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Appropriateness Criteria

Variant 1: Lower gastrointestinal tract bleeding. Active bleeding clinically observed as hematochezia or melena in a hemodynamically stable patient. Next step.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTA abdomen and pelvis without and with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv 8 8 0 1 1 0 0 2 3 7 4
References Study Quality
30 (28189213) 4
42 (25992504) 4
37 (25023179) 3
32 (22084211) 2
34 (22064550) 3
29 (12954894) 4
31 (20400333) 3
33 (20093615) 2
35 (16484350) 3
39 (20377709) 4
40 (18806152) 2
36 (28668429) Inadequate
38 (28278445) 4
41 (23836115) 3
Diagnostic/therapeutic colonoscopy Usually appropriate Strong N/A N/A 8 8 1 0 0 0 2 3 0 5 7
References Study Quality
45 (26631877) 4
47 (25812518) 3
46 (25786443) 3
48 (20648004) 2
43 (16279891) 1
44 (22468081) 4
RBC scan abdomen and pelvis Usually appropriate Limited ☢☢☢ 1-10 mSv 7 7 0 0 0 0 0 3 10 6 0
References Study Quality
53 (26956784) 4
55 (23407907) 3
54 (21757912) 4
56 (26646804) 2
52 (3494826) 4
57 (30526506) 3
Transcatheter arteriography/embolization May be appropriate Limited N/A N/A 5 5 1 0 0 2 11 3 0 2 0
References Study Quality
59 (27101433) 4
24 (23574847) 4
58 (104564) 4
7 (19568467) 4
MRA abdomen and pelvis without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 4 5 1 1 0 1 0 0
References Study Quality
49 (26355018) 4
Surgery Usually not appropriate Limited N/A N/A 2 2 7 4 6 0 1 0 0 0 0
References Study Quality
50 (18636299) 4
51 (-3149670) 4
Variant 2: Lower gastrointestinal tract bleeding. Active bleeding in a hemodynamically unstable patient or a patient who has required more than 5 units of blood within 24 hours. Next step.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTA abdomen and pelvis without and with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 8 8 0 0 0 0 0 0 6 11 2
References Study Quality
42 (25992504) 4
39 (20377709) 4
Transcatheter arteriography/embolization Usually appropriate Limited N/A N/A 8 8 1 0 0 1 0 2 2 9 3
References Study Quality
42 (25992504) 4
63 (16336385) 4
7 (19568467) 4
Diagnostic/therapeutic colonoscopy May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 0 0 2 1 0 1 3 11 1
References Study Quality
60 (28174123) Good
Surgery May be appropriate Limited N/A N/A 5 5 2 0 0 0 13 4 0 0 0
References Study Quality
61 (24267497) 4
62 (22677611) 2
50 (18636299) 4
51 (-3149670) 4
RBC scan abdomen and pelvis Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 3 3 3 4 7 1 2 1 0 1 0
MRA abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 5 3 1 0 0 0 0 0
Variant 3: Lower gastrointestinal tract bleeding. Colonoscopy localized the bleeding site and treatment was attempted. Ongoing or recurrent bleeding. Next procedure or intervention.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Transcatheter arteriography/embolization Usually appropriate Expert Consensus N/A N/A 8 8 0 0 1 0 0 0 3 6 8
Surgery May be appropriate Expert Consensus N/A N/A 6 6 0 0 0 1 7 9 2 0 0
CTA abdomen and pelvis without and with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv 5 5 0 3 0 8 3 3 1 1 0
Diagnostic/therapeutic colonoscopy May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 1 3 0 1 10 2 1 0 1
MRA abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 9 4 4 2 0 0 0 0 0
RBC scan abdomen and pelvis Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 5 7 3 0 2 1 0 0 0
Variant 4: Lower gastrointestinal tract bleeding. Transcatheter arteriography localized the bleeding site and treatment was attempted. Ongoing or recurrent bleeding. No other prior radiological or endoscopic investigations. Next procedure or intervention.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Diagnostic/therapeutic colonoscopy Usually appropriate Limited N/A N/A 7 7 0 0 0 1 1 2 7 7 1
References Study Quality
46 (25786443) 3
CTA abdomen and pelvis without and with IV contrast May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 6 6 0 2 0 0 5 5 4 3 0
Surgery May be appropriate Expert Consensus N/A N/A 6 6 0 0 0 1 5 8 2 3 0
Transcatheter arteriography/embolization May be appropriate Expert Consensus N/A N/A 6 6 0 1 1 0 3 6 5 3 0
MRA abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 7 2 1 1 0 0 0 0
RBC scan abdomen and pelvis Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 4 6 7 0 1 1 0 0 0
Variant 5: Lower gastrointestinal tract bleeding. Obscure (nonlocalized) recurrent bleeding in a hemodynamically stable patient (assumes a prior negative adequate colonoscopy and upper gastrointestinal endoscopy). Next procedure or intervention.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Capsule endoscopy Usually appropriate Limited N/A N/A 8 8 1 0 0 0 1 2 5 6 3
References Study Quality
64 (16279893) M
CT enterography abdomen and pelvis with IV contrast Usually appropriate Limited N/A N/A 7 7 0 0 0 1 3 0 7 6 1
References Study Quality
65 (17619098) 4
66 (21642417) 2
67 (23721134) M
68 (21460027) 3
69 (22270143) 3
RBC scan abdomen and pelvis May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 6 6 0 0 2 0 3 6 1 6 0
RBC scan with SPECT or SPECT/CT abdomen and pelvis May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 6 6 0 0 0 0 1 9 7 2 0
Push enteroscopy May be appropriate Limited N/A N/A 5 5 0 0 0 2 12 0 3 1 0
References Study Quality
74 (17324401) 1
Transcatheter arteriography/embolization May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 0 0 4 5 6 1 2 0 0
MR enterography May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 0 1 2 8 6 1 0 0 0
References Study Quality
72 (20132082) 3
73 (22528671) 2
71 (28668417) 2
Surgery Usually not appropriate Limited N/A N/A 3 3 3 4 8 1 1 0 1 0 0
References Study Quality
51 (-3149670) 4
Fluoroscopy small bowel follow-through Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 6 3 0 2 1 0 0 1
References Study Quality
70 (20138043) 1
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.