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Guidelines For Professional

Ultrasound Practice

Society and College of Radiographers and British Medical Ultrasound Society

December 2015 Revision 2, December 2017

SCoR/BMUSGuidelinesforProfessionalUltrasoundPractice.Revision2.December2017.

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SOCIETYANDCOLLEGEOFRADIOGRAPHERSANDBRITISHMEDICALULTRASOUNDSOCIETYGUIDELINESFORPROFESSIONALULTRASOUNDPRACTICEDECEMBER2015Revision2,December2017.LISTOFCONTENTSAcknowledgements 3Foreword 5Revision1,December2016 6Revision2,December2017 Introduction 7 Section1Generalinformation1.1 Explanationoftheprofessionaltitle‘sonographer’ 91.2 Registrationforsonographers 101.3 ProfessionalIndemnityInsurance 111.4 Professionvstool 111.5 Safetyofmedicalultrasound 121.6 Medico-legalissues 131.7 Transducercleaninganddisinfection 141.8 Screeningexaminationsusingultrasound 151.9 ErgonomicpracticeincludingmanagingthehighBMIpatient 171.10 Intimateexaminationsandchaperones 181.11 Examinationtimes 201.12 Communication,IDandconsent 211.13 Clinicalgovernance 231.14 E-LearningforHealthcare(E-LfH) 251.15 ImagingServicesAccreditationScheme(ISAS) 251.16 Ultrasoundequipmentandqualityassurancetesting 261.17Raisingconcerns;safeguarding;statutoryrequirementsforreportingfemalegenitalmutilation;DutyofCandour. 1.18Continuingprofessionaldevelopment(CPD) 281.19Codesofprofessionalconductforsonographers 291.20Independentpractice 31

Section2Theultrasoundexamination2.1 Overviewofultrasoundexaminationprocedures 332.2 Obstetric,vascularandechocardiographyexaminations 332.3 NICEandotherguidelines 34


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2.4 Vettingofultrasoundrequests 342.5 Justificationofultrasoundrequests 352.6 Recommendationsfortheproductionofanultrasoundreport 372.7 Gynaecologicalultrasoundexaminations 432.8 Abdominalultrasoundexaminations 50

Examinationspecificguidelinesandcommonscenarios2.8.1 Generalprinciples 502.8.2 Ultrasoundexaminationsoftheliver 542.8.3 Imagingofthegallbladderandbiliarytree 552.8.4 Transabdominalultrasoundofthepancreas 562.8.5 Ultrasoundofthespleen 572.8.6 Ultrasoundofthebowel 60

2.9Imagingoftheuro-genitalsystemincludingtestesandscrotum 632.10Ultrasoundoftheadultheadandneck 662.11 Paediatricultrasoundexaminations

2.11.1 Paediatricandneonatalliverandbiliarysystem(includingpancreasandspleen) 702.11.2 Paediatricurinarysystem 742.11.3 Paediatricgastro-intestinaltract 752.11.4 Neonatalhip 762.11.5 Neonatalintracranialultrasound 77

2.12 Musculoskeletalultrasoundexaminations 78Examinationspecificguidelinesandcommonscenarios 2.12.1 Shoulder 782.12.2Elbow 842.12.3Wristandhand 882.12.4Hip 912.12.5Knee 942.12.6Footandankle 972.12.7Rheumatologyultrasoundexaminations 101

2.13Elastography 1112.14ContrastEnhancedUltrasoundExaminations(CEUS) 1142.15Interventionalandextendedscopeexaminations(sonographers) 1152.16PatiendGroupDirections(PGD) 1162.17Acquisition,archivinganduseofultrasounddata 118 2.18Auditandlearningfromdiscrepancy 1202.19Recordingofimagesbypatientsduringultrasoundexaminations 1252.20‘HaveyouPausedandChecked’promptcardsandposters 126


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ACKNOWLEDGEMENTS,DECEMBER2015EDITION

TheSocietyandCollegeofRadiographersandtheBritishMedicalUltrasoundSocietywouldliketoacknowledgethehelpandassistanceprovidedbythefollowing:FortheSocietyandCollegeofRadiographers(SCoR)MrNigelThomson,ProfessionalOfficer(Ultrasound),SocietyandCollegeofRadiographersMsWendyWilliams,SuperintendentSonographer,UniversityHospitalLlandough,Cardiff.Member,UltrasoundAdvisoryGroup,SocietyandCollegeofRadiographers.AllpastandcurrentmembersofitsUltrasoundAdvisoryGroupwhohavecontributedtoorcommentedonpreviouslypublisheddocumentsavailableviawww.sor.orgThefollowingSCoRmembersprovidedfeedbackonthefinaldraft:AlexandraDrought,GillHarrison,SallyHill,SteveSavage,MargaretTaylor.FortheBritishMedicalUltrasoundSociety(BMUS)ProfessionalStandardsGroupDrOliverByass,ConsultantRadiologist,HullandEastYorkshireHospitalsNHSTrustMrPeterCantin,ConsultantSonographer,PlymouthHospitalsTrustDrNickDudley,MedicalPhysicist,UnitedLincolnHospitalsTrustDrRhodriEvans,ConsultantRadiologist/Assoc.Professor,CollegeofMedicine,SwanseaUniversityHonoraryTreasurerBMUSMissPatFarrant,Sonographer,KingsCollegeHospital,LondonMrsAlisonHall,ConsultantSonographer,KeeleUniversityMrGerryJohnson,ConsultantSonographer,TamesideHospitalsNHSTrustMrsPamelaParker,UltrasoundSpecialtyManager,HullandEastYorkshireHospitalsNHSTrust.ProfessionalDevelopmentOfficer,BMUS.DrPeterRodgers,ConsultantRadiologist,UniversityHospitalsofLeicesterMrsJaneSmith,ConsultantSonographer,UnitedLeedsHospitalTrustMrsJeanWilson,ProgrammeDirector,DiagnosticImaging,UniversityofLeedsDuerecognitionisgiventotheeditorsandcontributorstopreviouseditionsofUnitedKingdomAssociationofSonographers(UKAS)Guidelineswhoseearlierworkformsthefoundationofthisnewdocument.UKASmergedwiththeSocietyandCollegeofRadiographersinJanuary2009Theprevious2008UKAS‘GuidelinesforProfessionalWorkingStandards:UltrasoundPractice’hasbeenarchivedbutisavailableon-lineathttp://www.sor.org/learning/document-library/guidelines-professional-working-standards-ultrasound-practice


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ThanksisalsogiventoJMBridsonandGJohnsonofUniversityofLiverpool,andDrPRowlandsofTheRoyalLiverpoolandBroadgreenUniversityHospitalsNHSTrust,Liverpoolfortheirpreviousworkonthedocument"ClinicalStandardsandframeworkfortheassessmentofinitialandongoingcompetenceofultrasoundpractitioners"(BMUS2011)whichformsthefoundationforsection2.6:Recommendationsfortheproductionofanultrasoundreport.December2017RevisionAcknowledgementandthankstothefollowingcontributorstotheDecember2017revision:JBurdachofNanosonicsLtd,CKirkpatrickofUnitedLincolnHospitalsTrustandMSmithofCardiffUniversity


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FOREWORDTOTHEDECEMBER2015EDITIONItismypleasuretointroducetheupdated‘GuidelinesforProfessionalUltrasoundPractice’,inthepastaffectionatelyknowntosonographersasthe‘UKASGuidelines’.TheUnitedKingdomAssociationofSonographerswassetuptosupportsonographers,provideadviceandpracticeguidanceandultimatelygetsonographyrecognisedasaprofessioninitsownright.Tothisdaythelatterstillremainsachallenge!However,sincethelasteditionoftheGuidelineswasproducedin2008,UKAShasmergedwithSCOR,so,whileUKASnolongerexists,itslegacylivesoninthisreviseddocument.ItisatestamenttothequalityoftheoriginalGuidelinesthatsomesectionsarerelativelyunchanged.Theadviceisasequallysoundandrelevanttodayasitwasthen.Guidelines,however,needtokeepinstepwithevolvingtechnology,changesinpracticeandprofessionalprogression.Forthisreasonitwasdecidedtoproducetherevisedversionasaweb-baseddocumentthatcanberegularlyupdated,amendedandexpandedasandwhenrequired.

TheserevisedGuidelineshavebeenproducedincollaborationwiththeBritishMedicalUltrasoundSociety.Ithasbeenbothinformativeandenjoyableworkingwiththemandhopefullyitisjustthefirstofmanysimilarfutureventures.Aswithallpreviouseditions,theseGuidelinesarenotdesignedtobeprescriptivebuttoinformgoodpractice.MaytheycontinuetobeusedindepartmentsacrosstheUnitedKingdomforyearstocome.WendyWilliamsMember,UltrasoundAdvisoryGroup,SocietyandCollegeofRadiographers.FormerUKAScommitteememberDecember2015REVISION1,DECEMBER2016Itwasintendedthatthisdocumentwouldbereviewedandupdatedatyearlyintervals(ref:Introduction,page7).ThisfirstrevisionisdatedDecember2016andincludesthechangesindicatedbelow.Allpagesareclearlymarkedintheheaderas‘Revision1’.Ithasbeengivenapinkcover.TheDecember2015editionwillbearchivedbutisavailableforfuturereferenceifneeded.SummaryofmainchangesRe-orderedintotwomainsectionstosimplify.Additionalacknowledgementstorecognisepastcontributionstorelateddocuments.Allweblinksconfirmedascompletingandupdatedasnecessary.Significantchangestoinformationinthefollowingsections:1.2LinktoHCPCstatementonprofessionalregulation1.7NHSScotlandultrasoundprobecleaningrecommendations.Linkadded1.8DutyofCandourinthenationalscreeningprogrammes(linkalsoaddedtosection1.17)1.10MedicalDefenceUnionadviceonprotectingyourselfagainstasexualassaultallegation.Linkadded1.12GeneralMedicalCounciladviceonconsent.Linkadded1.12ClinicalImagingBoardadviceonpatientidentification.Linkadded.ThisadviceisendorsedbyBMUS1.14e-LearningforHealthcareinformationamendedandupdated1.16Updatedsectiononultrasoundequipmentqualityassurancetesting1.17HCPCguidanceonraisingconcerns.Linkadded1.18IntroductionofCPDaudittothePublicVoluntaryRegisterofSonographers.Linkadded1.20Independentsectorproviders.NHSLitigationAuthority(NHSLA).LinkaddedRegistrationofindependentclinicsinScotlandfromApril2017.Linkadded


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2.5 Justification-rationaleremainswithinthisdocumentbutspecificexaminationexamplesnowvialog-onatwww.bmus.org2.8.3 Updatedguidanceonbiliarytreeimaging2.8.4 Updatedguidanceonimagingofthepancreas2.8.5 Newsectiononultrasoundofthespleen2.8.6Newsectiononultrasoundofthebowel2.12.7 Newsectiononrheumatologyultrasoundexaminations2.13 Newsectiononelastography2.20‘Haveyoupausedandchecked’postersandpromptcards.Newsection.REVISION2,DECEMBER2017Web-linksupdatedwherenecessary,brokenlinksremovedorupdated.Minoramendmentstotext.Linksaddedfrom2017BMUS‘Ultraposts’intheGynaecology(2.7)andElastography(2.13)sections.1.7Transducercleaning.Re-drafted.Several2017publicationsandBMUSadviceadded.2014SCoRdocumentremoved.December2017-EuropeanSocietyofUltrasoundWorkingGroupadviceadded.1.8PublicHealthEnglande-learningplatform(screeningprogrammes),linkadded.1.12CompassioninPractice,linkadded.‘The6C’s’.UpdatedHCPCguidanceonconsentrelatingtothetheuseofanddisclosureofpatientrecords.1.14e-LearningforHealthsectionupdated.1.17NHSLitigationAuthoritybecomesNHSResolution1.20AmendmenttotextfollowingchangestoSCoRProfessionalIndemnityInsuranceschemethatbecameeffectiveonOctober1st2017.PUBLICATIONHISTORY-SUMMARYSCoR/BMUSGuidelinesforProfessionalUltrasoundPractice. December2015PurplecoverRevision1 December2016PinkcoverRevision2 December2017Lightbluecover


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INTRODUCTIONTODECEMBER2015EDITIONThisdocumentisasaresultofcollaborationbetweentheSocietyandCollegeofRadiographers(SCoR)andtheBritishMedicalUltrasoundSociety(BMUS).ItfollowsfivepreviousdocumentspublishedbytheUnitedKingdomAssociationofSonographers(UKAS)whichmergedwiththeSocietyandCollegeofRadiographers(SCoR)inJanuary2009.Fortherecordthesedocumentswere:i) GuidelinesforProfessionalWorkingPractice,publishedinDecember1993ii) GuidelinesforProfessionalWorkingPractice-Reporting,publishedinApril1995iii) GuidelinesforProfessionalWorkingStandards,publishedinAugust1996iv) GuidelinesforProfessionalWorkingStandards-Ultrasound,publishedinOctober2001v) GuidelinesforProfessionalWorkingStandards-UltrasoundPractice,publishedinOctober2008Ithasbeendesignedasaweb-baseddocumentandwillonlybeavailableon-lineforeasierupdatingandtoallowforactivehyperlinkstootherguidancedocumentsandorganisationstobeprovided.Asthisisanewformatandthereismuchnewandupdatedcontent,thedocumentwillinitiallyonlybeavailabletoSCoRandBMUSmembersviatheirlog-oncodes.Commentsandfeedbackarewelcomeandcanbedirectedto:https://www.sor.org/contact-usorhttps://www.bmus.org/contact-us/

SomelinkswithintheGuidelinesaretomembersonlySCoRorBMUScontentandmayrequireadditionallog-on.Clearindicationisgivenalongsidethehyperlinkwhenthisapplies.Itisproposedthatlog-onrequirementswillbereviewedinduecourseoncefeedbackandcommentshavebeentakenintoaccount.(Note:afterpublicationofRevision1inDecember2016thedocumentwillbecomeopen-accessonboththeSCoRandBMUSwebsites).Thedocumenthasbeenwrittentocomplementthe2014RoyalCollegeofRadiologists(RCR)andSocietyandCollegeofRadiographersjointdocumententitled‘StandardsfortheProvisionofanUltrasoundService’.https://www.rcr.ac.uk/publication/standards-provision-ultrasound-serviceItprovidesguidanceontopicsthatwerenotincludedinthejointRCR/SCoRStandardsdocumentandprovidesfurtherdetailedadviceonsomeareasofpracticethatwere.Therecanbeoverlapbetweentheterms‘Standards’,‘Guidelines’and‘Protocols’andthiscancauseconfusion.Forthepurposesofthisdocument,thedefinitionsusedarethesameasthoseintheabove2014RoyalCollegeofRadiologists(RCR)andSocietyandCollegeofRadiographers(SCoR)document.Standard:‘Arequiredoragreedlevelofqualityorattainment.Astandardisawayofensuringoptimumlevelsofcareorservicedelivery.Standardspromotethelikelihoodofanultrasoundexaminationbeingdeliveredsafelyandeffectively,areclearaboutwhatneedstobedonetocomply,areinformedbyanevidencebaseandareeffectivelymeasureable’.Guideline:‘Ageneralrule,principleorpieceofadvice.Guidelinesproviderecommendationsonhowultrasoundexaminationsshouldbeperformedandarebasedonbestavailableevidence.Theyhelpultrasoundpractitionersintheirworkbuttheydonotreplacetheirknowledgeandskills’.Protocol:Anagreement,preferablybasedonresearch,betweenpractitionerstoensurethedeliveryofhighqualitystandardisedultrasoundexaminations.Thetitleofthis2015edition‘GuidelinesforProfessionalUltrasoundPractice’reflectstheabovedefinitions.TheseGuidelines,whicharenotprescriptive,aremadeavailabletobeusedasrecommendationsforgoodpractice.SincethefirstpublicationoftheUKAS‘GuidelinesforProfessionalWorkingPractice'in1993,serviceprovision,technologyandpatientexpectationsinmedicalultrasoundhavebeentransformed.Theexamination-specificsection,includingguidelinesandcommonclinicalscenarios(ref:section2)hasbeencompiledbytheBritishMedicalUltrasoundSocietyProfessionalStandardsteamandispresentedasexamplesofbestpractice.


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Theyhavebeenincludedsothatdepartmentscanusethemasabasistogeneratetheirowndepartmentalexaminationprotocolswhentherearenonationallyagreedonesavailable.Therearealsosectionsgivinggeneralguidanceandadvice,includingreportingandaudit.HyperlinkshavebeenextensivelyusedtogiveaccesstothemanyrelevantdocumentsalreadypublishedonawiderangeoftopicsbyorganisationsotherthantheSCoRandBMUS.Theseguidelinesdonotandcannotcoverallelementsofanultrasoundexaminationand,inaddition,ultrasoundpractitionersareadvisedtoaccessstandardtexts,documentsandresearchinordertofullyinformlocaldepartmentalprotocolsandprocedures.Therearenoguidelinesincludedforobstetricultrasoundinthisedition.Practitionersarereferredtopublicationsfromthenationalfetalanomalyscreeningprogrammes,theRoyalCollegeofObstetriciansandGynaecologists(especiallytheirGreentopGuidelines),theFetalMedicineFoundation,AssociationofEarlyPregnancyUnits,BritishSocietyofGynaecologicalImagingandtheInternationalSocietyofUltrasoundinObstetricsandGynaecology.Thetermpatienthasbeenusedthroughoutthedocumentinpreferencetoothertermssuchasclientorserviceuser.Severalprofessionaltitlesareusedbythosewhopracticeultrasoundandthiscanleadtoconsiderableconfusion.Thetermultrasoundpractitionerisusedthroughoutthisdocumentwhenappropriatetodoso.Thisisconsistentwithuseofthistermwithinthe2014RCR/SCoRdocumentreferredtoabove.ThedefinitionofultrasoundpractitionerwithintheGlossarysectionoftheabovedocumentis:‘Ahealthcareprofessionalwhoholdsrecognisedqualificationsinmedicalultrasoundandisabletocompetentlyperformultrasoundexaminationsfallingwithintheirpersonalscopeofpractice.Theprofessionalbackgroundofultrasoundpractitionerscanbeveryvariedandwillincluderadiologists,radiographers,sonographers,midwives,physiotherapists,obstetriciansandclinicalscientists’.Adefinitionof‘sonographer’thatisusedinconnectionwiththePublicVoluntaryRegisterofSonographers(PVRS)whichisadministeredbytheSCoRcanbefoundinSection1.ThisdefinitionmakesadistinctionbetweenthoseultrasoundpractitionerswhoareregisteredwiththeGeneralMedicalCouncil(GMC)andthosewhoarenot.TheseGuidelineswillbeofrelevancetoall,hencetheuseoftheterm‘ultrasoundpractitioner’wheneverpossible.Occasionallytheterm‘operator’isused.ThistermisdefinedwithintheGlossaryofthe2014RCR/SCoRStandardsfortheProvisionofanUltrasoundServicedocumentas:‘Agenerictermusedforsomeonewhousesultrasoundequipment.Itdoesnotimplythattheyholdrecognisedultrasoundqualificationsaswouldanultrasoundpractitioner’.Itisthenatureofanydocumentwhetherpublishedinatraditionalformatoron-linethatitcanveryquicklybecomeoutofdate.ItistheintentionofBMUSandtheSCoRthatthisdocumentwillberegularlyupdatedbutitistheresponsibilityoftheultrasoundpractitionertoensurethattheyresearchandapplythemostuptodateevidenceinassociationwiththecontentsofthisdocument.Atthetimeofpublication(Revision1,December2016),allhyperlinkshavebeencheckedandarecomplete.Pleasereportanybrokenlinkstothefollowingcontactaddresses:https://www.sor.org/contact-usorhttps://www.bmus.org/contact-us/CommentsandfeedbackarealsoverywelcomeandwillguideusinthefurtherdevelopmentoftheseGuidelines. TheSocietyandCollegeofRadiographersandtheBritishMedicalUltrasoundSocietywouldliketothankallwhohavecontributedtothisnewon-lineeditionofwhatwaspreviouslytheUKASGuidelines.Pleaseseeacknowledgementssection.WewouldalsoliketoagaintakethisopportunitythankallthecontributorsandeditorsofpreviouseditionsoftheGuidelineswhohaveprovideduswithsuchafirmfoundationonwhichtobuild.


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SECTION1GENERALINFORMATION1.1 EXPLANATIONOFTHEPROFESSIONALTITLE‘SONOGRAPHER’

Althoughitistheintentionwithinthisdocumenttousewhereverpossibletheterm‘ultrasoundpractitioner(ref:Introduction),afullexplanationoftheterm‘sonographer’willbehelpfulforcontextandimportantintermsofprofessionalrecognitionandrecommendedqualifications.Sonographersarequalifiedhealthcareprofessionalswhoundertake,reportandtakeresponsibilityfortheconductofdiagnostic,screeningandinterventionalultrasoundexaminations.Theirindividualscopeofpracticecanbewideandvaried.Sonographersalsoperformadvanceddiagnosticandtherapeuticultrasoundproceduressuchasbiopsiesandjointinjections.SonographersareeithernotmedicallyqualifiedortheyholdmedicalqualificationsbutarenotregisteredasadoctorwithalicencetopracticewiththeGeneralMedicalCouncil(GMC).Thefollowingdefinitionof‘sonographer’isusedinconnectionwiththePublicVoluntaryRegisterofSonographers:‘Ahealthcareprofessionalwhoundertakesandreportsdiagnostic,screeningorinterventionalultrasoundexaminations.TheywillholdqualificationsequivalenttoaPostgraduateCertificateorDiplomainMedicalUltrasoundthathasbeenaccreditedbytheConsortiumfortheAccreditationofSonographicEducation(CASE).TheyareeithernotmedicallyqualifiedorholdmedicalqualificationsbutarenotstatutorilyregisteredwiththeGeneralMedicalCouncil.’Ref:https://www.sor.org/practice/ultrasound/register-sonographersScrolldownfor‘PolicyandProcesses’PDF.TheminimumqualificationsasonographerwouldbeexpectedtoholdtopracticeintheUKisapostgraduatecertificateinmedicalultrasoundthathasbeenaccreditedbytheConsortiumfortheAccreditationofSonographicEducation(CASE)orequivalent.Individualswithoutarecognisedqualification,includingstudentsonographersshouldalwaysbesupervisedbyqualifiedstaff.Atthetimeofthissecondrevisionamedicalultrasounddegreeapprenticehipisbeingdevelopedalongwithnewandinnovativepathwaysthatwillleadtorecognisedultrasoundqualifications.Thesearebeingco-ordinatedbyHealthEducationEnglandandarelikelytocometofruitionoverthenextfewyears.TheCASEwebsiteandalistofaccreditedcoursescanbefoundathttp://www.case-uk.org/TheBritishSocietyofEchocardiography(BSE)andSocietyforVascularTechnologyofGreatBritainandIreland(SVT)alsoaccreditindividualultrasoundpractitionersworkingwithintheirrespectivespecialties.http://www.bsecho.org/home/http://www.svtgbi.org.uk/TheSocietyandCollegeofRadiographers(SCoR)canprovideaccreditationofadvancedandconsultantpracticeforitssonographermembershttp://www.sor.org/career-progression(SCoRmemberlog-inrequired).Asonographershould:i) recogniseandworkwithintheirpersonalscopeofpractice,seekingadviceasnecessary;ii) ensurethatalocallyagreedandwrittenschemeofworkisinplace;iii) workwithreferencetonationalandlocalpracticeandguidelinerecommendations;iv) ensuretheyholdappropriateprofessionalindemnityinsuranceorobtainthisbyvirtueoftheir

employment(ref:section1.3).


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Seealsosection1.19oncodesofprofessionalconductforsonographers.

Thegeneralstandardsofeducationandtrainingforultrasoundpractitionersaresetoutonpage12ofthe2014RoyalCollegeofRadiologists/SocietyandCollegeofRadiographersdocument‘StandardsfortheProvisionofanUltrasoundService’:https://www.rcr.ac.uk/publication/standards-provision-ultrasound-service1.2REGISTRATIONFORSONOGRAPHERS

Thissectionusestheprofessionalterm‘sonographer’insteadofthegeneric‘ultrasoundpractitioner’(ref:Introduction)andreferstothelongrunningcampaigntohave‘sonography’recognisedasaprofessionandfortheprofessionaltitleof‘sonographer’tobelegallyprotected.

Theregistrationsituationforsonographersiscomplex.1Themajorityofsonographersarestatutorilyregisteredbutthiswilldependontheirprofessionalbackgroundandisnotachievableforall.StatutoryregistrationwillmostlikelybeasaradiographerorclinicalscientistwiththeHealthandCareProfessionsCouncil(HCPC)orasamidwifeornursewiththeNursingandMidwiferyCouncil(NMC)andnotasasonographer,whichisnotaprotectedtitle.Whetherstatutorilyregisteredornot,sonographersareencouragedtoapplytoregisterwiththePublicVoluntaryRegisterofSonographers(PVRS)whichisadministeredbytheSocietyandCollegeofRadiographers:http://www.sor.org/practice/ultrasound/register-sonographers

Forsomesonographers,thiswillbetheonlyregisteravailabletothem.Forthosesonographerswhoarealreadystatutorilyregistered,applyingtoregisterwiththePVRSwillhelptoprotectthepublicandsupportthecaseforstatutoryregulation.ThiswasrecommendedbythethenHealthProfessionsCouncil(HPC)totheSecretaryofStateforHealthin2009buthasnotprogressed.Governmentpolicysince2011hasbeennottobringfurtheraspirantgroupsintostatutoryregistrationunlessthereisaclearevidenceofclinicalriskthatrequiresthis.2

LinktoHCPCadviceonaspirantgroupsforregistration,includingtheirMay2016policystatementonextendingprofessionalregulation:http://www.hcpc-uk.co.uk/aboutregistration/aspirantgroups/andhttp://www.hcpc-uk.co.uk/assets/documents/10005047Policystatementonextensionofprofessionalregulation.pdfNHSemployershaveadviceonsonographerregistrationavailableat:http://www.nhsemployers.org/your-workforce/retain-and-improve/standards-and-assurance/professional-regulation/role-of-the-employer/medical-radiography-and-ultrasound-workforceTheSocietyandCollegeofRadiographershasadviceonultrasoundtraining,employment,registrationandprofessionalindemnityinsuranceat:https://www.sor.org/learning/document-library/ultrasound-training-employment-registration-and-professional-indemnity-insurance-0TheBritishMedicalUltrasoundSocietyhasinformationavailableat:https://www.bmus.org/careers-training/andhttps://www.bmus.org/careers-training/training/ForsomesonographersworkinginareasofpracticecomingwithintheremitoftheAcademyforHealthcareScience(AHCS),statutoryregistrationmaybeavailableeitherbyfollowingapprovededucationandtrainingroutesasaclinicalscientistorbybeingabletodemonstrate‘equivalence’.Statutoryregistration,ifitisobtainable,willbewiththeHCPCasaclinicalscientist.TheAHCSalsoadministersavoluntaryregisterthatisaccreditedbytheProfessionalStandardsAuthority.http://www.ahcs.ac.uk/https://www.professionalstandards.org.uk/accredited-registers


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TheRegistrationCouncilforClinicalPhysiologistsrunsavoluntaryregisterthatisrelevantforprofessionalsspecialisinginechocardiography:https://www.rccp.co.uk/References1)ThomsonN,PatersonA.SonographerregistrationintheUK-areviewofthecurrentsituation.UltrasoundFeb2014.22(1):52-562)Enablingexcellence.Autonomyandaccountabilityforhealthcareworkers,socialcareworkersandsocialcareworkers.London:HMSO.Feb20111.3 PROFESSIONALINDEMNITY

TheUKgovernmentintroducedlegislationin2014whichrequiresultrasoundpractitionerswhoarestatutorilyregisteredwiththeHealthandCareProfessionsCouncil(HCPC)(egasaradiographer,physiotherapistorclinicalscientist),NursingandMidwiferyCouncil(NMC)(egasanurseormidwife),orotherstatutoryregulator,tohaveaprofessionalindemnityarrangementasaconditionoftheirstatutoryregistration.Themajorityofstatutorilyregisteredultrasoundpractitionerswillalreadymeetthisrequirementandwillnotneedtotakeanyfurtheraction.Theywilleitherworkinanemployedenvironmentwheretheiremployerwillindemnifythem,and/oriftheyundertakeself-employedwork,theywillhavealreadymadetheirownprofessionalindemnityarrangements.However,somestatutorilyregisteredultrasoundpractitionersmayneedtotakestepstomakesurethattheyhaveappropriateprofessionalindemnityarrangementsinplace.Registrantsandapplicantsforstatutoryregistrationwillbeaskedtoconfirmthattheymeet,orwillmeet,thisrequirementbycompletingaprofessionaldeclarationwhenrenewingorregisteringforthefirsttime.TheHCPChavepublishedguidanceontherequirementsalongwithanaccompanyingflowdiagramwhichcanbedownloadedfrom:Professionalindemnityandyourregistration-GuidanceMeetingtheprofessionalindemnityrequirementsasaconditionofHCPCregistration

NMCguidance:http://www.nmc-uk.org/Registration/Professional-indemnity-arrangements/

GMCguidance:http://www.gmc-uk.org/doctors/information_for_doctors/insurance_and_indemnity.asp

Inadditiontoworkinginanemployedenvironment,professionalindemnityinsurancecanbeobtainedthroughmembershipoftradeunionsandprofessionalbodiesorbypurchasingfrommedicaldefenceunionsorcommercialinsurers.Ultrasoundpractitionersshouldcarefullyreviewandfollowthetermsofanyindemnityinsurancetheyhave.Ultrasoundpractitionerswhoareselfemployedorwhoworkinapartemployed/partself-employedenvironmentareparticularlyadvisedtoreadtheguidancepublishedbytheirstatutoryregulator.ThereisnoprofessionalindemnityinsuranceassociatedwithvoluntaryregistrationonthePublicVoluntaryRegisterofSonographers.Ifanultrasoundpractitionerisnotstatutorilyregistered,itisclearlygoodpracticetoensurethattheyhaveappropriateprofessionalindemnityarrangementsinplacebothtoprotectthepublicandthemselves.1.4 PROFESSIONvsTOOL

TherearemanyhealthcareprofessionalsworkingwithintheUKwhouseultrasoundasa‘tool’toassistwiththeiroveralltreatmentorevaluationofpatients.Thereispublishedadviceoneducationandtrainingavailabletothosewhouseultrasoundinthiswaybutwhosemainworkandroleisnotthatofanultrasoundpractitioner.Forthosewhousetheprofessionaltitleof‘sonographer’,ultrasoundistheirdailyworkandtheirprimaryprofession.Whenusedasa‘tool’,ultrasoundaidsandassistsahealthcarepractitionerwiththeirwiderexaminationandtreatment,butinoverallterms,ultrasoundisonlyasmallpartoftheirwork.Itisimportantforsafeandeffective


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servicedeliverythatallultrasoundexaminationsareundertakenbyappropriatelytrainedandcompetentpersonnelandthatthereisassociatedauditandcontinuingprofessionaldevelopmentintheuseofultrasound.i) CASEfocusedcoursesviahttp://www.case-uk.org/andhttp://www.case-uk.org/course-directory/ii) RoyalCollegeofRadiologists–‘Ultrasoundtrainingrecommendationsformedicalandsurgicalspecialities’

https://www.rcr.ac.uk/publication/ultrasound-training-recommendations-medical-and-surgical-specialties-third-edition

iii) RoyalCollegeofRadiologists-‘Focusedultrasoundtrainingstandards’http://www.rcr.ac.uk/publications.aspx?PageID=310&PublicationID=386

1.5SAFETYOFMEDICALULTRASOUND‘Ultrasoundisnowacceptedasbeingofconsiderablediagnosticvalue.Thereisnoevidencethatdiagnosticultrasoundhasproducedanyharmtopatientsinthefourdecadesthatithasbeeninuse.However,theacousticoutputofmodernequipmentisgenerallymuchgreaterthanthatoftheearlyequipmentand,inviewofthecontinuingprogressinequipmentdesignandapplications,outputsmaybeexpectedtocontinuetobesubjecttochange.Also,investigationsintothepossibilityofsubtleortransienteffectsarestillatanearlystage.Consequentlydiagnosticultrasoundcanonlybeconsideredsafeifusedprudently’.1Abroadrangeofultrasoundexposureisusedinthedifferentdiagnosticmodalitiescurrentlyavailable.DopplerimagingandmeasurementtechniquesmayrequirehigherexposuresthanthoseusedinB-andM-modes,withpulsedDopplertechniqueshavingthepotentialforthehighestlevels.Recommendationsrelatedtoultrasoundsafetyassumethattheequipmentbeingusedisdesignedtointernationalornationalsafetyrequirementsandthatitisoperatedbycompetentandtrainedpersonnel.Itistheresponsibilityoftheoperatororultrasoundpractitionertobeawareof,andapply,thecurrentsafetystandardsandregulationsandtoundertakearisk/benefitassessmentforeachexamination.Keyprinciplesforthesafeuseofultrasound:2i) Medicalultrasoundimagingshouldonlybeusedformedicaldiagnosisand/orasanaidtomedical/surgicalinterventions.ii) Ultrasoundequipmentshouldonlybeusedbypeoplewhoarefullytrainedinitssafeandproperoperation.

Thisrequires:

• anappreciationofthepotentialthermalandmechanicalbio-effectsofultrasound;

• afullawarenessofequipmentsettings;

• anunderstandingoftheeffectsofmachinesettingsonpowerlevels.

• Itishoweverrecognisedthatultrasoundisausefultoolusedforimprovingpatientsafetyduringproceduressuchaslineandneedleplacement.Whilstusersmaynothaveafullunderstandingofthephysicalpropertiesofultrasoundimaging,theymustbeawareoftheneedtolimitexaminationtimesandonlyuseequipmentfortheproposedmedicalpurpose.

iii) Examinationtimesshouldbekeptasshortasisnecessarytoproduceausefuldiagnosticresult.iv) Outputlevelsshouldbekeptaslowasisreasonablyachievablewhileproducingausefuldiagnosticresult.


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v) TheoperatorshouldaimtostaywithintheBMUSrecommendedscantimes(especiallyforobstetricexaminations).

vi) Scansinpregnancyshouldnotbecarriedoutforthesolepurposeofproducingsouvenirvideosor

photographs.TheBritishMedicalUltrasoundSocietyhasUKleadingadviceonultrasoundsafetythatallultrasoundpractitionersshouldbefamiliarwithathttps://www.bmus.org/policies-statements-guidelines/safety-statements/AlsoavailableviathislinkareGuidelinesforthemanagementofsafetywhenusingvolunteersandpatientsforpracticaltraininginultrasoundscanning.https://www.bmus.org/static/uploads/resources/MANAGEMENT_OF_SAFETY_WHEN_USING_VOLUNTEERS__PATIENTS_FOR_PRACTICAL_TRAINING_YtWarot.pdfBMUSGuidelinesforlivedemonstrationsofpatientscanstoanaudiencecanbefoundat:https://www.bmus.org/static/uploads/resources/GUIDELINES_FOR_LIVE_DEMONSTRATIONS_OF_PATIENT_SCANS_TO_AN_AUDIENCE.pdfBMUShaveasampleconsentformforultrasoundscanningforthepurposesofteachingand/ordemonstrationat:https://www.bmus.org/static/uploads/resources/Consent_Form_for_Ultrasound_Scanning_for_the_Purposes_of_Teaching.pdfReferences:1)BritishMedicalUltrasoundSociety,Statementonthesafeuseandpotentialhazardsofdiagnosticultrasound.2)BritishMedicalUltrasoundSociety,Guidelinesforthesafeuseofdiagnosticultrasoundequipment.

1.6 MEDICO-LEGALISSUES

Theplaceofworkshouldhaveawrittensetofprotocolsthataccuratelydescribestherangeofultrasoundexaminationsundertaken.Theircontentshouldaddresstheultrasoundexaminations,theirreportingandtheappropriatereferralpathwaysforpatientswithnormalandabnormalultrasoundfindings.Thedetailsintheprotocolsshouldbesuchthatanewstaffmember,havingreadthem,couldcarryoutandreporttheseexaminationsandappropriatelyreferthepatientaftertheexaminationtotheexpectedstandard.Protocolsshouldbeupdatedregularlyandtheirreviewdateshouldbeincludedintheircontent.Supersededprotocolsshouldbekeptonfilepermanently.RecordsarecurrentlyrequiredbylawtobekeptforanumberofyearsasspecifiedbyDepartmentofHealthadvice(ref:section2.11).Thefollowingguidanceshouldbeconsidered:

• ultrasoundpractitionersshouldbeawarethattheyarelegallyaccountablefortheirprofessionalactions,includingthereportingofultrasoundexaminations,inallcircumstances.

• thereportisapublicdocumentandpartofthepatient’smedicalrecord,togetherwithanyimages,and/orvideorecordingswhichmayaccompanyit.

• thepatientconsentstoanultrasoundexaminationthatheorshehastherighttoexpectwillbedeliveredandreportedbyacompetentultrasoundpractitioner.

• acompetentultrasoundpractitionerisonewhoworkstothestandardsdefinedbytheguidelinesofhisorherplaceofwork,thecodeofconductofhisorherprofessionalbody,theguidelinesofthatandotherrelevantbodiesandoftheregulatorybodywhereappropriate.


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• thestandardofcareprovidedbyacompetentultrasoundpractitioneristhatwhichthemajorityofsimilarindividualswouldprovideand/orwhichasignificantbodyofsimilarindividualswouldprovideinsimilarandcontemporaneouscircumstances.

• imagesthataccompanyanultrasoundexaminationcarriedoutbyacompetentultrasoundpractitionerevidencetheassumptionthatthenecessarystandardofcarehasbeendelivered(ref:section2.15).

• allimagesmustbecapableofbeingattributedtothecorrectexaminationandshouldincludethepatientidentifier(s),examinationdateandtime.

• nationallypublishedrequirementsforthestorageofimagesmustbefollowed.ExampleswouldbetheimagestoragerequirementsoftheabdominalaorticaneurysmandfetalanomalyscreeningprogrammesandthosepublishedbytheDepartmentofHealth(ref:section2.1).

SeealsoDutyofCandour,section1.17.4

1.7TRANSDUCERCLEANINGANDDISINFECTIONInadditiontothefollowingguidelinesultrasoundpractitionersshouldrefertopublishedlocalinfectioncontrolprotocolsandprocedures.Manyorgansiationsalsohaveinfectioncontrolleadswhoshouldbeconsultedasnecessary.TherehavebeentwopreviousMedicinesandHealthcareProductsRegulatoryAgency(MHRA)alertsrelatingtotransducercleaninganddisinfection:https://www.gov.uk/drug-device-alerts/medical-device-alert-reusable-transoesophageal-echocardiography-transvaginal-and-transrectal-ultrasound-probes-transducers-failure-to-appropriately-decontaminateThefollowingMHRAlinkreferstoprobeswithaninternallumenusedfortakingtransrectalprostatebiopsieshttps://assets.digital.cabinet-office.gov.uk/media/5485ac42ed915d4c100002a7/con065543.pdfGuidanceisnowavailableforthecleaninganddisinfectionofultrasoundtransducers.Definitionsofcritical,semi-criticalandtermsrelatingtosterilisationanddisinfectionaregiveninthefollowingNHSScotlandadvice:‘Guidanceforthedecontaminationofsemi-criticalultrasoundprobes,semi-invasiveandnon-invasiveultrasoundprobes’(2016).Thereisalsoimportantguidancewithinthedocumentontheuseofcoveringsheaths.http://www.hps.scot.nhs.uk/documents/hai/infection-control/guidelines/NHSScotland-Guidance-for-Decontamination-of-Semi-Critical-Ultrasound-Probes.pdf

NHSScotland-October2017researchdocumentassociatedwiththeabove:http://www.hps.scot.nhs.uk/resourcedocument.aspx?id=6237

WelshHealthTechnicalMemorandum01-06,publishedin2014,containsasectiononcleaninganddisinfectingtransvaginalandtransrectalprobes.http://www.wales.nhs.uk/sites3/Documents/254/WHTM%2001%2D06%20Part%20C.pdf

InfectionPreventionandControlinUltrasound.BestpracticerecommendationsfromtheEuropeanSocietyofUltrasoundWorkingGroup.NyshenC;HumphrysH;KoernerRetal.InsightsImaging(2017)8:523-535.(Pastelinkintowebbrowserifneeded).

https://link.springer.com/epdf/10.1007/s13244-017-0580-3?author_access_token=ucuFlwbByoAA3jVsaouDAfe4RwlQNchNByi7wbcMAY5qAf1QJlIvL5a-u8XkSdc6misaNm_s4jn8IHIl7gS9StnuVFFXARjYd9PoW5YMEbqV4-u7bwzQsVKFvO3G1bsjtcQAVDVoH6todYykboZnEw%3D%3D


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TheBritishMedicalUltrasoundSocietyhasthefollowingadvice(2017):

‘Allultrasoundtransducerprobesshouldbecleanedimmediatelyafterascantoremoveallorganicresiduesandbodyfluids.Thisinvolvesremovaloftheusedprobecover(ifused),wipingoffthegelfollowedbythoroughcleaningwithprobecompatiblecleaningagentsasperprobemanufacturer’sinstructions.

Ultrasoundprobesshouldthenundergoappropriatedisinfectionorsterilisation.Allcriticalprobes(probescontactingsteriletissuesorblood)shouldbepreferablysterilised,butifsterilisationisnotpossible,theyshouldasaminimumbehighleveldisinfectedandusedwithasterilesheath.Allsemi-criticalprobes(bothsemi-invasiveprobescontactingmucousmembranesandnon-invasiveprobescontactingnon-intact/brokenskin)should,asaminimum,behighleveldisinfectedeithermanuallyorwithautomatedsystems.Highleveldisinfectionisstillrequiredwhenusingasheathassheathscanhavemicro-perforationsorcanbreak.Allnon-criticalprobescontactingonlyintactskinmaybelowleveldisinfected.

Onlyprobemanufacturerrecommendedandprobecompatibledisinfectionproductsshouldbeusedtoavoidanydamagetotheprobe.Afterreprocessingtheprobesshouldbestoredsoastopreventrecontamination’

Forfurtherinformationonthedisinfectionandreprocessingofultrasoundprobes,thefollowingIrishandAustralianguidelineshavebeenrecentlypublished:

HealthServiceExecutive(HSE)ofIreland‘GuidanceforDecontaminationofSemi-criticalUltrasoundProbes;Semi-invasiveandNon-InvasiveUltrasoundProbes’(2017).https://hse.ie/eng/about/Who/QID/nationalsafetyprogrammes/decontamination/Ultrasound-Probe-Decontamination-Guidance-Feb-17.pdf

TheAustralasianCollegeforInfectionPreventionandControl(ACIPC)andtheAustralasianSocietyforUltrasoundinMedicine(ASUM)WorkingCommitteedevelopedandpublishedajointguideline‘ASUM/ACIPCGuidelineontheReprocessingofUltrasoundTransducers(2017).http://onlinelibrary.wiley.com/doi/10.1002/ajum.12042/epdf1.8 SCREENINGEXAMINATIONSUSINGULTRASOUND

TheUnitedKingdomNationalScreeningCommitteeadvisesministersinallfourcountriesandresideswithinPublicHealthEngland,anexecutiveagencyoftheDepartmentofHealth.BeforeanypathologyorconditionisacceptedfornationalscreeningthereisafullevaluationagainsttheNSCpublishedcriteria.TheNSCwebsitecanbefoundat:http://www.screening.nhs.uk/uknscDetailsoftheevidencereviewprocess:https://www.gov.uk/guidance/evidence-and-recommendations-nhs-population-screening#evidence-review-procesItshouldbenotedthattheremaybevariationsinthescreeningprogrammesthatoperateacrossthefourcountriesoftheUKandultrasoundpractitionersshouldcontacttherelevantorganisationsforcurrentadvice.Scotland:http://www.nsd.scot.nhs.uk/services/screening/Wales:http://gov.wales/topics/health/protection/public-health-screening/?lang=enNorthernIreland:http://www.publichealth.hscni.net/directorate-public-health/service-development-and-screening/screeningInEnglandtherehavebeenrecent(2015)majorchangestothescreeningprogrammewebsites.InformationforthepublichasbeenmovedtoNHSChoices.Informationforprofessionalsisnowhostedonthe.gov.ukwebsiteande-learningforprofessionalsandlinkedtotheprogrammesishostedbyHealthEducationEngland.Thefournationalscreeningprogrammesthatareofparticularrelevancetoultrasoundpractitionersare:


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i) AntenatalscreeningInEnglandtheFetalAnomalyScreeningProgramme(FASP)isresponsibleforthetwoultrasoundscansthatareofferedtoeverypregnantwoman.ThereareequivalentorganisationstoFASPinthedevolvedcountriesalthoughthe11+2wto14+1wscanisnotofferedasascreeningscaninNorthernIreland.ThetwoultrasoundscansforwhichFASP(England)isresponsiblearethe11+2to14+1wscanthatincludesthecombinedtestforTrisomies21,13and18andthe18wto20+6wfetalanomalyscan.FASPhaspublishedcomprehensiveinformationforprofessionalsthatisavailableat:https://www.gov.uk/topic/population-screening-programmes/fetal-anomalyEquivalentorganisationstoFASPinScotlandandWales:Scotland:NationalServicesDivision:http://www.pnsd.scot.nhs.uk/Wales:AntenatalScreeningWales:http://www.antenatalscreening.wales.nhs.uk/IndependentprovidersofferingscreeningultrasoundscanstoNHSpatientsduringpregnancymustworkwithinthepublishedscreeningprogrammestandardsforthecountryinquestion.ii) NHSAbdominalAorticAneurysm(AAA)ScreeningProgramme

TheAbdominalAorticAneurysmscreeningprogrammehasnowsuccessfullycompleteditsrolloutacrosstheUK.Adviceforprofessionalsisavailableat:https://www.gov.uk/topic/population-screening-programmes/abdominal-aortic-aneurysmInformationonAAAscreeninginthedevolvedcountriescanbefoundvia:Scotland:http://www.isdscotland.org/Health-Topics/Public-Health/AAA-Screening/

Wales:http://www.aaascreening.wales.nhs.uk/

NorthernIreland:http://www.publichealth.hscni.net/directorate-public-health/service-development-and-screening/abdominal-aortic-aneurysm-aaa-screening

iii) NHSBreastScreeningProgramme

http://www.cancerscreening.nhs.uk/breastscreen/Althoughultrasoundisnotpartoftheinitialscreeningexamination,specialistsinbreastultrasoundwilluseultrasoundtechniquesforfurtherevaluationandbiopsy.iv) NHSNeonatalandInfantPhysicalExamination(NIPE)screeningprogramme

ThisnationalscreeningprogrammeisresponsibleforissuingguidanceandstandardsregardingthephysicalexaminationofthenewborninEngland.Thereisnoequivalentscreeningprogrammeinthedevolvedcountries.Guidanceonwhenultrasoundexaminationsoftheneonatalhipshouldbeperformedcanbefoundat:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/572685/NIPE_programme_handbook_2016_to_2017_November_2016.pdf(page17)Theoverall‘Standards’documentfortheNIPEprogrammecanbefoundat:https://www.gov.uk/government/publications/newborn-and-infant-physical-examination-screening-standards


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Itisimportanttonotethattheneonatalhipultrasoundexaminationitselfisapost-screeningexaminationandisoutsidetheremitofNIPE.PublicHeathEnglandadviceonprivatescreeningfordifferentconditionsanddiseases.Informationoutliningtheadvantagesanddisadvantagesofscreeningoutsidethenationalprogrammescanbefoundviathefollowingweblink.Thereisinformationandleafletsavailableforhealthcareprofessionalsandlinkstoleafletswrittenforpatients.https://www.gov.uk/guidance/private-screening-for-health-conditions-nhs-recommendationsDutyofcandourguidanceinthescreeningprogrammesPublishedinOctober2016(Seealsosection1.17)PublicHealthEnglande-learningplatformThePublicHealthEnglandscreeningprogrammeshaveeducationalandupdatinginformationavailableviathee-LearningforHealthwebsite.Detailsat(scrolldown).https://phescreening.blog.gov.uk/2017/11/13/horses-for-courses-wheres-the-right-website/1.9ERGONOMICPRACTICEINCLUDINGMANAGINGTHEHIGHBMIPATIENTPreventionandmanagementofWorkRelatedMusculo-SkeletalDisordersWorkrelatedmusculo-skeletaldisorders(WRMSD)areknowntobeassociatedwithultrasoundpractice.Thereareseveralcausativefactorsincludinghighworkloads,increasingbodymassindexofpatients,poorequipmentandroomdesignandpoorposturewhenscanning.Itisimportantthatultrasoundpractitionerstakecareofthemselvesandtheirworkingenvironmentwhilstscanning.Employershavealegaldutyofcaretotheiremployeesandshouldbeguidedinwaystoavoidpotentialworkrelatedinjuriesiebysupplyingequipmentfitforpurposeandbeingrealisticabouttimemanagement.DepartmentalguidelinesshouldincludestrategiestominimisetheriskofWRMSD,includingappropriatemanagementofworkload(ref:section1.11).Manyadviceandguidancedocumentshavebeenpublishedtowhichultrasoundpractitionersarereferred:HealthandSafetyExecutive

Riskmanagementofmusculoskeletaldisordersinsonographywork(2012):http://www.hse.gov.uk/healthservices/management-of-musculoskeletal-disorders-in-sonography-work.pdfSocietyandCollegeofRadiographers

Workrelatedmusculo-skeletaldisorders(sonographers)(2014,RevisionAugust2016):https://www.sor.org/learning/document-library/work-related-musculo-skeletal-disorders-sonographersThecausesofmusculoskeletalinjuryamongstsonographersintheUK(2002):https://www.sor.org/learning/document-library?sort_by=field_date_published_value&title=causes+&taxonomy_topics_tid=All&field_archive_value=0Preventionofworkrelatedmusculoskeletaldisorders(2007):https://www.sor.org/learning/document-library?sort_by=field_date_published_value&title=SOR+prevention+of+work+related+musculoskeletal+disorders&taxonomy_topics_tid=All&field_archive_value=0

RoyalCollegeofRadiologistsandSocietyandCollegeofRadiographersStandardsfortheprovisionofanultrasoundservice(2014):


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https://www.rcr.ac.uk/publication/standards-provision-ultrasound-service(section2)ManagingthehighBMIpatient

Thefollowingisanextractfromthe2014SCoRdocument‘Workrelatedmusculo-skeletaldisorders’:1

FactorstoconsiderwhenscanningpatientswithahighBMI:

Thefollowingpointsareallparticularlyrelevantwhenscanninghighbodymassindex(BMI)/bariatricpatientsandareinadditiontogeneralgoodpracticemethodsofreducingtheincidenceofWRMSDs.

AllTrustsandHealthBoardsshouldhavepoliciesrelatingtocareandmanualhandlingassociatedwithhighBMI/bariatricpatientswhichshouldalsobeavailableandconsulted.

•use‘highBMI’presetsonthemachineasastartingpointtomanipulatingtheimage.Manufacturerscansettheseuptoyourrequirementsatthetimeofinstallationandwilloptimisefeaturessuchastransducerfrequencyandharmonics.

•Whereverpossiblethesonographerworkforceshouldberotatedtoensurethatitisnotthesamesonographergroupexposedtorisk.Thisisofcoursewilldependontheskillmixofthelocalsonographerworkforce.

•Donotextendtheexaminationtimebeyondwhatisnormallyallowedifthereisunlikelytobeanygain.Itmaybethatasecondappointmentisnecessaryinsomecases.FASPprovideguidancewithrespecttorepeatexaminationsonthosewomenattendingforthe18–20+6weeksfetalanomalyscanandwheretheimagequalityiscompromisedbysuchasbyanincreasedBMI.Thereisalso‘twiceonthecouchonly’adviceforthe11+2wto14+1wscanwhichformspartofthecombinedtest.TheFASPProgrammeHandbookcanbefoundat:

https://www.gov.uk/government/publications/fetal-anomaly-screening-programme-handbook(Seesections5.2page12and5.6.2page16).

•Avoidpressingunnecessarilyhardandfortoolong.ThismayincreasetheriskofWRMSDanditcanbeuncomfortableforthepatient.Firmpressuremaybecontra-indicatedforsometypesofpathologyorclinicalsituations.

•Useahelpertosupporttissue/fattyapronsandgenerallyassistwiththeexamination.

•Considerthepatient’sfeelings.

•Usegoodqualityequipmentwithgoodharmonics.

•Donotexceedthecouchweightlimitwhichshouldbeclearlyposted.

•Useavailablemanualhandlingaidswhennecessary;scanin-patientsintheirbedsratherthantransferringtoanexaminationcouch.

•Reportpain/injurytooccupationalhealth/linemanagerasarecordandsothatcurrentpractisecanbereviewed.

•BMIshouldberecordedonrequestformsifabove30.

•Ifimagequalityiscompromised,statehowtheexaminationhasbeenaffectedinthereport.

•RecordBMIonreport.

•KeepcurrentpracticeforhighBMIpatientsunderreview.

• Considerwordingofinformationleafletsaboutlimitationsofscanningattimeofbooking


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References1)Workrelatedmusculo-skeletaldisorders.2014London:SCoRhttps://www.sor.org/learning/document-library/work-related-musculo-skeletal-disorders-sonographers1.10 INTIMATEEXAMINATIONSANDCHAPERONES

Thedefinitionofanintimateexaminationmaydifferbetweenindividualpatientsforethnic,religiousorculturalreasons.Inaddition,somepatientsmayhaveaclearpreferenceforahealthcarerofspecificgenderduetotheirethnic,religiousorculturalbackground,becauseofpreviousexperiencesorinviewoftheirage.Wherepossible,suchindividualneedsandpreferencesshouldbetakenintoconsideration.Whenconductinganintimateexamination,theultrasoundpractitionershould:

• actwithproprietyandinacourteousandprofessionalmanner;• communicatesensitivelyandpolitelyusingprofessionalterminology,• useachaperonewhenappropriate;• respectthepatient’srightstodignityandprivacy;• complywithdepartmentalschemesofworkandprotocols.

Patientsshouldnotbeaskedtoremoveclothingunnecessarily.Whenrequired,private,warm,comfortableandsecurefacilitiesfordressingandundressingshouldbeprovided.Careshouldbetakentoensureprivacyinwaitingareasusedbypatientsnotfullydressedintheirownclothes.Duringtheultrasoundexamination,onlythosebodypartsunderexaminationshouldbeexposed.

Caremustbetakentomaintainconfidentialitywhennon-healthcarepersonnelarenearby.

Patientsshouldbegiventheopportunitytohaveachaperone,irrespectiveoftheultrasoundpractitioner’sgenderandtheexaminationbeingundertaken.Theultrasoundpractitionershouldgiveequalconsiderationtotheirownneedforachaperone,again,irrespectiveoftheexaminationbeingundertakenorthegenderofthepatient.

Arecordshouldbemadeinpatients’recordswhenchaperonesareofferedandused,andwhentheyaredeclined.Therecordshouldincludethenameanddesignationofthechaperone.Chaperonesshouldnormallybemembersoftheclinicalteamwhoaresufficientlyfamiliarwiththeultrasoundexaminationbeingcarriedouttobeabletoreliablyjudgewhethertheultrasoundpractitioner’sactionsareprofessionallyappropriateandjustifiable.

Patients’privacyanddignityshouldbemaintainedthroughouttheexaminationwhichshouldbeconductedwithoutinterruption.Onlypersonnelessentialforcarryingouttheexaminationshouldbeintheroom.

Itisgoodpractice(asforanyexamination)toensurethat,whenpossible,handwashingandequipmentcleaningarecarriedoutinfullviewofthepatientatthebeginningandendoftheexaminationtoreassurehimorherthateffectiveinfectioncontrolproceduresarebeingapplied.

Adviceonstudents/traineesandintimateexaminationsisgiveninthe2016SCoRdocumentandinthe2015RCRguidance(hyperlinksbelow).Thereareseveralorganisationsthathaveproducedadviceontheconductofintimateexaminationsandalsoontheuseandroleofchaperones.SocietyandCollegeofRadiographers(2016)IntimateExaminationsandChaperonePolicyhttps://www.sor.org/learning/document-library/intimate-examinations-and-chaperone-policy-0GeneralMedicalCouncil(2013)Intimateexaminationsandchaperoneshttp://www.gmc-uk.org/guidance/ethical_guidance/21168.asp


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RoyalCollegeofRadiologists(2015)Intimateexaminationsandtheuseofchaperoneshttps://www.rcr.ac.uk/sites/default/files/bfcr154_intimateexams.pdfTheMedicalDefenceUnion(2017)haspublishedadviceonprotectingyourselffromasexualassaultallegationhttps://www.themdu.com/guidance-and-advice/guides/protecting-yourself-from-a-sexual-assault-allegation1.11 EXAMINATIONTIMESThetimeallowedforanultrasoundexaminationshouldtakeintoaccountthefactthattheactualtransducertimeisonlyacomponentoftheoverallexamination.Timeneedstobeallowedforroompreparation,assessingtheultrasoundrequest,introductions,explanations,obtainingconsentandassistingthepatientwhennecessaryontoandofftheexaminationcouch.Post-proceduretimeisrequiredtodiscussthefindingswiththepatient,writethereport,archivetheimagesandattendtotheafter-careofthepatient,includingmakingarrangementsforfurtherappointmentsand/orfurtherinvestigations.Equipmentwillalsoneedcleaninganddisinfectingasrequiredpostexamination.Anultrasoundpractitionerhasaprofessionalresponsibilitytoensurethatthetimeallocatedforanexaminationissufficienttoenableittobecarriedoutcompetently.Itiscriticaltopatientmanagementthatnoultrasoundexaminationiscompromisedbydepartmentalandorgovernmenttargets.Theallocatedappointmenttimewillvarydependingonthetypeandcomplexityoftheultrasoundexamination.Itmayalsobeinfluencedbytheexpertiseoftheultrasoundpractitionerandtrainingcommitmentswithinthedepartment.Inaddition,thedurationoftheexaminationwillbeinfluencedbythescanfindingsand/orthephysicalconditionofthepatient.Thequalityofequipmentandgeneralsupportavailabletothesonographerarealsorelevant.ExaminationtimesshouldbedeterminedwithreferencetonationalstandardssuchasthosepublishedbytheFetalAnomalyScreeningProgramme,byorganisationssuchasNICEandbyproperevaluationofthelocalworkingarrangementsandresourcesthatwillbedifferentforeachserviceprovider.Examinationtimeswillneedtotakeintoaccountwhethertherearetraineespresentandtheirstageoftrainingifteachingistobeeffective.Althoughobtstricsisnotincludedinthescopeofthisdocumentthefollowingrecommendedtimesareincludedinthissetionforcompleteness.NHSEnglandhaspublishedservicespecifications(2017-2018)forcommissionersrelatingtofetalanomalyscreening.TherelevantservicespecificationsareNos.16(combinedtest)and17(18wto20w6dfetalanomalyscan).

https://www.england.nhs.uk/wp-content/uploads/2017/05/serv-spec-16.pdf

Extractfrompage10ofservicespecificationNo.16:

Tocompletetheultrasoundcomponentofthisscreeningstrategy,thescanappointmentshouldallocatetimetoincorporatepre-scancounselling,theultrasoundexamination,post-scancounsellingandreporting.Thetimeallocationforappointmentstomeettheserequirementsisaminimumoftwenty(20)minutes.

https://www.england.nhs.uk/wp-content/uploads/2017/05/serv-spec-17.pdfExtractfrompage12ofservicespecificationNo:17:

Theultrasoundscanappointmentshouldincorporatepre-scancounselling,theultrasoundexamination,post-scancounsellingandreporting.Thetimeallocationforappointmentstomeettheserequirementsforasingletonpregnancyisaminimumofthirty(30)minutesandforamultiplepregnancyisfortyfive(45)minutes.

TheNationalInstituteforHealthandCareExcellence(NICE)haspublishedrecommendationsformultiplepregnancy(growth)ultrasoundexaminations.‘Multiplepregnancy:Themanagementoftwinandtripletpregnanciesintheantenatalperiod‘(2011).CG129.Thesecanbefoundat:


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http://www.nice.org.uk/guidance/cg129/chapter/1-GuidanceSection1.3.3.4 Thirtyminutesisrecommended.TheSocietyandCollegeofRadiographershaspublishedguidanceonexaminationtimesat:http://www.sor.org/learning/document-library/ultrasound-examination-times-and-appointments-0Intheabsenceofanylocalevidence-baseddeterminationofexaminationtimesornationalstandards,theSCoRadvisesthat20minutesshouldbetheminimumforageneralabdominalultrasoundexamination.Thecompletedocumentshouldbereadforfullcontext.

Individualdepartmentscandetermineexaminationtimestakingintoaccountlocalcircumstances.Atooltohelpevaluatetheseistheformer‘NHSImprovement-ExaminationTimesAssessmentTool’.Thisisstillavailableviahttp://webarchive.nationalarchives.gov.uk/20130221101407/http:/www.improvement.nhs.ukFulldetailsofhowtoaccessareinAppendix3oftheSCoRexaminationtimesdocument.

Manyrequestformsareverynon-specificintermsofthepatient’ssymptomsanddueallowancemayneedtobemadeforthisinscheduleplanningifitisdecidedtoproceed(Ref:sections2.4,2.5).Forexample,itmaybenecessarytoperformbothtransabdominalandtransvaginalscanstofullyevaluatethefemaleabdomenandpelviswithultrasound.1.12 PATIENTIDENTIFICATION,COMMUNICATIONANDCONSENT.THE6C’s.

CompassioninPractice(the6C’s).

The6C’sareasetofvaluesthatunderpin‘CompassioninPractice’,avisionandstrategyfornursing,midwiferyandallhealthandcarestaff.https://www.healthcareers.nhs.uk/about/working-health/6csTheyareCare,Competence,Compassion,Communication,CourageandCommitment.Whileundertakinganyultrasoundexaminationandworkinginaccordancewithlocallyagreedpractice,ultrasoundpractitionersshould:

• correctlyidentifythepatient.ClinicalImagingBoardadvicethatisendorsedbyBMUSisavailableat:https://www.sor.org/sites/default/files/document-versions/cib_medical_ultrasound_examinations_document.pdf

• obtainsufficientverbaland/orwritteninformationfromthereferringcliniciantoundertakecorrectlytheexaminationrequested(ref:sections2.4,2.5);

• ensurethepropercareandmaintenanceofequipmentandnotusedamagedequipmentorequipmentthatisnotfitforpurpose

• bemindfuloftheneedtouseinterpretersasandwhennecessarytocommunicateadequatelywiththepatient;

• greetthepatientusinghisorherfullnameandstatus;

• beabletodiscusstherelativerisksandbenefitsoftheexaminationwiththepatient;

• explainthescanningprocedureappropriatelytothepatient;

• obtaininformedconsentfromthepatientortheirrepresentativebeingmindfulofhis/hercapacitytounderstand;

• beawareoftheindividualpatient’sspecialneedsincludingchaperoningandprivacyduringtheexamination(ref:section1.10);


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• beprofessionalandunderstandingthroughouttheexamination;managetheinteractionbetweenthepatientandanyaccompanyingadultsandchildreninawaythatenablestheexaminationtobecarriedouttoacompetentstandard;

• explainanddiscussthefindingswiththepatientwithinlocalguidelines;

• interpretandcommunicatethefindingsappropriatelyandinatimelyfashiontothereferringclinician;

• ensureappropriatearrangementshavebeenmadeforfurthercarebeforetheconclusionoftheexaminationasnecessary.

Validinformedconsentmustbeobtainedbeforecommencinganyultrasoundexaminationorprocedure.Ultrasoundpractitionerswhodonotrespecttherightofapatienttodeterminewhathappenstotheirownbodyinthiswaymaybeliabletolegalordisciplinaryaction.Theconsentprocessisacontinuumbeginningwiththereferringhealthcareprofessionalwhorequeststheultrasoundexaminationandendingwiththeultrasoundpractitionerwhocarriesitout.Itistheresponsibilityofthereferringprofessionaltoprovidesufficientinformationtothepatienttoenablethelattertoconsenttotheultrasoundexaminationbeingrequested.Itistheresponsibilityoftheultrasoundpractitionertoensurethatthepatientunderstandsthescopeoftheultrasoundexaminationpriortogivinghisorherconsent.Verbalinformedconsentmustbeobtainedforallexaminations.Additionalinformedverbalconsentshouldbeobtainedwhereastudentultrasoundpractitionerundertakespartoralloftheultrasoundexaminationundersupervision.Verbalinformedconsentforthoseexaminationsofanintimatenatureshouldberecordedintheultrasoundreport.Somecategoriesofultrasoundexamination(interventionalultrasound,guidedproceduresegbiopsy)willrequirewrittenconsent.Literaturewhichexplainsthescopeoftheexaminationclearlyandaccuratelyshouldbemadeavailabletopatientspriortotheultrasoundexamination.NHSChoicescarriesinformationonawiderangeoftopics.Anexampleforultrasoundexaminationsis:http://www.nhs.uk/conditions/Ultrasound-scan/Pages/Introduction.aspxThenationalscreeningprogrammeshaveexplanatoryliteratureavailableforpatientsobtainableviatheNHSChoiceswebsiteandhavepublishedconsentstandardswhichareusuallynowincludedwiththevariousNHSEnglandservicespecifications.NHSChoicesprovidesinformationonabdominalaorticaneurysmscreening(forexample)at:http://www.nhs.uk/conditions/abdominal-aortic-aneurysm-screening/pages/introduction.aspxIn2017TheHCPCupdatedtheirguidanceonconfidentialityandconsentrequirementsfortheuseanddisclosureofpatientrecords:http://www.hcpc-uk.org/mediaandevents/news/index.asp?id=844Thereismuchinformationthathasbeenpublishedoninformedconsent.Thefollowingareallrelevant:

RoyalCollegeofRadiologistsStandardsforpatientconsentparticulartoradiology(2012):https://www.rcr.ac.uk/standards-patient-consent-particular-radiology-second-editionGeneralMedicalCouncilConsent:PatientsandDoctorsmakingdecisionstogetherhttp://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp


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SocietyandCollegeofRadiographers(Updatedconsentguidanceisexpectedearlyin2018andwillreplacethefollowingSCoRdocuments)ConsenttoImagingandRadiotherapyTreatmentExaminations(2007)(SCoRlog-onrequiredandlinkmayneedtobecopiedintobrowser).https://www.sor.org/system/files/document-library/members/sor_consent_document.pdfPatientidentification,confidentialityandconsent,furtherguidance(2009):https://www.sor.org/learning/document-library/patient-identification-confidentiality-and-consent-further-guidanceConsentandadultsofimpairedcapacity(2010):https://www.sor.org/learning/document-library/consent-and-adults-impaired-capacityBritishMedicalUltrasoundSocietyStatementonpatientinformationandinformedconsent:https://www.bmus.org/static/uploads/resources/STATEMENT_ON_PATIENT_INFORMATION_AND_INFORMED_CONSENT_gQkvKTu.pdf1.13 CLINICALGOVERNANCE

Clinicalgovernanceisdefinedinthe1998consultationdocument‘AFirstClassServiceintheNewNHS’1andalsoin1998byScallyandDonaldson2intheBritishMedicalJournalas:“AframeworkthroughwhichNHSorganisationsareaccountableforcontinuouslyimprovingthequalityoftheirservicesandsafeguardinghighstandardsofcarebycreatinganenvironmentinwhichexcellenceinclinicalcarewillflourish."Asclinicalgovernanceisbasedonprofessionalvaluesandconcernforothers,theultrasoundpractitionerisactivelyinvolvedinthisprocessofaccountabilityaspartofhisorherdailyactivities.Bysafeguardinghighstandardsofcareandseekingtocontinuouslyimproveitsquality,itensuresthathealthcareprovisionispatient-centredwhichiscentraltotheconcept.Themaincomponentsofaclinicalgovernanceframeworkcanbesummarisedasfollows:3

i) Riskmanagementii) Clinicalauditiii) Education,trainingandContinuousProfessionalDevelopmentiv) Patientandcarerexperienceandinvolvementv) Staffingandstaffmanagement

AnexampleofpublishedTrustinformationonclinicalgovernancecanbefoundat:http://www.uhb.nhs.uk/clinical-governance-components.htmDepartmentofHealthadvicecanbefoundat:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213304/Final-NQB-report-v4-160113.pdfFortheultrasoundpractitioner,clinicalgovernanceinvolves:

i) clinicaleffectiveness:takingpartinpersonal,departmentalandwiderauditprogrammestoevaluateclinicalpracticeandservicetopatients.Thiswillincludeauditofultrasoundexaminationsandreports:participationinmulti-disciplinaryteammeetingsandradiologydiscrepancymeetingswouldbefurtherexamples;


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ii) patientidentification,communicationandconsent:(ref:section1.12);

iii) patientsafety:includingavoidingphysicalinjuryandfollowingpublishedultrasoundsafetyguidelines(ref:sections1.5,1.9);

iv) ensurethepropercareandmaintenanceofequipmentandnotusedamagedequipmentorequipmentthatisnotfitforpurpose

v) riskmanagement:ultrasoundpractitionershaveadutytoparticipateineducationandtrainingofferedbyemployersonsubjectssuchasbackcare,healthandsafetyandinfectioncontrol;

vi) education,trainingandContinuousProfessionalDevelopment(ref:section1.18)

vii) teamworking:RCR/SCoRdocument‘TeamWorkinginClinicalImaging’(2012);https://www.rcr.ac.uk/team-working-clinical-imaging

viii) patient,publicandcarerinvolvement;

ix) beingaccountableforone’sownactions;

x) theimplementationofnationalclinicalguidancewhichreflectsthebeststandardsofcare.ExampleswouldincludeimplementingNICEGuidelinesandnationalscreeningprogrammeguidanceandrequirements;

xi) incidentreportingandraisingconcerns.ThisisofparticularimportancefollowingthepublicationoftheFrancisReportin20134(ref:section1.17).

In2008theNationalUltrasoundSteeringGrouppublishedadocumententitled‘UltrasoundClinicalGovernance’.TheNationalUltrasoundSteeringGroupwasashort-termsub-groupoftheNationalImagingBoard.https://www.bmus.org/static/uploads/resources/ClinicalGovernanceInUltrasound-061108.pdfThefollowing‘fourlayer’advicefromtheGeneralMedicalCouncilforthosewhoworkinanemployedenvironmentaspartofwiderclinicalteams5isalsorelevanttothetopicofclinicalgovernanceandisincludedforconsideration:‘Thefirstlayer(ofpatientprotection)istheindividualpractitionerandtheircommitmenttoacommonsetofethics,valuesandprincipleswhichputspatientsfirst.Nextisteam-basedregulationwhichreflectstheimportanceofactingifacolleague’sconductorperformanceisputtingpatientsatrisk.AfterthatcomesworkplaceregulationwhichreflectstheresponsibilitiesofNHSandotherhealthcareprovidersandfinally,theregulator,throughworkonstandards,educationandfitnesstopractise’.WeblinksStandardsfortheprovisionofanultrasoundservice(2014):https://www.rcr.ac.uk/system/files/publication/field_publication_files/BFCR%2814%2917_Standards_ultrasound.pdf

UltrasoundClinicalGovernanceinWales:http://www.wales.nhs.uk/sitesplus/documents/1064/Ultrasound%20and%20Clinical%20Governance.doc

RoyalCollegeofRadiologistsStandardsforlearningfromdiscrepanciesmeetings(2014):https://www.rcr.ac.uk/publication/standards-learning-discrepancies-meetings

RoyalCollegeofRadiologistsCancermulti-disciplinaryteammeetings.Standardsforclinicalradiologists(Secondedition)(2014):https://www.rcr.ac.uk/sites/default/files/docs/radiology/pdf/BFCR%2814%2915_MDTMs.pdfReferences1) DepartmentofHealth(1998)AFirstClassService:QualityintheNewNHS.London.DH.


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2) ScallyG,DonaldsonL.ClinicalgovernanceandthedriveforqualityimprovementinthenewNHSinEngland.BritishMedicalJournal1998.317:61

3) UniversityHospitalBirminghamFoundationTrust4) ReportoftheMidStaffordshireNHSTrustPublicEnquiry.Chair:RobertFrancisQC.(2013)

https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry

5) GeneralMedicalCouncil.Reportandaccounts2004.1.14E-LEARNINGFORHEALTHCARE(e-LfH)

Formedfollowingaground-breakingprojectinRadiologye-LfHisanawardwinningHealthEducationEnglandprogrammeinpartnershipwiththeNHSandprofessionalbodiesprovidinghighqualitycontentfreeofchargeforthetrainingoftheNHSworkforceacrosstheUK.Inordertoaccessthesefree-learningsessionsitisnecessarytofirstregisterwiththeprogrammehttps://www.e-lfh.org.uk/e-LfHisnowintheprocessofdeliveringover300e-learningprojectsinpartnershipwithmedicalRoyalCollegesandotherhealthcareorganisations.Theon-linetrainingsessionsenhancetraditionallearning,supportexistingteachingmethodsandprovideavaluablereferencepoint.Theyaredesignedandbuilttobeengagingandinteractive,usingqualityimages,video,audioandanimationtohelptraineeslearnandretainknowledge.Contentispresentedusingvarioustemplatessuchas‘real-life’scenarios,casestudiesand‘knowledgebites’.Thefulle-LfHsyllabuscanbeviewedviatheembeddedlinkbelow.Therearesevenmodulesinultrasound,eachcontainsanumberofsessionsasindicatedbelow.

Module15-GynaecologicalUltrasound-8sessionsModule16-AbdominalUltrasound-19sessionsModule17-Men'sHealthUltrasound-3sessionsModule18-VascularUltrasound-6sessions

Module19-MusculoskeletalUltrasound-11sessionsModule20-HeadandNeckUltrasound-5sessionsModule21-ObstetricUltrasound-15sessions

Thesessionswithinthe‘imageinterpretation’programmehavebeenwrittenbyexpertultrasoundpractitionerstomatchtheformatusedbye-LfH.Thisisaveryvaluablelearningresourceandcancontributetoanultrasoundpractitioner’scontinuingprofessionaldevelopment(Ref:section1.18)Thegynaecological,abdominal,men’shealthandobstetricultrasoundsessionswerereviewedandupdatedin2017andtheremainingultrasoundsessionsarecurrentlybeingrevised.1.15 IMAGINGSERVICESACCREDITATIONSCHEME(ISAS)

AllprovidersofultrasoundservicesareencouragedtohavetheirservicesindependentlyassessedbytheUnitedKingdomAccreditationService(UKAS)againsttheImagingServicesAccreditationStandard(ISAS),jointlyestablishedbytheRoyalCollegeofRadiologistsandtheCollegeofRadiographers.ISASaccreditationprovidesstrongandindependentconfirmationthathighqualityservicesarebeingdelivered.DetailsonISASandhowtoapplycanbeobtainedfromhttps://www.rcr.ac.uk/clinical-radiology/service-delivery/imaging-services-accreditation-scheme-isasandtohttp://www.sor.org/imagine-services-accreditation-schemeISASisnowrecognisedbytheCareQualityCommissionandhasbeenapprovedforusewithinCQChospitalinspectionmethodology:http://www.isas-uk.org/CQC_Recognition.shtmlUKASarealwaysrecruitingnewassessorsfromallareasofimaging.Ifanyoneisinterestedinapplyingtobecomeanassessorpleasecontacthttp://www.isas-uk.org/jobs.shtml


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1.16 ULTRASOUNDEQUIPMENTANDQUALITYASSURANCETESTINGAnultrasoundpractitionerisexpectedto:i) Have detailed knowledge of ultrasound equipment in order to ensure that it is appropriate for

purpose;ii) Manipulatetheequipmentcorrectlysothatpatientdiagnosisandmanagementarenotcompromised;iii) Takecarewhenusingtheequipmentinordertoavoiddamage;iv) Ensurethatregularplannedpreventativemaintenanceiscarriedoutbyqualifiedpersonnel;v) Ensurethatanagreedqualityassuranceprogrammeisinplacethatincorporatestheregularinspectionof

ultrasoundmachinesandancillaryequipmentThestatedaimsofqualityassuranceproceduresappliedtoultrasoundequipmentaretoensureconsistentandacceptablelevelsofperformanceoftheimagingsystemandimagerecordingfacilitiesandtoensurethesafetyofthepatient.Thefoundationofagoodqualityassuranceprogrammeisregularvisualinspectionoftheequipmentandthereverberationpatternofeachprobebytheusers,sincethemajorityoffaultsmaybedetectedinthisway.Commonfaultsaredamagetoprobes,whichmaypresentanelectricalorinfectionhazardand/oraffecttheefficiencyofallorpartoftheprobe.Formalquality assurance protocols focus on theconsistency of specific features of image quality over time.Theacceptabilityofimagequalitymaynotbeapparentfrommeasurablechangesintheparameterstested.Theissueofwhatconstitutesunacceptableequipmentperformanceisstillverydifficulttoassessobjectively,butthereisevidencethatprobefaults,suchasdropoutaffectingmorethan1element,compromisediagnosticquality.Thereisasectionrelatingtoimagequalityrequirements,qualityassuranceandequipmentreplacementintheRCR/SCoRdocument‘Standardsfortheprovisionofanultrasoundservice’(2014):https://www.rcr.ac.uk/sites/default/files/documents/BFCR(14)17_Standards_ultrasound.pdf(section2)TheBritishMedicalUltrasoundSocietyhasrecommendedQualityAssurancetestingandmonitoring;adviceavailableathttp://ult.sagepub.com/content/22/1/6.short?rss=1&ssource=mfr

1.17RAISINGCONCERNS;SAFEGUARDING;STATUTORYREQUIREMENTSFORREPORTINGFEMALEGENITALMUTILATION(FGM),DUTYOFCANDOUR,1.17.1RaisingconcernsAnexecutivesummaryoftheFebruary2013ReportoftheMidStaffordshireNHSFoundationTrustPublicEnquiry(‘TheFrancisReport’)whichisrelevanttothissub-sectioncanbefoundat:http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdfNHSTrustsandHealthBoardswillhavetheirownpublishedpolicieson‘raisingconcerns’followingthepublicationoftheabovereport.Allhealthcareprofessionalshaveaprofessionaldutytoreportconcernstheymayhaveaboutthesafetyofpatientsandofservicedelivery.Thefollowingwillalsobeofhelpifneedingtoraiseconcerns:

NHSEnglandhasadviceat:https://www.england.nhs.uk/contact-us/complaint/HealthandCareProfessionsCounciladviceat:http://www.hpc-uk.org/registrants/raisingconcerns/


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TheCareQualityCommissionhasadviceentitled‘RaisingaconcernwiththeCareQualityCommissionifyouareamemberofstaff’http://www.cqc.org.uk/content/report-concern-if-you-are-member-staffTheSCoRhasinformationpublishedat:https://www.sor.org/learning/document-library?sort_by=field_date_published_value&title=raising+concerns&taxonomy_topics_tid=All&field_archive_value=0(SCoRmemberlog-onrequired).A‘DutyofCare’handbookforhealthcareprofessionalpublishedbyPublicWorldin2013isavailableat:http://www.publicworld.org/files/Duty_of_Care_handbook_April_2013.pdfThenewNHSResolutionapproachtopatientcomplaints(2017-Advise/Resolve/Learn).NHSResolutionwasformerlytheNHSLitigationAuthority.https://resolution.nhs.uk/Fiveyearsofcerebralpalsyclaims–NHSResolution(Septemer2017)https://resolution.nhs.uk/wp-content/uploads/2017/09/Five-years-of-cerebral-palsy-claims_A-thematic-review-of-NHS-Resolution-data.pdf1.17.2SafeguardingUltrasoundpractitionersalsohaveadutytoreportconcernsrelatingtochildrenandvulnerableadults.Employerswillhaveavailableadviceandpoliciesastothepathwaysthatultrasoundpractitionersarerequiredtofollow.Trainingandupdatinginlocalsafeguardingproceduresandpoliciesislikelytobeamandatoryrequirementoftheemployer.Furthergeneralinformationathttps://www.england.nhs.uk/wp-content/uploads/2015/07/safeguard-policy.pdf1.17.3FemaleGenitalMutilation(FGM)-statutoryrequirementsofpractitionersFrom31stOctober2015(EnglandandWales)thereisalegalrequirementforallstatutoryregisteredultrasoundpractitionerstoreportfemalegenitalmutilationinthoselessthan18yearsofagetothepolice.Thisdutyisontheindividualultrasoundpractitionerandnottheemployer;itcannotbetransferred.Complyingwiththedutydoesnotbreachanyconfidentialityrequirementorotherrestrictionofdisclosurethatmightapply.Thesameprinciplealsoappliestoultrasoundpractitionerswhoarenotstatutorilyregistered.UltrasoundpractitionersinScotlandandNorthernIrelandshouldusetheirestablishedsafeguardingprotocolsasrequired.TheHCPChaveadviceat:http://www.hcpc-uk.co.uk/mediaandevents/news/index.asp?id=727ThislinksthroughtoHomeOfficeadviceat:https://www.gov.uk/government/publications/mandatory-reporting-of-female-genital-mutilation-procedural-informationSeealso:https://www.gov.uk/government/publications/fgm-mandatory-reporting-in-healthcareforflowdiagramsandposters.NMCadviceat:https://www.nmc.org.uk/standards/code/female-genital-mutilation-cases/


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1.17.4DutyofCandourUltrasoundpractitionersshouldalsobeawareoftherequirementsoftheirProfessionalIndemnityInsurerifaskedtomakeanystatementsregardingpatientcare,complaintsandclaims.NHSResolution‘SayingSorry’https://resolution.nhs.uk/saying-sorry-leaflet/Dutyofcandourguidanceinthenationalscreeningprogrammes(October2016,PublicHealthEngland).https://phescreening.blog.gov.uk/2016/10/05/new-duty-of-candour-guidance-helps-ensure-were-open-and-honest-in-screening/GeneralMedicalCounciladvicehttp://www.gmc-uk.org/guidance/ethical_guidance/27233.aspNMCandGMCadvicehttps://www.gmc-uk.org/DoC_guidance_englsih.pdf_61618688.pdf1.18 CONTINUINGPROFESSIONALDEVELOPMENTContinuingprofessionaldevelopment(CPD)hasbeendefinedasfollows:"...istheprocessbywhichhealthprofessionalskeepupdatedtomeettheneedsofpatients,thehealthservice,andtheirownprofessionaldevelopment.Itincludesthecontinuousacquisitionofnewknowledge,skills,andattitudestoenablecompetentpractice..."

1

It isaprocessthatseamlesslycontinuesfromstartingasastudent,throughsuccessfulcompletionofafirstqualificationandlaststhroughoutasonographer'sprofessionallife.CPDisembeddedintheNHSclinicalgovernancestrategy(ref:section1.13).Allultrasoundpractitionersmustbeengagedwithcontinuingprofessionaldevelopment.ManyultrasoundpractitionersareregisteredwiththeHealthandCareProfessionsCouncil(HCPC)asaradiographerortheNursingandMidwiferyCouncil(NMC)asanurseormidwife.MedicallyqualifiedstaffwillberegisteredwiththeGeneralMedicalCouncil(GMC).TheseregulatorsallhavetheirownrequirementsforCPD.Someregulatorsusean‘outputs’basedmodelbasedonlearningandreflection(egHCPC).Otherregulatorsusean‘inputs’basedmodelwhichwillplaceemphasisoncertificatesandattendingstudydays.HCPCinformation,whichappliestomanyultrasoundpractitioners,canbefoundat:http://www.hpc-uk.org/registrants/cpd/standards/andhttp://www.hpc-uk.org/publications/index.asp?id=103#publicationSearchResultsEquivalentInformationwillbepublishedfortheirregistrantsbytheotherstatutoryregulatorsalso.Ifanultrasoundpractitionerisnotstatutorilyregistered,thesamegoodpracticeprinciplesofCPDwillstillapply.ForthoseultrasoundpractitionersregisteredwiththePublicVoluntaryRegisterofSonographers,theywillhavesignedatthepointofapplicationtostatethattheyundertakeCPDactivities.AuditofCPDbasedonHCPCprinciplesandsystemswasintroducedfromtheMarch1st2017renewalofvoluntaryregistration.https://www.sor.org/system/files/article/201702/2017.1.1_pvrs_cpd.pdfEvidenceofCPDisalsoarequirementtomaintainaccreditationwiththeSocietyofVascularTechnology(SVT)http://www.svtgbi.org.uk/education/EvaluationandreflectiononthelearninggainedfromthefollowingcanallbeusedasevidencetomeetHealthCareProfessionsCouncilrequirements.Otherregulatorsmayhaveadifferentemphasisorprocedures;


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ultrasoundpractitionersareadvisedtoconsultthewebsiteoftheirownregulatorwhereinformationwillbeavailable.

i) Successfullycompletingaprogrammeofstudyii) Attendanceat,andparticipationin,appropriateprofessionalworkshopsandconferencesiii) Definingandimplementingadepartmentalauditprogrammeiv) Implementingachangeprocessinpracticev) Mentoringanultrasoundstudentinpracticevi) Participationinanultrasoundorprofessionalresearchprojectvii) Attendanceatandparticipationincasereviewsviii) Attendanceatradiologydiscrepancymeetingsandmulti-disciplinaryteammeetingsix) Submissionofapapertoajournalx) Criticalevaluationofapeerreviewedresearchpaperxi) Teachingpeersandstudentsbothformallyandinformallyxii) CompletionofE-LearningforHealthmodulesandotheron-linelearningactivitiesxiii) Activeengagementwithaprofessionalultrasoundgroup,professionalorregulatorybodyor

scientificsocietyxiv) Promotingthepracticeofultrasoundtootherhealthcareprofessionalswithinawidercontextxv) Communicatingwith,andimaging,patients

Thelistofpossibleactivitiesaboveisforexampleonly.Therearemanyandvariedotheractivitiesthatcanalsocontributetoanindividual’sCPD.

Itisimportantthatsuitablerecordsaremaintainedandevidenceiscompiledonaregularbasis.Evidenceshouldnotonlyincludeattendancecertificatesateventsbutalsowrittenrecordsofpersonallearningandreflection.SocietyandCollegeofRadiographersmembershaveaccessto‘CPDNow’.Thisisauser-friendlyon-linetoolforidentifying,planning,evaluatingandrecordingCPDthatwillalsohelptheindividualifaskedtopresentevidenceofCPDbytheHCPC:https://www.sor.org/learning/cpd/cpd-nowA‘CPDNow’apphasrecentlybeenmadeavailableforandroiddevices,with‘Apple‘devicestofollow.References1)PeckC,McCallM,McLarenB,RotemT.(2000).Continuingmedicaleducationandcontinuingprofessionaldevelopment:internationalcomparisonsBritishMedicalJournal320(7232):432-4351.19CODESOFPROFESSIONALCONDUCTFORSONOGRAPHERSThesecodeshavebeenincludedtosupporttheuseoftheprofessionaltitleof‘sonographer’andthefuturedevelopmentandregulationofthesonographyprofession.Hencetheuseofthistermratherthanthegeneric‘ultrasoundpractitioner’(ref:Introduction)

ACodeofPracticecanbedefinedasasetofwrittenruleswhichexplainshowpeopleworkinginaparticularprofessionshouldbehave.Itisdesignedtocoverallcircumstances,iswritteninbroadtermsandexpressesethicalprinciples.ThestatementsbelowarefromtheCodeofPracticeforSonographerswhichwerepreviouslypublishedbytheUnitedKingdomAssociationofSonographers(UKAS)intheGuidelinesforProfessionalWorkingStandards–UltrasoundPractice(2008)andareasequallyrelevanttoday.Thesestatementsthatreflectbestpracticeareaguideandofferadvicetosonographers,educationalists,studentsofmedicalultrasoundandotherhealthcarepractitioners.Theyarestatementsofprofessionalconductthatreflecttheindividual'srights,localandnationalchangingpatternsofultrasoundservicedeliveryandtherequirementofsonographerstodemonstratecontinuingcompetencythroughpersonalandprofessionaldevelopment.


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Thereareothercodesthatsonographersandultrasoundpractitionersmayneedtofollow.IfstatutorilyregisteredwiththeGMC,HCPCorNMC,theseregulatorshavethemselvespublishedcodesofconductandethics.ProfessionalbodiessuchastheSocietyandCollegeofRadiographersandtheRoyalCollegeofMidwives,forexample,alsohavepublishedcodesofconduct.ThePublicVoluntaryRegisterofSonographershasassociatedwithitpublishedStandardsofConduct,PerformanceandEthicsandStandardsofProficiency.http://www.sor.org/practice/ultrasound/register-sonographersScrolldownfortherelevantPDFs.TheStandardsofConduct,PerformanceandEthicsdocumentalsocontainsaconscientiousobjectionstatementwhichiscopiedbelow.Acodeofpracticeforsonographers1. Sonographershaveadutyofcaretotheirpatientswithrespecttotheminimisationofultrasound

exposureconsistentwithdiagnosticneeds.2. Sonographersareethicallyandlegallyobligedtoholdinconfidenceanyinformationacquiredasaresult

oftheir professional and clinicalduties, exceptwhere there is alegal obligationfordisclosure.3. Sonographersmustbecommittedtotheprovisionofaqualityultrasoundservicehavingdueregardforthe

legislationandestablishedcodesofpracticerelatedtohealthcareprovisioninordertominimiserisktopatients,patients’carersandotherprofessionals.

4. Sonographersarelegallyandprofessionallyaccountablefortheirownpracticeandmustnotbeinfluenced

byanyformofdiscrimination.5. Sonographersmustidentifylimitationsintheirpracticeandrequesttrainingandsupporttomeettheir

perceivedneeds.6. Sonographerswilltakeallreasonableopportunitytomaintainandimprovetheirknowledgeand

professionalcompetencyandthatoftheirpeersandstudents.7. Sonographersmustpaydueregardtothewayinwhichtheyareremuneratedfortheirwork.8. Sonographershaveadutyofcaretoworkcollaborativelyandinco-operationwiththemulti-disciplinary

healthcareteamintheinterestsoftheirpatientsandpatients’carers?9. Sonographersmustactatalltimesinsuchamannerastojustifypublictrustandconfidence,touphold

andenhancethereputationofsonographyandtoservethepublicinterest.10. Sonographersmustensurethatunethicalconductandanycircumstanceswherepatientsandothersareat

riskarereportedtotheappropriateauthority.11. SonographerswhoareheldaccountableinanotherareaofhealthcaremustrelatethisCodetoothers

thatgoverntheirpractice.12. StudentsonographerspursuingaqualificationinmedicalultrasoundmustadheretotheirUniversityor

HigherEducationInstitution’sCodesofConductthatrelatetoallelementsoftheirultrasoundeducationandtraining.


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Conscientiousobjection

ThefollowingistheconscientiousobjectionclausefromtheStandardsofConduct,PerformanceandEthicsthatisassociatedwiththePublicVoluntaryRegisterofSonographers:‘Youmustreportinwritingtoyouremployingauthority,attheearliestdateinyouremployment,anyconscientiousobjectionthatmayberelevanttoyourprofessionalpractice.Youshouldexplorewiththemwaysinwhichyoucanavoidplacinganunreasonableburdenoncolleaguesbecauseofthis.Yourrighttoconscientiousobjectiondoesnotexemptyoufromprovidingserviceuserswithfull,unbiasedinformation;forexample,priortoprenatalscreeningortesting.Youdonothavetherighttorefusetotakepartinanyemergencytreatment’.TheNMChaveconscientiousobjectionadviceat:http://www.nmc.org.uk/standards/code/conscientious-objection-by-nurses-and-midwives/.Thisgivesfurtherdetailsofthelegalcircumstanceswhensuchaclausemightapply.1.20INDEPENDENTPRACTICE

ManyultrasoundpractitionersworkindependentlywheretheyarenotdirectlyemployedbyanorganisationsuchasaHealthBoard,Trustorindependentcompany;somewillcombineindependentworkwithanemployedpost.Someultrasoundpractitionerssetupprivateorotherformsofcompanies,workasfranchisorsorfranchiseesorasasoletrader.Thereisthereforeawiderangeofwaysinwhichindependentultrasoundpractitionerscanwork.SomeultrasoundpractitionershavebeensuccessfulinobtainingcontractsvialocalNHScommissioninggroupsandtheNHS‘AnyQualifiedProvider’scheme,eitherindividuallyorinpartnershipwithotherultrasoundpractitioners.TheseGuidelinescannotprovidespecificadvicealthoughthefollowinginformationmaybeofhelp.TheCareQualityCommission(CQC)regulationswhicharealegalrequirementapplytoEnglandonly.Ultrasoundpractitionerspracticingindependentlyinthedevolvedcountriesareadvisedtocontacttheequivalentorganisationsintheirowncountriesforadviceaboutanylegalrequirementsthatmayapply.i) Unlessexempted,thelegalbodythatprovidesaregulatedactivity(serviceprovider)mustbylawregister

withtheCareQualityCommission.Regulatedactivitiesincludeultrasound.Serviceproviderscanbeanindividual,company,charity,partnership,NHSTrustorotherorganisation.Theonusisontheserviceprovidertoregister.TheCQCScopeofRegistrationcanbefoundat:http://www.cqc.org.uk/sites/default/files/20150326_100001_scope_registration_march_2015_updated.pdfTheregulationsrelatingtohostingarrangements,subcontractedservicesand‘practisingprivileges’arecomplexandcanbefoundonpages8and9oftheaboveScopeofRegistrationdocument.OnlytheCQCcanformallyadviseastowhetherCQCregistrationisnecessary.ScotlandhaspublishedlegalrequirementsontheregistrationofindependentclinicsthatwillapplyfromApril2017at:http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/independent_healthcare/register_a_new_service.aspx

ii) ManycontractsofemploymentwithTrustsandHealthBoardsandindependentcompaniesrequire

disclosureofindependentworkandactivitiesthatmayhaveabearingontheworkoftheemployerand,evenifnotstated,maybeimpliedorjudgedtobesoonceoperational.Theremaybeconflictsofintereststhatarise.Independentpractitionersareadvisedtoseekadvice,forexample,fromtheiremployerorseekindependentlegaladvice.

iii) Ultrasoundpractitionersshouldbeentirelyclearonwhentheyareworkingindependently(self-employed)

andwhentheyareworkingasanemployee.Thisshouldbemadeclearinanywrittencontractsbutsomeareverypoorlywrittenandconstructedandthisisnotalwaysapparent.TheAdvisory,ConciliationandArbitrationService(ACAS)haveadviceathttp://www.acas.org.uk/index.aspx?articleid=1577or


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independentlegaladvicecanbesought.Independentpractitionersshouldbeawareofthedifferencesbetweena‘contractofservice’anda‘contractforservice’.Anemployee-employerrelationshipisa‘contractofservice’andacontractor-clientrelationshipisa‘contractforservices’.Furtherinformationat:http://www.contractorcalculator.co.uk/difference_contract_for_services_of_services_ir35.aspx

iv) ItisarequirementofstatutoryregistrationwithregulatorybodiessuchastheHealthandCareProfessions

CouncilandtheNursingandMidwiferyCouncilthatadeclarationofhavingprofessionalindemnityinsuranceinplaceismadeatthetimeofinitialregistrationoratrenewal.Seealsosection3.Ultrasoundpractitionersworkingindependentlymustbeawareof,andfollowtherequirementsandconditionsof,theirprofessionalindemnityinsurer:http://www.hpc-uk.org/registrants/indemnity/.Itisimportanttobefullyawareofanytermsandconditionsthatmayapplyandthatitisapplicabletoallareasoftheultrasoundpractitioner’swork.Manyprofessionalindemnitypolicieswillapplyonlytotheindividualpractitionerandnottocompanies.SomepoliciessuchastheSCoR’sProfessionalIndemnityInsurancearesecondarytoacontractofemploymentwhichmustbeinplacewiththeemployeracceptingprimaryvicariousliability.Seehttps://www.sor.org/being-member/professional-indemnity-insurance

Additionalinsurancesforpublicliability,employer’sliabilityandtheultrasoundequipmentitselfmayalsoberequireddependingoncircumstances.FromApril1st2013independentsectorprovidersofNHSserviceshavebeenabletojointheClinicalNegligenceSchemeforTrusts(CNST).

v) Thesafetyofpatientsisparamountandultrasoundpractitionersmusthavedocumentedevidenceoftheir

competencies,continuingprofessionaldevelopmentandreflectivepracticeandshowevidenceofauditofallaspectsoftheservice(s)theyprovide.Governancearrangementsshouldincludeprotocolsandproceduresforimageacquisition,storageandretention(Seesection2.11).Seealsothe2014RCR/SCoR‘Standardsfortheprovisionofanultrasoundservice’(seelinkinparagraphvii)below).

vi)IndependentprovidersofNHSservicesareadvisedthattheremaybearequirementtoholdaMonitor license.ProvidersareexemptiftheirannualapplicableturnoverfromtheprovisionofNHSservicesisless than£10millionbuttherecanbeotherfactorsaffectingthissuchasifservicesarespecificallydesignated bycommissionerstorequireaMonitorlicensetobeheld.Providersareadvisedtomaketheirown

enquirieswithclinicalcommissioninggroupswithwhichtheyholdcontractsastherulesarecomplex.MonitorregulationsapplyinEngland.

https://licensing-gateway.monitor.gov.uk/sites/monitor/Documents/GuidanceDocumentation.pdfvii) TheSCoRhaspublishedthefollowinginformationthatrelatestoindependentpractice:Independentpractitioners,StandardsandGuidance

http://www.sor.org/learning/document-library/independent-practitioners-standards-and-guidance

Adviceonindependentpractice(memberlog-onrequired)https://www.sor.org/career-progression/independent-practitionersAdviceonsettingupabusiness(memberlog-onrequired)https://www.sor.org/career-progression/independent-practitioners/setting-up-own-businessTheRCR/SCoRdocument‘StandardsfortheprovisionofanUltrasoundService’(RCR/SCoR,2014)appliestoindependentpracticeasitdoesforTrusts,HealthBoardsandindependentcompanies.

http://www.sor.org/sites/default/files/document-versions/bfcr1417_standards_ultrasound.pdf


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SECTION2THEULTRASOUNDEXAMINATIONThissectionincludesexamination-specificguidelinesandcommonclinicalscenarios.TheyhavebeencompiledbytheBritishMedicalUltrasoundSocietyProfessionalStandardsteamandarepresentedasexamplesofbestpracticewhichitishopedwillbeofvaluetodepartments.Guidelinesorlinkstoinformationonthevettingandjustifyingofultrasoundrequests,reportingandauditarealsoincluded.TheGuidelinespresentedherearenotprescriptive.TheseGuidelinesdonotandcannotcoverallelementsofanultrasoundexaminationandultrasoundpractitionersareadvisedtoaccessadditionalpublishedinformationandresearchinordertofullyinformtheirownlocaldepartmentalprotocolsandprocedureswhentherearenonationallyagreedonesavailable.2.1 OVERVIEWOFULTRASOUNDEXAMINATIONPROCEDURES

Relatingtoallultrasoundexaminations,theultrasoundpractitionershouldbeawareoflocallyagreedstandardsofpracticeandcurrentguidelinesofotherprofessionalbodiesandorganisations.Thefollowingpointsshouldbeconsideredforallultrasoundexaminations:

• thepatientiscorrectlyidentifiedfollowingrequireddepartmentalprocedures;• theclinicaldetailsprovidedare sufficient tocarryout theexaminationrequestedandthecorrect

examinationhasbeenrequested;• relevantinformationisavailablefromthecasenotes,previousinvestigationsandothersources;• theroleoftheultrasoundexaminationisunderstoodintheclinicalcontextforthepatient;• thepotentialrisksinvolvedintheprocedureareexplainedtothepatient;• informedconsentisobtainedbeforeproceedingwiththeexamination;• requirementsforchaperonesarefollowedwhereapplicable;• dueconsiderationisgiventotheneedforaninterpreter;• asystematicscanningapproachisadoptedthatcanbemodifiedasrequired;• requirementsandrecommendationsshouldtheexaminationbeincomplete;• theneed toextend theultrasoundexamination, and/orproceed toadditional imaging

techniqueswherenecessaryinaccordancewithlocallyagreedprotocol;• theaftercareofthepatient;• appropriatenationalandlocalhealthandsafetyregulationsincludinginfectioncontrolareapplied.

2.2 OBSTETRIC,VASCULAR,ECHOCARDIOGRAPHYANDBREASTEXAMINATIONS

Inthe2015editionandthesubsequentRevison1inDecember2016,therearenopracticeguidelinesincludedforobstetricandvascularultrasoundexaminations,echocardiographyorforultrasoundofthebreast.Earlypregnancyandobstetrics

Ultrasoundpractitionersarereferredinparticulartopublicationsfromthenationalfetalanomalyscreeningprogrammes,theRoyalCollegeofObstetriciansandGynaecologists(especiallytheirGreentopGuidelines),theFetalMedicineFoundation,theAssociationofEarlyPregnancyUnits,BritishSocietyofGynaecologicalImaging,theInternationalSocietyofUltrasoundinObstetricsandGynaecologyandtheNationalInstituteofHealthandClinicalExcellence(NICE).VascularFor information on this aspect of ultrasound practice, please see the website of the Society for VascularTechnologyofGreatBritainandIreland(SVT):http://www.svtgbi.org.uk/


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TheSVThavepublishedprotocolsforthevariousproceduresthatfallwithintheirscopeofpractice:http://www.svtgbi.org.uk/professional-issues/(SVTmemberloginrequired)Nationalrecommendationsforcarotidultrasoundexaminationscanadditionallybefoundvia:http://www.ncbi.nlm.nih.gov/pubmed/19046904EchocardiographyBritishSocietyofEchocardiography(BSE):http://www.bsecho.org/home/TheBSEhavepublishedprotocolsforthevariousproceduresthatfallwithintheirremit.2.3 NICEANDOTHERGUIDELINES

TheNationalInstituteforHealthandClinicalExcellencepublishawiderangeofGuidelines,manyofwhichhaveimplicationsforultrasoundpractice.NICEwebsitehttps://www.nice.org.uk/OtherorganisationspublishingGuidelinesincludethefollowing(thelistisforexampleonly):RoyalCollegeofObstetriciansandGynaecologists(particularlythe‘GreentopGuidelines’)https://www.rcog.org.uk/guidelinesBritishSocietyofGynaecologicalImaginghttp://www.bsgi.org.uk/RoyalCollegeofRadiologistshttps://www.rcr.ac.uk/BritishMedicalUltrasoundSocietywww.bmus.orgSocietyandCollegeofRadiographerswww.sor.orgBritishSocietyofEchocardiographyhttp://www.bsecho.org/home/SocietyforVascularTechnologyofGreatBritainandIrelandhttp://www.svtgbi.org.uk/InternationalSocietyofUltrasoundinObstetricsandGynaecologywww.isuog.orgNationalScreeningCommitteeandtheindividualnationalscreeningprogrammes(refsection1.8)FetalMedicineFoundationhttps://fetalmedicine.org/ClinicalImagingBoardhttps://www.rcr.ac.uk/clinical-radiology/faculty-structure/clinical-imaging-boardAssociationofEarlyPregnancyUnitshttp://www.earlypregnancy.org.uk/index.asp2.4 VETTINGOFULTRASOUNDREQUESTS

Introduction

Anultrasounddepartmentorprovidermayreceiverequestsfrommanydifferentsourcesincludingwards,outpatientdepartmentsandprimarycare.Somedepartmentsandproviderswillalsoacceptself-referralsforcertaintypesofexamination.

Afullycompletedultrasoundrequestineitherpaperorelectronicformwillnormallyberequiredforeveryexaminationundertaken.Departmentsandprovidersshouldmakeclearwithintheirlocalrequestingprotocolswhomayrequestanultrasoundexamination.Thismay,forexample,berestrictedtoamedicallyqualifiedpersonoraqualifiedandregisteredhealthcarepractitioner.Itisadvisedthatnon-medicalrequestorsofNHSultrasoundscanshaveanagreedschemeofworkapprovedbytheimagingdepartmentorproviderandbytheirrelevantclinicalleadpriortoreferralsbeingmade.Ifself-referralsareacceptedbythedepartmentorprovider,thecircumstanceswhenthismayoccurshouldberecordedwithinthelocalrequestingprotocols.

Theultrasoundscansthemselvesmaybeperformedbyavarietyofstaff,inavarietyoflocations,bothinandoutofnormalworkinghours.Itisessentialthatultrasounddepartmentsareproactiveinmanagingworkloadto


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ensurethattherightscanisperformedintherightplace,bytherightpersonandattherighttime.Protocolingofultrasoundrequestsbyanultrasoundpractitioneristhereforeimportant.

AimofVetting

• Toensurethatultrasoundscansarejustifiedandthatthecorrectscanhasbeenarrangedwiththecorrectpatientpreparation.

• Toensurethatclinicallyurgentrequestsareundertakeninatimelymanner.• Toensurethatthescansareundertakenbytherightperson,intherightplaceandattherighttime.

Therequestshouldbecheckedtoensurethatitisfilledoutcorrectlyandcomplieswithindividualdepartmentpolicies.Thevettingpractitionershouldbeconfidentthattheultrasoundrequestprovidessufficientclinicalinformationandisappropriatetoanswertheclinicalproblemposed.Thereshouldbeanagreeddepartmentalmechanismfordealingwithinappropriaterequestsandrequestsforwhichthevettingpractitionerisuncertain.

Itisrecommendedthatthereisaprocedureforflaggingclinicallyurgentrequeststogetherwithamechanismfordealingwithsuchrequests.2.5JUSTIFICATIONOFULTRASOUNDREQUESTSIntroduction

AdvicehasbeenproducedbyBMUStogivebestpracticeadvicetoultrasoundprovidersandisintendedtosupportprimarycarephysiciansandultrasoundprovidersintheappropriateselectionofpatientsforwhomultrasound(US)wouldbebeneficialintermsofdiagnosisandordiseasemanagement.TherelevantBMUSdocument:BMUSRecommendedGoodPracticeGuidelines:JustificationofUltrasoundRequests(version2,2016)isavailabletoBMUSmembersandcanbeaccessedfollowinglog-onat:https://www.bmus.org/policies-statements-guidelines/professional-guidance/Thisdocumenthasbeenwrittentoaidultrasoundprovidersinjustifyingthatanultrasoundexaminationisthebesttesttoanswertheclinicalquestionposedbythereferrer.Whileitisprimarilyaimedatprimarycare,theguidanceisalsorelevantforotherreferrergroups.ThisdocumenthasbeencompiledbyapanelofultrasoundexpertstosupportgoodpracticeinvettingandjustifyingreferralsforUSexaminations.Ithasbeenwrittenwithapragmaticapproachtomanagingreferralsbasedonthepanel’sexpertopinion.Thisdocumentcanbeusedtoassistandunderpinanylocalguidelinesthatareproduced.Referenceismadetotheevidence-basediReferpublication(RoyalCollegeofRadiologists)andshouldbeusedinconjunctionwiththis.http://www.irefer.org.uk/TheNICEguidanceNG12,SuspectedCancer:RecognitionandReferralpublishedinJune2015(updated2017)hasalsobeenconsideredintheproductionofthisupdatedpublication.https://www.nice.org.uk/guidance/ng12

Inmanyinstances,NICEadvisesurgentdirectaccessCTbutifthisisunavailable,itadvisesthatpatientsarereferredforanurgentultrasoundexamination.LocalpracticewilldictateappropriatepathwaysfollowingconsiderationofcapacityanddemandissuesineachTrust.

Principles

Thisdocumentisbasedonseveralnon-controversialprinciples:

• Imagingrequestsshouldincludeaspecificclinicalquestion(s)toanswer,and

• containsufficientinformationfromtheclinicalhistory,physicalexaminationandrelevantlaboratoryinvestigationstosupportthesuspecteddiagnosis(es).

• ThemajorityofUSexaminationsarenowperformedbyultrasoundpractitionerssuchassonographerswhoarenotmedicallyqualified.Suspecteddiagnosesmustbeclearlystated,notimpliedbyvague,non-specifictermssuchas“Painquerycause”or“pathology”etc.


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• AlthoughUSisanexcellentimagingmodalityforawiderangeofabdominaldiseases,therearemanyforwhichUSisnotanappropriatefirstlinetest(egsuspectedoccultmalignancy).

• Givensufficientclinicalinformation,mostNHSproviderswillre-directUSrequeststoCTorMRwhereappropriatewiththeagreementoflocalcommissioners.

Thisgeneralguidanceisbasedonclinicalexperiencesupportedbypeerreviewedpublicationsandestablishedclinicalguidelinesandpathways.Individualcasesmaynotalwaysbeeasilycategorisedandlocalarrangementsforpromptaccesstospecialistadviceareessential.

Localguidelinesshouldincludeidentificationofwhojustifiesthereferral,timescalesforvettingandappropriatetrainingforindividualsundertakingthisprocess.

Changestoguidelinesandpathwaysshouldbeapprovedbylocaltrustgovernanceprocesses.Itisrecommendedthatanyreferralsreturnedtothereferrerhaveanaccompanyingletterexplainingtherationalebehindthis.Allactionsshouldbedocumentedandrecordedonthelocalradiologyinformationsystem.

Implementation

ForpractitionersworkinginEngland,mostprimarycareultrasoundservicesarecommissionedviatheClinicalCommissioningGroup(CCG).ServicesthathaveadoptedtheBMUSGoodPracticeGuidelineshaveinitiallynegotiatedwiththeCCGsregardingtheservicethatistobecommissioned.Thiscanbeinformedbyserviceandgoodpracticeguidelinesshouldbeincorporatedintoanycontracts.ThesuggestedstepsaregivenasguidancetoserviceleadstoaidimplementationoftheGoodPracticeReferralGuidelines:

1. Beclearastowhyguidelinesaretobeintroducedinadditiontothesebeingbestpracticeguidelines.Theymayalsorepresentbestuseoflimitedresources,ormayberequiredtolimitdemand.

2. DiscussBMUSdocumentwithlocalservicecolleagues,amendingasnecessarytosuitlocalpractice.3. DiscusseditedBMUSdocumentwithlocalsecondarycareprovidersandconsultantstoensurethatthis

sitswithinlocalreferralpathwaysassomeexaminationsmaybebettersuitedtoprimaryorsecondarycaredependinguponlocalpractice.

4. Onceagreed,discusswithserviceprovidercontractslead(thismaybeateaminalargetrustoralocalmanagerifanindependentprovider)andenterintodiscussionswithlocalCCG.

5. EngagelocalCCGandGPrepresentatives,attendlocallearningevents,meetingsorcommitteestopresentcaseandneedforchange.Bepreparedtoeditdocumentfurthertoreflectlocalrequirements.

6. Onceagreed,planastartdateforimplementation.Alead-inperiodmaybeconsideredwherereferralsareacceptedbutwherethereferrersareinformedthattheydonotfitproposedguidelinesandwhy.

7. PlanvettingtimeintoschedulesasdecliningreferralsandcommunicatingwithGPsistimeconsuming.8. Ensureaclearandrobustcommunicationpathwayisinplacetoensurethereferrerisinformedifthe

referralisdeclined.Itisvitalthatthereasonsfordecliningareclearsothatreferrersmaylearnthenewguidelines.

9. Ensurethereisasysteminplacetorecordallreferrals,includingthosedeclined.Thismaybethedevelopmentofalocalcodeonthepatientinformationsystemthattheserviceusesorapasswordprotecteddatabase.

10. FeedbacktoCCGtheimpactthattheimplementationofguidelinesishavingonwaitinglists,referralqualityandofanynon-compliance.


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2.6 RECOMMENDATIONSFORTHEPRODUCTIONOFANULTRASOUNDREPORT

See also section 5 of the 2014 RCR/SCoR document ‘Standards for the provision of an ultrasound service’ onreportwriting:http://www.sor.org/sites/default/files/document-versions/bfcr1417_standards_ultrasound.pdfTheRoyalCollgeofRadiologists in2015publishedapositionstatementonrecordingthe identityofhealthcareprofessionalswhoreportultrasoundexaminationshttps://www.rcr.ac.uk/posts/position-statement-recording-identity-healthcare-professionals-who-report-imagingSafetystatement

Itisrecognisedthatallpersonnelundertakingultrasoundexaminationsshouldbeawareofthepotentialbiologicaleffects,situationsinwhichexaminationsmaybecontra-indicatedandbeawareofthenationallyrecommendedmechanicalandthermalindicesandtheALARAprincipletoreduceultrasoundpatientdose.1

Generalcomments

• Theultrasoundreportshouldbewrittenandissuedbytheoperatorundertakingtheultrasoundexaminationandviewedasanintegralpartofthewholeexamination.

• Thereportshouldbewrittenassoonaspossibleaftertheexaminationhasbeencompleted.

• Thenameandstatusoftheoperatorissuingthereportshouldberecordedonthereport.Whereapplicableitisgoodpracticetoincludethestatutoryregulatorybodyandregistrationnumberofreportauthor.

• Thereportauthorshouldtakeresponsibilityfortheaccuracyofthereportandensurethatthereportiscommunicatedtotheappropriatepersonnel.

• Thereportauthorshouldbeawareofhis/herlimitationsandconsequentlyseekclinicaladvicewhennecessary.

• Thereportauthorshouldbeawareatalltimesoftheimplicationsforthepatientofthecontentsofthereportandactinaccordancewithlocalguidelines,policiesandprocedures.

Nineessentialstepsforproductionofanultrasoundreport2

1. Understandingclinicalinformation

Sufficientclinicalinformationshouldbeprovidedbythereferringclinicianorbeavailabletoallowrelevantandappropriateinterpretationoftheimages.Thepersoninterpretingtheimagesandthenproducingthereportmustunderstandthereferringclinician’sinformationandrequest.Theyshouldensurethattheyfullyunderstandtheaimoftheultrasoundexaminationinordertoeffectaclinicallyusefulandrelevantreport.Thediagnosticimportanceofthereportintheclinicalmanagementofthepatientshouldbeunderstood.

2. Technicalknowledge

Ultrasoundisanoperator-dependenttechniqueandthediagnosticqualityoftheimagesisverydependentupontheskillsoftheoperator.Thepersoninterpretingandreportingtheimagesmustbeabletoreflectcriticallyupontheimagequalityandappraisetheimpactondiagnosticaccuracy.Wheretheimagesaretechnicallysub-optimal(eghighpatientBodyMassIndex),thereportingauthormustdecidewhetherthepatientrequiresrecallandre-scan.Itisrecommendedthatanytechnicallimitationsofascanareclearlyrecordedinthereport.


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3. Observation

Tominimisethepossibilityoferrorinproducingareportforthewrongpatient,itisessentialthatthereportauthorcross-checkstheuniquepatientidentificationwiththedateandtypeofultrasoundexaminationperformed.(ref:section1.12)Observationsmaybesub-classifiedas:

• normalfindings;• abnormalfindings:expectedorunexpected;• equivocalfindings:maybenormalorabnormal;• normalvariants.

Itisrecommendedthatasystematicapproachtoimagescrutinyisusedforbothliveandpost-scananalysistoensurethattheSize,Shape,Outline,TextureandMeasurementsofanyfindingsareappropriatelyconsidered(acronym:SSOTM).4. Analysis

Detailedcriticalanalysisoftheimagesshouldbeundertaken,takingintoaccounttheobservationsandclinicalreasoningtoformulateaclinicalopinionandtoconsideritsdiagnosticimplication.Examples:

arethefindingsabnormalanddotheydirectlyrelatetotheclinicalquestion?aretheappearancessimplynormalage-relatedchanges?

Iftheappearancesrepresentactivepathology,thenfurthercriticalanalysisisrequiredtoidentifythemostlikelydiagnosisand/ortoprovidealistofdifferentialdiagnoses.

5. Medicalinterpretation

Theinterpretationofthefindingsandsubsequentreportmustbeconsideredinthelightofthewiderclinicalpicture.Inordertoproducearelevantdiagnosticreport,reviewandunderstandingofanypreviousimagingorrelevantinvestigationsmayberequired.TheRoyalCollegeofRadiologists(RCR)2statesthat‘aclinicallyrelevantopinionencompassesalltheknownfactorsaboutthepatient,aswellastheimagingfindings’.Inthiscontext,itisessentialthatthereportauthorhasextensivemedicalknowledgetoreachadiagnosisoraseriesofrankeddifferentialdiagnosesonwhichclinicaldecisionscanbemade.Whetherthereportisproducedbyamedicallyqualifiedornon-medicallyqualifiedultrasoundpractitioner,itisessentialthattherearegovernanceproceduresinplacetoensurethattheindividualdoespossesstheknowledge,skillsandcompetencetoeffectthisdutywithoutdetrimenttothepatientoutcome.Inaddition,theremustbeafailsafemechanismtoensurethat,whenrequired,aradiologicalorequivalentexpertopinioncanbeobtainedpromptlytoallowissueofthereportwithoutunduedelay.

6. Advice

Itisessentialthatthereportauthorisawareofthediagnosticaccuracyoftheexaminationrelatedtotheindividualpatient.Thelevelofcertaintyordoubtinthediagnosisshouldbemadeevident.Ifadefinitivediagnosiscannotbemadethenadviceonfurtherappropriateimaginginvestigationsshouldbeprovided,whenrequired.Localpolicyshouldexistclearlystatingmechanismsforadvisingonrelevantfurtherinvestigationsthattakesaccountoftheprofessionalbackgroundofthereportauthor,whichmaybeanon-medicalone.


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7. Communicationwiththereferrer

Thereneedstobeaneffectivemechanisminplacelocallytoensuretimelydisseminationoftheultrasoundreport.3ThereportshouldbeissuedinlinewithRoyalCollegeofRadiologists’recommendations2.,3andmustprovideinformationwhichrelatestotheoriginalclinicalquestion,includingexpectedandunexpectedfindingsandtheirclinicalrelevance.Thereshouldbeanawarenessofthereferrer’sunderstandingofsuchreportsandtheyshouldbewordedtoensurethatthereferrerisabletounderstandtheclinicalinformationexpressed,includingtheiraccesstocomplementaryinvestigations(examplesCT/MRI).Amechanismtoallowthereferringcliniciantodiscussthereportfindingswiththereportauthortoensurebetterunderstandingoftheclinicalimpactofthereportonmanagementisappropriate.Forexample,adedicateddepartmentemailaddressmaybesetuptoallowcommunicationbetweenreferrersandreportersforsuchqueries.

8. Takingappropriateaction

Thereportauthoralsohasadutyofcaretothepatienttoensurethatwhenimmediateorurgentactionisrequiredthatthisinformationisdeliveredtothereferringclinicianpromptly.Thisshouldbeagreedatlocallevelthroughappropriate‘alertmechanisms’.Suchurgentcommunication(s)shouldberecordedinthereport.3

9. CommunicationwiththepatientItmay/maynotbepossibleforthereportauthortopassoninformationregardingtheoutcomeoftheexaminationtothepatient,particularlyiftherehasnotbeentimetoreviewthewiderclinicalaspectsofthecase.Cautionisrecommendedwhendiscussingtheclinicalfindingswiththepatient,particularlyinrespectofpossiblemanagementstrategieswherethereportauthormaynothaveadequateknowledge.Ultrasoundpractitionersshouldalsoadheretotheguidanceprovidedoncommunicationbytheirprofessionalbody.Appropriatetrainingshouldbeundertakenpriortogivinganybadnewstoensurethatsuchnewsisgivensensitivelyandeffectivelyandwithoutambiguity.Reportauthorsmustbeawarethatpatientsmayhaveaccesstothereportandthereforecautioninthewordingisadvocated.

Reportcontent

Itisrecommendedthatanultrasoundreportbedividedintothefollowingsections:

• Typeofexaminationperformed

Thetypeofultrasoundexaminationperformedshouldbestatedatthetopofthereporttoensurethereisatruerecord.

Examples: Ultrasoundexaminationoftheupperabdomen

Transvaginalultrasoundexaminationofthepelvis


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Thisisparticularlyimportantinthelatterexamplewhereitisessentialtodocumenttheintimatenatureoftheprocedure.Careisalsorequiredwhereadecisionmayhavebeenmadeforappropriatereasonsnottoexaminethepelviswhenanabdomenandpelviswasrequested.Standardgeneratedheaderseg“Ultrasoundabdomenandpelvis”mustbeamendedappropriatelyandthereasonsidentifiedinthereport.

• Summaryofclinicaldetails

Itisoftenhelpfultorecordanoverviewofkeyclinicalhistoryandfindingsatthestartofthereport.Ifthereferringclinicianhasonlyprovidedscantinformationandfurtherrelevantinformationhasbeengleanedfromthepatientbytheoperatorthenthisshouldberecordedaccordingly.Thiswillassistinsettingthereportinitstrueclinicalcontext.Incaseswheretheclinicalquestionwithinthereferralisunclear,itmaybeusefultostatetheinferredclinicalquestionwhichthereportthensetsouttoanswer.• Descriptiveelement

ItcanbehelpfultoincludeadescriptionoftheobservationsandfindingstoincludeanalysisoftheSize,Shape,Outline,TextureandanyMeasurementsofthestructuresexamined.

Forexample:

“Awelldefinedmasswithmixedechoesispresentintheleftrectussheath.Thelesionisexquisitelytender.Themassmeasures5.2x4.6x3.6cm.Appearancesandfindingsareinkeepingwitharectussheathhaematoma”.

Anytechnicaldifficultiesencounteredmustbenoted,togetherwiththeirimpactondiagnosticaccuracy.

Forexample:

“Onlylimitedintercostalviewsoftheliverobtainedowingtothepresenceofbowelgasobscuringaccess.However,whereseen,theliverisnormalinsizeandappearance”.

• Conclusion

Thestandarduseofaconclusionisgoodpracticeandshouldincludeaninterpretationoftheobservedexaminationfindingssetintotheclinicalcontext.ThemainprincipaldiagnosisshouldbegivenandwherepossibletheRCRrecommendthatyoucometoasinglediagnosis.Wherethisisnotpossiblethenthemostlikelydiagnosisshouldbehighlighted,withotheroptionslistedinrankorderoflikelihood.2

• Differentialdiagnoses

Wherethesearenecessary,theyshouldbelimitedinnumberandbriefandshouldincludeastatementastowhythesearelesslikelythantheprimarydiagnosis.

• Recommendationsforfurtherinvestigations/management

Toincludeanyappropriaterecommendationsforfurtherinvestigation(egCT/MRI/drainage/biopsyetc)dependentuponlocaldepartmentguidelinesandpractice.

• Identificationoftheauthorandcontributors

Thename,positionandprofessionofthepersonperformingandinterpretingtheultrasoundexaminationshouldbeclearlystated.2,3,4Thisshouldalsoapplytoanyoneinvolvedinsecondpartyreporting.Itisgoodpracticetostatethereportauthor’sGMC,HCPCoranyotherstatutoryregulatorybodynumber.Thespecificactionofanysecondaryinvolvementshouldalsobestatedeg‘’Dr---------,ConsultantRadiologistreviewedtheimagesandagreeswiththeaboveinterpretation”.


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• IdentificationofChaperonesDetailsofanychaperonesorthirdpartiesintheroomshouldbedocumentedgivingnameandprofessionalcapacity.Patient’sactionsregardingwhetherachaperonewasacceptedorofferedanddeclinedshouldbedocumented.Furtherinformationcanbefoundinsection1.10.

• ConsentDetailsofanyconsentgainedpriortotheprocedureshouldbedocumented.Forinstance,verbalconsentgainedforintimate(transvaginal)examinationsorwrittenconsentforbiopsyproceduresshouldbedocumented.Furtherinformationcanbefoundinsection1.12.

• AdditionalRelevantInformation

Anyfurtherinformationgainedduringtheexaminationwhichmayaffectfutureinvestigationsormayhaveresultedinanon-standardprocedurebeingundertakenshouldbeincluded.Forinstance“Duetolatexallergyalatexfreeprobecoverwasused”.(N.B.Localguidelineswillneedtobeconsideredifsuchstatementsaretobeused).

Reportstyle5

• Reportsshouldbesuccinct,clear,unambiguousandrelevantwhereverpossible.

• Astandardreportingtemplateishelpfulforboththeultrasoundoperatorandreferringclinicianstoestablisha‘housestyle’whichisclearlyunderstoodbyallpartiesinvolved.However,standardreportswhich are understood and accepted by staffwithin a hospitalmay need to bemodifiedforoutsidereferrals.Forexample,reportstoGPsmayrequireadditionaladviceregardingpatientmanagementthanreportsbeingwrittenforhospitalconsultantreferrals.

• Abbreviationsarenotrecommendedinordertoavoidambiguityandpotentialconfusion.

• ReportsshouldbewritteninplainEnglishlanguageandshouldbefreefromtheuseofanyultrasoundterminology(egtransonic,echogenicetc.)assuchphrasesaregenerallymeaninglesstonon-ultrasoundusersand,assuch,maybesubjecttomisinterpretation.Shortparagraphsandappropriatelayoutshouldbeused.

• Thereportshouldaddresstheclinicalquestionandgenerallypertaintothereasonforreferral.

Forexample:

“Thegallbladderisverytenderandcholecystitisisthelikelycauseoftherightupperquadrantpain”.

• Wheretheexaminationisextendedtoexamineotherareasotherthanthoseintheprimaryrequestthenthestructuresexaminedandthesubsequentfindingsmustbeclearlydocumented.Theexaminationandthetechnique(s)usedshouldbedocumented.

Forexample:

“Alargeleftsidedvaricocoeleispresentand,inviewofthis,thekidneyswereexamined.Bothkidneysappearnormalandinparticulartheleftkidneyisnormalonultrasoundexamination.”

• Anylimitations(technicalorclinical)oftheexaminationshouldbestatedand,ifarelevantorganhas

notbeenfullyexamined/assessed,thereason(s)shouldbeindicated.


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Forexample:

“Thepancreasisobscuredbybowelgasandnotseenadequatelyenoughtoassess.Thegallbladderiscontractedasthepatientisnotfastedthereforethepresenceofsmallgallstonescannotbeconfirmedorexcludedwithconfidence”.• Diagramsmaybeusefulindescribingthefindingstothereferringclinician(examples:vascular

studiesandgynaecologyexaminations)andastandardtemplatecanbeusedasanadjuncttothewrittenreport.

• Thereportshouldbeconclusivewherepossible,indicatingwhentheappearancesareconsistentwithaspecificdiagnosis.Wherenoconclusionispossible,alternativeexplanationsfortheultrasoundappearancesmaybeoffered.

• Anyrelevantactionsundertakenshouldbereported.

Forexample:

“Ihaveinformedthepatientthatshehasanovariancystwhichrequiresfollowup.Ihavearrangedafollowupscaninsixweekstime.Thepatientisawareofthisappointment.InviewofthefindingsIhavepersonallydiscussedtheseresultswiththereferringclinician,DrXXXbytelephone”.

• Ifsecondopinionshavebeensoughtandgiven,orifotherpersonnelhavescannedthepatient,their

status,actionsandopinionsshouldbestated.

Forexample:

“CasediscussedwithDrXXX,ConsultantRadiologist,whoagreedwithfindingsandreport.PatientalsoscannedbyMrsXXX,LeadSonographer,whoagreeswiththefindingsandreport”.

Inconclusion,agoodreportisareportthatanswerstheclinicalquestion.Theclinicalquestionisideallygiveninanappropriaterequest.Goodreportingavoidsconfusion,clearlyidentifiestheappropriatefindingsandgivesacorrectinterpretationinaclearandunambiguousformat.Ultimately,goodreportingequatestogoodcommunicationskillsand,intheclinicalcontext,willavoiderrorandpotentialharmtothepatient.

References1) terHaarG.(2012)TheSafeUseofUltrasoundinMedicalDiagnosis.BIR http://www.birpublications.org/pb/assets/raw/Books/SUoU_3rdEd/Safe_Use_of_Ultrasound.pdf2) TheRoyalCollegeofRadiologists(2006)StandardsfortheReportingandInterpretationofImaging

Investigations.RCR https://www.rcr.ac.uk/publication/standards-reporting-and-interpretation-imaging-investigations3. TheRoyalCollegeofRadiologists(2016)Standardsforthecommunicationofradiologicalreportsandfail-safe

alertmechansisms.https://www.rcr.ac.uk/publication/standards-communication-radiological-reports-and-fail-safe-alert-

notification4.TheRoyalCollegeofRadiologists(2016)StandardsandRecommendationsfortheReportingand

InterpretationofImagingInvestigationsbyNon-RadiologistMedicallyQualifiedPractitioners.https://www.rcr.ac.uk/publication/standards-reporting-imaging-investigations-non-radiologist-medically-qualified

5.EdwardsH,SmithJ,WestonM.(2014)WhatMakesaGoodUltrasoundReport?Ultrasound,22:57–60.


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2.7 GYNAECOLOGICALULTRASOUNDEXAMINATIONS

Revision2additionallinks:DrSusannahJohnsonhassetupawebsiteat:https://www.gynaecologyultrasound.co.uk/https://www.youtube.com/channel/UCP0cY8uFDvkV7PDxZH0eO3w

Thechannelcontainsmanyshortgynaecologyultrasoundvideos,containingstillimagesandultrasoundvideoclips,onawiderangeofsubjectsincludingOvarianMasses,PostMenopausalBleedingandCaseoftheWeek.IfyousubscribetotheYouTubeChannel,youwillreceiveanemailalerteverytimeanewvideoisuploaded.PleasealsorefertoadvicepublishedbyorganisationssuchastheBristishSocietyofGynaecologicalImaging,RoyalCollegeofObstetriciansandGynaecologistsandInternationalSocietyofUltrasoundinObstetricsandGynaecology.http://www.bsgi.org.uk/https://www.rcog.org.uk/https://www.isuog.org/GeneralscanningprinciplesClinicalhistoryPriortotheUSexamination,theultrasoundpractitionershouldconsidertheclinicalreferral.Aclinicalquestionshouldalsobeprovided.Inaddition,aclinicalhistoryshouldbetakentoinclude:

o Reason for referral, age, menstrual history, symptoms, relevant medication, previous gynaecologicalsurgery/treatment.

Technique

Allinitialgynaecologicalexaminationsshouldbeperformedusingtrans-abdominal(TA)andtransvaginal(TV)techniqueswherepossibletoenableathoroughandsystematicexamination.ThenecessaryinformedconsentforTVscanmustbeobtained;somepatientsmaydeclinethisoritmaybeinappropriate.Detailsoftypeofexaminationandpatientconsentshouldbedocumentedinthereport.

Itmaybepossibletore-examinespecificstructuresatfollow-upexaminationusingeitherTAorTV,dependingonthereasonforreferral/natureoftheabnormality.

TheTVexaminationwillonlyallowalimiteddepthexaminationandlargeordeeppelvicabnormalitiesmaynotalwaysbedemonstratedadequately.

TheTAexaminationrequiresafullbladdertoactasanacousticwindow.

TheTVexaminationrequiresanemptybladder.

Accesstopreviousimagingandreportsshouldbeavailable.ColourDopplerand/orpowerDopplermayberelevantinappropriateclinicalpresentationsegtheassessmentofmyometrialvascularity,ovarianangiogenesis,endometrialvascularity.3D/4Dultrasoundofferstheabilitytoassesstheuterusandovariesinmultisectionalandvolumetricreconstructionandmaybeusefulintheassessmentofpathologyandcongenitalmalformations.Structurestoexamine/evaluate

Thepelvicscanshoulddemonstrate:


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o normalanatomy/variantsincludingageandmenstrualstatus-relatedappearancesofthewholeorganinatleasttwoplanes

o assessmentofsize,outline,echotextureandechogenicity

o pathologicalfindings

Thefollowingstructuresshouldbeexamined:

o Bladder-size,shape,contents

o Cervix-internalos,externalos,cervicalcanal,continuitywithuterus,assessmentofsize,outline,echotexture

o Vagina-assessmentofoutline,echotexture

o Recto-uterinepouch(pouchofDouglas)-?fluidpresent?amount

o Uterus

• position-ifrelevant,note:anteversion,retroversion,anteflexion,retroflexion

• size-ifrelevant,note:uterinelengthandrefertoappropriatenormalrangedata(reproductive/post-menopausalyears)shape/outline-normalsmoothoutline,considercongenitalanomalies-bicornuate,septated,querydisruptedbymass?

• endometrium-considermenstrualrelatedappearances

• thicknessofendometrium-pre/post-menopausalnormalranges,dependingonmenstrualphase

• theantero-posterior(AP)diameteroftheendometriummeasuresapproximately2mm–14mminpre-menopausalwomen

• Ifasymptomaticandpostmenopausalupto10mm–11mmacceptablealthoughfeaturessuchasincreasedvascularityorparticulatefluidshouldbereportedandreferraltoagynaecologistshouldbeconsidered.Protocolsshouldbeagreedwithlocalclinicians.

Ref:https://www.rcog.org.uk/en/guidelines-research-services/guidelines/postmenopausal-thick-endometrium---query-bank/

• assessmentofechotexture-?fluidpresent?solidmass

• myometrium-assessmentofechotexture?hyperechoicorhypochoicareas

o Ovaries• assessmentofechogenicity

• position

• size(reproductive/post-menopausalyears)

• shape

• follicles-number(single/multiple),size,internalechopattern

o Adnexae(wherevisible)

• fallopiantubes

• broadligaments

• pelvicmuscles

• pelvicbloodvessels


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PathologyUterusMyometrium:

o Fibroidsfibroid/leiomyoma/myoma

• benigntumouroffibrousandsmoothmusculartissue

• position-intramural,subserosal,submucosal,pedunculated,cervical.Ifnearuterinecornua,mayimpingeontubeandimpairpatency

• single,multiple,varioussizes

• welldefinedmassofalteredechogenicity

• composedofsmoothmusclebutmaycontainfibroustissue,calcification,necrosis

• colourDopplermayshowvascularityandpresenceofadjacentvessels

• vascularpatternsvaryconsiderablyandmaynotbereliablefordiagnosis

o Adenomyosis

• diffuseornodulardepositsofendometriumwithinthemyometrium

• presentation:multiparous,mid40s,menorrhagia,dysmenorrhoea

• USappearances:

§ enlargeduterinefundusandbody,particularlytheposteriormyometrium.

§ acousticlinearstriations

§ indistinctendometrial/myometrialinterface

§ coarse,heterogeneousmyometrialechotexture

o Uterinesarcoma

• carcinomaofuterinemuscle

• veryheterogeneousmyometrium/cysticspaces

• rare–lessthan5%ofuterinemalignancies

• canresemblefibroidsorendometrialcarcinoma

• shouldbesuspectedifchangingrapidlyinsize

Endometrium

o Carcinoma

• 95%presentasabnormaluterinebleeding

• unscheduledpostmenopausalbleeding(PMB)

• 50%incidenceofpolypsorsubmucosalmyomas

• normalUSSthickness</=5mm,somecentresuse4mm.AgreePMBprotocolslocallywithclinicians

• alsoconsiderdrug-relatedappearanceofthickening/cystichyperplasiae.g.HRT,Tamoxifen

o Polyps

• commoninpreandpost-menopausalwomenwith‘thickenedendometrium’

• mostlyasymptomaticbutmaypresentwithinter-menstrualbleeding(IMB)orPMB

• USappearance:


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§ focalendometrialthickeningoranechogenicmasswithintheendometrialcavity

§ colourDopplermayhelpidentifyafeedervesselintoapolyp

o Asherman’ssyndrome

• fociofincreasedechogencityintheborderbetweentheendometriumandthemyometrium(junctionalzone)

• previoushistoryofD&C–adhesions

o Haematometrocolpos

• haematocolpos-accumulationofmenstrualbloodinthevagina–imperforatehymen,cervicalstenosispost-surgery

• haematometra-accumulationofmenstrualbloodintheuterus

• haematometrocolpos-Accumulationofmenstrualbloodintheuterusandvagina

Ovary

o Simplecyst

• simpleovariancystsarecommon

• 6%pre-menopausal

• USappearance-well-defined,echo-free,unilocular,thin,smoothwalls,goodthroughtransmissionofsound

• mostareasymptomatic,aremanagedconservativelyandresolvespontaneously

o Ovariantorsion

TheUSappearancesarecomplexandmaydevelopovertime.Theyinclude:

• enlarged,congested,oedematousovary

• USappearanceofacomplexadnexalmass

• freefluidinthepelvis

• reducedperfusion

• complete,partial,transientocclusion

• ischaemia,infarction

o Haemorrhagiccyst

Ahaemorrhagiccystiscommonlyhomogeneousinitiallyandbecomesheterogeneousasclotisformed.

• maypresentwithpain

• mayrupturewithperitonealirritation

• USappearancevarieswithtime

• diffusehomogeneouslowlevelechoes

• maybeseptated

• clotretraction

o Endometriosis


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• isthepresenceofendometrialtissueatothersitesinthepelvis

• fragmentsofendometriumhavethesamemenstrualcyclechangesasthosenormallysited

• patientsmaysuffercyclicalmenstrualpain

o Endometriomas

USappearance:

• smooth,thickwalled‘cysts’

• homogeneousechotexture

• goodthroughtransmission/acousticenhancement

• filledwitholdblood

• noloculationsorsolidelements

• sameinternalechogenicitythroughoutthecyst.

• +/-otherdepositsofendometriosisinthepelvis

o Polycysticovariansyndrome(PCOS)

PCOSisasyndromeofovariandysfunctionalongwiththecardinalfeaturesofhyperandrogenismandpolycysticovary(PCO)morphology.PCOSremainsasyndromeand,assuch,nosinglediagnosticcriterion(suchashyperandrogenismorPCO)Issufficientforclinicaldiagnosis.

PCOScriteria:

• Oligo-and/oranovulation

• Clinicaland/orbiochemicalsignsofhyperandrogenism

• Polycysticovaryappearanceonultrasound

• Clinical manifestations may include: menstrual irregularities, signs of androgen excess (hirsutism,acne),obesity

USPCOcriteria:

• presenceof12ormorefollicles

• folliclesmeasuring2-9mmindiameter

• and/orincreasedovarianvolume(>10ml)(TheRotterdamESHRE/ASRM-sponsoredPCOSconsensusworkshopgroup(2003))

Ovarianmasses

Roleofultrasoundinsuspectedovarianmass:

NICE(2011)guidelinesstate,‘IfserumCA125is35IU/mlorgreater,arrangeanultrasoundscanoftheabdomenandpelvis‘https://www.nice.org.uk/guidance/cg122

• acombinationofthetransvaginalandtransabdominalroutesmaybeappropriatefortheassessmentoflargermassesandextra-ovariandisease

• useofcolourflowDopplerhasgenerallynotbeenshowntosignificantlyimprovediagnosticaccuracy


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• combineduseofthetransvaginalrouteincombinationwithcolourflowmappingand3Dimagingmayimprovesensitivity,particularlyincomplexcases

Pre-menopausal

Agreeallprotocolswithlocalclinicians

o Simplecyst/haemorrhagiccyst

• singlethinseptum<3mmorsmallcalcificationinthewall.Almostcertainlybenign.Nofollow-up

• >30mm-<50mm-Reportasalmostcertainlybenign.Nofollow-up

• >50mm<70mm-Reportasalmostcertainlybenign.?6monthlyfollow-up

• >70mm-Gynaereferral,tumourmarkers

o Complexmass

• benignconsiderdermoid,endometrioma,hydrosalpinx

• indeterminateorsolid-unclearnatureororigin

• multiplethinsepta,nodule-noflow

• malignant-thicksepta>3mm

• multilocular

• focalwallthickening

• papillarynodules(+/-vascularity)

• ascites

Post-menopausal(highrisk)

Agreeallprotocolswithlocalclinicians

• >20mm-Gynaereferral,tumourmarkers

• anyothercystorsolidmass,multilocular,focalthickening,nodules

• reportaspossiblymalignantInternationalOvarianTissueAnalysis(IOTA).Simplerules

IOTAgroupultrasound‘rules’canbeusedtoclassifymassesasbenign(B-rules)ormalignant(M-rules).SeeRCOGGreen-topGuidelineNo.62:https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg62/B-rules

• unilocularcysts• presenceofsolidcomponentswherethelargestsolidcomponent<7mm• presenceofacousticshadowing• smoothmultiloculartumourwithalargestdiameter<100mm• nobloodflow

M-rules• irregularsolidtumour• ascites• atleastfourpapillarystructures


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• irregularmultilocularsolidtumourwithlargestdiameter≥100mm• verystrongbloodflow

Ovariancancer;therecognitionandinitialmanagementiscoveredbyNICEguidelineCG122,April2011:http://www.nice.org.uk/guidance/cg122/resources/ovarian-cancer-recognition-and-initial-management-35109446543557

o Dermoid

• cysticteratoma

• tumourcomposedofanumberoftissues(remnantsofembryologicalcells)

• USappearanceiscystic/complex,withsolidcontentwithin.Someacousticshadowingmaybeevident

o Adnexae

fallopianTubes/ligaments/pelviccavity

• infection

• acutePelvicInflammatoryDisease(PID)-pyo/hydrosalpinx.Dilatedtubularstructureinlongitudinalsection(LS)

§ cog-wheelappearanceincrosssection

§ incompletesepta

§ debris/lowlevelechoes

Extendingtheexamination

The ultrasound practitioner may need to consider proceeding to an abdominal ultrasound examination whenindicated.Forexample,examiningthekidneysinthepresenceofalargefibroid(toexcludehydronephrosis)ortoconfirm/excludeabdominalasciteswhereacomplexovarianmasshasbeenseen.

Pelvicultrasoundreporting

Thereportshouldcontainthefollowinginformation:

• summaryofclinicaldetails;

• typeofexaminationperformedi.e.whethertransvaginaland/ortransabdominal;

• report,includingaconclusion.

Itmaybeusefultohaveastandardisedreportingformatfornormalgynaecologicalscanswhichincludestheorgansroutinelyexaminedandwhichisacceptabletotheimagingdepartmentandreferringclinicians.--------------------------------------------------------------------------------------------------------------------------------------------------------------ReferralforpostmenopausalbleedingClinicaldetails:Age57yrs.Approx.6yearspostmenopause–intermittentbleedingforonemonth.Trans-abdominalandtransvaginalscansperformedwithpatient’sverbalconsent. Theuterusisnormalinsizebutthereisa6mmx4mmpolypwithintheendometrium.Theendometrialthicknessis3mmandisdistendedby4mmoffluid.Nootherabnormalitydetected.Bothovariesareofnormalappearance.Conclusion:Endometrialpolyp,otherwisenormaluterusandovaries.ChaperoneMrsXXXX,ImagingAssistant,waspresentduringexaminationwithpatient’sconsent-------------------------------------------------------------------------------------------------------------------------------------------------------


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ReferralforpelvicpainwithpalpablemassClinicaldetails:25dayspostLMP.Irregularcycle4-6weeks.IntermittentpainandO/Epelvicmasspalpated.Trans-abdominalandtransvaginalscansperformedwithpatient’sverbalconsent. Anteverteduteruscontainingseveralsubmucosalfibroidsontheanteriorwall,thelargestofwhichisXmmindiameter.Ultrasoundappearancesofbothovariesarenormalwithacorpusluteumintheleftovary.ChaperoneMrsXXXX,ImagingAssistant,waspresentduringexaminationwithpatient’sconsent-------------------------------------------------------------------------------------------------------------------------------------------------------ReferralfordeepdyspareuniaClinicaldetails:LMP-unsure?sixweeksago.Irregularcycle.Complainsofdeepdyspareuniaoftwomonthsduration. Trans-abdominalultrasoundperformed-patientdeclinedatransvaginalscan.NormalanteverteduteruswithendometrialthicknessXmm.Ultrasoundappearancesoftheleftovaryandadnexaearenormal.Therightovarydemonstratesnormalultrasoundappearances.AdjacenttotherightovaryisacomplextubularstructuremeasuringYxYxYmmcontaininglowlevelechoes.SmallamountoffluidnotedinthePouchofDouglas.Theseultrasoundappearancesareconsistentwithpyosalpinxortubo-ovarianabscess.ChaperoneMrsXXXX,ImagingAssistant,waspresentduringexaminationwithpatient’sconsent2.8 ABDOMINALULTRASOUNDEXAMINATIONS

2.8.1 GeneralprinciplesDuring an abdominal ultrasound examination, the anatomical structureswhich the ultrasoundpractitionershouldnormallyexaminemustbeinaccordancewiththeclinicalinformationgivenandareshowninthefollowingtable.TABLE1:StructuresforAbdominalUltrasoundExamination

STRUCTURES EVALUATIONLiver Size,shape,contourandultrasoundcharacteristicsofallsegments,appearanceofintrahepatic

vesselsandducts,portahepatisandadjacentareas.Portalvenous,hepaticvenousandarterialsystems

Diaphragm Contour,movement,presenceofadjacentfluid,masses,lobulationsLigaments Appearanceoffalciformligament,ligamentumteresandvenosumGallbladder Size,shape,contourandsurroundingarea.Ultrasoundcharacteristicsofthewallandthenature

ofanycontentsCommonduct

Maximumdiameter and contents; optimally it shouldbe visualised to theheadofpancreas

Pancreas Size,shape,contourandultrasoundcharacteristicsofhead,body,tailanduncinateprocess;diameterofmainduct

Spleen Size,shape,contourandultrasoundcharacteristicsincludingthehilum.Assessmentofsplenicveinbloodflowandpresence/absenceofcollateralvessels

Aorta Diameter,courseandbranchesincludingthebifurcation,appearanceofitswalls,lumenandpara-aorticregions

IVC Patency,diameter,appearanceofitslumenandpara-cavalregionsAdrenals Notroutinelyviewedbutanyapparentabnormalityofsizeandultrasoundcharacteristicsshould


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Duringtheexaminationtheultrasoundpractitionershoulddemonstrate:

• normal anatomy/variants of abdominal organs and structures including age-related appearancesofeachorganinatleasttwoplanes.(Thisshouldincludeassessmentofsize,outlineandultrasoundcharacteristics);

• pathologicalfindingsincludingfocalanddiffuseprocessesandassociatedhaemodynamicfindings

(pre-andpost-operativeassessments);• thepresenceofanyintra-abdominalfluid,focalfluidcollectionsormasses;

• whenclinicallyrelevant:vascularanatomyincludingposition,courseandlumenofrelevantvessels

(haemodynamicobservationsincludingthepresence/absenceofflow,itsdirection,velocityandDopplerwaveform).

Theultrasoundpractitionershouldbeabletotailortheexaminationaccordingtotheclinicalpresentation,andtheemphasisoftheexaminationoftheabdominalstructuresmaybealteredaccordingtotheclinicalscenarioandpatienthistory.Sufficientclinicalinformationshouldbesuppliedwiththerequest,togetherwitheitheraworkingdiagnosisoraspecificclinicalquestiontobeanswered(ref:BMUSGuidelinesonJustificationofUltrasoundRequests(2015)www.bmus.organdsection2.5ofthisdocument).

Accesstopreviousimagingandreportsshouldbeavailable.

Allabdominalorgansshouldbeexaminedintwoplanesielongitudinalsection(LS)andtransversesection(TS)withadditionalviewsasrequired.Thepurposeofthescanistosurveytheentireorganifpossiblewithrepresentativeimagesofnormalityandanypathologybeingtaken.Theimagesshoulddocumentallabnormalfeaturesmentionedinthereport.

UpperabdominalexaminationsAsurveyshouldbeperformedoftheliver,gallbladder,commonbileduct,pancreas,spleen,kidneys,IVC,aortaandpara-aorticareas.Bothhemidiaphragmsshouldbeexaminedandanyfluidmentioned.Leftsidedowndecubitus,leftposteriorobliqueandintercostalsurveysoftheliverandbiliarytreeareessentialiftheentireorganistobeevaluated,asthesepositionsallowsaccesstoareasofthelivernotseeninthesupineposition.Excludethepresenceoffreefluidintheupperabdomenbeforeturningthepatient.

benotedKidneys Size,shape,positionandorientation,outlineandultrasoundcharacteristicsofcortex,medulla,

collectingsystem,mainandintra-renalarteriesandveinsUreters Assessmentofthepresence/absenceofdilatation/reflux/uretericjetsUrinarybladder

Appearance of wall and contents.Assessment of volume pre- andpost-micturition

Prostate SizeandshapeGastro-intestinaltract

Wall thickness, contents, diameter of lumen, motility, presence/absenceofmasses

Otherstructures

Whererelevantinclude:omentum,muscles,abdominalwall,possiblehernias,lymphnodessitesforpotentialfluidcollection(includingupper/lowerabdomenandthethorax)

Proceedtoexaminationofthepelviswherenecessary(Refertogynaecologysection)


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Theintestinesarepartoftheabdominalcavityandgassybowelhastypicalpatternswhichshouldberecognisedbyexperiencedoperators.Bowelpatternsshouldbeimagedwherepossible.

Theabdominalultrasoundexaminationisinevitablyaclinicalexaminationandanytendernessduringascanshouldbenotedandstatedinthereport,indicatingwherepossiblewhetheritisorgan-specificordiffuse.TheabsenceoftendernessshouldalsobedocumentedwhererelevantegsonographicMurphy’ssignisnegative.

Reportingofabdominalexaminations

Generalprinciplesofreportingapplyandreferenceismadetothereportingsectionofthisdocument,section2.6.

Sampleabdominalultrasoundreports

Outlinedbelowaresamplereportsforvariouscommonclinicalscenarios.Theseareprovidedasguidancewithanaimofstandardisingandimprovingreportingskillsinthisimportantfieldofpractice.---------------------------------------------------------------------------------------------------------------------------------------------------Upperabdominalpain

Clinicaldetails:RUQpainwithoccasionalvomitingandfattyintolerance.?gallstones.

Abdominalultrasound:Normalliver.

Thegallbladderistender,hasathickened,oedematouswallandcontainsseveralstones.TheCBDisdilated-9mm-butthelowerendoftheductisnotdemonstratedduetooverlyingduodenalgas.Nointrahepaticductdilatation.

Thepancreasispoorlyvisualised,despiteawaterload.

Normalspleen,bothkidneysandabdominalaorta.

Conclusion:Acutecholecystitiswithgallstonesandadilatedcommonbileduct.ThelowerendoftheductisnotseenandMRCPisadvisedasthenextstep.------------------------------------------------------------------------------------------------------------------------------------------------------Painlessjaundice

Clinicaldetails:Painlessjaundice.Bilirubin400µmol/L

Abdominalultrasound:Thereisintrahepaticductdilatationaroundtheportahepatisandintotheleftlobeofliver.

Thegallbladderisnon-tenderandcontainssomesmallstones.

TheCBDisdilated–10mm-downtotheheadofpancreas,wherethereisa20mmmass.Thepancreaticductdistaltothemassisalsodilatedat3-4mm.

Althoughnoliverlesionsareseenonthisbaselinescan,anon-contrastscandoesnotexcludethepresenceofmetastases.

Noascitesorperi-pancreaticfluiddemonstrated.

Conclusion:20mmmassintheheadofthepancreascausingbiliaryobstruction.Thisislikelytobemalignant.UrgentCTisadvisedforstaging.ReportfaxedtoreferringclinicianorPancreaticMDTinformedor.... ------------------------------------------------------------------------------------------------------------------------------------------------------Chronicliverdisease

Clinicaldetails:Knownchronicalcoholicwithlivercirrhosis.Forsurveillance

Abdominalultrasound:Thereisa1.5cmnoduleinsegment6,whichisanewfindingsincethepreviousscanofx/x/x.


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Theportalandsplenicveinsremainpatentwithhepatopetalflowandtherearevaricesaroundthesplenichilumwhichhaveincreasedsincethepreviousexamination.

Splenomegaly-15.5cm.

Noascites

Comment:Anewliverlesionsuspiciousforhepatocellularcarcinomaispresent.AnurgentMRIisrecommended.

Relevantclinicalteaminformed---------------------------------------------------------------------------------------------------------------------------------------------------Palpablemass

Clinicaldetails:RUQpainfor5months.Palpablemassintherightflank,althoughpatientdifficulttoexamine.

Abdominalultrasound:Normalliverwithnofocallesions.

Thegallbladderhasathickenedoedematouswall,istenderandcontainsseveralstones.Thecommonbileductisnormalincalibre–6mm-butcontainsatleasttwosmallstonesatthelowerend.

Theheadandbodyofthepancreasarenormal,buttherearelimitedviewsofthetailduetobodyhabitus.

Normalappearancesofbothkidneys,spleenandabdominalaorta.

Conclusion:Cholecystitiswithstonesinthecommonbileduct.ERCPisrecommended.-------------------------------------------------------------------------------------------------------------------------------------------------------Liverlesionassessment

Clinicaldetails:focalliverlesiononCTscan.?nature

Abdominalultrasound:ArecentCTKUBdemonstratesa4cmliverlesioninsegment6.Thisisconfirmedonultrasoundtobeahyperechoicsolidlesion.Nootherliverlesionsarepresent.

2mlsofSonovuecontrastagentadministered.Noknowncontraindications.

Thelesiondemonstratesperipheralnodulararterialenhancementwithrapidcentripetalfillingandgoodcontrasttake-upinthesinusoidalphase.Conclusion:Benignincidentalhaemangiomaofnoclinicalsignificance.Theliverisotherwisenormal.----------------------------------------------------------------------------------------------------------------------------------------------------Abnormalliverfunctiontests(LFTs)

Clinicaldetails:PalpableliveredgewithabnormalLFTs,H/Oalcoholabuse.Smoker.

Abdominalultrasound:

(Additionalinformationfrompatientrecords:ASTxxx,ALTxxx,Bilixxx)

Fattyliverwithseveralareasoffattysparinginsegments4and8.Therearenofocallesionsbutthelivertextureisdiffuselynodularandthelivercapsuleisirregular.

Thenon-tendergallbladderiscontractedandcontainsseveralstones.Nobiliaryductdilatation.

Enlargedspleen-16cm.

Patentportalandsplenicveinswithhepatopetalflow.

Normalpancreas,bothkidneysandabdominalaorta.

Conclusion:Probablecirrhosiswithsignsofportalhypertension.Referraltoahepatologistisrecommended.-------------------------------------------------------------------------------------------------------------------------------------------------------


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2.8.2 Ultrasoundexaminationoftheliver

Theliverisalargeorganandcompleteexaminationrequiressupine,subcostalandintercostalaccess,supplementedbyrepeatingintheleftlateraldecubitus/leftposteriorobliquepositionsinordertocovertheentireorgan.

Imagingshoulddocumenttheliversize,parenchymalechotextureandthesurface.

Size

Livermeasurementshavebeencontroversialasalterationsinlivervolumemaynotbereflectedinisolatedmeasurements.However,therecommendedmeasurementisfromapexoftheliverundertherighthemidiaphragmdowntothetipoftherightlobe(fromanapproximatelymidclavicularprobeposition).

Thenormalrangevarieswithpatientsize(especiallyheight)andincongenitalvariationsofliversegments.

Ruleofthumb:

<15cm=normal

>16cm=enlarged

15-16cm=borderline(unlesspreviousimagingavailableforcomparison)

Earlyenlargementmaybemoresensitivelyidentifiedbythebluntingofthefreeinferioredgeoftherightliverwhichinhealthisasharppoint.

Variationinsizeandpositionofliversegmentsshouldbedocumentedegenlargementofthecaudate(segment1)inestablishedcirrhosis.

Echotexture

Theliverisminimallyhyperechoicorisoechoiccomparedtothenormalrenalcortex.

Whereabnormalityissuspected,ordiffuseliverdiseaseistheclinicalindicationforthescan,thenasplitscreencomparisonimageofliver/kidneyandspleen/kidneyshouldbetaken.Thisimprovesstandardisationoftheassessmentofliverechotexture.

Wherethelivertexturesuggestssteatosis(fattychange)thenthefollowingassessmentsshouldbespecificallymade:

• lossofsignalindeepliverduetoincreasedattenuation;• lossofprominenceofintrahepaticportalveinbranchwalls;• alteredliversurface(steatosisandfibroticchangeoftencoexist);• colourandpulsewaveDoppleranalysisofportalandhepaticveins.

Liversurface

Subtlealterationsinlivertexturemaybeconfirmedifthelivercapsulecanbedemonstratedtobeirregularratherthansmooth.Imagesoftheanterioraspectoftherightlobeshouldbeacquiredintercostallywithahighfrequencylinearprobe.Aleftsidedowndecubituspositionand/orleftposteriorobliquepositionmaybehelpful.Livervesselsandbloodflow

ImagesshouldroutinelyincludethehepaticveinsdrainingintotheIVCandtheportalveinattheliverhilum.Ifthelivertextureisdiffuselyabnormal,includingdiffusefattyinfiltration,orifportalhypertension/orchronichepatitisismentionedontherequest,thenDopplerstudiesoftheportalveinandhepaticvenouswaveformshouldbeobtained.Recordthepeakvelocityandthedirectionofflowintheportalvein(PV)andthehepaticvein(HV)waveformpattern.Normalrangeofpeakvelocityinthemainportalveinis12-25cm/s.Thiscanbe


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significantlyraisedinsomepatientsbutthisisofnosignificanceexceptinlivertransplantswhereitmayindicatevesselstenosisandneedsreportingifabove40cm/s(meanflowvelocity).Normalwaveformofhepaticveinsshouldbetriphasic.Biormonophasicflowindicatesalossoflivercompliance(reportaslossofelasticitytoGPs)butthisisaverynon-specificsignwhichisalsopresentinotherconditions.Theuseofelastographyisusefulinassessingtheliverstiffness.AsectiononElastographyhasbeenaddedtothisDecember2016firstrevision(section2.13).HighlypulsatilewaveformsinbothoreithertheportalveinorselectedhepaticveinisindicativeofcongestivecardiacfailureandthisshouldbereportedasmaybesuggestiveasacauseofabnormalLFTs.Seealso:https://www.nice.org.uk/guidance/ng122.8.3 ImagingofthegallbladderandbiliarytreeThegallbladderisnormallysituatedinferiortotherightlobeoftheliver.Itssizeandshapevary.Thegallbladderneckusuallysitsinthegallbladderfossaandthefundusisfrequentlymobile,dependentuponpatientposition.Thegallbladdershouldbescannedfollowingaperiodoffasting(drinkingclearfluidsonly)inordertodistendit.Itshouldbeexaminedinatleasttwopatientpositions-forexamplesupine,leftsidedowndecubitus,leftposteriorobliqueand/orerect-inordertoestablishmovementofanycontentsandtounfoldtheorgan.Itisgoodpracticetoexaminethegallbladderbothalongitslongandtransverseaxes.Theshapeandmeasurementsofthegallbladdervaryenormously.Thegallbladderisnormallypear-shapedwhenoptimallydilated,withanarrowneck,wideningtowardsthefundus.Averyroundedshapemayimplytensedilatation.Somegallbladdersmaybefolded,orhaveaPhrygiancapatthefundus.Theseshapescanconcealsmallstonesifcareisnottakento‘unfold’theorganandexamineitcomprehensively.Thewalloftheneckofthegallbladderisslightlythickerthanthewallofthebodyandfundusinanormalorgan.Frequentlytheneckdescribesa‘J’orreversedJshape,andparticularattentionshouldbepaidtothisareatoexcludepathologysuchastrappedstones.Thebilecontainedinthegallbladdershouldbeecho-free.Thewallshouldbethin(nomorethan3mm),smoothandwell-defined.Measurementsofwallthicknessshouldideallybetakenwiththewallperpendiculartothebeaminordertoreduceartefactduetobeamthickness.InpatientsattendingwithRUQpain,thetransducermaybeusedtogentlyexploretheexactsiteofthepain.Thisinformationmaybeusefulinconfirmingadiagnosisofcholecystitis.Gallstonesarefrequentlyasymptomaticsoitshouldnotbeassumedthatthefindingofgallstonesestablishesthecauseofpainandafullscanshouldalwaysbeconducted.Attentiontoequipmentsettingsisimportantindemonstratingtinystones,asposteriorenhancementfromthebilewithintheGBmayobscureshadowingfromsmallstonesifincorrectlyset.Ahighfrequencyisusefulforanteriorgallbladders.

Biliaryducts

Thecommonductnormallyliesanteriortothemainportalveinandisbestimagedusingtheliverasanacousticwindowatthispoint,withthebeamperpendiculartothevein.Theductshouldthenideallybetraceddistallytotheheadofpancreas,(allowingforduodenalgas,whichcansometimesbemovedbyalteringpatientpositionand/orgentlepressurefromthetransducer).

Thenormalcommonductshouldhaveadiameteroflessthan6mmintheadult,butthiscanincreaseinthepost-cholecystectomypatientandinanolderadultduetolossofelasticityoftheductwall.Themeasurementparametersquotedherearewithcallipersplacedinnerlumenwalltoinnerlumenmeasuredattheportahepatis.


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Theductmeasurementsshouldbetakeninclinicalcontextwithreferencetoprevioushistory,includingpreviouscholecystectomy,andliverfunctiontests.Inductswithluminaldiametersover6mm,assessmentofintrahepaticbiliarydilatationshouldbemade.Intrahepaticductdilatationisanabnormalfinding.

Aductofover6mmdiametershouldbeconsideredabnormalinasymptomaticpatientofanyageandeveryeffortmadetoexaminethelowerendforthecauseofobstruction.Recentstonepassagewillalsoleavetheducttemporarilydilated.AdilatedductshouldalwaysbecorrelatedwiththeLFTsandclinicalhistory.Itisworthnotingthataduct<6mmdiameterdoesnotnecessarilyimplynormality.Obstructioncanoccurwithanon-dilatedduct,particularlyifdiffuseliverdiseasepreventsdilatationorifthepatienthascholestaticdisease.

Ductwallthickeningisanabnormalsign,evenintheabsenceofdilatation,andisfrequentlyassociatedwithcholangitisorcholestaticdisease.

Itisdifficulttodemonstratenormalintrahepaticductspastthefirstorderofduct(rightandlefthepaticducts)buttheycanbeseeninyoung,thinpatientswithgoodequipmentandshouldnotbeconfusedforintrahepaticductdilatation.Comparisonshouldbemadewiththeaccompanyingveins.Inhealth,thebileductisnarrowerthantheparallelportalvein.

Incasesofintrahepaticductdilatation,effortsshouldbemadetoestablishthecausebytracingthesystemdowntothepointofobstruction.Isolatedsegmentsofintrahepaticductdilatation,withanormalcalibreextra-hepaticbiliarytree,raisesthepossibilityofseriousdiseasesuchasprimarysclerosingcholangitis(PSC)orcholangiocarcinoma.MRIisusefulinfurtherevaluation.

2.8.4 Transabdominalultrasoundofthepancreas

CTandMRIaretheprincipalimagingmodalitiesforassessingthepancreas.

Conventionalultrasoundstillhasasignificantfalsenegativeratefordetectingseriouspancreaticdisease.However,whenthepancreasiswellseen,ultrasoundmaygivebetterdetailthanCTandMRI.

Whileultrasoundscanningcanimagethepancreascompletelyinexquisitedetailunderoptimalconditions,theresultisoftendisappointingandthepublishedperformancedataforultrasoundinthedetectionoftreatablepancreaticcancerandchronicpancreatitisistoopoortorecommenditasafirstlinetechnique.

However,itisexpectedthatthepancreaswillbescannedfullyinallgeneralupperabdominalexaminations.Theentireglandshouldbeimagedinacombinationoftransverse,longitudinalandobliqueviews.

Thepancreasisslightlyhyperechoiccomparedwiththeliverandthisgenerallyincreaseswithage-associatedlossofglandularelementsandincreasingfibro-fattyproliferation.Thesizeofthepancreasisvariableandisnotroutinelymeasuredinpractice.Asruleofthumb,ifmeasurementsarerequired,themaximumantero-posteriormeasurement(scannedtransversely,presumably,alongthelengthofthepancreasthusmeasuringtheAPthicknessofthepancreas)oftheheadofpancreasisabout3.0cmtheneckandbody2.5cmandthetail2.0cm.Themainpancreaticductcanusuallybeidentifiedandmeasuredinthepancreaticheadorbody.Apancreaticductdiameterof2mmorlessisnormalbutsomeincreasewithageisassociatedwithglandatrophyuptoamaximumof3mm.Diffusepancreaticenlargementoratrophy:Changesinpancreaticvolumearedifficulttoassessasthehead,bodyandtailshowsignificantvariation.Ifstatementsaboutchangesinsizearemadetheseshouldbeaccompaniedbymeasurements(takenAPperpendiculartothemainpancreaticduct).


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Vettingultrasoundrequestsforpancreaticimaging(seealsosections2.4,2.5)Forthereasonsgivenabove,CTorMRIareusuallythemostappropriatefirstlinemodalitiesforsuspectedpancreaticcancerorchronicpancreatitis.RequestsforUSunderthesecircumstancesshouldbebroughttotheattentionofaradiologistwhowilldecideifCTorMRIismostappropriate.Highqualityultrasoundimagingofthepancreasisappropriatefornon-specificindicationssuchasepigastricpain.Butadditionalreferencestolossofappetiteorweightlossshouldbeinterpretedasindicatorsofsuspectedcancerandmanagedaccordingly.Scanningtechnique

Theadequacyofthescanwillbedependentongoodtechniqueasmuchasbodyhabitus.Improvingaccessthroughtheseobstacleswilldependuponpatientpreparation(4-6hrsfastingtoreducebowelgas),useofgradedcompression,supplementingsupinescanningwithdecubitusorerectpositions,andtheexperience/determinationoftheoperator.

Techniqueadjustmentsroutinelyusedbyexperiencedultrasoundpractitionersinclude:

1. usingtheleftlobeofliverasanacousticwindowinsuspendedinspiration;2. scanningindecubitusanderectpositions;3. intercostalscanningthroughthespleentoimagethepancreatictailatthesplenichilum;4. givingwaterorallytocreateanacousticwindowinthegastricantrum.

Acquiredimages

Thetexture,sizeandcontourofthepancreasshouldbeevaluated.Thepancreaticduct,distalcommonbileduct,splenic/superiormesenteric/portalveinsandthecoeliacaxis/superiormesentericarteryshouldbeidentified.Thehead/uncinateprocess,neck,bodyandtailofthepancreasshouldbeidentified.Thepancreatictailmaybebestdemonstratedcoronallythroughthespleen,andpartofthetailmaybeseenanteriorlythroughthegastricbody/fundus.Thediameterofthepancreaticductshouldbeassessed.Apancreaticductdiameterof2mmorlessisnormalbutsomeincreasewithageisassociatedwithglandatrophyuptoamaximumof3mm.Itisimportanttodocumentanyfocaldiffusechangeinechogenicityorductcalibre.Thepresenceofparenchymalatrophyshouldbenoted.Ifultrasounddoesdemonstratesuspectedinflammationoramass,itisusefultouseDopplertoverifythepatencyofthesplenicandportalveins.Reportingimages

Generalprinciplesapply.Reportsshouldbebrief,clearandtothepoint.Allmeasurementsshouldbeaccompaniedbynormalranges.Allevaluationsofchangesinsizefromnormalshouldbeaccompaniedbymeasurements.

Theterm‘normal’shouldnotbeappliedwhentheentireorganhasnotbeenexamined.

2.8.5 Imagingofthespleen

Thespleenisahomogenousorganwithasmoothechotextureandborder.Itishypoechoiccomparedtotheliverbuthyperechoiccomparedtothekidney.AusefulacronymtorememberechogenicityofthemajorabdominalorgansisPLiSK,rangingfromthemosthyperechoic(thepancreas)tothemosthypoechoic,(thekidneys)


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PLiSK1

Pancreas Liver Spleen Kidney

Hyperechoic Hypoechoic

Size

Thespleencanvarygreatlyinsizeandthenormalrangeisfrom5cmto12cm.Asaruleofthumb,thespleenlengthshouldbethesameorlessthantheleftkidney,assumingthekidneyisnormal.Thereforeinapatientwith9cmkidneys,aspleenlengthof12cmshouldbeconsideredenlargedandreportedassuch.Smallspleensarerarelycommenteduponandareofdoubtfulsignificance.

Measurementparameterscanvary.Itisimportantthereforetoestablishanagreedcalliperplacementwithintheteamofultrasoundpractitionersreportingthestudies.Acommoncalliperplacementparameteristhesuperior-medialbordertotheinferior-lateraltip.Howeverthespleenmayalsobemeasuredfromthesuperioraspectofthedomeofthelefthemi-diaphragmtotheinferior-lateraltip.

Carefulassessmentofthesplenichilumshouldbemadeasthisisacommonareaforsplenunculitodevelop.Asplenuculuswillbeofthesamesmoothandhomogenousechotextureasthespleenitselfandisnotpathological.Itisvaluabletoreporthoweverasinpatientswhohaveasplenectomyandco-existingsplenuculiarecommonlyreportedtohypertrophyandreplacethenativespleen

Commonpathologies

Splenomegaly

Themostcommonpathologicalconditionofthespleenissplenomegaly.Thiscanoccurduetoportalhypertension,haematologicalconditionsorunderlyinginfection.Correlationwithotherultrasoundfindings,previousmedicalhistoryandthepatient’sclinicalpresentationisrequired.

ThepresenceofsplenomegalyshouldleadthepractitionerontoassessingthehepaticperfusionwithDopplerassessmentoftheportalandhepaticveins.Assessmentofthesplenicvasculatureisrequiredtoevaluatethepresenceofvaricescommonlyassociatedwithportalhypertension.Inseverecasesspleno-renalvaricesandshuntsmaydevelop.

Trauma2

Thespleenisthemostfrequentlyinjuredintra-abdominalorgan.Ultrasoundisarapid,non-invasiveimagingmodalityandfocusedabdominalsonographyfortrauma(FAST)isanacceptedmethodforevaluatingtheunstableblunttraumapatientspresentingintheemergencydepartment.However,contrast-enhancedCTremainsthegoldstandardforevaluatingsplenicinjury,aswellasinjuryelsewherewithintheabdomenorchest.

SolitaryLesions2

Appearance Likelydiagnosisandcomments

Cysts Well-defined,thin-walled,anechoiclesions

Epidermoidcystshavecalcifiedwallsin10%ofcases

Hydatidcystsmaybeanechoicorofmixedechogenicityduetothepresenceofhydatidsandorinfoldedmembranes.Multiple,small,internalorsubjacentdaughtercystsmayarise

Haemangioma Well-circumscribedhyperechoiclesion

Usuallysolitary.MultiplelesionsmaybeassociatedwithKlippel–Tre´naunay–Weber,Beckwith–WiedemannorTurnersyndrome.


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Largelesionsmayresultinportalhypertensionorsplenicrupture

Lymphangiomas Complexsolid-cysticlesionwithahyperechoicperiphery

Rare,slow-growing,vascularlesionsthatmaybesingleormultiple

Infarction Ill-defined,oftenperipherallybased,wedge-shapedorroundedhypoechoiclesion

Maybedifficulttoidentifywithultrasoundintheacutesetting.Contrastenhancedultrasoundimagingcanaiddiagnosis.

MultipleLesions2

Appearance Likelydiagnosisandcomments

Infection Illdefined,hypoechoiclesions,whichmaycontainechogenicdebrisandinternalseptations

Splenicabscessesoccurmostfrequentlyinimmunocompromisedpatients,andmaybebacterial,fungalorgranulomatous.

“Spotty“Spleen Multiple,small(2–3mm),highlyechogenicfociwithorwithoutacousticshadowingandmaycorrespondtocalcifiedlesionsseenonplainfilmorCT

Multiplehighlyreflectivefocallesionswithinthespleengivesrisetotheso-called‘spottyspleen’appearance.Itisusuallysecondarytopreviousgranulomatousinfectionwithhistoplasmosisortuberculosis

Lymphoma Multipleill-definedandhypoechoic,however,hyperechoiclesionsofacomplexnatureandtargetlesionshavealsobeendescribed

Hodgkin’sandnon-Hodgkin’slymphomaaccountforthemajorityofsplenicmalignancies

Metastases variableappearance,rangingfromhypoechoicpoorly-definedlesionstohyperechoiclesions,withorwithoutahypoechoicrimorhalo

Uncommonsiteformetastaticdisease.Thecommonestprimarytumoursaremalignantmelanoma,breastandbronchogeniccarcinoma.

CTremainsgoldstandardforimagingmetastaticdisease

Sarcoidosis Multiplehypoechoicnodulesmeasuringuptoseveralcentimetres.

Hepatosplenomegalyandlymphadenopathyarecommonassociatedfindings.

Multisystemgranulomatousdiseaseofunknownoriginandsplenicinvolvementisrelativelyuncommon

MalignantInfiltration

Splenomegalywithnodiscerniblealterationsinsplenicechotexture

Diffuseleukaemicorlymphomatousinvolvementofthespleen.Clinicalcorrelationisrequired.Dopplerevaluationoftheportal


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veinmaybevaluable

References

1) Altyetal(2006)PracticalUltrasound:AnIllustratedGuide,CRCPressWalshetal(2005)APictorialReviewofSplenicPathologyatUltrasound:PatternsofDisease,Ultrasound,13(3)Downloadedfromult.sagepub.comatBMUSmemberaccessonSeptember18,2016References

2) Altyetal(2006)PracticalUltrasound:AnIllustratedGuide,CRCPress3) Walshetal(2005)APictorialReviewofSplenicPathologyatUltrasound:PatternsofDisease,Ultrasound,13

(3)Downloadedfromult.sagepub.comatBMUSmemberaccessonSeptember18,2016

2.8.6Ultrasoundofthebowel

Bowelsymptomsareacommoncauseforpatientspresentingtotheirdoctorsandbeingreferredforimaging.

Suspectedacuteappendicitis(AA),diverticulitisandinflammatoryboweldisease(IBD)areamongthecommonconditionswhereultrasoundcanandshouldmakeamajorcontributionindiagnosisanddiseasemonitoring.

Ultrasoundtechnique

Afterasixhourfast,thesmallbowelisquietwithreducedbowelgas;nootherpreparationisrequired.

Ageneralabdominalcurvilinearprobeisusefultoquicklyassessthelayoutoflargeandsmallbowel.Particularattentionshouldbegiventodeeperrecesses(e.g.rectovesicalpouch)whichareinaccessibletothehigherfrequencyprobesusedfordetailedinterrogationofthebowelwall.

Theboweldiseasesofinterestarethosewhichthicken/enlargebowel,anddisplacebowelgas/faecesmakingthemstandoutagainstnormalbowelsegments.

TOPTIP:Inflamedboweliseasiertoidentifythannormalbowel.

Focalbowelmasses,segmentsofwallthickening,ordilatedloopsmaybeapparentevenatlowerfrequenciesbuthighfrequencyprobesareessentialtocharacterizechangesinthelayersofthebowelwall.

Fortunatelythecommonboweldiseasesmostfrequentlyinvolvebowelsegmentslyingintheiliacfossaewhicharerelativelyclosetotheanteriorabdominalwall(2-5cms)andaccessibletohigherfrequencyprobes.

TOPTIP:UseHigherfrequencylinearprobes.

• thehigherfrequencythebetter• 2-3focalbandsclosetogetherinthetargetzone• harmonicsON• edgeenhancement• minimalcompounding• gradedcompression

Pressureappliedtotheintestinesisuncomfortable.Complainingofdiscomfortisnotanindicatorofdisease,thoughpatientswithIBSmaybeparticularlysensitive.

Agradualprogressiveincreaseinpressureappliedbringstheprobeclosertothebowel,displacingbowelgasandoverlyingbowelloopsandassessingthecompressibility/rigidityofnormalandabnormalbowelloopsandmesentericfat.

TOPTIP:UseLeftdecubitusscanning.


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Thecaecumandappendixareonavariablelengthmesenterywithsomefreedomofmovement.Decubitusscanningisroutinelyrecommendedasoverlyingloopsmayfallawayandthecaecumpositionadjuststorevealtheappendix.

Inthispositionthe“retrocaecal”appendixisoftenaccessible.

TOPTIP:Use“Mowingthelawn”technique

Surveyingtheentireintestinewithintheabdominalcavityrequiresasystematictechniquesuchastheuseofoverlappingverticalsweepsofahighfrequencyprobeupanddowntheabdomenlikealawnmower.

Normalbowel-ultrasoundfeatures

Theultrasoundappearanceofthebowelwalllargelyreflectstheanatomicallayeringandcomprisesfivealternatingbandsofhigherandlowerechogenicity.Theouterandinnerbrightbandsareextremelyfineandmaynotbeseen.

1. superficialmucosa(finebrightline)2. deepmucosaincludingthelaminapropria(grey)3. submucosa(bright)4. muscularispropria(dark)5. serosa(finebrightline)

Abnormalbowel-ultrasoundfindings

Oncetheappendixorasuspectbowelsegmenthasbeenidentified,thefollowingaspectsshouldbeassessed:

• wallthickening• alteredwalllayers• bowellumen• bowelplasticity/mobility/peristalsis• alteredbloodflowbloodflow• extramuralmesenteric/interloopchanges

WallthickeningThickeningofthebowelwallisthefeaturemostcommonlyidentifiedandmeasurementsshouldbetaken.Stomachwallisthickest(~<7mm).Largeandsmallbowelwallisusually<3mm.>4mmisdefinitelyabnormal.Thickeningmaybeduetothepresenceofoedema,haemorrhage,inflammation,tumourgrowthorinfiltration.Alteredbowelwalllayers(gutsignature)Dependingonthediseaseprocess,thegutsignaturemaybepreserved,exaggerated,distorted,diminishedorobliterated.

Bowellumen

Commonlywhenthebowelwallisthickened,thebowellumeniscompromised,becomingnarrowedorstrictured.Howeverultrasoundmayidentifyadilated,fluid-filled,obstructedappendix.Intheabsenceofclinicalorsonographicevidenceofacuteinflammation,thismaybeamucocele.

Bowelplasticity/mobility/peristalsis

Mostdiseasescausestiffeningoftheaffectedbowelsegmentwithreducedorabsentperistalsis.


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Alteredbloodflow

Asarule,Dopplersignalsarenotevidentinhealthybowelwall.Withacuteinflammation,vascularityincreasesanddots,linesandbranchesofvesselscanberecordedinthewall(mainlysubmucosa)andintheadjacentmesentery.

Extramural/mesentericchanges

Bowelwalldiseasemayextendtoinvolveperi-intestinalstructures,adjacentloopsorsolidorgans.Aroundinflammatorybowellesions,collectionsandabscesses,mesentericfatbecomesoedematous(swollenandhyperechoic)displacingadjacentstructures.

Ultrasoundofthenormalappendix

Thenormalappendixiselusive.Itvariesgreatlyinsize(averagelength8cm;range1-24cm)andposition(pelvic/descendingandretrocaecalbeingthemostcommon).AtTAUStheappendixisidentifiedasathin,blind-endingtube,withanormalgutsignature,incontinuitywiththecaecalpole,arisingapproximatelytwocentimetersfromtheileocaecalvalve.

Theappendixwallhasthesamelayeredstructureastheotherpartsoftheintestineandthesamethicknessof<2mm.Thelumeniscontinuouswiththecaecumviaasmallerorifice.Gas,fluid,semisolidresidueandappendicolithsareoftenseeninthenormalappendixlumen.Howeverobstructionoftheorificeisacommoncauseofappendicitis.

Acuteappendicitis(AA)

Sonographicsigns:

• localtenderness• wallthickening>2mm• walllayersmaythickenatfirst,thenbelostintransmurallowechos• thelumenmaydistend• themaximumouterdiameter(MOD)includesthetwowallsplusthelumen.AMODof>6mmdoesnot

meanappendicitisbutaMODof<6mmmakesAAunlikely.• HypervascularonDoppler• mesentericoedema:theinflamedappendixmaybesurroundedbyhyperechoicswollenfat.• loculatedperiappendicealfluidsuggestsimminentoractualperforation

Appendicolithsarefrequentlyidentifiedinasymptomaticpatientswithotherwisenormalultrasoundappearancesandarenotareliableindicatorofinflammation.

TOPTIP:InfocalappendicitistheMODmaynotexceed6mmandthediagnosismaybemissediftheentireappendixisnotvisualized.

Theperforatedappendixisevenmoredifficulttofindbutmaymostreliablybeidentifiedbylossofthehyperechoicappendicealwalllayer(indicatingtransmuralinflammation)andloculatedperiappendicealorpelvicfluidcollections.

Theappendixmaylielowinthepelvisorbeobscuredbybowel.Ifanormalappendixisnotidentifiedorasonographicdiagnosisofacuteappendicitisorconvincingalternativediagnosismade,furtherimaging(CT)isindicatedinatimelyfashon.


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Diverticulitis

USfeaturesofdiverticula

Diverticulaappearasbright“ears"outsidethebowelwallwithacousticshadowingduetothepresenceofgasorinspissatedfaeces.Athigherprobefrequencies,athinneddiverticularwallmaybedemonstratedwithareducedgutsignatureowingtotheabsenceofmuscularispropria.Theneckofadiverticulummaybeidentifiedasanechogenicbandtraversinghypoechoiccircularmusclewhichisoftenthickened.

Aninflameddiverticulumisidentifiedasanenlargedechopoorprotrusionfromthecolonwall,withanill-definedmarginsurroundedbyechogenicnon-compressiblefat.Thegutsignatureisobliteratedbytheinflammation.Inspissatedfaecesmaybeseenasacentralshadowingechogenicity.

InflammationwillcommonlyextendalongthebowelproducingasymmetricalorcircumferentialhypoechoicmuralthickeningthatmaybehyperaemiconDopplerscanning.Anintramuralorpericolicabscessmaybeidentifiedasananechoiccollectionthatmaycontainpocketsofairordebris.

2.9 Imagingoftheuro-genitalsystemincludingtestesandscrotum

Commonclinicalscenarios

Haematuria

Theultrasoundpractitionershouldestablishwhetherhaematuriaismicroscopicormacroscopicandbeawareoftheplaceofultrasoundinthediagnostictestingofapatientwithhaematuria.Theinvestigationofhaematuriamaybebestperformedinthecontextofadedicatedhaematuriaclinicaccordingtolocalpractice.Bothkidneys,ureters(ifvisible)andurinarybladdershouldbeassessed.

Lookforrenallesions,hydronephrosis,stones,andlesionswithintheurinarybladder.Thepractitionershouldbeawareofthelimitationsofultrasoundindetectionoftransitionalcelltumoursoftherenalpelvis.Thepatencyoftherenalveinsshouldbeassessedwhenasolidrenallesionissuspected.

Renalcystsshouldbedocumentedandassessedforcomplexity.Ultrasoundofsimple/minimallycomplexcystsissufficient.MorecomplexrenalcystsrequireformalBosniakgrading,eitherwithcontrastenhancedultrasoundorCTaccordingtolocalguidelines.

Thepractitionershouldbeawareofnormalanatomicalvariantsthatmaymimicrenallesionssuchashypertrophiedrenalcolumns(columnsofBertin),splenichumpsetc.Whilethemajorityofnormalanatomicalvariantsshouldbecorrectlyrecognisedwithultrasound,contrastenhancedultrasound,CTorMRIshouldbeconsideredwherethereremainsdoubtoverapotentiallesion.

Thepractitionershouldbeawarethatultrasoundhaslimitedsensitivityinassessmentfortransitionalcelltumoursintherenalcollectingsystem,uretersorurinarybladder.Patientswithunexplainedmacroscopichaematuriashouldbeconsideredforfurtherteststobetterdemonstratetheseregions(flexiblecystoscopyandCTurogram/IVU).

Acute/chronickidneyinjury(AKI–formerlyacuterenalfailure)

Themainaimofultrasoundisfirsttodeterminewhetherrenaldysfunctionisamedicalorsurgical(obstructive)problem.

Assessbothkidneysforsize,parenchymalthicknessandcorticalreflectivity.Thepractitionershouldbeawareofthechangesinrenalappearanceswithage.Theurinarybladdershouldbeassessedfordistension,presenceoftumours,trabeculation,wallthicknessanddiverticulumformation.Thesizeoftheprostateglandshouldbeestimatedinmalesandassessmentofbladderemptyingshouldbeperformed(wherepossible).


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Renalcorticalechogenicityshouldbeassessedbycomparisonwithadjacentliver/spleenandinternallybycomparisonwithmedullarypyramids.Increasedrenalcorticalechogenicityimplies‘medical’renaldiseasebutisanon-specificfinding.

Wherethekidneysareenlarged,thepatencyoftherenalveinsshouldbeconfirmed.

Therenalcollectingsystemshouldbeexaminedfordilatation.Incasesofpelvi-calycealdilatation,thecollectingsystems,ureters,andurinarybladdershouldbeexaminedtodeterminethelevelandcauseofanyobstruction.Thepractitionershouldbeawareofcommoncausesofbilateralrenalobstructionsuchastumoursoftheurinarybladder,pelvisandretroperitonum;inflammatoryconditionssuchasretroperitonealfibrosis,endometriosis,andbladderoutflowobstruction.Thepractitionerneedstobeawareofphysiologicalrenalpelvisdilatationsecondarytoafullbladderand,insuchcases,rescanningfollowingmicturitionisuseful.Incasesofacutekidneyinjury(AKI),pre-examinationpreparationwithfluidloadingshouldbeavoided.Insomecentres,in-patientsarerequestedtoattendwithanemptybladderorarecatheterised.

Loin/renalanglepain/obstruction

Lookforultrasoundfeaturesofrenalobstructionandrenallesions.Theultrasoundpractitionershouldbeawareofthelimitationsofultrasoundinassessinghighgradeurinaryobstruction.Thepresenceofpelvi-calycealdilatationisnotalwaysowingtourinaryobstruction,neitherdoestheabsenceofpelvi-calycealdilatationruleouthighgradeobstruction.Intheobstructedkidney,thedegreeofobstructiondoesnotcorrelatewellwiththedegreeofdilatation.Chronichydronephrosismaybeassociatedwithlossofparenchymalthickness.Therenalpelvisandcalycesshouldbeassessedforthepresenceofrenalcalculi.Whilelargercalculimaybevisible,ultrasoundisoflimitedsensitivityinthedetectionofsmallcalculi.Thepresenceofacousticshadowingishelpfulandthepractitionershouldbeawareofimageprocessingtechnologieswhichmayreducethepresenceofshadowing,particularlyspatialcompounding.ColourDopplermaybeusefultoassessforthepresenceof'twinkle’artefact.Assessforuretericdistensionandlevel/causeofobstruction.Notethatthemid-ureterisfrequentlynotvisibleduetooverlyingbowelgasbuttheureteratthelevelofthePUJandVUJisusuallyamenabletoultrasoundassessment.Secondarysignsofobstructionmayincludepresence/absenceofuretericjetswithinthebladderandincreasedvascularresistancetointra-renalarterialbloodflow;thepractitionershouldbeawarethatchangesinintra-renalbloodflowpatternswithinanobstructedkidneyfollowaspecifictimescheduleandthepractitionershouldbeconversantwiththis.Thepractitionershouldbeawareoftheutilityofotherimagingtests,plainx-ray,IVUandCTKUBandthecorrelativenatureofthesetests.

Urinarytractinfection(UTI)

Inacuteinfection,thekidneysarefrequentlynormal.Thekidneysshouldbeassessedforsize,position,morphologyandechogenicity.Thepractitionershouldbealerttothesignsofacuterenalinfectionsuchassmallamountsofperinephricfluid(renalsweat),hydronephrosis/pyonephrosis,diffuserenalenlargementorfocalcorticalabnormalitytosuggestfocalpyelonephritis.


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Thekidneysshouldbeexaminedforanatomicalvariantswhichmaypredisposetourinarytractinfectionsuchasduplexkidneys,horseshoekidneyandrenalectopia.Theuretersshouldbeassessedfordilatation.Theurinarybladdershouldbeexaminedfordistension,wallthickening,andothersignsofbladderoutflowobstruction.Assessprostateglandforsize.Bladderemptyingshouldbeassessedbyestimatingpost-micturitionresidualbladdervolume.Renaltransplant(immediatepost-operativeperiod)

Theobjectiveistodemonstrateanysurgicalcomplicationswhichmayrequireimmediateintervention.Thesizeandmorphologyofthetransplantkidneyshouldbeexaminedtoestablishabaselineforsubsequentscans.Thepractitionershouldestablishthepresence/absenceofperinephrichaematoma/collectionandexcludepelvi-calycealdilatation.ColourDoppleroftheentirekidneyshouldbeperformedtoestablishthatbloodflowispresenttoallareasofthekidney.PulsedwaveDoppleroftheinter-lobararteriesshouldalsobeperformedtoassessbloodflowpatternswhichmaygiveindirectevidenceofarterial(inflow)orvenous(outflow)problemsofthegraft.Dopplerindices(resistanceorpulsatilityindices)shouldberecorded.Thepresence/absenceofreversedarterialdiastolicflowshouldbeestablishedandthepractitionershouldbeawareofthepossiblecausesforthis.Finally,therenalveinshouldbeexaminedwithcolourDopplerultrasoundtoensurepatencythroughoutitslength.Thepractitionershouldbeawareofultrasoundappearanceswhichrequireimmediatesurgicalinterventionsuchasarterialorvenousocclusionofthetransplantkidneyanddiscusswiththesurgicalteamwhenthesearesuspected.Imagingofthetestesandscrotum

Commonclinicalscenarios

Scrotalmass

Theaimistolocalisethescrotallump(intra-orextra-testicular)andcharacteriseifpossible.

Bothtestesshouldbeassessedforsize,morphologyandthepresence/absenceofatesticularlesion.Thetestesshouldbeassessedforechogenicitybycomparingbothtestesonaside-by-sideviewonthesameimage.Thepractitionershouldfollowlocalguidelinesforreferral/alertingclinicalteamsofsuspectedtesticularcancer.

Assessmentoftheepididymalheads,bodiesandtailsshouldbemadeforthickening,presenceoflesions,cystsetc.Beawareofthepresenceofnormalmildepididymalthickeningaftervasectomytogetherwiththecommonappearancesofspermgranulomas.Thetunicalspaceshouldbeexaminedforthepresenceofhydrocoeleandthescrotalwallshouldbeexaminedforthepresenceofoedemaorthickening.Everyeffortshouldbemadetovisualiseandcharacteriseascrotalmass.Thepatientshouldbeaskedtolocalisethemasswithdirectscanningoverthisareawherethepractitionerisunabletovisualisethemassduringnormalscrotalscanning.

Suspectedtesticulartorsion

Inclinicallysuspectedtesticulartorsion,ultrasoundinvestigationshouldnotdelaysurgicalexplorationtoofferthebestchanceofpreservingtesticularviability.Ultrasoundcannotconfidentlyexcludetorsionbutanexaminationmaybeperformedincasesofacutetesticularpain.Practitionersneedtobeawareoftheultrasoundfeaturesoftorsionandifinanydoubt,urgenturologicaladviceshouldbesought.


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Assessthetestes,epididymidesandtunicalspace.ColourDopplerofbothtestesshouldbeundertaken,assessingpresenceandsymmetryofbloodflowwithinthetestes.Theabsenceofdiscerniblebloodflowwithinatestis(whereflowisvisibleonthecontra-lateralnormalside)ishighlypredictiveoftesticulartorsion.However,itshouldbenotedthatthepresenceofbloodflowdoesnotexcludetorsion,particularlyintermittenttorsion.Thespermaticcordshouldbeexaminedtoassessforthepresenceoftwistingofvesselswithinthespermaticcord(thewhirlpoolsign).Theultrasoundpractitionershouldbeawarethattesticulartorsioncanalsocauseepididymalswellingandhydrocoeleformation,mimickingepididymo-orchitis,althoughtheabsenceofintra-testicularflowmaybediagnostic.However,intermittenttesticulartorsioncandemonstrateincreasedintra-testicularbloodflowoncolourDopplerexaminationwhichmaybeindistinguishablefromepididymo-orchitis.2.10 UltrasoundoftheadultheadandneckGeneralprinciples

Asinallareasofultrasound,practitionersneedtobeawareofthevariousclinicalscenariosthatcanpropagateultrasoundrequests.Intheheadandneckregiontheclinicalquestionposedcanbeunfamiliartotheoccasionaloperator/reporter.Itisessential,inordertocarryoutacompetentexaminationandissueahelpfulreport,thattheultrasoundpractitionerunderstandsthequestionthatisbeingasked.Forexample,incaseswhereaheadandneckmalignancyissuspected,afullexaminationofallthemajorlymphnodeterritoriesisrequiredinordertoaccuratelystageandoptimallymanagethepatient.Thethreemostcommonmassesthatpresenttoheadandnecklumpclinicsare:lymphnode,thyroidandsalivary.Examinationandreportingneedstobetailoredtotherequestreceivedandthefindingsonultrasoundexaminationegifaparotidmassisidentifiedthenexaminationofthecontralateralparotidismandatorytolookforpotentialcontralateraltumours(Warthins)andthefindingsshouldberecordedinthereport.Examinationmaybetailoredtoaspecificareaoftheneck(egapalpablemass);dependingonthefindings,theexaminationmayfocusontheareainquestionalone,ormayneedtobeexpandedtoassesstheneckasawhole.Forexample:inapatientwithaposteriortrianglemass,ifthefindingisthatofasmallsuperficiallipomathentheexaminationcanbecontainedtothatareainquestion.Theextentofthestudyshouldberecordedinthereporteg“Ihavenotexaminedtheremainderoftheneck”.However,iftheultrasoundexaminationidentifiedanecroticlymphnodewhichispotentiallymetastaticthenafullassessmentoftheneckinitsentiretyismandatory.Anatomicalstructures

1. Lymphnodes

Knowledgeofthemajorlymphnodeterritoriesandchainsisessentialandanunderstandingoftheinterchangebetweenterminologyusedinthedescriptionoflymphnodegroups/chains(egdeepcervical/jugularchain)andthecommonlyusedLevelclassification1thatisfundamentaltoheadandneckcancermanagement.Confusioninthisareacanbeeasilycreated,bothinrequestingandreportingfortheunwary.Knowledgeofthetypicalcriteriafortheultrasounddifferentiationbetweenbenignandmalignantlymphadenopathyisessential.Descriptivereportsthatfailtoclassifythenodesintobenign,equivocalorpossibly/probablymalignantareunhelpful.Benignnodesareclassicallyfusiforminshape,containanechogenichilusandpossessacentralhilarbloodflowpattern.Whereasmalignantlymphnodestendtoberounded,thecentralhilustendstobeabsent,containareasofcoagulationorcysticnecrosisandexhibitderangedbloodflowpatternwithareasofvascularsparingandperipheralvessels.Nodalmetastasesfrompapillarycarcinomaofthethyroidaretypicallymoreechogenicandcontainpunctatemicro-calcification.Lymphomaclassicallypresentsasmarkedlyhypo-echoicnodes(pseudo-cysticappearance),roundedwithplethoricbloodflowwhichcommonlydisplaysabenigncentralhilarpattern.As


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thearchitectureoflymphomatousnodesispreserved,thisismirroredinpreservationofthe“benign”echogenichilussign.2.Salivarymasses

Ultrasoundistheoptimalinitialinvestigationforapatientwithasalivarymassandthereforethepractitionerneedstobeawareofthecommonappearancesofsalivarytumours.80%ofsalivarytumourswillbebenignpleomorphicadenomasandoccurinthesuperficialparotid.Theyaretypicallylobularandhypoechoic,oftenwithapseudo-cysticappearance.CysticchangeissuggestiveofWarthinstumoursasaremultiplicityandcontralateraltumours.Anirregular,spiculatedoutlinewouldsuggestacarcinoma.3.Thyroid

Practitionersshouldbeawareofthetypicalfeaturesthatenableadiagnosisofabenignthyroidnoduletobemadeandthosefeaturesthatindicateapotentialmalignancy.ThesehavebeenoutlinedinthelatestissueoftheBritishThyroidAssociationGuidelines2andhowtheycanbeusedtoclassifythethyroidmassintoabenign,equivocal/indeterminateor(suspicious)malignantcategory(U1–U5)withFNAorcorebiopsyrequiredforthoseintheindeterminateofmalignantcategories,ifindicated(ieU3-U5).Reportsshouldthereforeoutlinethefeaturesdisplayedandindicateinwhichcategorythefindingssit–allowingappropriatemanagement.Benignnodulesmayshowmicro-cysticorcysticchangewithringdownsignsofcolloid,eggshellcalcificationandperipheralcolourflow.Theyaretypicallyhyper-echoicoriso-echoicinrelationtothebackgroundechotexturewhereasasolidhypo-echoicnodulewhichcontainsmicro-calcificationishighlysuggestiveofathyroidcarcinoma–typicallyapapillarycarcinoma.Theshapeofthenodule(“tallerratherthanwide”)isalsoasignofpotentialmalignancy.Whenacarcinomaissuspected,asearchforpotentiallymphnodemetastasesisrequired,togetherwithadecisiontoproceedtoFNAorcorebiopsyinlinewithguidelines. ReportingOutlinedbelowareexamplesofsamplereportsforvariouscommonclinicalscenarios:------------------------------------------------------------------------------------------------------------------------------------------------------Palpablemass(a)ClinicaldetailsMobilemassleftposteriortriangle.2.5cmmass.Noknownprimarytumour,patientfitandwell.Cervicalultrasound.Thepalpablemassintheleftmidposteriortriangleisidentifiedasafusiformshapedlymphnodemeasuredat2.6cmx0.4cm.Itdisplaysanechogenichilus,theappearancesaretypicalofabenignlymphnode–nosinisterfeaturesidentified.Theremainderoftheleftnecklookedunremarkable;Ihavenotexaminedtherightsideoftheneck.Conclusion:benignleftposteriortrianglelymphnode.-------------------------------------------------------------------------------------------------------------------------------------------------------Palpablemass(b)(Primarycarereferral)ClinicaldetailsRightupper/midcervicalmass,increasinginsizeforpastthreemonths.Smoker.O/Ehardmassinrightuppercervicalregion?nodal.Nilelseonexamination.Cervicalultrasound


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Thepalpablemassisidentifiedasa3.4cmdiameterlymphnodemassintherightupperdeepcervicalchain.Therearesignsofcoagulationnecrosisandpossibleextracapsularspread–consistentwithametastaticlymphnodefromapotentialsquamouscellcarcinomaprimary.Furtherroundedsuspiciousnodesareseenintherightmiddeepcervicalchain.Nodesidentifiedintherightsubmandibularregionandlowerdeepcervicalchainandrightposteriortriangle-buttheseallappearbenign.Theleftsideofthenecklooksclear.Thesalivaryglandsandthyroidlookedunremarkable.Someincidentalbenignnodulesareseenwithintheleftlobeofthyroid-butnosignsofanythingsinister.IhaveperformedaFNA(21g)ontherightupperdeepcervicallymphnode,specimenobtainedandsentforcytology.Nocomplicationsidentified.Ihaveaskedthepatienttocontactyoursurgeryinoneweekstimetomakeanappointmentwithyoutodiscusstheresults.IsuggestthatheisreferredforanurgentENTreview.Conclusion:probablemetastaticrightupperandmiddeepcervicalchainlymphadenopathy,FNAperformed.UrgentENTreferralrecommended.Reporttobefaxedthroughtosurgery.-----------------------------------------------------------------------------------------------------------------------------------------------------Rightparotidmass.(ENTreferral)ClinicaldetailsPatientnoticedasoftlumpinparotidregionwhilstshaving,unsurehowlongpresent.O/E2cmsoftmassinrightparotidregion,VIIexamnormal.Nilelsetofind.Diagnosis:?Lymphnode?salivarymassUltrasoundcervicalregionA4.6cm(coronal)x3.4cm(AP)x3.7cm(sup/inf)massisidentifiedintheposterioraspectofthetailoftherightparotidgland,itispredominantlysolidwithasmallcysticelementposteriorly.Themassiswellencapsulatedandhypo-echoic.Noextensionintothedeepaspectoftherightparotidseen.Apartfromsomebenignlookingintraparotidnodes,theremainderoftherightparotidlooksnormal.Nosignificantlymphadenopathywithintherightcervicalregion.Acontralateraltumourisidentifiedintheinferioraspectoftheleftsuperficialparotid.Againasmallcysticelementispresent,thetumourmeasures2.2cm(AP)x1.3cm(coronal)x2.1cm(sup/inf)indiameterwithnodeeplobeinvolvement.Remainderoftheleftparotidlooksunremarkable,nosignificantleftcervicallymphadenopathyseen.Bothsubmandibularglandslooknormal.Nilelseofnote.21gFNAperformedoftherightparotidtumourperformed,mucoidmaterialobtainedandsentforcytology.Nocomplicationsidentified.Conclusion:probablebilateralWarthinstumours,FNAperformedoftherightparotidtumour.---------------------------------------------------------------------------------------------------------------------------------------------------Thyroidmass(a)ClinicaldetailsPatientcomplainingoffullnessinlowerneck,O/E?smallgoitre.Ultrasoundcervicalregion


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Multiplesmalliso-echoicnodulesareidentifiedinbothlobesofthethyroid,severalofthenodulesexhibitcysticchangewithringdownsignsindicativeofcolloid.Multi-cysticchangealsoseen.Nosignsofanythingsinisteridentified.Thyroidismildlyincreasedinsize,nosignificantassociatedlymphadenopathyandnoretro-sternalextensionpresent.Conclusion:smallbenignmultinodulargoitre.Nosignsofanythingsinister.RadiologicalclassificationU2–benign.------------------------------------------------------------------------------------------------------------------------------------------------------Thyroidmass(b)(ENTreferral)ClinicaldetailsLeftsidedthyroidnodule,patientstateshasbeenpresentfortwoyears.Thyroidfunctionnormal.O/Efirmnoduleleftlobeofthyroid,noretrosternalextension.NolymphnodesUltrasoundthyroidWithinthemidpoleregionoftheleftlobeofthethyroidthereisa2.6cmsolidhypo-echoicovoidmasswhichcontainssomeechogenicfoci–suggestiveofmicro-calcification.Severalsmallernodulesareseenintherightlobebutthesedisplaytypicalbenigncharacteristics.WithintheleftmiddeepcervicalchainthereisaroundedhyperechoiclymphnodejustlateraltotheIJVwhichalsodisplayssomehyper-echoicfoci.Thereminderoftheleftnecklooksclearasdoestherightneck.Thefindingsarehighlysuggestiveofasmallpapillarycarcinomaoftheleftlobeofthethyroidwithaprobableleftmiddeepcervicallymphnodemetastasis.IhavethereforeproceededtoaFNA(21g)ofboththeleftthyroidnoduleandtheleftmidcervicalnode.Specimensobtainedandsentforcytology.Nocomplicationsidentified.Conclusion:probablepapillarycarcinomaoftheleftthyroidwithleftmidcervicallymphnodemetastasis,FNAperformed.------------------------------------------------------------------------------------------------------------------------------------------------------Stagingultrasoundexamination(Maxillofacialreferral)ClinicaldetailsLeftlateral/posteriortongueprimarySCC,T3.Smoker.LeftLevelIInodesonexamination??rightIInodesalso,?BilateralmetastasesUltrasoundcervicalregionThetongueprimarytumourcanbeidentifiedonultrasound,withintheposteriorlefttongue.Itismeasuredat1.6cm(AP)by1.1cm(coronal)diameterbutdoesnotcrossthemidline.Superior/inferiordiameterdifficulttoassessbutmeasuredat1.9cm.Therearemultipleroundedlymphnodeswithsignsofcoagulationnecrosisintheleftuppercervicalregion,largestmeasuredat2.1cminmaximumdiameter.Therearealsosimilarsmallernodesintheuppermiddeepcervicalchain.Featuresarethoseofmetastaticlymphadenopathy.Therearesmallbenignlookingnodesinthesuperiorleftsubmandibularregionandwithinthelowerleftjugular(deepcervical)chainandposteriortriangle.Assessmentoftherightneckisunremarkable,benignnodesseenintherightupperdeepcervicalchainbutnosignsofcontralaterallymphnodemetastases.FNAofthelargestnodeintheleftupperdeepcervicalchain(LevelII)performed,nocomplicationsidentified.Haemorrhagicandnecroticmaterialobtainedandsentforcytology.Conclusion:lefttonguebase/midtonguetumour,withleftupperandmiddeepcervicalchain(levelsII&III)lymphnodemetastases.FNAperformedonleftupperdeepcervicalnode.Nocontralaterallymphnodemetastasesseen.


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------------------------------------------------------------------------------------------------------------------------------------------------------References1)Delineationofthenecknodelevelsforheadandnecktumours:a2013update.DAHANCA,EORTC,HKNPCSG,

NCIC,CTG,NCRI,RTOG,TROGconsensusguidelines.GregoireV,AngK,BudachWetal.Radiotherapy&Oncology110(2014)172-181.2014.http://dx.doi.org/10.1016/j.radonc.2013.10.010

2)Managementofthyroidcancer.BritishThyroidAssociationGuidelines.http://www.british-thyroid-association.org/Guidelines/

2.11PAEDIATRICULTRASOUNDEXAMINATIONSOxfordIllustration.Guideforchildrenhavingultrasoundhttps://www.youtube.com/watch?v=fDPUu31X0msExam-specificguidelinesandcommonclinicalscenarios

2.11.1PaediatricliverandbiliarysystemLiver:neonatesandinfants

Commonclinicalscenarios:jaundice,antenataldiagnosisofliverabnormality,RUQmass,hepatomegaly.Featurestolookforandincludeinreport:

• livershape,homogeneityandreflectivity;• commonduct(CD)normalordilated(upto1mminneonate),intrahepaticductsize.IfCDenlarged

aretherestones/inspissatedbileinit,isthereamassorenlargedlymphnodescompressingtheduct?

• gallbladder(GB)shape,sizeandwallthicknessandpresence/absenceofgallstones;• portalandhepaticveinpatency;• spleensize,shapeandposition.

Abnormalitiesthatmaybeseen:

• anabnormallyshapedliver,usuallyassociatedwithbiliaryatresiaifsitussolitus,ambiguous,orinversus.Chronicliverdiseasefeaturesofleftlobehypertrophyandrightlobeatrophy,willnothavehadtimetoevolveinaneonate;

• afattyliver;

• focalabnormalities;benign-calcification,haemangioendothelioma,haemangioma,focalfattychange,cyst;malignant-hepatoblastoma;

• bileductdilatation–owingtoinspissatedbileintheCD,choledochalcyst(nottobeconfusedwithacystattheportathatcannotbeconnectedtotheleftandrightducts–foundinsomecasesofbiliaryatresia);

• splenicsizeandposition(?leftorright)?polysplenia.Left-sidedpolysplenia+situssolitusorambiguousisdiagnosticofbiliaryatresia.

Ifanyabnormalityisfoundthenapaediatricreferralisnecessary.Ifanormalscanisfoundinaninfantwithconjugatedhyperbilirubinaemia,thenitismandatorytoreferthepatienttoapaediatricliverspecialistassoonaspossiblesothatbiliaryatresiamaybeconfirmedorexcludedandmanagedaccordingly.


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Liver:children

Examine:Liver,biliarytree,gallbladderandpancreas.Commonclinicalscenarios:jaundice,painfulRUQ,upperabdominaland/orbackpain,abnormalLFTs,heptomegaly.Featurestolookforandincludeinreport:

• livershape,homogeneityandreflectivity;• commonduct(CD),normalordilated(1mminneonate,upto6mminteenager,relativetoheight),

intrahepaticductsize.IfCDenlargedaretherestonesinit,isthereamassorenlargedlymphnodescompressingtheduct?

• gallbladder(GB)shape,sizeandwallthicknessandpresence/absenceofgallstones;• portalandhepaticveinpatency;• spleensize,shapeandposition;• pancreas:relativelylargerandoflowerreflectivitythananadultpancreas,duct>1mm.


• aliverofincreasedreflectivity(fattyliver)ordecreasedreflectivity(lowfatcontentifchildwell,acutehepatitisifunwell);

• anabnormallyshapedliver?CLD;• focalabnormalities-benign:cyst,calcification,haemangioma,focalfattychange,focalnodular

hyperplasia,adenoma,abscess;malignant:hepatoblastoma,hepatocellularcarcinoma(HCC)(usuallyinacirrhoticliver),fibrolamellarcarcinoma,sarcoma,metastases;

• bileductdilatation;• enlargedpancreas+/-ductdilatation.

GPpatientsshouldbereferredtoapaediatricspecialistifanyabnormalityisfoundorifnoabnormalityisfoundandthepatientremainsjaundicedand/orhasabnormalLFTs.Ifthepatientispain-freeandjaundice-freewhenthescanisperformedandtheCDisfoundtobebigthenanMRCPisnecessarytoseeifthereisacholedochalcystandcommonchannelpresent.Glossaryoftermsusedinpaediatricliverultrasoundreports

Focallesions:benign

Abscess:anearlyabscessmaybedifficulttoidentifyandtheonlycluemaybeposterioracousticenhancementandclinicalsymptoms.Thelesionthenbecomesecho-poorandmoreclearlydefinedandmaypossiblycontaingasiftheinfectioniscausedbyagas-formingorganism.Portalveinpatencymaybecompromised.Adenoma:uncommoninchildrenalthoughtheyareassociatedwithglycogenstoragedisorders.Theymaybeofeitherincreasedordecreasedreflectivity.Cysts:simple,choledochal(seebiliarysection).Calcification:thismaybeeitherincidentalsmallfocithatareasequelofanintra-uterineeventsuchasinfectionoritmaybepartofalargersolidlesion.Focalnodularhyperplasia(FNH):anotheruncommonlesioninchildren.Theyareassociatedwithportosystemicshuntsorportalatresia.


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Haemangioma:anincidentalfindingofasmalllesionofincreasedreflectivityineitherasubcapsularpositionoradjacenttoabloodvessel.Thedifferentialisanareaoffocalfattychange.Haemangioendothelioma:foundinneonatesorinfants.Theremaybemultiplesmallfocallesionsofreducedreflectivitythroughouttheliveroronelargevascularlesion.Thehepaticarteryislargewithhighvelocityintrahepaticflowandthediameteroftheabdominalaortadecreasesbelowthelevelofthecoeliacaxis.Theinfantmaypresentinheartfailureasmostofthearterialbloodisbeingshuntedthroughtheliver.Theseusuallyinvolutespontaneously.Mesenchymalhamartoma:awell-definedmainlycysticmasswithmultiplesepta.

Trauma:CTisusuallythefirstinvestigationasearlyliverlacerationsmaynotbevisibleonultrasound.Ultrasoundcanbeusedinfollow-uptomeasurefluidcollectionsbutCTorcontrastultrasoundisnecessarytomonitorforpossibledevelopmentofpseudo-aneurysms.Focallesions:malignantEmbryonalsarcoma:thistumourhasavariableappearance,sometimessolidandsometimescystic.Fibrolamellarcarcinoma:ararevariantofhepatocellularcarcinoma(HCC)thatusuallyoccursinolderchildren.Hepatoblastoma:occursinyoungchildren.Thelesionmaybesolitaryormultifocal,oftenpoorlydefinedandmaycontaincalcification.Adjacentvesselsmaybecomeinvaded.Hepatocellularcarcinoma(HCC):oftenassociatedwithacirrhoticliverasfoundinbiliaryatresiaortyrosinaemia.Thelesionmaybesolitaryormultifocal,oftenpoorlydefinedbutdoesnotusuallycontaincalcification.Thesetumourscannotbecharacterisedonultrasoundandcross-sectionalimaging+/-biopsyisnecessarytoconfirmthediagnosis.CTisusedundertheageofoneyearasMRIcontrastisnotlicensedforuseinthisagegroup.Metastases:thesemaybefoundinassociationwithneuroblastoma,Wilms’tumour,leukaemia,lymphoma.Oneconditionthatcanbediagnosedwithultrasoundisneuroblastomastage4S.Thisusuallyoccursininfantsunderoneyearoldandtheadrenalprimarytogetherwiththelivermetastasesofdecreasedreflectivityarecharacteristicofthiscondition.DiffuseliverdiseaseAcutehepatitis

Sometimesdescribedasa‘darkliver’ora‘starrysky’appearance.Theparenchymaisofreducedreflectivitycausingtheportaltractstostandoutmorethannormal.

• theliverisenlargedwithroundedinferiorborders• thegallbladderwallmaybeoedematous• +/-ascites.

Itispossibleforalivertohavealowfatcontentandthisappearancemustnotbeconfusedwithacutehepatitis;noneofthesecondarysignswillbepresentandthechildisusuallywell.Anotherpitfallisacutehepatitisinapatientwithafattyliver.Theparenchymamayappearofnormalreflectivity,lookfortheothersigns.


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Fattyliver

Fattyliversmaybefoundinassociationwithobesity,malnutrition,chemotherapy,steroids,storagedisordersleadingtoametabolicdisturbance(glycogenstoragedisorders,tyrosinaemia(increasedriskofHCC).A‘bright’liver;theparenchymaisofincreasedreflectivityandtheremaybesmallareasoffocalfattysparing.Thesearenotfocalabnormalities,theyaretheonlypartoftheliverwithanormalappearance.Theusualpositionsforfocalfattysparingareanteriortotherightportalveinandsuperiortothegallbladder.Iffocalfattysparingisthoughttobeinotherpositionsthenitisworthwhiledoingacontrastultrasoundscanasafocalabnormalitymaybepresent.Chronicliverdisease

Theliverhasafinelyorcoarselyheterogeneousappearancewithanirregularornodularsurface.Atypicalpositionforregenerativenodulesisanteriortotherightportalveinbutfurtherimagingmustbeperformedtoexcludemalignancy.Theremaybelobaratrophy/hypertrophy;oftentheleftlobeishypertrophiedandtheposteriorrightlobeatrophiedandthepara-umbilicalveinmaybepatent.Theremaybeanincreaseinperiportalreflectivityduetofibrosisaroundtheportaltracts.Vascular-relatedpathology.Budd-ChiariSyndrome:Thehepaticveinsthromboseandtheflowintheportalveinisreversed.Theremaybeascitesandsplenomegaly.InchronicBudd-Chiari,theparenchymabecomesheterogeneousandsmallserpiginousvenouschannelsdevelop.Theportalflowmayreverttoantegradeandtheascitesmayresolve.Ifclinicallyindicated,aportosystemicshuntproceduremaybeperformedthatshuntstheportalflowintotheIVC.Patentductusvenosus(DV):Thisnormallyclosessoonafterbirth.Itmayremainpatentbecauseitiscongenitallyabnormal.Ifthisisthecasethenitwillbeseveralmillimetreswide,theflowintheleftportalveinisreversedandthereisnoflowintherightportalveinasalltheportalflowisshuntedthroughthewidelypatentDVintotheIVC.IfleftuntreatedthentherightlobeatrophiesandFNHsmaydevelop.TheothersecondarycauseforapatentDVislivercellfailureanditistheliver’swayoftryingtodecompresstheintrahepaticportalpressure.ThelumenoftheDVismuchsmaller,usuallyamillimetreorless,andiftheliverrecoverstheshuntwillclosespontaneously.Theflowinbothleftandrightbranchesoftheportalveinisantegrade.Thepara-umbilicalveinmayalsobepatent.Portalveinthrombosis:Thisusuallyoccursifthechildhadanumbilicalcatheterinsertedasaneonate.Atypical‘bagofworms’appearanceisseenattheportaanteriortothepositionthattheportalveinshouldliein.Occasionallythereiscavernoustransformationwherethereisonevenouschannelthatmaybeinthepositionofthenormalportalveinandthisisnotdistinguishableonultrasound.Vascularmalformations:Theremaybeabnormalvascularconnectionsbetweentheportalveinandhepaticartery,withalargedraininghepaticvein.Multiplevascularchannelsmaybeseenwithbotharterialandvenousflowwithinthem.CT+/-arterialembolisationorresectionisnormallyperformed.Occasionallysmallshuntsbetweenportalandhepaticveinbranchesorbetweenhepaticveinsmaybeseenbuttheseareusuallyhaemodynamicallyinsignificantandclosespontaneously.Theportalvelocityshouldbeassessedandspleenlengthdocumented.


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Veno-occlusivedisease:Thisusuallyoccursafterchemotherapyandaffectsthesmallvessels,notthemainhepaticveins.Intheacutephasethereisnoout-flowinthehepaticveins,theyremainpatentbutthebloodonlyoscillatesduringrespiration.Theportalflowreversesandthereisascitesandsplenomegaly.Theliverbecomesfatty.Asthepatientimprovesthehepaticveinflowre-establishesandtheportalflowreturnstoantegradeflow.ThebiliarysystemObstructivejaundiceininfantsandchildrenisusuallycausedbycalculi,choledochalmalformations,pancreaticmasses,bileducttumours(rhabdomyosarcoma),enlargedlymphnodesorsub-hepaticmasses.Neonatesthatpresentwithconjugatedhyperbilirubinaemiamayhaveadilatedcommonductduetoinspissatedbilewithinit(haemolysis,totalparenteralnutrition[TPN],cysticfibrosis).Thegallbladdermayalsocontaininspissatedbile/smallcalculi.Thecommonductmaybeupto1mminaneonateand6mminanadolescent.Acholedochalcyst(cysticdilatationofthebileducts): TypeI–dilatationoftheextrahepaticcommonductTypeII–diverticulumofthecommonductTypeIII–dilatationoftheintra-duodenalcommonductTypeIV–intra-andextrahepaticdilatationTypeV–intrahepaticdilatationonly.AnMRCPscanshouldbeperformedifacholedochalcystisfoundtoseewhetherthereisacommonchannel(thepancreaticductopeningintothelowercommonductratherthantheduodenum,leadingtopancreatitis).Aneonatepresentingwithacystattheportahepatiswillhaveeitheracholedochalcystorbiliaryatresia.Acholedochalcystcanbeseentoconnectwiththebileducts,whereasthecystfoundinsomecasesofbiliaryatresiacannotbeseentoconnecttothebileducts.Thegallbladderalsohasanabnormalappearancein90%ofcasesofbiliaryatresia.Casesofbiliaryatresiaareassociatedwithsitusinversus,thelivermayhaveanoddconfiguration,oftenlyingcentrallyintheepigastriumwithtwoequal-sizedlobes.Theportalanatomymaybeunusualandoftenthereispolysplenia.Spontaneousperforationofthebileduct:theperforationoccursatthejunctionofthecysticduct/commonhepaticductandtheinfantpresentswithjaundiceandascites.2.11.2UrinarysystemNeonates

Commonclinicalscenarios:Antenataldiagnosisofdilatedrenalpelvisand/orhydronephrosis,singlekidney(pelvickidneysaresometimesmissedonantenatalscans),sepsis.Ababyshouldbescannedatleast48hoursafterbirthwhenfollowingupanantenataldiagnosisofadilatedrenalpelvis,sothatthebabyisnotdehydratedatthetimeofthescan,thusmaskinganypotentialrenalpelvicpathology.Featurestolookforandincludeinreport:

• twokidneysthatarenormalinshape,sizeandpositionwithnocollectingsystemdilatationandnormalcorticalreflectivity.Neonatalkidneysmayhaveincreasedcorticalreflectivityupto6months


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ofageandthepyramidsappearrelativelydark–nottobeconfusedwithcysts.Abnormalorientation(discussedinsectiononchildren)

• therenalpelviscanmeasureupto6mm• a‘cyst’intheupperpoleofakidney–thismaybeanobstructedupperpolemoietyinaduplex

kidney,associatedwithaureterocele• nonormalkidneyandseveralcystsintherenalposition-multicysticdysplastickidney• anormal-shapedbladderwithanormalwallthicknessandnoevidenceofloweruretericdilatationor

ureterocele.

Iftherenalpelvisisdilatedthenfollow-upscansshouldbeperformedat2and8weeksofage.Ifthedilatationcontinuesthenfurtherimagingwillberequired.Children

Commonclinicalscenarios:UTIs,loinpain,haematuriaFeaturestolookforandincludeinreport:

• twokidneysthatarenormalinshape,sizeandpositionwithnocollectingsystemdilatationandnormalcorticalreflectivity.

• anormal-shapedbladderwithanormalwallthicknessandnoevidenceofloweruretericdilatationorureterocele.Ifthepatientisabletomicturatewhenaskedthenapost-micturitionbladderscanshouldbeperformedtoensurecompleteemptying.


• onlyonekidneyfound:ifitisanormalsizethenthereshouldbeanectopickidney,oftenpelvic.Ifthekidneyishypertrophiedthentheotherkidneyhasinvoluted(multicysticdysplastickidneyfoundantenatally)orisabsent.

• abnormalorientation:horseshoekidneyshavetheirlowerpolesmoremedialthantheupperpolesandthereisabridgeoftissueconnectingthetwolowerpolesacrossthemidline;cross-fusedectopia:bothkidneyslieonthesamesidewiththeupperpoleofthelowerkidneyfusedwiththelowerpoleoftheupperkidney.

• a‘cyst’intheupperpoleofakidney,usuallyanobstructedupperpolemoietyofaduplexkidney,oftenassociatedwithaureterocele.

• hydronephrosis:PUJobstruction,VUJobstruction.• cysts:uncommoninchildren,associatedwithtuberosesclerosis.• infantilepolycystickidneys:autosomalrecessivedisorderassociatedwithcongenitalhepaticfibrosis.• big,brightkidneyswithmultiplecysts,(cystsmaybetiny).• adultpolycystickidneydisease,autosomaldominant,mayunusuallypresentinchildhood.• thecorticalreflectivitymaybeincreased(normalfindingupto6/12ofage),anon-specificfinding

associatedwithmedicalrenaldiseaseasinadults.• Wilms’tumour:themostcommonpaediatricabdominaltumour.

2.11.3 Paediatricgastro-intestinaltract

Pyloricstenosis.Projectilevomiting,non-biliousvomitinginaninfant

Scanthebabyaftera4hourfast.Featurestolookforandincludeinreport:

• turntheinfantintotherightlateraldecubitusposition(lyingonitsrightside)sothatanyresidualfluidinthestomachliesintheantrumoverthepylorusanddisplacesanygasfromthisarea.Ifthereisasignificantamountoffluidinthestomachthereisimpairedgastricemptying.Watchtoseeifthecanalopens.


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• IfthebabyisgassyandanNGtubeispresenttheninject20mlofsterilewaterintothestomachandwatchthepylorus;aspirateafterthescanifpositiveforpyloricstenosis.

• Upperlimitsfornormalmeasurementsare:

o Singlemusclewallthickness(notincludingmucosaorpyloriccanal)=3mmo Canallength=16mmo TSdiameter=11mm1

Reference1)deBruynR.PediatricUltrasound,How,WhyandWhen.Elsevier,2005pp185-187.

Intussusception

Abdominalpain,redcurrantjellystools,palpableabdominalmass.

Anintussusceptionisusuallyileo-colic.Mosthavenoobviouspathologyastheleadpoint,10%areduetoMeckel’sdiverticula,polypsandduplications.Itisalsoassociatedwithlymphoma,haematomaandcysticfibrosis(CF).

Featurestolookforandincludeinreport:

Asegmentofbowelprolapsesintoamorecaudalsegmentanditisseenasbowelwithinboweloncrosssection–appearanceslikeonionrings.

2.11.4 Neonatalhip

Breechdeliveryandfamilyhistoryofdevelopmentalhipdysplasiaarethemostcommonreferralcriteria.However,localpracticeandNewbornandInfantPhysicalExaminationscreeningprogramme(NIPE)1guidelinesshouldbetakenintoconsiderationwhenjustifyingreferrals.NotethattheconductoftheultrasoundexaminationoftheneonatalhipisnotitselfpartoftheNIPEscreeningprogramme.

Allbabieswithanabnormalitydetectedonclinicalexaminationshouldbescannedwithintwoweeksofage.Babieswithaknownriskfactorbutnodetectableabnormalityaretobescannedbysixweeksofage.2WhilenotmentionedintheNIPEstandards,experiencehasshownthat‘abnormal’featuresmaybephysiologicalbeforesixweeks-of-ageandthereforeprematurebabiesshouldbeage-correctedbeforeexamination.

Itishelpfultohaveacradletoputthebabyintoasitkeepstheminthelateralpositioncomfortably.

Scanlongitudinallyoverthegreatertrochanterparalleltothecradletoobtainacoronalimageoftheacetabulumatitsmaximumdepth.

αangle–thisgivesthedepthoftheacetabulum.Thebaselinegoesalongthestraightlateralmarginoftheilium.Thesecondlinegoesfromtheinferiorpointoftheiliacbonetangentialtothebonyacetabulum.Anangleofgreaterthan60°isnormal,asmallerangleindicatesdysplasia.

Ashallowacetabuluminababylessthan3/12oldmaybephysiologicalimmaturitybutiffoundafter3/12ofageitsignifiesdysplasia.

βangle–thisangleisusefulinclassifyingthedegreeofdysplasia.Theβangleisformedbetweentheverticalcortexoftheiliumandthetriangularlabralfibrocartilage.Thereisconsiderablevariabilityinthemeasurementofthisangleanditis,therefore,notalwaysused.

Neitheranglecanbemeasuredifthehipisdislocated.


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Movethehipandwatchitduringmanipulationtoseeifitsubluxes.Ifsothenfollowupin2weeks.Ifthehipisstillunstablethenreferralisnecessaryforaharnesstobefitted.

N.B.

• youcanmakeanormalhiplookabnormalbutyoucan’tmakeanabnormalhiplooknormal• femoralheadossificationcanbeseenanywherebetween2and8months.

Refertotextbooks/publishedarticlesfordiagramsoftheanglesreferredtoabove.

References1)Guidanceonwhenultrasoundexaminationsoftheneonatalhipshouldbeperformedcanbefoundat:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/572685/NIPE_programme_handbook_2016_to_2017_November_2016.pdf(page17)2)PublicHealthEngland.Newbornandinfantphysicalexaminationscreening:Programmeoverview.(2013,updated2016)https://www.gov.uk/guidance/newborn-and-infant-physical-examination-screening-programme-overview2.11.5NeonatalintracranialultrasoundTheultrasoundpractitionershouldbeawareofthepotentialbio-effectsofdiagnosticultrasound,particularlyheatingatbrain/skullinterface,andensurethatthemachineissettotheminimumpowerconsistentwithobtainingahighqualitydiagnosticultrasoundimage.ColourDopplershouldnotbeutilisedexceptforclearlydefinedclinicalreasonswhichprovideadditionaldiagnosticorprognosticinformation.Theultrasoundpractitionershouldbeawareofcommonandlesscommonlyusedacousticwindowstotheneonatalbrain.Whiletheanteriorfontanelleisusedasstandard,theposteriorfontanellecanbeusefultoexaminetheoccipitalhornofthelateralventriclesandthemastoidsuturemaybehelpfulinexaminingtheposteriorfossa,cerebellum,aqueductofSylviusand4thventricle.Asuggestedapproachforexaminingtheneonatalbrainisasfollows:PresenceofnormalanatomyTheultrasoundpractitionershouldbeawareofnormalbrainanatomyintheneonate,toincludechangeswithage,presenceofmidlinestructures,ventricularappearances,appearancesofbasalganglia,periventricularwhitematter,cerebellumandextra-axialspace.PresenceofintracranialhaemorrhageTheultrasoundpractitionershouldbeawareofcommonlocationsofintra-cranialhaemorrhage,howthismayvaryaccordingtogestationalage,andhowthesemaypresentonultrasound.Gradingofhaemorrhageshouldbeaccordingtolocalagreementandprotocol.VentricularsizeThesizeofthelateral,3rdand4thventriclesshouldbeassessedaccordingtolocalprotocol.Validatedmeasurementtechniques(egventricularindices)shouldbeutilisedincasesofventriculomegaly.Thiscanbeusefultoassesschangeinsizeovertimeandguidetimingofintervention.


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PeriventricularwhitematterTheultrasoundpractitionershouldbeawareofnormalandabnormalappearancesoftheperiventricularwhitematterandthelimitationsofultrasoundinexaminingthisregion.Follow-upshouldbeconsideredincasesofperiventricularflaringorsuspectedwhitematterdamage.BrainparenchymaTheultrasoundpractitionershouldbeawareofnormalsonographicappearancesofthebrainparenchymaandbeawareofthepotentialappearancesofacquiredabnormalities.2.12MUSCULOSKELETALULTRASOUNDEXAMINATIONS

Notesonmusculo-skeletalreports(seealsorecommendationsfortheproductionofanultrasoundreport,section2.6)

Thereportisarecordingandinterpretationofobservationsmadeduringtheultrasoundexamination.Itshouldbewrittenbythepersonundertakingthescanandviewedinclinicalcontext.Thereportisintendedtoansweraclinicalquestionandtoassistwiththepatientjourneysolocalopinionfromradiologists,rheumatologists,orthopaedicsurgeonsandphysiotherapistsshouldbetakenintoaccountintheconstructionoflocalreporttemplates.Asreportsarenowelectronic,theymaybeavailabletocliniciansinterveninglaterintheclinicalpathwayandsoshouldcontainallrelevantandappropriateinformation–forexampleanorthopaedicsurgeonmayaccessareportoriginallyrequestedbyageneralpractitionerorphysiotherapist.The report should include correctpatientdemographics;dateofexamination;examination typeand thenameand status of the ultrasound practitioner. See also RCR satenement at https://www.rcr.ac.uk/posts/position-statement-recording-identity-healthcare-professionals-who-report-imagingAsage-relatedchanges1,2arecommoninthemusculoskeletalsystemandmaynotbethecauseofthepatient’ssymptoms,ultrasoundappearancesmustalwaysbetakeninclinicalcontextandthereferrershouldbemadeawareofitslimitationsinthereport.Forexample:

• ultrasoundcannotexcludeintra-articularpathology• ultrasoundcannotexcludeimpingement.

Comparisonwiththecontralateralside(assumingitisasymptomatic)willhelpwhendeterminingtheclinicalsignificanceofage/activityrelatedchangesandshouldbeimagedanddocumentedinthereport.

Diagnosticultrasoundisoftenusedasaprecursortotherapeuticinjectionsandcareshouldbetakentoassistinthedirectionofthatinjection.Somestructuralchangesmaynotbecurrentlyrelevantandmaynotbeassociatedwithpain.

Thepitfallsofultrasoundinterpretationarewidelydocumented3andcanbereducedbyeducationandexperienceoftheindividualultrasoundpractitioner.

Examinationspecificguidelinesandcommonclinicalscenarios.

2.12.1 Shoulder

Purposeofscan

Toevaluatethefollowingstructures:


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• mainrotatorcufftendons–supraspinatus,infraspinatusandsubscapularistendons• longheadofbicepstendon• posteriorglenohumeraljoint• superficialacromioclavicularjoint.

Commonindications

Commonindicationsfortheperformanceofashoulderultrasoundscanare:

• ?rotatorcufftear/tendonopathy• restrictedrangeofmovement• painonabduction.

Contraindicationsandlimitations

Contraindicationsfordiagnosticshoulderscansareunlikely;however,somelimitationsexistandmayincludethefollowing:

• obesity• inabilitytoseestructuresthatliedeeptoboneorintra-articularstructuresoftheglenohumeraland

acromioclavicularjoints• casts,dressings,openwounds/ulcersetccanlimitvisualisation• severeoedema/swelling• patientswhoareunabletoco-operateorprovideaclinicalhistoryduetoreducedcognitivefunctions

egAlzheimer’sordementiaandthroughinvoluntarymovements.

Asage-relatedchangesarecommoninthemusculoskeletalsystem1,2 andmaynotbethecauseofthepatientssymptoms, ultrasound appearancesmust always be taken in clinical context and the referrer should bemadeawareofitslimitationsinthereport.Forexample:

• ultrasoundcannotexcludeimpingement• ultrasoundcannotexcludeintra-articularpathology.

Diagnosticultrasoundisoftenusedasaprecursortotherapeuticinjectionsandcareshouldbetakentoassistinthedirectionofthatinjection.Somestructuralchangesseenonultrasoundmaynotbecurrentlyrelevantandmaynotbeassociatedwithpain.Forexampleeffusioninthelongheadofbicepstendonsheathdoesnotalwaysreflectcurrenttenosynovitisbutmaybeanextensionofaglenohumeraljointeffusion.Theadditionofthesiteofcurrentsymptomonareportmayhelp.Subacromial/subdeltoidbursalthickeningmaybepresentontheasymptomaticshoulderanddoesnotalwaysreflectcurrent‘bursitis’soacomparisonimageandadditionofcurrentsymptomsmayhelp.Thepitfallsofultrasoundinterpretationarewidelydocumented3andcanbereducedbyeducationandexperienceoftheindividualultrasoundpractitioner.Scanprotocol

NumerousscanprotocolsfortheshoulderaredescribedintheliteratureincludingthatfromtheEuropeanSocietyofMusculoskeletalRadiology’s(ESSR)protocolfortheshoulder.4TrainingprotocolsalsoexistandmaybeusefultostandardisescanningandreportingsuchasthatdescribedbySmithetal.5Thestructuresthatshouldbeidentifiedasaminimuminastandardshoulderultrasoundscanare:


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• longheadofbicepstendon(LHBT)–forposition,tendonopathy,tears,calcification,tenosynovitis,effusion;

• rotatorinterval(RI)–ifLHBTisvisibleatthe(RI)itislikelytobeintactproximally;• subscapularistendon–fortendonopathy,tears,calcification;• infraspinatustendon-fortendonopathy,tears,calcification;• supraspinatustendon-fortendonopathy,tears,calcification;• anyvisiblebursaearoundtheshoulder–subacromial/subdeltoid,subcoracoid;• posteriorglenohumeraljoint–foreffusion,cysts,jointsynovitis;• acromioclavicularjoint–foreffusion,cysts,jointsynovitis.

Comparisonwiththecontra-lateralside(assumingitisasymptomatic)willhelpwhendeterminingtheclinicalsignificanceofage/activity-relatedchangesandshouldbeimagedanddocumentedinthereport.Anypathologyfoundshouldbedocumentedintwoplanes.Dynamicultrasoundassessment

Dynamicassessmentaroundtheshouldermaybecontroversialinsomecentresassomeindicationssuchas‘impingement’havemultiplepotentialcauses(someofwhichwillnotbeseenusingultrasound)andmaybeconsideredtobeapurelyclinicaldiagnosis.Dynamicassessmentusingultrasoundmayberequestedforthefollowing:

• longheadofbicepstendon:toassessitsstabilitywithinthebicipitalgrooveduringexternalrotation;• subscapularistendon:toidentifythemyotendinousareawhichnormallysitsbehindthecoracoid

processofthescapula;• supraspinatustendon:toassessforbunchingofthetendonand/oroverlyingsubacromialbursa

againsttheacromionorcoraco-acromialligamentduringabductionwhichmaybeacauseof‘impingement’;

• posteriorjointrecess:duringinternal/externalrotation,toassessforagleno-humeraljointeffusion.Thiswillbemostevidentduringexternalrotation.

Imagingprotocol

Astandardshoulderseriesshouldincludethefollowingminimumimagesforanormalscan:

• longheadofbicepstendon-longitudinalandtransverse;• rotatorintervalshowinganteriorportionofsupraspinatustendon,longheadofbicepsandlateral

edgeofsubscapularistendon;• subscapularistendon–longitudinalandtransverse;• supraspinatustendon–longitudinalandtransverse;• infraspinatustendon–longitudinalonly;• posteriorglenohumeraljointrecess;• acromioclavicularjoint.

Documentthenormalanatomyandanypathologyfound,includingmeasurementsandvascularityifindicated.Report(seealsorecommendationsfortheproductionofanultrasoundreport,section2.6)

Thereportisarecordingandinterpretationofobservationsmadeduringtheultrasoundexamination.Itshouldbewrittenbythepersonundertakingthescanandviewedinclinicalcontext.


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Areportisintendedtoansweraclinicalquestionandtoassistwiththepatientjourneysolocalopinionfromradiologists,rheumatologists,orthopaedicsurgeonsandphysiotherapistsshouldbetakenintoaccountintheconstructionoflocalreporttemplates.Asreportsarenowelectronic,theymaybeavailabletocliniciansinterveninglaterintheclinicalpathwayandsoshouldcontainallrelevantandappropriateinformation–forexampleanorthopaedicsurgeonmayaccessareportoriginallyrequestedbyageneralpractitionerorphysiotherapist.Thestandardshoulderreportshouldinclude:

• documentationofthenormalanatomy;• documentationofanypathologyincludingmeasurements/anyincreaseinvascularityifappropriate;• documentationofanylimitationtorangeofmovementandsiteanddegreethatpainorsymptoms

begin;• documentationofanydifficultieswithinterpretationoftheultrasoundappearances.

Thesamplereportsbelowareintendedasaguideonlyasreportingstylemaybespecifictoindividuals/departments.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportfornormalappearancesNormalappearancesoftherotatorcufftendons.Noevidenceoftearsorcalcificationoranybursalthickeningoreffusions.Thelongheadofbicepstendonisintactandinsitu.Noevidenceofagleno-humeraljointeffusion.UnremarkableACJnoted.Ifappropriate,thereportmayincludethefollowing:

• therotatorcufftendonshavereasonabledepthandtexture;• thereisevidenceofsubacromial/subdeltoidbursalthickeningbutnomoresothanonthe

symptomaticshoulder;• thereisgood,painfreesubacromialmovement;• non-tenderACJOAnoted.

--------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportfortendonopathyThesupraspinatustendonappearsgenerallythickened/thinnedandtendonopathicwithlossofthenormalfibrillarpattern.Notearsseen.Focaltendonopathicchangesarenotedattheanterior/middle/posteriorportionofthesupraspinatustendon,notearsseen.-------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportforcalcifictendonopathyAxmmintratendinouscalciumdepositis(calcificflecksare)notedwithintheant/mid/postaspectofthesupraspinatustendon;notearsevident.Thereisa6mmdenselyshadowingcalcificdepositwithinthesupraspinatustendon.Thereisa6mmnonshadowingdepositwithinthesupraspinatustendonlikelytobesoftcalcifictendonopathy.Thereismarkedcalcifictendonopathyoftherotatorcufftendons.Thelargestareaofcalcificationinthesupraspinatustendonmeasures15mmindiameterandthepatientistenderonscanning.


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------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportforbursitisThesubacromial/subdeltoidbursacontainsaneffusionandthewallishyperaemiconpowerDoppler.Thepatientistendertoscanhereandappearancesareconsistentwithbursitis.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportsforlongheadofbicepstendonThelongheadofbicepstendonisintactbuthasdislocatedfromthebicipitalgroovemediallyandissittingonthesurfaceofthesubscapularistendon.Thelongheadofbicepstendonhassubluxedontothemediallipofthebicipitalgroove.Thetendonisthickenedandappearsoedematous.Thetendonsheathishyperaemicandcontainsaneffusionandthepatientistendertoscanhere.Ultrasoundappearancessuggestanintactsubluxedlongheadofbicepstendonwithevidenceoftenosynovitis.------------------------------------------------------------------------------------------------------------------------------------------------------

TendontearsRotatorcufftendontearsareoftenseeninasymptomaticindividualsandarenotalwaysthecauseofsymptoms.Itissometimesdifficultfortheultrasoundpractitionertoappreciatethesignificanceofatearonthepatient’scurrentclinicalsymptomsandwhileitisimportanttoevaluateandaccuratelydescribetears,careshouldbetakenifdiscussingscanfindingswiththepatient.Whenreporting,itisimportanttodescribethetypeoftear–partial,fullorcomplete–andthedimensionsandsiteofthetear.Anopiniononthestateoftheremainingtendontissueisalsohelpful.Thesedetailsareimportantforsubsequenttreatmentandsurgicalplanningastendonswithseveretendonopathyarelesslikelytohaveasuccessfulrepairshouldsurgerybecomeappropriate.Measurements

Type,sizeandlocationoftearsisimportantandmeasurementsoffullthicknesstearsshouldbemadeintwoplanes–anteriortoposterior(transverse)andmedialtolateral(longitudinal).Thesiteofthetearmeasuredfromtherotatorintervalisalsouseful.

SiteofsupraspinatustendontearsThesupraspinatustendoncanbedividedintoanterior,midandposteriorportions.Theanteriorfreeorleadingedge,themid-substanceorfootprintandtheareathatabutstheinfraspinatustendon-thedistinctionbetweenthetwotendonscanbedifficulttodefine.Anteriorleadingedgetearsinvolvetheportionofthesupraspinatustendonthatliesadjacenttothelongheadofbicepstendonattherotatorinterval.Ifthereisstilltendontissueanteriortothetear,thetearissaidtobemidsubstance,crescentorfootprint.Ifthetearoccursatthesupraspinatus/infraspinatusinterfaceitissaidtobeposterior.Typesoftear

Partialthicknesstear:Arotatorcufftendontearthatinvolveseitherthejointorbursalsurfaceofatendonanddoesnotallowcommunicationbetweenthetwocompartments.Partialthicknesstearsmaybearticularsurface,bursalsurfaceorintrasubstance.Articularsurfacetear:Apartialthicknessrotatorcufftearinvolvingthearticularorjointsurfaceofthetendon.Inthesupraspinatus,theycanbecalled‘rimrent’orPASTAlesion–PartialArticularSupraspinatusTendonAvulsion.


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Bursalsurfacetear:Apartialthicknessrotatorcufftearinvolvingthebursalsurfaceofthetendon.Inthesupraspinatustendon,thisissometimescalled‘scuffing’asitiscausedbyfrictionfromtheundersurfaceoftheacromion.Intrasubstancetear:Apartialthicknessrotatorcufftearwithinthesubstanceofthetendon–sometimescalledconcealedinterstitialdelamination(CID).Acleftispresentwithinthetendonsubstancebutitdoesnotreacheitherthebursalorarticularsurfacesofthetendon.Fullthicknesstear:Arotatorcufftendontearthatextendsacrossthewholedepthofthetendon,involvesbothsurfacesandresultingincommunicationbetweenthejointandbursalcompartments,regardlessofthewidthofthetear.Somefullthicknesstearsmeasureover3cmindiameter;somelooklikepinholes.Completefullthicknesstear:Afullthicknesstendontearthatextendsacrossthewholewidthanddepthofthetendon,usuallyresultinginretractionbackfromtheinsertion.Iftheteariscomplete,theentirewidthofthetendonwillhavetorn,usually(butnotalways)attheinsertionandthereisretractionoftheproximalstump.Thedegreeofretractionwillvarybutinthesupraspinatusandsubscapularistendonscanresultintheproximalstumpsittingundertheacromion/coracoidandsonotvisiblewithultrasound.Thisisanimportantfindingforsurgeonsbecauseitislesslikelythatthetendoncanbepulledbackandrepaired.Asupraspinatustendontearisoftengivenanincreasedlevelofimportancecomparedtotheotherrotatorcufftendonsasitismoreoftensymptomaticandamenabletosurgery.------------------------------------------------------------------------------------------------------------------------------------------------------Samplereportsfortears

PartialthicknesstearThereisapartialthicknesstearofthebursal(orarticular)surface(orintrasubstance)oftheanterioraspectofthesupraspinatustendonwhichmeasures2mminlongitudinalsectionand3mmintransversesection.Thesupraspinatustendonappearsgenerallytendonopathicandthereisapartialthickness(articular)(bursal)surfacetearwithintheanterior/middle/posteriorportionofthistendon.Thistearmeasuresxxmmxxxmmandaffectsover(orunder)50%ofthetendondepth.Thereisapartialthicknesstearonthearticularsurfaceofthesupraspinatustendonlyingxmmposteriortotherotatorinterval.Itmeasuresxxmminwidthandextendsover(orunder)50%ofthetendondepth.Theremainderofthetendonhasreasonabledepthandtexture.FullthicknesstearThereisafullthickness,insertionaltearofthesupraspinatustendonlyingxxmmposteriortotherotatorinterval.Thetearmeasuresxxmminwidthandthereisxxmmretractionfromtheinsertion.Theremainderofthetendonhasreasonabledepthandtexture.CompletefullthicknesstearThesupraspinatustendonhascompletelyrupturedandretracted;theretractedtendonendisnotvisualised.Cuffarthropathynoted.Thereisacomplete,fullthicknesstearofthesupraspinatustendonwithproximalretractionofxmmfromtheinsertion.---------------------------------------------------------------------------------------------------------------------------------------------------


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GlossaryoftermsBursitis:thickeningandinflammationofabursa,oftencausinganeffusion.Thickeningofthebursaalonedoesnotconstitute‘bursitis’.Comparisonwiththeasymptomaticsideisimportant.Hyperaemiaofthebursalwallusingcolour/powerDopplerisoftenpresentinsymptomaticbursitis.Calcifictendonopathy:calcificationwithintendons.Thepresentationofcalcifictendonopathymayvaryfromtinycalcificfleckstolargeconglomerateswhichmayappear‘soft’andnon-shadowing,ordenserwithadenseposterioracousticshadow.Cuffarthropathy:arthritisoftheglenohumeraljoint,particularlythehumeralheadduetomassiverotatorcufftearsleavinga‘bare’humeralhead.Effusion:acollectionoffluidinatendonsheath,jointorbursa.Jointsynovitis:thickeningandoftenhyperaemiaofthesynoviumliningajoint.LHBtendondislocation:thelongheadofbicepstendonmovesoutofthebicipitalgroovemedially,owingtodisruptionofthetransversehumeralligament.Thismovementmaybetransient–subluxationonexternalrotationofthejoint,oritmaystaydislocated,regardlessofpatientmovement.Rotatorinterval:thespacebetweenthesubscapularisandsupraspinatustendonsthroughwhichthelongheadofbicepstendonpassesasitexitstheglenohumeraljoint.Tendonitis:notgenerallyusednowforrotatorcufftendonsasthissuggestsaninflammatoryprocessthathasnotbeenproven.Tendonopathy:Amoregeneraltermforadiseasedtendon.Tendonosis:adegenerativeprocesswithinatendon,disorderedbiomechanicsoftenleadingtomicrotears.Tenosynovitis:inflammationofthetendonandsheath–onlypossiblewithlongheadofbicepstendon.AppearancesshouldincludetendonsheaththickeningandhyperaemiaonDoppler,painonpalpation.Mayalsoincludeeffusionandtendonopathybutthesemaybepresentwithoutcurrenttenosynovitis.References1)GirishG,LoboLG,JacobsonJAetal.Ultrasoundoftheshoulder:asymptomaticfindingsinmen.AmJ

Roentgenol2011;197:W713–92)TempelhofS,RuppS,SeilR.Age-relatedprevalenceofrotatorcufftearsinasymptomaticshoulders.JShoulder

ElbowSurg1999;8:296–93)RuttenMJ,JagerGJ,BlickmanJG.FromtheRSNArefreshercourses:USoftherotatorcuff:pitfalls,limitations,

andartifacts.Radiographics2006;26:589–6044) BeggsI,BianchiS,BuenoA,etal.MusculoskeletalultrasoundtechnicalguidelinesI.Shoulder.European

SocietyofMusculoSkeletalRadiology.5)SmithMJ,RogersA,AmsoN,KennedyJ,HallA,MullaneyP.Atraining,assessmentandfeedbackpackagefor

thetraineeshouldersonographer.Ultrasound2015;23(1):29-412.12.2 ElbowPurposeofscan

Toevaluateanyofthefollowingstructureswhereappropriateandsymptomatic:


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• commonextensorandflexortendons;• medialulnarcollateralligament;• lateralradialcollateralligament;• distalbicepstendon;• tricepstendon;• cubitaltunnelandulnarnerve;• elbowjoints/olecranonfossa.

Commonindications

Commonindicationsfortheperformanceofanelbowultrasoundscanare:

• ?‘tennis’or‘golfers’elbow/epicondylitis;• restrictedrangeofmovement?effusion/synovitis;• ?distalbicepstendontear;• ?ulnarnervecompression;• olecranonbursitis.


Contraindicationsfordiagnosticelbowscansareunlikely;howeversomelimitationsexistandmayincludethefollowing:

• obesity;• inabilitytoseeintra-articularstructures;• casts,dressings,openwounds/ulcersetccanlimitvisualisation• severeoedema/swelling;• patientswhoareunabletocooperateorprovideaclinicalhistoryduetoreducedcognitivefunctions

egAlzheimer’sordementiaandthroughinvoluntarymovements.Asagerelatedchangesarecommoninthemusculoskeletalsystemandmaynotbethecauseofthepatient’ssymptoms,ultrasoundappearancesmustalwaysbetakeninclinicalcontextandthereferrershouldbemadeawareofitslimitationsinthereport.Forexample:

• ultrasoundcannotexcludeintraarticularpathology.Diagnosticultrasoundisoftenusedasaprecursortotherapeuticinjectionsandcareshouldbetakentoassistinthedirectionofthatinjection.Somestructuralchangesmaynotbecurrentlyrelevantandmaynotbeassociatedwithpain.Thepitfallsofultrasoundinterpretationarewidelyrecognisedandcanbereducedbyeducationandexperienceoftheultrasoundpractitioner.ScanprotocolNumerousscanprotocolsfortheelbowaredescribedintheliterature.1,2Unliketheshoulder,diagnosticscanningoftheelbowisusuallyfocussedonasinglestructure,forexamplethecommonextensortendonfor‘?tenniselbow’,butotherstructuresmaybeincludedifappropriateandsymptomaticandwithintheclinicalexperienceoftheultrasoundpractitioner.2Theseinclude:

• commonextensortendon-fortendonopathy,neovascularity,tears,calcification;• commonflexortendon-fortendonopathy,neovascularitytears,calcification;


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• distalbicepstendon-fortendonopathy,tears,calcification;• olecranonbursa-foreffusion/bursitis;• anteriorandposteriorjointrecesses-foreffusion,jointsynovitis;• cubitaltunnel-forulnarnerveenlargement/flattening/subluxation.

Anypathologyfoundshouldbedocumentedintwoplanes.Dynamicultrasoundassessment

Dynamicassessmentusingultrasoundmayberequestedforthefollowingbutdependsontheskillandexpertiseoftheultrasoundpractitioner:

• ?ulnarnervesubluxation• ?medial/lateralligamenttears

Imagingprotocol

Thereisnostandardelbowseriesastheareasscannedaredependentonsymptomsandpathologyfound.Thefollowingprotocolsareaguidetoeacharea:

• CEO/CFOlongitudinalwithcolourboxtoshowtheabsenceofneovascularity;• distalbicepstendoninlongitudinalandtransverse,distaltendoninsertioninlongitudinaland

myotendinousareaintransversetoexcludetear/tendonopathy/calcification.Comparisonwithcontralateralside;

• anteriorandposteriorjointrecesswithinandwithoutcolourboxtoshowtheabsenceofeffusionorsynovitis;

• cubitaltunnelwitharminflexion/extensiontoexcludesubluxationoftheulnarnerve;• medial/lateralligamentsinlongitudinalinstressedandrelaxedpositionsifappropriate.

Documentthenormalanatomyandanypathologyfound,includingmeasurementsandvascularityifindicated.Report(seealsorecommendationsfortheproductionofanultrasoundreport,section2.6)Thereportisarecordingandinterpretationofobservationsmadeduringtheultrasoundexamination.Itshouldbewrittenbythepersonundertakingthescanandviewedinclinicalcontext.Areportisintendedtoansweraclinicalquestionandtoassistwiththepatientjourneysolocalopinionfromradiologists,rheumatologists,orthopaedicsurgeonsandphysiotherapistsshouldbetakenintoaccountintheconstructionoflocalreporttemplates.Asreportsarenowelectronic,theymaybeavailabletocliniciansinterveninglaterintheclinicalpathwayandsoshouldcontainallrelevantandappropriateinformation–forexampleanorthopaedicsurgeonmayaccessareportoriginallyrequestedbyageneralpractitionerorphysiotherapist.Thestandardelbowreportshouldinclude:




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Thesamplereportsbelowareintendedasaguideonlyasreportingstylemaybespecifictoindividuals/departments.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportfornormalappearancesNormalappearancesofthecommonextensor/flexor/distalbicepstendonsoftheelbow.Noevidenceofsignificanttendonopathy,tearsorcalcification.Noevidenceofjointeffusionorsynovitisbutultrasoundcannotexcludeintra-articularpathology.Theulnarnerveappearsnormalincalibrearoundtheelbowandisstablewithinthecubitaltunnelondynamicscanning’.Nosolidorcysticlesionsseeninthecubitaltunnel.

----------------------------------------------------------------------------------------------------------------------------------------------------SamplereportfortendonopathyThetendonappearsgenerallythickened/thinnedwithlossofthenormalfibrillarpattern.ThereisevidenceofneovascularityonDopplerandappearancesareconsistentwithtendonopathy.Notearsseen.Focaltendonopathicchangesarenotedattheproximal/distalportionofthetendon,notearsseen.-----------------------------------------------------------------------------------------------------------------------------------------------------SamplereportforcalcifictendonopathyAxmmintratendinouscalciumdepositis(calcificflecksare)notedwithintheproximal/distalportionofthetendon,notearsevident.Thereisa6mmdenselyshadowingcalcificdepositwithinthetendon.Thereisa6mmnonshadowingdepositwithinthetendonlikelytobesoftcalcifictendonopathy.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportforolecranonbursitisTheolecranonbursacontainsaneffusionandthewallishyperaemiconpowerDoppler.Thepatientistendertoscanhereandappearancesareconsistentwithbursitis.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportfortendontearsWhenreporting,itisimportanttodescribethetypeoftear–partialorcomplete–andthedimensionsandsiteofthetear.Anopiniononthestateoftheremainingtendontissueisalsohelpful.Thereisawell-defined,cysticareawithintheproximalportionofthetendonmeasuringXXmmindiameterandextendingacrossapproximatelyxx%ofthetendondepth.Appearancesareconsistentwithcysticdegeneration/partialthicknesstear.Thereisacompleteinsertionaltearofthedistalbicepstendonwithretractionofxxmmfromtheinsertion.Thereislossofthenormalfibrillarypatterninthedetachedtendonsuggestingtendonopathy.Thereisalargefluidcollectionaroundthedistalpoleofthebicepsmusclelikelytobearesolvinghaematoma.Thedistalbicepstendonisintactattheinsertionbutappearstohavecompletelytornatthemyotendinousjunction.------------------------------------------------------------------------------------------------------------------------------------------------------GlossaryoftermsBursitis:thickeningandinflammationofabursa,oftencausinganeffusion.Thickeningofthebursaalonedoesnotconstitute‘bursitis’.Comparisonwiththeasymptomaticsideisimportant.Hyperaemiaofthebursalwallusingcolour/powerDopplerisoftenpresentinsymptomaticbursitis.


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Calcifictendonopathy:calcificationwithintendons.Thepresentationofcalcifictendonopathymayvaryfromtinycalcificfleckstolargeconglomerateswhichmayappear‘soft’andnon-shadowing,ordenserwithadenseposterioracousticshadow.Effusion:acollectionoffluidinatendonsheath,jointorbursa.Jointsynovitis:thickeningandoftenhyperaemiaofthesynoviumliningajoint.Tendonitis:notgenerallyusednowfortendonsasthissuggestsaninflammatoryprocessthathasnotbeenproven.Tendonosis:adegenerativeprocesswithinatendon,disorderedbiomechanicsoftenleadingtomicrotears.Tendonopathy:amoregeneraltermforadiseasedtendon.Tenosynovitis:inflammationofthetendonandsheath:AppearancesshouldincludetendonsheaththickeningandhyperaemiaonDoppler,painonpalpation.Mayalsoincludeeffusionandtendonopathybutthesemaybepresentwithoutcurrenttenosynovitis.References1)BeggsI,BianchiS,BuenoAetal.MusculoskeletalultrasoundtechnicalguidelinesI.Elbow.EuropeanSocietyofMusculoSkeletalRadiology.2)DraghiF,DanesinoGM,deGautardR,BianchiS.UltrasoundoftheelbowJournalofUltrasound(2007)10,76e842.12.3 Wristandhand

Purposeofscan


• extensorandflexortendons;• joints of the hand/wrist and metacarpophalangeal (MCP), proximal interphalangeal (PIP), distal

interphalangeal(DIP)andcarpometacarpal(CMC)joints;• ligamentsofthethumb/fingerjoints;• carpaltunnel;• Guyon’scanal.

Commonindications

Commonindicationsfortheperformanceofawrist/handultrasoundscanare:

• Swelling?ganglion• ?effusion/synovitis• ?tendontear


Contraindicationsfordiagnosticwrist/handscansareunlikely;howeversomelimitationsexistandmayincludethefollowing:

• obesity;• inabilitytoseeintra-articularstructures;• casts,dressings,openwounds/ulcersetc.canlimitvisualisation;


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• severeoedema/swelling;• patientswhoareunabletocooperateorprovideaclinicalhistoryduetoreducedcognitivefunctions

egAlzheimer’sordementiaandthroughinvoluntarymovements.Asage-relatedchangesarecommoninthemusculoskeletalsystemandmaynotbethecauseofthepatient’ssymptoms,ultrasoundappearancesmustalwaysbetakeninclinicalcontextandthereferrershouldbemadeawareofitslimitationsinthereport.Forexample:

• ultrasoundcannotexcludeintra-articularpathology.• Themediannerveisenlargedandappearsflattenedinthecarpaltunnelsuggestiveofcarpaltunnel

syndromeifthereisclinicalcorrelation.Diagnosticultrasoundisoftenusedasaprecursortotherapeuticinjectionsandcareshouldbetakentoassistinthedirectionofthatinjection.Somestructuralchangesmaynotbecurrentlyrelevantandmaynotbeassociatedwithpain.Thepitfallsofultrasoundinterpretationarewidelydocumentedandcanbereducedbyeducationandexperienceoftheindividualultrasoundpractitioner.Scanprotocol

Numerousscanprotocolsforthehandandwristaredescribedintheliterature.1,2Unliketheshoulder,diagnosticscanningofthehand/wristisusuallyfocussedtoasingleareaorpathology.Forexample,thedorsumofthewristfor‘?ganglion’orthejointsofthehandandwristfor‘?synovitis’.Otherstructuresmaybeincludedifappropriateandsymptomaticandwithintheclinicalexperienceoftheultrasoundpractitioner.Theseinclude:

• extensorandflexortendonsfortendonopathy,tenosynovitis,tears,calcification;• fingerpulleysfortriggering;• jointsofthehand/wristforsynovitisoreffusion;• bonycortexforerosions;• ligamentsofthethumb/fingersforsprainsortears;• carpalorGuyon’stunnelfornervecompression.

Comparisonwiththecontralateralside(assumingitisasymptomatic)willhelpwhendeterminingtheclinicalsignificanceofage/activity-relatedchangesandshouldbeimagedanddocumentedinthereport.Anypathologyfoundshouldbedocumentedintwoplanes.Imagingprotocol

Thereisnostandardwristandhandseriesastheareasscannedaredependentonsymptomsandpathologyfound.Thefollowingprotocolsareaguidetoeacharea:

• tendonsandsheaths-longitudinalwithcolourboxtoshowtheabsenceofneovascularity;• tendonsinlongitudinalandtransverse,distaltendoninsertioninlongitudinaltoexclude

tear/tendonopathy/tenosynovitis/calcification.Comparisonwithcontralateralside;• dorsalandvolarwristjointswithandwithoutcolourboxtoshowtheabsenceofeffusionor

synovitis;• fingerligamentsinlongitudinal,instressedandrelaxedpositionsifappropriate.

Documentthenormalanatomyandanypathologyfound,includingmeasurementsandvascularityifindicated.Report(seealsorecommendationsfortheproductionofanultrasoundreport,section2.6)


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Thereportisarecordingandinterpretationofobservationsmadeduringtheultrasoundexamination;itshouldbewrittenbythepersonundertakingthescanandviewedinclinicalcontext.A report is intended to answer a clinical question and to assistwith thepatient journey so local opinion fromradiologists, rheumatologists, orthopaedic surgeons and physiotherapists should be taken into account in theconstructionoflocalreporttemplates.Asreportsarenowelectronic,theymaybeavailabletocliniciansinterveninglaterintheclinicalpathwayandsoshould contain all relevant and appropriate information – for example an orthopaedic surgeon may access areportoriginallyrequestedbyageneralpractitionerorphysiotherapist.The report should include correctpatientdemographics;dateofexamination;examination typeand thenameandstatusoftheultrasoundpractitioner.Thestandardwrist/handreportshouldinclude:



Thesamplereportsbelowareintendedasaguideonlyasreportingstylemaybespecifictoindividuals/departments.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportfornormalappearancesNormalappearancesofcompartmentoneoftheextensortendons.Theextensorpollicisbrevisandabductorpollicislongustendonsappearnormal.NoevidenceofDeQuervain’stenosynovitis.NoevidenceofactivesynovitisoreffusionseenarisingfromthewristsorwithintheMCPorPIPjs.Notenosynovitis.Noerosionsseen.TheulnarnerveappearsnormalincalibrethroughGuyon’stunnelandissymmetricalwiththeasymptomaticside.Noevidenceofcompressionorasolidorcysticlesioninthetunnel.------------------------------------------------------------------------------------------------------------------------------------------------------Samplereportfortendonopathy/tenosynovitisThetendonappearsgenerallythickened/thinnedwithlossofthenormalfibrillarpatternconsistentwithtendonopathy.Notearsseen.Thereiseffusionandhyperaemiaoftheflexortendonsheathconsistentwithtenosynovitis.Noevidenceofatendontear.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportforjointsynovitisThesescansareusuallylimitedtorheumatologypatientsandthereareseveralgradingsystemsinuse.Itisimportantthatanygradingsystemisdiscussedwithrheumatologybeforebeingused.ThereisamoderatedegreeofactivesynovitisarisingfromtherightwristandwithintherightandleftindexandmiddlefingerMCPjs.NoevidenceofactivesynovitisseenintheleftwristortheremainderofMCPorPIPjs.Notenosynovitis.-----------------------------------------------------------------------------------------------------------------------------------------------------Samplereportfortendontears


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Whenreporting,itisimportanttodescribethetypeoftear–partialorcomplete–andthedimensionsandsiteofthetear.Anopiniononthestateoftheremainingtendontissueisalsohelpful.Thereisacompletefullthicknesstearofthemiddlefingerflexordigitorumprofundustendonatthedistalinsertion.ThetendonhasretractedbacktothelevelofthePIPjointandappearsthinandtendonopathic.Theflexordigitorumsuperficialistendonremainsintactandappearsnormal.-------------------------------------------------------------------------------------------------------------------------------------------------------Glossaryofterms

Calcifictendonopathy:calcificationwithintendons.Thepresentationofcalcifictendonopathymayvaryfromtinycalcificfleckstolargeconglomerateswhichmayappear‘soft’andnon-shadowing,ordenserwithadenseposterioracousticshadow.Effusion:acollectionoffluidinatendonsheath,jointorbursa.Jointsynovitis:thickeningandoftenhyperaemiaofthesynoviumliningajoint.Tendonitis:notgenerallyusednowfortendonsasthissuggestsaninflammatoryprocessthathasnotbeenproven.Tendonosis:adegenerativeprocesswithinatendon,disorderedbiomechanicsoftenleadingtomicrotears.Tendonopathy:amoregeneraltermforadiseasedtendon.Tenosynovitis:inflammationofthetendonandsheath:AppearancesshouldincludetendonsheaththickeningandhyperaemiaonDoppler,painonpalpation.Mayalsoincludeeffusionandtendonopathybutthesemaybepresentwithoutcurrenttenosynovitis.References1)BeggsI,BianchiS,BuenoAetal.MusculoskeletalultrasoundtechnicalguidelinesI.Wrist.EuropeanSocietyofMusculoSkeletalRadiology.2)McNallyEG.Ultrasoundofthesmalljointsofthehandsandfeet:currentstatusSkeletalRadiol(2008)37:99–1132.12.4HipPurposeofscan


• anteriorhipjoint;• trochantericbursaeandglutealtendons;• proximalhamstrings;• distalpsoastendon;• adductormuscle/tendons.

Commonindications

Commonindicationsfortheperformanceofahipultrasoundscanare:

• ?effusion/synovitis;• ?bursitis;• ?hamstringtear;


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• ?enthesopathy.Contraindicationsandlimitations

Contraindicationsfordiagnostichipscansareunlikely;howeversomelimitationsexistandmayincludethefollowing:

• obesity;• inabilitytoseeintra-articularstructures;• casts,dressings,openwounds/ulcersetccanlimitvisualisation;• severeoedema/swelling;• patientswhoareunabletocooperateorprovideaclinicalhistoryduetoreducedcognitivefunctions


As age-related changes are common in themusculoskeletal system andmay not be the cause of the patientssymptoms, ultrasound appearancesmust always be taken in clinical context and the referrer should bemadeawareofitslimitationsinthereportforexample:

• ultrasoundcannotexcludeintra-articularpathologyDiagnosticultrasoundisoftenusedasaprecursortotherapeuticinjectionsandcareshouldbetakentoassistinthedirectionofthatinjection.Somestructuralchangesmaynotbecurrentlyrelevantandmaynotbeassociatedwithpain.Thepitfallsofultrasoundinterpretationarewidelydocumentedandcanbereducedbyeducationandexperienceoftheindividualultrasoundpractitioner.

Scanprotocol

Hipscanningprotocolsaredescribedintheliterature1.Unliketheshoulder,diagnosticscanningofthehipisusuallyfocussedtoasingleareaorpathology.Forexampletheanteriorhipjointfor?effusion.Otherstructuresmaybeincludedifappropriateandsymptomaticandwithintheclinicalexperienceoftheultrasoundpractitioner.Theseinclude:

• anteriorhipjointforsynovitisoreffusion;• anteriorhip/psoastendonfortendonopathy,bursitis;• greatertrochantericareaforbursitis,glutealenthesopathy,tendonopathy/tears/calcification;• adductortendonsforenthesopathy,tears,tendonopathy,calcification;• anteriorthightendonsforenthesopathy,tears,tendonopathy,calcification;• posteriorhamstringtendonsenthesopathy,tears,tendonopathy,calcification.

Comparisonwiththecontralateralside(assumingitisasymptomatic)willhelpwhendeterminingtheclinicalsignificanceofage/activityrelatedchangesandshouldbeimagedanddocumentedinthereport.Anypathologyfoundshouldbedocumentedintwoplanes.Imagingprotocol

Thereisnostandardhipimagingseriesastheareasscannedaredependentonsymptomsandpathologyfound.Thefollowingprotocolsareaguidetoeacharea:


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• anteriorhipjointlongitudinalwithandwithoutcolourboxtoshownoeffusionorsynovitis(ensureDopplersettingscapableofdetectingdeepflow);

• anteriorhip/psoastendoninlongitudinalandtransversetoshownormaltendonwithnobursaleffusion;

• greatertrochantericareainlongitudinalandtransversetoshownormaltendonswithnobursaleffusion;

• adductortendonsinlongitudinaltoshownotears;• anteriorthightendoninsertionsinlongitudinalandtransverse;• posteriorhamstringtendonsinlongitudinalandtransverse.

Documentthenormalanatomyandanypathologyfound,includingmeasurementsandvascularityifindicated.Report(seealsorecommendationsfortheproductionofanultrasoundreport,section2.6)Thereportisarecordingandinterpretationofobservationsmadeduringtheultrasoundexamination;itshouldbewrittenbythepersonundertakingthescanandviewedinclinicalcontext.Areportisintendedtoansweraclinicalquestionandtoassistwiththepatientjourneysolocalopinionfromradiologists,rheumatologists,orthopaedicsurgeonsandphysiotherapistsshouldbetakenintoaccountintheconstructionoflocalreporttemplates.Asreportsarenowelectronic,theymaybeavailabletocliniciansinterveninglaterintheclinicalpathwayandsoshouldcontainallrelevantandappropriateinformation–forexampleanorthopaedicsurgeonmayaccessareportoriginallyrequestedbyageneralpractitionerorphysiotherapist.Thereportshouldincludecorrectpatientdemographics;dateofexamination;examinationtypeandthenameandstatusoftheultrasoundpractitioner.Thestandardhipreportshouldinclude:

• documentationofthenormalanatomy;• documentationofanypathologyincludingmeasurements/anyincreaseinvascularityifappropriate;• documentanylimitationtorangeofmovementandsiteanddegreethatpainorsymptomsbegin;• documentanydifficultieswithinterpretationoftheultrasoundappearances.

Thesamplereportsbelowareintendedasaguideonlyasreportingstylemaybespecifictoindividuals/departments.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportfornormalappearancesNoevidenceofajointeffusionorsynovitisseenarisingfromtheanteriorhipjointalthoughintra-articularpathologycannotbeexcludedwithultrasound.Normalappearancesofthedistaliliopsoastendonwithnoevidenceofbursitis.Normalappearancesoftheposteriorhamstringoriginattheischialtuberosity.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportfortendonopathyThegluteusmediustendonappearsgenerallythickened/thinnedwithlossofthenormalfibrillarpatternconsistentwithtendonopathy.Notearsseen.Noevidenceofatrochantericbursaleffusion.------------------------------------------------------------------------------------------------------------------------------------------------------Samplereportforjointeffusion


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Thereisaneffusionintheanteriorhipjointcapsulemeasuringxxmmindepthcomparedtoxmmontheasymptomaticside.Theeffusiondoesnotappeartobecomplexbutinfectioncannotbeexcluded.------------------------------------------------------------------------------------------------------------------------------------------------------GlossaryoftermsCalcifictendonopathy:calcificationwithintendons.Thepresentationofcalcifictendonopathymayvaryfromtinycalcificfleckstolargeconglomerateswhichmayappear‘soft’andnon-shadowing,ordenserwithadenseposterioracousticshadow.Effusion:acollectionoffluidinatendonsheath,jointorbursa.Jointsynovitis:thickeningandoftenhyperaemiaofthesynoviumliningajoint.Tendonitis:notgenerallyusednowfortendonsasthissuggestsaninflammatoryprocessthathasnotbeenproven.Tendonosis:adegenerativeprocesswithinatendon,disorderedbiomechanicsoftenleadingtomicrotears.Tendonopathy:amoregeneraltermforadiseasedtendon.Tenosynovitis:inflammationofthetendonandsheath:AppearancesshouldincludetendonsheaththickeningandhyperaemiaonDoppler,painonpalpation.Mayalsoincludeeffusionandtendonopathybutthesemaybepresentwithoutcurrenttenosynovitis.References1)BeggsI,BianchiS,BuenoA,etal.MusculoskeletalultrasoundtechnicalguidelinesI.Shoulder.EuropeanSocietyofMusculoSkeletalRadiology.2)RowbothamE,GraingerA.Ultrasound-guidedinterventionaroundthehipjointAJR2011;197:W122–W1272.12.5 KneePurposeofscan


• quadricepsandpatellartendons;• supra-patellar,pre-patellar,superficialanddeepinfra-patellarbursae;• medialandlateralcollateralligaments;• pesanserinetendonsandbursa;• iliotibialband;• bicepsfemorisinsertion;• poplitealfossa;• semimembranosus/medialgastrocnemiustendons/bursa.

Commonindications

Commonindicationsfortheperformanceofakneeultrasoundscanare1

• ?effusion/synovitis;• ?bursitis;• ?poplitealcyst;• ?quadriceps/patellartendontear.


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Contraindicationsfordiagnostickneescansareunlikely;howeversomelimitationsexistandmayincludethefollowing:

• obesity;• inabilitytoseeintra-articularstructures;• casts,dressings,openwounds/ulcersetc.canlimitvisualisation;• severeoedema/swelling;• patientswhoareunabletocooperateorprovideaclinicalhistoryduetoreducedcognitivefunctions

e.g.Alzheimer’sordementiaandthroughinvoluntarymovements.

As age-related changes are common in themusculoskeletal systemandmaynot be the causeof thepatient’ssymptoms, ultrasound appearancesmust always be taken in clinical context and the referrer should bemadeawareofitslimitationsinthereportforexample:

• ultrasoundcannotexcludeintra-articularpathologyIfmeniscalpathologyissuspectedeitherclinicallyorbyultrasound,furtherimagingwithmagneticresonanceimaging(MRI)orcomputedtomography(CT)iftherearecontraindicationstoMRIisadvisedasperlocalagreement.Diagnosticultrasoundisoftenusedasaprecursortotherapeuticinjectionsandcareshouldbetakentoassistinthedirectionofthatinjection.Somestructuralchangesmaynotbecurrentlyrelevantandmaynotbeassociatedwithpain.The pitfalls of ultrasound interpretation are widely documented and can be reduced by education andexperienceoftheindividualultrasoundpractitioner.Scanprotocol

Kneescanningprotocolsaredescribedintheliterature.2Unliketheshoulder,diagnosticscanningofthekneeisusuallyfocusedtoasingleareaorpathology.Forexamplethepoplitealfossafor?Baker’scyst.Otherstructuresmaybeincludedifappropriateandsymptomaticandwithintheclinicalexperienceoftheultrasoundpractitioner.Theseinclude:

• anteriorkneeforsynovitisoreffusioninthesuprapatellar,prepatellarorinfrapatellarbursae;• poplitealfossaforBaker’scystortoexcludeapoplitealarteryaneurysm;• extensortendonsordistalhamstringsfortendonopathy/tears/calcification/enthesopathy;• medialorlateralcollateralligamentsforstrains,tearsorcalcification.

Comparisonwiththecontralateralside(assumingitisasymptomatic)willhelpwhendeterminingtheclinicalsignificanceofage/activity-relatedchangesandshouldbeimagedanddocumentedinthereport.Asinallareas:anypathologyfoundshouldbeimagedintwoplanesandthefindingsdocumentedintwoplanes.Imagingprotocol

Thereisnostandardkneeimagingseriesastheareasscannedaredependentonsymptomsandpathologyfound.Thefollowingprotocolsareaguidetoeacharea:


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• anteriorkneelongitudinalimageswithandwithoutcolourboxtoshownoeffusionorsynovitisinthesuprapatellar,prepatellarorinfrapatellarbursae(ensureDopplersettingscapableofdetectingflowindeepstructures);

• longitudinalandtransverseimagesofquadricepsandpatellartendonstoshownormaltendonsandtheirinsertions;

• longitudinalimagesofmedialandlateralcollateralligaments;• longitudinalimagesofpoplitealfossatoshowposteriorjoint.

Documentthenormalanatomyandanypathologyfound,includingmeasurementsandvascularityifindicated.Report(seealsorecommendationsfortheproductionofanultrasoundreport,section2.6)Thereportisarecordingandinterpretationofobservationsmadeduringtheultrasoundexamination;itshouldbewrittenbythepersonundertakingthescanandviewedinclinicalcontext.Areportisintendedtoansweraclinicalquestionandtoassistwiththepatientjourneysolocalopinionfromradiologists,rheumatologists,orthopaedicsurgeonsandphysiotherapistsshouldbetakenintoaccountintheconstructionoflocalreporttemplates.Asreportsarenowelectronic,theymaybeavailabletocliniciansinterveninglaterintheclinicalpathwayandsoshouldcontainallrelevantandappropriateinformation–forexampleanorthopaedicsurgeonmayaccessareportoriginallyrequestedbyageneralpractitionerorphysiotherapist.Thereportshouldincludecorrectpatientdemographics;dateofexamination;examinationtype,siteexamined(includingcorrectsideorbothsides)andthenameandstatusoftheultrasoundpractitioner.Thestandardreportshouldinclude:



Thesamplereportsbelowareintendedasaguideonlyasreportingstylemaybespecifictoindividuals/departments.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportfornormalappearancesNoevidenceofeffusionorsynovitisseenwithinthesuprapatellar,prepatellarorinfrapatellarbursaealthoughintra-articularpathologycannotbeexcludedwithultrasound.Noevidenceofasolidorcysticlesionseeninthepoplitealfossa.NoBaker’scyst.Thepoplitealarteryisofnormalcalibre.Normalappearancesofthequadricepsandpatellartendons.Normalfibrillarpattern.Noevidenceoftendontears,calcificationorenthesitis.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportforquadricepstendontearThereisacompletetearofthequadricepstendonatitsinsertionontothesuperiorpoleofthepatellar.Withthekneejointextended,thetendonhasretractedproximallybyxxmm.Thepatellartendonisintact.------------------------------------------------------------------------------------------------------------------------------------------------------Samplereportforkneeeffusion


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There isasmall/medium/largeeffusion in thesuprapatellarbursawithevidenceofsynovitis. Theeffusiondoesnotappeartobecomplex.----------------------------------------------------------------------------------------------------------------------------------------SamplereportforBakerscyst/semi-membranosusThere is awell-defined, simple cystic lesion in themedial popliteal fossameasuring xxmm. It lies between themedial head of gastrocnemius and the semimembranosus tendon, measured at 5.6 cm in maximum axialdiameter.ThesiteandappearancesofthislesionareconsistentwithaBaker’scyst.------------------------------------------------------------------------------------------------------------------------------------------------------GlossaryoftermsCalcifictendonopathy:calcificationwithintendons.Thepresentationofcalcifictendonopathymayvaryfromtinycalcific flecks to large conglomerates which may appear ‘soft’ and non-shadowing, or denser with a denseposterioracousticshadow.Effusion:acollectionoffluidinatendonsheath,jointorbursa.Jointsynovitis:thickeningandoftenhyperaemiaofthesynoviumliningajoint.Tendonitis: not generally used now for tendons as this suggests an inflammatory process that has not beenproven.Tendonosis:adegenerativeprocesswithinatendon,disorderedbiomechanicsoftenleadingtomicrotears.Tendonopathy:amoregeneraltermforadiseasedtendon.Tenosynovitis:inflammationofthetendonandsheath:AppearancesshouldincludetendonsheaththickeningandhyperaemiaonDoppler,painonpalpation.Mayalsoincludeeffusionandtendonopathybutthesemaybepresentwithoutcurrenttenosynovitis.References1)RazekA,FoudaNS,ElmetwaleyN,ElbogdadyE.SonographyofthekneejointJournalofUltrasound(2009)12,53e602)BeggsI,BianchiS,BuenoA,etal.MusculoskeletalultrasoundtechnicalguidelinesVKnee.EuropeanSocietyofMusculoSkeletalRadiology.2.12.6 FootandAnklePurposeofscan


• anterioranklejoint;• medialankle–posteriortibial,flexordigitorumlongusandflexorpollicislongustendonsand

neurovascularbundle;• lateralankletendons–peroneusbrevisandlongus;• anteriortendons–anteriortibialextensorhallucislongusandextensordigitorumlongustendons;• achillestendonandinsertion,retrocalcanealandpre-Achillesbursa;• plantarfascia;• dorsalsurfaceoftarsaljoints;• MTPjoints;• interdigitalspaces;


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• someligaments–anteriortalofibular,anteriortibiofibular,calcaneofibular,deltoid.Commonindications

Commonindicationsfortheperformanceofafoot/ankleultrasoundscanare:

• ?Morton’sneuroma;• medialanklepain.?posteriortibialrupture/dysfunction;• injury.?Achillestendontear.


Contraindicationsfordiagnosticfoot/anklescansareunlikely;howeversomelimitationsexistandmayincludethefollowing:

• obesity;• inabilitytoseeintra-articularstructures;• casts,dressings,openwounds/ulcersetc.canlimitvisualisation;• severeoedema/swelling;• patientswhoareunabletocooperateorprovideaclinicalhistoryduetoreducedcognitivefunctions


Asage-relatedchangesarecommoninthemusculoskeletalsystemandmaynotbethecauseofthepatient’ssymptoms,ultrasoundappearancesmustalwaysbetakeninclinicalcontextandthereferrershouldbemadeawareofitslimitationsinthereportforexample:

• ultrasoundcannotexcludeintra-articularpathology• thereisevidenceofcompleteruptureoftheanteriortalofibularandtibiofibularligamentssuggesting

significantinstabilitybutultrasoundcannotexcludefurtherintra-articularinjuryandfurtherimagingissuggested.

Diagnosticultrasoundisoftenusedasaprecursortotherapeuticinjectionsandcareshouldbetakentoassistinthedirectionofthatinjection.Somestructuralchangesmaynotbecurrentlyrelevantandmaynotbeassociatedwithpain.Thepitfallsofultrasoundinterpretationarewidelydocumentedandcanbereducedbyeducationandexperienceoftheindividualultrasoundpractitioner.Scanprotocol

Numerousscanprotocolsforthefootandanklearedescribedintheliterature.1Unliketheshoulder,diagnosticscanningofthefoot/ankleisusuallyfocussedtoasingleareaorpathology.Forexample,interdigitalspacesfor?Morton’sneuroma.Otherstructuresmaybeincludedifappropriateandsymptomaticandwithintheclinicalexperienceoftheultrasoundpractitioner.Theseinclude:

• extensorandflexortendonsfortendonopathy,tenosynovitis,tears,calcification;• jointsofthefoot/ankleforsynovitisoreffusion;• ligamentsoftheankleforsprainsortears;• tarsaltunnelfornervecompression;• interdigitalspaces2/3and3/4forMorton’sneuromata;• plantarfasciaforfasciopathy;• Achillestendonfortendonopathy,enthesitis,enthesopathy,tears,calcification.

Comparison with the contralateral side (assuming it is asymptomatic) will help when determining the clinicalsignificanceofage/activity-relatedchangesandshouldbeimagedanddocumentedinthereport.


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Anypathologyfoundshouldbedocumentedintwoplanes.Imagingprotocol

Thereisnostandardfootandankleseriesastheareasscannedaredependentonsymptomsandpathologyfound.Thefollowingprotocolsareaguidetoeacharea:

• tendonsandsheaths/paratenon-longitudinalwithcolourboxtoshowtheabsenceofneovascularity;

• tendonsinlongitudinalandtransverse,distaltendoninsertioninlongitudinaltoexcludetear/tendonopathy/tenosynovitis/calcification.Comparisonwithcontralateralside;

• anterioranklerecessorMTPjointswithandwithoutcolourboxtoshowtheabsenceofeffusionorsynovitis;

• ankleligamentsinlongitudinalinstressedandrelaxedpositionsifappropriate.Documentthenormalanatomyandanypathologyfound,includingmeasurementsandvascularityifindicated.Report(seealsorecommendationsfortheproductionofanultrasoundreport,section2.6)Thereportisarecordingandinterpretationofobservationsmadeduringtheultrasoundexamination;itshouldbewrittenbythepersonundertakingthescanandviewedinclinicalcontext.Areportisintendedtoansweraclinicalquestionandtoassistwiththepatientjourneysolocalopinionfromradiologists,rheumatologists,orthopaedicsurgeonsandphysiotherapistsshouldbetakenintoaccountintheconstructionoflocalreporttemplates.Asreportsarenowelectronic,theymaybeavailabletocliniciansinterveninglaterintheclinicalpathwayandsoshouldcontainallrelevantandappropriateinformation–forexampleanorthopaedicsurgeonmayaccessareportoriginallyrequestedbyageneralpractitionerorphysiotherapist.Thereportshouldincludecorrectpatientdemographics;dateofexamination;examinationtypeandthenameandstatusoftheultrasoundpractitioner.Thestandardfoot/anklereportshouldinclude:



Thesamplereportsbelowareintendedasaguideonlyasreportingstylemaybespecifictoindividuals/departments.------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportfornormalappearancesNormalappearancesoftheposteriortibialtendon.Gooddepthandnormalfibrillarypatternwithnoevidenceoftearssignificanttendonopathyorintratendinouscalcification.Noevidenceoftenosynovitis.Noevidenceofactivesynovitisoreffusionseenarisingfromtheanterioranklejoint.Theanteriortalofibular,calcaneofibularandtibiofibularligamentsappearintactbutintra-articularpathologycannotbeexcluded.------------------------------------------------------------------------------------------------------------------------------------------------------Samplereportsfortendonopathy/tenosynovitis


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Thereisamoderatefusiformthickening(APdiametermeasuredat7mm)oftheAchillestendonwithlossofthenormalfibrillarpatternandamoderatedegreeofneovascularitywithinthemiddlethird.Normalappearancesoftheproximalanddistalthirdsofthetendon.Noevidenceofenthesitisorbursitis.AppearancesareconsistentwithamoderatemiddlethirdAchillestendonopathy.Nosignsoftearidentified.Theposteriortibialtendonappearsgenerallythickened/thinnedwithlossofthenormalfibrillarpatternbutnotearseen.Thereiseffusionandhyperaemiawithinthetendonsheathandappearancesareconsistentwithposteriortibialtenosynovitis.NB1:Basedonexpertexperience,fusiformthickeningcanbecategorisedintomild/moderate/severe.Generallymild4–6mm,moderate7-10mmandsevereanythingabove10mm.------------------------------------------------------------------------------------------------------------------------------------------SamplereportsforMorton’sneuroma/interdigitalbursitisThereisawell-definedhypoechoic,butsolid,lesionintheleft2ndwebspace(iebetween2ndand3rdmetatarsalheads).NoevidenceofvascularitywithinthelesiononDoppler.Itmeasuresxxmmintransversediameter(fullmeasurementsmmxmmxmm)andappearancesareconsistentwithaMorton’sneuromawhichissymptomaticonscanning.Theotherwebspaceslooknormal.Thereisalarge,ovoid,partiallycompressiblelesionintheinterdigitalspacebetweenthe2ndand3rdmetatarsalsoftheleftfoot.Itmeasuresxxmmintransverse(fullmeasurementsmmxmmxmm),showsincreasedperipheralvascularityandissymptomaticonscanning.UltrasoundappearancessuggestsecondwebspaceinterdigitalbursitisbutanadjacentMorton’sneuromacannotbeexcluded.Therearelarge,ovoid,partiallycompressiblelesionsinthe2ndand3rdwebspacesoftherightfoot.Theymeasuresxxmmintransverse(fullmeasurementsmmxmmxmm),showincreasedperipheralvascularityandaresymptomaticonscanning.UltrasoundappearancessuggestinterdigitalbursitisbutanadjacentMorton’sneuromacannotbeexcluded.NB2:absolutelyclarityisrequiredinlocation.Avoidtheterm2/3webspace:state‘between2ndand3rd‘etc.-----------------------------------------------------------------------------------------------------------------------------------------------------SamplereportfortendontearsWhenreporting,itisimportanttodescribethetypeoftear–partialorcomplete–andthedimensionsandsiteofthetear.Anopiniononthestateoftheremainingtendontissueisalsohelpful.Thereisacompletefullthicknesstearoftheposteriortibialtendonatthelevelofthemedialmalleolus.Thetendonendshaveretractedby6mmandtheremainingvisibletendonappearsthinandtendonopathic.ThereisacompletetearoftheAchillestendonlying34mmproximaltotheupperborderofthecalcaneum.Withtheankleinneutral,thereisretractionoftheproximalstumpbyapproximately24mm.Withtheankleindorsiflexion,thetendonendsdonotoppose–thereisherniationofKager’sfatpadinbetweenthetendonends.Thegapindorsiflexionismeasuredat14mm.Thereisrelativelynormalfibrillarpatternofthedistalstumpoftendonbuttheproximalstumpappearsseverelytendonopathic.------------------------------------------------------------------------------------------------------------------------------------------------------Samplereportsforplantarfasciitis/fasciopathyTheproximalplantarfasciaishypoechoicwithlossofthenormalfibrillarpattern.Itisthickenedtoxxmm(over4-4.3mm)andhe/sheistenderonscanning.Appearancesareconsistentwithplantarfasciitis.------------------------------------------------------------------------------------------------------------------------------------------------------Glossaryofterms.Calcifictendonopathy:calcificationwithintendons.Thepresentationofcalcifictendonopathymayvaryfromtinycalcificfleckstolargeconglomerateswhichmayappear‘soft’andnon-shadowing,ordenserwithadenseposterioracousticshadow.


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Effusion:acollectionoffluidinatendonsheath,jointorbursa.Jointsynovitis:thickeningandoftenhyperaemiaofthesynoviumliningajoint.Tendonitis:notgenerallyusednowfortendonsasthissuggestsaninflammatoryprocessthathasnotbeenproven.Tendonosis:adegenerativeprocesswithinatendon,disorderedbiomechanicsoftenleadingtomicrotears.Tendonopathy:amoregeneraltermforadiseasedtendon.Tenosynovitis:inflammationofthetendonandsheath:AppearancesshouldincludetendonsheaththickeningandhyperaemiaonDoppler,painonpalpation.Mayalsoincludeeffusionandtendonopathybutthesemaybepresentwithoutcurrenttenosynovitis.References1)BeggsI,BianchiS,BuenoA,etal.MusculoskeletalultrasoundtechnicalguidelinesVI.AnkleEuropeanSocietyofMusculoSkeletalRadiology.2)McNallyEG.Ultrasoundofthesmalljointsofthehandsandfeet:currentstatusSkeletalRadiol(2008)37:99–1132.12.7 RHEUMATOLOGYULTRASOUNDEXAMINATIONSExaminationspecificguidelinesandcommonclinicalscenariosforinflammatoryarthritis.Theseguidelinesareaimedatthosescanningpatientsfor‘?Inflammatoryarthritis’whoarenotdirectlyinvolvedinaRheumatologyservice–iesonographersscanningwithinRadiologydepartments.Rheumatologistsoftenhavelocalguidelinesfortheirownscanningofthesepatients.Purposeofanultrasoundscan

Toevaluatethefollowingstructures:Handsandwrists,feetandanklesfor:

• synovialhypertrophy–synovialproliferation• synovitis–synovialhypertrophywithvascularityonDoppler• erosions• tenosynovitis–inflammationofthetendonandsheath• enthesitis

Ifthesescansarecarriedoutwithinarheumatologydepartmentsetting,theywillbefocussedtoexcludeorconfirmevidenceofinflammatoryarthritis,notnecessarilytodeterminethecauseofhandorfootpain.Thisshouldbemadeclearontherequestformandthereportshouldincludetheclinicalquestiontobeanswered.RheumatoidarthritisThediagnosisofanydiseaseusuallyprogressesalongawell-definedpaththathasthreeparts:ahistoryofthecomplaint,bloodtestsand,usually,imaging(x-raysorscans)."Seropositive/seronegative"isatermthatreferstotheresultsofabloodtesttohelpestablishthediagnosisofrheumatoidarthritis(RA).Thislooksforthepresenceoftwoproteinsintheblood.1

Rheumatoidfactor(RF)isaveryoldbuttriedandtestedinvestigationthatwasfirstintroducedintorheumatologyinthe1940s.Anti-cycliccetrullinatedpeptide(Anti-CCP)antibodytestingismorerecent,ismoresensitivethanRFandmayappearmuchearlierinthecourseofRA.


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ApositiveRForanti-CCPtestdoesnotmeanthatthepatienthasRA.Otherfeaturesmustbepresentsuchassymptomsofpainandswellinginthejoints,involvementofmanyjointswithinflammation,morningstiffnessinthejointsforlongerthan45minutes,x-rayevidenceofthecharacteristicbonedamageinthejointsandextra-articularfeaturesofRA(meaningfeaturesthatareoutsidethejoints),suchasnodules.OtherbloodtestsoftenusedpriortodiagnosisincludeESRandCRP,whichmeasuretheamountofinflammationinthejoints.1

Commonindications

CommonindicationsfortheperformanceofaRheumatologyultrasoundscanare:• jointpainandswelling.?inflammatoryarthritis• RAondiseasemodifyinganti-rheumaticdrugs(DMARDS).?activesynovitis• RAinremission.?subclinicalsynovitis

Commonpathologies

JointeffusionAjointeffusionisacollectionoffluidwithinajointortendonsheath.Itistypicallyanechoic,compressibleanddoesnotdisplayanyinternalDopplersignal.2Smalleffusionsarecommonlyseeninnormaljointsbutiftheybecomelarge,orareassociatedwithotherinflammatoryappearances,theymaybeasignofacutedisease.Synovialhypertrophy

Synovialproliferationandresultinghypertrophyistheprimaryeventinrheumatoidarthritisthatisvisibleonimaging.Therecogniseddefinitionofsynovialhypertrophyonultrasoundis‘Abnormalhypoechoic(relativetosubdermalfat,butsometimesmaybeisoechoicorhyperechoic)intraarticulartissuethatisnon-displaceableandpoorlycompressible’.2However,thesignificanceofthepresenceofsynovialhypertrophyinjointswithoutinternalvascularityonDopplerisuncertainasitmaybepresentinbothinflammatoryarthritisandosteoarthritis.Activesynovitis

Wheninflamed,synovialhypertrophybecomesactivesynovitisandisasignofactiveinflammatoryarthritis.Itfrequentlyaffectsthewrists,MCPandPIPjointsofthehandsandanklesandMTPjointsofthefeet.Therecogniseddefinitionofsynovitisonultrasoundis:‘SynovialhypertrophywhichmayexhibitDopplersignal’.2

Thedegreeofsynovialhypertrophyandvascularitywithinjointsortendonsmaybeestimatedanddocumentedeitherusinganagreedgradingsystemor‘mild/moderate/severe’.Thereareseveralgradingsystemsforthedegreeofvascularity/gradeofactivesynovitis.Themostcommonlyusedgradesbothsynovialhypertrophyandactivesynovitis.3

Anypathologyfoundshouldbedocumentedintwoplanes.IfaDopplersignalisseenwithinajointinthelongitudinalplane,itssitemustbeconfirmedwithinthejointinthetransverseplane.


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Comparisonwiththecontra-lateralside(assumingitisasymptomatic)willhelpwhendeterminingtheclinicalsignificanceofage/activity-relatedchangesandshouldbeimagedanddocumentedinthereport.ErosionsRAischaracterisedbyachronicinflammatoryprocessthattargetsthesynovialliningofsomejoints.Asthediseaseadvances,thereisevidenceofprogressivedestructionofthestructuralcomponentsofthejointswhichtargetsthearticularcartilageandboneatthejointmargins.Therecogniseddefinitionofanerosiononultrasoundis:‘Anintra-articulardiscontinuityofthebonesurfacethatisvisibleintwoperpendicularplanes.’

2

Theaimofmoderntreatmentsistohaltsofttissueinflammationandpreventorarrestthedevelopmentofadjacentboneerosionsandjointdamage.Historically,radiographshavebeenusedtodetectandmonitorerosionsbutultrasoundisnowproventodetectthemearlierbutthereareareasofmostjointsthataredifficulttoaccesswiththetransducermakingerosionsdifficulttoexclude.ResearchstudiessuggestthatdetectionofflowwithinerosionsonDopplerissuggestiveofactivebonedestructionandshouldbehighlightedtothereferrer.TenosynovitisTenosynovitisisinflammationoftheliningofthesheaththatsurroundsatendon.Causesoftenosynovitisincludeinfection,overuseorinjurybuttenosynovitiscanalsobeassociatedwithsomekindsofinflammatoryarthritis.Inthenormalstate,thesheathofthetendoncanbarelybedetectedandisseenasathin,hypoechoicbandaroundthetendon.Onceinflamed,thesheathbecomesincreasinghypoechoic,thickenedandmaydisplayinternalvascularityonDoppler.Therecogniseddefinitionoftenosynovitisonultrasoundis:‘Hypoechoicoranechoicthickenedtissuewithorwithoutfluidwithinthetendonsheath,whichisseenintwoperpendicularplanesandwhichmayexhibitaDopplersignal.’2

Note:Notalltendonsaresurroundedbyasheathandtheultrasoundappearancesofinflammationvary–forexampletheextensortendonsofthefingers,overtheMCPjoints.Inflamedtendonswithoutsheathsmayhavemorediffuseperipheraloedemabecauseinflammatoryfluidisnotcontained.Insteadof‘tenosynovitis’,thesetendonsshowevidenceof‘Paratendinitis’.


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Spondyloarthropathies

SpondyloarthropathiesareagroupofinflammatorydiseasesinpatientswhosebloodtestsarenegativeforRA.Thesediseasesincludeankylosingspondylitis,reactivearthritis,enteropathicarthritisandpsoriaticarthritis(PsA).Commonfeaturesofseronegativediseasearelistedinthetablebelow4

Psoriaticarthritis(PsA)isprobablythemostcommonofthesearthritidesandaffectsaround30%ofpatientswhosufferfrompsoriasis.PsAmayalsoaffectpeoplewhohavenosignsofpsoriasisthemselves,butwhohaveafamilyhistoryofthedisease.Inadditiontojointsynovitis,PsAcommonlyaffectsthetendonsandenthesesaroundjoints.CommonultrasoundfeaturesincludeAchillestendonopathy/enthesopathy,plantarfasciitisanddactylitis.Unlikerheumatoidarthritis,theareasaffectedareoftennotsymmetricalinPsA.AsthesepathologiesarenotspecifictoPsA,theassociationbetweenultrasoundappearancesandahistory(orfamilyhistory)ofpsoriasismaybemadeduringscanningandsuggestedinthereport.

Achillesenthesitis–evidenceofinternalvascularityofthedistalAchillestendon,closetoandinvolvingthetendoninsertion.NoteanerosionwithadjacentDopplerflowonthesurfaceofthecalcaneum–asignofactiveenthesitis.Crystalarthritis


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Gout

Goutischaracterisedbyacuteattacksofinflammatoryarthritis,often,butnotonlyinthe1stmetatarsophalangealjointswhichbecomered,hot,tenderandswollen.Goutiscausedbyelevatedlevelsofuricacidinthebloodwhichcrystallises,andthecrystalsaredepositedinjointsandsofttissues.Ultrasoundappearancesthataresuggestiveofgoutincludesynovitisanderosionsbutalsoa‘doublecontour’sign.Thisisthoughttobeduetodepositionofuricacidcrystalsonthesurfaceofcartilageandisseenmostcommonlyontheheadsofthefirstmetatarsals.Researchintothisisongoing.Tophiareaggregatesofuricacidcrystalsinjointcapsulesorsofttissues.Onultrasound,theyareseenassolid,hyperechoicbutnon-shadowingdepositswithinjointcapsules,tendonsorbursae.

CalciumpyrophosphatedepositionCalciumpyrophosphatedeposition(CPPD)isanumbrellatermforthevariousclinicalsubsets,whosenamingreflectsanemphasisonparticularfeatures.Forexamplepseudogoutreferstotheacutesymptomsofjointinflammationorsynovitis:red,tender,andswollenjointsthatmayresemblegoutyarthritis.Chondrocalcinosis,1,4ontheotherhand,referstotheradiographicevidenceofcalcificationinhyalineand/orfibrocartilage.Commonsitesarethetriangularfibrocartilage(TFCC)ofthewristandthemeniscioftheknee.

ChondrocalcinosisofthewristTFCCPitfalls,contraindicationsandlimitations

Pitfallsinultrasoundscanningforinflammatoryarthritisincludetheuseofincorrectequipmentsettingsandlackofappreciationoftheeffectsofcurrenttreatments.

Scanningtechnique

Goodtechniqueforscanningisvitalinaccuratelyassessingjointsforsynovitis.Ofparticularimportanceisthelackoftransducerpressureontheskinsurface.ToomuchpressuremaycompressthesmallbloodvesselspresentinjointsynovitisortenosynovitisandobliteratetheDopplersignal.Gentle,meticulousscanningacrossthejointsisessentialtoexcludeinflammation.

Equipmentsettings


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AsDopplerisusedfrequentlytodetectthepresenceofactiveinflammationitisvitalthattheultrasoundsystemusedissensitivetodetectlowflow.Importantsettingsincludealowpulserepetitionfrequency(PRF),appropriategainsettingsandalowlevelofwallfilter.Steroidandnon-steroidalanti-inflammatorydrug(NSAID)useSteroids–oral,intramuscularorinfusion-eitherforthetreatmentofjointdiseaseorconcurrentproblemssuchasasthma,bronchiectasisandchronicobstructivepulmonarydisease,willtemporarilyreduceinflammationandhyperaemia.5ThereissomeevidencethatNSAIDShaveasimilareffect.6

Ininflammatoryarthritis,corticosteroidshavebeendemonstratedtoreducesynovialinflammationinimagingstudies.5Itisthereforeimportanttotakesteroiduseintoaccountwhenreportingonultrasoundstudiestodetectorgradeactivesynovitis.TheimagesbelowshowtheeffectsofsteroiduseonDopplerflowinacaseofRA.

Theuseoforal,intramuscularorintra-articularsteroidswillaffectthelevelofDopplersignalandmayevenremovetheultrasoundfeaturesofinflammatoryarthritis.Itisthereforesuggestedthatultrasoundexaminationsshouldbescheduledatleastsixweeksafteranysteroidintervention.Ifthatisnotpossible,thesonographershouldaddacommentinthereporttoensurethatthereferrerisaware.

Forexample:‘Thepatientreportsthathe/sheistakingoralsteroids/hashadarecentintra-articularorintramuscularsteroid.Thismayreducetheultrasoundfeaturesofinflammatoryarthritisandcouldaffecttruegradingofsynovitis.Ifthereisongoingclinicalconcern,arescan6weeksafteranysteroiduseissuggested.’

TheuseofNSAIDSpriortoascanmaybemoredifficulttomanageastheyarewidelyusedandrequiredforpainrelief.Itmaynotbepracticaltolimittheirusebutcareshouldbetakenwhenquestioningthepatienttoensurethatitisknownthattheyarebeingtaken.Inthesecases,areasofsynovialproliferationwithnoDopplersignalandnoobviouscaseshouldbetakenintoconsiderationwhenreportingandmayrequirerescan.Otherlimitationsinclude:

• obesity;• inabilitytoseestructuresthatliedeeptoboneorintra-articularstructures;• casts,dressings,openwounds/ulcersetccanlimitvisualisation;• severeoedema/swelling.

Considerationswhenscanning

A;showsthejointbeforesteroidtreatmentB;4weeksaftersteroidsC;12weeksaftertreatment


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Asage-relatedchangesarecommoninthemusculoskeletalsystemandmaynotbethecauseofthepatient’ssymptoms,ultrasoundappearancesmustalwaysbetakeninclinicalcontextandthereferrershouldbemadeawareofitslimitationsinthereport.Forexample:‘Ultrasoundcannotexcludeintra-articularpathology’Diagnosticultrasoundisoftenusedasaprecursortotherapeuticinjectionsandcareshouldbetakentoassistinthedirectionofthatinjection.Somestructuralchangesmaynotbecurrentlyrelevantandmaynotbeassociatedwithpain.ForexamplesynovialhypertrophywithoutDopplersignaltosuggestactivityisseeninmanykindsofarthritis.ThepresenceofaDopplersignalwithinthesynovialhypertrophyismoreindicativeofactivesynovitis.Theadditionofthesiteofcurrentsymptomsonareportmayhelp.Thepitfallsofultrasoundinterpretationarewidelydocumentedandcanbereducedbyeducationandexperienceoftheindividualultrasoundpractitioner.ScanprotocolHandsandwrists

Thestructuresthatshouldbeidentifiedasaminimuminahandultrasoundscanforrheumatologyare:• wrist/carpaljoints–scaninlongitudinalandtransversetointerrogatejointsandoverlyingextensor

tendons• extensorcarpiulnaristendon(ECU)–scaninlongitudinalandtransverse• alldorsalmetacarpophalangeal(MCP)joints–scaninlongitudinal,andifsuspectedpathology,confirmin

transverse• alldorsalproximalinterphalangeal(PIP)joints–scaninlongitudinal,andifsuspectedpathology,confirm

intransverse• flexortendons–scaninlongitudinalandtransverse• ifqueryingseronegativeinflammatoryarthritissuchasPsoriaticarthritis,itmaybeusefultoincludedistal

interphalangeal(DIP)joints.Wrists

Beginyourscanatthewristcrease.Scanthedorsalwrist/carpaljointinlongitudinalfromthemedialtothelateralborderandintransverse,tocoverthejoints.Lookfor:Synovialhypertrophy,effusion,boneerosions,degenerativechange.

RepeatthescanusingPowerDopplerScantheextensortendonsintransversefromthemusculo-tendinousjunctiontothedistalinsertionandtheninlongitudinal.Ifnecessary,comparewiththecontralateralside.Lookfor:Tendonsheaththickening,tendonthickening/thinning,tendondiscontinuity,effusionRepeatthescanusingPowerDoppler.Lookfor:Activetenosynovitis–mild,moderateorsevere

Scanthevolarwrist/carpaljointinlongitudinalfromthemedialtothelateralborderandintransverse,tocoverthejoints.Ifnecessary,comparewiththecontralateralside.Lookfor:Synovialhypertrophy,effusion,boneerosions,degenerativechange.

RepeatthescanusingPowerDoppler.Lookfor:Activesynovitis.Ifpresent,gradeusinggradingguidelines.


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Scantheflexortendonsintransversefromthemusculo-tendinousjunctiontothedistalinsertionandtheninlongitudinal.Ifnecessary,comparewiththecontralateralside.Lookfor:Tendonsheaththickening,tendonthickening,tendondiscontinuity,effusion

RepeatthescanusingPowerDoppler. Lookfor:Activetenosynovitis–mild,moderateorsevere

DorsalMCP/PIP/DIPjoints

Beginyourscanattherelevantjoint.Repeatforeachjointofeachdigit.

Scan the joint in longitudinal from the medial to the lateral border and in transverse, to cover the joint. Ifnecessary,comparewiththecontralateralside.

Lookfor:Synovialhypertrophy,effusion,boneerosions,degenerativechange

RepeatthescanusingPowerDoppler. Lookfor:Activesynovitis.Ifpresent,gradeusinggradingguidelines.

ImagingprotocolAstandardhandseriesshouldincludethefollowingminimumimagesforanormalrheumatologyscan:

Dorsalwristandcarpaljointsinlongitudinalwithcolourbox.

ECUtendonwithColourbox

AllMCPjsinlongitudinalwithColourbox

AllPIPjsinlongitudinalwithColourbox

FlexortendonswithColourbox


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FeetandanklesScanprotocolThestructuresthatshouldbeidentifiedasaminimuminafootultrasoundscanforrheumatologyare:

• ankle–tibiotalar joint–scan in longitudinalandtransverseto interrogate jointsandoverlyingextensortendons–anteriortibial,extensorhalluceslongusandextensordigitorumlongus.

• medial and lateral ankle tendons – posterior tibial, flexor digitorum longus and flexor halluces longustendonsmediallyandperoneuslongusandbrevislaterally.Scaninlongitudinalandtransverse

• alldorsalmetacarpophalangeal(MTP)joints–scaninlongitudinal,andifsuspectedpathology,confirmintransverseifpossible(thiscanbedifficultduetotheangleofthejoints–ahockeysticktransducermayhelp)

• MTheadson theplantar surface looking forerosions thatmaybedifficult toseeon thedorsalaspect,especiallyaroundthe5thMTheadlaterally

• flexortendons–scaninlongitudinalandtransverse• ifqueryingseronegativeinflammatoryarthritissuchasPsoriaticarthritis,itmaybeusefultoincludethe

Achillesandplantarfasciainsertions.Beginyourscanatanterioranklejoint.Scanthedorsaltibiotalarjointinlongitudinalfromthemedialtothelateralborderandintransverse,tocoverthejoint.Lookfor:Synovialhypertrophy,effusion,boneerosions,degenerativechange.RepeatthescanusingPowerDoppler.Scantheanterior,medialandlateraltendonsintransversefromthemusculo-tendinousjunctiontothedistalinsertionandtheninlongitudinal.Ifnecessary,comparewiththecontralateralside.Lookfor:Tendonsheaththickening,tendonthickening/thinning,tendondiscontinuity,effusion

RepeatthescanusingPowerDoppler. Lookfor:Activetenosynovitis–mild,moderateorsevere

ScantheplantarsurfaceoftheMTPjsinlongitudinalfromthemedialtothelateralborderlookingforerosions.Scantheflexortendonsintransversefromthemusculo-tendinousjunctiontothedistalinsertionandtheninlongitudinal.Ifnecessary,comparewiththecontralateralside.Lookfor:Tendonsheaththickening,tendonthickening,tendondiscontinuity,effusion

RepeatthescanusingPowerDoppler.Lookfor:Activetenosynovitis–mild,moderateorsevere

ImagingprotocolAstandardfoot/ankleseriesshouldincludethefollowingminimumimagesforanormalrheumatologyscan:Dorsalanklejointinlongitudinalwithcolourbox.

MedialtendonswithColourbox


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LateraltendonswithColourbox

AllMTPjsinlongitudinalwithColourbox

ReportsThereportisarecordingandinterpretationofobservationsmadeduringtheultrasoundexamination.Itshouldbewrittenbythepersonundertakingthescanandviewedinclinicalcontext.Areportisintendedtoansweraclinicalquestionandtoassistwiththepatientjourneysolocalopinionfromradiologistsandrheumatologistsshouldbetakenintoaccountintheconstructionoflocalreporttemplates.Asreportsarenowelectronic,theymaybeavailabletocliniciansinterveninglaterintheclinicalpathwayandsoshouldcontainallrelevantandappropriateinformation–forexampleanorthopaedicsurgeonmayaccessareportoriginallyrequestedbyageneralpractitionerorphysiotherapist.Thereportshouldincludecorrectpatientdemographics;dateofexamination;examinationtypeandthenameandstatusoftheultrasoundpractitioner.Thestandardshoulderreportshouldinclude:

• documentationofthenormalanatomy;• documentationofanypathologyincludingmeasurements/anyincreaseinvascularityifappropriate;• documentationofanylimitationtorangeofmovement,thesiteanddegreeofpain• documentationofanydifficultieswithinterpretationoftheultrasoundappearances.

Thesamplereportsbelowareintendedasaguideonlyasreportingstylemaybespecifictoindividuals/departments.----------------------------------------------------------------------------------------------------------------------------------------SamplereportforarheumatologyscanshowingnoevidenceofinflammatoryarthritisUltrasoundscanbothhands:NoevidenceofactivesynovitisseenarisingfromthewristsorwithintheMCPorPIPjs.Notenosynovitis.Noerosionsseen.OrUltrasoundscanbothhands:DegenerativechangesnotedbutnoerosionsseenandnoevidenceofactivesynovitisseenarisingfromthewristsorwithintheMCPorPIPjs.Notenosynovitis.OrUltrasoundscanbothhands:Degenerativechangesnotedwithmildinactivesynovialhypertrophyarisingfromthewrists.NoevidenceofactivesynovitisseenarisingfromthewristsorwithintheMCPorPIPjs.Notenosynovitis.-------------------------------------------------------------------------------------------------------------------------------------------------------


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SamplereportforarheumatologyscanshowingsynovialhypertrophyinapatientwhohashadarecentintramuscularsteroidinjectionUltrasoundscanbothhands:ThereisobvioussynovialhypertrophyarisingfromthedorsalsurfacesofbothwristsbutnoevidenceofinternalDopplersignal.ThepatientreportsanintramuscularinjectionofDepomedrone2weeksago.ThiswillreduceDopplersignalandmaymasktheultrasoundappearancesofactivesynovitis.Ifsymptomsreturnafter4-6weeksandthereisongoingsuspicionofinflammatoryarthritis,arescanissuggestedbeforeanyfurthersteroidsaregiven.-----------------------------------------------------------------------------------------------------------------------------------------Samplereportforarheumatologyscanwithpositivefindingsforinflammatoryarthritis.Ultrasoundscanbothhands:Thereisgrade2(ormoderate)activesynovitisarisingfromtherightwristandwithintherightindexandmiddleandleftindexfingerMCPjs.NoevidenceofactivesynovitisarisingfromtheleftwristorwithintheremainderoftheMCPjsorthePIPjs.Notenosynovitis.Noerosionsseen.-------------------------------------------------------------------------------------------------------------------------------------------------------SamplereportforapatientwithsuspectedseronegativeinflammatoryarthritisUltrasoundscanbothfeet:Thereisevidenceofmoderatesynovitisarisingfromtheleftanklejointbutnoneseenontheright.ThedistalportionofbothAchillestendonsarethickenedandhypoechoicwithlossofthenormalfibrillarpattern.Thereisamoderatedegreeofinternalvascularitywithinthetendonsattheinsertionanderosionsontheposterioraspectofthecalcaneum.Appearancessuggesterosiveenthesitis.Thereisalsoeffusionandhyperaemiaofbothretrocalcanealbursaesuggestingbursitis.Intheabsenceofanobviousbiomechanicalcausefortheseappearances,aninflammatoryarthropathyshouldbeconsideredandifthereisclinicalcorrelation,arheumatologyopinionissuggested.------------------------------------------------------------------------------------------------------------------------------------------------------

References1)RoyalCollegeofPhysicians.RheumatoidArthritis:Nationalclinicalguidelinesfortreatmentinadults20092)WakefieldRJ,BalintPV,SzkudlarekM,etal.Musculoskeletalultrasoundincludingdefinitionsforultrasonographicpathology.JRheumatol2005;32:2485–24873)BernerHammerH,Bolton-KingPetal‘Examinationofintraandinterraterreliabilitywithanewultrasonographicreferenceatlasforscoringofsynovitisinpatientswithrheumatoidarthritis’AnnrheumDisdoi:10.1136/ard.2011.1529264)KatariaRK,BrentLH.Spondyloarthropathies.AmFamPhysician.2004;69:2853-2260andGladmanDD.AmJMedSci.1998;316:234-2384.5)FilippucciE,FarinaA,CarottiM,SalaffiF,GrassiW.GreyscaleandpowerDopplersonographicchangesinducedbyintra-articularsteroidinjectiontreatment.AnnRheumDis2004;63:740–7436)ZayatS,ConoghanP,SharifM,FreestonJ.Donon-steroidalanti-inflammatorydrugshaveasignificanteffectondetectionandgradingofultrasound-detectedsynovitisinpatientswithRA?AnnRheumDis2011;70:1746-1751UsefulreadingBackhausM.Ultrasoundandstructuralchangesininflammatoryarthritis:synovitisandtenosynovitis.AnnNYAcadSci2009;1154:139-151BackhausM,BurmsterGetalGuidelinesformusculoskeletalultrasoundinrheumatologyAnnRheumDis60:641-649KangT,LanniSetalTheevolutionofultrasoundinrheumatology.Therapeuticadvancesinmusculoskeletaldisease2012Dec4(6):399-4112.13ELASTOGRAPHYAdvances in ultrasound technologies have expanded the clinical applications of ultrasound over recent years.Historicallyultrasoundhasbeenaprimaryimagingmodality,butitisnowcommonforultrasoundtechnologytobe utilised in other techniques such as needle placement, joint injections, guided biopsies, interventionalproceduresandmorerecentlyinthediagnosisandmanagementofpatientswithchronicliverdiseases.


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Recent advances in elastography techniques such as acoustic radiation force impulsion (ARFI) and transientelastography (TE)haveexpanded theuseofultrasound intodiseasemanagement. They canalsoenable lesioncharacterisation and the mapping of tissue stiffness. This reproduces / replaces the palpation performed byclinicians.Atpresenttherearetwomainformsofelastographywhicharebeingusedroutinelyinclinicalpractice.StrainElastography(SE)Quasi-staticorstrainelastography(SE),wherethetissuedeformationisproducedbyexternalpalpationwiththeultrasoundtransducer.Mostmanufacturersoverlayaspecklemapontheultrasoundimage,whichiscodedinacolour or greyscale to show a pattern of strain, which is inversely related to the tissue stiffness and can beassessed subjectively. These images are semi-quantitative and do not directly depict the elasticity which isderivedfromYoung’smodulus,(stress/strainratio).ShearWaveElastography(SWE)Conventionalultrasoundandshearwavesarebothpressurewavesthatareconductedthroughsofttissue.Unlikeconventionalultrasoundwaves;shearwavesaretransverseintheirdirectionality,theyarerapidlyattenuatedbysofttissueandtravelmoreslowly(between1and10m/s).TheirspeediscloselyrelatedtoYoung’smodulusofelasticity.Shearwavesarecreatednaturallyfrommusclemovementsorincardiacactivityandcanbeinducedbyultrasoundscannerswhichusethemtomeasuretheirspeedinaparticulartissueororgan.LiverFibrosisAssessmentMostchronic liverdiseaseshavealterations inthefunctionalandstructuralappearanceofthe liver.Theriskofdevelopingcirrhosisandliverrelatedcomplicationsinviralandnonviralchronicliverdiseasesiscorrelatedtotheamountofliverfibrosis. Thedetectionandclassificationofliverfibrosisispivotalforassessingprogressionandwhen to commence patients on antiviral therapies. Liver biopsy has long been the traditional approach forfibrosisassessmentanddiseaseclassification. Liverbiopsyby itsnature is invasiveandhaspotentially severecomplicationsinupto1%ofcases1withassociatedcostimplications.Recent(2015)advicefromNICE(MTG27)2,advocateselastographyinthediagnosisandmonitoringoffibrosisinchronichepatitisTheeconomicbenefitsofusingelastographyisexploredintheguideline,asavingofaround£434perpatientisquotedwhenusingVirtualTouchQuantification (VTq) over conventional liver biopsy. The safety implications to patients should also beconsideredaswellasitstolerabilityanditsabilitytobeundertakeninanoutpatientsetting.Givingtheeconomicchallengesfacinghealthcaretoday,thistechniquecouldhavethepotentialtodeliverlargesavings.http://nice.org.uk/guidance/mtg27One difficulty with liver elastography is the different methods and multitude of ultrasound manufacturersprovidingamethodofstiffnessassessment. This results inthevaryingcut-offvaluesbeingultrasoundscannerspecificandnottransferableacrossdifferentmakesofequipment.TransientElastography(TE)Onemethod of SWE is transient elastography (TE) which is being performed using the Fibroscan® (Echosens,Paris,France).This isamechanical systemusingasingleelementultrasoundtransducerwhich isusedtoapplylightpressureonthepatient’sskin,usuallyintercostallytoassesstheliverparenchyma.Theresultantshearwavetravels through liver tissue along the direction of the ultrasound beam and is used tomeasure its speed in amannersimilar toM-mode. InpatientswithchronichepatitisC, liverstiffness (LS)valuesaregreater than6.8-7.6kPa. The cut off for predicting cirrhosis range between 11.0 – 13.6 kPa. Evidence suggests that TE haslimitations indifferentiatingbetweenmildandsignificantfibrosis. Other limitations includetherequirementofdedicatedequipmentwithspecificprobesandanintercostalscanapproach. Thetechniqueisstandardisedand


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can be employed in various settings. It is currently being used mainly outside the radiology department inoutpatientsettings.AcousticRadiationForceImpulse(ARFI)ARFIgeneratesshearwavesbycausingsmalldisplacements inthesofttissue,causingsidewayspressurewavesawayfromtheultrasoundbeamwhichallowultrasoundsystemstomeasurespeedwithgoodspatialresolution.ARFI accuracy for the assessment of liver fibrosis has been similar to TE,with somemorepromising results inpatients with non-alcoholic fatty liver disease (NALFD), non-alcoholic steatohepatitis (NASH) and in posttransplantation. It has the advantage of allowing a radiological assessment of the liver parenchyma andmoreaccuratelocalisationofthesamplesite.Therefore,fattyinfiltrationcanbeavoidedsoasnottonotskewfibrosisscoring.Following the publication of the European Federation of Societies of Ultrasound in Medicine and Biology(EFSUMB)guidelinesontheclinicaluseofelastography,3itisrecommendedthatshearwaveelastographycanbeused to assess the severity of patients with liver disease with viral hepatitis. The guidelines also state thatshearwaveelastographyispromisinginNAFLDandpost-transplantation.ClinicalApplication

Whilstdifferingmanufacturershavedifferentshearwavevelocitiesforstagesofliverdiseaseitisnotedthatthefollowing (based on the VTq imaging as described in theNICE publication 2) are given as examples of diseasestaging

• Normal<1.2m/s• Fibrosis≥1.21–1.34m/s• Cirrhosis≥1.55–2.00m/s

Extremecaution is requiredwhenquoting shearwavevelocities inultrasound reports. It isuseful to report theshearwavevelocityandquotetherelevantreferencevaluesforthemachineusedtominimiseconfusionbetweennormal and abnormal readings compared to the stage of liver disease. Practitioners are advised to refer toindividualmanufacturers’referencerangeswhenreportingshearwavestudiesinliverdisease.

Practicalpointsonacquisition

• Thepatientshouldbefasted.Shearwavespeedmeasurementsareperformed intercostally in therightliverwithconventionalcurvedarrays.Theprobeisalignedalonganintercostalspace.

• 10measurementsshouldbeacquiredandthemeanvalueandstandarddeviationstated.• The recommendeddepth isbetween3and7cm.Shearwavemethodscanbeutilised inpatientswith

ascites.EFSUMBElastographyguidelineshttp://www.efsumb.org/guidelines/guidelines01.asp4References1.SeeffLB,EversonGT,MorganTR(2010)ComplicationrateofpercutaneousliverbiopsiesamongpersonswithadvancedchronicliverdiseaseintheHALT-Ctrial.ClinicalGastroenterologyHepatology,Vol8,pp877-883.2.NationalInstituteforHealthandCareExcellence(2015).VirtualTouchQuantification(VTq)todiagnoseandmonitorliverfibrosisinchronichepatitisBandC(MTG27)London:NICE3. Cosgrove D, et al (2013) EFSUMB Guidelines and Recommendations on the Clinical Use of UltrasoundElastography.Part2:ClinicalApplications.UltraschallinMedVol34pp238-253.4. Dietrich CF, et al (2017) EFSUMBGuidelines and Recommendations on the Clinical Use of Liver UltrasoundElastography,Update2017(LongVersion)UltraschallinMed38(04):e16-e47DOI:10.1055/s-0043-103952


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BibliographyGennisson et al (2013) Ultrasound Elastography: Principles and Techniques, Diagnostic and InterventionalImaging,Vol94,pp487-95.

2.14CONTRASTENHANCEDULTRASOUND(CEUS)

UltrasoundcontrastagentsareformulatedintoamicrobubblestructurewhichperformsasabloodpooltracerwhenusedinconjunctionwithcontrastspecificimagingmodesusingalowMechanicalIndex(MI)technique.Anexampleis‘Sonovue’(sulphurhexafluoride).Theseagentsareintravenouslyinjectedinordertodemonstratethevasculatureandmicrovasculatureoforgansandpotentiallesions.Theyareprimarilyusedforhepaticapplications1butarealsoproventobeusefulinavarietyofotherapplications.2AdministrationofultrasoundcontrastagentAdministrationisperformedviaanintravenouscannula.Useofcontrastagentsbynon-medicalstaff,usuallysonographers,shouldcomewithintheremitofapatientgroupdirection(PGD)orotherformallocalprocedurewhichallowstheprescribingandsafeadministrationofthedrug.AsonographermustbestatutorilyregisteredtofollowaPGD;voluntaryregistrationisnotsufficient.Anycontraindicationtotheagentusedshouldbecarefullyobserved,anddocumentationofthedoseadministeredrecordedaccordingtolocalrules.SafetyThemicrobubbleagentscurrentlyavailablearenotnephrotoxic,makingthemaveryusefulalternativeinpatientswithrenalcompromise.3TheyhaveaverylowincidenceofadversereactionsalthoughthereisasmallriskofanaphylactoidreactionstoCEUS(rateestimatedat1:10,000)andresuscitationfacilitieswithemergencyequipmentandpersonneltrainedinitsuseshouldbeavailable.Itisrecommendedtokeepthepatientunderclosemedicalsupervisionduring,andforatleast30minutesfollowingtheadministrationofsulphurhexafluoride(Sonovue).Aprogrammeofannualbasiclifesupporttrainingshouldbeinplaceforstaff.4Microbubbleagentsarecurrentlynotlicensedinpregnancyorinchildrenbutmaybeused‘offlicense’inchildren.TheFDAgaveapprovalinApril2016fortheuseofCEUSintheUSAinchildrenwhohavefocalliverlesions.RecentEFSUMBguidelinesassessthecurrentstatusofCEUSapplicationsinchildrenandmakesuggestionsforfurtherdevelopmentofthistechnique.5

EquipmentContrast-specificsoftwareisrequiredtoperformCEUS.AlowMItechniquehelpstopreservethemicrobubbles,enablingalongeravailablesurveytime.Thefacilitytorecordashortvideoclip,ofallphasesforatleastthreeminutes,isessentialwhenusingCEUStocharacteriselesions.ThetemporalresolutionofCEUSissuperiortoanyothercurrentimagingmodality,andtheabilitytoreviewthearterialphase,framebyframe,providesavaluablecontributiontothediagnosticprocess.Portalwashoutisahallmarkofmalignancy.Mainapplications

• Characterisationoffocalliverlesionsinnon-cirrhoticpatients.


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• Characterisationofbenignlesions.• Detectionoflivermetastasesinpatientsathighriskoflivermetastases(egthosewithaprimary

cancerwhohavenotundergoneCTstaging,patientswithsuddenunintentionalweightloss,abnormalLFTsandotherwiseequivocalliversonabaselinescan).Patientsforpre-treatmentstagingshouldideallyundergoCT.

• Doppler‘rescue’toidentifyflowintechnicallydifficultexaminationse.g.hepaticarterydemonstrationinadifficultpost-transplantscan.

• Lesionlocalisationpre-ablationandforUSguidedbiopsy.• Postablationchecks.• Trauma,toidentifysoftorgandamage,ifCTcannotbeperformed.• Traumafollow-uplookingforpseudo-aneurysmsandresolutionoflacerations.

CirrhoticpatientswithfocallesionsshouldideallybereferredtoMRIforcharacterisationandfurtherexclusionofhepatocellularcarcinoma(HCC).However,ifthepatientisunabletoundergoMRI,thenCEUSmayprovidevaluableadditionalinformationinlesioncharacterisation.Extrahepaticapplications

• Characterisationofcomplexrenalcysts6(egwithseptaorcontainingdebris/possiblesolidmaterial).CEUSmaybeofferedasafirstlinecharacterisation.Complex,obviouslysuspiciouscystsandsolidmasses(Bosniak4)shouldbereferredurgentlytoCT.

• Vascularpatency/detectionofinfarctsindifficultrenaltransplantscans.• Sentinelnodedetectioninpatientswithbreastcancer.• Follow-upofendovascularaneurysmrepair(EVAR)stentstoestablishpatencyandlookforleaks.• Hysterosalpingo-Contrast-Sonography(HyCoSy)fortubalpatencytesting.

Itisthepractitioner’sresponsibilitytobeawareofthelicenseduseofSonovue.WhereSonovueisused“offlicense”,localagreementtoitsuse,andbywhomwithinthedepartment,shouldbedocumented.Thepatient’sverbalconsentfortheuseofcontrast“offlicense”shouldbesoughtanddocumented.Furtherapplicationswithlesssupportiveevidenceatthisstagealsoincludethespleen,endoscopicUSincludingpancreas,GItract,scrotalandprostate.2CEUScanalsobeusedtofacilitateultrasoundguidedbiopsyindifficult-to-seelesions.References1)SonoVue(sulphurhexafluoridemicrobubbles)–contrastagentforcontrast-enhancedultrasoundimagingoftheliver.NICEdiagnosticsguidance[DG5]August2012.https://www.nice.org.uk/guidance/dg52)TheEFSUMBGuidelinesandRecommendationsontheClinicalPracticeofContrastEnhancedUltrasound(CEUS):Update2011onnon-hepaticapplicationsUltraschallinderMedizin/EuropeanJournalofUltrasound2012Issue13)PiscagliaF,BolondiL.ThesafetyofSonovueinabdominalapplications:retrospectiveanalysisof23188investigations.ItalianSocietyforUltrasoundinMedicineandBiology(SIUMB)StudyGrouponUltrasoundContrastAgents.UltrasoundMedBiol.2006Sep;32(9):1369-1375.4)RoyalCollegeofRadiologists/SocietyandCollegeofRadiographers.Standardsfortheprovisionofanultrasoundservice.London:RCR/SCoR(2014)Section4.5)SidhuPSetal.RoleofContrastEnhancedUltrasound(CEUS)inPaediatricPractice:AnEFSUMBPositionSatement.UltraschallMed,April2016.http://www.ncbi.nlm.nih.gov/pubmed/27414980?dopt=Citation6)AscentiGetal.Complexcysticrenalmasses:characterizationwithcontrastenhancedultrasound.RadiologyApril2007;243(1):158-165


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2.15INTERVENTIONALAND‘EXTENDEDSCOPE’EXAMINATIONS(SONOGRAPHERS)Thereisawiderangeofexaminationsthatcomewithintheoverallscopeofpracticeofultrasoundpractitioners.ForthosewhoarenotmedicallyqualifiedandregisteredwiththeGMC(e.g.sonographers)theyaresometimestermed‘extendedscope’examinations.Theyincludediagnosticproceduressuchasbiopsy,fineneedleaspiration,hystero-salpingocontrastsonography(HyCoSy),drainageofbodycavitiesandtherapeuticproceduressuchasjointinjections.Likeallultrasoundexaminations,thesonographermustbetrained,competentandauthorisedtoundertakethem.Examplesofthetypeofultrasoundexaminationsundertakenbysonographersandtowhichthissectionrefersareasfollows:i) Biopsy/fineneedleaspirationegbreast,prostate,liver,thyroid.ii) Drainageegdrainageofascitesiii) Therapeuticegjointinjectionsiv) Diagnosise.g.HyCoSy,contrastenhancedultrasound(CEUS).

Whensettingupsuch‘extendedscope’servicestheapprovaloftheclinicallead,servicemanagerandTrust,HealthBoardorproviderorganisationshouldbesought.Thefollowingwillallneedtobeconsidered:

• supportfromaleadmedicalpractitioner• appropriatetraining• professionalindemnityInsurance• qualityassuranceandauditprogrammes• consentproceduresandacceptancethatasonographeristhepersonwhoshouldobtainthis• protocolsavailableforeachindividualtypeofprocedurethatthesonographerwillundertake• PatientGroupDirections(PGD)setupasnecessary.Somesonographers,dependingonprofessional

background,maybesupplementaryorindependentprescribers.2.16PATIENTGROUPDIRECTIONS

Inordertodeliversafeandeffectivehealthcarethatalsoprovidesagoodexperienceforpatients,providersneedtoensurethattheyaremaximisingthefullpotentialoftheirentireclinicalworkforce.Theaimistoenablequalityimprovement,innovationandgreaterproductivityinservicedelivery.Sonographersareadiversegroupofhealthcareprofessionalswhodeliverhighqualitycaretopatientsacrossawiderangeofcarepathwaysinavarietyofclinicalsettings.Ultrasoundservicesarehavingincreasingdemandsontheirservices,notleastwithcompliancewithreferraltotreatmenttargets(RTT),sevendayworking,andgreateraccessforpatients.Anationalshortageofsonographersleadingtorecruitmentandretentionissuesfurtherintensifiesthechallengeofprovidingarobustultrasoundservice.Theexistingarrangementsbywhichsonographers,whoarealsostatutorilyregistered,prescribeandsupplymedicinestotheirpatientsarecomplex.Supplementaryprescribingtrainingisavailabletosomeprofessionalgroupsasistrainingtobeanindependentprescriber.PatientGroupDirectionsareavailabletomanysonographerswhoarealsostatutorilyregisteredas(forexample)aradiographer,physiotherapist,nurseormidwife.Traditionally,thepreferredwayforpatientstoreceivemedicinestheyneedisforaprescribertoprovidecareforapatientonaone-to-onebasis.ThismethodchangedfollowingpublicationofthefinalCrownreportreviewonprescribing,supplyandadministrationofmedicines(1999).1Legalframeworksweredevelopedthathave


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allowedservicestobere-designedandforhealthcareprofessionalstoworkmoreflexiblyforthebenefitsofpatients.Asaresulttherearenowseverallegaloptionsforsupplyingand/oradministeringmedicinesincludingthecommonlyusedPatientGroupDirections(PGDs).ThereareanincreasingnumberofPGDsthatwillallowmedicinestobeadministeredwithouttheneedforadoctortobepresent.Greaterflexibilityofprescribingandmedicinessupplyhasthepotentialtoreducetreatmentdelays,improvespecificityandresponsivenessofprescribingandtherebyreducepatients’exposuretosafetyrisks.Safetyconsiderationsrelatetotrainingarrangements,communicationofprescribingandgovernancearrangements.Thecurrentsituationanddefinitions

Thelawstatesthatsomegroupsofstatutorilyregisteredhealthcareprofessionalsareallowedtosupplyand/oradministermedicinesusingPatientGroupDirections.Someprofessionalgroupscantraintobecomesupplementaryprescribersorindependentprescribers.IndependentPrescribingIndependentPrescribingmeansthattheprescribertakesresponsibilityfortheclinicalassessmentofthepatient,establishingadiagnosisandtheclinicalmanagementrequired,aswellasprescribingwherenecessaryandtheappropriatenessofanyprescription.SupplementaryPrescribingSupplementaryPrescribingisdefinedasavoluntarypartnershipbetweenanindependentprescriber(adoctorordentist)andasupplementaryprescribertoimplementanagreedpatient-specificClinicalManagementPlanwiththepatient'sagreement.PatientSpecificDirections(supplyoradministration)APatientSpecificDirection(PSD)isadirectwritteninstructionforanamedpatientanddoesnotrequireassessmentofthepatientbytheindividualinstructedbeforeadministering,unlikeaPatientGroupDirection.Inprimarycare,thismightbeasimpleinstructioninthepatient'snotes.Examplesinsecondarycareincludeinstructionsonapatient'swarddrugchart.Ifaradiologistwritesthetype,strengthandamountofcontrastagenttobegiventoanamedpatientthenthatisaPatientSpecificDirection.Novariationisallowed.WhereaPatientSpecificDirectionexists,thereisnoneedforaPatientGroupDirection.AnyonecanfollowaPatientSpecificDirectionaslongastheyareactinginaccordancewiththedirectionsofanappropriatepractitioner(ietheradiologist)followingpatientassessment,anddelegationofsupplyand/oradministration.APatientSpecificDirectioncanalsobeusedwhereaPatientGroupDirectioncannotbeused,egwheretheadministrationiscarriedoutbyaregisteredprofessionalnotcoveredbyaPatientGroupDirectionoranunregisteredhealthcareprofessionalsuchasanassistantpractitionerorasonographerwhoisnotstatutorilyregistered.PatientGroupDirections(supplyoradministration)APatientGroupDirection(PGD)isawritteninstructionforthesupplyoradministrationofmedicinestogroupsofpatientswhomaynotbeindividuallyidentifiedbeforepresentationfortreatment.ItisnotaformofprescribingandthereisnospecifictrainingthathealthprofessionalsmustundertakebeforetheyareabletoworkunderaPatientGroupDirection.However,certainrequirementsapplytotheuseofPatientGroupDirections.PatientGroupDirectionsareawayforsomegroupsofstatutorilyregisteredhealthcareprofessionalstobeabletosupplyandadministermostmedicinesandcontrastagentsusedinimagingandradiotherapydepartments.


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N.B.Onlysome(notall)groupsofstatutorilyregisteredhealthcareprofessionalscanusePatientGroupDirections.AssistantpractitionersarenotaregisteredandregulatedworkforceandthereforearenotallowedtosupplyoradministerunderPatientGroupDirections.Somesonographerscannotachievestatutoryregistrationandareinsteadvoluntaryregistered.VoluntaryregistrationisnotsufficientfortheuseofPGDs;statutoryregistrationisrequired.FurtherinformationonPGDscanbefoundat:https://www.sor.org/practice/other-groups/prescribing

http://www.medicinesresources.nhs.uk/en/Communities/NHS/PGDs/

https://www.nice.org.uk/guidance/mpg2

PGDflowdiagrams:

to pgd or not to pgd.pdf

References1)DepartmentofHealth.Reviewofprescribing,supplyandadministrationofmedicines.Chair:DrJuneCrownLondon:DH,19992.17ACQUISITION,ARCHIVINGANDUSEOFULTRASOUNDDATAUltrasounddatareferstoultrasoundimages,ultrasoundreportsandrequestforms.Theyincludeimagescapturedandstoredindigital,video,filmandthermalpaperformatsandwrittenreports/requestsgeneratedeitherinelectronicformoronpaper.ImagerecordingThecompilationofanappropriatenumberofannotatedimagesthatrepresenttheentireultrasoundexaminationisgoodpracticeasitprovidesthefollowing:

• supportforthewrittenreport;1• asecondopiniontobegivenonthosepartsoftheexaminationthathavebeenimaged;• acontributiontoclinicalgovernancethroughauditandqualityassuranceprocedures;2,3• ateachingtool;• evidencethattheexaminationwascarriedouttoacompetentstandard;• evidencethatlocalguidelinesandprotocolswerefollowed.

Unlesstheentireexaminationisrecordeditmustberecognisedthattheultrasoundimagescannotbefullyrepresentativeofthatexamination.Thestoredimageswillhavebeenchosenbytheultrasoundpractitionerasareasonableselectiontosupporttheexaminationreportonly.Ifanabnormalityorotherpathologyhasbeenmissedduringtherealtimeexamination,itisunlikelytohavebeenincludedonanimage.4

Allimagesshouldhavethefollowingdemographicandmachineinformationcorrectlyrecordedonthem:

• Patientidentification• DateofExamination• Hospital/Trust/department/provideridentification.


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Ultrasoundpractitionersshouldbeawarethattheon-screeninformationisnotalwaysreproducedontherecordedimages.Forexample,thesafetyindicesdisplayedduringtherealtimeexaminationmaynotbereplicated.Thiswilldependonthemachineinuse.Managersofultrasoundservicesshouldensurethatthelocalprotocolsandguidelinesaddresstheissueof:

• ultrasounddataacquisition• storageandarchivingofspecificultrasounddatainaccordancewithnationalguidance

andcurrentlegislationincludingthedataprotectionandfreedomofinformationacts.Itistheultrasoundpractitioner’sresponsibilitytoensurethattheyarefamiliarwithlocalprotocolsforimagerecordingandstorage.Selectionofimages

Recordingofimagesshouldbedoneinaccordancewithagreedlocalprotocolsand/orasrequiredbynationalprotocolswheretheseexist(egwithinscreeningprogrammes).Ultrasoundpractitionersshouldensurethatstoredimagesarecorrectlyannotatedandcanbebenchmarkedagainstthenationalstandard.Professionaljudgementshouldbeexercisedintheselectionandrecordingofanyimagesinadditiontothoserequiredbyprotocoltosupporttheexaminationreportordemonstratethatameasurementhasbeenmade.Astechnologydevelops,entireexaminationsmaybeabletoberoutinelysaved,thusremovingtheneedtoselectspecificimagesforrecording.

Screeningprogrammerequirements

TheFetalAnomalyScreeningProgrammeandtheAbdominalAorticAneurysmScreeningprogrammeshavepublishedrequirementsfortheimagesthatmustberecorded.See:https://www.gov.uk/government/publications/fetal-anomaly-screening-programme-handbook(Section5.6.4)https://www.gov.uk/government/publications/aaa-screening-standard-operating-proceduresTheequivalentscreeningprogrammesinthedevolvedcountrieswillhavetheirownrecommendations(ref;section1.8).Independentwork(seealsosection1.20)Ultrasoundpractitionersworkingindependentlyshouldbeclearastowhoownstheimages,whattheirresponsibilitiesareforimagestorageandhavecleargovernanceproceduresrelatingtoimagerecordingandstorage.Ifimagesaretobegiventothepatientattheendoftheexaminationitisrecommendedthat,ataminimum,anidenticalimagesetisstoredbytheproviderforfuturereference.UltrasoundpractitionersworkinginEnglandundertheCareQualityCommission(CQC)‘practisingprivileges’exemptionshouldbeawareofthewordingonpage8oftheCQC‘ScopeofRegistration’.Thisstatesthatthehostingproviderwillownallrecordsandwillhaveresponsibilityforensuringthatessentiallevelsofqualityandsafetyaremet.http://www.cqc.org.uk/sites/default/files/20150326_100001_scope_registration_march_2015_updated.pdfOnlytheCQCcangiveformaladviceonregistrationrequirements,theonusisontheindependentprovidertoregisterunlessadvisedotherwisebytheCQC.http://www.cqc.org.uk/content/contact-us


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Generaladviceonindependentpracticecanbefoundathttps://www.sor.org/learning/document-library/independent-practitioners-standards-and-guidance,withinsection3.2oftheseGuidelinesandwithintheRCR/SCoR’s2014‘Standardsfortheprovisionofanultrasoundservice’document.2

NHSLitigationAuthorityreport.Seepage24onwards(1).StorageofimagesanddataTherearevaryingrequirementsforthestorageofimagesandassociatedultrasounddataincludingthereportandrequestform.Forobstetricscansthiscanbeupto25yearsormore.Scansonchildrenandyoungpeoplehavesimilarlylongretentiontimes.Fulldetailsathttp://www.nhs.uk/chq/Pages/1889.aspx?CategoryID=68Trusts,HealthBoards,departmentsandindependentprovidersshouldincludedetailsofimagestoragerequirementsandresponsibilitieswithintheirgovernanceprocedures.References1)NHSLitigationAuthority(nowNHSResolution).Tenyearsofmaternityclaims.AnanalysisofNHSLitigationAuthorityDatahttp://www.nhsla.com/safety/Documents/Ten%20Years%20of%20Maternity%20Claims%20-%20An%20Analysis%20of%20the%20NHS%20LA%20Data%20-%20October%202012.pdf2)RoyalCollegeofRadiologists,SocietyandCollegeofRadiographers.Standardsfortheprovisionofanultrasoundservice.London:RCR/SCoR,2014http://www.sor.org/sites/default/files/document-versions/bfcr1417_standards_ultrasound.pdf3)BMUSaudittoolhttps://www.bmus.org/policies-statements-guidelines/professional-guidance/bmus-recommended-audit-tool/(BMUSmemberlog-inrequired).4)BatesJ.2011AbdominalUltrasoundHow,WhyandWhen.(3rdEdn)Elsevier.p14

2.18 AUDITANDLEARNINGFROMDISCREPANCY

Introduction

AsoutlinedintheRoyalCollegeofRadiologists/SocietyandCollegeofRadiographers2014document’Standardsfortheprovisionofanultrasoundservice’,objectiveandrobustauditandreviewofnon-obstetricultrasoundimagingisdifficultowingtotheverynatureoftheimagingspecialty.Ultrasoundisanoperatordependentimagingmodalitywhereimageassessmentanddiagnosisoccursinreal-time.Therecordedstillimagesarearecordoftheexaminationthatwasperformedbuttheydonotnecessarilyreflectthequalityoftheexaminationundertaken.Thatsaid,assessmentofhardcopyimagescanbeanindicationofwhetheranyimagingparametershavebeenalteredandtechniquemodifiedinresponsetotheconditionsfoundwhileundertakingthescan.Therearemultiplelimitingfactorsaffectingthequalityandoutcomeofanyultrasoundexamination.Inadditiontopatientfactors,ageandqualityofthemachinebeingused,experienceoftheoperatorandnotleast,anunderstandingoftheclinicalquestionbeingaskedallhaveanimpactinthefinaloutcomeofanyexamination.Undertakingqualityassuranceofultrasoundstudiesundertheseconditionsischallenging.1Thesubjectivityandoperatordependenceofultrasoundimagingneedstoberecognisedwithinanyauditprogrammebeingimplemented.Priortoimplementation,itisessentialthatthereisanunderstandingofwhattheauditprogrammeistryingtoachieve.Itisalsoessentialthatstaffmemberswithintheteaminwhichtheauditprogrammeisbeingimplementedunderstandtherationaleforthisprogramme,understandtheprocessandengagewiththeprocessitself.Auditprogrammesshouldbeviewedasaprocessratherthansimplyameanstoanend.Itshouldhighlightareaswhereimprovementscanbemadewhilerecognisingthatresourcesandsupportwillbenecessarytoensure


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improvementscanbeimplemented.Learningoutcomesandactionspointsareanessentialpartofthisauditprogrammesothatimprovementtoclinicalpracticecanbemonitored,focusedandreviewed.Foranyultrasoundpractitionerworkinginisolationorwithinateamitisimportanttogainanunderstandingoftheexpectedandachievablestandardofpractice.Knowingandunderstandingthisstandardwillprovideevidenceforcommissionersofanycontractsbut,moreimportantly,itwillprovideabenchmarkagainstwhichpractitionerscanbemeasured,andcanmeasurethemselves.Whileissuesoffailingcompetencyarerare,theyareincrediblydifficulttodealwithifthereisnoknownstandardofpracticewithinaservice.2Reviewingimagesandreportsistheessentialfirststepinanultrasoundauditprogramme.Arangeofpracticesarealreadyinplacewhichmaybeusedtoassessqualityorinformservicesoftheirperformance.TheseoftenincludeContinuingProfessionalDevelopment(CPD)activitiessuchasfollow-upofindividualcases,image/discrepancyreviewsessionsandattendanceatMDTmeetings.WhilesuchCPDactivitiesarevitalindevelopingtheeducationofultrasoundpractitionertheyshouldbeusedinconjunctionwith,ratherthaninsteadofamoreformalqualityassuranceprogramme.1Whenundertakinganauditprogrammewithinanultrasoundservice,aholisticviewofthequalityofanultrasoundexaminationisrequired.Whileimagequalityandoverallreportaccuracyareimportant,itisessentialthatotherfactorssuchasclarity,content,readabilityandrelevanceofthereportshouldbeassessed.Alimitingfactortotheclarityofthereportmaybedue,inpart,tothequalityofthereferral.Itisrecommendedthatanyauditprogrammeassessesthereferralforrelevanceandclarityofclinicalquestioninadditiontoassessingtheultrasoundexaminationitself.Auditprogramme

Therearevariousmethodsofauditprocessproposedintheliteratureandcurrentlybeingundertakeninpractice1,2howevertheBritishMedicalUltrasoundSociety(BMUS)3havedevisedauniversalaudittoolthatcanbeusedtoevaluatethereferral,theimagequalityandreport.Whilethistoolmaynotencompassallauditprogrammes,itisrecommendedasastartingpointfromwhichin-houseaudittoolscanbedevelopedtomeetlocalneeds.Asyet,therearenonationalstandardsforexpectedqualityofimagesandreportsfornon-obstetricultrasound.Thebenchmarkstandardagainstwhichimagesandreportswillbeassessedwillbelimitedbytheindividualsordepartmentstandard.Anoptimumprogrammewouldbetorecruitexternalauditorstoreviewpractice,bethisneighbouringTrustsorcolleaguesbutitisrecognisedthatthismayencounterfinancialandtimeconstraints.InlinewithrecentRoyalCollegeofRadiologistsStandardpublicationsitisstronglyrecommendedthatthispeerreviewauditisundertakeninconjunctionwithadiscrepancymeeting.Itisrecommendedthateachserviceagreesatolerancelevelofacceptablequalityandanycasesfallingbelowthistolerancelevelshouldbediscussedopenlywithinadiscrepancymeetingandlearningpointsandfurtheractionagreedwithintheteamofpeers.4,5RecommendationsforuseoftheBMUSaudittool

Itisacknowledgedthatapeerreviewofimagesandreportstakestime.Areasonableestimationoftimerequiredistoallocateanaverageof5minutespercasereviewed.Itisrecommendedthatservicesshouldaimforareviewof5%ofallexaminationsandreports.4,5Atimelyretrospectiveauditofcasesisrequired.Servicesmaywishtoallocatetimeonadaily,weeklyormonthlybasis.AccesstoimageandreportstoragefacilitiesarerequiredandoftenassistancefromITdepartmentsorPACSmanagersisrequiredtoretrieveretrospectivedataofexaminationsperformed.Arandomisedsampleofexaminationswillreducebiasbetweenreviewersandusersofthistoolareadvisedtodetermineareliablemethodtobothretrievedataandensureitisrandomised.Someusersmaypreferthatthe


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casesareanonymousbutthiscanbedetrimentaltotheservicebeingabletoidentitylearningneedsofindividualpractitioners.Individualserviceswillneedtoagreewhowithintheteamistoperformreviewsbearinginmindthatanindividual’sinclusionintoauditprogrammeoftenimprovescompliancewiththemandenhancesasenseofownershipandresponsibility.Itisstronglysuggestedthatallpractitionerswithinateamparticipateintheprocess.Adatabaseforidentifyingcasesthathavebeenreviewedandstoringtheauditdatawillneedtobeestablished.Thiscanbeanelectronicdatabase,asystemlinkedtohospitalpatientrecordsorapaperfilingsystem.Servicesneedtobemindfulofdataprotectionandinformationgovernanceguidanceandlegislationwithregardstostoringpatientdata.Reviewprocess

Oncecasesforreviewhavebeenidentified,thereviewerwillneedtoaccessthereferralinformation,thestoredimagesandtheissuedreport.Allthreeaspectsoftheexaminationarereviewed.Initiallytheclinicalquestionshouldbereviewed.Isitclearandappropriate?Theimagesarethenreviewedandcategorisedintogood,acceptableorpoor.Thesejudgementswillbebasedonthereviewer’sownstandardofpractice.Thereportwillthenbereviewedandagaincategorisedintogood,acceptableorpoor.BMUSrecommendedreportingstandardsandbestpracticeisdocumentedinthefollowingarticle6availablefromtheUltrasoundjournalandwhichcanalsobefoundviatheBMUSwebsite.Finally,thereviewershoulddetermineiftheclinicalquestionhasbeenansweredandwhetherappropriateadviceoraconclusionhasbeengivenwhereappropriate.Thiscanincludeastatementofnormalityor‘nocauseofsymptomsdemonstrated’andmaybedictatedbydepartmentalpractice.Itisrecognisedthatinsomespecialisedcases,orcasesincludingintervention,aconclusionmaynotbedesirableorhelpful.Allscoresshouldberecordedonanappropriatedatabase.Itisrecommendedthatcasesfallingbelowthedepartmentspredeterminedminimumstandardslevelarediscussedwiththeindividualpractitionerbeforebeingdiscussedopenlyatadiscrepancymeeting.Itisstronglyrecommendedthatanysignificanterrors,suchasunreportedpathologyorsignificanttypographicalerrorsarerectifiedimmediatelybyissuingeitherasupplementaryreportorrecallingthepatientfollowingdiscussionwiththepractitionerand/orclinicianreferringtheexamination.Learningfromdiscrepancies

Anultrasounddisagreementisidentifiedbyapersonsecondreviewingimagesand/orareportandtheiropinionisdifferenttotheoriginalinretrospect.Thisreviewmayoccuraspartofpeerreview,MDTorX-raydiscussion,in-houseauditoraspartorroutinework.

Areportingdiscrepancyoccurswhenaretrospectivereview,orsubsequentinformationaboutpatientoutcome,leadstoanopiniondifferentfromthatexpressedintheoriginalreport.Notallreportingdiscrepanciesareerrors.ItisrecommendedthatlocalTermsofReferenceareagreedwhenestablishingthemeetings.Thetermsofreferenceshouldincludeasaminimum:


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• themembershipofthemeeting;• thechairofthemeeting;• confidentialityofthecasesanddiscussions;• agreementastowhetherthecasesareanonymousornot;• thereviewprocessforcasesbeingdiscussed;• howthecasesaredocumented;• anygradingand/orscoringsystembeingimplemented;• anyvotingprocessbeingused;• whoiseligibletovote;• whoisthearbitratorofanydiscussion;• howlearningoutcomesarerecorded;• howactionpointsarerecorded;• howdataisrecordedforreview;• dutyofcandouractions;• howseriouserrorsordiscrepanciesareescalated.

Suggestionsforholdingultrasounddiscrepancymeetings

Itisrecommendedthatdiscrepancymeetingsareheldeverymonth.Thosepresentwithappropriatequalificationsvoteonthecaseusingthefollowingsystem.Gradeofdisagreement

Theaimoftheoutcomeofdiscussionsatthediscrepancymeetingistogradetheseverityofthedisagreement.Thefollowinggradesaresuggested:

Grade Radiologicalsignificancenotclinicalsignificance

0 Nodiscrepancy-simplyadisagreement!

1 UnderstandablemissDisagreementwithreport–noactionrequired

2 Disagreementwithreport–reportamended(shouldbecalledmostofthetime)

3 Significantdisagreementwithreport–actionrequired(shouldbecalledalmosteverytime)Themajorityviewistaken.Grade0isnotadiscrepancybutsimplyadisagreementofopinionbetweenhealthcareprofessionals.Grade1isregardedasanunderstandablemiss.Twoexamplesaredetailedbelow:• Imagesoftheexaminationdemonstratethatthepara-aorticregionwasnotimagedorcommented

on.Operatorsneedtobeawareofreasonforscanningpara-aorticregion.Thisisdonetoassessforenlargedlymphnodesbutitisunderstandablewhythiswasnotimagedgiventheclinicaldetailsandpresenceofgasintheabdomen.

• Aliverthatappearstobehyperechoiccomparedtothekidneyonreviewoftheimagesmayhaveappearednormalatthetimeoftheexamination.Theappearancesmaybeduetothemachinequalityandsetting.OnlywithadditionalclinicalinformationsuchasincreasedLFT’swouldthepossibilityandsignificanceoffattyinfiltrationbeconsidered.

Thesearecontentiouspointsandthisiswhywetakeamajorityviewfromagroupofqualifiedpeers.


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Grade2and3arereportingdiscrepancies.Areportingdiscrepancyoccurswhenaretrospectivereview,orsubsequentinformationaboutpatientoutcome,leadstoanopiniondifferentfromthatexpressedintheoriginalreport.Notallreportingdisagreementsareerrors.Grade2maybeadiscrepancyinwhichthewordingofthereportisambiguousoradditionalstatementsarerequiredtoimprovediagnosis.Anexampleofagrade2discrepancyisdetailedbelow:

• Onreviewoftheimages,thereisapparentrightrenalpelvisfullnessbutnootherevidenceof

hydronephrosisorrenalobstruction.Noevaluationofresistanceindicesmadewhichmayhaveimproveddiagnosticconfidence.Thereportstatesnocauseforobstructionseenimplyingthekidneyisobstructed.Ondiscussionwiththepeers,themajoritywouldhavewordedthereportdifferentlywhichmayhaveaffectedfuturepatientmanagementbutnotsignificantlyaffectedoutcome.

Grade3maybeadiscrepancyinwhichanabnormalityisdemonstratedontheimagesandnotdocumentedonthereportorwheretheabnormalityimagedisinterpreteddifferentlyfromthemajorityview.Inthevastmajorityofthesecasesthepatientisrecalledforasubsequentfollowupultrasoundexaminationoralternativeimagingtoevaluatewhetheranabnormalityhasbeenmissedormisinterpreted.Thefindingsofanysuchreviewexaminationsarefedbacktotheindividualoperatorviaaonetoonediscussionandtheteamatthenextdisagreementmeeting.

TypeofdisagreementIfagrade3discrepancyhasoccurreditisrecommendedthatthediscrepancyisbenchmarkedtopromotepersonalandcorporatereflection.

Followingdiscussionandagreementofthegradeandtypeofdiscrepancy,themeetingshouldagreelearningoutcomesandactionpointsfortheindividualandteam.Thismayincludeachangetoguidelines,additionaltraining,arevisionofpathologiesandconditionsoccurringincertainpatientgroupsorsimplyareviewofasinglecase.Anysuchlearningoutcomesandactionpointsshouldberecorded,withacopybeingsenttotheindividualpractitionerandacopystoredsecurelywithinthedepartmentforfuturereference.DutyofCandour

Aprocessneedstobeestablishedastohowerrorsand/ordisagreementsarecommunicatedtothereferrerandsubsequentlythepatient.Itisrecommendedthatultrasoundpractitionersanddepartmentsseekadviceregardinglocalpracticeandguidelineswithintheirlocalservice.Seealsosection1.17.TheNMCandGMChaveadviceontheDutyofCandourat:https://www.gmc-uk.org/DoC_guidance_englsih.pdf_61618688.pdfUltrasoundPractitionersshouldalsobeawareoftherequirementsoftheirProfessionalIndemnityInsurerifaskedtomakeanystatementsregardingpatientcare,complaintsandclaims.References1)TheRoyalCollegeofRadiologists.StandardsfortheprovisionofanUltrasoundService.London:RCR/SCoR;20142)ParkerP,ByassO.SuccessfulImplementationofaPerformance-RelatedAuditToolForSonographers

TypeofDiscrepancyA ObservationB InterpretationC PoorimagingtechniqueD Poorwording


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UltrasoundOnlineFirst,publishedJanuary10,2015asdoi:10.1177/1742271X145668473)BritishMedicalUltrasoundSociety2015BMUSRecommendedPeerReviewAuditTool.Availableviawww.bmus.org4)TheRoyalCollegeofRadiologists.Qualityassuranceinradiologyreporting:peerfeedback.London:RCR;20145)TheRoyalCollegeofRadiologists.StandardsforLearningfromDiscrepancyMeeting.London:RCR;20146)EdwardsHetalWhatmakesagoodultrasoundreport?Ultrasound2014;22(1)57-60Furtherreading:NationalUltrasoundSteeringGroup(NUSG),asubgroupoftheNationalImagingBoard(2008)UltrasoundClinicalGovernance.Obtainablevia:https://www.bmus.org/static/uploads/resources/ClinicalGovernanceInUltrasound-061108.pdf

2.19RECORDINGOFIMAGESBYPATIENTSDURINGULTRASOUNDEXAMINATIONSThefollowingadviceisfromtheSCoRdocument:‘Therecordingofimagesduringdiagnosticimagingincludingscreeningandradiotherapy’(2014).https://www.sor.org/learning/document-library/recording-images-patients-during-diagnostic-imaging-including-screening-and-radiotherapy

Ultrasoundpractitionersmaybeaskedbyapatientorpersonaccompanyingthemiftheywillallowthemtomaketheirownreal-timerecordingofadiagnosticorscreeningexaminationortreatment.Thisrequestmaybetorecordtheexaminationortreatmentwithamobiletelephone,recordontoaDVDormemorydeviceorutiliseotherdigitaloranaloguerecordingmedia.Withrapiddevelopmentsincommunicationstechnology,thewaysinwhichsuchrecordingsareabletobemadearelikelytobecomeevermorevaried.

Therehavebeeninstanceswhereexaminationsortreatmentshavebeenrecordedandpostedtosocialmediasiteswithouttheultrasoundpractitioner’sconsent.Theserecordingshaveincludedconversationsbetweentheultrasoundpractitionerandthepatient.Itcanthenproveverydifficulttohavetheseremoved,especiallyifthereisnostatementofpolicyplacedinwaitingroomsorotherwisepubliclyavailable.Thedecisionastowhethertoallowimages,anexaminationortreatmenttoberecordedshouldbemadebytheindividualdepartmentsconcerned,butingeneraltermstheSCoRandBMUSwoulddiscouragethis.Departmentsshouldhaveaclearpolicyonthisissuefollowingariskassessmentthattakesaccountofthefollowing:i) theviewsofmembersoftheprofessionalworkforcebothasagroupandindividuallyshouldclearlybe

takenintoaccount.Manydonotwanttobefilmedorrecordedandtheirwishesshouldberespected.ii) possiblemedico-legalcomplicationsarisingif,forexample,anabnormalityisrecordedthatisnotreported

oractedupon.Conversationsbetweentheultrasoundpractitionerandthepatientandanyoneaccompanyingthemmayalsoberecorded.Theemployermustbeawareofanylocalarrangementsifitisdecidedtoallowthisastheymayimpactonitsriskstrategyandinsurancearrangements.

iii) itcanbeagreatdistractionandcanincreasestresslevelsfortheultrasoundpractitioneratatimewhentheyrequireveryhighlevelsofconcentration.

iv) ithasthepotentialtoextendthetimeoftheexaminationortreatmentwhichmaybecontrarytopublishedsafetyguidelinesandadvice.

v) providersshouldtakeintoconsiderationthepossibleexistenceoflocalpoliciesallowing,forexample,therecordingofabirth.ManyemployingauthoritiesdotrytofacilitatethistypeofrequestwithintheDirectoratesthathaveresponsibilityformaternityservices.

vi) providersshouldconsiderconsultingwithanyrelevantpatientliaisongroupsthattheemployingauthoritymayhaveandensurethefinalagreedpolicyispublicallyavailable.Removalofmaterialfromsocialmedia


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thathasincludedtheultrasoundpractitionerwithouttheirconsentmaybedifficult,particularlysoifnopriornoticeofpolicyhasbeenmadeavailable.

vii) providersmightalsowishtoconsiderhowstaffshouldrespondtosituationswherefilmingbeginsorcontinueswithoutpermissionandcontrarytotheagreedpolicy.

Thisadvicedoesnotrefertothetakingofimagesbyultrasoundpractitionersduringobstetricexaminationsandthatisagreedprocedurebetweentheultrasounddepartmentandtheemployingauthority.Thisisoftenforapreviouslyadvertisedfee.

2.20‘HAVEYOUPAUSEDANDCHECKED’POSTERSANDPROMPTCARDS‘Haveyoupausedandchecked?’postersandapromptcardhavebeenpublishedtosupportultrasoundpractitionersinclinicalimagingservices.Theyaredesignedtoactasareadyreminderofthechecksthatneedtobemadewhenanyultrasoundexaminationisundertaken.ThepostersaredesignedinPDFformattoallowforeasydownloadingandprinting.Theycanthenbedisplayedinthedepartmentasrequired.ThereareA4andA3sizesavailableandalsoanA6versionthatissmallenoughtobeplacedclosetoamachineorworkstation.ThepostershavebeendevelopedbyajointworkingpartyfromtheSocietyandCollegeofRadiographersandtheBritishMedicalUltrasoundSociety.https://www.sor.org/learning/document-library/have-you-paused-and-checked-ultrasound

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