Radiation protection in digestive endoscopy: European Society of Digestive Endoscopy (ESGE) Guideline

This article expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about radiation protection for endoscopic procedures, in particular endoscopic retrograde cholangiopancreatography (ERCP). Particular cases, including pregnant women and pediatric patients, are also discussed. This Guideline was developed by a group of endoscopists and medical physicists to ensure that all aspects of radiation protection are adequately dealt with. A two-page executive summary of evidence statements and recommendations is provided. The target readership for this Guideline mostly includes endoscopists, anesthesiologists, and endoscopy assistants who may be exposed to X-rays during endoscopic procedures.

• References

• 1 Dumonceau JM, Polkowski M, Larghi A et al. Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2011; 43: 897-912
• 2 Dumonceau JM, Andriulli A, Deviere J et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline: prophylaxis of post-ERCP pancreatitis. Endoscopy 2010; 42: 503-515
• 3 Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ 2001; 323: 334-336
• 4 International Commission on Radiation Units and Measurements. Fundamental quantities and units for ionizing radiation. ICRU Report. 2011 85.
• 5 International Electrotechnical Commission. Medical electrical equipment - Part 2–43: Particular requirements for the basic safety and essential performance of X-ray equipment for interventional procedures. 2010 IEC 60601–2-43. Ed. 2.0.
• 6 Council Directive 97/43/Euratom of 30 June 1997 on health protection of individuals against the dangers of ionizing radiation in relation to medical exposure, and repealing Directive 84/466/Euratom. Available at: http://ec.europa.eu/energy/nuclear/radioprotection/doc/legislation/9743_en.pdf Accessed: February 10 2011
• 7 Valentin J. Publication 103. The 2007 Recommendations of the International Commission on Radiological Protection.. Ann ICRP 2007; 37: 23-275
• 8 European Commission. Radiation Protection 154. European Guidance on estimating population doses from medical X-ray procedures. Luxembourg: Directorate General for Energy and Transport; 2008
• 9 Valentin J. Relative biological effectiveness (RBE), quality factor (Q), and radiation weighting factor (wR). ICRP Publication 92.. Ann ICRP 2003; 33: 1-121
• 10 European Commission. Radiation Protection 116. Guidelines on education and training in radiation protection for medical exposures. Luxembourg: Directorate General Environment, Nuclear Safety and Civil Protection. 2000 Available at: http://eceuropaeu/energy/nuclear/radiation_protection/doc/publication/116pdf Accessed: December 21 2010
• 11 Teunen D. The European Directive on health protection of individuals against the dangers of ionising radiation in relation to medical exposures (97/43/EURATOM). J Radiol Prot 1998; 18: 133-137
• 12 Vano E, Gonzalez L, Canis M et al. Training in radiological protection for interventionalists. Initial Spanish experience.. Br J Radiol 2003; 76: 217
• 13 Rehani MM, Vano E, Ciraj-Bjelac O et al. Radiation and cataract. Radiat Prot Dosimetry 2011; 147: 300-304 Epub 2011 Jul 14
• 14 Kleinerman RA. Cancer risks following diagnostic and therapeutic radiation exposure in children. Pediatr Radiol 2006; 36: 121-125
• 15 Buls N, Pages J, Mana F et al. Patient and staff exposure during endoscopic retrograde cholangiopancreatography. Br J Radiol 2002; 75: 435-443
• 16 Chen MY, Van Swearingen FL, Mitchell R et al. Radiation exposure during ERCP: effect of a protective shield. Gastrointest Endosc 1996; 43: 1-5
• 17 Cohen G, Brodmerkel GJ, Lynn S. Absorbed doses to patients and personnel from endoscopic retrograde cholangiopancreatographic (ERCP) examinations. Radiology 1979; 130: 773-775
• 18 Germanaud J, Legoux JL, Sabattier R et al. [Radiation protection of operators during endoscopic retrograde cholangiopancreatography]. Gastroenterol Clin Biol 1993; 17: 259-263
• 19 Heyd RL, Kopecky KK, Sherman S et al. Radiation exposure to patients and personnel during interventional ERCP at a teaching institution. Gastrointest Endosc 1996; 44: 287-292
• 20 Ismail S, Khan F, Sultan N et al. Radiation exposure to anaesthetists during interventional radiology. Anaesthesia 2010; 65: 54-60
• 21 Johlin FC, Pelsang R, Greenleaf M. Phantom study to determine radiation exposure to medical personnel involved in ERCP fluoroscopy and its reduction through equipment and behavior modifications. Am J Gastroenterol 2002; 97: 893-897
• 22 Larkin CJ, Workman A, Wright RE et al. Radiation doses to patients during ERCP. Gastrointest Endosc 2001; 53: 161-164
• 23 Naidu LS, Singhal S, Preece DE et al. Radiation exposure to personnel performing endoscopic retrograde cholangiopancreatography. Postgrad Med J 2005; 81: 660-662
• 24 Samara ET, Stratakis J, Enele Melono JM et al. Therapeutic ERCP and pregnancy: is the radiation risk for the conceptus trivial?. Gastrointest Endosc 2009; 69: 824-831
• 25 Selmaier M, Stillkrieg W, Müller RG et al. [Radiation burden in diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP)]. Z Gastroenterol 1994; 32: 671-674
• 26 Tsalafoutas IA, Paraskeva KD, Yakoumakis EN et al. Radiation doses to patients from endoscopic retrograde cholangiopancreatography examinations and image quality considerations. Radiat Prot Dosimetry 2003; 106: 241-246
• 27 Uradomo LT, Lustberg ME, Darwin PE. Effect of physician training on fluoroscopy time during ERCP. Dig Dis Sci 2006; 51: 909-914
• 28 Vañó E, González L, Beneytez F et al. Lens injuries induced by occupational exposure in non-optimized interventional radiology laboratories. Br J Radiol 1998; 71: 728-733
• 29 Vano E, Kleiman NJ, Duran A et al. Radiation cataract risk in interventional cardiology personnel. Radiat Res 2010; 174: 490-495
• 30 Olgar T, Bor D, Berkmen G et al. Patient and staff doses for some complex x-ray examinations. J Radiol Prot 2009; 29: 393-407
• 31 Brambilla M, Marano G, Dominietto M et al. Patient radiation doses and references levels in interventional radiology. Radiol Med 2004; 107: 408-418
• 32 Widmark A, Fosmark H, Einarsson G et al. Guidance levels in the Nordic countries: a preliminary report for selected interventional procedures. Radiat Prot Dosimetry 2001; 94: 133-135
• 33 Hart D, Hillier C, Wall B HPA-RPD-029. Doses to patients from radiographic and fluoroscopic X-ray imaging procedures in the UK – 2005 Review. Oxford, UK: Health Protection Agency; 2007. Avaiable at http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947413167 Accessed: September 27 2010.
• 34 Hart D, Hillier MC, Wall BF. National reference doses for common radiographic, fluoroscopic and dental X-ray examinations in the UK. Br J Radiol 2009; 82: 1-12
• 35 Amis E. Risks of radiation exposure in the endoscopy suite: principles, cautions, and risks to patients and endoscopy staff. Tech Gastrointest Endosc 2007; 9: 213-217
• 36 Pedrosa MC, Farraye FA, Shergill AK et al. Minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics. Gastrointest Endosc 2010; 72: 227-235
• 37 Campbell N, Sparrow K, Fortier M et al. Practical radiation safety and protection for the endoscopist during ERCP. Gastrointest Endosc 2002; 55: 552-557
• 38 Cousins C, Sharp C. Medical interventional procedures – reducing the radiation risks. Clin Radiol 2004; 59: 468-473
• 39 Järvinen H, Buls N, Clerinx P et al. Overview of double dosimetry procedures for the determination of the effective dose to the interventional radiology staff. Radiat Prot Dosimetry 2008; 129: 333-339
• 40 Cohen RV, Aldred MA, Paes WS et al. How safe is ERCP to the endoscopist?. Surg Endosc 1997; 11: 615-617
• 41 Uradomo LT, Goldberg EM, Darwin PE. Time-limited fluoroscopy to reduce radiation exposure during ERCP: a prospective randomized trial. Gastrointest Endosc 2007; 66: 84-89
• 42 Domienik J, Brodecki M, Carinou E et al. Extremity and eye lens doses in interventional radiology and cardiology procedures: first results of the ORAMED project. Radiat Prot Dosimetry 2011; 144: 442-447
• 43 Oonsiri S, Jumpangern C, Sanghangthum T et al. Radiation dose to medical staff in interventional radiology. J Med Assoc Thai 2007; 90: 823-828
• 44 Cordoliani YS. Organisation de la radioprotection dans un service d’imagerie médicale. Feuill Radiol 2004; 44: 381-387
• 45 Miller DL, Balter S, Wagner LK et al. Quality improvement guidelines for recording patient radiation dose in the medical record. J Vasc Interv Radiol 2009; 20: 200-207
• 46 Valentin J. Avoidance of radiation injuries from medical interventional procedures, ICRP Publication 85. Ann ICRP 2000; 30: 51
• 47 U.S. Food and Drug Administration (FDA). Recording information in the patient’s medical record that identifies the potential for serious X-Ray-induced skin injuries. Available at: www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm117030htm Accessed September 2 2011
• 48 Balter S. Methods for measuring fluoroscopic skin dose. Pediatr Radiol 2006; 36: 136-140
• 49 Le Heron JC. Estimation of effective dose to the patient during medical x-ray examinations from measurements of the dose-area product. Phys Med Biol 1992; 37: 2117-2126
• 50 U.S. Food and Drug Administration (FDA). Performance standard for diagnostic X-Ray systems and their major components. (21CFR 1020.30, 1020.31, 1020.32, 1020.33); Small entity compliance guide. 07.06.2007 Available at: www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm094370.htm Accessed: August 23 2011
• 51 International Electrotechnical Commission (IEC). Medical electrical equipment – Part 1–2: General requirements for basic safety and essential performance – Collateral standard. Electromagnetic compatibility. Requirements and tests. IEC 60601–1–2. Ed. 3.0. 2007.
• 52 Miller DL, Balter S, Cole PE et al. Radiation doses in interventional radiology procedures: the RAD-IR study: part II: skin dose. J Vasc Interv Radiol 2003; 14: 977-990
• 53 Amis ES, Butler PF, Applegate KE et al. American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol 2007; 4: 272-284
• 54 Baron TH, Schueler BA. Pregnancy and radiation exposure during therapeutic ERCP: time to put the baby to bed?. Gastrointest Endosc 2009; 69: 832-834
• 55 Kicken PJ, Bos AJ. Effectiveness of lead aprons in vascular radiology: results of clinical measurements. Radiology 1995; 197: 473-478
• 56 Rawlings DJ, Faulkner K, Harrison RM. Broad-beam transmission data in lead for scattered radiation produced at diagnostic energies. Br J Radiol 1991; 64: 69-71
• 57 Schueler BA. Operator shielding: how and why. Tech Vasc Interv Radiol 2010; 13: 167-171
• 58 O’Sullivan S, Bridge G, Ponich T. Musculoskeletal injuries among ERCP endoscopists in Canada. Can J Gastroenterol 2002; 16: 369-374
• 59 Goldstein JA, Balter S, Cowley M et al. Occupational hazards of interventional cardiologists: prevalence of orthopedic health problems in contemporary practice. Catheter Cardiovasc Interv 2004; 63: 407-411
• 60 Ross AM, Segal J, Borenstein D et al. Prevalence of spinal disc disease among interventional cardiologists. Am J Cardiol 1997; 79: 68-70
• 61 Shergill AK, McQuaid KR, Rempel D. Ergonomics and GI endoscopy. Gastrointest Endosc 2009; 70: 145-153
• 62 Khalil MT, Abdel-Moty ME, Rosomoff SR, Rosomoff H. Ergonomics in back pain: a guide to prevention and rehabilitation. New York: Wiley; 1993
• 63 Yaffe MJ, Mawdsley GE, Lilley M et al. Composite materials for x-ray protection. Health Phys 1991; 60: 661-664
• 64 Wagner LK, Mulhern OR. Radiation-attenuating surgical gloves: effects of scatter and secondary electron production. Radiology 1996; 200: 45-48
• 65 Nicholson RA. Technical note: the relationship between TV position and the effectiveness and comfort of protective spectacles in fluoroscopic procedures. Br J Radiol 1995; 68: 1021-1024
• 66 Maeder M, Brunner-La Rocca HP, Wolber T et al. Impact of a lead glass screen on scatter radiation to eyes and hands in interventional cardiologists. Catheter Cardiovasc Interv 2006; 67: 18-23
• 67 Whitby M, Martin CJ. Radiation doses to the legs of radiologists performing interventional procedures: are they a cause for concern?. Br J Radiol 2003; 76: 321-327
• 68 Balter S. Radiation safety in the cardiac catheterization laboratory: operational radiation safety. Catheter Cardiovasc Interv 1999; 47: 347-353
• 69 Valentin J. Diagnostic radiology. Ann ICRP 2000; 30: 15-19
• 70 Atomic Energy Regulatory Board (AERB). Safety code for medical diagnostic X-ray equipment and installations, No. AERB/SC/MED-2 (Rev 1). Mumbai: AERB; 2001
• 71 Tsalafoutas IA, Yakoumakis E, Sandilos P. A model for calculating shielding requirements in diagnostic X-ray facilities. Br J Radiol 2003; 76: 731-737
• 72 National Council on Radiation Protection and Measurements (NCRP). Report No 147 – Structural shielding design for medical X-ray imaging facilities. Bethesda, Maryland, USA: NCRP; 2004
• 73 Archer BR, Gray JE. Important changes in medical x-ray imaging facility shielding design methodology. A brief summary of recommendations in NCRP Report No. 147. . Med Phys 2005; 32: 3599-3601
• 74 Damilakis J, Perisinakis K, Theocharopoulos N et al. Anticipation of radiation dose to the conceptus from occupational exposure of pregnant staff during fluoroscopically guided electrophysiological procedures. J Cardiovasc Electrophysiol 2005; 16: 773-780
• 75 Jorgensen JE, Rubenstein JH, Goodsitt MM et al. Radiation doses to ERCP patients are significantly lower with experienced endoscopists. Gastrointest Endosc 2010; 72: 58-65
• 76 Hernandez RJ, Goodsitt MM. Reduction of radiation dose in pediatric patients using pulsed fluoroscopy. AJR Am J Roentgenol 1996; 167: 1247-1253
• 77 Scanavacca M, d’Avila A, Velarde JL et al. Reduction of radiation exposure time during catheter ablation with the use of pulsed fluoroscopy. Int J Cardiol 1998; 63: 71-74
• 78 Boland GW, Murphy B, Arellano R et al. Dose reduction in gastrointestinal and genitourinary fluoroscopy: use of grid-controlled pulsed fluoroscopy. AJR Am J Roentgenol 2000; 175: 1453-1457
• 79 Sprawls P. Physical principles of medical imaging‎. Available at: www.sprawls.org/ppmi2/SCATRAD/#CONTRAST Accessed: February 10 2011
• 80 Yanch JC, Behrman RH, Hendricks MJ et al. Increased radiation dose to overweight and obese patients from radiographic examinations. Radiology 2009; 252: 128-139
• 81 Vehmas T. Hawthorne effect: shortening of fluoroscopy times during radiation measurement studies. Br J Radiol 1997; 70: 1053-1055
• 82 Nicholson R, Tuffee F, Uthappa MC. Skin sparing in interventional radiology: the effect of copper filtration. Br J Radiol 2000; 73: 36-42
• 83 Morrell RE, Rogers AT, Jobling JC et al. Barium enema: use of increased copper filtration to optimize dose and image quality. Br J Radiol 2004; 77: 116-122
• 84 Balter S, Hopewell JW, Miller DL et al. Fluoroscopically guided interventional procedures: a review of radiation effects on patients' skin and hair. Radiology 2010; 254: 326-341
• 85 Hall EJ. Lessons we have learned from our children: cancer risks from diagnostic radiology. Pediatr Radiol 2002; 32: 700-706
• 86 Koenig TR, Mettler FA, Wagner LK. Skin injuries from fluoroscopically guided procedures: part 2, review of 73 cases and recommendations for minimizing dose delivered to patient. AJR Am J Roentgenol 2001; 177: 13-20
• 87 Strauss KJ, Kaste SC. ALARA in pediatric interventional and fluoroscopic imaging: striving to keep radiation doses as low as possible during fluoroscopy of pediatric patients – a white paper executive summary. J Am Coll Radiol 2006; 3: 686-688
• 88 Romagnuolo J, Bardou M, Rahme E et al. Magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary disease. Ann Intern Med 2003; 139: 547-557
• 89 Garrow D, Miller S, Sinha D et al. Endoscopic ultrasound: a meta-analysis of test performance in suspected biliary obstruction. Clin Gastroenterol Hepatol 2007; 5: 616-623
• e90 Jamidar PA, Beck GJ, Hoffman BJ et al. Endoscopic retrograde cholangiopancreatography in pregnancy. Am J Gastroenterol 1995; 90: 1263-1267
• e91 Farca A, Aguilar ME, Rodriguez G et al. Biliary stents as temporary treatment for choledocholithiasis in pregnant patients. Gastrointest Endosc 1997; 46: 99-101
• e92 Howden J. Endoscopic choledocholithiasis (CDL) during pregnancy: safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES). Gastrointest Endosc 2001; 53: AB96
• e93 Güitrón-Cantú A, Adalid-Martínez R, Gutiérrez-Bermúdez JA et al. [Endoscopic management of choledocholithiasis during pregnancy]. Rev Gastroenterol Mex 2003; 68: 11-15
• e94 Tarnasky PR, Simmons DC, Schwartz AG et al. Safe delivery of bile duct stones during pregnancy. Am J Gastroenterol 2003; 98: 2100-2101
• e95 Tham TCK, Vandervoort J, Wong RCK et al. Safety of ERCP during pregnancy. Am J Gastroenterol 2003; 98: 308-311
• e96 Kahaleh M, Hartwell GD, Arseneau KO et al. Safety and efficacy of ERCP in pregnancy. Gastrointest Endosc 2004; 60: 287-292
• e97 Simmons DC, Tarnasky PR, Rivera-Alsina ME et al. Endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy without the use of radiation. Am J Obstet Gynecol 2004; 190: 1467-1469
• e98 Gupta R, Tandan M, Lakhtakia S et al. Safety of therapeutic ERCP in pregnancy – an Indian experience. Indian J Gastroenterol 2005; 24: 161-163
• e99 Shelton J, Linder JD, Rivera-Alsina ME et al. Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos). Gastrointest Endosc 2008; 67: 364-368
• e100 Daas AY, Agha A, Pinkas H et al. ERCP in pregnancy: is it safe?. Gastroenterol Hepatol (NY) 2009; 5: 851-855
• e101 Tang S-J, Mayo MJ, Rodriguez-Frias E et al. Safety and utility of ERCP during pregnancy. Gastrointest Endosc 2009; 69: 453-461
• e102 Kammerer WS. Nonobstetric surgery during pregnancy. Med Clin North Am 1979; 63: 1157-1164
• e103 Lanzafame RJ. Laparoscopic cholecystectomy during pregnancy. Surgery 1995; 118: 627-631 discussion 631-623
• e104 Valentin J. Effects of in utero irradiation ICRP Publication 84. Ann ICRP 2000; 30: 9-12
• e105 ACOG Committee on Obstetric Practice. Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol 2004; 104: 647-651 ACOG Committee Opinion. Number 299, September 2004 (replaces No. 158, September 1995).
• e106 Al-Hashem H, Muralidharan V, Cohen H et al. Biliary disease in pregnancy with an emphasis on the role of ERCP. J Clin Gastroenterol 2009; 43: 58-62
• e107 Uomo G, Manes G, Picciotto FP et al. Endoscopic treatment of acute biliary pancreatitis in pregnancy. J Clin Gastroenterol 1994; 18: 250-252
• e108 Frossard JL, Dumonceau JM. The role of EUS in the biliary system. In: Shami VM, Kahaleh M, editors Endoscopic ultrasound. New York: Humana Press; 2010: 329-70
• e109 Vano E, Sanchez R, Fernandez JM et al. Importance of dose settings in the x-ray systems used for interventional radiology: a national survey. Cardiovasc Intervent Radiol 2009; 32: 121-126
• e110 Federal Office of Public Health. Directive R-08–06 Contrôles de qualité des installations radiologiques numériques pour la radiographie et/ou la radioscopie. Berne, Switzerland: Available at Accessed February 10 2011 www.bag.admin.ch/themen/strahlung/02883/02885/02889/index.html?lang=fr
• e111 New York State Department of Health Bureau of Environmental Radiation Protection. Guide for radiation safety/quality assurance program in small facilities. Part II – Fluoroscopic equipment. Available at: www.health.ny.gov/environmental/radiological/radiation_safety_guides/fluoroscopic_equipment.htm Accessed February 10 2011
• e112 Columbia University Environmental Health and Safety. Quality assurance programs for diagnostic radiology facilities. Available at: www.ehs.columbia.edu/QA.PDF Accessed December 11 2010