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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Kasotakis G.. Retroperitoneal and rectus sheath hematomas. [Review]. Surg Clin North Am. 94(1):71-6, 2014 Feb. Review/Other-Dx N/A To briefly discuss the management of retroperitoneal and rectus sheath hematomas. No results stated in abstract. 4
2. Simsek A, Ozgor F, Yuksel B, et al. Spontaneous retroperitoneal hematoma associated with anticoagulation therapy and antiplatet therapy: two centers experiences. Arch Ital Urol Androl. 86(4):266-9, 2014 Dec 30. Observational-Dx 9 patients To analyze the characteristics of the patients with diagnosis of spontaneous retroperitoneal hematoma associated with anticoagulation therapy and antiplatet therapy. Median age was 60 year-old. Abdominal pain and flank pain were common symptoms. Eight patients were taking only anticoagulation therapy, 2 only antiplatet therapy and 1 both anticoagulation and antiplatet therapy. Median initial hemoglobin value was 9,0 g/dL and median International Normalized Ratio level was 3.2 Patients were evaluated by abdominal ultrasonography or abdominal computer tomography. Seven patients were treated conservatively. Only one patient died because of septic shock with a mortality ratio of 11%. 4
3. Uludag N, Totterman A, Beckman MO, Sundin A. Anatomic distribution of hematoma following pelvic fracture. Br J Radiol. 91(1085):20170840, 2018 May. Observational-Dx 62 patients To assess the extent of pelvic hemorrhage on CT and to estimate its significance on outcome in patients with blunt high-energy pelvic trauma. Pelvic hemorrhage extended beyond the pelvis to the abdominal area in 47% of the patients, to the thighs in 25% and to the gluteal areas in 81%. The extent of hemorrhage was significantly associated with the need for blood transfusions (p = 0.011) and angiography (p < 0.001), but not with 30-day mortality. 3
4. Fitzpatrick J, Bhat R, Young JA. Angiographic embolization is an effective treatment of severe hemorrhage in pancreatitis. Pancreas. 43(3):436-9, 2014 Apr.Pancreas. 43(3):436-9, 2014 Apr. Review/Other-Tx 9 patients To analyze the role of radiologic embolization as a diagnostic and therapeutic modality for severe hemorrhage in pancreatitis. Nine separate bleeding episodes were treated with embolization (mean age, 56 years). This consisted of 6 patients who underwent primary angiographic embolization, with 3 patients requiring further embolization because of repeated bleeding from a different site. Most patients (83%) had chronic disease. The causative arteries were identified as splenic (6/9 patients), gastroduodenal (1/9 patients), left gastric (1/9 patients), and a small branch of the inferior mesenteric (1/9 patients). Clinical presentations were abdominal pain (3/9 patients), melena (3/9 patients), bleeding into retroperitoneal drain (2/9 patients), and hematemesis (1/9 patients). Bleeding was severe with an average drop in hemoglobin level of 6.3 g/dL. Of the 3 patients who required further embolization, all had splenic artery pseudoaneurysms and 2 patients experienced chronic pancreatitis with necrosis and proven peripancreatic infections. In all cases (9/9 patients), angiography succeeded in identifying and embolizing the causative vessel with a 1-year mortality of 0%. 4
5. Patell R, Gutierrez A, Rybicki L, Khorana AA. Identifying predictors for bleeding in hospitalized cancer patients: A cohort study. Thromb Res. 158:38-43, 2017 Oct. Observational-Dx 3525 patients To assess the incidence of in-hospital major and clinically relevant bleeding and identify risk factors at admission associated with in-hospital bleeding risk in a cohort of hospitalized cancer patients. The study population comprised 3358 patients of whom 69 (2.1%) developed MCRNMB. Median age was 62 (range, 19–98) years and 56% male. Median length of stay was 5 (range, 0–152) days. The majority of bleeding events were either gastrointestinal (GI) (N = 23, 33%) or retroperitoneal (N = 10, 14%). In multivariable analysis, anemia as the reason for admission (7.78, 95% CI 4.0–15.1, P < 0.001), GI cancer site (2.96, 95% CI 1.7–5.2 P < 0.001), BMI = 40 (3.08, 95% CI 1.3–2.9, P = 0.008) and thrombocytopenia (1.7, 95% CI 1.0–2.9, P = 0.05) were predictive. 4
6. Wang ZW, Xue HD, Li XG, Pan J, Zhang XB, Jin ZY. Life-threatening Spontaneous Retroperitoneal Haemorrhage: Role of Multidetector CT-angiography for the Emergency Management. Chin Med Sci J. 31(1):43-48, 2016 Mar 20. Observational-Dx 16 patients To evaluate the role of multidetector computed tomography-angiography (MDCTA) for management of life-threatening spontaneous retroperitoneal haemorrhage (SRH). The group of 16 patients included 11 men and 5 women, with a mean age of 51.5±16.4 years. All patients underwent MDCTA scan examinations, and active contrast media (CM) extravasation were found in 9 patients. Angiography was performed for 8 patients in the CM extravasation group. Bleeding vessels were found in 7 patients who underwent successful embolization. One patient in the CM extravasation group did not undergo angiography and died of bleeding. Seven patients without active CM extravasation underwent conservative management. Bleeding was controlled for all these 7 patients, and 1 patient died of multiple organ failure. Fourteen patients survived from SRH were successfully discharged. One patient died of heart failure during follow-up. 4
7. Caleo O, Bocchini G, Paoletta S, et al. Spontaneous non-aortic retroperitoneal hemorrhage: etiology, imaging characterization and impact of MDCT on management. A multicentric study. Radiol Med (Torino). 120(1):133-48, 2015 Jan. Observational-Dx 27 patients To assess the usefulness of multiphasic Computed tomography in the identification of spontaneous non-traumatic retroperitoneal hematoma (SRH) and its management, with references to the role of interventional radiology. CT identified SRH in all cases (100 %), showing the source of bleeding in 11 cases (40 %) and pointing out the source of bleeding in 15 cases (55 %). In one case (5 %), the bleeding origin was recognized only at surgery as adrenal source. CT has identified a contrast medium extravasation in the arterial phase in 17 patients (63 %), treated successfully by percutaneous embolization in 13 and by open-surgery in two cases. Two patients died before undergoing intervention and surgery, respectively. Ten patients (37 %) were non-operatively treated successfully with clinical, laboratory, and imaging follow-up. 3
8. American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/body-cta.pdf. 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
9. Tani R, Sofue K, Sugimoto K, et al. The utility of transarterial embolization and computed tomography for life-threatening spontaneous retroperitoneal hemorrhage. Jpn J Radiol. 37(4):328-335, 2019 Apr. Observational-Dx 19 patients To assess the safety and efficacy of transarterial embolization (TAE) and to evaluate the utility of contrast-enhanced computed tomography (CE-CT) for life-threatening spontaneous retroperitoneal hemorrhage (SRH). Active extravasation of contrast material was accurately observed in 78.9?84.2% of the patients on CE-CT. Angiograms revealed active extravasation in 37 arteries of 15 patients (78.9%), and 4 patients showed no sign of active bleeding. Sensitivity, positive predictive value, and accuracy rate of CE-CT for the detection of active bleeding vessels was 59.5%, 62.9?71.0% and 55.6?60.0% respectively. The successful embolization of 48 intended arteries was achieved in all the patients, including empirical TAE in four patients. Hemodynamic stabilization was achieved in 17 patients (89.5%) with a significant decrease in transfusion (p < 0.001). 3
10. Baekgaard JS, Eskesen TG, Lee JM, et al. Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage-Management, Risk Factors and Outcomes. World Journal of Surgery. 43(8):1890-1897, 2019 08. Observational-Dx 100 patients To identify early predictors of the need for angiographic or surgical intervention (ASI) in patients with SRRSH and define risk factors for mortality s Of 100 patients included (median age 70 years, 52% males), 33% were transferred from another hospital, 82% patients were on therapeutic anticoagulation, and 90% had serious comorbidities. Overall mortality was 22%, but SRRSH-related mortality was only 6%. Sixteen patients underwent angiographic intervention (n = 10), surgical intervention (n = 5), or both (n = 1). Flank pain (OR 4.15, 95% CI 1.21–14.16, p = 0.023) and intravenous contrast extravasation (OR 3.89, 95% CI 1.23–12.27, p = 0.020) were independent predictors of ASI. Transfer from another hospital (OR 3.72, 95% CI 1.30–10.70, p = 0.015), age above 70 years (OR 4.24, 95% CI 1.25–14.32, p = 0.020), and systolic blood pressure below 110 mmHg at the time of diagnosis (OR 4.59, 95% CI 1.19–17.68, p = 0.027) were independent predictors of mortality. 3
11. Fujimura N, Takahara M, Isogai N, et al. Retroperitoneal hematoma volume is a good predictor of perioperative mortality after endovascular aneurysm repair for ruptured abdominal aortic aneurysm. Journal of Vascular Surgery. 68(4):998-1006.e2, 2018 10. Observational-Dx 114 patients To validate the usefulness of retroperitoneal hematoma volume as a predictor of perioperative mortality after endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). Of 114 patients with rAAA managed during the study period, 101 (88.6%) underwent EVAR, 9 (7.9%) underwent open surgical repair, and 4 (3.5%) did not undergo any repair. Finally, 82 of 101 patients treated with EVAR were included in the analysis. Within 30 days after EVAR, the mortality rates for the 82 patients included in the analysis and the 19 excluded patients were 24.4% and 31.6%, respectively, without statistically significant differences (P ¼ .518). The retroperitoneal hematoma volume ratio was 3.59% 6 2.46% and 7.63% 6 3.45% in survivors and nonsurvivors, respectively (P < .001). Univariate analysis of other preoperative demographic and anatomic factors revealed that a Glasgow Aneurysm Score >85, systolic blood pressure <90mmHg, loss of consciousness, and mean minimum right external iliac artery diameter were statistically significant. Receiver operating characteristic curve analysis for the prediction of perioperative mortality revealed that retroperitoneal hematoma volume ratio was the best predictor of perioperative mortality in patients with rAAA of type >III in the Fitzgerald classification (area under the curve: retroperitoneal hematoma volume ratio, 0.880; Glasgow Aneurysm Score, 0.587; P < .001). Based on the Youden index, the optimal cutoff for the retroperitoneal hematoma volume ratio was 6.97%, providing a sensitivity of 0.833 and specificity of 0.860. 3
12. Goenka AH, Shah SN, Remer EM. Imaging of the retroperitoneum. Radiol Clin North Am 2012;50:333-55, vii. Review/Other-Dx N/A To discuss clinically relevant anatomy of the abdominal retroperitoneal spaces, their cross-sectional imaging evaluation with computed tomography and magnetic resonance imaging, and the imaging features of common retroperitoneal pathologic processes. No results stated in abstract. 4
13. Yumoto T, Kosaki Y, Yamakawa Y, et al. Occult Sources of Bleeding in Blunt Trauma : A Narrative Review. [Review]. Acta Med Okayama. 71(5):363-368, 2017 Oct. Review/Other-Dx N/A To describe “occult” or unusual sources of bleeding associated with blunt trauma. No results stated in abstract. 4
14. Thorne DA, Datz FL, Remley K, Christian PE. Bleeding rates necessary for detecting acute gastrointestinal bleeding with technetium-99m-labeled red blood cells in an experimental model. J Nucl Med. 28(4):514-20, 1987 Apr. Observational-Dx 14 dogs To determine the sensitivity of 99mTc-labeled red blood cells (RBCs) in detecting acute gastrointestinal bleeding in a dog model similar to that used for [99mTc] sulfur colloid. Bleeding rates of 4.6-0.2 ml/min were detected within 10 min in the colon and bleeding rates as low as 0.04 ml/min were seen by 55 min. Slower bleeding rates were not detected. Similar findings were noted for proximal jejunal bleeds. Based on the time of appearance, a minimum volume of approximately 2-3 ml labeled blood was necessary to detect bleeding. 4
15. Sunga KL, Bellolio MF, Gilmore RM, Cabrera D. Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome. J Emerg Med 2012;43:e157-61. Observational-Dx 89 patients To describe clinical characteristics of patients with SRH during an 8-year period. Of 346 patients screened, 89 were eligible. Median age was 72 years; 56.2% were male. Overall, 66.3% were anticoagulated: 41.6% on warfarin, 30.3% heparin, and 11.2% low-molecular-weight heparin; 30.3% were on antiplatelet therapy; 16.5% were taking both anticoagulant and antiplatelet medications; 15.3% were taking neither. Primary presentation to the Emergency Department was seen in 36%; 64% developed SRH during inpatient anticoagulation therapy. The most common symptom was pain: abdominal (67.5%), leg (23.8%), hip (22.5%), and back (21.3%); 10.1% were misdiagnosed upon their initial encounter. Computed tomography (CT) was performed in 98.8%, ultrasound in 22.1%, and magnetic resonance imaging in 3.5%. Of all subjects, 40.4% were managed in an intensive care unit; 24.7% underwent interventional radiology (IR) procedures and 6.7% surgical evacuation; 75.3% received blood transfusion. Mortality was 5.6%within 7 days, 10.1%within 30 days, and 19.1% within 6 months. 3
16. Georgieva M, Beyer L, Goecze I, Stroszczynski C, Wiggermann P, Jung EM. Contrast-enhanced ultrasound (CEUS) in an interdisciplinary intensive care unit (ICU): Diagnostic efficacy in the assessment of post-operative complications compared to contrast-enhanced computed tomography (CECT): First results. Clin Hemorheol Microcirc. 66(4):277-282, 2017. Observational-Dx 50 patients To evaluate the effectiveness of high-resolution contrast-enhanced ultrasound (CEUS) to diagnose early postoperative complications in an interdisciplinary intensive care unit. In 56 out of 64 cases (88%) the CEUS-based diagnosis corresponded with the CECT diagnosis. Vascular stenosis in hepatic arteries and portal veins were recognised in both imaging modalities but were evaluated differently [5 cases]. In 3 cases (5%) small peripheral splenic infarction, retroperitoneal hematoma and fluid collection around the liver were not diagnosed by CEUS. 3
17. Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med 2013;20:128-38. Review/Other-Dx 7 studies To provide a systematic review of the literature for the operating characteristics of emergency department (ED) ultrasonography for AAA. The initial search strategy identified 1,238 articles; application of inclusion/exclusion criteria resulted in seven studies with 655 patients. The weighted average prevalence of AAA in symptomatic patients over the age of 50 years is 23%. On history, 50% of AAA patients will lack the classic triad of hypotension, back pain, and pulsatile abdominal mass. The sensitivity of abdominal palpation for AAA increases as the diameter of the AAA increases. The pooled operating characteristics of ED US for the detection of AAA were sensitivity 99% (95% confidence interval [CI] = 96% to 100%) and specificity 98% (95% CI = 97% to 99%). 4
18. 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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