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Appropriateness Criteria

Variant 1: Initial therapeutic procedure for a patient with dilated bile ducts from choledocholithiasis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Moderate N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
7 (21872710) 3
10 (8813987) 2
Percutaneous internal/external biliary catheter May be appropriate Limited N/A N/A 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
24 (12204406) 4
25 (21638145) 3
23 (3566375) 4
26 (11577321) 4
27 (23782350) 4
Endoscopic US-guided biliary drainage (EUS-BD) May be appropriate Limited N/A N/A 4 4 0 0 0 0 0 0 0 0 0
References Study Quality
12 (26020052) 4
Removable biliary covered stent May be appropriate Expert Consensus N/A N/A 4 4 0 0 0 0 0 0 0 0 0
Medical management only Usually not appropriate Expert Consensus N/A N/A 2 2 0 0 0 0 0 0 0 0 0
Surgery Usually not appropriate Limited N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
25 (21638145) 3
28 (23999986) 4
Permanent biliary metallic stent Usually not appropriate Limited N/A N/A 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
7 (21872710) 3
11 (21684464) 4
Variant 2: Initial therapeutic procedure for a patient with elevated bilirubin and suspected sclerosing cholangitis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
39 (10483999) 2
38 (3584158) 4
35 (21241424) 4
Medical management only May be appropriate Strong N/A N/A 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
32 (24914504) 2
33 (27981301) 1
34 (15565569) 1
Percutaneous internal/external biliary catheter May be appropriate Limited N/A N/A 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
35 (21241424) 4
37 (3876737) 3
Removable biliary covered stent Usually not appropriate Limited N/A N/A 2 2 0 0 0 0 0 0 0 0 0
References Study Quality
40 (20630513) 3
Surgery Usually not appropriate Strong N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
43 (19845177) 4
41 (9527065) 2
42 (18471705) 2
Permanent biliary metallic stent Usually not appropriate Limited N/A N/A 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
11 (21684464) 4
40 (20630513) 3
Variant 3: Initial therapeutic procedure for a liver transplant recipient with elevated bilirubin and suspected biliary anastomotic stenosis or bile leak, with no dilated ducts.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
49 (21280189) 2
48 (16116539) 4
50 (18702031) 2
51 (29026597) Good
52 (24587819) 1
56 (23432435) 4
Percutaneous internal/external biliary catheter Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
49 (21280189) 2
46 (26689137) 4
56 (23432435) 4
Removable biliary covered stent May be appropriate Limited N/A N/A 5 5 0 0 1 0 6 2 0 0 0
References Study Quality
52 (24587819) 1
Endoscopic US-guided biliary drainage (EUS-BD) Usually not appropriate Expert Consensus N/A N/A 3 3 0 0 0 0 0 0 0 0 0
Surgery Usually not appropriate Strong N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
58 (11907771) 2
46 (26689137) 4
59 (2799642) 2
Medical management only Usually not appropriate Limited N/A N/A 2 2 0 0 0 0 0 0 0 0 0
References Study Quality
46 (26689137) 4
Permanent biliary metallic stent Usually not appropriate Limited N/A N/A 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
52 (24587819) 1
Variant 4: Initial therapeutic procedure for a patient with bile leak and dilated bile ducts following laparoscopic cholecystectomy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
61 (23322833) 4
62 (20575884) 4
67 (24954866) 4
66 (19220666) 2
Percutaneous internal/external biliary catheter Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
61 (23322833) 4
68 (14759778) 2
69 (18922456) 4
Surgery May be appropriate Limited N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
67 (24954866) 4
68 (14759778) 2
69 (18922456) 4
Endoscopic US-guided biliary drainage (EUS-BD) Usually not appropriate Expert Consensus N/A N/A 1 1 0 0 0 0 0 0 0 0 0
Medical management only Usually not appropriate Expert Consensus N/A N/A 1 1 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate Expert Consensus N/A N/A 1 1 0 0 0 0 0 0 0 0 0
Removable biliary covered stent Usually not appropriate Limited N/A N/A 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
71 (24661988) 4
Variant 5: Initial therapeutic procedure for a patient with dilated bile ducts and suspected biliary sepsis or acute cholangitis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
79 (1371206) 3
80 (9336514) 4
81 (28834389) 1
Percutaneous internal/external biliary catheter Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
69 (18922456) 4
77 (28419764) 4
Endoscopic US-guided biliary drainage (EUS-BD) May be appropriate Limited N/A N/A 4 4 0 0 0 0 0 0 0 0 0
References Study Quality
88 (27122677) 4
Medical management only Usually not appropriate Expert Consensus N/A N/A 2 2 0 0 0 0 0 0 0 0 0
Removable biliary covered stent Usually not appropriate Expert Consensus N/A N/A 2 2 0 0 0 0 0 0 0 0 0
Surgery Usually not appropriate Limited N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
79 (1371206) 3
80 (9336514) 4
Permanent biliary metallic stent Usually not appropriate Limited N/A N/A 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
81 (28834389) 1
Variant 6: Initial therapeutic procedure for a patient with malignant common bile duct obstruction (eg, pancreatic carcinoma).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
95 (26290631) 4
96 (22415652) 1
Percutaneous internal/external biliary catheter Usually appropriate Strong N/A N/A 7 7 0 0 0 0 0 0 0 0 0
References Study Quality
109 (25148939) Good
110 (19609609) 3
111 (24064748) 3
112 (12354980) 1
Percutaneous biliary metallic stent May be appropriate Strong N/A N/A 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
95 (26290631) 4
96 (22415652) 1
97 (16650542) 4
90 (26911896) 4
98 (20467870) 1
99 (21034892) 1
Removable biliary covered stent May be appropriate Strong N/A N/A 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
90 (26911896) 4
98 (20467870) 1
99 (21034892) 1
Surgery May be appropriate Strong N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
113 (21068488) 2
114 (19606687) 2
115 (-3138827) Good
116 (16632990) 4
Endoscopic US-guided biliary drainage (EUS-BD) May be appropriate Strong N/A N/A 4 4 0 0 0 0 0 0 0 0 0
References Study Quality
104 (21963067) 3
105 (23523301) 2
106 (23021167) 3
107 (22810111) 1
Medical management only Usually not appropriate Limited N/A N/A 3 3 0 0 0 0 0 0 0 0 0
References Study Quality
89 (26322156) 4
Variant 7: Initial therapeutic procedure for a patient with hilar biliary obstruction from malignant etiology (eg, Klatskin tumor).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous internal/external biliary catheter Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
118 (15922889) 2
119 (19756881) 2
120 (18585976) 1
121 (18657806) 2
122 (16437689) 3
Endoscopic internal biliary catheter (removable plastic stent) May be appropriate Strong N/A N/A 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
118 (15922889) 2
119 (19756881) 2
120 (18585976) 1
121 (18657806) 2
122 (16437689) 3
Permanent biliary metallic stent May be appropriate Expert Consensus N/A N/A 6 6 0 0 0 0 0 0 0 0 0
Removable biliary covered stent May be appropriate Expert Consensus N/A N/A 5 5 0 0 0 0 0 0 0 0 0
Surgery May be appropriate Expert Consensus N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Endoscopic US-guided biliary drainage (EUS-BD) Usually not appropriate Limited N/A N/A 3 3 0 0 0 0 0 0 0 0 0
References Study Quality
124 (25264761) 2
123 (25024600) 4
125 (23711555) 4
126 (26379410) 4
Medical management only Usually not appropriate Strong N/A N/A 2 2 0 0 0 0 0 0 0 0 0
References Study Quality
117 (17461441) 4
118 (15922889) 2
119 (19756881) 2
Variant 8: Initial therapeutic procedure for a patient with dilated bile ducts and coagulopathy (INR >2.0 or platelet count <60 K).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
128 (18042116) 4
81 (28834389) 1
Percutaneous internal/external biliary catheter May be appropriate Limited N/A N/A 6 6 0 0 0 0 0 0 0 0 0
References Study Quality
129 (20307987) 4
130 (22864606) 3
81 (28834389) 1
Medical management only May be appropriate Expert Consensus N/A N/A 4 4 0 0 0 0 0 0 0 0 0
Endoscopic US-guided biliary drainage (EUS-BD) Usually not appropriate Expert Consensus N/A N/A 3 3 0 0 0 0 0 0 0 0 0
Removable biliary covered stent Usually not appropriate Expert Consensus N/A N/A 2 2 0 0 0 0 0 0 0 0 0
Surgery Usually not appropriate Expert Consensus N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate Expert Consensus N/A N/A 1 1 0 0 0 0 0 0 0 0 0
Variant 9: Initial therapeutic procedure for a patient with dilated bile ducts and moderate to massive ascites.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 0 0 0
References Study Quality
133 (22464717) 2
Percutaneous internal/external biliary catheter May be appropriate Limited N/A N/A 5 5 0 0 0 0 0 0 0 0 0
References Study Quality
133 (22464717) 2
Medical management only May be appropriate Limited N/A N/A 4 4 0 0 0 0 0 0 0 0 0
References Study Quality
131 (6606961) 4
132 (24433643) 3
133 (22464717) 2
Removable biliary covered stent May be appropriate Expert Consensus N/A N/A 4 4 0 0 0 0 0 0 0 0 0
Endoscopic US-guided biliary drainage (EUS-BD) Usually not appropriate Limited N/A N/A 3 3 0 0 0 0 0 0 0 0 0
References Study Quality
134 (26811666) 4
135 (27129552) 2
Permanent biliary metallic stent Usually not appropriate Expert Consensus N/A N/A 2 2 0 0 0 0 0 0 0 0 0
Surgery Usually not appropriate Expert Consensus N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.