American College of Radiology
ACR Appropriateness Criteria®

Right Lower Quadrant Pain-Suspected Appendicitis

Variant 1: Right lower quadrant pain, fever, leukocytosis. Suspected appendicitis. 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] 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
28 (27318889) 2
36 (25714280) 3
5 (25488354) 2
32 (25127845) 3
26 (24598250) 2
24 (23845254) 2
34 (22818790) 2
CT abdomen and pelvis without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 1 4 6 4 1 0
References Study Quality
28 (27318889) 2
29 (26248155) 3
27 (26031278) Good
5 (25488354) 2
26 (24598250) 2
24 (23845254) 2
25 (22951113) 3
US abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
44 (27203288) 3
43 (25771443) 3
42 (25475515) 3
40 (24768483) 3
41 (22360013) 3
MRI abdomen and pelvis without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
51 (22033948) 2
US pelvis May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
47 (25499245) 3
48 (22421290) 3
46 (22273324) 3
MRI abdomen and pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
55 (26901006) Good
49 (26807893) 2
50 (26526902) 3
54 (24272981) 2
52 (24168926) 2
53 (23481162) 2
CT abdomen and pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 1 7 2 3 1 0 0 0
References Study Quality
5 (25488354) 2
32 (25127845) 3
24 (23845254) 2
Radiography abdomen Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 2 6 5 2 0 1 1 0 0
References Study Quality
56 (22574093) 3
Fluoroscopy contrast enema Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Tc-99m WBC scan abdomen and pelvis Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
57 (1456603) 3
Variant 2: Right lower quadrant pain, fever, leukocytosis. Possible appendicitis. Atypical presentation. 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 Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
38 (26341808) 2
29 (26248155) 3
58 (25419588) 3
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
38 (26341808) 2
29 (26248155) 3
58 (25419588) 3
US abdomen May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
60 (25667065) 2
59 (23356200) 3
US pelvis May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
47 (25499245) 3
48 (22421290) 3
MRI abdomen and pelvis without and with IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
55 (26901006) Good
MRI abdomen and pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
49 (26807893) 2
50 (26526902) 3
54 (24272981) 2
52 (24168926) 2
53 (23481162) 2
14 (23266968) 3
51 (22033948) 2
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 3 2 0 0 0
References Study Quality
31 (22226440) 4
Radiography abdomen Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 2 6 4 2 2 0 0 1 0
References Study Quality
56 (22574093) 3
Fluoroscopy contrast enema Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Tc-99m WBC scan abdomen and pelvis Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
57 (1456603) 3
Variant 3: Pregnant woman. Right lower quadrant pain, fever, leukocytosis. Suspected appendicitis. 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 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
63 (27554180) 3
62 (24151869) 3
64 (22370694) 3
MRI abdomen and pelvis without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
67 (26338256) 3
65 (26215327) 3
66 (25291255) 3
61 (25148766) 3
68 (23360736) 3
US pelvis May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
CT abdomen and pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
61 (25148766) 3
58 (25419588) 3
CT abdomen and pelvis without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
61 (25148766) 3
58 (25419588) 3
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
61 (25148766) 3
58 (25419588) 3
Fluoroscopy contrast enema Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
67 (26338256) 3
65 (26215327) 3
66 (25291255) 3
61 (25148766) 3
68 (23360736) 3
Tc-99m WBC scan abdomen and pelvis Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
45 (22638942) 4
Radiography abdomen Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 2 n/a 0 0 0 0 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.