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## Complete Summary

#### GUIDELINE TITLE

Acute onset flank pain, suspicion of stone disease.

#### BIBLIOGRAPHIC SOURCE(S)

Baumgarten DA, Francis IR, Bluth EI, Bush WH Jr, Casalino DD, Curry NS,
Israel GM, Jafri SZ, Kawashima A, Papanicolaou N, Remer EM, Sandler CM,
Spring DB, Fulgham P, Expert Panel on Urologic Imaging. Acute onset
flank pain, suspicion of stone disease. \[online publication\]. Reston
(VA): American College of Radiology (ACR); 2007. 5 p. \[45 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previous published version: Rosenfield AT, Choyke PL, Bluth
E, Bush WH Jr, Casalino DD, Francis IR, Jafri SZ, Kawashima A, Kronthal
A, Older RA, Papanicolaou N, Ramchandani P, Sandler C, Segal AJ, Tempany
C, Resnick MI, Expert Panel on Urologic Imaging. Acute onset flank pain,
suspicion of stone disease. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2005. 4 p. \[32 references\]

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\
 CONTRAINDICATIONS\
 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 onset of flank pain, suspicion of stone disease

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Internal Medicine\
Nephrology\
Obstetrics and Gynecology\
Radiology\
Urology

#### INTENDED USERS

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

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of radiologic examinations for patients
with acute onset flank pain or suspected urinary tract stones (calculi)

#### TARGET POPULATION

Patients with suspected ureteral stones who present with acute onset
flank pain

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Computed tomography (CT) of the abdomen and pelvis without contrast

2.  X-ray intravenous urography

3.  Doppler ultrasound (US) of the kidney, ureters and bladder (KUB)

4.  Magnetic resonance imaging (MRI) of the abdomen and pelvis

5.  X-ray of the abdomen

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in evaluating patients with suspected
ureteral stones who present with acute onset flank pain

### 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

Not stated

#### 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 performed.

#### 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 Onset Flank Pain**

**Variant 1: Suspicion of stone disease.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  CT abdomen and pelvis 8            Reduced-dose techniques           High
  without contrast                   preferred.                        

  X-ray intravenous     7                                              Low
  urography                                                            

  US kidney with        6            Preferred exam in pregnancy, in   Low
  Doppler and KUB                    patients who are allergic to      
                                     iodinated contrast, and if NCT is 
                                     not available.                    

  MRI abdomen and       4            MR urography technique should be  None
  pelvis                             performed. See comments regarding 
                                     contrast in text under            
                                     \"Anticipated Expectations.\"     

  X-ray abdomen         1            Most useful in patients with      Low
                                     known stone disease.              

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

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

**Variant 2: Recurrent symptoms of stone disease.**

  -----------------------------------------------------------------------------------
  **Radiologic          **Rating**   **Comments**                      **RRL\***
  Procedure**                                                          
  --------------------- ------------ --------------------------------- --------------
  CT abdomen and pelvis 7            Reduced dose techniques           High
  without contrast                   preferred.                        

  US kidney with        7                                              Low
  Doppler and KUB                                                      

  X-ray abdomen         6            Good for baseline and follow-up   Low
                                     post treatment.                   

  X-ray intravenous     2                                              Low
  urography                                                            

  MRI abdomen and       2                                              None
  pelvis                                                               

  **[Rating                                                            **\*Relative
  Scale]{.underline}:                                                  Radiation
  1=Least appropriate,                                                 Level**
  9=Most appropriate**                                                 
  -----------------------------------------------------------------------------------

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

**Summary of Literature Review**

Urinary tract stones (calculi) are thought to result from either
excessive excretion or precipitation of salts in the urine or a relative
lack of inhibiting substances. Men are more commonly affected than
women, and the incidence increases with age until age 60. Blacks and
children are affected less frequently. Renal calculi tend to be
recurrent, and flank pain is a nonspecific symptom that may be
associated with other entities; therefore, evaluation with imaging is
recommended at the initial presentation.

A renal calculus small enough to pass into the ureter may cause blockage
of urine flow with distension of the upper urinary tract. Ureteral
hyperperistalsis occurs, resulting in acute onset of sharp, spasmodic
flank pain and hematuria. The ureter contains several areas where
calculi commonly become lodged, (e.g., at the ureteropelvic junction),
the iliac vessels, and the ureterovesical junction. The probability of
spontaneous passage of a ureteral calculus measuring 5 mm in axial
diameter or less is very high. A 10 mm calculus, however, is very
unlikely to pass spontaneously. Therefore, the treating physician wants
to know the size of the calculus as well as its location and its effect
on renal function.

Patients with a suspected diagnosis of renal colic have traditionally
been evaluated with urinalysis, plain abdominal radiography (KUB), or
excretory urography, commonly referred to as intravenous pyelogram
(IVP). More recently, ultrasonography (US), computerized tomography
(CT), and magnetic resonance imaging (MRI) have been used.

**Radiography**

The plain-film of the abdomen may be sufficient to diagnose
ureterolithiasis in patients with known stone disease and previous KUBs.
The sensitivity of the KUB for ureterolithiasis in other patients is
poor. Studies by some researchers found sensitivities of 62% and 58%
when the radiographs were interpreted retrospectively. One study
correlated the KUB with noncontrast CT (NCT) retrospectively, so that an
exact correlation was made between stones on the CT scan and the
calcific density on the KUB. A sensitivity of only 59% was found for
detecting ureteral calculi on the KUB. Another study used the KUB as a
guide for US evaluation of flank pain. They found 64% sensitivity for
detecting ureteral calculi and had 6 false positive cases among the 66
patients evaluated. While the KUB may be a valuable part of the IVP or
US evaluation of flank pain, it has a very limited role when used alone,
and it should not be used to triage which patient should receive NCT.

**Computed Tomography**

Since the introduction of the use of helical (spiral) NCT as the initial
study in evaluating flank pain numerous investigations have confirmed it
to be the study with the highest sensitivity (95%-96%) and specificity
(98%) for ureterolithiasis. Virtually all stones are radio-opaque, and
stone size can be measured accurately in cross section, aiding in
predicting outcome. Stone location, accurately depicted by NCT, has also
been associated with spontaneous stone passage rates, with the more
proximal stones having a higher need for intervention. Recently, coronal
reconstruction of axial CT scans have been shown to more accurately
predict stone size in the craniocaudad direction, although this
dimension is not critical to estimating the likelihood of stone passage.
The degree of perinephric stranding present on the affected side on NCT
has also been shown to correlate inversely with the likelihood of stone
passage, giving additional prognostic information, but this finding has
been disputed in other studies.

The amount of stranding is related to the time after onset of pain and
is usually not seen in the first 2 hours following the onset of flank
pain. It may take up to 8 hours after the onset of pain to become
maximal. Secondary signs such as ureteral dilatation and perinephric
stranding allow CT to make a diagnosis of a recently passed stone.

NCT has been directly compared with the IVP in three series. NCT was
equal to the IVP in diagnosing obstruction and more reliable in
diagnosing the presence of nephrolithiasis. NCT is also reliable for
diagnosing flank pain due to causes other than ureterolithiasis such as
appendicitis, diverticulitis, and torsed ovarian masses. NCT is safer
than the IVP since it uses no contrast media, is rapid (with the entire
study taking minutes), and does not require the technical expertise that
US does. When CT is available, it is the best first study in the
nonpregnant adult presenting with flank pain likely to be due to stone
disease and has been shown to be more cost effective.

Concerns over radiation exposure, especially in young stone patients,
have led to the development and evaluation of reduced dose regimens.
Other recent technique refinement has included evaluation of the effect
of slice width and overlapping image reconstruction on stone detection.

**Intravenous Pyelography**

The IVP is the previous standard study for ureterolithiasis and is still
the best investigation if NCT is not available. It provides information
regarding site and degree of obstruction, size of stone, and effect of
obstruction on renal excretion. This examination has a number of
relative contraindications, including renal insufficiency, dehydration,
past reaction to iodinated contrast agents, and pregnancy. The
availability of nonionic iodinated contrast material has reduced the
risk of reaction. It may take several hours for excretion to occur in
the presence of acute obstruction, in which case it is more time
consuming than the alternative techniques. Another disadvantage is the
inability of the IVP to identify alternative diagnoses.

**Ultrasound**

US is a safe, noninvasive imaging modality that can be used to study the
urinary tract effectively. The diagnosis of obstructive urinary tract
calculi depends on identification of the offending calculus and
concomitant pelvicaliectasis and ureterectasis extending to the
obstructing site. Because it may take many hours for pelvicaliectasis
and ureterectasis to develop, US reportedly will miss over 30% of acute
obstructions caused by an uretheral stone in patients who are not
specifically hydrated for the study. Two studies detected hydronephrosis
in 7 of 20 patients (35%) and 16 of 22 patients (73%), respectively,
nonhydrated patients with uretheral calculi. More recently, US has been
found to be 100% sensitive for signs of obstruction (hydronephrosis,
ureteral dilatation, and/or perirenal fluid) perhaps indicating
improvement in US equipment. The use of intrarenal Doppler US improves
the detection of early obstruction by evaluating for elevated resistive
index (RI) in kidneys with nondilated collecting systems.

Since KUB is superior to US in detecting ureteral calculi, one study
recommended a combination of KUB and US. US in these cases is used to
detect ureteropyelocaliectasis and then to trace the dilated ureter to a
shadowing stone. US can also evaluate the presence and type of ureteral
jet (with obstruction the jets are absent, diminished significantly in
frequency or a constant slow trickle). In a series of 180 patients, the
authors showed a 95% negative predictive value of the KUB/US
combination, indicating that IVP was not likely to be helpful if the
KUB/US tests are negative. However, IVP was indicated if the KUB/US
combination was equivocal or if interventional treatment was
anticipated.

One group of researchers also performed a comparison of KUB, US,
combination of KUB/US, and IVP in 49 patients. The accuracies of KUB
(61%) and US (69%) were lower than that of IVP (92%). The accuracy of
the combination of KUB/US was 71%, still lower than that of IVP. In an
effort to reduce the number of IVP examinations needed, a model was
tested in which only patients with negative US results went on to have
an IVP. This algorithm showed 93% sensitivity and 79% specificity. The
KUB/US combination has also been compared to NCT. In this prospective
study of 66 patients, the KUB/US combination had a sensitivity of 79%
(vs. 93% for NCT) for detecting ureteral stones. All missed cases had
spontaneous stone passage, leading the authors to conclude that after a
negative KUB/US combination, NCT would not add useful information. They
suggest use of NCT in those who fail to respond to conservative
management or in those in whom surgery is anticipated. The advantage of
US is its lack of ionizing radiation and its ability to show some
calculi. For this reason it has been suggested for evaluating stones in
pregnant women. Its disadvantages include the need for skilled
personnel, its inability to accurately measure the size of the calculus,
the need to observe the ureteral jet phenomenon at the ureterovesical
junction, and its inability to differentiate dilatation without
obstruction from true obstruction.

**Magnetic Resonance Imaging**

One study applied magnetic resonance urography (MRU) to the evaluation
of 23 patients with acutely obstructed kidneys. They found 100%
sensitivity for diagnosing obstruction, with perirenal fluid seen in 21
of 23 obstructed kidneys (87%) and in no normal kidneys. The site of the
obstruction was seen in 80% of these obstructed kidneys. Round signal
voids corresponding to the location of stones on correlative IVPs were
seen in 12 of 18 patients with ureteric obstruction caused by a stone.
These appearances were nonspecific and were also seen secondary to blood
clot or tumor. Another study examined 60 patients with obstructive
uropathy. In the 13 patients with ureteric stones, MRU correctly
identified the site of obstruction in 12 (1 stone moved between the MRU
and confirmatory imaging). Forty-six percent of the stones were seen as
signal voids against a background of bright urine on T2-weighted images.
MRU has been successfully used in pregnant patients with flank pain.

**Recurrent Symptoms of Stone Disease**

In addition to pregnant patients, the patient with known stone disease
and recurrent symptoms also presents a challenge. In this setting, the
likelihood of stone disease as the cause of flank pain is higher, but
repeated NCTs raise a concern about excessive radiation exposure. One
group of researchers examined the issue of radiation exposure associated
with repetitive NCT in this setting. In a 6-year period, 5,564 NCTs were
performed for renal colic. While the vast majority of patients (96%)
underwent 1 or 2 NCTs with an estimated effective dose of 6.5-17 mSv,
176 patients had three or more NCTs with an estimated dose of 20-154
mSv. One patient had 18 NCTs over the 6- years! In this setting, every
effort should be made to use low-dose NCT. A recent study found
excellent sensitivity (95%) and specificity (97%) for detecting stones
with a low-dose protocol (30 mA) compared to a standard-dose protocol
(180 mA) in patients with a body mass index (BMI) of \<30. Further, if
the patient has persistence of symptoms from a documented stone and
repeat imaging is contemplated, a limited NCT of the area of the stone
through the bladder could be considered if stone passage is the main
question. Alternatively, if the stone can be seen by KUB, a repeat KUB
might provide useful information at a much lower dose.

**Anticipated Exceptions**

NCT is the most rapid and accurate technique for evaluating flank pain.
If there is uncertainty about whether a calcific density represents a
ureteral calculus or a phlebolith, contrast medium can be injected and
the scan repeated for definitive diagnosis. The IVP, which is readily
available and is familiar to nonradiologic physicians, is the technique
of choice if CT is not available. In pregnant patients with flank pain,
US is the best initial study. While a limited IVP has been used to
evaluate flank pain in pregnancy when the US study is not diagnostic,
MRU has potential utility in diagnosing acute urinary tract obstruction
without the use of ionizing radiation. NCT using an ultra-low-dose
protocol could also be considered.

Nephrogenic systemic fibrosis (NSF, also known as nephrogenic fibrosing
dermopathy) was first identified in 1997 and has recently generated
substantial concern among radiologists, referring doctors and lay
people. Until the last few years, gadolinium-based MR contrast agents
were widely believed to be almost universally well tolerated, extremely
safe and non-nephrotoxic, even when used in patients with impaired renal
function. All available experience suggests that these agents remain
generally very safe, but recently some patients with renal failure who
have been exposed to gadolinium contrast agents (the percentage is
unclear) have developed NSF, a syndrome that can be fatal. Further
studies are necessary to determine what the exact relationships are
between gadolinium-containing contrast agents, their specific components
and stoichiometry, patient renal function and NSF. Current theory links
the development of NSF to the administration of relatively high doses
(e.g., \>0.2 mM/kg) and to agents in which the gadolinium is least
strongly chelated. The FDA has recently issued a \"black box\" warning
concerning these contrast agents
(<http://www.fda.gov/cder/drug/InfoSheets/HCP/gcca_200705HCP.pdf>).

This warning recommends that, until further information is available,
gadolinium contrast agents should not be administered to patients with
either acute or significant chronic kidney disease (estimated GFR \<30
mL/min/1.73m^2^), recent liver or kidney transplant or hepato-renal
syndrome, unless a risk-benefit assessment suggests that the benefit of
administration in the particular patient clearly outweighs the potential
risk(s).

**Abbreviations**

-   CT, computed tomography

-   KUB, kidneys, ureters, bladder

-   MR, magnetic resonance

-   MRI, magnetic resonance imaging

-   NCT, noncontrast computed tomography

-   US, ultrasound

#### CLINICAL ALGORITHM(S)

None provided

### 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

Appropriate radiologic examinations for patients with acute onset of
flank pain or suspected urinary tract stones (calculi)

#### POTENTIAL HARMS

-   The relative radiation level is high for computed tomography (CT) of
    the abdomen and pelvis without contrast.

-   There is the potential for adverse reaction to iodinated contrast
    media.

-   Some patients with renal failure who have been exposed to gadolinium
    contrast agents (the percentage is unclear) have developed
    nephrogenic systemic fibrosis (NSF), a syndrome that can be fatal.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Relative contraindications to intravenous pyelogram (IVP) include renal
insufficiency, dehydration, past reaction to iodinated contrast agents,
and pregnancy.

### 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)

Baumgarten DA, Francis IR, Bluth EI, Bush WH Jr, Casalino DD, Curry NS,
Israel GM, Jafri SZ, Kawashima A, Papanicolaou N, Remer EM, Sandler CM,
Spring DB, Fulgham P, Expert Panel on Urologic Imaging. Acute onset
flank pain, suspicion of stone disease. \[online publication\]. Reston
(VA): American College of Radiology (ACR); 2007. 5 p. \[45 references\]

#### ADAPTATION

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

#### DATE RELEASED

1995 (revised 2007)

#### 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 Urologic Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Deborah A. Baumgarten, MD, MPH; Isaac R. Francis, MD;
Edward I. Bluth, MD; William H. Bush, Jr., MD; David D. Casalino, MD;
Nancy S. Curry, MD; Gary M. Israel, MD; S. Zafar H. Jafri, MD; Akira
Kawashima, MD; Nicholas Papanicolaou, MD; Erick M. Remer, MD; Carl M.
Sandler, MD; David B. Spring, MD; Pat Fulgham, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previous published version: Rosenfield AT, Choyke PL, Bluth
E, Bush WH Jr, Casalino DD, Francis IR, Jafri SZ, Kawashima A, Kronthal
A, Older RA, Papanicolaou N, Ramchandani P, Sandler C, Segal AJ, Tempany
C, Resnick MI, Expert Panel on Urologic Imaging. Acute onset flank pain,
suspicion of stone disease. \[online publication\]. Reston (VA):
American College of Radiology (ACR); 2005. 4 p. \[32 references\]

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/ExpertPanelonUrologicImaging/AcuteOnsetFlankPainSuspicionofStoneDiseaseDoc1.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 are 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.aspx).

-   ACR Appropriateness Criteria®. Relative radiation level information.
    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/RRLInformation.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on May 6, 2001. The information was
verified by the guideline developer as of June 29, 2001. This summary
was updated by ECRI on September 7, 2004. The updated information was
verified by the guideline developer on October 8, 2004. This summary was
updated by ECRI on February 7, 2006. This NGC summary was updated by
ECRI Institute on November 14, 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