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Title:

FLUOROSCOPY

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... 10 MM SEEM BY CT COLONOSCOPY ?? IMPORTANCE OF SMALL POLYPS ... PREP: NO EATING OR DRINKING 8 HOURS PRIOR TO PROCEDURE. SMA CCC 2/9/2006 ... day before and ... – PowerPoint PPT presentation

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Title: FLUOROSCOPY


1
FLUOROSCOPY ULTRASOUND AND CT TODAY DAVID L.
STEINBERG , M.D.
2
FLUOROSCOPY
  • UPPER GI
  • ESOPHAGRAM
  • SMALL BOWEL FOLLOW-THROUGH
  • BARIUM ENEMA

3
UGI
  • epigastric pain,
  • heartburn,
  • vomiting,
  • heme-positive stool,
  • early satiety
  • Patient preparation NPO after midnight or
    minimum of 4 hours

4
UGI TECHNIQUE
  • AIR CONTRAST
  • THICK AND THIN BARIUM
  • COAT AND IMAGE BOTH ANTERIOR AND POSTERIOR
    STOMACH WALLS
  • COMPRESSION

5
UGI FINDINGS
  • ULCERS
  • INFLAMMATION
  • NEOPLASM
  • HIATAL HERNIA
  • ADHESIONS OR OBSTRUCTIONS

6
Indications for an UGI exam include
  • 1) Gastritis
  • 2) Duodenitis
  • 3) Peptic ulcer disease
  • 4) Neoplasms
  • 5) Varices
  • 6) Gastric outlet obstruction
  • 7) Detection of spontaneous, posttraumatic or
    postsurgical leaks from the stomach,
  • esophagus, duodenum

7
Symptoms serving as an indication for an UGI
include (but are not limited to
  • Symptoms serving as an indication for an UGI
    include (but are not limited to)
  • 1) Abdominal pain
  • 2) Epigastric distress or discomfort
  • 3) Nausea
  • 4) Dyspepsia
  • 5) Vomiting
  • 6) Signs or symptoms of UGI bleeding
  • 7) Anemia
  • 8) Abdominal masses

8
REALITY
  • NUMBER OF UGIS DECLINING
  • ENDOSCOPY IS REPLACING UGIS AS INITIAL SCREENING
    TEST
  • ULCERS ARE DECREASING
  • TESTS FOR H.PYLORI
  • F/U FOR BARIATRIC SURGERY

9
ESOPHAGRAM
  • DYSPHAGIA
  • ASSESS SWALLOWING FUNCTION
  • ASSESS ABILITY TO PROTECT AIRWAY
  • HH EVALUATION
  • REFLUX EVALUATION
  • BARRETS ESOPHAGUS

10
ESOPHAGRAM TECHNIQUE
  • MODIFIED BARIUM SWALLOW WITH SPEECH THERAPIST
  • DOUBLE CONTRAST
  • PRONE AND SUPINE
  • BARIUM PILL 12 MM TO ASSESS SCHATZI RING
  • FIRST SIP TO ASSESS BYPASS OR GASTRIC BANDING

11
ESOPHAGRAM FINDINGS
  • ASPIRATION
  • DYSMOTILITY
  • SWALLOWING DYSCOORDINATION
  • DIVERTICULA
  • ULCERS
  • SCHATZI RING
  • HH
  • EROSIONS

12
REALITY
  • MOTILITY STUDIED BETTER WITH ESOPHAGRAM
  • SCHATZI RINGS ( LESS THAN 13 MM OFTEN
    SYMPTOMATIC) BETTER WITH ESOPHAGRAM
  • MUCOSA , ULCERS AND HH BETTER WITH ENDOSCOPY

13
SCHATZKI RING
14
SMALL BOWEL FOLLOW-THROUGH
  • BLIND AREA NOT EASILY ASSESSABLE FROM ABOVE OR
    BELOW
  • DONE PRIOR TO CAPSULE ENDOSCOPY TO INSURE NO
    STRICTURE OR OBSTRUCTION
  • ENTEROCLYSIS / CT ENTEROCLYSIS

15
CAPSULE ENDOSCOPY COMPLICATIONS
  • LESS THAN .1
  • RETAINED CAPSULES MOST FREQUENT COMPLICATION
  • MOST OFTEN IN CROHNS DX OR NSAIDS
  • DIVERTICULA
  • TUMOR OBSTRUCTION

16
CAPSULE ENDOSCOPY
17
CAPSULE ENDOSCOPY
  • OBSCURE GI BLEEDING MOST COMMON INDICATION
  • AVM , SMALL BOWEL TUMORS AND ULCERS MOST
    COMMON CAUSES AND FINDINGS
  • SMALL BOWEL -FOLLOW THROUGH HELPFUL IN
    LOCALIZING LESIONS FOUND BY CAPSULE ENDOSCOPY

18
CROHN DISEASE
19
CT OF TI WITH CAPSULE ENDOSCOPY CORRELATE
20
BARIUM ENEMA
  • NOW A SECOND LINE TEST FOR COLONIC DISEASE
  • AIR CONTRAST IS SUPERIOR TO SINGLE CONTRAST
  • USED FOR FAILED OR INCOMPLETE COLONOSCOPY
  • COLONOSCOPY IS INCOMPLETE IN 6-26 OF CASES

21
CT COLONOSCOPY
  • 32,700 MORE GI DOCS NEEDED IF COLONOSCOPY
    PERFORMED EVERY 10 YEARS!
  • 90 POLYPS LARGER THAN 10 MM SEEM BY CT
    COLONOSCOPY
  • ?? IMPORTANCE OF SMALL POLYPS
  • NOT IF BUT WHEN..

22
POLYPS TAKE 10 YEARS OR MORE TO BECOME CANCERS
23
COLON CANCER
24
CT COLONOGRAPHY
  • PROS
  • NO SEDATION
  • NO RISK OF PERFORATION
  • FAST SCHEDULING AND EXAM
  • FINDS OTHER PROBLEMS
  • LESS EXPENSE
  • CONS
  • LESS ACCURATE FOR SMALL LESIONS
  • FALSE POSITIVES
  • CANNOT TREAT
  • STILL NEED A PREP
  • MINIMAL DISCOMFORT

25
ULTRASOUND
  • ABDOMINAL ULTRASOUND
  • RENAL ULTRASOUND
  • CAROTID ULTRASOUND
  • VENOUS ULTRASOUND
  • ARTERIAL ULTRASOUND

26
ABDOMINAL ULTRASOUND
  • PRIMARY IMAGING TEST FOR ACUTE RUQ PAIN
  • BEST MODALITY TO DETECT GALLSTONES , GALLBLADDER
    WALL THICKENING AND SONOGRAPHIC MURPHY SIGN

27
ABDOMINAL ULTRASOUND
  • PREP NO EATING OR DRINKING 8 HOURS PRIOR TO
    PROCEDURE

28
ABDOMINAL ULTRASOUND
  • STATE OF THE ART INCLUDES
  • COLOR AND DOPPLER IMAGING
  • 3D AND 4D IMAGING
  • TISSUE HARMONICS AND NOISE REDUCTION

29
GALLBLADDER WITH SHADOWING STONE
30
WITH TISSUE HARMONICS
WITHOUT TISSUE HARMONICS
31
3D GALLBLADDER
32
RENAL ULTRASOUND
  • PRIMARY TEST FOR EVALUATION OF RENAL FAILURE OR
    RENAL CALCULI
  • CAN SCREEN FOR RENAL ARTERY STENOSIS USING POWER
    DOPPLER AND PULSED DOPPLER

33
RENAL ULTRASOUND
  • NPO FOR 8 HOURS

34
RENAL ULTRASOUND
35
EVALUATION OF RENAL ARTERIOLAR DISEASE
36
RENAL ARTERY STENOSIS
  • NOT THE SAME AS R.V.H. FROM 1 TO 30
  • ULTRASOUND IS VERY USER AND PT VARIABLE
  • CAPTOPRIL AUGMENTED RENOGRAPHY CAN PREDICT
    RESPONSE TO REVASCULARIZATION LIMITED VALUE IF
    CR GREATER THAN 2.
  • MRA AND CTA

37
CAROTID ULTRASOUND
  • Duplex ultrasonography (US) has become the most
    common screening and diagnostic test to evaluate
    extracranial carotid artery stenosis
  • Based on morphology and velocity
  • COLOR AND PULSED DOPPLER EVALUATION

38
CAROTID STENOSIS
  • NASCET SHOWED C.E. BENEFICIAL FOR70 STENOSIS
    IF M/M LESS THAN 3
  • ASYMPTOMATIC CAROTID STENOSIS STUDY SHOWED
    BENEFIT AT 60.
  • DOPPLER LEAST EXPENSIVE WITH ABOUT 90 S/S.
    OPERATOR DEPENDENT.

39
CAROTID STENOSIS
  • CTA AND MRA HAVE SIMILAR S/S
  • DOPPLER AND MRA OR CTA HAVE BETTER PREDICTIVE
    VALUE THAN DOPPLER ALONE OR MRA/CTA ALONE
  • MRA MAY OVER ESTIMATE STENOSIS AND IS MOTION
    SENSITIVE
  • CTA MAY END UP BEING MOST ACCURATE WITH MDCT
    IMAGING

40
VENOUS ULTRASOUND
  • IMAGING STUDY OF CHOICE FOR EVALUATION OF
    PATIENTS WITH SUSPECT DVT . BOTH UE AND LE
  • GOLD STANDARD IS 2 NEGATIVE ULTRASOUNDS ONE WEEK
    APART TO EXCLUDE DVT
  • EXCELLENT IN SYMPTOMATIC PATIENTS. NOT SO GOOD
    FOR SCREENING ASYMPTOMATIC PATIENTS.

41
VENOUS ULTRASOUND
  • PREPARATION NONE
  • NOT GREAT FOR RECURRENT DVT
  • ONLY NEED TO STUDY THE SYMPTOMATIC LEG
  • NEGATIVE D- DIMER TEST IN LOW PROBABILITY
    PATIENTS ELIMINATES NEED FOR ULTRASOUND

42
VENOUS ULTRASOUND
43
ARTERIAL ULTRASOUND
  • BASED ON BLOOD FLOW VELOCITY MEASUREMENTS
  • VESSEL MORPHOLOGY AS WELL
  • ABIS IMPORTANT
  • COLOR AND PULSED DOPPLER
  • CTA AND MRA MORE SENSITIVE

44
P.V.D.
  • SCREENING A.B.I. AND DOPPLER
  • CTA AND MRA BOTH COMPETITIVE
  • ANGIO HAS THE ADVANTAGE OF IMAGING AND
    INTERVENTION AT THE SAME TIME
  • DOPPLER MAY HELP STEER FURTHER IMAGING IE.,
    LARGE VESSEL SINGLE LEVEL DX. LIKELY AMENABLE TO
    PERCUTANEOUS INTERVENTION

45
AORTIC ANEURYSM
  • 5-7 OVER 60 YEARS OF AGE
  • AT RISK GROUP INCLUDE SMOKING HX, HTN .KNOWN
    VASCULAR DX AND 1ST DEGREE RELATIVES
  • ULTRASOUND IS THE MOST COST EFFECTIVE SCREENING
  • CTA OR MRA CLOSE TO BEING EQUALLY EFFECTIVE IN DX
    EXTENT

46
AORTIC ANEURYSM
  • ULTRASOUND ACCURATE TO 3MM
  • AVERAGE RATE OF EXPANSION IS 3 TO 5 MM A YEAR
  • RAPID EXPANSION AND SIZE OVER 5CM FAVOR SURGERY
  • SURGICAL MORTALITY 5
  • RUPTURE MORTALITY 80 .RR/YR OF 5CM ANEURYSM 7

47
CT TODAY
  • MULTISLICE 4-64 SLICES
  • NONIONIC CONTRAST
  • ACQUIRE VOXELS NOT PIXELS
  • ISOTROPIC IMAGING
  • 3D AND MULTIPLANAR REFORMATIONS THE NORM

48
CT PREPARATION
  • ORAL BARIUM FOR STUDIES OF ABDOMEN OR PELVIS
  • IF IV CONTRAST NEED A RECENT CREATININE
  • NPO FOR 4 HOURS IF CTA

49
CT RISKS
  • CONTRAST REACTION
  • CONTRAST INDUCED NEPHROPATHY

50
  • Contrast-Induced Nephrotoxicity
  • Due to renal vascular effects and direct toxicity
    to tubular cells
  • Third most common cause of in-hospital renal
    failure, after hypotension and surgery
  • Definition elevation of creatinine 25 or .5-1.0
    mg/dL within 72 hours

51
Contrast-Induced Nephrotoxicity
  • Usually asymptomatic creatinine peaks 3-5 days,
    in severe oliguric renal failure peaks 5-10
    days
  • Incidence
  • 7-8 arterial injections
  • 2-5 venous injections
  • 0 venous injections if no risk factors

52
  • Nephrotoxicity Risk Factors
  • Byrd and Sherman, 1979
  • Renal insufficiency (creat1.5)
  • Diabetes
  • Dehydration
  • Cardiovascular dz and diuretics
  • Age 70
  • Myeloma
  • Hypertension
  • Hyperuricemia

Highest risk (Parfey et al., 1989)
RENAL INSUFFICIENCY AND DIABETES

53
  • Nephrotoxicity Risk Factors
  • Creatinine measurement recommended
  • Hx of kidney dz
  • Family hx of kidney failure
  • IDDM for 2 years
  • NIDDM for 5 years
  • Paraproteinemia
  • Collagen vascular dz
  • Medications NSAIDs,aminoglycosides

54
  • Nephrotoxicity Prevention
  • HYDRATION
  • 100 ml/hr at least 4 hours before and 12 hours
    after
  • Mannitol
  • Furosemide
  • Dopamine
  • Theophylline
  • ANP

disappointing in clinical trials
55
  • Nephrotoxicity Prevention
  • N-Acetylcysteine (Mucomyst) Antioxidant with
    vasodilatory properties
  • NEJM 2000343(3) 180-183 nephrotoxicity occurred
    in 9/42 patients receiving placebo and 1/41
    patients receiving acetylcysteine after 75 ml
    iopromide
  • For premedication
  • 600mg PO BID day before and of study
  • Alternative 150mg/kg IV over 30 min prior to
    study, then 50mg/kg over 4 hours

56
  • Nephrotoxicity

57
19
  • Dec 18

Dec
21
Dec
58
CT PROCEDURES
  • CT ABDOMEN
  • CT CHEST
  • CTA PULMONARY
  • CTA AORTA
  • CTA CORONARY

59
CT ABDOMEN
  • DX APPENDICITIS 90-100
  • PANCREATITIS DX AND PROGNOSIS
  • BILIARY TRACT DX
  • NODAL DX
  • RENAL DX

60
TARGET SIGN
61
VALUE OF CORONAL IMAGING
62
APPENDICITIS??
63
PANCREATITIS
64
CT CHEST
  • INTERSTITIAL LUNG DISEASE
  • EVALUATE LUNG NODULES
  • STAGE LUNG CANCER
  • SOLVE CXRAY QUESTIONS

65
PULMONARY FIBROSIS
66
CAD FOR LUNG NODULES
67
(No Transcript)
68
CTA PULMONARY
  • MAY BE MORE SENSITIVE THAN PA WHEN SMALLER
    COLLIMATION IS USED 1.25 MM ( 64 SLICE ) CORONAL
    IMAGING
  • WHAT ABOUT SMALL PE
  • NO NEED FOR V/Q

69
PULMONARY EMBOLUS
  • CTA IS IT!!!!!!!!!!!!!!!!!!! V/Q SCAN IS GONE
  • HIGH S/S
  • NEGATIVE PREDICTIVE VALUE IS IMPORTANT. A
    NEGATIVE TEST MEANS THAT NO TREATMENT IS
    NECESSARY
  • LESS EXPENSIVE THAN AND AS ACCURATE AS PULMONARY
    ANGIO

70
CT PULMONARY ANGIO
71
PULMONARY EMBOLISM
72
CTA AORTA
  • PREOP FOR ENDOVACULAR REPAIR
  • F/U FOR ENDOVASCULAR REPAIR
  • WORKUP FOR PVD
  • WORKUP FOR ABDOMINAL ANGINA

73
CTA
74
RENAL CTA
75
CTA
76
ABDOMINAL ANGINA
77
CTA CORONARY ARTERIES
  • READY FOR PRIME TIME AT 64 SLICE
  • REPLACE CATH IN LOW RISK PATIENTS
  • LIMITED EVALUATION IN PTS WITH HIGH CALCIUM
    SCORE
  • PHYSIOLOGIC DATA INCLUDING WALL MOTION AND EF

78
ANOMALOUS ORIGIN OF RCA
79
CARDIAC MORPHOLOGY
80
THANKS FOR COMING AND LISTENING
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