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Appropriateness Criteria

Variant 1: Suspected acute pancreatitis. First time presentation. Epigastric pain and increased amylase and lipase. Less than 48 to 72 hours after symptom onset. 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 Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 4 1 1 8 2
References Study Quality
14 (26209440) 3
15 (24512896) 4
12 (24679420) 4
US duplex Doppler abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 0 1 4 7 3 0 1 0 1
References Study Quality
1 (28840381) 3
12 (24679420) 4
MRI abdomen without and with IV contrast with MRCP May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 2 2 8 5 0 0 0
References Study Quality
9 (18253063) 3
13 (27446845) 3
11 (25200693) 3
12 (24679420) 4
10 (20972954) 3
MRI abdomen without IV contrast with MRCP May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 2 6 9 0 0 0 0
References Study Quality
9 (18253063) 3
13 (27446845) 3
11 (25200693) 3
12 (24679420) 4
10 (20972954) 3
CT abdomen and pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 2 6 8 1 0 0 0
References Study Quality
4 (12034923) 4
7 (22186977) 3
1 (28840381) 3
6 (27426674) 3
5 (25239388) 3
8 (25078061) 3
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 8 6 1 0 2 0 0 0
References Study Quality
15 (24512896) 4
CT abdomen and pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 1 2 9 3 2 1 0 0 0
References Study Quality
4 (12034923) 4
7 (22186977) 3
1 (28840381) 3
6 (27426674) 3
5 (25239388) 3
8 (25078061) 3
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 1 10 1 1 2 0 0 0
References Study Quality
4 (12034923) 4
7 (22186977) 3
1 (28840381) 3
6 (27426674) 3
5 (25239388) 3
8 (25078061) 3
Variant 2: Suspected acute pancreatitis. Initial presentation with atypical signs and symptoms; including equivocal amylase and lipase values (possibly confounded by acute kidney injury or chronic kidney disease) and when diagnoses other than pancreatitis may be possible (bowel perforation, bowel ischemia, etc.). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast with MRCP Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 2 5 4 5 1
References Study Quality
6 (27426674) 3
18 (26102416) 4
20 (25457519) 2
8 (25078061) 3
19 (25585483) 4
17 (25356038) 4
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 1 0 0 0 0 2 0 8 7
References Study Quality
16 (19896558) 4
14 (26209440) 3
3 (23100216) 4
US abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 3 8 3 1 0 1
References Study Quality
15 (24512896) 4
US duplex Doppler abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 0 0 7 3 6 0 0 0 1
References Study Quality
24 (22613509) 2
MRI abdomen without IV contrast with MRCP May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 2 8 7 0 0 0
References Study Quality
6 (27426674) 3
18 (26102416) 4
20 (25457519) 2
8 (25078061) 3
19 (25585483) 4
17 (25356038) 4
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 4 11 1 0 0 0
References Study Quality
16 (19896558) 4
14 (26209440) 3
3 (23100216) 4
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 5 10 0 1 1 0 0 0
References Study Quality
15 (24512896) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 2 6 2 4 1 1 0 0
References Study Quality
16 (19896558) 4
14 (26209440) 3
3 (23100216) 4
Variant 3: Acute pancreatitis. Critically ill, systemic inflammatory response syndrome (SIRS), severe clinical scores (eg, Acute Physiology, Age, and Chronic Health Evaluation [APACHE]-II, Bedside Index for Severity in AP [BISAP], or Marshall). Greater than 48 to 72 hours after onset of symptoms.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast with MRCP Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 1 3 7 4 2
References Study Quality
11 (25200693) 3
22 (24015276) 2
24 (22613509) 2
23 (22366559) 2
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 3 6 9
References Study Quality
6 (27426674) 3
18 (26102416) 4
8 (25078061) 3
2 (25208277) 4
3 (23100216) 4
21 (22584543) 4
US duplex Doppler abdomen May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 1 4 4 4 3 1 1 0 0
MRI abdomen without IV contrast with MRCP May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 8 3 5 1 0
References Study Quality
11 (25200693) 3
22 (24015276) 2
24 (22613509) 2
23 (22366559) 2
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 4 3 8 2 0 0 1
References Study Quality
6 (27426674) 3
18 (26102416) 4
8 (25078061) 3
2 (25208277) 4
3 (23100216) 4
21 (22584543) 4
US abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 0 2 8 2 4 1 1 0 0
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 4 6 2 3 2 0 0 0
References Study Quality
15 (24512896) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 1 2 7 2 5 0 1 0 0
References Study Quality
6 (27426674) 3
18 (26102416) 4
8 (25078061) 3
2 (25208277) 4
3 (23100216) 4
21 (22584543) 4
Variant 4: Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast with MRCP Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 6 9 2
References Study Quality
26 (25425489) 2
22 (24015276) 2
21 (22584543) 4
CT abdomen and pelvis with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 5 13
References Study Quality
27 (27592205) 2
26 (25425489) 2
3 (23100216) 4
21 (22584543) 4
US abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 5 3 4 4 1 0 0
References Study Quality
21 (22584543) 4
US duplex Doppler abdomen May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 0 2 3 7 2 3 0 1 0
MRI abdomen without IV contrast with MRCP May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 7 6 3 1 1
References Study Quality
26 (25425489) 2
22 (24015276) 2
21 (22584543) 4
CT abdomen and pelvis without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 0 3 11 2 0 0 0
References Study Quality
27 (27592205) 2
26 (25425489) 2
3 (23100216) 4
21 (22584543) 4
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 3 6 6 1 0 1 0 0
References Study Quality
15 (24512896) 4
28 (24574783) 3
CT abdomen and pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 2 4 0 8 0 0 0 0
References Study Quality
27 (27592205) 2
26 (25425489) 2
3 (23100216) 4
21 (22584543) 4
Variant 5: Known necrotizing pancreatitis. Significant deterioration in clinical status, including abrupt decrease in hemoglobin or hematocrit, hypotension, tachycardia, tachypnea, abrupt change in fever curve, or increase in white blood cells.
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 Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 4 14
References Study Quality
29 (24441591) 1
US abdomen May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 0 3 4 5 4 2 0 0 0
US duplex Doppler abdomen May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 0 3 5 7 1 2 0 0 0
MRI abdomen without and with IV contrast with MRCP May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 7 9 0 1 0
References Study Quality
29 (24441591) 1
MRI abdomen without IV contrast with MRCP May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 4 12 0 1 0 0
References Study Quality
29 (24441591) 1
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 2 8 2 4 1 0
References Study Quality
29 (24441591) 1
CT abdomen and pelvis without and with IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 5 5 0 0 1 5 6 4 1 0 0
References Study Quality
29 (24441591) 1
US abdomen with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 0 4 8 4 2 0 0 0 0
References Study Quality
28 (24574783) 3
Variant 6: Acute pancreatitis. Known pancreatic or peripancreatic fluid collections with continued abdominal pain, early satiety, nausea, vomiting, or signs of infection. Greater than 4 weeks after symptom onset.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI abdomen without and with IV contrast with MRCP Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 3 10 4
References Study Quality
31 (26730150) 4
26 (25425489) 2
22 (24015276) 2
CT abdomen and pelvis with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 1 2 5 10
References Study Quality
26 (25425489) 2
US abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 2 6 6 3 0 0 0
References Study Quality
21 (22584543) 4
US duplex Doppler abdomen May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 0 2 5 6 2 1 1 0 0
MRI abdomen without IV contrast with MRCP May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 5 4 5 3 0
References Study Quality
31 (26730150) 4
26 (25425489) 2
22 (24015276) 2
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 4 10 3 0 0 0
References Study Quality
26 (25425489) 2
US abdomen with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 1 4 7 4 1 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 4 5 0 4 2 0 0 0
References Study Quality
26 (25425489) 2
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.