American College of Radiology
ACR Appropriateness Criteria®

Radiologic Management of Lower Gastrointestinal Tract Bleeding

Variant 1: Lower GI tract bleeding. Active bleeding with hematochezia or melena in a hemodynamically stable patient. Next procedure/intervention.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Transcatheter arteriography/intervention (TAI) May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Diagnostic/therapeutic colonoscopy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Surgery Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Tc-99m labeled RBC scan abdomen and pelvis Usually appropriate ☢☢☢ 1-10 mSv 7 n/a 0 0 0 0 0 0 0 0 0
CTA abdomen and pelvis with IV contrast Usually appropriate ☢☢☢☢☢ 30-100 mSv 7 n/a 0 0 0 0 0 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Lower GI tract bleeding. Active bleeding in a hemodynamically unstable patient or a patient who has required more than 5 units of blood. Next procedure/intervention.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Transcatheter arteriography/intervention (TAI) Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Diagnostic/therapeutic colonoscopy May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Surgery May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Tc-99m labeled RBC scan abdomen and pelvis Usually not appropriate ☢☢☢ 1-10 mSv 1 n/a 0 0 0 0 0 0 0 0 0
CTA abdomen and pelvis with IV contrast May be appropriate ☢☢☢☢☢ 30-100 mSv 5 n/a 0 0 0 0 0 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Lower GI tract bleeding. Colonoscopy localized the bleeding siteand treatment was attempted. Ongoing or recurrent bleeding. Next procedure/intervention.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Transcatheter arteriography/intervention (TAI) Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Diagnostic/therapeutic colonoscopy May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Surgery Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Tc-99m labeled RBC scan abdomen and pelvis Usually not appropriate ☢☢☢ 1-10 mSv 2 n/a 0 0 0 0 0 0 0 0 0
CTA abdomen and pelvis with IV contrast Usually not appropriate ☢☢☢☢☢ 30-100 mSv 3 n/a 0 0 0 0 0 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Lower GI tract bleeding. Intermittent or obscure nonlocalized recurrent bleeding. Next procedure/intervention (assumes prior negative endoscopy).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Transcatheter arteriography/intervention (TAI) May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Diagnostic/therapeutic colonoscopy May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Surgery Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Tc-99m labeled RBC scan abdomen and pelvis Usually appropriate ☢☢☢ 1-10 mSv 7 n/a 0 0 0 0 0 0 0 0 0
CTA abdomen and pelvis with IV contrast Usually appropriate ☢☢☢☢☢ 30-100 mSv 8 n/a 0 0 0 0 0 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Capsule endoscopy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Contrast small bowel radiography Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 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.