The Student will be able to:

Ultrasonography of the Gastrointestinal Tract

Kari L. Anderson, DVM, DACVR Associate Clinical Professor University of Minnesota

List limitations and advantages of GI ultrasonography Recognize and describe normal anatomy and sonographic appearance of the GI tract Recognize and describe diffuse and focal lesions of the GI tract and be able to generate an appropriate differential list

US of the GI tract

Indications
Chronic or acute vomiting or diarrhea that is unexplained by blood work and radiographs Evaluate abnormal radiographic findings Evaluate for cause of intestinal obstruction foreign body, intussusception, tumor Evaluate prior to endoscopy localize lesion, assess regional nodes

Important complementary diagnostic tool Should not replace survey abdominal radiography Limitations:

Lesion ID can be hit or miss Often cant precisely localize Very operator dependent thoroughness, sensitivity, skill Needs no special preparation Non-invasive Allows evaluation of entire wall Motility assessment without ionizing radiation Provides assessment of regional disorders Guides sampling

Advantages:

US of the GI tract Technical Considerations

Imaging Protocol

US can be compromised Gas is a barrier

Preparation

Fasting is helpful Must use highest frequency (7.5 MHz) for best resolution Routinely scanned in dorsal recumbency

Transducer Scan plane

Reverberation, comet tail, shadowing

Careful systematic approach Be careful about using as screening test

Reverberation and shadowing from gas

Common to change position to left or right or standing (ventral aspect pylorus, stomach body) to displace intraluminal fluid, can instill fluid into stomach Transverse plane generally preferred for measuring thickness

Transverse and longitudinal planes of the GI tract

US of the GI tract - Normal

US of the GI tract - Normal

5 layers to the wall Mucosal surface-luminal interface Mucosa Submucosa Muscularis propria Subserosa-serosa interface

Wall layering

stomach
From: Penninck p. 211 in Small Animal Diagnositc Ultrasound, Nyland and Matoon, 2002

jejunum

Long axis view of jejunum

US of the GI tract - Normal

US of the GI tract Normal

Wall thickness

Wall thickness
Stomach Duodenum 1.5-3.5 mm 5.1 mm 5.3 mm 6.0 mm Jejunum 1.5-3.5 mm 4.1 mm 4.4 mm 4.7 mm Colon 1.1-2.5 mm

Cat Dog <20kg Dog 2030kg Dog >30kg

2 mm, 4.4 mm 3-5 mm 3-5 mm 3-5 mm

Duodenum

Jejunum

Colon

US of the GI tract - Normal

US of the GI tract - Normal

Esophagus rarely may find distal esophagus

Stomach

Rugal folds
Create

orange slice or wagon wheel appearance when empty in transverse Makes wall thickness difficult to assess

Complete examination generally not possible Pylorus may or may not be visible

US of the GI tract - Normal

US of the GI tract - Normal

Stomach

Stomach

US of the GI tract - Normal

US of the GI tract - Normal

Duodenum

Only definitively distinguished from jejunum on basis of connection to stomach Generally slightly thicker wall than jejunum Generally SI loop found lateral and ventral to right kidney Descending portion has straight course with gentle caudal flexure May appreciate pseudoulcers (lymphoid aggregates) on ultrasound as square defect in mucosa Insertion of the common bile duct

Duodenum

US of the GI tract - Normal

US of the GI tract - Normal

Duodenum

pseudoulcers

Jejunum
Majority of the intestines Should be essentially empty in fasted patient Contents are echogenic fluid in an animal that has eaten, with active peristalsis Can be difficult to follow a single loop for any distance

US of the GI tract - Normal

US of the GI tract - Normal

Jejunum

Ileum
Short segment leading to colon In long axis, can give the illusion of more layers (still has the five) due to its folds In short axis, has a clover leaf or Maltese cross appearance

US of the GI tract - Normal

US of the GI tract - Normal

Ileum

Colon
Very thin-walled compared to other intestine Generally easily followed to pelvic inlet Normal contents highly echogenic with a dirty shadow because of gas and any mineral content Cecum similar to colon but ends in blind sac

Transverse colon

Longitudinal

ileum Ileocolic junction

US of the GI tract - Normal

US of the GI tract - Normal

Colon
jejunum colon

Intestinal patterns

Mucous pattern

Fluid pattern

US of the GI tract - Normal

US of the GI tract - Normal

Intestinal patterns

Peristalsis

Stomach: 4-5 per minute Intestine: 1-3 per minute

Gas pattern

Alimentary pattern

jejunum

US of the GI tract Interpretive Principles

Same principles as radiography and barium series Complete assessment

US of the GI tract Interpretive Principles

Intramural (mural) Intraluminal (luminal)

Size Shape Wall thickness Peristalsis versus rigidity

Intramural (mural) annular

Extramural

Think intramural, intraluminal, extramural lesion location

Images courtesy of Dr. Feeney

US of the GI tract Interpretive Principles

US of the GI tract Interpretive Principles

Think of pathology as:

Ileus

Abnormal function (ileus, spasticity)

Often

secondary issue

Abnormal contents (foreign bodies, fluid in fasted individual) Abnormal structure (infiltrate, mass, stricture)
Inflammatory Strictures

Obstructive: segmental dilation, increased peristalsis acutely Non-obstructive: generalized dilation, decreased motility

or neoplastic seldom identified on ultrasound

US of the GI tract Interpretive Principles

US of the GI tract Abnormal Stomach

Spasticity
Pancreatitis Regional peritonitis Inflammatory disease

Thick wall most common abnormality

Diffuse thickening difficult to recognize

Focal, asymmetrical thickening, loss of layering

Tumors, granulomas

Diffuse thickening, maintenance of layering, echogenicity alteration

Inflammatory diseases, edema

US of the GI tract Abnormal Stomach

US of the GI tract Abnormal Stomach

Masses (mural lesion)

Lymphoma: transmural, circumferential thickening Carcinoma: pseudolayered lesion Leiomyosarcoma: exophytic, large and complex Leiomyoma: incidental in older dogs, small mural mass Need aspirate/biopsy confirmation

Lymphoma

stomach

US of the GI tract Abnormal Stomach

US of the GI tract Abnormal Stomach

Carcinoma

Leiomyoma

pseudolayering

stomach

US of the GI tract Abnormal Stomach

US of the GI tract Abnormal Stomach

Gastric inflammatory infiltrate

Uremic gastritis

US of the GI tract Abnormal Small Intestine

US of the GI tract Abnormal Small Intestine

Foreign bodies (intraluminal lesion)

Foreign bodies
proximal dilation

Most are sharply defined, hyperechoic interface with shadowing

Some dont shadow (superball, shelled nuts)

Proximal intestinal dilation (2 populations of bowel) Ineffective hyperperistalsis Linear foreign bodies have classic ribbon candy plication If see dilated loop, must follow in both directions
Longitudinal Transverse

Pinecone foreign body with obstruction

US of the GI tract Abnormal Small Intestine

US of the GI tract Abnormal Small Intestine

Foreign bodies

Linear foreign bodies

Almond foreign body in duodenum leading to gastric outflow obstruction

US of the GI tract Abnormal Small Intestine

US of the GI tract Abnormal Small Intestine

Intussusception

Intussusception

Multilayered appearance of wall (concentric rings or ring sign) representing the superimposed wall layers of the intussusceptum and intussuscipiens

intussuscipiens

intussusceptum

fat

US of the GI tract Abnormal Small Intestine

US of the GI tract Abnormal Small Intestine

Inflammatory diseases (mural lesion)

Inflammatory

Extensive, symmetrical mild to moderate wall thickening

May

be normal sonographically!
Mild thickening mainly affecting mucosal layer

Maintenance of wall layering Alteration of echogenicity Rigid, hypomotile bowel

Moderate thickening with increased echogenicity of the mucosal layer Moderate thickening mainly affecting muscularis layer

US of the GI tract Abnormal Small Intestine

US of the GI tract Abnormal Small Intestine

Neoplasia (mural lesion)

Focal, asymmetric, thickening (most easy to recognize) Regional lymphadenopathy common Lymphoma commonly transmural, circumferential, hypoechoic

Lymphoma

Long or multiple segments Less likely to obstruct Shorter focal segment Often associated obstruction Can be annular constrictive lesion

Carcinoma localized, irregular, hypoechoic or mixed

Smooth muscle tumors often eccentric, poorly echogenic masses

Exophytic and rarely cause obstruction

Small intestine

Need aspirate or biopsy!

US of the GI tract Abnormal Small Intestine

US of the GI tract Abnormal Small Intestine

Lymphoma

Carcinoma

Jejunum

Regional lymphadenopathy Duodenum

US of the GI tract Abnormal Small Intestine

US of the GI tract Abnormal Small Intestine

Carcinoma

Smooth muscle tumor

lumen

mass

Ileum Exophytic mass

US of the GI tract Abnormal Small Intestine

US of the GI tract Abnormal Small Intestine

Ulceration
Gas tracking through wall

Perforation assess for peritoneal gas, fluid, and reactive mesentery

Free peritoneal gas Wall disruption

US of the GI tract - Conclusions

Is viable option in assessment of GI disease Should not replace abdominal radiography Successful evaluation dependent upon several things:

Machine resolution Patient cooperation Thoroughness of examination Operator experience and skill Dumb luck