The Right Imaging Study: A Guide for Physicians PDF
Preview The Right Imaging Study: A Guide for Physicians
The Right Imaging Study A Guide for Physicians Third Edition The Right Imaging Study A Guide for Physicians Third Edition Ronald L. Eisenberg, md, jd Associate Professor of Radiology, Harvard Medical School, Boston, Massachusetts, USA Radiologist, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA Alexander R. Margulis, md Professor Emeritus, University of California at San Francisco; Clinical Professor, Weill-Cornell Medical College of Cornell University, New York, New York, USA With a Foreword by Robert B. Taylor, MD Editors Ronald L. Eisenberg, MD, JD Associate Professor of Radiology Harvard Medical School Boston, Massachusetts 02215 Radiologist, Beth Israel Deaconess Medical Center Boston, Massachusetts 02215 Alexander R. Margulis, MD Professor Emeritus University of California at San Francisco Clinical Professor Weill-Cornell Medical College of Cornell University New York, New York 10065 ISBN: 978-0-387-73773-7 e-ISBN: 978-0-387-73774-4 DOI: 10.1007/978-0-387-73774-4 Library of Congress Control Number: 2007938315 The first and second editions of this book were published in 1996 and 2000, respectively, by Lippincott Williams & Wilkins, Philadelphia, PA., with the title What to Order When: Pocket Guide to Diagnostic Imaging. © 2008 Springer Science+Business Media, LLC All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper 9 8 7 6 5 4 3 2 1 springer.com To Zina, Avlana, and Cherina and To Hedi Foreword By Robert B. Taylor In an ideal world, the process of obtaining and interpreting an imaging study for a patient would be true consultation between two specialists: The clinician who has examined the patient and who has primary responsibility for the patient’s care would consult with a radiologist, and together they would select the most appropriate modality from among the panoply of imaging options available today. Unfortunately, we live in an imperfect world, and such spe- cialist-to-specialist consultation occurs all too infrequently. Instead, today the clinician is—in most instances—expected to know what diagnostic imaging study to order. With the time constraints and complexity of today’s practice, what should be a consultation becomes an “order.” I am a family physician who has been in practice for more than four decades. Even with my long experience, I am sometimes not sure of the best imaging test to order for some patients. Perhaps you also have occasional questions you would like to ask a radiologist before ordering a study. For example: What modality is the “gold standard” for the noninvasive diagnosis of appendicitis? (It is computed tomography.) Can mammography detect saline implant rup- ture in the breast? (Yes, in all cases.) When might I order the Waters view of the paranasal sinuses? (It is useful for moni- toring the treatment of acute sinusitis.) What is the role of vii viii Foreword radionuclide bone scanning in the diagnosis of osteomyeli- tis? (Little value.) And what is the most sensitive technique for detecting cerebral lesions responsible for headache? (It is magnetic resonance imaging. But patients with severe acute headaches should be imaged with noncontrast head CT because of the suspicion of subarachnoid hemorrhage, acute hydrocephalus, or an enlarging intracranial mass.) Features of the book that appeal to me include the follow- ing: The book discusses what imaging studies may help elu- cidate the causes of everyday problems, such as diarrhea and dysuria, as well as more uncommon clinical entities, such as sarcoidosis and Reiter’s syndrome. The likely causes of many signs and symptoms are listed, helping to guide the selection of the best study for the patient. Throughout the book are Caveats, such as: “Once the diagnosis of benign peptic ulcer disease has been made, recurrences should be treated symptomatically; there is no need to repeat an imag- ing procedure with each recurrence.” The book’s outline format eliminates unnecessary verbiage, and in many instances the authors identify the “most effec- tive” procedures and the “modality of choice.” Appendix I describes the various imaging modalities available, and Appendix II tells the relative costs of these modalities to the patient, relative to the cost of a two-view chest radiograph. For example, the technical and professional fee to the patient for an MRI study is 8–12 times the cost of a routine chest x-ray. And so, because most clinicians do not have a direct line and quick access to a radiologist, this book will be useful to the nonradiologists. In reviewing the manuscript, I found that it answered the questions above—and many more. In a sense, the book is like having a radiologic consultant “at your fi ngertips,” and I think you will fi nd it handy when deciding on the right imaging study. Keep the book in the location—probably your exam room—you are likely to be when deciding on imaging modalities to order, and perhaps Foreword ix have an extra copy for the staff person who actually schedules imaging studies. Robert B. Taylor Department of Family Medicine Oregon Health and Science University School of Medicine Portland, Oregon Preface to the Third Edition In the last three decades, medical imaging has undergone tremendous advances, changing from a valuable diagnostic adjunct to an essential tool for diagnosis, selection of the opti- mal therapeutic approach, and treatment follow-up. It is now common practice that specialists summoned by emergency room staff will not see a patient before cross-sectional imag- ing procedures have been obtained and interpreted. Important technological advances span the entire spec- trum of imaging procedures. In MRI, new sequences increase speed and offer better defi nition. Increases in detector rows have made CT a three-dimensional modality and signifi - cantly improved its spatial resolution. In ultrasound, Doppler and harmonic imaging and the development of better con- trast media have increased the information provided. Hybrid approaches to imaging are also rapidly emerging. PET/CT has become essential in oncology and is the fi rst clinical approach of molecular imaging. PET/MRI will probably be coming soon. The combination of ultrasound and MRI will likely be employed for image-guided biopsies. MR spectroscopic imaging has become a valuable clinical tool in the evaluation of brain tumors and is being increasingly used in addition to MR in imaging cancer of the prostate. Film as a recording device, like the fl at plate at the dawn of radiology, has practically disappeared and been totally xi xii Preface to the Third Edition replaced by electronic digital records. PACS is ubiquitous, allowing communication between hospital departments, pri- vate offi ces, and even centers in different geographic loca- tions. This technology has led to the development of telera- diography, with “nighthawk” services now available between different continents. The dramatic advances in medical imaging have also pro- duced some signifi cant problems. The total cost of health care services in the USA has risen to 1.8 trillion dollars in 2006, exceeding 16% of the GNP. Although medical imag- ing is only a small part of these huge expenditures, it is now its most rapidly escalating segment. Consequently, request- ing the right imaging procedure and avoiding a cascade of increasingly costly steps is essential in reducing costs. The benefi ts derived from interventional radiology and CT are indisputable, but they are also adding to the ionizing radiation burden of the population. Therefore, being aware of the radiation exposure in requesting imaging studies is important. In addition, the increasing sophistication of the available imaging approaches makes it critical for the refer- ring clinician to choose the right one to most expeditiously arrive at the diagnosis. These are among the compelling rea- sons for undertaking the writing of this book and enlisting the most prominent subspecialists in diagnostic imaging to collaborate. The Right Imaging Study is designed to provide valuable assistance to residents-in-training and practicing physicians in internal medicine, general practice, emergency medicine, and surgery, as well as to other health care workers who are on the fi ring lines and actually request imaging studies. It is essential that these individuals have a clear understanding of the advantages and limitations of both newer and traditional imaging procedures, as well as their relative costs and ion- izing radiation doses, so that they can make informed deci- sions regarding the most appropriate imaging strategies for their patients.
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