Referral Guidelines For Imaging
14
Abstract
The newly revised medical exposure
directive (97/43/Euratom) lays down the
15
European Commission
general principles of radiation protection
of individuals in relation to medical
exposure. Member States had to
transpose it into national legislation
KH-29-00-408-EN-C
until 13 May 2000. Article 6(2) of the
directive requires Member States to
e n s u re t h a t re c o m m e n d a t i o n s
concerning referral criteria for medical
RADIA
exposure are available to the prescribers
RADIATION PROTECTION 118
of medical exposure.
This booklet sets out referral guidelines
TION PROTECTION 118
that can be used by health professionals
qualified to refer patients for imaging,
in order to ensure that all examinations
are well justified and optimised.
Referral guidelines
This booklet has evolved from that
previously published by the UK Royal
College of Radiologists in 1998 and is
for imaging
entitled: Making the best use of a
department of clinical radiology:
guidelines for doctors. These referral
guidelines have been adapted by experts
representing European radiology and
nuclear medicine, in conjunction with
the UK Royal College of Radiologists,
and may now be adopted as models
for the Member States.
These referral guidelines are not binding
on Member States, and form part of a
number of technical guides drawn up
to facilitate implementation of the
medical exposure directive. Local
variations may be required according
to healthcare practice and provision.
Continued use of recommendations of
this kind should improve clinical practice
and lead to a reduction in the number
of referrals for investigation and
consequently to a reduction in
associated medical radiation exposure.
Price (excluding VAT) in Luxembourg: EUR 16
OFFICE FOR OFFICIAL PUBLICATIONS
OF THE EUROPEAN COMMUNITIES
L-2985 Luxembourg
EN
ISBN 92-828-9454-1
See our publications catalogue at:
9 789282 894545
http://europa.eu.int/comm/environment/pubs/home.htm
Radiation Protection 118
Referral guidelines
for imaging
Adapted by experts representing
European radiology and nuclear
medicine
In conjunction with
the UK Royal College of Radiologists
Co-ordinated by
the European Commission
European Commission
Directorate-General for the Environment
2000
Any views expressed in this document do not
necessarily reflect the views of the European
Commission. Neither the European Commission
nor any person acting on behalf of the
Commission is responsible for the use which
might be made of the following information.
A great deal of additional information on the
European Union is available on the Internet.
It can be accessed through the Europa server
(http://europa.eu.int).
Cataloguing data can be found at the end of this
publication.
Luxembourg: Office for Official Publications of
the European Communities, 2001
ISBN 92-828-9454-1
© European Communities, 2001
Reproduction is authorised provided the source is
acknowledged.
Printed in Italy
PRINTED ON WHITE CHLORINE-FREE PAPER
Preface
These referral guidelines for imaging have evolved
from the booklet ‘Making the best use of a
department of clinical radiology: guidelines for
doctors’, which was published by the UK Royal
College of Radiologists in 1998 (1). They have been
adapted by various expert groups from several
countries and comments have also been gathered from
radiological societies and nuclear medicine societies
of Member States through the European Association
for Radiology and Nuclear Medicine. The European
Commission co-ordinated this process. The referral
guidelines may now be adopted as models for the
Member States, even though it is recognised that
further local adaptation may be needed according to
varying health care practice and provision. The next
edition of the guidelines will be prepared by the
Royal College of Radiologists (Chairman of the
working party: Professor Gillian Needham,
Aberdeen), in conjunction with the European
Commission and the various expert bodies within the
European Community. They will be even more
evidence-based and take into account European as
well as UK practice.
The EU Council Directive 1997/43/Euratom (2)
declared that Member States shall promote the
establishment and use of diagnostic reference levels for
radiological examinations and guidance thereof. These
referral guidelines can be used for the above purposes.
This publication would not have been possible
without the work of a sub-committee which met three
times in 1999:
Professor Dr W Becker, Nuclear Medicine,
Göttingen, DE
Professor Angelika Bischof Delaloye, President,
European Association of Nuclear Medicine,
Lausanne, CH
3
Dr Vittorio Ciani, European Commission, Directorate-
General for Environment, Brussels, B
Professor Adrian K Dixon, Royal College of
Radiologists, Cambridge, UK
Mr Steve Ebdon-Jackson, Department of Health,
London, UK
Dr Keith Harding, Nuclear Medicine, Birmingham,
UK
Dr Elisabeth Marshall-Depommier, Paris, F
Professor Iain McCall, President, UEMS Radiology
Section, Oswestry, UK
Professor Gillian Needham, Royal College of
Radiologists, Aberdeen, UK
Professor Hans Ringertz, European Association of
Radiology, Stockholm, S
Dr Bruno Silberman, Hon. General Secretary, UEMS,
Paris, F
Dr Diederik Teunen, European Commission,
Directorate-General for Environment, Brussels, B
Dr Ciska Zuur, Ministry of Housing, Spatial Planning
and the Environment,
The Hague, NL
We owe them all a lot of thanks.
P Armstrong
Prof Hans Ringertz,
President
President (1999),
Royal College
European Association
of Radiologists
of Radiology,
London, UK
Stockholm, SE
Prof. Angelika Bischof Delaloye,
President (1999),
European Association
of Nuclear Medicine
Lausanne, CH
4
Contents
Foreword to the fourth edition (1998) of the
Royal College of Radiologists (RCR)
guidelines (1).....................................................
7
Introduction .......................................................
11
Why are guidelines and referral criteria
needed?........................................................
11
What advice is available? ...........................
12
What images are taken? ..............................
14
For whom are the guidelines designed? .....
14
Using the guidelines....................................
14
Pregnancy and protection of the foetus ............
16
Optimising radiation dose .................................
18
Typical effective doses from diagnostic
medical exposures in the 1990s..................
19
Communications with a department of clinical
radiology............................................................
22
Technique-based imaging..................................
23
Computed tomography (CT).......................
23
Interventional radiology (including
angiography and minimal access therapy) ...
24
Magnetic resonance imaging (MRI)...........
25
Nuclear medicine (NM) ....................................
27
Nuclear medicine therapy ...........................
28
Ultrasound (US) ................................................
29
Glossary .............................................................
31
5
Clinical problems, investigations,
recommendations and comments ......................
32
A. Head (including ENT problems)...........
32
B. Neck.......................................................
37
C. The spine ...............................................
40
D. Musculoskeletal system.........................
45
E. Cardiovascular system...........................
53
F. Thoracic system.....................................
57
G. Gastrointestinal system .........................
60
H. Urological, adrenal and genito-urinary
systems ..................................................
73
I. Obstetrics and gynaecology ..................
77
J. Breast disease ........................................
80
K. Trauma...................................................
84
L. Cancer....................................................
99
M. Paediatrics..............................................
110
Selected bibliography ........................................
121
Appendix ...........................................................
124
6
Foreword to the fourth
edition (1998) of the Royal
College of Radiologists
(RCR) guidelines (1)
This booklet has been prepared to help referring
clinicians make the best use of a department of
clinical radiology. Continued use of recommendations
of this kind leads to a reduction in the number of
referrals for investigation and also to a reduction in
medical radiation exposure (3–7). Nevertheless the
primary objective of this booklet is to improve
clinical practice. Such recommendations work best if
they are used in conjunction with clinico-radiological
dialogue and as part of the audit process. They are
intended to be used by both hospital doctors (all
grades) and primary care physicians. The editor
(Adrian Dixon, Cambridge) has been assisted by the
other members of the working party: Dr John
Bradshaw (Bristol), Dr Michael Brindle (President of
the Royal College of Radiologists, King’s Lynn), the
late Dr Claire Dicks-Mireaux (London), Dr Ray
Godwin (Bury St Edmunds), Dr Adrian Manhire
(Chairman of the RCR audit sub-committee,
Nottingham), Dr Gillian Needham (Aberdeen), Dr
Donald Shaw (London), Mr Chris Squire (RCR
clinical audit advisor), Dr Iain Watt (Bristol) and
Professor J Weir (Dean of the Faculty of Radiology,
Aberdeen). Mr Barry Wall from the National
Radiological Protection Board (NRPB) has again
kindly provided data regarding radiation doses for a
variety of investigations.
Since the third edition there has been yet further
advance within magnetic resonance imaging (MRI),
and this is reflected in the recommendations. This
edition also includes recommendations for some of
the new niche roles for ultrasound (US), computed
7
tomography (CT) and nuclear medicine (NM),
including positron emission tomography (PET). The
system based approach introduced in 1995 has been
retained; most feedback has suggested that this format
was more useful than the previous arrangement.
Once again we have indicated whether the statements
included within the booklet are based on rigorous
scientific evidence. In line with UK National Health
Service Executive policy on the development of
clinical guidelines (8), we have adopted the following
classification:
(A) randomised controlled trials (RCTs), meta-
analyses, systematic reviews; or
(B) robust experimental or observational studies; or
(C) other evidence where the advice relies on expert
opinion and has the endorsement of respected
authorities.
Interestingly, such grading systems have now become
quite commonplace in many aspects of health care,
now that ‘evidence-based medicine’ has become
accepted practice (9–10). Review of the evidence has
been very time consuming. The working party is very
grateful to Dr Rachael Harrison who did much of the
initial data trawl as part of the REALM project
funded by the Royal College of Radiologists (RCR).
Subsequent literature searches have been performed
by individual members of the working party and by
various members of specialist imaging groups who
have provided very useful data.
Around 85 000 copies of the third edition (1995) of
the booklet have been distributed and the contents
have, at various times, been commended by the
National Health Service Executive (NHSE) (8,11), the
UK chief medical officers and the Audit Commission
(12). It is of note that they have been adopted by
several purchasers, many of whom now link the use
8
of the RCR’s recommendations to contracts with
departments of clinical radiology. They have been
adopted in the private sector and adopted and
translated by the radiological societies of other
countries. The recommendations are also extensively
used as a standard for audit studies (13). A number of
forward-looking hospitals have obtained electronic
versions of these recommendations which can be
incorporated into hospital information systems. This
fourth edition has already been endorsed by the
Academy of Medical Royal Colleges and been
approved by the Guidelines Appraisal Unit at St
George’s Hospital, London, in the United Kingdom.
With such serious implications now attached to these
recommendations, the working party has been fully
aware of the importance of getting it ‘as right as
reasonably achievable’. We believe that this fourth
edition, which has been produced following wide
consultation (see Appendix), represents a current
reasonable view of how departments of clinical
radiology should be used for some of the more
common clinical problems. There will, undoubtedly,
be some unpopular decisions; we have occasionally
received diametrically opposite advice. However, this
is probably inevitable in one of the most rapidly
developing specialties within medicine.
We hope that this fourth edition will prove useful and
trust that we will continue to receive advice and
referenced comments so that the development of
these recommendations can continue. The next
edition of the RCR guidelines is planned for 2002.
Adrian K Dixon on behalf of the RCR guidelines
working party
9
Introduction
Why are guidelines and referral criteria
needed?
A useful investigation is one in which the result —
positive or negative — will alter management or add
confidence to the clinician’s diagnosis. A significant
number of radiological investigations do not fulfil
these aims and may add unnecessarily to patient
irradiation (14). The chief causes of the wasteful use
of radiology are:
(1) Repeating investigations which have already
been done: e.g. at another hospital, in an
outpatient department, or in the accident and
emergency department.
HAS IT BEEN DONE ALREADY? Every
attempt should be made to get previous films.
Transfer of digital data through electronic links
may assist in this respect in future years.
(2) Investigation when results are unlikely to
affect patient management: because the
anticipated ‘positive’ finding is usually
irrelevant, e.g. degenerative spinal disease (as
‘normal’ as grey hairs from early middle age) or
because a positive finding is so unlikely.
DO I NEED IT?
(3) Investigating too often: i.e. before the disease
could have progressed or resolved or before the
results could influence treatment. DO I NEED IT
NOW?
(4) Doing the wrong investigation. Imaging
techniques are developing rapidly. It is often
helpful to discuss an investigation with a
specialist in clinical radiology or nuclear
medicine before it is requested. IS THIS THE
BEST INVESTIGATION?
11
(5) Failing to provide appropriate clinical
information and questions that the imaging
investigation should answer. Deficiencies here
may lead to the wrong technique being used (e.g.
the omission of an essential view). HAVE I
EXPLAINED THE PROBLEM?
(6) Over-investigating. Some clinicians tend to rely
on investigations more than others. Some
patients take comfort in being investigated.
ARE TOO MANY INVESTIGATIONS BEING
PERFORMED?
What advice is available?
In some clinical situations firm guidelines have been
established. Guidelines are:
systematically developed statements to assist
practitioner and patient decisions about
appropriate health care for specific clinical
circumstances... (Field & Lohr 1992, 15).
Just as the term implies, a guideline is not a rigid
constraint on clinical practice, but a concept of good
practice against which the needs of the individual
patient can be considered. So while there have to be
good reasons for ignoring them they are not absolute
rules. No set of recommendations will command
universal support and you should discuss any
problems with your radiologists.
The preparation of guidelines has become something of
a science, with numerous papers emerging within the
evolving guidelines discipline. In particular, experts
have provided detailed methodology as to how
guidelines should be developed, produced and
appraised (8, 15–21). Using such methodology, the
development of a single scientifically robust guideline
represents a major piece of academic endeavour. For
the 280 clinical problems in this booklet, such
expenditure of time and resources is somewhat
impractical. Nevertheless much of the philosophy of the
methodology for the preparation of guidelines has been
12
followed during the preparation of these
recommendations. In particular there has been extensive
literature review with key references analysed. The
Royal College of Radiologists holds an archive of
references upon which statements within the text are
based. Every opportunity has been given to workers in
other disciplines and those representing patients to put
forward their views. Many groups have been
encouraged to comment on points of fact, local policies,
etc. In particular appropriate specialty imaging groups
have provided active support. There has been extensive
dialogue with other professional groups, including
patients’ representatives and all the royal colleges,
culminating in endorsement by the Academy of
Medical Royal Colleges (see Appendix). Indeed one of
the strongest features of these recommendations is that
they have been reviewed and modified during the
development of four editions since 1989.
Another concurrent development has been the
production of ‘appropriateness criteria’ by the
American College of Radiologists (22). Rather than
pronouncing on what is perceived to be the optimal
investigation, the ACR lists all possible investigations
and awards an appropriateness score (out of 10).
These have been developed using a modified Delphi
technique with consensus reached amongst experts.
The RCR has kept a watching brief on this interesting
development and has incorporated some of the ACR
conclusions.
Throughout the booklet the strength of the evidence
(8) for the various statements is indicated by:
(A) randomised controlled trials (RCTs), meta-
analyses, systematic reviews; or
(B) robust experimental or observational studies; or
(C) other evidence where the advice relies on expert
opinion and has the endorsement of respected
authorities.
13
In some clinical situations (e.g. the role of US in
normal pregnancy) there are conflicting data within a
large body of excellent scientific reports. Thus no
firm recommendations are given and the evidence is
classified as C. It should also be noted that there are
very few randomised trials comparing different
radiological diagnostic procedures – they are difficult
to perform and ethical approval may be denied.
What images are taken?
All imaging departments should have protocols for
each common clinical situation. Therefore no definite
recommendations are given about this aspect. Suffice
it to say that all examinations should be optimised to
obtain maximum information with the minimum of
radiation. It is important to be aware of this as the
patient may not get what the referring clinician
expects.
For whom are the guidelines designed?
These guidelines are intended to be used by all health
professionals entitled to refer patients for imaging. In
the hospital setting they are likely to be of most use
to newly qualified doctors and many hospitals give a
copy to each newly appointed junior doctor to
stimulate good practice.
The range of investigations available to different
health professionals must be determined in
consultation with local specialists in radiology and
nuclear medicine, bearing in mind the available
resources. The recommendations are also of value to
those interested in audit of a department’s referral
pattern and workload (13).
Using the guidelines
This booklet tends to highlight areas of difficulty or
controversy. The pages are mostly composed of four
columns: the first sets the clinical situation for
requesting an examination; the next lists some
possible imaging techniques (and the band of
14
radiation exposure involved); the third gives the
recommendation (and the grade of available
evidence) on whether or not the investigation is
appropriate; and the fourth provides explanatory
comments.
The recommendations used are:
(1) Indicated. This shows the investigation(s) most
likely to contribute to clinical diagnosis and
management. This may differ from the
investigation requested by the clinician: e.g. US
rather than venography for deep vein thrombosis.
(2) Specialised investigation. These are complex or
expensive investigations which will usually be
performed only for doctors who have the
relevant clinical expertise to evaluate the clinical
findings and act on the imaging results. They
usually justify individual discussion with a
specialist in radiology or nuclear medicine.
(3) Not indicated initially. This includes situations
where experience shows that the clinical problem
usually resolves with time; we therefore suggest
deferring the study for three to six weeks and
only performing it then if symptoms continue.
Shoulder pain is a typical example.
(4) Not indicated routinely. This emphasises that
while no recommendation is absolute, the request
will only be carried out if a clinician gives
cogent arguments for it. An example of such a
justification would be plain radiography in a
patient with backache in whom there were
clinical findings to suggest something more than
a degenerative disease (e.g.? Osteoporotic
vertebral fracture).
(5) Not indicated. Examinations in this group are
those where the supposed rationale for the
investigation is untenable (e.g. intravenous
urogram (IVU) for hypertension).
15
Pregnancy and protection
of the foetus
•
Irradiation of a foetus should be avoided
whenever possible (23–25). This includes
situations where pregnancy is not suspected by
the woman herself. The prime responsibility for
identifying such patients lies with the referring
clinician.
•
Women of reproductive age presenting for an
examination in which the primary beam
irradiates directly, or by scatter, the pelvic area
(essentially any ionising irradiation between the
diaphragm and the knees), or for a procedure
involving radioactive isotopes, should be asked
whether they are or may be pregnant. If the
patient cannot exclude the possibility of
pregnancy, she should be asked if her period is
overdue.
•
If there is no possibility of pregnancy the
examination can proceed, but if the patient is
definitely, or probably, pregnant (i.e. menstrual
period overdue) the justification for the proposed
examination should be reviewed by the
radiologist and the referring clinician, with a
decision taken on whether to defer the
investigation until after delivery or until the next
menstrual period has occurred. However, a
procedure of clinical benefit to the mother may
also be of indirect benefit to her unborn child
and a delay in an essential procedure until later
in pregnancy may increase the risk to the foetus
as well as to the mother.
•
If pregnancy cannot be excluded, but the
menstrual period is NOT overdue and the
procedure gives a relatively low dose to the
uterus the examination may proceed. However, if
16
the examination gives relatively high doses (in
most departments, the common examinations in
this category will probably be abdominal and
pelvic CT, IVUs, fluoroscopy and NM studies),
there will be discussion in line with locally
agreed recommendations.
•
In all cases, if the radiologist and referring
clinician agree that irradiation of the pregnant or
possibly pregnant uterus is clinically justified,
this decision should be recorded. The radiologist
must then ensure that exposure is limited to the
minimum required to acquire the necessary
information.
•
If it becomes obvious that a foetus has been
inadvertently exposed, despite the above
measures, the small risk to the foetus of the
exposure is unlikely to justify, even at the higher
doses, the greater risks of invasive fetal
diagnostic procedures (e.g. amniocentesis) or
those of a termination of the pregnancy. When
such inadvertent exposure has occurred, an
individual risk assessment should be made by a
radiation physicist and the results discussed with
the patient.
•
The RCR has recently co-authored (with the
NRPB and the College of Radiographers) a
guidance booklet on the protection of the foetus
during the diagnostic investigation of its mother
(25).
17
Optimising radiation dose
The use of radiological investigations is an accepted
part of medical practice, justified in terms of clear
clinical benefits to the patient which should far
outweigh the small radiation risks. However, even
small radiation doses are not entirely without risk. A
small fraction of the genetic mutations and malignant
diseases occurring in the population can be attributed
to natural background radiation. Diagnostic medical
exposures, being the major source of man-made
radiation exposure of the population, add about one
sixth to the population dose from background
radiation.
The 1997 EU directive (2) requires all concerned to
reduce unnecessary exposure of patients to radiation.
Responsible organisations and individuals using
ionising radiation must comply with these regulations.
One important way of reducing the radiation dose is
to avoid undertaking investigations unnecessarily
(especially repeat examinations).
The effective dose for a radiological investigation is
the weighted sum of the doses to a number of body
tissues, where the weighting factor for each tissue
depends upon its relative sensitivity to radiation
induced cancer or severe hereditary effects. It thus
provides a single dose estimate related to the total
radiation risk, no matter how the radiation dose is
distributed around the body.
Typical effective doses for some common diagnostic
radiology range over a factor of about 1 000 from the
equivalent of a day or two of natural background
radiation (0.02 mSv for a chest radiograph) to 4.5
years (eg, for computed tomography of the abdomen).
However, there is substantial variation in the
background radiation between and within countries.
The doses for conventional x-ray examinations are
based on results compiled by the NRPB from patient
18
Typical effective doses from diagnostic
medical exposures in the 1990s
Diagnostic procedure
Typical Equivalent Approximate
effective
No. of
equivalent
dose
chest
period of
(mSv)
x-rays
natural
background
radiation (1)
X-ray examinations:
Limbs and joints
(except hip)
<0.01
<0.5
<1.5 days
Chest (single PA film)
0.02
1
3 days
Skull
0.07
3.5
11 days
Thoracic spine
0.7
35
4 months
Lumbar spine
1.3
65
7 months
Hip
0.3
15
7 weeks
Pelvis
0.7
35
4 months
Abdomen
1.0
50
6 months
IVU
2.5
125
14 months
Barium swallow
1.5
75
8 months
Barium meal
3
150
16 months
Barium follow through
3
150
16 months
Barium enema
7
350
3.2 years
CT head
2.3
115
1 year
CT chest
8
400
3.6 years
CT abdomen or pelvis
10
500
4.5 years
Radionuclide studies:
Lung ventilation (Xe-133)
0.3
15
7 weeks
Lung perfusion (Tc-99m)
1
50
6 months
Kidney (Tc-99m)
1
50
6 months
Thyroid (Tc-99m)
1
50
6 months
Bone (Tc-99m)
4
200
1.8 years
Dynamic cardiac (Tc-99m)
6
300
2.7 years
PET head (F-18 FDG)
5
250
2.3 years
(1) UK average background radiation = 2.2 mSv per year: regional
averages range from 1.5 to 7.5 mSv per year.
With advice from Wall, B. National Radiological Protection Board.
19
dose measurements made in 380 hospitals throughout
the UK from 1990 to 1995. They are mostly lower
than those given in earlier editions of this booklet
which were based on data from the early 1980s,
indicating a gratifying trend towards improved patient
protection. The doses for CT examinations and
radionuclide studies are based on national surveys
conducted by the NRPB and BNMS and are unlikely
to have changed significantly since then.
Low-dose examinations of the limbs and chest are the
most common radiological investigations but
relatively infrequent high-dose examinations such as
body CT and barium studies make the major
contribution to the collective population dose. The
doses from some CT examinations are particularly
high, show no sign of decreasing and the use of CT is
still rising. CT now probably contributes almost half
of the collective dose from all x-ray examinations. It
is thus particularly important that requests for CT are
thoroughly justified and that techniques are adopted
which minimise dose while retaining essential
diagnostic information. Indeed some authorities
estimate the additional lifetime risk of fatal cancer for
an abdominal CT examination in an adult is around 1
in 2 000 (compared with the risk for a chest x-ray at
1 in a million) (26). However, this is a small excess
risk compared with the very high overall risk of
cancer (nearly 1 in 3) and is usually more than offset
by the benefit gained from the CT examination.
In these referral guidelines the doses have been
grouped into broad bands to help the referrer
understand the order of magnitude of radiation dose
of the various investigations.
20
TABLE Classification of the typical
effective doses of ionising
radiation from common imaging
procedures
Class
Typical effective
Examples
Dose (mSv)
0
0
US, MRI
I
<1
CXR, limb XR, pelvis
XR
II*
1–5
IVU, lumbar spine XR,
NM (e.g. skeletal
scintigram), CT head &
neck
III
5–10
CT chest and abdomen,
NM (e.g. cardiac)
IV
>10
Some NM studies (e.g.
PET)
* The average annual background dose in most parts of Europe falls
in Band II.
21
Communications with a
department of clinical
radiology
Referral for an imaging examination is generally
regarded as a request for an opinion from a specialist
in radiology or nuclear medicine. The outcome of this
request for opinion should be presented in the form of
a report to assist in the management of a clinical
problem.
Request forms should be completed accurately and
legibly in order to avoid any misinterpretation. You
should state clearly the reasons for the request and
give sufficient clinical details to enable the imaging
specialist to understand the particular diagnostic or
clinical problems that you are attempting to resolve
by radiological investigation.
In some cases the best investigation for resolving the
problem may be an alternative imaging examination.
If you are in doubt as to whether an investigation is
required or which investigation is best, you should
consult with an appropriate specialist in radiology or
nuclear medicine. Indeed imaging departments are
always pleased to discuss investigations with
referring doctors. Regular clinico-radiological
meetings provide a useful format for such discussion
and are considered good practice (27).
While it should be noted that these recommendations
have been widely endorsed, it is recognised that a
few departments will adapt them according to local
circumstances and policies.
22
Technique-based imaging
Computed tomography (CT)
CT is now quite widely available throughout Europe.
Furthermore there have been recent important
advances due to the development of spiral and
multislice CT which allows breath-hold volume data
acquisition. Such advances have opened up new
diagnostic opportunities, such as the use of spiral CT
in the diagnosis of pulmonary embolism. Nevertheless
different hospitals will have their own policies about
accepting CT requests. It is worth remembering that
CT is a relatively expensive study and imparts a high
x-irradiation dose. Thus it is always worth considering
alternatives, especially in view of the increasing role
of MRI. Indeed the UK National Radiological
Protection Board have published several general
recommendations with regard to CT in Protection of
the patient in x-ray computed tomography (26), some
extracts from which are reproduced here:
In view of the potential high doses CT should only
be carried out after proper clinical justification by
an experienced radiologist. Examinations on
children require a higher level of justification, since
such patients are at greater risk from radiation.
When clinically appropriate, the alternative use of
safer non-ionising techniques (US and MRI) or of
low dose x-ray techniques should be considered.
CT should not be carried out on the abdomen or
pelvis of pregnant patients without sound clinical
reasons and particular attention to low-dose
techniques.
Care should always be taken to minimise exposure
to the eyes, particularly for patients likely to
undergo multiple examinations.
As for all radiological requests, any CT referral
which falls outside established guidelines should be
discussed with a radiologist. Because of the need to
23
minimise the extent of the examination (and thereby
the cost and radiation dose), it is helpful if the
clinical notes and previous imaging investigations are
available for review at the time of CT.
A few further points:
•
CT remains the optimal investigation for many
clinical problems within the chest and abdomen,
despite the radiation risks.
•
CT is still widely used for intracranial problems,
especially CVA and trauma.
•
CT remains a simple method of staging many
malignant diseases (e.g. lymphoma) and in
monitoring the response to therapy.
•
CT provides valuable pre-operative information
about complex masses and is widely used for
post-operative complications.
•
CT allows accurate guidance for drainage
procedures, biopsies and anaesthetic nerve
blocks.
•
CT has an important role in trauma.
•
CT images may be degraded by prostheses,
fixation devices, etc.
•
CT provides better anatomical detail in obese
patients than US. In thinner patients and
children, US should be used wherever possible.
•
CT of the abdomen imparts a radiation dose
equivalent to about 500 CXRs.
Interventional radiology (including
angiography and minimal access
therapy)
This area of radiology is currently undergoing rapid
expansion. While all departments of clinical radiology
have been undertaking angiography and associated
24
procedures (e.g. angioplasty) for many years, several
new techniques have emerged recently. Most abscesses
in the abdomen are now treated by percutaneous
drainage procedures using radiological guidance.
Likewise the majority of liver biopsies are now
performed by radiologists (using US guidance). Lymph
node biopsies are routine in most US and CT units.
New technology is rapidly widening the range of
interventional radiology yet further. These
innovations include:
•
percutaneous diskectomy for lumbar disk
herniation (often using CT control);
•
percutaneous insertion of grafts for abdominal
aortic aneurysms;
•
various techniques to treat inoperable hepatic
lesions (e.g. laser ablation under imaging
control);
•
interventional MRI with ‘real-time’ imaging to
allow monitoring of therapeutic manoeuvres.
These examples of recent innovations require close
collaboration with clinical colleagues. The precise
arrangements vary considerably according to local
expertise and availability of equipment. There is
continuing discussion at national level about the best
arrangement for these interventional procedures.
Inevitably requests for all such procedures involve
detailed discussion between various specialists.
Magnetic resonance imaging (MRI)
There has been a substantial recent increase in the
number of MRI systems across Europe. Accordingly
there are numerous recommendations for the use of
MRI. Indeed, with the recent technical advances and
increasing experience, the role of MRI continues to
expand and the limiting factor for further expansion
is now often financial.
25
Because MRI does not use ionising radiation, MRI
should be preferred where both CT and MRI would
provide similar information and when both are
available. However MRI is in danger of being
subjected to inappropriate demands which may lead
to long waiting times. Thus, all requests for MRI
should be agreed with a radiologist.
A few further points:
•
MRI usually provides more information than CT
about intracranial, head and neck, spinal and
musculoskeletal disorders because of high
contrast sensitivity and multiplanar imaging
capability. This helps to establish the diagnosis
and institute appropriate management with
greater confidence. It is increasingly being used
in oncology.
•
Major recent advances include: breast and
cardiac MR imaging; angiographic and
interventional techniques; MRCP and other fluid-
sensitive MR techniques; functional MR imaging
of the brain. However, many of these techniques
await full evaluation.
•
MRI is not approved during the first trimester of
pregnancy. However it may well prove to be
safer than some of the alternative options.
Discuss all imaging in pregnancy with the
radiology department.
•
There are some definite contraindications to the
use of MRI: metallic foreign bodies (FBs) in the
orbits, aneurysm clips, pacemakers, cochlear
implants, etc. Furthermore MRI will give
reduced image quality close to prostheses, etc.
The full list of contraindications is provided in
several textbooks and monographs. Any
uncertainty about contraindications should be
discussed with the imaging department well in
advance.
26
Nuclear medicine (NM)
In EU countries NM is an independent specialty, the
use of unsealed sources of radionuclides for diagnosis
and therapy being restricted to NM specialists. In
some countries other specialists, usually radiologists,
can also provide NM services. Whatever the local
arrangements, an experienced specialist will be
available to discuss the appropriate NM techniques in
a given clinical situation. They will also be able to
advise on which particular NM investigation should
be used. Accordingly referring clinicians should
indicate the precise clinical problem requiring
investigation, because this will determine which
radionuclide (or alternative) investigation is used.
Despite some misconceptions, the radiation doses
imparted by most NM techniques compare
favourably with those of many other imaging
investigations which are regarded as ‘safe’. As shown
in the chart displayed in the section on minimising
radiation dose, the effective dose associated with
most routine NM studies is considerably less than
that for abdominal CT.
There is particular value in the functional data which
can be provided by NM techniques. At a basic level,
NM can determine whether a distended renal pelvis
shown by US is merely due to a capacious collecting
system, or caused by an obstructing lesion. The same
investigation can provide data on the percentage of
overall renal function provided by each kidney. More
complex studies can indicate the ejection fraction of
the left ventricle or the distribution of blood flow to
the cerebral cortex.
PET has recently made large strides and there is a
gradual increase in its availability. Because of the
short-lived nature of the key radionuclides (the
glucose analogue F-18 fluorodeoxyglucose, FDG, is
widely used), PET can only be offered close to a
27
cyclotron and radionuclide pharmacy. However, the
development of double-headed gamma cameras with
modified PET capabilities is a significant advance
which should increase availability; it is currently the
focus of much research. Because PET can identify
small foci of viable tumours, it offers exceptional
opportunities in the staging of various cancers (e.g.
bronchus) and in cancer follow-up (e.g. lymphoma),
where other imaging techniques may be unable to
distinguish between residual fibrotic masses and
active disease. PET can also provide unique data
about brain metabolism and myocardial viability and
there are several research units studying these
aspects. Over the next few years there will be an
increasing uptake of PET into clinical practice and its
potential use is flagged for certain clinical problems
in the ensuing recommendations.
Nuclear medicine therapy
Although not considered further in these referral
guidelines, it is worth considering the important role
of NM in the treatment of both benign and malignant
disease. The thyroid gland is still the most important
target but the field is rapidly expanding. Other
indications include neuroendocrine tumours, painful
skeletal metastases, some arthropathies,
polycythaemia, malignant effusions. NM treatment
options are being investigated in the
leukaemias/lymphomas and some liver tumours.
28
Ultrasound (US)
Since the previous edition of these guidelines, most
departments of clinical radiology have experienced a
large increase in referrals for US examinations.
During this period US equipment and expertise have
advanced and the scope of referrals (Colour Doppler,
Power Doppler, transvaginal (TV) gynaecological
work, etc.) has widened. These trends are to be
welcomed because US does not employ ionising
radiation. However there is scant evidence that the
increase in US has been accompanied by much
reduction in referrals for other radiological
investigations and a consequent reduction in total
radiation dose to the public.
In fact, the rising US workload has developed while
the demand for other radiological investigations has
also continued to increase. The one notable exception
is the IVU which is required much less often since the
advent of US. However, because US is non-invasive,
the total number of patients investigated with
uroradiological problems has increased. Departments
of clinical radiology have developed different local
policies for dealing with the increasing US workload.
The actual acquisition of US images has to be
undertaken by an experienced operator; even such an
operator may not be able to gain perfect images in
every patient. For example US can be difficult and
unsatisfactory in obese patients. Furthermore the
distribution of bowel gas may mask certain features.
Nevertheless the cheap, quick, reliable and non-
invasive nature of US make it an excellent initial
investigation for a wide range of clinical referrals.
Accordingly US has been recommended as the
appropriate investigation wherever possible.
Because US avoids ionising radiation and is relatively
inexpensive, it is often recommended where more
expensive studies (e.g. CT) cannot be justified or
29
resources are limited. Conversely, it is difficult to
refuse a request for US on grounds of invasiveness or
expense. There is thus a danger of US departments
being overloaded with requests which may be on the
margins of appropriateness. Accordingly, referring
clinicians still have a duty to consider carefully
whether each request for US is justified and whether
the result (e.g. the presence of gallstones) will affect
management (see Introduction, why are guidelines
needed?).
30
GLOSSARY
ABBREVIATION
DEFINITION
XR
Plain radiography one or more
films
CXR
Chest radiograph
AXR
Abdominal radiograph
US
Ultrasound
Skeletal survey
A series of XRs to show the
presence and extent of involved
skeleton
Mammogram
Breast radiography
Ba swallow/ meal/FT
Barium swallow/ meal/follow
through
Small bowel enema
Detailed Barium study via
nasoduodenal intubation
Ba enema
Barium enema
IVU
Intravenous urogram
CT
Computed tomography
CTA
CT angiography
HRCT
High resolution CT
NM
Nuclear medicine
SPECT
Single photon emission
tomography
MRI
Magnetic resonance imaging
MRA
MR angiography
MRCP
Magnetic resonance cholangio
pancreatography
DSA
Digital subtraction angiography
ERCP
Endoscopic retrograde cholangio
pancreatography
PET
Positron emission tomography
31
A. Head
A
and
in early
, MRA
gery contemplated.
Angiography
COMMENT
may be needed for bone
gery is contemplated. (b) an evolving CV
are more expensive alternatives to show the
adequately assesses most cases and
A
Definitive exam for all malformations and avoids
x-irradiation. 3D CT
anomalies. Sedation usually required for young
children. Consider US in neonates.
CT
shows haemorrhage.
MRI and NM more sensitive than CT
infarction and for posterior fossa lesions.
Exceptions for: (a) those with full recovery in whom
carotid sur
where dissection or embolus suspected.
If doubt about diagnosis or sur
Much depends on local policy and available expertise.
US (with Colour Doppler) provides functional data
about bifurcation disease.
CT
vessels. MRI and NM can be used to show function.
TION
{GRADE}
Indicated (C)
Indicated (C)
Specialised
investigation (B)
Not indicated
routinely (C)
Indicated (B)
RECOMMENDA
TION
{DOSE}
otids(0)
otids (0)
(II)
INVESTIGA
MRI (0)
CT
MRI (0) and
NM (II)
US car
US car
A1
A2
A3
CLINICAL PROBLEM
A); stroke
A. Head (including ENT problems)
ransient ischaemic
Congenital disorders
(for children see
Section M)
Cerebrovascular accident
(CV
T
attack (TIA)
(see also B5)
32
A. Head
%
more
does not
.
for demyelinating
negative CT
ficient in supratentorial
A
gery) and for posterior
for inflammatory causes. NM may
in delineating extent and location of
, assuming no contraindications
, especially post-radiotherapy
provides adequate data in most cases of
MRI much more sensitive than CT
disease. But MRI may still be negative in up to 25
of those with established multiple sclerosis. MRI also
superior to CT
other white-matter disease.
MRI more sensitive for early tumours, in resolving
exact position (useful for sur
fossa lesions. MRI may miss calcification. CT
widely available; and often suf
lesions and subdural haematomas. MRI superior in the
posterior fossa and for vascular lesions. NM may be
useful in certain circumstances — tumour viability
post-therapy
CT
subarachnoid and other intracranial haemorrhage and
associated hydrocephalus. NB:
exclude SAH and where suspected lumbar puncture
should follow
(e.g. obstructive hydrocephalus). Lumbar puncture
may also be needed to exclude meningitis.
MRI better than CT
be the most sensitive investigation for encephalitis and
can provide evidence of circulation derangement in
migraine.
Indicated (A)
Indicated (B)
Indicated (B)
Specialised
investigation (C)
(II) or
(II)
MRI (0)
CT
MRI (0)
CT
MRI (0) or
NM (II)
A4
A5
A6
Demyelinating and other
white matter disease
Space-occupying
lesion (SOL)
Headache: acute, severe
33
A. Head
.
gent
.
images often degraded
. CT
COMMENT
A13 below
if MRI not available. Ur
adequate for most cases; MRI sometimes
Radiography of little use in the absence of focal
signs/symptoms. See
Some exceptions for specialists or if evidence of raised
intracranial pressure, posterior fossa or other signs.
Demonstration of microadenomas may not be helpful
for management. CT
referral when vision deteriorating. Some centres use
specific NM agents.
Patients who require investigation need MRI or CT
MRI much better than CT
by beam hardening artefacts.
CT
necessary and may be more appropriate in children.
US first choice for infants. NM used in some centres,
especially for shunt function.
XR can demonstrate whole valve system.
TION
{GRADE}
Not indicated
routinely (B)
Not indicated
routinely (B)
Specialised
investigation (B)
Not indicated
routinely (C)
Indicated (A)
Indicated (B)
Indicated (C)
RECOMMENDA
TION
{DOSE}
(II) or
(II)
INVESTIGA
XR skull, sinus,
C spine (I)
CT
MRI (0)
MRI (0)
SXR (I)
MRI (0)
CT
XR
A7
A8
A9
A10
CLINICAL PROBLEM
Headache: chronic
(for children
see Section M)
Pituitary and
juxta-sellar problems
Posterior fossa signs
Hydrocephalus
(for children see
Section M)
34
A. Head
’
s
,
Alzheimer
ferentiate
. Low dose technique
, especially for acoustic
gical expertise.
readily provide functional data.
a good combination for
’
s
from other forms of dementia.
and SPECT
is more rewarding and provides unique
and SPECT
Evaluation of these symptoms requires ENT
neurological or neurosur
MRI much better than CT
neuromas. For deafness in children see M4.
Thickened mucosa is a non-specific finding and may
occur in asymptomatic patients.
CT
information about ostial anatomy
desirable. Indicated when maximal medical treatment
has failed, when complications arise or if malignancy
suspected.
Consider investigation if clinical course unusual or in
younger patient.
CT
disease. MRI better for structural changes and
assessment of ‘normal pressure hydrocephalus’.
PET
Cerebral blood flow studies may dif
Alzheimer
Specialised
investigation (B)
Specialised
investigation (B)
Not indicated
routinely (B)
Specialised
investigation (B)
Not indicated
routinely (B)
Specialised
investigation (B)
(II)
(II)
(II) or
CT
MRI (0)
Sinus XR (I)
CT
SXR (I)
CT
MRI (0) or
NM (III)
1
A1
A12
A13
A14
-ear
Middle or inner
symptoms (including
vertigo)
Sensorineural deafness
(for children see
Section M)
Sinus disease
(for children see
Section M)
Dementia and memory
disorders, first onset
psychosis
35
A. Head
.
maximises
.
. Specialists may require
COMMENT
rauma Section K for acute injury
gery is being considered. Ictal SPECT
provides better anatomical detail, particularly of
T
or MRI.
CT
bony structures (e.g. nasolacrimal duct). MRI avoids
radiation dose to lens (but contraindicated when
ferromagnetic FB suspected). Consider US for
intra-ocular lesions.
Especially for those who have worked with metallic
materials, power tools, etc. Some centres use CT
(see
Plain XRs rarely contributory
CT
Evaluation requires specialist expertise. Late onset
seizures should normally be investigated but imaging
may be unnecessary if clearly alcohol-related.
Partial/focal seizures may require detailed evaluation
if sur
likelihood of localising focus. Interictal functional
imaging also important. Much depends on local policy
which will determine combinations of procedures.
TION
{GRADE}
Specialised
investigation (B)
Indicated (B)
Not indicated
routinely (C)
Not indicated
routinely (B)
Specialised
investigation (B)
RECOMMENDA
TION
{DOSE}
(II) or
(II), MRI
INVESTIGA
CT
MRI (0)
XR orbits (I)
SXR (I)
SXR (I)
CT
(0) or NM (III)
A15
A16
A17
A18
CLINICAL PROBLEM
isual disturbances
Orbital lesions
Orbits
Metallic FB (before MRI)
V
Epilepsy (adult)
(for children see
Section M)
36
B. Neck
and MRI all
Also useful in
. Some clinicians
disease, toxic
rauma])
gement or multinodular
fect of neck extension, etc.
ferentiate between Graves’
geons. Much depends on local policy and available
Demonstrates morphology; allows guided aspiration
for cytology or biopsy for histology
will proceed to aspiration with no imaging.
Contemporary CXR needed to show trachea.
Can dif
nodular goitre and subacute thyroiditis. Provides
functional information about nodules.
thyroiditis.
NM excellent for small ectopic rests of thyroid tissue.
In generalised thyroid enlar
goitre US readily shows retrosternal extension; real
time studies show ef
CT/MRI needed to demonstrate full retrosternal extent
and tracheal compromise.
Seek advice. Diagnosis made on clinical/biochemical
grounds. Imaging can assist in pre-operative
localisation but may not be needed by experienced
sur
technology and expertise. US, NM, CT
accurate in the un-operated neck.
Indicated (B)
Indicated (B)
Indicated (C)
Specialised
investigation (C)
US (0) and
NM (I)
NM (I), US (0)
NM (I)
Imaging
B1
B2
B3
B4
(for the spine see Sections C [The spine] and K [T
gement
B. Neck
Soft tissues
Thyroid nodules
and enlar
Thyrotoxicosis
Ectopic thyroid tissue
(e.g. lingual thyroid)
Hyperparathyroidism
37
B. Neck
now of
.
sialography
COMMENT
usually only if recommended after
indication for CT
rauma K 30.
. MRI or CT
T
Significant internal carotid artery lesions are rarely
found.
See
US first-line investigation which can also direct
biopsy
radiological or specialist clinical opinion.
For intermittent, food related swelling. MR
sialography may be preferred in some centres.
Except in calculus in floor of mouth, where XR may
be all that is required.
US extremely sensitive and, dependent on local
expertise, should be first-line investigation. MRI
excellent for extensive or recurrent disease. CT
limited use. No
Not commonly required. Sialogram may be diagnostic
but NM provides better functional assessment. MR
sialography also used here.
TION
{GRADE}
Not indicated
routinely (B)
Indicated (C)
Indicated (C)
Not indicated
routinely (C)
Indicated (B)
Specialised
investigation (C)
RECOMMENDA
TION
{DOSE}
otids (0)
INVESTIGA
US car
US (0)
US (0) or
sialogram (II)
XR
US (0)
US (0) or
sialogram (II)
or NM (II)
B5
B6
B7
B8
B9
B10
CLINICAL PROBLEM
Asymptomatic carotid
bruit
Swallowed or inhaled
foreign body (FB)
Mass of unknown origin
Salivary obstruction
Salivary mass
Dry mouth — connective
tissue disease
38
B. Neck
fers a
Arthrography of
, as problems are usually
Radiographs will demonstrate bony abnormalities, but
are normal in great majority
related to articular disk dysfunction.
Following failure of conservative treatment when
internal derangement suspected.
true dynamic demonstration.
Specialised
investigation (B)
Specialised
investigation (B)
ography (II)
XR (I)
MRI (0) or
arthr
1
B1
emporo-mandibular joint
T
dysfunction
39
C. The spine
ge radiation
may be required to
may be needed if
. CT
COMMENT
e.g. Full-length standing radiograph for scoliosis. See
Section M for back pain (M10).
MRI defines all spinal malformations and excludes
associated thecal abnormality
delineate bony detail, but remember lar
burden.
MRI clear first choice for all spinal cord lesions and
to evaluate cord compression. CT
better bony detail is required. Myelography only if
MRI is unavailable or impossible. NM still widely
used to screen for metastases and for identifying focal
skeletal lesions (such as osteoid osteoma).
TION
{GRADE}
Specialised
investigation (C)
Specialised
investigation (B)
Indicated (B)
RECOMMENDA
TION
{DOSE}
INVESTIGA
XR (I)
MRI (0)
MRI (0)
C1
C2
CLINICAL PROBLEM
C. The spine
General (for trauma see Section K)
Congenital disorders
(for children
see Section M)
Myelopathy: tumours,
inflammation, infection,
infarction, etc.
40
C. The spine
fect on cord when XR
s Syndrome, etc. MRI
single lateral cervical spine XR with the patient in
fecting lifestyle or when there are neurological
A
supervised comfortable flexion should reveal any
significant subluxation in patients with rheumatoid
arthritis, Down’
(flexion/extension) shows ef
positive or neurological signs present.
Degenerative changes begin in early middle-age and
are often unrelated to symptoms which are usually due
to disk/ligamentous changes undetectable on plain XR.
MRI increasingly being used, especially when
brachalgia is present.
Consider MRI and specialist referral when pain
af
signs. Myelography (with CT) may occasionally be
required to provide further delineation or when MRI is
unavailable or impossible.
Indicated (C)
Not indicated
routinely (B)
Specialised
investigation (B)
XR (I)
XR (I)
MRI (0)
C3
C4
Cervical spine
Possible atlanto-axial
subluxation
Neck pain, Brachalgia,
degenerative change
41
C. The spine
ficult
ficult. Negative
gent referral in elderly
COMMENT
Degenerative changes are invariable from middle-age
onwards. Examination rarely useful in the absence of
neurological signs or pointers to metastases or
infection. Consider more ur
patients with sudden pain to show osteoporotic
collapse or other forms of bone destruction. Consider
NM for possible metastatic lesions.
MRI may be indicated if local pain persists, dif
to manage or if there are long tract signs.
Degenerative changes are common and non-specific.
Main value in younger patients (e.g. less than 20,
spondylolisthesis, ankylosing spondylitis, etc.) or in
older patients e.g. >55.
In cases where management is dif
findings may be helpful.
TION
{GRADE}
Not indicated
routinely (B)
Specialised
investigation (B)
Not indicated
routinely (C)
Specialised
investigation (C)
RECOMMENDA
TION
{DOSE}
INVESTIGA
XR (I)
MRI (0)
XR (II)
MRI (0) or CT
(II) or NM (II)
C5
C6
CLINICAL PROBLEM
Thoracic spine
Pain without trauma:
degenerative disease
Lumbar spine
Chronic back pain with
no pointers to infection
or neoplasm
42
C. The spine
Y
ALSEL
BE F
Y
gent specialist referral; MRI is usually
PLAIN XR MA
’
gether with ur
o
T
the best investigation. Imaging should not delay
specialist referral. NM is also widely used for possible
bone destruction, and in cases of chronic pain or
where infection is suspected.
(‘NORMAL
REASSURING).
(for children see Section M)
Indicated (B)
Imaging
C7
onset < 20, > 55 yrs
sphincter or gait
sphincter or gait
disturbance
saddle anaesthesia
severe or progressive
motor loss
widespread neurological
deficit
previous carcinoma
systematically unwell
HIV
weight loss
intravenous drug abuse
steroids
structural deformity
non-mechanical pain
Back pain with possible
serious features such as:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
43
C. The spine
, conus,
for post-
plain XRs may be
COMMENT
and should be considered
is needed before intervention (e.g.
Acute back pain is usually due to conditions which
cannot be diagnosed on plain XR (osteoporotic
collapse an exception). ‘Normal’
falsely reassuring. Demonstration of disk herniation
requires MRI or CT
immediately after failed conservative management.
MRI generally preferred (wider field of view
post-operative changes etc.) and avoids x-irradiation.
Either MRI or CT
epidural injection). MRI better than CT
operative problems.
TION
{GRADE}
Not indicated
routinely (C)
Not indicated
initially (B)
RECOMMENDA
TION
{DOSE}
INVESTIGA
XR (II)
MRI (0) or CT
(II)
C8
CLINICAL PROBLEM
Acute back pain: disk
herniation; sciatica with
no adverse features
(see above).
44
D. Musculoskeletal system
and US can
or if NM non
.
gery
, findings are not specific and
These statements apply to adults
chest if CXR negative to assess
can show bony detail better at some sites
. US may be helpful, especially in children, if
gical staging; should be performed before any
. CT
used to identify sequestra. Both CT
The 2–3 phase skeletal scintigram is more sensitive
than XR. However
further specialised NM with alternative agents may be
needed. Fat-suppressed MRI is becoming regarded as
the optimal investigation.
CT
demonstrate appropriate site for guided percutaneous
biopsy
metalware causes artefacts on MRI/CT
specific due to recent sur
XR may characterise the lesion.
MRI useful for further characterisation and necessary
for sur
biopsy
(e.g. spine) and for some small lesions and is needed
if MRI unavailable. MRI more useful for assessment
of extent. CT
pulmonary metastases for many primary malignant
lesions. (see L41).
and children.
Indicated (B)
Specialised
investigations (C)
Indicated (B)
Specialised
investigations (B)
NM (II)
+
(II) or
(II)
XR (I)
or MRI (0)
CT
US (0)
XR (I)
MRI (0) or
CT
D1
D2
D. Musculoskeletal system
Osteomyelitis
Primary bone tumour
45
D. Musculoskeletal system
, field of view is
COMMENT
, e.g. degenerative disease. In
NM readily assesses the whole skeleton and is much
more sensitive than plain XR, though less specific.
Localised XRs may be needed to exclude other causes
of increased activity
prostatic cancer biochemical markers (PSA) can be
used to follow up progress of skeletal involvement.
NM can also help characterise the lesion. (e.g. osteoid
osteoma) and is useful in follow-up.
MRI more sensitive and specific than NM, especially
for marrow-based lesions. However
limited.
TION
{GRADE}
Indicated (B)
Not indicated
routinely (C)
Specialised
investigation (C)
RECOMMENDA
TION
{DOSE}
INVESTIGA
NM (II)
Skeletal survey
(II)
MRI (0)
.
D3
CLINICAL PROBLEM
Known primary tumour
Skeletal metastases
46
D. Musculoskeletal system
. Consider NM
.
, delineation of
fuse osteopenia. Can
for exclusion, detection and
has greater sensitivity for
-mass assessment and follow-up.
. Survey can be very limited for
MRI better than CT
staging of soft tissue tumours (superior contrast
resolution, multiplanar capability
neurovascular bundle and muscle/compartment
involvement). CT
calcification. Increasing interest in US for some
anatomical sites. MR accepted as investigation of
choice for possible recurrence although US has its
proponents and can be used for biopsy
(e.g. PET).
Local view of symptomatic areas only
When symptoms persist and plain XRs negative.
For staging and identifying lesions which may benefit
from radiotherapy
follow-up.
Skeletal scintigraphy is often negative and
underestimates disease extent; consider bone marrow
studies.
MRI very sensitive, even limited to spine, pelvis and
proximal femora. Particularly useful in non-secretory
myeloma or in the presence of dif
be used for tumour
Indicated (B)
Indicated (B)
Indicated (B)
Indicated (C)
Not indicated
routinely (B)
Specialised
investigation (B)
MRI (0)
XR (I)
NM (II) or
MRI (0)
Skeletal survey
(II)
NM (II)
MRI (0)
,
D4
D5
D6
Soft tissue mass tumour
possible recurrence
Bone pain
Myeloma
47
D. Musculoskeletal system
gy
and some local
fice. If needed, this
COMMENT
Biochemical tests usually suf
should be limited (e.g. hands, CXR, pelvis and lateral
lumbar spine). Bone densitometry may be needed.
(see D9).
Skeletal scintigram good for complications
Localised XR to establish cause of local pain or
equivocal lesion on NM.
NM can show increased ‘activity’
complications. Bone densitometry may be needed.
(see D9).
Lateral views will demonstrate compression fractures.
NM or MRI more useful in distinguishing between
recent and old fractures and can help exclude
pathological fractures. Bone densitometry (dual ener
XR apsorptiometry (DEXA) or quantitative CT)
provides objective measurements of bone mineral
content; can also be used for metabolic bone disease
(see D7, D8).
TION
{GRADE}
Not indicated
routinely (C)
Indicated (C)
Indicated (B)
Specialised
Indicated (B)
RECOMMENDA
TION
{DOSE}
(II)
INVESTIGA
Skeletal survey
(II)
NM
XR (0)
NM (II)
XR (II) lateral
thoracic and
lumbar spine
D7
D8
D9
CLINICAL PROBLEM
Metabolic bone disease
Osteomalacia
Pain — osteoporotic
collapse
48
D. Musculoskeletal system
.
f
are common. Earlier XR if soft tissue
normal NM study excludes most late complications.
May be helpful to determine cause although erosions
are a relatively late feature.
In patients with suspected rheumatoid arthritis, XR
feet may show erosions even when symptomatic
hand(s) appear normal.
All can show acute synovitis. NM can show
distribution. MRI can show articular cartilage.
XRs needed by specialists to assist management
decisions.
Degenerative changes in the acromio-clavicular joints
and rotator cuf
calcification is expected.
A
Further specialised NM studies can help distinguish
loosening from infection.
Usually coupled with aspiration/biopsy/arthrography
Such intervention which provides a definitive result is
increasingly being used.
Indicated (C)
Indicated (C)
Not indicated
routinely (C)
Specialised
investigations (C)
Not indicated
routinely (C)
Not indicated
initially (C)
Indicated (B)
Specialised
investigation (C)
NM (II)
+
oscopy (II)
XR (I) affected
joint
XR (I)
hands/feet
XR (II) multiple
joint(s)
US (0) or
NM (II) or
MRI (0)
XR (I)
XR (I)
XR (I)
US (0) or
fluor
1
D10
D1
D12
D13
, presentation
, follow-up
Arthropathy
Arthropathy
Painful shoulder joint
Painful prosthesis
49
D. Musculoskeletal system
f tears.
gical plans.
COMMENT
gery is being considered and
.
Although impingement is a clinical diagnosis, imaging
is indicated when sur
precise delineation of anatomy is required. But
degenerative changes also common in the
asymptomatic population.
Subacromial and acromioclavicular joint impingement
are dynamic processes which can be assessed by US.
Glenoid labrum and synovial cavity are well
delineated by both techniques. Some gradient echo
MR techniques can show labrum well without
arthrography
Much depends on local expertise and sur
All three techniques demonstrate rotator cuf
TION
{GRADE}
Specialised
investigation (B)
Specialised
investigation (B)
Specialised
investigation (B)
Specialised
investigation (C)
Specialised
investigation (B)
RECOMMENDA
TION
{DOSE}
ography (II)
ography (0)
ography
INVESTIGA
MRI (0)
US (0)
CT
arthr
MR
arthr
Arthr
(II) or US (0)
or MRI (0)
D14
D15
D16
f tear
CLINICAL PROBLEM
Shoulder impingement
Shoulder instability
Rotator cuf
50
D. Musculoskeletal system
.
en.
en.
may
AP
can also provide information
when plain XRs equivocal; MRI
ecommendation does not apply to childr
ecommendation does not apply to childr
This r
This r
May help in investigation of sero-negative arthropathy
SI joints usually adequately demonstrated on
lumbar spine.
MRI or NM or CT
carries no radiation dose.
XR only if symptoms and signs persist or complex
history (e.g. chance of avascular necrosis, see D20)
NB:
Symptoms often transient. XR if hip replacement
might be considered or symptoms persist. PET
be helpful, if XR, MRI standard NM all normal.
NB:
Abnormal in established disease.
MRI useful when XR normal, especially in high risk
patients. NM and CT
here.
Indicated (B)
Specialised
investigation (C)
Not indicated
routinely (C)
Not indicated
initially (C)
Indicated (B)
Specialised
investigation (B)
(II)
XR SI joints (II)
MRI (0) or
NM (II) or
CT
XR pelvis (I)
XR pelvis (I)
XR Pelvis (I)
MRI (0)
D17
D18
D19
D20
SI joint lesion
Hip pain: full movement
(for children see
Section M)
Hip pain: limited
movement
(for children see
Section M)
Hip pain: avascular
necrosis
51
D. Musculoskeletal system
.
The
gery
changes
. Even in those
.
geons find pre-operative
gery
COMMENT
identify radio-opaque loose bodies.
o
Symptoms frequently arise from soft tissues and these
will not be demonstrated on XR. OA
common. XRs needed when considering sur
T
MRI can assist the management decision as to whether
or not to proceed with arthroscopy
patients with definite clinical abnormalities,
warranting intervention, sur
MRI helpful in identifying unsuspected lesions.
For assessment before sur
Plantar spurs are common incidental findings.
cause of the pain is seldom detectable on XR. US,
NM and MRI are more sensitive in showing
inflammatory change but the majority of patients can
be managed without imaging.
TION
{GRADE}
Not indicated
routinely (C)
Indicated (C)
Specialised
investigation (B)
Specialised
investigation (C)
Not indicated
routinely (B)
RECOMMENDA
TION
{DOSE}
INVESTIGA
XR (I)
XR (I)
MRI (0)
XR (I)
XR (I)
D21
D22
D23
D24
D25
CLINICAL PROBLEM
fusion (loose body)
Knee pain: without
locking or restriction in
movement
Knee pain: with locking,
restricted movement or
ef
Knee pain: arthroscopy
being considered
Hallux valgus
Plantar fasciitis —
calcaneal spur
52
E. Cardiovascular system
,
, etc.) and
, better
fers myocardial
. NM of
rans-oesophageal US and CT
T
systems provide very accurate results.
Angiography rarely necessary unless above
CXR must not delay admission to a specialised unit.
CXR can assess heart size, pulmonary oedema, etc.
and can exclude other causes. Department film
preferable. Subsequent imaging involves specialised
investigations (NM, coronary angiography
depend on local policy
perfusion and ventriculography data. Increasing
interest in MRI.
Mainly to exclude other causes; rarely diagnostic.
Seek advice from local radiologists. Much variation.
Modern CT
Often coupled with trans-thoracic US or
trans-oesophageal US. MRI probably the most
accurate and increasingly used, despite logistic
problems and constraints with some life-support
systems.
examinations are equivocal.
MRI best investigation to assess change in
longitudinal extent.
recommended.
Indicated (B)
Indicated (B)
Indicated (B)
Specialised
investigation (B)
(III) or
CXR (I)
CXR (I)
CT
US (0) or
MRI (0)
MRI (0)
E1
E2
E3
E. Cardiovascular system
Central chest pain
myocardial infarction
Chest pain: aortic
dissection: acute
Aortic dissection: chronic
53
E. Cardiovascular system
ormal
n
A
gently for
fect not
COMMENT
used increasingly as the initial
fusion volume/ef
.
Interpreted along with contemporary CXR. Equivocal
findings (e.g. intermediate probability) may necessitate
further clarification. Some centres use US to show
thrombus in leg veins for further proof.
perfusion NM study excludes pulmonary embolism in
most cases. Spiral CT
test, especially in patients with co-existing
cardiorespiratory disease, and ahead of pulmonary
angiography
May be normal; ef
determined.
Extremely accurate: may be needed ur
tamponade; can show best access for drainage. CT
sometimes needed for calcification, loculation, etc.
Used for initial assessment and when there is a change
in the clinical picture.
US may show remediable complications (VSD,
papillary rupture, aneurysm, etc.).
TION
{GRADE}
Indicated (B)
Indicated (B)
Indicated (B)
Indicated (B)
Indicated (B)
RECOMMENDA
TION
{DOSE}
(III)
diac US (0)
diac US (0)
INVESTIGA
NM (II) or
CT
CXR (I)
US (0)
CXR (I) and
car
Car
E4
E5
E6
E7
CLINICAL PROBLEM
fusion
Pulmonary embolus
Pericarditis — pericardial
ef
Suspected valvular
cardiac disease
Clinical deterioration
following myocardial
infarction
54
E. Cardiovascular system
.
. Most
gery
preferable for suspected
and MRI are being
gent sur
-flow Doppler
.
geons, especially with regard to
and MRI for relationship to renal vessels and
Only if signs or symptoms have changed, when
comparison with the CXR obtained at presentation
may be helpful.
Useful in diagnosis, determination of maximal
diameter and follow-up. CT
leak but should not delay ur
CT
iliacs. Increasing demand for detailed anatomical
information because of increasing consideration
for percutaneous stenting.
More sensitive with colour
clinically significant thrombi are detected. Increasing
experience with US for calf vein thrombi. May show
other lesions.
Extensive variation according to US expertise and
local therapeutic strategy
Local policy needs to be determined in agreement
with vascular sur
therapeutic interventions. US used in some centres as
first investigation. Spiral CT
developed.
Not indicated
routinely (B)
Indicated (A)
Indicated (A)
Indicated (A)
Not indicated
routinely (C)
Specialised
investigation (A)
(III) or
enography (II)
CXR (I)
US (0) aorta
CT
MRI (0)
US (0) lower
limb veins
V
Angiography
(III)
1
E8
E9
E10
E1
Follow-up of patients
with heart disease or
hypertension
Abdominal aortic
aneurysm
Deep-vein thrombosis
Ischaemic leg
55
E. Cardiovascular system
COMMENT
NM is the most established investigation for assessing
myocardial perfusion. Cardiac MRI only available in a
few centres.
TION
{GRADE}
Indicated (A)
RECOMMENDA
TION
{DOSE}
INVESTIGA
NM (III)
E12
CLINICAL PROBLEM
Myocardial evaluation
56
F. Thoracic system
, likely
gery
s disease show no
ietze’
T
. Many patients with cardio
rauma Section K).
Anaesthetists may also request CXRs for
Conditions such as
abnormality on CXR. Main purpose is reassurance.
Showing a rib fracture after minor trauma does not
alter management
(see T
Not justified except in a few high-risk categories (e.g.
at risk immigrants with no recent CXR). Some have to
be done for occupational (e.g. divers) or emigration
purposes (UK category 2).
Exceptions before cardio-pulmonary sur
admission to ITU, suspected malignancy or possible
TB.
dyspnoeic patients, those with known cardiac disease
and the very elderly
respiratory disease have recent CXR available; a
repeat CXR is then not usually needed.
Only if signs or symptoms have changed.
Not indicated
initially (C)
Not indicated
routinely (C)
Not indicated
Not indicated
routinely (B)
Not indicated
routinely (C)
Not indicated
routinely (B)
CXR (I)
CXR (I)
CXR (I)
CXR (I)
CXR (I)
CXR (I)
F1
F2
F3
F4
F5
F6
F
.
Thoracic system
Non-specific chest pain
Chest trauma
Pre-employment or
screening medicals
Pre-operative
Upper respiratory-tract
infection
Chronic obstructive
airways disease or
asthma; follow-up
57
F. Thoracic system
The
first (see Cancer
COMMENT
and then proceed to
.
fusion can be missed, especially on a frontal
confirm clearing, etc. Pointless to re-examine at
prove fluid consistency; to guide aspiration. CT
plus lateral view
o
o
CXR is most helpful when there has been a change
A
T
less than 10-day intervals as clearing can be slow
(especially in the elderly).
Small ef
CXR.
T
occasionally needed for better localisation, assessment
of solid components, etc.
P
Many centres use CT
bronchoscopy; increasing use of CT
L7). Consider bronchial arteriography in massive
haemoptysis.
A
in symptoms or insertion or removal of a device.
value of the routine daily CXR is being increasingly
questioned.
TION
{GRADE}
Indicated (A)
Indicated (B)
Indicated (B)
Indicated (B)
Specialised
investigation (B)
Indicated (B)
RECOMMENDA
TION
{DOSE}
(III)
INVESTIGA
CXR (I)
CXR (I)
US (0)
CXR (I)
CT
CXR (I)
F7
F8
F9
F10
fusion
CLINICAL PROBLEM
Pneumonia adults:
follow-up
(for children see
Section M)
Pleural ef
Haemoptysis
ITU/HDU patient
58
F. Thoracic system
fects of
can show abnormalities not
.
High resolution CT
evident on CXR, especially interstitial disease.
NM can assess disease activity (e.g. measure
permeability in alveolitis) and monitor ef
therapy
Indicated (B)
Specialised
investigation (B)
(II)
CT
NM (II)
1
F1
Occult lung disease
59
G. Gastrointestinal system
.
gery
.
. Detailed
COMMENT
ebs and pouches are well
W
for acid reflux but gives no anatomical
ideo swallows for suspected pharyngeal dysfunction
Ba studies are still recommended before possible
endoscopy; they will accurately localise lesions and
show the degree of obstruction caused by a stricture
and its length.
demonstrated. Subtle strictures may be demonstrated
by a marshmallow (or other bolus) study
fluoroscopy or NM needed for motility disorders.
V
in conjunction with speech therapists.
Although Ba swallow useful to demonstrate hernia,
reflux and their complications, not all such patients
need investigation. Reflux is common and not
necessarily the cause of pain. NM may be oversensitive;
pH monitoring is generally regarded as the ‘gold
standard’
information. Metaplasia and oesophagitis are best
detected by endoscopy which also allows biopsy
Increasing use of Ba studies before anti-reflux sur
TION
{GRADE}
Indicated (B)
Specialised
investigation (B)
Not indicated
routinely (C)
RECOMMENDA
TION
{DOSE}
INVESTIGA
Ba swallow (II)
NM (I)
Ba swallow
/meal (III)
G1
G2
CLINICAL PROBLEM
ficulty in swallowing
G. Gastrointestinal system
Gastrointestinal tract
Dif
Chest pain — hiatus
hernia or reflux
60
G. Gastrointestinal system
gical
.
. Red
-soluble
gery or intervention (e.g.
ficient, unless localisation for sur
. NM can detect bleeding rates as low
.
CXR may be suf
repair is planned.
Swallow should be performed with water
non- ionic contrast agents. Some centres use CT
Of no value.
Endoscopy provides diagnosis of upper GI lesions,
allows injection of varices, etc. Ba studies preclude
angiography
After endoscopy
as 0.1 ml/min; more sensitive than angiography
cell study is most useful in intermittent bleeding.
When considering sur
embolisation) for uncontrollable bleeding.
Indicated (B)
Specialised
investigation (B)
Not indicated
routinely (B)
Not indicated
routinely (A)
Specialised
investigation (B)
Specialised
investigation (B)
ed cell study)
CXR (I)
Swallow (II)
AXR (II)
Ba studies (II)
NM (II)
(r
Angiography
(III)
G3
G4
Oesophageal perforation
Acute GI bleeding:
haematemesis
61
G. Gastrointestinal system
.
,
go a trial of
COMMENT
fect of treatment of Helicobacter pylori.
, Ba meal remains a reasonable alternative.
Most patients under 45 yrs can be treated without
complex investigations and will under
therapy (anti-ulcer or reflux). Either Ba meal or
endoscopy for those who fail to respond. Other alarm
features pointing to early investigation include
unintentional weight loss, anaemia, anorexia, GI
bleeding, pain requiring hospitalisation, non-steroid
anti-inflammatory drugs, vomiting, no improvement
following treatment in those positive for Helicobacter
pylori.
Endoscopy is often the first line investigation.
However
The alternative investigation should be considered
whenever symptoms continue after negative result.
The main concern is the detection of early cancer
especially submucosal tumours.
Scarring precludes accurate assessment. Endoscopy
preferred to confirm complete healing and to obtain
biopsies (e.g. Helicobacter pylori, etc.) where necessary
Some centres use NM studies (Carbon-14 breath test)
to assess ef
TION
{GRADE}
Not indicated
routinely (C)
Indicated (C)
Not indicated
routinely (B)
RECOMMENDA
TION
{DOSE}
INVESTIGA
Imaging
(Ba meal (II)/
Endoscopy (0))
Imaging (Ba
meal (II)/
endoscopy (0))
Ba studies (II)
G5
G6
G7
CLINICAL PROBLEM
Dyspepsia in the younger
patient (e.g. under 45 yrs)
Dyspepsia in the older
patient (e.g. over 45 yrs)
Ulcer follow-up
62
G. Gastrointestinal system
There is
AXR normal and
, etc.). Cross-sectional
ficient to establish diagnosis
here – e.g. to establish site and
, etc.) may be needed to assess
AXR if supine
AXR to show free air if CXR supine.
AXR usually suf
assess anastomosis and transit through to small
o
T
bowel.
Gastric remnant best assessed by endoscopy (gastritis,
ulceration, recurrent tumour
imaging (US, CT
extramural disease. Endoscopic US can demonstrate
submucosal recurrence.
NM can provide functional data about emptying.
Only after upper and lower tract imaging (Ba studies
or endoscopy).
When all other investigations are negative.
Decubitus
Supine
and point to an anatomical level of obstruction.
Consider erect
strong clinical suspicion of obstruction.
increasing use of CT
cause of obstruction.
(C)
Indicated (B)
Not indicated
routinely (B)
Specialised
investigation (B)
Not indicated
initially
Specialised
investigation (B)
Indicated (B)
Specialised
Investigation (B)
s
ect)
ed
(II)
(II)
ater soluble
W
contrast medium
study (II)
Ba studies (II)
NM (II)
Ba small bowel
study (II)
NM (II) (r
cell or Meckel’
study) and/or
angiography (III)
CXR (I) (er
and AXR
CT
1
gery
G8
G9
G10
G1
gery (old)
Previous upper GI sur
(recent)
Previous upper GI
sur
Intestinal blood loss,
chronic or recurrent
Acute abdominal pain —
perforation— obstruction
63
G. Gastrointestinal system
COMMENT
in this situation which can determine level and
to assess bowel wall.
Studies with non-ionic agents can determine both the
site and completeness of obstruction. Some centres use
CT
likely cause.
Small bowel enema is the examination of choice.
Ba follow through tends to give a lower radiation dose
than small bowel enema. Some centres use US and/or
CT
Labelled white cell scintigraphy reveals activity and
extent of disease. Complementary to Ba studies. CT
and MRI reserved for complications.
TION
{GRADE}
Specialised
investigation (B)
Indicated (B)
Indicated (C)
Specialised
investigation (B)
RECOMMENDA
TION
(III)
{DOSE}
INVESTIGA
Contrast studies
(II) or CT
Small bowel
Ba study (II)
Ba small bowel
study (II)
NM (white cell
study) (III)
G12
G13
s
G14
CLINICAL PROBLEM
Small bowel
obstruction
Small bowel obstruction:
chronic or recurrent
Small bowel disease
suspected (e.g. Crohn’
disease)
64
G. Gastrointestinal system
for the
which can
. Good
ficult or
-soluble contrast
Although the irritable bowel
, reserving Ba enema for dif
Double contrast Ba is only useful if the bowel is
go rectal examination to assess suitability for Ba
NB:
properly prepared. Furthermore all patients should
under
enema and to exclude a low rectal tumour
practice requires a sigmoidoscopy before Ba enema.
Defer Ba enema for seven days after full thickness
biopsy via a rigid sigmoidoscope. Biopsies taken
during flexible sigmoidoscopy are usually superficial
and the risk of subsequent perforation is low (ideally a
48 hour delay). Some centres use colonoscopy
initially
incomplete examinations. Some centres use CT
frail elderly patient.
syndrome is the most common cause of a change in
bowel habit, Ba enema or colonoscopy is needed to
exclude other causes.
Single contrast (ideally water
medium) study can show narrowed area and exclude
‘pseudo-obstruction’. Some centres use CT
point to the likely cause.
Indicated (B)
Specialised
investigation (B)
Ba enema (III)
Enema (III)
G15
G16
ge bowel tumour or
ge bowel obstruction:
Lar
inflammatory bowel
disease: pain, bleeding,
change in bowel habit,
etc.
Lar
acute
65
G. Gastrointestinal system
AXR (for
AXR not
as a ‘catch-
. Supine
ficient. Erect
COMMENT
. Increasing use of CT
.
. Likewise Ba enema preferred for
gery
ficient for evaluation.
investigation here. US widely used as a
Often suf
Labelled white cell study best exam — will reveal
activity and extent of disease.
Ba enema is dangerous when toxic megacolon present;
unprepared enema in selected cases after discussion
with radiologists.
Colonoscopy follow-up preferred to identify
developing carcinoma in those at high risk, although
Ba enema is still often used, particularly after complex
intestinal sur
evaluating fistulae etc.
Local policy will determine strategy
gas pattern, etc.) is usually suf
indicated routinely
all’
preliminary survey
TION
{GRADE}
Indicated (B)
Indicated (B)
Not indicated
routinely (B)
Not indicated
routinely (B)
Indicated (B)
RECOMMENDA
TION
{DOSE}
ect CXR (I)
INVESTIGA
AXR (II)
NM (white cell
study) (III)
Ba enema (III)
Ba enema (III)
AXR (II) plus
er
G17
G18
G19
gical
CLINICAL PROBLEM
Inflammatory bowel
disease of colon
Inflammatory bowel
disease of colon:
long-term follow-up
General abdominal problems
Acute abdomen pain;
(warranting hospital
admission and sur
consideration)
66
G. Gastrointestinal system
may be better
Appendicitis is usually a
is an alternative and useful to exclude a lesion;
ide range of policy varying accordingly to local
ferentiation from gynaecological lesions. So too can
ACT). US recommended in children and young
US usually solves the problem and is very reliable in
thin patients, right upper quadrant and pelvis.
CT
particularly good in fat patients.
Imaging is not required for the diagnosis of coeliac
disease but may be indicated for jejunal diverticulosis
or when biopsy is normal/equivocal. CT
if lymphoma suspected.
Numerous NM investigations available which should
establish presence of malabsorption. Some of these are
non-radiological (e.g. breath test).
W
availability of equipment and expertise and the body
habitus of the patient.
clinical diagnosis. Imaging (e.g. US with graded
compression) can help in equivocal cases or in
dif
NM (white cell study) and focused appendix CT
(F
women.
Not indicated
routinely (C)
Indicated (B)
Indicated (A)
Not indicated
routinely (B)
Specialised
investigation (B)
Specialised
investigation (C)
(III)
AXR (II)
US (0)
CT
Ba study of
small bowel (II)
NM (I)
Imaging
G20
G21
G22
Palpable mass
Malabsorbtion
Appendicitis
67
G. Gastrointestinal system
probably
AXR alone.
WBC good
Also allows biopsy of nodes
COMMENT
AXR can help certain specialists (e.g.
Many normal adults show extensive faecal material;
although this may be related to prolonged transit time
it is impossible to assess significance on
But
geriatricians) in refractory cases.
Seek radiological advice; much depends on local
availability and expertise. US often used first (speed,
cost) and may be definitive, particularly when there
are localising signs; especially good for
subphrenic/subhepatic spaces and pelvis. CT
best test overall: infection and tumour usually
identified and excluded.
or tumour and drainage of collections (especially
recent post-operative). NM particularly good when
there are no localising features: labelled
for chronic post-operative sepsis; gallium will
accumulate at sites of tumour (e.g. lymphoma) and
infection.
TION
{GRADE}
Not indicated
routinely (C)
Indicated (C)
RECOMMENDA
TION
{DOSE}
INVESTIGA
AXR (II)
US (0) or CT
(III) or NM (III)
G23
G24
CLINICAL PROBLEM
Constipation
(for children
see Section M)
Abdominal sepsis;
pyrexia of unknown origin
(PUO)
68
G. Gastrointestinal system
, etc.)
, MRCP
. US should be the initial
, ERCP
and NM reliably show further characteristic
. MRI being increasingly used here. Some recent
The majority of metastases will be demonstrated by
US which also allows biopsy
investigation but metastases may show the same
reflectivity as the hepatic parenchyma and thus be
missed. CT/MRI used for further exclusion, where US
equivocal or surprisingly normal and where full
staging is needed or hepatic resection is planned (see
also Cancer L13). Recent interest in dual-phase spiral
CT
interest in NM (somatostatin analogues and PET).
MRI, CT
features of haemangioma and many other solitary
hepatic lesions.
Sensitive for bile duct dilatation. But dilatation may
be subtle in early obstruction and sclerosing
cholangitis. Shows gallstones and most forms of
hepatic disease. US also shows the level and cause of
any obstruction to common bile duct. Discuss
subsequent investigations (CT
with radiologist.
Indicated (B)
Specialised
investigation (B)
Indicated (B)
Specialised
investigation (B)
Indicated (B)
ed cell
(II) or
(III)
US (0)
CT
MRI (0)
MRI (0) or
CT
NM (r
study) (III)
US (0)
G25
G26
G27
, gallbladder and pancreas
Liver
Hepatic metastases
Hepatic haemangioma
(e.g. on US)
Jaundice
69
G. Gastrointestinal system
.
gans too.
% of gallstones.
AXR needed to
AXR.
COMMENT
Also useful in chronic cholecystitis.
show gallstones and to diagnose and follow
o
Plain XRs only show about 10
US allows evaluation of other or
Cholecystography is now rarely needed (e.g. poor
views at US). CT/endoscopy may be needed for
further delineation. Increasing interest in MRCP
Biliary scintigraphy shows cystic duct obstruction in
acute cholecystitis.
Unless diagnosis in doubt; then
exclude other causes of acute abdomen pain (see
G19). Some patients presenting with acute pancreatitis
have underlying chronic pancreatitis which may cause
calcification evident on
T
pseudocyst development, especially good in thin
patients.
TION
{GRADE}
Not indicated
routinely (C)
Indicated (B)
Specialised
investigation (B)
Not indicated
routinely (C)
Indicated (B)
RECOMMENDA
TION
{DOSE}
INVESTIGA
AXR (II)
US (0)
NM (II)
AXR (II)
US (0)
G28
CLINICAL PROBLEM
Biliary disease,
(e.g. gallstones)
Pancreatitis: acute
70
G. Gastrointestinal system
.
. Some
will show
will show
, but considerable risk
may also be indicated.
fect.
also used here. ERCP
(or MRI) good in the fatter
. Increasing use of endoscopic and
shows duct morphology
.
can help predict morbidity and mortality
show calcification.
o
Reserved for clinically severe cases (to assess extent
of necrosis), in patients who do not improve on
treatment or if there is uncertainty as to the diagnosis.
CT
centres use MRI, especially if repeated follow-up
likely
T
US may be definitive in thin patients; CT
calcification to good ef
ERCP
of acute pancreatitis. Hence current interest in MRCP
US will usually have shown the anatomy of the
collections, etc. NM study (HIDA) will show activity
at site of leak. MRCP
the anatomy of the leak and may allow intervention
(e.g. stent).
Especially in thin patients and for lesions in the head
and body
laparoscopic US. CT
patient and where US equivocal or where precise
staging needed. ERCP/MRCP
NM (eg PET) may help distinguish carcinoma from
pancreatitis.
Not indicated
routinely (B)
Indicated (B)
Indicated (B)
Specialised
investigation (C)
Indicated (C)
Indicated (B)
(II) or
(0)
(III) or
(IV)
(III)
CT
MRI (0)
AXR (II)
US (0) or
CT
ERCP
MRCP
NM (II)
US (0)
CT
or MRI (0)
G29
G30
G31
G32
Pancreatitis: chronic
Post-operative biliary leak
Pancreatic tumour
71
G. Gastrointestinal system
gery (out of
COMMENT
promising. Most centres seek two
ging as the best examination although arterial
When biochemical tests are convincing. MRI
emer
phase spiral CT
positive investigations before sur
CT/NM/MRI /angiography). Endoscopic and intra-
operative US also useful.
TION
{GRADE}
Specialised
RECOMMENDA
TION
{DOSE}
INVESTIGA
Imaging
G33
CLINICAL PROBLEM
Insulinoma
72
H. Urological systems
. Imaging
, patients in whom
. Increasing use
renal artery
go US, as IVU can fail to show a renal
AXR are the initial studies, but if negative, IVU
.
+
assess relative renal size and parenchymal pattern.
o
There is a wide variation in local policy
strategies should be agreed with the local
nephrologists and urologists. In many centres
US
is still indicated in patients with continuing
macroscopic haematuria or in the over 40s with
microscopic haematuria. Conversely
IVU and cystoscopy are normal who continue to bleed
should under
tumour and US will occasionally demonstrate a
bladder lesion not seen at cystoscopy
of CT
IVU is insensitive for renal artery stenosis. See H3.
T
Doppler US is not sensitive enough for use as a
screening tool.
Captopril renography is an established method of
determining functionally significant
stenosis.
Indicated (B)
Not indicated
routinely (A)
Indicated (B)
Indicated (B)
AXR
+
US (0)
(II) or IVU (II)
IVU (II)
US (0) kidneys
NM (II)
r
enogram
H1
H2
H. Urological, adrenal and genito-urinary systems
Haematuria macro-
or microscopic
Hypertension (without
evidence of renal disease)
Hypertension: in the
young adult or in patients
unresponsive to medication
73
H. Urological systems
a
acute
gency
AXR on its own is of
plain
gery or angioplasty is
A
COMMENT
and US are increasingly
. NM may be needed to determine
An IVU may be required before treatment to
show stenosis if sur
o
T
considered as a possible treatment.
For renal size, structure, obstruction, etc. NB:
normal US does not exclude obstruction.
When appropriate, renography can assess renal
perfusion, function and obstruction.
Imaging should be performed as an emer
examination whilst the pain is present, as radiological
signs disappear rapidly after passage of a stone.
Delayed films (up to 24 hrs) may be needed to show
the site of obstruction.
little value. Both CT
being used, especially in those with contraindications
to contrast medium.
AXR alone may be appropriate follow-up for previously
demonstrated calculi after an uncomplicated
attack.
show anatomy
relative function.
TION
{GRADE}
Specialised
investigation (C)
Indicated (B)
Indicated (B)
Indicated (B)
Indicated (C)
RECOMMENDA
TION
{DOSE}
+
AXR (II)
+
(III),
(III)
(III) or
(0))
A
INVESTIGA
Angiography
(DSA
CT
MRA
US (0)
AXR (II)
NM (II)
IVU (II) or US
(0) and
or CT
US (0)
AXR (II)
H3
H4
H5
H6
CLINICAL PROBLEM
Renal failure
Renal colic, loin pain
Renal calculi (in the
absence of acute colic)
74
H. Urological systems
here.
gical exploration. Doppler US can be used,
ferentiation of testicular from extra-
or MRI preferable for further evaluation. NM may
r
ansrectal US with guided biopsies after clinical
orsion is usually a clinical diagnosis. Imaging
US is good at distinguishing between cystic and solid
masses.
CT
be needed to determine relative function.
US can also assess upper tract and bladder volumes
before and after voiding, preferably with flow rates. It
can also show bladder calculi.
T
examination. Some interest in MRI and PET
US to evaluate the upper tracts (after catheterisation
and relief of bladder distension), particularly if urea
levels remain raised.
Allows dif
testicular lesions.
T
investigations must not delay the priority that must be
given to sur
when clinical findings are equivocal in the post
pubertal testis.
NM techniques can assist with this diagnosis but
prompt results essential.
Indicated (B)
Not indicated
routinely (C)
Indicated (B)
Not indicated
routinely (B)
Specialised
investigation (B)
Indicated (C)
Not indicated
routinely (C)
Indicated (B)
Specialised
investigation (C)
Specialised
investigation (C)
+
US (0)
AXR (II)
IVU (II)
US 0)
IVU (II)
US (0)
US (0)
IVU (II)
US (0)
US (0)
NM (II)
1
H7
H8
H9
H10
H1
H12
esticular torsion
Renal mass
Prostatism
Prostatic malignancy
Urinary retention
Scrotal mass or pain
T
75
H. Urological systems
and
ferentiate
en.
and MRI can dif
COMMENT
ferent lesions. NM can distinguish
This does not apply to childr
The majority do not need investigation unless there
are recurrent infections, renal colic or failure to
respond to antibiotics. Slightly lower threshold to
investigate male patients.
NB:
Whilst US may identify lesions of this type, CT
MRI provide the best anatomical delineation. Imaging
is rarely indicated in the absence of biochemical
evidence of such tumours.
MIBG locates functioning tumours and is particularly
useful for ectopic sites and metastases.
Local advice on the most appropriate examination
should be sought. Both CT
between the dif
between functioning and non-functioning adenomas.
So too can various MRI techniques.
TION
{GRADE}
Not indicated
routinely (C)
Specialised
investigation (B)
Specialised
investigation (B)
Specialised
investigation (B)
RECOMMENDA
TION
{DOSE}
+
(III) or
(III), NM
INVESTIGA
US (0)
AXR (II) or
IVU (II)
CT
MRI (0)
NM (II)
CT
(IV) or MRI (0)
H13
H14
s
H15
s and Conn’
CLINICAL PROBLEM
Urinary tract infection
in adults
(for children see
Section M)
Adrenal medullary
tumours
Adrenal cortical lesions,
Cushing’
disease and syndrome
76
I. Obstetrics and gynaecology
.
US preferred.
Where doubt exists
, delay in evacuation
TV
ferent countries.
There is wide variation in the use of
. It does provide useful information about
, except where selective termination of
Screening US has not been shown to alter perinatal
mortality
pregnancy is applied in the presence of gross foetal
abnormality
dating and multiple pregnancies. US is also of proven
value in assessing placenta praevia and intra-uterine
growth. In the specialist care of high-risk pregnancies,
Doppler US of the umbilical artery assists
management.
obstetric US in dif
Pregnancy testing most appropriate. US valuable
where molar pregnancy suspected.
After positive pregnancy test.
Colour flow Doppler increases sensitivity
Repeat US after a week may be needed (especially
when gestational sac < 20 mm or crown rump length
< 6 mm). Pregnancy test required.
about the viability of a pregnancy
of the uterus is essential.
Indicated (C)
Not indicated
routinely (C)
Indicated (B)
Indicated (C)
US (0)
US (0)
US (0)
US (0)
I1
I2
I3
I4
ransvaginal (TV) US equipment should be available in all departments performing pelvic US
T
I. Obstetrics and gynaecology
NB:
Screening in pregnancy
Suspected pregnancy
Suspected ectopic
pregnancy
Possible non-viable
pregnancy
77
I. Obstetrics and gynaecology
US often
ficult or
TV
s presence and
.
Some centres
ger foci of
.
COMMENT
gan of origin. See Cancer Section
still widely used.
ill show the major congenital and acquired
Combination of trans-abdominal and
required. US should confirm a lesion’
determine likely or
L. MRI is the best second line investigation, although
CT
Especially when clinical examination dif
impossible.
Can be useful to localise the lar
endometriosis.
Unless IUCD is not seen in uterus on US.
W
problems.
Supplements US for uterine anatomy
use hysterosalpingography
TION
{GRADE}
Indicated (C)
Indicated (C)
Specialised
investigation (B)
Indicated (C)
Not indicated
routinely (C)
Indicated (C)
Specialised
investigation (C)
RECOMMENDA
TION
{DOSE}
INVESTIGA
US (0)
US (0)
MRI (0)
US (0)
AXR (II)
US (0)
MRI (0)
I5
I6
I7
I8
CLINICAL PROBLEM
Suspected pelvic mass
Pelvic pain, including
suspected pelvic
inflammatory disease and
suspected endometriosis
Lost IUCD
Recurrent miscarriages
78
I. Obstetrics and gynaecology
fers a lower dose
.
generally of
.
. Some centres use MRI and/or
For follicle-tracking during treatment. For assessment
of tubal patency
hysterosalpingography
The need for pelvimetry is increasingly being
questioned. Local policy should be determined in
agreement with obstetricians. Furthermore MRI or CT
should be used wherever possible. MRI is best as it
avoids x-irradiation. CT
than standard XR pelvimetry
Indicated (C)
Not indicated
routinely (B)
Specialised
investigation (C)
(II)
US (0)
XR (II)
Pelvimetry
MRI (0) or
CT
I9
I10
Infertility
Suspected cephalopelvic
disproportion
79
J. Breast disease
.
ferent
.
omen on
W
This topic is being
COMMENT
yrs are not at increased risk of
1
for > 1
T
This topic is not considered further
50 yrs and over can be appropriately monitored
eta-analysis has shown women < 50 yrs who have
T
arious strategies have been adopted in dif
m
V
countries.
At present there is no evidence of benefit but there is
some evidence of harm. Screening should only be
contemplated after genetic risk assessments and
appropriate counselling as to the risks and unproven
benefits. Consensus at the moment is that screening
should only be contemplated when the lifetime risk of
breast cancer is greater than 2.5 times average. Units
should collect and audit their work.
rigorously discussed at the present time. Further
evaluation is usually obtained by US, NM and MRI
according to local expertise and availability
A
received HR
breast cancer compared to a peer group.
HR
by breast screening programmes.
TION
{GRADE}
arious
V
indications
Specialised
examination (C)
Not indicated
routinely (A)
RECOMMENDA
TION
{DOSE}
INVESTIGA
Mammography
(I)
Mammography
(I)
Mammography
(I)
J5
J6
J1–4
CLINICAL PROBLEM
T
J. Breast disease
omen < 50 yrs having
Asymptomatic patients
Breast screening
Family history of breast
cancer
W
or being considered for
HR
80
J. Breast disease
. Ultrasound can readily direct
US should be used in the context of
, imaging is unlikely to influence
.
Best considered as part of whatever national breast
screening policy applies (see J1–4).
Referral to a breast clinic should precede any
radiological investigation.
Mammography ±
triple assessment — i.e. clinical examination, imaging
and cytology/biopsy
biopsy
NM or MRI sometimes a useful adjunct to triple
assessment of an equivocal lesion.
In the absence of other signs suggestive of
malignancy
management. Focal, rather than generalised pain may
warrant investigation.
In the absence of other clinical signs suggestive of
malignancy and localised pain, investigation is
unlikely to influence management.
Indicated (B)
Specialised
investigation (B)
Specialised
investigation (B)
Not indicated
routinely (C)
Not indicated
routinely (B)
Mammography
(I)
Mammography
(I),
US (0)
NM (III) or
MRI (0)
Mammography
(I) or US (0)
Mammography
(I)
J7
J8
J9
J10
Asymptomatic women
with augmentation
mammoplasty
Symptomatic patients
Clinical suspicion of
breast cancer (diagnosis)
Generalised lumpiness,
generalised breast pain,
or tenderness, or
longstanding nipple
retraction
Cyclical mastalgia
81
J. Breast disease
also have a role when
COMMENT
fuse inflammation, and can guide
The assessment of integrity of breast implants or
coincident masses requires specialist skills and
facilities.
MRI is now an established investigation for implant
leakage. It can also show tumours.
Scintimammography and PET
other investigations are unhelpful.
The prevalence of coexistent breast cancer varies in
published studies, but its association is clear and
justifies specialist referral.
US can distinguish between an abscess requiring
drainage and dif
aspiration when appropriate. Mammography may be
of value where malignancy is possible.
TION
{GRADE}
Indicated (B)
Specialised
investigation (B)
Indicated (C)
Indicated (B)
RECOMMENDA
TION
{DOSE}
INVESTIGA
US (0)
MRI (0) or
NM (III)
Mammography
(I)
US (0)
1
J1
J12
J13
s disease of the
CLINICAL PROBLEM
Augmentation
mammoplasty
Paget’
nipple
Breast inflammation
82
J. Breast disease
. For locoregional
The role of sentinel node scintigraphy and localisation
is currently being evaluated.
For patients with a primary tumour >2cm and those
with bone pain.
Principles of triple assessment apply
recurrence, NM scintimammography and MRI have a
role.
Specialised
investigation (C)
Indicated (B)
Not routinely
indicated (C)
Indicated (A)
east/axilla
east NM
Br
br
axilla (III)
NM skeletal
(II)
US liver (0)
Mammography
(I)
J14
J15
Breast cancer
Staging: axilla
Staging: general
Breast cancer
Follow-up (surveillance)
83
K. Trauma
ements
equir
The recommendations
gical centre for your area in the
e?
essur
gical centres, etc.
essed?
e and, if so, is it depr
hage or raised intracranial pr
ed?
equir
eas involved?
, distances involved in transportation to neurosur
ed?
gical opinion r
osur
om non-imaging issues such as admission.
e evidence of brain injury?
e evidence of intracranial haemorr
e clinical evidence of a skull fractur
r
equir
e other systems/ar
Protocols for management of head injuries are constantly under review and will vary according to local
availability of CT
given here may need to be adapted following consultation with the neurosur
light of local circumstances and policies.
Is ther
Is ther
Is ther
Ar
Does the patient need admission to hospital for observation?
Is CT
Is a neur
rauma
K. T
Head: general
Head injury:
The key management and clinical questions in head injury are:
Clinical:
Management:
These questions underline key policies concerning management of patients. Decisions about imaging r
cannot be separated fr
84
K. Trauma
s
to
the
ficult
.
is increasingly being used as the first
is the simplest way of excluding significant
, in which case SXR is usually unnecessary
.
osurgical management include:
, imaging is required. CT
urgent neur
. If there is a history of loss of consciousness, neurological signs or symptoms (excluding a
High or mixed attenuation intracranial lesion
Shift of mid-line structures (e.g. third ventricle)
Obliteration of third ventricle
Relative dilatation of a lateral ventricle(s)
Obliteration of basal cisterns
Intracranial air
Sub-arachnoid or intraventricular haemorrhage.
. If non-accidental injury is suspected, a skull SXR as part of a skeletal survey is required. In addition, MRI of
en
ficulties with image interpretation or the management of the patient may be resolved by referrals via image transfer
gent, and the patient will be better examined when sober and more cooperative. CT
The usual indications for admission include: confusion or depressed consciousness; fracture on SXR; neurological symptoms
or signs; seizures; CSF or blood from nose or ear; coagulation disorders; lack of adult supervision at home; patient dif
assess (non-accidental injury (NAI), drugs, alcohol, etc.). If a decision is made to admit for observation, imaging becomes les
ur
investigation in those where there is a medium risk of intracranial injury
Dif
systems to designated neuroscience centres.
Intracranial abnormalities suggesting need for
Childr
Head injuries are relatively common in children; in the majority of cases, there is no serious injury: imaging and
hospitalisation are unnecessary
single vomit) or an inadequate or inconsistent history
brain injury
brain may be required later to further document timing of the injury
85
K. Trauma
Y
They
.
COMMENT
. If no fracture is seen, patients
is increasingly being used as the first and ONL
These patients are usually sent home with head injury
instructions to the care of a responsible adult.
may be admitted to hospital if no such adult is
available.
CT
investigation in this group of patients, to confidently
exclude cranial injury
will usually be sent home with head injury instructions
to the care of a responsible adult. If no responsible
adult is available or if a fracture is present, the patient
will usually be admitted. See Section M (M13) for
non-accidental injury in children. MRI of the brain
is the preferred investigation for intracranial injuries
in NAI, but SXR may still be needed to exclude
fractures missed on CT
TION
{GRADE}
Not indicated
routinely (C)
Not indicated
routinely (C)
Indicated (B)
RECOMMENDA
TION
{DOSE}
(II)
(II) or
INVESTIGA
SXR (I)
CT
CT
SXR (I)
K1
twice
vomiting
amnesia
neurological defects
serious scalp
haematoma
CLINICAL PROBLEM
o
o
o
o
iolent mechanisms
Head: low risk of intracranial injury
Fully orientated
N
N
N
laceration
N
Loss of consciousness
or amnesia
V
of injury
Scalp bruise, swelling
or laceration down to
bone or > 5 cm
Neurological symptoms
or signs (including
headache,
or more, return visit)
•
•
•
•
•
Head: medium-risk of intracranial injury
•
•
•
•
86
K. Trauma
on an
e.
hours of
rhinorrhoea/otorrhoea
. In
gical opinion.
should be available within four
CT
gent basis, seek neurosur
These patients will usually have been admitted for
observation. If there is any delay in getting CT
ur
NB:
admission in all patients with a skull fractur
SXR is not required before CT
NM can identify site of leakage in chronic phase.
Indicated (B)
(II)
CT
K2
skull
K3
to
injury
Inadequate history or
examination (epilepsy
/alcohol/child/etc.)
Child below 5 yrs:
suspected NAI, tense
fontanelle, fall more than
60 cm or on to hard
surface
Head: high risk of intracranial injury
Suspected FB or
penetrating
Disorientated or
depressed consciousness
Focal neurological
symptoms or signs
Seizure
Skull fracture or sutural
diastasis shown on SXR
CSF from nose or CSF/
blood from ear
Unstable systemic state
precluding transfer to
neurological unit
Diagnosis uncertain
•
•
•
•
•
•
•
•
•
•
87
K. Trauma
ANAESTHETIC
AND
COMMENT
TED, which should not be
policy: usually follow-up at an
. Management of the bruised nose
INDICA
NEUROSURGICAL
should be performed as an emergency (see
CT
or maxillo-facial clinic will determine the need
URGENT
REFERRAL
delayed by imaging.
NB:
K3 above).
Unless requested by a specialist. Poor correlation
between radiological findings and presence of
external deformity
will depend on local
ENT
for XR.
TION
{GRADE}
Indicated (B)
Not indicated
routinely (B)
RECOMMENDA
TION
{DOSE}
(II)
INVESTIGA
CT
SXR (I)
XR facial bones
(I), XR nasal
bones (I)
K4
K5
CLINICAL PROBLEM
ense fontanelle or
Head: very high risk of intracranial injury
Deteriorating
consciousness or
neurological signs
(e.g. pupil changes)
Confusion or coma
persistent despite
resuscitation
T
sutural diastasis
Open or penetrating injury
Depressed or compound
fracture
Fracture of skull base
•
•
•
•
•
•
Nasal trauma
88
K. Trauma
1.
injury possible
A16).
Advisable to delay
geon who may require
may eventually be required by
may be required; MRI
TMJ problems see B1
A16). (2) Investigation requested by
at an early stage.
Especially in those where ‘blow-out’
MRI or low dose CT
specialists, especially when XRs or clinical signs
equivocal.
When: (1) Radio-opaque intra-ocular FB is a
possibility (see
ophthalmologist. (3) Suspicion of damage to orbital
walls.
US or low-dose CT
contraindicated with metallic FB (see
But patient cooperation essential.
XR in uncooperative patients. In children, XR often
unhelpful.
Discuss with maxillofacial sur
low-dose CT
For non-traumatic
Indicated (B)
Indicated (C)
Specialised
investigation (B)
Indicated (B)
Specialised
investigation (B)
Indicated (C)
(II)
XR facial bones
(I)
XR orbits (I)
US (0) or
CT
XR facial bones
(I)
Low-dose CT
(II)
XR Mandible (I)
or orthopantomo-
gram (OPG) (I)
K6
K7
K8
K9
Orbital trauma:
blunt injury
Orbital trauma:
penetrating injury
Middle third facial injury
Mandibular trauma
89
K. Trauma
.
ficult to evaluate.
ficult in the severely
or MRI especially
COMMENT
ficult and:
time of initial study).
when XR equivocal or complex lesions.
In those who meet all of the following criteria:
(1) Fully conscious.
(2) Not intoxicated.
(3) No abnormal neurological findings.
(4) No neck pain or tenderness.
Must be of good quality to allow accurate evaluation.
But radiography may be very dif
traumatised patient and must avoid manipulation (see
also K12).
Cervical spine XRs can be very dif
Radiography also dif
1. Must show C7/T1.
2. Should show odontoid peg (not always possible at
3. May need special views, CT
Discuss with department of clinical radiology
TION
{GRADE}
Not indicated
routinely (B)
Indicated (B)
Indicated (B)
Specialised
investigation (B)
RECOMMENDA
TION
{DOSE}
(II) or MRI
INVESTIGA
XR C spine (I)
XR C spine (I)
XR C spine (I)
CT
(0)
1
K10
K1
K12
CLINICAL PROBLEM
Cervical spine
Conscious patient with
head and/or face injury
only
Unconscious head injury
(see K3/4)
Neck injury: with pain
90
K. Trauma
When
and MRI
myelography
A, other spinal
T
.
iews taken in flexion and extension (consider
low threshold to XR when there is pain/tenderness,
For orthopaedic assessment.
Some constraints with life support systems. MRI best
and safest method of demonstrating intrinsic cord
damage, cord compression, ligamentous injuries and
vertebral fractures at multiple levels. CT
may be considered if MRI not available.
V
fluoroscopy) as achieved by the patient with no
assistance and under medical supervision. MRI may
be helpful here.
Physical examination is reliable in this region.
the patient is awake, alert and asymptomatic, the
probability of injury is low
A
a significant fall, a high impact R
fracture present or it is not possible to clinically
evaluate the patient. Increasing use of CT
here.
Indicated (B)
Indicated (B)
Specialised
investigation (B)
Not indicated
routinely (B)
Indicated (B)
ea (II)
XR (I)
MRI (0)
XR C spine;
flexion and
extension (I)
XR (II)
XR painful
ar
K13
K14
K15
K16
rauma: no pain, no
rauma: with pain, no
Neck injury: with
neurological deficit
Neck injury: with pain
but XR initially normal;
suspected ligamentous
injury
Thoracic and lumbar spine
T
neurological deficit
T
neurological deficit or
patient not able to be
evaluated
91
K. Trauma
often used as patient
,
leak, rupture. Consider
COMMENT
can be useful when XR normal or
for other reasons. But MRI best
going CT
show urethral integrity
o
Where technically possible. CT
under
method of demonstrating intrinsic cord damage, cord
compression and vertebral fractures at multiple levels.
Physical examination may be unreliable. Check for
femoral neck fractures, which may not show on initial
XR, even with good lateral views. In selected cases
NM or MRI or CT
equivocal.
T
cystogram if urethra normal and suspicion of bladder
leak.
Normal appearances often misleading and findings do
not alter management.
TION
{GRADE}
Indicated (B)
Indicated (B)
Indicated (C)
Indicated (C)
Not indicated
routinely (C)
RECOMMENDA
TION
{DOSE}
ogram (II)
ograde
ethr
INVESTIGA
XR (II)
MRI (0)
XR pelvis (I)
plus lateral XR
hip (I)
Retr
ur
XR coccyx (I)
K17
K18
K19
K20
CLINICAL PROBLEM
rauma: with neurological
rauma to coccyx or
T
deficit — pain
Pelvis and sacrum
Fall with inability to
bear weight
Urethral bleeding and
pelvic injury
T
coccydynia
92
K. Trauma
As a
(see also
and MRI here.
, NM or MRI to exclude fracture
. CT/MRI may be needed where
fusion. Routine follow-up XRs not
fusion, no obvious fracture’
arthrography all have a role in soft tissue
.
show an ef
o
Some dislocations present subtle findings.
minimum, orthogonal views are required. US, MRI
and CT
injury
T
indicated in ‘ef
Section M). Increasing use of CT
Scaphoid fractures can be invisible at presentation.
Most centres repeat XR at 10–14 days if there are
strong clinical signs and initial XR negative. Some
departments use CT
earlier than this. Increasing use of MRI as the only
examination.
Especially where physical signs of injury are minimal.
Inability to bear weight or pronounced bony
tenderness, particularly at patella and head of fibula,
merit radiography
further information is required (see D23).
Indicated (B)
Indicated (B)
Indicated (B)
Specialised
investigation (B)
Not indicated
routinely (B)
XR shoulder (I)
XR elbow (I)
XR wrist (I)
NM (II) or
MRI (0)
XR knee (I)
K21
K22
K23
K24
rist injury
Upper limb
Shoulder injury
Elbow injury
W
Lower limb
Knee injury
(fall/blunt trauma)
93
K. Trauma
ficult;
ficult.
COMMENT
Features which justify XR include: the elderly patient,
malleolar tenderness, marked soft tissue swelling and
inability to bear weight.
Unless there is true bony tenderness. Even then the
demonstration of a fracture rarely influences
management. Only rarely are XRs of foot and ankle
indicated together; both will not be done without good
reason. Clinical abnormalities are usually confined to
foot or ankle.
Although often unrewarding.
Provides a means of early detection as well as visual
account of the biomechanical properties of the bone.
Some centres use US here.
All glass is radio-opaque; some paint is radio-opaque.
Radiography and interpretation may be dif
remove blood-stained dressings first. Consider US,
especially in areas where radiography dif
TION
{GRADE}
Not indicated
routinely (B)
Not indicated
routinely (B)
Indicated (B)
Indicated (B)
Indicated (B)
RECOMMENDA
TION
{DOSE}
INVESTIGA
XR ankle (I)
XR foot (I)
XR (I)
NM (II) or
MRI (0)
XR (I)
K25
K26
K27
K28
CLINICAL PROBLEM
Ankle injury
Foot injury
Stress fracture
The Foreign Body (FB)
Soft tissue injury:
FB (metal, glass, painted
wood)
94
K. Trauma
e
.
u
a
q
p
ficult.
-
o
i
o
a
d
r
,
especially if
a
r
e
l
y
s
r
i
-exposed, frontal
d
fice. In adults, a
o
o
e
:
w
u
a
q
p
-
o
i
o
a
d
t
r
o
s
n
AXR may be useful for localisation.
ferentiation from calcified cartilage can be dif
l
a
s
t
i
c
i
P
Soft-tissue US may show non-opaque FB.
After direct examination of oropharynx (where most
FBs lodge), and if FB likely to be opaque.
Dif
Most fish bones invisible on XR. Maintain a low
threshold for laryngoscopy or endoscopy
pain persists after 24 hours (see K33). NB: for
possible inhaled FB in children see Section M (M23).
The minority of swallowed FBs will be radio-opaque.
In children a single, slightly over
CXR to include neck should suf
lateral CXR may be needed in addition if frontal CXR
negative. Majority of FBs that impact, do so at crico
pharyngeus. If the FB has not passed (say within 6
days),
(B)
Not indicated
routinely
Indicated (B)
Indicated (C)
Not indicated
routinely (B)
Indicated (B)
Not indicated
routinely (B)
XR (I)
US (0)
XR soft
tissues of
neck (I)
AXR (II)
CXR (I)
AXR (II)
K29
K30
K31
wood)
(plastic,
Soft tissue injury:
FB
Swallowed FB suspected
in pharyngeal or upper
oesophageal region
(for children see
Section M)
Swallowed FB: smooth
and small (e.g. coin)
95
K. Trauma
. Lat CXR may
COMMENT
AXR may be needed if CXR negative,
normal CXR does not exclude aortic
A
AXR negative.
Most swallowed foreign bodies that pass the
oesophagus eventually pass through the remainder of
the gastrointestinal tract without complication. But
location of batteries is important as leakage can be
dangerous.
Unless
Dentures vary in radio-opacity; most plastic dentures
are radiolucent.
as may barium swallow or endoscopy
be helpful.
The demonstration of a rib fracture does not alter
management.
Frontal CXR for pneumothorax, fluid or lung
contusion.
injury and arteriography/CT/MRI should be
considered.
TION
{GRADE}
Indicated (B)
Not indicated
routinely (B)
Indicated (B)
Not indicated
routinely (B)
Indicated (B)
RECOMMENDA
TION
{DOSE}
INVESTIGA
AXR (II)
CXR (I)
CXR (I)
CXR (I)
CXR (I)
K32
K33
K34
K35
ge
CLINICAL PROBLEM
Sharp or potentially
poisonous swallowed FB:
(e.g. battery)
Swallowed FB: lar
object (e.g. dentures)
Chest
Chest trauma: minor
Chest trauma: moderate
96
K. Trauma
,
may be
go CT
. Some
. CT
ficient for minor
. Consider renal artery
. US often suf
Think of thoracic spinal and
gans, e.g. spleen, liver
. Many centres use a limited IVU, merely
and/or other views to show pneumothorax, lung
A
P
damage or fluid. US useful for pleural and pericardial
fluid.
In addition to CXR.
aortic injuries too.
US valuable for detecting haematoma and possible
injury to some or
needed (see K40–K42).
Discuss with radiologist. In agreement with local
policy and availability
local injury
to ensure normality of contralateral kidney
patients with major injury (see below) under
making IVU unnecessary
damage, especially in deceleration injuries;
arteriography may be needed. NM may be helpful to
assess residual function.
Indicated (C)
Indicated (C)
Indicated (B)
Indicated (B)
(II)
e
r
ect CXR (I)
CXR (I)
XR lateral
sternum (I)
Supine AXR
+
Imaging
K36
K37
K38
K39
Stab injury
Sternal fracture
Abdomen (including
kidney). Blunt or stab
injury
Renal trauma
97
K. Trauma
.
.
gency
. Perform only
gan-injury
C-spine may be combined
COMMENT
should precede peritoneal lavage.
s condition as a priority
. CT
head. Pelvic fractures often associated with
gery
Stabilise patient’
the minimum XRs necessary at initial assessment.
C-spine XR can wait so long as spine and cord
suitably protected, but CT
with CT
major blood loss. See Head Injury K1–K4.
Pneumothorax must be excluded. Pelvic fractures
which increase pelvic volume often associated with
major blood loss.
Sensitive and specific, but time-consuming and may
delay sur
Increasing interest in the use of US in emer
room to show free fluid plus solid or
Allows immediate management (e.g. pneumothorax).
Especially useful to exclude mediastinal haemorrhage.
Low threshold for proceeding to arteriography
TION
{GRADE}
Indicated (B)
Indicated (B)
Indicated (B)
Indicated (B)
Indicated (B)
RECOMMENDA
TION
{DOSE}
head (II)
abdo (III)
Chest (III)
INVESTIGA
C-spine XR (I),
CXR (I),
pelvis XR (I),
CT
CXR (I),
Pelvis XR (I)
CT
CXR (I)
CT
K40
K41
K42
CLINICAL PROBLEM
Major trauma
Major trauma — general
screen in the unconscious
or confused patient
Major trauma —
abdomen/pelvis
Major trauma – chest
98
L. Cancer
cies.
her
ions).
CXR is
les
A
sections. Brief
otocols rat
gery contemplated; to see
otocols (e.g. testicular
e driven by trial pr
.
gery
ed; some ar
equir
establish presence of a mass, particularly in
o
T
superficial lesions.
Useful in the deep portion of the gland and before
complex sur
Especially when complex sur
relations and involvement of deep lobe.
This is a clinical diagnosis.
MRI has the advantage of direct coronal imaging.
MRI will eventually supersede.
e often r
Indicated (B)
Indicated (B)
Indicated (B)
Not indicated
routinely (B)
Indicated (B)
ess (e.g. post-chemotherapy) ar
opriately funded.
ogr
elevant in this section. CXR is also part of many follow-up pr
pr
(II)
(II)
(II) or
most malignant lesions to identify possible pulmonary Metastases. Concern about radiation in
US (0)
MRI (0) or
CT
MRI (0) or
CT
Imaging
CT
MRI (0)
L1
L2
L3
L4
esentation for
L. Cancer
Many of the clinical problems related to the diagnosis of cancer have already partly been covered within the individual system
notes are provided here about the use of imaging in the diagnosis, staging and follow-up of some of the common primary malignan
Paediatric malignancies are not included as their management is always at specialist level. For breast cancer see Section J.
necessary at pr
diagnostic imaging is generally less r
Follow-up investigations to monitor
than clinical need and thus should be appr
Parotid
Diagnosis
Staging
Larynx
Diagnosis
Staging
99
L. Cancer
nodules
COMMENT
. NM is also used in follow-up
is superior in identifying lesions
. CT
assess local extent (e.g. retrosternal extension and
o
See Neck Section B1. US guided core biopsy is
increasingly being used, especially for ‘cold’
on NM.
T
nodes).
After thyroidectomy
when recurrence is suspected.
But can be normal, particularly with central tumours.
Many centres proceed directly to bronchoscopy which
allows biopsy
responsible for haemoptysis.
Despite limitations in specificity of nodal
involvement, etc. Some centres perform NM for
possible skeletal metastases.
TION
{GRADE}
Indicated (A)
Indicated (B)
Indicated (B)
Indicated (B)
Indicated (B)
Indicated (B)
RECOMMENDA
TION
{DOSE}
and
A
(II) or
(III)
chest, upper
INVESTIGA
US (0) and
NM (I)
CT
MRI (0)
NM (IV)
CXR P
Lat (I)
CT
CT
abdomen (III)
L5
L6
L7
CLINICAL PROBLEM
Thyroid
Diagnosis
Staging
Lung
Diagnosis
Staging
100
L. Cancer
.
gery
as a single expensive investigation can
most accurate in delineating tumour extent.
Assists in estimating local invasion of chest wall,
particularly for apical and peripheral lesions and
mediastinal invasion. Helps distinguish adrenal
adenoma from metastasis.
FDG-PET
identify small metastatic foci; may save a lot of other
investigations and inappropriate sur
Before endoscopy in dysphagia.
Despite limitations in sensitivity and specificity of
nodal involvement. Simpler than MRI for lung, liver
and intra-abdominal nodes.
Increasing use of transoesophageal US for local
staging where available.
The majority of lesions will be identified.
If biochemical markers elevated and US negative or
liver very cirrhotic. Enhanced MRI and arterial phase
CT
Specialised
investigation (B)
Specialised
investigation (B)
Indicated (B)
Indicated (B)
Indicated (A)
Indicated (B)
Indicated (B)
(III)
(III)
ransoeso-
MRI (0)
NM (IV)
Barium swallow
(II)
CT
T
phageal US (0)
US (0)
MRI (0) or
CT
1
L8
L9
L10
L1
Oesophagus
Diagnosis
Staging
Liver: primary lesion
Diagnosis
101
L. Cancer
arterial
techniques following
and MRI often part of
COMMENT
for very small metastatic foci.
.
MRI probably the optimal investigation in assessing
involved segments and lobes. Intra-operative US
useful where available.
US will show the majority of metastases and guides
biopsy
When US negative and clinical suspicion high. MRI
better for characterising lesions. CT
portography is sensitive but not specific, but many
now use triple phase spiral CT
intravenous enhancement. CT
other staging and follow-up protocols. Increasing
interest in PET
TION
{GRADE}
Indicated (B)
Indicated (B)
Indicated (B)
RECOMMENDA
TION
{DOSE}
(III)
(III) or
INVESTIGA
MRI (0) or
CT
US (0)
CT
MRI (0)
L12
L13
CLINICAL PROBLEM
Staging
Liver: secondary lesion
Diagnosis
102
L. Cancer
ide local
better in the
W
, others spiral
, which may
. MRI and CT
may also be needed.
here.
. Many centres now
, expertise and
.
or MRCP
gery contemplated.
. ERCP
. See Section G. Increasing interest in CT
; laparoscopic US also used.
Much depends on local expertise and body habitus.
US usually successful in thin patients; CT
more obese. MRI for clarification of problems. Biopsy
using US or CT
Endoscopic US, where available, most sensitive.
Increasing interest in PET
Especially if radical sur
variation: some centres use angiography
CT
Much depends on local policy
availability
and MRI of the colon, especially with virtual
endoscopic techniques.
For liver metastases. Endoluminal US useful for local
rectal spread.
Local pre-operative staging to assess rectal lesions
before pre-operative radiotherapy
treat liver secondaries very aggressively
necessitate MRI and/or detailed CT
often complementary; both can assess other abdominal
spread. Increasing interest in PET
Indicated (B)
Indicated (B)
Indicated (B)
Indicated (B)
Indicated (B)
(III) or
(II) or
Imaging
CT
MRI (0)
abdomen
Ba enema (III)
or colonoscopy
US (0)
CT
MRI (0)
abdomen, pelvis
L14
L15
L16
L17
Pancreas
Diagnosis
Staging
Colon and rectum
Diagnosis
Staging
103
L. Cancer
.
COMMENT
and monoclonal antibodies can identify liver
For liver metastases. Some debate about the value of
routine US follow-up in asymptomatic patients.
For liver metastases and local recurrence.
PET
metastases and local recurrence.
See Renal Mass H7.
For local extent, venous, nodal and ureteric
involvement, opposite kidney etc.
The presence of lung metastases does not usually
influence management.
Conventional NM can assess contralateral function.
Increasing interest in PET
TION
{GRADE}
(B)
Indicated
Indicated (B)
Specialised
investigation (B)
Indicated (B)
Indicated (B)
Not indicated
routinely (B)
Specialised
investigation (C)
RECOMMENDA
TION
{DOSE}
(III) or
(III) or MRI
(III) Chest
INVESTIGA
US (0) liver
CT
MRI (0)
abdomen, pelvis
NM (IV)
US (0)
CT
(0) abdomen
CT
NM (I)
L18
L19
L20
CLINICAL PROBLEM
Recurrence
Kidney
Diagnosis
Staging
104
L. Cancer
here.
is
widely used for radiotherapy
ransrectal US is widely used together with
T
assess kidneys and ureters for further urothelial
assess skeletal metastases, when PSA
o
o
For symptoms suggesting relapse around nephrectomy
bed. Routine follow-up not recommended.
Cystoscopy is the optimal (although not infallible, e.g.
diverticulum) investigation.
T
tumours.
When radical therapy contemplated. MRI is probably
more sensitive. CT
planning.
Some variation according to local availability and
expertise.
guided biopsies. Some interest in MRI and PET
Some variation in range of investigative and
therapeutic policies. Staging continued into the
abdomen when pelvic disease found.
T
significantly elevated.
Indicated (B)
Not indicated
routinely (B)
Indicated (B)
Indicated (B)
Indicated (B)
Specialised
investigation (B)
Indicated (A)
(III)
ectal
(III)
(III) or MRI
ransr
CT
abdomen
Imaging
IVU (II)
CT
(0) abdomen
and pelvis
T
US (0)
MRI (0)/CT
pelvis,
NM (II)
L21
L22
L23
L24
L25
Recurrence
Bladder
Diagnosis
Staging
Prostate
Diagnosis
Staging
105
L. Cancer
.
COMMENT
with Doppler), laparoscopy or
TV
. Some are identified by CT/MRI
can assess viability of residual masses.
Especially when clinical findings equivocal or normal.
Management now depends heavily on accurate
radiological staging. Increasing interest in PET
Some centres still routinely examine the chest as well,
especially for patients without biochemical evidence
of disease. Some debate as to whether whole pelvis is
needed at follow-up unless there are identified risk
factors.
PET
The majority of lesions are diagnosed by US
(including
laparotomy
investigations for abdominal symptoms. MRI useful
for elucidating problems.
TION
{GRADE}
Indicated (B)
Indicated (B)
Indicated (B)
Specialised
investigation (C)
Indicated (B)
RECOMMENDA
TION
{DOSE}
(III) chest,
(III)
INVESTIGA
US (0)
CT
abdomen, pelvis
CT
abdomen
NM (IV)
US (0)
L26
L27
L28
L29
CLINICAL PROBLEM
esticle
T
Diagnosis
Staging
Follow-up
Ovary
Diagnosis
106
L. Cancer
Also
.
.
.
or MRI in addition to
is still more widely
. CT
Also better for pelvic nodes. Para-aortic
and MRI can show extra-uterine disease. But
Many specialists require CT
staging by laparotomy
available.
Usually to assess response to adjuvant therapy
used, along with markers, to detect relapse.
Usually a clinical diagnosis. MRI may assist in
complex cases.
MRI provides better demonstration of tumour and
local extent.
nodes and ureters must also be examined. Some
centres now use transrectal US for local invasion.
MRI provides better information in the pelvis. Biopsy
(e.g. of nodal mass) easier with CT
MRI can give valuable information about benign and
malignant lesions.
Both CT
MRI can also demonstrate intra-uterine anatomy
Specialised
investigation (B)
Specialised
investigation (B)
Not indicated
routinely (B)
Indicated (B)
Specialised
investigation (B)
Indicated (B)
Specialised
investigation (B)
(III)/MRI (0)
(III)
(III)
CT
abdomen, pelvis
CT
abdomen, pelvis
Imaging
MRI (0) or CT
(III) abdomen
and pelvis
MRI (0) or CT
(III) abdomen
and pelvis
US (0) or
MRI (0)
MRI (0) or
CT
L30
L31
L32
L33
L34
L35
L36
Staging
Follow-up
Uterus: cervix
Diagnosis
Staging
Relapse
Uterus: body
Diagnosis
Staging
107
L. Cancer
.
here.
COMMENT
used in some centres.
.
good at evaluating nodal sites throughout the body
CT
Also allows biopsy although excision of whole node
preferable where possible.
NM (gallium) can show foci of occult disease (e.g.
mediastinum). PET
Depending on site of disease, head and neck may also
need to be examined. Increasing interest in PET
Increasing role for MRI in long term follow-up and
residual masses.
Consider NM for gallium positive disease. Some
centres use PET
TION
{GRADE}
Indicated (B)
Specialised
investigation (B)
Indicated (B)
Indicated (B)
Specialised
investigation (B)
RECOMMENDA
TION
{DOSE}
(III)
(III) chest,
(III) or
INVESTIGA
CT
NM (III)
CT
abdomen, pelvis
CT
MRI (0)
NM (III)
L37
L38
L39
CLINICAL PROBLEM
ymphoma
L
Diagnosis
Staging
Follow-up
108
L. Cancer
NM needed to
.
. Best before
.
for lung
.
Imaging and histology complementary
biopsy: See Musculoskeletal Section D
ensure that lesion is solitary
See Musculoskeletal Section D. CT
metastases.
Rarely beneficial. Some exceptions for specialists,
younger patients or favourable histology
Indicated (B)
Specialised
investigation (C)
Not indicated
routinely (C)
T
C
+
+
XR (I)
MRI (0)
MRI (0) local
disease
chest (III)
Imaging
L40
L41
L42
Musculoskeletal tumours
Diagnosis
Staging
Metastases from unknown primary tumour
Diagnosis of primary
lesion
Breast — see Section J
109
M. Paediatrics
-
.
gery
may be
. Ictal and inter
COMMENT
may be appropriate if MRI not
also used to identify focus before sur
Definitive exam for all malformations and avoids
x-irradiation. Sedation usually required for young
children. Consider US in neonates. 3D CT
needed for bone anomalies.
US indicated where anterior fontanelle is open.
Where sutures are closed/closing. MRI indicated for
older children. (CT
available.)
Poor yield.
MRI usually more appropriate than CT
ictal SPECT
TION
{GRADE}
Indicated (C)
Indicated (B)
Specialised
investigation (C)
Not indicated
routinely (B)
Specialised
investigation (B)
RECOMMENDA
TION
{DOSE}
rauma Section K)
INVESTIGA
MRI (0)
US (0)
SXR (I)
SXR (I)
MRI (0) or
NM (II)
M1
M2
M3
CLINICAL PROBLEM
M. Paediatrics
Minimise x-irradiation in children, especially those with long term problems
(for head injury in children see T
CNS
Congenital disorders
Abnormal head
appearance —
hydrocephalus —
odd sutures
Epilepsy
110
M. Paediatrics
if MRI
A6 for possible
-tilted OM view
s age.
single under
A
and MRI may be necessary in children with
Both CT
congenital and post-infective deafness.
XR should include whole valve system.
US if practical, MRI in older children (or CT
unavailable). NM used to evaluate shunt function.
See also M15 for skeletal investigation of growth
failure.
If persistent or associated with clinical signs refer for
specialised investigations.
In children MRI is preferable if available because of
absence of x-irradiation. See also
meningitis and encephalitis
Not indicated before 5 years as the sinuses are poorly
developed; mucosal thickening can be a normal
finding in children.
may be more appropriate than the standard OM view
depending on the child’
Specialised
investigation (C)
Indicated (B)
Indicated (B)
Specialised
investigation (B)
Not indicated
routinely (B)
Specialised
investigation (B)
Not indicated
routinely (B)
(II)
(II)
CT
MRI (0)
XR (I)
US (0) or
MRI (0)
Cranial MRI (0)
SXR (I)
MRI (0) or
CT
Sinus XR (I)
M4
M5
M6
M7
M8
A10)
A13
Deafness in children
Hydrocephalus —shunt
malfunction (see
Developmental delay —
cerebral palsy
Headaches
Sinusitis see also
111
M. Paediatrics
COMMENT
, neurological signs would
. MRI can also demonstrate juvenile disc
The Spine Section C. MRI defines spinal
common variation and not in itself significant (even
Deformity is usually due to spasm with no significant
bone changes. If persistent, further imaging (e.g. CT)
may be indicated following consultation.
Back pain is uncommon in children without a cause.
Follow-up is needed if infection is suspected.
When pain continues and XRs are normal. Useful in
painful scoliosis.
See also
malformations and excludes associated thecal
abnormality
lesions.
A
in enuresis). However
require investigation.
May be helpful in older children.
TION
{GRADE}
Not indicated
Indicated (B)
Specialised
investigation (B)
Specialised
investigation (B)
Not indicated
routinely (B)
Not indicated
routinely (B)
RECOMMENDA
TION
{DOSE}
INVESTIGA
XR (I)
XR (I)
NM (II)
MRI (0)
XR (I)
XR (I)
1
M9
M10
M1
CLINICAL PROBLEM
Neck and spine — For trauma see Section K
orticollis without trauma
T
Back or neck pain
Spina bifida occulta
Hairy patch, sacral dimple
112
M. Paediatrics
.
.
US may be useful in the neonatal period to screen for
underlying tethered cord, etc.
MRI particularly if neurological signs are present.
Local policies will apply; close clinical/radiological
liaison essential. Skeletal survey for those under two
years after clinical consultation. May occasionally be
required in the older child. CT/MRI of brain may be
needed, even in the absence of cranial apparent injury
Sensitive for occult spine/rib fracture.
Seek radiological advice.
2–18 yrs: left (or non-dominant) hand/wrist only
Premature infants and neonates: knee (specialised
investigation). May need to be supplemented with a
skeletal survey and MRI for hypothalamus and
pituitary fossa (specialised investigations).
Indicated (B)
Specialised
investigation (B)
Indicated (B)
Indicated (B)
Not indicated
routinely (B)
Indicated at
appropriate
intervals (B)
US (0)
MRI (0)
XR (I) of
affected parts
NM (II)
XR (I)
XR (I) for bone
age
M12
M13
M14
M15
Musculoskeletal
Non accidental injury —
child abuse (for head
injury see Section K)
Limb injury: opposite side
for comparison
Short stature,
growth failure
113
M. Paediatrics
.
. US can be helpful
, expertise and availability
COMMENT
fusions which can be aspirated for
, lateral XRs of both hips are needed.
US will delineate ef
diagnostic and therapeutic purposes. XRs can be
delayed, but should be considered when the symptoms
are persistent. Consider NM or MRI when Perthes’
disease is suspected and plain XRs are normal.
Gonad protection is used routinely unless shields will
obscure area of clinical suspicion. If slipped epiphyses
is likely
According to local policy
XR may be normal initially
particularly in osteomyelitis.
Increasing use of MRI here.
XR may be used to supplement US examination or
where expertise is not available. XR indicated in the
older infant.
TION
{GRADE}
Indicated (B)
Indicated (C)
Specialised
investigation (B)
Indicated (B)
Specialised
investigation (B)
Indicated (B)
RECOMMENDA
TION
{DOSE}
INVESTIGA
US (0)
XR pelvis (I)
US (0) or
NM (II) or
MRI (0)
XR (I) and
US (0)
NM (II) or
MRI (0)
US (0)
M16
M17
M18
M19
CLINICAL PROBLEM
Irritable hip
Limp
Focal bone pain
Clicking hip —
dislocation
114
M. Paediatrics
.
. Bronchoscopy is
’
s
disease these overlap with normal
and NM (ventilation scintigraphy).
Associated soft tissue swelling should be
, CT
may be helpful to show subtle air trapping.
ide variation in local policy about expiratory films,
Although bony radiological changes are visible in
Osgood–Schlatter
appearances.
assessed clinically rather than radiographically
Initial and follow-up films are indicated in the
presence of persisting clinical signs or symptoms or in
the severely ill child. Consider the need for CXR in
fever of unknown origin. Children may have
pneumonia without clinical signs.
Children with recurrent chest infection tend to have
normal CXRs (apart from bronchial wall thickening).
Routine follow-up CXR not indicated unless collapse
present on initial CXR. Suspected cystic fibrosis
requires specialist referral.
History of inhalation often not clear
indicated, even in the presence of a normal CXR.
NM/CT
W
fluoroscopy
Not indicated
routinely (C)
Not indicated
routinely (B)
Not indicated
routinely (C)
Indicated (B)
XR knee (I)
CXR (I)
CXR (I)
CXR (I)
M20
M21
M22
M23
’
s
Osgood–Schlatter
disease
Cardiothoracic
Acute chest infection
Recurrent productive
cough
Inhaled FB (suspected)
(see Section K)
115
M. Paediatrics
COMMENT
Where expertise is available, both
gical liaison.
Children with asthma usually have normal CXR apart
from bronchial wall thickening. Sudden unexplained
wheeze CXR indicated, may be due to inhaled FB
(above).
Epiglottitis is a clinical diagnosis, but consider FB
(above).
Specialist referral may be needed; cardiac US often
may be indicated.
Local policies require close paediatric, radiological
and sur
US and contrast enema (air or barium) can confirm
diagnosis and guide reduction.
TION
{GRADE}
Not indicated
routinely (B)
Not indicated
routinely (B)
Not indicated
routinely (C)
Indicated (C)
Specialised
investigation (B)
RECOMMENDA
TION
{DOSE}
see also Section G for more general abdominal problems
INVESTIGA
CXR (I)
XR neck (I)
CXR (I)
AXR (II)
Further imaging
M24
M25
M26
M27
CLINICAL PROBLEM
Wheeze
Acute stridor
Heart murmur
Gastrointestinal —
Intussusception
116
M. Paediatrics
AXR
is
r
auma,
T
The
,
upper GI contrast studies may
AXR after 6 days may be indicated.
Except for sharp or potentially poisonous FBs, e.g.
batteries. See Section K. If there is doubt whether the
FB has passed, an
If there is doubt whether the FB has passed, an
after 6 days may be indicated.
US may be used as initial investigation but CT
more specific, particularly in visceral trauma. XRs
may show bone injury in severe trauma.
principles for the investigation of major trauma in
children similar to those in adults (see Major
K40–K42).
US can confirm the presence of hypertrophic pyloric
stenosis, especially where clinical findings are
equivocal.
This symptom covers a wide range from obstruction in
the neonatal period to reflux, posseters and children
with migraine. US may be helpful to confirm
malrotation. However
be indicated to exclude malrotation even with normal
abdominal XR. Contrast studies in neonates should be
undertaken as a specialised investigation. Consider
NM for gastric emptying and gastro-oesophageal
reflux.
Not indicated
routinely (C)
Indicated (C)
Not indicated
routinely (C)
Indicated (A)
Not indicated
routinely (C)
AXR (II)
CXR (I)
(including neck)
AXR (II)
US (0)
Upper GI
contrast study
M28
M29
M30
M31
Swallowed FBs
(see Section K)
Minor trauma to abdomen
Projectile vomiting
Recurrent vomiting
117
M. Paediatrics
.
COMMENT
s disease is suspected, specialist
.
The absence of dilatation in the intrahepatic
s diverticulum is a possibility do NM first.
AXR can help specialists in refractory cases.
Early (< 10 weeks) and prompt investigation is
essential.
bile duct does not exclude an obstructive
cholangiopathy
If Meckel’
Small bowel contrast studies may also be necessary
NM also useful in investigation of inflammatory
bowel disease. Endoscopy is preferable to Ba enema
for assessment of polyps and inflammatory bowel
disease. US can be used to diagnose duplication cysts.
Many normal children show extensive faecal material;
impossible to assess significance of radiological signs.
But
If Hirschsprung’
referral plus biopsy is preferred to radiological studies.
If malignancy is suspected, further imaging should be
performed in a specialised centre.
TION
{GRADE}
Indicated (B)
Indicated (B)
Specialised
investigation (B)
Not indicated
routinely (C)
Not indicated
routinely (B)
Indicated (B)
RECOMMENDA
TION
{DOSE}
INVESTIGA
US (0)
NM (II)
NM (II)
AXR (II)
Contrast enema
US (0) and
AXR (II)
M32
M33
M34
M35
CLINICAL PROBLEM
Persistent neonatal
jaundice
Rectal bleeding
Constipation
Palpable abdominal/
pelvic mass
118
M. Paediatrics
.
locate inguinal testis. MRI may be helpful to locate
o
US and urodynamic studies may be needed in cases of
persistent enuresis.
Both examinations may be needed to evaluate duplex
system with ectopic ureter
T
an intra-abdominal testis, but increasingly laparoscopy
is the investigation of choice.
Local protocols should be established. Mild dilatation
can normally be monitored by US. Low threshold for
specialist referral.
Not indicated
routinely (B)
Indicated (B)
Indicated
Indicated (B)
Indicated (B)
Imaging
US (0)
IVU (II)
US (0)
US (0)
M36
M37
M38
M39
Uroradiology
Enuresis
Continuous wetting
Impalpable testis
Antenatal diagnosis of
urinary tract dilatation
119
M. Paediatrics
. Much depends
AXR is not
The age of the patient also
COMMENT
There is much current emphasis
There is wide variation in local policy
on local technology and expertise. Most patients
should remain on prophylactic antibiotics pending the
results of investigations.
influences decisions.
on minimising radiation dose; hence
indicated routinely (calculi rare). Expert US is the key
investigation in all imaging strategies at this age.
Thereafter NM provides data about renal structure
(DMSA) and has virtually replaced the IVU here. NM
will establish function, exclude obstruction and can
also be used for cystography (direct or indirect) to
show reflux. Formal direct XR cystography is still
needed in the young (e.g. < 2 yrs) male patient where
delineation of the anatomy (e.g. urethral valves) is
critical.
TION
{GRADE}
Specialised
investigations (C)
RECOMMENDA
TION
{DOSE}
NM (II)/
INVESTIGA
Imaging US (0)
//
cystography (III)
M40
CLINICAL PROBLEM
Proven urinary tract
infection
120
Selected bibliography
1
Royal College of Radiologists. Making the best
use of a department of clinical radiology:
guidelines for doctors. Fourth edition. Royal
College of Radiologists (ISBN 1 872599 37 0)
London, 1998.
2
European Union. Council directive 97/43/Euratom
of 30 June 1997 on health protection of
individuals against the dangers of ionising
radiation in relation to medical exposure
(OJ L 180, 9.7.1997, p. 22).
3
Roberts, C. J, ‘Towards the more effective use of
diagnostic radiology. A review of the work of the
RCR working party of the more effective use of
diagnostic radiology 1976–86’. Clin Radiol 1988,
39:3–6.
4
National Radiological Protection board and The
Royal College of Radiologists. Patient dose
reduction in diagnostic radiology
(ISBN 0 85951 327 0). HMSO London, 1990.
5
RCR working party. ‘A multi-centre audit of
hospital referral for radiological investigation in
England and Wales’. BMJ 1991, 303:809–12.
6
RCR working party. ‘Influence of the Royal
College of Radiologists’ guidelines on hospital
practice: a multi-centre study’. BMJ 1992,
304:740–43.
7
Roberts, C. J., ‘The RCR multi-centre guideline
study. Implications for clinical practice’. Clin
Radiol 1992, 45:365–8.
8
NHS Executive. Clinical guidelines: using
clinical guidelines to improve patient care within
the NHS (96CC0001). NHS Executive, Leeds,
1996.
121
9
Sackett, D. L., Richardson, W. S., Rosenberg, W.,
Haynes, R. B., Evidence-based medicine
(ISBN 0 443 05686 2). Churchill Livingstone,
Edinburgh, 1997.
10 Dixon, A. K., ‘Evidence-based radiology’. Lancet
1997, 350:509–12.
11 NHS Executive. NHSE Clinical guidelines
(annex to letter). NHS Executive, London,
September 1996.
12 Audit Commission. Improving your image: how
to manage radiology services more effectively.
(ISBN 0 11 8864 14 9). HMSO, London, 1995.
13 Godwin, R., de Lacey, G., Manhire, A., (eds).
Clinical audit in radiology. (ISBN 1 872599
19 2) Royal College of Radiologists, London,
1996.
14 The ionising radiation (protection of persons
undergoing medical examinations of treatment —
POPUMET) regulations (SI1988/778). HMSO,
London, 1988.
15 Field, M. J., Lohr, K. N., (eds). Guidelines for
clinical practice: from development to use.
National Academy Press, Washington D.C., 1992.
16 NHS Management Executive. Improving clinical
effectiveness: clinical guidelines 1993
(EL(93)115). NHS Management Executive,
London, 1993.
17 Dubois, R.W., ‘Should radiologists embrace or
fear practice guidelines?’ Radiology 1994,
192:43–46A.
18 Grimshaw, J. M., Freemantle, N., Wallace, S. et
al. ‘Developing and implementing clinical
practice guidelines’. Effective health care 1994,
8:1–12.
122
19 Grimshaw, J. M., Russell, I. T., ‘Achieving health
gain through clinical guidelines: 1. Developing
scientifically valid guidelines’. Quality in health
care, 1993, 2:243–8.
20 Eccles, M., Clapp, Z., Grimshaw, J., et al. ‘North
of England evidence-based guidelines
development project: methods of guideline
development’. BMJ 1996, 312, 760–62.
21 Cluzeau, F., Littlejohns, P., Grimshaw, J. M.,
Feder, G., Appraisal instrument for clinical
guidelines. St George’s Medical School, London,
1997.
22 American College of Radiology. Appropriateness
criteria for imaging and treatment decisions.
American College of Radiology, Reston, Virginia,
US, 1995.
23 Bury, B., Hufton, A., Adams, J., ‘Radiation and
women of child-bearing potential’. BMJ 1995,
310:1022–3.
24 National Radiological Protection Board. ‘Board
statement on diagnostic medical exposures to
ionising radiation during pregnancy and estimates
of late radiation risks to the UK population’.
Documents of the NRPB, 1993, 4:1–14.
25 National Radiation Protection Board/RCR/College
of Radiographers. Diagnostic medical exposures:
advice on exposure to ionising radiation during
pregnancy. NRPB, Didcot, 1998.
26 National Radiological Protection Board.
Protection of the Patient in X-ray computed
tomography, (ISBN 0 85951 345 8), HMSO,
London, 1992.
27 Leung, D.P.Y., Dixon, A.K., ‘Clinico-radiological
meetings: are they worthwhile?’ Clin Radiol,
1992, 46:279–80.
123
Appendix
List of bodies involved in the consultation exercise
for the 1998 UK RCR guidelines
Royal Colleges, etc
Academy of Medical Royal Colleges
Faculty of Accident and Emergency Medicine
Faculty of Dental Surgery, RCS
Faculty of Clinical Oncology, RCR
Faculty of Occupational Medicine
Faculty of Public Health Medicine
Royal College of Anaesthetists
Royal College of General Practitioners
Royal College of Paediatrics and Child Health
Royal College of Physicians of London
Royal College of Physicians and Surgeons of Glasgow
Royal College of Physicians of Edinburgh
Royal College of Physicians of Ireland
Royal College of Psychiatrists
Royal College of Obstetricians and Gynaecologists
Royal College of Ophthalmologists
Royal College of Pathologists
Royal College of Surgeons of Edinburgh
Royal College of Surgeons of England
Royal College of Surgeons of Ireland
Other organisations
British Institute of Radiology
British United Provident Association
Medical Defence Union
Medical Protection Society
National Radiological Protection Board
The Patients’ Association
Speciality groups
Association of Chest Radiologists
British Society of Nuclear Medicine
British Society of Gastroenterology
British Society of Interventional Radiology
British Society of Neuroradiologists
British Medical Ultrasound Society
British Society of Skeletal Radiologists
Dental Radiology Group
124
Paediatric Radiologists
Magnetic Resonance Radiologists Association UK
RCR Cardiac Group
RCR Breast Group
RCR Clinical Directors’ Group
RCR Interventional Radiology Sub-Committee
RCR Nuclear Medicine Sub-Committee
RCR Paediatric Group
RCR/RCOG Standing Committee on Obstetric US
RCR/RCP Standing Committee on Nuclear Medicine
UK Children’s Cancer Study Group
UK Neurointervention Group
The adaptation of the 1998 UK RCR guidelines into EU
2000 referral criteria was performed in consultation with:
European Association of Nuclear Medicine
European Association of Radiology
Union of European Medical Specialists
125
European Commission
Referral guidelines for imaging
Radiation Protection 118
Luxembourg: Office for Official Publications of the
European Communities
2001 —125 pp. — 10 x 19 cm
ISBN 92-828-9454-1
Price (excluding VAT) in Luxembourg: EUR 16
