1. Dr Aftab Qadir

2. Ultrasound imaging of Bowel pathology Technique and Keys to diagnosis in the Acute Abdomenhttp://www.ajronline.org/doi/full/10.2214/AJR.11.6594Maturen et al. Citation: American Journal of Roentgenology. 2011;197: 1067-W1075. 3. Outline Objective CT abdomen Normal Gut signature Mural Thickening Mesentery and Omentum Doppler Vascularity Dynamic Imaging Focused Scanning Transvaginal Imaging Conclusion 4. Objective Normal sonographic appearance of bowel Pathological Ultrasound technique 5. CT abdomen CT is emerging as the primary modality for evaluationfor the acute abdomen Rapid evaluation of bowel and mesentry Definitive assesment of abdominal,pelvic organs and major vessels 6. 1.Normal Gut signature Bowel has typical multilamellated sonographicappearance Alternating hyperechoic and hypoechoic lines representing the different layers of the gastrointestinal wall The different layers are: a) mucosa - echogenic b) muscularis mucosa - hypoechoic c) submucosa - echogenic, thickest d) muscularis propria - hypoechoic e) serosa - echogenic 7. Image of normal bowel in healthy 36-year-old woman. normal gastric antrum between liver (liv) and pancreas (panc) show physiologic lamellation of bowel wall, with five alternating concentric hyperechoic and hypoechoic bands. Innermost hyperechoic layer (arrowheads) is mucosal surface, followed by hypoechoic muscularis mucosa, hyperechoic submucosa, hypoechoic muscularis propria, and outermost hyperechoic serosal surface (arrows). Muscle is usually hypoechoic and fat is usually hyperechoic, but disease states can alter these normal appearances. 8. 34-year-old healthy woman with normal intestine 9. This pattern allows to distinguish bowel from adjacentstructures Disruption of the pattern aids the diagnosis of bowel pathology Masses may transgress the layers Edema may expand certain layers or obscure the margins 10. Mural Thickening Bowel wall thickening may be the most common andreliable sign of bowel disease Wall thickening is more typically concentric in benign and eccentric in malignant conditions 11. 6-year-old boy with Crohn disease. Gray-scale ultrasound image shows dramatic circumferential wall thickening of two adjacent small-bowel loops (arrowheads). Note also increased echogenicity of adjacent mesenteric fat (F), indicating inflammation. 12. 17-year-old girl with Crohn disease. Power Doppler image of terminal ileum (arrowheads) shows wall thickening and mural hyperemia, indicating active inflammation. Note also enlarged adjacent mesenteric lymph node (arrow) surrounded by echogenic fat. 13. 52-year-old woman with infectious colitis. Gray-scale ultrasound image shows concentric wall thickening and blurring of normal mural stratification (arrowheads) in colon. Power Doppler image (inset) reveals marked hyperemia (arrow) in affected segment. 14. 64-year-old woman with locally advanced colon cancer presenting as palpable mass in right upper quadrant.A, Transverse ultrasound image colonic wall thickening (arrowheads). 15. Mesentery and Omentum Mesenteric and omental fat are generallyinconspicuous except when inflamed. Abnormally echogenic fat may be the most conspicuous finding in bowel disease; this extraluminal finding may indicate an area of bowel that deserves closer attention. Creeping fat characteristic of inflammatory bowel. 16. 32-year-old man with perforated, gangrenous appendicitis.B, Power Doppler image in same area shows punctuate areas of vascularity adjacent to (arrowheads) but none within appendix. Nbnormal echogenicity of adjacent inflamed mesenteric fat (arrow). 17. Doppler Vascularity Color and power Doppler imaging supplement theinformation provided by gray-scale imaging increased vascularity visualized in a number of inflammatory and infectious diseases. Hyperemia, both of bowel wall and adjacent mesentery, is a notable marker of disease activity in inflammatory bowel disease. diminished vascularity is a specific, although probably not sensitive, sign of ischemia 18. 17-year-old girl with Crohn disease. Power Doppler image of terminal ileum (arrowheads) shows wall thickening and mural hyperemia, indicating active inflammation. Note also enlarged adjacent mesenteric lymph node (arrow) surrounded by echogenic fat. 19. 21-year-old woman with Crohn's disease. Transverse sonogram shows thick-walled cecum (C). Doppler sonogram showed increased transmural perfusion consistent with Crohn's disease. 20. 45-year-old man with acute appendicitis. Noncompressible tubular structure in right lower quadrant exhibits marked mural hypervascularity (arrowhead) on color Doppler image, solidifying diagnosis of acute appendicitis. 21. Dynamic Imaging Real-time imaging is a unique strength of ultrasound Dynamic information about bowel motility,compressibility, and changes in position Cine clips 22. 1. Peristalsis 2. Compression3. Valsalva Maneuver 23. Peristalsis Real-time observation and a sense of the normalappearance of peristalsis are essential to making this observation. A variety of causes may impair peristalsis, including small-bowel obstruction, ischemia, enteritis, and infiltrative processes 24. Compression Healthy bowel can be compressed and shifted bytransducer pressure. Direct pressure over an area of abnormality may reveal a lack of normal compressibility in appendicitis, intussusception The graded-compression technique enables isolation of abnormal bowel loops by pushing away adjacent mobile bowel. Correlation of compressibility with wall thickness and other imaging features will enable assessment of the significance. The efficacy of compression as a diagnostic indicator may be limited in obese adults. 25. 20-year-old man with acute nonperforating appendicitis. Long-axis (A) and transverse (B) sonograms of appendix typically situated in right iliac fossa show enlarged (9.6 mm) appendix (long arrows) and prominent hyperechoic inflamed periappendiceal fat (short arrows). 26. 5-month-old girl with massive ileocolic intussusception causing ischemia of distal ileum and right hemicolon.Gray-scale ultrasound image reveals targetoid noncompressible mass (arrowheads), constituting intussusception extending from right lower quadrant to left lower quadrant. Note marked wall thickening and loss of stratification, particularly in intussusceptum (outer loop). 27. Pneumatosis intestinalisColor Doppler image shows some vascularity (arrowheads) in tissue surrounding mass but none within loops of intussusceptum. Punctuate 28. Valsalva Maneuver Hernias of bowel, mesentery, and omentum may preset asabdominal wall or groin masses, and direct observation while the patient coughs or bears down to increase intraabdominal pressure Such maneuvers may reveal an intermittent hernia, show contiguity of a mass with the intraperitoneal space, allow better depiction of the hernia sac or abdominal wall defect, and show reducibility . High-frequency linear transducers ( 7 MHz) are most appropriate for this evaluation. 29. 57-year-old man with periumbilical hernia.Transverse midline ultrasound image shows tubular structure (arrowheads) protruding toward skin surface just medial to rectus muscle (R). 30. 57-year-old man with periumbilical hernia.Ultrasound image shows bulge changes and enlarges (arrowheads) with Valsalva maneuver, compatible with hernia. Some peristalsis was appreciable in real time, confirming bowel content in hernia sac. 31. Focused Scanning Direct evaluating the area of clinical concern may beextremely useful, particularly if the patient is able to localize the symptoms. For superficial lesions, high-frequency linear transducers may be most appropriate (710 MHz), but their use should be supplemented by lower-frequency curved-array imaging (38 MHz) to evaluate the complete deep extent of lesions. 32. when a bowel abnormality is initially identified duringroutine abdominal scanning at 38 MHz, highfrequency linear transducers can be used secondarily to provide detailed assessment of bowel wall and mesentery. a complete examination should usually include both probe types. 33. Transvaginal Imaging Transvaginal imaging is a routine part of pelvic imaging inwomen and may also contribute to bowel assessment Deeply positioned appendixes may be best visualized transvaginally other pathologies, including terminal ileitis, sigmoid or rectal inflammation, and pelvic masses or abscesses, may be optimally assessed in this fashion as well. 34. 21-year-old woman with pelvic inflammatory disease. Transvaginal ultrasound image shows complex fluid compatible with pus (P) surrounding uterus (Ut). Adjacent smallbowel loop is dilated and thick-walled (arrowheads), reflecting reactive enteritis and ileus. Note also increased echogenicity of pelvic and mesenteric fat (arrows), further indicator of inflammation. 35. Factors which decrease the reliability of sonographic evaluation operator dependent technique the presence of overlying bowel gas obesity of the patient. 36. Conclusion Given its widespread availability, relatively low cost,and absence of ionizing radiation or need for contrast materials, ultrasound has maintained an important role in evaluation of the acute abdomen even during the recent explosion of CT utilization Many sonographers and radiologists limit their focus to the solid organs 37. The pendulum of abdominal imaging may swing backtoward ultrasound. Awareness of normal and pathologic sonographic appearances of bowel and attention to technique will enable sonographers and radiologists to make optimal use of this imaging modality because bowel findings may be the key element of an otherwise negative abdominal ultrasound examination. 38. Take-Away Information 1.Diagnostics in inflammatory bowel disease: Ultrasound Deike Strobel, Ruediger S Goertz, and Thomas Bernatik Article information World J Gastroenterol. 2011 July 21; 17(27): 31923197. Published online 2011 July 21. doi: 10.3748/wjg.v17.i27.3192 PMCID: PMC3158394 CONCLUSION Transabdominal US is currently accepted as a clinically important first-line imaging technique in IBD in initial diagnosis and during the clinical course of the disease. 39. 2.Hypertrophic pyloric stenosis: tips and tricks for ultrasound diagnosis Slvia Costa Dias, Sophie Swinson, [...], and Vasco Mendes Article information Insights Imaging. 2012 June; 3(3): 247250. Published online 2012 May 1. doi: 10.1007/s13244-012-0168-x PMCID: PMC3369120 Conclusion Pyloric US examination is a dynamic investigation, which should be performed in a systematic way. The radiologist should be aware of the pitfalls of the examination and how to overcome them. It is important to be familiar with the normal and hypertrophied pyloric appearances, as this will provide a greater diagnostic confidence, assisting in early diagnosis and improving the management of infants with HPS. 40. 3.Transabdominal Sonography in Assessment of the Bowel in Adults Siarhei Kuzmich1, David C. Howlett1, Allan Andi1, Dhiren Shah1 and Tatsiana Kuzmich1 2 OBJECTIVE. We describe the key sonographic features and technical aspects of assessment of bowel disorders in adults. CONCLUSION. Initial imaging with transabdominal sonography in the radiologic evaluation of bowel disease in adults often is reserved for patients with equivocal historical, physical, and laboratory findings related to the gastrointestinal tract. Because of technologic advances and accumulatedexperience in interpretation of the images, sonography yields substantial information about gastrointestinal disorders.Read More: http://www.ajronline.org/doi/full/10.2214/AJR.07.3555 41. 4.Ultrasound diagnosis of intussusception: report of two cases. Source Medizinische Klinik 1 (Gastroenterologie, Endokrinologie und Diabetologie), St. Vincentius-Kliniken gAG, Karlsruhe. peter.matheiowetz@vincentius-ka.de Dtsch Med Wochenschr. 2010 Mar;135(12):563-6. doi: 10.1055/s-0030-1249211. Epub 2010 Mar 16. CONCLUSIONS: Intussusception is a possible cause of acute abdominal pain in adults. Ultrasonography should be the initial diagnostic investigation. Transient intussusceptions are seen in adults with celiac disease, in which case nonoperative treatment is possible. 42. 5.Bowel Wall Thickening on Transabdominal Sonography Hans Peter Ledermann1, Norbert Brner2, Holger Strunk3, Georg Bongartz1, Christoph Zollikofer4 and Gerd Stuckmann4 More: http://www.ajronline.org/doi/full/10.2214/ajr.174.1.1740 107 43. 6.Accuracy of ultrasonography in the diagnosis of acute appendicitis in adult patients: review of the literature Fabio Pinto1*, Antonio Pinto2, Anna Russo3, Francesco Coppolino4, Renata Bracale5, Paolo Fonio6, Luca Macarini7,Melchiorre Giganti8 The gold standard for the diagnosis of appendicitis still remains pathologic confirmation after appendectomy. In the published literature, gradedcompression Ultrasound has shown an extremely variable diagnostic accuracy in the diagnosis of acute appendicitis (sensitivity range from 44% to 100%; specificity range from 47% to 99% ). This is due to many reasons, including lack of operator skill, increased bowel gas content,obesity, anatomic variants, and limitations to explore patients with previous laparotomies. Conclusions: Graded-compression Ultrasound still remains our first-line method in patients referred with clinically suspected acute appendicitis: nevertheless, due to variable diagnostic accuracy, individual skill is requested not only to perform a successful exam, but also in order to triage those equivocal cases that, subsequently, will have to undergo assessment by means of Computed Tomography. 44. Sonographic signs of hypertrophic pyloric stenosis? Sonographic signs of intussusception? Sonographic signs of bowel obstruction? Songraphic signs of acute appendicitis? Songraphic signs of IBD? 45. Discussion and queries 46. The Eyes Don't See What the Mind Don't KnowThanks