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Appropriateness Criteria

Variant 1: Vomiting within the first 2 days after birth. Poor feeding or no passage of meconium. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography abdomen Usually appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 9 9 0 0 0 0 0 0 1 2 15
References Study Quality
8 (19380551) 4
US abdomen (UGI tract) Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 3 5 1 1 0 0 0 0
Fluoroscopy contrast enema Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 5 5 0 0 0 0 0 0
Fluoroscopy upper GI series Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 6 2 5 1 3 1 0 0 0
Nuclear medicine gastroesophageal reflux scan Usually not appropriate Expert Consensus ☢☢☢ 0.3-3 mSv [ped] 1 1 14 3 1 0 0 0 0 0 0
Variant 2: Vomiting within the first 2 days after birth. Radiographs show classic double bubble or triple bubble with little or no gas distally (suspected proximal bowel obstruction or atresia). Next imaging study.
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 May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 0 1 1 7 6 2 0 0 0
US abdomen (UGI tract) Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 2 6 1 0 0 1 0 0
Fluoroscopy contrast enema Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 5 0 1 1 0 0 0
References Study Quality
11 (26093906) 2
Nuclear medicine gastroesophageal reflux scan Usually not appropriate Expert Consensus ☢☢☢ 0.3-3 mSv [ped] 1 1 15 1 2 0 0 0 0 0 0
Variant 3: Vomiting within the first 2 days after birth. Radiographs show a distal bowel obstruction. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy contrast enema Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 2 16
References Study Quality
12 (29528714) 4
US abdomen (UGI tract) Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 3 4 0 0 0 0 0 0
Fluoroscopy upper GI series Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 6 2 5 0 4 1 0 0 0
Nuclear medicine gastroesophageal reflux scan Usually not appropriate Expert Consensus ☢☢☢ 0.3-3 mSv [ped] 1 1 14 3 1 0 0 0 0 0 0
Variant 4: Bilious vomiting within the first 2 days after birth. Radiographs show a nonclassic double bubble with gas in the distal small bowel, or few distended bowel loops, or a normal bowel gas pattern. Next imaging study.
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 Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 0 0 0 0 0 0 1 1 16
References Study Quality
5 (10546672) 4
17 (21763833) 3
6 (3717104) 4
15 (15378215) 4
16 (18265969) 2
18 (8628870) 4
11 (26093906) 2
US abdomen (UGI tract) May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 1 1 7 6 1 0 0 0
References Study Quality
15 (15378215) 4
19 (18678603) 4
22 (16677901) 3
23 (1529850) 3
24 (22684229) 4
25 (23132236) 4
28 (29049228) 3
21 (20552188) 4
20 (-3149156) 4
27 (19308378) 4
26 (23407700) 3
Fluoroscopy contrast enema Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 6 3 1 0 0 0 0 0
References Study Quality
4 (20432010) 4
13 (8337877) 4
14 (19551391) 4
Nuclear medicine gastroesophageal reflux scan Usually not appropriate Expert Consensus ☢☢☢ 0.3-3 mSv [ped] 1 1 16 1 1 0 0 0 0 0 0
Variant 5: Bilious vomiting in an infant older than 2 days (suspected malrotation). 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] 9 9 0 0 0 0 0 0 1 2 15
References Study Quality
5 (10546672) 4
17 (21763833) 3
6 (3717104) 4
15 (15378215) 4
16 (18265969) 2
18 (8628870) 4
US abdomen (UGI tract) May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 2 1 2 9 2 0 0 0
References Study Quality
15 (15378215) 4
19 (18678603) 4
22 (16677901) 3
23 (1529850) 3
24 (22684229) 4
25 (23132236) 4
28 (29049228) 3
21 (20552188) 4
20 (-3149156) 4
27 (19308378) 4
26 (23407700) 3
Radiography abdomen May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 5 5 1 4 1 2 5 3 0 0 1
References Study Quality
6 (3717104) 4
Fluoroscopy contrast enema Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 2 5 2 0 1 0 0 0
References Study Quality
29 (16973777) 4
Nuclear medicine gastroesophageal reflux scan Usually not appropriate Expert Consensus ☢☢☢ 0.3-3 mSv [ped] 1 1 17 0 1 0 0 0 0 0 0
Variant 6: Infant with nonbilious vomiting, and otherwise healthy (suspected uncomplicated esophageal reflux). 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 May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
2 (11525610) 4
34 (19745761) 4
Nuclear medicine gastroesophageal reflux scan May be appropriate (Disagreement) Expert Opinion ☢☢☢ 0.3-3 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
42 (7830141) 4
35 (6602471) 3
36 (8708772) 3
37 (19352210) 3
38 (8326376) 2
39 (21849926) 4
41 (3277230) 4
40 (18483812) 3
US abdomen (UGI tract) Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
47 (16926562) 1
43 (16622332) 3
44 (9805307) 3
45 (3532185) 4
46 (7972822) 3
Radiography abdomen Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopy contrast enema Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 7: Infant older than 2 weeks and up to 3 months old. New onset nonbilious vomiting (suspected hypertrophic pyloric stenosis). 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 (UGI tract) Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 2 16
References Study Quality
30 (1994426) 4
45 (3532185) 4
46 (7972822) 3
31 (19308372) 4
51 (3285655) 2
41 (3277230) 4
52 (17958692) 4
53 (15154530) 3
Fluoroscopy upper GI series May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 0 0 4 10 2 0 0 1
References Study Quality
4 (20432010) 4
3 (-3149148) 4
48 (9396536) 4
49 (10353929) 4
Radiography abdomen Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 6 0 4 2 5 1 0 0 0
References Study Quality
50 (-3157907) 4
Fluoroscopy contrast enema Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 2 0 0 0 0 0 0 0
Nuclear medicine gastroesophageal reflux scan Usually not appropriate Expert Consensus ☢☢☢ 0.3-3 mSv [ped] 1 1 11 1 1 1 3 1 0 0 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.