Good afternoon everyone. My name is Charlotte and thank you for joining us for today's lunchtime webinar, which is part of the FOVU ultrasound part 3 series. Today's webinar is session 2, the FOVU guide to the Complete Abdominal ultrasound examination, presented by Doctor Camilla Edwards.
Camilla graduated from vet school in Copenhagen, Denmark in 2006. She moved back to the UK and worked for a few years in mixed practise and small animal first opinion practise before spending eight years in emergency work, where she gained her certificate in advanced veterinary practise. In 2018, she set up her business, First Opinion veterinary ultrasound, otherwise known as FOBU.
Camilla offers a thepatic ultrasonography service as well as teaching ultrasound online and in person through the FOVU website and for various ultrasound machine companies. Therefore, lots to learn from Camilla in today's session. I wish to let you all know that today's session will be recorded and available on playback.
You will all receive a certificate for today's attendance also. Please use the Q&A box for any questions you may have for Doctor Camilla throughout the presentation, and at the end of today's session, we will see if we can answer any of these questions you may have. If we run out of time, the question's submitted, we will email out any responses to you in the next few days.
So with no further ado, I'd now like to hand over to Camilla just to start today's session. Thank you, Camilla. Thanks very much, Charlotte.
So, today, we're going to talk about the Fou guide to the complete abdominal ultrasound examination. And, yeah, we, we want to break it down, so that we repeat the same ultrasound exam each time we do it. So, thanks to Charlotte for introducing me, but I just wanted to introduce Fou as well.
So, first opinion veterinary ultrasound, was my business that I started in 2018. I offered peripatetic ultrasonography, so travelling to practises within 50 miles of Cambridge. There's now a waiting list for that service.
If you're interested, do get in touch with me. I also do ultrasound machine reviews, which can be found on the website. We, also, do webinars, on ultrasound for ultrasound companies.
And since 2020, I've been offering my own online courses, and so far, I've had over 200 students through the basics and the trickier bits courses. In 2021, I added in practise courses so where I come out to practise and teach you on your own machine. And in 2023, we're launching the Fou Club, which is going to be a membership, mentoring you through, your ultrasound learning journey.
And if you have signed up to hear from, Fou when you signed up to this, you should be getting emails, detailing that, and you'll get an early access, to that, membership, too. So, one of the things I get asked a lot is, which ultrasound machine should I get, for my practise. And some of you who watched the webinar last week, got in contact as well.
And if I haven't got back to you yet, I will. It, I just got a lot of emails, last week following the webinar, which is great, and I will get back to you in time. But if you want to have a look at my reviews, you can go to FOVU.co.uk/machine-reviews.
And this is, a selection of some of the companies that I have worked with, either they're providing courses or webinars, with or reviewing their machines. So let's get started on the theme of today. So the complete abdominal ultrasound.
So today I'm going to look at what current standards are there out there for doing a, a complete abdominal ultrasound examination. How do we prepare our patient for it and our machine? What do we need to get set up?
And then I'll talk about how to approach each individual organ. Obviously, we can't go through in, in great detail in an hour, but I will give you the principles of what you need to do with each organ. And then we'll talk about how to approach the whole abdomen.
And how you can build these skills. So, we can't go from 0 to understanding how to do an advanced abdominal ultrasound examination. So we do need to.
We do need to look at how we can break that down and get good at the basics and then build upon that. So the current standards out there, actually, just this last week, the ACVR, so the American College for Veterinary Radiology and the ECVDI, so the European College of Veterinary Diagnostic Imaging, came out with a consensus statement for the standardisation of the abdominal ultrasound examination. So this is a really useful paper to read if you're interested in the complete abdominal ultrasound scan.
That, that's one of the first sort of, peer-reviewed standards out there. So, really good paper to, to try and get hold of. The International Veterinary Ultrasound Society, also has, their own standards.
You can see that within their membership. Also, the British Medical Ultrasound, Society, who, do a human, ultrasound scanning. They deal with sonographers, human sonographers.
They are, producing a veterinary ultrasound guideline, which is on the way. But we need to think about how these standards apply in GP practise, because ultrasound is a small part of the GP's skill set. I think it's a very important part of the GP, skill set.
But, when you're a GP vet, as I am, you're dealing with lots of other skills and, and, and things that you're dealing with, with the patients as well. So sometimes we need to think about, is this a point of care ultrasound? So we have a specific question that needs a specific answer.
And that's, what I see a lot of happening in GP practise. So we want to know, for example, we've got hematuria, and we just scan the bladder and the kidneys, trying to get the answer, is there, are there uroliths, just having a very specific question and, scanning for that purpose. And That that that can be absolutely fine.
There are some cons and and there are also some huge benefits to doing a complete abdominal examination. So those benefits are that you get your eye tuned into what's normal. So, if you have this, case, for example, that has, you want to rule out or in Euroliths, but you look at the liver and the spleen, etc.
Etc. Which are normal, that tunes you into when you have got a liver case and you want to look at the liver. You're gonna spot any pathology much more easily.
It also means that if you're scanning the whole abdomen, you won't miss any pathology. So, it may have a uroli, but what if it's also got, a, a large mass on the spleen, for example? You don't want to miss out on, on any pathology which might change the treatment plan and how you are dealing with your patient.
And the more you do, the quicker you become, because often time is a constraint in practise, and that might be the reason you can't fit in a complete abdominal examination. When I first started doing complete abdominal examinations, they probably taken me an hour or just over an hour, if there's lots of pathology, and I was, I mean, and worrying about how important it was. But now, in a normal animal, I can do a complete abdominal ultrasound examination in 2025 minutes.
So it, it, it really does become quicker, and you, your eyes become more in tuned with it. So, although you're spending more time now, in the future, you're, you're really gaining lots of information and you're able to do this process much quicker. So, for me, the important aspects to a complete abdominal ultrasound examination are that it's repeatable.
And memorable, so you don't forget bits of it. So you can do the same pattern every time on every animal, and then it flows nicely so that your ultrasound probe just moves along the animal, and you don't need to remove the probe and stick it back on. The patients prefer this, but you can just move from one organ to the next, in a, in a, in a flowing pattern.
It's also, good to have a, a more basic level where you can attach some more advanced skills when you get up to those sort of levels. And it's really important that you feel like you have completed the examination and that you haven't missed any elements. And that nagging feeling of, of that someone else might have seen something that you missed.
You really want to see, feel that when you've looked at an organ, you've looked at the complete organ. When you've looked at the abdomen, you've looked at that complete abdomen. So let's talk about patient preparation.
So, ideally, you want them to be fasted for 12 to 24 hours. An empty gastrointestinal tract is really useful. Gas in the intestinal tract, which you get when there, there's food there too, really blocks, your view of opposing walls, and, and can make things really tricky to, to see.
Water can, however, be useful. So if you can fast your animal and then give them a nice big drink before, before scanning, that can be really, really useful as that the water fills the stomach and really makes the wall much, much more visible. Sedation is something I get asked a lot about.
Sedation is a really useful thing. We, it can avoid panting, which in turn causes aerophagia. So air in the guts is bad for ultrasound.
It avoids tense m. Sometimes animals can be so tense, you can't really feel where their ribs end and their abdomen begins. And so when they're, they're more relaxed, that can be really, really useful.
And you can get around behind the ribs much more easily. Also, they may be in pain from their conditions, so it's, it, it can be necessary so that they are comfortable doing the ultrasound scan. However, we scan for a myriad of different reasons.
So we don't want to, prescribe a sedation for an abdominal scan. It really depends on what, what is wrong with the patient, and, you know, their age, what other issues that they have going on. So we really need to tailor that to, their condition.
Clipping, we need to do that. To get the, the contact between the probe and the skin, we really need to do clip that first. So it's discussing with the owners what we want to do with that.
There'll be a difference, depending on whether you scan in dorsal recumbency or lateral recumbency. I prefer to scan in lateral recumbency. We also can apply alcohol to remove grease from the skin.
That is by far not always necessary. But in your older, greasier, Labrador types, often that's quite useful to, remove that grease. So that when we apply the gel, it absorbs into the skin and we get much better contact.
If we apply the gel onto greasy skin, it can often just slide off and be, and be really difficult to, to get that contact. So when we look at machines set up, obviously last week, we looked at optimising our image, but before we even get to that, we first need to switch the machine on. So we've got the on button highlighted at the top of this image.
And then we need to, to think. About our our probe that we're going to choose. So most small animal practises will have a microconvex probe.
So this is a probe with a small footprint, and the footprint is the part of the probe that is touching the animal. It has a small curve on it. And a linear probe, you may also have, and that can be appropriate for use in abdominal scanning as well, if you've got a skinny cats, for example, they can be brilliant.
And they have a a rectangular flat footprint, quite long, much longer than a phased array, which has a very small rectangular footprint and is basically used for, for, for, cardiac scanning. So choosing your probe, for the, appropriate, case that you've got. You need to add your patient details.
So that's the second button highlighted here. It's actually got a picture of two humans on it, on this machine. It may say patient on your machine, but there'll be a button somewhere where you can input, sometimes it's ID.
You can input, for example, the owner's surname, the animal's first name, age, neutral status, etc. Some machines will allow you to write more, others less, but just make sure that you've got, enough, details in there that you can identify by this patient. Then often we'll have a preset button, so the next button below here has got a picture of a probe on it and that's our preset button.
Again, that may be labelled differently on your machine. Often it will be labelled as preset, or it will be, have a picture of a probe or say probe on it. And this is really something that that somebody, usually the ultrasound machine company has installed, maybe you've had someone in your practise who liked fiddling with the ultrasound machines and they've made their own presets.
And basically, it's a starting point. We can adjust things so that, like we did, in the, in the last lecture, we looked at how to optimise our image, and we can do that absolutely, once we've selected a preset. Don't worry about the species.
So, for example, if there's no cat abdomens, but you've got a small dog option, choose that. Don't worry too much about the species. Just think about the size of the animal, really, how deep you're gonna be wanting to, to scan, and then, and then choose what seems most appropriate from that.
So what do we do with each individual organ? So we want to assess the individual organs in two planes, much like we do with X-ray. And we want to get a sagittal and a transverse view of each organ, essentially.
We want to optimise the image at all stages, so whether we're in Sagittal, whether we're in Traverse, whether we're following the organ, we want to optimise that image at all stages, using the 5 buttons I discussed last week. Then we want to scan all the way through to the edges of the organ, and even beyond, really, so we want to see all the way around the organ. .
And we want to scan all parts of the organ. So if we can't get all of the organ in one view, when we're fanning all the way through it, we're doing one sweep of the organ, then we want to take that in chunks and and scan different parts. We ideally want the probe pointing cranially so that the, left of the screen shows the, cranial part of the animal.
So on your probe, you'll find a little notch, and that should be pointing towards the head at all times. And that will mean that on your screen, the left hand side of the screen will be pointing cranially. If you're getting a transverse view, ideally, you want that notch to be pointing towards the right hand side of the body, so that on the screen, the left side is showing the right hand side of the body.
And we need to remember to freeze and annotate and measure, and then save those images and sine loops. Sin loops are especially useful if you want someone else to view the images afterwards. Images in ultrasound are really difficult once they're static.
We need some information about what organs are around it. And you can get much better feel for what's going on with the tiny loop. So here, I'm gonna just go through, show you how to scan the liver, because that's quite a, a standard, organ to, to view.
And, I can show you how we approach that. It's a large organ as well, so we need to take a, take it in chunks, to scan through it. Hi, I'm Doctor Camilla Edwards and I'm going to show you how to scan the liver of a dog.
So we place the probe behind the zippy sternum, and we get the liver here on the screen. So I'm just gonna adjust. I need a bit more depth so I can see the diaphragm at the bottom.
I need to Just my frequency, slightly lower than it is currently, so I can get a better, better image at the bottom of the screen. Again, I'm gonna put up slightly, but I just have to be aware that that might be poorer quality because the . The gel hasn't absorbed yet, and then I'll move my focal zone down to the.
Lower part of the liver that I can see on the screen and the time gain compensation I leave as it is, so that we've got a uniform image right the way through. So the first thing I want to do is get a sagittal view. Of the liver And I want to get the cranial part delivering.
So what I do is I move the tail of the probe cordially. So then we can see the diaphragm as it goes up there. We're also getting a nice mirror image artefact, and we're seeing some of the falciform fat in there as well.
Once we've got this cranial part of the liver, we keep that angle on our probe and we fan all the way down. Until the liver disappears and all the way up through that cranial part of the liver until the liver disappears. Now the mistakes I see people do here is not pulling the tail of the probe far enough back so that you're getting the cranial part of the liver and not fanning far enough through until the liver disappears, so we need to do that in both directions.
Once we've got the cranial part of the liver in sagittal, we want to get the caudal part in sagit. So to do that, we move the tail of the probe towards ourselves. We get the stomach in the image as well there.
And then we can fan all the way up. This is a great spot to look for, pointed part of the, liver to see that it's not enlarged. And then we can continue fanning until the liver disappears.
We found all the way down to the right hand side until the liver disappears again. So now we've seen the whole liver in the sagittal view, both the cranial part and the caudal part. Now we need to see in a different view, we get the transverse part.
So what we do is we rotate the probe 90 degrees and we normally have the probe pointing right to left. This is so that it's similar to in X-ray, we get the right of the body on the left of the screen. So I just need to adjust again because in this plane, we can see the, the horizontal diaphragm, but I just need to move my focal zone up a little bit there.
So we've got the liver contained there cranially. You can see the gallbladder. And then I found all the way cranially.
All the way cordially till the liver disappears and then I'm sure I've seen the whole of the liver. Great. So that was, my dog Pippi, who was assisting me there, to look at the whole liver.
What I'd just say is that, I was holding the probe quite distant, so that you guys could see what was going on with the probe head and where it was moving. I would usually have much closer contact. So, my hands right on the, the end of the probe, and having that contact with the animal with that hand, so I can really feel where I am.
So let's talk about the basic abdominal ultrasound examination. We're gonna start on the left-hand side, so with the dog in right lateral recumbency. And again, Pippi is helping out here.
So we start with the liver. It's a great organ to start with because, it's deep, so we can get all our settings adjusted. We can get our time gain compensation adjusted if it's not optimal for the whole way through.
And, we can get our overall gain, adjusted as well. So it's important to realise that the, the cranial part of the liver does follow down along the sternum, so we do need to push that probe into the abdomen to get round the corner, to see that cranial aspect. And because it's so large, we tend to, view it in, Sagita as a cranial chunk and a caudal chunk, and then a transverse view.
And sometimes, even in large dogs, we might need to split the transverse view into two chunks as well, a left hand side and a right-hand side of the liver. After that, we move on to the stomach. So, up here, we've got an image from a cat's stomach with lots of rugal folds here.
And that's quite a typical appearance, like a wagon wheel for a, for a cat's stomach. And over here, we've got a dog stomach, which is full of content, lots of, interesting chunks of food in there. Certainly, it doesn't look like a normal kibble diet.
And here we've got the, the wall, which we can see going around the stomach. So the stomach has sort of a C shape to it. So it goes up under the ribs, on this left hand side, up towards the fundus, and then it goes more or less straight down, eventually.
So we need to take into account that when we're fanning through, that we take into account that it, it sort of has a C shape, we need to adjust, so we're fanning up underneath the ribs, and then fanning down almost ventrally. And again, we want to get those two planes, so a more longitudinal view of the stomach and a transverse view of the stomach. The spleen.
It's important to get the splenic head. So we look underneath the ribs here for the splenic head. That's what we're seeing in this image in the top left.
So we've got here, we would have the stomach just off to the left in the image. We'd have, the left kidney off to the right in the image. And we're just fanning under the ribs quite superficially, so you need to fan a lot further than, than you think.
To get this really deep image of the spleen. So we really need to be adjusting our settings there, to see, view the whole of that. So we've got the spleen underneath the ribs there.
This is, the spleen over here on the right hand side of the image. We've got, the right hand image, sorry. We've got the spleen at the hillus, so where the, the splenic vessels enter and leave the, the spleen.
And we can see it's, it's a much thinner organ at this point, so we really need to readjust our settings again, particularly our depth, frequency, focal zone at this point. So, looking at the splenic head underneath the rib cage, and then following all the way to the tail. Now, the tail of the spleen is really mobile, so it might go down towards the urinary bladder, or it might go directly ventrally.
And it really varies in size in dogs as well. So it may even go round the corner of the abdomen. And you just need to follow it until you get to the tail of the spleen.
And again, you want to fan through it in, in transverse. All the way following it in transverse and then in a more longitudinal view, fanning through it at each level to get that longitudinal view. The left kidney is the next organ you get to, so this is the left kidney in a more surgical view in this top left image.
We're just taking a measurement of the length of the kidney here. And, I have to say, not all these images are from my dog Pippi. Some of them are from cats, and some, some are from dogs.
But just to give you an idea of the, the image that you're looking for. So here, we've got a more, more sagittal view or a longitudinal dorsal view, of, of the kidney. And here we've got a transverse view where we can see the, the pelvis very clearly, this dark area here.
And so, again, we want to get the transverse view, but not just one transverse view. We want to fan all the way through the organ. So we're seeing the whole organ in transverse.
And likewise, in this sort of dorsal or sagittal view, we, we fan all the way through the left kidney. The next organ we think about is the small intestine. So this is, the jaunum we're most interested on this left hand side of the body, .
And it's, it's fairly difficult to follow the intestine from one end to the other and would be very time consuming. It may be necessary in some cases, to try and follow some of the small intestine. For example, if you've got a dilated loop of intestine, you want to be able to follow that to see if you get to an obstruction.
But generally, when we're doing a full abdominal ultrasound scan, we might not need to do that. And so we want to take a logical approach, and we do, much like we would on a microscope slide slide, we do a castle pattern. So, starting up here at the last organ we were at, which was the left kidney, we perform a castle pattern, going across the abdomen, so that we can, maximise our, our chances of seeing any pathology if there is some.
So we will see, loops of intestine in different planes. So we might see, like here on the left, a transverse loop of jaunum, with the lumen in the middle, and then the different wall layers here. Or we might see in longitudinal, so where we've got the, the lumen here, and then the wall on one side here and the wall on the other side here.
And the different wall layering. And really, we want to be assessing as we go, through this. We may want to stop on a loop of intestine, to measure it, and to save it.
Maybe even save a sin loop if we see some peristalsis, for example. And then we continue on along this causal pattern. We continue on until we hit the bladder, because cordal to the bladder, there is no small intestine, so we stop when as soon as we see the bladder.
And the bladder, again, we want to get a transverse view and a longitudinal view, usually from the point of view that we're looking ventrally towards the spine, . Or from the ventral aspect towards the spine. And we look in longitudinal, so where the probe is pointing in a craniocordal direction and we fan all the way through, and we can rotate the probe and get a transverse view and fan all the way through again.
So this is what we'll see there. We'll have an anechoic area with, that's descending colon beyond, and we may be able to see a very thin bladder wall, which we may want to measure, to see if it is, normal, or if we believe that a focal area might be thickened, for example, then we might take a closer look at that. Next, we move up from the bladder up towards the colon, and then we follow that cranially.
So what we will get with the colon is a very thin wall and The, the ultrasound image will be artefact beyond that, really, because we'll get gas and faeces, and we'll just get a big acoustic shadow or a dirty acoustic shadow beneath it. So we won't get that much information on the opposite wall. And so we want to follow that colon cranially.
I add this in the basic, ultrasound examination because it's really good to start getting used to following a, a, an organ, and the colon is a nice big organ to be able to follow. So just wanted to show you a bit about the the flow of of this. So I talked about before that your probe shouldn't leave the animals side.
So we just look at each organ, but then we continue on to the next one. So we're starting with the liver, and we move up that costal arch. That's really, a significant landmark, and we move up past the liver, stomach, spleen, left kidney, and they're all on that side.
Behind the left kidney, if we, if the animal is entire, we might see the left ovary as well. Then we look at the small intestines via the castle pattern. We stop once we get to the urine bladder, assess that.
Also can look at the prostate and the uterus if they are there, and then look at the colon. It's important to also remember testicles and, and looking at those on ultrasound, if they are there. Sometimes I, I put that at the beginning of the examination, once I've written my notes saying it's maleti, that's one of the first things I will look at so that I don't forget.
So, we're still looking at the basic abdominal ultrasounds, and it's really important to look at the right side. We have some really important organs on this side and we get a lot more information even on the basic, ultrasound examination. So, the first things I look at are the gallbladder and the bladder.
So we basically just turned the animal over, and any sludge in the gallbladder and any sediment in the bladder will be disrupted. You'll get a snow globe effect when you look at them on ultrasound. So if you can look at those as soon as you can, once the animal's turned over, that can give you some useful information.
Sometimes when sediment or sludge is settled on, on one side, on the gravity dependent side, we won't see it as easily. But once, once you've sort of stirred it up by turning the animal over, you can get a much better view of it. So at the top here, we've got the kidney, and that's really where we start to place our, our probe on before, moving through what we need to move through on this side.
The right kidney on, the right hand side is a lot more cranial than the left. So we'll need to look under that rib cage. It can be harder to find.
So if you are struggling to find it, my key tips are to increase your depth massively. So increase your depth way beyond what you think you will need to look at it. And you fan all, all the way through in sections around the area you expect it to be in.
But not just the area you expect it to be in, fan through the surrounding areas also, but do it in a systematic way. So take a chunk, fan through it. Take the next chunk, fan through it.
But at a very increased depth, so that if the kidney is there, you, and not, not hidden behind some gas somewhere, then you will, will manage to see it. From there, you look at the small intestines. So when I talked about, we were looking at each organ in two different planes, .
The way I, I do it is to, for the small intestine, is to look at the small intestine from both sides of the abdomen. This is really useful as well, if you've got a larger dog, and, the, the ultrasound waves can't quite penetrate deep enough, so then you are getting the, the small intestine on this side. Plus, on the right hand side of the body, you're going to might bump into duodenum and ilium.
So there's some interesting loops of small intestine you might come across as well. So again, you do a castle pattern from that left kidney, sorry, right kidney, all the way back to the bladder again. So this is the sort of flow that you want, for the basic abdominal ultrasound examination on the right hand side of the body.
So you start with a gallbladder and urinary bladder. You move on to the right kidney, and if there's an ovary there, then you can have a look for that. And then you look at the small intestines, all the way back to the bladder, using the castle pattern.
So that was the basic abdominal ultrasound examination. It's a really good place to start. The organs are generally easy to find large organs.
And once you've got that down, you can start to build on that, towards the advanced abdominal ultrasound examination. So we'll have a look at that in the, on the left side, right lateral recumbency. We start, as we did before with the basic, because the advanced is just adding on a few bits, with the liver, stomach, spleen, and left kidney.
So moving up that costal arch, really having the probe tucked in contact with the costal arch so that you are following it up, to see each of those organs. They should just come one after another, then. You get up to the left kidney, and this is the first place where we will add a bit.
So we want to assess the aorta. So the aorta lies up here dorsally, and we can, can have a look at that. We follow it cordially first.
So we follow this, this is the aorta on our image here. We've got the cordial vena cava just slightly further away. But we look at the aorta and we get back to the trification.
So we can see here the external iliac artery, the aorta continues a little bit further before it breaks into the internal iliac arteries and just beyond this image, there's the right external iliac artery there. So lying up against this left external iliac artery, we will see the left medial iliac lymph node, so this thin hypoechoic structure lying up against it. So that's a really useful lymph node to check because it has a great landmark in the aorta and external iliac artery.
So it's quite easy to find. Although it's not easy to spot, because it's pretty isoechoic, so similar to the, to the surrounding tissue. Having said that, lymph nodes tend to get darker if they are abnormal.
So if there is an abnormality there, it gets easier to spot. Then what we want to do is follow the aorta cranially. So leaving the trification, following cranially, we get to this image over on the left hand side.
We've got the aorta here, and we come across the renal artery, which is a looped artery, a curved artery coming off the aorta. And just cranial to that, we will see the left adrenal gap gland, also caudal to the celiac artery and the cranial mesenteric artery, which we'll see a little bit further along. And also, we may be able to spot the frenico abdominal vein running across the left adrenal, these two poles of the, the left adrenal.
So, it can be useful to put Doppler on. As you can see, the left adrenal is a similar ecogenicity, so it's a similar shade of grey to the, the aorta. So it can be difficult to differentiate, and, colour Doppler can really help with that.
After that, we look at the small intestine. And we work our way back to the bladder, exactly the same as, in the basic examination, we, we perform a castle pattern, and again, just looking at specific loops, trying to get some, some measurements and, and seeing whether they're normal or not, and whether, whether there's, there are specific areas we need to focus on if they are different or abnormal. We look at the bladder as well.
It's important with the bladder, we discussed looking, through it in a, a sagittal plane where we fan all the way through, and also a transverse plane where we fan all the way through. But also, it can be really useful to get a gravity dependent plane. So where we place the probe on the bladder from, the top.
Down towards the table. That way we'll see if any urists will be in the, in the bottom of the image in the bladder. Then we want to follow the colon, and this time we're following the colon cranially, down towards the transverse colon.
So we're following the descending colon down towards the transverse colon. And that should get us to this sort of image where we've got, stomach over to the left of the image, cranial and spleen, dorsally in the image. And we'll get the transverse colon, all the left kidney in view as well.
And this is the area we'll, we'll find the left limb of the pancreas, near the splenic vessels. So we're near the hills of the spleen. We'll get the left limb of the pancreas, which is pretty isoechoic, difficult to spot.
But if we can get these landmarks in the image, then we can, definitely, get, get a chance of, of seeing them. So this is the flow of the advanced abdominal ultrasound exam on the left hand side, right lateral recumbency. So we follow the liver, gallbladder, stomach, s spleen, left kidney, and ovary if there is there.
And the things that we add on is the aorta, the left medial iliac lymph node, and then coming back to find the left adrenal. Once we're back there, we do the small small intestines, so the jaunum on this side. Before we hit the urinary bladder, again, once we're there, we look at the uterus and the prostate, if they are there.
And then we look at the, the colon, the descending colon, following that cranially to the transverse colon, where we will find our landmarks of the stomach, spleen, and transverse colon, to look for the left limb of the pancreas. And also, not forgetting those testicles if they are there. So let's have a look at the right side of the advanced abdominal ultrasound examination.
So this is the right side of the body, the dog is in left lateral recumbency. So again, we look first at the gallbladder and the bladder. That's essential that we have a look for any sludge or sediment, in those and assess how quickly they are, falling to the dependent side or whether they're suspended a bit.
That, that can be really useful information. We look for the right kidney, again, which is, as before, a little bit more cranial than the, the left, and, so it'll be under that, those ribs. We may want to go into costly, if, we're struggling to see it under the ribs.
Then we have a look at the cordo vena cava, and looking for the right medial iliac lymph node and the right adrenal. So, the cordo vena cava will be closest to the probe now. And like before, we follow, the corvina cava and the aorta cordially to get the right medial iliac lymph node, exactly as on the left hand side, the right medial iliac lymph node just lies on the right external iliac artery, as it did on the left with the left external iliac artery.
We follow the cordovena cava cranially and where those the corral vena cava sort of diverges away from the aorta, that's the area you want to find in for the right adrenal. After that, we look at the small intestine, again doing a castle pattern to minimise the risk of missing pathology. And then we want to have a look at the duodenum and the pylori duodenal junction.
So we do this as part of the castle pattern, really, because we're coming down from the area of the right kidney, and our first hit of small intestine that we get when we're doing the castle pattern will be the duodenum. It is the most dorsal. Most superficial, most straight loop of intestine.
So we should come across that quite quickly. We can follow it cordially to get the, cordal flexure. That will really tell us that this is the duodenum.
And we can follow it cranially underneath the ribs towards the pyloro duodenal junction here. So this is, in effect, what the duodenum should look like. We've got the lumen running through the middle here, and then wall on this side and wall on this side.
So we can see we really have just the abdominal wall layers here. So the skin and the muscle before hitting the duodenum. It's really, really superficial.
We won't see it floating around in the middle of the abdomen. It is, it will be right up close to the probe. It's really super straight.
So if we've got our probe in a craniocadal, rotation, then, it should be super straight across our, our screen, our image there. The next thing, when we're doing the costal patterns, so when we're coming down from the right kidney here, we'll hit the duodenum, and then we might hit the duojunal lymph nodes. Often we can see them, where we've got the duodenum in the, in the foreground, in the near field, and then a little bit further away, we have these two hypoechoic structures.
So here's one. And here's another. And they have a blood vessel running through between them.
And that can, that can be a good indicator. Sometimes we'll spot the, the blood vessel first because lymph nodes always like up against a blood vessel. So, but these are, these are good lymph nodes to look out for in the abdomen, because they are the largest abdominal lymph nodes.
So that's the reason that they stand out really well. They can be up to sort of 67 centimetres long, and still be normal. So keeping an eye out for, for them is really useful.
And then we want to look out for the ileosica Junction. We won't always spot this. Sometimes there's gas in the way, and, and that can make it much harder.
It's much easier to show on a video. We've got the ileum here, and that's disappearing off into the colon, and we can see that, on that video, on that sin loop there. So once we, we've spotted those, we just continue our castle patterns, so they're looking at the jaunum in, in a, in a second plane.
So this is the flow of our, advanced abdominal ultrasound examination. So, we've got the dog in, in, left lateral recumbency. We're looking at the right hand side.
We look at the gallbladder and urinary bladder first, and we look, then we start at the right kidney, essentially, and having a look at the right kidney, plus minus ovary. We look at the caudal vena cava. Follow that cordially and looking for the right medial iliac lymph node.
Then we follow that the cord vena cava cranially again, looking for the right adrenal gland. Looking at the duodenum, we might want to follow that cran accordingly to check that it's the duodenum if we're in any doubt, to see the caudal flexure, and then following a cranial to the hyalo duodenal junction. The duodenum is also where we will see the pancreas, the right limb of the pancreas, because that lies up against the duodenum.
And as we follow the down towards pyloriduodenal junction, we may be able to see the body of the pancreas also. Then we want to start doing our, our castle pattern, and we'll come across, the jaunal lymph nodes, and possibly, the ileum and the ileo colic junction as well, if we're lucky. Continue our castle pattern until we reach the bladder again.
So, in summary, there are guidelines out there, they, they are accessible. That most recent paper from the ACVR and ECVDI that consensus statement is a really useful guideline out out now. .
And I really advise, especially in GP practises where time is limited, to start with a basic scan, get good at that, and then build on it. So adding in those, those harder bits, and that doesn't have to alter the, the pattern, of your ultrasound scan, because you want it to be repeatable and memorable, and you want it to flow so that your ultrasound probe isn't leaving the animal too many times. And it's essential that you complete each organ.
So you want to look at each organ in two planes and fan all the way through them. And to, so you get the edges of the organs too. So, where can you find out more?
So, the Fou courses, I, I have two courses. One is the basics and one is the trickier bits. And essentially they, they work on, on teaching you each of these, these parts of abdominal scanning.
We have, they're 4 weeks online, pre-recorded webinars. There's lots of how to scan videos so you can see what my hand is doing, and where your hand needs to be. We discussed pathology and cases and there's an active discussion board, but you don't need to be present at any time during the course.
You can find out more about those at FOVU.co.uk/ultrasound courses.
Also just wanted to say thank you for coming and watching these webinars. I'm so grateful for you all turning up. If You would like, I know many of you did last week.
If you'd like an ebook that I've written on getting yourself started up on ultrasound on your machine, figuring out those 5 buttons on your machine, etc. Etc. Then do visit FOVu.co.uk, and look for this little video, and just sign up there.
And do get in touch with any questions. My email is [email protected].
I am receiving quite a lot of emails because of these webinars, so I will get to you. It may be next week, before I manage to reply. So, but please do send send emails with questions.
Just wanted to also let you know about next week's webinar. 10 small animal cases where ultrasound made a difference. So we're really gonna look at tonnes of images, in, in next week's, webinar.
We're gonna look at tonnes of pathology, and it's gonna be really typical cases that you see in general practise, and where ultrasound really, really made a difference. But have you got any questions today? Thank you for Camilla for presenting today's webinar.
We have had a few questions submitted, so I'll crack on and get through with what we can and obviously email responses if we can't get through them all. So the first one I've got is, can you please send us a copy of that ACVR and ECVDI consensus statements. For the standardisation of the abdominal ultrasound examination, is that possible?
But it's not, it's not free access, I'm afraid. So you do have to pay for it, at the moment. I have seen some, copies floating around the internet though, so, but do, do go to the Journal of Veterinary Radiy and you can access it, it there, but you will need to pay for that, I'm afraid.
Thank you. Our second question is, do you sedate patients for ultrasound as routine, and if so, which protocol is preferred? Yeah.
So, no, not as routine, really, only if necessary. If I think there's different opinions on this culturally around the world, what people do. I find that because I scan in lateral recumbency, lots of my patients really tolerate that very well, just restraint from one nurse or possibly two sometimes.
And then, I can get away with, with no sedation. But I will use sedation if there's any question about pain relief or panting, fidgeting, if we, if it's needed, or if if the animal's really distressed by being restrained, then it can be an advantage. It's really difficult to give a protocol because, when we're scanning an abdomen, it can be for a myriad of different reasons.
And in, it can be in patients that are, you know, a few weeks old to geriatric and everything in between. So having a protocol is difficult. What I would say is sticking with drugs that you know and you're used to using.
Means that there's less risk of, of, problems developing. And if you, if there are problems developing, you're more likely to spot them early. So stick with what you know, and, you really need to adapt it to, to each patient.
Thank you for that one. I've got, where do you set focus for liver if taking up the whole screen? Yeah.
So that's a good question, because, we really want the point of interest to be at the focal zone, right? That's what I told you last week. But, the focal zone below the focal zone is a lot worse than above the focal zone.
So really, if we're looking at a large organ like the liver, we place the focal zone right at the bottom of the liver, bottom of the diaphragm where we can see. If, however, you spot a lesion within the liver and you want to really look at that a bit more closely, then don't be afraid to change your depth to, so that that lesion is filling up the screen and move your focal zones, so it's on the lesion. Lovely, I've got someone who's just said, could you please put up the slide of the advanced abdominal examination on of the left side up again at the end of the talk.
Yeah, I can get back to that, I think. That one. I'm hoping that's the right one, or if she messages through again, I will let you know.
Let's have a look. Oh yes, thank you so much for such an excellent webinar, really useful. Just wondering if you have any tips on scanning a uterus for unusual things.
For example, I had a cat who passed their kittens a week before presenting to me, and then passed a mummified kitten in with us a week later. I offered to scan her, but honestly, we were not that confident on how it was, I was going to do it. Yeah.
Yeah. So, the thing with the uterus to, to remember, always remember, is that the uterus is the only organ that you will find between the bladder and the colon. So if you scan looking through the bladder up towards the colon, so coming from this ventral side, up, on the, if you put the probe on the midline in transverse, so looking from left to right, and you're looking through the bladder, up towards the colon here, the uterus will be the only organ lying in between it.
So if you've got a case like that, you, the mummified, kitten might not necessarily be right there, but I would expect the uterus to be quite prominent because there'll be inflammation. It won't have, involuted yet fully, and there may even be a bit of fluid in the uterus. So it should be easy to spot between the bladder and the colon, and then following it cranially until you get to that abnormality is, is what I would advise.
But looking in transverse through the bladder to the colon is key there. Cheers, and I think this image you've sort of gone over as well because we've got how can we, can you repeat how we position the probe and reference point when performing an abdominal ultrasound? Which sort of obviously covers what you've got.
Anyway, can you please repeat which landmarks used to identify the left limb of the pancreas, please? And is it normally easier to find that on the right side? So the left limb of the pancreas is easiest to find on the left side of the body.
And the landmarks that I use are cranial. I use the stomach, and then dorsal in the image, I, or in the near field of the image, I see the spleen. And then caudal, I see, the transverse colon or sometimes the left kidney can be a useful other landmark.
And then I'm really fanning in that area, looking for the splenic vein, because the left limb of the pancreas really follows the splenic vein. But the left limb of the pancreas is hard to find in dogs. It's usually a lot shorter than in cats.
The left limb of the pancreas is usually a lot longer in cats. And then the right limb of the, the pancreas, we look for on the right hand side of the body. And that really lies very close up against, the duodenum, medial to the duodenum.
If you're going to surgery, for, for any reason, a bite or you've got any abdominal surgery, next time you have a look, at the, the, particularly the right limb of the pancreas, how close that lies up against the duodenum. So really you're looking for the duodenum and then you're fanning through that. Again, When you're looking for organs, looking for them in transverse is often easier than looking for them in longitudinal.
So if you're struggling to see the right limb of the pancreas, rotate the probe, at the duodenum, 90 degrees, and then you should see the, the right limb of the pancreas. And the body of the pancreas is quite tricky to, to see, but you want to follow the Duodenum round to the pyloro duodenal junction, down to the stomach, and you should see the body of the pancreas between the stomach and the portal vein. Thank you.
Next one I've got is how can you recognise which part of the small intestine you are scanning? That's a great question. So we've got the duodenum, geoinum and ilium, and so the wall layering is slightly different in them.
The duodenum and duodunum look very, very similar. So, although usually the duodenum is slightly thicker than the duodunum. So the main reason that I know it's the duodenum is because it's the most dorsal loop of intestine on that right hand side, and that it behaves like a duodenum.
So when I follow it cordially, it, goes into the caudal flexure. And when I follow it cranially, I can follow it down to the pyloriduodenal junction. The jaunum has similar wall layering.
So for both the, duodenum, and jaunum, the mucosal layer is, is quite thick. And when we get back to the ilium, the ileum wall layering is, is quite different. It's much more like the, the stomach wall layering.
We didn't really go into that in this lecture, but, yeah, the wall layering, so the mucosa, submucosa, muscularis are all pretty equal in thickness in the ileum. So that's how you can tell that. Cheers.
Next one I've got is, do you scanning dorsal redundancy? I, I don't. I, have always scanned in lateral recumbency.
If I am struggling to see something, or if I'm taking fine needle aspirates and I need a different, slightly different view, then I might put the animal in dorsal recumbency. But not as a routine thing, no. I scan in lateral.
Thank you. Next one is, do you get RVMs during your ultrasound courses too? I do.
I do have ultrasound courses for RVN. So, that is a six-week course. Yeah, so that's on that, that website page as well.
That, that's, it's very similar, pre-recorded webinars, some tasks and quizzes. But yeah, I, I'm a great believer in the, the, nurses should be doing more with ultrasound. I think it's coming, and, yeah, definitely want to support that.
we do have a couple more, but unfortunately we are pretty much out of time now, so, we will get back to you on those last questions that we have, via email, so I do apologise, but, I'd just like to say again, thank you, Camilla for such an informative session. Obviously we had lots of questions, so great. See, everyone, again, we hope that you enjoyed today's, webinar and we hope to see you on, next Monday, 17th of October for our last session, same time, same place, again, where Camilla said we'll be talking about 10 small animal cases where ultrasound makes a difference.
Thank you all, for joining us today. Thank you.
