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Appropriateness Criteria

Variant 1: Patient with right lower quadrant abdominal pain, fever, and leukocytosis for 7 days. Physical examination shows no peritoneal signs. CT scan shows a thin-walled fluid collection, greater than 3 cm, adjacent to the cecum, nonvisualization of the appendix, and an appendicolith. Imaging findings are highly suspicious for appendicitis. Treatment includes antibiotics.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous catheter drainage only Usually appropriate Strong N/A N/A 8 8 0 0 1 0 1 3 1 6 1
References Study Quality
12 (10826415) 3
13 (8320186) 3
11 (12093344) 2
14 (12525909) 3
8 (22821308) 2
15 (23575402) 2
2 (24293807) 4
9 (28151844) 3
10 (16091990) 3
Percutaneous catheter drainage followed by delayed surgery Usually appropriate Strong N/A N/A 7 7 0 0 0 0 1 3 3 3 3
References Study Quality
17 (20149402) Inadequate
26 (22249438) 2
16 (16175691) 3
20 (17390174) 4
22 (22052039) 2
23 (11867780) 4
24 (17032194) 2
25 (21286921) 4
18 (27756361) 3
19 (29431586) 4
21 (29361105) 4
Needle aspiration May be appropriate Limited N/A N/A 5 5 0 1 0 1 6 2 3 0 0
References Study Quality
28 (16498095) 3
27 (16322960) 2
2 (24293807) 4
Surgical drainage May be appropriate Limited N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
30 (6709901) 4
29 (21299091) 2
31 (29180172) 4
Conservative management only Usually not appropriate Limited N/A N/A 3 3 1 4 5 1 2 1 0 0 0
References Study Quality
28 (16498095) 3
27 (16322960) 2
2 (24293807) 4
Variant 2: Patient with a history of left hemicolectomy 2 months ago for colon carcinoma. Two weeks after placement of a drain into an abdominal abscess; the patient presents with abdominal pain and fever. Drain output is 25 cc per day and the collection is unchanged in size by CT. Treatment includes antibiotics.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Catheter upsizing Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 3 7 3
References Study Quality
33 (20173165) 2
32 (14736682) 3
Intracavitary thrombolytic therapy and drainage Usually appropriate Strong N/A N/A 7 7 0 0 0 1 1 1 8 2 0
References Study Quality
40 (21482136) 4
34 (18372451) 4
36 (18309017) 3
37 (20036149) 4
38 (19190912) 1
39 (18503906) 1
41 (17867950) 1
35 (30202126) 4
Laparoscopic drainage May be appropriate Limited N/A N/A 6 6 0 0 0 0 3 11 0 0 0
References Study Quality
42 (11083215) 4
43 (15616752) 4
Open surgical drainage May be appropriate Limited N/A N/A 6 6 0 0 2 4 0 7 0 0 0
References Study Quality
46 (2479049) 4
44 (8607582) 4
45 (-3148208) 4
Continued antibiotics and drainage (no change in care) May be appropriate Limited N/A N/A 5 5 0 3 2 1 6 1 0 0 0
References Study Quality
47 (1719787) 2
48 (1627886) 4
23 (11867780) 4
Continued antibiotics and drain removal Usually not appropriate Limited N/A N/A 2 2 4 7 2 0 0 0 0 0 0
References Study Quality
2 (24293807) 4
Variant 3: Patient who is an intravenous drug abuser presents with fever and tachycardia and on imaging is found to have 2 noncommunicating splenic abscesses accessible percutaneously through a 1 cm rim of normal splenic tissue. Treatment includes antibiotics.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous catheter drainage only Usually appropriate Limited N/A N/A 8 8 0 0 0 1 0 1 4 7 0
References Study Quality
51 (16489650) 3
52 (16676856) 2
53 (20152354) 4
49 (21319348) 4
50 (30187605) 4
Splenectomy Usually appropriate Limited N/A N/A 7 7 0 0 0 0 0 6 8 0 0
References Study Quality
55 (29666665) 4
50 (30187605) 4
54 (19070526) 4
Needle aspiration May be appropriate Limited N/A N/A 6 6 0 0 0 1 4 7 1 0 0
References Study Quality
54 (19070526) 4
56 (30244225) 4
Conservative management only Usually not appropriate Limited N/A N/A 3 3 2 3 5 1 2 0 0 0 0
References Study Quality
55 (29666665) 4
57 (30326233) 4
Variant 4: Patient with abdominal pain radiating to the back 5 weeks after hospitalization for acute pancreatitis. Afebrile. CT scan shows a walled-off collection in the body of the pancreas indenting a broad portion of the body of the stomach, affecting the gastric outlet. The collection is percutaneously accessible with a 3-cm window. MR cholangiopancreatography shows a patent pancreatic duct.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic cystgastrostomy Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 1 12 0
References Study Quality
62 (11818936) 3
63 (10744807) 3
61 (23732774) 1
Percutaneous catheter drainage only May be appropriate Limited N/A N/A 6 6 0 0 0 0 3 4 3 3 0
References Study Quality
67 (8995072) 4
62 (11818936) 3
68 (1734573) 4
69 (3357953) 4
64 (1702557) 4
65 (24315454) 3
66 (30146334) 3
Surgical cystenterostomy May be appropriate Limited N/A N/A 6 6 0 0 1 0 5 2 3 1 1
References Study Quality
60 (26900288) 4
Percutaneous needle aspiration May be appropriate Limited N/A N/A 4 4 0 2 2 4 4 1 0 0 0
References Study Quality
73 (12607787) 4
74 (24955337) 4
75 (12911171) 4
Conservative management only Usually not appropriate Limited N/A N/A 3 3 0 3 4 3 2 0 1 0 0
References Study Quality
70 (11437038) 3
71 (17219288) 4
72 (10102326) 3
64 (1702557) 4
59 (27163588) 4
Variant 5: Patient with a 2 week history of cough, fever, and foul-smelling sputum. Worsening condition despite a full course of broad-spectrum antibiotics. Sputum cultures negative. CT scan shows a right lower lobe abscess. Treatment includes antibiotics.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous catheter drainage only May be appropriate Limited N/A N/A 6 6 0 1 0 0 1 5 2 3 1
References Study Quality
77 (1987590) 4
78 (3977469) 4
79 (21980735) 3
81 (21439848) 3
76 (26366400) 4
80 (22347342) 4
Surgery May be appropriate Limited N/A N/A 6 6 0 0 0 1 5 2 5 0 0
References Study Quality
76 (26366400) 4
82 (22361063) 4
Another course of antibiotics and postural drainage May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 0 4 4 2 0 3 1 0 0
References Study Quality
83 (17273583) 4
77 (1987590) 4
78 (3977469) 4
76 (26366400) 4
80 (22347342) 4
Needle aspiration Usually not appropriate Expert Consensus N/A N/A 3 3 0 0 7 2 3 1 0 0 0
Variant 6: Patient with a 3 week history of pneumonia, fever, dyspnea. Worsening condition despite a full course of broad-spectrum antibiotics. CT scan shows a loculated pleural collection with overlying pleural thickening (empyema). Treatment includes antibiotics.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous catheter drainage with administration of thrombolytic therapy Usually appropriate Moderate N/A N/A 8 8 0 0 0 0 1 1 4 3 4
References Study Quality
36 (18309017) 3
84 (28840000) Good
85 (28274565) 4
Video-assisted thoracic surgery decortication Usually appropriate Moderate N/A N/A 7 7 0 0 0 0 0 4 6 2 1
References Study Quality
84 (28840000) Good
87 (30370082) 4
Open decortication May be appropriate Moderate N/A N/A 6 6 0 0 0 3 2 6 1 1 0
References Study Quality
84 (28840000) Good
87 (30370082) 4
Needle aspiration Usually not appropriate Strong N/A N/A 3 3 2 3 4 2 0 1 1 0 0
References Study Quality
84 (28840000) Good
86 (22459772) Good
Another course of antibiotics and postural drainage Usually not appropriate Strong N/A N/A 2 2 1 9 1 0 1 0 1 0 0
References Study Quality
84 (28840000) Good
86 (22459772) Good
Variant 7: Woman of childbearing age with abdominal pain, fever, and leukocytosis. Marked tenderness on pelvic examination. CT scan shows a walled-off, probable tubo-ovarian abscess (TOA) greater than 3 cm. Treatment includes antibiotics.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Transabdominal percutaneous catheter drainage Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 3 10 1
References Study Quality
90 (12881584) 2
91 (12099560) 4
92 (10871453) 4
93 (9646800) 3
95 (15516608) 4
89 (15665222) 3
88 (27106643) 4
94 (26591964) 4
Transgluteal percutaneous catheter drainage Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 1 2 10 1
References Study Quality
90 (12881584) 2
91 (12099560) 4
92 (10871453) 4
93 (9646800) 3
95 (15516608) 4
89 (15665222) 3
88 (27106643) 4
94 (26591964) 4
Transrectal percutaneous catheter drainage Usually appropriate Limited N/A N/A 7 7 0 0 0 0 0 2 10 2 0
References Study Quality
90 (12881584) 2
91 (12099560) 4
92 (10871453) 4
93 (9646800) 3
95 (15516608) 4
89 (15665222) 3
98 (15219951) 4
88 (27106643) 4
94 (26591964) 4
Transvaginal percutaneous catheter drainage Usually appropriate Strong N/A N/A 7 7 0 0 0 0 0 1 8 5 0
References Study Quality
90 (12881584) 2
91 (12099560) 4
92 (10871453) 4
93 (9646800) 3
95 (15516608) 4
89 (15665222) 3
97 (19772677) 4
96 (22579130) 2
88 (27106643) 4
94 (26591964) 4
Transabdominal needle aspiration May be appropriate Expert Consensus N/A N/A 6 6 0 0 0 0 2 10 2 0 0
Transgluteal needle aspiration May be appropriate Expert Consensus N/A N/A 6 6 0 0 0 0 2 10 2 0 0
Transrectal needle aspiration May be appropriate Expert Consensus N/A N/A 6 6 0 0 0 0 2 10 2 0 0
Transvaginal needle aspiration May be appropriate Limited N/A N/A 6 6 0 0 0 0 2 10 2 0 0
References Study Quality
99 (26848871) 4
Conservative management only May be appropriate Limited N/A N/A 5 5 0 0 5 2 6 1 0 0 0
References Study Quality
100 (23539877) 2
99 (26848871) 4
Endoscopic US-guided drainage May be appropriate Limited N/A N/A 5 5 0 0 0 1 7 6 0 0 0
References Study Quality
105 (20659232) 4
104 (28918808) 4
Surgical/laparoscopic drainage May be appropriate Strong N/A N/A 5 5 0 0 0 0 11 3 0 0 0
References Study Quality
103 (19393776) 2
101 (21419651) 2
102 (-3148231) 4
Variant 8: Patient with recent endoscopic retrograde cholangiopancreatography and sphincterotomy now with 3 weeks of worsening right upper quadrant pain, fever, jaundice, and malaise. CT scan reveals 2 liver abscesses greater than 3 cm. MRCP demonstrates no biliary obstruction or stones. Treatment includes antibiotics.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous catheter drainage only Usually appropriate Limited N/A N/A 8 8 0 0 0 1 1 1 3 5 2
References Study Quality
106 (21195630) 4
107 (22578643) 4
108 (27350946) 4
109 (17715080) 1
110 (18306874) 3
Needle aspiration May be appropriate Limited N/A N/A 6 6 0 0 1 0 4 3 4 1 0
References Study Quality
114 (12567615) 4
115 (1863218) 4
108 (27350946) 4
116 (27047771) 4
117 (15708321) 4
118 (24046781) 4
Percutaneous catheter drainage with conversion to percutaneous biliary drain May be appropriate Limited N/A N/A 6 6 0 0 0 0 4 5 1 2 1
References Study Quality
111 (21879281) 3
112 (16528651) 3
113 (11918890) 2
Surgical management May be appropriate Limited N/A N/A 5 5 0 1 1 1 4 5 0 1 0
References Study Quality
108 (27350946) 4
116 (27047771) 4
110 (18306874) 3
119 (22536008) 3
120 (21472130) 4
121 (15729072) 3
Continued conservative management May be appropriate Limited N/A N/A 4 4 0 2 5 0 5 2 0 0 0
References Study Quality
114 (12567615) 4
115 (1863218) 4
108 (27350946) 4
Variant 9: Patient presents to the emergency department with 5 days of progressive ankle swelling and 2 days of fever. An ultrasound was obtained given the diffuse soft-tissue swelling around the ankle which revealed a subperiosteal abscess. Treatment includes antibiotics.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical drainage Usually appropriate Limited N/A N/A 8 8 0 0 0 0 1 1 1 7 3
References Study Quality
123 (24446020) 4
124 (26323185) 4
125 (28405074) 4
Needle aspiration May be appropriate Limited N/A N/A 5 5 0 0 0 2 11 1 0 0 0
References Study Quality
126 (27280623) 4
127 (15895789) 4
Percutaneous catheter drainage only May be appropriate Limited N/A N/A 5 5 0 0 0 5 7 1 1 0 0
References Study Quality
122 (8929301) 4
Continued conservative management Usually not appropriate Expert Consensus N/A N/A 2 2 1 7 3 0 0 1 0 1 0
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.