ACR Appropriateness Criteria on Acute Onset Flank Pain:Urolithiasis

Urinary tract stones 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. Children are affected less frequently. Stones 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.

Presently, non contrast computed tomography (NCCT) is commonly performed in the evaluation of patients with suspected renal colic. NCCT is highly accurate for the identification of stones, for detecting evidence of ureter al obstruction, and for the identification of other potential etiologies of flank pain. The major disadvantage of NCCT is radiation exposure to the patient. In patients with known urolithiasis and/or a presentation classic for renal colic, the combination of abdomen and pelvis radiography (KUB) and ultrasound (US) may be an acceptable and lower-radiation alternative for the diagnosis of clinically significant stones. Magnetic resonance imaging (MRI) is an excellent tool for the evaluation of hydronephrosis though is limited in its ability to detect small stones.

In the year 2015, the American College of Radiology came out with ACR's Appropriateness Criteria on Acute Onset Flank Pain — Suspicion of Stone Disease (Urolithiasis). The major criterion are as follows:

Variant 1: Suspicion of stone disease.

Radiologic Procedure	Rating	Comments	RRL*
CT abdomen and pelvis without contrast	8	Reduced-dose techniques are preferred.
CT abdomen and pelvis without and with contrast	6	This procedure is indicated if CT without contrast does not explain pain or reveals an abnormality that should be further assessed with contrast (e.g., stone versus phleboliths).
US color Doppler kidneys and bladder retroperitoneal	6		O
X-ray intravenous urography	4
MRI abdomen and pelvis without contrast	4	MR urography.	O
MRI abdomen and pelvis without and with contrast	4	MR urography.	O
X-ray abdomen and pelvis (KUB)	3	This procedure can be performed with US as an alternative to NCCT.
CT abdomen and pelvis with contrast	2
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Variant 2: Recurrent symptoms of stone disease.

Radiologic Procedure	Rating	Comments	RRL*
CT abdomen and pelvis without contrast	7	Reduced-dose techniques are preferred.
US color Doppler kidneys and bladder retroperitoneal	7	This procedure is indicated in an emergent setting for acute management to evaluate for hydronephrosis. For planning and intervention, US is generally not adequate and CT is complementary as CT more accurately characterizes stone size and location.	O
CT abdomen and pelvis without and with contrast	6	This procedure is indicated if CT without contrast does not explain pain or reveals an abnormality that should be further assessed with contrast (e.g., stone versus phleboliths).
X-ray abdomen and pelvis (KUB)	5	This procedure can be performed with US as an alternative to NCCT.
MRI abdomen and pelvis without contrast	4	MR urography.	O
MRI abdomen and pelvis without and with contrast	4	MR urography.	O
CT abdomen and pelvis with contrast	2
X-ray intravenous urography	2
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

Variant 3: Pregnant patient.

Radiologic Procedure	Rating	Comments	RRL*
US color Doppler kidneys and bladder retroperitoneal	8		O
CT abdomen and pelvis without contrast	6
MRI abdomen and pelvis without contrast	5		O
CT abdomen and pelvis without and with contrast	2
CT abdomen and pelvis with contrast	2
X-ray abdomen and pelvis (KUB)	2
X-ray intravenous urography	1
MRI abdomen and pelvis without and with contrast	1		O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate			*Relative Radiation Level

To read further click on the following link:

https://acsearch.acr.org/docs/69362/Narrative/