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CT Abdomen and Pelvis

1.1.1 Mesenteric Ischemia suspected

1.2.1 Bowel Obstruction suspected

1.2.2 Severe pain developing over a few hours (acute abdomen)

1.3.1.1 Malignant cytology

1.3.1.2 Low SAAG and high protein level

1.3.2.1 Internal echoes within the ascites

1.3.2.2 Loculated ascites

1.3.2.3 Tethered bowel loops along the posterior abdominal wall or other organs

1.4.1 Shock: inadequate tissue perfusion with an inadequate cardiac output

1.5.1 Prior studies including barium enema or endoscopy not diagnostic

1.6.1 Positive pregnancy test

1.6.2 Pelvic Ultrasound showing no intrauterine or tubal pregnancy

1.7.1 Abscess, appendicitis, diverticulitis suspected

1.7.2 Leukocytosis

1.7.3 Persistent abdominal or pelvic pain

1.7.4 Fever of Unknown Origin (fever >100.9 F / 38.3 C on several occasions over at least 3 weeks)

1.7.4.1.1 Three Blood Cultures, negative

1.7.4.1.2 Urine culture, negative

1.7.4.1.3 Tuberculin skin test, nonreactive

1.7.4.1.4 HIV antibody assay and HIV viral load for patients at high risk

1.7.4.1.5 Chest x-ray, negative

1.7.4.2 No diagnosis after 3 outpatient visits or 3 days of hospitalization

1.8.1 Not associated with a simple urinary tract infection

1.8.2 Persists despite treatment of urinary tract infection

1.8.3 Flank pain

1.10.1.1.1 No evidence of ruptured Baker’s cyst

1.10.1.1.2 No evidence of injury to the Gastrocnemius Muscle

1.10.1.1.3 Suspect pelvic venous compression/obstruction

1.10.1.2.1 No evidence of Reflex Sympathetic Dystrophy

1.10.1.2.2 Suspect Central Venous Obstruction (IVC)

1.11.1.1 Nondiagnostic Ultrasound exam or X-ray

1.11.2.1 Pelvic Mass in a Female

1.11.2.1.1 Must have a nondiagnostic Pelvic ultrasound prior to CT or MRI

1.11.2.1.2 Should be evaluated by MRI if ultrasound is nondiagnostic (send for physician review if no contraindication to MRI is described such as pacemaker)

1.12.1 Fever excluded as cause

1.12.2 Medications excluded as cause

1.12.3 Normal chest x-ray or CT

1.12.4 Normal CBC, TSH, and negative blood cultures

1.14.1.1 Fever

1.14.1.2 Leukocytosis

1.14.1.3 Rebound tenderness

1.14.1.4 Guarding

1.14.1.5 Elevated lipase or amylase (greater than 3 times normal)

1.14.1.6 Abnormal abdominal x-ray (KUB) suggesting bowel obstruction

1.14.1.7 Known malignancy elsewhere and suspect metastases

1.14.2.1.1 Interval evaluation after treatment

1.14.2.1.2 Worsening under treatment

1.14.2.2.1 Fever

1.14.2.2.2 Leukocytosis

1.14.2.2.3 Mass

1.14.2.3.1 New symptoms

1.14.2.3.2 Periodic follow up

1.14.2.4.1 Abdominal or back pain

1.14.2.4.2 Aortic dilatation seen or suspected on prior imaging

1.14.2.4.3 Pulsatile abdominal mass with nondiagnostic ultrasound

1.14.2.4.4 History of first-degree relative with abdominal aortic aneurysm and nondiagnostic ultrasound

1.14.2.4.5 Male age 65-75 with a history of smoking

1.14.2.4.6 Marfan’s syndrome

1.14.2.4.7 Ehlers-Danlos syndrome

1.14.2.4.8 Turner’s syndrome

1.14.2.5.1 Not a primary tool, require prior colonoscopy, sigmoidoscopy or barium enema

1.14.2.6.1 Positive pregnancy test

1.14.2.6.2 Pelvic ultrasound showing no intrauterine or tubal pregnancy

1.14.2.7.1 Obtain history of prior studies, send for physician review

1.14.2.8.1.1 Abdominal pain and diarrhea for more than 6 weeks

1.14.2.8.1.2 Fever

1.14.2.8.1.3 Perianal fistula or fissure

1.14.2.8.1.4 Enterovesical fistula

1.14.2.8.1.5 Enterovaginal fistula

1.14.2.8.1.6 Enterocutaneous fistula

1.14.2.8.1.7 Children with unexplained anemia, growth failure, and abdominal pain

1.14.2.8.2.1.1 Diarrhea

1.14.2.8.2.1.2 Tenesmus

1.14.2.9.1 Obtain history of prior studies, send for physician review

1.14.2.10.1 Systemic Lupus Erythematosus

1.14.2.10.2 Severe abdominal pain

1.14.2.10.3 Blood in stool

1.14.2.10.4 History of abdominal angina

1.14.2.10.5 Shock

1.14.2.11 Known malignancy elsewhere and suspect metastases

1.14.2.12.1 Obtain history of prior studies, send for physician review

1.14.2.13.1.1 Back pain

1.14.2.13.1.2 Mass

1.14.2.13.1.3 Abdominal tenderness

1.14.2.13.1.4 Post trauma

1.14.2.13.1.5 Ultrasound nondiagnostic

1.14.2.13.1.6 Worsening under treatment

1.14.2.13.2 Worsening clinical situation

1.14.2.14.1 Elevated amylase or lipase

1.14.2.15.1 Obtain history of prior studies, send for physician review

1.14.2.16 Perforated Bowel or Viscus

1.14.2.16.1 Free air on other imaging

1.14.2.16.2 Rebound tenderness or guarding

1.14.2.16.3 Fever

1.14.2.17.1 Recent trauma

1.14.2.17.2 Leukemia, AIDS or known splenomegaly

1.14.2.18.1 Obtain history of prior studies, send for physician review

1.14.2.19.1 Obtain history of prior studies, send for physician review

1.14.3.1.1 Interval evaluation after treatment

1.14.3.1.2 Worsening under treatment

1.14.3.2.1 Fever

1.14.3.2.2 Leukocytosis

1.14.3.2.3 Mass

1.14.3.3.1 New symptoms

1.14.3.3.2 Periodic follow up

1.14.3.4.1 Abdominal or back pain

1.14.3.4.2 Aortic dilatation seen or suspected on prior imaging

1.14.3.4.3 Pulsatile abdominal mass with nondiagnostic ultrasound

1.14.3.4.4 History of first-degree relative with abdominal aortic aneurysm and nondiagnostic ultrasound

1.14.3.4.5 Male age 65-75 with a history of smoking

1.14.3.4.6 Marfan’s syndrome

1.14.3.4.7 Ehlers-Danlos syndrome

1.14.3.4.8 Turner’s syndrome

1.14.3.5.1 Rapidly progressive, severe upper abdominal pain

1.14.3.5.2 Ascites

1.14.3.5.3 Hepatomegaly

1.14.3.5.4 Elevated liver enzymes

1.14.3.6.1 Fever and chills

1.14.3.6.2 RUQ abdominal pain

1.14.3.6.3 Jaundice

1.14.3.7.1 Ultrasound or HIDA scan nondiagnostic

1.14.3.8.1 Ultrasound or HIDA scan nondiagnostic

1.14.3.8.2 RUQ pain after meals

1.14.3.9 Gastric malignancy, known

1.14.3.10.1 Obtain history of prior studies, send for physician review

1.14.3.11.1 Obtain history of prior studies, send for physician review

1.14.3.12.1 Obtain history of prior studies, send for physician review

1.14.3.13.1.1 Worsened by straining or lifting

1.14.3.13.1.2 Worsened by prolonged standing

1.14.3.13.2.1 More prominent in upright position

1.14.3.13.2.2 More prominent with Valsalva maneuver

1.14.3.13.3.1 Colicky abdominal pain

1.14.3.13.3.2 Palpable mass

1.14.3.13.3.3 Signs of intestinal obstruction

1.14.3.13.4 After abdominal surgery with incisional pain associated with bulge or suspected defect

1.14.3.14.1 Systemic Lupus Erythematosus

1.14.3.14.2 Severe abdominal pain

1.14.3.14.3 Blood in stool

1.14.3.14.4 History of abdominal angina

1.14.3.14.5 Shock

1.14.3.15 Known malignancy elsewhere and suspect metastases

1.14.3.16.1 Obtain history of prior studies, send for physician review

1.14.3.17.1 Obtain history of prior studies, send for physician review

1.14.3.18.1.1 Back pain

1.14.3.18.1.2 Mass

1.14.3.18.1.3 Abdominal tenderness

1.14.3.18.1.4 Post trauma

1.14.3.18.1.5 Ultrasound nondiagnostic

1.14.3.18.1.6 Worsening under treatment

1.14.3.19.1 Elevated amylase or lipase

1.14.3.20.1 Obtain history of prior studies, send for physician review

1.14.4.1 Flank pain radiating to groin

1.14.4.2 Hematuria

1.14.4.3 History of prior stones

1.14.4.4 Hydronephrosis on other imaging

1.14.5.1.1 Interval evaluation after treatment

1.14.5.1.2 Worsening under treatment

1.14.5.2.1 Fever

1.14.5.2.2 Leukocytosis

1.14.5.2.3 Mass

1.14.5.3.1 New symptoms

1.14.5.3.2 Periodic follow up

1.14.5.4.1 Abdominal or back pain

1.14.5.4.2 Aortic dilatation seen or suspected on prior imaging

1.14.5.4.3 Pulsatile abdominal mass with nondiagnostic ultrasound

1.14.5.4.4 History of first-degree relative with abdominal aortic aneurysm and nondiagnostic ultrasound

1.14.5.4.5 Male age 65-75 with a history of smoking

1.14.5.4.6 Marfan’s syndrome

1.14.5.4.7 Ehlers-Danlos syndrome

1.14.5.4.8 Turner’s syndrome

1.14.5.5.1 Fever

1.14.5.5.2 Leukocytosis

1.14.5.5.3 RLQ tenderness

1.14.5.5.4 Rebound tenderness or guarding

1.14.5.6.1 Rapidly progressive, severe upper abdominal pain

1.14.5.6.2 Ascites

1.14.5.6.3 Hepatomegaly

1.14.5.6.4 Elevated liver enzymes

1.14.5.7.1 Fever and chills

1.14.5.7.2 RUQ abdominal pain

1.14.5.7.3 Jaundice

1.14.5.8.1.1 Positive Murphy’s Sign

1.14.5.9.1.1 RUQ pain after meals

1.14.5.10.1 Obtain history of prior studies, send for physician review

1.14.5.11.1 Systemic Lupus Erythematosus

1.14.5.11.2 Severe abdominal pain

1.14.5.11.3 Blood in stool

1.14.5.11.4 History of abdominal angina

1.14.5.11.5 Shock

1.14.5.12 Liver, pancreatic, or biliary malignancy, known

1.14.5.13 Known malignancy elsewhere and suspect metastases

1.14.5.14.1.1 Back pain

1.14.5.14.1.2 Mass

1.14.5.14.1.3 Abdominal tenderness

1.14.5.14.1.4 Post trauma

1.14.5.14.1.5 Ultrasound nondiagnostic

1.14.5.14.1.6 Worsening under treatment

1.14.5.15.1 Elevated amylase or lipase

1.14.5.16.1 Obtain history of prior studies, send for physician review

1.14.5.17.1 Obtain history of prior studies, send for physician review

1.14.5.18.1 Flank pain radiating to groin

1.14.5.18.2 Hematuria

1.14.5.18.3 History of prior stones

1.14.5.18.4 Hydronephrosis on other imaging

1.14.6.1.1 Interval evaluation after treatment

1.14.6.1.2 Worsening under treatment

1.14.6.2.1 Fever

1.14.6.2.2 Leukocytosis

1.14.6.2.3 Mass

1.14.6.3.1 New symptoms

1.14.6.3.2 Periodic follow up

1.14.6.4.1 Abdominal or back pain

1.14.6.4.2 Aortic dilatation seen or suspected on prior imaging

1.14.6.4.3 Pulsatile abdominal mass with nondiagnostic ultrasound

1.14.6.4.4 History of first-degree relative with abdominal aortic aneurysm and nondiagnostic ultrasound

1.14.6.4.5 Male age 65-75 with a history of smoking

1.14.6.4.6 Marfan’s syndrome

1.14.6.4.7 Ehlers-Danlos syndrome

1.14.6.4.8 Turner’s syndrome

1.14.6.5.1 Fever

1.14.6.5.2 Leukocytosis

1.14.6.5.3 Rebound tenderness or guarding

1.14.6.6 Colon cancer, known

1.14.6.7.1 Obtain history of prior studies, send for physician review

1.14.6.8.1 Leukocytosis

1.14.6.8.2 Fever

1.14.6.8.3 Known history of diverticular disease (diverticulosis)

1.14.6.9.1 Positive pregnancy test

1.14.6.9.2 Pelvic ultrasound showing no intrauterine or tubal pregnancy

1.14.6.10.1.1 Worsened by straining or lifting

1.14.6.10.1.2 Worsened by prolonged standing

1.14.6.10.2.1 More prominent in upright position

1.14.6.10.2.2 More prominent with Valsalva maneuver

1.14.6.10.3.1 Colicky abdominal pain

1.14.6.10.3.2 Palpable mass

1.14.6.10.3.3 Signs of intestinal obstruction

1.14.6.10.4 After abdominal surgery with incisional pain associated with bulge or suspected defect

1.14.6.11.1.1 Abdominal pain and diarrhea for more than 6 weeks

1.14.6.11.1.2 Fever

1.14.6.11.1.3 Perianal fistula or fissure

1.14.6.11.1.4 Enterovesical fistula

1.14.6.11.1.5 Enterovaginal fistula

1.14.6.11.1.6 Enterocutaneous fistula

1.14.6.11.1.7 Children with unexplained anemia, growth failure, and abdominal pain

1.14.6.11.2.1.1 Diarrhea

1.14.6.11.2.1.2 Tenesmus

1.14.6.12.1 Obtain history of prior studies, send for physician review

1.14.6.13.1 Systemic Lupus Erythematosus

1.14.6.13.2 Severe abdominal pain

1.14.6.13.3 Blood in stool

1.14.6.13.4 History of abdominal angina

1.14.6.13.5 Shock

1.14.6.14 Known malignancy elsewhere and suspect metastases

1.14.6.15.1 Obtain history of prior studies, send for physician review

1.14.6.16.1 Ultrasound nondiagnostic

1.14.6.17.1 Immunocompromised patient (HIV, transplant recipient, patient on chemotherapy, elderly)

1.14.6.17.2 Abdominal distention

1.14.6.17.3 Fever

1.14.6.17.4 Nausea or vomiting

1.14.6.17.5 Diarrhea

1.14.6.18.1 Flank pain radiating to groin

1.14.6.18.2 Hematuria

1.14.6.18.3 History of prior stones

1.14.7.1.1 Interval evaluation after treatment

1.14.7.1.2 Worsening under treatment

1.14.7.2.1 Fever

1.14.7.2.2 Leukocytosis

1.14.7.2.3 Mass

1.14.7.3.1 New symptoms

1.14.7.3.2 Periodic follow up

1.14.7.4.1 Abdominal or back pain

1.14.7.4.2 Aortic dilatation seen or suspected on prior imaging

1.14.7.4.3 Pulsatile abdominal mass with nondiagnostic ultrasound

1.14.7.4.4 History of first-degree relative with abdominal aortic aneurysm and nondiagnostic ultrasound

1.14.7.4.5 Male age 65-75 with a history of smoking

1.14.7.4.6 Marfan’s syndrome

1.14.7.4.7 Ehlers-Danlos syndrome

1.14.7.4.8 Turner’s syndrome

1.14.7.5.1 Leukocytosis

1.14.7.5.2 Fever

1.14.7.5.3 Known history of diverticular disease (diverticulosis)

1.14.7.6 Gastric malignancy, known

1.14.7.7.1 Obtain history of prior studies, send for physician review

1.14.7.8.1 Obtain history of prior studies, send for physician review

1.14.7.9.1 Obtain history of prior studies, send for physician review

1.14.7.10.1 Systemic Lupus Erythematosus

1.14.7.10.2 Severe abdominal pain

1.14.7.10.3 Blood in stool

1.14.7.10.4 History of abdominal angina

1.14.7.10.5 Shock

1.14.7.11 Known malignancy elsewhere and suspect metastases

1.14.7.12.1.1 Back pain

1.14.7.12.1.2 Mass

1.14.7.12.1.3 Abdominal tenderness

1.14.7.12.1.4 Post trauma

1.14.7.12.1.5 Ultrasound nondiagnostic

1.14.7.12.1.6 Worsening under treatment

1.14.7.13.1 Elevated amylase or lipase

1.14.7.14.1 Obtain history of prior studies, send for physician review

1.14.7.15 Splenomegaly

1.14.7.16.1 Recent trauma

1.14.7.16.2 Splenomegaly, known

1.14.7.16.3 Lymphoma, known

1.14.7.17.1 Flank pain radiating to groin

1.14.7.17.2 Hematuria

1.14.7.17.3 History of prior stones

1.14.8.1.1 Interval evaluation after treatment

1.14.8.1.2 Worsening under treatment

1.14.8.2.1 Fever

1.14.8.2.2 Leukocytosis

1.14.8.2.3 Mass

1.14.8.3.1 New symptoms

1.14.8.3.2 Periodic follow up

1.14.8.4.1 Abdominal or back pain

1.14.8.4.2 Aortic dilatation seen or suspected on prior imaging

1.14.8.4.3 Pulsatile abdominal mass with nondiagnostic ultrasound

1.14.8.4.4 History of first-degree relative with abdominal aortic aneurysm and nondiagnostic ultrasound

1.14.8.4.5 Male age 65-75 with a history of smoking

1.14.8.4.6 Marfan’s syndrome

1.14.8.4.7 Ehlers-Danlos syndrome

1.14.8.4.8 Turner’s syndrome

1.14.8.5 Colon cancer, known

1.14.8.6.1 Leukocytosis

1.14.8.6.2 Fever

1.14.8.6.3 Known history of diverticular disease (diverticulosis)

1.14.8.7.1 Positive pregnancy test

1.14.8.7.2 Pelvic ultrasound showing no intrauterine or tubal pregnancy

1.14.8.8.1.1 Worsened by straining or lifting

1.14.8.8.1.2 Worsened by prolonged standing

1.14.8.8.2.1 More prominent in upright position

1.14.8.8.2.2 More prominent with Valsalva maneuver

1.14.8.8.3.1 Colicky abdominal pain

1.14.8.8.3.2 Palpable mass

1.14.8.8.3.3 Signs of intestinal obstruction

1.14.8.8.4 After abdominal surgery with incisional pain associated with bulge or suspected defect

1.14.8.9.1.1 Abdominal pain and diarrhea for more than 6 weeks

1.14.8.9.1.2 Fever

1.14.8.9.1.3 Perianal fistula or fissure

1.14.8.9.1.4 Enterovesical fistula

1.14.8.9.1.5 Enterovaginal fistula

1.14.8.9.1.6 Enterocutaneous fistula

1.14.8.9.1.7 Children with unexplained anemia, growth failure, and abdominal pain

1.14.8.9.2.1.1 Diarrhea

1.14.8.9.2.1.2 Tenesmus

1.14.8.12 Known malignancy elsewhere and suspect metastases

1.14.8.12 Known malignancy elsewhere and suspect metastases

1.14.8.12 Known malignancy elsewhere and suspect metastases

1.14.8.10.1 Obtain history of prior studies, send for physician review

1.14.8.11.1 Systemic Lupus Erythematosus

1.14.8.11.2 Severe abdominal pain

1.14.8.11.3 Blood in stool

1.14.8.11.4 History of abdominal angina

1.14.8.11.5 Shock

1.14.8.12 Known malignancy elsewhere and suspect metastases

1.14.8.13.1 Obtain history of prior studies, send for physician review

1.14.8.14.1 Ultrasound nondiagnostic

1.14.8.15.1 Flank pain radiating to groin

1.14.8.15.2 Hematuria

1.14.8.15.3 History of prior stones

1.14.9.1.1 Interval evaluation after treatment

1.14.9.1.2 Worsening under treatment

1.14.9.2.1 Fever

1.14.9.2.2 Leukocytosis

1.14.9.2.3 Mass

1.14.9.3 Abdominal Distention

1.14.9.4.1 Fever

1.14.9.4.2 Leukocytosis

1.14.9.4.3 Rebound tenderness or guarding

1.14.9.5 Colon cancer, known

1.14.9.6.1 Obtain history of prior studies, send for physician review

1.14.9.7.1 Leukocytosis

1.14.9.7.2 Fever

1.14.9.7.3 Known history of diverticular disease (diverticulosis)

1.14.9.8.1 Positive pregnancy test

1.14.9.8.2 Pelvic ultrasound showing no intrauterine or tubal pregnancy

1.14.9.9 Fever

1.14.9.10 Guarding

1.14.9.11 Hematuria

1.14.9.12.1.1 Worsened by straining or lifting

1.14.9.12.1.2 Worsened by prolonged standing

1.14.9.12.2.1 More prominent in upright position

1.14.9.12.2.2 More prominent with Valsalva maneuver

1.14.9.12.3.1 Colicky abdominal pain

1.14.9.12.3.2 Palpable mass

1.14.9.12.3.3 Signs of intestinal obstruction

1.14.9.12.4 After abdominal surgery with incisional pain associated with bulge or suspected defect

1.14.9.13 Leukocytosis

1.14.9.14 Known malignancy elsewhere and suspect metastases

1.14.9.15 Rebound tenderness

1.14.9.16.1 Flank pain radiating to groin

1.14.9.16.2 Hematuria

1.14.9.16.3 History of prior stones

1.15 Weight Loss (involuntary) of more than 5% body weight over 6 months

1.16.1.1 Abdominal pain

1.16.1.2 Fever

1.16.1.3 Leukocytosis

1.16.1.4 Mass

2.1.1 Fever or chills

2.1.2 Leukocytosis

2.1.3 Rebound Tenderness or Guarding

2.1.4 Mass by physical exam or ultrasound

2.1.5 Purulent discharge

2.2.1 Abdominal or back pain

2.2.2 Aortic dilatation seen or suspected on prior imaging

2.2.3 Pulsatile abdominal mass with nondiagnostic ultrasound

2.2.4 History of first-degree relative with abdominal aortic aneurysm and nondiagnostic ultrasound

2.2.5 Male age 65-75 with a history of smoking

2.2.6 Marfan’s syndrome

2.2.7 Ehlers-Danlos syndrome

2.2.8 Turner’s syndrome

2.3.1 Acute onset of pain

2.3.2 Falling Blood Pressure

2.3.3 Shock

2.3.4 Pulsatile mass

2.4.1 Unequal blood pressure in the arms

2.4.2 Rapid onset of ripping or tearing severe chest or upper back or abdominal pain

2.4.3 Syncope and chest pain

2.4.4 Shortness of breath

2.4.5 Stroke

2.4.6 Loss of pulses

2.4.7 New aortic insufficiency murmur

2.4.8 Marfan’s syndrome

2.4.9 Recent aortic manipulation (such as catheter angiography)

2.4.10 Family history of aortic disease

2.4.11.1 1 month after repair

2.4.11.2 3 months after repair

2.4.11.3 6 months after repair

2.4.11.4 12 months after repair

2.4.11.5 Annually after 12 months

2.4.12 New symptoms after repair

2.5.1.1 Fever

2.5.1.2 Leukocytosis

2.5.1.3 Rebound tenderness

2.6.1.1 Malignant cytology

2.6.1.2 Low SAAG and high protein level

2.6.2.1 Internal echoes within the ascites

2.6.2.2 Loculated ascites

2.6.2.3 Tethered bowel loops along the posterior abdominal wall or other organs

2.8.1 Abdominal distention on exam

2.8.2 Constipation or obstipation (no stool or gas for 24-48 hrs)

2.8.3 Loud, high pitched bowel sounds on exam

2.8.4 Colicky abdominal pain

2.8.5 Tympani

2.8.6 Abdominal mass

2.8.7 Nausea and vomiting

2.8.8 Abdominal x-ray demonstrating or suggesting bowel obstruction

2.8.9 Incomplete or intermittent small bowel obstruction

2.9.1 MRCP preferred study (send for physician review)

2.10.1.1.1 < 1 cm on ultrasound, image every 3-6 months for 2 years

2.10.1.1.2 1-2 cm, image every 3 months if stable in size

2.10.1.1.3 > 2 cm, biopsy and if nondiagnostic, repeat imaging if stable

2.10.1.2 Rising AFP with negative ultrasound

2.10.1.3 CT or MRI did not find a mass and rising AFP, repeat imaging every 3 months until a mass is confirmed

2.10.2 Planned TIPS (transjugular intrahepatic portosystemic shunt – relatively noninvasive procedure for portal hypertension)

2.11.1.1 Abdominal pain and diarrhea for more than 6 weeks

2.11.1.2 Fever

2.11.1.3 Perianal fistula or fissure

2.11.1.4 Enterovesical fistula

2.11.1.5 Enterovaginal fistula

2.11.1.6 Enterocutaneous fistula

2.11.1.7 Children with unexplained anemia, growth failure, and abdominal pain

2.11.2 Infectious Colitis

2.11.3.1 Abdominal pain, tenderness, or cramping

2.11.3.2 Bloody stools (bright red or maroon-colored)

2.11.3.3 Urgency to move bowels

2.11.3.4 Diarrhea

2.11.4.1 Recent chemotherapy or broad spectrum antibiotics

2.11.5.1.1 Diarrhea

2.11.5.1.2 Pain

2.11.5.1.3 Tenesmus

2.15.1 Lower abdominal pain, tenderness, or mass

2.12 Congenital Anomalies of the Abdomen or Pelvis

2.13.1 Abdominal pain and diarrhea for more than 6 weeks

2.13.2 Fever

2.13.3 Perianal fistula or fissure

2.13.4 Enterovesical fistula

2.13.5 Enterovaginal fistula

2.13.6 Enterocutaneous fistula

2.13.7 Children with unexplained anemia, growth failure, and abdominal pain

2.14.1 MRI abdomen and pelvis are the preferred procedures; if MRI is contraindicated, then CT abdomen and pelvis

2.15.1 Lower abdominal pain, tenderness, or mass

2.15.2.1 Leukocytosis

2.15.2.2 Fever

2.15.2.3 Known History of diverticular disease (diverticulosis)

2.15.2.4 Rebound tenderness or Guarding

2.16.1.1 Three Blood Cultures, negative

2.16.1.2 Urine culture, negative

2.16.1.3 Tuberculin skin test, nonreactive

2.16.1.4 HIV antibody assay and HIV viral load for patients at high risk

2.16.1.5 Chest x-ray, negative

2.17.1 X-rays nondiagnostic

2.17.2 Normal x-ray but positive bone scan

2.17.3 Post radiation therapy to the pelvis with sacral or pubic pain

2.18.1.1 Worsened by straining or lifting

2.18.1.2 Worsened by prolonged standing

2.18.2.1 More prominent in upright position

2.18.2.2 More prominent with Valsalva maneuver

2.18.3.1 Colicky abdominal pain

2.18.3.2 Palpable mass

2.18.3.3 Signs of intestinal obstruction

2.19.1 Systemic lupus erythematous

2.19.2 Severe abdominal pain

2.19.3 History of abdominal angina

2.19.4 Blood in stool

2.19.5 Shock

2.20.1 Flank pain radiating to the groin

2.20.2 Hematuria

2.20.3 History of prior stones

2.20.4 Hydronephrosis on other imaging

2.21.1 Liver mass/nodule/lesion seen on ultrasound and finding was indeterminate (CT or MRI was recommended)

2.21.2.1 Follow up every 3 months if mass not characterized previously as benign hemangioma or cyst

2.22.1.1 < 1 cm on ultrasound, image every 3-6 months for 2 years

2.22.1.2 1-2 cm, image every 3 months if stable in size

2.22.1.3 > 2 cm, biopsy and if nondiagnostic, repeat imaging if stable

2.22.2 Rising AFP with negative ultrasound

2.22.3 CT or MRI did not find a mass and rising AFP, repeat imaging every 3 months until a mass is confirmed

2.23.1 Known malignancy elsewhere

2.23.2.1 Abnormal liver function tests and nondiagnostic ultrasound

2.23.2.2 Jaundice

2.23.2.3 Mass/nodule/lesion on ultrasound

2.24.1.1 Failed conservative management

2.24.2 Fasciculations

2.24.3 Muscle atrophy

2.24.4.1 Failed conservative management

2.24.5 Suspected pelvic mass with back pain radiating to the leg

2.24.6.1 Paresthesias

2.24.6.2 Sensory loss

2.24.6.3 Leg weakness

2.25.1 Numbness or dysesthesia of the thigh not responding to NSAIDs treatment or injection

2.26.1 Abdominal pain

2.26.2.1 Leukocytosis

2.26.2.2 Bloody stool, gross blood or occult

2.26.2.3 Nausea, vomiting, or diarrhea

2.26.2.4 History of abdominal angina (pain after eating for approximately 3 hours)

2.26.2.5 Shock

2.27.1.1 Surveillance (refer to Oncology Routines)

2.27.1.2 Change in condition (worsening clinical situation), suspect worsening metastatic disease

2.27.2.1.1 Ascites

2.27.2.1.2 Bowel obstruction

2.27.2.1.3 Change in bladder or bowel habits

2.27.2.1.4 Hematuria

2.27.2.1.5 Hydronephrosis

2.27.2.1.6 New abdominal or pelvic mass

2.27.2.1.7 Abdominal or pelvic pain

2.27.2.1.8 Rectal or abnormal vaginal bleeding

2.27.3 Malignancy elsewhere and Initial Staging for metastatic disease (refer to Oncology Routines for Initial Staging)

2.28.1.1 Elevated C Reactive Protein

2.28.1.2 Elevated Erythrocyte Sedimentation Rate

2.28.1.3 Fever

2.28.1.4 Leukocytosis

2.28.1.5 Positive Blood Cultures

2.29.1 Pancreatic mass on recent imaging and request for “Pancreatic Protocol”

2.29.2 Prior imaging demonstrating dilatation of the bile duct and/or pancreatic duct (US, ERCP, MRCP)

2.29.3 Painless Jaundice

2.29.4 Weight loss of greater than 5% of body weight in the past 6 months

2.29.5 Midepigastric pain which may radiate to the back

2.29.6.1 CA19-9 >35Ku/L

2.29.6.2 CEA >2.5 in nonsmoker

2.29.6.3 CEA >5.0 in smoker

2.30.1.1 Acute pancreatitis with onset at least 4 weeks earlier

2.30.1.2 Pancreatitis secondary to trauma

2.30.1.3 Chronic Pancreatitis

2.30.2.1 Abdominal or Back pain

2.30.2.2 Abdominal Mass

2.30.2.3 Abdominal tenderness

2.30.2.4 Ultrasound nondiagnostic

2.30.2.5 Worsening under treatment

2.31.1.1 Elevated amylase or lipase

2.32.1.1.1 Lower abdominal pain

2.32.1.1.2 Menstrual disturbance

2.32.1.1.3 Cervical and adnexal tenderness

2.32.1.2.1 Fever

2.32.1.2.2 Leukocytosis

2.32.1.2.3 Purulent cervical discharge

2.33.1 Obtain history of prior studies, send for physician review

2.34.1 Elevated catecholamines

2.34.2 Fractionated serum metanephrines > 3-4 times normal

2.34.3 Elevated 24 hour urinary total metanephrine

2.34.4 Elevated vanellylmandelic acid (VMA)

2.34.5 Hypertension not responding to medical therapy

2.35.1 Pelvic pain

2.35.2 Fever or chills

2.35.3 Leukocytosis

2.35.4 Pelvic mass on physical examination or ultrasound

2.35.5 Purulent cervical or vaginal discharge

2.35.6 Tenderness, pelvic, adnexal, or cervical

2.36 Preoperative for Transcatheter Aortic Valve Replacement (TAVR)

2.37.1.1 Suspect perinephric abscess

2.37.1.2.1 Nondiagnostic Renal Ultrasound

2.38.1 Flank pain radiating to the groin

2.38.2 Hematuria

2.38.3 History of prior stones

2.38.4 Hydronephrosis on other imaging

2.39 Small Bowel Tumor (CT Enterography)

2.40.1.1 Diarrhea

2.40.1.2 Pain

2.40.1.3 Tenesmus

2.41.1 Flank pain radiating to the groin

2.41.2 Hematuria

2.41.3 History of prior stones

2.41.4 Hydronephrosis on other imaging

2.42.1 Incontinence

2.42.2 Urinary frequency, urgency, burning on urination, dysuria

2.42.3 Dribbling, dyspareunia

3.1.1 Bowel Obstruction suspected

3.1.2 Severe pain developing over a few hours (acute abdomen)

3.2.1 Severe pain developing over a few hours (acute abdomen); (URGENT, approval should be issued without delay)

3.2.2.1 Fever

3.2.2.2 Leukocytosis

3.2.2.3 Mass

3.3.1.1 Severe pain developing over a few hours (acute abdomen); (URGENT, approval should be issued without delay)

3.3.2.1 Suspect small bowel obstruction

3.3.3.1 Suspect small bowel obstruction

3.4.1 Collapse, impending

3.4.2 Ruptured aneurysm suspected

3.5.1 Abscess, Appendicitis, Diverticulitis or other infection suspected

3.5.2 Persistent abdominal pain

3.6.1 Abscess, Appendicitis, Diverticulitis or other infection suspected

3.6.2 Persistent abdominal pain

3.6.3 Fever

3.6.4 Leukocytosis

3.6.5 Mass

3.7.1 Ventral Hernia (CT Abdomen)

3.7.2 Inguinal or Femoral Hernia (CT Pelvis)

3.9.1 Gradual onset of radicular pain and weakness

3.10.1.1 Nondiagnostic Ultrasound exam or X-ray

3.10.2.1.1 Must have a nondiagnostic Pelvic ultrasound prior to CT or MRI

3.10.2.1.2 Should be evaluated by MRI if ultrasound is nondiagnostic (send for physician review if no contraindication to MRI is described such as pacemaker)

3.11.1 Abscess, Appendicitis, Diverticulitis or other infection suspected

3.11.2 Abdominal pain

3.11.3 Fever

3.11.4 Leukocytosis

3.11.5 Mass

3.12.1 Abscess, Appendicitis, Diverticulitis or other infection suspected

3.12.2 Persistent abdominal or pelvic pain

3.12.3 Fever

3.12.4 Leukocytosis

3.12.5 Mass

3.13 Rovsing’s Sign (sign of appendicitis- touching the left lower quadrant causes increased pain in the right lower quadrant)

3.14.1 Abscess, Appendicitis, Diverticulitis or other infection suspected

3.14.2 Abdominal pain

3.14.3 Fever

3.14.4 Leukocytosis

3.14.5 Mass

3.15.1 Left upper quadrant pain

3.15.2 Recent trauma and suspect rupture

3.16.1 New finding

3.16.2 Condition worsening, new symptoms or findings

3.16.3.1 Aortic diameter 3.0 – 4.0 cm follow up once per year

3.16.3.2 Aortic diameter > 4.0 cm, follow up every 6 months

4.1 Abdominal Aortic Aneurysm on prior imaging

4.2.1.1.1 No change in size or < 1cm increase in size, then no further imaging

4.2.1.1.2 Enlarging (>1cm increase in size in one year), repeat CT

4.2.2.1.1 No change in size or < 1cm increase in size, repeat 6-12 months

4.2.2.1.2 Enlarging (>1cm increase in size in one year), no repeat imaging (see NCCN guidelines)

4.3.1 Hypertension that is drug resistant (need for >3 drugs)

4.3.2 Spontaneous (<3.5 mEq/L) or severe diuretic-induced (<3mEq/L) hypokalemia

4.3.3 Plasma aldosterone (ng/dL) to rennin ratio >10

4.3.4 24 hour urinary aldosterone excretion test >14μg/day

4.4.1 Abdominal pain

4.5.1.1 Malignant cytology

4.5.1.2 Low SAAG and high protein level

4.5.2.1 Internal echoes within the ascites

4.5.2.2 Loculated ascites

4.5.2.3 Tethered bowel loops along the posterior abdominal wall or other organs

4.6 Bilirubin elevated (CT ABDOMEN ONLY)

4.7.1 Elevated catecholamines

4.7.2 Fractionated serum metanephrines > 3-4 times normal

4.7.3 Elevated 24 hour urinary total metanephrine

4.7.4 Elevated vanellylmandelic acid (VMA)

4.7.5 Hypertension not responding to medical therapy

4.8.1 MRCP preferred study (send for physician review)

4.9.1.1.1 < 1 cm on ultrasound, image every 3-6 months for 2 years

4.9.1.1.2 1-2 cm, image every 3 months if stable in size

4.9.1.1.3 > 2 cm, biopsy and if nondiagnostic, repeat imaging if stable

4.9.1.2 Rising AFP with negative ultrasound

4.9.1.3 CT or MRI did not find a mass and rising AFP, repeat imaging every 3 months until a mass is confirmed

4.9.2 Planned TIPS (transjugular intrahepatic portosystemic shunt – relatively noninvasive procedure for portal hypertension)

4.10 Fracture seen on other imaging

4.11 Free air on other imaging (pneumoperitoneum)

4.12.1 Not associated with a simple urinary tract infection

4.12.2 Persists despite treatment of urinary tract infection

4.13.1 Prior to transplant

4.13.2.1.1 < 1 cm on ultrasound, image every 3-6 months for 2 years

4.13.2.1.2 1-2 cm, image every 3 months if stable in size

4.13.2.1.3 > 2 cm, biopsy and if nondiagnostic, repeat imaging if stable

4.13.2.2 Rising AFP with negative ultrasound

4.13.2.3 CT or MRI did not find a mass and rising AFP, repeat imaging every 3 months until a mass is confirmed

4.14.1 Hematuria

4.14.2 Flank pain radiating to the groin

4.14.3 History of prior stones

4.14.4 Recurrent urinary tract infections

4.14.5 Suspect obstructing lesion

4.15.1 Fever

4.15.2 Abscess, Appendicitis, Diverticulitis or other infection suspected

4.15.3 Abdominal or pelvic pain

4.16 Lipase elevated (CT ABDOMEN ONLY)

4.17.1 Direct bilirubin >0.2

4.17.2 Total bilirubin >1.9

4.17.3 Alkaline phosphatase >147 IU/L

4.17.4 Gamma GT or GGT >51 IU/L

4.17.5 AST >40 IU/L

4.17.6 ALT >56 IU/L

4.18.1 Liver mass/nodule/lesion seen on ultrasound and finding was indeterminate (CT or MRI was recommended)

4.18.2.1 Follow up every 3 months if mass not characterized previously as benign hemangioma or cyst

4.19.1.1 Cyst confirmed on prior imaging to be Bosniak class I cyst (simple cyst) or Bosniak class II cyst (<1 mm septations, fine calcifications within the septum or wall, <3 cm in diameter, or hyperdense cyst) – no further imaging is indicated

4.20.1.1 Pelvic mass in a female must have a nondiagnostic ultrasound first and should then be evaluated by MRI (send for physician review if no contraindication to MRI is described such as pacemaker)

4.21.1 Elevated catecholamines

4.21.2 Fractionated serum metanephrines > 3-4 times normal

4.21.3 Elevated 24 hour urinary total metanephrine

4.21.4 Elevated vanellylmandelic acid (VMA)

4.21.5 Hypertension not responding to medical therapy

4.22.1 Pancreatic mass on recent imaging and request for “Pancreatic Protocol”

4.22.2 Prior imaging with dilatation of the bile duct and/or pancreatic duct (US, ERCP, MRCP)

4.23.1 Left upper quadrant pain

4.23.2 Recent trauma and suspect rupture

4.24.1 Elevated catecholamines

4.24.2 Fractionated serum metanephrines > 3-4 times normal

4.24.3 Elevated 24 hour urinary total metanephrine

4.24.4 Elevated vanellylmandelic acid (VMA)

4.24.5 Hypertension not responding to medical therapy

5.1.1.1 2.5-2.9 cm every 5 years

5.1.1.2 3.0-3.4 cm every 3 years

5.1.1.3 3.5-3.9 cm every year

5.1.1.4 4.0-4.4 cm every year

5.1.1.5 4.5-4.9 cm every 6 months

5.1.1.6 5.0-5.5 cm every 3-6 months

5.1.2 New onset of pain

5.1.3.1 1 month after repair

5.1.3.2 3 months after repair

5.1.3.3 6 months after repair

5.1.3.4 Annually after repair

5.1.3.5 Suspicion of endoleak

5.1.3.6 New symptoms after repair

5.1.4 Planning for endovascular or surgical repair of documented aortic aneurysm

5.2.1 Aneurysm of any other intra-abdominal artery detected on other imaging

5.3.1.1 Condition unimproved or worsening while on treatment

5.3.1.2 Routine follow-up study after treatment, including evaluation for removal of drain

5.3.1.3 Follow up after percutaneous drainage of intra-abdominal, retroperitoneal or pelvic abscess

5.4.1.1 1 month after repair

5.4.1.2 3 months after repair

5.4.1.3 6 months after repair

5.4.1.4 12 months after repair

5.4.1.5 Annually after 12 months

5.4.2 New symptoms after repair

5.5.1.1 Malignant cytology

5.5.1.2 Low SAAG and high protein level

5.5.2.1 Internal echoes within the ascites

5.5.2.2 Loculated ascites

5.5.2.3 Tethered bowel loops along the posterior abdominal wall or other organs

5.6.1 Initial Staging

5.6.2 Interval follow up (surveillance- refer to Oncology Routines)

5.6.3 Restaging during treatment

5.6.4 Evaluate response to treatment

5.6.5 Treatment planning for Radiation Therapy

5.6.6 Worsening clinical picture

5.7.1.1.1 < 1 cm on ultrasound, image every 3-6 months for 2 years

5.7.1.1.2 1-2 cm, image every 3 months if stable in size

5.7.1.1.3 > 2 cm, biopsy and if nondiagnostic, repeat imaging if stable

4.7.1.2 Rising AFP with negative ultrasound

5.7.1.3 CT or MRI did not find a mass and rising AFP, repeat imaging every 3 months until a mass is confirmed

5.7.2 Planned TIPS (transjugular intrahepatic portosystemic shunt – relatively noninvasive procedure for portal hypertension)

5.8.1 Mass on abdominal, pelvic or rectal exam

5.8.2 Fever

5.8.3 Leukocytosis

5.8.4 Abdominal pain

5.8.5 Guarding

5.8.6 Rebound tenderness

5.8.7 Weight loss

5.8.8.1 Condition unimproved or worsening after treatment (drainage, antibiotics)

5.8.8.2 Condition unimproved or worsening after IV antibiotics for >1 week

5.8.8.3 Routine follow-up study after treatment, including evaluation for removal of drain

5.8.9 Fistula

5.8.10 Small bowel obstruction

5.8.11 Perianal fistula

5.8.12 Stricture or stenosis

5.8.13 Any evidence of clinical deterioration while on steroids or immunosuppressives

5.9.1 Prior to transplant

5.9.2.1.1 < 1 cm on ultrasound, image every 3-6 months for 2 years

5.9.2.1.2 1-2 cm, image every 3 months if stable in size

5.9.2.1.3 > 2 cm, biopsy and if nondiagnostic, repeat imaging if stable

5.9.2.2 Rising AFP with negative ultrasound

5.9.2.3 CT or MRI did not find a mass and rising AFP, repeat imaging every 3 months until a mass is confirmed

5.10.1 Liver mass/nodule/lesion seen on ultrasound and finding was indeterminate (CT or MRI was recommended)

5.10.2.1 Follow up every 3 months if mass not characterized previously as benign hemangioma or cyst

5.11.1.1 Surveillance (refer to Oncology Routines)

5.11.1.2 Change in condition (worsening clinical situation), suspect worsening metastatic disease

5.11.2.1.1 Ascites

5.11.2.1.2 Bowel obstruction

5.11.2.1.3 Change in bladder or bowel habits

5.11.2.1.4 Hematuria

5.11.2.1.5 Hydronephrosis

5.11.2.1.6 New abdominal or pelvic mass

5.11.2.1.7 Abdominal or pelvic pain

5.11.2.1.8 Rectal or abnormal vaginal bleeding

5.12.1 Interval follow up during and after treatment

5.12.2 Preoperative evaluation

5.12.3 Worsening clinical situation

5.13.1 Follow up immediately following surgery

5.13.2 Following completion of chemotherapy

5.13.3 Every 3-6 months for 2 years

5.13.4 Annually after 2 years

5.14.1 Hemodynamic instability

5.14.2 Falling hematocrit

5.14.3 Falling blood pressure

5.14.4 Fever

5.14.5 Leukocytosis

5.14.6 Leukopenia

5.14.7 Retroperitoneal air on prior CT

5.14.8 Positive blood culture

5.14.9 Signs of peritonitis (rebound, guarding or tenderness)

5.14.10 Poor oxygen saturation, signs of ARDS (adult respiratory distress syndrome)

5.14.11 Signs of renal failure (rising BUN and creatinine)

5.15.1 Periodic evaluation for change in size

5.15.2.1 Recurrent abdominal pain

5.15.2.2 Rising amylase or lipase

5.15.2.3 Fever

5.16.1 History of recurrent pancreatitis

5.16.2 Abdominal pain

5.16.3 No definitive diagnosis with Ultrasound or Endoscopic Ultrasound

5.17.1.1 3-12 months after resection up to 1 year

5.17.1.2 6-12 months for 2nd and 3rd years

5.17.1.3 Annually for years 4-10

5.17.1.4 Rising blood pressure or serum markers (metanephrines, urine VMA)

5.18.1 Initial staging

5.18.2.1 Rising PSA on 2 or more tests

5.18.2.2 Detectable PSA immediately after radical prostatectomy

5.18.3.1 Rising PSA

5.18.3.2 Positive digital rectal examination

5.18.4.1 Rising PSA

5.18.5 Repeat prostate biopsy suggests disease progression

5.19.1 Acute abdominal or pelvic pain

5.19.2 Fever

5.19.3 Leukocytosis

5.19.4 Rebound tenderness

5.19.5 Falling Blood Pressure

5.19.6 Falling Hematocrit

5.19.7 Shock

5.19.8 Follow up after percutaneous drainage of intra-abdominal, retroperitoneal or pelvic abscess

5.20 Preoperative for Transcatheter Aortic Valve Replacement (TAVR)

5.21.1 Initial evaluation if stable and if not already done in the emergency department

5.21.2 Hematuria

5.21.3.1 Periodic assessment

5.21.3.2 New or worsening symptoms or findings

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