BILIARY SYSTEM 3.

The Emptying Mechanism

■ It is claimed by some that
CHOLECYSTOGRAPHY there is reciprocal innervation
of the gallbladder and
CM relaxation of the sphincter.
- Biloptin (Sodium Ipodate)
- Telepaque (Iopanoic Acid) ■ There is also a hormonal
influence as follows: when
Contraindication practically any acid or any
- Patients who are allergic to iodine food substance particularly
dye fats and fatty acids comes
- Patient in early pregnancy into contact with the
- If the serum bilirubin level is greater duodenal mucosa,
than 1.8mg/dl cholecystokinin is formed,
which is absorbed into the
BILIARY CALCULI bloodstream and causes the
- Orally gallbladder to empty
- Intravenously
- By retrograde cannulation of the 4. The Secretory Function
papilla of water (?) ■ The gallbladder apparently
- Percutaneously into the hepatic secretes constituents of the
ducts bile, such as cholesterol
- By direct inject at operation mucin
- Through a drainage tube after
operation Methods of Study Employed in GB

Functions of GB
● Oral Method
1. The reservoir function In this case the contrast medium
is ingested and it is absorbed
2. The Concentration function through the intestinal mucosa by the
■ Water and salts are absorbed portal blood stream, and enters
in the gallbladder whereas through the portal vein. From the
the bile pigments are not and hepatic cells, the contrast substance
as a result, bilirubin is is excreted with the biled and
concentrated about 20 times, conveyed to the gallbladder, which
cholesterol, bile salts and after concentrating and storing
calcium about 5-10 times. sufficient amount of the specified
bile becomes radiopaque, it takes
■ In disease of the gallbladder, approx 20 - 12 hours for the contrast
this concentration function is medium to reach the gallbladder.
readily impaired The contrast medium is telepaque,
biloptin, cholebrine and cistobil
tablets
 ● Intravenous Method to detect transposition of the
organ
In this case the contrast medium 3. It frequently terminates the
Biligrafin forte or plain biligrafin is injected examination through the
into the vein and the opaque passes demonstration of a
through the blood circulation and enters the gallbladder filled with
liver through the hepatic artery. From the radiopaque stones.
hepatic cells the contrast substance is ● Fatty meals for lunch are eggs
excreted with the bile and conveyed to the butter, cream and milk in order to
gallbladder, which after concentrating and empty the gallbladder and thus to
storing sufficient amounts of the specified have it ready to receive the specified
bile becomes radiopaque. It takes the bile.
contrast medium to reach the gallbladder ● An evening meal that is free of fats
around 10 minutes after injection to prevent the possibility of
continued emptying of the
Indication in doing Cholecystography
gallbladder during the time the liver
1. To determine the function of the liver, is excreting the specified bile.
its ability to remove the contrast ● Oral media are usually administered
medium from the bloodstream and about 3 hours after the light evening
excrete it with the bile meal, with a little amount of water as
2. To determine the patency of the desired. One tablet for every 5
biliary ducts minutes interval or 2 tablets for
3. To evaluate the concentrating and double dose.
emptying power of the gallbladder ● NPO at 12 midnights for better
4. To detect such conditions as biliary intensification of the contrast media
calculi (stones and papillomas-small ● Breakfast is usually withheld
tumors ● Patient is told to report to the x-ray
department on time.
PREPARATION OF PATIENT
POSITIONING
● Reason why general survey film first
of the abdomen preceding
1. AP or PA proj - Localizing film
preparation for a cholecystography
examination is being taken first. ● Place the patient in the supine
position of comfort • Adjust the body
1. First if the intestinal tract is
and center the right side to the
found to be clean, and if the
midline of the table
contrast medium is to be
administered orally, the ● Adjust 10x12 film places lengthwise
examination can be so that its lower border is approx. 1
shortened by one day. inch below the iliac crest
2. The large film demonstrates ● CR is directed perpendicular to the
the location of the liver and mid point of the film Palpate the last
thus the possibility of failure rib as the RP
 ● Exposure is taken at the end of full 5. RLAT decubitus
exhalation
● Have the patient assumes the right
2. RAO lateral position of comfort that is
lying on his right side
● Ask the patient to assume supine ● Adjust the cassette 10x12 placed
position vertically on either the anterior or
● Oblique the body to separate posterior aspect of the body and
superimposition between the immobilize it with sandbags
gallbladder and the vertebra ● Elevate the body in such way as to
● Body obliquity: for hypersthenic center the gallbladder to the center
patient - 15-25 degrees of the cassette. Reference point -
● Asthenic patient - 25-45 degrees gallbladder
● RP: gallbladder previously located ● CR is directed horizontally passing
from the localization film through the RP and the midpoint of
● Central ray Perpendicular the film
● Take the exposure at the end of the ● Exposure is taken at the end of
exhalation exhalation

3. LPO 6. RLAT recumbent

● is in the same position as the Rlat
● Patient assumes in PA position decub
● Oblique the body in order to ● Center a plane that passes midway
separate the gallbladder from the between the mid-axillary and the
column RP anterior aspect of the abdomen
● CR is perpendicular to the film along the gallbladder to the midline
of the film
4. Upright Projection: PA ● CR is directed vertically to the mid
point of the film • Respiration is
● Patient is placed in the PA standing suspended for the exposure
position ● Use 10x12 film placed lengthwise
● Physiologic maneuver have the centered to the direction of the CR.
patient raised both upper extremities
with the hands holding the upper MODIFICATION
border of the VCH.
● RP-gallbladder that is 2 to 4 inches A. TRENDELENBURG MANEUVER
lower than in the recumbent
● Use 10x12 films placed lengthwise ● Place the patient in the supine or
and center it to the RP oblique as required •Center the right
● CR is directed horizontally passing side of the body to the midline of the
through the RP. table
● Exposure is taken at the end of
exhalation
 ● Tilt the table in such way that the PROJECTION:AP or PA recumbent
head is lower than the feet approx. upright
15-20° ● Patient maybe placed in the PA
● RP- gallbladder position.
● Use 10x12 films placed length wise ● Center the Right side to the midline
and centered the film; the gas is the of the table.
reference point. ● RP- gallbladder
● CR is directed to the midpoint of the ● Use 8x10 film placed lengthwise and
film vertically centered to the RP CR is directed
● Exposure is taken at the end of vertically to the mid point of the film
exhalation ● Exposure at the end of exhalation.

B. FLEISCHNER'S MODIFICATION

● This is a reverse Lindblom position

that the patient stands in the PA INTRAVENOUS CHOLANGIOGRAPHY
position t feet away From the VCH (IVC)
● Dorsiflex the body with the bands
grasping the upper border of the Contraindications
VCH and the abdomen against it.
● RP-T4
● Patients with an allergy to lodine
● Use 14x17 film placed lengthwise
and centered to the reference point.
dye. Patients with a bilirubin level
● CR is directed to the midpoint of the greater than 3.5 mg/dl
film vertically.
● Exposure is taken at the end Indication
exhalation
● To demonstrate the biliary ducts
POST MOTOR MEAL of cholecystectomized subject.
● To investigate the biliary ducts
This consists of giving the patient and gallbladder of non subject.
fatty foods to eat such as: 2 eggs, 1
● In cases of non-visualization of
glassful of milk and toasted bread
the gallbladder by the oral
with butter. The purpose of the fatty
meal is to evaluate the concentrating
method In cases where due to or
and emptying power of the diarrhea, the cannot retain the
gallbladder. This allows the sphincter orally administered long enough
of oddi to relax there by allowing the for its absorption.
gallbladder to empty its contents into
the small intestine. Preliminary Preparation

● The preparation of the patient in

this examination is the same as
that in the oral method
Contrast Medium ● Exposure is taken at the end of
exhalation
● Biligrafin (meglumine iodipamide)
or logycamide) Biliscopin (iotroxic Purpose
acid) Biligram (Meglumine
● To determine if the patient well
● One hundred (100) ml bottles for prepared for the examination
infusion are obtainable. ● To detect any incidental findings
Alternatively, ampoules of ● To check technical factor
contrast medium are used, mixed
with suitable diluents, the Injection Phase
quantities being from 10 ml to 1
ml/kg body weight and mixed with A. SENSITIVITY TEST - 5 cc of the
250-ml normal saline. C.M. Is injected intravenously by the
attending physician or the radiologist.
Things to be prepared for the Then the patient will observe untoward
injection reactions, such as nausea and vomiting,
and cold.
● Basic trolley containing sterilized
5 to 15 cc syringes and needles. B. DOSE - (25cc) this is injected 15-30
● A sterilized 30-50 cc syringe and minutes after the test dose, if no
disposable needle gauge 20 or reaction occurs.
21
● Cotton balls with alcohol
● Tourniquet IMMEDIATE OR OPERATIVE
● Ampoules of contrast medium CHOLANGIOGRAM BILIARY
and infusion bottle of saline SURGERY

Scout films, Supine position Indications

● Place the patient in the supine ● This is used in the investigation

position of comfort. Center the of the patency of the bile ducts
right side to the midline of the and the status of the sphincter of
body. of oddi
● Adjust a 10x12 film placed ● To reveal the presence of calculi
lengthwise so that its border is that cannot be detected by
approx. One inch below the iliac palpation
crest ● To demonstrate conditions such
● CR is directed vertically to the as tumor, stricture or dilation of
midpoint of the film the passages.
Things to be prepared for the OR. impregnated swab and the
injection of contrast medium is
● The necessary number of films made directly into the tube care
and cassettes, use 10x12 must be taken to ensure that no
● Hangers and lead apron bubbles are injected (as these
may stimulate calculi) and that
Procedures contrast medium does not leak
out on to the skin the injection is
1. Before entering the operating watched on the television monitor
room, change your shoes with and continued until the entire
slippers (rubber) er) and wear OR biliary tree has been satisfactorily
gown, cap and mask. demonstrated series radiographs
2. Following the removal of the are taken as required. When all
gallbladder the surgeon inserts necessary radiographs have
the T-tube into the common duct. been taken, the clip is from the
3. Before the C.M. is to be injected drainage tube.
(Urovison or Hypaque) position
the tube and the film (use Projections
stationary grid) and set the
factors. A. SCOUT FILM
4. First injection-10cc. Take 2
exposures. Then process the ● Patient is in the supine position of
films immediately bring the comfort
processed films and show it to ● Adjust the body and center the in
the surgeon for confirmation lying tube to the midline of the
5. If satisfied, the end of the table or RP-in lying tube cassette
examination. If not, another 10cc ● Use 10x12 film placed lengthwise
of the C.M. is injected through the and centered to the RP
in lying tube then another 2 ● CR is directed vertically to the
exposures, till the examination is midpoint of the film
finished. ● Suspend respiration for
exposure
DELAYED, POST OPERATIVE OR
T-TUBE CHOLANGIOGRAPHY Purpose

Procedure ● To be able to determine the exact

location of the T-tube
● The drainage tube is clipped off ● To demonstrate any remaining
by means of artery forceps. The . stone or calculi
tube is wiped with an antiseptic ● To check technical factor
B. INJECTION PHASE PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY (PTC)
● Before the C.M. is to be injected,
aspirate the bile contents of the CONTRAINDICATION
ducts thru the in lying tube for
better visualization of the ducts. ● Who have a tendency to bleeding
Then the attending physician or or prolong clotting times Patient
the radiologist injects 10 cc. of with the biliary tract infection
the via the tube and right after the ● Who have a history of sensitivity
injection takes 2 exposures to contrast media
simultaneously.
PATIENT PREPARATION
Positioning
● The prothrombin time is tested
AP proj and must be corrected if found to
● Patient is placed in supine be abnormal
position ● Prophylactic antibiotic cover is
● RP in lying tube, which is given
centered to the midline of the ● The patient must have nothing to
table eat or drink for five hours
● CR is directed vertically to the
film Premedication: Omnopon and
● Use10x12 films placed Scopolamine, or Diazepam Contrast
lengthwise Media: Conray 280 or its equivalent, 20
to 60 ml
RAO
● From the supine position oblique PRELIMINARY FILM
the body approx. 45 degrees.
● The left side is being elevated ● The patient lies supine on the
● RP in lying tube. fluoroscopy table, with his right
● CR is directed vertically to the band behind his hand. An
film anteroposterior view of the right
● Ask the patient to suspend side of the abdomen is taken,
respiration for exposure. If the using 10x12 cassettes with its
examination is not satisfactory, lower border at the level of the
the procedure is to be repeated. right iliac crest. Center the
midclavicular 1-2 inches above
the level of the lower costal
margin.
TECHNIQUE with the calibre of the ducts. If the
ducts are dilated, bile and
● The patient lies supine on the contrast medium are aspirated
fluoroscopy table, with his right from the ducts before the needle
behind his head. Blood pressure, is removed. After the needle has
puise, temperature and been removed, further
respiration are recorded. Under radiographs are taken with the
fluoroscopic control, the puncture patient in the supine, oblique,
site is chosen and marked on the lateral, erect and Trendelenburg
patient's skin. The examination is positions.
performed under strict aseptic
conditions. is prepared with a ● If the examination has revealed a
suitable antiseptic and draped dilated or obstructed room for
with sterile towels. determined laparotomy to be performed.
puncture site. The patient is biliary tree, the patient will I go
asked stop to The patient's Local straight to the operating If bile
anaesthetic is injected at the was not aspirated from the liver,
breathing in mid-respiration and and therefore no injection was
the Chiba needle is Inserted into made, the implication may be that
the liver. The stylet is removed the jaundice is not of obstructive
and the needle is connector, to a origin and the patient is usually
syringe containing contrast returned
medium. Under withdrawn while
contrast medium is gently ● In suspected extra hepatic biliary
injected, until a is connected via a obstruction, delayed films-taken 2
flexible polythene fluoroscopic hours after the Injection are of
control, bile duct the needle is value.
located, Contrast Into the bile
ducts radiographs are taken AFTER CARE OF THE PATIENT
using the under-couch tube. If
aspirated from the ducts the 1. The patient must be under
contrast medium slowly medium constant observation for 48 hours
is injected If the bile ducts are for any sign of hemorrhages,
dilated, bile is is injected. If a bile leakage of bile or peritonitis.
duct is not entered during the first 2. Temperature, pulse and blood
withdrawal of the needle, it can pressure are recorded every 10
be re-inserted up to 10 times minutes for 1 hour, then 2hourly
before the examination is for 4 hours, then 4 hourly for 24
abandoned. The quantity of hours.
contrast medium injected will vary
 ENDOSCOPIC RETROGRADE PREMEDICATION
CHOLANGIOPANCREATOGRAPHY
(ERCP) ● 30 minutes before the
examination, the patient is given
an Amethocaine lozenge (30mg)
INDICATIONS to suck, and 10 minutes before
he is given 20 mg
1. In the investigation of recurrent hyocine-N-butyl bromide
jaundice or other biliary tract (buscopan) intramuscularly, to
problems. produce duodenal anatomy.
2. In the investigation of pancreatic
disease. CONTRAST MEDIA
3. Patients with ascites or tendency
to bleeding when PTC is 1. Pancreatic duct. Meglumine
contraindicated. diatrizoate (angiografin) or CM
4. Patients who have obstructive that have high iodine content.
jaundice. 5. If the serum bilirubin 2. Biliary duct. Meglumine
is greater than 3mg%. jothalamate (conray 280) not be
too dense as otherwise small
CONTRAINDICATION opacities, such as caused by
papilloma or radiolucent biliary
● Patient with a positive serological calculi, may be obscured.
test for Australia antigen (surface
antigen of the hepatitis B virus Technique
(HBV) because it is not possible
to sterile the instrument. ● The patient lies on his left side,
● With a history of sensitivity to CM on the fluoroscopy table.
or other drugs Diazepam (Valium) is given
● With a pyloric stenosis, it would intravenously at the rate of 5 mg
be impossible to pass the per minute until dysarthria or
endoscope. ptosis occurs. The endoscope is
● With acute pancreatitis then introduced into the
● With and anticholinergic drugs is esophagus and passed through
inadvisable the stomach and into the
● Patients with acute cholangitis duodenal bulb. Duodenal juice
instilled to suppress frothing. is
Preparations aspirated and a silicone
1. NPO for at least five hours preparation is
2. Recent radiographs of the
abdomen
 ● The endoscope is positioned in AFTER CARE OF THE PATIENT
the second part of the duodenum
and the papilla of Vater is located. 1. NPO for about an hour after the
A polythene catheter is filled with examination
a contrast medium and is 2. Serum amylase level should be
inserted down the central channel estimated on the following day at
of the endoscope. Care must be intervals for about 3 weeks
taken to ensure that there are no
air bubbles in the catheter or in
the syringe, as these can INTRAVENOUS PYELOGRAPHY(IVP)
stimulate calculi. A stage, bile is
usually aspirated as further Indications
safeguard against introducing air
into the duct system. Just before
the papilla is cannulated, the ● Abdominal or pelvic mass
patient is gently turned into the ● Renal or ureteral calculi
prone position. To demonstrate ● Kidney trauma
the pancreatic duct, 2-4 ml of CM ● Flank pain
is injected under fluoroscopic ● Hematuria
control. As soon as the larger ● Hypertensions Renal failure
radicles of the pancreas have ● UTI
been filled, the injection is
stopped. As the finer radicles Contraindications
without with our further injection.
● Hypersensitivity to iodinated
Under the couch radiographs are contrast media Anuria or absence
taken of urine excretion
● Multiple myeloma
1. Patient in prone position ● Diabetes mellitus
2. Lateral position ● Severe hepatic or renal disease
3. Both posterior and oblique ● Congestive heart failure
positions.
Two methods of study employed
Over the couch radiographs are
taken ● Functional Method or Descending
or Excretory Pyelography- CM is
1. Patient in prone position injected intravenously.
2. Both oblique ● Instrumental Method or
3. Lateral position Retrograde or Ascending
Pyelography- CM is injected
 directly into the renal pelvis or Positioning of plain KUB
other parts of the canals by
means cystoscopy. AP

PREPARATION OF THE PATIENT ● Patient is placed in the supine

position of comfort
1. Take 2 Dulcolax tablets after ● Adjust the body and center the
lunch prior to examination MSP to the midline of the table.
2. Take light evening meals. otherwise umbilicus
3. Provide oral castor oil 30 cc.or ● RP midway between the ASIC
perform cleansing enema before otherwise umbilicus
bedtime until the return flow is ● Adjust the film placed
clear. lengthwise
4. NPO at 12 midnight to ensure ● CR is directed vertically to the
total emptying of stomach center of the film.
5. Insert Dulcolax suppository ● Ask the patient to suspend
rectally at 4:00 A.M. to cleanse respiration for exposure.
the distal end of the colon, or
cleansing enema again • STRUCTURE SHOWN:
6. No breakfast. no smoking.
● A faint of the kidneys. The psoas
Procedure should be clearly visualized.

● Take plain KUB before injecting Technique and time interval exposure
the contrast medium.
1. Nephrogram or Nephrotogram - taken
Purposes: immediately after completion of injection
to capture the early stages of the
1. To demonstrate the contour of the contrast medium entering the collecting
kidneys and their location in the system.
supine position.
2. To reveal the presence of any 2. Five minutes - (for kidneys) after the
renal or calculi completion of the injection.
3. To check the technical factor ● Patient in supine position of
4. To check the patients is well comfort.
prepared for the examination. ● MSP centered to the midline of
the table.
● RP midway between the ASIC
otherwise umbilicus
● Center the 10x12 film to the RP
 ● Central ray is directed to the RP Purposes:
● Respiration is suspended for
exposure. ● To demonstrate the mobility of
the organ, nephrotosis (positional
3. Fifteen minutes - views for the change of kidneys).
kidneys and ureters with the ● To evaluate the amount of urine
compression left in the urinary bladder.
● To detect the presence of turnor.
● Patient in supine position of ● In case of male patient to detect
comfort. any enlargement of the prostate
● MSP centered to the midline of gland pushing up on the floor of
the table. the gallbladder.
● RP midpoint between the ASIC
● Center the 10x12 film to the RP Positioning
● Central ray is vertically directed
to the RP ● Anteroposterior - Upright or
● Respiration is suspended for Recumbent - Preferably Upright -
exposure to detect Ptotic kidneys
● Place the patient in the AP
4. Thirty minutes - views for the kidneys, position
ureters and urinary bladder. Positioning ● Ad just the body and center the
is the same as the plain KUB exposure MSP to the midline of the
cassette
5. Additional time interval - exposure ● RP point of umbilicus
such as 5 minutes and 1 hour maybe ● Adjust the 14x17 cassette
taken upon the discretion of the lengthwise and center it to the
radiologist. ASIC
Right and left anterior Oblique- ● CR horizontally directed to the
projection may also taken. umbilicus
● Suspend respiration for exposure
6. Post Voiding or Post Micturation Film
view of the gallbladder is taken - This is
to be done after the radiologist has HYPERTENSIVE INTRAVENOUS
confirmed the time Interval. PYELOGRAPHY

Exposure films. This is being achieved PREPARATION OF THE PATIENT

by simply telling the patient to urinate as
much as he can. 1. Take 2 Dulcolax tablets after
lunch prior to examination
2. Take light evening meals.
 3. Provide oral castor oil 30 cc.or 5. Post vold or Micturation film after
perform cleansing enema before emptying the bladder with the urine
bedtime until the return flow is and contrast media.
clear.
4. NPO at 12 midnight to ensure 6. Upright position or AP projection.
total emptying of stomach
5. Insert Dulcolax suppository DRIP INFUSION or GRAVITY METHOD
rectally at 4:00 A.M. to cleanse IVP
the distal end of the colon, or
cleansing enema again PREPARATION OF THE PATIENT
6. No breakfast. no smoking.
1. Take 2 Dulcolax tablets after lunch
prior to examination
● Scout film before injection of
contrast medium intravenously 2. Take light evening meals
● Injection phase
● Sensitivity test - 1 cc of iodinated 3. Provide oral castor oil 30 cc.or
CM Is injected intravenously with perform cleansing enema before
15-30 minutes observation for bedtime until the return flow is clear.
any reactions.
4. NPO at 12 midnight to ensure total
Full dose emptying of stomach
Time Interval Exposures
5. Dulcolax suppository rectally at 4:00
1. Takes 1,2,3 minutes film after the A.M. to cleanse the distal end of the
completion of the injection using 10x12 colon, or enema again
films for adults, centered to the region of
the kidneys. 6. No breakfast. no smoking.

2. Five minutes - take exposure for the

entire urinary systems centered to the ● Scout film AP projection.
level of the ASIC with the in AP position. ● Sensitivity test 1cc CM
CR Is directed vertically to the RP.
Full dose
3. Fifteen minutes - applied ureteric
compression or take PA projection ● This is administered 30 minutes
after sensitivity test. In these
4. Thirty minutes - AP projection for the case, 2 ampoules of CM
entire urinary systems. (Telebrix, Anglografin, Conray,
 Hypaque, etc.) It is being Positioning
incorporated with a 200 cc or 5%
dextrose water. Prepare IV set ● The patient is requested to empty
and IV stand, and then adjust the his bladder.
height of the dextrose bottle in ● Position the patient in supine
such way that the fluid will flow as position with the MSP centered to
fast as possible by opening it full the midline of the table.
blast the tubing of the dextrose. ● RP midway between the ASIC
After the amount has been ● CR is directed vertically to the RP
consumed proceed in taking the ● Use 10x12 film Placed lengthwise
time interval exposure. and centered to the direction of
the CR
● Time Interval Exposures
- 5 minutes, 15 minutes, 30 3 Proj taken after after the filling of
minutes, 45 minutes, 1 the urinary bladder:
hour, 2 hours or even up to
24 hours, depending on 1. Anteroposterior projection - Position
the opacification of the as doing the scout film
systems.
2. Right and left oblique Projection
● From the supine position the
CYSTOGRAPHY body approx. 60 degrees.
● RP is 1 inch distal to the elevated
Preliminary procedure of the patient: ASIS
● CR is vertically to the RP
● The patient is instructed to void ● Use 10x12 film placed
before being placed to the x- ray crosswise.
table.
3. Lateral projection
Technique: ● Assume left or right lateral
position
● Scout film- to check whether the ● RP upper ASIS
lower bowels are free from gases ● CR is directed vertically
and fecal material. Chassard-Lapine Position
● If fecal matters are present the
patient is given cleansing enema. 4. This is the same in doing barium
● For gas, urologist inserts a enema examination.
catheter to dislodge the air while
the abdomen is being massage.
MICTURATING CYSTOGRAPHY Reducing risk of catheterization

● This examination is used mainly A. The catheter is lubricated with a

to demonstrate vesico-ureteric cream containing Hibitine
reflux, especially in children. It is
also used in the investigation of B. Rigid asepsis is observed
stress incontinence and of
outflow tract obstruction. It is C. time during which the catheter is in
performed under fluoroscopic position is kept to the minimum possible.
control, preferably with image
intensification and television. ● Any residual urine is drained,
measure and sent to the
Contraindication laboratory for examination. The
contrast medium is run into the
● The examination is contra bladder using a drip technique. A
indicated if there is acute infect of relatively slow infusion is
the bladder and urethra. necessary, usually with the bottle
about 90cc. (36 in) above the
PREPARATION OF THE PATIENT table and with tap in the full "ON"
position. The infusion is
● The patient micturates controlled by intermittent
immediately before the fluoroscopy of the abdomen. If
examination reflux is seen, appropriate
radiographs are taken; usually on
CM 10x12 cassettes, using the couch
tube. When the bladder is full the
● Dilute water soluble contrast catheter is withdrawn. The table
medium is used, such as is then tilted to vertical position
Hypaque 10-15% on its and the patient stands firmly on
equivalent the step.

Technique ● Under couch films are taken

during micturition. Some form of
● The patient lies supine in the receiver is required during the
fluoroscopy table. Under strict micturition series.
aseptic conditions, a catheter is
introduced into the bladder.
The patient in emptying the bladder DOUBLE CONTRAST
at this time may experience difficulty. CYSTOGRAPHY
This can be overcome by:
● For negative contrast
1. By affording the patient as cystography, simply catheterize
much privacy as possible. the bladder, drain all the urine
2. Ensuring that the bladder is from the bladder and through a
filled to its maximum capacity. three stop cock, instil air or gas
3. Reducing to a minimum the into the bladder until it becomes
time interval between removing slightly turgid. This examination is
the catheter and being ready to usually carried out to localize and
examine micturition. grade a bladder tumor before
radiotherapy. It is particular value
Positioning when the neoplasm lies in
diverticulum.
● For small children, the
examination is best demonstrated Patient preparation
in the supine position and
oblique. It is useful to continue 1. Patient should have not more than
the infusion until the micturition is one pint of fluid during the preceding 24
initiated, before the catheter is hours and nothing to drink for 8 hours.
removed. It is sometimes
advocated that the contrast 2. Patient micturates immediately before
media be introduced into the examination.
bladder through a supra-pubic
needle. CM
● When the examination on the
radiographs taken during • Sterile barium sulphate, such as
micturition, so that any reflux steripaque 120 ml.
occurring is demonstrated. Stress
Incontinence: Lateral projections Technique
are taken in erect position of the
bladder. • The patient lies supine on a foam
1. At rest mattress on the x-ray table. Under strict
2. Straining with the catheter aseptic condition, the bladder is
in situ catheterized and emptied and the
3. With the patient steripaque is run under fluoroscopic
micturating control, preferably with image
intensification and television. The
catheter is left in position and the 1. AP The patient lies on his side, facing
over-couch views will be taken. the tube with the knees extended. A grid
cassette is supported vertically behind
POSITION the pelvis with Its cauda border at the
level of the symphysis pubis.
AP
2. Supine lat-The patient lies supine,
● The patient lies supine. A 10x12 with the hands on the chest. The
cassette is used with its upper cassette is supported vertically at the
border at the level of the ASIC. side of the pelvis.
Center 1 inch below the anterior
iliac spines, with the tube angled 3. Prone lat - The patient lies prone, with
15 degrees caudad. the hands under his chin. The cassette
is supported vertically at the side of the
PAO pelvis.

● From the supine position the 4. AP - The position of the patient is

patient is rotated 35 degrees to reversed so that he can lie on the
each side in turn. Foam pads opposite side from the first antero
support the raised side of the posterior projection. The cassette is
pelvis. A 10x12 cassette is supported vertically behind the pelvis.
placed transversely, with its upper
border at the level of the iliac 5. Erect AP-From the horizontal position
crests A is taken in each position. the table is tilted until the patient is erect
Center 2.5 cm. below the anterior and standing comfortably on the
superior iliac supine of the raised footrest. The bucky is used for this
side. After the radiographs have projection. The lower border of the
been inspected, most of the cassette
contrast medium is drained off,
leaving only about 20 ml. Under
fluoroscopic control the bladder is
then distended with 60-to 80 ml.
Carbon dioxide. The barium
remaining in the bladder will coat
any tumor or ulcer but will not
adhere to normal mucosa. A
series of projections is taken
using a horizontal beams as
follows:
 the midline 2.5 cm. Below the
URETHROGRAPHY anterior superior iliac spines with
the tube angled 15 degrees
Preparation of the patient caudad.

● The patient should micturate Technique

immediately before the
examination. ● The catheter or cannula is
inserted into the urethra under
Contrast medium strict aseptic conditions. If a
cannula is used, it is firmly fixed
● Usually 30 to 40 ml. of viscous in position by adjustment of the
contrast medium such as arms of the clamp. If a catheter is
umbradil viscous is used. But in used, the balloon is inflated.
cases of suspected urethral
rupture, a water soluble contrast ● The patient is rotated into the
medium such as Urografin 60% right anterior oblique projection
or its equivalent may be with the right hip a knee flexed
preferred. and with the raised side of the
pelvis supported on foam pads.
Equipment The contrast is injected and serial
films are taken as acquired. A
● One method of introducing the typical series of films would be
contrast medium is by means antero-posterior and oblique of
Knutson clamp, but some the posterior urethra and bladder
authorities recommend the use of neck. The injection is continued
a Foley catheter. The until the base of the bladder is
examination is performed using outlined by the contrast medium.
either fluoroscopic or At the end of injection, an over
conventional methods. couch projection is taken, as for
the preliminary film. The cannula
Preliminary film or catheter is then removed and
the patient allowed emptying the
● The patient lies supine on the bladder.
x-ray table and an antero
posterior projection of the bladder Modifications
base and the urethra is taken. A
10x12 cassette is with its upper 1.The bladder may be distended with 10
border at the level of the anterior to 25%. Hypaque before the viscous is
superior iliac spines. Center in and projections during micturition are
then both obtained after the standard TRACHEA
projection taken.
● The trachea is a fibrous,
2. An entirely over-ouch technique can muscular tube with 16 to 20
be used after infusion or approx. 200 ml. C-shaped cartilaginous rings
Of contrast medium. Three radiographs embedded in its walls for greater
are taken with the patient lying in the rigidity
right posterior oblique position.
● It measures approximately 1/2
a. At the end of the infusion when inch (1.3 cm) in diameter and 4
the patient urgently requires 1/2 inches (11 cm) in length, and
voiding the bladder. its posterior aspect The last
tracheal cartilage is tis flat
b. During micturition elongated and has a hook like
process, the carina, which
c. After abruptly arresting extends posteriorly on its inferior
micturition. surface.

3. Double contrast technique is ● At the carina, the trachea divides,

sometimes used, with air as the or bifurcates, into two lesser
negative contrast in the investigation of tubes-the primary bronchi. One of
urethral diverticula. these bronchi enters the right
lung, and the other enters the left
lung
The nasopharynx lies posteriorly above ● The primary bronchi slant
the soft and hard palates. obliquely Inferiorly to their
entrance into the lungs, where
The oropharynx Is the portion they branch out to form the right
extending from the soft palate to the and left bronchial branches.
level of the hyoid bone.
● The right primary bronchus is
The laryngeal pharynx lies posterior to shorter, wider, and more vertical
the larynx, its anterior wall being formed than the left primary bronchus.
by the posterior surface of the larynx.
The laryngeal pharynx extends inferiorly LOBES OF THE LUNG
and is continuous with the esophagus.
● three to the right lung
● two to the left lung.
The secondary bronchi divide further neck and a broad base that,
and decrease in caliber. The bronchi resting on the obliquely placed
continue dividing into tertiary bronchi, diaphragm, reaches lower in back
then Into smaller bronchioles, and end and at the sides than in front.
in minute tubes called the terminal ● The right lung is about 1 Inch (2.5
bronchioles. The extensive branching of cm) shorter than the left lung
the trachea is commonly referred to as because of the large space
the bronchial tree because it resembles occupied by the liver, and It is
a tree trunk broader than the left lung
because of the position of the
Alveoli heart.
● The lateral surface of each lung
● The terminal bronchioles conforms with the shape of the
communicate with alveolar ducts. chest wall. The inferior surface of
the lung is concave, fitting over
● Each duct ends in several the diaphragm, and the lateral
alveolar sacs. The walls of the margins are thin.
alveolar sacs are lined with ● During respiration, the lungs
alveoli. move inferiorly for Inspiration and
● Each lung contains millions of superiorly for expiration.
alveoli. and carbon dioxide is ● During inspiration, the lateral
exchanged by diffusion within the margins descend into the deep
walls of alveoli. recesses of the parietal pleura; in
radiology, this recess is called the
Lungs costophrenic angle.
● The mediastinal surface is
● The lungs are the organs of concave with a depression called
respiration. the hilum that accommodates the
● They provide the mechanism for bronchi, pulmonary blood
introducing oxygen into the blood vessels, lymph vessels, and
and removing carbon dioxide nerves.
from the blood. ● The inferior mediastinal surface
● The lungs are composed of a of the left lung contains a
light, spongy, highly elastic concavity called the cardiac
substance, the parenchyma, and notch. This notch conforms to the
they are covered by a layer of shape of the heart.
serous membrane. ● Each lung is enclosed in a
● Each lung presents a rounded double-walled, serous membrane
apex that reaches above the level sac called the pleura.
of the clavicles Into the root of the
● The Inner layer of the pleural sac, ● The right superior lobe is divided
called the visceral pleura, closely further by a horizontal fissure,
adheres to the surface of the creating a right middle lobe.
lung, extends into the Interlobar
fissures, and is contiguous with ● The left lung has no horizontal
the outer layer at the hilum. fissure and no middle lobe.

● The outer layer, called the ● The portion of the left lobe that
parietal pleura, lines the wall of corresponds in position to the
the thoracic cavity occupied by right middle lobe is called the
the lung and closely adheres to lingula.
the upper surface of the
diaphragm. ● The lingula is a tongue-shaped
process on the anteromedial
● The two layers are moistened by border of the left lung. It fills the
serous fluid so that move easily space between the chest wall
on each other. The serous fluid and the heart.
prevents friction between the
lungs and chest walls during ● Each of the five lobes divides into
respiration. bronchopulmonary segments and
subdivides into smaller units
● The space between the two called primary lobules.
pleural walls is called the pleural
cavity. ● The primary lobule is the
anatomic unit of lung structure
● Each lung is divided into lobes by and consists of a terminal
deep fissures. The fissures lie in bronchiole with its expanded
an oblique plane inferiorly and alveolar duct and alveolar sac
anteriorly from above, so that the
lobes overlap each other in the BRONCHOGRAPHY
AP direction.
Bronchography is a contrast study for
● The oblique fissures divide the demonstration of the
lungs into superior and inferior broncho-pulmonary tree/segments
lobes.
Initially, it was the definitive diagnosis for
● The superior lobes lle above and bronchiectasis, however the advent of
are anterior to the inferior lobes. - CT-high resolution CT (HRCT) almost
push bronchography out of use
 ● Dribbling contrast over the back
Indications of the tongue-not reliable and
already abandoned

● Bronchiectasis Patient Prep

● Bronchial obstruction-site &
extent ● Chest physiotherapy postural
● Other possible indications-when drainage and percussion)
other Imaging modalities are ● NPO for 6 hrs prior to procedure
negative includes: ● Pre-medications-0.6mg Atropine
○ Recurrent & 10mg Morphine or omnopron
○ Haemoptysis ● Asthmatics should have steroid
○ Broncho-pleural fistula prophylaxis & salbutamol
○ Congenital pre-procedure
lesions-agenesis &
sequestration Preliminary Films

Contraindications ● AP and Lat

I. Acute respiratory infection Technique

II. Poor respiratory reserve
III. Others-massive hemoptysis, ● Trans-nasal method
active PTB & hx of allergy ● Cricothyroid method

Materials Trans-nasal method

● Fluoroscopic unit with overcouch ● If the examination is being

tube performed under local
● Catheter anaesthesia, the patient is given
● Contrast media-LOCM and anaesthetic lozenge to suck.
(lotrolan-300) 2-3ml per lung The nose, throat, nasopharynx
segment; ≤25ml/patient and trachea sprayed with topical
anaesthetic. A catheter is passed
Methods through the nose into the
nasopharynx and into the
● Catheter trachea. The proximal end of the
● Cricothyroid puncture-not for catheter is attached to the cheek
<12yr old by means of adhesive tape.
● Bronchoscope
● Others prefer to pass the catheter out to the periphery of the lung.
into the trachea through the He is then moved into the next
mouth, using direct laryngoscopy. position. All breathing should be
When the examination is calm and slow, so as to coughing.
performed under general
anaesthesia, the catheter is ● If both sides are being examined
passed down the endotracheal at one time, the right lung is
tube, which is already in situ. usually filled first but some
radiologists prefer to fill the of the
● Contrast Medium is injected suspected lesion first.
down the catheter, usually in 3 to
4 equal amounts, the first 2 or 3 Cricothyroid Method
portion being used to
demonstrate the lower and The lies supine or sits on chair. Local
middle lobes and the lingula, the anaesthetic is injected into the skin over
last portion being used to fill the the cricothyroid area and into the
upper lobe. To fill the middle and trachea through the crico-thyroid
lower lobes, the patient leans membrane. The patient leans toward the
towards the side being examined, side being examined and is supported
and then bends forwards, then by a nurse. A crico-thyroid needle is
sideways, then backwards, inserted into the trachea and when it is
contrast medium being injected in correctly sited contrast medium is
each position. To fill the upper injected. The needle is then withdrawn
lobe, the patient lies in the side and the patient placed in the positions
being examined, with the head previously described for the trans- nasal
raised and the feet lowered. method of filling the various parts of the
Following injection of the contrast lung.
medium, he is then turned
half-way on the face and then Films
half way on to the back, and
during these manoeuvres', the ● Anteroposterior and lateral views
head of the table is lowered are taken after the first side has
slightly. been filled with CM as for the
preliminary films.
● In each position the contrast ● Antero-posterior and right and left
medium is injected quite quickly. posterior oblique views are taken,
The patient is held in position for after the first side has been filled.
about 5 seconds during which he ● For posterior oblique views
is to take in deep breath slowly, patient is rotated 45 degrees from
so as to draw contrast medium the supine position towards each
 side in turn. The upper border of Selective Bronchography
the cassette should be 1 Inch
above level of the shoulders and May be carried out during bronchoscopy
the whole chest must be if a fibre optic bronchoscope is being
included. Each exposure is made used. Samples of lung tissue are
on arrested inspiration. obtained by cytology forceps, which are
Satisfactory views of the first side introduced down one of the channels of
must be obtained before the the endoscope. The same channel is
second side is filled. used for Injecting contrast medium
DIONOSIL OILY via a 100cm long
Aftercare disposable catheter to the part of the
lung being examined. The contrast
1. As soon as the examination is medium is injected under fluoroscopic
completed, the patient is encouraged to control. The Anteroposterior and oblique
cough in order to remove as much of the views of the chest are taken.
contrast medium as possible.
Percutaneous Lung Biopsy
2. The patient must have nothing to eat
or drink for at least 3 hours until the ● The purpose of this examination
effect of the anaesthetic have worn off. is to obtain specimens of lung
This is to avoid accidental aspiration of tissue for bacteriological and
food or drink histological analysis.

3. Physiotherapy (postural coughing and ● It is performed under fluoroscopic

percussion) is required to remove control using image
further contrast medium intensification and television if
possible a C arm intensifier is
4. If the examination has been used.
performed on an outpatient, the patient
must not be allowed to leave the ● The examination is
department before he has completely contra-indicated in patients with
recovered from the sedation and local sever generalized lung disease
anaesthetic. with pulmonary hypertension on
artificial ventilators.
5. Radiography of the chest is often
carried out 24 hours after the PATIENT PREP
examination, to see how much contrast ● Full radiographic examination of
medium remains the chest, including tomography
to localize the lesion must have
been carried out within the
 previous 24-48 hours. The patient pneumothorax is unlikely to occur later
must have nothing to eat or drink than 5 hours after the examination. The
for 4-6 hours patient must remain in the ward, under
observation for 24 hours.
PRE MEDICATION
● Diazepam Pre-sacral Pneumography
● It is used to demonstrate
TECHNIQUE retroperitoneal structures,
particularly the supra-renal
● Patient lies supine on the glands.
fluoroscopy table and is made as
comfortable as possible. PATIENT PREPARATION
● Under control, the optimum site
for puncture is located and its 1. The patient should take a suitable
position marked on the patient's apparent on each of the preceding two
skin. nights
● The skin is cleansed and local
anaesthetic is infiltrated. The 2. The patient should have nothing to
biopsy needle is inserted through eat or drink for five hours
the lung tissue, the patient is
asked to stop breathing so as to 3. Local preparation of the injection,
minimize the risk of air embolism. including shaving of the peer- anal area,
● Specimens of lung tissue are should be carried out.
sent to the pathology department
of analysis 4. The patient should micturate
● A radiograph of the chest, on immediately before the examination.
expiration, is taken 30 minutes to
one hour after the end of the PREMEDICATION
examination, to demonstrate
whether a pneumothorax is ● Omnopon
present.
CM
AFTER CARE OF PATIENT
● 300-600 ml of carbon dioxide
1. The patient must stay in bed for 6 each side.
hours and be observed frequently for
signs of pneumothorax APPARATUS

2. Radiograph of the chest may be ● tilting table with image intensifier

required during this time but a
 radiologist, using image
Pre-sacral Pneumography intensification and television.
● The patient is gently turned into
Preliminary Film the position, and the foot of the
Patient lays supine position using 14x17 couch is lowered about 15
film with the lower border at the level of degrees.
the illac crest. The diaphragm must be ● AP and OBLIQUE views are then
included on the radiograph. This taken using the under couch tube
radiograph is used to asses bowel ● The patient is then turned into the
clearance and to establish exposure AP position and AP view is taken
factors. Cassette is placed transversely,
with its lowered border at the
TECHNIQUE level of the iliac crests RP renal
areas
● Patient lies on his left side on the
tilting table ● Note: the patient remains in bed
● The peri-anal area is cleansed for 24 hours
with a mild antiseptic and local
anaesthetic is infiltrated between Upper Abdominal Pneumography
the anus and the coccyx
● A needle catheter or needle ● Is used to demonstrate the
cannula is then introduced inferior surface of the diaphragm
● When the needle is correctly and thus to evaluate masses in
positioned, 20 ml of saline are the upper abdomen or chest
injected to expand the pre sacral base.
space and to render it relatively ● It is also used to distinguish
more vascular between intrinsic and extrinsic
● The needle is then withdrawn so filling defects in the stomach and
that the injection of gas can be between benign and malignant
given through the catheter or gastric ulcers.
cannula, thus diminishing the risk
of embolism. PATIENT PREP
● The catheter is attached to the
patient by adhesive tape and 1. Patient should take suitable aperients
remains in situ until the on each of the nights preceding the
● The injection of carbon dioxide is examination.
given, half the gas being injected 2. Patient must have nothing to eat or
on each side. drink for at least four hours.
● This is actually carried out under 3. Patient should micturate immediately
fluoroscopic control by the before the examination.
PREMEDICATION ● Lower border of cassette is
● Omnopon and Scopolamine placed at the of the ASIS
● CR perpendicular
CM
● 1000 to 1500ml carbon dioxide LATERAL DECUBITUS

PRELIMINARY FILM ● Patient lies on the side not under

examination
● The bowel should be free from ● Grid cassette, supported
fecal shadows and the bladder vertically
must be empty but as this ● CR directed horizontally
preparation is not as critical as in
pelvic pneumography SUPINE LATERAL
●
● Patient lies in supine position on ● Patient lies supine on foam pads
the tilting table with lower border to raise him from the table top
of cassette at the level of the ● Grid cassette, supported
anterior superior iliac spines. vertically at the side of the patient
● CR directed horizontally
TECHNIQUE ● Erect or Supine views may also
be required
The procedure is the as the examination
of the pelvic viscera except that the Mediastinal Pneumography
patient is not tilted head downwards and a. in case of Myasthenia gravis or of
therefore a myelography harness is not primary or tertiary
necessary After instillation of the gas, hyperthyroidism where a
the patient is placed in whatever suspected tumour has not been
position will maneuver the gas into the demonstrated on plain films or by
appropriate region. If the diaphragm is tomography
being examined the table is brought b. in cases or esophageal
slowly into the vertical position so that carcinoma where the examination
the gas will rise under the diaphragm. If can be used to asses the extent
one of the abdomen is being examined, and operability of the tumour
the patient lies on the opposite side for a c. in the demonstration of
few minutes. mediastinal lymph nodes.

POSITIONING This examination is contra-indicated in

patients with impaired respiratory
● PRONE function
● Patient into the prone position
Patient Preparation
posterior to the anterior surface of the
1. Recent plain films of the chest sternum.
including penetrated views and lateral
tomograms of the anterior mediastinum TECHNIQUE:
are taken, usually the day before the
examination. ● The procedure is explained to the
patient
2. Patient must have nothing to eat or
drink for five hours ● Patient lies supine in tomography
table, with the neck extended
3. Patient is on anti-cholenergic drugs,
these must come to the department with ● The skin and tissues immediately
him and must be given at the set times behind the manubrium sterni are
even if this during the examination infiltrated with local anaesthetic.

4. Patients should micturate immediately ● Punctured is made above the

before the examination. suprasternal notch and the
needle, with stillete, is inserted in
PRE MEDICATION the midline, in line with the
manubrio-sternal joint.
Sodium Amytal but respiratory ● Gas is then injected, the quantity
depressants such as Morphine or usually between 100 to 500 ml.
Pethidine must be avoided. ● When the gas has been injected,
the patient sits up for one or two
CM minutes, and is then placed in
lateral position and tomograms
● Oxygen or Air 350 ml are taken in the midline and at
1cm. Intervals up to 4 cm on
PRELIMINARY FILM either side of the midline
● A multi section cassette is of
● A preliminary tomogram is taken advantage
to determine exposure factors
and depth of "cut required. AFTER CARE
Patient placed in a lateral position
and a midline tomogram of the 1. Pulse, temperature, respiration and
anterior mediastinum is taken. blood pressure are recorded every 15
● Center over the anterior mins. For 2 hours and then 4 hourly for
mediastinum at the level of the the next 24 hours.
manubrio-sternal angle 2 inch
2. Patient remains in bed for 24 hours
and must remain under observation in
the ward for a further 24 hours.