Image Presentation

Sonography of the
Gastrointestinal Tract

Nitin Chaubal, MD, DMRD, Manjiri Dighe, MD, DMRE,

Mohit Shah, DMRD, DNB, Jyoti Chaubal, MD, RDMS

Objective. The purpose of this presentation is to provide an overview of sonographic manifestations

of various gastrointestinal diseases. Methods. Patients were scanned with an HDI 3000 or HDI 5000
system (Philips Medical Systems, Bothell, WA) with both a 2- to 5-MHz curvilinear transducer and a
5- to 12-MHz linear transducer. The patients were asked to fast from the previous night. For accurate
visualization of the stomach, a cup of water was given to patients thought to have stomach or upper
gastrointestinal disease. Results. A satisfactory sonographic examination could be performed in all
patients. Conclusions. With recent technical advances, the increasing use of sonography in initial eval-
uation of patients with abdominal pain may allow earlier detection of bowel disease. Key words:
gastrointestinal tract; small bowel; sonography.

S
onography is the first imaging study performed in
patients with abdominal pain in developing coun-
tries, where access to expensive tests such as com-
puted tomography (CT) is limited, and the body
mass index of the population is fairly low, allowing a rea-
sonable view of the gastrointestinal (GI) tract on sonogra-
phy. An awareness of the sonographic appearance of
diseases of the GI tract is essential, predominantly in
acute abdomen cases. This presentation provides an
Abbreviations overview of the sonographic manifestations of various GI
CT, computed tomography; GI, gastrointestinal diseases.

Materials and Methods

Received June 14, 2005, from Thane Ultrasound
Centre, Thane, India (N.C., M.S., J.C.); Jaslok
Hospital and Research Centre, Mumbai, India
(N.C.); King Edward Memorial Hospital, Mumbai,
India (N.C.); and Body Imaging Faculty, University
of Washington Medical Center, Seattle,
Washington USA (M.D.). Revision requested June
25, 2005. Revised manuscript accepted for publica-
tion July 24, 2005.
Address correspondence to Nitin Chaubal, MD,
DMRD, Thane Ultrasound Centre, Shanti Nivas, Dr
Moose Road, Talaopali, Thane 400601, India.
E-mail: chaubal@bom3.vsnl.net.in
Patients were scanned with an HDI 3000 or HDI 5000
system (Philips Medical Systems, Bothell, WA) with both
a 2- to 5-MHz curvilinear transducer and a 5- to 12-MHz
linear transducer. The patients were asked to fast from
the previous night. For accurate visualization of the stom-
ach, a cup of water was given to patients thought to have
stomach or upper GI disease. If duodenal disease was
suspected, scanning was also performed in the right lat-
eral decubitus position. Color Doppler sonography was

© 2006 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2006; 25:87–97 • 0278-4297/06/$3.50
Sonography of the Gastrointestinal Tract
used is patients thought to have vascular etiolo-
gies. The patients ranged in age from 8 to 63 years,
and the weight of the patients ranged from 20 to
180 lb (mean, 120 lb).
Results and Discussion
Sonographic Appearance of the Normal
Bowel
The normal intestinal wall is seen as a multilay-
ered area with hyperechoic bowel content at the
center. Five distinct layers can be depicted on
sonography: an inner hyperechoic layer, which
is the interface between the mucosa and the
bowel contents; a second hypoechoic layer,
which is the deep mucosa; a third hyperechoic
layer, which is the submucosa; a fourth hypoe-
choic layer, which is the muscle proper; and a
last outer hyperechoic layer, which is the serosa
and the serosal fat (Figure 1).1
Sonographic Appearance of the Stomach
The normal stomach wall measures 3 to 5 mm
(Figure 2); however, wall thickness up to 7 mm is
considered within normal limits because ade-
quate distension is difficult to achieve on con-
ventional sonography.2 Thickening can be due
to neoplastic or inflammatory causes, and
thickening of greater than 1 cm is generally con-
sidered to be due to malignancy. Visualization
of the stomach can be improved by using a
water load.3
Figure 1. Sonographic appearance of the normal bowel shown
on a transverse image in the epigastrium) showing the 5 layers:
1, interface between the mucosa and bowel contents; 2, deep
mucosa; 3, submucosa; 4, muscle proper; and 5, serosa and
serosal fat.
88
Sonographic Appearance of the Small and
Large Bowel
The appearance of the small bowel on sonogra-
phy depends not only on the structure of the
individual segment but also, more importantly,
on its contents and degree of distension. The
bowel may be collapsed, containing only a small
amount of mucus (mucus pattern; Figure 3A) or
may contain fluid or gas (Figure 3B).4 The mucus
pattern is seen as a target appearance with a
highly reflective core of mucus. The fluid pattern
gives a tubular appearance on a longitudinal sec-
tion and a rounded pattern on a cross section.
The jejunum has valvulae conniventes, which
give a ladder pattern, and the ileum has smooth,
featureless walls. The site of the involved bowel
must also be inferred from the location of the
bowel loop. The large bowel has a similar appear-
ance; however, it can be distinguished by the
location in the paracolic regions and the pres-
ence of haustra (Figure 4).
Sonography of Inflammatory Bowel Diseases
Crohn Disease
The classic sonographic feature of Crohn disease
is the “target” sign, which is an anechoic rim of
thickened bowel with central echogenicity due to
the bowel contents. The transmural inflammation
Figure 2. Sonographic appearance of the normal stomach
(STM) shown on a sagittal section in the epigastrium.
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 Chaubal et al

B
Figure 3. Sonographic appearance of the normal small bowel.
A, Mucus pattern (note the prominent mucosal folds suggesting
that this is the jejunum) shown on a transverse image through
the mid abdomen. B, Gas pattern shown on a sagittal image
through the mid abdomen.
A

and fibrosis lead to complete circumferential usually in combination. (1) Intra-abdominal

loss of the typical gut wall layers, which results
in a thick hypoechoic rim (Figure 5, A and B).
Strictures are seen as marked thickening with a
fixed hyperechoic narrowed lumen with dilata-
tion and hyperperistalsis of the proximal gut.
Crohn disease is also associated with skip areas
and involvement of the distal ileum.5 The sono-
graphic sensitivity and specificity for the diag-
nosis of Crohn disease range from 75% to 94%
and 67% to 100%, respectively.6 Complications
of Crohn disease include fistulas, abscess for-
mation, mechanical bowel obstruction, and
perforation.7
fluid, which may be free or loculated and clear or
complex (with debris and septa), is commonly
seen. Localized fluid between 2 bowel loops, due
to local exudation from the inflamed bowel (inter-
loop ascites), may be seen. (2) Lymphadenopathy
Figure 4. Sonographic appearance of the normal colon shown
on a sagittal image in the left colic region. The large bowel is
filled with fluid and feces. Note the prominent haustra (arrow)
and large caliber.

Ulcerative Colitis
Ulcerative colitis is always limited to the colon,
which is continuous, and more or less extends
from the rectum to the upper colon. on sonogra-
phy, ulcerative colitis is seen as a continuous
thickening of the colonic wall. The mural stratifi-
cation is preserved because of the superficial
pattern of involvement, which also leads to
mucosal ulceration and fibrosis, giving a lead
pipe appearance (Figure 6). Pseudopolyps are
seen as small echogenic nodules visible at the
surface of the mucosa.8

Tuberculous Ileocolitis
Sonography is very useful for imaging abdominal
tuberculosis. The following features may be seen,

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Sonography of the Gastrointestinal Tract

A B
Figure 5. Crohn disease: circumferential thickening of the wall. A, Transverse sonographic image through the right lower quadrant
(arrow). B, Corresponding CT image (arrow).

may be discrete or conglomerated (matted). The secondary non-Hodgkin lymphoma is similar.

echo texture is mixed heterogenous, in con-
trast to the homogenously hypoechoic nodes
of lymphoma. Small discrete anechoic areas
representing zones of caseation may be seen
within the nodes. (3) Bowel wall thickening is
best appreciated in the ileocecal region. The
thickening is uniform and concentric (Figure
7, A–D).9
Vasculitis
Vasculitis, for example, from systemic lupus ery-
thematosus, appears as massive enlargement of
the valvulae conniventes due to the mucosal
edema and increased vascularity due to the
inflammation (Figure 8, A and B).10
On sonography, these tumors are hypoechoic
and show a variety of growth patterns, including
circumferential wall thickening as well as nodu-
lar or bulky tumor spread. The affected lumen
may show aneurysmal dilatation, which is
thought to be due to destruction of the auto-
nomic nerve plexus by the tumor. Enlarged
lymph nodes may be seen in the adjacent
mesentery (Figure 10).15
Colorectal Cancers
Colonic carcinomas have 2 typical sonographic
appearances (Figure 11, A and B). The first is a
localized hypoechoic mass with an irregular
shape and a lobulated contour. The second type

Sonography of Neoplastic Bowel Diseases

Figure 6. Ulcerative colitis: longitudinal image of the colon show-
ing circumferential continuous thickening of the colon wall.
Carcinoma of the Stomach
Carcinoma of the stomach is the most common
neoplasm of the upper GI tract, more common
in Japan compared with Western countries.
Tumors are seen as localized thickening of the
inner layer with hypoechoic tissue, which then
progresses to loss of the layered structure and
circumferential thickening. Growth patterns can
be polypoid, fungating, ulcerated, or infiltrative.
Benign tumors are also seen as polypoid or exo-
phytic lesions (Figure 9, A and B).11,12

Small-Bowel Tumors
The small bowel is more commonly affected by
lymphoma than the large bowel.13,14 The appear-
ance of small-bowel involvement in primary and

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 Chaubal et al

A
Figure 7. Abdominal tuberculosis. A, Ileocecal region with mild
wall thickening in the terminal ileum (arrows) shown on a trans-
verse image through the right lower quadrant. B, Enlarged
paramesenteric lymph nodes shown on a transverse image C
through the right lower quadrant. C, “Dry” type with mesen-
teric thickening (arrows) shown on a transverse image through
the mid abdomen. D, “Wet” type with mesenteric thickening
(arrow) along the surface of the bowel (arrowhead) shown on
a sagittal image through the left lower quadrant.

appears as segmental circumferential thicken-

ing of the colonic wall. The intraluminal gas
appears as a cluster of high amplitudes due to
areas of ulceration. Shirahama et al16 described
4 sonographic findings that allowed correct
diagnosis of colonic carcinoma in 90% of
patients: localized irregular thickening of the
colonic wall, an irregular contour, lack of move- D
ment or change in configuration on real-time
scanning, and absence of a layered appearance
of the wall. of 3 mm or greater are used as sonographic crite-
ria for the diagnosis of infantile hypertrophic
Sonography in the Acute Abdomen pyloric stenosis (Figure 12).17

Infantile Hypertrophic Pyloric Stenosis Acute Appendicitis

Infantile hypertrophic pyloric stenosis is a com-
mon entity and affects 2 to 3 per 1000 live births.
Boys are affected 4 times more frequently than
girls. A length of the pyloric channel of 14 mm or
greater and the thickness of the pyloric muscle
The normal appendix is seen as a blind-ending,
tubular structure. An increase in diameter to
greater than 6 mm in an adult patient with right
lower quadrant pain is highly suggestive of acute
appendicitis. Vascularity in the wall may be

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Sonography of the Gastrointestinal Tract

A B
Figure 8. Vasculitis: sagittal images through the right mid abdomen showing an abnormally thickened small-bowel loop (A, arrows)
with increased vascularity (B) in a patient with known systemic lupus erythematosus.

increased. Sonographic features associated with
perforation are loculated pericecal fluid, phleg-
mon, abscesses, and prominent pericecal fat
(Figure 13, A–C).18 The accuracy of sonography is
92%; sensitivity, 83%; and specificity, 95%. The
positive predictive value is 86%, and the negative
predictive value is 94%, as suggested by a study in
a community hospital.19
Diverticulitis
Diverticula are multiple and most commonly
located in the sigmoid and descending colon.
Complications of diverticulitis include macroper-
foration or microperforation and localized abscess
or fistula formation to the bladder, vagina, skin, or
other bowel loops. On sonography, segmental
concentric thickening of the colon is seen.
Inflamed diverticula appear as bright echogenic
foci with acoustic shadowing or a ring-down arti-
fact within or beyond the thickened gut wall.
Peridiverticular abscess formation is seen as locu-
lated fluid collections in an intramural pericolonic
or remote location. Intramural sinus tracts appear
as high-amplitude linear echoes often with a ring-
down artifact within the gut wall. Fistulas appear
as linear tracts that extend from the involved seg-
ments of the gut to the bladder, vagina, or adjacent
loops (Figure 14, A and B).20,21

Figure 9. Carcinoma of the stomach: sonographic images showing a localized large mass in the antrum of the fluid filled stomach
(A), which proved to be a large leiomyoma, and diffuse thickening of the stomach wall in the linitis plastica on a transverse image
through the epigastric region (B).

A B

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 Chaubal et al

Figure 10. Lymphoma: panoramic sonographic view showing a

thickened bowel loop with aneurysmal dilatation.

Intussusception
Intussusception is commonly seen in children as
ileocolic or jejunojejunal intussusception and
sometimes associated with a lead point in the
form of a tumor or hypertrophied Peyer patches.
In adults, intussusception is commonly associat-
ed with a lead point in the form of a tumor. The
sonographic appearance of concentric rings in
B
the transverse section is pathognomonic for
intussuception.22–24 Long axis scans reveal the Figure 11. Carcinoma of the colon: panoramic sonographic
views showing circumferential thickening (A, arrowheads) of
“hay fork” or “trident” sign, representing the the ascending colon with hyperechoic areas in the wall suggest-
appearances of an intussusceptum and intus- ing ulceration of the mucosa and a localized hypoechoic mass
suscepiens (Figure 15, A and B). with an irregular shape (B, arrows). UB indicates urinary bladder.

Midgut Malrotation
It predisposes to bowel obstruction and infarc-
tion. On sonography, an abnormal relationship Figure 12. Infantile hypertrophic pyloric stenosis: transverse
between the superior mesenteric vein and supe- image through the epigastric region showing a thickened pylorus
rior mesenteric artery is suggestive of this diag- with wall thickness greater than 4 mm and length greater than
14 mm, supporting diagnosis of infantile hypertrophic pyloric
nosis. On a transverse sonogram, reversal of the stenosis.
normal relationship between the mesenteric
vessels is seen; the superior mesenteric vein is on
the ventral left aspect of the superior mesenteric
artery (Figure 16, A and B).25,26

Colitis
Infection is a common cause of colitis. Cyto-
megalovirus is the most commonly associated
pathogen in colitis in post-transplant patients.
Other causes for colitis include ischemic factors,
parasites, and radiation. Colitis due to these
causes could also potentially be seen on sonog-
raphy. Sonographic findings include long seg-

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Sonography of the Gastrointestinal Tract

B
Figure 13. Acute appendicitis. A and B, Sagittal images in the
right lower quadrant showing an enlarged, thickened appendix
(A) with increased vascularity on color Doppler imaging (B).
C, Periappendiceal abscess (ABSC) as a common complication of
acute appendicitis shown on a transverse view through the right
A
lower quadrant. Note that the omentum appears abnormally
echogenic because of the periappendiceal inflammation.

Figure 14. Colonic diverticulitis: sagittal images through the left

lower quadrant showing a diverticulum (A, arrow), arising from
the colon (C) and a large abscess (B, ABS) adjacent to the bowel
in a patient with known diverticulosis due to localized perfora-
tion and abscess formation.
A

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 Chaubal et al

A
Figure 15. Intussusception: sonographic images through the
mid abdomen showing the concentric appearance on a trans-
verse section through an intussusception (A, arrows) and the
hay fork appearance on a longitudinal section (B). Black arrows
indicate intussuscipiens; and white arrows, intussusceptum.

ment, concentric, regular uniform thickening of Conclusions

the colonic wall. The entire colon is usually
involved in pseudomembranous colitis, which is
a necrotizing inflammatory bowel disease most
commonly attributable to the effect of the
Clostridium difficile toxin (Figure 17, A and B).25
With recent technical advances, the increasing
use of sonography in initial evaluation of
patients with abdominal pain may allow earlier
detection of bowel disease.

Figure 16. Midgut malrotation: transverse sonographic images through the mid abdomen showing the “whirlpool” sign (A), which
is the twisting of the small-bowel loops, and abnormal relationship between the superior mesenteric vein (V) and artery (A) with the
associated twisting of the vessels (B, arrowhead).

A B

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Sonography of the Gastrointestinal Tract
A B
Figure 17. Colitis. A, Transverse sonographic image through the right lower quadrant (RLQ) showing abnormal circumferential thick-
ening of the colon. B, Corresponding CT image in a patient with pseudomembranous colitis.
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