Fluoroscopic Studies

Question 1

What is Fluoroscopy

Answer 1

“Fluoroscopy is a type of medical imaging that shows a continuous X-ray image on a monitor, much like an X-ray movie.” (FDA, 2020)

“Fluoroscopy is a study of moving body structures–similar to an X-ray “movie.” A continuous X-ray beam is passed through the body part being examined. The beam is transmitted to a TV-like monitor so that the body part and its motion can be seen in detail. “ (Johns Hopkins, 2022)

Fluoroscopy is a type of imaging procedure that uses several pulses of an X-ray beam to take real-time footage of tissues inside your body. Healthcare providers use fluoroscopy to help monitor and diagnose certain conditions and as imaging guidance for certain procedures. (Cleveland Clinic, 2022

Question 2

What is Fluoroscopy?- Benefits

Answer 2

Combines anatomical and physiological/functional information.

Can be diagnostic and/or therapeutic in nature.

Can allow for dynamic guidance of clinicians during procedures.
Facilitates less invasive operative procedures.

Can produce continuous, pulsed, high-dose or single exposures.

Question 3

What is Fluoroscopy?- How it works (in brief)

Answer 3

X-ray generation is similar to conventional XR tubes, with more features to dissipate heat from the anode.

X-rays pass through patient into input phosphor, which emits light.

Light is converted to electrons that are emitted towards the output phosphor.

Output phosphor emits light which is ‘recorded’ by a camera and is put onto the television monitor.

Question 4

What is Fluoroscopy?- Examples of Procedures

Answer 4

Theatre Imaging
Barium Studies
Interventional Procedures
Angiography
Cardiac Angiography

Question 5

Barium Studies

Answer 5

Investigations that require the administration of barium sulphate- a positive contrast agent.

Higher atomic number (Ba=56) than surrounding tissues so attenuates more x-rays.

Appears hyperdense on an image.

Can be administered orally or rectally.

Nowadays comes in granular form to be mixed with water, which enables changes to viscosity.

Question 6

Barium Studies

Answer 6

Used to image the digestive system- ease of excretion.

Barium studies overall are being phased out of clinical practice, being replaced for imaging with improved sensitivity and specificity.

Studies of this session:
-Barium Swallow
-Barium Meal
-Barium Follow-Through
-Barium Enema

Question 7

Barium Swallow

Answer 7

Used to image the pharynx and oesophagus.
Single Contrast Study
Barium Sulphate solution- Positive Contrast Agent
Barium Sulphate administered orally.

Question 8

Barium Swallow

Answer 8

Live screening demonstrating the patient’s ability to swallow Barium.
Viscous drink
Usually 2-3 frames per sec.
Often undertaken in AP, Lateral and Oblique views of the patient’s oesophagus.
Patient is erect during imaging.

Question 9

Barium Swallow

Answer 9

Dyspepsia
Dysphagia
GORD (Gastro-Oesophageal Reflux Disease)
Hiatus Hernia Assessment
Failure to complete Upper GI Endoscope
SALT (Speech and Language Therapy) assessment

Question 10

Barium Swallow

Answer 10

Dyspepsia- AKA “Indigestion”, pain in the upper abdomen or behind the sternum (heartburn). Can be caused by a range of underlying conditions, including stomach acid irritating the oesophageal lining.

Dysphagia- Difficulty swallowing. Can be caused by eating habits OR by muscular/nervous damage causing narrowing (stricture.)

GORD- The impact of acid from the stomach causing damage to the oesophageal lining, weakening the oesophageal sphincter.

Hiatus Hernia- Upper aspect of the stomach pushes through the oesophageal opening of the diaphragm and into the distal oesophagus.

Contraindications- Allergy, perforation, post-surgical intervention

Question 11

Barium Meal

Answer 11

Used to image the stomach and duodenum.

Can be done as part of an Upper GI series (after Barium Swallow)

Either done as Single of Double Contrast Study

• Barium Sulphate solution- Positive Contrast Agent
• Effervescent Agent and Citric Acid- Negative Contrast Agent

Barium Sulphate administered orally.

Question 12

Barium Meal

Answer 12

Use of a smooth muscle relaxant.
Patient required to fast up to 8 hours before having procedure.
Imaging usually undertaken with patient in AP supine position.
Single shot imaging.

Question 13

Barium Meal (3)- Single Contrast v Double Contrast

Answer 13

Assesses thickness of gastric folds.
Evaluates emptying of stomach.

Uses effervescent granules to distend stomach/bowel with air.
Improves visualisation of mucosa/rugae.

Question 14

Barium Meal (4)- Clinical Indications/Presentation/Contraindications

Answer 14

Indications/Presentations:
-Epigastric Discomfort
-Gastrointestinal Reflux/ GORD
-Dyspepsia
-Unexplained Weight Loss
-Known Hiatus Hernia
-Negative Endoscopic Examination

Contraindications:
-Perforation
-Post-surgical Intervention
-Large Bowel Obstruction

Question 15

Barium Meal (5)- Radiographic Anatomy

Answer 15

lesser curve
fubdus
spine
body
greater curve
musocal folds
antrum
duodenum

Question 16

Barium Follow-Through

Answer 16

Used to image the small bowel

Duodenojejenal flexure to ileocaecal valve

Can be done as part of an Upper GI series (after Barium Swallow/Meal)

Single Contrast Study

Barium Sulphate administered orally.

No eating for up to 8 hours prior to procedure.

Question 17

Barium Follow-Through (2)

Answer 17

Laxatives sometimes used (depending on dept)

Single shot imaging whilst barium travels through small bowel.

Patient often asked to roll around/change position/ have abdomen compressed.

Imaging undertaken often in AP or PA position.

Can take many hours depending on transit time.

Question 18

Barium Follow-Through (3)- Indications/Contraindications

Answer 18

Clinical Indications:
Anaemia
Chronic Diarrhoea
Persistent Pain
Known Crohn’s Disease

Contraindications:
Perforation
Post-surgical Intervention
Known complete bowel obstruction

Question 19

Barium Follow-Through (4)- Radiographic Anatomy

Question 20

Barium Enema

Answer 20

Used to image the large bowel

Double Contrast Study

Barium Sulphate administered rectally

No eating for up to 8 hours prior to procedure.

Laxatives required prior to procedure- complete bowel emptying.

Question 21

Barium Enema (2)

Answer 21

May be required to use enema kit.

Smooth muscle relaxant given during procedure.

Single shot imaging.

Patient often asked to roll change position/ have abdomen compressed.

Imaging undertaken in a variety of views.

Question 22

Barium Enema (3)- Clinical Indications

Answer 22

Change in bowel habit (CIBH)
Anaemia (Iron Deficiency)
Rectal Bleeding
Left Iliac Fossa (LIF) pain
Palpable mass
?Polyps
Failed Colonoscopy

Question 23

Barium Enema (4)- Contraindications

Answer 23

Perforation
Post-surgical Intervention (including biopsy)

Known complete bowel obstruction

Toxic Megacolon- Extreme inflammation of the large bowel linked to fever/shock. Complication of UC/Crohn’s Disease.

Question 24

Barium Enema (5) –Equipment Used

Answer 24

Barium Sulphate and warm water
Enema bag and insufflation line
Clamp
Rectal Catheter
Drip stand
Lubricating jelly
Swabs
Adhesive Tape
Gloves
Muscle relaxant (buscopan or glucagon)
Cannula/needle
Syringe

Question 25

Barium Enema (6)-Procedural Steps

Answer 25

Patient lies in left lateral position

Insertion of rectal catheter

Catheter secured via tape.

Barium bag suspended onto drip stand.

Table tilted cranially so head goes down

Question 26

Barium Enema (7)-Procedural Steps (2)

Answer 26

6. Slow introduction of barium and air into bowel.
7. Patient will undergo a full rotation, to allow air and barium to coat the bowel.
8. Live screening undertaken during this time.
9. ‘Over couch’ projections undertaken when large bowel is well-inflated and has barium coverage.

Question 27

Barium Enema (8)-Procedural Steps (3)

Answer 27

“Over couch” Projections

Anterior-Posterior Abdomen

Posterior-Anterior Abdomen

Left Lateral Decubitus

Right Lateral Decubitus

Prone with 30 degree caudal angulation

Depends on departmental protocol.

Question 28

Other Fluoroscopic Procedures- Diaphragm Fluoroscopy

Answer 28

AKA The Sniff Test

Evaluates the functions of a patient’s diaphragm.

Patient asked to breathe as normal

Live screening as patient ‘sniffs’

Often used when chest x-ray shows elevated hemidiaphragm with no known cause.

No preparation needed

Question 29

Other Fluoroscopic Procedures- Cystogram

Answer 29

Imaging undertaken to demonstrate the appearance of the bladder and how it fills.

Flexible catheter inserted through urethra into bladder.

Water soluble contrast injected.

MICTURATING Cystogram then demonstrates emptying of bladder- common in paediatrics

Question 30

Other Fluoroscopic Procedures- ERCP/PTC

Answer 30

Endoscopic Retrograde Cholangio-Pancreatogram

Percutaneous Transhepatic Cholangiogram

Assesses the patency of the pancreatic and bile ducts.

ERCP- Endoscope passed through patient’s mouth through to duodenum. Ampulla of vater is cannulated and injected with iodine.

PTC- Undertaken when there is a blockage of the bile ducts.

PTC- Needle inserted externally into the liver and imaging undertaken through contrast injection.

NBM prior to procedure.

Question 31

Other Fluoroscopic Procedures- Proctogram

Answer 31

Observing the patency of a person’s pelvic floor/ability to release stool.

Patient NBM for 8 hours, and is given home enema kit.

“Paste” is injected into a person’s rectum, and asked to sit on a special toilet.

Patient asked to release paste as per usually passing stool.