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Weinstein S, Kim DH, Fowler KJ, Birkholz JH, Cash BD, Cilenti E, Dane B, Horvat N, Kambadakone AR, Korngold EK, Liu PS, Lo BM, McCrary M, Mellnick V, Pietryga JA, Santillan CS, Zukotynski K, Carucci LR. ACR Appropriateness Criteria® Left Lower Quadrant Pain: 2023 Update. J Am Coll Radiol 2023; 20:S471-S480. [PMID: 38040465 DOI: 10.1016/j.jacr.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
The differential diagnosis for left lower quadrant pain is wide and conditions range from the benign and self-limited to life-threatening surgical emergencies. Along with patient history, physical examination, and laboratory tests, imaging is often critical to limit the differential diagnosis and identify life-threatening abnormalities. This document will discuss the guidelines for the appropriate use of imaging in the initial workup for patients who present with left lower quadrant pain, patients with suspected diverticulitis, and patients with suspected complications from diverticulitis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California, San Diego, San Diego, California
| | - James H Birkholz
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Elizabeth Cilenti
- MedStar Georgetown University Hospital, Washington, District of Columbia, Primary care physician
| | - Bari Dane
- NYU Grossman School of Medicine, New York, New York
| | - Natally Horvat
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Bruce M Lo
- Sentara Norfolk General Hospital/Eastern Virginia Medical School, Norfolk, Virginia; American College of Emergency Physicians
| | - Marion McCrary
- Duke Signature Care, Durham, North Carolina; American College of Physicians
| | - Vincent Mellnick
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri; Committee on Emergency Radiology-GSER
| | - Jason A Pietryga
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Katherine Zukotynski
- McMaster University, Hamilton, Ontario, Canada; Commission on Nuclear Medicine and Molecular Imaging
| | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Galgano SJ, McNamara MM, Peterson CM, Kim DH, Fowler KJ, Camacho MA, Cash BD, Chang KJ, Feig BW, Gage KL, Garcia EM, Kambadakone AR, Levy AD, Liu PS, Marin D, Moreno C, Pietryga JA, Smith MP, Weinstein S, Carucci LR. ACR Appropriateness Criteria ® Left Lower Quadrant Pain-Suspected Diverticulitis. J Am Coll Radiol 2020; 16:S141-S149. [PMID: 31054740 DOI: 10.1016/j.jacr.2019.02.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 12/18/2022]
Abstract
This review summarizes the relevant literature regarding imaging of suspected diverticulitis as an etiology for left lower quadrant pain, and imaging of complications of acute diverticulitis. The most common cause of left lower quadrant pain in adults is acute sigmoid or descending colonic diverticulitis. Appropriate imaging triage for patients with suspected diverticulitis should address the differential diagnostic possibilities and what information is necessary to make a definitive management decision. Patients with diverticulitis may require surgery or interventional radiology procedures because of associated complications, including abscesses, fistulas, obstruction, or perforation. As a result, there has been a trend toward greater use of imaging to confirm the diagnosis of diverticulitis, evaluate the extent of disease, and detect complications before deciding on appropriate treatment. Additionally, in the era of bundled payments and minimizing health care costs, patients with acute diverticulitis are being managed on an outpatient basis and rapid diagnostic imaging at the time of initial symptoms helps to streamline and triage patients to the appropriate treatment pathway. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Samuel J Galgano
- Research Author, University of Alabama at Birmingham, Birmingham, Alabama.
| | | | | | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | | | - Barry W Feig
- The University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons
| | - Kenneth L Gage
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | | | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia
| | | | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | | | - Jason A Pietryga
- The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island
| | - Martin P Smith
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Pouli S, Kozana A, Papakitsou I, Daskalogiannaki M, Raissaki M. Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology. Insights Imaging 2020; 11:31. [PMID: 32086627 PMCID: PMC7035412 DOI: 10.1186/s13244-019-0823-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/29/2019] [Indexed: 12/11/2022] Open
Abstract
Gastrointestinal tract (GIT) perforation is a common medical emergency associated with considerable mortality, ranging from 30 to 50%. Clinical presentation varies: oesophageal perforations can present with acute chest pain, odynophagia and vomiting, gastroduodenal perforations with acute severe abdominal pain, while colonic perforations tend to follow a slower progression course with secondary bacterial peritonitis or localised abscesses. A subset of patients may present with delayed symptoms, abscess mimicking an abdominal mass, or with sepsis. Direct multidetector computed tomography (MDCT) findings support the diagnosis and localise the perforation site while ancillary findings may suggest underlying conditions that need further investigation following primary repair of ruptured bowel. MDCT findings include extraluminal gas, visible bowel wall discontinuity, extraluminal contrast, bowel wall thickening, abnormal mural enhancement, localised fat stranding and/or free fluid, as well as localised phlegmon or abscess in contained perforations. The purpose of this article is to review the spectrum of MDCT findings encountered in GIT perforation and emphasise the MDCT and clinical clues suggestive of the underlying aetiology and localisation of perforation site.
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Affiliation(s)
- Styliani Pouli
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece
| | - Androniki Kozana
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece
| | - Ioanna Papakitsou
- Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Greece
| | - Maria Daskalogiannaki
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece
| | - Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, Faculty of Medicine-University of Crete, Stavrakia, Voutes 21110, Heraklion, Crete, Greece.
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