CHAPTER ONE

CONTRAST MEDIA
OBJECTIVES:

After completing this chapter, the student will be able to:

 Discuss the term contrast medium, to include its definition purpose, and use in
radiography
 Identify specific materials that are used as contrast agents, including the chemical,
physical ,and radiographic characteristics of each
 Differentiate between positive and negative contrast media
 Identify the routes of administration of contrast media for various radiographic
examinations.
 Compare and contrast the use of ionic and nonionic iodinated contrast media
 Identify contraindications to the administration of a contrast medium and possible
complications resulting from its use
 Describe possible reactions to contrast media and categorize them according to their
severity
 CONTRAST MEDIA

INTRODUCTION

Contrast studies are those examinations in which contrast media are used to enhance
visualization of specific body structures. Because of the low subject contrast of the abdomen,
contrast media are used to demonstrate the anatomic structures of the urinary, digestive, and
biliary systems.

Contrast media are also used to evaluate other areas of the body, such as the spinal canal, female
reproductive system, and vasculature.

The radiologic technologist must understand the composition of contrast media, the effects they
can have on the body, and how they are used.

BASIC PRINCIPLES OF CONTRAST MEDIA

- Many structures and organs within the body have similarly low tissue densities. This is
determined by their atomic number, which is the number of protons (Positive charges) in
the nuclei of their atoms.
- When the x-ray beam is directed at a specific structure during a radiographic
examination, some of the x-rays pass through, and others are absorbed (Attenuated) by
the structure.
- More X-rays are absorbed by structures having a high atomic number, resulting in less
radiation reaching the film, whereas fewer X-rays are absorbed by structures having a
low atomic number. This accounts for the visible difference in densities on radiography.
For example, the calcium in bone has a higher atomic number than skin or muscle tissue;
therefore, the bone appears light on a radiograph and the soft tissue appears dark.
- Many organs, such as those of the digestive, urinary, biliary, and cardiovascular systems,
are about the same density as soft tissue, which has an atomic number of approximately
7.4. For this reason, they absorb nearly the same amount of x-radiation and appear
relatively similar on a radiograph. To make these structures more visible for diagnostic
purposes, a contrast medium or agent must be used.
 - A contrast medium is a pharmaceutical agent that is administered to a patient for a
radiographic examination to enhance the contrast of a particular structure. Its use allows
for differentiation between a structure and surrounding tissues by altering the density of
the structure, which in turn alters the absorption of x-rays.
- The type of contrast medium (negative or positive) affects the amount of radiation
reaching the film, and produces a visible change in the radiographic appearance of the
structure.

TYPES OF CONTRAST MEDIA

The two basic classifications of contrast media are

1. Negative contrast agents and
2. Positive contrast agents.

1. A negative contrast agent

- Is radiolucent, has a low atomic number, and allows x-rays to pass through quite easily.
As more x-radiation reaches the film, the structure that is filled with a negative contrast
agent appears dark (black) on radiography.
- Gases, such as oxygen, carbon dioxide, and nitrous oxide, may be used as negative
contrast media, although room air is the most common agent. For example, the air in the
lungs serves as a negative contrast medium on chest radiography.
- A negative contrast medium may be used alone, as in the case of an air arthrogram, It can
also be combined with a positive contrast agent to produce a double-contrast effect, such
as a barium enema examination with air. As a second contrast agent for upper
gastrointestinal examination, a negative contrast medium is generally administered as an
effervescent agent in powder, granule, or tablet form which forms carbon dioxide (CO2)
when mixed with water.
- The uses of negative contrast media are limited, however, as they may not provide
sufficient contrast of a structure when used singly. Also, they must never be injected
intravenously; doing so will have serious, if not fatal, consequences.

2. A positive contrast agent

 - Is radiopaque and has a high atomic number.
- As it absorbs approximately three times more x-rays than bone and five times as many x-
rays as soft tissue, an organ filled with a positive contrast agent appears light on the
resulting radiography.
- Barium sulfate (BaSO4) and Iodinated compounds are positive contrast media used in
radiography to enhance the visibility of particular structures.
- As demonstrated on the periodic Table of the Elements, the elements iodine (53) and
barium (56) have high atomic numbers compared with that of oxygen (8).

BARIUM SULFATE

Properties

- Barium is a heavy metal having an atomic number of 56. It is combined with oxygen and
sulfate to form the inert compound barium sulfate (BaSO4).
- Barium sulfate is a white, crystalline powder that is insoluble in water. For use in
radiography, it is mixed with water and stabilizing agents to form a suspension. Often,
artificial flavors and colors are added to the suspension used for upper gastrointestinal
radiography to make the barium sulfate more palatable to the patient.
- Barium sulfate is used for examination of the entire alimentary canal. Ideally, the
suspension should be dense to coat the mucosa and outline the visceral walls, yet it must
have the ability to flow smoothly through the alimentary canal.
- Barium sulfate products can be procured in a variety of concentrations depending on the
type of examination and specific anatomy of interest.
- The products are available commercially in paste, liquid, powder, and tablet form.
- Paste, having a viscosity approximate to that of honey, may be recommended for an
esophagram. As it will not pass down the esophagus as swiftly as a thinner suspension,
the radiologist and /or technologist have more time to take radiographs of the contrast
filled esophagus.
- A liquid barium sulfate suspension can also be used for radiographic examination of the
esophagus, as well as the stomach and both small and large intestines. It can be purchased
in premixed liquid form or in powder form, which must be mixed with water prior to use.
 In either case, it should be shaken or stirred immediately before administration, as
suspension tends to settle.
- Barium sulfate tablets are helpful in evaluating foreign objects or strictures in the
esophagus. They dissolve in either the esophagus or stomach when mixed with water.

Contraindications

- Because of its inability to be absorbed by the body, barium sulfate cannot be used
intravascularly or intrathecally.
- Also, its use is contraindicated in the case of a suspected perforation in the alimentary
canal, as it may leak into the peritoneal cavity, causing a vascular adhesions and
peritonitis. For this reason, it is also contraindicated in cases of recent or impending
abdominal surgery.

IODINATED COMPOUNDS

Properties

- With an atomic number of 53, the element iodine is almost as radiopaque as barium
sulfate.
- A 2, 4, 6-triiodinted benzene ring containing three atoms of iodine per molecule forms
the base of iodinated contrast media.
- Iodine is the element of choice for use as a contrast agent, as it forms stable compounds
and does not break down in the body. Like barium sulfate, it has a relatively low toxicity
and high atomic number.
- Unlike barium sulfate, it is generally absorbed by the body and excreted by the kidneys
within 24 hours of intravascular administration.
- As iodinated contrast media have a tendency to break down in the light, they should be
shielded from bright light.
- The viscosity, or thickness, of the contrast medium is greatly determined by the size the
concentration of the molecules in the solution.
- It is recommended that the liquid iodinated contrast media be prewarmed to body
temperature prior to use. Doing so reduces their viscosity, allowing for easier
administration and lessening the possibility of adverse reactions.
 - Iodinated contrast agents are administered for a variety of radiographic examination.
- From the many products available commercially, the radiology department or physician
selects a particular contrast agent according to the area of interest and type of
examination.
- As pharmaceutical products, iodinated contrast media are referred to by their generic
name, chemical name, or trade name, which is the manufacturer’s brand name for the
product. For example, Reno-60 is a trade name, whereas diatrizoate meglumine 60% is
the generic name for the same product.
- The opacity of an iodinated contrast agent is determined by its iodine content; therefore, a
product containing a high percentage of iodine will characteristically exhibit high opacity
and high radiographic contrast.
- Iodinated contrast agents often have a number or percentage after their names
representing the weight-to-volume ratio or concentration of iodine containing compounds
in the solution. Again, using Reno-60 as an example, this product contains 60 g of iodine-
containing salts per 100 ml of solvent, which is equivalent to a 60% concentration. An
iodinated contrast agent with a higher concentration is generally used for cardiovascular
studies, whereas a lower concentration is used for urography and cholegraphy.
- Iodinated contrast media are available as either oil-based or water-soluble agents. Each
type of medium is selected for use based on the anatomy to be examined.

Oil-based Iodinated Contrast Media

- The use of oil-based iodinated contrast media in radiography is relatively limited.

- They are used primarily for studies of the lymphatic system (lymphangiography).
- In the past, they were also used for studies of the female reproductive system
(hysterosalpingography), spinal cord (Myelography), bronchial tree of the respiratory
system (bronchography), salivary glands (sialography), and tear ducts
(dacryocystography), but have been replaced by water-soluble iodinated nonionic
contrast media.
- The oil-based iodinated contrast medium is used in hollow anatomic areas, enhancing the
radiographic contrast of the structure.
 - The oily base of the contrast medium is a fatty acid, which is responsible for making the
solution viscous (thick) and insoluble in water and body fluids.
- Because it is not miscible with blood, it should never be injected intravenously or intra-
arterially.
- It should also be noted that the oily medium tends to persist in the area that was examined
as it is very slowly absorbed by the body.

Water-soluble iodinated contrast media

- Water–Soluble (aqueous) iodinated contrast media are routinely used for radiographic
examinations of the urinary, biliary, and cardiovascular systems, as well as the digestive
system if barium sulfate is contraindicated.
- Water-soluble iodinated contrast media are also used in special examinations of the
skeletal system such as mayelography and arthrograhpy.
- They are available in liquid, tablet or granule form depending on the intended use.
- The injectable liquid media can be divided in to ionic and nonionic contrast agents.
 An ionic contrast agent is an organic iodine compound that has triiodinated
benzoic acid as its base. The compound dissociates or separates in water into two
electrically charged particles. One of the particles, called a cation, has a positive
change; the other particle, an anion has a negative charge.
 A nonionic contrast agent also contains iodine and is derivative of the triiodinated
benzoic acid base, but it does not contain an ionizing group. It is more soluble in
water and does not dissociate into changed particles; it is said to have a lower
osmolality than an ionic contrast agent.
 Fig.1.1.Classification of iodinated contrast agents by their molecular structure

Osmolality refers to the concentration or number of particles (cations and anions) in the
solution per kilogram of water and is directly related to occurrence of adverse patient
reactions. it is measured in osmoles, which are units of osmotic pressure.
 A contrast agent with a high osmolality has an increased number of particles and
more osmoles in the solution.
Any time a foreign substance is injected into the bloodstream, the homeostasis of the
body can be affected.
- There is less chance of an interruption of homeostasis if the osmolality of the injected
contrast agent closely resembles that of blood plasma, which is approximately 300
osmol/kg. On the average, nonionic contrast agents have around 750 osmol/kg, where as
Ionic contrast agents range from 1000 to 2400 osmol/kg.
- Because of their hyperosmolality, ionic contrast agents can cross the blood-brain barrier,
which is also a factor in the occurrence of adverse reactions.
- Nonionic contrast agents have a much lower level of neurotoxicity.
- Although the osmolality of nonionic contrast agents is still higher than that of blood
plasma, it is significantly lower than the osmolality of ionic contrast agents. For this
 reason, the use of nonionic contrast agents tends to produce fewer physiologic reactions
than use or their ionic counterparts.

Table1.2. Examples of ionic (high osmolar) iodinated contrast agents

Name Type Iodine content Osmolality

Ditrizoate(Hypaque 50) Monomer 300 mg/ml 1550

Iothalamate (Conray 60) Monomer 370 mg/ml 2100
Ioxaglate (Hexabrix ) Dimer 320 mg/ml 580

Table1.3. Examples of non-ionic (low osmolar) iodinated contrast agents

Name Type Iodine content Osmolality

Iopamidol (Isovue 370) Monomer 370 mg/ml 796

Iohexol (Omnipaque 350) Monomer 350 mg/ml 884
Ioversol (Optiray) Monomer 320 mg/ml 796
Iopromide (Ultravist 370) Monomer 370 mg/ml 774
Iodixanol (Visipaque 320) Dimer 320 mg/ml 290

Contraindications

- The most significant contraindication to the use of iodinated contrast media is an allergic
history to iodine.
- In some cases, the patient can be premeditated without causing an adverse reaction.
- Allergic reactions to oil based iodinated contrast media can occur but are rare.

The advantages of non ionic contrast media over ionic contrast media:

 Well tolerated by the patient

 Less heat and discomfort on injection
 Low osmolality
 Does not dissociate in to charged particles
  Low neurotoxicity
 Approximately one-fifth fewer adverse reactions than with the use of ionic contrast media
ROUTES OF ADMINISTRATION

Contrast media are considered to be pharmaceuticals (drugs), and as such they must be
administered appropriately to achieve the desired effect and to avoid unwanted complications.

THE FIVE RIGHTS OF MEDICINE ADMINISTRATION

i. The right patient should receive

ii. The right medication
iii. In the right amount
iv. Via the right route
v. At the right time
As listed above the five rights system, applies to the administration of all medications, including
contrast agents:
 The patient must be properly identified.
 The name of the contrast agent should be checked at least three times – at the time
of selection, preparation, just prior to administration.
 Although many contrast media are packaged in average dosage the amount may
have to be adjusted depending on the patient’s age, size and condition.
 The contrast medium must be administered by the proper route to be effective
and to avoid adverse complications.
 Contrast media should be administered at the correct time which is dependent on
the type of examination.
- The route of administration depends on the anatomy of interest, type of examination, and
particular contrast medium.
- Contrast medium can be administered orally, rectally, or intravascularly, or introduced
directly in to the intended site.

ORAL/RECTAL ROUTE
 - Barium sulfate products are administered by means of the oral route for examinations of
the esophagus stomach, and small intestine.
- Iodinated contrast agents such as Gastrografin and Hypaque can also be administered
orally for these same examinations.
- Iodinated agents known as oral cholecystopaques are administered orally in pill or
granule form for visualization of the gallbladder.
- A contrast medium is administered rectally as an enema for an examination of the large
intestine. Although barium sulfate is the most commonly used contrast medium for this
purpose, Hypaque or similar iodinated products may also be used.

INTRAVASCULAR ROUTE

Only water- soluble iodinated contrast media can be administered intravascularly.

Intravascular injection of contrast media includes both intravenous and intra-arterial routes.

The intravenous route is employed for excretory urography, as well as for CT and MRI
Examinations using contrast media.

- A vein in the antecubital region of the arm or on the dorsum of the hand provides the
easiest access site for injection.
- The technologist performing the venipuncture should follow universal precautions, which
include the use of gloves.
- After visual inspection of the site, it is then thoroughly cleansed by applying a sterile
alcohol or antiseptic swab in a circular motion, working outward from the center of the
site.
- The site should be allowed to dry completely. A tourniquet is applied snugly
approximately 3 to 4 in (7 to 10 cm) above the site.
- A butterfly needle, straight needle, or venous catheter is inserted smoothly at a 15 0 angle
to the skin (the bevel of the needle should face upward).Back flow of blood indicates
correct placement of the needle in the vein.
- After the tourniquet is released, the contrast medium can be injected in bolus fashion,
infusion, or by means of an automatic injector.
 - At the completion of the injection, a sterile gauze pad is placed over the site, the needle is
removed, and pressure is applied for several minutes until the bleeding stops.

The intra-arterial route is used for special radiographic procedures of the cardiovascular system.
Access to the artery is accomplished via the seldinger technique which is described in
angiography.

In lymphangiography, the contrast medium is injected intravascularly into the lymphatic vessels.

DIRECT ROUTE

Some radiographic examinations require that the contrast medium be introduced directly into the
anatomy of interest. This can be achieved by means of a catheter or needle. For example, in a
cystogram a catheter is inserted into the urinary bladder and a water-soluble iodinated contrast
medium is allowed to flow into the bladder until it is full.

During a myelogram, an intrathecal injection is performed by inserting a spinal needle into the
subarachnoid space between two vertebrae and injecting a water-soluble iodinated (nonionic)
contrast medium into the thecal sac.

Examples of other examination in which contrast media are directly administered include
arthrography, hysterosalpingography, sialography, and percutaneous transhepatic
cholangiograhy.

REACTIONS TO CONTRAST MEDIA

The potential exists for an adverse reaction to occur when a contrast medium is administered to a
patient. Although reactions can take place with the use of any contrast agent, they are more likely
to occur after intravascular injection. Very few reactions actually occur following administration
of barium sulfate or oil based iodinated contrast agents. The technologist or radiographer should
be aware of the possibility of adverse reactions and be prepared to handle them according to the
institution’s protocol.

 An emergency drug box or crash cart should be in the examination room or readily
available.
  It is recommended that the patient’s blood pressure, pulse, and respiration be assessed
prior to contrast medium administration. This provides baseline information in the event
a reaction occurs.
 Because it is inert, barium sulfate rarely causes any allergic reactions; however it does
tend to cause constipation as the water is absorbed from the mixture, leaving the solid
barium sulfate in the intestines. This is especially true in elderly patients who tend to
have decreased bowel motility.
 Following any examination in which barium sulfate is administered; the patient should
be advised to drink plenty of fluids to prevent a bowel obstruction. Care should be taken
when a patient feels nauseous or vomits after ingestion of barium sulfate so that the
contrast material is not aspirated. Aspiration of barium sulfate into the lungs can result in
pneumonia. Occasionally, a condition known as hypervolemia can occur from
administration of a barium enema. In this very serious condition, excessive water is
absorbed from the large intestine by the circulatory system. Pulmonary edema and/or
other complications can result from the fluid overload.

An allergic reaction is possible with the use of any iodinated contrast agent; however, few
reactions occur with the use of oil–based iodinated contrast media. The reactions to injectable
contrast agents can be described as systemic because the physiologic response of the body’s
systems is affected when the contrast media are injected into the cardiovascular system.
According to the chemotoxic Theory, hemodynamic changes occur as the body’s normal
physiologic functions and homeostasis are interrupted. The reactions seem to be directly related
to the following factors.

 Degree of chemotoxicity of the contrast medium

 Concentration of iodine in the contrast medium
 Certain properties of the contrast medium including osmolality, viscosity, and purity of
the solution
 Dosage administered
 Pace of the injection
 Physical condition of the patient
An anaphylactic reaction closely resembles a true allergic reaction in which the patient
demonstrates hypersensitivity when a foreign substance is injected. Although such a reaction
cannot be predicted, certain patients seem to be predisposed to experiencing adverse reactions. It
is critical that the radiographer take an accurate patient history prior to the administration. It is
critical that the technologist or radiographer take an accurate patient history prior to the
administration of a contrast medium, particularly to determine any allergies and previous
reactions to contrast media.

A vasovagal reaction is one that occurs in response to anxiety or fear. It generally involves a
vascular as well as a neurogenic response, with the patient experiencing mild symptoms of
pallor, dizziness, diaphoresis, nausea, and possibly bradycardia. The radiographer/technologist
can help alleviate the symptoms by being supportive and reassuring.

Extravasations Occurs during injection if some of the contrast medium seeps out of the vein to
the surrounding tissue. This reaction usually involves pain and discoloration at the site of
injection. The technologist or radiographer should apply a warm, moist compress to the site to
decrease pain and aid in the absorption of the extravasated contrast medium.

Adverse reactions are usually acute, with the majority occurring 5 to 20 minutes after injection of
the contrast medium. Although delayed reactions are possible, they are rare and typically mild.

Reactions are classified as mild, moderate, or severe according to the symptoms experienced by
the patient and the treatment needed to alleviate them.

Mild (Minor) reactions, such as a warm flush or metallic taste generally need little or no
treatment and are considered to be self limiting.
Moderate reactions require the administration of medication to relive the symptoms. For
example, a patient who develop hives on several areas of the body might be given and an
antihistamine such as Benadryl.
Severe reactions are considered to be life threatening. Immediate treatment is necessary
to stabilize the patient beginning with administration of 100% oxygen and accessing a
vein to start an intravenous line (5% dextrose in water or normal Saline). The patient’s
Blood pressure, pulse and respiration should be closely monitored.
 TABLE 1.1. Summary of a variety of adverse reactions, the particular body systems affected,
and the severity of the reactions

Severity of Reaction
System Reaction Mild Moderate Severe
Cardiovascular Arrhythmia 
Tachycardia or 
bradycardia
Extreme hypotension 
Cardiac arrest 
Hypervolemia 
Neurologic Headache  May Become severe
Unconsciousness 
Coma 
Seizures 
Aphasia 
Respiratory Coughing/sneezing 
Dyspnea 
Extreme change (up or down) in 
rate of respiration
Cyanosis 
Respiratory arrest 
Urinary Flank pain 
Hematuria 
Renal impairment/failure 

Gastrointestinal Nausea/vomiting 
Uncontrolled Vomiting 
Metallic taste

Integumentary Hot /flush 
Mild urticaria 
Excessive urticaria 
Pain or burning sensation from 
extravasation
Itching
Facial edema 


PATIENT CARE AND INSTRUCTION BEFORE ADMINISTERING

IODINATED CONTRAS AGENTS
  Patients who are to receive iodinated CM should be instructed to have adequate fluid
intake to hydrate the body prior to administration, because sufficient hydration helps to
prevent adverse reactions
 All iodinated contrast agents are most comfortable for the patient when administered at
body temperature, so, place the solution to be injected in to a basin of tepid ( Luke warm)
water for 10-15 minutes prior to administration
 Keep emergency Cart ( resuscitation drugs, like Adrenalin) readily available before
iodinated CM is administered
 Before administering CM, ask the patient for allergic foods, medicine, asthma, hayfever,
whether CM examination has been done for him/her previously and reaction happened or
not; if the reply is positive stops the procedure.
MEASURES TO BE TAKEN WHEN ANAPHYLACTIC REACTION
HAPPENED
If you observe the signs and symptoms of anaphylactic (allergic) reactions:-
 Stop the injection immediately
 Monitor vital sign
 Observe for respiratory distress
 If the patient is in anaphylactic shock, call emergency team (physicians and
nurses)
 Place the patient in Semi-fowler’s or sitting position (for cardiopulmonary
distress)
 If the patient becomes breath less and pulse less, administer cardiopulmonary
resuscitation

PATIENT CARE AND INSTRUCTION AFTER RECEIVING IODINATED

CONTRAST AGENTS
Instruct the patient to increase fluid intake to 3000ml for at least 24 hours to assist with the
dilution and excretion of the agent from the body.
UNIT SUMMARY

 Contrast media alter a structure’s density, thus affecting its radiographic appearance.
 Contrast media can be used to enhance structures that have low contrast such as the
urinary, digestive, and biliary system, spinal canal, female reproductive system, and
vasculature.
 Negative contrast media are radiolucent and appear dark on a radiograph. Room air is a
common example of a negative contrast media.
 Positive contrast media are radiopaque and appear light on a basis radiograph. Iodine and
barium sulfate form the basis of Positive contrast agents.
 Iodinated contrast media that are ionic dissociate in to charged particles, whereas
nonionic agents do not dissociate.
 Contrast media are pharmaceutical agents (drugs) and must be administered appropriately
with a physician’s order.
 Contrast media can be administered orally or intravascularly or introduced directly
depending on the type of examination and the type of contrast agent.
 An adverse reaction can occur with the use of any contrast media.
 Reactions are classified as mild (minor), moderate, or severe, depending on the
symptoms and required treatment.
 An emergency drug cart should be prepared during special procedures.
 Most contrast examinations use fluoroscopy and require some type of patient preparation
prior to the day of the examination.