Radiology

During the course of a patient’s journey they are likely to undergoing several imaging tests, these are may include a CT scan or an MRI. These tests are reviewed and interpreted by a radiologist, a doctor who specialises in diagnosis through medical images. A CT scan may be the first test to show a lesion of the pancreas but it is also useful to detect metastases to the liver or local lymph nodes. An MRI may also be used to detect lesions. It is of special use with intravenous contrast, this can allow more accurate imaging of the biliary tree. Accurate imaging and interpretation, in conjunction with a tissue sample, is extremely important for the planning of treatment.

CT SCAN

Computed tomography is commonly called “CT”. It was once called a “CAT” scan, though advances in scanning technology have resulted in the A being removed from the acronym. CT is a way of using X-rays to take pictures or images in very fine slices through the part of the body that the doctor has asked to be investigated. One way to think of it is of taking slices through a loaf of bread.
When CT scanners were first invented, they took one slice at a time and were quite slow when compared to today’s machines. Most modern scanners now take more than one slice at a time. This may range from 4 to 320 slices and up to 640 slices for the most recent machines. This is referred to as “multi-slice” or “multi-detector” technology and may be abbreviated as MSCT or MDCT.
When you take slices from your loaf of bread, you are able to see much more detail about the structures that make up the loaf. It is likely that this is why your doctor has chosen this test. The slices that are taken by an MSCT scanner are often less than 1 millimetre thick.
Once the radiographer has taken the scan, these very thin slices can be put all together to reconstruct the loaf (or in this case your body). Once they are put back together the radiographer  can cut it into the slices that will help the radiologist  (a doctor who has specialised in diagnostic imaging) to see the parts of the body that are of interest. Each scan is created specifically for the part of the body of interest and the condition that needs investigation. This will often involve creating several sets of pictures taken in different directions and also some 3-Dimensional (3D) pictures.
With all of these different slices and 3D reconstructions, the radiologist (a specialist doctor) will have a very detailed picture of the structures making up your body. This should help them to make a diagnosis (in other words, to understand the cause of your current problems) so that the right treatment can be planned as soon as possible.

PREPARATION

Many types of CT require an injection of an iodinated contrast material (see Iodine-containing contrast medium (ICCM)) to show blood vessels and some organs. For these tests, most hospital departments or radiology practices will ask you to fast (not eat or drink) prior to your appointment. Fasting for 2-4 hours is common and it is usually permitted to drink water over this time to avoid dehydration (losing too much water from your body). It is important that the need to fast does not affect you if you have special dietary requirements (e.g. diabetes). Please check with your doctor or the hospital or radiology practice where you are having the CT if you have any concerns.
If you do require an iodinated contrast injection for your test, it is likely that you will be taken into an area where a radiologist , a radiographer  or a nurse will discuss iodine contrast with you. They will then use a needle to insert a cannula (a small plastic tube) into a vein in your arm or the back of your hand so that the iodine contrast can be inserted into the cannula during the test.
While the iodinated contrast used for injections is considered very safe, there are precautions that must be taken when using it, particularly if you have poor kidney function or diabetes.
Tests investigating your abdomen may require you to drink a different kind of iodinated contrast solution to outline your intestine (part of your digestive system). This will also require fasting. This drink is given in a different way depending where you are having the CT done. You will usually be asked to drink part of the whole dose an hour prior to the scanning time and the rest of it just before entering the scanning room.

THE SCAN

CT scans are designed to look at specific parts of the body and are tailored for each person, to investigate their particular condition. This means that all CT scans are slightly different.
The CT scan equipment is a large square machine with a circular hole or gantry, sometimes described as looking like a “donut”. The general process involves you lying on a bed attached to the scanner (this may be feet first or head first depending on the part of the body being looked at). The bed will then be raised up to a height level with the circular hole in the scanner and the bed slides in and out of the hole several times while pictures are being taken. It is important to try not to move during the scan as it will affect the quality of the pictures and make them harder for the radiologist  to interpret.
The radiographer  performing the scan may ask you to hold your breath for some scans. The length of time for each breath hold is usually under 10 seconds. Most scanners in use now are able to give instructions in different languages to help you understand what you need to do and what is happening. They will also often have ways of communicating with you if your hearing is poor.
The first few scans are usually done to set up the machine ready for the test. When the test is programmed into the computer by the radiographer and the scan is ready to go, they may remind you to keep still. If your test requires an iodinated contrast  injection, the radiographer will come into the room to administer it using either a hand held syringe or a mechanical pump. The pump helps to put the iodinated contrast in at a set rate and allows for the scanner to target specific areas of the body.
When the iodinated contrast is injected, most people will get a strange metallic taste in the mouth and feel a warm sensation through the body. This warm sensation may concentrate around the groin or buttock region and can feel like you may have wet yourself, even though you have not. Do not be concerned if this happens, it is a common sensation and usually goes away within a couple of minutes.
Once the radiographer has reviewed the images briefly to check that the appropriate areas have been shown, they will come into the room to help you off the bed. The radiographer will not be able to give you any results after the scan; this is the responsibility of your doctor and the radiologist who interprets the pictures from the scan and provides a report to your doctor.
Once out of the scanner room, it is likely that you will be shown to an area where someone will check with you to make sure that you are feeling OK after the scan. They will then remove the cannula so that you can go home.

AFTERWARDS

The vast majority of people who have a CT scan have no after effects at all. After the test, you should be able to eat and drink as normal and resume regular activities.
If you have an injection of iodinated contrast, the sensations of warmth and the strange taste usually experienced should go away within a few minutes. In very uncommon cases, some people may be allergic to the iodinated contrast given into the vein in your arm or the back of your hand.
It is not possible to predict if a person will be allergic to the iodinated contrast, though the staff at the hospital or radiology practice are well trained to deal with allergic reactions should they arise. It is important to make the radiographer  or nurse aware of any other allergies that you may have, prior to having the injection.
People who are allergic to the iodinated contrast used in CT may get some of the following symptoms :
  • nausea and/or vomiting;
  • a skin rash or hives;
  • itching;
  • sneezing and/or watering eyes;
  • dizziness and/or headache;
  • gagging or feeling of suffocation or swelling of the inside of the throat or mouth;
  • change in blood pressure.
If you do feel any of these symptoms after your scan, it is important to tell the radiographer or nurse immediately. If these feelings come on after leaving the hospital or radiology practice, you should return there immediately (if this is close by) or attend the nearest doctor or emergency department.

MRI SCAN

Magnetic resonance imaging (MRI) is a scanning procedure that uses strong magnets and radiofrequency pulses to generate signals from the body. These signals are detected by a radio antenna and processed by a computer to create images (or pictures) of the inside of your body.
The MRI scanner is generally shaped like a large, covered box with a tunnel passing through it. A table, on which you lie, slides into the tunnel. Both ends of the scanner are open and will not close. The tunnel has lights in it and sometimes a mirror. Some of the MRI scanners have wider tunnels or are partially open (more like a ‘C’, rather than an ‘O’).

PREPARATION

Safety in the MRI scanner is vital. The strong magnetic fields can attract and interfere with metal objects that you might have in or on you (including electronic and magnetic devices). Some of these interactions are serious enough to cause harm or death.
To ensure it is safe for you to have an MRI, you will be required to complete a safety questionnaire.  Sometimes a questionnaire is mailed to you that you will need to complete and take with you to the appointment. If a friend or relative will be in the scanning room with you, they will also need to complete a safety questionnaire.
If you have a pacemaker or other implants, it is important to tell the radiology practice before having the scan. An alternative test might need to be arranged.
Objects in your body that can cause particular harm or be damaged include: pacemakers, aneurysm clips, heart valve replacements, neurostimulators, cochlear implants, metal fragments in the eye, metal foreign bodies, magnetic dental implants and drug infusion pumps. Some of these implants, particularly more recent devices, might be safe to go into the MRI scanner, but have to be accurately identified for the scan to proceed.
You should take any documents about your implants to the appointment.  These can help to correctly identify the type of implant to assess if it is safe for you to have the MRI.
It is important that you do not wear any makeup or hairspray, as many of these products have tiny metal particles that could interfere with the scan and reduce the quality of the images. They might cause the area to heat up and, on the rare occasion, burn your skin.
You will not be able to take anything with you into the scan room, and there are usually lockers available. It is easier if you leave objects such as watches, jewellery, mobile phones, belts, safety pins, hairpins and credit cards at home.
If you are pregnant, please discuss this with your doctor and tell the radiology practice before having the scan.
If you are claustrophobic (a fear of small or enclosed spaces) and think you might not be able to proceed with the scan, advise your doctor or the MRI facility when making your appointment. Sedative (calming) medication can be given. If this happens, you will not be able to leave the facility until you are fully awake and someone else will need to drive you home.
Some MRI facilities have stereos or CD and DVD players attached to the MRI scanner. You can take CDs or DVDs to listen to or watch while you are having the scan.
Fasting (going without food) for a MRI procedure might be required in some cases. When you make your MRI appointment, you will be advised of any fasting requirements.
Continue to take all your normal medications, unless you are otherwise advised when you make the booking for your MRI scan.
Please bring any previous X-ray, computed tomography or ultrasound films. The radiologist might like to review the older studies or see if your condition has changed since your last scan.

THE SCAN

The MRI procedure will be thoroughly explained to you, and your safety questionnaire reviewed and discussed before you enter the scan room. If you have any questions, please ask the radiographer, who will be operating the MRI scanner, as it is important that you are comfortable and know what will be happening. The radiographer will be able to see you from the control room throughout the scan.
You will usually be asked to change into a gown. This increases safety, with items in your pockets not being accidentally taken into the scan room.
You will be asked to lie on the scan table and given a buzzer to hold. When you squeeze it, an alarm sounds in the control room and you will be able to talk to the radiographer.
The MRI scanner is very noisy during the scans. It is at a noise level that can damage your hearing. You will be given earplugs or headphones to reduce the noise to safe levels.
Depending on the type of MRI you are having and your particular situation, at this point you might have:
  • leads placed on your chest to monitor your heartbeat if having a heart scan;
  • a small plastic tube (pulsoximeter) taped on your finger to check your breathing and heart rate if having sedative (calming) medication; and/or
  • a needle inserted into a vein in your arm if any medication is required during the scan.
If you are claustrophobic and find you are unable to proceed with the scan, a sedative can be injected. The radiology facility has special procedures for people with claustrophobia and will advise you of what to do if this applies to you.
The most common medication injected is a contrast agent or ‘dye’ called gadolinium contrast medium. This highlights the part of the body being scanned, which can give more information to the radiologist who is assessing your problem.
Other medication might be injected; for example, to slow down your intestinal movement if having an MRI of the rectum.
The part of your body to be scanned will be carefully positioned and gently secured, so you are comfortable and more likely to remain still. This part will then have special antennae (coils) positioned around it to pick up signals from your body for the computer to create images. The coils are usually encased in a plastic pad or frame. Depending on the part of the body being scanned, they might be wrapped around your shoulder or lie on top of your stomach. A frame containing the coils can be used; for example, around your knee or wrist, and also for your head and upper neck. Some coils are in the mattress of the scan bed, used when your back is being scanned.
The scan table will then move into the centre of the machine. Your head might be inside or outside the scanner, depending on the part of the body being scanned.
When the scan begins, you will hear a knocking noise that continues during each scan. Scanning is not continuous, and each scan varies in length from about 1 to several minutes, with a break in between. You will be able to talk to the radiographer between each scan and can press the buzzer if you are not comfortable or want to come out of the machine at any time.
The scanning process is painless. You might feel warm during scanning. If you do feel anything at all, it is important you tell the radiographer carrying out the scan.
You need to lie still and hold your position during the scan. In general, you can breathe normally. Occasionally, during some types of MRI, you will need to hold your breath. Breathing and movement can make the images blurry and assessment of your problem more difficult.

BILIARY DRAINAGE

Biliary drainage is the insertion of a tube into the bile duct. This is most commonly carried out when the bile ducts are blocked.
The bile ducts normally allow bile (a green-brown fluid that is produced by the liver to help with the digestion of fats) to drain from the liver to the small intestine .
When the bile ducts are blocked, bile cannot leave the body and builds up. This build-up produces a yellow colour in the skin called jaundice and can also cause itching and dark urine.
Blockage of the bile ducts can occur for a number of reasons, including gallstones impacted in the ducts, narrowings in the bile ducts after previous surgery and involvement of cancer in the ducts.
The drainage tube is placed through the skin into one of the bile ducts in the liver to allow bile out. Another common name for this procedure is a percutaneous transhepatic cholangiogram (PTC).

PREPARATION

Do not eat or drink for 4 hours before the procedure. This is because the procedure is carried out under sedation or general anaesthetic – if your stomach is full, stomach contents can inadvertently pass into your lungs, which can be harmful. This can happen any time you have sedative medication or anaesthesia, not just with biliary drainage, and is the reason you are asked not to eat or drink.
If you are diabetic, you are advised to check with the radiology practice before fasting.
You may need to stop medications that thin your blood, as these will increase your risk of bleeding. Examples include warfarin (often sold as Coumadin or Jantoven), clopidogrel (often sold as PIavix), asasantin, heparin and enoxaparin sodium (often sold as Clexane). If you think that you may be taking any of these medications, please discuss this with the radiology practice before the procedure.
Bring all of your usual medication(s) (or a complete list) with you.
It is also recommended that you bring any recent X-rays or scans with you if you have copies at home.
A relative or friend must be available to drive you home after the procedure, as you will not be allowed to drive after sedation or anaesthesia. It is also recommended that the relative or friend stay with you the night after the procedure in order to provide assistance.

THE PROCEDURE

This procedure is usually carried out with the assistance of either sedation (medication to relax you) or a general anaesthetic. Intravenous antibiotics are also routinely given before the procedure.
The skin of your abdomen is washed with antiseptic and then a very fine needle is inserted through the skin to administer local anaesthetic. This may sting for a few seconds before numbing the area.
A small cut is made in the skin and a thin needle is passed through the skin into the liver and then into a bile duct inside the liver. Contrast medium (also known as contrast agent of ‘dye’) is injected into the bile duct, which allows it to be seen on X-ray pictures. X-ray pictures or images are taken to see the path of the bile ducts.
A thin wire is passed through the centre of the needle so that it lies in the bile duct. A thin drain tube is then inserted over the top of the wire and into the bile duct.
One end of the drain tube will remain in the bile duct and the other end sits outside the skin where it is attached to a bag into which the bile drains. It is therefore normal for this bag to fill up with green-brown bile.
Inserting the drain usually takes 60–90 minutes. After the procedure, you will need to be monitored for at least 4–6 hours, and many patients are booked to stay in hospital overnight. If you are going home, you will require someone to drive you and stay with you overnight. It is advisable to discuss this with your doctor before the procedure.

SIRT/TACE THERAPY

Selective Internal Radiation Therapy (SIRT) is a treatment for liver cancers or tumours that delivers millions of tiny radioactive microspheres or beads called SIR-Spheres® directly to the liver tumours.
SIR-Spheres® are about one third the diameter of a strand of hair in size and they release a type of radiation energy called ‘Beta’ radiation. Beta radiation is a common type of radiation used in other nuclear medicine therapy and diagnostic procedures.
SIR-Spheres® are approved for the treatment of liver tumours that cannot be removed by surgery. These may be tumours that start in the liver (also known as primary liver cancer), or they may be tumours that have spread to the liver from another part of the body (also known as secondary liver cancer or metastases).
To perform SIRT, a small puncture or incision is made in the groin and a small thin tube called a catheter is placed in the artery and guided into the liver using X-ray pictures or images. SIR-Spheres® are delivered through the catheter and are then carried by the bloodstream directly to the tumours in the liver where they only lodge in the small vessels feeding the tumour.
The majority of SIR-Spheres® are lodged in the outside edge of the tumour/s and the radiation has a direct destructive effect on the tumour itself and the vessels feeding the tumour. Destroying the vessels feeding the tumour means that the tumour/s can no longer be supplied with the nutrients in the bloodstream. Most patients after SIRT will see a reduction or stabilisation of their liver tumours.
For most patients, treatment will result in increased survival time, but not a permanent cure.

PREPARATION

Your treatment team will want to know about your previous cancer history and any other medical conditions you may have. They will then conduct a number of initial tests to ensure that it is possible for you to receive SIRT safely. You will normally have two procedures where you will be conscious (awake) but you may have some sedation to make you drowsy so that you feel comfortable.

The treatment requires an overnight stay in hospital. Your treating doctor will advise what arrangements need to be made for hospital admission. You may need to check with the hospital what you need to bring with you for admission.

THE PROCEDURE

SIRT normally comprises two procedures – preparation and implanting.

Preparation or “work-up”
The first procedure for SIRT is the preparation phase for the treatment commonly known as the work-up that includes a radiology procedure known as an angiogram. The purpose of the angiogram or mapping is to prepare your liver for SIRT.

In preparation for the angiogram you will have blood tests to evaluate your kidney function and blood clotting. During the mapping procedure your interventional radiologist (a specialist doctor) may block (embolise) some of the liver blood vessels communicating with other blood vessels to minimise the potential for the SIR-Spheres® to travel to areas outside your liver (e.g. the stomach or intestine).

You will also receive a small amount of radioactive spheres (MAA) similar in size to SIR-Spheres® to check the amount of blood that flows from the liver to the lungs. This is also a trial run to see how the SIR-Spheres® will behave when injected into your body.

During the angiogram a small amount of dye (or contrast medium) is injected through a catheter (a thin plastic tube) inserted into an artery. The dye travels down the catheter into the liver and highlights the vessels. Images or pictures are taken throughout the procedure.

The interventional radiologist now has a map of your liver vessels to follow so that the catheter can be advanced closer to the site of the tumours in the liver. Most patients say they feel a little warm when the dye is injected. Throughout the whole procedure you should try to stay as still as possible to avoid moving or dislodging the catheter in place.

This work-up angiogram is done in a conscious state (awake) and a local anaesthetic is given so that the discomfort from the procedure is minimal around the puncture wound.

The work-up procedure for SIRT is normally done on an outpatient basis. You will be observed after the work-up procedure and may then return home. While you are being observed your doctor will review the X-ray images to determine your suitability for SIRT and to see if you are suitable to proceed with the SIR-Spheres® implant.

Implant of SIR-Spheres®
You will need to return to the hospital within 7-10 days of the work-up when a second angiogram is performed to implant the SIR-Spheres® (SIRT). It is identical to the work-up angiogram except that SIR-Spheres® are inserted.

For the procedure, you are admitted to hospital and then taken on a bed to the angiography suite.

Once inside the angiography suite an interventional radiologist (a specialist doctor) will perform the second angiogram. You do need to fast before the angiogram. The purpose of the angiogram this time is to implant the SIR-Spheres®. The catheter used during the angiogram is then guided by the interventional radiologist through the artery and placed close to the tumours in the liver.

While the implantation angiogram is taking place, the nuclear medicine department prepares an individually prescribed dose of radiation for you (SIR-Spheres®). The prescribed dose of SIR-Spheres® is put into a specialised perspex box which is transported from the nuclear medicine department to the angiography suite where your catheter is being inserted.

The perspex box is then brought to the side of the bed and the catheter inserted into your artery is connected to the perspex box. Once connected the system is then ready for the infusion of SIR-Spheres®.

SIR-Spheres® are then infused from the perspex box through the catheter into your liver. During this infusion the radiologist may also insert contrast medium into the catheter to ensure that the catheter has not moved during the procedure. This whole procedure may take about 60 minutes. Once the infusion is complete, the catheter is then removed from the liver and the box used to deliver the SIR-Spheres® microspheres is then taken back to the nuclear medicine department.

Once the catheter has been removed, the interventional radiologist will compress the puncture wound where the catheter was inserted for around 10 minutes. This compression is done to stop excess bleeding at the site of the puncture. You then stay near the angiography suite for about 3 hours for observation to ensure there are no problems following the procedure. After observation you are taken to a general ward for an overnight stay.

In rare circumstances, on the advice of the treating doctor, you may be required to stay more than one night in hospital. Most patients are discharged the day following the procedure.

You may experience pain and nausea during the implantation process. The interventional radiologist and the angiography team will make sure that you receive the necessary medications to make you comfortable.

SIRT is usually done as a single treatment but some patients may be re-treated with SIRT. Re-treatment may occur in rare circumstances and may be indicated where new tumours grow in the liver despite SIRT, or previously treated tumours start to enlarge.

PORTAL VEIN STENTING

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PREPARATION

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THE PROCEDURE

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