PART 1 — MYELOGRAM

Short Question 1 — What is a myelogram? [5 marks]

Answer

A myelogram is a radiographic examination of the spinal canal in which a contrast medium is combined with fluoroscopy to evaluate abnormalities of the spinal cord and nerve roots.

1. It is a radiographic examination.
2. Contrast medium is introduced into the subarachnoid space.
3. Fluoroscopy is used during the procedure.
4. It evaluates the spinal cord and nerve-root branches.
5. The examination usually takes approximately 30–60 minutes.

Short Question 2 — What are the types of contrast media used in myelography? [5 marks]

Answer

1. Oil-based contrast media
2. Water-soluble contrast media
3. Air contrast

The slides state that currently non-ionic, water-soluble, iodine-based contrast media are used.

The usual quantity is approximately 6–17 mL, depending on the concentration and manufacturer’s recommendation.

Short Question 3 — Where is contrast injected in myelography? [5 marks]

Answer

Contrast is injected into the subarachnoid space.

Two approaches mentioned in the slides are:

1. Lumbar puncture
   • Usually at L3–L4.
2. Cervical puncture
   • Usually at C1–C2.

The radiologist uses fluoroscopy to select the appropriate puncture site. The skin is cleaned and locally anesthetized before needle insertion.

Short Question 4 — What are the indications of myelography? [5 marks]

1. Spinal cord tumors
2. Cysts
3. Spinal nerve-root injury
4. Compression of spinal cord
5. Compression due to a herniated disc

Short Question 5 — What are the contraindications of myelography? [5 marks]

1. Blood in CSF
2. Increased intracranial pressure
3. Decreased platelet count
4. Patients receiving anticoagulation
5. Arachnoiditis

Short Question 6 — What are the risks of myelography? [5 marks]

1. Radiation exposure
2. Allergic reaction to contrast medium
3. Slight risk of infection from needle insertion
4. Headache
5. Headache may occur due to leakage of a small amount of CSF from the needle insertion site.

LONG QUESTION 1 — Describe myelography in detail. [15 marks]

Definition

Myelography is a radiographic study combining contrast medium and fluoroscopy to evaluate abnormalities of the spinal cord and nerve roots.

Contrast Medium

Types include:

• Oil-based
• Water-soluble
• Air contrast

Currently, non-ionic water-soluble iodine-based contrast is commonly used.

Dose: approximately 6–17 mL, depending on concentration and manufacturer recommendation.

Site of Injection

Lumbar approach

• Puncture at L3–L4
• Contrast is introduced into the subarachnoid space.

Cervical approach

• Puncture at C1–C2

Patient Position

Lumbar puncture

• Prone position
• Left lateral position with spine flexed to widen interspinous space

Cervical puncture

• Erect position
• Prone position with head flexed to open interspinous space

Imaging Technique

1. Contrast is injected.
2. The table is slowly tilted.
3. Tilting allows contrast to reach different levels of the spinal canal.
4. Footrests and shoulder supports prevent the patient from sliding.
5. Fluoroscopy is used.
6. Spot films are taken in different positions.
7. Table tilt is adjusted to concentrate contrast at the area of interest.
8. Conventional radiographs are obtained as requested.

Patient Preparation

1. Remove metal objects/clothing that may interfere with X-ray.
2. Sedative/muscle relaxant may be given approximately one hour before.
3. Solid food is avoided for several hours.
4. Increased fluid intake is advised on the day before examination.

Conventional Radiographic Positions

Cervical myelography

• Horizontal-beam lateral
• Swimmer’s lateral/horizontal-beam view

Thoracic myelography

• Right and left lateral decubitus
• Lateral vertical-beam view

Lumbar myelography

• Patient prone
• Arms flexed above head
• Table tilted
• Contrast concentrated at area of interest
• Central point around L3
• Horizontal-beam exposure
• Suspended respiration

Indications

• Spinal cord tumors
• Cysts
• Nerve-root injury
• Spinal cord compression
• Herniated disc

Contraindications

• Blood in CSF
• Increased intracranial pressure
• Low platelet count
• Anticoagulation
• Arachnoiditis

Benefits

• Obstruction and abnormalities can be well demonstrated.
• Can assist in accurate diagnosis.
• Relatively safe.
• Relatively painless.
• Diagnostic X-ray exposure generally has no immediate side effects.

Risks

• Radiation exposure
• Contrast allergy
• Infection
• Headache due to CSF leakage

Limitations

1. Mainly demonstrates the spinal canal and proximal nerve roots.
2. Abnormalities outside these areas may be better demonstrated by MRI.
3. Contrast injection can be difficult with structural spinal defects or certain injuries.
4. Usually avoided during pregnancy.

Important: The slides state that myelography has largely been replaced by MRI and CT.

PART 2 — GIT CONTRAST STUDIES

Short Question 7 — What are contrast media used for in GIT imaging? [5 marks]

Contrast media are used to:

1. Visualize the GI lumen
2. Demonstrate the mucosa
3. Evaluate motility
4. Increase radiographic contrast
5. Demonstrate abnormalities of the gastrointestinal tract

Short Question 8 — What is positive contrast media? [5 marks]

Positive contrast media appear white/radiopaque on X-ray/CT.

Main example:

Barium sulfate (BaSO₄)

Properties:

• Inert
• Insoluble
• High atomic number
• Excellent radiopacity
• Good mucosal coating

Uses include:

• Esophagography
• Barium meal
• Barium follow-through
• Barium enema

Short Question 9 — What are the contraindications of barium? [5 marks]

Barium is contraindicated/avoided when there is suspicion of:

1. Gastrointestinal perforation
2. Fistula
3. Obstruction

The major concern is leakage and the risk of peritonitis.

Short Question 10 — What are water-soluble iodinated contrast agents? [5 marks]

Examples:

• Gastrografin
• Iohexol

Indications

1. Suspected perforation
2. Postoperative leak
3. When barium is contraindicated

Disadvantage

They may be hyperosmolar, potentially causing dehydration and pulmonary complications if aspirated.

Short Question 11 — What is negative contrast media? [5 marks]

Negative contrast media appear black/radiolucent on X-ray/CT.

Examples:

• Air
• CO₂

They are commonly used with barium in double-contrast examinations to improve mucosal visualization.

LONG QUESTION 2 — Compare barium and iodinated contrast media in GIT studies. [15 marks]

Barium sulfate

• Most common positive contrast for routine GI studies.
• Inert and insoluble.
• Excellent coating.
• High contrast.
• Relatively cheap.

Iodinated contrast

Examples:

• Gastrografin
• Iohexol

Used in:

• Suspected perforation
• Postoperative leak
• Situations where barium is contraindicated

Aspiration

According to the slides:

• Aspirated barium can cause severe pneumonitis.
• Iodinated contrast can cause pulmonary edema or chemical pneumonitis.

Negative Contrast

Air/CO₂ appears black and can be combined with barium.

Double Contrast

Combination of:

Positive contrast + negative contrast

Advantages:

1. Better mucosal visualization
2. Detects small lesions
3. Helps demonstrate early cancers
4. Demonstrates ulcers
5. Demonstrates polyps

PART 3 — SINOGRAM / FISTULOGRAM

This is a very important long-question topic.

Short Question 12 — Define fistula. [5 marks]

A fistula is an abnormal pathway between two anatomical spaces.

It may connect:

• Two hollow organs
• A hollow organ and the exterior
• Two blood vessels

Short Question 13 — Classify fistulas according to location. [5 marks]

1. Internal fistula

Connection between the lumen of one viscus and another.

Examples:

• Vesicovaginal
• Enterorectal
• Rectovaginal

2. External fistula

Connection between a hollow viscus and the exterior.

Example:

• Enterocutaneous fistula

3. Vascular fistula

Connection between two vessels.

Example:

• Arteriovenous fistula

Short Question 14 — Classify fistulas according to openings. [5 marks]

1. Blind fistula

Has only one open end and may be a sinus tract.

2. Complete fistula

Has both external and internal openings.

3. Incomplete fistula

Has an external skin opening but does not connect to an internal organ.

Short Question 15 — Name common fistulas. [5 marks]

1. Perilymph fistula
2. Vesicovaginal fistula
3. Rectovaginal fistula
4. Anorectal fistula
5. Enterorectal fistula
6. Enterocutaneous fistula
7. Rectovesical fistula

Short Question 16 — What are the causes of fistula? [5 marks]

1. Congenital
2. Traumatic
3. Inflammatory
4. Post-medical treatment
5. Malignancy
6. Disease
7. Iatrogenic

Short Question 17 — What is a sinus? [5 marks]

A sinus is a blind tract that originates or ends at an epithelial surface.

Examples from the slides:

• Pilonidal sinus
• Actinomycosis sinus
• Median mental sinus

Short Question 18 — What is a sinogram/fistulogram? [5 marks]

A sinogram/fistulogram is a special X-ray examination used to visualize an abnormal passage such as a sinus or fistula after injection of contrast medium into its opening.

It may be performed:

• Under fluoroscopic control
• With full-size plain radiographs

It is usually painless and takes approximately 30 minutes.

Short Question 19 — What are the indications of sinogram/fistulogram? [5 marks]

1. Development/presence of a sinus
2. Development/presence of a fistula
3. Determine route of sinus/fistula
4. Determine its extent
5. Determine which organs are involved

Short Question 20 — What are contraindications of sinogram/fistulogram? [5 marks]

1. Severe pyrexia/fever
2. Severe localized infection

LONG QUESTION 3 — Describe sinogram/fistulogram in detail. [15 marks]

Definition

A sinogram/fistulogram is a special X-ray procedure in which contrast is introduced into a sinus or fistula to demonstrate its route, extent and connections.

Indications

• Presence of sinus/fistula
• Determine route
• Determine extent
• Determine involved organs

Contraindications

• Severe fever/pyrexia
• Severe localized infection

Equipment

1. High-power X-ray generator
2. X-ray tube
3. Floating/tilting X-ray table
4. Fluoroscopic unit with II-TV system
5. Resuscitative equipment

Accessories and Drugs

• IV cannula: 18G, 20G, 22G
• Sterile towels
• Gauze
• Cotton swabs
• Scissors
• Gloves
• Skin antiseptic
• Povidone iodine/spirit/Savlon
• Lignocaine
• Low-osmolar contrast medium
• LOCM approximately 150–280 mgI/mL
• Disposable syringes

Patient Preparation

1. No dietary restriction.
2. Check medical history.
3. Check allergies.
4. Serology may be checked.
5. Explain procedure.
6. Obtain consent.
7. Remove metallic objects.
8. Change into hospital gown.

Technique

Step 1 — Preliminary film

Take a preliminary X-ray to exclude a radiopaque foreign body.

Step 2 — Position

Patient lies supine on fluoroscopic table.

The sinus/fistula opening should be uppermost.

Step 3 — Preparation

Clean surrounding skin with antiseptic and place sterile towels.

Step 4 — Check discharge

If pus or mucus is being discharged, the slides state that contrast should only be injected appropriately; otherwise the procedure may be avoided.

Step 5 — Cannula/drainage tube

If a drainage tube is already present, contrast can be introduced through it.

Otherwise:

• Insert an appropriate cannula into the opening.
• Place gauze around the entry site to reduce reflux.

Step 6 — Contrast injection

Inject sufficient water-soluble contrast under fluoroscopic control.

Step 7 — Spot films

Spot films are obtained according to departmental protocol and patient condition.

Filming

Two images are generally taken at right angles:

1. AP or PA
2. Lateral

An erect horizontal-beam view may also be obtained.

After Procedure

If the fistula/sinus is inside:

• Rectum/back passage
• Vagina

the patient may be instructed to pass residual contrast.

If external:

• Clean the wound
• Dress the wound

Complications

Common

• Perforation of sinus/fistula opening
• Minor pain
• Bruising
• Infection at tube insertion site

Less common

• Contrast reaction
• Rash
• Hives
• Itching
• Nausea
• Fainting
• Shortness of breath

IMPORTANT SINUS/FISTULA EXAMPLES

Congenital

• Branchial fistula
• Tracheoesophageal fistula
• Congenital AV fistula
• Thyroglossal fistula

Traumatic

• Head trauma → perilymph fistula
• Trauma → AV fistula
• Obstructed labor → vesicovaginal/rectovaginal fistula

Post-medical treatment

• Gallbladder surgery → biliary fistula
• Radiation → vesicovaginal fistula

Disease

Crohn disease/IBD can produce:

• Anorectal fistula
• Enteroenteral fistula
• Enterocutaneous fistula

Malignancy

Carcinoma may invade an adjacent organ.

Example:

• Rectovesical fistula in rectal carcinoma

Iatrogenic

• Cimino AV fistula → hemodialysis
• ECK fistula → treatment of esophageal varices/portal hypertension

Special point

For tracheoesophageal fistula, the slides emphasize using thin barium, because ionic contrast aspirated into the trachea can cause chemotoxicity/chemical pneumonitis.

PART 4 — CATHETERIZATION

Short Question 21 — Define urinary catheterization. [5 marks]

Urinary catheterization is a procedure in which a catheter is inserted through the urethra into the urinary bladder using aseptic technique.

It is used to:

1. Empty the bladder
2. Allow urine drainage
3. Collect urine
4. Obtain a sterile specimen
5. Sometimes introduce liquids for diagnosis/treatment

Short Question 22 — What are the types of catheterization? [5 marks]

1. Intermittent catheterization
2. Indwelling catheterization

Short Question 23 — Name the types of urinary catheters. [5 marks]

1. Simple rubber catheter
2. Simple plastic catheter
3. Self-retaining catheter
4. Condom catheter
5. Foley catheter
   • Two-way
   • Three-way

Short Question 24 — Explain the three lumens of a three-way Foley catheter. [5 marks]

A three-way Foley catheter has:

1. One lumen for fluid/medicine instillation and bladder irrigation
2. One lumen for urine drainage
3. One lumen for sterile fluid used to inflate the balloon

Short Question 25 — What is a condom catheter? [5 marks]

A condom catheter is used mainly for a male patient with urinary incontinence.

Advantages:

• Less traumatic during insertion
• Applied externally
• Available in different diameters/sizes

Short Question 26 — What are the French gauge sizes used in catheterization? [5 marks]

According to the slides:

• Children: 8–10 FG
• Women: 14–16 FG
• Men: 16–18 FG

Short Question 27 — What are the indications of urinary catheterization? [5 marks]

Any five:

1. Retention of urine
2. Urinary incontinence
3. Obtaining sterile specimen
4. Assessing residual urine
5. Surgery
6. Childbirth
7. Bladder irrigation
8. Perineal surgery
9. Urinary obstruction
10. Oliguria/polyuria
11. Unconscious patient
12. Terminally ill patient

LONG QUESTION 4 — Describe urinary catheterization in detail. [15 marks]

Definition

Urinary catheterization involves insertion of a catheter through the urethra into the bladder using aseptic technique to empty or drain the bladder.

Types

• Intermittent
• Indwelling

Types of Catheters

• Rubber
• Plastic
• Self-retaining
• Condom
• Foley
  • Two-way
  • Three-way

Three-way Foley

1. Irrigation/medication
2. Urine drainage
3. Balloon inflation

Catheter Size

• Children: 8–10 FG
• Women: 14–16 FG
• Men: 16–18 FG

Indications

• Retention
• Incontinence
• Sterile specimen
• Residual urine
• Surgery
• Childbirth
• Bladder irrigation
• Perineal surgery
• Obstruction
• Oliguria/polyuria
• Unconscious patient
• Terminal patient

Articles

Sterile tray

• Sterile gloves
• Sterile catheter
• Antiseptic
• Sponge-holding forceps
• Sterile specimen bottle
• Cotton swabs/gauze
• Kidney tray

Clean tray

• Lubricating jelly
• Operation towel/drape
• Disposable gloves
• Kidney tray
• Adhesive tape
• Scissors
• 10-mL syringe
• Sterile water
• Needle
• Urine measuring container
• Mackintosh/draw sheet

Procedure

1. Introduce yourself.
2. Confirm patient identity verbally.
3. Check patient file.
4. Explain procedure.
5. Provide privacy.
6. Raise bed to appropriate level.
7. Position patient.
8. Place mackintosh/draw sheet.
9. Place sterile kidney tray.
10. Wash hands.
11. Apply sterile drape.
12. Wear sterile gloves.
13. Clean perineum with antiseptic.
14. Open catheter package.
15. Apply xylocaine jelly to catheter tip.

Position

Female

Dorsal recumbent, knees flexed and thighs abducted.

Male

Supine, thighs slightly abducted.

Female Insertion

• Insert approximately 5–6 cm.
• When urine starts flowing, insert another 3–5 cm.
• Inflate balloon with 10 mL sterile water.

Male Insertion

• Insert until urine begins to flow.
• Advance another approximately 5 cm/almost to bifurcation.
• Inflate balloon with 10 mL sterile water.

Aftercare

1. Measure urine.
2. Assess patient comfort.
3. Assess genital area.
4. Remove/dispose PPE and articles.
5. Remove drapes.
6. Help patient dress.
7. Give comfortable position.
8. Document and report.

PART 5 — SIALOGRAPHY

Short Question 28 — Define sialography. [5 marks]

Sialography is a radiographic examination of the salivary glands and their ducts after introduction of radiopaque contrast medium into the ductal system.

It evaluates:

• Structural abnormalities
• Functional abnormalities
• Duct obstruction
• Stones
• Lesions/masses

Short Question 29 — Name the three major salivary glands. [5 marks]

1. Parotid gland
   • Located in the preauricular region.
2. Submandibular gland
   • Located below the floor of the mouth.
3. Sublingual gland
   • Located under the tongue.

Short Question 30 — What are the indications of sialography? [5 marks]

1. Facial swelling
2. Salivary gland mass
3. Sialolithiasis
4. Pain and swelling
5. Functional disorder
6. Suspected ductal stricture

Short Question 31 — What are the contraindications of sialography? [5 marks]

1. Iodine hypersensitivity
2. Suspected pregnancy
3. Acute inflammation
4. Severe infection/sialadenitis
5. Calculus obstructing the duct opening

Short Question 32 — What is the maximum amount of contrast used for one salivary duct? [5 marks]

The slides state:

Maximum = 2 mL per duct.

The contrast is iodinated and injected manually under fluoroscopic guidance.

LONG QUESTION 5 — Describe sialography in detail. [15 marks]

Definition

Sialography is a radiographic examination of salivary glands following introduction of radiopaque contrast into their ductal system.

Anatomy

Three major salivary glands:

• Parotid
• Submandibular
• Sublingual

Indications

• Facial swelling
• Mass lesion
• Sialolithiasis
• Pain and swelling
• Functional disorder
• Ductal stricture

Contraindications

• Iodine hypersensitivity
• Pregnancy/suspected pregnancy
• Acute inflammation
• Severe infection
• Sialadenitis
• Obstructing calculus at duct opening

Patient Preparation

1. Remove radiopaque artifacts such as false teeth.
2. Explain the procedure.
3. Obtain consent.
4. Remove clothing/change into hospital gown.
5. IV line may be inserted.
6. Sedative may be administered.
7. Patient rinses mouth with mouthwash.
8. Scout film is taken.

Procedure

1. Patient lies supine on fluoroscopic table.
2. Mouth is widely opened.
3. Duct orifice is anesthetized with topical anesthetic.
4. If orifice is difficult to identify, lemon juice may be used.
5. Cannula is inserted into the duct.
6. Approximately 1–2 mL iodinated contrast is injected.
7. Injection is performed under fluoroscopy.
8. Maximum amount for one duct is 2 mL.
9. Radiographs are obtained.
10. Cannula is removed.
11. Patient rinses mouth.
12. Lemon juice/sialogogue is given to assess contrast evacuation.
13. After 5 minutes, further radiographs are obtained to assess residual contrast.

Filming

Immediate films

Same views as preliminary films.

Post-secretory films

Repeated approximately 5 minutes after administration of sialogogue.

Purpose:

• Demonstrate sialectasis.

Frontal view

Face rotated 5–10° toward side being examined.

Lateral view

Tube tilted approximately 15–20° cranially.

Submandibular gland

Lateral view with 15–20° cranial tube tilt.

Films are taken during injection and catheter remains until adequate films are obtained.

Complications

Direct complications

• Duct rupture
• Infection
• Inflammation
• Sialadenitis
• Abscess
• Duct stricture

Contrast reactions

Minor

• Nausea
• Vomiting
• Mild rash
• Mild headache
• Mild dyspnea

Intermediate

• Extensive urticaria
• Facial edema
• Bronchospasm
• Laryngeal edema
• Dyspnea
• Hypotension

Severe

• Circulatory collapse
• Pulmonary edema
• Severe angina
• Myocardial infarction
• Convulsions
• Coma
• Cardiac/respiratory arrest

PART 6 — VENOGRAPHY

This is another major long-question topic.

Short Question 33 — Define venography. [5 marks]

Venography/phlebography is an invasive radiographic examination of the venous system after injection of contrast medium into veins.

It is used to demonstrate venous anatomy and pathology.

The slides describe it as a traditional gold-standard examination for deep venous thrombosis, although it is now less commonly performed because of cost, invasiveness and availability of other modalities.

Short Question 34 — Name the specific venographic procedures. [5 marks]

1. Lower limb venography
2. Upper limb venography
3. Peripheral varicography
4. Inferior vena cavography
5. Superior vena cavography
6. Selective visceral venography
7. Renal venography
8. Hepatic venography
9. Portal venography
10. Cerebral venography
11. Capnocavography

Short Question 35 — What is the preparation for venography? [5 marks]

1. Fast for approximately 4–6 hours.
2. Check recent serum creatinine.
3. Check urea.
4. Review medical history.
5. Give appropriate premedication when required.
6. Change patient into appropriate gown.

Short Question 36 — What are relative contraindications of venography? [5 marks]

The slides emphasize concerns including:

• Renal dysfunction
• Anticoagulation
• Thrombophlebitis
• Other patient-specific risks related to invasive venography

Short Question 37 — Describe ascending lower-limb venography technique. [5 marks]

Important points:

1. Patient positioned with leg appropriately positioned.
2. Tourniquets are applied above ankle and below knee.
3. This helps direct contrast toward deep veins.
4. Table is tilted approximately 65°, feet down.
5. Leg is internally rotated.
6. Foot should not bear weight during injection.
7. Peripheral vein on dorsum of foot is cannulated.
8. Contrast is injected.
9. Serial radiographs are obtained.
10. Saline flush is used after the procedure.

Short Question 38 — What is upper limb venography? [5 marks]

Upper limb venography is radiographic examination of upper-limb veins following contrast injection.

Technique includes:

• Needle insertion into median cubital vein
• Basilic vein is avoided for the described technique because it can bypass the axillary vein.
• Approximately 30 mL contrast may be injected.
• Fluoroscopic/spot imaging is performed.

Short Question 39 — What is varicography? [5 marks]

Peripheral varicography is imaging of varicose veins using contrast.

According to the slides:

• Patient is supine.
• Table is tilted approximately 40° head-up.
• Butterfly needle is inserted into a suitable varix below knee.
• Contrast volume depends on extent of varicosities.
• Additional puncture/repositioning may be needed to adequately fill the veins.

Short Question 40 — What are the indications of inferior vena cavography? [5 marks]

1. Venous obstruction
2. Displacement of IVC
3. Infiltration
4. Transvenous interventional procedures
5. Congenital vascular anomalies
6. Assessment before IVC ligation

Short Question 41 — What is capnocavography? [5 marks]

Capnocavography demonstrates the inferior vena cava using carbon dioxide (CO₂) rather than iodinated contrast.

It may be useful in patients with:

• Iodinated contrast allergy
• Impaired renal function

Short Question 42 — What are complications of venography? [5 marks]

1. Hematoma
2. Vessel dissection
3. Infection at puncture site
4. Tissue necrosis due to extravasation
5. Other procedure-specific complications

LONG QUESTION 6 — Describe lower-limb venography in detail. [15 marks]

Definition

Lower-limb venography is an X-ray examination of lower-limb veins following injection of contrast medium.

Anatomy

The lower-limb venous system consists of:

Superficial system

Includes superficial veins and tributaries.

Deep system

Important deep veins include:

• Anterior tibial vein
• Posterior tibial vein
• Popliteal vein
• Femoral vein
• External iliac vein

The anterior and posterior tibial veins contribute to drainage of the foot/lower leg and join the popliteal system.

Indications

• Deep venous thrombosis
• Evaluation of venous obstruction
• Assessment of venous anatomy

Contrast

The slides mention approximately:

240 mgI/mL

and 50–150 mL, depending on the study.

Preparation

• Appropriate fasting/preparation
• Renal function assessment
• Medical history
• Premedication if needed
• Appropriate gown

Equipment

• X-ray/fluoroscopy equipment
• Spot-film device
• Contrast injector
• Needles/cannula
• Tourniquets
• Other sterile accessories

Ascending Phlebography Technique

1. Patient is positioned appropriately.
2. Preliminary radiograph of leg and thigh is obtained.
3. Tourniquet is applied above ankle.
4. Another tourniquet is applied below knee.
5. Tourniquets help occlude superficial venous flow.
6. Table is positioned approximately 65° from horizontal, feet down.
7. Leg is internally rotated.
8. Foot should not bear weight.
9. A peripheral vein on dorsum of foot is cannulated.
10. Contrast is injected by hand or pressure injector.
11. Radiographs are obtained during contrast filling.
12. AP and oblique/stereo views may be obtained.
13. Thigh/pelvic views are subsequently obtained.
14. Table is returned toward horizontal for pelvic veins.
15. Needle/cannula is flushed with 0.9% saline.

Imaging

• AP view of calf
• Internal and external oblique views
• Views of popliteal, femoral and iliac veins

Descending Phlebography

The slides describe femoral puncture and use of the Valsalva maneuver to demonstrate reflux.

Aftercare

The limb should be gently exercised to help wash out remaining contrast.

LONG QUESTION 7 — Describe venography and its major types. [15 marks]

Definition

Venography is an invasive radiographic examination of veins after injection of contrast.

Types

Peripheral

• Lower limb
• Upper limb
• Varicography

Central

• Inferior vena cavography
• Superior vena cavography

Selective visceral

• Renal
• Hepatic
• Portal
• Cerebral venography

Other

• Capnocavography

Inferior Vena Cavography

Indications

• Obstruction
• Displacement
• Infiltration
• Transvenous intervention
• Congenital anomalies
• Before IVC ligation

Technique

• Patient supine.
• Catheter introduced through femoral vein.
• Approximately 40 mL contrast injected over about 2 seconds.
• Valsalva can prolong filling.

Filming

• Approximately 2 frames/films per second
• AP and lateral
• Approximately 5–10 seconds depending on program.

Superior Vena Cavography

Indication

Mainly to evaluate:

• SVC obstruction
• SVC stenosis
• Thrombus

Technique

Contrast can be injected through an upper-limb vein/antecubital route or catheter.

The imaging should demonstrate opacification of:

• Subclavian veins
• Brachiocephalic veins
• SVC
• Right atrium

The slide mentions catheter injection around 10–15 mL/sec, with a total volume around 30 mL.

Renal Venography

Indications:

• Renal vein thrombosis
• Renin-related assessment

Technique:

• Usually femoral approach
• Contrast approximately 8 mL/sec
• Serial imaging for approximately 4 seconds

Hepatic Venography

Indications:

• Hepatic vein stenosis
• Hepatic vein thrombosis
• Pressure measurement

Technique:

• Catheter through jugular/upper limb or femoral approach
• Patient supine
• Liver and IVC included
• Contrast approximately 10 mL/sec
• Imaging for approximately 8 seconds

Portal Venography

Used to evaluate:

• Portal system anatomy
• Patency of portosystemic anastomosis

The slides mention:

• Contrast approximately 370 mgI/mL
• Approximately 50 mL
• Rapid serial radiography or digital subtraction imaging

Capnocavography

Uses CO₂ to demonstrate the IVC.

Particularly useful when iodinated contrast is problematic, such as:

• Contrast allergy
• Impaired renal function

Complications

• Hematoma
• Vessel dissection
• Infection
• Extravasation
• Tissue necrosis

Radiation Protection

• Minimize fluoroscopy time.
• Reduce unnecessary radiation exposure.
• Appropriate radiation protection should be used for staff and patient.

Other Modalities

Ultrasound/Doppler

• Widely used for venous system
• Low cost
• Readily available
• Non-invasive

CT

Useful for:

• Compression
• Thrombosis
• SVC/IVC
• Iliac veins
• Renal veins

MRI/MRV

Useful for selected venous conditions, particularly where non-ionizing imaging is desirable.

PART 7 — RADIOGRAPHIC PATHOLOGY

This section is extremely important for short questions, because the slides contain many named radiographic signs.

You should memorize these as:

SIGN → APPEARANCE → CONDITION

Short Question 43 — What is the silhouette sign? [5 marks]

The silhouette sign is loss of the normal interface between the lung and adjacent soft tissue because an opacity contacts that border.

It commonly affects:

• Heart borders
• Aorta
• Chest wall
• Diaphragm

Principle

If an intrathoracic opacity contacts a structure of similar radiographic density, the normal border becomes obscured.

Short Question 44 — What is the cervicothoracic sign? [5 marks]

The cervicothoracic sign helps determine whether a lesion at the thoracic inlet is anterior or posterior.

If the lesion is clearly visible above the clavicles:

It is located posteriorly and within the thorax.

If the superior border becomes obscured at/below the clavicles:

It suggests an anterior mediastinal lesion.

Short Question 45 — What is an air bronchogram? [5 marks]

An air bronchogram is a tubular outline of an air-filled bronchus made visible because surrounding alveoli are filled with fluid or inflammatory exudate.

Seen in:

1. Lung consolidation
2. Pulmonary edema
3. Non-obstructive atelectasis
4. Interstitial disease
5. Neoplasm
6. Normal expiration

Short Question 46 — What is the hilum overlay sign? [5 marks]

The hilum overlay sign occurs when a mass projects over the hilum on a frontal chest X-ray but is actually anterior or posterior to the hilum.

If the mass truly arises from the hilum, the pulmonary vessels are in contact with it and their silhouettes are obscured.

Short Question 47 — What is the deep sulcus sign? [5 marks]

The deep sulcus sign is a radiolucency extending from the lateral costophrenic angle toward the hypochondrium.

It is an important sign of pneumothorax in a supine patient.

In the supine position, pleural air collects anteriorly and produces prominent inferior/lateral lucency.

Short Question 48 — What is the air crescent/meniscus sign? [5 marks]

The air crescent sign results from accumulation of air between a mass/nodule and surrounding normal lung.

It is classically associated with aspergillosis, particularly in neutropenic patients.

Short Question 49 — What is the spinnaker/angel-wing sign? [5 marks]

The spinnaker sign is a sign of pneumomediastinum in neonates.

Air outlines the thymus and displaces its two lobes laterally, producing an appearance resembling spinnaker sails/angel wings.

Short Question 50 — What is Hampton’s hump? [5 marks]

Hampton’s hump is:

• Wedge-shaped
• Pleura-based consolidation
• Rounded/convex apex directed toward the hilum

It is classically associated with pulmonary embolism/infarction.

Short Question 51 — What is the Westermark sign? [5 marks]

Westermark sign is a decrease in pulmonary vascularity at the lung periphery due to mechanical obstruction or reflex vasoconstriction.

It is associated with pulmonary embolism.

Short Question 52 — What is the bulging fissure sign? [5 marks]

The bulging fissure sign occurs with lobar consolidation in which the affected portion of the lung becomes expanded and causes outward bulging of the fissure.

The slides mention that it is now rarely seen because of widespread antibiotic use.

Short Question 53 — What is the continuous diaphragm sign? [5 marks]

The continuous diaphragm sign is continuous lucency outlining the base of the heart.

It occurs due to pneumomediastinum, where air tracks between the heart and diaphragm.

Difference from pneumopericardium

Pneumopericardium tends to produce air circumferentially around the heart.

Short Question 54 — What is the fallen lung sign? [5 marks]

The fallen lung sign describes a collapsed lung occurring with a fractured bronchus.

The lung falls away from the hilum:

• Inferiorly and laterally in an upright patient
• Posteriorly on CT in a supine patient

Important distinction

In pneumothorax, the lung usually collapses toward the hilum.

Short Question 55 — What is the flat waist sign? [5 marks]

The flat waist sign refers to flattening of the contours of:

• Aortic knob
• Adjacent main pulmonary artery

It is seen in severe collapse of the left lower lobe and results from displacement and rotation of the heart.

Short Question 56 — What is the finger-in-glove sign? [5 marks]

The finger-in-glove sign is associated with a bronchocele.

It occurs when a bronchus becomes obstructed and the distal bronchus becomes dilated and filled with mucus.

Short Question 57 — What is the Golden S sign? [5 marks]

The Golden S sign occurs when a lobe collapses around a large central mass.

The mass prevents central collapse while the peripheral lung collapses.

The displaced fissure forms an S or reverse-S shape.

It is classically associated with right upper lobe collapse due to a central obstructing mass.

Short Question 58 — What is the juxtaphrenic peak sign? [5 marks]

It is a small triangular shadow obscuring the dome of the diaphragm.

It occurs due to upper-lobe atelectasis.

The appearance is caused by traction on:

• Lower end of major fissure
• Inferior accessory fissure
• Inferior pulmonary ligament

Short Question 59 — What is the Luftsichel sign? [5 marks]

The Luftsichel sign is a peri-aortic lucency.

The term comes from German:

• Luft = air
• Sichel = sickle

It is associated with left upper-lobe collapse, where the superior segment of the lower lobe becomes hyperinflated adjacent to the aortic arch.

Short Question 60 — What is the doughnut sign? [5 marks]

The doughnut sign occurs with mediastinal lymphadenopathy, particularly behind the bronchus intermedius in the subcarinal region.

On lateral radiograph:

• Enlarged lymph nodes form surrounding opacity.
• Central radiolucency creates a doughnut-like appearance.

Short Question 61 — What is the scimitar sign? [5 marks]

The scimitar sign indicates anomalous venous drainage of the right inferior pulmonary vein.

The vein may drain directly into:

• Hepatic vein
• Portal vein
• Inferior vena cava

On X-ray it appears as a curved/tubular opacity along the right heart border toward the diaphragm, resembling a Turkish sword/scimitar.

Associated with:

Scimitar syndrome / congenital hypogenetic lung syndrome.

HIGH-YIELD LONG QUESTION 8 — Describe important radiographic signs in chest pathology. [15 marks]

If your teacher asks a broad question about radiographic signs, organize the answer like this:

1. Silhouette sign

Loss of normal border due to adjacent opacity.

2. Cervicothoracic sign

Used to localize lesion as anterior/posterior at thoracic inlet.

3. Air bronchogram

Air-filled bronchus visible against airless alveoli.

4. Hilum overlay sign

Mass projected over hilum but actually anterior/posterior.

5. Deep sulcus sign

Supine pneumothorax.

6. Air crescent sign

Air between mass and lung; classically aspergillosis.

7. Spinnaker/angel-wing sign

Neonatal pneumomediastinum.

8. Hampton’s hump

Pleural-based wedge opacity associated with pulmonary embolic infarction.

9. Westermark sign

Peripheral oligemia associated with pulmonary embolism.

10. Bulging fissure sign

Expanded lobe with outward bulging fissure.

11. Continuous diaphragm sign

Pneumomediastinum.

12. Fallen lung sign

Bronchial fracture with lung displaced away from hilum.

13. Flat waist sign

Severe left lower-lobe collapse.

14. Finger-in-glove sign

Bronchocele/mucus-filled dilated bronchus.

15. Golden S sign

Lobar collapse around central obstructing mass.

LONG QUESTION — Explain the important signs of atelectasis/collapse. [15 marks]

This is a very useful grouping to memorize.

1. Golden S sign

• Central mass
• Lobar collapse
• S-shaped fissure
• Reverse-S appearance

2. Juxtaphrenic peak sign

• Triangular shadow
• Upper-lobe atelectasis
• Traction on fissure/accessory structures

3. Luftsichel sign

• Peri-aortic sickle-shaped lucency
• Associated with upper-lobe collapse

4. Flat waist sign

• Flattened aortic knob/main pulmonary artery contours
• Severe left lower-lobe collapse

5. Fallen lung sign

• Bronchial fracture
• Lung falls away from hilum

6. Finger-in-glove sign

• Bronchial obstruction
• Mucus plugging
• Bronchocele

LONG QUESTION — Explain radiographic signs associated with pulmonary embolism. [15 marks]

1. Hampton’s Hump

• Wedge-shaped pleural-based opacity
• Convex/rounded apex toward hilum
• Associated with pulmonary infarction

2. Westermark Sign

• Reduced peripheral vascular markings
• Due to obstruction/reflex vasoconstriction
• Associated with pulmonary embolism

These two should be memorized together:

Hampton = opacity
Westermark = decreased vascularity

VERY IMPORTANT RAPID-REVISION TABLE

Memorize this table before sleeping.

MASTER SHORT-QUESTION BANK

If you have very little time, these are the questions I would revise first.

Myelogram

1. Define myelogram.
2. Types of contrast used in myelography.
3. Sites of contrast injection.
4. Indications.
5. Contraindications.
6. Risks and limitations.
7. Patient preparation.
8. Radiographic positions.

GIT

9. Positive contrast media.
10. Barium sulfate.
11. Indications/contraindications of barium.
12. Water-soluble iodinated contrast.
13. Negative contrast.
14. Double-contrast technique.
15. Barium vs iodinated contrast.

Sinogram/Fistulogram

16. Define fistula.
17. Classification according to location.
18. Classification according to openings.
19. Causes of fistula.
20. Common fistulas.
21. Define sinus.
22. Define sinogram/fistulogram.
23. Indications.
24. Contraindications.
25. Equipment.
26. Technique.
27. Complications.

Catheterization

28. Define urinary catheterization.
29. Types of catheterization.
30. Types of catheters.
31. Three-way Foley.
32. Condom catheter.
33. French gauge.
34. Indications.
35. Articles.
36. Female insertion.
37. Male insertion.
38. Aftercare.

Sialography

39. Define sialography.
40. Three major salivary glands.
41. Indications.
42. Contraindications.
43. Patient preparation.
44. Procedure.
45. Maximum contrast volume.
46. Filming.
47. Complications.
48. Contrast reactions.

Venography

49. Define venography.
50. Types of venography.
51. Patient preparation.
52. Relative contraindications.
53. Lower-limb venography.
54. Ascending phlebography.
55. Upper-limb venography.
56. Varicography.
57. IVC cavography.
58. SVC cavography.
59. Renal venography.
60. Hepatic venography.
61. Portal venography.
62. Capnocavography.
63. Complications.
64. Radiation protection.
65. Other modalities.

Radiographic Pathology

66. Silhouette sign.
67. Cervicothoracic sign.
68. Air bronchogram.
69. Hilum overlay sign.
70. Deep sulcus sign.
71. Air crescent sign.
72. Spinnaker sign.
73. Hampton’s hump.
74. Westermark sign.
75. Bulging fissure sign.
76. Continuous diaphragm sign.
77. Fallen lung sign.
78. Flat waist sign.
79. Finger-in-glove sign.
80. Golden S sign.
81. Juxtaphrenic peak sign.
82. Luftsichel sign.
83. Doughnut sign.
84. Scimitar sign.

MASTER LONG-QUESTION BANK

These are the major 15-mark questions you should be prepared to write.

LONG Q1

Describe myelography in detail.

Study:

• Definition
• Contrast
• Injection site
• Positions
• Imaging technique
• Preparation
• Conventional radiographic positions
• Indications
• Contraindications
• Benefits
• Risks
• Limitations

LONG Q2

Describe sinogram/fistulogram in detail.

Study:

• Fistula definition
• Types
• Causes
• Sinus
• Definition of sinogram
• Indications
• Contraindications
• Equipment
• Accessories
• Preparation
• Technique
• Filming
• Aftercare
• Complications

LONG Q3

Describe sialography in detail.

Study:

• Definition
• Anatomy
• Indications
• Contraindications
• Preparation
• Procedure
• Contrast amount
• Filming
• Immediate/post-secretory images
• Complications
• Contrast reactions

LONG Q4

Describe venography in detail.

Study:

• Definition
• Types
• Preparation
• Contraindications
• Lower limb
• Upper limb
• Varicography
• IVC
• SVC
• Visceral venography
• Complications
• Radiation protection
• Alternative modalities

LONG Q5

Describe lower-limb ascending phlebography.

Study:

• Anatomy
• Indications
• Contrast
• Preparation
• Equipment
• Position
• Tourniquets
• 65° table
• Internal rotation
• Dorsal foot vein
• Injection
• Imaging
• Pelvic views
• Saline flush
• Aftercare

LONG Q6

Describe urinary catheterization.

Study:

• Definition
• Types
• Catheters
• Foley
• French gauge
• Indications
• Articles
• Position
• Aseptic procedure
• Female insertion
• Male insertion
• Balloon
• Aftercare

LONG Q7

Discuss contrast media used in GIT studies.

Study:

• Positive contrast
• Barium
• Uses
• Advantages
• Contraindications
• Water-soluble iodine
• Indications
• Disadvantages
• Negative contrast
• Double contrast
• Barium vs iodine

LONG Q8

Describe important radiographic signs seen in chest pathology.

Know all 19 signs:

Silhouette → Cervicothoracic → Air bronchogram → Hilum overlay → Deep sulcus → Air crescent → Spinnaker → Hampton → Westermark → Bulging fissure → Continuous diaphragm → Fallen lung → Flat waist → Finger-in-glove → Golden S → Juxtaphrenic peak → Luftsichel → Doughnut → Scimitar

 WHAT SHOULD MEMORIZE

If your time is extremely limited then,

Use this order:

PRIORITY 1 — Radiographic Pathology

Memorize all 19 signs.

Especially:

Silhouette
Air bronchogram
Deep sulcus
Hampton hump
Westermark
Continuous diaphragm
Fallen lung
Finger-in-glove
Golden S
Juxtaphrenic peak
Luftsichel
Doughnut
Scimitar

PRIORITY 2 — Sinogram/Fistulogram

Memorize this sequence:

Definition → Types → Causes → Indications → Contraindications → Equipment → Preparation → Technique → Filming → Aftercare → Complications

PRIORITY 3 — Sialography

Memorize:

3 glands → indications → contraindications → preparation → 1–2 mL contrast → maximum 2 mL/duct → fluoroscopy → AP/lateral/oblique → 5-minute post-secretory films → complications

PRIORITY 4 — Venography

Memorize:

Definition → types → preparation → lower limb → upper limb → varicography → IVC → SVC → visceral → complications → alternatives

The 65° lower-limb ascending phlebography position and 40° head-up varicography are particularly worth remembering.

PRIORITY 5 — Myelogram

Memorize:

6–17 mL → subarachnoid space → L3–L4 / C1–C2 → fluoroscopy → table tilt → indications → contraindications → risks → MRI/CT replacement

PRIORITY 6 — GIT

Memorize this one comparison:

Barium = excellent coating + routine studies
Iodine = perforation/leak
Air/CO₂ = negative contrast
Barium + air = double contrast

PRIORITY 7 — Catheterization

Memorize:

3-way Foley = irrigation + urine drainage + balloon

and:

Children 8–10 FG | Women 14–16 FG | Men 16–18 FG

and:

Female: 5–6 cm → urine → another 3–5 cm → 10 mL balloon

Male: urine → another ~5 cm/almost bifurcation → 10 mL balloon

LAST-NIGHT EXAM STRATEGY

For a 15-mark question, don’t write one giant paragraph.

Use:

Definition
↓
Types/Anatomy
↓
Indications
↓
Contraindications
↓
Patient Preparation
↓
Equipment
↓
Procedure/Technique
↓
Positioning/Filming
↓
Complications
↓
Aftercare/Limitations

That structure makes your answer look like a complete 15-mark answer.

For a 5-mark question, use:

Definition + 4–5 key points

Do not write a full long answer for a 5-mark question.

FINAL “MUST-KNOW” 15 TOPICS

If you can only revise 15 things before sleeping, revise these:

1. Sinogram/Fistulogram — complete procedure
2. Sialography — complete procedure
3. Venography — complete procedure
4. Lower-limb ascending phlebography
5. Myelogram — complete procedure
6. GIT contrast media — barium vs iodine
7. Urinary catheterization
8. Silhouette sign
9. Air bronchogram
10. Deep sulcus sign
11. Hampton’s hump
12. Westermark sign
13. Golden S sign
14. Luftsichel sign
15. Scimitar sign

One final memory trick:

PE → Hampton + Westermark

Supine pneumothorax → Deep sulcus

Bronchial obstruction + mucus → Finger-in-glove

Central mass + collapse → Golden S

Upper-lobe collapse → Juxtaphrenic peak / Luftsichel

Anomalous pulmonary vein → Scimitar

Neonatal pneumomediastinum → Spinnaker

Subcarinal lymph nodes → Doughnut

Bronchial fracture → Fallen lung