Ultrasound imaging of Bowel pathology Technique and Keys to diagnosis in the Acute Abdomen

1. Dr Aftab Qadir

2. Ultrasound imaging of Bowel
pathology
Technique and Keys to diagnosis in the Acute Abdomen
http://www.ajronline.org/doi/full/10.2214/AJR.11.6594
Maturen et al.
Citation: American Journal of Roentgenology. 2011;197:
1067-W1075.

3. Outline
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Objective
CT abdomen
Normal “Gut signature”
Mural Thickening
Mesentery and Omentum
Doppler Vascularity
Dynamic Imaging
Focused Scanning
Transvaginal Imaging
Conclusion

4. Objective
 Normal sonographic appearance of bowel
 Pathological
 Ultrasound technique

5. CT abdomen
 CT is emerging as the primary modality for evaluation
for the acute abdomen
 Rapid evaluation of bowel and mesentry
 Definitive assesment of abdominal,pelvic organs and
major vessels

6. 1.Normal “Gut signature”
 Bowel has typical multilamellated sonographic
appearance
 Alternating hyperechoic and hypoechoic lines
representing the different layers of the gastrointestinal
wall
 The different layers are:
a) mucosa - echogenic
b) muscularis mucosa - hypoechoic
c) submucosa - echogenic, thickest
d) muscularis propria - hypoechoic
e) serosa - echogenic

7. Image of normal bowel in healthy 36-year-old woman. normal gastric antrum between liver
(liv) and pancreas (panc) show physiologic lamellation of bowel wall, with five alternating
concentric hyperechoic and hypoechoic bands. Innermost hyperechoic layer (arrowheads) is
mucosal surface, followed by hypoechoic muscularis mucosa, hyperechoic submucosa,
hypoechoic muscularis propria, and outermost hyperechoic serosal surface (arrows). Muscle
is usually hypoechoic and fat is usually hyperechoic, but disease states can alter these
normal appearances.

8. 34-year-old healthy woman with normal intestine

9.  This pattern allows to distinguish bowel from adjacent
structures
 Disruption of the pattern aids the diagnosis of bowel
pathology
 Masses may transgress the layers
 Edema may expand certain layers or obscure the
margins

10. Mural Thickening
 Bowel wall thickening may be the most common and
reliable sign of bowel disease
 Wall thickening is more typically concentric in benign
and eccentric in malignant conditions

11. 6-year-old boy with Crohn disease. Gray-scale ultrasound image shows dramatic
circumferential wall thickening of two adjacent small-bowel loops (arrowheads). Note also
increased echogenicity of adjacent mesenteric fat (F), indicating inflammation.

12. 17-year-old girl with Crohn disease. Power Doppler image of terminal ileum (arrowheads)
shows wall thickening and mural hyperemia, indicating active inflammation. Note also
enlarged adjacent mesenteric lymph node (arrow) surrounded by echogenic fat.

13. 52-year-old woman with infectious colitis. Gray-scale ultrasound image shows
concentric wall thickening and blurring of normal mural stratification
(arrowheads) in colon. Power Doppler image (inset) reveals marked hyperemia
(arrow) in affected segment.

14. 64-year-old woman with locally advanced colon cancer presenting as
palpable mass in right upper quadrant.A, Transverse ultrasound image
colonic wall thickening (arrowheads).

15. Mesentery and Omentum
 Mesenteric and omental fat are generally
inconspicuous except when inflamed.
 Abnormally echogenic fat may be the most
conspicuous finding in bowel disease; this
extraluminal finding may indicate an area of bowel
that deserves closer attention. “Creeping fat”
characteristic of inflammatory bowel.

16. 32-year-old man with perforated, gangrenous appendicitis.B, Power Doppler image in
same area shows punctuate areas of vascularity adjacent to (arrowheads) but none within
appendix. Nbnormal echogenicity of adjacent inflamed mesenteric fat (arrow).

17. Doppler Vascularity
 Color and power Doppler imaging supplement the
information provided by gray-scale imaging
 increased vascularity visualized in a number of
inflammatory and infectious diseases. Hyperemia, both of
bowel wall and adjacent mesentery, is a notable marker of
disease activity in inflammatory bowel disease.
 diminished vascularity is a specific, although probably not
sensitive, sign of ischemia

18. 17-year-old girl with Crohn disease. Power Doppler image of terminal ileum (arrowheads)
shows wall thickening and mural hyperemia, indicating active inflammation. Note also
enlarged adjacent mesenteric lymph node (arrow) surrounded by echogenic fat.

19. 21-year-old woman with Crohn's disease. Transverse
sonogram shows thick-walled cecum (C). Doppler sonogram
showed increased transmural perfusion consistent with
Crohn's disease.

20. 45-year-old man with acute appendicitis. Noncompressible tubular structure in
right lower quadrant exhibits marked mural hypervascularity (arrowhead) on color
Doppler image, solidifying diagnosis of acute appendicitis.

21. Dynamic Imaging
 Real-time imaging is a unique strength of ultrasound
 Dynamic information about bowel motility,
compressibility, and changes in position
 Cine clips

22. 1. Peristalsis
2. Compression
3. Valsalva Maneuver

23. Peristalsis
 Real-time observation and a sense of the normal
appearance of peristalsis are essential to making this
observation.
 A variety of causes may impair peristalsis, including
small-bowel obstruction, ischemia, enteritis, and
infiltrative processes

24. Compression
 Healthy bowel can be compressed and shifted by
transducer pressure. Direct pressure over an area of
abnormality may reveal a lack of normal compressibility in
appendicitis, intussusception
 The graded-compression technique enables isolation of
abnormal bowel loops by pushing away adjacent mobile
bowel.
 Correlation of compressibility with wall thickness and
other imaging features will enable assessment of the
significance.
 The efficacy of compression as a diagnostic indicator may
be limited in obese adults.

25. 20-year-old man with acute nonperforating appendicitis. Long-axis
(A) and transverse (B) sonograms of appendix typically situated in
right iliac fossa show enlarged (9.6 mm) appendix (long arrows) and
prominent hyperechoic inflamed periappendiceal fat (short arrows).

26. 5-month-old girl with massive ileocolic intussusception causing ischemia of distal ileum
and right hemicolon.Gray-scale ultrasound image reveals targetoid noncompressible
mass (arrowheads), constituting intussusception extending from right lower quadrant to
left lower quadrant. Note marked wall thickening and loss of stratification, particularly
in intussusceptum (outer loop).

27. Pneumatosis intestinalis
Color Doppler image shows some vascularity (arrowheads) in tissue surrounding
mass but none within loops of intussusceptum. Punctuate

29. Valsalva Maneuver
 Hernias of bowel, mesentery, and omentum may preset as
abdominal wall or groin masses, and direct observation while the
patient coughs or “bears down” to increase intraabdominal
pressure
 Such maneuvers may reveal an intermittent hernia, show
contiguity of a mass with the intraperitoneal space, allow better
depiction of the hernia sac or abdominal wall defect, and show
reducibility . High-frequency linear transducers (≥ 7 MHz) are
most appropriate for this evaluation.

30. 57-year-old man with periumbilical hernia.Transverse midline ultrasound image shows
tubular structure (arrowheads) protruding toward skin surface just medial to rectus
muscle (R).

31. 57-year-old man with periumbilical hernia.Ultrasound image shows
bulge changes and enlarges (arrowheads) with Valsalva maneuver,
compatible with hernia. Some peristalsis was appreciable in real time,
confirming bowel content in hernia sac.

32. Focused Scanning
 Direct evaluating the area of clinical concern may be
extremely useful, particularly if the patient is able to
localize the symptoms.
 For superficial lesions, high-frequency linear transducers
may be most appropriate (7–10 MHz), but their use should
be supplemented by lower-frequency curved-array imaging
(3–8 MHz) to evaluate the complete deep extent of lesions.

33.  when a bowel abnormality is initially identified during
routine abdominal scanning at 3–8 MHz, highfrequency linear transducers can be used secondarily
to provide detailed assessment of bowel wall and
mesentery.
 a complete examination should usually include both
probe types.

34. Transvaginal Imaging
 Transvaginal imaging is a routine part of pelvic imaging in
women and may also contribute to bowel assessment
 Deeply positioned appendixes may be best visualized
transvaginally
 other pathologies, including terminal ileitis, sigmoid or
rectal inflammation, and pelvic masses or abscesses, may
be optimally assessed in this fashion as well.

35. 21-year-old woman with pelvic inflammatory disease. Transvaginal ultrasound image
shows complex fluid compatible with pus (P) surrounding uterus (Ut). Adjacent smallbowel loop is dilated and thick-walled (arrowheads), reflecting reactive enteritis and
ileus. Note also increased echogenicity of pelvic and mesenteric fat (arrows), further
indicator of inflammation.

36. Factors which decrease the reliability of
sonographic evaluation
 operator dependent technique
 the presence of overlying bowel gas
 obesity of the patient.

37. Conclusion
 Given its widespread availability, relatively low cost,
and absence of ionizing radiation or need for contrast
materials, ultrasound has maintained an important
role in evaluation of the acute abdomen even during
the recent explosion of CT utilization
 Many sonographers and radiologists limit their focus
to the solid organs

38.  The pendulum of abdominal imaging may swing back
toward ultrasound.
 Awareness of normal and pathologic sonographic
appearances of bowel and attention to technique will
enable sonographers and radiologists to make optimal
use of this imaging modality because bowel findings
may be the key element of an otherwise negative
abdominal ultrasound examination.

39. Take-Away Information
1.Diagnostics in inflammatory bowel disease: Ultrasound
Deike Strobel, Ruediger S Goertz, and Thomas Bernatik
Article information
World J Gastroenterol. 2011 July 21; 17(27): 3192–3197.
Published online 2011 July 21. doi: 10.3748/wjg.v17.i27.3192
PMCID: PMC3158394
CONCLUSION
Transabdominal US is currently accepted as a clinically important first-line
imaging technique in IBD in initial diagnosis and during the clinical course of
the disease.

40. 2.Hypertrophic pyloric stenosis: tips and tricks for ultrasound
diagnosis
Sílvia Costa Dias, Sophie Swinson, [...], and Vasco Mendes
Article information
Insights Imaging. 2012 June; 3(3): 247–250.
Published online 2012 May 1. doi: 10.1007/s13244-012-0168-x
PMCID: PMC3369120
Conclusion
Pyloric US examination is a dynamic investigation, which should be performed in
a systematic way. The radiologist should be aware of the pitfalls of the
examination and how to overcome them. It is important to be familiar with the
normal and hypertrophied pyloric appearances, as this will provide a greater
diagnostic confidence, assisting in early diagnosis and improving the
management of infants with HPS.

41. 3.Transabdominal Sonography in Assessment of the Bowel in Adults
Siarhei Kuzmich1, David C. Howlett1, Allan Andi1, Dhiren Shah1 and Tatsiana
Kuzmich1 2
 OBJECTIVE. We describe the key sonographic features and technical aspects
of assessment of bowel disorders in adults.
 CONCLUSION. Initial imaging with transabdominal sonography in the
radiologic evaluation of bowel disease in adults often is reserved for patients
with equivocal historical, physical, and laboratory findings related to the
gastrointestinal tract. Because of technologic advances and accumulated
experience in interpretation of the images, sonography yields substantial
information about gastrointestinal disorders.
Read More: http://www.ajronline.org/doi/full/10.2214/AJR.07.3555

42. 4.Ultrasound diagnosis of intussusception: report of two cases.
Source
Medizinische Klinik 1 (Gastroenterologie, Endokrinologie und Diabetologie), St.
Vincentius-Kliniken gAG, Karlsruhe. peter.matheiowetz@vincentius-ka.de
Dtsch Med Wochenschr. 2010 Mar;135(12):563-6. doi: 10.1055/s-0030-1249211. Epub
2010 Mar 16.
CONCLUSIONS:
Intussusception is a possible cause of acute abdominal pain in adults.
Ultrasonography should be the initial diagnostic investigation. Transient
intussusceptions are seen in adults with celiac disease, in which case
nonoperative treatment is possible.

43. 5.Bowel Wall Thickening on Transabdominal
Sonography
Hans Peter Ledermann1, Norbert Börner2, Holger
Strunk3, Georg Bongartz1, Christoph Zollikofer4 and Gerd
Stuckmann4
More: http://www.ajronline.org/doi/full/10.2214/ajr.174.1.1740
107

44. 6.Accuracy of ultrasonography in the diagnosis of acute
appendicitis in adult patients: review of the literature
Fabio Pinto1*, Antonio Pinto2, Anna Russo3, Francesco Coppolino4, Renata
Bracale5, Paolo Fonio6, Luca Macarini7,Melchiorre Giganti8
The gold standard for the diagnosis of appendicitis still remains pathologic
confirmation after appendectomy. In the published literature, gradedcompression Ultrasound has shown an extremely variable diagnostic
accuracy in the diagnosis of acute appendicitis (sensitivity range from 44% to
100%; specificity range from 47% to 99% ). This is due to many reasons,
including lack of operator skill, increased bowel gas content,obesity, anatomic
variants, and limitations to explore patients with previous laparotomies.
Conclusions: Graded-compression Ultrasound still remains our first-line
method in patients referred with clinically suspected acute appendicitis:
nevertheless, due to variable diagnostic accuracy, individual skill is requested
not only to perform a successful exam, but also in order to triage those
equivocal cases that, subsequently, will have to undergo assessment by means
of Computed Tomography.

45.  Sonographic signs of hypertrophic pyloric stenosis?
 Sonographic signs of intussusception?
 Sonographic signs of bowel obstruction?
 Songraphic signs of acute appendicitis?
 Songraphic signs of IBD?

49. Discussion and queries

50. The Eyes Don't See What the Mind
Don't Know
Thanks