RADIOLOGIC TESTS

Radiologic Tests
Introduction to Radiologic Tests
Learning to evaluate radiographic tests is essential for excellent patient care. A thorough knowledge
of anatomy and pathology is essential in this pursuit.
Computed Tomography (CT) Scan
CT is a more sensitive x-ray detection system which creates slice images through the body. The xray tube and detectors rotate around the patient, and a computer system manipulates the data. The
data can be reconstructed to create axial (transverse), sagittal, coronal, and 3 -D views.
When looking at an axial CT, imagine you are standing at the patient's feet looking toward their
head. Different window settings on the computer allow you to view certain structures better (e.g.
bone window lung window) IV and oral contrast can be used to evaluate arteries, veins and
gastrointestinal structures in more detail.
Fluoroscopy
A continuous beam of x-rays passes through the patient and gives a moving, real-time image;
basically a moving x-ray. Used in gastrointestinal barium and other contrast studies, angiography,
and most interventional radiology procedures. Commonly used intra-operatively in orthopedic
surgery and neurosurgery.
Magnetic Resonance Imaging (MRI)
The patient is placed within the bore of a powerful magnet that passes radio waves though
the body in a particular series of very short pulses. Each pulse causes a responding pulse to
be emitted from the patient. A computer manipulates the data which produces an image.
Contrast may be used to evaluate certain conditions. Different sequences include T1 in
which fluid appears dark and T 2 in which fluid appears bright white.
The benefits to the MRI include no radiation exposure and it provides more soft tissue
detail.
The cons to MRI include expense, contraindicated if the patient has metal hardware
implanted or a pacemaker takes longer than a CT, motion interference can distort images,
claustrophobic or severely anxious patient may not be able to tolerate scan, morbidly obese
may not be able to fit in the scanner.

Radionuclide Imaging (Nuclear Imaging)

Uses radiolabeled isotopes (radionuclide) attached to normal physiologic chemical substances to visualize
particular living organs and tissues. An image is obtained because the isotope emits gamma rays for a brief
period of time which are detected by special cameras.
Technetium-99m (99mTc): Most commonly used nuclide. Used in ionic form to detect a Meckel
diverticulum, or attached to organic phosphate for a bone scan. It can even be attached to patient's own
RBCs or WBCs.
Positron Emission Tomography (PET) Scan: Uses short-lived positron emitting isotopes most commonly
attached to a glucose analogue to detect areas of increased metabolic activity. Most common use is
evaluating for staging solid tumors and evaluating metastasis. PET can be fused with a CT scan to precisely
localize lesions.
Ultrasound (US)
Very high frequency sound is directed into the body from a transducer placed in
contact with the skin. The sound is reflected by tissue to produce echoes picked up
from the same transducer and converted into an electrical signal which produces 2 -D
or 3 -D images.
Ultrasound is a less expensive test that does not expose the patient to radiation. The test
is useful for obstetrical, gynecological, pediatric, and testicular conditions, determining
cystic (black) vs. solid (grey) structures. US can also produce moving images and can
be done at the bedside.
Ultrasound takes longer than a CT scan, results are operator dependent, it is not useful
for bone or lung since these entities almost completely absorb the ultrasound beam.
Doppler US: Sound reflected from a mobile structure shows a variation in frequency that corresponds to
the speed of movement. The shift in frequency can be turned into an audible signal (e.g. fetal heartbeat)
Flow can also be shown as the frequency changes depending on the direction of the flow in relation to the
transducer. This is illustrated by colors on the screen with red signifying flow toward the transducer and
blue signifying flow away from the transducer.
Examples of US exams: Echocardiography, obstetrical US , premature infant head US , suspected
abdominal aortic aneurysm (AAA) or deep vein thrombosis (DITT) , gallbladder US , trauma (focused
assessment with sonography for trauma or FAST exam) , pelvic US , breast US , testicular US , carotid US

X-rays
There are five basic densities on an x-ray
Air- Will appear black
Bone-Will appear white
Fat- Denser than air but less dense than soft tissues
Soft Tissue-Denser than fat but less dense than bone
X-rays are absorbed to a variable extent as they pass
through the body. This difference in absorption
produces an image. The projection is described by the
path of the x-ray beam (e.g. in a PA or posteroanterior
film the x-ray beam went through the patient's back
initially)
An x-ray will only produce 2 -D images, therefore perpendicular views may need to be obtained. Always
consider x-ray before a CT or MRI.
Specific Radiologic Tests
Abdominal CT
Commonly used with oral and IV contrast to evaluate trauma, appendicitis, pancreatitis, diverticulitis,
kidney stones (without contrast), and determine stages of cancer.

Abdominal Ultrasound
Used to rapidly evaluate the liver , gallbladder (gallstones, cholecystitis) , appendix, pancreas,
and abdominal aortic aneurysms.
Abdominal X-rays (Kidney Ureter Bladder or KUB)
The KUB is an x-ray of the abdomen taken in anteroposterior or AP direction. It is commonly
ordered in patients complaining of abdominal pain.
An abdominal x-ray can help identify foreign bodies, ileus, malrotation, small bowel obstruction
with air-fluid levels, and volvulus.
It can also detect perforation with "free-air" under the diaphragm or within structures air should
not normally be (e.g. intestinal wall or biliary tract) but the upright chest x-ray is the better
test.

Arthrography
Imaging following the injection of contrast (iodinated or air) into a joint to highlight the soft
tissue structures by coating their surfaces. It is used most often to define intra-articular structures or
to confirm intra-articular needle placement when joint aspiration is performed. Typically, contrast
material is injected in a joint using fluoroscopic guidance; the joint is then subjected to further imaging with either
CT or MRI.

Barium Enema
A barium enema is a test in which barium sulfate is placed into the patient's rectum in order to evaluate
the colon. X-rays are taken which will outline the location of the barium in the colon.
Patients undergo a bowel prep the night before with laxatives such as polyethylene glycol in order to "clean
out" the patient thoroughly for the examination, as is also done before procedures such as colonoscopies.
Barium Swallow
The patient is given barium to swallow while the esophagus is imaged via fluoroscopy. Used to
evaluate esophageal pathology , aspiration, and swallowing abnormalities.
In a modified barium swallow different consistencies of barium are swallowed by the patient. X-rays are
taken to monitor for aspiration. This helps determine what types of foods are safe for the patient to eat.
Bone X-ray
X-rays of the bones are ordered primarily to detect fractures. They may also help diagnose osteomyelitis
which may be visualized as an elevation of the periosteum.
Chest CT
Allows for detailed images of the chest cavity. Indications may include pneumonia, lung nodules,
pneumothorax, pulmonary embolism and rib fractures.

Chest X-ray
A chest x-ray is used to evaluate patients with complaints of shortness of breath, cough,
chest pain, fever, and hemoptysis as well as abnormal physical exam findings of the lungs
or chest wall.
It is typically ordered in patients who have suffered trauma and to verify correct placement
of lines and tubes.
The image will include the lungs, heart, mediastinum and upper portion of the abdomen.
A chest x-ray can reveal numerous pathology including aortic dissection, congestive heart
failure, emphysema, free air under the diaphragm from perforations, lung masses,
pneumonia, and a pneumothorax.

Posteroanterior (PA)
The posteroanterior or PA view is the standard projection for chest x-ray , such that the beam passes from
the patient 's back to their front. A patient will be standing for this x-ray
Anteroposterior (AP)
In an anteroposterior or AP view the beam passes from front to back. This view cannot be used to estimate
heart or mediastinum size. It is most often obtained on patient 's that cannot sit up or stand and is
sometimes called a "portable view" since the x-ray department may need to travel to the patient's room
using a mobile x-ray machine. An AP will typically be of poorer quality
Lateral
A lateral chest x-ray is often obtained to get a 3 -D picture and provide a more precise location
of an abnormality such as a mass or pneumonia. A pleural effusion may be seen with up to as
little as 50 mL of fluid is present.
Decubitus
A lateral decubitus chest film is one in which the patient is asked to lie on a specific side in
order to assess for a pleural effusion. The pleural fluid, if present, will "layer out" and can be
seen when as little as 175 mL of pleural fluid is present.

Chest CT
A chest CT can be used to more definitively evaluate for cancerous lesions and abnormal lymphadenopathy
interstitial lung disease, and pulmonary emboli.

Dual-energy X-ray Absorptiometry (DEXA) Scan

A test used to measure bone density and diagnose osteoporosis. Typically performed in women > 65
years. The T -score compares the patient's bone density to the optimal peak bone density
Osteopenia is diagnosed with a T-score < -1. Osteoporosis is diagnosed with a T-score <-2.5.
Head CT
A non-contrast head CT is used to evaluate head trauma, hematomas (epidural and subdural) , stroke and
subarachnoid hemorrhage.
A contrast head CT can be used as a first line test to identify infection and malignancies.
Hepatobiliary Iminodiacetic Acid Scan (HIDA scan)
The HIDA or hepatobiliany scan is a nuclear imaging test used in the evaluation of the gallbladder. In a
normal scan, the gallbladder is visualized after injection of the radioactive tracer. A diagnosis of
cholecystitis or obstruction of the cystic duct can be made if the gallbladder is not visualized after four
hours. HIDA scans are useful in the workup of right upper quadrant pain and neonatal biliary atresia.
Hysterosalpingogram
Contrast is injected into the uterus and imaged via fluoroscopy. The free spill of contrast into the perineum
indicates patent fallopian tubes. Used in specific cases of infertility, and can assess congenital variations in
uterine morphology.
Mammogram
X-ray examination of the breasts used to screen for breast cancer , or to evaluate a patient
presenting with an abnormal finding on exam. Can detect early breast cancer prior to a palpable
lump but cannot rule out cancer in a patient with palpable mass.
Meckel Scan
A noninvasive, nuclear imaging test utilized in the diagnosis of Meckel diverticulum.
Technetium- 99m pertechnetate is used to identify abnormally located gastric mucosa, commonly
found in a Meckel diverticulum.
Retrograde Urethrogram (Intravenous Pyelogram or IVP)
Patients who have experienced genitourinary trauma should undergo a retrograde urethrogram to determine any
injury to the genitourinary system. This may be suspected from the presence of blood at the urethral meatus.
Water soluble contrast is inserted into the urethra and a KUB obtained in order to assess for extravasation of the
contrast which would indicate disruption of the normal genitourinary anatomy.
Ultrasound of the Pelvis
Noninvasive procedure that allows rapid visualization of the female pelvic organs and structures.
May be performed transabdominal or transvaginal. Common indications are pregnancy, pelvic
pain, bleeding, infertility and ovarian cysts.

Upper Gastrointestinal Series with Small Bowel Follow Through (UGI and SBFT)
Serial x-rays are taken after barium is swallowed by the patient, usually at approximately 30
minute intervals. The barium appears white on the x-ray. Abnormalities will show as filling
defects.
Used to evaluate swallowing, gastroesophageal reflux, the esophagus, stomach, and small
intestines. Sometimes gas is used as a second contrast agent. This is called an air-barium doublecontrast study and allows for more mucosal definition.
Voiding Cystourethrogram (VCUG)
Test that uses x-rays to evaluate the urinary system during voiding. The bladder is filled with
contrast and vesicoureteral reflux is diagnosed if there is retrograde flow to the kidneys.