Hernia

Variant: 1 Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US abdomen	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
CT abdomen and pelvis without IV contrast	Usually Appropriate	☢☢☢
MRI abdomen without and with IV contrast	May Be Appropriate	O
MRI abdomen without IV contrast	May Be Appropriate	O
US pelvis	Usually Not Appropriate	O
Fluoroscopy upper GI series	Usually Not Appropriate	☢☢☢
Fluoroscopy upper GI series with small bowel follow-through	Usually Not Appropriate	☢☢☢
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
MRI pelvis without and with IV contrast	Usually Not Appropriate	O
MRI pelvis without IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Suspected groin hernia such as inguinal or femoral. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US pelvis	Usually Appropriate	O
MRI pelvis without and with IV contrast	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
CT abdomen and pelvis without IV contrast	Usually Appropriate	☢☢☢
CT pelvis with IV contrast	Usually Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Appropriate	☢☢☢
MRI pelvis without IV contrast	May Be Appropriate	O
Fluoroscopy small bowel follow-through	Usually Not Appropriate	☢☢☢
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Suspected deep pelvic hernia including obturator, sciatic, or perineal. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI pelvis without and with IV contrast	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
CT abdomen and pelvis without IV contrast	Usually Appropriate	☢☢☢
CT pelvis with IV contrast	Usually Appropriate	☢☢☢
CT pelvis without IV contrast	Usually Appropriate	☢☢☢
MRI pelvis without IV contrast	May Be Appropriate	O
US pelvis	Usually Not Appropriate	O
Fluoroscopy small bowel follow-through	Usually Not Appropriate	☢☢☢
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 4 Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
CT chest and abdomen with IV contrast	Usually Appropriate	☢☢☢☢
CT chest and abdomen without IV contrast	Usually Appropriate	☢☢☢☢
Radiography chest	May Be Appropriate	☢
Fluoroscopy upper GI series	May Be Appropriate	☢☢☢
MRI chest and abdomen without and with IV contrast	May Be Appropriate	O
MRI chest and abdomen without IV contrast	May Be Appropriate	O
US abdomen	Usually Not Appropriate	O
Fluoroscopy upper GI series with small bowel follow-through	Usually Not Appropriate	☢☢☢
Radiography abdomen and pelvis	Usually Not Appropriate	☢☢☢
CT chest and abdomen 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: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging.

Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging.
A. CT Abdomen and Pelvis

Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging.
B. Fluoroscopy Upper GI Series

Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging.
C. Fluoroscopy Upper GI Series with Small Bowel Follow-Through

Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging.
D. MRI Abdomen Without and With IV Contrast

Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging.
E. MRI Abdomen Without IV Contrast

Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging.
F. MRI Pelvis

Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging.
G. Radiography abdomen and pelvis

Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging.
H. US Abdomen

Variant 1: Suspected abdominal wall hernia such as umbilical, ventral, incisional, lumbar, or spigelian. Initial imaging.
I. US Pelvis

Variant 2: Suspected groin hernia such as inguinal or femoral. Initial imaging.

Variant 2: Suspected groin hernia such as inguinal or femoral. Initial imaging.
A. CT Abdomen and Pelvis

Variant 2: Suspected groin hernia such as inguinal or femoral. Initial imaging.
B. CT Pelvis

Variant 2: Suspected groin hernia such as inguinal or femoral. Initial imaging.
C. Fluoroscopy Small Bowel Follow-Through

Variant 2: Suspected groin hernia such as inguinal or femoral. Initial imaging.
D. MRI Pelvis

Variant 2: Suspected groin hernia such as inguinal or femoral. Initial imaging.
E. Radiography abdomen and pelvis

Variant 2: Suspected groin hernia such as inguinal or femoral. Initial imaging.
F. US Pelvis

Variant 3: Suspected deep pelvic hernia including obturator, sciatic, or perineal. Initial imaging.

Variant 3: Suspected deep pelvic hernia including obturator, sciatic, or perineal. Initial imaging.
A. CT Abdomen and Pelvis

Variant 3: Suspected deep pelvic hernia including obturator, sciatic, or perineal. Initial imaging.
B. CT Pelvis

Variant 3: Suspected deep pelvic hernia including obturator, sciatic, or perineal. Initial imaging.
C. Fluoroscopy Small Bowel Follow-Through

Variant 3: Suspected deep pelvic hernia including obturator, sciatic, or perineal. Initial imaging.
D. MRI Pelvis

Variant 3: Suspected deep pelvic hernia including obturator, sciatic, or perineal. Initial imaging.
E. Radiography abdomen and pelvis

Variant 3: Suspected deep pelvic hernia including obturator, sciatic, or perineal. Initial imaging.
F. US Pelvis

Variant 4: Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging.

Variant 4: Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging.
A. CT Chest and Abdomen

Variant 4: Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging.
B. Fluoroscopy Upper GI Series

Variant 4: Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging.
C. Fluoroscopy Upper GI Series with Small Bowel Follow-Through

Variant 4: Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging.
D. MRI Chest and Abdomen

Variant 4: Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging.
E. Radiography abdomen and pelvis

Variant 4: Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging.
F. Radiography Chest

Variant 4: Suspected diaphragmatic hernia including traumatic, Bochdalek, or Morgagni. Initial imaging.
G. US Abdomen

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

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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