Imaging diagnosis of gastrointestinal

foreign bodies in dogs and cats: Part 2

Petra Agthe CertVDI DipECVDI MRCVS
ANDERSON STURGESS VETERINARY SPECIALISTS, THE GRANARY, BUNSTEAD BARNS, POLES LANE, HURSLEY,
WINCHESTER, HAMPSHIRE. SO21 2LL

ABSTRACT: Gastrointestinal foreign bodies are an important differential diagnosis for patients presented for
vomiting, and radiography remains the main initial imaging modality in these cases. However, while the
detection of radiopaque foreign bodies is usually easy, radiolucent foreign bodies are more difficult to identify.
This is particularly true if the obstruction they cause is incomplete or very proximal in the gastrointestinal tract,
or if a linear foreign body is present. In these cases, ultrasonography can be a very useful complementary imaging
technique. This article describes common radiographic and ultrasonographic changes associated with
gastrointestinal foreign bodies. DOI: 10.1111/j.2044-3862.2011.00068.x
GENERAL RADIOGRAPHIC AND ULTRASONOGRAPHIC
FINDINGS ASSOCIATED WITH FOREIGN BODIES
Radiographic findings
The radiographic appearance of foreign bodies (FBs)
varies greatly depending on the shape and material
of the object (Fig. 1). The detection of a radiopaque
FB (e.g. stones and bones) will generally be easier
than that of radiolucent material. If the FB is
radiolucent, the radiographic diagnosis may depend
on detection of secondary changes (e.g. intestinal
distension), rather than the object itself. However,
with careful evaluation, it is often possible to detect
even less radiopaque objects due to a subtle
difference in texture and opacity compared to the
remaining gastrointestinal content. Some types of

Fig. 2: A lateral radiograph of the abdomen of a dog with a chronic partial

obstruction due to a foreign body. The obstructing object itself cannot be clearly
identified, but a ‘gravel sign’ is seen in a mildly distended small intestinal loop in
the ventral abdomen (thin arrow). Large intestinal content may appear similar,
but such a ventral position would be unusual for the colon. Furthermore, the
descending colon and the caecum (thick arrow) can be clearly identified in a
normal anatomical location. (Courtesy of the Radiology Department, University
of Cambridge.)

foreign bodies (e.g. corn cobs, peach stones) have a

characteristic internal structure which may aid
diagnosis.

Remember that a FB in the stomach may not

represent the cause of vomiting. If a gastrointestinal
FB is identified, it is therefore essential to consider
whether or not it is in a location and of appropriate
size to cause the clinical signs.

Fig. 1: A radiograph showing different radiopacities and
structures of objects which may be ingested: the most
radiopaque object, in the top left corner, is a pebble. Rubber
may have different radiopacities, which are illustrated by the
Kong and toy tyre (soft tissue opacity), and the small,
irregular ball in the centre of the image (mineral opacity).
Larger pieces of raw fruit or vegetable may occasionally act as
foreign bodies, in this case represented by a potato in the
bottom left corner (homogeneous soft tissue opacity). The
object of streakysoft tissue opacity to the right represents
wet fabric.
Small particles of mineral opacity (‘gravel sign’) may
accumulate proximal to chronic partial obstructions
caused by FB or mural lesions (Fig. 2).
On barium contrast series, FBs typically appear as
filling defects, although porous material (e.g. fabric)
may take up a larger amount of contrast. This type of
material may be easier to visualise in the later stages,
when the majority of contrast has passed leaving the
barium-coated FB.

© 2011 Blackwell Publishing Ltd Companion Animal Vol 16 June 2011 19


Figs. 3a and 3b: Lateral and ventrodorsal radiographs of the abdomen of a cat 24
hours following the administration of BIPS. Almost all of the smaller spheres are
located in the colon. A cluster of larger spheres are present in the central
abdomen, and the ventrodorsal projection reveals that they are not located in the
colon. Final diagnosis was a small intestinal stricture. At surgery, a larger amount
of non-digestible material (including the spheres) was identified proximal to the
stricture.
Figs. 4a, 4b, 4c and 4d: The ultrasonographic
appearance of different objects, examined in a water-
bath. Most commonly foreign bodies appear as strongly
echogenic interfaces with distal ‘clean’ acoustic
shadowing, as seen in this example of a stone (a) and a
sock (b). Some objects, including some types of rubber,
may transmit the ultrasound beam and reveal an
internal structure (c). When small gas bubbles are
contained within an object, in this case cotton ropes
(d), the ring-down artefact may be observed (arrow).

Fig. 4b

Fig. 3b.
Delayed gastrointestinal transit times are also
commonly seen with FBs. In the normal patient, the
stomach should be fully empty four hours following
administration of liquid barium, and the contrast
Fig. 4c
should reach the colon after approximately 90-120
minutes in dogs and 30-60 minutes in cats. With
BIPS studies, all spheres should reach the large
intestine within 24 hours (Fig. 3). However, delayed
gastric emptying and intestinal transit may also be
observed with functional disorders and this finding
alone does not allow the conclusive diagnosis of a
mechanical obstruction.
SMALL ANIMAL G IMAGING ##

Ultrasonographic findings
The ultrasonographic appearance of FBs is also
variable (Figs. 4a, 4b, 4c and 4d). Typically, a strongly
echoic interface is identified, with strong, ‘clean’,
distal acoustic shadowing. However, some types of
material may transmit the ultrasound beam allowing
the appreciation of their internal structure. Fabric
material may in some cases show a distal ring-down
artefact (also known as ‘dirty’ acoustic shadowing).
Fig. 4d
SPECIFIC SITES AND TYPES OF FOREIGN BODIES
Gastric foreign bodies
Radiography
The size and contents of the stomach may vary
greatly and should be evaluated in light of the last

Continued on page 22

20 Companion Animal Vol 16 June 2011 © 2011 Blackwell Publishing Ltd


Fig. 5: Lateral abdominal radiograph of a dog presented for acute vomiting. The
caudal aspect of the stomach is indicated by thin arrows; it is moderately filled
with gas and fluid. Additionally, a markedly distended small intestinal loop is seen
in the mid-ventral abdomen (thick arrow). These findings are consistent with an
acute mechanical obstruction. Ultrasonography revealed a distal duodenal foreign
body. (Courtesy of the Radiology Department, University of Cambridge.)
Figs. 6a and 6b: (a) A left lateral abdominal view of a dog with a linear foreign
body. There is poor serosal detail and multiple small intestinal loops are dilated
and contain material of mottled soft tissue opacity. The pylorus is seen in the
cranioventral abdomen (arrow) and has a similar mottled content, representing
the gastric portion of the foreign body. (b) Right lateral projection of the same
patient. The abnormal material in the stomach is difficult to appreciate in this
view, illustrating the value of positional radiography. (Courtesy of the Radiology
Department, University of Cambridge.)
Fig. 6b
22 Companion Animal Vol 16 June 2011
known food/water intake, and episode of vomiting.
The lumen may be difficult to identify, or show mild
to moderate degrees of distension with gas, fluid or
ingesta. In a severely vomiting patient, though, the
presence of larger amounts of fluid in the stomach is
highly suggestive of a pyloric or proximal intestinal
obstruction (Fig. 5). However, gross gastric distension
is less commonly seen with obstructions caused by a
FB, but more frequently associated with chronic pyloric
outflow disturbances due to, for example, chronic
pyloric hypertrophic gastropathy and pyloric masses.
If freely mobile, the position of the FB will depend
on the recumbency of the patient. However, FBs
resulting in clinical signs are more likely to be lodged
in the pylorus. Linear FBs are often ‘anchored’ in the
pylorus in dogs, whereas in cats they more frequently
wrap around the base of the tongue. The presence of
gas facilitates the visualisation of FBs, particularly
those of soft tissue opacity, and positional
radiography is particularly useful in these cases (Figs.
6a-b). Note that a fluid-filled pylorus may appear as
a circular soft tissue opacity on a right lateral
recumbent radiograph, and this appearance should
not be misinterpreted as a FB.
Ultrasonography
As discussed above, the ultrasonographic appearance
of the FB depends on its material. Caution has to be
exercised, as normal ingesta can occasionally contain
Figs. 7a and 7b: Ultrasonographic images of a patient
with a pyloric outflow obstruction due to a foreign
body: (a) The fundus is moderately distended with
echogenic fluid. (b) The foreign body (between calipers)
is present in the pylorus.
Fig. 7b
© 2011 Blackwell Publishing Ltd
 Great care should be taken to differentiate the large
intestine from dilated small bowel loops. The
differentiation is important, as a gas- or fluid-filled
colon may be occasionally mistaken for a distended
small intestinal segment. However, this is not always
easy, as the colon of patients with a FB may be
empty. In these cases, positional radiography,
ultrasonography or negative contrast radiography
(pneumocolon) may be helpful.

Ultrasonography
The ultrasonographic detection of distended small
intestinal loops may be easier than with radiography,
particularly if they contain fluid (Fig. 9a). It is usually
possible to identify the FB at the level of the
obstruction (Fig. 9b). The appearance of the
Fig. 8: This right lateral abdominal projection of a dog shows ‘two populations of
intestinal wall depends on the degree of distension
bowel’: there are some markedly distended small intestinal loops containing gas caused by the object, and the damage it may have
and fluid (thick arrow) while in the caudal abdomen, a larger number of normal- caused. The wall may have preserved wall layering
sized bowel loops are identified (small arrow). (Image courtesy of the Radiology and appear only slightly thinned as it is being
Department, University of Cambridge.) stretched. If more severe changes have occurred,
there may be loss of the normal wall layering with or
larger particles, which can be confused with FBs. without wall thickening. Distal to the obstruction,
Close correlation with the clinical and radiological the small intestinal diameter usually narrows
findings is important. In a clinically significant FB, abruptly and little or no luminal material is present.
additional findings may include gastric distension
due to outflow obstruction (Figs. 7a and 7b) or Linear foreign bodies
changes in the wall thickness and layering in cases Radiography
of associated gastritis. With linear FBs, crescent- or tear drop-shaped gas
pockets are often seen radiographically, but gross
Intestinal foreign bodies intestinal distension is usually absent. With this type
Radiography
Intestinal FBs are often associated with a marked
distension of the small intestinal loop (ileus).
Normally, the small intestinal diameter should be no
larger than the height of a lumbar vertebral body in
dogs, and less than 12 mm in cats. A diameter greater
than 1.6 times the height of the mid-body of L5 is
suggestive of an obstruction. Typically, the changes
are severe and focal (Fig. 8), involving only a few
intestinal loops, while other small intestinal segments
are of normal size (‘two populations of bowel’).
However, if the obstruction is incomplete or
affecting the proximal intestines (duodenum or Figs. 9a and 9b: Ultrasonographic appearanc of a small
proximal jejunum), the intestinal distension may not intestinal obstruction. (a) The intestine proximal to the
be detectable radiographically. obstruction is distended with echogenic ingesta. The
wall is thinned due to the degree of distension, but
normal wall layering is preserved. (b) The obstructing
The radiographic finding of small intestinal ileus
object can be identified (arrows); distal to this level, the
is not limited to luminal obstruction due to FBs. intestines had a normal appearance.
Differential diagnoses include other mechanical
obstructions (e.g. stricture or neoplasia) or functional
causes (e.g. peritonitis or severe gastroenteritis),
although the degree of distension is usually less severe.
SMALL ANIMAL G IMAGING ##

The normal small intestine is of homogeneous soft

tissue opacity, or may contain some gas, which usually
appears as lucent bands. Smaller pockets of gas or a
granular appearance of the intestinal lumen is
suggestive of abnormal transit of ingesta and/or foreign
material. With acute obstruction, the distended
intestinal segments generally contain a larger amount
of gas, but with time the amount of fluid increases. Fig. 9b.

© 2011 Blackwell Publishing Ltd Companion Animal Vol 16 June 2011 23

 of FB, ‘bunching’ of the small intestinal loops is often
observed (Fig. 10). This means, that the intestinal
loops are not evenly distributed throughout the
abdomen, but appear restricted to a relatively small
region and show short segments with sharp turns
(plication). Care has to be taken in obese cats, as
normal small intestines may appear crowded in a
central abdominal location in these individuals.
Ultrasonography
It is generally relatively easy to identify linear FBs
ultrasonographically (Fig. 11), and intestinal plication
is often easier appreciated than with radiography.
Linear FBs often cause damage to the intestinal wall,
acting as a ‘cheese wire’, and it is important to
evaluate the wall carefully for embedded material
and loss of wall layering.
Signs of perforation
Radiography
Radiographic findings of gastrointestinal perforation
include the presence of free gas in the abdominal
Fig. 10: A right lateral abdominal radiograph of a cat with a
linear foreign body. A radiopaque fishing hook is present in
the stomach. The small intestinal loops are bunched in the
mid-ventral abdomen showing an undulating outline consistent
with plication. (Image courtesy of the Radiology Department,
University of Cambridge.)
Fig. 11: Ultrasonographic appearance of a linear foreign
body in a dog: multiple linear structures with parallel
hyperechoic borders representing several strings
(arrows) arepresent in a small intestinal segment. This
portion of the intestine shows no plication.
24 Companion Animal Vol 16 June 2011
Fig. 12: Left lateral abdominal projection of a patient with free abdominal gas and
fluid: there is poor serosal detail and a large pocket of gas can be identified as a
lucency in the craniodorsal abdomen, highlighting the caudal aspect of the
diaphragm and the fundus of the stomach. (Image courtesy of the Radiology
Department, University of Cambridge.)
Fig. 13: Ultrasonographic image of a patient with septic
peritonitis: There is free abdominal fluid containing
echogenic particles (arrow). The mesentery deep to the
fluid is hyperechoic.
cavity and loss of serosal detail due to free abdominal
fluid and peritonitis (Fig. 12). Free gas is usually most
easily detected caudal to the diaphragm and around
the gastric fundus. Unless previous surgery has been
performed, the presence of free gas in the abdomen
is highly suggestive of gastrointestinal perforation.
Ultrasonography
Ultrasonography is very useful in patients where
gastrointestinal perforation is suspected. Although it
may be difficult to identify the exact site of
perforation, the detection of flocculent, free fluid and
hyperechoic mesentery are suggestive of septic
peritonitis (Fig. 13). Ideally, ultrasound-guided
abdominocentesis for fluid analysis and cytology
should be performed in these cases.
FURTHER READING
THRALL, D. E. (2007) Textbook of Veterinary Diagnostic Radiology.
Saunders.
O’BRIAN, R. and BARR, F. J. (2009) BSAVA Manual of Canine and Feline
Abdominal Imaging. BSAVA.
BRADLEY, K. (2005) Practical contrast radiography - Gastrointestinal
studies. In Practice 27, pp. 412-417.
© 2011 Blackwell Publishing Ltd
 CONTINUING PROFESSIONAL
DEVELOPMENT SPONSORED BY
B AY E R A N I M A L H E A LT H
These multiple choice questions are based on the above
text. Answers appear as supporting information in the
online version of this article.
1. Which of the following statements about the
radiographic detection of gastrointestinal foreign
bodies is correct:
a. Radiographic detection is always straightforward.
b. Some foreign bodies have a characteristic internal
structure which may aid diagnosis.
c. The gravel sign is indicative of an acute obstruction.
d. Foreign bodies are usually radiopaque.
2. Which statement about gastrointestinal foreign
bodies is incorrect:
a. Gastric foreign bodies are not always clinically
significant.
b. Positional radiography may aid detection of
foreign bodies.
c. The normal small intestinal diameter is the height
of a lumbar vertebra in dogs and 12 mm in cats.
d. Intestinal foreign bodies are not always significant.
3. Which statement about contrast radiography is
correct:
a. The normal stomach should be fully empty 30
minutes after the administration of liquid barium.
b. The stomach should normally be fully empty
30 minutes after the administration of barium
mixed with food.
c. The normal stomach should be fully empty
90-120minutes after the administration of liquid
barium.
d. The normal stomach should be fully empty four
hours after the administration of liquid barium.
4. Which statement about the ultrasonographic
diagnosis of gastrointestinal foreign bodies is
correct:
a. Foreign bodies always cause ‘clean’ acoustic
shadowing.
b. Foreign bodies always cause a characteristic
ring-down artefact.
c. In the stomach, larger particles in the normal
ingesta may occasionally mimic foreign body
material.
d. Solid foreign bodies usually cause characteristic
plication of the small intestines.
5. Which statement about gastrointestinal distension
is incorrect:
a. A small intestinal diameter greater than 1.6 times
of the height of the mid-body of L5 is suggestive
on an obstruction.
b. Intestinal foreign bodies are often associated with
marked intestinal distension.
c. Intestinal distension may have functional or
mechanical causes.
d. Gastric foreign bodies typically cause marked
gastric distension.
6. Which statement about linear foreign bodies is
correct:
a. Linear foreign bodies usually cause marked small
intestinal ileus.
b. Linear foreign bodies often cause characteristic
‘tear drop’-shaped gas pockets.
c. Linear foreign bodies in dogs are usually ‘anchored’
in the oesophagus.
d. Linear foreign bodies are usually radiopaque.

© 2011 Blackwell Publishing Ltd