CONTRAST MEDIA CONTRAST MEDIA Dr. Ahmed Refaey Dr. Ahmed Refaey FRCR FRCR
Feb 10, 2016
CONTRAST MEDIACONTRAST MEDIADr. Ahmed RefaeyDr. Ahmed Refaey
FRCRFRCR
Types of contrast mediaTypes of contrast media* * Iodinated Iodinated :: * HOCM* HOCM * LOCM* LOCM* * GIT contrast agentsGIT contrast agents * Barium sulphate* Barium sulphate * water soluble contrast media * water soluble contrast media
( Gastrographin)( Gastrographin)* * MRI contrast agentMRI contrast agent* * Ultrasound contrast agentUltrasound contrast agent
IODINATED CONTRAST IODINATED CONTRAST AGENTSAGENTS
Classification Classification High osmolar High osmolar contrast agents contrast agents ( HOCA )( HOCA )
Low osmolar Low osmolar contrast agents contrast agents ( LOCA )( LOCA )
* Ionic * Ionic * Ionic * Ionic * Non-ionic * Non-ionic
HOCM HOCM • HOCA are in use since the 1950.HOCA are in use since the 1950.
* Urovist.* Urovist. * Urogarfin* Urogarfin * Angiovist.* Angiovist. * Conray.* Conray. * Renografin.* Renografin. * Renovist.* Renovist. * Hypaque.* Hypaque.
LOCALOCANon-ionicNon-ionic Ionic Ionic UltravistUltravistOmnipaqueOmnipaqueVisipaue Visipaue Oxilan Oxilan
Hexabrix Hexabrix
• LOCA have a lower incidence of LOCA have a lower incidence of
adverse reactions by a factor of 6 for adverse reactions by a factor of 6 for all reactions , and by a factor of 9 for all reactions , and by a factor of 9 for the severe reactions.the severe reactions.
Toxic effects Toxic effects • Vascular toxicityVascular toxicity• Soft tissue toxicitySoft tissue toxicity• Cardiovascular toxicityCardiovascular toxicity• Haematological changesHaematological changes• Thyroid functionThyroid function• Nephrotoxicity Nephrotoxicity
Nephrotoxicity Nephrotoxicity • Incidence of contrast induced nephrotoxicity Incidence of contrast induced nephrotoxicity
5%5%• In the majority, renal impairment is temporaryIn the majority, renal impairment is temporary• Predisposing factors :Predisposing factors : * impairment of renal function* impairment of renal function * DM* DM * dehydration* dehydration * old age* old age * large doses of CM* large doses of CM * multiple myeloma* multiple myeloma
Reactions of CMReactions of CM• Fatal reactions ( death )Fatal reactions ( death )-1/140,000 for HOCM-1/140,000 for HOCM 1/300,000 for LOCM1/300,000 for LOCM-occur in minutes-occur in minutes-old age -old age -causes ( cardiac arrest – pulmonary edema -causes ( cardiac arrest – pulmonary edema
– respiratory arrest – coagulopathy – – respiratory arrest – coagulopathy – laryngeal edema- bronchospasm )laryngeal edema- bronchospasm )
• Non- fatal reactionsNon- fatal reactions
1-flushing, metallic taste in the mouth, nausea, sneezing, 1-flushing, metallic taste in the mouth, nausea, sneezing, cough—common & related to dose and speed of injection.cough—common & related to dose and speed of injection.
2- urticaria 2- urticaria 3- angioneurotic edema3- angioneurotic edema 4- bronchospasm4- bronchospasm 5- pulmonary edema5- pulmonary edema 6- arrythmia6- arrythmia 7- hypotension7- hypotension 8- delayed reactions: rashes , headaches, itching8- delayed reactions: rashes , headaches, itching
*Excluding death, adverse reactions can be *Excluding death, adverse reactions can be classified in terms of severity as:classified in terms of severity as:
• 1- 1- major reactionsmajor reactions : those that interfere : those that interfere with the examination and require with the examination and require treatment.treatment.
• 2- 2- intermediate reactionsintermediate reactions : those that : those that interfere with the examination but do not interfere with the examination but do not require treatment.require treatment.
• 3- 3- minor reactionsminor reactions : those that do not : those that do not interfere with the examination and require interfere with the examination and require only assurance only assurance
Risk factorsRisk factors• allergy , asthmaallergy , asthma• Cardiac diseaseCardiac disease• Hepatic failureHepatic failure• Poor hydrationPoor hydration• Co-administration of: glucophageCo-administration of: glucophage• Previous reaction to contrast mediaPrevious reaction to contrast media - HOCM----- 20%- HOCM----- 20% - LOCM ----- 5 %- LOCM ----- 5 %• Other factors:Other factors: * pheochromocytoma* pheochromocytoma * sickle cell disease* sickle cell disease * hyperprotinemia ( multiple myeloma )* hyperprotinemia ( multiple myeloma )
• High risk patients should either:High risk patients should either:
1 – be premeicated with steroids 1 – be premeicated with steroids 2- to be evaluated with other modality 2- to be evaluated with other modality
( U/S – MRI )( U/S – MRI )
• Route of administrationRoute of administration : intravenous : intravenous
• Uses :Uses : * CT study* CT study * urography ( IVP- urethrography_ * urography ( IVP- urethrography_
cystography )cystography ) * angiography ( arteriography – venography )* angiography ( arteriography – venography ) * PTC, ERCP, T-tube cholangiography* PTC, ERCP, T-tube cholangiography * hystrosalpingography* hystrosalpingography * sialography* sialography * fistulography* fistulography
Urography Urography
IVUIVU
Cystogram Cystogram
Urethrogram Urethrogram
Angiography Angiography
Sialogram Sialogram
Sialogram Sialogram
Fistulogram Fistulogram
PTCPTC
PTCPTC
ERCPERCP
T-tube cholangiogram T-tube cholangiogram
HSGHSG
HSGHSG
GIT contrast agentsGIT contrast agents
Gastrointestinal contrast Gastrointestinal contrast agentsagents
• BARIUM SULPHATEBARIUM SULPHATE
• WATER SOLUBLE CONTRAST WATER SOLUBLE CONTRAST MEDIUM (GASTROGRAFIN )MEDIUM (GASTROGRAFIN )
BARIUM SULPHATEBARIUM SULPHATE
Barium sulphateBarium sulphate• Thin bariumThin barium : for upper GI studies, : for upper GI studies,
small bowel follow through, barium small bowel follow through, barium enema ---- 40% BaSO4 solution.enema ---- 40% BaSO4 solution.
• Thick bariumThick barium : for double contrast : for double contrast studies ---- 85% BaSO4 solutionstudies ---- 85% BaSO4 solution
• AdvantagesAdvantages : : * excellent coating, allowing the * excellent coating, allowing the
demonstration of normal and demonstration of normal and abnormal mucosal patterns.abnormal mucosal patterns.
* cost * cost
• Complications:Complications: • Exacerbation of GI obstruction above Exacerbation of GI obstruction above
a preexisting bowel obstructiona preexisting bowel obstruction• Intraperitoneal extravasation through Intraperitoneal extravasation through
gut perforation results in extensive gut perforation results in extensive fibrosisfibrosis
• Contraindication :Contraindication :
• Bowel obstructionBowel obstruction• Bowel perforationBowel perforation
Water soluble contrast medium Water soluble contrast medium (gastrografin )(gastrografin )
Water soluble contrast medium Water soluble contrast medium (Gastrografin )(Gastrografin )• Oral contrast medium for Oral contrast medium for
opacification of GITopacification of GIT• Hygroscopic agentHygroscopic agent• Undiluted or dilutedUndiluted or diluted• Can be used as a substitute for Can be used as a substitute for
barium if GI perforation is suspected.barium if GI perforation is suspected.• In CT , diluted by 1:40In CT , diluted by 1:40
Complications Complications • Aspiration can cause chemical Aspiration can cause chemical
pneumonitis pneumonitis • Diarrhea Diarrhea • Hypovolemic shock if used undiluted Hypovolemic shock if used undiluted
CT contrast agentsCT contrast agents• IV contrast mediumIV contrast medium• Oral water soluble contrast medium Oral water soluble contrast medium
(gastrografin)(gastrografin)
MRI contrast agentMRI contrast agent
MRI contrast agentMRI contrast agent• Gadolinium Gadolinium
• Gd-DTPAGd-DTPA• IVIV
ULTRASOUND CONTRAST ULTRASOUND CONTRAST AGENTAGENT• Levovist / echovist Levovist / echovist • IVIV
• All agents consist of radiodense All agents consist of radiodense
iodinated Benzene ring.iodinated Benzene ring.• Ionic agent typically formulated as Ionic agent typically formulated as
Sodium and or meglumine salts.Sodium and or meglumine salts.