Sonography of fetal GIT

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A systematic approach to address the challenges faced in the examination and prenatal diagnosis of fetal GIT anomalies

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Sonography of fetal GIT

  1. 1. Ultrasound Diagnosis of Anomalies of the Fetal GIT “A Systematic Approach” Professor Hassan Nasrat FRCS, FRCOG www.hassannasrat.com JUCOG November 2013 Thursday, November 28, 13
  2. 2. Challenges in Sonography of the Fetal GIT ★Overlap Between Appearance Of Normal And Abnormal Fetal Bowel. Thursday, November 28, 13
  3. 3. Challenges in Sonography of the Fetal GIT MY OF THE GASTROINTESTINAL TRACT Overlap Between Appearance NAL WALL: ULTRASOUND APPROACH, Of Abnormal Fetal Bowel. LANES, AND DIAGNOSTIC POTENTIAL ★ Normal And ointestinal (GI) tems is that its ly during pregrse of the same iology of swalperistalsis. It is nted with the should also be or solid mass o be difficult to cystic anechoic agnoses accordhe adjacent visyst, choledochal Axial view of upper abdomen fetus. Note adrenal hemor- the Figure 7.1 Axial in a 35-week-oldabdomen in a the dilatation of the colon 35-week-old fetus. with the haustra. This finding may view of the upper an obstruction or may be normal, be indicative of ally, it should Note the dilatation of the colon with the haustra. This finding may be Thursday, November 28, 13
  4. 4. Challenges in Sonography of the Fetal GIT ★Appearance Varies Significantly During The Course Of Pregnancy And During The Course Of The Same Examination. 15 wks Thursday, November 28, 13 24 wks 36 wks
  5. 5. Challenges in Sonography of the Fetal GIT ★Overlap Between Appearance Of Normal And Abnormal Fetal Bowel. ★Appearance Varies Significantly During The Course Of Pregnancy And During The Course Of The Same Examination. ★Difficulty To Identify The The Origin Of Abnormal Sonographic Signs E.g. Cystic Or Solid Mass. ★Obstructive Trimester. Thursday, November 28, 13 Lesions Becomes Evident In The 3rd
  6. 6. Prenatal Ultrasonographic Detection Of Gastrointestinal Obstruction: Results From 18 European Congenital Anomaly Registries. EUROSCAN Study 52% 40% 34% 29% 25% 8% Overall Esophageal Duodenal Small B. Large B. Anal Atresia Haeusler MC, Berghold A, Stoll C, Barisic I, Clementi M, EUROSCAN Study Group Prenat Diagn. 2002;22(7):616. Thursday, November 28, 13
  7. 7. Ultrasound Diagnosis of Anomalies of the Fetal GIT “A Systematic Approach” Thursday, November 28, 13
  8. 8. ✤ Normal Sonographic Appearance of the GIT Tract. ✤ Systemic Approach to Fetal GIT Sonography. ✤ Sonographic Signs suggestive of Anomalies. Thursday, November 28, 13
  9. 9. ✤ Normal Sonographic Appearance of the GIT Tract. ✤ Systemic Approach to Fetal GIT Sonography. ✤ Sonographic Signs suggestive of Anomalies. Thursday, November 28, 13
  10. 10. Physiologic Midgut Herniation Physiologic Midgut Herination Between 9-11th Week Due To Rapid Growth Of The Intestine And Liver Beyond The Capacity Fo Of The Abdominal Cavity, Reduced By 12th Week Thursday, November 28, 13
  11. 11. Esophagus 30 Wks pharynx • The Fetal Esophagus Is Normally Collapsed And Typically Not Visualized. • Swallowing Occurs By 11 To 14 Weeks Of Gestation. Phases Of Swallowing Can Occur At 20-30 Minutes. Thursday, November 28, 13
  12. 12. Esophagus 30 Wks pharynx • The Fetal Esophagus Is Normally Collapsed And Typically Not Visualized. • Swallowing Occurs By 11 To 14 Weeks Of Gestation. Phases Of Swallowing Can Occur At 20-30 Minutes. Thursday, November 28, 13
  13. 13. Sagital Coronal Thursday, November 28, 13 Axial Render
  14. 14. Thursday, November 28, 13
  15. 15. Thursday, November 28, 13
  16. 16. Thursday, November 28, 13
  17. 17. Thursday, November 28, 13
  18. 18. Bowel In First And Second Trimesters: 15 wks • Fluid In The Lumen After 13 Weeks. Peristalsis Can Be Observed As Early As 18 Weeks. • The Colon Is Best Visualized After 24 Weeks. As Hypoechoic Regions Along The Periphery Of The Abdomen. 25 wks Late Second and Third Trimesters: • Increased echogenicity with accumulation of Meconium. • Normal small bowel loops do not exceed 7 mm in diameter or 15 mm in length. • The large colon can achieve a diameters up to 23 mm at term. Thursday, November 28, 13 36 wks
  19. 19. Magnetic resonance images of normal fetal bowel Normal fetal bowel at 24 weeks of gestation. (A) T2w coronal image shows high signal fluid filled loops of bowel throughout the abdomen. Minimal low signal meconium can be seen in the pelvis. (B) T1w coronal image better demonstrates high signal meconium filling the rectosigmoid and descending colon. Thursday, November 28, 13
  20. 20. ✤ Normal Sonographic Appearance of the GIT Tract. ✤ Systemic Approach to Fetal GIT Sonography. ✤ Sonographic Signs suggestive of Anomalies. Thursday, November 28, 13
  21. 21. Ultrasound Approach And Scanning Planes ★Cranial Views: ( Mouth, Pharynx, And Esophagus). ★Abdominal Views ( Ileum, Jejunum, Colon, Abdominal Wall) ★Views Of GIT Related Organs ( Liver, Spleen). Thursday, November 28, 13
  22. 22. Ultrasound Approach And Scanning Planes ★Cranial Views: ( Mouth, Pharynx, And Esophagus). ★Abdominal Views ( Ileum, Jejunum, Colon, Abdominal Wall) ★Related Intra-abdominal Organs ( Liver, Spleen). Thursday, November 28, 13
  23. 23. 208 08 a a ULTRASOUND OF CONGENITAL FETAL ANOM ULTRASOUND OF CONGENITAL FETAL ANOMAL Cranial Views ( Lips, Mouth, Pharynx) b b Axial View Oblique View Of views for the assessmentOf The Mouth With The Figure Cranial of upper gastrointest gure 7.27.2Cranial views for the assessment of(T) And, Behind, The Tongue thethe upper gastroint The Lips alnal tract (mouth and pharynx). (a) Oblique view of the lips. (b) A tract (mouth and pharynx). (a) ObliqueOropharynxthe lips. (b) Axi view of (arrows) Thursday, November 28, 13
  24. 24. ANOMALIES OF THE GAST The Esophagus (The Neck) Sagital And Coronal Views a a Neck c c (hypopharynx And Esophagus) Sagittal View Thursday, November 28, 13 b d b a The Same Region Shown In The d Coronal View, Using Threeb dimensional Volume Contrast Imaging.
  25. 25. The Esophagus (The Chest) Sagital And Axial Views cc dd Esophagus Sagittal View Thursday, November 28, 13 Axial 4-chamber View
  26. 26. Ultrasound Approach And Scanning Planes ★Cranial Views: ( Mouth, Pharynx, And Esophagus). ★Abdominal Views ( Ileum, Jejunum, Colon, Abdominal Wall) ★Related Intra-abdominal Organs ( Liver, Spleen). Thursday, November 28, 13
  27. 27. Right Para Sagittal View: Rt Hepatic Lobe Midsagittal View: The Cord Insertion And Rectal Pouch In The Pelvis Axial View Of The Upper Abdomen: Stomach And Right Hepatic Lobe Axial View Of The Lower Abdomen: Small Bowel Coronal View 3 D Imaging Thursday, November 28, 13 Left Para Sagittal View: The Stomach & Spleen
  28. 28. Axial View Of The Upper Abdomen: Stomach And Right Hepatic Lobe a Axial View Of The Upper Abdomen: b On The Left, The Gastric Bubble. On The Right, Most Of The Liver, Appears As A Weakly Hyperechogenic Structure. The Intrahepatic Tract Of The Umbilical Vein. Thursday, November 28, 13
  29. 29. Axial View Of The Lower Abdomen: Small Bowel b a) Sagittal s (arrowme amnie coronal CI-C). (c) Axial View Of The Lower Abdomen (ventral Approach) sophagusThe Bowel (ileus And Jejunum) And A Small Segment Of The Umbilical Vein (arrow) Are Figure 7.4 Axial abdominal views (stomach, bowel, liver, and on the 4spleen). (a) Axial view of the upper abdomen: the stomach is visible on Visible. he tempothe left, the right hepatic lobe on the right, and the intrahepatic tract of abnormal 28, 13 umbilical vein on the midline. (b) Axial view of the lower abdomen the Thursday, November
  30. 30. Midsagittal View: The Cord Insertion And Rectal Pouch In The Pelvis b 07-Ultrasound 8015.qxd 210 The Rectal Pouch Appears Filled With Hypoechoic Meconium Appears In The Pelvis Behind The Bladder 3/27/2007 3:22 PM Page 210 ULTRASOUND OF CONGENITAL FETAL ANOMALIES a c Small Part Of The Small Bowel Mid-sagital View (Ventral) Showing Cord Insertion And Rectal Pouch Of The Pelvis Thursday, November 28, 13 b
  31. 31. Right Para Sagittal View: Rt Hepatic Lobe c Rt. Para-Sagital View Showing The Rt. Lung, The Diaphragm, Rt Hepatic Lobe And Bowel Loops Figure 7.5 Other abdominal views (liver, abdominal wall, an rectum). (a) Midsagittal view of the abdomen: the cord insertio Thursday, November 28, 13
  32. 32. Coronal View 3 D Imaging The Right Lung The Diaphragm The Gall Bladder Coronal View Showing Topography Of Abdominal Organs Thursday, November 28, 13
  33. 33. Ultrasound Views Used In Examination Of Fetal Abdomen And Related Malformations Axial View Of The Upper Abdomen ★ Esophageal Atresia: ★ Duodenal Atresia/stenosis: ★ Hepatomegaly: ★ Splenomegaly: Axial View Of The Lower Abdomen ★Omphalocele: ★Gastroschisis: ★Choledochal Cyst: ★Small-bowel Atresia: ★Meconium Ileus: Mid-Sagital View ★Omphalocele, Gastroschisis. ★In Some Cases, Bladder And Cloacal Extrophy. Right Para-sagital Left Para-sagital Coronal View Thursday, November 28, 13 ★RL, Right Lung. ★Diaphragm (arrowheads). ★The Right Hepatic Lobe (Li). ★Some Ileal Loops. ★The Stomach And The Spleen ★Esophageal Atresia: ★Duodenal Atresia /stenosis: ★Hepatomegaly: ★Choledochal Cyst: ★Enteric Duplication Cyst: ★Splenomegaly: ★Small-bowel Atresia: ★Meconium Ileus:
  34. 34. ✤ Normal Sonographic Appearance of the GIT Tract. ✤ Systemic Approach to Fetal GIT Sonography. ✤ Sonographic Signs suggestive of Anomalies. Thursday, November 28, 13
  35. 35. Ultrasound Signs Suggestive Of GIT Anomalies ✦Non-visualization Of The Gastric Bubble. ✦Cystic Lesions . ✦Dilated Small Bowel. ✦Dilated Large Bowel. ✦“Echogenic Bowel”. ✦Large Liver / Spleen. ✦Abdominal Wall Defects Thursday, November 28, 13
  36. 36. ✦Non-visualization Of The Gastric Bubble. Thursday, November 28, 13
  37. 37. Non Visualization of the Stomach Rule out physiologic Emptying. Thursday, November 28, 13
  38. 38. Non Visualization of the Stomach Normal Amniotic Fluid Rule out physiologic Emptying. Thursday, November 28, 13 Absent Amniotic Fluid
  39. 39. Non Visualization of the Stomach Normal Amniotic Fluid Rule out physiologic Emptying. Thursday, November 28, 13 Absent Amniotic Fluid •PROM •Sever FGR •Bilateral Renal Agenesis
  40. 40. Non Visualization of the Stomach Normal Amniotic Fluid Associated Anomalies? Rule out physiologic Emptying. Thursday, November 28, 13 Absent Amniotic Fluid •PROM •Sever FGR •Bilateral Renal Agenesis
  41. 41. Non Visualization of the Stomach Normal Amniotic Fluid Associated Anomalies? Yes Rule out physiologic Emptying. Thursday, November 28, 13 Absent Amniotic Fluid •PROM •Sever FGR •Bilateral Renal Agenesis
  42. 42. Non Visualization of the Stomach Normal Amniotic Fluid Absent Amniotic Fluid •PROM •Sever FGR •Bilateral Renal Agenesis Stomach in Thorax Lt. Sided Diaphragmatic Hernia Associated Anomalies? Yes Contractures Facia Cleftings Rule out physiologic Emptying. Thursday, November 28, 13
  43. 43. Non Visualization of the Stomach Normal Amniotic Fluid Absent Amniotic Fluid •PROM •Sever FGR •Bilateral Renal Agenesis Stomach in Thorax Lt. Sided Diaphragmatic Hernia Associated Anomalies? Yes Contractures Facia Cleftings Rule out physiologic Emptying. Thursday, November 28, 13 FADS fetal akinesia deformation sequence
  44. 44. Non Visualization of the Stomach Normal Amniotic Fluid Absent Amniotic Fluid •PROM •Sever FGR •Bilateral Renal Agenesis Stomach in Thorax Lt. Sided Diaphragmatic Hernia Associated Anomalies? Yes Contractures Facia Cleftings Rule out physiologic Emptying. Thursday, November 28, 13 FADS fetal akinesia deformation sequence Cleft Lip/plalte
  45. 45. Non Visualization of the Stomach Normal Amniotic Fluid Associated Anomalies? Yes Absent Amniotic Fluid No Stomach in Thorax Contractures Facia Cleftings Rule out physiologic Emptying. Thursday, November 28, 13 •PROM •Sever FGR •Bilateral Renal Agenesis Esophageal Atresia Lt. Sided Diaphragmatic Hernia FADS fetal akinesia deformation sequence Cleft Lip/plalte
  46. 46. Non Visualization of the Stomach Normal Amniotic Fluid Associated Anomalies? Yes Absent Amniotic Fluid No Stomach in Thorax Contractures Facia Cleftings Rule out physiologic Emptying. Thursday, November 28, 13 •PROM •Sever FGR •Bilateral Renal Agenesis Esophageal Atresia Lt. Sided Diaphragmatic Hernia FADS fetal akinesia deformation sequence Cleft Lip/plalte
  47. 47. Esophageal Atresia Incidence: 1 /2500–1 /4000 Live Births. Thursday, November 28, 13
  48. 48. Esophageal Atresia Incidence: 1 /2500–1 /4000 Live Births. Etiology: Failure Of Division Of The Primitive Foregut Into The Ventral Tracheobronchial Part And The Dorsal Digestive Part Around About 8 Weeks Of Gestation. Associated Anomalies: ✦Chromosomal Extent, 18. Anomalies: (20–44%): Trisomies 21 And, To A Lesser ✦Non-chromosomal Syndromes: 50 % Have Additional Anomalies. Cardiac Malformations (25%). VACTERL (vertebral, Anal Atresia, Cardiac, Tracheoesophageal Fistula, Renal, Limb) Thursday, November 28, 13
  49. 49. 5T ypes of Esophageal atresia With a distal Fistula without fistula (85 %) (8 %) with fistula to both esophageal segments (<1 %) Isolated fistula No With proximal esophageal atresia Fistula (<4 %) (1%) Proximal Esoph. Trachea Distal Esoph. The Presence Of TE Fistula Is Responsible For The Poor Prenatal Diagnosis Of Esophageal Atresia. Thursday, November 28, 13
  50. 50. 5T ypes of Esophageal atresia With a distal Fistula without fistula (85 %) (8 %) with fistula to both esophageal segments (<1 %) Isolated fistula No With proximal esophageal atresia Fistula (<4 %) (1%) Proximal Esoph. Trachea Distal Esoph. The Presence Of TE Fistula Is Responsible For The Poor Prenatal Diagnosis Of Esophageal Atresia. Thursday, November 28, 13
  51. 51. Ultrasound Findings Diagnostic Triad (8-10 % In Cases): ✦Polyhydramnios: Becomes Evident In The Late 2nd Trimester. ✦Absent/Small Stomach: In 85% Of Cases It Is Visible. ✦The “Pouch Sign”: Dilated Proximal Esophageal Pouch. The Overall Detection Rate, Considering All Possible Signs Of Esophageal Atresia Is In The Range Of 24–42% Thursday, November 28, 13
  52. 52. Risk of non-chromosomal syndromes. Relatively high: VA(C)TER(L). Risk of non-chromosomal syndromes. Relatively high: VA(C)TER(L Absent/Small Stomach Outcome. Generally good, but depends mainly on the extent of the at Outcome. Generally good, but depends mainly on the extent of the a Confirmed Diagnosis at 30 weeks Suspected Diagnosis at 23 weeks a a b b Text persistent non-visualization of the gastric with development of polyhydramnios bubble in the abdomen. and the communication Definition. Definition. In esophageal atresia, the communication visualized. an atresia, the stomach is still not Etiology a Etiology between between the proximal and the distal tract of the esophagus the distal tract of the esophagus is absent, is absent, due to a lack of development of the intermediate development of the intermediate Thursday, November 28, 13 unknown. unknown the primit the primi
  53. 53. The Pouch Sign Sagittal view of the fetal neck, showing the course of the esophagus which is temporarily dilated by the swallowing of some amniotic fluid. Thursday, November 28, 13 The Coronal View, Using Threedimensional Volume Contrast Imaging .
  54. 54. Rendered three-dimensional ultrasound image of the fetus showing the pouch in the fetal mediastinum, and the trachea. The pouch extended to the level of the C7 vertebrae. Thursday, November 28, 13 MRI partially revealed the characteristic pouch sign. Esophageal atresia diagnosed with three-dimensional ultrasonography Ultrasound Obstet Gynecol 2005; 26: 307–308
  55. 55. Esophageal atresia Obstetric Management ★ Assessed For Associated Anomalies. ★ Genetic Amniocentesis. ★ Delivery At Tertiary Care Center. ★ Esophageal Abnormalities Alone Are For Altering The Route Of Delivery. Outcome: •The Extent Of The Atretic Tract. •Associated Anomalies. Thursday, November 28, 13 Not An Indication
  56. 56. Ultrasound Signs Suggestive Of GIT Anomalies ✦Non-visualization Of The Gastric Bubble. ✦Cystic Lesions (Double Bubble And Its DD). ✦Dilated Small Bowel. ✦Dilated Large Bowel. ✦Echogenic Bowel”. ✦Large Liver / Spleen. ✦Abdominal Wall Defects Thursday, November 28, 13
  57. 57. Persistent right Umbilical vein Cystic Lesions Urachal Cysts Umbilical Vein Varices Mesenteric cysts Ureterocele Choledochal cysts Enteric Duplication Cysts Hepatic cysts Duodenal Atresia Splenic Cysts Ovarian Cysts Multicystic Dysplastic Kidney Dilatation of the renal pelvis Adrenal Hemorrhage Duplex kidney For final diagnosis both the location of the mass and its ultrasound appearance should be taken in consideration Thursday, November 28, 13
  58. 58. Persistent right Umbilical vein Cystic Lesions Urachal Cysts Umbilical Vein Varices Mesenteric cysts Ureterocele Choledochal cysts Enteric Duplication Cysts Hepatic cysts Duodenal Atresia Splenic Cysts Ovarian Cysts Multicystic Dysplastic Kidney Dilatation of the renal pelvis Adrenal Hemorrhage Duplex kidney For final diagnosis both the location of the mass and its ultrasound appearance should be taken in consideration Thursday, November 28, 13
  59. 59. DUODENAL ATRESIA 22 wks Definition: The Tract Between The Proximal And Distal Portions Of The Duodenum Is Atretic. Thursday, November 28, 13
  60. 60. Incidence: 1/2500 - 1/10 000 Life Births. Atresia Accounts For Up To 75 Percent Of Intestinal Obstructions. Associated Anomalies: •Chromosomal Anomalies: Up To 40% Association With DS. • Non Chromosomal Anomalies: 40–50% Of Cases. (other GI, Vertebral (33%), Cardiac Anomalies (30%). Intestinal Malrotation (40%), More Severe Anomalies Of The Biliary Tract And Of The Pancreas (annular Pancreas). Thursday, November 28, 13
  61. 61. Incidence: 1/2500 - 1/10 000 Life Births. Atresia Accounts For Up To 75 Percent Of Intestinal Obstructions. The Etiology: Is Unknown. The Pathogenetic: Interruption Of Blood Supply During Organogenetic Period. Or Lack Of Duodenal Recanalization. Associated Anomalies: •Chromosomal Anomalies: Up To 40% Association With DS. • Non Chromosomal Anomalies: 40–50% Of Cases. (other GI, Vertebral (33%), Cardiac Anomalies (30%). Intestinal Malrotation (40%), More Severe Anomalies Of The Biliary Tract And Of The Pancreas (annular Pancreas). Thursday, November 28, 13
  62. 62. 3 Types of DUODENAL ATRESIA Type 1 The muscular wall is intact But Membranous mucosal atresia (69%) Type 2 Short fibrous cord connects the two ends of the atretic duodenum duodenum Thursday, November 28, 13 Type 3 Complete separation of the two ends plus biliary tract anomalies duodenum
  63. 63. Ultrasound Findings ★The classic double bubble With communication in between. ★ Associated polyhydramnios. aa bb Duodenal atresia. (a) At 23 weeks of gestation, initial evidence of a double bubble is detected (arrow). (b) After a few minutes, intestinal peristalsis demonstrates the communication between the stomach c (st) and the dilated proximal duodenum. dd c Thursday, November 28, 13
  64. 64. Ultrasound Findings cc dd Later 7.10 Figure in gestation, a clear double atresia. (a)has Three-dimensional gestation, initial eviDuodenal bubble (arrow) At 23 weeks of ultrasound with inversion Figure 7.10 Duodenal atresia. (a) At 23rendering: the site of the obstruction is developed, confirming the suspicion of duodenal mode weeks of gestation, initial ev dence of a double bubble is detected visible. atresia. clearly (arrow). (b) After a few dence of a double bubble is detected (arrow). (b) After a fe minutes, intestinal peristalsis demonstrates the communication between Thursday, November 28, 13
  65. 65. Ultrasound Findings • In the absence of communication between stomach and Duodenum the DD of other upper abdominal cysts should be considered. • Type 2 and 3 of duodenal stenosis are rarely diagnosed prenatally. • May be suspected late in pregnancy because of a constantly dilated stomach with evidence of the pylorum in late gestation. Thursday, November 28, 13
  66. 66. Duodenal Atresia Obstetric Management ★Karyotyping. ★Search For Associated Malformations (including Fetal Echocardiography). ★Measures Against Risk Of Preterm Delivery Because Of The Severe Polyhydramnios. ★Delivery In A Tertiary Referral Center. Prognosis: ✤ Isolated cases have have overall survival of about 90% ✤ Late- onset sequelae: e.g. megaduodenum, duodenogastroesophageal reflux, and peptic ulcers. Thursday, November 28, 13
  67. 67. Ultrasound Signs Suggestive Of GIT Anomalies ✦Non-visualization Of The Gastric Bubble. ✦Cystic Lesions (Double Bubble And Its DD). ✦Dilated Small Bowel. ✦Dilated Large Bowel. ✦Echogenic Bowel”. ✦Large Liver / Spleen. ✦Abdominal Wall Defects. Thursday, November 28, 13
  68. 68. ✦Dilated Small Bowel. ✴Ileal & Jejunal Atresia. ✴Meconium Ileus. Thursday, November 28, 13
  69. 69. Ultrasound Findings Suggestive Of GIT Malformations Axial View Of The Upper Abdomen ★Non-visualization Of The Gastric Bubble. ★Double Bubble. Coronal View Thursday, November 28, 13 Axial View Of The Lower Abdomen ★Dilated Bowel Loops. ★Echogenic Bowel. ★Cystic Lesions. Right Parasagital ★Rt. Lung. ★Diaphragm. ★The Rt. Hepatic Lobe. ★Some Ileal Loops. Left Parasagital ★The Stomach & The Spleen
  70. 70. Ileal & Jejunal ATRESIA Incidence: 1 /2500–1 /5000 Live Births. Diagnosis: Dilatation Of The Ileal Loops Proximal To The Obstruction. Polyhydramnios. • • Associated Anomalies: Low Risks Of Both Chromosomal And Non-chromosomal Syndromes. Pathogenesis: Intrauterine Vascular Accidents Leading To Ischemic Necrosis Of The Bowel And Resorption Of The Affected Segment. Thursday, November 28, 13
  71. 71. Types Of Jejunal And Ileal Atresia Poor Prognosis Type I 20% Intraluminal Membrane With Intact Bowel Wall & Mesentery Thursday, November 28, 13 Type II 35% Blind Ends Are Separated By A Fibrous Cord Type IIIa 35% Blind Ends Are Separated By AVshaped Mesenteric Defect Type IIIb “Apple-peel” type extensive mesenteric defect and a loss of the normal blood supply to the distal bowel. Type IV 5% Multiple segments of bowel atresia
  72. 72. Ileal Atresias Jejunal Atresias •More Often Single. • More Often Multiple. •Higher Tendency To • Tend To Dilate Rather •Higher Birth Weight. • Low Birth Weight. •Lesser Risk Of PTL. • More Tendency To PTL. Perforation. Thursday, November 28, 13 Than To Perforate.
  73. 73. Ultrasound Findings 24 Weeks Suspected Abnormal Dilatation Axial Midlevel Abdominal Scan At 24 Weeks Showing Doubtful Sign Of Atresia •Moderate Dilatation (>7mm) Of A Single Ileal/jejunal Loop. •Hyperechoic Bowel Walls. Thursday, November 28, 13
  74. 74. Ultrasound Findings Same case at third trimester The obstruction becomes evident, with moderately severe dilatation of various loops. Thursday, November 28, 13 At 36 Weeks The communication between the various dilated segments (the maximum transverse diameter of the loops was 23 mm).
  75. 75. Jejunal Atresia (37 Weeks Of Gestation) With Extremely Severe Dilatation Without Evidence Of Perforation (absence Of Meconium Peritonitis). Differentiate Between Ileal Or Jujenal Atresia Is Difficult. The Only Points Are The Evidence Of Intestinal Perforation (ascites With Particulate Matter And/or Calcifications) For The Ileal Or Extreme Dilatation Without Perforation For The Jejunal. Thursday, November 28, 13
  76. 76. Axial View at 27 weeks gestation showing several dilated loops of fluid filled bowel. Postnatally confirmed isolated ileal atresia. Thursday, November 28, 13
  77. 77. Differential Diagnosis: ✴ Hirschprung’s Disease (Aganglionic Megacolon) ✴ Volvulus (Appears Over 3-4 Days). ✴ Meconium Ileus . Thursday, November 28, 13
  78. 78. MECONIUM ILEUS A Mechanical ileal obstruction due to the increased consistency of meconium. It carries significant risk of perforation and consequent meconium peritonitis with a consequent severe adhesive peritonitis Associated Anomalies: Cystic Fibrosis (Approximately 10% of infants with cystic fibrosis develop meconium ileus and 90% of infants presenting with meconium ileus) Thursday, November 28, 13
  79. 79. Ultrasound Findings Macrocalcifications demonstrates the perforation dilatation of ileal loops with hyperechoic walls (arrow) Axial scan at 29 weeks Thursday, November 28, 13
  80. 80. Ultrasound Findings Oblique View Of The Same Case Demonstrates The Presence Of A Secluded Sac Of Ascites Containing Meconium Sludge (arrow). Thursday, November 28, 13
  81. 81. Ultrasound Findings Ultrasound Diagnosis. Meconium Peritonitis As Evident By Diffuse Intra-abdominal Calcifications Thursday, November 28, 13
  82. 82. Prenatal ultrasound image of ileal atresia with meconium pseudocyst Sagittal ultrasound at 28 weeks of gestation shows several dilated loops of bowel. Thursday, November 28, 13 Axial image shows a large cystic mass containing echogenic fluid anterior to dilated bowel loops consistent with a meconium pseudocyst.
  83. 83. Obstetric Management Thursday, November 28, 13
  84. 84. Obstetric Management Prognosis, Survival, And Quality Of Life: Depends On The The Presence Of Meconium Peritonitis. The Association With Cystic Fibrosis And Its Severity. Thursday, November 28, 13
  85. 85. Obstetric Management • Screening Parents For CF Carrier Status • Consider Amniocentesis For Fetal DNA Testing For Cystic Fibrosis. • Delivery In Tertiary Care Unit. Prognosis, Survival, And Quality Of Life: Depends On The The Presence Of Meconium Peritonitis. The Association With Cystic Fibrosis And Its Severity. Thursday, November 28, 13
  86. 86. Ultrasound Signs Suggestive Of GIT Anomalies ✦Non-visualization Of The Gastric Bubble. ✦Cystic Lesions (Double Bubble And Its DD). ✦Dilated Small Bowel (Ileal & Jejunal Atresia). ✦Dilated Large Bowel. ✦Echogenic Bowel. ✦Large Liver / Spleen. ✦Abdominal Wall Defects Thursday, November 28, 13
  87. 87. Echogenic Bowel Diagnosis Usually In Second Trimester. It Can Be Diffuse Or Focal. Diagnostic Criteria: Echogenicity Similar To Or Greater Than That Of Adjacent Bone. Provided US Gain Set To The Lowest Point At Which Bone Appears White. Prevalence: 0.4 -1% In The Second Trimester. In Normal Fetuses, It Is Generally Not Associated With Adverse Sequelae. Thursday, November 28, 13
  88. 88. Normal bowel The echotexture of the fetal bowel is homogenous, and is considerably less echodense than fetal bone. At low gain settings. Thursday, November 28, 13
  89. 89. Normal bowel The echotexture of the fetal bowel is homogenous, and is considerably less echodense than fetal bone. At low gain settings. Thursday, November 28, 13 Echogenic fetal bowel A very echogenic portion of fetal bowel seen in the mid abdomen that is as echodense as fetal bone.
  90. 90. Echogenic Bowel Aetiology ★Intraamniotic Bleeding: ★Aneuploidy: ★Cystic Fibrosis: ★Fetal Growth Restriction: ★Infection: ★Gastrointestinal Obstruction: ★Normal Finding In 0.4-1% Of Fetuses In Second Trimester With No Adverse Consequences. Thursday, November 28, 13
  91. 91. Intraamniotic bleeding Intraamniotic bleeding and gastric pseudomass in fetus at 21 weeks' gestational age, 2 weeks after transplacental amniocentesis Thursday, November 28, 13
  92. 92. Echogenic fetal bowel at 15 weeks' gestational age in 33-year-old woman with vaginal bleeding associated with subchorionic hemorrhage Thursday, November 28, 13
  93. 93. Echogenic bowel, Down syndrome In this transverse image at the level of the umbilical cord insertion, the bowel is diffusely echogenic. At very low gain settings, the bowel is as echogenic as bone. Amniocentesis revealed fetal Down syndrome. Thursday, November 28, 13
  94. 94. Echogenic bowel, cystic fibrosis In this longitudinal image, there is a very echogenic portion of fetal bowel seen in the mid abdomen that is as echodense as fetal bone. Both parents were known carriers of the ΔF508 cystic fibrosis mutation, and the newborn was found to be homozygous for this mutation. Thursday, November 28, 13
  95. 95. Meconium ascites echogenic loop of bowel fetal ascites In this 20 week fetus, fetal ascites is noted in the lower abdomen, adjacent to what appeared to be a markedly echogenic loop of bowel. Thursday, November 28, 13
  96. 96. Meconium Pseudocyst In this 20 week fetus, fetal ascites Two weeks later, the ascites has resolved. The echogenic cystic area is still visible. is noted in the lower abdomen, After birth, imaging studies identified a adjacent to what appeared to be a meconium pseudocyst. markedly echogenic loop of bowel. Thursday, November 28, 13
  97. 97. Echogenic Bowel Obstetric Management ✓Search For Other Markers (Trisomy). ✓Determine Recent History Of Bleeding. ✓Parental Screening For Cystic Fibrosis Carrier. ✓Maternal Serologic Testing For CMV And Toxoplasmosis. ✓Offer Amniocentesis For: ➡Fetal Karyotype: If The Priori Risk For Trisomy Is High. ➡DNA Testing For CF: If Both Parents Are Carriers. ➡PCR Testing For Infection (CMV&Toxoplasmosis): If There Is Serologic Evidence Of Recent Maternal Infection. ✓Fetal FGR. Thursday, November 28, 13 Surveillance For Fetuses With Echogenic Bowel And
  98. 98. Ultrasound Signs Suggestive Of GIT Anomalies ✦Non-visualization Of The Gastric Bubble. ✦Cystic Lesions (Double Bubble And Its DD). ✦Dilated Small Bowel (Ileal & Jejunal Atresia). ✦Dilated Large Bowel. ✦Echogenic Bowel. ✦Large Liver / Spleen. ✦Abdominal Wall Defects Thursday, November 28, 13
  99. 99. Colonic Obstruction Often Missed Prenatally Because Fluid Is Resorbed In The Small Bowel And Colonic Loops. The Small Bowel And Colon To Retain Normal Diameters Despite Distal Obstruction. ✤Hirschsprung disease: ✤Anorectal malformations: ✤Colonic atresia. Thursday, November 28, 13
  100. 100. Colonic Obstruction ✤Hirschsprung disease ➡ A Functional Obstruction Due To Aganglionosis Of A Segment Of Colon. ➡ Prenatal Diagnosis Is Rare Unless It Is Due To Total Colonic Aganglionosis Which Result In Small Bowel Dilatation. ➡ Associated Anomalies: Occur In 25% Of Cases, With A Strong Association With Trisomy 21. Thursday, November 28, 13
  101. 101. Colonic Obstruction ✤Anorectal malformations: •Types: ➡ “high” Supralevator Lesions: Above The Levator Sling, Typically Associated With Fistulas. ➡ “low” Infralevator Lesions: Below The Levator Sling, Not Associated With Fistulas. •Associated Anomalies: 50 % Of Cases. ➡Chromosomal Anomalies: High Risk Of Trisomy 21 And 18. ➡Non -chromosomal Syndromes: Include VACTERL Association (vertebral, Anal Atresia, Cardiac, Tracheoesophageal Fistula, Renal, Limb), Caudal Regression Syndrome, And Sirenomelia. Thursday, November 28, 13
  102. 102. Colonic Obstruction ✤Clonic Atresia: A Rare Condition Often Missed Prenataly. Occur Secondary To Vascular Accident Or Mecahnical Event “volvulus”. •Associated Anomalies: Occure In 1/3 Of Cases Include:gastroschisis, Omphalocele, Hirschsprung Disease, Or Ocular And Skeletal Anomalies Thursday, November 28, 13
  103. 103. Ultrasound Findings Normal Filling Of The Rectal Pouch (arrow), Behind The Bladder • Anorectal Atresia May Be Suspected In The Third Trimester Because Of Overdistension Of The Rectum , To A Lesser Extent, Of The Sigmoid Colon. • The Presence Of Polyhydramnios Suggest Associated Anomalies. Thursday, November 28, 13
  104. 104. Ultrasound Findings Normal Filling Of The Rectal Pouch (arrow), Behind The Bladder Dilatation Of The Rectum, Shows Hyperechoic Content • Anorectal Atresia May Be Suspected In The Third Trimester Because Of Overdistension Of The Rectum , To A Lesser Extent, Of The Sigmoid Colon. • The Presence Of Polyhydramnios Suggest Associated Anomalies. Thursday, November 28, 13
  105. 105. Differential Diagnosis Of Fetal Bowel Dilatation ➡Colonic Atresia. ➡Meconium Ileus. ➡Imperforate Anus. ➡Persistent Cloaca. ➡Meconium Plug Syndrome. ➡Fetal Diarrhea. ➡Megacystis Microcolon Hypoperistalsis Syndrome. Thursday, November 28, 13
  106. 106. Associated Anomalies Chromosomal anomalies: Risk high (trisomies 18 and 21). Non-chromosomal syndromes: Risk is high. Include ✦VA(C)TER(L): look for → anorectal malformation + vertebral anomalies + cardiac defects + esophageal atresia (TE fistula) + renal agenesis + limb anomalies. ✦Caudal regression syndrome: look for → anorectal malformation + renal agenesis + sacral agenesis + lumbar vertebral anomalies + femoral hypoplasia + talipes. ✦Sirenomelia: look for → anorectal malformation + fusion of inferior limbs + renal agenesis + severe vertebral anomalies + genital anomalies. Thursday, November 28, 13
  107. 107. VACTERAL Complex Vertebral defects Anal Atresia Cardiac defects Tracheoesophageal fistula Esophagyeal atresia Renal anomalies Limb defects Thursday, November 28, 13
  108. 108. Ultrasound Findings Suggestive Of GIT Malformations Axial View Of The Upper Abdomen ★Non-visualization Of The Gastric Bubble. ★Double Bubble. Coronal View Thursday, November 28, 13 Axial View Of The Lower Abdomen Right Parasagital ★Dilated Bowel ★Rt. Lung. ★Diaphragm. ★The Rt. Loops. ★Echogenic Bowel. ★Cystic Lesions. Hepatic Lobe. ★Some Ileal Loops. Left Parasagital ★The Stomach & The Spleen
  109. 109. Ultrasound Signs Suggestive Of GIT Anomalies ✦Non-visualization Of The Gastric Bubble. ✦Cystic Lesions (Double Bubble And Its DD). ✦Dilated Small Bowel (Ileal & Jejunal Atresia). ✦Dilated Large Bowel. ✦Echogenic Bowel. ✦Large Liver / Spleen. ✦Abdominal Wall Defects Thursday, November 28, 13
  110. 110. ✦The Liver Right parasagittal view, the degree of hepatomegaly is easily evaluated and the prominence of the abdomen in comparison with the normal thorax is evident. Thursday, November 28, 13
  111. 111. ✦The Liver Right parasagittal view, the degree of hepatomegaly is easily evaluated and the prominence of the abdomen in comparison with the normal thorax is evident. Thursday, November 28, 13
  112. 112. HEPATOMEGALY/SPLENOMEGALY ★ Incidence: Rare. Often due to severe fetal infections. ★ Diagnosis: Enlarged liver/spleen. ★ Risk of chromosomal anomalies: Low, except for the myeloproliferative disease typical of trisomy 21. ★ Risk of non-chromosomal syndromes: Rare but Hepatomegaly can be associated with the Beckwith– Wiedemann and Zellweger syndromes. ★ Outcome: Depends on the underlying cause. Thursday, November 28, 13
  113. 113. Etiology And Pathogenesis: ✦ Fetal Infections: “CMV” ✦ Myeloproliferative Disease Syndrome. Associated With Down ✦ Benign And Malignant Hepatic Tumors: Such As Hemangioma Or Hepatoblastoma. ✦ Venous Congestion Secondary To I Cardiac And Extracardiac Conditions Possibly Causing Heart Failure. ✦ Rare Syndromic Conditions, Namely The Beckwith– Wiedemann And Zellweger Syndromes. Thursday, November 28, 13
  114. 114. Ultrasound Findings At 19 weeks scanning patient with confirmed Hepatitis A shows evident hepatomegaly, with capsular macrocalcification and moderate ascites. Thursday, November 28, 13
  115. 115. Ultrasound Findings Left parasagittal view Left parasagittal view: The ascites and moderate enlargement of the left hepatic lobe (LL, arrowheads) are shown; in such a situation, the left hepatic lobe should not be mistaken for the spleen, which was normal in this case (c) (SPL and arrowheads). Thursday, November 28, 13
  116. 116. Ultrasound Findings Severe hepatomegaly due to CMV infection. The Liver is enlarged, hyperechoic, and rather inhomogeneous liver (arrows). Thursday, November 28, 13
  117. 117. Splenomegaly in two cases of severe fetal CMV infection Coronal view, at 37 weeks of gestation, The spleen is severely enlarged spleen (Spl), the lower pole of which reaches the bladder (Bl) and a concurrent similarly severe hepatomegaly (Li). Thursday, November 28, 13 A similar case, at 36 weeks of gestation, showing severe hepatosplenomegaly, ascites, and intraabdominal calcifications.
  118. 118. Obstetric Management •Test For Maternal Serologic Evidence Of Recent CMV Or Other Hepatotropic Infections. •Ultrasound Assessment Searching For Additional Signs Of Fetal Infection (cerebral Calcification, Hydrocephalus, •Ascites, And Cardiomegaly (myocarditis). Prognosis, Survival, And Quality Of Life: Depends On Its Cause. Thursday, November 28, 13
  119. 119. ✤ Normal Sonographic Appearance of the GIT Tract. ✤ Systemic Approach to Fetal GIT Sonography. ✤ Sonographic Signs suggestive of Anomalies. Thursday, November 28, 13
  120. 120. Ultrasound Signs Suggestive Of GIT Anomalies ✦Non-visualization Of The Gastric Bubble. ✦Cystic Lesions (Double Bubble And Its DD). ✦Dilated Small Bowel (Ileal & Jejunal Atresia). ✦Dilated Large Bowel. ✦Echogenic Bowel. ✦Large Liver / Spleen. ✦Abdominal Wall Defects Thursday, November 28, 13
  121. 121. Thanks Thursday, November 28, 13

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