American College of Radiology
ACR Appropriateness Criteria®

Dysphagia

Variant 1: Oropharyngeal dysphagia with an attributable cause. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy barium swallow modified Usually appropriate Limited ☢☢☢ 1-10 mSv 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
14 (18940640) 4
13 (18855050) 3
Fluoroscopy pharynx dynamic and static imaging May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 6 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopy single contrast esophagram May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 4 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopy biphasic esophagram May be appropriate Limited ☢☢☢ 1-10 mSv 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
15 (2110721) 4
CT neck and chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 3 4 8 0 0 0 0 0 0
Tc-99m transit scintigraphy esophagus Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT neck and chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 3 8 1 1 1 1 1 0 0
CT neck and chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 5 6 3 0 1 0 0 1 0
Variant 2: Unexplained oropharyngeal dysphagia. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy biphasic esophagram Usually appropriate Limited ☢☢☢ 1-10 mSv 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
17 (8605748) 3
16 (9798879) 4
15 (2110721) 4
12 (25605697) 3
Fluoroscopy single contrast esophagram May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 6 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopy barium swallow modified May be appropriate Limited ☢☢☢ 1-10 mSv 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
19 (25783698) 4
Fluoroscopy pharynx dynamic and static imaging May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 0 3 0 3 4 5 0 0 0
References Study Quality
18 (11976859) 3
Tc-99m transit scintigraphy esophagus May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 4 n/a 0 0 0 0 0 0 0 0 0
CT neck and chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 3 7 5 0 0 0 0 0 0
CT neck and chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 2 8 3 0 1 1 0 1 0
CT neck and chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 4 7 3 0 1 0 1 0 0
Variant 3: Retrosternal dysphagia in immunocompetent patients. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy biphasic esophagram Usually appropriate Limited ☢☢☢ 1-10 mSv 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
28 (8629536) 4
27 (15833990) 3
26 (3496755) 3
25 (7077058) 3
24 (4008906) 3
23 (3487939) 3
22 (4059545) 3
21 (6501826) 4
20 (9168701) 3
17 (8605748) 3
11 (3932116) 3
5 (19699405) 4
3 (22369033) 4
Fluoroscopy single contrast esophagram May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 6 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopy barium swallow modified May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 4 n/a 0 0 0 0 0 0 0 0 0
Tc-99m transit scintigraphy esophagus May be appropriate Limited ☢☢☢ 1-10 mSv 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
32 (12418460) 4
31 (8553100) 4
30 (9242756) 3
29 (19431219) 1
3 (22369033) 4
Fluoroscopy pharynx dynamic and static imaging Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 3 3 1 2 6 5 1 0 0 0 0
CT neck and chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 3 2 10 0 0 0 0 0 0
CT neck and chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 2 7 3 1 1 1 1 0 0
CT neck and chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 4 6 4 0 1 0 0 1 0
Variant 4: Retrosternal dysphagia in immunocompromised patients. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy biphasic esophagram Usually appropriate Limited ☢☢☢ 1-10 mSv 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
37 (3969456) 4
36 (3259822) 4
35 (2823585) 4
34 (19266596) 4
Fluoroscopy single contrast esophagram May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopy barium swallow modified May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 4 4 0 1 1 7 4 3 0 0 0
Fluoroscopy pharynx dynamic and static imaging Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 3 n/a 0 0 0 0 0 0 0 0 0
CT neck and chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 1 6 8 0 0 0 0 0 0
Tc-99m transit scintigraphy esophagus Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 n/a 0 0 0 0 0 0 0 0 0
CT neck and chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 3 9 3 0 0 0 0 0 0
CT neck and chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 3 6 4 0 1 1 1 0 0
Variant 5: Early postoperative dysphagia. Oropharyngeal or retrosternal. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy single contrast esophagram Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 0 1 2 2 9 2
References Study Quality
41 (23529533) 4
40 (23059739) 3
39 (27066433) 3
1 (25590391) 4
CT neck and chest with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 0 0 0 1 2 6 6 1
References Study Quality
43 (18559902) 2
40 (23059739) 3
CT neck and chest without IV contrast May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 6 6 0 1 0 3 4 5 2 1 0
Fluoroscopy biphasic esophagram Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 3 3 1 5 8 1 0 0 0 0 0
Fluoroscopy pharynx dynamic and static imaging Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 1 3 6 3 2 0 0 0 0
References Study Quality
42 (11016771) 3
Fluoroscopy barium swallow modified Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 0 4 4 6 1 0 0 0 0
References Study Quality
41 (23529533) 4
CT neck and chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 1 3 6 5 0 0 0 0 0
Tc-99m transit scintigraphy esophagus Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 4 12 0 0 0 0 0 0 0
Variant 6: Delayed (greater than 1 month) postoperative development of dysphagia. Oropharyngeal or retrosternal. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Fluoroscopy single contrast esophagram Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv 7 7 0 0 0 0 2 4 6 3 1
CT neck and chest with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 0 0 0 1 1 7 6 1
References Study Quality
49 (25794065) 4
48 (17374861) 4
Fluoroscopy biphasic esophagram May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 6 6 0 0 1 1 4 4 4 1 1
Fluoroscopy barium swallow modified May be appropriate Limited ☢☢☢ 1-10 mSv 6 6 0 0 1 3 4 4 3 1 0
References Study Quality
47 (12587251) 4
46 (25943964) 4
Tc-99m transit scintigraphy esophagus May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 4 4 0 5 3 4 3 1 0 0 0
Fluoroscopy pharynx dynamic and static imaging Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 1 3 5 2 4 0 0 0 0
References Study Quality
42 (11016771) 3
CT neck and chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 0 6 3 1 3 2 0 0 0
CT neck and chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 0 8 2 4 1 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.