Page 148 - Registrar Orientation Manual 2016

Reference:
1257
Effective date:
7 July 2015
Expiry date:
6 July 2018
Page:
31 of 35
Title:
Imaging Guidelines
Type:
Clinical Guideline
Version:
02
Authorising initials:
The ‘Choosing Wisely’ recommendations include:
Avoid requesting CT KUB in otherwise healthy ED patients, age <50 years, with a history of kidney stones, presenting with symptoms and signs consistent with uncomplicated renal colic
The National Community Radiology Access Criteria note referral for US is not typically indicated for:
• recurrent uncomplicated UTIs in adult females as underlying abnormalities are uncommon
• investigation of hypertension
• elevated PSA
• lower urinary tract symptoms
• investigation of isolated proteinuria (discuss with local relevant specialist)
• serial ultrasounds for polycystic kidneys unless there are clinical symptoms
In patients admitted to hospital the following have been suggested by the Renal service:
Acute Kidney Injury (AKI)
Imaging is required in most cases.
Usual initial imaging is an ultrasound of the urinary tract with/without a plain AXR. Clinical Urgency: Urgency depends on the clinical context.
Chronic Kidney Disease (CKD)
Imaging is not required in all cases.
Patients with stable mild to moderate CKD (eGFR >30 ml/min) usually do not require imaging. Consider imaging in patients with:
• Associated haematuria and/or proteinuria (urine protein:creatinine ratio >100 mg/mmol)
• Symptoms indicating possible structural problems of the urinary tract e.g. obstructive uropathy
• Progressive CKD (eGFR loss of > 5 ml/min/year or more than 15 ml/min over 5 years)
• Family history of polycystic kidney disease and are more than 20 years old
The recommended initial imaging is ultrasound of the urinary tract.
Clinical Urgency: Urgent imaging is not required unless there has been an AKI.
Stroke
The Stroke Imaging Pathway in the Australian guidelines recommends CT as the initial imaging
investigation of choice in acute stroke. MRI may be better but we are unable to offer it routinely.
In patients with a clinical stroke we accept an early CT may not demonstrate the ischaemic area but rules out a bleed and most stroke mimics, so further imaging is not usually required.
Contrast CT may be needed to exclude stroke mimics in patients with possible mass lesions.
CTA will be performed in patients who are candidates for thrombolysis.
CTA is indicated acutely in selected patients to rule out carotid or vertebral artery dissection.
MRA may be a better modality but in an emergency we recommend CTA as the first line investigation. CTA may have a role in the further investigation of other very selected cases (see Vascular Imaging) CTA requests will only be accepted if recommended by an on call SMO.
In young patients (<50) with no risk factors with a normal CT, MRI/MRA/MRV may be indicated to confirm the diagnosis and/or exclude a dissection or uncommon cause of stroke.
MRI may also be required if there is significant diagnostic uncertainty or atypical clinical or radiological features and the MRI findings would change the management of the patient.