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Gastrointestinal ultrasound is a practical, safe, cheap and reproducible diagnostic tool in inflammatory bowel disease gaining global prominence amongst clinicians. Understanding the embryological processes of the intestinal tract assists in the interpretation of abnormal sonographic findings. In general terms, the examination principally comprises interrogation of the colon, mesentery and small intestine using both lowfrequency and high-frequency probes. Interpretation of findings on GIUS includes assessment of bowel wall thickness, symmetry of this thickness, evidence of transmural changes, assessment of vascularity using Doppler imaging and assessment of other specific features including lymph nodes, mesentery and luminal motility. In addition to B-mode imaging, transperineal ultrasonography, elastography and contrast-enhanced ultrasonography are useful adjuncts. This supplement expands upon these features in more depth. © The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
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World Journal of
World J Gastroenterol 2017 October 14; 23(38): 6923-7058
ISSN 1007-9327 (print)
ISSN 2219-2840 (online)
Published by Baishideng Publishing Group Inc
6923 Evolving role of FDG-PET/CT in prognostic evaluation of resectable gastric cancer
De Raffele E, Mirarchi M, Cuicchi D, Lecce F, Cola B
6927 Staging chronic pancreatitis with exocrine function tests: Are we better?
Sperti C, Moletta L
6931 How to perform gastrointestinal ultrasound: Anatomy and normal ndings
Atkinson NSS, Bryant RV, Dong Y, Maaser C, Kucharzik T, Maconi G, Asthana AK, Blaivas M, Goudie A, Gilja OH,
Nuernberg D, Schreiber-Dietrich D, Dietrich CF
6942 Dysphagia: Thinking outside the box
Philpott H, Garg M, Tomic D, Balasubramanian S, Sweis R
6952 Role of endoscopic ultrasound in idiopathic pancreatitis
Somani P, Sunkara T, Sharma M
Basic Study
6962 Delayed and short course of rapamycin prevents organ rejection after allogeneic liver transplantation in
Hamdani S, Thiolat A, Naserian S, Grondin C, Moutereau S, Hulin A, Calderaro J, Grimbert P, Cohen JL, Azoulay D,
Pilon C
6973 Adipose-derived stromal cells resemble bone marrow stromal cells in hepatocyte differentiation potential
in vitro
Xu LJ, Wang SF, Wang DQ, Ma LJ, Chen Z, Chen QQ, Wang J, Yan L
6983 Fecal microbiota transplantation prevents hepatic encephalopathy in rats with carbon tetrachloride-
induced acute hepatic dysfunction
Wang WW, Zhang Y, Huang XB, You N, Zheng L, Li J
6995 Mitofusin-2 mediated mitochondrial Ca2+ uptake 1/2 induced liver injury in rat remote ischemic
perconditioning liver transplantation and alpha mouse liver-12 hypoxia cell line models
Liang RP, Jia JJ, Li JH, He N, Zhou YF, Jiang L, Bai T, Xie HY, Zhou L, Sun YL
Contents Weekly Volume 23 Number 38 October 14, 2017
I October 14, 2017
Volume 23
Issue 38
Contents World Journal of Gastroenterology
Volume 23 Number 38 October 14, 2017
7009 Expression of annexin II in gastric carcinoma and its role in gastric cancer metastasis
Han F, Shrestha S, Huang H, Lv HY, Nie C, Lin L, Lu ML
Retrospective Study
7016 Risk factors for postoperative recurrence after primary bowel resection in patients with Crohn’s disease
Yang KM, Yu CS, Lee JL, Kim CW, Yoon YS, Park IJ, Lim SB, Park SH, Ye BD, Yang SK, Kim JC
7025 Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center
study of 1000 consecutive cases
EI Nakeeb A, Askar W, Atef E, Hanafy EE, Sultan AM, Salah T, Shehta A, Sorogy ME, Hamdy E, Hemly ME, El-Geidi AA,
Kandil T, El Shobari M, Allah TA, Fouad A, Zeid MA, El Eneen AA, El-Hak NG, El Ebidy G, Fathy O, Sultan A, Wahab MA
Prospective Study
7037 Testing for hepatitis B virus alone does not increase vaccine coverage in non-immunized persons
Boyd A, Bottero J, Carrat F, Gozlan J, Rougier H, Girard PM, Lacombe K
7047 Gastric adenocarcinoma of fundic gland type spreading to heterotopic gastric glands
Manabe S, Mukaisho K, Yasuoka T, Usui F, Matsuyama T, Hirata I, Boku Y, Takahashi S
7054 High-grade myobroblastic sarcoma in the liver: A case report
Wen J, Zhao W, Li C, Shen JY, Wen TF
II October 14, 2017
Volume 23
Issue 38
World Journal of Gastroenterology
ISSN 1007-9327 (print)
ISSN 2219-2840 (online)
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Damian Garcia-Olmo, MD, PhD, Doctor, Profes-
sor, Surgeon, Department of Surgery, Universidad
Autonoma de Madrid; Department of General Sur-
gery, Fundacion Jimenez Diaz University Hospital,
Madrid 28040, Spain
Stephen C Strom, PhD, Professor, Department of
Laboratory Medicine, Division of Pathology, Karo-
linska Institutet, Stockholm 141-86, Sweden
Andrzej S Tarnawski, MD, P hD, DSc (Med),
Professor of Medicine, Chief Gastroenterology, VA
Long Beach Health Care System, University of Cali-
fornia, Irvine, CA, 5901 E. Seventh Str., Long Beach,
CA 90822, United States
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ISSN 2219-2840, DOI: 10.3748) is a peer-reviewed open access journal. WJG was estab-
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I-IX Editorial Board
III October 14, 2017
Volume 23
Issue 38
How to perform gastrointestinal ultrasound: Anatomy and
normal ndings
Nathan S S Atkinson, Robert V Bryant, Yi Dong, Christian Maaser, Torsten Kucharzik, Giovanni Maconi, Anil
K Asthana, Michael Blaivas, Adrian Goudie, Odd Helge Gilja, Dieter Nuernberg, Dagmar Schreiber-Dietrich,
Christoph F Dietrich
Nathan S S Atkinson, Translational Gastroenterology Unit,
Oxford University Hospitals NHS Foundation Trust, Oxford OX3
9DU, United Kingdom
Robert V Bryant, School of Medicine, University of Adelaide,
Adelaide, South Australia, 5005, Australia
Robert V Brya nt, Department of Gastroenterology and
Hepatology, Royal Adelaide Hospital, Adelaide 5000, Australia
Yi Dong, Department of Ultrasound, Zhongshan Hospital, Fudan
University, Shanghai 200032, China
Christian Maaser, Ambulanzzentrum Gastroenterologie,
Klinikum Lüneburg, 21339 Lüneburg, Germany
Torsten Kucharzik, Department of Gastroenterology, Städtisches
Klinikum Luneburg gGmbH, 21339 Lüneburg, Germany
Giovanni Maconi, Gastrointestinal Unit, Department of Biomedical
and Clinical Sciences, “L.Sacco” University Hospital, 20157
Milan, Italy
Anil K Asthana, Department of Gastroenterology and Hepato-
logy, The Alfred Hospital, Melbourne, Vic, Australia; Monash
University, Melbourne 3004 Vic, Australia
Michael Blaivas, Piedmont Hospital, Department of Emergency
Medicine, Atlanta, GA 30076, United States
Adrian Goudie , Fremantle Hospital and Health Service,
Emergency Department, Fremantle, WA 6160, United States
Odd Helge Gilja, National Centre for Ultrasound in Gastro-
enterology, Haukeland University Hospital, Bergen N-5021,
Odd Helge Gilja, Department of Clinical Medicine, University
of Bergen, 5021 Bergen, Norway
Dieter Nuernberg, Department of Gastroenterology, Brandenburg
Medical School, 16816 Neuruppin, Germany
Dagmar Schreiber-Dietrich, Christoph F Dietrich, Med.
Klinik 2, Caritas-Krankenhaus Bad Mergentheim, D-97980 Bad
Mergentheim, Germany
Author contributions: All authors contributed to this manuscript.
Conflict-of-interest statement: No potential conflicts of
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Open-Access: This article is an open-access article which was
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the use is non-commercial. See:
Manuscript source: Invited manuscript
Correspondence to: Christoph F Dietrich, MD, PhD, Med.
Klinik 2, Caritas-Krankenhaus Bad Mergentheim, Uhlandstr. 7,
D-97980 Bad Mergentheim, Germany.
Telephone: +49-7931-582201-2200
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Received: February 9, 2017
Peer-review started: February 11, 2017
First decision: April 25, 2017
Revised: May 30, 2017
Accepted: June 18, 2017
Article in press: June 19, 2017
Published online: October 14, 2017
Gastrointestinal ultrasound is a practical, safe, cheap
and reproducible diagnostic tool in inflammatory
6931 October 14, 2017
Volume 23
Issue 38
Submit a Manuscript:
DOI: 10.3748/wjg.v23.i38.6931
World J Gastroenterol 2017 October 14; 23(38): 6931-6941
ISSN 1007-9327 (print) ISSN 2219-2840 (online)
bowel disease gaining global prominence amongst
clinicians. Understanding the embryological processes
of the intestinal tract assists in the interpretation of
abnormal sonographic findings. In general terms, the
examination principally comprises interrogation of the
colon, mesentery and small intestine using both low-
frequency and high-frequency probes. Interpretation
of ndings on GIUS includes assessment of bowel wall
thickness, symmetry of this thickness, evidence of
transmural changes, assessment of vascularity using
Doppler imaging and assessment of other specific
features including lymph nodes, mesentery and luminal
motility. In addition to B-mode imaging, transperineal
ultrasonography, elastography and contrast-enhanced
ultrasonography are useful adjuncts. This supplement
expands upon these features in more depth.
Key words: Ultrasound; Intestinal; Inammatory bowel
disease; Guidelines; Teaching
Core tip: In general terms, gastrointestinal ultrasound
examination principally comprises interrogation of the
colon, mesentery and small intestine using both low-
frequency and high-frequency probes. In addition
to B-mode imaging, transperineal ultrasonography,
elastography and contrast-enhanced ultrasonography
are useful adjuncts.
Atkinson NSS, Bryant RV, Dong Y, Maaser C, Kucharzik
T, Maconi G, Asthana AK, Blaivas M, Goudie A, Gilja OH,
Nuernberg D, Schreiber-Dietrich D, Dietrich CF. How to perform
gastrointestinal ultrasound: Anatomy and normal ndings. World
J Gastroenterol 2017; 23(38): 6931-6941 Available from: URL: DOI:
Gastrointestinal ultrasound (GIUS) is an accurate
diagnostic imaging tool for inflammatory bowel
disease[1-3]. Utilisation has steadily increased in different
global regions including Asia-Pacific[4]. To correctly
interpret GIUS ndings, it is necessary to have a rm
grounding in intestinal anatomy, the fundamentals of
ultrasonography, as well as the examination techniques
and approach. The indications for intestinal ultrasound
are wide-ranging including inflammatory bowel
disease, assessment of functional aspects and general
gastroenterological conditions such as diverticular
disease. Various educational theories are relevant in the
process of learning intestinal ultrasonography including
the learning process itself, using formative assessments
such as DOPS (direct observation of procedural skills),
adopting the apprenticeship or core competencies
model and formulation of a GIUS curriculum. These
principles and a process of learning GIUS have been
recently proposed[1].
The purpose of this paper is to review our know
ledge of intestinal embryology relevant to GIUS.
Understanding the origins and evolution of abdominal
structures during the embryological process can assist
in highlighting the reasoning behind abnormalities
found on GIUS. We then expand upon examination
techniques relevant to different segments of and
structures around the intestine, including an overview
of transperineal ultrasonography. We describe specic
intestinal luminal parameters to be assessed in GIUS
including special techniques such as contrastenhanced
In the 6th and 8th week of intrauterine life, the primitive
mid-gut intestinal tube elongates on the mesentery
around the superior mesenteric artery (SMA), her
niating into the umbilical cord. As the gut grows
and returns into the peritoneal cavity, it eventually
rotates 270 degrees counterclockwise, such that
the duodenum rests behind the SMA[1]. The caecum,
initially in the upper abdomen, descends to the right
lower quadrant. Thus the mesentery attachment of the
small bowel takes an oblique course from the duodeno
jejunal junction at the level of the left L2 process,
over the 3rd part of the duodenum, down to the level
of the right sacroiliac joint[5]. Though the mesentery
attachment is only 1520 cm long, it supplies a length
of small intestine approximately 40 times its length, a
feat achieved through progressive fanlike rufes. Seen
with traditional barium enterography, each curve of the
intestine has a concave and convex aspect, the concave
generally pointing towards the mesentery whilst
the convex aspect representing the antimesenteric
border[6]. These can be viewed in real time with GIUS.
Towards the end of the first trimester, the
peritoneum of the newly forming ascending colon
and the hindgut derived left colonic segments, begin
to fuse with the posterior abdominal wall. Although
traditionally described as retroperitoneal structures,
modern postmortem studies have found that two
thirds of the ascending and a third of the descending
colonic segments have mobile portions of elongated
mesentery[7]. Nonetheless, peritoneal attachments
have significance for the flow of free fluid within the
abdomen as uid tends to ow caudally, medial to the
ascending colon towards the ileocaecal junction and
thus metastatic deposits may become lodged in the
mesenteric rufes en route.
Relative thickenings of the mesocolon provide liga
mental support to the colonic exures; the nephrocolic
ligament runs from the inferior aspect of the right
kidney to the hepatic flexure which then becomes
intimately related to the descending duodenum before
the transverse mesocolon begins; the splenic exure is
suspended by (1) the phrenicocolic ligament which runs
from the diaphragm and also supports the spleen; (2)
the splenocolic; and (3) the pancreaticocolic ligaments
which are essentially extensions of the transverse
6932 October 14, 2017
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Atkinson NSS
et al
. How to perform gastrointestinal ultrasound
mesocolon[5,7]. These attachments provide xed points
for ultrasound evaluation of the colon, which can at
times, be highly mobile within the abdomen.
The taenia coli, thickenings of the longitudinal
muscle layer grow from diffuse sheets at the caudal
end of the bowel, become more dened in the proximal
colon until they encase the caecum[6]. The taeniae
are one sixth shorter than the colon[5], forming the
haustrae. The muscle fibres in the longitudinal layer
end by turning at right angles to merge with the
circular bres and thereby acting as xed linkage points
for contraction. Contractions can occur asymmetrically
obliterating some haustrae, giving the false impression
of smallbowellike semicircular folds and bowel wall
Vascular supply of the colon flows from the me-
senteric border, vessels spreading around the colon.
The vasa recta penetrate through oblique connective
tissue clefts in the bowel wall, the site of diverticular
protrusion, but importantly enter these clefts on the
antimesenteric aspect. In practice, diverticula are
rare on the anti-mesenteric border between the taenia
omonetalis and taenia libera. A vasa recta vessel
runs over the long aspect of each diverticulum before
entering the submucosa at the antimesenteric border[6].
General considerations and examination technique
An optimal environment for United States is within a
dedicated space or consulting room, offering indirect
low light sources and facilitating patient comfort. Prior
cross-sectional imaging and endoscopy reports should
be available to inform of postsurgical and anatomical
In most scenarios patient preparation is not re-
quired but specific measures can be used. Fasting
for 4-6 h decreases bowel motility whilst two cups
of water can be used to improve visualisation of the
duodenum[8]. Negative oral contrast may improve
detection of jejunal and proximal ileal stenosis, par
ticularly where examination findings are negative;
250-800 mL of polyethylene glycol solution generally
reaches the terminal ileum after an average duration
of 30 min[9]. Once contrast is seen to flow into the
caecum, retrograde examination of the small bowel can
be performed.
Examination of the intestinal tract begins with a
comfortable patient, relaxed in a supine position so as
not to tense the abdominal wall. The transducer is held
maintaining contact with the patient’s skin to gauge
pressure, whilst the left hand is free to optimize image
characteristics on the machine. A systematic approach
in examining the whole intestine is encouraged (Figure
1). Firstly, the low frequency 38 MHz (multifrequency)
curvilinear probe initially allows orientation to the
anatomy and detection of gross changes, whilst high
frequency linear probes (717 MHz) are preferable for
interrogating specic regions of interest in depth.
Colonic examination
Beginning at the right anterior superior iliac crest and
moving medially to the edge of the rectus muscles in
a sagittal plane, the common iliac (iliacal) vessels are
identied. Rotating anticlockwise to a transverse plane
and moving cranially, the rst bowel loop crossing from
medial to lateral is identified as the terminal ileum.
This is followed to the ileocaecal (Bauhin’s) valve and
caecum. The base of the appendix can be identified
at the deep margin of the caecum where the colonic
taenia meet before the ascending colon is followed
up towards the hepatic exure. The rest of the colon
can be followed via the transverse segment distally
towards the rectum. Alternatively, the same technique
can be used on the left side identifying the sigmoid
colon as the first loop of bowel crossing the left iliac
vessels, which can be followed to the descending colon
and towards the spleen as far as the rib margin allows.
The iliopsoas muscle can be used as an alternative
landmark for identification of the terminal ileum
and sigmoid colonic segments in the right and left
iliac fossae respectively. Intercostal imaging may be
required to visualise the left or splenic exure where
it has attachment to the spleen; elevating the left arm
and rotating to a partial right decubitus position with
a straight left leg can spread the ribs and improve
image acquisition (Figure 1C). Placing the probe in the
epigastric region in sagittal orientation demonstrates
the liver and stomach; one can then follow the
gastrocolic ligament to the transverse colon. Although
the transverse colon can be followed on ultrasound,
it may not be reliably viewed in its entirety. Be aware
that the rectum and distal parts of the colon cannot
always be displayed satisfactorily by transabdominal
United States. Transperineal imaging, in such cases,
can be useful to evaluate the distal rectum and perianal
Mesentery and small intestine examination
Mesenteric fat is evident sonographically and is
considered to be abnormal if it extends over more
than half the circumference of the bowel loop, if it is
thickened beyond 56 mm or consistently greater than
the normal bowel wall thickness[10].
Examination of the mesentery begins in the
epigastrium at the duodenojejunal flexure which
then runs obliquely towards the right iliac fossa. To
aid visualization, the patient is asked to breath in
deeply and as they exhale, pressure is applied to the
transducer following which excellent views of the small
bowel mesentery sheets and abnormalities can be
achieved. A systematic scanning of the small bowel
may start in the right iliac fossa by dening the terminal
ileum and following its course in a proximal direction
as far as possible. Finally, a systematic overlapping
“Lawn Mowing” strategy is used, sweeping up and
down the abdomen to provide an overview of the small
bowel. This is performed with the probe in horizontal,
6933 October 14, 2017
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Atkinson NSS
et al
. How to perform gastrointestinal ultrasound
6934 October 14, 2017
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Perineal ultrasound
TPUS allows visualisation of the perianal tissues, anal
canal, sphincters, the distal 57 cm section of the
rectum, vagina and a part of urinary bladder. A point
for orientation is the symphysis. Knowledge of the
pelvic anatomy is essential[12,13] (EFSUMB Case of the
Month). No specific patient preparation is required.
sagittal and oblique (parallel to the mesenteric
attachment) orientations in order to allow one’s eye to
follow structures and detect abnormalities. A full video
explanation of abdominal and intestinal ultrasound
examination technique is freely available on the
EFSUMB website[11] (
Spleen SF
Figure 1 A systematic approach in examining the whole intestine. A: Examination begins in a relaxed ventral position; B: Beginning medial to the right anterior
superior iliac spine, the iliacal vessels (IAV) are identied and the rst bowel loop crossing medial-to-lateral is the terminal ileum (TI). The same technique on the right
identies the sigmoid colon; C: Elevating the arm spreads the rib spaces to improve visualisation of the splenic exure (SF); D: Gentle pressure as the patient breaths
out improves visualization of the mesentery and superior mesenteric artery (SMA) to exclude lymphadenopathy. The videos can be accessed via the efsumb website
Atkinson NSS
et al
. How to perform gastrointestinal ultrasound
6935 October 14, 2017
Volume 23
Issue 38
The patient is placed in the left lateral position as for
a digital rectal examination. The probe is covered in
either a sterile cover or an examination glove with
ultrasound gel between the layers.
Examination begins in the midline just above the
anus with the probe in a sagittal plane. The ultrasound
probe can be moved laterally, however angulated
views have reduced sensitivity for identification of
pathology. Fistulous tracts can be followed by first
placing the probe over the external opening. If
necessary, the probe can be placed in a coronal angle,
although this is usually less comfortable for the patient.
It is useful to start with an abdominal convex probe
(lower frequency) for the deeper structures and then
continue with a higher frequency probe (715 MHz).
Examination is also possible after rectal amputation
(e.g., QuénuOperation).
The anal canal, sphincter complexes, hemorrhoidal
plexus (Figure 2), rectovaginal plus anovaginal
septums, the walls of the vagina and distal rectum
can be defined. Fistulae should be classified as per
Parks’ classification[14] although TPUS has reduced
sensitivities for sphincteric relationships and therefore
the American Gastroenterological Association (AGA)[15]
distinction of “simple” from “complex” is of more clinical
utility; the former including low fistulae (superficial,
intersphincteric or intrasphincteric) below the dentate
line, with a single external opening and without
perianal complications or active proctitis[16]. Fistula and
abscesses visibility can be improved with ultrasound
contrast agents (UCA) using contrast enhanced ultra-
sound techniques[17,18]. Colour Doppler improves the
differentiation of inammatory reactions.
Bowel wall thickness
Bowel wall thickness (BWT) is the measure most
consistently reported in diagnostic and activity
trials. Wall thickness of the alimentary tract differs
by region and depends on the degree of distension
and contraction[19,20]. The overall thickness should be
measured under mild compression from just above
an air-mucosal interface to the outside of the outer
muscularis propria layer border, including the whole
bowel wall[21]. Under these standardised conditions, the
stomach wall thickness measures 36 mm; terminal
ileum 13 mm; and colon 0.52 mm. In fact, the
normal range is likely to be even lower than this[22].
Values in children can be reliably obtained without the
need for sedation[22] but bear in mind that values do
increase over childhood[23] whilst still remaining < 2
mm. The optimal threshold for abnormal thickness is
debatable, as specicity improves with increasing wall
thickness at the cost of sensitivity (Figures 3 and 4).
Bowel wall layers
The GI wall has five layers that usually can be
visualized with ultrasound. The sonographic layers
are a combination of interface echoes and the echo
characteristics of the histological layers[24-26]. When
imaged in the anterior wall of a bowel loop starting
from the lumen the hyperechoic layer 1 corresponds to
the interface between the mucosa and the lumen and
is not a part of the actual GI wall. The hypoechoic layer
2 corresponds to the mucosa without the interface
between the submucosa and mucosa, the hyperechoic
layer 3 to the submucosa including this interface echo,
the hypoechoic layer 4 to most of the proper muscle
and layer 5 to the hyperechoic interface echo between
the proper muscle and the serosa.
Interface echoes are always hyperechoic and
located distally to the actual tissue interface. Therefore,
the correspondence between histology and sonographic
layers differ slightly in the dorsal wall. Specifically,
the interface between lumen and mucosa (layer 1)
is a part of the actual mucosa and layer 2 represents
the rest of the mucosa without muscularis mucosae,
which normally is covered by an interface echo and add
thickness to layer 3. Moreover, the interface between
submucosa and the proper muscle adds thickness to
layer 3 and reduces the thickness of layer 4. Finally, the
interface between the proper muscle and serosa (layer
5) extends beyond the actual serosa[27,28].
The interface from the serosa is hard to delineate.
Accordingly, the measurement should be made
from the start of the hypoechoic layer of the proper
muscle to the end of the hypoechoic layer of the
mucosa. Transducer-compression of the bowel wall
will reduce thickness and can make it challenging to
distinguish wall layers[29,30]. However, some operators
practice mild compression suggesting that this
improves reproducibility of measurements[21,22,3133].
The examiner should also be aware of interpretation
difculties due to mucosal folds and haustrations and
to keep the probe angle perpendicular to the bowel
wall to avoid tangential measurements. In conclusion,
dosed compression is a prerequisite for a reproducible
examination for some authors whereas others use it
with caution.
Figure 2 Example on the use of color doppler imaging and continous
duplex scanning. Perineal ultrasound showing the hemorrhoidal pleaxus using
color doppler imaging and continous duplex scanning with the typical spectrum
of the hemorrhoids.
Atkinson NSS
et al
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The layered wall structure changes with disease[34].
In severe disease the stratification may disappear
due to deep mural ulcers, increasing inflammatory
infiltrate and neovascularisation. In chronic inactive
disease, accentuated wall layers are more common.
The distinctions are less apparent with milder disease
The symmetrical nature of changes is relevant. Asym
metry has been assumed to correspond to endoscopic
signs of focal ulceration or polypoid mucosal changes,
whilst diffuse thickening is evident with ulcerative colitis
(UC) or infectious colitis. The differential diagnoses for
chronic inflammatory bowel findings, with or without
asymmetry are listed in Tables 1 and 2.
Luminal diameter and motility
The small and large bowel can usually be distinguished
by scanning the haustrae of the colon and/or the
circular folds of Kerckring in the small intestine. In
unclear cases, scanning of the intestine during various
stages of lling may be helpful. Changes in Kerckring’s
folds and luminal uid quantity can be associated with
disease[35]. The small bowel diameter varies widely
depending on recent meals and activity, but dilatation
beyond 25 mm should be regarded as abnormal,
particularly when motility is reduced[36]. Assessment of
peristaltic activity and lumen compressibility are two
advantages of ultrasound over other imaging modalities.
Strictures may be identified by the coexistence of
thickened and stiffened bowel wall with narrowing of
the intestinal lumen, particularly if less than 10 mm[9].
The presence of proximal loop dilatation with fluid or
echogenic content is not required for the diagnosis[36]
but may carry clinical signicance.
Dilatation of the proximal small bowel loops with
hypo- or hyperperistalsis can be caused not only by
chronic brotic strictures but also by acute inammatory
stenosis or passenger invagination. Functional ultra
sonography is helpful in differentiation[37-40].
Extent of disease
Evaluating the length and extent of involved bowel
segments is performed by estimated longitudinal
Figure 3 Measurement of the bowel wall. The measurements are best taken ventrally since posterior artefacts occur (A) and the measurements (B) are not reliable.
Mu: Mucosa; SM: Submucosa.
Figure 4 Measurement of the bowel wall. In a patient with Crohn’s disease
of the small intestine, ultrasound was applied to evaluate disease extension
and wall thickness. B-mode image shows moderate wall thickening in the
ileum with well-preserved layer structure. Be aware the marked thickening
of the submucosal layer in white, often seen in IBD. The crosses mark the
wall thickness in the anterior and posterior wall denoting a slight difference in
Crohn’s disease
Mycobacteria tuberculosis
NSAID enteropathy
Table 1 Differential diagnosis of asymmetrical terminal ileal
thickening with chronic symptoms
Inammatory bowel disease
Mycobacterium tuberculosis
Tab le 2 Differential dia gnos is of c hron ic inflammatory
diseases of the bowel
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measurement and taking note of skip lesions. Bowel
wall thickening, luminal diameter for stenosis or
dilatation > 25 mm, and motility should be noted in
each region. Chronic inflammation tends to produce
an isolated, fixed segment without peristalsis and
abnormal angulation due to the brofatty proliferation
of the mesentery[41,42].
Transmural reactions
Transmural inammation and brosis may result in an
asymmetrically thickened, stratied bowel wall, which
are the typical findings of Crohn’s disease (CD). A
hypoechoic extension through the normal bowel wall
stratification correlates with cellular and oedematous
tissue inltration. Even though the extent of the bro
fatty proliferate correlates with the degree of intestinal
inammation in CD, there is no standardized method
to date to quantify the mesenteric fat by using GIUS.
Note should be made if the reaction extends beyond
the muscularis propria layer, and whether it does
so into the mesenteric or anti-mesenteric border.
Fistulae are identied as hypoechoic tracts extending
through the bowel wall, often with reverberations
(circumscribed bright air echoes) within them (Figure
5). Rounded hypoechoic areas (non-contrast imaging)
within the mesentry are suspicious for abscesses or
inflammatory phlegmons often with an irregular wall
or internal echoes (Figure 6). The occurrence of free
peritoneal fluid is important to note, though clinical
data corroborating its signicance are scant[21].
Fistulae and abscesses
Two prospective studies suggest a sensitivity and
specificity for the GIUS detection of fistulae of
72%87% and 90%96%, respectively[43]. This
performance is equivalent to CT/MR studies in meta
analysis[44], whilst small intestine contrast ultrasound
(SICUS) may have a sensitivity as high as 96%.
Estimates of the sensitivity and specicity for detecting
abscesses have been reported in a somewhat higher
range; 71%100% and 77%94% respectively[21,4549].
The direct application of contrast agents into the orice
of the stula may be helpful in determining the route
and connection(s)[12,13,50].
Mesenteric lymph nodes
Lymph node enlargement is a frequent sonographic
finding in CD[10], however their interpretation and
clinical implications remain to be further clarified in
the literature. It has been suggested that they may
represent a very early manifestation of CD in children
for example[22]. They are correlated with duration
of disease and the presence of fistulae but more
importantly, for the ultrasound learner, they provide a
Figure 5 Typical complications in Crohn’s disease, stula. Typical ultrasound ndings in Crohn’s disease include transmural inammation, stula and abscess
formation. A-C: The typical sign of stula is hypoechoic transmural inammation with (moving) air bubbles outside of the bowel lumen. The air bubbles are best
visualised using a real-time examination or video. Here we demonstrate single images of a video to demonstrate the changes within one second.
Figure 6 Typical complications in Crohn’s disease, abscess. Typical ultrasound ndings in Crohn’s disease include transmural inammation, stula and abscess
formation. Contrast enhanced ultrasound allows to better delineate larger (A) and smaller abscess formation (B) not clearly suspected using B mode ultrasound.
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marker of procedural competence and interpretation. B
mode characteristics of lymph nodes to consider include
their length and particularly for those < 15 mm; their
short axis dimension should be less than half their
longitudinal diameter. Furthermore, the normal lymph
node architecture and hilum should be preserved in
normal or inammatory nodes[51].
Mesenteric inammation, oedema and vascularity
The supporting structures of the intestine run within
the sheets of mesentery, seen as layers of mixed
echogenicity with hyperechoic serosal layers on either
side, which does not have peristaltic movement
and appears similar in both transverse and sagittal
planes. Fat wrapping has long been recognised by
surgeons as a common and specic feature of CD. So
called (creeping) fat, extending from the mesenteric
attachment to partially cover the small or large
intestine resulting in loss of bowel mesentery angle,
is seen as an early event in the disease course and
plausibly plays a role in the inflammatory milieu[52].
In practical terms the serosal planes on either side
of the mesentery may be detected and should cover
less than half of the bowel circumference. It is also
the most common cause of bowel loop separation[41].
A subjective impression of increased thickening and
echogenicity has been applied in the literature[10],
correlating with clinical severity and primary luminal
findings; although in long standing disease it can
become more heterogeneous and hypoechoic[41].
Doppler imaging of tissue and SMA parameters
Colour Doppler imaging of the bowel wall is part of
standard assessment of the intestine and mesenterial
vessels (Figure 7). Hyperaemia is associated with
inflammation, usually seen in the submucosal layer
and the penetrating vessels of the muscularis propria.
Use of Doppler evaluation increases the sensitivity of
US for evaluating disease activity[33,39,5359]. The degree
of vascularity can be graded by the Limberg scale, a
semiquantitative assessment[60] that lacks routine
practical relevance. Other more complex quantitative
measurements of Doppler parameters have been
proposed, however a standardised protocol to com
pensate for confounders has not yet become widely
used. Power Doppler assessment of the arterial inow,
in particular the inferior mesenteric artery (IMA) for left
sided colonic disease and SMA for proximal colon and
small bowel activity, can be assessed in the majority of
patients and correlates with other ultrasound markers
of disease activity. It should therefore be interpreted
in the overall context of ultrasound findings[61]. A
prognostic role for Doppler parameters was previously
proposed[62] but awaits further study and validation.
Contrast-enhanced US
Second generation contrast agents such as SonoVue®,
produce harmonic frequencies from microbubbles
approximately the size of a single red blood cell,
and are stable within the circulation[17,63]. Imaging
systems thereafter allow visualisation of individual
blood vessels through a tissue and thereby improve
the accuracy of Doppler US in evaluating bowel wall
vascularity. This technique has been shown to be
useful in the assessment of disease activity in CD, in
particular differentiating inflammatory masses from
abscesses and may help to distinguish inflammatory
from brotic strictures in certain situations[64-66]. Use of
Contrast-Enhanced US (CEUS) during GIUS has been
standardized, does not requires specic expertise, and
its use in IBD presently is increasing[67].
Similar to palpation, the elastic properties of a tissue
can be evaluated by assessing the speed of a sheer
wave through tissue or the amount of deformity
created by the sheer stress (strain imaging). Various
sonographic approaches to generating and measuring
these parameters are available[68], which may com
pliment standard B-mode assessment of a lesion.
Fibrotic lesions may appear stiff and inflammatory
lesions soft using elastography, which can help to
characterise intestinal lesions and has been correlated
with endoscopic ndings (Figure 8)[69,70].
Understanding the anatomy and embryology of the
intestinal tract is highly relevant in identifying sono
graphic abnormalities relevant to GIUS. The general
principles of examination involve specic interrogation of
the colon, small intestine and mesentery. Further work
is required to validate and understand the signicance
of certain sonographic parameters where understanding
is limited; this includes further evaluation of abnormal
wall thicknesses and quantifying this to a higher degree
of accuracy, understanding the signicance of peritoneal
fluid present as a reflection of transmural reactions,
Figure 7 Complications of inammatory bowel disease. Thrombosis of the
superior mesenteric vein. Partial recanalisation is shown by the markers.
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and the accurate interpretation and implications of
lymph nodes. Despite the presence of semiquantitative
measures, such as the Limberg score, they lack practical
relevance and so there is a need for further multicentre
prospective studies.
Various sonographic abnormalities can be detected
and interpreted currently but a standardized scoring
system for GIUS in inammatory bowel disease, akin
to validated endoscopic scores (such as the Ulcerative
Colitis Endoscopic Index of Severity) is lacking.
Ultimately, formulating a reproducible and validated
scoring system integrating different sonographic
parameters to reect severity will be highly relevant;
this will require agreement amongst GIUS experts and
validation in multicentre prospective studies. Finally, a
standardized method of documentation, including how
to capture images, needs to be developed.
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P- Reviewer: Capasso R S- Editor: Ma YJ L- Editor: A
E- Editor: Li D
Atkinson NSS
et al
. How to perform gastrointestinal ultrasound
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... Fasting or bowel preparation is not necessarily required for a standard IUS examination. [5] The patient should be in the supine position. The initial systematic scan is recommended to be performed with a low-frequency (3.5-5.0 ...
... MHz) curvilinear probe over the whole intestine and extraintestinal area. Then, high-frequency linear probes (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15) can be used to obtain the images of the intestinal wall at a higher spatial resolution; this step is crucial if the five-layer wall pattern of the gastrointestinal tract is to be accurately assessed. [6] Intraluminal air can be reduced through the IUS probe gradually compressing the bowel. ...
... [7] The process of sigmoid or terminal ileum identification in the left iliac fossa or right iliac fossa can be made easier by utilizing landmarks: the iliopsoas muscle and common iliac vessels, respectively. [5] Visualizing the colonic flexures (especially the left flexure) is difficult due to ligamentous fixation to the diaphragm. In addition, the location of the pelvis means that when using the transabdominal route, accurate visualization of the rectum and anal region is not possible. ...
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New and efficacious medical therapies have become available that have greatly enhanced clinicians' ability to manage inflammatory bowel diseases (IBDs). IBD activity should be assessed regularly in scheduled examinations as the part of a treat-to-target strategy for IBD care. The gold-standard approach to investigating IBD is colonoscopy, but this is an invasive procedure. Intestinal ultrasound (IUS) has played a crucial role in recent years regarding the assessment of IBD activity because it is noninvasive, safe, reproducible, and inexpensive. IUS findings could inform changes in therapeutic interventions for IBDs; this would necessitate fewer endoscopies and enable faster decision-making processes. Furthermore, patients are accepting and tolerant of IUS examinations. This review outlines the current evidence and gives indication regarding the use of IUS in the management of IBDs.
... In adults, it is recommended to complete an anatomical mapping scan of the abdomen first utilizing the lower frequency transducer to ensure any bowel loops ≥ 4 cm from the skin's surface are adequately identified, however, lower frequency transducers provide less detail. Therefore, a second assessment should be performed to assess the bowel wall layers in greater detail and if amenable, to obtain quantitative measurements of bowel wall thickness (BWT) and assessment of inflammatory features [9]. Children typically have a smaller abdominal habitus, allowing for optimal visualization with a higher frequency transducer, therefore, it is reasonable to begin with the higher frequency transducer. ...
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Purpose of review: Intestinal ultrasound (IUS) is an emerging non-invasive point-of-care tool utilized by pediatric gastroenterologists for accurately detecting and monitoring inflammatory bowel disease (IBD) activity. In this article, we reviewed the evidence supporting and technique to perform IUS for children with IBD. Recent findings: IUS technique can visualize the colon from the distal sigmoid until the cecum and the terminal ileum without the need for bowel preparation, fasting, or sedation in children with IBD. IUS has been shown to be accurate to endoscopy in children with ulcerative colitis and Crohn's disease. IUS may be the most accurate biomarker to follow as a marker of treatment response that is predictive of endoscopic outcomes in children with IBD. Multiple studies have demonstrated that IUS can be performed at the point-of-care for IBD activity assessment in children. Recent studies have demonstrated the accuracy of IUS to endoscopy and magnetic resonance enterography with an ability to be repeated as a monitor of treatment response for tight control monitoring.
... Hasi ultrahangvizsgálattal a hasűri szervek morfológiája, nagysága pontosan megjeleníthető, a fejlődési rendellenességek azonosíthatók, a szervek funkciójáról azonban kevés információt ad. A gastrointestinalis traktus ultrahangvizsgálatával, mely gyakran kiegészítő vizsgálata a natív hasi röntgenfelvételnek, gastrooesophagealis reflux, atresiák, meconiumileus, nekrotizáló enterocolitis, choledochuscysta, a lép, a máj, a pancreas, az extrahepaticus epeutak eltérései detektálhatók újszülöttkorban [8]. A vena umbilicalison keresztül felvezetett köldökvéna-katéter pozíciója és a katéter által okozott esetleges komplikációk -pitvar-kamra fali perforáció, érsérülés, thrombosis, thromboembolisatio, májnekrózis, abscessus, cystosus májelváltozás -is jól vizsgálhatók ultrahanggal [9]. ...
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Introduction: Previously, all admitted neonates to our tertiary Neonatal Unit, University of Szeged, had a cranial and abdominal ultrasound performed as part of their care. Objective: To analyze the findings and to evaluate the effectiveness of the universal ultrasound screening. Method: Results of cranial and abdominal ultrasound imaging performed in our Unit between 1st January 2014 and 31st December 2015 were analyzed retrospectively. Abnormalities found during the screening scans were studied further and assessed until discharge and during the first 2 years. All imagings were performed by a radiologist. Results: During the examined 2 years, 579 neonates were admitted (gestational age mean 34.2 weeks [23-41, SD ± 4.04]), abdominal ultrasound was performed in 562 (97%) and cranial ultrasound in 560 (97%) babies, on the 3.6th day of life at an average (0-18, SD ± 2.24). Of all abdominal ultrasound scans, 87% (n = 488) was carried out as screening, and the found abnormalities in 140 (29%) of the cases: renal pelvic dilatation (n = 67 [47.9%]), free abdominal fluid (n = 17 [12.1%]), echogenic kidneys (n = 13 [9.3%]), congenital abnormalities of the kidney and urinary tract (n = 9 [6.4%]), abnormalities of the liver, bile system, adrenal gland [n = 14 [10%]). The screening identified 4 (0.8%) neonates with renal abnormilaties requiring surgical correction. In regards of renal abnormalities, we observed male (p = 0.18) and left sided (p = 0.54) predominance. Screening cranial ultrasound was performed in 65% (n = 362) of all neonates, discovering 51 (14%) anomalies: plexus chorioideus cyst (n = 21 [41%]), plexus chorioideus hemorrhage (n = 9 [17.6%]), mild ventricular asymmetry (n = 8 [15.7%]), subependymal hemorrhage (n = 5 [9.8%]), abnormalities of the periventricular area (n = 4 [7.8%]), colpocephaly, hydrocephalus externus, echogenic meninx and thalamic nodule [n = 1-1 (1.9-1.9%)]. Conclusion: Abdominal ultrasound screening discovered renal abnormalities and umbilical line complications as clinically relevant findings. However, a small number of renal abnormalities identified by screening required surgical intervention. Further studies are needed to identify possible risk groups to develop more efficient screening strategy to decrease the number of screened babies for 1 relevant finding (number to screen). Cranial ultrasound screening did not identify any abnormalities that needed intervention. We can not recommend universal cranial ultrasound screening based on our results. Orv Hetil. 2023; 164(31): 1222-1230.
... The estimated mean age at diagnosis is in the sixth decade [6] with a wide range of symptoms depending on site, size and growth pattern. It has been reported that patients with GI bleeding constitute approximately 23-33% [1,9] especially when the GIST is located in the small intestine due to narrower intestinal wall [7]. Besides, when the tumor volume is large, it is more likely to develop ulcers or break through the intestinal cavity. ...
Full-text available
Introduction: A small bowel gastrointestinal stromal tumor (GIST) is a rare neoplasm of the gastrointestinal tract. The manifestation of bleeding is a diagnostic challenge and could present as a life-threatening situation that needs urgent intervention. Presentation of case: 64-year-old woman consulted for episodes of melena and anemia. The upper and lower endoscopies were not diagnostic. Capsule endoscopy (CE) revealed a probable jejunal hemangioma, however double-balloon enteroscopy and magnetic resonance imaging (MRI) did not show any intestinal nodule but MRI show a pelvic mass apparently related to the uterus confirmed by a gynecologist. Even so, the patient returned with melena, and a contrast-enhanced computed tomography (CT) scan again identified a pelvic mass, highlighting that its vascularization drained into the superior mesenteric territory and seemed to invade the jejunum, with active bleeding, suspicious for jejunal GIST. A laparotomy was performed to remove the jejunal mass. Histopathology and immunohistochemical studies confirmed the diagnosis. Discussion: Bleeding is a common symptom in small bowel GISTs but its diagnoses could be difficult because its location. In most cases, gastroscopy and colonoscopy are not useful and CE or imaging studies are necessary to find the cause of bleeding. Moreover, it has recently proved that bleeding is a prognostic risk factor because it is related to tumor rupture and tumor invasion of blood vessels. Conclusion: In this case, bleeding caused by small bowel GIST was misdiagnosed in endoscopic procedures and the clinical management was delayed. CT angiography was the most effective investigation to detect the source of bleeding.
... The examination starts by placing the transducer parallel to the iliac spine and visualizing 3 landmarks: the iliac vessels medially (the common iliac artery and vein), the iliopsoas muscle inferolaterally, and the hyperechoic iliac crest inferiorly to that. 11 When these landmarks are identified in the right lower abdomen of the patient, the terminal ileum will lie superiorly, and on the left lower abdomen, the sigmoid colon will lie superior to these landmarks. Visualization of the ileocecal valve or ileocolonic anastomosis can ensure that the terminal or neoterminal ileum is indeed the small bowel loop identified and not a more proximal small bowel loop, among other characteristics unique to the large and small bowel that are assessed as part of the examination. ...
Over the years, ultrasound (US) has gained an essential role as a point of care tool both for critical and noncritical patients. In the first assessment of traumatic patients, the extended focus assessment with sonography (eFAST) protocol has been extensively used and is now part of all trauma guidelines; nevertheless, point-of-care US (POCUS) can play a main role as a first-level investigation in the case of nontraumatic acute abdomen and can help to rule in and rule out important causes of acute abdominal pain. It goes without saying that echography, as with every imaging methodology, has its own strengths and weaknesses that we must always keep in mind to avoid false positive or false negative results. In this chapter we propose a systematic ultrasound approach for intensive care physicians while dealing with patients with a nontraumatic acute abdomen. Thus, we will focus on the main conditions that can be identified through US and on the sonographic signs that can guide the intensivist through the intricate maze of differential diagnosis of nontraumatic acute abdominal pain.
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This study aimed to investigate the cutoff value of leucine-rich alpha-2 glycoprotein (LRG) in predicting active intestinal ultrasonography (IUS) findings in patients with Crohn's disease (CD) in clinical remission. Data were retrospectively collected from patients with CD evaluated using LRG and undergoing IUS from September 2020 to August 2022. Patients with a Harvey-Bradshaw Index of ≤4 were included and those who underwent intestinal resection were excluded. Bowel wall thickness and stratification and blood flow signal using superb microvascular imaging (SMI) were used to assess ultrasonography findings. SMI signals were categorized into 4 grades following the Limberg score. Receiver operating characteristic curves were constructed and the area under the curve was calculated to determine the LRG cutoff values for predicting active IUS findings and were compared with those of C-reactive protein. This study included 213 patients. The LRG cutoff values to predict active bowel wall thickness, loss of bowel wall stratification, and SMI of ≥1, ≥2, and 3 were 14.6 μg/mL, 14.6 μg/mL, 14.6 μg/mL, 14.6 μg/mL, and 16.9 μg/mL, respectively, with significantly higher areas under the curve in SMI of ≥1 and 3 than in C-reactive protein. The best LRG cutoff value for predicting active IUS findings was 14.6 μg/mL in patients with CD in clinical remission, suggesting that LRG is better than C-reactive protein for detecting active IUS findings in CD.
Intussusception is typically considered an acute emergency; however, the increased utilisation of medical imaging has revealed that intussusceptions can also be transient, asymptomatic and possibly physiologic. Sonographers should be aware of three categories of intussusceptions: (i) persistent intussusceptions resulting in acute abdomen and requiring urgent intervention, (ii) transient symptomatic intussusceptions which may be amenable to a ‘wait‐and‐see’ strategy and (iii) transient asymptomatic intussusceptions which almost always involve the small bowel. In particular, the incidental discovery of enteroenteric intussusceptions in children should not be confused with acute pathology. In adults, sonographers should be mindful of the frequent presence of pathological lead points and further investigations may be warranted. In this literature review, we provide an overview of transient intussusceptions, highlight important differences between children and adults and describe sonographic appearances of various intussusceptions and their mimics.
The use of ultrasound is valuable in learning both the physiological and structural layout of the GI system. The gastrointestinal tract is essentially a 30-foot tube that lies in neatly folded yet still mobile layers stretching from the mouth to the rectum. Its purpose is to take in food, extract the useable components and eliminate what is not needed in the form of feces. While simple to summarize, digestion is an incredible complex process involving at least 9 organs and no fewer than 26 hormonal and peptide regulators. The epiglottis must move to cover the tracheal opening every time we swallow, approximately 600 times per day without fail, or food and secretions go into the lungs resulting in a condition called aspiration. It takes 50 pairs of muscles working in perfect synchrony to take a bite of food and pass it to the stomach and uncountable others to process the food from stomach through the intestines and out the anal canal.
The endocrine system provides a major mechanism by which the nervous system regulates homeostasis and many body functions, including growth, development, reproduction, blood pressure, blood ion concentrations, and even certain aspects of behavior. The endocrine system effects its actions by the secretion of hormones that affect target tissue functions, but unlike most neurons, which alter the activity of neurons and other targets by releasing neurotransmitters directly onto the target tissue, the neural control of the endocrine system acts by inducing endocrine glands throughout the body to alter their release of hormones into the blood supply, thus affecting the function of widespread organs.
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The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recommends that ultrasound should be used systematically as an easy accessible and instructive educational tool in the curriculum of modern medical schools. Medical students should acquire theoretical knowledge of the modality and hands-on training should be implemented and adhere to evidence-based principles. In this paper we report EFSUMB policy statements on medical student education in ultrasound that in a short version is already published in Ultraschall in der Medizin 1.
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To evaluate the efficacy of power Doppler sonography (US) in depicting internal fistulae and their vascularity, and to study the characteristics of blood flow within the fistula wall. The study involved 45 consecutive patients with Crohn's disease and suspected internal fistulae detected by grey scale US. The fistulae were subsequently evaluated using power Doppler US to reveal any areas of increased vascularity, and the results were compared with radiographic, endoscopic, or intraoperative findings. Whenever feasible, we also performed spectral analysis of blood flow revealed by power Doppler US, calculated its resistance index (RI), and analysed its characteristics, reproducibility, and relationship with biochemical and clinical variables (Crohn's disease activity index, disease duration, location, and abdominal complications). Power Doppler US revealed vascularity in all of the internal fistulae that where subsequently confirmed by diagnostic procedures. In the case of intra-abdominal abscesses in the vicinity of the fistula, vascular signals were detected mostly around and not within the lesions. The intensity and distribution of the signals differed within the fistulae tracks and had only slight day to day reproducibility; furthermore, there was no significant correlation with clinical or biochemical variables. Spectral analyses of blood flow within the fistulae revealed arterial flow in 96.7% of patients (median RI 0.715). RI was a more reproducible parameter and significantly correlated with clinical (r= 0.54) and biochemical activity (r= 0.56) of CD. It was also higher in fistulae complicated by abscesses. Power Doppler US can reveal the presence of vasculature within the wall of internal fistulae and therefore enhance grey scale US performance. The RI characteristics of blood flow within the fistulae are reproducible and correlate with biochemical and clinical disease activity.
Gastrointestinal ultrasound (GIUS) is an ultrasound application that has been practiced for more than 30 years. Recently, GIUS has enjoyed a resurgence of interest, and there is now strong evidence of its utility and accuracy as a diagnostic tool for multiple indications. The method of learning GIUS is not standardised and may incorporate mentorship, didactic teaching and e-learning. Simulation, using either low- or high-fidelity models, can also play a key role in practicing and honing novice GIUS skills. A course for training as well as establishing and evaluating competency in GIUS is proposed in the manuscript, based on established learning theory practice. We describe the broad utility of GIUS in clinical medicine, including a review of the literature and existing meta-analyses. Further, the manuscript calls for agreement on international standards regarding education, training and indications.
In October 2014 the European Federation of Societies for Ultrasound in Medicine and Biology formed a Gastrointestinal Ultrasound (GIUS) task force group to promote the use of GIUS in a clinical setting. One of the main objectives of the task force group was to develop clinical recommendations and guidelines for the use of GIUS under the auspices of EFSUMB. The first part, gives an overview of the examination techniques for GIUS recommended by experts in the field. It also presents the current evidence for the interpretation of normal sonoanatomical and physiological features as examined with different ultrasound modalities. © Georg Thieme Verlag KG Stuttgart · New York.
In October 2014 the European Federation of Societies for Ultrasound in Medicine and Biology formed a Gastrointestinal Ultrasound (GIUS) task force group to promote the use of GIUS in a clinical setting. One of the main objectives of the task force group was to develop clinical recommendations and guidelines for the use of GIUS under the auspices of EFSUMB. The first part, gives an overview of the examination techniques for GIUS recommended by experts in the field. It also presents the current evidence for the interpretation of normal sonoanatomical and physiological features as examined with different ultrasound modalities. © Georg Thieme Verlag KG Stuttgart · New York.
Introduction: The number of publications concerning mesenteric Doppler sonography (mesDS) is immense and does not correlate with the frequency of its use in clinical practice. This is astonishing since it provides real time blood flow (perfusion) information without side effects. Despite uncontrollable parameters like the technical limitations in some situations the optimization of (possibly) controllable parameters like standardization, production of normal values and reduction of the investigator variability by evaluating stable parameters could change the situation. Patients and methods: 10 investigators experienced in abdominal sonography ("DEGUM-Seminarleiter") performed mesenteric Doppler sonography in 5 healthy subjects with 5 different machines. Results: The portal vein at the confluence and the common hepatic artery provide a significant portion of investigations with intromission angles of more than 60°. Values of diameter, resistance index and pulsatility index of the celiac trunc could be obtained with inter-observer variability values below 25 %. The proper and the common hepatic artery show no differences in inter-observer variability values, whereas the intrahepatic measure point of the portal vein showed a higher reproducibility. Discussion: We define frame conditions for future mesenteric Doppler studies: the portal vein should be investigated at the intrahepatic measure point. Pathophysiological studies should refrain from velocity parameters except in the case of larger vessels running in a straight course towards the probe. © Georg Thieme Verlag KG Stuttgart · New York.
The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recommends that ultrasound should be used systematically as an easy accessible and instructive educational tool in the curriculum of modern medical schools. Medical students should acquire theoretical knowledge of the modality and hands-on training should be implemented and adhere to evidence-based principles. In this paper we summarise EFSUMB policy statements on medical student education in ultrasound. © Georg Thieme Verlag KG Stuttgart · New York.