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IEC Atlas of Endoscopic Ultrasound

Chapter · January 2013

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Marco Bianchi Claudio Giovanni De Angelis

San Filippo Neri Hospital, Rome, Italy Azienda Ospedaliera Città della Salute e della Scienza di Torino
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 4 NORMAL GI WALL AND
IMAGING ARTIFACTS
M. Bianchi, A. Pisani
By endo-ultrasonography (EUS) of gastro-intes-
tinal (GI) wall, the short distance to the structures to
be studied makes it possible to use transducers that
work at frequencies between 5 and 20 MHz: they
have an axial resolution (i.e. the ability to distinguish
between two points lying in the same direction) of
about 0.2 mm.
Increasing the frequency, the ability of the beam
to resolve tissue structures are increased.
Is usefull to utilize water to fill stomach and
rectum to minimize artefacts due to air interposing
between EUS beam and GI wall; moreover at the
tip of all echoendoscopes there is a balloon in which
we pump deareated water to obtain a perfect contact
with the mucosa.
The normal GI wall is 5-8 mm of thickness and
EUS identify in its structure five layers, due to the
interface echoes created by a change in acoustical im-
pedance between adjacent tissues:
–– the first hyperechoic layer: is due to the interface
between lumen of esophagus, stomach, duodenum,
rectum and their mucosa;
–– the second hypoechoic layer: constituted by the
inner part of the mucosa and muscularis mucosae,
the latter allowing to distinguish it from submucosa;
–– the third hyperechoic layer: is constituted by sub-
mucosa and the interface between itself and the
muscularis propria;
–– the fourth hypoechoic layer: represents the muscu-
laris propria. If we use a miniprobe (20-30 MHz),
expecially in antrum and rectum, we are able to
visualize, in spite of one, two layers due to the cir-
cular and longitudinal muscle fibers, divided by a
thin hyperecogenic layer;
–– the fifth hyperechoic layer: it represents the inter-
face between the muscularis mucosae and the ex-
ternal perivisceral fat or peritoneal layer (sierosa).
In the esophagus and the duodenum EUS usu-
ally individualized only 3 layers: in fact the first three
ATLANTE ENDOSCOPIA IMPAGINATO.indd 27
layers appear as a single echo rich layer, while the
second echo poor identify the muscularis propria and
the third echo rich one is the adventitia of this GI
tracts.
Finally, the probe may be tangential to the mu-
cosa to avoid the “salami” effect, due to an artificial
abnormal thickness of wall or layers created by echeos
not perpendicular to wall.
ARTIFACTS: DEFINITION
AND CLASSIFICATION
Artifacts are false images artificially generated
which can cause confusion, and even misdiagnosis,
if the sonographer is not familiar with them. They
generally are of three main types: 1- artifacts due to
the interactions between ultrasounds and anatomical
structures 2- artifacts due to instruments malfunc-
tion or to interference with other equipment 3- arti-
facts due to inappropriate use of instruments.
While type 1 artifacts may be also useful for di-
agnostic purposes, artifacts type 2 and 3 cause only
misdiagnosis.
1. Artifacts due to the interactions with anatomic
structures are caused by ultrasound “reflection”, “re-
fraction” and “absorption” depending on material
density. Reverberation, ring-down and mirror image
are due to ultrasound reflection. Enhancement and
shadowing are absorption artifacts. Shadowing that
extends deep to the edge of the structures is a typical
refraction artifact.
2. Artifacts due to technical problems such as
malfunction of electronic and mechanical probes, or
due to interference with other equipment such as the
magnetic field generated by electrosurgical device.
3. Artifacts due to inappropriate use of instru-
ments: typical examples are the increased thickness
of gastrointestinal wall caused by non orthogonal in-
cidence of the ultrasound beam, or the Doppler signal
generated by breathing movement.
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 28 IEC - ATLAS OF ENDOSCOPIC ULTRASOUND

Figure 4.1 – Schematic representation of GI wall and corre- Figure 4.2 – Normal echographic picture of gastric wall (ra-

4
spondence to the histological layers. dial echoendoscope).

Figure 4.3 – Normal ecographic picture of gastric folds (ra- Figure 4.4 – Echographic aspect of normal gastric wall by a
dial echoendoscope). high frequency minisonde (seven layers wall; courtesy of Dr.
P. Carucci).

Figure 4.5 – Echographic aspect (12 Mhz) of esophageal wall Figure 4.6 – A little scar in the antrum with a minimal altera-
(see in text). tion of five layers structure.

ATLANTE ENDOSCOPIA IMPAGINATO.indd 28 23/07/12 17:42


Figure 4.7 – Antral ectopic pancreas with its escretory duct.
Figure 4.9 – Ecographic aspect of angulus.
Figure 4.11 – Ring down artifact can be seen when ultra-
sound strikes a structure that begin to resonate or ring sending
back echoes to the transducer. The resulting trail of echoes ex-
tends deep to the ringing structure. Common structures that
generate ring down artifacts are metallic or air (courtesy of Dr.
P. Bocus).
ATLANTE ENDOSCOPIA IMPAGINATO.indd 29
4 • Normal GI wall and imaging artifacts 29
Figure 4.8 – Minimal vascular abnormalities in submucosa
4
layer.
Figure 4.10 – Mirror image artifact occurs when there is a
high reflective surface such as gas that functions as acoustic
mirror. In this case ultrasound is reflected and can reproduce
the image at different depth corresponding to the time it takes
to return to the transducer (courtesy of Dr. P. Bocus).
Figure 4.12 – Ring down artifact: Air in the common bile
duct (arrows).
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 30 IEC - ATLAS OF ENDOSCOPIC ULTRASOUND

Figure 4.13 – Ring down artifact: metallic prosthesis and air Figure 4.14 – Reverberation artifact occur when an echo is

4
in the common bile duct (arrows). reflected, and, then returning to the transducer is reflected
again if strikes a reflecting surface, generating images placed
deeply depending on time to return to the transducer. In this
case we can see images in the lumen of the aorta due to rever-
beration (black arrows) and a mirror image of intestinal wall
(white arrows).

Figure 4.15 – Shadowing occur when echoes strike a structure that both reflects and absorbs ultrasounds. In this case an area
devoid of echoes is seen deep to the structure (shadow). Classically structures that produce shadowing are bone and gallstones
(arrows).

Figure 4.16 – Shadowing due to an oesophageal plastic pros- Figure 4.17 – Enhancement occurs deep to a structure that
thesis make it difficult to see mediastinal organs. does not attenuate but does allow large amount of sound to be
transmitted through it. The result is a brighter echo behind
them (arrows).

ATLANTE ENDOSCOPIA IMPAGINATO.indd 30 23/07/12 17:42

 4 • Normal GI wall and imaging artifacts 31

Figure 4.18 – Refraction of the sound beam occur at the

4
curved surfaces of rounded structures such as blood vessels,
leading to shadowing that extends deep to their edge (arrows).

Figure 4.19 – Refraction and reflection phenomena could

cause false filling defect especially in fluid structures (false
filling defect in the common bile duct and gallbladder).

Figure 4.20 – Mechanical probe malfunction causing a bad

visualization of anatomical structures.

Figure 4.21 – Interference with the magnetic field from an Figure 4.22 – False thickening of gastric wall due to non or-
electrosurgical device. thogonal incidence of ultrasound beam (courtesy of P. Bocus).

ATLANTE ENDOSCOPIA IMPAGINATO.indd 31 23/07/12 17:42

 32 IEC - ATLAS OF ENDOSCOPIC ULTRASOUND

Figure 4.23 – False thickening of duodenal wall due to non Figure 4.24 – False thickening due to overlap of gastric and

4
orthogonal incidence of ultrasound beam. duodenal walls.

Figure 4.25 – Doppler signal generated by air and fluid movements in the duodenal lumen.

REFERENCES
Seewald S, Ang TL, Soehendra N. Radial EUS: the clinical
impact of T staging. Minerva Medica 2007;98:305-11.
Villman P. Endoscopy ultrasonography. 1st printing. Copen-
hagen: Munksgaard; 1998.

Figure 4.26 – Doppler signal generated by breathing move-

ments.

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