Oral Contrast-Enhanced Bowel Ultrasound 181

Oral Contrast-Enhanced Bowel Ultrasound 21

Giovanni Maconi, Salvatore Greco, and Gabriele Bianchi Porro

CONTENTS examination of the wall of these fluid-filled intestinal

tracts, by oral administration or direct instillation of
21.1 Introduction 181 water or non-absorbable solution [i.e., polyethylene
21.2 Hydrosonography of the Stomach 181 glycol (PEG) solution] into the intestinal lumen by a
21.3 Small Intestine Contrast naso-jejunal or rectal probe, have been proposed.
Ultrasonography 182
21.4 Hydrocolonic Sonography 186
References 186

21.2
Hydrosonography of the Stomach

Since US examination of the stomach wall and duo-

21.1
Introduction
The major limitation of conventional trans-abdomi-
nal ultrasound (US) in evaluating the gastrointestinal
tract is that it is difficult to achieve a detailed evalua-
tion of the bowel wall structure and its changes due
to the presence of air. In fact, luminal gas, in many
instances, causes inadequate ultrasonographic imag-
ing of the stomach, small intestine and, particularly,
colon.
In the 1990s, it was suggested that it was pos-
sible to overcome this limitation and considerably
improve ultrasonographic visualisation of the bowel
wall of the stomach, small bowel and colon, by filling
these organs with water or another echo-poor liquid.
Therefore, hydrosonography of the stomach, small
bowel or colon, in other words, ultrasonographic
G. Maconi, MD
S. Greco, MD
G. Bianchi Porro, MD, PhD
Chair of Gastroenterology, Department of Clinical Sciences,
“L. Sacco” University Hospital, Via G.B. Grassi 74, 20157 Milan,
Italy
denum may be compromised by artefacts due to the
presence of gas, resulting in sub-optimal images,
attempts at filling the stomach with water or liquids
to reduce acoustic artefacts caused by intra-luminal
gas, have been suggested.
Water, orange juice or methylcellulose and simeth-
icone have been used (Lund et al. 1992; Worlicek
et al. 1986, 1989). A clear advantage with the use of a
specific contrast agent in the detection of bowel wall
abnormalities has not been demonstrated. However,
compared with water, the orally administered ultra-
sonographic contrast agents may improve visualisa-
tion of the bowel with a decrease in the gas artefact.
In particular, cellulose and simethicone have been
used to achieve a uniform low level intraluminal
echogenicity and reduction of gas artefacts by dis-
placement and absorption of intra-luminal gas since,
while drinking water, more air may be ingested result-
ing in increased artefacts (Harisinghani et al. 1997;
Lund et al 1992).
To achieve adequate visualisation of the gastric
walls, a variable amount ranging from 500 to 1000 ml
of the above-mentioned fluids, should be given to
the fasting patient. Immediately prior to the exami-
nation, 20 mg of Hyoscine-N-butylscopolamine
(Buscopan, Boehringer, Germany) could be injected
intravenously to ensure appropriate relaxation of the
gastric wall, reducing peristalsis and delaying gastric
emptying.
182 G. Maconi, S. Greco, and G. Bianchi Porro
In head-down (angle of inclination 20q) and left
lateral position, the fundus and body of the stomach
can be better examined. In head-up (angle of incli-
nation 30–40q) left-lateral and supine position, the
body and proximal antrum can be displayed, while in
head-up right-lateral and standing position a better
visualisation of the distal antrum and duodenum can
be obtained.
The different parts of the stomach can be exam-
ined using a transducer operating at a frequency of
5–12 MHz, but for more distant areas of the fundus
and cardia 3.5–5 MHz transducers can guarantee a
greater depth of penetration and better visualisation.
While sonography and hydrosonography of the
stomach may detect gastric cancer (Ch. 16), gastric
submucosal tumours (Ch. 19) and gastroduodenal
ulcers, it can not be used for routine assessment of
the stomach in dyspeptic patients, endoscopy and
endoscopic ultrasound being much more accurate
diagnostic tools (Fig. 21.1).
However, when these investigations, for various
reasons, can not be performed, or in the case of sur-
veillance of submucosal lesions previously assessed
by endoscopic ultrasound, it should not be forgot-
ten that hydrosonography of the stomach can be an
effective, cheap, non-invasive and simple alternative.
In particular, hydrosonography of the stomach can
be considered a valid alternative to endoscopic ultra-
sound for: (1) diagnosis (and follow-up) of extralu-
minal gastric compression, and (2) detection and
surveillance of gastric submucosal tumours. In this
regard, it has been shown that in endosonographi-
cally diagnosed gastric submucosal tumours, the
lesion can also be visualised (and measured) using
a b
Fig. 21.1a,b. Large gastric submucosal tumour (smt) at endosonography (a) and gastric hydrosonography (b). Transabdominal
US visualisation of the gastric lesion was possible only after filling the stomach with water
trans-abdominal ultrasound of the water-filled stom-
ach in 69% of patients in a study by Polkowski et
al. (2002), and in 82.5% of cases, in another study by
Futagami et al. (2001). In the latter study, approxi-
mately 95% of gastric submucosal tumours, >20 mm
in diameter, were at least detected, and 97% of the
lesions, >30 mm in diameter, were correctly diag-
nosed (Futagami et al. 2001).
21.3
Small Intestine Contrast Ultrasonography
Like the stomach and duodenum, the small bowel
can be easily visualised by trans-abdominal US
when filled with water or echo-poor liquids. Water
or contrast agents can be directly infused into the
small bowel using a naso-jejunal tube by means of a
peristaltic pump (Folvik et al. 1999) or administered
orally (Pallotta et al. 1999a).
In both cases, the liquid contrast medium should
be non-absorbable and non-fermentable. Isotonic
anechoic electrolyte solution containing PEG, which
is used for bowel cleansing prior to colonoscopy, is
now considered the contrast medium of choice. The
ingestion of a variable amount of PEG (up to 1000 ml;
range 250–820 ml) provides an adequate distension
of the intestinal loops, removes gas making sequen-
tial visualisation of the entire small bowel from the
duodenum to terminal ileum easier and also allowing
measurement of wall thickness and luminal diameter
(Pallotta et al. 1999a,b, 2000) (Table 21.1).