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## Complete Summary

#### GUIDELINE TITLE

Hematuria---child.

#### BIBLIOGRAPHIC SOURCE(S)

Coley BD, Gunderman R, Blatt ER, Fordham L, Podberesky DJ, Prince JS,
Expert Panel on Pediatric Imaging. Hematuria - child. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2006. 6
p. \[39 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Royal SA, Slovis TL, Kushner
DC, Babcock DS, Cohen HL, Gelfand MJ, Hernandez RJ, McAlister WH, Parker
BR, Smith WL, Strain JD, Strife JL, Joseph D. Hematuria. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):841-6.

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)

Hematuria

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Family Practice\
Pediatrics\
Radiology\
Urology

#### INTENDED USERS

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

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
pediatric patients with hematuria

#### TARGET POPULATION

Pediatric patients with hematuria

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Ultrasound (US), kidney and bladder

2.  X-ray

    -   Abdomen and pelvis

    -   Intravenous pyelography (IVP)

    -   Retrograde urography

3.  Computed tomography (CT), abdomen and pelvis, with and without
    contrast

4.  Magnetic resonance imaging (MRI), abdomen and pelvis

5.  Invasive (INV)

    -   Voiding cystourethrography (VCUG)

    -   Angiography

#### 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 for reaching 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 participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, 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: Hematuria -- Child**

**Variant 1: Isolated hematuria.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  US, kidney and       7                    
  bladder                                  

  X-ray, abdomen and   2                    
  pelvis                                   

  INV, VCUG            2                    

  X-ray, intravenous   2                    
  pyelography (IVP)                        

  CT, abdomen and      2                    
  pelvis                                   

  MRI, abdomen and     2                    
  pelvis                                   

  INV, angiography     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 2: Painful hematuria (non-traumatic).**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, abdomen and      8                   Without contrast to evaluate for
  pelvis, with                             stones
  contrast                                 

  US, kidney and       7                    
  bladder                                  

  X-ray, abdomen and   6                    
  pelvis                                   

  X-ray, intravenous   2                    
  pyelography (IVP)                        

  INV, VCUG            2                    

  MRI, abdomen and     2                    
  pelvis                                   

  INV, angiography     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 3: Traumatic hematuria -- macroscopic.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, abdomen and      9                    
  pelvis, with                             
  contrast                                 

  X-ray, retrograde    6                   If blood present at urethral
  urography                                meatus.

  X-ray, abdomen and   2                    
  pelvis                                   

  US, kidney and       2                    
  bladder                                  

  X-ray, intravenous   2                    
  pyelography (IVP)                        

  MRI, abdomen and     2                    
  pelvis                                   

  INV, angiography     2                   May be appropriate for
                                           interventional therapy.

  ***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: Traumatic hematuria -- microscopic.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  CT, abdomen and      6                   CT may be indicated in the
  pelvis, with                             presence of risk factors such as
  contrast                                 pelvic fractures, flank pain and
                                           tenderness, hypotension, or other
                                           injuries.

  US, kidney and       4                   US can exclude mass or anomaly.
  bladder                                  

  X-ray, abdomen and   2                    
  pelvis                                   

  INV, VCUG            2                    

  X-ray, intravenous   2                    
  pyelography (IVP)                        

  MRI, abdomen and     2                    
  pelvis                                   

  INV, angiography     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.

**Summary of Literature Review**

Hematuria is the presence of red blood cells in the urine, either
visible or as viewed under the microscope. Detecting blood in the urine
of a child causes great alarm to patients, parents, and physicians.

The clinical evaluation of children with any form of hematuria begins
with a meticulous history. Topics covered in the history should include
urinary tract infection, strenuous exertion, tropical exposure, recent
strep throat, and recent trauma, menstruation, bleeding tendency, bloody
diarrhea, joint pains, rash, flank pain, frequency and dysuria.
Searching for occult forms of trauma, foreign body insertion, family
history of sickle cell disease or hemophilia, stone disease, hearing
loss, and familial renal disease, hematuria, and hypertension should be
undertaken. Factitious causes of \"hematuria\", such as food substances
or medicines coloring the urine without actually having red blood cells
in the urine, should also be investigated. An assessment of the child\'s
height and weight should be followed by a thorough physical examination.
Fevers, arthritis, rashes, edema, nephromegaly, abdominal masses,
genital or anal bleeding suggesting sexual abuse, deafness, and
costovertebral angle tenderness should be discerned.

The next step is a thorough evaluation of the urine. Tea-colored urine
and hematuria accompanied by proteinuria (\>2+ by dip stick), red blood
cell casts, and deformed red blood cells (best seen with phase contrast
microscopy) suggest a glomerular source of hematuria (i.e.,
glomerulonephritis). As will be discussed, imaging is seldom required
for glomerular sources of bleeding, whereas it may be useful in
nonglomerular sources of hematuria. White cells and organisms clearly
indicate the possibility of a urinary tract infection, which will direct
care and imaging by a different set of criteria. Evaluation for
hypercalciuria (such as a spot urine calcium/creatinine ratio) and a
urine culture may be indicated. Basic laboratory metabolic screening
will indicate findings of chronic renal insufficiency or long standing
acidosis; initial evaluation should include a blood urea nitrogen (BUN),
creatinine, complete blood count, and a platelet count. If suggested by
the initial clinical workup, more advanced medical assessment for
various causes of glomerulonephritis and vasculitis should be performed,
and an audiogram should be performed if indicated.

The need for imaging evaluation depends on the clinical scenario in
which hematuria presents. This review focuses on the following clinical
variations of childhood hematuria:

1.  Isolated hematuria

2.  Painful hematuria

3.  Renal trauma with gross hematuria

4.  Renal trauma with microscopic hematuria

The literature on pediatric hematuria generally consists of cohort
studies (most being retrospective), as well as literature reviews and
reports of personal experience. There are no randomized controlled
trials or comparison studies with control groups. Despite these
potential limitations, however, there are good and reasonably consistent
data in the more recent literature to provide guidance on whether and
how to image children with hematuria.

**Isolated Hematuria**

When the child has a definite medical diagnosis suggested by clinical
evaluation (such as postinfectious glomerulonephritis, Henoch-Schönlein
purpura, coagulopathy, sickle cell disease, systemic lupus
erythematosus, or infection), imaging may be necessary to assess the
size of the kidneys as an indicator of the chronicity of the renal
disease and also as a potential assessment before renal biopsy. In this
situation, ultrasound (US) is the best modality to display the anatomy,
size, and position of the kidneys (especially prior to biopsy), and to
screen for other pre-existing structural lesions in a patient with
glomerulonephritis. If the US findings are normal, renal biopsy can
sometimes add to the diagnosis of the common renal parenchymal diseases
causing hematuria, such as immunoglobulin A (IgA) nephropathy (Burger\'s
disease) or Alport\'s syndrome. However, many patients are followed
clinically at this point without more extensive workup.

While isolated asymptomatic gross hematuria may have benign and
self-limited processes (such as viral cystitis), there is fair to good
evidence to perform US on these patients. Renal and bladder tumors may
present with gross hematuria and are likely to be found with US. Since
the incidence of transitional cell uroepithelial neoplasia is extremely
rare in children, intravenous pyelography (IVP) is not indicated. While
computed tomography (CT) is an excellent modality for imaging the
genitourinary tract, given its expense and radiation exposure it is
probably not indicated as a first line test. In the cases of a suspected
vascular lesion, such as a distended left renal vein from the nutcracker
phenomenon or an intrarenal vascular malformation, US is still the best
method of initial evaluation, although contrast-enhanced CT and even
angiography may be necessary for further diagnosis.

Asymptomatic microscopic hematuria (usually defined as five or more red
blood cells per high-powered field on at least two of three consecutive
urine specimens) is a common entity, with an incidence estimated to be
0.25% to 1.0% in children 6 to 15 years of age. Patients without
proteinuria or dysmorphic red blood cells (which indicate glomerular
disease) are unlikely to have clinically significant renal disease, and
there is good evidence that no imaging is indicated. One study evaluated
325 patients with microscopic hematuria; 87% had renal US and 24% had
voiding cystoscopy urethrograms (VCUGs), and no findings were deemed to
be clinically significant. As with isolated gross hematuria, IVP is not
indicated in evaluating microscopic hematuria. Microscopic hematuria is
sometimes associated with hypercalciuria and/or hyperuricosuria, and
some authors advocate renal US to evaluate for renal calculi in these
patients, although others have found little value. In cases of
persistent unexplained microhematuria, US may be useful to evaluate for
occult anatomic abnormalities (cystic renal disease, vascular
abnormalities, congenital malformations, etc), although the yield of
these examinations is likely low. When nonmedical pressures (such as
parental anxiety over neoplasia) are an issue, US is the modality of
choice due to its relatively lower cost and lack of patient risk, and in
some cases it may be justified for the reassurance it provides. However,
it must be recognized that isolated microscopic hematuria is almost
never the presenting scenario of Wilms tumor.

If no diagnosis has been made and further workup is deemed necessary,
evaluation of children is different than in adults. Cystoscopy is rarely
indicated in the workup of a child with hematuria, whereas adults would
routinely have cystoscopy performed to evaluate for transitional cell
carcinoma of the bladder. Examination of the urinary bladder in the
child will be performed during the renal US to assess for the presence
of bladder lesions not diagnosed by the medical workup, such as polyps,
masses, or vascular lesions of the bladder. A VCUG should be considered
to evaluate for vesicoureteral reflux, posterior urethral valves in the
male, or other urethral causes of hematuria such as meatal stenosis,
Cowper\'s duct cyst, urethral stenosis, or an abnormality of the fossa
navicularis. A renal or bladder mass that is detected by US should have
further imaging with CT or magnetic resonance imaging (MRI) to define
extent of disease, vascular invasion (in the case of Wilms tumor), and
presence of metastases.

**Painful Hematuria**

In the patient with abdominal pain and hematuria, the principal
differential diagnosis is urolithiasis, although tumor and ureteropelvic
junction (UPJ) obstruction should also be included. In young patients
with genitourinary tract stone disease, the presenting symptoms may not
be as classic as in adults, which in turn leads to uncertainty about the
best imaging approach. Pediatric stone disease has an incidence less
than 2% of that in adults but is still commonly seen in busy pediatric
practices. While the literature provides some general suggestions and
guidelines, what imaging test to perform under what clinical scenario is
not universally agreed upon.

There **is** good evidence in the adult and pediatric imaging literature
that CT is the most accurate imaging modality in the identification of
stones and the quantification of stone burden. CT scanning of course
exposes these children to ionizing radiation. While with proper
techniques the CT dose can be lowered to that less than a traditional
IVP, it raises the question of whether other imaging modalities
(specifically plain radiographs and US) still play a role in pediatric
stone disease. In a study of 178 adult and pediatric patients, it was
found that plain radiographs had a 59% sensitivity for stone detection.
Another study reported that US found 75% of all urinary tract stones,
although US found only 38% of stones within the ureter. Similarly, a
third study showed that US correctly found stones in 78% of patients,
although it only found 25% of urethral stones. Limitations of both plain
radiography and US in children include greater obscuration by bowel gas
and contents, and smaller stone size than in adults, neither of which
impairs CT evaluation.

The evidence is very good for the use of CT to detect genitourinary
tract stones in children. However, given the often vague nature of
symptoms in pediatric nephrolithiasis, there is fair evidence that plain
radiographs may still have some use especially in a patient with a
personal or family history of stone disease. Similarly, US is still
recommended as an initial screening test, and if positive can then
direct patient management, with the caveat that a negative US does not
exclude stone disease. In this approach, dose-adjusted CT is reserved
for problematic cases. However, a reasonable argument can be made for
limited dose-adjusted CT as the initial study of choice (especially in
patients without a prior history of stones); it has the advantage of
providing information about other pathology. IVP is seldom indicated in
children as an initial examination, although a limited study may provide
information about stone position and movement after initial diagnosis.

**Traumatic Hematuria**

Hematuria is frequently found in the pediatric patient with blunt
abdominal trauma. In children, the most commonly injured viscera are the
spleen, liver, and kidney. The amount of hematuria that should trigger
radiologic investigation of the urinary tract is somewhat controversial,
but several facts are well accepted:

1.  Gross hematuria is a finding that necessitates a radiologic
    evaluation of the abdomen and pelvis.

2.  Isolated microscopic hematuria without any clinical or laboratory
    findings of visceral trauma does not need emergency investigation.

3.  The presence of blood in the urethral meatus in a patient with
    pelvic fractures should lead to an investigation of the urethra and
    bladder (50% incidence of genitourinary injury).

4.  Minor trauma to an anomalous kidney can cause major clinical
    repercussions (renal anomalies occur in 1% to 4% of the population).

5.  All CT scans must be done with IV contrast (enhanced CT).

6.  Hypotension is an unreliable clinical indicator for prompting
    imaging in children

**Macroscopic Hematuria**

There is good evidence from multiple adult and pediatric studies that
contrast-enhanced CT scan is the best modality for evaluating renal
trauma, and that such imaging is required in patients with gross
hematuria. While US has been advocated as a first line imaging test in
abdominal trauma, renal injuries are sometimes missed, and in the
setting of gross hematuria these patients are better served with CT. If
renal injury is detected on CT, then obtaining delayed scans to evaluate
for collecting system disruption should be considered.

Patients with gross hematuria and pelvic fractures are at high risk for
bladder rupture. The conventional fluoroscopic cystogram requires moving
the patient to another imaging suite. There is good evidence that CT
cystography is an accurate method of evaluation, with the advantage that
the patient need not be moved from the CT scanner. In general, images
are obtained with a contrast-filled bladder and then after drainage,
although one study in adults suggests that postvoid images may be
unnecessary.

Patients with blood at the urethral meatus, especially if associated
with pelvic fractures or straddle injuries, are at risk for urethral
injury and disruption. These patents should undergo retrograde urography
(RUG) prior to bladder catheter placement and may warrant a cystogram to
exclude concomitant bladder injury.

The limited or \"one-shot\" IVP was once a mainstay of adult renal
trauma imaging. In current practice in a hemodynamically stable
pediatric patient, the IVP has little role in the evaluation of
hematuria.

**Microscopic Hematuria**

Different threshold values have been used for evaluating post-traumatic
microhematuria, but in general \>50 red blood cells per high-powered
field (RBC/hpf) has been used as a threshold for imaging. However,
recent studies note at best a fair correlation between degree of
microhematuria and risk or severity of renal injury, and the use of a
cutoff value may not be appropriate.

For patients with isolated microscopic hematuria without coexistent
injury, there is good evidence that renal imaging with CT is unlikely to
disclose clinically significant findings. While there have been
advocates for US in this setting, it is unlikely to provide meaningful
patient management information.

However, children with microhematuria can have significant renal trauma,
almost always associated with coexistent injury or congenital
abnormalities, and associated clinical findings. There is good evidence
that patients with multi-organ injury, a history of deceleration injury,
localized flank pain, and ecchymosis should undergo CT imaging to
evaluate for renal injury. While hypotension is an unreliable clinical
indicator in the child (unlike the adult), a child with a falling
hemoglobin or hemodynamic instability should be considered for imaging.

**Abbreviations**

-   CT, computed tomography

-   INV, invasive

-   MRI, magnetic resonance imaging

-   US, ultrasound

-   VCUG, voiding cystourethrography

#### 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
pediatric patients with hematuria

#### POTENTIAL HARMS

Computed tomography exposes children to ionizing radiation.

### 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)

Coley BD, Gunderman R, Blatt ER, Fordham L, Podberesky DJ, Prince JS,
Expert Panel on Pediatric Imaging. Hematuria - child. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2006. 6
p. \[39 references\]

#### ADAPTATION

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

#### DATE RELEASED

1999 (revised 2006)

#### 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 Pediatric Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Brian D. Coley, MD; Richard Gunderman, MD, PhD; Ellen
R. Blatt, MD; Lynn Fordham, MD; Daniel J. Podberesky, MD; Jeffrey Scott
Prince, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Royal SA, Slovis TL, Kushner
DC, Babcock DS, Cohen HL, Gelfand MJ, Hernandez RJ, McAlister WH, Parker
BR, Smith WL, Strain JD, Strife JL, Joseph D. Hematuria. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215(Suppl):841-6.

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/ExpertPanelonPediatricImaging/HematuriaChildDoc4.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 NGC summary was completed by ECRI Institute on May 15, 2007.

#### 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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Date Modified: 11/3/2008