Good evening, everybody, and welcome to this Thursday evening session of our 11th annual virtual congress with the webinar vet. First of all, just a warm welcome to all of you and a huge big thank you to all our sponsors. My name is Bruce Stevenson, and I will be chairing the session for this evening.
If you have any questions for our presenter, please, would you just pop them in the Q&A box? So just move your mouse over the screen. The control bar will pop up at the bottom, click on Q&A and type away.
Time permitting, we will answer as many questions as we can tonight. If not, we will do our best to get you some answers, via email over time. So tonight's, first presenter is Jack Pye.
Jack began his career in first opinion practise and soon developed a passion for progression. After successfully qualifying in 2018, Jack decided to pursue a new challenge at a small animal hospital in Norfolk, where he worked solely in an out of hours emergency and critical care setting. He currently works as a locum in various clinical settings.
Jack gained his certificate in ECC in 2022 and has a particular keen interest in continuing personal and professional development. And he has a special interest in ultrasonography. He's currently an IMV imaging ambassador and vet nurse consultant speaker.
Alongside this, he also provides in-house ultrasound training for veterinary professionals. In November 2020, Jack was awarded recognition for his contributions to the veterinary industry by being named as one of the, the London Vet Show's 30 under 30 award winners. Jack is also enthusiastically involved with the British Veterinary Nurse Association after being elected to the council in 2019.
Jack, welcome to the webinar, vet, and it's over to you. Thank you very much for, for the introduction. Thanks everyone for joining in tonight.
There's quite a lot to get through, so hopefully we'll have time for questions at the end, but if not, feel free to email, the webinar vet and they'll get in touch with me, or feel free to contact me on social media as well. I don't mind, that's not a problem at all. So tonight it's about, responding fast to the use of ultrasound in emergency critical care.
There's a few sort of basic, sort of underpinning tools of ultrasound to get started with, and then we'll move on to sort of a bit of normal and abnormal organ structure, and then there's a few case scenarios as well. Just a quick conflict of interest declaration. I have a relevant financial interest arrangement with IMB as previously mentioned, as a brand ambassador and nurse consultant speaker.
And just a quick disclaimer, important to note, everything that's discussed in this webinar should be performed under the instruction of a veterinary surgeon in line with the RCBS code of conduct, which I'm sure we're all aware of. I'm obviously speaking from a nurse point of view, but this is for vets, practise managers, and everyone's sort of included within Osound, and I'll talk a bit more about how people can get involved with it. So, as previously mentioned, that's gone through, so I'll fly through this part.
I qualified in 2018. I'm currently a locum vet nurse, certificate holder in emergency and critical care, under 30, award winner, I'm the imaging brand ambassador and lecturer. I also own a Dachshund called Harry, who's on, on the screen there, who appears throughout the lecture because he's a bit of a car crash.
One, he's a dachshund. Two, he's a vet nurse's dog. So, it's bound to, bound to be a match made in heaven.
And also over 30 tortoises, which are very useful, cause I can't understand scam them. So, and I've found on Facebook and Instagram under Pie_RVN. So feel free to give me a follow.
That's where I tend to post all my updates or anything new that, I'm getting up to or any sort of CBD. And I tend to make a fool out of myself as well. So if you want to laugh, then feel free to have a little, have a little giggle at my expense.
Learning outcomes for this evening. So, hopefully by the end of it, you'll be able to understand the basics of ultrasonography findings in clinical practise. So to be a bit less scared of an ultrasound machine that might be sitting in the corner gathering dust.
Understand how the veterinary team can utilise ultrasound as a diagnostic imaging tool, because it's extremely handy. It can really benefit our patient care and recognise basic findings and understand when the use of ultrasound is indicated in some case scenarios, and then understand how ultrasound can benefit our patient outcomes as well. So, this is one of my favourite quotes that, I had in a bit of a discussion with, a vet, and we basically came to the conclusion that you don't need to be able to find a pancreas or an adrenal gland to start performing an ultrasound scan.
If you take this approach to your ultrasound scans, the only people that aren't, the only things that aren't gonna benefit from that are your patients, because they're gonna suffer at the end of it. Pick it up and have a go. If you can find fluid, you often people know what a bladder looks like, so you already know what fluid looks like.
If you can do that, you're gonna be able to spot free fluid, but we'll discuss things like that later on in the, in the webinar, and hopefully, you'll be able to pick up a few skills and take them into practise and get started and actually start to pick up some clinical findings that are relevant. So, ultimately, when can you use it? Personally, I would say all the time.
People used to get a bit fed up at sometimes in some of the practises I was in, because they would, basically ask, they'd be saying, you can't scan everything. I'd be like, Well, we can, because they're gonna benefit from it. So, I'm just trying to move the thing from the screen, sorry.
It's just getting in the way. . So, ultimately, post-op inpatient monitoring is a huge area that you can get involved with ultrasound scans.
We can become more proactive rather than reactive in these cases. So, anything that's had an X slap, GI surgery, enterectomy, gastrootomy, anything like that, we can do these post-op scans to see whether sort of things like peristalsis is happening, are they getting adequate nutrition to heal? Is there any breakdown of the wound inside?
Have they got any free fluid that's developing? Have they were flushed out, for instance, with their surgery? Is the free fluid reducing in size?
We can measure those pockets and see if the animal is improving. And by doing this, we see a picture on the inside before they start presenting with those declining clinical sort of parameters as such. So, you can be proactive rather than reactive when they're sitting in front of you, deteriorating, and we can be a bit more sort of, one step ahead of the game, if you like.
Triage assessments. So, anything that has sort of trauma, anything that's disneque, potentially that's coming in, we can scan, anything with a clinical indication. So, like those RTA patients that come in, we can check if they've got a bladder, any free fluid.
We can have a look at their chest. So very rapid, sort of, information gathering. Serial scanning, so if you want to keep an eye on things, see if they're sort of progressing or sort of getting worse or getting better, we can sort of perform those scans numerous times.
And then our point of care rosy scans of the thoracic and abdomen, just to sort of focus on those areas, if there's any particular organs that we really want to sort of focus on, if you've got sort of high liver parameters, for instance, you can sort of get a good organs sort of evaluation of, of that liver through ultrasound, which is quite useful. Gap mortality checks. So, again, this sort of ties in with that post-op inpatient monitoring.
If you've got those patients with ileus, then we can sort of keep a good sort of monitoring, sort of scan of whether that's improving. Do we need to change our treatment plan? Is there anything else we can do, or is it going in the right direction?
Also, rabbits, you could potentially use this for, but there are a lot, there is sort of a large amount of gas that it sometimes hinders our ultrasound scans a bit. Cardiac and thorax assessment as well. So we can look for sort of fluid, pleural effusions, pneumothoraxes, for instance, any pericardial effusions.
It's a very rapid sort of form of diagnostic imaging. You don't need to be the best imager. You don't need to find those, sort of, textbook cardiac views in order to find a, pericardial effusion.
So, again, pick it up and have a go. Bladder assessments, we can see whether there's a bladder wall, things like bladder stones, bladder tumours, for instance, a whole host of, of different things. So it's definitely worth sort of using it for, and I'll explain some sort of case scenarios later on that that comes into play.
And also. So foetal assessments, so we can see whether those, we've got a well pinned bitch, for instance, we can see whether those sort of foetuses are in distress potentially by counting their heart rates, which is obviously a, a good indication as to whether we need to sort of get involved with a C-section or not. So the benefits of ultrasound, especially sort of in our ECC setting, it's, non-invasive, sort of, we can identify cavitter infusions very quickly.
There's no radiation exposure, so it's a lot safer. We also can examine the structure of organs rather than sort of a just a, a 2D sort of image of them. It's mobile and portable, so we can take the ultrasound scanners to the patient, as opposed to sort of needing to bring them to a scan room, for instance.
There's a lot of these portable pro becoming available now, and the image quality on them is quite, quite substantially good. They're improving sort of every year on year, and the technology we have available now is definitely worth sort of utilising and, and having a go with. For instance, if you've got a patient that's compromised, we can take that to them whilst they're receiving supplemental oxygen, whilst they're receiving fluids, for instance, if we're rehydrating them, if they're in shock, it can be quite useful.
It gives us rapid answers that enables focused treatment plans, so we tend to be more streamlined in terms of what we need to do. We don't spend, we don't waste any time doing unnecessary things, just to sort of find out an answer. It can give us a lot more information rapidly, and without the need for sort of sedation, and sort of restraint for X-rays, for instance.
And we can also carry out ultrasound guided techniques. So things like fine needle aspirates, it could be very useful for. So if we want to focus that area of, of what we're looking at, we can sort of take fluid samples, take, samples of, sort of biopsies as well.
It can be quite useful. And it is also able to be carried out by both veterinary surgeons and veterinary nurses, which is a very sort of contentious issue. Some people don't sort of necessarily realise that veterinary nurses can carry this out because they think it's diagnosing.
Which I will sort of discuss, over the next couple of slides. So, I would definitely allow your nurses to utilise this skill. They can do it in practise.
It's no different to them taking an X-ray, running bloods, taking a heart rate, for instance. If they're doing an ultrasound scan, and they find free fluid, that free fluid is an observation, just the same as if they took a heart rate and that, that patient is tachycardic. They're gonna come and speak to the vet.
They're gonna notify them of what's going on. You can then make a treatment plan from there, have a clinical discussion. If they're finding free fluids and they find something that looks like a splenic mass, for instance, and they go and speak to the owner and say, Your dog's got a hemangiosarcoma.
I think that's probably crossing the line, which I think we can all agree with. So, as long as they remain within their code of conduct, that's absolutely fine. But it's information gathering, and the more people that harness the use of this diagnostic imaging tool, the better.
But understanding from veterinary professionals of what each other can do is, is also vital to sort of make sure that we're staying safe and sort of doing the best for our patients. So they can obtain the images of diagnostic quality and work within the vet led team. They can perform those point of care ultrasound scans and make observations, not diagnosis, the same as a high temperature, if they were to flag that up, that's not a diagnosis, that's, that's an observation.
And we can perform triage assessments which are gonna assist in improved patient outcomes. And we can lead in those inpatient care and monitoring scans as well, so there tends to be nurses on hospital shifts, so they can sort of do these scans on a regular basis to check sort of how the patient is doing in their treatment plan. And we can know what normal looks like as vet nurses, if we know what normal looks like, abnormalities will sort of flag up, stick out like a sore thumb, and we can then sort of put them to the way of the vet and sort of come up with a treatment plan from there on.
What veterinary nurses can't do. So this is definitely something to bear in mind, because some people aren't aware of this, but we can't perform centesis, so, abdomen and thorax, or entering a body cavity. We can't give a diagnosis, and we can't carry out ultrasound for you without any consent.
So, that's definitely worth considering. A lot of times, as a nurse, I've been asked to perform centesis. I always say no, because it's under, you know, it goes against our code of conduct.
So just vets, nurses, be aware of that, to say you're, you're keeping an arm with do code of conduct. So, now there's just a bit more of the basics of ultra sonography. It can be quite daunting with the physics and everything like that, but I don't delve too much into that.
I just sort of try and keep in line with the, the most important buttons that you need to know to get yourself started in those ECC settings, what you need, mainly to sort of optimise your image quality on the screen. So, sometimes the, the machines have tonnes of buttons on and you're terrified to break it, so people just tend to leave it alone. But these are the main ones that you need to ideally know where they are.
So, with, I refer to the ultrasound scans as pizza slices. Basically, sometimes I have weird analogies for all sorts of different things. If you want a bigger pizza slice, so if you want to see more of that organ, potentially, if you've got a large Labrador, for instance, as opposed to a small cat, you're gonna want to increase that width, so you have a better sort of field of view.
Your depth, again, if you want a deeper sort of image, so if you've got them large Labradors, new fountains, whatever you like, then you're gonna want to increase that depth so you can penetrate further into that sort of patient's chest or abdomen. As opposed to your cats, or small puppies, small dogs, kittens, we can have a much smaller depth. That ties in with our frequency, which, don't worry if you don't remember this, it's best if you, when you go back into practise, have a play with your frequencies on the screen and see how that alters your image quality that you have.
A low frequency gives you a good depth, but poor resolution. So in your larger animals, you're more likely gonna be using lower frequency, so you get a better penetration depth into that patient. However, your image resolution is gonna be slightly compromised.
So it's finding that balancing act between the two. And a higher frequency gives you poor depth, but it'll give you good resolution. So if you've got cats, for instance, or smaller dogs, you can use a higher frequency.
It's not gonna give you as much depth into that sort of patient's abdomen or thorax, but the resolution you're gonna get is gonna be far superior to a lower frequency, so it'll be much more crisper on the screen. Focus points, is worth noting. So it's usually like a little marker down the side of the ultrasound scan, that's what, that can be adjusted up and down.
And that basically means that you can pick your area, which you'd most like to focus on. So, you'll get your best resolution across that slice, sort of, along the ultrasound scan. Freeze and save buttons are important just to know where they are, just so you can capture those images.
If you click freeze a bit too late, don't worry, you usually have some playbacks if you've got that little scroll ball that's on there, you can scroll back through to capture the image that you need to, and always make sure that we're sort of annotating and, and labelling our, our images. If you don't know exactly what you're looking at, because you're sort of maybe not at that sort of skill set yet, don't worry. I would label it with roughly where you are on that patient's, abdomen or chest, just so you can hopefully relocate it if you need to.
And if it's something abnormal, you can obviously flag that up and hopefully relocate that. Calliper button is extremely useful for measuring sort of organs, thickness of sort of gastrointestinal tract and especially things like pockets of free fluids, cos then we can sort of monitor whether they're getting bigger or smaller, and we can see if our patient's sort of status is improving or not. And then lastly, is one that most people tend to forget about.
So, our presets. Most of your ultrasound machines that you'll have in practise will have these presets already plugged in. Use them to your advantage.
That means that if you fiddle with any of the settings, you'll always be able to go back to a basic start of a cat abdomen, large dog abdomen, medium dog abdomen, cat thorax, for instance. So use those to your advantage, and then it sort of helps not to be too scared of the ultrasound machine as well. So, as I previously mentioned, so this is the, the frequency, so low frequency gives you good depth of poor resolution, high frequency, poor depth, good resolution.
This is an, ultrasound image and we've got a kidney, sort of, which is sitting in there, which you can't see very clearly because the depth is so, so down, and sort of deep into that animal when it's, it's unnecessarily sort of deep. But what happens when you increase that, that frequ is you find that you lose the depth of that until you then start to make out more of a kidney. And when you increase it too much, you lose the depth completely, and all you're left with is that top area of the image.
If you then reduce your depth, you'd find that that sort of first few centimetres would be a decent resolution. You'd be able to actually see something. So, have a play with your frequencies on your machine and see how it alters your, your image in front of you.
And then knowing which probe to pick can be quite useful. So, specifically at ECC, you, if you've got a microconvex probe, which is our middle one in, in those three images, you're gonna be absolutely fine. Don't worry if you've not got a cardiac probe.
In terms of sort of your triage scans and your AASTA, your microconvex is gonna be, enough for what you need it to do. So, we'll go through in order. So, linear probe, we tend to use that for things like muscles, tendons, ligaments.
However, Our linear probes give us poor depth. So, if we've got smaller animals like cats, small puppies, small kittens, or, even sort of some small dogs, give your linear probe a go, because the frequency on your linear probe is far higher than any of the other probes on there. So, your image resolution literally will trouble the rest of them.
So it's quite remarkable what, what sort of image qualities your, your linear probes can give you for, for those sort of small, smaller patients that we have. And then our microconvex probe, I tend to sort of refer to that as like our universal probe. We can do that for abdominal sort of point of care ultrasound scans, AA, TAS.
We can get cardiac views of it as well. It is, does tend to fit through the rib spaces, OK. It's just not gonna get you those conventional sort of cardiac images, and sort of M modes and things like that.
But in terms of ECC, we don't really need to be focused on those too much. And then, lastly, our cardiac probe, which has a bit of a square footprint, and that fits between our rib spaces quite nicely. It's got different modes such as their mode that I previously mentioned.
So it's just important just to, if you're doing cardiac workups that you have, have one of those available. But if you've got microconvex probe, everything's sort of in this lecture, you're gonna be absolutely fine in terms of being able to, being able to utilise your ultrasound machine, in ECC and improve your patient sort of care that you're offering. So, a few of the basics.
Sometimes it can get a bit sort of confusing because some of them are a bit similar. But a lot of people say to me, I'm not very good at doing ultrasound scans. I can find a bladder, and that's it.
If you can find a bladder, you know that fluid is black instantly. So, that first image is a bladder, which is our anechoic, sort of, black fluid that's sitting within there. You know that it's contained within a wall, so it's not free flowing, which is another big tick.
So you already know a lot more than you think. So that's good. And then, secondly, we've got like a grainy sort of shadowing.
So that's tend to be sort of things like gas or dense material, as opposed to the image next to it, which is acoustic shadowing. And that's like more of a dense material. So it's quite common with things like foreign bodies.
So there's a bit of a difference between these two. This one's a bit hazy. There's still some sort of ultrasounds, rays sort of penetrating through and being returned back.
Whereas this one is blacking out along the whole screen. There's nothing in between, sort of, from where that sort of dense material is blocking those ultrasound waves. So there's a bit of a difference between the two.
And that just comes with practise, and they're in sort of a bit of anatomy in terms of where we're looking at. So, this is fairly typical for colon, as opposed to our, small intestine. And then our grey and white, which sometimes your ultrasound scan are gonna be full of, is your sort of soft tissue structures, so things like your spleen, your liver, and various other organs throughout.
And, a bit about patient preparation. So, I would always prepare your patient if you can. If you're in ECC sometimes you might not necessarily be able to do a proper sort of surgical grade clip, if you like.
But if you can, it will make your image quality far better, and you'll spend a lot less time sort of faffing around. In terms of ECC, if you haven't got time to clip and you just really need to get some ultrasound images very quickly, you can use Spirit. It's one of those myths that a lot of people will tell you, don't use spirit, cause it'll damage the probe.
As long as you're not submerging your probe and leaving it for hours in spirit, you're not gonna damage it. As long as you're wiping it over at the end and cleaning it and putting it back, it'll be absolutely fine. All the imaging companies will tell you the same.
It's a bit one of those sort of old wives' tales. So, do use Spirit if you need to, it'll help dampen down the fur. Or hair that you've got on your patient.
So, I'd always clip the fur I good pro contact, cause if you don't, what happens is, is when you leave that fur on, the minute you put ultrasound gel on, you create an air barrier, and air will block some of those ultrasound waves from going through. So your images are gonna be a bit crap, really. And you're probably gonna get a bit fed up, chuck your toys out of your pram, never go back to the ultrasound machine again cause you feel like you're rubbish at it.
So, If you have got time, clip them, degrease the skin with skin preparation, so for like diluted lorhexidine, that allows your gel to set in nicely, and it'll just help with your, your sort of pro contact and the image quality you get. A nice, quiet dark room so your patient's nice and settled. Sedation and restraint, if needed.
Obviously, it's down to the vet surgeon's direction. And also analgesic considerations. A lot of these patients sometimes won't tolerate an ultrasound scan, so we do need to think why they can be they can be painful.
So a lot of the time they've got something wrong with them, that's why we're scanning them. So do consider analgesia. I spoke to someone not so long back who had free fluid in their abdomen.
They had an ultrasound scan, they said it was the most horrifically painful thing they've ever, ever had when someone started pushing on their abdomen with their ultrasound probes that they, our patients are likely feeling that too. So, if they're not tolerating it, consider why, give them some analgesia, come back to them 10 minutes later, see if they're any better. Lateral recumbency is often most popular, but we can also do them on their backs or standing, depends on the patient's sort of, presentation if they're disne, we're obviously not gonna really want to lay them on their sides.
They're standing up, you know, you can get a sort of some chest views that way, that's not a problem. On their backs, I never thought any sort of patient would tolerate laying on their back conscious, but they do actually tolerate it remarkably well. So, if they've got a comfy bed underneath, it also allows you to do both sides of the abdomen in one go, rather than having to flip them over.
And I'll mention why it's important to do both sides of the abdomen if you have any sort of concerns later. But ultimately, patient preparation, better images obtained, and that's my dog when he ate his foreign body. So, next thing is ecogenicity.
So, we can use this in our sort of clinical reports as such. It's how we can sort of identify, well, not identify, but it's how we can sort of compare, and use them in sort of our, our reports in terms of our, our organ structures and, and what they're looking like. Hypoechoic, dark grey, so I just think hypo low being dark grey.
Hyper is light grey, so I tend to refer to our, diaphragm which is running by the side of the liver here, is a hypoechoic sort of bright white line, . And then isoechoic is equal in ecogenicity, so if you refer in like the liver and the spleen, they look similar in their ecogenicity in terms of their greyness, that's the term that you can use. And anechoic is black.
As I previously mentioned, knowing the difference between free fluid and fluid filled organ structures is a massive sort of thing that you need to know, ideally sort of in these ECC scenarios, is the fluid contained within an anatomical structure or is it free flowing? Cos it's gonna drastically change your sort of treatment plans and and what you look to do in the next steps. Their characteristics are very similar.
So, we've got fluid, which is anechoic black, sort of, in appearance. The only difference is between really, isn't, if you know a bit of anatomy and physiology, that's great, cause you're gonna know roughly where these are supposed to be situated. So, we've got bladder, gallbladder, uterus.
This is obviously abnormal, but it's contained. It's nice and smooth walled. All of these are sort of smooth-walled, and they're contained.
However, free fluids, anechoic black, sort of an appearance, but it's very jagged edges. It's not smooth. It's sort of free flowing through the abdomen.
You can agitate it if you were to sort of, provoke that abdomen sort of thing, you'd see that sort of flowing around and things sort of floating in it. And there's no organ or sort of border surround. So, knowing the difference is, is extremely important to sort of your, your treatment plan going forward.
So, we've got a few of the, the main organs that I would do on an abdominal scan. This is sort of normal photos, and they'll be followed by some common abnormalities, and things to look out for, in sort of emergency and critical care, or just sort of if you're doing any ultrasound scans, it doesn't have to be an ECC. And Harry is kindly demonstrating roughly where I'd be situating the probe for those, for those images.
So, liver is situated in our diaphragmatic hepatic window, so it's start right at that zippy sternum. And the liver always runs alongside the diaphragm. So, our diaphragm's this bright white line, and our liver is situated just next to it.
So, that diaphragm is a nice, and landmark to know that we're at the liver. Some people don't know whether it's the liver or the spleen. Is there a diaphragm next to it?
It's likely to be the liver, unless there's free fluids, sort of heavy amounts of free fluid in your abdomen that's sort of distorting where all your organs are. It can be vascular in appearance depending on what sort of axis we've got the probe in, and we can often see things like the billary tree or sort of portal veins running through. Mid-gray sort of an appearance, as that echogenicity, and we can also get a gallbladder view, through that.
Sort of through that image, as we found sort of up and down through the liver lobes. So, our gallbladder will be situated just sort of in the middle of those liver lobes. Cats can sometimes have a bilobed gallbladder, so that's, a bilobed gallbladder, which is perfectly normal.
And also through this view, we can also get a cardiac view, which will be sitting through that diaphragm. So that can sort of help in like a triage scan that you can sort of tick a few things off and see if there's things like pleural effusion or pericardial effusion. And, some liver and gallbladder abnormalities.
So, we can get mixed ecogenicity, so we can get like a mottled, sort of, classic, effect. So, this is like a bit of a mottled, mixed ecogenicity liver. And we can get abnormal shapes, uneven edges.
So if it's not smooth against that diaphragm, is there sort of maybe some neoplasia sort of changes going on, or sort of abnormal sort of edges. We can get free fluid sort of surrounding the liver, but it might not necessarily be associated specifically with the liver. So it's important to then do a full eva evaluation of the different organs that we have.
We can get distended vasculature, so this biary tree sort of running through, it's quite distended. That was a gallbladder blockage. And then we can also get some gallbladder abnormalities when you're doing, focusing on this area.
So, first one we've got is a, we've got our gallbladder here, and it's a bit edoema just around the outside, which is referred to as like a gallbladder halo. It's always important if you do see that to scan the heart because sometimes there can be pericardial effusions present, or it could be due to, anaphylaxis as well. And then our second one is the gallbladder mucous seal, and it looks like someone's sort of cut a kiwi or a grapefruit, and that's sort of sitting within that gallbladder.
Both, extremely painful, so make sure that we have got analgesia on board if you do come across any of these. And while we're on the subject of our, liver, gallbladder, and diaphragm, our diaphragm decides to chuck a spanner in the works, just to make the ultrasound a bit more tricky for you. And it basically, because it's so hyperrechoic, it causes a mirror effect.
So, it's basically looking like the liver and the gallbladder are sitting in the chest because it's mirroring that image straight through into the chest. The reason why I, I sort of mention this as being quite important is that if you've got abdominal fluid sitting between the liver and the diaphragm, it can look like there is free fluid in the chest and vice versa. So it's important to rule out whether it's in the abdomenal or the chest.
So, that's why I would do both an AAST and a TFAST, just to sort of get a clear, clear image of that. So you can see as you move that probe along, those sort of planes of image that it follows alongside that sort of diaphragm, you've got a complete mirror image on the other side. Moving on, from liver is then I'd sort of start to follow alongside the rib cage.
We'd come across sort of stomach and gastrointestinal tract, situated in the cranial abdomen underneath the rib cage, mixed appearance depending on the food intake. So, I'd always ask your sort of, pet carers when they last gave, gave them any food, if they've been starved, but the stomach's still full, then you might sort of start to wonder, are they not digesting the food properly, or have they actually given them breakfast and just trying to take porkies or not? So, top left is our stomach that's full of food, so it's blocking those old some ways, because that dense materials sitting in the stomach, as opposed to our empty stomach on the right hand side there, where you can sort of see the stomach folds in the middle.
We have a structural wall of the stomach, and it's located usually sort of between the liver and the spleen. Sometimes it can sort of hinder your old sound images quite a lot if there's a lot of gas in there, for instance, if they're aerophagic or if they've just recently eaten. But we can get a lot of information, sort of, from that stomach, potentially, if there's any sort of gastrointestinal clinical indications.
Intestines tend to look like coffee beans. This is a longitudinal piece of, gastrointestinal tract. But if you sort of cut it off there, then this sort of section would look like a coffee bean.
And we can also look for things like peristalsis as well. So, we want to see that snaking through, ideally, and sort of monitoring that, that, that intestinal tract is, is working sufficiently. Intestinal tract again, so as I've sort of previously mentioned, we can measure the thickness, with our calliper sort of tools as well to see if there's any irritation there potentially.
And we can also get those cross-sectional views, which are sort of typical coffee beans as well. Some more gastrointestinal abnormalities. So, gas shadow and acoustic shadowing, quite common with our foreign bodies.
This top right image here is sort of fairly typical of, sort of foreign body that we'd be looking at. We can get poor gut motility, so, ileus if there's lack of peristalsis, which is very important in terms of any post-op recover. Recovery, potentially, and what's causing that ileus.
We can get intestinal tumours, so they tend to be quite hypoechoic surrounding the lumen of the intestine, which is here. And then we've got a video where you can follow that, intestinal tumour. You can follow the lumen right the way through that intestinal tumour as well.
We can get inflamed layering and also fluid distension as well, which would all be abnormalities, which are gonna sort of, they're gonna stick out quite clearly. And stomach abnormality. So, we can get lots of fluid.
So, this is our stomach, and there's something in that stomach that's blocking those old sun waves, and we're get an acoustic shadowing below that. This was a Labrador on a training session that had decided to be a sock that morning. So, he was demonstrating quite nicely, that sort of foreign body, fairly sort of typical acoustic shadow and sit in the stomach and a large amount of fluid sort of sloshing around in there as well, cause it potentially can't pass past that.
And then moving on to our spleen. So, situated in the mid abdomen along the rib cage, it does obviously flip round in, in our larger animals as well. So you'll, you'll locate this on both sides.
It's mid-grain echogenic quite sort of slug-shaped. I, I call it. I have these weird analogies for everything, so do bear with me.
And we can often locate the high list of the, spleen. So the main blood supply going into the spleen. It tends to look a bit like a whale's tail, where it bifurcates off into the two different sort of sections.
So, quite close to the peripheral edge of the, of the ultrasound scan, so you can reduce that depth way up and sort of fan through that spleen so we can get a nice sort of assessment of the head right through to the tail of the spleen. We can look for things like, any sort of cavitated structures, any nodules. If there's an absence of a highlus, we can look for as well, or if it's sort of enlarged.
Splenic abnormalities, which I'm sure we're all aware of, because they tend to come in on a Friday evening when you're all getting ready to go home. Tend to sort of present with like a mixed eogenicity, mottled cavitated appearance. This is quite sort of fairly typical of that mottled, cavitated, sort of nastiness, that we can see on ultrasound scans.
Enlarged, we can get splenomegaly. Torsion potentially can cause it to be enlarged and sort of engorged. Any tumours, sort of fairly sort of similar to that sort of mottled appearance.
And free fluid as well can be associated, but it's not necessarily associated with that spleen. So, if you do have free fluid, we ideally want to be assessing that whole spleen look like, is there a mass associated with it, which might be potentially bleeding into the abdomen. And then, moving on to our kidneys, located in the hy axial muscle region, mid abdomen.
Right kidney is situated more cranial than the left, so just bear that in mind. You can find the right kidney from them being in the right lateral, but you tend to have to go under and up, and it can be a bit painful. So, I just prefer to pop them into the other lateral to get a good view of that.
Mix ecogenicity throughout due to the structural makeup. I used to say that these are really easy to find when I was doing my, when I started off doing my training. Soon found that they're not actually that easy to find, sometimes they're a bit mobile, so don't beat yourself up if you can't find them.
But the nice thing is that they are easily identifiable when you do find them, so you know what you're looking at. And then, kidney abnormalities, so, compared to the previous images, believe it or not, that is a kidney. It's just about ticking off every abnormality in the book, I think.
There's a complete loss of structural detail. We can get size differences so we can get a small or large kidney if there's blockages, for instance. And we get associated tumours with our kidneys or irregular shapes, any blockages like kidney stones, potentially or urethral obstructions as well, edematous or echogenic changes as well.
So, here, we've got free fluids surrounding that kidney. So there's a bit edematous. We've got hydronephrosis, and we've also got some, kidney stones that are sitting there which are blocking those ultrasound waves.
We're losing sort of the, the definition, the resolution underneath those, where it's blocking the rays from passing through. And in our bladder, so situated in our caudal abdomen, structural wall, unless it's ruptured. So it's always a good thing to look for if they've been in any sort of trauma incident.
So, our road traffic accidents, for instance, scan them and look for a bladder if you can't easily palpate one. Filled with anechoic fluid, nice. Easily identifiable.
It's always worth bearing in mind, if you can't, if you're struggling to find a bladder, just sort of think to yourself how much pressure you're putting onto the probe. The more pressure you put onto that to try and find it, you can press it and you'll potentially lose it. So just reduce that a bit and see if it then comes into view, potentially.
This bladder isn't actually normal, there's a lot, large amount of sort of sediment sitting in here, which is my dog's bladder as well, just to tick another sort of medical, condition off the list. If you agitated that, you'd find that that would snow globe all all the way around. And then some bladder abnormalities, so we can get uroli, so blocking of our sound waves.
So it'd be very sort of similar in appearance to how our, kidney was looking with that, with that kidney stone. So, you just lose the image, from underneath. We can get sediment, crystal urea, which sort of tends to present, sort of like that snow globe effect.
Your abdomen, which you, you would then struggle to find that bladder. We can get thickened and inflamed walls. So, here we've got a bladder, which is postcystootomy, which is why the, the, the wall is thickened.
In this respect, we could then do post-op scans to see whether that thickness was reducing and if that sort of inflammation was coming down. We can get tumours, associated with the sort of bladder neck or bladder wall. So this one here, you could sort of convince yourself, is it a tumour or is, or is that a sediment?
The way to tell the difference between the two is to agitate the bladder and see if it starts to swell around like that snow globe or stand your Patient up and see if it moves. That one was sediment, as opposed to, a tumour. However, this one here is a bladder tumour.
So we've got that sort of connected to that wall. If you agitated that, it didn't do anything. If you stood the, the patient up, it stayed in the same position as well.
And then we can get bladder distention as well. So our classic sort of blocked bladder caps, for instance, it's always worth scanning these because our, X-rays, as good as X-rays are, and they, they're another sort of imaging modality. They don't always pick up certain sort of types of bladder stone, for instance.
So, our ultrasound scans can be a bit more sort of sensitive to that. This one was a, blocked bladder that, had a urinary cat to place and we were just scanning it to check placement, making sure that it was in far enough. And what we came across was the diverticulum sitting within the bladder, which was causing that obstruction to sort of to keep happening.
So here's some abdominal in practise scenarios of when, old time really comes in useful. This can be from, a vet nurse's sort of perspective, or it can be from the vet's perspective as well, but working as a TV, it can just sort of help in terms of the case load that we're seeing. Obviously, it, most places are probably a bit short-staffed.
So utilise people's skills as much as possible to take the load off and improve our patient care and outcomes. Case scenario one, so, everyone usually knows where this is going before I've even started to talk about anything, because I've looked at the breed and already made their assumptions. They're probably correct.
However, this one was presented out of hours in a, busy, sort of, emergency hospital. The vet was tied up in, with other emergencies, so just asked for this one to be triaged. On triage, it was tachycardic, hypertensive, pale mucous membranes, tachypenic.
Collapsed and lethargic, so busy hospital, out of hours, vets were dealing with other emergencies, there was RVNs available, fed the clinical fundings back to the vet. In this instance, they sort of said, they quickly spoke to the owner, said what we'd found, and asked to perform an ultrasound scan. There was still, obviously, lots of emergencies coming through.
So this was sort of passed on to an RVN to carry out, in terms of our sort of AAS to see whether there was anything obvious, sort of presenting. We could then gain more information of what's going on. We have sort of permission to place IVs, take blood samples, and, and sort of further sort of diagnostics.
On, AFAST findings, there was large amounts of free fluid and a large sort of cavitated structure. So those images were saved, labelled, saved to the patient's record. And then at that point, the vet was pulled out of the potentially emergency itchy ear, for instance, and, sort of diverted to this sort of genuine emergency.
At that point, you can then start to plan ahead. Instead of waiting potentially half an hour for that scan to be carried out whilst you get on top of things, you can place IVs, you can take bloods, get them running, you can set up an X-ray, potentially, to see if there's any sort of, mets in the chest. We can set up a theatre.
You're then one step ahead of the game, rather than potentially being behind, waiting for that scan to sort of be done. As a vet nurse in this instance, I would go to the vet and say, there's large amounts of free fluid in the abdomen. There's a structure that looks sort of cavitated and motts, and I think it's associated with the spleen, and it's measuring about this, that there's, there's very large amounts of free fluid in, in the abdomen.
That's not a diagnosis, that's an observation, a clinical finding, same as tachycardia, hypertensive, all of those things. So we're not diagnosing, we're, we're gathering that clinical information for them to make their decisions from there. One of my little, tips is that if you scan something and it goes to surgery, I'd always go and look at it, especially when you're learning ultrasounds.
So there's a bit of gore for you. This is that, cavitated mass that you saw on the, the previous image. So, yeah.
This case ended with a positive outcome for the patient, which This is what I mean by sort of improved patient outcomes and improved patient care, because the ultrasound actors as part of that puzzle sort of piece, enabled veterinary teams to sort of give informed information to the owner. We can sort of then enable them to sort of make sort of faster treatment plans and intervention as well. Case scenario two, this is two separate cases, so the, the one on the left here, was a basic sort of interception that came in.
This is just a scan on a linear probe, which you can see the image resolution is sort of far superior to that of a microconvex probe, . That was just sort of, for, for information, really. The one on the right-hand side was a 6 month old cat with a history of chronic vomiting and diarrhoea.
It had enterectomy enterectomy surgery for interception the day before. It was then hospitalised post-op, It was a locum practise I went into, I just asked whether I could do, a scan just to check that it was, it had peristalsis, whether the nutrition was working through, if there was any free fluid, potentially. And we did come across the unfortunate event that it had re-intersuscepted.
. Unfortunately, this one had a large amount of gut removed the day before, so there wasn't any more scope to remove anymore. So it didn't end particularly well in terms of the outcome. However, that patient didn't sit in the kennel, clinically deteriorating until it was noticeable.
We picked up beforehand, and if it was picked up even sooner, we could have manipulated that apart rather than having to sort of consider things like enterectomies again. The benefit, sort of, things like this as well, we can do this kennel side. We can take the ultrasound machine to that sort of patient that's recovering in their kennel, instead of having to take them to a scan room.
And in these cases of, like, gastrointestinal surgery, I would always recommend to try to do, morning and evening scans as a minimum, or afternoon, evening sometimes, and everyone's about to leave if you need to then get involved with something. Put them on the hospital sheet, have them as a medication to tick off so that they actually get done, and you're, you're gonna pick up on things and improve your sort of patient care that you're offering. And this is, one of my favourite cases.
This is an eight year old female neutered greyhound that was presented. Again, vet's very, this was during the day. Vets are sort of very busy with other consults.
So they brought the patient on the back. She was tachycardia, pyreexic, lethargic, vomiting, and dry, dark pink mucus membranes. Myself and tachycardia greyhounds always have a bit of a history that there's always something really dramatically wrong with them.
So, it was asked that we could take bloods, feed them back to the vet, and then sort of go from there. Took bloods. There was a bit of dehydration.
Manual PCV was sort of, 70%. Lots of sort of, well, indications of hypovolemia on heart scans as well. So we just continued vital parameter monitoring, and then we were asked to do some, sort of diagnostic imaging in terms of ultrasound scans.
On ultrasound scan, this is what we are faced with. So, we have sort of distended loops of intestine. So, this is our intestine here with, sort of fluid distention.
And then we have this sort of large amounts of fluid regurgitate regurgitating backwards and forwards. And then again, more intestines sort of dilated there as well. When I see this sort of regurgitating fluid going backwards and forwards, I'm always very suspicious of things like, foreign body ingestion.
There's a blockage somewhere potentially. So he went on a bit of a foreign body hunt for acoustic shadowing somewhere throughout that small intestine. Couldn't find any with the patient in right lateral, tried and tried and tried.
Couldn't find anything, rehydrated them, pain relief, re-scanned them in sort of 20 minutes, popped them onto their left-hand side, and straight away, we're faced with, the images you've already seen of acoustic shadowing, following right the way through that ultrasound image. It's blocking the entire image below anything from that sort of specific area. And also at different sort of angles, it's sort of still there, so it's not just a random sort of bit of gas or a random piece of sort of dense material.
From there, the vet, obviously, I was sort of fed the information back to the vet. They had all of that information there for them to make an informed decision and speak to the, the client in terms of what they wish to then sort of do, following on from that. They did opt for surgery, as an ex-lap to see what was going on.
Adamant that the patient hadn't eaten anything that it shouldn't do, which we've heard all too many times, I'm sure. . And at that point, I was then like, Oh, God, if there's nothing wrong in this dog's abdomen, I'm gonna look very, very silly.
But lo and behold, surgery revealed there was a skewer perforating the intestine. So that would have been the part that was causing the, the acoustic shadowing coming from the small intestine. At that point, there was no free fluid on the scan, but if that would have been left any longer, I think you'd start to see things like sepsis or like, you know, free fluid, gastrointestinal contents leaking into the abdomen.
And I think this little bit was saving it from a bit of a plug at that point. Post-op care in terms of these, patients. So, repeat scans for that enterotomy site, make sure there's no free fluid, no breakdown of that sort of wound internally.
Morning and sort of afternoon as a minimum, but that can be increased to sort of 3 times a day if you've got better nurses doing the scans that are available on hospital shifts, for instance. But I'm mainly looking with that free fluid and peristalsis to make sure that nutritionist is performing that vital role in recovery, and there's no signs of breakdown. Case scenario 4, I'm sure you already know where that's going as well, again, with the, with the classic breed.
So, we've got a chocolate Labrador here, with this, distended, sort of fluid-filled stomach. And then we found acoustic shadowing as well, again, sort of, blocking those ultrasound rays. And then we've got sloshing of those fluid in the intestines.
So that's that regurgitating fluid in those intestines again. Clinical signs of vomiting, lethargy, and dehydration. This patient was about 6 months old and laid on his side for an ultrasound scan without anyone having to hold him, which I think, you know, they're, they're a bit sick at that point.
And we removed a corn on the cob from his intestine. Again, typical foreign body sort of presentation in that intestine, and this, that, that typical fluid regurgitate backwards and forwards. So if you do see that, just bear in mind potential sort of foreign body risk.
Just a recap about post-op care. So, gastrointestinal surgeries. Again, I do repeat scans for, for those, GI tract surgeries, morning and afternoon, add it to the hospital sheets, regular observations of pain scores, looking for a free fluid peristalsis.
That nutrition is a vital role in their recovery, so make sure that they're feeding sort of fairly quickly. We can see whether that's passing through or do we need to sort of intervene with sort of, assisted feeding plans, pro-kinetics, various things like that. Nurses can leave that inpatient scan monitoring and feed that back to the hospital vet, and it also enables sort of people to then, be proactive instead of reactive, so we can pick up on those, deterioration before they're clinically, sort of visually in front of us.
And then moving on to thoracic point of care ultrasound scan, there's not as much to, to, look at in the chest. But again, a lot of people can be quite scared of doing this because they're worried that they can't find those classic cardiac views. In terms of ECC, if you can find free fluid, if you can find a pericardial effusion, you can look at the chambers to see if there's any things like thrombuses that have formed, or if there's any pleural effusion or evidence anemothorax.
That's all we really need to be able to do in those ECC scenarios. So, thoracic ultrasound scans, we can look at the heart, the lung fields, and the pleural space. Basically, we can do that in lateral, sternal, however, the patient is most comfortable in terms of how they're sitting.
It can be a bit tricky if they're dysneic, because they're panting, but basically ask yourself the questions. Is there fluid where it shouldn't be? Is there soft tissue structures where there shouldn't be?
Is there things like thrombosis forming, and what, like, the size of the changes in the contractility looking like? Lung field assessment, assessment of the lung fields, we can do in lateral or sternal recumbency, you want to clip a patch between the ribs based on the most prominent area of that chest. This gives us a rapid, information sort of gathering in a very non-invasive way.
We can see whether there's any pleural effusion. We can see whether there's a glide sign, which I'll move, which I'll cover, sort of very shortly. We can look for things like bee lines, which are bad.
They can sort of indicate things like aspiration, ammonia. But we can get a very, sort of, a lot of information very quickly from sort of a very sort of small, sort of field of view. Two lines that you're looking for in terms of lung field.
So A lines, absolutely fine, normal. They come in their horizontal sort of shapes. The ribs will block the ultrasound waves, and you'll get like a typical thing that's called a gate to sign.
So, someone's put a little eyes on there for you so you can remember it. But these are the rib spaces that are Blocking those ultrasound ways because the bone is so dense that the ultrasound can't pass through. And then we have our lung fields sitting in between that.
Ideally, we want to be seeing that slide backwards and forwards, which will be our glide sign. If there is an absence of glide sign, we're looking at things like potentially like pneumothoraxis. And then moving on to our bee lines, which I just sort of say beelines are bad.
They're abnormal. So, unless there's sort of very few of them. You might hear them referred to as things like rockets, flashlights, search lights, and it can be indicative of things like aspiration, ammonia, fluid on the lungs.
These extend right the way throughout the image, and they're sort of very hyperchoic, bright white, sort of flashlights flashing all the way down. And then the glide sign, as I previously mentioned, so this is that typical sort of sliding motion that we want to be seeing. And if there's an absence of that glide sign, it can be due to a pneumothorax, normal, the normal glide sign is the lung sliding against the chest wall.
If they've been in lateral for a period of time, it's, it's sort of quite important just to sit them up for a bit, in case the lung has been compressed potentially and you're gonna sort of get a bit hindered image. And then, our pneumothorax, so, ultrasound isn't, doesn't have to be the only image modality. It works nicely with, obviously, radiographs as well, just to tie in what we're seeing.
So don't solely rely on it. It is very useful. So, this is our scan, that ties in with that image at the top.
So, this is our lung field here, and it's just not really sliding. It's kind of bouncing up and down as opposed to that nice slide that you saw before. It's not doing what we ideally really want it to be doing.
And then post drainage, so we took 2.7 litres of air out of this, patient's chest. After that, we then got that white hyperchoic line is starting to slide a bit better, as opposed to just bouncing up and down.
It's not perfect still, but it's better than what it was before. And then a few lung abnormalities, free fluid in that pleural cavity. Again, we don't need to be sort of, the best sonographer in the world to, to, to spot this free fluid in the pleural cavity.
We don't need to be getting those sort of routine cardiac views to, to check that chest. We can look for things like beelines and rockets that I've previously mentioned, absence of a glide sign, any presence of abdominal organs, for instance, like diaphramatic rupture and hernia, or any presence of sort of soft tissue structures and masses that shouldn't be there. So large amounts of free fluid in, in the chest will look like that, sort of like things sort of waving at you, bits of fibrin floating in the chest.
And then also this area here, so we've got our heart beating and lots of free, sort of free fluid surrounding it, as a pleural effusion. Getting a cardiac view, so I call that sort of the perfect view in my eyes in terms of if things come in dysneic, you're gonna get a lot of information if you can get a left atrium aortic ratio. If that's over 1.6 centimetres as a ratio, it's likely that your cause of whatever's going on is a cardiac cause as opposed to anything else.
So that will rule out or rule in a lot of things very quickly if you can get that image. It's very difficult to say how to get that image on a, on a webinar, for instance. That's something that you need to practically learn, ideally on your, on your fit to patients initially, so you can just get to grips with it.
What we're looking for is to get a Mercedes-Benz signed within that aorta, and then we've got our left atrium and we can basically measure along both, with our calliper, and it'll give you that ratio. Further cardiac abnormality. So, pericardial fusion, again, this isn't like a conventional heart for you as such, but we've got a large amount of pericardial effusion around the outside.
And that's also highlighting a bit of a, a, sort of a mass that's sitting within that pericardium as well, due to the difference in ecogenicity, sort of putting a ring around it as such. And then again, we've got a large sort of pericardial effusion, which is causing tamperard in this patient cos it's sort of restricting how that heart can, can do its job properly. And then another, abnormality, which is our, thrombus that's sitting in one of the chambers bouncing around.
Again, if you do see anything like these, you don't need to be able to get those conventional heart views, and they're gonna stick out like a sore thumb. So, pop the pro on and have a go. So further cardiac abnormalities, these are one of the worst sort of thrombuses that I've seen, within the chamber.
Obviously, that's not gonna be very pleasant if it escapes, somehow, but it looks far too large to even think about escaping. But both abnormalities, so a large sort of thrombus. Again, don't need to be getting those textbook cardiac views to be able to see this in an ECC setting.
You're gonna see those abnormalities in the high off. And then a thoracic, case example. So, this is a patient that came in out of hours, to us.
This is how it presented. So, it's in oxygen, very dynaic. Obviously, brachycephalic as well.
So it's got a few things going against it. Rapid, sort of, investigations included, an ultrasound scan, which can be done while it was receiving supplemental oxygen. This is what we found.
You've seen this video already. Large amounts of free fluid in the chest. Meant that we then could start preparing for thoracocentesis, and drain that off.
That patient was like a completely different patient as soon as that fluid was drained off, so it's like a life-saving procedure, essentially. So, this SBO2 drastically improved. It was able to sort of breathe much better by itself without sort of the need for oxygen support as well.
So, buys you a bit of time in, in order to find out what's going on, improve patient outcomes, and also probably a nice bit of job satisfaction for everyone involved as well. So, some top tips, I've probably flown through them quite quickly, just because I wanted to get a chance if you wanted to ask any questions, but if there is any that we don't get a chance, feel free to message me on Instagram or Facebook. Practise as much as possible.
Pre-medicated patients can work quite nicely if it's appropriate. So bit space tend to be clips for your abdomen scans anyway. Learn what the probe does.
Small movements, turning and angles, is more than one way to do it, but just learn that them small movements make, make quite a big difference. Prepare your patient, build up your image library, and be patient as well, it doesn't just happen the first time you're gonna do it, stick at it, build up sort of that image library as well, take pictures, send them to me if you want, my phone's full of ultrasound images. Watch more experienced stenographers if they're in your practise and ask questions.
Sometimes they fall into the trap of not saying anything. But ultimately, just have a go. So many people are too scared to have a go because they're not the best stenographer in their practise, or there's always someone better out there than them.
There is always gonna be someone out there better than you. But that, you know, have a go. The, the worst, there's not really too much that can go wrong.
And again, you don't need to be able to find a pancreas or an adrenal gland to start doing an ultrasound scan. So, yeah, thank you for, watching. If there's any questions I can answer them.
I do also provide in-house ultrasound CPD as well, so feel free to get in touch, which is more of a practical element, aside to this and a bit more in-depth, of a lecture beforehand. Yeah, thank you. Jack, thank you so much.
That was absolutely amazing. And we've had some fantastic comments through. Echoing that, your, your approach to it.
And I love the idea of just, just try it. Just get on with it. And, I have to say that the heart scares me no end.
And, and saying, you know, just put a probe on and you're gonna see stuff. That's fantastic advice. I, I love it.
So thank you very, very much for your time and for sharing it. I bet your in-house, in-person ultrasonography courses are an absolute Mine of information, so yeah, good for you. Thank you so much.
Oh thank you. Folks, I'm afraid we don't have enough time to to take questions tonight, but as Jack said, you can get hold of him, on social media, or all the questions that have come in will, go through, to Dawn, and she will get those over to Jack, and he will do the best he can, to answer those for you. So, once again, thank you so much, Jack, for your time.
No worries. Thank you, everyone. Our next session tonight is pre-recorded as dawn popped in the chat box, because our speaker, was not available on a strong enough Wi Fi to be able to broadcast for us.
So it is pre-recorded, which means that at the end, There won't be any questions. Now, please don't let that stop you popping questions in. Pete has agreed that, he would look at the questions and get back to you, in the next couple of days.
So if you want questions, please feel free to pop them in the Q&A box. But Pete Manus graduated from Aristotle University in Greece in 1994. He completed a diagnostic imaging residency at the Royal Veterinary College and then worked in first opinion practise and referral hospitals in London.
Pete spent a year at the Swedish Agricultural University in Uppsala. And then in 2000, he moved to the Royal College, where he became a senior lecturer in radiology. He remained there, until joining Dick White Referrals in 2017.
And then in 2019, he was appointed the head of diagnostic imaging. Pete is a European and RCVS specialist in veterinary diagnostic imaging. He's a fellow of the Higher Education Academy and a fellow of the Royal College of Veterinary Surgeons.
He is a regular author, speaker, and CPD tutor on small animal radiology, ultrasonography, CT and MRI imaging. So without further ado from me, Kyle, please start the broadcast. Well, hello, everyone, and welcome to this lecture that will be recorded for you with the title Wiss Dog Vomiting?
Abdominal Ray of the Dog and Cat. My name is Pete Montes. I am a radiologist working at Dick White Referrals where I am the head of diagnostic imaging there.
And in this lecture, we are going to go through the whole abdominal radiology. We'll concentrate also on the GI tract a little bit. More to get the basics out of it, but then we will expand to the rest and hopefully we'll finish within about, hopefully about 1 hour, 90 minutes somewhere in there, depends on the speed.
Now, for the duration of the lecture, I will have my video off so I can concentrate also on the slides and then hopefully I will remember to turn it on at the end. So without a further ado, in this kind of situation, and as soon as PowerPoint decides to function. So basically, every time I, I start a lecture like that, they like to give people some ideas of how to go about reading radiographs and without spending too much time on it, just the basics, the only rule is for you to read the whole radiography.
That's all we need to do. Easier said than done to my experience, probably it's easier for you than for me, but what I recommend to my students is try to go anatomically, organ by organ. See which organs we see normally in an abdominal radiograph, which organs we may see and which organs we shouldn't see, and try to look at all of them.
Then you have to identify the visual, visual features. So what do I mean by that? When you find something, That is actually looking to you abnormal, looking odd, you're not sure.
OK. It doesn't exactly look normal, but it could be. It doesn't matter.
Whatever you are not exactly sure, stop and describe. The radiographic signs number. Size Shape Location Margination And radio opacity.
OK. So avoid things like, you know, there is an opacity in the cranial abdom. That can be two things that could be, sorry, too many things, you know, we can have.
A better description that gives our brain the chance to come with an answer. So for example, we have one. You know, 2 centimetre, rounded, well marginated or, you know, marginate in the periphery, however you want to describe it, soft tissue opacity within the caudal liver lobe, for example.
This will give you an idea and your brain will start working more specifically to arrive at the diagnosis. Now, you notice one thing that I didn't mention, but now I will clarify for you. When we say radioacity, be specific.
You know, don't just say this is opaque because then it's like telling your brain there is a coloured car in the M25. It doesn't mean what colour is that. So you have to be specific.
It can be, sorry, gas, fat. Soft tissue. Born And metal going from the most lucent to the more opaque, and we can see all these opacities in the view.
So you don't have to try and remember how gas looks like on X-rays, how fat looks like on X-rays, how soft tissue looks like on X-rays, how bone or how metal. You can see that in each and every view and I will show you when we go to the views. Job afterwards, structural change, which means what has changed structurally and that will lead you to the type of pathology.
For example, In the example of the nodule. It's a soft tissue nodule. What has changed?
OK, it could be maybe a fluid or some cells over there or a combination of the two since we don't have anything like gas. So what fluids do we know? Could be pus, it could be blood, you know, could be cyst, like a cystic fluid, could be inflammatory cells, it could be neoplastic cells.
Immediately, just by saying that, you go to the first differential diagnosis, for example, if it is You know, cystic fluid, we're thinking about the cyst, common incidental in the liver. If it is blood, we're talking about the nematoma. If it is past, we're talking about the napses.
If it is inflammatory cells, we're talking about inflammation. If we talk about neoplasia with neoplastic cells, that's the other differential. Then we combine with the clinical signs.
For example, it could be that the animal has no other clinical signs, it could be incidental and, or it may be that the animal has a big Mass, for example, in the spleen. So automatically, the tumour will take a little bit of priority and then we prioritise our diagnosis in most likely. 2 least likely.
And then we have to think what we're going to do next, ideally something that will either give you the answer or exclude the majority of your differentials. OK. So, basically, what to keep from there is go organ by organ, which order, whichever order you like.
You want to go cranial to caudal, top to bottom in circles, zigzag. I don't care as long as when you finish, you have checked each and every organ and area on the radio. If you have a big elephant on that stands out, you know, you have a choice to just follow your system and ignore it.
Personally, because I can't take my eye from something that stands out, I prefer to start with the obvious and then follow the system to check the rest of the radio so I don't forget. OK. Then use the radiographic signs and be specific with the opacity, to avoid using the term opacity.
Only that will make a huge difference to how much you can see on abdominal radis. Don't forget, when you finish, ask yourself, did I check the whole film? OK, very, very important.
If you forgot something, go back. If it is something that commonly Seen with something else, go back and check for the something else a second time. OK.
That's what I mean here. So now that we went through the basics, let's concentrate on the abdomen. And in the abdomen, we have structures we normally usually, I would say see, like stomach, liver, urinary bladder, small intestine and colon.
Usually, we see the GI tract, it contains a little bit of gas, and faeces, and ingest that. We usually see that. So these structures we would expect to see.
There are structures that we either partially see or sometimes almost not seen. For example, spleen. OK, we may see the ventral extremity on the lateral view, the dorsal extremity on the video view, kidneys, we may see them, we may see very little of them or sometimes we may struggle to even see them.
That can be normal. Prostate gland. Also, if it's not particularly big, especially in a younger animal, we may not see it clearly or may struggle to see it because it's intrapelvic.
Organs we shouldn't expect to see. OK. We're talking about the pancreas.
We're talking about adrenal glands and you see this little caveat here. Why? Because sometimes, for example, in cats, we have adrenal mineralization, and that is considered kind of an incidental finding, you know, in dogs were a little bit more worried.
So we may see them in some cats. The ovaries we don't see and the mesenteric lymph nodes we don't normally see. Of course, if we have any masses in those organs, especially the lymph nodes, we're going to see these masses.
So how do we go about searching? As I said, Do it however you prefer. Personally, because of bad experience.
In the past, I will start from the periphery and go to the centre because I know and that if I concentrate just on the abdomen, I may forget to check the other structures. So in a dog like that, which is a male dog, I will start from the periphery looking at the subcutaneous tissues here and I will you see the same area on both views. The ventral abdominal wall, I will see the ribs and the caudal thorax, and I will do that.
Don't forget on both views. Anything I can count like ribs, like vertebrae, I will count. For example, I will go 1234567, lumbar vertebrae.
123, then reunited and then the caudal just count it and whatever thoracic vertebra there, the ribs, and I will do that on both views. And you will say, why? Because that way I force my eye to look in each and every vertebra in the view.
So I have, I'm less likely to actually miss something. I'll check the lungs with the Codavina cava cardiac silhouette. We see over there, the caudal pulmonary vessels on both use, you know, the lung parenchyma, the diaphragm, I'm going to see that.
And then after I'm happy, pelvis, you know, if I haven't seen femur, stifles, tibia, whatever is included o penis area of the urethra. And when I'm happy perineal area. That I'm, when I'm happy that they actually check all the peripheral structures, I will move in.
And then I like kind of go from cranial to caudal kind of. I'll check the liver. We'll talk about that a little bit later.
I'll check about the stomach. You can see here the extremity of the spleen. Let's see the liver again on the other view of the stomach.
I will do them together because I'm trying to create a three-dimensional picture. I will see the ventral extremity of the spleen on the latter and on the, the dorsal extremity over there. Then I will try and look at the kidneys and kind of we get an idea of some kidneys there on the other view, yeah, you know, you may be able to see a little bit better than I am.
I'm just guessing about that level. And as we said, the kidneys, we may see them, we may not. I will check the intestines with the small intestines and the large intestine and this kind of C-shaped sicum.
And also the area that I would expect the ureters to come in, the area of the prostate though here we struggle to see a little bit of prostate back there. And when I will finish looking at everything, my next question is, did I forgot something? For example, I didn't mention the mammary glands that we can see though it's a male, they shouldn't stand out much.
OK. So did I mean forgot to check something else? You remember that I told you we can see all opacities in every view so you don't have to remember.
Each and every past and we have clearly gas, you know, look at the lung, look at the intestine, you know, look at the black thing around. We have fat. You can see the fats from fat just below the liver.
We have soft tissue. Take your pigs, clean. Liver, cardiac silhouette, you name it.
It's there. We have bone, and of course we have bone all over the place. And then you will say, wait a minute, Pete, where is the mineral?
Mm mineral usually is either the market. Which is the most wide be on the radiograph. Or is the unexposed part of the film, if you're still using film in your practise.
OK. So, decide however you want to go about it. You know, whatever suits you best.
My advice is if something can be counted, do count because you focus your eye and make sure you check everything. If something stands out, usually most people are happy to get rid of that. So see that, describe it using the radiographic signs, number, size, shape, location, multination radioacity.
And then in radioacity be specific, as we said, is it gas? Fat, soft tissue, bone, or metal. OK, and be very, very specific.
Avoid things like it's opaque. OK. Now as we said that, let's start with the GI tract, which is mainly culprit, especially in cases of vomiting.
So GI tract, we have stomach. And we can see it kind of, not exactly particularly big in that animal. OK, we have the small intestine, which is this small loops that we see all over the place.
I will just put the drawing there. And then we have the colon, which is kind, OK, the sum, you already know it has this nice C shape a little bit to the right of the midline, and then we have the This is the rectum, descending column, transverse colon going towards towards the ascending column, you know, this pie shape, we can actually follow. And to use due to the faeces in there.
Now, So more tips for you. The stomach. What do we call the stomach big?
The rule of the thumb states, if the stomach exceeds the last rib, then it is dilated abnormally. If it is inside the rib cage on the lateral view, then we call that stomach filled with something rather than dilated. Here, of course, it is totally empty.
What about small intestine, and there are rules of the thumb for the small intestine, for example, In the dog and cat, in the dog, the, the width of the small intestine, the diameter should be less than the height of the body of a mid lumbar vertebra. Usually I like to use the L5, but you know, take your pick, or twice the width of the rib. In cats, the small intestine usually is less than 12 millimetres or sometimes you can use twice the width of the rib.
There is a, a thing that says it's twice the height of the end plate of basically the second lumbar vertebra. I think that's a little bit too high. Then the colon, the colonic diameter in the dog should be less than the length of L7, while in the cat less than 1.3 times.
The length of the L5 in the cut and it should be less than that. OK, more, it means it is dilated. So there are some rules of the thumb.
OK. Easy to remember. With practise, your eye becomes so accustomed that basically you don't need to use them, but in the beginning, especially when it's not a very clear one now, is it dilated or not.
You can use these rules of the thumb to guide you to a yes or a no. But with practise, you would need them. Now, whenever we see intestines, especially with animals and vomiting, some of them may have a little bit of diarrhoea.
First thing we are worried about is obstruction. OK. So, with abstraction, we have localised dilatation, which means we have two groups of small intestines, some that they are dilated, if you like, more than the L5 and some at the height of the body of the L5.
I mean, and some that they are not normal. So you have two groups. That means we see two groups like that, we have to consider obstruction.
Now, if the diameter of the small intestine is more than 1.6 times the height of the L5. Then, and you see why I like to use the L5, makes things easy.
This is highly predicted for intestinal obstruction. Now, if all the loops of intestines are dilated, Then we think functionally loose, not mechanical like before. And we see that usually with intestinal hypomotility, like in cases of carboviral enteritis, electrolyte imbalance, you know, some drugs may actually cause functional ills.
Parbovirus, by the way, in young dogs is the only non-obstructive. Disease for the small intestine, I mean, that may appear like two groups of small intestines and give you the impression of an obstruction. So, another reason that we can have generalised intestinal dilatation, I'm talking human which could be torsion of the intestine from the root of the mesentery.
Let's see an example here. Look at this dog, we can see some loops of small intestine. They're quite dilated, actually much more than the 1.6 times the height of the fifth lumbar vertebra.
Some others, they are normal. So I have these two groups of small intestines. So automatically, I will have to think obstruction.
And of course, here, you can see. The culprit that was a corn on the cob in this cocker, about 6 years old, maybe neutered, that was scavenging and came with acute history of vomiting. So it had the cone on the cob lodged into the intestine.
So immediately having two groups of intestines, one dilated and one not of small intestines, we have to consider obstruction. We have to Try to differentiate intestinal dilatation for from uterine dilatation. And one way we can do that is by just following the dilated part and see if it continues like here in towards the pelvis.
If that's the case, that must be uterus because small intestines should not go through the pelvic inlet. If we are unclear and we can't be sure, then maybe we can use ultrasound to distinguish. If we don't have, of course, any other signs to suggest, you know, a dilated uterus.
Then we have to consider doing an ultrasound. Here we have another case of, again, having two groups of intestines. One very dilated, OK?
And you can see in this cut, basically, that was a Maine Coon 6.5 years if memory doesn't fail. It's basically, sorry, that's a cut, so it's quite wide, so more than twice the width of the rib, more if you like than twice the end plate of the L2.
And we have other loops that they're quite small. So clearly we are suggesting. We are suspecting, sorry, obstruction.
But looking at here, we couldn't really identify what the cause of that obstruction is. Having a severe focal intestinal obstruction or dilatation, sorry, that's an indication for the next lab, and I think in this case, this animal they found on, on ultrasound first, we can do ultrasound to see the cause in the susception and then they went and corrected that. When all the loops of intestines are dilated, and you can see here, here they are also gas filled.
You know, and they can be really extensive, like in this German shepherd, almost 13 years old, you can see again all every loop, almost equal diameter throughout dilated. Then we're thinking functional ills, things like, you know, if it is a young arbovirus, if it is drugs, or sometimes, you know. It could be, electrolyte imbalance.
So in this case, you suspect that if we have an obstruction near the end of the small intestine, it may appear visually as a small intestinal dilatation functional ileus. So that's the one caveat here. If it is the obstruction near the end of the ileum, then it may give you still the appearance of the functional ileus, but Hopefully, you'll be able to, if that is a way to do an ultrasound for that.
This image, I think everybody recognised it immediately. The minute you saw it. First of all, the stomach is dilated.
Why? Because it extends beyond the last rib. OK.
And that's why we call it dilated. It's gas field and it is forced. It's rotated.
Why? Because the big part, which is the fundus is ventrally. OK, it's dorsalally normally and the pylo is the smaller part is dorsal and we have this compartmentalization that we, we see here.
So it's an image that every vet is, it's quite familiar with, so I don't think any of you had any issue to diagnose that. Now, what are we interested about when we see GDB on an X-ray? And for me, I will look for two things.
One is the spleen, if I can see it, because also the spleen can be tossed, and here we can't see it. Another one is if I have free gas in the abdomen. Why?
Because if I have free gas in the abdomen, it means that most likely we have necrosis of the wall of the stomach and rupture, which will make the prognosis really, really bad. And then you have to warn the owner, especially if you need to go to surgery, that, you know, you may find extensive necrosis with, you know, a bad outcome. So you have to actually look for that.
And in this case, we don't, looking behind the diaphragm, I don't see any gas. I don't see any gas in the intestine. But here is another case that had torsion and you can see again, some materials, pebbles in there, the compartmentalization, the very dilated stomach.
And you can also see the free gas in the abdomen, just behind the diaphragm. You remember from the diaphragm, we only see the cranial edge, not the caudal, because it silhouettes with the liver. But here we can see both edges and the Crush looks like a line because we have gas behind and we have gas down here.
The minute we see gas in the peritoneium, we have to suspect a gas that will rupture, probably secondary to necrosis and that affects. The prognosis for that animal series. Foreign material, foreign material, it's something we look often, especially with scavengers, you know, and you have to keep in mind, it can be the cause or the result of the obstruction.
You may have, for example, an obstruction because it had a stricture or it has a tumour and then it's all of the foreign body and loads there mainly because it was already blocked. Some of them, they're easy to see. If it is metallic or mineralized like coins, jewellery, bones, that makes it easy.
Some others are non-opaque, like fruit seeds, like the corn on the cob which also they are far more challenging to see. Here is a case I had a while back at the college when basically the animal was vomiting and you could see immediately the culprit, the foreign body there and of course, that was an action man. I don't think anybody had any doubt by looking, can actually see the shape.
OK. Here is another one we had in a cat. And most people when they see that, they go, that's a speedometer or something, you know, to, to, to, for training to count the time.
But actually what's that? That's the Saint Christopher. It was hanging in the car.
The cat saw it. Saint Christopher was moving along with the car. Ca soloed said Christopher.
So and it was removed, the cat was fine in the end, I think. OK, but some others are not as easy to see. Look at that.
That was from my early days as a radiologist. I went around the morning, didn't have all my coffee, you know, sitting there. And this was a puppy that came the previous night with vomiting.
They took the X-ray. They were not convinced there was something, but before they released it, they said, OK, let's wait for the radiologist. And as I was looking at that, you know, I could see the stomach here, all right.
But then there was a shadow I didn't particularly like, and the shadow was this one. They thought that doesn't look like the stoma. Looks like intestine.
If it is duodenum, looks far too wide or any small intestine there. So is there anything and because you have this kind of geometric shape, always be afraid of geometric shapes because that's most likely human-made. You know, is there a foreign body.
So we took it into the ultrasound as you can see here, and we found the nipple of the bottle they were feeding the puppy with, and thank God it was removed and everything was OK. But the reason I'm showing that is to show you how easy sometimes it is to miss a subtle change because not all foreign bodies, they show up clearly. Luminal shape is another thing we look at and we may have a filling defect because of a foreign body interception.
We may have alication, you know, looks like that, we a cut with a linear foreign body. You see how all these intestines are bunched up together. And you see how application, that's why I like this example.
You don't really need the contrast to see the application, but since, you know, this one can show us how application looks like because a lot of people are wondering how does it look like in reality. But linear foreign bods duplication, we can see it. Here is, you know, another cut that had the linear foreign body.
You can see how the intestines are bunched up together. You can see how the intestinal gas is not continuous. It's actually what we will call kind of bubbly.
I like the term that I've seen somewhat irregular gas pattern in the intestine. And we have this what they call hairpin loops, you know, gas bubbles that they go like pointy. You remember gas bubbles should be oval or rounded or oval, but they shouldn't be pointy.
So when we see those and all the intestines bunched up, we usually see them with a linear. Foreign body. And in case you think it's only cats, here is a dog with the same thing and you can see again this.
Loops, this hairpin kind of loops with a pointy outcome and all the intestines gathered together in one, in the ventral abdomen. Interoception, yeah, I was bound to show you. I have some examples of X-rays on interception, but I have to say for insusception, stick to ultrasound.
It's far too good and far too sensitive not to use. So if you suspect interoception, look and put a probe where you feel the inter susception and you should see a loop of intestine like here, the intersusceptum along another loop, which is the interuscipients. Sometimes you may see lymph nodes and fat.
You know, from the mecente being in the intercepted inside the interocipients. Ultrasound is very sensitive for intersusception. So I don't really think you can do X-rays.
In the X-rays, you can see the dilated loop. You know, but without contrast, it may be difficult, like the example I showed you before, that they found in susception in surgery, it may be difficult just From the X-ray, to see that it is an interception. You may not find the cause.
You may do though if it has quite a bit of gas. But the rule for me is if you suspect interception, do ultrasound. Now that we talked about the GI tract, now we know how stomach looks like normally.
We know that it has to exceed the last rib to call it . Dilate. We know the small intestine and how we measure it in the dog and cat, you know, the dog twice the width of the rib, height of the body of the L5, we said in the cat we can use twice the width of the rib, usually they go twice the caudal length plate of L2 and for the colon we said the L7 length up to for the dog, 1.3 times the L5 length.
You know, in the car, and these are nice rules of the thumb to use. After a while, you use them, you know, you will not need them, but it will help you make a decision. When you are unsure, and when we start looking and we start following the system, we'll see so much more.
So it's, it's a good idea to have something in your arsenal to help you decide, OK. Now, the liver, liver always visible in the cranio ventral abdomen, usually has a very pointy caudal margin, which is the left lateral liver sublobe, this pointy margin here, and usually it's within the rib cages. Sometimes if the animal, you know, breathes a little bit heavily, the liver makes it beyond, but it's still quite pointy in outline.
Now, one rule I like to use for ipatomegaly is the gastric axis. So looking at the stomach, if you bring a line from the fundus to the Pylorus that is the gastric axis. And usually this should be from vertical to the spine up to parallel to the ribs.
So here it's kind in that location. It can move within that corner. We said vertical to the spine, parallel to the ribs.
If it is extended to farcaudal, then we're talking about eppatomegaly because the lever as it gets bigger, it can deviate that axis caudally. If it is moved more cranially, then we're talking about microepatica, providing we don't have anything else like diaphragmatic hernia. The only exception for the microepatica would be a very deep-chested dog that the axis of the stomach can be a little bit more cranially.
So here are some references for you to use. And here you can see how big lever looks like. It extends beyond the rib gates.
It's quite rounded caudal margin. The gastric axis. You know, and I will remove the drawings so you can see clearly.
You can see here the pylorus, you can see the fundus bring the line middle to middle, and you can appreciate it's coal to. Vertical to the spine, parallel to the ribs, this axis goes further caudally than that because the big liver deviated caudally. And here is a dog with, you know, I think it had the shunt, if I remember correctly, and you can see now the gastric axis, that's the stomach.
If I put the gastric axis, it has shifted cranally because the liver is quite small. Even the ventral extremity of the spleen looks like it comes a little bit more cranially, where within the rib cage, we can see the liver here and the gastric axis has shifted cranially. So that's a way on X-rays to decide whether the liver is big or the liver is small and the gastric axis is a useful tool.
Now, for the spleen, you know, we may see, you know, sometimes, sometimes not so clear, especially in cats, we may not see it clearly. In dogs, usually we see the ventral extremity on the lateral and the dorsal extremity, the head, if you like, on the VD view. We don't do DV on abdomen unless we really have to.
We don't want to squeeze the abdomen. And change the anatomy. OK.
Normally evaluating the spleen, we look at the margins. Normally the margins of the spleen should be also a little bit pointy. When they start becoming a little bit rounded, it means that it's big.
OK, and the common reason could be if the animal is sedated or anaesthetized for the X-rays, could be other stuff also. In the old days in cats, they will say if you saw the spleen. On the X-ray, the spleen is big.
But actually, we can also in touch see the ventral extremity of the spleen on the lateral view and the spleen being normal like in this case. So don't assume. That seeing the spleen in cat makes it automatically splenomegaly for the animal.
OK, it can be seen also in cats. So, so far we talked about The GI tract, stomach, small intestine, large intestine. OK.
We talked about the liver and how to evaluate whether it is big or if it is small. We talked about the spleen, we move a little bit about the kidneys and ureters. So we'll go to the urinary tract now.
Now, the kidneys, as we said, they are organs that we may see. Partially or sometimes we almost not see them and that can be normal. So don't be surprised if you take a dog with no renal abnormalities and urinary abnormalities.
You take an X-ray and you struggle to see the kidneys that Can happen. So the location, I don't think I have to explain to you, you know, better than me and the dog and the cat usually, you know, from T13 22 in the dog for the right, L1 24 in in the cat, the left L2 to 4 on the dog, L2 to 5 in the cat. The left is a little bit cold to the right.
Now, for the length, we like to use the ventral dorsal view. So what I'm going to tell you is for the vivid view. So when I have the kidney, And I want to measure the length of the kidney.
I compare it to the length of the L2 vertebra. In the dog, it should be 2.5 to 3.5 times that.
In the cat, most books will have the 2.4 to 3 times the L2. You can use that.
I, I agree with some radiologists that actually cats now they have a little bit smaller kidneys. So what they use in cats is the 1.8 to 2.4, but you know, published out there is the 2.4 to 3, feel free to use that.
Regarding urine tests, we do not normally see unless they are obstructed or they contain calculate and they are dilated, then we may see them. But normally, we shouldn't really see the ureters. Adjust being them being normal.
We can use contrast studies like intravenous urogram or excretory urogram as as some people say, and check the ureters along with the kidney and get an idea also of renal function. OK. I'm not going to go into details about contrast studies, you know, it's beyond the scope and we only have so much time.
But it's a study we can do, make sure you can give the contrast, make sure the animal can be anaesthetized or no heart problems and that. And then usually it's 800 milligrammes of iodine. Per kilo, the dose, which usually works if you use a 3 to 375 milligrammes of iodine per mL, it works to about 2 mL per kg.
You inject IV and you take first the surveys before you inject lateral and ventral dorsal to make sure you don't have any abnormalities that can explain this the signs and then you don't need to do it. Also to check that you position the animal properly and that actually you don't have any. Bad exposure or you may need to correct that before you start the contrast.
Then you inject IV 2 mL per kg or 800 milligrammes of iodine per kilogramme, depends what you use. And then you take an immediate view ventro dorsal concentrated on the kidneys. Then a 5 minute concentrating on kidneys and ureters, 10 minute.
You take then a lateral and if you want, I like to do a VD first and then a lateral 10 minutes to check the ureters and termination in the bladder and then in the 15 minutes you go into the bladder to check the ureteral termination of the bladder itself. And before an intravenous urogram, I like personally after I do the surveys to empty the bladder and fill with air, OK, just to make sure that I can see the ureteral termination better. So just a quick going through the technique you can find it in many books so.
Here is a normal abdomen and you can see that I can kind of see the kidneys a little bit on the lateral with the Left being caudal to the right and the right not exactly very clearly visible. On the VD I get kind of an idea for the left and the right should be somewhere in there, but I can't swear I can see it, and that can be normal. The bladder and I have here a dog, and here I have a cat.
OK. It's soft tissue structure, it's caudal, OK, usually cranial to the pubis on the lateral view. And ventral to the descending column.
Now You see the cat is usually a little bit more intraabdominal than it is in the dog that can go quite far back. The urethra, we do not normally see if we want to see, we have a urethrogram. Another, you know, kind of straightforward study.
So basically, you can put a catheter at the beginning of the penis on the male or you use a fall in the female. In the mail, you will check 10 to 15 mLs of contrast and you Take an X-ray at the end of the injection while you're still injecting, so you maintain the urethra being big and then you can evaluate the lumen and you will actually be able to see the jet in the bladder. And in the female you again inject.
Using a foley catheter, of course, so you fill the vagina and then the urethra and you take near the end of the injection while you're still injecting. Usually what I say to, to my assistant is, shall take or if I do it, I shall take at, while I'm injecting the last 34 mLs of the contrast that I have already pre in the syringe, pre-calculated in the syringe. Always take survey views.
This dog had hematuria and of course just from the surveys we can see this humongous calcula in both renal pelvises, one on the right and quite multiple on the left. So effectively we know why this dog has hematuria here. We can see that.
Renal agenesis, that's the one thing you definitely need to contrastudy. And you will say, why we can do an ultrasound and see if we can see the left kidney and we can see the right, for example, in this case. Problem with ultrasound is what, that I've seen many times people seeing the same kidney and things the other side, especially people who don't scan with the animal on the back.
I scan on the side, which is pretty convenient for the dog and for me. But also, if the kidney is very, very small, you may not see it on ultrasound. And still be there.
So to confirm that there is no kidney, you will assume a genesis unless you know something else like somebody removed it, then you will see that with the contrast, there is no contrast uptake in the area of the kidney that is missing like here and then we can confirm agenesis. So for agenesis, you need excretory urogram or intravenous urogram, however you prefer to call it. We can see big kidneys like in this cat with lymphoma, and you can see this humongous kidneys.
You know, they are really, really big and squeezing everything ventrally, including the small intestine and actually pushing on the side and a little bit down the colon as we can see here. We can also check ectopic ureters, sometimes a combination of the urography in retrograde. Urethrography or paternal urethrography helps to actually identify the termination better and you can see here that these ureters are terminating.
In the uterus rather than in the urethra which should be down there. And here are the Another X-ray of the bladder that we can see humongous calculate. You can play Tombola with these things.
OK. And another reason why before you do any contrast study, including the cystography, you know, you need to take a survey radiograph to see if you have a reason to make sure the exposure is correct and the positioning is fine. And usually when I do a contrast study, the small tip is I like to go and notch up on the KV.
So if the survey is perfect and I give contrast, I like to go to 3 KV up. Why? Because it makes the whole thing a little bit darker, so the contrast kind of stands out.
Here I have a pneumocystogram and a double contrasystogram. And what's the dose? And a lot of people, there are a lot of arguments over there.
Some people, they say 10 mL per kilo, others say start with 5 and go to 10, you know, it depends who you believe and you listen to. My rule is I put 10, but I start giving 5 mL per kilo roughly, but while I'm injecting, I put my hand on the side of the dog or cat and feel the bladder. When it feels to me like it's tense, I stop and take an X-ray.
If from the X-ray, I say I have a little bit more to give, I continue. I prefer to go carefully and when it feels tenses to stop X-ray, make sure. That the bladder is full or have more space to give a little bit more than to give a predetermined amount for the cystogram and then rupture the bladder.
OK. So you can start with 5 mL per kilo and then fill it if it takes a little bit more. Continue injecting till it feels stents on your hand and then take an X-ray before you continue any further if needed.
For a negative contrast, you can use air and for air, I will advise you to put the animal on the left lateral because if it, it has been postulated and published that if there is an eruption in the mucosa, you have less chances of an embolism. If the animal lies on the left lateral while you inject it. And then you can turn it over and take on, on the right lateral view, but ideally, when you inject, you want it on the left lateral.
Not sure I believe it, especially if the embolism is big, but at the end of the day, there is a theoretical merit on that. And for positive contrast, you can use iodine, you can use, you know, non-ionic. You can also use ionic, but lately, most of us we use non-ionic.
For every contrast study, if you do a double contrast study in put first the air and fill up the bladder, and then 5 to 10 mL of contrast. You don't want to put the contrast first in the air second because then you have what I call the straw effect. What will happen if you blow air in.
Side fluid bubbles, and that's why you don't want to do first the fluid, then the air. You first put the air and then add 5 to 10 mL of contrast, and that will go in the middle of the urinary bladder like here because that's the dependent aspect of the urinary bladder is the animal lies on the side. So what do we look for inside the urinary bladder?
We look for calculate in the middle, roughly rounded. We look for blood clots. These guys, so these are blood clots.
This shall calculate. And blood clots can have any shape you like, whatever, you name it, they can have it. And we have gas bubbles.
Usually they are hydrogenic, and these are perfectly spherical and lie in the periphery of the contrast in a double contrast systemstogram. So here is a calculus, looked like a unique calculus, but that was, believe it or not, a, a lot of calculate together gathered down, but you can see them as a filling defect roughly around it in the middle of the urinary bladder, the dependent aspect. And you can see actually the catheter and the foley here for the cystogram.
Blood clots, two types. This looks like almost a parasite and they look like a worm of some sort, but that was a blood clot. Here is another one in the periphery of the contrast that has a little bit of an irregular oval shape.
So blood clots can have any shape you like. We can see masses and we can see them like here with air. We can see them with positive and negative contrast or double contrast and you can see the outline of these masses inside the bladder.
OK, this was an animal with polypoid cystitis and Here's the urethrogra that I told you about, you know, 10 to 15 mL in a male, inject, take out the last 23 mLs and you can see. Of the jet into the urinary bladder. So you know, and that maintains the urethra dilated for you to see.
Because if you inject, stop and then take the X-ray, the urethra is going to collapse. Here is the vaginal urethrogram. You see the balloon of the foley, inject the contrast.
Make sure you don't pass the urethral orifice and then you can see vestibular vagina and the urethra, and you can appreciate still. The jet because we are taking while we still inject contrast inside the urethra and you can clearly see the hook-like ureteral terminations in this case. You see how nice the gas in the bladder helps highlight this ureteral termination.
In the unit, we can see gas bubbles, but they are mostly valish because they're kind of squeezed, if you like, your space, or we can have irregular rounded or a little bit more blon calculi. A common location is at the coal led or caudal to the pinos in the male that's a very common location for calculator. We may see masses, and usually with masses because they arise from the wall, the contrast goes through one direction, but not all around it.
And that tells you that this lesion is most likely arising from the wall or can be stuck on the wall, but difficult to remain stuck really. And this was a transitional cell carcinoma, very common location, you know, ladder trigon and beginning of the urethra. That was a case of an animal that came in unable to urinate after a road traffic accident, and funny enough, the clinician could actually feel the bladder, so they thought, I can feel the bladder, you know, there is no actual why can't urinate?
And I'm like, what about the urethra? So we ended up doing a urethrogram just to, to see because it had some fractured pelvis. And basically you can see here the contrast coming in the urethra and then spreading all over the place because this urethra has been ruptured.
Always worry about the urethra in case of a road traffic accident, especially with Pelvic fracture secondary to that accident. So, we talked about the kidneys, we talked about the Bladder, we talked about the urethra and a little bit about the contrast studies, you know, it is recording, so I suppose you can listen to it again, slow and steady because we go through a lot of material here. Let's talk about the prostate.
The prostate, you know, it's normal. Usually, when it is less than 2/3 the width on the ventral dorsal or about less than 70% of the height from the sacral eminence to the pubic promontory. Both of these cases here, you can appreciate.
But the prostate is quite big. There are two different cases. One on the left you can see the mineralization.
And that I cannot. So prostatic mineralization is not a good sign. In the dog, you always suspect that there may be a tumour and there is a high possibility.
What we care about prostatomegaly, one, if we can say is it a uniform or non-uniform? And usually doing a urethrogram and seeing where the urethra passes can help, but nowadays, we will do an ultrasound for that. Because if it is a uniform prostatomegaly, no mineralization, will most likely drift towards prostatitis or inflammatory disease.
If it is basically mineralization or Not symmetrical. We have one lobe bigger than the other. We're going to think more of a mass type thing.
It could be tumour, but of course, it could be other masses like cysts, abscesses, you know, hematomas, you name it. In both of these cases, that was a prostatic carcinoma, unfortunately for the dog, and you can see actually the increased opacity also in the sublumbar region where the media lymph nodes are pushing a little bit of the colon down. So the rule for the prostate on X-rays is look.
At the pelvic inlet from the sacral promontory to the pubic eminence, and then the prostate should be less than about 70% at entrance. If you have a ventral dorsal, less than 2/3 the width of the pelvic inlet. OK, a good visual idea to see how we evaluate the prostate.
Uterine enlargement, of course, the uterus normally we don't really see it. If it is big, you know, it will look like a big tubular soft tissue structure. And of course we can confuse it as we said with the small intestines.
So we need to see, like in this case and in this case, if it goes towards the pelvis. If not, then we are unsure, then we will have to maybe do an X-ray unless we have any other signs to suggest that. And of course, we uterine enlargement unless we see other things like in a pregnant animal, we can see later on some skeletons in there.
Usually, it's fluid filled that has to do with either pyometra, amometra, muometer or hydrometra and unless clinically we can see something else, it's tricky to distinguish any of these four fluids. Foetal death nowadays for evaluation of the foetus, we have ultrasound much faster. On the X-ray, the foetus may be dead.
They're not showing yet because it died recently. It takes a while to show changes. OK.
But what do we see? A very early foetal death change on X-rays is overlapping of the calvareal bone. So we have the skull, and you remember I'll just draw here, we have the fontanels in the middle.
When they die, the brain dehydrates and there is overlap on the fontanels. That's kind of an early sign. Another thing is having gas either inside and or around the foetus, and you will say inside, what about the lungs?
Keep in mind the foetus has not taken a breath yet, so it should have gas inside. Now another thing would be to be bended in a very funky way or the skeleton being unclear with some. Looking like a skeleton other, looking like a mass of bones that you cannot really say what it is.
So there are signs we can diagnose foetal death on X-rays, but it is delayed in a way it takes longer. And nowadays, you will just put a probe and see if the heart is ticking and the foetus is alive or not. While on X-rays, it will take a while for that to happen.
We are getting near the end, you know, and as I said, we said a lot of stuff here, so hopefully, you can listen to it again and get more every time you listen. I will finish up a little bit with some things about the peritoneium and some masses and wall. And starting with the peritoneum, first thing we look is for rows of serosal detail in the peritoneum.
So is the detail in the peritoneium less obvious? That's what's lost, or it is increased where we see the margin much more clearer. And then you will say, OK, how do I say that?
Experience. Look at the rays, you know how much they should look, at least in adult animals, because in all younger puppies and kittens, you have lots of detail because they're quite thin. They have lack of fat, as we say.
So whenever the resolution in the abdomen does not look very clear, you can see the margins clearly. There are 4 main differentials to think of ascites, peritonitis, peritoneal seeding, which is basically micro nodular metastasis throughout. And as we said, lack of fat, very common in younger animals and very thin emaciated animals.
Increase detail we see in fat animals. Fat animals are dream for x-rays, not to dream for ultrasound, you need to press harder. And of course, pneumo peritoneium because the air will highlight the margins of the organs.
We can see peritoneal mineralization mainly because of ingestor inside the organs, could be a foreign body, as you've seen. We can have dystrophic or metastatic mineralization or it can be contrast medium either in or out of the intestine if we have rupture. And here is a puppy.
You can see the growth plates and you can see that except the gas in some intestines and stomach. I don't really see much detail. And that is because it has lack of fat.
There is no fat in there, in fact, you remember from the opacities we talked about, fat is a little bit less than soft tissue. So it helps highlight the margin of soft tissue organs. Here we have a cut with ascites and again, look at that.
You can immediately see that the margins are not there. I can see intestines. I can see the stomach, but I don't get a clear outline of the margins because of the fluid inside the abdomen of this cut.
OK. And actually judging a little bit by the gastric axis, if I can guess, I wonder if this cat had a little bit of impactomegaly and at the end it did have, which is also an ultrasound. Increase serosal detail.
Look at that. Normally I can see the internal wall of the stomach, but not the external. Look at that here.
It's so clear. I can actually highlight it. Look at these loops of intestine.
I can highlight the wall very clearly, which is much more than what I would expect in an animal. And why? Because this animal has free gas inside the peritoneium highlighting all the margins of those organs.
OK. And although when we see pneumo perittonium, gas in the peritonium, we all jump going. Oh God, it has a rupture intestine or, you know, a ruptured wall or whatever.
The most common cause by far, actually, it's surgery. So it had like this one, that this was after the next lap. You can see how from being very clear in the outline down here, I'm losing the detail at the area they actually opened the abdomen.
OK. If it's not a history of surgery, then we can always think about the ruptured stomach or a ruptured intestine or ruptured abdominal wall. And you can see also the gas bubbles over there and the gas over the other areas of the peritoneum and the bladder there.
Intraabdominal masses, it's a whole chapters on for that, we just need, you know, another couple of hours just to go through that. So we'll give you the Main rule to follow. So when you see a mass, see where it is located and see what organs are causing are displaced around the mass.
For example, if you have a midabdominal mass, this can be, for example, mesenteric that can be a lymph node, that can be intestinal, that can be the spleen. You know, it can be even pancreas providing the transverse colon is displaced cordially because the pancreas is kind of cranial to that if it is especially in the body and beginning of the left right lobes of the pancreas. So the location of the organ will give you a list of organs that this mass may originate from, OK?
The displacement of the organs around will provide you a little bit more detail to exclude some. But unless it's something like an intestinal muscle and you can see the lumen stopping there, it will be very difficult to just stick to one. And only one location for that mass.
So you will need to think more than one and then possibly do an ultrasound that will allow you to distinguish where this mass truly originates from. For example, hepatic mass will push the stomach accordingly. You know, very unlikely the stomach will be squeezed granually with any hepatic mass, but the splenic mass may do that.
So thinking logically, where is this mass? What organs are there that possibly or tissues that possibly can have that mass? OK.
And what displacement causes will narrow it down, but it is unlikely in most situations that you will end up with only one organ, though it is possible to end up only with one organ, especially in case, for example, hepatic mass. You know, so that's how you need to work around the mass and then do something else. And I know I've taken a lot of your time and probably tired you already.
So I'll finish up with the Rule check everything and in everything includes the abdominal wall. OK. Here, unfortunately whoever took that X-ray after hours, put the marker on exactly the lesion and you can see here that everything looks fine except the bladder and some loops of small intestine are outside.
The abdominal wall, which I can follow up to a point and then I lose it with herniation of the urinary bladder and intestines store towards the right side due to right abdominal wall hernia. You know, it would be embarrassing to lose something like that because simply you didn't look at the abdominal wall. So quickly to recoup before I, we adjourn and let you enjoy and keep your notes and maybe listen to it again if you find it helpful.
We talked today about the Gastrointestinal tract with the stomach. You remember the gastric axis and what we call the stomach dilated, it has to be beyond the last rib. For the small intestine, use the rules of the thumb.
It's usually the height of mid portion of the lumbar vertebra. Usually the L5 for the dog, 12 millimetres or twice the height of the caudal and plate of L2 for a small intestine and the cat. Large intestine, we use the length of L7 as a rule up to for the dog, 1.3 times the length of the L5 vertebra body for a cat.
OK. That is for the column. Then we talk about the kidneys and we said that we compare them on ventro dorsal only with the length of the L2.
You know, 2.5 to 3.5 times in the dog, 1.8 to 2.4 I using the cat, but most public is 2.4 to 3.
I agree with some radiologists that cats have a little bit of smaller kidneys nowadays, and we said kidneys are organs we may not really see clearly and that should be OK unless there's something else that we see that can explain it in an abnormal way. We talked about the bladder and then in the cat it's more intraabdominal than in the dog. We talked about the prostate and the rule with the pelvic inlet on the lateral about 70% or 2/3 the width of the pelvic inlet on the ventral dorsal view.
And we said the one thing I want to leave you with is always check the whole radiograph. Go however you like. In whichever order you like, but make sure you check everything and make sure you describe everything in detail.
Because using the radiographic signs, number, size, shape, location, margination, radio opacity and saying specifically what opacity from most lumen, for most loosen, sorry, to most opaque, we have gas, fat, soft tissue. By the way, fluid is soft tissue plastic, bone and metal, and we have seen that on every X-ray, so you don't need to guess. That will help your brain really come with the answers what I usually like to call the aha moment.
So you describe in detail and suddenly you have the aha moment. Now you understand what's going on. Thank you for your time.
I hope you found the presentation useful and you can go and use it into practise and help you improve your reading skills with abdominal radiographs. If any questions you have, feel free to email me at Pitmantes. At DWR.co.uk.
Thank you very much for your time. I hope you enjoy the lecture. Well, that's it, folks, for this diagnostic imaging session, of our Thursday evening, virtual congress.
Thank you all for attending. I hope you found those lectures as fascinating and stimulating as what I did. And a huge big thank you to all of you for the time that you have spent with us.
Thanks go to Jack and Pete as well for their fascinating presentations. And don't forget, Dawn has popped in Pete's email address. You can email him straight away, or you can send it to Dawn at the webinar vet and she will make sure that those get through to him.
To Dawn, to Kyle in the background for making everything run smoothly. Thank you very much. And from myself, Bruce Stevenson, it's good night.
