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