RAD 220 Radiological Imaging 4

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RAD 220Radiological Imaging 4

• Jens Loberg

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Introduction

• Gastro-intestinal system
• Genito-urinary system
• Biliary system
• Mammography

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Introduction

• Anatomy
• Indications
• Basic projections
• Patient preparation / care
• Including additional administration of
  drugs/chemicals.
• Technical parameters
• Critical assessment

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Gastro-intestinal system

• Barium
• Swallow
• Meal
• Meal / follow through (ft)
• Enema

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Barium

• A soft, silvery-white alkaline-earth metal, used
  to deoxidize copper and in various alloys. Atomic
  number 56 atomic weight 137.33 melting point
  725C boiling point 1,140C specific gravity
  3.50 valence 2.
• Radiography, use barium sulphate suspension.

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Barium Swallow
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Barium Swallow

• Anatomy
• Gross
• Radiographic
• Normal
• abnormal
• Indications
• Contraindications
• Technique
• Modified barium swallow (speech pathologists)

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Ba Swallow Anatomy

• Gross anatomy
• Mouth
• Tongue
• Epiglottis
• Larynx
• Trachea
• Hyoid bone
• Oesophagus
• Oesophageal opening through diaphragm
• Cardiac sphincter / Oesophageal sphincter
• Cardiac notch

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• Radiographic anatomy
• Oesophageal lumen filled with barium
• Functioning epiglottis
• Normal peristalsis
• Oesophageal sphincter
• Normal diameter of oesophagus

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Indications for Ba swallow

• Dysphagia
• Pain
• reflux
• Assessment of tracheo-oesophageal fistula
• Assessment of left ventricular enlargement
• Pre-operative assessment of carcinoma of the
  bronchus
• Assessment of perforation

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Diseases (indications)

• Oesophageal atresia
• Acute oesophagitis
• Chronic oesophagitis
• Hiatus hernia
• Achalasia of the cardia
• Varices
• Oesophageal obstruction

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Contraindications

• Impending surgery
• Alternative Gastrogaffin swallow
• Epiglottis failure
• Inhalation aspiration of barium
• Barium bronchogram

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Image sourced from internet http//knowledge.emed
icine.com/splash/shared/pub/xrotw/0030.jpg
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Technique

• Patient preparation.
• No patient preparation for this study is
  required. (only to turn up on time), unless a
  barium meal is to follow (see barium meal
  preparation).
• Patient to be undressed to underpants and have
  gown on with opening at back (posterior)
• Remove dentures, necklaces, bra and earrings
  tongue rings
• Preliminary film.
• None necessary.
• Contrast
• 100ml or more (dependant on patient size) of
  barium 30-50 weight volume sulphate suspension
• Water-soluble contrast is to be used if assessing
  perforation (eg. Gastrograffin)
• Contrast administered via straw, drinking, spoon
  depending on consistency of contrast.

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• Imaging
• Images taken on digital fluoroscopy unit if
  available.
• Cut film or CR split film
• Protect patients gonads where practical.
• Complications
• Aspiration
• Barium leakage from a perforation

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Basic projections

• Anteroposterior upper oesophagus
• Lateral upper oesophagus
• Lateral middle and lower oesophagus
• Right anterior oblique (RAO) left posterior
  oblique (LPO) oesophagus
• Trendelenburg position

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Anteroposterior

• Patient standing or sitting with posterior aspect
  against Bucky, centre in the midsagittal plane at
  level of C4-5 and centred to grid.
• FFD 100cm
• kVp 80-90, mAs dependant on patient size.
• Regular film/screen combination

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• holding onto cup full of contrast. collimating to
  skin edge
• patient is instructed to take mouthful of
  contrast and hold in their mouth, on the count o
  three to swallow. (timing here is extremely
  important)
• Images to be taken when the oesophagus is full of
  contrast.
• Evaluation
• Oesophagus filled with contrast
• Adequate penetration of contrast
• Oesophagus visible through the superimposed
  cervical spine
• No rotation

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Lateral upper oesophagus

• Patient standing or sitting with left or right
  aspect against Bucky always facing the
  radiographer. centre in the mid-coronal plane at
  level of C4-5 and centred to grid. collimating to
  skin edge
• FFD 100cm
• kVp 80-90, mAs dependant on patient size.
• Regular film/screen combination

Sourced from internet http//www.bsg.org.uk/clini
cal_prac/july_03/images/fig2as.gif
Sourced from internet http//www.healthsystem.vi
rginia.edu/internet/speech/images/servicespic1.jpg
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• holding onto cup full of contrast with left hand
  (or most appropriate hand).
• patient is instructed to take mouthful of
  contrast and hold in their mouth, on the count to
  three to swallow. (once again timing)
• Images to be taken when the oesophagus is full of
  contrast.
• Evaluation
• Oesophagus filled with contrast
• Adequate penetration of contrast
• No rotation
• Adequate visibility of trachea and oesophagus

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Sourced from internet http//www.bsg.org.uk/clini
cal_prac/july_03/images/fig2as.gif
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Lateral middle and lower oesophagus

• Patient standing or sitting with left or right
  aspect against Bucky always facing the
  radiographer. centre in the mid-coronal plane at
  level of T5-6 and centred to grid. collimating to
  region of interest
• Ensure patients arms are out of path of x-ray
• FFD 100cm
• kVp 80-90, mAs dependant on patient size.
• Regular film/screen combination
• patient is instructed to take mouthful of
  contrast and hold in their mouth, on the count of
  three to swallow. (once again timing)
• Images to be taken when the oesophagus is full of
  contrast.
• Evaluation
• Oesophagus filled with contrast
• Adequate penetration of contrast
• No rotation
• Oesophagus anterior to thoracic spine

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RAO or LPO oesophagus

• Patient standing or sitting in a RAO or LPO ,
  Have the midsagittal plane forming an angle of
  30-40 degrees to the grid at level of T5-6 and
  centred to grid.
• FFD 100cm
• kVp 80-90, mAs dependant on patient size.
• Regular film/screen combination

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• holding onto cup full of contrast. collimating to
  region of interest
• patient is instructed to take mouthful of
  contrast and hold in their mouth, on the count o
  three to swallow. (timing here is extremely
  important)
• Images to be taken when the oesophagus is full of
  contrast.
• Evaluation
• Oesophagus filled with contrast
• Adequate penetration of contrast
• Oesophagus visible between heart and spine
• No rotation

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Trendelenburg position

• Reflux
• Patient laying supine, with feet raised.
• May give drink of water to demonstrate
  swallowing, and assess oesophageal sphincter
  function

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Sourced from internet www.xray.com.uk
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Sourced from internet www.xray.com.uk
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Post examination patient care

• Warm wet cloth to clean mouth
• Assist to change cubicle
• Keep fluids up for next 24-48 hours

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Barium Meal
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Barium Meal

• Gross anatomy
• Cardiac sphincter / Oesophageal sphincter
• Stomach
• Fundus
• Body
• Pyloric antrum
• Rugae
• Pyloric sphincter
• Greater/lesser curve
• duodenum

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Indications

• Pyloric stenosis
• Peptic ulcer
• Perforation
• Haemorrhage
• Tumour
• Polyps
• Reflux
• Pain
• Vomiting
• Indigestion
• Blood in stool

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contraindications

• Large bowel obstruction
• Perforation

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Additional drugs

• Maxolon
• Buscopan
• E-Z gas

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Technique

• Radiographer is to be in lead gown with thyroid
  protection, positioned within the fluoroscopy
  room at back of x-ray tube head.
• Patient preparation.
• Nil by mouth 6 hours prior to examination
• Smoking should be avoided on day of study
• Patient should be instructed of the time required
  for examination
• Patient undressed to underpants and have gown on
  with opening at back.
• Preliminary film.
• Preliminary abdomen radiograph.

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Technique

• Effervescent granules
• Given in a small amount of water in a cup
  immediately prior to examination
• Must be able to produce adequate volume of gas
  (200-400ml)
• Non interfeering with Ba
• No bubble production
• Easily swallowed
• Low cost
• Contrast
• 100ml or more (dependant on patient size) of
  barium 30-50 weight volume sulphate suspension
• Water-soluble contrast is to be used if assessing
  perforation (eg. Gastrograffin)
• Contrast administered via straw, drinking, spoon
  depending on consistency of contrast.

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Technique

• Most barium meals are performed as barium swallow
  initially then as stomach fills the meal takes
  effect.
• After granules are given the most common thing
  for patient to do is to belch, this is something
  you dont want them to do.
• Tell them to keep swallowing.

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Technique

• Patient erect while drinking barium sulphate
  suspension
• Spot films are taken in
• AP
• RAO
• LPO
• lateral projections

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Anteroposterior

• Opacified air filled stomach and duodenum
• Film size
• 35/35 split
• 24/30 single spot films
• Patient position
• Supine (if laying)
• A-P erect
• Arms at sides outside of radiographic field
• Gonad shielding

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Anteroposterior

• Centering point
• Perpendicular to film plane
• Midclavicular line
• At level of L1 (1st lumbar vertebrae)
• Exposure
• 80-90 kVp
• 100-120 kVp (for single contrast studies)
• Patient instruction
• Suspended inspiration

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Anteroposterior

• Image criteria
• Entire opacified stomach and duodenum
• Fundus should bee seen filled with contrast
  medium, while body and antrum should be filled
  with air (double contrast)

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Right anterior oblique (RAO)

• Opacified stomach and duodenum
• Especially pyloric canal and duodenal bulb
• Film size
• 35/35 split
• 24/30 single spot films
• Patient position
• Semiprone (RAO)
• Patient resting on opposite side forearm and knee
  (can use radiolucent sponge)
• Patient head in right lateral position
• Gonad lead protection

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Right anterior oblique (RAO)

• Centering point
• Perpendicular to film plane
• midscapular line
• At level of L2 (approx level of duodenal bulb)
• Exposure
• 80-90 kVp
• 100-120 kVp (for single contrast studies)
• Patient instruction
• Suspended inspiration

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Right anterior oblique (RAO)

• Image criteria
• Pyloric canal and duodenal bulb should be well
  demonstrated and not superimposed.
• Duodenal loop is generally seen superimposed with
  lumbar vertebrae.

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Left posterior oblique (LPO)(AP oblique)

• Opacified stomach and duodenum
• Especially fundus
• Film size
• 35/35 split
• 24/30 single spot films
• Patient position
• LPO
• Patients head on pillow
• Left arm extended away from body, to prevent
  unwanted superimposition
• Gonad protection

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Left posterior oblique (LPO)

• Centering point
• Perpendicular to film plane
• midclavicular line
• At level of T12 (approx level body of stomach)
• Exposure
• 80-90 kVp
• 100-120 kVp (for single contrast studies)
• Patient instruction
• Suspended inspiration

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Left posterior oblique (LPO)

• Image criteria
• Fundus of stomach should be well demonstrated
  without motion.
• Pyloric canal and duodenal bulb should be seen
  without superimposition.

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Lateral

• Opacified stomach and duodenum
• Especially anterior and posterior walls of
  stomach, duodenal bulb, and duodenal loop.
• Film size
• 35/35 split
• 24/30 single spot films
• Patient position
• Right lateral
• Raise patients arms, no superimposition
• Flex knees
• Gonad protection

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Lateral

• Centering point
• Perpendicular to film plane
• Between midaxillary plane and anterior surface of
  abdomen
• At level of L1 (approx level of pylorus)
• Exposure
• 80-90 kVp
• 100-120 kVp (for single contrast studies)
• Patient instruction
• Suspended inspiration

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Lateral

• Image criteria
• Stomach should be in lateral position (can cross
  check with vertebrae)
• Anterior and posterior walls should be well
  demonstrated.
• Pyloric canal and duodenal bulb are well
  demonstrated.

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Complications

• Aspiration of barium.
• Leakage through perforation.
• If the bowel is obstructed, the barium meal can
  become impacted.
• The barium can lodge in the appendix and cause
  appendicitis.
• There may be side effects (such as blurred
  vision) from the drugs used during the test.

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Sourced from internet www.xray.com.uk