Urogenital Tract

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15.4 Large Intestine

Fig. 544a–c Acute infectious colitis (based on clinical and histologic findings, confirmed by serologic and bacteriologic testing). CE = cecum, BW = bowel wall, FL = fluid

Appendicitis (Fig. 545; see also Figs. 102 and 103, p. 76):

Tubular (longitudinal) or target-shaped (transverse) fluid-filled hypoechoic structure in the right lower quadrant of the abdomen

Diameter of the appendix i 6mm

Point tenderness over the appendix

Echogenic fatty tissue reaction (echogenic “omental cap”)

Aperistaltic, noncompressible appendix

Possible associated findings: circumscribed free fluid, inflammatory lymphadenopathy, bacterial gas collection, fecalith

Fig. 545a, b Acute appendicitis. a CDS: tubular structure with a layered

wall and hypoechoic center and an

inflammatory vascular reaction. IA = iliac artery. b Longitudinal B-mode scan: crosssectional view of the appendix with a typical target sign (cursors). CE = cecum

Gastrointestinal Tract

Diverticulitis (Fig. 546; see also Fig. 104, p. 77):

Inflammatory transformation of diverticula with hypoechoic peridiverticulitic wall thickening

Segmental bowel wall thickening with absent or decreased peristalsis

Echogenic omental cap (fatty tissue reaction)

369

15.4 Large Intestine

Gastrointestinal Tract

Fig. 546a, b Sigmoid diverticula and diverticulitis. a Series of numerous diverticula in the wall of the sigmoid colon (arrows). Hyperechoic air echoes, acoustic shadows, and increased thickness of the sigmoid wall. b “Peridiverticulitis”: curved zone of high-level echoes (arrow), acoustic shadow (S), hypoechoic perifocal inflammatory reaction, and the hypoechoic wall of the sigmoid colon (BW, with hypertrophy of the muscular coat)

Localized tenderness over the diverticulitis

CDS: inflammatory vascularity

Diffusely infiltrating carcinoma (Fig. 547):

Irregular, bizarre, hypoechoic areas of wall thickening

Aberrant tumor vessels

Possible infiltration of surrounding organs, lymph node metastases

Fig. 547 Tumor infiltrating a long segment of the sigmoid colon (T, cursors). Harmonic imaging demonstrates infiltrative tumor growth in and along the bowel wall (BW)

Diffuse involvement by malignant lymphoma:

Diffuse wall thickening of very low echogenicity

Wall layers often still defined

Circumscribed Wall Thickening

..............................................................................................................

Sites of circumferential wall thickening often present as a “target sign” (after Lutz;

548). Other patterns may be seen, however, depending on the site of occur-

Fig. rence and the mode of tumor growth and spread. Several forms can be distinguished by ultrasound:

Ulcerated carcinoma with a crater-like defect (Fig. 548)

Carcinoma with an endophytic-polypoid type of growth (Fig. 549)

Diffusely infiltrating carcinoma involving a long segment of bowel (Fig. 550)

370

15.4 Large Intestine

Fig. 549 Sigmoid carcinoma (T) show-

Fig. 548 Carcinoma of the ascending colon with a target sign: ulcerated form with a bright central echo (gas), distal

ing an endophytic polypoid type of growth. CDS: prestenotic luminal widening and spot-like tumor vessels

acoustic shadow (S), and scalloped hypoechoic wall thickening (BW). L = liver

Fig. 550a, b Carcinoma of the ascending colon (T), diffusely infiltrating form. a Thickened colon wall with a hyperechoic center (lumen) = “pseudo-kidney sign.”

K = kidney b In a zoom view, the tumor-infiltrated bowel wall has a nonhomogeneous hypoechoic appearance. Tumor (T) has obliterated most of the bowel lumen

Gastrointestinal Tract

Diverticula and diverticulitis (see p. 77 and Fig. 119, p. 90):

Small, rounded, echogenic (air-containing) structure with a distal acoustic shadow

Most lesions of diverticulitis (marked by typical left lower quadrant pain) are surrounded by a hypoechoic (inflammatory) halo

Polyp (adenoma, small polypoid carcinoma): appears as a rounded hypoechoic

lesion adherent to the bowel wall. Can be defined sonographically only by using special techniques such as hydrocolonic ultrasound, and generally when the location of the lesion has already been determined by endoscopy.

Incarcerated epiploic appendix:

– Sharply circumscribed hypoechoic mass on the outer wall of the intestine – Hypoechoic perifocal edema – Concomitant sectoral thickening of the bowel wall

Colorectal carcinoma (see Figs. 548–550, p. 371): One-third of cases occur in the

rectum and one-third in the sigmoid colon.

Target sign is present in typical cases

Sectoral thickening of the bowel wall

371

15.4 Large Intestine

Hypoechoic intraluminal tumor mass with associated luminal narrowing

CDS: aberrant tumor vessels

Possible associated findings:

– Prestenotic gaseous distention (due to bowel obstruction) – Tumor infiltration – Locoregional or lymphatic metastases – Distant metastasis

Carcinoid:

Primary tumor usually cannot be detected

Metastases: increased vascularity found by CDS

Gastrointestinal Tract

Malignant lymphoma (Fig. 551) : involves a long bowel segment but rarely affects

the large intestine

Circumferential tumor mass

Marked wall thickening; anatomical wall layers frequently still defined

a b

Fig. 551a, b Malignant lymphoma of the ascending colon. a Hypoechoic, scalloped area of tumor infiltration in the bowel wall. b Diagram corresponding to the ultrasound image

Evaluation and Further Testing

..............................................................................................................

Intestinal ultrasound is a difficult study that requires a highly experienced sonographer and high-resolution technology (appendicitis can be diagnosed or the bowel wall evaluated with a 5 MHz transducer and occasionally with a 7.5 MHz transducer using magnified views). When wall thickening is present, it is often necessary to use a high-resolution magnifying scanner in order to differentiate the wall, lumen, and intraluminal fluid.

Sonographic diagnosis of inflammatory bowel disease: The ultrasound classifi-

cation of inflammatory bowel diseases is subject to misinterpretation. Highly acute ulcerative colitis and severe infectious colitis may demonstrate the same features as Crohn disease (see Figs.

539–541, p. 367 and Fig. 544, p. 369). Similar

changes may also occur with swelling of the terminal ileum secondary to appendicitis with abscess formation. Accentuated walls may be found in all forms of inflammatory bowel disease. The diagnosis relies critically upon clinical manifestations, endoscopic findings, and histology.

Inflammatory mucosal lesions (ulcerative colitis), polyps, ulcers, and diverticula can be evaluated more accurately by endoscopy and radiography.

Sonography is eas good as CT in evaluating lesions with transmural spread (Crohn disease, abscesses, fistulae).

Sonographic differential diagnosis: The main sonographic patterns of wall swel-

ling and their association with specific diseases are reviewed in Table

372

66.

15.4 Large Intestine

Table 66.Clinical diagnoses suggested by different sonographic signs of

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Wall swelling Spread Clinical diagnosis

yyyyyyyyyyyyyyyyyyyy

Accentuated wall with luminal distention

Layered wall with luminal narrowing

Hypoechoic wall with loss of layered structure

wall swelling

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Inflammatory lymphadenopathy

Perimural spread (“mesenteritis”), fistulae, abscesses

Intraluminal spread (irregular wall thickness, luminal narrowing)

Sharp segmental boundaries, predilection for the left side, avascular by CDS

“Garden hose” appearance Intestinal hematoma

Circumscribed, circumferential wall swelling, symmetrical or asymmetrical

Crohn disease: Ultrasound is the most important modality in the follow-up of

Crohn disease Ulcerative colitis (with mild inflammation) Perifocal reaction

Crohn’s disease (with moderate inflammation) Ulcerative colitis (with severe inflammation)

Infectious enterocolitis Severe perifocal reaction (appendicitis, abscess formation)

Crohn disease (high activity)

Pseudomembranous colitis

Ischemic colitis

Intestinal tumor

this disease. Key criteria for interpreting sonographic findings are wall layering and periluminal changes. CDS can furnish additional criteria for evaluating the nature and extent of mural and mesenteric inflammation.

Ulcerative colitis : Endoscopy is superior to ultrasound in the diagnosis of ulcerative colitis.

False-positive findings: In extremely rare cases, endoscopy and histology may fail to detect a correlate for wall thickening noted on ultrasound. (In the few cases that we have seen to date, one involved a patient with a history of laxative abuse and hepatic cirrhosis, one was a clinically asymptomatic patient, and one was a patient with excretory pancreatic insufficiency and hepatic cirrhosis.)

Target sign: Always requires endoscopic and histologic investigation. In exceptional cases (refusal of endoscopy, very elderly patient, no therapeutic implications), a tumor can be detected or excluded with reasonable confidence by sonographic inspection of the entire colon combined with a rectal examination and stool examination for occult blood. If necessary, these tests may be supplemented by ultrasound-guided FNAB or proctosigmoidoscopy.

Appendicitis: Ultrasound provides a diagnostic accuracy of almost 100 % (besides detecting lesions important in differential diagnosis such as kidney stones, ovarian cysts, adnexitis, and gallstones).

Gastrointestinal Tract

373

15.4 Large Intestine

Gastrointestinal Tract

Rectal tumors: Endorectal ultrasound is an accurate technique for investigating the spread of rectal tumors into the perirectal fat and their fistulation into urogenital organs.

Endosonography: necessary and rewarding for all intramural, submucous lesions

of the stomach and for staging gastric neoplasms

Endoscopy: The procedure of first choice for examinations of the stomach and

colon. Exceptions are the follow-up of Crohn disease and the diagnosis of appendicitis (see above).

New technique: wireless capsule endoscopy

Double-contrast radiography: After endoscopy, double-contrast radiographs are

the method of choice for examining the stomach and colon. They are used exclusively for examining the small intestine (small-bowel contrast using the Sellink technique).

CT: should be used only to investigate abscesses and metastases (staging), espe-

cially in patients with rectal tumors and tumors of the lesser pelvis (conditions that limit the usefulness of ultrasound).

374

16.1 Examination

16 Urogenital Tract

16.1 Examination

Scan Planes

..............................................................................................................

Ureter:

A ureter affected by outflow obstruction can be imaged at the three levels shown in Fig.

552.

Urogenital Tract

Fig. 552 Ultrasound examination of the ureter: 1 = ureteropelvic junction area, 2 = preiliac segment of the ureter, 3 = supravesical segment of the ureter

The upper part of the ureter at the ureteropelvic junction can be identified in the posterior part of the flank scan and in the transverse renal scan. It lies posterior to the renal vein and artery and is directed anteriorly and medially (Fig.

553).

Urinary bladder:

Lower abdominal transverse scan (see Fig. 39, p. 30)

Lower abdominal longitudinal scan (see Fig. 40, p. 31)

Genital organs:

Lower abdominal transverse scan (see Fig. 39, p. 30)

Lower abdominal longitudinal scan (see Fig. 40, p. 31)

Special scan planes for the penis and testis

375

16.1 Examination

Urogenital Tract

Fig. 553 Topographic anatomy of the renal artery, renal vein, and ureter

Sonographic Anatomy and Normal Findings

..............................................................................................................

Ureter: The normal-sized ureter cannot be visualized with ultrasound.

Urinary bladder:

The normal bladder has a round, oval, or approximately triangular or square shape.

The bladder tapers cephalad and anteriorly when viewed in longitudinal section (Fig.

The bladder should be adequately distended with fluid for ultrasound scanning.

Normal bladder volume: 350–750 mL in men, 250–550 mL in women

554).

a b

Fig. 554a, b Bladder (B) and uterus (U) in a lower abdominal transverse scan

Male genital organs:

Seminal vesicles (Fig. 555): located between the bladder floor and prostate. They appear sonographically as two homogeneous, hypoechoic ovals that extend laterally upward from the bladder.

Prostate (Fig. 556): an elliptical, chestnut-shaped gland with smooth margins and a homogeneous internal echo pattern – The volume of the prostate is calculated by using the formula for an ellipsoid

(see Residual Urine Determination, p. 51). – Normal dimensions: width I 45 mm, depth I 35 mm, length I 35 mm,

376

volume I 25 mL

16.1 Examination

a b

Fig. 555a, b Sonographic appearance of the seminal vesicles between the bladder floor (B) and rectum (R). SV = seminal vesicles, arrows: ureteral ridges

a b

Fig. 556a, b Normal chestnut-shaped prostate (P) between the bladder (B) and rectum (R)

Penis: The penis can be scanned posteroanteriorly from the perineum. The corpora cavernosa display a fine pattern of low-level internal echoes. The corpus spongiosum is hyperechoic, and the urethra appears as an echogenic band.

Testis (Figs. 555, 557, 558): The anatomical location of the testis is shown in Fig.

557. It has a homogeneous, finely granular echo pattern.

Female genital organs (Fig. 559): The most anterior structure in the female pelvis

is the bladder. Behind it are the cul-de-sac and rectum.

Uterus: A transverse scan through the lower abdomen demonstrates the uterus as an elliptical hypoechoic organ situated between the bladder and rectum.

Vagina: The vagina appears sonographically as a delicate double-walled band with an echogenic streak-like lumen, located between the bladder and rectum.

Ovary: Normal ovaries are difficult to define with transabdominal ultrasound. They are hypoechoic and have a round-to-oval shape.

Urogenital Tract

377

Urogenital Tract

16.1 Examination

Spermatic cord (with vas deferens)

Bladder

Prostate

Head of epididymis

Testis

Fig. 558a, b Longitudinal scan of the testis (T) with the epididymis (E) and a small fluid collection (arrow, still within normal limits)

Scrotum

a b

Fig. 557 Anatomical overview of the testis, epididymis, and vas deferens

Fig. 559a, b Lower abdominal transverse scan of the female genitalia. UT = uterus, V = cervix and vagina, R = rectum, P = parametria

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