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Appropriateness Criteria

Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. 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] 7 7 0 1 0 1 2 1 6 6 0
References Study Quality
9 (23484989) 3
25 (23357727) 1
24 (16929022) 4
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 1 6 10
References Study Quality
21 (26055000) 3
9 (23484989) 3
22 (22284309) 3
CT abdomen and pelvis without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 1 0 0 0 1 2 5 5 3
References Study Quality
21 (26055000) 3
9 (23484989) 3
22 (22284309) 3
MRI abdomen without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 1 2 7 3 3 0 0
MRI abdomen without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 7 8 0 0 0
US pelvis Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 4 3 7 1 0 1 0 0 0
Fluoroscopy upper GI series Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 5 8 2 2 0 0 0 0 0
Fluoroscopy upper GI series with small bowel follow-through Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 3 4 6 0 0 0 0 0
References Study Quality
23 (16702448) 4
Radiography abdomen and pelvis Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 3 4 4 2 3 1 0 0 0
MRI pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 3 4 3 2 4 1 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 3 6 3 1 2 1 0 1 0
References Study Quality
21 (26055000) 3
9 (23484989) 3
22 (22284309) 3
Variant 2: Suspected groin hernia such as inguinal or femoral. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pelvis Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 5 3 8 1
References Study Quality
30 (22983696) Inadequate
39 (30340247) 3
40 (29761361) Good
45 (28812139) 3
44 (26657750) 3
42 (25944106) 3
37 (24407858) 3
38 (25094024) 3
43 (23559310) 4
41 (23341392) Good
36 (21059415) 3
MRI pelvis without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 7 7 1 0
References Study Quality
26 (28856355) 3
32 (25141884) 3
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 2 0 1 2 1 7 4
References Study Quality
32 (25141884) 3
31 (22733195) 4
CT abdomen and pelvis without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 0 3 5 8 0
References Study Quality
32 (25141884) 3
31 (22733195) 4
CT pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 0 2 6 5 4
References Study Quality
33 (31243553) 4
CT pelvis without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 1 0 0 1 4 4 7 0
References Study Quality
33 (31243553) 4
MRI pelvis without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 2 5 6 1 1
References Study Quality
26 (28856355) 3
32 (25141884) 3
Fluoroscopy small bowel follow-through Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 3 5 4 1 0 0 0 0
Radiography abdomen and pelvis Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 2 8 3 1 1 2 0 0 0
References Study Quality
32 (25141884) 3
31 (22733195) 4
CT pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 2 7 4 0 2 1 0 1 0
References Study Quality
33 (31243553) 4
Variant 3: Suspected deep pelvic hernia including obturator, sciatic, or perineal. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI pelvis without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 4 2 7 1 1
References Study Quality
54 (31501395) 4
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 1 0 0 1 2 7 5
References Study Quality
47 (22138700) 4
51 (24078001) 4
53 (26985818) 4
CT abdomen and pelvis without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 1 4 7 4 0
References Study Quality
47 (22138700) 4
51 (24078001) 4
53 (26985818) 4
CT pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 0 1 5 7 3
References Study Quality
47 (22138700) 4
51 (24078001) 4
53 (26985818) 4
CT pelvis without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 4 4 5 3 0
References Study Quality
47 (22138700) 4
51 (24078001) 4
53 (26985818) 4
MRI pelvis without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 4 5 4 1 2
References Study Quality
54 (31501395) 4
US pelvis Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 1 4 7 1 2 1 0 0 0
Fluoroscopy small bowel follow-through Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 5 3 4 1 0 0 0 0
Radiography abdomen and pelvis Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 n/a 0 0 0 0 0 0 0 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 3 3 1 1 0 1 0
References Study Quality
47 (22138700) 4
51 (24078001) 4
53 (26985818) 4
CT pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 1 6 9 0 0 0 0 0 0
References Study Quality
47 (22138700) 4
51 (24078001) 4
53 (26985818) 4
Variant 4: Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest and abdomen with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 9 9 0 0 0 0 0 0 1 6 9
References Study Quality
62 (30157820) 4
61 (28135794) 4
63 (26705205) 4
68 (26303737) 4
69 (21951119) 4
59 (20039230) 4
60 (19242298) 4
67 (15899350) 4
65 (26105131) 3
66 (26100355) 3
64 (30539157) 4
CT chest and abdomen without IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 0 1 0 2 2 4 5 2
References Study Quality
62 (30157820) 4
61 (28135794) 4
63 (26705205) 4
68 (26303737) 4
69 (21951119) 4
59 (20039230) 4
60 (19242298) 4
67 (15899350) 4
65 (26105131) 3
66 (26100355) 3
64 (30539157) 4
Radiography chest May be appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 5 0 0 0 1 9 3 3 0 0
References Study Quality
62 (30157820) 4
61 (28135794) 4
63 (26705205) 4
68 (26303737) 4
60 (19242298) 4
67 (15899350) 4
72 (22936226) 3
71 (29052830) 4
Fluoroscopy upper GI series May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 1 2 5 4 2 1 1 0 0
References Study Quality
61 (28135794) 4
63 (26705205) 4
MRI chest and abdomen without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 3 6 2 3 1 0
References Study Quality
69 (21951119) 4
67 (15899350) 4
70 (22090330) 4
MRI chest and abdomen without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 4 4 3 2 2 0
References Study Quality
69 (21951119) 4
67 (15899350) 4
70 (22090330) 4
US abdomen Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 2 6 3 2 0 1 0 0
References Study Quality
67 (15899350) 4
Fluoroscopy upper GI series with small bowel follow-through Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 2 4 4 1 1 1 0 0
Radiography abdomen and pelvis Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
CT chest and abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 2 8 6 0 0 0 0 0 0
References Study Quality
62 (30157820) 4
61 (28135794) 4
63 (26705205) 4
68 (26303737) 4
69 (21951119) 4
59 (20039230) 4
60 (19242298) 4
67 (15899350) 4
65 (26105131) 3
66 (26100355) 3
64 (30539157) 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.