Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal

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

Normal anatomy
Histology of the GI tract Publicationdate 3-4-2020
US fingerprint of the normal GI tract
Stomach Press ctrl+ for larger images and text on a PC
Small bowel
Jejunum
⌘
or  + on a Mac.
Terminal ileum Most images can be enlarged by clicking on them.
Intussusception
Omentum, mesentery and lymph nodes
Epiploic appendages
Appendix For critical comments and additional remarks:
Colon  j.puylaert@gmail.com

Normal anatomy

Histology of the GI tract

From inside to outside the layers of the small bowel
are the mucosa (M.), the submucosa (S.M.), the circu‐
lar muscle layer (C.M.), the longitudinal muscle layer
(L.M.) and the serosa (S.) 

Courtesy: Dr. Netter

US fingerprint of the normal GI tract

The classic five-layer-US-structure of the bowel wall is
easiest apprehended  by studying the wall of  the fluid
filled stomach. 
 The layers, starting from inside to outside, are hyper-
Abdomen Breast hypo-hyper-hypo-hyper-echoic
Cardiovascular Chest Head/Neck Musculoskeletal
or white-black-white-
black-white. 
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The US architecture of the wall is essentially the
same from the stomach to the rectum. 

Superficial mucosa

The superficial mucosa is brightly hyperechoic, due to

mucus and very tiny air-particles caught between the
small intestinal villi. 

It is not separately identifiable, when it blends with hy‐

perechoic feces, as in this US image of the colon. 

The outer white serosa can only be identified when

there is ascites.

When a high frequency probe is used, the middle

three layers, deep mucosa, submucosa and muscu‐
laris (black-white-black) are always visible. 

In this patient with severe coprostasis, the three-layer

wall architecture could only be recognized with a 12
MHz probe.

Deep Mucosa

The deep mucosa is hypoechoic and has a variable

thickness. It represents the packed glandular tissue
and - for only a small part-  the muscularis mucosae. 

Especially in the terminal ileum of children and young

adults, prominent echolucent lymphoid tissue is
found in the deep mucosa. 

These so-called Peyer’s patches (p) may be impress‐

ively large and asymmetrical.
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Submucosa

The submucosa contains vessels, nerves and fat and

is hyperechoic due to abundant loose connective
tissue.

In this patient with ulcerative colitis, prominent ves‐

sels (arrows) in the submucosa are visualized and
proven with color Doppler in the right image.

The submucosa “loosely connects” the mucosa with

the muscularis, and during contraction, the submu‐
cosa can be seen to follow the mucosal folds (left
upper). 

After drinking water, the mucosa and submucosa are

stretched and unfolded (right upper).

This loose connection also explains why gastroscop‐

ical biopsies can be taken unpunished, especially
when the submucosa is injected with saline first (right
under). 

Muscularis

The muscularis is hypoechoic due to muscular tissue

and as outer black layer is easy to identify. 
 It consists of  two layers: an inner circular muscle
Abdomen Breast layer and an outer
Cardiovascular longitudinal
Chest muscle
Head/Neck layer, which co‐
Musculoskeletal
operate to produce peristaltic movements. 

These twoMore
Neuroradiology Pediatrics muscular layers are separated by a thin
layer of connective tissue, containing the neural tis‐
sue of the Auerbach plexus. 

This thin layer (arrowheads) is hyperechoic on US and

can be seen in the small bowel of lean patients. 

Although clinically not relevant, the separate US iden‐

tification of the Auerbach plexus, underlines the high
resolution of US compared to CT and MRI.   

The muscularis of the large bowel is different from

that of the small bowel. 

The longitudinal muscle layer is limited to three lon‐

gitudinally oriented bands, known as teniae coli. In
the empty, compressed colon in thin patients, these
three teniae (arrowheads), can often be identified by
US as a local thickening of the muscular layer, separ‐
ated from the circular layer by a thin hyperechoic line.
(M= muscularis, BV= Bloodvessels, S= serosa, TC= tenia coli)

In this longitudinal view only one tenia coli (arrow‐

heads) is identified.

Serosa

The serosa or visceral peritoneum is the thin but

tough outer hyperechoic layer, which usually blends
 with the hyperechoic fatty tissue of mesentery and
Abdomen Breast omentum, surrounding  the
Cardiovascular bowel. Musculoskeletal
Chest Head/Neck

If there is intraperitoneal fluid, the hyperechoic serosa

(arrow) can
Neuroradiology Pediatrics be separately identified, as in these ileal
More
loops.

Stomach
In most patients referred for US, the stomach is
empty, either  because they have been asked not to
drink too much prior to the examination, or because
they have vomited associated with their acute abdom‐
inal problem.   

If the stomach is fluid-filled and  the patient denies

previous drinking, this is a relevant finding. 

It may be mechanical obstruction,  gastric paresis or

hypersecretion with stasis due to active peptic ulcer
disease. 

Antrum and duodenal bulb are the parts of the stom‐

ach best identified by US. 

The pylorus is recognized as a local thickening of the

muscularis distally to the antrum. 

The wall of the duodenal bulb is thinner than that of

the stomach. 

Gastric fluid can be used to improve visualization

of  the antrum and duodenal area, by turning patients
on their right side: air rises to the gastric fundus, and
fluid enters antrum and duodenal bulb. 

This is especially helpful in adults with  peptic ulcer

disease. 

The left image shows a gastric ulcer (arrow). 

Note the loss of layer structure in the ventral stomach

wall and the inflamed fat (asterisks) representing the
omentum and mesentery, trying to wall-off the immin‐
ent perforation from this deep penetrating gastric
ulcer. 

The right image shows an ulcer (arrow) in the ventral

wall of the fluid-filled duodenal bulb. 

Descending and horizontal duodenum are rarely ac‐

cessible for US. 
 When specifically looked for,  large air-filled duodenal
Abdomen Breast diverticula, present
Cardiovascular in 10-15
Chest % of theMusculoskeletal
Head/Neck normal
population,  can be identified. 

They present
Neuroradiology Pediatrics as a (curvi)linear reflection within the
More
pancreatic head. 

Note that these patients often have a wider common

bile duct than normal patients.

Small bowel
Enable Scroll
The normal small bowel is easily visualized by US and
is recognized by continuous and vivid peristalsis,
even if the lumen is empty.  

Note multiple small round echolucencies with a hy‐

perechoic border within the bright submucosa. 

These represent normal 0.4 – 0.5 mm vessels. 

Note also the thin hyperechoic line within the muscu‐

laris, representing the connective tissue separating
the longitudinal and circular muscle layer, containing
the Auerbach plexus.

Normal small bowel in the longitudinal plane.

Enable Scroll

Jejunum
The jejunum (left image) is mainly located in the LUQ,
and contains more Kerckring’s folds (valvulae con‐
niventes) than the ileum (right image), which is more
located in the RLQ.  

Measuring bowel wall thickness with US is difficult

because thickness changes with peristaltic
movements. 
 In this individual, measurements in the longitudinal
Abdomen Breast plane (upper panel)  and
Cardiovascular in the axial Musculoskeletal
Chest Head/Neck plane during light
compression (left under) vary considerably, but during
moderate compression (right under) measurements
are well reproducible
Neuroradiology Pediatrics More and accurate.

As the thin hyperechoic serosa is rarely discernible,

bowel wall thickness is  measured from the outer con‐
tour of the ventral muscularis to the outer contour of
the dorsal muscularis, and then of course, divided by
two.

Normally, single small bowel wall thickness during

compression is about 1.5 - 2.5 mm.

Measuring bowel wall thickness by US this way  is re‐

producible and comparable to what surgeons do with
their fingers during laparotomy to decide whether
small bowel is abnormal.  

In contrast to most diseased bowel loops, normal

small bowel loops are well compressible during
relaxation. 

Compare a normal terminal ileum (left) and a Crohn’s

ileum (right), without compression (upper images)
and with compression (lower images).

Note the same cm-scale in all four US-images.

Single wall thickness in the normal individual is 1.5

mm, in the Crohn patient 6.5 mm

Terminal ileum
The terminal ileum can often be identified separately
due to its specific location and course from the pelvis
toward the paracolic gutter. 

The  actual discharging of the normal terminal ileum

into the cecum can only be seen in thin patients with
an empty cecum. 
 The location of the ileocecal valve may vary widely,
Abdomen Breast but its average location
Cardiovascular is right of theMusculoskeletal
Chest Head/Neck umbilicus.

Note the lymphoid hyperplasia of the Peyer’s patches

in the terminal
Neuroradiology Pediatrics Moreileum. 

More frequently the terminal ileum can be followed

Enable Scroll until it disappears into the feces-filled cecum.

These are images of the terminal ileum in three differ‐

ent children and young adults with large Peyer’s
patches presenting as asymmetrical, hypoechoic
thickening of the deep mucosa. 

With every new antigen, the lymphoid tissue becomes

reactivated.  

In young patients both mesenteric lymph nodes and

Peyer’s patches are –also in absolute dimensions-
much larger than in adults.

The stimulated lymphoid tissue in youngsters not

only results in prominent Peyer’s patches in the ter‐
minal ileum and enlarged mesenteric lymph nodes
(left under), but also in a thickened deep mucosa of
the appendix (right under). 

Note that the –sometimes polyp-like- protrusions

(right upper), may act as lead-point in the classic ileo‐
cecal intussusception in young children
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Intussusception
Here the US image in a 2 year-old child with intermit‐
tent ileocecal intussusception, examined in between
attacks. 

The ileum with abundant Peyer’s patches shows pro‐

laps into the cecum.

Classic US image of ileocecal intussusceptions in two

different children. 

In both, the intussuscepted ileum is asymmetrically

positioned within the intussuscipiens, due to the hy‐
perechoic fatty mesentery, attached to the ileum and
following the ileum, when pulled in. 

Within the mesentery US shows an enlarged mesen‐

teric lymph node (ln) in both. 

These nodes are enlarged as part of the general

lymphoid hyperplasia and are not localised in the ileal
lumen. 

Therefore it is not the primary lead point. In the pa‐

tient on the right, the appendix (arrow) is pulled in
also.  

Note  the multi-layered aspect of the ventral wall of

the intussusception complex, representing three fol‐
ded bowel wall layers.

Although the lymphoid tissue in the terminal ileum is

most impressive in the young child, it may be found
 until the age of 20 years. 
Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal
In this young man of 15 years with an acute appendi‐
citis (arrowheads), there are still prominent Peyer’s
patches (p.)
Neuroradiology Pediatrics in the deep mucosa of the terminal
More
ileum.

During US examination, it is not unusual to witness a

small, transient, ileo-ileal intussusception. 

Apart from lack of symptoms, these can be discrimin‐

ated by US  from the real symptomatic intussuscep‐
tion, because they are smaller (< 2 cm), compressible,
transient and have no lead point. 

These transient intussusceptions may be associated

with celiac disease and it is important to exclude this
condition with blood tests.  

Omentum, mesentery and lymph nodes

The normal omentum is usually not separately
visible. 

When it is thickened e.g. in malignant or, more rarely,

in tuberculous peritonitis, it may present as omental
cake, especially if there is concomitant ascites. 

US can also visualize the omentum (arrowheads)  in

segmental omental infarction, in which the omentum
is swollen due to venous hemorrhagic infarction.

The small bowel is attached to the mesentery which

is folded like a fan. 

The mesentery contains a variable amount of fat, and

the folded, fatty mesentery has a multi-layered as‐
pect, especially when compressed during US. 
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The normal mesentery (arrows)  in thin patients is

only visible when there is ascites. 

In the obese, the mesentery contains a lot of fat and

can be visualized as a well-compressible, flat, multi-
layered structure. 

In one plane this may simulate a thickened bowel wall

(arrows in left image) . 

Turning the probe 90 degrees (right image), it is im‐

mediately recognized as a flat structure (arrows). 

At the edge of the fatty mesentery, vivid peristalsis in

two small bowel loops can be visualized.

Click image for animation.

Click image for animation.

Epiploic appendages
 Next to mesentery and omentum, also the properiton‐
Abdomen Breast eal fat is part of the
Cardiovascular intra-abdominal
Chest fatty tissue, as
Head/Neck Musculoskeletal
are the epiploic appendages (arrows).

They haveMore
Neuroradiology Pediatrics a fragile blood supply (white arrowheads) ,
prone to hemorrhagic infarction (epiploic
appendagitis). 

Normal epiploic appendages are only visible on US

and CT  in case of ascites.

Within the mesentery the mesenteric lymph nodes

can be visualized, predominantly in the region right of
the umbilicus. 

During graded compression in thin patients the nodes

appear very close to psoas muscle and iliac vessels. 

The dimensions of the normal mesenteric lymph

node are variable, in this case the dimensions in three
planes are 3 x 11 x 16 mm. 

Although transverse and longitudinal diameters may

even be larger, the shortest axial diameter in adults
should not exceed 5 mm. 

In case of enlarged mesenteric lymph nodes, it is -ini‐

tially- only the shortest axial diameter that increases. 

Therefore, to decide whether a node is normal or ab‐

normal, measuring the shortest axial diameter
suffices. 

The shape of  a normal versus an abnormal mesen‐

teric lymph node, is that of an almond versus an olive.
In children, especially those of 5 to 10 years old, the
mesenteric lymph nodes are much larger than in
adults, with short axial diameters up to 10 mm. 

These large mesenteric lymph nodes in children, may

be associated with viral infections, but can be found
in otherwise healthy kids.

Normal mesenteric lymph nodes have a relatively hy‐

perechoic center and a lobulated, echolucent peri‐
pheral zone, representing the germinal centers.
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Appendix
An experienced sonographer can identify  the entire
normal appendix -including the blind end-  in about 30
% of adult patients and 80 % of children.

US visualization of the entire normal appendix, ex‐

cludes appendicitis. 

The normal appendix has the same layers as in nor‐

mal bowel wall. In this young woman all five layers
are visible including the serosa, thanks to a little in‐
traperitoneal fluid. 

Note the empty lumen and the normal triangle-shaped

hyperechoic meso-appendix.

To compress the appendix, a rather firm underground

Enable Scroll is mandatory like iliac artery, psoas muscle or verteb‐
ral body. 

The normal appendix  (arrowheads) is discriminated

from small bowel by its location, its size, its absence
of peristalsis, its attachment to the cecal pole (c.p.)
and its blind distal end (arrows). 
 Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal

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The blind end of the normal appendix is firmly demon‐

Enable Scroll strated using a “mini-clip”. 

The US diameter of the appendix is measured the

same way as bowel: during moderate compression
from outer contour of the ventral muscularis to the
outer contour of the dorsal muscularis. 

Thus measured, the diameter of this normal appendix

(left)  is 4.5 mm and of this inflamed appendix (right)
8.5 mm. 

In many textbooks a cut-off value of 6 mm is repor‐

ted, however this is not a reliable value.

Rettenbacher (Radiology 2001; 218: 757-62) did a

large study and  found that  the diameter of the nor‐
mal appendix was 6 mm or larger in 27 % of cases,
with a range of 2-13 mm. 

The US criteria of appendicitis will be discussed  in a

special chapter on appendicitis.
 CT measurements overestimate the appendix dia‐
Abdomen Breast meter
Cardiovascular
compared Chest
to US. Head/Neck Musculoskeletal

In the literature the mean CT diameter of a normal ap‐

Neuroradiology Pediatrics More
pendix is 6.5- 8 mms (range, 3 to14 mm). 

The explanation for this discrepancy may be that on

CT:
The serosa is included in the measurement 
There is no compression involved. 
Also, the contours of the appendix on CT are
rather fuzzy, making measurements less
reproducible.
The left panel here shows a CT of a normal, feces-
filled appendix of 8.5 mm. 

The middle  panel  is a US image of a comparable nor‐

mal appendix in a different patient measuring 7.5
mm, the right panel shows that same appendix during
compression (5.5.mm).  

The literature indicates that the US diameter of the

normal appendix is 6 mms or less in 73  % of cases. 

Here you see the normal appendix during compres‐

sion in ten different patients with AP-diameters vary‐
ing from 2-10 mm (Note the same cm-scale). 

In the lower five, the lumen is filled with fecal material

of various reflectivity, which make the appendix less
compressible. 

The most important discriminating feature indicating

appendicitis is inflamed fat, followed by diameter,
non-compressibility, hyperemia and a fixed position. 

There are of course additional US features in ad‐

vanced appendicitis, as fluid collections and loss of
layer structure, but in these cases it is clear that the
appendix is inflamed.

More rarely, some intraluminal fluid is seen, in which

case the appendix is easily compressible.
 Not rarely, the blind ending tip  (arrowheads) of the
Abdomen Breast normal appendixChest
Cardiovascular has noHead/Neck
lumen due to fibrosis.
Musculoskeletal

Neuroradiology Pediatrics More

Unlike the inflamed appendix, the normal appendix

has no fixed position and during the US examination
may appear in different places in the abdominal
cavity. 

If lying in a curved position, the individual sections

(arrows) are close to each other, in contrast to the in‐
flamed appendix that becomes more rigid and
stretches to some extent.

Not infrequently strongly reflective structures (ar‐

rows) with an acoustic shadow are found, indicating
inspissated feces. 

As they are small and not calcified on CT, they are no

true fecoliths and also do not predispose for
appendicitis. 

US images in this 15 year old boy show a normal

compressible appendix with a large fecolith (arrows),
producing a hard acoustic shadow.  

The patient was symptom free at the time of the US

examination, but he recalled four,  one-day-lasting,
self-limiting episodes of severe RLQ pain over the
past nine months, suggestive for recurrent acute ap‐
pendicitis. After appendectomy he had no more
attacks. 

In children, the deep mucosa may show remarkable

hypoechoic thickening due to lymphoid hyperplasia,
which may also render the appendix less
compressible. 

This is a common finding in healthy kids, but in case

of very prominent hyperplasia, a viral infection may be
present. 

Note the complete absence of inflamed fat.  

Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal

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Colon
Longitudinal (left) and transverse (right) image of the
empty sigmoid in a lean patient.

In the transverse image three areas of local thicken‐

ing of the muscularis (arrowheads) represent the
three teniae coli (arrowheads).

Normal colon filled with feces (left), during contrac‐

tion (middle) and during relaxation and compression
(right). 

Normal colon wall thickness during compression is 3-

4 mms. 

Acoustic shadowing of the feces prevents US visual‐

ization of the  posterior wall (left). 

Colon is distinguished from small bowel by location,

fecal contents, scarce peristalsis and  a thick outer
muscle layer with three tenia coli.  

The muscularis of the sigmoid may considerably vary

in thickness, mainly due to contraction.

Permanent thickening of the muscularis is associated

with the development of diverticula (arrows).
 Sigmoid diverticulosis in four different patients.
Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal
Feces-filled diverticula are best visualized when the
colon is contracted. 
Neuroradiology Pediatrics More
They present as bright reflective structures with an
acoustic shadow on the outer contour of the colon.

Note the variable thickness of the muscularis in these

four patients.

Detailed US image of sigmoid diverticulum in very

lean 61-year old patient. 

There is a little feces present in the sigmoid lumen

and a large fecolith in the diverticulum (arrows).

Note the very thin wall of the diverticulum, consisting

of herniated (sub)mucosa covered by a very thin
serosa. 

The herniation through the muscularis, invariably oc‐

curs at a weak spot where the vessels penetrate the
circular muscle layer, immediately next to the tenia
coli (arrowheads). These penetrating vessels are
identified by color Doppler in another very lean patient
(left under) and illustrated in the Netter image right
under.  

Undigested vegetables may incidentally appear as so-

called “black feces” within the colonic lumen. These
can be differentiated from colonic polyps by their
edgy contours, lack of vascularity, their lack of adher‐
ence to the mucosa and their disappearance during
follow-up.
 Abdomen Breast Cardiovascular Chest Head/Neck Musculoskeletal

Neuroradiology Pediatrics More

Incidental finding of a round echolucent structure in

the sigmoid lumen. This proved to be a vascularized
polyp at color Doppler. Subsequent colonoscopy and
histology confirmed a polypoid, tubulovillous ad‐
enoma. Colonoscopy found also three other ad‐
enomas, not detected by US.

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