American College of Radiology
ACR Appropriateness Criteria®

Left Lower Quadrant Pain — Suspected Diverticulitis

Variant 1: Left lower quadrant pain. Suspected diverticulitis. 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 Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 2 17
References Study Quality
42 (16126929) 2
41 (26070499) 3
40 (26385800) 2
39 (16168267) 3
38 (9609151) 3
36 (15505294) 4
35 (19517148) 3
34 (24187459) 3
33 (25972914) 4
32 (29204676) 3
31 (12740709) 3
27 (20054539) 3
17 (27082846) 4
13 (12034590) 3
4 (26526432) 4
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 0 1 11 3 3 0
References Study Quality
36 (15505294) 4
35 (19517148) 3
34 (24187459) 3
33 (25972914) 4
32 (29204676) 3
31 (12740709) 3
27 (20054539) 3
17 (27082846) 4
13 (12034590) 3
4 (26526432) 4
MRI abdomen and pelvis without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 5 11 1 0 0
References Study Quality
44 (7767748) 4
43 (16632733) 4
26 (19419830) 2
15 (15088109) 4
14 (23319717) 4
13 (12034590) 3
12 (18443876) 1
11 (16625348) 4
10 (16132933) 2
MRI abdomen and pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 0 2 3 6 5 2 1 0 0
References Study Quality
43 (16632733) 4
26 (19419830) 2
15 (15088109) 4
14 (23319717) 4
13 (12034590) 3
12 (18443876) 1
11 (16625348) 4
10 (16132933) 2
US abdomen transabdominal May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 1 4 2 6 4 2 0 0 0
References Study Quality
49 (25542939) 3
48 (21365197) 2
46 (12761647) 4
45 (24065248) 4
47 (18523784) Good
CT abdomen and pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 1 2 7 1 6 0 2 0 0
References Study Quality
42 (16126929) 2
41 (26070499) 3
40 (26385800) 2
39 (16168267) 3
38 (9609151) 3
36 (15505294) 4
35 (19517148) 3
34 (24187459) 3
33 (25972914) 4
32 (29204676) 3
31 (12740709) 3
27 (20054539) 3
17 (27082846) 4
13 (12034590) 3
4 (26526432) 4
Fluoroscopy contrast enema Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 8 3 1 0 0 0 0
References Study Quality
17 (27082846) 4
13 (12034590) 3
Radiography abdomen and pelvis Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 1 7 5 5 0 0 1 0 0
US pelvis transvaginal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 3 11 0 2 3 0 0 0 0
References Study Quality
50 (25884745) 4
4 (26526432) 4
Variant 2: Left lower quadrant pain. Suspected complications of diverticulitis.
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 Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 1 18
References Study Quality
59 (26827740) 4
58 (24258427) 4
57 (21326763) 4
56 (24280147) 3
55 (16498095) 3
54 (20574812) 3
53 (22752330) 2
52 (23592303) 2
51 (22404743) 4
31 (12740709) 3
9 (18443803) 4
7 (23061533) 4
CT abdomen and pelvis without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 1 0 0 0 4 13 1 0 0
References Study Quality
58 (24258427) 4
55 (16498095) 3
54 (20574812) 3
53 (22752330) 2
52 (23592303) 2
51 (22404743) 4
31 (12740709) 3
9 (18443803) 4
7 (23061533) 4
CT pelvis with bladder contrast (CT cystography) May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 1 3 9 5 0 0
References Study Quality
61 (26211219) 4
60 (23550466) 3
MRI abdomen and pelvis without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 1 0 1 5 6 6 0 0
References Study Quality
44 (7767748) 4
43 (16632733) 4
26 (19419830) 2
15 (15088109) 4
14 (23319717) 4
13 (12034590) 3
12 (18443876) 1
11 (16625348) 4
10 (16132933) 2
Fluoroscopy contrast enema May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 0 2 15 1 0 0 0
References Study Quality
60 (23550466) 3
13 (12034590) 3
Fluoroscopy cystography May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 0 2 5 7 4 1 0 0
References Study Quality
63 (15546583) 4
62 (1925872) 4
MRI abdomen and pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 2 0 4 9 3 1 0 0
References Study Quality
43 (16632733) 4
15 (15088109) 4
14 (23319717) 4
13 (12034590) 3
12 (18443876) 1
11 (16625348) 4
10 (16132933) 2
US abdomen transabdominal May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 6 2 6 3 1 0 0 0
References Study Quality
66 (23838329) 3
65 (26871408) 4
64 (24366280) 3
57 (21326763) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 1 2 16 0 0 0 0 0 0
References Study Quality
59 (26827740) 4
58 (24258427) 4
57 (21326763) 4
56 (24280147) 3
55 (16498095) 3
54 (20574812) 3
53 (22752330) 2
52 (23592303) 2
51 (22404743) 4
31 (12740709) 3
9 (18443803) 4
7 (23061533) 4
US pelvis transvaginal Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 3 4 4 4 3 1 0 0 0
References Study Quality
66 (23838329) 3
65 (26871408) 4
64 (24366280) 3
58 (24258427) 4
57 (21326763) 4
55 (16498095) 3
53 (22752330) 2
Radiography abdomen and pelvis Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 2 7 3 4 2 0 0 1 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.