Good evening everybody, and welcome to a Thursday night members webinar. My name is Bruce Stevenson and I have the honour and privilege of chairing tonight's webinar. I don't think we have any new members tonight, so no need for much housekeeping.

Usual story. We will keep the questions, over to the end. And, Pete has very kindly agreed to go through as many of those as we can, as long as we have time permitting.

So our speaker tonight is Pete Mentis. He graduated from the Faculty of Veterinary Medicine of the Aristotle University in Greece. He completed his diagnostic imaging residency at the Royal Veterinary College.

Pete worked in first opinion practises and referral hospitals in London, and for a year at a Swedish agricultural university in Uppsala and staff as staff clinician in diagnostic imaging. In 2000, he moved to the Royal Veterinary College in London, where he became a senior lecturer in radiology and remained at the RBC until joining Dick White referrals in May 2017, where he is currently a consultant radiologist. Pete is a European and RCVS specialist in veterinary diagnostic imaging and a fellow of the Higher Education Academy.

He is a regular author, speaker, and CPD tutor on small animal radiology, ultrasonography, CT and MRI. Pete has authored a book, Practical Small Animal Ultrasonography of the abdomen, and he will be using some of those images tonight. So Pete, welcome back to the webinar vet and it's over to you.

Thank you, Bruce. Thank you for the very kind introduction and I would like to welcome all participants. I do appreciate your time.

I know after a whole busy day, you know, attending a lecture is, you know, something extra, and I will try to make it as palatable and as easy as possible. I will mainly concentrate on technique. With some tips, of course, on appearance and interpretation.

So, bear with me and we'll slowly go. I will use some videos, I would like to thank the RBC and my editor that allowing me to use them here so that you can actually see in action what I, I'm going to talk to you in theory. I put some description also on the slides, so when you get a handout, you have some guidance of how to go about.

So without further ado, I will start and like everything on ultrasound. We want to use landmarks and pancreas is one of those organs you really in the beginning, need to use them. It is a tricky organ to find simply because the ecogenicity is similar to the surrounding tissues.

So you may go there in the beginning, you may feel like, oh shoot, where is the pancreas? But looking carefully, your eye gets quickly accustomed and then you'll be able to pick it up. And of course, with the newer equipment you have, the easier it becomes.

Now, for the right lobe of the pancreas and hopefully my pain is going to work. Give me one second, set up. OK.

So basically, for the right kidney, we are going to for, sorry, for the right pancreas. So we are going to use the right kidney, the descending duodenum, and the pancreatic adenal vein. For the body of the pancreas, we will use pylori tantrum, portal vein, and the right pancreatic lobe.

Ideally, I can tell you now and you will see when we go through the technique that we are going to mainly use pyeloic rum and portal vein. For the left lobe of the pancreas, or what I could call the most tricky of the lot, most books will tell you, you find the stomach, you find the spleen, you find the transverse colon, you find the left kidney, and Between them it's the left lobe of the pancreas and of course as you can see here the left lobe. Basically, they are quite right.

It's between stomach, you know, colon, left kidney, and the cut actually it comes a little bit further back, if you like. But using all these organs without anything more specific makes it much trickier. So what I like to use is the splenic vein in the portal vein and look between the two because the splenic vein will be somewhere there, the portal vein comes somewhere at this level.

So between the two, you will see it crossing a little bit caudially. So again, for the right lobe, which is the lobe that I usually recommend to people to start with, kind of the easiest, locate the right kidney, locate the descending, duodenum, and then look for the vessel inside that lobe which is the pancreatico duodenal vein. For the body, you find the portal vein pyloriantrum.

And pylorus area and then you will see the body there. And for the left lobe, we will see how we use the splenic vein and the portal vein to find. OK.

Normal appearance before I'm start giving you the technique, what we look for. We look for a thing. Homogeneously ecogenic structure.

And if you read the books, they will tell you compare it with the liver. And the pancreas should be a little bit more white or hyperchoic, jargon of ultrasound or equal ecogen to the liver. Personally, I couldn't care about it.

OK. When we see the pancreas, we should have a little bit of difficulty seeing the margin. Maybe a little bit easier to see the margins in the cat than in the dog, but in both.

Animals, you should be having a little bit of difficulty to see the mars. You will be, it's about there most of the time, and that is fine. If you see a pancreas that stands up and you go, wow, that's one fantastic pancreas.

I can see it really clearly. It's really good. That means that it is probably abnormal and we will see a few examples of that later.

Now, for technique, now we know what we're looking for, for technique. The right lobe, which is the one we are going to start with. So your first target is for those who are starting ultrasound, go for the right lobe.

When we are comfortable with the right lobe, then move to the body. When you are comfortable with the body, leave the left lobe for last. OK.

For the right globe and because personally I like to scan animals on the side. So usually the animal is in right lateral recubcy when I scan for the abdomen. I find it a little bit easier and it allows the one assistant to hold the animal and you know how it is sometimes in practise, it's tricky to find one assistant, forget the two.

But some people, they like to do it on the back. You can actually follow a similar technique with the animal on the back. OK.

So, with the animal on the side, and we try to use that in, in actually in small size dogs and medium, I would not recommend them to use in large size dogs unless you want to have a repetitive strain injury on your, on your hand. OK. So we put, and there is a positioning, we put our Probe Below the animal, we actually slide under the animal to about 2/3 up.

We keep it close to the tabletop parallel to it, no more than a finger's thickness away, and we press. We have to be careful and you will see now when I will show you the video, what's very important in that technique is the machine actually is here on that side. The head points to the machine, legs are towards the examiner.

And you usually what I say ask your assistants to tilt the dog 45 degrees so you can place the probe underneath the animal at this level. But under the animal. And then you press to locate the right kidney.

Then you relieve the pressure and that will bring the duodenum to fall into your image. And after that, below the duodenum, you can see the right lobe of the pancreat. So let's see.

How that works. And this is a video I used from the online course that I have on the ABC one that we have the whole abdomen there, but here is just the pancreas and basically observe how I place the probe under the animal about this height here. I will put a dot just to know which level.

So I go quite high up and then first job is trying to locate, you need to press and sometimes you ask your assistant to put a hand on the back. Trying to locate the right kidney. That's job number one.

We maintain the probe remember with a marker pointing to the head. There's the right kidney. Up to one figure and then find the right kidney, release the pressure and you can see here the duodenum with a little bit of gas in this case coming into view and immediately you see this slightly grey area below with a small tunnel of vessel in there, the pancreatic adrenal vein that small where the green arrow is on the video.

This is the right lobe of the pancreas. So technique is find the kidney. Actually, let me just see if I can.

Freeze it. Mm, OK. Then let me just move to the arrow.

OK. So, find the kidney. Job number one.

They release the pressure. Now that you release the pressure, the duodenum comes into your, into place because as you went to find the kidney, you press the duodenum out of the way. And after you release even a little bit more of the pressure to look underneath the duodenum, you see the pancreas with adrenal vein there, this slightly darker hypoechoic area which is the right lobe of the pancreas.

OK. Now, sometimes when we start and we are new into that, we press, find the kidney, everybody's happy, which means we press towards the last rib. When we release though, we have this bad tendency of pulling our head upwards.

So we lose this orientation of our probe parallel to the table and we end up with far too many intestines to know which one is the duodenum. OK. With practise you will know to recognise it do you know, but in the beginning, if you are unsure what you need to do, and I think I have it further down on that video when all the explanation of the right is find your probe down towards the table.

That's what I'm doing here, to the point that you don't see anything. So literally, if you see my hand in the probe points towards the table. It is touching the, the animal.

I have found. Let's say the kidney, release the pressure. And then instead of looking at one intestine, I see a lot, which means I change the angle of the probe accidentally.

No problem. You're in the correct location, fan your probe, or if you like tilt is another word for fan. Your probe all the way towards the table so it faces the table and then slowly.

Start coming back up. First loop of small intestine you are going to see, like you see here, it's the duodenum. Or As the Americans like to call it, OK.

Because it's the most lateral loop of intestine. So it's the, do the, the first loop of intestine you're going to see. Now you know that's the duodenum, and now you know the drill.

Release a little bit of pressure more and look just behind it. You already see it in this view, the right lobe of the pancreas. And here I explain again, find the kidney, release pressure, find duodenum, look below the duodenum, that's where.

The right lobe of the pancreas lies. OK. So I hope it's clear to everyone about the steps.

There is again the duodenum after I release the pressure from the kidney, and you can see here the pancreas, the green arrow shows it just underneath. So, what we normally see, we normally see, let me just put the pen back up. OK.

We normally see the duodenum there. There it is. Well you can see the serosa area at this level.

You can see the pancreas between the lines I draw and you can see the pancreatico duodenal vein. OK. And sometimes if you have kept like here quite a big debt, you may still see the right kidney.

And you may see the liver. But don't lose your sleep over that. You don't have to have them in there.

Of course, when you find the pancreas, you can, if you like, reduce the depth and you can make a nicer image and here I just have an image where you can see. Sorry about the not so straight line, the pancreatico duodenal vein, which is one of our landmarks that the minute we see it, we say that's the right lobe of the pancreas. Now, in books, and they have done, they, they published various studies and various measurements, for example, for the dog, the left lobe 6.5 millimetres, the body about 6.3 mil, the right 8.

For the cats, they say, for example, the right lobe is up to 6, the The lobe is up to 9 millimetres. One rule I keep in my mind to make it simple as far as thickness is concerned, is one finger. So in dogs, personally, I also include cats, but you know, if you go with the books, cats, they have a 9 millimetre up to left, a 6 millimetre right.

But generally, one finger thickness is the one I keep in my mind as a bold mark of how thick the pancreas should be. Now this technique you can use it in a big dog like a Great Dane or an Irish wolfhound. Prepare to press a lot and of course, it's not something you can do a lot without damaging your hand.

So in large breeds of dogs, I tend to follow a different approach. So I flipped the dog over. So now the animal is lying on the left side in left lateral occupancy, and then I identify.

The kidney by going near the spine. The spine is here, oops. There, the spine is at this level, OK.

He is here. The tail is there and the machine is on that side. I'm sitting here and the legs is on the other side.

So having the market always towards the head, I go between the ribs that they lie here and identify the right kidney. That's my first job. I try to keep my probe 90 degrees to the skin.

From there, I slowly slide down. I keep the caudal pole of the kidney for sure in the middle of my screen and I just slide down and by slide down, I like to make it easy for myself. I let the ribs guide me.

Don't try to pass over any ribs, just follow the groove, as I like to say. Till when? Till you see the first loop of intestine at the top of your screen.

You may see colon, the colon always has a thinner wall than the small intestine with not much thicker mucosa than the other layers, OK. You may see other loops, but not a small intestine at the top of the screen. So you slide down and you stop when you see the first loop of small intestine at the top of your screen.

Now there with a little bit of funning you are going to be able to see the pancreas below. The drawback with that technique, and we will see it in action, is that now the duodenum is the most top loop of intestine, so you will get gas in there, and I will show you a tip of how to see it even if you have gas in the duodenum. You know, creating artefacts and making tough for you to find the right lobe.

So here's again another moment from my online course for the right lobe of the pancreas. Again, at the back, I found the right kidney, keeping it in the middle of the caudal bone and slide down. You can immediately see and I will actually go back to the arrow because I think I want to make it a little bit slower for you.

So we start with the kidney. My marker points to the head of the animal. You see the position, and then all I'm doing is literally following the groove.

Of the ribs as I slide slowly down, and as I slide slowly down, sometimes as I go down, first loop of intestine that I encounter like here may be the colon. You see how thin is the wall and usually they contain faeces with a lot of artefacts in there. I just continue further down.

Till I find a loop of small intestine, observe how the mucosa is much thicker than the other layers in the small intestine at the top of my screen. Now down here, up here, my wall stops at this level. So just below my wall, you see the top loop.

Of small intestine, which is the blueinum because the most lateral loop of intestine. Now, when I find that, I rotate my probe to make it long and you already can appreciate underneath. The right lobe of the pancreas and if you look carefully, I will go a little bit back.

You can actually see the pancreatic with adrenal vein, this black tunnel within there, which confirms to us that what we are looking is the right lobe of the pancreas. And of course, here I'm using the arrow in the machine to show the right lobe of the pancreas now, which is projected just below as we see it to the duodenum and you can see all this gas. And all this gas is causing artefacts, so you will never get such a good image, such an underneath.

There is. A way around it. And what is that?

I will show you in the next video that I have with the permission of the editor from my ultrasound book for the digital special version and basically you can see here again, find the kidney, caudal pole in the middle, mark it to the head, and then I slide down to find again the first group of intestine at the top of the screen. You see a little bit of the column here and then can you see at the top of the screen the Duodenum up at the top. And of course, you try to see the pancreas underneath, but if it has too much gas, oops, sorry, I pressed the wrong button traditionally.

If it has too much gas, It is tricky to actually see it. Then what we do, look at all this gas, how it creates havoc. You can't really see clearly below.

So what you can do is rotate your probe 90 degrees counterclockwise. So the marker is going to point. Can you see the movement there?

I look at my hand again. So I start from there and rotate counterclockwise 90 degrees. Now the marker points towards the spine of the animal and then you can see the duodio and you can see around 78 o'clock the right lobe of the pancreas in transverse orientation.

But now, The beauty of it is you don't have the gas falling on the pancreas. So we can see it. Here again, I go through the technique to show the duodino, make it nice and long, try to see the pancreas as far as I can underneath.

But of course in this particular animal the situation don't get a good image, rotate 90 degrees, counterclockwise and then about 7 to 8 o'clock. If we imagine the duodenum as a as a clock face, 7 to 8 o'clock we can actually see that. So.

For the right lobe of the pancreas, it will be your 1st, 1st step to go with. First job is to find the right kidney. Small, medium dogs, I would say 20, sometimes 25 kg if they are, you know, behaving well, slide under the animal 2/3 up.

With your probe having the market to the head, parallel to the tabletop, no more than a finger away from the tabletop, and pointer was the last rib to find the right kidney. When you find the right kidney, make a nice image of the right kidney. You want to see it nicely, and then they release the pressure slowly.

Suddenly you will see the duodenum drop into the view and then with a little bit of tilting your pro or fanning as we like to call it up and down, you will see the actual right globe of the pan. If you don't and you see a lot of loops of intestine, it means as you release the pressure, you find the probe upwards. No problem, stay there and fan all the way down towards the tabletop till you see nothing.

And then slowly find out. First loop of small intestine, you will see is the duodenum. You know the rest.

If it is a big dog, flip it over, find the kidney, ideally between the ribs or behind, but I like if I can between the ribs, and then let your probe, which faces with a market to the head. Slide down. First loop of small intestine at the top of the screen is the duodenum, below the duodenum is the right lobe of the pancreas.

If you have too much gas, rotate counterclockwise. And check about 7 to 8 o'clock if you imagine the duodenum has a clock face and you will see the right lobe. Now pancreatic body, it's not that tricky and it's a nice next step from the right lobe of the pancreas.

You can attempt and it works better when the animal lies on the back, to follow the right lobe of the pancreas cranially and find the body. And some dogs actually quite a few may have trouble doing that. So next best thing and quite easy is find the stomach from the midline.

So as the animal lies in the right lateral reccupancy, you go midline, caudal to the liver and locate the stomach. Fan all the way down and then slowly as you fan up, stop when you see the portal vein. If you literally freeze the image, when you see the portal vein, you will see the body of the pancreas between the portal vein and the pylorus.

Around between normally it's about 4 o'clock, but I would say anywhere between 3 and 6. So, let's see how it goes. So basically, you see the position of the animal and I will phrase it a little bit here.

The animal is lying on the right lateral occupancy. OK, let me do some drawing. The head is in that direction, so head is here.

The tail is back here. I'm sitting with the legs of the animal towards me and the head is towards the machine, which is about there so I can see. All right.

So now that you know these basics and you realise the position, you see that I'm in the middle, pressing and you need to press quite a bit to actually see that. And I identify the stomach which you see on the top screen there with the rui protruding. Now observe this movement found the stomach.

And then I found all the way towards the table. Look at the movement of the probe. And again Fill the stomach, tilt all the way down.

And then slowly, oops, yeah that was kind of too fast. So find the stomach, fan all the way down and at this level, slowly I'm fanning up and I'm looking carefully on the screen to find the portal vein. Can you see the portal vein coming in?

The black thing, oops, I went again, sorry about that. Technology when it works. So again, find the stomach.

Right in the middle of the screen, fan all the way down. I will let it run this time. And then slowly up until I see the portal vein, which is the big blood vessel, the first one I'm going to see, the most ventral, which you can actually see on the screen, this big black thing.

Now you can freeze the image at this level. You don't even need to find. The the body of the pancreas.

So you saw the portal vein freeze, then go into the stomach and look around 4 o'clock or between 3 and 6. You can already start seeing a more grey area there. As you can see, that's the arrow that is the actual body of the pancreas.

It's not tricky, but you need to maintain pressure when you do the movement. So fine, stomach, fine, I will run it again. So, find the stomach, find all the way towards the tabletop and Then slowly come back.

OK, so find the stomach, find all the way down, slowly come back until you see the first big vessel across the street, that's the portal vein where you can see it here. You can now freeze. You don't mind if you have seen the pancreas or not.

99.9% if not 100%, but 99.9%, the pancreas will be there.

You can see here the body of the pancreas. So that's the next step. You found the right lobe of the pancreas, you are happy.

With what you've seen, you move to the body of the pancreas. Now, normal appearance here, I have some examples and you can see again I have the stomach and if I imagine that is a clock face 12, 639, you can see around 4 o'clock we have the body, but it can be anywhere between 3 and 6 o'clock. And the minute we see the portal vein, the big vessel across the street, the first one is we fan up, we can actually freeze there.

Here is another dog again with a stomach. Portal vein and you can see here it's more towards 56 o'clock. And that's why although most of the time you have to look at 4 o'clock in some you may see it at 56 o'clock.

And that is the body of the pancreas. So, for me, that's the logical next step. When you move from the right lobe to move to the body.

Now the left lobe of the pancreas, my only advice here is before you attempt that, be very comfortable with the other lobes, OK? If you can easily find the body in the right lobe, you are ready to try this one. How do we find that one?

Again, I keep the animal on right lateral occupancy and find the spleen first of all, and you will say, how do you find the spleen. I start from the liver behind the xyphoid with the marker towards the head of the animal and I slide the probe on the left side of the abdominal wall following the last rib. So literally in front of my probe is the last rib and I stop when I see the spleen.

Then next to the spleen just below I will see the splenic vein. And then sliding a little bit further up until I see at the deep end of the portal vein, I look between the two. So let's see how that works in real time.

OK. So again, here is the left lobe or limb of the pancreas. So, here, and with your permission, I will.

Freeze a little bit, so because I did a little bit quickly just to highlight to you how it goes. I will start from the liver behind the xiphoid and then slowly, I will go up the last rib until I find the spleen. So here, I found the spleen.

At this level, you can actually see the spleen on the screen at the top. You can see the stomach, which is actually on the left of the screen and a little bit below the spleen, and you see the faeces in the transverse coum B on the back end on the right of the spleen below the spleen. Marker points to the head of the animal and the animal lies in the right lateral occupancy, which basically again so you can get your head around the position.

Head is down there. Tail is up here. Legs come towards us and the machine is.

You know, in front of us to, as the animal faces that. So back to my arrow, so I can allow the video to run. And you can see here, I found the straining vein.

You can see it on the top. You see the green arrow showing the splendid vein, and all I'm doing is I'm slowly sliding upwards, keeping my eye at the bottom to see where the portal vein is going to arrive. Can you see that?

Now, I have the splenic vein on the top and the portal vein on the bottom. I need to look between the two. To identify the left lobe of the pancreas, which you can see the green arrow pointing this grey structure there.

And usually when I do that in advanced courses, I say to people, do a V with the index finger and the middle finger in one hand and put the index finger on the splendid vein. The middle finger on the portal vein and look between your fingers. You can try that on your screen now.

Put your right index finger on the splenic vein and the middle finger on the portal vein, and the grey area you see between those two is the left lobe of the pancreas. And that way you can actually find the left lobe of the pancreas. Of any dog, small or large, and cats.

In cats, it will stand out a little bit more than that. Yes, they are right. It is between the stomach, it is between the spleen.

Travers colon can go up if you forward it back to the left kidney. So here, I think I go again, splenic vein on the top, slide slightly up. You see the portal vein on the bottom, freeze the image, and then look between the splenic vein and the portal vein.

And suddenly you can see here the left lobe of the pancreas between the splenic vein and the for the vein, you know, it works every time and some people, they say, but if sometimes I try to slide up. You know, some, some dogs, the sples further high up. So as I try to go up towards the spine, I'm going to enter between the ribs.

What shall I do? My advice there is go between the ribs, makes it easier rather than tilting your probe to avoid the ribs. So if as you slide up, you are to enter the intercostal space, enter and follow the intercostal space until you see the portal vein and the splenic vein together.

I hope that clarified, of course, this is the most difficult, if you like, of lobes. For us to identify. You can see here the green arrow just shows it.

I don't know if I can clean my drawings, OK? And you can see here the left lobe of the pancreas again and again. You can try.

Ideally, for your practise, I would say start with a smaller dog, 8 to 10 kg and then move up. So you practise the technique. Here again is an image that basically we have the left lobe of the pancreas.

And you can see the left lobe here. We can see The transvers column, the spleen, the stomach, the portal vein, and you will say, where is the splenic vein? The splenic vein just a couple of frames before it was here.

The minute I found the left lobe of the pancreas, I don't need to have the splenic vein in the image. This is for me to find. And of course, in the left lobe of the pancreas, we may see something that looks like a vessel.

That is not any pancreatic or duodenal vein or anything like that, OK. Let me erase that because my drawing was bad. So this is the pancreatic.

That What we see like a vessel in the left lobe of the pancreas. And of course, a lot of people, they use that to decide if there is pancreatitis. For example, they say in the dog it's usually 0.6 millimetres, and cats can be up to 1 millimetre and in older cats can go much higher without having a pancreatic disease, up to 2.5 millimetres.

I don't use it myself. OK. So as long as the pancreas is within a centimetre.

Though for the left lobe we said in the cards, they say 9 millimetres in the cold though I use a centimetre personally in thickness, and it doesn't stand out too much. I'm a happy bunny that this is normal. Here is the left lobe of the pancreas and the cat, we can see it as it is standing out a little bit more than in the dog, which helps a little bit to find it.

And especially in cats and small dogs like in this cat here, sometimes you may find yourself accidentally rotating your probe and finding the whole pancreas. So here what we have is the left lobe of the pancreas. It's what we started about, then comes to the body, the union, and then following down to the right lobe of the pancreas.

And of course, this on the left lobe of the pancreas is the pancreatic duct. I hope I'm not doing too fast. If anybody feels I'm doing too fast, please put it on the Q and A section, and I will be happy to slow even further further down.

Here is another cut again, sometimes we're lucky, we don't do it on purpose, and you may get the whole boomerang looking slightly hypoechoic to the fat around pan. And of course, why do we look for the pancreas? You know, you know, the drill usually comes with vomiting, some abdominal pain.

Everybody says pancreatitis. Let's do an ultrasound. And that's, we do it at the WR I did at the RBC.

Everybody does it. Is the ultrasound sensitive for the pancreas? No.

So an ultrasound, I may see a normal pancreas like this one, and this cut can have acute pancreatitis. I wouldn't even know. Or I may see a mixed eogenicity pancreas, not, not thick or anything else, and it may be a subclinical.

So currently the animal doesn't have anything, you know, it's what I like to call sometimes the animal is one pizza away from getting pancreatitis. You know, I'm just joking, of course. So, what do we see with pancreatitis?

With pancreatitis, we expect to see a thick hypoechoic pancreas. So a blacker. Hypoechoic means darker, hyperechoic means whiter, anechoic means black, and isoechoic means the same ecogenicity.

So we have to say with what? You can just say it's isoechoic. It means nothing.

You have to say with what? OK. So pancreatitis, normally we expect a large hypoecoid pancreat.

Now, what's the caveat with that? Pancreatitis can appear however it likes. It can be hyperechoic, it can be hypoechoic, it can be myogenic.

It can have cavitary lesions like irritation systems we'll talk later about, you know, so you can have any appearance you like under the sun. But the most common appearance and what we expect to see is this one, like in this seven year old Westie. OK.

So what do we expect to see on that? We expect to see a large hypooic pancreas. And you'll say, how do I know it's last?

Because this is more than 1 centimetre. Each dot in any machine you have is 1 centimetre. This thing is about 2.

So this is a thick pancreas. Again, that's another example. They went only for the right lobe and they found the body and the left lobe.

OK. Accidentally, not on purpose. And that's the most common thing we expect to find.

Of course, you realise that this is the do dinner. The dissenting to, you know, if you like to be specific. But also with pancreatitis may appear like that.

That's the right lobe of the pancreas. We can see the duodenum at the top with some gas here. And you can see now this very thick.

Mixed ecogenicity pancreas and you will say, Pete, wait a minute, why do you call it mixed ecogenicity? Because it has dark and white areas. It's not uniform.

Thus, it's mixed. So this is again from a dog with pancreatitis. Here is another one from a border collie that was 14 months old, female border collie.

And you can see here again the duodino, we can see a little bit of the right kidney. He, liver, and in between. Peter, I think we've just lost your sound again like we did earlier.

If you can . Just move your stuff around like you did before, please. Can you hear me?

Yes, you're back again. Thank you. OK, sorry about that.

I don't know. I decided, you know, technology when it goes wrong. Sorry about that, my apologies.

I don't know what went today. So basically, here, as I was saying, we have the duodenum at the top. We have the right kidney, we have the liver, and here we can see the right lobe of the pancreas and you can see bright areas, darker areas.

So it's a mixed eogenicity, thick pancreas, because if I go on my dots here, that is definitely more than 1 centimetre. So I have a thick Mexico the pancreas. Sometimes with pancreatitis, other things we may see is that we may have the surrounding mesentery being very bright.

Look how bright this. The part around this lobe of the pancreas is, this is a mixed ecogen is the pancreas again with hyperechoic mesentery, which means perippancreatic inflammation, peritonitis, and we can see a little bit of fluid. Which is also quite common.

We may even see thick duodenum because we have secondary duodenitis, and of course we may even get a dilated common bile duct secondary. Of course, pancreatitis is not only like I showed you here all these were right lobes, we have pancreatitis of the body and the left lobes. So we can see here the body.

Remember between the portal vein and the pylorus around 4 o'clock or 3 to 6, we can see the body quite thick and hypoechoic. It can affect the left lobe of the pancreas. There it is.

You see how thick. This thing is, it's actually clearly more than the 1 centimetre. Any machine you have, these dots are a centimetre, so they can give you a visual idea of the thickness.

And of course with pancreatitis, we have a dilated common bile duct and you say, wait a minute, wait, you didn't say anything about the common bile duct. Actually, We see that that was SIM means 13 years old with a dilated common bile duct here and pancreatitis, and we can see here the portal vein, the common bile duct, is actually just below the portal vein. The other thing that's below the portal vein is the patic artery and you will see how we distinguish them.

If you are in doubt and you see two things below, put the doppler. As you can see here in this transverse view, how dilated this common bile duct is is in comparison to the portal Bay. Yeah, they can be quite big.

Normally, how would they find the common bile duct? I can tell you and you can play with it. As you find the portal vein, remember for the body of the pancreas, go closer to the liver and just on your screen, OK, look on top of the portal vein.

Usually, you will see two vessel-like very small structures. So as you will have the portal vein in long axis, you will see two very small structures on top, hepatic artery and common bile duct. If in doubt, which is what, use the Doppler and it will tell you.

And here is the long axis of the same thing. You see the portal vein here. You see the stomach.

You see the liver and the gallbladder and you can see between the callipers, the common bile duct. For those wondering, the common bile duct normally in the dog should be less than 3 millimetres in diameter. While in the cat that is do here should be less than 4 millimetres in diameter.

This dog, this retriever, 13 years old, that had this common bile duck, he had also disappearance in the right lobe of the pan. Look how thick. And hypoechoic this pancreas is.

When you come to the point of so clearly highlighting the margins of the pancreas, that's not really normal, OK? And you see how hypericoic the mesentery around the pancreas is because we have, as we saw in previous examples, peripancreatic inflammation. Other things we can see in the pancreas, nodules, surprisingly commonly, and when we see them, we get this worrying if you like, what is going on in these nodules.

Pancreatic nodular hyperplasia is very, very normally found in older dogs. OK. This was a Doberman, about 4 years old, OK.

And had nodular hyperplasia. It's not usually related to the presence or absence of inflammation, necrosis, or fibrosis. It is there.

It is quite common. We need to get used to that. But of course it doesn't tell us there is nothing else going on here, but Usually we will see later, tumours, they look a little bit more exciting than just simple nodules.

So you can see it's definitely not a tumour, you will see that it doesn't typically look like that. So unless you have any other indications, don't really worry yourself. So about tumours, usually the exocrines that they are more common, they come from the acumen and the ductal epithelium, and they affect usually all the dogs and cats.

They, we expect about 10 to 12 years old, and they say they are deter years, they are predisposed to pancreatic adenocarcinoma. The endocrine are less common with insulinomas being the most common, but we have also other endocrine like the is that tumours, that basically, include the insulinomas, glucagonomas, and gas. No.

And this may be there and they may be functional, they may be non-functional. Usually with the endocrine, we expect and the medics among us to eat more, middle aged bloodre dogs more commonly affected with this, this kind of tumours. Insulinomas.

You may see them, you may don't. Now what's the caveat? On ultrasound.

You know, you suspect insulinnoma clearly by the appearance, the clinical history and everything, the findings. If you see them on ultrasound, that's a positive finding. If you don't, I'm afraid that's not a negative finding because it can be very small and you may not see them.

So if you see insulin moments, they will show you the exams, they look, the examples, they look like small nodules, hypoechoic, and they're usually spherical or lobular. They are very characteristic, then It's yes, but if you don't see them, it's equivocal. You have to keep it open because they make can be small.

Carcinomas, as you will see in the examples. Carcinomas, you don't have the problem of not seeing them. Carcinomas, they tend to be very big and they push everything around.

So you arrive at an area, you see humongous mass and you have to consider, oh, I mean the area of the pancreas. So you may consider pancreatic origin. Some of them you may see the lobe and you see a big mass over there.

Some of them, the mass is so big that displaces everything that you sit there looking at the mass that doesn't belong to. Liver, it doesn't belong to stomach. It doesn't belong to any intestine.

So you think could it be peritoneal, could it be lymph node, but you have to think, oh, that's the location we see the pancreas and here I have trouble finding it. Can this be also pancreas? And that's usually what I find the most common question we have with carcinomas.

Insulinoma is very typical. When we find it, here is the right globe of the pancreas, again, duodenum. Right lobe of the pancreas and you see this hypoipoid nodular area.

In this case, if I remember correctly, we found about 2 or 3 and in surgery, they found about 40 or 50. So that points that if you see them, yes, it's positive, but if you don't, it's not. And here's another one again.

That we can see this little nodule if I managed to draw. That Left lobe of the pancre. On the other hand, carcinoma.

You are not going to miss them. They are big, distorting. Cavity makesogenicity masses.

You can see here the duodenum. What you need to remember is that if it doesn't fit with any of the other organs in in the area of the pancreas like here, the right lobe of the pancreas, think of. The possibility of pancreatic origin.

Cysts, yeah, we have true cysts, we have pseudocysts. Usually they, they, they, they think it's secretions within pancreatic necrosis with pseudocysts and then they create some thickened wall and we have retention cyst which is usually blockage from Pancreatic duct and the accumulation of secretion. We even have pancreatic bladder that has been described in cats that basically is a cystic dilatation of the pancreatic duct.

Oh that is nice. We have so many different varieties of cysts, so how do I know what it is? And the simple answer is.

I don't. We need to take an aspirin and find out what it is. The ultrasound appearance does not tell me much.

And here we can see the body of the pancreas, you see the stomach? And you can see the right lobe there and we have this almost no wall, very thin wall cysts, and of course you can see here the favourite radiologist mark, which is the question mark. So if in doubt what type of cyst it is, you can put a question mark and you will say, but definitely that's not an abscess.

I actually could. You will say again, but abscesses look more like this one, OK? Basically they have a nice ecogenic stuff within the fluid.

They have a nice thick wall. Yeah, absolutely. But like this abscess, that was also an abs.

On the right lobe of the pancreas near the body, and in this abscess I can't see an ecogenic luminal fluid and I struggle to see the wall. Looking at this, most of us thought, oh, that must be a cyst of some sort. The Api gave us a different, different approach.

And here I think that's another video if this says that basically shows this pancreatic abscess. In the left lobe of the pancreas and you'll say, how do I know that's a pancreatic abscess? Guess what?

I put a needle in there and found out. And you need more info, just the appearance, I will tell you if it is just a cyst, an abscess, or even a hematoma. OK?

So you have to get some more info. I will finish with my favourite image of the pancreas, which is the pancreatic edoema that can be associated with pancreatitis, but you can also see it in cases of hyperbinemia or portal hypertension. And why do I, why do I like that?

Because with pancreatic edoema here also we have a little bit of ascites. OK. You can see the islands of the pancreas, this lovely triangles with these rivers.

Of edoema in between. It's a very characteristic appearance. Here is another one on the right lobe of the pancreas.

Again, I can see the islands and a little bit of fluid in between. And here that was a springer spaniel 4.5 years old.

Here, again, another image of the right globe of the pancreas. It's a very characteristic appearance. It is so characteristic that you can actually recognise it even if you don't have the landmarks.

Like here, I have all these societies. Humongous and then I see this thing and I turned to the clinician and said, this has an edematous pancreas. And he goes, how do you know that's the pancreas?

There is nothing else in the abdomen that looks like. I hope I didn't tyre you and I didn't exceeded my allotted time here. So I would like to thank you for spending this time with me and listening to me and I'm open to any questions you may have.

Bruce and Don, I hope I, I kept on time. Pete, it was absolutely fascinating. And yes, you kept your time very, very nicely.

I think your explanations were so clear and so thorough that you really have, explained it in such a way that, I know certainly things, that you've shown us today, were, were unusual for me to, to see. So, I, I don't have any questions for you at this stage, either from myself or from the audience, at, at the moment. I see there is a, there's one that's just popped up now, and it says, do you need to try and view the common bile duct and pancreatic duct in the same view?

No, you don't actually. The pancreatic duct, you will actually see it and you can follow the common bile duct further back and see the pancreatic duct and you can see the pancreatic duct in the left lobe of the pancreas because simply you know that the black line you see on the left lobe of the pancreas is the pancreatic duct, but you don't have to have them together. Another way to find the common bile duct, sorry, I gave you the shortcut, but another way is, of course, to follow the cystic duct from the gallbladder and then continuing that up and suddenly you will see another tunnel, the empatic duct, joining in.

After that is the, the common bile duct. The technique I told you it's, how shall I call it, the shortcut. So you find the portal vein, look below, there's a common bile duct.

You know, sometimes in clinics, you don't have a lot of time to, to, to spend on organs, so you have to find a more efficient way. But absolutely, you can start with the gallbladder, find the cystic duct, see the pathic duct, common bile duct, and then follow that back to the duodenal papilla and to check also the pancreatic duct. I hope that answers the question, Mallory, or if you have anything else.

Can you share for information on your online courses? That's a good question actually. Alistair, I would love, I don't have a link.

What I can do is because the ultrasound course just finished this year and they, they haven't sent me for next year. We only do it once a year because it's 6 weeks long and it takes quite a bit of time. But what I can do.

I can give you my email, which is relatively simple. It's Pitmantis, my first name.mantis last [email protected].

Actually, I may as well, I think, write it on the Q&A. I don't know if I have that option. Oh, it doesn't.

OK. I suppose if you go to DWR website, you'll find, email me and then I can find them and and locate the website, but I don't think they have arranged for one for Dawn has just popped in the chat box so. Very kind.

Thank you, Dan, appreciate it. Yeah, because my, as my son will tell you, I can't write clearly even if my life depends on it. You know, so I don't know if we have any other questions.

Yes, thank you, Donna, just right now, I had opened the page into the chat box. Excellent. I don't know.

Any other questions? By the way, now you have my email, even if you remember something afterwards, feel free to email me and I will be more than happy to reply back. Usually I come back within 24 hours, but, you know, if it is urgent, just please say urgent.

Otherwise, it may be a couple of days. Yeah, fantastic. I think we're just battling to get it to go out to everybody.

I'm just gonna see if I can, resend it again. Well, Dawn, if you can, I think we only got it out to the panellists last time. So if you can just make sure that the attendees get it as well, that would be great.

Thank you. Just so that everybody has got it. But, Pete, that was absolutely fascinating.

And, yeah, it was really, nice to, to speak to people or to listen to somebody who has, who has such experience and such insight, into What you make look so simple, which we all know, is, is not as simple as what it sounds. It just takes a lot of practise, but these little tricks and nuances that you, that you've given us certainly will make our lives a lot easier. Yeah, I can tell you there's basically the right lobe of the pancreas, guys, give it a try.

It's dead easy and when I show it into courses, people don't believe how easy it is. So start with that. When you're comfortable, move to the body.

The left lobe will trouble you a little bit, but when your hand becomes more confident, you wouldn't have much of an issue. Fantastic. Well, Pete, thank you for your time tonight.

I really do appreciate it and I'm sure all the attendees were hanging on every word, and learning loads from you with all your experience and everything. So thank you for your time tonight. Thank you for having me and thank you for joining after the busiest I'm sure day.

Thanks very much. Thanks folks for everybody for attending tonight and as always, to Dawn, my controller in the background, thank you for making everything happen seamlessly. From myself, it's good night.