CHOLEGRAPHY 3.

Cholecystangiography/Cholecystocholangiogr ORAL CHOLECYSTOGRAPHY

• It is the general term for a radiographic study aphy – radiographic examination of both the GB
of the biliary and biliary ducts. ❑ This is the examination of the gallbladder
system with the use of radiopaque contrast through the
media. • GALLBLADDER AND BILIARY DUCTS – These administration of contrast media by mouth.
• The methods involved in this examination is are the compositions of the biliary or ❑ The contrast medium will be absorbed
named according excretory system of the liver. through the small
to: intestines.
A. The route of entry of the medium • GALLBLADDER - It is a thin-walled, ❑ CONTRAST MEDIA: TELEPAQUE,
B. The portion of the GB and biliary tract to be more or less pear-shaped, BILOPAQUE, ORAGRAFIN
examined. Musculo membranous sac with a CAPSULES OR GRANULES, TEREDAX
capacity of approximately 2 ounces. ALSO KNOWN as GRAHAM’s EXAM
• To check the function of the liver. This functions to concentrate the bile
• To check the patency condition of the biliary and evacuate it during digestion. The CONTRAINDICATIONS:
ducts. muscular contraction of GB is • Vomiting
• To check the concentrating and emptying activated by the hormone • Diarrhea
power of cholecystokinin. • Pyloric obstruction
the gallbladder. • Malabsorption Syndrome
• To check the presence of stones. • The normal gallbladder is 7 to 10 • Severe Jaundice
cm long and approximately 3 cm • Liver Dysfunction
❑ By mouth – ORAL CHOLECYSTOGRAPHY wide. It generally holds 30 to 40 ml • Hepatocellular disease
❑ By injection to vein – INTRAVENOUS of bile. • Hypersensitivity to ICM
CHOLANGIOGRAPHY • Cholecystectomized patient
❑ By direct injection thru the ducts BILIARY DUCTS
1.Percutaneous Transhepatic Cholangiography / PATIENT INSTRUCTION:
Pre op • (NOTE: THE GALLBLADDER MOVES • AVOID LAXATIVES FOR 24 HOURS BEFORE THE
2. Operative or Immediate Cholangiography LATERALLY AND SUPERIORLY 1 TO 3 INCHES ON INGESTION OR
3. Post- operative, Delayed, or T-tube FULL EXPIRATION AND MEDIALLY AND INJECTION OF THE MEDIUM.
Cholangiography INFERIORLY 1 TO 3 INCHES ON FULL • VOMITING WITHIN TWO HOURS AFTER
INSPIRATION.) INGESTION OF THE
• More specific terms can be used to describe CONTRAST MEDIUM MAY AFFECT INGESTION
the portion of the INDICATION: OF THE
biliary system under investigation. CONTRAST MEDIUM.
BILIARY CALCULI
1.Cholecystography – radiographic examination ◦ PURE CHOLESTEROL BOWEL PREPARATION:
of GB. ◦ CALCIUM-CONTAINING * Scout radiographs on the day before
2. Cholangiography – radiographic examination • CHOLECYTSTITIS * Avoidance of laxatives for 24 hours before
of the biliary ducts. • NEOPLASMS ingestion or
• BILIARY STENOSIS injection of the medium
• CONGENITAL ANOMALIES
* NPO 6-8 hrs.
* Fat free for 1-2 days
*Telepaque CM (6 tabs)
(12 tabs)
*Food forbidden/H2O is encouraged
PRELIMINARY DIET:
• Noon meal rich in simple fats on the day
before the examination.
This fat causes the GB to contract; theoretically,
the contrast-filled bile will then be more
concentrated and clearly visible for OCG.
• Fat-free evening meal -
Prevent the GB from contracting and expelling
the opacified bile
CONTRAST ADMINISTRATION:
• Single dose (3 grams – 4 to 6 tablets)
approximately 2 to 3 hours after the evening
meal on the night before the examination.
• Absorption time: 10 to 12 hours for most
present-day oral agents
• IPODATE CALCIUM is rapidly absorbed – 1.5
hours visualization of biliary ducts and 3 to 4
hours for visualization of GB.
NOTE: NATANONG TO SA BOARDS!! MAY 2021
PROJECTION:
PROJECTION: PA
POSITION UPRIGHT OR PRONE
CR AND RP: PERPENDICULAR + CENTERED TO
GB ACCORDING TO HABITUS
STRUCTURE SHOWN: AXIAL REPRESENTATION
OF THE OPACIFIED GB
HYPERSTHENIC
• GB moves laterally and superiorly I to 3 inches
(2.5 to 7.6 cm) on full expiration.
ASTHENIC
• GB moves medially and inferiorly I to 3 inches
(2.5 to 7.6 cm) on full inspiration.
PROJECTION: PA OBLIQUE
POSITION: LAO- RECUMBENT 15 TO 40 DEGREES
CR + RP: PERPENDICULAR + CENTERED TO GB
ACCORDING TO HABITUS.
STRUCTURE SHOWN: OPACIFIED GB FREE OF
SUPERIMPOSITION.
PROJECTION: LATERAL
POSITION: RIGHT LATERAL RECUMBENT
CR + RP: PERPENDICULAR + CENTERED TO GB
ACCORDING TO HABITUS.
STRUCTURE SHOWN: DIFFERENTIATE
GALLSTONES FROM RENAL STONES OR
CALCIFIED MESENTERIC LYMPH NODES
PROJECTION: AP (WHELAN)
POSITION: RIGHT LATERAL DECUBITUS
CR + RP: HORIZONTAL + CENTERED TO GB
ACCORDING TO HABITUS.
STRUCTURE SHOWN: STRATIFICATION OF
GALLSTONES.
Fatty meal
Post- fatty film or delayed film (45-60 mins
after Fatty meal)
a. RPO – permits more rapid emptying rate of
the GB
b. AP and Lateral – every 15 minutes to check
emptying power
of the GB
INTRAVENOUS CHOLANGIOGRAPHY
• This is used to investigate the biliary ducts of
the cholecystectomized patients.
- 30 ml cm intravenously
- if GB is present a fatty meal maybe given
• Contrast Media: CHOLOGRAFIN, DUOGRAFIN,
BILIGRAFIN
CONTRAINDICATIONS
• Liver disease
• Non-intact biliary ducts
• Patient’s bilirubin is increasing or when it
exceeds 2 mg/dl
NORMAL:1.2 milligrams per deciliter (mg/dL) for
adults and usually 1 mg/dL for those under 18.
• Supine – preliminary radiograph
• RPO (15 to 40 degrees)
• 10- minute intervals
• Maximum opacification: 30 to 40 minutes
PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY
• This involves imaging the biliary system after
a needle
puncture has been made through the liver and
into the biliary
ducts for the injection of contrast medium.
• Made use of chiba (“skinny”) needle
• Use to place drainage catheter for
treatment of obstructive
jaundice
• 20 to 40 ml CM
• Contrast media: Telebrix, Conray, Hypaque
INDICATION
OBSTRUCTIVE JAUNDICE
STONE EXTRACTION AND BILIARY DRAINAGE
POSSIBLE COMPLICATIONS
1.Leakage of bile into the peritoneal cavity
2. Hemorrhage
3. Pneumothorax
4. Sepsis (infection)
Procedures
• Place the patient in supine position.
• The patient’s right side is surgically prepared
and draped.
• Local anesthesia is administered.
• The Chiba needle is held parallel to the floor
and inserted through the right lateral
intercostal space and advanced
toward the liver hilum. (7th- 11th Intercostals
space)
• Stylet of the needle is withdrawn and a
syringe of contrast medium is attached to the
needle.
• Fluoroscopy guided
OPERATIVE CHOLANGIOGRAM
• An image taken in the surgical suite directly
following a cholecystectomy to:
- Investigate the patency of the biliary tract
- Determine the functional status of the
hepatopancreatic
ampulla
- Reveal any choleliths not previously detected
- Demonstrate small lesion, strictures, or
dilatations within the
biliary ducts
- CM introduced directly to the CBD.
(TAKENOTE!!)
POST-OPERATIVE CHOLANGIOGRAPHY
• Postoperative, delayed, and t-tube
cholangiography
• Occurs 1 to 3 days after the surgery
• Contrast medium/a: water-soluble organic
contrast media (Density: no more than 25% to
30% because small stones may be obscured
with higher concentration.
Use to demonstrate:
• Caliber and patency of the ducts
• Status of the sphincter of the
hepatopancreatic ampulla
• Presence of residual or previously
undetected stones or
other pathologic condition
Preliminary preparation
• The drainage tube is clamped the day
preceding the examination (for filling the tube
with bile and prevent air bubbles entering the
ducts, where they would simulate cholesterol
stones).
• Preceding meal is withheld.
• When indicated, cleansing enema is
administered 1 hour before the
examination. No premedication.
Procedures:
• After preliminary radiograph, place the
patient in RPO position.
• Inject the contrast media under fluoroscopy.
Stern, Schein, Jacobson
• Obtain lateral projection to demonstrate the
anatomic
branching of the hepatic ducts in this plane and
detect any abnormality. (TAKENOTE!!!)
• This is the procedure used to diagnose
biliary and pancreatic pathologic conditions.
ERCP is a useful diagnostic method
when the biliary ducts are not dilated and
when no obstruction exists at the ampulla.
Procedures:
• Patient’s throat is sprayed with local
anesthesia.
• This causes temporary pharyngeal paresis, so
food and drink
are usually prohibited at least 1 hour after the
examination.
Food may be withheld for up to 10 hours after
the procedure
to minimize irritation to the stomach and small
bowel.
• After localization of the hepatopancreatic
ampulla (ampulla of
vater), a small cannula is passed through the
endoscope and
directed into the ampulla.
• Contrast media is injected into the common
bile duct.
• 5 minutes – normal drainage of ducts;
radiographs must be
exposed immediately.
(NOTE: ULTRASONOGRAPHY OF THE UPPER
ABDOMEN BEFORE ENDOSCOPY IS OFTEN
RECOMMENDED TO ASSURE THE ABSENCE OF
PSEUDOCYST BECAUSE CONTRAST MEDIA
INJECTED TO IT MAY CAUSE ITS INFLAMMATION
AND RUPTURE.)
ADDITIONAL PROJECTION (LUMABAS NG
BOARDS
TO NUNG MAY 2021)!!!
PA UPRIGHT- AXIAL VIEW OF GB
LAO- GB FREE FROM SUPERIMPOSITION
◦ 15-20 Deg- Asthenic
◦ 20-25 Deg- Sthenic
◦ 40 Deg- Hypersthenic
LPO- Projection calcium like bile.
RPO- Demonstrate biliary tracts.
Lateral- Demonstrate hepatic duct.
RPO- for increase/ speed up the evacuation of
the bile/contrast in GB.
RAO- Increase motility of the bowel(peristalsis).

ERECT- stratification and layering of the

gallstone

same as Right Lateral decubitus

LARGE BOWEL SERIES ◦ Give laxative to patient
◦ NPO at midnight
◦Radiographic examination of the large bowel or ◦Another shot of cleansing enema in the morning
intestine.’ ◦ No breakfast
◦Also known as “BARIUM ENEMA” PURPOSE: to empty alimentary canal
◦Contrast media: Barium Sulfate or Water- soluble
iodinated cm, and Air EQUIPMENT

ANATOMY AND PHYSIOLOGY CATHETER

◦Soft rubber rectal catheter (for those who have
◦ Large Intestine inflamed hemorrhoids, fissures, stricture, or any
-begins in the right iliac region, where it joins the abnormalities in anus)
ileum of the ◦ Disposable rectal retention tips
small intestine, forms an arch surrounding the ◦Air capacity –90 ml at one complete squeeze of
loops of the small inflator
intestine, and ends at the anus -5 feet (1.5 m) long ◦ Enema bags –3 quartz or
and is greater 3000 ml
in diameter than the small intestine. A filter may be used to prevent passage of nay
mixed lumps of barium (18 to 24 inches above the
THE LARGE INTESTINE HAS FOUR rectum)
MAIN PARTS: ◦ Tubing –6 ft long
• Cecum ◦KY Jelly
• Colon INSERTION OF ENEMA TIP
• Rectum ◦ Turn the patient to left in Sim’s position and lean
• Anal canal forward around 35 to 40 degrees
◦Adjust the IV pole so that the enema contents are
BARIUM ENEMA no higher than 24 inches (61 cm) above the level of
INDICATIONS the anus.
◦Colitis ◦ Following the angle of the anus, direct the tube
◦ Diverticulum anteriorly 1 to 1.5 inches. Then following the curve
◦ Intussusception of the rectum, direct the tube slightly superiorly.
◦ Neoplasm Insert the tube for no more than 3.5 to 4 inches.
◦Adenocarcinoma METHODS
◦ Polyps ◦ SINGLE-CONTRAST–12%to 25%for weight/
◦Volvulus volume
CONTAINDICATIONS ◦ DOUBLE- CONTRAST –high- density barium
◦Bowel perforation product; 75%to 95%weight/ volume ratio
◦ Large bowel obstruction 1. Warm barium enema
◦Appendicitis ◦ Temperature below body temperature
◦Anastamosis ◦ 85 deg F to 90 deg F (29 deg to 30 deg C)
2. Cold barium enema
◦ 41 deg F (5 deg C)
PATIENTPREPARATIONS
◦Cleansing enema 1 day before the examination
◦ Light supper
SINGLE-CONTRAST STUDY
◦ The colon is examined with a barium sulfate
suspension only.
◦ When occlusion of the enema tip occurs, displace
soft fecal material by withdrawing the rectal tube
about 1 inch. Then before reinserting the enema
tip, temporarily elevate the enema bag to increase
fluid pressure.
◦ For completion, a post evacuation radiograph is
taken and if shows inadequate for satisfactory
delineation of the mucosa, the patient may give
hot beverage (tea or coffee) to stimulate further
evacuation.
LOCATION OF LARGE INTESTINE
STRUCTURES IN RELATION TO
PERITONEUM:
◦ Intraperitoneal: within the peritoneal cavity
◦ Retroperitoneal: behind the peritoneal cavity
1.Cecum
2.Ascending colon
3.Transverse colon
4.Descending colon
5.Sigmoid colon
6.Upper rectum
7.Lower rectum
RELATIVE LOCATION OF AIR AND BARIUM
LARGE INTESTINE STRUCTURES
• SUPINE POSITION:
AIR: rises and fills the most anterior structures
(intraperitoneal structures)
BARIUM: sinks and fills the most posterior
structures (retroperitoneal structures)
PRONE POSITION: reversed above mentioned!
DOUBLE- CONTRAST STUDY
◦ Two- stage double- contrast procedure (Welin
technique)
◦Single- stage double- contrast procedure
TWO-STAGE DOUBLE CONTRAST
◦ For the investigation of smaller intraluminal
lesions
◦ Early diagnosis of ulcerative colitis, regional
colitis, and polyps
◦ Requirements (1) the colon must be cleansed as
thoroughly as possible, and (2) the colonic mucosa
must be prepared in such a way that an extremely
thin and even coating of barium can adhere to the
colonic wall.
◦ Patient does not have to be in the examination
room more than 20 to 25 minutes.
STAGE ONE
◦ Patient is in prone position to prevent possible
ileal leak
◦ The colon is then filled to the left colic flexure
(right lateral projection for rectum).
◦ The patient is then sent to the lavatory for the
evacuation of the material.
STAGE TWO
◦ The patient is again turn to prone position.
◦ Barium mixture to run up to the middle of the
sigmoid.
◦ Patient is then turned to right side, and air is
instilled into the enema tip.
◦ Patient is turned to provide adequate coating of
the
contrast agents.
◦ Instill enough air –1800 to 2000 ml or more –to
obtain proper distention of the colon.
◦ Radiographs are obtained.
SINGLE-STAGE DOUBLE CONTRAST
◦ The patient’s colon should be exceptionally clean.
◦Suitable barium suspension should be used (200%
weight/ volume ratio).
◦ Miller described 7- pump method for performing
this double contrast study.
◦ Patient is slowly turned 360 degrees and placed in
supine position
1. Insertion if enema tip creates closed system
◦ Flow rate controlled by:
◦ Degree of enema bag elevation
◦ Gentle manual pressure on bag
◦ Pressure cuff (for thicker mixture)
◦ Incorporated filter that prevents passage of
clumps into tubing
2. Barium is instilled in colon
3. Passive, controlled evacuation is affected by
lowering bag.
◦ Patient does not leave the table
◦ Enema tip is not removed
4. Amount of barium is adjusted
◦Siphoning of excess in retrograde manner
◦ Lowering bag, which enables bulk of enema to be
withdrawn with immediate relief of distention and
cramps and prevention of spillage
5. Filled colon is filmed
◦Reintroduction of the material as indicated by
condition of the patient
6. Double- contrast study is started immediately by
simply inverting the bag
◦ Carbon dioxide or air is introduced into
colon by applying gentle pressure
◦ Amount and rate of flow are controlled by
fluoroscopic observation
◦ Examination is complete. Closed system
has not been broken. Entire examination has been
performed in single stage.
CONTRAST MEDIA
1. BARIUM SULFATE
◦ Colloidal preparations –finely divided barium
particles that resists precipitation
◦ Suspended or flocculation- resistant preparations
–contain some form of suspending or dispersing
agent
◦ High- density barium sulfate –for uniform coating
of lumen especially for double- contrast studies
2. GASEOUS MEDIUM
◦ Air
◦ Carbon dioxide –more rapidly absorbed when
evacuation is incomplete
3. WATER- soluble, iodinated contrast agent –
used orally when retrograde filling of the colon
with barium is not possible or is contraindicated
◦ Transit time: (ingestion to colonic filling) 3 to 4
hours
PROJECTIONS
◦ PA OR AP PROJECTION
◦ Patient position: Prone/ Supine
◦ Part position: Center at the level of iliac crests.
Trendelenburg to help separate redundant and
overlapping loops of the bowel by spilling them out
of the pelvis.
◦ Central ray: Perpendicular
◦ Structure shown: Entire colon
◦ PA AXIAL OR AP AXIAL
◦ Patient position: Prone/ Supine
◦ Part position: Center at the level of the iliac crests
for PA Axial and 2 inches above the iliac crests if AP
Axial
◦ Central ray: 30 to 40 degrees
caudad if PA Axial and 30 to 40 degrees cephalad if
AP Axial
◦ Structure shown: Rectosigmoid area
with less superimposition.
◦PA OBLIQUE PROJECTION (RAO) OR
AP OBLIQUE PROJECTION (LPO)
◦ Patient position: Prone/ Supine
◦ Part position: 35 to 45 degrees
◦Central ray: Perpendicular
◦Structure shown: Right colic flexure, ascending
portion of the colon, sigmoid portion
◦PA OBLIQUE PROJECTION (LAO) OR
AP OBLIQUE PROJECTION (RPO)
Patient position: Prone/ Supine
◦ Part position: 35 to 45 degrees body rotation
◦Central ray: Perpendicular
◦Structure shown: Left colic flexure, descending
portion of the colon
◦ LATERAL PROJECTION (R OR L)
◦ Patient position: Lateral
recumbent
◦ Part position: Center at the ASIS level.
◦Central ray: Perpendicular
◦Structure shown: Rectum, distal sigmoid portion
◦ AP OR PA PROJECTION (RIGHT LATERAL
DECUBITUS POSITION)
◦ Patient position: Place the patient on his
right side with the back or abdomen against the IR
◦ Part position: Center at the level of the iliac
crests.
◦ Central ray: Horizontal and perpendicular
◦ Structure shown: “up” medial side of the
ascending colon and the lateral side of the
descending colon when the colon is inflated with
air
AP OR PA PROJECTION (LEFT LATERAL
DECUBITUS POSITION)
◦ Patient position: Place the patient on his left side
with the back or abdomen against the IR
◦ Part position: Center at the level of the iliac
crests.
◦ Central ray: Horizontal and perpendicular
◦ Structure shown: “up” lateral side of the
ascending colon and the medial side of the
descending colon when
the colon is inflated with air
◦ LATERAL PROJECTION (R OR VENTRAL
DECUBITUS POSITION)
◦ Patient position: Prone with right or left side
against the IR
◦ Part position: Center at the level of the iliac crests
◦ Central ray: Horizontal and perpendicular
◦ Structurer shown: ‘’up” posterior portions of the
colon and is most valuable in double- contrast
examination
◦AP, PA, OBLIQUE, LATERAL – UPRIGHT
◦ Identical to those of in recumbent position
◦ However, the IR is placed at a lower level to
compensate for the drop of the bowel
because of the effect of the gravity.
◦ AXIAL PROJECTION (CHASSARD- LAPINE
METHOD/JACK KNIFE POSITION/
SQUATSHOT)
◦ Patient position: Seat the patient on the
radiographic table.
◦ Part position: Abduct the thighs; Lean directly
forward as far as possible; have the patient grasp
the ankles for support.
◦ Central ray: Perpendicular through the
lumbosacral region at the level of greater
trochanters
◦ Structure shown: Rectum, rectosigmoid junction,
sigmoid in axial projection
MODIFICATIONS
◦BILLING MODIFICATION
◦ Patient/ Part position: Supine
◦Central ray: 35 to 45 degrees cephalad
◦Structure shown: Rectosigmoid junction (to avoid
overlapping of bowel loops)
◦ OPPENHEIMER MODIFICATION
◦ Patient/ Part position: Supine
◦Central ray: 12 degrees caudally to 1 inch
proximal to upper border of pubic symphysis
◦Structure shown: Rectosigmoid junction
◦ FLETCHER MODIFICATION
◦ Patient position: Supine
◦ Part position: Place the patient in Left Anterior
Oblique position
◦Central ray: 30 to 35 degrees cephalad to 2 inches
medial to elevated ASIS
◦Structures shown: best demonstration of
rectosigmoid colon
◦ROBIN MODIFICATION
◦Patient position: Recumbent
◦Part position: Left Lateral
◦Central ray: Perpendicular to 2 inches posterior to
midaxillary plane
◦Structures shown: Demonstrates direct lateral
view of the rectosigmoid colon without
superimposition
DEFECOGRAPHY
◦ This is a relatively new radiologic procedure
performed on patients with deflectional
dysfunction.
◦Also known as “EVACUATION PROCTOGRAPHY
OR DYNAMIC RECTAL EXAMINATION”
CONTRAST MEDIA:
◦ Early investigators mixed a diluted suspension of
barium sulfate, heated it, and added potato starch
to form a smooth barium paste that was semi-solid
and malleable.
◦ Now, 100%weight/ volume barium sulfate pastes
with special injector.
INDICATIONS
◦Rectocele
◦Rectal intussusception
◦ Prolapse of the rectum
EQUIPMENT
1.Fluoroscopic unit
2.Radiolucent commode chair
PROCEDURES
1. Place radiographic table vertical and attach
commode with clamps.
2. Prepare the appropriate contrast media
according to department specifications.
3. Set up imaging equipment (fluoroscopy or digital
recorder), or use digital fluoroscopy.
4. Ask patient to remove all clothing and change
into a hospital gown.
5. Take a scout image using a conventional x-ray
tube.
(Scout image must include the region of the
anorectal angle.)
6. Place patient in a lateral recumbent position on a
cart and instill contrast media.
7. Position patient on the commode and take
radiographs in the rest and strain phases, with
patient in a lateral position.
8. Using fluoroscopy imaging devices or digital
recorder, image patient during defecation.
9.Assist in taking of post evacuation radiograph.
FISTULOGRAM
◦ This procedure is performed to locate and
demonstrate the extent of a sinus or fistulous tract
and its connection to any cavity or hollow viscera.
This can be done by an injection of contrast media
through an orifice on the abdominal wall or
through a drainage tube already placed into the
orifice.
◦Also known as “SINOGRAM”
CONTRAST MEDIA
◦Water- soluble; if there’s any suggestion that
there is a connection with the pleural cavity, an oil-
based contrast medium such as Dionosil issued.
EQUIPMENT
◦ Fluoroscopic unit with a spot film device/ 105 mm
cine
◦ Fine catheter
◦ 20-ml syringe
◦Blunt needle
◦ Gauze padding (4x4)
PROCEDURE
◦AP projection (scout)
◦ The patient is placed on the table so that the
orifice of the sinus is easily accessible to the
radiologist.
◦ The technologist removes the dressing and fills
syringe with contrast medium.
◦A blunt needle is attached to the end of the
syringe.
◦ The filled syringe is attached to the catheter,
which is then inserted into the opening of sinus.
◦ Under fluoroscopic control, an AP projection is
taken immediately before injection.
◦ A pad of gauze is placed over the orifice of the
patent is asked to firmly place a gloved finger on
the gauze. This should prevent a reflux of contrast
medium back onto the skin.
◦ The contrast medium is injected under
fluoroscopic guidance, the amount depending on
the size of the sinus or fistula.
◦Radiographs are taken as required, usually AP,
both obliques, and lateral views.
◦At the completion, the catheter is removed, and a
fresh sterile dressing is placed over the opening.
MALE AND FEMALE RADIOGRAPHIC
PROCEDURES
FEMALE RADIOGRAPHY (NON-PREGNANT
PATIENT
– Radiologic investigation of the non-
pregnant uterus, accessory organs, and
vagina
are denoted by the terms
hysterosalpingography, pelvic
pneumography, and
vaginography.
ANATOMY AND PHYSIOLOGY
FEMALE REPRODUCTIVE SYSTEM
The female reproductive system consists of
an internal and an external group of
organs, with the two groups connected by
the vaginal canal.
OVARIES - The two ovaries are small,
glandular organs with an internal secretion
that
controls the menstrual cycle and an
external secretion containing the ova, or
female
reproductive cells.
UTERINE TUBES - These tubes collect ova
released by the ovaries and convey the cells
to the uterine cavity.
UTERUS - Its primary functions are to
receive and retain the fertilized ovum until
development of the fetus is complete and,
when the fetus is mature, to expel it during
birth.
VAGINA - The vagina is a muscular structure
with walls and a canal lying posterior to
the urinary bladder and urethra and
anterior to the rectum
PREPARATION
– A non- gas forming laxatives is
administered on the preceding evening if
the
patient is constipated.
– Before reporting for the examination, the
patient receives cleansing enemas until
the return flow is clear.
– The meal preceding the examination is
withheld.
– The patient is requested to completely
empty her bladder immediately before the
examination.
– This prevents pressure displacement of
any superimposition of the bladder on the
pelvic genitalia.
– Gynecologic examinations should be
scheduled approximately 10 days after the
onset of menstruation. This is the interval
during which the endometrium is least
congested. Most importantly, this time
interval is a few days before ovulation
normally occurs, there is little danger of
irradiating a recently fertilized ovum.
CONTRAST MEDIA
– Water soluble iodinated contrast media
HYSTEROSALPHIGOGRAPHY
– This is the radiographic examination of
the uterus and oviducts or fallopian tubes
after the introduction of contrast media. In
general, performed as part of an
infertility study and is superior in the
evaluation of tubal patency.
– The examination is performed by a
physician with the use of fluoroscopy or
conventional overhead tube.
• CM: liopodol, skiodan, kayopaque, salpix
• AP, PA, OBLIQUE & LATERAL
INDICATIONS:
– To determine the size, shape, and position
of the uterus and oviducts.
– To delineate lesions such as polyps,
submucous tumor masses, and fistula
tracts.
– To investigate the patency of oviducts in
case of sterility.
– To determine the reason of repeated
abortion.
– Infertility assessment
- Evaluation of the uterine tube after tubal
ligation or reconstructive surgery.
CONTRAINDICATIONS: – Oblique, Axial, Lateral, and Angled 4. Cleansing enema 1 hr. before the
Projection (these are taken some procedure.
– Chronic infection/ Pelvic infection or abnormality
untreated sexually transmitted diseases is not clearly seen in AP) PROCEDURE:
– Pregnancy
– Menstruation AFTER CARE: 1. Examination scheduled on 7th or 8th day
– Severe renal or cardiac disease after the menstrual cycle.
– Sensitivity to contrast media 1. Ensure that patient has no significant 2. Empty the bladder before the procedure.
– Recent dilation or curettage bleeding or discomfort before she leaves.
– Vaginal bleeding of unknown cause 2. Inform the patient that bleeding may PROJECTIONS:
occur 1-2 days with persisting pain in 2
EQUIPMENT: weeks’ – Scout film – prone position with table
time. angled to Trendelenburg
– Speculum position (45 degrees); the IR centered 2
– Tenaculum PELVIC PNEUMOGRAPHY inches above the pubic
– Cannula symphysis and the central ray directed
– catheter Radiographic examination of female perpendicular to the region
– Syringe reproductive organ after administration of coccyx or with an angulation of 15
of negative contrast media, degrees caudad.
PROCEDURE: – Also known as gynecography and
pangynecography which denotes – Supine position – table should be angled
– After irrigation of the vaginal canal, radiographic examination of the female with the head (end of the table
complete emptying of the bladder, and pelvic organs by means of lower about 20 to 25 degrees)
perineal cleansing, place the patient on the intraperitoneal gas insufflation. – Prone position – with the table angled to
examining table. – This is used in conjunction with HSG in the full Trendelenburg position (45
– Adjust the patient in lithotomy position investigation of gynecologic degrees); the IR centered 2 inches above
with knees flexed over leg rests. abnormalities the pubic symphysis and the central
– Center IR 2 inches proximal to the pubic ray perpendicular to the region of coccyx or
symphysis. CM USED: Negative contrast media (Nitrous with an angulation of 15
oxide and carbon dioxide.) degrees caudad.
PROJECTIONS:
PREPARATION: RECOMMENDATION:– Schulz and Rosen –
– Scout film recommend 15 degrees
– AP projection 1. Light evening meal angulation for view of the pelvic inlet
– AP projection (centered 2 inches above 2. Give patient laxative tablet
pubic symphysis) 3. NPO at midnight
PA Projection POINT The patient is then instructed to extend the
(Scout Film) 15 degrees caudal or ┴ to thighs and to hold them in close
2 inches above pubic approximation to keep the inflated balloon
BODY/PART POSITION symphysis or level of pressed firmly against the vaginal
Prone, MSP is centered to coccyx entrance.
the IR
Table in 45 deg. STRUCTURE SHOWN – In another technique, the tube is inserted
Trendelenburg position AND EVALUATION far enough to place the deflated balloon
CRITERIA within the distal end of the vagina, and the
CENTRAL SS: The anatomy of balloon is then inflated under fluoroscopic
RAY/REFERENCE interest with delineation of observation.
POINT negative CM
15 degrees caudal or ┴ to – The barium mixture is introduced with the
2 inches above pubic VAGINOGRAPHY usual enema equipment. The water-
symphysis or level of soluble medium is injected with a syringe.
coccyx – Radiographic examination of the wall of
the vagina. – For localized studies, the central ray is
STRUCTURE SHOWN – Used for the investigation of congenital directed at the level of the superior border
AND EVALUATION malformations and pathologic conditions of the pubic symphysis
CRITERIA such as vesicovaginal and enterovaginal
SS: The anatomy of fistulas. PROJECTION:
interest without – This examination is performed by
delineation of CM introducing contrast media into the vaginal – Scout film – Supine (AP Projection)
canal. – Lateral – low rectovaginal fistulas
AP/ PA Projection – Oblique – fistulous communication with
BODY/PART POSITION PROCEDURES: the sigmoid and/ or ileum
Supine/Prone, MSP is RECOMMENDATION:
centered to the IR – A rectal retention tube is employed for – Lambie, Rubin, and Dann – recommended
Supine – 20-25 deg. the introduction of the contrast agent so the use of thin barium sulfate mixture
Trendelenburg. that for the investigation of fistulous
Prone – 45 deg. the moderately inflated balloon can be used communications with the intestine. At the
Trendelenburg. to prevent reflux. end of the
– In one technique, the physician inserts examination, the patient is instructed to
CENTRAL only the tip of the tube in the vaginal expel as much of the barium mixture as
RAY/REFERENCE orifice. possible, and the canal is then cleansed by
vaginal irrigation.
– Coe – for the investigation of other The patient is requested to completely
conditions, he advocated the use of empty the bladder immediately before the
iodinated examination.
organic compounds. (Over filled bladder prevents the fetus
from descending to the most dependent
FETOGRAPHY portion of the uterine cavity).
The demonstration of the fetus in utero. RADIOGRAPHIC PELVIMETRY AND FETAL
• Avoided until after the eighteenth week of CEPHALOMETRY
gestation because of the danger of
radiation induced fetal malformations. are performed to demonstrate the
• Detect suspected abnormalities of architecture of the maternal pelvis and to
development, compare the size of the fetal head with the
• Confirm suspected fetal death, to size of the maternal bony pelvic outlet.
determine the presentation and position of The purpose of the procedure is to
the determine
fetus, whether the pelvic diameters are adequate
• Determine whether the pregnancy is for normal parturition or whether cesarean
single or multiple. section is necessary for the delivery.
FETOGRAPHY PLACENTOGRAPHY
-Radiographic examination in which the
POSITION: walls of the uterus are investigated to
PA or AP Projection locate the placenta in cases of suspected
Adjust the patient in prone position placenta previa.
whenever possible to
place the fetus closer to the film. METHOD OF PELVIMETRY
Lateral Position
Oblique Position Colcherr-sussman
For the demonstration of developmental • Supine (AP) and lateral employed in this
abnormalities method of pelvimetry require the use of the
(sometimes required). Colcher-Sussman pelvimeter.
• This device consists of a metal ruler
FETOGRAPHY perforated at centimeter intervals and
mounted on a
Preparation: small stand.
• Center the horizontal ruler to the gluteal
fold at the level of the ischial tuberosities
(10 cm
below superior border of symphysis pubis).
Thoms Method
Metal centimeter ruler (Lateral)
Torpin Thoms Apparatus (Inlet Position)
Ball Method - no apparatus needed
MALE RADIOGRAPHY
The regional terms applied to these
examinations are:
Vesiculography – radiographic examination
of the seminal ducts or vesicle after
the introduction of contrast media
Epididymography – radiographic
examination of the epididymis after the
introduction of contrast media
Epididymovesiculography – combination of
the examinations mentioned above
ANATOMY AND PHYSIOLOGY
INTERNAL GENITAL ORGANS
❑Ovaries
❑Uterine Tubes
❑Uterus
❑Vagina
VESICULOGRAPHY
INDICATIONS:
- Cyst
- Abscesses
- Tumors
- Inflammations
- sterility
CONTRAINDICATIONS:
- Infection of the ducts and vesicle
- Sensitivity to CM
CONTRAST MEDIA
water- soluble, iodinated compounds and
gaseous contrast agent (injected
into each scrotal sac to improve contrast in
the examination of extrapelvic
structures)
PROJECTION:
AP – centered at the level of the superior
border of the pubic symphysis
Oblique – no superimposition of the
seminal ducts by the iliac; no overlap of the
region of the prostate or urethra by the
uppermost thigh
RECOMMENDATION:
Mazurek – Recommended the use of
ChassardLapine projection
Boreau – Recommended the use of Perineo-
sacral view which the reversed
Chassard- Lapine projection to adapt it to
the anesthetized patient. Patient’s thighs
are flexed on the abdomen. The central ray
is directed to the peritoneum at angle
20 degrees cephalad.
PROSTATOGRAPHY above the pubic symphysis and the central
ray directed to the region of anus at an
Radiologic examination of the prostate angle 20
gland after the introduction of the contrast to 25 degrees caudad.
media.
This is the investigation of the prostate by Recommendations Sigiura and Hasegawa –
radiographic, cystographic, or reported contrast prostatography
vesiculographic procedures. wherein the water- soluble contrast
medium is injected directly into the
Indications: prostate gland by way
To check for cancerous deposits. of the rectal wall. Projections:
To presence for the presence of calculi Angled Projections
To check for carcinoma of the prostate Angled AP – central ray directed 5 degrees
gland. caudad
Angled PA – central ray directed 20 to 25
Contrast medium: Water- soluble iodinated degrees cephalad
compounds used in urography RPO and LPO – to place the prostate gland
in contact with the IR.
Preparations:
Evacuation of the lower bowel with
cleansing enemas.
Emptying of bladder immediately before
the examinations.
Examination is usually done in OR with
patient under general anesthesia.
PROJECTIONS
Supine Position (angled AP) – IR centered 1
inch above the pubic symphysis and central
ray 15 degrees caudally
Prone Position (angled PA) – most perfectly
used because it places the prostate closer
to
the IR and the sacrococcygeal vertebrae
further from the IR. Centered approximately
2 inches
SMALL INTESTINAL SERIESAND (descending), third (horizontal or

BARIUM FOLLOW-THROUGH inferior), and fourth (ascending)

SMALL INTESTINAL SERIES portions.

JEJUNUMAND ILEUM

◾ This the radiographic examination of the small
bowel.
◾ Also known as “SMALL BOWEL SERIES (SBS)”
◾ The upper GI and the SBS are often combined
thus, this are termed as small bowel follow-
through.
◾ CONTRAST MEDIA: Radiopaque contrast media
(BaSO4 or Iodinated)
ANATOMY AND PHYSIOLOGY
◾Small intestine - Digestion and absorption of food
occur in this portion of the alimentary canal. The
length of the adult small intestine averages about
22 feet (6.5 m), and its diameter gradually
diminishes from approximately I 1⁄2 inches (3.8
cm) in the proximal part to approximately I inch
(2.5 cm) in the distal part.
◾Contrast Media: Thin mixture of BaSO4
◾The small intestine is divided into
three portions:
Duodenum
Jejunum
Ileum
◾ The remainder of the small
intestine is arbitrarily divided
into two portions, with the
upper two fifths referred to as
the jejunum and the lower three
fifths as the ileum.
SMALL INTESTINAL SERIES
◾The purpose of this is to study the form and
function of the three components of the small
bowel, as well as detect any abnormal conditions.
Since this study also examines function of the small
bowel, the procedure must be timed. The time
should be noted when the patient finished drinking
the last of the contrast media.
INDICATIONS
◾ Regional Enteritis
◾ Neoplasm
◾ Malabsorption syndrome
◾ Ileus*
◾ Fistula
◾ Meckel’s diverticulum

◾ Sprue

◾ Malabsorption
DUODENUM
CONTRAINDICATIONS
◾ 8 to 10 inches (20 to 24 cm) in
◾ Perforated, hollow viscus
length and is the widest portion of the
◾ Large bowel obstruction
small intestine. Its four regions are
◾ Presurgical patients
described as the first (superior), second
PATIENT PREPARATIONS ◾ 30 minutes after the initial barium ingestion –
take PA projection of the proximal SB
◾ Soft or low- reside diet for two days before the
examination ◾ For first two hours, radiographs are obtained at
15 – 30 minutes interval
◾ NPO after evening meal and the morning before
the examination ◾ One-hour interval radiographs, if more time is
needed after 2 hours
◾ Cleansing enema may be administered but not
always recommended for ◾ Termination: Ileocecal valve

enteroclysis (enema fluid may be retained in the ◾ Plain abdomen radiograph (scout)
small intestine)
◾ 2 cups (16 oz.) of barium ingested – note time
◾ Patient’s bladder should be empty before and
during the procedure to ◾ 15-to-30-minute radiograph – centered high for
prox. SB
avoid displacing or compressing the ileum.
◾ Half-hour interval radiographs until barium
RATIONALE: to avoid displacing and compressing reaches large bowel (2 hrs.)
ileum.
◾ One-hour interval radiographs, if more time is
PRELIMANARY PROCEDURE needed
PLAIN ABDOMEN (KUB X-RAY) PROJECTIONS
◾Performed by: PROJECTION
UG-SB combination(mouth) AP or PA
Complete reflux filling (large volume BE) POSITION
Enteroclysis/small bowel enema
Supine
- Direct Injection into bowel through an intestinal
Prone
tube.
Trendelenburg Perpendicular
- Difficult to performed
CENTRAL RAY
Intubation Method
Perpendicular

BE & Enteroclysis: used when oral method fails to REFERENCE POINT

provide conclusive information. Center at the level of L2 for radiographs taken
UGI – SMALL BOWEL COMBINATION/ within 30 minutes after contrast media
BARIUM FOLLOW- THROUGH administration. For delayed radiographs, center at
the level if iliac
◾ Routine UGI first

◾ First cup of contrast media (8 oz.)

◾ Second cup
PURPOSE OF SUPINE: INTUBATION METHOD

-To take advantage of the superior and lateral shift
of the barium filled stomach
* for visualization of retro gastric portions of the
duodenum and jejenum.
◾ Nasogastric tube is inserted
-A long, specifically designed tube is inserted
through the nose and passed into the stomach.
(Peristaltic action carries the tube inferiorly).

- To prevent possible compression overlapping Example: Miller-Abbot double lumen, single

loops of the intestine. balloon tube

PURPOSE OF PRONE: ◾ Contrast media is instilled – note time

- To compress the abdominal contents ◾ 15 to 30 minutes radiograph

* Increase radiographic quality ◾ Filming sequence after 2 hours

-To separate the various loops bowel ◾ FOR DIAGNOSTIC AND THERAPEUTIC PURPOSES\
* Creates higher degree of visibility INTUBATION METHOD
PROJECTION – STRUCTURE SHOWN ◾ Single- lumen tube
◾ Small intestine progressively filling until the Site: proximal jejenum
barium reaches the ileocecal valve. Terminated at
cecum. Patient position: RAO
* Aids in passage of tube
ENTEROCLYSIS
Miller-Abott(M-A) tube
◾ Intubation into the duodenum
- A double lumen tube
◾ Barium sulfate suspension is instilled
- For therapeutic intubation
◾ Air or methylcellulose is instilled
INTUBATION METHOD
◾ Fluoroscopic spot films and conventional
radiographs are taken.
◾ Therapeutic Intubation
◾ Upon completion, intubation is removed.
Purposes:
Bilbao or Sell ink tube is used to administer the
contrast agent. 1. to relieve postoperative distention
The mentioned tubes are advanced to the end of 2. to decompress a small bowel obstruction
the duodenum at the duodenojejunal flexure, near
the ligament of Treitz.
Contrast medium/a: Rate of 100ml/ minute
COMPLETE REFLUX EXAMINATION
◾ The patient’s colon and small intestine are filled
by administering a barium enema

◾ Before the examination, glucagon (to relax the

intestine) and Diazepam/Valium
may be administered to the patient.
Contrast medium/a:15% ± 5% weight/ volume
barium suspension;4500 ml
for filling the colon and small intestine

◾ Retention enema tip is used, and the patient is in

supine position.

◾ Barium suspension is allowed to flow until the

duodenal bulb.

◾ The enema bag is then lowered to the floor to

drain the colon before the
small intestine be radiographed.

SMALL BOWEL SERIES

PROCEDURE(BALLINGER)
• First radiograph: 15 minutes
* After the patient drinks the barium
• Second Radiograph: 15-30 minutes
EXAMINATION: completed
* Depends on transit time of barium in 30-60
minutes
• Glass of ice water/ food stimulant:
* For patient with hypomotility
* Given after 3-4 hours of administering barium
PURPOSE: to accelerate peristalsis

• alternative methods of stimulate peristalsis:

* water soluble CM, tea or coffee
* peristaltic stimulants every 15 mins
The Digestive System 8. Defecation. Wastes, indigestible
substances, bacteria, cells sloughed from the
FUNCTION OF THE DIGESTIVE SYSTEM lining of the GI tract, & digested materials
that were not absorbed leave the body
1. Ingestion. process involves taking foods through the anus.
and liquids into the mouth.
TWO MAIN GROUPS
2. Secretion. Each day, cells within the walls
of the gi tract & accessory digestive organs Alimentary canal
secrete a total of
about 7 liters of water, acid, buffers, and Continuous coiled hollow
enzymes into the lumen of the tract. tube extends from the
mouth to the anus
3. Mixing & propulsion. Alternating through the ventral body
contraction and relaxation of smooth cavity.
muscles in the walls of the GI tract mix food & - 30 feet (9m) length
secretions & propel them towards the anus. Accessory organs

FUNCTION OF THE DIGESTIVE SYSTEM ORGANS OF THE GI TRACT

4. Motility – capability of the GI tract to mix A. MOUTH

and move material along its length. B. PHARYNX
C. ESOPHAGUS
5. Digestion- the mechanical and chemical D. STOMACH
breakdown of food to simple molecules that E. SMALL INTESTINE
can be absorbed and used by body cells F. LARGE INTESTINE

6. Enzymes - chemical substance that ACCESSORY DIGESTIVE ORGANS

usually speeds up a chemical reaction
A. TEETH
B. TONGUE
FUNCTION OF THE DIGESTIVE SYSTEM C. SALIVARY GLANDS
D. LIVER
7. Absorption. is the passage of digested E. GALLBLADDER
end products (plus vitamins, minerals, and G. PANCREAS
water) from the lumen of the GI tract through
the mucosal cells
by active or passive transport into the blood
or lymph.
LAYERS OF THE GI TRACT MESOCOLON
Binds the large intestine
MUCOSA to the posterior
inner lining abdominal wall.

SUBMUCOSA OMENTUM
with blood vessels, nerve Extends between two
endings, and lymphatics organs.

MUSCULARIS GI TRACT
muscle area
MOUTH
SEROSA Is formed by the lips, cheeks, hard and soft
is the superficial layer palates, and
tongue.
PERITONEUM
DIVISIONS: VESTIBULE
Is a space bounded externally by the
PARIETAL cheeks & lips and
PERITONEUM internally by the gums and teeth.

VISCERAL FAUCES
PERITONEUM Opening between the oral cavity and the
pharynx
LESSER OMENTUM
Connects the lesser UVULA
curvature of the stomach Hanging from the free border of the soft
to liver and diaphragm palate.

GREATER OMENTUM FRENULUM

Largest peritoneal fold
Drapes over the
transverse colon and
greater curvature of
stomach
A small fold of mucous membrane that
connects two parts
and limits movement.

MESENTERY
Is fan shaped and binds the
small intestine to the
posterior abdominal wall.
MOUTH: FUNCTION GI TRACT

Mastication (chewing) of STOMACH

food
Mixing masticated food Is a typically j-shaped enlargement
with saliva of the GI tract directly inferior to the
Initiation of swallowing diaphragm
by the tongue It can hold about 4 liters ( 1 gallon) of food.
Allowing for the sense of
taste STOMACH: FUNCTION

GI TRACT Food reservoir

Site of food breakdown
PHARYNX / THROAT Chemical breakdown of protein begins
A funnel shaped tube that (pepsin) by chief cell
extends from the internal Secretes hydrochloric acid by parietal cell
nares to the esophagus Delivers chyme to the small intestine
posteriorly and to the larynx
anteriorly. STOMACH: REGIONS
5 inches long
CARDIA
PARTS OF THE PHARYNX: Near the heart
Cardiac sphincter
ORAL PHARYNX FUNDUS
LARYNGEAL PHARYNX Most superior part of stomach.
NASAL PHARYNX BODY
Central portion of the stomach
GI TRACT Largest part of stomach
PYLORUS
ESOPHAGUS funnel-shaped terminal end
Is a collapsible muscular tube that lies Pyloric sphincter
posterior to the trachea.
Is about 10 inches long. GI TRACT
Transport food in the stomach
Secretes mucus. SMALL INTESTINE
The major events of digestion and
absorption
About 23 feet in length.
SMALL INTESTINE: REGIONS INTESTINAL GLANDS
Lie in the mucosa in the intervals between
DUODENUM the bases of the villi.
Shortest region ( 10 inch.) They are tubular glands and secrete
Site of chemical digestion in the intestinal juice containing digestive enzymes.
small intestine
Bile enters from the gall bladder GI TRACT
Pancreatic enzymes are delivered
JEJUNUM- means “empty” LARGE INTESTINE
Rationale: found empty at death. Is the final division of the digestive tube
2.5m Is about 5 feet (1.5m) long, 2.5 inches in
ILEUM- largest portion. diameter, extends from the ileum to the anus
3.5m
LARGE INTESTINE: FUNCTION
SMALL INTESTINE: FEATURES
No digestion
CIRCULAR FOLD Absorption of water
folds in the lining membrane of the small The production of certain vitamins
intestine that The formation of feces
encircles its lumen. Expulsion of feces from the body

VILLI LARGE INTESTINE: PARTS

fingerlike projections of the mucosal lining of
the small intestine that covers the circular CECUM
folds and the hollows among them. Pouch-like structure
Increase the absorptive surface. First part of the LI

SMALL INTESTINE: FEATURES APPENDIX

appendage of the cecum
AGGREGATED LYMPH FOLLICLES hollow pencil like structure that is attached
A collection of lymphatic tissue. (Peyer’s to the blind end of the cecum.
patches). The remaining food residue in the 2 to 6 inches in length
intestine contains huge numbers of bacteria,
which must be prevented from entering the
bloodstream.

Lacteals
lymphatic capillaries that absorbs milky
fatty lymph (CHYLE)
LARGE INTESTINE: PARTS SEMILUNAR FOLDS
are the folds visible on the inner surface of
ASCENDING PORTION the large intestine that pass
- RETROPERITONEAL POSITION part way around the intestine between
TRANVERSE PORTION- LONGEST PART OF THE haustra.
LI AND MOST MOVABLE
- INTRA PERITONEAL POSITION (WITHIN THE ACCESSORY ORGANS
PERITONEAL CAVITY)
• DESCENDING COLON Teeth
-RETROPERITONEAL Are accessory digestive organs located in
• SIGMOID COLON- INTRAPERITONEAL POSITION. sockets
- ENDS AT RECTUM(S3) of the alveolar process of the mandible and
maxillae.
LARGE INTESTINE: PARTS
TEETH: REGIONS
SIGMOID COLON
Is the “s” shaped curved part of the distal CROWN
colon is the visible portion above the level of the
gums
RECTUM NECK
Strong contraction to expel feces. Anterior to is the constricted junction of the crown
the sacrum and coccyx and root near the gum line
ANUS- anal canal ends, has two valves ROOT
- the internal anal sphincter
- the external anal sphincter. THE TOUNGE
- is an accessory digestive organ
LARGE INTESTINE: FEATURES composed of skeletal muscle covered with
mucous membrane. Together with its
TENIAE COLI associated muscles, it forms the floor of the
these are three bands of muscle fibers that oral cavity.
pass lengthwise along the
length of the large intestine. SALIVARY GLANDS
Replace the layer of longitudinal muscle Is any cell or organ that releases a secretion
found in other parts of this called saliva into the oral cavity.
tract, cause the puckering of the colon.

HAUSTRA
these are sac like pouches in the wall of the
large intestine resulting
from the puckering due to the teniae coli.
SALIVARY GLANDS GALLBLADDER

PAROTID GLAND GALLBLADDER

located inferior & anterior
to the ears
SUBMANDIBULAR GLAND
lies under the floor of the
mouth
pear shaped sac
Stores bile
FUNDUS- BROAD PORTION, INFERIORLY
BODY- CENTRAL PORTION, SUPERIORLY
NECK- TAPERED END, SUPERIORLY

SUBLINGUAL GLAND
lies in the floor of the
mouth. Superior to the
submandibular gland.
LIVER
PANCREAS
Approx. 12 – 15 cm (5-6 inches) long,
Produces digestive enzymes that drains to
duodenum by ducts

heaviest, largest gland of the body Parts:

second largest organ of the body. Head
Principal parts of the liver: Body
Tail
A large right lobe
A smaller left lobe
quadrate & caudate lobe

LIVER

Produces BILE

Function of Bile:

Emulsification
of fats
UPPER GASTRO INTESTINAL SERIES
(BARIUM MEAL)
Definition and purpose:
Radiographic examination
(ana/physio) of the:
1) distal esophagus,
2) stomach, and
3) duodenum.
ANATOMY OF THE STOMACH
G. gaster means
stomach/gastro
Located between
esophagus and small intestine
Most dilated portion of alimentary
track.
Serves as food reservoir
STOMACH SUBDIVISION:
1. FUNDUS-upper portion
of the stomach. Gas in
this portion is called
“gas bubble” or
“magemblase”
2. BODY- largest portion of
the stomach, between
fundus and pylorus
3. PYLORUS- small terminal
portion of the stomach
right or medial to
angular notch.
STOMACH CURVATURE
Lesser curvature- medial (concave)
border of the stomach extends
between cardiac and pyloric orifice
Greater curvature -lateral (convex)
border of the stomach. 4-5 times
longer than lesser
curvature. It extends between the
cardiac notch to pylorus.
Esophagastric junction- aperture
between esophagus and stomach
Cardiac sphincter- small circular
muscle between esophagus and
stomach that allows bolus to pass
through cardiac orifice
Pyloric sphincter- circular muscle
between stomach and duodenum
that controls the chyme to pass
through the duodenum.
Cardiac orifice – opening between
esophagus and stomach
Pyloric orifice- opening between
stomach and duodenum
Cardiac notch /incisura cardiac-
notch superior to cardiac orifice
Angular notch/incisura angularis-
notch or constricted ring- like area
which separate body to pylorus.
 Cardiac antrum- dilated distal
portion of the esophagus
Pyloric antrum- dilated portion of the
pylorus immediately distal to angular
notch
Air/Gas – barium distribution in
stomach
Supine: barium filled fundus
and air-filled body and pylorus
Prone: barium filled body and pylorus
and air-filled fundus
Erect: barium filled body and
pylorus and air-filled fundus
BARIUM DESCENDS BY GRAVITY
1 hr. delayed film purpose: determine
gastric emptying know how much
barium was left determine presence
of ascaris
6hrs. delayed film purpose: in cases
of suspected pyloric stenosis to assess
gastric emptying rate
24 hrs. delayed film purpose: if under
suspicious in the small intestine,
appendix, or colon.
ANATOMY OF THE DUODENUM
First portion of the small
intestine
Shortest, widest and most
fixed portion of the small
bowel.
C shaped “c-loop”
Relationship with the head
of the pancreas “romance of the
abdomen”
CONSIST OF 4 PARTS
1st (superior) portion
The only intraperitoneal portion of
the duodenum
Duodenal bulb/cap-First part of the
superior portion
2nd (descending) portion
Longest segment of duodenum
Contains duodenal papilla-opening
for the common bile duct and
pancreatic duct
3rd (horizontal) portion
A.k.a inferior portion
4th (ascending) portion
Final segment of the duodenum
connected to the second portion of
the small bowel which is the
jejunum
Duodenojejunal flexure-
connection between duodenum and
jejunum.
Ligaments of treitz (suspensory
muscle of the duodenum)- fibrous
muscular band which suspend in
place the Duodenojejunal flexure
BODY HABITUS
1. HYPERSTHENIC
Stomach is very high and in
transverse position
Stomach level - T9-T12 at midline
Duodenal bulb - T11-T12 right of
the midline
2. HYPOSTHENIC AND ASTHENIC
J-shaped stomach
Stomach level- T11-L5 to
the left of midline
Duodenal bulb level- L3-
L4 ,near the midline
3. STHENIC
Stomach level- T10-T11/L2
Duodenal bulb level - L1-L2
MOVEMENT OF STOMACH IN DIFF.
POSITIONS
Upright
• Stomach moves downward
3-6 inches.
Supine
• Stomach moves superiorly towards
the diaphragm
Prone
• Stomach moves slightly downward.
Right lateral recumbent
• Stomach moves forward.
• Body of the stomach to the
abdominal wall, Pylorus closer to
lumbar spine.
Left lateral recumbent
• Stomach moves backward.
• Body of the stomach swing closer to
the lumbar spine, Pylorus
closer to abdominal wall.
Stomach habitus
Eutonic/normotonic Habitus -
incisura angularis and
pylorus is about in the same level
Steer Horn Habitus- incisura
angularis is lower than
the pylorus by 1 cm.
Hypotonic Habitus- incisura
angularis is higher than
the pylorus by 1 cm.
VARIATIONS OF STOMACH
Cascade- fundus lower than the
cardiac notch.
Infantile - normal stomach but
pylorus is hidden at
back of antrum
Upper gastro Intestinal Series (UGIS)
Indications:
1. Gastric Carcinoma
UGI S is the gold standard for
detection of gastric
carcinoma.
 Radiographic appearance: irregular
filling defect
2. Diverticula
Pouchlike herniations of the mucosal
wall.
Radiographic appearance:
Outpouching of the
mucosal wall.
3)Bezoar (trichobezoar and
phytobezoar)
Trapped undigested food in the
stomach
Radiographic appearance: mass
filling defect
4)Gastritis
Inflammation of gastric mucosal wall
Radiographic appearance: absence
of rugae, thin gastric wall, speckled
appearance.
5) Ulcers
Erosion of the stomach or duodenal
mucosa
Radiographic appearance:
punctured collection of
barium and “halo” sign
6.) Hiatal Hernia
Condition in which portion of the
stomach herniates through
diaphragmatic opening.
Radiographic appearance:
protruding portion of the
stomach above diaphragm
7.) Hypertrophic Pyloric
Stenosis (HPS)
Gastric obstruction common
in infants. Caused by
hypertrophy of the antral
muscle of the orifice of the
pylorus.
Radiographic appearance:
Distended stomach, possible
“String sign”
8.) Emesis- act of vomiting
hematemesis – vomiting blood
Upper gastro Intestinal Series (UGIS)
Contraindication
1.) Perforation, Laceration, or viscous
rapture (BaSO4)
(water-soluble, iodinated CM e.g MD
Gastroview is use
instead of BaSO4)
2.) Hypersensitivity and dehydrated
(Iodinated)
Contrast Media for UGIS
1.BaSO4
Prepare a 2:1 (60 to 66%) or 3:1 (70 to
80%) barium mixture. Prepare only
enough amounts needed in the
examination, about 1/3 of a glass.
Mixed it thoroughly.
If necessary, prepare CM the night
prior to the examination and
refrigerate it so as to minimize its
unpalatable taste.
2. Negative CM
DIFFERENT WAYS OF PRODUCING
NEGATIVE CM (E.G. AIR) ON THE
STOMACH
Patient sip the barium mixture with
the use of two straws, one outside
the glass and the other inside.
Patient to breathe to his mouth or
swallow air after ingestion of the
barium mixture.
Carbonated drink
Patient take effervescent tablet(gas
producing) e.g. calcium and
magnesium citrate.
3.Water –soluble, Iodinated CM if
barium is contraindicated
PREPARATION OF PATIENT
Soft diet or low- residue diet for two
(2) days
Prevent gas formation as a result of
excessive fermentation
of intestinal contents
NPO after midnight or dinner
8-9 hrs. prior to examination
No smoking/chew gum after
midnight
Nicotine stimulates gastric secretion
& salivation
RATIONALE:
-PREVENT EXCESSIVE FLUID FROM
ACCUMULATINGTHE STOMACH.
-PREVENT DILUTING THE BARIUM
SUSPENSION.
TWO METHOD OF ADMINISTERING THE
CONTRAST MEDIUM
Double contrast – demonstrate the
mucosal pattern.
Single contrast- uses:
Children- since it usually is not
necessary to demonstrate mucosal
pattern.
Very ill adults to demonstrate gross
pathology only.
Two Method of Study Employed in UGIS
a. Overhead or Conventional Method
Most frequently employed, because
it is less hazardous both to the patient
as well as the Radiographer.
b. Fluoroscopy and
Overhead Technique
This is more hazardous. However, the
length of time of the examination is
considerably reduced.
This is also employed when taking
spot filming or serial radiography for
accuracy.
GENERAL GI EXAMINATION PROCEDURE
1. single contrast examination
barium sulfate 50 % 60% w/v
2. double contrast examination
Gold standard for the detection of
gastric carcinoma
small lesion & mucosal lining are
clearly visualized
barium sulfate between 40 & 120%
up to 250%
Antispasmodic medications
glucagon or other anticholinergic (IV
or IM) are used to (relax the GIT) allow
greater distention of stomach &
bowel for improved visualization.
GENERAL GI EXAMINATION PROCEDURE
3. Biphasic GI examination
combo. single + double contrast
both examinations performed on
same day
double contrast is performed first
on completion, patient is given
approx. 15% w/v barium sulfate and a
single contrast examination is
performed.
GENERAL GI EXAMINATION PROCEDURE
4. Hypotonic Duodenography
diagnostic tool for evaluation of
postbulbar duodenal
lesions & detection of pancreatic
disease.
-Less frequently performed.
requires duodenal intubation &
temporary drug-
induced paralysis so that a double-
contrast examination can be
performed
Double contrast
DESCRIBED BY LIOTTA- suggested
introduction of CM through intubation
passing through the nose and
mouth.
HYPOTONIC DUODENOGRAPHY
-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.
Upper gastro Intestinal Series (UGIS)
Basic/Routine
1. RAO (recumbent)
2. PA (recumbent)
3. Right lateral (recumbent)
4. LPO (recumbent)
5. AP (recumbent)
1. RAO (recumbent)
Part Position (PP): 40-70 deg anterior
oblique (more rotation in
hypersthenic px.)
Central ray (CR): sthenic:
perpendicular to level of L1 (1-2”
above lower lateral margin) midway
between spine andupside lateral
border of abdomen. 45-55 deg
oblique
Asthenic: 2” below level of L1 and near
midline. 40 deg
oblique
Hyperstenic: 2” above level of L1. 70
deg oblique
Stucture shown (SS): entire stomach
and c-loop of
duodenum.
RAO- gives the best image of pyloric
canal and duodenum
Hypersthenic- required greater
degree.
Sthenic- 45- 55 degree
Asthenic – 40 degrees less degree of
body rotation.
NOTE: Best position to demonstrate
pyloric canal and
duodenal bulb in STHENIC PATIENT!!!
2. PA/AP (recumbent)
PP: prone/supine
CR: perpendicular to IR
sthenic: level of L1 (1-2” above lower
rib margin) left tovertebral column
asthenic: 2” below level of L1
hypersthenic: 2” above level of L1 and
nearer midline
SS: entire stomach and duodenum,
air-filled fundus (PA),
Barium-filled (AP)
SUPINE POSITION
Full Trendelenburg- diaphragmatic
hernias
Partial Trendelenburg- for fundus
filling( asthenic px)
CR: Perpendicular
SS: 1. Best demonstrate retrogastric
portion of the
duodenum and jejenum
2.Barium filled fundic portion
3. Double contrast delineation of the
body, pyloric
portion and duodenum.
IN DIAPHRAGM: demonstrate organ
involved in gross
hernia protrusion.
SUPINE POSITION
TAKE NOTE:
STOMACH MOVES SUPERIORLY AND TO
THE LEFT.
PRONE POSITION
Prone- barium filled the body
stomach and duodenal
bulb.
TAKE NOTE:
PRONE: stomach moves superiorly 1.5 –
4 inch and
stomach spreads horizontally and
decrease in length
- In prone position fundus fill in
asthenic patient.
3. Right lateral (recumbent)
Upper gastro Intestinal Series (UGIS)
3. Right lateral (recumbent)
PP: patient in recumbent in a right
lateral position
CR: perpendicular.
•Sthenic: level of L1, lower lateral
margin of the rib, 1-
1.5” anterior to midcoronal plane
•Asthenic: 2” below L1
•Hypersthenic: 2” above L2
SS: Right Retrogastric Space.
Duodenal loop, duodenojejunal
junction
RIGHT LATERAL RECUMBENT
Structure Shown: anterior and
posterior aspect of the
stomach.
TAKE NOTE: BEST DEMONSTRATE
PYLORIC CANAL AND DUODENAL BULB IN
HYPERSTHENIC PATIENT!!!!
4. LPO (recumbent)
PP: 30-60 deg posterior oblique
CR: perpendicular
•Sthenic: level L1 (midway between
xyphoid tip and lower lateral
margin of ribs) and midway between
midline of the body and lateral margin
of abdomen. 40 deg. Oblique
•Asthenic: 2” below LI and near to the
midline, 30 deg oblique
•Hypersthenic: 2” above L1 . 60 deg
oblique.
SS: Fundic Portion of the stomach(
barium filled)
Modification in UGIS
1. GORDON’S MODIFICATION (PA
Projection)
PP: Patient is placed in prone position.
Adjust the body and center a plane
that passes 4” to
the left of the pylorus to the midline of
the table.
Reference Point(RP)– 4” to the left of
the pylorus.
C.R. – 35-45 degrees cephalad
SS: This is the best projection to
demonstrate the
pylorus and the bulb for Hyperstenic
Patients.
In this case filling of the distal half of
the stomach is achieved and double
contrast study in the fundus.
STRUCTURE SHOWN:
1. Greater and lesser curvature
2. Antral portion of the stomach
3. Pyloric canal and duodenal bulb
RATIONALE: to open up the high,
horizontal stomach of HYPERSTHENIC
PATIENT.
Modification in UGIS
1. GORDON’S MODIFICATION (PA
Projection)
2. Gugliantini’s Modification
The position of patient is the same as
Gordon’s Modification, only the central
ray is directed at an angle of 20-25
degrees cephalad.
Note: This modification is designed for
infant patients
STRUCTURE SHOWN:
1. Greater and lesser curvature
2. Antral portion of the stomach
3. Pyloric Canal and duodenal bulb
RATIONALE: to demonstrate pyloric
canal and duodenal bulb in INFANT
PATIENT
3. HAMPTON’S MODIFICATION (LPO
POSITION)
PP: Patient first assume in supine
position.
- Elevate the right side of the body
approximately 45 degrees or in such
away that the bulb is separated from
the vertebrae.
- Place support under the elevated
side.
- Center the midline of the table to the
MSP of the mid axillary plane to the
midline of the table.
R.P. – Along the level of the Pylorus.
C.R. – Directed Perpendicular.
SS: This is used for the best
modification to demonstrate a
leaf-like pattern of the pylorus and the
bulb.
4.POPPEL’S METHOD
(Right angle view of the stomach)
NOTE:
In this case the patient should
positioned right after
the ingestion of the contrast media.
.
SS: This is use to demonstrate the right
angle view of the
stomach and the retro gastric space
and at the same
time, for the evaluation of pancreatic
pathology, such
as Pancreatic Mass, Pancreatic CA,
and Pancreatitis.
RADIOGRAPHIC DEMONSTRATION OF
MINIMAL HIATAL HERNIAS
The modification or procedures
described are
modification of TRENDELENBURG
POSITION.
This technique were evolved for the
purpose of applying greater intra-
abdominal pressure that is
provided by the body angulations. And
thereby ensuring more consistent
results in the radiographic
demonstration of small sliding gastro
esophageal herniation through the
esophageal hiatus.
1. WOLF METHOD
This requires the use of a semi
cylindrical radio parent
compression device measure 22” in
length, 10 “ in width, and 8” in height.
This device provides:
1. Trendelenburg angulations of the
patient’s trunks.
2. Increase intra-abdominal pressure
enough to permit
adequate contrast filling and
maximum distention
of the entire esophagus.
1. WOLF METHOD
PP: Place the patient in the prone
position on the radiographic table.
Modified knee chest position.
Instruct the patient to assume a
modified knee-chest position during
placement of the compression device.
Place the compression device
horizontally under the abdomen and
adjust below the costal margin.
Adjust the patient in a 40 to 50
degrees RAO position, with the thorax
centered to the midline of the grid.
Instruct the patient to ingest the
barium suspension in rapid
continuous swallow.
To allow for complete filling of the
esophagus make the exposure during
the 3rd or 4th swallow.
Respiration: Suspend at the end of
expiration.
RP: T6 or T7
CR: Perpendicular o the long axis of
the patient’s back.
This position usually results in 10 to
20 degrees caudad angulations of the
central ray. ( take note!)
Demonstrate the relationship of the
stomach to the diaphragm and is
useful in diagnosing a hiatal hernia.
Compression device placement:
- Horizontally under the abdomen
- Below costal margin
BARIUM INGESTION: Rapid, continuous - C.R. – Directed at the right angles in
swallow. relation to the film.
MAKE EXPOSURE DURING 3rd and 4th - R.P. – Xyphoid process.
swallow. - Exposure is made during the MULLER
To allow complete filling of the MANEUVER.
esophagus

- For the purpose of applying greater

intra-abdominal
pressure.
- For the demonstration of small,
sliding gastroesophageal
herniation through the esophageal
hiatus.

2. SOMMER-FOEGELLE METHOD
This requires the use of a special
constructed 34 degrees
angle board which the patient is flexed
to place his trunk in
a Trendelenburg position. The upper
edge of the board is thickly padded to
exert pressure on the lower abdomen
and to further increase abdominal
pressure.
POSITIONING:
- Angle board is place on the
examining table with the film.
- Assist the patient in getting into the
table in kneeling position.
- Both thighs are placed against the
board.
- Ask the patient to lean straight
forward and rest his full
weight on the board.
UROGRAPHY
• This is the general term for the radiologic
investigation of the renal drainage,
or collecting, system.
• Urography is not synonymous to
Pyelography
ANATOMY AND PHYSIOLOGY
• Urinary System - includes the
two kidneys, two ureters, one urinary
bladder, and one urethra.
• Kidney - The functions of the kidneys
include removing waste products from
the blood, maintaining fluid and
electrolyte balance, and excreting
substances that affect blood pressure
and other important body functions.
The kidneys normally excrete 1 to 2 L
of urine per day.
• Kidneys lies on either side of the vertebral
column in the upper posterior abdomen.
• Posterior to the lower portion of the liver
on the right kidney and posterior
to the lower spleen of the left kidney.
T12 – superior border of the kidney.
L3- inferior border of the kidney
Left kidney is 1cm higher than the right.
• Ureters - convey the urine from
the renal pelves to the bladder by
slow, rhythmic peristaltic
contractions.
- 25 cm long muscular ducts
- retroperitoneal and run over the
psoas muscle, 5 cm from midline
- lies anterior to the kidney
• Reservoir for urine
• Total capacity: 350- 500ml
• The desire for micturation(urination)
occurs when about 250ml of urine is
in the bladder.
Trigon (a.k.a. vesical trigone)- triangular
inner, posterior surface of the bladder.
Muscular area formed by the entrance of 2
ureters and exit of the urethra.
- Area where there is no rugae
Kidney orientation
• 30° LPO position the right kidney parallel
to the IR
• 30° RPO position the left
kidney parallel to the IR
• Urinary Bladder - is a
musculomembranous sac that serves
as a reservoir for urine. The adult
bladder can hold approximately 500
ml of fluid when completely full.
The desire for micturition
(urination) occurs when about 250
ml of urine is in the bladder.
• Urethra – the organ which conveys the
urine out of the body, is a
narrow, musculomembranous tube with a
sphincter type of muscle at the neck of the
bladder.
Preparation
• Intestinal tract be free of gas and solid
fecal materials, bowel preparations are not
attempted in infants and children.
• Low- residue diet for 1 to 2 days.
• Light evening meal
• When indicated, administer a non- gas
forming laxative the evening before the
examination.
• NPO at midnight but should not be
dehydrated especially with
patients with multiple myeloma, high uric
acid levels, and diabetes
because of increased risk of renal failure.
• For patient to undergone retrograde
urogram, have them drink a
large amount of water (4 or 5 cups) for
several hours before the
examination to ensure excretion of urine in
an amount sufficient
for bilateral catheterized specimens and
renal function tests.
• Note that no patient preparation is usually
necessary for
examinations of the lower urinary tract.
Uremia- "urea in the blood“ an abnormal
accumulation of nitrogenous wastes
in the blood which may indicates renal
dysfunction.
CREATININE- 0.6-1.5 mg/dl
(BUN) Blood Urea nitrogen- 8-20 mg/dl
• “patient currently taking metformin can
be given iodinated contrast media only
if their kidney function levels are within
normal limits”
• Metformin is withheld for at least 48 hrs.
after the administration of iodinated
contrast media. Combination of the
metformin and iodinated contrast media
may increase the risk for contrast-induced
acute renal failure and or lactic
acidosis.
• Metformin + iodinated contrast media=
acute renal failure and or lactic acidosis
Recommendations
1. Hope and Campoy – infants and children
be given carbonated soft
drink to distend the stomach with gas.
• The gas- containing intestinal loops are
usually pushed inferiorly and the
upper urinary tracts, particularly those on
the left side of the body, are
then clearly visualized through the outline
of the gas- filled stomach.
• At least 2 ounces for newborn infants; full
12 ounces for child 7 or 8
years old.
• Highly- concentrated contrast medium
2. Berdon, Baker, and Leonidas – prone
position resolves the problem of obscuring
gas in majority of patients
• By exerting pressure on the abdomen, the
prone position moves the gas laterally away
from the pelvicalyceal structures.
• Although noted to overcome the dilemma
in patients with obscuring gas, this
occasionally fails to produce the desired
result in small infants when the small
intestine is dilated.
• The contrast medium may be
administered by rapid injection or
infusion namely:
Bolus injection nephrotomography
Infusion nephrotomography
TYPES OF EXAMINATION
• Excretory Urography
• Retrograde Urography
EXCRETORY UROGRAPHY
• Or the “ANTEGRADE FILLING”
• The contrast medium enters the system in
the normal direction of blood flow
• Excretory technique of urography used in
examinations of the upper urinary tracts in
infants and children.
• Preferred technique in adults unless
retrograde technique is indicated.
• Excretory technique is correctly referred
as intravenous urography.
EXCRETORY UROGRAPHY
• True functional test of the urinary system
(TAKE NOTE!!!)
PURPOSE:
-Visualize collecting portion of the urinary
system.
-Assessed the functional ability of the
kidneys.
- Empty bladder before examination:
-Bladder that is full could rupture.
- Urine dilutes the CM.
INDICATIONS
-Renal calculi- -Renal Cell Carcinoma
-Bladder Carcinoma - Wilm’s Tumor
-Congenital Anomalies - Pyelonephritis
- Cystitis - Renal Hypertension
- Glomerulonephritis- - Bladder diverticula
- Obstruction - Neurogenic Bladder
- Strictures
- Polycystic Kidney Disease
- Hydronephrosis
• Benign Prostatic Hyperplasia (BPH)
Also called Benign Prostatic Hypertrophy
Is an enlargement of prostate gland
• Duplication of ureter and renal pelvis
• Most common congenital anomaly of the
urinary system.
• Involves 2 ureters and / renal pelvis
originating in the same kidney.
b. Ectopic kidney
-describes a normal kidney that fails to
ascend into the abdomen but rather
remains in the pelvis.
-this type of kidney has a shorter than
normal ureter.
some obstruction of the ureter or renal URETERAL COMPRESSION
pelvis
• TRENDELENBURG -Same result to
• Renal obstruction compression device without risk to
- Caused by necrotic debris, calculus, the patient whose symptoms contraindicate
thrombus, or trauma. ureteric compression.

• Horseshoe Kidney CONTRAINDICATIONS BASIC IVU PROTOCOL

• -fusion of the kidneys during development
of the fetus - renal failure 1. Nephrogram
• -because the fusion of the lower pole the - severe hearth disease - 1 min after start of injection
kidneys do not ascend to their - Pregnancy 5 minutes
normal positions. - Hypersensitivity 20 minute oblique's
- Anuria - Full KUB
Kidney Malrotation - Diabetes Mellitus( methformin withheld - Supine is the preferred position
- An abnormal rotation of the kidney for 48 hours before the 15 minutes
administration of IOCM -full KUB
• Renal Agenesis - Supine is the preferred position
• -absence of one kidney (Unilateral renal Recommended doses: Children
agenesis-URA) Neonates - 4.0 ml/kg. 20-minute oblique's
or both kidney (Bilateral renal agenesis Babies - 3.0 ml/kg. - LPO and RPO position
(BRA Small Children - 1.5 ml/kg. Ureters away from the spine

• Polycystic kidney disease Ureteral Compression POST VOID

The most common cause of enlarged kidney
- It causes fluid-filled cysts to form in the
kidneys.
Renal Cell Carcinoma (hypernephroma)
Most frequent type of malignant tumor of
the kidney
• Hydronephrosis
- Distention of the renal pelvis and calyces
of the kidneys that results from
-taken after void
• In excretory urography, compression is -PA erect
sometimes applied over the distal ends of -Bladder should be included
ureters.
• Rationale: this is done to retard the flow IVU PROTOCOL
of the opacified urine into the bladder thus
ensure the adequate filling of the renal 1. Empty Bladder
pelves and calyces. Patient is instructed to empty his bladder
• Contraindicated to patients with urinary before the exam.
stones, abdominal mass or aneurysm, Rationale: to prevent dilution of the
colostomy, suprapubic catheter, or contrast medium with urine
traumatic injury.
2. Position the patient
- place the patient on the x-ray table in
supine position.
- Prepare for IV insertion
3. SCOUT FILM
4. Administration of contrast media
- iodinated contrast media is administered
intravenously
- 30-100 ml (depends of examining
physician)
5.Take exposure
- time interval should be indicated in each
image.
- depends on departmental protocol. (AP
projection at time intervals ranging from 3-
20 min.)
15-20 minutes- greatest concentration of
the contrast media in the kidneys after
injection.
• nephrogram phase/ immediate film- the
initial contrast “ blush” or
uptake of the kidney
- 10-15 sec (arm to kidney time)
- exposure is taken immediately after
contrast media injection.
-contrast medium is seen in the nephron
(renal parynchema) of
the kidneys; contrast media is start to filter
in the kidneys.
• nephrostomography- usually performed
during nephrogram phase.
- using conventional tomography eliminate
superimpositions of intestinal
content from intra-renal lesion and calculi.
- use when hypersthenic patient are being
examined
8.Post Micturation
- show the quality of emptying any
abdominal bladder shapes or reflux
- 150 caudad
- assess bladder emptying
- to aid the diagnosis of bladder tumors
- to confirm ureterovesical junction calculi
- demonstrate urethral diverticulum in
females
• NEPHROTOMOGRAPHY Primarily
performed to rule out renal
hypertension (TAKE NOTE!!!!)
POST VOID IVU
• CR perpendicular to iliac crests.
• Demonstrate enlarged prostate or
prolapse bladder.
• Ureteral reflux ERECT POST VOID
• Best demonstrates nephroptosis
(positional change of kidneys).
Types of Excretory Urography
• Percutaneous Antegrade Urography
(Percutaneous Renal
Puncture)
• Intravenous Urography
PERCUTANEOUS ANTEGRADE UROGRAPHY
• Direct introduction of the contrast agent
into the kidney by percutaneous
puncture of the renal pelvis.
• Introduced by Lindblom for the
investigation of renal masses.
• Specifically, it is used to differentiate cysts
and tumors of the renal parenchyma.
• In a similar procedure the renal pelvis is
entered percutaneously for direct
contrast filling of the pelvicalyceal system in
selected patients with hydronephrosis.
INTRAVENOUS UROGRAPHY
• Has been erroneously called Intravenous
Pyelography (radiographic examination of
renal pelves and calyces).
• Function is demonstrated by the ability of
the kidneys to filter contrast medium from
the blood and concentrate it with the
urine. Anatomic structures are usually
visualized as the contrast material follows
the excretion route of the urine.
Indications
• Evaluation of the abdominal
masses, renal cysts, and renal
tumors
• Urolithiasis
• Pyelonephritis
• Hydronephrosis
• Trauma
• Preoperative evaluation of the
function, location, size, and
shape of the kidneys and
ureters.
• Renal hypertension
Contraindications
• Relates to the ability of the kidneys to
filter contrast medium
from the blood
• Patient’s allergic history
• Asthma, circulatory or cardiovascular
disease, elevated creatinine
level,sickle cell disease, diabetes mellitus,
multiple myeloma
Procedure
• Empty the bladder (prevent dilution of the
contrast medium) and
change into appropriate radiolucent gown.
• Place a support under the knees of the
patient for comfort and to
reduce the lordotic curvature of the lumbar
spine.
Contrast Medium
• 30 to 100 ml (adult patient of average
size); the dosage administer
to infants and children is regulated
according to age and weight.
• Initial contrast blush: nephrogram phase
• Pelvicalyceal system: 2 to 8 minutes
(TAKENOTE!!)
• Greatest concentration of contrast in the
kidneys: 15 to 20
minutes (TAKENOTE!!)
Projections
• AP projection
• Patient position:
Supine
Upright or semi- upright
Trendelenburg
(head lowered about 15 to 20 degrees)
• Central ray: Perpendicular
Projections
AP Projection
• AP projection demonstrates the
kidneys, ureters, and bladder filled
with contrast medium.
Projection
• AP OBLIQUE
PROJECTION (RPO OR
LPO)
• Patient position: Supine
• Part position: MCP 30 degrees
from the IR plane.
• Central ray: Perpendicular
Projection
• AP OBLIQUE PROJECTION
(RPO OR LPO)
• Structure shown: The elevated
kidney will be parallel with the IR,
and the downside kidney will be
perpendicular with the IR.
Projection
• Lateral Projection (R or L Position)
• Patient position: Lateral recumbent
• Central ray: Perpendicular
• Structure shown: Used to demonstrate
conditions such as rotation
or pressure displacement of a kidney and to
localize calcerous areas and tumor masses.
(TAKE NOTE!!!)
Projection
• Lateral Projection (Dorsal decubitus
position)
• Patient position: Supine
• Part position: Center at the level of iliac
crests.
• Central ray: Horizontal and perpendicular
Projection
• Lateral Projection (Dorsal decubitus
position)
• Structure shown:
• Rolleston and Reay – recommended the
ventral decubitus position for the
demonstration of the ureteropelvic junction
in the presence of
hydronephrosis.
• Cook, Keats, and Seale – advocated this
position to determine whether an
extrarenal mass in the flank is
intraperitoneal or extraperitoneal, and they
stated that the position makes it easy to
screen both kidneys and ureters for
abnormal anterior displacement.
Projection
• Postvoid - Position may
demonstrate enlarged prostate
(possible BPH) or prolapse of
the bladder. The erect position
demonstrates nephroptosis
(abnormal positional change of
kidneys).
Other types of Excretory Urography
• Routine pyelography – for non-specific
condition of the patient
• Timed, minute, rapid, hypertensive
pyelography or urography –
For patients with HB pressure.
• Drip-infusion Pyelography – when
ordinary or routine IVP fails
to evaluate kidney functions
• Excretory Urethrography – male urethra
investigation during the
time of micturition or urination
Retrograde Urography
• Or the “RETROGRADE FILLING”
• The contrast medium is injected directly
into the canals by means of
urethral catheterization for contrast filling if
he lower part of the urinary tract.
• Provides more information about the
anatomy of the different part of
the collecting system.
• Used for the investigation of the lower
urinary tract – bladder, lower ureters, and
the urethra.
Contrast Media
•1904 – introduction of air into the urinary
bladder (retrograde
urography)
•1906 – first opaque medium, colloidal
silver preparation
(retrograde urography and cystography)
•1911 – silver iodide, nontoxic inorganic
compound
•1918 – sodium iodide and sodium
bromide, inorganic compounds
(retrograde urography)
Indication
• Evaluation of the collecting system in
patients who have renal
insufficiency or who are allergic to iodinated
contrast media.
RETROGRADE UROGRAPHY
• Non functional examination of the urinary
system.( TAKENOTE!!!)
• CM introduce directly retrograde (
backward against the flow) into the
pelvicalyceal
system.
• Requires catheterization of the ureter for
the injection of CM to the pelvicalyceal
system.
• Considered to be an operative procedure
combining urologic – radiologic under
careful aseptic condition
• The examination is performed in a
specially equipped cystoscopic radiologic
examination room.
Procedure
PELVICALYCEAL SYSTEMAND URETERS
• Carried out under careful aseptic
condition
• The radiographer positions the patient on
the cystoscopic table with knees
flexed over the stirrups of the adjustable leg
support.
(Note: This is modified lithotomy position;
the true lithotomy requires acute
flexion of the hips and knees.)
• If general anesthetic is not used, explain
the breathing procedure to the
patient.
Procedures
• Three AP projections: the preliminary
radiograph showing the
ureteral catheters in position, the
pyelogram, and the ureterogram.
• Head of the table to be lowered by about
10 to 15 degrees for the
pyelogram to prevent the contrast solution
from escaping into the
ureters.
• The head of the table may be elevated 35
to 40 degrees for the
ureterogram to demonstrate any tortuosity
of the ureters and the
mobility of the kidneys.
Procedure
• PELVICALYCEAL SYSTEM AND URETERS
• Contrast medium: Filling of the average
normal renal pelvis
requires 3 to 5 ml of contrast solution; a
larger quantity is
required when the structure is dilated. The
best index of complete
filling, and the most commonly used, is an
indication from the
patient as soon as sense of fullness is sense
in the back.
Procedure
• URINARY BLADDER, LOWER URETERS,
URETHRA, AND PROSTATE
• These examinations are identified
according to the specific
purpose of the investigation, by the terms
cystography,
cystoureterography, cystourethrography,
and prostatography.
RETROGRADE CYSTOGRAPHY
• Non functional radiographic examination
of the urinary bladder after instillation of an
iodinated CM via a urethral catheter
• Cystogram : is a common procedure to
rule out trauma, calculi, tumor &
inflammatory
disease of the urinary bladder
• No patient preparation but prior to
catheterization procedure, the patient
should empty the
bladder
• After catheterization under aseptic
condition, the bladder is drain of any
residual urine
• The bladder is then filled with dilute CM
(150-500 cc) in allowed to flow in by gravity
(never attempt to introduce pressure which
will result to rupture of the bladder ).
Procedure
Indications:
• Vesicoureteral reflux
• Recurrent lower urinary tract
infection
• Bladder trauma
• Lower urinary tract fistula
• Urethral stricture
• Posterior urethral valves
Contraindication:
• Related to catheterization of
the urethra
Procedure
• Contrast medium: Ionic solutions of either
sodium or meglumine diatrizoates or
nonionic contrast media
Procedures
• The initial cystographic images consist of
four projections: one
AP, two AP Oblique, and one lateral.
• Additional studies, including voiding
cystourethrogram, are
obtained as indicated.
• The Chassard- Lapine Method (also known
as “squat shot”) is
sometimes used to obtain an axial
projection of the posterior
surface of the bladder and the lower end of
the ureters when they
are opacified.
Projections for the Bladder
1. AP or PA Axial Projection
• Patient position:
• Supine
• Prone
• Trendelenburg (15 to 20 degrees)
• Part position: Center the IR 2 inches above
the upper border of the pubic symphysis or
at pubic symphysis for voiding studies.
• Central ray:
• AP -10 to 15 degrees caudal to the center
of the IR.
• Where the bladder neck and proximal
urethra are the main interest, a 5- degree
caudal angulation
• PA– 10 to 15 degrees cephalad, entering
about 1 inch distal to the tip of the coccyx
• If prostate is the area of interest, the
central ray is directed 20 to 25 degrees
cephalad to project it above the pubic
bones.
• Perpendicular for voiding studies.
• Structure shown: Bladder filled
with contrast. If reflux is present,
the distal ureters are also
visualized.
2. AP Oblique Projection (RPO or LPO)
• Patient position: Supine
• Part position: Rotate the patient 40 to 60
degrees RPO or LPO.
• Central ray: Perpendicular at 2 inches
above the upper border of pubic
symphysis and 2 inches to the upper ASIS.
When the bladder neck
and proximal urethra are the main areas of
interest, a 10-degree
caudal angulation is employed.
• Structure shown: Bladder filled
with contrast and distal ureters if
reflux is present.
3. Lateral Projection (R or Lposition)
• Patient position: Lateral recumbent
• Part position: Center the IR 2 inches
above the upper border of the pubic Voiding Phase
symphysis at the MCP. • Conventional/ fluoroscopic radiograph are
• Central ray: Perpendicular taken while urinating.
• Structure shown: Anterior and posterior
walls and the base of the bladder. NOTE: Postvoid is obtained after voiding
phase
Male Cystourethrography
AP and Oblique position
• AP Oblique Projection (RPO or LPO) Female: AP or slightly oblique
• Patient position: Supine Male: 30o RPO
• Part position: Rotate the patient’s body 35
to 40 degrees and adjust it so that the Retrograde Urethrography
elevated pubis is centered to the midline of
the table. • Radiographic examination of male urethra
• The superimposed pubic and ischial rami with retrograde administration of
of the down side and the body of the contrast media.
elevated pubis usually are projected Pathologic indications
anterior to the bladder neck, proximal 1. Trauma
urethra, 2. Obstructions
and prostate.
• Central ray: Perpendicular Procedure
• Structure shown: Bladder and urethra • Pt. in 30o RPO.
filled with contrast • Brodney Clamp is sometimes used which
is attached to distal penis.
Voiding Cystourethrogram (VCUG) • Contrast media is injected through the
special catheter until the entire urethra
• Functional study of the urinary bladder is filled.
and urethra, which evaluate the
patient’s ability to urinate.
• VCUG may be taken after routine Female Cystourethrography
cystogram.
• AP, Oblique, Lateral Projection – Injection
Method
Filling Phase • Patient position: Recumbent or Upright
• Bladder is fill with contrast media. • Part position: Center IR at the level of the
superior border of the
pubic symphysis; 35 to 40 degrees body
rotation for oblique;
lateral for voiding study of the
vesicourethral canal
• Central ray: 5 degrees caudad – free the
bladder neck from
superimposition
• Metallic Bead Chain
• Technique for the investigation of stress
incontinence in women
• Described by Stevens and Smith in 1937
and Barnes in 1940.
• This is used to delineate anatomic
changes that occur in the shape and
position of the bladder floor, in the
posterior urethrovesical angle, in the
position of the proximal urethral orifice,
and in the angle of inclination of
the urethral axis under the stress of
increased intraabdominal pressure as
exerted by Valsalva maneuver.
• Metallic Bead Chain
• Comparison AP and Lateral are made with
patient standing at rest
and straining.
• For this examination, a flexible metallic
bead chain is extended
through the urethral canal (proximal
portion within the bladder
and distal portion taped to the thigh.)
• For the demonstration of the length of the
urethra, a small metal
marker is attached with a piece of tape to
the vaginal mucosa just
lateral to the urethral orifice.
• After installation of the metallic chain, a
catheter is passed into
the bladder, the contents of the bladder are
drained, and an
opaque contrast solution is injected. The
catheter is removed for
the imaging procedure.
• Recommendation:
• Hodgkinson, Doub, and Kelly – Upright
position uses gravity and thus
stimulates the normal body activity. Two
sets of images (AP and Lateral) are
obtained, and the rest of the studies must
be exposed before the stress studies
are made because the bladder does not
immediately return to its normal resting
position after straining.
• Klawon found that the fear of involuntary
voiding can be relieved by placing a
folded towel or disposable pad between the
patient’s thighs before the stress
radiographs are taken.