FLOUROSCOPY

Dr Rubeena Ali
Senior Registrar
Radiology Department
RLMC/AMTH
WHAT IS FLOUROSCOPY???
FLOUROSCOPY

 When the X-ray beam is used with a video screen, the

technique is called fluoroscopy. This allows physicians
to visualize the movement of a body part or of an
instrument or dye (contrast agent) through the body in
real time.
 Fluoroscopy studies such as the upper gastrointestinal
series are popular to evaluate patients with suspected
gastroesophageal reflux and other problems such as
swallowing difficulty.
 This is useful for both diagnosis and therapy
 Occurs in
 general radiology
 interventional radiology
 image-guided surgery

Fluoroscopy is similar to radiography and X-ray computed tomography (X-ray

CT) in that it generates images using X-rays. The original difference was that
radiography fixed still images on film whereas fluoroscopy provided live
moving pictures that were not stored.
EQUIPMENT
EQUIPMENT

Components:
 High Voltage Generator
 X-Ray Tube (XRT)
 X-Ray Image Intensifier (XRII)
 Video Camera
XRII converts:
 low intensity X-ray
photon fluence
to
 high fluence of Visible
Photons
Fluoroscopic system with image intensifiers
 X-RAY IMAGE INTENSIFIER

 Input Phosphor converts: X-Rays to Light

 Photocathode converts: Light to Electrons
 Electrons:
 Released through photoelectric effect
 Repulsed from photocathode
 Accelerated towards anode by 25-30 kV
 Output Phosphor converts: Electrons to
Light
 OPTICAL SYSTEM

couples XRII to video camera

includes:
 Collimating Lens to shape the
divergent light from the
 Output Phosphor
 Aperture to limit the amount
of light reaching the video
camera
 Lens to focus the image onto
the video camera
VIDEO CAMERA

 captures the XRII output image

 and converts it to an analogue electrical signal that conforms to a recognized
video format
FLAT PANEL IMAGE RECEPTORS

 Replacing XRIIs in modern systems

 Advantages include:
 Larger Size
 Absence of Image Distortions
 Spot Film Device

 Used to make permanent images

during the radiographic
examination.
 Film is positioned b/w the
patient and the image intensifier.
 When the film is needed, the
radiologist actuates the control
that brings the cassette in
position. This changes the tube
from fluoroscopic mA to
radiographic mA.

APPLICATION - SPECIFIC DESIGN

 Several types of configuration

 Fluoroscopy Units
1/An over table model
Where the x-ray tube is placed above the table top, and the
image intensifier under the table surface.
Fluoroscopy Units
2/An under table model
Where the x-ray tube is placed under the table surface , and the
image intensifier over the table top.
 Most common is the configuration in which the XRT is located under the patient
table
 XRII on a movable tower above the patient table
 Lead curtains hang from the XRII tower and shield the operator from stray
radiation scattered from the patient
 This configuration is commonly used for Genitourinary (GU) and Gastrointestinal
(GI) imaging
Fluoroscopy Units

An under table model

Fluoroscopy Units

The table have the ability to tilt from horizontal to vertical

 Fluoroscopy Units
3/Single or bi-planar cine –fluoroscopy model

 Where the x-ray tube and

image intensifier are
fixed to c-arms.
 Mostly used in surgical
theatres.
Vascular and Interventional radiology procedures are usually
performed in angiographic suites equipped with C-Arm
Fluoroscopes
Fluoroscopy Units
 Remote control systems
 Can also be configured vertically for
seated examinations,
 such as the Ba swallow
IMAGE CONTRAST

Contrast is greatly improved through the use of

 Radio-Opaque markers on catheters and other instruments
 Exogenous Contrast Agents, e.g. iodine and barium

Catheter
Contrast

Catheter
COMMON PROCEDURES USING FLUOROSCOPY

 GIT: barium enemas, barium meals and barium swallows, and follow through.
 Angiography: of the leg, heart and cerebral vessels.
 Cardiology: diagnostic angiography, percutaneous coronary interventions,
(pacemakers)
 Liver biopsy is performed under fluoroscopic guidance at many centers.
 Orthopaedic surgery to guide fracture reduction and the placement of
metalwork.
 Urological surgery – particularly in retrograde pyelography.
HOW PROCEDURE IS PERFORMED
 Patient preparation (according to the procedure)
 Proper positioning on fluoroscopy table
 Ingestion of contrast (upper GI series)
 In case of angiography, catheter placement and injection of contrast
 Visualization under fluoroscopy
 Spot views of regions of interest
ANGIOGRAPHY
ANGIOGRAPHY

 A medical imaging technique used to visualize the inside, or lumen, of blood

vessels and organs of the body, with particular interest in the arteries, veins,
and the heart chambers
 This is traditionally done by injecting a radio-opaque contrast agent into the
blood vessel and imaging using X-ray based techniques such as fluoroscopy.
 Depending on the type of angiogram, access to the blood vessels is gained
most commonly through
 the femoral artery, to look at the left side of the heart and at the arterial
system
 the jugular or femoral vein, to look at the right side of the heart and at the
venous system.
 Using a system of guide wires and catheters, a type of contrast agent (which
shows up by absorbing the x-rays), is added to the blood to make it visible on
the x-ray images.
 Coronary angiography
 Neurovascular angiography
 Peripheral angiography
STENOSIS IN CORONARY Click icon to add picture
ARTERY
Click icon to add picture
HOW PROCEDURE IS PERFORMED????

 Aseptic technique
 Local anesthetic at the puncture site
 Needle inserted
 Stilette removed
 Guide wire passed under fluoroscopic guidance
 Catheter is then passed over the guide wire
 Contrast is injected
 After procedure pressure is maintained for 5-10min
CONTRAINDICATIONS (RELATIVE)

 Contrast allergy
 Bleeding disorders
 Local soft tissue infection(at puncture site)
 Uncontrolled hypertension
 Severe anemia
 Fever
 Kidney failure
 Uncompensated cardiac failure
GI SERIES
UPPER GI SERIES

 Barium swallow ESOPHAGUS

 Barium meal STOMACH
 Barium follow through SMALL INTESTINE
 Barium enema COLON
 TYPES

 SINGLE CONTRAST
 Positive contrast agent i.e barium only
 DOUBLE CONTRAST
 Positive as well as negative contrast agents i.e barium and air respectively
Ba swallow
HOW PROCEURE IS PERFORMED???

 Patient positioning
 Ingestion of barium
 Visualization under fluoroscopy
 Spot films
CONTRAINDICATIONS

NONE
Ba meal
HOW PROCEURE IS PERFORMED???

 NPO --- 6hrs

 Gas producing agent is swallowed (double contrast technique)
 Ingestion of barium
 Patient positioning
 Visualization under fluoroscopy
 Spot films
CONTRAINDICATIONS (RELATIVE)

 Complete large bowel obstruction

Ba follow through
HOW PROCEURE IS PERFORMED???

 Gas producing agent is swallowed (double contrast technique)

 Ingestion of barium
 Patient positioning
 Visualization under fluoroscopy
 Spot films
CONTRAINDICATIONS (RELATIVE)

 Complete large bowel obstruction

 Click icon to add picture

BA ENEMA
HOW PROCEURE IS PERFORMED???

 Low residue diet 3 days prior to exam

 Fluids only on the day prior to exam
 Patient lies on his left side
 Catheter of enema kit inserted into the rectum
 Infusion of barium is commenced, which is stopped

when barium reaches the hepatic flexure of colon

 Air is gently pumped
 Visualization under fluoroscopy
 Spot films
CONTRAINDICATIONS (RELATIVE)

 RELATIVE
 Incomplete bowel preparation
 Recent barium meal
 ABSOLUTE
 Recent rectal biopsy
 Toxic megacolon
CASES
CA ESOPHAGUS

APPLE CORE APPEARANCE

Achalasia cardia

RAT TAIL/BIRD BEAK

APPEARANCE
CA COLON
APPLE CORE APPEARANCE Click icon to add picture
BENEFITS VS RISKS
 FLOUROSCOPY --- BENEFITS
Fluoroscopy is used in a wide variety of examinations and procedures to diagnose or
treat patients. Some examples are:
 Barium X-rays and enemas (to view the gastrointestinal tract)
 Catheter insertion and manipulation (to direct the movement of a catheter through
blood vessels, bile ducts or the urinary system)
 Placement of devices within the body, such as stents (to open narrowed or blocked
blood vessels)
 Angiograms (to visualize blood vessels and organs)
 Orthopedic surgery (to guide joint replacements and treatment of fractures)
FLOUROSCOPY---- RISKS

 Radiation doses to the patient depend greatly on the size of the

patient as well as length of the procedure,
 Exposure times vary depending on the procedure being performed
 Typical skin dose rates quoted as 20–50 mGy/min
 Skin effects ranging from mild erythema to more serious burn
 Because fluoroscopy involves the use of ionizing radiation,
fluoroscopic procedures pose a potential for increasing the
patient's risk of radiation-induced cancer.
 Women should always inform their physician or x-ray technologist
if there is any possibility that they are pregnant.
 The probability that a person will experience these effects from a fluoroscopic
procedure is statistically very small. Therefore, if the procedure is medically
needed, the radiation risks are outweighed by the benefit to the patient.
 In fact, the radiation risk is usually far less than other risks not associated with
radiation, such as anesthesia or sedation, or risks from the treatment itself.
 To minimize the radiation risk, fluoroscopy should always be performed with
the lowest acceptable exposure for the shortest time necessary.
ANY QUERIES??????
 Flouroscopy is used in
a) general radiology
b) interventional radiology
c) image-guided surgery
d) All of the above
a) Input phosphor converts
a) X-ray to light
b) Light to x-ray
c) Xrays to electronic signal
 Which of the following is not a medical application of fluoroscopy?
a) Barium meal
b) Angiography
c) Orthopedic surgery
d) CT abdomen
RADIATION SAFETY
 RADIATION DOSE

Interventional
Radiology

CT

Radiography
17.2: Optimization of Protection in Interventional Radiology 74
Coronary angioplasty twice in a day followed by bypass graft because of
complication.
(b)

(a) (c)

(d) (e)

(a) 6-8 weeks after multiple coronary angiography and angioplasty

procedures.
(b) 16-21 weeks
(c) 18-21 months after the procedures showing tissue necrosis .
(d) Close-up photograph of the lesion shown in (c).
(e) Photograph after skin grafting. (Photographs courtesy of T. Shope & ICRP).
17.2: Optimization of Protection in Interventional Radiology 75
ICRP 85

Radiation induced opacities in the lens of an

interventional radiology specialist subjected to high
levels of scatter radiation from an over-table X Ray
tube. (Photograph from Vañó et al. (1998).
17.2: Optimization of Protection in Interventional Radiology 76
 Many of these injuries are
AVOIDABLE – all of the serious
ones are!

17.2: Optimization of Protection in Interventional Radiology 77

 Radiation Protection
General Rule

(ALARA Principle)
As
Low
As
Reasonably
Achievable
 PERSONNEL MONITORING

 X-ray devices users must wear personnel radiation monitoring

devices (dosimeters / film badges). Dosimeters measure and
document accrued dose to operators.

NGOJO 79
Film badge
RADIATION SAFETY CONSIDERATIONS FOR OPERATOR
PROTECTION

Three Cardinal Rules of radiation protection:

 Time
 Distance
 Shielding
Radiation Protection

more exposure

Time

Longer usage
 Radiation Protection

1.TIME
 Take foot off fluoro pedal if physician is not viewing the TV monitor

 Use last image hold (freeze frame)

 Five-minute timer

 Use pulsed fluoro instead of continuous fluoro

 Pulsed Low-Dose provides further reduction with respect to Normal

Dose continuous mode:

 Use record mode only when a permanent record is required

 Record beam-on time for review

 Radiation Protection
2.DISTANCE
Distance is large factor for reducing
exposure.
Distanc
e
Inverse Square law
“ When you double the distance the
exposure rate is decreased by 4 times ”
 Radiation Protection
DISTANCE
- One step back from tableside:
cuts exposure by factor of 4

- Move Image Int. close to patient:

less patient skin exposure less
scatter
 Radiation Protection
3.SHIELDING
Increasing the amount of shielding around a source of
radiation will decrease the amount of radiation exposure.

To avoid scatter Be sure to shield all directions.

+ -

Shielding
 Radiation Protection
Lead aprons: cut exposure by factor of 20
 Radiation Protection
Protection tools

Eye goggles curtain thyroid shield Lead Apron

88
Lead apron
RADIATION SAFETY CONSIDERATIONS FOR PATIENT
PROTECTION

 Moving the patient as far from the X-ray source as practical

 Placing the image receptor as close to the patient as possible (i.e. no air gap)
 Collimating the X-ray beam tightly to the anatomy of interest
Radiation Protection

X-ray Tube Position  Position the X-ray tube under the

patient not above the patient.
 The largest amount of scatter
radiation is produced where the
x-ray beam enters the patient.
 By positioning the x-ray tube
below the patient, you decrease
the amount of scatter radiation
that reaches your upper body.
 Radiation Protection
Collimation
Collimate tightly to the area of interest.
Reduces the patient’s total entrance skin exposure.
Improves image contrast.
Scatter radiation to the operator will also decrease.
OTHERS

 Non-Essential Personnel should exit the room while the XRT is energized
 Mobile Barriers and Suspended Shields should be used
 Persons remaining in the room should wear Protective Garments made of lead
or equivalent material like lead aprons as well as radiation monitoring devices
like film badges
 RADIATION POSTINGS

Radiation use should be LABELED on door, work area & storage area
 Appropriate Lab Attire

 Lab coat
 Eye protection
 Closed toe shoes
 Personnel monitoring
 Gloves