Hi and welcome to this webinar on ultrasound of equine medicine cases. So the outline of this session is we're gonna start with some medical ultrasound top tips, and then I'm gonna present some data about whether doing abdominal ultrasound evaluations is really worth it. Then we're gonna have a think about that approach to the complex medicine case, and then I'm gonna go through a series of cases and their ultrasound findings.

So, here is a range of ultrasound machines, and as many of you will know, in order to do particularly abdominal ultrasound in horses, we need a machine of a certain quality. And as the adage goes, you definitely do get what you pay for, but you can certainly get some very diagnostic images even with some of the good middle of the range machines that are on the market if you are really good at optimising your images. So, this machine down here is the Sunscape and it's a machine I have access to in the clinic where, where I work part time, and actually it gets very nice abdominal ultrasound images.

And then this machine in the top, top left hand corner, is a, is a, a GE vivid, a vivid IQ and that gets absolutely beautiful. You know, beautiful images, and it's only just a bit bigger than a laptop, so makes it really very easy to take these machines out to our patients rather than in the old days where machines were half the size of a room like this one in the middle of the picture, the horses had to come to them because they weren't very portable, and, or mobile. So my first top tip is you need to learn to fiddle with the knobs on your ultrasound machine.

I mean, here we've got the Vivid IQ set up with with a big convex probe, which is ideal for scanning abdomens with. You certainly can scan abdomens with haased array and microconvex probes, particularly when we're looking. Detail, but really we need a relatively low frequency probe.

But we're really going to need to change the depth continuously because if we've just got a piece of gas filled large intestine at the top of the screen, then that's the only bit that we're going to want to see because everything else below it is, is artefact or nothingness. Obviously if we want to image the liver or the spleen, then we're gonna want to maximise our depth and have a sort of lower frequency so that we can really get good quality images. The other thing to remember are your focuses, and you know, if you're not getting a beautiful image, make sure that the focus is, your little yellow arrows down the side, match the structure of interest that's on your screen.

And so my way to evaluate ultrasound medicine cases is preparation, which we're gonna come to, in a minute. But preparation is absolutely key. You're gonna want to clip the abdomen unless the horse has got a very, very thin short coat.

You're gonna want to potentially use spirit, but if you're doing whole abdominal exams, it really will benefit you from investing the time and the gym. In covering the whole area of interest and allowing that gel to soak in. And then sometimes, as we'll talk about in a minute, you need patience and invention in order to try and make sure you can get the images that you want.

And you should always start, particularly where you're not always sure it's gonna be an abdominal problem, but you want to scan the horse, always start with the abdomen cause abdominal disease, unless you have got, tachypnea, dyspnea, or a cough, is more likely to, is more likely to be, be a, a disease of the abdomen than the thorax. And then I always start cordially in the para lumbar fossa and dorsally and I work my way down the rib space. And then I move forward the rib space and then I move down the rib space and then at the end I scan the ventral abdomen.

You certainly can't rely. On the fact that that any form of disease is going to be beyond that ventrum, and it can be one of the trickier places to, to scan and get good quality images, especially cordially if you've got a horse that is well conditioned. And then you're gonna want low frequency evaluations for solid organs such as the liver and the spleen, and then you're gonna want to use the highest frequency you can in order to evaluate the intestinal wall, which is often what we're, what we're looking at when we're dealing with non-colic cases.

And then make sure if your machine allows, you save the images as cine loops rather than as still images. Still images are very, very difficult to go back and review after the fact, and if you did want to send them for a second opinion to someone, they mean almost nothing to anyone when they are, when they're viewing these, these images. So I said we'd come back to the patience and invention of patient preparation.

And I think that when you look at these two horses, you can easily understand which of these is gonna be straightforward to get abdominal ultrasound images on and which one is gonna be slightly trickier. And a very good colleague of, of, of, of mine once said, the best way to prepare this cob in the left-hand corner is to is to place your, your, your spirit, clip the animal, place your spirit in Your ultrasound coupling gel, wrap them in cling film and go and have a cup of coffee. And by doing that, you give the animal an opportunity for that gel to really soak into the skin and it will absolutely, improve the quality of the images that you get in that animal.

So, is abdominal ultrasound really worth it? So, and so we, I did a retrospective study that were presented at the Collic symposium in 2021 where we looked at the frequency of abnormality. That were detected using transabdominal ultrasound and these were for the presentations of weight loss, diarrhoea, pyrexia of unknown origin, and recurrent abdominal pain.

So not for acute, not for acute colics. And what we found was that ultrasound was very much the mainstay for evaluation of these cases. But what we also know is it can be quite time consuming, especially when we go back to that conditioned cob, and obviously it's expensive for the owner.

It's several 100 pounds. Is it worth it or should we just trial treat, with our best guess of what might be going on? And what we did in this study was we looked at the yield, the findings for the procedure, that were not flash scans.

So we went back over clinical and ultrasound case records for 5 years in horses that were greater than a year of age. And they had to have in their records the ultrasound findings and also final either confirmed or presumed diagnosis that were recorded as the outcome. And the abnormalities that were recorded were increased small and large intestinal wall thickness which was defined as greater than 4 millimetres.

An abnormal appearance of intestine, an abnormal appearance or volume of peritoneal fluid or some other abnormality of either the abdominal organ or something else, such as the peritoneal lining. We classified recurrent colic as greater than 3 episodes in 3 months, and chronic diarrhoea as greater than 7 days' duration. And all the images were obtained on the Vivid Q Ultrasound machine, which is a GE machine using a 3 megahertz convex and a 7.5 MHz microconvex probe.

And searching the records, we found 224 evaluations. The horses range from 3 to 28 years with a mean age of 13.15.

They were predominantly thoroughbred or part thoroughbred or Irish draught or part Irish draught, and majority of them were slightly thinner than perhaps the norm, so body condition scores 3 to 4 out of 9. 60% were geldings, 40% weremes, which would reflect the my case population that I would see. And 60% of the evaluations were for horses with weight loss, 24% current colic, 9% with diarrhoea, and 6% with other signs.

So we found abnormalities in 80% of these 224 evaluations. 19% had thick and small intestine, 40% thick and large intestine, 20% had thickened both small and large intestine. 4% had abnormal motility, which we can only really assess in animals that are not sedated.

8% had abnormal peritoneal fluid amount or appearance and were later diagnosed with either peritonitis or in one case, a mesothelioma. And 8% had other abnormalities, predominantly they were masses or abnormalities in solid organs. So again, one was a spleen and one was a, was an animal with very abnormal kidneys because they had secondary to chronic renal failure.

So let's just have a think about normal and abnormal small intestine. I think it can be pretty easy to identify where we've got . Where we've got the wall of the small intestine, so hopefully you can see my arrow here, I'll see if I can draw on there, I'll see if I can draw on this, on this picture.

So here we've got some small intestine, you can see it's got some, it's got some a very abnormal appearance here in the And the intima of this of this small intestine might have gas sitting just within the wall, but you can hopefully see with this arrow, you can see that this wall is quite thick and you can't see any form of normal layering. This image here, likely to be the duodenum sitting alongside the right dorsal colon, and if we could see more of this image, we would have the, the liver sitting up here on the right hand side. And then down at the bottom here we've got some large intestine and hopefully you can see actually this wall would be really difficult to, to measure, but we're looking at, you know, wall thicknesses, wall thicknesses here of, you know, a centimetre.

Or more and we know it should be less than 4 millimetres, as we've said. And you get the idea that this large intestine in this bottom left-hand image is pretty corrugated. And again, no, no real evidence of layering.

And yet, and again here another piece of, and this is actually left ventral colon in this case. And again, the wall thickness is, is really, really markedly thickened. Remember when you're measuring a large intestinal wall.

Not to include this gas cap, which you can see is this bright white line. The, the wall is above that and anything below where that bright white, that really white line starts is in fact there. And again, this is just another image here.

This is taken on the, on the left-hand side. We've got body wall, we've got, sorry, we've got skin and fat, we've got body wall, we've got the tip of the spleen down here, and then you can see we've got loops of small intestine. And I know this is a still image, the wall isn't actually that thick.

Based on the measurements that we've got here, but we've got some of the, small intestine with black ingestor, and we've got some here that are much more echoic, which again can can suggest to us that we, that we might have a, an obstruction. We've certainly likely got, got ileus in these cases. And then this is one of my favourite images.

You don't actually see these all that often but this is a small intestinal image. You can see that it looks rather like a dartboard, and this dartboard is often a sign of some form of small intestinal into the. So you're seeing all of the layers of the small intestine, which often become quite edematous, and then on the outside and then on the inside, you're seeing those layers of the small intestine that has, tracked into the other, the other small intestinal parts.

Again, this is an image here, this is the liver that we can see. Then we've got some small intestine, which in this view, likely to be the duodenum up on the right hand side, and then below it we've got the right dorsal colon. And you can see some of the layering here of the right dorsal colon, but hopefully you can see that this has got a really, really thickened duodenal wall.

And again, this is an image that we have and that I'm trying to show here where we've got colonic wool, doesn't look particularly thickened. We've probably got a loop of small intestine, hard to say, oh sorry, oops lazy. Hard to say whether what this is on a still image, but the reason that I've included this image is to show you that this is the skin and this is a small amount of fat, not very much.

This is the body wall, and this here is the peritoneal lining, and then all of a sudden, You see that we've got this much thicker section of peritoneum that sits sitting here. And when we got a biopsy of this and we we sent this off, this in fact did come back with a mesothelioma. Now you do have to be quite careful.

Diagnosing mesothelioma, particularly from peritoneal fluid samples, because if you get mesothelial cells and then you send them to the laboratory after they've been in the post, they can start to change and get changes that are consistent and that look a little bit. Like they are neoplastic. But this case was a, was a mesothelioma.

We managed it for a short period of time with some steroids, and then it's weight loss continued, the amount of peritoneal fluid it produced became, excessive and when we, we came to euthanize it. And then this is one of these cases again, we've got this is an upstasy, really nice image that we've got here that's labelled, and you can see it's appropriately optimised for depth. If we look back and we were going to criticise this image, you can see that probably the last 10 centimetres were totally irrelevant and we would have got a much better image and detail of this near field if we just reduced the depth.

But this image is appropriately optimised and you can see we've got the liver sitting here, and then sitting beneath the liver is the right dorsal colon. And again, the wall thickness is between these two white arrows, and you can see that the Wall is both thickened, but also the layers, which should be largely equal in size, you can see that actually that isn't the case and that this this middle layer here is much, much thicker and more hypoechoic than we would expect. This was a horse that had been on phenolbutisone.

No dose had probably been receiving it for around about 8 or 9 days, and then had started to lose weight and develop ventral edoema and had got right dorsal colitis. Remember that right dorsal colitis is the most common toxicity associated with non-steroidals, . And it's an idiosyncratic reaction.

They don't have to have received 10 times the dose. They don't have to have been on the drug for, for years. It can just be a normal dose, for a relatively short period of time.

Anyway, this horse, we stopped the non-steroidals, we switched the horse to, an alternative analgesic in the form of paracetamol or acetaminophen. And, and treated the horse with misoprostol and the right dorsal colitis resolved within a few weeks. OK, so the next, The next case is a 20 year old warm blood, gelding.

He'd initially presented with, with some colic, some, and it was, it was recurrent colic that then developed into weight loss over an eight-week period. And on his, abdominal ultrasound exam, the only real abnormality that we could see was down that involved the The right ventral colon that you could scan in the sort of cranial ventral part of the abdomen just before you, you would have started imaging the thorax. And what we could see was this structure that you can see on the, on the left hand side.

Look like this incredibly thick walled structure and and that you could then see this really irregular gas appearance. So my differentials for this case were an abdominal abs. And the horse did have quite an increase in serum amyloid A.

It was the only alteration on his blood work, or that we've got some very severe form of intestinal thickening. So, We went with the punch that because, because of the, because of the, the history and the increase in service the day, we tried managing this horse with oral doxycycline for a few weeks, and he really didn't make any improvements. The owners didn't really want further diagnostics done, so.

Assuming that this might have been some form of inflammatory bowel disease, although, to be honest, it's so thick, probably, you know, a few centimetres thick at this widest point, and we didn't really think they were likely to work and it, it was much more likely that this was something sinister. But we did try after the antibiotics failed, we did try with a, with a tapering course of oral prednisolone. And again, no improvements.

And then at euthanasia you can see why there was no improvement. And this was just a probably 30 centimetre segment. Of the left ventral colon, that was, and what we could see with the gas was this calcified, this sort of calcification that was sitting within the lumen, and then you can hopefully see, on this image just how thick this colon wall was.

And histopathology turned out that this was a, this is an adenocarcinoma. So this horse wasn't gonna get better with anything except for a, a colon resection. It hadn't spread to any other organs that we could see grossly.

And then this is an image taken from a 14 year old thoroughbred Irish draught mare that presented with weight loss. And this image to orientate you is probably in the 9th left intercostal space and the structure down here on the bottom left hand corner is the stomach, and then we've got free fluid and then we've got a loop on the right hand side of small intestine. And hopefully you can see that on the surface of the stomach, we've got this, we've got this mass.

And when the stomach, when the, when the rest of the abdomen moved, it was only when the sort of stomach moved away you could see that this mass seemed to be adhered to the stomach wall. And on gastroscopy, we had in fact, when we gastroscoped this horse, there was in fact an erosive lesion on the greater curvature in the squamous region, and samples taken showed that this was in fact a gastric squamous cell carcinoma. And there's no treatment for that, unfortunately at the moment.

The next case is a 13 year old thoroughbred gelding that's presented with colic and weight loss. And on abdominal ultrasound exam, majority of its abdominal ultrasound was pretty normal until we got down towards the ventral midline. And I'm sorry this It is not as clear as it might be, but you can hopefully see that we've got this sort of scalloped edge to a solid mass.

And that solid mass could have been associated in its, in its position with the left lobe of the liver, or alternatively, it was sitting down at the tip of the spleen. And so we did fine need aspirate and we did a biopsy, a true-cut biopsy of this mass and the fine needlapirate revealed the following on on cytology, and hopefully you can see that these are. Pretty large lymphoblasts, they've got very abnormal shapes to their to their nuclei, and that the nuclei contain multiple nucleoli, so fitting all of the criteria for, for metastatic disease, and this animal had just got a splenic lymphoma.

We did sample his bone marrow and his periphery, and there was nothing to tell. So the horse did in fact go and have a splenectomy, and did, did really, really well for at least 2 years after the procedure when he was lost to follow up. The next image is from a 19 year old Irish sports horse that had pyrexia of unknown origin and intermittent abdominal pain.

And this is an image taken up on that left sort of 13th intercostal space where hopefully you can see what should be a really homogeneous liver is in fact a sort of 2 centimetre mass that's got this, these sort of ecogenic centres within them. And you know, the differentials for this have to be, does it have some form of marked regenerative response, which is quite unusual in horses, not least because they don't normally lose that much blood and they don't develop anaemia for many of the reasons we see in small animals. Was this an abscess?

Was this a tumour? Was this a granuloma? So we biopsied this mass and this mass came back as an, as an, as a splenic abscess.

And we treated this, culture and sensitivity and revealed it was actually pretty sensitive to most, to, to most of the antibiotics. So this animal got Treated again with 4 weeks of, doxycycline, all based on what that serum amyloid A was doing, and the horse made a, a good recovery. You could still see some changes in the spleen where it had been, but it certainly did improve in its appearance.

And I just wanted to put in a word of warning about imaging of livers. So this was a pretty sentinel paper that got published in 2011 talking about starry skies and the starry sky's appearance of the, of the liver. And although both of these images look pretty dramatic, what we know is That horses can develop hepatic granulomas which appear like starry skies, actually very very easily.

Now some of them are associated with a very severe disease and others are incidental findings. So just be careful not to overinterpret them when we're looking at livers and. I actually find liver ultrasound of the liver really quite frustrating that you can have really marked abnormalities both of liver damage indicators and functional markers such as bile acids, and the livers can look largely normal on ultrasound and vice versa, you can have pretty normal.

Liver damage indicators and have very abnormal appearances to the, to the liver. But at least ultrasound gives us that opportunity to have a look, but also to find appropriate spots for for biopsy. Remember that it's really good understanding where the liver.

But when we come to biopsy, we normally aren't biopsying liver in normal animals. So that liver may be bigger or more commonly a lot smaller than you would expect and is the reason why we can end up sometimes biopsying anything that's not liver when we're doing our liver biopsies. And then this is another thing to warn people about.

This is this is actually the liver imaged on the, on that sort of left lobe which sits cranie ventrally on the left hand side, so behind the diaphragm and in front of the. Spleen. And I mean these again look very dramatic but are itinococcus cysts and horses can have many of them in their livers.

They sometimes will have mild changes in liver damage indicators and bile acids and sometimes they, they won't, . Although they look dramatic, they probably end up with minimal function and there is the recommendation for them is to leave well alone. So don't try aspirating them because you can just end up causing peritonitis.

This is an image from a 20 year old thoroughbred er cross Irish draught gelding that presented with recurrent colic and weight loss. And you can see that normally you have a really sharp edge to the. To the liver and that in this case we look like we've got these extra parts.

Now if someone sent me that image as a still image like I'm showing you, it would be very, very difficult to not know that that wasn't small intestine. And that's where the value of cine loops becomes so valuable. Now, in fact, we could see that this wasn't, this what these weren't intestinal loops because they didn't move and when the animal breathed and the liver did sort of, you know, move a small amount within the abdomen, and you could see it sort of moved with the liver and it wasn't, they certainly weren't constricting.

So we got biopsies of these, of these sections and again these came back as a a relatively high grade nonspecific, malignant neoplasm, in this, in this case. And actually liver tumours are not commonly reported in, in horses, but certainly this was one case. We obviously can't resect the liver in the way that we can the spleen, so, so there was no real treatment option sadly for this horse.

The next case was a 12 year old thoroughbred cross gelding. So again, had presented with signs of colic, acute colic. Heart rate wasn't particularly high, but was increased between 48 and 52.

And it had had some response but it wasn't complete to IV clinicin, no reflux, nothing on rectal examination, normal bulbargy, and. Passing faeces and the peritoneal tap was normal. So, it had a normal total protein on a refractometer of 20 grammes per litre.

So this is one of those cases. You look at, you look at it and you think it looks like it should have acute colic, but in fact, it's got relatively normal GI functions. So for me, this would be one of those cases.

Where I would be thinking non-intestinal might still be GI could be a problem within the, the thorax as well. So, you know, those sort of pseudo colics where in fact they've got, they've got pneumonia, they've got pleural pneumonia, they've got pyelonephritis, they've got something else, and that isn't a problem with the intestines. So I don't normally do hematologies and biochemistries on my acute colics, but the minute that you've got a puzzle, it can sometimes help you.

So actually in this case, as often is the way, haematology was unexciting and the biochemistry did reveal we'd got an increase in GGT increase in AST so, suggested that we'd got some form of liver damage affecting both. The biliary and the hepatocellular components and the bile acid was very, very slightly increased. And in this case on ultrasound of the liver, which as I've said already, can often be pretty unrewarding, we were able to, Identify these two structures that you can see that have got arrows in them.

And we don't normally see the bile ducts in in horses unless there is an abnormality. And what you can hopefully see here is that the bile ducts. It is very varied in its in its size, but that we've got these two spherical hyperechoic structures within them, and this one on this image you can see it clearly shadowing, suggesting that it's calcified.

So this was a case where we looked like we'd got some form of cholelithiasis, and we know from data in people that cholelithiasis can be incredibly painful. In horses, it's often secondary to an ascending cholangio hepatitis, not always, but that is, is frequently the case. So you end up having to manage the animal's pain while it passes these, while it passes the, the stones and then try and get on top.

Of any challenges that you've got in terms of, in terms of the cholangio hepatitis. So this horse got treated for 2 weeks with some oral trimethoprim sulphur and got managed with, oral phenylbutasone when it looked uncomfortable, and it had one further bout of colic and then. And then, the clinical signs and the appearance, this abnormal appearance of the liver both resolved.

The next case was a nine year old Connemara gelding that had abdominal pain that was waxing and waning. And it was one of these cases, as we will often see, where it got diagnosed with a pelvic flexure infection, which got managed, you know, pretty, pretty easily and quickly, but that it then became really unusually intermittently painful following the resolution of the impaction. Again, at this point, it doesn't quite look like you expected it to.

The creatinine was, top of the reference range on the biochemistry, and on urinalysis, which is often much more sensitive for looking at renal and other urinary tract problems, we've got 3+. Blood and 2 + protein with a specific gravity of 1016. So the horse could concentrate its urine.

Now that could mean it's got a unilateral problem and that the other kidney is compensating or it could just be that the animal's not got renal, he's not in renal failure. So here's the image of the right kidney. So hopefully you can see, you can see we've got a very beautiful image here of the kidney, but in the centre of the renal pelvis, we've got this sort of shadow, shadowing.

Very sort of smooth, whoops lazy, sorry, very smooth structure that we've got here that's shadowing, which is suggestive of a nephrolith. Now there's been various, descriptions of how you manage these cases. I can remember years ago we tried to, smash some nephrists using, lithotripsy like they would do in people, and it was, Partially successful, but wouldn't be something to recommend doing again partly because of cost.

And because this horse had got a normal left kidney, the, the, decision was made that we would, that we would in fact do a, a nephrectomy and we removed the right kidney and the horse's clinical signs resolved. The next case that I've got is a 3 year old warm blood mare that's always been fairly small for her age, and she developed weight loss and diarrhoea, and the blood work that was That was run on this, this animal was the creatinine was probably 3 times the top of the reference range. And so she came in for imaging to see really if there was anything that we could do.

Was, was there unilateral disease of the kidney, and was there anything that we could, we could do? So here is an image taken on the, on the left hand side. This is skin and body wall and this is spleen, this is the left kidney.

And you know, this should have been, she was probably about 400 kg. And you can see that actually this kidney's pretty small. It's got very poor cortico medullary definition, and it's got some sort of extra stuff around the, around the outside.

Sorry, let me just go back one minute. Taken of the right kidney and hopefully you can see that this kidney just looks like it's got sort of pockets of, well, I wondered if this kidney had had pyelonephritis, but we've just got these pockets of pus, but we've got, or what are consistent with pus. We've certainly got these pockets of a spherical ecogenic material within them.

There's absolutely no normal architecture that we can see in this kidney. So had this been the only, this the right kidney had been abnormal, the left kidney had looked OK, then you know the option for nephrectomy would have been present, but you can see here we, we are just doing a renal biopsy so the. That's the, the, true biopsy just popping into the, in through the renal capsule so that we could get a sample and just make sure that there was nothing that we could do.

So we biopsied both the left and the right kidneys, and this horse, unfortunately, for whatever reason had got had got evidence of end stage kidneys on both the. Left and, and right sides. So the decision was made to euthanize her.

And again, the, the changes can be really non-specific. You know, I was keen to know, had this animal had, you know, pyelonephritis or renal infection early on, and there was no way to know with that. All we'd got was, you know, end stage change.

The next case again is another, another one of these, these colics that probably is a non-GI related, event. So this was a 14 year old thoroughbred cross gelding and its heart rate was between 64 and 100 beats per minute. Res rate was 40, temperature was normal.

Again, reduced but present GI bulbri, which sort of didn't really fit with the fact that this horse was so tachycardic, if this was a primarily intestinal problem. No nasogastric reflux, normal peritoneal tap, and again, this horse passed some faeces whilst the exam was being done. The horse has got a great 4 out of 6 murmur with a point of maximal intensity in the left 4th intercostal space.

It wasn't known to have a murmur prior to this episode, but the owner couldn't remember that its heart had been auscultated for several years. So you look at this and you say, well, you've got to be suspicious that this horse might have a primary cardio. Respiratory, but certainly cardio, cardiac problem.

Does this horse have ventricular tachycardia and that the murmur is perhaps not relevant? Does this horse, has this horse gone into heart failure because of the, because of the underlying potential and valvular disease that it's got? So this was the image that we got when we scanned its heart, and hopefully you can all see that we've got some colour flow Doppler, where we've got blood flow in a region that we definitely shouldn't have.

So here we've got blood flow going running down the interventricular septum, which is consistent with an aortic root rupture. We do see them more in males, that's often installions. And these horses usually have a they have days to weeks before we find that the aortic route completely ruptures and the, and the horse dies.

So in conclusion, you can often get a really high yield using ultrasound, and I think that it was really valuable when I did that retrospective study looking back to say, you know, really, 80% yield is pretty good on those sort of chronic. Tricky medicine cases that you, that you're not entirely certain which treatment route to go down. And I think that ultrasound's not a very good fishing tool, so it's really helpful if you've got additional clues as to what the problems might be.

Try and get the settings on your machine to be the really best that they can be for your case load, and many of the companies that sell ultrasound to the veterinary market are really, really great. They've often got really good presets and if the presets that they've given you really aren't suiting you, then rather than grumble about it, you know, get them back out so that they can help you optimise those. But however good your presets are, you still need to ensure that you fiddle with your knobs throughout the scan, particularly changing the depth and the gain so that you can get the very most out of the image, out of the images that you obtain.

And it's all about attention to detail. If it doesn't look right, it almost certainly isn't. Now that's can be both helpful and frustrating because for some things, we know that they're abnormal, but we don't always know exactly.

What they are, and that case of that, colonic adenocarcinoma was a really good example of that. You can see it's very abnormal, but you only have your best guess as to what it might be. It doesn't always give us definitive answers.

And with that, I would just like to thank you and if anyone does have any questions after they watch this webinar, I'm always happy to answer them via via email. Thanks very much indeed.