Emergency Radiology

https://doi.org/10.1007/s10140-019-01670-7

REVIEW ARTICLE

Beyond appendicitis: ultrasound findings of acute bowel pathology

Jihee Choe 1 & Jeremy R. Wortman 2 & Aya Michaels 3 & Asha Sarma 4 & Urvi P. Fulwadhva 2 & Aaron D. Sodickson 1

Received: 16 December 2018 / Accepted: 3 January 2019

# American Society of Emergency Radiology 2019

Abstract
Bowel pathology is a common unexpected finding on routine abdominal and pelvic ultrasound. However, radiologists are often
unfamiliar with the ultrasound appearance of the gastrointestinal tract due to the underutilization of ultrasound for bowel
evaluation in the USA. The purpose of this article is to familiarize radiologists with the characteristic ultrasound features of a
variety of bowel pathologies. Basic ultrasound technique for bowel evaluation, ultrasound appearance of normal bowel, and key
ultrasound features of common acute bowel abnormalities will be reviewed.

Keywords Ultrasound . Emergency . Bowel . Abdominal pain

Introduction patient preparation, low cost, and capability of provid-

Acute abdominal pain is one of the most common clin-
ical presentations in the Emergency Department (ED) as
well as in the outpatient setting, accounting for 8% of
all ED visits in the USA in 2014 and 1.5% of outpa-
tient visits in the USA in 2015, the most recent years
for which published data are available [1, 2]. Imaging
evaluation of acute abdominal pain largely depends on
the differential diagnosis generated after a thorough
evaluation of the patient’s symptoms, physical examina-
tion, and laboratory testing are obtained. Ultrasound is
frequently the first examination performed in the evalu-
ation of patients with nonspecific abdominal pain, par-
ticularly in patients with right upper quadrant pain or in
female patients in whom a gynecologic etiology is
suspected. Ultrasound has the advantages of wide acces-
sibility, lack of ionizing radiation, lack of need for
* Jihee Choe
jchoe@partners.org
1
Department of Radiology, Brigham and Women’s Hospital and
Harvard Medical School, Boston, MA, USA
2
Department of Radiology, Lahey Hospital and Medical Center,
Burlington, MA, USA
3
Department Radiology, Weill Cornell Medicine, New York, NY,
USA
4
Department of Radiology and Radiological Sciences, Vanderbilt
University School of Medicine, Nashville, TN, USA
ing real-time information; however, drawbacks include
operator dependence and limited ability to evaluate
obese patients.
Characteristic features of abnormal bowel, such as wall
thickening, decreased motility, absence of luminal content,
and a fluid-filled distended lumen, can be readily detected
by ultrasound; however, these findings may be unfamiliar to
radiologists who are more accustomed to using CT for assess-
ment of the bowel. Bowel findings may be the only explana-
tion for abdominal pain on abdominal or pelvic ultrasound
exams. Therefore, familiarity with basic ultrasound scanning
technique for bowel evaluation and characteristic ultrasound
features of normal bowel and bowel pathologies is essential.
Bowel ultrasound technique
Ultrasound evaluation of bowel should be performed
with graded compression, which can significantly in-
crease sensitivity for bowel pathology [3]. Compression
should be applied in a graded fashion to minimize pain,
similar to gentle palpation on physical examination [3].
Graded compression displaces bowel contents, fecal ma-
terial, and gas, which commonly obscure the area of
interest. It also decreases distance between the area of
interest and the ultrasound probe, improving spatial res-
olution [3]. In female patients, a transvaginal transducer
may be used to assess bowel pathologies in the deep
pelvis, such as distal sigmoid diverticulitis or appendici-
tis in an unusual deep location.

General principles of bowel ultrasound
Ultrasound features that help distinguish normal from abnormal
bowel include wall layers, wall thickness, luminal diameter,
peristalsis, compressibility, vascularity, perienteric/pericolonic
fat inflammatory changes, and associated enlarged lymph
nodes.
Normal bowel on ultrasound is characterized by the
wall stratification Bgut signature^ sign, in which five dis-
tinct wall layers can be visualized (Fig. 1). Familiarity
with the Bgut signature^ sign allows one to recognize
bowel and distinguish it from other structures on ultra-
sound. Loss of the typical gut signature pattern is consid-
ered a sign of diseased bowel.
The average bowel wall thickness on ultrasound is
2–4 mm for small bowel and up to 5 mm for large bowel.
The gastric wall is usually thicker and measures up to
5–6 mm [4]. The wall thickness is measured from the
central hyperechoic line of the lumen to the outer
hyperechoic margin of the wall [5]. Bowel wall thicken-
ing is the most common finding of bowel pathology, but
is nonspecific. Evaluation of the symmetry, degree, and
distribution of wall thickening can help in determining the
cause of bowel wall thickening.
Assessment of the caliber of the bowel lumen is im-
portant in the evaluation for bowel pathology. Luminal
narrowing can be seen in various conditions, such as
inflammatory bowel disease [6] and neoplasm, and at
transition points in cases of small bowel obstruction. It
may be difficult to distinguish luminal narrowing from
transiently contracted bowel segments; in this situation,
other associated findings such as wall thickening or
Fig. 1 The normal five distinct layers of bowel wall on ultrasound, also
referred as the Bgut signature^ sign. The innermost hyperechoic layer
(pink) represents the interface between the mucosa and bowel contents.
The second, hypoechoic layer (peach) is the deep mucosa and third,
hyperechoic layer (green) is the submucosa. The fourth, hypoechoic
layer (cyan) represents the muscularis propria and the outermost,
hyperechoic layer (orange) represents the serosa and serosal fat
Emerg Radiol
decreased peristalsis can help to confirm true luminal
narrowing. In small bowel obstruction, small bowel
loops are dilated and typically measure greater than
3 cm in diameter [7].
Real-time imaging by ultrasound can identify alter-
ations in peristalsis. Absent or diminished peristalsis is
seen in various disease states, including but not limited
to bowel ischemia, infection, inflammation, and malig-
nancy. Hyperperistalsis is frequently observed in small
bowel obstruction and celiac disease [6, 8].
Normal bowel should be easily compressible by transducer
pressure. Lack of compressibility may indicate diseased bow-
el, as in appendicitis, intussusception, bowel malignancy, and
luminal distention from obstruction.
Color or power Doppler can provide additional infor-
mation about increased vascularity in inflammatory dis-
ease and solid masses. It is difficult to obtain Doppler
signal in the normal bowel wall, as it is thin and compli-
ant, with peristaltic activity [9, 10]. Decreased vascularity
in thickened bowel wall is highly suggestive of bowel
wall ischemia in certain clinical settings, although it is
not a sensitive finding [11, 12].
Inflammatory changes increase the echogenicity of the
perienteric/pericolonic fat in various infectious and in-
flammatory bowel disease, whereas normal perienteric/
pericolonic fat is generally inconspicuous. Enlarged
lymph nodes are also a sign of bowel inflammation and
bowel malignancies and can commonly be visualized
sonographically (Table 1).
Appendicitis
Ultrasound and CT are the most commonly used modali-
ties for diagnosing appendicitis. The decision to obtain
ultrasound or CT depends on operator experience, patient
age and body habitus, and institutional preference [13].
The major advantage of ultrasound over CT is lack of
radiation exposure, making ultrasound an ideal initial di-
agnostic imaging test for young patients with normal
BMI. Ultrasound has proven diagnostic value in acute
appendicitis, with reported sensitivity and specificity of
78–99 and 83–99%, respectively [14–17], and accuracy
of 70 to 99% [15–18].
Sonographic evaluation of appendicitis starts with
identifying the ascending colon and cecum, which is
achieved by scanning from the tip of the liver to the pel-
vic brim in the transverse plane, with several sweeps from
the lateral to the medial aspect of the right lower quadrant
[13]. The ascending colon and cecum are nonperistaltic
and can be distinguished from adjacent small bowel as a
gas-filled viscus with dirty shadowing and a Bbumpy^
outer contour. The terminal ileum is then identified as a
Emerg Radiol

Table 1 General principles of bowel ultrasound

Wall stratification/Bgut signature^ sign - Five distinct layers of the bowel wall can be visualized
- Loss of the typical gut signature pattern is a sign of diseased bowel
Wall thickness - The average thickness of small bowel wall on ultrasound is 2–4 mm and up to 5 mm for large bowel
- Wall thickening is the most common finding of bowel pathology
Luminal diameter - Luminal narrowing can be seen in various bowel abnormalities
- Dilated small bowel loops (>3 cm) can be found in small bowel obstruction
Peristalsis - Absent or diminished peristalsis is seen in various bowel diseases
- Hyperperistalsis is frequently observed in small bowel obstruction and celiac disease
Compressibility - Normal bowel should be easily compressible by transducer pressure
- Lack of compressibility may be evident in various causes of diseased bowel
Vascularity - Color or power Doppler can provide information about increased vascularity in inflammatory diseases
and suspicious solid masses
- Decreased vascularity in thickened bowel wall is highly suggestive of bowel wall ischemia in certain
clinical settings, although this is not a sensitive finding
Inflammation of adjacent fat - Inflammatory changes increase the echogenicity of the perienteric/pericolonic fat

compressible, peristalsing loop of bowel caudal to the
ascending colon. The appendix typically arises from the
posteromedial aspect of the cecum near the ileocecal
valve in any direction, 1–2 cm below the terminal ileum.
It is difficult to visualize a retrocecal appendix with a
standard anterior approach. The retrocecal appendix is
best identified via a lateral flank approach with the trans-
ducer positioned adjacent to the cecum or ascending colon
[19]. An appendix in the deep pelvis may also be difficult
to identify with transabdominal scanning and is best seen
with transvaginal scanning in female patients. Another
approach to identifying the appendix in suspected appen-
dicitis is to start by scanning in the area of the patient’s
localized maximum tenderness, which can be helpful in
identifying an aberrantly located appendix and reducing
the duration of the examination in positive cases. When
the patient can decisively localize the site of maximal
pain, there is a significant finding 95% of the time [20].
Eighty-five percent of patients with appendicitis are able
to self-localize the pain [20].
The normal appendix is seen as a tubular, blind-ending,
nonperistaltic structure that originates from the cecum. It
should be compressible and should measure less than 6 mm
in diameter when compressed (Fig. 2a). The inflamed appen-
dix is noncompressible, immobile, and dilated to greater than
6 mm in diameter (Fig. 2b). The measurement of the appen-
dix should be taken in the anteroposterior dimension from
outer wall to outer wall with full compression. Doppler ultra-
sound may show hyperemia in the wall of the appendix as
supporting evidence of inflammation. An appendicolith may
be seen as a discrete echogenic focus with acoustic
shadowing in the lumen of appendix. While an appendicolith
may occasionally be an incidental finding, the presence of an
appendicolith in a patient with acute abdominal pain and
suspected appendicitis is regarded as a highly specific finding
for the diagnosis of appendicitis. When an appendicolith is
identified in a patient with suspected appendicitis, ultrasound
is 65% sensitive and 86% specific for the diagnosis of appen-
dicitis [21]. Inflamed, hyperechoic periappendiceal fat is of-
ten evident. Phlegmonous change appears as a hypoechoic
area with poor margination [22]. Periappendical abscess man-
ifests as an organized fluid collection with mass effect.
Reactive enlarged mesenteric lymph nodes and reactive wall
thickening and edema of the cecum near the base of the
appendix can be seen.
Diagnostic pitfalls of appendicitis evaluation with ultra-
sound include perforated appendicitis and tip appendicitis.
Compared to CT, an important limitation of ultrasound in
the evaluation of appendicitis is lower sensitivity and speci-
ficity for perforated appendicitis. In a case of perforated ap-
pendicitis, the appendix may appear normal in diameter be-
cause the appendix is often decompressed when perforated
[13]. An inflamed appendix is identified by ultrasound in only
38–55% of patients with perforated appendicitis [23, 24].
Identification of secondary signs of a perforated appendix,
such as loculated fluid, phlegmon, or abscess, can be helpful
clues for the diagnosis of perforated appendicitis and should
increase suspicion (Fig. 2c) [25]. When inflammation is lim-
ited to the distal tip, the proximal appendix appears normal,
which may lead to a false-negative exam. Therefore, it is im-
portant to follow the appendix along its whole length and to
visualize the blind end as a part of every sonographic evalua-
tion of the appendix [26]. Rarely, the inflamed appendix can
get quite enlarged and be mistaken for small bowel due to its
unusually large caliber [9].
Infectious colitis
Infection is the most common cause of colitis. Infectious co-
litis can be bacterial, fungal, viral, or amebic in etiology. Most
of the causes of infectious colitis share similar ultrasound

Fig. 2 a Normal appendix. Ultrasound image shows a normal appendix,
which is seen as a tubular, blind-ending structure (arrow). The normal
appendix should be compressible and should measure less than 6 mm in
diameter. b Appendicitis in a 15-year-old male with abdominal pain. A
sonographic image of the right lower abdomen demonstrates a dilated
appendix that measures 1.0 cm in diameter (arrowheads) with at least
two appendicoliths within the proximal and distal aspects of its lumen
features of colonic wall thickening (> 5 mm) and pericolonic
fat inflammatory changes (Fig. 3). Ascites may or may not be
present. Because the normal colonic wall is not well visualized
sonographically, any visibly thickened wall should raise clin-
ical suspicion for colitis. In general, when wall thickening is
present, the affected segment of colon becomes much easier to
visualize.
Since there is considerable overlap of appearance among
various causes of infectious colitis, specific diagnosis can only
be made with clinical history and laboratory testing. The dis-
tribution and site of a colonic abnormality may suggest a spe-
cific infectious agent. Cytomegalovirus and Escherichia coli
most commonly cause pancolitis, and Yersinia, Salmonella,
and tuberculosis mainly affect the right colon. Colitis caused
by schistosomiasis, shigellosis, herpes, gonorrhea, syphilis,
and lymphogranuloma venereum is usually left-sided [27].
Pseudomembranous colitis
Pseudomembranous colitis is a type of colitis caused by toxins
produced by Clostridium difficile bacteria in the colon, usually
as a complication of antibiotic therapy and resultant bacterial
overgrowth [28]. It is also associated with abdominal surgery,
prolonged hypotension, colonic obstruction, and uremia.
Pseudomembranous colitis is most commonly a pancolitis.
Fig. 3 Colitis in a 34-year-old
female with abdominal pain. a
Longitudinal and b transverse
sonographic images of the right
lower abdomen demonstrate wall
thickening of the cecum
(arrowheads) with adjacent
echogenic fat suggesting
inflammation (asterisk)
Emerg Radiol
(arrows). c Perforated appendicitis in a 10-year-old male with abdominal
pain. Ultrasound image shows a blinding-ending tubular structure origi-
nating from the cecum measuring up to 1.1 cm in diameter (arrowheads),
consistent with an inflamed appendix. There is discontinuity in the tip of
the appendix (arrow) with surrounding extensive inflammatory changes
(asterisk), concerning for perforated appendicitis, which was confirmed
with subsequent CT
Pronounced wall thickening of the colon is present in most
cases of pseudomembranous colitis when compared with oth-
er types of colitis; however, definitive diagnosis is made with
stool assay for C. difficile toxin. Wall thickening represents
severely edematous submucosa and mucosa, giving the
Baccordion^ sign or Bgyral^ pattern (Fig. 4) [28, 29]. Wall
thickness ranges from 10 to 30 mm [28, 30]. Wall stratification
is usually preserved despite increased wall thickness [30].
Typhlitis
Typhlitis is also known as neutropenic enterocolitis and occurs
most commonly as a complication of neutropenia in a patient
receiving chemotherapy. It was first described in children with
acute leukemia treated with induction therapy [31]. It is a
necrotizing inflammatory disease mainly affecting the cecum
and often extending into the ascending colon and terminal
ileum [32]. Predilection for the cecum may be related to its
specific anatomic characteristics, including vascular supply
from terminal branches of the superior mesenteric artery, high
concentration of lymphatic tissue, distensibility, and relatively
static intraluminal contents [33, 34]. It may also occur in pa-
tients with other immunosuppressive conditions who are not
on chemotherapy. Pathogenesis of typhlitis is not completely
understood, but multiple factors severely damage the mucosa,
Emerg Radiol

Fig. 4 Pseudomembranous colitis

in a 2-year-old female.
Ultrasound images (a, b)
demonstrate diffuse marked wall
thickening of the large bowel
loops (arrowheads) with marked
submucosal edema (asterisk).
There is small ascites (arrows)

resulting in marked intramural edema and hemorrhage. The
severity of typhlitis ranges from mild gastrointestinal symp-
toms to sepsis with a potentially lethal outcome. The key
ultrasound feature of bowel wall thickening is not specific
for typhlitis; however, the diagnosis should be suspected when
wall thickening involves the cecum in a neutropenic patient
(Fig. 5) [35]. Other entities such as Crohn’s disease and infec-
tious colitis caused by Yersinia, Salmonella, and tuberculosis
commonly affect the right colon and should also be consid-
ered in the differential diagnosis; however, clinical history and
presentation usually allow distinction among these entities.
Colonic diverticulosis/diverticulitis
Colonic diverticulosis is characterized by herniation of the
mucosa and submucosa through an area of weakness in the
muscle layer of the bowel wall and mainly occurs in the distal
colon, with only 15% involving the right colon [36].
Diverticulitis develops due to microperforation of a diverticu-
lum when its neck is obstructed by a fecalith, stool, or inflam-
matory edema [37].
Ultrasound has been demonstrated to have high sensi-
tivity and specificity in diagnosing diverticulitis, with re-
ported sensitivity and specificity of 77–98 and 80–99%,
respectively [38–41]. Ultrasound features of diverticulitis
include the presence of diverticula with associated colonic
wall thickening and inflammatory changes in the
pericolonic fat (Fig. 6). A normal diverticulum presents
as a thin-walled round or oval hyperechoic focus that
protrudes from the colonic wall, with focal disruption of
the normal layer continuity and posterior acoustic
shadowing of variable intensity that is thought to arise
from air, feces, or enteroliths [37, 42]. An inflamed diver-
ticulum will be thick-walled [6], with inflamed surround-
ing pericolonic fat that is echogenic and thickened.
Diverticulitis is considered complicated when it is associ-
ated with bowel obstruction, free air, abscess formation,

Fig. 5 Typhlitis in a 21-year-old

patient with acute lymphocytic
leukemia on chemotherapy (a–c).
The walls of the ascending colon
and cecum are markedly
thickened (arrowheads), with
power Doppler demonstrating
increased blood flow (curved
arrow). The lumen of the bowel is
narrowed (arrow)
 Emerg Radiol

Fig. 6 Diverticulitis in a 44-year-

old female with abdominal pain.
Transverse (a) and longitudinal
(b) sonographic images in the
region of the patient’s maximal
tenderness (in the left lower
quadrant) demonstrate an
enlarged, inflamed diverticulum
(arrows) associated with colonic
wall thickening (letter C).
Associated hyperechoic
pericolonic fat is present
(asterisk), suggesting
inflammation

and fistula formation to adjacent structures such as blad- inflamed Meckel’s diverticulum may mimic appendicitis, as
der, vagina, skin, or other bowel loops. it may be noncompressible [48]. When it is compressible, it
may resemble a duplication cyst due to the presence of gut
signature sign in both entities; however, an inflamed Meckel’s
Meckel’s diverticulitis diverticulum will have an irregular internal wall, compared
with the smooth internal wall of a duplication cyst [49].
Meckel’s diverticulum is the most common congenital anom-
aly of the gastrointestinal tract, caused by failure of regression
of the omphalomesenteric duct. The omphalomesenteric duct Crohn’s disease
connects the yolk sac to the midgut through the umbilical cord
and typically is obliterated by the fifth to eighth week of ges- Crohn’s disease is an inflammatory bowel disease character-
tation [43]. Most Meckel’s diverticula are found within 40– ized by a chronic course with multiple episodes of remission
100 cm of the ileocecal valve and arise from the anti- and exacerbation. It can involve any portion of the gastroin-
mesenteric border of the distal small bowel [44]. They are testinal tract from the mouth to the anus, most often with ileal
present in approximately 2% of the population. On ultrasound, and/or colonic involvement. Granulomatous inflammation is
the Meckel’s diverticulum appears as a blind-ending, fluid-
filled tubular structure with typical gut signature that is con-
nected to a normal, peristaltic small bowel loop. Gut signature
sign helps to confirm origin from bowel. Enteroliths are pres-
ent in 10% of cases and are visualized as shadowing
echogenic foci [45].
Most affected patients remain asymptomatic during their
lifetime, but complications occur in 4–40% [43]. The most
common complications include bleeding, bowel obstruction,
diverticulitis, and intussusception. Hemorrhage is the most
frequent complication of Meckel’s diverticulum in the pediat-
ric population and is caused by peptic ulceration from hetero-
topic gastric and pancreatic mucosa [46]. Technetium-99m
pertechnetate scintigraphy is the imaging modality of choice
for evaluating pediatric patients presenting with gastrointesti-
nal hemorrhage from a suspected Meckel’s diverticulum [47].
Intestinal obstruction is the second most common complica-
tion of Meckel’s diverticulum, and the diagnosis of Meckel’s
diverticulum is most often made perioperatively. A Meckel’s Fig. 7 Meckel’s diverticulitis in a 6-year-old male with episodic, diffuse
diverticulum can become inflamed secondary to acid secretion abdominal pain for 3 days. A transverse sonographic image demonstrates
from ectopic gastric mucosa or due to obstruction by a blind-ending loop of bowel in the midline pelvis (arrow), with a mildly
thickened, slightly irregular wall (arrowheads). There is associated mild
enteroliths, foreign bodies, or neoplasms [43]. Ultrasound hyperemia within the wall with adjacent fat stranding (asterisk) and trace
signs of Meckel’s diverticulitis include thickened wall and free fluid (curved arrow). The finding of Meckel’s diverticulitis was
increased wall vascularity of the diverticulum (Fig. 7). An confirmed with CT and the patient was taken to surgery
Emerg Radiol
transmural and segmentally distributed, with skip areas and
bowel wall thickening. Deep fissures, sinuses, and fistulas are
seen in advanced disease. Strictures occur in longstanding
disease and result from edema, inflammation, and ultimately
fibrosis and scarring [22].
Ultrasound has proven to be of value in detecting Crohn’s
disease with reported sensitivity of 88% and specificity of
97% [50]. The most common sonographic finding of
Crohn’s disease is bowel wall thickening. A meta-analysis
evaluating different cutoff values for bowel wall thickness
showed that sensitivity and specificity of ultrasound in detect-
ing Crohn’s disease were 88 and 93%, respectively, when the
bowel wall measured > 3 mm, and sensitivity and specificity
were 75 and 97%, respectively, when a cutoff of 4 mm was
used [51]. The echotexture of the thickened wall in Crohn’s
disease is variable. Normal stratification can occasionally be
maintained or may be lost partially or completely [6]. In cases
with maintained stratification, variable enlargement of the mu-
cosal, submucosal, or muscular layers is demonstrated [52].
The typical gut layering can be lost secondary to transmural
inflammation, edema, and fibrosis, resulting in a thick
hypoechoic rim and the Btarget^ sign. The Btarget^ sign is
the classic ultrasound feature of Crohn’s disease, seen as a
hypoechoic rim of moderate to marked concentric wall thick-
ening with central echogenic bowel contents within the
narrowed lumen. The diseased bowel segment is relatively
rigid and noncompressible, with reduced or absent peristalsis
in the small bowel and loss of haustra in the colon [22].
Luminal narrowing results from gross inflammatory thicken-
ing of the bowel wall or fibrotic strictures [6]. Although these
findings are characteristic of Crohn’s disease, a number of
other conditions, including infectious, ischemic, neoplastic,
and radiation-induced bowel disease, can have a similar ap-
pearance. Diagnosis of Crohn’s disease can be suggested
when there is segmental, circumferential bowel wall thicken-
ing that affects the terminal ileum along with evidence of
complications of Crohn’s disease (e.g., abscess or fistula).
In Crohn’s disease, mucosal ulcerations may penetrate into
the submucosa, muscularis, serosa, and outside of the bowel
and lead to formation of fissures, fistulae, and sometimes
intra-abdominal or retroperitoneal abscesses [6, 52].
Intramural ulcerations or abscesses may be identified.
Ultrasound is a useful imaging technique for assessing fistu-
lae, with reported sensitivity and specificity of 80–100 and
92–94% [53–55]. A fistulous tract appears as a hypoechoic
tract containing bubbles of gas that extends from the bowel to
the adjacent structures [22]. Transmural inflammation leads to
perienteric edema and fibrosis involving the adjacent mesen-
tery that creep over the anti-mesenteric serosal surface of the
bowel, giving a Bcreeping fat^ appearance of a uniform
hyperechoic thick layer of fatty tissue with a mass-like appear-
ance [22]. Fibrofatty proliferation is an indication of active
inflammation. It occurs rapidly during an acute flare of disease
and resolves after inflammation subsides [56]. Reactive mes-
enteric adenopathy is frequently seen in Crohn’s disease dur-
ing active as well as chronic intestinal inflammation.
Intussusception
Intussusception is a condition in which a segment of the in-
testine (intussusceptum) invaginates into an adjacent distal
loop of intestine (intussuscipiens). It is much more common
in children than adults. In children, intussusception is most
often caused by hypertrophied lymphoid follicles in the distal
ileum (considered a Bnonpathologic^ lead point); therefore,
ileocolic intussusception is the most common type.
Pathologic lead points are identified in 75 to 85% of cases of
adult intussusception [57]. In adults, 50% of colocolonic in-
tussusceptions are caused by malignant tumors, whereas the
majority of small bowel intussusception lead points are benign
lesions such as polyps [58, 59]. The classic presentation of
intussusception includes colicky abdominal pain, vomiting,
and the presence of Bcurrant jelly^ stool in a pediatric patient.
This presentation is rare in adults, most of whom present with
vague abdominal pain [60].
Reported sensitivity and specificity of ultrasound in diag-
nosing intussusception are close to 100% in the pediatric pop-
ulation [61]. Ultrasound has also been shown to be a useful
imaging technique for detecting intussusception in adults [62].
A four-quadrant survey including Doppler imaging is per-
formed. The characteristic appearance of intussusception
when viewed transversely on ultrasound includes the presence
of the Btarget,^ Bdoughnut,^ or Bbull’s-eye^ sign, character-
ized by concentric hyperechoic and hypoechoic rings (Fig. 8)
[58, 63]. The hypoechoic ring represents the edematous walls
of the intussusceptum and intussuscipiens, while the
hyperechoic ring represents areas of decompressed mucosa
[61]. The terms Bhay fork,^ Btrident,^ and Bpseudokidney^
Fig. 8 Intussusception in a 2-year-old male with nonbloody, nonbilious
vomiting, and a tender, distended abdomen. A sonographic image
demonstrates a classic Btarget^ appearance of intussusception in the
right lower quadrant (arrows)

Fig. 9 Bowel lymphoma in a 15-year-old male with right lower quadrant
pain and a history of Crohn’s disease. An ultrasound image with color
Doppler demonstrates mass-like wall thickening of the cecum and
terminal ileum in right lower quadrant (arrows)
sign describe the appearance of the intussusceptum and
intussuscipiens on longitudinal images [62, 64].
Malignancy
Ultrasound can depict various bowel neoplasms, such as lym-
phoma, gastrointestinal stromal tumor, colonic carcinoma, and
metastatic disease. Although there is overlap between the ap-
pearances of benign and malignant conditions of the bowel,
some ultrasound features are helpful in differentiating benign
and malignant conditions. Malignant conditions are more
commonly associated with greater wall thickening, asymmet-
ric wall thickening, involvement of a short segment, loss of
stratification, and absence of pericolonic findings such as as-
cites, fistula, abscess, and abnormally echogenic pericolonic
fat [30].
Fig. 10 Small bowel obstruction
in an 84-year-old female with
diffuse abdominal pain, nausea,
and vomiting. Sonographic
images of the abdomen (a, b)
demonstrate multiple dilated
loops of small bowel
(arrowheads)
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Lymphoma
Most bowel lymphomas are extranodal marginal zone B cell
lymphomas or diffuse large B cell lymphomas [65].
Lymphoma affects the stomach, small bowel, and large bowel
in decreasing order of frequency and can involve multiple
sites [66].
The appearance of bowel lymphoma on ultrasound is var-
iable. The most common ultrasound imaging appearance of
lymphoma is circumferential wall thickening with loss of nor-
mal stratification. The thickened wall can measure up to 4 cm.
Other patterns, such as nodular and mass-like tumor or, rarely,
isolated mucosal involvement, may also be seen (Fig. 9) [67].
Features that suggest the diagnosis of lymphoma over adeno-
carcinoma include associated mesenteric lymphadenopathy,
preserved peristalsis, and absence of intestinal obstruction de-
spite the marked degree of wall thickening [68].
Colon cancer
Adenocarcinoma is the most common malignancy of the gas-
trointestinal tract and colon. On ultrasound, colonic adenocar-
cinoma appears as a short segmental thickening or as a bulky
mass of the colonic wall with heterogeneous low echogenicity
[69]. Wall thickening may be eccentric or circumferential.
Central linear echoes may represent air in the residual
narrowed lumen [70]. There is a lack of demonstrable move-
ment or change of configuration of the bowel on real-time
ultrasound scanning [71].
Small bowel obstruction
Small bowel obstruction is a common condition caused by
interruption of normal flow of intraluminal contents that can
be due to mechanical or functional causes. The most common
causes of mechanical small bowel obstruction are hernias and
Emerg Radiol
postoperative adhesions. Other causes include neoplasms,
strictures, volvulus, intussusception, gallstones, and foreign
bodies. In a case of mechanical small bowel obstruction, small
bowel loops proximal to the obstruction are dilated and fluid-
filled and bowel loops distal to the obstruction are
decompressed.
Ultrasound is a useful imaging technique for assessing
small bowel obstruction. Reported sensitivity and accuracy
of ultrasound in diagnosing bowel obstruction are 95 and >
80%, respectively [72, 73]. The ability to perform ultrasound
at the bedside allows for a quicker diagnosis for patients who
present with nonspecific symptoms of nausea, vomiting, and
abdominal pain and can expedite treatment. Small bowel ob-
struction is easily detected with ultrasound because fluid with-
in the bowel proximal to the point of obstruction serves as a
contrast medium and distends the bowel loops. Diagnosis of
small bowel obstruction is considered if multiple dilated (>
3 cm) fluid-filled loops of small bowel are seen (Fig. 10) along
with decompressed distal bowel loops. Peristalsis is increased
in dilated bowel loops as they attempt to pass the luminal
contents beyond the obstruction site [8]. Associated ascites
is frequently visualized. Occasionally, causes of bowel ob-
struction such as hernia, tumor, and intussusception can be
detected using fluid-filled bowel as a sonographic window.
When strangulation or excessive bowel dilatation occurs, per-
fusion of the bowel may be compromised, leading to infarc-
tion, necrosis, and perforation and increased morbidity and
mortality associated with small bowel obstruction. Ischemia
is suggested by bowel wall thickening and decreased or absent
peristalsis [73, 74]. The presence of free fluid between dilated
small bowel loops suggests worsening mechanical small bow-
el obstruction and the need for surgical management [75].
Conclusion
Given its lack of ionizing radiation, widespread availability,
low cost, and ability to provide real-time information, ultra-
sound continues to play an important role in the evaluation of
acute abdominal pain. Currently, many radiologists limit the
use of abdominal and pelvic ultrasound to solid organs.
However, ultrasound can be a valuable tool for assessment
of bowel diseases such as appendicitis, diverticulitis, colitis,
Meckel’s diverticulitis, small bowel obstruction, neoplasm,
and intussusception. Familiarity with normal and pathologic
ultrasound features of the bowel along with a good under-
standing of ultrasound technique can facilitate early detection
of bowel disease.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Publisher’s note Springer Nature remains neutral with regard to juris-
dictional claims in published maps and institutional affiliations.
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