RDSC 233 Unit 9Radiography of the Biliary Systemand assorted contrast examinations Bontrager page numbers in white

Procedures covered in unit 9

Oral Cholecystogram (OCG) 519-537 for all GB & biliarySurgical Cholangiogram T-tube CholangiogramPercutaneous Transhepatic Cholangiogram (PTC)Endoscopic Retrograde Cholangiopancreatography (ERCP) Intravenous Cholangiogram (IVC)

Myelography 734-738Sialography 739-741 Dacrocystography Arthrography 726-730Lymphangiogram 677 & 690Hysterosalpingography (HSG) 731-733Cavernosogram & Spongiosogram

Anatomy

I

RE

Done

Infrequent

Rare or extinct

D

Atlas of Human Anatomy Second edition (276)

Need to know

Gallbladder: fundus, body, neck

Cystic duct

Rt. & Lt. hepatic duct

Common bile duct

Common hepatic duct

Ampulla of Vater

Sphincter of Oddi

Pancreatic duct (of Wirsung)

Duodenal papilla (of Vater) indescending or 2nd part.

Atlas of Human Anatomy Second edition (277)

Note worthy

Variations inbiliary anatomy

Oral Cholecystogram (OCG)

Prior to ultrasound proving its value in hepatic and biliary imaging, the OCGwas a common examination for diagnosis of cholelithiasis (gallstones). It was often done in conjunction with an UGI

Patient Prep: Fatty meal day before (empties GB). Fat free evening meal.Contrast: Four or six tablets or capsules taken in ½ hour intervals NPO: at midnight. No fats after contrast is taken (or contrast is flushed from contractions of GB)

Calcium stones (opaque) seen in recumbent spots

Cholesterol stones (lucent) seen in recumbent spot. Note the stratification of the stones.

The examination begins with fluoroscopy.A 4-on-1 film is done upright, followed bya 4-on-1 supine. Inspiration, expiration,compression, and changes in position areused to free the GB from bowel gas, ribs,and the spine, to visualize hard to seestones.

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Oral Cholecystogram (OCG)

Following fluoroscopy, overhead films are often taken. Note the relationshipof the GB to the 12th rib on these examples.

The LAO is the gallbladder film.

Why? Consider the position ofthe gallbladderrelative to the spine.

Right lateraldecubitusprovides ahorizontal beam

Why right, andnot left?

The PA is usuallyroutine.

Gallbladders weremade for using acylinder cone.

Post fatty meal.

Bacon & eggs(or x-nog)to demonstratecontractibility.

Operative, Surgical, or Immediate Cholangiogram

Surgical cholangiograms are done to find residual stones in the hepatic or common bile ducts after a cholecystectomy (removal of the GB) thatis done as a laparotomy, (surgical opening of abdomen) or laprascopic surgery.

Iodine contrast is hand injected by the surgeon, through a catheter inserted into the opening that was the cystic duct.

This cholecystectomywas performed throughan incision, as evidencedby the hemostats.

Two films are taken. Thefirst injection is a few CCsto fill the biliary tree.

The second spills contrastinto the duodenum, assuring that nothing ismissed.

When the patent must be supine, the RPO positionfrees the biliary tree of superimposition on the spine

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T-Tube CholangiogramWhen the gallbladder is removed stones may be missed. If residual stones are suspect a T-Tube is left in the bile ducts. Bile drains through it, and the tube provides access to remaining stones without reopening the incision.

One side ofT in commonbile duct.

One side ofT in commonhepatic duct.

T-tube cholangiograms are performed underfluoroscopy. Positionsfor filming are AP and RPO.

When draining bile andpreparing for the contrast injection it isimperative to keep airout of the tube. Air bubbles look like cholesterol stones.

Air

Stones?

D

T-Tube Cholangiogram Stone Basket Removal

A basket catheter, passed throughthe T-Tube, can snare and remove residual stones.

Percutaneous Transhepatic Cholangiogram (PTC) I RE

When obstructioncasues dilationof the biliary tree,and cessation ofbile excretion, jaundice results.

Access to the biliarytree may be gainedby direct needle puncture throughthe liver (transhepatic).

Iodine contrast is injected and obstructionsare demonstrated by a filling defect, or bya columniation of contrast to the point ofobstruction.

Endoscopic Retrograde Cholangiopancreatography (ERCP) D

An ERCP is a fairly common examination that gains access to the bile ductsand pancreatic duct through catheterization via a duodenoscope. It is performed by a gastroenterologist, under fluoroscopic control.

Duodenoscope

Injection cannula

Cystic duct with spiral valves The potential for stone removal makesan ERCP diagnostic and theraputic

Intravenous Cholangiogram (IVC) RE

When the gallbladder did not visualizeusing the oral contrast of the OCG, a liquid iodine preparation could bedrip infused. Concentration in the bileducts was minimal, so tomograms were taken in the RPO position.

The exam could take over an hour, and the patient could not move inthe slightest.

Biliary Sent

Atlas of Human Anatomy Second edition (148)

Need to knowDura mater

Arachnoid mater

Subarachnoid space

Spinal cord and nerves

Pia mater

Myelography IRadiographic examination of the spinal cord and associated spinal nerves using iodine contrast. Herniation of intervertebral disk material is the primary indication.

Non-ion iodine contast is injected into the subarachnoid space.

Spinal nerve

Contrast

Encroachment on the spinal cord or nerves is demonstrated as a fillingdefect. Disk material, tumors, subluxed vertebra, or fracture fragmentsimpressing the vertebral canal will create such defects on a myelogram.

Atlas of Human Anatomy Second edition (55)

Need to know

Parotid glands

Stensen’s (parotid) duct

Submandibular glands

Sublingual gland

Wharton’s (submandibular) duct

Bartholin’s (sublingual) ducts

Caruncle

Sialography I Sialograms are radiographic investigations of the salivary ducts and glands for obstructions causedby tumors or calculi.

Sucking on a lemon promotes salivationand makes the ducts easier to find andcannulize.

Cannula in Stensen’s duct

Cannula in Wharton’s duct

Parotid gland

Shown on xerographic paper

Submandibulargland

A cardboard film in the mouth may demonstrate calculi in Bartholin’s ducts and the sublingual glands from an inferosuperior projection.

Atlas of Human Anatomy Second edition (77)

Need to know

Orbital part of lacrimal glandand ducts

Lacrimal sac

Inferior nasal meatus

Nasolacrimal duct

Dacrocystogram

Radiographic examination ofthe lacrimal apparatus.

The lacrimal duct is cannulizedwith a lacrimal cannula (may beused for a sialogram). Contrastis injected.

If contrast spills into the nasopharynx, the lacrimal ductis patent.

lacrimal cannula

contrast in the nasopharynx

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Atlas of Human Anatomy Second edition (477,48049)

Need to know

Synovial membranes

Articular cartlages

Menisci

Ligaments

Bursa

Arthrography D

Radiographic examination of synovial joints

Knees and shoulders are done most frequently, though tempromandibular (TMJ), hips, ankles, elbows, and wrists are possibilities.

Both air (negative) and iodine contrastmay be injected by a radiologist.

The part is exercised and stressedto maximize the visibility of tearsin menisci, the joint capsule,or ligaments.

Overhead films are thoseroutine for the part beingexamined.

Tear in the medial meniscus of the knee

Arthrography D

Spot films are typicallytaken during arthrograms.

Because the part of interest is small, and numerous views and stressing of the partis required, many exposures may be taken.

Here 9 on 1s are takenon a 9” x 9” spot film.

Atlas of Human Anatomy Second edition (321,249) Need to know

Lymph vessels and nodes

Lymphangiogram I

Radiographic examination of the lymphatic system, primarily for lymphoma.

1. Inject blue dye between toes to localize lymph channels2. Cut down to lymph vessel on dorsum of foot.3. Contrast is injected slowly (45 minutes to an hour) due to the fragility of lymph vessels. Pediatric needles are used.4. Films are taken the same day, though the contrast will not travel much further than the abdominal nodes.5. The patient returns in 24 hours for a full set of films, abdominal and thoracic, in frontal, oblique, and lateral positions.

First day films show mostlylymph channels.

Lymphangiogram

24 hour films show nodes.

Need to know

Uterus: fundus & body

Cervix

External and internal cervical os

Ovary

Fallopian tube (ovaduct)

Frimbriae

Atlas of Human Anatomy Second edition (337-346)

Hysterosalpingography (HSG)

Radiographic examination primarily doneto assess patency of the fallopian tubesin cases of infertility.

Done in the lithotomy positon. Gynecologistprepares for injection by speading the vaginal canal with a speculum.A catheter with an acorn or balloon tip seals the external os. Contrast isinjected into the body of the uterus

Contrastin body ofuterus

Catheter

Fallopian tubes

Catheter

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Hysterosalpingography

After filling the uterusand fallopian tubes,the contrast will spillinto the peritoneal cavity, which is the signof patent ovaducts.

Because the pressureof the contrast may clear the tubes of a blockage, a hysterosalpingogrammay be a theraputic as well as a diagnosticexamination.

The most commongynecological problemis a benign tumorcalled a leiomyoma(uterine fibroma orfybroid tumor are common,though improper names).

These benign tumors of the uterine muscle become troublesome when they become numerous or large, and sometimesbegin to bleed. Here an extraordinarily large, calcified leiomyoma.

Atlas of Human Anatomy Second edition (356, 338, 362)

Need to know

Corpus cavernosa of penis

Corpus spongiosum of penis

Crus of penis

Bulb of penis

Cavernosogram & Spongiosogram RE

Injection of iodine contrast into the corpus cavernosa or spongiosum toevaluate inflammation (cavernositis) or failures of the erectile tissue tofill or drain.

The quiz you may never take (as a quiz)

1. What is the name of the condition of having gallstones?

2. When doing an OCG, what body position best demonstrates the gallbladder free of superimposition of the spine

3. What is the name for the surgical removal of the gallbladder?

4. What is the name for surgically incising the abdominal cavity?

5. If a surgical cholangiogram demonstrates a large portion of the duodenum with contrast, which film in the series is it?

6. When doing a surgical cholangiogram, what body position best demonstrates the gallbladder free of superimposition of the spine?

7. What is a T-Tube? Where is it located?

The quiz you may never take (as a quiz)

8. What procedure is a stone basket catheter associated with?

9. Who is the medical specialist that performs an ERCP?

10. What is the name of the endoscopic instrument used for an ERCP?

11. What is the name of the space where contrast in injected for a myelogram?

12. At what vertebral interspace is a lumber puncture commonly performed?

13. Name the three glands associated with a sialogram

14. What is demonstrated on a dacrocystogram

15. What does “patent” mean?

The quiz you may never take (as a quiz)

16. What are the two most common arthrogram examinations?

17. What kind of joint is examined by arthrography?

18. What examination of the female reproductive tract is done to assess the patency of the fallopian tubes

19. What is the sign of patent tubes in the examination named in 18?

20. What are the names of the erectile tissues of the penis?

21. What is a radiographic examination of the lymphatic system called?

22. What is injected to localize lymph channels, and where is it injected?