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HO / MO guide to radiological investigations

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CONTENTS
Organisational chart of imaging departments
- Important people in the department
Pre-investigation preparation
- Contraindications
- Preparation
- Consent Taking and Risks of procedure
Radiological investigations
- FAQ
- Head And Neck / Neurology / Neurosurgery / ENT
- Respiratory / Cardiology / Cardiothoracic Surgery (CTS)
- Abdomen / Pelvis / Gastroenterology / HBS / Urology / Obstetrics /
Gynaecology / Breast
- Orthopaedics / Spine / Extermities / Trauma
Disclaimer

Organisational chart of imaging departments (aka Which department do I arrange


this scan with?)
However, most of the hospitals don’t have all three departments. For some scans, they will be
done by the radiology department; for others, the patient will have to travel to another hospital.
In addition, the radiology departments in larger hospitals separate their inpatient and outpatient
locations (E.g. SGH Inpatient is Blk 6, but outpatient is Blk 2)

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Important people in the department (aka Who do I look for?)


Who is he? His role When you need to look for him!

Radiologist Medical doctor specialising in Approve xray


Urgent requests
imaging requests
“Protocols” (gives
technical instructions) on Not sure which investigation (e.g. CT
how to do the scan. vs MRI), special circumstances (pregnancy,
Doesn’t actually do most implants in MRI, post-op anastomotic
scans! (except fluoro, U/S leak)
and angio)
Covers medical
Allergic reaction, collapse, resus
emergencies.
Interprets scans and
Urgent report, second opinion
issues report.
X-ray conferences Submit list of cases for round

Radiographer Technologist who runs the xray Person who actually


If you’ve brought the patient down
machines(Diploma holder after performs the xray, CT or
and can’t find anyone!
‘A’-level) MRI
Prints the xray films Need hardcopy film or CD

Sonographer Specialised radiographer that Specialises in


-
does ultrasound ultrasound

Clerk Runs the front desk! Receives your request


Check if form has been received
form

Schedules Check appointment date and ask for


appointments an earlier one (sometimes works!)

Issues instruction
Collect contrast/prep after urgent
phamplets, oral contrast,
request is approved
etc.

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Pre-investigation preparation
Contraindications(By modality)

Modality Absolute C/I Relative C/I


Plain Xrays - Pregnancy
i/v contrast: Allergy: CT Contrast, Iodine, Renal disease (Raised Cr)
-CT Fish Asthma
-IVU DM on metformin
Allergy: Multiple(> 3)
Ultrasound - -
MRI Cochlear implant Depending on model/operation date
Pacemaker Vascular clips
Intraocular foreign body Artificial heart valve
Other mobile ferrous objects
Barium swallow / Suspected perforation / leak Acute Intestinal obstruction
meal / enema (use water-soluble contrast) Patient unable to stand/weight
bear
Patient unable to turn over
Preparation (By modality)

Modality Fasting (8 hours)* Others


Plain Xrays No
Ideally in first 14 days of menses
Mammogram No
(will be arranged by the appt desk)
Ultrasound For HBS and renal arteries
Barium swallow / meal Yes
Barium enema Yes, overnight Bowel preparation 1-2 days before
IVU Yes Bowel preparation 1-2 days before
CT abdomen &/or pelvis Yes May require oral contrast 1-2 hours before
MRI For liver, MRCP

*- Implication: Keep the patient nil-by-mouth if you think you need the scan urgently!

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Consent Taking and Risks of procedure


When is written consent required?
Varies between hospitals, but in general:

1. Age < 21
2. Pregnant women
3. Women who have missed their period, or are in 2nd half of cycle (for high dose Ix)
4. All interventional procedures (including biopsy)
Radiation dose
Risk from radiation is a slope, there is no one “cut-off” point below which it is “perfectly safe” -
even small radiation doses may have some risk. Therefore, statutory regulations require the dose
to be “as low as reasonably achievable”.
Having said that, there is no absolute “legal” limit to the dose a patient can receive - go ahead
and order the scan if you think the investigation is medically indicated, and the benefits outweigh
the risk.
What then, is the risk, and how do you explain it to patients in layman terms?
Equivalent of “normal”
Modality / Procedure Risk of fatal cancer / death
daily background radiation
Xray – Limbs 1 day 0.0001% (1 in a million)
* Eating 2 bananas a week for 1 year 1 day
Xray – CXR 3 days 0.0003%
Xray – Skull 9 days 0.001% (1 in 100,000)
* Smoking 1 pack of cigarettes - 0.001%
* Flight from Singapore to New York 1 month
Mammogram 2 months 0.005%
Xray - Abdomen, Pelvis, Spine 4 months 0.01% (1 in 10,000)
Tc-99m thyroid scan 6 months
IVU 1 year 0.03%
Barium swallow, meal, follow-through 1 – 1.5 years 0.03%
CT Head 10 months 0.03%
Tc-99m dynamic cardiac scan 2 years 0.05%
CT Chest, abdomen or pelvis 3.5 years 0.1% (1 in 1,000)
* Dying in a home accident each year - 0.1% (1 in 1,000)
* Smoking 1 pack of cigarettes a day x 1 year - 0.35%

i/v contrast (IVU and CT scan)


(1) Allergic reaction / anaphylaxis
- Idiosyncratic, just like all other drugs
- Increased risk if (1)Multiple drug allergies (2)Recent asthma (<1 year ago)
- Prevention: Prednisolone 10mg x 3 days before the scan

(2) Extravasation
- Definition: When the contrast is forced outside the vein
- Background: About 50mls of contrast (which is as viscous as D50%) is injected as fast as
5mls/second under great pressure
(If you don’t believe, get a 20ml syringe, some D50%, a blue plug, and see if you can
inject everything out in 5 seconds!!).
- Problem: Vein bursts (damn, got to reset the plug ;-) --> Contrast leaks out into tissue -->
Draws water from surrounding tissues
--> (1)Dehydration (& cell death)of surrounding tissues and (2)Compartment
syndrome
- Prevention:
- i. Make sure plug works(They check, and you’ll just have to walk down to the
department to re-set it if it doesn’t work)
- ii. Large bore (Pink/Green) plug for procedures requiring high-injection rates (generally
anything vascular/arterial).
- iii. If all else fails, blue plugs (but not in tiny finger veins!) may be acceptable for slow-
injection rates (e.g. brain)
- iv. PICCs are NEVER acceptable. (1) The tiny tip can blast off into the pulmonary
arteries and (2) SVC rupture is not a pretty sight.
- Treatment:
- i. RICE (Rest, Ice-pack, Compress, Elevate extremity)
- ii. Watch for compartment syndrome, especially if large volume

(3) Contrast induced nephrotoxicity


- Defined as a 25% increase in serum creatinine (does not always require dialysis though).
- 1% in low risk patients
- 10% in high risk patients (Diabetes, CCF, renal impairment, nephrotoxic drugs, age > 70yrs)
- Prevention:
- i. Any high risk factors: Pre-hydrate patient
- ii. Renal impairment: Consider N-acetylcysteine (600mg bd x 2 day before and on day of
scan)
- iii. Space out contrast studies 72h apart, if possible (e.g. cancer staging)
- iv. Consider non-contrast CT or alternate studies (e.g. US, MRI)
- Paradoxically, patients whose kidneys have already failed and are on dialysis can ignore all
the above.

(4) Metformin-induced lactic acidosis


- Metformin: Stop on the day, and 2 days after the scan.
- Once again, do this proactively, if you think patient might be going for a contrast-CT soon!
(Just don’t forget to convert to insulin/another OHGA, and to re-start it later!)

(5) Breast feeding


- Can scan as per normal, but no breast feeding x 24h after the scan

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Radiological investigations

FAQ

Q: How do I know which scan to order?


A: Specifying the modality(i.e. CT, MRI), organ of interest and including an
adequate history is usually enough. For example, “CT lung” for “Lung
cancer” vs “PE” vs “Interstitial lung disease” will get you three different
scans, but as long as you include the diagnosis/history, there is no need to
specify the exact technical details. Even suspected clinical diagnosis or the
clinical indication, no matter how silly (e.g. “Hemoptysis for Ix”, “right
sided rib pain”, “TB x 40 years ago”).
Q: What do I write in the “History” column?
A: The keyword is “relevant”. Include whatever you think might be relevant
to the scan, such as Presenting complaint, Duration, Possible causes (e.g.
TB, prostate cancer), Physical findings/relevant investigations (e.g. axillary
LN, pyloric ulcer on OGD, Hep B carrier), Treatment so far (e.g. Subtotal
gastrectomy on 21/4/06), and any previous scans (e.g. U/S Feb 06: 4cm liver
mass). Also, include any questions your consultant had (e.g. ?increase in
size since 2004, ?anastomotic leak) so that they can be specifically
answered in the report (Which may well save you a trip down to bug an
irritated, overworked radiologist!).

Q: That’s a lot to write! What can I leave out?


A: More is better than less, especially if you’re unsure! (It’ll save you an
angry phone call from the radiologist, or even worse, having to explain to
the patient why he needs another $350 CT scan of the same organ when he
just had one yesterday, and to the consultant why the scan didn’t include
the pelvic anastomosis…). But you can safely leave out irrelevant
comorbidities (e.g. schizophrenia in a liver scan), and a summary of the
history/physical exam is enough (e.g. “R breast lump x 2/12” vs “Admitted
for # NOF. Incidental finding of R breast lump, 4.5cm, hard. L breast NAD.
etc. etc.)

Q: Does the scan require i/v contrast (a.k.a Do I need to set a plug)?
A: This is a tricky one. The full list is given below, but in general, the
following require contrast:
Most CT scans, including those looking at/for:
- Tumour
- Inflammation
- Blood vessels
Some MRI scans, especially those looking at
- Tumour
All interventional studies (except PermCath and Hickman lines, but
including PICC lines)
Common scans that do NOT require i/v contrast include:
CT head for stroke, trauma
CT spine and extremities for trauma
CT KUB for renal/ureteric stones
Q: How do I arrange for an “urgent” scan?
A: This varies by hospital, but here is a suggested approach:

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HEAD AND NECK /NEUROLOGY / NEUROSURGERY / ENT


Xray: Skull
Indication Investigation
Vault # Skull (AP,Lateral, Towne’s)
Maxilla # Skull (AP, Lateral, OM)
Mandible # Mandible X-xray
Orbit # Orbit X-ray
Orbital foreign body Orbit X-ray + Look up/down views
Sinusitis (chronic) X-ray Paransal sinuses
Xray: Non-Skull
Indication Investigation
FB Throat Neck xray,lateral (not C-spine)
C-spine xray (not Neck)
Cervical spine trauma
+/- Swimmer / Lat pull-down for C7/T1
Parotid stone Parotid xray (occlusal view)
Dental Occlusal / OPG

Fluoroscopy
Indication Investigation
(1)VFS if high % aspiration
Swallowing assessment / ?Aspiration
(2)Barium swallow (not gastrograffin)
(1)Gastrograffin swallow
FB throat / perforation / post-esophagect
(2)NB: CT neck better for FB
Nasolacrimal duct stenosis Dacrocystogram*
Salivary/Parotid duct stenosis Sialogram*
* - Specialised, rarely performed investigation

Ultrasound
Indication Investigation
Thyroid lump / goitre U/S thyroid
Young CVA U/S carotids

CT
Indication Investigation Contrast?
Stroke, hemorrhagic Head injury (see NICE criteria) CT brain No
Meningitis CT brain Maybe
Fits, brain tumour, mets CT brain Yes
Chronic sinusitis CT paranasal sinuses No
Hearing loss, conductive CT temporal bone No
Foreign body throat CT neck Maybe

MRI
Indication Investigation Contrast?
MRI brain (stroke protocol)
Stroke, hyperacute (< 12 hours) No
NB: CT is better to exclude bleed
Stroke, brainstem Posterior fossa lesions MRI brain (more sensitive than CT) Maybe
Hearing loss, sensorineural MRI IAM / MRI IAM screening Yes
Retrobulbar mass, orbital tumor MRI orbits Yes

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RESPIRATORY / CARDIOLOGY / CARDIOTHORACIC SURGERY


(CTS)
Chest X-ray
Indication Investigation Which side?
Basic CXR view CXR (Erect)
Rib # CXR (Oblique) Same side as suspected # i.e. R oblique for R #
Localise lung lesion CXR (Lateral) Same side as lesion
Loculated effusion, or patient cannot sit CXR (Lateral
Same side as effusion i.e. R LD for R effusion
up decubitus)
Small pneumothorax, or patient cannot CXR (Lateral Opposite side of pneumothorax i.e. R LD for L
sit up decubitus) pneumothorax
Sternal # Sternal Xray
General notes on CXR:
The ‘standard’ CXR view is PA erect, but patient must be able to stand, and it cannot be done portable. AP Sitting
is second best, followed by Supine.
Lateral views are not routinely required. Ask yourself – “how will it affect management?”

Fluoroscopy
Indication Investigation
Diaphragmatic paralysis Fluoroscopic sniff test*
* - Specialised, rarely performed investigation

CT
Indication Investigation Contrast
Most lung conditions CT Thorax / CT Chest
High resolution CT (HRCT) (NB: Slices are “skipped” – do not use for tumour
Interstitial lung disease No
detection)
Aortic aneurysm /
CT Aortogram / CT Thoracic aorta Yes (High rate)
dissection
Pulmonary embolism (PE) CT PE / CT Chest (PE protocol) Yes (High rate)
Coronary arteries CT Coronary Arteries / Cardiac CT Yes (High rate)

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ABDOMEN / PELVIS / GASTROENTEROLOGY / HBS /
UROLOGY / OBSTETRICS / GYNAECOLOGY / BREAST
Abdomen X-ray
Indication Investigation
Standard AXR view AXR (Supine)
Air-fluid levels AXR (Erect) or (Lateral decubitus)
Free air under diaphragm CXR (Erect) or (AP Sit)
Ureteric/bladder calculi KUB
General notes on AXR:
The ‘standard’ AXR does not always cover the pelvis. Order a KUB for pelvic pathology.
Erect or decubitus views are not routinely required, even in IO. The supine view shows bowel distribution better,
and free gas is better detected on the CXR.

Ultrasound
Indication Investigation Preparation Notes
Liver, gallbladder U/S liver / HBS Fast x 8 hours Includes a quick look at kidneys
Kidneys U/S kidneys -
Kidneys & bladder U/S kidneys + bladder Needs to have a full bladder Not routinely ordered
Renal arteries U/S renal artery Fast x 8 hours Specialised investigation
Aorta U/S abdominal aorta Fast x 8 hours CT preferred, if possible
Uterus/ovaries U/S pelvis Needs to have a full bladder May include endovaginal scan
Testes U/S testes -
General notes on ultrasound:
Do NOT order "ultrasound abdomen" – only solid organs can be scanned, and the vast majority of the “abdomen”
(including the bowel) is un-scannable.
You will either get a rejected request, a call from an irate radiologist, or a vague scan of the region based on the
clinical history in your form.
They will never scan the entire “abdomen”, so you might as well be more specific.

Intravenous urogram (IVU)


Indication Investigation Preparation
Hydronephrosis, ?stones IVU Fast overnight, bowel prep
General notes on IVU:
IVU as an inpatient is usually suboptimal due to (1)poor bowel preparation or (2)infeasible to keep patient in
hospital just for bowel prep.
Alternatives include CT KUB (if looking for hydro and stones, or if renal function is poor) or CT urogram (if looking
for renal function or pyelonephritis).
Disadvantages of CT are higher cost and radiation dose.

Fluoroscopy
Indication Investigation Requirements Notes
Esophagus /
swallowing Barium swallow Be able to stand
problem
Stomach / PUD / Be able to stand and
Barium meal
reflux / hiatus roll over.
Barium follow-through
Small bowel
pathology More invasive than follow-
Enteroclysis
through, but better results
Be able to stand and
Large bowel Barium enema roll over. No fecal
incontinence.
Include op details (incl
Water-soluble /
As for similar barium anastomosis type), and exact
?anastomotic leak gastrograffin swallow/
study. date study is required on
meal/ enema.
form.
Urethral stricture Ascending urethrogram Include op details if any
Vesico-ureteric
MCU Include op details if any
reflux
Post PCN Check nephrostogram

CT
Indication Investigation Contrast
Upper abdominal pathology CT abdomen Yes
Pelvic / gynae pathology CT pelvis Yes
Entire abdominal cavity required CT abdomen + pelvis (abdo/pelvis) Yes
Liver (Routine e.g. abscess) CT liver Yes
Liver lesion ?HCC CT liver (triphasic) Yes (High rate)
Liver HCC post-TACE CT liver (plain + triphasic) Yes
Pancreas CT pancreas (fine cuts) Yes
Renal /ureteric stone CT KUB (may differ by hospital) No
Kidneys CT kidneys Yes (High rate)
Kidneys, ureter, bladder CT urogram(may differ by hospital) Yes (High rate) and Lasix
Abdominal aorta CT abdominal aorta Yes (High rate)
Colon< td> CT colongraphy Yes and rectal gas
General notes on CT:
There are many, many different CT protocols for the abdomen (e.g. see CT liver above!). If unsure, it is best to
state the organ of interest, and provide sufficient history, rather than guess blindly.
Abdomen and Pelvis (in radiological protocol terminology) are completely different!! Your consultant may
casually order a “CT abdomen” for “?sigmoid CA” or “abd pain for ix”, when what he really means is “CT Abdomen
+ Pelvis”. The radiographers protocoling the scan are not medically qualified, and may or may not catch your
meaning, so make sure you fill the form in correctly! (As an aside, the main reason why the pelvis is not automatically
included in a “CT abdomen” is due to the high radiation dose to the gonads and bowel.)
Almost all abdo scans require fasting. If you’re clerking a patient and think he might need an urgent scan, keep
him NBM!

MRI
Indication Investigation Contrast
Liver MRI liver Yes
Bile duct stones MRCP Maybe
Pancreas MRI pancreas Yes
Kidneys MRI kidneys Yes
General notes on MRI:
There are many, many, many MRI protocols for the abdomen, even more than for CT. MRI liver for HCC alone
has 12 sequences. Don’t bother trying to specify them, just state the organ of interest, and provide sufficient history.

Breast
Indication Investigation Note
Screening Mammogram
Evaluation of breast lump Ultrasound + Mammogram
Biopsy of lump Ultrasound guided bx Specialised investigation
Biopsy of lesion on mammogram Mammotome / Stereotactic biopsy Specialised investigation
Implant rupture MRI breast Specialised investigation

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ORTHOPAEDICS / SPINE / EXTERMITIES / TRAUMA


General notes on orthopaedic xrays:
Othopaedic xrays are really easy to order – if you can name the bone that is likely to be fractured, then that's the
xray you ask for! So go ahead, and order xrays according to where you think the problem is.
Using radio-opaque markers, especially for foreign bodies, is highly recommended. If you can’t personally
accompany the patient and put the marker – just write a “with marker” on the xray form, and make sure the patient
can point out the site of the problem!

Plain x-rays
Skull
See head and neck

Spine
Cervical spine
Cervical spine (Swimmers view) or (Lateral pull-
down)
Open-mouth / Odontoid views
Thoracic spine
Lumbar spine
Oblique views of above
Coccyx

Upper limb
Clavicle
Scapula
Shoulder
Humerus
Elbow
Forearm or radius/ulna
Wrist
Scaphoid
Hand
x finger
Pelvis
Pelvis (AP)
Pelvis (Inlet / Outlet)
Judet views (for acetabulum)

Lower limb
Hip
Femur
Knee
Skyline (Patella)
Tib/Fib
Ankle
Calcaneum
Foot

CT / MRI for tumour or trauma


Specify region as above.
3D-reconstructions are not performed by default at most hospitals, so specify if your consultant needs them.

Ultrasound
Indication Investigation
Rotator cuff pathology U/S shoulder
Carpal tunnel, cysts, neuroma U/S wrist
DDH / CDH (< 4-6 mths) U/S hip

MRI
Spine (specify region, level, and side of
symptoms)
Shoulder*
Wrist*
Hip
Knee
Ankle
General notes on MRI:
While MRI is highly detailed, it is not cheap, and before ordering one, ask yourself if it will affect subsequent
management.
* - These procedures may involve use of intra-articular contrast injection (arthrogram), which depends on
indication for the scan, and varies between hospitals. Once again, include all relevant details on the request form (esp.
suspicion of tears and any previous operation) and advise patient he may require an injection.

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