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## Complete Summary

#### GUIDELINE TITLE

Right lower quadrant pain.

#### BIBLIOGRAPHIC SOURCE(S)

Bree RL, Blackmore CC, Foley WD, Gay SB, Glick SN, Heiken JP, Huprich
JE, Levine MS, Ros PR, Rosen MP, Shuman WP, Greene FL, Rockey DC, Expert
Panel on Gastrointestinal Imaging. Right lower quadrant pain. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2005. 7
p. \[43 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Ralls PW, Balfe DM, Bree RL,
DiSantis DJ, Glick SN, Levine MS, Megibow AJ, Saini S, Shuman WP, Greene
FL, Laine LA, Lillemoe K. Evaluation of acute right lower quadrant pain.
American College of Radiology. ACR Appropriateness Criteria. Radiology
2000 Jun;215(Suppl):159-66.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute right lower quadrant pain

#### GUIDELINE CATEGORY

Diagnosis

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Internal Medicine\
Nuclear Medicine\
Pediatrics\
Radiology\
Surgery

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
patients with acute right lower quadrant pain

#### TARGET POPULATION

Patients with acute right lower quadrant pain

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray

    -   Chest

    -   Anteroposterior and upright abdomen

    -   Barium enema, air contrast

    -   Barium enema, single contrast

    -   Small bowel series, with barium

    -   Small bowel, enteroclysis

2.  Ultrasound (US)

    -   Right lower quadrant (RLQ), graded compression

    -   Pelvic/endovaginal

3.  Computed tomography (CT)

    -   Without contrast

    -   With IV contrast

4.  Nuclear medicine

    -   White blood cell (WBC) scan

    -   Gallium scan

5.  Magnetic resonance imaging (MRI)

    -   Abdomen with or without enhancement

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed to reach agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus. 
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1 to 9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Acute Right Lower Quadrant Pain**

**Variant 1: Fever, leukocytosis, and classic presentation clinically
for appendicitis in adults.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, abdomen, with IV 8                    
  contrast                                 

  CT, abdomen, with    6                    
  contrast                                 

  US, abdomen RLQ,     6                    
  graded compression                       

  X-ray, abdomen, AP   5                    
  and upright                              

  X-ray, chest         5                    

  US, pelvis and       5                    
  endovaginal                              

  X-ray, barium enema, 4                    
  air contrast                             

  X-ray, barium enema, 4                    
  single contrast                          

  MRI, abdomen, with   4                    
  or without contrast                      

  X-ray, small-bowel   3                    
  series, with barium                      

  NUC, Gallium scan    3                    

  NUC, WBC scan        3                    

  X-ray, small bowel,  2                    
  enteroclysis                             

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Fever, leukocytosis; possible appendicitis, atypical
presentation, adults and adolescents.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, abdomen, with IV 8                    
  contrast                                 

  X-ray, abdomen, AP   6                    
  and upright                              

  CT, abdomen, with    6                    
  contrast                                 

  US, abdomen RLQ,     6                    
  graded compression                       

  US, pelvis and       6                    
  endovaginal                              

  X-ray, barium enema, 5                    
  air contrast                             

  X-ray, barium enema, 5                    
  single contrast                          

  X-ray, chest         5                    

  MRI, abdomen, with   5                    
  or without contrast                      

  X-ray, small-bowel   4                    
  series, with barium                      

  NUC, Gallium scan    3                    

  NUC, WBC scan        3                    

  X-ray, small bowel,  2                    
  enteroclysis                             

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: Fever, leukocytosis, pregnant woman.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  US, abdomen, RLQ,    8                    
  graded compression                       

  MRI, abdomen, with   7                    
  or without contrast                      

  CT, abdomen, with IV 6                    
  contrast                                 

  US, pelvis and       6                    
  endovaginal                              

  CT, abdomen, without 5                    
  contrast                                 

  X-ray, chest         4                    

  X-ray, abdomen, AP   2                    
  and upright                              

  X-ray, barium enema, 2                    
  air contrast                             

  X-ray, barium enema, 2                    
  single contrast                          

  X-ray, small-bowel   2                    
  series, with barium                      

  X-ray, small bowel,  2                    
  enteroclysis                             

  NUC, Gallium scan    2                    

  NUC, WBC scan        2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 4: Fever, leukocytosis, possible appendicitis, atypical
presentation in children (less than 14 years of age).**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  US, abdomen RLQ,     8                    
  graded compression                       

  CT, abdomen, with IV 7                   May be useful following negative
  contrast                                 US.

  X-ray, abdomen, AP   6                    
  and upright                              

  X-ray, chest         5                    

  CT, abdomen, without 5                    
  contrast                                 

  US, pelvis and       5                    
  endovaginal                              

  MRI, abdomen, with   5                    
  or without contrast                      

  X-ray, barium enema, 3                    
  air contrast                             

  X-ray, barium enema, 3                    
  single contrast                          

  X-ray, small-bowel   3                    
  series, with barium                      

  X-ray, small bowel,  2                    
  enteroclysis                             

  NUC, Gallium scan    2                    

  NUC, WBC scan        2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

Few comparative imaging studies evaluating right lower quadrant pain are
available. Most imaging reports center on disease processes, such as
appendicitis. Because appendicitis is the most common cause of right
lower quadrant pain, the focus of this narrative is on appendicitis and
the accuracy of imaging procedures in diagnosing appendicitis, although
consideration of other diseases is, of course, included.

Acute appendicitis is the most common acute abdominal disorder that
requires surgery. In most patients with acute appendicitis, imaging may
not be necessary, because the clinical presentation is sufficiently
diagnostic to allow surgery. To date, however, no prediction rules for
identifying subjects with appendicitis have been validated. In the
published studies for imaging in appendicitis, the selection criteria
for imaging are not often stated, but in most investigations, subjects
with definitive clinical exam findings of appendicitis undergo operation
without imaging. In the reported imaging studies, an average of 45 to
50% of imaged subjects had appendicitis, and 36% had nonspecific
abdominal pain. Data on the overall effect of imaging on surgical
treatment of appendicitis and patient outcome remain contradictory.

Plain film diagnosis is of limited value evaluating acute appendicitis,
except in occasional circumstances when an appendicolith or other
ancillary findings are identified. Although barium enema has been used
historically to diagnose appendicitis, it depends on the negative
finding of nonvisualization of the appendix and may be quite
uncomfortable in patients with acute appendicitis. Nonetheless, barium
small-bowel follow-through or barium enema may be useful for other
causes of right lower quadrant pain, including suspected small bowel
obstruction, infectious ileitis, and inflammatory bowel disease.
Finally, use of MRI for appendicitis has been reported in a few small
case series, including in pregnant women.

CT is the most accurate study for evaluating patients without a clear
clinical diagnosis of acute appendicitis. In a meta-analysis of
prospective studies of the accuracy of CT and ultrasonography in
adolescents and adults, CT demonstrated superior sensitivity (0.94, 95%
CI: 0.91 to 0.95) and specificity (0.95, 95% CI: 0.93 to 0.96) versus US
(sensitivity 0.86, 95% CI: 0.83 to 0.88; specificity 0.81, 95% CI: 0.78
to 0.84). This analysis was based on 12 studies of CT and 14 studies of
US identified through December 2003, and included four studies that
directly compared both modalities. The results of investigations of CT
showed consistent results across all studies and institutions, while US
investigations demonstrated heterogeneity, suggesting greater dependence
on operator skill. Another controversy is whether or not to use
intravenous contrast in the CT evaluation of appendicitis. High accuracy
has been reported for both techniques, and direct comparisons are
lacking. However, the majority of the available evidence is on CT with
intravenous contrast. Institutional experience may be the best
determinant appropriateness of intravenous contrast. Both CT and US may
be effective in detecting causes of pain unrelated to appendicitis. CT
has been reported to show a non-appendicitis cause of abdominal pain in
20% of subjects, versus 15% for US. The range of diseases studied
includes inflammatory bowel disease, infectious bowel disease, small
bowel obstruction, acute gynecological conditions and others.

CT appears superior to sonography in evaluating patients with
periappendiceal abscess, especially when the abscesses become large. CT
can be used to choose among different therapeutic options, including
antibiotic treatment (with small abscesses), percutaneous drainage (with
one to three well-defined medium-sized abscesses), and surgery (with
extensive abnormality not amenable to percutaneous drainage).

CT and US have been less well evaluated in children than in adults. Many
large prospective studies include subjects of all ages, despite the
potential differences in imaging accuracy between children and adults
due to smaller body size and less body fat in children. This makes it
difficult to determine the accuracy of imaging in different subgroups.
Further, the increased radiosensitivity of children makes the use of
ionizing radiation of more concern for them. A systematic literature
review through July 2004 revealed eight prospective evaluations of US
for appendicitis in children. The pooled sensitivity of graded
compression US was 91% (95% CI: 89 to 93%), and the specificity was 97%
(95% CI: 95 to 99%). Only a single prospective study of CT in children
was identified, reporting a sensitivity of 95%, and specificity of 98%.
There is also a small literature on use of US as an initial imaging
study, followed by CT for equivocal cases. Such protocols demonstrate
sensitivity of 95% (95% CI: 83 to 100%), and specificity 93% (95% CI: 87
to 97%). These results suggest that although CT is more accurate, US may
also be appropriate in experienced hands, particularly if equivocal
results are followed up by CT.

Nuclear medicine imaging with WBC scans has also been reported for
evaluating right lower quadrant pain.

Evaluation of the accuracy of imaging in pregnant women has received
little attention in the literature. In general, ionizing radiation from
CT should be avoided during pregnancy, and US is clearly a safer imaging
option. However, with the absence of evidence, no specific
recommendation can be made.

**Abbreviations**

-   AP, anteroposterior

-   CT, computed tomography

-   IV, intravenous

-   MRI, magnetic resonance imaging

-   NUC, nuclear medicine

-   RLQ, right low quadrant

-   US, ultrasound

-   WBC, white blood cell

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
patients with acute right lower quadrant pain.

#### POTENTIAL HARMS

-   Barium enema may be quite uncomfortable in patients with acute
    appendicitis.

-   In general, ionizing radiation from computed tomography (CT) should
    be avoided during pregnancy, and ultrasound (US) is clearly a safer
    imaging option.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (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 exams 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
U.S. Food and Drug Administration (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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Bree RL, Blackmore CC, Foley WD, Gay SB, Glick SN, Heiken JP, Huprich
JE, Levine MS, Ros PR, Rosen MP, Shuman WP, Greene FL, Rockey DC, Expert
Panel on Gastrointestinal Imaging. Right lower quadrant pain. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2005. 7
p. \[43 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Gastrointestinal
Imaging.

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Robert L. Bree, MD, MHSA; C. Craige Blackmore, MD, MPH;
W. Dennis Foley, MD; Spencer B. Gay, MD; Seth N. Glick, MD; Jay P.
Heiken, MD; James E. Huprich, MD; Marc S. Levine, MD; Pablo R. Ros, MD,
MPH; Max Paul Rosen, MD, MPH; William P. Shuman, MD; Frederick L.
Greene, MD; Don C. Rockey, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Ralls PW, Balfe DM, Bree RL,
DiSantis DJ, Glick SN, Levine MS, Megibow AJ, Saini S, Shuman WP, Greene
FL, Laine LA, Lillemoe K. Evaluation of acute right lower quadrant pain.
American College of Radiology. ACR Appropriateness Criteria. Radiology
2000 Jun;215(Suppl):159-66.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/RightLowerQuadrantPainDoc12.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on March 19, 2001. The information
was verified by the guideline developer on March 29, 2001. This summary
was updated by ECRI on March 24, 2006.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008