Contrast Exam~~~~~~~

Image Review

1

The following information is only a personal suggested guideline to

follow when positioning for Contrast exams.

For additional information on positioning of these exams, please

reference your Radiographic Positioning and Related Anatomy

Textbook. 2

EsophagramRoutine Views:

• AP/PA• Lateral• RAO/LPO• LAO/RPO

3

AP/PA Esophagram• Body is supine or prone• Align MS to midline• Ensure no rotation• CR ┴ to IR

• CP is to T5-T6(3”inferior to jugular notch)

• Collimate a hand width• Instruct patient to swallow

barium/expose

4

5

Lateral Esophagram• Body is in lateral recumbent• Midcoronal plane to midline• Ensure no rotation• CR ┴ to IR

• CP is to T5-T6(3”inferior to jugular notch)

• Collimate a hand width• Instruct patient to swallow

barium/expose

6

7

8

Pediatric Patient

9

RAO/LPOEsophagus will be visualized between the

thoracic spine and the heart.

10

RAO/LPO Esophagram• Body is rotated 35°-40°

• CR ┴ to IR

• CP is to T5-T6(3”inferior to jugular notch)

• Collimate to hand width

• Instruct patient to swallow barium/expose

11

12

13

LAO/RPOEsophagus will be visualized through the

heart.

14

LAO/RPO Esophagram• Body is rotated 35°-40°

• CR ┴ to IR

• CP is to T5-T6(3”inferior to jugular notch)

• Collimate to hand width

• Instruct patient to swallow barium/expose

15

16

17

EsophagusPathology

Obstruction

18

EsophagusPathology

Hiatal Hernia

19

EsophagusPathology

Zenker’sDiverticulum

20

EsophagusPathology

Cancer

21

EsophagusPathology

unknown

22

Upper GIRoutine Views:

• AP/PA• RAO• Rt Lateral• LPO

23

Upper Gastrointestinal System

24

I E

A

C

A

H

E

G

Stomach AnatomyC

F

D

B

25

26

Upper Gastrointestinal SystemAir = Black Barium = White

27

For all stomach images…Ask yourself:

What is in the fundus?What is the spine doing?

28

AP/PA UGI• Body is recumbent

• Ensure no rotation

• CR ┴ to IR

• CP for Sthenic is to L1* & 1” left of midline

• CP for Hypersthenic is 2” above L1 & near midline

• *one hand width above crest29

AP PA

What is in the fundus?What is the spine doing? Straight

Barium = Air =

30

RAO UGI• Body is rotated 40°-70°

• CR ┴ to IR

• CP for Sthenic is to L1* -w/45°-55° Oblique

• CP for Hypersthenic is 2” above L1 - w/70° Oblique

• And midway between spine & upside lateral abdomen

• *one hand width above crest31

What is in the fundus?What is the spine doing?

AirObliqued

32

Lateral UGI• Body is in lateral recumbent• Midcoronal plane to midline• Ensure no rotation• CR ┴ to IR

• CP for Sthenic is to L1* & 1-2” anterior to MC plane

• CP for hypersthenic is 2” above L1

• * one hand width above crest

33

What is in the fundus?What is the spine doing?

AirLateral

34

LPO UGI• Body is rotated 30°-60°

• CR ┴ to IR

• CP for Sthenic is to L1* w/45° Oblique

• CP for hypersthenic is 2” above L1 - w/60° Oblique

• And midway between MS & left lateral abdomen

• * one hand width above crest35

What is in the fundus?What is the spine doing?

BariumObliqued

36

UGITechnical

Error:

Positioning error:Centering point is too low. Fundus and pyloric sphincter are clipped.

37

UGITechnical

Error:

Positioning error:Centering point is too low. Fundus is clipped.

38

UGITechnical

Error:

Positioning error:Centering point is too low. Fundus is clipped. And there is motion.

39

UGITechnical

Error:

Positioning error:Centering point is too close to the spine. Body is clipped.

40

Upper GI PathologyHiatal Hernia

PA▲

◄AP41

Upper GIPathology

J-peg tube

42

Upper GIPathology

SitusInversus

of the stomach

43

Upper GIPathology

Peptic Ulcer

44

Upper GIPathology

Pyloric Stenosis

45

Upper GIPathology

Bezoar

46

Upper GIPathology

Cancer

47

Upper GIPathology

Cancer

48

Upper GIPathology

Unknown

49

Small Bowel Follow Through (SBFT)

Routine Views:

• PA/AP(timed)

50

(SBFT)Small Bowel Follow Through• The prone position allows

abdominal compression to separate the various loops of bowel, creating a higher degree of visibility. However follow departmental protocols

51

(SBFT)Small Bowel Follow Through

• Depending on departmental protocol, the Immediate, 15 & 30 min. images are generally centered at least 2” above crest. Additional timed images thereafter are centered at the crest to include pubic bone.

52

(SBFT)Small Bowel Follow Through

• SBFT is complete when the barium enters through the ileocecal valve into the cecum.

53

What quadrant(s) is the:1. Duodenum located? Length?2. Jejunum location? Length?3. Ileum location? Length?4. Ileocecal Valve location?

1. RUQ & LUQ – 10”

2. LUQ & LLQ – 2/5

3. RUQ, RLQ & LLQ – 3/5

4. RLQ54

55

Proximal Stomach & Duodenum Anatomy

56

57

Terminal Ileum & Proximal Colon Anatomy

A

B

C

D

E58

59

SBFTTechnical

Error:

Transverse lock of CR tube is not on center to the table bucky.

60

SBFTTechnical

Error:

Wrong centering.Anatomy is clipped for the appropriately timed image.Wrong

45 min61

SBFTImmediate

Image

Centered higher to include the stomach and duodenum.Good 62

SBFT15 minute

Image

Centered higher to include the stomach and proximal small bowel.Good

63

SBFT30 minute

Image

Centered higher to include the stomach and proximal small bowel.Good 30 min

64

45 min

SBFT45 minute

Image

Centered at the crest to include distal small bowel.Good

65

SBFT4 hourImage

Centered at the crest or slightly below to include distal small bowel/pubic bone.Good

66

Pathology

HiatalHernia

67

SBFT Pathology – Crohn’s

68

SBFTPathology

GastricBypass

69

SBFT Pathology Volvulus

70

Lower GI(BE)

Routine Views:

• AP/PA• LPO/RAO• RPO/LAO• Lateral• AP/PA Axial• AP/PA Axial Oblique• Rt & Lt Decubitus

71

Lower Gastrointestinal System

• Barium Enema - Single Contrast

• Barium Enema - Iodinated, Water-soluble Contrast

• Barium Enema - Double Contrast

• Defecogram – Barium mixed with potato starch

72

Lower GI (Colon) Exams

• Single Contrast - 100-125kV• Iodinated Contrast - 80-90kV• Double Contrast - 90-100kV• Barium/potato starch - 100-125kV

73

◄ Single contrast

Double contrast ►

Barium/Potato Starch

contrast ► 74

Lower GI in relation to the peritoneal cavity:

1. Jejunum?2. Ascending & descending?3. Ileum?4. Duodenum?5. Sigmoid?6. Transverse?7. Rectum?

1. Intraperitoneal

2. Retroperitoneal

3. Intraperitoneal

4. Retroperitoneal

5. Intraperitoneal

6. Intraperitoneal

7. Retroperitoneal & Infraperitoneal 75

What quadrant(s) is the:1. Hepatic flexure?2. Transverse colon?3. Splenic flexure?4. Sigmoid colon?5. Cecum?

1. RUQ

2. RUQ & LUQ

3. LUQ4. LLQ5. RLQ

76

Lower Gastrointestinal System

Hepatic

Flexure

Splenic

Flexure

77

Barium vs Air in Large Intestine

78

PA BE• Body is prone

• Align MSP to Midline

• Ensure no rotation

• CR ┴ to IR

• CP to iliac crest

79

80

RAO/LPO BE• Body is rotated 35°-45°

• CR ┴ to IR

• CP at the iliac crest & 1” to the left of MSP

• Right colic/hepatic flexure

81

82

LAO/RPO BE• Body is rotated 35°-45°

• CR ┴ to IR

• CP 1-2” ABOVE iliac crest & 1” to the upside of MSP

• Left colic/splenic flexure

83

Great positioning… However:On this view the most important anatomy is clipped!

84

Lateral Rectum BE

• Body is in lateral recumbent

• Midcoronal plane to midline

• Ensure no rotation

• CR ┴ to IR

• CP at level of ASIS & Midcoronal Plane

85

86

Lateral Decubitus BE

• Body is in lateral recumbent

• Ensure no rotation with IR

• CR is horizontal to IR

• CP at iliac crest*

• *possibly center higher for when Left colis/splenic flexure is up.

87

88

AP Axial BE• Body is supine

• Align MSP to Midline

• Ensure no rotation

• CR 30°-40° cephalad to IR

• CP 2” inferior to ASIS

89

90

AP Axial Oblique LPO (Butterfly) BE

• Body is rotated 30°-40° LPO

• CR 30°-40° cephalad to IR

• CP 2” inferior and 2” medial to right ASIS

• Elongates sigmoid colon91

92

93

PA Axial Oblique RAO (Butterfly) BE

• Body is rotated 35°-45° LPO

• CR 30°-40° caudad to IR

• CP at the level of the ASIS and 2” to the left of the lumbar spinous processes

• Elongates sigmoid colon94

AP Post Evac BE• Body is supine

• Align MSP to Midline

• Ensure no rotation

• CR ┴ to IR

• CP to iliac crest

95

96

BETechnical Error:

Rectal sigmoid decompressed. Give more air and repeat image.

97

Lower GI Pathology:Ulcerative Colitis

Normal Hustra

98

Lower GIPathology

Diverticulosis

99

Lower GIPathology

Sigmoid constriction

100

Lower GIPathology

Colon Herniated into the chest

101

Lower GIPathology

Herniawith constrictions

102

Lower GIPathology

Colon(Cecum)Cancer

“apple core”103

Urinary System

IVU Routine Views:

• AP & Tomo Scout• Nephrotomogram• Both Obliques• Uprt (opt)• PostvoidCystogram Routine Views:

• AP • Both Obliques• Postvoid/voiding

104

Urinary organs in relation to the peritoneal cavity:

1. Kidneys?2. Ureters?3. Adrenal glands?4. Bladder?5. Reproductive organs?

1. Retroperitoneal

2. Retroperitoneal

3. Retroperitoneal

4. Infraperitoneal

5. Infraperitoneal 105

106

AP Intravenous Urography

• Body is supine

• MS to midline

• Ensure no rotation

• CR ┴ to IR

• CP to level of iliac crest

• At timed intervals

107

108

AP Nephrogram Urography

• Body is supine

• MS to midline

• Ensure no rotation

• 10°-20° angle tomogram

• CR ┴ to IR

• CP midway between xiphoid & iliac crest

109

Understanding Kidney positioning for Tomography slices

Scout: Measure thickness of patient including pad. Divide by 2, then subtract 2.

110

Nephrogram

Tomography

111

LPO/RPO Intravenous Urography

• Body is rotated 30°

• CR ┴ to IR

• CP at the iliac crest

• LPO = Right kidney in profile, proximal left ureter & distal right ureter.

• RPO = Left kidney in profile; proximal right ureter & distal left ureter.

112

LPO RPO113

Oblique IVU

Kidney - UP

Proximal Ureter - DOWN

Distal Ureter - UP

114

AP Uprt/PA Post Void Intravenous Urography

• Body is AP Uprt or prone

• Align MSP to Midline

• Ensure no rotation

• CR ┴ to IR

• CP to iliac crest *MUST include bladder

115

116

IntravenousUrographyPathology

DoubleUreter

117

IntravenousUrographyPathology

StaghornCalculi

118

IntravenousUrographyPathology

Nephrocalcinosis

119

IntravenousUrographyPathology

Pregnancy

120

IntravenousUrographyPathology

Ureteral Stent

121

Intravenous Urography ProcedureSurgical Retrograde

122

AP Cystography

• Body is supine

• MS to midline

• CR 10°-15° caudad to IR

• CP 2” superior to pubic symphysis

123

LPO & RPO Cystography• Body is rotated 45°-60°

• CR 10°-15° caudad to IR

• CP 2” superior to pubic symphysis & 2” medial to upside ASIS

124

Lateral Cystography

• Body is lateral recumbent

• Midcoronal is ┴ to IR

• CR ┴ to IR

• CP 2” superior to and posterior to pubic symphysis

125

◄LPO

RPO►

◄ Lateral

CystographyName the view:

AP/Voiding►126

CystographyPathology

Reflux

127

CystographyPathology

BladderStones

128

Biliary Tract

SystemExams:

• Oral Chole• Surg Chole• Surg T-tube

• ERCP

129

Biliary Tract

Anatomy

130

131

Biliary Tract ProcedureOral Cholecystogram

132

Biliary Tract ProcedureSurgical Cholangiogram w/C-Arm

133

Biliary Tract ProcedureSurgical Postoperative T-tube Cholangiogram 134

Biliary Tract ProcedureEndoscopic Retrograde Cholangiopancreatography (ERCP) 135

~ The End ~

136