CT Protocols for Common Primary Care Diagnoses

Lacey J. McIntosh DO, MPH

University of Massachusetts Medical Center
UNECOM 2014
CME Program/Reunion and Alumni Weekend:
Primary Care in Today’s Changing Practice Environment
October 10-12, 2014
University of New England Biddeford Campus
CT Protocols – IV Contrast
• Indications • Imaging Phases
– Mass/malignancy/staging – Arterial phase
• May require a special multiphase • Contrast has not yet reached the
protocol organ, in arteries only
– Infection/Inflammation – *Portal venous phase
– “Pain” • Organ has perfused, contrast
returning through venous system
– Unsure
– Angiograms – Delayed phase
• Equilibrium state where contrast
• Contraindications has returned to venous system,
– Allergy beginning to be renally excreted
– GFR>30 (>45)
– Caution in hypertension, • Affected by cardiac function,
diabetes, renal transplant, single anatomy, and physiology
kidney, CRD
• Not needed
– Organ size
– Follow renal stones
– Hernia
– Retroperitoneal hemorrhage

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Renal Function Guidelines
eGFR > 60
• In the outpatient setting, the following (very low risk)
No restrictions
patient population will require renal
function screening within 30 days of
contrast administration: eGFR 45-60
If acute renal failure, consider IV hydration.
• Age >65 years Otherwise, encourage oral hydration and
(low risk)
salt loading as clinically appropriate.
• History of renal disease, including
– Kidney transplant Consider alternative exams (MRI/Ultrasound).
– Single kidney eGFR 30 – 44
Otherwise IV hydration required (see
– Kidney cancer below) unless documented that medical
(moderate risk)
emergency precludes hydration. Iodixanol
– Kidney surgery
(Visipaque) contrast is suggested.
– History of renal insufficiency
• History of hypertension requiring No IV contrast unless approved by nephrology
medical therapy or deemed a medical emergency, which
must be documented. Iodixanol
• History of diabetes eGFR < 30
(Visipaque) contrast is suggested in the
• Metformin (or metformin-containing (high risk)
event of a documented medical
drug combinations) emergency/override authorizing the
administration of IV contrast.

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Organ evaluation
Indication: “stone”

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Pyelonephritis Normal
Mass evaluation
Indication: “early satiety”

Extra-adrenal
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Pheochromocytoma
CT Protocols – Oral Contrast
• Indications - Body • Bladder Contrast
– Mostly for us to identify bowel – Fistula
• From other structures – Bladder wall integrity
• Evaluate wall • Rectal Contrast
– Volumen
– Functional – Fistula
– Evaluate gastric bypass – Post surgical
– Post surgical is a must! – Penetrating trauma
• Gastrograffin
• Contraindications
– Intolerance • “Size Matters”
– Will obscure your finding
• Not needed • Things are different in the ER
– Angiograms setting
– Organ specific exams

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 Early Acute Appendicitis
No Oral Contrast

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 Early Acute Appendicitis
With Oral Contrast

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 Late Acute Appendicitis
With Oral Contrast
+ “Internal Contrast”

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CT Abd/Pelvis I+ “Routine”
• 1 scan: Portal Venous

• Indications:
• Evaluate visceral organ
• Pain
• Unsure

• NOT optimal for looking at

arterial anatomy or for
occlusion (mesenteric ischemia)

Acute Pancreatitis
Necrosis
Splenic Vein Thrombus
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 Acute, Uncomplicated
Diverticulitis

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 Complicated Diverticulitis with
Gas-Containing Abscess

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 Acute Cholecystitis

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CT Abd/Pelvis I- or KUB
• 1 scan: Noncontrast

• Indications:
• Contrast is not necessary
to see the findings
– Retroperitoneal
hemorrhage
– Kidney stones
– Organ size
– Hernia
• Contrast might obscure
your finding
– Hepatic steatosis
• Patient cannot have Splenomegaly (Lymphoma)
contrast

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CT Liver I-/I+
• 4 scans: Noncontrast, Arterial Portal Venous, Delayed

• Indications:
• Should be considered in any patient with cirrhosis
– HCC detection or follow up
– Characterization of previously detected liver mass (seen on US,
Routine CT A/P)
– Follow up ablation or TACE
• Consider including pelvis if first time or looking for ascites

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 Noncontrast Arterial

Hepatocellular Carcinoma

16 | Portal Venous | Delayed

 Noncontrast Arterial

Massive Infiltrating Hepatocellular Carcinoma

17 | Portal Venous | Delayed

 Noncontrast Arterial

Cholangiocarcinoma

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CT Protocols |
Portal Venous Delayed
Arterial Portal Venous Delayed

Hemangiomas

Arterial

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CT Pancreas I-/I+
• 3 scans: Noncontrast, Arterial, Portal
Venous

• Indications:
• Not appropriate for screening for
pancreatic mass or for acute
pancreatitis
Noncontrast
– To characterize a previously
detected uncharacterized pancreatic
lesion, surgical planning
• Resectability
– Involvement of regional arteries and
veins

Pancreatic carcinoma
With encasement of the SMA
Arterial
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CT Renal Mass I-/I+
• 3 scans: Noncontrast, Arterial, Portal
Venous

• Indications:
• Not appropriate for screening
– To characterize a previously
detected renal lesion
Noncontrast
• Does not include a delayed phase, so
it is not optimal for looking at
collecting system abnormalities or
detecting TCC

Renal Cell Carcinoma

Arterial
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CT Urogram I-/I+
• 2 scans: Noncontrast, Combo
Nephrographic/Excretory

• Indications:
• Optimized study to look at renal
parenchyma AND collecting
system
– Microscopic hematuria
– Detecting transitional cell
carcinoma (TCC)
• Not good for looking at renal
(parenchymal based) mass or
indeterminate cysts

Transitional Cell Carcinoma

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Other Body CT Protocols
• CT Enterography I+O+ Volumen
– 1 scan: Portal Venous
– Indications:
• Crohns/IBD
• Malabsorption
• Renal Donor Protocol I-/I+
– 3 scans: Noncontrast, Arterial, Venous
• Liver Donor Protocol I-/I+
– 3 scans: Arterial, Venous, Delayed
• CT Colonography I-/O+/CO2+
– 2 scans: O+ prone and supine after previous day bowel prep

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 Thoracic Imaging

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CT Chest I- “Routine”
• 1 scan: Noncontrast

• Indications:
• Pneumonia/Atelectasis
• Emphysema
• Pulmonary nodules
• Pleural effusions

• Special scenarios:
• Low dose nodule f/u
• High resolution for interstitial
lung disease
• More scans
(supine/prone,
inspiratory/expiratory)

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Pneumonia
CT Chest I+ “Routine”
• 1 scan: Portal Venous

• Indications:
• Mass/Malignancy
• Especially
lymphadenopathy
• Initial sarcoid
• Empyema
• Pulmonary artery size

• Not good for looking for PE (too

late)

Empyema

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 Hilar Lymphadenopathy in
Small Cell Lung Carcinoma

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 Lymphoma

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 Carcinoid Tumor

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 Metastatic Anaplastic Thyroid Carcinoma

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CT Chest I+ PE Protocol
• 1 scan: Late Arterial (often done by bolus tracking)

• Indications:
• Pulmonary embolus

• Not good for looking at organs – contrast has not made it there yet

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 Saddle Pulmonary Embolism

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Other Thoracic Protocols
• Cardiac studies (depending on availability)
• May be gated
• May require beta blocker tx
• Valves
• Anatomy
• Coronary Artery Evaluation

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CT Angiograms
• CTA Stent I-/I+
• No oral contrast – 3 scans: Noncontrast, Arterial,
Delayed
• CTA Aneurysm I-/I+ – Indications:
– 2 scans: Noncontrast, Arterial • Evaluate endovascular repair
– Indications: – Delayed phase to look for
delayed leak
• Aortic aneurysm evaluation
• Acute bleed (liver, bowel,
spleen, etc) • CT Extremity Runoff I-/I+
– 2 scans: Noncontrast, Arterial
• CTA Dissection I-/I+ – Indications:
– 3 scans: Noncontrast, Arterial, • Cold limb, extremity ischemia
Portal Venous – Large field of view gives poor
– Indications: special resolution
• Aortic dissection – Usually ordered by vascular
– Portal venous phase is included surgery
to assess organ perfusion

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 Neuro

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CT Head I-
• 1 scan: Noncontrast

• Indications:
• Almost always the first
line evaluation
• Acute trauma, suspected
hemorrhage, stroke
• Seizures, apnea, syncope,
ataxia

• Workhorse of head CT

MCA Infarct

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 Traumatic Hemorrhage
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 Venous Sinus Thrombosis

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CT Head I+
• 2 scans: Noncontrast,
Contrast
– Almost always do in
ADDITION to I-

• Indications:
– Mass
– Infection

• Can obscure small

hemorrhage
• Different from CTA Head
(stroke)

Abscess
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CT Cervical Spine I-
• 1 scan: Noncontrast

• Indications (bone):
– Neck pain (DJD)
– Post trauma
– Post operative

• Not good for looking at the

soft tissues of the neck

Compression Fracture

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CT Neck I+
• 1 scan: Portal Venous

• Indications:
– Mass
– Malignancy
– Infection
– Lymphadenopathy

• Still see cervical spine

• Different from CTA Neck (for stroke or
dissection)

Branchial Cleft Cyst

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CTA Head and Neck I+
• 2 scans: Noncontrast head; Arterial
through the head and neck

• Indications:
– *Stroke
– Dissection
– Post traumatic

• Different from CT Head and Neck I+

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Other Misc Neuro Exams
• CT Nasal Bones I-
– Trauma
• CT Sinus/Maxillofacial I-
– I+ if looking for infection/abscess, neoplasm
• CT Temporal Bones I-
– Hearing loss, cholestatoma, post surgical
• CT Parathyroid I+
– 4D parathyroid CT for parathyroid adenoma

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Musculoskeletal Protocols
• For bone, contrast doesn’t add much
– Only use I+ if planning to evaluate soft tissues or soft tissue component
• CT is best for bone
– If concerned for soft tissues, MRI is far superior
• Ultrasound may be a good place to start (insurance issues)

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Thank You!
• Please feel free to contact me
with any questions about this
presentation, CT protocols, or
radiology in general!

• [email protected]

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Helpful References
• ACR Appropriateness Criteria
http://www.acr.org/Quality-Safety/Appropriateness-Criteria

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