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 3 07 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
34 (22818790) 2
24 (23845254) 2
26 (24598250) 2
32 (25127845) 3
5 (25488354) 2
36 (25714280) 3
28 (27318889) 2
CT abdomen and pelvis without IV contrast May be appropriate Strong 2 07 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 1 4 6 4 1 0
References Study Quality
25 (22951113) 3
24 (23845254) 2
26 (24598250) 2
5 (25488354) 2
27 (26031278) Good
29 (26248155) 3
28 (27318889) 2
US abdomen May be appropriate Limited 3 O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
41 (22360013) 3
40 (24768483) 3
42 (25475515) 3
43 (25771443) 3
44 (27203288) 3
MRI abdomen and pelvis without and with IV contrast May be appropriate Limited 1 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 3 O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
46 (22273324) 3
48 (22421290) 3
47 (25499245) 3
MRI abdomen and pelvis without IV contrast May be appropriate Strong 2 07 O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
53 (23481162) 2
52 (24168926) 2
54 (24272981) 2
50 (26526902) 3
49 (26807893) 2
55 (26901006) Good
CT abdomen and pelvis without and with IV contrast Usually not appropriate Strong 3 07 ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 1 7 2 3 1 0 0 0
References Study Quality
24 (23845254) 2
32 (25127845) 3
5 (25488354) 2
Radiography abdomen Usually not appropriate Limited 3 ☢☢ 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 ☢☢☢ 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 3 ☢☢☢☢ 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 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
58 (25419588) 3
29 (26248155) 3
38 (26341808) 2
CT abdomen and pelvis without IV contrast May be appropriate Limited 1 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
58 (25419588) 3
29 (26248155) 3
38 (26341808) 2
US abdomen May be appropriate Limited 1 O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
59 (23356200) 3
60 (25667065) 2
US pelvis May be appropriate Limited 3 O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
48 (22421290) 3
47 (25499245) 3
MRI abdomen and pelvis without and with IV contrast May be appropriate Moderate 3 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 3 07 O 0 mSv O 0 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
51 (22033948) 2
14 (23266968) 3
53 (23481162) 2
52 (24168926) 2
54 (24272981) 2
50 (26526902) 3
49 (26807893) 2
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited 3 ☢☢☢☢ 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 3 ☢☢ 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 ☢☢☢ 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 3 ☢☢☢☢ 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 3 O 0 mSv O 0 mSv [ped] 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
64 (22370694) 3
62 (24151869) 3
63 (27554180) 3
MRI abdomen and pelvis without IV contrast Usually appropriate Limited 3 O 0 mSv O 0 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
68 (23360736) 3
61 (25148766) 3
66 (25291255) 3
65 (26215327) 3
67 (26338256) 3
US pelvis May be appropriate Expert Consensus 1 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 3 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
58 (25419588) 3
61 (25148766) 3
CT abdomen and pelvis without IV contrast May be appropriate Limited 3 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
58 (25419588) 3
61 (25148766) 3
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited 3 ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
58 (25419588) 3
61 (25148766) 3
Fluoroscopy contrast enema Usually not appropriate Expert Consensus 1 ☢☢☢ 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 3 O 0 mSv O 0 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
68 (23360736) 3
61 (25148766) 3
66 (25291255) 3
65 (26215327) 3
67 (26338256) 3
Tc-99m WBC scan abdomen and pelvis Usually not appropriate Limited 3 ☢☢☢☢ 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 1 ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 2 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.