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Appropriateness Criteria

Variant 1: Incidentally detected pancreatic cyst less than or equal to 2.5 cm in size. Initial evaluation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast with MRCP Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 4 11
References Study Quality
23 (26811661) 4
6 (24690615) 4
3 (22534872) 4
7 (28533111) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
22 (19696285) 2
18 (17659551) 2
24 (21356393) 2
MRI abdomen without IV contrast with MRCP May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 1 0 2 5 2 4 1
References Study Quality
23 (26811661) 4
6 (24690615) 4
3 (22534872) 4
7 (28533111) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
22 (19696285) 2
18 (17659551) 2
24 (21356393) 2
CT abdomen with IV contrast multiphase May be appropriate Strong ☢☢☢☢ 10-30 mSv 6 6 0 0 0 0 4 4 4 3 0
References Study Quality
6 (24690615) 4
3 (22534872) 4
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
15 (16436817) 2
19 (-3141673) 4
20 (24355035) 4
21 (22347959) 4
22 (19696285) 2
18 (17659551) 2
US abdomen endoscopic Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 4 4 0 2 2 0 0 0
References Study Quality
25 (27523971) 4
26 (25798910) 3
6 (24690615) 4
27 (22744342) 3
17 (19767045) 3
CT abdomen without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 1 4 8 2 0 0 0 0 0
References Study Quality
6 (24690615) 4
3 (22534872) 4
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
15 (16436817) 2
19 (-3141673) 4
20 (24355035) 4
21 (22347959) 4
22 (19696285) 2
18 (17659551) 2
CT abdomen without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 5 7 2 0 0 0 0 0
References Study Quality
6 (24690615) 4
3 (22534872) 4
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
15 (16436817) 2
19 (-3141673) 4
20 (24355035) 4
21 (22347959) 4
22 (19696285) 2
18 (17659551) 2
Variant 2: Incidentally detected pancreatic cyst greater than 2.5 cm in size. No high-risk stigmata or worrisome features. Initial evaluation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast with MRCP Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 1 2 11
References Study Quality
23 (26811661) 4
6 (24690615) 4
3 (22534872) 4
7 (28533111) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
18 (17659551) 2
24 (21356393) 2
US abdomen endoscopic May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 0 6 3 1 2 2
References Study Quality
25 (27523971) 4
14 (27161060) 3
26 (25798910) 3
28 (24188361) 3
17 (19767045) 3
7 (28533111) 4
13 (28735806) 4
9 (25805375) 4
MRI abdomen without IV contrast with MRCP May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 1 0 1 6 0 4 3
References Study Quality
23 (26811661) 4
6 (24690615) 4
3 (22534872) 4
7 (28533111) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
18 (17659551) 2
24 (21356393) 2
CT abdomen with IV contrast multiphase May be appropriate Strong ☢☢☢☢ 10-30 mSv 6 6 0 0 0 0 3 6 3 3 0
References Study Quality
6 (24690615) 4
3 (22534872) 4
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
15 (16436817) 2
19 (-3141673) 4
20 (24355035) 4
21 (22347959) 4
22 (19696285) 2
18 (17659551) 2
CT abdomen without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 1 2 10 2 0 0 0 0 0
References Study Quality
6 (24690615) 4
3 (22534872) 4
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
15 (16436817) 2
19 (-3141673) 4
20 (24355035) 4
21 (22347959) 4
22 (19696285) 2
18 (17659551) 2
CT abdomen without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 3 6 5 2 1 0 0 0 0
References Study Quality
6 (24690615) 4
3 (22534872) 4
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
15 (16436817) 2
19 (-3141673) 4
20 (24355035) 4
21 (22347959) 4
22 (19696285) 2
18 (17659551) 2
Variant 3: Incidentally detected pancreatic cyst greater than 2.5 cm in size. High-risk stigmata or worrisome features. Initial evaluation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US abdomen endoscopic Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 3 12
References Study Quality
25 (27523971) 4
26 (25798910) 3
28 (24188361) 3
30 (24068205) 4
29 (21689229) 3
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
31 (25805376) 4
MRI abdomen without and with IV contrast with MRCP Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 5 1 3 5
References Study Quality
23 (26811661) 4
14 (27161060) 3
6 (24690615) 4
8 (22687371) 4
9 (25805375) 4
22 (19696285) 2
24 (21356393) 2
MRI abdomen without IV contrast with MRCP May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 1 2 9 2 2 0 1
References Study Quality
23 (26811661) 4
14 (27161060) 3
6 (24690615) 4
8 (22687371) 4
9 (25805375) 4
22 (19696285) 2
24 (21356393) 2
CT abdomen with IV contrast multiphase May be appropriate Limited ☢☢☢☢ 10-30 mSv 6 6 0 0 1 1 5 4 0 4 0
References Study Quality
14 (27161060) 3
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
19 (-3141673) 4
20 (24355035) 4
21 (22347959) 4
CT abdomen without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 6 2 0 0 0 0 0
References Study Quality
14 (27161060) 3
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
19 (-3141673) 4
20 (24355035) 4
21 (22347959) 4
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 1 6 5 2 3 0 0 0 0
References Study Quality
14 (27161060) 3
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
19 (-3141673) 4
20 (24355035) 4
21 (22347959) 4
Variant 4: Incidentally detected main pancreatic duct dilation greater than 7 mm in size. Suspected main duct intraductal papillary mucinous neoplasm (IPMN). Initial evaluation.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US abdomen endoscopic Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 0 0 0 3 11
References Study Quality
32 (23022726) 4
1 (22520033) 4
7 (28533111) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
MRI abdomen without and with IV contrast with MRCP Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 3 3 2 6
References Study Quality
6 (24690615) 4
32 (23022726) 4
1 (22520033) 4
7 (28533111) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
22 (19696285) 2
MRI abdomen without IV contrast with MRCP Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 1 0 0 1 3 10 1 1
References Study Quality
6 (24690615) 4
32 (23022726) 4
1 (22520033) 4
7 (28533111) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
22 (19696285) 2
CT abdomen with IV contrast multiphase May be appropriate Limited ☢☢☢☢ 10-30 mSv 5 5 0 0 0 4 5 3 3 0 0
References Study Quality
32 (23022726) 4
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
CT abdomen without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 4 5 2 0 0 0 0 0
References Study Quality
32 (23022726) 4
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 1 3 4 4 2 1 0 0 0
References Study Quality
32 (23022726) 4
1 (22520033) 4
7 (28533111) 4
13 (28735806) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
Variant 5: Follow-up imaging of pancreatic cyst.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast with MRCP Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 2 1 5 6
References Study Quality
14 (27161060) 3
26 (25798910) 3
7 (28533111) 4
8 (22687371) 4
9 (25805375) 4
33 (19098196) 2
34 (27246720) 2
MRI abdomen without IV contrast with MRCP Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 3 4 5 2
References Study Quality
14 (27161060) 3
26 (25798910) 3
7 (28533111) 4
8 (22687371) 4
9 (25805375) 4
33 (19098196) 2
34 (27246720) 2
CT abdomen with IV contrast multiphase Usually appropriate Limited ☢☢☢☢ 10-30 mSv 8 8 0 0 0 2 1 2 2 8 0
References Study Quality
7 (28533111) 4
8 (22687371) 4
9 (25805375) 4
US abdomen endoscopic Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 2 9 0 2 0 0 0 0
References Study Quality
7 (28533111) 4
10 (16327281) 4
8 (22687371) 4
9 (25805375) 4
CT abdomen without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 1 6 2 1 1 0 0 0
References Study Quality
7 (28533111) 4
8 (22687371) 4
9 (25805375) 4
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 5 9 0 0 0 0 0 0
References Study Quality
7 (28533111) 4
8 (22687371) 4
9 (25805375) 4
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.