US of Gastrointestinal Tract Disease

Published Online:

The US appearances of normal and abnormal bowel are discussed, with emphasis on a variety of benign and malignant pathologic conditions and potential errors at imaging interpretation.

The potential use of ultrasonography (US) in evaluating gut disease has been underappreciated in most diagnostic imaging departments in North America. The impression that US has a questionable role in bowel assessment is related to the operator-dependent nature of the modality, the technical challenges of performing bowel US examinations, and the lack of familiarity of radiologists and technologists with the US appearances of normal and abnormal bowel. However, with development of technical experience by the sonographer and integration of a clinical focus at patient evaluation, US can become a powerful tool for bowel assessment. Unlike computed tomography and magnetic resonance imaging, it provides a widely available, noninvasive, inexpensive method for evaluating the gut without the use of ionizing radiation. These factors are of particular importance in young patients and those who require recurrent follow-up imaging. Because US is performed with real-time imaging, the modality also allows the sonographer to view and assess the motility properties of the bowel, a feature that has not been previously used to its full potential. Color Doppler US can yield useful information about mural vascularity in bowel disease when used in conjunction with gray-scale findings and clinical symptoms. Radiologists should be familiar with the static and dynamic US appearances of the normal and abnormal bowel, recognize features of various pathologic conditions, and understand potential errors at imaging interpretation. Online supplemental material is available for this article.

©RSNA, 2015


  • 1. Brenner DJ, Hall EJ. Computed tomography: an increasing source of radiation exposure. N Engl J Med 2007;357(22):2277–2284.
 Crossref, MedlineGoogle Scholar
  • 2. Gaitini D, Kreitenberg AJ, Fischer D, Maza I, Chowers Y. Color-coded duplex sonography compared to multidetector computed tomography for the diagnosis of Crohn disease relapse and complications. J Ultrasound Med 2011;30(12):1691–1699. Crossref, MedlineGoogle Scholar
  • 3. Peloquin JM, Pardi DS, Sandborn WJ, et al. Diagnostic ionizing radiation exposure in a population-based cohort of patients with inflammatory bowel disease. Am J Gastroenterol 2008;103(8):2015–2022. Crossref, MedlineGoogle Scholar
  • 4. Dinter DJ, Chakraborty A, Brade J, et al. Endoscopy and magnetic resonance imaging in patients with Crohn’s disease: a retrospective single-centre comparative study. Scand J Gastroenterol 2008;43(2):207–216. Crossref, MedlineGoogle Scholar
  • 5. Novak KL, Wilson SR. Sonography for surveillance of patients with Crohn disease. J Ultrasound Med 2012;31(8):1147–1152. Crossref, MedlineGoogle Scholar
  • 6. Fleischer AC, Muhletaler CA, James AE Jr. Sonographic assessment of the bowel wall. AJR Am J Roentgenol 1981;136(5):887–891. Crossref, MedlineGoogle Scholar
  • 7. Rapaccini GL, Aliotta A, Pompili M, et al. Gastric wall thickness in normal and neoplastic subjects: a prospective study performed by abdominal ultrasound. Gastrointest Radiol 1988;13(3):197–199. Crossref, MedlineGoogle Scholar
  • 8. Ledermann HP, Börner N, Strunk H, Bongartz G, Zollikofer C, Stuckmann G. Bowel wall thickening on transabdominal sonography. AJR Am J Roentgenol 2000;174(1):107–117. Crossref, MedlineGoogle Scholar
  • 9. Huizinga JD, Lammers WJ. Gut peristalsis is governed by a multitude of cooperating mechanisms. Am J Physiol Gastrointest Liver Physiol 2009;296(1):G1–G8. Crossref, MedlineGoogle Scholar
  • 10. Sarna SK. Colonic motility: from bench side to bedside. San Rafael, Calif: Morgan & Claypool Life Sciences, 2010. Google Scholar
  • 11. Spiller RC. Small intestinal motility. Curr Opin Gastroenterol 1990;6(2):298–304. CrossrefGoogle Scholar
  • 12. Allgayer H, Braden B, Dietrich CF. Transabdominal ultrasound in inflammatory bowel disease: conventional and recently developed techniques—update. Med Ultrasound 2011;13(4):302–313. Google Scholar
  • 13. Shirahama M, Ishibashi H, Onohara S, Dohmen K, Miyamoto Y. Colour Doppler ultrasound for the evaluation of bowel wall thickening. Br J Radiol 1999;72(864):1164–1169. Crossref, MedlineGoogle Scholar
  • 14. Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology 1986;158(2):355–360. LinkGoogle Scholar
  • 15. Chang TS, Böhm-Vélez M, Mendelson EB. Nongynecologic applications of transvaginal sonography. AJR Am J Roentgenol 1993;160(1):87–93. Crossref, MedlineGoogle Scholar
  • 16. Damani N, Wilson SR. Nongynecologic applications of transvaginal US. RadioGraphics 1999;19(Spec No):S179–S200; quiz S265–S266. LinkGoogle Scholar
  • 17. Fraquelli M, Colli A, Casazza G, et al. Role of US in detection of Crohn disease: meta-analysis. Radiology 2005;236(1):95–101. LinkGoogle Scholar
  • 18. Lim JH, Ko YT, Lee DH, Lim JW, Kim TH. Sonography of inflammatory bowel disease: findings and value in differential diagnosis. AJR Am J Roentgenol 1994;163(2):343–347. Crossref, MedlineGoogle Scholar
  • 19. Olivier I, Théodorou V, Valet P, et al. Is Crohn’s creeping fat an adipose tissue? Inflamm Bowel Dis 2011;17(3): 747–757. Crossref, MedlineGoogle Scholar
  • 20. Hata J, Haruma K, Yamanaka H, et al. Ultrasonographic evaluation of the bowel wall in inflammatory bowel disease: comparison of in vivo and in vitro studies. Abdom Imaging 1994;19(5):395–399. Crossref, MedlineGoogle Scholar
  • 21. Maconi G, Radice E, Greco S, Bianchi Porro G. Bowel ultrasound in Crohn’s disease. Best Pract Res Clin Gastroenterol 2006;20(1):93–112. Crossref, MedlineGoogle Scholar
  • 22. Futagami Y, Haruma K, Hata J, et al. Development and validation of an ultrasonographic activity index of Crohn’s disease. Eur J Gastroenterol Hepatol 1999;11(9): 1007–1012. Crossref, MedlineGoogle Scholar
  • 23. Maconi G, Carsana L, Fociani P, et al. Small bowel stenosis in Crohn’s disease: clinical, biochemical and ultrasonographic evaluation of histological features. Aliment Pharmacol Ther 2003;18(7):749–756. Crossref, MedlineGoogle Scholar
  • 24. Drews BH, Barth TFE, Hänle MM, et al. Comparison of sonographically measured bowel wall vascularity, histology, and disease activity in Crohn’s disease. Eur Radiol 2009;19(6):1379–1386. Crossref, MedlineGoogle Scholar
  • 25. Neye H, Voderholzer W, Rickes S, Weber J, Wermke W, Lochs H. Evaluation of criteria for the activity of Crohn’s disease by power Doppler sonography. Dig Dis 2004; 22(1):67–72. Crossref, MedlineGoogle Scholar
  • 26. Ripollés T, Martínez MJ, Barrachina MM. Crohn’s disease and color Doppler sonography: response to treatment and its relationship with long-term prognosis. J Clin Ultrasound 2008;36(5):267–272. Crossref, MedlineGoogle Scholar
  • 27. Ohlsson B, Veress B, Lindgren S, Sundkvist G. Enteric ganglioneuritis and abnormal interstitial cells of Cajal: features of inflammatory bowel disease. Inflamm Bowel Dis 2007;13(6):721–726. Crossref, MedlineGoogle Scholar
  • 28. Jones MP, Bratten JR. Small intestinal motility. Curr Opin Gastroenterol 2008;24(2):164–172. Crossref, MedlineGoogle Scholar
  • 29. Maconi G, Sampietro GM, Ardizzone S, et al. Ultrasonographic detection of toxic megacolon in inflammatory bowel diseases. Dig Dis Sci 2004;49(1):138–142. Crossref, MedlineGoogle Scholar
  • 30. Dietrich CF, Braden B. Sonographic assessments of gastrointestinal and biliary functions. Best Pract Res Clin Gastroenterol 2009;23(3):353–367. Crossref, MedlineGoogle Scholar
  • 31. Ko YT, Lim JH, Lee DH, Lee HW, Lim JW. Small bowel obstruction: sonographic evaluation. Radiology 1993;188(3):649–653. LinkGoogle Scholar
  • 32. Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med 1998;338(21):1521–1526. Crossref, MedlineGoogle Scholar
  • 33. Vijayaraghavan SB. High-resolution sonographic spectrum of diverticulosis, diverticulitis, and their complications. J Ultrasound Med 2006;25(1):75–85. Crossref, MedlineGoogle Scholar
  • 34. Puylaert JBCM. Ultrasound of colon diverticulitis. Dig Dis 2012;30(1):56–59. Crossref, MedlineGoogle Scholar
  • 35. Pawel BR, de Chadarévian JP, Franco ME. The pathology of fibrosing colonopathy of cystic fibrosis: a study of 12 cases and review of the literature. Hum Pathol 1997; 28(4):395–399. Crossref, MedlineGoogle Scholar
  • 36. Verbanck J, Lambrecht S, Rutgeerts L, et al. Can sonography diagnose acute colonic diverticulitis in patients with acute intestinal inflammation? A prospective study. J Clin Ultrasound 1989;17(9):661–666. Crossref, MedlineGoogle Scholar
  • 37. Schwerk WB, Schwarz S, Rothmund M. Sonography in acute colonic diverticulitis: a prospective study. Dis Colon Rectum 1992;35(11):1077–1084. Crossref, MedlineGoogle Scholar
  • 38. Valentino M, Serra C, Ansaloni L, Mantovani G, Pavlica P, Barozzi L. Sonographic features of acute colonic diverticulitis. J Clin Ultrasound 2009;37(8):457–463. Crossref, MedlineGoogle Scholar
  • 39. Snyder MJ. Imaging of colonic diverticular disease. Clin Colon Rectal Surg 2004;17(3):155–162. Crossref, MedlineGoogle Scholar
  • 40. Lee TG, Brickman FE, Avecilla LS. Ultrasound diagnosis of intramural intestinal hematoma. J Clin Ultrasound 1977;5(6):423–424. Crossref, MedlineGoogle Scholar
  • 41. Frisoli JK, Desser TS, Jeffrey RB. Thickened submucosal layer: a sonographic sign of acute gastrointestinal abnormality representing submucosal edema or hemorrhage. AJR Am J Roentgenol 2000;175(6):1595–1599. Crossref, MedlineGoogle Scholar
  • 42. Rauh P, Uhle C, Ensberg D, et al. Sonographic characteristics of intramural bowel hematoma. J Clin Ultrasound 2008;36(6):367–368. Crossref, MedlineGoogle Scholar
  • 43. Ripollés T, Simó L, Martínez-Pérez MJ, Pastor MR, Igual A, López A. Sonographic findings in ischemic colitis in 58 patients. AJR Am J Roentgenol 2005;184(3):777–785. Crossref, MedlineGoogle Scholar
  • 44. Danse EM, Van Beers BE, Jamart J, et al. Prognosis of ischemic colitis: comparison of color Doppler sonography with early clinical and laboratory findings. AJR Am J Roentgenol 2000;175(4):1151–1154. Crossref, MedlineGoogle Scholar
  • 45. Taourel P, Aufort S, Merigeaud S, Doyon FC, Hoquet MD, Delabrousse E. Imaging of ischemic colitis. Radiol Clin North Am 2008;46(5):909–924, vi. Crossref, MedlineGoogle Scholar
  • 46. Marinis A, Yiallourou A, Samanides L, et al. Intussusception of the bowel in adults: a review. World J Gastroenterol 2009;15(4):407–411. Crossref, MedlineGoogle Scholar
  • 47. Marinis A, Yiallourou A, Samanides L, et al. Intussusception of the bowel in adults: a review. World J Gastroenterol 2009;15(14):407–411. Crossref, MedlineGoogle Scholar
  • 48. Alessi V, Salerno G. The “hay-fork” sign in the ultrasonographic diagnosis of intussusception. Gastrointest Radiol 1985;10(2):177–179. Crossref, MedlineGoogle Scholar
  • 49. Paster SB, Brogdon BG. Roentgenographic diagnosis of pneumoperitoneum. JAMA 1976;235(12):1264–1267. Crossref, MedlineGoogle Scholar
  • 50. Muradali D, Wilson S, Burns PN, Shapiro H, Hope-Simpson D. A specific sign of pneumoperitoneum on sonography: enhancement of the peritoneal stripe. AJR Am J Roentgenol 1999;173(5):1257–1262. Crossref, MedlineGoogle Scholar
  • 51. Moriwaki Y, Sugiyama M, Toyoda H, et al. Ultrasonography for the diagnosis of intraperitoneal free air in chest-abdominal-pelvic blunt trauma and critical acute abdominal pain. Arch Surg 2009;144(2):137–141; discussion 142. Crossref, MedlineGoogle Scholar
  • 52. Wilson SR, Burns PN, Wilkinson LM, Simpson DH, Muradali D. Gas at abdominal US: appearance, relevance, and analysis of artifacts. Radiology 1999;210(1):113–123. LinkGoogle Scholar
  • 53. Yoo CC, Levine MS, McLarney JK, Rubesin SE, Herlinger H. Value of barium studies for predicting primary versus secondary non-Hodgkin’s gastrointestinal lymphoma. Abdom Imaging 2000;25(4):368–372. Crossref, MedlineGoogle Scholar
  • 54. Goerg C, Schwerk WB, Goerg K. Gastrointestinal lymphoma: sonographic findings in 54 patients. AJR Am J Roentgenol 1990;155(4):795–798. Crossref, MedlineGoogle Scholar
  • 55. Stuckmann G, Zollikofer C. Gastrointestinal lymphomas: ultrasonic aspects [in German]. Schweiz Med Wochenschr 1996;126(19):813–818. MedlineGoogle Scholar
  • 56. Lim JH. Colorectal cancer: sonographic findings. AJR Am J Roentgenol 1996;167(1):45–47. Crossref, MedlineGoogle Scholar
  • 57. Rioux M, Langis P, Naud F. Sonographic appearance of primary small bowel carcinoid tumor. Abdom Imaging 1995;20(1):37–43. Crossref, MedlineGoogle Scholar
  • 58. Kothari MS, Kosmoliaptsis V, Meyrick-Thomas J. Small bowel gastrointestinal stromal tumors can physiologically alter gut motility before causing mechanical obstruction. Int Semin Surg Oncol 2005;2:24. Crossref, MedlineGoogle Scholar
  • 59. Chourmouzi D, Sinakos E, Papalavrentios L, Akriviadis E, Drevelegas A. Gastrointestinal stromal tumors: a pictorial review. J Gastrointestin Liver Dis 2009;18(3):379–383. MedlineGoogle Scholar
  • 60. Kaftori JK, Aharon M, Kleinhaus U. Sonographic features of gastrointestinal leiomyosarcoma. J Clin Ultrasound 1981;9(1):11–15. Crossref, MedlineGoogle Scholar

Article History

Received: Apr 13 2013
Revision requested: July 23 2013
Revision received: Apr 7 2014
Accepted: May 27 2014
Published online: Jan 15 2015
Published in print: Jan 2015