9. Fluoroscopy 2 Flashcards
1
Q
what separates the left and right liver lobes
A
falciform ligament
2
Q
what are the 3 organs involved in the biliary ductal system
A
pancreas
liver
gall bladder
3
Q
what does the pancreas do
A
produces enzymes which assist in breakdown of food for the digestive system
4
Q
what does the liver do
A
produce bile as a digestive function
5
Q
what does the gall bladder do
A
collects, stores and concentrates bile
6
Q
what are 3 structures taht ERCP is interested in
A
common bile duct, pancreatic duct and sphincter of oddi
7
Q
what is the ampulla vata
A
where the common bile duct feeds into 2nd part of duodenum
8
Q
what are the 3 hepatic ducts
A
left right and central
9
Q
what are the 4 ducts involved in the biliary ductal system
A
hepatic duct
cystic duct
common bile duct
pancreatic duct
10
Q
where is the cystic duct from
A
from gall bladder
11
Q
where does the common bile duct enter
A
enters duodenum
12
Q
what duct does the pancreatic common bile duct join
A
common bile duct
13
Q
what are 9 clinical indicates affecting the biliary system
A
assessment/treatment of biliary obstruction congenital anomalies cholecystitis choledocholithiasis polyps cholelithiasis strictures malignant tumors jaundice
14
Q
what is cholecystitis
A
gall bladder inflammation
15
Q
what is choledocholithiasis
A
gall bladder stones
16
Q
what is doledocholithiasis
A
common biliary duct stone
17
Q
what does ERCP stand for
A
endoscopic retrograde cholangiopancreatography
18
Q
what are the 2 fluro procedures of the biliary systems
A
ERCP
T tube cholangiogram
19
Q
what is an ERCP
A
endoscope into duodenum to access biliary system, diagnostic or therapeutic
Retrograde = going against the system/backwards
20
Q
when is T tube cholangiogram used
A
during surgery when patient has gall bladder removed
21
Q
what is the procedure of ERCPs
A
1/ endoscopic cannulation of ampulla vater
2/ retrograde injection of ICM into common bile duct
22
Q
in ERCPs where is the endoscope cannulated into
A
ampulla vater
23
Q
in ERCPs where is ICM injected into
A
common bile duct
24
Q
what are the 2 types of ERCPs
A
diagnostic or therapeutic
25
where is the sphincter of oddi
valve is where pancreatic and common bile ducts meet
26
what are 3 conditions that are contraindications for ERCPs
unstable cardiopulmonary/neurologic/cardiovascular status
GI conditions that impede access
presence of acute pancreatitis
27
what are 2 tests that are done before ERCPs to prepare the patient
coagulation studies
| liver function tests
28
what are dietary requirements for ERCP patient preparation
NPM overnight
29
what are the 3 premedications given to patients before ERCP
atropine
throat anesthetized (xylocaine spray)
glucagon IV
30
when is atropine given before a ERCP
1hr prior
31
when is glucagon given before a ERCP
10min prior to exam
32
what is atropine used for when its premedicated in ERCPs
to clear up saliva
33
what is glucagon used for when its premedicated in ERCPs
cause release of glucose from liver so drug reduces spasms in bowel and sphincter of oddi
34
what contrast media is used in ERCPS
omnipaque 350 diluted
35
why is omnipaque diluted in ERCPs
Diluted with saline as it goes into small ducts so need to make sure its not too dense or radiopaque as it may obscure a small calcificaiton
36
can stones in the common bile duct be removed
easily via ERCP but some can be too large to be pulled through spincter of oddi
37
what happens if the stone is too large in the common bile duct to pull out from the sphincter of oddi
sphincterotomy of the sphincter of oddi to widen the opening into the duodenum to remove larger stones
38
what is the procedure from start to finish of an ERCP
6 steps
1/ patient sedated and back of throat sprayed to numb the gag reflex
2/ antispasmodic drug is given to reduce spasms of the duodenum and relax sphincter of oddi for passage of endoscope and cannula insertion
3/ endoscope passed through mouth down esophagus into the stomach
4/ gastroenterologist observes the GI tract through the endoscope allowing advancement of scope through pyloric sphincter into descending duodenum
5/ cannula threaded through duodenoscope into ampulla of vater into the common bile/main pancreatic duct
6/ placement of cannula verified under fluoroscopy
39
what do staples in the bowels suggest in an ERCP
previous surgery - patient had gall bladder removed and there is a cystic shunt
40
how can ERCP be therapeutic in addition to diagnostic
if there is a tumor that obstructs flow of bile into duodenum, stent holds bile duct open to restore flow
41
what are 2 important things for the patient to know after the ERCP procedure
NBM following procedure as throat is numb
will be in recovery area until full consciousness regained
42
what are 7 imaging options for the urinary system
```
plain film KUB
fluoro - MCU/cystogram/urethrogram
Ultrasound
CT urography
Nuc Med
MRI urography
angiography
```
43
what is the collimation vertically and horizontal for KUB
T12-lower border of symph pubis
| ASIS laterally
44
what are important structures to get on KUB
upper border of kidney and need bladder on
45
if you cant see both kidneys in KUB what do you do
coned renal view
46
what is the centering for coned renal view
center midway between xiphisternum and lower costal margin in midline
47
when do you take a coned bladder view
if you havent got upper symphysis pubis
48
what is urolithiasis
very big kidney stone
49
what is the angulation for coned bladder view
15 degree caudal angulation
50
what is the centering point for coned bladder
midway between symphysis pubis and ASIS in the midline
51
why is there caudal angulation in coned bladder view
pelvic inlet is on angle so get pubic symphysis out of the way to see bladder
52
what is cystography
radiographic exam of urinary bladder and lower end of ureters
53
what 3 things is cystography used to demonstrate/detect
demonstrate bladder pathology
detect bladder injury post trauma
preliminary to micturating studies of vesico-ureteric reflux
54
what is micturating cystourethrogram used for and what kind of contrast media is used
low osmolar (150mg/L) water soluble contrast imaging of bladder and urethra during micturation
55
what is done to the CM befure a micturating cystourethrogram
CM is warmed up prior to administration
56
what is the control image in a micturating cystourethrogram
coned bladder
57
what are the 3 queries for early filling image in a micturating cystourethrogram
catheter position
bladder abnormalities
ureterocele
58
what are the 5 images taken in a micturating cystourethrogram
```
control image
early filling image
full bladder image
voiding urethral images
post void full length abdomen
```
59
what view is taken for a voiding urethral image in a micturating cystourethrogram
anterior oblique
60
what 2 queries are there for a post void full length abdomen image in a micturating cystourethrogram
bladder residue
| vesico-ureteric reflux
61
what is vesico ureteric reflux
stricture affects flow and forces urine and contrast back up towards kidney
62
what is ureteric reflux associated with
urinary tract infection
63
what is a consideration for retrograde urethrogram
limited number of people in room as its a very private examination
64
who is retrograde urethrogram performed on
male patients to demonstrate full length of urethra
65
how is CM used in a retrograde urethrogram
CM injected retrograde into the distal urethra until the entire urethra is filled
66
what is a clinical indication for retrograde urethrogram
trauma and/or obstruction of the urethra
67
what are three things that US is used to demonstrate or exclude
hydronephrosis
renal tumors
cysts and abscesses
68
what are 4 things that CT is used for in evaluating the urinary system
staging renal tumors
evaluating trauma to urinary tract
showing pathology in retro-peritoneum
CT urography
69
what is nuclear medicine used for in urinary systems
used for comparative renal function
70
what is MRI used for in urinary systems
show soft tissues in detail - blood vessels or other structures
71
when is MRI used in evaluating the urinary systems
if contrast is contraindicated
72
what is arteriography used in evaluating the urinary system
assess arterial flow
73
how is CM introduced in a hysterosalpingography
Introduce CM up vagina through cervix and into the uterus and look at flow into fallopian tubes
74
what is hysterosalpingography used to demonstrate - 2 things
uterus
fallopian tube patency (spillage of CM into peritoneum)
75
what are 4 clinical indications for hysterosalpingography
assessment of female infertility
pathology (unexplained utereine bleeding and pelvic pain)
assessment following tubal ligation
congenital anomalies
76
what is primary infertility
When person tried to conceive in a year and can't get pregnant
77
what is secondary infertility
when you’ve been pregnant before but have trouble conceiving
78
what are 3 contraindications for hysterosalpingography
pregnancy
acute/subacute pelvis inflammatory disease
active uterine bleeding
79
what is patient preparation for hysterosalpingography
in terms of when booking is made, how interacted with patient etc
booking made to exclude possibility of pregnancy - ie in first 7-12 days of menstrual cycle
consent
explanation
reassurance
80
what kind of CM is used for hysterosalpingography
water soluble ICM
81
what is water soluble ICM used in hysterosalpingography
absorbed easily
| doesn't leave residue in uterus or peritoneal cavity
82
historically what CM was used in hysterosalpingography
oil based ICM lipiodol
83
why is oil based ICM no longer used in hysterosalpingography
slow absorption
oil embolus risk
84
what is the procedure like for hysterosalpingography
5 steps
1/ patient placed in lithotomy position
2/ vaginal speculum placed in vagina
3/ cannula/catheter placed into cervical canal
4/ balloon catheter/suction cap may be used to prevent spillage of CM back into vagina
5/ CM filled syringe is attached to cannula/catheter
85
how much CM is introduced into the uterus in a hysterosalpingography and how is it introduced
introduced slowly
5mls initially but 5mls more may be needed to complete filling of fallopian tubes and if patent spillage into peritoneal cavity
86
what images are taken in a hysterosalpingography
fluoroscopic images with patient in supine position
87
what is done in hysterosalpingography to clear overlying anatomy
turn patient into an oblique position for further imaging
88
what is aftercare for a hysterosalpingography - 4 things
patient provided with sanitary pad and directed to bathroom
analgesics may be recommended
advise woman to protect against pregnancy before next period and to use contraception until that time
if heavy bleeding/extreme discomfort - advise to seek medical attention
89
what is a bicornuate uterus
congenital anomaly
Instead of uterus being one cavity, its conjoined cavity of 2 parts
90
what are 4 complications associated with ERCP
post ercp pancreatitis
bleeding
infection
perforation
91
what are 4 other modalities that can be used to investigate the biliary system
US
CT
Magnetic resonance cholangio-pancreatography
radionuclide cholangiography - cholescintigraphy
92
what is MRCP
non invasive magnetic resonance imaging exam that visualises entire gall bladder, biliary tree and pancreatic duct
93
when is MRCP performed relative to ERCP and what is it used for
before ERCP to determine if therapeutic ERCP is needed
94
is MRCP therapeutic and diagnostic
no only diagnostic
95
what is MRCP used to diagnose
identify and remove biliary tract stones
96
for whom is MRCP a good alternative
for patients who need biliary imaging but have renal complications or allergy to ICM
97
how is T tube placed
placed into stump of cystic duct and advanced until cap of T extends up the common hepatic duct and down the common bile duct
98
what does T tube allows
allows drainage of bile 'sludge' and any small stones remaining in biliary tree after surgical removal of gall bladder
99
what does T tube use CM for
to visualize the bile duct after the removal of the gall bladder - bile ducts drain bile from the liver to the duodenum
100
where is the T tube meant to go
common hepatic duct
101
what are 2 clinical indications for T tubes
rule out presence of stones in biliary tree post operatively following cholestectomy
assessment of biliary leaks following biliary surgery
102
what contrast media is used for T tube
Omnipaque 300/350
103
how much omnipaque is used in T tube and how is it administered
20mls diluted CM is injected into T tube
104
what images are taken in T tube
3 images
scout AP precontrast
spot films post contrast (generally AP, posterior obliques and lateral)
final image to see emptying
105
what are 3 clinical indications for imaging the urinary system
haematuria
pyuria/proteinuria
renal colic
106
what is hydronephrosis
swelling of kidney due to builds up of urine, since urine cant drain to bladder from kidney due to obstruction
107
what is hydroureter
dilated ureter
108
what is polycystic kidney
cysts on kidney
109
what can happen in polycystic kidney
kidney can become enlarged and lose function
110
what is staghorn calculi
big calculi that sits in the renal pelvis in at least 2 calyxes
111
what is ectopic kidney
kidney not in typical normal position
112
what is horseshoe kidney
2 kidneys fused as horseshoe across abdomen
113
where do transplanted kidneys go
into pelvis as diseased kidney stays in same place
114
what is pelvic ureteric obstruction
narrow Pelvic ureteric junction causing pelvis ureteric obstruction
115
what can pelvic ureteric obstruction lead to
can cause problems with flow of urine
116
what does renal artery stenosis lead to
kidney not getting enough blood supply so patients often have high blood pressure
117
what is urolithiasis
stone in kidney or ureter in urinary system
118
what is urinary reflux
urine goes against normal flow
119
what is pyuria
increased presence of white blood cells
120
what is renal colic
caused by obstruction such as stone (fine for short period of time and then pain)
