Lecture for MBBS, Radiology subject. simplified lecture, easy to understand in less time.

1. X-rays Modalities-
II
Dr. Bijay Kumar Yadav
MD-Radiology Resident
I.K. Akhunbaev KSMA
Bishkek, Kyrgyzstan

2. Contrast Media

3. Contrast Materials
 Help to distinguish or “contrast” selected areas of the
body from surrounding tissue.
 Enter the body in one of three ways.
They can be:
1. Swallowed
2. Administered by enema (given rectally)
3. Injected into a blood vessel (vein or artery)
 Following an imaging exam with contrast material, the
material is absorbed by the body or eliminated through
urine or bowel movements.

4. Atomically dense
and do not allow
x-rays to penetrate
through them.

5. Iodinated Contrast:
 It is a form of intravenous radio contrast agent containing iodine.
 It enhances the visibility of vascular structures and organs during
radiographic procedures.
 Some pathologies, such as CANCER have particularly improved
visibility with iodinated contrast.
 Iodinated contrast agents are generally safe however, side effects
remain an important issue.
 Iodinated contrast media: Cystografin, Gastrografin, Iodixanol,
etc.

9. Barium Swallow Meal
• Barium-sulfate is the
most common contrast
material taken orally.
 It is available in several
forms, including:
i. Powder- which is mixed
with water before
administration
ii. Liquid
iii. Paste
iv. Tablet

15. Barium swallow

21. Small Bowel Meal
 The small bowel
represents that portion of
the digestive tract that
lies between the stomach
above and the large
bowel (colon) below.
 The small bowel is
extremely long
(approximately 30 ft) and
tortuous, and therefore
very difficult to
investigate. One of the
best ways to investigate
the small intestine is
using barium.

22. Barium Follow Through

26. Barium Enema
 This examination evaluates the right or (ascending
colon), the transverse colon, the left or (descending
colon), the sigmoid colon and the rectum .
 The appendix and a portion of the distal small intestine
may also be included.

27. What are some common uses of the
procedure?
 Benign tumors (polyps)
 Cancer
 Ulcerative colitis (inflammatory bowel disease).
 Hirschsprung disease in children (a blockage of the large intestine).
The procedure is frequently performed to help diagnose
symptoms such as:
 Chronic diarrhea
 Blood in stools.
 Constipation
 Irritable bowel syndrome
 Unexplained weight loss.
 A change in bowel habits.
 Suspected blood loss.
 Abdominal pain.

28. How is the procedure performed?
 The patient is positioned on the examination table and
an x-ray film is taken to ensure the bowel is clean.
 After performing a rectal examination, the technologist
will then insert a small tube into the rectum and begin to
instill, using gravity, a mixture of barium and water into
the colon.
 Air may also be injected through the tube to help the
barium thoroughly coat the lining of the colon.

29.  Next, a series of x-ray images is taken.
 The patient may be repositioned frequently in order to
image the colon from several angles.
 Once the x-ray images are completed, the patient will
then expel the remaining barium and air in the restroom.
 A barium enema is usually completed within 30 to 60
minutes.

30. What Are The Benefits v/s Risks?
Benefits:
 X-ray imaging of the lower GI tract is a minimally invasive procedure with rare
complications.
 Radiology examinations such as the lower GI can often provide enough information
to avoid more invasive procedures such as colonoscopy
 Because barium is not absorbed into the blood, allergic reactions are extremely rare.
 No radiation remains in a patient's body after an x-ray examination.
 X-rays usually have no side effects in the typical diagnostic range for this exam.
Risks
 There is always a slight chance of cancer from excessive exposure to radiation.
However, the benefit of an accurate diagnosis far outweighs the risk.
 The effective radiation dose for this procedure varies.
 In rare cases, the barium could leak through an undetected hole in the lower GI tract
producing inflammation in surrounding tissues.
 Even more rarely, the barium can cause an obstruction in the gastrointestinal tract,
called barium impaction.
 Iodinated contrast administered rectally may cause allergic reactions, but this is very
rare.
 Women should always inform their physician or x-ray technologist if there is any
possibility that they are pregnant.

31. Special Procedures:
Are examinations that are usually invasive.
Some kind of contrast medium (iodine) is used and a
Radiologist performs the procedure.
Very little preparation is required for these tests that are
available on an outpatient basis.
Usually they require about an hour of the patient's time.
In this section, we will explain some of these procedures
and their preparations.

32. Special Procedures:
1. Hysterosalpingogram
2. Bronchography
3. Cholangiography
4. T-tube Cholangiogram
5. IVU / IVP or Intravenous Pyelogram
6. Angiocardiography
7. Interventional radiology – Nephrostomy
8. Interventional radiology – Nephrostomy
9. Venograms

38. Hysterosalpingogram (HSG)
 This is an X-ray procedure that is used to view the inside of the uterus
and fallopian tubes. Often is used to see if the fallopian tubes are partly
or fully blocked. Is an important test for infertility.
 Procedure: Firstly radiographic contrast (dye) is injected into the
uterine cavity through the vagina and cervix, The uterine cavity fills
with dye and if the fallopian tubes are open the dye will then fill the
tubes and spill out into the abdominal cavity.

39.  The uterine cavity is evaluated for the presence of polyps or fibroids .
 The fallopian tubes are also examined for any defects within the tube
like polys.
 Usually HSG study takes only about 15-20 minutes to perform.
Complications: associated with a hysterosalpingogram include:
i. The possibility of an allergic reaction to the dye, which is
uncommon. This usually manifests as a rash, but can rarely be more
serious.
ii. Pelvic infection or uterine perforation are also possible
complications. Both of these are very uncommon.
 Some doctors prescribe several days of antibiotics for their patients to
attempt to reduce the risk of infection after HSG.
 Analgesic before the examination may reduce the pain when contrast is
injected.
 HSG are only done in the first 10 days after a period to make certain you
are not pregnant.

40. Bronchography
PA and latero-lateral
Bronchography:
 The right bronchial tree is
filled with contrast material
 No obstruction or filling
defect can be detected.
Bronchography is a radiological technique, which involves x-raying the
respiratory tree after coating the airways with an iodine-based contrast
agent into the tracheobronchial tree. Bronchography is rarely performed,
as it has been made obsolete with improvements in computed
tomography and bronchoscopy.

41. Selective right Bronchography:
Local stenosis of the right upper lobe bronchus (arrow)
and compression of the right lower lobe with clustering
of airways.

42. Gallbladder X-ray
(Cholangiography)

43. What is an operative Cholangiography?
 Operative cholangiography involves the injection of a
radiopaque dye (iodine) directly into the ducts of the biliary
tract during gallbladder surgery.
 X-rays then reveal clear images of the biliary tract. This test is
used occasionally, when other less invasive tests do not
provide enough information.
Intra-operative cholangiograms (IOC):
are performed during
cholecystectomy by the surgeon, who
cannulates the cystic duct and injects
iodinated contrast under fluoroscopy.
IOCs are performed to assess biliary
anatomy and for choledocholithiasis.

45. Why would someone need an operative cholangiogram?
1. Reveal any cholelithiasis not previously detected – main purpose
2. Investigate biliary tract
3. Determine function of hepatopancreatic ampulla
4. Demonstrate small lesions, stricture, or dilatation of biliary ducts
Clinical indications for operative cholangiogram:
 Jaundice
 Pancreatitis
 Elevated bilirubin
 Abnormal liver function tests (LFT)

46. 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.
Indications
 Patient must have T-tube in-situ
 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
 Non-consent by patient to
procedure
 Contrast or iodine allergy
 Pregnancy (? pregnancy test
required)
 Barium study within last 3
days.

48. Patient identification (3 C’s):
1. Correct patient,
2. Correct side,
3. Correct procedure
 Patient should be wearing
a hospital gown
 Consent form
 No diet restrictions (some
centers suggest fasting
from solids food for 4
hours prior to procedure)
 Collect relevant previous
imaging for ease of access
prior to procedure
Preparation:

49. Procedure:
 The patient is positioned supine on the
X-ray table
 The tip of the T-tube is cleaned with
antiseptic
 The T-tube should be raised and
tapped to ensure there are no air
bubbles lurking in the tube.
 A butterfly needle should be inserted
into the T-tube
 The syringe plunger is withdrawn to
remove bile from within the duct.
(optional)
 An early filling image should be
obtained.
 The entire biliary tree should be
imaged during injection of contrast
medium.
 Injection should continue until the
entire biliary tree is opacified and
there is passage of contrast into the
duodenum.
 If the intrahepatic 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.
 At least 2 views of the entire
biliary tree should be recorded
by spot film, oblique views are
often taken

50. Post Procedure Care:
 Patient can eat and drink normally
 Warn patient to advise of any itching or rash post procedure
 Patient should remain in hospital for observation for at least 24
hours post procedure
 If the T-tube is removed at the end of the procedure, the wound
should be checked for bile leakage for 24 hours
Complications:
i. Persistent biliary fistula (rare)
ii. Biliary peritonitis
iii. Cholangitis

52. Cholangiogram Percutaneous trans hepatic biliary drainage

53. IVU / IVP or Intravenous Pyelogram
 The examination of the
kidneys, ureters and
bladder. It requires the
intravenous injection of
contrast medium
(containing iodine).
 Patient may notice a flushed
sensation during the test or
very rarely feel slightly
nauseated.
 Examination Time: 30
minutes to 1 hour.
 Precautions: Patients who
suffer from asthma or hay
fever or are allergic to
iodine or shellfish should
check with the radiologist
prior to scheduling.
 Patients with a history of renal
insufficiency should discuss with
the renal physician and the
radiologist whether it is safe to go
ahead with the procedure.

56. Angiocardiography
(cardiac catheterization)
Definition: It is the method of following the passage of blood
through the heart and great vessels by means of the intravenous
injection of a radiopaque fluid, whose passage is followed by
serialized X-ray pictures.
 Usually of an arm or a leg, and is then threaded through
circulatory system to the heart.
 Angiography is an important technique commonly used by
doctors to confirm or rule out an abnormality like narrowing
(stenosis) or blockages (occlusions) of blood vessels in any part
of the blood circulatory system or in organs.
 Angiography basically examines the blood vessels and the flow
of blood through them in the body.

58. Types of angiography
(Based on part of body to be examined)
1. Cerebral angiography (head and neck)
2. Coronary angiography (heart)
3. Pulmonary angiography (lungs)
4. Renal angiography (kidneys)
5. Extremity angiography (arms and legs)

59. Purpose Of Angiography
 To identify blocking or narrowing of arteries (atherosclerosis)
 To diagnose any heart disease in case of heart attack or angina
 To detect cerebral vascular disease, such as stroke or bleeding in the brain
 To assess kidney function
 To detect cysts or tumors in kidney
 To map renal anatomy in transplant donors
 To examine the blood flow in the retina of eye
 To get a vascular plan of the organ before a surgery like that of heart or brain etc.
 To detect any blood vessel injury after an accident
 To detect blood clots
 To locate internal bleeding

61. Lateral and AP views of selective angiography into the left coronary
artery which reveals two aneurysms (arrows). The proximal aneurysm is
of the left main coronary artery and the distal aneurysm is of the left
anterior descending artery.

62. (a) Invasive coronary angiography that demonstrated total occlusion of
the left circumflex coronary artery with filling defect suggestive of
thrombus, (b) the TIMI 3 flow was restored after repeated aspirations of
the thrombus

63. The Procedure:
 Local anesthesia will be administered over the artery where
the catheterization is to be performed.
 The local anesthetic may cause a slight sting or burning
sensation that lasts only a few seconds.
 A small puncture is made in the artery and a sheath (plastic
tube) is inserted. The catheter is then painlessly advanced
through the sheath to the heart arteries for dye injections, x-
ray pictures, and pressure measurements.
 After reviewing x-ray pictures, the cardiologists will choose
one of the following treatment options:
1. Coronary angioplasty
2. End the catheterization and remove the catheter : If
arteries do not have significant blockages.

65. Right renal arteriogram reveals two renal aneurysms.

66. Interventional radiology - Nephrostomy
 This is a procedure in which a catheter is placed
through a skin into a kidney to drain urine.
 Procedure is performed in the Radiology
Department. The radiologist may use ultrasound
or x-ray imaging to help guide the catheter into
exactly the right place to drain an urine. This is
done instead of surgery.
 Blockage of the ureter is a common reason to need
a nephrostomy. The kidney makes urine, which
drains down the ureter from the kidney to the
bladder.
 When ureter is blocked, the urine backs up in a
kidney. Signs of his are pain and fever, but some
people experience no symptoms.
 The blocked ureter needs treatment because urine
cannot drain out of the kidney and the kidney
may stop working.
 The nephrostomy will give the urine a way to
leave the kidney. There are other reasons when a
nephrostomy may be needed.
 Before the procedure given pain medication
intravenously. A local anesthetic will also be used
to numb the skin and deeper tissues in the area of
patients back where the catheter will be placed.
There are three major steps to the
procedure:
1. Placement of a needle into the kidney
2. Placement of a guide wire farther in the
kidney
3. Placement of the drainage catheter
The procedure normally takes 1-2 hours.

67. Interventional radiology - Arthrography
 Arthrograms are images made of
the sac surrounding the joint
space. This area cannot be
visualized with x-ray without
using contrast media.
 In a knee Arthograms, a needle is
placed under the knee cap in the
joint space and contrast agent
containing iodine is injected into
the space.
 Meniscal tears can be detected.
Other joints which are most
commonly examined are the
shoulder, ankle and the wrist.
 This procedure is sometimes
carried out prior to an MRI scan of
the joint.
Examination Time: Approx. 1 hour
Precautions: Patients who have an
allergy to iodine or local anesthesia
should discuss this with the
Radiologist prior to the
examination.
Patient Instructions: Bring recent
x-rays of area to be examined.

68. Venograms
 Venograms are x-rays usually
made of the vessels in the lower
extremity including inferior vena
cava, iliac veins, superficial and
deep femoral veins and veins in
the lower leg and ankle.
 Contrast agent containing Iodine is
injected into a vein in the foot and
is examined returning up the leg
into the inferior vena cava.
 Varicosities and obstruction in the
lower extremities are well defined
by the contrast.
 Examination Time: Approx. 30
minutes.
Note: Patients with a history of
renal insufficiency should discuss
with the Nephrologist and the
radiologist whether it is safe to go
ahead with the procedure.