Imaging  guidance  for  GP  commissioning    

First published in 1989, The Royal College of Radiologists (RCR) has produced the referral guidelines, Making the best use of clinical radiology services, to help GPs, clinicians, radiologists, radiographers and other healthcare professionals to determine the most appropriate imaging investigation(s) for a wide range of clinical problems. They provide practical guidance based on the best available evidence, together with expert opinion where evidence is lacking or conflicting.

The principal objectives of the RCR’s guidelines are:

To ensure patients have timely and accurate diagnosis by ensuring doctors and referring clinicians have knowledge of the most appropriate imaging investigation or intervention

To reduce unnecessary exposure of patients to radiation To assist in the efficient and equitable utilisation of available

diagnostic resources.

The process for development of the seventh edition of the guidelines (November 2011) has been formally approved under the NHS Evidence Accreditation Scheme.

The full resource consists of 330 guidelines designed to assist the clinician in selecting the most appropriate investigation for a given diagnostic or imaging problem. The guidelines are split into 12 sections:

Breast disease Cancer Chest and cardiovascular system ENT/head and neck Gastrointestinal system Interventional radiology

Musculoskeletal system Neurological system Obstetrics and gynaecology Paediatrics Trauma Urogenital and adrenal.

This summary lists the indicated investigations for guidelines which relate to the most common presentations in primary care. This list is based on investigations rather than the clinical problems to facilitate the commissioning process. It is not intended as a GP’s substitute for RCR referral guidelines but rather for those commissioning diagnostics wishing to know which essential radiological investigations to commission. The relevant RCR referral guideline is shown, with links to other related UK guidelines. Commissioners may choose to include other specialised investigations, such as MRI shoulder, which are often resource-intensive and usually only undertaken after discussion with the radiologist or in the context of locally agreed protocols.

In these referral guidelines, the doses have been grouped into broad bands to help the referrer understand the order of magnitude of radiation dose of the various investigations.

Symbol Typical effective dose (mSv)*

Examples

None 0 US; MRI

0 <1 CXR; XR limb, pelvis, lumbar spine; mammography

0 0 1–5 IVU; NM (eg, bone); CT head and neck

0 0 0 5.1–10 CT chest or abdomen; NM (eg, cardiac)

0 0 0 0 >10 Extensive CT studies, some NM studies (eg, some PET-CT)

*The average annual background dose in most parts of Europe falls within the 1–5 mSv range (0 0). [Key: US=ultrasound; MRI=magnetic resonance imaging; CXR=chest X-ray; XR=X-ray; IVU=intravenous urography; NM=nuclear medicine; CT=computed tomography; PET-CT=positron emission tomography co-registered with CT.

Access to the full seventh edition of the RCR guidelines is available via subscription – please see www.irefer.org.uk for further details.

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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines

BREAST

Mammography 0 B03 Breast screening: women 50–70 years old (the precise age for invitation will depend on national screening programmes)

NICE CG41. Familial breast cancer

B04 Breast screening: women >70 years old (the precise age will depend on national screening programmes)

B07 Breast screening: women ≥50 years old who have had augmentation mammoplasty

B09 Clinical suspicion of carcinoma in patients with augmentation mammoplasty (implants)

B15 Breast inflammation

Ultrasound None B08 Breast cancer diagnosis NICE. Guidance on Cancer Services. Improving Outcomes in Breast Cancer: Manual Update

B15 Breast inflammation

CHEST/CVS CXR 0 CC05 Suspected pericarditis or pericardial effusion

CC07 Suspected valvular heart disease

CC08 Suspected heart failure and/or myocarditis

CC21 Pneumonia SIGN 59. Community Management of Lower Respiratory Tract Infection in Adults

CC23 Pleural effusion suspected

CC24 Haemoptysis (including massive haemoptysis) NICE. The diagnosis and treatment of lung cancer (update)

CA12

Lung cancer: diagnosis

NICE. The diagnosis and treatment of lung cancer (update) NICE CG27: Referral guidelines for suspected cancer SIGN 80. Management of patients with lung cancer

CC12 Suspected deep vein thrombosis (DVT)

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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines

Ultrasound None CC23 Pleural effusion suspected

CC05 Suspected pericarditis or pericardial effusion

Echocardiography None CC07 Suspected valvular heart disease

CC08 Suspected heart failure and/or myocarditis

CT

0 0 0

CA12

Lung cancer: diagnosis

NICE. The diagnosis and treatment of lung cancer (update) NICE CG27: Referral guidelines for suspected cancer SIGN 80. Management of patients with lung cancer

ENT Ultrasound None E04 Thyroid nodules

E08 Neck mass of unknown origin

E09 Salivary obstruction

E10 Salivary mass

GASTROINTESTINAL US None G21 Palpable mass

G27 Jaundice

G28 Suspected gall bladder disease or post-cholecystectomy pain

Barium swallow 0 0 G01 Difficulty in swallowing: high dysphagia

Barium enema 0 0

G16 Change of bowel habit to looser stools with or without rectal bleeding persistent for 6 weeks: colorectal neoplasia

NICE. Guidance on Cancer Services. Improving Outcomes in Colorectal Cancers: Manual Update

CA23 Colon cancer: diagnosis

NICE CG27: Referral guidelines for suspected cancer NICE. Guidance on Cancer Services. Improving Outcomes in Colorectal Cancers: Manual Update SIGN 67. Management of Colorectal Cancer RCR. Recommendations for Cross-sectional Imaging

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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines

CT (incl colonography)

0 0 0 G16

Change of bowel habit to looser stools with or without rectal bleeding persistent for 6 weeks: colorectal neoplasia

NICE. Guidance on Cancer Services. Improving Outcomes in Colorectal Cancers: Manual Update

G21 Palpable mass

CA23 Colon cancer: diagnosis

NICE CG27: Referral guidelines for suspected cancer NICE. Guidance on Cancer Services. Improving Outcomes in Colorectal Cancers: Manual Update SIGN 67. Management of Colorectal Cancer RCR. Recommendations for Cross-sectional Imaging

MSK XR 0 M07 Osteomyelitis

M10 Soft tissue mass

M11 Bone pain

M13 Metabolic bone disease

M14 Suspected osteomalacia with pain

M15 Suspected osteoporotic collapse

M16 Arthropathy: presentation SIGN 123. Management of early rheumatoid arthritis

M19 Shoulder instability

M20 Sacroiliac pain

M21 Non-traumatic hip pain including suspected avascular necrosis

M23 Knee pain with locking

M24 Painful prosthesis

Ultrasound None M10 Soft tissue mass

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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines

MRI None M05 Acute back pain with potentially serious (red flag) features

NICE CG88. Low back pain

M07 Osteomyelitis

M10 Soft tissue mass

M11 Bone pain

M21 Non-traumatic hip pain including suspected avascular necrosis

M23 Knee pain with locking

DEXA 0 M13 Metabolic bone disease

NEUROLOGICAL

MRI None N02 TIA National Collaborating Centre for Chronic Conditions. Stroke. National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)

N03 Demyelinating and other white matter disease NICE CG08. Multiple sclerosis

N04 Space-occupying lesion NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual

N14 Epilepsy (adult) NICE CG20. The epilepsies

CA01

Brain and spinal cord tumours: diagnosis

RCR. Recommendations for Cross-sectional Imaging NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual

CT 0 0 N01 Acute stroke SIGN 108. Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention NICE CG68. Stroke DH. National Stroke Strategy easy access version DH. National Stroke Strategy National Collaborating Centre for Chronic Conditions. Stroke. National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)

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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines

N02 TIA National Collaborating Centre for Chronic Conditions. Stroke. National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA)

N04 Space-occupying lesion NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual

N05 Headache: sudden onset, severe; subarachnoid haemorrhage

RCP. National clinical guideline for stroke, Third edition

CA01 Brain and spinal cord tumours: diagnosis RCR. Recommendations for Cross-sectional Imaging NICE. Guidance on Cancer Services. Improving Outcomes for People with Brain and Other CNS Tumours. The Manual

O&G Ultrasound None OG01 Screening in pregnancy NICE. Antenatal care

OG04 Possible early intrauterine pregnancy failure

OG05 Postmenopausal bleeding: to exclude significant endometrial pathology

SIGN 61. Investigation of Post-Menopausal Bleeding

OG06 Suspected pelvic mass

OG07 Pelvic pain, including suspected pelvic inflammatory disease and suspected endometriosis

RCOG. Guideline 32. Management of Acute Pelvic Inflammatory Disease

OG08 Lost intrauterine contraceptive device (IUCD)

OG09 Recurrent miscarriages (3 or more) RCOG. Guideline 17. The Investigation and Treatment of Couples with Recurrent Miscarriage

OG10 Infertility NICE. CG24. Fertility assessment and treatment for people with fertility problems

OG12 Suspected polycystic ovary syndrome NICE. CG24. Fertility assessment and treatment for people with fertility problemsf

CA42 Ovarian cancer: diagnosis RCR. Imaging for Oncology RCR. Recommendations for Cross-sectional Imaging

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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines

CA48 Cancer of the uterine body: diagnosis RCR. Recommendations for Cross-sectional Imaging NICE CG27: Referral guidelines for suspected cancer

PAEDIATRICS XR 0 P03 Inhaled foreign body (suspected) in children

P22 Ingested foreign body in children

P36 Focal bone pain in children

Ultrasound None P24 Projectile vomiting in infants

P28 Acute abdominal pain in children

P30 Palpable abdominal/pelvic mass in children

P34 Hip pain in children: suspected irritable hip

P35 Limp (no trauma) in children

P37 Clicking hip: suspected developmental dysplasia of the hip (DDH) in infants

P40 Impalpable testis in children

MRI None P17 Back pain in children

TRAUMA XR 0 T10 Neck injury with pain NICE. Head Injury. Triage, assessment, investigation and early

management of head injury in infants, children and adults SIGN 110. Early management of patients with a head injury

T14 Thoracic and lumbar spine trauma with pain but no neurological deficit, or patient not able to be evaluated

T15 Thoracic and lumbar spine trauma with neurological deficit with or without pain

T16 Pelvic injury with inability to weight-bear NICE. The management of hip fracture in adults

T19 Shoulder injury

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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines

T20 Elbow trauma

T21 Wrist injury: suspected scaphoid fracture

T22 Knee trauma: fall/blunt trauma

T23 Acute ankle injury

T24 Foot injury

T25 Stress fracture

T26 Soft tissue injury: foreign body – eg, metal, glass, painted wood, thorns

T32 Sternal injury

Ultrasound None T26 Soft tissue injury: foreign body – eg, metal, glass, painted wood, thorns

MRI None T15 Thoracic and lumbar spine trauma with neurological deficit with or without pain

T25 Stress fracture

CT 0 0 T01 Head injury NICE. Head Injury. Triage, assessment, investigation and early management of head injury in infants, children and adults SIGN 110. Early management of patients with a head injury

UROGENITAL/ADRENAL Ultrasound None U02 Renal failure

U10 Lower urinary tract symptoms

U11 Scrotal mass or pain

U12 Suspected testicular torsion

U20 Microscopic haematuria

U21 Macroscopic haematuria

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Investigation Dose iRefer code Clinical problem(s) for which investigation is indicated Associated UK clinical guidelines

CA32

Kidney cancer: diagnosis

NICE. Guidance on Cancer Services. Improving Outcomes in Urological Cancers. The Manual NICE CG27: Referral guidelines for suspected cancer

CT 0 0 0 U04 Suspected ureteric colic

U21 Macroscopic haematuria

XR 0 U20 Microscopic haematuria

U21 Macroscopic haematuria