doi:10.1111/j.1447-0756.2011.01686.x J. Obstet. Gynaecol. Res. Vol. 38, No.

1: 215–219, January 2012

Antenatal sonographic features of ileal atresia jog_1686 215..219

Yun Sung Jo, Dong Gyu Jang, Sun Young Nam, Sae Kyung Choi, Jong Chul Shin and
Guisera Lee
Department of Obstetrics and Gynecology, Catholic University of Korea, Seoul, Korea

Abstract
Aim: The purpose of this study was to determine the antenatal sonographic features of ileal atresia.
Material and Methods: We identified neonates with surgically-confirmed ileal atresia who had antenatal
sonography performed in our institution between 1 January 1999 and 30 June 2009. The antenatal sonography
images and reports were reviewed.
Results: Sixteen neonates had surgically-confirmed ileal atresia in our institution in 11 years. Seven fetuses
(43.7%) did not have any intestinal abnormalities detected antenatally on ultrasonography. Nine fetu-
ses (56.3%) had various sonographic features of ileal atresia, including multiple dilated bowel loops, ascites,
cysts, and polyhydramnios with or without associated anomalies. Six of nine fetuses had multiple dilated
bowel loops and two fetuses had ascites. One fetus had a large, cystic, mixed, echogenic dilatation of bowel.
Polyhydramnios was present in three fetuses. Heart anomalies, kidney anomalies, or hydrops were present
in four fetuses. Eight of 16 fetuses (50%) had other intestinal problems, including intussusceptions in one
fetus, small bowel malrotation, meconium pseudocyst volvulus, meconium peritonitis, and a congenital
band.
Conclusion: The prenatal sonographic features of ileal atresia are not simple. Various sonographic findings are
shown and ileal atresia was detected in about 60% of cases.
Key words: ascites, fetus, intestinal atresia, ultrasonography.

Introduction Material and Methods

Intestinal atresia, 39% of which are jejunal or ileal, is
the most common cause of congenital bowel obstruc-
tion.1 However, because prenatal ultrasonography gen-
erally has not been an accurate means of detecting
lower intestinal obstruction, the ability to diagnose this
congenital anomaly is limited.1 Surgical series suggest
that only 23%–31% of such atresias are detected in
utero.2–5 To evaluate the prenatal ultrasonographic find-
ings of ileal atresia, we conducted a retrospective
evaluation of surgically-proven ileal atresias in our
institution.
We identified all neonates with surgically-confirmed
ileal atresia managed in our institution between 1
January 1999 and 30 June 2009.
The sonographic findings were reviewed. At our
clinic, a 3.5-MHz ultrasonograph (sonoace9900,
Medison, Korea [1999–2005], ACCUVIX XQ-3D,
Medison, Korea [2005–2009]) was used. During the
study period, every gravida underwent at least two
ultrasound evaluations in the second or third trimes-
ters by an expert sonographer with more than 5 years
of experience. If the bowel lumen diameter was

Received: February 16 2011.

Accepted: May 6 2011.
Reprint request to: Professor Guisera Lee, Department of Obstetrics and Gynecology, St. Vincent’s Hospital, 93-6 Ji-dong, Paldal-gu,
Suwon, Kyeonggi 442-723, Korea. Email: leegsr@catholic.ac.kr

© 2011 The Authors 215

Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
Y. S. Jo et al.

greater than 7 mm, abnormal bowel dilatation was
diagnosed. Sonography images were reviewed for
features of intestinal abnormalities, including mul-
tiple dilated loops of the bowel and abdominal cysts.
The obstetric data abstracted included gestational age
at delivery, associated anomalies, method of delivery,
birth weight, and gender. We differentiated the cases
of antenatally-predicted (antenatal diagnosed patient
[AD]) ileal atresia from the cases of antenatally never
predicted (postnatal diagnosed patient [PD]) ileal
atresia based on fetal sonography.
Statistical analysis was performed using an unpaired
t-test and c2 test. P < 0.05 was considered to be statisti-
cally significant.
Results
Sixteen neonates had confirmed ileal atresia in our
institution during the 11-year period. There were
35 030 deliveries at our institution during this time
period, and ileal atresia occurred with an incidence
of 4.6 per 10 000 deliveries. Of 16 neonates with
ileal atresia, 10 (62.5%) were delivered vaginally and
six (37.5%) were delivered by cesarean section. Two
of six cesarean sections were performed for non-
reassuring fetal heart patterns, eight (50%) were deliv-
ered at preterm, and three (18.7%) were intrauterine
growth restricted. The causes of preterm birth were
preterm labor in five fetuses, premature rupture of
membrane in two fetus, and fetal distress in one
fetus. The mean gestational age at birth was
36.0 ⫾ 3.5 weeks (range, 26.7–40.0 weeks). The mean
birth weight was 2.67 ⫾ 0.79 kg (range, 0.77–3.82 kg).
Nine fetuses were male (56.3%) and seven fetuses
were female (43.8%; Table 1). There were no cases of
chromosomal anomalies or recognized syndromic
disorders.
Seven fetuses (43.7%) had no abnormal findings
on ultrasonographic evaluations which were suspi-
cious for intestinal abnormalities (PD group). Nine
fetuses (56.3%) had abnormal sonographic features
(AD group). We separated the ultrasonographic

Table 1 Patient characteristics and antenatal ultrasonographic features of ileal atresia

No. Delivery Delivery Neonate Gender Associated Ultrasonographic feature Combined
week route birth anomalies Finding Finding of secondary intestinal
weight of ileal complication disease
(kg) atresia
Multiple Ascites Single Hydramnios
dilated cystic
loops mass
PD 1 40 VD 2.90 M - - - - - Intussusception
PD 2 38 VD 2.60 M ASD - - - - Small bowel
malrotation
PD 3 33 VD 2.20 M - - - - - Congenital band
PD 4 37.1 VD 3.31 F - - - - - Meconium
peritonitis
PD 5 39.7 VD 3.41 M - - - - - -
PD 6 26.7 VD 0.77 F - - - - -
PD 7 33 CS 1.04 M - - - - - -
AD 8 34 CS 3.12 M + - - + -
AD 9 36 VD 2.54 F Renal + - - - -
dysplasia
AD 10 36.9 CS 2.8 M Hydrocele - + - + Meconium
peritonitis
AD 11 38.1 CS 3.06 M - - - + - Meconium
pseudocyst
volvulus
AD 12 33 CS 2.83 M Ebstein - + - - Meconium
anomaly, peritonitis
hydrops
AD 13 39.9 VD 3.82 F - + - - - Volvulus
AD 14 38.1 VD 2.71 F - + - - - -
AD 15 37.5 CS 2.81 F - + - - + -
AD 16 35.6 VD 2.72 F - + - - - -

216 © 2011 The Authors

Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
 Sonographic features of ileal atresia

features as follows: findings of ileal atresia; and Discussion

findings of secondary complications. Multiple dila-
ted loops of bowel were a ‘finding of ileal atresia’; More than one-third of congenital bowel obstructions
while other findings, such as ascites, single large result from intestinal atresia. Although the duodenum
cysts, and polyhydramnios were ‘findings of second- is the most common site, the jejunum and ileum
ary complications’. Six neonates in the AD group account for 39% of cases of intestinal atresia.1 Reports of
(66.7%) had multiple dilated loops of bowel, prenatally-diagnosed ileal atresia consist of case reports
range of dilatation was 19–25 mm (Fig. 1) and three and small series, with sonographic detection typically
fetuses had ‘findings of secondary complications’ occurring late in the third trimester.6–11 Of our cases,
only. 56.3% were antenatally-diagnosed and all antenatally-
Two fetuses had ascites (22%; Fig. 2). One fetus diagnosed cases were detected in the third trimester.
(11.1%) had a large, cystic, mixed, echogenic mass
in the abdomen (Fig. 3). Polyhydramnios was pre-
sent in three fetuses (33.3%; Table 1). Other
fetal anomalies were noted in four fetuses (44.4%),
including an atrial septal defect (ASD), Ebstein
anomaly, fetal hydrops, hydrocele, and renal dys-
plasia (Table 1).
Eight of sixteen fetuses (50%) had other intestinal
problems, including intussusception in one fetus,
small bowel malrotation in one fetus, a meconium
pseudocyst in one fetus, volvulus in two fetuses, meco-
nium peritonitis in three fetuses, and a congenital band
in one fetus (Table 1).
There were no statistically significant differences
between the PD group and the AD group in terms of
gestational age at birth, birth weight, gender ratio, com-
bined anomalies, combined intestinal problems, and
preterm labor (Table 2).
Figure 2 Antenatal ultrasound scan showing massive
ascites in a fetus with ileal atresia.

Figure 1 Antenatal ultrasound scan showing multiple Figure 3 Antenatal ultrasound scan showing a large,
dilated loops of small intestine in a fetus with ileal mixed, echogenic cystic mass in the abdomen in a fetus
atresia. with ileal atresia.

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Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
Y. S. Jo et al.
Table 2 Differentiation between PD and AD groups
Gestational age at delivery
Birth weight
Gender ratio (M : F)
Combined anomalies
Combined intestinal problems
Preterm labor
AD, antenatally predicted ileal atresia; CS, cesarean section; F, female; M, male; PD,
antenatally never predicted ileal atresia; VD, vaginal delivery.
The diagnosis of ileal atresia may be difficult because
most cases are not apparent until the third trimester
and the sonographic features are not unique. Also, con-
siderable variability occurs in the appearance of the
bowel in the third trimester, such that a fetus with a
prenatal diagnosis of intestinal obstruction based on
bowel dilatation may prove to be normal at birth. Sono-
graphic findings of some cases of ileal atresia are
typical, such as multiple dilated loops of bowel, while
some cases are atypical, such as single cystic masses or
slightly dilated bowel or undetectable findings. In our
study, 43.7% of the fetuses did not have an intestinal
abnormality detected on antenatal ultrasonography.
Six of nine fetuses with various sonographic features of
ileal atresia had typical sonographic findings, such as
multiple dilated loops of bowel, and three fetuses had
atypical features, such as ascites or a single cystic mass.
Polyhydramnios was usually absent, and is more
common with jejuneal rather than ileal atresia. In our
study, 3 of 16 fetuses (13.8%) had polyhydramnios.
Ileal atresia can be found in combination with vol-
vulus, meconium pseudocysts, and intussusception. In
our study, volvulus, meconium pseudocysts, meco-
nium peritonitis, malrotation of the small bowel, con-
genital bands, and intussusception were combined
with ileal atresia; however, it was difficult to recognize
combined intestinal disease on antenatal ultrasound,
with the exception of meconium peritonitis and
meconium pseudocysts.
Meconium peritonitis results from perforation in the
intestines proximal to the site of obstruction caused by
atresia, stenosis, volvulus, or intussusceptions.12 The
antenatal ultrasound features of meconium peritonitis
are fetal ascites, abdominal calcifications, polyhydram-
nios, pseudocysts, and dilated loops of bowel.11,13 In
terms of a correlation between antenatal ultrasound
and postnatal outcome, persistent ascites is signifi-
cantly correlated with neonatal mortality.13 In our
study, meconium peritonitis caused by ileal atresia
occurred in three cases; one of three cases was not
218
Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology
PD AD P-value
35.4 ⫾ 4.8 36.6 ⫾ 2.1 0.671
2.32 ⫾ 1.05 2.93 ⫾ 0.38 0.368
5:2 4:5 0.286
14.3% 33.3% 0.392
71.4% 55.6% 0.451
42.9% 44.4% 0.671
predicted by the meconium peritonitis and the other
two cases had ascites.
Antenatal sonographic findings of meconium pseu-
docyst formation secondary to ileal atresia revealed
a large, hypoechoic, thin-walled, cystic abdominal
mass.11,14 A meconium pseudocyst is formed if the site of
intestinal perforation is not sealed by adhesions. The
diagnosis of meconium pseudocysts is not easy because
a sonographically-visualized intraabdominal cyst in a
fetus includes intestinal duplication cysts, mesenteric or
omental cysts, choledochal cysts, meconium pseu-
docysts, congenital cysts of the pancreas, renal cysts,
obstructive uropathy, urachal cysts, ovarian cysts,
ureteroceles, hematometrocolpos, myelomeningoceles,
and, occasionally, even a tumorous lesions, such as a
cystic sacrococcygeal teratoma. Although the combina-
tion of cyst location, relationship to adjacent abdominal
organs, nature of cyst contents, and fetal gender often
enable one to reduce the diagnostic possibilities, the
sonographic diagnosis is often inconclusive.
When small bowel atresia is diagnosed antenatally,
there is more pronounced in utero intestinal distension
than in cases not diagnosed with antenatal ultrasound.
This finding can predict the postnatal neonatal condi-
tion and is useful in counseling.2 However, the antena-
tal diagnosis for ileal atresia might not improve
perinatal outcomes, such as gestational age at birth,
birth weight, and detection of combined intestinal and
other anomalies.
The results of this study suggest that the antenatal
diagnosis of ileal atresia may not be straightforward
because there are variable features on ultrasound in the
third trimester. Physicians must pay attention to intes-
tinal features on ultrasound examinations in the third
trimester because most cases of intestinal obstruction
are not apparent until the third trimester and the sono-
graphic features are not unique. If bowel dilatation,
ascites, and single cystic masses with polyhydramnios
are detected, intestinal obstruction, especially ileal
atresia, must be considered.
© 2011 The Authors

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