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

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• 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.