Sonography of GIT
Sonography of GIT
Sonography of GIT
Sonography of the
Gastrointestinal Tract
S
onography is the first imaging study performed in
patients with abdominal pain in developing coun-
tries, where access to expensive tests such as com-
puted tomography (CT) is limited, and the body
mass index of the population is fairly low, allowing a rea-
sonable view of the gastrointestinal (GI) tract on sonogra-
phy. An awareness of the sonographic appearance of
diseases of the GI tract is essential, predominantly in
acute abdomen cases. This presentation provides an
Abbreviations overview of the sonographic manifestations of various GI
CT, computed tomography; GI, gastrointestinal diseases.
© 2006 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2006; 25:87–97 • 0278-4297/06/$3.50
Sonography of the Gastrointestinal Tract
used is patients thought to have vascular etiolo- Sonographic Appearance of the Small and
gies. The patients ranged in age from 8 to 63 years, Large Bowel
and the weight of the patients ranged from 20 to The appearance of the small bowel on sonogra-
180 lb (mean, 120 lb). phy depends not only on the structure of the
individual segment but also, more importantly,
Results and Discussion on its contents and degree of distension. The
bowel may be collapsed, containing only a small
Sonographic Appearance of the Normal amount of mucus (mucus pattern; Figure 3A) or
Bowel may contain fluid or gas (Figure 3B).4 The mucus
The normal intestinal wall is seen as a multilay- pattern is seen as a target appearance with a
ered area with hyperechoic bowel content at the highly reflective core of mucus. The fluid pattern
center. Five distinct layers can be depicted on gives a tubular appearance on a longitudinal sec-
sonography: an inner hyperechoic layer, which tion and a rounded pattern on a cross section.
is the interface between the mucosa and the The jejunum has valvulae conniventes, which
bowel contents; a second hypoechoic layer, give a ladder pattern, and the ileum has smooth,
which is the deep mucosa; a third hyperechoic featureless walls. The site of the involved bowel
layer, which is the submucosa; a fourth hypoe- must also be inferred from the location of the
choic layer, which is the muscle proper; and a bowel loop. The large bowel has a similar appear-
last outer hyperechoic layer, which is the serosa ance; however, it can be distinguished by the
and the serosal fat (Figure 1).1 location in the paracolic regions and the pres-
ence of haustra (Figure 4).
Sonographic Appearance of the Stomach
The normal stomach wall measures 3 to 5 mm Sonography of Inflammatory Bowel Diseases
(Figure 2); however, wall thickness up to 7 mm is
considered within normal limits because ade- Crohn Disease
quate distension is difficult to achieve on con- The classic sonographic feature of Crohn disease
ventional sonography.2 Thickening can be due is the “target” sign, which is an anechoic rim of
to neoplastic or inflammatory causes, and thickened bowel with central echogenicity due to
thickening of greater than 1 cm is generally con- the bowel contents. The transmural inflammation
sidered to be due to malignancy. Visualization
of the stomach can be improved by using a Figure 2. Sonographic appearance of the normal stomach
water load.3 (STM) shown on a sagittal section in the epigastrium.
B
Figure 3. Sonographic appearance of the normal small bowel.
A, Mucus pattern (note the prominent mucosal folds suggesting
that this is the jejunum) shown on a transverse image through
the mid abdomen. B, Gas pattern shown on a sagittal image
through the mid abdomen.
A
Ulcerative Colitis
Ulcerative colitis is always limited to the colon,
which is continuous, and more or less extends
from the rectum to the upper colon. on sonogra-
phy, ulcerative colitis is seen as a continuous
thickening of the colonic wall. The mural stratifi-
cation is preserved because of the superficial
pattern of involvement, which also leads to
mucosal ulceration and fibrosis, giving a lead
pipe appearance (Figure 6). Pseudopolyps are
seen as small echogenic nodules visible at the
surface of the mucosa.8
Tuberculous Ileocolitis
Sonography is very useful for imaging abdominal
tuberculosis. The following features may be seen,
A B
Figure 5. Crohn disease: circumferential thickening of the wall. A, Transverse sonographic image through the right lower quadrant
(arrow). B, Corresponding CT image (arrow).
Small-Bowel Tumors
The small bowel is more commonly affected by
lymphoma than the large bowel.13,14 The appear-
ance of small-bowel involvement in primary and
A
Figure 7. Abdominal tuberculosis. A, Ileocecal region with mild
wall thickening in the terminal ileum (arrows) shown on a trans-
verse image through the right lower quadrant. B, Enlarged
paramesenteric lymph nodes shown on a transverse image C
through the right lower quadrant. C, “Dry” type with mesen-
teric thickening (arrows) shown on a transverse image through
the mid abdomen. D, “Wet” type with mesenteric thickening
(arrow) along the surface of the bowel (arrowhead) shown on
a sagittal image through the left lower quadrant.
A B
Figure 8. Vasculitis: sagittal images through the right mid abdomen showing an abnormally thickened small-bowel loop (A, arrows)
with increased vascularity (B) in a patient with known systemic lupus erythematosus.
increased. Sonographic features associated with or fistula formation to the bladder, vagina, skin, or
perforation are loculated pericecal fluid, phleg- other bowel loops. On sonography, segmental
mon, abscesses, and prominent pericecal fat concentric thickening of the colon is seen.
(Figure 13, A–C).18 The accuracy of sonography is Inflamed diverticula appear as bright echogenic
92%; sensitivity, 83%; and specificity, 95%. The foci with acoustic shadowing or a ring-down arti-
positive predictive value is 86%, and the negative fact within or beyond the thickened gut wall.
predictive value is 94%, as suggested by a study in Peridiverticular abscess formation is seen as locu-
a community hospital.19 lated fluid collections in an intramural pericolonic
or remote location. Intramural sinus tracts appear
Diverticulitis as high-amplitude linear echoes often with a ring-
Diverticula are multiple and most commonly down artifact within the gut wall. Fistulas appear
located in the sigmoid and descending colon. as linear tracts that extend from the involved seg-
Complications of diverticulitis include macroper- ments of the gut to the bladder, vagina, or adjacent
foration or microperforation and localized abscess loops (Figure 14, A and B).20,21
Figure 9. Carcinoma of the stomach: sonographic images showing a localized large mass in the antrum of the fluid filled stomach
(A), which proved to be a large leiomyoma, and diffuse thickening of the stomach wall in the linitis plastica on a transverse image
through the epigastric region (B).
A B
Intussusception
Intussusception is commonly seen in children as
ileocolic or jejunojejunal intussusception and
sometimes associated with a lead point in the
form of a tumor or hypertrophied Peyer patches.
In adults, intussusception is commonly associat-
ed with a lead point in the form of a tumor. The
sonographic appearance of concentric rings in
B
the transverse section is pathognomonic for
intussuception.22–24 Long axis scans reveal the Figure 11. Carcinoma of the colon: panoramic sonographic
views showing circumferential thickening (A, arrowheads) of
“hay fork” or “trident” sign, representing the the ascending colon with hyperechoic areas in the wall suggest-
appearances of an intussusceptum and intus- ing ulceration of the mucosa and a localized hypoechoic mass
suscepiens (Figure 15, A and B). with an irregular shape (B, arrows). UB indicates urinary bladder.
Midgut Malrotation
It predisposes to bowel obstruction and infarc-
tion. On sonography, an abnormal relationship Figure 12. Infantile hypertrophic pyloric stenosis: transverse
between the superior mesenteric vein and supe- image through the epigastric region showing a thickened pylorus
rior mesenteric artery is suggestive of this diag- with wall thickness greater than 4 mm and length greater than
14 mm, supporting diagnosis of infantile hypertrophic pyloric
nosis. On a transverse sonogram, reversal of the stenosis.
normal relationship between the mesenteric
vessels is seen; the superior mesenteric vein is on
the ventral left aspect of the superior mesenteric
artery (Figure 16, A and B).25,26
Colitis
Infection is a common cause of colitis. Cyto-
megalovirus is the most commonly associated
pathogen in colitis in post-transplant patients.
Other causes for colitis include ischemic factors,
parasites, and radiation. Colitis due to these
causes could also potentially be seen on sonog-
raphy. Sonographic findings include long seg-
B
Figure 13. Acute appendicitis. A and B, Sagittal images in the
right lower quadrant showing an enlarged, thickened appendix
(A) with increased vascularity on color Doppler imaging (B).
C, Periappendiceal abscess (ABSC) as a common complication of
acute appendicitis shown on a transverse view through the right
A
lower quadrant. Note that the omentum appears abnormally
echogenic because of the periappendiceal inflammation.
A
Figure 15. Intussusception: sonographic images through the
mid abdomen showing the concentric appearance on a trans-
verse section through an intussusception (A, arrows) and the
hay fork appearance on a longitudinal section (B). Black arrows
indicate intussuscipiens; and white arrows, intussusceptum.
Figure 16. Midgut malrotation: transverse sonographic images through the mid abdomen showing the “whirlpool” sign (A), which
is the twisting of the small-bowel loops, and abnormal relationship between the superior mesenteric vein (V) and artery (A) with the
associated twisting of the vessels (B, arrowhead).
A B
A B
Figure 17. Colitis. A, Transverse sonographic image through the right lower quadrant (RLQ) showing abnormal circumferential thick-
ening of the colon. B, Corresponding CT image in a patient with pseudomembranous colitis.