American College of Radiology
ACR Appropriateness Criteria®

Acute Nonlocalized Abdominal Pain

Variant 1: Acute nonlocalized abdominal pain and fever. No recent surgery. 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 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 2 14
MRI abdomen and pelvis without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 2 7 4 2 0
US abdomen May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 0 3 1 7 3 1 1
CT abdomen and pelvis without IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 3 5 5 4 0 0 0
MRI abdomen and pelvis without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 5 0 0 0 3 9 1 2 1 0
CT abdomen and pelvis without and with IV contrast May be appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 4 4 0 2 3 6 5 0 0 0 0
Radiography abdomen May be appropriate ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 4 4 0 0 3 11 2 0 0 0 0
Tc-99m WBC scan abdomen and pelvis Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 4 4 4 0 0 0 0 0
Tc-99m cholescintigraphy Usually not appropriate ☢☢ 0.1-1mSv 3 3 3 4 2 5 2 0 0 0 0
In-111 WBC scan abdomen and pelvis Usually not appropriate ☢☢☢☢ 10-30 mSv 3 3 6 2 4 4 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 4 3 3 1 2 0 0 0
Fluoroscopy contrast enema Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 5 2 1 0 0 0 0 0
Fluoroscopy upper GI series with small bowel follow-through Usually not appropriate ☢☢☢ 1-10 mSv 2 2 8 4 3 1 0 0 0 0 0
Variant 2: Acute nonlocalized abdominal pain and fever. Postoperative patient. 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 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 2 14
MRI abdomen and pelvis without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 1 0 0 0 4 6 5 0 0
US abdomen May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 1 2 2 3 7 1 0 0
CT abdomen and pelvis without IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 2 5 5 5 0 0 0
MRI abdomen and pelvis without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 5 1 1 0 3 5 5 1 0 0
CT abdomen and pelvis without and with IV contrast May be appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 4 4 0 2 4 3 6 1 0 0 0
Fluoroscopy contrast enema May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 0 1 11 2 2 0 0 0
Fluoroscopy upper GI series with small bowel follow-through May be appropriate ☢☢☢ 1-10 mSv 4 4 0 0 2 10 2 2 0 0 0
Radiography abdomen May be appropriate ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 4 4 0 1 1 8 2 4 0 0 0
Tc-99m WBC scan abdomen and pelvis Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 6 3 4 0 1 0 0 0
Tc-99m cholescintigraphy Usually not appropriate ☢☢ 0.1-1mSv 3 3 0 6 3 3 3 1 0 0 0
In-111 WBC scan abdomen and pelvis Usually not appropriate ☢☢☢☢ 10-30 mSv 3 3 4 3 4 4 0 1 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 4 3 2 3 1 0 0 0
Variant 3: Acute nonlocalized abdominal pain. Neutropenic patient. 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 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 2 14
CT abdomen and pelvis without IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 0 0 9 5 1 1
MRI abdomen and pelvis without and with IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 3 7 4 0 0
US abdomen May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 1 2 4 4 4 1 0
MRI abdomen and pelvis without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 5 0 0 2 3 8 2 1 0 0
CT abdomen and pelvis without and with IV contrast May be appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 4 4 0 2 3 7 4 0 0 0 0
Tc-99m WBC scan abdomen and pelvis Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 4 2 2 1 0 0 0
In-111 WBC scan abdomen and pelvis Usually not appropriate ☢☢☢☢ 10-30 mSv 3 3 4 4 3 2 2 1 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 5 2 3 2 1 1 0 0
Radiography abdomen Usually not appropriate ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 0 2 10 3 1 0 0 0 0
Fluoroscopy contrast enema Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 7 0 2 0 0 0 0 0
Fluoroscopy upper GI series with small bowel follow-through Usually not appropriate ☢☢☢ 1-10 mSv 2 2 7 6 0 3 0 0 0 0 0
Tc-99m cholescintigraphy Usually not appropriate ☢☢ 0.1-1mSv 2 2 2 8 2 1 2 1 0 0 0
Variant 4: Acute nonlocalized abdominal pain. Not otherwise specified. 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 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 4 12
CT abdomen and pelvis without IV contrast Usually appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 0 8 7 0 1
MRI abdomen and pelvis without and with IV contrast Usually appropriate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 2 4 7 2 0
US abdomen May be appropriate O 0 mSv O 0 mSv [ped] 6 6 0 0 1 0 2 7 2 3 1
MRI abdomen and pelvis without IV contrast May be appropriate O 0 mSv O 0 mSv [ped] 5 5 0 0 0 3 6 2 3 2 0
CT abdomen and pelvis without and with IV contrast May be appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 4 4 0 2 3 8 3 0 0 0 0
Radiography abdomen May be appropriate ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 4 4 0 3 0 9 2 2 0 0 0
Fluoroscopy upper GI series with small bowel follow-through Usually not appropriate ☢☢☢ 1-10 mSv 2 2 8 4 1 3 0 0 0 0 0
Tc-99m WBC scan abdomen and pelvis Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 4 4 1 0 1 0 0 0
Tc-99m cholescintigraphy Usually not appropriate ☢☢ 0.1-1mSv 2 2 5 6 2 1 1 1 0 0 0
In-111 WBC scan abdomen and pelvis Usually not appropriate ☢☢☢☢ 10-30 mSv 2 2 6 4 4 1 0 1 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 6 4 3 2 1 0 0 0 0
Fluoroscopy contrast enema Usually not appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 5 1 1 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.