Contrast radiography uses X-rays and a special dye called a contrast medium to study organs. This test allows radiologists to evaluate structures not clearly seen on regular X-rays. The contrast medium highlights specific body areas like blood vessels, the stomach, and colon, helping them be seen more clearly on X-ray images. Contrast materials temporarily change how X-rays interact with the body, making certain tissues appear different to help physicians diagnose conditions.

1. Contrast radiography
is a method of studying organs using X-rays and the administration
of a special dye, called a contrast medium. This test allows the
radiologist to evaluate structures that are not clearly evident on
conventional X-ray exams.
X-rays work by passing through the body. Because bones block the X-
rays easily, they show up clearly. But organs and other tissue – such
as blood vessels, the stomach, and the colon – do not block the X-
rays so easily. The contrast medium highlights these specific areas in
the body and helps them to be seen in greater detail on the X-ray
image.

2. CONTRAST
MEDIA

3. Contrast Materials
Contrast materials, also called contrast agents or contrast media, are used to improve
pictures of the inside of the body produced by x-rays, computed tomography (CT),
magnetic resonance (MR) imaging, and ultrasound. Often, contrast materials allow the
radiologist to distinguish normal from abnormal conditions.
Contrast materials are not dyes that permanently discolor internal organs. They are
substances that temporarily change the way x-rays or other imaging tools interact with
the body. When introduced into the body prior to an imaging exam, contrast materials
make certain structures or tissues in the body appear different on the images than they
would if no contrast material had been administered. Contrast materials help distinguish
or "contrast" selected areas of the body from surrounding tissue. By improving the
visibility of specific organs, blood vessels or tissues, contrast materials help physicians
diagnose medical conditions.

4. Contrast materials enter the body in one of three ways.They can be:
1. swallowed (taken by mouth or orally)
2. administered by enema (given rectally)
3. injected into a blood vessel (vein or artery; also called given intravenously or intra-arterially)
taken by mouth or orally
given intravenously or intra-arterially
 Following an imaging exam with contrast material, the material is
absorbed by the body or eliminated through urine or bowel movements.

5. There are several types of contrast materials:
1. Iodine-based and barium-sulfate compounds are used in x-ray and computed tomography (CT) imaging exams.
Contrast materials can have a chemical structure that includes iodine, a naturally occurring chemical element. These
contrast materials can be injected into veins or arteries, within the disks or the fluid spaces of the spine, and into
other body cavities.
computed tomography (CT)
imaging exams
x-ray
Iodine-based contrast

6. MYELOGRAPHY

7. 2. Barium-sulfate is the most common contrast material taken by mouth, or orally. It is also used rectally and is
available in several forms, including:
a. powder, which is mixed with water before administration
b. liquid
c. paste
d. tablet
powder
liquid
paste
tablet

8. When iodine-based and barium-sulfate contrast materials are present in a specific area of the body, they block or limit
the ability of x-rays to pass through. As a result, blood vessels, organs and other body tissue that temporarily contain
iodine-based or barium compounds change their appearance on x-ray or CT images.
3. Gadolinium is the key component of the contrast material most often used in magnetic resonance (MR) exams.
When this substance is present in the body, it alters the magnetic properties of nearby water molecules, which
enhances the quality of MR images.
4. Saline (salt water) and gas (such as air) are also used as contrast materials in imaging exams. Microbubbles and
microspheres have been administered for ultrasound imaging exams, particularly exams of the heart.

9. Which imaging exams use contrast materials?
1. Oral Contrast Materials
o Barium-sulfate contrast materials that are swallowed or administered by mouth (orally) are used to enhance x-
ray and CT images of the gastrointestinal (GI) tract, including:
a. pharynx
b. esophagus
c. stomach
d. the small intestine
e. the large intestine (colon)
pharynx esophagus stomach small intestine colon
 In some situations, iodine-based contrast materials are substituted for
barium-sulfate contrast materials for oral administration.

10. 2. Rectal Contrast Materials
o Barium-sulfate contrast materials that are administered by enema (rectally) are used to enhance x-ray and CT
images of the lower gastrointestinal (GI) tract (colon and rectum).
In some situations, iodine-based contrast materials are substituted for barium-sulfate contrast materials for rectal
administration.

11. 3. Intravenous Contrast Materials
o Iodine-based and Gadolinium-based
o Iodine-based contrast materials injected into a vein (intravenously) are used to enhance x-ray and CT images.
Gadolinium injected into a vein (intravenously) is used to enhance MR images. Typically, they are used to enhance
the:
• internal organs, including the heart, lungs, liver, adrenal glands, kidneys, pancreas, gallbladder, spleen, uterus,
and bladder
• gastrointestinal tract, including the stomach, small intestine and large intestine
• arteries and veins of the body, including vessels in the brain, neck, chest, abdomen, pelvis and legs
• soft tissues of the body, including the muscles, fat and skin
• brain
• breast

12. Contrast materials are safe drugs; adverse reactions ranging from mild to
severe do occur but severe reactions are very uncommon. While serious
allergic or other reactions to contrast materials are rare, radiology
departments are well-equipped to deal with them.
Because contrast materials carry a slight risk of causing an allergic
reaction or adverse reaction, you should tell your doctor about:
• allergies to contrast materials, food, drugs, dyes, preservatives, or
animals
• medications you are taking, including herbal supplements
• recent illnesses, surgeries, or other medical conditions
• history of asthma and hay fever
• history of heart disease, diabetes, kidney disease, thyroid problems or
sickle cell anemia
You will be given specific instructions on how to prepare for your exam.

13. • stomachcramps
• diarrhea
• nausea
• vomiting
• constipation
Side effects and adverse and allergic reactions
Barium Sulfate Contrast Materials
You should tell your doctor if these mild side effects of barium-sulfate contrast
materials become severe or do not go away:
Tell your doctor immediately about any of these symptoms:
• hives
• itching
• red skin
• swelling of the throat
• difficulty breathing or
swallowing
• hoarseness
• agitation
• confusion
• fast heartbeat
• bluish skin color
You are at greater risk of an adverse reaction to barium-sulfate contrast materials if:
• you have a history of asthma, hay fever, or other allergies, which will increase your risk
of an
allergic reaction to the additives in the barium-sulfate agent.
• you have cystic fibrosis, which will increase the risk of blockage in the small bowel.
• you are severely dehydrated, which may cause severe constipation.
• you have an intestinal blockage or perforation that could made worse by a barium-
sulfate agent.

14. MILD REACTION
• nausea and vomiting
• headache
• itching
• flushing
• mild skin rash or hives
MODERATE REACTION
• severe skin rash or hives
• wheezing
• abnormal heart rhythms
• high or low blood pressure
• shortness of breath or difficulty breathing
SEVERE REACTION
• difficulty breathing
• cardiac arrest
• swelling of the throat or other parts of the body
• convulsions
• profound low blood pressure
A very small percentage of patients may develop a delayed reaction
with a rash which can occur hours to days after an imaging exam
with an iodine-based contrast material. Most are mild, but severe
rashes may require medication after discussion with your physician.

15. Contrast-Induced Nephropathy
Patients with impaired kidney (renal) function should be given special consideration before receiving iodine-based
contrast materials by vein or artery. Such patients are at risk for developing contrast-induced nephropathy (CIN), a
condition in which already-impaired kidney function worsens within a few days of contrast material administration.
Much of the research linking CIN with iodine-based contrast material is based on older contrast agents that are no
longer used, and some recent studies have found no increased risk of CIN in patients who received iodine-based
contrast material. If you have impaired kidney function, your doctor will assess the benefits of contrast-enhanced
CT against any risks
At-Risk Patients
Some conditions increase the risk of an allergic or adverse reaction to iodine-based contrast materials.These
include:
• previous adverse reactions to iodine-based contrast materials
• history of asthma
• history of allergy
• heart disease
• dehydration
• sickle cell anemia, polycythemia and myeloma
• renal disease
• the use of medications such as Beta blockers, NSAIDs, interleukin 2
• having received a large amount of contrast material within the past 24 hours

16. Being at increased risk for an allergic or adverse reaction to contrast material does not necessarily mean a patient cannot
undergo an imaging exam with contrast materials. Medications are sometimes given before the contrast material is
administered to lessen the risk of an allergic reaction in susceptible patients.
MR-Gadolinium
The contrast material used in MR called gadolinium is less likely to produce an allergic reaction than the iodine-based
materials used for x-rays and CT scanning.Very rarely, patients are allergic to gadolinium-based contrast materials and
experience hives and itchy eyes. Reactions usually are mild and easily controlled by medication. Severe reactions are
rare.

17.  What will I experience before and after receiving contrast material?
Barium-Sulfate Oral and Rectal Contrast Material
If a barium-sulfate contrast material (given orally or rectally) will be used during your exam, you will be asked not to eat
for several hours before your exam begins. If the contrast material will be given rectally, you may also be asked to
cleanse your colon with a special diet and medication (possibly including an enema) before your exam.
If you swallow the contrast material, you may find the taste mildly unpleasant; however, most patients can easily
tolerate it.
If your contrast material is given by enema, you can expect to experience a sense of abdominal fullness and an
increasing need to expel the liquid.The mild discomfort will not last long.
It is a good idea to increase your fluid intake after an imaging exam involving a barium-based contrast material to help
remove the contrast material from your body.
Barium-sulfate contrast materials are expelled from the body with feces. You can expect bowel movements to be white
for a few days. Some patients may experience changes in their normal bowel movement patterns for the first 12 to 24
hours.
Iodine-based Contrast Material
When an iodine-based contrast material is injected into your bloodstream, you may have a warm, flushed sensation
and a metallic taste in your mouth that lasts for a few minutes.
The needle may cause you some discomfort when it is inserted. Once it is removed, you may experience some bruising.
It is a good idea to increase your fluid intake after an imaging exam involving an iodine-based contrast material to help
remove the contrast material from your body.

18. Gadolinium-based Contrast Material
When the gadolinium is injected, it is normal to feel coolness at the site of injection, usually the arm for a minute or two.
The needle may cause you some discomfort when it is inserted. Once it is removed, you may experience some bruising.
Increased fluid intake will help eliminate the contrast material from your body. IV contrast is usually excreted by the
kidneys within the next 24 hours (assuming normal renal function).
Oral contrast is usually excreted within a day or two, but in people with constipation it may
not completely clear out for several days.There is no radiation in contrast used for CT.
Pregnancy and contrast materials
Prior to any imaging exam, women should always inform their physician or x-ray
technologist if there is any possibility that they are pregnant. Many imaging tests and
contrast material administrations are avoided during pregnancy to minimize risk to the baby.
For CT imaging, if a pregnant woman must undergo imaging with an iodine-based contrast
material, the patient should have a discussion with her referring physician and radiologist to
understand the potential risks and benefits of the contrast-enhanced scan.
For MR imaging, gadolinium contrast material administration is usually avoided due to
unknown risk to the baby, but may be used when critical information must be obtained that
is only available with the use of gadolinium-based contrast material.

19. Intravenous Contrast Material (Iodine and Gadolinium) and Breast-feeding:
Manufacturers of intravenous contrast indicate mothers should not breast-feed their babies for 24 to 48 hours
after contrast medium is given. However, both the American College of Radiology (ACR) and the European Society
of Urogenital Radiology note that the available data suggest that it is safe to continue breast-feeding after
receiving intravenous contrast.The Manual on Contrast Media from the ACR states:
"Review of the literature shows no evidence to suggest that oral ingestion by an infant of the tiny amount of
gadolinium contrast medium excreted into breast milk would cause toxic effects.We believe, therefore, that the
available data suggest that it is safe for the mother and infant to continue breast-feeding after receiving such an
agent.
If the mother remains concerned about any potential ill effects, she should be given the opportunity to make an
informed decision as to whether to continue or temporarily abstain from breast-feeding after receiving a
gadolinium contrast medium. If the mother so desires, she may abstain from breast-feeding for 24 hours with
active expression and discarding of breast milk from both breasts during that period. In anticipation of this, she
may wish to use a breast pump to obtain milk before the contrast study to feed the infant during the 24-hour
period following the examination."

20. BILIARY TRACT
Cholecystography and
Cholangiography

21.  Biliary tract examinations are employed to determine:
1. The function of the liver – its ability to remove the contrast
medium from the bloodstream and excrete it with the bile.
2. The patency and condition of the biliary ducts.
3. The concentrating and emptying power of the gallbladder.
 The greatest number of biliary tract examinations are probably
performed in quest of gallstones.
 The calculi, or stones, formed in the biliary tract vary widely in
composition, size, and shape.
Pure cholesterol stones appear as negative filling defects within the
opacified bile, while calcium-containing deposits, either as solitary
calculi or in the form of milk of calcium, can be readily detected on
the plain radiograph

22.  Cholecystogram
– Radiographic examination
involving the gallbladder.
 Cholegraphy
– is the general term used to denote
specialized radiologic examination
of the biliary tract with the use of a
radiopaque contrast material.

23.  Administration of contrast media:
1. By mouth (oral)
2. By injection into a vein in a single bolus or by drip infusion (intravenous)
3. By direct injection into the ducts:
a. Through percutaneous transhepatic puncture
b. During biliary tract surgery (operative or immediate)
c. Through an indwelling drainage tube (postoperative, delayed, or T-tube)
Postoperative cholangiogram
Operative cholangiogram
PTC examination.
Intravenous cholangiogram
Oral cholecystogram

24.  Each method of examination is named according to:
1. The route of entry of the medium.
2. The portion of the biliary tract examined
 Thus, designated by the route of entry;
o Cholecystangiography or Cholecystocholangiography demonstrates both the gallbladder and the bile ducts.
o Cholecystography, the gallbladder ( was developed by Graham et al, in 1924 and 1925)
o Cholangiography, the bile ducts
Visualization of the gallbladder by x-ray was first achieved in 1923 by the intravenous introduction into the
body of a halogenated compound which was excreted by the liver into the bile ducts and gallbladder . This
was the first time that visualization of an organ had been accomplished by introducing a substance into the
body and obtaining a roentgenogram after the substance had been metabolized and localized primarily in
one organ. Previously, visualization of an organ had been achieved only by introducing a substance opaque
to the x-ray directly into the lumen and obtaining a roentgenogram to outline its inner wall. By 1925
visualization of the gallbladder had also been accomplished by the oral administration of halogenated
compounds. The drugs employed for intravenous and oral cholecystography had been synthesized
specifically for that purpose based on earlier experimental work of other investigators. The following account
describes in detail the experimental background of cholecystography, its origin, and its development and use
during the ensuing fifty years.
Roentgenologic examination of the gallbladder. Preliminary report of a new method utilizing the intravenous
injection of tetrabromphenolphthalein. By Evarts A. Graham and Warren H. Cole.

25. ORAL CHOLECYSTOGRAPHY
Instruction to Patient:
The patient should be given clearly printed instructions covering:
1. Preliminary preparations of the intestinal tract
2. Preliminary diet
3. Exact time to ingest the oral medium
4. Avoidance of laxatives for 24 hrs before the ingestion or injection of the medium.
5. Avoidance of all food, both solid and liquid, after receiving an oral medium (water may be
taken as desired before the oral examination)
6. The time to report for the examination
The success of oral cholecystography depends on the integrative function:
1. Of the intestinal mucosa in absorbing the contrast substance and liberating it into the
portal bloodstream for conveyance to the liver.
2. Of the liver

26. Instructions to patient
Before OCG is performed, the following steps are observed:
• To secure full cooperation from the patient, explain the purpose of the preliminary preparation and the
procedure to be followed.
• Tell the patient the approximate time required for the examination, allowing for the possibility of delay if
the colon requires further cleansing or the emptying time of the gallbladder is delayed.
• Give the patient clearly printed instructions covering (1) the preliminary preparation of the intestinal tract,
(2) the preliminary diet, (3) the exact time to ingest the oral medium, (4) the avoidance of laxatives for 24
hours before the ingestion or injection of the medium, (5) the avoidance of all food, both solid and liquid,
after receiving an oral medium (water may be taken as desired before the oral examination), and (6) the
time to report for the examination.
• When the patient reports for the examination, ask the patient how each step of the preparation
procedure was followed.
• For the oral technique, ask the patient whether any reaction such as vomiting or diarrhea occurred.
Vomiting may be important if it occurs within 2 hours after ingestion of the contrast medium. Mild catharsis
may do no harm, but diarrhea can result in egestion of a majority of the contrast substance, so that only a
faint shadow, if any, of the gallbladder is visualized.
• Because prolonged fasting causes the formation of gas, as well as possible headache, give the patient an
early morning appointment if possible.

27. Preparation of Intestinal Tract
Much of the success of biliary tract examinations
depends on attaining a clear image of the right upper
quadrant of the abdomen . In some patients a scout
radiograph may be taken on the day before OCG.
This radiograph serves a dual purpose: (1) assessment
of bowel fecal content to determine the extent of
cleansing enemas required and (2) identification of
small radiopaque stones that might otherwise be
camouflaged by the contrast medium. Based on the
scout radiograph the bowel content may be judged
to be light to moderate so that it can be eliminated
with one or two cleansing enemas. Heavy bowel
content may require a laxative. Often, no
preparation is needed. If used, laxatives are
administered 24 hours before the ingestion or injection
of a contrast agent to alI ow irritation of the intestinal
mucosa to subside and, in the oral technique, to
prevent egestion of the contrast medium with the
fecal material.
AP abdomen
demonstrating prepared
intestinal tract.
AP abdomen demonstrating
unprepared intestinal
tract.

28. Contrast administration
The contrast medium available for OCG is normally given to the patient in a single dose approximately
2 to 3 hours after the evening meal on the night before the examination. The usual single dose of 3g is
administered in the form of four to six tablets. Breakfast is usually withheld on the morning of the
procedure. The contrast media used in oral cholecystography differ in their rate of absorption and
liberation into the portal bloodstream. The absorption time varies from 10 to 12 hours for most present-
day oral agents. The administration of the contrast agent is scheduled to allow enough time for
maximum concentration of the contrast agent in the gallbladder. An exception is ipodate calcium,
which is rapidly absorbed and allows visualization of the biliary ducts in an average of 1.5 hours and
visualization of the gallbladder in 3 to 4 hours.
Scout radiographs
To ensure that the contrast material was absorbed and concentrated in the gallbladder, one or more
preliminary radiographs are often obtained. The decision to continue OCG is frequently based on
whether the gallbladder is visualized on scout radiographs and, if so, how well. The scout radiographs
may be taken with the patient supine or prone. The prone position is generally preferred because it
places the structures of the biliary system closer to the IR.

29. Patient instructions and preparation validation
Before OCG is performed, the following steps are observed:
• Ensure that the patient has not had a cholecystectomy. If the gallbladder has been removed, there is no
reason to continue the procedure.
• When the patient reports for the procedure, determine that each step of the preparation was followed.
• Ask the patient if the contrast medium was administered and if any reaction such as vomiting or
diarrhea occurred. Vomiting may be important if it occurs within 2 hours after ingestion of the contrast
medium. Mild catharsis may do no harm, but diarrhea can result in egestion of most of the contrast
substance so that only a faint shadow, if any, of the gallbladder is visualized.
• Determine whether the patient has remained NPO.
• If the patient has correctly followed the preparation, discuss the procedure with the patient. Taking the
time to review the procedure and answer any questions will gain the patient's respect and cooperation.
• Once the patient understands the procedure, have the patient change into an examination gown if not
properly dressed.

30. Inspection of scout radiographs
As soon as the scout radiographs are available, they are
carefully inspected for the presence or absence of the
gallbladder. If contrast medium is present, it is important to
determine (1) whether the concentration of the contrast
medium is sufficient for adequate visualization, (2) the exact
location of the organ, and (3) whether a change in the exposure
factors is needed for proper demonstration of the organ.
When the gallbladder is not visualized, the entire abdomen
should be evaluated if that procedure has not already been
performed. A 35 X 43 cm (14 X 17 inch) scout radiograph is
recommended to evaluate the patient for possible transposition
of the abdominal organs and to check the iliac fossa of patients
with an asthenic body habitus. It is also possible that the
gallbladder may be obscured by fecal material in the colon. If
such is the case, it may be necessary to administer an enema to
clean the colon to the region of the right colic flexure. It may be
necessary to question the patient again about the preparation.
It is possible that the patient did not fast or did not take all of
the contrast medium. Normal AP gallbladder.

31. Fatty Meal
In the earlier years of radiology, patients were often given a fatty meal after satisfactory visualization of
the gallbladder. The fatty meal consisted of a commercially available bar, eggs and milk, or eggnog. The
meal caused the gallbladder to contract, and additional diagnostic information was seldom obtained. An
injection of the hormone cholecystokinin will also cause the gallbladder to contract. The fatty meal is
seldom used today because of the diagnostic capability of ultrasonography.
PA oblique
gallbladder. LAO
position. before fatty
meal.
PA oblique
gallbladder. LAO
position. after a fatty
meal in the same
patient

32. Postprocedure instructions
Once the gallbladder has been adequately visualized, the patient can go home or return to
the hospital room. Currently available contrast material is eliminated mainly through the
alimentary canal. The patient should be instructed to eat and drink normally.

33.  PA PROJECTION
Image receptor: 24 x 30 cm for scout radiograph, 8 X 10 inches (18 X 24 cm) for subsequent exposures
o Position of patient (Prone)
• Place the patient in the prone position with a pillow under the head.
• If the patient is thin, place the pillow lengthwise and adjust it so that it extends inferiorly as far as the transmamillary
line or a little below it.
Position of part Prone
• Adjust the patient's body so that the right side of the abdomen is centered to the midline of the grid.
• Rest the patient's left cheek on the pillow to rotate the vertebrae slightly toward the left side.
• Flex the patient's right elbow, and adjust the arm in a comfortable position. If necessary, place the left arm alongside
the body.
• Elevate the patient's ankles to relieve pressure on the toes.
• Center the IR according to the body habitus of the patient.
• If the patient has pendulous breasts, have her spread the breasts superiorly and laterally to ensure that the
gallbladder region is cleared.
• Immobilize the abdomen with a compression band if necessary.
• Shield gonads.
• Respiration: Suspend respiration at the end of expiration. Watch for an indication of tenseness, and allow about 2
seconds to elapse after the cessation of respiration before making the exposure. This interval pennits peristaltic action
to subside and gives the patient time to relax.

34. o Upright Position
• Adjust the body so that the previously localized gallbladder is centered to the midline of the grid.
• Elevate the gallbladder to (or almost to) the location it assumed in the prone position by instructing the patient to
fully extend the arms. Otherwise, depending on the habitus of the patient, center the IR 2 to 4 inches (5 to 10 cm)
below the prone level to allow for the change in gallbladder position. The remainder of the procedure is the same as
for the prone position.
o Central ray
• Perpendicular and centered to the gallbladder at a level appropriate to the patient's body habitus.
PA gallbladder.
PA gallbladder.
upright position.

35. o Structures Shown
The upright PA projection presents a somewhat axial representation of the opacified gallbladder. The foreshortening in
the PA projection is caused by the angle between the long axis of the obliquely placed gallbladder and the plane of the
IR. The degree of angulation and consequently the amount of foreshortening vary according to body habitus and are
influenced by body position, being less in the upright position.
PA gallbladder: hypersthenic patient. Note almost horizontal
position of gallbladder
PA gallbladder: asthenic patient.

36.  PA OBLIQUE PROJECTION
 LAO position
 LATERAL PROJECTION
 R lateral position
Image receptor: 8 x 10 inches (18 x 24 cm) lengthwise
o Position of patient
• Place the patient in the recumbent position for oblique and lateral
projections of the gallbladder.
Position of part LAO position
• The degree of rotation necessary for satisfactory demonstration of the
gallbladder depends on the location of the organ in reference to the
vertebrae (thin subjects require more rotation than do heavier patients),
the angulation of the long axis of the organ, and whether the right colic
flexure is clear.
• With the patient in the prone position, elevate the right side to the
desired degree of obliquity (15 to 40 degrees).
• Instruct the patient to support the body on flexed knee and elbow.
• Adjust the patient's body to center the previously localized gallbladder
to the midline of the grid.
• Place a foam sponge against the anterior surface of the abdomen
PA oblique gallbladder. LAO position.

37. R Lateral Position
• The patient lies on the right side, and the right lateral
position is used to differentiate gallstones from renal
stones or calcified mesenteric lymph nodes if needed. The
lateral position is also required to separate the
superimposition of the gallbladder and the vertebrae in
exceptionally thin patients and to place the long axis of a
transversely placed gallbladder parallel with the plane of
the IR.
• Center the patient to the IR at the point where the
gallbladder has been previously localized.
• Shield gonads.
• Respiration: Suspend at the end of expiration unless the
scout radiograph indicates otherwise.
Right lateral gallbladder
Central ray
• Perpendicular to the midpoint of the IR at a level appropriate for the
body habitus of the patient for both the oblique and lateral projections.

38. Structures shown
The oblique and lateral projections show the opacified gallbladder free from self-superimposition or
foreshortening and from the structures adjacent to the gaIlbladder
PA oblique gallbladder, LAO position. Right lateral gallbladder demonstrating stones
EVALUATION CRITERIA
The following should be clearly
demonstrated:
• Entire gallbladder and area of the
cystic duct
• Gallbladder with a short scale of
contrast
• No motion visible on the gallbladder
• Improved visibility in the oblique
projection if the gallbladder was
superimposed over bowel contents or
bony shadows in other projections
• Compensation for increased thickness in
lateral projection so that density is similar
to that in other projections

39. AP PROJECTION
R lateral decubitus position
The right lateral decubitus body position for demonstration of the gallbladder was developed by Whelan.
Image receptor: 8 x 10 inches (18 x 24 cm) or 24 X 30 cm placed vertically)
Position of patient
• Place the patient in the lateral recumbent position on a stretcher or movable table in front of a vertical grid device.
• Exercise care to ensure that the patient does not fall off the cart; lock alI wheels of the cart securely in position.
Position of part
• Place the patient on the right side with the body elevated 2 to 3 inches (5 to 7.6 cm) on a suitable radiolucent
support to center the gallbladder region to the vertically placed IR.
Central ray
• Directed horizontally to enter the localized area of the gallbladder
 Structures shown
The right lateral decubitus and upright positions are used to demonstrate stones that are heavier than bile and that
are too small to be visible other than when accumulated in the dependent portion of the gallbladder. These positions
are also used to demonstrate stones that are lighter than bile and that are visualized only by stratification

40. Air in
bowel
Iliac crest
Gallbladder

41. INTRAVENOUS CHOLANGIOGRAPHY
Intravenous cholangiography (IVC) is seldom performed because of a relatively higher incidence of
reactions to the contrast medium and the availability of other diagnostic procedures. When used, lVC is
employed to investigate the biliary ducts of cholecystectomized patients. It is also used to investigate the
biliary ducts and gallbladder of non cholecystectomized patients when these structures are not visualized
by OCG and when, because of vomiting or diarrhea, a patient cannot retain the orally administered
medium long enough for its absorption. In cases of non visualization, immediately instituting the
intravenous procedure may save time for the radiology department and the patient as well as spare the
patient the rigors of having the intestinal tract prepared again.
Position of patient
The following steps are observed:
• Place the patient in the supine position for a preliminary radiograph of the abdomen.
• Place the patient in the RPO position (15 to 40 degrees) for an AP oblique projection of the biliary ducts
• Obtain a scout (localization) radiograph and/or tomogram to check for centering and exposure factors.
• Advise the patient that a hot flush may occur when the contrast medium is injected.
• Timed from the completion of the injection, duct studies are ordinarily obtained at 10-minute intervals
until satisfactory visualization is obtained. Maximum opacification usually requires 30 to 40 minutes.

42. AP oblique, RPO position, showing biliary duct
(dots).
AP oblique biliary duct, RPO position, 10minutes after
injection of contrast medium.

43. Contraindications
Intravenous cholangiography is not generally indicated for patients who have liver disease or for those
whose biliary ducts are not intact. The probability of obtaining radiographs of diagnostic value greatly
decreases when the patient's bilirubin is increasing or when it exceeds 2 mg/dl (Milligrams per Deciliter).
In cases of obstructive jaundice and postcholecystectomy, ultrasonography has become the preferred
technique for demonstrating the biliary system.

44. PTC demonstrating obstruction stone at ampulla
(arrow).
PTC demonstrating stenosis (arrow) of common hepatic
duct caused by trauma.
PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY

45. PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY
Percutaneous transhepatic cholangiography
(PTC)I is another technique employed for
preoperative radiologic examination of the
biliary tract. This technique is used for patients
with jaundice when the ductal system has been
shown to be dilated by CT or ultrasonography
but the cause of the obstruction is unclear. The
performance of this examjnation has greatly
increased because of the availability of the
Chiba ("skinny") needle. In addition, PTC is often
used to place a drainage catheter for the
treatment of obstructive jaundice. When a
drainage catheter is used, both diagnostic and
drainage techniques are performed at the same
time.
PTC with Chiba needle (arrow) in position showing dilated
biliary ducts.

46. PTC is performed by placing the patient on the radiographic table in the supine position. The patient's right side is
surgically prepared and appropriately draped. After a local anesthetic is administered, the Chiba needle is held
parallel to the floor and inserted through the right lateral intercostal space and advanced toward the liver hilum.
The stylet of the needle is withdrawn, and a syringe filled with contrast medium is attached to the needle. Under
fluoroscopic control, the needle is slowly withdrawn until the contrast medium is seen to fill the biliary ducts. In most
instances the biliary tree is readily located because the ducts are generally dilated. After the biliary ducts are filled,
the needle is completely withdrawn and serial or spot AP projections of the biliary area are taken
BILIARY DRAINAGE PROCEDURE AND STONE EXTRACTION
If dilated biliary ducts are identified by CT, PTC, or ultrasonography, the radiologist, after consultation with the
referring physician, may elect to place a drainage catheter in the biliary duct. A needle larger than the Chiba
needle used in the PTC procedure is inserted through the lateral abdominal wall and into the biliary duct. A guide
wire is then passed through the lumen of the needle, and the needle is removed. Once the catheter is passed over
the guide wire, the wire is then removed, leaving the catheter in place.
The catheter can be left in place for prolonged drainage, or it can be used for attempts to extract retained stones
if they are identified. Retained stones are extracted using a wire basket and a small balloon catheter under
fluoroscopic control. This extraction procedure is usually attempted after the catheter has been in place for some
time

47. Post PTC image showing wire basket
(arrow) around retained stone.
PTC with drainage catheter in place.
Right hepatic duct
Catheter
Drainage catheter in
common bile duct
Contrast "spill"
into duodenum
Tip of catheter

48. PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY

49. Postoperative Cholangiography
Postoperative, delayed, and T-tube cholangiography are radiologic terms applied to the
biliary tract examination that is performed by way of the T-shaped tube left in the common
bile duct for postoperative drainage. This examination is performed to demonstrate the
caliber and patency of the ducts, the status of the sphincter of the hepatopancreatic ampulla,
and the presence of residual or previously undetected stones or other pathologic conditions.
Postoperative cholangiography is performed in the radiology department. Preliminary
preparation usually consists of the following:
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 I hour before the examination.
Premedication is not required. The contrast agent used is one of the water-soluble organic
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.
After a preliminary radiograph of the abdomen has been obtained, the patient is adjusted in
the RPO position (AP oblique projection) with the right upper quadrant of the abdomen
centered to the midline of the grid.

50. Contrast medium in duodenum
Right hepatic duct
Hepatic duct
T-tube
Common bile duct
Pancreatic duct
AP oblique postoperative cholangiogram, RPO position.

51. With universal precautions employed, the
contrast medium is injected under
fluoroscopic control, and spot and
conventional radiographs are made as
indicated. Otherwise 24 X 30 cm IRs are
exposed serially after each of several
fractional injections of the medium and
then at specified intervals until most of
the contrast solution has entered the
duodenum. Stern, Schein, and Jacobson I
stressed the importance of obtaining a
lateral projection to demonstrate the
anatomic branching of the hepatic ducts
in this plane and to detect any
abnormality not otherwise
demonstrated. The clamp generally is not
removed from the T-tube before the
examination is completed. Therefore the
patient may be turned onto the right side
for this study.
AP oblique postoperative cholangiogram, RPO
position, showing multiple stones in common bile
duct (arrows).
Right lateral cholangiogram showing
anteroposterior location of T-tube (dots),
common bile duct (arrow), and
hepatopancreatic ampulla (duct of Vater)
(arrowhead).

52. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used to diagnose biliary and pancreatic
pathologic conditions. ERCP is a useful diagnostic method when the biliary ducts are not dilated and when no
obstruction exists at the ampulla. ERCP is performed by passing a fiber-optic endoscope through the mouth into
the duodenum under fluoroscopic control. To ease passage of the endoscope, the patient's throat is sprayed with a
local anesthetic. Because this causes temporary pharyngeal paresis, food and drink are usually prohibited for at
least I hour after the examination. Food may be withheld for up to 10 hours after the procedure to minimize
irritation to the stomach and small bowel.
Cannulation procedure. Procedure is begun with patient
in left lateral position. This schematic diagram gives an
overview of the location of the examiner and the position
of the scope and its relationship to various internal organs.
Inset: Magnified view of the tip of the scope with cannula
in papilla.

53. After the endoscopist locates the hepatopancreatic ampulla (ampulla of Yater), a small cannula is passed through
the endoscope and directed into the ampulla. Once the cannula is properly placed, the contrast medium is injected
into the common bile duct. The patient may then be moved, fluoroscopy performed, and spot radiographs taken.
Oblique spot radiographs may be taken to prevent overlap of the common bile duct and the pancreatic duct.
Because the injected contrast material should drain from normal ducts within approximately 5 minutes, radiographs
must be exposed immediately.
The contrast medium that is used depends on the preference of the radiologist or gastroenterologist. Dense contrast
agents opacify small duct very well, but they may obscure small stones. If small stones are suspected, use of a more
dilute contrast medium is suggested.' A history of patient sensitivity to an iodinated contrast medium in another
examination (e.g., intravenous urography) does not necessarily contraindicate its use for ERCP. However, the patient
must be watched carefully for a reaction to the contrast medium during ERCP. ERCP is often indicated when both
clinical and radiographic findings indicate abnormalities in the biliary system or pancreas. OCG, ultrasound
examination, or IYC is usually performed before ERCP. Ultrasonography of the upper part of the abdomen before
endoscopy is often recommended to assure the physician that no pseudocysts are present. This step is important
because contrast medium injected into pseudocysts may lead to inflammation or rupture of the pseudocysts.

54. ERCP spot radiograph, PA projection. Pancreatic duct Cannula
Common hepatic duct
Pancreatic duct
Cystic stump
Common bile duct
Endoscope

55. ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY

56. Salivary Gland

57. 1. Parotid Gland
- It is the largest of the salivary glands and consists
of a flattened superficial portion and a wedge-
shape deep portion.
2. Submandibular/Submaxillary Gland
- It is irregularly shaped, is fairly large, and
extends posteriorly from a point below the first
molar almost to the angle of the mandible.
3. Sublingual Gland
- Composed of a small group of smaller glands, is
narrow and elongated in form. This gland is
located in the floor of the mouth beneath the
sublingual fold ( plica sublingualis)

58. Parotid Gland – Stensen’s Duct
Submandibular – Wharton’s Duct
Sublingual – ducts of Rivinus – main
sublingual duct – Bartholin’s duct –