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Journal of Feline Medicine and Surgery (2019) 21, 1047–1060

CLINICAL REVIEW

FELINE ABDOMINAL
ULTRASONOGRAPHY: WHAT’S
NORMAL? WHAT’S ABNORMAL?
The diseased gastrointestinal tract
Sally Griffin

Gastrointestinal wall thickening: Practical relevance:  Abdominal

diffuse vs focal thickening ultrasound plays a vital role in the
diagnostic work-up of many cats
Inflammatory conditions of the feline gastrointestinal (GI) tract may presenting to general and specialist
occasionally result in no changes to the appearance of the intestine practitioners. B-mode ultrasonography
on ultrasound and therefore a ‘normal’ ultrasound examination does is likely the most widely used modality for
not exclude the possibility of inflammatory disease. However, changes imaging the gastrointestinal (GI) tract in cats
and it can help in the diagnosis of GI masses, foreign
bodies and disorders of the ileocaecocolic junction.
Clinical challenges: Despite ultrasonography
being a commonly used modality, many
practitioners are not comfortable performing an
ultrasound examination or interpreting the resulting
images. Even differentiating between normal
variations and pathological changes can be
challenging for all but the most experienced.
For example, while for inflammatory conditions of
the feline GI tract changes are frequently identified
on ultrasound, there may occasionally be no
changes to the appearance of the intestine;
hence a ‘normal’ ultrasound does not exclude
the possibility of inflammatory disease.
Aim: This review, part of an occasional series
on feline abdominal ultrasonography, describes
Figure 1 Hypoechoic nodules (arrow), thought to represent lymphoid follicles, are visible within
the submucosa of the colonic wall the appearance of a range of conditions that affect
the feline GI tract; the normal GI tract is addressed
In all ultrasound images, unless stated otherwise, in an accompanying article in this issue of JFMS.
cranial is to the left and caudal is to the right of the image. Aimed at general practitioners who wish to improve
their knowledge and confidence in feline abdominal
are frequently present and typically take the form ultrasound, this review is accompanied by high-
of mild diffuse thickening of the intestinal wall resolution images and videos available online
with preservation of layering and/or thicken- as supplementary material.
ing of individual wall layers.1 Hypoechoic Equipment: Ultrasound facilities are readily
nodules 1–3 mm in diameter have been available to most practitioners, although
reported in the submucosa of the colonic THE NORMAL use of ultrasonography as a diagnostic
wall that are thought to represent reactive GASTROINTESTINAL TRACT tool is highly dependent on operator
intraparietal lymphoid follicles and may ‘Feline abdominal ultrasonography: experience.
What’s normal? What’s abnormal?
indicate the presence of colonic inflamma- The normal gastrointestinal
Evidence base: Information provided
tory disease (Figure 1).2 tract’ appears on pages
in this article is drawn from the published
1039–1046 of this issue literature and the author’s own clinical
of JFMS. experience.
Sally Griffin
BVSc, CertAVP, DipECVDI Keywords: Ultrasound; intussusception;
Radiology Department,
Willows Veterinary Centre and Referral Service, linear foreign body; neoplasia; duplication cyst
Highlands Road, Shirley,
Solihull B90 4NH, UK
Email: [email protected]

DOI: 10.1177/1098612X19880434
© The Author(s) 2019 JFMS CLINICAL PRACTICE 1047
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a b

Figure 2 (a) Moderate thickening and loss of layering of a portion of the ascending colonic wall (arrows) in a 12-year-old male neutered domestic shorthair cat.
A more normal appearance resumes in the colonic wall on the right, with which it is continuous. The final diagnosis based on histopathology was locally extensive
lymphoplasmacytic colitis. (b) Ultrasound image from a 12-year-old male neutered Tonkinese cat that was presented with a chronic history of vomiting, diarrhoea and weight
loss despite a good appetite. The wall of the jejunal loop (arrows) in the upper right portion of the image is moderately thickened with loss of normal layering. Although not
shown here, there was diffuse selective thickening of the muscularis layer affecting the remainder of the small intestine. The final diagnosis was inflammatory bowel disease

The presence of one or more mass lesions and submucosa, followed in the later stages by
within the GI tract (characterised by focal complete loss of layering, may be observed.4
regions of moderate to marked wall thicken-
ing), associated with partial or complete loss Selective thickening of the muscularis
of layering, is suggestive of neoplasia.3 Diffuse circumferential thickening of the muscu-
Particularly severe inflammation can, on occa- laris layer of the small intestine with preservation
sion, also produce loss of layering, although of wall layering and the absence of mass forma-
this is much less common (Figure 2); very tion has been reported in cats with eosinophilic
rarely, thickening of the bowel wall may be and, less commonly, lymphocytic enteritis and
associated with intestinal infarction.4 In the low-grade (small-cell) lymphoma (Figure 3).5–7
latter condition, prominence of the mucosa Thickening of the muscularis has been defined by

a b

c d

Figure 3 (a–d) Examples of selective thickening of the muscularis layer in three different cats. (a) Ultrasound image showing severe muscularis thickening of the ileocolic
junction in a 13-year-old female neutered domestic shorthair cat presenting with anorexia and lethargy. The final diagnosis was inflammatory bowel disease,
concurrent with bacterial cholangitis and pancreatitis. (b) Several loops of jejunum displaying uniform thickening of the muscularis layer in a 12-year-old male neutered
Birman. Final histopathological diagnosis was lymphocytic enteritis. Images (c) and (d) are from a 16-year-old male neutered domestic shorthair cat. Severe thickening
of the muscularis layer of several loops of jejunum (c) and of the ileal wall at the ileocolic junction (d) is shown. Two jejunal lymph nodes are visible in the centre of image (c).
The owner declined intestinal biopsy. Videos showing marked thickening of the muscularis layer of the jejunum and ileum are available as supplementary material

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Diffuse circumferential thickening of the muscularis layer of the

small intestine, with preservation of wall layering and the absence of mass formation,
has been reported in cats with eosinophilic and, less commonly, lymphocytic
enteritis and low-grade (small-cell) lymphoma.

the authors of one publication as a muscularis Selective muscularis thickening of the

layer that exceeds half the thickness of the intestine proximal to a stenosis caused by
submucosal layer.6 As mentioned in the alimentary lymphoma in one cat and an
accompanying article on the normal GI tract, intestinal foreign body in a second cat have
however, the results of a later study suggest also been reported, and in both cases
that the muscularis layer is normally equal to, was believed to be due to smooth muscle
or thicker than, the width of the submucosal hypertrophy.15 Mast cell tumours and
layer in the stomach, duodenum, jejunum and histoplasmosis have likewise been reported
ileum.8 The authors of the second study sug- to cause selective thickening of the muscularis
gest instead that the thickness of the muscu- of the small intestine in cats.16,17 Focal thicken-
laris layer may be compared with the diameter ing of a jejunal loop with loss of layering
of the aorta, and report mean ratios of 0.079, and peritoneal effusion were additional
0.087 and 0.14 for the duodenum, jejunum and findings in association with histoplasmosis.17
ileum, respectively, although specific upper An unusual case involving severe diffuse
limit cut-off values were not offered.8 It is thickening and increased echogenicity of
important to note that histopathology of the the muscularis layer of the stomach has
intestine was not performed and, therefore, been reported in a cat due to eosinophilic
it is not possible to rule out subclinical disease fibrosing gastritis.18 The authors of that study
in the cats included in this study. postulated that toxoplasmosis infection may
Diffuse selective thickening of the muscu- have been the underlying cause.18
laris layer is reported more commonly in cats
with low-grade lymphoma than inflamma- Focal gastrointestinal masses
tory bowel disease (IBD), probably owing to Focal Despite the descriptions below of the typical
the higher prevalence of the former.7 It should gastrointestinal appearance of various intestinal lesions, sig-
be noted that this statement is derived from a nificant overlap exists. This lack of specificity
study in which the cats diagnosed with lym- masses are means that the ultrasonographic appearance
phoma were significantly older than those cannot be regarded as pathognomonic for a
with IBD, which may have affected the
usually particular tumour type, or even for neoplasia
results.6 In cats with lymphoma, overall wall neoplastic, and vs benign disease, and thus sampling is
thickness is usually normal or increased and required for a definitive diagnosis.
wall layering is typically preserved.9 In a study lymphoma is
of cats with low-grade lymphoma, the mean typically Neoplastic gastrointestinal lesions
wall thickness was 4.3 mm (median 4.5 mm, Focal GI masses are usually neoplastic,
range 3.4–5 mm).9 Mesenteric lymphadeno- the most although exceptions can occur (see below).
pathy is also common.10 In a further study, It is generally agreed that lymphoma is the
22/27 (81%) cats with low-grade lymphoma common in most common intestinal tumour and adeno-
had evidence of intestinal thickening on ultra- the cat. carcinoma is the most common non-lymphoid
sound.11 Focal intestinal mass formation, tumour, followed by mast cell tumours,14,19–24
intussusception and increased mucosal echo- although a study by Rivers et al19 suggests that
genicity have also occassionally been observed adenocarcinoma may be the most common
in cats with low-grade lymphoma.9,12 tumour. The Siamese breed and increasing age
Lymphadenopathy can occur with both (particularly cats aged 10–14 years), equates
IBD and lymphoma, although any changes to an increased risk.23,24 Lymphoma is also the
present are often more marked with lym- most common tumour of the feline stomach;
phoma than with enteritis.1,6,13 Furthermore, conversely, and in contrast to the situation in
normal intestinal wall thickness and an dogs, gastric adenocarcinoma is very rare.25
absence of mesenteric lymph node changes do Lymphoma can present as solitary or multi-
not exclude the possibility of low-grade lym- ple intestinal masses or, as previously men-
phoma.14 Therefore, since there is substantial tioned, a diffuse thickening of the (small
overlap in the appearance of both disease intestinal) muscularis layer with otherwise
processes on ultrasound, further tests includ- normal wall layering. Masses owing to lym-
ing full thickness surgical biopsy, immuno- phoma are more likely to be intermediate or
histochemistry and clonality analysis should high grade in nature, and most commonly pre-
be considered.7 sent on ultrasound as transmural, hypoechoic,

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circumferential thickenings of the GI wall, asso- also been described and, on ultrasound,
ciated with loss of normal wall layering and resulted in the appearance of small hypoechoic
reduced motility of the affected intestinal seg- nodules within the adjacent mesenteric fat.28
ment (Figure 4).14,26–28 The mass may be sym- The ultrasonographic appearance of adeno-
metrical or asymmetrical, and ulceration may carcinomas of the feline GI tract has similarly
or may not be present.26,27 Ultrasonographic been reported.19 Adenocarcinomas typically
evidence of extraintestinal involvement, and present as solitary intestinal masses.31
especially regional lymphadenopathy, is com- Circumferential segmental wall thickening
mon,28–30 and often accounts for the mass effect characterised by transmural loss of normal
detected during abdominal palpation.9,26,27 wall layering is a feature that has been
Mesenteric involvement due to direct exten- described in cats with GI adenocarcinoma.19
sion from a lymphomatous colonic mass has These tumours may be symmetrical or

a b

c d

e f

Figure 4 Examples of gastrointestinal (GI) lymphoma. (a,b) GI masses in two adult cats due to lymphoma. In both cases there is a focal marked thickening
of the gastric wall (arrowheads), associated with complete loss of layering and an overall hypoechoic echogenicity. (c) Marked focal eccentric thickening of the
muscularis layer of a jejunal loop in a 5-year-old male neutered domestic shorthair cat. Diffuse mild to moderate thickening of the muscularis layer was also noted
throughout the jejunum. The final diagnosis of lymphoma was based on fine-needle aspiration of the mass. (d) Marked circumferential thickening of the jejunal
wall owing to lymphoma. Note the complete loss of layering in the affected portion of bowel wall. Hyperechoic material centrally represents intraluminal gas and
ingesta. (e) Marked focal circumferential thickening of the wall of a loop of jejunum in transverse orientation owing to lymphoma in a 7-year-old male neutered
domestic shorthair cat with a history of weight loss, inappetence and lethargy, and a palpable abdominal mass. There is almost a complete loss of layering. The
centrally located region of hyperechogenicity associated with distal acoustic shadowing represents gas within the intestinal lumen. (f) Eccentrically located mass
(located between the measuring calipers) in the ileum of a 14-year-old male neutered domestic shorthair cat. Concurrent ultrasonographic findings included
diffuse thickening of the muscularis layer and moderate enlargement of the jejunal and ileocolic lymph nodes. The final diagnosis was lymphoma. A video
showing a focal gastric mass due to confirmed lymphoma in a cat is available as supplementary material

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asymmetrical and can have a similar appearance the colon, small intestine, ICCJ and rectum,
to GI lymphoma.19 One reported difference is and may cause luminal narrowing.35 Finally,
that intestinal adenocarcinoma is more likely fibrosarcoma and leiomyosarcoma of the
to be of mixed echogenicity compared with feline GI tract have also been reported, albeit
lymphoma, which is more commonly associ- rarely.36 The latter presented ultrasonographi-
ated with a uniformly hypoechoic intestinal cally as a comma-shaped, heterogeneous
wall, although definitive diagnosis will mass in the intestine of a 13-year-old cat.37
always rely on tissue sampling.19 Intestinal
tumours and, in particular, adenocarcinomas Intestinal Non-malignant intestinal masses
can cause intestinal obstruction and fluid may Although less common, intestinal masses can
accumulate within the intestine proximal to adenocarcinoma also result from benign or non-neoplastic
the lesion owing to localised ileus.32 is more likely to lesions such as granulomas associated
Mast cell tumours have been reported to with feline infectious peritonitis (FIP), feline
present as focal masses in the duodenum or be of mixed gastrointestinal eosinophilic sclerosing fibro-
jejunum, at the ileocaecocolic junction (ICCJ) plasia (FGESF) and duodenal polyps.38,39
and in the colon or, much more rarely, as echogenicity In a recent case report, severe jejunal (up to
diffuse intestinal wall thickening.16,33 They are compared with 9 mm) and ileocolic intestinal wall thickening
most commonly described as a focal hypo- with loss of layering were described in associ-
echoic thickening of the intestinal wall asso- lymphoma. ation with FIP in a 9-month-old entire male
ciated with loss of normal layering and may domestic longhair indoor cat (Figure 5).
be either non-circumferential and eccentric or Following an enterectomy to remove the
circumferential, asymmetric and eccentric.16,33 affected segments of intestine, histopathology
Sporadic reports of unusual GI tumours in confirmed the presence of severe pyogranulo-
cats include a gastric smooth muscle hamar- matous enteritis with vasculitis.40
toma in an 11-year-old cat, which appeared on FGESF is an inflammatory condition that
ultrasound as a 2 cm diameter, poorly vascu- primarily affects middle-aged cats and it has
lar, hyperechoic mass within the gastric been suggested that Ragdolls may be over-
wall in the region of the cardia.34 Intestinal represented.41 FGESF is an important differential
haemangiosarcoma has been reported in for an intestinal mass in the cat and can mimic
three domestic shorthair cats variously affecting neoplasia (Figure 6).42 In a retrospective study of

a b

Figure 5 (a,b) Ultrasound images from a 9-month-old entire male domestic longhair cat infected with feline coronavirus. The jejunal wall (between the measuring
calipers) is markedly thickened with loss of layering. Severe pyogranulomatous enteritis with vasculitis consistent with feline infectious peritonitis was subsequently
demonstrated on histopathology. Images courtesy of Maria A Ernandes, Ambulatorio Veterinario Brollo, Fidenza (Parma), Italy

a b

Figure 6 Ultrasound images of suspected feline gastrointestinal eosinophilic sclerosing fibroplasia lesions in a 13-year-old female neutered domestic shorthair cat
presenting with a history of chronic haematochezia and weight loss. Both masses are heterogeneous and completely efface wall layering. The first (a) was at the ileocolic
junction and the second (b) within the wall of the mid-descending colon. There was also evidence of ileocolic lymphadenopathy. Cytology following fine-needle aspiration
revealed a predominantly eosinophilic inflammation. While this could also be associated with parasitism and neoplasia (such as mast cell tumour and lymphoma),
there was no direct evidence to support this in the examined smears. The owner declined an exploratory laparotomy for full-thickness gastrointestinal biopsies

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25 cats with FGESF, the condition presented duodenal layering was preserved.47 This is in
most commonly as an ulcerated intramural contrast to neoplastic lesions, which are typical-
mass with loss of layering at either the pyloric ly hypoechoic and result in partial or complete
sphincter or ICCJ junction, or, less commonly, loss of wall layering.39 Furthermore, while duo-
within the duodenum, jejunum or colon.43 denal polyps project into the lumen, carcinomas
Hyperechoic areas within FGESF lesions on and lymphoma usually affect the entire circum-
ultrasound have been described and are thought ference of the wall and smooth muscle tumours
to represent fibrotic regions.44 An extramural tend to be exophytic.39 Cats with duodenal
FGESF lesion has more recently been described polyps were mostly middle-aged to older (mean
in a 4-year-old male neutered cat. The lesion ± SD age of 9.6 ± 3.5 years),47 which is similar to
originated within the soft tissues of the retro- a previous report on 18 cats with duodenal
peritoneum and caused ventral displacement polyps.38 In both studies, acute vomiting was
and narrowing of the descending colon, result- one of the most common clinical signs at presen-
ing in obstipation. On ultrasound, the mass tation, presumably due to partial obstruction
was lobulated and heterogeneous with multi- of the duodenal lumen.38,47 The prognosis after
ple hypoechoic to anechoic centrally located surgical resection is reported to be excellent.38
regions. Colour Doppler revealed moderate vas-
cularity within the more peripheral regions of Intussusceptions
the mass.45 Mild ascites and hyperechoic mesen-
tery have also been reported on ultrasound An intussusception occurs when one part of
of a cat with FGESF limited to mesentery.46 the intestine (the intussusceptum) invaginates
Intracellular bacteria are also frequently into the lumen of an adjacent intestinal seg-
identified in FGESF lesions on histopathology, ment (the intussuscipiens).48 Any portion of
although it is uncertain whether the bacteria the bowel may be affected but jejunojejunal
are the cause or a result of the condition. It is and enterocolic intussusceptions appear to be
hypothesised that these bacteria may gain entry the most common types in the cat.49,50
to the intestinal wall as a result of damage such Publications detailing the ultrasonographic
as that caused by a penetrating foreign body appearance of intussusceptions in the cat are
or ulceration.41,43,44 This may help to explain sparse but, based on the limited information
the predominance of lesions at the pyloric available, the appearance closely resembles
sphincter and ICCJ, where physical forces are that seen in dogs.37,51 In the transverse plane,
usually greatest.43 In cats with a genetic predis- an intussusception forms a circular target-like
position to this lesion, a subsequent eosinophilic lesion (sometimes referred to as having a
response mounted against these intramural ‘bull’s eye’ appearance) owing to the presence
bacteria may result in the formation of FGESF of multiple concentric rings that represent the
lesions.43 Nevertheless, the exact pathogenesis of different layers within the adjacent walls of
FGESF remains unclear and food hypersensitiv- the intussuscipiens and intussusceptum
ity has also been proposed as a possible cause.43 (Figure 7a).37,51 In the longitudinal plane, the
Loss of layering within focal intestinal appearance is similar and again results from
lesions caused by FGESF and associated the multiple alternating hypoechoic and
lymph node enlargement are common find- hyperechoic parallel lines formed by numer-
ings, explaining why FGESF lesions can so ous wall layers.51 Hyperechoic tissue may be
easily be mistaken for neoplasia on ultra- visible within the centre of the lesion, repre-
sound.44 However, unlike most neoplastic senting mesenteric fat that has been pulled
lesions, FGESF lesions have been described as into the intussuscipiens along with the intus-
feeling ‘hard and gritty’ when fine-needle susceptum (Figure 7b). Anechoic areas within
aspiration or core biopsy are performed.41 the hyperechoic centre represent dilated lym-
A further differential for a benign intestinal phatics and blood vessels.51 In chronic cases,
mass is an adenomatous polyp, the ultrasono- the outer intussuscipiens segment can become
graphic appearance of which has recently been thickened and hypoechoic, and individual
reported at the pyloroduodenal junction in six wall layers may become less discernible
cats.47 The typical presentation described was owing to oedema and compromised blood
that of a small, echogenic homogeneous nodule flow.37 Mesenteric lymphadenopathy and
projecting into the lumen of either the proximal abdominal effusion have also been identified
duodenum or the pyloroduodenal junction.47 in cats with intussusceptions.49
The authors of the study found that the polyps
were easily mistaken for ingesta and, while In cases of intussusception,
benign, could cause luminal obstruction, GI
bleeding and obstruction of the biliary tract.47 the intestine should always be assessed carefully
One of the main differentials for a solid duode- on ultrasound to determine whether additional
nal mass in an older cat is primary intestinal
neoplasia. However, in 5/6 cats with polyps, conditions may be present.

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a b

Figure 7 Ultrasonographic appearance of an intussusception in a 13-year-old male neutered domestic shorthair cat. (a) The intussusceptum fills the lumen of the
intussuscipiens. (b) Echogenic fat and mesenteric vessels (arrows) have been drawn into the lumen of the intussuscipiens along with the intussusceptum. There is
partial disruption to the normal wall layering of the intussuscipiens, most likely owing to oedema of the wall

Since the condition in older cats has been exists, the diagnosis of a linear foreign body
reported to occur in association with IBD, can usually be confirmed on ultrasound.59
intestinal neoplasia, caecal inversion and the Evidence of intestinal plication on ultrasound
presence of a caecal polyp, the intestine Definitive is strongly suggestive of the presence of a
should always be assessed carefully to deter- diagnosis of a linear foreign body, although definitive diag-
mine whether additional conditions may be nosis relies on demonstrating the presence
present.49,51–55 linear foreign of linear foreign material within the lumen of
the plicated intestine (Figure 8b).59
Foreign bodies body on The term plication describes the folding of
ultrasound intestinal loops such that adjacent loops
Linear foreign bodies such as sewing thread, become stacked in an accordion-like pleated
dental floss and string are relatively common relies on fashion.60 All layers of the intestinal wall with-
in the cat and represent the most frequent type demonstrating in an affected bowel segment are involved,
of foreign body seen in this species.56,57 A por- including the serosa.
tion of the foreign material becomes anchored, its presence As with non-linear foreign bodies, the pre-
usually around the base of the tongue or less cise ultrasonographic appearance of a linear
commonly at the pylorus, while the remain- within the foreign body will depend on the degree to
der travels distally into the small intestine.57 lumen of which the material transmits or attenuates the
Peristaltic contractions unsuccessfully attempt ultrasound beam.59 Typically, however, the
to transport the foreign body aborally, eventu- plicated foreign material will be represented by an
ally leading to intestinal plication.57 If left unde- echogenic line of variable diameter, running
tected, complications such as intestinal wall intestine. through the middle of the plicated segment of
perforation and septic peritonitis can develop. intestine, and may or may not be associated
Radiographs can be helpful in the diagnosis with distal acoustic shadowing depending on
and may reveal bunching of small intestinal its physical properties.59 Since linear foreign
loops and abnormal ‘crescent’- or ‘teardrop’- bodies usually cause only partial obstruction
shaped intestinal gas bubbles (Figure 8a).58 of the intestine, there is often little or no
Where radiographs are inconclusive or doubt accompanying intestinal dilation.61

a b

Figure 8 (a) Cropped abdominal radiograph of a cat with a confirmed linear foreign body. The small intestine is bunched together within the mid-ventral abdomen.
Abnormal teardrop- and crescent-shaped intestinal gas bubbles (arrows) are visible. (b) Ultrasound image showing plicated intestine in a 5-month-old male
entire domestic shorthair cat that originally presented for further investigation of poor growth and inappetence. The linear foreign body is represented in the
image by the thin hyperechoic line (arrows) passing through the centre of the plicated intestine. Subsequent oral examination under sedation revealed the
presence of thread encircling the base of the cat’s tongue that extended down the oesophagus. A video showing the ultrasonographic appearance of plicated
intestine owing to a linear foreign body (which is also visible) in the 5-month-old kitten in part (b) is available as supplementary material

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a b

Figure 9 (a,b) Examples of corrugated intestine. In each ultrasound image, note that while the majority of the bowel wall is thrown up into a wave-like formation,
the serosal layer remains completely straight

Plication of the intestine should be differen- enhancement. The severity and chronicity of
tiated from intestinal corrugation, which the obstruction determines the extent to
describes regular, symmetrical undulations of which the intestine proximal to the foreign
the intestinal wall in the presence of a straight material dilates. One of the more common
serosa (Figure 9).39 Intestinal corrugation is a types of foreign body, seen particularly, but
non-specific change and may be associated not exclusively, in longhaired cats, are tricho-
with enteritis, pancreatitis, peritonitis, neo- bezoars, also known as hairballs (Figure
plasia and ischaemia of the bowel wall.62 11).39,63–66 The typical ultrasonographic appear-
Roundworms can also potentially mimic ance is that of a mixed echogenicity cylindri-
linear foreign material as they appear on cal or spherical mass associated with variable
ultrasound as paired parallel hyperechoic acoustic shadowing, which is largely deter-
lines within the intestinal lumen (Figure 10).39 mined by the size and density of the hairball.1
They are easily differentiated from linear for-
eign bodies, however, as they do not cause Gastrointestinal perforation
plication of the intestine, do not usually shad- Foreign bodies, intussusceptions and intestinal neoplasia all have the potential
ow and movement of live worms can often to cause GI perforation. Ultrasonographic findings of hyperechoic mesenteric
be observed.39 fat adjacent to the affected intestinal loop, free echogenic peritoneal fluid
Non-linear foreign bodies are occasionally and/or free peritoneal gas may be present in animals in which intestinal
seen in the cat and may be recognised by the perforation has occurred.67,68 Loss of wall layering, wall thickening, segmental
presence of an intraluminal structure with fluid dilation of intestinal loops and/or reduced intestinal motility at the site of
a strongly echogenic interface associated perforation may also be recognised.67,68
with variable strong clean distal acoustic

Figure 10 Ultrasound image from a 4-year-old male neutered domestic Figure 11 Ultrasound image depicting the typical appearance of a non-linear
shorthair cat with protein-losing nephropathy. A roundworm is visible in the foreign body. The jejunal loop is distended on the left by a structure with a
lumen of a loop of jejunum. Movement of the worm could be appreciated strong echogenic interface and clean distal acoustic shadowing. The intestinal
during real-time ultrasound. A large volume of anechoic peritoneal fluid was loop towards the right side of the image rapidly resumes a normal diameter
also present owing to marked hypoalbuminaemia as a result of a protein-losing distal to the obstructing material. Three empty small intestinal loops are
nephropathy. A video showing the roundworm present within the jejunal loop in visible in the transverse plane in the upper right corner of the image.
this cat is available as supplementary material The final diagnosis following an exploratory coeliotomy was a trichobezoar

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The clinical significance of a hyperechoic mucosal band paralleling the submucosa,

which is suggested to represent mucosal fibrosis, is currently unknown.

Mucosal fibrosis

A hyperechoic mucosal band paralleling

the submucosa has been reported in cats
(Figure 12).69 It was suggested that this band, Fibrotic small intestinal stricture
identified in cats with and without clinical
signs of GI disease, represents mucosal The ultrasonographic and histopathological
fibrosis.69 The clinical significance of this find- features of benign fibrotic small intestinal
ing is unknown at the present time. strictures have recently been described
in eight cats with chronic intestinal obstruc-
tion.70 The ages of the cats ranged from
2–10 years. Clinical signs included inter-
mittent vomiting, anorexia and severe leth-
argy. In more advanced cases, projectile,
large-volume fluid vomiting or regurgitation
was reported and transient diarrhoea was
observed in 3/8 cats.
Ultrasonographically, strictures were char-
acterised by a segment of bowel with a
non-distensible lumen and were identified in
the duodenum (1/8), mid- to distal jejunum
(4/8) and proximal ileum (3/8).70 In all cats,
there was evidence of moderate to marked
gastric and either generalised or segmental
small intestinal distension oral to the stenosis
a indicative of mechanical bowel obstruction.
The length of the stenosed segment varied
from 2–50 mm. The intestinal wall at
the stricture site was mildly to moderately
thickened (range 3–6 mm), with complete
or, more commonly, partial loss of layering
resulting in a predominantly hypoechoic
appearance. Mesentery surrounding the
stricture was hyperechoic in 6/8 cases.
In some cases, the presence of a kink at
the oral aspect of the stricture made ident-
ification of the stenotic segment more
challenging.
Histopathology revealed transmural pathol-
ogy, which was characterised by inflamma-
tion and marked fibrosis that affected the
mucosal layer most severely.70 Sections from
b
three of the cats enabled the authors to
demonstrate that fibrosis was indeed the main
Figure 12 (a) Ultrasound image of several jejunal loops in a 12-year-old male contributor to the narrowing of the intestinal
neutered Birman (same cat as Figure 3b). A thin hyperechoic line (arrow) is
visible within the mucosal layer, most clearly seen in the central loop and lumen. Although the aetiology of the fibrosis
suspected to represent mucosal fibrosis. (b) A subtle hyperechoic line (arrow) in these cats is unknown, infectious agents
is just visible within the jejunal mucosa in a 6-year-old male neutered domestic
shorthair cat. The ultrasound scan was performed to investigate kidney disease and/or bowel ischaemia were suggested as
and there were no clinical signs present to suggest concurrent intestinal disease potential underlying causes.

Ultrasonographically, benign fibrotic small

intestinal strictures are characterised by a segment of bowel with
a non-distensible lumen, with the intestinal wall at the stricture site
being mildly to moderately thickened.

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R E V I E W / Feline abdominal ultrasonography – the diseased GI tract

Abnormalities at the Conversely, ultrasound changes at the ICCJ

ileocaecocolic junction may also occasionally be seen in cats without
GI signs.72 In particular, a proximal caecal fol-
Disorders of the feline ICCJ are relatively licular layer exceeding 2 mm in thickness at
Absence of common and expected clinical signs might the caecal inlet is suggestive of possible mild
include weight loss, vomiting, dysorexia, subclinical caecal inflammation in asymp-
changes in the diarrhoea and haematochezia.71 One study tomatic cats.71
ileocaecocolic describing ultrasonographic abnormalities at
the ICCJ in 29 cats, of which 28 had GI signs, Uncommon conditions
junction region reported the presence of enlarged caecal
lymph nodes, focal hyperechoic mesenteric fat Duplication cysts
on ultrasound and focal accumulation of peritoneal fluid in There are occasional reports documenting
does not the region of the ICCJ (Figure 13).72 Ileal and the presence of duplication cysts at various
caecal wall thickening were also documented locations along the feline GI tract.74–77 Enteric
preclude the in six and 19 cats, respectively, although there duplications are rare congenital malforma-
may be substantial overlap in caecal wall tions that can arise at any level of the GI tract
possibility of thickness between healthy cats and cats with and result from the duplication of an intesti-
disease. an inflamed caecum (typhlitis).72,73 During nal segment.78,79 They can be small or large,
follow-up ultrasound examination, four cats singular or affect the intestine at multiple
Conversely, with resolution of their GI signs also had res- levels.80 Cysts arising at the level of the
olution of the ultrasonographic abnormalities oesophagus,75 duodenum,81 jejunum,82 ileum,82
ultrasound at the ICCJ, suggesting that such findings may colon83 and rectum77 have all been described
changes in this be clinically significant in cats with GI signs.72 in the cat. Similar to humans,79 affected cats
Similar abnormalities were documented in a are usually presented at a young age, most <2
region may smaller cohort of 18 cats with chronic clinical years old,74,80–82 although the condition is
occasionally signs of caecocolic disease.73 Loss of caecal occasionally recognised in older animals, pre-
wall layering was identified in 7/18 cats, sumably as a result of clinical signs being
be seen in a feature that is typically strongly associated overlooked and/or enlargement of the cyst
with neoplasia.73 Of these cats, five underwent as secretions accumulate.77 Indeed, a search
cats without biopsy and histopathology. Interestingly, of the human literature reveals occasional
gastrointestinal although neoplasia was not identified in reports of patients with enteric duplications
any cat, all had evidence of inflammation lead- and medical histories of chronic constipation
signs. ing the authors of the study to conclude that (up to 20 years’ duration) prior to a correct
loss of caecal wall layering in the cat is sugges- diagnosis being made.84–86
tive of typhlitis but not necessarily neoplasia.73 In both humans and cats, duplication cysts
Local steatitis and lymph node size were can cause non-specific GI signs such as
also found to be unreliable indicators of vomiting due to partial intestinal obstruction
the severity of inflammation or presence of following accumulation of secretions within
neoplasia, and an absence of changes in the the cyst80,81,87 and constipation77 depending
ICCJ region on ultrasound did not preclude on the location of the cyst. In other cases,
the possibility of disease; as such, biopsy some cats may be asymptomatic79,82 and the
should be considered in cats with chronic duplication cysts only identified by the
clinical signs.73 presence of a palpable abdominal mass.74,78–80,82

a b

Figure 13 Ultrasound images from a 12-year-old male neutered domestic shorthair cat with confirmed inflammatory bowel disease. (a) Adjacent to the caecum
there is an enlarged hypoechoic lymph node (arrow) measuring 7.9 mm in the short axis. Note the abnormal hyperechoic reactive fat surrounding the node.
(b) A larger area of hyperechoic reactive fat (short arrows), associated with several reactive lymph nodes (long arrows) measuring up to 4.5 mm in the short axis,
is visible at the level of the ileocaecocolic junction (not seen). A video showing an enlarged, hypoechoic lymph node and mildly hyperechoic fat adjacent to the
caecum is available as supplementary material

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Intestinal duplication cysts are defined by Gastrointestinal pneumatosis

three key characteristics: a close association The term pneumatosis describes the abnormal
with the GI tract; a well-developed smooth accumulation of gas within tissue.91 The con-
muscle layer; and an epithelial lining that may dition has only rarely been reported, with just
differ from that of the adjacent bowel seg- four cats in the literature with pneumatosis
ment.78,82 They also usually share a common within the gastric,91,92 small65,66 and large93
blood supply with the adjacent segment of intestinal wall.
intestine.79,82 They may be recognised ultra- Reported ultrasonographic findings includ-
sonographically as fluid-filled spherical or ed diffuse wall thickening (and in one case
tubular cysts containing sterile fluid;83 as in thinning), loss of or indistinct wall layering
humans, they do not usually communicate with and the presence of one or more strong
the intestinal lumen.74,77–79,82,88 The presence of echogenic intramural interfaces within the
a distinct hypoechoic layer of smooth muscle GI wall associated with a reverberation
within the cyst wall has recently been described artefact.91,92,94 All four cats presented with
as a ‘muscular rim sign’74 and is typically con- vomiting or regurgitation; two of them were
tinuous with smooth muscle of the adjacent collapsed, one cat showed progressive clinical
intestinal segment.74,82 The cyst wall thus com- deterioration and the remaining cat improved
prises an inner hyperechoic rim (the mucosa) following partial gastrectomy and medical
surrounded by an outer hypoechoic layer (mus- management.91–94 The final diagnosis in
cular layer), an appearance that is considered one cat was severe multifocal necrotising
to be relatively specific for this condition.74,79 haemorrhagic enterotyphlocolitis secondary
While duplication cysts are benign, malig- to Clostridium difficile toxicity.94 In another of
nant transformation of a duodenal duplication the cats, gastric wall necrosis and ulceration
cyst has been described in a 15-year-old allowing the entry of gas-producing bacteria
domestic shorthair cat.76 Surgical excision is was suspected to be the cause of the gastric
therefore recommended and usually curative, pneumatosis91 and, similarly in a third cat,
although recurrence has been reported.74,80 gastric ulceration was suspected to be
Definitive diagnosis requires histopathology, the underlying cause.92 In the final case,
which reveals a normal GI mucosal although Clostridium perfringens
lining, thereby allowing differenti- and Escherichia coli (both of which
ation from other intra-abdominal have the potential to result in
cystic lesions.79 Duplication cysts Earlier articles in the series emphysematous disease) were
have also been reported in associa- ✜ The liver (2019; 21: 12–24) cultured from the bowel wall,
tion with vertebral abnormalities ✜ The biliary tree (2019; 21: 429–441) specimens were collected post
in various species and, according- ✜ Hepatic vascular anomalies (2019; 21: mortem and so it was not possible
ly, radiography should be consid- 645–654) to confirm that these were the cause
ered in affected animals.77,89,90 of the intestinal pneumatosis.93

Interventional procedures: sampling considerations

Percutaneous ultrasound-guided fine-needle aspiration (FNA) fine-needle aspirates of lymphomatous mesenteric lymph nodes
of intestinal masses is a useful and safe technique that can be were incorrectly reported as benign lymphoid hyperplasia in
used to obtain a definitive diagnosis, in many instances negating 8/17 cats in one study.9 Therefore, if the clinical index of suspi-
the need for endoscopic or more invasive surgical biopsies. cion of neoplasia (such as lymphoma) remains high, but FNA
The technique is particularly beneficial for sampling lesions that results are inconsistent with such a diagnosis, further sampling
are not accessible by endoscopy, such as those affecting the should be considered.
jejunum. The author typically uses a 23 G needle attached to a Cytology may also be sufficient to make a tentative diagnosis
5 ml syringe applying approximately 1 ml of aspiration during of FGESF in some cases where the cytological findings closely
sampling. It is important to avoid penetrating the intestinal lumen match those expected from histopathology.43 However, in other
as this can potentially cause leakage of ingesta and peritoneal cases, cytology may only reveal one element of the mass, such
contamination. as dense collagen trabeculae or large numbers of mast cells,
If both an intestinal mass and enlarged regional lymph nodes leading to potential misdiagnosis.43 Therefore, histopathology
are present, sampling both structures is likely to increase may be required for a correct and definitive diagnosis in cases
diagnostic yield.39 However, samples from ultrasound-guided where the results of cytology are considered questionable.

Percutaneous ultrasound-guided fine-needle aspiration

is particularly beneficial for sampling lesions that are not accessible
by endoscopy, such as those affecting the jejunum.

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3 Penninck D, Smyers B, Webster CR, et al. Diagnostic value of

KEY POINTS ultrasonography in differentiating enteritis from intestinal
neoplasia in dogs. Vet Radiol Ultrasound 2003; 44: 570–575.
✜ Selective thickening of the muscularis layer of the
4 Wallack ST, Hornof WJ and Herrgesell EJ. Ultrasonographic
small intestine is most suggestive of either IBD or
diagnosis – small bowel infarction in a cat. Vet Radiol
small-cell lymphoma.
Ultrasound 2003; 44: 81–85.
✜ According to the majority of sources, lymphoma 5 Tucker S, Penninck DG, Keating JH, et al. Clinicopathological
is the most common GI tumour in the cat and can and ultrasonographic features of cats with eosinophilic
present as one or more masses. An important enteritis. J Feline Med Surg 2014; 16: 950–956.
differential for a GI neoplastic mass is a mass that 6 Zwingenberger AL, Marks SL, Baker TW, et al.
is due to eosinophilic sclerosing fibroplasia, since Ultrasonographic evaluation of the muscularis propria in
the two conditions can have a similar appearance cats with diffuse small intestinal lymphoma or inflam-
on ultrasound examination. matory bowel disease. J Vet Intern Med 2010; 24: 289–292.
✜ The ultrasonographic appearance of an 7 Daniaux LA, Laurenson MP, Marks SL, et al.
intussusception in the cat is consistent with that Ultrasonographic thickening of the muscularis propria in
described in the dog; in the transverse plane the feline small intestinal small cell T-cell lymphoma and
affected intestinal segment assumes a circular inflammatory bowel disease. J Feline Med Surg 2014; 16: 89–98.
‘target-like’ or ‘bull’s eye’ appearance. 8 Winter MD, Londono L, Berry CR, et al. Ultrasonographic
evaluation of relative gastrointestinal layer thickness in cats
✜ Linear foreign bodies are relatively common in the without clinical evidence of gastrointestinal tract disease.
cat and cause intestinal plication, which is readily J Feline Med Surg 2014; 16: 118–124.
identifiable on ultrasound examination. 9 Lingard AE, Briscoe K, Beatty JA, et al. Low-grade alimentary
✜ A thin hyperechoic line within the mucosal layer of the lymphoma: clinicopathological findings and response to
small intestine may indicate mucosal fibrosis, the treatment in 17 cases. J Feline Med Surg 2009; 11: 692–700.
clinical significance of which is presently unknown. 10 Baez JL, Hendrick MJ, Walker LM, et al. Radiographic,
ultrasonographic, and endoscopic findings in cats with
✜ Pathology at the ICCJ may be detected
inflammatory bowel disease of the stomach and small
ultrasonographically in the form of ileal and/or
intestine: 33 cases (1990–1997). J Am Vet Med Assoc 1999; 215:
caecal wall thickening, enlargement of the caecal
349–354.
lymph nodes, hyperechoic mesenteric fat and/or a
11 Stein TJ, Pellin M, Steinberg H, et al. Treatment of feline
focal accumulation of peritoneal fluid in the region
gastrointestinal small-cell lymphoma with chlorambucil
of the ICCJ.
and glucocorticoids. J Am Anim Hosp Assoc 2010; 46: 413–417.
✜ A cyst with a muscular rim sign 12 Carreras JK, Goldschmidt M, Lamb M, et al. Feline epi-
adjacent to a segment of intestine theliotropic intestinal malignant lymphoma: 10 cases
is suggestive of a duplication cyst. (1997–2000). J Vet Intern Med 2003; 17: 326–331.
13 Evans SE, Bonczynski JJ, Broussard JD, et al. Comparison
of endoscopic and full-thickness biopsy specimens for
Conflict of interest diagnosis of inflammatory bowel disease and alimentary
tract lymphoma in cats. J Am Vet Med Assoc 2006; 229:
The author declared no SUPPLEMENTARY 1447–1450.
potential conflicts of MATERIAL 14 Barrs VR and Beatty JA. Feline alimentary lymphoma: 1.
interest with respect to Videos illustrating ultrasonography Classification, risk factors, clinical signs and non-invasive
the research, author- of the diseased GI tract – see figure diagnostics. J Feline Med Surg 2012; 14: 182–190.
legends 3, 4, 8, 10 and 13 for more
ship, and/or publica- 15 Diana A, Pietra M, Guglielmini C, et al. Ultrasonographic
information – are available as
tion of this article. supplementary material at: jfms.com and pathologic features of intestinal smooth muscle hyper-
DOI: 10.1177/1098612X19880434 trophy in four cats. Vet Radiol Ultrasound 2003; 44: 566–569.
Funding 16 Laurenson MP, Skorupski KA, Moore PF, et al.
Ultrasonography of intestinal mast cell tumors in the cat.
The author received no Vet Radiol Ultrasound 2011; 52: 330–334.
financial support for the 17 Mavropoulou A, Grandi G, Calvi L, et al. Disseminated
research, authorship and/or histoplasmosis in a cat in Europe. J Small Anim Pract 2010; 51:
publication of this article. 176–180.
18 McConnell JF, Sparkes AH, Blunden AS, et al. Eosinophilic
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