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COMPREHENSIVE PHASE
HANDOUT
SPECIAL RADIOGRAPHIC PROCEDURES WITH CONTRAST
Prepared By: Dexter J. Buluran, RRT
DEC 2023 Radiologic Technology Licensure Examination Review

A radiographic method that uses sophisticated machines to visualize certain anatomical structures or
organs after the administration, injection or introduction of Contrast Media.

CONTRAST MEDIA
A substance that is being ingested or injected and serves as a diagnostic aid to physician to visualize
certain tissues/organs of the body and to obtain information on organ function.
It’s either + CM (Radiopaque – White appearance) Ex.BaSO4 and Iodinated CM, or,
- CM (Radiolucent – Black appearance) Ex. Air, O2, and CO2 gas.

A. Barium Sulfate (BaSO4)

Atomic number of Barium 56.
The most common CM used for the visualization of GIT. It works by coating the inside of the
esophagus, stomach and intestines.
Non-toxic powdered, chalklike substance.
Barite/ Baryte minerals – primary main source of Barium.
Water + BaSO4 = Colloidal Suspension, not a solution.
➢ 2 Types of Barium Preparation
1. Colloidal Preparation
2.Suspended or Flocculation resistant Preparation – contains dispersing agent

Sodium Carbonate or Sodium Citrate – examples of dispersing agent that prevent flocculation.

Inert – physically and chemically inactive

➢ Contraindications of Barium Sulfate

1. Fistula
2. Obstruction
3. Pre/Post Abd. Operation
4. Perforation
5. Allergy to BaSO4 (Rare)

➢ 2 Types of BaSO4
1. Plain BaSO4
2. Commercial BaSO4

➢ Density of Barium Mixtures

1. weight/weight ex. 95% w/w (95 grams of barium present in 100 grams of the product)
2. weight/volume ex. 200% w/v (200 grams of barium present in 100 ml of barium mixture)

B. Iodinated Water Soluble Contrast Media (dye)

Atomic number Iodine 53.
Used primarily for Angiography, Biliary, Urographic procedures.
Used also in GIT when BaSO4 is contraindicated.
Strongly bitter taste.

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 HOCM - High Osmolar Contrast Media
LOCM - Low Osmolar Contrast Media
IOCM – Iso Osmolar Contrast Media

➢ Types of Iodinated Water Soluble CM:

1. Ionic CM - Higher osmolality and has greater chance of reaction. Contains Cation and Anion.
6 to 8 times higher osmolarity than blood plasma.
HOCM – high osmolar CM.
Cation (+ charged) - Sodium and Meglumine.
Increases the solubility of the contrast media.
Anion (– charged) - Diatrizoate, Iothalamate, Ioxaglate and Metrizoate.
Stabilizes the contrast media compound.

2. Non-Ionic CM - Lower osmolality and has lesser chance of reaction.

LOCM – low osmolar CM
“Amide or Glucose”.
2 to 3 times higher osmolarity than blood plasma.

IOCM – iso-osmolar CM. Type of contrast having osmolality equal to blood plasma.

➢ Iodine –Particle Ratio

1. Ionic Monomer (3:2)
2. Ionic Dimer (6:2 or 3:1)
3. Non-ionic Monomer (3:1)
4. Non-ionic Dimer (6:1)

➢ Contraindications of Iodinated CM
1. Hypersensitivity to Iodinated CM
2. High Creatinine Level
3. Renal Failure
4. Patient taking Metformin

C. Air Contrast Media - The radiolucent contrast medium either room air, O2 or CO2 gas. Commonly used in
GIT.
Gas producing crystals - Calcium & Magnesium Citrate
Gas producing tablets - Gastroluft

D. Oil Contrast Media (Non Water Soluble CM)

Commonly used in Myelography, Bronchography and Lymphography.
Clear yellow or pale amber color. It is not miscible and is not absorbable, tend to persist for long periods.
Examples : Ethiodol, Pantopaque, Dionosil
The most commonly used oil CM is Ethiodol.

➢ Categories of Contrast Media Reactions

1. Local Reaction – Extravasation and Phlebitis
2. Systemic Reaction – Mild, Moderate, and Severe

➢ Factors to consider in Selecting CM:

1. Viscosity - The resistance of fluid to flow.
2. Osmolality - A measure of the total number of particles in a solution/kg of water.
3. Miscibility - The ability of the medium to mix with other fluids.
4. Persistence - The amount of time the contrast media stays in the body.
5. Iodine Content - The volume distribution of iodine in the contrast agent.
6. Toxicity - Low iodine content, less toxic.
Toxicity is higher if the osmolality and viscosity of CM compound is high.

➢ 4 Physical States of Contrast:

1. Liquid
2. Powder
3. Oil
4. Tablet

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 ➢ Methods of Administering Contrast Media:
1. Direct Method – using specialized catheter and/or through injection (parenteral method).
Ex. BE, RGP, VCUG, RUG, Cystography, Sialography, Myelography, Bronchography, Angiography, Arthrography

2. Indirect Method – Orally or through injection.

Oral - Ex. Esophagogram, UGIS, SIS, Oral Cholangiogram
Parenteral – introduction of contrast through injection.
Ex. IVP, IVC, Lymphography

➢ Methods of Introducing Sensitivity Test:

1. Intravenous – 1 or 2 cc of contrast is injected into the vein.

2. Sub-lingual – a drop of contrast is deposited into the inferior base of the tongue.
3. Intradermal – 1 or 2 cc of contrast is injected just beneath the skin.
4. Scleral – a drop of contrast into the eyeball.

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 SPECIAL RADIOGRAPHIC PROCEDURES WITH CONTRAST (OLD PROCEDURES)

❖ SIALOGRAPHY
Is the radiographic examination of the salivary glands and ducts.
Contrast: Water soluble contrast

1. PAROTID gland - are the largest of the salivary glands.

- Stensen’s duct
2. SUBMANDIBULAR gland- these glands are each about the size of a walnut and are situated below and
medial to the body of the mandible.
- Wharton’s duct
3. SUBLINGUAL gland - Smallest among the salivary glands.
- Duct of Rivinus and Bartholin’s duct

Clinical Indications:
1. Calculus
2. Inflammation
3. Fistula
4. Obstruction of ducts
5. Stenosis
6. Tumor/ mass

Secretory stimulant – is used to open the duct for easier passage of catheter. Ex. Lemon
- It is also used for rapid evacuation of contrast

Basic Views:
1. Tangential – Parotid
Position: rotate the head slightly towards the side being examined
CR: directed to mandibular ramus

2. Lateral – Parotid and Submandibular

CR: 1 inch superior to gonion for parotid gland
CR: Inferior margin of gonion for the submandibular gland

3. Axial projection / Intra Oral Method – Submandibular and Sublingual

Projection: SMV or VSM

For the Intra Oral method: Using occlusal film

- This method will shows the unobstructed image of the sublingual gland.

Projection: SMV
CR: Intersection of MSP and coronal plane passing through the 2nd molars.

❖ PALATOGRAPHY – radiographic examination for the investigation of suspected soft palate tumor.

Contrast: BaSO4
Position: Lateral

1st palatogram - have the patient swallow a small amount of a thick, creamy barium sulfate suspension to coat
the inferior surface of the soft palate.
2nd palatogram - 0.5 ml of the creamy barium suspension is injected into each nasal cavity to coat the superior
surface of the soft palate and the posterior wall of the nasopharynx.

❖ NASOPHARYNGOGRAPHY

1. Using Positive Contrast – is performed to assess the extent of nasopharyngeal tumors.

Contrast: BaSO4 or Oil Contrast

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SMV projection of the skull and cross table lateral projection centered to the nasopharynx, centered to
the nasopharynx, ¾ inch directly anterior to the EAM.

2. Using Negative Contrast - for the demonstration of hypertrophy of pharyngeal tonsils or adenoids.

Projection: Lateral
The image must be exposed during the intake of a deep breath through the nose to ensure filling of the
nasopharynx with air.

❖ PHARYNGOGRAPHY
Radiographic examination of the pharynx.

Contrast: BaSO4

Projection: AP & Lateral

Projections are made during deglutition (exposure must coincide with the peak of the anterior movement
of pharynx).

Gunson method – modification of pharyngography

- using dark colored shoe string.

❖ LARYNGOPHARYNGOGRAPHY - radiographic examination of the laryngopharynx.

1. Positive Contrast LPG – usually performed to determine the exact site, size and extent of tumor mass.

Contrast: Thin barium or Oil contrast

Projection: AP & Lateral upright

2. Negative Contrast LPG – provide information about alterations in the normal anatomy and function of
laryngopharyngeal structures.
Projection: AP (chin up)

5 Maneuvers:

a. Quiet inspiration – open vocal cords

b. Normal Phonation – closed vocal cords

c. Inspiratory Phonation – laryngeal ventricle

d. Valsalva Maneuver – complete closure of glottis and to test the elasticity and functional integrity of the
glottis.

e. Modified Valsalva – to test the elasticity of the laryngeal pharynx (hypopharynx) and the piriform recesses

❖ DACRYOCSTOGRAPHY

Is the term used to denote radiologic examination of the nasolacrimal drainage system.

Indications: abnormalities of nasolacrimal passages such as defective development, stenosis and chronic
mucosal thickening.

Contrast: an oil-based, iodinated contrast medium (Ethiodized Oil) is employed.

CM is injected into the punctum of the canaliculus.

Projections: Caldwell, Waters and Lateral projections.

FEMALE RADIOGRAPHY:

1. For Non-pregnant patients

a. Hysterosalpingography

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b. Pelvic Pneumography
c. Vaginography

2. For Pregnant patients

a. Fetography
b. Pelvimetry and fetal cephalometry
c. Placentography

❖ HYSTEROSALPINGOGRAPHY
It involves the introduction of a radiopaque contrast medium through a uterine cannula to demonstrates the
uterus and uterine (fallopian) tubes of the female reproductive system.

Indications:
1. Infertility assessment and to diagnose structural or functional defects.
2. Abnormal uterine bleeding
3. Polyps, fibroids, adhesions
4. Pelvic mass, fistula, congenital defect
5. Evaluation of fallopian tubes after ligation

Preparations:
1. Bowel prep
2. NPO
3. Cleansing of the perineal region
4. Empty the bladder before examination

Position: lithotomy position, with the knees flexed over leg rests.
Projection: AP
RP: perpendicular to 2 inches above symphysis pubis

Contrast: water soluble contrast or a gaseous contrast medium may then be injected via the cannula into the
uterine cavity.

❖ PELVIC PNEUMOGRAPHY
Radiologic examination which requires the introduction of a gaseous contrast medium directly into the
peritoneal cavity.

❖ VAGINOGRAPHY
Is performed to investigate congenital abnormalities, vaginal fistulae, and other pathologic conditions involving
the vagina.

❖ FETOGRAPHY
Radiographic exam for the demonstration of the fetus in utero.

Fetography is employed to:

1. determine the age, position and presentation of the fetus
2. detect single or multiple pregnancy
3. detect congenital abnormalities
4. to confirm suspected fetal death
5. hydramnios.

Preparation: The pxn is requested to empty the bladder before the examination.

Projections: 1. AP (supine) or PA (prone) and

2. Lateral projections

Radiographic Pelvimetry and Fetal Cephalometry

Are performed to demonstrate the architecture of the maternal pelvis and to compare the size of the
fetal head with the size of the maternal bony pelvic outlet.

Methods of Pelvimetry:
1. Colcher-Sussman Method - Using Colcher-Sussman Pelvimeter
Position: 1. Supine
2. Lateral Recumbent

2. Thoms Method

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Position: 1. Erect lateral with metal centimeter ruler 2. Inlet position using Torpin-Thoms apparatus

3. Ball Method - Requires no special apparatus or accessories in exposing the films.

Position: 1. Erect, AP projection
2. Erect, Lateral projection

❖ PLACENTOGRAPHY
Is the radiographic examination in which the walls of the uterus are investigated to locate the placenta in cases
of suspected placenta previa.

MALE RADIOGRAPHY:
Contrast: Water soluble contrast
Duct system is inspected by introduction of contrast into the ductus deferens.

VESICULOGRAPHY
Is the radiographic examination of the seminal vesicles.
Projections:
1. AP Projection
RP: level of the superior border of the symphysis pubis

2. Oblique Projection
RP: level of the superior border of the symphysis pubis

EPIDIDYMOGRAPHY
Radiographic examination of the Epididymis.

PROSTATOGRAPHY
Is a term applied to the investigation of the prostate by radiographic, cystographic, or vesiculographic
procedures.

Clinical Indications:
1. Benign Prostatic Hyperplasia
2. Inflammation
3. Carcinoma

Rectal prostatography – introduction of CM via rectal wall puncture.

Position: Supine
CR: directed 1 inch above symphysis pubis at caudal angulation of 15 degrees.

Position: Prone
CR: directed to anal region with angulation of 20 to 25 degrees cephalad.

❖ ARTHROGRAPHY
Arthrography is the study of synovial joints and related soft tissue structures that employs contrast media.
Joints studied include the hip, knee, ankle, shoulder, elbow, wrist, and temporomandibular joints (TMJs).

3 Types of Arthrography
1. Pneumoarthrography - A gaseous medium is employed
2. Opaque Arthrography - A water- soluble iodinated medium is used
3. Double-Contrast Arthrography - A combination of gaseous and water- soluble iodinated media

Knee Arthrography – for the demonstration of ligamentous tear, joint capsule etc. that occurs during knee
trauma. It is also used for the demonstration of non-trauma pathology like baker’s cyst.

Position:
1. AP and Lateral – using conventional x-ray
2. 9 spot images – using fluoroscopy. With 20 degrees leg rotation per exposure to demonstrate the entire
meniscus.

Shoulder Arthrography – suspected rotator cuff tear / frozen shoulder.

Position: Supine / AP Projection with internal and external rotation

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Puncture site: ½ inch inferior and lateral to coracoid process

Dose: Single contrast - 10-12ml dye

Double contrast - 3-4 ml (+ contrast) and 10-12 ml (- contrast)

Wrist Arthrography – pain, trauma, limitation of motion

Position: PA, Lateral Oblique

Puncture site: Dorsal wrist, articulation between scaphoid, radius and lunate

Dose: 1.5-4ml dye

TMJ Arthrography
Puncture site: ½ inch anterior to tragus
Dose: 0.5-1ml dye

Hip Arthrography – this is performed for children with congenital hip dislocation before and after treatment
and for adult to detect a loose hip prosthesis.

Puncture site: ¾ inch distal to inguinal crease and ¾ inch lateral to palpated femoral pulse.

❖ CEREBRAL PNEUMOGRAPHY
For the demonstration of brain ventricles.

Contrast: Air, O2, CO2 or Helium

1. Pneumoventriculography – introduction of air contrast wherein air is injected through the holes drilled
into the skull.

2. Pneumoencephalography - introduction of air contrast by way of lumbar puncture

❖ MYELOGRAPHY
The radiographic study of the spinal cord using CM.

The procedure is performed by introducing a contrast medium into the subarachnoid space by spinal puncture,
most commonly at L3-L4 interspace using G20-G22 needle.

Clinical Indication:
1. Herniated nucleus pulposus
2. Cancerous or benign tumors
3. Cysts
4. Possible bone fragments (trauma cases)

Contraindications:
1. Blood in cerebrospinal fluid
2. Arachnoiditis
3. Increased intracranial pressure
4. Recent lumbar puncture

Recommended dose: 9 to 15 ml of dye

Alternative puncture site – Cisterna Magna (between C1 and occipital bone)

MYELOGRAPHY POSITIONING
1. CERVICAL REGION –
a. Horizontal Beam Lateral
b. Swimmer’s Lateral - Horizontal Beam

2. THORACIC REGION
a. R and L Lateral Decubitus Position – Horizontal Beam
b. Right or Left Lateral - Vertical Beam

3. LUMBAR REGION
a. Semierect Lateral—Horizontal Beam
b. Obliques with a vertical or horizontal beam

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c. Supine AP projection.

Conus Projection – is used to demonstrate the conus medullaris

AP Position
CR: T12-L1
Cross table lateral radiograph

❖ DISKOGRAPHY AND NUCLEOGRAPHY

- are terms used to denote the radiologic examination of individual intervertebral disks.

Diskography is used in the investigation of internal disk lesions, such as rupture of the nucleus pulposus, which
cannot be demonstrated by myelographic examination.

Double needle combination technique (20G and 26 G needle).

❖ DUCTOGRAPHY
- Examination of milk ducts.
The purpose of the examination is to rule out an intraductal mass as the possible cause of the discharge.

Contrast: water soluble contrast

Dose: 0.2 to 0.4 ml dye

3ml for very distended breast

❖ LYMPHOGRAPHY
- is a general term applied to radiologic examinations of the lymph vessels and nodes.

Lymphangiography - radiographic study of the lymph vessels. Visualization of vessels after 1 hour.

Lymphadenography – radiographic study of the lymph nodes. Visualization of nodes after 24 hours.

Blue dye – for vessel identification

Contrast: oil based contrast
Dose: 6ml each lower limb
4ml for each upper limb

Injection Sites: Limited to Hands and Feet (1st and 2nd interdigital web spaces)

Injection of the feet provide visualization of:

1. lymphatic structures of the lower limb
2. groin
3. iliopelvic and abdominoaortic region
4. Thoracic duct

Injection of the hands provide visualization of:

1. lymphatic structures of the upper limb
2. axillary
3. infraclavicular
4. supraclavicular region

THYROIDOLYMPHOGRAPHY –
Lymphographic technique for the delineation of the thyroid gland and cervical lymph nodes.

Percutaneous injection of 2 ml of ethiodized oil (Ethiodol) directly into the thyroid gland.

10 minutes after injection, the lobe of the thyroid gland is clearly outline.
24 hours after, cervical lymph nodes are visualized.

ORTHOROENTGENOGRAPHY – used to obtained radiograph of the long bones without magnification for
patients with limb length discrepancies using Bell Thompson Ruler.

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 SPECIAL RADIOGRAPHIC PROCEDURES WITH CONTRAST

❖ BILIARY SYSTEM
Cholegraphy - the general term for the radiographic study of the biliary system that requires the introduction
of contrast media.

Cholecystography is the radiographic investigation of the gallbladder, developed by Graham, Cole, and
Copher in 1924 and 1925.

Cholangiography is the radiographic study of the biliary ducts.

Cholecystangiography or Cholecystocholangiography is the radiography of both the gallbladder and the

biliary ducts.

Routes of Contrast Administration:

1. By mouth
2. By Injection into a vein
3. Direct Injection into the Ducts

Cholecystopaques – Contrast agents used in the biliary examination.

Clinical Pathology Involving the Biliary System:

1. Biliary Calculi
2. Cholecystitis
3. Gallbladder Neoplasm
4. Biliary Stenosis

❖ ORAL CHOLECYSTOGRAPHY / OCG

The contrast medium, when given by mouth is absorbed through the intestines and carried to the liver through
the portal vein.

GB localization:
- Right upper quadrant, 9th costal cartilage (sthenic)
- 2 inches higher for hypersthenic
- 2 inches lower for asthenic
- At full inspiration, the GB moves 1 to 3 inches medially and inferiorly
- At full inspiration, the GB moves 1 to 3 inches laterally and superiorly

Types of Contrast for OCG:

1. Telepaque (Iopanoic acid) – type of CM, with longer absorption time.

Can be taken 2 to 3 hours after evening meal.

Dose: total of 3 grams (6 tablets, 0.5 mg per tablet)

10 to 12 hours – max opacification of GB after the ingestion of Telepaque.

2. Oragrafin (Ipodate Calcium or Sodium Ipodate) - faster rate of absorption compare to telepaque.

Sodium Ipodate – allows visualization of GB about 4 hours after ingestion.

Calcium Ipodate - allows visualization of GB about 3 to 4 hours after ingestion and an average of 1 ½ hours
for the visualization of the biliary ducts.

Preparation:
1. Laxatives are administered 24 hours prior the ingestion of contrast.
2. Fat free evening meal
3. If using Telepaque as oral contrast, the contrast should be administered 2 to 3 hours after the evening meal.
4. NPO 12 midnight

Cholecystagogues – gallbladder stimulants that can cause the GB to empty to demonstrate the function. This
is being used after taking the radiographic images of the GB.
Ex. 1. Fatty meal / Boyden Meal – commercially available bar or egg or eggnog.

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2. Neo-Cholex or Bile-Evac

“Exposure should be made at the end of expiration”.

Projection:
1. PA Projection Prone or Upright - axial representation of the opacified gallbladder.
PA projection upright – this is used to demonstrate stones that are heavier or lighter than bile.

2. LAO position 15 to 40 degrees – used to separate the superimposition of the GB and vertebrae.

3. Right Lateral Position – it is used also to separate the superimposition of the GB and vertebrae for
extremely thin patients.
- it is also used to differentiate gallstones from renal stones.

4. Right lateral decubitus position - used to demonstrate stones that are heavier than bile or stones lighter
than bile when the patient cannot stand for an upright PA projection.

Contraindications:
1. Vomiting
2. Diarrhea
3. Pyloric obstruction
4. Malabsorption syndrome
5. Severe jaundice
6. Liver dysfunction
7. Allergy to contrast media

❖ INTRAVENOUS CHOLANGIOGRAPHY IVC

Radiographic examination of the biliary ducts after intravenous infusion of contrast.

Contrast: Cholagrafin
Position: RPO position (15 to 40 degrees)

Time of contrast infusion – 10 minutes (slow intravenous infusion).

“Radiographic exposure every 10 minutes intervals”

30 to 40 minutes – maximum opacification of biliary ducts

80 minutes up to 2 hours – maximum opacification of GB

Contraindications:
1. Obstructive jaundice
2. Increasing patients bilirubin (0.2 to 0.8 mg/dl normal bilirubin)

❖ PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)

-for patients with jaundice when the ductal system has been shown to be dilated by CT or ultrasonography.

- Chiba ("skinny") needle is used to access the biliary duct under fluoroscopy.

- PTC is often used to place a drainage catheter for the treatment of obstructive jaundice.
- Direct injection of CM to biliary ducts.
Position: Supine

❖ OPERATIVE CHOLANGIOGRAM / IMMEDIATE CHOLANGIOGRAM

Used in the investigation of the patency of the bile ducts and the functional status of the hepatopancreatic
ampulla, during biliary tract surgery.

Introduced by Mirizzi

Position: RPO position 15- 20 degrees.

CM is introduced through a needle, small catheter, or after T tube placement.

❖ T-TUBE CHOLANGIOGRAM / POSTOPERATIVE, DELAYED CHOLANGIOGRAM

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This examination is performed to demonstrate the caliber and patency of the ducts, the status of the sphincter
of the hepatopancreatic ampulla, and the presence of residual, undetected stones after surgery.

Introduction of contrast via T-tube catheter that is placed during biliary tract surgery.

Position: RPO position

❖ ENDOSCOPIC RETROGRADE CHOLANGIO PANCREATOGRAPHY ERCP

- A procedure used to diagnose biliary and pancreatic pathologic conditions.
- A useful method when the biliary ducts are not dilated and when no obstruction exists at the ampulla.
- It is performed by passing a fiberoptic endoscope through the mouth into the duodenum under
fluoroscopic control.
- Cannulation of Ampulla of Vater for the injection of CM.

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 SPECIAL RADIOGRAPHIC PROCEDURES WITH CONTRAST

❖ UROGRAPHY
-Radiographic study of the renal drainage or collecting system using contrast media.

➢ Two Techniques in Urography:

1. Antegrade Urography - allows the contrast medium to enter the kidney in the normal direction of blood flow.
Ex. IVU and Antegrade Nephrostogram

2. Retrograde Urography - the contrast material is introduced against the normal flow.
Ex. RGP, VCUG, RUG and Cystogram

Clinical Indication:
1. Benign prostatic hyperplasia
2. Bladder calculi
3. Bladder carcinoma
4. Congenital anomalies
5. Cystitis
6. Glumerulonephritis
7. Polycystic kidney
8. Renal calculi
9. Renal cell carcinoma
10. Pyelonephritis
11. Hydronephrosis
12. Renal hypertension
13. Renal obstruction
14. Bladder diverticula
15. Vesicorectal fistula
16. Neurogenic bladder

❖ INTRAVENOUS UROGRAM /
EXCRETORY UROGRAPHY /
INTRAVENOUS PYELOGRAPHY

IVU is the radiographic procedure of the urinary system in which contrast media is injected intravenously to visualize
the minor and major calyces, renal pelvises, ureters, and urinary bladder.

Preparation:
1. Light evening meal
2. Bowel cleansing laxative
3. NPO after midnight
4. Cleansing enema in the morning
5. Patients creatinine should be normal (0.6 to 1.2 mg/dL normal creatinine range)
6. Metformin should be withheld 48 hours before and after the procedure.

Contrast: Water soluble contrast

“Most CM reactions will occur within the first 5 minutes following the injection of contrast.”

2 to 8 minutes – appearance of CM at the pelvicalyceal system.

15 to 20 minutes – greatest concentration of CM in the pelvicalyceal system.

“Exposure should be made at the end of expiration”.

Position:
1. Supine, AP projection
Nephrogram – RP: midway between the xiphoid process and the iliac crest.
- Initial radiograph, focus only on kidneys.
- Taken after the completion of injection.

KUB – RP: MSP at the level of the iliac crest

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 - 5 minute image KUB
- 10 to 15 minute KUB

2. RPO and LPO Positions – body rotation of 30°

- The kidney on the elevated side is placed parallel to the IR.
RP: Iliac crest level
- 20 minute Obl image

3. Erect, AP Projection – Post Void

RP: Iliac crest level
- To view the residual contrast.
- The erect position may demonstate nephroptosis.

IVU Ureteric Compression Method – is a method used to enhance the filling of the pelvicalyceal system and proximal
ureters.
- Using 2 inflatable pneumatic paddles wrapped with Velcro band placed over the outer pelvic brim area to
compress the distal part of the ureter.

Position: Supine
RP: midway between the xiphoid process and the iliac crest.

Post release / Post spill Radiograph – taken after the release of the compression device.
Position: Supine

Contraindications of the Ureteric Compression:

1. Possible ureteric stones
2. Abdominal mass
3. Abdominal aortic aneurysm
4. Recent abdominal surgery
5. Severe abdominal pain
6. Acute abdominal trauma

Trendelenburg position (15 degrees) – alternative position if the ureteric compression is contraindicated.

❖ HYPERTENSIVE INTRAVENOUS UROGRAPHY

The hypertensive study includes at least 1, 2, and 3-minute radiographs, with the possibility of additional radiographs
every 30 seconds.

❖ RETROGRADE UROGRAPHY / RETROGRADE PYELOGRAPHY (RGP)

The procedure requires cystoscopy and the placement of a catheter for contrast injection to opacify the renal pelvis
and the ureter.
This procedure is used to determine the location of the urinary calculi and other types of ureteric obstruction.
The pxn is under general or regional anesthesia.

Position: Modified lithotomy

Dose: 3 to 5 ml / per injection

❖ CYSTOGRAPHY
Radiographic examination of the urinary bladder that is performed after instillation of an iodinated contrast media via
a urethral catheter.
Drip infusion of contrast to the urinary bladder.

Position:
1. Supine, AP projection
CR: 5° caudad (LS area of the spine is arch enough)
15 ° to 20 ° Caudad (Patients having loss of normal lumbar lordosis)

RP: 2 inches superior to symphysis pubis

2. LPO and RPO position - 40° to 60° body rotation

RP: 2 inches superior to symphysis pubis and 5cm medial to ASIS
SS: Postero-lateral aspect of the bladder and the UV junction

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3. Lateral Position
SS: used to demonstrate the anterior, posterior, and base of the bladder.

❖ VOIDING CYSTOURETHROGRAPHY (VCUG)

This examination provides a study of the bladder and the urethra and evaluates the patient’s ability to urinate.
The female is usually examined in the AP or slight oblique position.
The male is best examined in a 30°- 40° RPO position.
The voiding phase of the examination is best conducted using a fluoroscopy unit with image acquisition capability.
Usually done to demonstrate CM reflux from bladder to ureter or kidney and to assess proper reflux grading (grade 1
to grade 5).

Vesico-ureteric Reflux Grading:

Grade 1 – ureter only
Grade 2 – ureter up to kidney without dilation
Grade 3 - ureter up to kidney with mild dilation
Grade 4 – with dilation of the ureter without twisting, and loss of sharp calyceal fornices of the kidney
Grade 5 – with twisted and significant dilation of the ureter and kidney

❖ RETROGRADE URETHROGRAPHY (RUG)

It is performed on the male patient to demonstrate the full length of the urethra and to demonstrate any pathology
within the urethra.

Clinical Indications:
1. Urethral strictures
2. Traumatic urethral injury
3. Urethral calculi
4. Fistula
5. Diverticula

Position: 30° RPO position

Using Brodney Clamp

❖ PERCUTANEOUS NEPHROSTOMY (PCN)

A percutaneous nephrostomy is the placement of a small, flexible rubber tube (catheter) through the skin into the
kidney to drain the urine.

❖ ANTEGRADE NEPHROSTOGRAM
Antegrade Nephrostogram is done by introducing the contrast material directly into the kidney through a
percutaneous puncture of the renal pelvis for direct contrast filling of the pelvo-calyceal system in elected patients with
hydronephrosis.

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 SPECIAL RADIOGRAPHIC PROCEDURES WITH CONTRAST

❖ ESOPHAGOGRAM
A radiographic examination in which the patient is instructed to drink a radiopaque contrast medium that enables the
radiologist to study radiographically the function and appearance of the pharynx and esophagus and assess the swallowing
process.

➢ Clinical Indication
1. Achalasia
2. Chalasia
3. Barrett’s esophagus
4. Dysphagia
5. Odynophagia
6. Esophageal varices
7. Esophageal carcinoma
8. Foreign bodies
9. GERD
10. Zenker’s diverticulum
11. Diffuse esophageal spasm

Two Types of Esophagogram:

1. Single-Contrast Esophagram - in which only barium or another radiopaque contrast agent is used to fill the esophageal
lumen.

2. Double-Contrast Esophagram - using barium and carbon dioxide crystals as the two contrast agents.

➢ Two Phases of Esophagogram:

1. Filling Phase – used to distend the lumen of the esophagus thereby giving approximation of its entire length.
- Barium preparation: 2:1 or 3:1

2. Mucosal Phase – used to demonstrate the mucosal pattern of the esophagus.

- Barium preparation: 4:1

➢ Esophagogram Routine:
✓ Scout Film - AP and Lateral views of the Chest including the neck area.

1. RAO POSITION (35 – 40 degrees)

RP: level of T5 or T6
➢ Best position to demonstrate the entire length of the esophagus free from superimposition of the heart shadow
and vertebral structures

2. LATERAL POSITION
RP: level of T5 or T6
➢ This position determines the anterior and posterior displacement of the esophagus.

3. AP PROJECTION
RP: level of T5 or T6
➢ This position determines the degree of lateral displacement of the esophagus.

4. LAO POSITION (35-40 degrees)

CR: level of T5 or T6
➢ Esophagus is seen between hilar region of lungs and thoracic spine.

Methods employed for the Demonstration of Esophageal Reflux:

(1) Breathing Exercises
(2) Water Test
(3) Compression Paddle Technique
(4) The Toe-touch Maneuver

❖ UPPER GI SERIES (UGIS) / BARIUM MEAL

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 Radiographic study of the form and function of the distal esophagus, stomach, and duodenum as well as to detect any
abnormal anatomic and functional conditions using contrast media.

➢ Clinical Indication
1. Bezoar
2. Diverticula
3. Emesis
4. Gastric carcinoma
5. Gastritis
6. Hiatal hernia
7. Hypertrophic pyloric stenosis
8. Ulcers

➢ Three Types of UGIS Procedure:

1. Single-Contrast GI Series – 30% to 50%w/v

2. Double Contrast GI Series – 250% w/v

3. Biphasic GI Examination - Both single and double contrast incorporated together.

Introduced by Op den Orth.

Preparation:
1. NPO after midnight
2. The patient should not smoke or chew gum during the NPO period

➢ Upper GI Series Routine:

✓ Scout Film - AP view of the upper abdomen.

1. RAO POSITION (40-70 degrees) - Recumbent

RP: 1. level of L1 (duodenal bulb) – for sthenic, 45° to 55° body rotation
2. 2 inches below level of L1 – for asthenic, 40° body rotation
3. 2 inches above level of L1 – for hypesthenic, 70° body rotation

➢ This projection gives the best image of the pyloric canal and the duodenal bulb in patients whose habitus
approximates the sthenic type.
➢ Used for serial studies of the pyloric canal and duodenal bulb.

(2) PA PROJECTION - Prone

RP: level of L1 – sthenic
2 inches below L1 – asthenic
2 inches above L1 – hypersthenic

➢ The pyloric canal and duodenal bulb are well demonstrated in patients with an asthenic or a hyposthenic habitus.

(3) RIGHT LATERAL POSITION - Recumbent

RP: level of L1
2 inches below L1 – asthenic
2 inches above L1 – hypersthenic

➢ The right lateral projection affords the best image of the pyloric canal and the duodenal bulb in patients with a
hypersthenic habitus.

➢ This position will shows the anterior and posterior aspect of the stomach, the retrogastric space, pyloric canal,
duodenal bulb and loop and the duodenojejunal junction.

(4) LPO POSITION (30-60 degrees) - Recumbent

RP: 1. level of L1 (duodenal bulb) – for sthenic, 45° body rotation
2. 2 inches below level of L1 – for asthenic, 30° body rotation

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 3. 2 inches above level of L1 – for hypesthenic, 60° body rotation

➢ With a double-contrast procedure, fundus is filled with barium, the body and pylorus and occasionally
duodenal bulb are air-filled and may better demonstrate signs of gastritis and ulcers.

(5) AP PROJECTION – Supine

RP: level of L1 – sthenic
2 inches below L1 – asthenic
2 inches above L1 – hypersthenic

➢ An AP projection of the stomach shows a barium-filled fundic portion and usually a double-contrast delineation
of the body, pyloric portion, and duodenum.

➢ This position affords the best AP projection of the retrograstric portion of the duodenum and jejunum.

➢ Wolf Method – Application of intraabdominal pressure for the demonstration of Hiatal Hernia.

Requires the use of a semi-cylindrical radiolucent compression device measuring 22 inches in length, 10
inches in width and 8 inches in height

Position: RAO (40° to 45°)

CR: perpendicular to the long axis of the body at the level of T6 or T7, the position of the body will results into 10 to 20
degrees caudal angulation.

❖ HYPOTONIC DUODENOGRAPHY
It requires intubation and is used for the evaluation of postbulbar duodenal lesions and the detection of pancreatic
disease.
Introduced by Liotta.

Indications:
1. Duodenitis
2. Pancreatitis
3. Abdominal mass affecting c-loop

❖ Modification of UGIS
1. Gordons Method – bulb and pylorus of hypersthenic pxn

2. Gugliantini Method – for infant

3. Hamptons Method – leaf like pattern of the bulb and pylorus

4. Poppels Method – for retrograstric space of the stomach and evaluation of pancreatic disease

❖ SMALL INTESTINAL SERIES (SIS)

Small Bowel Series is the radiographic study of the small intestine.

➢ Clinical Indication
1. Enteritis
2. Giardiasis
3. Ileus
4. Meckel’s diverticulum
5. Neoplasm
6. Sprue and malabsorption
7. Whipples disease
8. Malrotation

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 ➢ Four Methods:
1. Small intestinal series (SIS)
- The patient generally ingests two cups (16 oz) of barium.
Position: Prone or Supine
RP: 1. level of L2, for radiographs taken within 15 minutes after the CM administration
2. level of iliac crest, for the succeeding delayed radiographs

Radiographic exposures every 15 minutes

End point of contrast: Ileocecal area

2. Upper GI–Small Bowel Follow Through

- Combined UGIS and Small Bowel Series.

Step 1: Drink 8 oz of barium for UGIS routine

Step 2: Drink another 8 oz of barium for SIS follow through
Step 3: Delayed radiographs of the abdomen
Radiographic exposures every 15 minutes

End point of contrast: Ileocecal area

3. Enteroclysis
➢ Special catheter advanced to duodeno-jejunal junction.
➢ The contrast medium is injected through a Bilbao or Sellink tube.
➢ 100ml/minute (rate of instillation of thin barium mixture)
➢ Instillation of air or methylcellulose
Indications:
1. Small bowel ileus
2. Crohn’s disease
3. Malabsorption syndrome

4. Intubation method
➢ A nasogastric tube is passed through the patient’s nose, through the esophagus, stomach, and duodenum, and
into the jejunum.
➢ Using thin barium mixture or water soluble contrast.

2 Methods:
1. Diagnostic method – using single lumen tube
2. Therapeutic intubation – to relieve postoperative distention or to decompress a small bowel obstruction
- using double-lumen catheter (Miller-Abbott tube)

5. Complete Reflux filling

➢ The patient's colon and small intestine are filled by administering large amount of Barium suspension to
demonstrate the colon and small bowel.

Position: Supine
Dose: 4,500ml of contrast
End point of contrast: duodenal bulb

❖ Barium Enema / Retrograde Enema (Lower GI Series)

The radiographic study of the large intestine using contrast media to demonstrate the large intestine and its
components.

➢ Clinical Indication
1. Colitis
2. Diverticulum
3. Intussusception
4. Neoplasm
5. Volvulus
6. Hirschsprung’s disease

➢ Types of Lower GI Examinations

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 (1) Single Contrast BE – 12% to 25% w/v

(2) Double Contrast BE – 75% to 95% w/v

2 types of Double Contrast BE:

1. Single stage BE

2. Two stage BE (Welin method)

Ideal for intraluminal lesions (polyps, ulcerative and regional colitis)

Preparation:
1. Light evening meal
2. Laxative and/or cleansing enema
3. NPO after midnight
4. No smoking or chew gum during the NPO period

Barium Enema Containers - with at least 6 feet long plastic tubing with disposable rectal retention tips.
- Having a capacity of 3 quarts (3000 ml).
- 90ml air capacity of the balloon rectal retention tip
- Enema bag are no higher than 24 inches above the level of the radiographic table.

SIMS POSITION (LAO 35-40 dgrees) – used for the insertion of enema tip. It relaxes the abdominal muscles and decreases
pressure within the abdomen.

Initial insertion should be aimed towards the umbilicus.

Direct the tube anteriorly 1 to 1.5 inches, then direct the tube slightly superiorly.

3.5 to 4 inches – total distance of enema tip insertion.

❑ Warm barium preparation

➢ 85° to 90°F (29° to 30°C).
❑ Cold barium preparation
➢ 41°F (5°C)

➢ Barium Enema Routine:

✓ Scout Film Abdomen

1. LEFT LATERAL POSITION

➢ The lateral projection best demonstrates the rectum and distal sigmoid portion of the colon.

2. AP AXIAL PROJECTION
CR: 30° to 40° cephalad
➢ The AP axial projection best demonstrates the rectosigmoid area of the colon

3. AP OBLIQUE PROJECTION (LPO position, 30 to 40 degrees)

➢ Less superimposition of rectosigmoid segments of the large intestine.

4. RPO POSITION (35 to 45 degrees)

➢ The RPO position best demonstrates the left colic flexure and the descending colon.

5. LPO POSITION (35 to 45 degrees)

➢ Best demonstrates the right colic flexure and the ascending and sigmoid portions of the colon.

6. AP PROJECTION
➢ The AP projection demonstrates the entire colon.

7. RIGHT LATERAL DECUBITUS POSITION

➢ This position best demonstrates the "up" medial side of the ascending colon and the lateral side of the descending
colon when the colon is inflated with air.

8. LEFT LATERAL DECUBITUS POSITION

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 ➢ This position best demonstrates the "up" lateral side of the ascending colon and the medial side of the descending
colon when the colon is inflated with air.

9. VENTRAL DECUBITUS POSITION

➢ The ventral decubitus position demonstrates the “up” posterior portion of the colon.

10. PA PROJECTION, PRONE - Post Evacuation

➢ Entire large intestine should be visualized with only a residual amount of contrast media.
➢ For mucosal pattern

End point of contrast: barium in Caecum

❖ Modification (Rectosigmoid)
1. Chassard-Lapine

2. Trendelenburg

3. Billings

4. Oppenheimers

5. Fletchers

6. Robins

❖ DEFECOGRAPHY
Aka: Evacuation Proctography / Dynamic Rectal Examination

- Used for patients with defecational dysfunction.

- Anorectal angle.

Indications:
1. Rectocele
2. Rectal prolapse
3. Rectal intussusception

Supplies and Equipments:

1. Fluoroscopy
2. Radiolocent commode chair
3. BaSO4 (mashed potato consistency)

Position:
1. Lateral recumbent – barium installation
2. Lateral sitting – during evacuation

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 SPECIAL RADIOGRAPHIC PROCEDURES
WITH CONTRAST

❖ ADDITIONAL FACTS

2-4 or 2-6 hours - The average emptying time of the normal stomach.
3-4 waves/min – average peristaltic movement of a normal stomach.
The highest degree of motor activity is normally found in the stomach and proximal part of the small intestine.
1 cm/min - Rate of movement of chyme through the small intestine.
Chyme normally takes 3 to 5 hours to pass through the entire small intestine.
2- 3 hours - The first part of a barium meal normally reaches the ileocecal valve.
4-5 hours - The last portion of the barium meal reaches the ileocecal valve.
24 hours - The barium usually reaches the rectum.
An iodinated solution normally clears the stomach in 1-2 hours.
The entire iodinated contrast column reaches and outlines the colon in about 4 hours.
Use an exposure time of 0.1 second or less for upright radiographs of the esophagus.
In examinations of the stomach and small intestine,
“Use an exposure time of 0.2 - 0.5 second for patients with normal peristaltic activity”.
“The exposure time should be 0.1 second or less for those patient with hypermotility”.

❖ Body Position in Relation to Stomach Orientation

1. Erect – stomach moves inferiorly especially the distal and pyloric portion with the pylorus moving from as high as T12
to as low as the sacrum.
2. Supine – superior displacement of the stomach.
3. Prone – Low positioned stomach and falls obliquely forward and downward.
4. Right Lateral Recumbent – duodenum swings forward from its 2 areas of fixation changing the relationship of the retro-
gastric structures.

❖ Body Position in Relation to Barium/Air Distribution

1. Supine Position
▪ The fundus of the stomach is the most posterior portion and is where the heavy barium settles.
▪ Best position that demonstrate double contrast study of the body and pylorus (mucosal study of the distal half of
the stomach).
2. RAO Recumbent Position
▪ The fundus is in the highest position, causing the air to fill this portion of the stomach (double contrast study of
the fundus).
▪ The barium settles in the more anterior body and pylorus portions of the stomach.

3. Erect Position
▪ Air rises to fill the fundus, whereas barium descends by gravity to fill the pyloric portion of the stomach.
4. Right Lateral Position
▪ Offers depiction of the pyloro-bulbar area.
▪ Filling of pyloric bulb and duodenum (C-loop) with barium and double contrast study of the fundus.
5. LPO Position
▪ Filling of the fundus with barium and double contrast study of the pylorus and duodenal bulb.

❖ Stomach Location in each Body Habitus

1. Hypersthenic
General stomach - level T9 to T12.
Pyloric portion - level T11 to T12, at midline.
Duodenal bulb location - level T11 to T12, to right of midline.
2. Sthenic
General stomach – level T10 to L2.
Pyloric portion—level L2, near midline.
Duodenal bulb location—level L1 to L2, near midline.
3. Hyposthenic/ Asthenic
General stomach - level T11 to L5.
Pyloric portion - level L3 to L4, to left of midline.
Duodenal bulb location - level L3 to L4, at midline.

The kidneys normally excrete 1 to 2 L of urine per day.

Normal respiratory excursion of the kidneys varies from 0.5 to 1.5 inches.
A 30° LPO positions the right kidney parallel to the IR, and a 30° RPO positions the left kidney parallel to IR.

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The adult bladder can hold approximately 500 ml of fluid when completely full.
The desire for micturition (urination) occurs when about 250 ml of urine is in the bladder.
1.5 to 2 minutes – total injection time of CM during IVU.
Most reactions to contrast media occur within the first 5 minutes after administration.
30 to 100ml of CM is administered to adult patients during IVU.
Contrast agent normally begins to appear in the pelvicalyceal system w/in 2 to 8 minutes.
The greatest concentration of pelvicalyceal system occuring in 15 to 20 minutes.
Filling of the average normal renal pelvis requires 3 to 5 ml of contrast solution.

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