Hampshire Hospitals NHS Foundation Trust

Guidelines for Justification of Ultrasound Requests

April 2022

Based on:

British Medical Ultrasound Society; Recommended Good Practice

Guidelines for Justification of Ultrasound Requests, October 2021

Royal College of Radiologists; iRefer, 8th Edition, 2018

National Institute for Health and Care Excellence Guidelines

HHFT Multidisciplinary Clinical Consultation

CCG Clinical Consultation

 INDICATION COMMENT ACCEPTED

ABDOMEN

Significant unintended For suspicion of malignancy, as per NICE

weight loss guidelines consider 2WW referral and CT

If direct access CT is not available and a 2WW YES

is not being triggered, Ultrasound is justified

Iron deficiency anaemia Ultrasound not indicated unless there is a NO

specific clinical question

‘Altered LFTs’ Please include:

See footnote 1 Duration of abnormality.

A single episode of mild – moderate elevation
does not justify an US scan

Specific diagnosis to be considered

Specific LFT result or be available on ICE

With Pain or Jaundice YES

Two or more occasions of abnormal LFT’s in YES

otherwise asymptomatic patients

Patients with raised NAFLD scores or Fib4 YES

scores are indicated for liver ultrasound or
secondary referral

‘Raised ALT’ (other LFTs Please include relevant information

normal)
ALT>200 on a single test YES
See footnote 1
US is justified if raised ALT (>120) is YES
persistent (3-6 months) despite following
weight loss and altered lifestyle guidance
and/or change in medication

US is justified if persistently raised ALT >120 YES

(3 months) and no other risk factors
 Jaundice Any jaundice requires imaging

Bil <150: Urgent US and 2WW referral YES

Bil >150: Urgent referral. Imaging should not NO

be performed in primary care.

Pain (RUQ) Assessment of gallbladder YES

Suspected GB disease Pain plus fatty intolerance and/or dyspepsia YES

GB polyp Polyp >10 mm: Surgical referral NO

Polyp 6-9 mm: YES

- Symptomatic, PSC or Asian ethnicity:
Surgical referral
- Asymptomatic: Surveillance US at 6
months, 1 year, 2 years if patient fit for
surgery

Polyp ≤5mm: YES

- Age >60, PSC or Asian ethnicity:
Surveillance US at 6 months, 1 year, 2
years if patient fit for surgery
- If none of above risk factors, no
surveillance required except at request
of HPB team

During surveillance
- Increase in size ≥2 mm: Surgical
referral
- Discharge if:
o No growth after 2 years
surveillance
o Polypoid lesion disappears

Bloating/ As the only symptom NO

abdominal distension
Suspecting malignancy – 2WW and CT scan NO
recommended

Persistent or frequent occurring over 12 times YES

in one month, in women especially over 50
with other symptoms or raised Ca125

Suspicion of Ascites YES

Suspected Pancreatic Presenting symptoms:
Cancer Weight Loss
Nausea and vomiting
Back pain
New onset diabetes

Recommend 2WW referral and CT scan NO

Ultrasound cannot assess the entire pancreas

Altered bowel habit/ No role in management of IBS or DD NO

diverticular disease
If suspected bowel ca refer via 2WW NO

Diabetes US does not have a role in the diagnosis or NO

management of Diabetes.

Up to 70% of patients with DM have a fatty

liver with raised ALT.
This does not justify a scan.

RENAL TRACT

UTI (ADULT) First episode NO

Recurrent (>/= 3 episodes in 12 months) YES

Non-responders to antibiotics YES

Frequent re-infection YES

H/O stone or obstruction YES

UTI (CHILDREN) As per NICE guidelines YES

See footnote 2

Hypertension Routine imaging is not indicated. NO

RAS (renal artery screening) is NOT offered

Renal tract to assess for renal disease YES

Renal Failure Acute or acute on chronic YES

To assess renal size and rule out obstructive
causes
Haematuria(micro/macro) Most haematuria at HHFT go through the YES
‘haematuria one-stop clinic’

Renal Colic Females <40 YES

Any Males and Females >40 NO

Direct access for CT KUB

SMALL PARTS

Lymphadenopathy Patients with clinically benign groin, axillary or NO

neck lymphadenopathy do not need US

Small nodes in the groin, neck or axilla are

commonly palpable. If new and a source of
sepsis is evident, US is not required

Signs of malignancy include increasing size, YES

fixed mass, rubbery consistency

In children, an ultrasound scan is not required NO

when:

Size <2cm

Site – cervical, axillary, inguinal

History – recent viral infection or immunisation

Examination- eczema, viral URTI

Soft tissue lump 2WW sarcoma referral if >5cm, tender or YES

enlarging

<5cm stable, soft, non-tender lumps NO

Scrotal mass Following full clinical examination:

Any patient with a swelling or mass in the body YES

of the testis should be referred for URGENT
US

Extra-testicular mass, eg epididymal cyst NO

Generalised scrotal swelling ‘?hydrocoele’ NO

 Suspected varicocoele YES

Scrotal pain Chronic (>3 months) pain in the absence of a NO

palpable mass does NOT justify US

Acute pain ?torsion requires URGENT NO

Urology/Surgical referral

Acute pain in the absence of suspected torsion YES

Eg.,Epididymo-orchitis ?Abscess

Inguinal hernia Characteristic history and exam findings NO

including reducible palpable lump or cough Consider
impulse. Ultrasound NOT justified. Surgical
referral
Irreducible and/or tender lumps may suggest
incarcerated hernia and require URGENT
surgical referral.

Vague request ?hernia ?something else NO

If groin pain, consider MSK causes and refer NO

accordingly

HEAD & NECK

Thyroid Ultrasound may be required where there is YES

doubt as to the origin of a cervical mass,
ie thyroid in origin

Clinical features that increase the likelihood of

malignancy include history of irradiation, male
sex, age (<20,>70), fixed mass, hard/firm
consistency, cervical nodes, change in voice,
family history of MEN II or papillary Ca

Routine follow up of benign nodules (U2) is NO

not recommended

Salivary mass History suggestive of salivary duct obstruction YES

Suspected salivary mass/tumour YES

 GYNAECOLOGY
See Footnote 4

Pelvic pain ?cause US is unlikely to contribute to patient NO

management if pain is the only symptom

In patients <50, request will be returned for NO

more information, unless symptoms are
suggestive of endometriosis

In patients >50, the likelihood of pathology is YES

increased.

Please include a specific clinical question

Pelvic pain +

Palpable mass The addition of another clinical symptom YES

Raised CRP/WCC justifies the request
Menstrual irregularity
Deep dyspareunia Please include a specific clinical question/
differential diagnosis.

Pelvic pain +

H/o ovarian cyst These do not represent further clinical NO

H/o PCOS symptoms

‘Severe’ or ‘Sudden’ Reassurance scans will be referred back NO

Loose stools pending more information
?appendicitis
?ovarian cyst

Bloating As only symptom or intermittent bloating NO

See footnote 3 Persistent, especially over 50. YES

Persistent and palpable mass/ raised Ca 125

YES
(Referral and alternative tests required for GI
tract related symptoms)
 F/up of benign lesions, Usually there is no role for US in follow-up of NO
eg fibroid, dermoid, cyst these lesions in pre-menopausal women
unless:

On the advice of secondary care YES

The patient has undergone a clinical change YES

Follow-up US of benign lesions can be YES

performed at 4 months and 1 year in post-
menopausal women to ensure no change

PMB Please include information about the LMP (i.e. YES

post- rather than peri-menopausal) and
relevant HRT status

Heavy menstrual US recommended if YES

bleeding - Uterus is palpable abdominally
- Vaginal examination yields a pelvic mass
See Footnote 4 - Pharmaceutical treatment fails

Irregular bleeding As only symptom <40 NO

inter menstrual, With abdominopelvic mass YES

post-coital,
frequent, Heavy irregular bleeding >40 YES
prolonged, - Refer to Gynaecology for consideration of
irregular cycle hysteroscopy

See Footnote 5

Post natal bleeding Women who are up to 21 days PN should be NO

referred to O&G for consultant input or DPAU
scan

Women who are over 3 weeks PN should be YES

seen in the EPAU or main scanning
department
 PCOS Only useful in secondary care if investigating NO
subfertility

Diagnosis of PCOS is based on:

1. Irregular menses
2. Symptoms and signs of hyperandrogenism
3. Biochemical evidence of hyperandrogenism
with free androgen index
4. Biochemical exclusion of other confounding
conditions

Ultrasound should not be used for the NO

diagnosis of PCOS in adolescents

Investigation of Accepted if concurrent referral made to fertility YES

subfertility service

IUCD/Mirena US to assess for presence of fibroids if YES

placement of Mirena is considered

US to identify presence of IUCD when threads YES

not visible

Sonographer will arrange AXR if IUCD not

found on US

MSK

Shoulder Impingement/rotator cuff pathology YES

SCJ OA/pathology NO

Elbow Common flexor/extensor tenosynovitis YES

Wrist/hand Specific tendon/joint YES

Hip Palpable lump – bursitis? YES

Knee Patellar/quadriceps tendinopathy YES

Popliteal cyst YES

 Meniscal pathology NO

Ankle/foot Achilles tendinopathy YES

Plantar fasciitis YES

Mortons neuroma YES

Anterior talofibular ligament NO

Any body part Diffuse pain/swelling NO

Non-specific requests, eg NO
“joint/tendon/ligament pathology?”

Palpable lump – if changing YES

Whole limb requests NO

Intra-articular pathology NO

For indications that fall outside these guidelines,

radiologist discussion is recommended on the Hot Hub
telephone number:

01256 313982
FOOTNOTES

1. Liver Function tests - Isolated enzyme rises – US generally not indicated

ALT alone: Fatty liver (risk factors; obesity, hyperlipidaemia, DM) or Drugs (statins/
oral contraceptive pill)

ALP alone: Probably bone, not liver (adolescent growth, Paget’s disease, recent
fracture)

GGT alone: Usually alcohol. Consider prescribed drugs. Fatty liver (risk factors;
obesity, TGs, DM)

AST alone: Muscle injury or inflammation.

Bilirubin alone: Gilberts syndrome (usually <80mols/L)

2. UTIs in under 16s.

https://www.nice.org.uk/guidance/cg54/chapter/1-guidance

3. Ovarian cancer – NICE guidance for women aged 18 and over.

1 Guidance | Ovarian cancer: recognition and initial management | Guidance | NICE

4. Heavy Menstrual Bleeding

https://www.nice.org.uk/guidance/ng88