Welcome everybody to our third webinar on on the topic of ultrasounds. So, my name is Sylvia Janska. I'm also a vet and I'll be your chair for today, and I am joined by Camilla Edwards, who's a good friend and colleague of mine.
And thank you very much to your company Fou or first Opinion veterinary ultrasound for sponsoring this 3 part series of of the webinars. So for those who don't know or who haven't been to the previous two webinars, if you want to catch up, you can just go to the webinar website. They're all listed there, all three of them, and you will be obviously able to watch this one retrospectively as well.
And today's webinar is we'll we'll hear about the you can see on the title 10 small animal cases where ultrasound made a difference. I'm very, very excited to, well, to learn and to see, and so before we start, I just wanna introduce Camilla a little bit, because obviously, yeah, some of you may have already met her and seen her speak, but for those who haven't. Kamala graduated from vet school in Copenhagen in 2006.
She then moved back to the UK and worked for a few years in a mixed, mixed practise and a small small animal first opinion practise before spending eight years in emergency work, where she gained her certificate in advanced veterinary practise. And then in 2018, she set up her own business, first opinion veterinary ultrasound, otherwise known as Fou. And Camilla offers a peripatetic ultrasonography service as well as teaching ultrasound online and in person through her FO website.
So I'm very, very glad to, be chairing you again, Kamila. I'm very excited, and, before I hand over to you, just one other note for everybody listening. If you have any questions, then if you can please pop them into the Q&A box, and then we'll be answering them, at the end.
That'd be great. So welcome and thank you very much and over to you, Camilla. Great.
Thanks very much, for having me for the 3rd webinar in the series. Like Sylvia said, the other two are available on demand. So do catch up if, if you want to.
So I wanted to do, a webinar where I just throw a lot of images at you because seeing lots of images is what gets us in tune with what's normal and what's not normal, with ultrasound. So I'm trying to pack in as many cases as I can, in, in the, our slot that we have. So, here are the 10 cases.
We're gonna start with case number 1, which is a Westie poo, 12 years old, male neutered, who had urinary tract signs. And, the vet who, sent this case to me, said that they'd palpated a large prostate. OK, so we're going to jump straight through like last week, we looked at the whole Series of how to scan the abdomen.
So these images will be in, in that order as, as far as possible, to see what I came across as I was doing the full abdominal scan. But I've just picked out the, the interesting bits, as it were. So this is the aorta, looking cordially along the aorta to the trifification here.
And what we're seeing is the lumbar lymph nodes around here. So, we've, we've got some really large prominent, lymph nodes, these hypoechoic areas. There's one here, there's one large one here.
And one here that we can see. And normally, we wouldn't see this many lymph nodes in this area. We might see one thin one, along the length of the aorta, so the left medial iliac lymph node.
But there are lots of really prominent hypoechoic, rounded lymph nodes here. So I'm starting to get a little bit concerned about what, what's going on. These are the lymph nodes that drain, the pelvic area, and, the caudal abdomen.
And when we get to the bladder, my concerns are heightened. So this is the bladder, and we can see we've got this enormously thickened wall here. It's a little bit heterogeneous with, some hypoechoic areas and some hypoas.
So, quite a concerning picture there. So I, I put the colour Doppler on to basically rule out whether this could be a blood clot stuck to the wall, but we can see there's blood flow in this thickened wall, and that suggests that this is an actual thickening or a tumour of, of the bladder wall. So as we can see, it's measuring at about 1.2 centimetres.
We'd normally expect the bladder wall to be less than a quarter of a centimetre, so this is really, really thickened. And as we go cordially, we've got the bladder up to the left, and we can see the prostate come into view. So the bladder up there and the prostate.
And remembering this is a male neutered dog, so we expect the prostate to be really small. This is really quite a large and heterogeneous prostate. So starting to think whether there's, some tumour process going on in, in the bladder and the prostate.
Here I've measured the thickness, we can see the 22 poles of the, of the prostate there, or the two lobes of the prostate. And that's, that's really, really large for a neutered dog. So what did we find?
We found those enlarged lymph nodes in a cat. They should be under 0.5 centimetres in thickness in dogs, they should be, less than, a centimetre, if they're normal over that, then we really start to worry.
Rounded and hypoechoic lymph nodes are indicative of inflammatory or neoplastic infiltration, and the larger the lymph node, the more likely neoplasia becomes. But it's a grey area, so we really need samples to be sure. The prostate appeared abnormally enlarged for a castrated dog, and unfortunately, the, the, most likely diagnosis is therefore, transitional cell carcinoma.
And with the bladder wall appearing very thickened, especially in the, in the caudal trigonal area, we are, we're extremely suspicious of transitional cell carcinoma. We, we ideally don't want to take fine needle aspirates as a first line route. We can either choose to do, a bra urine test, which, has great sensitivity and specificity, or we can, do a, traumatic catheterization or prostatic wash in this case, would, would lead us to our diagnosis.
So this is case one. Case number 2. So this was a French bulldog, 4 year old male neutered.
Similar history. We had, intermittent hematuria, but this has been lasting for 6 months, and, urine analysis was inconclusive. And as we can see here, the X-ray didn't, demonstrate much.
We've got the bladder here and we can't really see. Much abnormality going on there. So we performed an ultrasound scan.
So here we've got the aorta, and we're following it to the trification. We've got the left medial, or this is the right hand side, so this is the right medial iliac lymph node here. So, this is a much more normal, lymph node compared to the previous lymph node we saw.
So, it's much more similar to the surrounding tis tissue, so it doesn't stand out very much. And, very long and thin, unlike the rounded lymph nodes we saw before. Here was the bladder though.
So we've got the, the bladder, and we've got the anechoic fluid in here, and we've got this thickened wall, so. What's going on here? We're, we're worried, again, you know, this, is, is this, a tumour?
Could this be a tumour coming from the, the bladder wall? Again, we've got the, the bladder here, the anechoic lumen, and we've got the, this thickened wall. But it was more in the cranial part of the bladder.
We'd normally expect to see tumours in the, in the trigone, in the caudal bladder. However, this is what we found looking more thoroughly through the bladder, and remembering that dependent view we talked about, last week. So looking directly down through the dog into the table, we could see this hyper-echoic, content here with an acoustic shadow.
And this tells us that the ultrasound waves are coming down, hitting whatever this is, and bouncing right back. No ultrasound waves are getting through, whatever this is. And this, that's causing an acoustic shadow beneath it, because no sound waves get to this area.
And that is, due to mineralization. So we've got some euroliths in, in this bladder here. OK.
So we've got the, the bladder off to the left, and then we've got the prostate here. And this is much more normal prostate for a male neutered dog. So we've got, it's very small, they can often be smaller than this, even.
But often hypoechoic in neutered males, whereas in entire males, they're often a bit brighter. But we can see that the previous prostate was very, very abnormal, and this, this is normal for a neutered male dog. There we go.
So measuring much less than the previous prostate was as well. And this is what we found at surgery. So, many, many small euroliths, were discovered at surgery.
The bladder was, was hugely inflamed, and that's why it had a thickened wall. Remember, this dog had had hematura for over 6 months. So, the inflammation was what was causing the thickened wall.
But so it's important to, to differentiate, and, and assess, everything that's going on, and not just assume that a thickened wall is down to, a tumour. Right, case number 3. So, this was a border collie, 11 year old female neutered.
She had a history of vomiting, and a CT scan showed he hepatomegaly. And an undefined gall gallbladder abnormality, which they couldn't tell what was from the CT scan. So we decided to do an ultrasound scan to see whether we could get more information on that.
So here is the liver. So we've got a transverse view of the liver, where we've got the horizontal diaphragm here. And we've got the gallbladder on the right hand side, of the body, left hand side of the image.
And we can see the odd hepatic vein and portal vein in, in here also. In the gallbladder, we would normally expect, bile to show up as a normal fluid. So anechoic, black with an acoustic enhancement below.
So, where the ultrasound waves come through, hit the gallbladder, they, they are, the sound waves are not attenuated, and beyond it appears brighter, as opposed to sound waves that have just passed through tissue. So, what we're not, we're not seeing, an anechoic gallbladder here. What we are seeing is that it has some content, and this content is in a steellate pattern, what we call a cellate pattern.
So where we've got these protrusions out from the edge, and the content is sort of suspended in the centre of the gallbladder. And this is really typical for a gallbladder mucous cele. We've got a still image here as well, where we can see these projections out from the side, with this hypoechoic area in between, and this hypoechoic content suspended in the gallbladder.
So really typical for a gallbladder mucousy. Which is often, a surgical problem, needs to be sorted out, rapidly, particularly when the animal's unwell like this, will need stabilisation and and surgery to, to remove the gallbladder. OK.
So, case number 4. This was a domestic short-haired cat, a male neutered, 9 year old. History of weight loss and jaundice, so not an uncommon presentation in general practise for, for an older cat.
So, we're looking at liver here. We've got, got the liver in this area. We're looking in Sagittal.
And we can see that between the liver lobes and between the diaphragm, this bright white light line down here, we've got some free fluid. So there's free fluid around the around the liver in this cranial part of the abdomen here. We can also see that there's a hypoechoic area in the liver that looks slightly different to the to the rest of the liver.
And if we look carefully, some of these Anechoic tubes seem a bit thicker and, and wider than, than the rest. So these anechoic tubes in the liver are either going to be hepatic veins. They don't have a bright white wall, portal veins, which do have a bright white wall like this one up here, or bile ducts.
We shouldn't really be seeing bile ducts. They're pretty small. But when we see, Anechoic tubes that are larger than the rest, we have to think, well, could this be, could this be bile ducts?
We see the gallbladder here, full of sludge. Again, no, no anechoic content there, but we can see stuff moving around, and we can also see this mineralized area here. So we've got a choleolith in the gallbladder, and we can see this acoustic shadow beneath, working just exactly the same way as the Eurolith did.
So we've got the sound waves coming in, hitting the coleolith, bouncing back, and no sound waves get through to make Get any information from this area below it. As we're scanning the rest of the liver as well, we can see that there is, mineralized areas within, the liver, so in the intrahepatic, bile ducts here, causing acoustic shadows. And there's also this abnormal area here and here.
So we've, we've got nodules within the liver, and we've got hyperchoic content in, in the bile ducts. So here, again, we, we're looking more in the centre of the liver. We've got this hypoechoic area, and we can really see these larger dilated areas.
So we want to know, are these blood vessels or are they bile ducts? So, applying Doppler is the key way. Well, we can see there's some blood vessels here, but in this big anechoic tube here, there's no flow.
So this is a, is a bile duct. But this bile duct is enormous, we shouldn't be seeing anything that big. .
This is, is measuring it at 3/4 of a centimetre across, which is, is very large and very prominent and, and we could easily spot that on ultrasound. As we followed this large bile duct, so here. We came to an obstruction.
So, a mass, which was blocking, the bile ducts. We couldn't follow it on from there, so it was obviously so small that we couldn't follow it after this obstruction. But rather than it being a cholelilith, I think this mass had, obstructed the bile ducts and just the, the back pressure had, meant that these deposits were causing choleoliths.
So this soft tissue obstruction here was causing a blockage with the bile ducts there. What we also found was that this was causing a knock-on effect, and we had a pancreatitis. So this is the pancreas here, and we can see the pancreatic duct going through it.
So this is in the left limb of the pancreas. So we've got the spleen at the top, the stomach over to the left, and we would have the left kidney or the transverse colon over on the right hand side, just out of image. And we can see the left limb of the pancreas.
It's really hypoechoic, really stands out compared to the surrounding tissue. So, this, this is, when people worry about what that they won't spot a pancreatitis. This is often how they will appear.
They're really, really prominent, and much more obvious than usual. Here's a moving image of the same thing, so we look down towards the body of the pancreas and we've got the left limb of the pancreas across here. So we had small amounts of free fluid.
There was evidence of pancreatitis. The liver had multiple hypoechoic nodules, and there was mineralized sludge and a cholelith within the gallbladder, and intrahepatic bile ducts. The, cystic duct or was, tortuous and, and dilated, up to a soft tissue swelling in the wall of the bile duct, which was causing a complete obstruction.
Unfortunately, surgery wasn't an option in this case, and this cat was put to sleep. Case number 5. So, we've got a, male neutered, 11-year-old Staffordshire bull terrier, weighing in at 23 kg.
He had a history of hyperadrenal corticism, and the vets dealing with him were really struggling to stabilise him on, Bettery. So, we thought we'd do an ultrasound scan to see what was going on. So here we've got, the left adrenal.
If we remember our landmarks, we've got the aorta. You can just see a little cross section of it here. We've got the renal artery coming around, and then we've got the, cranial mesenteric artery and celiac arteries here.
And so this large structure here is the left adrenal. So we've got the cranial pole, the left adrenal here. And we've got the caudal pole here with the frenico abdominal vein crossing over halfway.
So we can see that this doesn't look exactly peanut shaped. This caudal pole looks pretty enlarged. And at 2.66 centimetres, it definitely was enlarged.
A dog of this size, 23 kg, I'd probably expect it to be around 0.6, 0.7 centimetres.
So this is, this is really, really large. Checking for blood flow is always key in these cases, because adrenal glands, tumours can, invade local vasculature. So it's important if you do come across a large adrenal gland that you check that there's no turbulence in the flow around the adrenal gland and get an, idea of how vascular the adrenal gland itself is.
This is in comparison the same dog, the right adrenal gland. So what we have here is we can see the aorta here with the left renal artery coming off just pops into view there. And then we've got the higher up, we've got the cord will be the caver popping into view there.
And right up against that is the right adrenal here. So this hypoechoic organ here. So, I've just reduced my depth a little bit.
I think actually this is the aorta, and the cord of vena cava is a little bit further up, but this is a typical view of a, a normal, A right adrenal gland, and we can see in this case, the size of it even at its maximum is a lot, lot less than the left side. So we have likely got an adrenal dependent hyperadrenal corticism, and it's likely due to a primary functional tumour. We didn't find any local invasion into the blood vessels or kidneys, anything like that, and we didn't find any metastasis, having checked, lymph nodes through the abdomen.
In this case, surgical resection of the left adrenal gland, was performed, and the dog's doing really well since. OK. Case number 6.
So this is, a greyhound. Oh, I haven't put, put how old he was. He he's a male neutered, 8 8 8 kg isn't right either.
He's, developed a cough after running into a hedge after a deer. So, he was, he was an adult, but not an elderly dog. So, OK, so we, we, we're scanning the chest to see what's going on in, in the lungs with this cough.
We're looking at a mid thorax on the left hand side. So, for those of you who haven't scanned, chest, I'll just explain what we're seeing here. So we've got one rib here and one rib here.
This is known as the gait view. So where we've, we've got, if you imagine this is one alligator eye, and this is the other alligator eye, we've got an alligator looking right at us. This is the the, the plural line.
So where the two, sides of the pleura, meet, they move against each other. And we get this movement, this sideways movement across here. And that's called the gliding sign.
So, I don't know if you can see little ants walking across. It can sometimes appear as, or, basically a sideways movement. As the lungs move, we get this, sideways movement.
When ultrasound hits gas, which we're essentially doing right here on the pleura, it bounces all the way back. And it bounces multiple times back and forth between the probe and this line, because it's so close, so full of energy still. And this is all before the next sound wave is, is, is sent.
So what the machine, the machine interprets this as is, multiple white lines coming from further and further away, because it's taking longer and longer time for each time it to hit the probe again. So we get these white lines, these white horizontal lines, Periodically down the image. And these are called, called a lines.
So they're, they are, they're good. They tell us that there's air in the space. And that, that is very, very useful in the lungs to have, air in this space.
So what we've got here is, is a normal bit of lungs. So we've got, We've got gliding sign, and we've got a line. So that tells us there's air and it's in the lungs.
We know it's in the lungs because we've got this gliding sign. OK. Again, we've got the gate of view with one rib here, casting a shadow, and another rib here casting a shadow.
Much like the eurolith and the cholelith. This is mineralized, and it will cause a shadow. Then we've got some sideways movement, this gliding sign here.
And, a bit harder to see some A lines, but they are there. OK, so one thing we can do when we're assessing lungs is use our M mode. So don't be terrified, there's a button on your machine that says M mode on it, and we can look just down this line.
Do that's reflects down here over time. OK? So, in this normal piece of lung, what we see is because there's sideways movement back and forth, we get what we call a beach effect.
So in this area, it's quite mottled. This area is really reflected of it here. So we get this beach effect.
And that's due to the gliding sign. That tells us the gliding signs there. So, occasionally it can be really difficult to see the gliding sign.
And we, we can apply MO to help us assess whether the gliding sign is there or not. Then we looked at the dorsal thorax on the left hand side. So, up here, the, the ribs were a bit wider apart, so we haven't managed to get them on the image there.
But we've got the lung space just in between, and we've got a lines periodically down here. So we know that there's gas there because we've got a lines. However, I can't really see, a gliding sign here.
There's no real sideways movement in this plural space here. So, we know we've got gas, but is it actually in the lung space? Again, we've got, one rib here, the other rib off, to the side here, and we've got the plural space here, and then A lines down here.
And, again, I'm not really seeing the gliding sign here, so it's a little bit concerning. There's even a bit more of a, up and down movement to it. And when we, apply the M mode to this area, what we get is a barcode effect.
So, this is where we've just got, straight lines. We don't have this beach effect where it's a bit more mottled. We just got these straight lines, and that tells us there's no sideways movement up here.
And, we, we, therefore, know that we have got air, but it's not in the lung space. So we have a pneumothorax. The ventral tech chest, we could see we've got the, the liver here, with the diaphragm and the heart here cranially, and we've got some effusion down here also.
So we did take a sample of that fusion, and we had a hemothorax. So dorsally, we, we saw the pneumothorax with the With, in M mode, we saw the barcode sign, and, we, we saw this hemothorax ventral in the chest. It proved to be fairly self-limiting.
The dog hadn't done too much damage to itself, running into this hedge, full pelt, and, and did well afterwards, it resolved, by itself. OK. Case number 7.
So we had an English springer spaniel. It's 11 years old, a female neutered. So I have some recordings of heart auscultations.
But they're quite quiet. May not be able to hear that very well. Let me just see if I can put the volume up, that's as high as it will go.
OK. So this dog had a history of a cough, and we were wondering whether it was cardiac or a respiratory cause. So, there was no murmur on, on that ascultation there.
On an X-ray, we were querying whether the heart was slightly enlarged. And that Made us want to check the heart out again. So here we've got what we call the right parasternal long axis view of the heart.
So we've got 4 chambers. We've got the left ventricle. So this is the wall.
We've got the septum here, and we've got the right ventricle here. We've got the tricuspid valves opening and closing here, and we've got the right atrium up here. We've got the Mitral valves here and the left atrium here.
And that is looking much like a, a normal heart functioning very normally. Here we've got the LAAO view, so we've got the aorta with the aortic valves opening and closing, and we've got a fairly small left atrium here. OK, the dorsal chest, we could see this, the gliding sign, and a lines, no issues there.
The ventrals chest on the right hand side, we were getting these bee lines. So this is a new, new thing for you to consider. So these, Vertical, lines occur when there is a little bubble of gas with, some fluid around it within the lungs.
So this is what, what we see, if it's throughout the lungs, and we've got a typical cardiac case, we'll have pulmonary edoema. This was only happening in the ventral chest, though, so that we were getting these beelines and lots of them between each ribs space. The dorsal lung field on the right hand side, I could have decreased my depth here to get a much better view, but we've got the plural space here and, some A lines.
So looking pretty normal, normal gliding sign scene as well. And in the ventral field, we were getting much more beelines again. So the beelines, in ventral lungs on both sides of the chest.
And when we did question the owner, the owner did say that the dog had had a big choke on, on some food, and, it was quite prone to doing this. And actually, when we started to treat it for an aspiration pneumonia, started to do much, much better. Case number 8.
OK. So this was a male neutered, 12 year old can terrier cross, weighing in at 9 kg. Had a history of a moderate systolic heart murmur, a point of maximum intensity on the left hand side.
See if we can play this murmur. Not sure if you can hear, but there is a good murmur there. OK.
So, you'd be familiar from the previous case about what normal looks like, when we look in the heart. This again, is the right parasternal four-chamber long axis view. So we've got the left ventricle here.
We've got the right ventricle here, the tricuspid valves, the right atrium, the mitral valves here, and the left atrium. I think we can tell that the left atrium is a bit bigger than the previous case we were looking at. So, again, we've got the LAAO view.
So we've got the aorta here with the, the valves opening and closing here. And then we've got the left atrium with the pulmonary vein coming in here. So we can see that it's a little bit bigger than than the previous case we were looking at.
And again, we can see the LAAO was 1.87, and, this, this is larger than the 1.6, we, would expect a normal dog to be below.
You can also see, this is the left-sided view, but we get a good idea of the regurgitation that might be going on the mitral valve. So we can see, with colour Doppler, that, blue, the colour blue is, moving away from the probe, and red is towards the probe. So we'd expect.
The flow to be, red, moving from the left atrium into the left ventricle, and then blue moving out of the left ventricle into the aorta down here. So, what we can see is there's a nice shot of blue as the ventricles contract and push the, the, the flow out into the aorta. But we can also see that there is some turbulent flow, so a bit of a mixture of, blue and red here at the same time.
So there's a regurgitation into the left atrium also. So, we had, mitral valve disease here, and we staged it at B2. So advanced pre-clinical and recommended starting himendin in this case.
Great. So case number 9, a Cavalier King Charles, 9 year old, mal neutered we weighing 8 kg. He had a history of a cough, a severe heart murmur with a point of maximum intensity on the left hand side.
Is the auscultation recording. So a severe heart murmur there and no prizes for guessing that we had a a mitral valve disease dog here. So, again, we were looking at lungs.
This isn't, the, the greatest machine, for, for getting these images, but we still could see lots. So we've got one rib here and one rib here. We've got the plural line here, and we were getting practically a vertical whiteout.
So we had lots and lots of B lines, really struggling to see any A lines. And this is the view that we got when we were looking at the heart. So again, this is a right parasternal four chamber long axis view.
We've got the left ventricle here. With it's bloommen here, so we've got the septal wall here, the right ventricle here. Got the right atrium here, very tiny, and the tricuspid valves opening and closing across here.
We've got the mitral valves, which you can see are are very thickened compared to the previous, two hearts that we've seen and here. And this left atrium is absolutely enormous. I think there's no doubting that.
And this is the LAAO view, so again, the aortic valve, closed there and the left atrium seen here. So we had a massive LAAO there. Can see how many times you can fit the aorta in in across the left atrium.
And it's, it's certainly more than 2 there. So, a massively increased LAAO. We also had clinical signs, so we had the cough, and we had bee lines, despite being on frozamide.
So, we staged, this dog as stage C, for mitral valve disease, and we started Pimmoendin and recommended increasing the furosemide dose. So we are racing through all these cases. So case number 10, we have male neutered, 11 year old, 4.8 kg domestic short-haired cat with a history of recent pancreatitis.
So here we, we're looking at the small intestines. So we've got a a loop of small intestine across here. This is a longitudinal loop here, so we can see the lumen in the middle, if I just pause.
There. We've got the hyperchoic lumen in the middle, and then we've got one wall side here and one wall side here. And we can see it's got a thick mucosal layer with this dark layer, a thin submucosa, which is a, a, a bright layer, and then a muscularis layer, which is dark, and a serosal layer, which is bright, on, on this side and the same on the opposite side.
So this, that's a fairly normal looking loop of intestines, but this loop over here, which we've got a transverse view, we've actually got the lumen here. And then we've got the thickened wall here, quite a focal thickening, so we'll watch the video there and see if you can see. So we've got normal intestine there coming up into this thickened area.
We can also see there's a bit of a reaction around this thickened area too. So quite a focal area. When we're scanning the intestine, I talked about doing a castle pattern.
To, view as much of the small intestine as possible. And we're really trying to minimise missing pathology. But as you can see, a small area like this could go, unnoticed, if, if we progress too quickly through the castle pattern, or we don't take enough sweeps with the castle pattern.
So it's really important, to, to do that thoroughly. We also need to be picking up on areas like this, the that are inflamed around a specific area. So keep keeping your eyes out for for abnormalities like that.
So here are still, we've got the lumen here and this thickened focal thickened wall here. And so here we can see this progressed, we were able to follow the small intestine, and there was this further thickening and inflammatory tissue in the area. So here is the abnormal intestine that we were looking at before and we've got this area too, nearby.
Blood vessel running through it. And we can also see there's a hypoechoic area and a hypoechoic area as well. So here we've got the hypoechoic area, and there we've got the hypoechoic area.
Right. So again, following that in the opposite direction, we're getting, we can see this abnormal area again. We're looking for the best route we can take, to take, a sample, because this is a really perfect, thing to do a fine needle aspirate on, in the area.
Our main concern being whether we can rule in or out, some sort of tumour. So we had this focal mass associated with the jaunum. And we really wanted to figure out how we can take an FNA.
So we want to avoid actually hitting the lumen of the small intestine, and we want to avoid any blood vessels around in the area. And we want to figure out that taking the shortest route. So where I said, for the animal, to, to assess the small intestines, we want to have the animal in right lateral recumbency.
We really want to have the shortest route possible, and this may mean moving the animal into dorsal recumbency, whatever suits the lesion best, really. And we always want to remember to check post fine needle aspirate. So here I'm taking a fine needle aspirate of the lesion, of the big lesion.
So we've got the needle coming through here and we can see I'm moving the needle back and forth in a woodpecker technique. To get a sample, what you can see is there's some gas bubbles being left in in the tumour itself. So here I'm advancing the needle into the area.
I can see the tip of the needle, and I move that back and forth to get some cells. Leaving behind a little bit of gas in the there which is, it is visible on the ultrasound and then retracting the needle while I'm still scanning. So cytology in this case revealed a mast cell tumour.
This is the 3rd most common intestinal neoplasia in, cats after lymphoma and carcinoma. Metastases are common to local draining lymph nodes and liver, but we didn't see any issues with that. So, the option was there to try and, resect this tumour.
That that gave the owners that, that option of, of what to do now that they knew what the tumour was and the prognosis with it. So those are the, the 10 cases. So in summary, I just want to say that ultrasound is awesome.
It can really enhance, your, your skills that you already have as a GP vet. It can really help to progress cases. I showed you lots of cases there where, CT hadn't given the answers, X-ray hadn't given the answers, and where ultrasound really quickly, and non-invasively often.
And fairly cheaply as well could give the answers and give move along the case to the next steps. So I really want to encourage you to start picking up your probe, to help your patients, and to, to, yeah, just get started, because that's how your confidence will grow, start looking at those cases that you can. I'd be delighted to take any questions, but I just want to remind you about the free ebook that you can get, at my website, which is FOVU.co.uk.
Also, to those of you who have signed up through the webinar that and given permission for me to contact you. I will be dropping it into your email box. And I've got a very exciting offer, which is, the possibility of joining the Fou Club, which is a membership where I help support you and mentor you in, developing your ultrasound skills.
So, do keep an eye out for those emails. There will be an opportunity, again in January. If you miss this one, to join again.
So do keep an eye out on social media for that and do sign up and subscribe to the email list at fou.co.uk.
Thank you very much for listening. Thank you very much, Camilla, for all the amazing insight, and I think this is really, really useful way to learn, and I'm sure I'll be joined by others because there's loads of questions popping up. So we have a sort of a few minutes left, so let's see how many we can get through.
Some of them are pretty straightforward, some of them maybe not so, but . Just going back to some of the cases, I think it was one of the 1st, 1st or second case of, somebody's asked, how do you differentiate a bladder stones from a bladder polyp? Yeah.
So good question. So, a bladder stone will inherently have a mineralized portion to it. So with mineralization, ultrasound just can't pass through.
So, what we get is complete reflection of the ultrasound waves. So that tends to give us a very bright white line. And then, essentially, to confirm that it's mineralized, we're not getting any penetration through that.
So below that white line in the image, we will have a complete blackout. So we'll have an acoustic shadow beneath it. So no ultrasound waves are getting through those stones.
So we've just got no information below it. If we've got a polyp, that's soft tissue. And, it will appear like soft tissue.
So, it can be many, many different shades of grey, but you will get sound waves penetrating through it. You may be able to see a blood supply on it, in, if you apply colour Doppler as well. So, definitely, can differentiate between those on ultrasound.
Perfect. Thank you. Even though I'm a, an equine but, I totally understood that.
Brilliant. We've got Laurie asking, if you can remind us please what are bee lines. Yeah, so.
We've got A lines and B lines. So the A lines are normal. They tell us that there is gas in the area.
So what we have there is when the ultrasound waves hit gas, very much like mineralization, it, it can't penetrate. It gets totally reflected back to the probe. And what What happens is we get this bouncing between the probe and the gas.
And this, means that each time it hits the probe, the probe thinks that, that there's gas further and further away in the image. So it draws these horizontal lines deeper and deeper in the image. Those are a lines.
So they're horizontal or, or parallel to the, to the, to the probe line, if you like. And, with bee lines, you get those when you have, it's an artefact, and it's caused by, a little pocket of air with a little pocket of fluid around it. We often see that in pulmonary edoema.
And what happens is we get these, it's also known as lung rockets or comet tails. They're, they're all the same thing. We get them right up by the surface of the lung, right by that plural line, where we should see the gliding sign moving backwards and forwards, and they're vertical bright white lines that shoot down the image.
And they, they often move from side to side with the gliding sign as well. So those are bee lines. If we've got palmary edoema, we'd normally expect to see that throughout the lung fields.
And we'd normally expect to see some changes in the heart when we're, we're scanning that also, to show that it's cardiac caused pulmonary edoema. We may get different patterns, so. We might see more bee lines in different areas of the lungs, just like we did in that case with the, springer spaniel.
We saw a lot of beelines in the ventral lung. And that made us think about aspiration pneumonia, and, and question the owners as a bit more closely on the history, which, which confirmed our suspicions about the aspiration pneumonia. So it's, it's important about the, the patterns, that we see the bee lines in.
And it's important not to just take one area of the lungs, because we even might have a normal area of lung, that has no beelines, or, we might get the odd beeline, and it, that may be, may be within normal limits. So it's important to, to assess whether we're getting lots of beelines over the entire lung field. OK.
Thank you. Very, thorough explanation. Awesome.
We have somebody else, and I can't quite remember which case this was, but they were asking, what was the test that you mentioned in the first case? Yeah. So that will be the Bra test that, people haven't heard so much about.
I haven't actually used it myself yet, but, it basically looks at a genetic mutation, which most transitional cell carcinoma. Cells have. And, yeah, it's, it's, done on a urine sample.
They look for this genetic mutation. And, it's, it's extremely useful to look if we suspect, so if we've got evidence of a, a wall thickening, it's not something to do as a, as a screening test on, on lots of animals, because then you'll get false negatives. False, yeah, false negatives, false positives.
But if you are doing it in a case where you have a thickened wall, then, it is well worth sending off. It's a non-invasive test. You just need a urine sample, and it apparently works when you've got, even if you've got secondary infections, etc.
Etc. But it's a, a really, really useful new test. Awesome, fantastic.
Thank you. The next one, Julie's asking us what's the best way to see the needle during an FNA? Oh, great question.
So, the best way is to progress your needle, . In line with the probe. So think about where the image is, is coming from, and you want to, hit that image, basically.
So you want to line the probe up and, line the needle up, next to it. So, preferably where the marker is, so that you know which side on the screen, on the image you're gonna come in from, so that you're looking in the right place where it's going to come to. And then just progress your needle slowly.
If you can't see it straight away, then don't, don't move your needle. Move your probe to try and get it into view. Never move your needle if you can't see it, in the ultrasound image.
What I always do before taking an FNA is I get an image, of, of the area that I want to, to, take a fine needle ask for it from. And then I measure from that top corner in the image, down. Actually, I can show you.
In this image that I took. So I'll show you where, where I would measure from. So I'd measure from here.
To the area that I want to take a sample from, and that gives me the needle length that I need. So that, that's quite an, a useful thing to, to do before you take a fine needle aspirate. But you want to, if you imagine the probe is up here, and you're inserting your needle here, you need to stay in line in the image and not go off that plane.
OK. Mhm. Perfect.
Great. And we've got Vanessa asking us, If there is a way to differentiate between inflamed lymph nodes from metastatic ones. Yeah.
Fine needle aspirates, are really the, the way to do that. The, the bigger and the rounder and the darker they are, the more likely they are to be neoplastic. But there's no, there's no, definite line above which, or below which you've got, neoplasia or inflammation.
So, it's adding all the, everything up together as well, you know, the history. So, figuring out what, what is, what is this lymph node draining, and can I find any abnormalities in there? And what is that, is that more likely to be neoplastic or inflammatory?
But really, definitively, you need, a fine needle aspirate or, or even a biopsy to, to, assess whether it's inflammatory or neoplastic. Perfect. Thank you very much.
And a couple more questions unless people send us more, but we only have a few minutes left anyway. So the next one we've got actually somebody asking us about immaendin and what does it do for heart problems? OK.
So then we're going into pharmacology now. Might be off topic, but, we can always, I mean, I mean, the main, main point when it comes to ultrasound and Pimabendin is that it, it really does have a huge impact on our, our mitral valve disease cases. So, if you, catch these dogs at stage B1, where, or B2, where the, the, The left atrium has enlarged slightly, but so there's starting to be some cardiac remodelling with the mitral valve disease.
But there's no clinical signs yet. You can prolong life massively with Pimabendin. So, from that point of view, I'm not gonna go into the pharmacology of it, but it was really, really strongly associated with, with ultrasound for that reason.
That if we can see a bit of cardiac remodelling, but no clinical signs, and you can stop himendin, you're really gonna make a difference to that animal's life. Fantastic, thank you. And then, actually a couple more questions still, one somebody asked actually in the chat about, I think what they mean is the intestine, but like in the last case was that the diverticulum of the intestine.
No. No, it wasn't. It was the wall itself that was thickened.
So we could see the lumen, but we couldn't, yeah. And, and that extra bit, I, I was considering whether that might be the, the local lymph node. It was difficult to assess exactly what it was.
but it was all associated, sort of together. We had this very focal. Intestinal wall thickening, and then this mass, very local to it that seemed part of the same inflammatory process.
We, you often it with, with lots of changes in the in in the abdomen, you get. Local, reaction around it, and that can really help highlight it on ultrasound. But often the fat around it is, is reactive and gets brighter.
So it often highlights the, the changes, very usefully, on ultrasound. And that's what we were seeing. It, it, that, that other mass wasn't, wasn't really part of the intestine, but potentially part of the dinal lymph node, system.
. But it came back as, as more cell tumour in that area. Thank you. And staying on the topic of intestines, somebody's just asked us, whether you think that taking an FNA from the intestines can cause cellular seeding.
I'm not actually sure what that is, so I'm diverting the question to you. So, seeding is where we, we're, we're taking a sample of, usually by fine needle aspirate, of a tumour. As we withdraw the needle, we, we may be depositing some of those cells as we withdraw.
So in the muscle layers of the abdominal wall, etc. Etc. And that might grow, then into a tumour in that location.
So we see this with carcinomas, and particularly transitional cell carcinomas. So, that's why it's always good to not take samples from liver, sorry, bladder wall, thickenings like the one we saw in the first case, because we don't want to seed into the abdominal wall, a new tumour. And that, that does happen.
The problem is with intestines, yes, we might get, we might have carcinoma, but by far the most common tumour we see is lymphoma. So, and fine needle aspirates are great for diagnosing that. So, there is always a risk of, seeding, but even if it is a carcinoma, We're not gonna see it every time we take a sample.
So we do have to weigh up these things, and it can be a really useful, and, and much less invasive than doing biopsies, you know, exploratory laparotomies. So we have to weigh up the risk benefits. So I would, wouldn't rule out doing, gastrointestinal.
Finding res on, on those grounds. Mhm. Perfect, fantastic.
Thank you. And, before we wrap up, because we're kind of running out of time, a quick question. I'm guessing it's from a vet nurse because she's asking what techniques do you teach vet nurses.
Is it plus or TFAST? Yeah, so nurses, definitely, we want to be teaching nurses how to use the ultrasound machine, how they can help triage patients for us. And that involves definitely the emergency scanning, that we do.
So, thoracic and abdominal, fast scanning, absolutely. Perfect, and, I think I, I had a few questions lined up as well, but I think I'll save them for later. And since we're out of time, but thank you so so much for brilliant cases.
We had a few thank yous come through as well, so I'm hoping that all of our, attendees enjoyed it. I'm sure they found it really, really useful. So thank you again to Felber and to Camilla, for, coming and delivering this, 3 of the series of webinars.
So thank you. Thank you very much.
