The document provides guidance on performing an oral cholecystography procedure to visualize the gallbladder. It begins by explaining that oral cholecystography involves administering a radiopaque contrast agent by mouth that is then excreted by the liver and collects in the gallbladder. The examination involves three stages - a control radiograph, administration of the contrast agent the evening before, and imaging the following day. Factors like diet, contrast agent dose, and imaging after a fatty meal are discussed to optimize visualization of the gallbladder and any gallstones. Contraindications to the procedure and different contrast agents used are also mentioned.

1. IN THE NAME Of GOD
Amir al-Muminin, peace be upon him, said:
There is no wealth like wisdom, no destitution like ignorance, no
inheritance like refinement and no support like consultation.
‫املومنين‬‫ر‬‫امي‬(‫ع‬)‫فرمودند‬:
‫هيچ‬‌‫ي‬‫‌نياز‬‫ي‬‫ب‬‌‫ن‬‫چو‬،‫عقل‬‌‫و‬‫هيچ‬‌‫ي‬‫فقر‬‌‫ن‬‫چو‬‫ناداني‬،‫نيست‬‫هيچ‬‫ثي‬‫ر‬‫ا‬‌‫ن‬‫چو‬،‫ادب‬‌‫و‬‫هيچ‬
‫پشتيباني‬‌‫ن‬‫چو‬‫ت‬‫ر‬‫مشو‬‫نيست‬.

2. Contrast Media
September, 2014
Prepared by:
Behzad Ommani
Bachelor of Radiology
Master of Medical Engineering
Instructor Radiology Group

3. Biliary Tract

4. In vertebrates the gallbladder (Cholecyst, Biliary Vesicle) is a small organ that
aids mainly in fat digestion and concentrates bile produced by the liver.
Human anatomy

5. Human anatomy
The gallbladder is a hollow system that sits just beneath the liver. In adults, the
gallbladder measures approximately 8 centimetres (3.1 in) in length and 4
centimetres (1.6 in) in diameter when fully distended.
It is divided into three sections: fundus, body and neck.
The neck tapers and connects to the biliary tree via the cystic duct, which then
joins the common hepatic duct to become the common bile duct.
At the neck of the gall bladder is a mucosal fold called Hartmann's pouch, where
gallstones commonly get stuck. The angle of the gallbladder is located between
the costal margin and the lateral margin of the rectus abdominis muscle.

6. Human anatomy

7. Function
When food containing fat enters the digestive tract, it stimulates the secretion of
cholecystokinin (CCK).
In response to CCK, the adult human gallbladder, which stores about 50
millilitres (1.7 U.S. fl oz; 1.8 imp fl oz) of bile, releases its contents into the
duodenum. The bile, originally produced in the liver, emulsifies fats in partly
digested food.
 cholecystokinin (CCK) is a peptide hormone of the gastrointestinal system
responsible for stimulating the digestion of fat and protein

8. Oral cholecystography (O.C.G)
Oral cholecystography is a procedure used to visualize the gallbladder by
administering, by mouth, a radiopaque contrast agent that is excreted by the
liver.
This excreted material will collect in the gallbladder, where reabsorption of
water concentrates the excreted contrast.
Since only 10% of gallstones are radiopaque, the remaining 90% will appear as
translucent on an opaque background in an abdominal x-ray

9. • Proven hypersensitivity to iodinated contrast agents
• Sever hepatic renal disease
• Dehydration
• Cholecystectomy
• Malabsorption syndrome
• Diarrhea
• Drug Vomiting
• Bilirubin higher than 3 milligram
Contraindications

10. Contrast media nomens
 Past :
• Tetra Bromophenolphtalein (Graham)
• Tetra Aiodophenolphtalein (Graham)
• Priodax
• Telepaque (Hopp & Archer 1952)
 Today :
• Obsil
• Cholebrine
• Bliopaque
• Biloptin
• Solu-Biloptin

11. Contrast media Dose
Telepaque or Biloptin:
Normal patient
6 (Tablet) × 0/5 (gram iodine) = 3 gram iodine
Fat patient
12 (Tablet) × 0/5 (gram iodine) = 6 gram iodine
 Higher Dose is danger and to be affected with kidney .

12. Exam Stages
The examination is a three stage process :
1) Day 1 the patient takes a laxative for two days prior to the examination days,
(check contraindications to laxative preparation, care with diabetics, and
conditions like Crohns disease)

13. 2) Day 2 a single control radiograph of the whole abdomen or the right side of
the abdomen.
(This film is then examined to determine, the position of the gallbladder (level with
the upper margin of the hepatic flexure of the colon, to demonstrate any radio
opaque calculi, evaluate the efficacy of the laxative preparation and judge the
exposure for the second part of the examination.)
 The evening before the examination the patient takes the oral contrast agent
tablets as directed by the manufacturer, typically 3 grams of Calcium Ipodate
(Biloptin) with plenty of water, the patient remains nil by mouth except for water
until the examination 14 hours after taking the contrast medium.
Exam Stages

14. 3) The day of the examination check the patient has taken the tablets as directed,
followed the dietary instructions and not been sick or had diarrhea.
The evening of the day before the examination the patient is encouraged to have
a high fat meal to empty the gall bladder. It can help to better absorb Telepaque
but it is not affect on Bilopaque and Biloptin.
AFM or After Fatty Meal Film. If the gall bladder is adequately demonstrated
with obvious calculi then a fatty meal is given, either a proprietary product such
as "Prosperol" or a glass of full fat milk or two eggs , 40 minutes later the gall
bladder is imaged in whichever projection best demonstrated .
Exam Stages

15. Exam case

16. Gallstone
A gallstone is a crystalline concretion formed within the gallbladder by
accretion of bile components. These calculi are formed in the gallbladder, but
may pass distally into other parts of the biliary tract such as the cystic duct,
common bile duct, pancreatic duct, or the ampulla of Vater.
On the basis of their composition, gallstones can be divided into the following
types:
 Cholesterol stones
Cholesterol stones vary in color from light-yellow to dark-green or brown and are
oval 2 to 3 cm in length, often having a tiny dark central spot. To be classified as
such, they must be at least 80% cholesterol by weight.

17. Gallstone
 2. Pigment stones
Pigment stones are small, dark stones made of bilirubin and calcium salts that are
found in bile. They contain less than 20% of cholesterol (or 30%, according to
the Japanese classification system).
 3. Mixed
75 % people have mixed stones.

18. Gallstone

19. Intra venous cholangiography (I.V.C)
X-ray examination of the bile ducts, using a radiopaque dye as a contrast
medium. In the intravenous method, the dye is administered intravenously and is
excreted by the liver into the bile ducts.
Preparation of the patient for the intravenous method requires restriction of
fluids to concentrate the dye and may also include cleansing of the intestinal
tract on the day prior to the examination with a laxative or enema so that fecal
material and gas will not obscure the biliary tract.
X-ray films are taken at 10-minute intervals as the dye is excreted via the cystic,
hepatic, and common bile ducts into the intestinal tract. The excretion is usually
completed within 4 hours.

20. I.V.C Application
• Cholecystectomy
• O.C.G is not satisfactory
• Coldo-colelitiasis
• Bilirubin higher than 3 milligram
 Contraindications :
• Sever hepatic renal disease
• Bilirubin higher than 5 milligram

21. Contrast media nomens
Cholografin
Cholevue
Biligram
Endobil
Biligrafin
 This contrast media after injection to be connected Albumin Protein more than
O.C.G contrast media, then they have higher toxicity than O.C.G Contrast
media.

22. T-tube Cholangiogram
A T-tube cholangiogram is a fluoroscopic procedure in which contrast medium
is injected through a T-tube into the patient's biliary tree. The T-tube is most
commonly inserted during a cholecystectomy operation when there is a
possibility of residual gall stones within the biliary tree.

23. Indications & Contraindications
 Indications
Patient must have T-Tube insitue
Patient's with possibility of residual small gallstones post cholecystectomy
Obstructive Jaundice
Bile duct Stricture
Surgeon unable to explore Bile duct during cholecystectomy surgery
 Contraindications
Contrast or iodine allergy
Pregnancy ( pregnancy test required)
Barium study within last 3 days

24. Examination
1. The drainage tube is clamped the day preceding the examination to let the tube
fill with bile as a preventive measure against air bubbles entering the ducts,
where they would simulate cholesterol stones.
2. The preceding meal is withheld.
3. When indicated, a cleansing enema is administered about 1 hour before the
examination.
Premedication is not required.

25. Examination
The patient is positioned supine on the X-ray table than a slightly RPO position
20ْ can help to ensure the CBD is not superimposed over the patient's spine.
A preliminary/scout image of the RUQ should be acquired.
Injection should continue until the entire biliary tree is opacified and there is
passage of contrast into the duodenum.
If the Intra Hepatic ducts do not fill, the patient can be tilted Trendelenburg and
further contrast injected into the T-tube.
The patient may need to lie on their left hand side to fill the left hepatic duct.

26. Contrast media
The density of the contrast medium used in postoperative
cholangiograms is recommended to be no more than 25% to 30%
because small stones may be obscured with a higher concentration.
Urografin 60%
Conray 280
Omnipaque

27. Case

28. Endoscop Retrograde Cholangio paceratography (E.R.C.P)
Endoscopic retrograde cholangiopancreatography is an endoscopic procedure
that involves the use of fiberoptic endoscopes. You will be lightly sedated and
your doctor will insert an endoscope through the mouth, down the esophagus,
and into the stomach and small bowel. A smaller tube or catheter is passed
through the endoscope and into the bile ducts. Dye is injected into the ducts,
and the doctor takes X-rays that can show whether a tumor is present in the bile
ducts.

29. E.R.C.P

31. Arthrogrphy
An arthrogram is a series of images, often X-rays, of a joint after
injection of a contrast medium
An arthrogram is used to:
Find problems in your joint capsule, ligaments, cartilage (including tears,
degeneration, or disease), and the bones in the joint. In your shoulder, it may be
used to help find rotator cuff tears or a frozen shoulder.
Find abnormal growths or fluid-filled cysts.
Confirm that a needle has been placed correctly in your joint before joint fluid
analysis, a test in which a sample of joint fluid is removed with a thin needle.
Check needle placement before a painkilling injection, such as a corticosteroid
injection.

32. Arthrogrphy
The joint area will be cleaned and a local anesthetic will be injected into the
tissues around the joint to reduce pain.
Next, if fluids are present in the joint, the physician may suction them out
(aspirate) with a needle. These fluids may be sent to a laboratory for further
study.
Contrast agents are then injected into the joint through the same location by
attaching the aspirating needle to a syringe containing the contrast medium.
The purpose of contrast agents in x-ray procedures is to help highlight details of
areas under study by making them opaque.

33. Contrast media
Agents for arthrography are generally air and water-soluble dyes, the most
common containing iodine. Air and iodine may be used together or
independently. After the contrast agent is administered, the site of injection will
be sealed and the patient may be asked to move the joint around to distribute the
contrast.
Radiolucent Contrast media :
Air
Carbon dioxide
Oxygen
Radioopaque Contrast media :
Urografin 60% - Conray 240 – Hexabrix
Omnipaque - Visipaque - Ultravist

34. Case

35. Radiographic examination involving opacification of pathological tracks or
extravasation of contrast medium from hollow organs (gastrointestinal tract,
bladder) or tubular structures (bile ducts, ureter) .
One of the main indications of fistulography is to look for postoperative
anastomotic leaks or injuries of the bile ducts and ureters.
Fistulous tracks may also develop from infections, inflammatory or tumour
lesions and may brake through to the skin (abscesses, osteomyelitis). In these
cases the fistulous track may be demonstrated by inserting a blunt needle or
small catheter into the mouth of the fistula.
Fistulography

36. Contrast media
Oily Contrast media :
lipiodol
Ethiodol
Myodile
Water soluble Contrast media :
Urografin 76% - Conray 240 – Hypaque
Omnipaque - Visipaque - Niopam

37. Case