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US of the GI tract - Technique
Julien Puylaert
Medical center Haaglanden in the Hague and Academical Medical Center in Amsterdam, the Netherlands

Examination technique
US machines and probes Publicationdate 3-4-2020
The “over-processed” US image
US examination of bowel The GI tract is the most challenging part of the abdo‐
Graded compression
men to examine by US.
Preparation of the patient
Although technically demanding, its results have great
clinical implications in early triage of bowel diseases
and in the acute abdomen.
This is the first of a series on US of the GI tract.

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For critical comments and additional remarks:

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Examination technique

Modern ultrasound machines provide high resolution

images of the GI tract, like in this patient with massive
thickening of mucosa and submucosa in Clostridium
colitis.

However nowadays cheap ultrasound systems con‐

sisting of a 1200 euro transducer connected to a tab‐
let or phone will produce images of good quality (see
next image).
Thickening of mucosa and submucosa in Clostridium colitis
We expect that more doctors and health workers will
use ultrasound in their daily practice.
Knowledge of technique, normal anatomy and patho‐
logy of the GI tract will be important for patient
management.

US machines and probes

US machines are getting better, smaller and less
expensive. 
 In the future one probe connected to a tablet,
covering 0-25 cm depth. 
Abdomen Breast Cardiovascular
At present aChest Head/Neck
high-end Musculoskeletal
US machine for GI tract
still mandatory.
Learning US is best mastered by practicing on
Neuroradiology Pediatrics
thin More
patients with a high-end machine. This
expertise will enable to successfully exam
obese patients with a less fancy probe.
In this lean person, the normal terminal ileum and the
normal, compressed appendix (arrow) are visualized
on a tablet connected to a 1200 euro probe.

US image made with a 1200 euro probe and tablet.

For the average abdominal US program with patients

of varying habitus, still three probes is the minimum. 

The cm’s indicate the range where image resolution is

optimal.

Since bowel lies close to the abdominal wall, the

middle and small probe are the workhorses in US of
the GI tract. 

Choice of the probe is based on the depth where the

bowel is visualized during compression.

For example, the fluid-filled stomach in this obese pa‐

tient (left), is best studied with the middle-transducer,
the normal ileum and appendix in a thin patient
(right), with the small transducer. 

Pre-sets for specific abdominal organs can be helpful,

but we use only two abdominal pre-sets per probe:
normal and XL for large and obese patients.

The “over-processed” US image

The processed US image: speckle-noise-reduction 
Advantages: sharper reflective contours,
anechoic cysts and vessels, “smoothed image” 
Drawbacks:  creation of unrealistic boundaries
and reflections, lower image resolution
Use with great caution, as confusing artifacts
may outweigh its advantages
Compare the native US images (left) of the pancreatic
region with the strongly processed US images (right). 

In these over-processed images the vessels have a

sharper delineation with a completely anechoic
 lumen. 
Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal
However, also unrealistic reflections and contours are
“created”. 
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Note the unnatural bright reflections in the area
dorsal from the pancreatic tail (right upper image)
and note the bizarre contour of the stomach and the
falciform ligament (right lower image). 

US examination of bowel
US of the GI tract has been quite unpopular in the
past because of the interference of gas and other
bowel contents (upper image). 

The good news is that pathological bowel usually is

often conspicuous, due to local wall thickening and
an empty lumen, e.g. in this patient with segmental
Crohn’s colitis (lower image).

Searching and screening for bowel pathology is best

done using the so-called  “mowing-the-lawn”
technique. 

This technique requires graded compression, a high-

frequency probe and not too viscous US gel. 

Like in mowing the lawn, overlapping lanes are neces‐

sary, not to miss any pathology.  

Most commercially available US gels are quite

viscous.

It has several advantages to make it more fluent by

adding about one third of hot tap water.
Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal

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Better skin contact  prevents disturbing artifacts (ar‐

row)    

It is time-efficient to put the US gel on the patient, and

not on the probe. 

With a normal habitus, one large dose ( ~25 cc)

of  diluted US gel is sufficient for the entire
examination. 

A small reservoir in the epigastric area may be used

for “dipping”. 

In general, liberal use of US gel has great advantages.

There are however two drawbacks: things may get
quite messy and hygiene may be endangered. 

This requires “US gel discipline” and a lot of towels or

cleaning tissue. 

To avoid the cable getting sticky, you can put it around

your neck or place it on the patient’s chest when
studying the left flank. 

US gel should be removed from the probe, before put‐

ting the probe back. 

Proper cleaning of the probes after each patient

speaks for itself. 

Ask the manufacturer what to use as cleaning fluid. 

 It is very important to keep the fingers of the probe-
Abdomen Breast hand free of US gel:
Cardiovascular the Head/Neck
Chest combinationMusculoskeletal
of rather forceful
compression with subtle rotational movements re‐
quires a dry hand. 
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Graded compression
Advantages compression 
closer to the bowel allows high frequency probe 
compressing and/or displacing gas-filled bowel
Compression should be graded and gentle
not to cause pain
to avoid pushing bowel entirely out of the US
plane
Graded compression is remarkably well tolerated,
even in peritonitis. 

The CT scan shows how intra-abdominal anatomic

relations are altered by graded compression.
During compression, the ventral wall of the bowel is
compressed against the dorsal wall, eliminating the
disturbing effect of gas and other bowel contents. 

This sagittal CT scan demonstrates a retrocecal, in‐

flamed appendix (arrowheads) with an obstructing fe‐
colith (arrow). 

By graded compression with the US probe, the air-

filled cecum is pushed aside and the appendix is
visualized  close to the abdominal wall (note cm-
scale). 

CT shows contracted colon (arrow) in obese patient. 

 During light compression (middle) the contracted
Abdomen Breast colon can be visualized
Cardiovascular with a 12 MHz
Chest Head/Neck probe.
Musculoskeletal

During moderate compression (right), the relaxed

colon canMore
Neuroradiology Pediatrics even be seen flattened against the dorsally
located psoas muscle.

CT of an obese patient with inactive ulcerative colitis.

The sigmoid lies 9 cms from the skin.

During compression (arrowheads) this distance was

decreased to 2.5 cms allowing the use of a high fre‐
quency probe.

To visualize a tubular structure (e.g. the inflamed ap‐

pendix) in two perpendicular planes, it is essential to
bring the structure in its axial view in the middle of the
US image. 

This allows to keep the structure visible, while rotat‐

ing the probe 90 degrees (click on image). 

Gentle “rocking” of the probe during rotation helps in

keeping a small tubular structure in sight.
Click on image for animation
The rather ovoid than round shape of most probe-
handles is not very helpful in making easy and subtle
rotational movements combined with compression. 

Try to develop a grip that allows you to rotate the

probe from your wrist, and not from your arm or
shoulder, always trying to hold the red line axis. 

Preparation of the patient

1. Allow light breakfast (a cup of tea, juice, some
crackers etc.)
2. No ratio for absolute fasting (unpleasant,
hazardous for diabetics, patients may skip vital
medication)
3. No full bladder (unpleasant for the patient and
hampers the US examination hindering
compression and displacing bowel dorsally).
4. A half-full bladder is best, but it may be difficult
to instruct patients
A half-full bladder allows optimal examination of the
bladder and distal ureters and uterus and ovaries in
women (images).
In patients with acute abdominal pain, preparation is
not an issue: most of the patients have not eaten or
 have vomited, and are readily instructed not to eat or
Abdomen Breast drink, until a surgical
Cardiovascular Chestcondition is ruled
Head/Neck out.
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