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

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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.