Ultrasound guidance

Overview

UHBW and NBT Radiology Guidance for GPs Requesting Non-obstetric Ultrasound Examinations.

Click on the link above to access guidelines that have been developed by the local ultrasound departments and a GP representative with a view to help general practitioners use ultrasound most effectively. Advice from the Royal College of Radiologists, British Medical Ultrasound Society, NICE Guidance and relevant local guidelines have been utilised. The ultrasound departments at both trusts will also use the same guidance to vet ultrasound requests, therefore providing a more standardised service to the Primary Care setting.

The guidance covers the following areas, with links to the relevant section from page 2 of the document:

• Testes
• Abnormal Liver Function Tests (LFTs)
• General Abdominal Symptoms
• Biliary symptoms
• Miscellaneous Abdominal Symptoms/indications
• Renal tract
• Haematuria
• Gynaecology
• Hernias
• Lymph nodes
• Head and Neck

There may be specific clinical situations that do not fit within the scope of these guidelines. In such cases, or if there are any clinical queries, please contact the relevant departments for advice or to discuss.

Contact Details:

• UHBW (Bristol) Main Ultrasound Department: 0117 342 9362
• UHBW (Weston) Ultrasound Department: 01934 636363
• NBT Main Ultrasound Department: RadiologyQueries@nbt.nhs.uk

Common inappropriate USS requests

The most common inappropriate ultrasound requests are:

1. Vague requests for generalised abdominal/pelvic pain with no specific clinical history or clinical question given.

Imaging requests should include a specific clinical question(s) to answer and contain sufficient information from the clinical history, physical examination and relevant laboratory investigations to support the suspected diagnosis (es)

Vague requests for generalised abdominal pain will usually be of a low value and in some cases CT or MRI would be more appropriate especially if bowel symptoms or ? suspected occult malignancy. Given sufficient clinical information, we may re-direct US requests to CT or MR where appropriate with input from our consultant radiologists.

Some scan requests are for UABPE (abdomen and pelvis) with limited clinical information relevant to only one area ie. upper abdomen/renal/pelvis. The examination will be tailored to fit the clinical history/question given and only this area will be scanned. Please give all relevant clinical information for all areas to enable to correct scan to be performed.

2. Abnormal LFTs with little or no other clinical information given.

These requests will be rejected. Please provide the specific LFT results and patient’s symptoms as indicated by the abnormal liver function tests algorithm pathway - see the Liver Disease page for details.

Requests just stating ‘Abnormal LFTs’ with no other clinical information will be rejected. Please provide specific LFT results and all relevant clinical history e.g. previous conditions, whether the patient is symptomatic, the duration of the abnormality, risk factors such as obesity, diabetes, drugs/statins, has there been a change of medication or altered lifestyle guidance.

3. Confirmation of PCOS with PCOS symptoms and no blood results.

Ultrasound is only indicated if the endocrine profile is normal. A clinical assessment and blood tests should be performed initially and US is not required if this assessment already confirms the diagnosis - see PCOS page for details.

Referrals for patients under the age of 20 or for patients under 25 with onset of menarche less than 8 years ago are not justified.

Ultrasound can be useful in secondary care when investigating fertility but in these cases it is the specialist who needs to make this referral

4. MSK /Soft tissue lumps and bumps

Ultrasound is justified if a new or known lesion presents with rapid/accelerated growth or pain. If the lesion is over 5 cm in size it may be more appropriate to perform MRI (unless contra-indicated). See Suspected Bone and Soft Tissue Cancer page for details.

The majority of soft tissue lumps are benign; if there are classical clinical signs of a benign lump then US is not routinely required for diagnosis (i.e. < 5cm stable, soft, mobile, non-tender lumps). Uncomplicated ganglia, sebaceous / epidermal inclusion cyst and small lipomata do not routinely require imaging. If scan is still indicated, please specify the site of any lump / mass, time since first noticed, any rapid growth, skin changes and pain symptoms. We are trying to ensure the ultrasound is used most effectively to benefit all patients, reducing demand for unnecessary scans and creating more capacity for the urgent scans. Clinical examination in the primary setting will ensure referrals are appropriate and urgent cases are prioritised. Without providing the aforementioned clinical information, requests will be rejected. Some MSK examinations require a specialist. Insufficient clinical information will result in unnecessary delays if a request is unclear.

Hernias: If it is clinically a reducible hernia, there is no need for ultrasound confirmation.

5. Head and Neck ultrasound of soft tissue lumps

The majority of soft tissue lumps are benign; if there are classical clinical signs of a benign lump then US is not routinely required for confirmation of diagnosis. Routine ultrasound imaging of established benign nodules/ goitre/ hyperthyroidism/ hypothyroidism/ benign skin cysts/ lipoma/ neck pain without swelling or lump, is not justified.

Small cervical nodes in young patients, unchanged for many weeks do not require an ultrasound scan. See General tips on referral on the Children and Young People - 2WW page for further details.

If US is still felt to be indicated, then clinical history should include symptoms, duration, a precise description of clinical findings and cause of concern.

6. Scan Requests for ? Malignancy/Cancer or ? Mass with no other clinical history.

This information is too vague and may delay the correct form of imaging or examination being performed. Clinical symptoms and a clinical question raising suspicion of specific malignancy are required. Please include any relevant blood tests. For query abdominal mass, please include location (subcutaneous/deep) and detail regarding the suspected organ in question (where appropriate) and symptoms, with clinical a question.

This additional information will help determine if ultrasound is the most appropriate form of imaging and the urgency of the scan. Although US is an excellent imaging modality for a wide range of abdominal diseases, there are many for which ultrasound is not an appropriate first line test (e.g. suspected occult malignancy). Given sufficient clinical information, we may re-direct US requests to CT or MR where appropriate with input from our consultant radiologists.

Insufficient clinical information will result in unnecessary delays if a request is unclear as it could lead to the wrong examination being performed. We aim to perform the correct examination for the patient the first time. 

Duplicate requests

The US departments have advised Remedy that some GPs are sending out duplicate requests for the same patient e.g. to NBT and BRI / Weston.

They have requested that duplicate requests should not be made, as it does waste appt slots if patients have already been seen on one site and do not contact us to let them know when they have received a second appt for another site. 

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.