RADIOLOGY HEALTH: Examinations: Diagnosing Disease and Injury

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OUTLINE
Patient Preparation and Contrast Media

Radiographic Studies

Skull and Headwork

Thoracic Cavity Extremities

Spine

Abdomen

Fluoroscopic Examinations

Esophagram

Upper Gastrointestinal Series

Barium Enema

Urinary System Studies Endoscopic Retrograde Cholangiopancreatography

Special Radiographic Procedure

Arteriogram (Angiogram)

Arthrogram

Hysterosalpingogram

Lithotripsy

Mammogram

Myelogram Sialogram

Venogram

Conclusion

Radiography is one of the primary methods of diagnosing disease. Positioning and procedures will be covered in depth during
your education, but this chapter provides an excellent overview of what you will observe and experience in the clinical setting. Not all
institutions perform all of the procedures described here because hospital and clinic services vary. However, you should be familiar
with all types of studies because your actual employment may be elsewhere. In addition, as a student radiographer, you must
become competent in many of the procedures performed by diagnostic radiographers.

The radiographic examinations discussed in this chapter are divided into radiographic, fluoroscopic, and special procedures. Bear in
mind that these procedures may be performed using digital fluoroscopy, digital radiography, or film-screen imaging, or they may
even be in the process of being replaced by other imaging modalities such as computed tomography (CT). The two important
components of most radiographic examinations are (1) patient preparation and (2) contrast media.

PATIENT PREPARATION AND CONTRAST MEDIA

Depending on the examination, patient preparation is performed either internally or externally. External preparation requires
removing clothing and jewelry that may be covering the area of the body through which the x-rays must pass. Many types of clothing
material show up on film as obscure shadows. Buttons and zippers may hide small disease processes or fractures. If a region of the
head is being radiographed, dentures must be removed because they interfere with the passage of x-rays through the mouth. Rings
and watches must be removed when radiographing the hand or wrist. One of the most common mistakes is forget- ting to remove a
necklace before performing a chest examination (Fig. 9-1, A). Always ask each patient to remove jewelry before beginning an
examination. In addition, ask the patient if the area of the body to be radiographed is pierced; if so, request that all piercing jewelry
be removed from the body part. Failure to do so results in a double dose of radiation to the patient because the radiographs must be
retaken. Note if a tattoo is in the area being radiographed. If the ink used in the tattoo contains metallic pig- mentation, it may
appear as a faint shadow on the radiographic image. Proper examination of the patient is the responsibility of the radiographer.
Checks for unwanted objects should be verbal, visual, and tactile.

Internal preparation for some examinations includes cleansing enemas, which are performed so that structures in the abdomen are
not obscured by gas and fecal material. Most of these preparations are administered on the nursing units or by the patient at home.
However, awareness of hospital procedures helps explain the importance of this preparation and answers any questions the patient
may have. As a competent radiographer, you must be aware of all aspects of patient care that relate to the examination, regardless of
whether you perform them.

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RADIOLOGY HEALTH: Examinations: Diagnosing Disease and Injury
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Contrast media are solutions or gases introduced into the body to provide contrast on a radiograph between an organ and its
surrounding tissue. The three general types of contrast media used in radiography are (1) iodine-based media, (2) barium-based
media, and (3) air.

The element iodine has a relatively high atomic number. Because x-rays do not readily pass through iodine, solutions that contain
this element are placed in organs and blood vessels to provide a contrast between these structures and their surrounding tis- sues.
The radiographer must be alert to possible adverse reactions the patient may experience when using iodinated contrast media. The
use of non- ionic contrast media greatly reduces the occurrence of such side effects, but it does not eliminate them.

The element barium has approximately the same contrast qualities as iodine, but the similarities end there. Barium sulfate is inert
and cannot be absorbed by the body; this makes it the medium of choice for gastrointestinal studies (Fig. 9-1, B-C), Patient allergic
reaction to barium is almost nonexistent because of its inert properties.

However, exceptions exist. For example, if surgery appears imminent or if a perforated stomach or intestine is suspected, barium
would not be used because it cannot be absorbed. In such cases, a water-soluble iodine contrast agent is used because it is readily
absorbed should spill- age into the abdominal cavity occur.

Air is used as a contrast agent primarily in chest radiography. Unlike iodine and barium, air is eas- ily penetrated by x-rays, thus
providing contrast between lung tissue, vessel markings, and the air sacs themselves. Air may also be used with bar- ium-based or
iodine-based contrast media to pro- vide a double contrast; this combination is used in air-contrast colon studies and arthrography.

RADIOGRAPHIC STUDIES
Radiographic studies are examinations performed by the radiographer on particular regions of the body with the use of the x-ray
tube. The images are recorded on an imaging plate or radiographic film and subsequently interpreted by the radio- logist. The
radiographic examinations performed are listed in the following text according to body region, and a few comments are offered that
will help you understand the studies.

Skull and Headwork

Radiographic studies of the region above the neck make up the skull and headwork category. Many of these procedures are
performed primarily with CT or panoramic tomography. Examinations that may still be performed without CT, or in
conjunction with CT, include the skull, facial bones, nasal bones, mandible, temporomandibular joints (TMJs), and sinuses.
These examina- tions require multiple views, and some are rather difficult to perform. Headwork imaging is usually
performed to evaluate possible fractures, locate foreign bodies, or examine abnormalities. Areas such as the sella turcica,
zygomatic arches, mastoids, and orbits are increasingly imaged using CT. The mandible and TMJs are primarily imaged using
panoramic tomography.

Thoracic Cavity

The thoracic cavity includes the bones and tis- sues of the chest region and is the most com- monly radiographed region of
the body. Exact positioning and careful exposure techniques are essential for proper imaging. Other studies of the thoracic
cavity include the ribs, sternoclavicu- lar joints, and sternum. Thoracic studies may be performed to evaluate fluid in the
lungs, overex- pansion, collapsed lungs, tumors, heart enlarge- ment, and other heart and lung abnormalities, as well as
fractures of the ribs, sternoclavicular joints, and sternum.

Extremities

The extremities category is generally divided into the upper and lower regions and also includes the shoulder and pelvic
regions. Upper extrem- ity studies include radiographs of the fingers, hands, wrists, forearms, elbows, humeri, shoul- ders,
clavicles, acromioclavicular joints, and scapulas. Lower extremity studies include radio- graphs of the toes, feet, heels,
ankles, lower legs, knees, patellae, femurs, hips, and pelvis. Bone studies always require at least two views that are taken at
right angles to one another; joint stud- ies may also include an oblique view. Care must be taken when performing bone and
joint studies because of the possibility of broken bones (fractures). Studies in patient care explain how injured patients are
properly handled. Radiologic examinations of the extremities are performed to evaluate bone fractures, dislocations,
arthritis, osteoporosis, and tumors.

Spine

The spine category includes studies of the cervical spine, thoracic (dorsal) spine, lumbar spine, sacroiliac joints, sacrum, and
coccyx. In addition, examinations such as scoliosis evaluation and bone age determination are included in this category.
Patients with spinal injuries must be care- fully handled because further injury can result if the nerves are damaged. Spinal
injuries are painful, and the radiographer must make the patient as comfortable as possible while obtaining as many
diagnostic radiographs as necessary for the physician's evaluation. In addition to evaluating severe trauma, spinal studies
are performed to evaluate the extent of arthritis of the spine, abnormal curvatures, muscle spasms that may be causing the
spine to curve, and slipped vertebrae.

Abdomen

Many of the studies involving the abdomen require the use of fluoroscopy and are discussed more fully in the next section.
However, some radiographic surveys are made of the abdomen without the use of contrast agents and fluo- roscopy. Careful
patient handling is important because many patients who are having abdomen examinations are quite ill and in pain. Again,
providing proper care for the patient is your responsibility in the radiology department. Abdominal studies often determine
the presence of foreign masses; calcifications; the distribution of air in th intestines; the size, shape, and location of major

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RADIOLOGY HEALTH: Examinations: Diagnosing Disease and Injury
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organs such as the liver, kidney, and spleen; and bony and soft-tissue damage. These studies are also used to evaluate
individual organs, although most such studies are performed using CT.

FLUOROSCOPIC EXAMINATIONS
Fluoroscopic studies require a radiologist or radi- ologist assistant (RA) to perform and monitor the examination in most
circumstances. Viewing the study "live" is necessary. The following dis- cussion highlights the most commonly performed
examinations. Digital images or spot films are obtained by the radiologist during the fluoros- copy. Radiography of the body part and
region on larger radiographic film follows nondigital fluoroscopic studies. Digital studies involve post- processing of the digital
fluoroscopic image.

Esophagram

The esophagram, which is a study of the esophagus, requires the patient to swallow a barium sulfate preparation. The
radiologist or RA obtains digital images or spot films. Often, the patient has difficulty swallowing the barium because of its
thick, paste like mixture that lingers in the esophagus. Esophagrams may visualize tumors, constrictions, and spasms.

Upper Gastrointestinal Series

Studies of the stomach, often called an upper gastrointestinal (GI) series, are performed with the use of barium sulfate. The
patient must drink the solution while fluoroscopically controlled images are obtained (Fig. 9-2). The upper GI series is
performed to evaluate hiatal hernias, peptic ulcers, and other stomach disorders. If the small intestine must be evaluated, a
small bowel examination is performed. This examination involves radiographing the abdomen every hour to watch the
progress of the barium meal through the small intestine. Advising the patient ahead of time that this study will take several
hours to perform is important. Small bowel studies are performed to investigate tumors, inflammation, obstructions, and
the malabsorption of nutrients. Fiberoptic endoscopy is also used to examine the stomach.

Barium Enema

The radiographic examination of the colon, which is called a barium enema, involves introducing a barium solution into the
colon. Although this study is not unduly painful, it is often considered uncomfortable. Because the barium solution may
cause cramping and discomfort, the radiologist and radiographer must work rapidly and accurately so that the barium
solution can be excreted as soon as possible. Glucagon is often used in air-contrast studies of the colon to reduce cramping
and peristalsis. Barium studies may indicate tumors, bowel obstructions, diverticula, and inflammation. A study called the
air-contrast barium enema is performed by introducing air in addition to the barium to provide a double contrast, which
allows for better visualization of abnormalities in the colon such as diverticula and polyps. Colonoscopy using an endoscope
is proving to be a more effective tool in visualizing the colon and has the advantage of being able to obtain a biopsy at the
same time. Both the bar- ium enema and the virtual colonoscopy, which is a CT procedure used to reconstruct the colon
using computer images, are gradually replacing the barium enema.

Urinary System Studies

Examination of the urinary system is increasingly being performed using CT. It may be performed as part of a study called
excretory urography, which is also called intravenous. urography or intravenous pyelograms (IVPs). in this case it is called a
CT/IVP. When per- formed without CT, IVPs involve the use of an iodinated contrast agent injected into the bloodstream
through a vein in the arm. Radiographs are obtained at intervals of several minutes during the time that the kidneys,
ureters, and bladder are highlighted by the contrast material. Intravenous urography helps visualize stones in the urinary
system and evaluate kidney function. In addition to the IVPs, studies of the urinary system may be performed under
fluoroscopic control. For example, the cystogram, which is a study of the urinary bladder, involves filling the bladder with a
contrast agent and then taking radiographs of the bladder. A voiding cystourethrogram, which evaluates urination, is similar
except that the patient empties the bladder while under fluoroscopic observation.

Endoscopic Retrograde Cholangiopancreatography

An endoscopic retrograde cholangiopancreato- graphy (ERCP) is performed to diagnose anoma- lies in the biliary system or
pancreas. A contrast medium is injected into the common bile duct after it is located with a fiber-optic scope passed down
the esophagus, through the stomach, and into the small intestine. Radiographs are then taken with a digital fluoroscope or
spot-film device.

SPECIAL RADIOGRAPHIC PROCEDURES

Special radiographic procedures are studies that require special equipment or that are not routinely performed. The following studies
require the use of x-rays and do not include special imaging modalities, which are included in Chapter 23.

Arteriogram (Angiogram)

The arteriogram is a study that visualizes the arter- ics of a particular body region. An iodine-based contrast material is injected, and
a very rapid sequence of images is made; these images allow for the viewing of the blood flow through the artery and an evaluation
of the shape and condi- tion of the artery itself. Performing arteriography involves the use of digital fluoroscopy, automatic injectors,
and a sterile field (Fig. 9-3, A).

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CONSTANTINO_JERRY MAR
RADIOLOGY HEALTH: Examinations: Diagnosing Disease and Injury
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Arthrogram

Arthrography has largely been replaced by mag- netic resonance imaging (MRI), although arthro- grams may still be used in
your clinical sites. The arthrogram is used to evaluate the struc- tures in and around a joint space. The most com- mon joints
involved are the knee and shoulder. An iodinated contrast medium is injected directly into the joint space. Fluoroscopy is
used and, if digital, images are obtained by the radiologist. Spot films obtained by the radiographer may be taken after
routine fluoroscopy.

Hysterosalpingogram

The hysterosalpingogram is an examination of the uterus and fallopian tubes. This examination allows for the evaluation of
the shape of the uterus and patency of the oviducts. Usually an oil-based iodinated contrast medium is used to fill these
structures. Fluoroscopy is used, and follow-up radiographs may also be obtained.

Lithotripsy

The radiographer may also be involved in a litho- tripsy procedure, which destroys stones in the kidney or ureter by using
sonic shock waves. The patient is placed in a tub of water against a special probe. The shock wave passes into the body and
destroys the stone. The radiographer's role may include tak- ing localizing radiographs and assisting with fluoros- copy,
which is necessary for the proper placement of equipment both inside and around the patient.

Mammogram

A mammogram is a radiographic study of the breast. Because breast tissue has little inherent contrast, high-contrast
radiographic film and specially designed cassettes are used. The breast is compressed to allow for maximum visual- ization.
Modern imaging equipment provides the detail that is of critical importance in the early detection of breast cancer. Most
dedicated breast imaging rooms are in the process of being replaced by digital mammography units.

Myelogram

Myelography has generally been replaced by MRI, although your clinical sites may still per- form them. The myelogram is an
examination of the subarachnoid space of the spinal cord (Fig. 9-3, B). After the removal of some of the spinal fluid, a
water-soluble iodine-contrast agent is injected into the space through the patient's back or neck. Fluoroscopy is used to
guide the flow of the contrast agent and to obtain radiographs of the region. The patient may be given a sedative, which
causes drowsiness; therefore patient care must be at its best.

Sialogram

A sialogram is a study of the salivary glands after they have been injected with a contrast agent. Both fluoroscopy and
routine radiography of the mandible may be used, usually to detect block- ages caused by stones.

Venogram

A venogram is a study used to evaluate the veins in a particular area of the body. Contrast medium is injected into the veins,
and radiographs are made. Fluoroscopy is not usually used when only a venogram is performed. Venograms of the lower
extremities may be performed with a device that allows for the visualization from the pelvis to the feet on one film.
Venograms of other body parts are performed with cassettes sized to match the body part. Venography is supplemented
with and gradually being replaced by sonography.

CONCLUSION
The preceding discussion of radiographic, fluoro- scopic, and special radiographic examinations is not meant to be all-inclusive; the
studies described in this text are the ones that you will most likely see in average and large departments. Smaller departments may
never perform some of the pro- cedures, whereas others are involved with even more specialized studies. The step-by-step proce-
dures for performing these examinations will be presented in your course on radiographic proce- dures. However, you may soon be
observing these procedures or hearing discussions about them. This basic knowledge of examinations will help you become oriented
to the clinical environment.

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CONSTANTINO_JERRY MAR