Clinical imaging: Imaging pathways and interventional radiology

🩻 Imaging pathways and interventional radiology — page 6 of the Clinical Imaging chapter. Most imaging decisions follow well-established pathways — for chest pain, suspected cancer, jaundice, haematuria and bleeding. Following them avoids wasted scans and delays. Interventional radiology now treats many conditions that once needed open surgery — bleeding, abscesses, blocked kidneys and bile ducts, aneurysms and stroke — and ward doctors prepare patients for these procedures and look after them afterwards.
Your four questions for every imaging pathway or IR referral: Which pathway does this patient fit, and what is the first test? How urgently is it needed? For a procedure — is it indicated, consented and safe (clotting, anticoagulants, kidney function, allergy)? Who monitors the patient afterwards, and what complications should they watch for?

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Using Imaging Pathways

• Pathways (NICE, RCR iRefer, local protocols) set out the first test, the timeframe and what happens next for common presentations — they reduce variation, radiation and delay.
• Direct-access imaging — GPs can request CT, MRI and ultrasound directly for many suspected cancer and diagnostic pathways.
• Community diagnostic centres — NHS England sites offering imaging, endoscopy and other tests outside acute hospitals.
• Rapid diagnostic centres — for non-specific but concerning symptoms (weight loss, fatigue, abdominal pain, abnormal bloods) — often CT chest, abdomen and pelvis as the first test.
• Suspected cancer pathways — the Faster Diagnosis Standard — cancer diagnosed or ruled out within 28 days of urgent referral.
• Imaging in MDTs — radiologists review imaging in cancer, ILD, vascular and other multidisciplinary meetings.
• Patient preparation and information — explain what the test involves, why, risks, and how results will be given.

Chest Pain, PE and the Aorta

• Acute chest pain — ECG within 10 minutes, high-sensitivity troponin; chest X-ray for alternative diagnoses (pneumothorax, pneumonia, widened mediastinum).
  • STEMI — primary PCI (coronary angiography) — no imaging delay.
  • NSTEMI — angiography within 72 hours (risk-guided); echo for LV function.
• Stable chest pain of suspected cardiac origin (NICE CG95) — CT coronary angiography first line (unless clinical assessment shows non-anginal pain); functional imaging (stress echo, myocardial perfusion scan, stress cardiac MRI) if CTCA is non-diagnostic or shows disease of uncertain significance; invasive angiography if functional imaging is non-diagnostic or for revascularisation.
• Suspected PE (NICE NG158) — two-level Wells score → D-dimer (PE unlikely) or CTPA (PE likely); V/Q if CTPA contraindicated (contrast allergy, severe renal impairment) or in pregnancy with a normal chest X-ray; bedside echo if too unstable for CT (RV dilatation).
• Suspected DVT — proximal leg vein compression ultrasound within 4 hours (interim anticoagulation if delayed).
• Suspected aortic dissection — CT aortogram urgently (TOE if unstable in theatre or ICU).
• Pericardial effusion and tamponade — echocardiography — urgent pericardiocentesis if tamponade.
• Heart failure — NT-proBNP then echocardiogram (within 2 weeks if NT-proBNP over 2,000 ng/L; within 6 weeks if 400–2,000 — NICE NG106).

Suspected Cancer — Which Scan?

Cancer	First imaging or test (NICE NG12 and pathways)	Staging
Lung	Chest X-ray within 2 weeks (40+ with symptoms); suspected cancer referral if suggestive; CT if X-ray normal but suspicion persists; lung cancer screening (low-dose CT) for eligible smokers	Contrast CT chest and upper abdomen; PET-CT before radical treatment; EBUS
Colorectal	FIT (10 µg Hb/g or more → urgent referral); colonoscopy; CT colonography if frail or colonoscopy incomplete	CT chest, abdomen and pelvis; MRI pelvis (rectal); liver MRI
Oesophageal and gastric	Urgent direct-access endoscopy	CT; PET-CT; EUS; staging laparoscopy (gastric)
Pancreatic	Urgent direct-access CT (within 2 weeks) in over-60s with weight loss and relevant symptoms; jaundice — suspected cancer referral	Pancreatic protocol CT; EUS (biopsy); MRI liver
Liver (HCC)	Ultrasound surveillance in cirrhosis (6-monthly)	Multiphase CT or MRI (LI-RADS)
Breast	Suspected cancer referral → triple assessment	CT or bone scan if advanced; MRI in selected cases
Prostate	PSA and DRE → referral → multiparametric MRI before biopsy	MRI; bone scan or PSMA PET (high risk)
Bladder and kidney	Visible haematuria (45+) → CT urogram and cystoscopy	CT chest, abdomen, pelvis
Ovarian	CA125 → pelvic ultrasound	CT chest, abdomen, pelvis
Endometrial	Postmenopausal bleeding → transvaginal ultrasound (4 mm threshold) ± hysteroscopy	MRI pelvis; CT
Brain	Direct-access MRI (within 2 weeks) for progressive subacute focal neurology	MRI with contrast; CT body for metastases
Lymphoma	Lymph node ultrasound and biopsy (excision or core)	PET-CT
Myeloma	Protein electrophoresis and free light chains	Whole-body low-dose CT or whole-body MRI
Sarcoma	Urgent X-ray (bone) or ultrasound (soft tissue)	MRI of the lesion; CT chest — at the sarcoma centre
Unknown primary	CT chest, abdomen and pelvis	PET-CT if CT unhelpful; biopsy

Breast Imaging

• NHS Breast Screening Programme — mammography every 3 years for women aged 50 to 71 (and those aged 71 and over can self-refer); about 1 in 10 recalled cancers are interval cancers.
• Higher risk women (family history, BRCA, TP53, chest radiotherapy for Hodgkin lymphoma before 30) — annual MRI and/or mammography from an earlier age (very high risk protocol — see Genetics chapter).
• Symptomatic women (lump, nipple change, skin change) — triple assessment in a one-stop clinic:
  • Clinical examination.
  • Imaging — mammography (usually 40 and over) plus ultrasound; ultrasound alone under 40 (dense breasts, radiation).
  • Biopsy — ultrasound- or stereotactic-guided core biopsy (FNA for cysts or nodes).
• Scoring (UK) — 1 (normal) to 5 (malignant) for each modality (M1–M5, U1–U5) — scores of 3 or above need biopsy.
• Breast MRI — high-risk screening, lobular cancer extent, implant integrity, occult primary with axillary nodes, response to neoadjuvant chemotherapy.
• Men — ultrasound for gynaecomastia vs cancer (mammography if suspicious).
• Pregnancy and breastfeeding — ultrasound first; don't dismiss a persistent lump.
• Axillary staging — ultrasound with biopsy of abnormal nodes; sentinel node biopsy.

Neck Lumps and Thyroid Nodules

• Neck lumps:
  • Ultrasound is first line — characterises lymph nodes, thyroid, salivary glands and cysts; guides FNA or core biopsy.
  • Suspected cancer referral (NICE NG12) — unexplained neck lump in people aged 45 and over, persistent unexplained neck lump, unexplained thyroid lump; neck lump with weight loss, night sweats or other lymphoma features.
  • Young adults with tender nodes after infection — usually reactive; reassess at 2–6 weeks.
  • CT or MRI neck — head and neck cancer staging (with PET-CT).
• Thyroid nodules (British Thyroid Association):
  • Ultrasound U-classification — U1 normal, U2 benign (e.g. spongiform, cystic), U3 indeterminate, U4 suspicious, U5 malignant (hypoechoic, microcalcification, irregular margins, taller-than-wide, abnormal nodes).
  • FNA for U3–U5 nodules; cytology graded Thy1–Thy5.
  • Check TSH — if suppressed, thyroid uptake scan ("hot" nodules are rarely malignant).
  • Incidental thyroid nodules on CT, MRI or carotid Doppler — ultrasound if clinically indicated; FDG-avid nodules on PET need assessment.
• Parathyroid adenoma localisation — neck ultrasound and sestamibi scan (or 4D-CT, choline PET) before surgery.
• Salivary gland swelling — ultrasound (stones, tumours, Sjögren's); MRI for tumours.

Jaundice and Abnormal Liver Tests

• Jaundice — ultrasound first — is the biliary tree dilated?
  • Dilated ducts (obstructive) → find the level and cause:
    • MRCP — stones, strictures, cholangiocarcinoma, PSC.
    • Pancreatic protocol CT — pancreatic or ampullary tumour (double duct sign), staging.
    • EUS — small stones, small tumours, biopsy.
    • ERCP — therapeutic (stone extraction, stenting) rather than diagnostic.
    • PTC (percutaneous transhepatic cholangiography) and drainage — hilar obstruction or failed ERCP.
  • Non-dilated ducts → hepatocellular or intrahepatic cholestasis — liver screen bloods (viral serology, autoantibodies, immunoglobulins, ferritin, caeruloplasmin, alpha-1 antitrypsin), drug history, alcohol; MRI or biopsy if unclear.
• Painless jaundice with weight loss in an older adult — pancreatic or biliary cancer until proven otherwise — urgent CT.
• Abnormal liver tests (BSG 2018) — standard liver aetiology screen plus ultrasound; fibrosis assessment in MASLD and alcohol (FIB-4 or ELF, then transient elastography); refer advanced fibrosis or cirrhosis to hepatology.
• Cirrhosis — 6-monthly ultrasound for HCC; endoscopy for varices (or elastography-based criteria).
• Acute liver failure — Doppler ultrasound (hepatic and portal vein patency — Budd–Chiari).
• Right upper quadrant pain with fever — ultrasound (cholecystitis, liver abscess); CT if ultrasound is inconclusive.

Haematuria, Prostate and Scrotal Problems

• Visible haematuria (without UTI, or persisting after treatment) — suspected cancer referral in people aged 45 and over (NICE NG12) — flexible cystoscopy plus upper tract imaging — CT urogram (or ultrasound in lower-risk or younger patients per BAUS guidance).
• Non-visible haematuria — confirm on repeat dipstick, exclude UTI; age 60 and over with dysuria or raised white cell count — suspected cancer referral; ultrasound and cystoscopy; check renal function, BP and ACR (nephrological causes — IgA nephropathy, Alport's).
• Renal colic — CT KUB within 24 hours (see page 3).
• Lower urinary tract symptoms — post-void residual (bladder scan), renal ultrasound if retention, AKI or recurrent infection; imaging isn't routine.
• Suspected prostate cancer — multiparametric MRI before biopsy (NICE NG131) — PI-RADS 3–5 → biopsy (transperineal); PI-RADS 1–2 with low PSA density — may avoid biopsy.
• Scrotal swellings:
  • Testicular torsion — clinical diagnosis — emergency surgical exploration; don't delay for ultrasound.
  • Testicular mass — urgent ultrasound — solid intratesticular mass = cancer until proven otherwise (suspected cancer referral; tumour markers AFP, hCG, LDH; CT staging).
  • Epididymo-orchitis (increased flow), hydrocele (anechoic fluid — ultrasound to see the testis), varicocele (left-sided; new right-sided or non-reducing — image the abdomen for a renal mass), epididymal cyst.
• Recurrent UTI — renal tract ultrasound (structural abnormality, residual, stones) in men and in women with recurrent pyelonephritis or atypical features.

GI Bleeding

• Upper GI bleeding — endoscopy is diagnostic and therapeutic (within 24 hours; immediately after resuscitation if unstable — NICE CG141); CT angiography and interventional radiology embolisation if endoscopy fails or rebleeding occurs (e.g. gastroduodenal artery).
• Lower GI bleeding (BSG 2019):
  • Unstable (shock index over 1 after resuscitation) — CT angiography → catheter angiography and embolisation (ideally within 60 minutes) or endoscopic/surgical treatment.
  • Stable major bleed — admit for colonoscopy.
  • Minor bleed (Oakland score 8 or less) — discharge with outpatient investigation.
  • Exclude an upper GI source (urea raised, haemodynamic instability) — gastroscopy first if suspected.
• Obscure or small bowel bleeding — capsule endoscopy, CT enterography, double-balloon enteroscopy; Meckel's scan (technetium pertechnetate) in children and young adults.
• Haemoptysis (massive) — CT angiography → bronchial artery embolisation.
• Variceal bleeding refractory to endoscopic therapy — TIPS.
• Haemobilia, pseudoaneurysms (pancreatitis — splenic or gastroduodenal artery) — CT angiography and embolisation.

Imaging Children

• Children are more sensitive to radiation and live longer to express its risk — minimise ionising radiation: use clinical decision rules, ultrasound and MRI first where possible, child-specific CT protocols ("Image Gently").
• Ultrasound first for:
  • Appendicitis — non-compressible appendix over 6 mm.
  • Intussusception (6 months–2 years — colicky pain, drawing up legs, "redcurrant jelly" stool) — target sign — air enema reduction.
  • Pyloric stenosis (2–8 weeks — projectile vomiting) — thickened pylorus (muscle over 3 mm, length over 15 mm).
  • Hips (DDH, irritable hip), renal tract after UTI, neonatal brain (cranial ultrasound through the fontanelle), scrotum, neck lumps.
• Bilious vomiting in a neonate — malrotation with volvulus until proven otherwise — urgent upper GI contrast study (or ultrasound) and surgical review.
• Necrotising enterocolitis (preterm infants) — AXR — pneumatosis, portal venous gas, free gas.
• Inhaled foreign body — chest X-ray (often normal; air trapping — inspiratory and expiratory films or decubitus views); bronchoscopy if suspected.
• MRI in children — "feed and wrap" in infants; sedation or general anaesthesia in young children; play specialists.
• Safeguarding imaging — skeletal survey and CT head (see page 5).
• Consent — explain to parents and, where able, to the child; Gillick competence.

Imaging Older and Frail People

• Atypical presentations — low threshold for imaging (CT head after falls on anticoagulants, CT abdomen for vague abdominal pain, occult fractures after falls).
• Proportionality — ask whether the result would change management in the context of frailty, prognosis and the patient's wishes; avoid cascades of investigation for incidental findings that will never cause harm.
• Capacity and consent — assess capacity for interventional procedures; best-interests decisions under the Mental Capacity Act; involve families and advance care plans.
• Practicalities — transport, positioning (kyphosis, contractures), pressure care during long waits, hearing and visual impairment, delirium risk, toileting, continuity of drugs (Parkinson's medication on time).
• MRI tolerance — claustrophobia, inability to lie flat, implants (pacemakers) — consider alternatives.
• Contrast — reduced kidney function is common — check eGFR; hydration.
• Interpretation — age-related changes (atrophy, small vessel disease, degenerative spine, osteopenia, aortic calcification) are common and often not the cause of symptoms.
• Bone health — vertebral fractures on imaging should trigger osteoporosis assessment.

Interventional Radiology — Overview

• Interventional radiology (IR) — minimally invasive, image-guided diagnosis and treatment using needles, wires, catheters, balloons, stents and embolic agents through small skin punctures — usually under local anaesthetic and sedation.
• Advantages — less pain, faster recovery, shorter stays, lower risk than open surgery (especially in frail or unstable patients); can be life-saving in haemorrhage.
• Imaging guidance — fluoroscopy and angiography, ultrasound, CT, cone-beam CT, MRI.
• Access — arterial (common femoral or radial artery), venous (femoral, jugular), percutaneous (direct into an organ or collection).
• Interventional neuroradiology — stroke thrombectomy, aneurysm coiling, AVM embolisation.
• 24/7 IR services — required for major trauma centres and acute bleeding; networked across regions.
• Interventional radiologists see patients in clinic, consent them and manage them on wards — work alongside surgeons in hybrid theatres.

Vascular Interventions

Procedure	Uses
Angioplasty and stenting	Peripheral arterial disease (critical limb ischaemia), renal artery stenosis (selected), carotid stenting (selected), mesenteric ischaemia, dialysis fistula stenoses, venous stenoses
EVAR / TEVAR	Endovascular repair of abdominal and thoracic aortic aneurysms and type B dissection — lifelong surveillance (endoleak)
Mechanical thrombectomy	Acute ischaemic stroke (large vessel occlusion); acute limb ischaemia; selected PE and DVT (catheter-directed therapy)
Catheter-directed thrombolysis	Selected massive or submassive PE, iliofemoral DVT, acute limb ischaemia
IVC filter	Acute proximal DVT or PE when anticoagulation is contraindicated — retrieve when anticoagulation can start (complications if left — thrombosis, migration)
TIPS	Refractory variceal bleeding, refractory ascites, Budd–Chiari — risk of hepatic encephalopathy
Central venous access	PICC lines, tunnelled lines (Hickman), ports, dialysis catheters
Venous sampling	Adrenal vein sampling (primary aldosteronism — unilateral vs bilateral); inferior petrosal sinus sampling (pituitary vs ectopic Cushing's)
Varicose veins and venous disease	Endovenous laser or radiofrequency ablation, sclerotherapy, iliac vein stenting

Embolisation for Bleeding

• Embolisation — blocking a bleeding or abnormal vessel through a catheter with coils, particles, glue, plugs or gelatin sponge.
• Emergency uses:
  • Trauma — spleen, liver, kidney, pelvic arterial bleeding (pelvic fractures).
  • GI bleeding — upper GI after failed endoscopy; lower GI (diverticular, angiodysplasia).
  • Massive haemoptysis — bronchial arteries (bronchiectasis, CF, TB, cancer).
  • Postpartum haemorrhage — uterine arteries (when medical and surgical measures fail).
  • Post-procedural bleeding — after biopsy, surgery or PCNL; pseudoaneurysms.
  • Epistaxis (refractory), haematuria from tumours, bleeding renal angiomyolipoma.
• Elective uses:
  • Uterine fibroid embolisation — alternative to hysterectomy.
  • Prostate artery embolisation — benign prostatic hyperplasia (selected).
  • Varicocele and pelvic congestion embolisation.
  • AVMs (including pulmonary AVMs in HHT), aneurysms (visceral, intracranial coiling).
  • Pre-operative tumour embolisation; portal vein embolisation before liver resection.
• Complications — non-target embolisation (ischaemia of other organs), post-embolisation syndrome (pain, fever, nausea), infection or abscess, access site bleeding, contrast effects.

Biopsy, Drainage and Non-vascular Interventions

• Image-guided biopsy (ultrasound or CT):
  • Lung (CT-guided) — pneumothorax is common (about 1 in 5; a chest drain is needed in about 1 in 20), haemoptysis.
  • Liver and kidney (native and transplant) — bleeding is the main risk — check clotting; transjugular liver biopsy if coagulopathy or ascites.
  • Lymph nodes, bone, soft tissue masses (sarcoma — at the specialist centre), breast, thyroid, adrenal (exclude phaeochromocytoma first).
• Drainage:
  • Abscesses (liver, intra-abdominal, pelvic, post-operative, diverticular), empyema, pleural effusions, ascites (paracentesis — usually ward-based with ultrasound), pericardial effusions.
• Urinary:
  • Percutaneous nephrostomy — infected obstructed kidney (emergency), obstruction from tumours or stones, ureteric leaks.
  • Antegrade ureteric stents.
• Biliary:
  • PTC and biliary drainage or stenting — malignant hilar obstruction, failed ERCP, post-surgical leaks.
  • Percutaneous cholecystostomy — acute cholecystitis in patients unfit for surgery.
• GI:
  • Radiologically inserted gastrostomy (RIG) — enteral feeding (e.g. MND, head and neck cancer) when PEG isn't possible.
  • Oesophageal, duodenal and colonic stents — palliation of malignant obstruction (colonic stent as a bridge to surgery in some).
• MSK and spine — joint injections and aspirations, nerve root and facet injections, vertebroplasty or kyphoplasty (painful osteoporotic or malignant vertebral fractures — selected cases).

Interventional Oncology

• Tumour ablation — destroying tumours with heat or cold through a needle probe:
  • Radiofrequency and microwave ablation — small HCC (under 3 cm), colorectal liver metastases, small renal cancers (older or comorbid patients), lung tumours, osteoid osteoma.
  • Cryoablation — renal tumours, some bone and soft tissue tumours.
• Transarterial chemoembolisation (TACE) — intermediate-stage HCC — chemotherapy and embolic particles into the hepatic arterial supply of the tumour.
• Selective internal radiation therapy (SIRT) — yttrium-90 microspheres for liver tumours (selected cases).
• Palliative interventions — stents (biliary, oesophageal, colonic, airway, SVC), nephrostomies, drains for malignant ascites and effusions (indwelling pleural and peritoneal catheters), coeliac plexus block for pancreatic cancer pain, cementoplasty for bone metastases.
• SVC obstruction (lung cancer, lymphoma) — SVC stenting gives rapid symptom relief; obtain tissue diagnosis where possible.
• MDT decisions — IR oncology options are discussed alongside surgery, radiotherapy and systemic therapy.

Before an IR Procedure — Consent, Clotting and Anticoagulants

• Indication and plan — discuss with the IR team; check previous imaging; confirm what the procedure is expected to achieve.
• Consent — usually taken by the operator or a trained member of the IR team (GMC — risks, benefits, alternatives, including doing nothing); assess capacity; best-interests process if lacking capacity.
• Bloods — FBC (platelets), clotting (INR) for higher-risk procedures, U&E and eGFR (contrast), group and save (higher bleeding-risk procedures).
• Bleeding risk (SIR and BSIR guidance — follow local policy):
  • Low-risk procedures (e.g. paracentesis, thoracentesis, superficial biopsy, PICC, dialysis access) — routine clotting tests often not needed; correct only very abnormal values.
  • High-risk procedures (e.g. liver or renal biopsy, nephrostomy, biliary drainage, TIPS, deep biopsies) — typically aim for INR about 1.5 or less (up to 1.8 per some guidance) and platelets over 50 × 10⁹/L.
• Anticoagulants and antiplatelets (balance bleeding against thrombosis risk):
  • Warfarin — usually stop about 5 days before high-risk procedures; bridging with LMWH only for very high thrombotic risk (e.g. mechanical mitral valve).
  • DOACs — stop 1–3 days before (longer with renal impairment, especially dabigatran) for high-risk procedures.
  • LMWH — omit the dose before (prophylactic 12 hours; treatment dose 24 hours).
  • Clopidogrel, prasugrel, ticagrelor — usually stop 5–7 days before high-risk procedures (check with cardiology if recent stents); aspirin is often continued.
  • Restart as advised by the operator (typically 24–48 hours for high-risk procedures).
• Other preparation — fasting if sedation is planned (local policy), IV access, contrast allergy and metformin checks, antibiotic prophylaxis (biliary, urinary, some embolisations), diabetes management, pregnancy test.

⚠️ Safety Pearl: Many IR delays and cancellations are avoidable. For a high-risk procedure, check platelets, INR, kidney function and group and save the day before, and agree with the operator — in writing — when to stop and restart each anticoagulant or antiplatelet.

After an IR Procedure — Monitoring and Complications

• Observations — pulse, BP, oxygen saturation and pain (e.g. every 15 minutes for the first hour, then every 30 minutes, then hourly for several hours — follow the post-procedure instructions).
• Arterial access (femoral or radial):
  • Bed rest for a set period after femoral puncture (shorter with closure devices).
  • Check the puncture site and distal pulses.
  • Complications — groin haematoma (press firmly above the puncture site), pseudoaneurysm (pulsatile mass with bruit — ultrasound; thrombin injection or compression), retroperitoneal haemorrhage (back or flank pain, hypotension, falling Hb with little visible bleeding — CT), arterial dissection or occlusion, AV fistula.
• Organ-specific complications:
  • Lung biopsy — pneumothorax (chest X-ray at 1–4 hours or if symptomatic).
  • Liver or renal biopsy — bleeding (tachycardia, pain, falling Hb, haematuria) — CT angiography and embolisation if significant.
  • Biliary and urinary drainage — sepsis (rigors within hours — blood cultures, IV antibiotics), drain dislodgement, bile or urine leak.
  • Embolisation — post-embolisation syndrome; non-target ischaemia.
  • TIPS — encephalopathy, heart failure.
• Drains and tubes — record output, flush as instructed, secure them; know who to contact if a drain stops working or falls out.
• Contrast — check kidney function in high-risk patients; restart metformin when appropriate.
• Communication — clear post-procedure instructions in the notes (observations, mobilisation, when to eat, anticoagulant restart, follow-up imaging, drain care, results of biopsies).

Imaging Pathways at a Glance

Presentation	First test → next step
Stable chest pain	CT coronary angiography → functional imaging → invasive angiography
Suspected PE	Wells → D-dimer or CTPA (V/Q in pregnancy or contrast contraindication)
Suspected aortic dissection	CT aortogram
Heart failure	NT-proBNP → echo
Suspected lung cancer	Chest X-ray within 2 weeks → CT → PET-CT before radical treatment
Suspected bowel cancer	FIT → colonoscopy (CT colonography if frail)
Breast lump	Triple assessment — ultrasound under 40, mammography + ultrasound 40 and over
Thyroid nodule	TSH; ultrasound — FNA for U3–U5
Jaundice	Ultrasound → dilated: MRCP or CT; not dilated: liver screen
Visible haematuria (45+)	CT urogram + cystoscopy
Suspected prostate cancer	PSA → mpMRI → targeted biopsy
Testicular mass	Urgent ultrasound (torsion — surgery, not scan)
Unstable lower GI bleed	CT angiography → embolisation
Massive haemoptysis	CT angiography → bronchial artery embolisation
Infected obstructed kidney	Ultrasound or CT → nephrostomy
Child — RIF pain / intussusception / pyloric stenosis	Ultrasound
Neonate with bilious vomiting	Urgent upper GI contrast — malrotation

Spot the Diagnosis

Scenario	Best answer
Stable exertional chest tightness in a 58-year-old	CT coronary angiography
Suspected PE with eGFR 22 and a normal chest X-ray	V/Q scan
Weight loss, new diabetes and back pain in a 68-year-old	Urgent CT (pancreatic cancer)
Breast lump in a 28-year-old woman	Ultrasound (triple assessment)
U4 thyroid nodule	Ultrasound-guided FNA
Hot thyroid nodule with suppressed TSH	Toxic adenoma — rarely malignant
Painless jaundice; dilated intra- and extrahepatic ducts and dilated pancreatic duct	Pancreatic protocol CT
Visible haematuria in a 63-year-old smoker	CT urogram and flexible cystoscopy
PSA 9 in a 66-year-old	Multiparametric MRI before biopsy
Sudden testicular pain and a high-riding testis in a 14-year-old	Emergency exploration — not ultrasound
Fresh rectal bleeding with shock index 1.4 after fluids	CT angiography → embolisation
Coughing 300 mL of blood in a man with bronchiectasis	Bronchial artery embolisation
Recurrent variceal bleeding despite banding	TIPS
Acute DVT 3 days after a craniotomy (anticoagulation contraindicated)	Retrievable IVC filter
Resistant hypertension with low potassium; bilateral adrenal nodules	Adrenal vein sampling
Acute cholecystitis in a frail 92-year-old unfit for surgery	Percutaneous cholecystostomy
Facial swelling, distended neck veins and a right hilar mass	SVC obstruction — stent (after tissue diagnosis if possible)
Tachycardia and back pain 4 hours after femoral angiography	Retroperitoneal haematoma — CT
Pulsatile groin swelling with a bruit after cardiac catheterisation	Femoral pseudoaneurysm — ultrasound
Rigors 2 hours after a nephrostomy	Procedure-related sepsis — cultures and IV antibiotics
Breathless after CT-guided lung biopsy	Pneumothorax — chest X-ray
Projectile vomiting in a 5-week-old baby	Ultrasound — pyloric stenosis

Exam-style Scenarios

1. A 74-year-old man with diverticular disease has heavy fresh rectal bleeding. After 2 L of fluid his HR is 125 and BP 90/55. Hb 82.
Answer: Unstable lower GI bleed.

• Major haemorrhage protocol; transfuse; reverse anticoagulants; consider an upper GI source (gastroscopy if suspected).
• CT angiography to locate the bleeding point.
• Catheter angiography and embolisation (IR); surgery if IR fails or isn't available.

2. A 70-year-old woman on apixaban (for AF) and clopidogrel needs a liver biopsy for suspected metastases. eGFR 45.
Answer: High bleeding-risk procedure — plan anticoagulant and antiplatelet interruption.

• Agree with the IR team — stop apixaban about 2–3 days before (renal function) and clopidogrel about 5–7 days before (check with cardiology about stents).
• Bloods — FBC (platelets over 50), INR, U&E, group and save; consent including bleeding risk.
• Clear written restart plan (usually 24–48 hours if no bleeding); post-procedure observations.

3. A 55-year-old woman has a 2.5 cm hard thyroid nodule. TSH is normal. Ultrasound shows a hypoechoic nodule with microcalcification and irregular margins (U5).
Answer: Suspected thyroid cancer.

• Ultrasound-guided FNA (and of any abnormal nodes).
• Suspected cancer referral to the thyroid MDT.
• Thyroid cancer surgery and staging per cytology.

4. A 67-year-old man has painless jaundice and 6 kg weight loss. Ultrasound shows a dilated common bile duct and intrahepatic ducts; the pancreas is obscured.
Answer: Suspected pancreatic head or periampullary cancer.

• Pancreatic protocol CT (staging and resectability); CA19-9.
• EUS with biopsy; HPB MDT.
• Biliary drainage (ERCP stent or PTC) if cholangitis or before chemotherapy; avoid unnecessary stenting before potential early surgery.

5. A 60-year-old woman has rigors and loin pain. CT KUB shows a 9 mm obstructing proximal ureteric stone with hydronephrosis. BP 92/58, lactate 3.4.
Answer: Infected obstructed kidney — urological emergency.

• Sepsis bundle — blood and urine cultures, IV antibiotics, fluids.
• Urgent decompression — percutaneous nephrostomy (IR) or retrograde ureteric stent (urology) — check clotting.
• Definitive stone treatment later, once infection has resolved.

Key Points

• Follow imaging pathways — the right first test avoids delay and unnecessary radiation.
• Stable chest pain — CTCA first; PE — CTPA (V/Q in pregnancy or contrast contraindication); dissection — CT aortogram.
• Suspected cancer — chest X-ray (lung), FIT (bowel), direct-access CT (pancreas), triple assessment (breast), mpMRI (prostate), CT urogram and cystoscopy (haematuria), CA125 and ultrasound (ovary).
• Faster Diagnosis Standard — diagnose or rule out cancer within 28 days.
• Breast — ultrasound under 40; mammography plus ultrasound 40 and over; screening every 3 years aged 50–71.
• Thyroid nodules — TSH and ultrasound; FNA for U3–U5.
• Jaundice — ultrasound first; dilated ducts → MRCP or CT.
• Testicular torsion is clinical — operate, don't scan; solid testicular mass is cancer until proven otherwise.
• Unstable GI bleeding and massive haemoptysis — CT angiography then embolisation.
• Children — ultrasound first; minimise radiation; bilious vomiting in a neonate is malrotation until proven otherwise.
• IR — embolisation, stents, EVAR, TIPS, nephrostomy, biliary drainage, biopsy, ablation, IVC filters (only if anticoagulation contraindicated).
• Before high-risk IR — platelets over 50, INR about 1.5 or less, plan anticoagulant interruption and restart.
• After IR — watch for bleeding (retroperitoneal haematoma, pseudoaneurysm), pneumothorax after lung biopsy, sepsis after drainage.

Guidelines and Further Reading

• Royal College of Radiologists: iRefer; Standards for interventional radiology
• NICE NG12: Suspected cancer — recognition and referral; NHS England: Faster Diagnosis Standard and rapid diagnostic centres
• NICE CG95: Chest pain of recent onset; NICE NG158: VTE diseases; NICE NG106: Chronic heart failure
• British Thyroid Association: Guidelines for the management of thyroid cancer (ultrasound U-classification)
• British Society of Gastroenterology: Acute lower GI bleeding (2019); guidelines on the management of abnormal liver blood tests (2018)
• British Association of Urological Surgeons: Haematuria guidance; NICE NG131: Prostate cancer
• British Society of Interventional Radiology (BSIR) / Society of Interventional Radiology (SIR): Peri-procedural management of thrombotic and bleeding risk
• NHS Breast Screening Programme guidance
• BNF — for current doses