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Appropriateness Criteria

Variant 1: Epigastric pain with clinical suspicion for acid reflux or esophagitis or gastritis or peptic ulcer or duodenal ulcer. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy biphasic esophagram Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 1 0 0 0 1 0 4 12 2
References Study Quality
6 (23973101) 4
14 (16170017) 4
15 (6828761) 2
16 (6771981) 3
Fluoroscopy upper GI series Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 0 1 0 2 1 2 8 4
References Study Quality
17 (18096527) 4
Fluoroscopy single contrast esophagram May be appropriate Limited ☢☢☢ 1-10 mSv 6 6 1 0 0 0 3 7 8 1 0
References Study Quality
12 (26562229) 4
CT abdomen and pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 0 6 10 2 1 0
References Study Quality
12 (26562229) 4
8 (29571554) 4
9 (29190519) 3
11 (26598795) 3
7 (25117561) 4
10 (22277022) 4
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 2 4 6 4 2 0 0 0
References Study Quality
12 (26562229) 4
8 (29571554) 4
9 (29190519) 3
11 (26598795) 3
7 (25117561) 4
10 (22277022) 4
CT abdomen with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 2 5 6 4 3 0 0
References Study Quality
12 (26562229) 4
MRI abdomen without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 5 4 1 1 0 1 0 1
MRI abdomen without and with IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 9 1 4 1 1 0 1 0 1
MRI abdomen without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 5 3 2 0 1 1 0 0
MRI abdomen without IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 9 2 3 2 0 1 0 1 0
CT abdomen without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 3 6 5 3 1 0 0 0
References Study Quality
12 (26562229) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 5 5 6 1 0 0 0 0 1
References Study Quality
12 (26562229) 4
8 (29571554) 4
9 (29190519) 3
11 (26598795) 3
7 (25117561) 4
10 (22277022) 4
CT abdomen with IV contrast multiphase Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 3 3 3 5 2 3 4 0 0 0 1
References Study Quality
12 (26562229) 4
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 6 3 5 1 3 0 0 0 0
References Study Quality
12 (26562229) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 2 0 0 0 0 0 2
References Study Quality
13 (22919350) 3
Variant 2: Epigastric pain with clinical suspicion for gastric cancer. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy upper GI series Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 1 0 1 0 1 4 4 7 0
References Study Quality
17 (18096527) 4
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 1 0 0 1 2 2 9 3
References Study Quality
12 (26562229) 4
8 (29571554) 4
19 (26280126) 4
7 (25117561) 4
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 0 3 5 5 2 0 0 1
References Study Quality
12 (26562229) 4
8 (29571554) 4
19 (26280126) 4
7 (25117561) 4
CT abdomen with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 2 0 3 3 10 1 0
References Study Quality
12 (26562229) 4
19 (26280126) 4
CT abdomen without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 3 3 7 3 2 0 0 0
References Study Quality
12 (26562229) 4
19 (26280126) 4
CT abdomen with IV contrast multiphase May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 2 0 5 4 5 0 1 0 1
References Study Quality
12 (26562229) 4
Fluoroscopy biphasic esophagram Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 9 4 6 0 0 0 0 0 1
Fluoroscopy single contrast esophagram Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 9 2 4 1 1 0 0 0 1
MRI abdomen without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 13 2 0 0 0 0 0 0
MRI abdomen without and with IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 11 2 0 0 0 0 0 0
MRI abdomen without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 11 2 0 0 0 0 0 0
MRI abdomen without IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 4 3 0 2 1 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 2 5 4 1 4 0 1 0 1
References Study Quality
12 (26562229) 4
8 (29571554) 4
19 (26280126) 4
7 (25117561) 4
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 3 7 3 2 2 0 1 0 0
References Study Quality
12 (26562229) 4
19 (26280126) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 9 3 0 0 0 0 0 0
Variant 3: Epigastric pain with clinical suspicion for hiatal hernia. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy biphasic esophagram Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 1 0 0 0 0 1 4 9 5
References Study Quality
21 (29713739) 4
23 (29063954) 4
6 (23973101) 4
22 (19756887) 3
14 (16170017) 4
15 (6828761) 2
16 (6771981) 3
Fluoroscopy single contrast esophagram Usually appropriate Limited ☢☢☢ 1-10 mSv 7 7 0 0 0 0 0 2 13 4 1
References Study Quality
14 (16170017) 4
Fluoroscopy upper GI series Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 0 0 0 0 1 5 11 3
References Study Quality
6 (23973101) 4
14 (16170017) 4
17 (18096527) 4
MRI abdomen without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 4 2 0 0 0 1 0 0
MRI abdomen without and with IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 1 2 0 0 0 0 2
MRI abdomen without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 2 1 1 0 1 0 1
MRI abdomen without IV contrast with MRCP Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 2 1 0 0 0 0 2
CT abdomen and pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 7 2 2 3 2 1 0 0 1
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 5 1 4 0 0 0 0 1
CT abdomen with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 2 2 2 2 0 2 0 0
CT abdomen without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 7 1 3 5 1 1 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 11 4 1 0 0 0 0 1 1
CT abdomen with IV contrast multiphase Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 11 2 3 0 0 0 1 0 1
CT abdomen without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 9 5 2 0 0 1 0 1 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 1 0 0 0 0 0 2
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.