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CONTRAST MEDIACONTRAST MEDIA
Dr. Ahmed RefaeyDr. Ahmed RefaeyFRCRFRCR
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.
LOCALOCA
Non-ionicNon-ionic Ionic Ionic
UltravistUltravist
OmnipaqueOmnipaque
Visipaue 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 *Excluding death, adverse reactions can
be classified in terms of severity as:be classified in terms of severity as:
• 1- 1- major reactionsmajor reactions : those that : those that interfere with the examination and interfere with the examination and require treatment.require 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 interfere with the examination and require only assurance require 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.