Unit 9 Radiography of the Biliary System RDSC 233 and assorted contrast examinations Bontrager page numbers in white Anatomy D Done I Infrequent RE Rare or extinct Procedures covered in unit 9 Oral Cholecystogram (OCG) 519-537 for all GB & biliary Surgical Cholangiogram T-tube Cholangiogram Percutaneous Transhepatic Cholangiogram (PTC) Endoscopic Retrograde Cholangiopancreatography (ERCP) Intravenous Cholangiogram (IVC) Myelography 734-738 Sialography 739-741 Dacrocystography Arthrography 726-730 Lymphangiogram 677 & 690 Hysterosalpingography (HSG) 731-733 Cavernosogram & Spongiosogram Atlas of Human Anatomy Second edition (276) Need to know Gallbladder: fundus, body, neck Cystic duct Rt. & Lt. hepatic duct Common hepatic duct Common bile duct Ampulla of Vater Sphincter of Oddi Pancreatic duct (of Wirsung) Duodenal papilla (of Vater) in descending or 2nd part. Atlas of Human Anatomy Second edition (277) Note worthy Variations in biliary anatomy Oral Cholecystogram (OCG) I Prior to ultrasound proving its value in hepatic and biliary imaging, the OCG was 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 NPO: in ½ hour intervals at midnight. No fats after contrast is taken (or contrast is flushed from contractions of GB) Calcium stones (opaque) seen in recumbent spots The examination begins with fluoroscopy. A 4-on-1 film is done upright, followed by a 4-on-1 supine. Inspiration, expiration, compression, and changes in position are used to free the GB from bowel gas, ribs, and the spine, to visualize hard to see stones. Cholesterol stones (lucent) seen in recumbent spot. Note the stratification of the stones. Oral Cholecystogram (OCG) Following fluoroscopy, overhead films are often taken. Note the relationship of the GB to the 12th rib on these examples. The LAO is the gallbladder film. Why? Consider the position of the gallbladder relative to the spine. Right lateral decubitus provides a horizontal beam Why right, and not left? The PA is usually routine. Post fatty meal. Gallbladders were made for using a cylinder cone. Bacon & eggs (or x-nog) to demonstrate contractibility. Operative, Surgical, or Immediate Cholangiogram D Surgical cholangiograms are done to find residual stones in the hepatic or common bile ducts after a cholecystectomy (removal of the GB) that is 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 cholecystectomy was performed through an incision, as evidenced by the hemostats. Two films are taken. The first injection is a few CCs to fill the biliary tree. The second spills contrast into the duodenum, When the patent must be supine, the RPO position assuring that nothing is frees the biliary tree of superimposition on the spine missed. T-Tube Cholangiogram One side of T in common hepatic duct. One side of T in common bile duct. D When the gallbladder is removed stones may be missed. If residual stones are suspect a TTube is left in the bile ducts. Bile drains through it, and the tube provides access to remaining stones without reopening the incision. T-tube cholangiograms are performed under fluoroscopy. Positions for filming are AP and RPO. When draining bile and preparing for the contrast injection it is imperative to keep air out of the tube. Air bubbles look like cholesterol stones. Air Stones? T-Tube Cholangiogram Stone Basket Removal A basket catheter, passed through the T-Tube, can snare and remove residual stones. Percutaneous Transhepatic Cholangiogram (PTC) I RE When obstruction casues dilation of the biliary tree, and cessation of bile excretion, jaundice results. Access to the biliary tree may be gained by direct needle puncture through the liver (transhepatic). Iodine contrast is injected and obstructions are demonstrated by a filling defect, or by a columniation of contrast to the point of obstruction. Endoscopic Retrograde Cholangiopancreatography (ERCP) D An ERCP is a fairly common examination that gains access to the bile ducts and pancreatic duct through catheterization via a duodenoscope. It is performed by a gastroenterologist, under Duodenoscope fluoroscopic control. Injection cannula Cystic duct with spiral valves The potential for stone removal makes an ERCP diagnostic and theraputic Intravenous Cholangiogram (IVC) RE When the gallbladder did not visualize using the oral contrast of the OCG, a liquid iodine preparation could be drip infused. Concentration in the bile ducts was minimal, so tomograms were taken in the RPO position. The exam could take over an hour, and the patient could not move in the slightest. Biliary Sent Atlas of Human Anatomy Second edition (148) Need to know Dura mater Arachnoid mater Subarachnoid space Pia mater Spinal cord and nerves Myelography I Radiographic 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. Contrast Spinal nerve Encroachment on the spinal cord or nerves is demonstrated as a filling defect. Disk material, tumors, subluxed vertebra, or fracture fragments impressing 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 Wharton’s (submandibular) duct Sublingual gland Bartholin’s (sublingual) ducts Caruncle Sialography I Sialograms are radiographic investigations of the salivary ducts and glands for obstructions caused by tumors or calculi. Sucking on a lemon promotes salivation Cannula in and makes the ducts easier to find and Stensen’s cannulize. duct Cannula in Wharton’s duct Parotid gland Shown on xerographic paper A cardboard film in the mouth may demonstrate calculi in Bartholin’s ducts and the sublingual glands from an inferosuperior projection. Submandibular gland Atlas of Human Anatomy Second edition (77) Need to know Orbital part of lacrimal gland and ducts Lacrimal sac Nasolacrimal duct Inferior nasal meatus Dacrocystogram I lacrimal cannula Radiographic examination of the lacrimal apparatus. The lacrimal duct is cannulized with a lacrimal cannula (may be used for a sialogram). Contrast is injected. If contrast spills into the nasopharynx, the lacrimal duct is patent. contrast in the nasopharynx Atlas of Human Anatomy Second edition (477,48049) Need to know Synovial membranes Articular cartlages Menisci Bursa Ligaments 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 contrast may be injected by a radiologist. The part is exercised and stressed to maximize the visibility of tears in menisci, the joint capsule, or ligaments. Overhead films are those routine for the part being examined. Tear in the medial meniscus of the knee Arthrography D Spot films are typically taken during arthrograms. Because the part of interest is small, and numerous views and stressing of the part is required, many exposures may be taken. Here 9 on 1s are taken on 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 channels 2. 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 mostly lymph channels. Lymphangiogram 24 hour films show nodes. Atlas of Human Anatomy Second edition (337-346) Need to know Uterus: fundus & body Cervix External and internal cervical os Fallopian tube (ovaduct) Frimbriae Hysterosalpingography (HSG) I Radiographic examination primarily done to assess patency of the fallopian tubes in cases of infertility. Done in the lithotomy positon. Gynecologist prepares for injection by speading the vaginal canal with a speculum. A catheter with an acorn or balloon tip seals the external os. Contrast is injected into the body of the uterus Fallopian tubes Contrast in body of uterus Catheter Catheter Hysterosalpingography After filling the uterus and fallopian tubes, the contrast will spill into the peritoneal cavity, which is the sign of patent ovaducts. The most common gynecological problem is a benign tumor called a leiomyoma (uterine fibroma or fybroid tumor are common, though improper names). Because the pressure of the contrast may clear the tubes of a blockage, a hysterosalpingogram may be a theraputic as well as a diagnostic examination. These benign tumors of the uterine muscle become troublesome when they become numerous or large, and sometimes begin 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 Bulb of penis Crus of penis Cavernosogram & Spongiosogram RE Injection of iodine contrast into the corpus cavernosa or spongiosum to evaluate inflammation (cavernositis) or failures of the erectile tissue to fill 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?