ACR logo

Appropriateness Criteria

Variant 1: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 1 0 0 1 4 15
References Study Quality
8 (21215552) 2
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 0 5 8 5 5 0
References Study Quality
6 (32971451) 2
7 (25468363) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 1 8 10 1 1 1
References Study Quality
6 (32971451) 2
7 (25468363) 4
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 1 1 1 0 1 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 1 2 0 1 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 3 0 1 0 1 1 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 2 0 0 0 0 0 0 0
Variant 2: Suspected or confirmed sepsis. Cough or dyspnea or chest pain. Normal or equivocal or nonspecific chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 2 0 4 6 9
References Study Quality
6 (32971451) 2
7 (25468363) 4
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 1 0 2 3 1 9 5
References Study Quality
6 (32971451) 2
7 (25468363) 4
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 3 1 1 0 2 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 3 1 1 2 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 2 3 0 2 0 0 1 1
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 4 0 2 5 1 1 0 0
References Study Quality
12 (33827655) 2
11 (30788532) 2
10 (22176803) 2
9 (23776621) 2
Variant 3: Suspected or confirmed sepsis. Acute abdominal pain. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 2 0 1 9 9
References Study Quality
13 (6600545) 4
7 (25468363) 4
6 (32971451) 2
US abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 4 6 8 1 1
References Study Quality
18 (23422051) 4
17 (26441019) 4
16 (11307365) 4
15 (26754121) 4
13 (6600545) 4
CT abdomen and pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 2 0 2 6 7 3 3 0
References Study Quality
6 (32971451) 2
7 (25468363) 4
Radiography abdomen Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 4 11 4 4 0 0 0 0 0
References Study Quality
15 (26754121) 4
16 (11307365) 4
Fluoroscopy contrast enema Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 2 2 0 1 0 0 0 0
Fluoroscopy upper GI series with small bowel follow-through Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 2 1 1 1 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 6 3 2 1 2 0 0 0
References Study Quality
14 (32072724) 4
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 6 0 2 1 0 0 0 0
Nuclear medicine scan gallbladder Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 14 4 1 0 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] 2 2 11 10 2 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 3 1 0 0 0 0 0 0
WBC scan abdomen and pelvis Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 13 5 0 2 1 0 0 0 0
Variant 4: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 7 7 0 1 0 1 0 0 13 4 4
References Study Quality
8 (21215552) 2
US abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 2 0 0 8 11 2 0 0
References Study Quality
18 (23422051) 4
17 (26441019) 4
16 (11307365) 4
15 (26754121) 4
13 (6600545) 4
CT abdomen and pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 2 7 5 3 5 0
References Study Quality
6 (32971451) 2
7 (25468363) 4
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 1 7 7 5 2 0
References Study Quality
6 (32971451) 2
7 (25468363) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 5 2 4 7 2 0
References Study Quality
6 (32971451) 2
7 (25468363) 4
CT chest abdomen pelvis with IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 0 5 9 0 7 1
References Study Quality
6 (32971451) 2
7 (25468363) 4
CT chest abdomen pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 4 6 7 0 2 3 1 0 0
References Study Quality
6 (32971451) 2
7 (25468363) 4
Radiography abdomen Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 7 7 4 5 0 0 0 0 0
References Study Quality
15 (26754121) 4
16 (11307365) 4
Fluoroscopy contrast enema Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 2 2 0 0 0 0 0 0
Fluoroscopy upper GI series with small bowel follow-through Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 2 1 1 0 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 9 4 3 2 1 1 0 1 0
References Study Quality
14 (32072724) 4
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 9 6 2 3 0 0 1 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 3 0 1 0 1 1 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 2 0 2 0 1 0 0 0
Nuclear medicine scan gallbladder Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 14 2 3 0 1 1 0 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 7 5 1 6 1 1 0 0
References Study Quality
6 (32971451) 2
7 (25468363) 4
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 2 3 0 0 0 1 1
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 7 5 4 3 0 0 1 0 1
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 10 10 3 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 3 2 0 1 0 0 0 0
WBC scan abdomen and pelvis Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 15 1 3 2 0 0 0 0 0
Variant 5: Suspected or confirmed sepsis. No specific symptoms suggestive of origin, or symptoms cannot be assessed. Normal or equivocal or nonspecific chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 2 5 3 9 2
References Study Quality
6 (32971451) 2
7 (25468363) 4
13 (6600545) 4
US abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 2 0 3 9 6 2 0 0
References Study Quality
18 (23422051) 4
17 (26441019) 4
16 (11307365) 4
15 (26754121) 4
13 (6600545) 4
CT abdomen and pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 4 6 5 0 3 5 0 0 0
References Study Quality
6 (32971451) 2
7 (25468363) 4
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 1 1 0 0 5 8 7 1 0
References Study Quality
6 (32971451) 2
7 (25468363) 4
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 1 0 1 1 3 5 8 1 1
References Study Quality
6 (32971451) 2
7 (25468363) 4
CT chest abdomen pelvis with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 2 0 0 3 9 2 5 1
References Study Quality
6 (32971451) 2
7 (25468363) 4
CT chest abdomen pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 3 7 6 1 1 5 0 0 0
References Study Quality
6 (32971451) 2
7 (25468363) 4
Radiography abdomen Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 8 8 6 1 0 0 0 0 0
References Study Quality
15 (26754121) 4
16 (11307365) 4
Fluoroscopy contrast enema Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 2 2 0 0 0 0 0 0
Fluoroscopy upper GI series with small bowel follow-through Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 2 1 1 0 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 7 6 1 1 1 1 0 0
MRI abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 7 6 2 0 0 0 1 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 10 7 1 1 0 1 0 1 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 10 7 1 2 0 0 1 0 0
Nuclear medicine scan gallbladder Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 14 3 1 1 0 2 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 3 1 1 0 0 0 2
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 13 9 1 0 0 0 0 0 0
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 12 11 0 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 5 6 4 0 0 1 0 0
References Study Quality
12 (33827655) 2
11 (30788532) 2
10 (22176803) 2
9 (23776621) 2
WBC scan abdomen and pelvis Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 7 7 4 4 1 0 0 0 0
References Study Quality
22 (16404232) 2
21 (2112472) 4
20 (8583440) 4
19 (-3196415) 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.