When non-contrast vs contrast?

Non-contrast: urolithiasis, suspected acute hemorrhage, stone follow-up. IV contrast: appendicitis, diverticulitis, mesenteric ischemia, staging, abscess. Portal venous phase is the standard for abdomen.

When prefer MRI over CT?

Focal liver lesion characterization (especially cirrhosis / LI-RADS), biliary tree (MRCP), deep endometriosis, complex pelvic lesion and pregnant patients.

Appendicitis — sensitivity?

Contrast-enhanced CT has > 95% sensitivity and > 95% specificity for acute appendicitis in adults — superior to US and clinical evaluation alone.

Report template — CT of abdomen upper without contraste

When to use

Abdominal CT is the method of choice for acute abdominal pain (appendicitis, diverticulitis, ischemia, perforation), complicated pancreatitis, urolithiasis (non-contrast), oncologic staging and stable abdominal trauma. For focal liver lesion characterization, hepatobiliary MRI is generally superior.

What to evaluate

Solid viscera: size, attenuation, focal lesions, enhancement.
Bowel: caliber, wall thickness, content, inflammatory signs.
Urinary tract: stones, hydronephrosis, filling defects.
Vessels: aorta, mesenteric, portal — caliber, thrombosis, occlusions.
Lymph nodes, ascites, free air, collections.

Interactive template

Fill the blanks0/0

Técnica: Obtidas imagens axiais por metodologia multislice, sem a injeção intravenosa do meio de contraste. Análise: - Transição toracoabdominal: bases pulmonares de aspecto preservado. - Fígado: não há lesões focais ou alterações difusas. - Vias biliares: não há dilatação das vias biliares intra ou extra-hepáticas. - Pâncreas: dimensões normais e atenuação preservada. Não há dilatação do ducto pancreático principal. - Baço: normal. - Rins: tópicos, de dimensões normais, sem cálculos ou hidronefrose. - Adrenais: sem nódulos. - Alças intestinais: alças do intestino delgado e grosso incluídas no estudo sem particularidades ao método. - Peritôneo e retroperitôneo: ausência de linfonodomegalias ou líquido livre. - Vasos: aorta, veia cava inferior e veia porta de calibre e morfologia habitual. - Partes moles e estruturas ósseas: sem alterações significativas. Comparação: Exames anteriores não disponíveis para a análise. Conclusão: Exame sem achados significativos.

Template in Brazilian Portuguese (clinical reporting language). Adapt to your service protocol. Not medical advice — the physician reviews, edits and signs.

How to use

Replace each [...] with the exam's measurement or descriptor.
Adapt the conclusion to your service protocol before signing.
Use the template as a starting point — not a replacement for physician review.
In Laudos.AI, dictate findings in natural speech and the AI structures text in this format for review.

Related classifications

Frequently asked

When non-contrast vs contrast?: Non-contrast: urolithiasis, suspected acute hemorrhage, stone follow-up. IV contrast: appendicitis, diverticulitis, mesenteric ischemia, staging, abscess. Portal venous phase is the standard for abdomen.
When prefer MRI over CT?: Focal liver lesion characterization (especially cirrhosis / LI-RADS), biliary tree (MRCP), deep endometriosis, complex pelvic lesion and pregnant patients.
Appendicitis — sensitivity?: Contrast-enhanced CT has > 95% sensitivity and > 95% specificity for acute appendicitis in adults — superior to US and clinical evaluation alone.

References

ACR Appropriateness Criteria — Right Lower Quadrant Pain.
Eisenhauer EA et al., Eur J Cancer 2009 (RECIST 1.1).