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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 Inflammatory Bowel Disease ers, which results in a thick hypoechoic rim on
produced by the submucosa and the muscu- The classic sonographic feature of Crohns axial images. Strictures are shown as marked
laris propria interface. The muscularis pro- disease is the target sign (Fig. 2) on trans- thickening of the gut wall with a fixed hyper-
pria is seen as a fourth hypoechoic layer. verse images, which means a strong echogenic echoic narrowed lumen (Fig. 3A), dilatation,
Finally, the marginal interface to the serosa is center surrounded by a relatively sonolucent and hyperperistalsis of the proximal gut. Peri-
seen as the fifth small hyperechoic layer. The rim of more than 5 mm. This transmural in- intestinal inflammation leads to the creeping
average thickness of the normal gut wall is flammation or fibrosis can lead to complete fat sign, which appears as a uniform hyper-
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24 mm [6]. circumferential loss of the typical gut wall lay- echoic mass typically seen around the ileum
and cecum. Mesenteric lymphadenopathy is
Fig. 1.4-year-old girl with gastroenteritis. Sagittal seen as multiple oval hypoechoic masses, usu-
sonogram shows normal gut wall layering of rectum ally in the right lower quadrant. In contrast to
(RE) from lumen outward. Note small echogenic layer
in lumen that reflects superficial mucosal interface
other forms of colitis, Crohns disease is sug-
(short thin arrow ). Deep mucosa, including muscu- gested by skip areas and involvement of the
laris mucosa, is seen as second hypoechoic layer distal ileum [7]. Possible complications of
(long thin arrow ). Third broad hyperechoic layer is Crohns disease comprise fistulas, abscess for-
produced by submucosa and muscularis propria inter-
face (open arrow ). Muscularis propria is seen as mation, mechanical bowel obstruction, and
fourth hypoechoic layer (short thick arrow ). Marginal perforation [8]. Abscesses are seen as poorly
interface to serosa is seen as small fifth hyperechoic defined, mostly hypoechoic focal masses that
layer (curved arrow ). ASC = ascites in retrovesical
space, B = bladder. 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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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-
A B 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


Sonography of Bowel Wall

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.
A B

C D

presence of visible hyperemia or increased ficult to diagnose on sonography. Because CT amyloid is frequently seen [41]. Marked hypo-
flow in the hypoechoic muscular layer of the has been shown to be more accurate in staging echoic thickening of the affected bowel seg-
bowel wall may be a marker of appendicitis, periappendiceal inflammation and abscesses ments is found [42, 43].
whereas increased flow in the mucosal layer [5, 28, 36], CT may be preferred in patients Eosinophilic enteritis is a rare disease charac-
most likely represents enteritis [26]. Increased with suspected perforation or abscess; CT reli- terized by infiltration of the stomach or bowel
flow in the fat surrounding the appendix is in- ably differentiates phlegmon from abscess and wall with eosinophilic leukocytes. In three re-
dicative of transmural extension of the inflam- serves as an accurate road map for potential ported cases, hypoechoic thickening of multiple
mation with mesenteric response. An inflamed abscess drainage. ileal loops, narrowing of the lumen, and loss of
appendix rarely measures more than 15 mm in layer structure were described [44, 45].
transverse diameter [33], which usually allows Small-Bowel Diseases
differentiation from ileitis. A markedly en- Mesenteric infarction in its late stages
larged or perforating appendix or dilated fallo- leads to small-bowel wall thickening [37, 38].
pian tubes may lead to interpretive pitfalls [33]. In the early stages, however, no bowel wall
Perforation occurs in 2030% of young pa- thickening may be seen. Doppler sonography
tients with appendicitis (Fig. 6D). A statisti- can aid in differentiating ischemic and in-
cally significant association exists between flammatory bowel wall thickening. In ap-
perforation and two sonographic findings: loc- proximately 90% of cases, small-bowel
ulated pericecal fluid and loss of the echogenic infarctions are due to arterial hypoperfusion;
submucosa [35]. Abscess formation is the ma- only 10% are caused by mesenteric vein oc-
jor complication of perforating appendicitis. clusion. Acute intramural intestinal he-
Abscesses may extend into the pelvis or into matoma leads typically to a homogeneous
the peritoneal spaces of the upper abdomen. hypoechoic symmetric thickening of a long
They may be sonolucent or appear as a com- stretch of the affected bowel segment, with
plex mass. Advantages of sonography are wide reduced or absent peristalsis and marked lu-
availability, lack of radiation, and lack of con- minal narrowing [39] (Fig. 7). In the subacute Fig. 7.72-year-old woman with intramural hematoma
trast administration. Limitations of sonogra- stage, strong internal echoes caused by due to anticoagulant drug therapy. Patient was sent for
phy occur in obese and extremely meteoristic sonography to rule out atypical appendicitis. Trans-
thrombi may mimic an abscess [40]. verse sonogram of small-bowel segment discloses cir-
patients and in patients with severe pain due to Amyloidosis is a rare condition; however, cumferential hypoechoic thickening of bowel wall with
peritonitis. Retrocecal appendicitis may be dif- gastrointestinal involvement in patients with loss of stratification and compression of lumen.

AJR:174, January 2000 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


Sonography of Bowel Wall

propria in all cases. Carcinoid tumors of the ap- Colitis 10B), intramural or pericolic abscess (Fig.
pendix were described in two cases [55] as hy- The sonographic features of pseudomembra- 10C), and (usually) severe local tenderness in-
poechoic, well-delineated elongated masses in nous colitis have been described in a number of duced by graded compression. Diverticula are
the distal lumen and the tip of the appendix. reports [61, 62]. Striking thickening of the co- round or oval echogenic foci seen in or right
Lipomas are the second most common tumors lonic wall with a wide inner circle of heteroge- next to the gut wall, mostly with internal
of the small intestine and occur with greatest fre- neous medium echogenicity surrounded by a acoustic shadowing. Thickening of the bowel
quency in the distal ileum and at the ileocecal wall is usually considered present when the
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narrow hypoechoic muscularis propria is found


valve. The location of these tumors is submu- in all patients, reflecting the gross submucosal distance from the echogenic lumen interface to
cosal, or, less frequently, is subserosal. In three edema. The lumen of the colon is almost com- the hyperechogenic serosa and pericolic fat ex-
fourths of cases, the tumors are clinically silent pletely effaced by the mural edema, and 64 ceeds 4 mm [5]. Inflammatory changes in the
[56]. If the lipoma becomes larger than 4 cm, 77% of the patients have ascites [61, 62]. The pericolic fat are seen as ill-defined echogenic
chronic hemorrhage caused by ulceration of the presence of these sonographic features in a pa- areas surrounding the thickened colon seg-
mucosa or intestinal obstruction resulting from in- tient with watery diarrhea and a history of anti- ment. Pericolic abscesses typically present as
tussusception may cause symptoms [57, 58]. Typ- biotic therapy strongly suggests the diagnosis hypoechoic masses adjacent to the inflamed
ical sonographic features are a well-circumscribed of pseudomembranous colitis. Pseudomembra- bowel. The major sonographic finding in pa-
hyperechoic round or oval mass with deformation nous colitis shows typically a strong folding or tients with uncomplicated acute diverticulitis
under compression. Leiomyomas and schwanno- gyral pattern of the swollen submucosa. of the right colon has been found to be a hypo-
mas are seen as hypoechoic intramural round Ischemic colitis cannot be differentiated echoic round or oval focus protruding from the
structures with smooth boundaries [52, 58, 59]. solely by sonography from inflammation or any segmentally thickened colonic wall and repre-
Ulceration of the mucosa may cause gastrointesti- other form of colonic wall thickening. However, senting small abscesses in the pericolic fat
nal hemorrhage of varying severity. Leiomyosar- duplex and color Doppler sonography may be [68]. The sensitivity of sonography in the diag-
comas were described as large irregular masses helpful in differentiating between ischemic and nosis of acute colonic diverticulitis ranges in
with a heterogeneous echo pattern [58]. Adeno- inflammatory bowel wall thickening [63]. Ab- the literature from 84% to 100% [5, 6971]. In
carcinoma is the second most common small in- sence of or barely visible color Doppler flow a recent study comparing sonography and CT
testine malignancy and the peak incidence is in and absence of arterial signal suggest ischemia. in the evaluation of acute colonic diverticulitis,
the seventh decade of life [52]. A series of four On the other hand, readily visible color Doppler both techniques reached a similar sensitivity
cases with duodenal adenocarcinomas showed flow and a stratified echo texture suggest in- (85% and 91%, respectively) and specificity
moderately large intraluminal masses with me- flammation. Various case reports have described (84% and 77%, respectively) [5]. False-nega-
dium echogenicity [58]. The authors report im- colonic wall thickening in different forms of in- tive results may occur if inflammatory bowel
proved sonographic detection of small-bowel fectious and noninfectious colitis [24, 6467]. wall thickening is only mild [3]. False-positive
tumors by intermittent observation of the small- results are reported in adenocarcinoma, lym-
bowel lesions during the first hour after water phoma, Crohns disease, ischemic colitis, and
ingestion. Transabdominal sonography reached Diverticulitis extracolic inflammatory conditions adjacent to
excellent sensitivity in detecting small-bowel Sonographic features of diverticulitis in- the colonic wall [69, 71]. False-positive results
tumors in unexplained gastrointestinal bleeding clude visualization of diverticula (Fig. 10A), may be reduced with Doppler sonography
[59] and in small-bowel obstruction [60]. In thickening of the bowel wall, inflammatory [63]. Potential pitfalls in diagnosing pericolic
most cases, the tumors were seen as round and changes in the pericolic fat (typically on the abscesses are collections smaller than 2.5 cm
smoothly delineated hypoechoic masses. mesenteric side of the colonic wall) (Fig. in diameter [5], interloop abscesses, and ab-

A B C
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 113


Ledermann et al.

scesses with gas inclusions [69]. CT is more colonic obstruction. Rectum carcinomas are inal sonography is not an effective screening
accurate than sonography in revealing ab- seen only when the bladder is well-filled (Figs. technique in the diagnosis of colonic cancer.
scesses [5, 28, 36] and is helpful in planning 11B and 11C). Sonography enables localiza-
percutaneous drainage by exactly delineating tion of large-bowel obstruction in 85% of Intussusception
the bowel loops [5]. patients and diagnosis of the cause of large- Only 510% of all intussusceptions occur in
bowel obstruction in 81% of patients [76]. adults [78, 79]. The clinical symptoms may sug-
Colonic Carcinoma Shirahama et al. [77] described four sono- gest partial obstruction of the intestine, but diag-
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Abdominal sonography may be the first im- graphic patterns that allowed correct diagnosis nosis may be difficult because symptoms are
aging method that patients with colonic cancer of colonic carcinoma in 90% of patients: local- often nonspecific [79]. The ileocecal region is
undergo when they present with nonspecific ized irregular thickening of the colonic wall the most commonly affected area in children,
gastrointestinal symptoms. Careful sono- with heterogeneous low echogenicity; irregu- whereas there is no clearly preferred anatomic
graphic evaluation of the bowel may disclose a lar contour; lack of movement or change in site in adults. Most intussusceptions in children
focal mass or mural thickening. Sonographic configuration on real-time scanning; and ab- are idiopathic and are presumed to be the result
diagnosis of colonic carcinoma has been de- sence of a layered appearance of the colonic of enlarged lymphoid follicles in the terminal il-
scribed by several authors [7274]. Colonic wall. Other findings include lymphadenopathy eum. An organic cause can be shown in as many
carcinomas have two typical sonographic ap- in most patients and abscess formation in 10% as 90% of cases in adults [78, 79]. The leading
pearances [75]. The first type is seen as a local- of patients. In a recent publication, malignant mass is nearly always a tumor of the intestinal
ized hypoechoic mass up to 10 cm or more conditions of the colon showed the following wall, usually malignant in intussusceptions of
with an irregular shape and a lobulated con- characteristics: loss of stratification, absence of the colon [80] and benign in intussusceptions of
tour. The intraluminal gas, seen as a cluster of perigut findings, and involvement of a short the small intestine [57, 78]. The sonographic
high amplitude, is usually eccentrically located bowel segment with significantly greater wall hallmark of intussusception has been described
around the mass (Fig. 11A). The second type thickness than is present in benign processes as the target [81], doughnut, or bulls-eye
shows segmental eccentric or circumferential [62]. However, negative findings on sono- sign [82]. Typically, one finds two hypoechoic
thickening of the colonic wall. The mural graphic examinations do not rule out the diag- rings separated by a hyperechoic ring or crescent
thickening may be irregular but not as severe nosis of colonic carcinoma because small on axial images (Fig. 12). On longitudinal im-
as in the first type (Fig. 11B). The central echo masses and overlying bowel gas can lead to ages, a pseudokidney structure or layering of hy-
clusters are small because the diseased lumen false-negative results [72, 76]. Because of poechoic lines with hyperechoic areas is
is usually narrow. This type leads frequently to these limitations, mainly in sensitivity, abdom- 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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116 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