SPECIAL PROCEDURES WITH CONTRAST | AN MARI M.

CAPUZ, RRT

SPECIAL PROCEDURES WITH CONTRAST – PART 1

CONTRAST MEDIA (C.M.)
- Substances administered in the body to demonstrate a visible image of hollow organs in the body.
- High or low atomic number chemicals or substances compared to adjacent structures.
- Improves demonstration of different density in the human body.
PURPOSE: COV
1. Contrast Study
2. Opacification
3. Visualization
TYPES OF CONTRAST MEDIA
POSITIVE C.M. NEGATIVE C.M.
Radiopaque Radiolucent
Absorb more x-rays Transmit x-rays
High Atomic Number (Z) Low Atomic Number (Z)
Bright/White Dark/Black
Radionuclide: C.M. used in nuclear medicine

SUBSTANCE USED AS C.M.

1. Air and Gases – Calcium Carbonate crystal, Magnesium Citrate, Room Air, Carbonated Beverages
2. Inorganic Iodides - Sodium Potassium and Silver Iodide (urography)
3. Organic Iodides – Telepaque and Iopanoic Acid (Cholegraphy)
4. Iodized Oil (Non-Absorbable) – Lipiodol and Iodocholorol (Sialagrophy)
5. Iodized Oil (Absorbable) – Pantopaque and Dionosil (Bronchography)
6. Heavy metallic salts – Barium Sulfate (Barium Enema (BaE) and Gastrointestinal Series (GIS))
Barium Sulfate (BaSO4) – non- absorbable, high atomic number, relatively cheap, less irritating contrast media. It
cannot be dissolved in water (colloidal suspension) and is not applicable on patients with suspected perforation.
TYPES OF BaSO4 MIXTURES
1. PASTE MIXTURE (75% C.M. + 25% WATER) - Esophagography
2. THICK MIXTURE (50% C.M. + 50% WATER) – Upper Gastrointestinal Series (UGIS)/Small Intestinal
Series (SIS)
3. THIN MIXTURE (25% C.M. + 75% WATER) – Barium Enema
4. MILK MIXTURE (2 tbsp. C.M. + 1 glass WATER)
IODINATED FORM C.M.
IONIC NON-IONIC
More Iodine Concentration Less Iodine Concentration
High Osmolality Less Osmolality
Cheap Expensive
More probability of allergic reactions Less probability of allergic reactions
Hypaque/Conray Ultravist/Optiray

CHOOSING A GOOD CONTRAST MEDIA: ROUTE OF ADMINISTRATION

1. Adequate Viscosity 1. Ingestion (Oral)
2. Physiologically Inert 2. Retrograde Administration (Rectal)
3. Suitable Persistence 3. Parenteral (Intrathecal, Intraarterial, Intravenous)
4. Non-toxic or less toxic 4. Intubation
5. Miscibility
6. Eliminated Unchanged
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

RULES IN CONTRAST ADMINISTRATION (5Rs)

1. Right patient 4. Right amount (dose of contrast media)
2. Right contrast media 5. Record on the chart of patient the C.M. used
3. Right time (of administration)
Note: Never hold tablet or powder form contrast media with your bare hands.
EFFECTS OF C.M.
1. Histamine imbalance (patient cannot tolerate c.m.)
2. Hemodynamic (occurs during administration of c.m.) – systemic shock, Myocardial Infarction, Renal Shutdown,
Hypertension, Urticaria
3. Psychosomatic reaction (mild transient effect if patients are experiencing fatigue or anxiety)
4. Extravasation with burning pain and hematoma.
5. Pyrogenic Reaction
6. Organ Reaction (Chemotoxic and Idiosyncratic)
ADVERSE REACTION OF C.M.
1. 1st degree (MILD) – no treatment necessary but frequent patient observation is a must
-patient may exhibit metallic taste in the mouth, nausea, vomiting, mild urticarial and flushing of skin.
2. 2nd degree (MODERATE) – require some treatment such as histamine administration
- patient may exhibit mild drop in BP, urticarial of increased severity.
3. 3rd degree (SEVERE) – possible hospitalization and is life threatening
- patient may exhibit prolong drop in BP, collapsed circulatory system, cardiac arrhythmia, coma, convulsion, seizure.
4. 4th degree (FATAL) – includes cardiac and respiratory arrest.
IMPORTANT DRUGS TO HELP RELIEVE C.M. REACTIONS.
1. Ampoule Benadryl (Diphenhydramine HC) – intramuscular administration. (moderately severe reactions)
2. Antistine – relieves itching and irritation affecting the eyes within 5-10 mins. After administration and will last up to 2-6
hrs.
3. Epiniphrine – bronchodilator
SENSITIVITY TESTING
- Process where in a few amounts of contrast media is administered to the patient before administrating the whole
amount. Reactions usually occur 10-15 mins after sensitivity testing.
METHOD OF SENSITIVITY TESTING
1. Scleral – 1 drop of C.M. to the scleral of the eye (Possible effects: Eye irritation, redness, swelling).
2. Sublingual – 1 drop C.M. to the base of the tongue (Possible Effects: Tongue irritation, swelling, vomiting,
salivation).
3. Intradermal – 1-2 cc of C.M. injected beneath the skin (Possible Effects: Vomiting, salivation, dilatation).
4. Intravenous – 1- 2 cc of C.M. injected in the veins (Possible Effects: Nausea, vomiting, dizziness, itching).
TYPES OF RADIOGRAPHIC CONTRAST STUDY
1. SINGLE – uses 1 kind of C.M.
2. DOUBLE – uses 2 kinds of C.M.
3. DUAL - uses 2 kinds of C.M. in 2 different ways of introduction
4. MUCOSAL PHASE STUDY – small amount of C.M. is used to coat the lining membrane of the hollow organ.
5. FILLING PHASE STUDY – full dose of C.M. is used to fill the hollow organ and to study the general outline, shape,
size, position and anatomical contour and morphological deformities of the organ.
6. HYPOTONIC DUODENOGRAPHY – C.M. is administered via tube passing through the mouth or nose and into
duodenum after administration of glucagon. A positive and negative C.M. are used to detect lesions.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

PURPOSE OF SCOUT FILM

1. Check proper patient preparation 4. Compare films with and without contrast
2. Check correct position of organ 5. Adjust correct technical factor
3. Draw presence of foreign body 6. Localize exact localization point

RESPIRATION TECHNIQUES (RESPIRATORY STRESS MANEUVERS):

1. QUIET INSPIRATION – test abduction for vocal cords, take exposure before chest comes to rest.
2. NORMAL PHONATION (EXPIRATORY PHONATION) – test adduction vocal cords, take a deep a breath then
exhales slowly and phonate low pitch ‘ah’ or high pitch ‘eh’.
3. INSPIRATORY PHONATION (REVERSE PHONATION/ASPIRANT MANEUVER) –demonstrate laryngeal ventricle,
exhale completely then slowly inhale to make a sound. (Powers, Holtz, Ogura)
4. VALSALVA MANEUVER – complete closure of glottis, test elasticity and functional integrity of glottis. Take a deep
breath and while holding the breath in, bear down as though trying to move the bowels.
5. MODIFIED VALSALVA MANEUVER – test elasticity of the hypopharynx and piriform. Pinch off the nose, close the
mouth and tries to blow the nose. Like blowing out a balloon.
6. MUELLER MANEUVER – exhale then tries to inhale against the closed glottis.
Note: Phonation typically performed in exhalation.

SPECIAL PROCEDURES WITH CONTRAST – PART 2

Salivary glands – associated on the mouth, mixes food (bolus), helps digestion. Three pairs of salivary glands, releases 1 L
of saliva per day.
Bolus – Food ingested mixed with saliva.

3 PAIRS OF SALIVARY GLANDS

1. PAROTID GLANDS – anterior to external ear, inferior to mandibular ramus

- Largest salivary gland. Wedged shaped glands.
- Stensen’s Duct – duct associated in parotid glands. Run anteriorly and medially opposite to 2nd molar and opens
saliva in the oral vestibule. About 5cm long.
2. SUBMANDIBULAR (SUBMAXILLARY) GLANDS - posterior to first molar almost angle of the mandible or below the
mandible/maxilla.
- Fairly large. Irregular in shape.
- Wharton’s Duct – narrower than stensens. Run anteriorly and superiorly in the frenulum then opens in the
mouth. About 5cm long.
3. SUBLINGUAL GLANDS – floor of the mouth/ below the tongue, in contact laterally with the mandible and posterior
side of the frenulum. Adjacent submandibular gland.
- Smallest of the three glands. Narrow and elongated in shape.
- Rivinus Duct – small ducts forms Bartholin’s Duct opens to the floor of the mouth.

SIALOGRAPHY (PTYALOGRAPHY)

- Radiographic examination of the salivary glands.

INDICATIONS:
- Obstruction - Tumor
- Calculus - Stenosis
- Epiglottitis - Foreign body
- Fistula - Etc.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

CONTRAINDICATIONS:
- Severe infection of gland
- Known allergies to C.M.
MATERIALS:
- Syringe
- Cannula or Catheter
- Drip stand (For Hydrostatic Pressure administration only.)
- Syringe barrel (For Hydrostatic Pressure administration only.)
- Lemon wedge
- Timer
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive C.M.
- Administered directly to the main duct.
For Manual Pressure:
Iodized Oil Non-Absorbable C.M.
For Hydrostatic Pressure
Water soluble Iodinated C.M.

PROCEDURE:
1. Take preliminary radiograph to detect conditions before administration of C.M.
2. About 2-3 minutes before the procedure ask the patient to suck lemon wedge. This will serve as secretory stimulant
that will help to open the ducts for identification of its orifice and for easier passage of cannula for contrast
administration.
3. Inject C.M. in the main duct. For Manual Pressure use syringe attached to a cannula or catheter. For Hydrostatic
Pressure place the solution container to a drip stand that is set on 28 in. (70cm) above the patient’s mouth.
4. After the procedure ask again the patient to suck lemon wedge. This will serve as secretory stimulant that will help for
the evacuation of the C.M.
5. 10 mins. After the procedure take another radiograph to assure clearance of C.M.

PROJECTIONS:
BODY/PART POSITION CENTRAL PT. STRUCTURE
RAY/REFERENCE INSTRUCTIONS SHOWN AND
POINT EVALUATION
CRITERIA
TANGENTIAL Supine – Rest on the Parotid Gland Fill mouth with SS: Parotid gland
PROJECTION occiput. Making the ┴ lateral surface of air. and Stensens gland.
mandibular rami ┴ to the ramus to the parotid EC: Mastoid
long axis of IR. gland. overlapping upper
Prone – Rest chin on the IR portion of gland.
(For Stensens duct rest Gland is lateral to
forehead and nose on the mandibular rami.
IR)
Rotate toward affected side
LATERAL Semi prone/Seated Parotid: ┴ 1 in. SS: Parotid and
PROJECTION Parotid: extend patients superior to Submandibular
(For deeper portion of neck so space between mandibular rami. Ducts
submandibular and cervical and mandibular rami Submandibular: ┴ EC: Rami free from
parotid gland – are cleared. Affected side Inferior margin of cervical vertebrae
closest to the IR. IR centered angle of the mandible shows Parotid
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

oblique position is on 1 in. superior to superimposed over

required) mandibular rami. MSP ramus.
rotated 15o towards the Superimposed
affected from true lateral mandibular rami and
position. angle indicates true
Submandibular: True lateral lateral position and
position. Inferior margin of evidence of no
angle of the mandible is rotation.
centered on the IR. Acc. Demonstrate an
Iglauer depress the floor of oblique view of the
the mouth for better parotid glands.
visualization of the gland.
AXIAL PROJECTION Uses occlusal film (57 x ┴ to the plane of the SS: Sublingual
(INTRAORAL 76cm), long axis is directed film. Intersection of glands and
METHOD) horizontally. the MSP and MCP anteromedial portion
Elevate thorax in supine of submandibular
(Only projection for position. gland.
unobstructed Flex knee. EC: Dental arch and
sublingual gland or Have the neck in full mandibular rami are
VSM projection for extension position after symmetrical
submandibular lesion placing the film intraorally. indicates no tilt and
on posterior or lateral Shoulder should be in the rotation.
to the oral cavity) same transverse plane.
MSP is centered on the fill.

SPECIAL PROCEDURES WITH CONTRAST – PART 3

Neck – occupies the region between the skull and thorax. It is divided into 2, the anterior (soft tissues) and the posterior
(osseous components)

ORGANS IN THE NECK

1. THYROID GLAND – composed of 2 lobes that lies from C5 (thyroid cartilage) to T1. It is about 5cm x 3cm in size.
- The two lobes are connected by a narrow portion called isthmus. Each lobe has 2 parathyroid glands, 1 lies
superiorly and the other lies inferiorly.
2. PHARYNX – a passage of air and food, located in front of the vertebrae, and lies behind the nose (nasopharynx),
mouth (oropharynx) and larynx (laryngopharynx).
- It is 13 cm (5 in) long that extends from sphenoid to C6 and C7.
- It is divided into three parts. The part that lies above the soft and hard palate (nasopharynx), the part that
extends from soft palate to hyoid bone (oropharynx) and the part that lies posterior to larynx and connects with
esophagus (laryngopharynx).
Note: Air-containing nasopharynx and oropharynx are visualized in lateral position.
3. LARYNX – voice box or organ of voice. It lies between the pharynx and trachea. It is a movable tubular structure that
is 3.8 cm (1.5 in) long that extends from hyoid bone to C4.
- Epiglottis (leaf shaped) – junction of larynx with trachea. Traps to prevents leakage of bolus/fluids into pharynx
during acts of swallowing.
- Laryngeal prominence (Adam’s apple)
- Piriform recess – pouch like fossa shown as triangular areas in AP projection.
- Folds – protects the lateral and posterior larynx. Space above the laryngeal folds is known as laryngeal vestibule
Vestibular folds – 2 superiorly lying folds known as false vocal cords
Vocal folds – 2 inferiorly lying folds separated by Rima glottides known as true vocal cords.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

PALATOGRAPHY

- Radiographic examination of the soft palate

INDICATIONS:
- Cleft Palate - Tumors of soft palate
- Abnormalities during act of swallowing - Abnormalities during act of chewing

CONTRAINDICATIONS:
- Known allergies to C.M.
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive C.M. (BaSO4)
For Bloch and Quantrill
Thick BaSO4 through swallowing and 0.5 ml of BaSO4 administered to nasal cavity.
For Morgan
Barium impregnated chocolate fudge
For Ohara
BaSO4 through swallowing

PROCEDURE/PROJECTIONS:
For Bloch and Quantrill
- Seat patient laterally to VCH. Swallow C.M. to coat the inferior surface and uvula then administer 0.5ml of C.M.
to coat superior surface and posterior wall of nasopharynx.
- For suspected tumors of soft palate.
For Morgan
- In cineradiography the child is asked to chew the Ba-impregnated chocolate fudge.
- Detects chewing and swallowing abnormalities in children
For Ohara
- Lateral position, IR centered in nasopharynx region.
- Exposure during acts of phonation.
- Designated for cleft palate studies.

NASOPHARYNGOGRAPHY

- Radiographic examination of the nasopharynx taken during inhalation.

INDICATIONS:
- Hypertrophy of Pharyngeal tonsils - Asses extend of tumors

CONTRAINDICATIONS:
- Known allergies to C.M.
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive C.M. (Iodized oil or finely ground BaSO4 ) via pressure blower
PROCEDURE/PROJECTIONS:
1. Preliminary radiographs are taken in SMV position. Supine the patient or in upright AP projection.
2. Administer local anesthesia
3. Extend the neck to make OML 40-45 degrees from the horizontal. (Elevate the shoulder in supine position to support
neck extension)
4. Central Ray is directed 15-20 degrees cephalad to ¾ inch anterior to EAM or directed just between the mandibular
angles.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

5. Take preliminary radiograph. Then install C.M. to the nasal cavity then take another basal projection
6. Obtain lateral projection using horizontal x-ray beam
7. After the procedure, ask the patient to sit and blow the nose to eliminate the C.M. the remaining C.M. is eliminated
through swallowing.

For Chittinand, Patheja and Wisenberg (without topical anesthesia)

1. Seat the patient.

2. Preliminary radiographs are obtained in both lateral and SMV positions.
3. Introduce C.M. (Micropaque powder to each nostrils) to the nasal cavity via spray bottle.
4. Take 2 SMV projections. One in resting phase and the other during modified Valsalva maneuver.
5. Take lateral projection.
6. Ask the patient to eliminate the C.M. by blowing his/her nose. C.M. that are not expelled while blowing the nose are
eliminated through swallowing.
7. Chest X-ray is taken for follow up radiograph after 24 hrs. to check if the region is free from C.M.

PHARYNGOGRAPHY

- Radiographic examination of the pharynx and upper esophagus during active deglutition.
Technique: shortest possible exposure time or/and spot films (almost 12 frames/sec)
INDICATIONS:
- Abnormalities in deglutition.
CONTRAINDICATIONS:
- Known allergies to C.M.
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Thick creamy Barium sulfate held by the tongue administered via swallowing.
PROCEDURE/PROJECTIONS:
1. Hold C.M. in the mouth until signaled to swallow.
2. Attempt mucosal study by restricting the patient from swallowing again.
3. Take mucosal study using Modified Valsalva Maneuver for double contrast delineation.
For Gunson Method.
1. Synchronized the procedure by height of swallowing.
2. Tie black/dark shoestring (no metal tips) around patient throat above C5.
3. Exposure should be made on the anterior movement of C5 according to Templeton and Kredel.
Note: Elevate shoestring = anterior movement of pharynx, Displaced shoestring = superior movement of pharynx.

LARYNGOGRAPHY

- Radiographic examination of laryngeal structures using C.M.

TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Negative C.M. (To demonstrate air containing laryngeal structures)
- Positive C.M. (5 hrs. NPO) – 10-15 ml of Dionosil.
PROCEDURE/PROJECTIONS:
1. Have the patient position in Seated Upright/Supine AP and Lateral and used soft tissue technique during exposure.
2. Head is extended to prevent superimposition of mandible to larynx during AP projection.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

3. If negative and positive C.M. are used the procedure is made during Respiratory Stress Maneuvers.
FOR TOMOLARYNGOGRAPHY (Tomographic study of laryngeal structures):
1. Made during quiet inspiration and expiration phonation.
2. Exposure made using arc of 40-50 degrees.
FOR POSITIVE C.M. LARYNGOGRAPHY (For exact size, shape, and site of tumor masses):
1. Anesthetize the patient topically to avoid motion
2. Take preliminary radiographs
3. Test respiratory stress maneuver.
4. Attach the syringe to a curved cannula.
5. Drip iodized oil behind the tongue into the larynx
6. Take radiograph with all the respiratory stress maneuvers.
EXAMINATION OF THE THYROID GLAND WITH CONTRAST MEDIA

- Radiographic examination of VISIBLE goiter or thyroid mass.

PROCEDURE/PROJECTIONS:
1. Position the patient in lateral making the thyroid mass tangent to the IR.
2. Rotate shoulders posteriorly in LATERAL POSITION to demonstrate intrathoracic extension of goiter.
3. Obtain OBLIQUE views of the neck to demonstrate Nodular enlargement.
For additional studies:
1. Exposures are made during Valsalva or Modified Valsalva maneuvers.
2. Exposure are made during height of act of swallowing using 1 tbsp. of creamy barium sulfate.
3. Ask the patient to do the modified Valsalva maneuver after swallowing C.M.
4. Have the patient do phonation routine after opacification of C.M.
5. Take tomographic views during phonation of high pitched “ee”
Note: Scout films are taken during quiet nasal breathing which will fill the passage with air.
PROJECTIONS FOR SPECIAL PROCEDURES WITH C.M. IN NECK REGION/AREA.

BODY/PART CENTRAL PT. STRUCTURE

POSITION RAY/REFERENCE INSTRUCTIONS SHOWN AND
POINT EVALUATION
CRITERIA
AP PROJECTION Supine/Upright. ┴ to laryngeal Depends on stress SS: Pharynx and
MSP centered in the IR prominence maneuver used Larynx.
Place the shoulder in EC: No overlap of
the same transverse laryngeal area by
plane to avoid rotation. mandible
IR centered on
laryngeal
prominence.
Extend head to
prevent
superimposition of
mandibular shadow.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

LATERAL Stand/Seat Laterally. Nasopharynx and cleft SS: Pharyngeal

PROJECTION MCP passing palate: ┴ to IR. About 1 structures. (Soft
(For deeper portion of anteriorly to TMJ inch below EAM. palate, pharynx, and
submandibular and centered to IR. Oropharynx: Angle of larynx)
parotid gland – oblique MSP // to IR. mandible EC: No
position is required) Depressed shoulder Laryngopharynx: superimposition of
to lie in the same laryngeal prominence trachea by shoulder.
transverse plane. Closely
Extend Head slightly. superimposed
mandibular shadow.

FOR ADDITIONAL STUDIES:

1. PHONATION OF VOWELS – For Vocal cords and cleft palate
2. VALSALVA MANEUVER – For distention of subglottic larynx and trachea with air.
3. MODIFIED VALSALVA MANEUVER - For distention of supraglottic larynx and laryngopharynx with air.
4. HEIGHT OF ACT OF SWALLOWING OF 1 TBSP. OF CREAMY C.M. - For Pharyngeal structures.
5. ACT OF SWALLOWING WITH TUFT/PLEDGET OF COTTON SATURATED IN C.M. – For non-opaque foreign
bodies in pharynx and upper esophagus.
SPECIAL PROCEDURES WITH CONTRAST – PART 4

Esophagus – situated posterior to trachea and pharynx and anterior to vertebral column; passes through the diaphragm in
front of the aorta to enter the stomach, measuring about 10 inches (25-30cm).
3 segments:
1. Cervical
2. Thoracic
3. Intraabdominal
4 points of narrowness
1. Cricoid
2. Level of aortic know
3. Opposite the crossing of the left bronchus
4. Through the diaphragm

Stomach – a pear-shaped organ connected proximally to the esophagus and distally to the small intestine. In the absence of
food, the stomach deflates inward, and its mucosa and submucosa fall into a large fold called a ruga.
Anatomical Placement of Stomach
1. Eutonic – same level of pylorus and incisura by 1 cm (normotonic)
2. Hypotonic – pylorus higher than incisura by 1 cm
3. Steer-Horn – incisura higher than pylorus by 1 cm.
Regions of the Stomach
1. Cardia (Cardiac Region) - point where the esophagus connects to the stomach and through which food passes into
the stomach.
2. Fundus -domed-shaped portion situated inferior to the diaphragm, above and to the left of the cardia.
3. Body – Main part of the stomach
4. Pylorus – funnel shaped portion that links the stomach to the duodenum.
a. Pyloric antrum – wider end of the funnel, links to the body of the stomach
b. Pyloric canal – narrower end of the funnel, links to duodenum
c. Pyloric sphincter - latter point of connection and controls stomach emptying.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

2 curvature of the stomach

1. Greater - convex lateral surface of the stomach
2. Lesser - concave medial border
Small Intestine – long tube structure connecting to the stomach and the colon, measuring about 22 ft. It is where most of the
nutrient absorption happens.
3 Parts
1. Duodenum –c-shaped part situated proximally and connected to the stomach, measuring about 10 inches, shortest
segment. (RUQ, LUQ)
2. Jejunum – has coiled spring, feathery appearance in the radiograph, measuring about 2/5 of the total length of the
small intestine (2.5m) where most digestion happens. (LUQ, LLQ)
3. Ileum – last section, measuring about 3.5 meters, longest segment where most absorption happens. (RUQ)
Ileocecal Valve – valve that connects to large intestine.

Large Intestine – also called the large bowel, measuring about 1/5 of the total length of the digestive tract (around 5 meters),
1.5-2.4 inches in diameter. Connected to one part of the small intestine and to the anus
4 parts
1. Cecum - beginning of the large intestine and is also connected to the appendix. It receives chyme from the ileum and
is connected to the ascending colon.
2. Colon - final section of the digestive system
4 parts of the colon
a. Ascending - extends from the cecum to the bend on the right side below the liver
b. Transverse - longest and most movable part of the colon. It crosses the abdomen from the ascending colon at
the hepatic or right colic flexure with a downward convexity to the descending colon where it curves sharply on
itself beneath the lower end of the spleen forming the splenic or left colic flexure.
c. Descending - located on the left side of the large intestine, extending from the bend below the spleen to the
sigmoid colon.
d. Sigmoid - last section of the bowel. S-shaped portion that attaches to the rectum.
3. Rectum - stores the feces until the body feels that it is time for defecation
4. Anal Canal - where the feces pass through as they are discharged from the body

Gallbladder – balloon liked and pear-shaped organ that sits just under the liver. It stores bile produced by the liver. After
meals, the gallbladder is empty and flat, like a deflated balloon and before a meal, the gallbladder may be full of bile.
4 Parts
1. Fundus – the rounded, distal portion of the gallbladder. It projects into the inferior surface of the liver in the mid-
clavicular line.
2. Body – the largest part of the gallbladder. It lies adjacent to the posteroinferior aspect of the liver, transverse colon,
and superior part of the duodenum.
3. Neck – the gallbladder tapers to become continuous with the cystic duct, leading into the biliary tree.
4. Biliary tree - series of gastrointestinal ducts allowing newly synthesized bile from the liver to be
concentrated and stored in the gallbladder. (Common hepatic duct, cystic duct, common bile duct,
hepatopancreatic duct and pancreatic duct)
Gallbladder location (Usually situated in the last rib)
1. Hypersthenic – T9-T10
2. Sthenic – T10-T11
3. Hyposthenic – T11-T12
4. Asthenic – T12-L1
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

ESOPHAGOGRAPHY

- Radiographic examination of the pharynx and esophagus investigate suspected lesion of the heart and great
vessels. Also, called barium swallow.
INDICATIONS:
- Dysphagia - Achalasia
- Barrett’s esophagus syndrome - Hiatal Hernia
- Carcinoma - Cardiomegaly
- Mediastina Mass - Foreign Body
- Chalasia
CONTRAINDICATIONS:
- Leakage from esophagus
- Aspiration to bronchial tree.
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- 30-50% weight/volume suspension BaSO4 mixture
- Low viscosity high density
- Air and Iodinated CM
2 PHASED EMPLOYED
1. Filling Phase – distend the lumen of esophagus
2. Mucosal Phase – demonstrate mucosal pattern of esophagus
PREPARATION:
1. Light evening meal
2. Remove metallic material
3. Wear Patient gown
4. Prepare patient psychologically

PROCEDURE:
1. Fluoroscopic, spot film in upright position
2. May use horizontal/ Trendelenburg as indicated
3. After spot film, patient is instructed to take-up the CM using the left hand and drink it (Swallowing several mouthfuls
of Ba, so act of deglutition is observed).
4. Respiratory stress maneuvers are further instructed as indicated.
FOR OPAQUE FB
1. Demonstrated without CM
2. Soft tissue technique of the neck
3. Radiographs obtain at the height of swallowing
4. Ask the patient to swallow to elevate the intrathoracic esophagus at 2 cervical segments placing it above clavicle.
5. Use tuft/ pledgets, non-opaque CM to demonstrate obstruction.
ESOPHAGEAL REFLUX PROCEDURE
1. Breathing Exercises – Valsalva Maneuver (hold breath, swallow bolus then performs respiratory maneuver)
2. Mueller Maneuver – Patient exhales then tries to inhale against close glottis
3. Water Test – Swallow mouthful of water through straw
4. Compression Technique (Wolf Method) – compression paddle provides pressure or may alternate the equipment with
prone position. (Wolf’s compression paddle and Bar ray’s compression paddle)
5. Toe-touch maneuver – possible regurgitation into the esophagus, patient bends and touches the toes.
OTHER TECHNIQUES
1. Double contrast – air mouthful immediately before CM administration
2. Trendelenburg position – will demonstrate hiatal hernia, barium at the left hand is swallowed upon instruction.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

PROJECTIONS:
BODY/PART CENTRAL PT. STRUCTURE SHOWN AND
POSITION RAY/REFERENCE INSTRUCTIONS EVALUATION CRITERIA
POINT
AP/PA Projection Upright, MSP is ┴ level of T5-T6 SS: Entire length of
(Scout Film) placed perpendicular esophagus without CM.
to the IR Opaque FB
IR is placed 4 inches
above the shoulder
AP/PA Projection Upright, MSP is ┴ level of T5-T6 SS: Entire length of
placed perpendicular esophagus with CM.
to the IR
IR is placed 4 inches
above the shoulder
RAO Position, Upright, place the ┴ level of T5-T6 SS: Entire esophagus free
RPO Projection MSP 35-40 deg. from superimposition of heart
IR is placed 4 inches and vertebrae
above the shoulder
Lateral Upright, MCP is ┴ level of T5-T6 SS: Entire esophagus with
Projection (Left placed perpendicular CM in lateral view.
Lateral Position) to the IR
IR is placed 4 inches
above the shoulder

UPPER GASTROINTESTINAL SERIES (UGIS)

- Radiographic examination of the distal esophagus, stomach, and duodenum after administration of CM. Also
called Barium meal or GI Series. Used to study radiographically the form and function of distal esophagus,
stomach, and duodenum
INDICATIONS:
- Peptic Ulcer - Bezoar
- Hiatal Hernia - Tumor or Carcinoma
- Gastric Varices/ Colic - Gastritis
CONTRAINDICATIONS:
- Bowel Perforation
- Laceration
- Rupture of Viscus
- Use of BaSO4 on same day
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive CM, Barium Sulfate, 30-50% Weight/Volume
- Thin (typically used) and Thick (for gas forming examination)
- Water Soluble Iodinated CM
- Gas Producing Substance.
TYPE OF EXAMINATION
1. Single Contrast Exam – gross pathology, very ill patients, and children. 1 type of contrast media is used usually
positive CM.
2. Double Contrast Exam – small lesion, mucosal lining. Combination of positive and negative CM. Have the patient
turn from side to side to cover the whole organ.
3. Dual/Biphasic/Welin Technique – combination of single exam and double exam on the same day.
4. Hypotonic Duodenography – less frequently done examination, duodenal lesion.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

Liotta – suggested introduction of CM through intubation passing through the nose and mouth.

PREPARATION:
1. Intake of Glucagon prior to examination or introduction of CM (use to relax abdominal muscles)
2. Light Evening Meal
3. NPO at midnight
4. Food withhold for 8 hrs. (<1 y/o = 4 hrs., 1 y/o = 6 hrs.)
5. No Breakfast until exam is finished
SPECIAL DEVICE USED:
- Pneumatic compression paddle placed in duodenal loop
POST PROCEDURAL CARE:
1. Instruct the patient to drink plenty of fluids; and
2. To take mild laxative
PROJECTIONS:
BODY/PART CENTRAL PT. STRUCTURE SHOWN
POSITION RAY/REFERENCE INSTRUCTIONS AND EVALUATION
POINT CRITERIA
AP Projection Upright/Supine, MSP ┴ level of L1-L2 SS: Delineate the entire
(Scout Film) is placed structure without CM
perpendicular to the
IR
AP Projection Supine, MSP is ┴ level of L1-L2 SS: Well filled: FUNDUS
Recumbent Position placed perpendicular Delineation of body and
to the IR antral portion.
Trendelenburg
position.
PA Projection Prone, MSP is placed ┴ level of L1-L2 SS: Barium filled
Recumbent Position perpendicular to the stomach and duodenal
IR bulb
RAO Position, RPO Recumbent, place the ┴ level of L1-L2 SS: Best demonstrate
Projection MSP 40-70 deg. pyloric canal and
duodenal loop
LPO Position, LAO Recumbent, place the ┴ level of L1-L2 SS: Best demonstrate
Projection MSP 30-60 deg. barium filled fundic
portion
PA Projection Upright Upright, MSP is ┴ 6 inches inferior to SS: Size, shape, and
Position placed perpendicular L1-L2 relative position of the
to the IR stomach
Lateral Projection (Left Upright, MCP is ┴ level of L3 SS: Demonstrate Left
Lateral Upright placed perpendicular Retrogastric space
Position) to the IR

Gordon’s (PA Axial) Prone, MSP is placed 35-45 deg. Cephalad SS: Demonstrate
perpendicular to the to level of L1-L2 transversely place
IR stomach (Hypersthenic)
Gugliantini (PA Axial) Prone, MSP is placed 20-25 deg. Cephalad SS: Demonstrate
perpendicular to the to level of L1-L2 transversely place
IR stomach (Infants)
Wolf (modification of Recumbent RAO 10-20 deg caudad to SS: Sliding Hiatal
Trendelenburg w/ position, place MSP T6-T7 Hernia, relative
compression device) 40-45 degrees.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

relationship of stomach
and diaphragm
Hampton’s (Oblique Recumbent LPO ┴ level of pylorus SS: Demonstrate leaf
Supine) position, place MSP like pattern in the
45 degrees stomach
Poppels (Right Lateral 2 exposure – ┴ center of IR SS: Retrogastric Space
View) Horizontal supine, (Supine) and Pancreatic
and lateral view Mass (Lateral)
Lateral Projection Recumbent, MCP is ┴ level of L1-L2 SS: Demonstrate Right
(Right Lateral placed perpendicular Retrogastric space
Position) to the IR

SMALL INTESTINAL SERIES (SIS)

- Radiographic examination of the three components of the small bowel to detect abnormal conditions and to
study form and function.
INDICATIONS:
- Diverticula - Bowel perforation
- Obstruction - Bowel neoplasm
- Fistula - Enteritis
- Polyps/Tumor - Meckel’s Diverticulum
CONTRAINDICATIONS:
- Perforation
- Obstruction
- Dehydration
- Pre-surgical patient
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive CM, Barium Sulfate
- Thin mixture, 4500 ml of BaSO4 for complete reflux study.
- Water Soluble Iodinated CM
- Gas Producing Substance.
TYPE OF EXAMINATION
1. Single Contrast Exam – gross pathology, very ill patients, and children. 1 type of contrast media is used usually
positive CM.
2. Double Contrast Exam – small lesion, mucosal lining. Combination of positive and negative CM. Have the patient
turn from side to side to cover the whole organ.
3. Dual/Biphasic/Welin Technique – combination of single exam and double exam on the same day.
4. Hypotonic Duodenography – less frequently done examination, duodenal lesion.
-Ingest BaSO4 mixture then take AP/LAO projection films, administer probonthine or buscopan through intramuscular
route (to help relax muscle) and wait for 15 minutes before taking films. Delay film is taken after 1 hour.
Liotta – suggested introduction of CM through intubation passing through the nose and mouth.
5. Complete Reflux – filling of the small bowel using about 4500ml of BaSO4 (so that colon and small bowel are filled
completely). Administration of glucagon to relax intestinal muscles and Diazepam to diminish discomfort is key to perform
the procedure and to take films smoothly.
PREPARATION:
1. 2 days low residue diet
2. NPO after midnight
3. No breakfast
4. Cleansing enema be given in some cases to clear the colon
OTHER PROCEDURES:
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

1. Enteroclysis (double contrast study) – contrast media is introduced into the duodenum to examine small bowel.
Special Equipment needed: Polyethylene Tube; Bilbao/Sellink Tube; 1200ml of CM mixture (administer slowly by
30ml of CM to 60ml of Water).
Preparation: No cleansing enema needed; Low residue diet
2. Intubation Method (single contrast study) – single lumen catheter advance to jejunum, uses water soluble iodinated
contrast media or thin mixture of BaSO4

PROJECTIONS (ORAL METHOD):

BODY/PART POSITION CENTRAL PT. STRUCTURE SHOWN AND
RAY/REFERENCE INSTRUCTIONS EVALUATION CRITERIA
POINT
AP/PA Supine/Prone, MSP is ┴ level of L2 Suspend SS: Delineate the entire
Projection placed perpendicular to Respiration structure without CM
(Scout Film) the IR/table
Films are taken every 15 minutes or depending on the case of the patient and/or request of attending physician.
AP/PA Supine/Prone, MSP is ┴ level of L2 Suspend SS: Gastric emptying and to
Projection placed perpendicular to Respiration know how much Ba left;
(1hr the IR/table presence of ascaris
delayed)

AP/PA Supine/Prone, MSP is ┴ level of L2 Suspend SS: suspected pyloric

Projection placed perpendicular to Respiration stenosis; assess gastric
(6hrs the IR/table emptying rate
delayed)

AP/PA Supine/Prone, MSP is ┴ level of L2 Suspend SS: suspicion in the small

Projection placed perpendicular to Respiration intestine, appendix, or colon
(24hrs the IR/table
delayed)

Barium Enema (BaE)

- Radiographic examination of the colon or large intestines after administration of CM. Used to study
radiographically the form and function of large intestines.
INDICATIONS:
- Colitis - Volvulus
- Diverticula - Intussusception
- Polyp/tumor - Ulcerative Colitis
- Change of bowel habit - Neoplasm
CONTRAINDICATIONS:
- Perforated hollow viscus - Recent Barium Meal
- Large bowel obstruction - Toxic Megacolon
- Appendicitis - Rectal Biopsy
- Incomplete bowel perforation
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive CM, Barium Sulfate, Weight/Volume = 15%-25% for single contrast and 75%-95% for double contrast.
- Warm CM (85-90 o F (29-30 o C) and Cold CM (41 o F (5 o C)
- Water Soluble Iodinated CM
- Gas Producing Substance (Room air, nitrogen, carbon dioxide)
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

TYPE OF EXAMINATION
1. Single Contrast Exam – gross pathology, very ill patients, and children. 1 type of contrast media is used usually
positive CM.
2. Double Contrast Exam – small lesion, mucosal lining. Combination of positive and negative CM. Have the patient
turn from side to side to cover the whole organ.
a. Single stage – same time administration of positive and negative CM
b. Two stage – one contrast media is administered first followed by the next contrast media. Usually
positive CM then negative.
c. Evacuative Proctography – defacogram
PREPARATION:
1. Cleansing Enema 1 day before the examination
2. Light Supper/ Light Evening Meal
3. Give Laxative
4. NPO at midnight
5. No Breakfast until exam is finished
MATERIALS:
1. Enema Can (2-3 quarts) or Enema Bag
2. Stop cock/clamp
3. Enema Tip
4. Inflating Bulb/Inflator
5. Foley catheter
6. KY Jelly
PATIENTS INSTRUCTION:
1. Not to PUSH the tip out of the rectum
2. Relax abdominal muscles
3. Concentrate breathing by the mouth
PROJECTIONS:
BODY/PART CENTRAL PT. STRUCTURE SHOWN
POSITION RAY/REFERENCE INSTRUCTIONS AND EVALUATION
POINT CRITERIA
AP Projection Supine, MSP is placed ┴ level of Iliac Crest Suspend at the SS: Delineate the entire
(Scout Film) perpendicular to the end of exhalation structure without CM, and
IR evaluate adequate patient
preparation
PA Projection Prone, MSP is placed ┴ level of Iliac Crest Suspend at the SS: Demonstrate Barium
Recumbent perpendicular to the end of exhalation filled colon.
Position IR

PA Axial Prone, MSP is placed 30-40 deg. Caudad Suspend at the SS: Demonstrate
Projection perpendicular to the level of ASIS end of exhalation rectosigmoid area
Recumbent IR
Position

RAO and LPO Recumbent, place the ┴ level of Iliac Crest, Suspend at the SS: Demonstrate right
Projection MSP 35-45 deg. approximately entering end of exhalation hepatic flexure, ascending
elevated side 1-2 colon, and sigmoid colon
inches lateral to
the midline of
body on elevated
side
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

LPO and RAO Recumbent, place the ┴ level of Iliac Crest, Suspend at the SS: Demonstrate left
Projection MSP 35-45 deg. approximately entering end of exhalation splenic flexure and
elevated side 1-2 descending colon.
inches lateral to
the midline of
body on elevated
side.
Lateral Upright, MCP of the ┴ to 5-7cm superior to Suspend at the SS: Demonstrate rectum
Projection (Left abdomen is placed level of pubic symphysis end of exhalation and rectosigmoid colon
and Right lateral perpendicular to the
Position) IR
AP Projection Supine, MSP is placed ┴ level of Iliac Crest Suspend at the SS: Demonstrate colon in
Recumbent perpendicular to the end of exhalation its entirety.
Position IR
AP Axial Supine, MSP is placed 30-40 deg. Cephalad 2 Suspend at the SS: Demonstrate
Projection perpendicular to the inches inferior to level of end of exhalation rectosigmoid area
Recumbent IR ASIS
Position
Right Lateral The patient Horizontal and ┴ level Suspend at the SS: Demonstrate “up-
Decubitus is lying on of Iliac Crest end of exhalation medial” side of ascending
Position the right colon and “up-lateral” side
side, MSP is centered of descending colon.
and placed
perpendicular to the
IR
Left Lateral The patient Horizontal and ┴ level Suspend at the SS: Demonstrate “up-
Decubitus is lying on of Iliac Crest end of exhalation medial” side of descending
Position the left colon and “up-lateral” side
side, MSP is centered of ascending colon.
and placed
perpendicular to the
IR
Ventral The patient ┴ level of Iliac Crest Suspend at the SS: Demonstrate rectum
Decubitus is lying on end of exhalation and most valuable in
(Lateral the back, MCP of double contrast
Projection) abdomen is centered examinations.
and placed
perpendicular to the
IR
Upright Upright, MSP ┴ level of Iliac Crest Suspend at the SS: Demonstrate Entire
Positions (AP, centered for AP and end of exhalation Colon
Oblique, PA, PA
Lateral) Midway between MSP
and lateral aspect of
side of interest
centered for Oblique
MCP centered for
lateral
PA Projection Prone, MSP is placed ┴ level of Iliac Crest Suspend at the SS: For detection of
Recumbent perpendicular to the end of exhalation Polyps (Small Polyps)
Position IR
(Post Evacuation
Film)
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

Chassard Lapine Seated, Patient grasp ┴ to Lumbosacral SS: Demonstrate Rectum,

(PA Axial ankle for support. region level of greater rectosigmoid junction,
Projection) trochanter sigmoid colon; Rectum and
sigmoid filled with CM

OTHER METHODS:
1. Welin Technique – used for early diagnosis of ulcerative/regional colitis and polyps, also used to diagnose
intraluminal lesions (1800-2000 cc CM is used)
2. Billings Modification (Supine) – used for prevention of overlapping of loops, CR is directed at 35-45 deg. Cephalad
toward the level of ASIS
3. Robins Modification (Lateral view) – demonstrate the rectosigmoid colon without overlapping in lateral view.
4. Colostomy – surgical procedure that forms an opening to the intestine
Preparation: 24-48 hrs. low residue diet
5. Post-operation Enema – determine efficacy of treatment in cases of diverticulitis and detect new/recurrent lesion.
6. Defecography – study of the anus and rectum that is conducted during evacuation and rest phase of defecation.
Used to measure anarectal angle and to diagnose the following:
a. rectoceles
b. rectal prolapse
c. rectal intussusception
Materials: Commode and very high density BaSO4
CHOLEGRAPHY

- Radiographic examination of the biliary system after administration of CM. Used to study radiographically the
form, patency, and function of biliary system. (Cholecystography: gallbladder; Cholangiography: biliary ducts;
Cholecystocholangiography: gallbladder and biliary ducts)
INDICATIONS:
- Cholelithiasis - Biliary Stenosis
- Choledocholithiasis - Neoplasm
- Cholecystitis - Congenital Anomalies
CONTRAINDICATIONS:
- Vomiting and diarrhea - Liver dysfunction
- Pyloric obstruction - Hepatocellular disease
- Malabsorption syndrome - Elevated bilirubin
- Severe jaundice - Known allergies to iodinated CM
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive CM, iodinated water soluble
- Oral – absorb by the intestine carried to liver via portal veins then entering GB (taken 1-3 hrs. for maximum
opacification of Biliary tract and 10-12 hrs. for GB – 6-12 (4-6) tablets)
- Intravenous – Single bolus or drip-infusion (include in blood circulation enters liver via hepatic artery then
entering GB)
- Direct into the biliary ducts – PTC, IOC, T-tube Cholangiography.
- Cholecystokinin – hormone injected
- Cholecystopaque – orally taken CM
PREPARATION FOR ORAL CHOLECYTOGRAPHY:
1. Cleansing Enema (afternoon (3pm) a day before the examination and morning (5am) on the day of the examination)
2. Light Supper/ Light Evening Meal
3. Give Laxative (Optional) administered 24 hrs. before ingestion or injection of CM
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

4. 6-12 (4-6) tablets of CM (1 tablet every 5 mins followed by small amount of water). Tablets should all be taken 2-3
hrs. after evening meal or 10-12 hrs. before the examination
5. NPO at midnight
6. No breakfast.

PROJECTIONS:
BODY/PART CENTRAL PT. STRUCTURE SHOWN AND
POSITION RAY/REFERENCE INSTRUCTIONS EVALUATION CRITERIA
POINT
Scout Film Prone, Right side ┴ to RUQ (3 inches to Suspend at the SS: taken to locate
PA of abdomen right of spine and 4 end of exhalation the GB and check
Projection centered to the IR inches superior to IC) patient preparation and
concentration of the contrast
medium in the GB shows the semi
axial
view of the opacified GB (May be
taken 24 hrs. before examination)
PA PA, Right side of ┴ to 2-4 inches inferior to Suspend at the SS: Demonstrate layering of
Projection, abdomen pre-located GB end of exhalation gallstones.
Upright centered to the IR
Position
LAO Position semi prone, right ┴ to 4 inches superior to Suspend at the SS: Best projection for oral
side is rotated 15- the iliac crest end of exhalation cholecystography. Places GB
40 deg. closest and most parallel to IR.
Demonstrate GB free from
superimposition. A body rotation of
20 deg. In upright oblique position
will demonstrate the exact shape
of GB.
Right Lateral Recumbent, lying ┴ to 4 inches superior to Suspend at the SS: used to differentiate
Position on the right side. the iliac crest end of exhalation gallstones from renal stones or
calcified mesenteric lymph nodes
if needed.
Also required to separate the
Superimposition of the GB and
the vertebrae in exceptionally thin
patients
Right Lateral Recumbent, lying ┴ and horizontal to 4 Suspend at the SS: for the visualization of
Decubitus on the right side inches superior to the end of exhalation small gallstones used to
iliac crest demonstrate stones that are
lighter than bile and that are
visualized only by stratification
colon.
Fatty Meal (motor) – given after satisfactory visualization of GB with administration or intake of food or hormonal
substance that causes GB to contract.
Post Fatty Film or Delayed Film – after 15-30 mins. fatty meal intake similar series are taken to check the emptying
power of GB.

OTHER EXAMINATION
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

1. Intravenous Cholangiogram (IVC) - performed when GB is not visualized in OCG, when patient was
cholecystectomized and when patient is experiencing severe vomiting and diarrhea.
Procedure: Scout Film (Plain Abdomen Upright) and RPO Position; CR: ┴ to level of IC.
2. Percutaneous Transhepatic Cholangiography (PTC) – radiographic examination of the biliary system after
administration of 20-40 ml of contrast media into the biliary tract via a long needle (CHIBA/SKINNY) puncture through
the liver. Uses local anesthesia. After CM administration, fluoroscopic spot films were taken.
INDICATIONS: Obstructive Jaundice and Stone Extraction and Biliary Drainage
Possible complication of PTC:
a. Leakage of bile into peritoneal cavity c. Pneumothorax
b. Hemorrhage d. Sepsis/Infection
3. Operative/Immediate Cholangiogram – radiographic images obtain in operating room directly following a
cholecystectomy
Purpose:
a. Investigate patency of biliary duct
b. Determine the functional status of hepatopancreatic ampulla
c. Reveal choleliths that are not detected previously
d. Demonstrate small lesions, strictures, or dilatation within biliary tracts.
4. Post-Operative Delayed and T-tube Cholangiogram – radiographic examination to rule out residual stones or to
check status of biliary tract after operation. Performed 1-3 days after surgery under fluoroscopy.
Purpose:
a. Residual or undetected choleliths
b. Evaluate Status of biliary ducts
c. Demonstrate small lesions, strictures, or dilatation within biliary tracts.
Materials:
a. Water soluble urographic CM
b. T-tube (flexible rubber tube about the size of straw; crossbar extending into hepatic and common bile duct,
and base into cystic duct). Bile drainage until edema of CBD subsides and route for administration of CM.
5. Endoscopic Retrograde Cholangiopancreatography (ERCP) – retrograde examination of the common bile duct
using small endoscope that passes through hepatopancreatic ampulla.
Purpose:
d. Residual or undetected choleliths
e. Evaluate Status of biliary ducts
f. Demonstrate small lesions, strictures, or dilatation within biliary tracts.
Materials and Preparation:
c. Stone basket – for removal of calculi
d. Anesthesia
e. NPO for 1 hr. before the examination
CHOLEGASTRO-INTESTINAL SERIES – radiographic examination of the gallbladder, biliary ducts, and gastro-intestinal tract
Contrast Media: BaSO4 and Telepaque
Projections:
1. Scout Film (PA projection)
2. PA Projection – GB
3. LAO Projection – GB
4. Esophagogram
5. Film of Stomach and duodenum
6. Post-motor – PA GB
7. Delayed Film – AP Abdomen
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

SPECIAL PROCEDURES WITH CONTRAST – PART 6

Reproductive system – are organs of the body that is responsible for procreation

Female Reproductive System - designed to carry out several functions. It produces the female egg cells necessary for
reproduction, called the ova or oocytes. The system is designed to transport the ova to the site of fertilization, provide wall of
uterus for implantation of fertilize egg during early stage of pregnancy, produces female sex hormones, and maintain the
reproductive cycle.

Male Reproductive System – it produces, maintains, and transports sperm (the male reproductive cells) and protective fluid
(semen), discharges sperm within the female reproductive tract during sexual intercourse, and produces and secretes male
sex hormones responsible for maintaining the male reproductive system.

Parts of Female Reproductive System:

1. Labia majora – The labia majora enclose and protect the other external reproductive organs. Literally translated as
"large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males.
2. Labia minora – Translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just
inside the labia majora and surround the openings to the vagina and urethra.
3. Bartholin's glands – Glands are located beside the vaginal opening and produce a fluid (mucus) secretion.
4. Clitoris – The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in
males. The clitoris is covered by a fold of skin, called the prepuce, which is like the foreskin at the end of the penis.
5. Vagina – is a canal that joins the to the outside of the body. It also is known as the birth canal.
6. Uterus (womb) – is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into
two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the
corpus. The corpus can easily expand to hold a developing baby.
7. Ovaries – are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and
hormones.
8. Fallopian tubes – are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova
(egg cells) to travel from the ovaries to the uterus. Fertilization of an egg by a sperm occurs in the fallopian tube.

Parts of Male Reproductive System:

1. Penis – is the male organ used in sexual intercourse. It has three parts: the root, which attaches to the wall of the
abdomen; the body, or shaft; and the glans, which is the cone-shaped part at the end of the penis, called the head of
the penis, is covered with a loose layer of skin called foreskin.
2. Scrotum – the loose pouch-like sac of skin that hangs behind and below the penis. It contains the testicles (also
called testes), as well as many nerves and blood vessels. The scrotum acts as a "climate control system" for the
testes.
3. Testicles (testes) – are oval organs about the size of large olives that lie in the scrotum. The testes are responsible
for making testosterone, the primary male sex hormone, and for generating sperm.
4. Epididymis – is a long, coiled tube that rests on the backside of each testicle. It transports and stores sperm cells
that are produced in the testes and bring the sperm to maturity.
5. Vas deferens – is a long, muscular tube that travels from the epididymis into the pelvic cavity, to just behind the
bladder. It transports mature sperm to the urethra, the tube that carries urine or sperm to outside of the body, in
preparation for ejaculation.
6. Urethra – is the tube that carries urine from the bladder to outside of the body. In males, it has the additional function
of ejaculating semen when the man reaches orgasm.
7. Seminal vesicles – are sac-like pouches that attach to the vas deferens near the base of the bladder. It produces a
sugar-rich fluid (fructose) that provides sperm with a source of energy to help them move.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

8. Prostate gland – is a walnut-sized structure that is located below the urinary bladder in front of the rectum. It
contributes additional fluid to the ejaculate and nourish the sperm.
9. Bulbourethral glands - Also called Cowper's glands, these are pea-sized structures located on the sides of the
urethra just below the prostate gland. These glands produce a clear, slippery fluid that empties directly into the
urethra.

HYSTEROSALPINGOGRAPHY

- Radiographic examination of the uterus and fallopian tubes after administration of contrast media. Evaluates
patency of fallopian tubes and cases of sterility.
INDICATIONS:
- Sterility - Following tubal surgery
- Repeated Abortion - Intrauterine pathologies
- Foreign Body
CONTRAINDICATIONS:
- Pregnancy
- Menstruation
- Pelvic Infection
- Recent D&C
- Vaginal bleeding of unknown cause
- Sensitivity to CM
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive contrast media, contrast media administered directly via syringe and cannula flows from distal end of the
tubes to the peritoneal cavity.
- Water Soluble Iodinated – 10-20 ml, pain may occur several hours after the procedure.
- Oil Based CM – not recommended, low incidence of pain.
MATERIALS
1. Speculum – dilates opening of cavity
2. Tenaculum – for holding and gathering material in place.
3. Cannula – balloon catheter
4. Syringe
5. HSG tray – includes speculum, basin, medicine cup, sterile gauze and drapes, 10 ml syringes, 16/18G needles,
cotton balls, extension tubing and lubricating jelly.
6. Sterile gloves
7. Antiseptic solution
PREPARATION:
1. Light evening meal
2. Give patient laxative tablet
3. NPO at midnight
4. Cleansing enema 1 hr. before the procedure.

PROCEDURE:
1. Examination scheduled on 7th or 8th day after the menstrual cycle.
2. Empty the bladder before the procedure.
3. Patient is place in lithotomy position.
4. Cervix and Vagina are cleansed before the procedure.
5. Air is removed with the aid of syringe and cannula.
3. Trendelenburg position – will demonstrate hiatal hernia, barium at the left hand is swallowed upon instruction.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

PROJECTIONS:
BODY/PART CENTRAL PT. STRUCTURE SHOWN AND
POSITION RAY/REFERENCE INSTRUCTIONS EVALUATION CRITERIA
POINT
AP Projection Supine, MSP is ┴ to 2 inches above SS: The anatomy of interest
(Scout Film) centered to the IR pubic symphysis. without delineation of positive
and negative CM
AP Projection Supine, MSP is ┴ to 2 inches above SS: The anatomy of interest with
centered to the IR pubic symphysis. delineation of positive CM

LPO or RPO Semi supine, place ┴ to 2 inches above SS: Taken to diagnose indication
projection the MSP 30 deg. pubic symphysis. not seen in AP projection.

AFTER CARE:
1. Ensure that patient has no significant bleeding or discomfort before she leaves.
2. Inform the patient that bleeding may occur 1-2 days with persisting pain in 2 weeks’ time.

VAGINOGRAPHY

- Radiographic examination of vaginal walls after administration of CM.

INDICATIONS:
- Congenital Abnormalities - Pathologic Conditions of vagina
- Vaginal Fistulas
CONTRAINDICATIONS:
- Pregnancy
- Menstruation
- Recent D&C
- Sensitivity to CM
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive contrast media, directly into vaginal cavity via rectal retention tube.
- Thin BaSO4 (Lambie, Ruth and Dann)
- Iodinated organic compound (Coe)

PREPARATION:
1. Vagina is cleanse before the procedure
2. Patient is instructed to empty the bladder before the procedure.

PROJECTIONS:
BODY/PART CENTRAL PT. STRUCTURE SHOWN AND
POSITION RAY/REFERENCE INSTRUCTIONS EVALUATION CRITERIA
POINT
AP Projection Supine, MSP is ┴ to level of superior SS: The anatomy of interest
(Scout Film) centered to the IR border of pubic without delineation of
symphysis positive and negative CM
AP Projection Supine, MSP is ┴ to level of superior SS: The anatomy of interest
centered to the IR border of pubic with delineation of positive
symphysis CM
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

Lateral Supine, MCP of the ┴ to level of superior SS: Low rectovaginal fistula.
Projection (L lower pelvic Cavity is border of pubic
and R) centered to the IR symphysis

LPO or RPO Semi supine, place the ┴ to level of superior SS: Demonstrate fistula
projection MSP 30 deg. border of pubic connected to sigmoid or
symphysis ileum.

PELVIC PNEUMOGRAPHY

- Radiographic examination of female reproductive organ after administration of negative contrast media, known
as gynecography.
INDICATIONS:
- Gyne pathologies.
CONTRAINDICATIONS:
- Pregnancy
- Menstruation
- Recent D&C
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Negative contrast media
- Nitrous oxide and carbon dioxide.
PREPARATION:
1. Light evening meal
2. Give patient laxative tablet
3. NPO at midnight
4. Cleansing enema 1 hr. before the procedure.

PROCEDURE:
1. Examination scheduled on 7th or 8th day after the menstrual cycle.
2. Empty the bladder before the procedure.

PROJECTIONS:
BODY/PART POSITION CENTRAL PT. STRUCTURE
RAY/REFERENCE POINT INSTRUCTIONS SHOWN AND
EVALUATION
CRITERIA
PA Projection Prone, MSP is centered to 15 degrees caudal or ┴ to 2 SS: The anatomy of
(Scout Film) the IR inches above pubic interest without
Table in 45 deg. symphysis or level of coccyx delineation of CM
Trendelenburg position
AP/ PA Supine/Prone, MSP is 15 degrees caudal or ┴ to 2 SS: The anatomy of
Projection centered to the IR inches above pubic interest with
symphysis or level of coccyx delineation of
Supine – 20-25 deg. negative CM
Trendelenburg.
Prone – 45 deg.
Trendelenburg.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

RAO or LAO Semi prone, place the MSP ┴ to 2 inches above pubic SS: The anatomy of
projection 30 deg. And in full symphysis or level of interest with
Trendelenburg coccyx. delineation of
negative CM
Lateral Prone, MCP of the lower ┴ to 2 inches above pubic SS: The anatomy of
Projection pelvic Cavity is centered to symphysis or level of interest with
(Cross-table the IR, table is in full coccyx. delineation of
lateral) Trendelenburg negative CM

AFTER CARE:
1. Reduce the table to 20-25 degrees angulation.
2. Turn to supine position for removal of CM.

VESICULOGRAPHY

- Radiographic examination of the seminal ducts and vesicle after administration of CM.
EPIDIDYMOGRAPHY

- Radiographic examination of the epididymis after administration of CM.

INDICATIONS:
- Cyst - Inflammations
- Abscesses - sterility
- Tumors
CONTRAINDICATIONS:
- Infection of the ducts and vesicle
- Sensitivity to CM
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive CM, water soluble iodinated.
FOR EPIDIDYMOGRAPHY
1. CM administered in extra-pelvic ducts (proximal exam) or intra-pelvic ducts (distal exam)
2. Negative CM may be used for extra-pelvic structures administered directly through scrotal sacs.

PREPARATION:
1. Cleansing enema
2. Emptying of urinary bladder
3. General anesthesia

PROJECTIONS:
BODY/PART CENTRAL PT. STRUCTURE SHOWN AND
POSITION RAY/REFERENCE INSTRUCTIONS EVALUATION CRITERIA
POINT
AP Projection Supine, MSP is ┴ to level superior to SS: The anatomy of interest
(Scout Film) centered to the IR pubic symphysis. without delineation of positive
and negative CM
AP Projection Supine, MSP is ┴ to level superior to SS: The anatomy of interest with
centered to the IR pubic symphysis. delineation of positive CM
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

LPO or RPO Semi supine, place ┴ to level superior to SS: The anatomy of interest with
projection the MSP 30 deg. pubic symphysis. delineation of positive CM

Chassard Lapine – Recommended by Mazurek

Peritoneal Sacral View – Boreau, J. Reversed Chassard Lapine with 20 deg. Cephalad angulation with thigh flex towards
abdomen.

PROSTATOGRAPHY

- Radiographic examination of the prostate glands after administration of CM.

INDICATIONS:
- Cancerous deposits - calculi
CONTRAINDICATIONS:
- Infection of the ducts and vesicle
- Sensitivity to CM
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive CM, water soluble iodinated.
PREPARATION:
1. Cleansing enema
2. Emptying of urinary bladder
3. General anesthesia

PROJECTIONS:
BODY/PART CENTRAL PT. STRUCTURE SHOWN AND
POSITION RAY/REFERENCE POINT INSTRUCTIONS EVALUATION CRITERIA
AP Axial Supine, MSP is 15 deg. Caudad to 1-inch SS: The anatomy of interest
Projection centered to the IR superior to pubic symphysis. without delineation of positive
(Scout Film) and negative CM
AP Axial Supine, MSP is 15 deg. Caudad to 1-inch SS: The anatomy of interest
Projection centered to the IR superior to pubic symphysis. with delineation of positive CM

PA Axial Prone, MSP is 20-25 deg. Caudad to 2 SS: The anatomy of interest
Projection centered to the IR inches superior to pubic with delineation of positive CM.
symphysis. Brings the prostate gland
closer to IR.
Direct administration of CM to gland via rectal wall. (Sigiura and Hasegawa)
AP – 5 deg. cauda
PA – 20-25 deg. cephalad
RPO/LPO – Brings anatomy in contact with IR

SPECIAL PROCEDURES WITH CONTRAST – PART 7

ARTHROGRAPHY

- Radiographic examination of the joints after direct administration of contrast media.

VENTRICULOGRAPHY

- Radiographic examination of the brain after administration of negative contrast media into the ventricular system,
also known as cerebral pneumography. It is the study that demonstrate intracranial lesions.
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

Indications and contraindications: depend on the location of the intracranial lesion/disorder

Contrast Media: air, oxygen, and carbon dioxide (pneumoventriculography: direct administration of CM to CNS;
pneumoencephalography: direct administration via sub-arachnoid route)
Projection: AP and lateral Projection – upright position, AP, PA, Right and Left Lateral – Recumbent Position, and Axial
Projection (25-30 deg. Caudally and cephalad).

BRONCHOGRAPHY

- Radiographic examination of the lungs and bronchial tree after administration of positive contrast media via
bronchi.
INDICATIONS:
- Bronchiectasis - Recurrent hemoptysis
- Obstruction of the lower bronchial tree
CONTRAINDICATIONS:
- Impairment of pulmonary function
- Recent pneumonia
- Active tuberculosis
- Known allergies
TYPE OF C.M AND ROUTE OF ADMINISTRATION
- Positive contrast media, non-ionic water-soluble CM, and oil-based compounds.
- Supraglottic method – based of the tongue then into the glottis
- Intraglottic method – into the glottis
- Transglottic Intratracheal method – passing through the glottis and into the trachea into the main stem bronchus
- Percutaneous Cricothyroid – needle passing through subglottic tracheal space through cricothyroid membrane.
MATERIALS
1. Laryngeal cannula and mirror
2. Catheter
3. Cotton
4. Kidney basin
5. 30 cc syringe and CM
PREPARATION:
1. Mild sedation
2. Chest physiotherapy
3. NPO 2 hrs. before the procedure.
4. Intake of antibiotic (if there is infection)
5. Prophylactic therapy (for asthmatic patients)
6. Inform patient regarding the discomfort when performing the procedure
7. Instruct the patient to refrain from coughing during the procedure.
8. Administer topical anesthesia.

PROJECTIONS:
1. AP Projection – Supine position
2. PA Projection – Upright Position
3. Right and Left Oblique Position
4. Lateral Position – only one side is injected, for bilateral examination take radiograph of the first side injected with CM.
5. PA Projection – CXR after 4 hrs. (For delay film) to see respiratory complications and residual CM.

DACRYOGRAPHY
 SPECIAL PROCEDURES WITH CONTRAST | AN MARI M. CAPUZ, RRT

- Radiographic examination of the nasolacrimal drainage system after administration of positive contrast media via
filling of the lumina canals.
INDICATIONS:
- Abnormalities of the canal - Chronic mucosal thickening
- Stenosis - Obstruction
CONTRAINDICATIONS:
- Known allergies

TYPE OF C.M AND ROUTE OF ADMINISTRATION

- Positive contrast media, oil-based iodinated compounds, or water-soluble CM (for more closely anatomical
related images due to same characteristic of the CM to tear)
MATERIALS
1. Sterile pack: punctum dilators and lacrimal needles
2. Sterile sponge forceps
3. Sterile normal saline solution
4. Sterile cotton balls and gauze
5. Waste basin
6. 2 ml Luer-lock syringes and contrast media

PROCEDURE/PROJECTIONS:
1. Scout films – Caldwell, Waters, and lateral positions.
2. Introduce anesthesia in the conjunctiva and puncta.
3. Administer CM in seated position, directly next the VGD, or in supine position.
4. Turn the patient in prone position before taking radiographs in rapid succession. (Caldwell, Waters, and lateral)
5. Take other radiographs after 7-10 minutes and in 15-20 minutes interval (CM seen on floor of nasal cavity).
6. For contralateral examination, rotate head 10-15 deg. Away from IR to prevent superimposition of the opacified
ducts.
MYELOGRAPHY
- Radiographic examination after injection of contrast material to evaluate the spinal cord, nerve roots and spinal
lining (meninges).