ACR Appropriateness Criteria® Right Lower Quadrant Pain—Suspected Appendicitis

Abstract

The most common cause of acute right lower quadrant (RLQ) pain requiring surgery is acute appendicitis (AA). This narrative's focus is on imaging procedures in the diagnosis of AA, with consideration of other diseases causing RLQ pain. In general, Computed Tomography (CT) is the most accurate imaging study for evaluating suspected AA and alternative etiologies of RLQ pain. Data favor intravenous contrast use for CT, but the need for enteric contrast when intravenous contrast is used is not strongly favored. Radiation exposure concerns from CT have led to increased investigation in minimizing CT radiation dose while maintaining diagnostic accuracy and in using algorithms with ultrasound as a first imaging examination followed by CT in inconclusive cases. In children, ultrasound is the preferred initial examination, as it is nearly as accurate as CT for the diagnosis of AA in this population and without ionizing radiation exposure. In pregnant women, ultrasound is preferred initially with MRI as a second imaging examination in inconclusive cases, which is the majority.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Imaging in acute appendicitis: What, when, and why?

“…In this context, we also strongly recommend that the ACR appropriateness criteria 4 for diagnosing AA (2011) need to be revisited in view of the radiation concern associated with CT scan and restated efficacy of USG. It is also time to integrate imaging (USG and or CT/MRI) findings into the already existing scoring systems and develop new clinico-pathological-radiological scoring systems for maximizing diagnostic accuracy.…”

“…A multitude of widely divergent and at times conflicting publications discussing about the ideal diagnostic modality and treatment algorithm for AA are being added regularly in the scientific knowledge bank, which by itself is a testimony for the uncertainty that exists in this field today. [3][4][5][6][7][8] Without a clearly defined, universally accepted diagnostic algorithm for AA, a condition which is so common in our day to day practice, diagnosticians are at crossroads in selecting the right path. In this review, we intend to make an attempt to organize the approach to AA, especially with reference to the imaging diagnosis.…”

A study the profile of pathological disorders resulting in acute abdominal non-traumatic surgical emergencies in a tertiary care hospital, North India

“…5,6 American College of Radiology has recommended using different imaging studies to assess abdominal pain based on pain location: ultrasonography (US) is recommended to assess the right upper quadrant pain, and computed tomography (CT) is recommended for the right and left lower quadrant pain. 7 Other direct visualization techniques such as colonoscopy/endoscopy and laparoscopy can also identify abnormal findings and improve the outcome in a majority of patients with abdominal pain, as it allows surgeons to see and treat many abdominal conditions that cannot be diagnosed otherwise. 8,9 The general rule of thumb is that any abdominal pain that persists for more than 6 hours is usually caused by disorders of surgical significance.…”

Ultrasonography as an integrated tool in clinical decision-making in the Emergency Department

“…Appropriate imaging training is required in order to reduce operator errors. Clinical evidence gathered for the past 15 years has allowed the inclusion of US examinations into the diagnostic and treatment algorithms for acute appendicitis, aortic aneurysms, acute heart failure, closed abdominal trauma, etc [1][2][3][4][5]. All these led to the introduction of basic training in US for the management of clinical problems in diagnostic and treatment algorithms [6].…”