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Good practice ultrasound referrals

Ultrasound referral principles

  • Requests should include specific clinical questions to answer
  • Clinical information must contain sufficient details from the clinical history and/or physical examination
  • Referrers should include relevant laboratory investigations to support the suspected diagnoses
  • The majority of ultrasound examinations are performed by sonographers rather than doctors. Suspected diagnoses must be clearly stated and not implied by vague, non-specific terms such as:
    • Pain query cause
    • Pathology
    • Abnormal LFTs
  • Ultrasound is an excellent imaging modality for a wide range of abdominal diseases. But ultrasound is not an appropriate first line test for many abdominal diseases such as suspected occult malignancy or bowel pathology

Ultrasound referral principles are based on clinical experience which is supported by peer reviewed publications and established clinical guidelines and pathways.

Ultrasound referral examples

The following examples cover the most common referral requests and is not a definitive list. 

Accepted ultrasound referrals

Abdomen

Clinical detailsComments
Abnormal LFTs

With at least one of the following:

  • Duration of derangement provided
  • Clinical picture/clinical question
  • Symptomatic/asymptomatic
Persistent raised ALT Accepted when timeframe provided (minimum three months)
Fatty liver
  • Ultrasound can be used to confirm fatty liver. However, clinical picture should be provided
  • Often ultrasound is not required in patients with high risk factors that affect liver function such as DM, obesity, statins and other medications
Jaundice Requires ultrasound and urgent specialist referral on 2WW
Pain (with abnormal bloods provided and/or appropriate clinical question)
  • Accepted with abnormal bloods and/or appropriate clinical question
  • Not accepted in isolation
Gallbladder disease
  • Unless previously confirmed on ultrasound
  • Cannot be accepted if symptoms are unchanged
Abdominal distension/abdominal bloating
  • If persistent/frequent (more than 12 times in a month) then ultrasound is indicated
  • In the presence of a palpable mass ultrasound is indicated
  • Querying ascites (should indicate cause of potential ascites on request)

Renal

Clinical detailsComments
Male UTI First presentation accepted
Female UTI Recurrent infections need to be demonstrated (>3 episodes in 12 months) with no underlying risk factors (non-responders to antibiotics or frequent re-infections)
Chronic kidney disease (CKD)

Accelerated progression of CKD (eGFR <30ml/min and rapid >25% decrease in renal function and change in CKD category in 12 months. Please use the renal ultrasound form which is available on your practice management system for you to complete electronically.
Decrease in eGFR
  • Urgent: sustained decrease in eGFR >15ml/min/1.73m2 or more per year (use ultrasound renal imaging referral form)
  • Routine: first renal imaging in a patient with eGFR <30ml/min/1.73m2 (use ultrasound renal imaging referral form)

Please use the renal ultrasound form which is available on your practice management system for you to complete electronically.
Haematuria

Visible or persistent invisible haematuria in a low cancer risk group. <45 years or >60 with recurrent or persistent unexplained urinary tract infection. Please use the renal ultrasound form which is available on your practice management system for you to complete electronically.
Polycystic kidney disease (PKD)

Family history of polycystic kidney disease age >20 years. Please use the renal ultrasound form which is available on your practice management system for you to complete electronically.

Gynaecology

Clinical detailsComments
Suspicion of malignancy If persistent bloating along with other symptoms such as CA125 level between 35-70 IU/ml or a palpable mass as per NICE guideline NG12:

Please use the urgent pelvic ultrasound (ovarian premenopausal) referral form which is available on your practice management system for you to complete electronically.
Pain along with
  • Palpable mass
  • Raised CRP or WCC
  • Nausea/vomiting
  • Menstrual irregularities
  • Dyspareunia >6 weeks
  • Pain in isolation is not accepted for patients <50
Pain in isolation in patients >50   If the patient is >50, the likelihood of pathology is increased and the request may be accepted
PCOS Ultrasound is indicated when there is diagnostic uncertainty from clinical and biochemical tests
PMB Indicated for ultrasound, but needs to be on local PMB pathway (send request to Birmingham Women's Hospital)

Small parts

Clinical detailsComments
Scrotal mass Any patient with swelling or mass in the body of the testis should be referred for ultrasound urgently
Scrotal pain In the presence of a palpable mass
Soft tissue lump Only if swellings are more than 5cm, infiltrative changes or rapidly increasing ultrasound indicated

Head and neck

Clinical detailsComments
Thyroid swelling
  • Sudden onset thyroid swelling especially if <40 years old. This is usually due to haemorrhage into a benign thyroid nodule or cyst. Routine ultrasound can confirm diagnosis
  • Rapidly enlarging swelling especially if >40 years old. Patients >40 years should be referred for Urgent US +/- FNA under 2WW pathway to rule out tumour
  • Gradually increasing thyroid swelling. This is usually due to a benign goitre but small proportion could have a tumour. If not investigated previously, US to confirm diagnosis
  • New thyroid swelling +/- palpable enlarged lymph nodes. If any red flag signs (hard swelling, palpable nodes, family history, childhood radiation exposure) refer under 2WW pathway
  • Clinical features that increase the likelihood of malignancy include: history of irradiation, male sex, age (<20, >70), fixed mass, hard/firm consistency, cervical nodes, change in voice, family history of MEN II or papillary Ca
Salivary mass, dry mouth
  • If there is a history suggestive of salivary duct obstruction, ultrasound imaging is helpful
  • For a suspected salivary tumour, patient should be referred to an ENT surgeon for evaluation and US (+/- FNA/core biopsy )
Dysphagia 2WW referral
Hoarse voice 2WW referral

Rejected ultrasound referrals

Abdomen

Clinical indicationReason for rejection
Abnormal liver function (no duration, symptoms, clinical picture provided) As per Good Practice Guidelines, the duration of the abnormality, symptoms and clinical picture need to be provided. Please seek A&G if needed.
Asymptomatic deranged LFT (single episode) As per Good practice guidelines, US is not a first line investigation for asymptomatic deranged LFT.
Isolated raised ALT US not justified for a single episode of raised ALT. US is not required in patients with high risk factors such as DM, Obesity, Statins and other medications
Pain in isolation Pain in isolation does not warrant an abdominal US. Please see Good Practice Guidelines.
Altered bowel habit/diverticular disease US does not have a role in the management of IBS or diverticular disease.
Diabetes US does not have a role in the management of diabetes. CT may be appropriate via 2ww if considering pancreatic CA.
Solitary episode of abdominal distension/Abdominal Bloating A solitary episode of bloating does not warrant a US scan
LUQ Pain Ultrasound is not helpful in this context. Unclear clinical picture. Requires further information and consider further referral to medical/surgical speciality as appropriate. 
LUQ Mass Ultrasound not indicated. Radiology Advice and Guidance. 
Loin pain/swelling Non-specific request. Ultrasound not indicated. Radiology Advice and Guidance.
Pancreatic pathology As per NICE guidance, ultrasound is not indicated as CT may be more appropriate. Please seek Radiology A&G.
RUQ pain/epigastric pain with previous cholecystectomy If LFT’s are normal please refer back to the Surgeons for further assessment. If LFT’s are abnormal (ALP out of proportion with ALT and/or bilirubin) then consider MRCP.
Hepatomegaly Unclear clinical picture, no clinical question provided. Please provide more information.
Hepatitis Not indicated for ultrasound. Please consider referral to hepatology. 
Palpable organomegaly Unclear clinical picture, no clinical question provided. Please provide more information.
Lower leg swelling compressing mass Please seek Radiology Advice and Guidance.
Advice and Guidance – Specialist Consultant recommended US scan  The specialist consultant needs to refer patient for ultrasound. 
Iron deficiency anaemia Ultrasound not indicated.
Abdominal Aortic Aneurysm Please refer to vascular surgery. 
Chronic alcoholism, excess etoh? Consider further hepatology Advice and Guidance. Ultrasound is unlikely to yield helpful results.

Renal

Clinical indicationReason for rejection
Female UTI (first episode, or no duration of recurrent infection provided)
  • First episode of infection does not warrant an ultrasound in female patients
  • Not indicated if solitary episode
  • Ultrasound is indicated if three or more episodes in twelve months, without previous investigation/known cause
  • Renal colic
  • Renal calculus
  • Renal angle pain
  • CT is the test of choice. Please see CT renal colic pathway and use the CT KUB renal colic imaging referral form
  • History of renal calculus or previous obstruction does warrant an ultrasound, however this is best advised via a specialist urology referral – the urgency of which is at the referrer’s discretion

Please consider using the CT KUB renal colic form which is available on your practice management system for you to complete electronically.
  • Hypertension
  • Suspected renal artery stenosis (RAS)
  • Nephrotic syndrome (e.g. periorbital swelling, proteinuria)
  • Ultrasound is justified if there has not been previous investigation or a cause established
  • It should be understood by the referrer that renal ultrasound does not reliably assess for RAS – although other causes of hypertension such as atrophy and polycystic disease can be assessed on routine ultrasound
  • Small adrenal masses may not be identified
  • If the query relates to including/excluding any of these pathologies, please submit this as part of the clinical information
  • If hypertension is resistant to treatment, a specialist Renal Medicine referral is advocated – the urgency of which is at the referrer’s discretion
  • If nephrotic syndrome is suspected, concurrent specialist Renal Medicine referral is recommended
  • Renal artery doppler will not be offered
Haematuria Visible/non-visible haematuria in those outside of the low risk cancer group (as set out in good practice guidelines) should recommend a specialist Urology referral – either 2WW or advice and guidance route at the referring GPs discretion
Hydronephrosis

In isolation is not justified. Please consider using the CT KUB renal colic form which is available on your practice management system for you to complete electronically.
Lower urinary tract symptoms (LUTS)
  • Routine ultrasound is not indicated as first line
  • Specialist Urology referral recommended

Gynaecology

Clinical indicationReason for rejection
Pain in isolation (patients <50) Ultrasound is unlikely to contribute to patient management if pain is the only symptom (in patients <50)
Pain along with
  • History of simple ovarian cyst <5cm
  • Loose stools
Intermittent bloating Isolated intermittent bloating as a solitary feature does not warrant an ultrasound scan. Suggest correlation with clinical and biochemical features. Refer to NICE guideline NG12:
Follow up of benign lesions Benign lesions such as fibroids, dermoids and cysts do not require US follow up, unless the patient has undergone a clinical change, then re-scan would be appropriate.

Small parts

Clinical indicationReason for rejection
Scrotal pain Chronic pain (>3 months) in the absence of a palpable mass, recommend referral via Advice & Guidance route.
Groin
  • Characteristic history and exam findings( include reducible palpable lump or cough impulse) do not require ultrasound to confirm.
  • Irreducible and/or tender lumps suggest incarcerated hernia and require urgent general surgical referral.
  • If groin pain present, clinical assessment should consider MSK causes and recommend referral via Advice & Guidance route.
Soft tissue lump The majority of soft tissue lumps are benign and if there are classical clinical signs of a benign lump then US is not routinely required for diagnosis

Head and neck

Clinical indicationReason for rejection
Thyroid Swelling Routine follow up of benign nodules is not recommended
Hyperthyroidism Refer to Endocrinologist (see RCP guidelines). US is not first line but used with nuclear medicine (and usually requested by specialist)
Hypothyroidism US Imaging is not indicated, unless palpable lump present - refer via 2WW Pathway
Hyperparathyroidism and hypercalcaemia
  • Elevated CA2+ and PTH may be due to a variety of causes including drugs, Vit D deficiency and renal failure. Correct Vit D deficiency first
  • US only indicated in biochemically proven PRIMARY hyperparathyroidism as part of a localisation procedure. Specialist referral required
Globus and throat discomfort US not useful
Persistent throat discomfort US not useful, A&G
Posterior or lateral neck pain, supraclavicular fossa pain, Temporomandibular joint issues US not useful

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Referral forms

Only print and manually complete a referral form if you do not have access to an electronic version on your practice management system.

Please note that any forms completed by hand must contain the wet signature of the GP referring the patient otherwise it will be rejected.

See also

Downloads

pdfUrgent pelvic ultrasound (ovarian premenopausal) imaging referral form (0.17 MB)

pdfUrgent pelvic ultrasound pathway (0.45 MB)

pdfRenal ultrasound imaging referral form (0.18 MB)

pdfCT KUB renal colic imaging referral form (0.18 MB)

Last reviewed: 12 May 2023