Sonography of fetal GIT

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

Challenges in Sonography of the Fetal GIT

★Overlap

Between Appearance Of Normal And
Abnormal Fetal Bowel.



MY OF THE GASTROINTESTINAL TRACT
Overlap Between Appearance
NAL WALL: ULTRASOUND APPROACH, Of
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


★Appearance Varies Significantly During The Course Of

Pregnancy And During The Course Of The Same
Examination.

15 wks


24 wks

36 wks


★Overlap

Between Appearance Of Normal And

★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.


Lesions Becomes Evident In The 3rd

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.

Ultrasound Diagnosis of
Anomalies of the Fetal GIT
“A Systematic Approach”


✤ Normal Sonographic Appearance of the
GIT Tract.

✤ Systemic Approach to Fetal GIT
Sonography.

✤ Sonographic Signs suggestive of
Anomalies.


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

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.


Sagital

Coronal

Axial

Render

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.


36 wks

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.

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).


Ultrasound Approach And Scanning Planes

★Cranial Views:

( Mouth, Pharynx, And Esophagus).

★Abdominal Views ( Ileum, Jejunum, Colon, Abdominal Wall)
★Related Intra-abdominal Organs ( Liver, Spleen).


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)

ANOMALIES OF THE GAST

The Esophagus (The Neck)
Sagital And Coronal Views
a

a

Neck
c
c
(hypopharynx And Esophagus)
Sagittal View

b

d

b

a

The Same Region Shown In The
d
Coronal
View,
Using
Threeb
dimensional Volume Contrast Imaging.

The Esophagus (The Chest)
Sagital And Axial Views
cc

dd

Esophagus
Sagittal View

Axial 4-chamber View

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


Left Para
Sagittal View:
The Stomach &
Spleen

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.

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

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

b

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


Coronal View
3 D Imaging

The Right Lung

The Diaphragm

The Gall Bladder

Coronal View Showing Topography Of Abdominal Organs

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


★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:

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

Non Visualization of the
Stomach

Rule out physiologic Emptying.

Stomach
Normal Amniotic Fluid


Absent Amniotic Fluid

Stomach



•PROM
•Sever FGR
•Bilateral Renal Agenesis

Stomach

Associated Anomalies?



•PROM
•Sever FGR

Stomach


Yes



•PROM
•Sever FGR

Stomach


•PROM
•Sever FGR

Stomach in Thorax

Lt. Sided Diaphragmatic
Hernia


Yes

Contractures

Facia Cleftings

Stomach


•PROM
•Sever FGR

Stomach in Thorax

Hernia


Yes

Contractures

Facia Cleftings

FADS
fetal akinesia deformation
sequence

Stomach


•PROM
•Sever FGR

Stomach in Thorax

Hernia


Yes

Contractures

Facia Cleftings

FADS
sequence

Cleft Lip/plalte

Stomach


Yes


No

Stomach in Thorax

Contractures

Facia Cleftings

•PROM
•Sever FGR

Esophageal Atresia

Hernia
FADS
sequence

Cleft Lip/plalte

Esophageal Atresia
Incidence: 1 /2500–1 /4000 Live Births.


Esophageal Atresia
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)


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.

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%


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


unknown.
unknown
the primit
the primi

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.

The Coronal View, Using Threedimensional Volume Contrast Imaging .

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.


MRI partially revealed the characteristic
pouch sign.
Esophageal atresia diagnosed with three-dimensional ultrasonography Ultrasound
Obstet Gynecol 2005; 26: 307–308

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.

Not An Indication

Anomalies

✦Cystic Lesions (Double Bubble And Its DD).
✦Echogenic Bowel”.

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

DUODENAL ATRESIA
22 wks

Definition: The Tract Between The Proximal And Distal Portions
Of The Duodenum Is Atretic.

Incidence: 1/2500 - 1/10 000 Life Births. Atresia Accounts For Up
To 75 Percent Of Intestinal Obstructions.


•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).


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.


•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).


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


Type 3
Complete
separation
of the two
ends plus
biliary tract
anomalies

duodenum

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

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

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.


Duodenal Atresia

★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.


Anomalies

✦Echogenic Bowel”.
✦Abdominal Wall Defects.


✴Ileal & Jejunal Atresia.
✴Meconium Ileus.


Ultrasound Findings Suggestive Of GIT
Malformations
Axial View Of The
Upper Abdomen

★Non-visualization
Of The Gastric
Bubble.

★Double Bubble.

Coronal View

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

Ileal & Jejunal ATRESIA
Diagnosis:
Dilatation Of The Ileal Loops Proximal To The Obstruction.
Polyhydramnios.

•
•

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.

Types Of Jejunal And Ileal Atresia
Poor Prognosis
Type I
20%
Intraluminal
Membrane
With Intact
Bowel Wall &
Mesentery


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

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.


Than To Perforate.

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.

Ultrasound Findings
Same case at third trimester

The obstruction becomes evident, with
moderately severe dilatation of various
loops.

At 36 Weeks

The communication between the various
dilated segments (the maximum
transverse diameter of the loops was 23
mm).

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.

Axial View at 27 weeks gestation showing several
dilated loops of fluid filled bowel. Postnatally
confirmed isolated ileal atresia.

Differential Diagnosis:

✴ Hirschprung’s Disease (Aganglionic Megacolon)
✴ Volvulus (Appears Over 3-4 Days).
✴ Meconium Ileus .


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
Cystic Fibrosis (Approximately 10% of infants with cystic fibrosis
develop meconium ileus and 90% of infants presenting with meconium
ileus)


Ultrasound Findings
Macrocalcifications
demonstrates the
perforation

dilatation of ileal
loops with
hyperechoic walls
(arrow)

Axial scan at 29 weeks

Ultrasound Findings

Oblique View Of The Same Case Demonstrates The Presence Of A Secluded
Sac Of Ascites Containing Meconium Sludge (arrow).

Ultrasound Findings
Ultrasound Diagnosis.

Meconium Peritonitis As Evident By Diffuse Intra-abdominal
Calcifications

Prenatal ultrasound image of ileal atresia with meconium
pseudocyst

Sagittal ultrasound at 28 weeks of
gestation shows several dilated
loops of bowel.


Axial image shows a large cystic mass
containing echogenic fluid anterior to
dilated bowel loops consistent with a
meconium pseudocyst.


Prognosis, Survival, And Quality Of Life:
Depends On The The Presence Of Meconium Peritonitis.
The Association With Cystic Fibrosis And Its Severity.



• Screening Parents For CF Carrier Status
• Consider

Amniocentesis For Fetal DNA Testing For Cystic

Fibrosis.

• Delivery In Tertiary Care Unit.

Depends On The The Presence Of Meconium Peritonitis.
The Association With Cystic Fibrosis And Its Severity.


Anomalies

✦Dilated Small Bowel (Ileal & Jejunal Atresia).
✦Echogenic Bowel.

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.


Normal bowel

The echotexture of the fetal bowel is
homogenous, and is considerably less
echodense than fetal bone.
At low gain settings.

Normal bowel

The echotexture of the fetal bowel is
homogenous, and is considerably less
echodense than fetal bone.
At low gain settings.

Echogenic fetal bowel

A very echogenic portion of fetal bowel
seen in the mid abdomen that is as
echodense as fetal bone.

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.


Intraamniotic bleeding

Intraamniotic bleeding and gastric pseudomass in fetus at 21
weeks' gestational age, 2 weeks after transplacental
amniocentesis

Echogenic fetal bowel at 15 weeks' gestational age in 33-year-old woman
with vaginal bleeding associated with subchorionic hemorrhage

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.

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.

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.

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.

Echogenic Bowel

✓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.


Surveillance For Fetuses With Echogenic Bowel And

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.

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.


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.


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


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.

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.

Differential Diagnosis Of Fetal Bowel Dilatation

➡Colonic Atresia.
➡Meconium Ileus.
➡Imperforate Anus.
➡Persistent Cloaca.
➡Meconium Plug Syndrome.
➡Fetal Diarrhea.
➡Megacystis Microcolon Hypoperistalsis Syndrome.


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.


VACTERAL Complex
Vertebral defects
Anal Atresia
Cardiac defects
Tracheoesophageal ﬁstula
Esophagyeal atresia
Renal anomalies
Limb defects


Ultrasound Findings Suggestive Of GIT
Malformations
Axial View Of The
Upper Abdomen

★Non-visualization
Of The Gastric
Bubble.

★Double Bubble.

Coronal View

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

✦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.

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.


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.


Ultrasound Findings

At 19 weeks scanning patient with conﬁrmed Hepatitis A shows evident
hepatomegaly, with capsular macrocalciﬁcation and moderate ascites.

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).

Ultrasound Findings

Severe hepatomegaly due to CMV infection. The Liver is enlarged,
hyperechoic, and rather inhomogeneous liver (arrows).

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).

A similar case, at 36 weeks of gestation,
showing severe
hepatosplenomegaly, ascites, and intraabdominal calcifications.


•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).
Depends On Its Cause.


Thanks

Sonography of fetal GIT

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