ACR Appropriateness Criteria for Imaging in RLQ Pain/Suspected Appendicitis

In 2018, the American College of Radiology (ACR) issued revised recommendations for imaging in patients with right-lower-quadrant (RLQ) pain and suspected appendicitis.^[20]

For patients with RLQ pain, fever, leukocytosis, and suspected appendicitis, initial imaging recommendations include the following:

Usually appropriate - Computed tomography (CT) of abdomen and pelvis with intravenous (IV) contrast
May be appropriate - CT of abdomen and pelvis without IV contrast; ultrasonography (US) of abdomen; magnetic resonance imaging (MRI) of abdomen and pelvis without and with IV contrast; US of pelvis; MRI of abdomen and pelvis without IV contrast
Usually not appropriate - CT of abdomen and pelvis without and with IV contrast; radiography of abdomen; fluoroscopy contrast enema; technetium 99m (Tc-99m) white blood cell (WBC) scan of abdomen and pelvis

For patients with RLQ pain, fever, leukocytosis, possible appendicitis, and an atypical presentation, initial imaging recommendations include the following:

Usually appropriate - CT of abdomen and pelvis with IV contrast
May be appropriate - CT of abdomen and pelvis without IV contrast; US of abdomen; MRI of abdomen and pelvis without and with IV contrast; US of pelvis; MRI of abdomen and pelvis without IV contrast
Usually not appropriate - CT of abdomen and pelvis without and with IV contrast; radiography of abdomen; fluoroscopy contrast enema; Tc-99m WBC scan of abdomen and pelvis

For pregnant women with RLQ pain, fever, leukocytosis, and suspected appendicitis, initial imaging recommendations include the following:

Usually appropriate - US of abdomen; MRI of abdomen and pelvis without IV contrast
May be appropriate - US of pelvis; CT of abdomen and pelvis with IV contrast; CT of abdomen and pelvis without IV contrast
Usually not appropriate - MRI of abdomen and pelvis without and with IV contrast; CT of abdomen and pelvis without and with IV contrast; radiography of abdomen; Tc-99m WBC scan of abdomen and pelvis; fluoroscopy contrast enema

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Author

Steven L Lee, MD Chief of Pediatric Surgery, Harbor-UCLA Medical Center; Associate Clinical Professor of Surgery and Pediatrics; University of California, Los Angeles, David Geffen School of Medicine

Steven L Lee, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoscopic and Robotic Surgeons, International Pediatric Endosurgery Group, Pacific Association of Pediatric Surgery, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Veronica F Sullins, MD Resident Physician, Department of Surgery, Harbor-UCLA Medical Center

Veronica F Sullins, MD is a member of the following medical societies: American College of Surgeons, American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Jeffrey J Du Bois, MD Chief of Children's Surgical Services, Division of Pediatric Surgery, Kaiser Permanente, Women and Children's Center, Roseville Medical Center

Jeffrey J Du Bois, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, California Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association

Disclosure: Nothing to disclose.