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Appropriateness Criteria

Variant 1: Acute variceal bleeding. Child-Pugh class A, cirrhotic with index bleed from acute esophageal variceal hemorrhage, MELD 10, no encephalopathy. Initial therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic management Usually appropriate Strong N/A N/A 9 9 0 0 0 0 0 0 1 2 9
References Study Quality
30 (26047908) 4
32 (7635414) 1
33 (10430341) 1
34 (9222662) 4
35 (16127560) 1
36 (21084988) 1
37 (16904224) 1
38 (7611595) M
31 (19386609) 1
39 (16534680) 1
40 (10576359) 4
41 (12143259) 2
Medical therapy with vasoactive drugs Usually appropriate Strong N/A N/A 9 9 0 0 0 1 0 0 0 2 9
References Study Quality
27 (25788386) M
21 (9388396) 1
22 (11136956) 1
23 (22447260) 4
24 (7564670) 1
25 (10421644) 1
26 (11870374) M
28 (12076458) 4
29 (21707680) Not Assessed
Transjugular intrahepatic portosystemic shunt Usually not appropriate Limited N/A N/A 3 3 0 6 6 0 0 0 0 0 0
References Study Quality
30 (26047908) 4
Surgical shunt Usually not appropriate Limited N/A N/A 2 2 0 8 2 1 1 0 0 0 0
References Study Quality
42 (7601427) 4
43 (7484994) 1
Coated esophageal self-expandable metal stent Usually not appropriate Expert Consensus N/A N/A 1 1 7 4 0 1 0 0 0 0 0
Variant 2: Acute variceal bleeding. Child-Pugh class B, cirrhotic with active esophageal variceal hemorrhage, MELD 12, previously treated with octreotide and variceal ligation (EVL) on three prior occasions, no encephalopathy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic management Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 1 2 6 2
References Study Quality
31 (19386609) 1
39 (16534680) 1
40 (10576359) 4
41 (12143259) 2
Medical therapy with vasoactive drugs Usually appropriate Strong N/A N/A 8 8 0 0 0 1 1 0 1 3 5
References Study Quality
20 (22486630) M
27 (25788386) M
21 (9388396) 1
22 (11136956) 1
23 (22447260) 4
24 (7564670) 1
25 (10421644) 1
26 (11870374) M
Transjugular intrahepatic portosystemic shunt Usually appropriate Strong N/A N/A 7 7 0 0 0 0 0 2 4 3 2
References Study Quality
61 (14512892) 2
30 (26047908) 4
68 (26858143) M
49 (8608893) 1
50 (9163286) 1
51 (9362350) 1
52 (9425916) 1
53 (9107241) 1
54 (9163285) 1
55 (9352865) 1
56 (10429698) M
57 (10462365) M
59 (15382120) 1
60 (15046218) 1
64 (15118117) 2
65 (20801686) 2
67 (23517374) 4
69 (11171831) 1
58 (20573925) 1
66 (22940408) 2
62 (17617116) 1
63 (19097918) 2
Surgical shunt May be appropriate Strong N/A N/A 4 4 0 1 3 3 2 2 0 0 0
References Study Quality
47 (16697728) 1
42 (7601427) 4
44 (3527852) 4
45 () 4
46 (22463885) 1
48 (20726417) M
Coated esophageal self-expandable metal stent Usually not appropriate Expert Consensus N/A N/A 1 1 6 2 0 3 0 0 0 0 0
Variant 3: Acute variceal bleeding. Child-Pugh class C, cirrhotic with active esophageal and junctional variceal hemorrhage, previously treated with octreotide and endoscopic sclerotherapy, MELD 17, intermittent mild hepatic encephalopathy managed as an outpatient with nutritional support.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic management Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 1 1 7 2
References Study Quality
31 (19386609) 1
39 (16534680) 1
40 (10576359) 4
41 (12143259) 2
Medical therapy with vasoactive drugs Usually appropriate Strong N/A N/A 8 8 0 0 0 0 2 0 0 6 3
References Study Quality
20 (22486630) M
27 (25788386) M
21 (9388396) 1
22 (11136956) 1
23 (22447260) 4
24 (7564670) 1
25 (10421644) 1
26 (11870374) M
Transjugular intrahepatic portosystemic shunt Usually appropriate Strong N/A N/A 7 7 0 0 0 1 2 2 3 2 1
References Study Quality
61 (14512892) 2
30 (26047908) 4
26 (11870374) M
57 (10462365) M
72 (24148622) 4
77 (23066315) 2
74 (20844956) 4
75 (25864219) 2
79 (19721833) 2
78 (15886944) 3
76 (23312989) 3
73 (28501536) 3
71 (21625271) 2
Coated esophageal self-expandable metal stent May be appropriate Limited N/A N/A 5 5 1 0 1 2 5 1 1 0 0
References Study Quality
80 (22269340) 4
81 (23626509) 4
82 (19879564) 4
83 (23828748) 4
Surgical shunt May be appropriate Limited N/A N/A 5 5 0 2 2 1 5 1 0 0 0
References Study Quality
41 (12143259) 2
48 (20726417) M
70 (15650633) 4
Variant 4: Acute variceal bleeding. Child-Pugh class C, cirrhotic with hepatocellular carcinoma, branch portal vein tumor thrombus, and active esophageal and gastroesophageal type 1 (GOV1) variceal hemorrhage, MELD 24.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic management Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 1 1 8 1
References Study Quality
31 (19386609) 1
39 (16534680) 1
40 (10576359) 4
41 (12143259) 2
Medical therapy with vasoactive drugs Usually appropriate Strong N/A N/A 8 8 0 0 0 1 0 0 1 5 4
References Study Quality
21 (9388396) 1
22 (11136956) 1
23 (22447260) 4
24 (7564670) 1
25 (10421644) 1
26 (11870374) M
Percutaneous transhepatic embolization Usually appropriate Expert Consensus N/A N/A 7 7 0 0 1 0 1 2 7 0 0
Coated esophageal self-expandable metal stent May be appropriate Limited N/A N/A 5 5 0 0 1 2 3 5 0 0 0
References Study Quality
80 (22269340) 4
81 (23626509) 4
82 (19879564) 4
83 (23828748) 4
84 (18622540) 4
Transjugular intrahepatic portosystemic shunt May be appropriate Expert Consensus N/A N/A 5 5 0 0 0 0 7 5 0 0 0
Surgical shunt Usually not appropriate Expert Consensus N/A N/A 3 3 2 3 5 1 0 0 0 0 0
Variant 5: Ascites. Initial therapy for Child-Pugh class B cirrhotic asymptomatic patient with small-volume ascites.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical therapy and dietary modification Usually appropriate Expert Consensus N/A N/A 9 9 0 0 0 0 0 0 1 3 8
Large-volume paracentesis Usually not appropriate Expert Opinion N/A N/A 3 3 0 3 6 2 1 0 0 0 0
Volume expansion Usually not appropriate Expert Consensus N/A N/A 3 3 0 4 5 0 2 1 0 0 0
Peritoneovenous shunt Usually not appropriate Expert Consensus N/A N/A 2 2 4 7 1 0 0 0 0 0 0
Transjugular intrahepatic portosystemic shunt Usually not appropriate Expert Consensus N/A N/A 2 2 1 10 1 0 0 0 0 0 0
Variant 6: Ascites. Child-Pugh class B cirrhotic with chronic ascites despite daily diuretic therapy and low-sodium diet.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical therapy and dietary modification Usually appropriate Strong N/A N/A 8 8 0 0 0 1 0 1 2 4 3
References Study Quality
108 (18508290) 1
109 (20102356) 1
110 (20541828) 1
111 (20583214) 1
107 (21836029) Good
Large-volume paracentesis Usually appropriate Strong N/A N/A 7 7 0 0 0 0 0 1 8 1 1
References Study Quality
101 (21916992) 4
112 (8550036) 4
113 (1875966) 1
114 (12830009) 4
115 (19475696) 4
118 (3655306) 1
117 (3297907) 1
116 (24627607) M
Transjugular intrahepatic portosystemic shunt Usually appropriate Strong N/A N/A 7 7 0 0 0 0 0 2 4 4 1
References Study Quality
13 (17389705) 4
116 (24627607) M
132 (8878773) 1
133 (10841872) 1
134 (12612902) 1
135 (12454841) 1
136 (20632194) 1
137 (15349901) 1
Volume expansion Usually appropriate Strong N/A N/A 7 7 0 0 0 1 1 2 4 3 0
References Study Quality
127 (20492521) 4
119 (3360270) 1
120 (8119542) 2
121 (9247479) 2
122 (18410283) 1
123 (8831595) 1
124 (1699835) 1
125 (12717396) 1
126 (16420509) 1
128 (18251131) 1
129 (11772973) 1
130 (16460491) 1
131 (18547224) 1
Peritoneovenous shunt Usually not appropriate Strong N/A N/A 3 3 1 2 6 0 1 1 0 0 0
References Study Quality
113 (1875966) 1
138 (4415019) 4
139 (22997394) 4
140 (17278034) 4
141 (16181832) 4
142 (1736394) 4
143 (15166968) 1
144 (11376582) 4
Variant 7: Ascites. Child-Pugh class B cirrhotic with chronic ascites undergoing weekly large-volume paracentesis; rapidly declining renal function unresponsive to diuretic withdrawal.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Transjugular intrahepatic portosystemic shunt Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 2 2 7 0
References Study Quality
14 (19201943) 4
161 (10896924) 1
162 (9696006) 2
163 (8470157) 3
164 (14696397) 2
165 (15239086) 2
Medical therapy and dietary modification Usually appropriate Moderate N/A N/A 7 7 0 0 0 1 1 0 4 3 2
References Study Quality
145 (26896734) 1
146 (28052382) Good
Volume expansion Usually appropriate Expert Consensus N/A N/A 7 7 0 0 0 0 2 1 5 3 1
Large-volume paracentesis May be appropriate Strong N/A N/A 6 6 0 0 0 2 1 4 3 1 0
References Study Quality
127 (20492521) 4
119 (3360270) 1
120 (8119542) 2
121 (9247479) 2
122 (18410283) 1
123 (8831595) 1
124 (1699835) 1
125 (12717396) 1
126 (16420509) 1
128 (18251131) 1
129 (11772973) 1
130 (16460491) 1
131 (18547224) 1
Peritoneovenous shunt Usually not appropriate Strong N/A N/A 3 3 2 2 5 0 1 1 0 0 0
References Study Quality
113 (1875966) 1
140 (17278034) 4
141 (16181832) 4
142 (1736394) 4
143 (15166968) 1
144 (11376582) 4
166 (3537462) 1
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.