WJ R

World Journal of
Radiology
World J Radiol 2016 July 28; 8(7): 656-667
ISSN 1949-8470 (online)

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DOI: 10.4329/wjr.v8.i7.656

2016 Baishideng Publishing Group Inc. All rights reserved.

REVIEW

Abdominal ultrasonography of the pediatric gastrointestinal

tract
Heather I Gale, Michael S Gee, Sjirk J Westra, Katherine Nimkin
evaluation of pediatric gastrointestinal pathology; it
can provide real-time evaluation of the bowel without
the need for sedation or intravenous contrast. Recent
improvements in ultrasound technique can be utilized
to improve detection of bowel pathology in children:
Higher resolution probes, color Doppler, harmonic and
panoramic imaging are excellent tools in this setting.
Graded compression and cine clips provide dynamic
information and oral and intravenous contrast agents aid
in detection of bowel wall pathology. Ultrasound of the
bowel in children is typically a targeted exam; common
indications include evaluation for appendicitis, pyloric
stenosis and intussusception. Bowel abnormalities that
are detected prenatally can be evaluated after birth
with ultrasound. Likewise, acquired conditions such as
bowel hematoma, bowel infections and hernias can
be detected with ultrasound. Rare bowel neoplasms,
vascular disorders and foreign bodies may first be
detected with sonography, as well. At some centers,
comprehensive exams of the gastrointestinal tract are
performed on children with inflammatory bowel disease
and celiac disease to evaluate for disease activity
or to confirm the diagnosis. The goal of this article
is to review up-to-date imaging techniques, normal
sonographic anatomy, and characteristic sonographic
features of common and uncommon disorders affecting
the gastrointestinal tract in children.

Heather I Gale, Michael S Gee, Sjirk J Westra, Katherine

Nimkin, Department of Radiology, Division of Pediatric Radio
logy, Massachusetts General Hospital, Boston, MA 02114, United
States
Author contributions: All authors equally contributed to this
paper with conception and design of the study, literature review
and analysis, drafting and critical revision and editing, and final
approval of the final version.
Conflict-of-interest statement: No potential conflicts of
interest.
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
Manuscript source: Invited manuscript
Correspondence to: Katherine Nimkin, MD, Department
of Radiology, Division of Pediatric Radiology, Massachusetts
General Hospital, 55 Fruit Street, Ellison 237, Boston, MA
02114, United States. knimkin@partners.org
Telephone: +1-617-7244207
Fax: +1-617-7268360

Key words: Ultrasound; Pediatric; Gastrointestinal tract;

Bowel; Enteritis

Received: January 22, 2016

Peer-review started: January 23, 2016
First decision: March 24, 2016
Revised: April 11, 2016
Accepted: June 1, 2016
Article in press: June 3, 2016
Published online: July 28, 2016

The Author(s) 2016. Published by Baishideng Publishing

Group Inc. All rights reserved.

Core tip: Ultrasound is increasingly utilized to evaluate

gastrointestinal disorders in children. Recent improvements
in ultrasound technique allow detailed evaluation of bowel
pathology. We present a comprehensive review of bowel
pathology in children with emphasis on ultrasonographic
technique and findings. This review will describe the
variety of sonographic techniques available to optimize

Abstract
Ultrasound is an invaluable imaging modality in the

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Gale HI et al . Ultrasonography of the pediatric gastrointestinal tract

assessment of bowel disease and sonographic features of

normal bowel will be described. Common and uncommon
disorders of bowel in children will include congenital,
acquired, inflammatory and neoplastic processes.
Gale HI, Gee MS, Westra SJ, Nimkin K. Abdominal ultrasono
graphy of the pediatric gastrointestinal tract. World J Radiol
2016; 8(7): 656-667 Available from: URL: http://www.wjgnet.
com/1949-8470/full/v8/i7/656.htm DOI: http://dx.doi.org/10.4329/
wjr.v8.i7.656

12345

Figure 1 Normal small bowel. Ultrasound image of small bowel obtained

after ingestion of water, using high-resolution linear probe. Five wall layers
include: 1-mucosal interface with lumen (hyperechoic), 2-mucosa (hypoechoic),
3-submucosa (hyperechoic), 4-muscularis (hypoechoic), and 5-serosa
(hyperechoic).

INTRODUCTION
Ultrasound is an ideal imaging modality in the pediatric
population because it is a real-time, non-invasive,
relatively low cost examination without ionizing radiation
that requires no sedation. Several recent reviews have
emphasized the utility of ultrasound in the evaluation
[1-3]
of pediatric bowel pathology
. Ultrasound of the
bowel in children is typically a targeted examination,
designed to answer a specific question, and common
indications include evaluation for appendicitis, intus
susception, and pyloric stenosis. Other focused exami
nations include evaluation of congenital abnormalities
detected prenatally, confirmation of suspected hernia,
and problem solving in the patient with necrotizing
enterocolitis (NEC). Unsuspected bowel abnormalities
may be found during screening for non-specific
abdominal pain, including foreign body, tumor, infection,
or bowel hematoma. A more comprehensive exami
nation of the entire bowel is used at some centers to
evaluate inflammatory bowel disease (IBD) and celiac
disease in children.

applications in the assessment of bowel wall edema

[8]
and/or fibrosis, particularly in IBD .

NORMAL ANATOMY
Normal bowel loops have a stratified pattern on highresolution ultrasound with the following 5 layers:
Mucosal interface with lumen (hyperechoic), mucosa
(hypoechoic), submucosa (hyperechoic), muscularis
(hypoechoic) and serosa (hyperechoic) (Figure
1). Typically, however, only 2 layers are visible on
ultrasound, including an inner hyperechoic layer and
outer hypoechoic layer. In normal children, small bowel
loops are compressible, show minimal vascularity, and
[9]
have wall thickness < 2.5 mm . Jejunal loops have
more folds and peristalse more than ileum, and the
colon contains more air, fewer folds, and wall thickness
[9]
is < 2 mm .

IMAGING TECHNIQUE
SPECTRUM OF PEDIATRIC
GASTROINTESTINAL DISORDERS

Ultrasound examinations are typically performed with

the patient supine without any preparation. Recent
improvements in ultrasound technology, including highresolution linear probes (12-15 MHz) and harmonic and
[3,4]
panoramic imaging, improve image quality . Color
Doppler evaluation can detect increased perfusion in
inflamed loops of bowel. Ultrasound cine clips document
bowel motility, and graded compression assesses
compressibility and improves resolution by displacing
air from the bowel lumen. Oral administration of noncarbonated fluid 30 min prior to the examination will
[4]
reduce air in the bowel . Other promising newer
techniques include oral contrast agents, such as isoosmolar polyethylene glycol (PEG), to improve bowel
distension, referred to as small-intestine contrast
[5]
enhanced ultrasound . Intravenous contrast agents are
not approved for children but are increasingly utilized
[4,6]
off-label, particularly in pediatric patients with IBD .
The pattern of contrast enhancement has been useful
to assess disease activity and adjacent inflammatory
[7]
changes . Lastly, bowel elastography may have

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Congenital abnormalities

Intestinal malrotation: Intestinal malrotation occurs

when the midgut does not undergo its expected rotation
around the axis of the superior mesenteric artery
[10]
during fetal development . Symptoms of malrotation
are most commonly caused by volvulus or obstructing
peritoneal bands, which typically manifest during the
[10]
first year of life . Ultrasound may be performed in
the vomiting infant to evaluate for pyloric stenosis and
malrotation may be an unexpected finding (Figure 2).
On ultrasound, there is usually reversal of the position
of the superior mesenteric artery (SMA) and superior
mesenteric vein (SMV). When volvulus is present,
transverse sonographic images show dilated fluidfilled duodenum with alternating rings of low and high
echogenicity at the base of the mesentery (concentric
[11]
circle sign) . Color Doppler ultrasound can reveal a
spiral appearance of the mesenteric vessels, termed

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Gale HI et al . Ultrasonography of the pediatric gastrointestinal tract

Figure 2 Congenital bowel abnormalities. A, B: Malrotation. Unsuspected finding in an 8-wk-old vomiting infant being evaluated for pyloric stenosis. Transverse
midline images show alternating rings of high and low echogenicity with whirlpool sign on grayscale (A) and color Doppler (B) images (arrowheads); C: Gastric
duplication cyst. Five-year-old girl with enteric duplication cyst near the gastroesophageal junction detected prenatally (not shown). A second cyst was noted
incidentally in the anterior wall of the stomach on subsequent imaging. The cyst demonstrates bowel signature (2 layers), and shares its hypoechoic, muscularis
propria layer with the anterior gastric wall (arrowheads); D, E: Meckel diverticulum. Four-year-old with abdominal pain. Ultrasound shows a cyst with bowel signature (D).
Computed tomography abdomen is shown for correlation (E, arrow); F, G: Rectourinary fistula with enteroliths. Newborn with abdominal calcifications on radiograph (F,
arrows); confirmed to be enteroliths on ultrasound (G, arrows). The fistula was later confirmed with contrast enema (not shown).
[10,11]

[15-17]

cation, and may contain ectopic pancreatic tissue

.
Complications include ulceration, hemorrhage, perfora
[15]
tion, and inflammation .
On ultrasound, gastrointestinal duplication cysts are
fluid-filled structures, typically with a central anechoic
[15]
component . The mucosal and submuscosal layers
are echogenic, and the shared muscularis layer is
[15,17]
hypoechoic
(Figure 2C). Rarely, other abdominal
cysts may have a pseudo gut signature, including
mesenteric cysts and teratomas; high-resolution
transducers should delineate multiple bowel wall layers
[18,19]
in true duplication cysts
. Further characterization
can be performed with Tc-99m nuclear scintigraphy,

the whirlpool sign

. There may be dilatation of
[12]
the distal SMV . Some authors advocate ultrasound
rd
evaluation of the 3 portion of the duodenum to confirm
its location behind the SMA to exclude malrotation,
[13]
however, this has not found general application .
Gastrointestinal duplication cyst: Gastrointestinal
duplication cyst is an additional segment of fetal gut
that can occur from the esophagus to the rectum, most
[14-17]
commonly at the terminal ileum
. Gastrointestinal
duplication cysts demonstrate a connection with the
gastrointestinal (GI) tract by a common wall of serous
and muscle membrane, usually without luminal communi

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Gale HI et al . Ultrasonography of the pediatric gastrointestinal tract

[15]

which targets parietal cells in gastric mucosa

cyst, juvenile polyp, and lymphoma (Figure 3A). Ileoileocolic intussusception is associated with decreased
[27]
reduction rate and increased morbidity .
It is critical to differentiate ileocolic intussusception
from small bowel-small bowel intussusception, as the
latter are typically managed conservatively and air
reduction is not indicated. A recent review noted that
larger intussusception diameter and the presence of
lymph nodes within the intussusception favored ileocolic
[28]
intussusception . In one review, mean AP diameter
of ileocolic intussusception was 2.53 cm compared to
[29]
1.38 cm of small bowel intussusception . Small bowel
intussusceptions have very little fat centrally and occur
in older children with bowel disorders such as HenochSchonlein Purpura, Crohn disease, and celiac sprue;
they are also seen in post-operative patients and in
patients with small bowel mass acting as a lead point.
Small bowel intussusception length greater than 3.5 cm
[30]
is a strong predictor of need for surgical intervention .
However, most small bowel intussusceptions are
[31]
idiopathic and transient .

Meckel diverticulum: Meckel diverticulum is the

most common malformation of the small bowel, which
results from partial or complete failure of involution of
[10]
the omphalomesenteric duct . It is a true diverticulum
that contains all layers of the intestinal wall, and it may
[10]
contain heterotopic gastric and pancreatic mucosa
(Figure 2). It is seen in 0.3%-3% of the population,
and approximately 2%-4% of affected patients become
[10]
symptomatic . Complications include bleeding, small
bowel obstruction, inflammation (Meckel diverticulitis),
[10]
and neoplasm . Sonographic imaging findings are
reflective of the specific complication, and can include
wall thickening, intussusception, and associated
[10]
mass . A surrounding hyperemic and echogenic layer
[20]
is suggestive of associated perforation .
Annular pancreas: Annular pancreas is a rare con
genital abnormality that can present in childhood with
[21]
duodenal obstruction or pancreatitis . In the vomiting
nd
infant, ultrasound may show narrowing of the 2 portion
of the duodenum, with a surrounding ring of pancreatic
tissue. The anomalous branch of the pancreatic duct
may be seen on ultrasound coursing obliquely and to the
[21,22]
right, anterior to the duodenum
.

Hypertrophic pyloric stenosis: Hypertrophic pyloric

stenosis (HPS) is an idiopathic cause of gastric outlet
nd
obstruction, which typically occurs during the 2 to
th
7 week of life and is more common in boys than
[1,32,33]
girls
. Ultrasound is performed in supine and right
lateral decubitus positions with a high-frequency lineararray transducer (12-5 MHz). If sufficient fluid is not
present within the stomach to outline the antrum and
pylorus, 1-2 ounces of sugar water can be given orally.
Axial sonographic images demonstrate the donut
sign, characterized by a rim of thickened muscle and
[32]
an echogenic center of mucosa and submucosa .
In longitudinal plane, the pylorus remains closed and
[32,34]
no fluid passes into the duodenum
. The mucosa
can protrude into the distended distal gastric antrum,
[32,34]
creating the nipple sign
.
Current guidelines for ultrasound diagnosis of HPS
are pyloric muscle thickness > 3 mm, pyloric length >
15 mm, pyloric diameter > 11 mm, and pyloric volume
[1,35]
> 12 mL
. Patient age and weight correlate with
pyloric muscle wall thickness, and a lower ultrasound
threshold for diagnosis should be used in smaller
[36,37]
neonates
. Imaging the pylorus over time allows the
differentiation of HPS and pylorospasm, the latter being
[3]
a transient phenomenon . Follow-up can be utilized in
[3]
equivocal cases .

Rectourinary fistula: Rectovesical or rectourethral

fistula typically occurs in patients with an anorectal
[23,24]
malformation such as imperforate anus
. Neonates
with rectourinary fistula may develop enterolithiasis due
[23,24]
to mixing of meconium and urine
. Enterolithiasis
appears as calcifications on radiographs, and can be
further evaluated with high-frequency, high-resolution
real time ultrasound to confirm intraluminal location
[24]
and distinguish this entity from meconium peritonitis
(Figure 2). Enterolithiasis can also be seen in other
cases of intestinal obstruction such as ileal stenosis,
jejunal atresia, and functional obstruction of the ile
[23,24]
um
. Transperineal ultrasonography can also be
performed in patients with anal atresia to identify the
[25]
internal fistula .

Acquired disorders

Intussusception: Intussusception is the most com

mon cause of bowel obstruction in children, and it
typically occurs between ages 6 mo and 2 years.
The most common type is ileocolic, and most cases
are idiopathic. Ultrasound is critical for a prompt and
accurate diagnosis of intussusception, and has nearly
[26]
100% sensitivity for detection . Imaging features
of intussusception are characteristic, described as
the pseudokidney or donut sign, with alternating
hyperechoic and hypoechoic concentric layers. Fluid
trapped between layers of the intussusception and
absence of color flow may reflect decreased likelihood
of reduction and bowel ischemia. Lead points are
typically seen in older children and may be detected by
ultrasound, including Meckel diverticulum, duplication

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Inguinal hernia: Ultrasound is 95.5% accurate for

[38]
detecting inguinal hernias in boys . The internal
ring is measured at rest and with straining (standing,
[38]
crying, coughing, or bearing down) . In boys of any
age, inguinal canal diameter > 4 mm at the internal
ring (width of the spermatic cord) is 95% accurate in
[39,40]
diagnosing inguinal hernia at surgery
. Fluid in the
processus vaginalis or bowel loops/other peritoneal
structures within the inguinal canal are also diagnostic
[39,41]
of hernia
. Contralateral hernias occur in up to

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Figure 3 Acquired bowel disorders. A: Ileocolic intussusception with Meckel diverticulum as lead point. Six-month-old with small bowel obstruction on radiograph
(not shown) and intussusception (arrow) demonstrated on ultrasound with lead point (arrowheads); B: Incarcerated inguinal hernia. Two-year-old boy with abdominal
pain and left groin mass. Sagittal image of the left inguinal region show a cystic structure that did not clearly communicate with abdominal bowel loops (B, arrows;
T = testicle). Testicular edema was also noted (not shown); C, D: Duodenal hematoma secondary to child abuse. One-year-old with abdominal pain and distension.
Sagittal midline ultrasound image shows a complex mass in the expected location of the duodenum (C, arrowheads). Upper gastrointestinal series confirmed duodenal
narrowing (D, arrows). Abuse was later confirmed.

22.4% of patients, and bilateral ultrasonography can

[42]
guide pre-operative planning .
Indirect hernias, the most common type of inguinal
hernia in children, occur superolateral to the epigastric
vessels, direct hernias occur inferomedial to the
epigastric vessels, and femoral hernias occur below the
[38,43]
inguinal ligament
. In the case of herniated bowel
loops, ultrasound is used to assess bowel peristalsis,
wall thickness, and vascularity. Incarcerated hernias
may not show clear continuity with abdominal bowel
loops (Figure 3B). Inguinal hernias can compress
gonadal vessels and cause testicular hypovascularity
[44]
and enlargement on ultrasound .

passage of gastric contents detected on ultrasound can

[47,48]
be correlated temporally with symptoms
. It can be
helpful to detect GERD in an infant with suspected HPS
and a normal pylorus. A short intra-abdominal segment
of esophagus and/or a wide esophageal angle have
[48,49]
been shown to be associated with reflux
.
Duodenal intramural hematoma: Duodenal hema
tomas in children are typically post-traumatic. If there
is no history of trauma, there is a high association with
child abuse and additional imaging is warranted (Figure
3). Hematomas may also result from endoscopic
biopsy of the duodenum or in children with bleeding
[50-52]
disorders
. Once identified, the hematoma can
persist for at least two weeks, typically resolving by 6
wk. On ultrasound, duodenal intramural hematomas
appear as a heterogeneous, nonvascularized mass
along the course of the duodenum, which can obstruct
[50-52]
the duodenal lumen and/or the common bile duct
.
During resolution, the hematoma becomes cystic.
Differential diagnostic considerations include duodenal
duplication, abscess, pancreatic pseudocyst, or tumor.
Ultrasound is also useful for serial follow-up to docu
ment either resolution or worsening obstruction requir
ing intervention.

Hiatal hernia and gastroesophageal reflux disease:

To evaluate for hiatal hernia and gastroesophageal
reflux disease (GERD) with ultrasound, the transducer
is placed inferior to the xiphoid process in sagittal plane
and directed cranially. The diameter of the esophageal
hiatus is measured in transverse plane using the liver
[45]
as an acoustic window . Esophageal hiatal diameters
have been shown to be greater in patients with hiatal
[45]
hernias compared to control subjects . Absence of
paraesophageal fat may be a more reliable indicator
than hiatal widening because it is not affected by age,
[46]
obesity, or BMI .
Although ultrasound is not recommended for eva
luation of GERD, it can be used in cases of unusual
posturing or aspiration, because episodes of retrograde

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Infectious and inflammatory disorders

Appendicitis: Appendicitis is one of the most common

surgical emergencies in children, and delay in diagnosis

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Gale HI et al . Ultrasonography of the pediatric gastrointestinal tract

can result in morbidity from an associated complication
[53,54]
such as appendiceal rupture or bowel obstruction
.
Non-operative management of acute uncomplicated
[55,56]
appendicitis in children is also used in select cases
.
Symptoms of acute appendicitis are variable and can
include periumbilical and/or right lower quadrant pain,
[54,57]
anorexia, nausea, fever, and leukocytosis
.
Ultrasound is the first imaging choice for suspected
[53,57]
appendicitis at most centers
. Both grayscale and
color Doppler imaging are utilized with 5-MHz curved,
[58]
9-MHz linear, or 15-MHz linear transducers . Ultra
sound is 88% sensitive and 94% specific for the
[59]
diagnosis of acute appendicitis . Diagnostic criteria
for appendicitis include appendiceal diameter > 6 mm
(outer wall to outer wall) and associated evidence of
inflammation including appendiceal non-compressibility,
wall thickening > 2 mm or hyperemia, fluid-filled
appendix, increased echogenicity of periappendiceal fat,
[58]
and/or presence of periappendiceal fluid . Ultrasound
diagnosis of perforated appendicitis is made by the
presence of marked inflammatory changes in the
right lower quadrant with or without visualization of
the appendix, an appendicolith without visualization of
the appendix, echogenic free fluid, or a fluid collection
[58]
indicating peritonitis or abscess .
Equivocal findings on ultrasound are associated
[58,59]
with surgical appendicitis in 12.5%-50% of cases
.
Increasing the size threshold to 7.5-8 mm in equivocal
cases has been shown to increase specificity and
[58,60]
accuracy
. Children at low risk for appendicitis with
equivocal ultrasound findings are amenable to obser
[59]
vation and reassessment . When the patients white
9
blood cell count is < 11.0 10 /L, a non-diagnostic
ultrasound or non-visualized appendix on ultrasound are
associated with negative predictive values of 95.59%
[61]
and 96.99%, respectively .

for ascites and fluid collections, and the portal venous

system is evaluated for gas (Figure 4). Small amounts
of free air may be more easily seen with ultrasound
[66]
than with radiography . In one recent review, poor
outcome was associated with dilated and fluid-filled
bowel, echogenic free fluid, focal fluid collections,
increased bowel wall echogenicity, and increased bowel
[66]
wall thickness . Free intraperitoneal air and focal fluid
[64]
collection predicted poor outcome in another series .
Infectious enteritis/typhlitis: Bacterial enterocolitis
may be caused by a variety of pathogens, including
Salmonella, Shigella, E. Coli and Campylobacter.
Ultrasound findings include bowel wall thickening,
hyperechogenicity, and hyperemia, usually in the terminal
[67]
ileum and cecum (Figure 4C). Adjacent lymph nodes,
free fluid, and echogenic mesenteric fat are common.
Viral gastroenteritis usually does not demonstrate bowel
wall thickening, though ascites and enlarged nodes
[67]
may be present . Intestinal tuberculosis may show
bowel wall thickening, typically with associated hepato
splenomegaly and omental thickening; findings may
[68,69]
mimic Crohn disease
. Typhlitis, or inflammation
of the cecum, is more frequently seen in immunocom
promised patients and is characterized by marked
thickening and hypervascularity; increased thickness
[70,71]
of the wall may correlate with a worse prognosis
.
Ascariasis infection can be detected with ultrasound;
worms are mobile, tubular hypoechoic intraluminal
structures with echogenic walls (Figure 4D). Parallel
echogenic line or lines within the worm represent the
[72]
digestive tract .
Allergic gastroenterocolitis: Allergic proctocolitis
from cows milk allergy is the main cause of rectal
[73,74]
bleeding in infants
. It occurs from early exposure
to heterologous proteins such as cows milk or cows milk
proteins derived from maternal breastfeeding. Ultrasound
shows colitis with bowel wall thickening ( 3 mm)
and increased vascularity, especially in the descending
[73]
and sigmoid colon . Increased Doppler vascularity
is measured as 5 or more vessels in the bowel wall
2[73]
in a segment of approximately 2 cm
. The most
pronounced thickening is visualized in the mucosa,
and the highest number of vessels is seen in the
submucosa. In some cases bowel layers are not well
defined. Allergic gastritis may mimic HPS on ultrasound;
in allergic gastritis the mucosal and submucosal layers
are thickened, while in HPS only the muscular layer
[75]
is thickened
(Figure 4). In some patients, allergic
[76]
gastritis and HPS may coexist .

Necrotizing enterocolitis: Necrotizing enterocolitis

(NEC) is a common cause of morbidity and mortality
in premature infants. In NEC, there is bowel necrosis
of unknown etiology; mucosal integrity may be com
promised, leading to pneumatosis and portal venous
[62]
gas . The clinical presentation ranges from feeding
intolerance or abdominal distension to fulminant
[63]
shock and death . Indications for surgery in NEC are
pneumoperitoneum and deterioration with medical
treatment alone. Patients with bowel necrosis may also
benefit from surgery, and ultrasound has been shown
to be 100% sensitive and 95.4% specific identifying
[63]
necrosis .
Radiographs are the primary imaging tool when
evaluating for NEC; ultrasound can be used as a
problem-solving tool in select cases when surgery is
considered. For diagnosis of NEC, ultrasound evaluates
for (1) wall hyperechogenicity (greater than anterior
abdominal wall musculature); (2) wall thickening (
3 mm); (3) wall thinning (< 1 mm); (4) intramural
gas; (5) hypervascularity; (6) hypovascularity; and
[63-66]
(7) aperistalsis
. The peritoneal cavity is evaluated

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Inflammatory bowel disease: Ultrasound has been

found to have a high correlation with MR imaging
[77]
findings in pediatric small bowel Crohn disease .
Ultrasound demonstrates mural thickening with loss of
wall stratification, hyperemia, and decreased peristalsis.
Fluid collections, fistulae, lymph nodes, and mesenteric
[7,9,78]
inflammation can also be seen
(Figure 4). Strictures

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Gale HI et al . Ultrasonography of the pediatric gastrointestinal tract

Figure 4 Infectious and inflammatory bowel disorders. A, B: Necrotizing enterocolitis. Targeted ultrasound of the abdomen in a premature infant shows bowel
wall thickening and echogenic intramural air (A, arrows). This corresponded to an area of pneumatosis on recent radiograph (not shown). Transverse image of the
liver show punctate, echogenic foci in the liver periphery, consistent with portal venous gas; the foci of air are too small to cause posterior artifact (B, arrows); C:
Campylobacter enterocolitis. Ten-year-old with fever and abdominal pain with suspected appendicitis. Sagittal right lower quadrant ultrasound image shows mural
thickening and increased echogenicity in the cecum and ascending colon (arrowheads). Stool cultures confirmed the diagnosis; D: Ascariasis. Two-year-old boy
from Africa with abdominal pain. Ultrasound of the small bowel shows a mobile, hypoechoic, tubular structure with echogenic walls (arrowheads) and central linear
echogenicity (arrow). Worms were later identified in the stool; E, F: Allergic (eosinophilic) gastritis. Ultrasound of the stomach in a 3-mo-old infant with persistent
vomiting shows mural thickening in the antrum with prominent mucosal and submucosal layers (E, arrowheads). Endoscopy confirmed the diagnosis. Ultrasound of
child with pyloric stenosis (F), for comparison, shows thickening primarily of the muscularis layer (arrows); G, H: Crohn disease. Transverse image of the right lower
quadrant in a 15-year-old girl with longstanding Crohn disease shows a thick-walled ileum in cross section (arrow) with a fistula extending posterolaterally (arrowheads),
confirmed with MRI (not shown) (G, arrows). Color Doppler ultrasound image in another patient with Crohn disease demonstrates mural thickening and hyperemia of
the inflamed terminal ileum (H).

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Gale HI et al . Ultrasonography of the pediatric gastrointestinal tract

Figure 5 Burkitt lymphoma. Eight-year-old boy presented with weight

loss and abdominal pain. Abdominal ultrasound showed ileocolic
intussusception with soft tissue mass (M) as a lead point (A). Bilateral
renal masses were also present (not shown). Sagittal reformatted
computed tomography image shows ileocolic intussusception (B,
arrowheads). Diagnosis was confirmed with biopsy.

Figure 6 Henoch Schonlein purpura. Seven-year-old boy with purpuric rash and abdominal pain. Ultrasound image with color Doppler shows thick walled and
hyperemic small bowel loops (A, arrowheads) and small bowel-small bowel intussusception (A, arrow). Computed tomography shows stratified enhancement of thick
walled small bowel with submucosal edema (B, arrowhead).
[83]

may be identified, associated with prestenotic dilatation,

[9]
hyperperistalsis, and fecalization . Small intestine
contrast ultrasonongraphy, using oral administration of
iso-osmolar PEG, improves evaluation of the small bowel
[79]
in patients with Crohn disease . Contrast enhanced
ultrasound using IV administration of microbubble
contrast shows promising results; the pattern of mural
enhancement may aid in assessment of disease activity
[80]
and/or response to therapy . Ultrasound elastography,
a technique that measures tissue stiffness, may help
to differentiate inflammation from fibrosis in Crohn
[77]
disease .
Ultrasound also has a role in evaluating ulcerative
colitis. In children, the sensitivity and specificity of
ultrasound for colonic inflammatory lesions is 88%
[81]
and 93%, respectively . Characteristic features
include colonic and ileal wall thickening ( 3 mm), wall
hypervascularity, loss of haustra coli, altered stratification
of the bowel wall, and enlarged mesenteric lymph
[81]
nodes .

quency transducer for improved bowel detail . Oral

administration of 750 mL isotonic polyethylene glycol can
[83]
improve visualization of bowel walls and fold pattern .
Ultrasound findings include dilated small bowel (> 2.5
cm including the wall), bowel wall thickening ( 3
mm), increased or decreased peristalsis, mesenteric
lymphadenopathy, ascites, reversed jejunoileal fold
pattern (effaced mucosa in the jejunum and thickened
folds in the ileum), and small bowel-small bowel
[82-86]
intussusception
.

Neoplastic disorders

Ultrasound is the preferred study for the initial evalua

tion of suspected abdominal masses to determine the
organ of origin and the characteristics of the mass in
the pediatric population. GI tumors are rare in children,
and benign tumors are more common than malignant
[87]
tumors . Benign lesions include polyps, hemangiomas,
neurofibromas, leiomyomas, gastrointestinal stromal
tumors, lipomas, and neurofibromas. Isolated juvenile
polyp is the most common polyp in children; ultrasound
(US) may demonstrate a hyperemic intraluminal mass
[88]
in the bowel . The most common malignant GI tumor
in children is lymphoma, typically Burkitt lymphoma.
Ultrasound findings are often unsuspected in a child
imaged for non-specific abdominal symptoms and
may show hypoechoic bowel wall thickening, enlarged
mesenteric or retroperitoneal lymph nodes, and

Celiac disease: Celiac disease is an autoimmune mala

[82]
bsorptive enteropathy caused by gluten intolerance .
Ultrasound for celiac disease is performed with 5-2
MHz convex and 12-5 MHz linear transducers in the
[82]
morning after fasting 10 h . All abdominal quadrants
are scanned with the lower frequency transducer
for a preliminary survey followed by the higher fre

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Gale HI et al . Ultrasonography of the pediatric gastrointestinal tract

intussusception (Figure 5).

radiation or need for patient sedation. Ultrasound is the

often the initial modality detecting abnormalities of the
GI tract in children, either as part of a targeted exam
at the site of symptoms or as an incidental finding.
Radiologists interpreting US examinations in children
should be familiar with the sonographic appearance
of both the normal and abnormal GI tract in order
to provide the best care for pediatric patients with
abdominal diseases.

Vascular disorders

Vasculitis: Henoch-Schonlein purpura is the most

common vasculitis in children. It is an immune-mediated
vasculitis affecting multiple organs, and it typically
presents with a palpable purpuric rash and abdominal
pain. The jejunum and ileum are commonly involved;
ultrasound shows small bowel wall thickening that
may reflect hemorrhage, inflammation or infarction.
Transient small bowel-small bowel intussusception,
obstruction, and pneumatosis intestinalis may be
[89]
present
(Figure 6). Bowel wall hyperemia suggests
inflammation, while absent color Doppler flow reflects
[90]
ischemia and potential risk for perforation .

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