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Hello and welcome to Noon Conference hosted by MRI Online

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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by creating a free MRI online account.

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Today we are honored to welcome Dr.

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Alka Singal for a lecture entitled Ultrasound of the Bowel.

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Dr. Singal is currently an associate director

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of radiology at Madon Division of radiology

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and nuclear medicine.

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She's a renowned expert in diagnostic whole body

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ultrasound imaging.

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Dr. Singal, who is dedicated to quality, accuracy

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and patient satisfaction, has earned fame as one

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of the best radiologists in the area

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and has a great passion for her work, both

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for diagnostics and academics.

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At the end of the lecture, please join Dr.

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Singal in a q and a session

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where she will address questions you may

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have on today's topic.

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Please remember to use the q

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and a feature to submit your questions so we can get to

1:07

as many as we can before our time is up.

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With that, we are ready to begin today's lecture. Dr.

1:13

Singal, please take it from here.

1:15

Thank you so much. Thank you so much.

1:18

So at the outset, thank you. Am I on line for inviting me?

1:22

And uh, uh, the topic today is ultrasound of the bowel.

1:26

So ultrasound of the bowel.

1:28

I'm sure we all come across this every day.

1:32

It doesn't come in as a separate request, it just part

1:36

and parcel of the whole abdomen ultrasound.

1:38

The first and the foremost key question to understand is

1:41

that every request that it come, that comes to us

1:45

for a whole abdomen.

1:46

Ultrasound by default includes the ultrasound of the bowel.

1:52

With that awareness will be able

1:55

to diagnose more ultrasound, bowel pathologies.

1:58

Then we really go back in retro. Okay, was it for the bowel?

2:02

Okay, now I need to go back and have a second look.

2:05

So often that leads to misdiagnosis.

2:07

So that's my first and the key message to understand, uh,

2:10

to all the people who are holding the ultrasound probe,

2:14

scan any patient with acute

2:16

or chronic abdomen, that bowel is part

2:18

and parcel open hole abdo ultrasound evaluation.

2:21

However, the areas

2:23

where it really produces wonders in

2:26

diagnosis, let's discuss those.

2:28

Right. So common indications vary from pediatric age group

2:33

to adult age groups.

2:34

So adults, we, of course we use various other modalities

2:37

because of various reasons we, um,

2:41

but pediatrics ultrasound is like a gold standard, right?

2:44

Uh, it's like the first line of imaging, right?

2:46

So because, um, being safe non, uh, non radiation

2:51

and other factors coming to adult population,

2:54

it's mainly the inflammatory diseases

2:56

and often focal masses, ischemic disorders, trics

2:59

and Crohn's disease that you can pick up.

3:03

However, in pediatric age group

3:05

and v par in all age group appendicitis is the commonest

3:10

diagnosis of the bowel that we put in on ultrasound.

3:13

Beyond tric, lymph falls, of course, diverticulitis,

3:16

ischemic colitis, obstruction, malrotation,

3:19

really foreign bodies, trauma

3:21

and others in neoplastic disorders.

3:25

Now the technique,

3:27

the technique is the most important area for bowel imaging.

3:30

We are very, uh, focused

3:33

normally on the solid organ evaluation that we tend

3:36

to ignore the bowel anatomy.

3:38

We tend to ignore the diagnosis

3:41

that is possible with the bowel.

3:42

However, just an understanding of the anatomy, a simple, uh,

3:47

going down from esophagus to stomach to odium

3:50

to small bowel, to large bowel direct, uh, to, uh,

3:54

ilial junction to sigmoid.

3:57

If we understand the anatomy, the bowel ts

3:59

and how, uh, how the peristalsis

4:02

and everything happens, we will know what are the normal

4:04

and abnormal features

4:06

and what is it that I need to do to get an enhanced imaging

4:11

to get better diagnosis.

4:13

Of course, going with the same formula

4:15

for ultrasound imaging,

4:16

the highest possible transducer frequency

4:19

to get the required depth of uh, penetration,

4:22

I normally begin my scans with the same transducer

4:25

that I'm holding for an abdominal imaging,

4:27

the 3.5 megahertz,

4:28

and of course I switch down to a higher frequency transducer

4:32

to get more detail, especially for lean thin patients.

4:35

It's very rewarding. Of course, we'll use all modalities.

4:39

Color doppler, contrast, uh,

4:42

and the technique mainly is a graded compression technique,

4:45

which we'll discuss more in later,

4:47

which is gradual displacement of the air.

4:50

And so we can really, really flatten out

4:54

and evaluate the bowel per se.

4:58

Fluid gives us a good contrast,

5:00

but the air does not give us the good contrast.

5:02

So we have to strike a balance between, as in hollow organ,

5:06

GI contains air and fluid, fluid is good.

5:10

Contrast a is a poor medium.

5:12

So patient preparation will improve the diagnostic in, uh,

5:16

quality of the examination.

5:17

So we do prefer our, all our patients to have fasting.

5:20

However, in cases of acute abdomen, that

5:22

of course is totally, uh, out bounds

5:25

and we have to evaluate as the status is.

5:30

So we will get the patient to be fasting

5:33

and of course sometimes like evaluation of pancreas

5:37

or there's any motion, there's a motion of normality.

5:40

If I think there is a stricture or a stenosis

5:42

and something is not passing beyond getting the patient

5:44

to drink some water on the table, that really also helps in,

5:48

uh, uh, understanding the pastoral flow

5:52

and uh, giving a better diagnosis.

5:55

That's another thing you can always try, especially it works

5:57

for, um, the upper GID.

6:01

Right? So using the detail from uh, now the key areas

6:06

where we really, really found, uh,

6:08

find ultrasound bowel to be very helpful.

6:10

Of course, as we always acute appendicitis, we discuss

6:13

that a detail, acute diverticulitis.

6:16

Basically our patient will clinically present to us

6:19

with an acute abdominal.

6:20

So now we are trying to look at the differential diagnosis.

6:23

Of course, the surgical

6:25

and the abnormalities, which are time-bound and treatable.

6:29

Those are the ones which we really need

6:30

to be focused on and diagnose.

6:32

And of course, other differential diagnosis must always,

6:35

always be remembered and clinically diagnosed.

6:39

Most of the gi d conditions,

6:41

however, are a clinical diagnosis, including appendicitis.

6:44

However, a confirmation

6:46

of the features on ultrasound imaging really supports

6:51

the inpatient counseling and, uh, in, uh, management.

6:56

So, uh, acute tic colitis,

6:58

we can have a thickening inflammation

7:00

and other features, ischemic colitis.

7:02

Of course, we will need a CT to evaluate the bowel perfusion

7:07

and uh, uh, vascularture

7:10

and obstruction primarily we do the plain x-rays,

7:14

but you can pick up, um, suspect

7:18

the abnormality and uh, also sometimes see the lead point.

7:22

Other, uh, site of obstruction centric lymph nodes, which we

7:28

commonly see on a ultrasound are, um, representative

7:32

of background abnormality that is going on,

7:35

which can per se be the lead points

7:37

to various other abnormalities.

7:39

And of course the other area abnormalities. Now patient

7:49

so comes to with acute abdo.

7:52

The commonest causes, we know

7:56

depending on the age when, um, I'm audible

8:01

and okay, so depending on the age, so up to two years,

8:06

the commonest differential diagnosis are intersection

8:09

malrotation, bori stenosis

8:10

during obstruction, incarcerated hernia.

8:14

Of course, all these have characteristic symptoms,

8:16

so these are really clinically suspected

8:18

and we have to document and ma uh, guide in the management.

8:22

Now, when we come to a little bit older age group, two

8:25

to five years of age, commonest presentation

8:28

for a bowel abnormality is acute appendicitis, then followed

8:31

by int interception mal rotation, valis

8:34

and other extra abdominal, uh, um, GIT related causes coming

8:39

to five to 12 years.

8:41

Again, appendicitis leads the communist diagnosis followed

8:45

by intussusception, valis

8:46

and others coming to older than 12 years.

8:49

Here, here, more

8:50

of the solid organ abnormalities tend to predominate.

8:54

However, acute appendicitis kind of remains

8:56

as a communist differential across all ages, right?

9:00

So less common, of course,

9:02

are the other abdominal pathologies.

9:06

Now, before we differentiate abnormal, as you know,

9:09

by radiology, the first thing which we really, really need

9:12

to know is the, what is that?

9:13

No understanding the normal gut signature is the key factor.

9:18

Like I understand that there is bowel, there's fluid,

9:21

it's sometimes, uh, we cannot even appreciate.

9:24

But if you really, uh,

9:27

stay on hold onto your transducer there static

9:31

and let things move and settle down,

9:33

and you do a grad graded compression, you can perceive,

9:38

see that our bodies like basically the target side

9:41

appearance goes to lymph nodes, to kidneys

9:43

and to bowel, like almost everywhere.

9:45

It just comes, it's just a similar signature.

9:47

However, here, what are the layers?

9:50

In a most pot, uh, portion represents a lumen,

9:53

the first hyper coic layer, which represents the interface

9:57

between the mucosa lumen.

10:00

Then the second layer, uh, is the hyper coic, uh,

10:04

hyper to the mucosa.

10:05

The third layer hyper coic to the mucosa.

10:07

Fourth layer, which is hyper coic, the muscular is propria,

10:11

and the fifth layer is hyper coic interface

10:13

between the muscularis and the serosa.

10:16

Identification of all these layers in longitudinal

10:19

and in transverse section is very important.

10:22

And often in transverse section you can see the symmetry

10:25

and there is any focal lymphoid nodule or focal structure

10:29

or focal thickening or any deposit or any ulcer or any mass.

10:33

Those are the abnormalities you can pick up

10:37

provided it's like, um, not so gaseous

10:40

and a little bit fluid is okay for us to scan.

10:44

There's a 3, 6, 9 rule, I'm sure we've all heard of that.

10:48

So which is a simple, uh,

10:50

we've known it since our residency.

10:52

The diameters of the bowel, small ball,

10:54

usually less than three centimeters,

10:56

large bowel less than sits appendix,

10:58

less than six millimeters, cecum less than nine centimeters

11:01

above these dimensions,

11:02

the bowel is generally considered TATed and obstruction

11:06

and other differentials must to be considered.

11:08

Let's understand acute appendicitis in detail.

11:12

Now, this is a commonest cause

11:13

of acute surgical abdominal in children

11:16

and it presents with the right lower

11:18

quadrant pain and tenderness.

11:19

It could just be a para pain,

11:21

it could be just pain everywhere.

11:23

Child may not be able to describe to you,

11:25

but it's the common as differential

11:26

that we do keep in our mind clinically, the bear with pain,

11:30

fever, uh, vomiting

11:32

and hyper, uh, uh,

11:33

raised leukocyte count ultrasound is an important part in

11:37

diagnosis, and we use the grade compression technique.

11:40

And how does an appendix appear?

11:41

As we all know, AP peristaltic, non-compressible thick

11:46

or more than sitter color, upper

11:49

hyperemia stable structure with a blind dent.

11:52

You may or may not be able to see at the pentical.

11:56

Of course, others has perpen fat, trending, genic,

11:59

fat inflamed, local les free fluid and complications.

12:03

You can have perforation or an abscess formation.

12:06

Now, typically the age group is two plus

12:09

rarely under two years.

12:11

It presents as a challenging differential diagnosis

12:14

because of various reasons kids cannot describe

12:17

and, uh, often it's ignored

12:20

and sometimes there's a late presentation.

12:24

Now, typical ultrasound findings.

12:28

Now first let's understand e ethio pathology.

12:31

Why does it happen? Basically,

12:33

appendix is a vestal organ, which is there.

12:36

Now there's a blind end.

12:37

So there, there has to be a free drainage

12:40

of the contains, right?

12:41

So if anything happens, which obstructs the free drainage

12:45

of the contains, and it could be just due to mucosal edema

12:49

or stasis or any prominent lymphoid tissue

12:53

or any, uh, food part, uh, food, uh, or any worms

12:57

or in lesions of the appendix.

12:59

So that will lead to buildup of the fluid, inflammation,

13:03

secondary infection, uh, infection, congestion,

13:06

ischemia and necrosis.

13:08

So that is the seally of events that will happen.

13:11

So first diseases, anything

13:13

that obstructs the drainage leads to distention, leads

13:16

to irritation of the, uh, uh,

13:18

surrounding tissue inflammation and of course, untreated

13:22

and left unresolved.

13:23

It may lead to perforation and gang brain

13:25

and mass formation.

13:27

Clinically, we know we read

13:30

during all throughout our residency McBurney's point, point,

13:36

uh, uh, tenderness over the McBurney's point.

13:39

However, classics in location of the pain may not be there

13:44

shifting dullness, rebound tenderness,

13:46

and when you move, move around the patient,

13:50

all those things are there signs, clinically fever,

13:54

pulse rate, elevated tenderness, and uh, rope in sign

13:59

and all those things are there.

14:01

Okay? So clinically

14:05

appendicitis is actually a clinical diagnosis.

14:09

However, ultrasound is highly accurate.

14:11

In the diagnosis with a great sensitivity

14:13

and specificity, we'll use a graded compression technique.

14:18

So how do we go about localizing the appendix?

14:21

That goes again to the question goes to the anatomy.

14:24

There is a normal location

14:26

and there are other locations, so we have

14:28

to know all the locations and

14:29

accordingly of course, we will start a scan

14:32

with right eye crosser,

14:34

but we'll go beyond to look at all the various positions.

14:38

Patient positioning, we will move around,

14:41

we'll start it spine, we can go to left posterior bleak

14:44

and then come back to sine.

14:45

That often does help you in shifting the gas

14:49

and getting a better imaging knowledge

14:53

of the various locations of the appendix.

14:55

Retro, subsequent pelvic

14:57

and elongated appendix is very helpful.

15:00

Now, normally appendix is less than six millimeters.

15:03

You can see it is a smooth appearing with a smooth ward

15:06

and not no inflammation

15:09

and, uh, non-tender and smooth.

15:13

However, you can have it seen it as dilated

15:15

or a lesion and inflamed.

15:18

There could be situations where it could be mild, very mild

15:22

or borderline appearances between six to eight millimeters.

15:25

Those are often managed by, uh, supportive treatment

15:30

and watched over a period of time.

15:33

So often they would come to you for a serial scan.

15:36

That's when you have to really document the diameters very

15:39

precisely the measurements

15:41

and support the clinician in managing the patient.

15:45

So longitudinal, uh, images

15:47

and inflamed non perforated appendix appears is a fluid

15:50

filled uncompressible blind and tubular structure,

15:54

and the diameter from outer

15:56

to outer wall is more than six mm.

16:00

Okay? And of course, transfers,

16:01

you'll see the target sign appearance.

16:03

So these are the typical appearances,

16:04

often inflamed appendix, non-compressible.

16:08

At times when you see appendic coate,

16:10

it's just a calculus which is sitting in the appendix.

16:12

So it appears as an equation and there's a disturb.

16:17

Now for this to demonstrate shadowing,

16:20

as we know the focus point, the beam focus has

16:24

to be at the level of the calculus.

16:26

So your, your scanning parameters have

16:29

to be very precise and appropriate.

16:32

And uh, I can see the images

16:36

with the video only is the video blink.

16:47

Okay? Okay,

16:51

so, all right.

16:53

Okay, we'll continue.

16:55

So you will see the append length,

16:56

you can see shadowing areas,

16:58

you can see multiple shadowing areas,

17:00

and I'm very grateful to my colleagues to support me

17:02

with these beautiful images.

17:04

Thank you so much. And you will see a echogenic momentum

17:08

that is the inflammation of the fat around.

17:10

That's another we'll look at the ancillary criteria

17:14

of the supporting parameters that really

17:16

support you in the diagnosis.

17:19

Okay, so next, now you, um, we have

17:23

to remember to scan the entire length of the appendix

17:26

because sometimes you can just have a little bit

17:29

of inflammation at the terminal end.

17:32

So that's very important, which is often, uh, missed out.

17:37

So we have to remember that in summary,

17:40

maximum diameter more than eight,

17:42

more than six seven maximum tenderness over the appendix in

17:46

compressibility appendic length

17:48

and on color double you signs.

17:50

We will come to separately

17:51

because normally it is actually a BM O diagnosis in itself.

17:54

However, with the advent

17:56

of very high resolution state apart ultrasound equipment,

18:00

we are very tempted to put in color

18:01

and get those classic images that I will share some.

18:05

And of course, so this is the typical B mode appearance

18:09

where you see the appendix

18:10

and you see trans transverse section.

18:13

And when you see appendic, that's how it looks like it,

18:16

and we'll measure the diameter.

18:18

Uh, this is, uh, increased.

18:20

Now, this is what I'm talking about, the e echogenic fat

18:23

around and air shared weight secondary ultrasound plant,

18:27

hyper quick A per appendicular fat tissue complex fluid,

18:31

fluid collections, peral abscesses,

18:34

and are pre, uh, uh, sickle lymphadenopathy

18:38

and per appendicular fluid.

18:40

Now. So all these are supportive and diagnosis,

18:44

and per se, the complications

18:46

of fluid collections often happen post perforation abscess

18:49

formation, lung formation, and intestinal case structure.

18:53

So the, the complications

18:57

that we are already is perforation.

18:59

Now what are the features of perforation?

19:01

Sometimes perforation may happen,

19:02

the diameter may actually go down.

19:05

So you have to be very careful if the clinic,

19:08

that's why it is mainly a clinical diagnosis.

19:11

So you may have absolute diameters may not match.

19:15

So ultrasound features of perforation include loss

19:17

of genic mucosal layer, presence of ated per appendicular

19:22

or pelvic fluidic collection on an abscess.

19:24

Great. So color doppler when you will do

19:28

for a non perforator peric typically demonstrates particular

19:31

hyperemia affecting inflammatory hyper per

19:35

in the early inflammation.

19:41

Uh, we, and we can also check on the blood flow.

19:45

We'll look at the, in the images now.

19:47

So this is how appendix is looking like.

19:49

Now, can you see the, uh, the loss of the contour

19:52

of the mucosal layers and there's all thickening

19:55

and inflammation that is happening.

19:57

And you see there is a increased,

20:01

there's a fluid collection, there is increased hyperemia.

20:05

I'm, uh, thankful to my colleague

20:07

for sharing these beautiful images with me.

20:10

Thank you. So you can see the great perfusion

20:13

that is going on,

20:15

and then it, sometimes you can have normal findings,

20:19

but e even the it append can be very long going all the way

20:23

towards the very, uh, pushed towards the pelvis

20:28

or any other area.

20:30

So you have to really look at the pelvis in the entire

20:34

length and really scan it all the way down to demonstrate.

20:37

Now see it's going beyond the crossing of the Oleg vessels.

20:40

You can see the pelvis really, really going, uh, appendix,

20:43

really going beyond that into the pelvis.

20:46

Now, when perforation happens, how do we see, we see

20:50

appendix which has, where the fluid contains are kind of,

20:55

uh, there is a collection around, there is a particular lid

20:58

and there is a localized collection.

21:00

So you can see there is a discontinuity in the wall

21:03

of the appendix and there is a, the continuity

21:05

with the adjacent collection.

21:08

So with those findings, you obviously would send the patient

21:12

to CT for, uh, monitoring and uh, further evaluation.

21:16

And you can see the collection, the appendicular

21:21

and the inflamed wall,

21:23

and that's the corresponding surgical image,

21:33

okay?

21:35

Right? That's the B mode image, the same patient,

21:39

and then of course perforation the lump

21:41

that forms that's there.

21:44

So must always, always confer what, what,

21:47

what are the areas can, you can mix up this

21:49

with bowel the common.

21:51

So confirming that the structure is actually the appendix,

21:55

you have to demonstrate that it does have that blind eye

21:58

because then you will not mistake it as about

22:03

and of course identify the terminal idiom

22:05

and really connecting

22:06

with the anatomy the dots is very

22:08

important and very helpful.

22:11

When the appendix is retrocecal

22:13

or other areas which you cannot, then you have to uh, accept

22:17

that this is the amount that you can diagnosis.

22:19

And of course, like I discussed,

22:20

when the perforations happen

22:21

and if you've missed the diagnosis of patient clinically

22:24

or being given a lot of painkillers and things.

22:26

So then you have to understand that the absolute criteria

22:30

of the diameter may not really be applicable.

22:33

Okay, now muco seal of the appendix.

22:36

So basically as we, uh, uh, as the literature says

22:39

that you see a large cystic mass void or be shaped

22:44

and it has got the characteristic onion skin appearance

22:47

or a whipped cream appearance, which is due

22:49

to concentric echogenic layers of the mucin,

22:52

which resembles an onion in the cross section.

22:55

So that kind of a cystic mask you can see in at times in the

23:01

uh, abdomen.

23:03

Now ancillary findings are cosmes

23:07

and drink lymph nodes, which we see normally.

23:08

They will have the characteristic inflammatory hilum

23:11

and vascularity.

23:12

That is really, uh, a central hilum

23:15

and, uh, inflammatory vessels.

23:17

And what we have to really see is the, uh,

23:21

diameter and the harmony.

23:23

Many are there and where are they located.

23:25

And these can act as lead points to interception

23:28

and various A factors that we'll discuss later.

23:33

So we will look at them entr lymph nodes

23:36

and document size, number, location,

23:40

other differential findings that we can see.

23:42

Macular diabetic, you can see a thick bowel walls medial

23:46

to mac point

23:48

and the rule of two for back diverticulitis,

23:51

it frequently contains heterotopic tissues.

23:53

When it does its gastric muco counts of 50% macr di

23:58

vertical markers in 2% population two inches in length

24:01

and is about two feet from ileocecal wall

24:03

and usually presents before the two years of age.

24:06

Okay, so coming to other uh, uh, complications,

24:10

it can lead to other factors of bowel inflammation,

24:14

diverticulitis, basically, uh, inflammation.

24:18

And you will see asymmetric thickening out pouching ears

24:23

or an echogenic fat in the area.

24:26

Then you can suspect that you're probably looking at that.

24:29

Of course, you would send the patient for further imaging

24:32

to confirm the diagnosis.

24:36

So lymph nodes of course you will see coming

24:38

to the other important area into interception.

24:41

So that is a very common area, which is primarily the domain

24:45

of ultrasound imaging.

24:47

And of course it's also diagnostic

24:50

and it's also a therapeutic work that we do.

24:53

So most common causes of acute len c one of the range,

24:58

six months to two years portion

25:00

of the digestive tract becomes telescoped between

25:04

into the adjacent bowel segment.

25:05

First majority are ilio colleague.

25:09

So there's a classical clinical trait

25:11

of the three things are current jelly stools.

25:14

Clinically, there is fresh blood in the anus

25:16

and there's a palpable mass

25:18

that often displaces the HSN power loops

25:20

that you can actually feel on the, uh, abdomen.

25:24

So what it actually consists of that mass is

25:28

interceptions the receiving loop,

25:31

which contains the folded intercepted donor loop

25:34

and which has the two components entering limb

25:37

and the returning limb.

25:39

So with this and this

25:41

accordingly, once we understand there's the entering limb

25:43

and then there's a returning limb, and then

25:46

accordingly when we located in the transverse section.

25:50

So you will see this kind of a, uh,

25:51

target sign kind of an appearance.

25:55

So depend findings will depend upon

25:57

where you are scanning ultrasound at the base, at the EPIs

26:01

or near the EPIs.

26:03

So ultrasound, if you open at the EPIs,

26:05

so it will shows the hypergo outer ring separated from

26:08

hypergo center, biotin hypergo ring,

26:10

which likely present the post series surface

26:13

of the intercept.

26:15

And near the near the aps will be multiple concentric rings

26:20

surrounding hyper coic ring, which,

26:23

and if you come at the base, we'll show the central limb

26:27

of the intussusception is eccentrically surrounded

26:29

by the hyper coag, which,

26:31

and showing the classic re donut sign.

26:35

So at the base of course, ridge sign is formed

26:38

by the three parallel, uh, band separated by the nearly

26:43

hyper path.

26:45

Now with this understanding, when you actually slice

26:49

through, so you have

26:51

to have a three dimensional understanding of the bowel,

26:53

and then you will be able to see,

26:55

and on real time when you're actually observing the persis

26:59

and you or if there is an obstruction,

27:02

there's no balance stances, there's a different scenario,

27:04

then you can really see

27:05

that if you are cutting it transverse this,

27:07

these are the kind of appearance you will get.

27:09

And if you're cutting it longitudinally, that's the kind

27:12

of appearance you'll get.

27:13

So the target sign in the transverse section

27:15

and the signage sign in the longitudinal section is

27:18

what you will see in cases of interception.

27:21

So what's the sandwich sign is obtained at the center

27:23

of the mass longitudinally.

27:25

On a longitudinal scan you have parallel hypoechoic band

27:28

separated by hypoechoic band

27:31

and the uh, transverse sign, the target sign has got

27:37

intercepts and the central, uh, lead point,

27:41

which could often a lymph node can also be seen.

27:44

And of course on doppler, you will see the swirling

27:47

of the arteries in the case of intersection,

27:50

as we will see in the case, right?

27:54

So let's look at some cases

27:57

and uh, ultra ultrasound is one of the modalities

28:01

with great sensitivity

28:03

and specificity in the diagnosis of intersection.

28:07

Now this is a case, uh, pain, uh,

28:11

abdomen and without any signs of uh, bowel obstruction,

28:15

you see the target sign in right eye, like versa.

28:18

You see the mass, which is typically, uh, located surpri,

28:22

uh, above the right kidney,

28:25

and you have a classic target sign in transverse image

28:28

and classes sandwich sign in the longitudinal image.

28:32

So again, another case where you see the target

28:34

and the sandwich sign, both another case

28:38

where you have the target sign

28:40

and proximal bowel is dilated with free fluid.

28:43

So there's not much movement happening, so possibly

28:48

suggestive obstruction associated as well.

28:53

So again, another case you see a transfer

28:55

or target sign on transverse image

28:57

and sandwich sign with, again, good vascularity

29:00

and there are no signs of mild obstruction.

29:02

There's no proximal dilatation.

29:04

Again, another case of in interception

29:06

with on transverse you have the target sign

29:12

and on the udal image there is a sandwich sign.

29:17

Recognizing the lead point is very important

29:19

because that helps you to, um,

29:27

identify.

29:28

Now that's a clip.

29:29

So you can see there's a

29:36

classic target sign.

29:38

Okay? And that's the, the

29:43

elongated image coming to

29:49

the next thing, hydrostatic, uh, reduction

29:52

of the interoception in children.

29:54

So it's commonly done in the ultrasound department.

29:57

The pit team joins and, and that's done.

30:00

So, uh, how you carefully we select the patients.

30:05

So symptoms are less than four days old.

30:07

There's no significant signs of abdominal distension,

30:10

no obstruction signs, no peritonitis,

30:12

and it's not intercept should not apply out of the rectum.

30:16

Those are the, uh, criteria to select.

30:19

And of course, what do you do?

30:21

IV e will connect

30:23

and tric tube, ral catheter, you will, uh,

30:27

monitor the renal function.

30:29

Test is good. You have the basic, uh,

30:31

blood counts and all are done.

30:33

And of course, as a plan B, you have preparations ready

30:36

for surgery in case things don't work

30:38

out the way you want it.

30:40

Child is sedated, you fit an anima back and erectile tube

30:44

and then you put the warm, a normal saline in a drip

30:48

with an initial height of a hundred

30:49

centimeters above the couch.

30:51

Height can be increased to hundred

30:52

and 30, depending upon how much

30:55

of gravitational force you required

30:56

to reduce the mass rectal tube is inserted into the rectum,

31:00

but moon is inflated

31:01

and almost line is allowed to flow into the rectum.

31:03

Ultrasound is machine is used as a guide to

31:07

the reduction till the mask goes, uh, beyond the idio valve.

31:11

So the rule of three, maximum

31:13

of three attempts at hydrostatic reduction are made

31:16

with each episode lasting for not more than three minutes.

31:20

Okay, so it is how, how do you say that it has reduced?

31:25

One, it disappears.

31:27

Two, you visualize, uh, there's a reflux

31:29

of fluid in air purpose with CM in the colon

31:32

and distant demonstration

31:34

that your fluid in coming into the ilum

31:36

and absence of course, uh,

31:38

post evacuation ultrasound examination,

31:40

you see normal finite, it's a great, uh, modality,

31:45

uh, saves the xray surgery or anything else.

31:49

And coming to the next, uh, uh,

31:53

coming to the next hypertrophic palate stenosis.

31:57

So it's a common condition affecting young infants in four

32:00

to seven years of, uh, on supply and main nature.

32:04

Presentation is seven weeks of life.

32:06

Uh, weeds of life, male to female ratios four to one.

32:10

Typically, uh, in the first few weeks they'll present

32:14

with projectile formatted.

32:16

That is it. So what do we see?

32:19

We see, uh, we in the, in the epic stream

32:24

in the uh, supine position when you're scanning

32:27

you can see the um, ultrasound findings of thickness

32:32

of the uh,

32:34

bowel wall in the ulu.

32:37

So what is the classic bullseye sign?

32:40

It's formed by the outer rim

32:43

and the circular, which is circular muscle, uh, circular

32:46

smooth muscle and inner e echogenic mucosa submucosa.

32:51

So normal transfers diameter of the Es when you measure

32:54

between these two layers is about, uh,

32:57

less than a centimeter 0.7 to 1.1,

33:00

and the normal length is one to 1.3 centimeters

33:03

and the thickness of the ular muscle is normally too thin

33:05

to measure, but when you can see it,

33:07

that means it is abnormally enlarged.

33:10

So cross uh, uh, section.

33:13

So if you see a prominent and,

33:17

and the thickness is more than even if you can measure like

33:21

0.4, three, four millimeter, that's what it is considered

33:25

as something abnormal.

33:28

And of course you will see the length,

33:30

you'll measure the length and the transverse diameter.

33:34

Now you have a normal appearance is you see there is

33:39

a normal bori canal

33:41

and normal free flow of contains from the stomach

33:43

to the odium and hypertrophic palus is a thicker

33:47

and a longer than normal

33:48

and does not permit the passage

33:49

of the gastric contains into the odor.

33:52

So we can see this uh, findings

33:55

and we will measure the diameters and report them.

34:00

So pori length

34:02

and the muscle thickness more than three millimeter.

34:06

Now here we have two months male with presenting with P.

34:11

That's a long channel length that we can see

34:15

and there is some centric atrophy of the pori muscles here.

34:19

Another case where we have the docket sign

34:21

or the donut sign in the plarre

34:23

and is a long pori that we can see here.

34:27

So when the muscle thickening is not more than three,

34:31

but it is measurable, so it is between two

34:34

to three millimeter, so can come to normal

34:37

or may eventually progress to plastic bori stenosis.

34:39

We have to uh, keep them on a follow up

34:42

or a conservative management, not really go for surgery.

34:46

So again, this is an elongated channel.

34:49

However, muscle wall thickening is just

34:51

three millimeters, not more.

34:52

So we keep them on a uh, follow up.

34:56

Again, there's a small channel length here with the opening

34:59

of pilar in the muscle.

35:01

Voltage is only two millimeters.

35:03

Again, we'll keep on a conservative management.

35:07

SPUs pass is temporary of when you have to wait for it

35:11

to go technically

35:12

and uh, be patient with,

35:14

that's actually a pitfall of diagnosis.

35:16

So you really have to give it some time

35:18

before you actually conclude on your findings.

35:22

So a plasma is obviously temporary and

35:32

right, so that's the best way to differentiate that GE

35:36

as an adult you can just see a focal thickening

35:39

or any other focal abnormality, ulcer and mass

35:42

or anything that you can pick up as like

35:45

abnormalities coming to the odm.

35:47

You can see during res stenosis, beds and vans.

35:50

So in pediatric age groups, 16 days male you have,

35:54

when you see the SME

35:57

and SME relationship as bleeding in this case.

36:00

And you can see there's a distended odum

36:03

and with a dis gastric reflux

36:05

and there was a AL valve which is causing the stenosis.

36:08

In this case of course, it's a, um,

36:11

retrospective diagnosis rather

36:14

and uh, great learning experience.

36:19

Mm-hmm, okay, one second.

36:23

So that's where we just, uh, we paused, we did gastritis

36:26

and we come into the AL obstruction.

36:29

We can see juvenile atia, osis, web and bend.

36:32

So again, we have two, uh,

36:35

these findings can be an incidental pickup

36:38

or they could sometimes be retrospective findings

36:40

where the imaging has been done

36:42

and you're actually following them on,

36:44

on conservative management.

36:46

So understanding is very important

36:47

and to be here in this case, there was a reflux

36:50

of the contains back into the gastric from the coming

36:55

to the V vous and malrotation and other abnormalities.

36:59

These are classic clinical manifestation of malrotation

37:02

and newborn is ous vomiting with

37:03

or without dis distinction associated

37:05

with al constructive band or mid gut ulu.

37:09

And of course it's a life-threatening condition in which the

37:12

small bowel or proximal colon twists around the SMA.

37:15

And it's a, uh, abdominal emergency ultrasound.

37:19

You can see the twisted bowel.

37:20

So typically like you really see this.

37:23

So it may be symptomatic, asymptomatic,

37:26

and it's a surgical emergency

37:28

because it is a risk of bowel ischemia.

37:30

And uh, you can see the classic appearance.

37:35

So here you can see this relationship is ordered.

37:38

There's a centric twist with whirlpool sign.

37:42

So you can see there is a twist

37:49

and there is a,

37:58

okay, again,

38:06

here we are

38:21

again, another case we have again.

38:24

So these are the findings which you really need

38:26

to hold your transducer at a spot

38:29

and with the clinical suspicion you can really, uh,

38:35

focus on it and give the diagnosis.

38:39

Again, here is another case

38:40

where we have reverse bowel stasis seen in the case

38:43

of a small bowel obstruction.

38:45

So when you sit and you observe the direction of flow

38:47

of the bowel campaigns, that's when you'll be able

38:49

to pick that up.

38:58

Okay? Again, another case,

39:03

large bowel obstruction.

39:04

Similarly, rarely we do come across infectious disorders.

39:09

So of course we know the communist is of course, uh,

39:12

bacteria, infections, lymph nodes, ic, lymph nodes,

39:16

and then tubercle lymph neuropathy is common in, uh, Asia

39:20

and Southeast Asia and other uh, uh,

39:24

EB stic conditions.

39:28

S and round forms are also occasionally seen.

39:31

So being aware to the possibility of them being there,

39:35

so gives you those instance for their diagnosis.

39:38

So adult forms are seen as stimulus structures,

39:40

which are often outlined by the fluid.

39:43

They can be seen as large curry, uh, icogen strip with

39:48

antiqua within the antiqua, uh, bowel canal.

39:51

You can really see them as large rounded

39:53

as scars in the bar.

39:56

Now you can also see the abnormalities.

39:59

They get very complicated when you have hernia

40:02

and the abnormalities can be there in that hernia.

40:05

So anything could actually be there in the hernia area.

40:09

It's just a little bit more challenging.

40:10

And the most important thing to look

40:12

for is a associated bowel structure.

40:16

So, which you really need to look for.

40:20

Now coming to the adults mainly in Crohn's disease

40:23

or other inflammatory disorders, Europe

40:27

and other places, they're really, uh, focusing on uh,

40:30

evaluating them with uh,

40:33

ultrasound over other imaging for follow-ups

40:37

and for the management a periodic pullup.

40:41

Now what happens in Crohn's disease, as we all know,

40:44

there's an inflammatory bowel thickening.

40:46

So ultrasound as we know, is a very good modality to really,

40:50

uh, appreciate that.

40:52

And if you actually understand the anatomy

40:54

and actually scroll through the whole thing systematically,

40:57

you can by going in longitudinal and transfers, longitudinal

41:01

and transfers, you can pick up areas

41:04

and structures and diagnosis.

41:06

Of course, as you all understand,

41:08

findings can be non-Specific findings are what loss

41:13

of peristalsis, neural hyperemia, fibro fatty

41:17

proliferation at is as evidenced by hyper coic layer,

41:21

basically fat inflammation.

41:23

And then the loss of compressibility of the bald wall

41:26

and fibrosis, which may uh,

41:27

mimic bo normal bald wall submucosa

41:30

and of course associated lymph nodes

41:32

and interperitoneal, uh, fluid may be there rarely.

41:36

You can see absence formation and fistula formation.

41:40

Now also focal pathologies in the bowel focal masses.

41:44

Of course the diagnostic gold standard is endoscopy.

41:47

However, sometimes we do suspect these when there there's an

41:52

obstruction, we do suspect these as a abnormality.

41:57

If we suspect it, we may be able to be in a position

42:00

to pick up early diagnosis as well.

42:03

So we know that the symmetric, the BWA on or around.

42:08

So whenever we do not see any symmetrical signature in

42:11

transverse image provided, the gas is a little bit settled.

42:15

So that's why routinely we do have fasting.

42:18

So fasting also, not only for solid organs

42:21

but also to evaluate the bowel.

42:23

So this appearance, we, we will only be able

42:26

to diagnose when there is less of air in the bowel.

42:29

So fasting and preparation becomes very important

42:33

and not too much of water has to be there

42:35

because then sometimes it's over distended

42:38

power with the water.

42:40

So optimum water and fasting both.

42:44

So of course, uh, malignancy, primary

42:47

or secondary can appear as focal endo or uh, ex masses

42:53

and infiltrative wall thickening.

42:55

And uh, you can see pelvic endometriosis deposits in uh,

43:00

uh, female patients as well and various other abnormalities.

43:04

So CIE can appear in various shapes and various sizes

43:08

and uh, you can have focal abnormalities as mouse

43:13

lymphomas can be seen as a lymphoid,

43:15

aggregates in the wild wall, uh, and which are very classic.

43:20

And you can see, uh, collections

43:22

and fistulas can, I am not doing that work.

43:25

But yes, of course you can technically

43:28

follow them up as well.

43:30

So to conclude, ultrasound of the bowel is a part

43:35

and parcel of the whole abdominal ultrasound.

43:38

So please include that in your survey

43:41

after you've done the solid organs.

43:43

Just run through

43:45

as if now you are mentally imaging the whole of the GIT

43:48

starting from the sase fatal junction going scanning the

43:53

stomach, uh, the pylori theum,

43:58

a small bowel, large bowel rectosigmoid and talk.

44:01

So it's just a simple sweep

44:03

that if you would just take it all across the abdomen,

44:06

you will understand the anatomy more and more.

44:09

You will correlate it with the clinical symptomatology

44:11

of the patient and you'll be in better position

44:14

to really diagnose abnormalities

44:16

or suggest further imaging that could support the patient.

44:20

Okay? Okay. So just a summary.

44:24

Of course, we have to move sequentially

44:28

and systematically, like I just discussed, discuss,

44:31

and, uh, thank you so much, uh, for all your listening

44:34

and uh, thank you for all your questions.

44:37

If there are any, I'm happy to take them out. Thank you.

44:41

Thank you so much for sharing your lecture

44:42

with us today, Dr.

44:44

Singal. So at this time, the floor, uh, is open

44:46

for any questions from our audience

44:48

and you may submit your questions

44:50

through the q and a feature.

44:52

Dr. Singal, I don't know if you see your Zoom tool toolbar

44:55

with the q and a box.

44:58

Yes, I do see seven questions over there. Yeah.

45:01

Yes, so great, thank you.

45:03

How much free fluid is normal in, uh, para poll,

45:06

uh, colleague in children?

45:08

See, uh, there's no ML guidelines

45:11

or anything that you can measure.

45:12

So even if I see a little interval fluid

45:16

and if it's in the area that is corresponding

45:18

to the clinical abnormality, I would document that

45:21

because that actually points to the area

45:23

where you have a likely diagnosis.

45:26

So that's my simple and straightforward answer to that.

45:28

Thank you. Does normal appendix is peristaltic?

45:32

Uh, I would say so, yeah,

45:35

but it's basically what the tendon is.

45:37

I mean, it's not that much amount of content

45:40

that you may be able to demonstrate it on ultrasound,

45:42

so I wouldn't, uh, really be focused on that.

45:47

It's more the, what the literature says is the diameter,

45:50

the vascularity, the compressibility,

45:52

the tenderness, those are the pointers.

45:55

How is a particular mass seen on ultrasound?

45:58

We had cases, so where we have the, uh,

46:02

hypoechoic, uh, uh, inflamed area with the

46:08

fluid and a plaque formation, basically that's

46:12

what he would say it.

46:13

Six millimeter, the cutoff even in kids.

46:15

Yes, that is what it is.

46:17

So 6 2 8 is often a borderline of management

46:20

and of course clinical symptomatology

46:22

and other factors are also very important points in

46:27

consideration for a diagnosis

46:28

because it is basically a clinical diagnosis.

46:32

But yes, that by imaging wise, yes, that is the thing.

46:36

6 2 8 is kind of a borderline scenario.

46:38

Managed conservatively, how to differentiate subacute

46:42

and acute appendicitis.

46:44

I think these are clinical terminologies

46:46

and on the timelines for an ultrasound perspective,

46:49

we give the diameters and we give the condition

46:52

and the descriptors, and those are clinical parameters

46:55

for the clinician to figure it out

46:58

because there's nothing in the literature for these.

47:01

How about what would we suggest to the findings that equ

47:04

acute appendicitis, equ vocalist situate Ms BI literature

47:09

says, and of course you have inflammation, you have, uh, uh,

47:12

surrounding fat inflammation

47:14

and you have centric lymph nodes

47:16

and the other ancillary factors you just document

47:19

and all of them and leave it to the clinician to

47:22

evaluate all the other blood parameters

47:24

and correlate the clinical scenario.

47:26

Thank you. How to diagnose IOC colitis

47:29

or colitis even in collapsed bowel loops?

47:32

I think collapsed bowel loops would be, um,

47:37

if there is an inflammation

47:38

and collapsed bowel loop together

47:41

normally wouldn't be there.

47:43

There's some symptomology would be, there's some distension

47:46

or some inflammation

47:48

or some genicity of the, uh, joining fat.

47:51

You will see some signs I would say how

47:55

to diagnose patients.

47:56

Patients. Again, if you just, um, it's basically per se,

48:00

I mean, um,

48:09

anywhere you just just hold your transducer

48:10

and ask the patient to gently breathe.

48:12

And if you see that the whole structure is moving per se

48:16

together, it's not like you're not able

48:17

to separate the two things.

48:19

So that means the two things are just moving together.

48:22

So example, if the uterus and the Aries are adherent

48:24

and I see the uterus in the ovaries both going together

48:27

and together and together,

48:28

I don't see them moving sliding relative to one another.

48:32

That's when I think there is an addition.

48:34

So if I see two bowel lesions, like

48:37

for example recently I had a case which had a, uh,

48:40

endometrioid deposits in the ovary

48:42

and it also had endometrioid deposit in the bowel.

48:45

But also there was an area where, where I couldn't actually,

48:50

uh, de separate the, uh, endometrioid uh, deposit

48:54

and the bowel wall out.

48:55

And I said, this looks like a clear cut adherent.

48:57

So they may be wanting to clear up the gyne,

49:00

but they may need to have an, uh,

49:02

gastro surgery also on call along with.

49:05

So those are the things you can suspect.

49:08

And of course, imaging, uh, cross-section will confirm,

49:11

but uh, those are the ways I apply in my practice.

49:16

So what are the constitutes on a particular mass?

49:19

You have the, uh, fluid, uh, distention collection

49:24

and, uh, interval fluid.

49:28

And sometimes appendix will be

49:30

around seven, but no inflammation.

49:32

That's what the borderline case you'll put on conservative

49:34

management and you'll follow up along

49:36

and correlate with the other clinical parameters.

49:39

How to differentiate mucosal and cin.

49:41

Adenocarcinoma of appendix on ultrasound, it's a,

49:44

these are the, is basically histopathological diagnosis.

49:47

It's like a follicular adenoma versus follicular carcinoma.

49:51

We can only, uh, say clinically.

49:53

And what it comes on on histopathology is histopathology

49:57

only, so only mild terminal

50:02

alien wall thickening.

50:03

And with non visualized appendix,

50:06

no obvious lymph nodes, is it considered high?

50:09

I mean, you may not see the lymph nodes,

50:11

but it is a wall thickening.

50:12

There is some inflammation and procedure is going on.

50:15

So you would technically think, and we

50:18

and correlate, uh, clinical correlation would be suggested.

50:22

Do interception and palate stenosis occurring at us?

50:25

I have not seen so, so primarily a pediatric age diagnosis

50:30

to, in my experience, how do it differentiate inflammatory

50:33

and infective etiology?

50:35

Uh, etiology is histopathology.

50:38

I mean, uh, we, you can only just see the thickening.

50:42

That's it. And uh, it's, uh,

50:44

you cannot say whether it's infective

50:46

unless you have any other signs of infective, uh,

50:50

processes happening around then you can give a suggestion.

50:54

Thank you. Would you please explain where exactly?

50:56

Usually we do we search a structure related to SK disease.

51:01

You can see it anywhere.

51:02

You don't search for it, they just hit you.

51:05

I mean, it's just that you are not diagnosing a skill.

51:08

Uh, you don't start your search for a scales per, per se,

51:12

but yes, you just see them I classic like a linear hypergo

51:15

area, something that's looking like a standard like heat,

51:20

but it's not a standard like adhere in this area.

51:22

That's what, that's how it hits you on, uh, diagnosis.

51:29

Thank you. Four month baby is suspected with exception, uh,

51:33

sonography confirmed concentrate target sign.

51:35

What's a good ex, what is a good explanation

51:37

for our colleague?

51:39

So you give them a measurement of the length, uh, uh,

51:44

uh, who wants to confirm?

51:46

Yeah, yeah, you just, you you give your findings, right?

51:50

And they, they want the reduction. You can do the reduction.

51:53

That's what you can do. Thank you.

51:56

And, uh, rupture appendix differentiation from acute

52:00

appendix other than breach incontinuity, clinically,

52:04

of course there were patient would

52:09

and would be sick then, um, if it is ruptured

52:12

and uh, you might have fluid, you might have aus uh,

52:15

acute appendicitis may

52:17

or may not have fluid, may not have sitis

52:19

and uh, the counts will tell you the diameter may go

52:23

down or be normal.

52:25

So those are the things. Thank you.

52:29

Can be diagnosed meningitis by ultrasound.

52:32

It's a technically a challenging diagnosis,

52:34

but I'm sure there are reports in literature saying, uh,

52:37

it's document diagnosis can be a start as

52:40

with diagnosed on ultrasound.

52:42

Basically if you see any, uh, focal asymmetry at the wall

52:46

or any thickening, that's what you can report.

52:49

Uh, first se and of course adequate bowel preparation

52:53

and scanning is required.

52:55

Neonates and pens is 3 6 9 rule.

52:58

Well, it is a cut of obstruction door, it is lower.

53:01

I don't really use that for neon ranges.

53:03

I just use the MM criteria.

53:05

It's just a interesting thing for literature, probably

53:08

for adults, I think.

53:10

Can I like this, be diagnosed on ultrasound?

53:13

I mean if you have a focal stricture

53:14

or any thickening, that's all you can diagnose area.

53:18

Clinical diagnosis, basically what is normal?

53:20

Bowel, walls and thickness for a small enlarged bowel

53:23

and ultrasound, that's what be did.

53:25

3, 6, 9. Peace can need to comment on the maneuver.

53:29

So peace, patience is very challenging. Really speaking.

53:33

You can try and, um, um, get them to drink, uh,

53:38

prepare them well get them to drink some water

53:42

and uh, like

53:48

you can use the best trans user capabilities

53:53

list and what to do.

53:54

That's the best way. Suggest cross-section imaging.

53:57

Why is inception recommended to try or

54:01

because not more than three times

54:03

because, you know, uh, if there's any other pathology,

54:07

that's how the, it's documented in the literature

54:11

because we don't want to go through

54:15

so many more attempts.

54:16

You have to leave it. Dietician colleagues would know that.

54:20

How to diagnose me's tic colitis.

54:22

We had the case in description to go through the recording.

54:26

Thank you. Can be diagnosed neuroendocrine tumor.

54:28

Basically you'll see a focal lesion in the

54:30

ball, in the tumor.

54:32

So, and you will just see there's a focal deposit

54:36

or a lesion or an asymmetry in the wall.

54:39

And what exactly it is, that is something, uh,

54:43

endoscopic biopsy

54:44

or a sampling will only tell you what it is.

54:48

So thank you so much for all your questions

54:51

and making it so interesting and so interactive.

54:56

Thank you so much Dr.

54:57

Zing golfer answering all those questions.

54:59

That was rapid fire. That was amazing.

55:02

Um, and thank you to everyone for

55:05

participating in our noon conference

55:06

and asking such great questions.

55:08

You can access the recording

55:10

of today's conference in all our previous noon conferences

55:12

by creating a free MRI online account.

55:15

We'll also email out a link to the replay later today.

55:20

Be sure to join us next week on Tuesday,

55:22

October 8th at 12:00 PM Eastern, where Dr.

55:26

Brian RA will deliver a lecture entitled Cardiac

55:30

CT in Practice From Prevention to Post Revascularization.

55:35

You can register for it@mrionline.com

55:37

and follow us on social media

55:39

for updates on future noon conferences.

55:41

Thanks again and have a great day.