Objectives

1. Recognition of the normal sonographic appearances of the colonic wall and mesentery

2. Demonstrating and identifying colonic pathology including colonic carcinoma, appendix orifice tumours and intraluminal colonic lesions such as a tubulovillous adenoma (TVA) and lipoma

3. Demonstrating a variety of sonographic appearances of inflammatory colonic disease including inflammatory bowel disease, diverticular disease and active diverticulitis

4. Using ultrasound to confirm computed tomography (CT) appearances represent colonic wall spasm

Background

Colonic ultrasound is currently performed in our institution by gastrointestinal (GI) radiologists with an expertise in small bowel and colonic imaging.

Assessment and interpretation of the colon on CT can be limited by segmental spasm, colitis, complex diverticular disease, residual faecal material and poor insufflation. At our institute we regularly use colonic ultrasound to both diagnose and troubleshoot colonic pathology.

Imaging findings OR Procedure findings

The following findings will be discussed:

1. Normal appearances of the colonic wall layers and mesentery

2. Sonographic appearance of colonic carcinoma with loss of normal colonic wall layering and assessment of mucosal thickness

3. Demonstration of colonic wall depth invasion at varying T stages of disease

4. The appearance of submucosal lesions

5. Sonographic appearances of Crohn’s disease and ulcerative colitis including deep penetrating ulcers and fistulation

6. Uncomplicated diverticular changes

7. Acute diverticulitis and associated complications

8. Spasm versus true colonic pathology

9. Contrast ultrasound assessment of colonic ischaemia

Conclusion

Colonic ultrasound has a wide range of potential clinical uses both to diagnose and trouble-shoot pathology.

Objectives

To demonstrate a standardised US technique with pictorial representation for evaluating ileocolic Crohn’s Disease (CD) intra-operatively based on a reliable and reproducible method.

Background

Intraoperative assessment of CD is not standardised and left to a mixture of surgeons experience and tactile feedback, which can result in intra/inter-observer variability. This potentially risks patients having incorrect mapping of CD affecting the surgical outcomes and postoperative decision making on need for medical treatment.

Imaging findings OR Procedure findings

Following laparoscopic mobilisation, the small bowel is exteriorised via a wound protector and evaluated macroscopically by a colorectal surgeon with expertise in CD. A gastrointestinal radiologist with expertise in small bowel ultrasound repeats the intraoperative assessment, evaluating the ultrasound appearances of the bowel wall and mesentery segment by segment. The probe is prepared using a sterile cover with saline as the acoustic agent. Following any difficulty accessing small bowel mesentery the surgeon assists by mobilising the required segments.

Length, location and number of CD segments are documented together with assessment using the MREnterography or ulTRasound in Crohn's disease (METRIC) scoring guide. Some of the criteria assessed include: lymph node presence, functional obstruction, mesenteric fat echogenicity and bowel wall thickness and appearance. Finally, surgical and radiological findings are documented, focusing on location and length for each segment of disease. Location and distance is estimated using a sterile ruler from the landmarks of the duodenojejunal flexure and ileocecal valve.

Conclusion

Standardised intraoperative ultrasound creates a patient-centred surgical approach based on multidisciplinary mapping of CD.

Funding: Innovation Grant of the forCrohns charity