FLUOROSCOPY

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FLUOROSCOPY ULTRASOUND AND CT TODAY DAVID L.
STEINBERG , M.D.
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FLUOROSCOPY

• UPPER GI
• ESOPHAGRAM
• SMALL BOWEL FOLLOW-THROUGH
• BARIUM ENEMA

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UGI

• epigastric pain,
• heartburn,
• vomiting,
• heme-positive stool,
• early satiety
• Patient preparation NPO after midnight or
  minimum of 4 hours

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UGI TECHNIQUE

• AIR CONTRAST
• THICK AND THIN BARIUM
• COAT AND IMAGE BOTH ANTERIOR AND POSTERIOR
  STOMACH WALLS
  
• COMPRESSION

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UGI FINDINGS

• ULCERS
• INFLAMMATION
• NEOPLASM
• HIATAL HERNIA
• ADHESIONS OR OBSTRUCTIONS

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Indications for an UGI exam include

• 1) Gastritis
• 2) Duodenitis
• 3) Peptic ulcer disease
• 4) Neoplasms
• 5) Varices
• 6) Gastric outlet obstruction
• 7) Detection of spontaneous, posttraumatic or
  postsurgical leaks from the stomach,
  
• esophagus, duodenum

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Symptoms serving as an indication for an UGI
include (but are not limited to

• Symptoms serving as an indication for an UGI
  include (but are not limited to)
  
• 1) Abdominal pain
• 2) Epigastric distress or discomfort
• 3) Nausea
• 4) Dyspepsia
• 5) Vomiting
• 6) Signs or symptoms of UGI bleeding
• 7) Anemia
• 8) Abdominal masses

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REALITY

• NUMBER OF UGIS DECLINING
• ENDOSCOPY IS REPLACING UGIS AS INITIAL SCREENING
  TEST
  
• ULCERS ARE DECREASING
• TESTS FOR H.PYLORI
• F/U FOR BARIATRIC SURGERY

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ESOPHAGRAM

• DYSPHAGIA
• ASSESS SWALLOWING FUNCTION
• ASSESS ABILITY TO PROTECT AIRWAY
• HH EVALUATION
• REFLUX EVALUATION
• BARRETS ESOPHAGUS

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ESOPHAGRAM TECHNIQUE

• MODIFIED BARIUM SWALLOW WITH SPEECH THERAPIST
• DOUBLE CONTRAST
• PRONE AND SUPINE
• BARIUM PILL 12 MM TO ASSESS SCHATZI RING
• FIRST SIP TO ASSESS BYPASS OR GASTRIC BANDING

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ESOPHAGRAM FINDINGS

• ASPIRATION
• DYSMOTILITY
• SWALLOWING DYSCOORDINATION
• DIVERTICULA
• ULCERS
• SCHATZI RING
• HH
• EROSIONS

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REALITY

• MOTILITY STUDIED BETTER WITH ESOPHAGRAM
• SCHATZI RINGS ( LESS THAN 13 MM OFTEN
  SYMPTOMATIC) BETTER WITH ESOPHAGRAM
  
• MUCOSA , ULCERS AND HH BETTER WITH ENDOSCOPY

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SCHATZKI RING
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SMALL BOWEL FOLLOW-THROUGH

• BLIND AREA NOT EASILY ASSESSABLE FROM ABOVE OR
  BELOW
  
• DONE PRIOR TO CAPSULE ENDOSCOPY TO INSURE NO
  STRICTURE OR OBSTRUCTION
  
• ENTEROCLYSIS / CT ENTEROCLYSIS

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CAPSULE ENDOSCOPY COMPLICATIONS

• LESS THAN .1
• RETAINED CAPSULES MOST FREQUENT COMPLICATION
• MOST OFTEN IN CROHNS DX OR NSAIDS
• DIVERTICULA
• TUMOR OBSTRUCTION

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CAPSULE ENDOSCOPY
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CAPSULE ENDOSCOPY

• OBSCURE GI BLEEDING MOST COMMON INDICATION
• AVM , SMALL BOWEL TUMORS AND ULCERS MOST
  COMMON CAUSES AND FINDINGS
  
• SMALL BOWEL -FOLLOW THROUGH HELPFUL IN
  LOCALIZING LESIONS FOUND BY CAPSULE ENDOSCOPY
  

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CROHN DISEASE
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CT OF TI WITH CAPSULE ENDOSCOPY CORRELATE
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BARIUM ENEMA

• NOW A SECOND LINE TEST FOR COLONIC DISEASE
• AIR CONTRAST IS SUPERIOR TO SINGLE CONTRAST
• USED FOR FAILED OR INCOMPLETE COLONOSCOPY
• COLONOSCOPY IS INCOMPLETE IN 6-26 OF CASES

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CT COLONOSCOPY

• 32,700 MORE GI DOCS NEEDED IF COLONOSCOPY
  PERFORMED EVERY 10 YEARS!
  
• 90 POLYPS LARGER THAN 10 MM SEEM BY CT
  COLONOSCOPY
  
• ?? IMPORTANCE OF SMALL POLYPS
• NOT IF BUT WHEN..

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POLYPS TAKE 10 YEARS OR MORE TO BECOME CANCERS
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COLON CANCER
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CT COLONOGRAPHY

• PROS
• NO SEDATION
• NO RISK OF PERFORATION
• FAST SCHEDULING AND EXAM
• FINDS OTHER PROBLEMS
• LESS EXPENSE

• CONS
• LESS ACCURATE FOR SMALL LESIONS
• FALSE POSITIVES
• CANNOT TREAT
• STILL NEED A PREP
• MINIMAL DISCOMFORT

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ULTRASOUND

• ABDOMINAL ULTRASOUND
• RENAL ULTRASOUND
• CAROTID ULTRASOUND
• VENOUS ULTRASOUND
• ARTERIAL ULTRASOUND

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ABDOMINAL ULTRASOUND

• PRIMARY IMAGING TEST FOR ACUTE RUQ PAIN
• BEST MODALITY TO DETECT GALLSTONES , GALLBLADDER
  WALL THICKENING AND SONOGRAPHIC MURPHY SIGN

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ABDOMINAL ULTRASOUND

• PREP NO EATING OR DRINKING 8 HOURS PRIOR TO
  PROCEDURE
  

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ABDOMINAL ULTRASOUND

• STATE OF THE ART INCLUDES
• COLOR AND DOPPLER IMAGING
• 3D AND 4D IMAGING
• TISSUE HARMONICS AND NOISE REDUCTION

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GALLBLADDER WITH SHADOWING STONE
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WITH TISSUE HARMONICS
WITHOUT TISSUE HARMONICS
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3D GALLBLADDER
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RENAL ULTRASOUND

• PRIMARY TEST FOR EVALUATION OF RENAL FAILURE OR
  RENAL CALCULI
  
• CAN SCREEN FOR RENAL ARTERY STENOSIS USING POWER
  DOPPLER AND PULSED DOPPLER

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RENAL ULTRASOUND

• NPO FOR 8 HOURS

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RENAL ULTRASOUND
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EVALUATION OF RENAL ARTERIOLAR DISEASE
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RENAL ARTERY STENOSIS

• NOT THE SAME AS R.V.H. FROM 1 TO 30
• ULTRASOUND IS VERY USER AND PT VARIABLE
• CAPTOPRIL AUGMENTED RENOGRAPHY CAN PREDICT
  RESPONSE TO REVASCULARIZATION LIMITED VALUE IF
  CR GREATER THAN 2.
  
• MRA AND CTA

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CAROTID ULTRASOUND

• Duplex ultrasonography (US) has become the most
  common screening and diagnostic test to evaluate
  extracranial carotid artery stenosis
  
• Based on morphology and velocity
• COLOR AND PULSED DOPPLER EVALUATION

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CAROTID STENOSIS

• NASCET SHOWED C.E. BENEFICIAL FOR70 STENOSIS
  IF M/M LESS THAN 3
  
• ASYMPTOMATIC CAROTID STENOSIS STUDY SHOWED
  BENEFIT AT 60.
  
• DOPPLER LEAST EXPENSIVE WITH ABOUT 90 S/S.
  OPERATOR DEPENDENT.
  

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CAROTID STENOSIS

• CTA AND MRA HAVE SIMILAR S/S
• DOPPLER AND MRA OR CTA HAVE BETTER PREDICTIVE
  VALUE THAN DOPPLER ALONE OR MRA/CTA ALONE
  
• MRA MAY OVER ESTIMATE STENOSIS AND IS MOTION
  SENSITIVE
  
• CTA MAY END UP BEING MOST ACCURATE WITH MDCT
  IMAGING
  

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VENOUS ULTRASOUND

• IMAGING STUDY OF CHOICE FOR EVALUATION OF
  PATIENTS WITH SUSPECT DVT . BOTH UE AND LE
  
• GOLD STANDARD IS 2 NEGATIVE ULTRASOUNDS ONE WEEK
  APART TO EXCLUDE DVT
  
• EXCELLENT IN SYMPTOMATIC PATIENTS. NOT SO GOOD
  FOR SCREENING ASYMPTOMATIC PATIENTS.

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VENOUS ULTRASOUND

• PREPARATION NONE
• NOT GREAT FOR RECURRENT DVT
• ONLY NEED TO STUDY THE SYMPTOMATIC LEG
• NEGATIVE D- DIMER TEST IN LOW PROBABILITY
  PATIENTS ELIMINATES NEED FOR ULTRASOUND
  

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VENOUS ULTRASOUND
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ARTERIAL ULTRASOUND

• BASED ON BLOOD FLOW VELOCITY MEASUREMENTS
• VESSEL MORPHOLOGY AS WELL
• ABIS IMPORTANT
• COLOR AND PULSED DOPPLER
• CTA AND MRA MORE SENSITIVE

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P.V.D.

• SCREENING A.B.I. AND DOPPLER
• CTA AND MRA BOTH COMPETITIVE
• ANGIO HAS THE ADVANTAGE OF IMAGING AND
  INTERVENTION AT THE SAME TIME
  
• DOPPLER MAY HELP STEER FURTHER IMAGING IE.,
  LARGE VESSEL SINGLE LEVEL DX. LIKELY AMENABLE TO
  PERCUTANEOUS INTERVENTION
  

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AORTIC ANEURYSM

• 5-7 OVER 60 YEARS OF AGE
• AT RISK GROUP INCLUDE SMOKING HX, HTN .KNOWN
  VASCULAR DX AND 1ST DEGREE RELATIVES
  
• ULTRASOUND IS THE MOST COST EFFECTIVE SCREENING
• CTA OR MRA CLOSE TO BEING EQUALLY EFFECTIVE IN DX
  EXTENT

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AORTIC ANEURYSM

• ULTRASOUND ACCURATE TO 3MM
• AVERAGE RATE OF EXPANSION IS 3 TO 5 MM A YEAR
• RAPID EXPANSION AND SIZE OVER 5CM FAVOR SURGERY
• SURGICAL MORTALITY 5
• RUPTURE MORTALITY 80 .RR/YR OF 5CM ANEURYSM 7

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CT TODAY

• MULTISLICE 4-64 SLICES
• NONIONIC CONTRAST
• ACQUIRE VOXELS NOT PIXELS
• ISOTROPIC IMAGING
• 3D AND MULTIPLANAR REFORMATIONS THE NORM

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CT PREPARATION

• ORAL BARIUM FOR STUDIES OF ABDOMEN OR PELVIS
• IF IV CONTRAST NEED A RECENT CREATININE
• NPO FOR 4 HOURS IF CTA

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CT RISKS

• CONTRAST REACTION
• CONTRAST INDUCED NEPHROPATHY

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• Contrast-Induced Nephrotoxicity

• Due to renal vascular effects and direct toxicity
  to tubular cells
  
• Third most common cause of in-hospital renal
  failure, after hypotension and surgery
  
• Definition elevation of creatinine 25 or .5-1.0
  mg/dL within 72 hours
  

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Contrast-Induced Nephrotoxicity

• Usually asymptomatic creatinine peaks 3-5 days,
  in severe oliguric renal failure peaks 5-10
  days
  
• Incidence
• 7-8 arterial injections
• 2-5 venous injections
• 0 venous injections if no risk factors

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• Nephrotoxicity Risk Factors

• Byrd and Sherman, 1979
• Renal insufficiency (creat1.5)
• Diabetes
• Dehydration
• Cardiovascular dz and diuretics
• Age 70
• Myeloma
• Hypertension
• Hyperuricemia

Highest risk (Parfey et al., 1989)
RENAL INSUFFICIENCY AND DIABETES

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• Nephrotoxicity Risk Factors

• Creatinine measurement recommended
• Hx of kidney dz
• Family hx of kidney failure
• IDDM for 2 years
• NIDDM for 5 years
• Paraproteinemia
• Collagen vascular dz
• Medications NSAIDs,aminoglycosides

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• Nephrotoxicity Prevention

• HYDRATION
• 100 ml/hr at least 4 hours before and 12 hours
  after
  
• Mannitol
• Furosemide
• Dopamine
• Theophylline
• ANP

disappointing in clinical trials
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• Nephrotoxicity Prevention

• N-Acetylcysteine (Mucomyst) Antioxidant with
  vasodilatory properties
  
• NEJM 2000343(3) 180-183 nephrotoxicity occurred
  in 9/42 patients receiving placebo and 1/41
  patients receiving acetylcysteine after 75 ml
  iopromide
• For premedication
• 600mg PO BID day before and of study
• Alternative 150mg/kg IV over 30 min prior to
  study, then 50mg/kg over 4 hours

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• Nephrotoxicity

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19

• Dec 18

Dec
21
Dec
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CT PROCEDURES

• CT ABDOMEN
• CT CHEST
• CTA PULMONARY
• CTA AORTA
• CTA CORONARY

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CT ABDOMEN

• DX APPENDICITIS 90-100
• PANCREATITIS DX AND PROGNOSIS
• BILIARY TRACT DX
• NODAL DX
• RENAL DX

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TARGET SIGN
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VALUE OF CORONAL IMAGING
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APPENDICITIS??
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PANCREATITIS
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CT CHEST

• INTERSTITIAL LUNG DISEASE
• EVALUATE LUNG NODULES
• STAGE LUNG CANCER
• SOLVE CXRAY QUESTIONS

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PULMONARY FIBROSIS
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CAD FOR LUNG NODULES
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(No Transcript)
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CTA PULMONARY

• MAY BE MORE SENSITIVE THAN PA WHEN SMALLER
  COLLIMATION IS USED 1.25 MM ( 64 SLICE ) CORONAL
  IMAGING
  
• WHAT ABOUT SMALL PE
• NO NEED FOR V/Q

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PULMONARY EMBOLUS

• CTA IS IT!!!!!!!!!!!!!!!!!!! V/Q SCAN IS GONE
• HIGH S/S
• NEGATIVE PREDICTIVE VALUE IS IMPORTANT. A
  NEGATIVE TEST MEANS THAT NO TREATMENT IS
  NECESSARY
  
• LESS EXPENSIVE THAN AND AS ACCURATE AS PULMONARY
  ANGIO
  

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CT PULMONARY ANGIO
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PULMONARY EMBOLISM
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CTA AORTA

• PREOP FOR ENDOVACULAR REPAIR
• F/U FOR ENDOVASCULAR REPAIR
• WORKUP FOR PVD
• WORKUP FOR ABDOMINAL ANGINA

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CTA
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RENAL CTA
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CTA
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ABDOMINAL ANGINA
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CTA CORONARY ARTERIES

• READY FOR PRIME TIME AT 64 SLICE
• REPLACE CATH IN LOW RISK PATIENTS
• LIMITED EVALUATION IN PTS WITH HIGH CALCIUM
  SCORE
  
• PHYSIOLOGIC DATA INCLUDING WALL MOTION AND EF

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ANOMALOUS ORIGIN OF RCA
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CARDIAC MORPHOLOGY
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THANKS FOR COMING AND LISTENING