AJR 2002; 179:201-205
© American Roentgen Ray Society
Graded Compression Sonography of the Colon in the Diagnosis of Polyps in Pediatric Patients
Matteo Baldisserotto1,
José Vicente Noronha Spolidoro2 and
Maria da Graça Soares Bahú3
1 Departamento de Ultra-sonografia, Hospital São Lucas-Pontifícia
Universidade Católica do Rio Grande do Sul, Av. Ipiranga, 6690, Porto
Alegre, RS, Brazil, CEP 90610-000.
2 Departamento de Pediatria, Hospital São Lucas-pontifícia
Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil,
CEP 90610-000.
3 Departamento de Gastrenterologia Pediátrica, Hospital da Criança
Conceição, Av. Francisco Trein, 596, Porto Alegre, RS, Brazil,
CEP 91350-200.
Received July 2, 2001;
accepted after revision January 23, 2002.
Address correspondence to M. Baldisserotto.
Abstract
OBJECTIVE. We report seven cases of juvenile polyps detected by
graded compression gray-scale and color Doppler sonography in five children
with nonspecific symptoms.
CONCLUSION. Intestinal polyps can be detected by graded compression
gray-scale and color Doppler sonography without colonic preparation. On
gray-scale sonography, polyps appeared as spherical or ovoid hypoechoic
nodules in the colon lumen. Small cysts were identified inside the nodules.
Four polyps had fewer and smaller cysts, whereas three others contained many
cysts. A hyperechoic layer surrounding the polyp corresponded to the
submucosa. In two patients, the polyp was visualized in the transverse colon
and caused a colocolic intussusception, which reduced spontaneously during
sonography. Color Doppler sonography showed four hypovascularized and three
hypervascularized polyps.
Introduction
Most patients with juvenile polyps present with intestinal bleeding at
clinical examination. Double-contrast barium enema or colonoscopy or both are
indicated to determine diagnoses in these cases
[1]. A few patients, however,
may present with other symptoms, such as crampy abdominal discomfort and mild
diarrhea, iron deficiency anemia, or minimal intestinal bleeding
[2,
3]. Because these are
nonspecific signs and symptoms, sonography may be used as the first diagnostic
procedure in the evaluation of patients with these symptoms.
Only two studies so far have stressed the value of gray-scale sonography
after bowel cleansing and colon filling with water or saline in the diagnosis
of juvenile polyps in children
[4,
5]. Our study included five
patients with nonspecific symptoms who first underwent sonography without
colonic preparation. Seven polyps were detected. We report gray-scale and
color Doppler sonographic findings and correlate them with colonoscopic and
pathologic findings.
Subjects and Methods
Our study included five children, three boys and two girls, seen from 1997
to 2000 in the pediatric out-patient services of two hospitals, a university
general hospital and a public pediatric hospital. Their ages ranged from 4 to
11 years. They presented with non-specific symptoms: two with abdominal pain
only, two with abdominal pain and a small amount of blood in the stool, and
one with anemia. Intestinal polyp was not initially suspected in any patient.
They were referred to our service for gray-scale and color Doppler sonography,
which revealed seven polyps. Our study reviews clinical, sonographic, and
pathologic findings in these patients.
A certified radiologist with experience in pediatric radiology and
sonography performed the sonographic examinations. Scanning was performed with
an XP 10 scanner (Acuson, Mountain View, CA). Patients were asked to fast for
8 hr, but they did not undergo colonic preparation.
Our routine procedure for abdominal sonography starts with a general
examination of the abdomen and includes examination of the intestine. We used
a convex 5.0-MHz transducer for the general examination of the abdomen. The
intestine was then scanned with a linear 7.5-MHz transducer with graded
compression as described by Puylaert
[6] for the investigation of
acute appendicitis. The objective of compression was to bring the anterior
wall of the intestine closer to the posterior wall and to displace gas and
fecal matter. Examination of the colon started at the cecum and ileocecal
valve and extended to the ascending, transverse, and descending colon and the
sigmoid flexure. We could not examine the hepatic flexure because of its
subcostal location. Because the rectum and the distal portion of the sigmoid
flexure are located deep in relation to the abdominal cavity, they were
examined with a convex 5.0-MHz transducer without compression. We examined the
ascending colon from the posterior aspect in the right flank, thus avoiding
the overlapping of intestinal loops. Next, the small intestine and all the
abdominal quadrants were scanned. Parameters for adjustment were standardized
to optimize the detection of low-velocity flows on color Doppler sonography.
The gate was set at 2, the filter at 1, and the velocity at 0.06-0.16 m/sec.
The criterion for color Doppler gain adjustment was the appearance of the
first color artifacts. The focus was adjusted to the depth of the field to be
examined. The compressive examination of the intestinal wall took 5 min on
average.
All patients underwent colonoscopy and colonoscopic biopsy, and the
material collected was sent to the laboratory for pathologic examination.
Results
Table 1 presents the
findings of gray-scale and color Doppler sonography. The five patients
underwent colonoscopy, which detected eight intestinal polyps. Seven polyps
had been previously detected on sonography. The eighth polyp was located in
the rectum and was not detected sonographically.
Gray-scale sonography showed polyps as spherical or ovoid hypoechoic
nodules in the colon lumen (Fig.
1A). Polyp diameter ranged from 1 to 2.5 cm. Cysts with diameters
of 2-3 mm were visualized in the polyps. Four polyps had fewer and smaller
cysts, whereas three others contained many cysts
(Fig. 1A). The correlation
between sonographic and pathologic findings showed that the cysts were glands
distended by mucus (Fig. 1D). A
hyperechoic layer surrounded the polyps and corresponded to the submucosa
displaced by the lesion. Pedicles extending to the colon wall were identified
(Figs. 1C,
2C and
3B). Pedicles were 1-2.5 cm
long, and the polyps with longer pedicles moved during compression. In two
patients, the polyp was imaged in the transverse colon, where it caused a
colocolic intussusception that reduced spontaneously during sonography (Fig.
3A,3B,3C,3D).
View larger version (137K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —9-year-old boy with abdominal pain for several months.
Gray-scale sonogram reveals polyp with small cysts (arrowhead) in
sigmoid flexure (large arrows), with hyperechoic peripheral submucosa
(small arrows).
|
|
View larger version (121K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3C. —7-year-old girl with abdominal pain for 1 year. Gray-scale
sonogram obtained in transverse plane shows proximal colocolic intussusception
(arrows), which reduced spontaneously during scanning.
|
|
Color Doppler sonography showed four hypovascularized
(Fig. 2A) and three
hypervascularized polyps (Fig.
1B). Blood vessels that supplied arterial and venous blood to the
polyp (Fig. 2C) were
symmetrically distributed inside the lesion, and the smaller vessels radiated
from the center.
All patients underwent polypectomy. After resection, one patient had
pneumoperitoneum, was conservatively treated, and recovered. The other
patients' recoveries were uneventful. At clinical follow-up at 6 months, a
patient with abdominal pain was still symptomatic. This patient underwent
endoscopy, which revealed gastritis. The other patients who initially
presented with abdominal pain or intestinal bleeding or both were
asymptomatic. The patients who had been anemic before polypectomy had a normal
blood count.
Discussion
The technical and scientific development of sonography with high-frequency
transducers has made it possible to detect small changes in the thickness of
the intestinal wall [6].
However, this diagnostic method has rarely been used in the detection of
intestinal polyps. In 1992, Walter et al.
[4] described a juvenile polyp
detected on sonography in a child examined after instillation of 800 mL of
water in the colon. In 1994, after colonic preparation, Nagita et al.
[5] sonographically examined 39
children suspected of having intestinal polyps and reported good sensitivity
for polyp detection. These children underwent a cleansing enema with saline,
colon filling, and sedation. This preparation made the sonographic procedure
invasive and not practical.
Color Doppler sonography can evaluate blood flow in the intestinal wall
[7] and the activity of
inflammatory bowel diseases
[8]. To our knowledge, its use
in the diagnosis of intestinal polyps has not been previously reported. Our
study shows that graded compression sonography of the colon with
high-frequency transducers and color Doppler sonography without intestinal
preparation can be useful in the detection of juvenile polyps. The compressive
maneuver brings the anterior wall of the intestine close to the posterior wall
and displaces fecal contents or gases or both so that polyps can be
visualized.
The visualization of a hypoechoic nodule in the colon lumen with a
hyperechoic peripheral layer containing small cysts and a pedicle extending to
the wall of the colon is a characteristic presentation of a polyp and
differentiates it from fecal matter on gray-scale sonography. Color Doppler
sonography images the arterial and venous vessels inside the polyp and its
pedicle in different degrees. In one patient, the intestinal polyps were less
clearly visualized because of the patient's obesity and gaseous
distention.
The correlation of the sonographic findings with the pathologic examination
of the polypoid specimens showed that the cysts corresponded to secreting
tubules containing mucus. Nagita et al.
[5] have drawn attention to
this sonographic finding in juvenile polyps. The hyperechoic margin of the
polyp corresponds to the intestinal submucosa displaced by the polyp.
In our study, sonography detected the polyp in the "head" of
the colocolic intussusception in two patients with chronic abdominal pain.
This finding led to adequate treatment of the patients. After these patients
underwent colonoscopy with polypectomy, their symptoms improved. Sonography
can also be useful in investigating polyps in patients with intestinal
bleeding or anemia, as was the case with three patients in our series. Two had
minimal intestinal bleeding, one of them also with abdominal pain, and the
third had anemia only.
A 7-mm polyp located in the rectum was the only polyp not detected on
sonography. The rectum and the hepatic flexure are potentially the two most
difficult colon segments to evaluate sonographically. Because the rectum is
located deep in the pelvic cavity, compressive maneuvers and the use of
high-frequency transducers are difficult. The hepatic flexure and the rectum
could not be examined in our sonographic study. Polyps in these segments may
thus be overlooked. Our patients did not present with flatulence or fecal
mass, conditions that may complicate the compressive sonographic examination.
Because of these limitations, we do not believe that graded compression
sonography will take the place of barium enema or colonscopy in the diagnosis
of polyps.
The sensitivity and specificity of color Doppler sonography in comparison
with colonoscopy in the detection of intestinal polyps were not determined. We
do not know how many patients seen during this study had polyps that were not
detected on sonography. We correlated the sonographic findings with
colonoscopy and pathology only for our five patients. In our small series of
eight polyps, only one was not detected.
We recommend the use of graded compression sonography in the routine
examination of children with abdominal pain or minimal intestinal bleeding for
three reasons. First, if a polyp is detected, the patient can be referred for
colonoscopy. Secondly, this technique can also detect other intestinal
diseases [7]. Finally, this
procedure takes only 5 min on average. Sonography is an operator-dependent
examination, but we believe that when carefully performed following the
procedure we propose, sonography can play an important role in the diagnosis
of intestinal polyps.
Our study shows that intestinal polyps have characteristic aspects
identifiable on graded compression and color Doppler sonography of the colon.
Knowledge of these aspects can make it easier to detect juvenile polyps on
sonography. In spite of its limitations, we believe that this technique may be
useful in the treatment of patients with polyps who present with nonspecific
symptoms because invasive examinations, such as barium enema or colonoscopy,
would not be indicated as the first diagnostic procedure for these patients.
Future prospective studies with a larger number of patients should be carried
out to define the accuracy of this technique in the diagnosis of juvenile
polyps.
References
-
Cynamon HA, Milov DE, Andres JM. Diagnosis and management of
colonic polyps in children. J Pediatr
1989;114:593
-596[Medline]
-
Seibert JJ. The child with bloody stools. In: Hilton SW, Edwards DK
III, eds. Practical pediatric radiology, 2nd ed.
Philadelphia: Saunders, 1994:159
-189
-
Soper RT. Intestinal polyps. In: Ashcraft KW, Holder TM, eds.
Pediatric surgery, 2nd ed. Philadelphia: Saunders,
1993: 498-508
-
Walter DF, Govil S, Korula A, William RR, Chandy G. Pedunculated
colonic polyp diagnosed by colonic sonography. Pediatr
Radiol 1992;22:148
-149[Medline]
-
Nagita A, Amemoto K, Yoden A, Yamazaki T, Mino M, Miyoshi H.
Ultrasonographic diagnosis of juvenile colonic polyps. J
Pediatr 1994;124:535
-540[Medline]
-
Puylaert JB. Acute appendicitis: US evaluation using graded
compression. Radiology
1986;158:355
-360[Abstract/Free Full Text]
-
Siegel JM, Fiedland JA, Hildelbolt CF. Bowel wall thickening in
children: differentiation with US. Radiology
1997;203:631
-635[Abstract/Free Full Text]
-
Ruess L, Blask AR, Bulas DI, et al. Inflammatory bowel disease in
children and young adults: correlation of sonographic and clinical parameters
during treatment. AJR
2000;175:79
-84[Abstract/Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
K. Yabunaka, T. Katsuda, S. Sanada, and T. Fukutomi
Sonographic Appearance of the Normal Appendix in Adults
J. Ultrasound Med.,
January 1, 2007;
26(1):
37 - 43.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
