Pe d i a t r i c I m a g i n g R ev i ew

Anupindi et al.
Bowel Ultrasound in Children

Pediatric Imaging
Review

Common and Uncommon

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Applications of Bowel Ultrasound

FOCUS ON:

With Pathologic Correlation

in Children
Sudha A. Anupindi1 OBJECTIVE. The purpose of this article is to describe the indications and techniques for
Mark Halverson1 bowel ultrasound for inflammatory bowel disease and other common and uncommon entities and
Asef Khwaja1 describe and illustrate their imaging appearances, including endoscopic or surgical correlation.
Mihajlo Jeckovic2 CONCLUSION. Ultrasound is a useful tool for the evaluation of inflammatory bowel
Xing Wang3 disease and many other bowel diseases. Radiologists must become familiar with the full po-
1 tential of ultrasound in the evaluation of the bowel in children because the need for alternative
Richard D. Bellah
radiation-free imaging techniques continues to grow.
Anupindi SA, Halverson M, Khwaja A, Jeckovic M,
Wang X, Bellah RD

Keywords: bowel ultrasound, foreign bodies,
Henoch-Schnlein purpura, inflammatory bowel disease,
necrotizing enterocolitis, polyps
DOI:10.2214/AJR.13.11661
Received August 2, 2013; accepted after revision
December 18, 2013.
1
Department of Radiology, The Childrens Hospital of
Philadelphia, University of Pennsylvania Perelman
School of Medicine, 34th St and Civic Center Blvd,
Philadelphia, PA 19104. Address correspondence to
S. A. Anupindi (anupindi@email.chop.edu).
2
Department of Radiology, Institute for Children and
Youth Health Care of Vojvodina, Hajduk Veljkova Novi
Sad, Serbia.
3
Department of Radiology, Beijing Childrens Hospital,
Beijing, China.
This article is available for credit.
AJR 2014; 202:946959
0361803X/14/2025946
American Roentgen Ray Society
T
argeted ultrasound has been well
established for the evaluation of
bowel pathology in children for in-
tussusceptions, appendicitis, and
hypertrophic pyloric stenosis for more than a
decade. In many places, ultrasound is the first
line of imaging over CT and radiography for
these diagnoses. Ultrasound of the bowel is a
routine part of the evaluation of both adults and
children with inflammatory bowel disease
(IBD) in Europe but is only recently emerging
as a potential technique in the evaluation of pa-
tients in North America. With attention on ra-
diation safety and awareness by health care
staff, patients, parents, and media, now is an
opportune time to shift the focus of IBD imag-
ing from radiation-dependent modalities, such
as fluoroscopy and CT, to radiation-free mo-
dalities, such as ultrasound. Ultrasound is easy
to perform, accessible, and inexpensive. It can
be performed with little preparation and with-
out sedation, making it more appealing in the
pediatric population. However, there are limi-
tations in performing bowel ultrasound, includ-
ing: children with large body habitus, excessive
bowel gas, and postoperative patients in whom
the anatomy may be distorted. Other challeng-
es of bowel ultrasound include the need for spe-
cialized training and experience to perform
and interpret these examinations. Publications
in the last few years have shown that ultrasound
can depict both the intramural and extramural
pathology of IBD, particularly Crohn disease
[1, 2]. Because of increasing concern for radia-
tion exposure, pediatric imagers have been op-
timizing and expanding the role of ultrasound
in the assessment of bowel pathology.
We introduced dedicated nonemergent
bowel ultrasound in our department for IBD
more than 3 years ago, and we have expand-
ed the indications for using bowel ultrasound
and tailored the ultrasound technique for dif-
ferent clinical scenarios. Because of the lim-
ited role of ultrasound in the workup of bow-
el neoplasms, infections, and celiac disease,
we have chosen not to focus our discussion on
these topics. At our institution, targeted bowel
ultrasound is used not only in the evaluation of
children with IBD but also for detection and di-
agnosis of other disease processes, such as nec-
rotizing enterocolitis (NEC), Henoch-Schn-
lein purpura (HSP), foreign bodies, and polyps.
Our aim is to enhance the clinicians and ra-
diologists knowledge of these useful, perhaps
uncommon, applications. The purpose of this
article is to describe the indications and cur-
rent techniques for bowel ultrasound and illus-
trate exemplary cases with correlation with en-
doscopy or surgery and provide practical key
teaching points to optimize imaging and rec-
ognize hallmarks of each disease.
Bowel Ultrasound Technique
Patient Preparation and Oral Contrast
Administration
In general, neonates and young children
being evaluated for NEC, HSP, malrota-
tion, or other non-IBD indications do not re-
quire any preparation before the ultrasound
and are not restricted to nothing by mouth

946 AJR:202, May 2014


(NPO). The examinations are usually done
in the emergent setting, whereas ultrasound
studies for evaluation of IBD are performed
electively. Older children who have suspect-
ed or known IBD are required to be NPO for
solids for 4 hours before the ultrasound ex-
amination. Yet, we encourage the oral intake
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of at least 1216 ounces (360480 mL) of
clear liquids, which distends the bladder and
therefore helps push the small-bowel loops
out of the pelvis for better compression. To
reduce air in the bowel, children should not
consume carbonated drinks. Oral contrast
material, although only available for clini-
cal use in Europe and off-label research use
in the United States, can be administered in
small quantities to distend the bowel and has
been shown to have an excellent safety pro-
file, be well tolerated, and yield high diag-
nostic performance [1]. Studies in the litera-
ture on the efficacy of oral and IV ultrasound
contrast agents have been focused on IBD.
Despite these advantages, the use of contrast
agents is controversial, and the main limita-
tion is in its lack of availability.
Protocol
In general, the ultrasound protocol is
based on having simultaneous anterior and
posterior manual compression [2]. A hand
is placed underneath the patient and man-
ual pressure is applied in an upward move-
ment from behind while simultaneously us-
ing the transducer to compress the bowel
down (Fig. 1). In this manner, pressure and
compression are used from two directions in
all areas of the bowel. Conventionally, ultra-
sound examinations of the abdomen or pel-
vis are performed using the sector low-fre-
quency transducer first, followed by use of
a higher-resolution linear probe. However, in
our practice, we first scan with a high-res-
olution linear probe (1215 MHz) and then
with the lower-frequency sector probe. Using
the high-resolution linear transducer, we per-
form gray-scale and color Doppler imaging
in the sagittal and transverse planes along
the entire length of the bowel, starting with
the terminal ileum and ileocecal valve in the
right lower quadrant and continuing along
the colon into the left lower quadrant. Using
the same compression technique, we evalu-
ate the jejunal loops in the left upper quad-
rant and ileal loops in the mid and lower ab-
domen. The jejunum is characterized by its
normal folds as opposed to the ileum. Sub-
sequently, it is customary to have the patient
drink water and image the stomach and du-
AJR:202, May 2014 947
Bowel Ultrasound in Children
odenum with the patient in a decubitus po-
sition. In this manner, gastric and duodenal
wall abnormalities can be depicted easily. To
complete the examination, using the 58
MHz transducer, we evaluate the mesentery
for fluid collections, abscesses, or dilated
loops of bowel.
The Doppler portion of the examination
is performed with a low wall filter and the
lowest pulse repetition frequency to prevent
aliasing. Some authors advocate taking the
power Doppler assessment of the superior
mesenteric artery with waveforms and cal-
culation of resistive indexes as well [3]. In
addition to the static gray-scale and color
Doppler images, cine clips are acquired to
assess peristalsis of bowel segments. This
systematic approach will provide both ana-
tomic and functional information, which is
a direct benefit of ultrasound over modalities
such as CT.
Modified Protocols
The bowel ultrasound technique needs to
be modified to answer specific clinical ques-
tions. For example, to distinguish between
free air and pneumatosis in an infant with
NEC, the infant should be scanned in the
supine and decubitus positions to determine
whether the air shifts or remains in the bow-
el wall. In HSP, evaluation of the jejunum in
the left upper quadrant is essential to look
for jejunojejunal intussusceptions. Color and
power Doppler assessment of the superior
mesenteric artery (SMA) and vein (SMV) is
essential when evaluating a child for malro-
tation and possible volvulus. For visualiza-
tion and localization of enteric foreign bod-
ies in the stomach or proximal small bowel, a
fluid-filled stomach will provide an excellent
acoustic window. In a similar fashion, for
evaluation of rectal prolapse or large-bow-
el polyps, administering a retrograde saline
enema will help identify the mass or polyp
readily in a background of a saline-filled co-
lon. These technique modifications will be
emphasized throughout this article because
performing ultrasound examinations in the
assessment of NEC, HSP, foreign bodies,
and polyps is more challenging compared
with assessing IBD.
Normal Bowel on Ultrasound
Manual anterior and posterior compression
techniques will help displace air and bowel
loops. The high-frequency probes enable one
to visualize and characterize the changes in
the layers of the bowel wall. When the prop-
er technique is applied, each of the five lay-
ers of the bowel wall can be visualized from
the inner echogenic mucosal layer to the out-
er echogenic serosa (Fig. 2). In normal bowel
segments the bowel wall stratification is pre-
served and well depicted. Normal bowel wall
thickness is less than 2.5 mm for small bowel,
and for the colon it is normally less than 2 mm.
Peristalsis should be visible in healthy bowel
segments, and the segments should be com-
pressible. In color Doppler examination, nor-
mal bowel does not show much vascularity;
therefore, hyperemia can be easily detected.
Increased vascularity can be assessed quali-
tatively by visual inspection or more quantita-
tively by examining the density of vessels and
measuring the flow velocities and resistive in-
dex of the SMA.
Inflammatory Bowel Disease
There are currently three categories of
IBD: Crohn disease, ulcerative colitis, and
indeterminate colitis. Of these, Crohn dis-
ease is the one that requires frequent imag-
ing because of its extensive involvement of
the gastrointestinal tract and lifelong epi-
sodes of relapses and remissions. Crohn dis-
ease is a chronic transmural process with a
multifactorial cause. Current imaging tech-
niques to evaluate for Crohn disease include
conventional small-bowel follow-through
examinations, CT, CT enterography (CTE),
and MR enterography (MRE). Yet, there is
an emerging role for ultrasound as well. Ul-
trasound is easy to perform, fast, accessible,
inexpensive, and able to provide high-resolu-
tion images to quickly answer clinical ques-
tions. Because of the inherent limitations
and challenges in performing and interpret-
ing high-resolution bowel ultrasound without
contrast administration, bowel ultrasound in
its current form cannot replace MRE or CTE
but can provide complementary information
in the evaluation of IBD.
To date, the published reports on contrast-
enhanced ultrasound (CEUS) with oral con-
trast agents, such as polyethylene glycol,
have shown increased sensitivity, specifici-
ty, and accuracy for the detection of Crohn
disease lesions and strictures of the proximal
small bowel and terminal ileum over trans-
abdominal ultrasound [4]. The sensitivity
and specificity of both ultrasound methods
in detecting Crohn disease lesions is 75%
and 100% for transabdominal ultrasound
and 100% and 100% for CEUS, respectively
[4]. In addition, the performance of CEUS
is comparable to small-bowel follow-through

and CT examinations [5]. Similarly, the use
of IV contrast agents has been described to
increase the overall sensitivity, specificity,
and accuracy of detecting Crohn disease,
which correlated well with the Crohn disease
activity index [6].
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Indications of Bowel Ultrasound for
Inflammatory Bowel Disease
The reported diagnostic performance of
ultrasound for the diagnosis of Crohn dis-
ease has sensitivity of 7594% and specifici-
ty of 67100% [7, 8]. In our experience, bow-
el ultrasound has a role in the evaluation of
Crohn disease in the following clinical sce-
narios: diagnosis, particularly when MRE is
not possible due to young age or need for se-
dation; follow-up treatment changes, particu-
larly isolated terminal ileum disease; follow-
up to MRE; and assessment and follow-up of
complications, such as abscess or phlegmon.
Ultrasound Features of Inflammatory
Bowel Disease
The characteristic mural and extramural
features of Crohn disease and its complica-
tions visible on other cross-sectional exam-
inations, such as MRE and CT, are easily
seen on ultrasound. The key pathologic ul-
trasound features of IBD will be discussed in
brief because a full discussion is beyond the
scope of this article.
Bowel wall thickening and loss of the nor-
mal bowel wall stratification are the prima-
ry imaging features of Crohn disease and
are manifestations of the chronicity of the
disease. On average, in children with active
Crohn disease, diseased segments of bowel
are hyperemic, noncompressible, and hypo-
peristaltic and have a hypoechoic wall with
a minimal thickness of 45 mm (Fig. 3).
Loss of bowel wall stratification is progres-
sive over time with infiltration by ulcers and
fissures. Luminal narrowing should be as-
sessed concomitantly with bowel wall thick-
ening. The hallmark of active disease is hy-
pervascularity on color Doppler imaging. A
visual inspection of thickened bowel wall
segments that show increased vascularity
has been highly associated with active Crohn
disease [9]. Spalinger et al. [10] have shown
that vessel density in an affected segment
can be helpful to diagnose Crohn disease.
In children with Crohn disease, identifying
bowel wall thickening greater than 5 mm
with vascular density (i.e., more than two
vessels per square centimeter) in color Dop-
pler imaging, is strongly indicative of active
948 AJR:202, May 2014
Anupindi et al.
disease, with 88% specificity and 95% posi-
tive predictive value (PPV) [10]. Additional-
ly, SMA flow velocities in patients with active
Crohn disease were higher, but SMA resistive
indexes were lower in this group [9, 11].
Important extramural abnormalities that
are easily depicted on ultrasound include
thickened, echogenic, and hyperemic mes-
entery (Fig. 4A), which simulate creeping
fat, disruption of bowel wall, and phlegmon
(Fig. 4B). Enlarged hyperemic lymph nodes
within the mesentery are also a common fea-
ture seen in acute Crohn disease. Common
complications of Crohn disease are stric-
tures, fistulas, and abscesses. These abnor-
malities can be readily seen on CTE or MRE
and, in experienced hands, can be seen on ul-
trasound as well.
Strictures are manifested by progres-
sive luminal narrowing resulting in proxi-
mal upstream dilatation and impaired bowel
function. On ultrasound, the transition from
narrowed to dilated bowel is seen with ac-
companying hyperperistalsis of the preste-
notic component, best depicted on real-time
cine clips. Strictures are identified in 70
79% of cases by ultrasound. The sensitivity
of ultrasound in detecting strictures varies
between 58% and 74%, and the sensitivity
is higher for ileal strictures (85%) than for
more-proximal small bowel [9].
Fistulas are more common in adults than
children, but when clinical symptoms are
suggestive, these abnormal communications
between bowel loops and bladder, other bow-
el loops, urethra, vagina, or prostate should
be identified (Figs. 5A and 5B). In our expe-
rience, fistulas can be difficult to diagnose.
They can be better seen on MRE because of
its multiplanar capability and greater resolu-
tion (Fig. 5C). Fistulas can be suggested on
ultrasound on the basis of clinical and imag-
ing findings, and ultrasound can provide sup-
porting evidence of fistula presence when al-
ready suggested on cross-sectional imaging.
On ultrasound, fistulas are hypoechoic tracts
between bowel loops or in close relationship
to adjacent organs. The sensitivity of ultra-
sound for the diagnosis of fistulas ranges
from 31% to 87% [9].
An abscess is identified as an irregular
thick-walled aperistaltic hypoechoic collec-
tion with low-level internal echoes in contrast
to a thin-walled peristalsing loop of bowel.
The sensitivity of ultrasound in detection of
abscesses ranges from 83% to 91% [9]. Ab-
scesses can be difficult to discern on ultra-
sound for a few reasons: They can mimic an
adjacent bowel loop, and a deep pelvic or ret-
roperitoneal location can limit visibility. Al-
though abscesses are readily seen on MRE or
CT, ultrasound can be used in follow-up.
Ultrasound also can help differentiate be-
tween inflammatory and fibrotic strictures
because active inflammatory strictures will
show increased vascularity, whereas fibro-
sis has little or no vascularity. In general, ul-
trasound is a practical, easy modality to use
in following IBD complications in addition
to evaluating posttreatment changes in focal
bowel segments.
Necrotizing Enterocolitis
NEC is a common and important cause
of morbidity and mortality in premature in-
fants in the neonatal ICU setting. A prompt
and accurate diagnosis is important for opti-
mal management. The precise cause of NEC
is not known, but multiple factors may con-
tribute. As NEC progresses, the bowel wall
thickens with an inflammatory reaction.
Eventually, mucosal integrity may be com-
promised, allowing pathogenic organisms to
enter the bowel wall and leading to the de-
velopment of pneumatosis intestinalis, which
can subsequently lead to the presence of por-
tal venous gas. Eventually, the bowel wall
can become necrotic and perforate, leading
to pneumoperitoneum and requiring surgical
intervention. The distal ileum and proximal
colon are most commonly affected.
Abdominal distention, feeding intolerance,
and bloody diarrhea may raise clinical suspi-
cion of NEC and imaging is often requested,
typically with radiography. However, ultra-
sound can provide information beyond ra-
diographic evaluation. The diagnostic perfor-
mance of ultrasound for the diagnosis of NEC
according to a study by Faingold et al. [12] is
sensitivity of 100%, specificity of 90%, PPV
of 83%, and negative predictive value (NPV)
of 100%. Ultrasound can be offered for detec-
tion of pneumatosis and portal venous gas not
seen on radiography when a paucity of bow-
el gas on radiography limits evaluation of the
bowel, a loop of bowel is unchanged on mul-
tiple consecutive radiographs raising suspi-
cion, or the clinical examination remains con-
cerning but radiography has failed to confirm
evidence of NEC. Currently, the role of ultra-
sound in the follow-up of treated patients is
unclear, and we have limited experience.
Gray-scale ultrasound can show the bowel
wall thickening of the inflammatory compo-
nent of NEC or bowel wall thinning as the
bowel becomes necrotic and progresses to-

ward perforation. Bowel wall thinning is de-
fined as a bowel wall measuring less than 1
mm [12]. Color Doppler images may show
hyperemia of the inflammatory reaction or
an avascular wall in more advanced NEC
with bowel wall necrosis [13] (Fig. 6).
Pneumatosis intestinalis is a sign of NEC
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and can be visualized as the presence of
punctate or granular echogenic foci within
the bowel wall. It is helpful to identify these
foci in the nondependent bowel wall to help
distinguish intramural from intraluminal gas
(Fig. 7). True pneumatosis intestinalis will
not change with changes in patient position,
whereas intraluminal gas is freely mobile.
Ultrasound has been shown to be more sen-
sitive for pneumatosis than radiography [14].
Dirty acoustic shadowing may be pro-
duced by the gas bubbles. A thin linear echo-
genic ring, or circle sign, may be visible,
and manual compression may help confirm
that the gas is not in the bowel lumen [15].
The gas bubbles may create a twinkling arti-
fact on color Doppler images [16].
Simple ascites is not rare in the setting of
any inflammatory process. However, in the
case of NEC, complex ascites and fluid col-
lections are signs suggestive of perforation
and have been correlated with a poor out-
come. Assessment of bowel motility is an es-
sential component of the examination in in-
fants with possible NEC because diseased or
necrotic bowel segments have decreased to
absent peristalsis [12, 17, 18].
Portal venous gas is another important sign
of necrotizing enterocolitis in the appropriate
clinical setting, and it manifests on ultrasound
as the presence of punctate and curvilinear
mobile echogenicities within the portal venous
branches. Portal venous gas is sometimes de-
tected in the absence of demonstrable pneuma-
tosis and can help differentiate surgical NEC
from other neonatal intestinal disease [19].
Tips: When it is difficult to determine the
precise location of echogenic foci of gas in
the abdomen (intraluminal, intramural, or
free in the peritoneal cavity), placing the pa-
tient in multiple positions can be helpful to
observe movement of the air. Peristalsis of
the bowel is usually assessed over 1 minute
to determine the presence or absence of mo-
tility or contractions.
Henoch-Schnlein Purpura
HSP is an autoimmune vasculitis that
variably affects the bowel, skin, joints, and
kidneys. Ultrasound plays an important role
in the evaluation of abdominal pain and bow-
AJR:202, May 2014 949
Bowel Ultrasound in Children
el abnormalities in these patients because
gastrointestinal involvement occurs in about
5075% of cases [20]. Patients with HSP
with bowel involvement may show bowel
dilatation, hypomotility, bowel wall thicken-
ing, and transient small-bowel intussuscep-
tions [21].
The evidence-based data on the perfor-
mance of ultrasound in the diagnosis of HSP
are limited. However, in one report, the sen-
sitivity, specificity, PPV, and NPV for the di-
agnosis of HSP involving the gastrointesti-
nal tract were 83%, 100%, 100%, and 54%,
respectively [22]. The bowel wall thicken-
ing is a result of submucosal hemorrhage,
which can be asymmetric (Fig. 8A). Com-
monly, HSP involves the stomach and small
bowel, particularly the duodenum, as noted
in a large series by Chang et al. [23]. This
can be helpful in distinguishing HSP from
IBD, which invariably involves the terminal
ileum and colon. Loss of the multilayered ar-
chitectural definition of the bowel wall has
also been described as an important observa-
tion in HSP, with greater loss of demonstra-
ble multilaminar bowel wall structure imply-
ing a worse prognosis with greater duration
of symptoms and longer hospitalization [22]
(Fig. 8B). Although these findings are not
specific to HSP, they may aid in diagnosis
when combined with the clinical history and
physical examination, for example, in the
setting of the characteristic rash of HSP or
in a child with arthritis and abdominal pain.
Surgical complications in children with
HSP are rare, occurring in about 4.6% of
patients. The most common complication is
small-bowel intussusceptions [20]. The in-
tussusceptions are commonly in the jejunum
or ileum and are self-limiting (Fig. 8C). How-
ever, in cases in which there is delay in diag-
nosis or treatment of the HSP, the intussus-
ception may require surgery. Color Doppler
imaging has an important role in assessing
perfusion to these segments of intussuscep-
tions. The presence of a persistent jejunal or
ileal intussusception with decreased or ab-
sent vascularity and dilated proximal bowel
should warrant early surgical investigation to
militate against irreversible ischemia or per-
foration. Bowel ischemia resulting in full-
thickness bowel necrosis and perforation is
a potential but rare complication. Ultrasound
can suggest these complications, but this
finding may need to be confirmed using CT,
which is more sensitive for perforation.
Tips: The bowel wall thickening in HSP
may be much more pronounced than the de-
gree of hyperemia and can precede the charac-
teristic rash. In the absence of the characteristic
rash and other clinical findings, the differential
diagnosis for the ultrasound appearance would
include IBD and infectious enteritis. Jejuno-
jejunal or ileoileal intussusceptions should be
suspected in HSP patients.
Malrotation
An association between intestinal malro-
tation and a reversal of the relationship be-
tween the SMA and SMV (with the vein lo-
cated anterior and to the left of the artery)
has been observed for decades but remains
controversial [24]. However, some children
with malrotation have a normal vascular re-
lationship, and other children with reversal
of the vessel position do not have malrota-
tion [2527]. A fluoroscopic upper gastro-
intestinal series has remained the reference
standard in the evaluation of malrotation.
Normal intestinal rotation is defined as vi-
sualization of the duodenum retroperitoneal
in location on the lateral view and with the
duodenal-jejunal junction coursing to the left
of the spine and to the level of the duodenal
bulb on the frontal view. Any other configu-
ration or position of the duodenojejunal junc-
tion would be considered abnormal rotation,
or malrotation of the midgut.
Recently, an argument has been made that
ultrasound evaluation of the position of the
third portion of the duodenum (D3) to en-
sure its normal course between the abdomi-
nal aorta and the SMA could replace the up-
per gastrointestinal series evaluation. The
claim is made that a normal retromesenteric
D3 excludes malrotation [28]. The same au-
thor performed a feasibility study showing a
consistent ability to visualize the course of the
duodenum in newborns on ultrasound [29].
However, a subsequent review of patients with
surgically proven malrotation who underwent
abdominal CT examinations showed a case of
a normal retromesenteric D3 in a patient with
malrotation, implying that the retromesenter-
ic position of D3 is not a perfect indicator of
normal rotation [30]. Not all authors agree
about the utility of using the D3 location to
exclude malrotation [31].
Performing ultrasound for malrotation or
other variations of bowel fixation, such as
nonrotation, is challenging because the en-
tire bowel distribution and position of the
cecum is difficult to discern on ultrasound.
However, in infants and young children,
identifying acute volvulus is easily achieved
using ultrasound and may be the first exami-

nation in which it is discovered. Prompt rec-
ognition of ultrasound gray-scale and color
Doppler signs of volvulus is crucial. Gray-
scale findings on ultrasound of malrotation
with midgut volvulus are the following: du-
odenal dilatation, tapered appearance of the
duodenum, fixed aperistaltic bowel, and the
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whirlpool sign [32]. In addition to the whirl-
pool of the bowel and the clockwise swirl-
ing of the SMV around the SMA axis, other
important ancillary vascular signs on color
Doppler imaging are a hyperdynamic pulsat-
ing SMA, truncated appearance of the SMA,
and a dilated SMV [33].
Tips: The SMV is typically located ante-
rior and to the right of the SMA, and the two
vessels course roughly parallel to one anoth-
er as the artery descends from its origin and
courses inferiorly. A swirling, twisting, or
whirlpool relationship between the vessels is
characteristic of a volvulus (Fig. 9).
Inguinal Hernia
In the setting of a groin or scrotal mass
or pain, ultrasound can be used to evaluate
the possibility of an inguinal hernia. The
literature on pediatric ultrasound for the di-
agnosis of inguinal hernias reports accu-
racy of 97% in surgically confirmed cases
[34], sensitivity of 92.7%, and specificity of
81.5% [35]. Gray-scale ultrasound images
can show the presence or absence of her-
niated bowel loops into the inguinal canal
and scrotum as well as the wall thickness
of the bowel. Ultrasound can be performed
dynamically with the patient performing a
Valsalva maneuver in both supine and up-
right views (depending on the age and dis-
position of the child) to help provoke the
hernia sac to enlarge and protrude through
the defect in the inguinal canal with in-
creased abdominal pressure. Infants when
crying are also performing a Valsalva ma-
neuver. Ultrasound enables real-time dy-
namic observation of bowel peristalsis as
well. Color Doppler images can be used to
evaluate the vascularity of the bowel wall
and testes simultaneously. Especially in in-
fants, it is important to remember that ingui-
nal hernias can lead to testicular ischemia
and infarction from compression of the go-
nadal vessels within the inguinal canal, and
ultrasound also provides evaluation of the
status of the testes in the setting of inguinal
hernia [36] (Fig. 10).
Tips: Targeted ultrasound should be per-
formed of the inguinal regions and of the
scrotum with color Doppler imaging be-
950 AJR:202, May 2014
Anupindi et al.
fore and after hernia reduction to assess
intratesticular blood flow.
Foreign Bodies
Conventional radiography is usually the
modality of choice in the evaluation of the in-
gestion of foreign bodies. However, not all for-
eign bodies are visible on radiography, with
radiographic detectability depending on mul-
tiple factors, including the composition and
the location of the foreign body [37]. Ultra-
sound provides an additional option for gas-
trointestinal tract foreign body detection and
localization [38, 39] (Fig. 11A). To date, the
literature includes case reports and a few orig-
inal works describing use of ultrasound for
evaluation of foreign bodies, and the diagnos-
tic performance of ultrasound is not known.
There have been reports of a wide vari-
ety of different gastrointestinal tract for-
eign bodies detected on ultrasound, ranging
from items such as sponges, pens, and tooth-
picks to smuggled drug containers [4043]
(Fig. 10). For example, small-bowel bezoars
can be seen as intraluminal masses with an
arclike markedly hyperechoic surface and
posterior acoustic shadowing and sometimes
with twinkle artifact on color Doppler imag-
es [44, 45]. Most foreign bodies are detected
as fixed echogenic structures that often show
posterior acoustic shadowing with a clean-
er shadow than that created by bowel gas.
In our experience, we have used ultrasound
both to localize foreign bodies seen on radi-
ography, such as coins, and to identify and
localize objects not visible on radiography,
such as plastic toys or wooden objects (Figs.
11B and 12). The standard bowel ultrasound
technique is modified by having the patient
drink 610 ounces (180300 mL) of water
to distend the stomach and then placing the
patient in a decubitus position to image the
stomach and proximal duodenum. The water
provides an acoustic window and can outline
the configuration of the foreign body [39].
Tips: A foreign body may not be clinical-
ly suspected as the cause of abdominal pain,
but the radiologist should carefully search for
bowel foreign bodies when bowel ultrasound
is used to evaluate nonspecific complaints.
Administer water to distend the stomach if a
better acoustic window is needed.
Duplication Cyst
Enteric duplication cysts are rounded or
tubular fluid-filled lesions that can occur
anywhere along the gastrointestinal tract
(most commonly in the distal ileum, second
most commonly in the esophagus) and con-
tain the same multilayered wall architecture
expected in the normal portions of the gas-
trointestinal tract [46]. Despite the fact that
ultrasound is the first line of imaging in the
evaluation of this entity, there is little evi-
dence-based data on the accuracy of ultra-
sound for the evaluation of duplication cysts.
They can form the lead point for an intussus-
ception or result in acute bleeding if there is
ectopic gastric mucosa.
This multilaminar or gut signature ap-
pearance can be well visualized by ultrasound
(Figs. 13A and 13B). Sometimes the cyst and
bowel walls appear bilaminar, with a hyper-
echoic mucosa and submucosa distinguished
from the hypoechoic muscularis propria (Fig.
13). When the serosa is also well defined, the
bowel wall will be seen as trilaminar. High-
er-resolution depiction of the wall can show
the thin linear hypoechoic muscularis mucosa
between the mucosal and submucosal layers,
creating a five-layered appearance [46, 47].
Ultrasound aids in characterizing the cystic
nature of this lesion and is excellent for the
evaluation of intussusceptions; however, in
practice CT or MRI is usually performed to
provide additional information for surgical
management (Figs. 13C and 13D).
Tips: Look for the multilaminar or layered
wall structure of any cystic lesion in the ab-
domen. Linear high frequency transducers
may provide the enhanced resolution neces-
sary to identify the bowel wall layers.
Polyps
Gastrointestinal tract polyps in childhood
are typically hamartomas or adenomas. Such
polyps can occur in isolation or as part of an
inherited polyposis syndrome, such as Peutz-
Jeghers syndrome or juvenile polyposis coli.
Children can present with painless frank
or occult rectal bleeding or rectal prolapse,
but polyps can also be discovered in chil-
dren presenting with nonspecific abdominal
symptoms who commonly undergo abdomi-
nal ultrasound [48].
Graded compression imaging with lin-
ear transducers typically shows colonic juve-
nile polyps as hypoechoic intraluminal sol-
id nodules with small anechoic cystic areas
on gray-scale images. Color Doppler images
show internal vascularity, particularly along
the stalk, which can sometimes be visualized
(Figs. 14A14C). The appearance of small-
bowel hamartomatous polyps, such as those
seen in Peutz-Jeghers syndrome, is similar
(Fig. 14D). The polyps of the small bowel can

also act as the lead point of an intussuscep-
tion [48, 49]. The literature on ultrasound of
large- and small-bowel polyps is limited, and
studies have focused on the compression tech-
nique and feasibility of identification of the
polyps [48, 50]. There is limited information
on the diagnostic performance of ultrasound
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in the detection of polyps. In a recent publica-
tion, Zhang et al. [51] showed excellent corre-
lation between polyp detection on ultrasound
with surgery and colonoscopy.
A retrograde saline infusion into the rec-
tum (hydrocolonic ultrasound) in prepara-
tion for evaluation of the large bowel can
be useful because it increases the ability to
detect and characterize colonic polyps [52].
Hydrocolonic ultrasound has also been used
intraoperatively to guide polyp localization
and resection [53]. This can be done with
less risk than with conventional colonosco-
py. A small-caliber catheter is placed in the
rectum and 200500 mL of saline (depend-
ing on patient size) is instilled via gravity un-
der real-time ultrasound visualization.
Ultrasound is not conventionally used to
evaluate pediatric bowel diseases such as ce-
liac disease, infections, or neoplasms of the
bowel. To date, celiac disease is primarily di-
agnosed using serologic tests, such as levels of
antitissue transglutaminase IgA and positive
antiendomysium antibody levels in conjunction
with duodenal biopsy. There is no direct role
for ultrasound in the diagnosis or monitoring
of these children. Enteritis is the most common
type of infection of the bowel. It is often viral in
cause and is clinically diagnosed and conser-
vatively treated, not requiring any imaging ex-
cept for occasional abdominal radiography. If
ultrasound is performed in the setting of enteri-
tis, one will commonly see dilated fluid-filled
small- and large-bowel loops with hyperperi-
stalsis with or without some free fluid. Ultra-
sound does not play a large role in the diagnosis
of small- or large-bowel tumors or in the set-
ting of small-bowel obstruction except when a
child presents with an intussusception in which
the tumor acts as a lead point [54].
Conclusion
It is important to realize the full poten-
tial of bowel ultrasound in the evaluation of
a wide variety of conditions, far beyond ap-
pendicitis and intussusception alone. Target-
ed bowel ultrasound can be used for problem
solving and provides complementary infor-
mation to radiography, CT, and MRI, as il-
lustrated in our cases. Familiarity with the
compression technique and important find-
AJR:202, May 2014 951
Bowel Ultrasound in Children
ings on bowel ultrasound enables unique and
effective evaluation of the bowel without the
use of ionizing radiation.
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Fig. 123-year-old healthy female volunteer. Photograph shows anterior and

posterior compression technique with manual pressure applied from behind in
upward direction simultaneously with compression from anterior with transducer.

952 AJR:202, May 2014

 Bowel Ultrasound in Children
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A B
Fig. 215-year-old boy who underwent ultrasound for possible inflammatory
bowel disease but was found to have normal results.
A, Sagittal ultrasound image of normal bowel wall of transverse colon (arrows).
B, Ultrasound image enlarged to show five layers of bowel wall (numbered arrows):
1 = hyperechoic mucosal interface, 2 = hypoechoic mucosa, 3 = hyperechoic
submucosa, 4 = hypoechoic muscularis, and 5 = hyperechoic serosa.
C, Ultrasound image shows panoramic sagittal view of normal bowel wall (arrows)
of terminal ileum. Dashed line shows length of scan.

Fig. 311-year-old boy with Crohn disease.

A and B, Transverse gray-scale (A) and sagittal color Doppler (B) images of
terminal ileum show asymmetric bowel wall thickening (arrows, A) and hyperemia
(arrow, B) indicative of acute active disease. There is loss of visualization of
stratified multilaminar bowel wall architecture.
C, Endoscopic image of colon shows friable ulcerated colonic mucosa. Scope
could not be passed into terminal ileum because of marked inflammatory
changes and luminal narrowing.
C

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 Anupindi et al.
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A B
Fig. 4Crohn disease.
A, Sagittal ultrasound image in 14-year-old boy shows abnormal loop of descending colon with loss of bowel wall stratification (arrowheads) and adjacent thickened and
echogenic mesentery (arrows), result of chronic inflammation.
B, Sagittal ultrasound image in 13-year-old boy shows transmural disease with disruption in wall of loop of distal ileum in right lower quadrant (arrows), which later
developed into localized phlegmon.

A B

Fig. 513-year-old girl with Crohn disease who reported stool in her urine and had
urinary tract infection.
A, Transverse ultrasound image shows tethering of bowel loops and clear
connection between two loops of small bowel (arrow) indicating enteroenteric
fistula.
B, Panoramic sagittal ultrasound image depicts loop of ileum adhering to dome of
bladder with extension into bladder (arrows) confirming enterovesical fistula.
C, Coronal contrast-enhanced T1-weighted MR enterography (MRE) image shows
abnormal enhancing loops of ileum in pelvis (arrow) extending to dome of bladder,
which correlates with ultrasound image from B. MRE first suggested possibility of
enterovesical fistula, and ultrasound also suggested fistula.
C

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 Bowel Ultrasound in Children
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A B

Fig. 65-week-old girl born at 25 weeks of gestation with necrotizing enterocolitis.

A, Gray-scale transverse ultrasound image shows multiple thickened loops of
small bowel (arrows) surrounded by ascites.
B, Color Doppler image shows hyperemia (arrow) within majority of bowel loops.
C, Color Doppler image of segment of small bowel in right lower quadrant shows
thinner (< 1 mm) avascular wall (arrows). Bowel wall necrosis and perforation
were found at surgical exploration.

A B
Fig. 72.5-week-old boy born at 37 weeks of gestation with tetralogy of Fallot who has elevated lactate and heme-positive stools, raising concern for necrotizing enterocolitis.
A and B, Transverse gray-scale ultrasound images show numerous punctate echogenic foci within walls of several small-bowel loops (arrows). These foci are within
dependent and in wall of nondependent small-bowel segment and did not change with patient position, consistent with pneumatosis.

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 Anupindi et al.
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A B
Fig. 8Two children with Henoch-Schnlein purpura (HSP).
A, Gray-scale sagittal ultrasound image in 5-year-old boy diagnosed with HSP
who presented with multiple joint pain, purpuric rash, and abdominal pain shows
marked thickening of small-bowel wall (arrows).
B and C, Gray-scale transverse ultrasound images in 6-year-old boy with
polyarticular arthritis, purpuric rash, and abdominal pain who was diagnosed with
HSP and treated with prednisone for 3 weeks show severe bowel wall thickening
with effacement of multilaminar architecture (arrows, B) of bowel wall, unlike
patient in A. Jejunojejunal intussusception (arrow, C) is seen in left upper quadrant
within loop of jejunum.

Fig. 92-week-old boy with midgut volvulus

discovered on ultrasound after bilious vomiting.
Malrotation and volvulus were confirmed at surgery.
A and B, Transverse color Doppler images oriented
along course of superior mesenteric artery (SMA)
and vein (SMV) from targeted bowel ultrasound
show prominent swirling, or whirlpool, of vessels
(arrows), representing midgut volvulus around SMA
axis. At surgery, 360 volvulus was discovered and
Ladd procedure was performed. Patient did not
undergo fluoroscopic upper gastrointestinal series
and went directly to surgery.
A B

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B
Fig. 102-month-old boy with vomiting and concern for small-bowel obstruction
found to have inguinal hernia and testicular ischemia.
A, Longitudinal gray-scale ultrasound image shows loop of small bowel
descending through right inguinal canal into scrotum (thin arrows), which contains
small amount of bowel fluid at point (thick arrow) where it turns and ascends back
into abdomen. Mildly complex hydrocele is also noted (arrowhead).
B and C, Color Doppler images show flow in left testis that is normal in
echotexture. There is heterogeneous echotexture and absence of flow in right
testis (arrow), concerning for ischemia. Testis was found to have hemorrhagic
infarction at surgery.

Fig. 11Children with foreign body ingestions.

A, 5-year-old girl who was doing cartwheels with
two quarters and cookie in her mouth when she
accidentally swallowed quarter. There was question
after abdominal radiography whether coin was
in stomach or had passed into bowel. Gray-scale
ultrasound image with patient in steep right anterior
oblique position after drinking water shows gastric
location of quarter, which showed expected disk
shape, serrated edge, and diameter of U.S. quarter
coin (arrows).
B, 18-month-old boy who presented after swallowing
pieces of toy. Longitudinal ultrasound image
after water administration shows multiple oblong
hypoechoic foreign bodies (arrows) (plastic toys
swallowed by child) floating in debris.
A B

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 Anupindi et al.

Fig. 1220-month-old
boy with foreign body
ingestion.
A, Supine abdominal
radiograph shows
abnormal bowel gas
pattern with paucity
of bowel gas in right
lower quadrant and
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few nonspecific dilated

loops (arrow).
B, Transverse
ultrasound image
shows thickened
loops of bowel
(arrows) concentrated
in right lower
quadrant, suggesting
inflammatory process
(bowel loops elsewhere
were normal in
appearance).
A B C, Transverse ultrasound
image in right lower
quadrant depicts
presence of reproducibly
demonstrable fixed linear
echogenic structure
oriented perpendicular
to long axis (cursors) of
bowel loop (arrow) and
appearing to traverse
expected confines
of small-bowel wall.
Complex free fluid was
present.
D, Surgical photograph
shows toothpick
perforating through
Meckel diverticulum
(arrow).

C D

A B
Fig. 1311-year-old girl with duplication cyst causing intussusception.
A and B, Transverse (A) and sagittal (B) ultrasound images show centrally avascular mass with multilaminar wall, classic gut signature,
within proximal colon (arrow).
(Fig. 13 continues on next page)

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C D
Fig. 13 (continued)11-year-old girl with duplication cyst causing intussusception.
C, Contrast-enhanced axial CT image depicts ovoid mass (arrow), with dark mesenteric fat in center representing intussusceptions.
D, Contrast-enhanced coronal CT reformation image suggests cystic nature of mass (arrow). Surgical resection was performed, and
pathology showed duplication cyst lined by colonic mucosa and filled with thick mucinous material acting as lead point.

A B C

Fig. 14Intestinal polyps.

AC, Color Doppler image (A) in 3-year-old boy shows highly vascularized stalk
(arrow) leading to hypoechoic, rounded, solid nodular tip of polyp with very
small cystic areas. After retrograde saline infusion into rectum, gray-scale
ultrasound image (B) shows polyp (arrows) surrounded by fluid, confirming its
colonic intraluminal location. Colonoscopy image (C) shows rectal polyp (arrow)
correlating with ultrasound findings.
D, Ultrasound image in 5-year-old boy with Peutz-Jeghers syndrome shows jejunal
polyp with stalk (arrow).
D

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