Direct Access CT - Referral Guidance

  • Head
  • Chest
  • Abdomen
  • Pelvis

  • Cancer - any patient with suspected cancer which meets the 2ww criteria should be referred by 2ww pathway (unless scan is requested by Radiologist following a suspicious plain film).
  • Children under 18 years of age.
  • Patients needing general anaesthetic, hospital inpatients and non-NHS patients.
  • Note: BMI restrictions dependent on weight limits of couch (please check with provider for thresholds).
  • Note: body parts not stated in the inclusions list are expressly excluded from this service provision.

If you have any queries or need clinical advice as to the appropriateness of the request, please contact the chosen provider for information. The provider is at liberty to refuse a request or phone the clinician for further details if they feel the imaging is inappropriate.

When considering ordering imaging, please consider the following:

  • The Royal College of Radiologists iRefer Guidelines should be used to support decisions around clinical appropriateness - see National and NICE Guidance.
  • Consider the NOT insignificant radiation for a CT scan (see iRefer Guidelines for more info on the dose specific to each body part).
  • You will need to explain the findings to the patient, so be clear that the investigation is indicated and you know what to do with the result
  • Be aware that scans show incidental findings in a number of cases that can then lead to further possibly unnecessary imaging and associated financial cost and anxieties.

The brief information below is a guide and does not replace the full advice, diagnosis and management that an outpatient referral can give. Please refer to the RCR iRefer Guidelines for further information.

  • A CT head takes about 5 minutes and is usually well tolerated by the elderly and confused.  An MRI head takes 30 minutes and the patient must keep still.  It is used generally for more specific diagnoses and therefore should be requested by specialists unless you have experience in this area.
  • Standard indications for CT head are to rule out/investigate stroke, bleeds, tumours, subdural, dementia and headaches.
  • An MRI head is more sensitive for MS, pituitary tumours, acoustic neuromas as well as posterior fossa abnormalities.

  • Indicated for non-specific abdomen pain and weight loss in patients not fit for procedures. Oral contrast is used as more sensitive to look for luminal lesions.
  • If iron deficiency anaemia is present, a colonoscopy/upper GI endoscopy as well as CT abdomen / pelvis are the investigations of choice if the patient could tolerate this.
  • Indicated for acute renal colic with good clinical history for stones and dipstick positive haematuria.

If a patient is over 65 or has diabetes they will need an eGFR and this is to be dated within 3 months of their scan appointment for a CT with contrast. Failure to have undertaken this test and shared the results with the scan provider within the specified timescales, could lead to a delay in the patient receiving their scan.
Chest and Cardiovascular - iRefer CT Diagnostic Guidance

Scan indicated: CT Chest
Additional Information: CT may help in the detection of pleural fluid. CT may also identify and characterise underlying pleural disease.
Other images or tests that should be done prior to undertaking this: CXR (Chest X-Ray)
How to access scan indicated: Please see Services and Referrals section

Scan indicated: CT Chest
Additional Information: CT or specialist referral may be needed in cases of pneumonia not resolving by 6-12 weeks.
Other images or tests that should be done prior to undertaking this: CXR (Chest X-Ray)
How to access scan indicated: Please see Services and Referrals section
Gastrointestinal - iRefer CT Diagnostic Guidance

Scan indicated: CT Abdomen
Additional Information:

Colonoscopy is the firstline investigation in younger patients, avoiding radiation and enabling biopsy.

Fully prepared CT colonography, where available, is the radiological investigation of choice for detecting colorectal cancer and large polyps. It has similar accuracy to colonoscopy.  Limited preparation CT colonography, although of slightly lower accuracy, is well tolerated by the older or frail patient.  Please note GPs do not have direct access to either of these tests therefore please refer to secondary care consultant.

Ba enema is an alternative and is widely used for investigating change in bowel habit in the absence of rectal bleeding but limited access due to supply of Barium.

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: CT Liver 
Additional Information: The choice of MRI or CT depends on clinical context and local provision. MRI is more accurate than CT and will be preferable to evaluate an incidental lesion. If malignancy is suspected, CT is also helpful to assess extra-hepatic disease.  Solitary isolated cysts with normal LFTs found on USS do not need further imaging.
Other images or tests that should be done prior to undertaking this: Ultrasound
How to access scan indicated: Please see Services and Referrals section

Scan indicated: CT Abdomen
Additional Information: US often solves the problem.  CT is used when US is inconclusive, and to provide more complete assessment of disease extent before definitive treatment.  If definite Neoplasm proceed to CT.  MRI may be helpful for distinguishing malignancy when ultrasound and CT are equivocal.
Other images or tests that should be done prior to undertaking this: NOUS before CT, CT before MRI 
How to access scan indicated: Please see Services and Referrals section
Neurological System - iRefer CT Diagnostic Guidance

Scan indicated: CT Head
Additional Information:

Structural imaging with MRI or CT should be used in the assessment of people with suspected dementia to exclude other cerebral pathology and help establish the subtype diagnosis. In a small minority of cases, imaging will show an alternative cause such as a tumour, hydrocephalus or subdural collection. The yield for these lesions is higher if imaging is restricted to those with a rapid or atypical presentation, patients with focal signs, history of gait ataxia, incontinence or head injury. MRI may be useful in acute dementias, including limbic encephalitis, and conditions such as Creutzfeldt-Jakob disease.

CT is generally adequate, MR only for specific problem solving

Only to be requested as part of full dementia assessment

GPs must request coronal views of the head

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

  • Recent onset and rapidly increasing frequency and severity of headache
  • Headache causing patient to wake from sleep
  • Associated dizziness, lack of co-ordination, tingling or numbness
  • Headache precipitated by coughing, sneezing or straining
  • Patients with malignancy or who are immunocompromised
  • Recent onset headache in patients older than 50.
Scan indicated: CT Head
Additional information:

Imaging is not usually useful for isolated headache without abnormal neurological features (see clinical problem).

Cervical spine XRs or paranasal sinus imaging are usually unhelpful even when neck signs suggest origin from the neck as they do not alter management.
 
If features of subarachnoid haemorrhage, immediate referral to ED without imaging

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan indicated: CT Head
Additional information: CT is often sufficient for excluding intracranial space occupying lesions and for identifying supratentorial lesions. If the initial CT is not diagnostic, MRI should be performed.
Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section
Urogenital and Adrenal - iRefer CT Diagnostic Guidance

Scan identified: CT KUB
Additional information:

Low dose unenhanced CT provides the best baseline assessment in patients with renal stone disease. AXR is less accurate but has a lower dose and is still adequate in routine practice to detect and follow up the majority of renal calculi, which contain calcium.

US is less sensitive than unenhanced CT for the detection of renal calculi. Both unenhanced CT and US can detect urate calculi.

If calculi can be identified on AXR or US, they should be followed up as such to minimise radiation dose from multiple CT examinations.

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan identified: CT KUB
Additional information:

Pre- and post-contrast-enhanced CT is the firstline investigation for the characterisation of a a suspected solid or complex cystic renal mass.

Very small "minimally complex cysts" less than 2 cms are better followed up with ultrasound.

Other images or tests that should be done prior to undertaking this: Renal ultrasound
How to access scan indicated: Please see Services and Referrals section

Scan identified: CT KUB
Additional information:

MDCT is the most accurate investigation in suspected ureteric colic and a low-radiation-dose CT technique should be used.

Other images or tests that should be done prior to undertaking this: None
How to access scan indicated: Please see Services and Referrals section

Scan identified: CT KUB
Additional information: Contrast-enhanced CT is useful in determining both the intrinsic and extrinsic cause of urinary tract obstruction.
Other images or tests that should be done prior to undertaking this: NOUS
How to access scan indicated: Please see Services and Referrals section 
Direct Access CT Referral Pathway

     

Expand all