening of the passageway
the falciform ligament. into the duodenum is a circular muscle fiber
• The liver secretes 800-1,000 ml or 1 quart of called the Hepatopancreatic sphincter or
bile per day. Sphincter of Oddi. This sphincter relaxes when
• The major of function of bile is to aid in levels of CCK increases in the bloodstream.
digestion of fats by emulsifying or breaking
down fat globules.
• Bile is formed in the small lobules in the liver
and travels through the right or left hepatic
ducts.
 ADMINISTRATION OF CM
GB LOCATION VS BODY HABITUS 1. By mouth
HYPERSTHENIC  Absorb through the intestines and
• GB located higher and more lateral. carried to the liver through the portal
• 15-20 degrees LAO body rotation to separate vein.
GB from vertebral spine. 2. By injection into a vein – (single bolus or by
drip infusion) intravenous.
STHENIC/HYPOSTHENIC  Most commonly injected at the
• GB located halfway between the xiphoid tip and antecubital veins and passes through
lower lateral rib margin. the heart into the arterial circulation.
• 20-25 degrees LAO body rotation to separate The CM enters the liver via the hepatic
GB from the vertebral spine. artery and portal vein.
ASTHENIC 3. Direct injection into the ducts – during biliary
• GB is lower and medial at the level of the iliac tract surgery or through an indwelling tube.
crest.
• 35-40 degrees LAO body rotation to separate ORAL CHOLECYSTOGRAM(OCG)
GB from vertebral spine. The most common SRE to study the GB.

CHOLEGRAPHY  The purpose of OCG is to study

• General term for a radiographic study of the radiographically the anatomy and
biliary system. function of the biliary system.
CHOLECYSTOGRAPHY  CM is ingested orally.
• SRE of the gallbladder.  Ingestion of 4-6 tablets or capsules
• ALSO CALLED CHOLECYSTOGRAM during the evening before the
CHOLANGIOGRAPHY examination.
• SRE of the biliary ducts.  Sodium ipodate (Biloptin); 6 capsules
• ALSO CALLED CHOLANGIOGRAM each containing 500 mg. This is the
CHOLECYSTANGIOGRAPHY most widely used agent.
• SRE of gallbladder and biliary ducts.  Iopanoic acid (Telepaque); 6 capsules
• ALSO KNOWN AS each containing 500 mg.
CHOLECYSTOCHOLANGIOGRAPHY  The oral CM use for visualization of
the GB is called cholecystopaques.
CHOLELITHS
INDICATIONS:
Gallstones
 Function of the liver – ability to remove
• CHOLELITHIASIS the CM from the bloodstream and
excrete it with the bile.
• Condition of having gallstones.
 Patency and condition of the biliary
• CHOLECYSTITIS
ducts.
• Inflammation of the GB
 Concentrating and emptying power of
• CHOLECYSTECTOMY the GB.

• Surgical removal of the GB  Gallstones, calculi

 Pure cholesterol stones – appear as

negative filling defects.

 Calcium containing stones –

radiopaque stones
  Cholelithiasis – gallstones/calculi in the BILIARY NEOPLASM
GB, most common abnormalities
 GB carcinoma are rare however it is aggressive
diagnosed during OCG
and spread to the liver, pancreas and GI tract.
 Choledocholithiasis – calculi in the CBD  80% of the patients with carcinoma of the GB
have stones.
 Cholecystitis – acute or chronic
 CT and UTZ are the best modalities to
inflammation of the GB,common
demonstrate neoplasm of the GB.
complication of cholelithiasis.
BILIARY STENOSIS
 Biliary neoplasia, mass, biliary stenosis –
narrowing of the CBD.  narrowing of the CBD.
 CHOLELITHIASIS  Cholecystitis and jaundice may result from
 stones/calculi in the GB biliary stenosis.
 most common abnormalities
CONTRAINDICATIONS:
diagnosed during OCG.
 Increased levels of calcium, bilirubin 1. Advanced hepatorenal disease
and cholesterol may lead to formation 2. Active gastrointestinal disease
of gallstones. 3. Hypersensitivity to iodinated CM
 CHOLEDOCHOLITHIASIS-calculi in the 4. Pregnancy
CBD
PRELIMINARY DIET
INDICATIONS:
 Avoidance of laxative 24 hours before
 CHOLECYSTITIS ingestion of CM.
 Avoidance of all food after receiving the CM.
 acute or chronic inflammation of the  Noon meal that is rich in simple fats & a light
GB, evening meal that is fat free (oral media is
 common complication of cholelithiasis. administered 3 hours after the evening meals)
 CM given 10 – 12 hours prior to the procedure
 Blockage of the cystic duct restricts flow –most effective (CM reach the GB).
of bile from the GB into the CBD, the  Evening meal that is fat free to prevent the
blockage is due to a stone lodged in the possibility of continued emptying of the GB
neck of the GB. and release of radiopaque bile.
 Symptoms of acute cholecystitis include  CM is given 2-3 hours after evening meal.
abdominal pain, tenderness in the RUQ  Absorption time is 10-12 hours.
and fever.  Ipodate calcium rapidly absorbed and allows
visualization of the biliary ducts in 1.5 hours and
 In chronic cholecystitis the symptoms visualization of the GB in 3-4 hours.
include RUQ pain, heartburn and  Patient must refrain form chewing gum and
nausea following a meal. smoking until after exams.
 Pancreatitis and carcinoma of the GB is  70-80 kVp should be used.
associated with chronic cholecystitis.  Non-visualization on the first day may result in a
2- day study with a second dose of CM.
 Radionuclide scan and UTZ may also
demonstrate stone in the GB.
FATTY MEAL - (POST MOTOR MEAL)

 Given after the satisfactory visualization of the

GB
  Consist of commercially available bars or eggs  Oblique GB, with less foreshortening and self-
& milk or eggnog. superimposition than in PA.

 Cause GB to contract & additional diagnostic

ORAL CHOLECYSTOGRAM (OCG) RIGHT LATERAL
information can be obtained - functional /
POSITION
contracting ability of GB.
 Used to differentiate gallstones from renal
 Study of the extrahepatic ducts. stones or calcified mesenteric lymph nodes
 Demonstrates opacified GB away from
 Patient is placed in an RPO position so that GB vertebral column and bowel loops.
can best drain.

 Radiographs are obtain in the RPO position ORAL CHOLECYSTOGRAM (OCG)RIGHT LATERAL
every 15 minutes. DECUBITUS

 Was developed by Whelan.

Additional techniques  Fluid and calculi level of the GB.
 For better visualization of the ducts,  Opacified GB away from the vertebral column.
manufacturers make the following  Demonstrate multiple small stones that cannot
recommendations: be detected in other projections.
1. Biloptin  Demonstrate stratification or layering of
 12 capsules at the usual time or gallstones.
 6 capsules 10-12 hours before the examination  Alternative to PA upright.
plus another 6 capsules 3 hours before.
2. Telepaque ORAL CHOLECYSTOGRAM (OCG) PA UPRIGHT
 3-6 tablets are taken 4 hours after a fatty lunch PROJECTION
on the day preceding the examination, and then
a full dose of 6 tablets after a fat-free meal in the Upright PA
evening. • center the IR 2-4 inches below the prone level
ORAL CHOLECYSTOGRAM (OCG) PA PROJECTION - to allow change in the GB position.
SCOUT • Demonstrate stratification or layering of
Sthenic gallstones.
• CR perpendicular to level of L2 (1/2 – 1 inch • Axial representation of the opacified GB.
above lowest margin of rib cage) and 2 inches to • Demonstrate mobility of the GB to detect
right of MSP. presence of stone that are too small to cast
• Determine presence and location of opacified individual shadows & to differentiate papiloma
GB. or other tumor shadow from cholesterol
• Choleliths calculi shadow
• Correctness of exposure factors. • GB inferior and medial.
• Best demonstrate milk calcium bile.
ORAL CHOLECYSTOGRAM (OCG)
ORAL CHOLECYSTOGRAM (OCG)LAO POSITION • The right lateral decubitus and upright positions are
 Rotate the patient 15°-40°. used to demonstrate stones that are heavier than
 Greater obliquity (40◦) for asthenic patients bile and that are too small to be visible other than
than for hypersthenic (15◦) when accumulated in the dependent portion of the
 Best demonstrates opacified GB away from gallbladder. These positions are also used to
vertebral column. demonstrate stones that are lighter than bile and
 Ideal projection to delineate between gas in that are visualized only by stratification.
the bowel and radiolucent stones in the GB. • The right lateral decubitus position has the further
 The most common basic position of the GB. advantage of permitting the gallbladder to
gravitate toward the dependent right side, where it
 will lie below any adjacent gas containing loops of dilated by CT or ultrasonography but the cause
the intestine and away from bony superimposition of the obstruction is unclear.
when it occupies a low and/or medial position. • The performance of this examination has
• The decubitus position is also used when patients greatly increased because of the availability of
cannot standfor an upright PA or AP projection. the Chiba ("skinny") needle.
• Upright/ decubitus: small stone layer gravitate on • Often used to place a drainage catheter for
fundus of GB treatment of obstructive jaundice
• INDICATION : obstructive jaundice, stone
INTRAVENOUS CHOLANGIOGRAPHY extraction & biliary drainage.
Employed to investigate the biliary ducts of • RISK: liver hemorrhage, pneumothorax and
cholecystectomized patients. escape of bile.
• It is also used to investigate the biliary ducts • PTC is performed by placing the patient in
and gallbladder of non-cholecystectomized supine position on radiographic table
patients when these structures are not • R side is surgically prepared & appropriately
visualized by OCG and when, because of draped
vomiting or diarrhea, a patient cannot retain • Following local anesthesia, skinny needle is held
the orally administered medium long enough parallel to the floor & inserted through the
for its absorption. right lateral intercostal space & advanced
• Place the patient in the supine position for a towards the liver hilum
preliminary radiograph of the abdomen. • Stylet of the needle is withdrawn & syringe
• Place the patient in the RPO position (15 to 40 filled with CM is attached to the needle
degrees) for an AP oblique projection of the • Under fluoroscopic control the needle is slowly
biliary ducts. withdrawn until CM is seen to be filled the
• Timed from the completion of the injection, biliary ducts
duct studies are ordinarily obtained at 10- • Following filling of biliary ducts, needle maybe
minute intervals until satisfactory visualization completely withdrawn & serial or spot radiograph
is obtained. taken
• CM is supplied in an isotonic saline or glucose
solution by slow IV infusion. OPERATIVE – IMMEDIATE CHOLANGIOGRAPHY
• Maximum opacification usually requires 30 to
40 minutes. Performed during cholecystectomy.
• Intravenous cholangiography is not generally Use to investigate the:
indicated for patients who have liver disease or 1. patency of the bile ducts
for those whose biliary ducts are not intact. 2. functional status of the sphincter of the
• In cases of obstructive jaundice and post- hepato- pancreatic ampulla
cholecystectomy, ultrasonography has become 3. reveal the presence of previously undetected
the preferred technique for demonstrating the biliary tract calculi.
biliary system. • CM (6-8 cc) is introduced into the CBD; small
catheter is inserted into the remaining portion
PERCUTANEUS TRANSHEPATIC CHOLANGIOGRAPHY of the cystic duct.
(PTC) • The 15-20 degress RPO is helpful in projecting
Technique employed for pre-operative radiologic the biliary ducts away from the spine,
examination of the biliary tract. especially in hyposthenic patient.
• More invasive than other forms of
• An iodinated contrast agent is introduced into
cholangiography.
the common bile duct to evaluate biliary
• It involves a direct puncture of the biliary ducts.
patency and that of the hepatopancreatic
• This technique is used for patients with jaundice
ampulla.
when the ductal system has been shown to be
 • Any calculi can be detected and removed before a small cannula is passed through the
completion of surgery endoscope and directed into the ampulla
• Post –operative “delayed” & T-tube • Once the cannula is properly placed, the
cholangiography are radiologic terms applied contrast medium is injected into the common
to the biliary tract examination that is bile duct.
performed by way of the t-shaped tube left in • Oblique spot radiographs may be taken to
the common bile duct for post operative prevent overlap of the common bile duct and
drainage. the pancreatic duct.
• Use to demonstrate the caliber & patency of the • Injected CM must be drain from the normal
ducts; status of the sphincter of the hepato- ducts within approximately 5 minutes.
pancreatic ampulla & the presence of residual • ERCP is often indicated when both clinical and
or previously undetected stones or other radiographic findings indicate abnormalities in
pathologic condition. the biliary system or pancreas.
• Water soluble CM is used (25% – 30%) • OCG, ultrasound examination, or IVC is usually
concentration. performed before ERCP.
• Trendelenburg position – CM fills the
POST-OPERATIVE CHOLANGIOGRAPHY intrahepatic ducts.
Scout film • Semi-erect - CM fills the lower end of the CBD.

• Fluoro guided or overhead projection

OPERATIVE PANCREATOGRAPHY
• 15-20 degrees RPO
• Lateral : to demonstrate anatomic branching of • Surgico radiologic procedure wherein a soluble-
the hepatic duct & to detect any abnormalities iodinated CM is introduced into the main
not demonstrated in RPO pancreatic duct (duct of Wirsung).
• Clamped is not removed from the t-tube • Perform to rule-out abnormalities of the
before completion of the examination pancreas.
• T-shaped tube is left in the common bile duct • May be done via:
for postsurgical drainage.
1. Reflux filling from an injection to the CBD.
ENDOSCOPIC RETROGRADE
2. Direct injection through the transduodenal
CHOLANGIOPANCREOTOGRAPHY (ERCP)
catherization of the duct.
• SRE of the biliary and main pancreatic ducts.
DIGESTIVE SYSTEM
• ERCP is a useful diagnostic method when the
biliary ducts are not dilated and when no • Radiolucent and radiopaque CM are used to
obstruction exists at the ampulla. visualize the GI tract.
• ERCP is performed by passing a fiberoptic • Radiolucent or negative CM nclude
endoscope through the mouth into the swallowed air, carbon dioxide, gas crystals
duodenum under fluoroscopic control. To ease and gas bubbles in the stomach.
passage of the endoscope, the patient's throat • Calcium and magnesium citrate carbonate
is sprayed with a local anesthetic. Because this crystals are most commonly used to
causes temporary pharyngeal paresis, food and produce carbon dioxide gas.
drink are usually prohibited for at least I hour • The most common positive or radiopaque
after the examination. CM used in the GI system is barium sulfate.
• Food may be withheld for up to 10 hours after
the procedure to minimize irritation to the THICK BARIUM
stomach and small bowel . • 3-4 parts barium sulfate and 1 part water.
• 2-3 spoonfuls should be ingested.
• After the endoscopist locates the • More difficult to swallow and descends
hepatopancreatic ampulla (ampulla of Vater), slowly and use to coat the mucosal lining.
• Well suited for use in the esophagus.
THIN BARIUM ESOPHAGOGRAM
• 1 part barium sulfate and 1 part water. • Special radiographic examination of the
• 3-4 continuous swallow. esophagus and pharynx with the used of
• Well suited for study of the entire GI tract. single/double CM.
• Also called barium swallow.
DOUBLE CONTRAST • No preparation is needed
• For full column, single CM technique, a 30%-
• Enhance the diagnosis of certain disease
50% weight/ volume suspension is useful
and conditions of the upper GI’s.
• If double CM: barium or carbon dioxide crystal
• Was 1st developed in Japan where a high
is used
incidence of stomach carcinoma exist.
• For double CM: a low viscosity, high density
• High density barium sulfate is used to
barium developed for double contrast gastric
provide coating of the stomach mucosa.
examination is used.
• Calcium and magnesium citrate are the
• Esophagogram generally uses thin and thick
two common forms of crystals used as
barium
negative CM.
• The gas mixes with the barium sulfate and SINGLE CM
forces it against the stomach mucosa
• Scout film: upright of the esophagus
providing better coating and visibility of the
• Patient is instructed to take a cup of barium
mucosa and its patterns.
suspension in the left hand & drink it on
• Polyps, diverticulum and ulcers are best
request.
seen in double CM technique.
• Fluoroscopist asked patient to swallow several
mouthful of barium so that the act of
ABDOMINAL FISTULAE AND SINUSES
deglutition can be observed to determined the
• Fistulae (abnormal passages between two
abnormality.
internal organs).
• Various breathing maneuvers under
• Sinuses (abnormal channels leading to
fluoroscopic observation is done to
abscesses).
demonstrate lesion.
• To explore fistulae and sinuses in the abdominal
region, have the intestinal tract as free of gas
DOUBLE CM
and fecal material as possible.
• A free flowing, high density barium is used.
Oblique projections
• A gas producing substance usually carbon
• demonstrate the full extent of a sinus tract.
dioxide crystal is added to the barium mixture
Modified gastrointestinal procedure or can be given by mouth immediately before
the barium suspension is given.
• detect the origin of colonic fistulae.
• Iodized oil is frequently used in conjunction • Same procedure is done & delayed images
with a thin suspension of barium sulfate. maybe taken on request.
• For demonstration of a colonic fistula, the colon
FILLING PHASE
is filled with an enema consisting of the full
• Use to distend the lumen of the esophagus to
amount of water but only about one-third the
demonstrate the entire length.
amount of barium ordinarily used.
• 2:1 or 3:1 barium preparation.
• For demonstration of a fistula of the small
MUCOSAL PHASE
intestine, the patient ingests a thin barium
• Use to demonstrate the mucosal pattern of the
suspension.
esophagus.
• The fistulous tract is then injected with the
• 4:1 barium preparation
iodized oil.
 • Barium passes through the esophagus fairly Esophageal Varices
slowly if it is swallowed at the end of full
• Dilation of the veins in the distal esophagus.
inspiration.
• Has the radiographic appearance of wormlike or
• Barium is delayed in the lower part for several
cobblestone.
seconds if it is swallowed at the end of full
expiration. BEST SEEN IN RECUMBENT POSITION.
INDICATIONS: Foreign Bodies
Achalasia • Bolus of food, metallic objects may lodge in the
esophagus.
• Motor disorder of the esophagus in which
peristalsis is reduced on the distal 2/3 of the Zenker’s Diverticulum
esophagus.
• Large out-pouching of the esophagus just above
• Also called cardiospasm. the esophageal sphincter.
Barrett’s Esophagus
ESOPHAGOGRAM RECUMBENT POSITION
• The replacement of the normal squamous
epithelium with columnar-lined epithelium • The recumbent position is used to obtain more
ulcer tissue in the lower esophagus. complete contrast filling of the esophagus
(especially filling of the proximal part) by
• NM (Tc-99m pertechnetate) is the modality of
having the barium column flow against gravity.
choice to rule out this pathology.
• The recumbent position is routinely used for the
Carcinoma demonstration of esophageal varices.

• Adenocarcinoma is the most common form of TECHNIQUES FOR THE DEMONSTRATION OF

cancer of the esophagus. ESOPHAGEAL REFLUX

• Carcinosarcoma – large irregular polyp. 1. Breathing Exercise

• Esophagogram and endoscopy are modality of • Valsalva maneuver - is the most common
choice to detect these tumors. breathing exercise.

• CT-Scan is performed in staging of the tumor • Mueller maneuver – patient exhales and tries
and whether it has metastasize beyond the to inhale against a clossed glottis.
inner layer of the mucosa of the esophagus.
2. Water Test
Dysphagia
• Done with the patient in supine position and
• Difficulty in swallowing. turned slightly to the left side (LPO) position.

• Video and digital fluoroscopy are the modality • The barium fills the fundus, then the patient is
of choice. asked to swallow a mouthful of water through
a straw.
Esophageal Reflux
• A positive water test occurs when significant
• Reported as heartburn by patients.
amount of barium regurgitate into the
• It is the entry of gastric contents to the esophagus from the stomach.
esophagus.

• Excessive intake of aspirin, alcohol, caffeine and

smoking increases the incidence of reflux.
 ESOPHAGOGRAM AP/PAPROJECTION

3. Compression Paddle Technique • CR 1 inch inferior to sternal angle (T5-T6).

• Esophagus must be adequately demonstrated
• Placed under the patient in the prone position,
through the superimposed thoracic vertebrae.
the paddle is inflated
UPPER GASTRO-INTESTINAL
to provide pressure to the stomach region.
• The stomach must be empty for an examination
4. Toe-touch maneuver
of the upper gastrointestinal tract (the stomach
• Performed to study possible regurgitation into and small intestine).
the esophagus from the stomach. • It is also desirable to have the colon free of gas
and fecal material .
• The cardiac orifice is observed fluoroscopically. • Preparation usually consists of a soft, low-
• Esophageal reflux and hiatal hernias are residue diet for 2 days to prevent gas formation
demonstrated in this technique. from excessive fermentation of the intestinal
contents.
ESOPHAGOGRAM RAO POSITION • Cleansing enemas may be given to ensure a
• MSP 35 to 40 degrees to IR. properly prepared colon.
• CR perpendicular to T5- T6 (2-3 inches below • An empty stomach is ensured by withholding
jugular notch). both food and water after midnight for a period
• Demonstrate the entire contrast filled of 8 to 9 hours before the examination.
esophagus free from superimposition of the • When a small intestine study is to be made,
heart and vertebra. food and fluid are withheld after the evening
• Best single projection of barium-filled meal.
esophagus • Because it is believed that nicotine and chewing
gum stimulate gastric secretion and salivation,
ESOPHAGOGRAM LATERAL POSITION some physicians tell patients not to smoke or
chew gum after midnight on the night before
• Place the patient in the lateral position facing
the examination. This restriction is made to
the radiographer.
prevent excessive fluid from accumulating in
• CR perpendicular to T5-T6 (2-3 inches below
the stomach and diluting the barium
jugular notch).
suspension enough to interfere with its coating
• Entire esophagus between thoracic spine and
property.
heart.
• Two general procedures are routinely used to
Swimmer’s lateral examine the stomach:
• The single-contrast method and the double-
• Allows better demonstration of the upper
contrast method.
esophagus without superimposition of the
• A biphasic examination is a combination of the
arms and shoulders.
single-contrast and double-contrast methods on
• 2 – 3 exposure in rapid succession before the
the same day.
CM passes into the stomach if it is swallowed
• Barium meal" normally reaches the ileocecal
at the end of full inhalation
valve in 2 to 3 hours and the last portion in 4 to
• For demonstration of entire esophagus;
5 hours.
exposure is made while patient is drinking the
• The barium usually reaches the rectum within
CM through a straw in a rapid & continuous
24 hours.
swallow.
UPPER GASTRO-INTESTINAL SINGLE CM • For even coating of the stomach walls, the
barium must flow freely and have a low
• In the single-contrast method - 30% to 50%
viscosity.
weight/volume range .
• Barium suspensions have weight/volume
• Begin the examination with the patient in the
ratios of up to 250%.
upright position.
• Place the patient in the recumbent position,
• The radiologist may first examine the heart and
and instruct him or her to turn from side to side
lungs fluoroscopically and observe the
or to roll over a few times.
abdomen to determine whether food or fluid is
• This movement serves to coat the mucosal
in the stomach.
lining of the stomach as the carbon dioxide
• The radiologist asks the patient to swallow two
continues to expand.
or three mouthfuls of the barium. During this
• Just before the examination the patient may be
time, examine and expose any indicated spot
given glucagon or other anticholinergic
films of the esophagus.
medications intravenously or intramuscularly
• By manual manipulation of the stomach
to relax the gastrointestinal tract.
through the abdominal wall , the radiologist
• These medications improve visualization by
then coats the gastric mucosa.
inducing greater distention of the stomach and
• After studying the rugae and as the patient
intestines.
drinks the remainder of the barium suspension,
observe the filling of the stomach and further UPPER GASTRO-INTESTINAL BIPHASIC
examine the duodenum. EXAMINATION
• Determine the size, shape, and position of the
• The biphasic gastrointestinal examination
stomach.
incorporates the advantages of both the
• Examine the changing contour of the stomach
single-contrast and double- contrast upper
during peristalsis.
gastrointestinal examinations, with both
• Observe the filling and emptying of the
examinations performed on the same day.
duodenal bulb.
• The patient first undergoes a double
• Detect any abnormal alteration in the function
contrast examination of the upper
or contour of the esophagus,stomach, and
gastrointestinal tract.
duodenum.
• When this study is completed, the patient
• Fluoroscopy is performed with the patient in
is given an approximately 15%
the upright and recumbent positions while the
weight/volume barium suspension and a
body is rotated and the table is angled so that
single-contrast examination is performed.
all aspects of the esophagus, stomach, and
• This biphasic approach increases the
duodenum are demonstrated.
accuracy of diagnosis without significantly
• If esophageal involvement is suspected, a study
increasing the cost of the examination.
is usually made with a thick barium suspension.
• The principal advantages of this method over BODY HABITUS
the single- contrast method are that small
lesions are less easily obscured and the HYPERSTHENIC
mucosal lining of the stomach can be more • Stomach is high and transverse level of T9-T12.
clearly visualized. • Pyloric portion level of T11-T12, at midline.
• To begin the examination, place the patient on • Duodenal bulb is at the level of T11-T12 to
the fluoroscopic table in the upright position. right of midline.
• Give the patient a gas-producing substance in HYPOSTHENIC,ASTHENIC
the form of a powder, crystals, pills, or a • J-shaped stomach, low and vertical, T11-L4.
carbonated beverage. • Pyloric portion level of L3- L4 to left of midline.
• Give the patient a small amount of high-density • Duodenal bulb at the level of L3-L4.
barium suspension.
STHENIC • 1 full cup (2 ounces) of BaSO4

• Stomach T10-L2. UGIS PA PROJECTION

• Pyloric portion level of L2 near midline.
PA recumbent position.
• Duodenal bulb L2 near midline.
• For radiographic studies of the stomach and
duodenum.
AIR-BARIUM IN THE STOMACH
• CR to L1.
SUPINE • Stomach moves superiorly I ½ to 4 inches ( 3.8
• The fundus which is the most posterior part of to 10 cm).
the stomach is at the lowest part. PA upright position
• Barium fills the fundus part.
• Demonstrates the size, shape and relative
• Barium – Fundus
position of the stomach, but it does not give an
• Air – Pylorus
adequate demonstration of the unfilled fundic
PRONE
portion of the organ.
• The fundus is in the highest position.
• CR to 3-6 inches below L1-L2.
• Barium – Pylorus
• Air - Fundus UGIS PA PROJECTION
ERECT
• Air – Fundus • The greatest visceral movement between the
• Barium – Pylorus prone and the upright positions occurs in
• Air-Barium in a straight line asthenic patients.
• Do not apply an immobilization band for
STOMACH standard radiographic projections of the
Upright stomach and intestines because the pressure is
• Stomach moves downward 3-6 inches. likely to cause filling defects and because it
Supine interferes with emptying and filling of the
• Stomach moves superiorly. duodenal bulb, factors that are important in
Prone serial studies.
• Stomach moves slightly downward. UGIS PA PROJECTION
Right lateral recumbent
• Stomach moves forward. Sthenic
• Pylorus closer to lumbar spine. • CR to L1 and 1 inch left of vertebral column.
Left lateral upright Asthenic
• Stomach moves backward. • CR 2 inches below L1.
• Pylorus closer to abdominal wall Hypersthenic
• 2 inches above L1.
UGIS • Body and pylorus filled with barium and air in
• SRE distal esophagus, stomach, duodenum & the fundus.
proximal jejunum • Polyps, diverticulum, bezoars and gastritis in
• Soft residue diet for 2 days to prevent gas the body and pylorus.
formation as a result of excessive fermentation Asthenic/Hyposthenic
of the intestinal content • pyloric canal and duodenal bulb in profile.
• Cleansing enema is given to assure a properly Sthenic
prepared colon • Pyloric canal and duodenal bulb partially
• Food & drinks are withheld after midnight 8– 9 superimposed by prepyloric portion of
hours before the examination. stomach.
• When the small intestine study is to be made,
food & drinks are withheld after evening
meals.
Hypersthenic Recumbent right lateral
• Pyloric canal and duodenal bulb completely
• Demonstration of the right retrogastric space,
superimposed by prepyloric portion of
duodenal loop, and duodenojejunal junction.
stomach.
• Demonstrates anterior and posterior aspects
UGIS PA AXIAL PROJECTION
of the stomach, the pyloric canal, and the
GORDON METHOD duodenal bulb
• Best image of the pyloric canal and the
• CR 35 to 45 degrees cephalad.
duodenal bulb in patients with a hypersthenic
• Best demonstrates and open up high habitus.
transverse stomach for hypersthenic patients. • C-loop.
• Stomach located higher in this position than in
• Greater and lesser curvatures in profile. PA and RAO.
GUGLIANTINI • CR to L1 1-1 ½ inches anterior to MCP.

• 20 to 25 degrees cephalad for demonstration of UGIS AP PROJECTION

the stomach in infants. • The stomach moves superiorly and to the left in
UGIS RAO POSITION this position.
• Tilt the table to full or partial Trendelenburg for
• 40-70 degrees body rotation. the demonstration of hiatal hernia.
• Hypersthenic patients require a greater degree • The best AP projection of the retrogastric
of rotation than do sthenic and asthenic portion of the duodenum and jejunum.
patients.
• Best demonstrates pyloric canal and the Partial Trendelenburg
duodenal bulb free of superimposition of the • Helps fills fundus with barium on thin asthenic
pylorus because gastric peristalsis is usually patient.
more active when the patient is in this
position. Full Trendelenburg
• C-loop in profile but superimposed on lumbar
• Demonstration of hiatal hernia.
vertebra.
• Air in the fundus. UGIS WOLF METHOD
• Barium in the body, pylorus and duodenum.
• The Wolf method' is a modification of the
• Polyps, ulcers of the pylorus.
Trendelenburg position
• serial studies must be taken at an interval of
• The technique was developed for the purpose of
30 – 40 seconds.
applying greater intraabdominal pressure than
UGIS LPO POSITION is provided by body angulation alone and
thereby ensuring more consistent results in the
• Body rotated 30 to 60 degrees (45 degrees).
radiographic demonstration of small, sliding
• Demonstrates the fundic portion of the
gastroesophageal herniations through the
stomach filled with barium.
esophageal hiatus.
• Good position for double contrast of body,
• The Wolf method requires the use of a
pylorus, and duodenal bulb.
semicylindrical radiolucent compression device
UGIS RIGHT LATERAL POSITION measuring 22 inches (55 cm) in length, 10 inches
(24 cm) in width, and 8 inches (20 cm) in height.
Upright left lateral
• A further advantage of the device is that it does
• Demonstration of the left retrogastric space. not require angulation of the table; thus the
patient is able to hold the barium container and
ingest the barium suspension through a straw
with comparative ease.
 • Patient in a 40- to 45-degree RAO position. INDICATIONS:

• To allow for complete filling of the esophagus, 1. Study the form and function of the 3
make the exposure during the third or fourth components of the small bowel.
swallow. 2. Detect abnormal conditions.
CONTRAINDICATIONS:
• CR Perpendicular to the long axis of the patient's
back and centered at the level of either T6-T7. 1. Pre-surgical patient
2. Perforated hollow viscus
• This position usually results in a 10-20-degree
3. Large bowel obstruction. Use iodinated CM.
caudad angulation of the central ray.

UGIS RAO SERIAL AND MUCOSAL STUDIES

PATIENT PREP
• The use of a pneumatic paddle for the
• Low-residue diet for 2 days before the small
demonstration of the gastric mucosa after the
intestine study.
fluoroscopic examination.
• NPO 8 hours before the exam.
• The paddle is placed under pyloric sphincter
• No cigarette or chewing gum.
and duodenal bulb.
• Patient is asked to empty the bladder to
• A radiograph is obtained with the pneumatic
prevent displacement of ileum to the distended
paddle inflated, and additional radiographs are
bladder.
taken as the paddle is deflated.
• The fluoroscopic portion of this examination is UGI-SMALL BOWEL COMBINATION
performed by the radiologist.
• 1st cup (8 ounces) of barium – time noted.
• This method demonstrates a compression and a
• Routine stomach study.
non compression study of the pyloric end of
• 2nd cup of barium is given.
the stomach and the duodenal bulb at different
• 30 minutes after initial barium intake a PA
stages of filling and emptying.
projection of the proximal small bowel is
• A compression study of the mucosa of a
perform.
localized area of the gastrointestinal tract
• The 1st radiograph of the SIS (30 minutes) is
HYPOTONIC DUODENOGRAPHY perform 15 minutes after UGIS.
• For the first 2 hours of the SIS radiographs are
• Examination that uses intubation for the
obtained in 15- to 30-minute intervals.
evaluation of post bulbar duodenal lesion & for
• After 2 hours radiographs are obtained every
detection of pancreatic diseases.
hour until it reaches the ileo-cecal valve.
• The tubeless technique requires temporary
SMALL BOWEL ONLY SERIES
drug induce duodenal paralysis so that a
double contrast examination can be performed • 2 cups of BaSO4 ingested.
without interference from peristaltic activity. • 1st radiograph taken 15 or 30 minutes after
ingestion.
SMALL INTESTINAL SERIES
• Half-hour radiographs for for 2 hours time
• SRE of the small intestine by administering the frame.
barium sulfate by: • After 2 hours radiographs are taken at 1 hour
1. mouth intervals
2. by complete reflux filling with a large volume of
barium enema
3. by direct injection into the bowel through an
intestinal tube which is called the electrolysis
• Patient preparation: same as UGIS.
ENTEROCLYSIS DOUBLE CM SMALL BOWEL SIS METHOD OF IMAGING
PROCEDURE
PRONE
• CM is injected into the duodenum to examine
1. Allows abdominal compression to separate
the small bowel.
various bowel loops.
• CM injected through a BILBAO or SELLINK tube
2. Higher degree of visibility.
into the terminal duodenum.
• Barium is given at a rate of 100 ml/min
TRENDELENBURG
• Air or Methylcellulose is injected to distend
and provides double contrast effect. 1.Separate overlapping loops of ileum.
INDICATIONS
1. Bowel ileus SUPINE
2. Regional enteritis 1. To take advantage of the superior and lateral
3. Malabsorption syndrome (sprue). shift of the barium-filled stomach for
visualization of the retrogastric portions of the
DISADVANTAGES duodenum and jejunum
1. Increased patient discomfort.
2. Bowel perforation 2. To prevent possible compression overlapping
of loops of the intestine
INTUBATION METHOD SINGLE CM LARGE INTESTINE
• Also known as small bowel enema.
• Uses NGT for introduction of CM for therapeutic • There are two basic radiologic methods of
and diagnostic purposes. examining the large intestine by means of
• Therapeutic - (Miller-Abbott tube) to relieve diagnostic or contrast enemas the:
post- operative distention and small bowel
1. single-contrast method - colon is examined with
obstruction.
a barium sulfate suspension only.

COMPLETE REFLUX EXAMINATION 2. double-contrast method - two-stage or single-

stage procedure.
• Complete reflux filling of the small bowel
• In the two-stage double-contrast procedure, the
• Glucagon is administered to relax the intestine
colon is examined with a barium sulfate
• Diazepam (valium) may also be given to
suspension and then, immediately after
diminish discomfort during initial portion of the
evacuation of the barium suspension, with an
filling of the bowel
air enema or another gaseous enema.
• 15% weight volume barium suspension is often
• Barium demonstrates the anatomy and tonus of
used and a large amount of suspension (about
the colon and most of the abnormalities to
4500ml) is required to fill the colon & small
which it is subject.
intestine
• The gaseous medium serves to distend the
• Retention enema tip is used & the patient is
lumen of the bowel and to render visible
place in supine position
through the through the transparency of its
• Barium is allowed to flow until it is observed in
shadow.
duodenal bulb
• Most enema bags have a capacity of 3 quarts
• The enema bag is then lowered to the floor to
(3000 m l ) when fully distended
drain the colon before filming of the small
• The tubing is approximately 6 feet long.
intestine.
• For single-contrast 12% to 25% for
weight/volume.
• For double contrast examinations, a relatively
high density barium product is used.
• 75% to 95% weight/volume ratio is common.
 • Barium sulfate temperature should be below BARIUM ENEMA LATERAL (RECTUM) ROBIN’S
body temperature about 85°to 90° F (29° to 30° MODIFICATION
C).
• True lateral position.
• An enema that is too warm is injurious to
• CR to MCP between ASIS and posterior
intestinal tissues and produces so much
sacrum.
irritation that it is difficult, if not impossible, for
• Best demonstrates polyps, strictures and
the patient to retain the enema long enough
fistula between the bladder and uterus.
for a satisfactory examination.
• Best demonstrates the rectum and
• Cold barium enema suspensions about 41°F
rectosigmoid portion.
(5°C) have been recommended on the basis
• The most important modification in barium
that the colder temperature
enema.
1. produces less irritation,
• Demonstrates a direct lateral view of the
2. has a mild anesthetic effect that relaxes the
recto- sigmoid colon without
colon,
superimposition.
3. stimulates tonic contraction of the anal
sphincter. BARIUM ENEMA RPO POSITION

BARIUM ENEMA • 35- 45 degree rotation from the table.

• Best demonstrates the left colic flexure and the
• SRE of the large intestine. descending colon.
• Insertion of enema tip – sims’ position – 35 to • Similar image can also be seen in LAO position.
40 degrees lean forward on left side
• This position relaxes the abdominal muscle , BARIUM ENEMA LPO POSITION
which decreases Intra- abdominal pressure on • 35- 45 degree rotation from the table.
the rectum and makes relaxation of the anal • Best demonstrates the right colic flexure and
sphincter less difficult. the ascending and sigmoid portions of the
• Height of barium content at 18-24 inches (45- colon.
60 cm) above the level of the anus • Similar image can also be seen in RAO position.
• Tube is inserted for a total distance of 3 ½ to 4
inches (8.7 to 10 cm) AP PROJECTION
• Inserted during exhalation: directed anteriorly • Air filled transverse colon filled.
1 – 1 ½ inch following curve of rectum then • Opacified colon including flexures and rectum.
slightly superiorly
TRENDELENBURG
SUPINE
• Air rises to the most anterior portion of the • Separates redundant and overlapping loops of
large intestine. the bowel.
1. Transverse colon
PA PROJECTION
2. Sigmoid colon
• Barium filled transverse colon filled.
Barium fills the: • Opacified colon including flexures and rectum
1. Ascending colon
2. Descending colon
AP AXIAL /AP AXIAL OBLIQUE PROJECTION (butterfly)
PRONE
Air fills the: AP AXIAL PROJECTION
1. Rectum
• CR 30- 40 degrees cephalad to 2 inches inferior
2. Ascending colon
3. Descending colon to ASIS.
BARIUM
• Transverse colon
AP AXIAL OBLIQUE PROJECTION • Demonstrates the anterior and posterior
surfaces of the lower portion of the bowel and
• LPO position (30°-40°) body rotation.
permits the coils of the sigmoid to b e
• CR 30°- 40° cephalad to 2 inches inferior and 2
projected free from overlapping.
inches medial to right ASIS
• Best demonstrates an elongated view of the BILLING’S
rectosigmoid area than on other views
• Supine
BARIUM ENEMA PA AXIAL/PA AXIAL OBLIQUE • CR 35-45 degrees midway between ASIS.
PROJECTION BUTTERFLY POSITION • Prevent overlapping loop and separates
sigmoid colon.
PA AXIAL
• Demonstrates recto- sigmoid area.
• CR 30◦-40° caudad to level of ASIS
OPPENHEIMERS
PA AXIAL OBLIQUE PROJECTION • Supine
• RAO position (35°-45°) body rotation. • CR 12 degrees caudad to 1 inch proximal to the
• CR 30°- 40° caudad to ASIS and 2 inches to left upper border of the symphysis pubis.
of lumbar spinous process. FLETCHERS MODIFICATION
• Best demonstrates an elongated view of the • LAO position (30°-35°)
rectosigmoid area than on other views • CR 30°-35° cephalad
BARIUM ENEMA RIGHT LATERAL DECUBITUS DEFECOGRAPHY
• Functional study of the anus and rectum during
• CR horizontal to level of the iliac crests. evacuation and rest phase of defecation.
• Best demonstrates the "up" medial side of the • Performed for the patient with a defecation
ascending colon and the lateral side of the dysfunction.
descending colon when the colon is inflated • Also known as evacuation proctography,
with air. dynamic rectal examination.
• Air inflated portion of the colon is of primary • 100% weight/volume barium sulfate paste with
importance. a special injector mechanism is use to instill the
barium directly into the rectum.
BARIUM ENEMA LEFT LATERAL DECUBITUS • Lateral projections are obtained during
• CR horizontal to level of the iliac crests. defecation by spot filming.
• Best demonstrates the "up" lateral side of the • This evaluation includes measurements of the
ascending colon and the medial side of the anorectal angle and the angle between the long
descending colon when the colon is inflated axis of the anal canal and rectum.
with air
• Air inflated portion of the colon is of primary URINARY SYSTEM
importance. • The kidneys normally excrete I to 2 L of urine
BARIUM ENEMA VENTRAL DECUBITUS per day.
• CR to level of the iliac crests. • The kidneys normally extend from the level of
• Best demonstrates the "up" posterior portions the superior border of T12 to the level of the
of the colon and is most valuable in double- transverse processes of L3 in persons of
contrast examinations. sthenic build.
• Respiratory movement of 1 inch and normally
AXIAL PROJECTION CHASSARD-LAPINE METHOD drop no more than 2 inches (5 cm) in the
change from supine to upright position.
• Demonstrates an axial projection of the
• The adult bladder can hold approximately 500
rectum, rectosigmoid junction, and sigmoid.
ml of fluid when completely full.
• A right angle view to the AP projection,
• The desire for micturition (urination) occurs
when about 250 ml of urine is in the bladder.
 • Urography – radiographic examination of the • Empty bladder before examination:
urinary system 1. Bladder that is full could rupture.
• CM introduced to bloodstream by intravenous 2. Urine dilutes the CM.
injection (IVU).
• Catheterization (RGP). INTRAVENOUS UROGRAPHY PROCEDURE
• Temporary hot flash and metallic taste in the URETERAL COMPRESSION
mouth are the common side effects occurring • Method to enhanced filling of the pelvocalyceal
after IV injection of iodinated CM. system and proximal ureters.
• RT must check the BUN and Creatinine • Applied over the distal ends of the ureters. This
(diagnostic indicators of the kidneys). is done to retard flow of the opacified urine
• Normal BUN – 8-25 mg/100 ml. into the bladder and thus ensure adequate
• Normal Creatinine 0.6-1.5 mg/dl. filling of the renal pelves and calyces.
• Glucophage (metformin) should not be given • Compression is generally contraindicated if a
iodinated CM 48 hours before the procedure patient has urinary stones, an abdominal mass
and withheld for another 48 hours after the or aneurysm, a colostomy, a suprapubic
procedure. catheter, or traumatic injury.
• Patient should never be left alone after IV RESPIRATION
injection of CM. • All exposures are made at the end of the end of
• Physician must be summoned immediately expiration.
for any moderate or severe reaction. • Normal respiratory excursion of the kidneys
varies from 1-1 ½ inches.
PREPARATION OF CM TRENDELENBURG
• Before withdrawing the CM from the vial.
• Same result to compression device without risk
1. Confirm the correct contents.
to the patient whose symptoms
2. Expiration date
contraindicate ureteric compresion.
3. Read the label very carefully.
4. empty bottles should be shown to the IVU AP PROJECTION NEPHROGRAM
radiologist.
• For 50-100 ml of CM use 18-20 gauge butterfly • CR midway between xiphoid tip and iliac crets.
needle. • Single AP projection of the kidney taken 60
• 23-25 gauge needle for pediatric patients. minutes after injection.
• Most reactions to contrast media occur within NEPHROTOMOGRAPHY
the first 5 minutes after administration. • Primarily performed to rule out renal
• 2-8 minutes CM appears at the pelvocalyceal hypertension.
system.
• 15-20 minutes after injection is the greatest IVU RPO AND LPO POSITIONS
concentration of CM in the kidneys. • CR perpendicular to iliac crets.
• 30 degrees body rotation.
INTRAVENOUS UROGRAPHY • Kidney farthest from IR in profile.
• Most common SRE of the urinary system. • Ureter nearest IR projected away from the
• also referred to as IVP (refers only to renal vertebral spine.
pelpes).
• Commonly referred to as IVU or excretory IVU POST VOID
urography. • CR perpendicular to iliac crets.
• True functional test of the urinary system. • Demonstrate enlarged prostate or prolapse
PURPOSE: bladder.
1. Visualize collectiong portion of the urinary • Ureteral reflux ERECT POST VOID
system. • Best demonstrates nephroptosis (positional
2. Assessed the functional ability of the kidneys. change of kidneys).
 IVU AP PROJECTION URETERIC COMPRESSION URETHROGRAM : patient is instructed to inhale deeply
& then to suspend respiration at the end of full
• CR midway between xiphoid tip and iliac crets.
expiration
• Best demonstrates pyelonephritis.
• RPO or LPO as an additional view
• LATERAL – patient turn lateral on affected side
RETROGRADE UROGRAPHY
is taken to demonstrate anterior displacement
• Non functional examination of the urinary
of the kidney or ureter to delineate a
system.
perinephritic abscess
• CM introduce directly retrograde ( backward
• CROSS TABLE LATERAL – supine or prone;
against the flow) into the pelvicalyceal system.
useful for demonstration of ureteropelvic
• Requires catheterization of the ureter for the
region in patient with hydronephrosis.
injection of CM to the pelvicalyceal system.
• Considered to be an operative procedure
RETROGRADE CYSTOGRAPHY CYSTOGRAM
combining urologic – radiologic under careful
• Non functional radiographic examination of
aseptic condition
the urinary bladder after instillation of an
• The examination is performed in a specially
iodinated CM via a urethral catheter
equipped cystoscopic radiologic examination
• Cystogram : is a common procedure to rule out
room.
trauma, calculi, tumor & inflammatory disease
• The patient is place on a cystoscopic table &
of the urinary bladder
the knees are flex over the stirrups of the
• No patient preparation but prior to
adjustable leg support (modified lithotomy
catheterization procedure, the patient should
position)
empty the bladder
• Catheterization of the ureter is performed
• After catheterization under aseptic condition,
through a ureterocystoscope & the catheter is
the bladder is drain of any residual urine
inserted into the vesicoureteral orifices
• The bladder is then filled with dilute CM (150-
• Frequently performed to determined the
500 cc) in allowed to flow in by gravity ( never
localization of urinary calculi or other type of
attempt to introduce pressure which will
obstruction.
result to rupture of the bladder ).
• Sodium iodide and sodium bromide first used
for RGU.
AP BLADDER & PROXIMAL PART OF URETHRA
• Patient drink a large amount of water (4 or 5
• CR 15 degrees caudad.
cups) for several hours before the examination
RPO : 40 – 60 degrees rotation
to ensure excretion of urine in an amount
• CR perpendicular or 10 degrees caudad
sufficient for bilateral catheterized specimens
PA BLADDER :
and renal function tests.
• CR to bladder neck at 10 – 15 degrees cephalad
• The retrograde urogram is indicated for
• Use to project the shadow of prostate above
evaluation of the collecting system in patients
that of the pubic bone.
who have renal insufficiency or who are
LATERAL
allergic to iodinated contrast media.
• Use for demonstration of the anterior &
• Preliminary radiograph showing the
posterior bladder wall & the base of the
urethral catheter in position
bladder.
• Pyelogram
CHASSARD LAPINE
• Urethrogram
• Squat shot use to obtain axial image of the
PYELOGRAM : some radiologist recommends that the
posterior surface of the bladder & of the lower
head of the table to be lowered 10 – 15 degrees for
end of the ureter when they are opacified
the pyelogram to prevent the CM from escaping into
AP OF DISTAL URETER
the ureter
• Lowering the head of the table 15 – 20 degrees
• 3 – 5 ml of solution will fill the average normal
to permit the filled bladder to stretch
renal pelvis.
superiorly
VOIDING CYSTOURETHROGRAM FETOGRAPHY
• A functional study of the bladder & the • The demonstration of the fetus in utero.
urethra; evaluates the ability of the patient • Avoided until after the eighteenth week of
to urinate gestation because of the danger of
• Maybe taken after the routine cystogram radiation induced fetal malformations.
• Common pathologic indication are trauma • Detect suspected abnormalities of
or incontinence development,
• After voiding shot is complete; a voiding AP • Confirm suspected fetal death, to
must be done determine the presentation and position
• The voiding face of the examination is best of the fetus,
done with fluoroscopy with image • Determine whether the pregnancy is single
acquisition capability. or multiple.
• MALE : patient in supine or upright 30-40
degrees RPO position. PLACENTOGRAPHY
• FEMALE : in supine slight oblique position • Radiographic examination in which the
walls of the uterus are investigated to
METALLIC BEAD CHAIN CYSTOURETHROGRAPHY locate the placenta in cases of suspected
• Investigates anatomic abnormalities placenta previa.
responsible for stress incontinence in
women. DISKOGRAPHY
• SRE of the intervertebral disk injected into
HYSTEROSALPINGOGRAPHY the center of the disk with a double entry
• SRE of the fallopian tube, ovaries & uterus needle.
using positive CM
• Demonstrate patency of oviduct in cases of CEREBRAL ANGIOGRAPHY
infertility • SRE of the blood vessel of the brain by
• Scheduled about 10 days after start of means of injecting the CM in the carotid
menstruation. artery
• CM: liopodol, skiodan, kayopaque, salpix • INDICATION: intracranial aneurysm,
• AP, PA, OBLIQUE & LATERAL vascular lesion, tumor,
MYELOGRAPHY
PELVIC PNEUMOGRAPHY
• SRE of the central nervous system, spinal
• Pelvic pneumography, gynecography, and
cord
pangynecography are the terms used to
• Introduction of CM in sub-arachnoid space
denote radiologic examinations of the
at level of L3 – L4
female pelvic organs by means of
• CM: Iopaniro (iodized oil)
intraperitoneal gas insufflation.
• AP, PA, R & L OBLIQUE & CROSS TABLE
LATERAL
VAGINOGRAPHY
• Used in the investigation of congenital
COLCHERR-SUSSMAN
malformations and pathologic conditions
• AP and lateral employed in this method of
such as vesicovaginal and enterovaginal
pelvimetry requirethe use of the Colcher-
fistulas.
Sussman pelvimeter.
 • This device consists of a metal ruler
perforated at centimeter intervals and
mounted on a small stand.
• Center the horizontal ruler to the gluteal
fold at the level of the ischial tuberosities
(10 cm below superior border of
symphysis pubis).

ANGIOGRAPHY
Radiographic examination of the vessels after
injection of CM.

LYMPHOGRAPHY
Radiographic examination of the lymphatic vessels.
1 hour of injection – lymph vessel.
24 hours after injection – lymph nodes.