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Abdominal Pain-Child
Variant: 1
Child. Acute abdominal pain. Suspected constipation. Initial imaging.
| Procedure | Appropriateness Category | Peds Relative Radiation Level |
| Radiography abdomen and pelvis | May Be Appropriate | ☢☢☢ |
| US abdomen | Usually Not Appropriate | O |
| US duplex Doppler abdomen | Usually Not Appropriate | O |
| Radiography pelvis | Usually Not Appropriate | ☢☢ |
| Fluoroscopy barium enema single-contrast | Usually Not Appropriate | ☢☢☢☢ |
| Fluoroscopy contrast enema | Usually Not Appropriate | ☢☢☢☢ |
| MRI abdomen and pelvis with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without and with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without IV contrast | Usually Not Appropriate | O |
| CT abdomen and pelvis with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen and pelvis without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen and pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢☢ |
Variant: 2
Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
| Procedure | Appropriateness Category | Peds Relative Radiation Level |
| US abdomen | Usually Appropriate | O |
| Radiography abdomen and pelvis | May Be Appropriate | ☢☢☢ |
| US duplex Doppler abdomen | Usually Not Appropriate | O |
| Fluoroscopy barium enema single-contrast | Usually Not Appropriate | ☢☢☢☢ |
| Fluoroscopy contrast enema | Usually Not Appropriate | ☢☢☢☢ |
| MRI abdomen and pelvis with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without and with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without IV contrast | Usually Not Appropriate | O |
| CT abdomen and pelvis with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen and pelvis without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen and pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢☢ |
Variant: 3
Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
| Procedure | Appropriateness Category | Peds Relative Radiation Level |
| Radiography abdomen and pelvis | Usually Appropriate | ☢☢☢ |
| US abdomen | May Be Appropriate | O |
| US duplex Doppler abdomen | May Be Appropriate | O |
| CT abdomen and pelvis with IV contrast | May Be Appropriate | ☢☢☢☢ |
| Fluoroscopy contrast enema | Usually Not Appropriate | ☢☢☢☢ |
| Fluoroscopy small bowel follow-through | Usually Not Appropriate | ☢☢☢☢ |
| Fluoroscopy upper GI series | Usually Not Appropriate | ☢☢☢ |
| Fluoroscopy upper GI series with small bowel follow-through | Usually Not Appropriate | ☢☢☢☢ |
| MRI abdomen and pelvis with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without and with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without IV contrast | Usually Not Appropriate | O |
| CT abdomen and pelvis without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen and pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢☢ |
| CT abdomen without and with IV contrast | Usually Not Appropriate | ☢☢☢☢☢ |
Variant: 4
Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
| Procedure | Appropriateness Category | Peds Relative Radiation Level |
| Radiography abdomen and pelvis | Usually Appropriate | ☢☢☢ |
| CT abdomen and pelvis with IV contrast | Usually Appropriate | ☢☢☢☢ |
| US abdomen | May Be Appropriate | O |
| US duplex Doppler abdomen | Usually Not Appropriate | O |
| Fluoroscopy contrast enema | Usually Not Appropriate | ☢☢☢☢ |
| Fluoroscopy small bowel follow-through | Usually Not Appropriate | ☢☢☢☢ |
| Fluoroscopy upper GI series | Usually Not Appropriate | ☢☢☢ |
| Fluoroscopy upper GI series with small bowel follow-through | Usually Not Appropriate | ☢☢☢☢ |
| MRI abdomen and pelvis with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without and with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without IV contrast | Usually Not Appropriate | O |
| CT abdomen and pelvis without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen and pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢☢ |
| CT abdomen without and with IV contrast | Usually Not Appropriate | ☢☢☢☢☢ |
Variant: 5
Infant. Suspected necrotizing enterocolitis. Initial imaging.
| Procedure | Appropriateness Category | Peds Relative Radiation Level |
| US abdomen | Usually Appropriate | O |
| Radiography abdomen and pelvis | Usually Appropriate | ☢☢☢ |
| US duplex Doppler abdomen | Usually Not Appropriate | O |
| Fluoroscopy contrast enema | Usually Not Appropriate | ☢☢☢☢ |
| MRI abdomen and pelvis with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without and with IV contrast | Usually Not Appropriate | O |
| MRI abdomen and pelvis without IV contrast | Usually Not Appropriate | O |
| CT abdomen and pelvis with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen and pelvis without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT abdomen and pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢☢ |
Panel Members
HaiThuy N. Nguyen, MDa; Sherwin S. Chan, MD, PhDb; Brandon P. Brown, MD, MAc; Brooks D. Cash, MDd; Scott R. Dorfman, MDe; Jason D. Fraser, MDf; Morgan P. McBee, MDg; Helen R. Nadel, MDh; Anh-Vu H. Ngo, MDi; Emily S. Orscheln, MDj; Hannibal Person, MDk; Emily Rose, MDl; Elizabeth J. Snyder, MDm; George S. Wu, MDn; Ramesh S. Iyer, MD, MBAo.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
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)
OR
- 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: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
A. CT abdomen and pelvis with IV contrast
A. CT abdomen and pelvis with IV contrast
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
B. CT abdomen and pelvis without and with IV contrast
B. CT abdomen and pelvis without and with IV contrast
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
C. CT abdomen and pelvis without IV contrast
C. CT abdomen and pelvis without IV contrast
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
D. Fluoroscopy barium enema single-contrast
D. Fluoroscopy barium enema single-contrast
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
E. Fluoroscopy contrast enema
E. Fluoroscopy contrast enema
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
F. MRI abdomen and pelvis with IV contrast
F. MRI abdomen and pelvis with IV contrast
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
G. MRI abdomen and pelvis without and with IV contrast
G. MRI abdomen and pelvis without and with IV contrast
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
H. MRI abdomen and pelvis without IV contrast
H. MRI abdomen and pelvis without IV contrast
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
I. Radiography abdomen and pelvis
I. Radiography abdomen and pelvis
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
J. Radiography pelvis
J. Radiography pelvis
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
K. US abdomen
K. US abdomen
Variant 1: Child. Acute abdominal pain. Suspected constipation. Initial imaging.
L. US duplex Doppler abdomen
L. US duplex Doppler abdomen
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
A. CT abdomen and pelvis with IV contrast
A. CT abdomen and pelvis with IV contrast
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
B. CT abdomen and pelvis without and with IV contrast
B. CT abdomen and pelvis without and with IV contrast
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
C. CT abdomen and pelvis without IV contrast
C. CT abdomen and pelvis without IV contrast
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
D. Fluoroscopy barium enema single-contrast
D. Fluoroscopy barium enema single-contrast
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
E. Fluoroscopy contrast enema
E. Fluoroscopy contrast enema
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
F. MRI abdomen and pelvis with IV contrast
F. MRI abdomen and pelvis with IV contrast
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
G. MRI abdomen and pelvis without and with IV contrast
G. MRI abdomen and pelvis without and with IV contrast
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
H. MRI abdomen and pelvis without IV contrast
H. MRI abdomen and pelvis without IV contrast
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
I. Radiography abdomen and pelvis
I. Radiography abdomen and pelvis
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
J. US abdomen
J. US abdomen
Variant 2: Child. Acute abdominal pain. Suspected intussusception. Initial imaging.
K. US duplex Doppler abdomen
K. US duplex Doppler abdomen
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
A. CT abdomen and pelvis with IV contrast
A. CT abdomen and pelvis with IV contrast
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
B. CT abdomen and pelvis without and with IV contrast
B. CT abdomen and pelvis without and with IV contrast
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
C. CT abdomen and pelvis without IV contrast
C. CT abdomen and pelvis without IV contrast
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
D. CT abdomen with IV contrast
D. CT abdomen with IV contrast
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
E. CT abdomen without and with IV contrast
E. CT abdomen without and with IV contrast
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
F. CT abdomen without IV contrast
F. CT abdomen without IV contrast
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
G. Fluoroscopy contrast enema
G. Fluoroscopy contrast enema
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
H. Fluoroscopy small bowel follow-through
H. Fluoroscopy small bowel follow-through
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
I. Fluoroscopy upper GI series
I. Fluoroscopy upper GI series
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
J. Fluoroscopy upper GI series with small bowel follow-through
J. Fluoroscopy upper GI series with small bowel follow-through
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
K. MRI abdomen and pelvis with IV contrast
K. MRI abdomen and pelvis with IV contrast
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
L. MRI abdomen and pelvis without and with IV contrast
L. MRI abdomen and pelvis without and with IV contrast
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
M. MRI abdomen and pelvis without IV contrast
M. MRI abdomen and pelvis without IV contrast
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
N. Radiography abdomen and pelvis
N. Radiography abdomen and pelvis
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
O. US abdomen
O. US abdomen
Variant 3: Child. Acute abdominal pain. Suspected bowel obstruction. No prior abdominal surgery. Initial Imaging.
P. US duplex Doppler abdomen
P. US duplex Doppler abdomen
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
A. CT abdomen and pelvis with IV contrast
A. CT abdomen and pelvis with IV contrast
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
B. CT abdomen and pelvis without and with IV contrast
B. CT abdomen and pelvis without and with IV contrast
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
C. CT abdomen and pelvis without IV contrast
C. CT abdomen and pelvis without IV contrast
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
D. CT abdomen with IV contrast
D. CT abdomen with IV contrast
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
E. CT abdomen without and with IV contrast
E. CT abdomen without and with IV contrast
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
F. CT abdomen without IV contrast
F. CT abdomen without IV contrast
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
G. Fluoroscopy contrast enema
G. Fluoroscopy contrast enema
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
H. Fluoroscopy small bowel follow-through
H. Fluoroscopy small bowel follow-through
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
I. Fluoroscopy upper GI series
I. Fluoroscopy upper GI series
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
J. Fluoroscopy upper GI series with small bowel follow-through
J. Fluoroscopy upper GI series with small bowel follow-through
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
K. MRI abdomen and pelvis with IV contrast
K. MRI abdomen and pelvis with IV contrast
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
L. MRI abdomen and pelvis without and with IV contrast
L. MRI abdomen and pelvis without and with IV contrast
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
M. MRI abdomen and pelvis without IV contrast
M. MRI abdomen and pelvis without IV contrast
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
N. Radiography abdomen and pelvis
N. Radiography abdomen and pelvis
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
O. US abdomen
O. US abdomen
Variant 4: Child. Acute abdominal pain. Suspected surgical complication. Initial imaging.
P. US duplex Doppler abdomen
P. US duplex Doppler abdomen
Variant 5: Infant. Suspected necrotizing enterocolitis. Initial imaging.
Variant 5: Infant. Suspected necrotizing enterocolitis. Initial imaging.
A. CT abdomen and pelvis with IV contrast
A. CT abdomen and pelvis with IV contrast
Variant 5: Infant. Suspected necrotizing enterocolitis. Initial imaging.
B. CT abdomen and pelvis without and with IV contrast
B. CT abdomen and pelvis without and with IV contrast
Variant 5: Infant. Suspected necrotizing enterocolitis. Initial imaging.
C. CT abdomen and pelvis without IV contrast
C. CT abdomen and pelvis without IV contrast
Variant 5: Infant. Suspected necrotizing enterocolitis. Initial imaging.
D. Fluoroscopy contrast enema
D. Fluoroscopy contrast enema
Variant 5: Infant. Suspected necrotizing enterocolitis. Initial imaging.
E. MRI abdomen and pelvis with IV contrast
E. MRI abdomen and pelvis with IV contrast
Variant 5: Infant. Suspected necrotizing enterocolitis. Initial imaging.
F. MRI abdomen and pelvis without and with IV contrast
F. MRI abdomen and pelvis without and with IV contrast
Variant 5: Infant. Suspected necrotizing enterocolitis. Initial imaging.
G. MRI abdomen and pelvis without IV contrast
G. MRI abdomen and pelvis without IV contrast
Variant 5: Infant. Suspected necrotizing enterocolitis. Initial imaging.
H. Radiography abdomen and pelvis
H. Radiography abdomen and pelvis
Variant 5: Infant. Suspected necrotizing enterocolitis. Initial imaging.
I. US abdomen
I. US abdomen
Variant 5: Infant. Suspected necrotizing enterocolitis. Initial imaging.
J. US duplex Doppler abdomen
J. US duplex Doppler abdomen
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.
Gender Equality and Inclusivity Clause
The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.
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
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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.