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74
CHAPTER 5
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IMAGING PROCEDURES
A
B
C
FIGURE 5-3
75
CHAPTER 5
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Evaluation Criteria
• Anatomy from diaphragm and lower is included
• No evidence of rotation
• Demonstrates superimposition of anterior superior
iliac spine (ASIS), iliac crests, and posterior ribs
Demonstrates
• Air-fluid levels in the GI tract
• Anterior abdominal soft tissue anatomy and prever-
tebral region
• Pathologies including but not limited to: retroperi-
toneal air, abnormal masses, aneurysms, aortic
calcifications
Dorsal Decubitus Abdomen
Positioning Criteria
• Patient is placed supine on radiolucent sponge
• Utilize 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) gridded IR with mid-
point aligned at 2⬙ (5 cm) above iliac crest; gonadal
region shielded
• Central ray directed horizontally to midpoint of IR
and midcoronal plane
• Collimate to all sides to include all pertinent
anatomy
• Place appropriate side marker in light field at lower
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
• Image taken on full expiration
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CHAPTER 5
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IMAGING PROCEDURES
Evaluation Criteria
• True lateral position with posterior ribs superimposed
• Entire esophagus visualized
• Seen between T-spine and heart
Demonstrates
• Entire esophagus filled with barium
• Visualized between spine and heart
• Pathologies including but not limited to: anatomic
anomalies, dysphagia, varices, diverticulum
Anteroposterior/Posteroanterior Esophagus
Positioning Criteria
• Place patient supine on the table; shield gonadal region
• Place top of 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR 2⬙ (5 cm)
above shoulder
• Use either arm to hold cup; place straw in mouth
• Central ray perpendicular to IR centered at approxi-
mately T5–T6 and at MSP
• Collimate crosswise to create a band of 5⬙ to 6⬙ (12.5
to 15 cm)
• Minimum SID: 40⬙ (100 cm)
• Patient is instructed to drink barium; on third/fourth
swallow, image is taken
Evaluation Criteria
No rotation as noted by sternoclavicular joints
Demonstrates
• Barium-filled esophagus
• Alternate PA can be performed in the prone position
with same positioning, centering, and collimation
• Pathologies including but not limited to: anatomic
anomalies, dysphagia, varices, diverticulum
Left Anterior Oblique Esophagus
Positioning Criteria
• Place patient in an LAO 35 degrees to 40 degrees;
shield gonadal region
• Place top of 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR 2⬙ (5 cm)
above shoulder
• Cup of barium in patient’s right hand with straw in
mouth
• Central ray perpendicular to IR centered at approx-
imately T5–T6 and 2⬙ (5 cm) anterior to the spine
(up side)
• Collimate crosswise to create a band of 5⬙ to 6⬙ (12.5
to 15 cm)
• Minimum SID: 40⬙ (100 cm)
• Patient is instructed to drink barium; on third/fourth
swallow, image is taken
BARIUM STUDIES
For all upper gastrointestinal (UGI) studies, small bowel
series (SBS), and barium enemas (BEs), a scout view of
the abdomen is performed. The entire abdomen must
be demonstrated prior to contrast administration.
Esophagus Projections
Patient Preparation
No special preparation is necessary unless the patient
is also having a UGI exam.
Right Anterior Oblique Esophagus
Positioning Criteria
• Place patient in an RAO 35 degrees to 40 degrees;
shield the gonadal region
• Place top of 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR 2⬙ (5 cm)
above shoulder
• Cup of barium in patient’s left hand with straw in mouth
• Central ray perpendicular to IR centered at approxi-
mately T5–T6 and 2⬙ (5 cm) anterior to the spine (up side)
• Collimate crosswise to create a band of 5⬙ to 6⬙ (12.5
to 15 cm)
• Patient is instructed to drink barium; on third/fourth
swallow, image is taken
Evaluation Criteria
• Entire esophagus visualized
• Seen between the spine and heart
Demonstrates
• Entire esophagus filled with barium
• Visualized between spine and heart
• Pathologies including but not limited to: anatomic
anomalies, dysphagia, varices, diverticulum
Right Lateral Esophagus
Positioning Criteria
• Place patient in a right lateral with arms anterior to
body, elbows flexed; shield gonadal region
• Place top of 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR 2⬙ (5 cm)
above shoulder
• Cup of barium against patient’s flexed elbows, straw
in mouth
• Central ray perpendicular to IR centered at approxi-
mately T5–T6 and at midcoronal plane
• Collimate crosswise to create a band of 5⬙ to 6⬙ (12.5
to 15 cm)
• Patient is instructed to drink barium; on third/fourth
swallow, image is taken
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Posteroanterior Upper Gastrointestinal
Positioning Criteria
• Patient placed in a prone position on the table; shield
the gonadal region
• Central ray perpendicular to IR centered at level of
duodenal bulb
• Level of duodenal bulb varies based on body habitus
Asthenic patient: L2–L3
Sthenic patient: L1
Hypersthenic patient: T12
• Collimate to size of IR or smaller
• Minimum SID: 40⬙ (100 cm)
• Image taken on full exhalation
Evaluation Criteria
• Entire stomach and duodenum are visualized
Demonstrates
• Entire stomach and duodenum barium filled
• Pathologies including but not limited to: polyps,
diverticula, bezoars, gastritis
Right Lateral Upper Gastrointestinal
Positioning Criteria
• Place patient in a left lateral with arms anterior to
body, elbows flexed; shield gonadal region
• Utilize a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR placed in the Bucky
• Central ray perpendicular to IR centered at level of
duodenal bulb
Evaluation Criteria
• Entire esophagus visualized
• Seen between the spine and hilar region of lungs
Demonstrates
• Entire esophagus filled with barium
• Visualized between spine and hilar region of lungs
• Pathologies including but not limited to: anatomic
anomalies, dysphagia, varices, diverticulum
Swallowing Dysfunction Study (Modified
Barium Swallow)
1
• Exam performed by the physician initially
• Utilizes fluoroscopy in the AP and lateral positions to
assess patient’s swallowing function
• Spot radiographs are taken to document
• Technologist may perform an esophagram series
postprocedure (see above section)
Upper Gastrointestinal Projections
Patient Preparation
• Patient should have nothing by mouth (be NPO) for
8 hours for stomach to be empty
• No smoking or chewing gum during this time
Right Anterior Oblique Upper
Gastrointestinal
Positioning Criteria
• Place patient in a 40-degree to 70-degree RAO; shield
gonadal region
• Utilize a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR placed lengthwise
in the Bucky
• Central ray perpendicular to IR centered at level of
duodenal bulb
• Level of duodenal bulb varies based on body habitus:
Asthenic patient: lumbar vertebrae L2–L3
Sthenic patient: L1
Hypersthenic patient: T12
• Collimate to size of IR or smaller
• Minimum SID: 40⬙ (100 cm)
• Image taken on full exhalation
Evaluation Criteria
• Entire stomach and C-loop of duodenum are visualized
• Duodenal bulb in profile
Demonstrates
• Fundus of stomach filled with air
• Body and pylorus of stomach filled with barium
• Pathologies including but not limited to: polyps,
ulcers
FIGURE 5-4
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CHAPTER 5
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Anteroposterior Upper Gastrointestinal
Positioning Criteria
• Place patient supine on the table; shield gonadal
region
• Utilize a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR placed in the Bucky
• Central ray perpendicular to IR centered at level of
duodenal bulb and midway between MSP and lateral
margin
• Approximate level of duodenal bulb varies based on
body habitus
Asthenic patient: L2
Sthenic patient: L1
Hypersthenic patient: T12
• Collimate to size of IR or smaller
• Minimum SID: 40⬙ (100 cm)
• Image taken on full exhalation
Evaluation Criteria
• Entire stomach and duodenum are visualized
• Lower lung field included
Demonstrates
• Fundus of stomach filled with barium
• Pathologies including but not limited to: hiatal hernia
Small Bowel Series Projections
Types of Small Bowel Series
Performed in combination with UGI, SBS only, or
enteroclysis
Patient Preparation
• Patient should be NPO for 8 hours for stomach to be
empty
• No smoking or chewing gum during this time
Posteroanterior (Follow-through)
Small Bowel Series
• Several images are taken in the PA projection to fol-
low the barium through the small intestine
• Place the patient prone on the imaging table
• First image taken at 15 to 30 minutes after barium in-
gested centered 2⬙ (5 cm) above iliac crest; all other
images centered at iliac crest
• Utilize shield providing it does not cover pertinent
anatomy
• Place appropriate side marker in light field at lower
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
• Image taken on full expiration
• Level of duodenal bulb varies based on body habitus
Asthenic patient: L2–L3
Sthenic patient: L1
Hypersthenic patient: T12
• Collimate to size of IR or smaller
• Minimum SID: 40⬙ (100 cm)
• Image taken on full exhalation
Evaluation Criteria
• Vertebral bodies in lateral position
• Intervertebral foramen open in true lateral position
• Entire stomach visualized
Demonstrates
• Entire stomach and duodenum visualized
• Retrogastric space
• Pylorus and C-loop demonstrated
• Pathologies including but not limited to: polyps,
diverticula, tumors in the posterior margin of the
stomach
Left Posterior Oblique Upper
Gastrointestinal
Positioning Criteria
• Place patient in a 30-degree to 60-degree left posterior
oblique (LPO); shield gonadal region
• Utilize a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR placed in the Bucky
aligned with central ray
• Central ray perpendicular to IR centered at level of
duodenal bulb and midway between MSP and lateral
margin
• Approximate level of duodenal bulb varies based on
body habitus
Asthenic patient: L2
Sthenic patient: L1
Hypersthenic patient: T12
• Collimate to size of IR or smaller
• Minimum SID: 40⬙ (100 cm)
• Image taken on full exhalation
Evaluation Criteria
• Entire stomach and C-loop of duodenum are visualized
• Duodenal bulb in profile
Demonstrates
• Fundus of stomach filled with barium
• Body and pylorus of stomach filled with air for a
double-contrast study
• Pathologies including but not limited to: gastritis and
ulcers during a double-contrast study
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CHAPTER 5
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IMAGING PROCEDURES
placed into the terminal duodenum. During this dou-
ble-contrast procedure, barium is injected through the
duodenojejunal tube and the patient is imaged in the
same manner as a traditional SBS. Then air or methyl-
cellulose is injected to distend the bowel. Catheter is
removed when study is complete. The study provides
increased detail from the standard SBS procedure;
however, there is increased risk of perforation owing
to catheter placement.
Barium Enema Procedure
Patient Preparation
Patient preparation may vary from facility to facility;
however, it typically includes the following:
• If time permits, the patient should be on a light diet
for 2 to 3 days prior to the exam
• Clear liquid diet for the immediate 24 hours before
the study
• Increased fluid intake, two glasses per hour from
12 pm until 12 am
• 10 ounces of magnesium citrate or equivalent night
before
• NPO 8 to 12 hours prior to exam
• Cleansing enema morning of exam
Preparation for Tip Insertion
• Patient is placed in the Sims position (LAO) on the
table after changing
• Patient is instructed prior to tube placement to:
Keep sphincter contracted to hold tube in place
Concentrate on breathing to keep abdominal muscles
relaxed to reduce spasms
• Lubricated enema tip is inserted 1⬙ to 1½⬙ (2.5 to
4 cm) anterior toward the umbilicus, then superior
and slightly anterior
• Total insertion should not exceed 1⬙ to 1½⬙ (2.5 to
4 cm)
• Hang barium bag no more than 24⬙ (60 cm) above the
table
Left Lateral Rectum Barium Enema
Positioning Criteria
• Patient is placed in a left lateral position on the table
• Central ray is directed to the level of ASIS and mid-
coronal plane
• Utilize a 10⬙ ⫻ 12⬙ (25 ⫻ 30 cm) IR lengthwise cen-
tered to the central ray
• Collimate to the size of the IR
• Minimum SID: 40⬙ (100 cm)
• Image taken on expiration
Evaluation Criteria
• Anatomy from stomach and inferior is visualized
• No evidence of rotation
• Iliac wings and obturators (if visible) are symmetrical
• Spinous processes centered on vertebrae; transverse
processes equidistant to vertebrae
Demonstrates
• PA view of abdomen
• Documentation of entire stomach and small bowel
barium filled with series of pictures
• Study complete when barium reaches the ileocecal
valve
FIGURE 5-5
• Pathologies including but not limited to: enteritis,
Meckel diverticulum, Whipple disease, and Crohn
disease
Ileocecal Spots Small Bowel Series
Physician will image the ileocecal valve under fluoro-
scopic guidance using compression.
Enteroclysis Small Bowel Series
Indicated for patients with clinical history of Crohn dis-
ease, small bowel ileus, or malabsorption syndrome.
Under fluoroscopic guidance, a duodenojejunal tube is
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CHAPTER 5
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IMAGING PROCEDURES
Evaluation Criteria
• No rotation as evident by appearance of pelvis and spine
• Entire large intestine is included
Demonstrates
• Provides detail of the air-filled structures of the large
intestine, medial aspect of the ascending colon, and
lateral aspect of the descending colon
• Entire colon with air-fluid levels
• Pathologies including but not limited to: presence of
polyps, diverticula
Left Posterior Oblique Barium Enema
Projection
Positioning Criteria
• Patient is positioned in a 35-degree to 45-degree LPO
• Central ray is directed to the level of iliac crest and 1⬙
(2.5 cm) medial to the elevated ASIS
• Utilize a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR in table Bucky
lengthwise centered to central ray
• Collimate to size of IR
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• Ala of left ilium will be elongated; right will be fore-
shortened
• No tilt is present
• Entire large intestine visualized
Demonstrates
• Right colic flexure seen open and free of superim-
position
• Ascending and rectosigmoid portions should appear
open
• Pathologies including but not limited to: obstruc-
tions, volvulus, ileus, diverticula, and polyps during
a double-contrast study
This projection can also be performed in the PA RAO
position to demonstrate the same anatomy free of su-
perimposition.
Right Posterior Oblique Barium
Enema Projection
Positioning Criteria
• Patient is positioned in a 35-degree to 45-degree right
posterior oblique (RPO)
• Utilize a 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR in table Bucky
lengthwise aligned with central ray
• Central ray is directed 1⬙ to 2⬙ (2.5 to 5 cm) superior to
iliac crest and 1⬙ (2.5 cm) medial to the elevated ASIS
Evaluation Criteria
• No rotation
• Femoral heads are superimposed
• Visualize rectum barium filled
Demonstrates
• Barium-filled rectum in a lateral projection
• Pathologies including but not limited to: polyps, di-
verticulum, strictures, and fistulas between rectum
and bladder/uterus
For double-contrast study, IR is taken utilizing a hori-
zontal central ray with the patient in a ventral decubi-
tus position. Centering is the same. Demonstration in
this view also includes air-fluid level in the rectum.
Left Lateral Decubitus Barium Enema
Projection
Positioning Criteria
• Performed as part of a double-contrast BE study only
• Can be performed with the patient AP or PA (PA pre-
ferred to reduce gonadal dose)
• Patient is placed in a left lateral position against the
14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) gridded IR
• Central ray is directed horizontally to MSP and iliac crest
• Minimum SID: 40⬙ (100 cm)
• Image taken on expiration
Evaluation Criteria
• No rotation as evident by appearance of pelvis and spine
• Entire large intestine is included
Demonstrates
• Provides detail of the air-filled structures of the large
intestine, lateral aspect of the ascending colon, and
medial aspect of the descending colon
• Entire colon with air-fluid levels
• Pathologies including but not limited to: presence of
polyps, diverticula
Right Lateral Decubitus Barium Enema
Projection
Positioning Criteria
• Performed as part of a double-contrast BE study only
• Can be performed with the patient AP or PA (PA pre-
ferred to reduce gonadal dose)
• Patient is placed in a right lateral position against the
14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) gridded IR
• Central ray is directed horizontally to MSP and iliac crest
• Minimum SID: 40⬙ (100 cm)
• Image taken on expiration
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CHAPTER 5
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This projection can also be performed in the AP position
to demonstrate the same anatomy. During a double-con-
trast study, the air will now be in the transverse and
loops of the sigmoid colon.
Anteroposterior Axial (Butterfly) Projection
Positioning Criteria
• Place patient in the supine position on the table
• Central ray is directed 30 degrees to 40 degrees
cephalic at MSP and 2⬙ (5 cm) below ASIS
• Collimate to area of interest
• Alternate position: Patient can be placed in the LPO
position if the sigmoid is tortuous; centering is then
adjusted to 2⬙ (5 cm) inferior to ASIS and 2⬙ (5 cm)
medial to the right ASIS
• Collimate to size of IR
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• Ala of right ilium will be elongated; left will be fore-
shortened
• No tilt is present
• Entire large intestine visualized
Demonstrates
• Left colic flexure seen open and free of superimposi-
tion
• Ascending and rectosigmoid portions should appear
open
• Pathologies including but not limited to: obstruc-
tions, volvulus, ileus, diverticula, and polyps during
a double-contrast study
This projection can also be performed in the PA LAO
position to demonstrate the same anatomy free of
superimposition.
Posteroanterior Barium Enema Projection
Positioning Criteria
• Patient is placed in the prone position on the table
• Central ray is directed at iliac crest and MSP
• 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR in table Bucky lengthwise
aligned with central ray
• Collimate to size of IR
• Minimum SID: 40⬙ (100 cm)
Evaluation Criteria
• No rotation visible
• Spine is centered and in middle of image (unless
patient has scoliosis)
• Iliac wings are even and symmetrical
Demonstrates
• Entire colon
• For double-contrast study, air will be in the rectum
and ascending and descending portions of the colon
FIGURE 5-6
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CHAPTER 5
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IMAGING PROCEDURES
• Place 14⬙ ⫻ 17⬙ (35 ⫻ 42.5 cm) IR in Bucky aligned
with iliac crest at midpoint of receptor
• Central ray directed perpendicular to midpoint of IR
and MSP
• Collimate to all sides to include all pertinent anatomy
• Place appropriate side marker in light field at lower
lateral aspect of image
• Minimum SID: 40⬙ (100 cm)
• Image taken on full expiration
Evaluation Criteria
• Anatomy from kidneys to bladder is visualized
• Colon visualized
• No evidence of rotation
• Iliac wings and obturators (if visible) are symmetrical
• Spinous processes centered on vertebrae; transverse
processes equidistant to vertebrae
Demonstrates
• Residual barium in colon
• Small polyps and defects can be noted
Evaluation Criteria
• Rectosigmoid junction seen free of superimposition
• Adequate tube angle noted by elongation of rectosig-
moid junction
Demonstrates
• Less overlapping of the rectosigmoid junction
• Pathologies including but not limited to: polyps, neo-
plasm, colitis
This projection can also be performed in the PA RAO
position with a 30-degree to 40-degree tube angle cen-
tered at iliac crest and MSP. Same anatomy is demon-
strated with reduced gonadal dose.
Posteroanterior Postevacuation Barium
Enema Projection
Positioning Criteria
• Projection taken after patient has evacuated barium
• Patient prone; gonadal shield for male patients;
breast shield for females
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CHAPTER 5
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IMAGING PROCEDURES
the AP projection is obtained either before or following
surgical removal of the gallbladder. A contrast medium
is injected into the biliary system to check for residual
stones and proper drainage into the duodenum.
SURGICAL CHOLANGIOGRAPHY
This exam is performed in the operating room with the
C-arm. The technologist must be able to manipulate the
C-arm to image the biliary ductal system. A picture in