American College of Radiology
ACR Appropriateness Criteria®

Right Upper Quadrant Pain

Variant 1: Right upper quadrant pain. Suspected biliary disease. 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 Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 1 13
References Study Quality
2 (26526429) 4
4 (7255722) 3
5 (7730462) 3
6 (7979854) 4
7 (14661666) 4
8 (15256633) 4
9 (19098200) 4
10 (10749232) 2
11 (12467321) 3
12 (24224584) 4
13 (26070243) 4
CT abdomen with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 4 2 4 3 0 1
References Study Quality
2 (26526429) 4
7 (14661666) 4
8 (15256633) 4
9 (19098200) 4
12 (24224584) 4
15 (11804880) 3
16 (16671375) 3
17 (19559349) 2
18 (20489092) 4
19 (19497464) 3
MRI abdomen without and with IV contrast with MRCP May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 3 1 6 2 1 0
References Study Quality
21 (19711404) 4
22 (17581902) 3
23 (14628868) 2
2 (26526429) 4
MRI abdomen without IV contrast with MRCP May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 3 2 6 2 1 0 0
References Study Quality
2 (26526429) 4
21 (19711404) 4
22 (17581902) 3
23 (14628868) 2
Tc-99m cholescintigraphy May be appropriate Limited ☢☢ 0.1-1mSv 5 5 0 0 5 0 4 5 1 0 0
References Study Quality
4 (7255722) 3
7 (14661666) 4
8 (15256633) 4
9 (19098200) 4
14 (21339427) 3
CT abdomen without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 3 2 6 1 1 0 0 0
References Study Quality
2 (26526429) 4
7 (14661666) 4
8 (15256633) 4
9 (19098200) 4
12 (24224584) 4
15 (11804880) 3
16 (16671375) 3
17 (19559349) 2
18 (20489092) 4
19 (19497464) 3
CT abdomen without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 4 4 3 0 0 1 0 0
References Study Quality
2 (26526429) 4
7 (14661666) 4
8 (15256633) 4
9 (19098200) 4
12 (24224584) 4
15 (11804880) 3
16 (16671375) 3
17 (19559349) 2
18 (20489092) 4
19 (19497464) 3
20 (25424561) 3
Variant 2: Right upper quadrant pain. No fever or high white blood cell (WBC) count. Suspected biliary disease. Negative or equivocal ultrasound.
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] 8 8 0 0 0 1 0 0 3 9 1
References Study Quality
2 (26526429) 4
23 (14628868) 2
CT abdomen with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 0 4 6 5 0
References Study Quality
2 (26526429) 4
20 (25424561) 3
MRI abdomen without IV contrast with MRCP Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 1 4 5 3 0
References Study Quality
2 (26526429) 4
23 (14628868) 2
Tc-99m cholescintigraphy May be appropriate Limited ☢☢ 0.1-1mSv 5 5 0 0 0 0 11 2 1 1 0
References Study Quality
24 (23731969) 4
CT abdomen without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 1 5 7 1 0 0 0 0
References Study Quality
2 (26526429) 4
20 (25424561) 3
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 1 4 7 1 0 0 1 0 0
References Study Quality
2 (26526429) 4
20 (25424561) 3
Variant 3: Right upper quadrant pain. Fever, elevated WBC count. Suspected biliary disease. Negative or equivocal ultrasound.
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 1 1 4 7 1
References Study Quality
2 (26526429) 4
22 (17581902) 3
23 (14628868) 2
25 (19879969) 4
27 (22332066) 2
28 (10937751) 2
29 (9676460) 2
CT abdomen with IV contrast Usually appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 1 2 1 4 5 1
References Study Quality
2 (26526429) 4
7 (14661666) 4
8 (15256633) 4
9 (19098200) 4
12 (24224584) 4
15 (11804880) 3
16 (16671375) 3
17 (19559349) 2
18 (20489092) 4
19 (19497464) 3
20 (25424561) 3
26 (22798223) Good
Tc-99m cholescintigraphy Usually appropriate Limited ☢☢ 0.1-1mSv 7 7 0 0 0 0 1 1 7 5 1
References Study Quality
6 (7979854) 4
25 (19879969) 4
MRI abdomen without IV contrast with MRCP May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 2 4 4 2 0
References Study Quality
2 (26526429) 4
23 (14628868) 2
25 (19879969) 4
27 (22332066) 2
28 (10937751) 2
29 (9676460) 2
21 (19711404) 4
22 (17581902) 3
CT abdomen without IV contrast May be appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 2 2 7 3 0 0 0 0
References Study Quality
2 (26526429) 4
7 (14661666) 4
8 (15256633) 4
9 (19098200) 4
12 (24224584) 4
15 (11804880) 3
16 (16671375) 3
17 (19559349) 2
18 (20489092) 4
19 (19497464) 3
20 (25424561) 3
26 (22798223) Good
CT abdomen without and with IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 4 6 1 0 0 1 0 0
References Study Quality
2 (26526429) 4
7 (14661666) 4
8 (15256633) 4
9 (19098200) 4
12 (24224584) 4
15 (11804880) 3
16 (16671375) 3
17 (19559349) 2
18 (20489092) 4
19 (19497464) 3
20 (25424561) 3
26 (22798223) Good
Variant 4: Right upper quadrant pain. Suspected acalculous cholecystitis. Negative or equivocal ultrasound.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Tc-99m cholescintigraphy Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 0 0 1 2 4 3 4
References Study Quality
30 (26526902) 3
CT abdomen with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 0 3 5 4 1 1
References Study Quality
2 (26526429) 4
15 (11804880) 3
31 (20489669) 3
Percutaneous cholecystostomy May be appropriate Strong Varies Varies Varies 6 6 0 0 0 3 4 4 3 0 0
References Study Quality
32 (21814147) 2
33 (25539703) 4
34 (7579876) 4
35 (22192897) 2
36 (22133709) 2
37 (21318431) 2
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 1 2 6 1 4 0
References Study Quality
2 (26526429) 4
21 (19711404) 4
22 (17581902) 3
23 (14628868) 2
MRI abdomen without IV contrast with MRCP May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 10 2 1 1 1
References Study Quality
2 (26526429) 4
21 (19711404) 4
22 (17581902) 3
23 (14628868) 2
CT abdomen without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 1 4 7 0 1 1 0 0
References Study Quality
2 (26526429) 4
15 (11804880) 3
31 (20489669) 3
CT abdomen without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 2 8 1 1 0 0 0 0
References Study Quality
2 (26526429) 4
15 (11804880) 3
20 (25424561) 3
31 (20489669) 3
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.