Imaging Essentials: Ultrasonography of the Gastrointestinal Tract—Ileum, Cecum, Colon
Elizabeth Huynh, DVM
Clifford R. Berry, DVM, DACVR University of Florida
LOCALIZATION AND SCANNING TECHNIQUE
Dogs and cats are positioned in dorsal or lateral recumbency for scanning of the gastrointestinal tract. Longitudinal axis and transverse axis views of the different segments of the gastrointestinal tract are necessary for a complete examination.
Maintain a consistent sequence when evaluating the complete gastrointestinal tract; preferably, in the following order: stomach, duodenum, jejunum (see “Ultrasonography of the Gastrointestinal Tract: Stomach, Duodenum, and Jejunum” [January/February 2018]), ileum, (cecum), ileocecocolic (cat) or ileocolic (dog) junction, cecum, and parts of the colon (ascending, transverse, descending).
The normal canine and feline ileum is short and is typically located in the right cranial to mid-quadrant of the abdominal cavity, medial to the right kidney. The ileum can be found using the transverse colon or ileo(ceco)colic junction as a guide.
The transverse colon, which is immediately caudal to the gastric body, is followed to the right of midline to the level of the ascending colon; continuing in an oral direction, bypass the ileo(ceco)colic junction to image the ileum.
The ileum is more difficult to identify in dogs than cats due to interposition of the normal gas filled cecum.
Ileocecocolic and Ileocolic Junctions
The ileocecocolic junction (cats) or ileocolic junction (dogs) is usually located within the right cranial abdominal quadrant medial to the right kidney (FIGURES 1 AND 2).
The canine and feline cecum is a blind sac that is medial to the descending duodenum and can usually be found caudolateral to the ileo(ceco)colic junction. Due to the superimposition of gas filled intestinal segments, the cecum is not always identifiable.
All parts of the colon are fully evaluated by beginning at the level of the ileocecocolic junction in the cat and ileocolic junction in the dog and sweeping the transducer cranially along the ascending colon. The ascending colon is a short segment of large intestine in the right cranial abdominal quadrant.
Continue leftwards along the transverse colon. The transverse colon spans the right to left cranial abdomen and can readily be identified using the stomach as a landmark; it is located immediately caudal to the greater curvature of the stomach (FIGURE 1). Finish scanning the colon by continuing caudally along the descending colon.
Using the urinary bladder as a landmark to identify the descending colon (FIGURE 2), a reversed approach (descending colon, transverse colon, and then ascending colon) can also be used. The descending colon, usually containing gas or feces, is located immediately dorsal to the urinary bladder, within the far field of the image.
Criteria for assessing the ileum and colon include:
- Uniformity in diameter
- Wall thickness (TABLE 1)
- Discrete wall layering
- Presence of luminal contents
NORMAL ULTRASONOGRAPHIC FEATURES OF THE GASTROINTESTINAL TRACT
Ileum and Cecum
The ileum of cats has prominent submucosa and muscularis layers (FIGURE 3) and, due to a limited accumulation of mucus and gas, commonly has an ultrasonographically absent lumen-mucosal surface. The ileum of dogs has a prominent submucosa (FIGURE 4).
Anatomically, the ileum is contiguous to the ileocecocolic junction in the cat, leading to the ascending colon. In the dog, there is a separate ileocolic junction and cecocolic orifice.
The normally gas filled cecum has an appearance similar to a segment of normal gas filled colon. In the normal dog cecum, the wall layers of the mucosa, submucosa, and muscularis have a uniform thickness.13 Ultrasonographically, the normal feline cecum has a hypoechoic nodular inner layer (composed of multiple lymphoid follicles) and an adjacent hyperechoic submucosal layer.8 The combined mucosal and submucosal layer is referred to as the follicular layer.
The colon is divided into three parts: ascending, transverse, and descending. The colon typically has the thinnest wall of all intestinal segments (FIGURE 2), and the wall layering is normally indistinguishable due to distension with gas and feces. Gas and feces are seen as hyperechoic reverberation artifact with irregularly marginated, hyperechoic, partial distal acoustic shadowing material. Foreign material within the small intestines should be distinguished from gas and feces within the colon.
An empty colon may appear undulating with distinguishable layers (FIGURE 5).
Nonneoplastic Ileal Wall Thickening
Common inflammatory diseases affecting the ileum can be found in “Ultrasonography of the Gastrointestinal Tract: Stomach, Duodenum, and Jejunum” (January/February 2018) where duodenal and jejunal wall thickening was discussed.
Malignant Ileal Neoplasms
Lymphoma is the most common intestinal neoplasm in the cat. It appears as a focal mass, multiple masses, or diffuse infiltrative neoplasia; characterized by thickening and/or loss of the normal layered appearance of the intestinal wall (FIGURE 6).9,10,14
Adenocarcinoma is the second most common intestinal neoplasm in the cat, appearing as a circumferential transmural thickening with a loss of normal intestinal layering. Predilection sites for adenocarcinoma in the cat are the jejunum and ileum.15
Mast cell tumor is the third most common intestinal neoplasm in the cat. It more commonly involves the small intestines, including the ileum, but can involve the ileo(ceco)colic region or the colon (FIGURE 7).16,17
Sonographic abnormalities of intestinal mast cell tumors in dogs have not been widely reported.
Hemangiosarcoma is a rarely described cause of luminal narrowing in the ileum of cats.18,19
Benign Ileal Neoplasms
Leiomyoma cannot be differentiated from leiomyosarcoma using ultrasonography alone; cytologic or histopathologic diagnoses must be performed to confirm its diagnosis. Leiomyoma is uncommon in the cat.
CECUM AND COLON ABNORMALITIES
Most intussusceptions occur in young dogs and cats and are secondary to viral, bacterial, and parasitic etiologies.
An intussusception has a multilayered appearance in longitudinal axis and concentric ring appearance in transverse axis (FIGURE 8).20-24
Intussusceptions are named according to the segments involved; enteroenteric, ileocolic, and cecocolic intussusceptions are the most common types. An ileocolic intussusception is seen within the ascending and transverse colon. A cecocolic intussusception is short and localized to the area of the cecum and proximal ascending colon. A colocolic intussusception involves the colon only.
Large intestinal neoplasms are not as common as small intestinal neoplasms. Adenocarcinoma25 and lymphoma are most common large intestinal tumors in cats; other large intestinal tumors include mast cell tumor and hemangiosarcoma. Adenocarcinoma and leiomyosarcoma are most common large intestinal tumors in dogs.
Intestinal adenocarcinoma affects the cecum, colon, and mid-to-distal rectum of dogs. This intestinal neoplasia appears nodular, pedunculated, and may cause annular constriction. Ultrasonographically, these neoplasms appear as circumferential transmural thickening with loss of normal intestinal layering (FIGURE 9).
Lymphoma commonly affects the cecum and colon in dogs.
Mast cell tumors can produce focal or diffuse wall thickening of the colon of cats.16,17
Leiomyosarcomas are considered the second most common canine intestinal tumor and the most common intestinal sarcoma in dogs.26 Leiomyosarcoma causes large, eccentrically located, single or multiple, hypoechoic or anechoic area(s) of wall thickening.27 They have a low incidence of developing in the cecum and colon (FIGURE 10).28
Leiomyosarcoma is uncommon in the cat.
Hemangiosarcoma causes luminal narrowing and has been identified in the colon and rectum of cats.18,19
Gastrointestinal stromal tumors arise from the interstitial cells of Cajal; these are cells that regulate intestinal motility and peristalsis. They have histologic features similar to that of intestinal smooth muscle tumors but can be distinguished by immunohistochemistry.29 The predilection sites for these tumors are the cecum and colon, whereas, smooth muscle tumors are more likely to be affect the stomach and small intestine.29
Gastrointestinal stromal tumor has been described in the feline jejunum as a hypoechoic mass with heterogeneous regions.30
Adenomatous polyps are infrequently seen lesions that have been identified in the rectum of dogs and small intestines of cats.15,25 They appear as small, round to ovoid, mixed or varying echogenicity, pedunculated or broad based structures extending into the intestinal lumen; they can arise from the mucosal or submucosal surfaces.31-34There is a great potential for malignant transformation if they are large (FIGURE 11).
Nonneoplastic Wall Thickening
Nonmalignant diseases, such as histiocytic,35 granulomatous,36 and fungal37 colitis, can cause focal wall thickening or masses.
Eosinophilic sclerosing fibroplasia has been described in the ileocecocolic junction and the colon of cats (FIGURE 12);38,39 these lesions appear as masses or focal wall thickening with a loss of normal wall layering, similar to neoplastic lesions.39
Pythiosis can cause multifocal pyogranulomatous infections of the colon, causing focal wall thickening with a loss of wall layering, although an eccentric colonic mural mass was identified in one dog.40
Common intestinal inflammatory bowel diseases, such as lymphocytic-plasmacytic enteritis, are usually associated with mild to moderate wall thickening, affecting several or all intestinal segments with variable severity.35,36 Other ultrasonographic features of intestinal inflammatory diseases include symmetric, mild to moderate wall thickening, affecting primarily the mucosa, submucosa, and/or muscularis layer; diffuse increased echogenicity of the mucosa; or presence of bright mucosal speckles (FIGURE 13).41,42
In severe cases of colitis, the wall layering may be altered or lost. Additionally, micronodular, submucosal hypoechoic and/or anechoic lesions measuring 1 to 3 mm in diameter, representing intraparietal lymphoid follicles, may be present in dogs and cats with inflammatory bowel disease.43
Differentiation between colitis and large intestinal infiltrative neoplasia may be difficult;44 however, according to recent literature, dogs with intestinal tumors had significantly greater wall thickness, loss of wall layering, and more focal lesions than dogs with enteritis.42 Ultimately, histopathology is required to differentiate between colitis and infiltrative neoplasia.44
Common ultrasonographic abnormalities of the dog and cat gastrointestinal tract may have neoplastic or nonneoplastic etiologies and, once identified, may require further diagnostics for definitive diagnosis. A systematic examination of the gastrointestinal tract is a routine part of the complete abdominal evaluation.
- Penninck DG, Nyland TG, Fisher PE, Kerr LY. Ultrasonography of the normal canine gastrointestinal tract. Vet Radiol Ultrasound 1989;30(6):272-276.
- Newell SM, Graham JP, Roberts GD, et al. Sonography of the normal feline gastrointestinal tract. Vet Radiol Ultrasound 1999;40(1):40-43.
- Goggin JM, Biller DS, Debey BM, et al. Ultrasonographic measurement of gastrointestinal wall thickness and the ultrasonographic appearance of the ileocolic region in healthy cats. J Am Anim Hosp Assoc 2000;36(3):224-228.
- Stander N, Wagner WM, Goddard A, Kirberger RM. Normal canine pediatric gastrointestinal ultrasonography. Vet Radiol Ultrasound 2010;51(1):75-78.
- Penninck DG, d’Anjou M. Atlas of Small Animal Ultrasonography. 2nd ed. Ames: Wiley Blackwell; 2015.
- Di Donato P, Penninck D, Pietra M, et al. Ultrasonographic measurement of the relative thickness of intestinal wall layers in clinically healthy cats. J Feline Med Surg 2014;16(4):333-339.
- Larson MM, Biller DS. Ultrasound of the Gastrointestinal Tract. Vet Clin North Am: Small Anim Pract 2009;39:747-759.
- Hahn H, Pey P, Baril A, et al. Ultrasonographic, endoscopic and histological appearances of the caecum in cats presenting with chronic clinical signs of caecocolic disease. J Feline Med Surg 2017;19(2):94-104.
- Mahony OM, Moore AS, Cotter SM, et al. Alimentary lymphoma in cats: 28 cases (1988-1993). JAVMA 1995;207(12):1593-1598.
- Penninck DG, Moore AS, Tidwell AS, et al. Ultrasonography of alimentary lymphosarcoma in the cat. Vet Radiol Ultrasound 1994;35(4):299-306.
- Gladwin NE, Penninck DG, Webster CR. Ultrasonographic evaluation of the thickness of the wall layers in the intestinal tract of dogs. Am J Vet Res 2014;75(4):349-353.
- Winter MD, Londono L, Berry CR, Hernandez JA. Ultrasonographic evaluation of relative gastrointestinal layer thickness in cats without clinical evidence of gastrointestinal tract disease. J Feline Med Surg 2014;16(2):118-124.
- Besso JG, Rault D, Begon D. Feline cecum and ileocecocolic junction: normal ultrasonographic features and clinical applications (abstract). Vet Radiol Ultrasound 2004;45:599.
- Grooters AM, Biller DS, Ward H, et al. Ultrasonographic appearance of feline alimentary lymphoma. Vet Radiol Ultrasound 1994;35(6):468-472.
- Tams TR. Handbook of Small Animal Gastroenterology. 2nd ed. St. Louis: Saunders; 2003.
- Sato AF, Solano M. Ultrasonographic findings in abdominal mast cell disease: a retrospective study of 19 patients. Vet Radiol Ultrasound 2004;45(1):51-57.
- Laurenson MP, Skorupski KA, Moore PF, Zwingenberger AL. Ultrasonography of intestinal mast cell tumors in the cat. Vet Radiol Ultrasound 2011;52(3):330-334.
- Sharpe A, Cannon MJ, Lucke VM, Day MJ. Intestinal haemangiosarcoma in the cat: clinical and pathological features of four cases. J Small Anim Pract 2000;41(9):411-415.
- Culp WT, Drobatz KJ, Glassman MM, et al. Feline visceral hemangiosarcoma. J Vet Intern Med 2008;22(1):148-152.
- Penninck DG, Nyland TG, Kerr LY, Fisher PE. Ultrasonographic Evaluation of Gastrointestinal-Diseases in Small Animals. Vet Radiol Ultrasound 1990;31(3):134-141.
- Larson MM, Biller DS. Ultrasound of the gastrointestinal tract. Vet Clin North Am Small Anim Pract 2009;39(4):747-759.
- Garcia DA, Froes TR, Vilani RG, et al. Ultrasonography of small intestinal obstructions: a contemporary approach. J Small Anim Pract 2011;52(9):484-490.
- Patsikas MN, Papazoglou LG, Papaioannou NG, et al. Ultrasonographic findings of intestinal intussusception in seven cats. J Feline Med Surg 2003;5(6):335-343.
- Patsikas MN, Jakovljevic S, Moustardas N, et al. Ultrasonographic signs of intestinal intussusception associated with acute enteritis or gastroenteritis in 19 young dogs. J Am Anim Hosp Assoc 2003;39(1):57-66.
- Rissetto K, Villamil JA, Selting KA, et al. Recent trends in feline intestinal neoplasia: an epidemiologic study of 1,129 cases in the veterinary medical database from 1964 to 2004. J Am Anim Hosp Assoc 2011;47(1):28-36.
- Cohen M, Post GS, Wright JC. Gastrointestinal leiomyosarcoma in 14 dogs. J Vet Intern Med 2003;17(1):107-110.
- Myers NC, Penninck DG. Ultrasonographic diagnosis of gastrointestinal smooth-muscle tumors in the dog. Vet Radiol Ultrasound 1994;35(5):391-397.
- Beck C, Slocombe RF, O’Neill T, Holloway SA. The use of ultrasound in the investigation of gastric carcinoma in a dog. Aust Vet J 2001;79(5):332-334.
- Frost D, Lasota J, Miettinen M. Gastrointestinal stromal tumors and leiomyomas in the dog: a histopathologic, immunohistochemical, and molecular genetic study of 50 cases. Vet Pathol 2003;40(1):42-54.
- Suwa A, Shimoda T. Intestinal gastrointestinal stromal tumor in a cat. J Vet Med Sci 2017;79(3):562-566.
- Diana A, Penninck DG, Keating JH. Ultrasonographic appearance of canine gastric polyps. Vet Radiol Ultrasound 2009;50(2):201-204.
- Castillo-Alcala F, Mans C, Bos AS, et al. Clinical and pathologic features of an adenomatous polyp of the colon in a domestic ferret (Mustela putorius furo). Can Vet J 2010;51(11):1261-1264.
- Bemelmans I, Kury S, Albaric O, et al. Colorectal hamartomatous polyposis and ganglioneuromatosis in a dog. Vet Pathol 2011;48(5):1012-1015.
- Daure E, Jania R, Jennings S, et al. Ultrasonographic and clinicopathological features of pyloroduodenal adenomatous polyps in cats. J Feline Med Surg 2017;19(2):141-145.
- Hostutler RA, Luria BJ, Johnson SE, et al. Antibiotic-responsive histiocytic ulcerative colitis in 9 dogs. J Vet Intern Med 2004;18(4):499-504.
- Manchester AC, Hill S, Sabatino B, et al. Association between granulomatous colitis in French bulldogs and invasive Escherichia coli and response to fluoroquinolone antimicrobials. J Vet Intern Med 2013;27(1):56-61.
- Schumacher LL, Love BC, Ferrell M, et al. Canine intestinal histoplasmosis containing hyphal forms. J Vet Diagn Invest 2013;25(2):304-307.
- Linton M, Nimmo JS, Norris JM, et al. Feline gastrointestinal eosinophilic sclerosing fibroplasia: 13 cases and review of an emerging clinical entity. J Feline Med Surg 2015;17(5):392-404.
- Weissman A, Penninck D, Webster C, et al. Ultrasonographic and clinicopathological features of feline gastrointestinal eosinophilic sclerosing fibroplasia in four cats. J Feline Med Surg 2013;15(2):148-154.
- Graham JP, Newell SM, Roberts GD, Lester NV. Ultrasonographic features of canine gastrointestinal pythiosis. Vet Radiol Ultrasound 2000;41(3):273-277.
- Baez JL, Hendrick MJ, Walker LM, Washabau RJ. Radiographic, ultrasonographic, and endoscopic findings in cats with inflammatory bowel disease of the stomach and small intestine: 33 cases (1990-1997). JAVMA 1999;215(3):349-354.
- Penninck D, Smyers B, Webster CR, et al. Diagnostic value of ultrasonography in differentiating enteritis from intestinal neoplasia in dogs. Vet Radiol Ultrasound 2003;44(5):570-575.
- Citi S, Chimenti T, Marchetti V, et al. Micronodular ultrasound lesions in the colonic submucosa of 42 dogs and 14 cats. Vet Radiol Ultrasound 2013;54(6):646-651.
- Carrasco V, Rodriguez-Bertos A, Rodriguez-Franco F, et al. Distinguishing intestinal lymphoma from inflammatory bowel disease in canine duodenal endoscopic biopsy samples. Vet Pathol 2015;52(4):668-675.