Ratification Date: 13/05/2022

Next Review Date: 13/09/2024

Ultrasound – Improving Primary Care Access to Radiology Services (QEH)

Content under review by QEH, but remains current

Introduction

The Radiology Dept at QEHKL has always aimed to nurture a good relationship with our local GP colleagues with access to imaging, and to encourage the use of imaging to provide good clinical outcomes. These guidelines have been produced to support GP’s and direct access referrers to select appropriate next investigations, so to aid diagnosis and disease management. This guidance is also to be used by ultrasound providers to justify that an ultrasound examination is appropriate to answer the clinical question.

For many years we have provided direct access for Plain Films and Ultrasound. We provide “open access” for CXR Monday-Friday 9am-4pm.

We have, for several years, provided direct access to Consultant Radiologists via the “Hot Doc” direct line (01553 613160 – Mon-Fri 8am-8pm, Sat-Sun 9am-5pm).

This guidance gives us an opportunity for us to ensure we are all making best us of the imaging to improve patient experience and management. We should all aim to make the best use of resources, in order to shorten patient pathways and make appropriate use of facilities with the aim of maximising positive patient outcomes.

This document is inevitably brief and covers some of the most common clinical presentations that most frequently result in referral to Radiology. Guidance on the use of a Radiology department is available in the Royal Collage of Radiologists (RCR) document “iRefer” which is the successor to “Making the best use of a department of Clinical Radiology.”

https://www.irefer.org.uk/

24/7, 365 days a year >90% of Ultrasound investigations have a report available within 24 hours of the examination.

Radiology referrals in general

General principles of imaging requesting should be applied, ie. Referrers are encouraged to clearly state the clinical condition they wish to confirm or exclude. In effect, referrers should always ask themselves the question: “Have I fully explained the clinical problem”. The layout of the request form should allow for this. This will hopefully reduce the need for requests for additional information from the GP which may delay the examination.

It is essential reports are accurate, concise, and informative and provide clear advice to the referrer in the form of a “conclusion”. Therefore, as much relevant clinical history as possible by the referrer.

The following principles should be adhered to:

Will the result of the test affect clinical management?
Is the test being requested too quickly?
Is the test the correct one?
Has the test already been performed elsewhere or in the recent past? If so the need for repetition should be seriously questioned.

To help the Radiologists at QEHKL

Please state the specific clinical question to be answered on your request. Any referrals which contain insufficient data will be returned.
Please ensure that the referral contains sufficient clinical information from the clinical history, physical examination and relevant laboratory investigations, to allow us to guide appropriate imaging and provide as useful a report as possible.
Suspected diagnoses must be clearly stated and not implied by vague non-specific terms such as ‘pain query cause’ or ‘?pathology’
Suspicion for malignant pathology/red flags should be clearly stated.
Please make sure that all relevant contact details are included. The Radiology Department does telephone many patients to arrange appointments, particularly urgent cases, and delays do occur if contact details are missing.
Remember – a Consultant Radiologist is available as the Hot Doc for queries etc. from 8am to 8pm Monday to Friday, and 9am -5pm Sat/Sun on 01553 613160 and the on call Radiologist is available outside of these hours via QEHKL Switchboard (01553 613613) in case of emergency.
There is Open Access for Chest X-Rays Monday to Friday 9am until 4pm – Please note a CXR is not indicated for “? Simple rib fracture”
For urgent X-Ray for “? Acute fracture” please contact QEHKL Radiology department directly who will arrange a time for the patient on the same day.
The following sections include some of the most common requests but is not intended to be exhaustive.

Cardio-Vascular

Clinical indication	Imaging indicated	Notes
Possible abdominal aortic aneurysm	Ultrasound Aorta	Indicated for diagnosis, measurement, and follow-up, but not include screening.

Endocrinology

Clinical indication

Imaging indicated

Notes

Clinical polycystic ovary syndrome (only in the presence of suggestive clinical features and any supporting biochemistry)

Ultrasound Pelvis

Useful in secondary care if investigating subfertility.

PCOS diagnosis can be made without the need for imaging with the use of clinical/biochemical indicators.

Gastrointestinal

Clinical indication

Imaging indicated

Notes

Abdominal pain

Ultrasound abdomen

Pain plus intolerance to fatty foods and/or dyspepsia would be suspicious for gallbladder disease.

If generalised or localised abdominal pain, with abnormal bloods, with no suspicion for gallbladder disease, CT would be more appropriate.

Rectal bleeding + / – change of bowel habit

Primary investigation endoscopy. Patient should be referred via 2WW pathway.

Ultrasound has no role to play in initial diagnosis.

Palpable abdominal mass

CT abdo/pelvis. If red flag symptoms then referral via 2WW pathway

CT is more appropriate.

Abnormal liver function tests

Ultrasound Abdomen may be indicated. See notes.

Please specify if patient is symptomatic/asymptomatic, nature and duration of abnormal liver function.

Mildly abnormal LFTs particularly minimally raised enzymes are often associated with other conditions including heart failure, infection, diabetes, etc.

Liver ultrasound is frequently unhelpful for asymptomatic patients with isolated elevation of gamma GT, or an elevation of gamma GT with only modest derangement of the transaminases.

Single episode of raised ALT is not justified for an ultrasound.

Persistently raised ALT of 3 months duration without risk factors and despite following guidance to address risk factors (DM, obesity, statins and other medications that affect the liver) is justified.

Jaundice

Ultrasound Abdomen

Need to know if painless/painful and weight loss or not.

New onset overt and/or painless jaundice requires urgent ultrasound and a 2ww referral.

Isolated unconjugated hyperbilirubinaemia with no evidence of haemolysis – Gilberts Syndrome, no imaging needed. If haemolysis is present then refer to haematology.

Dysphagia

Primary investigation endoscopy

Dyspepsia

Primary investigation endoscopy

Endoscopy indicated after conservative management failure. Barium studies are no longer appropriate for first line.

Suspected pancreatic cancer

CT pancreas is more appropriate with a 2WW referral

CT is more appropriate

Diabetes – known

No imaging role

Ultrasound does not have a role to play in well controlled diabetes. 70% of patients with diabetes will have a fatty liver with a raised ALT – this abnormal liver function itself does not justify a scan.

Diabetes – new onset or unexplained worsening control of diabetes

CT pancreas

If patient is over 60 and there is a clinical concern for pancreatic pathology then CT is more appropriate,

Gallbladder polyps follow-up – only if >6mm

Ultrasound abdomen or referral to GI surgeons

1 or more 6-10mm polyps with no risk factors for gallbladder carcinoma – 6 month follow-up for 1 year and then annually for 5 years if stable.

1 or more 6-10mm polyps with risk factors for gallbladder carcinoma – refer to GI surgeons.

Polyp(s) >10mm – refer to GI surgeons.

Polyps with biliary symptoms – refer to GI surgeon.

Altered bowel habit, diverticular disease

Referral via 2WW pathway if bowel cancer suspected.

Ultrasound does not have a role.

Weight loss and anaemia

Referral via 2WW pathways. Endoscopy is usually primary investigation.

Gynaecology

Clinical indication	Imaging indicated	Notes
Bloating/abdominal distension	Ultrasound abdomen +/- pelvis. Ca125 should be measured and the level indicated on the referral. CT may be indicated.	If this is the only symptom then imaging is not indicated. Persistent or frequent bloating with additional symptoms such as palpable mass, increased girth, raised Ca125 – ultrasound is acceptable and requested urgently with a 2WW referral. Clinical concern for ascites; can be several causes – liver, heart, malignancy. If liver then gastro/hepatic referral, if cardiac then check BNP, if malignancy CT is recommended.
Pelvic Pain	Ultrasound pelvis	Ultrasound is unlikely to contribute to management if only symptom and <50years old. In patients >50 a request may be accepted if a specific clinical question has been asked. Pain of suspected gynaecological origin with the following should be referred to gynaecology; palpable mass, raised CRP or WCC, nausea, menstrual irregularities, dyspareunia. > 6 weeks duration. An ultrasound may be appropriate after clinical assessment and an appropriate clinical question posed.
PCOS	Please see endocrinology section	Please see endocrinology section
Unexplained amenorrhoea of >3 months duration with a negative pregnancy test	Not indicated	Refer to gynaecology
Ovarian cancer	Not for screening	Refer to gynaecology
Post-menopausal bleeding	Referral to gynaecology. Ultrasound pelvis – which will be performed at the gynaecology PMB clinic	Refer directly to the PMB clinic. Do not request scan.
Infertility investigation	Refer directly to the infertility service. They will perform all the ultrasound pelvis examinations	Refer directly to the infertility service.
Menorrhagia/Abnormal Uterine Bleeding Pre and peri-menopausal patients	Ultrasound Pelvis See notes	Not part of pathway, but may be useful if uterus bulky to look for fibroids. Does not replace clinical examination. US is not a first line investigation for AUB but may be useful if uterus bulky or tender, or if examination is difficult or inconclusive due to BMI., provided a clinical question is asked. Indicate findings from clinical/PV examination. Appendix 2
Pelvic Mass	Ultrasound Pelvis	If clinical concern for malignancy then 2WW gynaecology referral.
Cyst follow up	Ultrasound Pelvis	Pre-menopausal; <5cm – likely physiological so no follow-up. Only if cyst greater than 5cm should the cyst be followed up. If cyst is greater than 7cm refer to gynaecology. Appendix 1 Post-menopausal cyst 1 -5cm should have Ca 125 and if Ca 125 normal a follow up scan at 6 months. If then no change, no further action required. If Ca125 elevated or cyst is indeterminate refer to Gynaecologists.
Follow-up of other benign ovarian lesions	Ultrasound Pelvis	Dermoids; <2cm – no follow-up, >2cm refer to gynaecology Follow-up of other lesions is only appropriate if indicated by gynaecologist. If patient has undergone a clinical change then re-scan is appropriate.
Retained products of Conception	Direct O&G referral.	Direct O&G referral.
Lost IUCD	Ultrasound Pelvis	If we cannot see on ultrasound we will arrange a AXR we will arrange a AXR.
Dating of Termination of Pregnancy	Refer to BPAS	The QEH does not provide this service.

Musculoskeletal

Clinical indication	Imaging indicated	Notes
Inflammatory poly-arthritis lasting longer than 2 weeks	X-ray of hands and feet
Persistent single joint symptoms	X-ray of relevant joint
Knee pain (>50 years)	X-ray Knee	Knee MRIs are of limited value for patients over 50 years of age. After clinical assessment, the over 50s should have an X-ray as a first investigation.
Knee: Suspected significant intra-articular pathology; positive clinical signs for meniscal tears/cruciate damage; intermittent locking; clear history of trauma particularly if twisting injury.	MRI Knee may be appropriate	Refer via CATS (Clinical assessment & treatment service) who will refer on for MRI if appropriate – as agreed by ICB
Knee – popliteal swelling (>50 years)	Ultrasound knee	Routine ultrasound assessment for ?effusion, ?OA or ?Baker’s cyst is not indicated. If the swelling is pulsatile, rapidly enlarging or otherwise atypical, ultrasound to assess for popliteal aneurysm/sarcoma is indicated.
Osteoporosis	DEXA	Refer direct using specified referral form
Shoulder pain/impingement; rotator cuff degeneration/tear; frozen shoulder	X Ray shoulder Ultrasound Shoulder Image-guided shoulder injections	X-ray is appropriate Ultrasound not typically required as a first line test. Many patients, particularly > 65 yrs, have rotator cuff tears/bursitis and these may not be the cause of the symptoms. Typically plain film and conservative management/physiotherapy +/- ‘blind’ steroid injection is sufficient. If <65 years old and in the setting of acute trauma then ultrasound is indicated. 65+ years: ultrasound not typically indicated prior to referral to CATS/physio/orthopaedics. The ICB have set a very high threshold for authorising image-guided injections; as a general rule, these are via specialist referral only.
Heel/Achilles tendon pain and/or swelling	Ultrasound Achilles	Chronic Achilles tendinosis does not require imaging from primary care and should be treated conservatively initially. If this fails then specialist referral is advised. Ultrasound is appropriate for potential acute high grade traumatic ruptures.
Muscle / tendon injuries	Ultrasound soft tissues	Generally not indicated from primary care for potential partial / low grade tears. Potential high grade tears should have clinical referral where MRI or ultrasound will be considered.
Lateral hip pain	X-ray pelvis/hip Ultrasound hip	First line investigation Ultrasound of the hip in adults is a specialist request for a few very specific indications. Trochanteric bursitis (greater trochanteric pain syndrome) is a clinical diagnosis in which imaging has very little role.
Elbow pain	X-ray elbow Ultrasound elbow	Plain film is appropriate. Ultrasound has no role in initial diagnosis of flexor/extensor tendinopathy. Specialist referral only. Acute clinical distal biceps rupture should be referred urgently to orthopaedics as there is a narrow window of opportunity for repair.
Forefoot pain	X-ray foot Ultrasound foot	First line investigation Ultrasound to investigate for possible Morton’s neuroma or plantar fascia abnormalities are rarely useful due to exceptionally poor sensitivity and specificity. Specialist referral only.

Neurology, Head and Neck

Clinical indication	Imaging indicated	Notes
New onset seizure disorder OR Chronic Headache	MRI Head	Be aware of contraindications for MRI There is a dedicated ‘First fit’ pathway incorporating MRI and Neurology outpatient assessment. Please use the proforma A pathway for chronic headache is available. MRI may be part of this.
Salivary mass	Ultrasound Neck. Sialogram may also be appropriate.	If suspected salivary mass/ tumour ultrasound is recommended with appropriate 2WW ENT referral. If the history indicates salivary duct obstruction then sialography may be more appropriate.
Thyroid	Ultrasound thyroid	Routine follow-up is not recommended. If malignant neck mass is suspected then ENT 2WW referral should be made.

Urology and Genito-Urinary

Clinical indication	Imaging indicated	Notes
Persistent microscopic haematuria without an identified cause	Ultrasound Renal Tract
Macroscopic haematuria	CT IVU if >40 years Ultrasound Renal Tract if <40 years	Choice of imaging investigation depends on details of individual case. Info provided must include macro vs micro, painful vs painless and presence/absence of medical causes, to allow us to arrange the most appropriate investigation Likely to need referral as 2WW to urology.
Deteriorating renal function	Ultrasound Renal Tract	Indicated if obstruction is suspected. AKI needs urgent clinical assessment. Ultrasound is appropriate after assessment if; cause is not obvious, AKI not recovering, obstruction is suspected. Chronic kidney injury is indicated to measure kidney size etc and to exclude obstruction.
Urinary tract infection (adults)	Ultrasound Renal Tract plus post micturition	Indicated for recurrent UTI; concern over complicated infection or failure to respond to antibiotics. For adult males, investigate after first proven UTI.
Urinary tract infection (paediatrics)	Ultrasound Renal Tract plus post micturition	Paediatric referral if atypical/severe infection.
Refractory hypertension or hypertension associated with symptoms or signs of peripheral vascular disease	Ultrasound Renal Tract	Routine imaging is not indicated. Renal artery screening is not offered. Ultrasound is less accurate then CT/MRI angiography.
Testicular mass	Ultrasound Testes	Any patient with a swelling/mass in the body of the testis should be referred for urgent ultrasound. The majority of palpable scrotal masses are epididymal cysts and do NOT need imaging if clearly separate from the testis. Suspected hydrocele and varicoceles are an indication for imaging.
Scrotal pain	Ultrasound testes	Suspected torsion requires urgent urological referral and should not be delayed by imaging. Chronic pain >3 months then ultrasound may be helpful. Acute pain in the absence of suspected torsion is appropriate to refer for imaging.

Renal

Clinical indication

Imaging indicated

Notes

Renal colic – Acute
1. Acute (<48hrs) unilateral loin pain
2. Urinalysis positive for blood
3. Age >18
4. 10 day rule or negative pregnancy test, where applicableExclusion criteria
1. Urinalysis positive for leucocytes/ nitrites
2. History or clinical suspicion of abdominal aortic aneurysm (AAA) 3. History of trauma

CT Urogram

Ideally contact the Hot Doc on 01553 613160 and fax request after discussion with full clinical info.

Include full contact details – we will typically contact the patient by phone

NB. if patient has had a CT Urogram within 18 months, positive or negative, consider US in the first instance to assess for hydronephrosis. Get advice from Hot Doc.

Soft Tissues

Clinical indication	Imaging indicated	Notes
Soft tissue lump Lymphadenopathy	Ultrasound soft tissues	Most soft tissue lumps are benign and with the classical clinical signs of a benign lump do not require imaging. Sarcoma 2WW referral with ultrasound is recommended if soft tissue lump is >5cm, fixed, tender, enlarging or overlying skin changes. If lymphadenopathy secondary to malignancy suspected then ultrasound +/- FNA, +/- biopsy is required with appropriate specialist referral.
Neck mass of unknown origin	Ultrasound Neck	If you are confident the mass is of thyroid origin NICE guidance recommends referral to an endocrinologist. NOTE: Neck lumps are excluded from AQP criteria.
?Lipoma	Ultrasound Soft Tissue	The vast majority of ?lipomata do NOT need imaging. If clinically a lipoma an ultrasound is NOT required unless painful, fixed, > 5cm in diameter, overlying skin changes or increasing significantly in size.
Breast symptoms and signs including breast pain	None	Refer to Breast care unit
?Hernia	None	Characteristic history and examination findings do not require ultrasound imaging – refer to general surgical team. Equivocal cases – ICB request referral to surgical team who will image if necessary Groin pain with normal examination findings – consider musculoskeletal causes. Imaging rarely indicated acutely – may be appropriate in a chronic pain situation.

Spine

Clinical indication	Imaging indicated	Notes
Cervical: Clinical evidence of cervical radiculopathy (brachalgia) or myelopathy; neurological symptoms / signs	MRI Cervical Spine	Via CATS (Clinical assessment & treatment service)
Lumbar: Sciatica (or buttock groin pain) more than 6 weeks duration, unresponsive to conservative management; neurological symptoms/signs,	MRI Lumbar Spine	Refer through CATS (Clinical assessment & treatment service) / back care pathway.