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Appropriateness Criteria

Variant 1: Right lower quadrant pain. 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 1 0 0 0 0 0 0 5 12
References Study Quality
29 (26341808) 2
33 (25419588) 3
27 (23023965) 2
26 (19843741) 2
34 (19733421) 4
31 (2239906) 4
28 (31743429) Good
32 (31219315) 4
1 (32684379) 3
30 (33211574) 3
US abdomen May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 4 10 1 2 0 0
References Study Quality
49 (25667065) 2
48 (23356200) 3
46 (10493202) 3
45 (3547490) 3
44 (3282253) 2
47 (15615956) 2
43 (1546592) 3
42 (2934762) 4
US pelvis May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 0 3 9 2 2 1 0
References Study Quality
51 (25499245) 3
50 (22421290) 3
24 (-3194700) 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 1 1 4 9 2 1 0
References Study Quality
40 (26901006) Good
36 (26807893) 2
37 (26526902) 3
38 (24272981) 2
35 (24168926) 2
39 (23481162) 2
21 (23266968) 3
3 (22033948) 2
MRI abdomen and pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 2 12 3 0 0 0
References Study Quality
40 (26901006) Good
36 (26807893) 2
37 (26526902) 3
38 (24272981) 2
35 (24168926) 2
39 (23481162) 2
21 (23266968) 3
3 (22033948) 2
CT abdomen and pelvis without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 0 2 6 7 1 0 0
References Study Quality
29 (26341808) 2
33 (25419588) 3
27 (23023965) 2
26 (19843741) 2
34 (19733421) 4
31 (2239906) 4
28 (31743429) Good
32 (31219315) 4
1 (32684379) 3
30 (33211574) 3
Radiography abdomen Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 2 4 11 0 0 0 0 0 0
References Study Quality
41 (22574093) 3
Fluoroscopy contrast enema Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 5 3 1 0 0 0 0 1
CT abdomen and pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 2 9 6 0 0 0 0 0 0
References Study Quality
29 (26341808) 2
33 (25419588) 3
27 (23023965) 2
26 (19843741) 2
34 (19733421) 4
31 (2239906) 4
28 (31743429) Good
32 (31219315) 4
1 (32684379) 3
30 (33211574) 3
WBC scan abdomen and pelvis Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 4 6 6 0 1 0 0 0 1
References Study Quality
52 (1456603) 3
Variant 2: 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
57 (27318889) 2
18 (26518583) 2
29 (26341808) 2
58 (26248155) 3
56 (26031278) Good
62 (25831188) 4
66 (25714280) 3
8 (25488354) 2
59 (25320531) 3
67 (25154940) 3
61 (25127845) 3
64 (24633221) 2
55 (24598250) 2
53 (23845254) 2
54 (22951113) 3
27 (23023965) 2
63 (22818790) 2
60 (22226440) 4
31 (2239906) 4
10 (21251432) Good
28 (31743429) Good
65 (29916776) Good
30 (33211574) 3
US abdomen May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
72 (27203288) 3
71 (25771443) 3
70 (25475515) 3
68 (24768483) 3
73 (22638942) 4
69 (22360013) 3
42 (2934762) 4
65 (29916776) Good
74 (31404675) Good
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
51 (25499245) 3
50 (22421290) 3
75 (22273324) 3
MRI abdomen and pelvis without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
40 (26901006) Good
36 (26807893) 2
37 (26526902) 3
38 (24272981) 2
39 (23481162) 2
3 (22033948) 2
65 (29916776) Good
23 (31420704) 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
40 (26901006) Good
36 (26807893) 2
37 (26526902) 3
38 (24272981) 2
39 (23481162) 2
3 (22033948) 2
65 (29916776) Good
23 (31420704) 3
CT abdomen and pelvis without IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
57 (27318889) 2
18 (26518583) 2
29 (26341808) 2
58 (26248155) 3
56 (26031278) Good
62 (25831188) 4
66 (25714280) 3
8 (25488354) 2
59 (25320531) 3
67 (25154940) 3
61 (25127845) 3
64 (24633221) 2
55 (24598250) 2
53 (23845254) 2
54 (22951113) 3
27 (23023965) 2
63 (22818790) 2
60 (22226440) 4
31 (2239906) 4
10 (21251432) Good
28 (31743429) Good
65 (29916776) Good
30 (33211574) 3
Radiography abdomen Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
41 (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
CT abdomen and pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
57 (27318889) 2
18 (26518583) 2
29 (26341808) 2
58 (26248155) 3
56 (26031278) Good
62 (25831188) 4
66 (25714280) 3
8 (25488354) 2
59 (25320531) 3
67 (25154940) 3
61 (25127845) 3
64 (24633221) 2
55 (24598250) 2
53 (23845254) 2
54 (22951113) 3
27 (23023965) 2
63 (22818790) 2
60 (22226440) 4
31 (2239906) 4
10 (21251432) Good
28 (31743429) Good
65 (29916776) Good
30 (33211574) 3
WBC scan abdomen and pelvis Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
52 (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
86 (27554180) 3
85 (24151869) 3
87 (22370694) 3
42 (2934762) 4
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
82 (26338256) 3
80 (26215327) 3
81 (25291255) 3
78 (25148766) 3
83 (23360736) 3
84 (-3188535) 4
76 (29869102) 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
78 (25148766) 3
33 (25419588) 3
79 (29948087) 4
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
78 (25148766) 3
33 (25419588) 3
79 (29948087) 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
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
82 (26338256) 3
80 (26215327) 3
81 (25291255) 3
78 (25148766) 3
83 (23360736) 3
84 (-3188535) 4
76 (29869102) 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
78 (25148766) 3
33 (25419588) 3
79 (29948087) 4
WBC scan abdomen and pelvis Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
73 (22638942) 4
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.