American College of Radiology
ACR Appropriateness Criteria®

Radiologic Management of Biliary Obstruction

Variant 1: Initial therapeutic procedure for a patient with dilated bile ducts from choledocholithiasis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Moderate N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (21872710) 3
10 (8813987) 2
Percutaneous internal/external biliary catheter May be appropriate Limited N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
23 (3566375) 4
24 (12204406) 4
25 (21638145) 3
26 (11577321) 4
27 (23782350) 4
Surgery Usually not appropriate Limited N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
25 (21638145) 3
28 (23999986) 4
Medical management only Usually not appropriate Expert Consensus N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate Limited N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
7 (21872710) 3
11 (21684464) 4
Removable biliary covered stent May be appropriate Expert Consensus N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Endoscopic US-guided biliary drainage (EUS-BD) May be appropriate Limited N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
12 (26020052) 4
Variant 2: Initial therapeutic procedure for a patient with elevated bilirubin and suspected sclerosing cholangitis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
35 (21241424) 4
38 (3584158) 4
39 (10483999) 2
Percutaneous internal/external biliary catheter May be appropriate Limited N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
35 (21241424) 4
37 (3876737) 3
Surgery Usually not appropriate Strong N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
41 (9527065) 2
42 (18471705) 2
43 (19845177) 4
Medical management only May be appropriate Strong N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
32 (24914504) 2
33 (27981301) 1
34 (15565569) 1
Permanent biliary metallic stent Usually not appropriate Limited N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
11 (21684464) 4
40 (20630513) 3
Removable biliary covered stent Usually not appropriate Limited N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
40 (20630513) 3
Variant 3: Initial therapeutic procedure for a liver transplant recipient with elevated bilirubin and suspected biliary anastomotic stenosis or bile leak, with no dilated ducts.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Strong N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
48 (16116539) 4
49 (21280189) 2
50 (18702031) 2
51 (29026597) Good
52 (24587819) 1
56 (23432435) 4
Percutaneous internal/external biliary catheter Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
46 (26689137) 4
49 (21280189) 2
56 (23432435) 4
Surgery Usually not appropriate Strong N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
46 (26689137) 4
58 (11907771) 2
59 (2799642) 2
Medical management only Usually not appropriate Limited N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
46 (26689137) 4
Permanent biliary metallic stent Usually not appropriate Limited N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
52 (24587819) 1
Removable biliary covered stent May be appropriate Limited N/A N/A 5 5 0 0 1 0 6 2 0 0 0
References Study Quality
52 (24587819) 1
Endoscopic US-guided biliary drainage (EUS-BD) Usually not appropriate Expert Consensus N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Initial therapeutic procedure for a patient with bile leak and dilated bile ducts following laparoscopic cholecystectomy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
61 (23322833) 4
62 (20575884) 4
66 (19220666) 2
67 (24954866) 4
Percutaneous internal/external biliary catheter Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
61 (23322833) 4
68 (14759778) 2
69 (18922456) 4
Surgery May be appropriate Limited N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
67 (24954866) 4
68 (14759778) 2
69 (18922456) 4
Medical management only Usually not appropriate Expert Consensus N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate Expert Consensus N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent Usually not appropriate Limited N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
71 (24661988) 4
Endoscopic US-guided biliary drainage (EUS-BD) Usually not appropriate Expert Consensus N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Initial therapeutic procedure for a patient with dilated bile ducts and suspected biliary sepsis or acute cholangitis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
79 (1371206) 3
80 (9336514) 4
81 (28834389) 1
Percutaneous internal/external biliary catheter Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
69 (18922456) 4
77 (28419764) 4
Surgery Usually not appropriate Limited N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
79 (1371206) 3
80 (9336514) 4
Medical management only Usually not appropriate Expert Consensus N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate Limited N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
81 (28834389) 1
Removable biliary covered stent Usually not appropriate Expert Consensus N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Endoscopic US-guided biliary drainage (EUS-BD) May be appropriate Limited N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
88 (27122677) 4
Variant 6: Initial therapeutic procedure for a patient with malignant common bile duct obstruction (eg, pancreatic carcinoma).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
95 (26290631) 4
96 (22415652) 1
Percutaneous internal/external biliary catheter Usually appropriate Strong N/A N/A 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
109 (25148939) Good
110 (19609609) 3
111 (24064748) 3
112 (12354980) 1
Surgery May be appropriate Strong N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
113 (21068488) 2
114 (19606687) 2
115 (-3138827) Good
116 (16632990) 4
Medical management only Usually not appropriate Limited N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
89 (26322156) 4
Percutaneous biliary metallic stent May be appropriate Strong N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
90 (26911896) 4
95 (26290631) 4
96 (22415652) 1
97 (16650542) 4
98 (20467870) 1
99 (21034892) 1
Removable biliary covered stent May be appropriate Strong N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
90 (26911896) 4
98 (20467870) 1
99 (21034892) 1
Endoscopic US-guided biliary drainage (EUS-BD) May be appropriate Strong N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
104 (21963067) 3
105 (23523301) 2
106 (23021167) 3
107 (22810111) 1
Variant 7: Initial therapeutic procedure for a patient with hilar biliary obstruction from malignant etiology (eg, Klatskin tumor).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) May be appropriate Strong N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
118 (15922889) 2
119 (19756881) 2
120 (18585976) 1
121 (18657806) 2
122 (16437689) 3
Percutaneous internal/external biliary catheter Usually appropriate Strong N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
118 (15922889) 2
119 (19756881) 2
120 (18585976) 1
121 (18657806) 2
122 (16437689) 3
Surgery May be appropriate Expert Consensus N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Medical management only Usually not appropriate Strong N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
117 (17461441) 4
118 (15922889) 2
119 (19756881) 2
Permanent biliary metallic stent May be appropriate Expert Consensus N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent May be appropriate Expert Consensus N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
Endoscopic US-guided biliary drainage (EUS-BD) Usually not appropriate Limited N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
123 (25024600) 4
124 (25264761) 2
125 (23711555) 4
126 (26379410) 4
Variant 8: Initial therapeutic procedure for a patient with dilated bile ducts and coagulopathy (INR >2.0 or platelet count <60 K).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
81 (28834389) 1
128 (18042116) 4
Percutaneous internal/external biliary catheter May be appropriate Limited N/A N/A 6 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
81 (28834389) 1
129 (20307987) 4
130 (22864606) 3
Surgery Usually not appropriate Expert Consensus N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Medical management only May be appropriate Expert Consensus N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Permanent biliary metallic stent Usually not appropriate Expert Consensus N/A N/A 1 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent Usually not appropriate Expert Consensus N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Endoscopic US-guided biliary drainage (EUS-BD) Usually not appropriate Expert Consensus N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
Variant 9: Initial therapeutic procedure for a patient with dilated bile ducts and moderate to massive ascites.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endoscopic internal biliary catheter (removable plastic stent) Usually appropriate Limited N/A N/A 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
133 (22464717) 2
Percutaneous internal/external biliary catheter May be appropriate Limited N/A N/A 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
133 (22464717) 2
Surgery Usually not appropriate Expert Consensus N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Medical management only May be appropriate Limited N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
131 (6606961) 4
132 (24433643) 3
133 (22464717) 2
Permanent biliary metallic stent Usually not appropriate Expert Consensus N/A N/A 2 n/a 0 0 0 0 0 0 0 0 0
Removable biliary covered stent May be appropriate Expert Consensus N/A N/A 4 n/a 0 0 0 0 0 0 0 0 0
Endoscopic US-guided biliary drainage (EUS-BD) Usually not appropriate Limited N/A N/A 3 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
134 (26811666) 4
135 (27129552) 2
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.