Patients who are allergic to or sensitive to medications, contrast media, iodine, or latex should notify their doctor. Also, patients with kidney failure or other kidney problems should notify their doctor.
Certain factors or conditions may interfere with the accuracy of a fluoroscopy procedure. A recent barium X-ray procedure may interfere with exposure of the abdominal or lower back area. There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure. Medically appropriate fluoroscopy examinations provide clinical benefits that outweigh the risk from the radiation received during the examination.
When used by highly trained, board certified radiologists and radiologic technologists, fluoroscopic examinations provide substantial diagnostic benefit to patients and is instrumental in guiding treatment plans.
Patients and parents of pediatric patients should talk with their personal physician and their radiologist about the examination. All fluoroscopy machines are regulared by the Food and Drug Administration FDA and must meet specific criteria to be considered safe and effective.
Johns Hopkins radiology equipment meets all federal and state requirements. Other options will be discussed with you and your doctor. A gown will be provided for you. Lockers are provided to secure your personal belongings. Please remove all piercings and leave all jewelry and valuables at home. Barium enema. Barium swallow. Lumbar puncture. Interventional radiology procedures. Interventional neuroradiology procedures.
Upper gastrointestinal series. Small bowel series. Fluoroscopy may be performed on an outpatient basis or as part of your stay in a hospital. This procedure is commonly used in the management of common bile duct stones, malignant obstructive jaundice, and post-operative bile leaks.
A diagnostic ERCP uses a side-viewing duodenoscope to cannulate the common bile duct with a guidewire under fluoroscopic guidance, followed by passage of a catheter through which contrast is injected to complete the cholangiogram Figure 1. From there, numerous therapeutic interventions can be performed, including biliary and pancreatic stent placement, biopsy brushings, and balloon sweeps on the bile duct to remove stones and debris.
Fluoroscopy has afforded this great asset in management of these biliary-pancreatic conditions. A growing indication for fluoroscopy in endoscopy is the placement of enteral stents. These include esophageal, gastric, duodenal, and colonic stents used in the setting of advanced malignancies for palliative restoration of luminal patency. Off-label use is expanding rapidly to address benign conditions including strictures and leaks. Although, ongoing investigation is needed to evaluate relative efficacy compared to standard surgical interventions.
Fluoroscopy guides placement of these stents, monitoring for intra-operative and post-operative complications i. Off-label, but common usages for self-expandable stents include benign esophageal disorders such as tracheoesophageal fistulas, benign esophageal strictures, esophageal perforations, and leaks. Although esophageal stents may be safely placed with only endoscopic guidance, fluoroscopy is a reliable method for placing stents across strictures that are not amenable to dilation or scope passage 3 , 4.
Esophageal stents are placed using thick, semi-rigid delivery systems and utilize a guidewire for safe placement. An endoscope can be used alongside the stent for direct visualization, to accurately assess the length of the obstruction, and to mark the proximal and distal extent. Endoscopic placement of clips, radiocontrast injection in the submucosa, and extracorporeal marking are all methods that assist in accurate placement of the stent while avoiding the upper and lower esophageal sphincters 5.
Self-expanding plastic stents include barium markings in both ends and the middle for ease of fluoroscopic placement, and are being used for benign conditions 6. Gastric outlet obstruction due to unresectable malignancy i. Although randomized control trial data presents mixed results, current data from non-randomized trials comparing open surgical gastrojejunostomy to endoscopic placement self-expanding metallic stents favors stenting due to shorter time to tolerating an oral intake, similar rate of complications, lower mortality and a shorter hospital stay 7.
Fluoroscopy is crucial for accurate characterization of the stricture and stent placement as the obstruction is often too advanced to allow passage of an endoscope. Furthermore, fluoroscopy can identify the presence of multiple duodenal strictures, which can be common in peritoneal carcinomatosis and a relative contraindication to stenting. The stent is deployed using guidewire and through-the-scope technology when possible 5.
Malignant large bowel obstruction is the most common indication for placement of a colonic stent, and occasionally benign conditions such as diverticular stricture warrant stenting. Fluoroscopy easily demonstrates the dilated colon proximal to the obstruction and monitors for perforation, which is high risk because the colon is often very distended and friable 2. Endoscopic stenting under fluoroscopic guidance for acute colonic obstruction may serve as a bridge to a single-stage partial colectomy, potentially sparing patients a two-stage procedure and stoma 8.
Without the use of fluoroscopic guidance, particularly when a lesion cannot be traversed with the scope and requires distal injection of contrast via a catheter to confirm luminal placement of the guidewire, this expanding array of clinical applications of stents would not be possible. Another endoscopic option for management of benign strictures is balloon dilation, which is often accompanied by fluoroscopic guidance.
Similar to the principles described above for stent placement, if a stricture is unable to be traversed by the scope Figure 2A , contrast can be injected distally via a catheter over a guidewire to confirm intraluminal location of the guidewire Figure 2B. Balloon dilation can then be performed over the guidewire, with contrast inside the balloon to further confirm adequate location of the balloon Figure 2C.
As the balloon is inflated, in addition to monitoring the pressurization of the balloon, the endoscopist can fluoroscopically watch the waste eliminate from the balloon. This is another tool for assuring adequate dilation made possible by fluoroscopy. In addition to ERCP, stents and balloon dilation, fluoroscopy is also being used in the management of chronic fistulae of the gastrointestinal tract.
This has evolved with advancements in endoscopic techniques including the use of over the scope clips, through-the-scope clips, suturing, stenting, etc. Fluoroscopy is used to identify the fistula tract, and can detect the presence of multiple fistula tracts, as these tracts can be challenging to visualize with endoscopy alone.
Once a suspected orifice is identified Figure 3A , a catheter is used to inject contrast through the orifice to confirm correct location for clip application Figure 3B.
Following deployment of the over the scope clip Figure 3C , fluoroscopy is again used endoscopically to confirm complete closure. As endoscopists increasing gain comfort in the use of fluoroscopy, it is exciting to see how its application will continue to evolve and how these techniques will transform patient care. While the indications for fluoroscopy during endoscopic procedures continue to expand, formal training in radiation exposure and protection is still not widely emphasized during advanced endoscopy training However, to improve this risk-to-benefit ratio, especially since only the patient receives the benefit while both the patient and staff assume exposure risk, it is imperative that the operator understands principles behind radiation and how to minimize exposure.
Radiation exposure can result in two major categories of adverse effects: skin injury, and malignancy. These adverse effects are due to the ionizing nature of X-ray radiation, which involves loss of electrons from molecular structures resulting in free radicals.
These free radicals can damage DNA. Schechter GL. Systemic causes of dysphagia in adults. Modified barium swallow: Clinical and radiographic correlation and relation to feeding recommendations. Dysphagia ; The use and misuse of upper gastrointestinal endoscopy.
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Aviv JE. Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. Laryngoscope ; Evaluation of swallowing safety with fiberoptic endoscope: Comparison with videofluoroscopic technique. The yield and the predictors of esophageal pathology when upper endoscopy is used for the initial evaluation of dysphagia. Gastrointest Endosc ;
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