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CURRENT PATHOLOGY IMAGING GUIDELINES CONTENTS A. Neck and thorax B. Upper abdomen Imaging resources Problem management 1. Trauma 2. Painful syndrome with fever 3. Painful syndrome without fever 4. Anorexia, weight loss, nausea, emesis 5. Liver function tests disturbance 6. Upper digestive tract haemorrhage 7. Upper intestinal occlusion C. Genitourinary system D. Vascular system E. Central nervous system F. Spine G. Extremities H. Nuclear Medicine IMAGING RESOURCES Abdominal plain film, supine calcifications (vascular, biliary), foreign bodies, surgical clips mass effect extraluminal gas, intestinal distension bone abnormalities Abdominal plain film, upright or left lateral decubitus sometimes useful (pneumoperitoneum, hydroaeric levels, calcification shift) Barium meal swallowing dysfunction, dysphagia, hiatal hernia, reflux, gastro-duodenal pain anastomosis patency: use of water soluble contrast medium only when any risk of bronchoaspiration is excluded (chemical pneumonitis) barium follow-through: less accurate than enteroclysis. Enteroclysis malabsorption, intestinal adhesions, suspicion of Meckel diverticulum, of small bowel neoplasia, of ileitis Barium enema intrinsic colonic diseases, extrinsic compression (pancreatitis, tumoral mass, metastases), suspicion of fistula double contrast: allows better mucous membranes surfaces depiction contraindications: toxic megacolon, impending perforation, pseudomembranous colitis, recent endoscopic biopsy, pregnancy, poor intestinal preparation, recent barium meal, scheduled CT-scan for the few next days Ultrasound first step examination for solid organ diagnosis (liver, gallbladder, spleen, pancreas, kidneys) and vascular diseases, retroperitoneum, ascitis detection Doppler: portal hypertension, Budd-Chiari, thromboses, aneurysm, artery stenosis abdominal wall (eventration, umbilical hernia, abscess) hollow organs: less accurate; ultrasound is often able to show parietal thickening or a mass attached to the digestive tract guided puncture or drainge CT-scan first choice work-up tool of neoplasia before treatment obese patients with low diagnostic quality ultrasound better than ultrasound for: retroperitoneum (included pancreas, kidneys and adrenals), digestif tract, mesentery, peritoneal surfaces equivalent accuracy to US (complementary): liver and spleen less accurate than US for: gallstones angio-CT, CT colonoscopy (virtual endoscopy), CT-enterography guided punctures or drainages MRI as a complement to CT: neoplasic local extension work-up, lesion detection and analysis in liver, kidneys, pancreas preferred to CT-scan in: pregnant women, patients with iodine contrast media allergy, children MR-cholangiopancreatography: biliary tract obstruction; as accurate for diagnosis than ERCP MR-angiography, MR-colonoscopy, MR-enterography PROBLEM MANAGEMENT 1. Trauma Ultrasound: peritoneal effusion, liver, spleeen, kidney lesion CT: polytrauma work-up, retroperitoneum and great vessels lesions, mesentery Abdomen plain film: skeletal lesion, pneumoperitoneum, retroperitoneal air, masse effect, foreign body 2. Painful syndrome with fever Ultrasound: cholecystitis, liver abscess, kidneys, ascitis, splenomegaly CT complementary to US: deep abscesses, retroperitoneum, pyelonephritis, inflammation of or digestive tract perforation, perihepatitis, septic thrombosis, mesenteric infarct 3. Painful syndrome without fever Ultrasound: gallstone, bile duct stone, liver, splenic, pancreatic lesion, aneurysm of the aorta CT-scan: retroperitoneal lesion, pancreas, digestive tract, internal hernia Barium meal (enteroclysis): peptic or reflux disease, oeso-gastro-duodenal tumors, stenoses (pylorus, small bowel, adhesions), internal hernia of the small bowel CT colonography (or barium/hydrosoluble contrast enema): tumor, diverticulitis, ischemia, irritable bowel syndrome MRI: added to CT (retroperitoneum / kidney tumor extension) 4. Anorexia, weight loss, nausea, emesis Ultrasound: cirrhosis, portal hypertension, liver neoplasic invasion, biliary tract lithiasis, pancreas, ascitis, pylorus stenosis(paediatrics), etc. CT-scan: pancreas, retroperitoneum, liver, stomach, oesophagus, colon Barium meal (enteroclysis): peptic or reflux disease, oesophagus or gastric tumor, stenoses (pylorus, small bowel, adhesions), enteropathy CT-enterography or MR-enterography MRI: if needed as complement after CT 5. Liver function tests disturbance Ultrasound: fatty liver infiltration, fibrosis, cirrhosis, portale hypertension (Doppler), ascitis, biliary tract lithiasis, acute hepatitis CT-scan: complementary to ultrasound, pancreatic diseases MRI: same as CT + MR cholangiography 6. Upper digestive tract haemorrhage Gastroscopy (ulcers, tumors, varices) CT-scan and/or ultrasound : portal hypertension, liver lesion, upper digestive tract tumor Arteriography: active bleeding > 0,5 ml/min. Embolisation of a bleeding artery. Barium meal: second look when hemorrage under control, and only if no angiography is to be done later 7. Proximal intestinal occlusion Abdomen plain film supine and upright: intestinal dilatation, digestive gas in an abnormal location, pneumoperitoneum, air-liquid levels, mass effect, lung bases infiltration CT-scan Water soluble contrast study uf the upper digestive tract, enteroclysis US: pylorus stenosis (infants), intussusception Pierre Bénédict, MD, FMH radiologist, Lausanne, 1997-2008 References: Eisenberg R.L., Margulis A.R.: "Radiology Pocket Reference: what to order when", Lippincott, 2nd ed., 1999 ACR (American College of Radiology) guidelines Radiation protection 118: Referral guidelines for imaging (Office for official publications of the European Communities) Paul Rodriguez "MRI Indications for the Referring Physician", Aurora, 1997