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Inaoka et al. Wo m e n ’s I m a g i n g • C l i n i c a l O b s e r v a t i o n s
MRI of Fetal
Gastrointestinal Tract

VIBE MRI for Evaluating the

Normal and Abnormal
W O M E N ’S
IMAGING Gastrointestinal Tract in Fetuses
Tsutomu Inaoka1 OBJECTIVE. The great potential of MRI for assessing gastrointestinal abnormalities in fe-
Hiroyuki Sugimori1 tuses has been described. T1-weighted images may add additional information to T2-weighted
Yoshihito Sasaki2 images in diagnosing fetal gastrointestinal abnormalities. The objective of this study was to as-
Koji Takahashi1 sess the performance of a 3D volumetric interpolated breath-hold sequence (VIBE) in evaluat-
Kazuo Sengoku2 ing the normal and abnormal fetal gastrointestinal tract.
CONCLUSION. VIBE provides high-quality T1-weighted and 3D MR colonography
Nobuhisa Takada1
images for the evaluation of the normal and abnormal gastrointestinal tract in fetuses, and 3D
American Journal of Roentgenology 2007.189:W303-W308.

Tamio Aburano1
MR colonography provides excellent delineation of the meconium.
Inaoka T, Sugimori H, Sasaki Y, et al.
renatal diagnosis of fetal gas- additional information to T2-weighted images

P trointestinal tract malformations,

Keywords: fetus, gastrointestinal tract, meconium, MR
colonography, MRI, obstetrics, pediatrics, volume
interpolated breath-hold imaging, women’s imaging
DOI:10.2214/AJR.07.2063
Received February 17, 2007; accepted after revision
June 24, 2007.
1Department
of Radiology, Asahikawa Medical College,
2-1-1-1 Midorigaoka-Higashi, Asahikawa City, Hokkaido,
078-8510, Japan. Address correspondence to T. Inaoka
(tinaoka@asahikawa-med.ac.jp).
2Department
of Obstetrics and Gynecology, Asahikawa
Medical College, Asahikawa City, Hokkaido, Japan.
WEB
This is a Web exclusive article.
AJR 2007; 189:W303–W308
0361–803X/07/1896–W303
© American Roentgen Ray Society
including bowel dilatation, polyhy-
dramnios, hyperechoic bowel, and
ascites, is commonly made with sonographic
findings. However, these findings are not spe-
cific and may relate to transient normal variants
[1–3]. In addition, sonography has some disad-
vantages, such as operator dependence, low im-
age contrast, and a small field of view [1–3].
Therefore, it is occasionally challenging for ob-
stetric sonographers to assess fetal gastrointes-
tinal abnormalities when accurate recognition
of the bowel condition is required to determine
fetal and neonatal management [1, 2].
The usefulness of fast MRI, including sin-
gle-shot fast spin-echo sequences, for evaluat-
ing fetal abdominal disorders has been re-
ported with increasing frequency. The great
potential of MRI for the assessment of the fetal
gastrointestinal tract has been described; in di-
agnosing abnormal cases, it is important to as-
sess whether meconium is present in the fetal
bowel [2–5]. MRI is more sensitive than
sonography for detecting the presence of
meconium [2]. The location and amounts of
meconium in the fetal bowel depend on gesta-
tional age; however, the accumulation of
meconium may steadily advance from the anal
canal in a normal fetus after 20 weeks’ gestation
[2–6]. Meconium exhibits an intermediate or
low signal intensity on T2-weighted images
and a high signal intensity on T1-weighted im-
ages because of its high protein and mineral
content [2–4]. T1-weighted images may add
in diagnosing fetal gastrointestinal abnormali-
ties because meconium is more apparent on
T1-weighted than on T2-weighted images [5].
Three-dimensional MR images generated
from T1-weighted images, which were ob-
tained using 2D or 3D fast gradient-echo MR
sequences, are useful for 3D understanding in
the diagnosis and monitoring of fetal gas-
trointestinal tract malformations [4, 7]. For
conventional T1-weighted sequences, a 4-mm
or greater section thickness is required to per-
form imaging through the fetus during a lim-
ited acquisition time [2–7]. However, addi-
tional thin sections of 3 mm or less are needed
to better characterize abnormal findings and to
make 3D MR images of sufficient quality be-
cause a mean diameter of the intestine in fe-
tuses after 20 weeks’ gestation is 3 mm or
greater [4, 6, 7]. Conventional sequences are
still limited in temporal resolution for obtain-
ing T1-weighted images of such thin sections
with adequate anatomic coverage for evaluat-
ing fetal gastrointestinal abnormalities.
Recently, a 3D volumetric interpolated
breath-hold sequence (VIBE), which is a
modified fast 3D gradient-echo sequence,
has been applied to T1-weighted images in
clinical body MRI [8–10]. This sequence
may provide isotropic or nearly isotropic
resolution in three dimensions while pre-
serving wide anatomic coverage in a short
acquisition time [8–10]. Motion artifacts are
also reduced by the rapid data acquisition
[10]. Therefore, 3D MR images of high qual-

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Inaoka et al.

TABLE 1: Normal Gastrointestinal Tract Features Having High Signal Intensity in Fetuses 19 Weeks 4 Days’ to 40 Weeks
5 Days’ Gestational Age
Small Intestine Colon
Fetal Age and Imaging Type Stomach Duodenum Proximal Distal Ascending Transverse Descending Sigmoid Rectum
Overall (n = 28)
T2-weighteda 28 (100) 28 (100) 23 (82.1) 19 (67.9) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
T1-weightedb 0 (0) 0 (0) 11 (39.3) 15 (53.6) 26 (92.9) 28 (100) 28 (100) 28 (100) 28 (100)
MR colonographyc 0 (0) 0 (0) 9 (32.1) 12 (42.9) 26 (92.9) 28 (100) 28 (100) 28 (100) 28 (100)
< 32 weeks’ gestation (n = 12)
T2-weighteda 12 (100) 12 (100) 7 (58.3) 6 (50) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
T1-weightedb 0 (0) 0 (0) 5 (41.7) 8 (66.7) 12 (100) 12 (100) 12 (100) 12 (100) 12 (100)
MR colonographyc 0 (0) 0 (0) 3 (25) 5 (41.7) 12 (100) 12 (100) 12 (100) 12 (100) 12 (100)
≥ 32 weeks’ gestation (n = 16)
T2-weighteda 16 (100) 16 (100) 16 (100) 13 (81.3) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
T1-weightedb 0 (0) 0 (0) 6 (37.5) 7 (43.8) 14 (87.5) 16 (100) 16 (100) 16 (100) 16 (100)
MR colonographyc 0 (0) 0 (0) 6 (37.5) 7 (43.8) 14 (87.5) 16 (100) 16 (100) 16 (100) 16 (100)
Note—Data are number (%) of patients.
a HASTE.
American Journal of Roentgenology 2007.189:W303-W308.

b Three-dimensional volumetric interpolated breath-hold fast gradient-echo.

c Three-dimensional.

ity can be available because of the resultant
minimization of partial volume averaging ef-
fects and motion artifacts [8, 10]. We at-
tempted to obtain thin-section T1-weighted
images through the fetus using VIBE and to
generate 3D MR colonography images of the
fetus from the VIBE data sets. The purpose
of this study was to assess the performance
of VIBE in evaluating the normal and abnor-
mal fetal gastrointestinal tract.
Materials and Methods
Subjects
Between June 2004 and September 2006, 45
patients underwent fetal MRI after sonography in
our institute. Fetal MRI was limited to cases in
which complex anomalies were suspected at sec-
ond- or third-trimester fetal sonography screening
or in which the sonography results were equivocal
or undetermined. Before the examination, all sub-
jects were informed about the procedure and the
safety of the technique by obstetricians, and all
provided their informed consent. Of the 45 partic-
ipants, 35 who fulfilled the following inclusion
criteria were enrolled in this retrospective study.
The first criterion was that HASTE T2-weighted
and VIBE T1-weighted images were both ob-
tained through the fetus. The second criterion was
that diagnoses were confirmed after delivery in
our institute. Although there was one twin preg-
nancy, we examined only the indicated fetus.
On the basis of the medical records of postnatal
diagnoses, 28 of the 35 fetuses had a normal gas-
trointestinal tract. The gestational ages of the fe-
tuses with a normal gastrointestinal tract ranged
from 19 weeks 4 days to 40 weeks 5 days (mean, 30
weeks 5 days). These fetuses had other abnormali-
ties: CNS abnormalities (n = 10), urogenital abnor-
malities (n = 7), musculoskeletal abnormalities
(n = 6), and hydrops fetalis (n = 1). Four of those
fetuses had normal findings. The remaining seven
fetuses were confirmed as having gastrointestinal
abnormalities, which included duodenal atresia
(n = 3), congenital diaphragmatic hernia (n = 2),
gastroschisis (n = 1), and ileal atresia with meco-
nium peritonitis (n = 1).
MRI Protocol
MRI was performed on a 1.5-T MR unit (Mag-
netom Sonata, Siemens Medical Solutions) using a
phased-array body coil. In the fetal MR examina-
tions, HASTE T2-weighted sequences (TR/TEeff,
1,100/81; flip angle, 150°; field of view, 400 mm;
slice thickness, 5.0 mm; section gap, 1.0 mm; slice
number, 18; image matrix, 256; bandwidth, 476
Hz/pixel; turbo factor, 164; 1 signal acquisition;
scanning time, 20 seconds) were obtained through
the fetus in the transverse, sagittal, and coronal
planes. T1-weighted images were obtained through
the fetus in the coronal plane using VIBE (TR/TE,
4.45/1.34; flip angle, 15°; field of view, 400 mm;
slice thickness, 3 mm; section gap, 0–0.6 mm; num-
ber of slices, 32–40; image matrix, 256 [interpola-
tion, 512]; bandwidth, 490 Hz/pixel; 1 signal acqui-
sition; scanning time, 24–28 seconds). Although
the images were basically obtained during a single
breath-hold, these were sometimes acquired during
quiet respiration. Neither sedatives nor IV gadolin-
ium-based contrast material was used. The preg-
nant patients were instructed to walk for 10 minutes
before the MR examination.
MR Image Processing and Evaluation
We generated 3D MR colonography images
from the VIBE data sets using a volume-render-
ing algorithm at a computer workstation (Aquar-
ius, version 3.2, Elk Corporation). T2-weighted
images, T1-weighted images, and 3D MR
colonography images were simultaneously as-
sessed on an image viewer. In the fetuses with a
normal gastrointestinal tract, signal characteris-
tics of the stomach, the duodenum, the proximal
small intestine, the distal small intestine, the as-
cending colon, the transverse colon, the descend-
ing colon, the sigmoid colon, and the rectum were
assessed. The small intestine was subdivided into
the duodenum, the proximal small intestine, and
the distal small intestine because a distinction be-
tween the jejunum and the ileum was not feasible.
The identification of the respective intestine was
made on the basis of the anatomic location, the
continuity, and the presence or absence of haus-
tra. The liver was used as a landmark of the ana-
tomic position in the fetal abdomen. Signal inten-
sity (high or low) of the precise intestinal
segments was subjectively determined on both
T2- and T1-weighted images. Particularly on T1-
weighted images, we compared the signal inten-
sity with that of muscle because the T1-weighted
signal in the small and large intestine is greater
than that of muscle [4]. On 3D MR colonography
images, visualization of the intestine was judged

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MRI of Fetal Gastrointestinal Tract

TABLE 2: Fetuses with Gastrointestinal Abnormalities

Patient No. Gestational Age
1 28 wk 6 d
2 29 wk 5 d
3 30 wk 2 d
4 33 wk 0 d
5 34 wk 0 d
6 34 wk 2 d
7 37 wk 5 d
Note—VIBE = volumetric interpolated breath-hold.
American Journal of Roentgenology 2007.189:W303-W308.
Diagnosis T1-Weighted VIBE and 3D MR Colonography Findings
Gastroschisis No intestinal complications (volvulus, atresia, perforation)
Duodenal atresia No other intestinal complications
Ileal atresia, meconium peritonitis Ileal atresia
Left diaphragmatic hernia Colon involved, liver not involved
Duodenal atresia No other intestinal complications
Duodenal atresia No other intestinal complications
Left diaphragmatic hernia Colon involved, liver not involved

A B C
Fig. 1—MR images of fetus at 35 weeks 4 days’ gestation show normal gastrointestinal tract. St = stomach, pSm = proximal small intestine, dSm = distal small intestine,
As = ascending colon, Tr = transverse colon, Ds = descending colon, Sg = sigmoid colon, R = rectum, L = liver, B = urinary bladder.
A, Coronal T2-weighted image shows high signal intensity from stomach to small intestine but low signal intensity from transverse colon to sigmoid colon.
B, Coronal 3D T1-weighted gradient-echo image shows low signal intensity in stomach and high signal intensity from distal small intestine to colon and rectum. Proximal
small intestine shows higher signal intensity than liver does.
C, Volume-rendered image in anteroposterior view visualizes through distal small intestine to rectum and also shows liver.

to be satisfactory when its signal intensity was Results Discussion

distinguished from that of background and when
the continuity of the intestine was confirmed.
We divided the fetuses with a normal gas-
trointestinal tract into two age groups of less than
32 weeks’ gestation (n = 12) and 32 weeks’ or
more gestation (n = 16) on the basis of a previous
report [2]. Whether there was herniation, obstruc-
tion, dilatation, or narrowing of intestine in the fe-
tal gastrointestinal abnormalities was qualita-
tively assessed. The diagnosis of herniation was
made when the intestine was seen outside the ab-
domen, whereas the diagnosis of obstruction was
made when the intestine was constricted with a
resultant dilatation of the bowel proximal to the
site of obstruction.
In all 28 normal and seven abnormal cases,
HASTE T2-weighted imaging, VIBE T1-
weighted imaging, and 3D MR colonography
were performed. A summary of the normal
findings is presented in Table 1; abnormal
findings are listed in Table 2. In the three
cases of duodenal atresia, VIBE imaging and
3D MR colonography did not add to the diag-
nosis. In the two diaphragmatic hernias and
one gastroschisis case, VIBE imaging and 3D
MR colonography clearly showed colon in-
volvement in the defect but did not provide
additional information. In the case of ileal
atresia with meconium peritonitis, the ileal
atresia was confirmed (Figs. 1–3).
In fetal MRI, signal intensity of the gas-
trointestinal tract is basically determined by
the location and amounts of swallowed am-
niotic fluid and meconium [2–4, 6]. Meco-
nium is formed from secretions of the liver
and intestinal glands, desquamated intestinal
epithelium, and some amniotic fluid after 13
weeks and slowly migrates from the small
intestine to the colon and rectum [4]. There-
fore, signal intensity of the intestine greatly
varies depending on gestational age. Ac-
cording to previous reports [2–4], signal in-
tensity of the stomach through the proximal
small intestine is hyperintense on T2-
weighted images after 26–27 weeks’ gesta-

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Inaoka et al.

hyperintense in more than half of cases be-

fore 32 weeks’ gestation; thereafter, it re-
mains hyperintense in almost 40% of cases
[3]. The visualization of the proximal small
intestine on T1-weighted images is limited
[2–4]. In our results, the percentages of the
respective intestine segments showing a high
signal intensity on HASTE T2-weighted and
VIBE T1-weighted images were equal or su-
perior to the previously published data; how-
ever, the percentage of the proximal small
intestine having a high T1 signal was much
higher than in previous reports. The rate of
the distal small intestine showing a high sig-
nal intensity on HASTE T2-weighted im-
ages in fetuses at 32 weeks’ gestation or
longer was higher than that in fetuses at less
than 32 weeks’ gestation. The rate of the
proximal small intestine showing a high sig-
nal intensity on T1-weighted images in fe-
American Journal of Roentgenology 2007.189:W303-W308.

tuses at less than 32 weeks’ gestation is

higher than that in fetuses at 32 weeks’ ges-
A B tation or longer.
The VIBE sequence, which is a modified
3D fast gradient-echo sequence, uses a sym-
metric echo in the read direction, partial in-
plane Fourier sampling in the phase-encoding
direction, and asymmetric echo sampling and
sinc interpolation along the partition direction
[8–11]. This sequence has the ability to pro-
vide thinner sections, higher signal-to-noise
ratio, higher image contrast, and a shorter ac-
quisition time than conventional sequences
while preserving adequate anatomic coverage
[8–11]. In fetal MRI, rapid data acquisition is
important because it may reduce motion arti-
facts of both mothers and fetuses. Indeed,
VIBE enabled us to obtain 32–40 sections of
3-mm section thickness through the fetuses
with a short acquisition time, and it provided
high-quality T1-weighted imaging and 3D
MR colonography of the fetuses.
Several investigators have suggested that
3D MR images were useful in surgical simu-
lation and treatment planning before birth [7,
12–14]. Rotation of 3D MR colonography
C D images on an image viewer aids in under-
Fig. 2—MR images of fetus with congenital diaphragmatic hernia at 37 weeks 5 days’ gestation. R = rectum, standing the anatomic position of the intestine
L = liver. and the relation between the intestine and the
A and B, Coronal T2-weighted (A) and 3D T1-weighted gradient-echo (B) images show herniated intestine in left liver. We have actually presented 3D MR
thoracic space. Extent of colon into left thoracic space (arrows) is clearly visualized.
C and D, Volume-rendered images in anteroposterior (C) and posteroanterior (D) views show anatomic relationship colonography images, with their excellent de-
between herniated colon and liver. Colon beyond diaphragm (arrows, C), is clearly shown. Liver has normal shape. lineation of the meconium, at family counsel-
Small intestine is not visualized. ing and at conferences with neonatologists
and pediatric surgeons. In our results, T1-
weighted and 3D MR colonography images
tion, whereas that of the distal small intes- signal intensity from the sigmoid colon to of sufficient quality were generated from the
tine through the colon is intermediate to low the rectum is always bright after 23 weeks’ same VIBE data sets. The percentages of the
signal intensity. On T1-weighted images, gestation [2, 3]. The distal small intestine is recognition of the proximal and distal small

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MRI of Fetal Gastrointestinal Tract

Fig. 3—MR images of fetus with gastroschisis at 28 weeks 6 days’ gestation. Sm = small intestine, As = ascending
colon, Tr = transverse colon, Ds = descending colon, R = rectum, L = liver, St = stomach.
A, Sagittal T2-weighted image shows extraabdominal bowel (arrows) has low signal intensity.
B, Coronal 3D T1-weighted gradient-echo image shows absence of colon in abdominal cavity.
C and D, Sagittal multiplanar reformatted (MPR) T1-weighted images show eviscerated bowel has high signal
intensity, which is consistent with normal colon. Small intestine appears normal. When coronal image sections
cannot show abnormal findings, MPR images are useful for evaluation.
E–H, Volume-rendered images in anteroposterior (E), oblique left-to-right (F), left-to-right (G), and right-to-left (H) views
show condition of eviscerated bowel segments of gastroschisis. No volvulus or bowel atresia is seen. Site of abdominal wall
defect is predictable because intestine becomes constricted just at defect site (arrows). Small intestine is not visualized.

C
American Journal of Roentgenology 2007.189:W303-W308.

A B D

E F H

AJR:189, December 2007 W307


intestine on 3D MR colonography images
were lower than those on VIBE images. On
3D MR colonography images, the visualiza-
tion of the small intestine in fetuses at less
than 32 weeks’ gestation was inferior to that
in fetuses at more than 32 weeks’ gestation.
We thought that the difference may have been
related to the small diameter of the small in-
testine in fetuses at earlier gestational ages.
Our study has some limitations. Because
we enrolled a limited number of the fetuses
with normal and abnormal gastrointestinal
tracts, the sample size is relatively small.
Most fetuses were in the third trimester, and
the gastrointestinal tract has a different ap-
pearance at earlier gestational ages. A large
series is required to precisely determine using
VIBE the visualization of the respective seg-
ments of the fetal gastrointestinal tract at dif-
ferent gestational ages. In addition, we could
American Journal of Roentgenology 2007.189:W303-W308.
not determine signal characteristics of fetal
gastrointestinal abnormalities, although it has
been reported that signal characteristics are
more conspicuous in abnormal cases [5]. The
impact of VIBE on findings and diagnosis in
the abnormal cases is not yet clear.
In conclusion, we report the appearances
of normal and abnormal fetal gastrointesti-
nal tracts on HASTE T2-weighted imaging,
VIBE T1-weighted imaging, and 3D MR
colonography. VIBE allowed better visual-
ization of the fetal gastrointestinal tract
than techniques used in previous reports
W308
Inaoka et al.
[2–4] despite the fact that this sequence
provided thinner slice sections through the
fetus. We believe that the routine use of
VIBE for fetal MRI may offer T1-weighted
imaging and 3D MR colonography of high
quality for the evaluation of fetal gas-
trointestinal abnormalities.
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