Intravenous Contrast-Enhanced Bowel Ultrasound

  • Doris Schacherer
Part of the Medical Radiology book series (MEDRAD)


In this chapter, we describe the role of ultrasound in case of gastrointestinal disorders. We try to illustrate the historical development and different types of contrast agents and their advantages, limitations, and applications with respect to bowel diseases. Brightness mode (B-Mode) represents an early diagnostic tool for almost all entities of intestinal disease and is able to investigate the localization of intestinal disease, length of the intestinal segments involved, loss of stratification, intestinal obstruction or stenoses, and mesenterial changes as well as associated. B-mode imaging is always a prerequisite for the useful application of Doppler and ultrasound contrast imaging techniques. Combining (Power) Doppler imaging and ultrasound contrast agents improves the visualization of smaller vessels and vessel continuity (i.e., length). Several studies were performed to detect bowel wall hyperemia in inflammatory bowel disease. Contrast harmonic imaging at a low mechanical index is technically feasible for the demonstration of increased intestinal perfusion in inflammatory bowel disease by using high frequency ultrasound transducers. Furthermore, contrast-enhanced power Doppler sonography may help to discriminate the origin of small bowel stenosis in Crohn`s disease. Different studies evaluated the vascularization of the thickened terminal ileum in Crohn`s disease patients using CEUS and compared the clinical activity measured by the Crohn`s disease activity index (CDAI) with the sonographic findings. Using certain perfusion parameters (peak value, time-to-peak, regional blood volume), studies could show differences between inflamed and normal bowel wall vascularity in terms of significant higher peak values and significant higher regional blood volume in the bowel wall of patients with an active episode of Crohn`s disease. Additionally, CEUS can be a useful technique to monitor the activity of Crohn`s disease, to increase the accuracy of color Doppler ultrasound in diagnosis, and followup of patients with Crohn`s disease and to assess disease activity. Fewer studies exist concerning ulcerative colitis, bowel ischemia, graft-versus-host-disease, and appendicitis.


Contrast Agent Ulcerative Colitis Acute Appendicitis Bowel Wall Mechanical Index 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Blomley MJ, Albrecht T, Cosgrove DO et al (1999) Improved imaging of liver metastases with stimulated acoustic emission in the late phase of enhancement with the US contrast agent SH U 508A: early experience. Radiology 210:409–416PubMedGoogle Scholar
  2. Blomley MJ, Cooke JC, Unger EC et al (2001) Microbubble contrast agents: a new era in ultrasound. Br Med J 322:1222–1225CrossRefGoogle Scholar
  3. Blomley M, Cosgrove D (1997) Microbubble echo-enhancers: a new direction for ultrasound? Lancet 349:1855–1856PubMedCrossRefGoogle Scholar
  4. Bouakaz A, De Jong N, Cachard C (1998) Standard properties of ultrasound contrast agents. Ultrasound Med Biol 24:469–472PubMedCrossRefGoogle Scholar
  5. Campani R, Calliada F, Bottinelli O (1998) Contrast enhancing agents in ultrasonography: clinical applications. Eur J Radiol 27(Suppl 2):161–170CrossRefGoogle Scholar
  6. Darge K, Troeger J, Duetting T et al (1999) Reflux in young patients: comparison of voiding US of the bladder and retrovesical space with echo enhancement versus voiding cystourethrography for diagnosis. Radiology 210:201–207PubMedGoogle Scholar
  7. Dietrich CF, Jedrzejczyk M, Ignee A (2007) Sonographic assessment of splanchnic arteries and the bowel wall. Eur J Radiol 64:202–212PubMedCrossRefGoogle Scholar
  8. Duda VF, Rode G, Schlief R (1993) Echocontrast agent enhanced color flow imaging of the breast. Ultrasound Obstet Gynecol 3:191–194PubMedCrossRefGoogle Scholar
  9. Esteban JM, Aleixandre A, Hurtado MJ et al (2003) Contrast-enhanced power doppler ultrasound in the diagnosis and follow-up of inflammatory abdominal masses in Crohn’s disease. Eur J Gastroenterol Hepatol 15:253–259PubMedCrossRefGoogle Scholar
  10. Forsberg F, Goldberg BB (1997) New imaging techniques with ultrasound contrast agents. In: Goldberg BB (ed) Ultrasound contrast agents. Martin Dunitz Ltd, London, pp 177–192Google Scholar
  11. Fukuta N, Kitano M, Maekawa K (2005) Estimation of the malignant potential of gastrointestinal stromal tumors: the value of contrast-enhanced coded phase-inversion harmonics US. J Gastroenterol 40:247–255PubMedCrossRefGoogle Scholar
  12. Geleijnse ML, Nemes A, Vletter WB et al (2009) Adverse reactions after the use of sulphur hexafluoride (SonoVue) echo contrast agent. J Cardiovasc 10:75–77CrossRefGoogle Scholar
  13. Girlich C, Jung EM, Huber E et al (2011a) Comparison between preoperative quantitative assessment of bowel wall vascularization by contrast-enhanced ultrasound and operative macroscopic findings and results of histopathological scoring in Crohn’s disease. Ultraschall Med 32:154–159PubMedCrossRefGoogle Scholar
  14. Girlich C, Jung EM, Iesalnieks I et al (2009) Quantitative assessment of bowel wall vascularization in Crohn’s disease with contrast-enhanced ultrasound and perfusion analysis. Clin Hemorheol Microcirc 43:141–148PubMedGoogle Scholar
  15. Goldberg BB, Merton DA, Forsberg F et al (1996) Color amplitude imaging: preliminary results using vascular sonographic contrast agents. J Ultrasound Med 15:127–134PubMedGoogle Scholar
  16. Gorg C, Wollenberg B, Beyer J et al (2005) High-resolution ultrasonography in gastrointestinal graft-versus-host disease. Ann Hematol 84:33–39PubMedCrossRefGoogle Scholar
  17. Gramiak R, Holen J (1984) CW and pulsed Doppler echocardiography utilizing a stand-alone system. Ultrasound Med Biol 10:215–224PubMedCrossRefGoogle Scholar
  18. Gramiak R, Shah PM (1968) Echocardiography of the aortic root. Invest Radiol 3:356–366PubMedCrossRefGoogle Scholar
  19. Guidi L, De Franco A, De V et al (2006) Contrast-enhanced ultrasonography with SonoVue after infliximab therapy in Crohn’s disease. Eur Rev Med Pharmacol Sci 10:23–26PubMedGoogle Scholar
  20. Hamada T, Yamauchi M, Tanaka M et al (2007) Prospective evaluation of contrast-enhanced ultrasonography with advanced dynamic flow for the diagnosis of intestinal ischaemia. Br J Radiol 80:603–608PubMedCrossRefGoogle Scholar
  21. Harvey CJ, Blomley MJ, Eckersley RJ et al (2000) Pulse-inversion mode imaging of liver specific microbubbles: improved detection of subcentimetre metastases. Lancet 355:807–808PubMedCrossRefGoogle Scholar
  22. Hata J, Kamada T, Haruma K et al (2005) Evaluation of bowel ischemia with contrast-enhanced US: initial experience. Radiology 236:712–715PubMedCrossRefGoogle Scholar
  23. Holt S, Samuel E (1979) Grey scale ultrasound in Crohn’s disease. Gut 20:590–595PubMedCrossRefGoogle Scholar
  24. Incesu L, Yazicioglu AK, Selcuk MB et al (2004) Contrast-enhanced power doppler US in the diagnosis of acute appendicitis. Eur J Radiol 50:201–209PubMedCrossRefGoogle Scholar
  25. Ionescu A (2009) Bubble trouble: anaphylactic shock, threatened myocardial infarction, and transient renal failure after intravenous echo contrast for left ventricular cavity opacification preceding dobutamine stress echo. Eur J Echocardiography 10:707–710CrossRefGoogle Scholar
  26. Jeffrey RB Jr, Laing FC, Lewis FR (1987) Acute appendicitis: high-resolution real-time US findings. Radiology 163:11–14PubMedGoogle Scholar
  27. Keyzer C, Zalcman M, De Maertelaer V et al (2005) Comparison of US and unenhanced multi-detector row CT in patients suspected of having acute appendicitis. Radiology 236:527–534PubMedCrossRefGoogle Scholar
  28. Klein SA, Martin H, Schreiber-Dietrich D et al (2001) A new approach to evaluating intestinal acute graft-versus-host disease by transabdominal sonography and colour doppler imaging. Br J Haematol 115:929–934PubMedCrossRefGoogle Scholar
  29. Kolkman JJ, Falke TH, Roos JC et al (1996) Computed tomography and granulocyte scintigraphy in active inflammatory bowel disease. Comparison with endoscopy and operative findings. Dig Dis Sci 41:641–650PubMedCrossRefGoogle Scholar
  30. Kratzer W, von Tirpitz C, Mason R et al (2002) Contrast-enhanced power doppler sonography of the intestinal wall in the differentiation of hypervascularized and hypovascularized intestinal obstructions in patients with Crohn’s disease. J Ultrasound Med 21:158–159Google Scholar
  31. Kumar P, Domja J, Bhandari P et al (2009) Is there an association between intestinal perfusion and Crohn’s disease activity? A feasibility study using contrast-enhanced ultrasound. Br J Radiol 82:112–117PubMedCrossRefGoogle Scholar
  32. Kunihiro K, Hata J, Manabe N (2007) Predicting the need for surgery in Crohn’s disease with contrast harmonic ultrasound. Scand J Gastroenterol 42:577–585PubMedCrossRefGoogle Scholar
  33. Lassau N, Lamuraglia M, Chami L et al (2006) Gastrointestinal stromal tumors treated with imatinib: monitoring response with contrast-enhanced sonography. Am J Roentgenol 187:1267–1273CrossRefGoogle Scholar
  34. Ludwig D, Wiener S, Brüning A et al (1999) Mesenteric blood flow is related to disease activity and risk of relapse in Crohn’s disease: a prospective follow-up study. Am J Gastroenterol 94:2942–2950PubMedCrossRefGoogle Scholar
  35. Maconi G, Sampietro GM, Sartani A et al (2008) Bowel ultrasound in Crohn’s disease: surgical perspective. Int J Colorectal Dis 23:339–347PubMedCrossRefGoogle Scholar
  36. Meairs S, Daffertshofer M, Neff W et al (2000) Pulse-inversion contrast harmonic imaging: ultrasonographic assessment of cerebral perfusion. Lancet 355:550–551PubMedCrossRefGoogle Scholar
  37. Migaleddu V, Scanu AM, Quaia E et al (2009) Contrast-enhanced ultrasonographic evaluation of inflammatory activity in Crohn’s disease. Gastroenterology 137:43–61PubMedCrossRefGoogle Scholar
  38. Mulvagh SL, DeMaria AN, Feinstein SB et al (2000) Contrast echocardiography: current and future applications. J Am Soc Echocardiogr 13:331–342PubMedCrossRefGoogle Scholar
  39. Nanda NC, Carstensen C (1997) Echo-enhancing agents: safety. In: Nanda NC, Schlief R, Goldberg BB (eds) Advances in echo imaging using contrast enhancers. Kluwer Academic Publishers, Dordrecht, pp 115–131CrossRefGoogle Scholar
  40. Ophir J, Parker KJ (1989) Contrast agents in diagnostic ultrasound. Ultrasound Med Biol 15:319–333PubMedCrossRefGoogle Scholar
  41. Parente F, Greco S, Molteni M et al (2003) Role of early ultrasound in detecting inflammatory intestinal disorders and identifying their anatomical location within the bowel. Aliment Pharmacol Ther 18:1009–1016PubMedCrossRefGoogle Scholar
  42. Parente F, Maconi G, Bollani S et al (2002) Bowel ultrasound in assessment of Crohn’s disease and detection of related small bowel strictures: a prospective comparative study versus x ray and intraoperative findings. Gut 50:490–495PubMedCrossRefGoogle Scholar
  43. Plikat K, Klebl F, Buchner C et al (2004) Evaluation of intestinal hypereamia in inflamed bowel by high resolution Contrast Harmonic Imaging (CHI). Ultraschall Med 25:257–262PubMedCrossRefGoogle Scholar
  44. Quaia E, Migaleddu V, Baratella E et al (2009) The diagnostic value of small bowel wall vascularity after sulfur hexafluoride-filled microbubble injection in patients with Crohn’s disease. Correlation with the therapeutic effectiveness of specific anti-inflammatory treatment. Eur J Radiol 69:438–444PubMedCrossRefGoogle Scholar
  45. Rapaccini GL, Pompili M, Orefice R et al (2004) Contrast-enhanced power doppler of the intestinal wall in the evaluation of patients with crohn’s disease. Scand J Gastroenterol 39:188–194PubMedCrossRefGoogle Scholar
  46. Ries F, Honisch C, Lambertz M et al (1993) A transpulmonary contrast medium enhances the transcranial doppler signal in humans. Stroke 24:1903–1909PubMedCrossRefGoogle Scholar
  47. Ripollés T, Martinez MJ, Paredes JM et al (2009) Crohn’s disease: correlation of findings at contrast-enhanced US with severity at endoscopy. Radiology 253:241–248PubMedCrossRefGoogle Scholar
  48. Robotti D, Cammarota T, Debani P et al (2004) Activity of crohn disease: value of color-power-doppler and contrast-enhanced ultrasonography. Abdom Imaging 29:648–652PubMedCrossRefGoogle Scholar
  49. Schirin-Sokhan R, Winograd R, Tischendorf S et al (2011) Assessment of inflammatory and fibrotic stenoses in patients with crohn’s disease using contrast-enhanced ultrasound and computerized algorithm: a pilot study. Digestion 83:263–268PubMedCrossRefGoogle Scholar
  50. Schlottmann K, Fuchs-Koewel B, Demmler-Hackenberg M et al (2005a) High-frequency contrast-harmonic imaging of ophthalmatic tumor perfusion. AJR Am J Roentgenol 184:574–578PubMedCrossRefGoogle Scholar
  51. Schlottmann K, Klebl F, Zorger N et al (2004) Contrast-enhanced ultrasound allows for interventions of hepatic lesions which are invisible on conventional B-mode. Z Gastroenterol 42:303–310PubMedCrossRefGoogle Scholar
  52. Schlottmann K, Kratzer W, Schoelmerich J (2005b) Doppler ultrasound and intravenous contrast agents in gastrointestinal tract disorders: current role and future implications. Eur J Gastroenterol Hepatol 17:263–275PubMedCrossRefGoogle Scholar
  53. Schneider M (1999) Characteristics of SonoVue (trademark). Echocardiography 16:743–746PubMedCrossRefGoogle Scholar
  54. Schreyer AG, Finkenzeller T, Gossmann H et al (2008) Microcirculation and perfusion with contrast enhanced ultrasound (CEUS) in crohn’s disease: first results with linear contrast harmonic imaging (CHI). Clin Hemorhoeol Microcirc 40:143–155Google Scholar
  55. Schreyer AG, Landfried K, Zorger N et al (2011) Transmural penetration of intravenously applied microbubbles during contrast-enhanced ultrasound as a new diagnostic feature in patients with GVHD of the bowel. Bone Marrow Transplant 46:1006–1011PubMedCrossRefGoogle Scholar
  56. Schulte-Altedorneburg G, Demharter J, Linné R et al (2003) Does ultrasound contrast agent improve the diagnostic value of colour and power doppler sonography in superficial lymph node enlargement? Eur J Radiol 48:252–257PubMedCrossRefGoogle Scholar
  57. Serra C, Menozzi G, Labate AM et al (2007) Ultrasound assessment of vascularization of the thickened terminal ileum wall in crohn’s disease patients using a low-mechanical index real-time scanning technique with a second generation ultrasound contrast agent. Eur J Radiol 62:114–121PubMedCrossRefGoogle Scholar
  58. Smith MD, Elion JL, McClure RR et al (1984) Left heart opacification with peripheral venous injection of a new saccharide echo contrast agent in dogs. J Am Coll Cardiol 13:1622–1628CrossRefGoogle Scholar
  59. Smith MD, Kwan OL, Reiser HJ et al (1989) Superior intensity and reproducibility of SHU-454, a new right heart contrast agent. J Am Coll Cardiol 3:992–998CrossRefGoogle Scholar
  60. Tarjan Z, Toth G, Gyorke T et al (2000) Ultrasound in crohn’s disease of the small bowel. Eur J Radiol 35:176–182PubMedCrossRefGoogle Scholar
  61. von Herbay A, Vogt C, Willers R et al (2004) Real-time imaging with the sonographic contrast agent SonoVue—differentiation between benign and malignant hepatic lesions. J Ultrasound Med 23:1557–1568Google Scholar
  62. Yamaguchi T, Yoshida S, Tanaka S et al (2009) Predicting the clinical response to cytapheresis in steroid-refractory or—dependent ulcerative colitis using contrast-enhanced ultrasonography. Scand J Gastroenterol 44:831–837PubMedCrossRefGoogle Scholar

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© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Department of Internal Medicine IUniversity of RegensburgRegensburgGermany

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