BNO-IVU

• Indications
• Renal trauma, abdominal mass, renal cyst
• Urolithiasis, pyelonephritis, glomerulonephritis, hydronephrosis
• Renal hypertension
• Renal shape, size, & location for preoperative evaluation
• Contraindications
• Hypersensitivity to contrast, renal failure (Ur/Cr )
• CV disease, DM, sickle cell disease, multiple myeloma → risk of CIN
• Pheochromocytoma → risk of hypertensive crisis
• Pregnancy
• Stop metformin 48 hours before & after the examination
• Check renal function prior to restarting metformin
BNO-IVU
• Patient preparation
• NPO – 8 hrs
• No smoking
• Bowel prep (dulcolax 2 tab & bisacodyl supositoria)
• Pretreatment protocol for IV contrast
• Prednisone 50 mgPO / IV 13 hrs, 7 hrs and 1 hrs before examination
• Diphenhydramine 50 mg PO / IV 30-60 minute before examination
CONTRAST-INDUCED NEPHROPATHY (CIN)
• CIN is defined as an elevation of serum creatinine (Scr) of more than 25% or ≥0.5
mg/dl (44 μmol/l) from baseline within 48 h after excluding other factors that may
cause nephropathy, such as nephrotoxins, hypotension, urinary obstruction, or
atheromatous emboli.
• CIN is the third leading cause of acute kidney injury in hospitalized patients.
• Increases short and long term morbidity and mortality.
• Treatment is limited to supportive measures while awaiting the resolution of renal
impairment.
• Prevention is the one to be emphasized in case of CI –AKI.
DIAGNOSTIC CRITERIA FOR CIN
PATHOPHYSIOLOGY
• Vasoconstriction
• There is a selective decrease in the medullary blood flow
and oxygen saturation due to an imbalance between
vasodilators and vasoconstrictors
• Contrast media seem to reduce renal blood flow directly
through afferent arteriole vasoconstriction via activation of
adenosine receptor A1.
• In concert, contrast agents also disrupt the vasodilatory
systems like NO and prostaglandins bringing about an
intense vasocontriction and reduced medullary blood supply.
• Oxidative Stress
• The intense vasoconstriction and loss of
autoregulatory capacity can contribute to additional
renal injury through the release of reactive oxygen
species (eg, superoxide [OH].).
• Damage is due to overwhelming of the anti-oxidant
factors by the excess generation of ROS.
• Underlying diseases like CKD and Diabetes already
have high ROS and thus predisposes for CIN.
• Benefit of anti-oxidants gives an indirect clue.
• Direct Tubular Toxicity
• Marked osmotic diuresis is observed following
contrast administration.
• “Osmotic nephrosis”
• The most common histopathologic features of this
disorder include intense focal or diffuse
vacuolization of the proximal tubules or overt tubular
necrosis.
RISK FACTORS
1. Patient-related:
• Preexisting renal insufficiency (eGFR <60 ml/min) and DM are the
most important patient-related risk factors.
• Others
• age >75 years
• uncontrolled hypertension
• hypotension requiring inotropes
• congestive heart failure (CHF)
• hyperuricemia anemia
• hypoalbuminemia,
• liver cirrhosis.
RISK FACTORS
2. Procedure-related : include high contrast volume, osmolality or viscosity, and
repeated exposures to CM within 72 h.
• Mode of administration (IA>IV)
• PCI for acute MI.
• Use of intra-aortic balloon pump (IABP).
• Other factors that may increase the risk of CIN include the concomitant use
of diuretics or nephrotoxic drugs (NSAIDs and aminoglycosides).

Adv Med Sci 2009;54:221-4.

 CIN MEHRAN RISK SCORE
Risk Factors Integer Score
Hypotension 5

IABP 5

CHF 5

Age >75 years 4 Risk Risk Risk of

Score of CIN Dialysis
Anemia 3
≤5 7.5% 0.04%
Diabetes 3

Contrast media volume 1 for each 100 cc3 Calculate 6 to 10 14.0% 0.12%

Serum creatinine > 1.5mg/dl 4 11 to 16 26.1% 1.09%

OR
2 for 40 – 60 ≥ 16 57.3% 12.6%
eGFR <60ml/min/1.73 m2 4 for 20 – 40
6 for < 20
eGFR < 60ml/min/1.73 m2 =
186 x (SCr)-1.154 x (Age)-0.203
X (0.742 if female) x (1.210
if African American)

Mehran et al. JACC 2004;44:1393-1399.

HYSTEROSALPINGOGRAPHY
HYSTEROSALPINGOGRAPHY
• The end of 1 st week after the menstrual period
• Empty bladder before investigation
• Technique :
• Patient is placed in the lithotomy position on the screening table
• The external os is visualized through a vaginal speculum and is swabbed with a
mild antiseptic solution
• The anterior lip of the cervix is grasped by vulsellum forceps and a cannula is then
inserted into the cervical canal
• Contrast media : Water soluble non ionic (Iopamiro) 6-10 cc
INDICATIONS
• Infertility
• Congenital abnormalities of uterus and tubal obstruction
• After tubal surgery
• Patency & configuration of the Fallopian tubes following surgery for tubal obstruction
• After tubal ligation  6 weeks after
• After ectopic pregnancy
• Recurrent abortion
• The width and configuration of the internal os and cervical canal
• Distortion of the uterine cavity
• Uterine fibroids
• Abnormal uterine bleeding
• Fibroids, endometrial polyps, adenomyosis and intrauterine adhesions
• Post-caesarean section
• The integrity of the uterine scars following caesarian section
CONTRA-INDICATIONS
• Pregnancy
• Pelvic infection
• Salpingitis 6 months before
• Acute vaginitis
• Cervicitis
• Immediate pre- and postmenstrual phases
• Thickened/denuded endometrium  venous intravasation
• Water soluble media  obscure adrenal detail
• Sensitivity to contrast medium
• Antihistamine
• Corticosteroid
COMPLICATIONS
• Pain
• Distension of the uterus & Fallopian tubes
• Peritoneal spillage
• Pelvic infection
• Acute exacerbation of pre-existing chronic pelvic infection
• Haemorrhage
• Organic lesion  Polyps ,carcinoma,endometrial damage
• Allergic phenomena
• Urticaria, asthma, laryngeal oedema
• Vasovagal attack
• Venous intravasation
TECHNIQUES
• After an initial film, 3 to 5 mL of dye should be injected slowly to allow adequate
visualization of the uterine cavity. A second film is then taken. Cervical traction is often
necessary to completely evaluate the uterine cavity. A small acorn tip is preferred over
balloon-type catheters because the latter obstructs the visualization of the cavity. After
this, another 5 mL is injected to evaluate tubal patency, followed by a third film. A follow-
up film is taken to evaluate peritubal adhesions and usually is performed in 10 minutes
(using water-soluble media) or 24 hours (using oil-based media).
RADIOLOGICAL ANATOMY
GASTROINTESTINAL FLUOROSCOPIC
CONTRAST STUDY
CONTRAST MEDIUM FOR GI
Water Soluble
• Can be used postoperatively to assess
anastomoses for leak or obstruction or
when perforation is suspected
• Ionic (Gastrografin) can lead to
pulmonary edema if aspirated.
• Non- Ionic ( Low Osmolar) relatively
safer if aspirated.
Barium ( Non-water soluble)
• Provides better anatomic detail &
easier visualization
• Can induces granulomatous
response that lead to adhesion &
obstruction in perforation or leakage
 PHARMACOLOGICAL AGENTS
Agents Purpose Useful
Glucagon (0.3 mg iv) Relax smooth muscles Barium enema examination
(hypotonic agent for the (Used for patients with
stomach and duodenum) glaucoma & cardiovascular
disease)
Anticholinergic drugs Relax smooth muscles Barium enema examination
(Buscopan)
Maxalon (20 mg iv/oral) Increases gastric peristalsis Follow through examinations)
Carbex (Tablets) Gas producing agent Double contrast Ba Meal
Methyl cellulose (Syrup) Small bowel double contrast
BARIUM STUDIES
• Barium swallow / Esophagography → Cervical & Thoracic esophagus
• Barium meal / Maag-duodenography → Thoracic esophagus, stomach, duodenal bulb
• Follow through
• Enteroclysis → radiation dose 6 x that follow through
• Barium enema / Colon in loop
CONTRAST SWALLOW
(ESOPHAGOGRAPHY)
• Examination of esophageal morphology & motility

• Indications: • Contraindications:
• Dysphagia • Aspiration
• Pain
• Reflux
• Anemia
• Tracheo-esophageal fistula
• Perforation
BARIUM MEAL (MAAG-DUODENOGRAPHY)

• Indications: • Contraindications
• Dyspepsia • Complete large bowel
obstruction
• Upper abdominal mass
• Weight Loss
• Gastrointestinal Hemorrhage.
• Pateint preparation:
• Partial Obstruction
• NPO ---6 hrs
• Assessment for perforation
• No smoking– increases GI
motility
SMALL BOWEL FOLLOW THROUGH
SMALL BOWEL ENEMA (ENTEROCLYSIS)
• Indications: • Contraindications
• Pain • Complete obstruction
• Diarrhoea
• Anemia/GI bleed • Patient Preparation:
• Partial Obstruction • Low residue diet
• Malabsorption • Bowel Prep (Dulcolax -2-4 Tab)
• Abdominal mass

• SBFT vs Enteroclysis
• SBFT : The patient swallows barium and sequential abdominal films are
obtained at 15-30 minute interval until the barium reaches the caecum
• Enteroclysis : Barium is pumped through the tube, which passed through
the nose/mouth, into the GI tract
• Radiation dose is 6x in enteroclysis study but sensitivity for subtle disease
is better
Small Bowel follow through VS Small bowel enema
BARIUM ENEMA

• Indications: • Contraindications:
• Change in bowel habits • Toxic megacolon
• Pain • Pseudomembranous colitis
• Mass • Suspected perforation
• Melena / Anemia • Sigmoidoscopy – 24 hours
• Single contrast – Obstruction & • Colonic biopsy – past 6 days
Intussusception .

• Preparation: (Two days)

• Low residue diet
• Bowel prep (Dulcolax – 4 Tab)