Left Lower Quadrant Pain

Variant: 1 Left lower quadrant pain. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
US abdomen transabdominal	May Be Appropriate	O
US pelvis transvaginal	May Be Appropriate	O
Radiography abdomen and pelvis	May Be Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	May Be Appropriate	O
MRI abdomen and pelvis without IV contrast	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
Fluoroscopy contrast enema	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Left lower quadrant pain. Suspected diverticulitis. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	May Be Appropriate	O
MRI abdomen and pelvis without IV contrast	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
US abdomen transabdominal	Usually Not Appropriate	O
US pelvis transvaginal	Usually Not Appropriate	O
Fluoroscopy contrast enema	Usually Not Appropriate	☢☢☢
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Left lower quadrant pain. Suspected complication(s) of diverticulitis. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
Fluoroscopy contrast enema	May Be Appropriate	☢☢☢
Fluoroscopy cystography	May Be Appropriate	☢☢☢
MRI abdomen and pelvis without and with IV contrast	May Be Appropriate	O
MRI abdomen and pelvis without IV contrast	May Be Appropriate	O
CT abdomen and pelvis without IV contrast	May Be Appropriate	☢☢☢
CT pelvis with bladder contrast (CT cystography)	May Be Appropriate	☢☢☢☢
US abdomen transabdominal	Usually Not Appropriate	O
US pelvis transvaginal	Usually Not Appropriate	O
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Left lower quadrant pain. Initial imaging.

Variant 1: Left lower quadrant pain. Initial imaging.
A. CT Abdomen and Pelvis

Variant 1: Left lower quadrant pain. Initial imaging.
B. Fluoroscopic Contrast-Enhanced Enema

Variant 1: Left lower quadrant pain. Initial imaging.
C. MRI Abdomen and Pelvis

Variant 1: Left lower quadrant pain. Initial imaging.
D. Radiography Abdomen and Pelvis

Variant 1: Left lower quadrant pain. Initial imaging.
E. US Abdomen Transabdominal

Variant 1: Left lower quadrant pain. Initial imaging.
F. US Pelvis Transvaginal

Variant 2: Left lower quadrant pain. Suspected diverticulitis. Initial imaging.

Variant 2: Left lower quadrant pain. Suspected diverticulitis. Initial imaging.
A. CT Abdomen and Pelvis

Variant 2: Left lower quadrant pain. Suspected diverticulitis. Initial imaging.
B. Fluoroscopic Contrast-Enhanced Enema

Variant 2: Left lower quadrant pain. Suspected diverticulitis. Initial imaging.
C. MRI Abdomen and Pelvis

Variant 2: Left lower quadrant pain. Suspected diverticulitis. Initial imaging.
D. Radiography Abdomen and Pelvis

Variant 2: Left lower quadrant pain. Suspected diverticulitis. Initial imaging.
E. US Abdomen Transabdominal

Variant 2: Left lower quadrant pain. Suspected diverticulitis. Initial imaging.
F. US Pelvis Transvaginal

Variant 3: Left lower quadrant pain. Suspected complication(s) of diverticulitis. Initial imaging.

Variant 3: Left lower quadrant pain. Suspected complication(s) of diverticulitis. Initial imaging.
A. CT Abdomen and Pelvis

Variant 3: Left lower quadrant pain. Suspected complication(s) of diverticulitis. Initial imaging.
B. CT Pelvis with Bladder Contrast (CT Cystography)

Variant 3: Left lower quadrant pain. Suspected complication(s) of diverticulitis. Initial imaging.
C. Fluoroscopy Contrast Enema

Variant 3: Left lower quadrant pain. Suspected complication(s) of diverticulitis. Initial imaging.
D. Fluoroscopy Cystography

Variant 3: Left lower quadrant pain. Suspected complication(s) of diverticulitis. Initial imaging.
E. MRI Abdomen and Pelvis

Variant 3: Left lower quadrant pain. Suspected complication(s) of diverticulitis. Initial imaging.
F. Radiography Abdomen and Pelvis

Variant 3: Left lower quadrant pain. Suspected complication(s) of diverticulitis. Initial imaging.
G. US Abdomen Transabdominal

Variant 3: Left lower quadrant pain. Suspected complication(s) of diverticulitis. Initial imaging.
H. US Pelvis Transvaginal

Summary of Recommendations

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

References

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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