Practice Guidelines

ACR Appropriateness Criteria for Acute Onset of Flank Pain with Suspicion of Stone Disease


Am Fam Physician. 2016 Oct 1;94(7):575-576.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Helical (spiral) noncontrast CT has high clinical accuracy, allowing for the precise measurement of a mass, as well as providing a clear depiction of where in the ureter a stone has become lodged.

• A low-dose CT radiation regimen should be used in place of conventional dosing when evaluating for renal or ureteral stones.

• Ultrasonography is the imaging tool of choice in pregnant patients.

From the AFP Editors

Imaging modalities used in the initial evaluation of acute flank pain provide physicians with the information necessary to diagnose and predict the outcome of abdominal conditions such as urinary tract stones. Because of the variety of radiologic options available for detecting suspected urolithiasis, and the different contexts that might influence their use, the American College of Radiology (ACR) has established appropriateness criteria to assist in the selection process. Procedures with a rating of 9 are considered most appropriate, and those with a rating of 1 least appropriate. These guidelines rate the suitability of computed tomography (CT), ultrasonography, radiography, and magnetic resonance imaging for patients who present with suspected stone disease, recurrent stone disease symptoms, or abdominal pain in pregnancy.



For more than two decades, helical (spiral) noncontrast CT of the abdomen and pelvis has been heavily relied on in the detection of suspected stone disease. It has 95% or higher sensitivity and specificity, allowing for the precise measurement of a mass, as well as providing a clear depiction of where in the ureter a stone has become lodged. The ACR assigned it an appropriateness rating of 8 (usually appropriate). Size and location of the stone are essential for determining the level of intervention required; smaller, more proximal stones are likely to pass spontaneously.

Patients who undergo noncontrast CT are exposed to a greater radiation dose than with other imaging tests,

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.

A collection of Practice Guidelines published in AFP is available at



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