Bontrager Chapter 19
what are the 3 contraindications for post-op cholangiography?
1. hypersensitivity to iodine 2. acute infection of the biliary system 3. elevated creatinine/BUN levels
What are the 4 contraindications for ERCP?
1. hypersensitivity to iodine 2. acute infection of the biliary system 3. elevated creatinine/BUN levels 4. possible pseudocyst
What are the 4 segments of the uterine tubes?
1. interstitial 2. ampulla 3. infundibulum 4. isthmus
What are the structures of interest for knee arthrography?
1. joint capsule 2. menisci 3. collateral/cruciate ligaments
What are the 2 clinical indications for ERCP?
1. residual calculi 2. strictures
What are the 2 clinical indications for post-op cholangiography?
1. residual calculi 2. strictures
What type of needle is commonly used for shoulder arthrograms?
2 3/4 - 3 1/2" spinal needle
What type of needle is most often used to introduce contrast media during a shoulder arthrogram?
2 3/4 - 3 1/2" spinal needle
The absorption of the water-soluble of the water-soluble contrast media in the vascular system of the body begins approximately _____ minutes after injection and is totally undetectable radiographically after _____ hours.
30 minutes; 24 hours
When should HSG be performed?
7-10 days after the onset of menstruation
What type of radiographic table must be used for myelography?
90/45-degree or 90/90-degree tilting table
If both lower limbs are radiographed together on one image receptor, why should two rulers be used with one under each limb rather than placing one midway between the two limbs?
A single center-placed ruler makes it difficult or impossible to shield the gonads without obscuring the upper part of the ruler.
When performing an orthoroentgenographic procedure, what device must be placed on top of the table next to the affected limb?
A special metallic (Bell-Thompson) ruler to measure bone length from one joint to another
What is the literal meaning of the term orthoroentgenogram?
A straight or right-angle radiograph
Indicate the correct sequence of events for a myelogram by numbering the following steps in order (from 1 through 8): A. Introduce needle into subarachnoid space B. Collect CSF and send to laboratory C. Take overhead radiographic images D. Explain procedure to the patient E. Introduce contrast medium F. Have patient sign informed consent form G. Take fluoroscopic images H. Prepare patient's skin for puncture
A. 4 B. 5 C. 8 D. 1 E. 6 F. 2 G. 7 H. 3
How many exposures are made, and how much is the leg rotated, between each exposure for horizontal beam knee arthrograms? A. Number of exposures per meniscus: B. Degrees of rotation between exposures:
A. 9 B. 20 degrees
A. On average, how many exposure are taken of each meniscus during fluoroscopy of the knee? B. How many degrees of rotation of the leg are used between exposures?
A. 9 images per meniscus B. 20 degrees
List the two routine projections for conventional radiographic projections used for knee arthrography:
A. AP B. Lateral
List the six projections frequently taken during a shoulder arthrogram:
A. AP Scout B. AP internal rotation C. AP external rotation D. Glenoid fossa (Grashey) projection E. Transaxillary (inferosuperior axial) projection F. Intertubercular (bicipital) sulcus projection
List the overhead projections that may be requested for a shoulder arthrogram: Scout
A. AP internal and external rotation shoulder scout
List the three contraindications for a hysterosalpingogram:
A. Acute pelvic inflammatory disease B. Active uterine bleeding C. Pregnancy
Which two blood chemistry values must be checked before a postoperative (T-tube) cholangiogram?
A. BUN B. Creatinine
List the four common contraindications for myelography:
A. Blood in the cerebrospinal fluid B. Arachnoiditis C. Increased intracranial pressure D. Recent lumbar puncture (within 2 weeks)
List three clinical indications for a shoulder arthrogram:
A. Chronic pain B. General weakness C. Suspected tear in the rotator cuff
Which of the following terms is not an aspect of the uterine tube? A. Cornu B. Ampulla C. Isthmus D. Infundibulum
A. Cornu
What are the two other clinical indications for HSG?
A. Demonstration of intrauterine pathology B. Evaluation of the uterine tubes after tubal ligation or reconstructive surgery
List the four factors that determine the amount of blurring:
A. Distance the object is from the objective plane B. Exposure angle or amplitude C. Distance the object is from the IR (OID) D. Alignment of anatomic part to tube movement
List the three common types of lesions that can be demonstrated during a hysterosalpingogram:
A. Endometrial polyps B. Uterine fibroids C. Intrauterine adhesions
List the three layers of tissue that form the uterus (from the innermost to the outermost layer):
A. Endometrium B. Myometrium C. Serosa
A. A radiographic procedure of examining the biliary and main pancreatic ducts is called a(n) _____. B. What initials are commonly used as an abbreviation for this procedure? C. What type of special endoscope is commonly used for this procedure? D. Which member of the health care team usually performs this procedure? E. Why should a patient remain NPO at least 1 hour after this procedure?
A. Endoscopic retrograde cholangiopancreatogram B. ERCP C. Duodenoscope or video endoscope D. Gastroenterologist E. To prevent aspiration of food or liquid into the lungs
List the four divisions of the uterus:
A. Fundus B. Corpus (body) C. Isthmus D. Cervix
List the four common lesions or clinical indications demonstrated during myelography:
A. Herniated nucleus pulposus (HNP) B. Cancerous or benign tumors C. Cysts D. Possible bone fragments (in the case of trauma)
Level of CR for this projection/position: Cervical region
A. Horizontal beam lateral (prone), C5 B. Horizontal beam lateral (Swimmer's) C7
What four aspects of shoulder anatomy are demonstrated with shoulder arthrography?
A. Joint capsule B. Rotator cuff C. Long tendon of biceps D. Articular cartilage
List the two synovial types of joints most commonly examine with an arthrogram:
A. Knee B. Shoulder
What is the most common spinal puncture site for a lumbar myelogram? A. L3-L4 B. L1-L2 C. L4-L5 D. L5-S1
A. L3-L4
In addition to the supine position, what two other positions may be imaged to visualize adequately the pertinent anatomy for an HSG?
A. LPO B. RPO
List the two common puncture sites for contrast media injection during myelography: Which is preferred?
A. Lumbar (L3-L4) - preferred B. Cervical (C1-C2)
Which of the following is not a tissue layer of the uterus? A. Osseometrium B. Myometrium C. Endometrium D. Serosa
A. Osseometrium
List the two types of contrast media used for a knee arthrogram:
A. Positive or radiopaque media such as iodinated, water-soluble contrast agent B. Negative or radiolucent contrast agents, such as room air, oxygen, or carbon dioxide
What is the patient's general body position for each of the following punctures? (NOTE: May be more than one acceptable answer for each.) A. Lumbar B. Cervical
A. Prone or left lateral B. Erect or prone
Level of CR for this projection/position: Thoracic region
A. R lateral decubitus (AP or PA), T7 B. L lateral decubitus (AP or PA), T7 C. R or L lateral, vertical beam, T7
Level of CR for this projection/position: Lumbar region
A. Semierect horizontal beam lateral (prone), L3
List the two contraindications for an arthrogram:
A. Sensitivity to iodine B. Sensitivity to local anesthetics
Myelography is a radiographic study of the:
A. Spinal cord B. Nerve root branches
List the three common forms of knee injury that may require arthrography:
A. Tears of the joint capsule B. Tears of the menisci C. Tears of ligaments
List four common adjustments or features found on the tomographic control panel:
A. Tube travel speed B. Objective plane C. Tube center/prep D. Fulcrum level
The contrast medium preferred by most radiologists for a hysterosalpingogram is: A. Water-soluble, iodinated B. Oil-based, iodinated C. Oxygen D. Nitrogen
A. Water-soluble, iodinated
List the two types of contrast media commonly used for a knee arthrogram:
A. iodinated water soluble B. Carbon dioxide, oxygen, or room air
What are the two primary contraindications for arthrography of any joint?
Allergic reactions to iodine-based contrast media and allergic reactions to local anesthetics
Central segment of the uterine tube where the isthmus (constricted portion of the uterine tube) widens. This segment then arches over the ovaries
Ampulla
Study of synovial joints and related soft tissue structures that employs contrast
Arthrography
The most common pathologic indication for the hysterosalpingogram (HSG) is:
Assessment of female infertility - dx any fxnal/structural defects
What is the minimum exposure time required to produce a breathing lateral projection of the thoracic spine? A. 1 second B. 2 seconds C. 4 seconds D. 6 seconds
B. 2 seconds
List the overhead projections that may be requested for a shoulder arthrogram: Post-injection
B. AP internal rotation C. AP external rotation D. Glenoid fossa (Grashey) projection E. Transaxillary (inferosuperior axial) projection F. Intertubercular (bicipital) groove projection (Fisk method)
Postoperative (T-tube) cholangiograms are usually performed to detect: A. Pancreatitis B. Biliary Stones C. Liver Cyst D. Infected gallbladder
B. Biliary Stones
Which of the following terms is used to describe the "degree of openness" of the uterine tube? A. Stenosis B. Patency C. Atresia D. Gauge
B. Patency
To gain maximum blurring of the body of the sternum during tomography, it should be placed _____ to tube movement. A. Parallel B. Perpendicular C. Diagonally D. at a 5-degree angle
B. Perpendicular
When injecting contrast for post-op cholangiography, why should you be careful not to inject air bubbles?
B/c they may be perceived as stones
Give an example of nontraumatic pathology of the knee joint indicating arthrography. Where does it commonly occur?
Baker's cyst. Popliteal area
What is the proper name for the special metal ruler used for long bone measurement?
Bell-Thompson ruler
Define: Distortion of objects outside the objective plane
Blur
Define: The area of distortion of objects outside the objective plane
Blur
Another term for tomography is _____.
Body section radiography
The contrast medium most commonly used for myelography provides good radiopacity up to _____ after injection. A. 20 minutes B. 30 minutes C. 1 hour D. 8 hours
C. 1 hour
Which of the following exposure angles would produce the least amount of blurring outside of the objective plane? A. 10 degrees B. 20 degrees C. 5 degrees D. 40 degrees
C. 5 degrees
What dosage range of contrast medium is usually injected for myelography? A. 8 to 10 mL B. 20 to 30 mL C. 9 to 15 mL D. Approximately 1 mL
C. 9 to 15 mL
The most common clinical indication for a myelogram is: A. Benign tumors B. Spinal cysts C. HNP D. Bony injury to the spine
C. HNP
Which of the following procedures might be performed during a postoperative (T-tube) cholangiogram? A. Removal of the gallbladder B. Removal of a liver cyst C. Removal of a biliary stone D. Catheterization of the hepatic portal vein
C. Removal of a biliary stone
Which position will move the contrast media column from the lumbar to the cervical region during a myelogram? A. Fowler B. Left later decubitus C. Trendelenburg D. Prone
C. Trendelenburg
What are the chief disadvantages of using CT over orthoroentgenography for long bone measurements?
CT is more costly and requires specialized equipment.
What type of contrast does CT use for arthrograms? MRI?
CT: iodine MRI: gadolinium
Distal cylindrical portion of the uterus that projects into the vagina, ending as the external os
Cervix
The distal aspect of the uterus extending to the vagina is the _____.
Cervix
What is the normal appearance of synovial fluid?
Clear and tinged yellow
Why are the contrast media for a T-tube cholangiogram occasionally diluted before injection?
Contrast media that are too concentrated may obscure small stones in the biliary ducts
Type of imaging used to obtain a dx image of a specific layer of tissue or an object that is superimposed by other tissues/objects
Conventional tomography
Larger central component of the uterus
Corpus
The largest division of the uterus is the _____.
Corpus
Where is the CR centered for radiographic projections taken during an HSG using a 10 x 12" IR? A. At level of ASIS B. Symphysis pubis C. Iliac crest D. 2" superior to the symphysis pubis
D. 2" superior to the symphysis pubis
Which of the following exposure angles would produce the greatest amount of blurring outside of the objective plane? A. 10 degrees B. 8 degrees C. 5 degrees D. 20 degrees
D. 20 degrees
Which of the following conditions may contraindicate an ERCP? A. Biliary obstruction B. Stone in main pancreatic duct C. Jaundice D. Pseudocyst
D. Pseudocyst
A cervical puncture is indicated for an upper spinal region myelogram if: A. The patient has severe lordosis B. The patient has mild scoliosis C. The patient has HNP of the L4-L5 level D. The patient has complete blockage at the T-spine level
D. The patient has complete blockage at the T-spine level
What are the therapeutic uses for HSG?
Dilate/straighten narrow, tortuous, occluded uterine tubes
Inner lining that lines the uterine cavity and undergoes cyclic changes of the menstrual cycle
Endometrium
What is the name of the surgical procedure that shortens a limb by fusing the epiphyses?
Epiphysiodeses
How is the contrast medium removed from the body after myelography?
Excreted by kidneys
Define: The factor that determines slice thickness
Exposure angle
Define: The total distance that the x-ray tube travels during the actual exposure; controls sectional thickness
Exposure angle
True/False: Anatomy at the fulcrum level becomes blurred and difficult to see on a radiograph.
False
True/False: Bile is sterile, and standard precautions do not apply when handling it.
False
True/False: More blurring occurs with a shorter exposure angle.
False
True/False: The Bucky tray lock must be securely locked before a tomographic exposure.
False
True/False: The uterine tubes are connected directly to the ovaries.
False
True/False: A surgeon usually performs T-tube cholangiography during a colectomy.
False (during cholecystectomy)
True/False: The wrist is examined in the pronated position (PA) for a long bone study of the upper limb.
False; PA would cross radius and ulna
True/False: Epiphysiodesis is an operation to lengthen bone by widening the epiphyseal plate.
False; a premature fusion of the epiphysis is to shorten a bone
True/False: To measure the length of a long bone properly, the entire lower limb should be included on a single projection.
False; ends of bone must be on separate projections
True/False: As the exposure angle decreases, slice thickness also decreases (becomes thinner).
False; increases
True/False: Myelography of the cervical and thoracic spinal regions is most common.
False; most common are cervical and lumbar regions
True/False: After the contrast medium is introduced into the knee joint, the knee must not be flexed or exercised.
False; needs to be flexed to distribute contrast media
True/False: Objects closer to the objective plane will experience maximum blurring.
False; objects away from the objective plane have the greatest blurring
True/False: The proximal humerus must be rotated internally for the shoulder projection taken during upper limb orthoroentgenography.
False; patient is supine, arm extended, and hand supinated, external rotation position
True/False: An oil-based contrast medium is preferred for the majority of hysterosalpingograms.
False; water-soluble is preferred
Why is a large positioning block placed under the abdomen for a lumbar puncture in the prone position?
For spinal flexion to widen the interspinous spaces to facilitate needle placement
Define: The pivot point between tube and IR
Fulcrum
Define: The pivot point of the connecting rod between tube and IR (measured in cm)
Fulcrum
All structures at ______ level are in object plane and remain in the same position on IR during exposure, clear and in focus?
Fulcrum level
Define: The distance from tabletop to fulcrum; controls object plane
Fulcrum level
Rounded superior portion of the uterus
Fundus
Other than a radiologist, what type of physician often performs ERCP?
Gastroenterologist
Of the four clinical indications, which is most common for myelography?
Herniated nucleus pulposus (HNP)
Which three joints are included on one IR for a long bones study of the lower limb?
Hip, knee, and ankle
What are the joints that may be studied with arthrography?
Hip, knee, ankle, shoulder, elbow, wrist, and TMJ
Which position is performed during a cervical myelogram to demonstrate the C7-T1 region?
Horizontal beam Swimmer's lateral
What demos the patency of the uterine tubes?
If contrast spills into the peritoneal cavity during HSG
Postoperative (T-tube) cholangiograms are generally performed _____. Why?
In the radiology department. b/c dr is concerned about residual stones in the bile duct
Most distal segment of the uterine tube, contains finger-like fimbriae that attaches to each ovary. Opens into the peritoneal cavity
Infundibulum
Proximal segment of the uterine tube that communicates with the uterine cavity
Interstitial segment
Why is water-soluble iodine the most ideal contrast for HSG? Why not oil-based?
Iodine: absorbed easily, leaves no residue, BUT does cause pain when injected into uterine cavity Oil: very slow absorption rate, persists in body cavities, increases risk of embolus in lungs
Narrow constricted segment that joins the cervix at the internal os
Isthmus
An indication of a possible Baker's cyst suggests the need for an arthrogram procedure for the _____.
Knee
(Small/large) structures are best imaged with thick object plane at reduced exposure angle (10*)?
Large
What patient prep is needed for HSG?
Laxative/suppository/enema so reproductive system is unobstructed. Empty bladder immediately prior to exam so reproductive anatomy is not displaced
What is the approx length and width of the uterine tubes?
Length: 10-12 cm Width: 1-4 mm
Which locks on the x-ray tube must be opened or unlocked during linear tomography?
Longitudinal tube, Bucky tray, and angle locks
Arthrography is rarely used for TMJ, which modality is preferred?
MRI
Other than conventional radiography of synovial joints (e.g., arthrography), which imaging procedure is preferred by physicians for studying synovial joints?
MRI or CT
Middle layer of the uterine cavity that consists of smooth muscle and constitutes most of the uterine tissue
Myometrium
What is the patient prep for post-op cholangiography?
NPO 8 hours
What type of contrast medium is most commonly used for myelography?
Nonionic, water-soluble, iodine-based
Define: The plane or section of the object that is clear and in relative focus; controlled by fulcrum level
Object plane
Define: The plane where the target anatomy is clear
Object plane
What does the fulcrum level determine?
Object plane
The formal term for a radiographic long bone measurement study is _____.
Orthoroentgenography
A tomographic principle in which the anatomic structure moves but the IR/tube remain stationary is called _____.
Orthostatic breathing technique
How does the uterus appear?
Pear-shaped, hollow, muscular organ. Lies in anteflexed position
Which condition of the pancreas may contraindicate an ERCP?
Pseudocyst
Situation: A T-tube cholangiogram image demonstrates the biliary ducts superimposed over the spine. The patient is in an AP position. Which position would remove the ducts from the spine?
RPO position
The uterus is situated between the _____ posteriorly and the _____ anteriorly.
Rectosigmoid colon; urinary bladder
What is the general name for the conjoined tendons of the four major shoulder muscles?
Rotator cuff
Define: The thickness of the objective or focal plane; controlled by exposure angle
Sectional thickness
What does exposure angle determine?
Sectional thickness
Outer surface of the uterus, lined with peritoneum and forms a capsule around the uterus
Serosa
Which three joints are included on one IR for a long bones study of the upper limb?
Shoulder, elbow, wrist
To help facilitate the flow of contrast media into the uterine cavity, in which position is the patient placed following the injection of contrast media?
Slight Trendelenburg
(Small/large) structures are best imaged with thin object plane at greater exposure angle (40*)?
Small
In which space is the contrast medium injected during a myelogram?
Subarachnoid space
Into which spinal space is the contrast medium introduced during myelography?
Subarachnoid space
Which position is performed to demonstrate the region of C7 during a cervical myelogram?
Swimmer's lateral using a horizontal x-ray beam
Which classification of joints are studied with arthrography?
Synovial joints
What device might be needed to aid the insertion and fixation of the cannula or catheter during the hysterosalpingogram?
Tenaculum
The term rotator cuff refers to what structures of the shoulder?
The conjoined tendons of the four major shoulder muscles
Briefly describe the tomographic blurring principle. (Why, or how, does blurring occur for some objects whereas others remain in sharp focus?)
The movement of the tube and IR will blur objects farther from the fulcrum level or objective plane. Objects closer to this fulcrum level and those that are parallel to tube travel will remain almost stationary and experience little or no blurring.
What are the therapeutic uses for ERCP? Dx uses?
Therapeutic: relieve pathologies (remove choleliths/lesions, repair stenosis) Dx: endoscopic insertion and retro injection of contrast into biliary ducts
How is the contrast medium instilled into the biliary ducts during an ERCP?
Through a special catheter introduced through the duodenoscope
What is the most common clinical reason for performing a T-tube cholangiogram?
To detect, post-operatively, any residual stones in the biliary ducts that may have gone undetected during the cholecystectomy.
Why should the patient's head and neck remain hyperextended during cervical myelography?
To keep the contrast media from entering the cranial subarachnoid space
Why should separate projections be taken on limb joints rather than including the entire extremity on a single projection?
To prevent elongation (magnification) of the limb as a result of the divergence of the x-ray beam
What is the purpose of flexing the knee gently after the contrast medium has been injected for an arthrogram procedure?
To provide a thin, even coating of positive contrast media over the soft tissues of the knee joint
Demos a clear image of an object lying in a specific plane with blurring of structures located above/below the specific plane
Tomogram
Define: Radiograph produced by a tomographic unit
Tomograph
Define: The image produced during a tomographic procedure
Tomograph
Many pathologic processes that occur in the knee are due to?
Trauma
True/False: An arthrogram must be approached as a sterile procedure. Proper skin prep and sterility must be maintained.
True
True/False: As the distance from the IR increases. object blurring increases.
True
True/False: Blurring is a desired outcome of tomography.
True
True/False: Both right and left lower limbs can be placed on the same radiograph for a long bone study.
True
True/False: Fertilization of the ovum occurs in the uterine tube.
True
True/False: For a bilateral study, all three joints of both lower limbs can be placed on the same 14 x 17" IR.
True
True/False: For a long bone study of the upper limb, all three projections must be taken with the IR placed in the Bucky tray.
True
True/False: Hysterosalpingography can be a therapeutic procedure in correcting certain obstructions within the uterine tube.
True
True/False: If a long bone study of both lower limbs is ordered, the use of two metal rulers is recommended with both limbs exposed at the same time on the same IR.
True
True/False: Increased blurring occurs when the object is farther from the IR.
True
True/False: Maximum blurring of anatomy is achieved when it is perpendicular to tube travel.
True
True/False: Movement of the body part between exposures compromises the long bone study.
True
True/False: Myelography has been largely replaced by MRI and CT.
True
True/False: The distal portion of the uterine tube opens into the peritoneal cavity.
True
True/False: The primary factor affecting the sectional thickness, as controlled by the operator, is exposure angle.
True
True/False: Generally, AP supine, PA prone, or horizontal beam lateral projections are not taken during thoracic spine myelography.
True - Right and Left lateral decubitus positions are taken
What does HSG best demo?
Uterine cavity and patency (degree of openness) of the uterine tubes
Communicate with the uterine cavity from a superior/lateral aspect btwn the body and the fundus
Uterine tubes
The hysterosalpingogram is a radiographic study of the _____ and _____.
Uterus and uterine tubes
What are the organs of the F reproductive system?
Vagina, uterus, uterine tubes, ovaries
Define: Using an exposure angle of ≤10 degrees
"Thick cut"
To reduce patient anxiety, a sedative is usually administered _____ hour(s) before the procedure.
1 hour