G a s t r o i n t e s t i n a l I m a g i n g C l i n i c a l Pe r s p e c t i ve

Kuzmich et al.
Sonography of Small bowel Perforation

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Gastrointestinal Imaging
Clinical Perspective

Sonography of Small Bowel

Perforation
Siarhei Kuzmich1,2
Christopher J. Burke 3
Chris J. Harvey 1
Tatsiana Kuzmich 4
Daniel T. M. Fascia1
Kuzmich S, Burke CJ, Harvey CJ, Kuzmich T, Fascia DTM

OBJECTIVE. This article aims to illustrate the spectrum of sonographic findings in perforation of the small bowel due to a variety of causes and discusses the potential role of sonography in the diagnosis.
CONCLUSION. Although sonography is not the first-line investigation of choice in suspected small intestinal perforation, an understanding of the characteristic appearances seen
during general abdominal sonography may aid the radiologist in the early diagnosis. Recognition of small bowel perforation on general abdominal sonography will shorten the time to
diagnosis and ultimate surgical management.

Keywords: CT, small bowel perforation, sonography

DOI:10.2214/AJR.12.9882
Received August 28, 2012; accepted after revision
October 28, 2012.
1
Department of Imaging, Hammersmith Hospital, London,
United Kingdom.
2

Present address: Department of Radiology, Newham

University Hospital, Glen Rd, London E13 8SL, United
Kingdom. Address correspondence to S. Kuzmich
(siarheikuzmich@yahoo.co.uk).

Department of Radiology, Guys and St. Thomas

Hospitals, London, United Kingdom.

4
Department of Radiology, North Middlesex University
Hospital, London, United Kingdom.

WEB
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American Roentgen Ray Society

erforation of the mesenteric small

bowel, although uncommon in
North America and Western Europe, remains a potentially lifethreatening condition associated with high
morbidity and mortality and poorer outcomes
when the diagnosis is delayed [13]. The radiologist is usually the first to suggest a preoperative diagnosis because the clinical presentation of small bowel perforation may be
variable and is related to a multitude of factors, including the source of the perforation
and its mechanism, the site and extent of the
perforation, time since perforation, the degree
of contamination of the peritoneal cavity, and
the patients age and comorbidity burden.
Causes of small bowel perforation are manifold and include trauma and iatrogenic injury, inflammatory conditions, infection, ischemic change, diverticula, foreign bodies,
and malignancy. Although some contributing conditions such as traumatic or iatrogenic
injury and Crohn disease are often anticipated, other rare culprits such as an ingested foreign body are commonly unexpected. Another unusual but important causeperforated
intestinal tuberculosisis likely to continue
to present a diagnostic challenge to the radiologist; this old disease is a growing concern,
particularly in urban areas, because of combined effects of immigration, HIV infection,
drug resistance, and rising poverty [47].
Whatever the cause, the rarity of small bowel perforation combined with its propensity
for nonspecific clinical presentation makes

establishing the correct diagnosis more challenging for the radiologist.

CT is the modality of choice and is the best
radiologic tool currently available for revealing both perforation and the underlying condition when the diagnosis is unexpected. Unlike
CT, sonography does not typically play a role
in investigation of suspected small bowel perforation or other acute abdominal conditions
associated with overt peritonitis, pneumoperitoneum, and bowel obstruction. However, sonography may be the initial test chosen in patients with localized abdominal symptoms
when gastrointestinal perforation is not a major clinical consideration. This patient group
typically includes referrals for acute appendicitis, cholecystitis, pyelonephritis, colonic diverticulitis, and pelvic inflammatory disease.
Therefore, we believe that an understanding
of the appearances of small bowel perforation
seen during general abdominal sonography
will aid the radiologist in identifying the true
cause of abdominal pain when this condition
presents with nonspecific symptoms. Furthermore, there is a growing interest in recognizing the role of sonography in imaging of the
bowel [8], which, combined with the rising
utilization of this noninvasive radiation-free
modality in both the emergency department
and outpatient settings [9], makes this area of
abdominal imaging particularly pertinent to
the radiologist.
In a recent article [10], investigators highlighted the potential role of sonography in
the diagnosis of perforated pyloroduodenal

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Kuzmich et al.
Fig. 1Sonographic
appearance of normal
small bowel in healthy
25-year-old man. Oblique
color Doppler image,
paraumbilical view,
obtained using 10-MHz
transducer depicts
cross sections of mid
small bowel (asterisks),
captured during peristaltic
wave, and mesentery with
vessels (m).

peptic ulcer. By contrast, this article stems

from our wish to share our experiences in sonographic diagnosis of common and unusual
perforations of the jejunum and ileum encountered during general abdominal sonography.
Correlation with CT is given when possible,
and examples of surgically and histologically
proven cases are discussed.
Sonographic Considerations
Technique and Normal Appearances
The primary general abdominal survey is
followed by focused assessment of the symptomatic area using 2-6MHz curvilinear and
6-12MHz linear multifrequency transducers, depending on the achievable distance to
the area of interest. Any area of potential bowel-related disease or injury is analyzed as described later in this article. Probe compression
is used judiciously to facilitate visualization
by bringing the area of interest into focus and
displacing loops of bowel. We did not use hydrosonography for any of the cases presented
here. This technique can potentially improve
bowel conspicuity and aid evaluation but may
be of limited use in practice because small
bowel perforation is usually encountered when
it is not expected and the patient may be in
pain and experiencing nausea, making administration of water unwanted. Furthermore, the
finding of perforation would precipitate a nilby-mouth status as a prerequisite to a possible
operative procedure.
In most patients, much of the small bowel, from the duodenum to the terminal ileum,
can be imaged with conventional sonography

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Like elsewhere in the gastrointestinal tract,

the bowel wall can be visualized as a five-layered structure under optimal scanning conditions, but basic identification of thin dark
muscularis and more echogenic mucosa will
usually suffice in practice [12].
Abnormal Small Bowel
When diseased, the bowel wall often thickens and becomes rigid with reduced or absent
peristalsis. Sonographic identification of the
site of abnormality therefore relies on detection of tangible bowel wall thickening, which
varies in extent depending on the underlying
condition. Similar to a pattern approach used
in CT evaluation, observing the degree of
wall thickening, the length of abnormal bowel, and associated perienteric changes on sonography can be used to narrow the differential diagnosis [13].

without any special preparation [11]. The

small intestine usually lies in a regular manner
in the abdomen with the jejunum positioned
higher and more to the left and the ileum lower
and more to the right, although loops can alter
their position. The caliber of the normal small
bowel does not usually exceed 3 cm. The normal wall thickness is less than 3 mm. Small
bowel loops are usually mobile; are compressible; and show peristalsis, which may be lively
or sluggish depending on the physiologic state
(Fig. 1). The circular folds are more prominent
in the jejunum, diminishing toward the terminal ileum, which may be foldless.

Sonographic Signs of Perforation

Like with gastrointestinal perforation from
locations other than the small bowel, pneumoperitoneum may be present but is often minimal or absent outside the setting of traumatic
and iatrogenic bowel injuries. Walled-off or
localized perforation is common. Free spontaneous perforation usually results in a dramatic
clinical presentation with generalized peritonitis and thus is optimally imaged with CT.
On sonography, small amounts of free gas
are seen as strongly echogenic foci or lines
on the liver surface producing ring-down or
comet-tail artifacts (Fig. 2A). Free air can
also be detected beneath the anterior abdom-

Fig. 2Sonographic appearances of free intraperitoneal gas.

A, 39-year-old man with perforated ileal tuberculosis. Right intercostal view obtained with 6-MHz transducer shows
bright echogenic line of free air (arrows) overlying liver (L) surface with posterior comet-tail artifact (arrowheads).
Inset shows corresponding axial CT image.
B, 35-year-old woman with Crohns disease who presented with perforated ileum. Transverse right flank
view obtained with 6-MHz transducer depicts pocket of dependent free gas (arrows) with dirty shadowing
(arrowheads) in fluid collection (asterisks) beneath abdominal wall (aw). Inset shows corresponding axial CT image.

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Sonography of Small bowel Perforation

Fig. 3Perforated versus nonperforated small bowel diverticulitis.

A, 61-year-old man who presented with 5-day localized left abdominal pain and fever thought to be caused by pyelonephritis. Sonogram of left flank obtained with 6-MHz
transducer shows oblique section of mildly thickened jejunum (j) and two small fluid collections (asterisks) of similar shape surrounded by echogenic fat. Small bright free
gas bubbles (arrows) are difficult to see on this still image but were obvious during real-time scanning. Surgical resection revealed perforated jejunal diverticulitis and
mesenteric abscess. Inset shows corresponding axial CT image.
B, 32-year-old woman who presented with 3-day history of right upper quadrant pain and low-grade fever thought to be result of cholecystitis. Inset shows position of
transducer (bar). Sonogram obtained with 3.5-MHz transducer depicts hypoechoic blind-ending structure (d) with thick irregular wall (arrowheads) arising from mildly
thickened ileum (i). No extraluminal gas was identified. Pathology confirmed nonperforated inflamed Meckel diverticulum, which measured 3 2 cm.
C, 72-year-old man with perforated ileal diverticulitis. Oblique pelvic view obtained using 3.5-MHz transducer shows segment of mildly thickened ileum (i) and adjacent
fluid collection (asterisks) with surrounding echogenic fat. Note extraluminal gas pocket (arrows) seen as bright dependent line with dirty shadowing (arrowheads) in
collection on left. Inset shows corresponding axial CT image.

inal wall where it accumulates with the patient supine [10] (Fig. 2B). With judicious
use, careful sonography can detect a minimal
amount of free gas, equating to a single bubble, because of its exclusive ability to produce distinctive bright echoes and artifacts
[14, 15]. Nevertheless, it is worth remembering that although sonography has a number
of strengths including its unique real-time
value and excellent spatial resolution, the diagnostic quality of a sonographic study can
be compromised by obesity, extensive fecal
loading in the colon, bowel obstruction, and
pain. Other potential weaknesses of this modality may be related to the skill of the operator; the equipment used; and availability of expertise for this type of evaluation, which will
depend on the local radiology practice model.
Sonographic findings that suggest a perforation site typically include unusual fluid
collections related to a thickened segment of
bowel associated with echogenic change in
adjacent perienteric fat due to inflammation.
Similar to CT, the presence of extraluminal
gas on sonography provides a useful clue to
the diagnosis [16, 17].
Perforated Diverticulum
Jejunal Diverticulum
Jejunal diverticula are usually multiple acquired pseudodiverticula along the mesenteric border seen in middle-aged and elderly

patients. Most patients are asymptomatic. Jejunal diverticula can be recognized on sonography as fluid-filled pouchlike structures adjacent to the normal bowel [18].
Diverticulitis and perforation do occur and
are thought to be caused by infection, blunt
trauma, and foreign-body impaction [1921].
Localized perforation with abscess formation
is common. Sonography often shows a collection of fluid related to a segment of mildly
thickened jejunum, echogenic perienteric fat
caused by inflammatory change, and pockets
of extraluminal gas [22] (Fig. 3A).
Ileal Diverticulum
Ileal diverticulum is usually caused by a
congenital Meckel diverticulum but can also
be acquired [2325]. The rule of twos is
frequently quotedthat is, Meckel diverticulum occurs in 2% of the population 2 feet
from the ileocecal valve and is usually 2
inches long. However, the size and site vary.
Right lower quadrant and mid abdominal locations with a tendency of the diverticulum to lie
toward the midline are frequently reported [26].
Uncomplicated Meckel diverticulum is
usually too subtle and is rarely seen. When
diverticulitis occurs, the area of abnormality
may become conspicuous and is recognized
owing to the presence of echogenic inflammatory change in the fat surrounding the diverticulum next to a mildly thickened ileal

segment. The inflamed diverticulum is visualized as a blind-ending thick-walled pouch

or tubular fluid-filled structure surrounded
by echogenic fat. This structure is usually constant in position and inflexible. Visualization
of a communication of the structure with the
ileum provides a helpful clue to the diagnosis (Fig. 3B). Similar to our experience, sonographic manifestation of an inflamed Meckel
diverticulum has been consistently described,
both in children and adults [2729].
When perforation occurs, sonography
shows a fluid collection next to a thickened
segment of small bowel and often the presence of extraluminal gas in the fluid [30]
(Fig. 3C). In our experience, a perforated
diverticulum may or may not be evident depending on its size, the degree of its collapse resulting from perforation, and the
quality of the sonographic study, which may
be restricted by guarding.
Potential pitfalls may arise, most commonly
from perforated appendicitis and colonic diverticulitis, that can result in fluid collections and
extraluminal gas lying near the small bowel.
A periappendiceal abscess, for instance, can
mimic perforated Meckel diverticulum when
it involves the ileum. Visualization of an abnormal appendix in such cases will confirm
the correct diagnosis (Fig. 4A). Care should be
taken not to confuse colonic diverticulum for
a pocket of extraluminal gas when it lies close

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Kuzmich et al.

Fig. 4Potential mimics of perforated small bowel diverticula.

A, 30-year-old woman with perforated appendicitis. Inset shows position of transducer (bar). Sonogram obtained with 2.5-MHz probe shows mildly thickened ileum (i)
next to small fluid collection (asterisk) that contains pocket of dependent gas (arrowhead) with shadow. Because there is also enlarged appendix (arrow) involved in
collection, small periappendiceal abscess was suggested, which was confirmed at surgery.
B, 69-year-old man with colonic diverticulitis. Inset shows position of transducer (bar). Sonogram obtained using 10-MHz transducer shows jejunum (j) lying close to
descending colon (c) and colonic diverticulum seen as bright shadowing pocket (arrowhead) between cross sections of jejunum and colon. This finding should not be
confused with pocket of extraluminal gas seen in perforation.
C, 66-year-old man with sigmoid diverticulitis complicated by pericolonic abscess. Sonogram of left iliac fossa obtained with 3.5-MHz probe depicts abscess (asterisks)
lying close to bowel loop that was identified to be sigmoid colon (s) with diverticulosis on careful survey. Inset shows corresponding axial CT image.

to the small bowel (Fig. 4B). In perforated colonic diverticulitis, the diverticular abscess
may also lie close to the small bowel. In this
case, sonography can suggest the true cause
by showing involvement of the mildly thickened colon with evidence of diverticulosis.
Although sonographic differentiation may be
problematic, CT will usually help (Fig. 4C).
Finally, when extensive bowel thickening, a
mass, or significant lymphadenopathy is pres-

ent, other causes including perforated malignancy should be considered.

Crohn Disease
Because sonography readily displays thickened small bowel, this noninvasive radiationfree modality is increasingly being chosen as
both the initial test and follow-up technique
in Crohn disease, particularly in the younger
population [31]. Sonographic manifestations

Fig. 5Nonperforated versus perforated small bowel in patients with Crohns disease.
A, 50-year-old woman with Crohns disease involving distal ileum. Inset shows position of transducer (bar).
Color Doppler sonogram obtained with 3.5-MHz probe shows thick-walled hyperemic ileum in cross section (i)
next to bladder (ub). Note thickened echogenic mesentery (m) and layer of echogenic fat (arrowheads) encasing
whole bowel circumference including antimesenteric border.
B, 25-year-old woman with Crohns disease involving terminal ileum complicated by mesenteric abscess. Inset
shows position of transducer (bar). Sonogram obtained with 3.5-MHz probe shows thickened terminal ileum (i)
and adjacent abscess (asterisk).

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of active Crohn disease are often characteristic. The hallmark of the disease is circumferential encasement of a thickened bowel loop
with echogenic fat, which reflects transmural
inflammation and is sometimes referred to as
the creeping fat sign [32] (Fig. 5A). The
mesentery is often thickened and echogenic.
A predilection of this disease for the terminal
ileum is well known.
Abscess formation is common and can result from transmural inflammation and a deep
ulcer penetrating into perienteric tissues or
may be caused by localized perforation [32,
33]. A Crohn abscess is usually walled off
because of preexisting fibrotic and adhesive
perienteric changes and may be mesenteric,
interloop, abdominal wall, or retroperitoneal in location. Sinuses and fistulas are frequent. Free spontaneous perforation and intraperitoneal rupture of a Crohn abscess also
occur, although much less frequently [34].
Free perforation will typically present with
overt peritonitis unless the patient is receiving high-dose corticosteroid therapy.
Sonography can be the first modality to detect an extraluminal Crohn abscess, which is
usually visualized as a fluid collection with
or without free gas near the diseased bowel
(Fig. 5B). Focal perforation may be seen as a
track of bright echogenic gas bubbles extending through the irregularly thickened bowel
wall beyond its outline [32]. Detection of free
intraperitoneal gas will suggest free perforation (Fig. 2B).

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Sonography of Small bowel Perforation

Fig. 6Nonperforated versus perforated small bowel in patients with ileal tuberculosis.
A, 29-year-old man with ileocecal tuberculosis. Inset shows position of transducer (bar). Sonogram obtained using 3.5-MHz probe shows thickened terminal ileum (ti) and
cecum (c). Note gas pocket (arrowhead) retained within terminal ileum wall; this finding suggests presence of ulceration.
B, 34-year-old man with perforated distal ileum from tuberculosis. Inset shows position of transducer (bar). Sonogram obtained using 3.5-MHz probe shows cross
section of thickened terminal ileum (ti) and large pockets of dependent extraluminal gas (arrow) in adjacent fluid collection (asterisk), which is obscured by gas shadow
and thus is poorly seen.
C, Same patient as in B. Coronal reformatted CT image depicts cecum (c), distal ileum (i), pockets of gas (arrow), and fluid collection (asterisk). These findings were
difficult to assess with sonography. Site of perforation is not evident on CT, but subsequent surgery revealed ileal perforation was 4 cm proximal to ileocecal junction.

The major differential diagnosis of Crohn

disease is tuberculosis, which should be considered in a high-risk population.
Intestinal Tuberculosis
The clinical manifestations of intestinal tuberculosis are often nonspecific. Patients may
present with diarrhea, weight loss, and abdominal pain [35, 36]. The ileocecal region is the
most common intestinal site. Ulcerative, hypertrophic, and combined forms are usually
described [37, 38].
Fig. 7Peritoneal involvement in tuberculosis versus
mesothelioma and carcinomatosis.
A, 52-year-old man with peritoneal tuberculosis.
Transverse sonogram of right flank obtained using
6-MHz transducer shows omental cake (o) adherent
to mildly thickened hypoechoic parietal peritoneum
(asterisk) in ascites. Corresponding axial CT image
(inset) shows findings indicating close correlation
between two modalities.
B, Same patient as in A. Transverse sonogram of left
flank (inset) shows jejunal loops (b) clumped together
and small pool of ascitic fluid, which allows visualization
of small adhesion (arrow), nodule (arrowhead), and
minimally thickened parietal peritoneum (asterisk).
Minimal peritoneal thickening is also evident on
corresponding axial CT image, but adhesion and nodule
are not visible.
C, 62-year-old man with malignant abdominal
mesothelioma. Inset shows position of transducer (bar).
Sonogram of left flank obtained using 9-MHz transducer
shows small bowel (b) encased by extensively thickened
visceral peritoneum (asterisk) outlined with ascites.
D, 59-year-old man with peritoneal carcinomatosis
from colorectal carcinoma. Inset shows position of
transducer (bar). Transverse sonogram of right flank
shows ascites (A) and peritoneal metastatic deposits
(arrows).

The most frequent finding in cases of intestinal tuberculosis on sonography is moderate

hypoechoic thickening of the terminal ileum
and cecum, which may be quite irregular depending on the disease stage (Fig. 6A). When

the distal ileum becomes tightly narrowed in

advanced disease, dilatation of the proximal
bowel will be seen. Mesenteric lymphadenopathy is often evident, which may show central
necrosis but can be nonspecific.

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Kuzmich et al.

Fig. 840-year-old man with abdominal pain and

known polyarteritis nodosa. Inset shows position of
transducer (bar). Paraumbilical view obtained using
6-MHz transducer shows concentrically thickened
ileal loops (i) and small amount of ascites (asterisk).
Moderate dilatation of proximal small bowel was also
present (not shown).

Diseased bowel can perforate spontaneously during and after antituberculous treatment.
Perforation is frequently solitary and walled off
but can also be multifocal and free, resulting in
generalized peritonitis [3, 39]. Sonography may
uncover the usual features of perforation such
Fig. 9Perforations caused by foreign bodies.
A, 62-year-old man with acute left abdominal colicky
pain suspected of having renal colic. Sonographic view
(inset) of left flank obtained using 10-MHz transducer
shows linear foreign body (arrows) embedded in
thickened wall of jejunum (j) and trace of fluid (asterisks),
which correlates with subsequent CT. No free gas is
present. Fish bone perforating jejunum was found at
surgery.
B, 64-year-old man suspected of having colonic
diverticulitis. Sonogram of left lower flank obtained using
6-MHz transducer shows fluid collection (asterisks) next
to thickened small bowel (j) and echogenic curvilinear
structure piercing bowel wall with its end (arrow) in fluid
collection. A few small bubbles of gas were present in
collection. Correlation of these sonographic findings
is shown with unenhanced axial CT image (inset).
Chicken bone fragment perforating mid small bowel was
revealed at surgery.
C, 40-year-old man with paraumbilical pain of 5 days
duration with fever. Paraumbilical sonogram shows
echogenic linear structure (arrows) related to fluid
collection (asterisks). Patient consented to CT 2 days
later after his symptoms had worsened. Multiplanar
reformatted CT image (inset) shows corresponding
foreign body, which is now lying deeper than on
sonography 2 days earlier, surrounded by larger
collection. No free gas is present. Surgery revealed
toothpick in perienteric collection and perforated ileum.
D, 30-year-old woman who presented with 2-month
history of nonspecific pelvic pain and low-grade fever.
Infraumbilical sonogram reveals bright linear structure
(cursors) embedded in abdominal wall at one end
and projecting toward abdomen with another end
(arrows). Sonogram (inset) obtained using 10-MHz
transducer shows morphology suggestive of intrauterine
contraceptive device (IUCD). IUCD embedded in ileum
with interloop abscess was found at surgery.

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as a fluid collection, pneumoperitoneum, and

extraluminal gas pockets near thickened bowel. Sonographic evaluation, however, may be
complicated by pockets of extraluminal gas
obscuring views and by guarding in the area
of interest (Fig. 6B). CT in these cases is more
likely to be diagnostic (Fig. 6C).
Other helpful sonographic findings are related to peritoneal involvement, which is often associated with intestinal tuberculosis.
These findings are ascites, mesenteric thickening, omental caking, peritoneal thickening,
adhesions, and peritoneal tuberculous nodules [4043]. Ascites may be diffuse or loculated, with fluid ranging from simple to complex containing movable strands and strings.
The mesentery is often thickened and echogenic with mesenteric leaves clamped together. Bowel loops are frequently fixed, which
is recognized by their lack of movement
and lack of separation in ascites. The greater omentum is often thickened, echogenic, and
heterogeneous. Omental cakes are recognized
as bulks of thickened omentum seen beneath
the abdominal wall anterior to the bowel
loops. Omental caking is most easily seen in

ascites (Fig. 7A). Omental cakes may be free

floating or may be adherent to the abdominal
wall or visceral peritoneum. Mild hypoechoic
thickening of the parietal and visceral peritoneum may be evident.
The presence of ascites greatly enhances
the sonographic ability to detect subtle peritoneal changes that are otherwise occult such as
minimally thickened peritoneum, adhesions,
and small tuberculous nodules (Fig. 7B). Detecting these signs on sonography, which are
often too subtle to be seen on CT, will provide
valuable additional clues to the diagnosis.
The appearances of peritoneal tuberculosis
largely overlap with those of malignant conditions involving the peritoneum such as mesothelioma and carcinomatosis. Care should
be taken not to confuse thickened peritoneum
and nodules caused by malignant mesothelioma with peritoneal tuberculosis. Unlike tuberculosis, peritoneal thickening and nodules
in mesothelioma tend to be much more extensive (Fig. 7C). Peritoneal implants in carcinomatosis are much larger, are discrete, or
are congregated soft-tissue nodules of varying sizes, whereas tuberculous nodules are

D
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Sonography of Small bowel Perforation

typically small [35, 44] (Fig. 7D). Nontuberculous peritonitis should also be considered.
In the correct clinical context, combined
sonographic and CT findings may be highly
suggestive but often are nonspecific. Tuberculosis, unfortunately, remains a great mimicker.
Vasculitis
Vasculitis is a rare cause of perforation, but
sonography may be the initial investigation in
patients with vasculitis of various causes presenting with abdominal symptoms. The main
finding is usually diffuse small bowel thickening, which is thought to be caused by a combination of edema and hemorrhage in the bowel
wall (Fig. 8). Sonography will also show edematous mesentery; bowel dilatation; ascites; and,
in the case of perforation, free gas. Similar to the
CT appearances of vasculitis, the sonographic
appearances are nonspecific and overlap considerably with findings of other conditions such
as infection, ischemia, radiation enteritis, angioedema, and hemorrhage [4547].
Polyarteritis Nodosa
Polyarteritis nodosa is a fibrinoid necrotizing vasculitis that mainly involves small
and medium-sized arteries of the muscles.
When it occurs in the small bowel, the condition causes acute abdominal pain. Perforation occurs in an estimated 5% of cases [48].
Wegener Granulomatosis
Wegener granulomatosis is an uncommon
multisystemic disorder characterized histopathologically by necrotizing granulomatous vasculitis that can affect the small bowel, although it
most commonly involves the respiratory tract and
kidneys. Bowel ulcerations resulting in perforations have been reported [4951].
Henoch-Schnlein Purpura
Henoch-Schnlein purpura is frequently associated with bowel involvement, but perforation is very rare [52, 53].
Foreign Bodies
Perforation is uncommon because ingested
foreign bodies that have passed below the diaphragm will usually pass in the stool. When
perforation occurs, localized abdominal symptoms usually imitate various inflammatory
conditions depending on the site of the perforation and the patients medical history and
age [5456]. Most patients will have no recollection of ingesting a foreign body. Both sharp
and blunt foreign bodies can cause bowel perforation, which is thought to result from slow
pressure necrosis.

Fig. 10Nonperforated versus perforated small bowel in patients with lymphoma.

A, 62-year-old woman with proven non-Hodgkin B-cell lymphoma involving mid ileum. Inset shows position of
transducer (bar). Paraumbilical sonogram obtained with 5-MHz probe shows abnormal segment of ileum with
concentrically thickened hypoechoic wall (w) and dilated lumen (L). This sonographic finding was unexpected
in this patient who was clinically suspected of having cholelithiasis.
B, 56-year-old woman with follicular lymphoma involving mid small bowel loop who presented with increasing
abdominal pain and rising inflammatory markers. Coronal CT image shows large mesenteric mass (M)
infiltrating and causing perforation of jejunal loop (j) with adjacent pockets of free gas (arrows) and free fluid
(asterisk) extending into pelvis.

In very recent or early perforation, there may

be no fluid collection or extraluminal gas, but
sonography may uncover the cause of abdominal pain by showing a foreign body embedded
in the thickened bowel wall (Fig. 9A). However, more commonly, sonography will reveal
a fluid collection adjacent to a short segment
of mildly thickened bowel and inflammatory
change in the perienteric fat [5760]. Extraluminal gas next to the bowel is a helpful finding, but
free gas is not always present in our experience.
Examples of ingested foreign bodies include fish and chicken bones and toothpicks,
which are seen as bright linear or curvilinear objects of peculiar geometry piercing the
bowel wall or lying in a fluid collection adjacent to the bowel [6163] (Figs. 9B and 9C).
Ingested wire bristle from a grill cleaning
brush is another example of a potential perforating foreign body that radiologists should
be aware of, as Grand and colleagues [64] reported in a recent study. Perforating ingested
plastic bread-bag clips have also been reported, although rarely [65, 66].
A variety of other rare perforating foreign
bodies have been reported in the literature. On
the very odd occasion, even an intrauterine
contraceptive device may perforate the uterus
and invade the small bowel [67, 68] (Fig. 9D).
Malignancy
A variety of intraabdominal malignancies,
both primary and secondary, may cause small
bowel perforation. Even benign desmoid tu-

mors leading to perforation have been reported

[69, 70]. Nevertheless, of all small bowel malignant perforations, lymphoma is the most frequent cause [71].
Intestinal lymphomas may be primary lesions or part of disseminated disease and are
usually non-Hodgkin type. Typical sonographic findings include concentric asymmetric or symmetric homogeneous hypoechoic
bowel thickening with loss of the layered pattern. Wall thickening is usually more than 2
cm. The affected segment is frequently in the
ileum and may be single or multiple with narrowing or enlargement of the lumen. Aneurysmal dilatation of the lumen, although not
always present, is characteristic (Fig. 10A).
Single or multiple ill-defined extraluminal
masses and mesenteric and retroperitoneal
lymphadenopathy may be evident.
Perforation can occur spontaneously and
during treatment [72, 73]. Sonography may
detect both an intestinal lesion and typical
signs of perforation as discussed earlier, but
the role of this modality is limited and CT is
invariably preferred (Fig. 10B).
Other Causes
Sonography is of very limited use and is typically not chosen for evaluation of traumatic
and iatrogenic perforations, which are usually a
major clinical consideration.
Advanced segmental or focal bowel ischemia of various causes such as thromboembolic
occlusion of the mesenteric vessels, strangu-

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Kuzmich et al.
lated hernias, adhesive bands, volvulus, and
vasculitis can result in transmural necrosis and
perforation. At our institutions, sonography is
not chosen when ischemic bowel is a consideration. Although a variety of suggestive features such as bowel thickening and dilatation,
free fluid, portal vein gas, and mesenteric and
portal vein thrombosis may be identified, sonographic assessment is often disappointing
when such patients are, on occasion, referred
for sonography instead of CT.
Radiotherapy for cervical carcinoma and
other intraabdominal malignancies may be associated with late complications including
bowel perforation [74]. AIDS-related infections such as Mycobacterium aviumintracellulare and cytomegalovirus infections may
involve the small bowel and may cause perforation in severely immunocompromised patients
[75, 76]. Long-standing use of nonsteroidal antiinflammatory drugs may lead to small bowel ulceration and perforation, although this is
rare. Various small bowel infections and infestations, particularly typhoid, can cause small
bowel perforation, but these entities are exceptionally rare in the western population [77].
Conclusion
Small bowel perforation is uncommon but
often produces subtle yet diagnostic sonographic abnormalities of which the radiologist should
be aware. Detection of localized extraluminal gas, a fluid collection, and inflammatory
change adjacent to a thickened bowel segment
should alert the radiologist to suspect a perforation. A targeted CT study may be instigated
when required depending on the initial sonographic study.
Familiarity with the characteristic sonographic appearances combined with a careful
sonographic technique should allow a timely
diagnosis during general abdominal sonography. Prompt diagnosis will facilitate correct
management planning and a prompt operative procedure.
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