Ferri's Best Test: A Practical Guide to Laboratory Medicine and Diagnostic Imaging, 2nd Edition (Ferri's Medical Solutions)

440 Pages·2009·8.76 MB·English

by  Fred F. Ferri MD FACP

1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899 ISBN: 978-0-323-05759-2
FERRI’S BEST TEST: A PRACTICAL GUIDE TO CLINICAL LABORATORY MEDICINE
AND DIAGNOSTIC IMAGING
SECOND EDITION
Copyright © 2010, 2004 by Mosby, Inc., an affi liate of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any
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Notice
Knowledge and best practice in this fi eld are constantly changing. As new research and
experience broaden our knowledge, changes in practice, treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and
duration of administration, and contraindications. It is the responsibility of the practitio-
ner, relying on their own experience and knowledge of the patient, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor
the Author assumes any liability for any injury and/or damage to persons or property
arising out of or related to any use of the material contained in this book.
The Publisher
Library of Congress Cataloging-in-Publication Data
Ferri, Fred F.
Ferri’s best test : a practical guide to clinical laboratory medicine and diagnostic
imaging / Fred F. Ferri. — 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-323-05759-2
1. Diagnosis, Laboratory—Handbooks, manuals, etc. 2. Diagnostic imaging—Handbooks,
manuals, etc. I. Title. II. Title: Best test. III.
Title: Practical guide to clinical laboratory medicine and diagnostic imaging.
[DNLM: 1. Clinical Laboratory Techniques—Handbooks. 2. Diagnostic Imaging—
Handbooks. 3. Reference Values—Handbooks. QY 39 F388f 2010]
RB38.2.F47 2010
616.07’5—dc22
2008040453
Acquisitions Editor: James Merritt
Developmental Editor: Nicole DiCicco
Project Manager: Bryan Hayward
Design Direction: Gene Harris
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
FM-i_xxvi-A05759.indd iv 1/19/09 10:09:16 AM
ACKNOWLEDGMENTS
I extend a special thank you to the authors and contributors of the following texts
who have lent multiple images, illustrations, and text material to this book:
Grainger RG, Allison D: Grainger & Allison’s Diagnostic Radiology, a Textbook of
Medical Imaging, ed 4, Philadelphia: Churchill Livingstone, 2001
Mettler FA: Primary Care Radiology, Philadelphia, WB Saunders, 2000
Pagana KD, Pagana TJ: Mosby’s Diagnostic and Laboratory Test Reference,
ed 8, St. Louis, Mosby, 2007
Talley NJ, Martin CJ: Clinical Gastroenterology, ed 2, Sidney, Churchill
Livingstone, 2006
Weissleder R, Wittenberg J, Harisinghani MG, Chen JW: Primer of Diagnostic
Imaging, ed 4, St. Louis, Mosby, 2007
Wu AHB: Tietz Clinical Guide to Laboratory Tests, Philadelphia,
WB Saunders, 2006
Fred F. Ferri, MD, FACP
Clinical Professor
Alpert Medical School
Brown University
Providence, Rhode Island
v
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PREFACE
This book is intended to be a practical and concise guide to clinical laboratory
medicine and diagnostic imaging. It is designed for use by medical students, in-
terns, residents, practicing physicians, and other health care personnel who deal
with laboratory testing and diagnostic imaging in their daily work.
As technology evolves, physicians are faced with a constantly changing arma-
mentarium of diagnostic imaging and laboratory tests to supplement their clinical
skills in arriving at a correct diagnosis. In addition, with the advent of managed
care it is increasingly important for physicians to practice cost-effective medicine.
The aim of this book is to be a practical reference for ordering tests, whether
they are laboratory tests or diagnostic imaging studies. As such it is unique in
medical publishing. This manual is divided into three main sections: clinical
laboratory testing, diagnostic imaging, and diagnostic algorithms.
Section I deals with common diagnostic imaging tests. Each test is approached
with the following format: Indications, Strengths, Weaknesses, and Comments. The
approximate cost of each test is also indicated. For the second edition, we have
added several new additional diagnostic modalities such as computed tomographic
colonography (virtual colonoscopy), CT/PET scan, and video capsule endoscopy.
Section II has been greatly expanded with the addition of 113 tests, for a total
of 313 laboratory tests. Each test is approached with the following format:
• Laboratory test
• Normal range in adult patients
• Common abnormalities (e.g., positive test, increased or decreased value)
• Causes of abnormal result
Section III includes the diagnostic modalities (imaging and laboratory tests)
and algorithms of common diseases and disorders. This section has been expanded
with the addition of 9 new algorithms for a total of 231.
I hope that this unique approach will simplify the diagnostic testing labyrinth
and will lead the readers of this manual to choose the best test to complement
their clinical skills. However, it is important to remember that lab tests and x-rays
do not make diagnoses, doctors do. As such, any lab and radiographic results
should be integrated with the complete clinical picture to arrive at a diagnosis.
Fred F. Ferri, MD, FACP
vii
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2
This section deals with common diagnostic imaging tests. Each test is
approached with the following format: Indications, Strengths, Weaknesses,
Comments. The comparative cost of each test is also indicated. Please note that
there is considerable variation in the charges and reimbursement for each diag-
nostic imaging procedure based on individual insurance and geographic region.
The cost described in this book is based on RBRVS fee schedule provided by
the Center for Medicare & Medicaid Services for total component billing.
$ Relatively inexpensive $$$$$Very expensive
A. Abdominal/Gastrointestinal (GI) Imaging p.
1. Abdominal fi lm, plain (kidney, ureter, and bladder [KUB]) p.
2. Barium enema p.
3. Barium swallow (esophagram) p.
4. Upper GI series (UGI) p.
5. Computed tomographic colonoscopy (CTC, Virtual colonoscopy) p.
6. CT of abdomen/pelvis p.
7. Helical or spiral CT of abdomen/pelvis p.
8. Hepatobiliary (iminodiacetic acid [IDA]) scan p.
9. Endoscopic retrograde cholangiopancreatography (ERCP) p.
10. Percutaneous biliary procedures p.
11. Magnetic resonance cholangiography (MRCP)
12. Meckel scan (Tc-99m pertechnetate scintigraphy) p.
13. MRI of abdomen p.
14. Small-bowel series p.
15. Tc-99m sulfur colloid scintigraphy (Tc-99m SC) for GI bleeding p.
16. Tc-99m–labeled red blood cell (RBC) scintigraphy for GI bleeding p.
17. Ultrasound of abdomen p.
18. Ultrasound of appendix p.
19. Ultrasound of gallbladder and bile ducts p.
20. Ultrasound of liver p.
21. Ultrasound of pancreas p.
22. Endoscope ultrasound (EUS) p.
23. Video capsule endoscopy (VCE) p.
B. Breast Imaging p.
1. Mammogram p.
2. Breast ultrasound p.
3. Magnetic resonance imaging of breast p.
C. Cardiac Imaging p.
1. Stress echocardiography p.
2. Cardiovascular radionuclide imaging (thallium, sestamibi, dipyridamole
[Persantine] scan) p.
3. Cardiac MRI (CMR) p.
4. Multidetector computed tomography p.
5. Transesophageal echocardiogram (TEE) p.
6. Transthoracic echocardiography (TTE) p.
D. Chest Imaging p.
1. Chest radiograph p.
2. CT of chest p.
3. Helical (spiral) CT of chest p.
4. MRI of chest p.
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3
E. Endocrine Imaging p.
1. Adrenal medullary scintigraphy (metaiodobenzylguanidine
[MIBG] scan) p.
2. Parathyroid scan p.
3. Thyroid scan p.
4. Thyroid ultrasound p.
F. Genitourinary Imaging p.
1. Obstetric ultrasound p.
2. Pelvic ultrasound p.
3. Prostate ultrasound p.
4. Renal ultrasound p.
5. Scrotal ultrasound p.
6. Transvaginal (endovaginal) ultrasound p.
7. Urinary bladder ultrasound p.
8. Hysterosalpingography (HSG) p.
9. Intravenous pyelography (IVP) and retrograde
pyelography p.
G. Musculoskeletal and Spinal Cord Imaging p.
1. Plain x-ray fi lms of skeletal system p.
2. Bone densitometry (dual-energy x-ray absorptiometry [DEXA]
scan) p.
3. MRI of spine p.
4. MRI of shoulder p.
5. MRI of hip p.
6. MRI of pelvis p.
7. MRI of knee p.
8. CT of spinal cord p.
9. Arthrography p.
10. CT myelography p.
11. Nuclear imaging (bone scan, gallium scan, white blood cell
[WBC] scan)
H. Neuroimaging of Brain p.
1. CT of brain p.
2. MRI of brain p.
I. Positron Emission Tomography (PET) p.
J. Single-Photon Emission Computed Tomography
(SPECT) p.
K. Vascular Imaging p.
1. Angiography p.
2. Aorta ultrasound p.
3. Arterial ultrasound p.
4. Captopril renal scan (CRS) p.
5. Carotid ultrasonography p.
6. Computed tomographic angiography (CTA) p.
7. Magnetic resonance angiography (MRA) p.
8. Magnetic resonance direct thrombus imaging (MRDTI) p.
9. Pulmonary angiography p.
10. Transcranial Doppler p.
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4
11. Venography p.
12. Venous Doppler ultrasound p.
13. Ventilation/perfusion lung scan (V/Q scan) p.
L. Oncology
1. Whole-body integrated (dual-modality) positron emission tomography
(PET) and CT (PET/CT)
2. Whole-body MRI
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A. Abdominal/Gastrointestinal (GI) Imaging 5
1. Abdominal Film, Plain (Kidney, Ureter, and Bladder [KUB])
Indications
• Abdominal pain
• Suspected intraperitoneal free air (pneumoperitoneum) (Fig. 1-1)
• Bowel distention
Strengths
• Low cost
• Readily available
• Low radiation
Weaknesses
• Low diagnostic yield
• Contraindicated in pregnancy
• Presence of barium from recent radiographs will interfere with interpretation
• Nonspecifi c test
Comments
• KUB is a coned plain radiograph of the abdomen, which includes kidneys,
ureters, and bladder.
• A typical abdominal series includes fl at and upright radiographs.
• KUB is valuable as a preliminary study when investigating abdominal
pain/pathology (e.g., pneumoperitoneum, bowel obstruction, calcifi cations).
Fig. 1-2 describes a normal gas pattern
• This is the least expensive but also least sensitive method to assess bowel
obstruction radiographically.
• Cost: $
Figure 1-1 Plain abdominal x-ray examination
of small bowel obstruction showing distended
loops of small bowel with multiple fl uid levels
and absence of colonic gas. (From NJ Talley,
CJ Martin: Clinical Gastroenterology, ed 2,
Sidney, Churchill Livingstone, 2006.)
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6 A. Abdominal/Gastrointestinal (GI) Imaging
A B
C
Figure 1-2 A to C, Normal bowel gas pattern. Gas is normally swallowed and can be
seen in the stomach (st). Small amounts of air normally can be seen in the small bowel
(sb), usually in the left midabdomen or the central portion of the abdomen. In this patient,
gas can be seen throughout the entire colon, including the cecum (cec). In the area where
the air is mixed with feces, there is a mottled pattern. Cloverleaf-shaped collections of air
are seen in the hepatic fl exure (hf), transverse colon (tc), splenic fl exure (sf), and sigmoid
(sig). (From Mettler FA: Primary Care Radiology, Philadelphia, WB Saunders, 2000.)
2. Barium Enema
Indications
• Colorectal carcinoma
• Diverticular disease (Fig. 1-3)
• Infl ammatory bowel disease
• Lower GI bleeding
• Polyposis syndromes
• Constipation
• Evaluation of for leak of postsurgical anastomotic site
Strengths
• Readily available
• Inexpensive
• Good visualization of mucosal detail with double-contrast barium enema
(DCBE)
Weaknesses
• Uncomfortable bowel preparation and procedure for most patients
• Risk of bowel perforation
• Contraindicated in pregnancy
• Can result in severe postprocedure constipation in elderly patients
• Poorly cleansed bowel will interfere with interpretation
• Poor visualization of rectosigmoid lesions
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A. Abdominal/Gastrointestinal (GI) Imaging 7
Figure 1-3 Diverticular disease showing
typical muscle changes in the sigmoid and
diverticula arising from the apices of the
clefts between interdigitating muscle
folds. (From Grainger RG, Allison D:
Grainger & Allison’s Diagnostic Radiology:
A Textbook of Medical Imaging, Churchill
Livingstone, ed 4, 2001.)
Comments
• Barium enema is now rarely performed or indicated. Colonoscopy is more sen-
sitive and specifi c for evaluation of suspected colorectal lesions.
• This test should not be performed in patients with suspected free perforation,
fulminant colitis, severe pseudomembranous colitis, or toxic megacolon or in a
setting of acute diverticulitis.
• A single-contrast BE uses thin barium to fi ll the colon, whereas DCBE uses
thick barium to coat the colon and air to distend the lumen. Single-contrast
BE is generally used to rule out diverticulosis, whereas DCBE is preferable for
evaluating colonic mucosa, detecting small lesions, and diagnosing infl ammatory
bowel disease.
• Cost: $$
3. Barium Swallow (Esophagram)
Indications
• Achalasia
• Esophageal neoplasm (primary or metastatic)
• Esophageal diverticuli (e.g., Zenker diverticulum), pseudodiverticuli
• Suspected aspiration, evaluation for aspiration following stroke
• Suspected anastomotic leak
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