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THE DILATED FETAL BOWEL

Normal small bowel

The normal fetal bowel varies in appearance during gestation. The small bowel appears brighter than the liver. The fetal small bowel can be seen sonographically as early as 12 weeks of gestation. Between 12-16 weeks, it appears homogenous.

\\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\1.jpg

Meconium accumulates in the small bowel from the early 2nd trimester.

\\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\2.jpg

As pregnancy progresses, the bowel becomes more heterogenous, centrally located and well defined with echogenic walls and hypoechoic contents. Late in pregnancy discrete fluid filled loops of bowel can be seen in virtually all fetuses.

\\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\4.jpg   \\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\3.jpg

Individual segments of small bowel should not exceed approximately 7-10 mm in diameter and 15 mm in length.

Peristalsis within the fetal bowel can be seen as early as 16 weeks of gestation.

Normal large bowel

The large bowel is not clearly recognizable with prenatal sonography until the early third trimester. Thereafter it becomes increasingly easy to recognize.

\\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\5.png

The colon frames the fetal ab domen, appearing as a continuous tube with a hypoechoic lumen.

The normal colon can be erroneously considered dilated small bowel. The identification of haustral folds, peripheral location, hypoechoic appearance and minimal peristalsis should allow small bowel to be distinguished from colon. The large bowel is seen ascending on the right side in the fetal abdomen to the hepatic flexure, transverse to the splenic flexure and inferior to the sigmoid and rectum.

The large bowel exhibits wide variation in diameter but rarely exceeds 23-26 mm.

 

The dilated bowel

 

The fetal bowel can be altered by a number of pathological processes. The commonest pathology is a bowel dilatation characteristically recognized as one or more tubular structures within the fetal abdomen. Bowel dilatation is due to obstruction which may either

  •   Mechanical
  •   Functional

Mechanical obstruction – result from either

 

      · Intrinsic lesions – like absent (atresia) or partial recanalization (stenosis) of the intestine. In cases of atresia, the two segments of the gut may  be either completely separated or connected by a fibrous cord. In cases of stenosis, the lumen of the gut is narrowed or the two intestinal segments are separated by a septum with a central diaphragm.

 

  · Extrinsic obstructions – are caused by malrotation of the colon with volvulusmeconium ileus, and agangliosis.

Functional causes - for bowel obstruction include congenital chloride diarrhoeamicrocystis megacolon intestinal hypoperistalsis syndrome.

 

USG appearance

 

·         Most intestinal obstructive disorders do not occur until the third trimester (a second trimester scan is usually normal).

·         Multiple interconnecting over distended bowel loops.

         \\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\6.jpg   \\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\7.jpg

  • Individual small bowel loops of >15 mm in length or 7 mm in diameter and large bowel > 23 mm in diameter
  • The number of dilated bowel loops depends on the level of obstruction (the lower the level the greater the number).
  • Peristalsis in the obstructed loops confirms that we are indeed looking at bowel.

\\Fileserver\mediscan\doctors\FELLOWSHIP\DR. PREETI\PREETI CUSP\images\INTEST OBSTRUCTION\4979878.jpg          \\Fileserver\mediscan\doctors\FELLOWSHIP\DR. PREETI\PREETI CUSP\SLIDES\HIRSCH\4212450.jpg

·         Polyhydramnios (more common in higher obstructions).

·         Complications include bowel obstruction, perforation and ischemic necrosis due to vascular compromise which may be seen as intra abdominal calcification, ascites and matted bowel loops.

 

Pitfalls

The following conditions can mimic a dilated bowel

1.      Normal meconium filled colon mistaken for abnormally dilated small bowel

\\Fileserver\mediscan\doctors\FELLOWSHIP\DR. PREETI\normal bowel\6783964.jpg

             2.      Normal dilatation of intestinal loops due to peristalsis

             3.      Renal tract anomalies – multicystic dysplastic kidney, dilated ureter  

         \\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\9.jpg    \\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\8.jpg

                                MCDK                                                             hydroureter

 

Intestinal obstruction

 

Obliteration of single or multiple segments of small or large bowel causing obstruction and segmental dilatation.

        1 per 2000 live births

        More than one third of congenital bowel obstructions result from intestinal atresias

         In about half the cases there is small bowel obstruction and in the other half, anorectal atresia.

 

Small bowel obstruction 

 

a. Jejuonoileal atresiaThe most frequent site of small bowel obstruction is distal ileum (35%), followed by proximal jejunum (30%), distal jejunum (20%), and proximal ileum (15%).

\\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\10.jpg

Jejunoileal atresia is commonly categorized as follows

  • Type I – Membrane
  • Type II – Blind ends joined by fibrous cord
  • Type IIIa – Disconnected blind end
  • Type IIIb – Apple-peel deformity
  • Type IV – Multiple, string of sausages

 

 

 

 

JEJUNAL

ILEAL

  • No. Of atresias
  • Multiple
  • Usually solitary
  • Degree of dilatation
  • Marked dilatation of loops
  • Usually only minor dilatation of a few loops
  • Enlargement of stomach & duodenum
  • Common
  • Uncommon
  • Perforation
  • Unusual
  • Common
  • Ascites
  • Very rare
  • Frequent
  • Polyhydramnios
  • Frequent
  • Rare
  • Peritoneal calcification
  • Frequent
  • Frequent
  • Associated anomalies
  • Frequent
  • Rare

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Meconium ileus

 

        Impaction of abnormally thick and sticky meconium in the distal ileum-functional obstruction

        Nearly all newborns have cystic fibrosis

        Dilated bowel segments containing echogenic meconium - usually seen after 26 weeks

        USG findings include

  • Polyhydramnios
  • Dilated bowel loops
  • Meconium peritonitis
  • Abnormal areas of increased echogenicity

        All the above findings are non specific and definitive diagnosis is difficult.

 

 

 

\\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\11.jpg

 

Large bowel obstruction

 

Large bowel obstruction is rare and more difficult to diagnose because of wide variations in the diameter of a healthy fetus’s colon. Abnormalities of the large bowel causing a bowel dilatation include Anorectalatresia and Hirschsprung disease.

 

a.      Anorectal atresia

·        1 in 2000 births

·        Rarely seen as dilated colon in the lower abdomen or pelvis

·        Calcified intraluminal meconium pellets seen either proximal or distal to the site of obstruction

·        Amniotic fluid volume usually normal. May be reduced when associated with bilateral renal disorders.

\\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\12.jpg

b.            Hirschsprung disease

·        Characterized by congenital absence of intramural myenteric nerve ganglia and sympathetic nerve plexus in a bowel segment.

·        1 in 10000 to 20000.

·        Rarely presents prenatally, but when it does it is usually due to total colonic agangliosis.

·        Sonographic features are non specific and rare. May be seen as dilated bowel segments and mild polyhydramnios

\\Fileserver\mediscan\Cusp 2010\SB " SC CUSP\IMAGES dilated fetal bowel\13.jpg

Volvulus

·        Bowel loops twist around the mesenteric artery or it’s branches.

·        The ischemic necrosis may lead to intestinal atresia

·        Characteristic ultrasound marker- ‘Whirlpool sign’ – the twisted bowel loop and it’s accompanying mesentery and mesenteric vessels exhibit a whirlpool like configuration. But this sign is not depicted in all cases.

·        Other non specific sonographic appearance includes – dilated bowel loops, ascitespolyhydramnios, intra abdominal cystic mass.

\\Fileserver\mediscan\doctors\FELLOWSHIP\DR. PREETI\PREETI CUSP\images\VOLVULUS\4169370.jpg

 

Congenital chloride diarrhoea

·        Rare

·        Autosomal recessive

·        Disorder of chloride transport in distal ileum and colon

·        USG – moderately dilated intestinal fluid filled loops (entire jejunum and ileum) with good peristalsis.

 

 Conclusion

 

Ultrasound can differentiate a dilated small bowel from dilated large bowel. However the prenatal ultrasound demonstrates true insufficiencies in fixing the precise etiology.

 

Normal fetal bowel has a wide range of appearances. It is therefore important to be aware of the various patterns attributable to the normal gastrointestinal tract and consider the possibility of normal bowel or a process arising elsewhere in the fetus before diagnosing a gastrointestinal abnormality.

 

Nevertheless, a simple dilatation of the bowel may refer to a more severe disorder e.g. bowel volvulus, multiple atresiameconium ileus or a megacystis micro colon intestinal hypoperistalsis syndrome. Hence a pre natal estimation of the problem helps us to be better prepared on arrival of the neonate.

 

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