Long term repeat follow up required, seeking to reduce radiation exposure
Meets criteria for CT of Abdomen but CT is not feasible, contraindicated or patient is allergic to iodinated contrast
1.1.1 Confirmed microscopically (required only when hematuria is detected by dip stick test alone)
1.1.2 Urine is grossly (visibly) bloody
1.1.3.1 Ramesh Mazhari and Paul L Kimmel Hematuria: an algorithmic approach to finding the cause. Cleveland Clinic Journal of Medicine 2002; 69(11):870;
1.1.3.2 American College of Radiology ACR Apprpriateness Criteria Hematuria 2005 page 4 accessed 2/11/09
1.2.1 Elevated lipase or Amylase
1.3.1.1 Reife Carol M, “Chapter 41. Weight Loss” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17th Edition: http://www.accessmedicine.com/content.aspx?aID=2867909. 4/1/09
2.1.1 Abdominal and back pain
2.1.2 Dilation seen or suspected on prior imaging
2.1.3 Pulsatile abdominal mass
Jonathan Golledge, Juanita Muller, Alan Daugherty, and Paul Norman Abdominal Aortic Aneurysm: Pathogenesis and Implications for Management Arterioscler. Thromb. Vasc. Biol., Dec 2006; 26: 2605 – 2613.
David B. Hellmann, David J. Grand, and Julie A. Freischlag Inflammatory Abdominal Aortic Aneurysm JAMA, Jan 2007; 297: 395 – 400.
Stephen A. Badger, Mark E. O’Donnell, Muhammed A. Sharif, Christopher S. Boyd, Raymond J. Hannon, Louis L. Lau, Bernard Lee, and Chee V. Soong Risk Factors for Abdominal Aortic Aneurysm and the Influence of Social Deprivation Angiology, Oct 2008; 59: 559 – 566.
Miriam B. Rodin, Martha L. Daviglus, Gordon C. Wong, Kiang Liu, Daniel B. Garside, Philip Greenland, and Jeremiah Stamler Middle Age Cardiovascular Risk Factors and Abdominal Aortic Aneurysm in Older Age Hypertension, Jul 2003; 42: 61 – 68.
Martin R. Back Surveillance After Endovascular Abdominal Aortic Aneurysm Repair Perspectives in Vascular Surgery and Endovascular Therapy, Dec 2007; 19: 395 – 400.
C.A. Spencer, K. Jamrozik, P.E. Norman, and M.M.D. Lawrence-Brown The potential for a selective screening strategy for abdominal aortic aneurysm J Med Screen, Dec 2000; 7: 209 – 211.
Debbie Davis and Marveen Craig Unsuspected Abdominal Aortic Aneurysm Journal of Diagnostic Medical Sonography, May 2002; 18: 154 – 157.
Jack L. Cronenwett A Myth Exposed: Fast Growth in Diameter Does Not Justify Precocious Abdominal Aortic Aneurysm Repair Perspectives in Vascular Surgery and Endovascular Therapy, Mar 2004; 16: 79 – 80.
Salah D. Qanadli, Benoît Mesurolle, Marc Coggia, Olivier Barré, Sumio Fukui, Olivier A. Goeau-Brissonnière, Sophie Chagnon, and Pascal Lacombe Abdominal Aortic Aneurysm: Pretherapy Assessment with Dual-Slice Helical CT Angiography Am. J. Roentgenol., Jan 2000; 174: 181 – 187
2.2.1 Dilated biliary tree on prior imaging
2.2.2.1 Ryo Tamura, Tadashi Ishibashi, and Shoki Takahashi; Chronic Pancreatitis: MRCP versus ERCP for Quantitative Caliber Measurement and Qualitative Evaluation; Radiology 2006 238: 920-928; [favorably compares measurement accuracy of MR to ER CP]
2.2.2.2 M.-J. Kim, D. G. Mitchell, K. Ito, and E. K. Outwater ; Biliary Dilatation: Differentiation of Benign from Malignant Causes-Value of Adding Conventional MR Imaging to MR Cholangiopancreatography1; Radiology, January 1, 2000; 214(1): 173 – 181.
2.2.2.3 S. Saini; Imaging of the Hepatobiliary Tract . Engl. J. Med., June 26, 1997; 336(26): 1889 – 1894.
2.2.2.4 Taouli, Bachir, Ehman, Richard L., Reeder, Scott B. Advanced MRI Methods for Assessment of Chronic Liver Disease Am. J. Roentgenol. 2009 193: 14-27
2.3.1 Dilated biliary tree on prior imaging
2.3.2.1 Ryo Tamura, Tadashi Ishibashi, and Shoki Takahashi; Chronic Pancreatitis: MRCP versus ERCP for Quantitative Caliber Measurement and Qualitative Evaluation; Radiology 2006 238: 920-928; [favorably compares measurement accuracy of MR to ER CP]
2.3.2.2 M.-J. Kim, D. G. Mitchell, K. Ito, and E. K. Outwater ; Biliary Dilatation: Differentiation of Benign from Malignant Causes-Value of Adding Conventional MR Imaging to MR Cholangiopancreatography1; Radiology, January 1, 2000; 214(1): 173 – 181.
2.3.2.3 S. Saini; Imaging of the Hepatobiliary Tract . Engl. J. Med., June 26, 1997; 336(26): 1889 – 1894.
2.4.1 Pain, weight loss, or fever
ACR Appropriateness Criteria Crohn Disease Reviewed 2012
Rakesh Sinha, Ratan Verma, Sadhna Verma, and Arumugam Rajesh Review: MR Enterography of Crohn Disease: Part 2, Imaging and Pathologic Findings AJR July 2012 197:80-85
Hara, Amy K., Alam, Shayan, Heigh, Russell I., Gurudu, Suryakanth R., Hentz, Joseph G., Leighton, Jonathan A. Using CT Enterography to Monitor Crohn’s Disease Activity: A Preliminary Study Am. J. Roentgenol. 2008 190: 1512-151
Seung Soo Lee, Ah Young Kim, Suk-Kyun Yang, Jun-Won Chung, So Yeon Kim, Seong Ho Park, and Hyun Kwon Ha Crohn Disease of the Small Bowel: Comparison of CT Enterography, MR Enterography, and Small-Bowel Follow-Through as Diagnostic Techniques Radiology June 2009 251:751-761;
2.5.1 Hepatomegaly
2.5.2 Elevated alanine or aspratate aminotransferase
2.5.3.1 Angulo, Paul Nonalcoholic Fatty Liver Disease N Engl J Med 2002 346: 1221-1231 “Nonalcoholic fatty liver disease is an increasingly recognized condition that may progress to end-stage liver disease. The pathological picture resembles that of alcohol-induced liver injury, but it occurs in patients who do not abuse alcohol. A variety of terms have been used to describe this entity, including fatty-liver hepatitis, nonalcoholic Laënnec’s disease, diabetes hepatitis, alcohol-like liver disease, and nonalcoholic steatohepatitis.
2.6.1 Abnormal liver function tests
2.6.2 Jaundice
2.6.3 Known malignancy elsewhere
2.6.4 Mass on US
2.7.1.1.1 Blood Pressure falling
2.7.1.1.2 Fever
2.7.1.1.3 Hematocrit falling
2.7.1.1.4 Renal Failure
2.7.1.2.1.1 Back Pain
2.7.1.2.1.2 Mass, back pain, or abdominal tenderness
2.7.1.2.1.3 Post trauma
2.7.1.2.1.4 Tenderness
2.7.1.2.1.5 US findings nondiagnostic
2.7.1.2.1.6 Worsening under treatment
2.7.2.1 Elevated Lipase or Amylase
2.7.2.2 Pain
2.8.1 reference: NCCN update March 2014
2.9.1 Elevated catecholamines
2.9.2 Elevated metanephrines
2.9.3 Elevated VMA
2.9.4 Hypertension not responding to medical therapy
2.9.5.1 Shulkin BL, Ilias I, Sisson JC et al. Current trends in functional imaging of pheochromocytomas and paragangliomas. Ann N Y Acad Sci 2006;1073:374–382
2.9.5.2 Lumachi F, Tregnaghi A, Zucchetta P et al. Sensitivity and positive predictive value of CT, MRI and 123I-MIBG scintigraphy in localizing pheochromocytomas: A prospective study. Nucl Med Commun 2006;27:583–587
2.9.5.3 Adler, Joel T. , Meyer-Rochow, Goswin Y. , Chen, Herbert , Benn, Diana E. , Robinson, Bruce G. , Sippel, Rebecca S. , Sidhu, Stan B. Pheochromocytoma: Current Approaches and Future Directions Oncologist 2008 13: 779-793;
2.10.1 Cholangitis
2.10.2 Colicky abdominal pain and nondiagnostic ultrasound exam
2.10.3 Common bile duct stone on ultrasound
2.10.4.1 Common bile duct dilated to greater than 10 mm on ultrasound if gallbladder removed (post cholecystectomy) or greater than 6 mm if gallbladder present
2.10.5 Elevated direct bilirubin level
2.10.6 Elevated liver function tests (AST, ALT, alkaline phosphatase)
2.10.7 Elevated pancreatic enzymes (amylase or lipase)
2.10.8 Jaundice
2.10.9 Pancreatitis, known
ASGE Standards of Practice Committee The Role of Endoscopy in the Evaluation fo Suspected Choledocholithiasis Gastrointest Endosc 2010; 71:1
3.1 Mass, abdominal or rectal
3.2.1 Elevated lipase or amylase
4.1.1 Interval assessment for stability (6 months, 12 months and two years)
4.1.2.1 Young, William F., Jr.; The Incidentally Discovered Adrenal Mass; N Engl J Med 2007 356: 601-610
4.2 Aldosterone elevated
4.3.1 Dilated biliary tree on prior imaging
4.3.2.1 Ryo Tamura, Tadashi Ishibashi, and Shoki Takahashi; Chronic Pancreatitis: MRCP versus ERCP for Quantitative Caliber Measurement and Qualitative Evaluation; Radiology 2006 238: 920-928; [favorably compares measurement accuracy of MR to ER CP]
4.3.2.2 M.-J. Kim, D. G. Mitchell, K. Ito, and E. K. Outwater ; Biliary Dilatation: Differentiation of Benign from Malignant Causes-Value of Adding Conventional MR Imaging to MR Cholangiopancreatography1; Radiology, January 1, 2000; 214(1): 173 – 181
4.3.2.3 S. Saini; Imaging of the Hepatobiliary Tract . Engl. J. Med., June 26, 1997; 336(26): 1889 – 1894
4.3.2.4 Taouli, Bachir, Ehman, Richard L., Reeder, Scott B. Advanced MRI Methods for Assessment of Chronic Liver Disease Am. J. Roentgenol. 2009 193: 14-27
4.4.1 Hypertension
4.4.2.1 Moser, Marvin, Setaro, John F. Resistant or Difficult-to-Control Hypertension N Engl J Med 2006 355: 385-392
4.5.1.1.1 any number thicker than 1mm
4.5.1.1.2 Multiple thin
4.5.1.2 Thick cyst wall
4.5.1.3 Intrarenal
4.5.1.4 3cm in diameter of greater
4.5.1.5 calcification(s)
4.5.1.6 Contrast enhancement on CT
Gary M. Israel, Nicole Hindman, and Morton A. Bosniak Evaluation of Cystic Renal Masses: Comparison of CT and MR Imaging by Using the Bosniak Classification System Radiology 2004 231: 365-371.
Thomas Whelan Guidelines on the management of renal cyst disease Can Urol Assoc J. 2010 April; 4(2): 98–99
Balci, NC, Semelka, RC, Patt, RH, Dubois, D, Freeman, JA, Gomez-Caminero, A, Woosley, JT, Complex renal cysts: findings on MR imaging ; Am. J. Roentgenol. 1999 172: 1495-1500
M. Suh, F. V. Coakley, A. Qayyum, B. M. Yeh, R. S. Breiman, and Y. Lu Distinction of Renal Cell Carcinomas from High-Attenuation Renal Cysts at Portal Venous Phase Contrast-enhanced CT Radiology, August 1, 2003; 228(2): 330 – 334.
Freire, Maxime, Remer, Erick M. Clinical and Radiologic Features of Cystic Renal Masses Am. J. Roentgenol. 2009 192: 1367-1372
4.6.1.1.1 Role of Magnetic Resonance Cholangiopancreatography in Patients With Suspected Choledocholithiasis Mari M. Calvo, Luis Bujanda, Angel Calderón, Iñaki Heras, José L. Cabriada, Antonio Bernal, Victor Orive, and Angel Capelastegi Mayo Clin Proc. May 2002 77(5):422-428;
4.6.1.1.2 Magnetic Resonance Cholangiopancreatography: A Meta-Analysis of Test Performance in Suspected Biliary Disease Joseph Romagnuolo, Marc Bardou, Elham Rahme, Lawrence Joseph, Caroline Reinhold, and Alan N. BarkunAnn Intern Med October 7, 2003 139:547-557
4.7 Aldosterone elevated
4.8 Urine free cortisol elevated
4.9.1.1.1 Stable continue imaging with same modality as first used
4.9.1.1.2 Enlarging proceed as indicated by size
4.9.2.1.1 If not diagnostic for carcinoma perform 2nd type of 4 phase liver imaging (MRI or CT)
4.9.2.1.2 If still not diagnostic continue with follow up imaging
NCCN Guidelines Hepatocellular Carcinoma 2.2012 accessed 8/2/2012
Bruix J and Sherman M. Management of hepatocellular carcinoma: An Update. Hepatology July 2010;1-35
4.10.1 Note: CT is preferred. MRI may be approved for children, pregnant women, those unable to tolerate iodinated contrast material, and those who have already been examined for this reason with MRI.
4.10.2 Confirmed microscopically (requires a urinalysis)
4.10.3.1 American College of Radiology ACR Apprpriateness Criteria Hematuria 2005 page 4 accessed 2/11/09
4.11.1 hypertension
5.1.1 Dilated biliary tree on prior imaging
5.1.2.1 Ryo Tamura, Tadashi Ishibashi, and Shoki Takahashi; Chronic Pancreatitis: MRCP versus ERCP for Quantitative Caliber Measurement and Qualitative Evaluation; Radiology 2006 238: 920-928; [favorably compares measurement accuracy of MR to ER CP]
5.1.2.2 M.-J. Kim, D. G. Mitchell, K. Ito, and E. K. Outwater ; Biliary Dilatation: Differentiation of Benign from Malignant Causes-Value of Adding Conventional MR Imaging to MR Cholangiopancreatography1; Radiology, January 1, 2000; 214(1): 173 – 181.
5.1.2.3 S. Saini; Imaging of the Hepatobiliary Tract . Engl. J. Med., June 26, 1997; 336(26): 1889 – 1894.
5.1.2.4 Taouli, Bachir, Ehman, Richard L., Reeder, Scott B. Advanced MRI Methods for Assessment of Chronic Liver Disease Am. J. Roentgenol. 2009 193: 14-27
5.2.1 Dilated biliary tree on prior imaging
5.2.2.1 Ryo Tamura, Tadashi Ishibashi, and Shoki Takahashi; Chronic Pancreatitis: MRCP versus ERCP for Quantitative Caliber Measurement and Qualitative Evaluation; Radiology 2006 238: 920-928; [favorably compares measurement accuracy of MR to ER CP]
5.2.2.2 M.-J. Kim, D. G. Mitchell, K. Ito, and E. K. Outwater ; Biliary Dilatation: Differentiation of Benign from Malignant Causes-Value of Adding Conventional MR Imaging to MR Cholangiopancreatography1; Radiology, January 1, 2000; 214(1): 173 – 181.
5.2.2.3 S. Saini; Imaging of the Hepatobiliary Tract . Engl. J. Med., June 26, 1997; 336(26): 1889 – 1894.
5.3.1 Initial staging,
5.3.2 Interval follow up.
5.3.3 Restaging during treatment,
5.3.4 Worsening clinical picture
5.4.1 Portal hypertension, preoperative evaluation
5.4.2.1.1.1 < 1 cm on ultrasound, image every 3-6 months for 2 years
5.4.2.1.1.2 1-2 cm, image every 3 months if stable in size
5.4.2.1.1.3 > 2 cm, biopsy and if nondiagnostic, repeat imaging if stable
5.4.2.2 Rising AFP with negative ultrasound
5.4.2.3 CT or MRI did not find a mass and rising AFP, repeat imaging every 3 months until a mass is confirmed
5.4.3 Patient awaiting transplantation
Taouli, Bachir, Ehman, Richard L., Reeder, Scott B. Advanced MRI Methods for Assessment of Chronic Liver Disease Am. J. Roentgenol. 2009 193: 14-27
Denzer UW, Lüth S .Non-invasive diagnosis and monitoring of liver fibrosis and cirrhosis. Best Pract Res Clin Gastroenterol. 2009;23(3):453-60. Review.
5.5.1 Pt. in a life long monitoring program
5.5.2 Change in clinical status
Seung Soo Lee, Ah Young Kim, Suk-Kyun Yang, Jun-Won Chung, So Yeon Kim, Seong Ho Park, and Hyun Kwon Ha
Crohn Disease of the Small Bowel: Comparison of CT Enterography, MR Enterography, and Small-Bowel Follow-Through as Diagnostic Techniques Radiology June 2009 251:751-761; ACR Appropriateness Criteria Crohn Disease Reviewed 2012 Rakesh Sinha, Ratan Verma, Sadhna Verma, and Arumugam Rajesh Review: MR Enterography of Crohn Disease: Part 2, Imaging and Pathologic Findings AJR July 2012 197:80-85
5.6.1.1 Dexamethasone suppression
5.6.1.2 Diurnal Rhythm
5.6.1.3 Urine Free Cortisol
5.6.2.1 Acne
5.6.2.2 Buffalo Hump
5.6.2.3 Central obesity
5.6.2.4 Easy bruising, impaired wound healing
5.6.2.5 Glaucoma
5.6.2.6 Hirsutism and virilization may occur with adrenal carcinomas
5.6.2.7 Hypertension
5.6.2.8 Oligomenorrhea or amenorrhea (or impotence in males)
5.6.2.9 Osteoporosis or avascular bone necrosis
5.6.2.10 Purple striae (especially around the thighs, breasts, and abdomen)
5.6.3.1 eMedicine Medicine Specialties > Endocrinology > Adrenal Gland; Cushing Syndrome Author: Gail K Adler, MD, PhD, FAHA, accessed 04/13/10
5.7 Dilated Biliary tree (bile ducts) on prior imaging (MRCP requested: 74181, 74182, 74183, or S8037)
5.8.1 Elevated iron saturation
5.8.2 Elevated serum ferritin
5.8.3.1 McElroy, Vanessa Hemochromatosis: A Literature Review Journal of Diagnostic Medical Sonography 2009 25: 325-328
5.8.3.2 Alexander R. Hover; Sharon M. McDonnell; Wylie Burke Changing the Clinical Management of Hereditary Hemochromatosis: Translating Screening and Early Case Detection Strategies Into Clinical Practice Arch Intern Med. 2004;164(9):957-961
5.9.1 Prior to Transplant
5.9.2.1.1 < 1 cm on ultrasound, image every 3-6 months for 2 years
5.9.2.1.2 1-2 cm, image every 3 months if stable in size
5.9.2.1.3 > 2 cm, biopsy and if nondiagnostic, repeat imaging if stable
5.9.2.2 Rising AFP with negative ultrasound
5.9.2.3 CT or MRI did not find a mass and rising AFP, repeat imaging every 3 months until a mass is confirmed
Anderson, Lesley A., Pfeiffer, Ruth, Warren, Joan L., Landgren, Ola, Gadalla, Shahinaz, Berndt, Sonja I., Ricker, Winnie, Parsons, Ruth, Wheeler, William, Engels, Eric A. Hematopoietic Malignancies Associated with Viral and Alcoholic Hepatitis Cancer Epidemiol Biomarkers Prev 2008 17: 3069-3075 “In summary, HCV, but not other causes of hepatitis, was associated with the elevated risk of non-Hodgkin lymphoma and acute myeloid leukemia. HCV may induce lymphoproliferative malignancies through chronic immune stimulation.”
Taouli, Bachir, Ehman, Richard L., Reeder, Scott B. Advanced MRI Methods for Assessment of Chronic Liver Disease Am. J. Roentgenol. 2009 193: 14-27
5.10 Kidney tumor
5.11.1.1.1 Blood Pressure falling
5.11.1.1.2 Fever
5.11.1.1.3 Hematocrit falling
5.11.1.1.4 Renal Failure
5.11.1.2.1.1 Back Pain
5.11.1.2.1.2 Mass, back pain, or abdominal tenderness
5.11.1.2.1.3 Post trauma
5.11.1.2.1.4 Tenderness
5.11.1.2.1.5 US findings nondiagnostic
5.11.1.2.1.6 Worsening under treatment
5.11.2.1 Elevated Lipase or Amylase
5.11.2.2 Pain
5.12.1 Recurrent pancreatitis
5.12.2 Unresponsive or worsening under treatment
5.13.1 reference: NCCN update March 2014
5.14.1.1 Taouli, Bachir, Ehman, Richard L., Reeder, Scott B. Advanced MRI Methods for Assessment of Chronic Liver Disease Am. J. Roentgenol. 2009 193: 14-27
5.15.1 Initial staging
5.15.2 Surveillance imaging (SEE ONCOLOGY ROUTINE IMAGING)
5.15.3.1 NCCN Practice Guidelines in Oncology Testicular Cancer V2.2009
5.15.3.2 M. L. Harvey , T. R. Geldart , R. Duell , G. M. Mead , and K. Tung Routine computerised tomographic scans of the thorax in surveillance of stage I testicular non-seminomatous germ-cell cancer-a necessary risk? Ann Oncol 13: 237-242. [Paper indicates no real value from routine CT follow up, but increased risk of radiation induced malignancy.]
5.15.3.3 Sohaib, S. Aslam, Koh, Dow-Mu, Husband, Janet E. The Role of Imaging in the Diagnosis, Staging, and Management of Testicular Cancer Am. J. Roentgenol. 2008 191: 387-395 [Takes a more favorable view of using chest CT. But recognizes the risk.]