ROBERT HARTMAN, MD

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Radiological Tests: Which One is Most Appropriate for My Patient?

Robert Hartman, M.D.

©2016 MFMER | slide-1

Disclosures

No Disclosures

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Objectives • Discuss tools to aid in the ordering of Radiology examinations • Radiologist • ACR appropriateness criteria® • Review case vignettes of common situations

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Choosing the Correct Imaging Protocol • Complete information often available for the radiologist • Patient presenting to acute care or ED • 45-year-old male CT without contrast using • Training for a marathon Renal • Acute onset of Stone left flankProtocol pain • History of calcium oxalate renal calculi • Afebrile • Microscopic hematuria

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Choosing the Correct Imaging Protocol • Complete information often available for the radiologist • Patient presenting to acute care or ED • 45-year-old male Belly Pain • Training for a marathon • Acute onset of left flank pain • History of calcium oxalate renal calculi • Afebrile • Microscopic hematuria

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Find your go-to radiologist • Many cases do not require consultation based on clinical experience • Radiologists are happy to assist when deciding on the choice of imaging test • Appropriate test for definitive information to aid in management • “Best guess” ©2016 MFMER | slide-6

ACR Appropriateness Criteria® • Free to access online • https://www.acr.org/Quality -Safety/AppropriatenessCriteria

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ACR Appropriateness Criteria® • Evidence based guidelines • Assist referring physicians in making the most appropriate imaging or treatment decision • Many topics addressed • Multiple variants of many diseases

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ACR Appropriateness Criteria®

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ACR Appropriateness Criteria®

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Case Vignettes

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Case 1 • 61-year-old male • Emergency department • Knocked off bicycle by car • Wearing helmet • No loss of consciousness • Left hip pain • No gross deformity on physical exam • “Catching” discomfort when straining against resistance • Pain with weight bearing • Negative plain films of the hip and pelvis ©2016 MFMER | slide-12

Management? 20%

20%

20%

20%

C.

D.

20%

A. CT With Contrast B. MRI Without Contrast

C. Tc-99 Bone Scan D. Ultrasound E. CT Without and With Contrast A.

B.

E.

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ACR Appropriateness Criteria® Acute Hip Pain

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MRI

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Case 2 • 54-year-old female • Emergency department • Acute onset 10/10 epigastric pain • Radiating to back

• Vomiting, non-bloody, non-bilious • PMH: • GERD (omeprazole)

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Case 2 • Labs • • • •

Lipase 8200 AST 800 ALT 400 Serum bilirubin 2.6

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Management? 20%

20%

20%

20%

C.

D.

20%

A. CT With Contrast B. MRI With Contrast

C. Ultrasound D. CT Without Contrast E. MRI Without Contrast

A.

B.

E.

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ACR Appropriateness Criteria® Acute Pancreatitis

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US

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US

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Case 3 • 64-year-old male • No meds • Positive family history of CAD (Father MI @ 63) • No history of angina • No congestive heart failure • No cardiac rhythm disturbance

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Case 3 • BP 128/78 • Labs • Cholesterol • Triglycerides • HDL • LDL • Non- HDL

208 72 45 125 163

• ASCVD risk = 12.9% • Has completed life style changes • Reluctant to take statin – “only if I really need” ©2016 MFMER | slide-23

Management? A. CT Angiogram Coronary Arteries

20%

20%

20%

20%

C.

D.

20%

B. CT Without Contrast Coronary Calcium C. Tc-99 SPECT Rest and Stress D. US Echocardiography E. MRI Heart with contrast A.

B.

E.

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ACR Appropriateness Criteria®

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Coronary CT

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Coronary CTA

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Online Risk Calculator

• https://www.mesanhlbi.org/MESACHDRisk/ MesaRiskScore/RiskScore .aspx

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Case 4 • 72-year-old female • Emergency department • Black stools • Some orthostatic hypotension • Anemia • Negative colonoscopy 1 year ago • Negative upper endoscopy at local ED

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Management? 20%

20%

20%

20%

C.

D.

20%

A. CT Without Contrast B. CT Enterography C. Tc-99 labeled RBC scan D. Ultrasound

E. MRI With Contrast

A.

B.

E.

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ACR Appropriateness Criteria®

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CT Enterography (triple phase)

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Case 5 • 46-year-old female • Executive health physical • Family history of breast cancer • Dense breast on mammography • Breast MRI • Partially imaged liver lesion • US • Indeterminate > 1cm lesion right hepatic lobe

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Case 5 • Occasional alcohol • Never smoker • No other health problems • No medications

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Management? A. CT Without Contrast

20%

20%

20%

20%

C.

D.

20%

B. MRI Without and With Contrast C. Tc-99 Sulfur Colloid Liver Scan D. FDG PET/CT E. Percutaneous biopsy A.

B.

E.

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ACR Appropriateness Criteria®

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ACR Appropriateness Criteria®

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MRI (Eovist®)

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MRI (Eovist®)

10 min

20 min ©2016 MFMER | slide-39

Case 6 • 29-year-old male • Neurology clinic • Chronic neck pain • Acute onset of right shoulder weakness • No trauma • No malignancy

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Case 6 • Upper extremities, -1 weakness on the Mayo scale (4/5 on the MRC scale) involving the deltoid, triceps, finger extensors on the right side • Subjective cape-like-distribution numbness that extends from the base of his neck down to about the upper thoracic level • Negative C-Spine x-ray

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Management? 20%

20%

20%

20%

C.

D.

20%

A. MRI Without and With Contrast B. MRI Without Contrast C. CT Without Contrast

D. CT With Contrast E. Tc-99 bone scan

A.

B.

E.

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ACR Appropriateness Criteria® Chronic Neck Pain

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ACR Appropriateness Criteria® Chronic Neck Pain

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MRI C-Spine

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Summary • Radiology imaging is increasingly useful • Increasingly complex to know where to start • Radiologists can be a useful tool • Knowledge of which exam is best starting point • Know strengths of particular practice • ACR Appropriateness criteria • Imaging choice • When imaging not necessary

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Thank You

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