Variant 4.

Hospitalized patient with fever, elevated white blood cell count, and positive Murphy sign

Radiologic Procedure	Rating	Comments	Relative Radiation Level
Ultrasound abdomen	9		○
CT abdomen with contrast	7		☢ ☢ ☢
MRI abdomen without and with contrast	6	See statement regarding contrast in text under “Anticipated Exceptions.”	○
Cholescintigraphy	6	This is performed if ultrasound is inconclusive.	☢ ☢
Percutaneous cholecystostomy	6	This can be both diagnostic and therapeutic, particularly with intensive care unit patients. Consider using this for the nonoperative patient or if other causes of sepsis have been excluded. This usually requires imaging first. It is performed only in certain patients (elderly, immunocompromised, etc).	Varies
MRI abdomen without contrast	5		○
CT abdomen without contrast	4		☢ ☢ ☢
CT abdomen without and with contrast	3		☢ ☢ ☢ ☢

Note: Rating scale: 1, 2, and 3 = usually not appropriate; 4, 5, and 6 = may be appropriate; 7, 8, and 9 = usually appropriate.