CONTRAST MEDIA

WHAT, WHY, WHEN, WHO AND

HOW
WHAT IS CONTRAST
MEDIA?
CHECK THE PICTURE BELOW.
WITHOUT CONTRAST MEDIA

Identify as many anatomical parts as you can

CHECK THE PICTURE BELOW
WITH CONTRAST MEDIA

Identify as many anatomical parts as you can

Based on your observation
what is CM?
What is Contrast media
1, Contrast media permits visualisation of the details of the internal structure or
organs that would not otherwise be demonstrable in a plain radiographic
procedure.

2. Substances which help in better differentiation between adjacent tissues

WHY CONTRAST MEDIA IS
NECESSARY?
THE COLOR OF
RADIOGRAPHIC
IMAGE
We all love colors.

But radiographic image is

composed only of

● Black
● White
● 50 shades of gray
Defining Structures With Shades
The shades of black and white on a radiograph is the result of attenuation based
on the structure atomic number.

● High atomic number will appear white

● Medium to low atomic number will appear as shades of gray to black

This is why blood vessels and alimentary canal is almost impossible to be seen on
a plain radiographic exam.

Contrast media will make the invisible,..... visible

OUR COMPLEX ANATOMICAL
STRUCTURE
OUR BODY IS COMPOSED OF

SOLID-

-Bones, soft tissues

LIQUID-

-blood, body fluid, milk tea

GAS-

-O2, CO2, and Fart

 ACTIVITY

Which organs do you think

will have an even or almost
same shades of gray? WHY?
LETS COLOR THE PART

BONE SOFT TISSUES AIR

IDENTIFY PARTS
BASED ON COLOR
Where are the Bones?

Where are the soft tissues?

Where are is the air?

Now try to locate the ff:

Kidneys

Ureter

Urinary bladdder
Can you easily locate them?
Now you know why CM is
necessary.
When did it
all began?
History of CM
History
● In 1896, in the year after X-rays were discovered, inspired air became the
first recognised contrast agent in radiographic examinations
● the first contrast studies were carried out on the upper gastrointestinal tract
of a cat using bismuth salts (very toxic salt)
● 1910 barium sulphate and bismuth solutions were being used in conjunction
with the fluoroscop
● Images of the urinary system were achieved in the early 1920s
● In 1923 the first angiogram and opacification of the urinary tract was
performed using sodium iodide
History
● The first iodine-based contrast used was a derivative of the chemical ring
pyridine, to which a single iodine atom could be bound in order to render it
radio-opaque.
● Iodine-based contrast media have been used ever since
● Modern ionic contrast agents were introduced in 1950 and were derivatives
of tri-iodo benzoic acid;
○ this structure enabled three atoms of iodine to be carried, rendering it more radio-opaque.
However, the agents still caused adverse effects, as they were still of high osmolarity
History
● In the 1970s and 1980s non-ionic low-osmolality contrast media became
widely available, with the first non-ionic contrast medium being introduced
in 1974
● New media are highly hydrophilic, resulting in lower chemotoxicity, and
they are iso-osmolar with the respective body fluids, meaning they can be
used for examinations such as angiography and computed tomography (CT)
arteriography, which require high doses of contrast media to be
administered and where low toxicity is essential.
HOW CONTRAST MEDIA
WORKS?
Before we study how contrast media works, first we need to know the quality of a
safe CM

● Easy to administer
● Non-toxic
● A stable compound
● Rapidly eliminated when necessary
● Non-carcinogenic
● Appropriate viscosity for administration
● Cost effective
Two types of CM
NEGATIVE POSITIVE

● Radiolucent
● low atomic number
● appear darker on the X-ray image.
● Gases are commonly used to produce
negative contrast
● Radio-opaque
● high atomic number
● less readily penetrated by X-rays
● Appears white in radiograph
● Barium- and iodine-based solutions are
used in medical imaging to produce
positive contrast
 POSITIVE
CONTRAST
MEDIA
Barium sulphate solutions (BaSO4) used in gastrointestinal
imaging
The following characteristics make barium solutions suitable for imaging of the
gastrointestinal tract:

● High atomic number (56) producing good radiographic contrast

● Insoluble
● Stable
● Relatively inexpensive
● Excellent coating properties of the gastrointestinal mucosa
Barium sulphate solutions (BaSO4)
COMPOSITION CONCENTRATION OF BARIUM IN A SOLUTION

● pure barium sulphate ● 1 g of barium sulphate per 100 mL of

● mixed with additives and dispersing agent water
● Compounds to stabilise the suspension
are added
● A dispersing agent is added to prevent
sedimentation
● defoaming agent, used to prevent bubbles
that may mimic pathology in the
gastrointestinal tract
CONTRAINDICATION
● Suspected perforation
● Suspected fistula
● Suspected partial or complete stenosis
● Paralytic ileus
● Haemorrhage in the gastrointestinal tract
● Toxic megacolon
● Prior to surgery or endoscopy
● If the patient has had a recent gastrointestinal wide bore biopsy (usually
within 3–5 days) or a recent anastomosis
WHAT IF ITS CONTRAINDICATED?
When barium sulphate solutions are
contraindicated for gastrointestinal imaging, a
water-soluble iodine-based contrast medium
(e.g. Gastrografin or Gastromiro) should be
used. These can be administered orally, rectally
or mechanically, e.g. via stomas. The iodine
concentration of Gastrografin is 370 mg/mL
and of Gastromiro 300 mg/mL. When used for
imaging the gastrointestinal tract, watersoluble
contrast produces a lower-contrast image than
barium owing to its lower atomic number.
 Iodine-based
contrast media
Iodine-based contrast media used in medical imaging and
their development
The largest group of contrast media used in imaging departments are the
water-soluble organic preparations in which molecules of iodine are the opaque
agent.

● iodine has an atomic number of 53

● K edge = 32 keV (binding edge of iodine K-shell electron
● The iodine-based compounds are divided into four groups
CLASSIFICATION OF CONTRAST MEDIA
BENZENE RING
CHEMICAL STRUCTURE MONOMER
NORMAL BENZENE MONOMER
Anions and Cations
Ionic compounds dissociate (dissolve) into charged particles when entering a
solution. They dissociate into positively charged cations and negatively charged
anions. For every three iodine molecules present in ionic media, one cation and
one anion are produced when it enters a solution.

● Their ‘effect’ ratio is therefore 3:2. These solutions are highly hypertonic,
with an osmolality approximately five times higher than human plasma
(1500–2000 mOsm/kg H2O compared with 300 mOsm/kg H2O for plasma).
● the higher the ‘effect’ ratio the lower the osmolarity of the contrast media.
WHY DIMERS ARE NEEDED
● An attempt was made to increase the ‘effect’ ratio and produce a contrast
medium with lower osmolarity. This was achieved by linking together two
conventional ionic contrast media molecules. The resulting dimeric ionic
contrast medium was an improvement on the HOCM
● Characteristics
○ Reduced osmolality
○ still dissociates into two particles, a positive cation and a negative anion
○ iodine atom-toparticle ratio of 6:2
CHEMICAL STRUCTURE OF DIMERS
NON IONIC MONOMER
LOCM
NON IONIC MONOMER
● These are low osmolar agents and do not dissociate into two particles in a
solution, making them more tolerable and safer to use than ionic contrast
● For every three iodine molecules in a non-ionic solution, one neutral
molecule is produced.
● Non-ionic contrast media are therefore referred to as 3:1 compounds
● Two major advantages
○ negative carboxyl group is eliminated,
○ elimination of the positive ion reduces osmolality to 600–700 mOsm/kg H2O

Non-ionic LOCM is recommended for intrathecal and vascular radiological procedures

Non-ionic dimers
(isotonic)
the gold standard
NON IONIC DIMER
● Non-ionic dimers are dimeric
non-dissociating molecules; for
every one molecule there are six
iodine atoms. The ratio is
therefore 6:1
● Non Ionic Dimer is isotonic
● water-soluble iodine contrast
medium.
● plays a significant role in
imaging venous phase images
following arterial injections
PERCENTAGE SOLUTION OF CONTRAST MEDIA
The percentage solution indicates the amount of solute in the solvent. The
percentage solution does not indicate the percentage iodine content
SOLVENT VISCOSITY RELATIONSHIP
● The solvent affects the viscosity of the contrast agent.
● Viscosity is the resistance to flow of a contrast medium and relates to the
concentration, molecular size and temperature of the contrast
● The lower the solvent percentage value the higher the viscosity
● The volume and density of contrast used is dependent upon the
examination being undertaken, the pathology being investigated, the age of
the patient and the patient’s medical status.
MAJOR DIFFERENCES AMONG GENERAL CM
Viscosity

● The viscosity of a liquid is assessed by measuring its rate of flow through a

standard thin capilliary tube under standard conditions of pressure and
temperature.
● viscosity is inversely related to temperature
Osmolality

● The higher concentration solution can be said to 'draw' water from the lower
concentration solution. This process is called osmosis, and the force exerted
is called osmotic pressure.
TAKE NOTE
Both the viscosity of a contrast medium and its osmolality are related to the
concentration of the contrast medium, usually referred to as its strength. The
strength of a contrast medium is usually given as its concentration in iodine, a
figure after the brand name, indicating the concentration in milligrams of iodine
per millilitre.
Chemotoxicity
Chemotoxicity

● The term 'chemotoxicity' refers to the mechanism responsible for causing

the toxic effects of contrast media that cannot be explained by other means
(e.g. osmolality, electrical charge). There are a number of properties of
contrast media that relate to this tem (e.g. hydrophilicity/lipophilicity,
protein-binding, histamine release).
CHEMOTOXICITY
The hydrophilicity of a contrast medium is its preference for aqueous solvents,
whereas its lipophilicity refers to its preference for fat-like (lipid) organic
solvents such as the chemical solvent n-butano.

Lipophilicity has been found to correlate roughly with the toxicity of ionic
contrast media. Non-ionic contrast media seem to be too hydrophilic to make
differences in the partition coefficient a critical issue.
CHEMOTOXICITY
Protein-binding refers to the percentage of contrast medium which becomes
bound to the plasma proteins in the blood stream. The cholegraphic media
discussed in the previous chapter derive their ability to be excreted and
concentrated in the bile, rather than to be rapidly eliminated by the kidneys,
from their very high degree of protein-binding. In line with the above hypothesis,
the cholegraphic agents (which are also ionic) have a rather higher
chemotoxicity than the urographic contrast media.
CHEMOTOXICITY
Histamine release is a characteristic of allergic reactions. A possible model for
the contrast media to cause allergy-like reactions is their property of releasing
histamine from mast cells. Experimentally, it is expressed as a percentage of the
total histamine content of the cells.
Essential criteria for the ‘ideal’ intravenous contrast agent
● Water soluble
● Heat/chemical/storage stability
● Non-antigenic
● Available at the right viscosity and density
● Low viscosity, making them easy to administer
● Persistent enough in the area of interest to allow its visualisation
● Selective excretion by the patient when the examination is complete
● Same osmolarity as plasma or lower
● Non-toxic, both locally and systemically
● Low cost
POSSIBLE SIDE-EFFECTS OF IONIC-BASED CONTRAST MEDIA
high osmolarity and chemotoxic effects of the medium can potentially cause
physiological adverse effects. both ionic and non-ionic iodine media have
physiological effects on the bod.

ionic media are of higher osmolarity and potentially cause more side effects in
the patient. ionic contrast has approximately five times the osmolarity of human
plasma

Watersoluble organic iodine contrast media have two effects: the desirable
primary effect of attenuating X-rays and providing the radiographic image with
adequate contrast, and the unwanted secondary effect of inducing potential side
effects in patients.
Primary effect of Contrast Media
IMAGE CONTRAST

Optimum attenuation is achieved by selecting the appropriate concentration of

iodine in solution for the planned examination

When comparing two contrast media with the same iodine concentration, a
higher venous concentration of iodine is obtained when diffusion of contrast
medium is slowed down by using large molecules (dimers) and osmotic effects
are reduced by reducing the number of molecules/ions in solution (monomers).
Secondary effect of Contrast Media
ADVERSE REACTION

● Idiosyncratic reactions are dose dependent and usually anaphylactoid in

nature. These are unpredictable, having a prevalence of 1–2% (0.04–0.22%
severe), and are fatal in 1 in 170 000.5
● Non-idiosyncratic reactions are divided into chemotoxic and osmotoxic.
Chemotoxic effects can be minimised through the use of LOCM. As LOCM
are available at a reasonable cost the use of higher-toxicity substances could
be challenged medicolegally.
TOXICITY
Contrast media
Cardiovascular toxicity
● Pain can occur at the injection site during intravascular contrast
administration
● Thrombus formation and endothelial damage may occur, and contrast may
impair platelet aggregation and blood clotting, possibly provoking a painful
sickle cell crisis.
● can also cause vasodilatation
● can produce an intravascular hypervolaemic state, systemic hypertension
and pulmonary oedema.
● Can cause an angina attack
Nephrological ●
●
Ionic contrast may affect renal output
increase in serum creatinine by more than
toxicity 25% or 44 mmol/L
● The following conditions may increase the
incidence of nephrotoxicity in patients who
receive an intravascular contrast medium:
○ Pre-existing kidney disease
○ Diabetes mellitus
○ Multiple myeloma
○ Dehydration
○ Large volume of contrast injected
○ Age of patient
Neurotoxicity
neurotoxicity of contrast media is related
to the osmolality of the solution

Ionic media are hyperosmolar with respect

to human plasma and may dehydrate the
cerebral endothelial cells causing a major
problem to the brain.

Neurotoxicity can be reduced by using a

low osmolar contrast medium as these are
less likely to breach the blood–brain
barrier.
CONTRAST MEDIA
ADMINISTRATION
INTRAVENOUS ADMINISTRATION OF CM
LOCM should be administered intravenously to all patients, but especially to:

● Infants
● the elderly
● those with cardiac or renal impairment
● Diabetics
● patients with a history of asthma or severe allergy
● patients with a history of a previous reaction to contrast media
PRECAUTION CHECK FIRST:
● Know the patient and ● Consider the
their medical history following high-risk
● Reassure the patient factors which are
and obtain their associated with the
consent administration of
● If the patient is a intravenous contrast
high-risk patient medium:
administer a low ● ETC.
osmolar contrast
medium
● asthma or a significant
allergic history
● proven or suspected
hypersensitivity to
iodine
 ASSIGNMENT

Look for the list of precautionary

measure before the administration
of contrast media
CONTRAST MEDIA
PROCEDURES
GASTROINTESTINAL TRACT
IMPORTANT
POSITIONING
UPPER GI TRACT
The aim of a contrast examination is
to outline these structures in single
and/or double contrast to obtain
optimum visualisation. The most
common contrast agent used is a
barium sulphate suspension, although
ionic and non-ionic contrast agents
can be used.
INDICATIONS FOR UPPER GI IMAGING WITH CM
Barium swallow

● Sensation of ‘lump in throat’ (globus)

● Regurgitation of unaltered food
● Dysphagia
● Gastro-oesophageal reflux (GOR)
● Assessment of oesophageal perforation (water-soluble contrast must be
used)
● Known hiatus hernia – anatomical roadmap required prior to surgery
CONTRAINDICATION
• Known aspiration during ingestion (although this can be overcome by using
non-ionic water-soluble contrast)

Suspected perforation
UPPER GI EXAM TECHNIQUE
● The patient is initially asked to stand erect in the AP
● The patient is turned into the left lateral position in order to commence with
routine assessment of possible aspiration
● They are asked to take a ‘normal’ (for them) mouthful of the liquid and hold it
in their mouth until asked to swallow
● a frame rate of 3 per second is suggested as an initial choice
● The patient is then asked to swallow and the exposure is initiated.
● Real-time recording (exposure) is terminated when the barium bolus passes
beyond the screened image or point of interest
COMMON ABNORMALITY FINDING
IN UPPER GI
● persistent cricopharyngeal
impressions or diverticula
● most common diverticulum type
being ZenkerS,causing patients to
be referred because of regurgitation
of undigested food some time after
they have eaten
ESOPHAGEAL WEB

Oesophageal webs are also

best seen on the lateral
projection, shown on the
anterior wall, although they
are best viewed with rapiD
BARIUM MEAL
This examination is performed to show the stomach and duodenum. It is
becoming less frequently requested owing to the increase in the use of endoscopy
as the front-line examination, and is recommended for use in a very limited
number of circumstances
CONTRAINDICATION
● Complete large bowel obstruction
●
PATIENT PREPARATION
Patient preparation is as for all upper tract examinations
Contrast agents and pharmaceutical aids for the
examination
● Barium sulphate suspension 250% w/v
● Effervescent granules and citric acid, or other gas-producing agent
● An antispasmodic agent such as hyoscine-N-butyl bromide (Buscopan) may
be used intravenously. These help to reduce peristalsis in the stomach and
prevent rapid progress of the barium into the small bowel14
ADDITIONAL EQUIPMENT
1. Disposable cup
2. Small cup for effervescent agent
3. Tissues
4. A straw may be required for ingestion of barium sulphate when the table is
horizontal (if needed)
Technique
1. Administration of an antispasmodic (As per instructionof physician)
2. patient is asked to stand on the step of the fluoroscopic couch and then the procedure
for ingesting the gas-producing agent is explained
3. The patient is given the effervescent agent (dry, or mixed with a small amount of water
if this is more tolerable for the patient)

4. The patient is turned slightly to their left and asked to swallow a mouthful of the
barium

5. After three or four reasonable mouthfuls of barium have been ingested, the table is
tilted horizontally and the patient asked to rotate (at least once) through 360° to enable
the barium to coat the stomach mucosa
TECHNIQUE
● Once the patient has completed their rotation and good mucosal coating and
distension of the stomach have been noted, it is possible to obtain the spot
images
POSITIONING
● the patient with their right side
raised (LPO) demonstrates the
antrum and the greater curve
POSITIONING
● if the patient is supine this
demonstrates the antrum and the
body of the stomach and also the
lesser curve
POSITIONING
Turning the patient into the RPO
position demonstrates the lesser curve
en face
POSITIONING
● moving the patient into the right
lateral position with head tilted up
shows the fundus
POSITIONING
The patient can then be tilted erect and turned
slightly to the left to show the fundus (Fig. 29.11).
If visualisation of the duodenal cap has been
poor during the earlier (table horizontal) stages
of the examination, turning the patient in both
directions (while they are standing) may provide
better views of the duodenal cap
● A combination of the following
positions will help to best
demonstrate the duodenal loop
and duodenal cap. It may be
necessary to use magnification at
this point to optimise the view:
○ LPO
○ Supine
○ RPO, centred on and collimated to
the duodenal loop
○ prone
Aftercare
● A damp tissue should be provided for the patient to clean their mouth
● The patient should be informed that their stools will be paler or white for a
few days, and to keep their fluid intake up to reduce any chance of
constipation. Encourage a high-fibre diet for several days
● Ensure that the patient knows how to obtain their results
● If a muscle relaxant is used, the patient must remain in the department until
any blurring of their vision has passed
POSSIBLE COMPLICATIONS
● Leakage of barium from an unsuspected perforation
● Constipation
● Partial bowel obstruction becoming complete obstruction due to barium
impaction
SMALL BOWEL
The small bowel (from the duodenojejunal flexure to the ileocaecal valve) can be
examined by one of two methods: the barium followthrough (BaFT) or the small
bowel enema. The aim is to produce a continuous column of barium suspension
outlining the small bowel.3
INDICATION
● Anaemia
● Diarrhoea
● Persistent pain
● Crohn’s disease
● Meckel’s diverticulum
Barium follow-through (BaFT)
During this examination the patient has to drink a volume of barium sulphate
suspension, and images (fluoroscopy and/or permanent image recording) are
taken as the small bowel fills. The examination frequently takes 2 hours, and in
some instances can take most of the day.22
CONTRAINDICATION
● Suspected perforation
● Complete obstruction
●
Patient preparation
Patient preparation is usually the same for both follow-through and small bowel
enema, and imaging department protocols do vary. Generally the patient is not
allowed to eat or drink for 5–6 hours prior to the examination. Some centres may
give the patient a mild laxative and/or a clear fluid diet the day before the
examination.
Contrast agent
At least 300 mL 100% w/v barium sulphate suspension is required for an adult
BaFT.14 The constituents of the drink are:

● . Barium sulphate suspension

● Effervescent agent (may be carbonated barium sulphate suspension)
● Water
● Accelerator, e.g. Gastrografin or metoclopramide hydrochloride (Maxalon)
Technique
● The patient is asked to drink the barium sulphate suspension steadily
● The imaging technique used depends on the equipment available, the
preference of the practitioner or local imaging department protocol. The
actual timing of imaging depends on each individual patient and the motility
speed of the bowel
● • A series of over-couch abdominal radiographs for prone positioning) may
be taken at predetermined time intervals, e.g. every 30 minutes, or
alternatively each image is individually assessed in order to determine the
timing of the subsequent image
TECHNIQUE
● The first image is usually taken
15–20 minutes after drinking
commenced. When the barium has
been seen to reach the terminal
ileum, fluoroscopy is used to image
the ileocaecal area, although
over-couch images can be taken if
necessary
TECHNIQUE

● With fluoroscopy the proximal jejunum is often imaged supine or in the RPO
position. All the other loops are usually imaged supine until the terminal
ileum is reached.
● Regardless of imaging modality, all bowel loops should be palpated (using
lead rubber gloves with hands outside the primary beam) or the abdominal
wall compressed with a radiolucent pad during imaging.
● Fluoroscopy of the terminal ileum frequently requires an LPO position, but
sometimes RPO or prone positions are more satisfactory
● An erect abdominal view may be required to show fluid levels, usually
required when jejunal diverticulosis is present.
Complications
● Constipation
● Abdominal pain
● Transient diarrhoea (due to a large volume of fluid)
Patient aftercare
1. Ask the patient to increase their fluid intake over the next 48 hours to
prevent constipation
2. Warn the patient about white stools
3.
Small bowel enema
During a small bowel enema the
duodenum is intubated and a contrast
agent introduced.

This is arguably the ideal method for

imaging the small bowel as it results in
improved visualisation of the bowel
loops
Contraindications
● Facial surgery or trauma
● The patient is prone to nose bleeds
● Active Crohn’s disease
● Severe gastro-oesophageal reflux/hiatus hernia
● Suspected perforation
● Complete obstruction
Patient preparation
● As for BaFT
● The procedure must be carefully explained, as it is often difficult for the
patient to tolerate
Contrast agent
For single contrast, typically 1000 mL of fluid is used.15 The mixture comprises
barium sulphate suspension and water; the ratio of barium sulphate to water
tends to vary according to the preferences of the examining radiographer or
radiologist. For double-contrast examination 150–200 mL barium sulphate
suspension is followed by up to 2 L methylcellulose 0.5%.1
Additional equipment
● Nasogastric or duodenal catheter
● Lubricating jelly for the tube
● Anaesthetic spray
● Tissues
● Sterile gloves
● Swabs to wipe the tube after removal
TECHNIQUE
● The patient lies supine and, under fluoroscopic control, the duodenal or
nasogastric catheter is inserted until the tip of the catheter is shown in the
duodenojejunal flexure
● The guidewire within the catheter acts as a stiffener to prevent coiling and
enables manipulation into the correct position
● The barium solution is infused by gravity or by an enteroclysis pump
● Imaging is usually by fluoroscopy, but spot films can be taken as well. The
terminal ileum may need prone imaging as for BaFT
● For a double contrast study methylcellulose solution is infused after the
barium sulphate suspension until the terminal ileum is demonstrated in
double contrast
TEACHNIQUE
● During a single-contrast examination air may be introduced at the end of the
examination to demonstrate the terminal ileum in double contrast. Air may
be introduced via the duodenal catheter or by a rectal cathete
● All the loops of bowel are usually imaged supine until the terminal ileum is
reached and oblique views may be needed
Lower GI tract-LARGE BOWEL
The large bowel comprises the colon, rectum and caecum and is usually
examined by the double-contrast barium enema. At the point of publication
(2012) CT colonoscopy is rapidly overtaking the barium enema as a mainstream
examination.
INDICATION
● Change in bowel habit
● Iron deficiency anaemia
● Rectal bleeding
● Tenesmus
● Left iliac fossa pain
● Palpable mass
● Documented cancer on endoscopy: to exclude synchronous lesions
Double-contrast barium enema (DCBE)
The aim of this examination is to image the entire large bowel in double contrast,
using gas (CO2 or air) to distend the bowel, to facilitate a fine coating of barium
on the bowel mucosa and to act in extreme contrast with the dense barium.
Contraindications
● Biopsy via rigid sigmoidoscope within 7 days
● Incomplete optical colonoscopy
● Toxic megacolon
● Incomplete bowel preparation
● Incomplete bowel preparation
● Suspected perforation
● Obstruction
Patient preparation
● instruct the patient to follow a low-residue diet and take laxatives 48 and/or
24 hours before the examination.
● cleansing enemas can be given and some centres also restrict fluids for 4–6
hours prior to the examination
● In certain cases laxative use is contraindicated (ileostomy, currently
clinically active inflammatory bowel disease) or should be used with caution,
as in patients with a colostomy
● Elbow pads may be provided immediately prior to the examination to reduce
the risk of skin damage in the frail or elderly
Contrast agents
Barium sulphate suspension. Warm water is added to the barium sulphate
powder/liquid to ensure a high-density lowviscosity suspension. The powder is
usually supplied in an enema bag

Air or carbon dioxide

Additional equipment/pharmaceuticals
● Funnel to fill enema bag with water or barium sulphate suspension
● Additional clamp (although rare, clamps supplied on enema bags may fail)
● Rectal catheter with additional gas insufflation line
● Drip stand for barium bag
● Air or CO2 insufflation device
● Lubricating jelly
● Gauze swabs for application of lubricant to catheter
● Wide adhesive tape to help maintain position of catheter
● Latex or vinyl gloves
● Muscle relaxant, needle and syringe
TECHNIQUE
● When the barium sulphate suspension reaches the splenic flexure the patient
turns prone until the barium sulphate suspension has filled half of the
transverse colon. At this point the patient turns back onto their left side and
the bag/bottle of barium sulphate suspension is placed on the floor to enable
excess fluid to drain back out of the patient
● Air or carbon dioxide is then gently insufflated into the rectum and the
imaging sequence begins. The gas is insufflated throughout the examination
as required to ensure double contrast throughout; as CO2 is absorbed by the
colon, it is more likely to require additional insufflation than air
Technique
● The patient lies on their left side with their knees and hips flexed and a
lubricated catheter is inserted into the rectum
● The catheter is then taped in place. A hypotonic agent (also known as a
smooth muscle relaxant), e.g. Buscopan or glucagon, is frequently given at
this point to reduce bowel spasm. Contraindications for buscopan include
cardiovascular disease and glaucoma, so glucagon may be given instead
● The bag or bottle of barium sulphate suspension is suspended on the drip
stand about 1 m higher than the patient. The patient remains on their left
side and the table is tilted slightly (with the patient’s head down); the clamp
on the barium sulphate suspension is released and the fluid is slowly run
into the colon
RECTOSIGMOID
LATERAL RECTUM
Technique
It can be difficult to move barium and air around the bowel, and some strategies
are available to achieve this:

1. . Tipping the patient head down (supine position) clears barium from the
caecum
2. Lying the patient on their left side, turning them to prone then back to the
left side also clears the caecum. However, if the ascending colon is long and
the caecum lies in the midline or left of the midline it may be necessary to
turn the patient from supine to lie on their right side and then back to supine
TECHNIQUE
3. Turning the patient 360° to coat the mucosa effectively. This will only work
if enough barium is in the region of interest, and may require additional
barium to be run into the region, or rotation of the patient to bring barium to
the area
• Once the bowel is coated and
adequately gas-filled, projections are
taken and may include:

1. LPO of the rectum and sigmoid

2, RAO of the rectum and sigmoid
(any areas obscured by barium
sulphate suspension in the LPO view
should now be outlined with air)

3. Prone rectum

4. Lateral rectum
5. RPO descending colon

6. Supine and erect

TECHNIQUE
7. Erect RPO splenic flexure

8. Erect LPO hepatic flexure

9. LPO ascending colon and caecum

10. Slight RPO and supine caecum with palpation. The table may be tilted
slightly head-down for these views

11. Left lateral decubitus (positioned with left side down and right side
raised). This view demonstrates the medial wall of the rectum, sigmoid,
descending colon; the superior and inferior wall of the transverse colon; the
lateral wall of the caecum, ascending colon and hepatic flexure
7. ERECT RPO SPLENIC FLEXURE
8. ERECT LPO HEAPTIC FLEXURE
12. Right lateral decubitus (right side down). This view demonstrates the lateral
wall of the rectum, sigmoid and descending colon; the superior and inferior walls
of the transverse colon; the medial wall of the caecum and ascending colon

13. When the rectum is included on lateral decubitus views it is not always
possible to include the splenic flexure. It is preferred that the rectum be included
in preference to the splenic flexure, which should have been included on spot
images
14. For additional information on the distal descending colon and sigmoid, use
the prone 30–35° projection (described later in this section and shown in

15. The examination is not complete until the appendix and ileocaecal junction
are adequately demonstrated.
LATERAL DECUBITUS ABDOMEN
The lateral decubitus projection is most frequently used as part of the barium
enema examination but is also useful to demonstrate free extraperitoneal air in
acute cases when the patient cannot sit erect. The patient is examined on both
sides as for barium enema, the projection affording demonstration of lateral
aspects of the large bowel mucosa. The raised side ensures that air rises above
the barium, showing mucosal detail.
POSITIONING
● The patient lies on the table-top on a thick radiolucent pad and turns to a
lateral position with their back to the radiographer, with the right or left side
raised. The arms are raised onto a pillow and the knees flexed to aid stability
● The tube side of the IR will now be in contact with the patient’s abdomen and
its long axis coincident with the median sagittal plane (MSP). The MSP is
perpendicular to the IR
● A PA anatomical marker is applied within the primary beam
Beam direction and focus receptor distance (FRD)

● Horizontal, 90° to the IR 100–120 cm FRD

Centering

● Over the fourth lumbar vertebra, in the midline at the level of the iliac crests

Collimation

● Symphysis pubis, as much upper abdomen as possible, lateral soft tissue or

bowel outlines
AP lateral decubitus
If AP positioning is required the MSP is still positioned as perpendicular to the IR
and centring is as for the AP abdomen, using a horizontal beam and AP marker.
The centring point is in the midline, level with the iliac crests. The beam is
horizontal and at 100–120 cm FRD.
Prone 30–35° to demonstrate the sigmoid colon: Hampton’s
projection
In the case of the barium enema examination, if additional information on the
sigmoid colon is required, the Hampton’s projection may be used. An IR with grid
is used horizontally for this projection
Positioning
● The patient is prone, head turned to the side and arms raised onto the pillow
for stability and comfort
● The MSP is coincident with the long axis of the table
● For males, lead rubber or lead gonad protection is applied below the
buttocks to protect the gonads
● ASIS (anterior superior iliac spines) are equidistant from the table-top
Beam direction and FRD
● A vertical central ray is angled 30–35° caudally 100 cm FRD

The IR is displaced until its centre is coincident with the central ray.

Centring

● Over a point in the midline, at the level of the first sacral segment

Collimation

● Rectum, sigmoid colon.

Patient aftercare
● Remove the catheter and escort the patient to the toilet
● Warn the patient about constipation; encourage a high-fibre diet and plenty
of fluids over the next 48 hours
● Warn the patient about white stools
● Ensure the patient knows how to obtain results
● If a muscle relaxant has been used, warn of the possibility of blurred vision
and ensure that the patient does not leave the department until any blurring
of vision has resolved
Complications
● Constipation
● Impaction
● Obstruction
● Barium appendicitis
 ASSIGNMENT
List down the positioning steps and techniques for Colonography
CT colonography (CTC)
The DCBE was a long-standing first-choice radiographic investigation of the
large bowel, but it has largely been superseded by CTC, which is minimally
invasive and better tolerated by the majority of patients. Evidence has also
established that CTC sensitivity to polyps >10 mm is between 91% and 100%25
compared to DCBE, which has a variable detection rate of between 48%26 and
81%.27 It also has the advantage of being able to detect extracolonic lesions,
particularly beneficial when the patient presents with vague symptoms relating to
the large bowel.
Indications
CTC is indicated for the same reasons as DCBE and, in addition:

● Incomplete optical colonoscopy

● To evaluate the colon proximal to an obstruction
● If optical colonoscopy is contraindicated
Contraindications
● Risk of perforation
● Following colonic biopsy
● Inflammatory bowel disease
Patient preparation
Laxative use for bowel preparation prior to CTC has commonly been replaced by
a technique know as ‘faecal tagging

● requires the patient to follow a low-residue diet 2 days prior to the

examination and ingest oral contrast the day before (100 mL of
Gastrografin in two separate doses of 50 mL, at 0800 and 1600 hours).
Contrast agents
Gastrografin (see section on patient preparation, above); non-ionic water soluble
contrast agent, e.g. Niopam 300 (Iopamidol 61.2% w/v). Some centres do not use
intravenous contrast agent unless sinister pathology is noted during CTC.
Additional equipment
● Automatic CO2 insufflator (preferable) or air or CO2 hand insufflation device
● Rectal catheter to attach to CO2 insufflator
● Lubricating jelly
● Gauze swabs for application of lubricant to tip of catheter
● Vinyl or nitrile gloves
● Antispasmodic agent (hyoscine butylbromide 20 mg/mL IV, e.g. Buscopan)
● 2 mL syringe and filter needle
● Intravenous cannula (Venflon) for administration of contrast medium and
muscle relaxant
● 10 mL saline and 10 mL syringe (optional)
Preparation immediately prior to the examination
● All radio-opaque objects should be removed from the patient’s chest,
abdominal and pelvic region
● Check all equipment is readily available. Plug in the CO2 insufflator and
switch on. Open the valve to the insufflator using the spanner provided,
ensuring that there is sufficient CO2 in the cylinder (gauge on the insufflator)
to commence the examination
● The rectal catheter is attached to the CO2 insufflator in accordance with the
manufacturer’s instructions
Acquisition parameters
● Supine: 120 kV
● 160 mAs (effective)
● 16 collimation × 0.75 mm
● Prone: 120 kV
● 50 mAs (effective)
● 16 collimation × 0.75 mm
Complications
With CTC there is a small risk of colonic perforation, and this should be excluded
before the patient leaves the department: the CT scan is reviewed to ensure that
there is no free air in the abdomen and, as the patient should remain in the
department for 15–20 minutes after a contrast agent injection, they can be
assessed periodically for signs and symptoms of perforation; these signs and
symptoms include severe abdominal pain, nausea and, in extreme cases, fever
and vomiting.