Ferri’s Best Test A PRACTICAL GUIDE TO CLINICAL LABORATORY MEDICINE AND DIAGNOSTIC IMAGING Third Edition Fred F Ferri, MD, FACP Clinical Professor Alpert Medical School Brown University Providence, Rhode Island 1600 John F Kennedy Blvd Ste 1800 Philadelphia, PA 19103-2899 FERRI’S BEST TEST: A PRACTICAL GUIDE TO CLINICAL LABORATORY MEDICINE AND DIAGNOSTIC IMAGING ISBN: 978-1-4557-4599-9 Copyright © 2015 by Saunders, an imprint of Elsevier Inc Copyright © 2010, 2004 by Mosby, Inc., an affiliate of Elsevier Inc Cover Images: From Adams JG et al: Emergency medicine: clinical essentials, ed 2, Philadelphia, Elsevier, 2013 From Ballinger A: Kumar & Clark’s essentials of medicine, ed 6, Edinburgh, Saunders, Elsevier, 2012 All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, 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 practitioners, relying on their own experience and knowledge of their patients, 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 authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein Library of Congress Cataloging-in-Publication Data Ferri, Fred F., author Ferri’s best test : a practical guide to laboratory medicine and diagnostic imaging / Fred F Ferri Third edition p ; cm Best test Includes bibliographical references and index ISBN 978-1-4557-4599-9 (spiral bound) I Title II Title: Best test [DNLM: Clinical Laboratory Techniques Handbooks Diagnostic Imaging Handbooks Reference Values Handbooks QY 39] RB38.2 616.07’5 dc23 2013045624 Senior Content Strategist: James Merritt Content Development Specialist: Lauren Boyle Publishing Services Manager: Hemamalini Rajendrababu Project Manager: Divya Krish Designer: Steven Stave Marketing Manager: Melissa Darling Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 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, interns, 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 armamentarium 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 third edition, we have added several new additional diagnostic modalities such as magnetic resonance enterography and intravascular ultrasound Section II describes more than 300 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 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 laboratory tests and x-rays not make diagnoses Doctors As such, any laboratory and radiographic results should be integrated with the complete clinical picture to arrive at a diagnosis Fred F Ferri, MD, FACP 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 edition and prior editions: Broder JS: Diagnostic imaging for the emergency physician, Philadelphia, Saunders, 2011 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 5, St Louis, Mosby, 2011 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 Section I Diagnostic Imaging 2   Section I n Diagnostic Imaging 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 diagnostic imaging procedure based on individual insurance and geographic region The costs described in this book are based on the Resource-Based Relative Value Scale (RBRVS) fee schedule provided by the Centers for Medicare and Medicaid Services for total component billing $ Relatively inexpensive–$$$$$ Very expensive    A Abdominal and Gastrointestinal (GI) Imaging Abdominal film, plain (kidney, ureter, and bladder [KUB]) Barium enema (BE) Barium swallow (esophagram) Upper GI (UGI) series Computed tomographic colonoscopy (CTC, virtual colonoscopy) CT scan of abdomen and pelvis Magnetic resonance enterography (MRE) Hepatobiliary iminodiacetic acid (HIDA) scan Endoscopic retrograde cholangiopancreatography (ERCP) 10 Percutaneous biliary procedures 11 Magnetic resonance cholangiopancreatography (MRCP) 12 Meckel scan (TC-99m pertechnetate scintigraphy) 13 MRI scan of abdomen 14 Small-bowel series 15 Tc99m sulfur colloid (Tc99m SC) scintigraphy for GI bleeding 16 Tc-99m-labeled red blood cell (RBC) scintigraphy for GI bleeding 17 Ultrasound of abdomen 18 Ultrasound of appendix 19 Ultrasound of gallbladder and bile ducts 20 Ultrasound of liver 21 Ultrasound of pancreas 22 Endoscopic ultrasound (EUS) 23 Video capsule endoscopy (VCE) B Breast imaging Mammogram Breast ultrasound MRI of the breast C Cardiac imaging Stress echocardiography Cardiovascular radionuclide imaging (thallium, sestamibi, dipyridamole [Persantine] scan) Cardiac MRI (CMR) scan Multidetector CT scan Transesophageal echocardiogram (TEE) Transthoracic echocardiography (TTE) Intravascular ultrasound (IVUS) D Chest imaging Chest radiograph CT scan of chest MRI scan of chest E Endocrine imaging Adrenal medullary scintigraphy (metaiodobenzylguanidine [MIBG] scan) Parathyroid (PTH) scan Thyroid scan (radioiodine uptake study) Thyroid ultrasound Section I n Diagnostic Imaging   F Genitourinary imaging Obstetric ultrasound Pelvic ultrasound Prostate ultrasound Renal ultrasound Scrotal ultrasound Transvaginal (endovaginal) ultrasound Urinary bladder ultrasound Hysterosalpingography (HSG) Intravenous pyelography (IVP) and intravenous retrograde pyelography G Musculoskeletal and spinal cord imaging Plain x-ray films of skeletal system Bone densitometry (dual-energy x-ray absorptiometry [DEXA] scan) MRI scan of spine MRI scan of shoulder MRI scan of hip and extremities MRI scan of pelvis MRI scan of knee CT scan of spinal cord Arthrography 10 CT myelography 11 Nuclear imaging (bone scan, gallium scan, white blood cell [WBC] scan) H Neuroimaging of brain CT scan of brain MRI scan of brain I Positron emission tomography (PET) J Single-photon emission computed tomography (SPECT) K Vascular imaging Angiography Aorta ultrasound Arterial ultrasound Captopril renal scan (CRS) Carotid ultrasonography Computed tomographic angiography (CTA) Magnetic resonance angiography (MRA) Magnetic resonance direct thrombus imaging (MRDTI) Pulmonary angiography 10 Transcranial Doppler 11 Venography 12 Compression ultrasonography and venous Doppler ultrasound 13 Ventilation/perfusion (V/Q) lung scan L Oncology Whole-body integrated (dual-modality) PET-CT Whole-body MRI A. Abdominal and Gastrointestinal (GI) Imaging 1. Abdominal Film, Plain (Kidney, Ureter, and Bladder [KUB]) Indications • Abdominal pain • Suspected intraperitoneal free air (pneumoperitoneum) • Bowel distention 4   Section I n Diagnostic Imaging Strengths • Low cost • Readily available • Low radiation Weaknesses • Low diagnostic yield • Contraindicated in pregnancy • Presence of barium from recent radiographs will interfere with interpretation • Nonspecific test Comments • KUB is a coned plain radiograph of the abdomen, which includes kidneys, ureters, and bladder • A typical abdominal series includes flat and upright radiographs • KUB is valuable as a preliminary study when investigating abdominal pain and pathologic findings (e.g., pneumoperitoneum, bowel obstruction, calcifications) Fig 1-1 describes normal gas pattern Normal gas collections under the diaphragm can also be seen on chest radiographs (Fig 1-2) • This is the least expensive but also least sensitive method to assess bowel obstruction radiographically • Cost: $ st hf tc sf cec sb ESOPHAGUS GASTRIC RUGAE GASTRIC CANAL PYLORUS PYLORIC SPHINCTER sig A B SEMILUNAR FOLDS CIRCULAR FOLDS C DUODENUM SMALL INTESTINE LARGE INTESTINE Figure 1-1  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 flexure (hf), transverse colon (tc), splenic flexure (sf), and sigmoid (sig) (From Mettler FA: Primary care radiology, Philadelphia, WB Saunders, 2000.) Section I n Diagnostic Imaging   R L Figure 1-2  Colonic interposition This is a normal variant in which the hepatic flexure can be seen above the liver This is seen as a gas collection under the right hemidiaphragm ­(arrow), but it is clearly identified as colon, owing to the transverse haustral markings (From Mettler FA: Essentials of radiology, ed 3, Philadelphia, Elsevier, 2014.) 2. Barium Enema (BE) Indications • Colorectal carcinoma • Diverticular disease (Fig 1-3) • Inflammatory bowel disease (IBD) • Lower GI bleeding • Polyposis syndromes • Constipation • Evaluation 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 (incidence 1:5000) • Contraindicated in pregnancy • Can result in severe postprocedure constipation in older adult patients • Poorly cleansed bowel will interfere with interpretation • Poor visualization of rectosigmoid lesions Section III n Diseases and Disorders   367 130. Thrombocytosis (Fig 3-206) Diagnostic Imaging Lab Evaluation Best Test(s) • None Best Test(s) • Bone marrow examination Ancillary Tests • CT of chest and abdomen Ancillary Tests • CBC • Reticulocyte count • Stool for occult blood × • Serum ferritin, TIBC, iron Serum Fe (decreased), TIBC (increased) Ferritin level (decreased) Decreased Hb/Hct Increased platelets Ferritin, reticulocyte count, TIBC, serum iron Normal CBC No anemia Iron deficiency anemia with reactive thrombocytosis Consider CT of chest and abdomen to rule out neoplasm Bone marrow aspiration and biopsy (rule out essential thrombocythemia p-vera, CML) Figure 3-206  Diagnostic algorithm 368   Section III n Diseases and Disorders 131. Thyroid Nodule (Fig 3-207) Diagnostic Imaging Lab Evaluation Best Test(s) • Thyroid ultrasound to evaluate size and composition of nodule (solid vs cystic) Best Test(s) • FNAB Ancillary Tests • Thyroid scan with Tc-99m classifies nodule as hyperfunctioning (hot), normally functioning (warm), or nonfunctioning (cold); thyroid scan can also be performed with iodine Ancillary Tests • TSH, free T4 • Antimicrosomal Ab • Serum calcium • Serum thyroglobulin level in patients with confirmed thyroid carcinoma Thyroid nodule on examination TSH, Free T4 Normal ↑Free T4, ↓TSH Thyroid ultrasound Thyroid scan and RAIU Solitary thyroid nodule Multinodular goiter Any nodule >1 cm FNAB Insufficient Indeterminate Benign nodule Repeat FNAB Gene expression classifier profile Thyroid suppression with levothyroxine or observation Benign Monitor Suspicious Surgery Figure 3-207  Diagnostic algorithm Malignant/suspicious nodule Surgery Section III n Diseases and Disorders   369 132. Thyroiditis (Fig 3-208) Diagnostic Imaging Lab Evaluation Best Test(s) • 24-hour RAIU scan (Fig 3-209): Useful in distinguishing Graves’ disease (increased RAIU) from thyroiditis (normal/low RAIU) Best Test(s) • None Ancillary Tests • TSH, free T4 • CBC with differential (leukocytosis with left shift occurs with subacute and suppurative thyroiditis) • Antimicrosomal Ab (detected in > 90% of patients with Hashimoto’s thyroiditis) • Serum thyroglobulin level (increased in patients with autoimmune lymphocytic thyroiditis) Ancillary Tests • Thyroid ultrasound Elevated Suspected thyroiditis Graves’ disease 24-hr RAIU Normal/low Thyroiditis Ancillary labs Thyroid ultrasound Figure 3-208  Diagnostic algorithm B A C Figure 3-209  Technetium-99m thyroid scans A, Normal B, Graves’ disease, showing enlarged thyroid with increased uptake C, Low patchy uptake in destructive thyroiditis (From Besser CM, Thorner MO: Comprehensive clinical endocrinology, ed 3, St Louis, Mosby, 2002.) 370   Section III n Diseases and Disorders 133. Tinnitus (Fig 3-210) Diagnostic Imaging Lab Evaluation Best Test(s) • Audiometry/tympanometry Best Test(s) • None Ancillary Tests • Carotid Doppler ultrasound • MRI of brain and auditory canals • Brain MRA Ancillary Tests • CBC • Lipid panel Carotid bruit Ultrasound of carotids Hearing loss and/or neuro defects on exam MRI of brain and auditory canal Suspected AV aneurysm or stenosis of intracranial vessel MRA of brain Normal results Rule out secondary to neuro trauma; rule out anxiety disorder with somatization; rule out psychosis Audiometry Tympanometry Rule out MS, CVA, neoplasm Tinnitus Auscultation of carotids Detailed neuro exam Figure 3-210  Diagnostic algorithm Section III n Diseases and Disorders   371 134. Transient Ischemic Attack (TIA) (Fig 3-211) Diagnostic Imaging Lab Evaluation Best Test(s) • Carotid Doppler (to identify carotid stenosis) Best Test(s) • None Ancillary Tests • CT of head without contrast (r/o hemorrhage or subdural hematoma) • Echocardiography (if cardiac source is suspected) • Brain MRA if posterior circulation TIA is suspected Ancillary Tests • PT, PTT, platelet count • Lipid panel, FBS • ESR Transient neuro deficit TIA Brain CT (rule out Subdural hematoma, mass) Ancillary tests Diagnostic (hypercoagulable state, giant cell arteritis) Anterior circulation Posterior Suspected cardioembolic source Carotid Doppler MRA Echocardiogram (TEE preferred) Hemodynamic stenosis (≥70%) Hemodynamic stenosis Angiography Angiography Diagnostic Figure 3-211  Diagnostic algorithm Nondiagnostic Holter monitor 372   Section III n Diseases and Disorders 135. Urethral Discharge (Fig 3-212) Diagnostic Imaging Lab Evaluation Best Test(s) • None Best Test(s) • Gram stain of exudate • Gonorrhea culture on Thayer-Martin medium or PCR assay • Culture for C trachomatis or PCR assay Ancillary Tests • None Ancillary Tests • Wet mount for Trichomonas • HIV, VDRL Urethral discharge, no vaginal discharge, no pyuria Gram stain of urethral exudate Presence of neutrophils but no gonococcal organisms Presence of intracellular Gram-negative diplococci PCR assay or culture for Chlamydia trachomatis Negative Wet mount exam for Trichomonas Positive Positive Nongonococcal urethritis (NGU) PCR assay or cultures for gonorrhea on Thayer-Martin medium Gonococcal urethritis Figure 3-212  Diagnostic algorithm Section III n Diseases and Disorders   373 136. Urolithiasis (Fig 3-213) Diagnostic Imaging Lab Evaluation Best Test(s) • Noncontrast CT of urinary tract (Fig 3-213) Best Test(s) • Urinalysis Ancillary Tests • Renal sonogram • IVP (demonstrates size and location of calculus) • Plain film of abdomen (can identify radiopaque stones [e.g., calcium]) Ancillary Tests • Chemical analysis of recovered stone • Serum calcium, phosphate, uric acid, BUN, creatinine • Urine C&S • 24-hour urine for calcium in patients with calcium stones Diagnostic CT of urinary tract (Fig 3-214) Suspected urolithiasis Consider IVP only in selected cases (e.g., indinavirinduced stones) Negative Urinalysis Diagnosis excluded Figure 3-213  Diagnostic algorithm B A C Figure 3-214  Obstructing left ureteral calculus On this noncontrasted computed tomography scan, at the level of the kidneys (A) there is stranding (arrows) around the left kidney but not around the right kidney At a lower level (B) a dilated left ureter is seen (arrow), and at the level of the bladder (C), a calculus is seen at the left ureterovesicular junction (arrow) The small rim of soft tissue around the calculus helps distinguish it from a phlebolith (From Mettler FA: Essentials of radiology, ed 3, Philadelphia, Elsevier, 2014.) 374   Section III n Diseases and Disorders 137. Urticaria (Fig 3-215) Diagnostic Imaging Lab Evaluation Best Test(s) • None Best Test(s) • None Ancillary Tests • Chest radiograph Ancillary Tests • CBC with differential • ANA • Hepatitis screen • ALT, Monospot • Thyroid antibodies • Stool for ova and parasites Urticaria r/o drug sensitivity r/o contact urticaria r/o food allergy (e.g., nuts, shellfish) r/o anxiety disorder Resolved with elimination of causative agent Persistent urticaria Ancillary tests Diagnostic Nondiagnostic Refer for skin biopsy (r/o angioedema, vasculitis, urticaria pigmentosa, dermal erythema multiforme, bullous pemphigoid) Biopsy diagnostic Biopsy inconclusive r/o occult neoplasm r/o psychological stress Figure 3-215  Diagnostic algorithm Section III n Diseases and Disorders   375 138. Vaginal Discharge (Fig 3-216) Diagnostic Imaging Lab Evaluation Best Test(s) • None Best Test(s) • Wet mount and KOH preparation Ancillary Tests • None Ancillary Tests • Gonococcal culture on Thayer-Martin medium • Culture for C trachomatis • HIV Vaginal discharge, no urethral discharge Pelvic exam, wet mount, KOH preparation Negative Trichomonas organisms on wet mount Positive wet mount for Trichomonas organisms PCR assay or cultures for gonorrhea on ThayerMartin medium, Chlamydia PCR or culture Trichomoniasis Positive “clue cells” and fishy odor that intensifies with “whiff test” Bacterial vaginosis Figure 3-216  Diagnostic algorithm Positive yeast/hyphae Candida vaginitis 376   Section III n Diseases and Disorders 139. Vertigo (Fig 3-217) Diagnostic Imaging Lab Evaluation Best Test(s) • MRI of brain Best Test(s) • None Ancillary Tests • MRA of posterior circulation (CT of cerebellopontine region if MRI is contraindicated) Ancillary Tests • CBC with differential • Serum glucose, creatinine, ALT, electrolytes Vertigo Ancillary lab tests Detailed neurologic exam (including Nylen-Bárány maneuver) Diagnostic abnormal labs Focal neuro deficits Positive Nylen-Bárány maneuver Investigate MRI of brain to rule out MS, neoplasm Benign positional vertigo Normal exam MRA of posterior circulation in elderly patient with risk factors Sensorineural hearing loss Observe in young, otherwise healthy patient Brainstem auditory sensory evoked response Normal Abnormal Rule out Ménière’s disease, labyrinthitis MRI or CT of cerebellopontine angle to rule out acoustic neuroma Figure 3-217  Diagnostic algorithm Section III n Diseases and Disorders   377 140. Viral Hepatitis (Fig 3-218) Diagnostic Imaging Lab Evaluation Best Test(s) • None Best Test(s) • Hepatitis panel (should include HBsAg, anti-HBc IgM, anti-HAV IgM, anti-HCV) Ancillary Tests • None Ancillary Tests • ALT, AST • Alkaline phosphatase, bilirubin, PT • ANA, ASMA, AMA if autoimmune hepatitis is suspected Rule out autoimmune hepatitis Negative serology Suspected viral hepatitis Hepatitis panel, ancillary labs Positive serology ANA, anti–smooth muscle Ab, antimitochondrial Ab, MLK-1 Ab Rule out hepatotoxic agents Rule out CMV, EBV hepatitis +Anti-HAV IgM Acute hepatitis A +Anti-Hbc IgM Acute hepatitis B +Anti-HCV Acute or chronic hepatitis C Figure 3-218  Diagnostic algorithm 378   Section III n Diseases and Disorders 141. Wegener’s Granulomatosis (Fig 3-219) Diagnostic Imaging Lab Evaluation Best Test(s) • Chest radiograph (Fig 3-220, A): May reveal bilateral multiple nodules, cavitated mass lesions, pleural effusion Best Test(s) • Biopsy of affected organ (e.g., lung, nasopharynx) Ancillary Tests • Ultrasound of kidneys • CT of sinuses and chest (see Fig 3-220, B) Suspected Wegener’s granulomatosis Chest x-ray and ancillary labs, CT of sinuses and CT of chest Suspicious Ancillary Tests • Serum c-ANCA level • Urinalysis (hematuria, RBC casts, proteinuria) • CBC (anemia, leukocytosis) • BUN, creatinine (increased) • ESR (increased) Biopsy of affected organ Ultrasound of kidneys, PFTs Figure 3-219  Diagnostic algorithm A B Figure 3-220  Wegener’s granulomatosis A, Chest radiograph showing bilateral patch airspace opacities; there is no evidence of caviation B, Computed tomography scan through the upper zones with multifocal regions of dense parenchymal opacification (From Grainger RG, Allison DJ, Adam A, Dixon AK, eds: Grainger & Allison’s diagnostic radiology, ed 4, Churchill Livingstone, Philadelphia, 2001.) Section III n Diseases and Disorders   379 142. Weight Gain (Fig 3-221) Diagnostic Imaging Lab Evaluation Best Test(s) • None Best Test(s) • TSH Ancillary Tests • Ultrasound of abdomen if cirrhosis or nephrosis suspected Ancillary Tests • FBS, BUN, creatinine, ALT, AST, albumin • Urinalysis • Serum dehydroepiandrosterone level Weight Gain • Determine calorie intake • Evaluate activity level • Medications (e.g., antipsychotics, SSRIs, steroids) • Recent smoking cessation • Examine for presence of edema, ascites, anasarca, Cushingoid appearance, myxedema Dietary weight gain Refer to nutritionist, increase physical activity Improved Positive drug history Consider change to alternate agent Persistent weight gain Improved TSH level Ancillary labs Diagnostic Normal Serum dehydroepiandrosterone level Figure 3-221  Diagnostic algorithm 380   Section III n Diseases and Disorders 143. Weight Loss, Involuntary (Fig 3-222) Diagnostic Imaging Lab Evaluation Best Test(s) • None Best Test(s) • TSH, free T4 Ancillary Tests • Chest radiograph Ancillary Tests • CBC, glucose • ESR (nonspecific) • ALT, creatinine, serum albumin • Urinalysis Involuntary weight loss Rule out depression with poor appetite Rule out recent initiation of diuretic or stimulant medication Positive Positive Negative Discontinue medication TSH, free T4, CBC, urinalysis, FBS, ALT, creatinine, albumin Rule out malignancy Treat Diagnostic Ancillary tests Consider colonoscopy, CT of abdomen/pelvis/ chest x-ray Normal Rule out substance abuse Negative Rule out malabsorption Figure 3-222  Diagnostic algorithm Positive screen Section III n Diseases and Disorders   381 References Ballinger A: Kumar & Clark’s essentials of medicine, ed 5, Edinburgh, 2012, Elsevier Besser CM, Thorner MO: Comprehensive clinical endocrinology, ed 3, St Louis, 2002, Mosby Broder JS: Diagnostic imaging for the emergency physician, Philadelphia, 2011, Saunders Cameron JL, Cameron AM: Current surgical therapy, ed 10, Philadelphia, 2011, Saunders Cohen J, Powderly WG: Infectious diseases, ed 2, St Louis, 2004, Mosby Crawford MH, DiMarco JP, Paulus WJ, editors: Cardiology, ed 2, St Louis, 2004, Mosby DeLee D, Drez D: DeLee and Drez’s orthopedic sports medicine, ed 2, Philadelphia, 2003, Saunders DuBose TD: Jr: Acid-base disorders In Brenner BM, editor: Brennor and Rector’s the kidney, ed 8, Philadelphia, 2008, Saunders Ferri F: Ferri’s best test, ed 2, St Louis, 2010, Mosby 10 Ferri F: Practical guide to the care of the medical patient, ed 8, St Louis, 2011, Mosby 11 Fielding JR, et al.: Gynecologic imaging, Philadelphia, 2011, Saunders 12 Goldman L, Schafer AI: Goldman’s Cecil medicine, ed 24, Philadelphia, 2012, Saunders 13 Grainger RG, Allison DJ, Adam A, Dixon AK, editors: Grainger & Allison’s diagnostic radiology, ed 4, Philadelphia, 2001, Churchill Livingstone 14 Greer IA, Cameron IT, Kitchener HC, Prentice A: Mosby’s color atlas and text of obstetrics and gynecology, London, 2001, Harcourt 15 Hochberg MC, Silma AJ, Smolen JS, Weinblatt ME, Weisman MH, editors: Rheumatology, ed 3, St Louis, 2003, Mosby 16 Johnson RJ, Feehally J: Comprehensive clinical nephrology, ed 2, St Louis, 2000, Mosby Fig 3–30 17 Kliegman RM, et al.: Nelson textbook of pediatrics, ed 19, Philadelphia, 2011, Saunders 18 Kuhn JP, Slovis TL, Haller JO: Caffrey’s pediatric diagnostic imaging, vol 2, ed 10, Philadelphia, 2004, Mosby 19 Mettler FA, Guibertau MJ, Voss CM, Urbina CE: Primary care radiology, Philadelphia, 2000, WB Saunders 20 Souhami RL, Moxham J: Textbook of medicine, ed 4, London, 2002, Churchill Livingstone 21 Symonds EM, Symonds IM: Essential obstetrics and gynecology, ed 4, Edinburgh, 2004, Churchill Livingstone 22 Talley NJ, Martin CJ: Clinical gastroenterology, ed 2, Sidney, 2006, Churchill Livingstone 23 Townsend CM, Beauchamp RD, Evers BM, Mattox KL, editors: Sabiston textbook of surgery, ed 17, Philadelphia, 2004, Saunders 24 Vincent JL, Abraham E, Moore FA, Kichnek PM, Fink MP: Textbook of critical care, ed 6, Philadelphia, 2011, Saunders 25 Weissleder R, Wittenberg J, Harisinghani MG, Chen JW: Primer of diagnostic imaging, ed 5, St Louis, 2011, Mosby 26 Zipes DP, Libby P, Bonow RO, Braunwauld E: Braunwauld’s heart disease, ed 7, Philadelphia, 2005, Elsevier [...]... Evaluation of abdominal mass, pelvic mass • Suspected lymphoma • Staging of neoplasm of abdominal and pelvic organs • Splenomegaly • Intraabdominal, pelvic, or retroperitoneal abscess • Abdominal and pelvic trauma • Jaundice • Pancreatitis: contrast-enhanced CT is considered the gold standard for diagnosing pancreatic necrosis and peripancreatic collections, and for grading acute pancreatitis... cervical and thoracic esophagus are obtained • Barium is generally used because it provides better anatomic detail than watersoluble contrast agents; however, diatrizoate (Hypaque) or Gastrografin should be used rather than barium sulfate in suspected perforation or anastomotic leak because free barium in the peritoneal cavity induces a granulomatous response that can result in adhesions and peritonitis;... • Hepatic trauma • Hepatic parenchymal disease (e.g., fatty infiltration, hemochromatosis, hepatitis, cirrhosis, portal hypertension) • Ascites (Fig 1-23) a SB a SB a SB A R L SB SB A A A A A A B Figure 1-23  Ascites On a plain film of the abdomen (A) , only gross amount of ascites (a) can be identified This is usually seen, because the ascites have caused a rather gray appearance of the abdomen and pushed... the dark bile and the bright pancreatic tissue is increased by the administration of IV contrast, because the pancreas enhances as a result of high blood flow The fat surrounding the pancreas is dark, which is normal and indicates the absence of inflammatory stranding—almost the entire pancreas is outlined in fat and has distinct border Incidentally, the patient has an abnormal dilated gallbladder... is passed into the duodenum Note the small catheter being advanced into the biliary duct (From Pagana KD, Pagana, TJ: Mosby’s diagnostic and laboratory test reference, ed 8, St Louis, Mosby, 2007.) 18   Section I n Diagnostic Imaging Figure 1-13  Endoscopic retrograde cholangiopancreatography demonstrating gallstones within the gallbladder and common bile duct (From Talley NJ, Martin CJ: Clinical gastroenterology,... • Evaluation of adrenal mass • Cervical cancer staging • Endometrial cancer staging • Evaluation of renal mass in patients allergic to iodine and in patients with diminished renal function • Staging of renal cell carcinoma 22   Section I n Diagnostic Imaging Figure 1-17 Hepatic cavernous hemangiomas on magnetic resonance imaging (MRI) Contrast-enhanced fat-suppressed gradient-echo MRI scan shows... duct stones (Fig 1-13) • Well suited to evaluate for and treat bile duct leaks and biliary tract injury after open or laparoscopic biliary surgery • ERCP in management of pancreatic and biliary cancer allows access to obstructed bile and pancreatic ducts for collecting tissue samples and placement of stents to temporarily relieve obstruction Figure 1-12  Endoscopic retrograde cholangiopancreatography... and thoracic esophagus are obtained, whereas in a UGI series films are taken of the thoracic esophagus, stomach, and duodenal bulb • Barium provides better anatomic detail than water-soluble contrast agents; however, water-soluble contrast agents (Gastrografin, Hypaque) are preferred when perforation is suspected or postoperatively to assess anastomosis for leaks or obstruction because free barium in... peripancreatic fat is nearly black, indicating no inflammatory stranding tail of pancreas spleen inferior vena cava portal vein aorta Figure 1-10  Normal pancreas, computed tomography with intravenous (IV) and oral contrast, soft-tissue window This scan shows a normal pancreas In many patients, the pancreas is not so horizontally oriented and is therefore difficult to see in a single slice Here, the... right anterior oblique, and right lateral views start at 40 minutes after injection GB did not visualize at 4 hours (not shown) (From Specht N: Practical guide to diagnostic imaging, St Louis, Mosby, 1998.) 9. Endoscopic Retrograde Cholangiopancreatography (ERCP) Indications • Evaluation and treatment of diseases of the bile ducts and pancreas • Treatment of choice for bile duct stones (Fig 1-12) and