Functional Disorders

n (Gastro)enteritis (Fig. 528a):

• Secretory fluid collection

• Increased intraluminal bowel contents, may be anechoic to echogenic (depending on the contents)

• Dilated bowel loops

• Hyperperistalsis

• Accentuated wall

Functional Bowel Obstruction
Fig. 528a, b Functional disorders of the small intestine. a Acute enteritis: fluid-filled bowel loops (B). b Sprue: the "washing machine" sign

• Hypoechoic wall thickening (edema)

• Distention of the fluid-filled lumen

• Real-time ultrasound: "washing machine" sign n Diabetic autonomic neuropathy (Fig. 529): common in patients with a > 8year history of diabetes, accompanied by other diabetic sequelae. Patients present clinically with refractory diarrhea and steatorrhea. Many cases show cardiopathy with tachycardia and peripheral neuropathies.

• Distended bowel loops

• Hypo- or hyperperistalsis n Partial or complete mechanical bowel obstruction: The bowel may be obstructed by adhesions, a gallstone or foreign body, etc. (Figs. 530 and 531; see also Figs. 110 and 111, p. 82, 83). The obstructed bowel may become strangulated as a result of intussusception or volvulus.

Fig. 529 Diabetic autonomic neuropathic enteropathy: dilated loops of terminal ileum (TI) with hyperperistalsis and no wall thickening. The patient had a long clinical history of type II diabetes mellitus with recurrent diarrhea. AI = iliac artery

Keyboard Sign Ultrasound
Fig. 530a, b Partial or complete bowel obstruction. a Fluid-filled bowel loops with a "keyboard sign." b "Stepladder sign" of bowel obstruction

Fig. 531 Adhesive bowel obstruction: distended, fluid-filled terminal ileum. A keyboard or stepladder sign is not observed because of the absence of valvulae conniventes

• Dilated bowel loops

• Increased intraluminal fluid (anechoic to hyperechoic contents)

• As a rule, peristalsis is initially increased but later is diminished or absent (bidirectional peristalsis)

• "Keyboard sign" and "stepladder sign" (fluid-outlined valvulae conniventes in the jejunum). The bowel loops have a keyboard-like appearance when imaged in longitudinal section and a stepladder-like appearance when imaged tangen-tially (Fig. 530). Valvulae conniventes are absent in the ileum, where the dilated bowel loops present an essentially smooth inner surface (Fig. 531).

• Possible circumscribed free fluid

• Obstruction by a gallstone or bezoar (Fig. 112, p. 83): signs of obstruction proximal to the stenosis. The obstructing object can be identified as an intraluminal mass (stone: typical stone features with distal shadowing; bezoar: nonshadow-ing hypoechoic mass)

• Obstruction due to intussusception:

- The telescoped bowel segments appear as concentric outer and inner hypoe-choic rings with a hyperechoic middle ring ("target-in-a-target" pattern; common with polyps, tumors, and lymph nodes)

- Slight wall thickening, possibly with a thin fluid rim

- Absence of peristalsis in the intussusceptum n Partial or complete paralytic ileus (see Fig. 114, p. 84):

! Caution: Paralytic ileus is frequently associated with peritonitis.

• Dilated, atonic bowel loops crowded close together

• Echogenic contents

• Peristalsis is usually absent

• Bowel wall layers are delineated

• Possible circumscribed free fluid

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