Fluoro Procedures

Contrast Agents

• Barium

  • Pros:

    • Gives best images

  • Cons:

    • Cannot use if there is concern for perforation or leak due to risk of mediastinitis/peritonitis, etc.

• Gastrograffin

  • Pros:

    • Water soluble can be used if there is concern for leak or perforation

  • Cons:

• Omnipaque (Iohexol)

  • Pros:

    • Can be used i

  • Cons:

    • Can only use 150 ml

    • Expensive

Arthrogram Shoulder

• Cocktail ~12 cc

  • MRI

    • 0.1 cc gadolinium

    • 5 cc omnipaque

    • 15 cc saline

  • CT

    • 8cc omnipaque

    • ~8 of other shit i guess

Small Bowel Follow Through:

• Indications

  • Bowel Obstruction

• Steps

  • Pre-op plain AP film to asses for

    • Ensure NG tube is in proper position

      • Most patients will have this procedure ordered for obstruction so they will usually already have an NG tube

    • Ensure no evidence of perforation (air under diaphragm)

    • Residual contrast from prior procedure

  • Obtain multiple films 15 min, 30 min, 1 hour, and so on until contrast is visualized in the large bowel/colon - look for haustra!

  • Once contrast is visualized in the colon/large bowel you are done and no longer need to get new pictures

Esophagram

• Indications

• Steps

  • Give sip of THIN contrast and check for aspiration - if patient aspirates then you are done

  • Give fizzies with water and allow this to distend stomach - tell patient to resist urge to burp

  • Give THICK contrast and take pictures (sine) in the following positions

    • AP

    • RPO

    • LPO

    • Single lateral (doesn’t matter if right or left)

  • If checking for reflux do the following steps

    • Lay patient down in RAO (stomach down, left leg bent up, right leg straight

    • Give patient one sip of THIN contrast and follow the esophagus to evaluate peristalsis flow while taking sine

    • Give patient multiple continuous sips of contrast to try and overload the stomach and focus on GE junction to see if there is reflux

  • Give barium pill with water and take sine

Cystogram

• Indications

  • Evaluate for bladder leak (commonly done after prostatectomy)

• Patient will have a foley catheter in place for injection of contrast

• Steps

  • Inject 150 ml of contrast (maximum amount to be used) and take non-sine periodically to ensure contrast is actually filling in the bladder

  • Take non-sine in the following postions

  • AP

    • Right lateral

    • Left lateral (get femurs to overlie each other = good lateral)

    • Oblique (doesn’t matter which side)

• Done

Modified Barium Swallow

• Indications

• Steps

  • Give several different mediums (cracker, apple sauce, liquids etc.) each with contrast added to them and take non-sines while eating/drinking to look for aspiration

• Many times it is performed with speech therapy

• Done

Urethrogram

• Indications

• Steps

  • Sterile procedure so will need to don gloves and prep & drape area

  • Inject contrast via pediatric catheter or directly from syringe into penis

  • Take sine while injecting contrast and evaluate for contrast to reach the distal urethra

• Done

Upper GI Series

• Indications

• Need to see upper esophagus down to the duodenum and need to specifically see where the duodenum crosses midline

• Steps

  • Esophagram

  • If doing in a kid or adult laying down, have patient lay on left lateral view while evaluating esophagus this way contrast stays within the stomach while doing the esophagram and does not pass into the duodenum which is the major thing you want to watch

  • Lay patient down and take lateral, RAO, LAO and evaluate stomach and duodenum

  • Duodenal roll - patient right side down and rapid rotation to supine position as bowel fills for the first time - allows you to see the duodenal-jejunal junction

    • Should be done as a continuous fluoro video

• Done

Retrograde Urethrogram

• Prep penis and surrounding area

• Want patient in oblique positioning to start

• Lube the catheter

• Insert catheter and inject contrast with holding catheter through the penis firmly

• Inject contrast until you can see the bladder/proximal urethra

• Ensure to take image with penis elongated (hold out to the side)

• You will be taking fluoros, not sine/exposures

Arthrogram

• Shoulder

  • Mix contrast agents - ratio used here is

    • 15 ml NS : 5 ml omnipaque : 0.1 ml gadolinium

  • Position patient with arm externally rotated

  • Mark target location

    • Target area is upper and inner aspect of head of humerus

    • Ideally should be near level of coracoid?

  • Prep area

  • Numb skin

  • Drop needle in

  • Inject contrast - look to ensure contrast is within the joint space

Loopogram

• Used to evaluate ileal conduit

• pseudo-sterile - since dealing with open bowel essentially, it is not sterile but should wear sterile gloves and clean area with betadine

• use omni

• insert largest foley catheter you can into stoma

• inject contrast

• will likely need to inflate foley balloon and pinch insertion of tube into foley because contrast will push out otherwise

• look for reflux of contrast into ureters and calyces

• reflux is normal and what you want, if there is no reflux that is abnormal

• take sine and stills

Fistulagram

• Used to assess fistula (typically enterocutaneous fistula)

• clean stoma

• insert tube into stoma

• inject contrast and see where the contrast goes

VCUG

• Patient supine and inject contrast into the bladder - take spot fluoro as the bladder is filling

• Take spot images as the bladder fills looking to see if there is any opacification of the ureters or kidneys (may look like dark bowel at first!)

• Put lateral and check insertion site of the ureters if they are opacified

• Keep spot fluoroing the bladder until patient starts to urinate

• once they urinate you want to be fluoro-ing the urethra as they pee to see the contrast leave the urethra - need a fluoro image of the urethra

• If everything was normal you will need to repeat this process again as sometimes first pass does not allow reflux to show adequately

  • This is typically only done for kids <1 yo in whom adequate distention was not achieved (i.e. <75 ml was given before voiding)

• If you see bad reflux you likely do not need to repeat the whole process twice

• Tips - can put patient lateral while in filling phase and take fluoro spot to look for ureteroceles

• Tips - some say you need to remove foley while peeing because it artificially keeps urethra open which gives in accurate results, others say it is wrong to insert foley twice in a kid (stricture risk, traumatic, etc.)

• Tips - if kid refuses to pee, removing the foley commonly helps them to pee

Contrast Enema

• Pediatric

• On lateral will see rectosigmoid junction at about S1-S2 and therefore would want to get a measurement on lateral view above and below this level to compare the recto-sigmoid ratio

• All spot fluoro, not exposure, not sine

• Start lateral and get rectosigmoid filling

• Watch colon fill

• Get RPO for splenic flexure (LUQ) and LPO for hepatic flexure (RUQ)

• Need reflux into TI/small bowel

References: