Ultrasound Obstet Gynecol 2003; 21: 161164

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.26

In-utero development of the fetal colon and rectum:

sonographic evaluation
Y. ZALEL*, Y. PERLITZ, R. GAMZU*, D. PELEG and M. BEN-AMI
*Department of Obstetrics & Gynecology, Sheba Medical Center (affiliated to the Sackler School of Medicine, Tel-Aviv University),
Tel-Hashomer, and Department of Obstetrics & Gynecology, Poriya Hospital, Tiberias (affiliated to the Bruce Rappaport Faculty
of Medicine, Technion, Israel Institute of technology, Haifa), Israel

K E Y W O R D S: fetal colon; fetal bowel; nomogram; ultrasound biometry

ABSTRACT
Objective To construct a normal range for the internal
diameter of the fetal descending colon and rectum
during gestation.
Subjects and Methods This was a prospective, crosssectional study including 379 healthy pregnant women
with normal singleton pregnancies at 1940 weeks
of gestation. Measurements of the fetal descending
colon (maximum internal diameter) and the fetal
rectum (at the level of the bladder, measuring the
anteroposterior diameter), were performed by highresolution transabdominal sonography.
Results Adequate bowel measurements were obtained in
all 379 fetuses. The diameter of the descending colon
and rectum plotted as a function of gestational age had
a sigmoid curve; the curve estimation was expressed by
a cubic regression equation with R2 of 0.848 and 0.831,
respectively (P < 0.0001). The normal mean and the 95%
prediction limits were defined.
Conclusion The present data provide a normal range of
fetal bowel (descending colon and rectum) diameters from
the early second trimester of pregnancy onwards. They
may allow intrauterine assessment of the development of
the fetal colon and may serve as reference values in the
detection of anomalies of the fetal bowel. Copyright
2003 ISUOG. Published by John Wiley & Sons, Ltd.

INTRODUCTION
Modern sonographic technology and user experience
have made it possible to identify an increasingly
large number of abnormalities of the fetal colon and
rectosigmoid. Fetal gastrointestinal malformations occur
with an incidence of approximately 6 in 1000 live

births. Colonic atresia is responsible for 5% to 10% of

bowel atresia, of which anal atresia is the most common
type, occurring once in every 5000 live births1 . Colonic
atresia and many other fetal intestinal disorders have
been previously reported, including anorectal atresia2 ,
Hirschsprungs disease3 , megacolon with anal-urethral
atresia4 , and dilated descending colon associated with
JohansonBlizzard syndrome5 .
However, little has been reported in the literature which
indicates the differences between pathologically dilated
descending colon or rectum and the normal appearance
of these organs, as visualized by ultrasound.
The aim of this study was to construct a normal range
for the diameter of the fetal descending colon and rectum
at 1940 weeks gestation, for singleton normal fetuses, in
order to help distinguish normal from abnormally dilated
fetal descending colon and rectum.

MATERIALS AND METHODS

This was a cross-sectional study on 379 singleton
pregnancies, scanned at 1940 weeks gestation. The data
were used to establish the range for the diameter of the
descending colon and the rectum during normal gestation.
The study group consisted of pregnant women who
fulfilled the following criteria: (1) history of regular
menses, and a known date of the beginning of the
last menstrual period; (2) gestational age based on
sonographic measurement of the crownrump length in
early pregnancy; (3) absence of maternal disease and a
clinically normal fetus at term; (4) a fetus whose estimated
fetal weight was within the mean.
The colon could be recognized sonographically by its
peripheral location and known anatomical configuration,
its haustral folds being seen in most cases. The diameter
of the colon was obtained during routine sonographic

Correspondence to: Dr M. Ben-Ami, Department of Obstetrics & Gynecology, Poriya Hospital, Tiberias, MPO Lower Galilee, 15208, Israel
(e-mail: benamimo@netvision.net.il)
Accepted: 22 October 2002

Copyright 2003 ISUOG. Published by John Wiley & Sons, Ltd.

ORIGINAL PAPER

Zalel et al.

162

examination performed to rule out malformations, as

well as during routine third-trimester sonographic followup. Each patient was scanned only once during the study
by a single experienced sonographer (Y.Z.).
The measurement obtained of the fetal descending
colon diameter was the maximum internal diameter
observed, in the parasagittal plane (Figure 1). The
measurements of the fetal rectum were taken at the
level of the fetal bladder in the transverse plane
(Figure 2). Freeze-frame ultrasound capabilities and
electronic on-screen calipers were used for the bowel
measurements. Ultrasound scanning was performed with
a transabdominal 3.55.0-MHz curvilinear transducer
(ATL HDI 3000, Advanced Technology Laboratories,
Bothell, WA, USA). Each measurement was repeated
three times in each fetus and the mean diameter was
determined. The coefficient of variation was calculated
in order to determine the intraobserver variability; this
was calculated in 35 cases as [(x1x2)/xm], where
x1 and x2 are two measurements performed by the
same sonographer and xm is the mean of these two
measurements.

Figure 1 Measurement of the maximum internal diameter of the

fetal descending colon in the parasagittal plane. C, colon.

The means and 95% confidence intervals (CIs) of

the diameters of the colon and rectum for consecutive
gestational ages were calculated. The colon and the rectal
diameters were not linearly related. Instead of performing
transformations we used a cubic mathematical function
for curve estimation. All data processing was performed
using the statistical software package SPSS 9.0 (SPSS,
Chicago, IL, USA).

RESULTS
The median maternal age was 27 (range, 1942)
years. Descending colon (r = 0.89) and rectal (r =
0.88) diameters demonstrated a cubic correlation with
gestational age, reaching a maximum of 18.0 mm and
13.0 mm at term, respectively.
The colon and rectal diameters as a function of
gestational age were not linearly related to one another,
thus we used a cubic model for curve estimation.
The regression equation for the descending colon
modeled as a function of gestational age (GA) in
weeks was:
Descending colon diameter (mm) = 4.66 0.01
GA2 + 0.0004 GA3 (Figure 3).
The R2 value was 0.848, and found to be highly
statistically significant (P < 0.0001).
The regression model for rectal diameter was also cubic:
Rectal diameter (mm) = 2.88 0.014 GA2 + 0.0002
GA3 (Figure 4).
The R2 value was 0.831, and found to be highly
statistically significant (P < 0.0001).
Table 1 presents the calculated values of descending
colon and rectal diameters by gestational age and the
lower and upper limits of the 95% CI for ages 20 to
40 weeks.
We succeeded in measuring the fetal descending colon
and rectal diameters at as early as 19 weeks gestation, and
in 100% of our attempts. The intraobserver variations for

Descending colon diameter (mm)

20

16

12

0
18

26

34

42

Gestational age (weeks)

Figure 2 The anteroposterior diameter of the fetal rectum,

measured at the level of the fetal bladder in the transverse plane.
B, bladder.

Copyright 2003 ISUOG. Published by John Wiley & Sons, Ltd.

Figure 3 Regression analysis of descending colon diameter and

gestational week using a cubic model. The 95% confidence interval
is shown.

Ultrasound Obstet Gynecol 2003; 21: 161164.

Fetal colon and rectal development

163

14

Rectal diameter (mm)

12
10
8
6
4
2
18

42

26
34
Gestational age (weeks)

Figure 4 Regression analysis of rectal diameter and gestational

week using a cubic model. The 95% confidence interval is shown.

Table 1 Descending colon and rectal diameters according to

gestational age
Descending colon
diameter (mm)

Week of

Rectal diameter
(mm)

gestation

Number

Mean

95% CI

Mean

95% CI

1920
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

10
16
28
29
29
29
13
7
7
7
8
10
11
17
14
29
32
18
26
17
22

3.52
3.59
3.69
3.82
3.98
4.18
4.43
4.71
5.04
5.42
5.84
6.32
6.86
7.45
8.10
8.81
9.59
10.44
11.35
12.34
13.40

0.796.26
0.866.32
0.966.41
1.096.54
1.266.7
1.466.9
1.707.15
1.997.43
2.327.76
2.698.14
3.128.57
3.609.05
4.139.58
4.7210.17
5.3710.82
6.0911.53
6.8712.31
7.7113.16
8.6314.08
9.6115.07
10.6616.15

3.64
3.79
3.95
4.14
4.34
4.57
4.82
5.08
5.38
5.69
6.04
6.41
6.80
7.23
7.68
8.17
8.68
9.23
9.81
10.43
11.08

1.455.82
1.615.97
1.786.13
1.976.31
2.176.52
2.406.74
2.646.99
2.917.26
3.207.55
3.527.87
3.868.21
4.238.58
4.638.98
5.059.40
5.519.85
5.9910.34
6.5110.85
7.0611.40
7.6411.98
8.2512.61
8.8913.26

measurement of the diameters of the descending colon

and rectum were 6.5% and 5.2%, respectively.

DISCUSSION
During the 6th week of fetal development, the endodermal epithelium of the gut tube proliferates and completely
occludes the lumen. Over the next 2 weeks, however, it
vacuolates and recanalizes6 . Congenital stenosis or duplication of the fetal colon may result from incomplete
recanalization, resulting in intestinal obstruction6 . Abnormal rotation and fixation of the fetal primary intestinal

Copyright 2003 ISUOG. Published by John Wiley & Sons, Ltd.

loop may result in a variety of malformations, including

compression or volvulus of the intestine6 .
During recent years, many women have been referred
to our ultrasound unit for suspected dilatation of the fetal
bowel, based on the small number of cases described in the
literature and the different dimensions given. Therefore,
we have conducted this study in order to provide reference
values of the normal fetal bowel. Although Parulekar7 has
described the dimensions of the colon in 300 fetuses, his
study included 66 fetuses below 20 weeks gestation, and,
as he has stated: The colon could not be definitely
demonstrated in fetuses between 10 and 18 weeks
gestation. Therefore, we included in our study fetuses
from 19 weeks onwards, and, in so doing, have provided
the largest dataset at these gestational ages. Moreover, we
have measured both the descending colon and the rectum,
in order to give reference values for these organs. We
observed a cubic correlation between descending colon
(r = 0.89) and rectal (r = 0.88) diameters with gestational
age. The maximum descending colon and rectal diameters
were 18 mm and 13 mm at term, respectively. Our results
are in accordance with those of Nyberg et al.8 , who
presented the normal appearance of the fetal colon in
a prospective study of 130 fetuses; they found that the
colon diameter demonstrated a linear relationship with
menstrual age (r = 0.82), reaching a maximum of 18 mm
at term. Tepper et al.9 measured the fetal colon in 136
normal pregnancies and reported the results as ratios
of colon circumference to abdominal circumference. We
prefer to provide actual dimensions of the fetal bowel,
believing these to be of greater use to sonographers.
We were able to visualize the fetal descending colon
and rectum in all fetuses examined from 19 weeks of
gestation onwards. This is in contrast to the study of
Nyberg et al.8 , in which the colon was seen in some
fetuses at 22 menstrual weeks and in all fetuses examined
only after 28 weeks. Parulekar7 also stated that the colon
could be seen in only 44% of the fetuses between 18 and
25 weeks and in 89% of the fetuses between 20 and 25
gestational weeks. Only after 25 weeks gestation, could
the colon be seen in 100% of the fetuses examined. We
believe that our improved rate of visualization of the fetal
colon can be attributed to the developments in diagnostic
imaging that have taken place in recent years.
Anal atresia, meconium plug syndrome, Hirschsprungs
disease and other colorectal malformations are all
sonographically visualized as dilated or hyperechogenic
fetal colon10 . Harris et al.2 showed abnormally dilated
bowel segments in five of 12 diagnosed cases of anorectal
atresia. A V-shaped or U-shaped segment of dilated
bowel in the lower pelvis makes the diagnosis of
anorectal atresia more likely2 . When a dilated loop of
colon is detected sonographically, Hirschsprungs disease
must be considered in the differential diagnosis. Eliyahu
et al.3 presented the prenatal sonographic appearance of
Hirschsprungs disease in a fetus in the second trimester.
The aganglionic colon and ileum were dilated, the
abdominal circumference was increased and there was
mild polyhydramnios. Moreover, concurrent anomalies

Ultrasound Obstet Gynecol 2003; 21: 161164.

164

are often associated with bowel obstruction, especially

with anorectal atresia. Likewise, additional anomalies
were found in 92% of fetuses in the study of Harris
et al.2 , and have been reported in up to 72% of
cases in neonatal series11 , usually as part of the
VACTERL syndrome12 . Therefore, whenever dilated
bowel loops are suspected, a detailed sonographic
evaluation should be carried out in order to exclude
additional malformations.
In summary, we have constructed a nomogram of
the diameters of the descending colon and rectum
between 19 and 40 weeks gestation. We suggest that,
when the descending colon and rectal internal diameters exceed the values given for any gestational age,
a pathological bowel dilatation should be suspected.
At term, these measurements should not be beyond
18 mm for the colon and 13 mm for the rectum.
If there is apparent dilatation the referring physician
and pediatrician should be informed and the appropriate pre- and postnatal examinations should be carried out.

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