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Principles of radiology
Chris J Harvey

be altered by changing the tube voltage and current, the target anode material and by using filters.

Tissue differentiation
At the energies used in diagnostic imaging, different tissues appear more or less transparent to X-rays. The resulting shadows can be detected by various means such as use of intensifying screen/photographic film combinations or fluoroscopic systems. The most common technique for imaging an X-ray is to expose a single image on a film sandwiched between two fluorescent screens, which convert X-rays to visible light, in a cassette. In digital systems an image is captured and scanned into a computer (computed radiography). The advent of digital technology has allowed the development of picture archiving and communication systems (PACS), with images viewed on computer monitors in a filmless department. Real-time fluoroscopy is also possible using image intensifiers and television systems. Different tissues produce different degrees of X-ray attenuation, basically reflecting their density, thickness and atomic number. Air, such as in the lungs, is transparent to X-rays and therefore appears black. Most soft tissues are of intermediate characteristics, whereas calcified tissues, such as bone, appear white. When there is a large difference in either density or atomic number between two organs, then the contours of the structures are clearly visualized on a radiograph because of the high inherent natural contrast (e.g. heart and lungs, bone and soft tissue). Four basic densities can be resolved on a conventional radiograph: air (Figure 1), fat, soft tissues and calcified tissues. An

Abstract
This article discusses the principles of conventional radiography. The production of X-rays is described along with the different techniques available to image them. The different types and applications of contrast agents are discussed along with adverse side effects and how to avoid or minimize them. Standard radiographic projections are described and methods used to improve image quality. X-rays cause tissue ionization. The radiation dose for a number of radiographic procedures is listed along with regulations governing their administration. methods of reducing dose are discussed. X-rays are high-energy electromagnetic photons produced by bombarding an anode with high-energy electrons. X-rays are used in diagnostic imaging, both in conventional radiography and CT. Different tissues absorb X-rays according to their density. Conventional radiographs allow the resolution of four densities (air, fat, soft tissue and calcification). Imaging can also be performed fluoroscopically or digitally. Exogenous contrast agents can be used to artificially enhance tissue visualization when there is no natural contrast; these have a wide spectrum of applications. Contrast agents may be classified as positive (e.g. barium) or negative (e.g. air) according to whether they are of high or low radiodensity. X-ray exposure should be performed only when it produces a net benefit to the patient and should be kept as low as reasonably achievable (the aLaRa principle). The Ionizing Radiation (medical Exposure) Regulations (IR(mE)R) require by law that all medical exposures to ionizing radiation are clinically justified and authorized.

Keywords aLaRa principle; contrast agents; IR(mE)R; radiation dose;

radiography; radiology; X-rays

An understanding of the basic principles of plain film radiography, its limitations and the precautions necessary to reduce exposure to ionizing radiation are essential to ensure maximum diagnostic benefit to the patient. This article discusses the role of conventional radiography and the part played by contrast agents in enhancing diagnostic yield. X-rays were discovered just over a century ago by Roentgen, and are used in all forms of conventional radiography, angiography and CT. They lie at the high-energy end of the electromagnetic spectrum and are produced by passing a high voltage across two terminals in a vacuum tube, causing high-energy electrons from the cathode to bombard the anode. The resulting interaction of electrons produces X-rays. The energy of the X-rays can

Chris J Harvey MRCP FRCR is a Consultant Radiologist and Honorary Senior Lecturer at Imperial College, Hammersmith Hospital, London, UK. Conflicts of interest: none declared.

Figure 1 a plain abdominal film of a patient with severe abdominal pain showing free intraperitoneal gas as air on either side of the colon (closed arrows; Riglers sign). The falciform ligament (open arrows) is also outlined by intraperitoneal gas. Reproduced with permission from Harvey CJ, Roberts H, Davies n, Strickland n, Scurr J, eds. Self assessment cases in surgical imaging. Oxford: Oxford Univerisity Press, 2005.

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example of the value of natural contrast is loss of the silhouette sign. On a normal chest radiograph the heart and mediastinal interface is clearly visualized against the black lungs. In the presence of parenchymal lung disease (collapse/consolidation) adjacent to the heart border, however, the density of the diseased lung is equal to that of the heart and so the cardiac contour is lost (loss of the silhouette sign).

Contrast agents
When there is no natural contrast, contrast agents are used to artificially alter X-ray attenuation locally (e.g. blood vessels in an organ). Contrast media may be divided into positive contrast agents of high radiodensity (e.g. iodine, barium) and negative agents of low density (e.g. air, CO2). Iodine and barium block Xrays, and appear white, whereas gas (air or CO2) appears black. Double-contrast combinations of air and barium can also be used in many situations to opacify body compartments. Contrast media may be used to demonstrate structural abnormalities (e.g. colonic cancer in double-contrast barium enema) or to derive functional information (e.g. delayed opacification of the renal tract due to obstruction in intravenous urography). Contrast agents have a wide spectrum of applications (Table 1) and may be introduced orally, by cannulation of orifices (e.g. sialography), via tubes (e.g. T-tube cholangiography), intravenously or percutaneously.

Applications of contrast agents

Site gastrointestinal tract Procedure Parotid/submandibular sialography Barium swallow Small bowel follow-through/enema Barium enema/proctography Sinography/fistulography Stomagraphy (colostomy/ileostomy) Endoscopic retrograde cholangiopancreatography Intravenous urography Pyelography (antegrade/retrograde) Urethrography Cystography nephrostography Ileal conduit studies Hysterosalpinography Percutaneous transhepatic cholangiography T-tube cholangiography Cholecystostomy angiography/venography/ lymphangiography arthrography (joint opacification) myelography (thecal sac opacification) Tubography (contrast introduced via a surgical drain)

Positive contrast agents Water-soluble contrast agents are based on iodine, which forms soluble compounds with low toxicity and has a high atomic number making it an efficient X-ray absorber. The compounds are in either non-ionic or ionic form. The older ionic agents are largely used for non-vascular studies. Newer non-ionic agents have lower osmolalities than an ionic contrast medium of the same iodine concentration, and are closer to plasma osmolality. Because of their lower osmolality they have fewer side effects and are routinely used intravenously. Side effects water-soluble contrast media are among the safest pharmaceutical agents available. The most serious side effects are anaphylactoid and are independent of dose. They range from flushing, bronchospasm and urticaria to anaphylaxis. Life-threatening anaphylaxis occurs in about 1 in 50,000 intravenous administrations, even with the newer non-ionic agents, and so resuscitation equipment should be available immediately. Dose-related adverse reactions also occur as a result of chemotoxicity and hyperosmolarity, and consist of vasodilatation (causing a feeling of warmth and hypotension), hypervolaemia (caused by fluid shifts), cardiac depression and discomfort at the injection site. Caution should be exercised in the following situations. Contrast agents may precipitate a deterioration in renal function (usually transient) in patients with diabetes, myeloma, renal impairment or dehydration. Adequate hydration, and possibly use of the antioxidant N-acetylcysteine, may help prevent this. There is a small risk of lactic acidosis in patients taking metformin. Current UK Royal College of Radiologists guidelines suggest cessation of the drug for 48 hours after the administration of iodinated contrast agents. The serum creatinine level should be checked before recommencement. Care should be taken in patients with a history of allergy, asthma or previous reactions to contrast (the use of predosing with corticosteroids is controversial). Cardiac impairment may cause problems (as cardiac failure may be precipitated, especially if large contrast loads are given). Hyperosmolar agents may cause cardiac depression and fluid shifts in neonates and the elderly. Crises may be precipitated in patients with sickle cell disease. Barium agents are almost exclusively used in the gastrointestinal tract. Barium sulphate suspensions have better coating properties than iodinated contrast media and form thin layers over the mucosa, providing excellent double-contrast imaging with air (Figure 2) or CO2. Single-contrast barium studies may be performed in suspected colonic obstruction, small bowel problems and children. Different barium formulations are used in the upper and lower gut. Patient preparation consists of bowel cleansing in colonic studies and a 6-hour fast before a barium swallow or meal. Side effects barium should not be used when a bowel perforation is suspected because barium in the peritoneal cavity incites an inflammatory reaction with a high mortality risk. Fibrosis, adhesions and granulomatous reactions occur. A similar effect occurs in mediastinal barium leak. Barium enema is contraindicated in toxic megacolon and for 710 days after a deep biopsy (i.e. performed at rigid sigmoidoscopy) or snare polypectomy because of the risk of perforation. Barium enema should be delayed for 48 hours after biopsies taken during flexible sigmoidoscopy because they are usually superficial. If perforation
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Urogenital tract

Biliary

Vascular miscellaneous

Table 1

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their distance from the cassette. Thus, anterior structures appear relatively larger on an AP compared with a PA film. Therefore, heart size cannot be assessed adequately on an AP chest radiograph. Other projections are described with respect to the side closest to the cassette: in a left lateral view, the X-ray beam passes from right to left, and in a right anterior oblique projection the right anterior body is closest to the cassette decubitus views are taken with the patient lying on the table on his/her side, but with the X-ray beam horizontal passing from anterior to posterior through the patient, to expose a posteriorly positioned radiograph. Other aspects A radiograph is a composite two-dimensional projected image. It is often advisable to image a three-dimensional structure (e.g. suspected bone fracture) in at least two planes to avoid missing a lesion. The phase of respiration is important in chest radiography. Conventional inspiratory films usually show the lung fields well, but expiratory views may show air trapping (e.g. distal to an inhaled foreign body) or a pneumothorax. Airfluid levels in bowel or abcesses may be revealed using a horizontal X-ray beam (e.g. placing the patient erect, or by performing a decubitus view). Improving image quality Various techniques may be used to improve image quality. A grid is a device consisting of multiple parallel lead strips that, when interposed between the patient and the cassette, improves image quality by filtering out obliquely scattered radiation, which degrades the image. Restricting (coning) the X-ray beam to the area of interest improves image quality and reduces the patients dose of X-rays. Computed radiography is generally much more tolerant to underexposure or overexposure. It tends to produce a higher proportion of diagnostic radiographs, therefore permitting a reduction in radiation dose. Portable machines are usually limited in the types of exposure that can be used and the films taken are of poorer quality. Radiographic positioning and radiation protection are also usually inferior with portable machines.

Figure 2 Double-contrast barium enema showing a 3-cm polypoid carcinoma at the hepatic flexure. The colonic mucosa is diffusely abnormal, with a granular pattern consistent with superficial ulceration due to ulcerative colitis. note that the colon is featureless with loss of the normal haustral pattern as a result of long-standing ulcerative colitis. Reproduced with permission from Harvey CJ, Roberts H, Davies n, Strickland n, Scurr J, eds. Self assessment cases in surgical imaging. Oxford: Oxford Univerisity Press, 2005.

is suspected a water-soluble agent (e.g. Gastrografin) should be used. If there is a risk of aspiration, Gastrografin should not be used because it may cause pulmonary oedema, and a dilute nonionic iodinated agent is preferred. Negative contrast agents Air is used as part of a double-contrast barium study (combined positive and negative contrast agents) to image the stomach, duodenum and colon. Rectal insufflation of air into the colon has recently been employed with promising results in CT pneumocolon and virtual colonoscopy. CO2 is used in double-contrast upper gastrointestinal studies, generated from swallowed effervescent granules. CO2 has also been used in peripheral angiography when iodinated agents are contraindicated, and is remarkably safe and well tolerated.

Radiographic techniques
Patient positioning Standard projections: most radiographs are taken using standardized projections. Conventionally, these are described with respect to the direction of the X-ray beam. Frontal projections are those where the patients sagittal axis is in line with the X-ray beam. Lateral views are taken parallel to the coronal axis. A PA chest radiograph is taken with the tube behind the patient and the cassette (or detector) against the anterior chest. These directions are reversed in the anteroposterior (AP) projection. The direction of the X-ray beam is important because X-ray beams diverge from a point source, and magnify objects in proportion to
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Radiation dose
X-rays cause tissue ionization, resulting in liberation of electrons and the production of an ion pair. This can lead to potentially harmful physicochemical effects, including the production of free radicals. Biological tissues, especially genetic material, are particularly susceptible to both the ionization and free radicals, which may lead to both carcinogenesis and mutagenesis. These effects are cumulative, increasing directly with respect to exposure, and are described as stochastic effects. There is no safe dose of radiation. Other radiation effects, such as the production of cataracts and skin erythema, do not occur below a certain threshold exposure and are termed non-stochastic. Approximately 87% of radiation exposure in the population occurs through natural causes (e.g. cosmic radiation, environmental

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effective dose from radiological procedures (approximate values)

Radiation dose (mSv) Chest X-ray (single Pa film) abdominal X-ray (single) Lumbar spine series Intravenous urography CT of abdomen/pelvis Barium enema Table 2 0.02 1 1.3 2.5 10 7 Relative dose 1 50 65 125 500 350 equivalent period of background dose 3 days 6 months 7 months 14 months 4.5 years 3 years

radon); the remaining, man-made exposure (13%) results almost entirely from the use of X-rays and radionuclides in medicine. The biological damage produced by a given exposure can be estimated by weighting the dose by the radiation sensitivity of different tissues. This value (the effective dose equivalent) is measured in milliSieverts (mSv), and gives an estimate of the adverse effects of different types of radiograph. Most medical staff working with radiation experience whole-body doses of less than 5 mSv/year; the maximum permitted dose is 50 mSv/year. By comparison, the average background radiation exposure in the UK is 2.5 mSv/year. The dose from a chest X-ray is very low (comparable to that experienced from cosmic radiation during a flight from London to Paris), whereas the dose from procedures such as CT may be hundreds of times higher (Table 2).

Minimizing exposure
The effects of X-ray ionization occur mainly along the line of the primary beam (i.e. within the patient) but X-rays are scattered in many directions when they pass through matter. Such scattered radiation is a danger to both the patient and anyone nearby. It is extremely important that the radiation dose both to patients and medical personnel is minimized. Complex regulations exist on this subject; the underlying principles are that X-ray exposure should be avoided unless it produces a net benefit to the patient, and that exposure should be kept as low as reasonably achievable (the ALARA principle). The Ionizing Radiation (Medical Exposure) Regulations (IR(ME)R), introduced by the Department of Health in 2000, require that all medical exposures to ionizing radiation are justified clinically and authorized. Furthermore, the radiation dose must be documented for each patient. Special consideration should be taken with respect to X-rays of the abdomen and pelvis in women of child-bearing age. Such a woman presenting for any examination involving radiation between the diaphragm and the knees should be asked whether she might be pregnant or if her period is overdue. If this is the case postponement of the examination should be considered. The fetus is more susceptible to ionizing radiation because cells are dividing rapidly, increasing the potential for radiation-induced chromosomal damage and thus mutations. Procedures involving relatively high exposures (e.g. abdominal/ pelvic CT and some barium studies) should be restricted to the first 10 days of the menstrual cycle, when pregnancy is unlikely, unless the clinical situation dictates otherwise. Fluoroscopy involves continuous irradiation and so almost always produces a much higher net dose than spot films. Spot films
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are individual films taken in the conventional way with an X-ray film rather than continuous real-time screening (as in fluoroscopy). The use of a tightly defined X-ray beam, or collimation, reduces the dose and improves image quality. Care in setting up for an exposure reduces the need for repeat images. In the UK, all personnel working with ionizing radiation must be trained appropriately. For example a surgeon wishing to use theatre X-rays must, by law, complete an approved short training course. All personnel working with X-rays should have their radiation dose monitored (e.g. with a film badge or similar device). Medical personnel should avoid any exposure to the primary beam, and stay as far away as feasible from any source of scattered radiation (e.g. the patient) as radiation dose decreases with distance according to an inverse square law. Staff must wear lead aprons during screening procedures; lead gloves and glasses are desirable. Pregnant staff should avoid involvement with screening procedures.

FuRTheR ReAdINg grainger and allisons Diagnostic Radiology. a textbook of medical Imaging. adam a, Dixon aK, eds. Vol 13, 5th edn. Edinburgh: Churchill-Livingstone, 2005. making the best use of clinical radiology services, 6th edn. London: Royal College of Radiologists, 2007.

Practice points
X-rays are high-energy electromagnetic photons Conventional radiographs allow the resolution of four densities (air, fat, soft tissue and calcification) Exogenous contrast agents artificially enhance tissue visualization and have a wide spectrum of applications Contrast agents may be classified as positive (e.g. barium) or negative (e.g. air) according to whether they are of high or low radiodensity X-ray exposure should only be performed when it produces a net benefit to the patient and should be kept as low as reasonably achievable (the aLaRa principle) The Ionizing Radiation (medical Exposure) Regulations (IR(mE)R) require by law that all medical exposures to ionizing radiation are clinically justified and authorized

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