Acute (Nonlocalized) Abdominal Pain and Fever or Suspected Abdominal Abscess Postoperative patient with fever.

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Date of origin: 1996
Last review date: 2012
American College of Radiology
ACR Appropriateness Criteria®
Clinical Condition: Acute (Nonlocalized) Abdominal Pain and Fever or Suspected Abdominal Abscess
Variant 1: Postoperative patient with fever.
Radiologic Procedure Rating Comments RRL*
CT abdomen and pelvis with IV contrast 8 ☢☢☢☢
CT abdomen and pelvis without IV 7 ☢☢☢☢
contrast
US abdomen 6 O
MRI abdomen and pelvis without and with 6 O
IV contrast
X-ray abdomen 5 To evaluate for bowel perforation. ☢☢
MRI abdomen and pelvis without IV 5 O
contrast
X-ray contrast enema 4 ☢☢☢
Ga-67 scan abdomen 4 ☢☢☢☢
X-ray upper GI series with small bowel 4 Helpful when anastomotic leak is ☢☢☢
follow-through suspected.
CT abdomen and pelvis without and with May be helpful in select cases but should ☢☢☢☢
3 be used with caution because of increased
IV contrast
radiation dose.
Tc-99m WBC scan abdomen and pelvis 3 ☢☢☢☢
In-111 WBC scan abdomen and pelvis 3 ☢☢☢☢
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

Clinical Condition: Acute (Nonlocalized) Abdominal Pain and Fever or Suspected Abdominal Abscess
Variant 2: Postoperative patient with persistent fever and no abscess seen on CT scan within the last 7
days.
Radiologic Procedure Rating Comments RRL*
CT abdomen and pelvis with IV contrast 8 ☢☢☢☢
CT abdomen and pelvis without IV 6 ☢☢☢☢
contrast
US abdomen 6 O
Tc-99m WBC scan abdomen and pelvis 6 ☢☢☢☢
In-111 WBC scan abdomen and pelvis 6 ☢☢☢☢
X-ray abdomen 5 To evaluate for bowel perforation. ☢☢
X-ray upper GI series with small bowel 5 ☢☢☢
follow-through
Ga-67 scan abdomen 5 ☢☢☢☢
MRI abdomen and pelvis without IV 5 O
contrast
MRI abdomen and pelvis without and with 5 O
IV contrast
X-ray contrast enema 4 ☢☢☢
CT abdomen and pelvis without and with May be helpful in select cases but should ☢☢☢☢
3 be used with caution because of increased
IV contrast
radiation dose.
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

 

 

 

Clinical Condition: Acute (Nonlocalized) Abdominal Pain and Fever or Suspected Abdominal Abscess
Variant 3: Patient presenting with fever and no recent operation.
Radiologic Procedure Rating Comments RRL*
CT abdomen and pelvis with IV contrast 8 ☢☢☢☢
CT abdomen and pelvis without IV 6 ☢☢☢☢
contrast
US abdomen 6 O
X-ray abdomen 6 To evaluate for bowel perforation. ☢☢
MRI abdomen and pelvis without IV 5 O
contrast
MRI abdomen and pelvis without and with 5 O
IV contrast
X-ray upper GI series with small bowel 4 ☢☢☢
follow-through
X-ray contrast enema 4 ☢☢☢
CT abdomen and pelvis without and with May be helpful in select cases but should ☢☢☢☢
3 be used with caution because of increased
IV contrast
radiation dose.
Ga-67 scan abdomen 3 ☢☢☢☢
Tc-99m WBC scan abdomen and pelvis 3 ☢☢☢☢
In-111 WBC scan abdomen and pelvis 3 ☢☢☢☢
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

Clinical Condition: Acute (Nonlocalized) Abdominal Pain and Fever or Suspected Abdominal Abscess
Variant 4: Pregnant patient.
Radiologic Procedure Rating Comments RRL*
US abdomen 8 O
MRI abdomen and pelvis without IV 7 O
contrast
CT abdomen and pelvis with IV contrast 5 Only after other studies without ionizing ☢☢☢☢
radiation have been used.
CT abdomen and pelvis without IV 5 ☢☢☢☢
contrast
X-ray abdomen 4 To evaluate for bowel perforation. ☢☢
CT abdomen and pelvis without and with May be helpful in select cases but should ☢☢☢☢
2 be used with caution because of increased
IV contrast
radiation dose.
Because it is unclear how gadolinium-
based contrast agents will affect the fetus,
MRI abdomen and pelvis without and with these agents should be administered only
2 with extreme caution. Gadolinium-based O
IV contrast
contrast agents are only recommended for
use during pregnancy when there are no
alternatives and benefit outweighs risk.
X-ray upper GI series with small bowel 2 ☢☢☢
follow-through
X-ray contrast enema 2 ☢☢☢
Ga-67 scan abdomen 2 ☢☢☢☢
Tc-99m WBC scan abdomen and pelvis 2 ☢☢☢☢
In-111 WBC scan abdomen and pelvis 2 ☢☢☢☢
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

ACUTE (NONLOCALIZED) ABDOMINAL PAIN AND FEVER OR SUSPECTED ABDOMINAL ABSCESS

Expert Panel on Gastrointestinal Imaging: Vahid Yaghmai, MD, MS 1 ; Max P. Rosen, MD, MPH2; Tasneem Lalani, MD3; Mark E. Baker, MD4; Michael A. Blake, MB, BCh5; Brooks D. Cash, MD6; Jeff L. Fidler, MD7; Frederick L. Greene, MD8; Nicole M. Hindman, MD9 ; Bronwyn Jones, MD10; Douglas S. Katz, MD11; Harmeet Kaur, MD12; Frank H. Miller, MD13; Aliya Qayyum, MD14; William C. Small, MD, PhD15; Gary S. Sudakoff, MD16; Mark Tulchinsky, MD17; Gail M. Yarmish, MD18; Judy Yee, MD.19

 

Summary of Literature Review

 

Introduction/Background

Acute abdominal pain with fever raises clinical suspicion of an intra-abdominal abscess or other condition that may need immediate surgical or medical attention. Infection or other inflammatory conditions are the usual cause. In these circumstances, emergency imaging plays an important role, in conjunction with other clinical information, to make a quick and accurate diagnosis. This is crucial, as proper diagnosis facilitates expeditious and appropriate therapy, thus improving patient outcome. This discussion is limited to illnesses affecting the abdomen and pelvis and excludes the gynecologic and urinary tracts. Pediatric patients are not considered.

The range of pathology that can produce abdominal pain and fever with or without abscess is very broad. It includes pneumonia, hepatobiliary disease, complicated pancreatic processes, gastrointestinal (GI) perforation or

inflammation, bowel obstruction or infarction, abscesses anywhere in the abdomen, and tumor among others. Of all patients who present to the emergency department with abdominal pain, about one-third never have a diagnosis established, one-third have appendicitis, and one-third have some other documented pathology. In the “other” category, the most common causes include (in order of frequency): acute cholecystitis, small-bowel obstruction, pancreatitis, renal colic, perforated peptic ulcer, cancer, and diverticulitis [1]. When fever is also present, the need for quick, definitive diagnosis is considerably heightened. Imaging may be especially helpful in the elderly with acute abdominal pain. In this population, many laboratory tests are nonspecific and may be normal despite serious infection [2,3].

 

Clinical Presentations

 

A variety of clinical presentations occur in patients with acute abdominal pain accompanied by fever. This review concentrates on the evaluation of patients with acute diffuse abdominal pain, immunocompromised patients with acute abdominal pain, and patients with suspected abdominal abscess. Other Appropriateness Criteria® topics address acute right upper quadrant pain, acute right lower quadrant pain, and acute left lower quadrant pain. Imaging evaluation varies among patients with different clinical presentations.

Acute diffuse abdominal pain with fever can be caused by conditions that ordinarily instigate more localized pain. These conditions include: complicated appendicitis, intestinal obstruction, complicated acute calculous or acalculous cholecystitis, bile duct obstruction with infectious cholangitis, hepatitis, hepatic abscess, pancreatitis with or without infection, pyelonephritis or renal infarction, renal stones, omental infarction, epiploic appendagitis, mesenteric adenitis, and diverticulitis [4]. Other conditions that typically present with diffuse abdominal pain and fever include bowel ischemia or infarction, bowel perforation from ulcer or tumor, diffuse colitis, typhlitis and other GI infections, peritonitis, small-bowel inflammatory disease, abdominal abscess, intraperitoneal or retroperitoneal hemorrhage, vasculitis, pelvic inflammatory disease (PID), and diffuse malignancy [5-10].

In patients with intestinal ischemia, CT is helpful for detecting vessel thrombosis, intramural or portal gas, and lack of bowel wall enhancement. A meta-analysis of the diagnostic accuracy of multidetector computed tomography (MDCT) for acute mesenteric ischemia has shown a pooled sensitivity of 93.3% and a pooled specificity of 95.9% [11]. Reduced segmental bowel-wall enhancement has been shown to be 100% specific for segmental bowel ischemia [12], stressing the importance of intravenous (IV) contrast material administration in this setting. For intestinal infarction, CT (sensitivity 82%) considerably outperforms radiography plus ultrasound (US) (sensitivity 28%) [13]. In bowel perforation, while radiographs are sensitive to small volumes of free air, CT is more sensitive to even smaller volumes and can detect additional loculated air or air in the mesenteric root [14].

In patients with Crohn disease or inflammatory colitis, the presence of fever raises the possibility of associated abscess or phlegmon, although CT is the procedure of choice for diagnosing abscess, regardless of cause. Please refer to the ACR Appropriateness Criteria® on “Crohn Disease” for further discussion. Pseudomembranous (ie, clostridium difficile) colitis may be accompanied with fever; CT findings are present in the colon in 88% of cases

  • Rarely, diffuse tumors such as lymphomas or metastases may present with abdominal pain and fever; again, CT is the procedure of choice due to its depiction of all abdominal organs and lymph node chains.

 

Neutropenic Patients

 

In neutropenic patients, abdominal pain remains a diagnostic challenge due to the lack of classic clinical and laboratory signs of intra-abdominal disease [16]. Therefore, the diagnosis of acute abdomen may be delayed in these patients [17]. Neutropenia is being encountered more commonly in clinical practice and may be due to cytotoxic chemotherapy or immunosuppressive therapy. Abdominal complications of neutropenia include clostridium difficile colitis, cytomegalovirus (CMV) colitis, graft-versus-host disease, neutropenic enterocolitis, and bowel ischemia and perforation [16,18]. Furthermore, acute abdomen may be due to the toxicity of chemotherapeutic agents [19]. The liver and biliary tree may be involved with HIV-related cholangiopathy, hepatic abscesses, or hepatic bacillary angiomatosis, a peliosis- like condition. The spleen is subject to focal infarction or abscess [20]. Bowel mucosal disease may include GI tuberculosis, CMV colitis, clostridium difficile colitis, histoplasmosis, candida, mycobacterium avium complex-related enteritis, and other opportunistic bowel infection (cryptosporidiosis, giardia, isospora, and strongyloides). Tumors with adenopathy and bowel involvement include Kaposi’s sarcoma and lymphoma of bowel, either of which may lead to bowel obstruction, pneumatosis intestinalis, perforation, or intussusception.

CT is the imaging procedure of choice to diagnose GI complications in immunocompromised patients. CT with oral, IV, and (frequently) rectal contrast is almost always the procedure of choice in an HIV-positive patient with acute abdominal pain and fever [21,22]. Supplemental barium studies of the mucosa of the stomach, small bowel, and colon may add additional information to that obtained from CT, particularly when mucosal lesions are small and fine. If there is any chance of bowel perforation, barium should not be used.

Occasionally, US of the biliary tree and gallbladder may be useful in evaluating HIV-related cholangiopathy. If CT is performed, radiographs have little incremental value. The utility of radionuclide scanning in this subgroup has not been validated in large prospective studies.

 

Abdominal Radiography

 

Conventional radiography may be performed in the setting of acute abdominal pain. Abdominal radiography, however, has a limited role in the evaluation of nontraumatic abdominal pain in adults [23-26]. While it has been shown to have high sensitivity (90%) for detecting intra -abdominal foreign bodies and moderate sensitivity for detecting bowel obstruction (49%), its low sensitivity for sources of abdominal pain and fever or abscess limit its role in this setting [27]. In a study of 874 patients who underwent abdominal radiography in a nontrauma emergency department, abdominal radiography was helpful in changing clinical management in only 4% of patients [24].

 

X-ray Upper Gastrointestinal Series with Small-Bowel Follow-Through and Contrast Enema

 

X-ray contrast studies of the GI tract have a limited role in the initial evaluation of adult patients without a history of recent surgery and with nonlocalized abdominal pain and fever. They may, however, be helpful in evaluating intestinal anastomotic leak, particularly when CT cannot be obtained or when there are equivocal findings on CT [28]. The sensitivity of upper GI contrast examination for detecting leak after bariatric surgery varies among

 

reports between 22%-75% [29-31]. Endoscopy is the preferred initial examination of the stomach and colon in patients suspected of having inflammatory bowel disease (IBD).

 

Ultrasound

 

US may be useful in selected conditions, including cholecystitis, cholangitis, liver abscess, diverticulitis, appendicitis, and small-bowel inflammation, where it may be used to assess activity of Crohn disease [32-34]. While US may be able to depict portions of an abscess or malignancy (such as lymphoma), it is blind to many areas of the abdomen, particularly in the presence of increased bowel gas or free air. The shortcomings of US are partially offset by its lack of ionizing radiation, particularly in younger patients [35].

 

Computed Tomography

 

In general, CT is the most important modality in evaluating nonpregnant patients with abdominal pain, more so in those with fever. Several studies have shown that CT improves the final diagnosis and management of patients who present with abdominal pain [2,36- 41]. Two reports have found CT to be superior to clinical evaluation for finding the cause of abdominal pain. CT interpretation was correct in 90%-96% of cases, while clinical evaluation was correct in 60%-76% of cases [42-44]. Additionally, the use of CT in patients with acute abdominal pain increases the emergency department clinician’s level of certainty and reduces hospital admissions by 24% [45].

 

In a study of 584 emergency department patients presenting with nontraumatic abdominal pain, CT was shown to change the diagnosis, improve diagnostic certainty, and affect potential patient management decisions [41]. In this study, CT was used to alter the leading diagnosis in 49% of the patients (P<0.00001) and increased mean physician diagnostic certainty from 70.5% (pre-CT) to 92.2% (post -CT) (P<0.001). The management plan was changed by CT in 42% of the patients (P<0.0001). In a study of 93 emergency department patients, abdominal-pelvic CT with z-axis restriction based on patients symptoms was shown to reduce radiation but included all acute pathology in only 33% of abnormal cases [46].

 

Abdominal CT has been shown to have an excellent interobserver agreement for specific urgent diagnoses such as diverticulitis (kappa value of 0.90), appendicitis (kappa value of 0.84), and bowel obstruction (kappa value of 0.81) [47]. The presence of an elevated white blood count (WBC) >11.5 correlated with a positive abdominal CT, and the combination of WBC >11.5, male sex, and age <25 years correlated with a diagnosis of appendicitis [48]. Conversely, in a study of 522 young adult patients presenting to the emergency department with abdominal pain, no laboratory test was sufficient to offer reassurance that a CT is not necessary [49]. Abdominal CT without the use of oral or IV contrast has been advocated as an alternative to abdominal radiographs for evaluating appendicitis [23,38]. However, the use of contrast agents increases the spectrum of detectable pathology [45,50]. Advances in CT technology have resulted in isotropic image acquisition. Multiplanar reformations have been shown to improve diagnostic confidence in patients with abdominal pain [51 -53]. Again, abdominal radiographs may provide useful information about bowel gas pattern or free air, but they offer no incremental information if CT is performed [35,42].

 

Magnetic Resonance Imaging

 

Magnetic resonance imaging (MRI) offers imaging without ionizing radiation. It has been shown to provide clinically useful information for rapid diagnosis of acute bowel pathology [54-57] and the following gynecological emergencies: ovarian hemorrhage, ectopic pregnancy, tumor rupture, torsion, hemorrhage, infarction, and PID [58-60].

 

Nuclear Medicine

 

The role of nuclear medicine is limited in the evaluation of acute nonlocalized abdominal pain. While Tc-99m HMPAO white-cell-labeled scanning has a high sensitivity for IBD (91%-98%) and may have some role in diagnosing appendicitis in older patients [61,62], it does not do as well as CT in depicting the complications of abscess and fistula [63].

 

Suspected Abdominal Abscess

Patients suspected of having abdominal abscesses may present in a number of ways: with fever, with diffuse or localized abdominal pain, or with a history of a condition that may predispose to abdominal abscesses, such as recent surgery and IBD, pancreatitis, etc. Imaging studies that have been used to detect abdominal abscesses include radiographs (supine and upright, and occasionally decubitus views); nuclear medicine studies such as gallium-, indium-, or technetium-tagged leukocyte or florine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) studies; US; CT; and more recently MRI.

To our knowledge, there is little current information on radiography’s role in detecting abdominal abscesses. Some reports suggest that radiographs may be useful, but this is far from proven. CT of the abdomen has been shown to be the first and best test for diagnosing intra-abdominal abscess in patients who have recently had abdominal surgery, and in patients with localizing signs for abscess [64,65]. Among intensive care unit (ICU) patients with sepsis of unknown origin, CT of the abdomen and pelvis revealed the source of sepsis in seven of 45 patients [66]. The CT can be very helpful in determining whether a patient with pancreatitis has developed a pancreatic abscess, and it can be useful in detecting abscess formation in patients with diverticulitis or Crohn disease [67-71]. Although CT can be quite accurate in detecting abnormalities of the psoas, the differentiation of psoas abscesses from other psoas lesions is difficult when only imaging criteria are used [72]. In select cases, delayed CT images after the initial acquisition may help in differentiating an abscess from unopacified bowel loops or bladder or establishing extravasation of oral or IV contrast material.

 

US is often useful in specific cases, but when compared with CT its results are usually of lower sensitivity and specificity [73-75]. Gallium scan and indium and technetium leukocyte scans are often useful when the CT scan is negative or equivocal [74,76,77]. Nuclear scintigraphy permits whole-body imaging and the detection of sites of infection beyond the abdominal region. The literature on technetium-labeled leukocytes suggests a very high sensitivity and specificity for abdominal abscesses as well, although there are no adequate recent comparisons with CT [78]. Although gallium is excreted in the GI tract, making it a poor choice for the primary imaging of abdominal abscesses, among patients with persistent fever following colorectal surgery the diagnostic accuracy for Ga-67 in detecting occult abscesses has been reported to be as high as 91.2% (compared to 97.1% for CT among the same patients) [79].

FDG-PET and FDG-PET/CT are currently under investigation for evaluating infection and inflammation. They potentially could replace nuclear medicine studies such as gallium-, indium-, or technetium-tagged leukocyte studies [80]. FDG-PET has several advantages over conventional nuclear medicine techniques, particularly in neutropenic patients [81], but its relative benefit in detection of abdominal abscess remains to be studied. MRI is an accurate examination for detecting abdominal and pelvic abscesses when the image acquisition is optimized for this purpose [57]. Patients without previous surgery or with a low clinical suspicion of abscess are effectively evaluated with CT, and may also be studied with indium- or technetium-labeled leukocytes to search for infection or inflammation [82].

Recent literature has focused on the role of US and CT in percutaneous drainage of abdominal abscesses [83-86].

Minimally invasive image-guided drainage of abdominal abscesses can produce excellent results [85-88].

Endoscopic US has been proposed as an alternative approach for drainage of abdominal [89] and pelvic abscess

  • and infected necrosis [89]; however, there are limited data to our knowledge comparing its performance with other modalities.

 

Abdominal Pain and Fever in Pregnant Patients

 

For discussion regarding evaluation of pregnant patients with right lower quadrant abdominal pain, see the ACR Appropriateness Criteria® on “Right Lower Quadrant Pain — Suspected Appendicitis.” Diagnosing the source of abdominal pain in pregnancy is difficult for several reasons. Physiologic and anatomic changes that take place during pregnancy may lead to abdominal or pelvic symptoms that can mimic disease. These symptoms may accompany physiologic leukocytosis of pregnancy, further complicating accurate diagnosis. In pregnant patients with abdominal or pelvic pain, US should be the initial imaging modality because of its availability, portability, and lack of ionizing radiation [91].

MRI is being used more frequently in the evaluation of pregnant patients with abdominal pain who have had an inconclusive US examination. A survey of academic centers in the United States has shown that MRI is the preferred imaging modality for diagnosing appendicitis and abscess in pregnant patients in their first trimester

  • However, this survey showed that CT is more frequently used in the second and third trimesters of pregnancy to evaluate abdominal pain [92]. In pregnant patients presenting with acute abdominal or pelvic pain, MRI has been shown to have excellent sensitivity and specificity for diagnosing appendicitis or other causes of abdominal and pelvic pain [60,93,94].

When CT is used to diagnose appendicitis, it has been shown to have a sensitivity of 88%-100% for diagnosing appendicitis in pregnancy versus 33%-46.1% for US [91,95]. In a study of pregnant women with nontraumatic abdominal pain, CT established the diagnosis in 30% of these patients when US or clinical methods had failed, and had a 99% negative predictive value for appendicitis [96].

 

Summary

 

In nonpregnant patients with acute nonlocalized abdominal pain and fever, CT with IV contrast is the imaging modality of choice.

In pregnant patients, US and MRI are the initial imaging modalities of choice for evaluating nonlocalized abdominal pain and fever.

A variety of clinical presentations occur in patients with acute abdominal pain accompanied by fever. In neutropenic patients, abdominal pain remains a diagnostic challenge due to the lack of classic clinical and laboratory signs.

 

Safety Considerations in Pregnant Patients

 

Imaging of the pregnant patient can be challenging, particularly with respect to minimizing radiation exposure and risk. For further information and guidance, see the following ACR documents:

 

ACR Practice Guideline for Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing Radiation

 

ACR-ACOG-AIUM Practice Guideline for the Performance of Obstetrical Ultrasound ACR Manual on Contrast Media

 

ACR Guidance Document for Safe MR Practices

 

Relative Radiation Level Information

 

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

 

Relative Radiation Level Designations

 

Relative Radiation Level* Adult Effective Dose Estimate Pediatric Effective Dose Estimate
Range Range
O 0 mSv 0 mSv
<0.1 mSv <0.03 mSv
☢☢ 0.1-1 mSv 0.03-0.3 mSv
☢☢☢ 1-10 mSv 0.3-3 mSv
☢☢☢☢ 10-30 mSv 3-10 mSv
☢☢☢☢☢ 30-100 mSv 10-30 mSv

 

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies”.

Supporting Documents

For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.

References

  1. Mindelzun RE, Jeffrey RB. Unenhanced helical CT for evaluating acute abdominal pain: a little more cost, a lot more information. 1997;205(1):43-45.
  2. Lewis LM, Klippel AP, Bavolek RA, Ross LM, Scherer TM, Banet GA. Quantifying the usefulness of CT in evaluating seniors with abdominal pain. Eur J Radiol. 2007;61(2):290-296.
  3. Yeh EL, McNamara RM. Abdominal pain. Clin Geriatr Med. 2007;23(2):255-270, v.
  4. Jalaguier A, Zins M, Rodallec M, Nakache JP, Boulay-Coletta I, Julles MC. Accuracy of multidetector computed tomography in differentiating primary epiploic appendagitis from left acute colonic diverticulitis associated with secondary epiploic appendagitis. Emerg Radiol. 2010;17(1):51-56.
  5. Gore RM, Miller FH, Pereles FS, Yaghmai V, Berlin JW. Helical CT in the evaluation of the acute abdomen. AJR Am J Roentgenol. 2000;174(4):901-913.
  6. Ju JH, Min JK, Jung CK, et al. Lupus mesenteric vasculitis can cause acute abdominal pain in patients with SLE. Nat Rev Rheumatol. 2009;5(5):273-281.
  7. Levsky JM, Den EI, DuBrow RA, Wolf EL, Rozenblit AM. CT findings of sigmoid volvulus. AJR Am J 2010;194(1):136-143.
  8. Rosenblat JM, Rozenblit AM, Wolf EL, DuBrow RA, Den EI, Levsky JM. Findings of cecal volvulus at CT. 2010;256(1):169-175.
  9. Tsai HL, Hsieh JS, Yu FJ, et al. Perforated colonic cancer presenting as intra-abdominal abscess. Int J Colorectal Dis. 2007;22(1):15-19.
  10. Yehia M, de Zoysa JR, Collins JF. Is computerized tomography useful in identifying abdominal catastrophes in patients presenting with peritonitis? Perit Dial Int. 2008;28(4):385-390.
  11. Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: systematic review and meta-analysis. 2010;256(1):93-101.
  12. Sheedy SP, Earnest Ft, Fletcher JG, Fidler JL, Hoskin TL. CT of small-bowel ischemia associated with obstruction in emergency department patients: diagnostic performance evaluation. 2006;241(3):729-736.
  13. Klein HM, Lensing R, Klosterhalfen B, Tons C, Gunther RW. Diagnostic imaging of mesenteric infarction. 1995;197(1):79-82.
  14. Jeffrey RB, Federle MP, Wall S. Value of computed tomography in detecting occult gastrointestinal perforation. J Comput Assist Tomogr. 1983;7(5):825-827.
  15. Fishman EK, Kavuru M, Jones B, et al. Pseudomembranous colitis: CT evaluation of 26 cases. 1991;180(1):57-60.
  16. Badgwell BD, Cormier JN, Wray CJ, et al. Challenges in surgical management of abdominal pain in the neutropenic cancer patient. Ann Surg. 2008;248(1):104-109.
  17. Spencer SP, Power N, Reznek RH. Multidetector computed tomography of the acute abdomen in the immunocompromised host: a pictorial review. Curr Probl Diagn Radiol. 2009;38(4):145-155.
  18. Kirkpatrick ID, Greenberg HM. Gastrointestinal complications in the neutropenic patient: characterization and differentiation with abdominal CT. 2003;226(3):668-674.
  19. Torrisi JM, Schwartz LH, Gollub MJ, Ginsberg MS, Bosl GJ, Hricak H. CT findings of chemotherapy-induced toxicity: what radiologists need to know about the clinical and radiologic manifestations of chemotherapy toxicity. 2011;258(1):41-56.
  20. Bernabeu-Wittel M, Villanueva JL, Pachon J, et al. Etiology, clinical features and outcome of splenic microabscesses in HIV-infected patients with prolonged fever. Eur J Clin Microbiol Infect Dis. 1999;18(5):324-329.
  21. Kuhlman JE, Fishman EK. Acute abdomen in AIDS: CT diagnosis and triage. 1990;10(4):621-634.
  22. Wu CM, Davis F, Fishman EK. Radiologic evaluation of the acute abdomen in the patient with acquired immunodeficiency syndrome (AIDS): the role of CT scanning. Semin Ultrasound CT MR. 1998;19(2):190-199.
  23. Haller O, Karlsson L, Nyman R. Can low-dose abdominal CT replace abdominal plain film in evaluation of acute abdominal pain? Ups J Med Sci. 2010;115(2):113-120.
  24. Kellow ZS, MacInnes M, Kurzencwyg D, et al. The role of abdominal radiography in the evaluation of the nontrauma emergency patient. 2008;248(3):887-893.
  25. Sala E, Watson CJ, Beadsmoore C, et al. A randomized, controlled trial of routine early abdominal computed tomography in patients presenting with non-specific acute abdominal pain. Clin Radiol. 2007;62(10):961-969.
  26. van Randen A, Lameris W, Luitse JS, et al. The role of plain radiographs in patients with acute abdominal pain at the ED. Am J Emerg Med. 2011;29(6):582-589 e582.
  27. Ahn SH, Mayo-Smith WW, Murphy BL, Reinert SE, Cronan JJ. Acute nontraumatic abdominal pain in adult patients: abdominal radiography compared with CT evaluation. 2002;225(1):159-164.
  28. Nicksa GA, Dring RV, Johnson KH, Sardella WV, Vignati PV, Cohen JL. Anastomotic leaks: what is the best diagnostic imaging study? Dis Colon Rectum. 2007;50(2):197-203.
  29. Doraiswamy A, Rasmussen JJ, Pierce J, Fuller W, Ali MR. The utility of routine postoperative upper GI series following laparoscopic gastric bypass. Surg Endosc. 2007;21(12):2159-2162.
  30. Gonzalez R, Sarr MG, Smith CD, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg. 2007;204(1):47-55.
  31. Madan AK, Stoecklein HH, Ternovits CA, Tichansky DS, Phillips JC. Predictive value of upper gastrointestinal studies versus clinical signs for gastrointestinal leaks after laparoscopic gastric bypass. Surg 2007;21(2):194-196.
  32. O’Malley ME, Wilson SR. US of gastrointestinal tract abnormalities with CT correlation. 2003;23(1):59-72.
  33. Dietrich CF. Significance of abdominal ultrasound in inflammatory bowel disease. Dig Dis. 2009;27(4):482-493.
  34. Spence SC, Teichgraeber D, Chandrasekhar C. Emergent right upper quadrant sonography. J Ultrasound 2009;28(4):479-496.
  35. Lameris W, van Randen A, van Es HW, et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. 2009;338:b2431.
  36. Coursey CA, Nelson RC, Patel MB, et al. Making the diagnosis of acute appendicitis: do more preoperative CT scans mean fewer negative appendectomies? A 10-year study. 2010;254(2):460-468.
  37. Krajewski S, Brown J, Phang PT, Raval M, Brown CJ. Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a meta-analysis. Can J Surg. 2011;54(1):43-53.
  38. Merlin MA, Shah CN, Shiroff AM. Evidence-based appendicitis: the initial work-up. Postgrad Med. 2010;122(3):189-195.
  39. Ng CS, Palmer CR. Assessing diagnostic confidence: a comparative review of analytical methods. Acad 2008;15(5):584-592.
  40. Stromberg C, Johansson G, Adolfsson A. Acute abdominal pain: diagnostic impact of immediate CT scanning. World J Surg. 2007;31(12):2347-2354; discussion 2355-2348.
  41. Abujudeh HH, Kaewlai R, McMahon PM, et al. Abdominopelvic CT increases diagnostic certainty and guides management decisions: a prospective investigation of 584 patients in a large academic medical center. AJR Am J Roentgenol. 2011;196(2):238-243.
  42. MacKersie AB, Lane MJ, Gerhardt RT, et al. Nontraumatic acute abdominal pain: unenhanced helical CT compared with three-view acute abdominal series. 2005;237(1):114-122.
  43. Siewert B, Raptopoulos V, Mueller MF, Rosen MP, Steer M. Impact of CT on diagnosis and management of acute abdomen in patients initially treated without surgery. AJR Am J Roentgenol. 1997;168(1):173-178.
  44. Taourel P, Baron MP, Pradel J, Fabre JM, Seneterre E, Bruel JM. Acute abdomen of unknown origin: impact of CT on diagnosis and management. Gastrointest Radiol. 1992;17(4):287-291.
  45. Rosen MP, Sands DZ, Longmaid HE, 3rd, Reynolds KF, Wagner M, Raptopoulos V. Impact of abdominal CT on the management of patients presenting to the emergency department with acute abdominal pain. AJR Am J Roentgenol. 2000;174(5):1391-1396.
  46. Broder JS, Hollingsworth CL, Miller CM, Meyer JL, Paulson EK. Prospective double-blinded study of abdominal-pelvic computed tomography guided by the region of tenderness: estimation of detection of acute pathology and radiation exposure reduction. Ann Emerg Med. 2010;56(2):126-134.
  47. van Randen A, Lameris W, Nio CY, et al. Inter-observer agreement for abdominal CT in unselected patients with acute abdominal pain. Eur Radiol. 2009;19(6):1394-1407.
  48. Roth C, Tello R, Sutherland K, Ptak T. Prediction rule for etiology of vague abdominal pain in the emergency room: utility for imaging triage. Invest Radiol. 2002;37(10):552-556.
  49. Scheinfeld MH, Mahadevia S, Stein EG, Freeman K, Rozenblit AM. Can lab data be used to reduce abdominal computed tomography (CT) usage in young adults presenting to the emergency department with nontraumatic abdominal pain? Emerg Radiol. 2010;17(5):353-360.
  50. Howell JM, Eddy OL, Lukens TW, Thiessen ME, Weingart SD, Decker WW. Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Ann Emerg 2010;55(1):71-116.
  51. Jaffe TA, Martin LC, Miller CM, et al. Abdominal pain: coronal reformations from isotropic voxels with 16-section CT–reader lesion detection and interpretation time. 2007;242(1):175-181.
  52. Yaghmai V, Nikolaidis P, Hammond NA, Petrovic B, Gore RM, Miller FH. Multidetector-row computed tomography diagnosis of small bowel obstruction: can coronal reformations replace axial images? Emerg 2006;13(2):69-72.
  53. Zangos S, Steenburg SD, Phillips KD, et al. Acute abdomen: Added diagnostic value of coronal reformations with 64-slice multidetector row computed tomography. Acad Radiol. 2007;14(1):19-27.
  54. Hammond NA, Miller FH, Yaghmai V, Grundhoefer D, Nikolaidis P. MR imaging of acute bowel pathology: a pictorial review. Emerg Radiol. 2008;15(2):99-104.
  55. Heverhagen JT, Klose KJ. MR imaging for acute lower abdominal and pelvic pain. 2009;29(6):1781-1796.
  56. Heverhagen JT, Sitter H, Zielke A, Klose KJ. Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Dis Colon Rectum. 2008;51(12):1810-1815.
  57. Siddiki H, Fidler J. MR imaging of the small bowel in Crohn’s disease. Eur J Radiol. 2009;69(3):409-417.
  58. Birchard KR, Brown MA, Hyslop WB, Firat Z, Semelka RC. MRI of acute abdominal and pelvic pain in pregnant patients. AJR Am J Roentgenol. 2005;184(2):452-458.
  59. Pedrosa I, Levine D, Eyvazzadeh AD, Siewert B, Ngo L, Rofsky NM. MR imaging evaluation of acute appendicitis in pregnancy. 2006;238(3):891-899.
  60. Singh A, Danrad R, Hahn PF, Blake MA, Mueller PR, Novelline RA. MR imaging of the acute abdomen and pelvis: acute appendicitis and beyond. 2007;27(5):1419-1431.
  61. Arndt JW, Grootscholten MI, van Hogezand RA, Griffioen G, Lamers CB, Pauwels EK. Inflammatory bowel disease activity assessment using technetium-99m-HMPAO leukocytes. Dig Dis Sci. 1997;42(2):387-393.
  62. Lin WY, Kao CH, Lin HT, Wang YL, Wang SJ, Liu TJ. 99Tcm-HMPAO-labelled white blood cell scans to detect acute appendicitis in older patients with an atypical clinical presentation. Nucl Med Commun. 1997;18(1):75-78.
  63. Kolkman JJ, Falke TH, Roos JC, et al. Computed tomography and granulocyte scintigraphy in active inflammatory bowel disease. Comparison with endoscopy and operative findings. Dig Dis Sci. 1996;41(4):641-650.
  64. Porter JA, Loughry CW, Cook AJ. Use of the computerized tomographic scan in the diagnosis and treatment of abscesses. Am J Surg. 1985;150(2):257-262.
  65. Antevil JL, Egan JC, Woodbury RO, Rivera L, Oreilly EB, Brown CV. Abdominal computed tomography for postoperative abscess: is it useful during the first week? J Gastrointest Surg. 2006;10(6):901-905.
  66. Barkhausen J, Stoblen F, Dominguez-Fernandez E, Henseke P, Muller RD. Impact of CT in patients with sepsis of unknown origin. Acta Radiol. 1999;40(5):552-555.
  67. Ambrosetti P, Robert J, Witzig JA, et al. Incidence, outcome, and proposed management of isolated abscesses complicating acute left-sided colonic diverticulitis. A prospective study of 140 patients. Dis Colon Rectum. 1992;35(11):1072-1076.
  68. Crass RA, Meyer AA, Jeffrey RB, et al. Pancreatic abscess: impact of computerized tomography on early diagnosis and surgery. Am J Surg. 1985;150(1):127-131.
  69. Labs JD, Sarr MG, Fishman EK, Siegelman SS, Cameron JL. Complications of acute diverticulitis of the colon: improved early diagnosis with computerized tomography. Am J Surg. 1988;155(2):331-336.
  70. Rotman N, Chevret S, Pezet D, et al. Prognostic value of early computed tomographic scans in severe acute pancreatitis. French Association for Surgical Research. J Am Coll Surg. 1994;179(5):538-544.
  71. Tack D, Bohy P, Perlot I, et al. Suspected acute colon diverticulitis: imaging with low-dose unenhanced multi-detector row CT. 2005;237(1):189-196.
  72. Lenchik L, Dovgan DJ, Kier R. CT of the iliopsoas compartment: value in differentiating tumor, abscess, and hematoma. AJR Am J Roentgenol. 1994;162(1):83-86.
  73. Dobrin PB, Gully PH, Greenlee HB, et al. Radiologic diagnosis of an intra-abdominal abscess. Do multiple tests help? Arch Surg. 1986;121(1):41-46.

 

  1. Field TC, Pickleman J. Intra-abdominal abscess unassociated with prior operation. Arch Surg. 1985;120(7):821-824.
  2. Lundstedt C, Hederstrom E, Brismar J, Holmin T, Strand SE. Prospective investigation of radiologic methods in the diagnosis of intra-abdominal abscesses. Acta Radiol Diagn (Stockh). 1986;27(1):49-54.
  3. Baba AA, McKillop JH, Cuthbert GF, Neilson W, Gray HW, Anderson JR. Indium 111 leucocyte scintigraphy in abdominal sepsis. Do the results affect management? Eur J Nucl Med. 1990;16(4-6):307-309.
  4. Goldman M, Ambrose NS, Drolc Z, Hawker RJ, McCollum C. Indium-111-labelled leucocytes in the diagnosis of abdominal abscess. Br J Surg. 1987;74(3):184-186.
  5. Lantto EH, Lantto TJ, Vorne M. Fast diagnosis of abdominal infections and inflammations with technetium-99m-HMPAO labeled leukocytes. J Nucl Med. 1991;32(11):2029-2034.
  6. Tsai SC, Chao TH, Lin WY, Wang SJ. Abdominal abscesses in patients having surgery: an application of Ga-67 scintigraphic and computed tomographic scanning. Clin Nucl Med. 2001;26(9):761-764.
  7. Kumar R, Basu S, Torigian D, Anand V, Zhuang H, Alavi A. Role of modern imaging techniques for diagnosis of infection in the era of 18F-fluorodeoxyglucose positron emission tomography. Clin Microbiol 2008;21(1):209-224.
  8. Mahfouz T, Miceli MH, Saghafifar F, et al. 18F-fluorodeoxyglucose positron emission tomography contributes to the diagnosis and management of infections in patients with multiple myeloma: a study of 165 infectious episodes. J Clin Oncol. 2005;23(31):7857-7863.
  9. Paling MR, Gouse JC. Efficacy of abdominal computed tomography in evaluation of possible abdominal abscess. J Comput Tomogr. 1986;10(2):111-114.
  10. Azzarello G, Lanteri R, Rapisarda C, et al. Ultrasound-guided percutaneous treatment of abdominal collections. Chir Ital. 2009;61(3):337-340.
  11. Golfieri R, Cappelli A. Computed tomography-guided percutaneous abscess drainage in coloproctology: review of the literature. Tech Coloproctol. 2007;11(3):197-208.
  12. Lagana D, Carrafiello G, Mangini M, et al. Image-guided percutaneous treatment of abdominal-pelvic abscesses: a 5-year experience. Radiol Med. 2008;113(7):999-1007.
  13. Lee DH, Kim GC, Ryeom HK, Kim JY, Kang DS. Percutaneous paracoccygeal catheter drainage of deep pelvic abscesses using a combination of sonographic and fluoroscopic guidance. Abdom Imaging. 2008;33(5):611-614.
  14. Arellano RS, Gervais DA, Mueller PR. CT-guided drainage of abdominal abscesses: hydrodissection to create access routes for percutaneous drainage. AJR Am J Roentgenol. 2011;196(1):189-191.
  15. McCann JW, Maroo S, Wales P, et al. Image-guided drainage of multiple intraabdominal abscesses in children with perforated appendicitis: an alternative to laparotomy. Pediatr Radiol. 2008;38(6):661-668.
  16. Seewald S, Ang TL, Teng KY, et al. Endoscopic ultrasound-guided drainage of abdominal abscesses and infected necrosis. 2009;41(2):166-174.
  17. Puri R, Eloubeidi MA, Sud R, Kumar M, Jain P. Endoscopic ultrasound-guided drainage of pelvic abscess without fluoroscopy guidance. J Gastroenterol Hepatol. 2010;25(8):1416-1419.
  18. Butala P, Greenstein AJ, Sur MD, Mehta N, Sadot E, Divino CM. Surgical management of acute right lower-quadrant pain in pregnancy: a prospective cohort study. J Am Coll Surg. 2010;211(4):490-494.
  19. Jaffe TA, Miller CM, Merkle EM. Practice patterns in imaging of the pregnant patient with abdominal pain: a survey of academic centers. AJR Am J Roentgenol. 2007;189(5):1128-1134.
  20. Oto A, Ernst RD, Ghulmiyyah LM, et al. MR imaging in the triage of pregnant patients with acute abdominal and pelvic pain. Abdom Imaging. 2009;34(2):243-250.
  21. Oto A, Ernst RD, Shah R, et al. Right-lower-quadrant pain and suspected appendicitis in pregnant women: evaluation with MR imaging–initial experience. 2005;234(2):445-451.
  22. Shetty MK, Garrett NM, Carpenter WS, Shah YP, Roberts C. Abdominal computed tomography during pregnancy for suspected appendicitis: a 5-year experience at a maternity hospital. Semin Ultrasound CT MR. 2010;31(1):8-13.
  23. Lazarus E, Mayo-Smith WW, Mainiero MB, Spencer PK. CT in the evaluation of nontraumatic abdominal pain in pregnant women. 2007;244(3):784-790.

1Principal Author, Northwestern University, Chicago, Illinois. 2 Panel Chair, Beth Israel Deaconess Medical Center, Boston, Massachusetts. 3Panel Vice-chair, Inland Imaging Associates and University of Washington, Seattle, Washington. 4Cleveland Clinic, Cleveland, Ohio. 5Massachusetts General Hospital, Boston, Massachusetts. 6Walter Reed National Military Medical Center, Bethesda, Maryland, American Gastroenterological Association. 7 Mayo Clinic, Rochester, Minnesota. 8Carolinas Medical Center, Charlotte, North Carolina, American College of Surgeons. 9New York University Medical Center, New York, New York. 10Johns Hopkins Hospital, Baltimore, Maryland. 11Winthrop University Hospital, Mineola, New York. 12 MD Anderson Cancer Center, Houston, Texas. 13Northwestern University Feinberg School of Medicine/NMH, Chicago, Illinois. 14University of California San Francisco, San Francisco, California. 15Emory University, Atlanta, Georgia. 16Medical College of Wisconsin, Milwaukee, Wisconsin. 17Milton S. Hershey Medical Center, Hersey, Pennsylvania, Society of Nuclear Medicine. 18Staten Island University Hospitals, Staten Island, New York. 19University of California San Francisco, San Francisco, California.

 

The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.

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The 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 examinations 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 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.