American College of Radiology
ACR Appropriateness Criteria®

Suspected Appendicitis-Child

Variant 1: Child. Suspected acute appendicitis, low clinical risk. 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 RLQ Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 0 8 7 3 0 0 0 0 0
References Study Quality
13 (24379237) 3
16 (24076607) 2
17 (21242447) 3
48 (27215717) 2
49 (26797233) 4
50 (27029683) 3
CT abdomen and pelvis with IV contrast Usually not appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 6 1 1 4 0 0 0 0
References Study Quality
38 (15837022) 2
39 (18074913) 3
50 (27029683) 3
53 (17543650) 3
54 (24595877) 3
55 (24682520) 3
MRI abdomen and pelvis without IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 2 6 6 3 3 0 0 0 0 0
References Study Quality
55 (24682520) 3
13 (24379237) 3
16 (24076607) 2
17 (21242447) 3
48 (27215717) 2
49 (26797233) 4
50 (27029683) 3
MRI abdomen and pelvis without and with IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 2 7 6 2 3 0 0 0 0 0
References Study Quality
55 (24682520) 3
13 (24379237) 3
16 (24076607) 2
17 (21242447) 3
48 (27215717) 2
49 (26797233) 4
50 (27029683) 3
US abdomen Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 2 1 10 5 2 0 0 0 0 0
References Study Quality
13 (24379237) 3
16 (24076607) 2
17 (21242447) 3
48 (27215717) 2
49 (26797233) 4
50 (27029683) 3
US pelvis Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 2 1 13 2 1 1 0 0 0 0
References Study Quality
13 (24379237) 3
16 (24076607) 2
17 (21242447) 3
48 (27215717) 2
49 (26797233) 4
50 (27029683) 3
52 (18082786) 3
Radiography abdomen Usually not appropriate Moderate ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 4 10 2 1 1 0 0 0 0
References Study Quality
13 (24379237) 3
16 (24076607) 2
17 (21242447) 3
48 (27215717) 2
49 (26797233) 4
50 (27029683) 3
51 (16456751) 3
CT abdomen and pelvis without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 4 0 1 1 0 0 0 0
References Study Quality
38 (15837022) 2
39 (18074913) 3
50 (27029683) 3
53 (17543650) 3
54 (24595877) 3
55 (24682520) 3
CT abdomen and pelvis without and with IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 12 5 0 1 0 0 0 0 0
References Study Quality
38 (15837022) 2
39 (18074913) 3
50 (27029683) 3
53 (17543650) 3
54 (24595877) 3
55 (24682520) 3
Variant 2: Child. Suspected acute appendicitis, intermediate clinical risk. 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 RLQ Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 6 11
References Study Quality
13 (24379237) 3
US abdomen Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 1 0 0 0 0 1 10 5 1
CT abdomen and pelvis with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 6 1 0 1 1 2 7 2 3 1
References Study Quality
53 (17543650) 3
54 (24595877) 3
55 (24682520) 3
38 (15837022) 2
39 (18074913) 3
CT abdomen and pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 4 3 1 3 2 4 1 0
References Study Quality
38 (15837022) 2
39 (18074913) 3
53 (17543650) 3
54 (24595877) 3
55 (24682520) 3
MRI abdomen and pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 6 1 0 0 2 5 4 3 3 0
References Study Quality
40 (26458209) 3
41 (26901006) Good
43 (25783291) 3
54 (24595877) 3
55 (24682520) 3
MRI abdomen and pelvis without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 4 2 3 2 3 3 2 2 1 0
References Study Quality
40 (26458209) 3
41 (26901006) Good
43 (25783291) 3
54 (24595877) 3
55 (24682520) 3
Radiography abdomen May be appropriate (Disagreement) Expert Opinion ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 5 2 2 10 0 0 1 2 1 1 0
References Study Quality
51 (16456751) 3
CT abdomen and pelvis without and with IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 6 6 3 0 2 0 1 0 0
References Study Quality
38 (15837022) 2
39 (18074913) 3
53 (17543650) 3
54 (24595877) 3
55 (24682520) 3
US pelvis Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 3 8 3 0 2 1 1 0 0
References Study Quality
52 (18082786) 3
Variant 3: Child. Suspected acute appendicitis, high clinical risk. 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 May be appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 1 0 1 0 3 11 0 2 0
References Study Quality
14 (25488354) 2
38 (15837022) 2
39 (18074913) 3
MRI abdomen and pelvis without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 1 0 4 4 7 1 1 0
US abdomen RLQ May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 1 1 0 3 7 5 0 1
References Study Quality
58 (25708690) 4
CT abdomen and pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 5 1 2 4 6 0 0 0
References Study Quality
14 (25488354) 2
38 (15837022) 2
39 (18074913) 3
MRI abdomen and pelvis without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 2 2 4 5 3 0 1 0
US abdomen May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 6 0 2 1 0 3 8 3 1 0
References Study Quality
58 (25708690) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 8 4 4 0 1 1 0 0 0
References Study Quality
14 (25488354) 2
38 (15837022) 2
39 (18074913) 3
US pelvis Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 1 12 2 0 2 1 0 0 0
References Study Quality
52 (18082786) 3
Radiography abdomen Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 11 3 3 1 0 0 0 0 0
References Study Quality
51 (16456751) 3
Variant 4: Child. Suspected acute appendicitis, equivocal or nondiagnostic right lower quadrant ultrasound. Next imaging study.
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 8 0 0 0 0 0 1 4 6 7
References Study Quality
18 (22849662) 3
37 (26518583) 2
38 (15837022) 2
39 (18074913) 3
61 (20053244) 2
65 (24917390) 3
68 (25903701) 2
69 (23217887) 3
70 (21324843) 3
MRI abdomen and pelvis without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 1 0 0 4 6 5 1
References Study Quality
40 (26458209) 3
41 (26901006) Good
48 (27215717) 2
71 (23617477) 2
72 (24590746) 3
MRI abdomen and pelvis without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 0 4 8 4 1
References Study Quality
40 (26458209) 3
41 (26901006) Good
48 (27215717) 2
71 (23617477) 2
72 (24590746) 3
CT abdomen and pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 7 0 2 2 3 1 1 3 6 0
References Study Quality
18 (22849662) 3
37 (26518583) 2
38 (15837022) 2
39 (18074913) 3
61 (20053244) 2
65 (24917390) 3
68 (25903701) 2
69 (23217887) 3
70 (21324843) 3
US abdomen May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 2 1 5 6 3 0 0 0
US abdomen RLQ May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 2 5 4 5 1 0 0
References Study Quality
67 (25808065) 2
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 6 7 0 0 1 0 0 1
References Study Quality
38 (15837022) 2
39 (18074913) 3
US pelvis Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 8 3 0 2 0 0 0 0
References Study Quality
52 (18082786) 3
Radiography abdomen Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 2 2 5 8 1 2 1 0 0 1 0
References Study Quality
51 (16456751) 3
Variant 5: Child. Suspected acute appendicitis with clinical suspicion or initial imaging suggestive of complication (eg, abscess, bowel obstruction). Next imaging study.
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 8 0 0 0 1 0 0 0 11 6
References Study Quality
38 (15837022) 2
39 (18074913) 3
CT abdomen and pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 3 1 2 8 2 2 0 0 3 0
References Study Quality
38 (15837022) 2
39 (18074913) 3
MRI abdomen and pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 2 2 2 1 5 4 1 1 0
References Study Quality
40 (26458209) 3
MRI abdomen and pelvis without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 4 2 2 3 4 2 1 0
References Study Quality
40 (26458209) 3
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 3 6 7 0 0 0 1 0 1
References Study Quality
38 (15837022) 2
39 (18074913) 3
US abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 5 1 5 3 3 1 0 0 0
US abdomen RLQ Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 2 5 4 2 0 1 0 0
References Study Quality
2 (26810020) 3
Radiography abdomen Usually not appropriate Limited ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 3 3 5 3 3 2 3 2 0 0 0
References Study Quality
51 (16456751) 3
US pelvis Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 5 4 2 0 1 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.