Ultrasound referral guidelines

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These guidelines are intended to support referrers to Ultrasound (US) and ultrasound providers in the appropriate selection of patients for whom ultrasound would be beneficial in terms of diagnosis and or disease management. They have been written to aid ultrasound providers in justifying that an ultrasound examination is the best test to answer the clinical question posed by the referral.

Our local guidelines are underpinned by the BMUS Recommended Good Practice Guidelines: Justification of Ultrasound Requests (2017) (https://www.bmus.org/static/uploads/resources/Justification_of_Ultrasound_Requests_v4_Dec_2017.pdf), which is compiled by a panel of ultrasound experts to support good practice in vetting and justifying referrals for US examinations.

Reference is made to the evidence based iRefer publication (http://www.irefer.org.uk/) and should be used in conjunction with this. The NICE guidance, NG12, Suspected Cancer: Recognition and Referral published in June 2015 has also been considered in the production of this updated publication.

These guidelines have been produced with the aim of providing practical advice as to best practice in the acceptance and justification of US referrals.

Principles

This document is based on several non-controversial principles:

  • Imaging requests should include a specific clinical question(s) to answer, and
  • Contain sufficient information from the clinical history, physical examination and relevant laboratory investigations to support the suspected diagnosis(es)
  • The majority of US examinations are now performed by sonographers not doctors. Suspected diagnoses must be clearly stated, not implied by vague, nonspecific 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)

This general guidance is based on clinical experience supported by peer reviewed publications and established clinical guidelines and pathways.

Abdomen

ABDOMEN

BMUS Guidelines 2017

Justified?

References & Notes

Abnormal/Altered LFTs
(liver function tests)

Ultrasound is NOT justified in patients with high risk factors (Diabetes, obesity, statins & other medications which affect the liver)

Refer back for further information if this is the only information given. Ultrasound not useful if asymptomatic. A single episode of mild – moderate elevation does not justify an ultrasound scan

 

 NICE Guidelines

BMJ. Sattar, 2014: “The additional benefit of routinely requesting liver ultrasonography to diagnose NAFLD (Non-Alcoholic Fatty Liver Disease) in patients with suggestive phenotypic and biochemical features and no features of other liver disease or more advanced liver disease is therefore unproved and highly questionable. “

Liver Function tests - Isolated enzyme rises – ultrasound generally not indicated

No

ALP (Alkaline Phosphatase) alone: probably bone NOT liver (adolescent growth, Paget’s disease, recent fracture)

No

ALT (Alanine Transaminase) alone: Fatty liver (risk factors; obesity, hyperlipidaemia, Diabetes) or Drugs (statins/oral contraceptives)

No

AST (Aspartate Transaminase) alone: Muscle injury or inflammation.

Bilirubin alone: Gilberts syndrome (usually <80mols/L)

No

GGT (Gamma Glutamyl Transpeptidase) alone: usually alcohol. Consider prescribed drugs. Fatty liver (risk factors; obesity, Diabetes)

No

If ALT or ALP is at 2.5 times the upper limit of normal or sudden rise

Yes

Local Guidelines Apply:

Signs and symptoms of advanced liver disease

Yes

?Obstruction or ?cholecystitis

Yes

If urgent specialist referral is being considered

Yes

Suspicion of malignancy

Yes

Ultrasound is not justified for a single episode of raised ALT

+ one or more of the following:

  • Patient is symptomatic (including  weight loss)
  • Persistent (3-6 months) duration of abnormality
  • Specific LFT results must be included in the referral
  • A specific diagnosis

Yes

Jaundice

Request must state whether painless or not.

Overt &/or painless jaundice – new onset, cause unknown - requires urgent ultrasound and referral to 2 week wait clinic.

Yes

 

Pain (RUQ (right upper quadrant)/ Iliac fossa)

Refer back for further information

Generalised or localised pain as the only symptom is not a justification for ultrasound

No

 
Upper Abdominal Mass

Consistent with stomach cancer

 No

 

Consistent with an enlarged gallbladder

Yes

 

Consistent with an enlarged liver

Yes

 

Suspected Gallbladder Disease

Pain plus fatty intolerance and/or dyspepsia

Yes

 

Bloating/Abdominal Distention


 


 


 


 

As the only symptom

No

 

Persistent or frequent occurring over 12 times in one month, in women especially over 50

Yes

 

With a palpable mass

Yes

 

Ascites? Usually due to liver or heart failure or malignancy. Likely cause should be indicated on request: Liver/Cardiac

Yes

 

Malignancy/cancer – CT scan

No

 

Altered Bowel Habit / Diverticular Disease

Ultrasound does not have a role in the management of Irritable Bowel Syndrome or diverticular disease.

Refer back for further information

No

 

Suspected Pancreatic Cancer

Presenting symptoms of any of the following:

  • Diarrhoea or constipation
  • Nausea or vomiting
  • Back pain with weight loss
  • New onset Diabetes with weight loss

Ultrasound imaging in the first instance may be appropriate depending upon local pathways. Advise to discuss and agree local guidelines with secondary care physicians

Yes

 

The pancreas is variably demonstrated and malignancy cannot be excluded in almost all cases
Diabetes

 

Ultrasound does not have a role in the management of diabetes. Up to 70% of patients with Diabete Mellitus have a fatty liver with raised ALT. This does not justify a scan.

No

 

Gynae

GYNAE

BMUS Guidelines 2017

Justified?

References & Notes

Pelvic Pain

Ultrasound is unlikely to contribute to patient management if pain is the only symptom.

 

No

 

Pain +

  • Chronic (>6 months)
  • Palpable mass
  • Raised CRP or WCC
  • Nausea/Vomiting
  • Menstrual Irregularities
  • Dyspareunia >6 wks

In patients >50, the likelihood of pathology is increased, and the request may be accepted, provided a specific clinical question has been posed.

If pain is chronic (>6 months) then scan is justified

The addition of another clinical symptom justifies the request.

Yes

 

Pain +

  • History of ovarian cyst
  • History of PCOS
  • ‘Severe’ or ‘Sudden’
  • ?appendicitis
  • ?ovarian cyst
  • ?anything else

These do not represent further clinical symptoms, and the request should be referred back.

Requests for purposes of reassurance should be rejected pending more information.

No

 

Bloating


 

Refer back for further information.

Intermittent bloating is not acceptable (CT may be the preferred test in gastrointestinal tract related symptoms, and further clinical info is required.)

No

 

Persistent or frequent occurring over 12 times in one month, in women especially over 50 with a palpable mass

Persistent bloating with the addition of other symptoms, such as a palpable mass/ raised Ca 125, is acceptable.

A specific clinical question is required.

Yes

 
Follow-up of benign lesions e.g. fibroids, dermoids
 

There is no role for US in follow-up or in treatment monitoring.

No

 

If the pt has undergone a clinical change, then re-scan is acceptable

Yes

Gynae referrals accepted

Follow-up of benign cysts; 
Pre Menopausal Women

Repeating ultrasound assessment in the postmenstrual phase may be helpful in cases of doubt and endometrial views may contribute to diagnosis in cases of estrogen-secreting tumours of the ovary.

Cysts >5cm already followed up

Yes 

RCOG Green-top Guideline No. 62, Management of Suspected Ovarian Masses in Premenopausal Women, 2011

Follow-up of benign cysts; 
Post Menopausal Women

Asymptomatic, simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy. In the presence of normal serum CA125 levels, these cysts can be managed conservatively, with a repeat evaluation in 4–6 months. It is reasonable to discharge these women from follow-up after 1 year if the cyst remains unchanged or reduces in size, with normal CA125, taking into consideration a woman’s wishes and surgical fitness. If a woman is symptomatic, further surgical evaluation is necessary.

Yes

RCOG Green-top Guideline No. 34, The Management of Ovarian Cysts in Post-menopausal Women, 2016
Vaginal discharge (unexplained) either at first presentation or with thrombocytosis or with haematuria, in women 55 +

NICE Guidance

Suspected endometrial cancer

Consider a direct access ultrasound scan

Yes

 
Blood glucose levels high with visible haematuria in women 55 +

Suspected endometrial cancer

Consider a direct access ultrasound scan

Yes

 
PCOS (Polycystic Ovarian Syndrome)

Only useful in secondary care if investigating infertility

Diagnosis of PCOS should be based on:

  1. Irregular menses.
  2. Clinical symptoms and signs of hyperandrogenism (acne, hirsutism)
  3. Biochemical evidence of hyperandrogenism
  4. Biochemical exclusion of other confounding conditions
No  

Lumps, bumps, hernias

SMALL PARTS

Lumps, bumps, hernias  BMUS Guidelines 2017

Justified?

References & Notes

Lymph Nodes

Patients with clinically benign groin, axilliary or neck lymphadenopathy do not benefit from US.

Small nodes in the groin, neck or axilla are commonly palpable.

If new and a source of sepsis is evident, Ultrasound is not required.

If malignancy is suspected US +/- fine needle aspiration or core biopsy is appropriate.
Signs of malignancy include: increasing size, fixed mass, rubbery consistency.
Appropriate imaging will depend upon the nature of the suspected primary.

No

 

Soft Tissue Lump


 

The majority of soft tissue lumps are benign and if there are classical clinical signs of a benign lump then ultrasound is not routinely required for diagnosis.

<5cm stable, soft, mobile, non-tender lumps do not routinely warrant ultrasound.

Uncomplicated ganglia and small lipomata do not routinely require imaging.

No

Clinical indications for musculoskeletal ultrasound, Kaluser A, Tagliafico A, Allen G; Eur Radiol (2012) 22:1140-114812,
Practical Musculoskeletal Ultrasound, Eugene McNally Second edition Churchill Livingstone 2014

If findings are equivocal however and diagnosis is essential to management eg “wrist mass, ?ganglion, ?radial artery aneurysm, excision planned” – then ultrasound is clearly warranted on a routine basis.

Significant findings (including >5cm, fixed, tender mass, increasing in size, overlying skin changes, etc) should either be scanned on an urgent basis or referred into a soft tissue sarcoma pathway (depending on local policy).

Yes

 

?Hernia

 

If characteristic history & exam findings, eg reducible palpable lump or cough impulse, then ultrasound is not routinely required.

Irreducible and/or tender lumps suggest incarcerated hernia and require urgent surgical referral.

If groin pain present, clinical assessment should consider musculoskeletal causes and refer accordingly.

No

Local guidelines suggest surgical referral for groin symptoms in first instance

Musculoskeletal

MUSCULOSKELETAL

BMUS Guidelines 2017

Justified?

Hip


 

Effusion/synovitis

Adductor tear

Yes

Trochanteric pain - Can be used to guide diagnostic/ therapeutic injections but often nil seen on initial diagnostic scan. Cannot definitively excluded trochanteric bursitis/trochanteric pain syndrome

Not Routinely Required - should be a clinical diagnosis

Ankle/foot


 

Peroneal tendon tenosynovitis/ subluxation

Posterior tibial tendonopathy

Yes

Anterior talofibular ligament
Calcaneofibular ligament
Posterior talofibular ligament
Deltoid ligament

Anterior/mid lateral ligaments can be seen, difficult to exclude pathology in medial ligaments, however patients with potential ankle instability may need referral to a specific orthopaedic pathway for assessment +/- MRI

No

Shoulder

Acromioclavicular osteoarthritis/ instability, Sternoclavicular joint disease

May be used to confirm origin of mass Ie. osteoarthritic joint if clinical concern

Yes

Elbow

Distal biceps tendon tear - Small insertional tears may be difficult to exclude

Ulnar nerve neuropathy/ subluxation - To exclude mass at ulnar canal/medial epicondyle and can confirm subluxation

Median/Radial nerve compression - To exclude external compression (difficult to assess for focal neuritis)

Yes


Wrist/Hand

 

Pulley/sagittal band injury/ruptures

Thumb/finger collateral ligament injuries

Median nerve - Indicated to look for carpal tunnel mass only. May detect neuritis, however cannot diagnose Carpal Tunnel Syndrome on ultrasound

Ulnar nerve compression - To exclude mass causing compression of ulnar nerve

Yes

Triangular Fibrocartilage Complex tear - MRI superior

Triangular Fibrocartilage Complex calcification - Seen on X-ray

No

Joints
 

Effusion - To confirm/exclude effusion and guide aspiration if required

Septic arthritis

Yes

Loose bodies
Labral pathology
Cartilage pathology
Intra-articular pathology

No

Soft tissues – general

Tenosynovitis/rupture

Tendinopathy – specific tendon should be mentioned

Tendon sheath effusions -specific tendon should be mentioned - Cannot differentiate between infected and non-infected effusion – US guided aspiration may be required

Calcific tendinopathy - specific

Yes

Testes

TESTES

BMUS Guidelines 2017

Justified?

References & Notes

Scrotal Mass

 

Any patient with a swelling or mass in the body of the testis should be referred urgently.

Yes

 




Scrotal Pain
 

Acute pain, in the absence of suspected torsion or acute epididymo-orchitis is an appropriate indication for an ultrasound referral. (Suspected torsion requires urgent urological referral which should not be delayed by imaging)

Where the clinical diagnosis is unclear US is indicated and will influence management.

Yes

NICE cks

These recommendations are based on expert opinion from narrative reviews Evaluation of scrotal masses (Crawford and Crop, 2014) and Pediatric scrotal masses (Hagerty and Yerks (2009) Clinical Pediatric Emergency Medicine 10(1), 50-55.

 

Uncomplicated epidiymo-orchitis does not require routine US examination.

Extra-testicular masses don’t need scanning

No

US is appropriate to evaluate suspected complications eg abscess or when pain and symptoms persist despite antibiotic treatment.

Yes

Chronic varicocele, uncomplicated hydrocele and epididymal cysts do not require routine ultrasound evaluation providing that the clinical examination is unequivocal in identifying that the mass is extra testicular.

No

However where there is clinical doubt, and if the testicle cannot be palpated separate to the mass (eg large hydrocele) then US is warranted.

Yes

Ultrasound in chronic testicular pain in the absence of a mass/abnormal examination is generally unhelpful; it may be more prudent to refer to Urology

No

Urinary Tract

URINARY TRACT BMUS Guidelines Justified? References and Notes
Urinary Tract Infection First episode No  

Recurrent (> = 3 episodes in 12 months) , especially in the over 60 age group

Non-responders to antibiotics

Frequent re-infections

H/O stone or obstruction

Yes

https://www.nice.org.uk/guidance/qs90

https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/references/
Hypertension

Routine imaging not indicated.

RAS (renal artery screening) no longer routinely offered.

Yes - Local Guidelines

 

Haematuria

Suspected Bladder
Cancer/Suspected Renal
Cancer

  • Aged 45 and over and have unexplained visible haematuria without urinary tract infection
  • OR Visible haematuria that persist or recurs after successful treatment of a UTI
  • Are aged over 60 and have unexplained non-visible haematuria AND either dysuria or raised white cell count
Yes

British Association of Urological Surgeons:
https://www.baus.org.uk/_userfiles/pages/files/Publications/
BAUS%20Cancer%20Guidelines%20Summary.pdf

Last reviewed: 30 June 2021

Next review: 30 June 2024

Author(s): Sonographer

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Sonographer

Document Id: TAM465