Transabdominalultrasoundfor Bowelevaluation: Peter M. Rodgers,, Ratan Verma
Transabdominalultrasoundfor Bowelevaluation: Peter M. Rodgers,, Ratan Verma
Transabdominalultrasoundfor Bowelevaluation: Peter M. Rodgers,, Ratan Verma
B o w e l Ev a l u a t i o n
Peter M. Rodgers, FRCRa,*, Ratan Verma, FRCRb
KEYWORDS
Ultrasound Sonography Bowel Diverticulitis Appendicitis Crohns disease Strategy
KEY POINTS
Transabdominal ultrasound (TAUS) of the bowel has the potential to play a significant role in
imaging strategies directed at managing acute and elective gastrointestinal disorders and their
mimics.
However, this potential cannot be achieved without the systematic provision of adequate numbers
of specifically trained personnel to match the clinical need. Imaging in acute and elective scenarios
is most effective when the prevalence of the suspected conditions is high.
Provision of an appendicitis scanning service within limited hours or for a population largely expected not to have appendicitis or performed by operators who seldom identify a normal appendix,
is unlikely to perform to standards that justify continued provision of the service.
Similarly, TAUS for Crohns disease needs to be a strategically supported part of a multimodality
imaging service within a multidisciplinary inflammatory bowel disease team to achieve results justifying clinical confidence in referring clinicians and patients.
are rarely available outside office hours. US is notoriously operator-dependent, requiring not only
excellent general and specific technical training
and aptitude but also considerable experience of
a case-mix appropriate to the clinical differential
being considered.
US TECHNIQUE
In the authors practice, TAUS of the bowel begins
with a complete examination of the abdomen and
pelvis, including the solid and hollow extraintestinal
viscera. The complications of bowel disease often
extend to involve adjacent organs, the mesentery,
and peritoneal recesses (eg, subdiaphragmatic
and pelvic collections), or spread hematogenously,
particularly via the portal vein to the liver. Using
a lower frequency curvilinear probe, particular
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INTRODUCTION
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GRADED COMPRESSION
Puylaert4 introduced the term graded compression to describe the gradual progressive increase
in the pressure the operator applies to the probe
while making gentle sweeping movements. Done
carefully to avoid causing pain, this is an essential
technique in bowel scanning. Overlying soft tissues
are compressed, bringing the probe closer to the
bowel, gas is displaced from bowel loops to reveal
the posterior bowel wall, overlying bowel loops are
displaced from those beneath, and the compressibility and/or rigidity of normal and abnormal bowel
loops and mesenteric fat can be assessed.
Fig. 2. Normal left colon (short white arrows) compressed between rectus and psoas muscles with a high
frequency probe. Bowel wall layers clearly shown. IA,
Iliac Artery.
Box 1
Sonographic gut signature
hemorrhage, inflammation, tumor growth, or infiltration. Any of these may result in the classic US
feature of an hypoechoic circumferential thickening around a strong echogenic center (lumen),variously referred to as the target sign, ring sign,
or pseudokidney sign (Fig. 4).
BOWEL LUMEN
When the bowel wall is thickened, the bowel lumen
is usually narrowed or strictured. An uncommon
exception to this is aneurysmal dilatation in which
the lumen in the diseased segment enlarges. This
is most commonly seen in intestinal lymphoma.
Dilatation of the bowel lumen is seen proximal to
an obstructing lesion, where it may initially be
accompanied by increased peristalsis. Dilatation
with no peristalsis may be due to late-stage
obstruction or paralytic ileus (most commonly
seen after abdominal surgery).
EXTRAMURAL CHANGES
Bowel wall disease may extend out to involve adjacent loops or solid organs, or be the result of
external disease involving the bowel loop. Identification of peri-intestinal fluid, collections or
abscesses or fistulous tracks, and altered mesenteric fat are important features to characterize
processes and assess local complications.
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Fig. 3. Normal small bowel ultrasound. Graphic representation of a transverse US view of distal small bowel (A)
demonstrating the five layer structure (gut signature). Transverse US images of normal distal small bowel in contracted (B) and distended (C) states. Only the bright submucosa and dark muscularis propria are easily discernible.
(Adapted from Rodgers PM. Small intestine. In: Allan PL, Baxter GM, Weston MJ, eds. Clinical Ultrasound, 3rd ed.
Edinburgh: Churchill Livingstone, 2011; with permission.)
MESENTERIC LYMPHADENOPATHY
Lymph node size, shape (oval or round), echotexture (hyperechoic or hypoechoic, heterogeneous),
smooth or irregular surface, conglomeration or
matting, should be documented because these
may aid in narrowing the diagnosis.
ACUTE APPENDICITIS
Acute appendicitis is the most common indication
for urgent abdominal surgery and one of the most
common causes of acute abdominal pain. It is
more prevalent in older children and young adults.
Box 2
A useful checklist for TAUS bowel examinations
Bowel wall thickness
Altered gut signature
Bowel lumen
Bowel plasticity
peristalsis
and/or
mobility
and/or
Fig. 5. Long section of normal appendix; a thin, blindending tube with clear gut signature (white arrows)
compressed between rectus and psoas muscles.
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Fig. 6. Partial views of normal appendix. (A) Axial section showing normal gut signature (black arrowhead). (B)
Long oblique section showing appendix (white arrowheads) deep to an adjacent ileal loop (long white arrows).
Box 3
Sonographic criteria for appendicitis
Noncompressible blind-ending tube
Lumen distension (MOD >6 mm)
Wall thickness greater than 3 mm
Loss of gut signature
Hyperemia on Doppler scanning
Hyperechoic periappendiceal fat-thickening
Local transducer tenderness
Fig. 8. Acute appendicitis. (A) Long section distended (10 mm MOD), noncompressible appendix with tip appendicolith (long arrow). (B) Wall thinned with no gut signature indicating ischemic necrosis. Acute suppurative
appendicitis confirmed post-resection within 24 hours.
ACUTE DIVERTICULITIS
Acute colonic diverticulitis is a common reason for
acute hospital admission. Clinical differentiation
from nonspecific abdominal pain and a range of
acute abdominopelvic pathologic findings is
inexact (Table 2) and imaging is used in most
cases although 85% will recover with nonoperative
Fig. 9. Acute appendicitis. (A) Long section showing appendiceal wall thickening with gut signature intact. (B)
Axial section of thickened enlarged appendix tip with loss of signature and hyperemia on power Doppler.
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Table 1
Alternative diagnoses made by US in the
absence of acute appendicitis
PATHOGENESIS
Most colonic diverticula are false diverticula
containing no muscularis propria. The diverticula
wall consists of mucosa-submucosa blown out
through defects in the muscularis propria. These
occur at weak points in the colonic wall, generally
at the site of entry of a blood vessel. Diverticula are
most commonly seen in sigmoid colon where they
are often associated with other typical features of
Fig. 11. Perforated appendix. Low-frequency sonogram showing axial sections of the appendix surrounded by loculated fluid (white arrow heads)
contained by increased hyperechoic mesenteric fat
(stars).
Diagnosis
Frequency
17
14
9
6
5
4
3
3
3
3
1
1
1
1
1
1
1
Table 2
Alternative diagnosis in 47 of 175 patients
clinically suspected of having diverticulitis
Epiploic appendagitis
Ureterolithiasis
Urinary tract infection
Pelvic Inflammatory disease
Ischemic colitis
Infectious enterocolitis
Perforated carcinoma
Small bowel obstruction
Ulcerative colitis
Hemorrhagic ovarian cyst
Musculoskeletal pain
Appendicitis
Crohns disease
Nonspecific colitis
Small bowel infarction
Cholecystitis
8
6
4
4
3
3
3
2
2
2
2
2
1
1
1
1
diverticular disease (eg, muscularis propria thickening, shortening, and narrowing of the lumen).
Diverticula vary in size from tiny intramural and
transient phenomena to permanent protrusions
up to several centimeters in diameter, and rarely
much greater. The prevalence of diverticula
increases with age, affecting 50% of patients
over 70 years old.
Retention of fecal matter within a diverticulum
may produce mucosal abrasion resulting in infection or inflammation of the diverticulum wall (diverticulitis). The process may produce a focal
intramural inflammatory mass or abscess, infiltrate
along the bowel wall to produce an inflammatory
bowel segment, and perforate into sigmoid mesentery where the process is usually contained.
However, perforation can cause intraperitoneal
contamination that is associated with a much higher morbidity and mortality. The incidence of diverticulitis increases with the duration of diverticulosis.
SONOGRAPHIC FEATURES OF
DIVERTICULOSIS
Sonographic features of diverticulosis include
Diverticula appear as bright ears out with
the bowel wall with acoustic shadowing due
to the presence of gas or inspissated feces
A thinned diverticular wall may be demonstrated at higher probe frequencies with
a reduced gut signature due to the absence
of muscularis propria (Fig. 13).
The neck of a diverticulum may be identified
as an echogenic band traversing hypoechoic muscularis propria that is often
thickened.
CLINICAL FEATURES
Compared with patients with nonspecific abdominal pain, those with diverticulitis are more likely
to have subacute onset of pain (>1 hr), tenderness
to palpation only in the left lower quadrant, and
Fig. 13. Sigmoid diverticula. Two thin-walled, gasfilled, reduced gut signature outpouchings (long
arrows) through the thickened muscularis propria of
the sigmoid colon (short arrow).
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Fig. 14. Acute diverticulitis: pericolic abscess. Echopoor pericolic collection (short arrows) containing
central bright gas echo. Asymmetrical thickening of
muscularis propria (long arrow).
CROHNS DISEASE
Crohns disease (CD) is a lifelong inflammatory GI
condition of uncertain cause characterized by
episodes of remission and relapse. The inflammatory process may extend through all the bowel layers
and beyond, resulting in intraperitoneal disease and
involvement of adjacent bowel loops and/or organs.
CD may involve any part of the GI tract and may
involve multiple segments at the same or different
times. Large bowel, ileocolic, and terminal ileal
disease are most common patterns with the
terminal ileum being involved in up to 75% of
cases at presentation. Proximal small bowel CD
without terminal ileal involvement is seen in only
3% of cases.
Management depends on characterizing the
behavior of lesions into the subtypes inflammatory, stenosing, fistulating, and/or penetrating.
The disease course may be modified by medical
CLINICAL FEATURES OF CD
Patients with CD may present at any age but most
commonly present in their late teens and early
adulthood. Diarrhea of more than 6 weeks duration, abdominal pain, and weight loss are the
most common presenting symptoms. The young
patient with right iliac fossa pain and a mass may
easily be misdiagnosed as having acute appendicitis. Blood and/or mucus in the stool generally
indicate colonic involvement. Perianal fistulas are
present in 10% of patients at presentation.
FAT-WRAPPING
Transmural inflammation stimulates proliferation
of mesenteric or subserosal fat, which creeps
around the inflamed bowel segment, a distinguishing characteristic of transmural CD (Fig. 18).
VASCULAR CHANGES
Actively inflamed bowel segments have an
increased blood flow that may be demonstrated
with color Doppler or power Doppler imaging
(Fig. 19). Studies have shown this phenomenon
to be helpful in distinguishing active inflammatory
lesions from fibrotic strictures and in monitoring
response to medical therapies. The use of US
contrast media may further increase the
diagnostic confidence by quantifying this
phenomenon.41
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Fig. 18. (A and B) Ileocecal and sigmoid CD: the 24-year-old male presenting with RIF pain, blood mixed with stool
and raised inflammatory markers. (A) Transmural hypoechoic thickening of the terminal ileum with creeping fat
(arrowheads). (B) LIF axial image showing a thickened, contracted large bowel with hypoechoic disruptions of
the submucosa (short arrows). Subsequent colonoscopy was limited by Crohn stricture in the left colon.
LOCOREGIONAL LYMPHADENOPATHY
Active intestinal CD is usually accompanied by
lymphadenopathy in the mesentery.
LOCAL COMPLICATIONS OF CD
Transmural inflammation is a hallmark of CD,
resulting in the local complications of stricture,
abscess, and fistula. US is useful in detecting these
complications but, as with all imaging modalities,
may miss subtle enteroenteric fistulas.42
STRICTURE
Narrowing of the bowel lumen sufficient to
produce impaired intestinal function and obstructive symptoms may be seen both in active
Fig. 19. CD TI power Doppler: power Doppler indicates hyperemia with flow seen clearly in a vessel
running within the submucosa (short arrows).
Fig. 21. (A) CD enterocolic fistula: US. Angulated ileal (short arrow) and colon (long arrow) loops connected by
echo-poor fistula (arrow heads) with moving, bright, gas echoes in real-time. (B) CD enterocolic fistula: CT. Sameday CT scan confirms an inflammatory mass involving small and large bowel extending onto the posterior pelvic
brim. A tiny gas bubble marks the fistula.
Fig. 22. Non hodgkins lymphoma (NHL) jejunum. A 76-year-old male presenting with weight loss, abdominal
pain and vomiting. (A) Coronal CT image showing a greater than 10 cm segment of continuous thickening of
proximal small bowel (long arrow) with local lymphadenopathy (short arrow). Malignant or inflammatory differentials were considered and US was performed to characterize the lesion. (B) Long image from the middle of the
lesion shows low/mixed echo circumferential thickening (arrowheads) and bright gas in a deep ulcer (long
arrow). (C) Axial image showing preservation of the gut signature with mucosal and submucosal thickening
and blurring. Doppler showed vascular flow in the submucosa. At endoscopy the mixed features of raised edges
and complex ulcers left the diagnosis unclear. However, biopsy and subsequent resection showed enteropathyassociated T-cell lymphoma.
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SUMMARY
Fistula
In up to one-third of patients, penetrating fissures
can extend to create an abnormal communication
between the lumen of the diseased bowel
segment and adjacent bowel loops or any adjacent hollow organ (eg, uterus, bladder).
The communication between adherent bowel
loops may be difficult to identify and underestimated by all imaging modalities. At US fistula are
identified as irregular tubular hypoechoic tracks
(Fig. 21) and, occasionally, may demonstrate
small hyperreflective air bubbles within.43 However, the presence of adjacent indrawn, angulated
bowel loops connected by mixed hypoechoic
inflammatory exudate is highly suspicious of
fistulation.
Disease Activity
Management decisions in CD depend on estimates
of disease activity. Clinical assessment and laboratory results are central and are commonly used to
monitor therapeutic responses. However, symptoms may be due to factors other than active
inflammation (eg, cold strictures, bacterial overgrowth) and US may usefully contribute to assessment of disease activity by documenting the
vascularity of lesions with color or power Doppler.
Current research suggests accuracy may be
improved by the use of intravenous contrast
agents.44
Differential Diagnosis
Caution is required in interpreting any of the above
imaging findings because there is considerable
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