SPECIAL

INVESTIGATION IN
RADIOGRAPHY

GROUP VI
TABLE OF CONTENT
INTRODUCTION
DEFINITION OF SPECIAL INVESTIGATION
TYPES OF SPECIAL INVESTIGATION
INDICATIONS FOR SPECIAL INVESTIGATION
RADIOGRAPHIC CONTRAST MEDIA AND THEIR TYPES
CONTRAST MEDIA REACTIONS AND TREATMENT
PROJECTIONS FOR SPECIAL INVESTIGATION
PATIENT PREPARATION
EXAMINATION PROCEDURE
IMAGE EVALUATION AND TECHNICAL CONSIDERATION
CONCLUSION
RECOMMENDATION
DEEFINITION OF SPECIAL
INVESTIGATION
Special investigation should
be only requested to answer
specific question with the
use of contrast.
Some investigation have
high specification and
sensitivity for a particular
disease.
TYPES OF SPECIAL
INVESTIGATION
INTRAVENOUS UROGRAPHY [IVU]
HYSTEROSALPINGOGRAPHY [HSG]
FISTULOGRAPHY
CYSTOGRAPHY
MICTURATING CYSTOURETHROGRAM [MCUG]
RETROGRADE URETHROGRAM [RUG]
BARIUM ENEMA
BARIUM SWALLOW
BARIUM MEAL
RADIOGRAPHIC CONTRAST
MEDIA
Contrast media or Agents are substances which can be used to demonstrate organs,
vessels and parts of the body clearly. They increase the clarity of the image.
TYPES OF CONTRAST AGENTS
Negative contrast have a low atomic weight and therefore provide a negative
contrast on film as they absorb very little radiation.
Positive contrast have a high atomic weight and therefore provide a positive contrast
on the film as they absorb most of the radiation.
NEGATIVE CONTRAST
MEDIA/AGENT
1] Air-this may be introduced by the patient. For example in a chest radiograph taken
on arrested inspiration air in the lungs gives a good tissue detail.
2] Barium enema- air is introduced through the rectum via rectal pump. this provides
a double contrast with the barium sulphate.
3] Valsalva manoeuvre – forced expiration on a closed glottis outlines the trachea on
thoracic inlet radiograph.

3]Carbon-di-oxide- for example barium meals it provides a double contrast with the
barium sulphate ,It can be informed of tablet, liquid or powder
POSITIVE CONTRAST
MEDIA/AGENT
1] Barium meals-it can be in powder form or liquid [Baritop], it is non iodinated.
Contra-indications
Can not be used for suspected fistula or sinus because the barium sulphate is not
absorbed by the body.
2] Gradolinium -for MRI imaging.
3] Iodine compounds/contrast media-is a contrast media containing iodine, it is used
in radiography to increase the clarity of the image. This is divided into
Ionic iodinated contrast media
Non ionic iodinated contrast media
 IONIC IODINATED CONTRAST
MEDIA/AGENT
Ionic and non ionic varies in their uses, properties and toxic effects.
Ionic iodinated contrast media were produced and in use before non ionic iodinated
contrast media and have high osmolarity. They are mainly used for cavities
procedure[HSG, MCUG, Fistulogram].
Due to its higher risk of patient reaction it is advisable that they should be used on
low risk patients and not intravenously .for example Urografin ,conray, Gastrografin
[used for CT abdomen and also diluted and used for esohageal studies
NON-IONIC IODINATED
CONTRAST MEDIA/AGENT
Non-ionic iodinated contrast media the iodine is bound to an organic compound and
has a low osmolarity.
OSMOLARITY- the concentration of the body fluids [plasma,urine] measured in
terms of amount of dissolved substances per unit mass of water and its unit is
mOsmkg-1.
Examples of such contrast include :omnipoque, iopamidol -300/370,ultraist
300/370,scanlux 300/370,contrapaque 300/370,lekpamidol 300/370 etc.
They are most commonly used in CT investigations, IVU ,Angiography for all
intravenous and intramuscular administered procedures.
ADVANTAGES NON-IONIC
OVER IONIC CONTRAST
MEDIA AND ITS
DISADVANTAGES
Advantages
- They do not dissociate in water
- Risk of minor allergic reactions is reduced.
- Rapidly excreted via the kidneys.
- Have lower viscosity.
- Have lower osmolarity.
Disadvantages
They are expensive.
May provoke anaphylactic reactions.
 PRECAUTIONS AND CONTRA-
INDICATIONS OF NON-IONIC CONTRAST.
PRECAUTONS TO BE TAKEN WHEN HANDLING NON-IONIC CONTRAST
A]Store the agent correctly ,usually room temperature away from sunlight.
B]Check if the patient has any history of allergy/asthma/hay fever/bronchitis.
C]Have a full resuscitation facility
D]Give drugs at body temperature
E]Manufacturer’s doses should not be exceeded.
Contra-indications of non ionic contrast agents
-patient with an allergy to iodine
-if the patient has poor liver or renal function, do not dehydrate.
-if the patient is diabetic with high serum creatinine ,they should not be examined.
DOSAGE OF CONTRAST
MEDIA
Dosage varies according to:
- Patient age
-Patient condition
- Patient weight
- Method of introduction
- Examination been undertaken
- molecular size of the medium.
REACTIONS OF CONTRAST
MEDIA AND TREATMENT
Minor reactions-warmth ,metallic taste in the mouth ,nausea ,itching, sneezing
Treatment- reassure the patient, observe the patient, if severe administer anti-histamine
Major reactions
Erythema, edema of the larynx ,convulsions ,coma, pulmonary oedema, hypotensive
shock, cardiac arrest, difficulty in breathing, respiratory arrest ,cerebral oedema
Treatment
Seek medical help.
Oxygen may be required ,initiate resuscitation procedure if required
Transfer to ICU.
NB- record all information concerning type of reaction ,contrast Agent, dose and batch
number drugs given
 INTRAVENOUS UROGRAPHY
[IVU]
IVU is also called excretory urography. It denotes a complete radiographic survey of the
urinary tract after the introduction of an opaque medium [non ionic contrast media]. It is
done by Appointment.
Indications
- suspected urinary tract pathology
-renal stone
-Abdominal mass
-Neuroblastoma
-ectopic kidney
-polycystic kidney
-pain on the left or right flank.
Reduced volume of urine
 ANATOMY OF KUB
Kidney are retroperitoneal organs ,their
main function is to maintain electrolyte
homeostasis and waste excretion
They empty medially in to the ureters,
ureters course inferiorly into the pelvis
and enter the urinary bladder.
The urine is temporarily stored in the
urinary bladder till it is cleared to the
exterior through the urethra.
The kidney is located between the
upper border of the 12th thoracic
vertebra and lower border of the 3 rd
lumbar vertebra ,in upright position the
kidney descends by 2cm or 3cm.,both
kidney move with respiration.
ANATOMY OF KUB
The ureters are bilateral thin [3to 4cm] tubular structure that connect the kidneys to
the urinary bladder, transporting urine from the renal pelvis into the bladder ,the
muscular layers are responsible for the peristaltic activity that the ureter uses to
move the urine from the kidneys to the bladder.
Functions of the ureter
- the filter blood and create urine as a waste product.
-they filter urea from the blood
They blood to parts of the body
They allow urine to pass from the kidney to bladder
They store urine that is produced by the kidney.
PATIENT PREPARATION FOR IVU
Bowel preparation is very essential.
10 Dulcolax tablets are prescribed
4 tablets to be taken 7pm 3 days to investigation
4 tablets to be taken 7pm 2 days to investigation
2 tablets to be taken 7pm a day to investigation
50 mls castor oil to be taken 9pm a day to investigation OR Insert Dulcolax
suppository into anus 6am on the day of investigation.
No breakfast and nothing by mouth at least 5 to 6 hours before the investigation.
For children[7-12] years half dosage of Dulcolax
0-6 years no bowel preparation
4-6 years no breakfast
13 years and above bowel preparation
 PATIENT PREPARATION FOR
IVU
Patient is advised to be ambulant 2-3 hours before investigation to reduce bowel gas.
Bed ridden patients can go on laxative for bowel preparation.
The Nurse should carry out colonic washout on the patient on the day of the
investigation.
The patient should sit up if he or she can and walk before the investigation.
On Arrival on the day of investigation
Patient registers requests card
Vital signs and blood pressure is taken by the nurse
Doctor checks the patients using the consent form [the practitioner is mindful of the
high risk patient e.g diabetic ,sickle cell anemia etc]
Patient signs consent form in acceptance of the procedure.
Patient change to hospital gown
EXAMINATION PROCEDURE
FOR IVU
The preliminary radiograph is taken [KUB] with a view to checking of the effects of the
foregoing preparation of the patient. [for any pathological development]
Ascertain the correct exposure factors.
Size of film used is 35cm x43cm, placed longitudinally with the lower border at the level of the
symphysis pubis.
If bowel preparation is adequate.
Patient is positioned supine on the x-ray table in preparation for the exposure of the renal area
immediately after the injection of contrast media [50mls of non ionic iodinated contrast].
NB: the injection site is the median antecubital vein.
This exposure is labelled 0 mins.
A 12 x 10 cassette is placed transversely with its lower border at the level of iliac crest.
Ensure anatomical marker is in position.
The exposure is made 10-14s after the injection shows the kidney time, centre to the middle of
the film ,its 3mins to show the nephrogram [ the parenchyma opacified by contrast medium in
the renal tubules
 EXAMINATION PROCEDURE
5 mins film- AP of the renal area, a 12x10 cassette is used, this cassette is taken to determine if
excretion is symmetrical.
15 mins- AP of the renal area using a 12x10 cassette positioned longitudinally, this film should
show more excretion of contrast media by the kidneys.
30 mins- supine AP abdomen, lower border of the film at the level of the symphysis pubis.
Kidney and bladder must be visualized.
Bladder view-when the bladder is full take AP Bladder with 10x8 cassette placed longitudinally
with the tube angled 15 degrees caudad and centered 5cm above the symphysis pubis.
After this view patient micturates.
Post micturition film- this is a conned view of the bladder ,taken after the patient micturates.
The principal value of this film is to assess bladder emptying, to demonstrate a return to normal
of dilated upper tracts with relief of bladder pressure to aid diagnosis of bladder tumors to
confirm ureterovesical junction calculi and uncommonly to demonstrate a urethral diverticulum
in females.
NB- catheter is withdrawn before exposures are made and the contrast used is urografin and
lastly right and left obliques and sometimes true lateral can be requested for.
LEFT AND RIGHT POSTERIOR
OBLIQUE
From the supine position the patient is rotated 30 degrees to each side respectively
For each exposure a 12x10 cassette is placed transversely to include both kidneys
with its lower margin below the iliac crest.
Centre parallel to the film over the midline of the table at the level of lower costal
margin.
RADIOGRAPHS FOR IVU
A preliminary film AP Film 15 mins after contrast
TECHNICAL CONSIDERATION
The examination of the bladder may also be a part of IVU at the stage of micturition when the
bladder is full before micturition if their interest in examining the bladder .
Focal film distance-100 to 120cm
Structures shown
AP Supine-Distal ureters ,bladder ,and proximal urethra
Oblique- Distal ureters, bladder and proximal urethra
Positioning
AP Supine- urinary bladder not superimposed by pubic bones
Oblique- urinary bladder not superimposed by partially flexed legs
Radiation protection
Adequate collimation
Use of appropriate exposure factors
In follow up visits gonad shield must be used but careful not to obscure the area of interest
HYSTEROSALPINGOGRAPHY
[HSG]
HSG is an xray imaging of the uterus and fallopian tubes following the injection of water soluble
contrast medium.
Indications
- Inferility [ primary and secondary infertility] as a result of occluted fallopian tubes
Uterine fibroids
- following tubal/ectopic pregnancy surgery
- before myomectomy to show the shape of the uterine cavity and the extent of removal of the fibroid.
- Asherman syndrome- a condition in which amenorrhoea and infertility follows a major haemorrhage
in pregnancy.
- Recurrent miscarriage
Contraindication
pregnancy
A purulent discharge on inspection of the vulva or cervix –pelvic infection
Contrast medium – high osmolar contrast medium [HOCM] OR low osmolar contrast medium [LOCM].
Volume : 10 to 20 mls but could use more volume in case of a large uterus.
ANATOMY
Anatomic considerations for HSG include the
principal organs of the female reproductive system
—the vagina, uterus, uterine tubes, and ovaries.
Emphasis is placed on the uterus and uterine tubes.
Additional anatomic considerations include the
subdivisions, layers, and supporting structures of the
female organs. The female reproductive organs are
located within the true pelvis.
The uterus is the central organ of the female pelvis.
It is a pear-shaped, hollow, muscular organ that is
bordered posteriorly by the rectosigmoid colon and
anteriorly by the urinary bladder. The size and shape
of the uterus vary, depending on the patient’s age
and reproductive history. The uterus is positioned
most commonly in the midline of the pelvis in an
anteflexed position supported chiefly by the various
ligaments. The position may vary with bladder or
rectosigmoid distention, age, and posture
ANATOMY
The uterus is subdivided as follows: (1) fundus, (2) corpus (body), (3) isthmus, and
(4) cervix (neck) (Fig. 19-22). The fundus is the rounded, superior portion of the
uterus. The corpus (body) is the larger central component of the uterine tissue
The uterus is composed of inner, middle, and outer layers. The inner lining is the
endometrium, which lines the uterine cavity and undergoes cyclic changes in
correspondence to the woman’s menstrual cycle. The middle layer, the
myometrium, consists of smooth muscle and constitutes most of the uterine tissue.
Uterine tubes The uterine (fallopian) tubes communicate with the uterine cavity
from a superior lateral aspect between the body and the fundus.
PATIENT PREPARATION
Equipment: a] fluoroscopy unit with spot film device
B] vaginal speculum, vulsellum forceps and a uterine cannula [leech Wilkinson cannula]
C] over head x-ray machine.
Patient preparation
A] the patient should abstain from intercourse between booking the appointment and the time
of examination unless she uses a reliable method of contraception.
OR
The examination can be booked between the 4th and 10th day in a patient with a regular 28
day cycle.
B] Apprehensive patient may need premedication [ 5-10mg diazepam
C] Paracetamol 1g 1 hour prior to the examination
D] Empty bladder prior to investigation.
EXAMINATION PROCEDURE
Preliminary film
- a conned AP view of the pelvic cavity with a 12x10 film placed transversely
- conned PA view of the pelvic cavity [fluoroscopy]
Technique
1] the patient lies supine on the table with legs placed in the lithotomy position.
2] using aseptic technique the doctor inserts a speculum and cleans the vagina and cervix with
chlorhexidine.
3] The anterior lip of the cervix is steadied with the vulsellum forceps and the cannula is inserted into the
cervical canal. If a foley catheter is used, there is usually no need to grasp the cervix with the vulsellum
forceps.
4] care must be taken to expel all air bubbles from the syringe and the cannula,as these would otherwise
cause confusion in interpretation.
Contrast medium is injected slowly under intermittent fluoroscopic control.
Film- using the under crouch tube
A] as the tube begin to fill [AP]
B] when the peritoneal spill has occurred and with all the instrument remove [posterior oblique]
EXAMINATION PROCEDURE
Using over couch
AP taken after injecting 10mls [ diluted contrast medium ]
Posterior obliques taken after the injecting another 5-10mls.
If the doctor is satisfied with the images, instruments are removed.
The patient is instructed to urinate.
AP projection [post micturition] is taken
The procedure ends.
After care
- it must be ensured that the patient is not serious discomfort nor has significant bleeding before she
leaves.
-the patient must be advised that she may have bleeding in the vagina 1-2 days and pain may persist
up to a week.
HSG
HSG procedure After contrast
 CYSTOGRAPHY
cystography refers to radiographic evaluation of the bladder following the injection
of ionic contrast media diluted with normal saline introduced into the bladder via a
urethral catheter, allowing visualization of anatomic defects and workup of
functional abnormalities
Related Anatomy
The bladder is a muscular organ that sits behind the pubic symphysis in the pelvis.
Its function (and lack thereof) depends on a careful balance of musculoskeletal,
neurologic (both autonomic and somatic), and psychological inputs that control
filling and voiding. There must be coordination between detrusor muscle relaxation
and contraction of the bladder neck and pelvic floor muscles, which both maintain
the contents of the bladder. By the same token, detrusor contraction and sphincter
relaxation facilitate the passage of urine from the bladder.
 CLINICAL INDICATION AND
CONTRA-INDICATION FOR
CYSTOGRAPHY
Indications
-haematuria [blood in the urine]
Bladder tumor
Urine retention [difficulty in urination]
Trauma
-Contra-indications
Pregnancy
Urinary tract infection
Allergy
Severe dementia
PROJECTIONS FOR BLADDER
Special consideration must be taken when performing this procedure in spinal cord injury
patients who are affected above the splanchnic sympathetic outflow tract (T5-T6). It is necessary
to fill the bladder with contrast during cystourethrography and urodynamics, which can induce
autonomic dysreflexia (changes include sudden, severe hypertension with diaphoresis and
flushing, and compensatory bradycardia). For these patients, it is important to have a urinary
catheterization kit prepared in case the bladder needs to be drained emergently. In patients with a
history of autonomic dysreflexia, consider prophylactic nifedipine or an alpha-blocker, in
addition to careful blood pressure monitoring.
 Basic projections
AP 15° caudad (AP SUPINE OF THE BLADDER)

Right/left posterior oblique

PATIENT PREPARATION
Appointment is given
Vital signs are taken by the nurse
Patient is clerked by Doctor
Patient signs Consent Form
Patient changes into the hospital gown
Patient is asked to urinate to empty the bladder
 EXAMINATION PROCEDURE
 A Pre-limb film (AP bladder(Kub)) is taken using 12x10 cassette
placed longitudinally.
 Patient lies Supine for AP 15° Caudally
 Urethral Catheter is inserted by Doctor/ if patient comes with in-
situ
 Urografin is Used 76%, diluted with 1 ampule to 100ml of normal
saline
 After Injecting, The Urethral Catheter is removed and exposures
are Taken.
 A 12x10 cassette is positioned longitudinally in the Bucky
 An anatomical marker is placed
 Using Vertical Beam, the Cassette’s upper border is placed at
ASIS(Anterior Superior Iliac Spine) and 5cm above the symphysis
Pubis.
 Exposure is taken
POSITIONING
 From Spine position, The left or right side are alternatively turned through 30degree
 The Knee in contact with the X-ray table is flexed and the other is extended
 The raised Side is supported with a triangular Foam-pad
 The 12x10 Cassette is placed transversely with the Upper margin coinciding with the level of the
Right/Left posterior Oblique
 ASIS(landmarks of ASIS should be Checked)
 The central ray is vertical and perpendicular to the center of the film.
 FFD: 90-100cm
 
Additional Projection
 True lateral (on Doctor’s Request)

 
AFTERCARE
Drink water to flush irritants out of your bladder. Try to drink 16 ounces (473 milliliters)
of water each hour for the first two hours after the procedure
 Take an over-the-counter pain reliever.
 Place a warm, damp washcloth on the opening to your urethra to ease pain, repeating as
needed.
 Take a warm bath, unless your doctor asks you to avoid baths.
Radiation protection
Collimation
Low radiation dose
Shielding
distance
 FISTULOGRAPHY
Most Common: Anal Fistula (bowel and bladder)
A Fistula is an abnormal communication between 2 hollow organs connecting 2 mucosa lined surfaces or between
a hollow organ and the exterior ( surface of the body) .
INDICATION
1.Recto-vaginal fistula ( rectum to Vagina)
2.Ano-rectal Fistula (Anus- rectum)
3. Linkage between the Bladder and Anus
Fistulography is a Radiological procedure used to visualize the extent of a fistula and the structure in which it
communicates.
1.Gastrocolic fistula ( stomach& Colon)
Contra-indication
Severe infection
High fever
Pregnancy
Very ill patient

 
 FISTULOGRAM
X-ray fistulogram of a semi-horseshoe fistula showing Deshpande’s technique of
double-contrast fistulography with malecot rubber catheter in the anorectal canal to
fill air into the rectum (yellow arrow) with a metal marker at anal verge (white
arrow). Blue arrow demonstrates the level of the anorectal junction.
Note: A fistula must have a surface discharge at the time of the investigation in order
to indicate the point of entry for the catheter and contrast medium.
Contrast medium
5mls of Urografin diluted 5:20mls of normal saline
Equipment Preferred: Fluoroscopy
If not, The Xray head to Couch is Used.
Fistulography is a sterile procedure which include sterile trolley with dressing
materials (Antiseptic solution(spirit or savlon), Gauze, Cotton swabs and scissors)
Local anesthetics : lignocaine/ zylocaine
Disposable syringe: 5mls/10mls/20mls
PATIENT PREPARATION
Patient Preparation
 Appointment is given
 Patient is clerked by Doctor on Allergies and medical History and also explain the procedure
 Patient signs Consent Form
 Patient changes into the hospital gown
EXAMINATION PROCEDURE
 A preliminary film is taken Ap/Pa of the fistula area
 Fluoroscopy machine is preferable, if not a Overhead couch machine can be used
 The patient lies supine exposing area to be examined .
 The skin surrounding the area is cleaned using cotton wool and a suitable antiseptic solution .
 Sterile towel or gauze are placed around the opening .
Note : The procedure can only be carried out if there is discharge of pus o mucus or liquid from the opening
as at the time of the investigation if not the patient is instructed to come back when their is discharge.
 If a drainage tube is in situ, the contrast agent may be introduced through it
 If not than a catheter of appropriate size is inserted into the orifice of the fistula, a gauge is firmly placed
around the site of opening to restrict reflux
 sufficient quantity of a soluble contrast agent in injected under fluoroscopy or without to outline the extent
of the fistula
 Spot films are taken if using fluoroscopy and if not, Normal films are taken with overhead Xray machine.
 
PROJECTION AND AFTERCARE
1. AP / PA
2 Lateral
Erect views using a horizontal beam may be talky on radiologist request .
AFTER CARE
-Patient passes out contrast if fistula is in anus or vagina.
• If on body surface, the nurse cleans the site and dress the wound .
• Ensure patient is comfortable b/4 Leaving the department.
Radiation protection
  Collimation

 Low radiation dose

 Shielding (lead apron)

 Distance
 MALE URETHROGRAM
Urethrogram in the male is by the ascending through a catheter passed through the
urethra or descending [peri-catheter] passage of the opaque medium, filling the bladder
micturating is recorded it is checked if they is any abnormality in the urethra
Urethrography refers to the radiographic study of the urethra using iodinated media and
is generally carried out in males.
when the urethra is studied with installation of contrast into the distal/anterior urethra it
is referred to as
- Retrograde urethrogram [RUG]
- Ascending urethrogram [ASG]
When the posterior urethra is studied micturition, this is referred to as
- voiding cystourethrography
- Descending urethrography
- Micturating urethrography
INDICATIONS
Bladder outlet obstruction
Haematuria
Urethral stricture
Difficulty in passing urine
Obstructive uropathy
Recurrent urethral stricture
Trauma to the urethra
Contra-indication
Urethral infection or Acute urinary infection
Hypersensitivity to contrast medium or
Contrast –high osmolarity contrast medium [HOCM]
Urografin 76% [ionic contrast medium diluted with normal saline: 20mls:100mls of saline
Total volume used 250-300 mls of dilution
ANATOMY OF URETHRA
In females: length of 3-4cm
The female has the widest at bladder neck, its
narrowest and least distensible at meatus
In males: 20cm in length
It has four named regions- a] prostatic
urethra[approximately 3cm in length and passes
through the prostate gland.
B] Membranous urethra – approximately 1 cm in
length and passes through the urogenital
diaphragm.
C] Bulbar urethra-from inferior aspect of urogenital
diaphragm to penoscrotal junction
D] Spongy [penile] urethra- passes through the
length of the penis.
SPHINCTERS OF URETHRA
INTERNAL URETHRAL EXTERNAL URETHRAL
SPHINCTERS SPHINCTERS
- it regulates involuntary control of urine -It provides the voluntary control of
flow from the bladder to the urethra. urine flow from the bladder to the
urethra
- supplied by the sympathetic nerves
- supplied by perineal branch of the
- Involuntary in nature prudendal nerves [S2-S4]
- voluntary in nature
MICTURATING
CYSTOURETHROGRAPHY
[MCUG] AND ASCENDING
URETHROGRAPHY [RUG]
Voiding cystourethrography [VCUG] is a fluoroscopic study of the lower urinary
tract in which contrast is introduced into the bladder via a catheter. The purpose for
this examination is to assess the bladder,urethra, postoperative anatomy and
micturition in order to determine the presence or absence of bladder and urethral
abnormalities including vesicoureteral reflux [VUR].
VUR is the term for abnormal flow of urine from the bladder into the upper urinary
tract and is typically a problem encountered in children.
RUG is considered to be the best initial study for urethral and periurethral imaging in
men and is indicated in the evaluation of urethral injuries, strictures and fistulas.
EXAMINATION PROCEDURE
Explain the procedure to the patient
Take written informed consent
Empty the bladder prior to the procedure
Sedation may be given to children
The doctor makes sures the area is cleaned to sterilize it.
The patient lies supine on the x-ray table
A preliminary film is taken first [AP Pelvis]
The bladder is filled with contrast using an infant feeding tube aseptic precautions; a foley catheter is used for
other children.
Intermittent screening of the patient on fluoroscopy while the distending bladder with contrast is necessary to
check for a ureterocoele or VUR.
After the bladder is filled to its capacity [which will vary per age of patient] the patient is now asked to void
EXAMINATION PROCEDURE
Bladder is filled until the patient is seen to start voiding or there is an uncomfortable urge to micturate .
Spot radiographs of full bladder are taken in PA and oblique projections
The patient is positioned erect against the erect bucky for a posterior oblique projection.
The doctor then removes the catheter
The patient is the instructed to micturate while exposure is made, a urine receiver is provided
[urinating pan]
Lateral projection of the bladder will be taken only on the request by the doctor.
A post void film is taken to record post void residual contrast in bladder.
Post void film should include the whole KUB region to demonstrate any reflux of contrast medium
that might have occurred unnoticed into the kidney.
NB-the size of cassette used is 35x35cm
EXAMINATION PROCEDURE
For children – in infants and children with a neuropathic bladder micturition is accomplished by
suprapubic pressure.
- infants and young children micturates onto absorbant pads or cloth on the table
-they are instructed to micturate once the catheter is withdrawn.
Note
1] AP with full bladder for the demonstration of the presence or absence of VUR.
2] both obliques to demonstrate bilateral vesicoureteric junctions
3] post void film to check for a ureterocele.
AFTERCARE
Due to pain ,a simple analgesics is helpful
In case of patient is bleeding ,ensure it stops before leaving the deoartment.
Reassure the patient.
MCUG RADIOGRAPHS
BARIUM SWALLOW

A barium swallow is a test used to determine the cause of painful swallowing, difficulty with
swallowing, abdominal pain, or unexplained weight loss.
Clinical indications
Disorders of swallowing
Abnormally enlarged veins in the esophagus that cause bleeding
Ulcers Narrowing of the esophagus (the muscular tube between the back of the throat and
the stomach)

Tumors
Polyps (growths that are usually not cancerous, but could be precancerous)
PATIENT PREPARATION
Do not eat or drink
anything, including
water, after midnight
before the test.
If you are pregnant, or
think you might be,
tell the staff before the
x-ray is taken.
THE ESOPHAGUS
THE
ESOPHAGUS
When the esophagus is empty , the mucosa coat is
thrown into three or four straight longitudinal folds
appeared as straight parallel lines throughout the
esophagus
 NORMAL
INDENTATIONS
There are Two normal
indentations of the
esophagus

1- At the aortic arch

2- At the left bronchus

BASIC
PROJECTIONS
Right anterior oblique [RAO ]35° to 40°
Lateral
Anteroposterior[AP]
Left anterior oblique [LAO]
 REASONS FOR EACH
PROJECTION
- lateral is done Because the esophagus
is thrown away from the spine, allowing
better visualization.
The esophagus is seen between the heart
and the spine

-For right anterior oblique: The patient

is rotate 35- 40 degrees with the RT side
against the table
N.B image I [LAO]
Image II [RAO]
WHAT YOU SHOULD EXPECT
IN BARIUM SWALLOW
• No special preparations are required.
• Study of the larynx, pharynx, and esophagus.
• A thick barium mixture(350-450 mL ) is swallowed in supine position.
• Fluoroscopic images of the swallowing process are made.
• The procedure is repeated several times with the examination table tilted
at various angles.
• Normally, 90% of ingested fluid should have passed into the
stomach after 15 seconds.
PATIENT PREPARATION
1. NPO for 6 hours prior to the examination.
2. Smoking should be avoided on the day of examination.
3. Muscle relaxants before the procedure
4 Ensure that no contra indication to the contrast agent.
5 Check pregnancy status for female of child bearing age.
6 Procedure should be explained to the patient before under
7. Going the procedure and the duration the exam may take.
8.Any other medical history needed.
PATIENT POSITIONING FOR A
SINGLE-CONTRAST
ESOPHAGRAM
Place the patient in the right anterior oblique (RAO) position to offset the esophagus
from the spine. The patient’s right arm is placed alongside the body, with the left knee
flexed.rm is placed alongside the body, with the left knee flexed.
 The Radiographer should place the cup barium in the patient’s left hand, with the
straw between the patient’s teeth.
Patients who are unable to tolerate this position may be imaged in the left posterior
oblique (LPO) position.
 Position the fluoroscope so that the apex of the left lung appears at the top of the monitor.
 The technologist will ask the patient to continuously drink the barium. This fills and
distends the esophagus while the technologist obtains images of the proximal esophagus,
midesophagus, and the distal esophagus, including an open lower esophageal sphincter (magnified
if possible).
CRITIQUE CRITERIA
Right Anterior Oblique,Lateral Oblique's
The RAO should demonstrate the entire barium filled Esophagus.
Like the RAO stomach , which is the single best projection, the Right anterior oblique
is also best for the esophagus.

The heart provides a homogeneous back ground to contrast it Against and the distal
esophagus traversing the esophageal
Hiatus is laid out in profile.
BASIC PROJECTION
RAO (35° to 40°)
Lateral
AP
LAO
 RAO
The esophagus is seen between the heart and the spine

The patient is rotate 35- 40 degrees with the RT side against the table
AP PROJECTION
The esophagus is seen between the heart and the spine

The patient is rotate 35- 40 degrees with the RT side against the table
XRAY VIEWS
AP or PA Projection:-
 Pt. supine or prone
 Center midsagittal plane to cassette
 Bottom of cassette should be placed just below tip of xiphoid
 Pt. drinks contrast before exposure and
continues drinking during exposure.
 Shield!
LATERAL
XRAY VIEWS
RAO or LAO Positions:-
 To throw the esophagus clear of the spine.
 Pt should be rotated 35 - 40 degrees
 Center about 2 inches lateral to MSP
 Bottom of cassette below xiphoid.
 RADIOGRAPHIC PROJECTION -
LATERAL
RAO or LAO Positions:-
 To
LATERAL
Because the esophagus is thrown away from the spine, allowing better
visualization
LAT-RAO
ABNORMALITIES
OESOPHAGEAL VARICES
They appear inside the oesophagus and occasionally they occur in the stomach.
Varices develop when most of the normal liver tissue has been replaced by scar
tissue. Because the scar tissue pushes upon the veins in the liver, blood cannot flow
normally through the veins.
ZENKER'S DIVERTICULUM
Is a blind sac (pouch) that branches off the cervical esophagus. It is the most
common type of esophageal diverticulum.
CONCLUSION
Special investigation in radiography is a very sensitive aspect of radiography, as
qualified and certified radiographers, we must remain sensitive to the physical and
emotional needs of our patients through good communication and basic patient care.
As radiographers our top priority is to apply knowledge ,maintain high degree of
positioning accuracy and techniques to produce a diagnostic result
Lastly our primary goal is to protect our patient, ourselves and the public by the use
of radiation protection principles and guidelines.
RECOMMENDATION
Adequate seminars and workshops should be conducted to equip radiographer on
specials skills like resuscitation.
REFERENCES
8th Textbook of radiographic positioning and related anatomy
13th edition Clark’s positioning.
Radiopaedia.com