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The Evolving Role of the
Radiologist Assistant
Richard Danieli
Outline
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Introduction
Radiology journey R.R.T. to R.A.
Education as a Radiologist Assistant student
Registered Radiologist Assistant (R.R.A.) Handbook ARRT
RA education requirements
Procedure List
Mandatory procedures
Elective procedures
Competency requirements
CR1 Forms
CR2 Forms
Summative Evaluations
Board license eligibility
Exam outline
Career outlook
Current legislation
HR 3032 Medicare Access to Radiology Care Act
Society of Radiology Physician Extenders
Interesting Case studies
Fibrin sheath port injection study
Hiatal Hernia on UGI
Loopogram obstruction
TFC tear wrist arthrogram
Questions and Answers
Introduction
• Clark F. Miller School of Radiologic Technology at
Central Maine Medical Center
• Central Maine Community College
• Florida Hospital College of Health Science
• Currently at Quinnipiac University Masters in
Health Science Radiologist Assistant
– 24 Month Full time: first year classroom, second year
clinicals. Clinical placement:
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Yale New Haven Hospital, CT.
Fallon Clinic Worcester, MA.
Baystate Medical Center Springfield , MA.
Cooper Univerisity Hospital Camden, NJ.
Uconn Medical Center Farmington, CT
R.R.T. to R.A.
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R.R.T. license in every state for clinicals
Advance Cardiac Life Support (ACLS)
– Moderate/Conscious sedation
– Response to a code/anaphylaxis/allergic reaction
– Cardiac rhythyms
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Educational structure differences and the importance of good educators
The bridge between Radiologist and Technologist
– Technician difficulties and interpretation difficulties
– logistics (PACS,RIS, proper orders etc…)
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Responsibilities- need to recognize pathology
– RT’s have Merrills. RA’s have….. Pathology, experience, Radiologist preferences.
– IR-Coagulation factors
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If you don’t know about it, you don’t look for it
– Radiologist-4 years undergrad, 4 years medical school, 1 year surgery/ internal medicine
internship, 4 years residency, 1 year fellowship= 14 years education
– RA’s- 4 years undergrad, 2 years graduate school= 6 years education
Q.U. Education Courses
• Clinical Pharmacology I
• Human Anatomy
• Human Anatomy Lab
• Imaging Pathophysiology
• Radiation Safety and Health
Physics
• Image Critique & Pathologic
Pattern Recognition I
• Image Critique & Pathologic
Pattern Recognition II
• Interventional Procedures I
• Interventional Procedures II
• Patient Assessment,
Management and Education
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Research Methods and Design
Clinical Seminar I
Clinical Seminar II
Clinical Seminar III
Radiologist Assistant Clinical I
Radiologist Assistant Clinical II
Radiologist Assistant Clinical III
Radiologist Assistant Clinical IV
Thesis I
Thesis II
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GastroIntestinal and Chest
Esophageal study must fluoro and image the
esophagus, may be with UGI
Swallow Function Study (participate in
procedure and provide initial observations to
radiologist
Upper GI Study
Small Bowel study- direct the study and spot
TI
Small bowel study via enteroclysis tube
Enema with barium, air, or water soluble
contrast
Nasogastric/enteric and orogastric/enteric
tube placement-may not require image
guidance
T-tube cholangiogram
Defecography
Perform chest fluoroscopy for diaphragmatic
motion
Genitourinary
Antegrade urography through existing tube
(e.g. pyelostography, nephrostography)
Cystography or voiding cystourethrography,
with minimum of 10 bladder catheterizations
Retrograde urethrography or
urethrocystography
Loopography through existing tube
Hysterosalpinography- imaging only
Hysterosalpinography- procedure and image
(physian participation required)
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Invasive Nonvascular
Arthrogram (radiography, CT, MR joint
injection and aspirations)
Lumbar Puncture
Cervical, thoracic, or lumbar myelographyimaging only
Lumbar Puncture with contrast
Thoracentesis with or without catheter
Placement of catheter for pneumothorax
Paracentesis
Abscess, fistula, sinus tract study
Injection sentinel node localization
Breast needle localization
Change of percutaneous tube or drainage
catheter
Thyroid biopsy
Liver biopsy
Invasive Vascular
Peripheral insertions of central venous
catheter placement
Insertion of non-tunneled central venous
catheter
Insertion of tunneled central venous
catheter
Port injection
Extremity Venography
Post processing
Perform CT post processing
Perform MR post processing
Clinical Portfolio
• The Clinical Portfolio consists of the following
components:
– (1) Clinical Experience Documentation and Clinical
Competence Assessments
– (2) Professional Activities and Accomplishments
Record
– (3) Case Studies
– (4) Summative Evaluation Rating Scales.
Form CR-1: Summary of Clinical Experience and
Competence Assessments
• 1. This form is completed by the student as he or she: (a) completes
the requisite number of cases for the mandatory and elective
procedures; and (b) is evaluated by a radiologist on the mandatory
and elective procedures.
• 2. The student records the number of cases completed for each
mandatory and elective procedure he or she performs.
• 3. The student records only the date that the competency
assessment was completed. Note that the actual competence
assessments are completed by a radiologist using Form CR-2
• 4. The preceptor and program director must verify and sign the
bottom of Form CR-1. This form is submitted to ARRT at the time of
application.
Form CR-2: Clinical Competence
Assessments (Forms CR-2A through CR-2E)
• 1. These forms are completed by the radiologist at the time
he or she evaluates the student. There are separate
evaluation forms for each class of radiologic procedures:
– Form CR-2A: GI/Chest Form CR-2C: invasive nonvascular
– Form CR-2B: GU Form CR-2D: invasive vascular
– Form CR-2E: post-processing activities
• 2. The radiologist and student are required to sign the
bottom of Form CR-2 for each assessment, which is
subsequently reviewed and signed by the program director.
• 3. The student must submit a minimum total of 15
assessment forms to ARRT (12 mandatory and 3 elective
procedures).
Summative Evaluation
• The Summative Evaluation Rating Scales
address five skill areas:
– (1) evaluation of medical information
– (2) patient communication
– (3) radiation safety
– (4) professionalism
– (5) specific procedural skills
R.R.A. Exam Board Eligibility
• 1. ARRT Certified and Registered in
Radiography
• 2. One year of Acceptable Clinical Experience
• 3. Educational Program Completion
• 4. Didactic Competence Requirement
R.R.A. Licensing Exam Board Eligibility
• 5. Clinical Education Requirements
– 5A. Component 1: Clinical Experience
Documentation and Competence Assessments
– 5B. Component 2: Professional Activities and
Accomplishments Record
– 5C. Component 3: Case Studies
– 5D. Component 4: Summative Evaluation Rating
Scales
R.R.A. Licensing Exam Board Eligibility
• 6. Baccalaureate Degree
• 7. ARRT Ethics Requirements
• 8. Application for Certification
Registered Radiologist Assistant
Examination Content Categories
• Multiple Choice:
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A.Patient Communication, Assessment, and Management- 45 points
B. Drugs and Contrast Materials -30 points
C. Anatomy, Physiology, and Pathophysiology- 55 points
D. Radiologic Procedures- 40 points
E. Radiation Safety, Radiation Biology, and Fluoroscopic Operation- 15
points
– F. Medical-Legal, Professional, and Governmental Standards -15 points
– Total Number- 200 points
– Testing Time Allowed 3.5 hours
• 2 Case Studies
– Each case is followed by four to six essay questions worth 3 or 6 points
each.
– Testing Time Allowed 2.5 hours
Career Outlook
• Momentarily Difficult
– New Profession, Myths, and Fears (lack of support)
– Reimbursement issues (CMS Guidelines and supervision
requirements)
• R.R.A. roles beyond ARRT
– Image interpretation ( think radiology residence)
– Radiology Procedures not listed (bone marrow biopsy, IVC
filter placement, drainage tube insertion, port removal,
radiologist comfort etc…)
– Liability
• United kingdom
– Advanced radiographer Practitioner
• Quality of service provided
– Clinical training of RA vs resident, PA, NP
HR 1148 Medicare Access to Radiology
Care Act of 2013
• To amend title XVIII of the Social Security Act
to provide for payment for services of
qualified radiologist assistants under the
Medicare program.
• More senator Co-sponsorship needed.
Society of Radiology Physician
Extenders
• “The Society of Radiology Physician Extenders (SRPE) is a
non-profit organization for the RPA and RRA sharing a
common bond within the global mid-level radiology
profession and medical community in general. The society
holds an annual conference conducting seminars and
presentations. The SRPE is an active participant with other
health care professionals and organizations to educate and
promote the role of the mid-level radiology extender. Our
organization is committed to fostering the highest values
and promoting superior lifelong success both personally
and professionally.”
– Conferences with Continuing Education Credits
– Legislative involvement
• http://www.srpeweb.org/DesktopDefault.aspx
References
• A.R.R.T (2013). Registered Radiologist
Assistant (R.R.A.) | ARRT - The American
Registry of Radiologic Technologists.
Retrieved January 12, 2013, from
https://www.arrt.org/Certification/RegisteredRadiologist-Assistant
• S.R.P.E. (2013). Society of Radiology
Physician Extenders Inc. Society of Radiology
Physician Extenders Inc. Retrieved January
12, 2013, from
http://www.srpeweb.org/DesktopDefault.aspx
Richard Danieli
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55 year old female
Right breast grade 3 infiltrating ductal carcinoma
Mammogram of Right Breast
Breast Cancer
Ultrasound of Right Breast
Breast Cancer
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Left sided portacatheter placed 5/23/12 in
good location and functional
Portacatheter needed for chemothereapy
treatment for cancer of the right breast
Initial post port chest x-ray on 5/23/12
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No blood return from port when accessed two days
ago
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Left sided portacatheter placed to keep right
side open for surgical and radiation options
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Portacatheter was accessed using sterile
technique
Patient was positioned supine on fluoroscopy
table
Scout spot x-ray obtained
Patient was positioned in right anterior oblique
10 cc non ionic iodinated contrast was injected
in the port
Live fluoroscopy and rapid sequence imaging
was obtained
Scout fluoroscopy image 1 month post port placement
Note: Loop in
catheter
Note: Distal
location of
catheter
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Malposition of the distal end of the
portacatheter
Loop in middle portion of portacatheter
Fibrin sheath formation of distal portacatheter
lumen
Port Injection Image
Note: contrast
jetting superiorly
and laterally from
catheter.
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Extravasation of contrast through fracture or
hole of catheter
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Migration of the catheter tip superiorly with a
mid-portion loop is known complication
especially with left sided ports due to the
vessel pathway
Fibrin sheath formation of the distal catheter
lumen another known complication of
portacatheters allowed a limited forward flush,
but no blood aspiration
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Removal of current portacatheter
Replace with a new portacatheter
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John:
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1. What are the indications for a central venous port?
2. What are the indications for a left chest port placement?
Stacy:
1. If a large symptomatic venous air embolism is caused,
in what position do you place your patient?
 2. What is the treatment for a large symptomatic venous
air embolism?
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Tina:
1. What are the post op port placement instructions for
patients?
 2. Describe the details involved with using tissue
plasminogen activator to treat fibrin sheaths or clots at
the catheter tip.
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Kandarpa, K., & Machan, L. (2011). Handbook of interventional
radiologic procedures (4th ed.). Philadelphia: Wolters
Kluwer/Lippincott Williams & Wilkins Health.
Kessel, D., Robertson, I., & Sabharwal, T. (2011). Interventional
radiology: A survival guide (3rd ed.). Edinburgh: Churchill
Libingstone/Elsevier.
Kim, F. M., Burrows, P. E., Hoffer, F. A., & Chung, T. (1996).
Interpreting the results of pediatric central venous catheter studies.
Radiographics, 16, 747-754. Retrieved from
http://radiographics.rsna.org/content/16/4/747.full.pdf+html.
Mauro, M. (1998). Delayed complications of venous access.
Techniques in Vascular and Interventional Radiology, 1(3), 158-167.
doi:10.1016/S1089-2516(98)80145-5 .
Slaby, J., & Navuluri, R. (2011). Chest Port Fracture Caused by
Power Injection. Seminars in Interventional Radiology, 28(3), 357358. doi:10.1055/s-0031-1284463.
Richard Danieli
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77 year old female
No known surgery to gastrointestinal tract
No weight loss
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Dysphagia
Pharyngeal perforation, aspiration, and fistula
were not clinically indicated therefore thick
and thin barium contrast was used and not
water soluble contrast.
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The patient stated “food gets stuck in my
throat”
Other clinical reasons for performing an
esophagram include:
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Dysphagia (difficulty swallowing)
Odynophagia (painful swallowing)
Globus (sensation of a lump in the throat)
Suspected aspiration
Postoperative assessment of laryngectomy
Penetrating Trauma
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Endoscopy showed antral deformity follow up
with GI study recommended
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Esophagram performed
Thick and thin barium used in vertical and
horizontal positions
Patient positioned upright in right lateral, AP,
and LPO
Patient positioned supine in RAO, AP and RPO
Images obtained of esophagus collapsed and
dilated with barium
Modifications of routine exam to image
visualized pathology
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The chest x-ray shows
the Hiatal Hernia.
Notice the
circumscribed lucency
behind the heart.
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Notice the small
Zenker’s
diverticulm.
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Notice the distal
esophageal
diverticulum with
barium distending
distal esophagus
Image obtained in
upright position
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Notice distal
esophageal
diverticulum has
barium pooling. In
comparison to
previous image there
are tertiary
contractions of the
distal tortuous
esophagus
Image obtained in
upright position
stomach
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Notice the location of
the diaphragm, clearly
showing a Type IV
complex
paraesophageal hiatal
hernia.
Image obtained supine
notice difference in
appearance from prior
images done upright
showing or movement
of the hernia
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Results:Multiple tertiary contractions of the esophagus
are seen associated with prominence of the
cricopharyngeus sphincter. 5mm in diameter Zenkers
diverticulum is noted. No aspiration or penetration is
seen. Large Hiatal hernia is seen with the majority of
the stomach herniated into the chest cavity. There is
considerable gastroesophageal reflux. A 2cm diameter
outpouching is noted of the distal aspect of the
esophagus compatible with distal esophageal
diverticulum.
Impression: Prominence of the cricopharyngeal
sphincter associated with small Zenkers diverticulum.
Significant motility dysfunction of the esophagus.
Diverticulum of the distal esophagus as described.
Large hiatal hernia. See above
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The differentials for the hiatal hernia on the frontal
chest x-ray are:
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retrocardiac lung abscess
retrocardiac empyema
epiphrenic esophageal diverticulum
There are no differentials for the esophagram images.
They could potentially be wrongly diagnosed.
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The stomach could be wrongly diagnosed as a volvulus or
malrotation if the interpreter did not notice the level of the
diaphragm, but these diagnosis should be done on an UGI
where the duodenum is visualized
The zenckers diverticulum could be wrongly diagnosed as an
ulcer
The distal esophageal diverticulum could be wrongly
diagnosed as a large ulcer
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Zenker’s diverticulum correlates with the sensation
of food getting stuck in the upper esophagus
Motility dysfunction which contributes to the
patient’s dysphagia.
Considerable gastroesophageal reflux (suspected
treatment or forgot to mention symptoms)
Asymptomatic distal esophageal diverticulum
Asymptomatic type IV complex paraesophageal
hiatal hernia
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Treatment for the reflux would be recommended
such as Prilosec (an antacid).
Surgery of hiatal hernia only necessary if hernia
causes strangulation which cuts off the blood
supply or causes an obstruction
No treatment for asymptomatic type IV complex
paraesophageal hiatal hernia
No treatment for 77 year old asymptomatic distal
esophageal diverticulum
No treatment for the Zencker’s diverticulum
No treatment for dysmotility
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Upper gastrointestinal barium study to
visualize the stomach and duodenum could be
done for further evaluation
Small bowel follow through with barium could
also be done to further evaluate potential areas
of obstruction.
CT with oral contrast of the abdomen and
pelvis could be performed to further evaluate
the anatomy
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John:
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Stacy:
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What are the four types of Hiatal Hernias?
What are two properly named diapragmatic hernias?
Discuss the indications and contraindications of
using a barium tablet during an esophagram
Discuss the indications and contraindication of
administering effervescent granules
Tina:
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Define a Zenker’s diverticulum
Discuss another type of esophageal diverticulum

Herring M.D., W. (2007). Recognizing Tumors, Tics, and Ulcers: Radiology of the Gastrointestinal Tract. In Learning
Radiology Recognizing the Basics. (1st ed.). (pp. 181-196). Philadelphia, Pennsylvania: Mosby Elsevier.

Houston M.D., J. D., & Davis M.D., M. D. (2001). Pharyngeal and Esophageal Examinations. In Fundamentals of
Fluoroscopy. (1st ed.). (pp. 15-47). Philadelphia, Pennsylvania: W.B. Saunders Company.

Mettler,JR., M.D., F. A. (2005). Gastrointestinal System. In Essentials of Radiology. (2nd ed.). (pp. 170-188).
Philadelphia, Pennsylvania: Elsevier Saunders.
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Pretorius,M.D., E. S., Solomon,M.D., J. A., & Rubesin,M.D., S. E. (2011). Upper Gastrointestinal Tract. In Radiology
Secrets Plus. (3rd ed.). (pp. 101-118). Philadelphia, Pennsylvania: Mosby Elsevier.

Sandstrom,M.D., C. K., & Stern, M.D., E. J. (2011). Diaphragmatic Hernias: A Spectrum of Radiographic
Appearances. Current Problems in Diagnostic Radiology, 40(3), 95-115.
doi:http://dx.doi.org/10.1067/j.cpradiol.2009.11.001,
Richard Danieli
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A 68 year old male with history of muscle
invading bladder cancer.
Post operative robotic assisted radical
cystoprostatectomy
Post operative ileal conduit urinary diversion
performed
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History of bladder cancer
Prior CT
Filling defects in the dilated left renal pelvis
 Absence of contrast opacification of the left ureter,
 Recommend direct inspection of the left collecting
system with cystoscopy and ureteroscopy.
 Interval worsening of the left
hydroureteronephrosis.
 Anastomotic stricture at the junction between the
ureter and ileal conduit cannot be excluded
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Recommendation from prior CT
Evaluate Ileal Conduit
Evaluate left ureter by retrograde contrast
administration
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History of bladder cancer
Obstructed proximal left ureter seen on prior
CT
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24-gauge Foley catheter inserted into stoma
with 30 cc balloon inflated
Conray-60 introduced into ileal conduit by
gravity infusion
Reflux into right ureter
No contrast entered the left ureter despite
various positional changes and delayed
imaging.
Patient vomited possibly due to relative over
distention of the ileal bladder in attempts to
induce left ureteral reflux
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Normal right upper urinary tract
Normal ileal conduit contour
No reflux into left ureter due to obstruction at
the ureteroileal junction
Note: No
contrast in left
ureter
Catheter
Right ureter
Catheter
balloon
Ileal conduit
Catheter
Note: No
contrast in
left ureter
Catheter
balloon
Right ureter
Ileal
conduit
Right ureter
Note: No
contrast in left
ureter
Catheter
balloon
Catheter
Ileal conduit
IV contrast
in right
ureter
IV contrast
remained in
left renal pelvis
IV contrast
in right
ureter
IV contrast
remained in
left renal
pelvis
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No contrast extravasated therefore obstructed
Ureteral obstruction post ileal conduit
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Improperly fashioned anastomosis
Ischemia of the ureter with subsequent fibrosis and
stricture
Recurrent tumor in the ureter (rare)
Infection or abscess formation with reaction
Edema
Calculus
Sloughed papilla
Adhesions or scarring.
Torsion or compression at the sigmoid
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No extravasation of contrast outside of the ileal
conduit or the right ureter
Normal contour of ileal conduit and right
ureter
No contrast filling into the left ureter during
the loopogram.
Left ureter not evaluated from retrograde
contrast administration via loopogram or
antegrade contrast administration via CT
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Renal ultrasound
Renal radionuclide studies,
Percutaneous nephrogram/ureterogram
Intravenous pyelogram (IVP)
Abdomen/pelvis CT (with oral contrast, with
and without IV contrast)
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John:
1. Where are post operative ileal conduit obstructions
most common?
 2. Besides obstruction, what is the other most common
abnormality post operative ileal conduit surgery.
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Stacy:
1. Describe pseudoobstruction (conduit malfunction) and
the cause.
 2. What is a mucus plug in reference to a loopogram?
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Tina:
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1. Describe two renal complications of an ileal conduit.
2. What risks are associated with an excessive length of an
ileal conduit?


Appleby, S., & Atala, A. (2010, September 2). Urostomy and Continent Urinary Diversion. National
Kidney and Urologic Diseases Information Clearinghouse. Retrieved July 7, 2012, from
http://kidney.niddk.nih.gov/kudiseases/pubs/urostomy/index.aspx

Banner, M. P., Pollack, H. M., Bonavita, J. A., & Ellis, P. S. (1984). The radiology of urinary
diversions. Radiographics, 4, 885-913. Retrieved from
http://radiographics.rsna.org/content/4/6/885.full.pdf+html?sid=b58c27e0-59a3-40e3-bba639316da2f87d

Fernbach, S., & Holland, E. (1988). Undiversion of the urinary tract: The pre-and postoperatie
evaluation. Radiographics, 8, 213-233. Retrieved from
http://radiographics.rsna.org/content/8/2/213.full.pdf+html?sid=b58c27e0-59a3-40e3-bba639316da2f87d

Noble, J., Amin, Z., Kessel, D., & Rickards, D. (1994). Recurrent upper tract urothelial tumours: the
use of loopography following cystectomy for bladder cancer. British Journal of Radiology, 67(803),
1057-1061. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7820396

Thiruchelvam, N., Harrison, M., & Page, A. C. (2007). The double wire technique: an improved
method for treating challending ureteroileal anastomotic strictures and occlusions. British Journal of
Radiology, 80, 103-106. Retrieved from http://bjr.birjournals.org/content/80/950/103.long
Rich Danieli


19 year old female continued right wrist
discomfort for four months status post surgery
for fracture of 5th metacarpal due to traumatic
fall
Patient continues to have pain with movement
and therefore range of motion is slightly
limited.
An evaluation of patient and patients chart shows no
contraindication for arthrogram or MRI (not pregnant,
not claustrophobic, non-ferrous orthopedic hardware, no
other metallic hardware, normal coagulations, no
infection, and no known allergies.
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Bleeding
Infection
Contrast Reaction
Joint Capsule Rupture.
It assists and increases the ability to diagnose
pathology within the wrist on the MRI.
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Do nothing
MRI without gadolinium
Arthogram without gadolinium and MRI
Wrist arthroscopy.

20ml syringe Gadolinium mixture
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Injection site of the wrist

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15ml saline
5ml isovue iodinated contrast
0.2ml of gadolinium.
radioscaphoid joint
Small patient and small joint

only 2.5ml of Gad mixture was injected.

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
Exercise wrist
Final images obtained and recorded
Send patient to MRI

Artifact

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Gadolinium injected in the wrong area
Delayed gadolinium injection time from MRI scan
time

homogenous structure
composed of articular
disc, the dorsal and
volar radioulnar
ligaments, the
meniscus homologue,
the ulnar collateral
ligament, and the
sheath of the extensor
carpi ulnaris


Arthrogram right wrist with
contrast and gadolinium
injection
Partial sprain
triangular
fibrocartilage complex
ligament at its
attachment to the
ulnar styloid
Internal sprain
triangular fibro
cartilage.


MRI right wrist with gadolinium
Partial sprain TFC
ligament at its
attachment to the
ulnar styloid
Internal sprain
triangular fibro
cartilage.


MRI right wrist with gadolinium
Partial sprain TFC
ligament at its
attachment to the
ulnar styloid
Internal sprain
Triangular fibro
cartilage.

No prior MRI available for comparison, intra-articular
injection performed prior to patient’s arrival to the MRI
center.. There is normal marrow signal in the distal radius
and ulna, carpal bones and the base of the metacarpal bones.
There is no eveidence of fracture or bone contusion. There is
a partial tear of the triangular fibrocartilage ligament at it
attachment to the ulnar styloid. There is a sprain of the
scapholunate ligament. There is no evidence of vascular
necrosis of the scaphoid. Surrounding soft tissue structures
are unremarkable. There is no joint effusion. The median
nerve has a proper signal characteristic in the caudal tunnel.
There is no abnormal fluid collection. There is metal artifacts
along the diaphysis of the fifth metacarpal. Posterior
rotation of the distal ulna and a shallow ulnar notch of the
distal radius suggesting distal radial ulnar instability.

John


What is the specific components of the patient’s
orthopeadic hardware made of that make it
compatible with MRI?
What are the typical sequences used for an MRI of
the wrist with Gadolinium?

Tina


What are the pros and cons of patient positioning
when performing an MRI of the wrist between
having the wrist above the head (superman position)
or having the wrist by the patient’s side?
If the patient was pregnant, what would have been
the best diagnostic test to perform?

Stacy


What is a patient assessment test to check for
triangular fibrocartilage complex injury and how is it
performed?
Was an MRI with Gadolinium necessary for this
patient to determine her diagnosis?





David W. Stoller, The wrist, Seminars in Roentgenology, Volume
30, Issue 3, July 1995, Pages 265-276, ISSN 0037-198X,
10.1016/S0037-198X(05)80015-X.
Houston,MD, J., & Davis, MD, M. (2001). Musculoskeletal
Examinations. In Fundamentals of Flouroscopy. (1st ed.). (pp. 135138). Philadelphia, PA: W.B. Saunders Company.
Luis Cerezal, Faustino Abascal, Roberto García-Valtuille,
Francisco del Piñal, Wrist MR Arthrography: How, Why, When,
Radiologic Clinics of North America, Volume 43, Issue 4, July
2005, Pages 709-731, ISSN 0033-8389, 10.1016/j.rcl.2005.02.004.
Robinson, P. (2005). MR imaging of the wrist. Current
Orthopaedics, 19(3), 196-208.
Usha Chundru, Geoffrey M. Riley, Lynne S. Steinbach, Magnetic
Resonance Arthrography, Radiologic Clinics of North America,
Volume 47, Issue 3, May 2009, Pages 471-494, ISSN 0033-8389,
10.1016/j.rcl.2009.02.001.