The solution should be warmed to body temperature before administration. The injection is made slowly without undue pressure, taking great care to avoid introducing bubbles.
Operative— If no resistance is encountered, from 10 mL to 15 mL (sometimes up to 25 mL) of a 30 to 60 percent solution is injected or instilled into the cystic duct or common bile duct, as indicated. In patients with obstructive jaundice, 40 mL to 50 mL of the medium may be injected indirectly into the gallbladder after aspiration of its contents.
Postexploratory or completion T tube cholangiography may also be performed after exploration of the common bile duct.
Postoperative— Delayed cholangiograms are usually made from the fifth to the tenth postoperative day prior to removal of the T tube.
Percutaneous transhepatic cholangiography is recommended for carefully selected patients for the differential diagnosis of jaundice due to extrahepatic biliary obstruction or parenchymal disease. The procedure is only employed where oral or intravenous cholangiography and other procedures have failed to provide the necessary information. In obstructive cases, percutaneous transhepatic cholangiography is used to determine the cause and site of the obstruction to help plan surgery. The technique may also be of value in avoiding laparotomy in poor risk jaundice patients since failure to enter a duct suggests hepatocellular disease. Careful attention to technique is essential for the success and safety of the procedure. The procedure is usually performed under local anesthesia following analgesic premedication (eg, 100 mg meperidine intramuscularly).
As the needle is advanced or withdrawn, a bile duct may be located by frequent aspiration for bile or mucus into a syringe filled with normal saline. As much bile as possible is aspirated. The usual dose of HYPAQUE meglumine 60 percent is 20 mL to 40 mL but the range can be from 10 mL to 60 mL depending on degree of biliary dilatation present. The injection may be repeated for exposures in different planes. If a duct is not readily located by aspiration, entry may be established by the injection of successive small doses of 1 mL or 2 mL of the medium under x-ray observation as the needle is withdrawn. If a duct is not located after three or four attempts, the procedure should be abandoned. Inability to enter a duct strongly suggests hepatocellular disease.
Splenoportography is usually performed under mild preoperative sedation and under local anesthesia.
Splenoportography should not be performed on any patient for whom splenectomy is contraindicated, since complications of the procedure at times make splenectomy necessary. Other contraindications include prolonged prothrombin time or other coagulation defects, significant thrombocytopenia, and any condition which may increase the possibility of rupture of the spleen.
Prior gastrointestinal x-ray examination should include particular attention to the lower esophageal area. A hematologic survey, including prothrombin time and platelet count, should be performed. To minimize risk of bleeding, manipulation during or after entry of the needle should be avoided. Caution is advised in patients whose spleen has recently become tender and palpable.
Following splenoportography, the patient should lie on his left side for several hours and should be closely observed for 24 hours for signs of internal bleeding.
Internal bleeding is the most common serious complication of splenoportography. Although leakage of up to 300 mL of blood is apparently not uncommon, sometimes blood transfusions and, rarely, splenectomy, may be required to control hemorrhage. Peritoneal extravasation may cause transient diaphragmatic irritation or mild to moderate transient pain which may sometimes be referred to the shoulder, the periumbilical region, or other areas. Because of the proximity of the pleural cavity, accidental pneumothorax has been known to occur. Inadvertent injection of the medium into other nearby structures is not likely to cause untoward consequences.
A preliminary small “pilot” dose is injected to confirm splenic entry, followed usually by rapid injection of 20 mL to 25 mL of HYPAQUE meglumine 60 percent. Rapid serial exposures are started with the injection of the dose and continued until contrast is observed in the entire portal system.
Arthrography may be helpful in the diagnosis of posttraumatic or degenerative joint diseases, synovial rupture, the visualization of communicating bursae or cysts, and in meniscography. However, the technique is of little value unless the arthrograms are interpreted by well-trained personnel.
Arthrography is contraindicated when there is infection in or near the joint.
See PRECAUTIONS—General. A strict, aseptic technique is required to avoid introducing infection.
See ADVERSE REACTIONS—General. Injection of HYPAQUE meglumine 60 percent into the joint usually causes immediate but transient discomfort. However, delayed, severe, or persistent pain may occur occasionally. Severe pain often results from undue use of pressure or the injection of large volumes. Joint swelling after injection is rare. Effusion, occasionally requiring aspiration, can occur in patients with rheumatoid arthritis.
The procedure is usually performed with analgesic premedication and under local anesthesia. The amount of HYPAQUE meglumine 60 percent injected depends solely on the capacity of the joint. The damaged joint may require doses greatly exceeding those for normal joints. As much fluid as possible should first be aspirated from the joint; then, the medium should be injected gently to avoid overdistention of the joint capsule. Passive manipulation is sometimes used to disperse the medium in the joint. Sometimes, a 1 mL or 2 mL test dose is injected; immediate pain may indicate extravasation or extracapsular injection which, if confirmed by x-ray, requires relocation of the needle.
A single injection is usually adequate for multiple exposures. Contrast is good during the first 10 minutes after injection, adequate at 10 to 15 minutes, and begins to fade at 15 to 25 minutes.
The following approximate volumes have been used in normal adult joints:
- Knee, shoulder, hip—5 mL to 15 mL
- Temporomandibular—0.5 mL
- Other—1 mL to 4 mL
“Double contrast arthrography,” using a mixture of the medium and air or a dilution of HYPAQUE meglumine 60 percent to a 30 percent concentration, has been employed.
Cervical discography is a more hazardous procedure than lumbar discography, and the interpretation of the cervical discograms is more difficult.
The injected medium gradually diffuses throughout the disc and is absorbed rapidly. In a normal disc, good contrast is evident for 10 to 15 minutes. In a ruptured disc, the medium is absorbed more rapidly. Aspiration of the medium on completion of discography is considered unnecessary.
Discography is contraindicated when there is infection or open injury near the region to be examined.
Inadvertent subarachnoid injection must be avoided since even the small dose of the medium used in discography might result in convulsions and death. The onset of signs of pain, cramps, or convulsions (requiring anesthesia) may occur within minutes to an hour.
A strict, aseptic technique is required to avoid introducing infection. The examination should be postponed if local or systemic infection is present. In cervical discography, care should be taken to avoid contamination of the disc by inadvertent puncture of the esophagus. Laceration of the disc by use of a needle that has become barbed by forceful impingement on a vertebra, should be avoided. The patient should be cautioned not to move during introduction of the needle.
In the normal disc, only minor discomfort will occur during injection. More discomfort will result if excessive pressure or volume is used. Pain is unusual and may indicate extravasation.
In the damaged disc, however, the injection can cause pain, sometimes severe, which mimics the symptoms. Transient backache or headache, as in lumbar puncture, often occurs. Extravasation from the disc into the lateral recesses and extradurally into the spinal canal or local soft tissue does not usually cause adverse effects.
During discography extreme care is advised to avoid inadvertent intrathecal injection since the injection of even small amounts of the contrast medium may cause convulsions, permanent sequelae, or fatality. Should the accident occur, the patient should be placed upright to confine the hyperbaric solution to a low level, anesthesia may be required to control convulsions, and if there is evidence of a large dose having been administered, a careful cerebrospinal fluid exchange-washout should be considered.
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