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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. American College of Radiology. ACR–SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=23+&releaseId=2 Review/Other-Dx N/A To assist practitioners in providing appropriate radiologic care for pregnant or potentially pregnant adolescents and women by describing specific training, skills and techniques. No abstract available. 4
2. American College of Radiology. ACR Committee on MR Safety. 2024 ACR Manual on MR Safety. Available at: https://www.acr.org/-/media/ACR/Files/Radiology-Safety/MR-Safety/Manual-on-MR-Safety.pdf. Review/Other-Dx N/A Guidance document to promote the use of magnetic resonance (MR) safe practices. No abstract available. 4
3. De Santis M, Straface G, Cavaliere AF, Carducci B, Caruso A. Gadolinium periconceptional exposure: pregnancy and neonatal outcome. Acta Obstet Gynecol Scand. 2007;86(1):99-101. Review/Other-Dx 26 pregnant women Prospective cohort study to determine whether gadolinium derivatives exposure in periconceptional period is a risk factor for pregnancy or fetal development. The authors report the outcome of 26 pregnant women exposed to gadolinium derivatives in the first trimester without adverse effect on pregnancy and neonatal outcome. 4
4. American College of Radiology. ACR Committee on Drugs and Contrast Media. Manual on Contrast Media. Available at: https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf. Review/Other-Dx N/A Guidance document to assist radiologists in recognizing and managing the small but real risks inherent in the use of contrast media. No abstract available. 4
5. Kao LY, Scheinfeld MH, Chernyak V, Rozenblit AM, Oh S, Dym RJ. Beyond ultrasound: CT and MRI of ectopic pregnancy. [Review]. AJR Am J Roentgenol. 202(4):904-11, 2014 Apr. Review/Other-Dx N/A To discuss various forms of ectopic pregnancy and its complications that may occasionally be further evaluated with MRI or may be incidentally detected on CT or MRI when an alternative diagnosis is suspected. No results stated in abstract. 4
6. Huang Q, Zhang M, Zhai RY. The use of contrast-enhanced magnetic resonance imaging to diagnose cesarean scar pregnancies. Int J Gynaecol Obstet. 127(2):144-6, 2014 Nov. Observational-Dx 44 patients To evaluate whether contrast-enhanced magnetic resonance imaging (MRI) could be used as a routine method for diagnosing cesarean scar pregnancy (CSP). CSP was accurately diagnosed in 42 cases (95.5%) using contrast-enhanced MRI compared with 39 cases (88.6%) using ultrasonography (P<0.05). Two cases with a heterogeneous signal intensity pattern using MRI were initially misdiagnosed as a uterine leiomyoma and a trophoblastic tumor. No contrast agent-related complications occurred. The typical findings of a gestational sac embedded in the anterior lower part of the uterus in the sagittal T2-weighted views were identified in all the patients. All patients recovered well without experiencing major morbidity after treatment. 3
7. Srisajjakul S, Prapaisilp P, Bangchokdee S. Magnetic resonance imaging in tubal and non-tubal ectopic pregnancy. [Review]. Eur J Radiol. 93:76-89, 2017 Aug. Review/Other-Dx N/A To summarize imaging findings in tubal and non-tubal ectopic pregnancy with an emphasis on the roles and protocols of MRI, key MRI features, and differential diagnosis. No results stated in abstract. 4
8. Ramanathan S, Raghu V, Ladumor SB, et al. Magnetic resonance imaging of common, uncommon, and rare implantation sites in ectopic pregnancy. [Review]. Abdom Radiol. 43(12):3425-3435, 2018 12. Review/Other-Dx N/A To review the MRI appearances of tubal and non-tubal implantation sites in ectopic pregnancy. No results stated in abstract. 4
9. Durur-Karakaya A, Seker M, Durur-Subasi I. Diffusion-weighted imaging in ectopic pregnancy: ring of restriction sign. Br J Radiol. 91(1082):20170528, 2018 Feb. Observational-Dx 40 patients To demonstrate the diffusion-weighted imaging (DWI) findings of ectopic pregnancy (EP) and introduce the "ring of restriction" sign by discussing possible causes. All of them were haemodynamically and clinically stable and could be imaged adequately. Locations were ovary (n = 3, 37.5%), tuba (n = 2, 25%), Caesarean section scar (n = 2, 25%) and parauterine (n = 1, 12.5%). In all eight EPs, the gestational sac diameter was compatible with 7-9 weeks. With DWI, the gestational sac was seen as a thick-walled cyst-like structure. The thick wall showed diffusion restrictions in all patients (ring of restriction sign). 3
10. Leong GTT, Leonardi M, Lu C, et al. Doppler Color Scoring System in Women With an Incomplete Miscarriage: Interobserver and Intraobserver Reproducibility Study. J Ultrasound Med. 38(9):2437-2445, 2019 Sep. Review/Other-Dx N/A To assess inter- and intraobserver reproducibility of the DCS system in women with incomplete miscarriage noted on transvaginal sonography. Interobserver agreement for all observers for DCS allocation ranged from 0.480 to 0.751. Overall interobserver agreement for 5 observers was substantial (kappa, 0.626). Overall interobserver agreements for the 2 inexperienced and 3 experienced observers compared to G.C. were 0.521 and 0.618, respectively. Experienced observers achieved overall almost perfect intraobserver agreement, compared to substantial agreement for inexperienced sonologists. 4
11. Braffman BH, Coleman BG, Ramchandani P, et al. Emergency department screening for ectopic pregnancy: a prospective US study. Radiology. 1994;190(3):797-802. Observational-Dx 1,427 consecutive patients Prospective analysis of pelvic sonograms to determine the effectiveness of pelvic sonography as a screening test for ectopic pregnancy. Sonograms were diagnostic in 1,158 patients and indeterminate in 269. When indeterminate studies were considered falsely negative, the diagnostic accuracy was 81%. Sensitivity and specificity of screening US for ectopic pregnancy were 99% and 84%, respectively. Pelvic sonography is an effective screening test for ectopic pregnancy. 3
12. Frates MC, Doubilet PM, Peters HE, Benson CB. Adnexal sonographic findings in ectopic pregnancy and their correlation with tubal rupture and human chorionic gonadotropin levels. J Ultrasound Med. 33(4):697-703, 2014 Apr. Observational-Dx 231 pregnancies To determine whether the distribution of transvaginal sonographic findings of ectopic pregnancy has changed since the studies done 20 years ago and to explore the correlation of tubal rupture with transvaginal sonographic findings and human chorionic gonadotropin (hCG) levels. Our study included 231 ectopic pregnancies. A positive sonographic adnexal finding was present in 219 cases (94.8%): adnexal mass in 218 (94.4%) and a moderate-to-large amount of free fluid in 84 (36.4%). The adnexal masses were graded as follows: 1, nonspecific mass (125 cases [54.1% of total]); 2, tubal ring without a yolk sac or embryo (57 [24.7%]); 3, yolk sac but no embryonic heartbeat (19 [8.3%]); and 4, embryo with cardiac activity (17 [7.4%]). The mean hCG level increased as the grade ascended from 1 to 4. Thirty-six patients had tubal rupture at surgery within 24 hours of the sonogram. A moderate-to-large amount of free fluid was significantly associated with tubal rupture (P < .05) but had low sensitivity, specificity, and positive predictive value for rupture. Other sonographic findings and hCG levels were not significantly related to tubal rupture. 3
13. American College of Radiology. ACR–ACOG–AIUM–SPR–SRU Practice Parameter for the Performance of Ultrasound of the Female Pelvis. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=63+&releaseId=2 Review/Other-Dx N/A Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. No abstract available. 4
14. Doubilet PM, Benson CB, Bourne T, Blaivas M. Diagnostic criteria for nonviable pregnancy early in the first trimester. Ultrasound Q. 2014;30(1):3-9. Review/Other-Dx N/A Diagnostic criteria for nonviable pregnancy early in the first trimester. No results stated in abstract. 4
15. Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA. 2013;309(16):1722-1729. Review/Other-Dx 14 studies with 12,101 patients To systematically review the accuracy and precision of the patient history, clinical examination, readily available laboratory values, and sonography in the diagnosis of ectopic pregnancy in women with abdominal pain or vaginal bleeding during early pregnancy. All components of the patient history had a LR+ <1.5. The presence of an adnexal mass in the absence of an IUP on TVU (LR+ 111; 95% CI, 12–1028; n = 6,885), and the physical examination findings of cervical motion tenderness (LR+ 4.9; 95% CI, 1.7–14; n = 1,435), an adnexal mass (LR+ 2.4; 95% CI, 1.6–3.7; n = 1,378), and adnexal tenderness (LR+ 1.9; 95% CI, 1.0–3.5; n = 1,435) all increase the likelihood of ectopic pregnancy. A lack of adnexal abnormalities on TVU (LR- 0.12; 95% CI, 0.03–0.55; n = 6,885) decreases the likelihood of ectopic pregnancy. Existing studies do not establish a single serum hCG level that is diagnostic of ectopic pregnancy. 4
16. Goldstein SR, Snyder JR, Watson C, Danon M. Very early pregnancy detection with endovaginal ultrasound. Obstet Gynecol. 1988;72(2):200-204. Review/Other-Dx 235 patients Prospective study to observe imaging of early pregnancy with US. Imaging of normal pregnancies is possible when: Sac is >0.4 cm; hCG is >1025 mIU/mL; Uterus is normal with a homogeneous echo pattern. 4
17. Mehta TS, Levine D, Beckwith B. Treatment of ectopic pregnancy: is a human chorionic gonadotropin level of 2,000 mIU/mL a reasonable threshold? Radiology. 1997;205(2):569-573. Review/Other-Dx 676 patients Review medical records and US scans to determine whether hCG level of 2,000 mIU/ml is a reasonable threshold for diagnosing ectopic pregnancy in the absence of US findings of IUP in order to prevent inappropriate treatment. 548 patients had evidence of a normal or abnormal IUP. 51 (40%) of the 128 patients without evidence of an IUP had an hCG level >2,000 mIU/ml. Of 51 patients, 15 (29%) were treated for ectopic pregnancy; 17 (33%) were not immediately treated for ectopic pregnancy and had a normal IUP at follow-up US. hCG level of 2,000 mIU/ml without US findings of IUP is not diagnostic. 4
18. Barnhart KT, Fay CA, Suescum M, et al. Clinical factors affecting the accuracy of ultrasonography in symptomatic first-trimester pregnancy. Obstet Gynecol. 2011;117(2 Pt 1):299-306. Observational-Dx 1,880 women To evaluate factors associated with accuracy of initial US in patients with symptomatic first-trimester pregnancy. 1,880 women were evaluated. Overall accuracy of initial US diagnosis was 78%. A probable US diagnosis of ectopic pregnancy (adnexal mass without the presence of a yolk sac or embryo) resulted in a higher sensitivity (42.1% compared with 13.2%: P<.001) but a lower PPV (82.7% compared with 98%: P<.01) compared with a definite diagnosis. A probable US diagnosis of IUP (double decidual sign without yolk sac or embryo) resulted in a higher sensitivity (36.0% compared with 4.0%; P<.001) and lower PPV (58.8% compared with 87.0%; P>.001) compared with a definite diagnosis. The sensitivity (34.3% compared with 75.9%; P<.01) and PPV (80.4% compared with 91.5%; P=.02) were lower for diagnosis of ectopic pregnancy when serum hCG level was <2,000 mIU/mL. US was less accurate when bleeding was the chief complaint (72.7% compared with 84.8% P<.006) but not substantially altered by pain as a chief complaint (78.0% compared with 77.8% P>.99). 3
19. Moschos E, Twickler DM. Endometrial thickness predicts intrauterine pregnancy in patients with pregnancy of unknown location. Ultrasound Obstet Gynecol 2008;32:929-34. Observational-Dx 591 patients; complete data available for 517 patients To determine whether endometrial thickness and other parameters are useful predictors of normal IUP in the setting of vaginal bleeding and sonographic diagnosis of pregnancy of unknown location. 4 variables (maternal age, estimated gestational age by last menstrual period, endometrial thickness and serum beta-hCG) were significant in the prediction of normal IUP (area under the ROC curve = 0.86). As maternal age, estimated gestational age by last menstrual period and beta-hCG increased, the likelihood of a normal IUP decreased, while as the endometrial thickness increased, the likelihood of a normal IUP increased. For each millimeter increase in endometrial thickness, the odds increased by 27% that the patient would have a normal IUP. No normal IUP had an endometrial thickness <8 mm. 3
20. Shyu JY, Khurana B, Soto JA, et al. ACR Appropriateness Criteria® Major Blunt Trauma. J Am Coll Radiol 2020;17:S160-S74. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for major blunt trauma. No results stated in abstract. 4
21. Duigenan S, Oliva E, Lee SI. Ovarian torsion: diagnostic features on CT and MRI with pathologic correlation. AJR Am J Roentgenol. 2012;198(2):W122-131. Review/Other-Dx N/A CT and MRI features of ovarian torsion are illustrated with gross pathologic correlation. Ovarian enlargement with or without an underlying mass is the finding most frequently associated with torsion, but it is nonspecific. A twisted pedicle, although not often detected on imaging, is pathognomonic when seen. Subacute ovarian hemorrhage and abnormal enhancement is usually seen, and both features show characteristic patterns on CT and MRI. Ipsilateral uterine deviation can also be seen. 4
22. Wattar B, Rimmer M, Rogozinska E, Macmillian M, Khan KS, Al Wattar BH. Accuracy of imaging modalities for adnexal torsion: a systematic review and meta-analysis. BJOG. 128(1):37-44, 2021 01. Meta-analysis 15 studies To compare the test accuracy of ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) to diagnose AT. We screened 3836 citations, included 18 studies (1654 women, 665 cases), and included 15 in the meta-analyses. Ultrasound pooled sensitivity (n = 12, 1187 women) was 0.79 (95% CI 0.63-0.92) and specificity was 0.76 (95% CI 0.54-0.93), with negative and positive likelihood ratios of 0.29 (95% CI 0.13-0.66) and 4.35 (95% CI 2.03-9.32), respectively. Using Doppler with ultrasound (n = 7, 845 women) yielded similar sensitivity (0.80, 95% CI 0.67-0.93) and specificity (0.88, 95% CI 0.72-1.00). For MRI (n = 3, 99 women), the pooled sensitivity was 0.81 (95% CI 0.63-0.91) and specificity was 0.91 (95% CI 0.80-0.96). A meta-analysis for CT was not possible with two case-control studies and one cohort study (n = 3, 232 women). Its sensitivity range was 0.74-0.95 and specificity was 0.80-0.90. Good
23. Jeong WK, Kim Y, Song SY. Tubo-ovarian abscess: CT and pathological correlation. Clin Imaging 2007;31:414-8. Observational-Dx 13 patients To discern characteristic computed tomography (CT) findings of tubo-ovarian abscess (TOA). The main pelvic lesion on CT mostly corresponded to ovarian abscess, and satellite lesions corresponded to pyosalpinx on pathological examination. 4
24. Hiller N, Fux T, Finkelstein A, Mezeh H, Simanovsky N. CT differentiation between tubo-ovarian and appendiceal origin of right lower quadrant abscess: CT, clinical, and laboratory correlation. EMERG. RADIOL.. 23(2):133-9, 2016 Apr. Observational-Dx 91 patients To investigate which clinical, laboratory, and CT findings potentially facilitate the differential diagnosis between tubo-ovarian abscess (TOA) and periappendicular abscess (PAA). . Pain on cervical motion (67 %) and vaginal discharge (21 %) were significantly more common in TOA; other clinical signs were similar. The presence of right ovarian vein entering the mass on CT had 100 % specificity and 94 % sensitivity to TOA. Distended right fallopian tube (79 %), mass posterior to mesovarium (76 %), contralateral pelvic fat stranding (55 %), and thickening of sacrouterine ligaments (55 %) were significantly more common in TOA. Positive "arrowhead sign" (91 %), mesenteric lymphadenopathy (85 %), small bowel wall thickening (55 %), fluid in the right paracolic gutter (50 %), and cecal wall thickening (48 %) were significantly more common in PAA;internal gas was revealed only in PAA (33 %). 3
25. Li W, Zhang Y, Cui Y, Zhang P, Wu X. Pelvic inflammatory disease: evaluation of diagnostic accuracy with conventional MR with added diffusion-weighted imaging. Abdom Imaging. 2013;38(1):193-200. Observational-Dx 187 patients To determine the incremental value of MR diffusion-weighted imaging for the diagnosis of PIDs. Laparoscopic and pathological findings confirmed the diagnosis in all patients. Conventional MR findings were consistent with a diagnosis of PID in 90.7% (117/129) and of non-PID in 93.3% (28/30) of the 159 patients. The sensitivity, specificity, PPV, NPV, and accuracy of conventional MRI findings vs the addition of diffusion-weighted imaging to conventional MR protocols for predicting PID were 90.7%, 93.3%, 98.3%, 70.0%, and 91.2% and 98.4%, 93.3%, 98.4%, 93.3%, and 97.5%, respectively. 2
26. Sofic A, Husic-Selimovic A, Katica V, et al. Magnetic Resonance Imaging (MRI) and Transvaginal Ultrasonography (TVU) at Ovarian Pain Caused by Benign Ovarian Lesions. Acta Inform Med 2018;26:15-18. Observational-Dx 74 patients To define the possibilities of TVU and the MRI in the diagnosis of the most common benign ovarian lesions which cause pelvic pain. TVU demonstrated sensitivity of 83.3% for ectopic pregnancy, 83.3% for ovarian torsion, 84% for endometriotic cyst, 88.2% for hemorrhagic cysts, 58.3% for tubo-ovarian abscesses, 62.5% for dermoid cysts. Overall sensitivity of TVU for all these pathological entities was 78.4%. MRI showed a sensitivity of 100% for ovarian ectopic pregnancy, 83.3% for ovarian torsion, 100% for endometriotic cyst, 100% of hemorrhagic cysts, 83.3% tubo-ovarian abscess, and 87.5% for dermoid cysts. Overall sensitivity of MRI in all of these pathological entities was 94.6%. The analysis using the chi square test shows that there is a significant difference in the sensitivity between the US and MRI in favor of greater overall MRI sensitivity in diagnosing ovarian pain caused by benign lesions. (chi2 = 14.352, df = 9, p = 0.0021). 3
27. Wang T, Li W, Wu X, et al. Tubo-Ovarian Abscess (with/without Pseudotumor Area) Mimicking Ovarian Malignancy: Role of Diffusion-Weighted MR Imaging with Apparent Diffusion Coefficient Values. PLoS ONE. 11(2):e0149318, 2016. Observational-Dx 69 patients To assess the added value of diffusion-weighted magnetic resonance imaging (DWI) with apparent diffusion coefficient (ADC) values compared to MRI, for characterizing the tubo-ovarian abscesses (TOA) mimicking ovarian malignancy. The mean ADC value of the cystic component in TOA was significantly lower than in malignant tumors (1.04 +/- 0 .41 x 10(-3) mm(2)/s vs. 2.42 +/- 0.38 x 10(-3) mm(2)/s; p < 0.001). The mean ADC value of the enhanced solid component in 26 TOAs was 1.43 +/- 0.16x10(-3) mm(2)/s, and 46.2% (12 TOAs; pseudotumor areas) showed significantly higher signal intensity on DW-MRI than in ovarian malignancy (mean ADC value 1.44 +/- 0.20x10(-3) mm(2)/s vs.1.18 +/- 0.36 x 10(-3) mm(2)/s; p = 0.043). The combination diagnosis of ADC value and dilated tubal structure achieved the best AUC of 0.996. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MRI vs. DWI with ADC values for predicting TOA were 47.1%, 91.4%, 84.2%, 64%, and 69.6% vs. 100%, 97.1%, 97.1%, 100%, and 98.6%, respectively. 3
28. Bazot M, Darai E, Hourani R, et al. Deep pelvic endometriosis: MR imaging for diagnosis and prediction of extension of disease. Radiology. 232(2):379-89, 2004 Aug. Observational-Dx 195 Patients To prospectively evaluate the accuracy of magnetic resonance (MR) imaging for the preoperative diagnosis of deep pelvic endometriosis and extension of the disease. Pelvic endometriosis was confirmed at pathologic examination in 163 (83.6%) of 195 patients. Endometriomas, peritoneal lesions, and deep pelvic endometriosis were diagnosed on the basis of surgical findings, alone or combined with pathologic findings, in 111 (68.1%), 83 (50.9%), and 103 (63.2%) of 163 patients, respectively. Torus uterinus and USL were the most frequent sites of deep pelvic endometriosis. The sensitivity, specificity, positive and negative predictive values, and accuracy of MR imaging for deep pelvic endometriosis were 90.3% (93 of 103), 91% (84 of 92), 92.1% (93 of 101), 89% (84 of 94), and 90.8% (177 of 195), respectively. The sensitivity, specificity, and accuracy, respectively, of MR imaging for the diagnosis of endometriosis in specific sites were as follows: USL, 76% (57 of 75), 83.3% (100 of 120), and 80.5% (157 of 195); vagina, 76% (16 of 21), 95.4% (166 of 174), and 93.3% (182 of 195); rectovaginal septum, 80% (eight of 10), 97.8% (181 of 185), and 96.9% (189 of 195); rectosigmoid, 88% (53 of 60), 97.8% (132 of 135), and 94.9% (185 of 195); and bladder, 88% (14 of 16), 98.9% (177 of 179), and 97.9% (191 of 195). 3
29. Nizar K, Deutsch M, Filmer S, Weizman B, Beloosesky R, Weiner Z. Doppler studies of the ovarian venous blood flow in the diagnosis of adnexal torsion. J Clin Ultrasound. 37(8):436-9, 2009 Oct. Observational-Dx 199 patients To evaluate the role of ovarian Doppler studies in diagnosing adnexal torsion. Sensitivity and specificity of tissue edema, absence of intra-ovarian vascularity, absence of arterial flow, and absence or abnormal venous flow in the diagnosis of adnexal torsion were: 21% and 100%, 52% and 91%, 76% and 99%, and 100% and 97%, respectively. Abnormal ovarian venous flow may be the only abnormal US sign observed during the early stage of adnexal torsion. 3
30. Navve D, Hershkovitz R, Zetounie E, Klein Z, Tepper R. Medial or lateral location of the whirlpool sign in adnexal torsion: clinical importance. J Ultrasound Med. 32(9):1631-4, 2013 Sep. Review/Other-Dx 30 patients To describe the location of the whirlpool sign (lateral or medial to the ovary) and to evaluate the clinical importance of the location. 16/30 patients had right-sided torsion. Of these, 7 had a lateral whirlpool sign. All 7 of these patients had an ovarian or paraovarian mass. 9 of these 16 patients had a medial whirlpool sign. Of these, 7 had an ovarian or paraovarian mass, and 2 had no mass. Of the 14 patients with left-sided torsion, all had a medial whirlpool sign. 9/14 these patients had an ovarian or paraovarian mass, and 5 had no mass. The mean volume of the masses among cases with the lateral whirlpool sign was significantly greater compared to those with the medial whirlpool sign (304 vs 108 cm(3); P=.035). In 25/30 cases, the torsed components included the ovary. 4
31. Valsky DV, Esh-Broder E, Cohen SM, Lipschuetz M, Yagel S. Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion. Ultrasound Obstet Gynecol. 2010;36(5):630-634. Observational-Dx 80 women To evaluate the efficacy of the whirlpool sign in the diagnosis of torsion, as compared to a protocol based on ‘classic’ sonographic signs of torsion alone. 80 women were referred for laparoscopy for suspected adnexal torsion during the study period. In 22 women the ultrasound investigation had included the whirlpool sign (study group) while 58 had been examined by the standard protocol (control group). Twenty women in the study group had a positive whirlpool sign on ultrasound, 18 of whom (90.0%) had confirmed torsion on laparoscopy. In the control group 32 of 58 (55.2%) women had confirmed torsion on laparoscopy. 3
32. Molander P, Sjoberg J, Paavonen J, Cacciatore B. Transvaginal power Doppler findings in laparoscopically proven acute pelvic inflammatory disease. Ultrasound Obstet Gynecol. 17(3):233-8, 2001 Mar. Observational-Dx 30 study groups, 20 reference groups To assess the usefulness of Doppler TVU in diagnosing PID. To assess the diagnostic reliability of specific sonographic findings. Overall accuracy of Doppler TVU was 93%. 3
33. Romosan G, Bjartling C, Skoog L, Valentin L. Ultrasound for diagnosing acute salpingitis: a prospective observational diagnostic study. Hum Reprod. 28(6):1569-79, 2013 Jun. Observational-Dx 52 patients Aim of study is (i) to describe US findings in cases of acute mild, moderate and severe salpingitis verified by laparoscopy and (ii) to estimate the sensitivity and specificity of TVU for diagnosing acute salpingitis in patients with clinical signs of PID. Of the 52 patients, 23 (44%) had a final diagnosis unrelated to genital infection, while the other 29 had cervicitis (n = 3), endometritis (n = 9) or salpingitis (n = 17; mild n = 4, moderate n = 8, severe, ie, pyosalpinx n = 5). Bilateral adnexal masses and bilateral masses lying adjacent to the ovary were seen more often on US in patients with salpingitis than with other diagnoses (bilateral adnexal masses: 82 vs 17%, ie, 14/17 vs 6/35, P=0.000, positive LR 4.8, negative LR 0.22; bilateral masses adjacent to ovary: 65 vs 17%, ie, 11/17 vs 6/35, P=0.001, positive LR 3.8, negative LR 0.42). In cases of salpingitis, the masses lying adjacent to the ovaries were on average 2–3 cm in diameter, solid (n = 14), unilocular cystic (n = 4), multilocular cystic (n = 3) or multilocular solid (n = 1), with thick walls and well vascularized at color Doppler. In no case were the cogwheel sign or incomplete septae seen. All 13 cases of moderate or severe salpingitis were diagnosed with US (detection rate 100%, 95% CI, 78%–100%) compared with 1 of 4 cases of mild salpingitis. 3 of 6 cases of appendicitis, and 2 of 2 ovarian cysts were correctly diagnosed with US, and 1 case of adnexal torsion was suspected and then verified at laparoscopy. 2
34. Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS. Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound Obstet Gynecol. 1998;12(1):56-66. Observational-Dx 77 patients To identify sonographic markers of inflammatory disease of the pelvis. Tubo-ovarian complex and the TOA can be differentiated with TVU. 3
35. Adhikari S, Blaivas M, Lyon M. Role of bedside transvaginal ultrasonography in the diagnosis of tubo-ovarian abscess in the emergency department. J Emerg Med 2008;34:429-33. Observational-Dx 20 patients To describe the role of emergency department (ED) bedside transvaginal ultrasonography (US) in the diagnosis of TOA. Ages ranged from 14 to 45 years (mean 27 years). Seven (35%) patients reported a prior history of PID or sexually transmitted disease, and 1 (5%) was febrile. All had lower abdominal tenderness and 9 (45%) had cervical motion or adnexal tenderness. The sonographic abnormalities included 14 (70%) with a complex adnexal mass, 5 (25%) with echogenic fluid in the cul-de-sac, and 3 (15%) patients with pyosalpinx. The discharge diagnosis was TOA by the admitting gynecology service for all patients. 4
36. Abrao MS, Goncalves MO, Dias JA Jr, Podgaec S, Chamie LP, Blasbalg R. Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis. Hum Reprod. 22(12):3092-7, 2007 Dec. Observational-Dx 104 endometriosis patients To evaluate the capacity of digital vaginal examination, transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) to diagnose rectosigmoid and retrocervical involvement. Endometriosis was histologically confirmed in 98 of 104 (94.2%) patients. With respect to the rectosigmoid and retrocervical sites, respectively, digital vaginal examination had a sensitivity of 72 and 68%, specificity of 54 and 46%, positive predictive value (PPV) of 63 and 45%, negative predictive value (NPV) of 64 and 69% and accuracy of 63 and 55%. For TVUS, sensitivity was 98 and 95%, specificity 100 and 98%, PPV 100 and 98%, NPV 98 and 97% and accuracy 99 and 97%. MRI had a sensitivity of 83 and 76%, specificity of 98 and 68%, PPV of 98 and 61%, NPV of 85 and 81% and accuracy of 90 and 71%. 3
37. Lazarus E, Mayo-Smith WW, Mainiero MB, Spencer PK. CT in the evaluation of nontraumatic abdominal pain in pregnant women. Radiology. 2007;244(3):784-790. Observational-Dx 78 patients To retrospectively determine sensitivity and specificity of CT for the diagnosis of appendicitis in pregnant women with nontraumatic abdominal pain and retrospectively compare findings at CT and US in patients who underwent both examinations, with surgery or clinical follow-up as a reference standard. CT findings established the diagnosis in 35% of examinations in pregnant women with abdominal pain (28/80), with a NPV of 99% for appendicitis; when CT followed negative US findings, CT findings established the diagnosis in 30% of patients. 3
38. Raj MH, Mullins JN, Chi JM, Choy AH, Grimaldi GM, Friedman B. The utility of abdominopelvic CT in pregnant patients with abdominal pain and a negative or inconclusive abdominal MRI. Clin Imaging 2020;59:88-94. Review/Other-Dx 8 patients To describe CT findings in the pregnant population after negative or inconclusive MRI. No results stated in abstract. 4
39. Long SS, Long C, Lai H, Macura KJ. Imaging strategies for right lower quadrant pain in pregnancy. AJR Am J Roentgenol. 2011;196(1):4-12. Review/Other-Dx 6 articles To determine the best imaging technique to evaluate right lower quadrant pain in a pregnant patient. MRI provides a valuable tool for the evaluation of pregnant patients with right lower quadrant pain and can help avoid unnecessary laparotomies and radiation exposure from CT. Because cases of the nonvisualized appendix on MRI pose a diagnostic difficulty, further studies are needed to improve imaging protocols to decrease the incidence of nonvisualized appendix. 4
40. Theilen LH, Mellnick VM, Longman RE, et al. Utility of magnetic resonance imaging for suspected appendicitis in pregnant women. Am J Obstet Gynecol. 212(3):345.e1-6, 2015 Mar. Observational-Dx 171 pregnant women To estimate the rate and risk of appendix nonvisualization and alternative diagnoses made with magnetic resonance imaging (MRI) for suspected appendicitis in pregnant women. Over the 5-year period, 171 pregnant women underwent MRI for suspected appendicitis. The rate of nonvisualization was 30.9% (n = 53). Of the remaining 118 women with a visualized appendix, 18 women had imaging findings that were consistent with appendicitis and underwent appendectomy. Twelve cases of appendicitis were confirmed on pathologic evaluation (66.7%). Women with nonvisualization of the appendix on MRI were more likely to be beyond the first trimester (odds ratio, 2.1; 95% confidence interval, 1.0-4.5). Seventy-four women had disease diagnosed on MRI (43.3%). In the group of 43 women who had a nondiagnostic ultrasound scanning before the MRI, the rate of subsequent diagnostic MRI was 65% (n = 28). 3
41. Pedrosa I, Levine D, Eyvazzadeh AD, Siewert B, Ngo L, Rofsky NM. MR imaging evaluation of acute appendicitis in pregnancy. Radiology. 2006;238(3):891-899. Observational-Dx 51 patients To determine accuracy of MRI in pregnant patients with non-visualization of the appendix with US. MRI 100% accurate and 94% specific. Only 4 patients had appendicitis. 3
42. Amitai MM, Katorza E, Guranda L, et al. Role of Emergency Magnetic Resonance Imaging for the Workup of Suspected Appendicitis in Pregnant Women. Israel Medical Association Journal: Imaj. 18(10):600-604, 2016 Oct. Observational-Dx 49 patients To describe the process in setting up an around-the-clock MRI service for diagnosing appendicitis in pregnant women and to evaluate the contribution of abdominal MR in the diagnosis of acute appendicitis. In 88% of women appendicitis was ruled out and surgery was prevented. MRI diagnosed all cases with acute appendicitis and one case was inconclusive. The overall statistical performance of the study shows a negative predictive value of 100% (95%CI 91.9-100%) and positive predictive value of 83.3% (95%CI 35.9-99.6%). 3
43. Al-Katib S, Sokhandon F, Farah M. MRI for appendicitis in pregnancy: is seeing believing? clinical outcomes in cases of appendix nonvisualization. Abdom Radiol. 41(12):2455-2459, 2016 12. Observational-Dx 58 patients To determine the clinical outcomes in cases of appendix nonvisualization with MRI in pregnant patients with suspected appendicitis and the implications of appendix nonvisualization for excluding appendicitis. The rate of appendix visualization among the three radiologists ranged from 60 to 76% (p = 0.44). The appendix was nonvisualized by at least one of the three radiologists in 25 cases (50%). Of these, none had a final diagnosis of appendicitis including one patient who underwent appendectomy. MRI suggested an alternate diagnosis in 6 (24%) patients with appendix nonvisualization. For the three reviewers, the agreement level on whether or not the appendix was visualized on the MRI had a Light's kappa value of 0.526, indicating a "moderate" level of agreement (p value < 0.01). 3
44. Shin I, An C, Lim JS, Kim MJ, Chung YE. T1 bright appendix sign to exclude acute appendicitis in pregnant women. Eur Radiol. 27(8):3310-3316, 2017 Aug. Observational-Dx 125 patients To evaluate the diagnostic value of the T1 bright appendix sign for the diagnosis of acute appendicitis in pregnant women. The T1 bright appendix sign was seen in 51% of patients with normal appendices, but only in 4.5% of patients with acute appendicitis. The overall sensitivity, specificity, PPV, and NPV of the T1 bright appendix sign for normal appendix diagnosis were 44.9%, 95.5%, 97.6%, and 30.0%, respectively. All four patients with borderline sized appendix with appendicitis showed negative T1 bright appendix sign. 3
45. Wi SA, Kim DJ, Cho ES, Kim KA. Diagnostic performance of MRI for pregnant patients with clinically suspected appendicitis. Abdom Radiol. 43(12):3456-3461, 2018 12. Observational-Dx 125 patients To evaluate the accuracy of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis in pregnant patients and the value of additional diffusion-weighted MRI (DWI). The sensitivity, specificity, and accuracy of MRI for acute appendicitis were 100%, 95%, and 96%, respectively. The sensitivity, specificity, and accuracy of MRI without DWI (n = 72) vs. with DWI (n = 53) were 100%, 94.7%, and 95.8% versus 100%, 95%, and 96%, respectively. 3
46. Spencer JA, Chahal R, Kelly A, Taylor K, Eardley I, Lloyd SN. Evaluation of painful hydronephrosis in pregnancy: magnetic resonance urographic patterns in physiological dilatation versus calculous obstruction. J Urol. 2004;171(1):256-260. Review/Other-Dx 24 consecutive pregnant women To evaluate MRU appearances in hydronephrosis in pregnancy and compare urographic patterns in physiological and calculous disease. MRU is a valuable and well tolerated investigation for evaluating painful hydronephrosis in pregnancy. 4
47. Torkzad MR, Bremme K, Hellgren M, et al. Magnetic resonance imaging and ultrasonography in diagnosis of pelvic vein thrombosis during pregnancy. Thromb Res. 2010;126(2):107-112. Observational-Dx 27 patients To evaluate the agreement between US and MRI in diagnosing the extent of DVT into the pelvic veins during pregnancy. All 27 patients were imaged with both techniques at an average gestational age of 29 weeks (range 23–39). 3 cases (11.5%) of DVT in the pelvic veins were missed on US but detected by MRI. The upper limit of the DVT was always depicted at a higher (20 cases, 65.4%) or the same level (7 cases, 34.6%) on MRI than on US. Agreement expressed as kappa was 0.33 (95% CI, 0.27–0.40) demonstrating only fair agreement. In 1 woman the thrombus had propagated into the inferior vena cava, shown only on MRI. 3
48. Aras A, Karaman E, Peksen C, Kiziltan R, Kotan MC. The diagnosis of acute appendicitis in pregnant versus non-pregnant women: A comparative study. Rev Assoc Med Bras. 62(7):622-627, 2016 Oct. Observational-Dx 38 pregnant patients;169 non pregnant patients To investigate whether the diagnosis of acute appendicitis is affected by pregnancy or not. The time from admission to the operation was not statistically different (2.17+/-1.47 days in group I vs. 1.98+/-1.66 day in group II; p=0.288). The pregnant group had longer hospital stay than the non-pregnant group (p=0.04). Ultrasonography (USG) was used as the first diagnostic modality in 36/38 patients in group I and 161/169 in group II. The non-visualized appendix on ultrasound was seen in 17 patients in group I and 51 patients in group II, which was not statistically different. Sensitivity and specificity of USG in diagnosis of acute appendicitis were 61.29 and 80.00% in group I, and 93.0 and 31.6% in group II, respectively. 4
49. Segev L, Segev Y, Rayman S, Nissan A, Sadot E. The diagnostic performance of ultrasound for acute appendicitis in pregnant and young nonpregnant women: A case-control study. Int J Surg. 34:81-85, 2016 Oct. Observational-Dx 586 patients To compare the diagnostic performance of ultrasound in pregnant and young nonpregnant women with suspected acute appendicitis. Of 586 young women treated for appendicitis during the study periods (92 pregnant, 494 non-pregnant), 200 underwent preoperative ultrasound [67 pregnant, and 133 nonpregnant young women]. The pregnant and nonpregnant groups were comparable in age and presenting symptoms. There was no significant difference in the predictive performance of ultrasound between the two groups (AUC 0.76 and 0.73 respectively, p = 0.78) or within the pregnant group, by trimester [first (n = 23), AUC 0.73; second (n = 32), AUC 0.67; third (n = 12), AUC 0.86; p = 0.4]. Ultrasound had a positive predictive value of 0.94 in the pregnant group and 0.91 in the nonpregnant group; corresponding negative predictive values were 0.40 and 0.43. 3
50. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Radiology. 241(1):83-94, 2006 Oct. Meta-analysis Children: (26 studies, 9,356 patients); Adults (31 studies, 4,341 patients) To perform a meta-analysis to evaluate the diagnostic performance of US and CT for the diagnosis of appendicitis in pediatric and adult populations. Children: Sensitivity of 88% (95% CI: 86%, 90%) and specificity of 94% (95% CI: 92%, 95%), for US studies and sensitivity of 94% (95% CI: 92%, 97%) and specificity of 95% (95% CI: 94%, 97%) for CT studies. Adults: Pooled sensitivity and specificity for diagnosis were 83% (95% CI: 78%, 87%) and 93% (95% CI: 90%, 96%), respectively, for US studies and 94% (95% CI: 92%, 95%) and 94% (95% CI: 94%, 96%), respectively, for CT studies. CT had higher sensitivity and specificity than US. From a safety perspective, US should be considered initially in children. M
51. Crocker C, Akl M, Abdolell M, Kamali M, Costa AF. Ultrasound and CT in the Diagnosis of Appendicitis: Accuracy With Consideration of Indeterminate Examinations According to STARD Guidelines. AJR Am J Roentgenol. 215(3):639-644, 2020 09. Observational-Dx 790 patients To determine the accuracy of ultrasound (US) and CT in diagnosing appendicitis at our institution while taking into account the number of indeterminate examinations in accordance with the Standards for Reporting Diagnostic Accuracy (STARD) guidelines. A total of 473 of 562 US examinations had indeterminate findings (overall test yield, 15.8%); sensitivity and specificity in the 89 diagnostic examinations were 98.5% and 54.2%, respectively. Thirteen of 522 CT examinations were indeterminate (overall test yield, 97.5%); sensitivity and specificity in the remaining 509 CT examinations were 98.9% and 97.2%, respectively. Taking indeterminate studies into account, the accuracy was 13.7% for US and 95.6% for CT. The negative appendectomy rates were 17.7% (11/62) for US and 3.3% (9/276) for CT (p = 0.0002). Time to surgery was longer for patients who underwent US and CT (mean +/- SD, 17.7 +/- 8.9 hours) than US alone (12.9 +/- 6.4 hours; p = 0.002) but was not longer for patients who underwent CT alone (16.3 +/- 8.4 hours; p = 0.45). 3
52. Ranieri DM, Enzerra MD, Pickhardt PJ. Prevalence of Appendicoliths Detected at CT in Adults With Suspected Appendicitis. AJR Am J Roentgenol. 216(3):677-682, 2021 03. Observational-Dx 248 patients To investigate the prevalence of appendicoliths at CT in adults with suspected appendicitis. The prevalence of appendicoliths at CT was 38.7% (96/248) among patients with appendicitis and 4.4% (11/248) among control subjects (p < .001). Among the 96 patients with appendicitis who had visible appendicoliths, mean width, length, and maximum attenuation of the dominant appendicolith were 6.0 mm, 8.2 mm, and 313 HU, respectively. In 70.8% (68/96) of patients appendicoliths were obstructing, and 32.3% (31/96) of patients had more than one appendicolith. Inflammation (1.75 vs 1.43) and likelihood of perforation (2.07 vs 1.51) (p < .05) scores were higher among patients with appendicitis who had appendicoliths. Extraluminal appendicoliths were seen in five cases of perforated appendicitis. 3
53. Tang SJ, Pickhardt PJ, Kim DU, Pooler BD. Positive Oral Contrast Solution at MDCT for Suspected Acute Appendicitis in Adults: Rate of Appendiceal Luminal Filling of Normal and Inflamed Appendixes. AJR Am J Roentgenol. 213(5):W211-W217, 2019 11. Observational-Dx 684 patients To assess the rate of appendiceal filling with a positive oral contrast solution at MDCT performed for suspected acute appendicitis in adults. Cecal opacification was confirmed in 313/519 (60.3%) patients, with no difference between those considered to be positive (68/107, 63.6%) or negative (245/412, 59.5%) for appendicitis (p = 0.506). When positive oral contrast solution reached the cecum, appendiceal filling was seen in none of the 68 (0%) with appendicitis and in 205 of the 245 (83.7%) without appendicitis (p < 0.0001). Among CTC control subjects, appendiceal filling was similar to the cohort considered to be without appendicitis (2240/2552 [87.8%], p = 0.070). 3
54. Wadhwani A, Guo L, Saude E, et al. Intravenous and Oral Contrast vs Intravenous Contrast Alone Computed Tomography for the Visualization of Appendix and Diagnosis of Appendicitis in Adult Emergency Department Patients. Can Assoc Radiol J. 67(3):234-41, 2016 Aug. Observational-Dx 211 patients To compare radiologist's ability to 1) visualize the appendix; 2) diagnose acute appendicitis; and 3) diagnose alternative pathologies responsible for acute abdominal pain among adult patients undergoing computed tomography (CT) scan with 3 different protocols: 1) intravenous (IV) contrast only; 2) IV and oral contrast with 1-hour transit time; and 3) IV and oral contrast with 3-hour transit time. Frequency of visualizing the appendix within IV group alone was 87.3%, IV with oral for 1 hour was 94.1%, and IV with oral for 3 hours was 93.8%. Both oral contrast groups had 100% sensitivity and negative predictive value in diagnosis of acute appendicitis. Specificity for the 1- and 3-hour oral contrast groups was 94.1% and 96.1%, respectively and positive predictive value for both groups was 92%. 2
55. Naeger DM, Chang SD, Kolli P, Shah V, Huang W, Thoeni RF. Neutral vs positive oral contrast in diagnosing acute appendicitis with contrast-enhanced CT: sensitivity, specificity, reader confidence and interpretation time. Br J Radiol. 84(1001):418-26, 2011 May. Observational-Dx 200 patients with neutral and 200 with positive oral contrast To compare the sensitivity, specificity, confidence and interpretation time of readers of differing experience in diagnosing acute appendicitis with contrast-enhanced CT using neutral vs positive oral contrast agents. Average reader sensitivity was found to be 96% (range 91%–99%) with positive and 95% (89%–`98%) with neutral oral contrast; specificity was 96% (92%–98%) and 94% (90%–97%). For each reader, no statistically significant difference was found between the 2 agents (sensitivities P>0.6; specificities P>0.08), in the area under the ROC curve (range 0.95–0.99) or in average interpretation times. In cases without appendicitis, positive oral contrast demonstrated improved appendix identification (average 90% vs 78%) and higher confidence scores for 3 readers. Average interpretation times showed no statistically significant differences between the agents. 2
56. Kim K, Kim YH, Kim SY, et al. Low-dose abdominal CT for evaluating suspected appendicitis. N Engl J Med. 366(17):1596-605, 2012 Apr 26. Experimental-Tx 891 patients To evaluate the rate of negative (unnecessary) appendectomy after low-dose vs standard-dose abdominal CT in young adults with suspected appendicitis. The negative appendectomy rate was 3.5% (6/172 patients) in the low-dose CT group and 3.2% (6/186 patients) in the standard-dose CT group (difference, 0.3 percentage points; 95% CI, -3.8 to 4.6). The 2 groups did not differ significantly in terms of the appendiceal perforation rate (26.5% with low-dose CT and 23.3% with standard-dose CT, P=0.46) or the proportion of patients who needed additional imaging tests (3.2% and 1.6%, respectively; P=0.09). 1
57. Sippola S, Virtanen J, Tammilehto V, et al. The Accuracy of Low-dose Computed Tomography Protocol in Patients With Suspected Acute Appendicitis: The OPTICAP Study. Ann Surg. 271(2):332-338, 2020 02. Observational-Dx 60 patients To compare diagnostic accuracy of contrast enhanced low-dose computed tomography (CT) accomplished in the OPTICAP trial phantom phase to standard CT in patients with suspected acute appendicitis. The low-dose protocol was not inferior to standard protocol in terms of diagnostic accuracy; 79% [95% confidence interval (CI) 66%-89%) accurate diagnosis in low-dose and 80% (95% CI 67%-90%) in standard CT by primary radiologist. Accuracy to categorize appendicitis severity was 79% for both protocols. The mean radiation dose of low-dose CT was significantly lower compared with standard CT (3.33 and 4.44 mSv, respectively). 4
58. Tamburrini S, Brunetti A, Brown M, Sirlin C, Casola G. Acute appendicitis: diagnostic value of nonenhanced CT with selective use of contrast in routine clinical settings. Eur Radiol. 17(8):2055-61, 2007 Aug. Observational-Dx 536 To determine the (1) frequency with which nonenhanced computed tomography (CT) (NECT) permits conclusive diagnosis of acute appendicitis, (2) accuracy of NECT when findings are conclusive, and (3) overall accuracy of a CT protocol consisting of NECT with selective use of contrast. Sensitivity, specificity,and positive and negative predictive value for diagnosis of acute appendicitis were (1) 90%, 96.0%, 84.8%, and 97.4% in patients with conclusive NECT (n=404); (2) 95.6%, 92.3%, 73%, and 99% in patients with inconclusive NECT followed by repeat CT with contrast; and (3) 91.3%, 95%, 82%, and 98% in all patients. The initial diagnosis of appendicitis may be made by NECT in 75% of patients, with contrast administration reserved for inconclusive NECT studies. 2
59. Desai V, Cox M, Deshmukh S, Roth CG. Contrast-enhanced or noncontrast CT for renal colic: utilizing urinalysis and patient history of urolithiasis to decide. Emergency Radiology. 25(5):455-460, 2018 Oct. Observational-Dx 350 patients To investigate the combined utility of urinalysis and history of urolithiasis in identifying patients who are unlikely to have urolithiasis and may benefit from a contrast-enhanced study. 175 patients (62%) had an obstructing calculus. RBC-positive urinalysis was present in 231 patients with calculi on CT (sensitivity 82%). Patient history of urolithiasis plus urinalysis had a sensitivity of 94% for detecting calculi. Thirty-five patients (10%) had alternative diagnoses, 33 of which were in patients without obstructing calculi. Sixty-seven patients underwent noncontrast CT despite no history of urolithiasis and a negative urinalysis, 10 of which (15%) had alternative diagnoses. Only three cases in this subset (4%) had nonobstructing 1-2-mm calculi, potentially missed with contrast. In this subset, the projected proportion of optimally characterized cases with intravenous contrast is 96%, compared to 85% without contrast (p = .03). 3
60. Kim BS, Hwang IK, Choi YW, et al. Low-dose and standard-dose unenhanced helical computed tomography for the assessment of acute renal colic: prospective comparative study. Acta Radiol. 2005;46(7):756-763. Observational-Dx 121 patients Prospective study to compare the efficacy of low-dose and standard-dose CT for the diagnosis of ureteral stones. Compared with standard scans using 260 mAs, low-dose CT using 50 mAs results in 81% decrease in radiation dose. 2
61. Niemann T, Kollmann T, Bongartz G. Diagnostic performance of low-dose CT for the detection of urolithiasis: a meta-analysis. AJR Am J Roentgenol. 2008;191(2):396-401. Meta-analysis 7 studies with 1061 patients A meta-analysis evaluating low-dose CT (<3 mSv) for detection of urinary calculi. Pooled sensitivity and specificity of low-dose CT for the diagnosis of urinary calculi were 0.966 and 0.949, respectively. M
62. Poletti PA, Platon A, Rutschmann OT, Schmidlin FR, Iselin CE, Becker CD. Low-dose versus standard-dose CT protocol in patients with clinically suspected renal colic. AJR Am J Roentgenol. 2007;188(4):927-933. Observational-Dx 125 patients To compare a low-dose CT protocol with standard-dose unenhanced CT in patients with suspected renal colic. Low-dose CT has sensitivities and specificities close to those of standard-dose CT. In patients with a body mass index of <30, low-dose CT achieved 96% sensitivity and 100% specificity for the detection of indirect signs of renal colic and a sensitivity of 95% and a specificity of 97% for detecting ureteral calculi. Low-dose CT was 86% sensitive for detecting ureteral calculi <3 mm and 100% sensitive for detecting calculi >3 mm. 2
63. Inoue A, Furukawa A, Nitta N, et al. Accuracy, criteria, and clinical significance of visual assessment on diffusion-weighted imaging and apparent diffusion coefficient quantification for diagnosing acute appendicitis. Abdom Radiol. 44(10):3235-3245, 2019 10. Observational-Dx 51 patients To assess the accuracy, criteria, and clinical significance of diffusion-weighted imaging (DWI) signal intensity and apparent diffusion coefficient (ADC) quantification for diagnosing acute appendicitis. For diagnosing acute appendicitis, the accuracy improved from 78.4% using only T2WI to 86.3% using combined T2WI and DWI for reader 1 and from 82.4 to 86.3% for reader 2. For the appendix, the cut-off ADC values that diagnosed appendicitis were 1.41 x 10(-3) and 1.26 x 10(-3) mm(2)/s with accuracies of 78.4% and 76.5%, respectively. For the peri-appendiceal tissue, these values of 1.03 x 10(-3) and 0.91 x 10(-3) mm(2)/s differentiated between uncomplicated and complicated appendicitis with an accuracy of 97.1%. 3
64. Leeuwenburgh MM, Wiezer MJ, Wiarda BM, et al. Accuracy of MRI compared with ultrasound imaging and selective use of CT to discriminate simple from perforated appendicitis. Br J Surg. 101(1):e147-55, 2014 Jan. Observational-Dx 230 patients To estimate the accuracy of magnetic resonance imaging (MRI) in distinguishing between simple and perforated appendicitis, and to compare MRI against ultrasound imaging with selected additional (conditional) use of computed tomography (CT). MRI was performed in 223 of 230 included patients. Acute appendicitis was the final diagnosis in 118 of 230 patients, of whom 87 had simple and 31 perforated appendicitis. MRI correctly identified 17 of 30 patients with perforated appendicitis (sensitivity 57 (95 per cent confidence interval 39 to 73) per cent), whereas ultrasound imaging with conditional CT identified 15 of 31 (sensitivity 48 (32 to 65) per cent) (P = 0.517). All missed diagnoses of perforated appendicitis were identified as simple acute appendicitis with both imaging protocols. None of the MRI features for perforated appendicitis had a positive predictive value higher than 53 per cent. 2
65. Muthusami P, Bhuvaneswari V, Elangovan S, Dorairajan LN, Ramesh A. The role of static magnetic resonance urography in the evaluation of obstructive uropathy. Urology. 81(3):623-7, 2013 Mar. Observational-Dx 69 patients To assess the diagnostic accuracy of static MRU in hydronephrosis and to compare parameters of hydronephrosis in MRU with IV urography. The sensitivity and specificity MRU in detecting hydronephrosis were 95% and 100%, respectively. In determining the level of obstruction, the strength of agreement between IV urography and MRU using kappa statistics was kappa = 0.66, which corresponds to a good level of agreement. The Spearman correlation coefficient for the grade of hydronephrosis on MRU and IV urography was 0.92 (95% CI, 0.86–0.95), with a P<.0001. The correct diagnosis was made in 89.2% of the cases by IV urography and in 93.8% of the cases by MRU. 2
66. Lourenco P, Brown J, Leipsic J, Hague C. The current utility of ultrasound in the diagnosis of acute appendicitis. Clin Imaging. 40(5):944-8, 2016 Sep-Oct. Observational-Dx 354 patients To evaluate the current performance of ultrasound in the diagnosis of acute appendicitis. Our data demonstrates that ultrasound (US) relative to surgery-confirmed appendicitis has a sensitivity and specificity of 48.4% and 97.9%, respectively. The diagnostic accuracy was further increased when there was a low pre-test probability, with a negative predictive value (NPV) of up to 96.6%. 3
67. Geerdink TH, Augustinus S, Atema JJ, Jensch S, Vrouenraets BC, de Castro SMM. Validation of a Scoring System to Distinguish Uncomplicated From Complicated Appendicitis. J Surg Res. 258:231-238, 2021 02. Observational-Dx 678 patients To externally validate the scoring system. A total of 678 patients with suspected acute appendicitis based on clinical and ultrasonography findings were identified, of whom 175 (25.8%) had complicated appendicitis, 491 (72.4%) had uncomplicated appendicitis, and 12 (1.8%) had an alternative disease. Of the 678 patients, 272 had a score of five points or less, of whom 17 (6.2%) had complicated appendicitis, giving a negative predictive value of 93.8%. 4
68. Shirah BH, Shirah HA, Alhaidari WA, Elraghi MA, Chughtai MA. The role of preoperative graded compression ultrasound in detecting acute appendicitis and influencing the negative appendectomy rate. Abdom Radiol. 42(1):109-114, 2017 01. Observational-Dx 1073 patients To evaluate the graded compression ultrasonography in the diagnosis of acute appendicitis, its influence on the clinical judgment to operate, and its role in lowering the negative appendectomy rate. 647 (60.3%) patients were males and 426 (39.7%) females. The mean age was 26.5 years. Positive ultrasound findings were recorded in 892 (83.13%), while negative findings were recorded in 181 (16.87%). Positive appendectomy was recorded in 983 (91.6%), while negative appendectomy was recorded in 90 (8.4%). The sensitivity was 83%, specificity was 100%, and the rate of negative appendectomy was 8.39%. 3
69. Ulusan S, Koc Z, Tokmak N. Accuracy of sonography for detecting renal stone: comparison with CT. J Clin Ultrasound. 2007; 35(5):256-261. Observational-Dx 50 patients To determine accuracy of US in the detection of renal stones. Noncontrast CT is used as the gold standard. Also correlated the accuracy of US with stone size, kidney affected (right vs. left) and body mass index (BMI). Sensitivity of US was 52%-57% for the right kidney and 32%-39% for the left kidney. The overall accuracy of US in detecting a stone in the right kidney by radiologists 1 and 2 was 67% and 77%, respectively. The corresponding accuracy values for the left kidney were 53% and 54%, respectively. 2
70. Sternberg KM, Pais VM Jr, Larson T, Han J, Hernandez N, Eisner B. Is Hydronephrosis on Ultrasound Predictive of Ureterolithiasis in Patients with Renal Colic?. J Urol. 196(4):1149-52, 2016 Oct. Observational-Dx 144 patients To investigate whether the presence of hydronephrosis on ultrasound is associated with a ureteral stone in patients who undergo both ultrasound and computerized tomography during the evaluation of acute renal colic. Ureteral stones were present in 85 of 144 patients. Ultrasound identified hydronephrosis in 89.8% of patients and a ureteral stone in 25.9%. Computerized tomography identified hydronephrosis in 91.8% of patients and a ureteral stone in 98.8%. In 75.0% of cases the presence or absence of hydronephrosis on ultrasound correctly predicted the presence or absence of a ureteral stone on computerized tomography. Hydronephrosis on ultrasound had a positive predictive value of 0.77 for the presence of a ureteral stone and a negative predictive value of 0.71 for the absence of a ureteral stone. 3
71. Yan JW, McLeod SL, Edmonds ML, Sedran RJ, Theakston KD. Normal renal sonogram identifies renal colic patients at low risk for urologic intervention: a prospective cohort study. CJEM, Can. j. emerg. med. care. 17(1):38-45, 2015 Jan. Review/Other-Dx 610 patients To determine if normal renal sonogram could identify low-risk renal colic patients, who were defined as not requiring urologic intervention within 90 days of their initial ED visit and can be managed conservatively. Of 610 patients enrolled, 341 (55.9%) had US for suspected renal colic. Of those, 105 (30.8%) were classified as normal; none of these patients underwent urologic intervention within 90 days of their ED visit. Ninety (26.4%) US results were classified as suggestive, and nine (10%) patients received urologic intervention. A total of 139 (40.8%) US results were classified as visualized ureteric stone, and 34 (24.5%) patients had urologic intervention. Seven (2.1%) US results were classified as findings unrelated to urolithiasis, and none of these patients required urologic intervention. The rate of urologic intervention was significantly lower in those with normal US results (p<0.001) than in those with abnormal findings. 4
72. Fields JM, Fischer JI, Anderson KL, Mangili A, Panebianco NL, Dean AJ. The ability of renal ultrasound and ureteral jet evaluation to predict 30-day outcomes in patients with suspected nephrolithiasis. Am J Emerg Med. 33(10):1402-6, 2015 Oct. Observational-Dx 77 patients To identify findings on bedside renal ultrasound that predicted need for hospitalization in patients with suspected nephrolithiasis. Thirteen patients were admitted. Reasons for admission included intractable pain, infection, or emergent urologic intervention. All 13 patients requiring admission had hydronephrosis present on initial bedside ultrasound. Patients with moderate hydronephrosis had a higher admission rate (36%) than those with mild hydronephrosis (24%), P<.01. Of patients without hydronephrosis, none required admission within 30 days. The sensitivity and specificity of hydronephrosis for predicting subsequent hospitalization were 100% and 44%, respectively. Loss of the ipsilateral ureteral jet was not significantly associated with subsequent hospital admission and did not improve the predictive value when used in combination with the degree of hydronephrosis. 4
73. Taylor M, Woo MY, Pageau P, et al. Ultrasonography for the prediction of urological surgical intervention in patients with renal colic. Emerg Med J. 33(2):118-23, 2016 Feb. Observational-Dx 500 patients To determine the sonographic findings of renal colic that predict surgical intervention. Of the 500 identified patients, 483 met our eligibility criteria. Of this group, 67 (13.9%) received a surgical intervention. Ultrasound (US) findings were 97% (95% CI 88.7% to 99.5%) sensitive and 28.1% (23.9% to 32.8%) specific in 'diagnosing' the requirement for surgery when the ultrasound (US) showed either at least a stone present or showed moderate to severe hydronephrosis. The presence of stone and moderate to severe hydronephrosis had a + likelihood ratio (LR) 3.86 (2.46 to 6.07) and a -LR 0.72 (0.60 to 0.86). Having a stone >/=6 mm had a sensitivity of 77.6% (65.5% to 86.5%), a specificity of 73.6% (69.0% to 77.7%), a +LR of 2.94 (2.39 to 3.6) and a -LR 0.30 (0.19 to 0.48). 3
74. Abdel-Gawad M, Kadasne RD, Elsobky E, Ali-El-Dein B, Monga M. A Prospective Comparative Study of Color Doppler Ultrasound with Twinkling and Noncontrast Computerized Tomography for the Evaluation of Acute Renal Colic. Journal of Urology. 196(3):757-62, 2016 Sep. Observational-Dx 815 adults To perform a prospective comparison of the use of twinkling color Doppler ultrasound and noncontrast computerized tomography in the diagnosis of renal colic in emergency room patients. Of 815 patients 723 (88.72%) had ureteral stones, 60 (7.36%) had kidney stones and 32 (3.93%) had pain from extra-urinary causes. Mean patient age was 37.17±11 years. Of the 723 patients with ureteral stones 619 (85.6%) were male and 104 (14.4%) were female. The stones were located on the right side in 340 (47%) patients and on the left side in 383 (53%). Color Doppler ultrasound successfully identified the stones in 702 (97.1%) patients and failed in 21 (2.9%). Noncontrast computerized tomography confirmed stones in 720 (99.6%) patients and was negative in 3 (0.4%). The diagnosis was 166 (23%) upper ureter stones, 63 (8.7%) in the middle and 494 (68.3%) in the lower ureter. The color Doppler ultrasound results were significantly affected by the stone site and maximum transverse diameter (p = 0.03 and 0.007, respectively). 3
75. American College of Radiology. ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=89+&releaseId=2 Review/Other-Dx N/A To promote safe and optimal performance of fetal magnetic resonance imaging (MRI). No abstract available. 4
76. American College of Radiology. ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=28+&releaseId=2 Review/Other-Dx N/A To promote the safe and effective use of diagnostic and therapeutic radiology by describing the key elements of standard ultrasound examinations in the first, second, and third trimesters of pregnancy. No abstract available. 4
77. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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