1. Radiographic Contrast RTEC - A 2012 1.SUBJECT & FILM CONTRAST 2.CONTRAST MEDIA

2. 2 types of Radiographic “Contrast” 1.Subject contrast – patient 2.Film contrast – Inherent in equipment – The BLACKS & WHITES ON THE FILM / IMAGE

3. “Subject” Contrast

4. Subject Contrast Range of differences in the intensity of the x-ray beam After it has been attenuated by the subject.

5. SUBJECT CONTRAST Radiographic object - influenced by 1.Atomic Number of object 2.Density of object 3.Thickness of object 4.5 materials seen on a radiograph, – Gas/air, fat, soft tissue (muscle/organs), – bone and metals

6. Atomic Number 1.Fat = 6.46 2.Water = 7.51 3.Muscle = 7.64 4.Bone = 12.31

7. Tissue Subject Contrast 1.Atomic # of object 2.Density of object 3.Thickness of object 1.Higher atomic # = more attenuation 2.Denser = more attenuation 3.Thicker = more attenuation

8. PATHOLOGY 1. Pleural Effusion 2. Excessive fluid in lung 3. More dense than air

9. Pneumothorax 1.Lung collapses 2.No tissue in space 3.Easy to penetrate with x-ray photons

11. Film Contrast AKA Radiographic Contrast

12. Radiographic Contrast influenced by: 1.Radiation Quality (KVP) 2.Film attributes 3.Radiographic object (Patient)

13. What is good contrast ? 1.High contrast (black and white) 2.Low contrast (more shades of gray)

15. RADIOGRAPHIC IMAGE Radiation Quality = kVp 1.High kVp ↑ 80 2.Low contrast 3.Lots shades of gray 4.Long Scale 5.Little differences in adjacent structures 1.Low kVp ↓ 70 2.High contrast 3.Black and White 4.Short Scale 5.Great differences in adjacent structures

16. Contrast changes with the use of a grid Less scatter radiation – shorter scale = “better contrast” With Grid No Grid

17. QUALITY – KVP A visible change in contrast will not be seen until kVp is changed 4-12 % – kVp level change change in kVp 30-50 kVp4-5 %1-3 kVp 50-90 kVp8-9 %4-8 kVp 90-130 kVp 10-12 %9-16 kVp

18. Scenario Low subject contrast in the area of interest. – You want to see the difference between muscle & fat & organs? What can be done to attain medical information and define organ structure and function? _____________________________________

19. Scenario Low subject contrast in the area of interest. – You want to see the difference between muscle & fat & organs? What can be done to attain medical information and define organ structure and function? USE CONTRAST MEDIA

20. Changing Subject Contrast with CONTRAST MEDIA

21. 21 Barium has a higher z# more asorbtion of photons

23. Contrast Media changes the density of the organs 3) Changes radiographic (film contrast) 2) Changes subject contrast 1) Use contrast media

24. Purpose of Contrast Media 1.To enhance subject contrast or render high subject contrast 1.In a tissue that normally has low subject contrast. 2.Creates bigger differences in atomic number (z #’s)

25. Categories of Contrast Media Negative contrast 1.(AIR OR CO2) 2.Radiolucent 3.Low atomic # material 4.Black on film Positive contrast 1.(all others) 2.Radiopaque 3.High atomic # material 4.White on film

26. 1.RADIOLUCENT - dark on image – AIR, CO 2 2.RADIOPAQUE - white on image – BARIUM – IODINE

27. Negative Contrast 1. AIR / CO 2 2.Naturally seen in the – LUNGS – STOMACH – (gas in intestines)

30. POSTIVE CONTRAST MEDIA

31. 2 BASIC TYPES OF ‘”Positive” CONTRAST MEDIA BARIUM Z# 56 KVP 90 – 120* 1.NON WATER SOLUABLE 2.GI TRACT ONLY INGESTED OR RECTALLY IODINE Z# 53 KVP BELOW 90* USUALLY 70 – 80 KvP 1.WATER SOLUABLE 1.POWDER 2.LIQUID 3.INTRAVENOUS OR 4.GI TRACT 2.OIL BASED 1.DUCTS /ORGANS

32. Positive Contrast Material INGESTED /INSTILLED – (ORALLY OR RECTALLY) 1.BARUIM 2.IODINES – GASTROGRAFIN – HYPAQUE POWDER INJECTED – IV – INTO BLOOD VESSELLS – Organs and ducts 1.IODINES – IONIC OR NON-IONIC VESSELLS & ORGANS 2.OIL BASED – DUCTS /ORGANS ONLY

33. Methods of Administration of Contrast Material 1.INGESTED / INSTILLED – (ORALLY OR RECTALLY) 2.INJECTED – IV – INTO BLOOD VESSELLS 1.RETROGRADE – AGAINST NORMAL FLOW (Vessels & Organs) 2.INTRATHECAL – Spinal canal 3.PARENTERAL 4. (IV, Intrathecal) – Injecting into bloodstream – (anything other than oral)

34. BARIUM BARIUM SULFATE

35. HISTORY OF BARIUM BaSo 4 1.LEAD SUBSTRATE – TOXIC 2.BISMUTH SUBNITRATE – TOXIC 3.THORIUM – RADIOACTIVE 4.BARIUM SULFATE - INERT 1.(goes in and comes out the same – not absorbed) 5. NOTE SOME PATIENT MAY SHOW ALLERGY TO SUSPENSION SOL.

36. Barium Sulfate BaSO+ 1.High atomic number 2.Not soluble in water 3.Used to coat the lining of organs 4.Supplied in different thicknesses 5.Used 1.Esophogram, UGI, Small Bowel,Lower GI or BE

37. Barium Sulfate BaSO+ 1.Because it is not water soluble – it must be mixed in a SUSPENSION with water 2.FLOCCULATION – when barium clumps (separates from the water) 3.Barium residue in the colon can dry and cause an obstruction 4.Drink plenty of fluids after exam

38. BARIUM 1.MIXED IN A SUSPENSION 2.MUST BE SHAKEN 3.CHECK THE CAP (LID) FIRST !!!!!!! 4.SUSPENSION – sodium citrate, vegetal gums, flavoring and sweeteners to improve palatability

39. ADVERSE REACTIONS 1.SUSPENSION MAY CAUSE ALLERGY 2.OCG TABLETS (IODINE) ALLERGY 3.AFTER EXAM – MAY SOLIDIFY DIFFICULT TO EVACUATE 4.INCREASE FLUIDS, MILD LAXATIVE 5.EXTRAVASATION OF CONTRAST INTO PERITONEUM

40. BARIUM “THICK & THIN” 1.THICK – 1.DOUBLE CONTRAST 2.THIN – 1.SINGLE CONTRAST

43. BARIUM ORAL OR RECTAL 1.LABELS ARE DIFFERENT 2.CHECK CAREFULLY BEFORE GIVING TO THE PATIENT

44. Palatability OF BARIUM 1.Chalky taste with barium sulphate/water mixture 1.Contain a flavoring agent, sweetners 1.To disguise the unpleasant taste 2.Thicker or thinner suspensions may be used 3.Many commercial preparations contain carboxymethyl cellulose (Raybar, Barosperse) 1. Which retains fluid and prevents precipitation of the barium suspension in the normal small bowel

45. GASTOINTESTINAL exams BARIUM COATS LINING OF INTESTINE 1.SINGLE CONTRAST - BARIUM ONLY 2.DOUBLE CONTRAST – WITH AIR CARBON DIOXIDE TABLETS – FIZZIES / CRYSTALS 3.SODA 4.ROOM AIR (LOWER GI)

47. EXTRAVASATION 1.LEAKAGE THROUGH A DUCT OR VESSEL OR ORGAN INTO THE SURROUNDING TISSUE 2.Barium should not be given in cases of suspected perforation

48. Extravasation 1.Following a Colonoscopy with biopsy

49. Extravasation of BA in abd

50. GASTROINTENSTIAL CONTRAST MEDIA PROCEDURES 1.ESOPHOGRAM / OPMS 2.UPPER GI (UGI) 3.SMALL BOWEL (SMBFT) 4.BARIUM ENEMA (BE) 5.GASTRO ENEMA

52. Drinking Ba for Esophogram

55. Hiatal Hernia Reflux “heartburn”

57. Supplies for BE

58. “DOUBLE CONTRAST” studies with Barium 1.Air used with other contrast agents 2.Better to see internal structures BE – room air mixed with Ba UGI – gas “fizzies” used

59. DOUBLE CONTRAST EXAMS 1.To achieve double contrast examination of the stomach, air or carbon dioxide gas must be introduced 2. Most radiologists use effervescent tablets (sodium bicarbonate, tartaric acid & calcium carbonate) 3.To react with the gastric contents to produce carbon dioxide

60. BE SINGLE DOUBLE (AC)

61. UGI double contrast single contrast

62. DOUBLE CONTRAST WITH IODINE Iodine mixed with air of a bladder (canine)

63. IODINE CONTRAST

64. Iodine 1.Water Soluble 2.High atomic # 53 3.Radiopaque 4.Used to radiograph – Vessels – Arteries – Veins – Function of internal organs – Gastrointestinal system – Ducts

65. IODINATED CONTRAST WATER BASED 1.INJECTED 2.VESSELLS/DUCTS 1.Ionic 2.Non-ionic 3.INGESTED or instilled 4.OPEN WOUNDS OIL BASED 1.INJECTED 2.NEVER VESSELLS 3.ONLY DUCTS 4.NOT INGESTED 5.OPEN WOUNDS

66. Gastrointestinal studies: Gastrograffin or Hypaque (Iodine) 1.High atomic # – Close to iodine 2.Water soluble 3.Similar usage as Barium

67. Gastrograffin Water soluble iodine- containing contrast media are of value when there is a suspected perforation or leakage of an anastomosis after operation Oral or Rectal use

68. GASTROGRAFIN POWDERED FORM – MIXED WITH H20 LIQUID IN BOTTLE – MAY BE MIXED USED WHEN PATIENTS ARE ILL, SUSPECTED PERFORATIONS PRE-OPERATIVELY (BITTER TASTE) CAN INCREASE PERISTALSIS (SMB STUDY)

69. GASTROGRAFIN 1.Bitter taste 2.Better if chilled or mixed with ice 3.Monitor patient closely

70. Gastrograffin via NG tube

71. Peptic ulcer 1.Use Gastro 2.Contrast may leak 3.Into the peritoneum 4.Causing peritonitis

72. Gastric neoplasm w/ perforation EXTRAVASATION OF CONTAST INTO THE PERITONEUM

73. Gastrografin enema

74. SINGLE CONTRAST ENEMA BARIUM (110 KVP) GASTROGRAFIN (90 KVP)

75. GASTROGRAFIN Adverse Reactions 1.Water soluble, safe in the abdominal cavity – Safe to use if perforation is suspected 2.Very harmful to the lung tissue – Do not use if aspiration is possible

76. Never force contrast Patient might aspirate into the lungs!

77. INJECTABLE CONTRAST MEDIA INVASIVE PROCEDURES IVP / IVU

78. Intravenous injections are INVASIVE ALWAYS GET PATIENT’S HISTORY AND CONSENT BEFORE BEGINNING OR GIVING ANY CONTRAST MEDIA

79. Patient Assessment Check List Information update !!

80. INJECTED CONTRAST 1.IODINE BASED 1.IONIC 1.NON IONIC

81. IODINATED Contrast Agents IONIC High Osmolality (Higher risk of complications) 1.(Hypaque) 2.(Conray) NON-IONIC Low Osmolality (Lower risk of complications) 1.(Isovue)

82. Iodine Contrast Material 1.Ionic Contrast – Anion - – Cation + – More patient allergic reactions 2.Ionic contrast media dissociates into two molecular particles in blood plasma = 3.Causing pt reactions 1.Non-Ionic Contrast Less patient allergic reactions

83. Newer Contrast Agents Balance Safety and Visualization

84. IODINE WATER BASED CONTRAST 1.IONIC 2.LESS $$$ – $25 per bottle 3.MORE REACTIONS 1.NON IONIC 2. MORE $$$ – $200 per bottle 3.LESS REACTIONS

85. CONTRAST REACTIONS 1.> 10 million diagnostic procedures / year 2.Conventional ionic contrast reactions - 10% 3.1 in 1000 severe

86. Allergic to Iodine General Rule: 1.No Iodine Contrast will be given 1.Pre – medication is available 2.May or may not react if previous iodine given

87. REACTIONS & TreatmentTreatment USUALLY** WITHIN FIRST 5 MINUTES 1.Nausea & Vomiting & UrticariaNausea & Vomiting & Urticaria 2.Hypotension (bradycardia)Hypotension (bradycardia) 3.Hypertension (tachycardia)Hypertension (tachycardia) 4.BronchospasmBronchospasm 5.AnaphylactoidAnaphylactoid 6.SeizuresSeizures 7.ExtravasationExtravasation

89. ALWAYS –know the location of drug trays and crash carts

90. INJECTED IODINE STUDIES GENITOURINARY Contrast injected into the VEIN 1.IVP / IVU 2.CYSTOGRAMS (Retrograde may use a foley catheter) 3. GASTROINTESTINAL 4. ERCP – (CBD)

91. 15 MIN POST CONTRAST INJECTION - IVP CYSTOGRAM

93. Cholelithiasis GB STONES

94. Normal ERCP (checks for stones/blockage in bile duct)

95. GB STONES

96. Other Injected Contrast Studies

97. Cerebral Angiogram

99. Renal Arteriogram

101. MYELOGRAM (SPINAL CORD) INTRATHECAL INJECTION

102. Extravasation

103. “To BE or not to BE” 1.Massive retroperitoneal air 2.pneumomediastinum 3. subcutaneous air 4. secondary to bowel perforation 5.after barium enema

104. Extravasation of Contrast into soft tissue of arm

106. Contrast leaking from bladder

107. OIL – BASED IODINE CONTRAST

108. Oil Based Iodine 1.Fatty Acids 2.Insoluble in water 1.White on the radiograph = Radiopaque 3.Uses 1.Bronchography (lungs) 2.Tear ducts 3.Salivary glands 4.Lymphatic system 5.Hysterrosalpingogram 6.Galactography (breast ducts)

109. To check fertility

110. LYMPHANGIOGRAM

111. Galactography - Breast Duct

112. Oral & IV contrast CT Scan

113. CT showing Abnormal GB

114. ORAL & IV CONTRAST (CT/ MRI)