Imaging Decisions in Internal Medicine - PowerPoint Presentation

Slide1

Imaging Decisions in Internal Medicine

Mariana DeFreitas – PGY1Slide2

Learning Objectives

Acquire a broad understanding of imaging decisions encountered in primary care

Become more comfortable with choosing appropriate imaging studies

Become familiar with appropriateness criteria imaging resources

Understand advantages and disadvantages of certain imaging modalities and know when to use themSlide3

ABIM Applications

We will cover one question relating to imaging in each of the following content categories:

Cardiology

Pulmonology

GI

Infectious Diseases

Heme

/

onc

Rheumatology

Nephrology/UrologySlide4

Ewan C. Lantus is a

65

yo

gentleman who is admitted to your service from the ED for management of hyperglycemia. He has type 2 DM and has not been compliant with his insulin regimen at home. His blood glucose was 630 mg/dl in the ED. When you examine the patient, you find a purulent and foul smelling necrotic ulcer over the medial aspect of his R great toe measuring about 2cm x 1cm. Probing does not contact bone. His labs are significant for WBC of 16,000 cell/mm

3

and ESR of 76 mm/hr. You wish to rule out osteomyelitis. How should you proceed?A. X-ray of R footB. MRI of R footC. 3-phase bone scanD. Order no additional imaging and treat empirically

Question #1Slide5

Ewan C. Lantus is a

65

yo

gentleman who is admitted to your service from the ED for management of hyperglycemia. He has type 2 DM and has not been compliant with his insulin regimen at home. His blood glucose was 630 mg/dl in the ED. When you examine the patient, you find a purulent and foul smelling necrotic ulcer over the medial aspect of his R great toe measuring about 2cm x 1cm. Probing does not

contact

bone. His labs are significant for WBC of 16,000 cell/mm3 and ESR of 76 mm/hr. You wish to rule out osteomyelitis. How should you proceed?A. X-ray of R footB. MRI of R footC. 3-phase bone scan

D. Order no additional imaging and treat empirically

Question #1Slide6

Sensitivity and Specificity

Zaiton

,

Fatma

, et al. "Evaluation of diabetic foot osteomyelitis using probe to bone test and magnetic resonance imaging and their impact on surgical intervention." 

Insulin

 84 (2014): 82-4.Slide7

Osteomyelitis MRI

Donovan, Andrea, and Mark E. Schweitzer. "Use of MR imaging in diagnosing diabetes-related pedal osteomyelitis." 

Radiographics

30.3 (2010): 723-736.

T2 Sequence

High signal from fluid

T1 Sequence

Low signal due to bone marrow edemaSlide8

Anita Smoke is an 82

yo

woman

with HTN, hyperlipidemia, and a 45 pack-year history of smoking who is admitted to your MTS 4 service for an episode of slurred speech which lasted about 10 minutes. Her physical exam is normal. You are currently working on her stroke workup. When prompted regarding any questions, the patient notes that she is scared of having lung cancer, as her younger brother was diagnosed with stage IV adenocarcinoma at age 75, and had no history of smoking. She reports that she quit smoking 10 years ago. She wonders if she should be "worked-up" for lung cancer. She denies any respiratory symptoms and ROS is negative. What do you say?

A. "We can get a chest-

xray

to alleviate your concern" B. "You should discuss undergoing a low-dose chest CT scan with your PCP as an outpatient”C. "We do not recommend any lung cancer screening for you”D. "Let's get a sputum sample for cytology"Question #2Slide9

Anita Smoke is an 82

yo

woman with HTN, hyperlipidemia, and a 45 pack-year history of smoking who is admitted to your MTS 4 service for an episode of slurred speech which lasted about 10 minutes. Her physical exam is normal. You are currently working on her stroke workup. When prompted regarding any questions, the patient notes that she is scared of having lung cancer, as her younger brother was diagnosed with stage IV adenocarcinoma at age 75, and had no history of smoking. She reports that she quit smoking 10 years ago. She wonders if she should be "worked-up" for lung cancer. She denies any respiratory symptoms and ROS is negative. What do you say?

A. "We can get a chest-

xray

to alleviate your concern" B. "You should discuss undergoing a low-dose chest CT scan with your PCP as an outpatient”C. "We do not recommend any lung cancer screening for you”D. "Let's get a sputum sample for cytology"Question #2Slide10

US Preventative Task Force Lung CA Screening Recommendation

“The USPSTF recommends annual screening for lung cancer with low-dose computed tomography in adults aged

55 to 80 years

who have a

30 pack-year smoking history and currently smoke or have quit within the past 15 years.

”Slide11

Radiologic Characteristics

of Lung Nodules

Characteristics

Benign

Malignant

Calcifications

Diffuse, central, popcornOther patterns

Size

< 1 cm> 1 cm

Progression

Stable over

time

Rapid change

Shape

Smooth margins

Spiculated

/lobulated

Appearance

Fully solid

Ground

glassSlide12

Benign and Malignant Features

Benign -

Dr

Yi-

Jin

Kuok,

Radiopaedia.org, rID: 17407

Malignant -

Sim, Yee Ting, and Fat Wui

Poon. "Imaging of solitary pulmonary nodule—a clinical review." 

Quantitative imaging in medicine and surgery

 3.6 (2013): 316

.

Benign Features

Smooth Margins

Popcorn Calcifications

~10 mm

74

yo

man with

hx

of RA – screening CT

initial, 6 months, 1 year

Malignant Features

Rapid change

Groundglass

areas

Spiculated

Margins

Pulmonary

Hamartoma

Squamous Cell Lung Cancer

75

yo

man - screening CTSlide13

Question #3

During your ED rotation, you are assigned to Moe Smirnoff, a 19

yo

 male who is bent over, with both his hands over his epigastric region, having copious amounts of emesis. He reports he is rushing for a fraternity at U of M and drank one bottle of vodka on the day prior. Today, he started to experience an intense, epigastric pain, radiating to his back. He denies any prior medical history. You astutely suspect acute pancreatitis and become overly excited that you are finally seeing a case of this. You are hoping to admit this patient to IHA with a diagnosis of acute pancreatitis. When staffing with the ED senior, what do you say?

"Let's get a lipase level! If it is above 500, it will be enough for me to make the diagnosis!”

B. "We need both lipase above 500 and an US of the abdomen to make the diagnosis!”

C. "We need both lipase above 500 and an IV contrast CT of the abdomen to make the diagnosis!”D. "We need both lipase above 500 and a PO contrast CT of the abdomen to make the diagnosis!"Slide14

Question #3

During your ED rotation, you are assigned to Moe Smirnoff, a

19

yo

 male who is bent over, with both his hands over his epigastric region, having copious amounts of emesis. He reports he is rushing for a fraternity at U of M and drank one bottle of vodka on the day prior. Today, he started to experience an intense, epigastric pain, radiating to his back. He denies any prior medical history. You astutely suspect acute pancreatitis and become overly excited that you are finally seeing a case of this. You are hoping to admit this patient to IHA with a diagnosis of acute pancreatitis. When staffing with the ED senior, what do you say?

"Let's get a lipase level! If it is above

500, it will be enough for me to make the diagnosis!”B. "We need both lipase above 500 and an US of the abdomen to make the diagnosis!”C. "We need both lipase above 500 and an IV contrast CT of the abdomen to make the diagnosis!”D. "We need both lipase above 500 and a PO contrast CT of the abdomen to make the diagnosis!"Slide15

Acute Pancreatitis - Diagnosis

According to International Association of

Pancreatology

:

Two out of three of the following criteria must be met for the diagnosis of acute pancreatitis:

Clinical (upper abdominal pain)

Laboratory (serum amylase or lipase >3 upper limit of normal)Imaging (CT, MR, ultrasound) criteriaHigh clinical suspicion of AP with amylase and lipase levels not fulfilling diagnostic criteriaDetermining the cause when it is unclearAssessing for complications: necrosis, pseudocysts, etc.

So, when do we get imaging?Slide16

Appropriateness Criteria for AP

American College of Radiology ACR Appropriateness Criteria®Slide17

Appropriateness Criteria for AP (Cont.)

American College of Radiology ACR Appropriateness Criteria®Slide18

Question #4

Alice Harding is a

72

yo

woman admitted to MTS11 after presenting with for multiple complaints, including back pain in the ED. She was found to have lytic lesions and compression fractures of her lumbar and thoracic spine. Her lab workup was significant for calcium level of 12.1 mg/dl. The

heme/onc service performed a bone marrow biopsy which showed 22% plasma cells. Her urine electrophoresis is significant for monoclonal protein. When seeing the patient, she complains of L hip pain and L shoulder pain from a fall one week prior. What imaging would you order?Pelvis and L shoulder x-rayDEXA ScanTechnetium-99 bone scan

X-ray skeletal surveySlide19

Question #4

Alice Harding is a

72

yo

woman admitted to MTS11 after presenting with for multiple complaints, including back pain in the ED. She was found to have lytic lesions and compression fractures of her lumbar and thoracic spine. Her lab workup was significant for calcium level of 12.1 mg/dl. The

heme/onc service performed a bone marrow biopsy which showed 22% plasma cells. Her urine electrophoresis is significant for monoclonal protein. When seeing the patient, she complains of L hip pain and L shoulder pain from a fall one week prior. What imaging would you order?Pelvis and L shoulder x-rayDEXA ScanTechnetium-99 bone scan

X-ray skeletal surveySlide20

Skeletal Surveys

What is a skeletal survey?

Bilateral

anteroposterior

(AP) and

posteroanterior

(PA) of hands, forearms, humerus, feet, leg, femur, pelvis, spine and skull. What are some indications for skeletal surveys?Child abuseSkeletal dysplasiasMultiple myeloma

Metabolic bone disease

Metastatic bone diseaseSlide21

Other Bone Scans

What is a technetium-99m Bone Scan?

Nuclear study with three phases following IV injection of the tracer

Flow phase – perfusion and blood flow

Blood pool phase – inflammation

Delayed phase – blood flow and rate of new bone formation

Indications are: Occult fractures

Blastic

lesionsOsteomyelitis

What about DEXA scans?

Dual energy x-rays – allows to calculate composition of tissues

Used for osteopenia and osteoporosisSlide22

Question #5

Lara G. Hart is a

32

yo

with recently diagnosed ALL admitted to your service. She is about to undergo induction therapy, and you meet with the patient to discuss the chemotherapy she will be receiving. She says: “I am worried because my grandpa died of heart failure and my cancer doctor told me that one of the agents I will be receiving may affect my heart function”. She wants to know what the team plans to do to monitor her heart function. What do you say?

We will obtain a stress test and echo to determine your current heart function.

We will obtain a stress myocardial perfusion study to determine your current heart function.

We will obtain a MUGA scan to determine your current heart function.

You do not need any studies to assess your heart function until you have completed your induction therapy.Slide23

Question #5

Lara G. Hart is a

32

yo

with recently diagnosed ALL admitted to your service. She is about to undergo induction therapy, and you meet with the patient to discuss the chemotherapy she will be receiving. She says: “I am worried because my grandpa died of heart failure and my cancer doctor told me that one of the agents I will be receiving may affect my heart function”. She wants to know what the team plans to do to monitor her heart function. What do you say?

We will obtain a stress test and echo to determine your current heart function.

We will obtain a stress myocardial perfusion study to determine your current heart function.

We will obtain a MUGA scan to determine your current heart function.

You do not need any studies to assess your heart function until you have completed your induction therapy.Slide24

Cardiac Imaging

Nuclear medicine test that uses radioactive tracers to tag RBCs

Aka radionuclide ventriculography and radionuclide angiography

Highly accurate and reproducible

These are desired qualities for a patient receiving

cardiotoxic

chemotherapy

What is a MUGA scan?

Why use MUGA?

What is the difference between MUGA and myocardial perfusion tests?

MUGA pump function – blood in and out

Better for accurate LVEF

Myocardial perfusion – heart tissue

Better for assessing ischemic cardiomyopathySlide25

Chemotherapy Management

Patients Initiating

Chemotherapy with

Anthracyclines

Baseline

EF <30%Anthracyclines contraindicated

Baseline EF 30-50%

Modified dosing

Baseline EF >50%

Normal Dosing

Decrease of EF >10%

Discontinuation of therapySlide26

Question #6

You are taking care of Mia

Hippurts

, a 61

yo

lady who was admitted with a history of SLE and end-stage kidney disease who has not been compliant with dialysis, and presented with symptoms of uremia. She takes 20 mg/day of prednisone for her lupus and drinks 2 glasses of wine daily. When performing the physical exam, you notice that the patient has pain with movement of her right hip. She reports that she has been having groin pain and walking with a limp over the past 2 weeks. What imaging study would identify the most likely diagnosis?

A. Pelvic x-rayB. R hip x-rayC. MRI of left hipD. CT of pelvis with IV contrastSlide27

Question #6

You are taking care of Mia

Hippurts

, a 61

yo

lady who was admitted with a history of SLE and end-stage kidney disease who has not been compliant with dialysis, and presented with symptoms of uremia. She takes 20 mg/day of prednisone for her lupus and drinks 2 glasses of wine daily. When performing the physical exam, you notice that the patient has pain with movement of her right hip. She reports that she has been having groin pain and walking with a limp over the past 2 weeks. What imaging study would identify the most likely diagnosis?

A. Pelvic x-rayB. R hip x-rayC. MRI of left hipD. CT of pelvis with IV contrastSlide28

Osteonecrosis of Femoral Head

What are some risk factors?

Autoimmune disease

Steroid use

Alcohol use

Smoking

What are symptoms?Pain of hip, buttock, and groinExacerbated with movement and weight bearingWhy is MRI the most helpful?Sensitivity 71-100%Specificity 94-100%

Glickstein

MF, Burk DL, Schiebler

ML et-al. Avascular necrosis versus other diseases of the hip: sensitivity of MR imaging. Radiology. 1988;169 (1): 213-5Slide29

Osteonecrosis of Femoral Head

T1 – low intensity representing edema, may have high intensity borders representing blood products

Case courtesy of

Dr

Ahmed

Abd

Rabou, Radiopaedia.org, rID: 22633

T2 - hyper-intense inner line between normal marrow and ischemic marrow, highly specificSlide30

Question #7

Ben P.

Inred

is a 49

yo

gentleman who is admitted to the hospital for a COPD exacerbation. On ROS, the patient reports that he has been noticing blood in his urine for the past month. He denies any recent viral illness, pain with urination, and fevers. You order a UA, and the RN notifies you that Mr.

Inred’s urine was grossly bloody. You decide to order an imaging study. Which of the following is the best choice?A. CT of pelvis with contrastB. CT of abdomen and pelvis with contrastC. CT of abdomen and pelvis with and without contrastD. CT of chest, abdomen, and pelvis with and without contrastSlide31

Question #7

Ben P.

Inred

is a

49

yo

gentleman who is admitted to the hospital for a COPD exacerbation. On ROS, the patient reports that he has been noticing blood in his urine for the past month. He denies any recent viral illness, pain with urination, and fevers. You order a UA, and the RN notifies you that Mr. Inred’s urine was grossly bloody. You decide to order an imaging study. Which of the following is the best choice?A. CT of pelvis with contrastB. CT of abdomen and pelvis with contrastC. CT of abdomen and pelvis with and without contrastD. CT of chest, abdomen, and pelvis with and without contrastSlide32

Hematuria Appropriateness CriteriaSlide33

Abdominal CT Imaging Pearls

Abdomen and pelvis imaging go together

If kidney stones or other diseases involving calcifications are on the differential, no contrast is beneficial

Use IV contrast when able for any pelvic or abdominal pathology

What about PO contrast

?

Traditionally used for improving accuracyImaging qualities have improvedPO contrast is time consuming and may delay diagnosis and extended ED staysIV + PO contrast has similar diagnostic accuracy to IV contrast alone*

*

Kepner, Andrew M., Jerome V. Bacasnot

, and Barbara A.

Stahlman

. "Intravenous contrast alone vs intravenous and oral contrast computed tomography for the diagnosis of appendicitis in adult ED patients." 

The American journal of emergency medicine

30.9 (2012): 1765-1773.Slide34

Take Home Points

We are often faced with many decisions regarding imaging in primary care

All internal medicine subspecialties have imaging implications

ACR Appropriateness Criteria is a free and useful resource

An understanding of pros and cons of different modalities is helpful in making decisions regarding imaging

Commenting on what you are looking for is beneficialSlide35

Thank You!