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Write short notes on the following techniques of: a) Bronchography b) Sialography c) Deep venography d) Micturating cystourethrography

Outlines
Introduction/Definitions Indications Contraindications Materials & methods Patients preparations Techniques proper Aftercare Complications

Bronchography
Is a contrast study for demonstration of the broncho-pulmonary tree/segments. Initially, it was the definitive diagnosis for bronchiectasis, however the advent of CT esp.ly high resolution CT (HRCT) had almost push bronchography out of use Not many indications for bronchography are known
 Bronchiectasis  Bronchial obstruction site & extent  Other possible indications when other imaging modalities are negative includes:
o Recurrent Haemoptysis o Broncho-pleural fistula o Congenital lesions agenesis & sequetration

Contraindications i. Acute respiratory infection ii. Poor respiratory reserve iii. Others massive haemoptysis, active PTB & hx of allergy Materials & Methods
Materials o Fluoroscopic unit with overcouch tube o Catheter o Contrast media LOCM (Iotrolan-300) 23ml per lung segment; 25ml/patient

Methods 4 types 1) Catheter 2) Cricothyroid puncture not for <12yr old 3) Bronchoscope 4) Dribbling contrast over the back of the tongue not reliable and already abandoned Patient prep Chest physiotherapy NPO for 6hrs prior to procedure Pre-medications 0.6mg Atropine & 10mg Morphine Asthmatics should have steroid prophylaxis & salbutamol pre-procedure Preliminary films - PA & Lateral

Technique Local anaesthesia agent application to the nasal, oral & larynx (including the vocal cords) in form of lozenges (amethocaine) and 4% Xylocaine spray Depending on the method, the catheter is advanced thru the nasal/oral cavity, thru the larynx and well down the trachea The catheter is then secured by taping to the pxs cheek Each side is usually done in turns Upper lobe (right) patient lies on his/her Rt side with head up. Contrast agent is injected briskly and the px tipped head down, then turns semi-prone and then semi-supine Lower Lobe (right) patient leans to the right and bends forward. After contrast injection, px will swing sideways and then backwards

Films - the preliminary film are repeated & then additional views - 450 RPO & LPO for the left side Aftercare Coughing/chest physiotherapy NPO till anaesthesia wears out to prevent aspiration Patients that used cricothyroid puncture are advised to press on the site while coughing to make coughing effective 24hrs post-procedure CXR to view residual contrast is usually done

Complications Contrast
Nausea, vomiting, pyrexia, headache, etc Bronchospasm Impaired respiratory fxn Segmental collapse Allergic rxn - LOCM Subcutaneous emphysema Haematoma Tracheal injury Soft tissue injury

Technique

Sialography
Is the contrast procedure for demonstration of the salivary ducts Indications 1) Pain & swelling of the salivary glands 2) Sicca syndrome which includes xerostomia, xero-ophthalmia & anhydrosis Contraindications Acute infection or inflammation

Materials/equipment
Skull unit with macro-radiography facilities Silver lachrymal dilator Silver cannula or 18G blunt needle and polythene catheter Contrast agents HOCM/LOCM or Lipiodol ultra fluid

Patient prep
None specific, except for removal of all radio-opaque foreign bodies esp.ly false teeth (dentures)

Preliminary films
Parotid AP with 50 rotation, lateral & lateral oblique Submandibular Infero-superior (occlusal film) for showing calculi, lateral with depressed floor of the mouth, lateral oblique

Technique Localization of the salivary ducts parotid and submadibular Dilatation of the ducts and cannulation 1-2mls of LOCM is introduced which should be stopped as soon as px feels pain Films are taken immediately the above preliminary films and post-secretory film after sialogogue administration (to demonstrate sialectasis) Aftercare None Complications pain, damage to duct orifices, rupture of ducts & infections

Deep Venography
Etymologically better refer to as Phlebography rather than venography. It is the contrast procedure for demonstration of the deep veins of the limbs esp.ly the lower limbs Indications i. DVT and its complications (PE) ii. Demonstration of incompetent perforating veins iii. Oedema of unknown cause iv. Extrinsic venous obstruction tumours v. Congenital abnormality of venous system Contraindications
Local sepsis

Materials/equipment Fluoroscopy unit with spot film devices Tilting radiography table Contrast agents LOCM preferably 40-60ml Methods Indirect Direct ascending &/or descending Patient prep None per se except for oedematous limb that warrant overnight elevation to reduce the oedema for better vascular access

Technique (ascending) Patient in supine position and tilted 400 head up to delay contrast transit time Venous access is gained using distal veins on the dorsum of the foot Tourniquets or inflatable cuffs are applied to just above the ankle & knee to prevent contrast bypassing or flow into the superficial veins 40ml of LOCM is injected with 1st series of films taken Further 20ml of contrast is injected with px performing valsalva manoeuvre and/or pressure on the femoral vein at the inguinal region. Another series of films are taken 1-2s after releasing the pressure

Descending Phlebography
Seldinger technique of femoral vein vascular access is carried out with the catheter advanced 5cm into the vein Contrast medium is injected patient in erect position and performing valsalva manoeuvre Contrast will reflux down to the popliteal vein thru incompetent valves

Radiographs
AP (calf) & both oblique AP popliteal, common femoral & iliac veins

Aftercare flush the needle and the vein with normal saline b/4 terminating the procedure The limb should be exercised Complications Contrast
General and allergic rxn Thrombophlebitis DVT Tissue necrosis from extravascular contrast injection Cardiac arrhythmias

Technique
Haematoma Pulmonary embolism clot or air

Micturating CystoUrethrography
Is one of the contrast procedure for evaluating the bladder. Primarily, it is performed for the assessment of vesicoureteric reflux and its therefore an investigation of childhood. Also, it is the commonest fluoroscopic examination in infants and young children. However, in adults, it is usually performed along side or ffing RUCG

Indications Vesico-ureteric reflux PUV Abnormalities of the bladder diverticulum Stress incontinence Study of the urethral during micturition Trauma with bladder injury Fistulae VVF, VUF, Urachal Post-operative evaluation anastomosis, repairs & bladder reconstructions Recurrent UTI Contraindications Acute UTI

Materials Fluoroscopy unit with spot film device Video recorder Catheter Jaques or foleys, feeding tubes (57FG) for infants Contrast media HOCM/LOCM 150mg/ml iodine concn. Patient prep None per se Patient only have to empty the bladder prior to the procedure Preliminary film Coned down view of the bladder

Technique Px supine on x-ray tube Using aseptic technique, px is catheterized with residual urine drained and sample taken for m/c/s Contrast is slowly introduced by drip into the bladder under intermittent fluoroscopy volume between 100-250ml is introduced depending on indication and pxs bladder capacity Vesico-ureteric reflux is usually by spot filming during contrast filling Px are allowed to micturate when the urge came. In children, imaging begins when urine start to leak peri-catheter Radiographs 1st oblique views are to demonstrate mild vesicoureteric reflux RAO and LAO of micturition phase is taken showing the urethra Full abdominal/renal region radiographs are taken to demonstrate reflux, esply if it occurred unnoticed Lateral bladder for VVF Erect radiogaphs for stress incontinence

Aftercare No special care per se Analgesics Antibiotics for those which reflux was demonstrated Complications Contrast Adverse reaction Cystitis contrast induce (chemical) Technique UTI Catheter trauma Complications of bladder filling perforation from bladder over-distension prevented by using none retaining catheter Jaques in place of Foleys Catheterization of vagina/ectopic ureteral orifice Retention of foleys catheter