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Home Nonvariceal Upper Gastrointestinal Bleeding
Variants
Scenario Scenario ID Procedure Adult RRL Peds RRL Appropriateness Category
Upper GI bleeding suspected, nonvariceal, no endoscopy, initial imaging 3102193
CTA abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢
Usually appropriate
Arteriography visceral
1-10 mSv
☢☢☢
May be appropriate
Fluoroscopy upper GI series
1-10 mSv
☢☢☢ 		0.3-3 mSv [ped]
☢☢☢ 		Usually not appropriate
MR enterography
0 mSv
O 		0 mSv [ped]
O 		Usually not appropriate
CT abdomen and pelvis with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen and pelvis without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA abdomen with IV contrast
1-10 mSv
☢☢☢
Usually not appropriate
CTA chest with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA chest without and with IV contrast
1-10 mSv
☢☢☢
Usually not appropriate
RBC scan abdomen and pelvis
1-10 mSv
☢☢☢
Usually not appropriate
CT abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		Usually not appropriate
CT abdomen without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		Usually not appropriate
CT enterography
10-30 mSv
☢☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA abdomen and pelvis with IV contrast
10-30 mSv
☢☢☢☢
Usually not appropriate
CTA abdomen without and with IV contrast
10-30 mSv
☢☢☢☢
Usually not appropriate
Scenario Scenario ID Procedure Adult RRL Peds RRL Appropriateness Category
Upper GI bleeding, nonvariceal, clear source on endoscopy, treatment not possible, initial imaging 3102194
Arteriography visceral
1-10 mSv
☢☢☢
Usually appropriate
CTA abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢
Usually appropriate
CTA chest without and with IV contrast
1-10 mSv
☢☢☢
May be appropriate
CTA abdomen without and with IV contrast
10-30 mSv
☢☢☢☢
May be appropriate
Fluoroscopy upper GI series
1-10 mSv
☢☢☢ 		0.3-3 mSv [ped]
☢☢☢ 		Usually not appropriate
MR enterography
0 mSv
O 		0 mSv [ped]
O 		Usually not appropriate
CT abdomen and pelvis with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen and pelvis without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA abdomen with IV contrast
1-10 mSv
☢☢☢
Usually not appropriate
CTA chest with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
RBC scan abdomen and pelvis
1-10 mSv
☢☢☢
Usually not appropriate
CT abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		Usually not appropriate
CT abdomen without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		Usually not appropriate
CT enterography
10-30 mSv
☢☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA abdomen and pelvis with IV contrast
10-30 mSv
☢☢☢☢
Usually not appropriate
Upper GI bleeding, nonvariceal, clear source on endoscopy, continued bleeding after treatment, initial imaging 3197481
Arteriography visceral
1-10 mSv
☢☢☢
Usually appropriate
CTA abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢
Usually appropriate
CTA chest without and with IV contrast
1-10 mSv
☢☢☢
May be appropriate
CTA abdomen without and with IV contrast
10-30 mSv
☢☢☢☢
May be appropriate
Fluoroscopy upper GI series
1-10 mSv
☢☢☢ 		0.3-3 mSv [ped]
☢☢☢ 		Usually not appropriate
MR enterography
0 mSv
O 		0 mSv [ped]
O 		Usually not appropriate
CT abdomen and pelvis with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen and pelvis without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA abdomen with IV contrast
1-10 mSv
☢☢☢
Usually not appropriate
CTA chest with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
RBC scan abdomen and pelvis
1-10 mSv
☢☢☢
Usually not appropriate
CT abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		Usually not appropriate
CT abdomen without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		Usually not appropriate
CT enterography
10-30 mSv
☢☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA abdomen and pelvis with IV contrast
10-30 mSv
☢☢☢☢
Usually not appropriate
Scenario Scenario ID Procedure Adult RRL Peds RRL Appropriateness Category
Upper GI bleeding, nonvariceal, no clear source on endoscopy, initial imaging 3102195
CTA abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢
Usually appropriate
Arteriography visceral
1-10 mSv
☢☢☢
May be appropriate
CTA chest without and with IV contrast
1-10 mSv
☢☢☢
May be appropriate
RBC scan abdomen and pelvis
1-10 mSv
☢☢☢
May be appropriate
CT enterography
10-30 mSv
☢☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		May be appropriate
Fluoroscopy upper GI series
1-10 mSv
☢☢☢ 		0.3-3 mSv [ped]
☢☢☢ 		Usually not appropriate
MR enterography
0 mSv
O 		0 mSv [ped]
O 		Usually not appropriate
CT abdomen and pelvis with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen and pelvis without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA abdomen with IV contrast
1-10 mSv
☢☢☢
Usually not appropriate
CTA chest with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		Usually not appropriate
CT abdomen without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		Usually not appropriate
CTA abdomen and pelvis with IV contrast
10-30 mSv
☢☢☢☢
Usually not appropriate
CTA abdomen without and with IV contrast
10-30 mSv
☢☢☢☢
Usually not appropriate
Scenario Scenario ID Procedure Adult RRL Peds RRL Appropriateness Category
Upper GI bleeding, nonvariceal, endoscopy negative, initial imaging 3102196
CT enterography
10-30 mSv
☢☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually appropriate
CTA abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢
Usually appropriate
MR enterography
0 mSv
O 		0 mSv [ped]
O 		May be appropriate
RBC scan abdomen and pelvis
1-10 mSv
☢☢☢
May be appropriate
CT abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		May be appropriate
CTA abdomen without and with IV contrast
10-30 mSv
☢☢☢☢
May be appropriate
(Disagreement)
Arteriography visceral
1-10 mSv
☢☢☢
Usually not appropriate
Fluoroscopy upper GI series
1-10 mSv
☢☢☢ 		0.3-3 mSv [ped]
☢☢☢ 		Usually not appropriate
CT abdomen and pelvis with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen and pelvis without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA abdomen with IV contrast
1-10 mSv
☢☢☢
Usually not appropriate
CTA chest with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA chest without and with IV contrast
1-10 mSv
☢☢☢
Usually not appropriate
CT abdomen without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		Usually not appropriate
CTA abdomen and pelvis with IV contrast
10-30 mSv
☢☢☢☢
Usually not appropriate
Scenario Scenario ID Procedure Adult RRL Peds RRL Appropriateness Category
Upper GI bleeding, nonvariceal, postsurgical cause, endoscopy contraindicated, initial imaging 3197482
Arteriography visceral
1-10 mSv
☢☢☢
Usually appropriate
CTA abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢
Usually appropriate
CT abdomen and pelvis with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		May be appropriate
CTA chest without and with IV contrast
1-10 mSv
☢☢☢
May be appropriate
CT abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		May be appropriate
CT enterography
10-30 mSv
☢☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		May be appropriate
Fluoroscopy upper GI series
1-10 mSv
☢☢☢ 		0.3-3 mSv [ped]
☢☢☢ 		Usually not appropriate
CT abdomen and pelvis without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA abdomen with IV contrast
1-10 mSv
☢☢☢
Usually not appropriate
CTA chest with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
RBC scan abdomen and pelvis
1-10 mSv
☢☢☢
Usually not appropriate
CT abdomen without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		Usually not appropriate
CTA abdomen and pelvis with IV contrast
10-30 mSv
☢☢☢☢
Usually not appropriate
CTA abdomen without and with IV contrast
10-30 mSv
☢☢☢☢
Usually not appropriate
Upper GI bleeding, nonvariceal, traumatic cause, endoscopy contraindicated, initial imaging 3197483
Arteriography visceral
1-10 mSv
☢☢☢
Usually appropriate
CTA abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢
Usually appropriate
CT abdomen and pelvis with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		May be appropriate
CTA chest without and with IV contrast
1-10 mSv
☢☢☢
May be appropriate
CT abdomen and pelvis without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		May be appropriate
CT enterography
10-30 mSv
☢☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		May be appropriate
Fluoroscopy upper GI series
1-10 mSv
☢☢☢ 		0.3-3 mSv [ped]
☢☢☢ 		Usually not appropriate
CT abdomen and pelvis without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CT abdomen without IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
CTA abdomen with IV contrast
1-10 mSv
☢☢☢
Usually not appropriate
CTA chest with IV contrast
1-10 mSv
☢☢☢ 		3-10 mSv [ped]
☢☢☢☢ 		Usually not appropriate
RBC scan abdomen and pelvis
1-10 mSv
☢☢☢
Usually not appropriate
CT abdomen without and with IV contrast
10-30 mSv
☢☢☢☢ 		10-30 mSv [ped]
☢☢☢☢☢ 		Usually not appropriate
CTA abdomen and pelvis with IV contrast
10-30 mSv
☢☢☢☢
Usually not appropriate
CTA abdomen without and with IV contrast
10-30 mSv
☢☢☢☢
Usually not appropriate
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