Bowel Ultrasound - Society for Pediatric Radiology

Bowel Ultrasound - More Than Just A Load Of 💩💩💩💩Patricia Lacy Gandor, BS, RDMS, RVT, RT Ann & Robert H. Lurie Children’s Hospital of Chicago Department of Radiology May 2017

No Disclosures

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Objectives

• Recognize anatomy of the gastrointestinal tract. • Identify proper technique for gastrointestinal ultrasound. • Recognize common findings seen in the emergent setting of abdominal

pain and vomiting. - Hypertrophic pyloric stenosis - Enteritis - Obstruction - Appendicitis

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Introduction

• Ultrasound is emerging as a reliable tool for bowel interrogation. • Lack of radiation and non-invasive properties make ultrasound especially

ideal for pediatric patients. • Certain challenges accompany bowel imaging - excessive contents and gas - pain level - lack of training • Special challenges face pediatric bowel imaging - symptoms can be misleading - late presentation

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“Gut Signature”

• The gastrointestinal tract runs from the esophagus to the rectum • The wall has a multilayered appearance called the “gut signature” - alternating hypoechoic and hyperechoic layers • The “gut signature” appearance can help differentiate normal vs abnormal

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Gut Signature

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• Multiple layers comprise the bowel wall (inner-outer) - mucosa - submucosa - muscularis propria - serosa

Lumen

The Pyloric Sphincter• Thin band of smooth muscle which controls

the passage of stomach contents into the duodenum.

• Can use ultrasound to view contents pass through the pylorus.

7newhealthguide.org

Evaluation for Pyloric Stenosis• Highest resolution transducer possible, 15L

or 9L depending on size of patient. • RLD patient position. • Use the liver as your window, aim near the

gallbladder. • Be cautious of the gastroespohageal

junction! • Glucose water feed during exam.

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Evaluation for Pyloric Stenosis• Highest resolution transducer possible, 15L

or 9L depending on size of patient. • RLD patient position. • Use the liver as your window, aim near the

gallbladder. • Be cautious of the gastroespohageal

junction! • Glucose water feed during exam.

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Evaluation for Pyloric Stenosis• Highest resolution transducer possible, 15L

or 9L depending on size of patient. • RLD patient position. • Use the liver as your window, aim near the

gallbladder. • Be cautious of the gastroespohageal

junction! • Glucose water feed during exam.

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GB

pylorus

Evaluation for Pyloric Stenosis• Highest resolution transducer possible, 15L

or 9L depending on size of patient. • RLD patient position. • Use the liver as your window, aim near the

gallbladder. • Be cautious of the gastroespohageal

junction! • Glucose water feed during exam.

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If you can see the hepatic veins, you’re probably looking at ge junction!! Feeding will run into stomach

Hepatic v.

Hepatic v.

ge junction

Evaluation for Pyloric Stenosis• Highest resolution transducer possible, 15L

or 9L depending on size of patient. • RLD patient position. • Use the liver as your window, aim near the

gallbladder. • Be cautious of the gastroespohageal

junction! • Glucose water feed during exam.

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Fasting W/Feeding

Non-Fasting W/O Feeding

Hypertrophic Pyloric Stenosis• Enlargement of the pyloric muscle creating

an obstruction • Most common reason for abdominal surgery

in the first 6 months of life • Infants between 2-13 weeks old • Non-bilious projectile vomiting • Ultrasound is the exam of choice

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Long

Trvs

Hypertrophic Pyloric Stenosis - Findings• Elongated pyloric canal (cervix sign) - >15mm • Thickened pyloric muscle (target sign) - >4mm • Hyperplasia and hypertrophy of the muscle cause a loss of

the "gut signature" appearance • No contents passing through the pylorus after feeding

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Normal Abnormal

Hypertrophic Pyloric Stenosis - Findings• Elongated pyloric canal (cervix sign) - >15mm • Thickened pyloric muscle (target sign) - >4mm • Hyperplasia and hypertrophy of the muscle

cause a loss of the "gut signature" appearance • No contents passing through the pylorus after

feeding

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Normal Abnormal

Hypertrophic Pyloric Stenosis - Findings• Elongated pyloric canal (cervix sign) - >15mm • Thickened pyloric muscle (target sign) - >4mm • Hyperplasia and hypertrophy of the muscle

cause a loss of the "gut signature" appearance • No contents passing through the pylorus after

feeding

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NormalAbnormal

Hypertrophic Pyloric Stenosis - Findings• Elongated pyloric canal (cervix sign) - >15mm • Thickened pyloric muscle (target sign) - >4mm • Hyperplasia and hypertrophy of the muscle

cause a loss of the "gut signature" appearance • No contents passing through the pylorus after

feeding

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Normal Abnormal

The Small Intestine• Extends from the pyloric sphincter to

ileocecal valve. • Responsible for digestion and absorption of

nutrients. • Divided into 3 sections: duodenum,

jejunum, ileum.

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blausen.com

The Small Intestine - Normal Characteristics

• The jejunum has deep folds. • The ileum is smooth / small folds. • Normal wall has multiple layers seen and measures approx 3mm (varies

slightly with age). • Motility is rhythmic and propels the contents through the bowels.

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The Small Intestine - Normal Characteristics

• The jejunum has deep folds. • The ileum is smooth / small folds. • Normal wall has multiple layers seen and measures approx 3mm (varies

slightly with age). • Motility is rhythmic and propels the contents through the bowels.

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The Small Intestine - Normal Characteristics

• The jejunum has deep folds. • The ileum is smooth / small folds. • Normal wall has multiple layers seen and measures approx 3mm (varies

slightly with age). • Motility is rhythmic and propels the contents through the bowels.

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The Small Intestine - Normal Characteristics

• The jejunum has deep folds. • The ileum is smooth / small folds. • Normal wall has multiple layers seen and measures approx 3mm (varies

slightly with age). • Motility is rhythmic and propels the contents through the bowels.

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The Large Intestine• Extends from the ileocecal valve

to the rectum. • Responsible for water and salt

absorption. • Divided into 4 sections: - Ascending colon - Transverse colon - Descending colon - Sigmoid colon

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The Large Intestine - Normal Characteristics

• The colon has haustra. • The normal wall is multilayered and measure approx 4mm (varies slightly

with age). • Motility is infrequent and therefore difficult to evaluate. • Motility occurs when the muscular layer contracts and empties long

segments of bowel.

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The Large Intestine - Normal Characteristics

• The colon has haustra. • The normal wall is multilayered and measure approx 4mm (varies slightly

with age). • Motility is infrequent and therefore difficult to evaluate. • Motility occurs when the muscular layer contracts and empties long

segments of bowel.

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The Large Intestine - Normal Characteristics

• The colon has haustra. • The normal wall is multilayered and measure approx 4mm (varies slightly

with age). • Motility is infrequent and therefore difficult to evaluate. • Motility occurs when the muscular layer contracts and empties long

segments of bowel.

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Technical Factors

• Highest resolution transducer • Harmonic imaging • High contrast settings - rejection - gray maps • Graded compression

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Technical Factors

• Highest resolution transducer • Harmonic imaging • High contrast settings - rejection - gray maps • Graded compression

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Technical Factors

• Highest resolution transducer • Harmonic imaging • High contrast settings - rejection - gray maps • Graded compression

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Graded Compression

Imaging Planes

• Multiple slices in longitudinal and transverse.

• “Target scanning” is more accurate. • Follow colon along its path. • Use a lawn mower approach for the small

bowel.

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Imaging Planes

• Multiple slices in longitudinal and transverse.

• “Target scanning” is more accurate. • Follow colon along its path. • Use a lawn mower approach for the small

bowel.

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Enteritis

• Inflammation of the small intestine - inner and middle layer

• Can also involve the stomach and colon

• Can be caused by numerous reasons including - viral or bacterial infection - medication induced - poor blood flow - inflammatory conditions, Crohn’s disease

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Enteritis

• Associated findings include: - enlarged lymph nodes - fluid collection and ascities - fat infiltration

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Obstruction!!

• Can happen anywhere. • Can have many appearances. • May be complete or partial. - partial may not be seen with US. • Look for indirect signs. • Most common type of obstruction

is ileocecal intussusception.

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electablog.com

Signs of Obstruction

• Contents do not move with bowel motility. • Dilated loops of bowel as well as collapsed loops of bowel. • Hypermotility with to-and-fro movement of bowel contents.

Potential Ischemia • Free fluid between distended loops of bowel. • Thickened bowel wall. • No motility.

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Obstruction! Intussusception

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• Intussusception is the most common medical emergency affecting children under 3 years old, with a peak age of 6 months - 1 year.

• More common in boys, 3:2 ratio. • It’s an invagination of one portion of

intestine into another. • Usually idiopathic, but may have a lead

point. • Look for “donut sign” in trvs and

“pseudokidney" sign in long

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Appendicitis - Evaluation

• Find the ileocecal valve - Looking at the cecum in transverse - Find the location of ileum dumping into cecum near RLQ (appendix is approx 1.5cm away from ileocecal valve

• Can be in any direction around cecum • Use graded compression as well as simultaneous anterior/posterior

compression.

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Terminal Ileum

Colon Appendix Cecum

Bladder A

V

Appendicitis - Findings

• Dilated to >6mm • Non-Compressible • Appendicolith • Hypervascular • Fat infiltration • Periappendiceal fluid

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1.18cm

0.41cm

Appendicitis - Findings

• Dilated to >6mm • Non-Compressible • Appendicolith • Hypervascular • Fat infiltration • Periappendiceal fluid

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Appendicitis - Findings

• Dilated to >6mm • Non-Compressible • Appendicolith • Hypervascular • Fat infiltration • Periappendiceal fluid

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Appendicitis - Findings

• Dilated to >6mm • Non-Compressible • Appendicolith • Hypervascular • Fat infiltration • Periappendiceal fluid

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Appendicitis - Findings

• Dilated to >6mm • Non-Compressible • Appendicolith • Hypervascular • Fat infiltration • Periappendiceal fluid

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Normal

Appendicitis - Findings

• Dilated to >6mm • Non-Compressible • Appendicolith • Hypervascular • Fat infiltration • Periappendiceal fluid

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Conclusion

• Advances in sonographic resolution has opened a door in the evaluation of numerous gastrointestinal abnormalities.

• We must do out part by learning this relatively "new" exam type. • Sonography is an ideal choice because it is highly accurate, portable, not-

invasive, fast, lacks radiation, and is cost-effective.

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References

1.Tarantino, L. (n.d.). Abdominal Ultrasound in Infectious Enteritis. Retrieved April 21, 2017, from touchophthalmology.com

2.Chao, A., & Gharahbaghian, L. (n.d.). Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction - A Better Diagnostic Tool? Retrieved April 21, 2017, from acep.org

3.Park, N. H. (2011). Ultrasonography of normal and abnormal appendix in children. World Journal of Radiology, 3(4), 85. doi:10.4329/wjr.v3.i4.85

4.Riccabona, M. (2014). Pediatric Ultrasound Requisites and Applications. Graz, Austria: Springer. Doi: 10.1007/978-3-642-39156-9

5.blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1(2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.N.

6.Acute Appendicitis. (2013). Retrieved April 21, 2017, from https://pedclerk.uchicago.edu/page/acute-appendicitis

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