Primary Care Ultrasound Referral Guidelines

Transcription

1 Primary Care Ultrasound Referral Guidelines Introduction Radiology Department These guidelines are designed to support primary care physicians in the appropriate selection of patients for whom ultrasound (US) would be beneficial in terms of diagnosis and or disease management. This document has been compiled by a panel of ultrasound experts (from BMUS - British Medical Ultrasound Society) and adapted for use at SFT. Reference is made to irefer (Good practice guidelines from Royal College Radiologists) and should be used in conjunction with this publication. Principles This document is based on several non-controversial principles: Imaging requests should include a specific clinical question to answer, and should contain sufficient information from the clinical history, physical examination and relevant laboratory investigations to support the suspected diagnosis The majority of US examinations are now performed by Sonographers, not by Radiologists. Therefore, suspected diagnoses must be clearly stated, not implied by vague, non-specific terms such as Pain query cause or pathology etc. Although US is an excellent imaging modality for a wide range of abdominal diseases, there are many for which US is not an appropriate first line test (e.g. suspected occult malignancy) The following examples of primary care referrals address the more common requests. It is not intended to be exhaustive. This guidance is based on clinical experience supported by peer reviewed publications, and established clinical guidelines and pathways. Individual cases may not always be easily categorised and the Duty Radiologist is available for further advice, on extension 4873 between 9 am - 5 pm, Monday - Friday. All actions are documented and recorded on the local radiology information system. Referrals will be returned electronically if insufficient clinical information.

2 GENERAL ABDOMEN Abnormal/ altered LFTs See Note 1 COMMENTS / GUIDANCE Please state if the patient is symptomatic (US may be useful) or asymptomatic (US not useful in the context of abnormal LFTs) Please provide duration of abnormality (A single episode of mild moderate elevation does not justify US) Specific LFT results must be included in the referral (please provide actual numbers not raised ALT etc.) Please provide a specific suspected diagnosis to be considered Elevated of ALT (other LFTs normal) US is NOT justified in patients with high risk factors (DM, obesity, statins & other medications which affect the liver) US is not justified for a single episode of raised ALT US is justified if raised ALT is persistent (3-6 months) despite following weight loss and altered lifestyle guidance such as weight reduction and/or change in medication US is justified in patients with persistently raised ALT (3-6 months) and no other risk factors Note 1: Liver Function tests: Elevated ALT alone: Fatty liver (risk factors; obesity, hyperlipidaemia, DM) or Drugs (statins/oc) Elevated ALP with normal ggt: probably bone NOT liver (adolescent growth, Paget s disease, recent fracture) Elevated GGT alone: usually alcohol. Consider prescribed drugs. Fatty liver Elevated Bilirubin alone: Gilbert s syndrome (usually <80mols/L) Diabetes Jaundice Bloating/Abdominal distension US does not have a role in the management of diabetes Up to 70% of patients with DM have a fatty liver with raised ALT- US is not indicated Referral to upper GI cancer team using ICID form ICID / Clinical Management / Gastrointestinal Medicine / Rapid Access Jaundice Clinic Referral (US is performed as part of this assessment) US is indicated for persistent bloating or with the addition of other symptoms, such as a palpable mass, increased abdominal girth or raised Ca 125 A specific clinical question is required Intermittent bloating does not warrant US? Ascites Altered bowel habit /Diverticular US is useful for confirming the presence of ascites and assessing the liver e.g. cirrhosis or metastases US does not have a role in the management of altered bowel habit or diverticular disease For change in bowel habit / suspected bowel cancer - direct referral is indicated

3 disease RENAL TRACT UTI (adult) COMMENTS / GUIDANCE US is indicated for the first episode in a male (not in a female) US is indicated in recurrent ( 3 episodes in 12 months) in a male or female with no underlying risk factors. US may be indicated in non-responders to antibiotics or those with frequent re-infections, history of stone or obstruction UTI (children) Infants and children of all ages with clinically atypical/severe UTI: - Paediatric specialist referral - US of the urinary tract during the acute infection is appropriate to identify structural abnormalities such as obstruction US is indicated in infants <6 months old with first-time UTI US is not routinely indicated >6 months old unless recurrent or atypical infection Hypertension Routine imaging is not indicated RAS (renal artery screening) no longer offered Haematuria (non-visible or visible) Direct rapid referral (2ww) to Urology for one-stop haematuria clinic Deteriorating renal function US is indicated if obstruction is suspected Acute kidney injury (AKI) is defined as a 1.5 x increase from most recent baseline or 6 hours of oliguria - URGENT clinical referral is recommended for assessment URGENT renal tract and bladder US (including residual bladder volume) is appropriate after assessment if: - cause of AKI is not obvious - AKI not recovering - obstruction suspected

4 SMALL PARTS Lymph nodes COMMENTS/GUIDANCE Patients with clinically benign, pea-sized groin, axillary or neck lymphadenopathy do not benefit from US - small nodes in the neck, groin and axilla are commonly palpable If there is clinical concern and the aetiology of a lump is uncertain, US is helpful to establish the likely nature/aetiology If a new source of infection is evident, US is not required Lymphadenopathy If malignancy is suspected (increasing size, fixed mass, rubbery consistency) rapid referral to an appropriate clinic e.g. Head and Neck or Breast Clinic is required Scrotal mass Any patient with a swelling or mass in the body of the testis should be referred URGENTLY (2ww) to US is indicated for: Extra-testicular mass e.g. epididymal cyst Generalised scrotal swelling Suspected hydrocele or varicocele should be referred routinely Scrotal pain Acute pain with clinical suspicion of torsion should be referred to urology IMMEDIATELY Chronic (>3 months) pain in the absence of a palpable mass is unlikely to be helpful, but testicular tumours can present with pain so US may be helpful if there is clinical concern? Groin hernia US is not indicated as a referral from primary care Surgical outpatient referral is advised (as per Royal College of Surgeons)? Abdominal hernia US of the abdominal wall is indicated Note: Irreducible and/or tender lumps suggest an incarcerated hernia and require surgical referral IMMEDIATELY

5 HEAD AND NECK Thyroid COMMENTS/GUIDANCE Routine imaging of established thyroid nodules / goitre is not recommended US may be required where there is doubt as to the origin of a cervical mass i.e. is it thyroid in origin? FNA is reserved for when US is equivocal, suspicious or malignant features are detected If a malignant neck mass is suspected then URGENT referral to ENT one stop OPD on 2WW where patients get US neck as part of appointment Routine follow-up of benign nodules is not recommended Thyrotoxicosis is not normally an indication for US (check antibodies and refer to endocrinology) Salivary mass US is indicated if the history is suggestive of salivary duct obstruction For a suspected salivary tumour, rapid referral to Head and Neck clinic is recommended (US will be performed at the same visit and is requested once assessed by clinic) MSK COMMENTS/GUIDANCE All body parts Trauma X-ray is usually the first imaging investigation required Shoulder Pain < 50 years of age Impingement or rotator cuff pathology US only after failed conservative management (including physiotherapy and injection if appropriate, and if patient suitable for surgical repair) Pain > 50 years of age Impingement or rotator cuff pathology X-ray is first line investigation If X-ray is normal, then US may be considered after failed conservative management (including physiotherapy and injection if appropriate, and if patient suitable for surgical repair) If X-ray is abnormal, orthopaedics or physiotherapy referral is required Shoulder instability /recurrent dislocation X-ray and orthopaedic referral

6 Elbow Suspected epicondylitis Epicondylitis is usually a clinical diagnosis and US is not required Wrist / hand / thumb Tenosynovitis Suspected erosive arthritis US If clinical suspicion of erosive arthropathy, then X-ray and specialist referral is advised Referral for US of small joints will not be accepted Suspected carpal tunnel syndrome US indicated Hip?Trochanteric bursitis US is of limited benefit and does not alter management prior to specialist referral Consider referral if conservative management fails Note: Trochanteric bursitis is a clinical diagnosis which frequently reflects tendinopathy of the gluteus medius insertion on the greater trochanter, without a bursal fluid collection Knee Anterior knee pain with suspected injury to extensor mechanism US can demonstrate quadriceps tendinopathy or patellar tendinopathy Suspected Baker s cyst Imaging not usually required X-ray can be helpful to show the cause of a Baker s cyst most commonly osteoarthritis US is only indicated if there are atypical or potentially sinister features Ankle/foot Tendinopathy/ US is indicated in the acute setting

7 tenosynovitis No imaging indicated in chronic Achilles tendinopathy Injury US has no role following ankle sprain or suspected ligamentous injury Acute Achilles tendon rupture Urgent Emergency Department referral Chronic Achilles tendon rupture US provides limited information Consider clinical referral if conservative treatment fails Morton s neuroma / intermetatarsal bursitis US not indicated In the case of clinically suspected Morton s neuroma an X-ray can be helpful to determine presence of osteoarthritis which is the most common cause of forefoot / toe pain

8 GYNAECOLOGY COMMENTS / GUIDANCE Pain? cause Further information should be provided with regards to any - Palpable mass - Raised CRP or WCC - Nausea/vomiting - Ascites - Menstrual irregularities - Dyspareunia - previous surgery or diagnosis / hormonal contraception use A specific clinical question / differential diagnosis is required Risk factors such as increasing age, previous gynaecological history, genetic predisposition should be provided US is not an effective screening tool for ovarian cancer although is appropriate if clinically suspected Abnormal bleeding Menorrhagia or intermenstrual / post coital bleeding is indicated in premenopausal women if fibroids or polyps are suspected Similarly ovarian pathology can also be excluded as a cause Bloating / Abdominal Distension Persistent bloating US indicated Intermittent bloating US not indicated see also General abdominal section Follow up of benign lesions, e.g. fibroids, dermoids, ovarian cysts There is no role for US in follow-up or in treatment from primary care unless specified in the previous imaging report or after gynaecological advice If the patient has undergone a clinical change, then a repeat scan is an acceptable first line investigation but should not replace referral if indicated Post Menopausal Bleeding Direct rapid referral to Gynaecology (2ww) (US performed on same day)

9 PCOS Diagnosis of PCOS should be based on: Irregular menses Clinical symptoms and signs of hyperandrogenism such as acne or hirsutism Biochemical evidence of hyperandrogenism with a raised free androgen index (the testosterone is often at the upper limit of normal) Scan can be requested if there is ambiguity in the other parameters Lost IUCD US as initial investigation May need abdominal X-ray if not found on US which can be organised after a negative scan BREAST COMMENTS/GUIDANCE Suspected Breast pathology All GP referrals are directed to the one-stop breast clinic where triple assessment is available Direct rapid referral (2ww) for one-stop Breast Clinic to shc-tr.salisburyrapidreferralcentre@nhs.net Imaging will be performed on the same day VASCULAR COMMENTS/GUIDANCE Suspected DVT Use ICID referral form ICID / Clinical Management / Vascular / Suspected DVT (Form developed with anti-coagulation team as part of the prevention and treatment of VTE) For patients with negative or equivocal results the patient will be advised to see their GP for follow-up Asymptomatic AAA or AAA surveillance For US assessment or surveillance of AAA refer via Vascular Investigation form available on ICID ICID / Clinical Management / Vascular / Documents

10 Document Control Information Consultation Schedule Name and Title of Individual Date Consulted Dr Nicola Bell, Consultant Radiologist January 2019 The following people have submitted responses to the consultation process: Name and Title of Individual Date Responded Dr Mark Wills, Consultant Radiologist January 2019 Dr Lucy Bushby, Consultant Radiologist November 2018 Dr Sarah Cook, Consultant Radiologist November 2018 Dr Katie Johnson, Consultant Radiologist November 2018 Dr Graham Lloyd-Jones, Consultant Radiologist January 2019 Date for next review: January 2020