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## Complete Summary

#### GUIDELINE TITLE

Blunt abdominal trauma.

#### BIBLIOGRAPHIC SOURCE(S)

Shuman WP, Holtzman SR, Bree RL, Bettmann MA, Casciani T, Foley WD, Gay
SB, Gomes AS, Rosen MP, Sacks D, Greene FL, Expert Panel on
Gastrointestinal Imaging. Blunt abdominal trauma. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2005. 8
p. \[98 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Shuman WP, Ralls PW, Balfe
DM, Bree RL, DiSantis DJ, Glick SN, Levine MS, Megibow AJ, Saini S,
Greene FL, Laine LA, Lillemoe K, Berland L. Imaging of blunt abdominal
trauma. American College of Radiology. ACR Appropriateness Criteria.
Radiology 2000 Jun;215(Suppl):143-51.

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)

Blunt abdominal trauma

#### GUIDELINE CATEGORY

Diagnosis

#### CLINICAL SPECIALTY

Emergency Medicine\
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 blunt abdominal trauma

#### TARGET POPULATION

Adults with blunt abdominal trauma

**Note**: Penetrating trauma and pediatric cases are not considered.

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray

    -   Chest, upright

    -   Abdomen, supine and upright

    -   Cystogram

2.  Computed tomography (CT)

    -   Abdomen and pelvis

    -   Cystogram, abdomen and pelvis

3.  Invasive (INV)

    -   Angiography embolization

    -   Renal angiogram

4.  Ultrasound (US)

    -   Screen for hemoperitoneum

    -   Organ sonogram

    -   Bladder

5.  Magnetic resonance imaging (MRI)

    -   Organ evaluation

    -   Diaphragm evaluation

    -   Kidneys and bladder

6.  Retrograde urethrogram

7.  Intravenous urography (IVU)

#### 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 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 this 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®]{.underline}**

**[Clinical Condition]{.underline}: Blunt Abdominal Trauma, Adults**

**[Variant 1]{.underline}: Stable patient.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest,        8                   Computed tomography (CT) and
  upright                                  x-rays may be appropriate. See
                                           original guideline document text
                                           for details.

  X-ray, abdomen,      8                   CT and x-rays may be appropriate.
  supine and upright                       See original guideline document
                                           text for details.

  CT, abdomen & pelvis 8                   Multidetector CT (MDCT) is
                                           preferable. CT and x-rays may be
                                           appropriate. See original
                                           guideline document text for
                                           details

  INV, angiography     8                   Not a screening procedure.
  embolization                             Angiography is indicated to
                                           delineate and treat active
                                           bleeding or other lesions amenable
                                           to angiographic therapy, but only
                                           when this type of lesion is first
                                           detected or suspected, either by
                                           CT or by some other means.

  US, screen for       4                   Low sensitivity of ultrasound to
  hemoperitoneum                           injuries that require surgery
                                           (active hemorrhage, viscus
                                           perforation) and its inability to
                                           exclude injuries that require
                                           in-hospital observation lessen its
                                           usefulness for key triage
                                           decisions.

  US, organ sonogram   3                    

  MRI, organ           2                    
  evaluation                               

  MRI, diaphragm       2                    
  evaluation                               

  ***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]{.underline}: Unstable patient.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest,        7                    
  upright                                  

  US, screen for       7                    
  hemoperitoneum                           

  X-ray, abdomen,      6                    
  supine and upright                       

  US, organ            4                    

  INV, angiography     4                    
  embolization for                         
  bleeding                                 

  CT, abdomen & pelvis 4                   MDCT is preferable. Clinical
                                           judgment needed on stability of
                                           patient versus need for diagnostic
                                           information.

  MRI, organ           2                    
  evaluation                               

  MRI, diaphragm       2                    
  evaluation                               

  ***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]{.underline}: Hematuria \> 35 Red Blood Cells (RBC)/High
Power Field (HPF) (stable).**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest,        8                   CT and x-rays may be appropriate.
  upright                                  See original guideline document
                                           text for details.

  X-ray, abdomen,      8                   CT and x-rays may be appropriate.
  supine & upright                         See original guideline document
                                           text for details.

  CT, abdomen & pelvis 8                   MDCT is preferable. CT and x-rays
                                           may be appropriate. See original
                                           guideline document text for
                                           details.

  CT cystogram,        7                    
  abdomen & pelvis                         

  Retrograde           7                   If urethral injury is suspected.
  urethrogram                              

  IVU                  4                    

  X-ray, cystogram     4                    

  INV, renal angiogram 4                    

  US, organ            3                    

  US, bladder          3                    

  MRI, kidneys and     2                    
  bladder                                  

  ***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.

This review considers only the issue of blunt abdominal trauma in
adults. Penetrating trauma and pediatric cases are not considered.

**Category A**

*Hemodynamically unstable* patients presenting to the emergency room
with clinically obvious major abdominal trauma and with unresponsive
profound hypotension need rapid clinical evaluation and immediate
resuscitation with volume replacement. If such unstable patients do not
respond to resuscitation (become hemodynamically stable), *and* if they
have clear clinical evidence of abdominal injury, they should go
immediately to the operating room without imaging. During resuscitative
efforts if time and circumstances permit, conventional radiographs of
the chest and abdomen are often obtained as part of trauma protocols.
This may help identify a pneumothorax, pneumoperitoneum, or significant
bone injury. Ultrasound performed by an experienced sonologist to check
for intraperitoneal free fluid may quickly provide information that can
support a decision to operate immediately, with the caveat that the
false negative rate is at least 15%. More detailed ultrasound to check
for organ injury takes too long in this setting and suffers from poor
sensitivity. There is now general agreement that routine diagnostic
peritoneal lavage (DPL) is obsolete because of its invasive nature, lack
of specificity, and inability to predict the need for therapeutic
surgery.

**Category B**

*Hemodynamically stable* patients, patients with mild to moderate
responsive hypotension presenting to the emergency room after blunt
abdominal trauma, and unstable patients who stabilize after initial
resuscitation are in a separate category. These patients typically have
a history of significant trauma and have at least moderate suspicion of
intra-abdominal injury based on clinical signs and symptoms. For these
patients, two decisions need to be made: (1) Is urgent therapeutic
surgery or angiography needed? (2) If surgery is not needed, is a period
of close observation warranted? If computed tomography (CT) is to be
performed, plain films will offer little if any incremental help with
those questions. Rather, the decision to proceed with urgent surgery
depends on the identification of specific CT criteria that predict that
the surgery will be therapeutic: active hemorrhage, parenchymal
\"blush\" or pseudoaneurysm in the spleen, or perforation of a hollow
viscus (including the pancreatic duct). In patients with active
hemorrhage or pseudoaneurysm of the spleen, angiographic embolization
may also be therapeutic. The decision to operate urgently does not
solely depend on the identification of hemoperitoneum or the
identification of parenchymal injury to the liver or spleen, because
most patients in this category ultimately do not need surgery. However,
accurate identification of hemoperitoneum or organ injury is important
because patients with these findings require at least a period of close
observation. Patients with multiple organ injury or significant active
bleeding may need surgery even if they are hemodynamically stable.
Conversely, stable patients with isolated organ injury may not need
surgery (or may need only angiography plus embolization) even with a
large amount of hemoperitoneum.

Either way, time is available in such patients to obtain chest and
abdominal radiographs, a hematocrit plus blood chemistries, and a
urinalysis. If a reliable abdominal exam can be performed (the patient
is conscious and does not need prolonged anesthesia for other
procedures) and all the above preliminary tests are unremarkable, a
period of close observation may be all that is needed. However, if a
reliable abdominal exam cannot be performed (patient is unconscious or
prolonged nonabdominal surgery is anticipated) or if a clinical
evaluation suggests organ injury, hemoperitoneum, or peritonitis,
further imaging is needed.

At this point, ultrasound is not a good modality for further imaging
because it misses up to 25% of liver and spleen injuries, most renal
injuries, and virtually all pancreatic, mesenteric, and gut injuries. It
also misses a high proportion of retroperitoneal hemorrhage and of
bladder rupture. Combining the results for ultrasound in 1535 abdominal
trauma patients from eight published series yields an average
sensitivity for hemoperitoneum of 88% and for organ injury of 74%.
Unfortunately, a negative ultrasound (absence of hemoperitoneum) does
not rule out significant organ or viscus injury that might require
surgery or observation.

Although ultrasound is 63% sensitive to moderate amounts of free
intraperitoneal fluid (compared with computed tomography), 400 to 600
cc\'s are needed for ultrasound detection of fluid in the trauma
setting. Almost regardless of volume, an ultrasound diagnosis of free
fluid alone does not predict that surgery is needed or that surgery will
be therapeutic. In addition, in the best of hands, there is at least a
15% false negative rate for detecting hemoperitoneum with ultrasound.
Further, ultrasound is quite insensitive in detecting organ injury: 62%
of spleen and 14% of liver injuries are missed compared with computed
tomography and operative findings. Ultrasound poorly identifies active
hemorrhage and also does not accurately predict the need for surgery in
splenic injuries.

Ultrasound is also insensitive to perforation of gut and to pancreatic
injury. For these reasons, it is not very useful in deciding when a
patient needs urgent therapeutic surgery or angiography. For the same
reasons, ultrasound is not an accurate modality to determine whether a
patient needs a period of close observation; thus, if a negative
ultrasound is the sole imaging modality used to triage a patient, for
safety reasons it must be followed by a 12- to 24-hour period of
in-hospital observation. It should be noted that 96% of trauma centers
perform fewer than two trauma ultrasound exams per month, so there is
currently little national experience with or teaching of trauma
ultrasound.

In contrast, for category B trauma patients, computed tomography
accurately predicts if therapeutic surgery is urgently needed by
identifying active hemorrhage, splenic injury (either parenchymal
contrast blush or pseudoaneurysm), gut perforation, and pancreatic
injury. For these reasons, it is an excellent modality for deciding
whether a patient needs urgent therapeutic surgery or is a candidate for
therapeutic angiography. Because computed tomography is sensitive in
detecting both hemoperitoneum and injury to the liver (sensitivity 93%)
and spleen (sensitivity 95%), it is an accurate modality for deciding if
a patient needs a period of close observation. The trend toward placing
helical computed tomography scanners close to or in emergency
departments has substantially diminished the delay in getting patients
to the computed tomography scanner and has decreased actual scan time to
less than 40 seconds. In most circumstances, results from a helical
computed tomography of the abdomen and pelvis can be obtained faster
than results from a detailed ultrasound that includes evaluation of
abdominal organs and gut.

If multidetector computed tomography with rapid image display capability
is available in or next to an emergency department, abdominal computed
tomography can be performed in about 2 minutes - excluding time needed
for patient transport, computed tomography scan setup, and archiving of
images. Including all time requirements, patient turnaround with
rapid-process multidetector computed tomography can be less 10 minutes
for a trauma patient. For single-slice incremental computed tomography,
turnaround time is somewhat longer, usually 20 minutes. Scanning
multiple body regions increases these times variably.

An experienced radiologist should carefully examine images on film,
picture archiving and communication system (PACS), or at the computed
tomography console, where images can be altered to seek bone injury,
pneumoperitoneum, or subtle organ injury. Particular care should be
taken to find minimal injury of the spleen because these patients may
need observation for potential delayed hemorrhage. In some instances,
stable patients with more severe injuries of the liver or spleen plus
hemoperitoneum may be managed conservatively with only close
observation. It should be noted, however, that various schemes for using
computed tomography to grade liver or spleen lacerations are not helpful
in deciding whether a patient needs surgery. This decision must be based
on the clinical status of the patient in combination with the image
findings. If evidence of active hemorrhage is discovered on computed
tomography exams, the patient may be taken to the operating room or
undergo arteriography plus embolization to control the hemorrhage.

The computed tomography exam should be carefully examined for subtle
signs of pancreatic injury because these patients may need immediate
surgery or close observation for signs of complications. Duodenal
perforation produces subtle but frequent findings on computed
tomography, e.g., typically extraluminal air or contrast in the
retroperitoneum or elsewhere; these findings mandate surgical
intervention. Duodenal hematoma may not require surgery but does need
close observation. Other gut injury or perforation produces direct or
indirect findings on computed tomography in 50% to 94% of cases.
However, if the computed tomography is negative for gut injury in the
face of a high clinical suspicion, diagnostic peritoneal lavage,
laparoscopy, or a period of observation plus repeat computed tomography
may be used to further evaluate the patient.

There may be a rationale for creating a subcategory of stable patients
with trivial trauma, a low clinical index of suspicion, and no signs or
symptoms of intraabdominal injury. In such patients, a negative
ultrasound alone may be adequate to release the patient from observation
at a lower cost than if computed tomography had been used. Computed
tomography is necessary, however, if there are any positive findings on
ultrasound.

It may also be reasonable to use computed tomography, in conjunction
with the clinical information, to decide whether to observe patients in
the hospital for a day or send them home promptly at the completion of
their investigation in the emergency department. The high sensitivity of
computed tomography in detecting injuries that require observation in
the hospital means that a negative computed tomography may be adequate
to release the patient to home in selected cases. Ultrasound has a
substantially lower sensitivity to the kind of injuries that must be
observed in the hospital. For this reason, a negative ultrasound is not
adequate to safely release the patient to home. This weakness of
ultrasound is reflected in the design of many outcomes-based
investigations on the use of ultrasound in trauma: all keep patients
with a negative ultrasound in the hospital for a period of observation
of 12 to 48 hours before release.

**Category C**

*Patients with hematuria* require some modification to the imaging
workup. Patients with microscopic hematuria (less than 35 red blood
cells per high power field) do not need specific urinary tract imaging.
All patients with microscopic hematuria greater than 35 red blood cells
per high power field, with macroscopic hematuria, or with
fracture/diastasis of the symphysis pubis and its rami plus any
hematuria need imaging of the urinary tract. If the urethral meatus has
gross blood, if there is a floating prostate, or if a Foley catheter
cannot be passed, a retrograde urethrogram should first be performed to
rule out urethral injury. However, if clinical evaluation or the
urethrogram indicates no urethral injury, a computed tomography
cystogram should be added to the abdominal computed tomography (see
appendix to the original guideline document). Computed tomography images
should be examined carefully for evidence of renal perfusion,
hemorrhage, or extravasation of contrast or urine from the kidney or
bladder. Two studies have documented the poor ability of ultrasound to
detect injuries of the kidney. All but the worst renal injuries are
treated with observation; intraperitoneal bladder rupture is usually
treated with surgical repair.

**Abbreviations**

-   CT, computed tomography

-   INV, invasive

-   IVU, intravenous urography

-   MRI, magnetic resonance imaging

-   US, ultrasound

#### 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 blunt abdominal trauma

#### POTENTIAL HARMS

Not stated

### 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
radiologist, radiation oncologist, 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)

Shuman WP, Holtzman SR, Bree RL, Bettmann MA, Casciani T, Foley WD, Gay
SB, Gomes AS, Rosen MP, Sacks D, Greene FL, Expert Panel on
Gastrointestinal Imaging. Blunt abdominal trauma. \[online
publication\]. Reston (VA): American College of Radiology (ACR); 2005. 8
p. \[98 references\]

#### 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

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*: William P. Shuman, MD (*Co-Author*); Stephen R.
Holtzman, MD (*Co-Author*); Robert L. Bree, MD, MHSA; Michael A.
Bettmann, MD; Thomas Casciani, MD; W. Dennis Foley, MD; Spencer B. Gay,
MD; Antoinette S. Gomes, MD; Max Paul Rosen, MD, MPH; David Sacks, MD;
Frederick L. Greene, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Shuman WP, Ralls PW, Balfe
DM, Bree RL, DiSantis DJ, Glick SN, Levine MS, Megibow AJ, Saini S,
Greene FL, Laine LA, Lillemoe K, Berland L. Imaging of blunt abdominal
trauma. American College of Radiology. ACR Appropriateness Criteria.
Radiology 2000 Jun;215(Suppl):143-51.

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/BluntAbdominalTraumaDoc3.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 NGC
summary was updated by ECRI on January 4, 2006. The updated information
was verified by the guideline developer on January 19, 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

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008