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Acute Onset Flank Pain-Suspicion of Stone Disease (Urolithiasis)
Variant: 1
Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| CT abdomen and pelvis without IV contrast | Usually Appropriate | ☢☢☢ |
| US color Doppler kidneys and bladder retroperitoneal | May Be Appropriate (Disagreement) | O |
| US kidneys and bladder retroperitoneal | May Be Appropriate (Disagreement) | O |
| Radiography abdomen and pelvis | May Be Appropriate | ☢☢☢ |
| Radiography intravenous urography | Usually Not Appropriate | ☢☢☢ |
| MRI abdomen and pelvis without and with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without IV contrast | Usually Not Appropriate | O |
| MRU without and with IV contrast | Usually Not Appropriate | O |
| MRU without IV contrast | Usually Not Appropriate | O |
| CT abdomen and pelvis with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT abdomen and pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CTU without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
Variant: 2
Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| CT abdomen and pelvis without IV contrast | Usually Appropriate | ☢☢☢ |
| US color Doppler kidneys and bladder retroperitoneal | May Be Appropriate (Disagreement) | O |
| US kidneys and bladder retroperitoneal | May Be Appropriate | O |
| Radiography abdomen and pelvis | May Be Appropriate | ☢☢☢ |
| CT abdomen and pelvis with IV contrast | May Be Appropriate | ☢☢☢ |
| Radiography intravenous urography | Usually Not Appropriate | ☢☢☢ |
| MRI abdomen and pelvis without and with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without IV contrast | Usually Not Appropriate | O |
| MRU without and with IV contrast | Usually Not Appropriate | O |
| MRU without IV contrast | Usually Not Appropriate | O |
| CT abdomen and pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CTU without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
Variant: 3
Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US kidneys and bladder retroperitoneal | Usually Appropriate | O |
| US color Doppler kidneys and bladder retroperitoneal | May Be Appropriate (Disagreement) | O |
| MRU without IV contrast | May Be Appropriate | O |
| CT abdomen and pelvis without IV contrast | May Be Appropriate | ☢☢☢ |
| Radiography abdomen and pelvis | Usually Not Appropriate | ☢☢☢ |
| Radiography intravenous urography | Usually Not Appropriate | ☢☢☢ |
| MRI abdomen and pelvis without and with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without IV contrast | Usually Not Appropriate | O |
| MRU without and with IV contrast | Usually Not Appropriate | O |
| CT abdomen and pelvis with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT abdomen and pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CTU without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
Variant: 4
Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
| Procedure | Appropriateness Category | Relative Radiation Level |
| MRU without and with IV contrast | May Be Appropriate | O |
| CT abdomen and pelvis with IV contrast | May Be Appropriate | ☢☢☢ |
| CTU without and with IV contrast | May Be Appropriate | ☢☢☢☢ |
| US color Doppler kidneys and bladder retroperitoneal | Usually Not Appropriate | O |
| US kidneys and bladder retroperitoneal | Usually Not Appropriate | O |
| Radiography abdomen and pelvis | Usually Not Appropriate | ☢☢☢ |
| Radiography intravenous urography | Usually Not Appropriate | ☢☢☢ |
| MRI abdomen and pelvis without and with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without IV contrast | Usually Not Appropriate | O |
| MRU without IV contrast | Usually Not Appropriate | O |
| CT abdomen and pelvis without IV contrast | 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: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
A. CT Abdomen and Pelvis With IV Contrast
A. CT Abdomen and Pelvis With IV Contrast
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
B. CT Abdomen and Pelvis Without and With IV Contrast
B. CT Abdomen and Pelvis Without and With IV Contrast
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
C. CT Abdomen and Pelvis Without IV Contrast
C. CT Abdomen and Pelvis Without IV Contrast
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
D. CTU Without and With IV Contrast
D. CTU Without and With IV Contrast
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
E. MRI Abdomen and Pelvis Without and With IV Contrast
E. MRI Abdomen and Pelvis Without and With IV Contrast
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
F. MRI Abdomen and Pelvis Without IV Contrast
F. MRI Abdomen and Pelvis Without IV Contrast
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
G. MRU Without and With IV Contrast
G. MRU Without and With IV Contrast
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
H. MRU Without IV Contrast
H. MRU Without IV Contrast
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
I. Radiography abdomen and pelvis
I. Radiography abdomen and pelvis
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
J. Radiography Intravenous Urography
J. Radiography Intravenous Urography
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
K. US Color Doppler Kidneys and Bladder Retroperitoneal
K. US Color Doppler Kidneys and Bladder Retroperitoneal
Variant 1: Acute onset flank pain. Suspicion of stone disease. No history or remote history of stone disease. Initial imaging.
L. US Kidneys and Bladder Retroperitoneal
L. US Kidneys and Bladder Retroperitoneal
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
A. CT Abdomen and Pelvis With IV Contrast
A. CT Abdomen and Pelvis With IV Contrast
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
B. CT Abdomen and Pelvis Without and With IV Contrast
B. CT Abdomen and Pelvis Without and With IV Contrast
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
C. CT Abdomen and Pelvis Without IV Contrast
C. CT Abdomen and Pelvis Without IV Contrast
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
D. CTU Without and With IV Contrast
D. CTU Without and With IV Contrast
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
E. MRI Abdomen and Pelvis Without and With IV Contrast
E. MRI Abdomen and Pelvis Without and With IV Contrast
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
F. MRI Abdomen and Pelvis Without IV Contrast
F. MRI Abdomen and Pelvis Without IV Contrast
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
G. MRU Without and With IV Contrast
G. MRU Without and With IV Contrast
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
H. MRU Without IV Contrast
H. MRU Without IV Contrast
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
I. Radiography abdomen and pelvis
I. Radiography abdomen and pelvis
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
J. Radiography Intravenous Urography
J. Radiography Intravenous Urography
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
K. US Color Doppler Kidneys and Bladder Retroperitoneal
K. US Color Doppler Kidneys and Bladder Retroperitoneal
Variant 2: Acute onset flank pain in patient with known current stone disease, diagnosed on recent imaging. Recurrent symptoms of stone disease. Follow-up imaging.
L. US Kidneys and Bladder Retroperitoneal
L. US Kidneys and Bladder Retroperitoneal
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
A. CT Abdomen and Pelvis With IV Contrast
A. CT Abdomen and Pelvis With IV Contrast
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
B. CT Abdomen and Pelvis Without and With IV Contrast
B. CT Abdomen and Pelvis Without and With IV Contrast
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
C. CT Abdomen and Pelvis Without IV Contrast
C. CT Abdomen and Pelvis Without IV Contrast
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
D. CTU Without and With IV Contrast
D. CTU Without and With IV Contrast
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
E. MRI Abdomen and Pelvis Without IV Contrast
E. MRI Abdomen and Pelvis Without IV Contrast
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
F. MRI Abdomen and Pelvis Without and With IV Contrast
F. MRI Abdomen and Pelvis Without and With IV Contrast
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
G. MRU Without and With IV Contrast
G. MRU Without and With IV Contrast
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
H. MRU Without IV Contrast
H. MRU Without IV Contrast
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
I. Radiography abdomen and pelvis
I. Radiography abdomen and pelvis
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
J. Radiography Intravenous Urography
J. Radiography Intravenous Urography
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
K. US Color Doppler Kidneys and Bladder Retroperitoneal
K. US Color Doppler Kidneys and Bladder Retroperitoneal
Variant 3: Pregnant patient. Acute onset flank pain. Suspicion of stone disease. Initial or follow-up imaging.
L. US Kidneys and Bladder Retroperitoneal
L. US Kidneys and Bladder Retroperitoneal
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
A. CT Abdomen and Pelvis With IV Contrast
A. CT Abdomen and Pelvis With IV Contrast
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
B. CT Abdomen and Pelvis Without and With IV Contrast
B. CT Abdomen and Pelvis Without and With IV Contrast
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
C. CT Abdomen and Pelvis Without IV Contrast
C. CT Abdomen and Pelvis Without IV Contrast
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
D. CTU Without and With IV Contrast
D. CTU Without and With IV Contrast
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
E. MRI Abdomen and Pelvis Without and With IV Contrast
E. MRI Abdomen and Pelvis Without and With IV Contrast
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
F. MRI Abdomen and Pelvis Without IV Contrast
F. MRI Abdomen and Pelvis Without IV Contrast
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
G. MRU Without and With IV Contrast
G. MRU Without and With IV Contrast
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
H. MRU Without IV Contrast
H. MRU Without IV Contrast
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
I. Radiography abdomen and pelvis
I. Radiography abdomen and pelvis
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
J. Radiography Intravenous Urography
J. Radiography Intravenous Urography
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
K. US Color Doppler Kidneys and Bladder Retroperitoneal
K. US Color Doppler Kidneys and Bladder Retroperitoneal
Variant 4: Acute onset flank pain. Suspicion of stone disease. CT without contrast is inconclusive for the presence of stones. Next imaging study.
L. US Kidneys and Bladder Retroperitoneal
L. US Kidneys and Bladder Retroperitoneal
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.
Safety Considerations in Pregnant Patients
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.