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11110 Gastrointestinal Tract
typically reveals benign tissue though complications may arise from cyst growth over time [26].
Necrotizing Enterocolitis
Necrotizing enterocolitis (NEC) is a multifactorial disease that leads to disruption of intestinal integrity followed ultimately by bowel necrosis and
bacterial translocation. Birth weight is inversely
associated with incidence (1:1000) and mortality
%). Younger gestational age is also a pre-
(15–30
dictor of poor outcome.
of NEC includes feeding intolerance, abdominal
distention, and often bloody stool [27].
Currently, abdominal radiograph remains the
preferred modality of choice for diagnosis and
classification of NEC. However, abdominal ultrasound is increasingly being applied in NEC
diagnosis and management for the advantages
it offers over standard radiographs. Ultrasound
permits visualization of bowel wall thickness and
echogenicity, peristalsis, free fluid, and bowel
wall perfusion [28]; this may allow for earlier
diagnosis of bowel compromise and expedition
of needed surgical intervention when bowel is
threatened, but before actual perforation or frank
necrosis occurs.
Pneumatosis intestinalis (PI) has been used as
a marker for the condition. Most often observed
in the ileum and colon, the finding is almost
pathognomonic for NEC, though its presence
ranges between 13 and 100
ing on the study examined. Ultrasound has proven superior
in the early diagnosis of PI. In a study
of 40 neonates with Bell stage I NEC, ultrasound
located PI in all 40, despite the lack of such findings on abdominal radiographs, demonstrating
the value of ultrasound in making an early, definitive diagnosis [29]. However, for patients in
Bell stage II NEC, abdominal
≥
been shown, in some studies, to be superior in
identifying pneumatosis. Given this variation,
more studies are needed to clarify the role of ultrasound in diagnosing PI in neonates with NEC.
The protocol for ultrasound of the abdomen
for NEC has been well described by Faingold
al. [30] and includes evaluation of the intestine
et
The clinical presentation
% of cases, depend-
radiographs have
Fig. 10.13 Necrotizing enterocolitis—intramural gas
for increased
ing (greater than 2.7
wall thinning (less than
wall echogenicity, wall thicken-
mm) suggestive of edema,
mm) suggestive of
1.0
ischemia, intramural gas (PI; Fig. 10.13), bowel
wall perfusion on color Doppler, and bowel
peristalsis. The peritoneal
cavity of the abdomen and pelvis is then evaluated for free-fluid or
discrete-fluid collections, and the liver and portal
venous system are evaluated for portal venous
gas (Fig.
10.14). The splanchnic
and hepatic circulation should then be assessed via Doppler for
flow and perfusion. The sensitivity, specificity,
Fig. 10.14 Necrotizing enterocolitis—portal venous gas
112 C. M. Leeper et al.
positive predictive value, and negative predictive
values of sonography for the detection of bowel
necrosis were reported to be 100, 95, 80, and
100 %, respectively [31].
Appendicitis
Ultrasound is a reliable tool in the workup of
pediatric abdominal pain and diagnosis of acute
appendicitis (sensitivity 72.5 % (95 % CI = 58.8–
86.3 %) and specificity 97.0 % (95 % CI = 96.2–
97.9 %)) [32, 33]. It is now the standard of care
in pediatric centers to obtain ultrasound imaging
as the first-line modality with selective use of CT
scan in some cases. This demonstrates a change
in practice that has decreased the burden of ionizing radiation in pediatric patients without an
increase in the negative appendectomy or missed
appendectomy rates [34, 35].
The sonographic criteria to diagnose acute appendicitis in children include visualizing a blindending tubular structure that is noncompressible
(Fig. 10.15) and lacks peristalsis, with an appendicular diameter greater than 6 mm and/or a wall
thickness greater than 2.0 mm.
Other signs to support the diagnosis of appendicitis include the lack of air in the appendiceal
lumen, periappendiceal fat stranding, presence
of appendicolith, complex right lower quadrant
mass, enlarged mesenteric lymph nodes, and
presence of free fluid [36] (Fig. 10.16). Recent
Fig. 10.16 Appendicitis—enlarged tubular blind-ending
structure in right lower quadrant with fecalith visible at
the base, longitudinal view
evidence suggests that using a cutoff point of
7.0 mm appendicular diameter and 1.7 mm wall
thickness [37] may be more predictive of acute
appendicitis in pediatric patients.
Ultrasound is operator dependent and is
limited by the lie of the appendix. In up to one
third of the cases, the appendix may be nonvisualized on ultrasound imaging with the patient in the traditional supine position. Some
protocols recommend turning the patient to left
posterior oblique position in an attempt to identify a potentially retrocecal appendix [38]. In the
absence of a leukocytosis, patients with a nonvisualized appendix can be safely observed without
the immediate need for additional imaging [39].
Fig. 10.15 Appendicitis—sagittal view of noncompressible enlarged appendix
11310 Gastrointestinal Tract
Anorectal Malformations
Anorectal malformations are a complex group
of congenital anomalies with an incidence of
approximately 1:5000 births. The most common presentation in males is imperforate anus
(anal atresia) with a rectourethral fistula, and in
females imperforate anus with a rectovestibular
fistula [39]. Some patients are diagnosed antenatally after visualizing dilated distal bowel or
rectum on obstetric ultrasound [40, 41], though
the technical difficulty in making that diagnosis
means that most patients are identified by physical examination on the first day of life. Ultrasound plays many roles in the care of patients
with anorectal malformations, including diagnosis and preoperative planning, intraoperative
guidance, and postoperative assessment.
For children with imperforate anus, early
diagnosis and clarification of the patient’s anatomy is critical in planning the appropriate surgical
intervention. The distance from bowel to skin is a
determining factor in the type of procedure that is
indicated: for a low defect (< 1 cm bowel-skin distance), an anoplasty typically can be done without
a colostomy; but for an intermediate or high defect
(> 1 cm bowel-skin distance), a decompressive
colostomy may be created before posterior sagittal anorectoplasty described by Pena [42]. Both
radiographs (invertogram and prone cross-table
lateral views) and ultrasound can be utilized to obtain this information. Transperineal ultrasound is
feasible and valid for determining bowel-skin distance with sensitivity 100 % and specificity 86 %
with an error in distance measurement of 0.12 cm
(± 0.33) [43, 44] (Fig. 10.17).
Another important consideration in patients
with imperforate anus is the location of fistulae
to adjacent anatomic structures. Transperineal ultrasound can be utilized to identify the presence
of multiple types of fistulae including rectourethral, rectovaginal, rectovestibular, rectovesical,
and rectocloacal [45, 46]. Finally, preoperative
evaluation is not complete without identification
of any associated anomalies that frequently accompany imperforate anus—a thorough evaluation typically includes abdominal, pelvic, and
spine ultrasound [46].
Fig. 10.17 a and b Imperforate anus—a Transperineal
ultrasound shows blind-ending rectum of a low imperforate anus without fistula (note the round shape of the
rectal tip), the ruler measures the bowel-skin distance ( A
= skin); b Transperineal ultrasound of a different patient:
the position of the rectum, the rectourethral fistula and the
urethra can be clearly differentiated. To aid identification
of the urethra, placement of a Foley catheter is helpful
114 C. M. Leeper et al.
Laparoscopy-assisted sagittal anorectoplasty
with intraoperative ultrasound is an alternative to
the traditional open procedure in some centers.
A transperineal ultrasound probe in addition to
electrical stimulation of the anal sphincter complex is applied to aid in identification of anatomic
structures and creation of the pull through canal
[47, 48].
Endoanal ultrasound may also be useful following repair of anorectal malformations. An
evaluation of the presence and function of the
internal and external anal sphincters can guide
therapy such as feedback training for symptoms
like constipation or incontinence with the goal of
improving quality of life [49].
Hirschsprung’s Disease
Hirschsprung’s disease (HD; incidence 1:5000)
is the congenital absence of ganglion cells in
the myenteric and submucosal plexuses of the
intestine. In over 80 % of the cases, the affected
location is the rectum or rectosigmoid. The diagnostic pathway at present includes either a contrast enema or anorectal manometry followed by
confirmation with tissue biopsy [50]. Abdomi-
nal ultrasound is not a first-line test in HD but,
if utilized, will show massively dilated colon,
possibly filled with meconium, and a contracted
and empty rectum [51]. Orno and colleagues
validated the use of ultrasound in visualizing the
rectoanal inhibitory reflex, the reflex relaxation
of the internal anal sphincter caused by distention
of the normally innervated rectum that is absent
in HD. The internal anal sphincter is viewed as
a hypoechoic structure that decreases in diameter and allows passage of injected contents in
a reactive test, but does not contract or result in
movement of rectal contents in an inconclusive
or nonreactive test [52].
Fig. 10.18 Ascites—anechoic, mobile fluid overlying the
liver
sonographic characteristics of the fluid, such as
wall structure, contour, and echogenicity, can
aid in determining the underlying etiology [53].
A fluid collection may be anechoic (acute hemorrhage, ascites; Fig. 10.18), hypoechoic (old
hematoma, bile, and pus; Fig. 10.19), or hyperechoic (air). A collection may be fixed (mass)
or mobile (fluid), well circumscribed or poorly
defined [54] (Fig. 10.20). Abdominal ultrasound
is capable of providing an accurate depiction of
peritoneal fluid which can greatly impact the
management of the pediatric patient.
Peritoneal Fluid
Ultrasound can detect as little as 5–10 mL of
fluid within the abdominal cavity. The differential diagnosis for intraperitoneal fluid is vast;
Fig. 10.19 Organized hematoma—large, irregular, com-
plex fluid collection in the pelvis displacing loops of intestine
11510 Gastrointestinal Tract
Fig. 10.20 Free fluid—anechoic, mobile, ill-defined
pelvic fluid adjacent to bladder, associated with acute appendicitis
Abscess
Ultrasound is useful in both the diagnosis and
management of abdominal and pelvic abscesses.
The etiology is attributed to the introduction of
enteric microorganisms into the peritoneal compartment. This may occur from perforated appendicitis, inflammatory bowel disease (IBD),
and NEC, or ischemic enteritis; it may also occur
after direct contamination from surgery or trauma. Mixed aerobic and anaerobic flora are typically found within the abscess [55].
Walled-off fluid collections can be localized
by scanning the subhepatic, subdiaphragmatic,
pelvic, and interloop locations. Diagnosis is
made through the identification of a hypoechoic
mass with irregular contour or an extraluminal
air fluid level, with or without a localized ileus
(Fig. 10.21). Ultrasound in the diagnosis of abscess is sensitive but not very specific, meaning
that it is difficult to exclude abscess with ultrasound alone.
Traditional ultrasound can be used to guide
transabdominal percutaneous drainage of these
abscesses with published success rates of anywhere from 33 to 100 % depending on abscess
location and etiology [55]. Transrectal ultrasound
can also be used for localization and drainage
of deep pelvic abscesses. Transrectal aspiration
and/or drain placement can be accomplished with
high success rates and low incidence of complication [56].
Inflammatory Bowel Disease
Crohn’s disease (annual incidence 1–8.5:100,000)
and ulcerative colitis (annual incidence
1–4.3:100,000) are common GI pathologies in
pediatric patients. Diagnosis can be delayed due
to the nonspecific nature of patient complaints
and often relies on a variety of imaging studies as
well as endoscopy, tissue biopsy, and laboratory
testing [57]. The low cost, lack of radiation, and
high-negative predictive value make abdominal
ultrasound an important initial imaging modality
in the workup of suspected IBD. It can also be
Fig. 10.21 Abscess—17-year-old female patient who presented with ruptured appendicitis, ultrasound demonstrated
an irregular, localized, hypoechoic fluid collections in the pelvis and left lower quadrant (pictured)
116 C. M. Leeper et al.
Fig. 10.22 Perianal abscess—Transrectal ultrasound
demonstrates a perianal, heterogeneous, localized fluid
collection measuring 6.3 × 3.3 × 5.9 cm that is surrounded
by hyperemia
used to surveil patients who carry a diagnosis of
IBD for active inflammation and complications
like abscess or stricture [58] (Fig. 10.22). Accuracy for diagnosing the number and site of small
bowel lesions is enhanced when oral contrast is
given [59]. Importantly, limitations to the use
of ultrasound in IBD include the fact that many
findings are nonspecific, the intestine cannot be
assessed over its entire length, and the quality of
the images and interpretation are operator dependent [57].
Other Diseases
Ultrasound may also demonstrate nonspecific
findings including dilated, fluid-filled loops
of intestine, wall thickening or hyperemia
(Fig. 10.23). These findings are seen across a
range of pathology and may indicate infectious
or inflammatory enteritis, partial obstruction, or
other issue. Imaging in this case is not diagnostic
but can help to guide the clinician in conjunction
with the clinical history, laboratory testing, and
physical examination.
Abdominal ultrasound is a common first-line
test for pediatric patients presenting with general
abdominal pain, and consequently may identify
unusual pathology that is more commonly associated with other imaging modalities. For instance,
a patient with Henoch–Schönlein purpura who
Fig. 10.23 Nonspecific finding of mildly dilated, thick-
ened loops of small bowel
presented with hematochezia was found to have
severe bowel-wall thickening throughout the abdomen, consistent with intramural hemorrhage
(Fig. 10.24a and b). A bezoar can be detected as
an intraluminal mass with a hyperechoic curved
surface and an acoustic shadow [60]. In developing regions where certain infectious etiologies
are more common and in patients who offer a
history of travel to such locations, the differential must include parasitic and tuberculin disease.
Intestinal ascariasis may be diagnosed after visualizing echogenic structures within the lumen
at multiple locations, arranged in a thin line or
coil [61]. Intestinal tuberculosis may appear as
bowel-wall thickening with intramural abscesses,
with or without fistula; there may also be evidence of mesenteric thickening accompanied by
enlarged mesenteric lymph nodes [62]. Hydatid
cysts, commonly located in the abdomen or the
liver, show a typical ultrasound appearance.
Summary
Abdominal ultrasound is a popular modality for
the screening and diagnosis of GI pathology in
pediatric patients. There is a steep learning curve
for the operator given the challenges of imaging
the dynamic and variable intestine; however, proficiency can be achieved with training and experience. Ultrasound can be utilized to identify a
broad spectrum of pathology.
11710 Gastrointestinal Tract
Fig. 10.24 a and b Henoch–Schoenlein purpura—extreme wall thickening consistent with intramural hemorrhage
118 C. M. Leeper et al.
Hernanz-Schulman M. Infantile hypertrophic py-
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