Ultrasound referral guidelines



  • Argyll & Bute HSCP and Highland HSCP
  • Primary and Secondary Care.

Ultrasound referral guidelines

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) (see resources) 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 (see resources) and should be used in conjunction with this. The NICE guidance, NG12, Suspected Cancer: Recognition and Referral published in June 2015 (see resources) 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.


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.



BMUS Guidelines 2017


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


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


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


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

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


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


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


Local Guidelines Apply:

Signs and symptoms of advanced liver disease


?Obstruction or ?cholecystitis


If urgent specialist referral is being considered


Suspicion of malignancy


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



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.



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


Upper Abdominal Mass

Consistent with stomach cancer



Consistent with an enlarged gallbladder



Consistent with an enlarged liver



Suspected Gallbladder Disease

Pain plus fatty intolerance and/or dyspepsia



Bloating/Abdominal Distention





As the only symptom



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



With a palpable mass



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



Malignancy/cancer – CT scan


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



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


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

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.




BMUS Guidelines 2017


References & Notes

Pelvic Pain

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




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.



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.





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.)



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.


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

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



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


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


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.


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


Blood glucose levels high with visible haematuria in women 55 +

Suspected endometrial cancer

Consider a direct access ultrasound scan


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

Lumps, bumps, hernias


Lumps, bumps, hernias  BMUS Guidelines 2017


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.



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.


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).





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.


Local guidelines suggest surgical referral for groin symptoms in first instance

Neck lump

Neck lump    Justified ?   
Thryoid goitre or lump Stable thyroid goitre does not require referral. New onset goitre with normal thyroid function or stridor, and focal thyroid lumps, should be referred to ENT for further investigation. Ultrasound and FNA may then be requested by ENT with follow up by ENT in line with British Thyroid Association guidelines. No
Local guidelines
Thyroid dysfunction Ultrasound not routinely required. Hypothyroid with thyroid nodule refer to ENT. Hyperthyroid refer to endocrinology. Useful guidelines from British thyroid association. No  Local guidelines 
Salivary masses Refer to ENT. Ultrasound and FNA may then be requested by ENT. No Local guidelines
Other neck lumps Refer to ENT for assessment. Ultrasound and FNA may be requested by ENT if necessary. May be justified Local guidelines



BMUS Guidelines 2017





Adductor tear


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



Peroneal tendon tenosynovitis/ subluxation

Posterior tibial tendonopathy


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



Acromioclavicular osteoarthritis/ instability, Sternoclavicular joint disease

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



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)




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


Triangular Fibrocartilage Complex tear - MRI superior

Triangular Fibrocartilage Complex calcification - Seen on X-ray



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

Septic arthritis


Loose bodies
Labral pathology
Cartilage pathology
Intra-articular pathology


Soft tissues – general


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




BMUS Guidelines 2017


References & Notes

Scrotal Mass


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



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.


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


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


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.


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


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


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




Routine imaging not indicated.

RAS (renal artery screening) no longer routinely offered.

Yes - Local Guidelines



Suspected Bladder
Cancer/Suspected Renal

  • 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

British Association of Urological Surgeons:


Further information for Patients

(Scroll down to see all information)

Self-management information 

Last reviewed: 17 February 2023

Next review: 27 February 2026

Author(s): Radiology Department

Version: 3

Approved By: TAMSG of the ADTC

Reviewer Name(s): Helen Shannon, Consultant Radiologist

Document Id: TAM465

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