This document discusses various fluoroscopic procedures used in radiology. It begins by describing fluoroscopy as an imaging technique using real-time x-ray images. It then discusses the components of a fluoroscopy unit and how images are monitored. Various procedures using fluoroscopy and barium are described, including barium swallow, barium meal, follow through, and enema. Common indications, techniques, findings, and complications are summarized for each procedure. Contrast agents and preparation for GI studies are also outlined.

1. FLOUROSCOPIC
PROCEDURES
DR NANI LAMPUNG
JR1 DEPT OF RADIODIAGNOSIS
JNMCH AMU ALIGARH

2. TO BE DISCUSSED
 FLOUROSCOPY
 CONTRAST AGENTS
 PROCEDURES
o BARIUM SWALLOW
o BA MEAL
o BA MEAL FOLLOW THROUGH
o ENTEROCLYSIS
o BARIUM ENEMA
o DISTAL LOOPOGRAM
o MCU, RGU AND HSG
 AND FINDINGS

3. FLOUROSCOPY
Imaging technique that uses x-rays to
obtain real time images

4. HISTORY
• Thomas Edison 1896
• Screen (zinc-cadmium
sulfide) placed over
patient’s body
• Red goggles-30 minutes
before exam
• 1950s image
intensifiers developed

5. Fluoroscopic Equipment
General purpose fluoroscopic system

6. Mobile fluoroscopic
system for routine
procedures during
surgery
Fluoroscopic Equipment (cont)

7. Components of Fluoroscope
x-ray generator
 x-ray tube
 collimator
 filters
 patient table
 grid
 image intensifier
 optical coupling
television system
image recording
IMAGE
INTENSIFIER
XRAY
TUBE

8. Fluoroscopy : dynamic (real time) imaging

9. Image intensifier
 The image intensifier is a complex electronic device
that receives the remnant X-Ray beam, converts it
into light, and increases the light intensity.

10.  The principal advantage- increased image
brightness.
Image monitoring:
Two methods -used to electronically convert the
visible image on the output phosphor of the image
intensifier into an electronic signal.
1. Thermionic television camera tube
2. The solid state charge-coupled device (CCD).

11. Camera tube:
• The TV camera consists of cylindrical housing, approx 15 mm
in diameter by 25 cm in length, that contains the heart of the
camera, TV camera tube.
• It also contains electromagnetic coils (used to properly steer
the electron beam inside the tube)
• Vidicon and its modified version, the Plumbicon, are used
most often.

13. • Two methods are commonly used to couple the
television camera tube to the image-intensifier
tube.
– Fiber optics.
– Lens system.

14. • The video signal is amplified and is transmitted by cable to
the television monitor, where it is transformed back into a
visible image.

15. Fluoroscopy Uses
• Barium studies
• Catheter Insertion
• Blood Flow Studies
• Orthopedic Surgery

16. OTHERS
• Injections into the knees (Viscosupplementation injections)
• Locating foreign bodies
• Percutaneous Vertebroplasty (Treating compressed fractures of
the spine)
• Injections into joints or spine
• Image-guided anesthetic injections

17. CONTRAST used
1. BARIUM SULPHATE
SUSPENSION
• Inert
• Insoluble in water
• Good mucosal coating
• No major sequalae if aspirated
• Cost effective
DISADVANTAGES
• Mediastinitis
• Peritonitis
• may collect in GIT

18. 2. WATER SOLUBLE CONTRAST
• Gastrograffin, Gastromiro
• USE- suspected perforation
DISADVANTAGES
• Poor mucosal coating
• Allergic reactions
• Chemical pneumonitis

19. 3. GASES
• Co2
• Air
• room air for Ba Enema

20. TYPES OF BARIUM STUDIES
1. SINGLE CONTRAST- single contrast medium
2. DOUBLE CONTRAST- two contrast media
• Ba sulphate suspension (+ve contrast )
• Air (-ve contrast)

21. SINGLE CONTRAST
• Elderly & uncooperative pts
• Low concentration
• Poor mucosal coating
• Less sensitive for polyps,
erosions, linear ulcerations,
superficial gastric ca, subtle
mucosal abnormalities
DOUBLE CONTRAST
• younger
• higher conc.
• good mucosal coating
• more sensitive polyps &
small mucosal lesions

22. DOUBLE CONTRAST SINGLE CONTRAST

23. PREPARATION FOR GI BARIUM STUDIES
• Maintain Low residual diet
• Laxatives
• Increase fluid intake
• NPO from midnight
• Follow up care –colour change/constipation
• 2 times cleansing enema for barium enema studies

24. PREPARATION FOR GI BARIUM STUDIES
• Take h/o related to medications & any allergy to
contrast agents
• Ask patient to remove jewellery, eyes glasses or any
metallic objects / clothings
• Explain the procedure to patient & take consent

25. BARIUM SWALLOW
• Radiographic evaluation of pharynx and entire
oesophagus upto gastroesophageal junction

26. INDICATIONS
• DYSPHAGIA,ODYNOPHAGIA
• HEARTBURN,RETROSTERNAL PAIN
• HIATUS HERNIA,STRICTURE FORMATION
• ESOPHAGEAL CA
• MOTILITY D/O-ACHALASIA,DIFFUSE OESOPHAGEAL SPASMS
• THORACIC MASS LESIONS
• MITRAL VALVE DISEASE
• OESOPHAGEAL VARICES
• ASSESSMENT OF ABNORMALITY OF
A. PHARYNGOESOPHAGEAL J/N INCLUDING ZENKERS DIVERTICULUM
B. CRICOID WEB
C. CRICOPHARYNGEAL ACHALASIA

27. CONTRAINDICATIONS
• Suspected leakage into the mediastinum,
pleural or peritoneal cavities
• Tracheo-esophageal fistula

28. TECHNIQUE
• PHARYNX
• Mouthful contrast bolus with high density (250%w/v)
• Pt is asked to swallow once & stop swallowing
thereafter( to get optimum mucosal coating)
• frontal and lateral view x-ray taken

29. SP-soft palate
V-valeculla
P-pyriform sinus
LATERAL VIEW AP VIEW

30. ESOPHAGUS (SINGLE CONTRAST)
• Multiple mouthful 80% w/v barium suspension is given
• Take the flouroscopic unit to pt neck command to
swallow
• Observe the Ba passing down the esophagus upto GE J/N
USEFUL IN –
Ext compression, Displacement, Motility d/o
• Prone swallow to assess esophageal contraction
(esophageal web, hiatal hernia & esophageal varices)

31. DOUBLE CONTRAST
• Effervescent powder is added to the Ba mixture
250% w/v
• Inj buscopan i.v may be given to keep esophagus
distended for a longer time
• FILMS
1. Control film
2. Spot films- AP/Lateral views of upper, mid & lower
oesophagus

32. 32
AP VIEW LATERAL VIEW

33. COMPLICATIONS
• Aspiration
• Leakage of Ba from perforation l/t mediastinitis

34. SPECIFIC FINDINGS

35. OESOPHAGEAL WEB
• SHELF-LIKE INFOLDING OF
MUCOSA(1-2 MM THICK)
• PARTIALLY OBSTRUCTING
CERVICAL ESOPHAGEAL
WEB
• JET PHENOMENON
• ASSOCIATION-EB,BP,PVS

36. ZENKERS DIVERTICULUM
• ZENKER’S
DIVERTICULUM • Pulsion false diverticulum
• Killian’s dehiscence
• Defect in cricopharyngeus
muscle

37. KILLIAN JAMIESON DIVERTICULUM
• Pulsion diverticulum
• Lateral anatomic weak site
• Below cricopharyngeus

38. DIFFUSE ESOPHAGEAL SPASM
• Irregular areas of
narrowing &
dilatations
• Cork screw/shish
kebab/rosary bead
appearance

39. ACHALSIA CARDIA
*With short segment
stricture.
* A “bird-peak " like
tapering of the
esophagus at the GE
junction. OR
• DEGENERATION OF
NEURONS OF
AURBACH’S PLEXUS
• Dilatation of body
• Short segment stricture
• BIRD BEAK like tapering
at GE J/N

40. ESOPHAGEAL VARICES
• Mild dilatation of the
esophagus
with multiple
persistent filling
defects in the lower
third of the
esophagus and/or
longitudinal furrows.
• Mild dilatation
with multiple
persistent filling
defects

41. TRACHEOESOPHAGEAL FISTULA
• Congenital/Acquired
• Ideal contrast non ionic
water soluble media
• In case fistula not
identified laterally, put in
prone.
• If fistula seen, stop
procedure as barium
aspiration result in
inflammation and
granuloma

42. Diaphragmatic hernia
Herniation of abdominal viscera into thoracic
cavity through-
DIAPHRAGMATIC HIATUS:-
 sliding hernia
 rolling hiatus hernia
CONGENITAL DEFECT:-
 Bochdalek hernia
 Morgagni hernia

43. SLIDING HIATUS HERNIA
Develop due to stretching or
tear of phrenico-esophageal
ligament
stomach protrudes >2cm
above the hiatus
>3 folds seen across the
hiatus
diameter of hiatus >3cm

44. Rolling hiatus hernia
Fundus herniates
alongside lower esophagus
while cardia remains below
the diaphragm
 T/T–
Nissen’s fundoplication

45. Esophageal carcinoma
NARROWING OF LUMEN WITH MUCOSAL
IRREGULARITY AND SHOULDERING

46. BARIUM MEAL
• Radiological study of esophagus, stomach, duodenum
till the Gastroduodenal J/N

47. INDICATIONS
• Peptic ulceration
• Malignancies of GE junction, stomach, duodenum
• Motility d/o
• Hiatus hernia
• Gastric or duodenal obstruction
• Children- GER, pyloric obstruction, malrotation

48. CONTRAINDICATIONS
• Complete large bowel obstruction
• Suspected perforation (unless water soluble
contrast medium is used)

49. TECHNIQUE
DOUBLE CONTRAST
kilovolt range-70 – 120 kv
• Inj buscopan(20mg) /glucagon(0.1-0.2 mg) iv-relax
stomach & suspend peristalsis
• Effervescent agent is given
• Standing in RAO position- 120ml of high
density barium(250%w/v) double contrast
views of lower esophagus is obtained

50. • FOR STOMACH-Pt
placed in recumbent position & roll the
patient from side to side ( encourages mucosal
coating & adequate distension)
• FOR DUODENUM-When
Ba enters duodenum pt is turned to RAO
position to fill duodenum with gas and then DC
films are taken

51. DOUBLE CONTRAST STUDY
ADVANTAGES
• Highly accurate detecting abnormalities
following gastric sx,
• Bile reflex gastritis, marginal ulcerations
• Recurrent Ca

52. TYPICAL FILMING SEQUENCES
POSITIONING
• ERECT RAO
AP
• SUPINE-RAO
AP
LAO
RL
• PRONE (PAD ↓ ANTRUM)-AP
• SUPINE-RAO
DEMONSTRATES
 ESOPHAGUS {PRONE LPO(SC)}
 FUNDUS
 BODY+ANTRUM WITH LESSER CURVE
 BODY + ANTRUM
 BODY WITH LESSER CURVE
 FUNDUS
 DUODENAL LOOP
 DUODENAL CAP

53. SINGLE CONTRAST STUDY
• Ba mixture given in erect position wherever possible
• Compression films are taken to obtain good mucosal detail
• kilovolt range-120 to 150 kv
ADVANTAGES-
• pylorospasm, fistulae, enlarged gastric rugae best seen
• filling defect due to large mass easily identifiable
DISADVANTAGES-
• lack of sensitivity for small polyps, ulcers, superficial Ca

54. MODIFICATIONS
• FRAIL IMMOBILE ELDERLY PT- SC study with 100% w/v barium
• PARTIAL GASTRECTOMY OR GASTRIC DRAINAGE
PROCEDURE(PYLOROPLASTY/GASTROENTROSTOMY)-
early flooding
- start examination in prone swallow using high density barium
-when Ba reaches duodenum or gastroentrostomy pt is quickly
turned supine and dc films are taken
• HIATUS HERNIA- patient put in prone with abdominal
compression applied by pillow or pad

55. Normal mucosal pattern
Areae gastricae Rugal folds

56. 56
Duodenal cap
• Symmetric triangular
structure formed by
first part of duodenum
• Shows a fine velvety
surface pattern due to
presence of villi

57. Peptic ulcer
An ulcer is a focal area of mucosal disruption
On barium meal examination- an ulcer
dependent wall – round or ovoid collection of
barium filling the ulcer crater
nondependent wall – circular or hemispheric ring
due to barium coating the rim of unfilled ulcer

58. BENIGN GASTRIC ULCER MALIGNANT GASTRIC ULCER
• Smooth round/ovoid
ulcer
• Hampton’s
hump/smooth ulcer
collar
• Smooth, straight
radiating folds
• Projects outside luminal
contour
• Irregular shaped,
abnormally surfaced
ulcer
• Mucosal nodularity at
edge
• Lobulated, enlarged or
club shaped folds
• Lies within the outline
of stomach

59. BENIGN ULCER MALIGNANT ULCER

60. Gastric volvulus
ORGANOAXIAL TYPE-
• Commonest
• Stomach rotates around
an axis between
duodenum and GE
junction
• Greater curvature rotates
forward and upward
GREATER CURVE LIES ABOVE
THE LESSER CURVE

61. MESENTEROAXIAL –
• Rotates around an axis
between midpoint of
lesser and greater
curvature
• Posterior surface of
stomach lies anteriorly
GASTRIC ANTRUM LYING ABOVE
THE G-E JUNCTION

62. 62
WIDENED C-LOOP OF DUODENUM
• D/D-
Normal variant
Pseudocyst or pancreatic
mass
 AAA
Choledochal cyst
Retroperitoneal mass
Mesenteric lymph nodes

63. BARIUM MEAL FOLLOW THROUGH
• Demonstrate the whole of small bowel from
duodenal flexure to ileocaecal junction

64. INDICATIONS
• MALABSORPTIONS
• INTESTINAL TB
• MALROTATION IN INFANTS/NEONATES- TO KNOW LEVEL &
CAUSE OF OBSTRUCTION

65. TECHNIQUE
• Following drinking contrast(50-100%w/v)
patient lies in prone or on right side until ba
has left the stomach
• AIM- to produce continous column of Ba in
small bowel
• spot films may be made of any loops or
segments of bowels

66. WELL PERFORMED BARIUM MEAL
• Entire BL should be included in each
radiograph
• Stomach & duodenum should be documented
in initial films
• Time marker should be clearly visible
• Ileocaecal j/n should be well visualised

67. Feathery app. of
jejunum
Smooth contour
of ileum

68. Enteroclysis/small bowel enema
• Radiographic procedure in which contrast
medium is injected directly beyond duodenum
• ADVANTAGE- Eliminates the obscuration of
individual segment of small bowel by
complete filling of tract with Ba

69. TECHNIQUE
• Under flouroscopic control the tube with stiff
guidewire is advanced upto duodenojejunal flexure
• Contrast (200 ml of 110% w/v) mixed with 350 ml of
H2O infused ↓ gravity control followed by 500 to
1000 ml of fresh water is given @ 100 ml/min
• When Ba is injected the radiologist follows the
barium column carefully with fluoroscopy & spot
radiographs are taken at appropriate times

70. ADVANTAGES
Better visualization
of mucosal lesions
Distension can be
controlled by rate of
infusion
Shorter duration
DISADVANTAGES
More exposure
Patient discomfort

71. Ileocecal tuberculosis
EARLY PHASE-
Incompetence and
thickening of illeoceacal
valve with narrowing of
terminal ileum
ADVANCED STAGE –
Narrowing of ileum
with shrunken,
retracted( out of illiac
fossa) caecum

72. BARIUM ENEMA
• LARGE BOWEL EXAMINATION

73. INDICATIONS
1. BLEEDING PR
2. COLITIS
3. SUSPECTED LARGE BOWEL OBSTRUCTION
4. COLONIC POLYPS & COLORECTAL CA
5. FAILED COLONOSCOPY
6. FOLLOW UP SCREENING FOR POST OP COLORECTAL CA
7. NON SPECIFIC ABDOMINAL PAIN

74. CONTRAINDICATIONS
• TOXIC MEGACOLON
• PSEUDOMEMBRANOUS COLITIS
• SUSPECTED PERFORATION
• WEEK BEFORE OR AFTER RECTAL BIOPSY
• POSSIBBILITY OF CA IN ULCERATIVE COLITIS
• PREGNANCY

75. TECHNIQUE
• Perform P/R examination
• Insert enema tip with patient in lt lateral position
with knees flexed
• Check for any blocks
• Look intermittently under flouroscopy to check for
progression of Ba column
• Gas insufflation done intermitently
• change position of patient and table accordingly

76. SPOT FILMS
• Rectum & sigmoid colon-RAO in lying position
• Splenic flexure-LAO(erect)
• Hepatic flexure-RAO(erect)
• Caecum-supine lying on rt side with head down tilt
and compression
• Over head film- lying position

77. COMPLICATIONS
• BOWEL PERFORATION
• INJURY TO RECTAL MUCOSA OR ANAL CANAL DUE TO ENEMA
TIP
• VENOUS INTRAVASATION
• Ba IMPACTION,WATER INTOXICATION
• ALLERGIC RXNS & CARDIAC ARRHYTMIAS
• TRANSIENT BACTERAEMIA

79. Colonic polyps
Sessile polyps- BOWLER’S HAT sign
(dome of hat points towards the lumen)
Colonic diverticula-dome
points away from lumen

80. 80
Pedunculated polyp - Mexican hat sign
(outer ring- head of polyp
inner ring- stalk seen through the head)

81. Ulcerative colitis
ACUTE STAGE-
• Fine mucosal granularity(d/t
edema and hyperemia)
• ULCERATIONS -
Collar button (flask shaped ulcer)
Double tracking (longitudinal ulcer
in submucosa)

82. • Pseudopolyps-raised
area of inflammed
tissue
CHRONIC STAGE-
Loss of haustrations
shortening & narrowing
of colon
( lead pipe colon)

83. Crohn’s disease
• Mucosal granularity with
aphthous ulcer
• Cobblestone app.(deep
longitudinal and
trasverse ulcer with
adjacent mucosal edema)
• Skip lesions with rectal
sparing

84. 84
STRING SIGN-
• narrowing of terminal
ileum due to edema,
spasm and fibrosis

85. diverticulosis
• Small outpouchings
from colonic wall
which are filled by
barium

86. 86
Sigmoid volvulus
Barium fills to point of
obstruction and twist of sigmoid
colon
Xray abdomen-Massively
distended sigmoid colon –
COFFEE BEAN sign

87. 87
Colonic cancer
Annular, irregular and
ulcerating lesion
appear as
circumferential
irregular filling defect
with narrowing of
lumen(apple core sign)

88. INSTANT BARIUM ENEMA
• DEVELOPED BY YOUNG (1963)
INDICATIONS
• Identify level of suspected obstruction
• Show d/s extent & severity of mucosal lesions during an a/c
episode of uc
CONTRAINDICATIONS
• Toxic megacolon, suspected perforation
• Recent rectal biopsy
ADVANTAGE- DONE IN UNPREPARED BOWEL
GUIDE TREATMENT

89. DISTAL LOOPOGRAM
• MAIN INDICATION -
to know the patency of
distal bowel prior to
reclosure of
ileostomy/colostomy
• Mainly single contrast study

90. MICTURATING CYSTOGRAPHY (MCU)
INDICATIONS
1. Outflow obstruction
2. Stress incontinence
3. Vesicoureteric reflux (children)
CONTRAINDICATIONS
Acute infections bladder / urethra

91. PATIENT PREPARATION
• Micturates immediately before examination
• In cathetherised patient, clamp release to
decompress the bladder
CONTRAST MEDIUM-sodium
iodide conc 12% w/v

92. TECHNIQUE
• Cathether introduction-by drop
infusion/manually through huggusons syringe
• Full bladder AP radiograph in erect
• Pt positioned in oblique position
• Next radiograph taken moment urine is seen on
external meatus
why in oblique ?
• assess urethra in its entire length free of bony
superimposition
• then post micturition film

93. POSTERIOR URETHRAL VALVE

94. CHRISTMASS TREE SIGN

95. RETROGRADE URETHROGRAPHY
INDICATIONS
1. Stricture
2. Diverticula
3. False passages in urethra
CONTRAST MEDIUM
60% Urograffin or NaI

96. TECHNIQUE
• Preliminary film of bladder base & urethra
• Film in oblique position- bladder neck &urethra
• Brodney clamp introduction
• Radiographs during injection/distension of urethra
• Procedure repeated in other oblique positions &
appropriate films are taken

97. STRICTURES

98. HYSTROSALPHINGOGRAM
INDICATION- Infertility
• Establish tubal patency
• Delineate- contour & cavity of uterus
• BEST PERIOD- 7-10 days of menstruation
• Jointly performed by gynaecologist &
radiologist

99. TECHNIQUE
• Preliminary film- Supine
• CONTRAST AGENT
60% urograffin or diaginol viscous
• cannulation
• contrast loaded syringe attached to cannula ( airtight)
• slowly injected – fill uterus & tubes until free peritoneal
spillage
• under couch exposure made to assess uterus & tubes
• another exposure after intruments removal
• occasionally 45 mins film (pooling d/t adhesions)

100. HYDROSALPHINGES

101. CT FLUOROSCOPY
• Recently developed acquisition mode that allows faster image
reconstruction,near-continous image update,& image
viewing during a CT guided procedures
• kV 120, tube current settings in CTF
10mA paeds,10-40 mA chest,40-50 mA abdominal
• In typical CTF system cross sectional images are reconstructed
at reduced spatial resolution & updated continually at a rate
of several frames per second by using high speed array
processor

102. TWO OPERATIONAL MODES-
• continuous(real- time)
• intermittent(quick- check)
ADVANTAGES
• convenient room table controL
• potential for decrease in pt radiation &
• increased procedure efficiency
HOWEVER GREATER POTENTIAL FOR RADIATION INJURY TO
PATIENT & HEALTH PERSONNEL IF IMPROPERLY DONE

103. APPLICATIONS
• Core biopsies
• RF Ablation
• Fluid collection aspirations
• Local drug inj, lumbar nerve root blocks, Precise needle
placement
• vertebroplasty , arthrography, etc

104. THANK YOU…