Echogenic Fetal Bowel


 
Echogenic bowel (arrows) is seen in the lower fetal abdomen & pelvis

 

Findings:

Bright bowel is identified in the lower abdomen and pelvis of this second trimester fetus. This fetus was normal without evidence of cystic fibrosis or aneuploidy.

Discussion:

In the 1980's it was recognized that an area of increased echogenicity in the lower abdomen and pelvis was frequently seen on fetal sonograms. The area of increased echogenicity is thought by most investigators to represent either the walls of collpased small bowel, mesenteric fat or echogenic intraluminal bowel contents. Although usually seen most notably in the second trimester, this echogenicity has been reported to persist in some fetuses throughout gestation. The increased echogenicity is conglomerate as opposed to punctate calcification which can be seen in cases of either meconium peritonitis or from intra-abdominal infection. In several published reviews of the subject, investigators have attempted to subjectively define the degree of echogenicity by comparing the "brightness" of the hyperechogenic bowel to the echogenicity of the fetal skeleton. Those cases thought to have unequivocally abnormally bright bowel have an echogenicity equal to that of fetal skeleton. Using this criterion the incidence of echogenic bowel has been reported to range from 0.2-1.8% of second trimester fetuses. It is interesting to note that the development of higher frequency ultrasound transducers has made this finding more difficult to sort out. Virtually all studies reported have been performed with 3-4 mHz transducers. When transducers of 5mHz-10 mHz are utilized most cases will demostrate bright bowel.

2nd Trimester fetus with normal bowel echogenicity (3.5 mHz) Same fetus scanned at 8 mHz now demonstrates bright bowel

For several years it was assumed that this increased echogenicity was a normal variant which was likely bowel related and in most cases would disappear by the third trimester. Subsequently reports appeared in the medical literature noting an association of hyperechogenic bowel with a variety of conditions including: cystic fibrosis, karyotypic abnormalities, fetal growth retardation and fetal death. These associations with hyperechogenic bowel will be discussed below.

Cystic Fibrosis:

Ever since the early reports of the detection of hyperechogenic bowel using ultrasound there have been numerous cases in which cystic fibrosis developed in neonates in which this finding was detected antenatally in fetuses. In the study by Dicke and Crane 13% of the patients in their study with hyperechogenic bowel had cystic fibrosis as compared to .05% expected in the general population. Cystic fibrosis is said to be the most common autosomal recessive disesase affecting Caucasions. The gene responsible for the development of cystic fibrosis was discovered in 1989. The gene was identified on the long arm of chromosome 7 at region q(31). Most cases of cystic fibrosis (>70%) are due to the ?F 508 allele. Genetic testing is not perfect as there are 400-500 other cystic fibrosis alleles and differences between different ethnic groups. As the fetus and neonate will only develop cystic fibrosis if both parents are carriers, testing of parental blood for carrier status using DNA probes can be carried out in a large percentage of the population, when indicated.

Three studies reported in 1996 evaluated the association of cystic fibrosis with hyperechogenic bowel. In the study by Slotnick and Abuhamad, they analyzed the relationship between echogenic bowel and cystic fibrosis and aneuploidy in 145 patients found to have hyperechogenic bowel. They subjectively "quantitated" the degree of echogenicity by comparing the echogenicity to the fetal iliac bone, with 0 being normal and the brightest bowel having a score of 3. Of the 40 fetuses with a score of 1, with mild increase in bowel echogenicity, none had cystic fibrosis or aneuploidy. Of those fetuses with a score of 2, moderately increased echogenicity, 2 patients had cystic fibrosis and 2 had aneuploidy. In the 24 cases with a score of 3, markedly increased bowel echogenicity, 5 patients had cystic fibrosis and 6 had trisomy 21. In the study by Sepulveda et al cystic fibrosis testing was performed in 45 pregnancies in which there was echogenic bowel. Three carriers for cystic fibrosis were detected, however no cases of cystic fibrosis subsequently developed in any of these fetuses. Their conclusion was that " the prevalence of cystic fibrosis mutations is not increased in a low-risk population of pregnancies complicated by fetal echogenic bowel". In a study of bowel abnormalities in the fetus, not limited to cases of echogenic bowel, Corteville et al found that six of the fetuses with dilated and hyperechogenic fetal bowel had gastrointesintal abnormalities diagnosed after birth, including three with cystic fibrosis. They concluded that hyperechoic bowel in conjunction with dilated bowel was more predictive of cystic fibrosis than was hyperechoic bowel alone, 3 of 10 vs 1 of 33.

Chromosomal Abnormalities:

Numerous songraphic findings have been described in fetuses subsequently found to have trisomy 21. In the past 10 years cases of echogenic bowel in fetuses with trisomy 21 have been reported. While in many cases there are other sonographic findings eg nuchal thickening, short limbs; cases of echogenic bowel being the only sonographic finding have been reported in fetuses with trisomy 21. Dicke and Crane found one case of Trisomy 18 in which echogenic bowel was the only finding. They concluded that cytogenetic testing should be reserved only for those fetuses with other strucural abnormalties. While virtually all of the reported cases of echogenic bowel and fetal trisomies have been described in the second trimester, a report by Sepulveda et al described a case of trisomy 21 in which normal bowel was seen in the second trimester but became echogenic in the third trimester.

The incidence of chromosomal abnormalities in patients with echogenic bowel is between 3.3% reported by Dicke and Crane and 25-27% reported by Scioscia et al and Nyberg et al. In the study by Bromley et al hyperechogenic bowel was found in 0.6% of patients. Of 50 fetuses with echogenic bowel 58% were normal and 16 of the fetuses were aneuploid. They noted 12.5% of fetuses with trisomy 21 diagnosed by second trimester karyotyping had hyperechogenic bowel. As a result of their findings, their estimate of the hypothetical calculated risk for having a trisomy 21 fetus when hyperechogenic bowel is the only finding is 1.4%.

Poor Outcome:

In the study of Dicke and Crane echogenic bowel was associated with fetal growth retardation in 23% and perinatal death in 17%. Other groups have also noted these associations. When echogenic bowel is seen in pregnancies in which the maternal serum AFP is elevated the pronosis is poor. In the study by Achiron et al all six fetuses with the combination of elevated maternal serum AFP and echogenic bowel were growth retarded. Four of these fetuses died in utero and one of the two live-born infants died in the neonatal period.

 

References:

Parulekar SG. Sonography of normal fetal bowel. J Ultrasound Med 10:211-220, 1991

Fakhry J, Reiser M, Shapiro LR et al. Increased echogenicity in the lower fetal abdomen: a common normal variant in the second trimester. J Ultrasound Med 5:489, 1986

Lince DM, Pretorius DH, Manco-Johnson ML. The clinical significance of increased echogeniciy in the fetal abdomen. Amer J Roentgenol 145:683, 1985

Dicke JM, Crane JP. Sonographically detected hyperechoic fetal bowel: significance and implication for pregnancy management. Obstet Gynecol 80:778-782, 1992

Sepulveda W, Bower S, Fisk NM. Third-trimester hyperechogenic bowel in Down syndrome. Am J Obstet Gynecol 172:210-211, 1995

Bromley B, Doubilet P, Frigoletto FD, Krauss C, Estroff JA, Benacerraf BR. Is fetal hyperechoic bowel on second-trimester sonogram an indication for amniocentesis? Obstet Gynecol 83:647-651, 1994

Slotnick RN, Abuhamad AZ. Prognostic implications of fetal echogenic bowel. Lancet 347:85-87, 1996

Rypens FF, Avni EF, Absehsera MM, Donner C, Vermeylen DF, Struyven JL. Areas of increased echogenicity in the fetal abdomen: diagnosis and significance. Radiographics 15:1329-1344, 1995

Scioscia AL, Pretorius DH, Budorick NE, Cahill TC, Axelrod FT, Leopold GR. Second-trimester echogenic bowel and chromosomal abnormalities. Am J Obstet Gynecol 167:889-894, 1992

Sepulveda W, LeungKY, Robertson ME, Kay E, Mayall ES, Fisk NM. Prevalence of cystic fibrosis mutations in pregnancies with fetal echogenic bowel. Obstet Gynecol 87:103-106, 1996

Corteville JE, Gray DL, Langer JC. Bowel abnormalities in the fetus-correlation of prenatal ultrasonographic findings with outcome. Am J Obstet Gynecol 175:724-9, 1996

Achiron R, Seidman DS, Horowitz A, Mashiach S, Goldman B, Lipitz S. Hyperchogenic fetal bowel and elevated serum alpha-fetoprotein: a poor fetal prognosis. Obstet Gynecol 88:368-371, 1996

 

  This is a clickable imagemap, for hyperlinks, see text below.

Home | Teaching Files | Literature | Bulletin Board