OK, and thank you very much for that kind introduction and welcome everyone to this webinar. What I want to try to do during the next hour is to get you to think very critically about your radiological interpretation and so that you can get the most out of your equipment in the practise. So this is going to be a case-based presentation, and the first case I want to present is a Rhodesian Ridgeback, 12 year old male called Bonham.
And Bonham was presented with a previous history of gastric dilation and vulvulus, which was treated surgically with gastropexy and splenectomy 4 years previously. She, he had also had an osinophilic enteritis diagnosed 4 years ago, and that was treated by diet and prednisolone. But recently, he'd started to cough and wretch, and he was now becoming subdued and inappetent.
Clinical examination was pretty unremarkable. He was reasonably bright, alert and responsive. His pulse was 80 beats per minute and was a strong in, in volume, and his thoracic auscultation and percussion was unremarkable.
Because of the cough, he had some thoracic radiographs taken, and so I'll share these with you. This is the right lateral radiograph. Showing his thorax.
And this is the left lateral radiograph. And what I want you to do is to say, where is the nodule that you can see? Is it in the left cranial lung lobe?
Is it in the right cranial lung lobe, the cranial mediastinum, or is it outside the thoracic cavity? So just have a quick look at those again. That's the left lateral.
That's the right lateral. Can you identify where that nodule is? So if you'd like to poll the question, please.
So, let's see the answers, look at the results. So 30% of people have said the left cranial lung globe. 40% have said the right cranial lung globe, 16% have said the cranial mediastinum, and 14% have said outside the thoracic cavity.
Let's know the answer, right. OK, so let's look as to where this nodule is. Well, we could have taken a dorsoventral view.
Of the thorax and that quite clearly shows the nodule here on the left hand side. And just to orientate yourselves, I will always present the radiographs with the right on your left and the left on your right. It helps.
Helps very much if you look at radiographs in the same way each time, you'll pick up smaller lesions and minor changes much more readily if you always present the radiographs to yourself in the same format. Now, why is the possible from those two laterals to show where the radiograph, where the nodule is? And first of all, we need to know that the right lateral and left lateral actually show you different aspects of the lung tissue.
And that is because when you lie an animal on its right hand side, these right lung lobes deflate, so there's less air in those lung lobes to show up small lesions. And so in a right lateral view, the nodule should become more clear because the left lung lobes overinflate and show better contrast between any changes within the lungs. So on the right lateral, the nodule was much clearer in definition than it was on the left lateral.
The reason being that on the left lateral, the left lung lobes deflate, the right lung lobes overinflate, and therefore, there's less air around the nodule to show the nodule in that left lateral radiograph. So, we could, from those Two lateral radiographs define which side those lesions are. And from the point of view of looking at lung pathology, we should realise that the right lung lobe, the right lateral projection will show us the left lung lobes and the left.
The left lateral projection will show us the right lung lobes. So we can see a different appearance very often when there's diffuse lung changes by taking both the lateral views, and they give us a lot more information if we take both of those views and a dorsoventral. We normally take the dorsoventral view because we don't want to move and change the pathology within the thorax by tipping the animal onto its back and possibly moving the heart around in the chest, so it's less less orientated towards the normal position.
OK, what we also need to understand though, by our radiographs is that we can only identify nodules that are greater than the surrounding blood vessels, and that's usually defined as around about 3 to 5 millimetres in diameter. And if we were to do a CT and therefore do transverse images through the thorax with no over Lying structures, then we can see much smaller lesions developing within the lung tissue. And as we come back, we can see that they're nodules on both sides that aren't connected to these blood vessels that we can see dividing and going out towards the periphery of the lung parenchyma in the in in the In the lung.
So with this rhodesian ridge back had developed a primary lung tumour, that was the nodule that we could see, and from the CT we could see that there was metastatic spread throughout the other lung lobes. So the prognosis was not so good, certainly in terms of removing the primary lung tumour, that would not be possible, and just Treating the animal symptomatically for its cough, was the way that we did that, and the animal went for about 6 months following that. The second case is an Italian Spanoni.
This Italian Sinoni is 2 year old female called Bracken, and she was presented with a 2-week history of acute onset, hemoptysis. And this hemoptysis was progressive over this two week period, and now she was dull, depressed, and inappetent. On clinical examination, there was dried blood around her nostrils.
Her mucous membranes were rather tacky. She was tachycardic, she had increased respiratory effort and increased lung sounds and crackles, especially in the right middle lung fields. So radiographs were taken.
And here we have the left lateral view for you to look at because that will show you the right lung fields. And then a dorsoventral view as well, showing this pathology. So I'll let you look at these for a few moments, and then I'll ask you a question about these radiographs.
So you have the left lateral here. The right of the dorsoventral here. And what I want you to know is, what is your diagnosis?
Has the animal got pleural effusion? Has it got a lung lobe torsion? Has it got a primary lung tumour, or has it got diffuse lung pathology with consolidation of one or more lobes?
So if you can launch the polling question, Yeah, I'll just launch the polling question now and give you 30 seconds to respond. As I say, you're not gonna get beaten by a stick if you don't get the answer right, but it's just good to see what people's thoughts are. And it's always good to commit yourself because you'll learn a lot more if you commit yourself and you're wrong, than if you don't commit yourself at all.
OK, I'll just give people 5 more seconds. Any last stragglers who are trying to make up their mind. OK, and I'll end the pole in there.
Right, so a bit more clear cut in terms of people's fronts this time. So a pleural effusion has got 9%, 16% of people have said lung lobe torsion, 4% have said primary lung tumour, and overwhelming 71% have said diffused lung pathology with consolidation. OK, that's a really good result actually, because when you look at this radiograph, you can see that there's a consolidated area of lung tissue affecting the right cranial and middle lobe, and you can see that there's an air bronchogram passing down through this lobe, which branches out, but it Solid around it.
So there's alveola filling and consolidation of those lung lobes. But if you look at the less well affected areas, you can see also that there's a bronchial and an interstitial pattern affecting the other lung lobes cordially to that. Mass, and when we see in the dorsoventral, we can see that it's caudal and also on the left hand side.
So you've got this consolidated area, particularly affecting the right middle lung lobe, but also affecting the right cranial lung lobe, and you've got generalised pathology around the area. Now this animal came in as an emergency, and our surgeons felt that this might be a lung lobe torsion, so they went into surgery. Just before that, we had indeed just done the ultrasound of this, and this shows you how ultrasound can be used for the thorax.
We all know that. Ultrasound doesn't like gas or air. So if you trasound a normal thorax, everything will be reflected back from the gas interface.
Here we can see the chest wall and the ribs, and then through that, we can actually identify this consolidated lung lobe here. And then beyond that, we can see a gas. Structure, and we can't see very much beyond that because of this dirty shadowing, which means that this area of tissue is quite aerated, not fully aerated because we've got areas where we can see that there's some consolidation, but certainly more air filled than the lung that's closest to the chest wall.
And as we move around, we can see other areas where there's consolidation, other areas where we can't see anything, suggesting that there's gas sparkling through the areas of consolidation. This in real time would sort of sparkle away. As I said, the surgeons felt that this was probably a lung lobe torsion, so they went in and removed the consolidated lung tissue.
And here on this slightly blurred view, you can see this very enlarged left to middle and cranial lung lobe, and then some fairly normal looking lung tissue in that it's sort of pale pink in colour, deep to that. So the lung lobe was removed, and this is what came back from the pathology, was that it was an eosinophilic granuloma. This is the most severe type of change that we see with pulmonary infiltrate with eosinophils or eosinophilic bronchoneneumopathy, as it's now called.
And usually the earsinophils infiltrate the bronchial walls of the interstitial tissue, and it's rarely that they go for the alveola causing a alveo an osinophilic pneumonia. The signs can be quite variable, but coughing is usually the primary complaint. Dyspnea, tachynia, weight loss, depression, and anorexia may also occur.
This is a more typical view, again, in a young dog, usually between 1 and 3 years of age, with acute onset of coughing, and we can see that there's a bronchial and interstitial pattern here. There's no air bron cramps, we can identify bronchi moving out towards the periphery, but only because of this thickening of the tissue around the bronchus, not because there's consolidation of the lung lobes. This is the left lateral view here, and then the dorsoventral view here, showing that in the caudal lobe, there's a little bit more, but some of that may be due to the animal lying on that side for a short time.
If you do bronchoscopy, then you usually find this yellowish green discharge that you can collect that's rich in eosinophils, and these eosinophils can be seen on the broncho alveola lavage in these cases, usually in quite large numbers, in the dogs with pulmonary infiltrate with osinophils. It responds very nicely to prednisolone, starting off with a immunosuppressive level, 1 milligramme per kilogramme twice daily, and then as the clinical signs improve and the radiograph signs resolve, then we reduce the prednisolone to the lowest effective dose. Some animals will come off treatment, others may require alternate day dosing to control the coughing long term.
And the prognosis is usually good for all cases, apart from the severe granulomatous form of the disease that we saw in this case, although in this case, the dog responded really well to having had surgery to going on to prednisolone, long term, there was complete resolution in the other lung lobes. The next case I'd like to present is a Cavalier King Charles Spaniel, a one year old female called Maggie, and Maggie was presented with a three-week history of lethargy, coughing, and increased respiratory rate. There was no response to routine antibiotics and steroid medication.
There was some weight loss, despite the fact that Maggie maintained a reasonable appetite. On clinical signs, there was an increased respiratory rate and effort, and increased breath sounds were heard over all lung fields, and she had a little bit of cyanosis of her mucous membranes. These are the radiographs of Maggie, first of all, a dorsoventral, which will be our first radiographic projection in any animal that shows marked degrees of dysnea.
We don't want to rotate an animal and put it in a position whereby, for example, fluid within the pleural cavity would move around compressing the lung lobes that are. Aerated before the collapsed lung lobes that were there before could reaerate. So do be careful with dysneic animals.
It shows that they maximise their respiratory reserve and therefore, if you take a dorsoventral view, you're less likely to do any harm, and these animals should not have adverse effects from the radiographic examination. So this is the dorsoventral view. This is the right lateral view.
And what I want to know about these radiographs is what is the predominant pulmonary pattern. So here we have the dorsal ventral view again. Here we have the right lateral projection, left lateral projection look pretty similar because this is a very diffuse change within the lungs, and this is what I want to know.
Is the predominant pulmonary pattern bronchial, interstitial, vascular, alveolar, or a mixed pattern? Mm OK, polling has ended. So what was the predominant pulmonary pattern?
3% of people have said bronchial, 33% have said inter interstitial. No one has said vascular, 34% have said alveolar, and 29% have said mixed pattern. OK, so let's look at in detail now at this.
And, and the thing about an alveolar pattern, which is the most severe infiltration or pattern that can occur within the lungs, is that you have fluffy, ill-defined coalescing opacities with air bronchograms. And what you see here, I think, is that the whole of the lung tissue has a grey appearance. There's no really good aerated areas of of lung where we can see black lung.
We can see the bronchial walls, but they're not particularly prevalent or obvious. We can see the vessels as they pass down towards the periphery. On both sides is the right caudal lobe artery, the right caudal lobe bronchus, for example, quite clearly defined there.
And if you can see the vessels, then they can't also be an alveolar pattern because those would disappear in the fluid around the vessels associated with the alveolar filling. So this is a predominantly interstitial pattern. The background opacity is not black.
It's gone to a grey colour. We know that that is true because the X-rays that don't pass through the body have produced a nice black silhouette around the body, so it's nothing to do with being under exposed. It's a question that there's no normal air pattern within these lungs.
All the interstitial tissue has been increased. Now, on the lateral view, it looks as though there's more opacity within the dorsal lung fields than the ventral lung fields, but this is only because the dorsal lung feels are thicker. The X-rays that passed dorsal to the heart have Pass through much more lung tissue, and because the lung tissue has pathological changes, it absorbs the X-rays, and that's what gives rise to this appearance that the dorsal lung lobes are more affected than the ventral lung lobes.
So this, Maggie had certainly some degree of hypoxia and the partial pressure of carbon dioxide in the arterial gas was increased, typical of interstitial lack of exchange. Red blood cell picture was quite normal. The white blood cell picture showed a slight elevation in total white cells, which was mostly due to neutrophils, the lymphocytes, plasma and sinophils were.
Normal, the monocytes were slightly raised, suggesting that this was a more chronic reaction, but really not a florid white cell reaction that you might expect if this was a bacterial bronchopneumonia, for example. The bronchoalveola lavage on this dog was quite interesting because it shows these magenta coloured trophyzoites, very, many of them throughout the whole of the bronchoalvelavage. And in other areas, we could see eosinophils, which were the predominant type of inflammatory cells, a few macrophages, and, a few, neutrophils, although there are no neutrophils on this particular, view of the cytology on this case.
So what are these trophozoites? Well, these trophozoites are diagnostic of pneumocystis carini, which is now considered to be a yeast-like fungus, although previously it was classified as a protozoan. So it's on the border between those two genera.
And this dog has some degree of immunosuppression, which allows the pneumocystis carini, which is an opportunist organism, to get a hold, and it affects the interstitial tissue within the lung, reducing gaseous exchange. And producing quite a dysneic dog, and usually of the Cavalier King Charles Spaniel or miniature dachshunds, those are the breeds that have been most commonly sighted with pneumocystis carina. And here we've got the evidence of that, the IGG levels in this dog were reduced.
However, that doesn't mean to say that it won't respond, because actually the treatment for pneumocystis Carini is to use potentiated sulfonamides, and potentiated sulfonamides will result. Solve the condition fairly rapidly. The dyspnea goes within about 3 or 4 days, and then a month later, you can see that the lungs have cleared quite considerably.
This is the same dog. We can now see much more aeration within the lungs, much less interstitial Capacity, but you can still see that there is an interstitial pattern still present here. So there is going to be permanent damage to those lungs, but hopefully the dog shouldn't show clinical signs, and this one, resolved clinically, completely, and didn't have any relapse when the, potentiated sulfonamides were stopped.
So the next case I'd like to present is a German short-haired pointer, 4 years old, female neutered, and this German short-haired pointer was presented with a 3 week history of coughing, a dry, unproductive cough with noticeable halitosis to the breath. And this is the right lateral radiograph. This is the left lateral radiograph and the dorsoventral radiograph.
I'll just give you a few moments to look at those, so the right lateral radiograph. The left lateral radiograph. The dorsoventral radiograph.
And what I want to know now is, does this dog have bronchop pneumonia? Has it got a lung tumour? Has it got an inhaled foreign body, or has it got a lobar pneumonia?
Fantastic. Oh, I've launched the poll questions, so give you 15 seconds to get your vote across. Come on, there's a few more out there that's where viewing but not voting, so come on, let's get your votes in.
OK, and I'll just finish the polling now. OK, so quite a close affair, this one, Mike. So from what is your diagnosis, 35% have said bronchopneumonia, 2% have said lung tumour, 33% have said inhaled foreign body, and 30%, 30% sorry, have said lo but pneumonia, so quite close there.
OK, yes, yes. Well, the first thing about bronchan pneumonia in our species, particularly dogs and cats, is that if you get bronchan pneumonia, it spreads throughout the lung tissue. So, it comes up the bronchi, it spreads down the other bronchi, and so it should be quite a generalised appearance.
So if you put lobar pneumonia. Which is correct in terms of the pathology in this case. You have to say, why is it just involving one lobe, and there has to be a reason why it involves one lobe.
And the reason in this case is that it has an inhaled foreign body. So lobar pneumonia is not wrong, but you have to find a reason why it has lobar pneumonia. Otherwise it would become bronchop pneumonia with all lung lobes affected.
And as we can see from this right view, it's mainly an opacity within the caudal lung field, a little bit in the ventral caudal lobe, and maybe just extending into the middle lobe. Now when we compare the right lateral with the left lateral. We can see that the right caudal lobe is the one that is most affected, and this right caudal lobe bronchus is not clearly identified.
It should be coming down here. We can see the left caudal bronchus with the artery. Lateral and the vein medially coming right the way down to around about the 10th or 11th rib space.
But here we can see it coming down, and there it seems to be blocked. We can't see any aeration going beyond that. So this is a low bar change within the right caudal lung lobe.
And that change is associated with a blockage to the bronchus, and that blockage is most likely in a youngish dog with halitosis to be inhaled foreign body, usually a whole year of wheat or barley. So looking at that closely, we can perhaps just about make out that there might be something in the bronchus, that it might have a point at this end, and then it branches out. This will be the foreign body in the right caudal lung lobe, so we know where to look, and that's what we found on this, that particular case.
This is another dog. This was a dog with a chronic cough. Soft, moist cough for about 6 to 8 weeks, not responsive to antibiotics or febendazole.
No impact though on the exercise tolerance of the dog. It would still run for miles and miles. It was worse in the morning or after lying down.
That's usually associated with stasis of the mucuscillary carpet, and then when the animal gets up, the mucus moves around, which causes irritation, then causes coughing. This dog also had mild halitosis on clinical examination, and a mild diastolic murmur was, was noted, but that was pretty non not important clinically. And it was referred to my colleague, for a CT.
And these were the radiographs, and actually, if you looked at the radiographs, the answer is on the radiographs. This radiograph could have been better because it's markedly rotated, and to prevent that, you need to put a foam wedge, which is radiolucent. Underneath the sternum to bring the sternum up to the same height as the thoracic spine.
That way you won't get this rotation of the dorsal ribs, which means that you see less of the lung tissue. But on the dorsoventral, you can see that this change is mainly affecting the left caudal lobe, and the left caudal lobe has an increased capacity. So it has, if you like, a lobar pneumonia.
There has to be a cause of that. It could be tumour, it could be a foreign body, but in this case, it was a foreign body and this just two slices of the CT. So we can see the trachea, we can see the division into the right main stem bronchus, the left main stone bronchus going into the left caudal lobe, and in the caudal lobe bronchus, we can see this ear of wheat or barley that is blocking that bronchus.
Now, knowing that there's a whole layer of wheat there is important because if you do bronchoscopy, you will only, of course, see the tip of this ear of wheat. And unless you are sure that you've removed all of the ear of wheat. Then, it is likely that the clinical signs won't resolve, because if you have a foreign body there, it will fester, with anaerobic organisms producing the halitosis and producing discharge and cough.
So we need to make sure that we don't just pick off a few seeds. Actually, if they do break up, a seed will just be coughed up on the mucustillery carpet. It's the fact that it's lodged in the bronchus with the horns, preventing it from being coughed up.
Here again, you can see the ear of wheat have gone in there, and until you've received and removed the whole of the ear of wheat, you shouldn't be satisfied that you've resolved the problem. So this is something that you see mainly in the summer months, moving on into the autumn time. As I've shown you already, some animals may have had a cough for some months before they they're presented, so don't rule it out on the fact that you didn't notice the sudden onset coughing when the animal was running through a field of wheat or barley.
OK, the next case is a golden retriever, 10 year old male called Whiskey. And whiskey had clinical signs of gastric dilation and vulvulus that was suspected by the referring veterinary surgeon, and they decompressed the stomach on two occasions in the last 36 hours, and then decided that they should refer whiskey for further investigation. And so I'm going to show you the full views of the stomach, and what you need to think about is how the gas and fluid or ingestor move around in the stomach.
So this is the dorsoventral view. This is the view that we would take normally for the thorax, but not for the abdomen. This is the ventral dorsal view which we normally take for the abdomen.
And again, the right hand side will be on the left of your screen, the left hand side will be on the right of your screen. And then this is a right lateral view. And this is a left lateral view.
And what I want to know from you, quite simply is, has this dog got dilation and torsion currently? So you have a dorsoventral view. You have a ventri dorsal view.
You have a right lateral view. And you have a left lateral view. Has this dot got gastric dilation and vulvulus?
OK, I've launched the poll questions, so if you'd like to, it is a simple yes or no, please do apologise. There is an intestinal obstruction option as well, but it, we are looking for a yes or no on this one. Let's give it a couple more seconds.
I think that's most serious, so I'll end the polling now. So we have, 56% have said yes it is, and 35% have said no. OK.
Well, The stomach is moderately full of air. The fundus of the stomach is on the left side, and the pyloris is on the right hand side. So the question then is, can we connect the two together and we can see the wall coming around, the greater curvature towards the pyloris.
So on the dorsoventral view, where the gas should be in the upper part of the fundus and also in the upper part of the pyloris, it looks as though the stomach is in the normal position. On the ventral dorsal view, then the air should go into the body of the stomach, and fluid and ingestor would go into the fundus. So here's the fundus, full of fluid and ingestor.
Here's the gas within the body of the stomach coming over towards the right hand side, and the pylori should be on the right hand side. So in the right lateral view, then fluid and ingestor should go into the pyloris, and the pyloris then should appear as a round circular mass. The gas should go into the fundus, and so we can see gas within the fundus here.
We can see the pyloris here, and we can see some gas within the body of the the stomach. But one of the things that I hope some people noticed was that this gastric wall is markedly thickened in this area around here. So the greater curvature has quite a lot of thickening to the stomach wall.
Also, for a gastric dilation and vullus, there should be congestion of the spleen, and the spleen here looks quite a normal sort of appearance. In the left lateral view, then the food and ingestor should go into the fundus of the stomach, and the gas should come over towards the pyloris. So here we have the pyloris coming over onto the right side, .
With the gas within it, fluid and ingesture remaining in the stomach. But again, look at the thickness of this wall. This is quite abnormally thick, considering the stomach is reasonably distended, and it's consistent on all the views.
So, having noticed this thickening of the stomach, we then took the dog to ultrasound, where we can identify the stomach wall. This stomach wall is several centimetres thick. It doesn't have the normal layering.
Appearance of the mucosa, the muscularis, and the serosal surface of the stomach in the usual way. It's lost that layering, and that would be worrying because that would suggest that there was infiltration of the gastric wall. So a fine needle aspirate was taken from this wall, and this fine needle aspirate showed that there was inflammatory cells, mesenchymal cell proliferation, but a neoplastic process could not be ruled out.
So, having not been able to definitively say that this was not tumour, we took the animal to a surgical biopsy to get a full thickness biopsy, and this showed that there was severe gastritis with massive necrosis of the stomach wall. And thrombi formation consistent with a clinical history of gastric dilation and torsion, with subsequent vascular damage to the stomach wall. And that area of thickening was then removed at surgery.
And the animal made a full recovery. So at the time that we took the radiographs, the important thing is that it didn't have a gastric dilation and vulvulus, and the animal therefore could be treated and for longer while we made the diagnosis and then it went for surgery, which was then resolves the problem. This is another dog, not this one, to show you that the thickening you can get with chronic gastric ulceration.
This is in a Pyrenean mountain dog. This is reasonably normal stomach mucosa, but this is a large gastric ulcer. You can see the wall of the stomach is grossly thickened and Infiltrated with fibrous tissue, and that can occur in chronic ulceration, as well, of course, as it can occur with gastric tumours.
So be careful, don't subscribe all of these animals to the fact that they have a non-resectable tumour. The next case I want to present is a 9 month old Labrador retriever. This 9 month old Labrador retriever had two days of vomiting.
It was seen by a referring veterinary surgeon who decided to give this dog some barium impregnated polystyrene spheres. Anyone who uses these bits should know that there are quite a lot of problems with the interpretation. Of these barium impregnated polystyrene spheres.
The owner, after 24 hours, couldn't afford any more radiography, and so they were referred to our RSPCA clinic where we have the ability to do some subsidised treatment and so we took the dog in and we radiographed this dog, and this is the radiograph from this dog. So this principle. Of the barium impregnated spheres is that you have a group of large spheres and a group of small spheres, and the smaller spheres should get through any narrowed area, whereas the larger spheres might get held up by a foreign body or an obstruction.
So this is 24 hours afterwards. We've got some large spheres that have gone down into the intestines, some smaller, spheres that have gone down into the intestine, and we've still got some large and small ones that may be still in the stomach. Now, that would be abnormal 24 hours after giving barium or giving food, then there should be a complete emptying of the stomach.
Now, on the left lateral view, the appearance is even less clear. We've got some larger spheres that have probably gone back into the fundus of stomach. We've got some smaller ones that have dispersed within the stomach.
We've still got some which are in small intestine. And two here which are in small intestine, because we can identify large intestine coming descending colon, transverse colon up towards the scum. So we know that these are not within the colon.
So there's some degeneration, some deterioration in the transport of these BIPs, but I'm not sure that you can make a diagnosis from their position. However, what I do want you to tell me is from those radiographs, is this normal? Is there a gastric foreign body?
Is there an intestinal foreign body? Is there a linear foreign body, or is there some gastroenteritis that is just upsetting the flow and motility of the small intestine? OK, the poll questions are live, so please do cast your vote.
I'll give you, say, 1520 seconds to for as many people to vote as possible. OK, 5 seconds for you to find your final considerations. And we're in the polling there.
Right, so what was your diagnosis? 2% have said it was normal. 23% have said it was a gastric foreign body.
21% have said it's an intestinal obstruction. 25% have said it's a linear foreign body, and 29% have suggested it is gastroenteritis. OK.
Well, gastroenteritis can upset, motility, but, but actually those those bits should actually pass through. So, I wouldn't expect them to still be in stomach unless there was some problem with gastric emptying, and that's not usual with gastroenteritis. So looking at this, we can see that the spheres are still within the stomach.
We can see some normal loops of small intestine, but as we come cordially, we can see some abnormally positioned small intestine. We know that it's small intestine, because, as I identified before, you can see large intestine coming across here transverse up towards Seum. So this would tend to suggest that this was in the jujunal area of the small intestine, and these gas-filled areas, if they're consistent.
Would suggest that there is a problem in that area, and here they look on the left as though there is a problem in this area because those loops of small intestine have an abnormal appearance to them. They're not linear as they should be, with walls with gas or fluid filled. They are very placated and curled in this particular area here.
That's true also in the ventral dorsal view. Again, we can see the secum, the ascending colon, transverse colon descending colon, but in this area, and this is small intestine, we can these curved loops of gas-filled small intestine, some of which are getting quite large, but they are fairly consistent, for all of the three views that I've shown you in this particular case. So the animal went to, to ultrasound to see why those loops should be placated.
And you can see that they are here in stomach. We can see that there is something in the stomach. And leaving the stomach, we can see a strand of foreign material.
That foreign material passes down into the duodenum. And passes down here with placation of the small intestine. So this is a linear foreign body anchored in the stomach with a ball of a string or a ball of of of cotton, and then the linear part goes down the intestine, and then with peristaltic activity, it will just march up the string, which is anchored and placate the small.
Intestine into these very convoluted areas. And this appearance is absolutely characteristic of a linear foreign body. And so surgery confirmed the presence of a linear foreign body.
There was a mass of cotton in the stomach with a a loop of cotton going down the intestine, and 40 centimetres of placated small bowel, mainly jujunum, was found at laparotomy. This isn't, this is a different dog, but this shows you the sort of placation you get with a linear foreign body. And the important thing is really to diagnose it sooner rather than later, because as the placation progresses, so you will get necrosis.
At the pinch points of these lications. And then you have an intestine that has multiple holes in the intestinal wall, which gives rise to real problems in terms of peritonitis and septicaemia, later. The final two cases, at least the final one, if we don't have enough time, as I see time is moving on, is a 6 year old Labrador retriever, male neutered called Galaxy.
And Galaxy had a history of intermittent vomiting for two weeks. This had followed a waxing and waning course, and more recently, there'd been cranial abdominal pain. And these are the radiographs of of him and what I want you to tell me, is, have a look at these and think about what is actually going on in this particular case.
So. Now, this is Jacubus's lateral view. Many of you may not be aware about this particular projection.
The animal's lying on its side. I think that hopefully all of you can see that there's a loss of serosal detail in this abdomen. This wispy appearance is not connected to the intestine or the organs surrounding it.
This is free within the abdomen. So there's evidence of free fluid within the abdomen and the intestine. Seems to be fairly diffusely spread across the abdomen.
Again, in the ventral dorsal view, we've got this serosal detail loss, and we can see that the fat has some infiltration within this little specks within the less, obvious, or the less opaque areas of the abdomen, which is associated with the fat. Now the decupidus lateral view is to look for free air. And if you lie an animal on its side, then the air will percolate up to the highest point, and that is just underneath the rib cage.
So this is the view that you want to, well, this is the area you want to centre on to see whether there's free gas. And with this . Fluid gas interface with this straight line across here and the liver falling away from this area.
We know that this is an area of free gas present within the abdomen. A little trick that can help you. But actually, ultrasound will also help you because in this particular case, we can see the mesentry is very bright because of the inflammation.
There is free fluid, but that free fluid is not a. It's very echoic, and in real time, you could see these little ecogenicities floating around with every breath. So they actually move, whereas organ ecogenicity does not move.
And so, you know, this is fluid. We can find in the duodenum, this defect within the duodenal wall that is consistent, and we were worried that this was a duodenal ulcer that had then perforated. And that's what we found at surgery.
So this dog went to surgery and had the duodenal ulcer removed. The pancreas was quite normal. It's quite, consistent and homogeneous throughout its, depth, it's a normal thickness, and you can see the pancreaticoduodenal vein, parallel to the duodenum.
So this had a ruptured duodenal ulcer. This was resected along with some normal bowel. The abdomen was flushed and there was a good recovery.
Now, under ultrasound guidance, this was the kind of fluid that we removed from this animal. And this could be examined cytologically, in which case you would find bacteria within the cells, which is classic of septic peritonitis. But one of the things that Harold Pearson, who was professor of surgery at Bristol, used to tell his Students was that if you take a 5 mil syringe and you pull out the fluid, and you turn it around so you can't see the gradations on the syringe, then that's a surgical case.
And that's something that usually comes true from my experience as well. The last case, very briefly, is a 12 year old golden retriever neutered female with acute onset of vomiting for 4 days. Vomiting was with water and food, but no blood.
There was moderate weight loss. More recently, there had been some melena, and the referring veterinary surgeon giving some of these barium impregnated polystyrene spheres. So this is the radiograph.
Just take a few moments to look at the radiograph and then I'll show you the answer. OK, you could make your diagnosis normal, gastroenteritis into susception or intestinal foreign body. If you've got time for that, then please vote quickly.
OK. Just give me 5 seconds. The vote's coming in thick and fast.
OK, we'll just leave the polling there, thank you very much. So what it's diagnosis, normal 3%, gastroenteritiss 6%. Insuction 49%, and intestinal foreign body 43%.
OK, so let's look at this radiograph. Well, first of all, we can see that all the bits seem to be in the stomach, so they've not progressed, which would suggest that there is some interference with pyloric outflow. And then if you follow the stomach down into the duodenum, then here we can see a peach stone.
There's the peach stone, enlarged for you. It's got this undulating surface. Often we can see the kernel in the centre of the peach stone, and we know that this is a high obstruction, and this requires a fairly immediate surgery, which was done in this case.
So I hope that during this afternoon, you've committed yourselves to making some of the diagnosis. Maybe you didn't get them right, but I hope that in my explanation, I've shown you some of the things that you should look for, so you can improve your radiographic interpretation in the future. Thank you very much for listening.
I'm happy to answer any questions that you might have. Thanks a lot for that, Mike. As You say, hopefully, if we answer those que ask those questions again, I'm sure everyone will be getting 100%.
Just, we've got a minute or two if you want to ask a couple of questions before we bring on our next speaker. So I'll let you, type a couple of questions and just make a couple of announcements. Hopefully you did all find that very informative and, for those of you who would like to delve a bit deeper into diagnostic imaging.
Mike is going to be doing another diagnostic expertise course. That is a series of 4 webinars, that we will be hosting at the webinar vet, starting with the first live one on the 28th of February. My colleagues Lewis and, Megan have just posted.
A link to the masterclass, which is called diagnostic imaging, so you can see the link in the chat box. And for this weekend only, there is a 15% discount off the series. The series is 97 pounds minus the 15%.
To get that 15% off, merely put VC VC 15 off. That's VC 15 off all capitals, to take advantage of that course. Also just a quick one, people have been asking about recordings.
There is a link there to tell you when all the recordings will be available and how to get your certificates. And if you click click that link, that'll give you all the information you need. So let's have a look at the questions.
We had one question, previously, Mike, around the, is there any research or any guidance, on the exposure of radiography to, animals? Obviously there's, guidance around how humans can be exposed, and is this something that is happening in the veterinary world, or is there any guidance on that? I, I, I think that, the, the guidance should always be that you use the lowest exposure factors, .
Commensurate with getting a diagnostic film and that you should only take radiographs when there's a clinical reason to do so. I think the risk of radiographs in in our species living for say 20 years perhaps is, is not that great. If you look at the evidence from humans, then the risk of you know, a chess series or even a barium series is not that great, in terms of the likelihood of cancer developing, often 20 to 30 years later, but it's a low incidence.
I think where we don't have the information at the moment is the CTs. There's a great move to Ah, CT everything so that you haven't missed anything. And the worry with that is that we are using much, much greater exposure to radiation.
And if these animals have repeat CTs, then there is certainly a real chance that there could be a tumour developing. Now, again, it's a, it's a risk analysis that needs to be performed in each case. But if you're just doing a full body CT to see what if, then that probably is not a good clinical reason for doing the CT examination.
Thank you for that. One last question from notenee, do we have licenced pot sulfs in UK now? Licenced pot so S U L P H S.
Do you know what that refers to? No, no. OK, one last one then, what probe and frequency do you use for abdominal ultrasound?
So our machine is about 8 megahertz for the . For the abdomen. It has a range from 5 to 10, and depending on the depth, it chooses the most appropriate frequency.
But I would say for abdominal ultrasound, then a modern 8 megahertz probe would be the, the ideal for getting good information. That will give you good, resolution down to about 8 centimetres, and it would have to be a very large dog that you got beyond that, or you couldn't get to that area by scanning each side. Mm OK.
Well, fantastic, thank you very much for that, very informative webinar, Mike. As I say, Mike has got an expertise series previously, but there is the new one starting on the 28th of Feb, so please do. Sign up for that for a more in-depth look over a course of 4 webinars, looking at orthopaedic, abdominal, so that might be of interest to yourself, Julie, and also 2 webinars on thoracics as well.
So thank you very much for joining us. Please do stay with us though, because we've got another excellent speaker coming up. And just give us 2 seconds while we swap over slides.
So thank you very much, Mike, and enjoy the rest of your weekend. OK, thank you and thank you everyone for listening. Cheers.
