Bowel Ultrasound: How I do it !

Tanya Chawla
Abdominal Imaging
JDMI
University of Toronto
I HAVE NO DISCLOSURES
 Objectives
• Discuss normal sonographic anatomy
• Patient preparation
• Tips
• Case based discussion of applications
– Acute
– Inflammatory
– Neoplastic
– Obstruction
– Miscellaneous
Anatomy Technique Inflammation Miscellaneous Obstruction Neoplasia

GUT signature
• Alternating layers • Variation in superficial
echogenic and mucosal layers
hypoechoic – Rugae
• Muscular layers are – V.conniventes
hypoechoic • Location best clue to
– M.Mucosa which segment involved
– M.Propria • Constant location if
fixed peritoneal
attachment
 Anatomy
• 5 distinct layers when
examined with high
frequency probe 5-15
MHz
 Anatomy
• Stomach:
– Rugae
– Thick
pyloric
muscle
 Anatomy
• Jejunum:
– Thick folds
– Fill lumen
– Herringbone
pattern
– Step ladder
morphology
– Peristalsis (active)
• Diminishes in
fasting state
 Anatomy
• Ileum:
– Thin walls
– Smooth and
featureless
– Small caliber
– Fewer folds
– Peristalsis(less
active)
– Distal TI shows
increased layer of
submucosa
 Anatomy
• Appendix
• Graded compression
• Mural stratification
• < 6mm
• Readily compressible
• Morphology also helpful
for discrimination
– Rounded vs ovoid
• CD is also helpful
 Anatomy
• Colon:
– Haustra
– location
– Gas filled
– No peristalsis
Anatomy Technique Inflammation Miscellaneous Obstruction Neoplasia

Technique
• Fasting 4-6 hours
• Real time abdominal
survey 3.5-5 mHz
• Gives overview
– Look for normal signature
– Any gross lesions/masses
• Look with and without a
full bladder
– May facilitate assessment
in some cases
• TVUS
– Must
– Rectum, sigmoid colon,
distal ileum and appendix
all well seen on TVUS
– ADDITIONAL measures
• Hydrosonography
• Fleet enema
 Hydrosonography

• Oral contrast
• Echo poor
• Distends small bowel
• Displaces air
• Well tolerated
• PEG
• Klean prep/1l of water
• Scan 20 mins after
ingestion
 What you need
• Essential
– Curvilinear 3.5 MHz
– Linear 6 MHz
Patient
preparation:
• Useful Minimum
4 hours fasting
– Linear 12 MHz
– Curvilinear 6 MHz
– Transvaginal probe
Transducer with short
focal zone
Works with
Linear probes
5-9mHz convex
probes
Probe used to “palpate”
 Approach
• Use fixed landmarks
• Cecum/TI
• Most constantly found
lying over iliopsoas in RIF
• Orient probe in transverse
plane to identify cecum
• Then change to
longitudinal direction to
identify haustrations

Hollerweger A, Dirks K, Szopinsk K

EFSUMB –Transabdominal ultrasound of the
gastrointestinal tract
 What are we assessing when we
scan?
• Bowel wall thickness • Is there preservation or
• Echotexture destruction of the wall
• Vascularity layers?
• Flexibility • Is there symmetric or
eccentric involvement
• Motility
• What is the distribution
• Assess peri-enteric or length of the
– Fat abnormality?
– nodes
Anatomy Technique Inflammation
Acute abdomen ;what clues are we
looking for
• Gas in unusual location
– Intra-peritoneal
– Retroperitoneal
– Within bowel wall
– Contained in collection
Arch Surg 2009 Moriwaki et al
Miscellaneous Obstruction Neoplasia
• Sensitivity of US for
detection of air in
setting of blunt trauma
was 85.7% and
specificity of 99.6%
Perforated peptic ulcer
• Free intraperitoneal gas
• Thickened pylorus/duodenum
• Echogenic fat
Free intraperitoneal gas

Echogenic peritoneal stripe

Reverberation artifact

Dirty Shadowing
 Gastric ulcer on ultrasound
• Focal outpouching with dense lesion
– Posterior shadowing
– Wall around ulcer is thickened
– Mucosal edema
– ?preservation of wall layers
 Abscess
• Loculated collections can
mimic GI tract
• Assess wall morphology
to discriminate from gut
signature
• Look for peristaltic
activity
• Interloop collections
– Follow contour of AAW or
adjacent bowel loops
– Acute angles
 Signs of inflammation on ultrasound
• Thickened bowel wall
– Normal wall thickness of distended bowel
• Stomach 3-7 mm
• Small bowel/colon 1-3 mm

• Hyperemia
• Accentuation or loss of gut signature
• Echogenic fat
• Enlarged Nodes
46 year old ♂ presents with RLQ pain
 Epiploic appendagitis
• Fatty tags on serosa of colon
• Non compressible
• Ovoid mass
• Visceral peritoneal thickening
• Bowel wall thickening minimal if
any
• Inflammation reflection of
– Torsion along long axis
– Venous thrombosis Differential
– Central dot sign • Appendicitis
• Segmental omental
• Results in ischemia/infarction infarction
• Pain may be disproportionate
 Echogenic Fat
• Fatty tissue infiltrated with edema
– Passive congestion
– Inflammation
• Equivalent of increased density of fat on CT

N
N
 Pattern recognition
• Inflammatory Is infiltration of the fat a
discriminator?
– Diffuse
– Involve long segments of
the gut
– Symmetric involvement
– Preserved wall layers
– Hyperemia reflects
activity of the
inflammatory process
 CASE
60 F with urosepsis
Watery diarrhea
 Pseudomembranous Colitis
• Cytotoxin produced by Clostridium difficile
• Complication of antibiotic therapy
• Marked colonic wall thickening
– Typically pancolitis
– May be segmental
– Loss of stratification
• Prominent submucosal gyral pattern
• Opposed mucosa due to profound thickening
• Pseudo membranes =linear echogenic lines
• Ascites common
• Significant overlap
Differential
• IBD
• Infectious colitis
• Rt colon
(salmonella/shigella)
• Diffuse E.coli
 Salmonella enteritis

Infectious enteritis
• Fluid filled loops
• Hyperperistalsis
• Wall & fold thickening
• Hyperemia
Cryptosporidium enteritis • +/- edema in mesentery
35 YEAR OLD F 4/52 FOLLOWING
STEM CELL TRANSPLANTATION
 Acute typhilitis
• Association with immune compromise/severe
neutropenia
– Oncological
– Hematological malignancy (leukemia /stem cell Tx)
– HIV/AIDS
• Organisms associated with include
– CMV, cryptosporidium
• Marked mural thickening of cecum/ascending colon
• Deep ulcerations
• Sub-mucosal edema
• Risk: Pneumatosis,extraluminal fluid and perforation
Neutropenic Colitis

Salmonella Colitis
CASE:29 year old F with RLQ pain ?appendicitis
 Right sided diverticulitis
• Female>male
• Asian
• True diverticulum
• Congenital and solitary
• All layers of bowel wall
• Mistaken for appendicitis
• Fecoliths within these diverticula are larger and the
neck is wider
• Occurs at any age
• Favourable outcome
– Free perforation and abscess are rare
Case: 19 F with RLQ pain
 Appendicitis
• 50% of cases US able to
demonstrate a normal
appendix
• 70% of cases able to
establish an alternate
diagnosis(Gaensler et al )
• Normal diameter < 7 mm
• Easily compressible
• Normal gut signature but
blind ending
• Follow proximal end to base
of cecum
 Abnormal appendix
• Non compressible
• variable luminal distension 7-16
mm
• 30% of cases fecolith in lumen
• Rounded or partly round
appendix also likely to be
positive
• Echogenic fat at periphery
• Marked increase in vascularity

Loculated collection
Loss of submucosa of the
appendix
32 year old presentation with RUQ pain and elevated WCC
37 YEAR old presents to ER
with RLQ pain
 Crohns appendicitis
• Most commonly seen as Crohn’s with involvement of
IC region
• Isolated granulomatous appendicitis rare (0.2-0.5%)
• Symptoms more protracted
• Enlarged appendix with
– marked thickening of the wall
– Wall layer preservation
– Luminal surface is often apposed
• +/- fibrous adhesions
• DDX Yersinia, Actinomycosis or foreign body reaction
Diverticulitis
• Outpouching through defect
• Echogenic fat; mass like
• Peri-diverticular fluid
• Hyperemia
• Other non-inflamed diverticula
• US sensitivity and specificity for
diagnosis 85% and 80%
 Left lower quadrant pain
• Classic triad of LLQ • HALLMARK FEATURES
pain,fever and – Segmental gut
leucocytosis thickening
• Common in western – Hypoechoic due to
hypertrophic muscularis
population
– Echogenic foci within or
• 50% by 9th decade beyond gut wall
• Inspissated fecal – Intra-mural sinus tracts
material obstructs apex – Echogenic fat
of diverticulum – Linear tracts to
• Bladder, vagina, adjacent
loops
Segmental hypoechoic wall thickening
Tip
• Diverticula
– Arrayed in parallel rows
along margins of teniae
coli
– Find thick segment
– Tilt transducer to
demonstrate long axis
– Look at lateral margins
CASE : LLQ pain in a 39 year old female
Anatomy Technique Inflammation Miscellaneous Obstruction Neoplasia

Endometriosis
• Seen in 12-37% of cases
• 75-90% impacts anterior rectum and sigmoid
• Rectal lesions are associated with a second
lesion in 55% of cases
• Typically hypoechoic
• Minimal vascularity
• Located on serosa of bowel wall
• May show mass effect on deeper layers
 Imaging
• Masses blend with outer
layer of bowel wall
– Surface plaque with tapering
appearance in long axis
– Eccentric in cross section
– May involve m.propria and
submucosa
– Wall thickening and luminal
stenosis may occur
– Involve just one wall of the
gut
– Typically along anti-
mesenteric border
CASE 24 year old female with diffuse abdominal pain (renal failure)
Edema of the bowel wall
• Increased thickness(mucosa)
• Preservation of layers Necrotizing vasculitis of small vessels
Edema and hemorrhage in bowel wall
 Vasculitides
• Most common with GI • Common sonographic
involvement features
– Behcet’s – Bowel wall thickening
– Henoch Schonlein – Loss of bowel
– Polyarteritis stratification
nodosa(PAN) – Bowel dilatation
– SLE – Hypoechoic fingerlike
projections into fluid
Presentation filled lumen
Typically abdominal pain and ascites
DDx: Hypoalbuminemia, CCF and venous
thrombosis
Anatomy Technique Inflammation Miscellaneous Obstruction Neoplasia

Bowel obstruction
• Distended loops of
• Find Level of
bowel
Obstruction:
• Edematous bowel – Gastric outlet
• Ascites – Small bowel
• To/Fro peristalsis – Colonic
• Check Cecum
• As obstruction
– Check hernia orifices
progresses
– High grade or complete US has a sensitivity and specificity of
– Peristalsis absent 83 and 100% respectively
Limited if significant gaseous
distension
Ko et al Radiology 1993
CASE : 76 year old male with vomiting and
obstipation
Incarcerated inguinal hernia
CASE 56 year old with severe abdominal
pain and vomiting
Small bowel
volvulus
• Twisting of
mesentery
• SMV anterior/left
of SMA
CASE
26 year old F
Abdominal
pain and
cramping
Celiac
• Malabsorption, hypomotility
and luminal dilatation
• Ileal villous hypertrophy
• Changes in vascularity
include
• Inc SMA velocities
• Reduced RI
 Intussuception
• Invagination of one bowel • Lead point
segment (intussusceptum) – Benign lipoma,
into another leiomyoma,polyp
(intussuscipiens)
– Malignant
• Rare cause of MBO in adult
– Intrinsic primary, mets or
patients
lymphoma
• Typically associated with an
underlying lead point (85%)
• Long segment associated
with obstruction and
ischemia
Ileocolic intussusception
• Thick edematous intussusceptum
• Asymmetrical echogenic mesentery
• Lead-point difficult to recognize
Anatomy Technique Inflammation Miscellaneous Obstruction Neoplasia

Disruption of gut signature what does it mean?

• Annular, polypoidal or mural growth pattern

• Characterized by wall layer destruction
• Typically short segment
• Asymmetric wall involvement
• Increased vascularity
• Multi-centric disease may be seen
• Peri-enteric adenopathy and infiltration of fat
 Growth patterns

• Destruction of layers
• Asymmetric involvement
• Hypervascularity
Polypoidal
Exophytic
=Intraluminal

Annular =mural
 Bowel Masses/Neoplasm
• Rounded or Polypoid
– Benign/malignant mucosal polyps
– Submucosal tumors: GIST tumors
– Metastases: Melanoma, Renal cell carcinoma

• Infiltrative tumors
– Primary adenocarcinoma
– Carcinoid tumors
– Lymphoma
– Metastases: Lung, breast, Signet ring cell adenoca
 Gastric Lymphoma

Gastric Adenocarcinoma
56 year old previous liver transplant
Attends for routine Doppler assessment of graft
Complains of “vague” epigastric discomfort
 Rounded or Polypoidal masses

Brunner gland hyperplasia SB Melanoma metastasis

Cecal polyp
CASE :72 year old US for recurrent UTI
• Hypoechoic well defined
cystic mass
• Variable internal
echogenicity
• Wall thickness
• Whorled appearance
• Lamellated
• Mobile
• Retrocecal
 Mucocele
• Macroscopic definition • Ovoid cystic mass
• Distended appendix with • Internal echogenic
mucin
layers/onion skin
• Etiology
– Non neoplastic/retention cyst • Dystrophic calcification
– Mucin secreting neoplasms (<50%)
• New classification system • Pear shaped
2016
– Adenoma
– LAMN, HAMN,mucinous
adenocarcinoma
 Conclusion
• Sonographic assessment of
bowel increasing in
importance
• Pattern based approach
helps limit differential
• Many disease processes
have a pathognomonic
appearance on US
• Interpret in context of
provided scenario when
differential wider