Vomiting in Infants

Variant: 1 Vomiting within the first 2 days after birth. Poor feeding or no passage of meconium. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Radiography abdomen	Usually Appropriate	☢☢
US abdomen (UGI tract)	Usually Not Appropriate	O
Fluoroscopy contrast enema	Usually Not Appropriate	☢☢☢☢
Fluoroscopy upper GI series	Usually Not Appropriate	☢☢☢
Nuclear medicine gastroesophageal reflux scan	Usually Not Appropriate	☢☢☢

Variant: 2 Vomiting within the first 2 days after birth. Radiographs show classic double bubble or triple bubble with little or no gas distally (suspected proximal bowel obstruction or atresia). Next imaging study.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Fluoroscopy upper GI series	May Be Appropriate	☢☢☢
US abdomen (UGI tract)	Usually Not Appropriate	O
Fluoroscopy contrast enema	Usually Not Appropriate	☢☢☢☢
Nuclear medicine gastroesophageal reflux scan	Usually Not Appropriate	☢☢☢

Variant: 3 Vomiting within the first 2 days after birth. Radiographs show a distal bowel obstruction. Next imaging study.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Fluoroscopy contrast enema	Usually Appropriate	☢☢☢☢
US abdomen (UGI tract)	Usually Not Appropriate	O
Fluoroscopy upper GI series	Usually Not Appropriate	☢☢☢
Nuclear medicine gastroesophageal reflux scan	Usually Not Appropriate	☢☢☢

Variant: 4 Bilious vomiting within the first 2 days after birth. Radiographs show a nonclassic double bubble with gas in the distal small bowel, or few distended bowel loops, or a normal bowel gas pattern. Next imaging study.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Fluoroscopy upper GI series	Usually Appropriate	☢☢☢
US abdomen (UGI tract)	May Be Appropriate	O
Fluoroscopy contrast enema	Usually Not Appropriate	☢☢☢☢
Nuclear medicine gastroesophageal reflux scan	Usually Not Appropriate	☢☢☢

Variant: 5 Bilious vomiting in an infant older than 2 days (suspected malrotation). Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Fluoroscopy upper GI series	Usually Appropriate	☢☢☢
US abdomen (UGI tract)	May Be Appropriate	O
Radiography abdomen	May Be Appropriate (Disagreement)	☢☢
Fluoroscopy contrast enema	Usually Not Appropriate	☢☢☢☢
Nuclear medicine gastroesophageal reflux scan	Usually Not Appropriate	☢☢☢

Variant: 6 Infant with nonbilious vomiting, and otherwise healthy (suspected uncomplicated esophageal reflux). Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Fluoroscopy upper GI series	May Be Appropriate	☢☢☢
Nuclear medicine gastroesophageal reflux scan	May Be Appropriate	☢☢☢
US abdomen (UGI tract)	Usually Not Appropriate	O
Radiography abdomen	Usually Not Appropriate	☢☢
Fluoroscopy contrast enema	Usually Not Appropriate	☢☢☢☢

Variant: 7 Infant older than 2 weeks and up to 3 months old. New onset nonbilious vomiting (suspected hypertrophic pyloric stenosis). Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US abdomen (UGI tract)	Usually Appropriate	O
Fluoroscopy upper GI series	May Be Appropriate	☢☢☢
Radiography abdomen	Usually Not Appropriate	☢☢
Fluoroscopy contrast enema	Usually Not Appropriate	☢☢☢☢
Nuclear medicine gastroesophageal reflux scan	Usually Not Appropriate	☢☢☢

Panel Members

Adina L. Alazraki, MD^a; Cynthia K. Rigsby, MD^b; Ramesh S. Iyer, MD, MBA^c; Dianna M. E. Bardo, MD^d; Brandon P. Brown, MD, MA^e; Sherwin S. Chan, MD, PhD^f; Tushar Chandra, MD, MBBS^g; Ann Dietrich, MD^h; Richard A. Falcone Jr., MD, MPHⁱ; Matthew D. Garber, MD^j; Anne E. Gill, MD^k; Terry L. Levin, MD^l; Michael M. Moore, MD^m; Jie C. Nguyen, MD, MSⁿ; Narendra S. Shet, MD^o; Judy H. Squires, MD^p; Andrew T. Trout, MD^q; Boaz Karmazyn, MD^r.

Summary of Literature Review

Introduction/Background

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Vomiting within the first 2 days after birth. Poor feeding or no passage of meconium. Initial imaging.

Variant 1: Vomiting within the first 2 days after birth. Poor feeding or no passage of meconium. Initial imaging.
A. Radiography Abdomen

Variant 1: Vomiting within the first 2 days after birth. Poor feeding or no passage of meconium. Initial imaging.
B. Fluoroscopy Contrast Enema

Variant 1: Vomiting within the first 2 days after birth. Poor feeding or no passage of meconium. Initial imaging.
C. Fluoroscopy Upper GI Series

Variant 1: Vomiting within the first 2 days after birth. Poor feeding or no passage of meconium. Initial imaging.
D. Nuclear Medicine Gastroesophageal Reflux Scan

Variant 1: Vomiting within the first 2 days after birth. Poor feeding or no passage of meconium. Initial imaging.
E. US Abdomen (UGI Tract)

Variant 2: Vomiting within the first 2 days after birth. Radiographs show classic double bubble or triple bubble with little or no gas distally (suspected proximal bowel obstruction or atresia). Next imaging study.

Variant 3: Vomiting within the first 2 days after birth. Radiographs show a distal bowel obstruction. Next imaging study.

Variant 3: Vomiting within the first 2 days after birth. Radiographs show a distal bowel obstruction. Next imaging study.
A. Fluoroscopy contrast enema

Variant 3: Vomiting within the first 2 days after birth. Radiographs show a distal bowel obstruction. Next imaging study.
B. Fluoroscopy upper GI series

Variant 3: Vomiting within the first 2 days after birth. Radiographs show a distal bowel obstruction. Next imaging study.
C. Nuclear medicine gastroesophageal reflux scan

Variant 3: Vomiting within the first 2 days after birth. Radiographs show a distal bowel obstruction. Next imaging study.
D. US abdomen (UGI tract)

Variant 4: Bilious vomiting within the first 2 days after birth. Radiographs show a nonclassic double bubble with gas in the distal small bowel, or few distended bowel loops, or a normal bowel gas pattern. Next imaging study.

Variant 5: Bilious vomiting in an infant older than 2 days (suspected malrotation). Initial imaging.

Variant 5: Bilious vomiting in an infant older than 2 days (suspected malrotation). Initial imaging.
A. Fluoroscopy contrast enema

Variant 5: Bilious vomiting in an infant older than 2 days (suspected malrotation). Initial imaging.
B. Fluoroscopy upper GI series

Variant 5: Bilious vomiting in an infant older than 2 days (suspected malrotation). Initial imaging.
C. Nuclear medicine gastroesophageal reflux scan

Variant 5: Bilious vomiting in an infant older than 2 days (suspected malrotation). Initial imaging.
D. Radiography abdomen

Variant 5: Bilious vomiting in an infant older than 2 days (suspected malrotation). Initial imaging.
E. US abdomen (UGI tract)

Variant 6: Infant with nonbilious vomiting, and otherwise healthy (suspected uncomplicated esophageal reflux). Initial imaging.

Variant 6: Infant with nonbilious vomiting, and otherwise healthy (suspected uncomplicated esophageal reflux). Initial imaging.
A. Fluoroscopy contrast enema

Variant 6: Infant with nonbilious vomiting, and otherwise healthy (suspected uncomplicated esophageal reflux). Initial imaging.
B. Fluoroscopy upper GI series

Variant 6: Infant with nonbilious vomiting, and otherwise healthy (suspected uncomplicated esophageal reflux). Initial imaging.
C. Nuclear medicine gastroesophageal reflux scan

Variant 6: Infant with nonbilious vomiting, and otherwise healthy (suspected uncomplicated esophageal reflux). Initial imaging.
D. Radiography abdomen

Variant 6: Infant with nonbilious vomiting, and otherwise healthy (suspected uncomplicated esophageal reflux). Initial imaging.
E. US abdomen (UGI tract)

Variant 7: Infant older than 2 weeks and up to 3 months old. New onset nonbilious vomiting (suspected hypertrophic pyloric stenosis). Initial imaging.

Variant 7: Infant older than 2 weeks and up to 3 months old. New onset nonbilious vomiting (suspected hypertrophic pyloric stenosis). Initial imaging.
A. Fluoroscopy contrast enema

Variant 7: Infant older than 2 weeks and up to 3 months old. New onset nonbilious vomiting (suspected hypertrophic pyloric stenosis). Initial imaging.
B. Fluoroscopy upper GI series

Variant 7: Infant older than 2 weeks and up to 3 months old. New onset nonbilious vomiting (suspected hypertrophic pyloric stenosis). Initial imaging.
C. Nuclear medicine gastroesophageal reflux scan

Variant 7: Infant older than 2 weeks and up to 3 months old. New onset nonbilious vomiting (suspected hypertrophic pyloric stenosis). Initial imaging.
D. Radiography abdomen

Variant 7: Infant older than 2 weeks and up to 3 months old. New onset nonbilious vomiting (suspected hypertrophic pyloric stenosis). Initial imaging.
E. US abdomen (UGI tract)

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Stinger DA, Babyn PS, eds. Pediatric Gastrointestinal Imaging and Intervention. 2nd ed. Hamilton, Ontario, Canada: Decker; 2000.
2.	Rudolph CD, Mazur LJ, Liptak GS, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32 Suppl 2:S1-31.
3.	Hilton S. The child vomiting. In: Hilton S, Edwards D, eds. Practical Pediatric Radiology. Philadelphia, Pa.: BC Decker; 1994:297-99.
4.	Ryan S, Donoghue V. Gastrointestinal pathology in neonates: new imaging strategies. Pediatr Radiol. 2010;40(6):927-931.
5.	Hernanz-Schulman M. Imaging of neonatal gastrointestinal obstruction. Radiol Clin North Am. 1999;37(6):1163-1186, vi-vii.
6.	Lilien LD, Srinivasan G, Pyati SP, Yeh TF, Pildes RS. Green vomiting in the first 72 hours in normal infants. Am J Dis Child. 1986;140(7):662-664.
7.	Nehra D, Goldstein AM. Intestinal malrotation: varied clinical presentation from infancy through adulthood. Surgery. 149(3):386-93, 2011 Mar.
8.	Gilbertson-Dahdal DL, Dutta S, Varich LJ, Barth RA. Neonatal malrotation with midgut volvulus mimicking duodenal atresia. AJR Am J Roentgenol. 192(5):1269-71, 2009 May.
9.	Leonidas JC, Berdon W. The neonate and young infant: the gastrointestinal tract. In: Silverman F, Kuhn J, eds. Caffey’s Pediatric X-Ray Diagnosis. 9th ed. St. Louis, MO: Mosby; 1993:2048-55.
10.	Chandrasekaran S, Asokaraju A. Clinical profile and predictors of outcome in congenital duodenal obstruction. International Surgery Journal 2017;4:2605.
11.	Parmentier B, Peycelon M, Muller CO, El Ghoneimi A, Bonnard A. Laparoscopic management of congenital duodenal atresia or stenosis: A single-center early experience. J Pediatr Surg. 50(11):1833-6, 2015 Nov.
12.	Ngo AV, Stanescu AL, Phillips GS. Neonatal Bowel Disorders: Practical Imaging Algorithm for Trainees and General Radiologists. [Review]. AJR Am J Roentgenol. 210(5):976-988, 2018 May.
13.	Rescorla FJ, Grosfeld JL. Contemporary management of meconium ileus. World J Surg. 1993;17(3):318-325.
14.	Choudhry MS, Rahman N, Boyd P, Lakhoo K. Duodenal atresia: associated anomalies, prenatal diagnosis and outcome. Pediatr Surg Int. 25(8):727-30, 2009 Aug.
15.	Strouse PJ.. Disorders of intestinal rotation and fixation ("malrotation"). [Review] [82 refs]. Pediatr Radiol. 34(11):837-51, 2004 Nov.
16.	Sizemore AW, Rabbani KZ, Ladd A, Applegate KE. Diagnostic performance of the upper gastrointestinal series in the evaluation of children with clinically suspected malrotation. Pediatr Radiol. 38(5):518-28, 2008 May.
17.	Hsiao M, Langer JC. Value of laparoscopy in children with a suspected rotation abnormality on imaging. J Pediatr Surg. 46(7):1347-52, 2011 Jul.
18.	Long FR, Kramer SS, Markowitz RI, Taylor GE, Liacouras CA. Intestinal malrotation in children: tutorial on radiographic diagnosis in difficult cases. Radiology. 1996;198(3):775-780.
19.	Cribbs RK, Gow KW, Wulkan ML. Gastric volvulus in infants and children. Pediatrics. 2008;122(3):e752-762.
20.	Lederman HM, Demarchi G. Disorders of the Esophagogastric Junction. In: Slovis TA, ed. Caffey's Pediatric Diagnostic Imaging. 11th ed. St Louis, Mo: Mosby/Elsevier Science; 2008:2042-55.
21.	Yousefzadeh DK, Kang L, Tessicini L. Assessment of retromesenteric position of the third portion of the duodenum: an US feasibility study in 33 newborns. Pediatr Radiol. 40(9):1476-84, 2010 Sep.
22.	Orzech N, Navarro OM, Langer JC. Is ultrasonography a good screening test for intestinal malrotation? J Pediatr Surg. 2006;41(5):1005-1009.
23.	Weinberger E, Winters WD, Liddell RM, Rosenbaum DM, Krauter D. Sonographic diagnosis of intestinal malrotation in infants: importance of the relative positions of the superior mesenteric vein and artery. AJR 1992; 159(4):825-828.
24.	Menten R, Reding R, Godding V, Dumitriu D, Clapuyt P. Sonographic assessment of the retroperitoneal position of the third portion of the duodenum: an indicator of normal intestinal rotation. Pediatr Radiol. 42(8):941-5, 2012 Aug.
25.	Karmazyn B. Duodenum between the aorta and the SMA does not exclude malrotation. Pediatr Radiol. 2013;43(1):121-122.
26.	Alehossein M, Abdi S, Pourgholami M, Naseri M, Salamati P. Diagnostic accuracy of ultrasound in determining the cause of bilious vomiting in neonates. Iran. j. radiol.. 9(4):190-4, 2012 Nov.
27.	Applegate KE.. Evidence-based diagnosis of malrotation and volvulus. [Review] [16 refs]. Pediatr Radiol. 39 Suppl 2:S161-3, 2009 Apr.
28.	Zhang W, Sun H, Luo F. The efficiency of sonography in diagnosing volvulus in neonates with suspected intestinal malrotation. Medicine (Baltimore). 96(42):e8287, 2017 Oct.
29.	Applegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. [Review] [59 refs]. Radiographics. 26(5):1485-500, 2006 Sep-Oct.
30.	O'Keeffe FN, Stansberry SD, Swischuk LE, Hayden CK, Jr. Antropyloric muscle thickness at US in infants: what is normal? Radiology. 1991;178(3):827-830..
31.	Hernanz-Schulman M. Pyloric stenosis: role of imaging. Pediatr Radiol. 2009;39 Suppl 2:S134-139.
32.	De Giacomo C, Maggiore G, Fiori P, et al. Chronic gastric torsion in infancy: a revisited diagnosis. Australas Radiol. 1989;33(3):252-254.
33.	Hayden CK, Jr., Swischuk LE, Rytting JE. Gastric ulcer disease in infants: US findings. Radiology. 1987;164(1):131-134.
34.	Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr. 2009;49(4):498-547.
35.	Seibert JJ, Byrne WJ, Euler AR, Latture T, Leach M, Campbell M. Gastroesophageal reflux--the acid test: scintigraphy or the pH probe? AJR Am J Roentgenol. 1983;140(6):1087-1090.
36.	Villanueva-Meyer J, Swischuk LE, Cesani F, Ali SA, Briscoe E. Pediatric gastric emptying: value of right lateral and upright positioning. J Nucl Med. 1996;37(8):1356-1358.
37.	Yapici O, Basoglu T, Canbaz F, Sever A. The role of coughing as a gastroesophageal-reflux provoking maneuver: the scintigraphical evaluation. Nucl Med Commun. 30(6):440-4, 2009 Jun.
38.	Orenstein SR, Klein HA, Rosenthal MS. Scintigraphy versus pH probe for quantification of pediatric gastroesophageal reflux: a study using concurrent multiplexed data and acid feedings. J Nucl Med. 1993;34(8):1228-1234.
39.	Othman S.. Gastroesophageal reflux studies using milk in infants and children--the need for multiple views. Nucl Med Commun. 32(10):967-71, 2011 Oct.
40.	Morigeri C, Bhattacharya A, Mukhopadhyay K, Narang A, Mittal BR. Radionuclide scintigraphy in the evaluation of gastroesophageal reflux in symptomatic and asymptomatic pre-term infants. Eur J Nucl Med Mol Imaging. 35(9):1659-65, 2008 Sep.
41.	Bowen A. The vomiting infant: recent advances and unsettled issues in imaging. Radiol Clin North Am. 1988;26(2):377-392.
42.	Heyman S, Eicher PS, Alavi A. Radionuclide studies of the upper gastrointestinal tract in children with feeding disorders. J Nucl Med. 1995;36(2):351-354.
43.	Argon M, Duygun U, Daglioz G, Omur O, Demir E, Aydogdu S. Relationship between gastric emptying and gastroesophageal reflux in infants and children. Clin Nucl Med. 31(5):262-5, 2006 May.
44.	Cohen HL, Zinn HL, Haller JO, Homel PJ, Stoane JM. Ultrasonography of pylorospasm: findings may simulate hypertrophic pyloric stenosis. J Ultrasound Med. 1998;17(11):705-711.
45.	Haller JO, Cohen HL. Hypertrophic pyloric stenosis: diagnosis using US. Radiology. 1986;161(2):335-339.
46.	Hernanz-Schulman M, Sells LL, Ambrosino MM, Heller RM, Stein SM, Neblett WW, 3rd. Hypertrophic pyloric stenosis in the infant without a palpable olive: accuracy of sonographic diagnosis. Radiology. 1994;193(3):771-776.
47.	St Peter SD, Holcomb GW 3rd, Calkins CM, et al. Open versus laparoscopic pyloromyotomy for pyloric stenosis: a prospective, randomized trial. Ann Surg. 244(3):363-70, 2006 Sep.
48.	Hulka F, Campbell JR, Harrison MW, Campbell TJ. Cost-effectiveness in diagnosing infantile hypertrophic pyloric stenosis. J Pediatr Surg. 32(11):1604-8, 1997 Nov.
49.	Mandell GA, Wolfson PJ, Adkins ES, et al. Cost-effective imaging approach to the nonbilious vomiting infant. Pediatrics. 103(6 Pt 1):1198-202, 1999 Jun.
50.	Donnelly LF, Donnelly LF. Fundamentals of pediatric imaging. 2nd ed. Philadelphia, PA: Elsevier, Inc.; 2017.
51.	Blumhagen JD, Maclin L, Krauter D, Rosenbaum DM, Weinberger E. Sonographic diagnosis of hypertrophic pyloric stenosis. AJR Am J Roentgenol. 1988;150(6):1367-1370.
52.	Forster N, Haddad RL, Choroomi S, Dilley AV, Pereira J. Use of ultrasound in 187 infants with suspected infantile hypertrophic pyloric stenosis. Australas Radiol. 51(6):560-3, 2007 Dec.
53.	Cohen HL, Blumer SL, Zucconi WB. The sonographic double-track sign: not pathognomonic for hypertrophic pyloric stenosis; can be seen in pylorospasm. J Ultrasound Med. 23(5):641-6, 2004 May.
54.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.