Fluoroscopy for the gastroenterologist: Minimizing your risk

By Douglas Faigel and Nalini Guda

In endoscopy, the use of fluoroscopy for extended periods of time is restricted to only a few procedures, especially endoscopic retrograde cholangiopancreatography and sometimes other complex interventional endoscopic procedures.

  1. The amount of radiation to be used is based on the “ALARA” principle – As Low as Reasonably Achievable
  2. Fluoroscopy time alone is not a measure of the degree of radiation exposure
  3. Radiation exposure is proportional to the body mass index (BMI) of the patient
  4. Radiation exposure is proportional to the complexity of the procedure. Procedures done for assessment and therapy of the intrahepatic ducts or proximal biliary strictures carry higher exposures
  5. When positioning the patient, ensure that the source is at least 15 cm away (the farther the better) from the patient, and the detector is closer – 10 cm (the closer the better)
  6. Keep the exposure rate to the lowest possible pulses per second – 3 PPS
  7. Avoid magnification as far as possible, as this increases exposure
  8. Avoid angulation and limit fluoro “on” time
  9. Collimation or decreasing the field of exposure reduces the risk of radiation exposure
  10. Use of “last image hold” and “fluorosave”, instead of spot films minimizes exposure
  11. Skin erythema and toxicity can be seen at exposures >2 Gy
  12. When ERCP is done in pregnant patients, the uterus MUST be shielded
  13. Transabdominal ultrasound, endoscopic ultrasound, and magnetic resonance cholangiopancreatography can be done to confirm diagnoses before resorting to ERCP. Thus ERCP should be done only if needed, using the least radiation possible, and by experienced endoscopists
  14. Personal protection equipment is mandatory and should include a thyroid shield, lead glasses, and a well-fitting body shield (smock or wraparound). A wraparound shield is better since it also protects the back
  15. Dosimeter badges should be worn outside the lead shield
  16. Scatter of radiation from the patient increases staff exposure. Maintaining an adequate distance and use of a lead shield/curtain help to minimize exposure
  17. Quality assessments and staff education are critical for the safety of staff, patient, and endoscopist


This article is based on the presentation by Professor Douglas Faigel at DDW 2018.

Douglas Faigel
Professor of Medicine – Mayo Clinic College of Medicine
Chair – Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic
Consultant – Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic

Aurora St.Luke’s Medical Center, Milwaukee
Clinical Adjunct Professor of Medicine
University of Wisconsin, School of Medicine and Public Health
Program Director, Advanced Endoscopy Fellowship,
GI Associates, Milwaukee, WI.