Referral and justification Protocols
for
ULTRASOUND IMAGING
(Supporting effective demand
management)
CLINICAL DIRECTOR:
DATE:
REVIEW DATE:
Dr J Reynolds
October 2014
October 2015
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Authors: Dr Morus, Dr Cooper, Dr Tudway, W Gregory, M Peplow
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Review Date: October 2013
Authorised By: Dr L Morus
CONTENTS
Page number
1.0
Introduction
3
2.0
Abdominal Scans
4
3.0
Renal Tract Scans
6
4.0
Thyroid Scans
7
5.0
Neck Scans
7
6.0
Doppler Scans ?D.V.T.
7
7.0
Other Vascular
8
8.0
Neonatal Spine
8
9.0
Female Pelvis
8
10.0 Other Pathways
9
11.0 Testicular Scans
9
12.0 Carotid Scans
10
13.0 Lumps
11
14.0 M.S.K.
12
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1.0 INTRODUCTION
Protocols have been devised to ensure that ultrasound capacity is used
appropriately and demand managed effectively. These protocols are not
exhaustive and if there is ever any clinical doubt about the justification of a
request Consultant advice should be sought. For in-patient requests this can be
from the duty Radiologist on the GH site and on the BHH/Sol sites initially from
the Consultant who has a list during that session. Outpatient specialist requests
where there is a query should be directed to a named Radiologist with relevant
expertise.
2.0
ABDOMINAL SCANS : adults
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Justified:
 Right upper quadrant pain? Gallstones
 ? acute or chronic cholecystitis
 Dyspepsia
 Acute abdominal pain although CT may be a more appropriate investigation
 ? acute appendicitis or appendix mass
 Altered L.F.T.s, elevated A.L.T or other biochemical indications
 Abdominal pain + vomiting associated with food.
 Alcoholic liver disease
 Acute or chronic liver disease
 H.C.C. surveillance
 Jaundice/Itching/prutitis
 Pain radiating to back
 ?acute pancreatitis
 Lower abdominal pain
 Palpable abdominal or pelvic mass.
 Abdominal bloating : if no further information is given then a TA scan
abdomen and pelvis is appropriate
 Abdominal sepsis/PUO: although CT is often a better investigation
 ? intra abdominal or pelvic collection: although CT is often a better
investigation
 ?ascites
 Some instances of post operative follow up, e.g. post laparoscopic
cholecystectomy or appendicectomy
 C.F surveillance
 Suspected small bowel disease: specialised investigation
 ? hernia: to be protocolled as abdominal wall or groin scan depending on
the suspected site of hernia.
Request more information:
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 If clinical information simply states groin pain: this is not enough clinical
info to justify the request, please seek additional information
 Abdominal pain area not specified
 ? intra –abdominal malignancy with no further information
If bowel symptoms are mentioned CT may be more appropriate, check with
consultant.
If the request is for a suspected intra-abdominal abscess then CT may be the
investigation of choice.
Ultrasound should not be considered as the correct modality if the query is
regarding any retroperitoneal pathology such as a psoas collection etc-please
discuss with a Radiologist.
Specific USS requests may be received for small bowel eg Crohn’s which should be
passed to appropriate consultants for vetting eg MG/KA at Heartlands, MJC at
GHH.
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3.0 RENAL TRACT SCANS : adults
Justified:
 Urinary tract infection in adults: 1 x UTI in men; proven recurrent UTI in
women; immunocompromised or diabetic patients; UTI that fails to settle
rapidly.
 Acute renal failure
 Chronic kidney disease
 Deteriorating G.F.R.
 Lower urinary tract symptoms to be performed with post void residual
 Prostatic symptoms: with post void residual
 Microscopic (non-visible) haematuria: see note below
 Macroscopic (visible) haematuria: see note below
 Suspected ureteric colic: US may be indicated when CT is contraindicated eg
in pregnancy.
 Loin pain
 Hypertension in the young or unresponsive to treatment: see note below
 Suspected renal mass
 Characterisation of masses detected on CT
 Serial follow up of renal cysts if suspicious features - discuss with
Radiologist if not sure
 Urinary tract obstruction: diagnosis and causes
 Renal transplant dysfunction: with Doppler studies
Other pathways:
 Frank/macroscopic/visible haematuria and persistent microscopic/nonvisible haematuria especially in patients over 40 should ideally be referred
to rapid access haematuria clinic
 Acute loin to groin pain with microscopic haematuria and/or clinical history
of suspected renal calculi: the investigation of choice for most patients is
CT K.U.B. unless there is a relatively contraindication eg pregnancy.
 Hypertension: US may be indicated as a first line for renal size. Doppler for
renal artery stenosis is a specialist investigation. Many of these patients
should be referred for MRA/CTA. Refer to Radiologist.
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4.0 THYROID SCANS
Justified:
 Unilateral/bilateral thyroid swelling
 Thyroid masses/enlargement
 ? goitre
 Swallowing difficulties
NB : Request for thyroid cyst/nodule follow up, if no change clinically and no
cancer risk features seen on initial scan: request not indicated routinely.
Requests for Thyroid biopsies/FNA to be vetted by specialist Radiologists.
Thyrotoxicosis-specialist request only
5.0 NECK SCANS
Justified:
 Neck lumps /masses
 Lymph node enlargement/masses
 Salivary glands eg obstruction, mass
 Hyperparathyroidism/parathyroid enlargement
 Thyroglossal cysts,
 Branchial cleft cysts
 Neck abscess
6.0 DOPPLER SCANS ?D.V.T.
Follow the DVT pathways at the BHH, SH and GHH sites.
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In brief:
1. If Modified Wells score is >/= 2 : scan the major leg veins down to and
including the popliteal vein.
2. If Modified Wells score is <2 but D- Dimer is positive then scan as above.
3. If Modilfed Wells score is <2 but D -Dimer is negative then scan is not
indicated.
Local arrangements for the management of patients with suspected DVT is
according to the processes that have been developed on the BHH, GH and SH
sites. However, all patients with a positive DVT diagnosed at ultrasound should be
sent from Ultrasound to AMU.
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7.0 VASCULAR
 Assess haemodialysis shunts
 ? abdominal aneurysm on palpation (if acute or assoc. with pain CT is
indicated)
 ? false aneurysms in groin following femoral vascular access

The following requests should not be rejected but should be re-directed to the
vascular lab :
Vascular insufficiency
Intermittent claudication
Varicose veins
Vein mapping
8.0 NEONATAL SPINE
 Sacral dimple – baby needs to be less than 6 months old
9.0 FEMALE PELVIS
Justified:
 Menorrhagia
 Unilateral/bilateral iliac fossa pain
 Irregular menstrual bleeding
 Dysmenorrhoea
 ?endometriosis
 Suspected pelvic inflammatory disease
 Follow up of cysts as per gynae protocols
 Follow up of post menopausal cyst as per gynae protocols
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Oligmenorrhea + other symptoms of polycystic ovary syndrome
? position of I.U.C.D.
Dyspareunia
Primary or secondary amenorrhoea
? uterine anomaly
? precocious puberty
Elevated Ca 125 with or without symptoms
Urinary frequency and urgency
Bulky uterus ? fibroids
Increasing size of fibroids
Bloating/elevated Ca125 suspected ovarian malignancy
Pelvic mass
Post menopausal bleeding-but see note below
Suspected ectopic pregnancy : but most will be referred via EPAC
10.0 0THER PATHWAYS
 Post menopausal bleed should ideally be referred via rapid access clinic
Request further information:
 Ovarian cyst follow up-please review the need for this. We should not be
repeating scans unnecessarily. Patients need a clinical opinion as to the
need for follow up, definitive treatment or discharge. Please forward the
requests to a dedicated Gynae Radiologist if unsure.
 Simple cysts of < 5 cm in asymptomatic women of reproductive age do not
need routine 6 week re call.
11.0 TESTICULAR SCANS
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 Pain
 Unilateral/bilateral swelling
 Palpable lump-if ? malignancy should be fitted in on the day if request
from urology clinic
 ?Hydrocoele
 ?varicocoele (Should have renal USS also)
 ? undescended
 ? torsion – immediate by discussion with radiologist in scan room
Paediatric scrotal scans should be rejected when referred from primary care and
a specialist referral advised.
12.0 CAROTID SCANS
Justified;
 High risk TIA/ABCD2 score>4 scan within 24 hours
 TIA/stroke that resolves completely-within 7 days
 Pre cardiac surgery
 Amaurosis fugax; temporary loss of vision in a single eye – not
homonymous hemianopia
 Established stoke if fit for surgery
Unjustified;
 GP requests
 Unresolved strokes if patient not fit for surgery (Grey area; surgeons say
they will operate on some patients with unresolved stroke - that is why
previous protocol says patient must be ‘fit for surgery’. This phrase also
covers patients with severe co-morbidities which render active
management of carotid stenosis impossible-discuss with a Radiologist) .
 Neurological deficit not within the carotid artery territory-if in doubt ask a
Consultant!
 Dizziness, faintness
 Vertebro-basilar ischaemia
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13.0 LUMPS
To be accepted the request should ideally have the following information about
the lump;
 Size
 Position
 Consistency – is it fluctuant, soft, hard, perhaps bony, definitely bony Is it
subcutaneous, deeply situated, don’t know, not applicable Length of history
 Has it enlarged or otherwise changed recently?
 And, if possible, state the suspected diagnosis and any other reasons why
the lump is causing clinical concern
Unjustified:
 The lump is definitely bony – ultrasound is rarely the initial investigation of
choice
 No abnormality is found on clinical examination and a specific cause of a
transient lump, particularly hernia, is not suspected
Note; perhaps the most important component of this protocol is the
insistence on information of a basic clinical examination which should
encourage critical evaluation of the problem by the referrer
14.0 M.S.K.
SHOULDERS - Any mention of rotator cuff tendinopathy, tears or impingement.
ANKLES - Tendinopathy (peroneals, Tibialis posterior). If ankle instability is
mentioned and if request states injury to ATFL or CFL . Achilles the most
common request
HANDS/WRISTS - requests for tendinopathy, tenosynovitis or tendon rupture.
Many requests are for ganglions which is ok.
If requests states synovitis as is from rheumatology needs msk Cons
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Review Date: October 2013
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FOOT - ?Mortons neuroma ? plantar fasciitis (resistant cases) ? ganglion
?synovitis ?bursitis ?infective collection, esp. in diabetics
We do not have the capacity to scan all patients with plantar fasciitits routinely.
This should be reserved for difficult intractable cases eg severe pain of more than
3 months duration not responding to routine treatment and where a scan will
alter management-from orthopaedics only. If in doubt discuss with Consultant.
KNEE ? Bakers cyst
? patellar tendon/quadriceps tendon tendinopathy / tear.
? prepatellar bursitis
? pes anserinus enthesopathy
? Ilio-tibial band bursitis
Lumps around the knee
Any request for meniscal tear or joint problems need MRI or x-ray –
this includes if there is any mention of locking, clicking or giving way.
All of these suggest the possibility of internal derangement and
therefore suggest changing to MRI.
NB Knee Ultrasound requests for tendinopathies from GP’s should be
rejected with the advice that a specialist opinion should be sought.
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Certain requests are urgent, these are generally for tendon ruptures and include
1. Quadriceps
2. Patellar tendon
3. Achilles tendon ( if any doubt if the request is acute check with requesting
Dr, many patients are sent home in plaster or boot to await scan )
4. Biceps tendon
These should be done within a week
Also;
 Damage, abnormality or compression of peripheral nerves, e.g. peroneal
or upper limb nerve
 Hips; trochanteric bursitis, metallosis, (? MRI better test-picks up
more)
 infant hip effusions
 Muscle injuries
 Enthesopathies e.g. at adductor tubercle
 Elbow - tennis elbow etc.
 Where management will change as a result of the scan.
GROIN pain without a palpable abnormality ? MRI better test pick up
conjoint/adductor tendinopathies.
If unsure discuss with relevant Radiologist
PAEDIATRIC SCANS – abdominal and pelvis.
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