UNIVERSITY OF WASHINGTON

HOSPITALS
MANUAL OF GASTROINTESTINAL
AND GENITOURINARY
RADIOLOGY PROCEDURES

CONTRIBUTORS:
Charles A. Rohrmann, Jr., M.D.
Joel E. Lichtenstein, M.D.
William H. Bush, Jr., M.D.
Scott J. Schulte, M.D.
James A. Nelson, M.D.
Sidney W. Nelson, M.D.
Albert A. Moss, M.D.
Patrick C. Freeny, M.D.
Lee B. Talner, M.D.

Revised 11/8/02
 2

TABLE OF CONTENTS
Page
General Considerations 3
Pharyngoesophagram 5
Triphasic Esophagram 10
Water Soluble Contrast Esophagram 13
Single Contrast Upper Gastrointestinal Series 14
Biphasic Upper Gastrointestinal Examination 18
Small Bowel Examination 23
Small Bowel Enteroclysis 25
Double-Contrast Barium Enema (DCBE) 28
Single-Contrast Barium Enema 33
Retrograde Ileostomy, Colostomy 37
Tube Cholangiogram 39
Herniogram 41
Endoscopic Retrograde Cholangiopancreatography/ 43
Endoscopic Sphincterotomy
Hysterosalpingogram 44
Excretory Urogram (EU) 45
Limited Excretory Urogram 50
Cystogram 51
Voiding Cystourethrography 53
Retrograde Urethrography (RUG) 54
Harborview Protocol For CT Urogram (CT IVU) 58

Appendix 1 Preparation Protocols

Esophagram, Pharyngoesophagram, 1-A
Upper GI Series, Small Bowel Series (Outpatient)
Barium Enema (Outpatient) 1-B
Barium Enema (Inpatient) 1-C
Esophagram, Pharyngoesophagram, 1-D
Upper GI Series, Small Bowel Series (Inpatient)
Excretory Urogram/Intravenous Pyelogram 1-E
Appendix 2 Cystograms and Autonomic Dysreflexia
Appendix 3 Contrast Media Summary
Premedication Regimens 3-A
Treatment of Contrast Reactions 3-B
Extravasation of Contrast Medium 3-C
Contrast Reaction Report 3-D
Patient Informational Sheet for Contrast Material 3-E
Injection
Indications for Serum Creatinine 3-F
Contrast Media Available at UWMC 3-G
 3

GENERAL CONSIDERATIONS

No fluoroscopic examination should be considered routine. Each should be

tailored to answer specific clinical questions, even if the task is to document
normality. Blundering through "routine" exams without a goal in mind is routinely
counterproductive.

Get whatever history is available. Always ask about: 1) previous similar

examinations and their results and 2) prior surgery upon the region under study.
Find and LOOK AT any available prior studies and reports BEFORE starting the
procedure. Contact referring physicians to clarify the purpose of the exam.
Review all available requests the evening before the studies and new ones in the
morning to allow timely clarification before the patient is on the table and the
schedule gets backed up. Summarize your plan to your attending before
starting.

Patients should not leave the department before studies are checked for
technical adequacy. The referring physician should be notified at once of any
findings that are unexpected or of immediate clinical importance. For out-
patients, an attempt should be made (and documented) to assure appropriate
follow-up of such findings prior to the patient's departure.

The physicians, not the technologists, are responsible for the smooth progression
of the work. Residents must keep the technologists informed of their
whereabouts at all times.

There are almost as many ways to do GI fluoroscopy as there are fluoroscopists.

The following protocols are designed to produce excellent studies and a
consistent starting point for teaching and learning. All are the result of
compromises and may be modified. Modifications, however, must be justifiable.

We frequently are looking for mucosal disease, which may be demonstrated best
by high-quality double-contrast studies, so these are our routine. Quality implies
excellent coating, distention and preparation. Lack of any of these badly
compromises a double contrast study, often making it misleading or unreadable.
Well performed single contrast studies are capable of excellent results and
generally are preferable to compromised double contrast exams. Advanced age
should not deter a double contrast exam, but limited mobility, or inability to
cooperate, should exclude it.
 4

RADIOGRAPHIC CONTRAST AGENTS:

A wide variety of products are available and usage differs between institutions.
Unfortunately labeling is not well standardized or consistent.

Barium contrast is always a particulate suspension. The concentration may be

specified as the ratio of weight of barium to volume of suspension (W/V) (or, less
commonly, as the ratio of weight of barium to weight of final suspension (W/W))
and for historical reasons is expressed as percentages. The two ratios are similar
for dilute suspensions but diverge rapidly at high concentrations. Four ranges of
concentrations are in common use with variations for special purposes such as
enteroclysis. Dilute (“thin”) 20-25% wt/vol is used for single contrast enemas and
retrograde small bowel studies. Dense (“thick”) barium for air contrast enemas is
85-100% W/V. Regular or medium density (often also called “thin”) for single
contrast UGI’s and general use is usually 60-65% W/V. High density (also often
called “thick” but only minimally more viscous) barium for double contrast UGI’s
is 225-250% W/V.

Iodinated, water soluble contrast is most rationally specified by its concentration

of organically bound iodine, but is often labeled by concentration of the complex
molecule which is commonly about twice the figure for the iodine content.

NOTE! In the following discussions, patient positioning is indicated relative to

the TOP of the fluoro table.

Supine: AP = on back
Prone: PA = on belly
Supine obliquities: LPO = left posterior oblique
RPO = right posterior oblique
Prone obliquities: LAO = left anterior oblique
RAO = right anterior oblique
Lateral: LL = left side down lateral
RL = right side down lateral
 5

PHARYNGOESOPHAGRAM
INDICATIONS:

For anatomic and physiologic evaluation of the pharynx and esophagus. The
examination should be tailored for specific patient problems, rarely will the entire
study be performed.

CONTRAINDICATIONS:

If there is a question of perforation of the esophagus use protocol for water

soluble contrast esophagram.

PREPARATION:

NPO after midnight (no smoking or chewing gum)

MATERIALS:

50 cc 250% w/v barium suspension (See Appendix 2A)

One packet effervescent agent
5 cc water with 2 drops of mylicon
300 cc 60% w/v barium suspension (See Appendix 2A)
1 cm diameter marshmallows
Barium tablets

PREPROCEDURE POINTS:

l. There is no scout film for a pharyngoesophagram.

2. Question the patient regarding relevant chief complaint, prior GI surgery, or

swallowing difficulty and plan the study accordingly.

3. Check that the fluoroscopy unit is fully operational before beginning the
examination.
TECHNIQUE FOR RADIOLOGISTS:

Air contrast evaluation of esophageal mucosa

l. Standing LPO: Have patient put effervescent granules in the back of the
mouth and wash down quickly with water and mylicon. Stress to patient
not to belch.

2. Have patient drink one moderate sized swallow of high-density (250%)

barium and fluoroscopically follow the bolus from the cricopharyngeus
through the EG junction.

3. Position the fluoroscope to frame the esophagus from EG junction to thoracic

inlet, and hold in this position during filming. While the patient is drinking
(gulping) the remaining barium with rapid, successive swallows, film full
length air contrast esophageal views. Encourage the patient to continue
"dry swallowing" after the barium is swallowed and while the filming is in
 6

progress. This will inhibit primary wave activity and enhance distension of
the esophagus.

Air contrast evaluation of the pharynx

1. Standing right lateral: Have the patient hold a moderate sized mouthful of
high density barium and center the fluoroscope at the pharynx. The palate
and cricopharyngeal area should be at the superior and inferior aspects of
the field, respectively.

2. Have the patient gargle and swallow the barium. During prolonged "eee"
phonation and inspiration, take spot films.

3. With patient in the AP projection and with the mandible superimposed over
the occiput, repeat 1 and 2 above.

Full column evaluation of the pharynx

1. Standing right lateral: Have the patient hold one mouthful of medium (65%)
barium, center at the pharynx (as above) and video record two swallows.

2. Standing lateral: Have the patient hold one mouthful of thin barium, center at
the pharynx (as above) and take spot films at 4 per second during
swallowing. Be sure to activate the camera before telling the patient to
swallow by using the “1-2-3-swallow” count and activate camera on “2”.
Film two swallows.

3. Observe the patient's ability to maintain the bolus in the oral cavity, dribbling,
or hesitancy in initiating a swallow, and passage of the bolus into the
oropharynx. This process is oropharyngeal transfer and proceeds as
follows:

l) The tongue actively compresses the bolus against the hard

palate forcing it posteriorly.

2) The soft palate is elevated superiorly and posteriorly to appose

Passavant's cushion to prevent nasopharyngeal regurgitation.

3) The larynx is elevated and the hypopharynx is narrowed by the

action of the pharyngeal constrictors.

4) The epiglottis tilts dorsally and then downward to prevent

aspiration.

5) As the barium bolus touches the posterior pharyngeal wall, the

cricopharyngeus muscle relaxes.

6) Following bolus passage, the cricopharyngeus muscle constricts

initiating the primary esophageal peristaltic wave.

4. Standing AP: Repeat 1. and 2. above.

5. Observe for laryngeal elevation, pharyngeal asymmetry, presence of lateral

pharyngeal pouches, pharyngeal constrictor asymmetry, and asymmetric
 7

epiglottic tilt. Also, note retention of barium in the valleculae and pyriform
sinuses. It is abnormal if present after a dry swallow.

Full column and mucosal relief evaluation of the esophagus

1. Prone RAO: Have the patient take a single medium-sized swallow of

medium-density (65%) barium. Caution the patient not to take a second
swallow which will generate an inhibitory wave. Evaluate esophageal
motility by following the tail of the barium column from the pharynx to the
stomach. Repeat if necessary.

2. Have the patient take several swallows of medium-density (65%) barium in

rapid succession and then perform a Valsalva maneuver as the barium
bolus approaches the distal esophagus. Observe for rings, stenoses, and
hiatal hernia. Take spot films of upper, mid and distal esophagus and of
EG junction during Valsalva. Spot film the esophagus in mucosal relief
(collapsed). A 1 cm marshmallow may be used to determine caliber of
stenosis or ring.
Evaluation for G-E reflux

Evaluate for G-E reflux unless reflux has been noted earlier in the
examination. Have the patient roll through left side down to the supine
position and intermittently fluoroscope to observe for reflux. Note that this
method of rotation accentuates barium filling of the gastric fundus and is
opposite from the rotation for coating the stomach. With patient 10˚ head
down, roll onto right side and return to supine. Observe fluoroscopically
and spot film if reflux. Other stress maneuvers may be considered: with
the fundus filled – in AP or 10° RPO position, Valsalva, coughing and
swallowing.
 8

TECHNIQUE FOR TECHNOLOGISTS:

No scout film.

Post fluoroscopy filming:

RAO esophagus filmed during swallowing,

120 kVp

REFERENCES:

Cunningham ET, Jones B, Donner MW. Normal anatomy and techniques of

examination of the pharynx. Chapter 4, pp. 94-113. In: Freeny and Stevenson,
Alimentary Tract Radiology, 1994.

Rubesin SE, Yousem DM. Pharynx: normal anatomy and techniques. Chapter
15, pp. 202-225. In: Gore, Levine, Laufer, Textbook of Gastrointestinal
Radiology, 1994.
Jones B, Donner MW. Abnormalities of pharyngeal function. Chapter 16, pp.
226-243. In: Gore, Levine, Laufer, Textbook of Gastrointestinal Radiology,
1994.
 9

Examination Summary

Pharyngoesophagram

Objective Patient Position Filming

l. Air contrast Upright:LPO Spot

esophagus

2. Air contrast Upright:R. lat. Spot

pharynx Upright:AP Spot

3. Full column Upright:lat. Video

pharyngeal motility Upright:AP Video

4. Tubular esophagus: Prone:RAO Video

single swallow for
motility

5. Tubular and distal Prone:RAO Spot

esophagus: full column
Valsalva and mucosal
relief

6. Gastroesophageal Turn:RAO:PA:AP:RPO As needed

reflux

Post fluoroscopy filming:

RAO esophagus filmed during swallowing, 120 kVp.

Others at direction of radiologist.
 10

TRIPHASIC ESOPHAGRAM
INDICATIONS:

For anatomic and physiologic evaluation of the esophagus. The triphasic

examination includes air contrast, full column, and mucosal relief views. It can
be combined with the pharyngogram for full evaluation of swallowing disorders
(see pharyngoesophagram protocol).

CONTRAINDICATIONS:

There are no absolute contraindications to this study although it should not be

done in patients suspected of having colon obstruction or esophageal perforation
(a water soluble study should precede).

PREPARATION:
NPO after midnight (no smoking or chewing gum)

MATERIALS:

50 cc 250% w/v barium suspension

One packet effervescent granules
5 cc water with 2 drops of mylicon
300 cc 65% w/v barium suspension
1 cm diameter marshmallows

PREPROCEDURE POINTS:

l. There is no scout film for an esophagram.

2. Question the patient regarding relevant chief complaint, GI surgery, and

swallowing difficulty and plan the study accordingly.

TECHNIQUE FOR RADIOLOGISTS:

Air contrast evaluation of esophageal mucosa

l. Standing LPO: Have patient put effervescent granules in the back of the
mouth and wash down quickly with water and mylicon. Stress to patient
not to belch.

2. Have patient drink one moderate sized swallow of high-density (250%)

barium and fluoroscopically follow the bolus from the cricopharyngeus
through the E-G junction.

3. Position the fluoroscope to frame the esophagus from EG junction to thoracic

inlet, and hold in this position during filming. While the patient is drinking
(gulping) the remaining barium with rapid, successive swallows, film full
length air contrast esophageal views. Encourage the patient to continue
"dry swallowing" after the barium is swallowed and while the filming is in
progress. This will inhibit primary wave activity and enhance distension of
the esophagus.
 11

Full column and mucosal relief evaluation of the esophagus

1. Prone RAO: Have the patient take a single swallow of medium (65%)
barium. Caution the patient not to take a second swallow which will
generate an inhibitory wave. Evaluate esophageal motility by following the
tail of the barium column from the pharynx to the stomach. Repeat if
necessary.

2. Have the patient take several swallows of medium (65%) barium in rapid
succession and then perform a Valsalva maneuver as the barium bolus
approaches the distal esophagus. Observe for rings, stenoses, and hiatal
hernia. Take spot films of upper, mid and distal esophagus while
distended and of EG Junction during Valsalva. Spot film the esophagus in
mucosal relief (collapsed). A 1 cm marshmallow may be used to
determine caliber of stenosis or ring.

Evaluation for G-E reflux

Evaluate for G-E reflux unless reflux has been noted earlier in the
examination. Have the patient roll through left side down to the supine
position and intermittently fluoroscope to observe for reflux. Note that this
method of rotation accentuates barium filling of the gastric fundus and is
opposite from the rotation for coating the stomach. With patient 10˚ head
down, roll onto right side and return to supine. Observe fluoroscopically
and spot film if reflux. Other stress maneuvers may be considered: with
the fundus filled in AP or 10° RPO position, Valsalva, coughing and
swallowing.

TECHNIQUE FOR TECHNOLOGISTS:

No scout film.

Post fluoroscopy filming:

RAO esophagus filmed during swallowing, 120 kVp

REFERENCES:

Laufer I, Levine, M. Double Contrast Gastrointestinal Radiology, Chapter 4,

Saunders, 1992.
 12

Examination Summary

Triphasic Esophagram

Objective Patient Position Filming

l. Air contrast Upright:LPO Spot

esophagus

2. Tubular esophagus: Prone:RAO Video

single swallow for
caliber and motility

3. Esophagus: full column, Prone:RAO Spot

Valsalva and mucosal
relief

4. Gastroesophageal Turn:RAO:PA:AP:RPO +/- Spot

reflux

Post fluoroscopy filming:

RAO esophagus filmed during swallowing, 120 kVp

 13

WATER SOLUBLE CONTRAST ESOPHAGRAM

INDICATIONS AND CONTRAINDICATIONS:

For use when esophageal disruption or postsurgical anastomotic leakage is

suspected. The major contraindication to iodinated water soluble contrast
material is aspiration. In these patients, non ionic media should be considered
as the primary contrast agent.

PREPARATION:

NPO after midnight (no smoking or chewing gum)

MATERIALS:

Iodinated contrast (60-70%). Non-ionic low osmotic contrast if aspiration is a risk.

300 cc 65% w/v barium suspension.
TECHNIQUE FOR RADIOLOGISTS:

This examination is tailored to the clinical indication. Identify the site of

anastamosis or suspected perforation. Emphasize filming of this region. Semi
upright LPO, if possible, should be the initial position with spot filming. Supine
LPO or prone RAO views can follow. Single frame and rapid sequence spot
filming are used as is videotape recording.

If the water-soluble examination does not identify a perforation or leak, single

contrast barium examination should be undertaken.

TECHNIQUE FOR TECHNOLOGISTS:

Filming: Spot filming as dictated by the patient's condition and needs of the
examination.

REACTIONS, SIDE EFFECTS, AND THEIR TREATMENT:

Pulmonary aspiration of water-soluble contrast media is the most serious

potential side effect. The patient should be carefully monitored for development
of pulmonary edema.

REFERENCES:

Skucas J. Contrast media. Chapter 2, pp. 17-30. In: Gore, Levine, Laufer,
Textbook of Gastrointestinal Radiology, 1994.
 14

SINGLE CONTRAST UPPER GASTROINTESTINAL SERIES

INDICATIONS:

For anatomic and physiologic evaluation of the esophagus, stomach and

duodenum. It is especially useful in elderly or disabled patients who are unable
to turn on the fluoroscopic table or when preceding a dedicated small bowel
examination. It should also be used when gastric outlet obstruction is suspected.

CONTRAINDICATIONS:

If there is a question of perforation of the gastrointestinal tract, undiluted

iodinated contrast material should be used. Colonic obstruction is a
contraindication to the use of barium. Postoperative stomachs should be
examined with biphasic technique.

PATIENT PREPARATION:

NPO after midnight (no smoking or chewing gum).

MATERIALS:

360 cc barium 60-70% w/v barium suspension (Barosperse, EZ-Paque or similar)

1 cm marshmallows
Paddle compression device
Lead gloves

PREPROCEDURE POINTS:

l. Examine scout film for free intra-abdominal air, gastric distension, colon
obstruction or retained barium.

2. Question the patient regarding relevant chief complaint, GI surgery, or

difficulty swallowing, and plan the study accordingly.

3. Check that the fluoroscopy unit is fully operational before beginning the
examination.

TECHNIQUE FOR RADIOLOGISTS:

Evaluation of the gastroesophageal junction

1. If patient is able to stand, start upright: With patient LPO to project the
esophagus off the spine, follow 2-3 small swallows from mouth to stomach
observing motility and distensibility.

2. Palpate and compress stomach to coat entire mucosa and to assess

pliability. Spot films optional if abnormality is suspected.

3. Table horizontal, patient supine or slight LPO. Spot gastric mucosal fold
pattern.

4. Turn patient to RAO prone oblique. Spot mucosal fold pattern of fundus &
body.
 15

5. Observe esophageal motility during single swallow. Then obtain drinking

spot images of esophagus. Spot EG junction during Valsalva maneuver.

6. Observe peristalsis in stomach and duodenum. Spot film bulb one view
including antrum and at least one view with sweep filled.

7. With patient prone and hand on patient, raise table. Turn to LPO. Have
patient drink enough barium to distend stomach. If esophageal abnormality
is suspected, spot film esophagus trying for air contrast.

8. Spot distended fundus with barium coming through EG junction, standing

LPO.

9. Examine angularis and spot in best profile (compression optional), standing

AP.

10. Compression spots of duodenal bulb, antrum, C-loop, in LPO & RPO.
Magnified, using 9” or 6” field of view.

11. Place table horizontal and patient L lateral or LPO to get air contrast views
of antrum and bulb. Often no extra gas is needed for this so try without it
first. Consider: A) Effervescent agent to distend questionable areas,
especially fundus. B) Glucagon for distention of suspicious areas especially
bulb and C-loop.
12. Modify as needed especially for patient unable to stand or roll. Begin with
drinking views as near RAO as possible then go for supine or LPO, and
then continue as above. Spot distended fundus with patient prone or prone
oblique and table tilted, or spot it supine distended with barium.
 16

TECHNIQUE FOR TECHNOLOGISTS:

Scout PA abdomen film to show diaphragms, 70-80 kVp

Fluoroscopy spot films 120kVp

Post fluoroscopy filming:

RAO esophagus filmed during swallowing, 120 kVp

RAO stomach, l20 kVp
PA stomach, l20 kVp

REFERENCES:

Gelfand DW. Barium studies: single contrast. Chapter 6, pp. 81-92. In: Gore,
Levine, Laufer, Textbook of Gastrointestinal Radiology, Saunders, 1994.

Nelson SW. Radiol Clin N. Amer. April 1969; 7:5-25.

 17

Examination Summary

Single Contrast UGI

Objective Patient Position Filming

1. Full column Upright: LPO + Spot

Survey esophagus
and EG junction

2. Survey and palpate Upright: LPO - RPO + Spot

stomach

3. Gastric mucosal Supine: AP/LPO Spot

relief
4. Gastric mucosal Prone: RAO Spot
relief

5. Full column Prone: RAO Spot

esophagus

6. EG Junct w/ Prone: RAO Spot

Valsalva

7. Fundus Upright LPO Spot

8. Angularis Upright AP Spot

9. Compression Upright: LPO - RPO Spot

stomach (distended)

10. Duodenal bulb Upright: LPO, Left Spot

(compression, Lateral, RPO
full column)
11. Air contrast Supine: LPO, AP Spot
stomach and
duodenal bulb

12. GE Reflux Turn:AP:LPO:RPO As needed

Post fluoroscopy filming:

RAO esophagus filmed during swallowing, 120 kVp

RAO stomach, l20 kVp
PA stomach, l20 kVp
 18

BIPHASIC UPPER GASTROINTESTINAL EXAMINATION

INDICATIONS:

For anatomic and physiologic evaluation of esophagus, stomach and duodenum.

CONTRAINDICATIONS:

If there is question of perforation of the GI tract, undiluted iodinated contrast

material should be used by the single contrast protocol (p. 13). Food or fluid in
stomach and esophageal or gastric outlet obstruction limit mucosal coating.
Colonic obstruction is a contraindication to the use of barium. Obtunded or
acutely ill patients and patients with likelihood of aspiration should be considered
for alternative methods of evaluation.

PREPARATION:
NPO after midnight (no smoking, or chewing gum).

MATERIALS:

50 cc 250% w/v barium suspension

One packet effervescent agent
5 cc water with 2 drops of mylicon
300 cc 65% w/v barium suspension
1 cm marshmallows
Paddle compression device
Lead gloves

PREPROCEDURE POINTS:

l. Examine scout film for free intra-abdominal air, gastric distension, colon
obstruction or retained barium.

2. Question the patient regarding relevant chief complaint, GI surgery, or

difficulty swallowing and plan the study accordingly.
3. Check that the fluoroscopy unit is fully operational before beginning the
examination.

TECHNIQUE FOR RADIOLOGISTS:

Air Contrast Examination of the Esophageal Muscosa

l. Standing LPO: Have patient put effervescent granules in the back of the
mouth and wash down quickly with water and mylicon. Stress to patient
not to belch.

2. Have patient drink one moderate sized swallow of high-density (250%)

barium and fluoroscopically follow the bolus from the cricopharyngeus
through the EG junction.

3. Position the fluoroscope to frame the esophagus from EG junction to thoracic

inlet, and hold in this position during filming. While the patient is drinking
 19

(gulping) the remaining barium with rapid, successive swallows, film full
length air contrast esophageal views. Encourage the patient to continue
"dry swallowing" after the barium is swallowed and while the filming is in
progress. This will inhibit primary wave activity and enhance distension of
the esophagus.

Air Contrast Evaluation of the Stomach

1. With the patient maintained in the steep LPO position, immediately tilt the
table to the horizontal position. Then have the patient roll to the left 360°
returning to the LPO position.

2. Make a quick fluoroscopic check of the stomach - if the stomach is well

coated, begin filming. If coating is inadequate, have the patient roll to the
right or to a fluoroscopically determined position to optimize coating, then
return to the LPO position.
3. Take air contrast films of the stomach and duodenum:

a. LPO stomach (antrum)

b. AP stomach (body)
c. Right lateral stomach (fundus)
d. LPO, left lateral (duodenum)

Compression Evaluation of the Duodenum and Stomach

1. With the patient RAO prone use the compression paddle to obtain spot films
of the duodenal bulb and pylorus.

2. With the patient PA prone similarly compression film the antrum, body and
fundus of the stomach. Deep inspiration may allow for better fundal
compression.

3. The stomach may also be compressed with the patient AP supine and
upright.
 20

Full column and mucosal relief evaluation of the esophagus

1. Prone RAO: Have the patient take a single swallow of medium (65%)
barium. Caution the patient not to take a second swallow which will
generate an inhibitory wave. Evaluate esophageal motility by following the
tail of the barium column from the pharynx to the stomach. Repeat if
necessary.

2. Have the patient take several swallows of medium (65%) barium in rapid
succession and then perform a Valsalva maneuver as the barium bolus
approaches the distal esophagus. Observe for rings, stenoses, and hiatal
hernia. Take spot films of upper, mid and distal esophagus while
distended and of EG Junction during Valsalva. Spot film the esophagus in
mucosal relief (collapsed). A 1 cm marshmallow may be used to
determine caliber of stenosis or ring.

Full Column and Motility Evaluation of the Stomach and

Duodenum

1. Evaluate gastric motility in the prone RAO by observing the normal peristaltic
waves as they progress from body through the pylorus.

2. Observe the duodenal bulb and sweep through the ligament of Treitz.
Examine for abnormalities of peristalsis, evidence of fixation, or mucosal
disease. Obtain filled spot views.

Evaluation for G-E reflux

Evaluate for G-E reflux unless reflux has been noted earlier in the
examination. Have the patient roll through left side down to the supine
position and intermittently fluoroscope to observe for reflux. Note that this
method of rotation accentuates barium filling of the gastric fundus and is
opposite from the rotation for coating the stomach. With patient 10˚ head
down, roll onto right side and return to supine. Observe fluoroscopically
and spot film if reflux. Other stress maneuvers may be considered: with
the fundus filled in AP or 10° RPO position, Valsalva, coughing and
swallowing.

Air Contrast Evaluation of the Duodenum

If air contrast films of the duodenum were not optimal previously, return
the patient to the LPO position or L Lat. and film the distended duodenum.
 21

TECHNIQUE FOR TECHNOLOGISTS:

Scout AP abdomen film to show diaphragms, 70-80 kVp

Fluoroscopy spot film at 90kVp for air contrast, 120 kVp for single contrast.

Post fluoroscopy filming:

RAO esophagus during swallowing, 120 kVp

RAO stomach, 120 kVp
PA stomach, 120 kVp

REFERENCES:

Laufer I, Levine M. Double Contrast Gastrointestinal Radiology, Chapters 1-5,

pp. 1-156, and Chapter 10, pp. 321-362, Saunders, 1992.

Laufer, I. Barium studies: principles of double contrast diagnosis. Chapter 4,

pp. 38-49. In: Gore, Levine, Laufer, Textbook of Gastrointestinal Radiology,
Saunders, 1994.
Rubesin SE, Laufer, I. Chapter 5, pp. 50-80. In: Gore, Levine, Laufer, Textbook
of Gastrointestinal Radiology, Saunders, 1994.

Harris KM, Roberts GM, Lawrie DW. Normal anatomy and techniques of
examination of the stomach and duodenum. Chapter 14, pp. 382-310. In:
Freeny, Stevenson, Alimentary Tract Radiology, Mosby, 1994.
 22

Examination Summary

Biphasic Upper Gastrointestinal Examination

Objective Patient Position Filming

l. Air contrast Upright: LPO Spot

esophagus

2. Air contrast Supine: LPO, AP, Spot

stomach right lateral

3. Air contrast Supine: LPO,

duodenum left lateral Spot

4. Compression Prone: RAO, PA Spot

stomach,
duodenum

5. Tubular esophagus: Prone:RAO Video

Full column for Spot
caliber and motility

6. Distal esophagus: Prone:RAO Spot

full column and
mucosal relief

7. Stomach and Prone:RAO Spot

duodenal sweep:
filled, motility

8. GE reflux Roll:RAO, left

decubitus, AP, RPO As needed

9. Air contrast Supine: LPO Spot

duodenum
(if not obtained
3. above)

Post fluoroscopy filming:

RAO esophagus during swallowing, 120 kVp

RAO stomach, 120 kVp
PA stomach, 120 kVp
 23

SMALL BOWEL EXAMINATION

INDICATIONS:

For anatomic and physiologic examination of the small intestine

CONTRAINDICATIONS:

Intestinal perforation, colonic obstruction

PATIENT PREPARATION:

NPO after midnight (no smoking, or chewing gum)

MATERIALS:

360-720 cc (12-24 fluid oz.) 65% w/v barium suspension

Paddle and “spoon” compression devices
Lead gloves

PREPROCEDURE POINTS:

l. Examine scout film for free intra-abdominal air, gastric distension, or retained
barium.

2. Question the patient regarding relevant chief complaint, GI surgery, or

difficulty swallowing, and plan the study accordingly.

3. Check that the fluoroscopy unit is fully operational before beginning the
examination.

TECHNIQUE FOR RADIOLOGISTS:

1. If this examination is done as a primary examination, i.e., an UGI study did

not precede it, give the patient 720 cc of 65% w/v barium. If this study is
to follow an UGI examination, the technologist should give the patient 360
cc of 65% w/v barium in addition to that given with the upper GI series.

2. Fifteen minutes following ingestion, with the patient supine, manually

separate, compress and inspect all barium filled loops of small bowel
using a quadrant approach: Left upper quadrant, then left lower quadrant,
then right upper quadrant, then right lower quadrant. Oblique or lateral
positions may be needed to optimally visualize the segments in profile.
Spot film all quadrants. A PA film should be obtained at this time.
 24

3. Re-film the patient and repeat fluoroscopic examinations as above in

approximately 30 minutes. If fluoroscopy is not available, obtain a PA film.
Fluoroscopy should follow as soon as possible. This process should be
repeated as scheduled by the radiologist. Spot film segments not flimed
before. If the bowel loops are inadequately opacified, more barium may
be needed. The examination is completed when the terminal ileum is
visualized, examined, and filmed.

TECHNIQUE FOR TECHNOLOGISTS:

Scout AP abdomen film to show symphysis pubis

(if not taken before upper GI), 70-80 kVp

Post fluoroscopy filming:

PA abdomen films as requested by radiologist,

120 kVp
If patient immobile: AP supine films, 120 kVp

REFERENCES:

1. Summers S, Stevenson GW. The Small Bowel: Anatomy and Nontube

Examinations. Chapter 25, pp. 512-532, In: Freeny and Stevenson,
Alimentary Tract Radiology, 1994.
 25

SMALL BOWEL ENTEROCLYSIS (SMALL BOWEL ENEMA)

INDICATIONS:

For detailed evaluation of small bowel for intrinsic masses or sites of partial
obstruction.

Can be accomplished by double contrast (with methylcellulose) or single contrast

technique.

CONTRAINDICATIONS:

Gastric outlet obstruction or contraindications to barium administration

PREPARATION:

Schedule only after contact with requesting attending physician. (Attending to

attending contact.) Patient's physician must explain procedure to patient,
including need for small bowel intubation and duration of procedure, and
possibility of rectal air insuflation.

Patent should have liquid only dinner prior evening then NPO except medication
laxative such as Dulcolax evening prior unless contraindicated.

MATERIALS:
Silicone fluid for guidewire lubrication
Cetacaine spray
Maglinte small bowel balloon catheter with guide wire
10 cc syringe
Five 60 cc Luer lock syringes
Tongue depressor
Gloves, nonsterile
Lead lined gloves
1 box 4 x 4 gauze pads
1 towel
Emesis basin
Extension tubing for syringe
Glucagon
Viscous Lidocaine for nasal anesthesia

For double contrast:

50-85% w/v barium sulfate suspension (Entero-H or Enterobar)
2 liters warm methylcellulose 0.5% solution (dilute 1% 1:1 with water)

For single contrast:

20-30% w/v barium suspension
 26

PREPROCEDURE POINTS:

1. Examine the scout film for free intraperitoneal air, distended fluid filled bowel
loops, or signs of gastric outlet obstruction

2. Explain to patient the details of the examination.

3. Check that the fluoroscopy unit is fully operational before passing the
intestinal catheter.

TECHNIQUE FOR RADIOLOGISTS:

1. Apply silicone lubricant to guidewire.

2. Anesthetize the oropharynx with cetacaine spray. One spray of one second
may be repeated once. Have the patient gargle the spray and then spit
contents into emesis basin

3. Lubricate catheter and nostril with Viscous Lidocaine.

4. With patient in a sitting position on the fluoroscopy table, pass the Maglinte
catheter per orally into the stomach.

5. Start with the patient in the supine position and advance the catheter past the
ligament of Treitz under fluoroscopic localization. Because reflux of barium
or methylcellulose into the stomach results in vomiting, optimal tube position
is past the ligament of Treitz. Instruct patient to keep the catheter in place
by holding it at their lips. Inflate the catheter balloon while monitoring
fluoroscopically.

6. For double contrast enteroclysis:

a. Administer 150-400 cc of barium at an approximate rate of 75-100

cc/min. Administer until barium column reaches proximal ileum.
Fluoroscopically monitor the appearance of opacified jejunum.

b. Administer methylcellulose at a rate of 100-150 cc/min and observe

intermittently the distal barium column and the more proximal loops
with the double-contrast effect. Using palpation and patient position
changes, visualize all bowel loops, and document normal and
abnormal regions with spot films.

c. When the advancing barium column reaches the cecum, stop and
obtain overhead films. If all of the small bowel has not been
completely evaluated, continue methylcellulose administration and
obtain double contrast effect to the distal ileum with spot filming.
 27

d. When the examination is completed, deflate the catheter balloon and

remove the catheter.

6. For single contrast enteroclysis:

a. Administer barium suspension at approximate rate of 75-100 cc/min

and observe with intermittent fluoroscopy to confirm satisfactory
passage of barium and to examine for obstructive or intraluminal
lesions. Using palpation and patient position changes, visualize all
bowel loops and document normal and abnormal regions with spot
films.

b. When the advancing barium column reaches the cecum and right
colon, stop and obtain overhead films.

c. When the examination is completed, deflate the catheter balloon and

remove the catheter.

TECHNIQUE FOR TECHNOLOGISTS:

Scout PA abdomen film to show symphysis pubis, 70-80 kVp.

Post-fluoroscopy filming:

Use vertical filming for normal sized patients, horizontal filming for large patients.

PA, RAO, LAO abdomen films, 90 kVp for double contrast and 120 kVp for single
contrast.

REFERENCES:

Herlinger H. Barium examinations of small bowel. Chapter 43, pp. 766-766. In:
Gore, Levine, Laufer, Textbook of Gastrointestinal Radiology, Saunders, 1994.

Maglinte DDT. Biphasic enteroclysis with methylcellulose. Chapter 26, pp. 533-
547. In: Freeny and Stevenson, Alimentary Tract Radiology, Mosby, 1994.
 28

DOUBLE CONTRAST BARIUM ENEMA (DCBE)

INDICATIONS:

The DCBE permits visualization of mucosal detail. For this reason it is

considered the radiographic examination of choice in the evaluation of
inflammatory bowel disease and for detection of small neoplasms.

CONTRAINDICATIONS:

If there is a question of perforation of the colon, a single contrast examination

with iodinated contrast material should be used. Contraindications include toxic
colon, any polypectomy within the past 14 days or biopsy through a rigid
sigmoidoscope in the same interval.

PREPARATION:
See barium enema preparation sheets (Appendices 1-B,C).

MATERIALS:

500 cc 100% w/v high density barium

Double contrast barium bag and tip with air cuff
Air insufflator (blue bulb)
Paddle and “spoon” compression devices
Lead gloves
Examination gloves and lubricant
IV pole
Small-hemostat (plastic c1amp on the white
air cuff will not suffice)
Glucagon (do not premix)
Lucite wedge for decubitus films

PREPROCEDURE POINTS:

l. Examine the scout film for free intraperitoneal air, distended fluid filled bowel
loops, retained barium or residual fecal material, and for abnormalities
which might be obscured by barium.

2. Check that the fluoroscopy unit is fully operational before inserting the enema
tip.

3. Do not administer glucagon if there is a history of hypersensitivity to a prior

injection, or in patients with pheochromocytoma or insulinoma.

4. If glucagon is administered to a diabetic, the patient and their physician

should be notified as it might alter blood glucose.

TECHNIQUE FOR RADIOLOGISTS:

In addition to the points listed under general information, the following are some
specific considerations in the DCBE.
 29

1. Prior to the start of the examination, introduce yourself and briefly explain the
sequence of the examination to the patient. Question patient regarding
adequacy of preparation. Explain that the colon will feel very full, but is
not painful to the majority of patients. (ex: "Your doctor has asked me to
examine your large intestine. This is a very important examination as it
can determine the presence of serious disease which may not cause
symptoms nor be detectable by a physical examination. Thus, it is
important to continue the exam even if you feel discomfort or pressure.
We will do the exam as rapidly as possible. Let us know of any problems
you may have during the exam.") Patients who understand exactly what
will be happening will better be able to tolerate the examination, thus
allowing a more diagnostic study.

2. Preliminary rectal examination: with the patient in the left lateral decubitus
position, perform a careful rectal examination checking for mass, stricture,
stool and the direction of the anal canal. Never insert an enema tip
without first performing a digital rectal examination.
3. With gentle pressure, insert the enema tip so that the collapsed balloon lies
totally within the rectal ampulla. Turn the patient to the prone position.

4. Prior to inflating the rectal balloon, put in a small amount of barium and
confirm location of the enema tip in the rectal ampulla under fluoroscopy.
The height of the barium bag should not exceed 1 meter. Inflate the
balloon with fluoroscopic monitoring so that it touches the rectal margin
but does not deform it. Ascertain that there is no stricture, or obstructing
lesion. Gentle traction to snug the balloon against the internal sphincter
will help prevent leakage. Do not inflate a rectal balloon in patients with
proctitis, rectal carcinoma or rectal surgery.

5. Administer barium with gravity flow to the level of the splenic flexure. Head-
down positioning will assist barium flow.

6. As the barium passes into the mid transverse colon, turn off the barium and
insufflate with air to advance the barium across the transverse colon to the
hepatic flexure. Turn patient to the right decubitus position and then
supine to facilitate flow through the flexure.

7. Confirm barium has reached ascending colon, place the patient supine and
then erect. Place the enema bag on the foot board and drain the barium.
Repeat with air insufflation as needed.

8. Return the table to the horizontal position and, with the drainage tube
clamped, continue air insufflation. Spot film the recto-sigmoid in
appropriate obliquities (LPO, left lateral & RAO) while rotating the patient
360° to the left, adding air to propel the barium and maintain distension.

9. Maneuver the patient to assure good barium coating of the right colon and
adequate distention.

10. Place patient erect and spot film first the splenic flexure (RPO) then the
hepatic flexure (LPO).
 30

11. Lower table to the horizontal and spot the cecum at least twice in optimal
supine or LPO projections. If cecum is full of barium and/or medially
positioned, place patient right side down and lower table head down to
drain cecum. Then, with head still down return to LPO and spot cecum as
above.

12. Quickly recheck entire colon, cecum to sigmoid, respotting any previously
suboptimally visualized or questionable segments. Before leaving the
room, check to make sure that the colon is well distended with air.

TECHNIQUE FOR TECHNOLOGISTS:

Scout AP abdomen film to show symphysis pubis, 70-80 kVp

Post-Fluoroscopy Filming:

Use vertical filming for normal sized patients, horizontal filming for large patients.
Right and left lateral decubitus films obtained with 8 to 1 cross hatch grid, 90 kVp

PA and AP abdomen to show the entire colon, 90 kVp

15° RAO rectosigmoid with 35° caudad angulation (if a large right sided sigmoid
loop exists, substitute PA
with 35° caudad angulation), 90 kVp

Prone, cross-table lateral rectum, with slight head-down positioning, 90 kVp

*Balloon tip should be removed for last two films.

POTENTIAL PROBLEMS:

Inability to retain barium and air

Poor rectal tone and/or colonic spasm may render some patients unable to retain
the barium and air necessary for the examination. Initially, encourage the patient
to relax by taking slow breaths and apply downward traction to the rectal balloon.
If there is persistent colon spasm or hyper-motility and difficulty in retaining the
barium, 0.5-1.0 mg of glucagon may be administered intravenously slowly over 1
minute to aid bowel relaxation. Contraindications to glucagon use include
pheochromocytoma and insulinoma.

Failure to fill the riqht colon with barium

Patients with tortuous redundant loops of colon may require larger amounts of
barium to make it easier to ensure filling the right colon. Rolling the patient
allows gravity to be of help in directing barium flow. Fluoroscopic observation is
crucial in moving the barium into the intended loops. For example, with a
tortuous hepatic flexure, one occasionally may have to first place the patient in
the LPO or left lateral position and then into supine, head-down, right lateral, and
upright positions in order to allow the barium to travel through redundant loops
and reach the cecum. When difficulty is encountered, do not continue to
forcefully administer air to excessive amounts which may prevent completion of
 31

the examination. Take the time to evaluate where the difficulty is and which
maneuvers may be helpful.

Identification of a constricting lesion

Correct identification of constricting neoplasms in the colon requires exclusion of

spasm simulating a real lesion. Annular lesions should be reexamined following
the administration of 1.0 mg glucagon intravenously if the appearance is atypical.
Barium should not be forced proximal to a severe stenosis.

REFERENCES:

Laufer, I. Double Contrast Barium Enema: Technical Aspects. Chapter 12, pp.
423-446. In: Double Contrast Gastrointestinal Radiology, 2nd ed., W. B.
Saunders, 1992.

Laufer I. Barium studies of the colon. Chapter 57, pp. 1028-1040. In: Gore,
Levine, Laufer, Textbook of Gastrointestinal Radiology, Saunders, 1994.
 32

Examination Summary

Double Contrast Barium Enema

Objective Patient Position Filming

1. Inflate balloon Prone : small amount --

of barium in rectum

2. Barium into Prone, head-down, turn --

descending colon off barium at mid-transverse
colon

3. Barium into Prone, right lateral, supine --

transverse &
right colon

4. Drain barium Erect/AP --

5. Recto-sigmoid Head-down, supine to LPO Spots

filming with air left lateral to prone to RAO
insufflation to supine

6. Flexure filming Upright:

Splenic flexure - RPO Spot
Hepatic flexure - LPO Spot

7. Cecum filming Supine: LPO, AP Spots

8. Colon Survey Supine, Obliques prn --

Post fluoroscopy filming:

Right and left lateral decubitus, 90 kVp
PA and AP abdomen, 90 kVp

15° RAO rectosigmoid with 35° caudad

angulation, 90 kVp
Prone, cross table lateral rectum, 90 kVp
*Balloon tip should be removed for the last two films.
 33

SINGLE-CONTRAST BARIUM ENEMA

INDICATIONS:

For anatomic and physiologic evaluation of the colon. Especially for colon
obstruction, intussusception, subacute diverticulitis, fistula, and in some patients
with complications of inflammatory bowel disease.

CONTRAINDICATIONS:

If there is a question of free perforation of the colon, iodinated contrast material

should be used. Contraindications include toxic colon, any polypectomy within
the past 14 days or biopsy through a rigid sigmoidoscope in the same interval.
Incomplete preparation is a relative contraindication. Patients suspected of
having inflammatory bowel disease or who are referred for colon cancer
screening are best studied by double contrast barium enema.
PREPARATION:

See barium enema preparation sheet.

MATERIALS:

20% w/v barium suspension or 40% powdered hypaque

Barium infusion bag and tip with air cuff
Paddle compression device
Lead gloves
Examination gloves and lubricant
IV pole
Hemostat
Glucagon (do not premix)

PREPROCEDURE POINTS:

Same as DCBE
TECHNIQUE FOR RADIOLOGISTS:

Follow sequence 1-4 of DCBE protocol except position the patient supine to
initiate the fluoroscopic portion of the examination.

l. Supine: AP, LPO, and L. Lat. RPO - Center at the rectosigmoid. With control
of barium flow, fill to the sigmoid colon and make spot films in RPO or
LPO and lateral positions as necessary. Spot film the rectum AP and left
lateral.

2. Supine RPO: Center at the distal descending colon. Adjust the patient's
position such that the descending colon is adjacent to the spine.
Compress and spot film each segment in profile distal to proximal.

3. Supine: Center at the left transverse colon. Compress and spot film each
segment in profile left to right, obliquing the patient as needed.
 34

4. Supine LPO: Center at the hepatic flexure. Adjust the patient's position such
that the ascending colon is adjacent to the spine. Spot film the hepatic
flexure in profile.

5. Supine LPO: Center at the cecum. Examine the distended cecum in two
positions (90° to each other, i.e., RPO/LPO) en face and in profile. Spot
film the cecum with compression.
 35

TECHNIQUE FOR TECHNOLOGISTS:

Scout AP abdomen film to show symphysis pubis, 80 kVp

Post fluoroscopy filming:

Use longitudinal filming for normal sized patients,

transverse filming for large patients.

With the colon filled:

PA and AP abdomen, RAO, LAO obliques to show the entire colon, 120
kVp

15° RAO rectosigmoid with 35° caudad angulation, 120 kVp

(If patient is unable to be prone use LPO and 35°
cranial angulation.)
10 x 12 lateral rectum with slight
Head-down positioning, 120 kVp

*Balloon tip should be removed for last 2 films.

Post-evacuation:

AP abdomen to show the entire colon, 120 kVp

REFERENCES:

Stevenson GW. Normal anatomy and techniques of examination of the colon.

PP. 692-724. In: Freeny and Stevenson, Alimentary Tract Radiology, Mosby,
1994.
 36

Examination Summary

Single Contrast Barium Enema

Objective Patient Position Filming

1. Rectosigmoid Supine: RPO, LPO, Spot

Left lateral

2. Descending colon Supine: AP, RPO Spot

and splenic
flexure

3. Transverse Supine: AP Spot

colon
4. Hepatic flexure Supine:LPO Spot
and ascending
colon

5. Cecum AP, RPO, LPO Spot with & w/o

compression

Post fluoroscopy filming:

With colon filled:

PA and AP abdomen, 120 kVp

15° RAO rectosigmoid with 35° caudad
angulation, 120 kVp
Lateral rectum with slight head-down positioning,
120 kVp

*Balloon tip should be removed for the last film.

Post evacuation:

AP abdomen, 120kVp
 37

RETROGRADE ILEOSTOMY, COLOSTOMY

INDICATIONS/CONTRAINDICATIONS:

Retrograde ileostomy or colostomy is indicated for evaluation of recurrent or new

disease in the postoperative intestine, bowel obstruction, or stomal dysfunction.
Contraindications include suspected bowel perforation.

PATIENT PREPARATION:

Ileostomy: NPO after midnight.

Colostomy: See barium enema preparation sheet.

MATERIALS:

20% w/v barium suspension

Barium infusion bag
Lead gloves
Paddle compression device
Examination gloves and lubricant
IV pole
Hemostat
18-24 French Foley catheter with 30 cc balloon or EZEM cone catheter.

TECHNIQUE FOR RADIOLOGISTS:

1. Use a colostomy irrigation bag or work through a hole in a regular colostomy

bag to contain spillage and collect evacuated material.

2. With the patient supine, do a gentle digital examination of the stoma. Using a
large Foley catheter, fully inflate the balloon externally, coat the catheter tip
and stoma with lubricant, and carefully cannulate the stoma with the tip of
the catheter. The balloon should not be inflated inside the stoma. The
inflated balloon will allow an external seal if compressed firmly by the
patient. Have the patient wear a glove on the hand closest to the stoma
and instruct them to place the Foley catheter between two fingers and
compress the balloon firmly against the stoma.

Alternatively, specially designed ‘ostomy cone’ injection devices may be

used.

3. Instill the barium by gravity flow with the bag not exceeding one meter above
the table top. After instilling the first 25-50 cc's, turn the patient laterally as
steeply as possible and spot film the stoma in profile. With the patient then
in the supine position, fill the proximal bowel either to the ileocecal valve
(colostomy) or to the duodenum (ileostomy).

4. Carefully fluoroscope with compression and spot film any abnormalities.

When studying a colostomy that is double-barreled or which is vented by a
distal ostomy or by the rectum, use of inflated balloons, gloves, or other
devices may be required in order to allow bowel distention without
excessive contrast spill. In these situations (e.g., studying both the
proximal and distal limbs of a diverting colostomy prior to reanastomosis),
 38

plan the most rational approach to the problem. Generally, if colonic

segments both proximal and distal to a colostomy (e.g. “Loop” or Double
Barrel Colostomy or Oversewn Distal Loop (Hartmann Pouch)) are to be
studied, the distal portion is studied first.

TECHNIQUE FOR TECHNOLOGISTS:

Scout AP abdomen film to show symphysis pubis, 70-80 kVp

Post fluoroscopy filming:

Ileostomy:

AP, LPO and RPO abdomen, 120 kVp

Colostomy:
AP, LPO, RPO and left lateral decubitus, 120 kVp

AP abdomen following evacuation, 120 kVp

 39

TUBE CHOLANGIOGRAM
INDICATIONS AND CONTRAINDICATIONS:

The tube cholangiogram is used postoperatively to evaluate the biliary duct

system for stones, strictures, tumors, or anatomic variants.

PATIENT PREPARATION:

No solid foods should be taken after midnight. Clear fluids may be taken as
desired.

MATERIALS:

Conray 43
K51 extension tubing
L. lock syringe
TECHNIQUE FOR RADIOLOGISTS:

1. After obtaining the scout film, the biliary tube should be attached with a
connecting tube to the syringe of contrast material. Air should be aspirated
from the system. Be careful not to put traction on the tube or the infusion
apparatus with the image intensifier or shielding devices.

2. With the patient supine or slight RPO, use extremely gentle hand pressure
and slowly inject contrast material to fill the biliary duct system. Obtain
early spot films and then filled spot films.

3. To fill the left hepatic ducts, LPO or left lateral positioning may be needed.
The junction of the right and left hepatic ducts is usually best demonstrated
in LPO position.

4. Tilt the patient’s feet down until drainage of the common bile duct into the
duodenum can be documented. Spot film filled and emptying.
5. Do not over distend the ductal system, since this can cause pain, vagal
reaction, or biliary-venous reflux of potentially infected bile. It is especially
important in liver transplant patients to avoid distension of the system. For
such examinations, contrast opacification of the extrahepatic duct systems
and only the central portion of the intrahepatic duct systems is required.
Fluoroscopically monitor for pancreatic duct reflux. Try to minimize such
reflux by decreasing injection pressure and positioning the patient in an
RPO position.
 40

6. When the entire system has been examined fluoroscopically, the procedure
can be terminated after all spot films have been examined and approved. If
an overhead film is desired, put the patient back into head-down position
(15˚ maximum) and in the RPO supine position for film of the right upper
quadrant. When the technician is ready to take the film, instruct the patient
to stop breathing in mid expiration, and inject 5-10 cc of contrast media
(previous fluoroscopically controlled filling will allow an estimate of the
volume required) before instructing the technician to make the exposure.
Extra films or views may be indicated based on your fluoroscopic
observations. Remember, any air bubbles causing apparent filling defects
can be better defined by obtaining upright and decubitus views in order to
make the air rise in the ductal system. When films have been evaluated
and you are satisfied that the entire ductal system has been evaluated,
unclamp the tube (if previously unclamped), remove the needle and
discharge the patient.

TECHNIQUE FOR TECHNOLOGISTS:

Obtain a scout film of the patient's right upper quadrant centered at the site that
the t-tube appears to enter the patient's abdomen. Use 110 kVp technique and
show the film to the examining radiologist.

When fluoroscopy is complete the procedure may be terminated unless the

radiologist feels an overhead film is necessary. If an overhead film is obtained,
use a 110 Kvp technique as the radiologist fills the ducts. Occasionally the
radiologist may ask for a decubitus film or for a post drainage film, which should
be obtained using the same techniques as the scout film unless the technique
has to be increased to account for a large panniculus on a decubitus film.

REFERENCE:

Thompson WM, Halvorsen RA, Gedgaudas K, et al. High Kvp vs. low Kvp for t-
tube and operative cholangiography. Radiology 146:635-642, 1983.

Letourneau JG, Thompson WM. Intraoperative and postoperative

cholangiography. Seminars in Ultrasound, CT and MR 1987;8:126-133.
 41

HERNIOGRAM (PERITONEOGRAM) (STERILE PROCEDURE)

INDICATIONS:

Search for occult hernias in patients with unexplained groin pain.

PATIENT PREPARATION:

NPO for 4 hours. Empty bladder immediately before study.

MATERIALS: (syringes, needles to be set out on sterile field)

Betadine with Tray & 4 x 4’s

1-20G spinal needle
1-25G spinal needle for deep local anesthesia (not
contrast)
60 cc Optiray 320, or other low osmolality, nonionic
contrast medium, in Luer lock syringe
1-K-51 extension tubing
Lidocaine 1% in 10 cc syringe
2- 18G needles (pink)
1- each 25G 5/8 and 1/2” needle
Sterile towels or drape
Band-Aid

TECHIQUE FOR RADIOLOGIST:

1. Scout: PA abdomen, 20 degree head up (center low to include scrotum)

2. IV started with saline drip to hydrate patient. (they tend to faint!) (Know
where atropine is located.)

3. Prep and drape lower abdomen.

4. Anesthetize skin and subQ tract with Lidocaine in midline halfway between
umbilicus and symphysis.

5. With patient supine 20 degrees head up, insert 20-gauge spinal needle
attached by connecting tube to contrast. May feel “pop” passing through
peritoneum. Use tiny test injections rather than aspiration beyond
superficial layers to avoid potential contamination with bowel contents.
Contrast should flow without resistance and spread around bowel loops. If
not, needle is likely still in abdominal wall. Inject whole syringe and remove
needle.

6. Keeping table 20˚ head up, turn patient prone and roll side to side with
intermittent straining. Obtain spot films PA and both obliques. Be sure
lead R or L markers are on correct side of tower for prone films. Observe
at rest, with straining and with maneuvers that accentuate the patient’s
symptoms.

7. Post:

PA prone 20˚ head up

 42

TECHNIQUE FOR TECHNOLOGISTS:

Scout: PA abdomen semi-upright 20˚ head up (center low to include scrotum)

Foot board must be on so spot films can be taken immediately after

injection

Post:
PA abdomen semi-upright

REFERENCES:

Ekberg O. Inguinal herniography in adults: Technique, normal anatomy, and

diagnostic criteria for hernias. Radiology 1981 (Jan);138:31-36.
Harrison LA, et al. Abdominal wall hernias: review of herniography and
correlation with cross-sectional imaging. Radiographics 1995; 15:315-332.

Van den Berg JC, Stijk SP. Groin hernia: role of herniography. Radiology 1992;
184:191-194.

Ekberg O. Complications after herniography in adults. AJR 1983(Mar); 140:491-

495.
 43

ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP) AND ENDOSCOPIC
SPHINCTEROTOMY (ERS)
INDICATIONS AND CONTRAINDICATIONS:

ERCP is indicated for evaluation of diseases affecting the pancreatic and biliary
duct systems. It is done as a close cooperative effort with experienced
gastrointestinal endoscopists. ERS is indicated for treatment of common bile
duct stones and relief of distal bile duct obstruction. It can be used to open the
distal common bile duct to allow placement of stents, drainage catheters, and
dilating balloons. Contraindications include gastric outlet obstruction and
intestinal perforation.

TECHNIQUE FOR RADIOLOGISTS:

The radiologists' contributions to these procedures are: l) consultation regarding

the appropriateness of the examination and review of prior studies, 2)
fluoroscopic monitoring during contrast injection, 3) appropriate filming to
demonstrate normal or pathologic anatomy, 4) interpretation of the radiographic
results and consultation.
TECHNIQUE FOR TECHNOLOGISTS:

Preliminary and post procedure abdomen with the diaphragms visible.

Filming Kvp: 75 Kvp for pancreatic duct and normal bile ducts
85 Kvp for dilated bile ducts

Contrast material: Conray 60 or similar

REACTIONS, SIDE EFFECTS, AND THEIR TREATMENT:

Reactions to intraductal contrast material are nearly nonexistent due to the small
amount of contrast used and the prolonged time of injection. Overfilling of the
pancreatic duct can cause hyperamylasemia and should be prevented by limiting
opacification to secondary duct filling. Reactions, side effects, and treatment
relating to medications administered by the gastroenterology team and
complications of the endoscopic procedure may require specific therapy by the
medical team managing the patient.

REFERENCES:

Silvis SE, Rohrmann CA, Ansel HJ. Text and Atlas of ERCP. Igaku-Shoin, New
York, 1995.
 44

HYSTEROSALPINGOGRAM
INDICATIONS AND CONTRAINDICATIONS:

Hysterosalpingography (HSG) is indicated for assessment of uterine anatomy,

tubal patency and peritubal diseases. HSG has frequent and specific use in the
workup of infertility, habitual abortion, and prior to tubal reanastomosis.
Pregnancy is a contraindication to the study.

TECHNIQUE FOR RADIOLOGISTS:

When accomplished in cooperation with members of the Obstetrics and

Gynecology faculty, the radiologist provides fluoroscopy during uterine injection,
obtains spot films appropriate to demonstrate the anatomy, and provides
interpretative consultation. Spot film Kvp - 80. It is important to watch for
intravasation during injection of oil-based contrast medium due to danger of
pulmonary embolism. Alert gynecologist to stop injection.
TECHNIQUE FOR TECHNOLOGISTS:

Assist OB/GYN physician and radiologist to prepare contrast media as

designated by the attending physician:

Water soluble contrast media: Sinografin (diatrizoate meglumine and

iodipamide meglumine; 38% I)

Oil contrast medium: Ethiodol (iodized fatty acids of poppy seed oil; 37%
I)
 45

EXCRETORY UROGRAM (EU) (IVP)

INDICATIONS:

For anatomic and physiologic evaluation of the kidneys, pelvocalyceal system,

ureters, and bladder

CONTRAINDICATIONS:

Although there are no absolute contraindications to EU, there are clinical

situations where patients may be at risk if intravascular contrast material is
administered. Any patient with abnormal renal function (particularly if caused by
diabetes, multiple myeloma, or markedly elevated uric acid levels) is at risk for
worsening of renal dysfunction by the contrast medium, and efforts should be
made to obtain the necessary diagnostic information from a noncontrast imaging
method such as plain tomography, CT without contrast, ultrasound, nuclear
medicine or MRI. Prior allergic reaction to contrast media is a significant risk
factor but is not an absolute contraindication. If, on reevaluation, the EU is felt
necessary it may be done if the patient is pretreated with corticosteroids
(Appendix 3A) and nonionic contrast material is used (possibility of reaction
reduced substantially but not eliminated).

PREPARATION:*

An adequate, though not excessive, liquid intake should be maintained (NPO

status should be avoided to minimize dehydration-induced contrast
nephrotoxicity). Necessary medications should be taken.

Bowel preparation for potentially constipated patients: Two bisacodyl (Dulcolax)

tablets are given at bedtime on the day before the exam. An intense bowel prep
is not utilized so as to avoid dehydration, as well as avoid creation of large
amounts of gas in bowel. Tomography solves the problem of seeing the kidneys
through any residual stool.

Children, or patients with diabetes, renal insufficiency, gout, or multiple myeloma

should not undergo bowel preparation or fluid restriction.

*Note: Dietary restriction or bowel preparation is not necessary for

ambulatory outpatients. A light breakfast with normal fluids is
encouraged. A large meal should be avoided to minimize risk of
vomiting.
 46

PREPROCEDURE POINTS:

1. All patients are to empty their bladder prior to scout film.

2. Tomographic studies are to be performed in all patients. Exception is if only

the ureters are being evaluated.

3. Abdominal compression is used except in patients with aortic aneurysm,

large abdominal mass, severe abdominal pain, recent surgery, ileostomy,
continent urinary diversion, colostomy, extreme obesity, children, or renal
transplant patients. It is used in patients with suspected calculus disease
(distend and evaluate collecting systems), but not if patient having
substantial colic.

4. All patients should be asked about prior contrast injections and reactions to
contrast media, asthma, or other known allergies. A brief explanation of
potential complications should be mentioned, for example: "The reason I
asked about prior reactions is that a small percentage of patients have a
reaction to the contrast material, just as some people are allergic to
penicillin or bee stings. Most often these reactions are mild, such as
itching or nasal congestion, but rarely can be more serious, and if you'd
like, I can go into more detail concerning these rare reactions. We have
medications and treatment readily available should it be necessary."
5. Angiocath (instead of butterfly needle) placement for contrast injection is
encouraged to ensure IV access in the event of contrast reaction.

6. A physician must remain immediately available following all contrast

injections. (Treatment of contrast reaction: see Appendix 3B.)

7. If there is extravasation of contrast: cold pack and elevate arm. Contact

departmental R.N. or IV therapy team for assistance with management.
Follow-up of the patient is important. (Instruct patient regarding any return
visit and to use cold or warm packs on area after leaving the department.)
(See Appendix 3C.) (Report any reaction on Reaction Report Form
available near CODE boxes; see Appendix 3D.)

MATERIALS:

CONTRAST AGENTS: Only low osmolality, nonionic contrast media (e.g.

Optiray 320) is used for intravascular injection. Ideal contrast dose is
determined by grams of iodine. Approximately 30 grams of iodine is
optimal for evaluating an average adult patient with normal renal function.
See the contrast media chart (Appendix 5) for properties and appropriate
dosage of commonly used contrast media.

Contrast vials should be presented to the radiologist beside the filled

injection syringes for confirmation of appropriateness of contrast material.
Dose and type of contrast material administered will vary depending on
clinical indications, size of patient, and the patient's renal function.

Ureteral compression device

 47

FILM TECHNIQUE:

60-75 kVp (tomographic and routine) at 500 to 700 mA.

FILMING SEQUENCE:

TIMING FILM SIZE (inches)

1. Scout (KUB) l4 x l7

AP scout to include the symphysis pubis in females and to the ischium in

males. Additional l0 x l2 of the kidneys is added in large patients. Oblique
preinjection l0 x l2 kidney films or tomography should be used to localize
calcifications overlying a kidney on scout films.

2. Scout Tomogram(s) l0 x l2 (10° arc; 1.5 cm thickness)

AP section through kidneys if tomographic exam to be done. Level
through kidneys is predetermined by patient thickness (1/3 of body
thickness at costal margin). Radiologist will select appropriate sections for
post-injection filming.

Three or 4 preinjection tomograms are obtained for patients with

suspected renal calculus disease. (10° arc; 1.5 cm intervals), unless done
within past 6 months and specific calculus question not of primary
concern.

3. Immediately post
injection 10 x 12
(within 30 seconds after completion of injection)

Single AP tomographic section to see complete renal outlines. If

nontomographic examination is done, obtain single coned AP film of
kidneys.

4. 3 min. 10 x 12

AP coned kidney film. After filming, apply compression unless

contraindicated (see above).

5. 10 min. 10 x 12

Three or 4 tomographic sections (10° arc) of the kidney at 1.5 cm

intervals, additional levels may be necessary – be sure the upper pole is
defined on the more posterior tomos and the lower pole on the more
anterior tomos. (goal: define collecting system and renal margins). (Add
oblique tomographic films to define anterior and posterior margins as
needed.)

6. 15 min. 10 x 12

Both oblique views (RP0, LPO) of the kidneys.

7. 20 min. 14 x 17
 48

AP abdomen film, immediately following compression release

8. Post-void 8 x 10

AP coned bladder film obtained as soon as possible after voiding (full KUB
may be used to again image ureters). Post-void image should include
urethra in females to evaluate for diverticula.

POSTPROCEDURE POINTS:

1. Following the examination the patient should ingest moderate amounts of

fluid.

REFERENCES:

1. Amis S and Newhouse J. Essentials of Uroradiology, Little Brown Co., 1991.

2. Lalli A. The Tailored Urogram, Year Book Medical Publ., Chicago, IL, 1980,
310 pages.

Additional References:

1. Barbaric ZL. Principles of Genitourinary Radiology, New York, George

Thieme Verlag, 1991.

2. Bush W. Urologic Imaging and Interventional Techniques, Urban and

Schwarzenberg, Baltimore, 1989, Chapters 1,2,3, pp. 1-27.

3. Davidson AJ, Hartman DA. Radiology of the Kidney, W.B. Saunders Co.,
Philadelphia, PA, l994. Chapter I: Diagnostic Uroradiologic Techniques.

4. Dunnick NR, McCallum R, Sandler C. Textbook of Uroradiology, Williams &

Wilkins, 1991.

5. Pollack H., McClennan BL, Clinical Urography, 2nd Edition, Williams and
Wilkins, 2000 ("The Bible").
 49

LIMITED EXCRETORY UROGRAM

INDICATIONS:

A limited EU is indicated for follow-up exam of ureteral calculi, following

urological procedures, if a recent complete EU with tomography has been
performed; and in pregnant patients.

PREPARATION, PREPROCEDURE POINTS, MATERIALS AND FILM

TECHNIQUE as with Full Excretory Urogram.

FILMING SEQUENCE:

TIMING FILM SIZE (inches)

Scout l4 x l7
AP abdomen to include kidneys and symphysis pubis in females and the
ischium in males. An additional l0 x l2 centered at kidneys may be
necessary.

Post Injection Films:

Post injection filming sequence is determined by the patient's condition

and diagnosis. It should be planned with the radiologist.

Tomography can usually be avoided.

For pregnant patients: Obtain scout and a single KUB 4 hours post
injection. Subsequent film at longer interval determined by findings on 4
hour film.
 50

CYSTOGRAM
INDICATIONS:
To define bladder contour and diverticula.
To investigate suspected bladder rupture.
To evaluate for fistulae involving the bladder.
To evaluate for ureteral reflux (see section on VCU).
CONTRAINDICATIONS:
Current infection of the urinary tract (relative contraindication).
PREPARATION:
If patient is a quadriplegic or high paraplegic (T1-T6),
blood pressure monitoring will be necessary (see Appendix 3 - Autonomic
Dysreflexia).
MATERIALS:
300 cc of dilute contrast material (14% organically bound
iodine)
I.V. pole and I.V. tubing
Clamp
PREPROCEDURE POINTS:
1. Inpatients should arrive in the radiology department
with a Foley catheter in place. Outpatients will have the catheter placed
by the radiology department nursing staff or supervising radiologist.

2. Drain the bladder completely prior to procedure.

TECHNIQUE FOR RADIOLOGISTS:

1. Supine position: Observe bladder filling under gravity pressure (the contrast
bottle should be 24"-30" above the table top). Intermittently fluoroscope
for ureteral reflux or extravasation of contrast material.

2. Fill the bladder to maximal capacity (determined by patient discomfort or until

contrast bottle is empty or stops filling by gravity). An estimate of contrast
volumes required is:

Newborn infant 35-50 cc

Young child 200 cc
Adult 300+ cc

Obtain spot films (1 on 1) of distended bladder in the AP, LPO, and RPO
position. If rupture is of concern and none seen, obtain a lateral projection
film, if possible. [Note: CT combined with a dilute (1%) cystogram is more
sensitive for detecting bladder rupture. 15 ml of Conray 60 is diluted in
500 cc NS for CT cystos.]

TECHNIQUE FOR TECHNOLOGISTS (cystogram):

Filming: 70 KVP

Scout: AP abdomen (to include kidneys and symphysis pubis)

 51

Post fluoroscopy: AP abdomen (to include kidneys and symphysis pubis)

At this stage, drain bladder empty and obtain post-drain film: 8 x 10 pelvis AP;
add oblique films in trauma patients or if question on frontal film.
 52

VOIDING CYSTOURETHROGRAPHY
INDICATIONS:

To evaluate for vesicoureteral reflux and to investigate abnormalities of the

bladder neck and urethra.

FOLLOW CYSTOGRAM SHEET THROUGH TECHNIQUE FOR

RADIOLOGISTS. THEN CONTINUE AS FOLLOWS:

Stand patient erect (unless physically unable, or small child); steep oblique; rapid
sequence filming of urethra during voiding (into urinal, male or female style);
observe kidneys and ureter fluoroscopically for reflux. After completion of voiding
obtain 14 x 17 AP of abdomen; 8 x 10 AP post-void film to include the urethral
area must be obtained in females to evaluate for diverticula.

TECHNIQUE FOR TECHNOLOGISTS:

Filming: 70 KVP

MALES

Scout: AP abdomen (to include kidneys and symphysis pubis)

Oblique pelvis to include urethra and bladder

Post-void Film: Abdomen (to include kidneys and bladder)

FEMALES

Scout: Abdomen (to include kidneys and

bladder)

Post-void Film: Abdomen (kidneys and bladder), urethra area

(females only)
 53

RETROGRADE URETHROGRAPHY (RUG)

INDICATIONS:

1. Pelvic trauma with blood at meatus.

2. Pelvic trauma without blood when likelihood of urethral injury is high (e.g.,
pelvic diastasis, displaced pubic fractures).

3. "Trouble" passing Foley

4. Stricture assessment

CONTRAINDICATIONS:

1. Signs of urethral infection; e.g., urethral discharge

2. Recent instrumentation with bloody urethral discharge. Performing RUG
will likely cause extravasation with venous filling.

TECHNIQUE FOR RADIOLOGISTS:

A. Materials

1. Urethral catheterization package

2. 14 Fr. Foley catheter with 3 cc balloon (alternatively may use

pediatric Foley 8-10 F if small urethra or distal stricture)

3. Full strength contrast media; e.g., Conray 60, Hypaque 60.

B. Method

1. Test 3 cc balloon by injecting approximately 2 cc of saline or

water. Deflate balloon. Leave syringe attached to balloon
port.

2. Fill Foley catheter with contrast and clamp catheter.

3. Cleans glans with Betadine or something similar.

4. Insert Foley catheter approximately 2 inches into urethra and

inflate balloon in the fossa navicularis. Patient may
experience discomfort, but unless balloon is inflated
sufficiently, it will “slide out” during the examination and
everything will have to be restarted. You don’t want this.
Clues to adequate inflation: slight reaction or grimace by
patient; “blanching” of the glans. Do not lubricate Foley
catheter before inserting into urethra, since this increases
the chances that it will slide out during the procedures. [If
the patient is extremely sensitive, you may inject Xylocaine
jelly first.]
 54

5. Patient in 45° RPO (if head to your left) with right knee
flexed, left leg nearly straight. Under fluoroscopy, a good
test for the proper obliquity is to see the right obturator
foramen completely “closed.”

6. Slowly inject contrast using a 60 cc catheter tip syringe. All

urethral kinks should be eliminated by placing the penis on a
slight stretch (another reason to inflate the balloon enough).

7. Take first spot film with horizontal collimation to show the

anterior urethra up to and including the region of the
membranous urethra (single arrow). Expose the film when
you observe contrast passing through the external sphincter
and entering the posterior urethra and bladder.

8. If the anterior urethra appears normal, change to vertical

collimation and make another exposure during contrast
injection, as contrast is passing through the posterior urethra
and entering the bladder. The posterior urethra will not
distend on the retrograde injection.

9. If the urethra appears normal and the clinical question is

answered, the examination is finished. However, if the
question involves the prostatic urethra and obstruction, then
filling of the bladder and a voiding cystourethrogram (VCUG)
should be considered (optimally, this should be discussed
with the clinician prior to beginning the RUG). Bladder filling
can be achieved by switching contrast to a more dilute
solution (i.e. cystoConray 30%) and continuing to infuse
through the urethral catheter or, the catheter can be
advanced up into the bladder and the bladder filled with the
30% contrast solution. During bladder filling, use fluoroscopy
intermittently to be sure that extravasation is not occurring
and to observe for utereal reflux.

10. After the bladder is appropriately filled, a voiding

cystourethrogram (VCUG) is done: [see discussion of that
technique under the Sections on VOIDING
CYSTOURETHROGRAPHY and CYSTOGRAM (pages 50-
52).
Caveats:

1. If, during the procedure, you note filling of the penile veins, terminate the
procedure. The contrast is taking the path of least resistance. Filling of
penile veins may be seen in patients with chronic inflammation, stricture,
or trauma.

2. In patients with complete urethral obstruction secondary to stricture

associated with pelvic fracture, the patient will usually have a suprapubic
tube in place. It is desirable to demonstrate the length of the stricture by
performing simultaneous antegrade and retrograde urethrography. First
perform the retrograde study and leave the catheter clamped when the
urethra is distended up to the stricture in a retrograde direction. Then
 55

distend the bladder through the suprapubic tube [using 30% cystoConray]
and ask the patient to attempt to void and expose the film with contrast
outlining both ends of the stricture.

3. Alternate methods of performing RUG:

1. Brodney clamp

2. 8 Fr. feeding tube into urethra meatus plus penile clamp

(Cunningham or a similar device) works well when the Foley
catheter method cannot be used for anatomic reasons.

Pericatheter RUG (Foley already in bladder)

1. 8 Fr. straight pediatric feeding (not a balloon catheter) tube

alongside Foley about 2 inches in.
2. Cut a rubber band (yes, an ordinary desk top rubber band), apply in
“tourniquet” fashion just proximal to glans, using hemostat to create
tension on rubber band.

3. Tape feeding tube to Foley to prevent it slipping out.

4. Inject contrast, as with RUG.

 56

REFERENCES:

Dunnick NR, McCallum RW, Sandler CM. Textbook of Uroradiology. Baltimore,

Williams & Wilkins, 1991, pp. 4-9 and 51-52.

McCallum RW. The adult male urethra: normal anatomy, pathology and method
of urethrography. Radiol Clin North Am 17:227, 1979.

McCallum RW, Colapinto V. The role of urethrography in urethral disease: I.

Accurate radiological localization of the membranous urethra and distal
sphincters in normal male subjects. J Urol 122:607, 1979.
 57

HARBORVIEW PROTOCOL FOR CT UROGRAM (“CT IVU”)

MAIN INDICATION: Painless hematuria.

Note: This is a screening CT IVP. When a renal abnormality (e.g., a renal mass)
is already known to be present, a dedicated renal CT should be done, for which
there is a separate protocol.

Technique:
1) KUB before moving patient to helical CT scanner.

2) Helical CT: 5 mm collimation at 1.5 to 1 pitch, before and 2 minutes after

beginning contrast injection (100 ml at 3 ml/sec), through kidneys (reconstruct at
7.5 mm intervals); all images to fit on two sheets of film. FOV smallest to
accommodate kidneys.

3) Patient taken immediately to main department for full abdomen radiograph (5

min film). Immediately apply abdominal compression unless question of
obstruction. Then process 5 min film.

4) Coned down AP of kidneys after 3 min of compression. Obliques with

compression at discretion of radiologist.

5) Post-release KUB centered to include symphysis pubis. (It's OK to exclude

the upper poles of the kidneys on this film, because they have been imaged on
the CT part of the exam)

6) Coned down post void film of bladder if appropriate

NOTE: The post-CT plain films should be tailored to the patient's problem by the
radiologist monitoring the exam.

Lee Talner, MD
Harborview Medical Center
Seattle, WA
July 31, 2000