1. During an operative (surgical) cholangiogram, the C-arm is used in the AP position. Which C-arm orientation BEST reduces scatter to the head and neck of the surgical team?
ERCP and cholangiograms
Three exams fill the bile ducts with contrast. In an ERCP, a gastroenterologist passes a scope into the duodenum and injects contrast into the ducts. An operative cholangiogram is done in surgery during gallbladder removal. A T-tube cholangiogram is done in radiology after surgery, through a drain left in the bile duct.
What the ARRT tests
- ERCP: endoscopic retrograde cholangiopancreatography. Contrast goes in through the duodenal papilla (ampulla of Vater), the opening of the common bile duct and pancreatic duct.
- ERCP can be therapeutic: removing stones, cutting the sphincter (sphincterotomy) and placing stents.
- Pancreatitis is the main complication of ERCP.
- Operative (intraoperative) cholangiogram: contrast through the cystic duct during a cholecystectomy, to check the common bile duct for stones before the surgeon finishes.
- T-tube (postoperative) cholangiogram: through the T-tube left in the common bile duct, to check for leftover stones and flow into the duodenum before the tube is removed.
- Bile duct path: right and left hepatic ducts, common hepatic duct, then (after the cystic duct joins) the common bile duct to the duodenum.
Why it's done
- Stones in the bile duct, jaundice, a blocked duct or stent, or a narrowing (stricture).
- Pancreatic duct problems.
- Checking the ducts during or after gallbladder surgery.
Who's in the room
- Gastroenterologist or surgeon
- Runs the scope or surgery, injects contrast, and asks for images.
- Anesthesia or sedation nurse
- Sedates and monitors the patient (ERCP and surgery).
- Radiographer (you)
- Runs the fluoro or C-arm, saves the images, positions the unit, and handles radiation protection for the team.
Step by step
- ERCP setup. Patient prone or semiprone on the fluoro table, sedated. You run fluoro on request while the doctor cannulates the duct and injects. Save each image the doctor needs.
- Operative cholangiogram. C-arm over the right upper abdomen with the tube under the table. The surgeon injects through a catheter in the cystic duct; you take images on command, with metal instruments moved out of the way.
- T-tube cholangiogram. In radiology: the radiologist injects through the T-tube while watching the ducts fill and drain into the duodenum.
- After. Save and send the images, record fluoro time and dose, and clean the equipment.
Your job
- Lead for everyone in the room; the doctor at the patient's head is close to the beam for ERCP.
- Pulsed fluoro, last-image hold, and keep your hand off the pedal unless asked.
- In surgery: keep the C-arm draped and out of the sterile field until called.
Watch out for
- ERCP patients are sedated: protect pressure points and watch the patient when moving the table.
- Air bubbles in the ducts can look like stones; the injection should be free of bubbles.
- Sterile field in surgery: don't touch draped areas with the C-arm.
Images
Quick check
2. ERCP like the one shown is both diagnostic and therapeutic. Which condition is MOST commonly treated during the same procedure?
3. To fill the ducts with contrast during this ERCP, the physician passes a catheter through which opening in the descending duodenum?
4. After an ERCP with sphincterotomy, a supine abdomen shows branching gas lucencies within the bile ducts of the liver. What is air within the biliary tree called?
5. In this ERCP image, the gallbladder and cystic duct contain multiple rounded lucencies outlined by contrast. What do these most likely represent?
Practice it in 3D
More in the guide
C-arm basics
The parts, the movements, the dose modes, and where to stand.
Sterile basics
What's sterile, what you can touch, and how to move around the field.
Esophagram and upper GI series
Barium swallow and UGI: why they're ordered, the positions, and your role.
Modified barium swallow (swallow study)
Video swallow study with speech therapy: bolus types, the field of view, and your role.
Small bowel follow-through
Timed films as barium moves from the stomach to the colon.
Barium enema
Single- and double-contrast BE: prep, tip insertion, positions, and overheads.
Cystogram and VCUG
Bladder filled through a catheter: leak checks, reflux, and voiding images.
Hysterosalpingogram (HSG)
Uterus and fallopian tubes for infertility: timing, setup, and dose.
Arthrogram
Joint injection under fluoro, usually before MRI or CT.
Myelogram
Contrast in the spinal canal: needle site, table tilt, and keeping contrast out of the head.
Lumbar puncture (fluoro-guided)
Spinal tap under fluoro when bedside attempts fail.
Hip pinning (hip fracture fixation)
The most common C-arm case: the fracture table, the two views, and your role.
Ankle and wrist ORIF
Open reduction and internal fixation of the ankle or wrist: the views, the mini C-arm, and hands in the beam.