imaging: choosing the appropriate exam · 2018. 4. 14. · 1 rob milman, md texas nurse...

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Rob Milman, MD

Texas Nurse Practitioner Dallas,TX

September 24, 2015

Austin Radiological Association

Imaging: Choosing the Appropriate Exam

What is a Radiologist?

n  A physician who specializes in diagnosing and treating disease and injury by using medical imaging techniques

Radiology: Diagnostic Imaging and Imaging-guided Interventions

n  “Imaging is like oxygen; medicine without imaging cannot survive”

n King Li, MD, MBA

Radiology n  Make tremendous difference in patients’

lives: n  Diagnosing or excluding disease and injury n  Evaluating response to therapy n  Imaging guided treatments

n  Wide variety of pathology n  Intellectually stimulating

Answer Clinical Question

n  Image interpretation in context of clinical signs and symptoms

Ordering The Right Test n  Questions to answer

n  Is an imaging study necessary?

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Ordering The Right Test n  Questions to answer

n  Is an imaging study necessary? n  Will the results alter therapy?

Ordering The Right Test n  Questions to answer

n  Is an imaging study necessary? n  Will the results alter therapy? n  What risks are associated with the test?

Ordering The Right Test n  Questions to answer

n  Is an imaging study necessary? n  Will the results alter therapy? n  What risks are associated with the test? n  Does the potential benefit outweigh those

risks?

Ordering The Right Test n  Questions to answer

n  Is an imaging study necessary? n  Will the results alter therapy? n  What risks are associated with the test? n  Does the potential benefit outweigh those

risks? n  What test will most likely answer the clinical

question?

Ordering The Right Test n  Questions to answer

n  Is an imaging study necessary? n  Will the results alter therapy? n  What risks are associated with the test? n  Does the potential benefit outweigh those

risks? n  What test will most likely answer the clinical

question? n  What is the most cost effective imaging

strategy?

Modalities

n  Radiography: X-rays, Fluoroscopy n  Ultrasound n  CT n  MRI, fMRI n  Nuclear Medicine n  Molecular Imaging n  Angiography, conventional vs. CTA or

MRA n  Interventional Radiology

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Health Care Reform

n  Best outcomes – Quality n  Low cost n  Value = Quality/cost n  Evidence based

American College of Radiology (ACR) Appropriateness Criteria

n www.acr.org/ac

Gastrointestinal

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Gastrointestinal Gastrointestinal

Imaging Workup Caveat

n  The complexity and severity of the clinical condition should dictate selection of appropriate imaging procedures or treatments – ACR

n  Each patient is unique and workup may vary due to clinical circumstances such as age, condition, comorbidity, etc.

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Pros and Cons

n  Ultrasound n  CT n  MRI

Ultrasound

n  PROS: n  Noninvasive n  No ionizing radiation n  Real time imaging n  Safe and relatively

painless n  Cost

n  CONS: n  Operator dependent n  Large body habitus n  Air (bowel gas)

interference n  Bone interference

CT

n  PROS: n  Soft tissue contrast n  Any body habitus n  Bone imaging n  Fast

n  CONS: n  Uses ionizing radiation n  Relatively expensive

MRI

n  PROS: n  Excellent soft tissue

contrast n  No ionizing radiation n  Safe

n  CONS: n  Must hold still for

extended periods of time

n  Claustrophobia n  Patient size n  Indwelling metallic

devices n  Expensive

Abdominal Pain

n  Differential very broad n  Work-up based on symptoms, exam, lab, and

location (RUQ, RLQ, LUQ, LLQ, Epigastric, Flank)

RUQ Pain

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Gallbladder disease

n  Abdominal sonograms n  Hepatobiliary scan with CCK n  CT n  MRCP

Gastrointestinal

41 y/o female with RUQ pain, no fever, normal WBC

Hepatobiliary scan

n  70 y/o female with nausea and pain. Normal gallbladder ultrasound.

MRCP

n  MR Cholangiopancreatography n  Evaluate for duct abnormalities

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RLQ Pain RLQ pain – Appendicitis

n  CT Abdomen and Pelvis n  Ultrasound (operator dependent)

n  Children (CT if US is non-diagnostic) n  Pregnant (first and early second trimester)

n  MRI n  Pregnant

Left Lower Quadrant Pain

n  CT n  Pelvic sonograms n  MRI n  Abdomen radiographs n  Barium enema

54 y/o male with fever, chills, and left lower quadrant pain

Urologic Imaging-Stone Disease

n  CT without contrast is gold standard n  Identifies stone n  Determines degree of obstruction n  May provide alternative diagnosis (e.g.

appendicitis, diverticulitis) n  Quick n  No need for IV contrast

n  US: pregnancy and children

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Acute Pyelonephritis

n  No imaging needed if uncomplicated n  CT with IV contrast n  MR with IV contrast

Pelvic Imaging - Gynecologic

n  Ultrasound n  MRI

Radiology 2010; 256: 943-954

Polycystic Ovarian Syndrome (Stein-Leventhal)

n  Infertility n  Hirsutism n  Acne n  Obesity n  Menstrual Disturbance

n  Oligomenorrhea n  Amenorrhea n  Anovulation

Imaging workup of abnormal vaginal bleeding

n  Transvaginal pelvic sonograms n  Sonohysterography n  MRI

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Pelvic Sonograms

n  Endometrial stripe thickness - normal n  Postmenopausal (not on HRT) < 5mm n  Premenopausal < 16 mm

Neurological Algorithms

MR vs. CT Brain

n  CT n  acute trauma n  acute severe headache n  acute stroke n  unexplained acute altered mental status n  inner ear problems n  bony abnormality n  patients unable to have MRI

n  MR for everything else

Headache - when to image

n  Sudden severe headache (worst HA of life or thunderclap HA): CT

n  Headache significantly different than past headaches or with neurologic symptoms: MR

n  HA developing in pt with known condition (cancer, immunocompromised, drug abusers, etc.): MR

Headache

n  Acute: CT n  Subacute or chronic: MRI n  Pre-existing condition: MRI

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Spine: MRI vs. CT n  Radiographs n  CT:

n  Acute trauma n  Bone tumors

n  MRI: Everything else n  CT Myelogram:

n  MRI contraindicated n  Spinal stenosis: Can image upright

Low Back Pain

n  One of the most common health problems n  Cost of evaluation and treatment is billions

of dollars each year, not including lost productivity

Low Back Pain-Uncomplicated Low Back Pain- Red Flags n  Trauma n  Unexplained weight loss n  Unexplained fever n  Immunosuppression n  History of cancer n  IV drug use n  Osteoporosis or chronic

steroid use n  Age >70 n  Motor function or sensory

loss

n  Trauma n  Unexplained weight loss n  Unexplained fever n  Immunosuppression n  History of cancer n  IV drug use n  Osteoporosis or chronic

steroid use n  Age >70 n  Motor function or sensory

loss

Acute low back pain with neurologic findings

n  MRI n  Without contrast n  With contrast: postop or suspicion for infection

or cancer n  CT Myelogram

n  Problem solving or if MR contraindicated

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Musculoskeletal Pain or Instability

n  Radiographs n  MRI n  CT n  Bone scan n  Ultrasound