All right. Yes, good morning, my dear colleagues from over here on the other side. Well, Ontario, Canada, it's 10 a.m.
Sunny, a little bit of, snow and cold, but, ready to go and share, this, exciting, . Information about ultrasound and some practical tips about how ultrasound can help us during the day by day cases in our hospital, in our practise. So, as I go, you are more than welcome to send a question about anything you want to ask and I would be more than happy to answer that question, as we go or you can just hold it up to the end.
So, ultrasound, a fascinating, diagnostic techniques, one of my favourite and I, I think, most of, radiologists, agree that, this is quite fascinating, diagnostic tool, and, because of multiple advantages, over radiology. In essence, ultrasonography is quite, can be done quite, rapid, fast, obviously after, good, training, we can achieve that, expertise, and it is a diagnostic tool that is non-invasive, relatively less expensive compared to, for example, CT, MRI and we can gain quite a bit of good information, still. Particularly, nice advantage is that, ultrasonography allows us to evaluate internal organs in a different manner compared to radiologist, radiology.
Can I just interrupt you for two seconds, if you could just start your PowerPoint slide because we're just seeing the individual slides at the moment. So if you just go to, on the top and it says slide show and start slide. And then we can see the, slides on the full screen, that'd be fantastic.
And then if I just go down, there's the advantages of ultrasonography, can you see that Rob? Yes I can. Yep, OK, we should be good to go then, so if you just say next each time you wanna move on the slide, then I can do that for you.
OK, sounds good. All right, so, moving on, yeah, so internal organs are better, evaluated with ultrasonography due to the interaction of the ultrasound being with the internal organs which is quite different compared to radiology and I will go on that later on. Ultrasound also allow us to evaluate some function of, physio physiologic aspects of, some of the organs, particularly, the heart through echocardiography and very important, ultrasound is and not, not ionising radiation.
So I think, as of today, as far as I can tell. My knowledge, I, I have not, read any publication, any paper, any case reports about, adverse reaction on living tissue caused by diagnostic ultrasonography. The only maybe, disadvantage might be like ultrasound, ultrasonography, is extremely operator dependent.
So, like for example in human medicine. Any abdominal case, they rather prefer most of the time to send the patient to a CT, even though if it is just, a GI problem, because of this, situation, like extremely operator dependent. But, that's how, you know, training, is gonna become a good, .
Part of the process of learning about ultrasonography as an important diagnostic tool. So training, doing it, practising, I know, general practitioner are very busy taking care of the patients and the imaging sometimes becomes a little bit of left behind or, you know, not, not enough time to, to, go over these, and, but, it's just a matter of, doing it and next. Next please.
And very important, before learning how to perform, an ultrasound in Our little patients. A sonographer must become quite familiar with the following. Inadequate, knowledge of physics of auto sonography and interaction with the organs is very important.
So you understand what you're looking at, what you're seeing, and similarly, this applies to any imaging modalities and a photo, understanding on the physics and interaction of the energy. With the tissues is very important for a good understanding and obviously or any images modalities is subject to artefacts and that we need to know those artefacts, what is causing it, how can we fix it? Is it helpful?
Because in ultrasound, we have artefacts and some of them could be helpful actually to, get a, a, a, a diagnosis, and then to, or at least to prioritise a list of differential diagnosis quite accurately. Also, you have to be become very familiar with your ultrasound machine and what is, and what is called nobiology. You have to know your, your knobs, your controls, your gain, your brightness and how to quickly adjust those factors.
So ultrasound as an imaging tool is a very dynamic process. It's not a static process. You take a picture and then that's it like an like an X-rays.
You just place the document in the on the table, you take the X-ray, and then you get a picture and that that's pretty much it as part of the process of taking the obtaining the images. Ultrasound is very dynamic. It's a very important, it requires a very important coordination between your mind and your hand.
That coordination is very important as you move the probe around the dog. What are you looking at? Keeping in mind you, the next, the next, .
Topic that I'm gonna mention knowledge about the topographic anatomy, gross anatomy, and obviously ultrasonographic anatomy. There is a topographic anatomy which is the gross anatomy in the patient and there is also an ultrasonographic anatomy like a radiographic anatomy. So we need to become very familiar with those things so that we can obtain a meaningful ultrasonographic study.
With diagnostic characteristics that is quite diagnostic and to avoid obtaining images that are completely plague of distortion of the, of the image of the images. Geometric distortion of the images, which is also quite common in the, in, in the novice, the, when you start doing ultrasonography, ultrasound images, images. Are quite plague of geometric distortion of the images.
And I have seen that since I am doing teleradiy now and I read ultrasound studies from colleagues, from practitioners, I can, I can see the the geometric distortion and the geometric distortion of the images, not only in ultrasound but also radiography is quite important and critical because it may, this may create so lesions or may obscure real lesions. So not only in radiology, when you take an X-ray and the X-ray is oblique, the dog is twisted, the dog, please just take the, go the extra mile and repeat the X-rays no matter how busy you are, no matter. How your texts are because that may be quite critical and important to obtain an accurate diagnosis and, and apply the correct therapy and medication.
And obviously, not only ultrasonographic anatomy but normal ecogenicity of the organs. So it has been established that every organ has normal ecogenicities. Directional terms, anatomic terms is very important.
What is dorsal, what is ventral, cranial, coral is very important. When you're doing ultrasound, you need to add this information to the images. Next.
Next, please. Hello. Interaction of the ultrasound with the, organs.
You can, the ultrasound beam can go transmitted through fluid. The ultrasound beam could be attenuated, sorry, a part of my, typo there, is obviously on abortion is absorption. So the ultrasound beam can be absorbed, reflected, dispersed, or refracted by any particular organ.
And, and this can happen in different ways, depending on the character the characteristic or the anatomic of the, of the organ. Next. An important take home message is about the transducer and the frequency.
High frequency transducers, you can have very good resolution, very nice, pretty images at expense of penetration. So good resolution but poor penetration. So you can use transducers by high frequency in small dogs, thin dogs.
And then you become, and then if you have a larger medium sized dog, you may go with a lower frequency transducers. You can get a poor resolution or, or, not as good as high frequency transducer, but penetration is gonna be good, so you're gonna be, you can, are gonna be able to see organs that are located deeper in the animal. Next, please.
More advantages of ultrasound, technique is that, you know, you take an X-ray and all the animal has poor abdominal detail, reduced abdominal detail. Is that, that could be because of achexia, lack of intraabdominal fat. It's a very young dog, so, or could be a mild asciis or a small amount of free fluid which is, is still possible in patients with poor abdominal detail.
Ultrasound can help us with that and completely rule out the possibility of a very mild or small amount of free fluid, in the abdomen. Obviously, internal anatomy of the organs can be characterised by ultrasound, which is very important, compared to radiology and I, I, I, I will explain that later. And it's connected to that the ultrasound can help us to characterise masses, soft tissue masses.
It's very important when we, when we start teaching radiology, we start learning radiology in the vet school. One of the, in my, in my, in my opinion, one in what I like to start teaching is the five basic radiographic opacities. Once you got stuck in your head, the 5 basic radiographic opacities, you are going to have a very nice understanding.
Or evaluation of the x-rays and interpretation of the x-rays, what you're seeing in the X-ray. The only thing is that, for example, you can have soft tissue opacities in the, in the x-ray, but the soft tissue opacity. It has the same level of grey compared to a fluid-filled structure.
So, a fluid-filled structure is gonna look about the same or the same as compared to a soft tissue mass on X-rays. This problem can be solved by performing a quick abdominal ultrasound. Ultrasound, you're gonna see that fluid is gonna look completely different compared to a soft tissue mass because the soft tissue mass is going to absorb the, and reflect the ultrasound beam, whereas the fluid fill structure is going to transmit completely the ultrasound beam, so it's gonna look different on the, in the image.
You can visualise motion and very important. Percutaneous biopsy or final aspirate can be readily easily performed on the ultrasound guidance. Next.
The scanning technique has to become very systematic. You have to come with your own technique. Once you have your own technique, systematic approach to the abdomen, you have to stick with it so you don't miss any corner of the abdomen, any organ of the abdomen to be evaluated.
Very important. Every organ should be evaluated on sagittal and transverse planes and to achieve this, you have to rotate the transducer. So the transducer don't stay static on one plane.
You have to rotate the transducer to obtain these saggital and transverse plane images. Next, This is a common setting, you know, when you are doing ultrasound, with ultrasound machine, animal holders, sedation, and GA not required most of the time unless the patient is aggressive, is kind of, a small dog. Tend to be, you know, very wiggly.
They don't wanna stay, going on their backs. So, in that case, light sedation may just work quite well, but, most of the time, not required. So you have to just, .
Look at the patient and decide if this patient, this patient requires sedation or not. Obviously, most final aspirates, aspirates, techniques require sedation. Biopsies, true-cut biopsies require general anaesthesia.
Next. So, now let's go to the topic. How we can, how really our day can get revolutionised by performing an abdominal ultrasound or an ultrasound in our patients.
Next. Again, as I said before, differentiation of radio opaque soft tissue structure. Is achieved with an ultrasound, a quick ultrasound.
You place the probe, let's say there is an abdominal, the mediastinal mass. We place the, the probe quickly in the intercourse spaces to look at that opacity and you can tell is there a fluid-filled structure, is a soft tissue mass and after that, you do a ultrasound guided final aspirate, do a cytology. And boom, you can probably solve the case right there in the spot without the necessity to do, for example, for there to advance images modality like CT or MRI unless you decide that the dog may need surgery or, or planning for radiation because the dog have a soft tissue mass, a tumour in the mediastinum, for example.
For the characterization of organomegaly, sometimes in, you know, you take an X-ray and there is, heparomegaly, there is cardiomegaly. There is enlargement of the area in the tendons or the ligaments. Well, ultrasound can help us with that because heparomegaly, we cannot tell for sure what is causing heparomegaly.
Is it the nodules? Is it diffusely . Affected like a diffuse neoplasia, hepatic lipidosis, acute hepatitis.
Ultrasound can give us some information about that. GI signs sometimes they, they can be accurately obtained a, a good diagnosis almost sometimes. Final diagnosis on ultrasound compared to X-rays.
Most, some GI signs, some dogs with GI signs, you take an X-ray and the dog looks perfect, the radiograph looks perfectly normal, you need to do an abdominal ultrasound to, to try to obtain it for the diagnosis. And again, final aspirates to a biopsies quite easily done with ultrasound. Sometimes you may need to practise with there are some models on.
Models with gelatin. You can prepare those models with some, gelatin, put some grapes in the gelatin, well, wait until the solidifies and you can just practise with your ultrasound and your needles. Next.
Any questions so far? You may have. All right.
Let's go deeper into our discussion. The abdominal cavity overall. The ultrasound again is, is, is, has been, determined that is, is, is the, it is a good diagnostic tool to, diagnose free fluid mild asciis, even though the Abdominal radiograph may look normal or lack of er detail still could be normal due to lack of intraabdominal fat.
Well, with ultrasound, we can determine very small amount of free fluids. Next. In this particular case, I remember this case, I, It was, the patient, only came to the consult to the hospital because of, ain't doing right.
So stop eating and pretty much depressed. And the radiograph, nothing much. And clinically, it was determined that the, the, the patient was febrile, but, you know, fever of unknown origin.
Nothing. Radiograph was normal. Everything was in terms of radiographically, speaking, was, was normal.
Quick abdominal ultrasound, we just, found. Little bit of prominent mesenteric lymph nodes, little bit hypoechoic, probably reactive lymphadenopathy to something that is going in the abdomen. And then for evaluation of the abdomen, we saw a focal area of a focal anechoic area.
Anechoic areas. Which are blocking ultrasound are fluid-filled structures. Now, once we saw this, anechoic area.
We have to determine whether or not it's confined into an abdominal organ and we look around and nope, it's not inside any organ, it's not inside a GI structure, not intestinal, not abdominal. This is the abdominal wall right here. It was just right, opposed against the abdominal wall, and then we determined that was just a small pocket of intraabdominal fluid.
Now, What could be causing this, that, that's the next question. OK. How can we answer that question?
What could be causing just this small amount of free fluid? Well, You know, the, we, we have a, we have a wide list of list of what could be causing this fluid. In this particular case, what we decided to do it was Let's do just a quick FNA.
Next, I think I have in the next slide. Yeah, so in this slide, I'm showing you a different case, obviously. You can tell, but it was kind of the same clinical situation.
We found a very small amount of free fluid focal an echoic area, very small, and you can see how, this hyper-echoic, very bright line is the image. Of the needle. So we sed the dog because the pocket of fluid was very small, so we cannot compromise the patient with accidentally poking any internal organs in a vently.
So in this case, sedation was required. We, little by little slowly on the ultrasound guidance, put the needle inside the dog, aspirate the fluid, and it was septic. But the rest of the abdominal organs were fairly ultrasonographically normal and the dog was treated for septic abdomen and the final diagnosis that we came up with was Translocated or translocated, yeah, translocated peritonitis.
Sometimes out of nowhere, the peritoneum gets gets seeded by bacteria, maybe bad teeth, in . periodontal disease, severe periodontal disease, just bacteremia goes into the peritoneum causing these translocated peritonitis. Quite uncommon in, in, in small animals, very common in farm animals, but, be aware of that you can have this situation as well.
Next. Free gas, as was mentioned in the previous lecture, can be also, quite easily, sometimes challenging, but, can be also determined with ultrasound. My apologies, I don't have any cases with free gas, but, it's also possible.
Organomegaly, OK? In this case, we have a lateral radiograph of a dog. You can see that the, in the cranial abdomen, the hepatic silhouette extends beyond the causal arch and it has quite rounded margins, a little bit.
The pylorosis right here and it's being slightly displaced dorsally. So obviously there is heparomegaly, but What can be causing this heparomegaly? How to determine on, on X-rays.
If you perform an abdominal ultrasound, you can probably determine if the, whether or not the hepaarchemia has increased the cogenicity or decreased the cogenicity. And as any diagnostic tool, ultrasound has also limitations and then, but But is, it's a help. It's a, it's a little, it's a quite a good help.
when come to that you have questions on X-rays, those questions can be answered with ultrasound followed by FNA final aspirates and then cytology and get the final answer. Increase the cogenicity the liver of the liver, the liver is gonna look brighter than normal. And the list of differentials, common list of differential diagnosis is hepatic lipidosis.
It could be fibrosis or cirrhosis, but guess what? The liver is enlarged. So fibrosis, cirrhosis is gonna be much, much less likely.
So we stick with lipidosis or could be a steroid hepatopathy, still could be lymphoma. Or muscle tumour, or the lymphoma most likely causes decrease the cogenicity of the liver. So we play with all those situations, OK, those as ultrasonographic findings and then we go away, but hepatic lipidosis causes liver enlargement, increase the cogenicity, could be lymphoma, but less likely because why?
Because It is the lymphoma is more likely to, to have to cause a hypoechoic liver diffusely, therefore, it's less likely. And then we, OK, are there any evidence, is there any evidence of lymphadenopathy in the abdomen? No, there is not.
Therefore, lymphoma much, much less likely. And then we analyse the whole case after we are done with the abdominal ultrasound and obviously, more, medi physical findings, his history, etc. Is gonna play a role to get the final diagnosis, but You can see that ultrasound readily can help us quite a bit to try to solve the situation.
And the next step is FNA and FNA, go to cytology, is gonna help us in most cases. Next. Here we have quite a few images on this right here, there is a, a liver image of the liver with increased ecogenicity.
This is the gallbladder. Over the right hand side, we have a liver with decreased ecogenicity, hypocoid diffusely, maybe a little bit heterogeneous. This one is diffusely homogeneously hyperchoic.
Over the bottom, we have two, We have over here, that's, this is the area of the spleen. This is the the cranial pole of the left kidney. Over here, we have, this is a splitted, a splitted screen.
Over here we have the liver which looks less brighter compared to the kidney. So you can compare the ecogenicities of the renal cortex, the liver, and the spleen. And the, you can see that there normally the the spleen should be brighter than the renal cortex.
The renal cortex should be less or sorry, about the same ecogenicity compared to the liver. So here you can see that the liver has decreased ecogenicity. And in this particular case, over the right, bottom side, you can have liver, you can see the liver compared to the, to the spleen, and you can see that they are, they have about the same ecogenicity, similar brightness indicating that the liver has increased ecogenicity.
And you can also compare it to the falciform fat, which is, this is the abdominal wall. Immediately below the abdominal wall, you're gonna find or on top of the abdominal wall, you're gonna find the falciform fat and the liver should be about the same ecogenicity compared to the falciform fat. Next, and here you can see, this is a sagittal plane, image of the liver.
Increase the cogenicity of the liver compared to the falsiform fat. So, therefore we determined that yes, there is increased ecogenicity of the liver. Same case, liver versus spleen, same ecogenicity so therefore, the liver has increased ecogenicity.
Next. Focal lesions easily to see on, on ultrasound, nodules, masses, etc. Abscesses, hematomas next.
Here we have a focal lesion in the liver, but guess what? You have, you can see that the lesion has an anechoic centre indicating that it is a fluid-filled cavity and, but the flufi cavity is also echogenic inside. It's like a composite fluid.
So we say that this patient the or the differential diagnosis in this case would be either a liver abscess or could be a hematoma, but the dog is febrile, depressed, so an abscess is quite likely. You can see like a thick capsule or a thick wall as well. So mostly like a, like an abscess.
Over the right hand side, you can see a hypoechoic nodule. Differentials are wide. You can sort of the benign nodular hyperplasia, nodular regeneration.
And if the dog is an old dog, just came for a routine recheck or old dog recheck, incidental, probably, you can still try an FNA or recheck in 4 to 6 weeks to follow up on any changes. Next. Wide variety of, nodular lesions.
Again, multi, multicystic lesions, multicystic lesions in cats is quite frequent in all cats and, is, is commonly associated with, what is the so-called benign cyst adenomas, benign. Tumours from biliary tissue and most of most patients, it is benign in most cases, but, be aware that it might transform into a cysto adenocarcinoma, but it's very, very uncommon. Next.
Gallbladder, obviously quite easily to identify. Ecogenic sediment inside the gallbladder, quite common in dogs, incidental. Next.
Abnormal biliary content is the so-called the Kiwi appearance of the biliary content frequently associated with the Oh, I have a mental break here. The gallbladder mucocele, OK? The mucocele, very, very bad inflammatory process of the gallbladder, and the surgery is required in most, in most patients.
Next, particularly next, when you have, this is a dog with, this is the gallbladder, quite a bit of muco still, not as pretty as the last case, but it looks like a star, . Star-like or kiwi fruit appearance. There is some free fluid.
You can see this anechoic area here indicating rupture of a mucocele which is is an, is an emergency and the dog needs to go to surgery right away. Next. Calculi, biliary calculi incidental in most, dogs as long as they are confined to the gallbladder.
But when they travel to the common bile duct, then, it warrants, surgery. But you can see that, stones, calculi, they look very, very bright, on ultrasound and they cast a black . Pathway which is called the shadowing artefact caused by a very solid calcified structure.
Bones, bony foreign bodies, any any foreign body that is very solid, calculi in the abdomen. Next. For the pancreas, it also quite easily identified on ultrasound.
Next. We can, this is the normal pancreas on transverse view in a dog. This is the duodenum, the pancreas next to the duodenum, and then several images next.
Here we have several images showing you an enlarged pancreas, hypoechoic pancreas, heterogeneous pancreas compared to the normal pancreas right here. And if you have a case with an acute pancreatitis, severely enlarged pancreas, and you are evaluating the area of the pancreas on the right cranial abdomen, you are gonna, you're not gonna miss it. some cases, it also depend on the, the body conformation.
The dogs, some dogs are easier, is, Compared to other breeds, to get a nice image of the pancreas, but there are tricks, you can do, intercostal ultrasound, put place the probe in the licensecostal spaces to access that right cranial. Quadrant of the abdomen and case in the rib case, you can access that intercostal. That's why, you know, practise technique, attending, wet labs with ultrasound, how to do these techniques, tricks and tips are, are very helpful.
Next, and those tricks and tips we learn in our residency. That's why we, we spent 3 or 4 years in our residency doing this every day, every day, ultrasound and then it becomes like a nature, muscle memory to, to, to do all those tricks. This is another, case.
No more pancreas over here. And then transverse duodenum and then a hypoechoic pancreas very regular in shape. Hyperechoic fat saponification or steatitis of the fat because of leakage of the pancreatic enzymes is classic for pancreatitis.
Next. Cystic lesions of the pancreas, you can have pancreatic necrosis, pseudocyst or abscesses. Again, an anechoic structure easily defined with ultrasound.
Next. Spleen, one of the organs that is quite easily to find, quite easy to find, on ultrasound. You can see that, very homogeneous parenchyma, brighter than the, kidney, which is normal.
Next. This is, A list of differential diagnosis depending on the changes in the ecogenicity of the spleen. Diffusely can be increased and this is the list of differential.
Diffusely can be decreased and this is the list of differential and then still the, the, the spleen, still the spleen can be normal, fairly normal, but associated with some abnormalities. But if it is normal, the spleen, if it is normal in ecogenicity. But with abnormal infiltration, the spleen should be enlarged.
Next. Police He is a I'm sorry, a spleen diffusely enlarged and diffusely hypoechoic. Next, And here we have a spleen diffusely enlarged but now with tiny coalescence nodules, quite classic ultrasonographic pattern for splenic lymphoma.
Next. And other, other images, with a splenic mass here, splenic, splenic mass with a cystic structure, in this case, FNA, should be performed to try to obtain the final diagnosis. Next.
Hemaosarcoma is, you know, is one of the most common, major concerns in, in, in, in, in patients. OK? So hemaosarcoma, sometimes different, difficult to differentiate from hematoma, but typically you can have, you know, hemoabdomen from ruptured hemangiosarcoma.
Metastatic lesions are, are quite well characterised by the so-called target lesions. The target lesions are those nodules that have a hyperechoic centre and hypoechoic halo. Those are the target lesions, those are the nodular lesions that have been found.
With a quite high positive predictive value for malignancy, either either metastatic or primary. Next. different masses here, FNA is required to obtain the final diagnosis.
Differential diagnosis in this particular case, for example, could be a granuloma, fibrosarcoma, any, any sarcoma, less likely hemangiosarcoma because it's not cystic. Next. For the urinary system, you can evaluate the kidneys, the ureters, and the urinary, obviously the urinary bladder.
Next. Kidney, left kidney, quite easy to find an ultrasound. Right kidney is more challenging because it's, in, in that right cranial quadrant of the abdomen inside the rib cage.
Next. This is a series of images normal anatomic, normal autosographic anatomy of the kidney, and it varies as you, as you move saggital, surgically. These, these are sagittal images as you.
You move side to side, obviously the anatomy is gonna, is gonna change. Here you have the, this is the hyloss of the kidney, fat in this, in the, in the pelvis, in the area of the pelvis of the kidney. Over here, we have the pelvic diverticuli, renal cortex, renal medulla right here.
You can see the difference in ecogenicity between the renal cortex and the renal medulla. This is transverse, transverse plane of the kidneys at the level of the pelvis, the illus of the, of the kidney. Next.
Normal kidney evaluation of the kidney, you have to, as in every imaging modalities, you have to evaluate the organ in terms of size, shape, position, in this case, ecogenicity instead of radioacity to get a meaningful orographic evaluation next. Kidney can be enlarged again, but what is causing the enlargement, ultrasonography can help us to determine that. Is that a, is that a focal anechoic structure?
Yes. Then it could be a cyst or an abscess or a perirenal cyst. Next.
It is diffusely affected, the parenchyma of the kidney, then the kidney could be hypoechoic, and we have a list of differential diagnosis here. Could be hyperchoic, and then we have a list of differentials and hyperchoic kidney still could be normal, particularly in geriatric patients. So, in most instances, we need to do blood work.
We need to do, BUN creatinine, and SDMA, which is the newer, fairly newer, tech, of, technique, part of the blood work to determine, renal failure. Next. Kidney ecogenicity can be, can change.
In this case, we have a hyperchoic cortex, hyperchoic cortex compared to the liver, hypercoid cortex, hyperchoid cortex. Next, hypercoid cortex with A perirenal fluid, like in this case, like in this case, is abnormal. So mild perirenal fluid has been associated with acute renal failure, inflammatory, or lymphoma.
In this case, is hyperchoic cortex with a probably a pseudocyst, very large pseudocyst or could be haemorrhage if there is a trauma involved in the in the patient. Next. composite renal masses, quite classic for renal carcinoma.
In this case, we have different images of, kidneys with, pretty much not much normal anatomy, no, no normal sonographic anatomy that can be seen, but just a very, large heterogeneous ecogenic mass. Next. Look at this case.
We have a lateral radiograph with a mass effect in the retroperitoneal space in the mid dorsal abdomen. A pro is obviously the area of the where the kidneys are located. Probably the left kidney, this could be the right kidney, maybe.
And then we need to do, we need to do an abdominal ultrasound to see if this is a mass, could be chronic or acute or pyelonephritis, hydronephrosis, multi polycystic disease, etc. Ultrasound revealed a very large excuse me, heteroechoic mass associated with this kidney. Next.
Pelvis and ureters also can be easily evaluated with ultrasound next. Normally, we don't see the renal pelvis and the renal pelvis, when they start, when the renal pelvis starts to get dilated. We start seeing a very nice triangular shape anechoic structure in the hilus of the kidney is when we noticed that the renal pelvis is dilated.
In this case, we have a transverse plane image of the kidney with the little tiny anechoic area there. We can also see it, we also see it in the sagittal view. Sometimes incidental, in some dogs, particularly if they are receiving fluid therapy, IV fluids, the renal pelvis gets a little bit dilated.
In this particular case right here, or severe dilation of the renal pelvis and renal and renal diverticula, confirming hydronephrosis. And also here you can follow the ureter. Ureter is also distended.
In this particular case, severe hydronephrosis and the and the atrophy of the renal cortex, so likely to be an obstructive, hydronephrosis. On the, on this X-ray is a VD is we just see a huge kidney. How can we tell if that is a tumour versus severe hydronephrosis versus a cyst or other with ultrasound?
Just, just perform an ultrasound. You can get, you can get a quick answer to the owner right away if you do an abdominal ultrasound right away. Next.
In this case, we have distended pelvis. You can do a very nice and thorough follow up on the, on the ureter and then this is what we found. You, we follow the ureter.
It's a little bit distended, but we follow it, we follow it and then boom. It disappeared and we found a tiny hypeechoic, focal hypeechoic structure with shadowing artefact and the diagnosis is a very small tiny calculus lodged in the, in the ureter, but it's not causing complete obstruction at this point. It's partial there is partial obstruction.
Some cases, particularly in cats, they, these cases get resolved with aggressive fluid therapy, and the follow up and then follow up with ultrasound, and these, these tiny, sometimes this, this is just sand accumulation in the ureters and we can rinse that out with the fluid therapy and get that solved. Next. This is a similar case with a tiny renal calculi as well as a tiny calculus in the ureter.
Next. All right, urinary bladder, also an organ very easily to find. Get next.
And we can talk with hematuria, and right now I have, I am doing the the radiology, and the clinical question that I get from the colleagues, this dog has hematuria. Do you see a tumour in the bladder in the x-rays? They send the X-rays.
Well, No, we cannot see tumours inside the urinary bladder in X-rays because the, because simply, simply because there is no contrast between the urine and the mass because they have the same radio opacity. So we need to do a double contrascystogram which is nicely, can, can, can show us the mass. But if you have an ultrasound in your hospital in-house, you can just quickly put the probe and then voila, you see the anechoic urine and then bloom, the mass inside the urinary bladder.
Next. Now, if you're, this is another case. Now, if your machine is equipped with colour flow Doppler, that is a winning, that is a that is a, a winning point, that is a very nice thing to have because Again, anechoic, I mean hypoechoic structures still can be soft tissue masses but still also can be, for example, a blood clot, a recent blood clot.
In this particular case, a patient with hematuria. Look at this image here. It's not colour but .
You can see that there is severe thickening in the wall, quite a bit like muscle-like type lesion, and the colour flow Doppler shows colour signal inside that structure indicating that it's alive, it's receiving vascularization, it's vascularized, therefore, it is likely to be a soft tissue mass. And once you determine that there is a mass in the inside the urinary bladder, you can do a traumatic ultrasound guide, ultrasound guided traumatic catheterization to get sampling of that mass. In this image right here, you can see this structure which has two hyperchoic lines.
This is a urinary catheter inside the urinary bladder. Once it's there, you can massage the or, or move the catheter around back and forth trying to hit the mass to get a sam some sample samples of that mass and then put it in the centre for cytology. It has been, it has been reported that if you, if you do a percutaneous FNA of those masses, you can see the cancer cells as the needle goes out and then you're gonna spread the cancer in outside the urinary bladder.
So, for bladder masses, ultrasound-guided traumatic catheterization is the way to go to get some samples and submitted for diagnosis. Next. Hi, Rob, just to check, we've got about 5 minutes left.
OK, just that, cheers. All right, thank you. Next.
And, speaking of colour flow Doppler, can help us to diagnose ectopic ureter in some cases. You can, in this particular case, is a dog suspected with ectopic ureters, but nicely, the colour flow doppler right here is showing us the, the jet, the urethral jet as the urine. joins the the area of the trigon and then put the, is put in the urine in the urinary bladder.
This is the urethral jet on the right side and this is the urethral jet on the other side. Next case. Next, in this, sorry, the previous?
In this particular case, you can see that there is a distended structure by the neck of the urinary bladder. And which is probably one of the ureters that is passing by the bladder is ectopic. And you can see the other ureter showing you a jet, urethral jet, detected by colour flow Doppler.
Just let me know when I should stop, please. Next, The urethra can be also evaluated, particularly in males, but you have to angle the ultrasound probe in a certain way that you are aiming for the urethra and you can see urethral masses, in the urethra. Next.
Calculi are very easy to see on ultrasound, right? You can see the hyperchoic structure inside the urinary bladder casting a clean shadowing artefact. Next.
Adrenals, adrenals might be quite challenging, and it requires, quite a bit of, a good manoeuvre, a, a particular manoeuvre compared to other organs because of its location, really close to midline in the, in the, in the abdomen, and they are not completely. Parallel to the long axis of the of the spine or the dog. They are a little bit off like in a, in a oblique way.
So it requires a little bit of a tricky, tricky manoeuvre to get a nice visualisation of the adrenals. Next. Sorry, Rob, as there's so much fantastic information there, and I think we could probably go on for another half hour at least.
But if I ask you just to sort of summarise some of the key points, because I know that you've kindly also provided, notes to go with the presentation and saw some multiple choice questions at the attend. These can obviously access afterwards as well as, as we wait for a few questions, can, can we go to the very last slides because I wanna, I wanted to focus also on fine needle aspirate. File aspirate is aspirate, is, is quite a bit of a fantastic, .
Technique that you can easily perform under ultrasound guidance there. Go back a little. Go back well, let's, let's focus in next.
Let's focus on this one here. So we tend to think on ultrasound, oh no, it's just, you know, abdominal organs and then a little bit of thinking on, thorax, mediastinal, but It, it may work also for bony musculoskeletal bony lesions, particularly if they are associated with osteolysis, rupture of the cortex of the, of the bones. So once the, once the cortex of the bone is ruptured, you can gain access to the area.
Of inside the medullary cavity where particularly in primary bone tumours, in primary bone tumours, you are gonna have what is called the intramedullary neoplastic matrix which is reach of cancer cells. So if there is cortical lysis and you can determine that with ultrasound in this particular case, Left, top left, you have ultrasound of normal bone. You can see that the cortex right here is, is a hypoechoic line, and you can see it very well.
And then, let's go down, left, left, button here. You can, this is a, this is this case over here. You can see the disruption of the cortex and you can Easily direct the needle through the cortex.
You're gonna feel the crunchiness of the lytic lesion and then get an FNA of that and submit it for cytology, and to try to get a final answer, final diagnosis as to, you know, is that a neoplastic process versus osteomyelitis versus fungal osteomyelitis and it, it also works quite well. I can hopefully entertain a few questions or you can also provide my, my email and I can I can be very quite gladly to answer any questions sent to me after the fact, I mean after the presentation. Fantastic.
Yeah, then that'd be great, thank you, Rob. So as I say, we've got time for one quick question. Rob, if you'd like to share your .
Email address with the attendees if you're happy for them to post any questions. I think it is also probably on your notes as well for your, for the presentation, but if you could just let them know what your email address is, that'd be great. And if someone's got a quick question, I'll happily field you that question as well.
OK, you here in the, in the chat, the Zoom webinar chat. Yeah, if you want to type your email address into there. Has anyone got a quick question for Rob on that, very thorough, presentation, as I say, all the notes are there for you as well, so you can go and access them afterwards.
You have been sent the links, but as I say, we will be sending those links again. So I'll just give you a minute to see if you've got any questions before then we move I thank, Robert for his time, and then we'll, start with our next presenter which is Ed Hall. So has anyone got any questions?
A couple of things. What's this coming in here, potentiated sulfan, oh, OK, that was from the previous one, I think, was it? Yeah, that was from the previous presentation.
So I don't think we have got anyone posting any questions. So once again, thank you very much for your time, Doctor. Cruise.
It was really interesting and as I say, your, all your notes are available online, so please do access them after the webinar and enjoy the rest of your day. Thank you. Thank you.
You too. Thank you so much for attending and thanks for inviting me. I'm very excited and see you next time.
Thank you. See you.