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Appropriateness Criteria

Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US abdomen Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 5 8
References Study Quality
14 (19304694) 4
13 (19716568) 4
11 (20574093) 2
10 (20185194) 3
9 (12198701) 3
8 (21618575) Good
7 (24381873) 4
6 (24849827) 4
12 (26673807) 4
US duplex Doppler abdomen Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 1 11 2 1
References Study Quality
16 (9694471) 3
17 (24829735) 4
US shear wave elastography abdomen May be appropriate Moderate O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 1 8 5 1 0
References Study Quality
18 (24476011) Good
MR elastography abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 0 0 4 9 1 0 0 0
References Study Quality
27 (21460032) 4
MRI abdomen without and with IV contrast with MRCP May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 1 4 1 3 5 1 0 0
MRI abdomen without IV contrast with MRCP May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 1 0 1 0 3 5 5 0 1
References Study Quality
33 (20594607) 3
32 (21997548) 4
31 (25086936) 4
30 (22025886) 4
29 (22923718) 3
28 (23382293) 4
11 (20574093) 2
10 (20185194) 3
9 (12198701) 3
CT abdomen and pelvis without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 3 2 2 7 0 0 0 0
References Study Quality
24 (25914777) 4
23 (17185663) 4
22 (9252082) 3
21 (17449775) 3
20 (16484355) 2
19 (22733892) 3
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 1 7 2 2 0 0 0 0
References Study Quality
15 (25068001) 3
CT abdomen and pelvis with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 1 4 9 1 0 0 0 0 0
References Study Quality
26 (30190781) 4
25 (9663278) 3
20 (16484355) 2
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 6 0 9 0 0 0 0 0 0
Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US abdomen Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 5 2 9
References Study Quality
59 (15256619) 4
58 (7403553) 4
57 (7054838) 4
56 (25444098) 4
55 (3881796) 4
54 (31054739) 4
US duplex Doppler abdomen Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 1 8 4 2
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 0 3 10 2 0
References Study Quality
40 (15851049) 3
39 (21410060) 4
38 (8539386) 3
37 (23674857) 3
MRI abdomen without and with IV contrast with MRCP May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 3 6 4 2 0
References Study Quality
51 (25030459) 3
53 (33081713) 4
52 (33034671) 4
50 (28266528) 4
49 (8610556) 4
48 (20010061) 4
47 (10358327) 4
46 (2704798) 4
45 (15503331) 3
44 (9672968) 4
43 (24808418) 4
38 (8539386) 3
MRI abdomen without IV contrast with MRCP May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 3 2 7 3 0 0
References Study Quality
53 (33081713) 4
52 (33034671) 4
51 (25030459) 3
50 (28266528) 4
49 (8610556) 4
48 (20010061) 4
47 (10358327) 4
46 (2704798) 4
45 (15503331) 3
44 (9672968) 4
43 (24808418) 4
38 (8539386) 3
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 1 3 3 5 2 1 0 0
References Study Quality
40 (15851049) 3
39 (21410060) 4
38 (8539386) 3
37 (23674857) 3
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 2 6 2 1 2 0 0 0
References Study Quality
60 (23137926) 4
US shear wave elastography abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 2 4 9 0 0 0 0 0 0
MR elastography abdomen Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 4 3 1 1 1 1 0 0
References Study Quality
41 (23837611) 3
42 (24166665) 3
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 0 5 1 5 1 0 0 0
References Study Quality
40 (15851049) 3
39 (21410060) 4
38 (8539386) 3
37 (23674857) 3
Variant 3: Abnormal liver function tests. Cholestatic predominance. Elevated alkaline phosphatase with or without elevated gamma-glutamyl transpeptidase. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US abdomen Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 3 3 10
References Study Quality
73 (25719223) M
72 (26895915) 4
71 (24124333) 4
70 (22071641) 3
65 (18722735) 4
MRI abdomen without and with IV contrast with MRCP Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 1 5 4 4 1
References Study Quality
66 (26205638) 3
65 (18722735) 4
64 (24780789) 3
51 (25030459) 3
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 1 1 2 2 6 4 0
References Study Quality
63 (28154908) 3
US duplex Doppler abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 0 1 3 4 6 1 0 0 0
References Study Quality
74 (30347616) 4
MRI abdomen without IV contrast with MRCP May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 4 5 5 0 1
References Study Quality
69 (21765298) 4
68 (22160649) 3
67 (25001391) 4
CT abdomen and pelvis without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 0 2 5 6 0 0 0 0
US abdomen with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 6 2 5 2 0 0 1 0 0
US shear wave elastography abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 5 3 5 1 2 0 0 0 0
MR elastography abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 5 2 6 1 2 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 3 9 0 0 0 0 0 0
Variant 4: Abnormal liver functions tests. Hyperbilirubinemia. Acute or subacute cholestasis. Conjugated or unconjugated. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US abdomen Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 4 11
References Study Quality
81 (25305349) 4
MRI abdomen without and with IV contrast with MRCP Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 0 2 7 4 2
References Study Quality
54 (31054739) 4
80 (29101993) 4
MRI abdomen without IV contrast with MRCP Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 4 3 8 0 1
References Study Quality
54 (31054739) 4
80 (29101993) 4
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 1 1 1 4 4 5 0
References Study Quality
79 (20524442) 3
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 1 3 5 3 3 0 0 0
References Study Quality
79 (20524442) 3
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 3 4 2 0 1 0 0 0
References Study Quality
54 (31054739) 4
US duplex Doppler abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 1 2 12 0 0 0 0 0 0
US shear wave elastography abdomen Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 4 2 9 0 0 0 0 0 0
References Study Quality
18 (24476011) Good
MR elastography abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 5 3 4 2 1 0 1 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 0 5 1 5 1 0 0 0
References Study Quality
79 (20524442) 3
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.