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Review
Bowel Wall Thickening on Transabdominal Sonography
Hans Peter Ledermann 1, Norbert Brner 2, Holger Strunk 3, Georg Bongartz 1, Christoph Zollikofer 4, Gerd Stuckmann 4

T he potential value of transabdom-

inal sonography in the diagnosis
of bowel diseases is often not suf-
bowel segment in context with the clinical in-
formation often leads to a limited differential
diagnosis or to the correct diagnosis.
gastrointestinal tract. If intestinal wall thick-
ening is found, detailed evaluation of the dis-
eased segment is performed with a linear or
ficiently appreciated and is even underesti- The differential diagnoses of small- curved high-frequency (7.513 MHz) trans-
mated. Bowel gas artifacts and the somewhat bowel wall thickening and of colonic wall ducer. When the affected bowel segment is
confusing sonographic appearance of the gas- thickening are shown in Appendixes 1 and far from the abdominal surface and when the
trointestinal tract may render orientation and 2, respectively. patient is obese, a fair amount of pressure
interpretation of sonographic structures diffi- This article provides a systematic overview must be applied to the transducer to get ac-
cult. Bowel wall thickening, the main sono- of diseases that may cause bowel wall thick- ceptable images. For optimal results, it may
graphic correlate of bowel disorders, seems at ening. Typical sonographic features of these be necessary to change the patients position
first glance a very nonspecific sign, which disorders are discussed and compared. A re- several times during the examination. Only
may explain why inexperienced investigators view of the literature further summarizes the careful methodic examination of the entire
do not feel confident in the sonographic eval- reported diagnostic potential of sonography abdomen leads to acceptable results; the ac-
uation of the gastrointestinal tract. However, and its limitations. curacy of the examination depends largely
it has been shown that transabdominal sonog- on the radiologists experience and patience
raphy achieves good to excellent results as a [5]. Ideally, patients fast overnight before the
directed tool for evaluating potential bowel Technique examination, but at least 45 hr of fasting are
disorders: appendicitis can be diagnosed with Examination of the intestinal tract usually needed to avoid excessive gas in the intesti-
a sensitivity ranging from 80% to 93% and a begins with a systematic standardized survey nal lumen.
specificity between 94% and 100% [1, 2]. using a curvilinear 3.55-MHz transducer. In
Reported sensitivity rates for evaluating in- patients with localized abdominal pain, how-
flammatory bowel disease range between ever, it may be helpful and timesaving to let Normal Sonographic Bowel Wall
67% and 96%, with specificities of 7997% patients indicate the position of maximum Anatomy
[3, 4]. Equal diagnostic accuracy of 84% was pain with their fingers on the abdominal wall The typical sonographic appearance of the
found for CT and for sonography in the and begin the examination there. In case of normal bowel wall consists of five concen-
workup of diverticulitis, with sensitivities of diffuse abdominal pain, the frame of the co- tric, alternately echogenic and hypoechoic
91% and 85%, respectively, and specificities of lon is identified by its strong gas artifacts and layers that we describe from the lumen out-
84% and 77%, respectively [5]. Although the is screened from the cecum to the sigmoid ward (Fig. 1). First, a small echogenic layer
sonographic appearance of bowel wall thick- colon. The rest of the abdomen is examined is seen that reflects the superficial mucosal
ening of different diseases sometimes over- in an individual standardized fashion to interface. The deep mucosa, including the
laps, careful examination of the thickened assure complete coverage of the entire muscularis mucosa, is seen as a second hyper-
Received January 27, 1999; accepted after revision June 7, 1999.
1
Department of Radiology, University Hospital of Basel, Petersgraben 4, CH-4031 Basel, Switzerland. Address correspondence to H. P. Ledermann.
2
Gastroenterologische Gemeinschaftspraxis, Parcusstr. 8, 55116 Mainz, Germany.
3
Department of Radiology, Friedrich-Wilhelms-Universitt Bonn, Sigmund-Freud-str. 25, 53105 Bonn, Germany.
4
Department of Radiology, Kantonsspital Winterthur, Brauerstr. 15, 8400 Winterthur, Switzerland.
AJR 2000;174:107117 0361803X/00/1741107 American Roentgen Ray Society

AJR:174, January 2000 107

 Ledermann et al.

echoic layer. A third hyperechoic layer is
produced by the submucosa and the muscu-
laris propria interface. The muscularis pro-
pria is seen as a fourth hypoechoic layer.
Finally, the marginal interface to the serosa is
seen as the fifth small hyperechoic layer. The
average thickness of the normal gut wall is
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Inflammatory Bowel Disease
The classic sonographic feature of Crohns
disease is the target sign (Fig. 2) on trans-
verse images, which means a strong echogenic
center surrounded by a relatively sonolucent
rim of more than 5 mm. This transmural in-
flammation or fibrosis can lead to complete
ers, which results in a thick hypoechoic rim on
axial images. Strictures are shown as marked
thickening of the gut wall with a fixed hyper-
echoic narrowed lumen (Fig. 3A), dilatation,
and hyperperistalsis of the proximal gut. Peri-
intestinal inflammation leads to the creeping
fat sign, which appears as a uniform hyper-

24 mm [6]. circumferential loss of the typical gut wall lay-
Fig. 1.4-year-old girl with gastroenteritis. Sagittal
sonogram shows normal gut wall layering of rectum
(RE) from lumen outward. Note small echogenic layer
in lumen that reflects superficial mucosal interface
(short thin arrow ). Deep mucosa, including muscu-
laris mucosa, is seen as second hypoechoic layer
(long thin arrow ). Third broad hyperechoic layer is
produced by submucosa and muscularis propria inter-
face (open arrow ). Muscularis propria is seen as
fourth hypoechoic layer (short thick arrow ). Marginal
interface to serosa is seen as small fifth hyperechoic
layer (curved arrow ). ASC = ascites in retrovesical
space, B = bladder.
echoic mass typically seen around the ileum
and cecum. Mesenteric lymphadenopathy is
seen as multiple oval hypoechoic masses, usu-
ally in the right lower quadrant. In contrast to
other forms of colitis, Crohns disease is sug-
gested by skip areas and involvement of the
distal ileum [7]. Possible complications of
Crohns disease comprise fistulas, abscess for-
mation, mechanical bowel obstruction, and
perforation [8]. Abscesses are seen as poorly
defined, mostly hypoechoic focal masses that
can contain hyperechoic gas (Fig. 3B). Fistulas
are a hallmark of Crohns disease and are seen
in as many as one third of patients with ad-
vanced disease as hypoechoic tracts with gas
inclusions connecting bowel loops or adjacent

A B

Fig. 2.25-year-old woman with Crohns disease who presented with new onset of crampy abdominal pain.
A, Transverse sonogram shows concentric echolucent wall thickening producing typical target sign.
B, Close-up longitudinal sonogram of same segment as A shows circular hypoechoic wall thickening and loss of
stratification that, together with clinical information, led to diagnosis of Crohns disease.
C, Small-bowel contrast-enhanced enema shows segmental bowel wall edema (arrow ) with thumbprinting and
narrowing of jejunal lumen in left lower abdomen. Diagnosis of Crohns disease was later clinically confirmed.
C

108 AJR:174, January 2000

 Sonography of Bowel Wall
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A B C
Fig. 3.Complications of Crohns disease.
A, Stricture with obstruction in 52-year-old man. Transverse sonogram of ileum (arrows) shows severe narrowing of small hyperechoic central lumen caused by exces-
sively echolucent wall thickening and loss of stratification, indicating scarring of entire bowel wall.
B, Hypoechoic ileal abscess (A) in highly hypertrophic and inflamed hyperechoic fat of mesentery of 25-year-old woman.
C, Sonogram obtained at time of suspected relapse of 31-year-old woman shows hypoechoic fistula with small hyperechoic gas inclusion (arrow ).

structures (bladder, abdominal wall, vagina, assessment of the extent of the inflammatory lution equipment using 510-MHz broadband
psoas muscle) (Fig. 3C). Detection of gas bub- lesion is requested [3]. linear transducers. In ulcerative colitis, sensitiv-
bles in abnormal locations raises the possibil- Determination of disease activity by sonog- ity reaches 89% and specificity reaches 100%
ity of fistulous communication. raphy is controversial. Whereas some investiga- [11]. Differentiation between Crohns disease
In expert hands, the distribution of frank tors showed correlation with disease activity [4, and ulcerative colitis based on sonographic find-
lesions of inflammatory bowel disease can 10, 11], others found only a loose correlation ings includes the location of the disease, the
be determined with a sensitivity of 7387% between bowel wall thickening and disease ac- presence of skip lesions, and the presence of
on sonography [3, 9, 10]. However, mild le- tivity [9]. The ranges of reported sensitivities pericolic abscesses [14]. Bowel wall thickening
sions that produce less bowel wall thicken- and specificities in the diagnosis of Crohns dis- is usually less marked in ulcerative colitis with
ing are frequently not diagnosed, and the ease are 6796% and 7997%, respectively [4, preserved stratification [15] (Fig. 4). However,
sensitivity for these lesions drops to 52% 1214]. The relatively wide range in the values definite differential diagnosis is difficult on
[3]. These results indicate that sonography of sensitivity and specificity may be explained transabdominal sonography [4, 16].
cannot replace a contrast-enhanced exami- by the use of low-frequency transducers (3.5
nation or endoscopy when highly accurate MHz) in older studies and the use of high-reso-
Non-Hodgkins Lymphoma of the
Gastrointestinal Tract
The gut is the most commonly involved ex-
tranodal site of lymphoma [17]. The most
common sites, in order of descending fre-
quency, are stomach, small intestine, and co-
lon, especially cecum [17]. Eighty percent of
gastrointestinal lymphomas are of B-cell ori-
gin. In patients with underlying celiac disease,
however, T-lymphocyte origin predominates.
Sonography classically shows transmural cir-
cumferential, profoundly hypoechoic wall
thickening up to 4 cm in diameter [18], with
loss of normal stratification (Fig. 5A). This
pattern, also known as the pseudokidney
sign in longitudinal views, is observed in 70%
of patients [19] (Fig. 5B). The pseudokidney
A B
sign is often seen in lymphoma because of ex-
Fig. 4.26-year-old man with ulcerative colitis and new onset of bloody diarrhea. tensive hypoechoic bowel wall thickening, but
A, Sagittal sonogram of descending colon reveals only subtle thickening of bowel wall (4.2-mm-thick submucosa it can be seen in any bowel disorder leading to
between crosses) with preserved stratification and normal echo texture of adjacent mesenteric fat.
B, Large-bowel enema with fine granularity of mucosa reflecting hyperemia and edema confirms suspected marked bowel wall thickening [20, 21]. Other
sonographic diagnosis of early changes in ulcerative colitis. findings include nodular or bulky tumor spread

AJR:174, January 2000 109

 Ledermann et al.

and 10 mm with hypoechoic swollen ileal

folds in the edematous mucosa [24, 25]. Hypo-
echoic enlarged mesenteric lymph nodes rang-
ing from 7 to 21 mm in diameter were found in
most patients. Color Doppler sonography in
patients with infectious ileitis shows increased
flow centrally rather than peripherally (as in
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A B
appendicitis) [26].
Tuberculous enteritis and Behets syn-
drome also predominantly affect the ileoce-
cal region [27]. In a series of 45 patients
suffering from ileocecal tuberculosis, sonog-
raphy showed segmental predominantly con-
centric thickening of the terminal part of the
ileum and cecum in 43 patients [13], with en-
largement of the regional mesenteric lymph
nodes in 50% of these patients.

Appendicitis
The typical finding of acute appendicitis in
transverse sonograms is the target sign with a
hypoechoic center, an inner hyperechoic ring,
and an external thicker hypoechoic ring (Fig.
6A). In sagittal images, the inflamed appendix
is seen as a blind-ending noncompressible tu-
bular structure (Fig. 6B). Focal or circumferen-
C D tial loss of the inner layer of echoes usually
indicates gangrenous inflammation and ulcer-
Fig. 5.Four typical sonographic variants of non-Hodgkins lymphoma. ation of the submucosa. Several studies
A, Most common circular involvement of entire wall with preserved peristalsis in 45-year-old man with unchar- achieved sensitivities of 8093% and specifici-
acteristic abdominal pain. Transverse sonogram reveals profound hypoechoic wall thickening.
B, Pseudokidney sign in ileocecal region: marked hypoechoic thickening of bowel wall resembling form of kid- ties of 94100% in the sonographic workup of
ney in longitudinal sonogram of cecum. Patient is 57-year-old woman. acute appendicitis [1, 2]. On the other hand, CT
C, Bulky disease in cecum in 63-year-old woman. Axial sonogram reveals large eccentric hypoechoic mass with has shown sensitivities of 90100% with speci-
compression of hyperechoic lumen.
D, Isolated mucosal involvement in 43-year-old man. Transverse sonogram of ileum with marked hyperechoic gy-
ficities of 8398% [2830]. In one study with a
ral thickening of mucosa and preserved layering of bowel wall. low (76%) sensitivity for sonography, CT was
found to be more accurate than sonography in
the diagnosis of acute appendicitis [28].
caused by extraluminal involvement [18] (Fig. bowel [23]. The most commonly involved Graded compression sonography gained wide-
5C). Mesenteric tumor spread and bulky tumor nodal groups in non-Hodgkins lymphoma of spread acceptance as a useful technique to
growth need biopsy for definite diagnosis be- the gastrointestinal tract are the celiac, retro- examine patients with atypical signs of appen-
cause they cannot be reliably differentiated crural, perirenal, perisplenic, perihepatic, and dicitis [31]. In a prospective study, the pro-
from other diseases such as primary bowel tu- mesenteric nodes [22]. posed treatment after clinical examination
mors or metastases. Isolated mucosal in- changed in 26% of all patients after sono-
volvement is rare and leads to hyperechoic graphic examination [2]. The diagnosis can be
thickening of the mucosa (Fig. 5D). Sono- Acute Terminal Ileitis established with confidence if the appendix is
graphic patterns favoring the diagnosis of a The clinical symptoms of acute ileitis are noncompressible, shows no peristalsis, and
non-Hodgkins lymphoma over adenocarci- right-sided lower abdominal pain, diarrhea, measures more than 6 mm in diameter [32] on
noma are transmural circumferential, pro- and nausea, with an accelerated erythrocyte axial images, and if compression leads to a lo-
foundly hypoechoic wall thickening with sedimentation rate, positive C-reactive protein, calized pain response. The surrounding mesen-
preserved peristalsis; lack of intestinal obstruc- and leukocytosis. Only careful evaluation in tery is often inflamed, which can be seen as a
tion, because narrowing of the lumen is un- the preoperative workup for suspected appen- hyperechoic diffuse halo sign around the ap-
common; involvement of a long stretch of the dicitis can prevent an unnecessary operation pendix (Fig. 6A). If an appendicolith is identi-
gut; and the presence of multiple prominent [24]. Acute ileitis is caused by Yersinia species fied in an appendix of any size, the findings of
regional lymph nodes [22]. Typical complica- but Campylobacter and Salmonella species the examination are always considered positive
tions are mucosal ulceration leading in 10 may also be cultured. Reported sonographic [33] (Fig. 6C). A simple additional color Dop-
50% of patients to bleeding, perforation of the features include hypoechogenic mural thicken- pler examination may be helpful in the diagno-
small intestine, and intussusception of the ing of the terminal ileum and cecum between 6 sis of early acute appendicitis [34]. The

110 AJR:174, January 2000


Fig. 6.Sonographic findings in acute appendicitis.
A, Target sign (curved arrows) in acute appendicitis
in 12-year-old girl. On transverse image, inflamed ap-
pendix is seen with hypoechoic center, inner hyper-
echoic ring, and outer hypoechoic ring. Note
hyperechoic circular area (straight arrows) of in-
flamed mesentery (halo sign).
B, Longitudinal sonogram of inflamed appendix in
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same patient shows blind-ending tubular structure
(arrow ) of at least 6 mm in diameter.
C, Multiple appendicoliths in 6-year-old girl. Longitudi-
nal section of inflamed appendix reveals five round
hyperechoic appendicoliths with acoustic shadows.
D, Perforating appendicitis in 6-year-old girl. Longitu-
dinal sonogram of inflamed appendix shows typical
blind-ending tubular structure and hypoechoic collec-
tion around tip, indicative of perforation.
presence of visible hyperemia or increased
flow in the hypoechoic muscular layer of the
bowel wall may be a marker of appendicitis,
whereas increased flow in the mucosal layer
most likely represents enteritis [26]. Increased
flow in the fat surrounding the appendix is in-
dicative of transmural extension of the inflam-
mation with mesenteric response. An inflamed
appendix rarely measures more than 15 mm in
transverse diameter [33], which usually allows
differentiation from ileitis. A markedly en-
larged or perforating appendix or dilated fallo-
pian tubes may lead to interpretive pitfalls [33].
Perforation occurs in 2030% of young pa-
tients with appendicitis (Fig. 6D). A statisti-
cally significant association exists between
perforation and two sonographic findings: loc-
ulated pericecal fluid and loss of the echogenic
submucosa [35]. Abscess formation is the ma-
jor complication of perforating appendicitis.
Abscesses may extend into the pelvis or into
the peritoneal spaces of the upper abdomen.
They may be sonolucent or appear as a com-
plex mass. Advantages of sonography are wide
availability, lack of radiation, and lack of con-
trast administration. Limitations of sonogra-
phy occur in obese and extremely meteoristic
patients and in patients with severe pain due to
peritonitis. Retrocecal appendicitis may be dif-
AJR:174, January 2000
Sonography of Bowel Wall
A B
C D
ficult to diagnose on sonography. Because CT amyloid is frequently seen [41]. Marked hypo-
has been shown to be more accurate in staging echoic thickening of the affected bowel seg-
periappendiceal inflammation and abscesses ments is found [42, 43].
[5, 28, 36], CT may be preferred in patients Eosinophilic enteritis is a rare disease charac-
with suspected perforation or abscess; CT reli- terized by infiltration of the stomach or bowel
ably differentiates phlegmon from abscess and wall with eosinophilic leukocytes. In three re-
serves as an accurate road map for potential ported cases, hypoechoic thickening of multiple
abscess drainage. ileal loops, narrowing of the lumen, and loss of
layer structure were described [44, 45].
Small-Bowel Diseases
Mesenteric infarction in its late stages
leads to small-bowel wall thickening [37, 38].
In the early stages, however, no bowel wall
thickening may be seen. Doppler sonography
can aid in differentiating ischemic and in-
flammatory bowel wall thickening. In ap-
proximately 90% of cases, small-bowel
infarctions are due to arterial hypoperfusion;
only 10% are caused by mesenteric vein oc-
clusion. Acute intramural intestinal he-
matoma leads typically to a homogeneous
hypoechoic symmetric thickening of a long
stretch of the affected bowel segment, with
reduced or absent peristalsis and marked lu-
minal narrowing [39] (Fig. 7). In the subacute Fig. 7.72-year-old woman with intramural hematoma
stage, strong internal echoes caused by due to anticoagulant drug therapy. Patient was sent for
sonography to rule out atypical appendicitis. Trans-
thrombi may mimic an abscess [40]. verse sonogram of small-bowel segment discloses cir-
Amyloidosis is a rare condition; however, cumferential hypoechoic thickening of bowel wall with
gastrointestinal involvement in patients with loss of stratification and compression of lumen.
111
 Ledermann et al.
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A B C
Fig. 8.50-year-old man with Whipples disease (intestinal lipodystrophy) presenting with steatorrhea.
A, Longitudinal sonogram depicts marked hyperechoic jejunal fold thickening.
B, Transverse sonogram shows jejunal thickening and hyperechoic lobulated lymph node (arrow ).
C, CT scan shows prominent jejunal folds and enlarged mesenteric lymph nodes. (Courtesy of Disler M, Kantonsspital Liestal, Switzerland)

The sonographic features of primary lym- may lead to irregular wall thickening with the the distal ileum (Fig. 9). All small-bowel carci-
phangiectasia have been described in four pa- typical contraction of several bowel loops to a noids are considered malignant because they
tients [46, 47]. Diffuse hypoechoic small-bowel conglomerate. Most frequent primary tumors eventually grow, invade, and metastasize. Me-
wall thickening, ascites, mesenteric edema, and originate from the ovary, stomach, colon, pan- tastases will occur in 10% of lesions smaller
thickened walls of the gallbladder and urinary creas, gallbladder, lung, and uterus. Primary than 1 cm and 95% of lesions larger than 2 cm
bladder are found. small-bowel tumors constitute only 36% of [53]. Only 4% of patients present with the typi-
One case report describes the sonographic gastrointestinal neoplasms. Abdominal symp- cal carcinoid syndrome [54]. In a series of six
findings of nontropical sprue (celiac disease) toms are usually vague and poorly defined, and patients, small bowel carcinoids presented as
as diffuse hypoechoic thickening of the entire conventional radiography of the upper and hypoechoic, homogeneous predominantly
small-bowel wall that disappears completely lower intestinal tract often has normal results. intraluminal masses with smooth intralumi-
after 3 months of a gluten-free diet [48]. These factors may lead to a delayed diagnosis. nal contour [54]. The tumors were attached to
Sonographic findings in a patient with Carcinoid tumor is the most frequent small- the wall by a broad base, with interruption of
Whipples disease (intestinal lipodystrophy) bowel tumor [52] and occurs in 80% of cases in the submucosa and thickening of the muscularis
disclosed hyperechoic concentric thickening
of the small bowel with enlarged hyper-
echoic lymph nodes [49]. The hyperechoic
structure of the intestinal wall and the en-
larged lymph nodes are explained by fat ac-
cumulation in these structures [50] (Fig. 8).
Markedly thickened hypoechoic bowel loops,
preferentially in the distal ileum, were found in
intestinal anisakiasis, a parasitic disease of the
gastrointestinal tract caused by ingestion of
Anisakis larvae in raw or undercooked fish [51].
Hypoechoic small-bowel wall thickening
reaching 11 mm and revealing a pseudokid-
ney appearance was found in a patient suffer-
ing from intestinal Behets disease [21].
Cytomegalovirus enteritis in AIDS patients
leads to wall thickening of the small and
large bowels with preserved stratification. A B
Fig. 9.57-year-old man with ileal carcinoid tumor presenting with mechanical small-bowel obstruction.
Tumors of the Small Intestine Other A, Transverse sonogram of terminal ileum reveals hypoechoic, homogeneous intraluminal mass with smooth in-
Than Lymphomas traluminal contour and broad-based hypoechoic infiltration of submucosa posteriorly. Note fluid-distended
small-bowel segments ventral to tumor, indicating mechanical obstruction.
Peritoneal carcinomatosis is the most fre- B, CT scan reveals strongly enhancing mass (arrow ) in terminal ileum, with infiltration of mesenteric fat dorsally
quent malignant lesion of the small bowel and and mechanical obstruction of small bowel.

112 AJR:174, January 2000


propria in all cases. Carcinoid tumors of the ap-
pendix were described in two cases [55] as hy-
poechoic, well-delineated elongated masses in
the distal lumen and the tip of the appendix.
Lipomas are the second most common tumors
of the small intestine and occur with greatest fre-
quency in the distal ileum and at the ileocecal
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valve. The location of these tumors is submu-
cosal, or, less frequently, is subserosal. In three
fourths of cases, the tumors are clinically silent
[56]. If the lipoma becomes larger than 4 cm,
chronic hemorrhage caused by ulceration of the
mucosa or intestinal obstruction resulting from in-
tussusception may cause symptoms [57, 58]. Typ-
ical sonographic features are a well-circumscribed
hyperechoic round or oval mass with deformation
under compression. Leiomyomas and schwanno-
mas are seen as hypoechoic intramural round
structures with smooth boundaries [52, 58, 59].
Ulceration of the mucosa may cause gastrointesti-
nal hemorrhage of varying severity. Leiomyosar-
comas were described as large irregular masses
with a heterogeneous echo pattern [58]. Adeno-
carcinoma is the second most common small in-
testine malignancy and the peak incidence is in
the seventh decade of life [52]. A series of four
cases with duodenal adenocarcinomas showed
moderately large intraluminal masses with me-
dium echogenicity [58]. The authors report im-
proved sonographic detection of small-bowel
tumors by intermittent observation of the small-
bowel lesions during the first hour after water
ingestion. Transabdominal sonography reached
excellent sensitivity in detecting small-bowel
tumors in unexplained gastrointestinal bleeding
[59] and in small-bowel obstruction [60]. In
most cases, the tumors were seen as round and
smoothly delineated hypoechoic masses.
Fig. 10.Sonographic features of diverticulitis.
A, Diverticulum of sigmoid colon in 63-year-old man is seen as focal hyperechoic intramural structure with acoustic shadow.
B, Massive hyperechoic inflammatory infiltration in 76-year-old woman is seen on mesenteric side of sigmoid colon.
C, Echolucent fistula in 67-year-old woman is seen in mesentery with small, hyperechoic, gas-containing abscess (arrow ).
AJR:174, January 2000
Sonography of Bowel Wall
Colitis
The sonographic features of pseudomembra-
nous colitis have been described in a number of
reports [61, 62]. Striking thickening of the co-
lonic wall with a wide inner circle of heteroge-
neous medium echogenicity surrounded by a
narrow hypoechoic muscularis propria is found
in all patients, reflecting the gross submucosal
edema. The lumen of the colon is almost com-
pletely effaced by the mural edema, and 64
77% of the patients have ascites [61, 62]. The
presence of these sonographic features in a pa-
tient with watery diarrhea and a history of anti-
biotic therapy strongly suggests the diagnosis
of pseudomembranous colitis. Pseudomembra-
nous colitis shows typically a strong folding or
gyral pattern of the swollen submucosa.
Ischemic colitis cannot be differentiated
solely by sonography from inflammation or any
other form of colonic wall thickening. However,
duplex and color Doppler sonography may be
helpful in differentiating between ischemic and
inflammatory bowel wall thickening [63]. Ab-
sence of or barely visible color Doppler flow
and absence of arterial signal suggest ischemia.
On the other hand, readily visible color Doppler
flow and a stratified echo texture suggest in-
flammation. Various case reports have described
colonic wall thickening in different forms of in-
fectious and noninfectious colitis [24, 6467].
Diverticulitis
Sonographic features of diverticulitis in-
clude visualization of diverticula (Fig. 10A),
thickening of the bowel wall, inflammatory
changes in the pericolic fat (typically on the
mesenteric side of the colonic wall) (Fig.
A B
10B), intramural or pericolic abscess (Fig.
10C), and (usually) severe local tenderness in-
duced by graded compression. Diverticula are
round or oval echogenic foci seen in or right
next to the gut wall, mostly with internal
acoustic shadowing. Thickening of the bowel
wall is usually considered present when the
distance from the echogenic lumen interface to
the hyperechogenic serosa and pericolic fat ex-
ceeds 4 mm [5]. Inflammatory changes in the
pericolic fat are seen as ill-defined echogenic
areas surrounding the thickened colon seg-
ment. Pericolic abscesses typically present as
hypoechoic masses adjacent to the inflamed
bowel. The major sonographic finding in pa-
tients with uncomplicated acute diverticulitis
of the right colon has been found to be a hypo-
echoic round or oval focus protruding from the
segmentally thickened colonic wall and repre-
senting small abscesses in the pericolic fat
[68]. The sensitivity of sonography in the diag-
nosis of acute colonic diverticulitis ranges in
the literature from 84% to 100% [5, 6971]. In
a recent study comparing sonography and CT
in the evaluation of acute colonic diverticulitis,
both techniques reached a similar sensitivity
(85% and 91%, respectively) and specificity
(84% and 77%, respectively) [5]. False-nega-
tive results may occur if inflammatory bowel
wall thickening is only mild [3]. False-positive
results are reported in adenocarcinoma, lym-
phoma, Crohns disease, ischemic colitis, and
extracolic inflammatory conditions adjacent to
the colonic wall [69, 71]. False-positive results
may be reduced with Doppler sonography
[63]. Potential pitfalls in diagnosing pericolic
abscesses are collections smaller than 2.5 cm
in diameter [5], interloop abscesses, and ab-
C
113
 Ledermann et al.

scesses with gas inclusions [69]. CT is more
accurate than sonography in revealing ab-
scesses [5, 28, 36] and is helpful in planning
percutaneous drainage by exactly delineating
the bowel loops [5].
Colonic Carcinoma
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colonic obstruction. Rectum carcinomas are
seen only when the bladder is well-filled (Figs.
11B and 11C). Sonography enables localiza-
tion of large-bowel obstruction in 85% of
patients and diagnosis of the cause of large-
bowel obstruction in 81% of patients [76].
Shirahama et al. [77] described four sono-
inal sonography is not an effective screening
technique in the diagnosis of colonic cancer.
Intussusception
Only 510% of all intussusceptions occur in
adults [78, 79]. The clinical symptoms may sug-
gest partial obstruction of the intestine, but diag-

Abdominal sonography may be the first im-
aging method that patients with colonic cancer
undergo when they present with nonspecific
gastrointestinal symptoms. Careful sono-
graphic evaluation of the bowel may disclose a
focal mass or mural thickening. Sonographic
diagnosis of colonic carcinoma has been de-
scribed by several authors [7274]. Colonic
carcinomas have two typical sonographic ap-
pearances [75]. The first type is seen as a local-
ized hypoechoic mass up to 10 cm or more
with an irregular shape and a lobulated con-
tour. The intraluminal gas, seen as a cluster of
high amplitude, is usually eccentrically located
around the mass (Fig. 11A). The second type
shows segmental eccentric or circumferential
thickening of the colonic wall. The mural
thickening may be irregular but not as severe
as in the first type (Fig. 11B). The central echo
clusters are small because the diseased lumen
is usually narrow. This type leads frequently to
graphic patterns that allowed correct diagnosis
of colonic carcinoma in 90% of patients: local-
ized irregular thickening of the colonic wall
with heterogeneous low echogenicity; irregu-
lar contour; lack of movement or change in
configuration on real-time scanning; and ab-
sence of a layered appearance of the colonic
wall. Other findings include lymphadenopathy
in most patients and abscess formation in 10%
of patients. In a recent publication, malignant
conditions of the colon showed the following
characteristics: loss of stratification, absence of
perigut findings, and involvement of a short
bowel segment with significantly greater wall
thickness than is present in benign processes
[62]. However, negative findings on sono-
graphic examinations do not rule out the diag-
nosis of colonic carcinoma because small
masses and overlying bowel gas can lead to
false-negative results [72, 76]. Because of
these limitations, mainly in sensitivity, abdom-
nosis may be difficult because symptoms are
often nonspecific [79]. The ileocecal region is
the most commonly affected area in children,
whereas there is no clearly preferred anatomic
site in adults. Most intussusceptions in children
are idiopathic and are presumed to be the result
of enlarged lymphoid follicles in the terminal il-
eum. An organic cause can be shown in as many
as 90% of cases in adults [78, 79]. The leading
mass is nearly always a tumor of the intestinal
wall, usually malignant in intussusceptions of
the colon [80] and benign in intussusceptions of
the small intestine [57, 78]. The sonographic
hallmark of intussusception has been described
as the target [81], doughnut, or bulls-eye
sign [82]. Typically, one finds two hypoechoic
rings separated by a hyperechoic ring or crescent
on axial images (Fig. 12). On longitudinal im-
ages, a pseudokidney structure or layering of hy-
poechoic lines with hyperechoic areas is
observed. The outer hypoechoic ring is formed

A B C

Fig. 11.Sonographic features of colonic carcinoma.

A, Eccentric type in 52-year-old man. Transverse sonogram shows typical irregular eccentric thickening of cecum
wall and loss of stratification. Note eccentrically located intraluminal air (arrow ).
B, Circumferential type in 66-year-old man. Longitudinal sonogram of sigmoid colon with irregular circumferential
thickening (arrows) of short colonic wall segment.
C, Polypoid rectal carcinoma in 59-year-old man. Transvesical transverse sonogram of rectum shows endoluminal
round polypoid tumor measuring 3 cm in diameter (between crosses).
D, CT correlation of lesion in C.
D

114 AJR:174, January 2000

 Sonography of Bowel Wall
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A B
Fig. 12.57-year-old man with intussusception of anastomosed jejunum into remaining stomach after a Billroth
II procedure (subtotal gastrectomy).
A, Transverse sonogram shows hypoechoic kidney-shaped mass reflecting remnant of stomach with intussus-
ception in its lumen. Small hyperechoic ring formed by invaginated mesentery divides intussuscipiens (gastroje-
junal anastomosis) on outside from intussusceptum (jejunum) and leads to a ring-in-ring structure.
B, CT correlation confirms intussusception.
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AJR:174, January 2000
 Sonography of Bowel Wall

APPENDIX 1: Differential Diagnosis of Small-Bowel Wall Thickening

Common: Inflammatory bowel disease (Crohns disease and backwash ileitis)
Acute ileitis (Yersinia, Campylobacter species)
Postoperative edema
Peritoneal carcinomatosis
Mesenteric infarction (arterial, venous)
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Extraintestinal inflammatory conditions adjacent to bowel wall

Less common: Intestinal hematoma
Cytomegalovirus enteritis in AIDS patients
Intussusception
Lymphoma
Carcinoid and other malignant tumors
Benign tumors (lipoma, adenoma, and schwannoma)
Rare: Tuberculosis
Celiac disease
Whipples disease
Eosinophilic enteritis
Endometriosis
Amyloidosis
Anisakiasis
Behets disease
Sarcomas

APPENDIX 2: Differential Diagnosis of Colonic Wall Thickening

Common: Diverticulitis
Carcinoma
Inflammatory bowel disease (Crohns disease and ulcerative colitis)
Colitis
Appendicitis
Postoperative edema
Peritoneal carcinomatosis
Less common: Extracolic inflammatory conditions adjacent to the colonic wall
Intussusception
Rare: Lymphoma
Amyloidosis
Endometriosis

AJR:174, January 2000 117