CONTRAST MEDIA

OBJECTIVES:

After completing this chapter, the student will be able to:

 Discuss the term contrast medium, to include its definition purpose, and use in
radiography

 Identify specific materials that are used as contrast agents, including the chemical,
physical ,and radiographic characteristics of each

 Differentiate between positive and negative contrast media

 Identify the routes of administration of contrast media for various radiographic

examinations.

 Compare and contrast the use of ionic and nonionic iodinated contrast media

 Identify contraindications to the administration of a contrast medium and possible

complications resulting from its use

 Describe possible reactions to contrast media and categorize them according to their
severity CONTRAST MEDIA

INTRODUCTION

Contrast studies are those examinations in which contrast media are used to
enhance visualization of specific body structures. Because of the low subject contrast of
the abdomen, contrast media are used to demonstrate the anatomic structures of the
urinary, digestive, and biliary systems.

Contrast media are also used to evaluate other areas of the body, such as the spinal
canal, female reproductive system, and vasculature.

The radiologic technologist must understand the composition of contrast media, the
effects they can have on the body, and how they are used.
BASIC PRINCIPLES OF CONTRAST MEDIA

- Many structures and organs within the body have similarly low tissue densities. This is
determined by their atomic number, which is the number of protons (Positive charges)
in the nuclei of their atoms.

- When the x-ray beam is directed at a specific structure during a radiographic

examination, some of the x-rays pass through, and others are absorbed (Attenuated) by
the structure.

- More X-rays are absorbed by structures having a high atomic number, resulting in less
radiation reaching the film, whereas fewer X-rays are absorbed by structures having a
low atomic number. This accounts for the visible difference in densities on radiography.
For example, the calcium in bone has a higher atomic number than skin or muscle
tissue; therefore, the bone appears light on a radiograph and the soft tissue appears
dark.

– Many organs, such as those of the digestive, urinary, biliary, and cardiovascular
systems, are about the same density as soft tissue, which has an atomic number of
approximately 7.4. For this reason, they absorb nearly the same amount of x-radiation
and appear relatively similar on a radiograph. To make these structures more visible for
diagnostic purposes, a contrast medium or agent must be used.

- A contrast medium is a pharmaceutical agent that is administered to a patient for a

radiographic examination to enhance the contrast of a particular structure. Its use allows
for differentiation between a structure and surrounding tissues by altering the density of
the structure, which in turn alters the absorption of x-rays.

- The type of contrast medium (negative or positive) affects the amount of radiation
reaching the film, and produces a visible change in the radiographic appearance of the
structure.

TYPES OF CONTRAST MEDIA

The two basic classifications of contrast media are

1. Negative contrast agents and

2. Positive contrast agents.

1. A negative contrast agent

- Is radiolucent, has a low atomic number, and allows x-rays to pass through quite
easily. As more x-radiation reaches the film, the structure that is filled with a
negative contrast agent appears dark (black) on radiography.

- Gases, such as oxygen, carbon dioxide, and nitrous oxide, may be used as
negative contrast media, although room air is the most common agent. For
example, the air in the lungs serves as a negative contrast medium on chest
radiography.

- A negative contrast medium may be used alone, as in the case of an air

arthrogram, It can also be combined with a positive contrast agent to produce a
double-contrast effect, such as a barium enema examination with air. As a
second contrast agent for upper gastrointestinal examination, a negative
contrast medium is generally administered as an effervescent agent in powder,
granule, or tablet form which forms carbon dioxide (CO2) when mixed with
water.

- The uses of negative contrast media are limited, however, as they may not
provide sufficient contrast of a structure when used singly. Also, they must never
be injected intravenously; doing so will have serious, if not fatal, consequences.

2. A positive contrast agent

- Is radiopaque and has a high atomic number. - As it absorbs approximately

three times more x-rays than bone and five times as many x- rays as soft tissue,
an organ filled with a positive contrast agent appears light on the resulting
radiography. - Barium sulfate (BaSO4) and Iodinated compounds are positive
contrast media used in radiography to enhance the visibility of particular
structures. - As demonstrated on the periodic Table of the Elements, the
elements iodine (53) and barium (56) have high atomic numbers compared with
that of oxygen (8).

BARIUM SULFATE

Properties
- Barium is a heavy metal having an atomic number of 56. It is combined with oxygen
and sulfate to form the inert compound barium sulfate (BaSO4).

- Barium sulfate is a white, crystalline powder that is insoluble in water. For use in
radiography, it is mixed with water and stabilizing agents to form a suspension. Often,
artificial flavors and colors are added to the suspension used for upper gastrointestinal
radiography to make the barium sulfate more palatable to the patient.

- Barium sulfate is used for examination of the entire alimentary canal. Ideally, the
suspension should be dense to coat the mucosa and outline the visceral walls, yet it
must have the ability to flow smoothly through the alimentary canal.

- Barium sulfate products can be procured in a variety of concentrations depending on

the type of examination and specific anatomy of interest.

- The products are available commercially in paste, liquid, powder, and tablet form.

- Paste, having a viscosity approximate to that of honey, may be recommended for an

esophagram. As it will not pass down the esophagus as swiftly as a thinner suspension,
the radiologist and /or technologist have more time to take radiographs of the contrast
filled esophagus.

- A liquid barium sulfate suspension can also be used for radiographic examination of
the esophagus, as well as the stomach and both small and large intestines. It can be
purchased in premixed liquid form or in powder form, which must be mixed with water
prior to use. In either case, it should be shaken or stirred immediately before
administration, as suspension tends to settle.

- Barium sulfate tablets are helpful in evaluating foreign objects or strictures in the
esophagus. They dissolve in either the esophagus or stomach when mixed with water.

Contraindications

- Because of its inability to be absorbed by the body, barium sulfate cannot be used
intravascularly or intrathecally.

- Also, its use is contraindicated in the case of a suspected perforation in the alimentary
canal, as it may leak into the peritoneal cavity, causing a vascular adhesions and
peritonitis. For this reason, it is also contraindicated in cases of recent or impending
abdominal surgery.
IODINATED COMPOUNDS

Properties

- With an atomic number of 53, the element iodine is almost as radiopaque as barium
sulfate.

- A 2, 4, 6-triiodinted benzene ring containing three atoms of iodine per molecule forms
the base of iodinated contrast media.

- Iodine is the element of choice for use as a contrast agent, as it forms stable
compounds and does not break down in the body. Like barium sulfate, it has a relatively
low toxicity and high atomic number.

- Unlike barium sulfate, it is generally absorbed by the body and excreted by the kidneys
within 24 hours of intravascular administration.

- As iodinated contrast media have a tendency to break down in the light, they should
be shielded from bright light.

- The viscosity, or thickness, of the contrast medium is greatly determined by the size
the concentration of the molecules in the solution.

- It is recommended that the liquid iodinated contrast media be prewarmed to body

temperature prior to use. Doing so reduces their viscosity, allowing for easier
administration and lessening the possibility of adverse reactions.

- Iodinated contrast agents are administered for a variety of radiographic examination.

- From the many products available commercially, the radiology department or

physician selects a particular contrast agent according to the area of interest and type of
examination.

- As pharmaceutical products, iodinated contrast media are referred to by their generic

name, chemical name, or trade name, which is the manufacturer’s brand name for the
product. For example, Reno-60 is a trade name, whereas diatrizoate meglumine 60% is
the generic name for the same product.

- The opacity of an iodinated contrast agent is determined by its iodine content;

therefore, a product containing a high percentage of iodine will characteristically exhibit
high opacity and high radiographic contrast.
- Iodinated contrast agents often have a number or percentage after their names
representing the weight-to-volume ratio or concentration of iodine containing
compounds in the solution. Again, using Reno-60 as an example, this product contains
60 g of iodine- containing salts per 100 ml of solvent, which is equivalent to a 60%
concentration. An iodinated contrast agent with a higher concentration is generally used
for cardiovascular studies, whereas a lower concentration is used for urography and
cholegraphy.

- Iodinated contrast media are available as either oil-based or water-soluble agents.

Each type of medium is selected for use based on the anatomy to be examined.

Oil-based Iodinated Contrast Media

- The use of oil-based iodinated contrast media in radiography is relatively limited.

- They are used primarily for studies of the lymphatic system (lymphangiography).

- In the past, they were also used for studies of the female reproductive system
(hysterosalpingography), spinal cord (Myelography), bronchial tree of the respiratory
system (bronchography), salivary glands (sialography), and tear ducts
(dacryocystography), but have been replaced by water-soluble iodinated nonionic
contrast media.

- The oil-based iodinated contrast medium is used in hollow anatomic areas, enhancing
the radiographic contrast of the structure.

- The oily base of the contrast medium is a fatty acid, which is responsible for making
the solution viscous (thick) and insoluble in water and body fluids.

- Because it is not miscible with blood, it should never be injected intravenously or intra-
arterially.

- It should also be noted that the oily medium tends to persist in the area that was
examined as it is very slowly absorbed by the body.

Water-soluble iodinated contrast media

- Water–Soluble (aqueous) iodinated contrast media are routinely used for radiographic
examinations of the urinary, biliary, and cardiovascular systems, as well as the digestive
system if barium sulfate is contraindicated. - Water-soluble iodinated contrast media are
also used in special examinations of the skeletal system such as mayelography and
arthrograhpy. - They are available in liquid, tablet or granule form depending on the
intended use. - The injectable liquid media can be divided in to ionic and nonionic
contrast agents.  An ionic contrast agent is an organic iodine compound that has
triiodinated benzoic acid as its base. The compound dissociates or separates in water
into two electrically charged particles. One of the particles, called a cation, has a positive
change; the other particle, an anion has a negative charge.  A nonionic contrast agent
also contains iodine and is derivative of the triiodinated benzoic acid base, but it does
not contain an ionizing group. It is more soluble in water and does not dissociate into
changed particles; it is said to have a lower osmolality than an ionic contrast agent.
Fig.1.1.Classification of iodinated contrast agents by their molecular structure

Osmolality refers to the concentration or number of particles (cations and anions) in the
solution per kilogram of water and is directly related to occurrence of adverse patient
reactions. it is measured in osmoles, which are units of osmotic pressure.  A contrast
agent with a high osmolality has an increased number of particles and more osmoles in
the solution. Any time a foreign substance is injected into the bloodstream, the
homeostasis of the body can be affected.- There is less chance of an interruption of
homeostasis if the osmolality of the injected contrast agent closely resembles that of
blood plasma, which is approximately 300 osmol/kg. On the average, nonionic contrast
agents have around 750 osmol/kg, whereas Ionic contrast agents range from 1000 to
2400 osmol/kg.- Because of their hyperosmolality, ionic contrast agents can cross the
blood-brain barrier, which is also a factor in the occurrence of adverse reactions.-
Nonionic contrast agents have a much lower level of neurotoxicity.- Although the
osmolality of nonionic contrast agents is still higher than that of blood plasma, it is
significantly lower than the osmolality of ionic contrast agents. For this reason, the use
of nonionic contrast agents tends to produce fewer physiologic reactions than use or
their ionic counterparts.

Table1.2. Examples of ionic (high osmolar) iodinated contrast agents

Name Type Iodine content Osmolality

Ditrizoate(Hypaque 50) Monomer 300 mg/ml 1550 Iothalamate (Conray 60) Monomer
370 mg/ml 2100 Ioxaglate (Hexabrix ) Dimer 320 mg/ml 580

Table1.3. Examples of non-ionic (low osmolar) iodinated contrast agents

Name Type Iodine content Osmolality

Iopamidol (Isovue 370) Monomer 370 mg/ml 796 Iohexol (Omnipaque 350) Monomer
350 mg/ml 884 Ioversol (Optiray) Monomer 320 mg/ml 796 Iopromide (Ultravist 370)
Monomer 370 mg/ml 774 Iodixanol (Visipaque 320) Dimer 320 mg/ml 290

Contraindications

- The most significant contraindication to the use of iodinated contrast media is an

allergic history to iodine. - In some cases, the patient can be premeditated without
causing an adverse reaction. - Allergic reactions to oil based iodinated contrast media
can occur but are rare.

The advantages of non ionic contrast media over ionic contrast media:

 Well tolerated by the patient  Less heat and discomfort on injection  Low osmolality
 Does not dissociate in to charged particles  Low neurotoxicity  Approximately one-
fifth fewer adverse reactions than with the use of ionic contrast media ROUTES OF
ADMINISTRATION

Contrast media are considered to be pharmaceuticals (drugs), and as such they must
beadministered appropriately to achieve the desired effect and to avoid unwanted
complications.

THE FIVE RIGHTS OF MEDICINE ADMINISTRATION

i. The right patient should receive ii. The right medication iii. In the right amount iv. Via
the right route v. At the right timeAs listed above the five rights system, applies to the
administration of all medications, includingcontrast agents:  The patient must be
properly identified.  The name of the contrast agent should be checked at least three
times – at the time of selection, preparation, just prior to administration.  Although
many contrast media are packaged in average dosage the amount may have to be
adjusted depending on the patient’s age, size and condition.  The contrast medium
must be administered by the proper route to be effective and to avoid adverse
complications.  Contrast media should be administered at the correct time which is
dependent on the type of examination. - The route of administration depends on the
anatomy of interest, type of examination, and particular contrast medium. - Contrast
medium can be administered orally, rectally, or intravascularly, or introduced directly in
to the intended site.

ORAL/RECTAL ROUTE - Barium sulfate products are administered by means of the oral
route for examinations of the esophagus stomach, and small intestine. - Iodinated
contrast agents such as Gastrografin and Hypaque can also be administered orally for
these same examinations. - Iodinated agents known as oral cholecystopaques are
administered orally in pill or granule form for visualization of the gallbladder. - A
contrast medium is administered rectally as an enema for an examination of the large
intestine. Although barium sulfate is the most commonly used contrast medium for this
purpose, Hypaque or similar iodinated products may also be used.

INTRAVASCULAR ROUTE

Only water- soluble iodinated contrast media can be administered intravascularly.

Intravascular injection of contrast media includes both intravenous and intra-arterial

routes.

The intravenous route is employed for excretory urography, as well as for CT and
MRIExaminations using contrast media.

- A vein in the antecubital region of the arm or on the dorsum of the hand provides the
easiest access site for injection. - The technologist performing the venipuncture should
follow universal precautions, which include the use of gloves. - After visual inspection of
the site, it is then thoroughly cleansed by applying a sterile alcohol or antiseptic swab in
a circular motion, working outward from the center of the site. - The site should be
allowed to dry completely. A tourniquet is applied snugly approximately 3 to 4 in (7 to
10 cm) above the site. - A butterfly needle, straight needle, or venous catheter is
inserted smoothly at a 15 0 angle to the skin (the bevel of the needle should face
upward).Back flow of blood indicates correct placement of the needle in the vein. - After
the tourniquet is released, the contrast medium can be injected in bolus fashion,
infusion, or by means of an automatic injector. - At the completion of the injection, a
sterile gauze pad is placed over the site, the needle is removed, and pressure is applied
for several minutes until the bleeding stops.

The intra-arterial route is used for special radiographic procedures of the cardiovascular
system.Access to the artery is accomplished via the seldinger technique which is
described inangiography.

In lymphangiography, the contrast medium is injected intravascularly into the lymphatic

vessels.

DIRECT ROUTE

Some radiographic examinations require that the contrast medium be introduced

directly into theanatomy of interest. This can be achieved by means of a catheter or
needle. For example, in acystogram a catheter is inserted into the urinary bladder and a
water-soluble iodinated contrastmedium is allowed to flow into the bladder until it is
full.

During a myelogram, an intrathecal injection is performed by inserting a spinal needle

into thesubarachnoid space between two vertebrae and injecting a water-soluble
iodinated (nonionic)contrast medium into the thecal sac.

Examples of other examination in which contrast media are directly administered

includearthrography, hysterosalpingography, sialography, and percutaneous
transhepaticcholangiograhy.

REACTIONS TO CONTRAST MEDIA

The potential exists for an adverse reaction to occur when a contrast medium is
administered to apatient. Although reactions can take place with the use of any contrast
agent, they are more likelyto occur after intravascular injection. Very few reactions
actually occur following administrationof barium sulfate or oil based iodinated contrast
agents. The technologist or radiographer shouldbe aware of the possibility of adverse
reactions and be prepared to handle them according to theinstitution’s protocol.

 An emergency drug box or crash cart should be in the examination room or readily
available.  It is recommended that the patient’s blood pressure, pulse, and respiration
be assessed prior to contrast medium administration. This provides baseline information
in the event a reaction occurs.  Because it is inert, barium sulfate rarely causes any
allergic reactions; however it does tend to cause constipation as the water is absorbed
from the mixture, leaving the solid barium sulfate in the intestines. This is especially true
in elderly patients who tend to have decreased bowel motility.  Following any
examination in which barium sulfate is administered; the patient should be advised to
drink plenty of fluids to prevent a bowel obstruction. Care should be taken when a
patient feels nauseous or vomits after ingestion of barium sulfate so that the contrast
material is not aspirated. Aspiration of barium sulfate into the lungs can result in
pneumonia. Occasionally, a condition known as hypervolemia can occur from
administration of a barium enema. In this very serious condition, excessive water is
absorbed from the large intestine by the circulatory system. Pulmonary edema and/or
other complications can result from the fluid overload.

An allergic reaction is possible with the use of any iodinated contrast agent; however,
fewreactions occur with the use of oil–based iodinated contrast media. The reactions to
injectablecontrast agents can be described as systemic because the physiologic
response of the body’ssystems is affected when the contrast media are injected into the
cardiovascular system.According to the chemotoxic Theory, hemodynamic changes
occur as the body’s normalphysiologic functions and homeostasis are interrupted. The
reactions seem to be directly relatedto the following factors.

 Degree of chemotoxicity of the contrast medium  Concentration of iodine in the

contrast medium  Certain properties of the contrast medium including osmolality,
viscosity, and purity of the solution  Dosage administered  Pace of the injection 
Physical condition of the patient An anaphylactic reaction closely resembles a true
allergic reaction in which the patientdemonstrates hypersensitivity when a foreign
substance is injected. Although such a reactioncannot be predicted, certain patients
seem to be predisposed to experiencing adverse reactions. Itis critical that the
radiographer take an accurate patient history prior to the administration. It iscritical that
the technologist or radiographer take an accurate patient history prior to
theadministration of a contrast medium, particularly to determine any allergies and
previousreactions to contrast media.

A vasovagal reaction is one that occurs in response to anxiety or fear. It generally

involves avascular as well as a neurogenic response, with the patient experiencing mild
symptoms ofpallor, dizziness, diaphoresis, nausea, and possibly bradycardia. The
radiographer/technologistcan help alleviate the symptoms by being supportive and
reassuring.

Extravasations Occurs during injection if some of the contrast medium seeps out of the
vein tothe surrounding tissue. This reaction usually involves pain and discoloration at
the site ofinjection. The technologist or radiographer should apply a warm, moist
compress to the site todecrease pain and aid in the absorption of the extravasated
contrast medium.

Adverse reactions are usually acute, with the majority occurring 5 to 20 minutes after
injection ofthe contrast medium. Although delayed reactions are possible, they are rare
and typically mild.

Reactions are classified as mild, moderate, or severe according to the symptoms

experienced bythe patient and the treatment needed to alleviate them.

Mild (Minor) reactions, such as a warm flush or metallic taste generally need little or no
treatment and are considered to be self limiting. Moderate reactions require the
administration of medication to relive the symptoms. For example, a patient who
develop hives on several areas of the body might be given and an antihistamine such as
Benadryl. Severe reactions are considered to be life threatening. Immediate treatment is
necessary to stabilize the patient beginning with administration of 100% oxygen and
accessing a vein to start an intravenous line (5% dextrose in water or normal Saline). The
patient’s Blood pressure, pulse and respiration should be closely monitored. TABLE 1.1.
Summary of a variety of adverse reactions, the particular body systems affected, and the
severity of the reactions

Severity of Reaction System Reaction Mild Moderate SevereCardiovascular Arrhythmia 

Tachycardia or  bradycardia Extreme hypotension  Cardiac arrest  Hypervolemia 
Neurologic Headache  May Become severe Unconsciousness  Coma  Seizures 
Aphasia Respiratory Coughing/sneezing  Dyspnea  Extreme change (up or down) in 
rate of respiration Cyanosis  Respiratory arrest Urinary Flank pain  Hematuria  Renal
impairment/failure 

Gastrointestinal Nausea/vomiting  Uncontrolled Vomiting  Metallic taste

Integumentary Hot /flush  Mild urticaria  Excessive urticaria  Pain or burning
sensation from  extravasation Itching Facial edema  

PATIENT CARE AND INSTRUCTION BEFORE ADMINISTERING IODINATED CONTRAS

AGENTS  Patients who are to receive iodinated CM should be instructed to have
adequate fluid intake to hydrate the body prior to administration, because sufficient
hydration helps to prevent adverse reactions  All iodinated contrast agents are most
comfortable for the patient when administered at body temperature, so, place the
solution to be injected in to a basin of tepid ( Luke warm) water for 10-15 minutes prior
to administration  Keep emergency Cart ( resuscitation drugs, like Adrenalin) readily
available before iodinated CM is administered  Before administering CM, ask the
patient for allergic foods, medicine, asthma, hayfever, whether CM examination has
been done for him/her previously and reaction happened or not; if the reply is positive
stops the procedure. MEASURES TO BE TAKEN WHEN ANAPHYLACTIC REACTION
HAPPENEDIf you observe the signs and symptoms of anaphylactic (allergic) reactions:- 
Stop the injection immediately  Monitor vital sign  Observe for respiratory distress  If
the patient is in anaphylactic shock, call emergency team (physicians and nurses)  Place
the patient in Semi-fowler’s or sitting position (for cardiopulmonary distress)  If the
patient becomes breath less and pulse less, administer cardiopulmonary resuscitation

PATIENT CARE AND INSTRUCTION AFTER RECEIVING IODINATED CONTRAST

AGENTSInstruct the patient to increase fluid intake to 3000ml for at least 24 hours to
assist with thedilution and excretion of the agent from the body. UNIT SUMMARY

 Contrast media alter a structure’s density, thus affecting its radiographic appearance. 
Contrast media can be used to enhance structures that have low contrast such as the
urinary, digestive, and biliary system, spinal canal, female reproductive system, and
vasculature. Negative contrast media are radiolucent and appear dark on a radiograph.
Room air is a common example of a negative contrast media. Positive contrast media
are radiopaque and appear light on a basis radiograph. Iodine and barium sulfate form
the basis of Positive contrast agents. Iodinated contrast media that are ionic dissociate
in to charged particles, whereas nonionic agents do not dissociate. Contrast media are
pharmaceutical agents (drugs) and must be administered appropriately with a
physician’s order. Contrast media can be administered orally or intravascularly or
introduced directly depending on the type of examination and the type of contrast
agent. An adverse reaction can occur with the use of any contrast media. Reactions
are classified as mild (minor), moderate, or severe, depending on the symptoms and
required treatment. An emergency drug cart should be prepared during special
procedures. Most contrast examinations use fluoroscopy and require some type of
patient preparation prior to the day of the examination.