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Flouroscopic procedures

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Flouroscopic procedures

  1. 1. FLOUROSCOPIC PROCEDURES DR NANI LAMPUNG JR1 DEPT OF RADIODIAGNOSIS JNMCH AMU ALIGARH
  2. 2. TO BE DISCUSSED  FLOUROSCOPY  CONTRAST AGENTS  PROCEDURES o BARIUM SWALLOW o BA MEAL o BA MEAL FOLLOW THROUGH o ENTEROCLYSIS o BARIUM ENEMA o DISTAL LOOPOGRAM o MCU, RGU AND HSG  AND FINDINGS
  3. 3. FLOUROSCOPY Imaging technique that uses x-rays to obtain real time images
  4. 4. HISTORY • Thomas Edison 1896 • Screen (zinc-cadmium sulfide) placed over patient’s body • Red goggles-30 minutes before exam • 1950s image intensifiers developed
  5. 5. Fluoroscopic Equipment General purpose fluoroscopic system
  6. 6. Mobile fluoroscopic system for routine procedures during surgery Fluoroscopic Equipment (cont)
  7. 7. Components of Fluoroscope x-ray generator  x-ray tube  collimator  filters  patient table  grid  image intensifier  optical coupling television system image recording IMAGE INTENSIFIER XRAY TUBE
  8. 8. Fluoroscopy : dynamic (real time) imaging
  9. 9. Image intensifier  The image intensifier is a complex electronic device that receives the remnant X-Ray beam, converts it into light, and increases the light intensity.
  10. 10.  The principal advantage- increased image brightness. Image monitoring: Two methods -used to electronically convert the visible image on the output phosphor of the image intensifier into an electronic signal. 1. Thermionic television camera tube 2. The solid state charge-coupled device (CCD).
  11. 11. Camera tube: • The TV camera consists of cylindrical housing, approx 15 mm in diameter by 25 cm in length, that contains the heart of the camera, TV camera tube. • It also contains electromagnetic coils (used to properly steer the electron beam inside the tube) • Vidicon and its modified version, the Plumbicon, are used most often.
  12. 12. • Two methods are commonly used to couple the television camera tube to the image-intensifier tube. – Fiber optics. – Lens system.
  13. 13. • The video signal is amplified and is transmitted by cable to the television monitor, where it is transformed back into a visible image.
  14. 14. Fluoroscopy Uses • Barium studies • Catheter Insertion • Blood Flow Studies • Orthopedic Surgery
  15. 15. OTHERS • Injections into the knees (Viscosupplementation injections) • Locating foreign bodies • Percutaneous Vertebroplasty (Treating compressed fractures of the spine) • Injections into joints or spine • Image-guided anesthetic injections
  16. 16. CONTRAST used 1. BARIUM SULPHATE SUSPENSION • Inert • Insoluble in water • Good mucosal coating • No major sequalae if aspirated • Cost effective DISADVANTAGES • Mediastinitis • Peritonitis • may collect in GIT
  17. 17. 2. WATER SOLUBLE CONTRAST • Gastrograffin, Gastromiro • USE- suspected perforation DISADVANTAGES • Poor mucosal coating • Allergic reactions • Chemical pneumonitis
  18. 18. 3. GASES • Co2 • Air • room air for Ba Enema
  19. 19. TYPES OF BARIUM STUDIES 1. SINGLE CONTRAST- single contrast medium 2. DOUBLE CONTRAST- two contrast media • Ba sulphate suspension (+ve contrast ) • Air (-ve contrast)
  20. 20. SINGLE CONTRAST • Elderly & uncooperative pts • Low concentration • Poor mucosal coating • Less sensitive for polyps, erosions, linear ulcerations, superficial gastric ca, subtle mucosal abnormalities DOUBLE CONTRAST • younger • higher conc. • good mucosal coating • more sensitive polyps & small mucosal lesions
  21. 21. DOUBLE CONTRAST SINGLE CONTRAST
  22. 22. PREPARATION FOR GI BARIUM STUDIES • Maintain Low residual diet • Laxatives • Increase fluid intake • NPO from midnight • Follow up care –colour change/constipation • 2 times cleansing enema for barium enema studies
  23. 23. PREPARATION FOR GI BARIUM STUDIES • Take h/o related to medications & any allergy to contrast agents • Ask patient to remove jewellery, eyes glasses or any metallic objects / clothings • Explain the procedure to patient & take consent
  24. 24. BARIUM SWALLOW • Radiographic evaluation of pharynx and entire oesophagus upto gastroesophageal junction
  25. 25. INDICATIONS • DYSPHAGIA,ODYNOPHAGIA • HEARTBURN,RETROSTERNAL PAIN • HIATUS HERNIA,STRICTURE FORMATION • ESOPHAGEAL CA • MOTILITY D/O-ACHALASIA,DIFFUSE OESOPHAGEAL SPASMS • THORACIC MASS LESIONS • MITRAL VALVE DISEASE • OESOPHAGEAL VARICES • ASSESSMENT OF ABNORMALITY OF A. PHARYNGOESOPHAGEAL J/N INCLUDING ZENKERS DIVERTICULUM B. CRICOID WEB C. CRICOPHARYNGEAL ACHALASIA
  26. 26. CONTRAINDICATIONS • Suspected leakage into the mediastinum, pleural or peritoneal cavities • Tracheo-esophageal fistula
  27. 27. TECHNIQUE • PHARYNX • Mouthful contrast bolus with high density (250%w/v) • Pt is asked to swallow once & stop swallowing thereafter( to get optimum mucosal coating) • frontal and lateral view x-ray taken
  28. 28. SP-soft palate V-valeculla P-pyriform sinus LATERAL VIEW AP VIEW
  29. 29. ESOPHAGUS (SINGLE CONTRAST) • Multiple mouthful 80% w/v barium suspension is given • Take the flouroscopic unit to pt neck command to swallow • Observe the Ba passing down the esophagus upto GE J/N USEFUL IN – Ext compression, Displacement, Motility d/o • Prone swallow to assess esophageal contraction (esophageal web, hiatal hernia & esophageal varices)
  30. 30. DOUBLE CONTRAST • Effervescent powder is added to the Ba mixture 250% w/v • Inj buscopan i.v may be given to keep esophagus distended for a longer time • FILMS 1. Control film 2. Spot films- AP/Lateral views of upper, mid & lower oesophagus
  31. 31. 32 AP VIEW LATERAL VIEW
  32. 32. COMPLICATIONS • Aspiration • Leakage of Ba from perforation l/t mediastinitis
  33. 33. SPECIFIC FINDINGS
  34. 34. OESOPHAGEAL WEB • SHELF-LIKE INFOLDING OF MUCOSA(1-2 MM THICK) • PARTIALLY OBSTRUCTING CERVICAL ESOPHAGEAL WEB • JET PHENOMENON • ASSOCIATION-EB,BP,PVS
  35. 35. ZENKERS DIVERTICULUM • ZENKER’S DIVERTICULUM • Pulsion false diverticulum • Killian’s dehiscence • Defect in cricopharyngeus muscle
  36. 36. KILLIAN JAMIESON DIVERTICULUM • Pulsion diverticulum • Lateral anatomic weak site • Below cricopharyngeus
  37. 37. DIFFUSE ESOPHAGEAL SPASM • Irregular areas of narrowing & dilatations • Cork screw/shish kebab/rosary bead appearance
  38. 38. ACHALSIA CARDIA *With short segment stricture. * A “bird-peak " like tapering of the esophagus at the GE junction. OR • DEGENERATION OF NEURONS OF AURBACH’S PLEXUS • Dilatation of body • Short segment stricture • BIRD BEAK like tapering at GE J/N
  39. 39. ESOPHAGEAL VARICES • Mild dilatation of the esophagus with multiple persistent filling defects in the lower third of the esophagus and/or longitudinal furrows. • Mild dilatation with multiple persistent filling defects
  40. 40. TRACHEOESOPHAGEAL FISTULA • Congenital/Acquired • Ideal contrast non ionic water soluble media • In case fistula not identified laterally, put in prone. • If fistula seen, stop procedure as barium aspiration result in inflammation and granuloma
  41. 41. Diaphragmatic hernia Herniation of abdominal viscera into thoracic cavity through- DIAPHRAGMATIC HIATUS:-  sliding hernia  rolling hiatus hernia CONGENITAL DEFECT:-  Bochdalek hernia  Morgagni hernia
  42. 42. SLIDING HIATUS HERNIA Develop due to stretching or tear of phrenico-esophageal ligament stomach protrudes >2cm above the hiatus >3 folds seen across the hiatus diameter of hiatus >3cm
  43. 43. Rolling hiatus hernia Fundus herniates alongside lower esophagus while cardia remains below the diaphragm  T/T– Nissen’s fundoplication
  44. 44. Esophageal carcinoma NARROWING OF LUMEN WITH MUCOSAL IRREGULARITY AND SHOULDERING
  45. 45. BARIUM MEAL • Radiological study of esophagus, stomach, duodenum till the Gastroduodenal J/N
  46. 46. INDICATIONS • Peptic ulceration • Malignancies of GE junction, stomach, duodenum • Motility d/o • Hiatus hernia • Gastric or duodenal obstruction • Children- GER, pyloric obstruction, malrotation
  47. 47. CONTRAINDICATIONS • Complete large bowel obstruction • Suspected perforation (unless water soluble contrast medium is used)
  48. 48. TECHNIQUE DOUBLE CONTRAST kilovolt range-70 – 120 kv • Inj buscopan(20mg) /glucagon(0.1-0.2 mg) iv-relax stomach & suspend peristalsis • Effervescent agent is given • Standing in RAO position- 120ml of high density barium(250%w/v) double contrast views of lower esophagus is obtained
  49. 49. • FOR STOMACH-Pt placed in recumbent position & roll the patient from side to side ( encourages mucosal coating & adequate distension) • FOR DUODENUM-When Ba enters duodenum pt is turned to RAO position to fill duodenum with gas and then DC films are taken
  50. 50. DOUBLE CONTRAST STUDY ADVANTAGES • Highly accurate detecting abnormalities following gastric sx, • Bile reflex gastritis, marginal ulcerations • Recurrent Ca
  51. 51. TYPICAL FILMING SEQUENCES POSITIONING • ERECT RAO AP • SUPINE-RAO AP LAO RL • PRONE (PAD ↓ ANTRUM)-AP • SUPINE-RAO DEMONSTRATES  ESOPHAGUS {PRONE LPO(SC)}  FUNDUS  BODY+ANTRUM WITH LESSER CURVE  BODY + ANTRUM  BODY WITH LESSER CURVE  FUNDUS  DUODENAL LOOP  DUODENAL CAP
  52. 52. SINGLE CONTRAST STUDY • Ba mixture given in erect position wherever possible • Compression films are taken to obtain good mucosal detail • kilovolt range-120 to 150 kv ADVANTAGES- • pylorospasm, fistulae, enlarged gastric rugae best seen • filling defect due to large mass easily identifiable DISADVANTAGES- • lack of sensitivity for small polyps, ulcers, superficial Ca
  53. 53. MODIFICATIONS • FRAIL IMMOBILE ELDERLY PT- SC study with 100% w/v barium • PARTIAL GASTRECTOMY OR GASTRIC DRAINAGE PROCEDURE(PYLOROPLASTY/GASTROENTROSTOMY)- early flooding - start examination in prone swallow using high density barium -when Ba reaches duodenum or gastroentrostomy pt is quickly turned supine and dc films are taken • HIATUS HERNIA- patient put in prone with abdominal compression applied by pillow or pad
  54. 54. Normal mucosal pattern Areae gastricae Rugal folds
  55. 55. 56 Duodenal cap • Symmetric triangular structure formed by first part of duodenum • Shows a fine velvety surface pattern due to presence of villi
  56. 56. Peptic ulcer An ulcer is a focal area of mucosal disruption On barium meal examination- an ulcer dependent wall – round or ovoid collection of barium filling the ulcer crater nondependent wall – circular or hemispheric ring due to barium coating the rim of unfilled ulcer
  57. 57. BENIGN GASTRIC ULCER MALIGNANT GASTRIC ULCER • Smooth round/ovoid ulcer • Hampton’s hump/smooth ulcer collar • Smooth, straight radiating folds • Projects outside luminal contour • Irregular shaped, abnormally surfaced ulcer • Mucosal nodularity at edge • Lobulated, enlarged or club shaped folds • Lies within the outline of stomach
  58. 58. BENIGN ULCER MALIGNANT ULCER
  59. 59. Gastric volvulus ORGANOAXIAL TYPE- • Commonest • Stomach rotates around an axis between duodenum and GE junction • Greater curvature rotates forward and upward GREATER CURVE LIES ABOVE THE LESSER CURVE
  60. 60. MESENTEROAXIAL – • Rotates around an axis between midpoint of lesser and greater curvature • Posterior surface of stomach lies anteriorly GASTRIC ANTRUM LYING ABOVE THE G-E JUNCTION
  61. 61. 62 WIDENED C-LOOP OF DUODENUM • D/D- Normal variant Pseudocyst or pancreatic mass  AAA Choledochal cyst Retroperitoneal mass Mesenteric lymph nodes
  62. 62. BARIUM MEAL FOLLOW THROUGH • Demonstrate the whole of small bowel from duodenal flexure to ileocaecal junction
  63. 63. INDICATIONS • MALABSORPTIONS • INTESTINAL TB • MALROTATION IN INFANTS/NEONATES- TO KNOW LEVEL & CAUSE OF OBSTRUCTION
  64. 64. TECHNIQUE • Following drinking contrast(50-100%w/v) patient lies in prone or on right side until ba has left the stomach • AIM- to produce continous column of Ba in small bowel • spot films may be made of any loops or segments of bowels
  65. 65. WELL PERFORMED BARIUM MEAL • Entire BL should be included in each radiograph • Stomach & duodenum should be documented in initial films • Time marker should be clearly visible • Ileocaecal j/n should be well visualised
  66. 66. Feathery app. of jejunum Smooth contour of ileum
  67. 67. Enteroclysis/small bowel enema • Radiographic procedure in which contrast medium is injected directly beyond duodenum • ADVANTAGE- Eliminates the obscuration of individual segment of small bowel by complete filling of tract with Ba
  68. 68. TECHNIQUE • Under flouroscopic control the tube with stiff guidewire is advanced upto duodenojejunal flexure • Contrast (200 ml of 110% w/v) mixed with 350 ml of H2O infused ↓ gravity control followed by 500 to 1000 ml of fresh water is given @ 100 ml/min • When Ba is injected the radiologist follows the barium column carefully with fluoroscopy & spot radiographs are taken at appropriate times
  69. 69. ADVANTAGES Better visualization of mucosal lesions Distension can be controlled by rate of infusion Shorter duration DISADVANTAGES More exposure Patient discomfort
  70. 70. Ileocecal tuberculosis EARLY PHASE- Incompetence and thickening of illeoceacal valve with narrowing of terminal ileum ADVANCED STAGE – Narrowing of ileum with shrunken, retracted( out of illiac fossa) caecum
  71. 71. BARIUM ENEMA • LARGE BOWEL EXAMINATION
  72. 72. INDICATIONS 1. BLEEDING PR 2. COLITIS 3. SUSPECTED LARGE BOWEL OBSTRUCTION 4. COLONIC POLYPS & COLORECTAL CA 5. FAILED COLONOSCOPY 6. FOLLOW UP SCREENING FOR POST OP COLORECTAL CA 7. NON SPECIFIC ABDOMINAL PAIN
  73. 73. CONTRAINDICATIONS • TOXIC MEGACOLON • PSEUDOMEMBRANOUS COLITIS • SUSPECTED PERFORATION • WEEK BEFORE OR AFTER RECTAL BIOPSY • POSSIBBILITY OF CA IN ULCERATIVE COLITIS • PREGNANCY
  74. 74. TECHNIQUE • Perform P/R examination • Insert enema tip with patient in lt lateral position with knees flexed • Check for any blocks • Look intermittently under flouroscopy to check for progression of Ba column • Gas insufflation done intermitently • change position of patient and table accordingly
  75. 75. SPOT FILMS • Rectum & sigmoid colon-RAO in lying position • Splenic flexure-LAO(erect) • Hepatic flexure-RAO(erect) • Caecum-supine lying on rt side with head down tilt and compression • Over head film- lying position
  76. 76. COMPLICATIONS • BOWEL PERFORATION • INJURY TO RECTAL MUCOSA OR ANAL CANAL DUE TO ENEMA TIP • VENOUS INTRAVASATION • Ba IMPACTION,WATER INTOXICATION • ALLERGIC RXNS & CARDIAC ARRHYTMIAS • TRANSIENT BACTERAEMIA
  77. 77. Colonic polyps Sessile polyps- BOWLER’S HAT sign (dome of hat points towards the lumen) Colonic diverticula-dome points away from lumen
  78. 78. 80 Pedunculated polyp - Mexican hat sign (outer ring- head of polyp inner ring- stalk seen through the head)
  79. 79. Ulcerative colitis ACUTE STAGE- • Fine mucosal granularity(d/t edema and hyperemia) • ULCERATIONS - Collar button (flask shaped ulcer) Double tracking (longitudinal ulcer in submucosa)
  80. 80. • Pseudopolyps-raised area of inflammed tissue CHRONIC STAGE- Loss of haustrations shortening & narrowing of colon ( lead pipe colon)
  81. 81. Crohn’s disease • Mucosal granularity with aphthous ulcer • Cobblestone app.(deep longitudinal and trasverse ulcer with adjacent mucosal edema) • Skip lesions with rectal sparing
  82. 82. 84 STRING SIGN- • narrowing of terminal ileum due to edema, spasm and fibrosis
  83. 83. diverticulosis • Small outpouchings from colonic wall which are filled by barium
  84. 84. 86 Sigmoid volvulus Barium fills to point of obstruction and twist of sigmoid colon Xray abdomen-Massively distended sigmoid colon – COFFEE BEAN sign
  85. 85. 87 Colonic cancer Annular, irregular and ulcerating lesion appear as circumferential irregular filling defect with narrowing of lumen(apple core sign)
  86. 86. INSTANT BARIUM ENEMA • DEVELOPED BY YOUNG (1963) INDICATIONS • Identify level of suspected obstruction • Show d/s extent & severity of mucosal lesions during an a/c episode of uc CONTRAINDICATIONS • Toxic megacolon, suspected perforation • Recent rectal biopsy ADVANTAGE- DONE IN UNPREPARED BOWEL GUIDE TREATMENT
  87. 87. DISTAL LOOPOGRAM • MAIN INDICATION - to know the patency of distal bowel prior to reclosure of ileostomy/colostomy • Mainly single contrast study
  88. 88. MICTURATING CYSTOGRAPHY (MCU) INDICATIONS 1. Outflow obstruction 2. Stress incontinence 3. Vesicoureteric reflux (children) CONTRAINDICATIONS Acute infections bladder / urethra
  89. 89. PATIENT PREPARATION • Micturates immediately before examination • In cathetherised patient, clamp release to decompress the bladder CONTRAST MEDIUM-sodium iodide conc 12% w/v
  90. 90. TECHNIQUE • Cathether introduction-by drop infusion/manually through huggusons syringe • Full bladder AP radiograph in erect • Pt positioned in oblique position • Next radiograph taken moment urine is seen on external meatus why in oblique ? • assess urethra in its entire length free of bony superimposition • then post micturition film
  91. 91. POSTERIOR URETHRAL VALVE
  92. 92. CHRISTMASS TREE SIGN
  93. 93. RETROGRADE URETHROGRAPHY INDICATIONS 1. Stricture 2. Diverticula 3. False passages in urethra CONTRAST MEDIUM 60% Urograffin or NaI
  94. 94. TECHNIQUE • Preliminary film of bladder base & urethra • Film in oblique position- bladder neck &urethra • Brodney clamp introduction • Radiographs during injection/distension of urethra • Procedure repeated in other oblique positions & appropriate films are taken
  95. 95. STRICTURES
  96. 96. HYSTROSALPHINGOGRAM INDICATION- Infertility • Establish tubal patency • Delineate- contour & cavity of uterus • BEST PERIOD- 7-10 days of menstruation • Jointly performed by gynaecologist & radiologist
  97. 97. TECHNIQUE • Preliminary film- Supine • CONTRAST AGENT 60% urograffin or diaginol viscous • cannulation • contrast loaded syringe attached to cannula ( airtight) • slowly injected – fill uterus & tubes until free peritoneal spillage • under couch exposure made to assess uterus & tubes • another exposure after intruments removal • occasionally 45 mins film (pooling d/t adhesions)
  98. 98. HYDROSALPHINGES
  99. 99. CT FLUOROSCOPY • Recently developed acquisition mode that allows faster image reconstruction,near-continous image update,& image viewing during a CT guided procedures • kV 120, tube current settings in CTF 10mA paeds,10-40 mA chest,40-50 mA abdominal • In typical CTF system cross sectional images are reconstructed at reduced spatial resolution & updated continually at a rate of several frames per second by using high speed array processor
  100. 100. TWO OPERATIONAL MODES- • continuous(real- time) • intermittent(quick- check) ADVANTAGES • convenient room table controL • potential for decrease in pt radiation & • increased procedure efficiency HOWEVER GREATER POTENTIAL FOR RADIATION INJURY TO PATIENT & HEALTH PERSONNEL IF IMPROPERLY DONE
  101. 101. APPLICATIONS • Core biopsies • RF Ablation • Fluid collection aspirations • Local drug inj, lumbar nerve root blocks, Precise needle placement • vertebroplasty , arthrography, etc
  102. 102. THANK YOU…

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