EUROPEAN COMMISSION

RADIATION PROTECTION 118

Update Mars 2008

Referral Guidelines For Imaging

Guidelines for Healthcare Professionals who prescribe Imaging

Investigations involving Ionising Radiation

Final Report to the European Commission for Grant Agreement

SUBV99/134996

University Court of the University of Aberdeen

Professor Gillian Needham and Professor Jeremy Grimshaw

Directorate-General for Energy and Transport

Directorate H — Nuclear Energy
Unit H.4 — Radiation Protection
2007
FOREWORD

Luxembourg, October 2007

Foreword

The European Commission has issued a booklet with referral guidelines for imaging
(Radiation Protection 118) for use by health professionals referring patients for medical
imaging. The booklet proved to be of great value in ensuring that radiological imaging
prescriptions are justified, in application of Articles 3.1 and 6.2 of Council Directive
97/43/EURATOM on "health protection of individuals against the dangers of ionising
radiation in relation to medical exposure".

This document was published in 2000; however, there is a need for a regular update of
such guidance, in the light of rapid technical developments.

Such an update was prepared in 2003 under contract no. SUBV. 99/134996 (concluded
at the time with DG Environment but now under the responsibility of DG Energy and
Transport). While many experts in Europe were involved in this project, which should
provide assurance on the quality of the updated guidance, circumstances prevented the
prompt finalisation of this document's publication.

This is why the document is only now being posted on our website, at a time when a
new update is already being prepared. It is available in English only, whereas Radiation
Protection 118 was published in booklet form in 11 languages.

Pending the publication of a new update of publication 118 we hope that many users will
nevertheless benefit from this intermediate version.

A. Janssens
Head of Unit
DG TREN.H.4
Radiation Protection

3
CONTENTS

Foreword 3

Contents 5

1 Introduction 7

2 Classification of evidence 7

3 Collection of evidence 8

4 Guidelines 8

5 Why are guidelines needed? 8

6 What advice is available? 9

7 What images are taken? 10

8 For WHOM are the Guidelines designed? 10

9 Using the Guidelines 10

10 Pregnancy and protection of the fetus 11

11 Optimising radiation dose 12

12 Communications with a department of clinical radiology 15

13 Imaging techniques 15
13.1 Computed tomography (CT) 15
13.2 Interventional radiology (including angiography and minimal
access therapy) 16
13.3 Magnetic resonance imaging (MRI) 17
13.4 Nuclear medicine (NM) 17
13.5 Nuclear medicine therapy 18
13.6 Ultrasound (US) 18

14 Glossary 19

15 Selected bibliography 21

See second file

16 Clinical problems: investigations, recommendations and comments 24

17 Appendix:List of bodies involved in the consultation exercise 158

5
 INTRODUCTION

1 INTRODUCTION

These guidelines have been prepared to help referring practitioners make the
best use of a Department of Clinical Radiology. The Guidelines have been
designed to assimilate, evaluate, and implement the ever-increasing amount
of evidence and opinion on current best practice. The EU Council Directive
1997/43/Euratom declared that member states will promote the
establishment and use of diagnostic reference levels for radiological
examinations and the guidance thereof. The present guidelines can be used
for this purpose.
Continued use of recommendations of this kind can lead to a reduction in the
number of referrals and also to a reduction in medical radiation exposure [1-
5]. However, the primary objective of the guidelines is to improve clinical
practice. Such guidelines work best if they are used as part of clinico-
radiological dialogue and the audit process. They are intended for use by all
referring practitioners. The development methodology minimises context-
specificity: they should be of relevance and value throughout the European
Community (EC) and, indeed, internationally.
The editorial process was undertaken by Professor Gillian Needham
(Aberdeen), Professor Iain McCall (Stoke-on-Trent), and Dr Mike Dean
(Shrewsbury), under the auspices of the European Guideline Development
Steering Group (see below), and the processes of literature searching, critical
appraisal, synthesis and grading were carried out by European and UK Special
Interest Groups (SIGs) and Specialist Societies (see below). Mr Chris Squire
(RCR Clinical Audit Officer) developed the evidence-gathering template. Mr
Barry Wall from the National Radiological Protection Board (NRPB) advised on
dosimetric data and scoring.

2 CLASSIFICATION OF EVIDENCE

Classification of evidence levels has been translated into grades of

recommendation based on the system developed by the US Department of
Health and Human Services, Agency for Health Care Policy and Research [6-
7]. The levels are

[A]

• High quality diagnostic studies in which a new test is independently and

blindly compared with a reference standard in an appropriate spectrum of
patients

• Systematic review and meta-analyses of such high quality studies

• Diagnostic clinical practice guidelines/clinical decision rules validated in a

test set

[B]

• Studies with a blind and independent comparison of the new test and
reference standard in a set of non-consecutive patients or confined to a
narrow spectrum of subjects

• Studies in which the reference standard was not performed on all subjects

7
 • Systematic reviews of such studies

• Diagnostic clinical practice guidelines/clinical decision rules not validated in

a test set

[C]

• Studies in which the reference standard was not objective

• Studies in which the comparison between the new test and the reference
standard was not blind or independent

• Studies in which positive and negative test results were verified using
different reference standards

• Studies performed in an inappropriate set of patients

• Expert opinion.

3 COLLECTION OF EVIDENCE

The evidence gathering, synthesis and grading processes that are so crucial to
best guideline development have been undertaken by over 200 radiologists
across the EC. This truly collaborative effort, cascaded-out by European and
UK special interest groups (SIGs) and societies, has been supported by
guideline development teams in London (based at the RCR) and Aberdeen
(based in the Health Services Research Unit, University of Aberdeen).
Training in the guideline development process was delivered early on in the
project.

While wide consultation across the whole of Europe and the UK (see
Appendix) was undertaken in the development of this booklet, and best-
evidence methodology applied, undoubtedly there will be some decisions that
will not accord with local practice. Evidence has at times been conflicting and
this has required compromise and interpretation. We would welcome
referenced comments, to allow continued development of these Guidelines.

4 GUIDELINES

A ‘gold standard’ search strategy for diagnostic-imaging tests has been

developed as part of this project, as has work to investigate the feasibility of
establishing a comprehensive register of studies. At the time of publication
however, we continue to rely on the Guideline Development Steering Group
for strategic direction and SIGs for detailed content.

5 WHY ARE GUIDELINES NEEDED?

A useful investigation is one in which the result - positive or negative - will

alter clinical management and/or add confidence to the clinician's diagnosis. A

8
 WHAT ADVICE IS AVAILABLE?

significant number of radiological investigations do not fulfil these aims and

may add unnecessarily to patient irradiation [14]. The chief causes of the
wasteful use of radiology are:

1 Repeating investigations which have already been done: e.g., at

another hospital, in an outpatient department, or in an accident and
emergency department. HAS IT BEEN DONE ALREADY? Every attempt
should be made to get previous films. Transfer of digital data through
electronic links may assist in this respect in future years.

2 Investigation when results are unlikely to affect patient

management: because the anticipated 'positive' finding is usually
irrelevant, e.g. degenerative spinal disease (as 'normal' as grey hairs
from early middle age) or because a positive finding is so unlikely. DO I
NEED IT?

3 Investigating too often: i.e. before the disease could have progressed
or resolved or before the results could influence treatment. DO I NEED IT
NOW?

4 Doing the wrong investigation. Imaging techniques are developing

rapidly. It is often helpful to discuss an investigation with a specialist in
clinical radiology or nuclear medicine before it is requested. IS THIS THE
BEST INVESTIGATION?

5 Failing to provide appropriate clinical information and questions

that the imaging investigation should answer. Deficiencies here
may lead to the wrong technique being used (e.g. the omission of an
essential view). HAVE I EXPLAINED THE PROBLEM?

6 Overinvestigating. Some clinicians tend to rely on investigations more

than others. Some patients take comfort in being investigated. ARE TOO
MANY INVESTIGATIONS BEING PERFORMED?

6 WHAT ADVICE IS AVAILABLE?

In some clinical situations firm Guidelines have been established. Guidelines

are:

systematically developed statements to assist practitioner and

patient decisions about appropriate health care for specific clinical
circumstances... [Field & Lohr, 1992, 15].

Just as the term implies, a Guideline is not a rigid constraint on clinical

practice, but a concept of good practice against which the needs of the
individual patient can be considered. So while there have to be good reasons
for ignoring them they are not absolute rules. No set of recommendations will
command universal support, and you should discuss any problems with your
radiologists.

The preparation of Guidelines has become something of a science, with

numerous papers emerging within the evolving Guidelines discipline. In
particular, experts have provided a detailed methodology as to how guidelines
should be developed, produced and appraised [8, 15-21]. Using such a
methodology, the development of a single, scientifically robust guideline
represents a major piece of academic endeavour. For the 331 clinical

9
 problems in this booklet, such expenditure of time and resources is somewhat
impractical. Nevertheless, increasing effort has been made to ensure the
methodology for the preparation of guidelines has been followed during the
preparation of these recommendations. In particular, there has been expert
development of a search strategy, extensive systematic literature review, and
critical appraisal by relevant special interest groups. The Royal College of
Radiologists holds an archive of references upon which statements within the
text are based. Every opportunity has been given to workers in other
disciplines and those representing patients to put forward their views. Many
societies and groups across Europe have been encouraged to comment on
points of fact, local policies, and other related matters. There has been
extensive dialogue with other professional groups, including patients’
representatives, European professional associations and specialist societies,
and all the medical Royal Colleges (see Appendix).

In some clinical situations (e.g., the role of ultrasound in normal pregnancy)

there are conflicting data within a large body of excellent scientific reports.
Thus no firm recommendations are given and the evidence is graded C. It
should be noted that there are very few randomised trials comparing different
radiological procedures – they are difficult to perform and ethical approval
may be denied.

7 WHAT IMAGES ARE TAKEN?

All imaging departments should have protocols for each common clinical
situation. Therefore no definite recommendations are given about this aspect.
Suffice it to say that all examinations should be optimised to obtain maximum
information with the minimum of radiation. It is important to be aware of
this, as the imaging performed may not be what the referring clinician
expects.

8 FOR WHOM ARE THE GUIDELINES DESIGNED?

These Guidelines are intended to be used by all ‘referrers’, including in

particular general practitioners. In the hospital setting they are likely to be of
most use to newly qualified doctors, and many hospitals give a copy to each
newly appointed junior doctor to stimulate good practice.

The range of investigations available to different health professionals must be

determined in consultation with local specialists in radiology and nuclear
medicine, bearing in mind the available resources. The recommendations are
also of value to those interested in audit of a department’s referral pattern
and workload [13].

9 USING THE GUIDELINES

These guidelines tend to highlight areas of difficulty or controversy. The

pages are composed of five columns: the first sets the clinical situation for

10
 PREGNANCY AND PROTECTION OF THE FETUS

requesting an examination; the next lists some possible imaging techniques;

the third gives the recommendation (and the grade of available evidence) on
whether or not the investigation is appropriate; the fourth provides
explanatory comment; and the fifth shows the band of radiation exposure
involved.

The recommendations used are:

1. Indicated. This shows an investigation most likely to contribute to

clinical diagnosis and management. This may differ from the
investigation requested by the clinician: e.g., US rather than
venography for deep vein thrombosis.

2. Specialised investigation. These are frequently complex, time-

consuming or resource-intensive investigations which will usually only
be performed after discussion with the radiologist or in the context of
locally-agreed protocols.

3. Not indicated initially. This includes situations where experience

shows that the clinical problem usually resolves with time; we
therefore suggest deferring the study for three to six weeks (timescale
may be shorter for children) and only performing it then if symptoms
continue. Shoulder pain is a typical example.

4. Indicated only in specific circumstances. These are non-routine

studies which will only be carried out if a clinician provides cogent
reasons or if the radiologist feels the examination represents an
appropriate way of furthering the diagnosis and management of the
patient. An example of such a justification would be plain radiography
in a patient with backache in whom there were clinical findings to
suggest something more than a degenerative disease (e.g.,
osteoporotic vertebral fracture).

5. Not indicated. Examinations in this group are those where the

supposed rationale for the investigation is untenable (e.g., skull
radiograph for dementia).

10 PREGNANCY AND PROTECTION OF THE FETUS

Irradiation of a foetus should be avoided whenever possible [23-25]. This

includes situations where the woman herself does not suspect pregnancy.
The prime responsibility for identifying such patients lies with the referring
clinician.

Women of reproductive age presenting for an examination in which the

primary beam irradiates directly, or by scatter, the pelvic area (essentially,
any ionising irradiation between the diaphragm and the knees), or for a
procedure involving radioactive isotopes, should be asked whether they are or
may be pregnant. If a patient cannot exclude the possibility of pregnancy,
she should be asked if her period is overdue.

If there is no possibility of pregnancy the examination can proceed, but if the

patient is definitely or possibly pregnant (i.e., menstrual period is overdue)
the justification for the proposed examination should be reviewed by the
radiologist and the referring clinician, with a decision taken on whether to
defer the investigation until after delivery or until the next menstrual period

11
 has occurred. However, a procedure of clinical benefit to the mother may also
be of indirect benefit to her unborn child, and a delay in an essential
procedure may increase the risk to the foetus as well as to the mother.

If pregnancy cannot be excluded, but the menstrual period is not overdue and
the procedure gives a relatively low dose to the uterus, the examination may
proceed. However, if the examination gives relatively high doses (in most
departments, the common examinations in this category will probably be
abdominal and pelvic CT, IVUs, fluoroscopy and nuclear medicine studies),
there will be discussion in line with locally agreed recommendations.

In all cases, if the radiologist and referring clinician agree that irradiation of
the pregnant or possibly pregnant uterus is clinically justified or is not
clinically justified, this decision should be recorded. If it is decided that the
irradiation is justified, the radiologist must then ensure that exposure is
limited to the minimum required to acquire the necessary information.

If it becomes obvious that a foetus has been inadvertently exposed, despite

the above measures, the small risk to the foetus of the exposure is unlikely to
justify, even at the higher doses, the greater risks of invasive foetal diagnostic
procedures (e.g., amniocentesis) or those of a termination of the pregnancy.
When such inadvertent exposure has occurred, a radiation physicist should
make an individual risk assessment and the results should be discussed with
the patient.

The RCR has co-authored (with the National Radiation Protection Board
(NRPB) and the College of Radiographers) a guidance booklet on the
protection of the foetus during the diagnostic investigation of its mother [25].
(This publication is available from the NRPB website at http://www.nrpb.org.).

11 OPTIMISING RADIATION DOSE

The use of radiological investigations is an accepted part of medical practice

justified in terms of clear clinical benefits to the patient, which should far
outweigh the small radiation risks. However, even small radiation doses are
not entirely without risk. A small fraction of the genetic mutations and
malignant diseases occurring in the population can be attributed to natural
background radiation. Diagnostic medical exposures, being the major source
of man-made radiation exposure of the population, add about one-sixth to the
population dose from background radiation.

The 1997 EU directive [2] requires all concerned to reduce unnecessary

exposure of patients to radiation. Responsible organisations and individuals
using ionising radiation must comply with these regulations. One important
way of reducing the radiation dose is to avoid undertaking investigations
unnecessarily (especially repeat examinations).

The effective dose for a radiological investigation is the weighted sum of the
doses to a number of body tissues, where the weighting factor for each tissue
depends upon its relative sensitivity to radiation-induced cancer or severe
hereditary effects. It thus provides a single dose estimate related to the total
radiation risk, no matter how the radiation dose is distributed around the
body.

12
 OPTIMISING RADIATION DOSE

Table 1 Typical effective doses from diagnostic medical exposure in the 2000s

Diagnostic procedure
Typical effective dose (mSv)
Equivalent
no. of
chest
radiographs
Approximate
equivalent period of natural background radiation 1
___________________________________________________________

Radiographic examinations:
Limbs and joints
(except hip) <0.01 <0.5 <1.5 days
Chest (single PA film) 0.02 1 3 days
Skull 0.06 3 9 days
Thoracic spine 0.7 35 4 months
Lumbar spine 1.0 50 5 months
Hip 0.4 20 2 months
Pelvis 0.7 35 4 months
Abdomen 0.7 35 4 months
IVU 2.4 120 14 months
Barium swallow 1.5 75 8 months
Barium meal 2.6 130 15 months
Barium follow through 3 150 16 months
Barium enema 7.2 360 3.2 years
CT head 2.0 100 10 months
CT chest 8 400 3.6 years
CT abdomen or pelvis 10 500 4.5 years
___________________________________________________________
Radionuclide studies:
Lung ventilation (Xe-133) 0.3 15 7 weeks
Lung perfusion (Tc-99m) 1 50 6 months
Kidney (Tc-99m) 1 50 6 months
Thyroid (Tc-99m) 1 50 6 months
Bone (Tc-99m) 4 200 1.8 years
Dynamic cardiac (Tc-99m) 6 300 2.7 years
PET head (F-18 FDG) 5 250 2.3 years

1UK average background radiation = 2.2 mSv per year: regional averages range from 1.5 to 7.5
mSv per year.
With advice from B Wall, National Radiological Protection Board.

13
Typical effective doses for some common diagnostic radiology procedures
range over a factor of about 1000 from the equivalent of a day or two of
natural background radiation (e.g. 0.02 mSv for a chest radiograph) to 4.5
years (e.g., for computed tomography of the abdomen). However, there is
substantial variation in the background radiation between and within
countries. The doses for conventional x-ray examinations are based on
results compiled by the NRPB from patient dose measurements made in 380
hospitals throughout the UK from 1990 to 1995. They are mostly lower than
those given in earlier editions of this booklet, which were based on data from
the early 1980s, indicating a gratifying trend towards improved patient
protection. The doses for CT examinations and radionuclide studies are based
on national surveys conducted in 2002 by the NRPB and the British Nuclear
Medicine Society (BNMS) and are unlikely to have changed significantly since
then.

Low-dose examinations of the limbs and chest are among the most common
radiological investigations, but relatively infrequent high-dose examinations
such as body CT and barium studies make the major contribution to the
collective population dose. The doses from some CT examinations are
particularly high and show no sign of decreasing. The use of CT is still rising.
CT now probably contributes almost half of the collective dose from all
radiographic examinations. It is thus particularly important that requests for
CT are thoroughly justified and that techniques are adopted which minimise
dose while retaining essential diagnostic information. Indeed, some
authorities estimate the additional lifetime risk of fatal cancer from an
abdominal CT examination in an adult is around 1 in 2000 (compared with the
risk from a chest radiograph at 1 in a million) [26]. However, the overall risk
of cancer in the general population is nearly 1 in 3, and in comparison to this
the excess risk of a CT scan is very small and should be more than offset by
the gain from a CT scan.

In these referral Guidelines the doses have been grouped into broad bands to
help the referrer understand the order of magnitude of radiation dose of the
various investigations.

Table 2 Band Classification of the typical effective doses of ionising radiation

from common imaging procedures

Band Typical effective dose (mSv) Examples

0 0 US, MRI
I <1 CXR, XR limb, XR pelvis
II* 1-5 IVU, XR lumbar spine,
NM (e.g. skeletal
scintigram), CT head & neck
III 5-10 CT chest and abdomen,
NM (e.g. cardiac)
IV >10 Some NM studies (e.g.
some PET)

* The average annual background dose in most parts of Europe falls in band II.

14
 COMMUNICATIONS WITH A DEPARTMENT OF CLINICAL RADIOLOGY

12 COMMUNICATIONS WITH A DEPARTMENT OF

CLINICAL RADIOLOGY

Referral for an imaging examination is generally regarded as a request for an

opinion from a specialist in radiology or nuclear medicine. The outcome of
this request for an opinion should be presented in the form of a report to
assist in the management of a clinical problem.

Request forms should be completed accurately and legibly in order to avoid

any misinterpretation. Reasons for the request should be clearly stated and
sufficient clinical details should be supplied to enable the imaging specialist to
understand the particular diagnostic or clinical problems to be resolved by
radiological investigation.

In some cases the best investigation for resolving the problem may be an
alternative imaging investigation.

If there is doubt as to whether an investigation is required or which

investigation is best, an appropriate specialist in radiology or nuclear medicine
must be consulted. Indeed, imaging departments are always pleased to
discuss investigations with referring doctors. Regular clinico-radiological
meetings provide a useful format for such discussion and are considered good
practice [27].

While it should be noted that these recommendations have been widely

endorsed, it is recognised that a few departments will adapt them according
to local circumstances and policies.

13 IMAGING TECHNIQUES

13.1 Computed tomography (CT)

CT is now quite widely available throughout Europe. Furthermore, there have

been recent important advances due to the development of spiral and
multislice CT, which allows the acquisition of a large amount of data from a
single breath hold. Such advances have opened up new diagnostic
opportunities, such as the use of multi-slice CT in the diagnosis of coronary
artery disease. Nevertheless, different hospitals will have their own policies
about accepting CT requests. It is worth remembering that CT imparts a
relatively high x-irradiation dose. Thus it is always worth considering
alternatives, especially in view of the increasing role of MRI. The UK National
Radiological Protection Board has published several general recommendations
with regard to CT in Protection of the patient in x-ray computed tomography
[26], and they are currently reviewing the advice.

Like all radiological requests, any CT referral which falls outside established
guidelines should be discussed with a radiologist. Because of the need to
minimise the extent of the examination (and thereby the cost and radiation
dose), it is helpful if the clinical notes and previous imaging investigations are
available for review by the imaging department at the time of the proposed
CT.

A few further points:

15
 • CT remains the optimal investigation for many clinical problems within
the chest and abdomen, despite the radiation risks.

• CT is still widely used for intracranial problems, especially

cerebrovascular accident and trauma.

• CT remains a simple method of staging many malignant diseases (e.g.,

lymphoma) and of monitoring the response to therapy.

• CT provides valuable pre-operative information about complex masses

and is widely used to investigate post-operative complications.

• CT allows accurate guidance for drainage procedures, biopsies, and

anaesthetic nerve blocks.

• CT has an important role in the management of trauma.

• CT images may be degraded by prostheses, fixation devices, etc.

• CT provides better anatomical detail in obese patients than US. In

thinner patients and children, US should be used whenever possible.

• CT of the abdomen imparts a radiation dose equivalent to about 500

chest x-rays.

13.2 Interventional radiology (including angiography and

minimal access therapy)

This area of radiology is now fully established. Most abscesses in the

abdomen are now treated by percutaneous drainage procedures using
radiological guidance. Likewise, the majority of liver biopsies is now
performed by radiologists (using US guidance). Lymph node biopsies are
routine in most US and CT units. While all departments of clinical radiology
have been undertaking angiography and associated procedures (e.g.,
angioplasty) for many years, new techniques are constantly developing.

New technology is rapidly widening the range of interventional radiology yet

further. Innovations include:

• Percutaneous vertebroplasty for collapsed vertebral bodies

• Percutaneous insertion of grafts for abdominal aortic aneurysms

• Various techniques to treat inoperable hepatic lesions (e.g.,

radiofrequency ablation under imaging control)

• Interventional MRI with ‘real-time’ imaging to allow monitoring of

therapeutic manoeuvres

These examples of recent innovations require close collaboration with clinical

colleagues. The precise arrangements vary considerably according to local
expertise and availability of equipment. There is continuing discussion at
national level about the best arrangement for these interventional procedures.

16
 IMAGING TECHNIQUES

Inevitably, requests for all such procedures call for detailed discussion
involving various specialists.

13.3 Magnetic resonance imaging (MRI)

There has been a substantial recent increase in the number of MRI systems
across Europe. Accordingly, there are numerous recommendations for the
use of MRI. Indeed, with the recent technical advances and increasing
experience, the role of MRI continues to expand, and the limiting factor for
further expansion is now often financial.

Since MRI does not use ionising radiation, MRI should be preferred in cases
where it would provide information of similar value to that provided by CT
(and when both are available). However, MRI is in danger of being subjected
to inappropriate demands, which may lead to long waiting times. Thus, all
requests for MRI should be agreed with a radiologist.

A few further points:

• MRI usually provides more information than CT about intracranial, head

and neck, spinal and musculoskeletal disorders because of its high
contrast sensitivity and multiplanar imaging capability. This helps
clinicians to establish the diagnosis and institute appropriate
management with greater confidence. It is increasingly being used in
oncology.

• Major recent advances include: breast and cardiac MRI; angiographic and
interventional techniques; magnetic resonance cholangiopancreatography
(MRCP) and other fluid-sensitive MRI techniques; functional MRI imaging
of the brain. However, many of these techniques await full evaluation.

• MRI is not approved during the first trimester of pregnancy. However, it

may well prove to be safer than some of the alternative options. All
imaging of pregnant women should be discussed with the radiology
department.

• There are some definite contraindications to the use of MRI: metallic

foreign bodies (FBs) in the orbits, aneurysm clips, pacemakers, cochlear
implants, etc. Furthermore, MRI will give reduced image quality close to
prostheses. The full list of contraindications is provided in several
textbooks and monographs. Any uncertainty about contraindications
should be discussed with the imaging department well in advance of the
proposed investigation.

13.4 Nuclear medicine (NM)

In some EU countries NM is an independent specialty and the use of unsealed

sources of radionuclides for diagnosis and therapy is restricted to NM
specialists. In some countries other specialists, usually radiologists, provide
NM services. Whatever the local arrangements, an experienced specialist will
be available to discuss the appropriate NM techniques for a given clinical
situation. The specialist will also be able to advise on which particular NM
investigation should be used. Accordingly, referring clinicians should indicate

17
 the precise clinical problem requiring investigation, because this will
determine which radionuclide (or alternative) investigation is used.

Despite some misconceptions, the radiation doses imparted by most NM

techniques compare favourably with those of many other imaging
investigations regarded as ‘safe’. As shown in Table 1 the effective dose
associated with most routine NM studies is considerably less than that for
abdominal CT.

There is particular value in the functional data that can be provided by NM

techniques. At a basic level, NM can determine whether a distended renal
pelvis shown by US is merely due to a capacious collecting system or is
caused by an obstructing lesion. The same investigation can provide data on
the percentage of overall renal function provided by each kidney. More
complex studies can indicate the ejection fraction of the left ventricle or the
distribution of blood flow to the cerebral cortex.

Positron emission tomography (PET) has recently made large strides, and its
availability is gradually increasing. Because of the short-lived nature of the
key radionuclides (the glucose analogue F-18 fluorodeoxyglucose, FDG, is
widely used), PET can only be offered at a reasonable distance from a
cyclotron and radionuclide pharmacy. PET can identify small foci of viable
tumours, so it offers exceptional opportunities in the staging of various
cancers (e.g., bronchus) and in cancer follow-up (e.g., lymphoma), where
other imaging techniques may be unable to distinguish between residual
fibrotic masses and active disease. PET can also provide unique data about
brain metabolism and myocardial viability, and there are several research
units studying these aspects. Over the next few years there will be an
increasing uptake of PET into clinical practice, and its potential use is flagged
for certain clinical problems in the ensuing recommendations.

13.5 Nuclear medicine therapy

Although it is not within the scope of these referral Guidelines, it is worth

remembering that NM has an important role in the treatment of both benign
and malignant disease. The thyroid gland is still the most important target,
but the field is rapidly expanding: other indications include neuroendocrine
tumours, painful skeletal metastases, some arthropathies, polycythaemia, and
malignant effusions. NM treatment options are being investigated in the
leukaemias/lymphomas and some liver tumours.

13.6 Ultrasound (US)

Since the previous edition of these Guidelines, most departments of clinical

radiology have experienced a large increase in referrals for US examinations.
During this period US equipment and expertise have advanced and the scope
of referrals (colour Doppler, power Doppler, transvaginal gynaecological work,
etc.) has widened. These trends are to be welcomed because US does not
employ ionising radiation. However, there is scant evidence that the increase
in US referrals has been accompanied by much reduction in referrals for other
radiological investigations and a consequent reduction in total radiation dose
to the public. The one notable exception is the IVU, which is required much
less often since the advent of US. However, because US in non-invasive, the
total number of patients investigated with urological problems has increased.

18
 GLOSSARY

Departments of clinical radiology have developed different local policies for

dealing with the increasing US workload.

The actual acquisition of US images has to be undertaken by an experienced

operator; even such an operator may not be able to gain perfect images in
every patient. For example, US can be difficult and unsatisfactory in obese
patients. Furthermore, the distribution of bowel gas may mask certain
features. Nevertheless, the cheap, quick, reliable, and non-invasive nature of
US makes it an excellent initial investigation for a wide range of clinical
referrals. Accordingly, US has been recommended as the investigation of
choice whenever appropriate.

Since US avoids ionising radiation and is relatively inexpensive, it is often

recommended where more expensive studies (e.g. CT) cannot be justified or
resources are limited. Conversely, it is difficult to refuse a request for US on
grounds of invasiveness or expense. There is thus a danger of US
departments being overloaded with requests that may be on the margins of
appropriateness. Referring clinicians therefore still have a duty to consider
carefully whether each request for US is justified and whether the result (e.g.,
the presence of gallstones) will affect management (see Introduction: Why
are guidelines needed?).

14 GLOSSARY

Abbreviation Definition
ACTH Adrenocorticotrophic hormone
AVM Arteriovenous malformation
AXR Abdominal radiograph
COPD Chronic obstructive pulmonary disease
CSF Cerebrospinal fluid
CT Computed tomography
CTA Computed tomographic angiography
CTM Computed tomographic myelography
CXR Chest radiograph
DEXA Dual energy x-ray absorptiometry
DMSA Dimercaptosuccinic acid
DSA Digital subtraction angiography
EDTA Ethylenediaminetetraacetiacid
ERCP Endoscopic retrograde cholangiopancreatography
ERNVG Equilibrium radionuclide ventriculography
FB Foreign body
FDG F-18-fluorodeoxyglucose
FDG-PET Positron emission tomography using F-18
fluorodeoxyglucose

19
FNAC Fine-needle aspiration cytology
GA General anaesthesia
GFR Glomerular filtration rate
GI Gastrointestinal
HDU High dependency unit
HIDA Hydroxy iminodiacetic acid
HRCT High resolution computed tomography
HRT Hormone replacement therapy
ITU Intensive treatment unit
IUCD Intrauterine contraceptive device
IV Intravenous
IVC Inferior vena cava
IVU Intravenous urogram
LP Lumbar puncture
LV Left ventricle
MAG3 Mercaptylacetyltriglycerine
MCUG Micturating cystourethrogram
MEN Multiple endocrine neoplasia
MIBG Metaiodobenzylguanidine
MRA Magnetic resonance angiography
MRCP Magnetic resonance cholangiopancreatography
MRI Magnetic resonance imaging
MS Multiple sclerosis
MUGA Multiple-gated acquisition (radionuclide angiography)
NAI Non-accidental injury
NM Nuclear medicine
NRPB National Radiological Protection Board
OIH Ortho-iodohippurate
OPG Orthopantomographic
PET Positron emission tomography
PSA Prostate-specific antigen
PTA Percutaneous transluminal angioplasty
PUJ Pelvic-ureteric junction
PV loss Vaginal bleeding
rCBF Regional cerebral blood flow
RV Right ventricle
SAH Subarachnoid haemorrhage

20
 SELECTED BIBLIOGRAPHY

SOL Space occupying lesions

SPECT Single photon emission computed tomography
SVC Superior vena cava
SXR Skull radiograph
T N M staging A system of clinicopathological evaluation of tumours
based on the extent of tumour involvement at the
primary site (T), lymph node (N) and metastasis (M)
TIA Transient ischaemic attack
TIPS Transjugular intrahepatic portosystemic shunt
TOE Transoesophageal echocardiography
Triple assessment Clinical examination/imaging/needle biopsy
performed in the clinical suspicion of breast cancer
TRUS Transrectal ultrasonography
US Ultrasonography
UTI Urinary tract infection
V:Q Ventilation-perfusion scintigraphy
VSD Ventriculoseptal defect
WBC White blood cell
XR Radiograph

15 SELECTED BIBLIOGRAPHY

1 Royal College of Radiologists. Making the best use of a department of

clinical radiology:Guidelines for Doctors. Fourth edition. Royal College of
Radiologists (ISBN 1 872599 37 0). London, 1998.

2 European Union. Council Directive 97/43/Euratom of 30 June 1997 on

health protection of individuals against the dangers of ionizing radiation in
relation to medical exposure (OJ L 180, 9.7.1997, p. 22).

3 Roberts, C. J. ‘Towards the more effective use of diagnostic radiology. A

review of the work of the RCR Working Party on the more effective use of
diagnostic radiology 1976–86’. Clin Radiol 1988, 39:3–6.

4 National Radiological Protection Board and The Royal College of Radiologists.

Patient dose reduction in diagnostic radiology (ISBN 0 85951 327 0). HMSO
London, 1990.

5 RCR Working Party. ‘A multi-centre audit of hospital referral for radiological

investigation in England and Wales’. BMJ 1991, 303:809–12.

6 US Department of Health and Human Services, Agency for Health Care

Policy and Research. Acute Pain Management, Rockville, MD: The Agency,
1993. Clinical Practice Guideline No 1.

21
7 SIGN 50: A guideline developer’s handbook. Scottish Intercollegiate
Guidelines Network, February 2001.

8 RCR Working Party. ‘Influence of the Royal College of Radiologists’

Guidelines on hospital practice: a multi-centre study’. BMJ 1992, 304:740–43.

9 Roberts, C. J. ‘The RCR multi-centre guideline study. Implications for clinical

practice’. Clin Radiol 1992, 45:365–8.

10 NHS Executive. Clinical guidelines: using clinical guidelines to improve

patient care within the NHS (96CC0001). NHS Executive, Leeds, 1996.

11 Sackett, D. L., Richardson, W. S., Rosenberg, W., Haynes, R. B. Evidence-

based medicine (ISBN 0 443 05686 2). Churchill Livingstone, Edinburgh,
1997.

12 Dixon, A. K. ‘Evidence-based radiology’. Lancet 1997, 350:509–12.

11 NHS Executive. NHSE Clinical guidelines (annex to letter). NHS Executive,

London, September 1996.

13 Audit Commission. Improving your image: how to manage radiology

services more effectively. (ISBN 0 11 8864 14 9). HMSO, London, 1995.

14 Godwin, R., de Lacey, G., Manhire, A. (eds). Clinical audit in radiology

(ISBN 1 87259919 2). Royal College of Radiologists, London, 1996.

15 The ionising radiation (protection of persons undergoing medical

examinations of treatment — POPUMET) regulations (SI1988/778). HMSO,
London, 1988.

16 Field, M. J., Lohr, K. N. (eds). Guidelines for clinical practice: from

development to use. National Academy Press, Washington D.C., 1992.

17 NHS Management Executive. Improving clinical effectiveness: clinical

guidelines 1993 (EL(93)115). NHS Management Executive, London, 1993.

18 Dubois, R.W. ‘Should radiologists embrace or fear practice guidelines?’

Radiology 1994, 192:43–46A.

19 Grimshaw, J. M., Freemantle, N., Wallace, S., et al. ‘Developing and

implementing clinical practice guidelines’. Effective health care 1994, 8:1–12.

20 Grimshaw, J. M., Russell, I. T. ‘Achieving health gain through clinical

guidelines: 1. Developing scientifically valid guidelines’. Quality in health care,
1993, 2:243–8.

21 Eccles, M., Clapp, Z., Grimshaw, J., et al. ‘North of England evidence-
based guidelines development project: methods of guideline development’.
BMJ 1996, 312, 760–62.

22 Cluzeau, F., Littlejohns, P., Grimshaw, J. M., Feder, G. Appraisal

instrument for clinical guidelines. St George’s Medical School, London, 1997.

23 American College of Radiology. Appropriateness criteria for imaging and

treatment decisions. American College of Radiology, Reston, Virginia, US,
1995.

24 Bury, B., Hufton, A., Adams, J. ‘Radiation and women of child-bearing

potential’. BMJ 1995, 310:1022–3.

22
 SELECTED BIBLIOGRAPHY

25 National Radiological Protection Board. ‘Board statement on diagnostic

medical exposures to ionising radiation during pregnancy and estimates of
late radiation risks to the UK population’. Documents of the NRPB 1993, 4:1–
14.

26 National Radiation Protection Board/RCR/College of Radiographers.

Diagnostic medical exposures: advice on exposure to ionising radiation during
pregnancy. NRPB, Didcot, 1998.

27 National Radiological Protection Board. Protection of the patient in x-ray

computed tomography, (ISBN 0 85951 345 8), HMSO, London, 1992.

28 Leung, D.P.Y., Dixon, A.K. ‘Clinico-radiological meetings: are they

worthwhile?’ Clin Radiol 1992, 46:279–80.

The Guidelines Development Steering Group was constituted by:

Gillian Needham (Chairman)

Wolfgang Becker (EANM, until February 2002)
Fritz Cörstens (EANM, from February 2002)
Hans Ringertz (EAR)
Antonio Cuocolo (UEMS, NM Section)
Bruno Silberman (UEMS, Radiology Section)
Peter Armstrong (PRCR, until September 2001)
Martin Eccles (Guideline Methodologist, Newcastle University)
Iain McCall (Dean, Faculty of Clinical Radiology, RCR, until September 2001)
Mike Dean (Dean, Faculty of Clinical Radiology, RCR, from September 2001)

The Project Team (Aberdeen) was constituted by:

Gillian Needham
Jeremy Grimshaw (until September 2001)
Miriam Brazzelli (until December 2001)
Margaret Astin
Jill May

The RCR Project Team was constituted by:

Gillian Needham
Iain McCall
Mike Dean (from September 2001)
Nan Parkinson
John Vandridge-Ames
Niree Phillips (until June 2001)

Gillian Needham on behalf of the Guidelines Steering Group.

23
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

A. Head (including
ENT problems)

Congenital disorders MRI Indicated Definitive exam for all malformations. CT may be 0
[B] needed to define bone and skull base anomalies.
Sedation or GA may be required for infants and
young children.
(For children see
section M) (For congenital disorders in children see M01 and
A01 M02)
Acute stroke CT Indicated A policy of CT for most strokes as soon as reasonably II
[diagnosis B, possible is to be encouraged, but at least within 48
treatment A] hours, as this will ensure accurate diagnosis of the
cause, site, and appropriate primary treatment and

A. Head (including ENT problems)

secondary prevention.
MRI Specialised MRI should be considered in young patients with 0
investigation stroke, in patients presenting late where it is essential
[B] to know whether they have previously had a
haemorrhage, and in suspected posterior fossa stroke
in patients in whom it is important to demonstrate the
site of the stroke lesion.
US carotids Indicated only Should only be performed in: (1) those with full 0
in specific recovery in whom carotid endarterectomy is
circumstances contemplated for secondary prevention; (2) suspected
(See also N01, N02) [B] dissection; or (3) young patients, whether disabling or
A02 non-disabling ischaemic stroke.
Transient ischaemic CT Indicated May be normal. Can detect established infarction and II
attack (TIA) [B] haemorrhage and exclude disease processes that can
mimic stroke syndromes, such as glioma,
extracerebral haemorrhage, and cerebritis.
US carotids Indicated To assess suitability for carotid endarterectomy or 0
[B] angioplasty. Angiography, MRA, and CTA are
(See also B05) alternatives to show the vessels. MRI and NM can be
A03 used to show function.
Demyelinating and MRI Indicated MRI is viewed as the most sensitive and specific 0
other white matter [A] investigation for establishing a diagnosis of multiple
disease sclerosis. The diagnosis is made by demonstrating
dissemination of clinical events and lesions in space
A04 and time.
Space occupying MRI Indicated MRI is more sensitive for early tumours, in resolving 0
lesion (SOL) [B] exact position (useful for surgery), and for posterior
fossa lesions. MRI may miss calcification.
CT Indicated CT is often sufficient in supratentorial lesions. II
A05 [B]

24 25
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Headache: acute, CT Indicated The clinical history is critical. A clinician should be II
severe; subarachnoid [B] able to diagnose patients who have classical migraine
haemorrhage (SAH) or cluster headaches without CT. SAH headache
comes on typically in seconds, rarely in minutes, and
almost never over more than 5 minutes. CT will
provide evidence of haemorrhage in up to 98% of
patients with SAH if performed on a modern scanner
within the first 48 hours of ictus. An LP should still be
performed on all patients (delayed 12 hours after ictus
for xanthochromia) with suspected SAH but with
negative CT. CT is indicated in patients with acute-
onset headache with focal neurological signs, nausea
or vomiting, or GCS (Glasgow Coma Score) below 14.
An LP is the diagnostic test of choice for meningitis
unless there are focal signs or a significantly
depressed level of consciousness.

A. Head (including ENT problems)

MRI/NM Specialised MRI is better than CT for inflammatory causes. SPECT 0/II
investigation may be the most sensitive investigation for
[C] encephalitis and can provide evidence of circulatory
A06 derangement in migraine.
Headache: chronic CT/MRI Indicated only In the absence of focal features imaging is not usually II/0
in specific useful. The following features significantly increase the
circumstances odds of finding a major abnormality on CT or MRI:
[C] • Recent onset and rapidly increasing frequency and
severity of headache
• Headache causing to wake from sleep
• Associated dizziness, lack of coordination, tingling
or numbness
(For headache in children see M08)
(See also A13 below)
SXR, XR sinus, Indicated only XR is of little use in the absence of focal signs/ I/I/I
(For children see XR cervical in specific symptoms.
section M) spine circumstances
A07 [B]
Pituitary and MRI Specialised Urgent referral when vision is deteriorating. 0
juxtasellar problems investigation
[B]
SXR Not indicated Patients who require investigation need MRI or CT. I
A08 [C]
Posterior fossa signs MRI Indicated MRI is the investigation of choice. CT is often 0
A09 [A] degraded by beam hardening artefacts.
Hydrocephalus, CT Indicated CT is adequate for most cases; MRI is sometimes II
shunt function [B] necessary and may be more appropriate in children.
US is first choice for infants.
(For hydrocephalus in children see M06)
(For children see XR Indicated If there is evidence of hydrocephalus on CT, XR can I
section M) [C] demonstrate the whole valve system.
A10

26 27
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Middle or inner ear CT Specialised Evaluation of these symptoms requires ENT, II
symptoms (including investigation neurological, or neurosurgical expertise.
vertigo) [B]
A11
Sensorineural hearing Specialised MRI is much better than CT, especially for acoustic 0
MRI
loss investigation neuromas.
[B]
(For children see (For hearing loss in children see M05)
section M)
A12
Sinus disease XR sinus Indicated only Acute sinusitis can be diagnosed and treated I
in specific clinically. If it persists past 10 days on appropriate
circumstances treatment, XR sinus may be required. Signs on XR
[B] sinus are often non-specific and encountered in
asymptomatic individuals.
(For sinus disease in children see M09)

A. Head (including ENT problems)

CT sinus Specialised CT is useful to demonstrate the presence and II
investigation distribution of disease and sinonasal anatomy. Low-
[B] dose technique is desirable. CT is indicated for failure
(For children see of maximal medical treatment, development of
section M) complications (such as orbital cellulitis), or if
A13 malignancy is suspected.
Dementia and memory CT Indicated only Yield is low, even in younger patients; neurological II
disorders, first-onset in specific signs and rapid progression increase it. Over the age
psychosis circumstances of 65, CT can be reserved for patients with an onset
[A] within the last year or an atypical presentation, rapid
unexplained deterioration, unexplained focal
neurological signs or symptoms, a recent head injury
(preceding the onset of dementia), or urinary
incontinence and/or gait ataxia early in illness.
MRI Not indicated More sophisticated examinations (MRI, SPECT) have 0
NM [B] no proven clinical value, although they may be used II
in research.
SXR Not indicated SXR should only ever be used to show clinically I
A14 [A] relevant abnormalities of the skull bones.
Orbital lesions CT Specialised CT remains the investigation of choice. MRI may be of II
investigation value if CT is unhelpful or gives insufficient detail.
[A] Consider US for intraocular lesions.
XR Not indicated Suspected orbital lesions require specialist referral. I
A15 [A]
Orbital lesions: CT Specialised CT is indicated when orbital trauma may be II
trauma investigation combined with major facial fracture. If a less severe
[A] blowout fracture is suspected, CT is carried out only if
A16 the patient is a candidate for surgery.

28 29
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Orbital lesions: CT Specialised Indicated when XR fails to show a strongly suspected II
suspected foreign investigation foreign body which may not be metallic, when
body [A] multiple foreign bodies are present, or when it is not
certain whether a foreign body already demonstrated
is intraocular.
XR orbits Indicated A single ‘soft’ lateral XR is the only projection I
[A] required to exclude a metallic foreign body; eye-
moving images are only for confirmation of the
intraocular position of a foreign body once
demonstrated. Prior to an MRI study a
posteroanterior XR is adequate to exclude a significant
metallic foreign body. If a foreign body is confirmed
CT may be required by some specialists.
US Indicated US may be indicated for radiolucent foreign bodies or 0
A17 [B] where XR is difficult.

A. Head (including ENT problems)

Acute visual loss: SXR Not indicated Specialists can diagnose many cases without resorting I
visual disturbances [A] to imaging.
MRI/CT Specialised MRI is preferable for suspected lesions of the optic 0/II
investigation chiasm. CT is preferable for orbital lesions.
[A]
Cerebral Specialised Specialist referral is indicated. III
angiography investigation
A18 [A]
Epilepsy (adult) MRI Specialised Structural imaging is the technique of choice. Higher 0
investigation soft-tissue resolution and multiplanar capability give
[B] greater sensitivity and specificity for the identification
of small cortical lesions. Particularly valuable in the
evaluation of partial epilepsy, e.g. temporal lobe
epilepsy.
(For epilepsy in children see M04)
CT Specialised Following trauma. CT may complement MRI in the II
investigation characterisation of lesions, e.g. calcification.
[B]
NM Specialised Ictal SPECT or interictal PET is useful in the planning II
investigation of epilepsy surgery when MRI is negative or its results
(For children see [B] conflict with EEG or neurophysiological evidence.
section M) Regional cerebral blood flow (rCBF) agents are also of
A19 value.

30 31
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

B. Neck (for spine see

sections C & K)
Soft tissues

Thyroid nodules US Indicated only US is excellent for differentiating between thyroid and 0
in specific extrathyroid masses, for guiding aspiration or biopsy
circumstances (particularly in difficult-to-palpate or small thyroid
[B] nodules), and for the detection of associated
lymphadenopathy in thyroid malignancy. While US
can be specific for malignancy, it has poor sensitivity.
In generalised thyroid enlargement or multinodular

B. Neck (for spine see sections C & K)

goitre US readily shows retrosternal extension; real-
time studies show effect of neck extension, etc. CT/
MRI is needed to demonstrate full retrosternal extent
and tracheal compromise. NM has no role in the
initial evaluation of thyroid nodules.
US-guided Indicated Thyroid nodules are extremely common; the majority 0/0
FNAC/FNAC [B] are benign. Conventional fine-needle aspiration
(FNAC) (without imaging) is the most cost-effective
B01 initial investigation.
Thyrotoxicosis NM Indicated NM can differentiate between Graves’ disease, toxic II
[B] nodular goitre, and subacute thyroiditis. Provides
functional information about nodules. Also useful in
B02 thyroiditis.
Ectopic thyroid tissue NM Indicated NM excellent for small ectopic rests of thyroid tissue. II
(e.g. lingual thyroid) [C]
B03

Hyperparathyroidism US/NM/CT/ Specialised Seek advice. Diagnosis made on clinical/biochemical 0/II/

MRI investigation grounds. Imaging can assist in pre-operative II/0
[C] localisation but may not be needed by experienced
surgeons. Much depends on local policy and available
technology and expertise. US, NM, CT, and MRI are
all accurate in the un-operated neck. MRI is probably
evolving as the best investigation for ectopic and
residual tumours. Super-selective venography for
B04 sampling after previous imaging may be useful.
Asymptomatic US carotids Indicated only US not usually valuable as evidence suggests that 0
carotid bruit in specific surgery is not recommended for asymptomatic carotid
circumstances stenosis.
B05 [B]
Swallowed or inhaled Lateral XR soft Indicated only The majority of foreign bodies are not seen on XR. The I
foreign body tissues of neck in specific clinical history and findings are more accurate
circumstances indicators of the presence of a foreign body. Direct
[B] examination of the oropharynx, laryngoscopy, and
(See also K27–K29)
endoscopy are the investigations of choice.
(For children see
section M) (For swallowed or inhaled foreign body in children
B06 see M26 and M31)

32 33
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Neck mass of unknown US Indicated First-line investigation for characterisation of neck 0
origin [C] mass. May be combined with FNAC.
CT/MRI Indicated only CT/MRI may be indicated if the full extent of the II/0
in specific lesion is not determined by US, for identifying other
circumstances lesions, and for staging.
B07 [C]
Salivary obstruction US/Sialogram Indicated For intermittent, food-related swelling. MR 0/II
[C] sialography may be preferred in some centres.
XR Indicated only Where there is calculus in the floor of the mouth, XR I
in specific may be all that is required.
circumstances
B08 [C]
Salivary mass US Indicated US is the initial investigation of choice for a suspected 0
[B] salivary mass; it can be combined with FNAC, if

B. Neck (for spine see sections C & K)

necessary. It is extremely sensitive and has high
specificity.
MRI/CT Specialised Whenever deep lobe involvement or extension into 0/II
investigation deep spaces is suspected, MRI or CT should be carried
B09 [B] out.
Dry mouth: US/ Specialised Not commonly required. Sialogram may be 0/II/
connective tissue Sialogram/ investigation diagnostic, but NM provides better functional II
disease NM [C] assessment. MR sialography is also used here.
B10
Temporomandibular MRI Specialised XRs do not often add information as the majority of 0
joint dysfunction investigation temporomandibular joint problems are due to soft
[B] tissue dysfunction (usually subluxation of the intra-
articular disk) rather than bony changes, which
B11 appear late and are often absent in the acute phase.

34 35
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

C. Spine (for trauma

see section K)
General
Congenital disorders MRI Indicated MRI defines all spinal malformations and excludes 0
[B] associated thecal abnormality. CT may be needed to
delineate bone detail. Sedation or GA may be required
for infants and young children.
(For congenital disorders in children see M01, M02)
(For children see XR Specialised E.g. full-length standing XR for scoliosis. I
section M) investigation
C01 [C] (For congenital disorders in children see M01, M02)
Myelopathy: tumours, MRI Indicated MRI is the initial investigation of choice for all spinal 0

C. Spine (for trauma see section K)

inflammation, infection, [B] cord lesions, to evaluate cord compression and to give
infarction, etc. an indication of post-operative prognosis.
CT/CTM Specialised CT may be needed if better bony detail is required. CT II/II
investigation myelography (CTM) only if MRI is unavailable or
[B] impossible.
NM Specialised NM is still widely used to screen for metastases and to II
C02 investigation [B] identify focal skeletal lesions (such as osteoid osteoma).

Cervical spine
Possible atlanto-axial XR Indicated A single lateral cervical spine XR with the patient in I
subluxation [B] supervised comfortable flexion should reveal any
significant subluxation in patients with rheumatoid
arthritis, Down’s syndrome, etc.
MRI Specialised MRI in flexion/extension shows effect on cord when 0
C03 investigation [B] XR is positive or neurological signs are present.
Neck pain, brachialgia, XR Indicated only Neck pain generally improves or resolves with I
degenerative change in specific conservative treatment. Degenerative changes begin in
circumstances [B] early middle age and are often unrelated to symptoms.
MRI Specialised Consider MRI and specialist referral when pain affects 0
investigation lifestyle or when there are neurological signs. CT
[B] myelography may occasionally be required to provide
further delineation or when MRI is unavailable or
C04 impossible.

Thoracic spine
Pain without trauma: XR Indicated only Degenerative changes are invariably present from I
degenerative disease in specific middle age onwards. Imaging is rarely useful in the
circumstances absence of neurological signs or pointers to metastases
[C] or infection. Consider more urgent referral in elderly
patients with sudden pain to show osteoporotic
collapse or other forms of bone destruction. Consider
NM for possible metastatic lesions.
MRI Specialised MRI may be indicated if local pain persists or is 0
C05 investigation [C] difficult to manage, or if there are long tract signs.

36 37
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

Lumbar spine
Chronic back pain with XR Indicated only Degenerative changes are common and non-specific. II
no pointers to infection in specific Main value of XR is in younger patients (e.g. < 20
or neoplasm circumstances years) with spondylolisthesis, ankylosing spondylitis,
[C] etc., or in older patients (e.g. > 55 years). In cases
where management is difficult, negative findings may
be helpful.
MRI Specialised When symptoms persist or are severe or where 0
investigation management is difficult, MRI is considered the first-
[C] choice investigation. Imaging findings need to be
interpreted with caution because many imaging
‘abnormalities’ occur with high frequency in
asymptomatic individuals and therefore have an
uncertain relationship with back pain. The significance
of imaging findings depends upon correlation with
C06 clinical signs. Negative findings may be helpful.

C. Spine (for trauma see section K)

Back pain with possible MRI Indicated Together with urgent specialist referral, MRI is 0
serious features such as: [B] usually the best investigation. Imaging should not
• Onset at < 20 or delay specialist referral.
> 55 years
• Sphincter or gait (For back pain in children see M11)
disturbance
• Saddle anaesthesia
• Severe or progressive
motor loss
• Widespread
neurological deficit
• Previous carcinoma
• Systemic unwellness NM Indicated NM is also widely used for possible bone destruction II
• HIV [B] due to metastases, where infection is suspected, or in
• Weight loss some cases of chronic pain.
• Intravenous drug
abuse ‘Normal’ plain XR may be falsely reassuring.
• Steroids
• Structural deformity
• Non-mechanical pain
(For children see
section M) C07
Acute back pain: disk XR Indicated only Acute back pain is usually due to conditions that II
herniation; sciatica with in specific cannot be diagnosed on XR (osteoporotic collapse is
no adverse features circumstances an exception).
[C]
‘Normal’ plain XR may be falsely reassuring.
(For acute back pain in children see M11)
MRI/CT Specialised Demonstration of disk herniation requires MRI or CT 0/III
investigation and should be considered after failed conservative
[B] management. MRI is generally preferred (wider field
of view visualising the conus, post-operative changes,
etc.). Clinico-radiological correlation is important as a
significant number of disk herniations are
(For children see
asymptomatic.
section M)
C08 (For acute back pain in children see M11)

38 39
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

D. Musculoskeletal
system
Osteomyelitis XR Indicated [C] Initial investigation. I
MRI Specialised MRI accurately demonstrates infection, especially in 0
investigation the spine.
[C]
CT Specialised CT is valuable for demonstration of sequestra. II
investigation
[C]
US Indicated US may be valuable in acute osteomyelitis to 0
[C] demonstrate subperiosteal abscess, but there is a high
false negative rate.
NM Specialised The two- or three-phase skeletal scintigram is more II-III
investigation sensitive than XR in detecting suspected focal

D. Musculoskeletal system
[C] osteomyelitis. If osteomyelitis is suspected but there
are no localising signs or symptoms, a skeletal
scintigram is useful. Findings on a skeletal scintigram
are not specific and further specialist NM imaging
with alternative agents may be required.
White cells: the use of Tc-99m-HMPAO or In-111-
labelled white cells may be useful in confirming
infection in bone or joint. False negative results may
D01 be encountered in the spine.
Primary bone XR Indicated XR should be carried out where there is bone pain that I
tumour [B] is not resolving.
MRI Specialised If the XR appearances are suggestive of primary bone 0
investigation tumour, referral to a specialist centre should not be
[B] delayed.
MRI is the investigation of choice for local staging.
NM Indicated If the XR appearances are suggestive of primary bone II
[B] tumour, the acquisition of skeletal scintigraphy
should not delay referral to a specialist centre. The
scintigram may overestimate local tumour extent. The
role of FDG-PET remains to be clarified.
CT Specialised CT may improve diagnostic information in some II
investigation tumours, such as osteoid osteoma, and demonstrate
[B] intratumoral calcification and ossification.
CT-guided biopsy of primary bone tumours should be
carried out in specialised bone tumour centres where
histological expertise and knowledge of surgical
approach is available.
US Specialised US-guided biopsy of certain superficial primary bone 0
investigation tumours should be carried out in specialised bone
(See also L44, L45) [B] tumour centres where histological expertise and
D02 knowledge of surgical approach is available.

40 41
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Known primary MRI Indicated More sensitive and specific than NM, MRI is the 0
tumour, skeletal [B] primary investigation of choice, particularly in the
metastases axial skeleton. May underestimate some peripheral
lesions.
NM Indicated A sensitive test, but correlative imaging is required to II
[B] increase specificity.
NM is useful for assessing the presence and extent of
skeletal metastases in patients with known primary
cancers. The skeletal scintigram is insensitive in
assessing the extent of myeloma. It may also be used
to assess response to treatment, although the flare
phenomenon may suggest disease progression if
performed too soon after systemic therapy. It is
usually only appropriate to repeat a skeletal
scintigram within 6 months if there are new
symptoms.
XR skeletal Not indicated XRs are indicated only for specific focal symptomatic II
D03 survey [B] areas or for correlation with a NM examination.

D. Musculoskeletal system
Soft tissue mass MRI Indicated Provides best local staging and can provide a tissue 0
tumour [B] diagnosis in a proportion of patients.
US Indicated US can answer specific questions (e.g. cystic/solid) 0
[C] and can monitor progress of benign masses such as
D04 haematomas.
Bone pain XR Indicated Local view of the symptomatic area. I
[C]
MRI Indicated MRI is appropriate if pain persists with normal XR or 0
[C] apparently normal NM. If pain is diffuse, MRI is not
always practicable (depends on the technical
capabilities of the MRI unit). MRI may also provide
further information when XR and/or NM findings are
abnormal.
NM Indicated If pain persists with normal XR or equivocal and II
[C] abnormal XR in specific circumstances (e.g. suspected
osteoid osteoma, osteomyelitis, or metastases).
CT Specialised To define bony anatomy in areas of abnormality on II
investigation XR/MRI/NM, especially if bone biopsy is indicated.
D05 [C]
Myeloma MRI Specialised Sensitive, limited to spine, pelvis, and proximal 0
investigation femora. Particularly useful in non-secretory myeloma
[B] or in the presence of diffuse osteopenia. Can be used
for tumour mass assessment and follow-up.
XR skeletal Indicated For staging and identifying lesions which may benefit I-II
survey [C] from radiotherapy. Survey can be limited to specific
areas for follow-up.
NM Not indicated Skeletal scintigraphy is often negative and II
[B] underestimates disease extent; consider bone marrow
D06 studies.

42 43
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Metabolic bone disease NM Indicated Skeletal scintigraphy may be useful in differentiating II
[C] causes of hypercalcaemia, e.g. metastases and
hyperparathyroidism, and of raised alkaline
phosphatase, e.g. Paget’s disease and metastases.
XR Indicated May be helpful in differentiating new from old II
[C] vertebral fractures or identifying a different cause of
pain unrelated to osteoporosis. Correlation with NM
will be required.
DEXA Indicated Measurement of bone density. DEXA or quantitative II
[A] CT provides objective measurements of bone mineral
D07 content.
Osteomalacia XR Indicated Localised XR to establish cause of local pain or I
[B] equivocal lesion identified on NM.
NM Specialised Can show increased activity and some local II
(See also D09) investigation complications, such as pseudo-fractures.
D08 [C]
Lateral XR Indicated Lateral views will demonstrate compression fractures. I-II

D. Musculoskeletal system
Pain:
osteoporotic collapse thoracic and [B] NM or MRI more useful in distinguishing between
(See also D08) lumbar spine recent and old fractures and can help exclude
D09 pathological fractures.
Arthropathy: XR affected Indicated May be helpful to determine cause, although erosions I
presentation joint [C] are a relatively late feature.
XR hands/feet Indicated In patients with suspected rheumatoid arthritis, XR I
[C] feet may show erosions even when symptomatic
hand(s) appear normal.
XR multiple Indicated only Symptomatic joints only. II
joints in specific
circumstances
[C]
US/NM/MRI Specialised All can show acute synovitis. NM can show 0/II/
investigation distribution. MRI can show articular cartilage and 0
D10 [C] early erosions.
Arthropathy: XR Indicated only May be needed by specialist to assist management I
follow-up in specific decisions.
circumstances
D11 [C]
Painful shoulder XR Not indicated Degenerative changes in the acromioclavicular joints I
initially and rotator cuff are common.
D12 [C]

44 45
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Shoulder impingement XR Indicated only Pre-operative investigation. I
syndrome in specific
circumstances
[B]
MRI Specialised Has value in the demonstration both of bursal 0
investigation inflammatory change and the aetiology of associated
[B] abnormalities. Dynamic MRI or MRI in the abducted
position may be of diagnostic value in subacromial
impingement syndrome.
US Specialised Clinical diagnosis can be aided by US findings. 0
investigation
D13 [B]
Shoulder instability CT/MRI Specialised Glenoid labrum and synovial cavity are well II/0
investigation delineated by both techniques. Some gradient echo
[B] MRI techniques can show labrum well without
arthrography. Arthrography (with or without CT), US,
D14 and MRI may all be used in the diagnosis.

D. Musculoskeletal system
Rotator cuff tear Arthrography/ Specialised MRI has the advantage of providing a global I/0/0
US/MRI investigation assessment of structures around the shoulder and
[C] when combined with arthrography has the highest
accuracy.
D15 US valuable for demonstrating complete tears.
I
Sacroiliac XR sacroiliac Indicated May help in investigation of sero-negative
joint lesion joints [B] arthropathy. Sacroiliac joints are usually adequately
demonstrated on AP XR lumbar spine or pelvis.
0/II/
MRI/CT/NM Specialised MRI or CT or perhaps NM when XR is equivocal; MRI II
investigation can detect earlier than XR. Dynamic contrast
[C] enhancement may be useful. MRI is particularly
D16 useful in children and adolescents.
I
Hip pain: full or limited XR pelvis Indicated only XR and MRI only if symptoms and signs persist or
movement in specific there is a complex history.
circumstances
[C]
0
MRI Indicated only MRI is useful to demonstrate inflammation and MR
in specific arthrography for evaluation of acetabular labral tears
circumstances or loose bodies. Intra-articular local anaesthetic
[C] injections have still to be evaluated properly.
II
NM Not indicated May be helpful if XR is normal.
(For children see
initially
section M) This recommendation does not apply to children.
[B]
D17 (For hip pain in children see M18, M21)
I
Hip pain: avascular XR pelvis Indicated Abnormal in established disease.
necrosis [B]
0
MRI Indicated MRI is the most sensitive in the detection of early
[B] avascular necrosis and will demonstrate its extent.
II/II
NM/CT Specialised The use of pinhole collimator or SPECT is important.
investigation
D18 [B]
I

46 47
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Knee pain XR Indicated only Symptoms frequently arise from soft tissues and these
without locking or in specific will not be demonstrated on XR. Osteoarthritis
restriction of circumstances changes are common. XR is needed when considering
movement D19 [C] surgery.
I
Knee pain with XR Indicated To identify radio-opaque loose bodies.
locking D20 [C]
0
Knee pain MRI Specialised MRI is only appropriate where there is a specific
investigation clinical management decision, e.g. arthroscopy being
[B] considered. MRI may also be required in defining the
extent of rheumatological disorders, e.g. rheumatoid
arthritis. Even in patients with definite clinical
abnormalities warranting intervention, some surgeons
find pre-operative MRI helpful in identifying
D21 unsuspected lesions.
I
Painful prosthesis XR Indicated XR is useful to detect established loosening.
[B]
II-III
NM Indicated Two- to three-phase skeletal scintigraphy is useful for

D. Musculoskeletal system
[B] diagnosing and differentiating infection and
loosening. A normal NM study excludes most late
complications. Further specialised NM studies can
help distinguish loosening from infection.
It may be difficult to differentiate post-surgical
changes from pathology in the early stages. If
infection is suspected, further, more specific imaging
may be required. Combined leukocyte and marrow
imaging is currently the technique of choice for peri-
prosthetic infection.
II
Arthrography Specialised Aspiration in conjunction with arthrography is useful
(aspiration/ investigation when findings are equivocal, when there is a high
biopsy) [B] clinical suspicion of infection, or when a cause of pain
is not established.
0
US Specialised Accurate for detection of peri-prosthetic abscess or
investigation superficial infection.
D22 [C]
I
Hallux valgus XR Indicated only Useful for assessment before surgery.
in specific
circumstances
D23 [C]
II/0/
Heel pain: NM/US/MRI Indicated only Calcaneal spurs are common incidental findings. 0
plantar fasciitis or in specific The cause of pain is rarely detectable on XR. Other
calcaneal spur circumstances imaging, NM, US, and MRI, are more sensitive in
[B] showing inflammatory change and should be used
selectively. The majority of patients should be
managed on the basis of clinical findings without
D24 imaging.

48 49
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

E. Cardiovascular system

Acute central chest CXR Indicated CXR must not delay admission to a specialised unit. I
pain: myocardial [B] CXR can assess heart size, pulmonary oedema,
infarction tumour, etc., and can exclude other causes.
E01 Departmental radiograph preferable.
Chronic ischaemic CXR Indicated only May be helpful only if signs or symptoms have I
heart disease in specific changed, when comparison with the CXR obtained at
and assessment after circumstances presentation.
myocardial infarction [B]
NM Indicated Appropriate method of determining prognosis/ II
(myocardial [B] diagnosis, ischaemic burden, and specific ischaemic
perfusion zone. Either pharmaceutical or exercise stress can be
imaging) used in conjunction with isotopes. Tl-201 imparts a
higher radiation burden but may be a better
prognostic/viability agent. Tc-99m has a higher
energy and allows concomitant assessment of LV

E. Cardiovascular system
contraction to be made via gated imaging. Particular
uses are:
• Prognostic assessment
• Diagnosis in atypical or asymptomatic individuals
• Assessing patients for revascularisation strategies
• Risk stratification prior to non-cardiac surgery
Angiography Indicated Only technique currently available for detailed III
[B] assessment of coronary artery anatomy. Essential
prerequisite for interventional strategies and
sometimes to establish diagnosis.
MRI Specialised The role of MRI perfusion is still to be evaluated. 0
investigation
[B]
NM Specialised Can assess both LV and RV function after myocardial III
(radionuclide investigation infarction. Echocardiography is the preferred
angiography: [B] technique for assessment of LV contraction, etc.
MUGA or
ERNVG)
US echo- Indicated Allows assessment of residual LV contraction, valves, 0
cardiography [A] and complications such as myocardial rupture. Can
easily be used sequentially, particularly if
E02 haemodynamic clinical deterioration is noted.

50 51
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Chest pain: CXR Indicated Mainly to exclude other causes; rarely diagnostic. I
aortic dissection [B]
US trans- Indicated TOE is a useful and accurate bedside technique, but 0
oesophageal [B] not as good as CT for aortic arch.
echo-
cardiography
(TOE)
CT Indicated CT with IV contrast is the most reliable and practical III
[B] technique.
MRI Specialised MRI is accurate and assesses any change in 0
investigation longitudinal extent, but practical difficulties can limit
E03 [B] imaging potential. Useful for sequential follow-up.
Pulmonary embolism CXR Indicated CXR should be the preliminary investigation to I
[B] demonstrate consolidation and pleural effusion, but a
normal CXR does not exclude a pulmonary embolus.
NM Indicated Ventilation/perfusion (V:Q) scintigraphy can be II
(ventilation/ [B] diagnostic if used selectively in patients without

E. Cardiovascular system
perfusion COPD or consolidation on CXR, or less often if used
scintigraphy) non-selectively. A normal perfusion scintigram
excludes clinically significant pulmonary emboli.
Spiral CT Indicated Spiral CT is the investigation of choice, is as accurate III
[B] as pulmonary angiography in the detection of
pulmonary emboli, and reliably excludes clinically
important pulmonary embolism. It is the investigation
of choice for patients with COPD or an abnormal
(See also N03, E13) CXR, and may be used following a non-diagnostic
E04 V:Q scintigram.
Pericarditis, pericardial US echo- Indicated Useful for assessment of concomitant pathology (e.g. 0
effusion cardiography [B] effusion). Can make assessment of size of pericardial
effusion, suitability for drainage, development of
tamponade, etc. Best for sequential follow-up.
CXR Indicated May reveal concomitant pathology (e.g. tumour) or I
(including left [B] calcification in pericardium.
E05 lateral)
Suspected valvular CXR Indicated Used for initial assessment and when there is a change I
cardiac disease [B] in the clinical picture.
US echo- Indicated Best method of sequential follow-up. TOE may be 0
cardiography [B] needed for prosthetic valves.
MRI Indicated Can be useful but is generally impracticable. 0
[B] Contraindicated for many prosthetic valves. Useful in
E06 the context of congenital heart disease.
Clinical deterioration US Indicated US may show remediable complications 0
following myocardial echo- [B] (ventriculoseptal defect, papillary rupture, aneurysm,
infarction cardiography etc.).

CXR Indicated I
E07 [B]

52 53
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Hypertension CXR Indicated Assesses cardiac size and possible associated I
[B] pathology such as coarctation or rib erosion from
collaterals.
US echo- Indicated Most practical method of assessing LV hypertrophy. 0
cardiography [B]
MRI Specialised Most accurate method of assessing LV hypertrophy. 0
investigation
E08 [B]
Suspected CXR Indicated Globular cardiac silhouette suggestive of dilated I
cardiomyopathy, [B] cardiomyopathy.
myocarditis
US Indicated Allows clear assessment of dilated, hypertrophic, and 0
echo- [A] constrictive/restrictive cardiomyopathy and
cardiography associated cardiac abnormalities. Not so useful for
arrhythmogenic RV dysplasia. TOE can distinguish
constrictive from restrictive cardiomyopathy.
NM Specialised Rest radionuclide angiography is indicated in the III
(radionuclide investigation determination of initial and serial LV and RV

E. Cardiovascular system
angiography) [B] performance in patients with myocarditis or dilated,
hypertrophic and restrictive cardiomyopathy and in
patients receiving chemotherapy with doxorubicin.
Myocardial perfusion imaging may help to
differentiate ischaemic and dilated cardiomyopathy
and to assess myocardial ischaemia in hypertrophic
E09 cardiomyopathy.
Congenital heart US echo- Indicated Provides diagnostic and functional data. Facilitates 0/0
disease cardiography/ [B] follow-up. Specialist area.
US trans-
TOE can provide additional useful information to
oesophageal
transthoracic echocardiography.
echo-
cardiography
(TOE)
MRI Indicated Best assessment/follow-up tool. Contraindicated for 0
E10 [B] many prosthetic valves.
Unstable angina NM Specialised Tc-99m or Tl-201 scintigraphy in diagnosis, prognosis, III
investigation and assessment of therapy in patients with unstable
[B] angina is indicated in the:
• Identification of ischaemia in the distribution of the
culprit lesion or in remote areas
• Measurement of baseline LV function
• Identification of the extent and the severity of
disease in patients with ongoing ischaemia or
myocardial hibernation
Coronary Specialised Only tool currently available for assessment of III
angiography investigation coronary artery anatomy. Essential prerequisite for
[B] interventional strategies and sometimes to establish
E11 diagnosis.

54 55
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Abdominal aortic US Indicated Useful in diagnosis, determination of maximal 0
aneurysm [A] diameter, and follow-up. CT preferable for suspected
leak but should not delay urgent surgery.
CT/MRI Indicated CT (especially spiral) and MRI for relationship to III/0
[A] renal and iliac vessels. There is increasing demand for
(See also N05) detailed anatomical information because of increasing
E12 consideration of percutaneous stenting.
Deep vein thrombosis US Indicated More sensitive with colour flow Doppler. Most 0
[A] clinically significant thrombi are detected. There is
increasing experience with US for calf vein thrombi.
May show other lesions.
Venography Indicated only Extensive variation according to US expertise and II
in specific local therapeutic strategy.
circumstances
E13 [B]
Ischaemic leg Angiography Specialised Local policy needs to be determined in agreement III
investigation with vascular surgeons, especially with regard to
[A] therapeutic interventions. US used in some centres as

E. Cardiovascular system
first investigation.
CTA/MRA Specialised CTA and MRA are increasingly used for diagnosis. III/0
(See also N06–N09) investigation
E14 [C]
Ischaemic upper limb Angiography Specialised Local policy needs to be determined in agreement III
investigation with vascular surgeons, especially with regard to
E15 [B] therapeutic intervention.

56 57
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

F. Thoracic system
Non-specific chest CXR Not indicated Conditions such as Tietze’s disease show no I
pain initially abnormality on CXR. Main purpose is reassurance.
F01 [C]
Minor chest trauma CXR Indicated only Showing a rib fracture does not alter management. I
in specific
(See also K30) circumstances
F02 [C]
Pre-employment or CXR Indicated only Not justified except in a few high-risk categories (e.g. I
screening medicals in specific at-risk immigrants with no recent CXR). Some have to
circumstances be done for occupational (e.g. divers) or emigration
F03 [B] purposes (UK category 2).
Routine pre-operative CXR Not indicated Routine pre-operative CXR is not indicated in patients I
CXR [A] aged < 60 years undergoing non-cardiothoracic
surgery. The yield of abnormalities increases in patients
> 60 years. However, if patients without known cardio-
F04 respiratory disease are excluded, the yield is still low.

F. Thoracic system
Upper respiratory CXR Not indicated There is no documented evidence of the effect of CXR I
tract infection [C] on the management or outcome of upper respiratory
F05 tract infection.
Acute exacerbation CXR Indicated only Patients presenting with asthma but without I
of asthma in specific localising signs in the chest, pyrexia, or leucocytosis
circumstances do not require CXR, except when the asthma is life-
[B] threatening or fails to respond to treatment
F06 adequately.
Acute exacerbation CXR Indicated only Patients presenting with COPD but without localising I
of COPD in specific signs in the chest, pyrexia, or leucocytosis do not
circumstances require CXR, except when the condition is life-
[B] threatening or fails to respond to treatment
F07 adequately.
Pneumonia CXR Indicated The majority of patients with community-acquired I
[C] pneumonia will show radiological resolution at four
weeks, but this may be prolonged in the elderly,
smokers, and those with chronic airway disease.
Further CXR after resolution in asymptomatic patients
(For children see
is not indicated.
section M)
F08 (For pneumonia in children see M23)
Pneumonia: follow-up CXR Indicated only CXR need not be repeated before hospital discharge I
in specific in those who have made a satisfactory clinical
circumstances recovery from community-acquired pneumonia.
[B] CXR should be arranged after about six weeks for all
patients who have persistent symptoms or physical
signs or who are at higher risk of underlying
malignancy (especially smokers and patients > 50
(For children see
years), whether or not they are admitted to hospital.
section M)
F09 (For pneumonia in children see M23)

58 59
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Pleural effusion CXR Indicated CXR may detect small quantities of pleural fluid. I
suspected [C]
US Indicated US may be used to confirm the presence of pleural 0
[B] fluid, characterise it, detect pleural metastases, and
guide thoracentesis.
CT Indicated only CT with IV contrast may help in the detection and III
in specific characterisation of pleural fluid.
circumstances
F10 [B]
Haemoptysis CXR Indicated All patients presenting with haemoptysis should have I
[B] a CXR. If this is normal and the haemoptysis was
significant and occurred out of the context of a
concurrent chest infection, referral for further
investigation should be considered.
CT Not indicated CT should be used in conjunction with bronchoscopy III
initially to investigate the majority of patients with
[B] haemoptysis. CT may detect malignancies not
identified on CXR or bronchoscopy, but is insensitive
F11 in detecting mucosal and submucosal disease.

F. Thoracic system
ITU/HDU patient CXR Indicated A CXR is most helpful when there has been a change I
[B] in symptoms or insertion or removal of a device. The
value of the routine daily CXR is being increasingly
questioned. CT is a useful adjunct to CXR for
F12 problem-solving in critically ill patients.
Occult lung disease CT Specialised There is evidence to indicate that high resolution CT III
investigation (HRCT) may be histospecific; valuable information
[B] about disease reversibility and prognosis may be
F13 gleaned from HRCT.

60 61
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

G. Gastrointestinal system
Gastrointestinal tract

Difficulty in Video- Indicated Video recording of swallow is essential. Webs and II

swallowing: fluoroscopy [B] pouches are well demonstrated. Motility disorders, which
high dysphagia and Ba must be looked for in prone or supine position, may be
(lesion may be high swallow seen despite normal endoscopy. Subtle strictures, not seen
or low) at endoscopy, best demonstrated by marshmallow or
other bolus study. Multi-disciplinary approach with
G01 speech therapist and ENT surgeon is optimal.
Difficulty in Ba swallow Indicated only in Endoscopy is required (biopsy of strictures essential). II
swallowing: specific Ba swallow used to demonstrate motility disorder or
low dysphagia circumstances [B] subtle stricture, if endoscopy normal.
(lesion will be low)
NM Specialised Radionuclide oesophageal transit study is indicated as II
investigation an alternative non-invasive assessment of
G02 [B] oesophageal motility.

G. Gastrointestinal system
Heart burn/chest pain: Ba swallow/ Indicated only Reflux is common and investigation is only indicated II
hiatus hernia meal in specific where lifestyle changes and empirical therapy fail.
or reflux circumstances While pH monitoring is the gold standard for reflux,
[B] endoscopy alone will reliably show early changes of
reflux oesophagitis and allows detection and biopsy
of metaplasia. Ba studies aimed at assessing
oesophageal motility prior to anti-reflux surgery do
G03 not reliably predict post-operative dysphagia.
Oesophageal CXR Indicated Will be abnormal in 80% of cases, but pneumo- I
perforation [B] mediastinum is present in only 60%.
Contrast Indicated Non-ionic iodinated contrast is the only safe agent. II
swallow [B] It is sensitive, but if no leak is seen then proceed to
immediate CT.
CT Indicated CT is sensitive both for the presence of perforation and III
G04 [A] for the detection of mediastinal and pleural complications.
Acute GI bleeding: Endoscopy Indicated Endoscopy provides diagnosis in the majority of cases 0
haematemesis/ [A] of upper GI bleeding and can be used to deliver
melaena haemostatic therapy.
AXR Not indicated [B] Of no value. I
Abdominal US Indicated only in Only useful to look for signs of chronic liver disease. 0
specific
circumstances [B]
Ba studies Not indicated [C] Precludes angiography. II
NM Specialised After endoscopy. Red cell labelling can detect II
investigation bleeding rates as low as 0.1 ml/minute; more sensitive
[B] than angiography. Red cell study is most useful in
intermittent bleeding.
(See also N10, N11, Angiography Specialised In uncontrollable bleeding. Angiography can III
N13, N14) investigation accurately direct surgery and transcatheter
G05 [B] embolisation may be used as the primary treatment.

62 63
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Dyspepsia in the Ba studies Indicated only Most patients < 45 years can be treated without II
younger patient in specific investigations and will undergo a trial of therapy
(e.g. < 45 years) circumstances (anti-ulcer or reflux). If symptoms recur or persist, the
[B] Helicobacter pylori status should be assessed
serologically or by using the C-14 urea breath test. If
positive or patient has alarm symptoms (weight loss,
anorexia, iron deficiency anaemia, severe pain or non-
steroid anti-inflammatory drug use), endoscopy is the
G06 investigation of choice.
Dyspepsia in the Ba studies Indicated only Endoscopy is the investigation of choice. The main II
older patient in specific concern is the early detection of cancer. If endoscopy
(e.g. > 45 years) circumstances is negative and symptoms persist, then Ba meal
G07 [B] should be considered.
Ulcer: Ba studies Not indicated Scarring precludes accurate assessment. Endoscopy is II
follow-up [B] preferred to confirm complete healing and to obtain
biopsies where necessary.
NM Indicated only Most centres use C-14 urea breath test to assess effect I-II
in specific of treatment for Helicobacter pylori.

G. Gastrointestinal system
circumstances
G08 [B]
Previous upper GI Contrast Indicated If water-soluble contrast swallow does not II
surgery (recent) to swallow/meal [B] demonstrate a leak in the anastomotic site and there is
check for anastomotic a clinical concern, then immediate CT should be
leaks performed as it is more sensitive. Ba should not be
G09 used as the contrast agent.

Previous upper GI Ba studies Indicated only Gastric remnant best assessed by endoscopy (gastritis, II
surgery (not recent): in specific ulceration, dysplasia, recurrent tumour, etc.)
dyspeptic symptoms circumstances
G10 [B]
Previous upper GI Ba studies Indicated Shows surgical anatomy and may demonstrate dilated II
surgery (not recent): [B] afferent loop, narrowed anastomoses, internal hernias,
dysmotility/ closed loops, etc.
obstructive symptoms
NM Specialised Good method for assessment of gastric emptying, II
investigation dumping, and stasis.
G11 [B]
Intestinal blood loss: Ba studies Not indicated The initial investigation is endoscopy of the upper GI II
chronic or recurrent initially tract and colon. Small bowel follow-through is not
[B] sufficiently sensitive for lesions likely to cause chronic
bleeding and should not be used.
Ba small bowel Indicated More sensitive than Ba follow-through for small II
enema [B] discrete lesions. However, early results of ‘capsule’
endoscopy in chronic bleeding suggest that this will
be the investigation of choice when small bowel
strictures have been excluded.
NM Indicated When all other investigations are negative, labelled II
(See also N14) [B] red cell and/or Meckel’s study may be useful in
detecting and localising the site of chronic and/or
Continued G12 recurrent bleeding.

64 65
CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Intestinal blood loss: CT Indicated IV contrast-enhanced CT is a useful technique to look III
chronic or recurrent [B] for lesions that may be bleeding (e.g. tumours). CTA
may demonstrate bowel angiodysplasia.
Continued
Angiography Specialised Angiography is sensitive for angiodysplasia (with III
investigation early filling vein) and to demonstrate tumour neo-
(See also N14) G12 [B] vascularity.
Acute abdominal pain: AXR and Indicated Supine AXR may be sufficient to establish diagnosis of I+I
perforation/ CXR erect [B] obstruction and point to an anatomical level. Consider
obstruction erect AXR if supine AXR normal and strong clinical
suspicion of obstruction. Lateral decubitus AXR
indicated to show free gas if CXR has to be supine.
US Indicated Widely used as a survey following AXR. It is sensitive 0
[C] for free fluid in perforation.
CT Indicated For small sealed perforations and for establishing site III
[B] and cause of obstruction.
(For children see
section M) This recommendation does not apply to children.

G. Gastrointestinal system
G13 (For acute abdominal pain in children see M37)
Small bowel Contrast Indicated only Frequently unhelpful. II
obstruction: acute studies in specific
circumstances
[B]
CT Indicated When AXR suggests small bowel obstruction, CT III
[B] confirms diagnosis, indicates level, and may show
cause. When AXR equivocal but small bowel
obstruction suspected clinically, volume challenge (i.e.
CT with water or methylcellulose ingestion) may be
G14 required for complete assessment.
Small bowel Ba small bowel Indicated Will reveal presence and level of obstruction in most II
obstruction: enema [B] cases and may suggest a cause.
chronic or recurrent
CT Indicated Performed with or without volume challenge. CT will III
[B] be diagnostic as for small bowel enema, but may be a
better guide to management in complex cases, e.g. in
(See also G13, G14) patients with a previous malignancy or following
G15 complicated abdominal surgery.
Suspected small bowel Ba small bowel Indicated A useful survey examination for the diagnosis of II
disease (Crohn’s meal [B] small bowel disease, including Crohn’s disease.
disease)
Ba small bowel Indicated This is the investigation of choice to establish extent of II
enema [B] disease prior to surgery, in cases where fistula is
suspected, and to diagnose the cause of obstructive
symptoms in patients with known Crohn’s disease.
US/CT/MRI Specialised Use of these techniques is evolving, e.g. in assessment 0/
investigation of disease activity, and they are particularly useful to III/0
[B] assess extramural complications.
NM Specialised Labelled white cell scintigraphy reveals activity and III
investigation extent of disease and is complementary to Ba studies.
G16 [B]

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Change of bowel habit Ba enema Indicated Colonoscopy is often the first-line investigation. Ba III
to diarrhoea and rectal [B] enema is an alternative to colonoscopy and is widely
bleeding in the absence used as the first-line investigation of change of bowel
of perianal symptoms: habit in the absence of rectal bleeding. Ba enema is
colorectal neoplasia insufficient with rectal bleeding, but flexible
sigmoidoscopy followed by immediate Ba enema is a
good alternative to colonoscopy. Defer Ba enema for
seven days after full thickness biopsy via a rigid
sigmoidoscope. No delay is needed for superficial
biopsies taken via flexible sigmoidoscopy.
CT Specialised CT has an established and developing role in the III
investigation demonstration and exclusion of colorectal neoplasia.
[B] Its use can range from a minimally invasive approach
with no oral contrast and no bowel preparation to full
CT colonography. The minimally invasive approach is
preferable to Ba enema in frail elderly patients.
Accuracy is increased by oral contrast over 24 hours
with no purgation. Alternatively, a water enema is
helpful. CT colonography with full bowel preparation

G. Gastrointestinal system
and air enema is more accurate than Ba enema and
closely approaches the accuracy of colonoscopy. It is
already the technique of choice for the proximal colon
G17 when colonoscopy has been incomplete.
Large bowel AXR Indicated May suggest diagnosis and indicate likely level. I–II
obstruction: acute [B]
Contrast Indicated Water-soluble or air-contrast enema can confirm III
enema [B] diagnosis and level of obstruction and may indicate
likely cause. In some cases interpretation is difficult
and if no abnormality is seen it is important to
understand that although this may indicate pseudo-
obstruction, a significant obstructing lesion may have
been missed.
CT Specialised The value of CT, particularly in sick and very frail III
investigation patients, is becoming established. It is likely that it
[B] will prove a more accurate and less uncomfortable
G18 alternative to water soluble enema.
Inflammatory bowel AXR Indicated Often sufficient to determine disease severity and I–II
disease of the colon: [B] extent.
acute exacerbation
Ba enema Indicated Unprepared ‘instant’ enema complements AXR and III
[B] confirms extent of disease. It is contraindicated in
toxic megacolon.
NM Indicated Labelled white cell study will reveal activity and III
[B] extent of disease.
MRI Specialised MRI is extremely valuable in guiding surgical 0
G19 investigation [B] management of patients with anorectal sepsis.
Inflammatory bowel Ba enema Indicated only Ba enema has a limited role after complex surgery and III
disease of colon: in specific in the evaluation of fistulae. Colonoscopy is the most
long-term follow-up circumstances reliable investigation to identify complications
G20 [B] including dysplasia, stricture, and carcinoma.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

General abdominal problems

Acute abdominal pain AXR and Indicated Local policy will determine strategy. Supine AXR (for I-II/
warranting hospital CXR erect/ [B] gas pattern, etc.) is usually sufficient; erect AXR is 0
admission for con- US indicated only in specific circumstances. Erect CXR is
sideration of surgery used for exclusion of perforation. US is widely used as
a preliminary survey.
(See also G13, G14,
G15, G30, G32) CT Indicated CT is increasingly used. III
G21 [B]
Palpable mass AXR Indicated only in Rarely of value. I-II
specific
circumstances [C]
US Indicated [B] Often solves the problem. 0
CT Indicated Where US is inconclusive and to provide more complete III
G22 [B] assessment of disease extent prior to definitive treatment.
Malabsorption Ba small bowel Indicated only Imaging is not required for the diagnosis of coeliac II
meal in specific disease but may be indicated for other causes of small

G. Gastrointestinal system
circumstances bowel malabsorption or when biopsy is normal/
[B] equivocal.
NM Specialised Numerous NM investigations are available, which II
investigation should establish presence of malabsorption. Some of
G23 [B] these are non-radiological (e.g. breath test).
Constipation AXR Indicated only May be useful in geriatric and psychiatric specialties II
in specific to show extent of faecal impaction.
circumstances
[B] (For constipation in children see M38)
Intestinal Specialised A simple investigation using radio-opaque shapes can I-II
transit studies investigation [B] confirm normal intestinal transit.
NM Specialised In-111 colonic transit study enables a more detailed III
investigation study of colonic delay than radio-labelled pellets.
[B] Important before colectomy is undertaken.
(For children see Evacuation Specialised In some patients constipation is secondary to a II
section M) proctography investigation disorder of evacuation, which can be demonstrated
G24 [B] and characterised by this investigation.
Abdominal sepsis; US Indicated Seek early radiological advice. US is often used first 0
pyrexia of unknown [C] and may be definitive, particularly when there are
origin localising signs; it is especially good for subphrenic/
subhepatic spaces and pelvis.
CT Indicated CT is probably best test overall. Infection and tumour III
[C] are usually identified or excluded. It also allows
biopsy of nodes or tumour and drainage of collections
(especially recent post-operative when US is difficult).
NM Indicated NM is particularly good when there are no localising III
[C] features. Labelled white blood cell (WBC) study is
good for chronic post-operative sepsis; Ga will
(See also N16, N17) accumulate at sites of tumour (e.g. lymphoma) and
G25 infection.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

Liver, gallbladder and pancreas

Hepatic metastases US Indicated Will often be the initial investigation. US is reliable for 0
[B] lesions >2 cm in diameter, but for smaller lesions the
sensitivity is reduced. Developments in therapy for
hepatic metastases, particularly in colorectal cancer,
dictate the use of more sensitive tests. US, however,
will often be used as the first-line exclusion of hepatic
metastases.
CT Indicated CT is significantly more sensitive than US for III
[B] detection of liver metastases, particularly smaller
lesions. It is essential for accurate staging of patients
with metastases being considered for liver resection.
MRI Specialised With liver-specific contrast agents MRI is even more 0
investigation sensitive than CT in detecting metastases, but it is also
[B] useful in accurate characterisation of small lesions. It
(See also N33–N35) is widely used in the pre-operative assessment of
G26 candidates for liver resection.

G. Gastrointestinal system
Solitary hepatic lesion CT/ MRI Specialised Both techniques reliably show characteristic features III/0
on US, haemangioma, investigation of haemangioma and many other solitary hepatic
metastases, other [B] lesions.

(See also L15) G27

Known cirrhosis, US Indicated Very sensitive for ascites. US may show varices, 0
complications [B] particularly in the splenic hilum in portal hypertension.
It is the initial screening test for hepatoma.
CT Specialised Particularly when US is equivocal in the presence of III
investigation raised alpha feto-protein and in the staging of
[B] hepatoma.
MRI Specialised With liver-specific contrast agents MRI is at least as 0
G28 investigation [B] sensitive as CT for hepatoma.
Jaundice US Indicated US reliably differentiates between obstructive and non- 0
[B] obstructive jaundice, but bile duct dilatation may be
subtle in early obstruction. When US indicates obstructive
jaundice, subsequent investigation will depend on the
level of obstruction, presence or absence of stones in the
gall bladder and ducts, as well as the clinical situation.
Early discussion with radiologist is required.
ERCP Specialised If US shows duct stones, proceed to ERCP for II
investigation confirmation and therapy. ERCP remains the gold
[B] standard for intrahepatic duct changes in sclerosing
cholangitis.
CT Specialised Frequently the next investigation for US-proven III
investigation obstructive jaundice, particularly if US level of
[B] obstruction is below the hilum. For pancreatic cancer
CT reliably predicts unresectability. In malignant
hilar-level obstruction, CT may provide staging
(See also N18–N20) information critical to the planning of surgery or
Continued G29 palliative therapy.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Jaundice MRI, including Specialised In hilar-level obstruction, MRCP (magnetic resonance 0
MRCP investigation cholangiopancreatography) is now the investigation
Continued
[B] of choice following US. MRCP reliably and non-
invasively depicts the pattern and extent of duct
involvement, thus facilitating planning of curative
surgery or interventional treatment.
In malignant hilar-level obstruction, MRI may provide
staging information critical to the planning of surgery
or palliative treatment.
If US shows gallstones, but no definite duct stones,
then MRCP is indicated prior to ERCP.
Endoscopic US Specialised Is the most accurate method for detection of small 0
investigation duct stones and small papillary or peri-ampullary
(See also N18–N20) [B] tumours. It allows biopsy of pancreas without risk of
G29 tumour seeding.
Biliary disease (e.g. AXR Not indicated Only shows about 10% of gallstones. I-II
gallstones, post- [C]

G. Gastrointestinal system
cholecystectomy pain)
US Indicated Is the investigation of choice for the demonstration or 0
[B] exclusion of gallstones and acute cholecystitis. It is the
initial investigation of biliary pain but cannot reliably
exclude common duct stones. Cholecystography is
virtually never used.
CT Specialised Has a limited role in cholelithiasis but is useful in the III
investigation [B] evaluation of gallbladder wall and gallbladder masses.
MRCP Specialised Indicated in stone disease where the symptoms, signs, 0
investigation and/or liver function tests suggest the possibility of
[B] duct calculi not confirmed by US, and in the
investigation of post-cholecystectomy pain.
(See also N20) NM Specialised Biliary scintigraphy shows cystic duct obstruction in II
G30 investigation [B] acute cholecystitis.

Post-operative US Indicated First investigation of suspected leak. US will show the 0

biliary leak [B] size and anatomical position of collections
ERCP Indicated Definitive investigation to detect and demonstrate the II
[B] site of the leakage and for treatment by stent placement.
NM Specialised HIDA scan will show activity at site of leak. II
G31 investigation [B]
Pancreatitis: AXR Indicated Presents as non-specific acute abdominal pain. AXR is I-II
acute [C] needed to exclude other causes.
US Indicated Must be performed early to identify patients with 0
[B] gallstones, indicating a diagnosis of gallstone pancreatitis,
in which case early ERCP may be considered.
CT Indicated CT with IV contrast enhancement is used early in III
[B] severe cases to assess extent of necrosis, which is
helpful in prognosis. In follow-up, it is used to detect
and monitor complications, and for this purpose it is
(See also G21) superior to US. US is used to monitor more chronic
G32 pseudocysts, to avoid high radiation dose of CT.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Pancreatitis: AXR Indicated To show calcification (calcified duct stones) but is of I
chronic [B] limited value in exclusion.
US/CT Indicated US may be definitive, particularly in thin patients. CT 0/III
[B] is highly sensitive for pancreatic calcification but
poorly sensitive for early parenchymal changes.
ERCP/MRCP Specialised ERCP shows duct morphology. MRCP (particularly II/0
investigation with secretin) shows moderate and severe ductal
[B] changes and may indicate exocrine function. MRCP
does not reliably show minor side branch changes in
G33 mild chronic pancreatitis.
Pancreatic US Indicated US is good at detecting the primary lesion in thin 0
tumour [B] patients, particularly for lesions in the head and body,
but is insufficient where precise staging is required.
CT Indicated CT is of value in diagnosis, when US is inconclusive, III
[B] and in staging, where IV contrast-enhanced spiral CT
reliably predicts unresectability.
Endoscopic US Specialised May provide detailed staging information in 0

G. Gastrointestinal system
investigation candidates for surgical resection after CT and allows
[B] image-guided biopsy of pancreatic masses.
ERCP Specialised Demonstrates anatomy of strictures and facilitates II
investigation tissue diagnosis and intervention, e.g. stent placement
G34 [B] in selected cases.
Insulinoma Endoscopic US Specialised Accurate localisation of the tumours is essential if 0
investigation surgery is to be curative. Invasive preoperative
[B] vascular techniques (i.e. arterial stimulation with
venous sampling) combined with intra-operative US
and operative palpation represent the gold standard
for localisation and surgical planning. Endoscopic US
appears promising and may offer a less invasive
alternative to angiography in the future. US, CT, MRI
and NM are non-invasive but often fail to
demonstrate insulinoma(s) responsible for clinical
hyperinsulinaemia. These studies are probably of
G35 greatest value in the diagnosis of metastatic disease.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

H. Urological, adrenal,
and genitourinary systems
Haematuria, IVU Indicated There is wide variation in local policy. Imaging II
macro- or microscopic [B] strategies should be agreed with local nephrologists
and urologists. Neither IVU nor US and AXR is ideal
for detecting upper urinary tract causes of bleeding: in
most patients both IVU and US should be used, either
together or in sequence.

H. Urological, adrenal, and genitourinary systems

US and AXR/ Indicated In young patients with microscopic haematuria only 0 + I/
CT [B] US and AXR may be used to evaluate the upper tracts: II
this strategy misses some upper tract pathology,
including some calculi. Bladder US detects many
bladder tumours but is not sufficiently sensitive to
obviate cystoscopy. There has been recent interest in
using CT to evaluate the upper tracts in haematuria
but there are insufficient data to make a
H01 recommendation.
Hypertension without IVU Not indicated IVU is not indicated for the evaluation of II
evidence of renal [B] hypertension with no evidence of renal disease.
disease
(See also H03) H02
Hypertension: in the Angiography Specialised To show stenosis if surgery or angioplasty is III/
young adult or in (DSA/CTA/ investigation considered as a possible treatment. III/0
patients unresponsive MRA) [C]
to medication
MRA Specialised Imaging is only appropriate if renovascular 0
investigation hypertension is clinically suspected, since the
[B] prevalence of renal artery stenosis in essential
hypertensives is very low. MRA is the best non-
invasive method to visualise the renal arteries directly.
CTA Specialised CTA is as sensitive as MRA but more invasive III
investigation (iodinated contrast medium, irradiation) and should
[B] only be used if MRA is not available.
NM Specialised Captopril renography is best to check for functionally II
investigation significant renal artery stenosis.
[B]
US Specialised Doppler US can be sensitive and specific but needs 0
(See also N21, N22) investigation special expertise.
H03 [B]

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Renal failure Renal US and Indicated US is indicated as the first investigation in renal 0+I
AXR [B] failure to measure kidney size and parenchymal
thickness and to check for pelvicalyceal dilatation
indicating possible obstruction. AXR is necessary to
show calculi not detectable by US.
CT Not indicated CT (unenhanced or enhanced, depending on renal III
initially function) helps if US is non-diagnostic or does not
[B] show the cause of obstruction.
IVU Not indicated [B] II
MRI Specialised MRI is a possible alternative to CT and avoids 0

H. Urological, adrenal, and genitourinary systems

investigation potentially nephrotoxic contrast medium. On rare
(See also N23) [C] occasions, obstruction occurs without dilatation seen
H04 with any imaging method.
Measurement of renal NM Specialised GFR is preferred by many authorities to assess global II
function: investigation renal function: Hippurate OIH labelled with either
• Effective renal [B] I-123, I-125 or I-131 is used, but Tc-99m MAG3 may be
plasma flow (ERPF) used as a substitute.
• Glomerular filtration NM Specialised Single-sample Cr-51 EDTA at 3 hours if well calibrated II
rate (GFR) investigation and GFR >30 ml/min.
[A]
Accurate preparation of standards and injection
without loss are crucial: 51Cr EDTA clearance, four-
sample method.

• Relative function NM Specialised Tc-99m MAG3 is recommended for the measurement II

investigation of relative renal function.
[A]

• Renal transit NM Specialised Renal Tc-99m MAG3 should be used with an II

investigation established method of deconvolution analysis for
[B] parenchymal transit time index for obstructive
nephropathy and mean parenchymal transit time for
H05 renovascular disorder.
Suspected ureteric colic CT Indicated Unenhanced CT is the method of choice in suspected III
[B] ureteric colic.
IVU Indicated [B] IVU is a satisfactory alternative to CT. II
US/AXR Indicated only US and AXR may be used where radiation/contrast 0+I
in specific medium are contraindicated, e.g. in cases of
circumstances pregnancy and contrast allergy. To maximise US
(See also N25) [B] sensitivity, patients should be well hydrated. US is
H06 less accurate than CT or IVU.
Renal calculi in AXR/CT Indicated AXR or CT provide the best baseline assessment in I/III
absence of acute colic [B] patients with renal stone disease. In routine practice
AXR is adequate to detect the majority of renal calculi,
which contain calcium. For detailed detection of renal
calculi, CT is more sensitive.
US Indicated only in US is less sensitive than either AXR or CT for 0
specific circum- detecting renal calculi but can detect urate calculi.
(See also N25)
stances[B]
H07

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Renal mass US Indicated US is sensitive at detecting renal masses > 2 cm and 0
[B] accurately characterises masses as cystic or solid. US
helps to characterise some masses indeterminate at CT.
IVU Not indicated IVU is less sensitive than US for the detection of renal II
[B] masses. IVU does not characterise renal masses
accurately.
CT Indicated CT is sensitive at detecting renal masses of 1.0–1.5 cm III
[B] or greater and accurately characterises masses.
MRI Specialised MRI (including contrast-enhanced imaging) is as 0
investigation sensitive as contrast-enhanced CT for detecting and

H. Urological, adrenal, and genitourinary systems

[B] characterising renal masses. MRI should be used if
masses are not adequately characterised by CT and
US or if iodinated contrast medium is contra-
indicated because of diminished renal function or
H08 allergy.
Urinary tract IVU Indicated only May be used to define anatomy prior to surgery or II
obstruction in specific other intervention.
circumstances
[B]
US Indicated Useful to assess the upper tracts. 0
[B]
NM Indicated Tc-99m-MAG3 with frusemide diuresis is used. II
[A] Output (outflow) efficiency study provides reliable
quantification of frusemide response independent of
renal function. Parenchymal transit time index
measurements aid assessment of obstructive
H09 nephropathy.
Urinary tract infection US and AXR Indicated only The majority of adults with urinary tract infection do 0+I
in adults in specific not require imaging. Imaging is indicated (1) if
circumstances infection does not settle rapidly with antibiotics and (2)
[B] after infection has settled in men with one proven UTI
or women with a proven recurrence of UTI.
CT Specialised US and AXR offer a good first investigation. Contrast- III
investigation enhanced CT may be necessary in severe infection not
[B] responsive to treatment, since CT detects renal sepsis
and changes of pyelonephritis more sensitively than US.
IVU Indicated only IVU may be helpful in the non-acute phase in patients II
in specific who are suspected of having underlying renal disease
(For children see
circumstances (e.g. calculus, papillary necrosis, reflux nephropathy).
section M)
[B]
H10 (For urinary tract infection in children see M43)
Renal transplant NM Indicated Tc-99m-MAG3 studies are more sensitive than US for II
evaluation [B] acute rejection after transplantation. Such changes in
renal function usually predate clinical and chemical
indices. This study is helpful for detection of renal
H11 artery stenosis and obstructive uropathy.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Urinary retention IVU Not indicated Has low yield. II
[B]
US Indicated only Renal US is indicated to check for upper tract 0
in specific dilatation (after catheterisation to relieve bladder
circumstances distension), especially if renal function is impaired.
H12 [B]
Prostatism IVU Not indicated US is indicated to check for dilatation of the upper II
[B] urinary tract.
US Indicated Bladder US (with measurement of post-void residual 0
[B] volume and urine flow rate) is indicated in

H. Urological, adrenal, and genitourinary systems

prostatism. Renal US is only necessary if there is a
(See also L28) post-void residue, haematuria, raised serum
H13 creatinine, or infection.
Scrotal mass or pain US Indicated US is indicated for scrotal swelling and when 0
[B] presumed inflammatory scrotal pain does not respond
to treatment. Allows differentiation of testicular from
H14 extratesticular lesions.
Testicular torsion US Indicated Frequently a clinical diagnosis. Urgent management is 0
[B] essential and imaging should not delay intervention
when appropriate. Colour Doppler US has a high
sensitivity in suspected testicular torsion. Intermittent
H15 torsion remains a significant diagnostic problem.
Adrenal medullary US/CT/MRI Specialised Whilst US may identify lesions of this type, CT and 0/III
tumour investigation MRI provide the best anatomical delineation. Imaging /0
[B] is rarely indicated in the absence of biochemical
evidence of such tumours.
NM Specialised MIBG locates functioning tumours and is particularly II
investigation useful for ectopic sites and metastases.
H16 [B]
Adrenal cortical CT/MRI, NM, Specialised Local advice on the most appropriate examination III/0,
lesions; Cushing’s and/or investigation should be sought. CT/MRI may be able to identify an II/III
syndrome adrenal [B] adrenal cause for Cushing’s syndrome. However,
venous nodular adrenal hyperplasia can occur in a significant
sampling proportion of patients with ACTH-dependent and
ACTH-independent Cushing’s syndrome. In such a
situation CT may be unable to distinguish adrenal
adenoma and nodular hyperplasia, and further
investigation with scintigraphy and/or adrenal
H17 venous sampling may be required.
Adrenal cortical CT/MRI, NM Specialised Local advice on the most appropriate examination III/0,
lesions; primary and/or investigation should be sought. Both CT and MRI can distinguish II/III
hyperaldosteronism adrenal [B] between a unilateral adrenal adenoma and bilateral
(Conn’s syndrome) venous adrenal hyperplasia. NM may be useful in
sampling distinguishing between adrenal hyperplasia and an
adenoma. However, adrenal venous sampling may be
required where other imaging techniques are
H18 inconclusive.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

I. Obstetrics and
gynaecology
NB: Transvaginal US equipment should be available in all
departments performing pelvic US
Screening in US Indicated Screening in early pregnancy (9–13 weeks) accurately 0
pregnancy [B] dates a pregnancy by measuring the total crown-rump
length. This reduces the intervention rate for infants
born at or after full term. US accurately assesses fetal
number and chorionicity and improves outcome for
multiple pregnancies. Screening for structural
abnormality at 18–20 weeks has not been shown to
alter perinatal mortality except where selective
termination of pregnancy is applied in the presence of
gross fetal abnormality. US has a proven value in
assessing placenta praevia and intrauterine growth

I. Obstetrics and gynaecology

restriction. In the specialist care of high-risk
pregnancies, Doppler US is essential for the safe
practice of intervention and therapeutic procedures
such as amniocentesis, fetal blood sampling, and
I01 transfusions during pregnancy.
Suspected US Indicated only There is no indication that diagnosing pregnancy by 0
pregnancy in specific US, other than for dating, is appropriate. If early
circumstances pregnancy is symptomatic, e.g. pain or vaginal
[C] bleeding, US is indicated. Pregnancy testing is the
I02 most appropriate test.
Suspected ectopic US Indicated After a positive pregnancy test. Transvaginal US is 0
pregnancy [B] most accurate. Colour Doppler increases sensitivity.
I03
Possible non-viable US Indicated Pregnancy test is required. Repeat US after a week 0
pregnancy [C] may be needed (especially when gestational sac < 20
mm or crown-rump length < 6 mm). Where doubt
exists about the viability of a pregnancy, delay in
I04 evacuation of the uterus is essential.

Uterus: body
Post-menopausal US Indicated Transvaginal US is indicated to exclude significant 0
bleeding: to exclude [B] endometrial pathology in post-menopausal bleeding.
significant endometrial Endometrial thickening > 5 mm requires biopsy for
pathology specific diagnosis.
I05
Suspected pelvic mass US Indicated Combination of transabdominal and transvaginal US 0
[C] is often required. US should confirm the presence of a
lesion and determine the likely organ of origin.
Transvaginal scanning should be used to define the
(See also L39-L40) anatomy further. MRI is the best second-line
I06 investigation, although CT is still widely used.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Pelvic pain, including US Indicated Especially when clinical examination is difficult or 0
suspected pelvic [C] impossible. US has a poor predictive power when
inflammatory disease diagnosing pelvic inflammatory disease.
and suspected
endometriosis

MRI Specialised Can be useful to localise the larger foci of 0

investigation endometriosis.
I07 [B]
Lost IUCD US Indicated To confirm or refute the presence of the IUCD 0
[C] in uterus.
AXR Indicated only Indicated only when IUCD is not seen in uterus on I-II
in specific US.
circumstances
I08 [C]
Recurrent US Indicated Will show the major uterine congenital and acquired 0

I. Obstetrics and gynaecology

miscarriages [C] problems and is useful to identify polycystic ovaries.
MRI Specialised Supplements US for uterine anatomy. 0
investigation
I09 [C]
Infertility US Indicated For follicle tracking during treatment. For assessment 0
[C] of tubal patency, US is not yet widely practised. Some
centres use MRI and/or laparoscopy and/or
I10 hysterosalpingography.
Suspected XR Not indicated The need for pelvimetry is increasingly being II
cephalopelvic pelvimetry [B] questioned. Local policy should be determined in
disproportion agreement with obstetricians. MRI or CT should be
used wherever possible.
MRI/CT Specialised MRI is best as it avoids x-irradiation. CT generally 0/I
investigation offers a lower dose than standard XR pelvimetry.
I11 [C]

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

J. Breast disease
Asymptomatic patients

Screening women Mammography Not indicated There is no evidence to support screening of women I
< 40 years old [B] < 40 years old who are not at increased risk of breast
J01 cancer.
Screening women Mammography Indicated only Women seeking screening at this age should be made I
40–49 years old in specific aware of the risks and benefits.
circumstances
[A]
US Indicated only Useful adjunct to mammography in women with 0
in specific dense breasts and those with implants.
circumstances
J02 [B]
Screening women Mammography Indicated Women aged 50–64 are invited for screening at I
50–64 years old [A] 3-yearly intervals in the UK under the auspices of the
NHS Breast Screening Programme.
US Indicated only Useful adjunct to mammography in women with 0

J. Breast disease
in specific dense breasts and those with implants.
circumstances
J03 [B]
Screening women Mammography Indicated Currently self-referral to the NHS Breast Screening I
> 65 years old [A] Programme is required, but screening by invitation is
being extended up to age 70 by 2005.

US Indicated only Useful adjunct to mammography in women with 0

in specific dense breasts and those with implants.
circumstances
J04 [B]
Family history of breast Mammography Specialised Evidence of benefit is emerging for women at I
cancer investigation significantly increased risk in their 40s and appears to
[B] outweigh the harm of screening. Screening should
only be undertaken after genetic risk assessments and
appropriate counselling as to the risks and benefits.
Consensus is that screening of women < 50 years old
with a family history should only be undertaken
when the lifetime risk of breast cancer is greater than
twice the average. Further guidelines for
mammographic and other forms of screening in these
women remain under review.
US Indicated only Useful adjunct to mammography in women with 0
in specific dense breasts and those with implants.
circumstances
J05 [B]

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Women < 50 years old Mammography Indicated only HRT has been shown to increase density and benign I
having or being in specific changes within the breast. There is a subsequent fall in
considered for HRT circumstances sensitivity and specificity and an increased recall rate
[C] from screening. There is no evidence for routine
mammography prior to starting HRT.
US Indicated only Useful adjunct to mammography in women with 0
in specific dense breasts and those with implants.
circumstances
J06 [B]
Breast screening in Mammography Indicated Sensitivity for cancer detection is lower than in the I
women aged 50 and [C] non-augmented.
over who have had
US Indicated only Useful adjunct to mammography in women with 0
augmentation
in specific dense breasts and those with implants.
mammoplasty
circumstances
J07 [B]

Symptomatic patients

Clinical suspicion of Mammography Indicated Referral to a breast clinic should precede any I
carcinoma [B] radiological investigation. Mammography and US
should be used in the context of triple assessment (i.e.

J. Breast disease
mammography, US, and needle tests).
US Indicated Mammography is appropriate for women > 35 years 0
[B] old. For women 35 years old, US is the imaging
investigation of first choice. Performed in the context
of triple assessment at a specialist breast clinic.
NM Indicated only Scintimammography is to be performed only if III
in specific additional information is required after triple
circumstances assessment, e.g. if there is a disagreement between
[A] imaging and pathology.
MRI Indicated only To be performed only if additional information is 0
in specific required after triple assessment, e.g. if there is a
circumstances disagreement between imaging and pathology.
J08 [B]
Augmentation Mammography Indicated Mammography is indicated when there is clinical I
mammoplasty [B] suspicion of carcinoma in women with implants.
(clinical suspicion of
carcinoma)
(See also J08)
J09
Generalised lumpiness, Mammography Not indicated May be worthwhile in women > 40 years old with I
pain or tenderness, initially persisting non-suspicious breast symptoms.
long standing nipple [C]
retraction
US Indicated only In the absence of other signs suggestive of 0
in specific malignancy, breast US is unlikely to influence
circumstances management.
J10 [C]

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Cyclical mastalgia Mammography Not indicated Should not be performed in women with breast pain I
[B] in the absence of clinical signs.
US Not indicated 0
J11 [B]
Assessment of integrity US and MRI Specialised US is quick and simple and a normal US study is 0+0
of silicon breast investigation highly predictive of an intact implant. Symptomatic
implants [B] women with implants > 10 years old and positive US
have a 94% probability of rupture. MRI can
reasonably be used for confirmatory testing in other
J12 subsets.
Suspected Paget’s Mammography Indicated Mammography will show an abnormality in 50% of I
disease of the nipple [C] women. It is helpful to determine the possibility of
image-guided biopsy. When invasive disease is
confirmed it will influence the surgical management
J13 of the axilla.
Breast inflammation Mammography Specialised Helps to diagnose or exclude malignancy when there I
investigation is clinical doubt.
[C]
US Indicated Also useful in drainage and follow-up. 0
J14 [C]

J. Breast disease
Breast cancer follow-up Mammography/ Indicated Mammography, US, and MRI may all be used for I/0/
(surveillance) US/MRI/NM [A] follow-up of the conserved breast. In suspected 0/III
locoregional recurrence the principles of triple
assessment apply. Occasionally, scintimammography
may have a role.
J15

94 95
K. Trauma
Head: General

Head injury:
• The primary aim of clinical and radiological assessment is to • Current Royal College of Surgeons Guidelines state that
identify those patients with clinically important brain injury 24-hour availability of CT is required in all centres receiving
and, most crucially, those with an intracranial haematoma head-injured patients. In circumstances where, for whatever
requiring urgent neurosurgical management. reason, CT is not promptly available, skull radiographs may
• There are an estimated 700,000 hospital attendances per still have a role. Other local circumstances may require
annum for head injury in England and Wales. The large modification of these guidelines.
majority of these are classified as mild with a low risk of • MRI, SPECT, and transcranial Doppler US are specialised
intracranial haematoma. Recent UK practice has relied investigations in head injury whose role is still under
heavily on the use of skull radiography to triage patients evaluation.
with mild head injury, but sensitivity for detection of
intracranial haematoma may be as low as 38%. CT has both Associated injuries:
sensitivity and specificity close to 100% but carries a high • Assessment of the cervical spine including imaging if
radiation burden and major resource implications if used indicated (see sections K7-11) is essential in all head-injured
indiscriminately. patients. The opportunity to perform CT of the cervical
• A number of attempts have been made to derive clinical spine while the patient is having a head scan should be
decision rules that can identify patients who are not at risk carefully considered, especially if the patient is unconscious.
of a neurosurgical haematoma or other clinically important Multi-slice CT scanners enable the whole cervical spine to be
brain injury and do not require cranial imaging. The scanned at high resolution and multiplanar reformats to be

K. Trauma
Canadian Head CT Rule was derived from a cohort of more generated with relative ease. Sensitivity to fractures is
than 3,000 patients using a methodologically sound superior to plain radiographs.
multivariate analysis of several risk factors. Coagulopathy, • Occipital condylar fractures are uncommon, but serious
focal neurological deficit, post-traumatic seizure, and injuries are associated with high-energy blunt trauma to the
clinically suspected open or depressed skull fracture were head and/or upper cervical spine. They are difficult to
considered a priori indications. Five further clinical risk diagnose clinically although they should be suspected in
factors identified 100% of patients who required any patient showing signs of lower cranial nerve palsy after
neurosurgical intervention, with a further two factors injury. Demonstration on plain radiographs is extremely
identifying 98.4% with clinically important brain injury. difficult and radiological diagnosis requires good quality
• At the time of publication of these Guidelines the validation CT. This region should be routinely reviewed on ‘bone
study of this rule has not yet been completed and it windows’ in head-injured patients, with additional high
therefore constitutes Level 2 evidence. These Guidelines resolution imaging if necessary.
adopt the Canadian Head CT Rule as the basis for selection
of patients for CT scanning, but may be subject to change as
Children:
new evidence emerges. • The Canadian Rule was derived from a cohort that did not
include children. Children have a lower risk of intracranial
• If CT is normal or the patient does not qualify for a CT scan
haematoma than adults, and it is considered safe to apply
and no other clinical risk factors or social factors are present,
the rule to this age group. If non-accidental injury is
the risk of complications requiring hospital care is low
suspected, a skull radiograph as part of a skeletal survey is
enough to warrant discharge to the care of a responsible
required. In children 0–2 years old, CT of the head is
adult with head injury instructions.
mandatory. In addition, MRI of the brain may be required
• These recommendations are likely to increase the use of CT later to further document timing of the injury.
in head trauma in most UK centres. There are implications
(For non-accidental injury in children see M15)
for population radiation dose and cost, although routine CT
followed by patient discharge if CT is negative may be cost- Trivial head injury:
effective. CT scanning protocols should be optimised to
• Patients with head injury who are fully orientated, have no
minimise dose, especially in children.
history of loss of consciousness or amnesia nor any other
clinical risk factors have a negligible risk of a clinically
important brain injury and do not require imaging.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

Head injury:
Any of the following SXR Not indicated When CT is not available SXR could be justified for I
clinical features [B] triage.
indicates that there is a
An important exception is in the case of suspected
risk of a clinically
non-accidental injury in children, where SXR is
significant brain injury
routinely indicated as part of a skeletal survey. In
requiring neuro-
children 0-2 years old, CT of the head is mandatory.
surgical intervention:
(For non-accidental injury in children see M15)
• GCS < 13 at any
CT Indicated CT should be performed within 1 hour except in II
point since the injury
[B] patients with only retrograde amnesia of > 30 minutes
• GCS 13 or 14 with
and/or dangerous mechanism of injury as risk factors.
failure to regain GCS
These patients are not at risk of a haematoma
15 within 2 hours of
requiring neurosurgical intervention and CT may be
injury
delayed for up to 8 hours.
• Suspected open or
depressed skull Deterioration in GCS by 1 point, particularly if on the
fracture motor score, may warrant an urgent CT.
• Any sign of basal
If a patient with a normal initial CT fails to regain
skull fracture (haemo-
GCS 15 within 24 hours, a further CT or MRI may be
tympanum, ‘racoon
appropriate.
eyes’, CSF otorrhoea,
Battle’s sign)
• More than one

K. Trauma
episode of vomiting
• Age > 64 years
• Post-traumatic
seizure
• Coagulopathy,
including anti-
coagulant therapy
• Focal neurological
deficit
The following two
features in the absence
of any of the above
indicates a risk of a
clinically significant
brain injury that does
not require neuro-
surgical intervention:
• Retrograde amnesia
of greater than 30
minutes
• Dangerous
mechanism of injury:
pedestrian struck by
motor vehicle,
occupant ejected
from a motor vehicle,
fall from a height
> 3 feet or 5 stairs
K01

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

Face and orbits

Nasal trauma SXR/ Not indicated XRs are unreliable in diagnosing nasal fractures and, I/I/I
XR facial [B] even when positive, they do not usually influence
bones/ patient management. They may be requested at ENT/
K02 XR nasal bones maxillofacial follow-up depending on local policy.
Blunt orbital trauma XR facial Indicated Especially where a blowout injury is suspected. MRI I
bones [B] or direct coronal CT may be required by specialists
where there is persistent diplopia or XRs and clinical
K03 signs are equivocal.
Orbital trauma: XR orbits Indicated Indicated for suspected radio-opaque (metallic) intra- I
penetrating injury [B] orbital foreign body.
CT Specialised Indicated for suspected poorly opaque (small or non- II
investigation metallic) intraorbital foreign body.
[B]
US Specialised Indicated for anterior intraocular foreign bodies. 0
investigation
[B]
MRI Specialised Hazardous with metal intraorbital foreign bodies. 0
investigation Specialised investigation is needed in cases when
[B] there is a strong clinical suspicion but failure of
(See also A16, A17) localisation or identification of the foreign body on

K. Trauma
K04 other imaging.
Middle third facial CT Specialised Patient cooperation is essential to obtain views of II
injury investigation diagnostic quality. Consider delay if patient is unco-
[B] operative.
XR facial Indicated Discuss with maxillofacial surgeon, who may request I
bones [B] low dose CT at an early stage in management of
K05 complex injuries.
Mandibular trauma XR mandible Indicated Panoramic XR is not appropriate in uncooperative or I
K06 or OPG [A] multiply injured patients.

Cervical spine
Conscious patient with XR cervical Indicated only XR will not be necessary, provided that all five of the I
head and/or facial spine in specific following criteria are met:
injury only circumstances
• No midline cervical tenderness
[A]
• No focal neurological deficit
• Normal alertness
• No intoxication
K07 • No painful, distracting injury.
Unconscious patient XR cervical Indicated Good quality XRs should demonstrate the whole of I, II
with head injury spine, [B] the cervical spine down to T1/2. If the cervico-
CT thoracic junction is not clearly seen or there are any
possible areas of fracture then CT is required. Where
available, spiral CT may be used as an alternative to
XR, and is essential if the cervico-thoracic junction is
not clearly seen on XR. Both techniques may be
difficult in the severely traumatised patient, and
K08 manipulation must be avoided.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Neck injury with pain XR cervical Indicated Discuss with department of clinical radiology. I
spine [B]
CT/MRI Specialised May be valuable when XR is equivocal or lesion II/0
investigation complex.
K09 [B]
Neck injury with XR cervical Indicated For orthopaedic assessment. XR must be of good I
neurological deficit spine [B] quality to allow accurate interpretation.
MRI Indicated MRI is the best and safest method of demonstrating 0
[B] intrinsic cord damage, cord compression, ligamentous
injuries, and vertebral fractures at multiple levels.
Some constraints with life support systems.
CT Specialised CT myelography may be considered if MRI is not II
investigation practicable.
K10 [B]
Neck injury with pain XR cervical Specialised Views taken in flexion and extension (consider I
but XR initially normal; spine investigation fluoroscopy) as achieved by the patient with no
suspected ligamentous [B] assistance and under medical supervision.
injury
MRI Specialised MRI demonstrates ligamentous injuries. 0
investigation
K11 [C]

Thoracic and lumbar spine

K. Trauma
Trauma without pain or XR Not indicated Physical examination is reliable in this region. When I
neurological deficit [A] the patient is alert and asymptomatic without
neurological signs, the probability of a radiological
K12 finding that would alter management is low.
Trauma with pain, no XR Indicated Threshold to XR is low when there is pain/ I
neurological deficit, or [B] tenderness, a significant fall, a high-impact road traffic
patient not able to be accident, and presence of other spinal fracture, or
evaluated when it is not possible to clinically evaluate the
patient. If XR suggests instability or posterior element
K13 fractures, CT or MRI is essential.
Trauma: with XR Indicated Initial investigation, but CT/MRI is essential. I
neurological deficit [B]
with or without pain
CT Indicated Detailed analysis of bone injury is achieved with CT II
[B] with or without reconstructions.
MRI Indicated Whole-spine MRI is indicated when there are 0
[B] multilevel or ligamentous injuries and cauda equina
K14 injuries.

Pelvis and sacrum

Fall with inability to XR pelvis and Indicated Physical examination may be unreliable. Check for I+I
weight-bear Lateral XR hip [C] femoral neck fractures, which may not show on initial
XR, even with good lateral views. In selected cases,
NM or MRI or CT can be useful when XR is normal or
K15 equivocal.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Urethral bleeding and Retrograde Indicated To show urethral integrity, leak, or rupture. II
pelvic injury urethrogram [C] Cystography or delayed post-contrast CT should be
considered if urethra is normal and haematuria is
present to assess for other urinary tract injuries. There
is increasing first use of MRI in the non-acute
K16 situation.
Trauma to coccyx or XR Indicated only Normal appearance is often misleading and findings I
coccydynia in specific do not alter management.
circumstances
K17 [C]

Upper limb
Shoulder injury XR Indicated Some dislocations present subtle findings. As a I
[B] minimum, orthogonal views are required. US, MRI,
and CT may play a role in complex cases or soft tissue
injury. Consider assessment of rotator cuff in over-50s
K18 who mobilise poorly following a first dislocation.
Elbow trauma XR Indicated To show effusion. Routine follow-up XRs are not I
[B] indicated in cases of effusion with no obvious
K19 fracture. MRI is a specialist investigation.
Wrist injury: XR Indicated Four-view series is needed where scaphoid fracture I
suspected scaphoid [B] suspected.
fracture

K. Trauma
MRI/NM/CT Indicated If clinical doubt persists, MRI/NM/CT studies are 0/
[B] reliable. MRI is preferable as it is more specific. II/II
Increasingly, MRI is being used as the only
K20 examination.

Lower limb
Knee trauma: XR Indicated only When blunt trauma or a fall is the mechanism of I
fall/blunt trauma in specific injury. XR is warranted when age < 12 or > 50 years or
circumstances patient cannot walk four weight-bearing steps. CT/
[B] MRI may be needed where further information is
K21 required.
Acute ankle injury XR Indicated only Features which justify XR include: inability to weight- I
in specific bear immediately and in the emergency room, point
circumstances tenderness over the medial malleolus, and/or the
[B] posterior edge and distal tip of the lateral malleolus.
K22
Foot injury XR Indicated only Indicated only if there is true bony tenderness or on- I
in specific going inability to weight-bear. Demonstration of a
circumstances fore-foot injury rarely influences management. Only
[A] – Mid-foot rarely are XRs of foot and ankle indicated together;
[B] – Fore-foot both will not be done without good reason. If XRs are
not taken, advise return in one week if symptoms are
not improved. For complex mid-foot injuries, CT is
K23 required.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Stress fracture XR Indicated Although often unrewarding. I
[B]
NM/MRI/CT Indicated Provides a means of early detection as well as a visual II/0/
[B] account of the biomechanical properties of the bone. II
K24 Some centres use US here.

Imaging of a foreign body

Soft tissue injury: XR Indicated All glass is radio-opaque. Remove blood-stained or I
foreign body, e.g. metal, [B] soiled dressings first where possible.
glass, painted wood
US Indicated US may be indicated for radiolucent foreign body or 0
K25 [B] where XR is difficult.
Soft tissue injury: XR Indicated only I
Plastic is not radio-opaque: wood is rarely radio-
foreign body, e.g. in specific
opaque.
plastic, wood circumstances
[B]
US Indicated only 0
Soft tissue US may show non-opaque foreign body.
in specific
circumstances
K26 [B]
Swallowed foreign XR Indicated only After direct examination of oropharynx (where most I
body suspected in in specific foreign bodies lodge), and if foreign body is likely to
pharyngeal or upper circumstances be opaque. Differentiation from calcified cartilage can

K. Trauma
oesophageal region. [C] be difficult. Most fish bones are invisible on XR.
AXR Indicated only Maintain a low threshold for laryngoscopy or II
(See also K28 and K29) in specific endoscopy, especially if pain persists after 24 hrs.
circumstances
(For children see (NB For possible inhaled or swallowed foreign body
[B]
section M) in children see M26, M31)
K27
Swallowed foreign CXR Indicated The minority of swallowed foreign bodies will be I
body: smooth and [B] radio-opaque. In children a single, slightly over-
small, e.g. coin exposed, frontal CXR to include neck should suffice.
In adults, a lateral CXR may be needed in addition if
frontal CXR is negative.
AXR Indicated only The majority of foreign bodies that impact do so at the I
in specific cricopharyngeus muscle. If the foreign body has not
circumstances passed within 6 days, AXR may be useful for
K28 [B] localisation.
Sharp or potentially AXR Indicated Most swallowed foreign bodies that pass the I
poisonous swallowed [B] oesophagus eventually pass through the remainder of
foreign body, e.g. the gastrointestinal tract without complication.
battery However, the location of a battery is important, as
leakage can be dangerous.
CXR Indicated only Indicated only if AXR is negative. I
(For children see in specific
(For children see M31)
section M) circumstances
K29 [B]

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

Chest
Chest trauma: CXR Indicated only The demonstration of a rib fracture does not alter I
minor in specific management.
circumstances
K30 [B]
Chest trauma: CXR Indicated Frontal CXR for pneumothorax, fluid, or lung I
moderate [B] contusion.
CT Specialised May be required. III
investigation
K31 [C]
Stab injury CXR Indicated PA and/or other views to show pneumothorax, lung I
[C] damage, or fluid. US is useful for pleural and
K32 pericardial fluid.
Sternal fracture Lateral XR Indicated In addition to CXR, lateral XR of the sternum is required. I
K33 sternum [C] Think of thoracic spinal and aortic injuries too.

Abdomen (including kidney)

Blunt or stab injury AXR supine Indicated Supine AXR and erect CXR are indicated. US valuable I/I/0
and CXR [B] for detecting haematoma and possible injuries to
erect/US some organs, e.g. spleen and liver.
CT Specialised CT may be needed. III

K. Trauma
investigation
K34 [C]
Renal trauma IVU Indicated only Adults with blunt renal trauma, microscopic II
in specific haematuria, and no shock or major associated intra-
circumstances abdominal injuries can safely be spared imaging.
[B]
US Indicated only US can be useful in the initial assessment of patients 0
in specific with suspected renal injury, but a negative US does
circumstances not exclude renal injury.
[B]
CT Indicated CT is the imaging technique of choice in patients with III
[B] major injury ± hypotension, ± macroscopic
(See also N27) haematuria. Delayed (excretory phase) CT must be
K35 included to assess the collecting system.

Major trauma
Major trauma: XR cervical Indicated Patient’s condition must be stabilised as a priority.
I/I/
general screen in the spine/CXR/ [B] Only the minimum XRs necessary for initial
I/III
unconscious or XR pelvis/CT assessment will be performed. XR cervical spine can
confused patient head wait as long as spine and cord are suitably protected.
Pelvic fractures are often associated with major blood
(See also K1, K37, K38
loss.
and N27)
K36

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Major trauma: CXR, XR Indicated Pneumothorax must be excluded. Pelvic fractures I+I
abdomen/pelvis pelvis [B] which increase pelvic volume are often associated
with major blood loss.
US/CT Indicated Sensitive and specific, but time-consuming and may 0/III
[B] delay surgery. CT should precede peritoneal lavage.
US widely used in the emergency room to show free
fluid plus solid organ injury. US has replaced lavage
(See also N27) in most circumstances, but has a low sensitivity for
K37 splenic injury. If doubt remains, CT should follow US.
Major trauma: chest CXR Indicated [B] Allows immediate management (e.g. pneumothorax). I
CT chest Indicated Especially useful to exclude mediastinal haemorrhage III
[B] and aortic injury. Low threshold for proceeding to
K38 arteriography.

K. Trauma

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

L. Cancer
Many of the clinical problems related to the diagnosis of A CXR is necessary at presentation for most malignant
cancer have already been partly covered within the lesions to identify possible pulmonary metastases.
individual system sections. Brief notes are provided here
CXR is also part of many follow-up protocols (e.g.
about the use of imaging in the diagnosis, staging, and
testicular lesions). Follow-up investigations to monitor
follow-up in some of the common primary malignancies.
progress (e.g. post-chemotherapy) are often required.
Paediatric malignancies are not included as their
Some are driven by trial protocols rather than clinical need
management is always at specialist level. (For breast
and thus should be appropriately funded. Concern about
cancer see also section J)
radiation dose in diagnostic imaging is generally less
relevant in this section.

Mouth and pharynx

Diagnosis MRI/CT Indicated Diagnosis is commonly by clinical examination, 0/II
[B] supported by MRI or CT when there is high suspicion
L01 of occult disease.
Staging MRI/CT Indicated Imaging is not commonly needed for diagnosis. 0/II
[B] Staging should include cervical node groups; colour
Doppler US may improve N staging. Chest may be
examined by XR or (preferably) CT, but clinical

L. Cancer
effectiveness of M staging is unproven.
PET Specialised To identify recurrent disease in previously treated IV
investigation patients.
L02 [C]

Parotid
Diagnosis US Indicated Useful for superficial lobe tumours. If FNAC (fine- 0
[B] needle aspiration cytology) is required, US can be
used for guidance. If US is unable to visualise the
entire tumour, then MRI is the investigation of choice
for extent.
MRI/CT Specialised MRI is preferred for the assessment of parotid masses. 0/II
investigation Limitations in ability to identify calcification make CT
[B] better for inflammatory disease. MRI cannot reliably
differentiate benign from malignant lesions and does
not obviate the need for a tissue diagnosis in
indeterminate cases. However, MRI is better than CT
for soft tissue resolution. Dental amalgam may also be
a problem on CT. CT should be used if MRI is
impracticable and for suspected inflammatory
disease.
PET Not indicated PET is poor at differentiating benign from malignant IV
L03 [B] lesions.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Staging MRI/CT Indicated MRI should be used in preference to CT for the 0/II
[B] staging of parotid masses because of its superior soft
tissue resolution, multiplanar capability, and ability to
define both the extent of disease and any intracranial
involvement.
PET Specialised May have a role in staging tumours as it will identify IV
investigation metastases in normal-sized lymph nodes.
L04 [C]

Larynx
Diagnosis CT/MRI Indicated only Clinical endoscopy and biopsy for diagnosis. II/0
in specific
circumstances
L05 [B]
Staging CT/MRI Indicated Where available, MRI is preferable to CT for T II/0
[B] staging. Either can be used for N staging.
US Specialised Can be used for T and N staging and follow-up in 0
investigation centres with appropriate expertise.
L06 [B]

Thyroid
Diagnosis NM Indicated For detection of residual/recurrent differentiated II
[B] thyroid cancer after thyroidectomy.

L. Cancer
US Indicated Used in combination with or to guide FNAC. 0
L07 [B]
Staging CT/MRI Indicated To assess large primary tumours, detect distant II/0
[B] metastases, and for medullary thyroid carcinoma in
MEN syndromes.
NM Indicated For the detection of residual/recurrent disease after IV
[B] thyroidectomy.
US Indicated Where appropriate expertise is available. 0
L08 [B]

Lung
Diagnosis CXR Indicated Lung cancer can have several different clinical I
[A] presentations and, if it is suspected, CXR is indicated.
A proportion of cancers will be radiographically
occult despite the presence of malignant cells in the
sputum.
CT Indicated CT has not yet been proven to be of benefit as a III
(See also N29–N31) [B] screening tool for lung cancer. CT will increase
L09 sensitivity of detection of early tumours.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Staging CT Indicated When correlated with histological findings, CT has an III
[A] overall accuracy of up to 80% in the detection of
mediastinal lymphadenopathy. Mediastinal lymph
node biopsy will be required in some cases to confirm
the CT findings prior to thoracotomy. PET is more
accurate (see below).
MRI Indicated only In the majority of patients with lung cancer MRI does 0
in specific not offer any benefits over CT. However, it is of value
circumstances in patients with superior pulmonary sulcus
[C] (Pancoast’s) tumours. MRI may also be of value in
demonstrating the vascular anatomy of the
mediastinum in those patients allergic to iodinated
contrast media. Studies have shown MRI to be better
than CT at differentiating tumour from distal
atelectasis.
PET Indicated FDG-PET is significantly more accurate than CT or IV
[B] MRI in the staging of patients with non-small-cell
lung cancer and has a high negative predictive value
L10 for nodal metastases.

Oesophagus
Diagnosis Ba swallow Indicated Before endoscopy in dysphagia, Ba studies are II
L11 [B] sensitive for the diagnosis of oesophageal cancer.

L. Cancer
Staging CT Indicated Many patients present with advanced disease that is III
[B] inoperable. CT can be used as the initial investigation
to exclude these patients. Endoscopic US is needed for
more accurate TNM staging, particularly if this will
alter the surgical approach.
Endoscopic US Indicated Requires expertise. If available, it can be initial 0
[B] investigation. Often used if CT suggests patient is
operable, to plan most appropriate surgery.
PET Specialised PET is of use in the pre-surgical assessment of patients IV
investigation with oesophageal cancer in order to detect metastases.
L12 [B]

Stomach
Diagnosis Endoscopy/ Indicated Endoscopy and double contrast Ba meal are equally 0/II
Ba meal [B] sensitive in the diagnosis of advanced gastric cancer.
L13 Endoscopy allows biopsy for histology.
Staging CT Indicated CT is currently the best staging investigation if active III
[B] treatment is planned. Endoscopic US is useful for local
staging. Laparoscopy is most sensitive for small
L14 peritoneal deposits.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

Liver: primary lesion

Diagnosis US Indicated The majority of lesions will be identified by US. 0
[B]
MRI/CT Specialised Indicated if biochemical markers are elevated and US 0/III
(See also N33, N34, investigation is negative or the liver is very cirrhotic. Enhanced MRI
N35) [B] and arterial-phase CT are most accurate in delineating
L15 tumour extent.
Staging MRI/CT Indicated MRI is probably the optimal investigation for 0/III
[B] assessing the involved segments and lobes. CT arterial
portography and intra-operative US are useful where
L16 available.
Liver: secondary lesion
Diagnosis US Indicated US will reliably detect metastases > 2 cm and can 0
[B] guide biopsy.
CT/MRI Indicated Indicated when US findings are negative and clinical III/0
[B] suspicion is high. MRI is better for characterising
lesions. CT arterial portography is sensitive but not
specific, but many now use triple-phase spiral CT
techniques following IV enhancement. CT and MRI
often form part of other staging and follow-up
protocols.

L. Cancer
PET Specialised Indicated when other imaging is equivocal, to exclude IV
investigation other metastatic disease prior to surgery.
L17 [C]

Pancreas
Diagnosis US/CT Indicated Much depends on local expertise and the patient’s 0/III
[B] body habitus. US is usually successful in thin patients;
CT is better in the more obese patient. Biopsy can be
performed using US or CT. Endoscopic US is the most
sensitive.
MRI/MRCP/ Specialised MRI for clarification of problems. MRCP or ERCP 0/0/
ERCP investigation may also be needed. Interest in PET is increasing. II
L18 [C]
Staging MRI/CT Indicated Especially if radical surgery is contemplated. There is 0/III
[B] wide local variation: some centres use angiography;
others, spiral CT.
PET Specialised Of use in cases where there is a significant possibility IV
investigation of distant spread.
[B]
Endoscopic US Specialised Should be reserved for those patients in a tertiary 0
investigation referral centre whose disease is deemed resectable on
L19 [B] the basis of CT/MRI.

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PROBLEM [GRADE]

Colon and rectum

Diagnosis Ba enema/ Indicated Much depends on local availability and expertise. III/0
colonoscopy [B]
CT Specialised Increasing interest in CT, particularly in the elderly III
investigation and infirm.
L20 [C]
Staging CXR, US Indicated For pulmonary and liver metastases. Endoluminal US I, 0
[B] is useful for local rectal spread.
CT, MRI Indicated Local pre-operative staging to assess rectal lesions III, 0
[B] before pre-operative radiotherapy. Many centres now
treat liver secondaries aggressively, which may
necessitate MRI and/or detailed CT. MRI and CT are
often complementary; both can assess other
L21 abdominal spread. Interest in PET is increasing.
Follow-up US Indicated For liver metastases. Preliminary evidence now 0
[B] supports routine imaging follow-up in asymptomatic
patients.
CT/MRI Indicated For liver metastases and local recurrence. III/0
[B]
PET Specialised PET is the best imaging technique for the evaluation IV
investigation of suspected local recurrence in patients with

L. Cancer
[A] colorectal cancer and is of use in the assessment of
L22 patients prior to hepatic resection for metastases.

Kidney
Diagnosis CXR Indicated To look for pulmonary metastases. I
[C]
US Indicated US is a sensitive detector of renal masses > 2 cm and 0
[B] accurately characterises masses as cystic or solid. US
helps to characterise some masses indeterminate at
CT.
IVU Not indicated Less sensitive than US for the detection of renal II
[B] masses. However, this is the method of choice for
detecting transitional cell carcinoma of the
pelvicalyceal system or ureters.
CT Indicated A sensitive detector of renal masses 1.0–1.5 cm and III
[B] accurately characterises masses.
MRI Specialised Contrast-enhanced MRI is as sensitive as contrast- 0
investigation enhanced CT for detecting and characterising renal
[B] masses. MRI should be used if masses are not
adequately characterised by CT and US or if iodinated
contrast medium is contraindicated because of
diminished renal function or allergy to iodinated
L23 contrast agents.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Staging CT/MRI Indicated MRI is better at detecting advanced stages, e.g. renal III/0
[B] vein involvement. CT and MRI are equivalent at
staging T1 disease.
PET Not indicated Current evidence with PET demonstrates no IV
[C] advantages for staging or detection of renal
L24 carcinoma.
Recurrence CT Indicated For symptoms suggesting relapse around III
[B] nephrectomy bed. Routine follow-up is not
L25 recommended.

Bladder
Diagnosis IVU Indicated only Cystoscopy is the investigation of choice to diagnose II
in specific bladder tumours.
circumstances
[B]
US Indicated only Not sufficiently accurate to assess small ( < 5 mm) 0
in specific bladder tumours, but enables assessment of upper
circumstances tract.
L26 [B]
Staging IVU Indicated To assess kidneys and ureters for further urothelial II
[B] tumours.
CXR Indicated To look for pulmonary metastases. I

L. Cancer
[C]
MRI Indicated Sensitive and specific and useful in invasive 0
[B] transitional cell carcinoma. CT is less specific than
MRI, but of use if MRI is not practicable.
PET Specialised Role yet to be clarified. IV
investigation
L27 [C]

Prostate
Diagnosis US Indicated Some variation according to local availability and 0
[B] expertise. TRUS (transrectal ultrasonography) is
L28 widely used together with guided biopsies.
Staging MRI Specialised Some variation exists in the range of investigative and 0
investigation therapeutic policies. MRI with appropriate coils is
[B] sensitive for assessment before possible radical
prostatectomy. Staging is continued into the abdomen
when pelvic disease is found. CT is of no value for
local staging.
NM Indicated To assess skeletal metastases, when PSA (prostate- II
L29 [B] specific antigen) is significantly elevated.

Testicle
Diagnosis US Indicated In suspected testicular malignancy and when 0
[B] presumed inflammatory disease does not respond to
L30 treatment

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Staging CT chest, Indicated CT is the mainstay of staging, and at initial diagnosis III-IV
abdomen, and [B] should include the chest, abdomen and pelvis. Pelvis
pelvis can be omitted if all risk factors, including abdominal
nodal disease, have been excluded. For non-
seminomatous germ cell tumours, thoracic CT is more
sensitive in the detection of pulmonary metastases
L31 than CXR.
Follow-up CT Indicated If risk factors for pelvic nodal disease have been III-IV
[B] excluded, pelvic CT may be omitted. The appearance
of residual masses may assist in decisions on whether
to undertake surgery. MRI has no clear advantage
over CT, apart from reducing radiation burden. CT of
previously involved areas can demonstrate
morphological evidence of enlargement of masses.
PET Specialised When a marker rises following treatment, F-18 FDG- IV
investigation PET may be helpful in identifying the site of relapse.
L32 [B]

Ovary
Diagnosis US Indicated Most ovarian lesions are initially identified on clinical 0
[B] examination or US. Transabdominal US supplemented
by transvaginal US and colour Doppler are used in
their evaluation.

L. Cancer
MRI abdomen Specialised MRI is useful for problem solving, as it is more 0
and pelvis investigation accurate than US in determining the presence of
[B] malignancy. Surgery is still required in some cases to
L33 distinguish benign from malignant disease.
Staging CT abdomen Specialised Many specialists request imaging in addition to III
and pelvis investigation staging by laparotomy.
[B]
MRI abdomen Specialised MRI is useful when enhanced CT is contraindicated, 0
and pelvis investigation the patient is pregnant, or for problem solving.
[B]
PET Specialised Indicated in difficult management situations to assess IV
investigation distant and local spread.
L34 [C]
Follow-up CT abdomen Specialised CT/MRI defines extent, but normal findings do not III
and pelvis investigation exclude recurrence. CT is used to assess treatment
[B] response.

MRI abdomen Specialised MRI is useful for surgical planning and problem 0
and pelvis investigation solving.
[B]
NM Specialised Clinical examination and the serum Ca-125 II
investigation radioimmunoassay are used to detect recurrent
L35 [C] disease.

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

Uterus: cervix
Diagnosis MRI Indicated only Usually a clinical diagnosis. MRI may assist in 0
in specific complex cases.
circumstances
L36 [B]
Staging MRI Indicated MRI provides better demonstration of tumour and 0
[B] local extent than CT, and is also better for pelvic
nodes. Para-aortic nodes and ureters must also be
examined. Some centres now use TRUS for local
invasion.
PET Indicated only PET is useful in difficult situations to define the extent IV
in specific of disease with accompanying image registration.
circumstances
L37 [C]
Relapse MRI abdomen Specialised MRI provides better information in the pelvis than CT. 0
and pelvis investigation Biopsy (e.g. of nodal mass) is easier with CT.
L38 [B]

Uterus: body
Diagnosis US/MRI Indicated MRI can give valuable information about benign and 0/0
L39 [B] malignant lesions.
Staging MRI Indicated MRI is the optimum technique for staging 0

L. Cancer
[B] endometrial carcinoma.
CT Not indicated CT is of limited value for local staging and is therefore III
L40 [B] unlikely to affect management.

Lymphoma
Diagnosis CT Indicated Diagnosis will usually be made by excision biopsy of III-IV
[B] a lymph node, but CT demonstration of extensive
nodal enlargement may strongly suggest the
diagnosis of lymphoma. For disease confined to the
torso it will also allow the selection of a site for image-
guided biopsy.
NM Specialised Ga-67 can show foci of occult disease (e.g. II
investigation mediastinum). PET is used in some centres.
L41 [B]
Staging CT Indicated Depending on the site of disease, the head and neck III-IV
[B] may also need to be examined.
MRI Indicated only While MRI is not indicated routinely as an initial 0
in specific staging test, it shows nodal sites as well as CT and can
circumstances image marrow burden of disease, which has
[B] prognostic implications.
PET Specialised FDG-PET is as accurate as CT. IV
investigation
L42 [B]

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Follow-up CT Indicated CT of areas affected at staging for Hodgkin’s disease. III-IV
[B] If there is clinical suspicion of relapse or progression,
it is appropriate to examine chest, abdomen and
pelvis, especially for non-Hodgkin’s lymphoma.
MRI Not indicated MRI may help assess the nature of a residual mass 0
initially detected at CT.
[B]
NM/PET Specialised Studies directly comparing Ga-67 and FDG-PET are III/IV
investigation limited. It is clear that FDG-PET is more sensitive and
[B] specific than Ga-67, especially for small masses and
below the diaphragm. With Ga-67 a pre-treatment
image must be obtained.
CXR Indicated For initial assessment of response in overt thoracic I
L43 [B] disease the CXR is entirely appropriate.
Musculoskeletal tumours
Diagnosis XR and MRI Indicated Imaging and histology are complementary. Best before I+0
[B] biopsy.
(See also section D)
NM Indicated To ensure that a lesion is solitary. III
L44 [B]
Staging MRI and CT Specialised MRI is best for local spread and extent. CT is used to 0 + III
chest investigation detect lung metastases.

L. Cancer
[C]
PET Specialised PET is best imaging technique for detecting IV
(See also section D) investigation metastases from an unknown primary tumour.
L45 [C]

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CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

Metastases from unknown

primary tumour
Diagnosis of primary CXR Indicated CXR can help to identify the source of the occult I
lesion. [B] primary.
CT chest, Specialised CT is the most sensitive investigation in determining IV
abdomen, and investigation the primary site. This may allow effective treatment,
‘Carcinoma, unknown
pelvis [B] e.g. for lung cancer, and palliation. It also allows entry
primary’ is a diagnosis
into clinical trials and has unquantified psychological
of exclusion and not a
benefits to patient and doctor.
diagnosis in its own
right. Mammography Indicated only Breast cancer survival is better from occult breast I
Histology review is key in specific cancer metastases. Even in the presence of metastases,
to identifying likely circumstances it is worthwhile to diagnose and treat cancer of the
sites of primary [C] breast.
tumours and treatable
MRI breast Specialised MRI may demonstrate a primary breast carcinoma 0
tumours, e.g.
investigation with axillary lymph node metastases despite a normal
lymphomas, germ cell
[B] mammogram and US.
tumours, and head and
neck primary tumours. PET head and Specialised After full work-up, including CT or MRI. IV
The site of initially neck, supra- investigation
identified metastases diaphragmatic, [C]
determines the likely or whole body
origin, e.g. disease in
upper cervical lymph

L. Cancer
nodes is likely to come
from head and neck
primaries, disease in
axillary lymph nodes
from breast carcinoma,
and cancer cells in
ascites from ovarian
carcinoma in women.

(For breast disease see

section J)
L46

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

M. Paediatrics
(For head injury in children see section K)
Central nervous system

Congenital disorders: MRI Indicated Definitive exam for all malformations, avoiding x- 0
head [B] irradiation. CT may be needed to define bone and
Minimise x-irradiation in children, especially those with long-term problems

skull base anomalies. Sedation or GA may be required

for infants and young children, and in some cases
M01 therefore CT may be preferred.
Congenital disorders: MRI Indicated Definitive exam for all malformations, avoiding x- 0
spine [B] irradiation. CT may be needed to delineate bone
detail. Sedation or GA may be required for infants and
M02 young children.
Abnormal head US Indicated US indicated where anterior fontanelle is open. Where 0
appearance: [B] sutures are closed/closing, MRI is indicated (older
hydrocephalus children). CT may be appropriate if MRI is not
available.
SXR Specialised SXR and low-dose CT with 3-D reconstructions are I

M. Paediatrics
investigation indicated in craniostenosis.
M03 [C]
Epilepsy MRI Specialised Specialist clinical assessment and EEG investigation 0
investigation should usually be undertaken before MRI, unless
[A] there are signs of raised intracranial pressure or an
acute neurological deficit. There is no routine
indication for CT.
PET/NM/ Specialised Useful in pre-surgical evaluation. II-IV
SPECT/rCBF investigation
[B]
(See also A19)
M04 SXR Not indicated [B] Poor yield. I
Deafness in children MRI and/ Specialised Both MRI and CT may be necessary in children with 0/II
or CT investigation congenital and post-infective deafness.
M05 [C]
Hydrocephalus XR Indicated XR should include whole valve system. I
?shunt malfunction [B]
US/MRI Indicated US if practicable; MRI in older children (or CT if MRI 0/0
[B] unavailable). Neurosurgeons may still want cross-
sectional imaging even if US is performed. New
programmable valves cause problems in MRI.
(See also A10 ) US of abdomen is indicated if CSF (cerebrospinal
M06 fluid) collection is likely.
Developmental delay MRI Specialised Remains a controversial area with regard to whom to 0
?cerebral palsy investigation screen and why. Further studies are needed to
[C] improve the accuracy of predicting patient outcome,
particularly using newer MRI techniques of diffusion,
M07 spectroscopy, and functional imaging.

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Headache SXR Not indicated If headache is persistent or associated with clinical I
[C] signs, refer patient for specialised investigations.
MRI/CT Specialised In children MRI is preferable if available because of 0/II
investigation absence of x-irradiation.
(See also A06, A07,
[B]
A13) (See A06 for possible meningitis and encephalitis,
M08 and see also A07 and A13)
Sinusitis XR sinus Indicated only Not indicated at < 5 years old as the sinuses are I
in specific poorly developed; mucosal thickening can be a
Minimise x-irradiation in children, especially those with long-term problems

(See also A13) circumstances normal finding in children.

M09 [B]

Neck and spine

Torticollis without XR Indicated only Muscular causes are most common, but when history I
trauma in specific and examination are atypical, XRs are advised.
circumstances
[B]
CT Indicated only Persistent torticollis for one week justifies further II
in specific imaging following consultation.
circumstances
[B]

M. Paediatrics
US Indicated In congenital torticollis, US of neck muscles is a useful 0
[B] diagnostic tool in confirming sternocleidomastoid
tumour in infants. If US is negative, XR and cross-
M10 sectional imaging are indicated.
Back pain MRI/CT Indicated Persistent back pain in children may have an 0/II
[B] underlying cause and justifies investigation. Choice of
(See also C07-C08) imaging following consultation. Back pain with
M11 scoliosis or neurological signs merits MRI/CT.
Spina bifida occulta US/MRI Not indicated A common variation and not in itself significant. 0/0
[C] Investigation is only indicated if neurological signs
M12 are present.
Hairy patch, US/MRI Indicated only Isolated sacral dimples and pits may be safely ignored 0/0
sacral dimple in specific (< 5 mm from midline; < 25 mm from anus). US of the
circumstances neonatal lumbar spine and canal is the initial
[B] investigation of choice if there are other stigmata of
spinal dysraphism or associated congenital
abnormalities, e.g. cloacal exstrophy anorectal
malformation spectrum (CEARMS). MRI is indicated
if neurological signs are present, or there is a
M13 discharging lesion.
Neonatal NM Specialised Tc-99m or I-123 thyroid scintigraphy is the most II
hypothyroidism investigation accurate diagnostic test to detect thyroid dysgenesis
[B] or one of the inborn errors of T4 synthesis in patients
M14 with congenital hypothyroidism.

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

Musculoskeletal
Non-accidental injury/ Skeletal survey Indicated Age 0–2 years, CT of the head is mandatory. II
child abuse (age 0–2 years) Age 3–5 years, XR clinically suspicious area.
[A] Age > 3 years skeletal survey is not generally
indicated, as children >3 years can usually describe
where pain is located.
Examinations should be performed by radiographers
trained in paediatric radiographic techniques.
Minimise x-irradiation in children, especially those with long-term problems

(For head injury see NM Indicated Bone scintigraphy is indicated in children > 2 years if II
section K) [B] the skeletal survey is equivocal. Abnormal bone
findings must always be correlated with clinical
M15 history, physical examination, and pertinent XRs.
Limb injury: Comparison Not indicated Seek radiological advice. I
opposite side for XRs of the [B]
comparison joint on the
contralateral
M16 side
Short stature, XR for bone Indicated Child aged 1 year and over: left (or non-dominant) I
growth failure age [A] hand/wrist only.
XR may need supplementing with further specialised

M. Paediatrics
investigations. Skeletal scintigraphy if dysplasia is
suspected. MRI of hypothalamus-pituitary fossa if
M17 central hormone failure is a possibility.
Irritable hip US Indicated US will confirm presence of an effusion but will not 0
[B] discriminate sepsis from transient synovitis.
XR Not indicated XR, which may include a frog lateral view, is required I
initially if slipped upper femoral epiphysis or Perthes’ disease
[C] is suspected or if symptoms persist. If symptoms
(See also M19, M21) persist, then follow-up should be as for the limping
M18 child
Limping US Indicated US will confirm the presence of an effusion but will 0
[B] not discriminate sepsis from transient synovitis.
XR Not indicated Children with a limp need proper clinical assessment. I
initially If pain persists, or localising signs are present, XR is
[B] indicated.
MRI Specialised Should be used after discussion with radiologist. 0
investigation
[C]
NM Not indicated XR and US should be performed before NM. NM is II
initially useful for localisation when XR and US are normal.
[B] The age of the child is an important factor in limiting
M19 the diagnostic possibilities.

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Focal bone pain XR Indicated XR should be the first-line investigation, though MRI I
[B] and NM are more sensitive than XR in detecting
occult infection or fracture.
NM Specialised XR should be obtained initially. Skeletal scintigraphy II
investigation is useful if pain is not well localised. A negative
[B] multiphasic study does not exclude active arthritis.
MRI Specialised Particularly useful if the child can localise the site of 0
investigation the pain.
Minimise x-irradiation in children, especially those with long-term problems

[C]
US Specialised US can detect occult infection. 0
investigation
M20 [C]
Clicking hip: US Indicated US is indicated where there is clinical doubt about 0
dislocation [A] developmental dysplasia of the hip but not for routine
M21 screening. XR may be necessary in the older child.
Osgood-Schlatter XR Indicated only Although bony radiological changes are visible in I
disease in specific Osgood-Schlatter disease, these overlap with normal
circumstances appearances. Associated soft tissue swelling should be
M22 [C] assessed clinically rather than radiographically.

Cardiothoracic

M. Paediatrics
Acute chest infection CXR Indicated only CXR indicated if symptoms persist despite treatment I
in specific or in severely ill children. If CXR is performed and
circumstances demonstrates simple pneumonia, routine follow-up
M23 [A] CXR is not required.
Recurrent productive CXR Indicated only In general, children with recurrent productive cough I
cough in specific have CXRs which are normal or show peribronchial
circumstances thickening. Routine follow-up CXR is not indicated
[C] unless atelectasis is seen on initial CXR. Suspected
cystic fibrosis or immune deficiency require specialist
M24 referral.
Cystic fibrosis NM Indicated only Perfusion lung scintigraphy is useful in selected cases, II
in specific especially if surgery is contemplated.
circumstances
M25 [B]
Inhaled foreign body CXR Indicated CXR is indicated, though often normal. If there is I
(suspected) [B] clinical suspicion of an inhaled foreign body,
bronchoscopy is mandatory.
While air trapping is the most common sign seen in
patients with inhaled foreign bodies, it is seen
(See also section K27, infrequently and the routine use of expiratory XRs is
K28 and B06) not warranted. Fluoroscopy is often a better and
M26 easier alternative to expiratory XR.
Wheeze CXR Indicated only In most children with wheeze, the CXR is either I
in specific normal or shows features of uncomplicated asthma or
circumstances bronchiolitis, such as hyperinflation or peribronchial
[B] cuffing. In selected cases, such as those with fever or
(See also M26) localised crackles, the CXR may be useful in guiding
M27 patient management.

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Acute stridor Lateral XR soft Indicated only Epiglottitis and croup are clinical diagnoses. Lateral I
tissue neck in specific neck XRs may be of value in children with a stable
circumstances airway in whom an obstructing foreign body or
M28 [B] retropharyngeal abscess is possible.
Heart murmur CXR/US Indicated only Specialist referral is needed; cardiac US may be I/0
in specific indicated.
circumstances
M29 [C]
Minimise x-irradiation in children, especially those with long-term problems

Gastrointestinal
Intussusception US-guided or Indicated US has high sensitivity in diagnosing intussusception 0/II
fluoroscopy- [A] but is operator-dependent. It is useful in assessing
guided blood flow and identifying lead points and small
hydrostatic/ bowel intussusceptions.
pneumatic
Pneumatic reduction has a higher success rate than
reduction
traditional hydrostatic reduction. However, there is a
slightly higher risk of perforation (approximately 1%).
Absolute contraindications are perforation, shock, and
M30 peritonitis.
Swallowed foreign AXR Indicated only Only for sharp or potentially poisonous foreign body, I
body in specific e.g. battery.

M. Paediatrics
circumstances
[C]
(See also B06, K27-K29) CXR, Indicated If there is doubt whether the foreign body has passed, I
M31 including neck [B] an AXR after six days may be indicated.
Blunt abdominal AXR Indicated only Clinical assessment of the patient should be used to I
trauma in specific determine which patients require further evaluation
circumstances by imaging. AXR is of limited use after minor trauma
[B] unless there are positive physical signs suggestive of
intra-abdominal pathology or injury to the spine or
bony pelvis.
US Indicated only US may be used to search for the presence of free fluid 0
in specific following blunt abdominal trauma, but a negative
circumstances examination does not exclude the presence of intra-
[B] abdominal injury.
CT Specialised CT with IV contrast remains the primary imaging III
investigation investigation of choice to detect the presence and
[B] extent of intra-abdominal injuries following blunt
abdominal trauma, and will guide the level or
intensity of hospital and post-discharge management
of the patient. US may be useful in the follow-up of
known organ injuries, to reduce the total radiation
M32 burden to the patient.
Projectile vomiting US Indicated US can confirm the presence of hypertrophic pyloric 0
in infants [A] stenosis, especially where clinical findings are
M33 equivocal.

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Recurrent vomiting Contrast meal Indicated only Recurrent vomiting in children can be caused by a II
± follow- in specific wide variety of conditions, many of which cannot be
through circumstances diagnosed radiologically. An upper GI contrast study
[C] is not indicated for the diagnosis of simple gastro-
oesophageal reflux. Where significant gastro-
oesophageal reflux has been shown on pH studies, an
upper GI contrast study may be indicated to exclude a
significant structural abnormality such as hiatus
hernia or malrotation. If there are other associated
Minimise x-irradiation in children, especially those with long-term problems

clinical symptoms/signs, e.g. bile-stained vomit, the

case for contrast studies is much stronger.
NM Specialised Gastric emptying may be measured with Tc-99m – II
investigation labelled solid or fluid meal. This may be combined
[B] with scintigraphic evaluation and gastro-oesophageal
M34 reflux.
Persistent neonatal US Specialised Early (< 10 weeks) and prompt investigation is 0
jaundice investigation essential. The absence of dilatation in the intrahepatic
[B] bile duct does not exclude obstructive cholangiopathy.
NM Specialised Hepatobiliary scintigraphy with Tc-99m – labelled II
investigation IDA derivatives. This cannot confirm biliary atresia if
M35 [B] there is no bowel activity.

M. Paediatrics
GI bleeding (per AXR Indicated only Imaging strategy depends on the age of the patient I
rectum) in specific and severity of bleeding, diagnostic possibilities, and
circumstances clinical presentation. AXR is required if necrotising
[C] enterocolitis is suspected.
US Specialised US for diagnosis of intussusception and 0
investigation demonstration of duplication cysts. Upper or lower GI
[C] endoscopy is often the most useful next investigation.
Consider a small bowel enema if the suspected
pathology is inaccessible to endoscopy.
NM Specialised NM is used for detecting active bleeding sites II
investigation including Meckel’s diverticulum. Angiography is
[C] used for investigation of rapid haemorrhage or
M36 chronic haemorrhage not found by other means.
Acute abdominal pain US Specialised Acute abdominal pain can be due to a diverse range 0
investigation of causes. US can be helpful in further assessment but
[C] needs to be guided by clinical findings.
AXR Indicated only Rarely of value and best performed under specialist II
in specific guidance. Generally AXR is not undertaken prior to
circumstances US.
M37 [C]
Constipation AXR Indicated only There is a wide variation in the amount of faecal II
in specific residue shown on the AXR and good correlation with
circumstances constipation has not been proven. Additionally there
[C] is inter-observer variation in interpretation. AXR can
help specialists in the management of intractable
Continued M38 constipation.

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Constipation Contrast Indicated only Non-radiological investigations, i.e. rectal manometry II
enema in specific and biopsy are preferred. Contrast enema may have a
Continued
circumstances role if these are not available and referral is difficult.
M38 [B]
Palpable abdominal/ US Indicated Indicated in the evaluation of all suspected abdominal 0
pelvic mass [C] masses. If the presence of a mass is confirmed, the
M39 patient should be referred to a specialist centre.

Genitourinary
Minimise x-irradiation in children, especially those with long-term problems

Continuous wetting US Indicated In toilet-trained girls with a history of continuous 0

[B] dribbling/wetting, an ectopic infrasphincteric ureter
must be excluded. US of the whole renal tract
including the bladder and pelvis is recommended in
addition to video-urodynamics. Imaging of the
urinary tract in children with solely night-time
enuresis is of limited value.
XR Indicated Indicated in children with abnormal neurology or II
lumbosacral [B] skeletal examination, in addition to those with
spine bladder wall thickening/trabeculation demonstrated
on US or neuropathic vesicourethral dysfunction on
video-urodynamics.

M. Paediatrics
NM Indicated only DMSA imaging is useful in the detection and location II
in specific of the dysplastic kidney and upper moiety of a duplex
circumstances system.
[B]
IVU Indicated only To confirm the ectopic infrasphincteric ureters in girls II
in specific with a known duplex system on US and/or DMSA
circumstances imaging.
[B]
CT/MRI Specialised CT/MRI may be of value to locate the dysplastic III/0
investigation kidney or dysplastic occult moiety when US and
[B] DMSA imaging have failed. MRI urography, if
M40 available, is an alternative to IVU.
Impalpable testis US Indicated To locate testis within the inguinal canal. 0
[B]
MRI/ Specialised MRI may be of value after US to locate intra- 0
laparoscopy investigation abdominal testis, but laparoscopy is generally
M41 [C] preferred.
Fetal renal pelvic US Indicated Ideally US should be performed post-partum at 72 0
dilatation [B] hours and again at 4 to 6 weeks. Other imaging
investigations including MCUG (micturating
cystouretography) and diuretic renography should be
performed as per local protocol.
NM Specialised In cases of persistent postnatal pelvic dilatation, II
investigation MAG-3 diuretic renography is essential to estimate
[B] renal uptake function (differential function) as well as
M42 drainage.

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Proven urinary tract US Specialised There is wide variation in local policy. Much depends 0
infection investigation on local technology and expertise. Most patients
[C] should remain on prophylactic antibiotics pending the
results of investigations. The age of the patient also
influences decisions. There is much current emphasis
on minimising radiation dose; hence AXR is not
indicated routinely (calculi are rare). Expert US is the
key investigation in all imaging strategies at this age.
NM Specialised There is an increasing trend to examine the acutely ill II
Minimise x-irradiation in children, especially those with long-term problems

investigation child secondary to urinary tract infection with a

[A] DMSA study in the acute setting. In the out-patient
setting, to exclude a scar a DMSA study should be
done 3 to 6 months after a proven urinary tract
infection. NM will establish function and exclude
obstruction.
XR Specialised Direct XR cystography is still needed in the young II
cystography investigation (e.g. < 2 years old) male patient where delineation of
[A] the anatomy (e.g. urethral valves) is critical.
NM Specialised NM can also be used for direct or indirect II
investigation cystography.
M43 [B]

M. Paediatrics

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]

N. Interventional
radiology
NB Dosages will vary with fluoroscopy time, and this depends on the degree of complexity of each case

Asymptomatic carotid Endovascular Indicated only Critical appraisal of the literature reveals a need for III
disease (angioplasty in specific further studies.
(See also B05) and stents) circumstances
N01 management [C]
Symptomatic carotid Percutaneous Indicated only The recommended treatment for the majority of III
disease balloon in specific patients remains endarterectomy. Potential indications
angioplasty circumstances for endovascular treatment include unsuitability for
and stent [B] endarterectomy, status post radiotherapy, surgical
placement restenosis, high lesions, or circumstances where
treatment is closely audited or part of structured
N02 research in an experienced unit.

N. Interventional radiology
Pulmonary embolus Insertion of Indicated only In the presence of known lower limb and/or pelvic II
IVC filter in specific venous thrombosis the insertion of an IVC (inferior
circumstances vena cava) filter is only indicated if there are proven
[B] pulmonary emboli despite adequate anticoagulation,
N03 or when anticoagulation is contraindicated.
Pulmonary Pulmonary Specialised A prerequisite to other diagnostic intervention at the III
arteriovenous angiography investigation time of treatment by embolisation.
malformation and [B]
(AVM) embolisation
CT Specialised May be useful in the diagnosis of pulmonary AVMs. III
investigation Non-contrast helical study is usually all that is
[B] needed. Some centres recommend this study prior to
treatment by embolisation in order to measure feeding
vessels and assess anatomy.
CXR Indicated CXR is indicated when this diagnosis is suspected and I
[B] to assess response to treatment. Follow-up
assessment is initially performed six-monthly or
yearly after embolisation and then five-yearly if no
growth. CXR is also indicated as a screening tool in
relatives of patients with pulmonary AVMs associated
with hereditary haemorrhagic telangiectasia.
MRI brain Specialised To look for evidence of previous paradoxical cerebral 0
investigation embolisation in patients with pulmonary AVM
[C] diagnoses. MRI is also used to look for evidence of
cerebral AVMs in patients with associated hereditary
haemorrhagic telangiectasia.
MRI thorax Specialised As an alternative to thoracic CT, to confirm diagnosis 0
investigation of pulmonary AVMs. MRI thorax may be useful for
[C] diagnosis, but is not necessary in the majority of
Continued N04 patients.

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Pulmonary NM Specialised Perfusion scintigraphy is performed with Tc-labelled II
arteriovenous investigation macroaggregates for measurement of right to left
malformation (AVM) [B] shunt. It is useful for diagnosis and follow-up
NB Dosages will vary with fluoroscopy time, and this depends on the degree of complexity of each case

Continued assessment after treatment.

US Specialised Research tool only at present. Doppler US of carotids 0
investigation or cardiac chambers is performed after IV injection of
[C] agitated saline or US contrast agent to determine
presence of right to left shunt. It is useful for
N04 diagnosis.
Abdominal aortic Insertion of Specialised Endovascular repair of abdominal aortic aneurysms is III
aneurysms stent-grafts intervention a procedure that should only be performed in
N05 [B] specialist units.
Leg ischaemia Primary Indicated The decision to place a stent following angioplasty III
(claudication, rest pain angioplasty [A] depends on a number of factors, one of which is a
with or without tissue plus selective residual pressure gradient across the treated area. The
loss) with iliac stenotic stenting exact pressure gradient after PTA (percutaneous
disease transluminal angioplasty) that mandates stent

N. Interventional radiology
placement is unknown. In general, a mean pressure
N06 gradient of 10 mm Hg is considered appropriate.
Leg ischaemia Iliac stent Indicated The policy of primary stenting for iliac occlusive III
(claudication, rest pain placement [B] disease is accepted.
with or without tissue
loss) with iliac
occlusive disease
N07
Leg ischaemia Superficial Indicated PTA of the superficial femoral and popliteal arteries is III
(claudication, rest pain femoral/ [B] effective for restoring patency in the short term, but
with or without tissue popliteal repeat angioplasty can be performed to avoid the
loss) with femoral artery need for surgical bypass. Primary clinical success
occlusive disease angioplasty rates are inferior to those of surgical bypass grafts.
N08
When there is a suitable lesion in the tibioperoneal III
Leg ischaemia Tibioperoneal Indicated trunk, angioplasty should be the first-line treatment in
(claudication, rest pain trunk [B] patients with critical ischaemia and claudication.
with or without tissue angioplasty
loss) with tibioperoneal
occlusive disease.
N09
Severe acute GI Endoscopy/ Specialised Stabilising the patient is a priority. Endoscopy is the 0/III
bleeding from DSA with or intervention first-line intervention.
unknown source without [C]
If endoscopy is negative or unsuccessful, DSA and
requiring continuous embolisation
embolisation follow immediately. However, the
substitution
patient must be actively bleeding as contrast
extravasation is the only diagnostic sign to locate a
N10 source. Unsuccessful embolisation indicates surgery.

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Variceal haemorrhage TIPS Indicated only Endoscopic therapy should be the first-line treatment III
in specific for bleeding varices, with TIPS (transjugular
circumstances intrahepatic portosystemic shunt) reserved for
NB Dosages will vary with fluoroscopy time, and this depends on the degree of complexity of each case

[A] treatment failures. Surgical portosystemic shunting is

more durable and may be preferred in medically fit
N11 patients.
Ascites due to portal TIPS Indicated only TIPS is of limited efficacy and is associated with III
hypertension in specific substantial mortality, particularly in Child’s grade C
circumstances liver disease and/or renal impairment.
N12 [B]
Acute massive lower GI DSA and/or Indicated DSA and embolisation is safe and effective when GI III
haemorrhage embolisation [B] bleeding is life-threatening.
N13
Chronic or recurrent DSA and/or Specialised Only undertaken after appropriate imaging. III
upper GI haemorrhage embolisation intervention Recurrent blood loss can be investigated with DSA
[C] and/or NM (red cell) study.
(See also G05)
N14

N. Interventional radiology
Chronic mesenteric Superior Indicated In carefully selected patients mesenteric artery III/III
ischaemia mesenteric [B] PTA can be performed relatively safely with good
artery PTA/ technical and clinical results. Superior mesenteric
superior artery stenting can improve the result of angioplasty
mesenteric and may become the therapy of choice in ostial
N15 artery stenting superior mesenteric artery stenosis.
Subphrenic abscess US-/CT- Indicated US is the best technique for draining subphrenic 0/III
guided [C] abscesses as it allows an angled approach and real-
percutaneous time imaging. CT may also be helpful in that it may
drainage of provide a more detailed road map including accurate
subphrenic localisation of the pleural space.
N16 abscess
Pelvic abscess CT-/US- Indicated Percutaneous-transperineal, -transsciatic, -transrectal, III/0
guided [B] and -transvaginal routes are all effective in the
catheter treatment of pelvic abscess. The presence of an enteric
N17 drainage fistula is a risk factor for failure.
High biliary Percutaneous Indicated Choice of endoscopic or transhepatic route for III
obstruction transhepatic [B] cholangiography may depend on local expertise.
(intrahepatic ducts or cholangio- Percutaneous drainage is not recommended as a long-
upper half of graphy term option due to catheter problems such as peri-
extrahepatic bile duct) drain leak, drain displacement, and cholangitis. For
surgical reconstruction percutaneous transhepatic
cholangiography may be more valuable than
endoscopic retrograde cholangiography since it
N18 defines the anatomy of the proximal biliary tree.
Low biliary obstruction Percutaneous Indicated Preference for transhepatic or endoscopic retrograde III
(lower half of transhepatic [B] cholangiography may depend on local expertise.
extrahepatic bile duct cholangio-
or pancreatic duct) graphy
N19

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Actual or suspected Percutaneous Indicated Percutaneous transhepatic or transperitoneal III
acute calculous or transhepatic or [B] cholecystotomy is appropriate in the diagnosis and
acalculous cholecystitis transperitoneal management of actual or suspected acute calculous or
NB Dosages will vary with fluoroscopy time, and this depends on the degree of complexity of each case

chole- acalculous cholecystitis in high-risk patients.

N20 cystostomy
Hypertension due to Renal PTA Indicated Renal PTA in a specialist centre is indicated. III
fibromuscular with or [B]
dysplasia without stent
N21
Hypertension due to Renal PTA Indicated only Hypertension due to atherosclerotic renal artery III
atherosclerotic renal with or in specific stenosis should be treated by medical therapy. Renal
artery stenosis without stent circumstances PTA/stenting may be beneficial in selected patients
[A] with uncontrollable hypertension.
N22
Renal failure due to Renal PTA Indicated only Indications for renal PTA/stenting are not established. III
atherosclerotic renal with or in specific These procedures should only be performed after
artery stenosis without stent circumstances careful patient selection in specialist centres.

N. Interventional radiology
N23 [B]
Flash pulmonary Renal PTA Indicated Renal PTA/stenting should be considered in patients III
oedema due to with or [B] with recurrent pulmonary oedema with tight bilateral
atherosclerotic renal without stent renal artery stenosis or stenosis in a single kidney.
artery stenosis
N24
Renal calculi Percutaneous Indicated Percutaneous nephrolithotomy is generally accepted III
nephro- [C] as the first-line treatment for renal stone 3 cm or more
lithotomy in maximum diameter, as well as with certain
anatomical abnormalities such as calyceal diverticula
and rotated/ectopic kidneys, and in morbidly obese
patients, when other treatment modalities have failed.
N25
Varicocele Embolisation Indicated Embolisation is effective in the management of III
of varicocele [A] varicocele, either for subfertility or for symptoms, and
N26 is associated with fewer complications than surgery.
Abdominal trauma DSA/ Specialised Intervention when the patient is stable. The patient III
with acute GI bleeding embolisation intervention must be actively bleeding as contrast extravasation is
with or without [C] essential for the source of haemorrhage to be located
retroperitoneal or by DSA. Embolisation or surgery may follow as
intraperitoneal appropriate.
haemorrhage
(See also K34-K37)
N27
Embolisation for Pelvic Indicated Patients with pelvic fracture who remain III
uncontrolled embolisation [A] haemodynamically unstable after initial resuscitation
haemorrhage after should undergo diagnostic pelvic angiography with
pelvic fracture embolisation if a source of arterial bleeding is
N28 identified.

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Pulmonary mass: Fluoroscopic Specialised Fluoroscopic lung biopsy in appropriately selected III
diagnosis lung biopsy intervention cases and performed by experienced operators has a
[B] low complication rate and high diagnostic yield for
NB Dosages will vary with fluoroscopy time, and this depends on the degree of complexity of each case

pulmonary malignancy.
CT-guided Specialised CT-guided lung biopsy is an accurate means of III
lung biopsy intervention obtaining a diagnosis of malignancy or benign disease
[B] (if a cutting needle is used) in patients with large or
small pulmonary nodules.
US-guided Specialised For appropriately selected patients with pulmonary 0
lung biopsy intervention lesions abutting the chest wall, US-guided biopsy is a
N29 [B] safe and accurate method of obtaining a tissue diagnosis.
Mediastinal mass (non- CT-guided Specialised CT guidance can be used to aid biopsy of anterior, III
vascular) biopsy intervention middle, and posterior mediastinal masses.
[B]
US-guided Specialised The majority of anterior mediastinal masses can be 0
biopsy intervention safely and accurately biopsied using US guidance.
[B] Alternative biopsy routes to the parasternal approach

N. Interventional radiology
N30 such as a supraclavicular approach may be helpful.
Vena caval obstruction SVC/IVC stent Specialised Patients with malignant SVC/IVC obstruction are often III
placement intervention frail and have a short life expectancy. Their symptoms are
[B] distressing and are usually incompletely relieved by
radiotherapy. SVC/IVC stenting is a simple palliative
procedure performed under local anaesthesia. Following
stenting, most patients will remain asymptomatic.
Symptomatic recurrence occurs in about 10% of patients
and is usually amenable to repeat treatment. Early
referral is preferable as extensive venous thrombosis
complicates treatment. Stenting should be the first-line
treatment of malignant SVC/IVC obstruction caused by
cancers that do not respond quickly to chemotherapy or
radiotherapy. Alternatives to stenting (angioplasty and
surgery) should be considered in patients with benign
N31 strictures and those with a long life expectancy.
Percutaneous Percutaneous Specialised There is little to choose between percutaneous and III
gastrostomy required gastrostomy intervention endoscopic placement of gastrostomy catheters. The
for enteral nutrition [B] technique of choice may be dependent on the local
N32 expertise available.
Focal liver lesion(s) CT-/US- Indicated The guideline assumes normal coagulation indices. III/0
requiring biopsy guided biopsy [B] Image guidance is dependent on local expertise.
N33
Unresectable liver Radiofrequency Specialised Radiofrequency ablation should be used in patients III
tumours ablation intervention with a small number of accessible liver tumours
N34 [B] unsuitable for hepatic resection.

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 CLINICAL/DIAGNOSTIC INVESTIGATION RECOMMENDATION COMMENT DOSE
PROBLEM [GRADE]
Primary hepatoma and Radiofrequency Indicated Radiofrequency ablation is indicated for primary III/III
liver metastases ablation/ [B] hepatoma and liver metastases. For the vast majority
hepatic of liver metastases it is more effective than
chemo- chemoembolisation. Hepatic chemoembolisation has a
embolisation significant antitumoral effect but this is offset by liver
decompensation secondary to embolisation of non-
tumour-bearing liver. Selective chemoembolisation
should minimise the side-effects of this treatment.
Chemoembolisation has also been used for palliation
N35 in neuroendocrine tumours and metastatic sarcoma.

Appendix
List of bodies involved in the consultation exercise:

Royal Colleges, etc. Royal College of Pathologists

European Association of Radiology Royal College of Surgeons of Edinburgh
European Congress of Radiology Royal College of Surgeons of England
Faculty of Accident and Emergency Medicine Royal College of Surgeons of Ireland
Faculty of Dental Surgery, RCS Royal Society of Medicine
Faculty of Clinical Oncology, RCR The Society and College of Radiographers
Faculty of Occupational Medicine
Other organisations
Faculty of Public Health Medicine
British Institute of Radiology
Royal College of Anaesthetists
British United Provident Association
Royal College of General Practitioners
European Commission
Royal College of Paediatrics and Child Health
Medical Defence Union
Royal College of Physicians of London
Medical Protection Society
Royal College of Physicians and Surgeons of Glasgow
National Radiological Protection Board
Royal College of Physicians of Edinburgh
Radiological Protection Institute of Ireland
Royal College of Physicians of Ireland
Union of European Medical Specialists
Royal College of Psychiatrists
Professional associations in radiology in each European state
Royal College of Obstetricians and Gynaecologists
Royal College of Ophthalmologists

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Specialty groups
Association of Chest Radiologists
British Society of Thoracic Radiologists
British Society of Nuclear Medicine
British Society of Gastroenterology
British Society of Interventional Radiology
British Society of Neuroradiologists
British Medical Ultrasound Society
British Society of Paediatric Radiologists
British Society of Skeletal Radiologists
Cardiovascular & Interventional Radiological Society of Europe
Dental Radiology Group
European Association of Nuclear Medicine
European Society of Breast Imaging
European Society of Cardiac Radiology
European Society of Gastrointestinal & Abdominal Radiology
European Society of Head & Neck Radiology
European Society of Thoracic Imaging
European Society of Neuroradiology
European Society of Musculoskeletal Radiology
European Society of Paediatric Radiology
European Society of Urogenital Radiology
Magnetic Resonance Radiologists Association UK
RCR Cardiac Radiology Group
RCR Breast Group
RCR Clinical Directors’ Group
RCR Interventional Radiology Sub-Committee
RCR Nuclear Medicine Sub-Committee
RCR Paediatric Group
RCR/RCOG Intercollegiate Standing Committee on
Obstetric Ultrasound
RCR/RCP Intercollegiate Standing Committee on
Nuclear Medicine
SIG in GI and Abdominal Radiology (SIGGAR)
UK Children’s Cancer Study Group
UK Neurointervention Group

160