seminar 7 ultrasonography of the gastrointestinal tract ... · gastrointestinal tract, liver,...

Seminar 7

Ultrasonography of the

gastrointestinal tract, liver, pancreas

and abdominal lymphnodes

European Veterinary Diagnostic Imaging

Annual Scientific Conference 2010

July 20th

Giessen, Germany

Ultrasonography of the gastrointestinal tract, liver, pancreas and

abdominal lymphnodes

Date: Tuesday, 20.07.2010

Time: 8.00 am に 3.30 pm

Lecturer: Prof. Dr. Dominique Penninck

Cummings School of Veterinary Medicine at Tufts University, North

Grafton, USA

Dr. Federica Rossi

Clinica Veterinaria dell`Orologio, Sasso Marconi, Bologna, Italy

Prof. Dr. Jimmy Saunders

University of Gent, Belgium

Program:

8.00 am に 8.15 am Reception and welcome.

8.15 am に 9.30 am Gastro-intestinal ultrasonography.

J. Saunders

9.30 am に 10.15 am Ultrasonography of the liver.

F. Rossi

10.15 am に 10.30 am coffee break

10.30 am に 12.00 pm Practical exercises.

12.00 pm に 1.00 pm lunch

1.00 pm に 1.30 pm Ultrasonography of the pancreas.

D. Penninck

1.30 pm に 2.00 pm Ultrasonography of abdominal lymphnodes.

J. Saunders

2.00 pm に 2.15 pm coffe break

2.15 pm に 3.15 pm Practical exercises.

3.15 pm に 3.30 pm Evaluation and closure of the seminar.

Gastro-intestinal

Ultrasonography

Jimmy Saunders

7/6/2010

1

Gastro-intestinal

ultrasonography

Jimmy H. Saunders

Ghent University, Belgium

Crico-pharyngeal dysphagia, motility disorders esophagus,

Hiatal hernia, pyloric stenosis

Qualitative comparison of detection rates of various common

gastrointestinal abnormalities by radiography and

ultrasonography - Lamb 1999

Modality

Lesion Survey

Radiography

Contrast

Radiography

Ultrasonography

Gastric lesion

Delayed gastric emptying

Intestinal hemorrhage

Dilated intestine

Intestinal foreign body

Thickened intestinal wall

Intussusception

Intestinal mass

Pancreatic lesions

Lymphadenopathy

-

+

-

++

++

+

+

+

+

+

++

+++

-

+++

+++

++

++

++

+

+

+

++

-

++

++

+++

+++

+++

++

++

+ = limited information; ++ = useful information; +++ = detailed assessment, with accurate

diagnosis often possible

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2

Computed tomography ?

Yes for stomach but not so good for bowel

Endoscopy ?

Emergence of ultrasonography

%

Year

1999 2003 20042002200120001998

RX

RX + US

US

60

50

40

30

20

10

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3

Materials and Methods

RX and US abdomen dogs

191 reports

From 01/11/2003 until

01/04/2005

No final diagnosis in

record file (60%)

No radiographs, bad

positioning or exposure (40%)

68 reports

Results

SYSTEM Number % (> 100)

Gastro-intestinal 38 56

Urinary 19 28

Reticulo-endothelial 14 21

Female reproductive tract 6 9

Male reproductive tract 6 9

General aspect (adrenals, peritoneum, perineal

hernia, ascites, abdominal neoplasia)

11 17

Is it justified ?

Results

SYSTEM LESIONS

Gastro-intestinal-FB (10)

-Acute gastroenteritis (7)

-Lymphocytic-plasmocytic enteritis (5), eosinophilic enteritis

(2), parasitic gastro-enteritis (2), E Coli enteritis(1)

-Gastritis/Atrophic gastritis (3)

-Stomach dilatation (1)

Urinary-Nephro-urolithiasis (5)

-Cystitis (4), pyelonephritis (1)

-Acute renal failure (5)

-Transitional cell carcinoma (2)

Reticulo-endothelial-Spleen: neoplasia (5), rupture (1)

-Liver: hepatitis (4), neoplasia (3), PSS (2), DGN (1)

Female reproductive tract-Pyometra (5)

-Ovarian cysts (1)

Male reproductive tract-PBH/Prostatis (3)

-Paraprostatic cysts (1)

General aspect-Peritonitis (3), hernia perinealis (1), hypoadrenocorticism (1),

carcinomatosis (1), abdominal neoplasia (1), lymphoma (1)

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4

Results

68 cases

US > RX

41 (60%)

US = RX

24 (35%)

RX > US

3 (5%)

US*

7 (11%)

US°

17 (24%)

US* = US confirmed or proved the organ but without providing a

final diagnosis

US° = US did not provide more information than RX

RX > US: 3x gastro-intestinal (2x stomach, 1x

duodenum), 3x foreign body (total 10 GI FB)

Main concern: gas artefact

• Excessive gas in the GI tract may interfere with transmission of

the ultrasound beam

• However, in most dogs and cats, gas does not cause a problem

Multiple positions of the patient and movement of the

transducer allow mostly to find an adequate acoustic window

Use of any luminal fluid to enhance ultrasound transmission

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5

Positioning

Specific positioning for specific region:

• Left recumbency: fundus

• Right recumbency: pylorus, duodenum

• Standing: pylorus, ventral aspect body

Dorsal recumbency

Depends of dog’s conformation and patient cooperation

Material

Ultrasound transducers:

• Linear with a frequency >7 MHz

•Microconvex (curvilinear) > 5MHz (below

and between ribs)

Ultrasound machine: preferably new

US has a high sensitivity (81%) en specificity (71%)

for detection of stomach tumors.

Sensitivity and specificity are highly dependent of the

experience and technical skills of the radiologist.

Learning curve: the sensitivity increases from 40%

detection to 81% detection after 2 years of training.

Penninck et al., 1997

Learning curve

7/6/2010

6

Ultrasonographic criteria

Motility

Layering

Wall thickness

Luminal content

Wall layers / Echogenicity

Wall layers (inner to outer) Echogenicity

Mucus/ Lumen content Hyperechoic unless fluid (hypo-)

Mucosa Hypoechoic

Sub-mucosa Hyperechoic

Muscularis Hypoechoic

Serosa Hyperechoic

Wall layers / Echogenicity

7/6/2010

7

Wall thickness

Wall thickness Dog (mm) Cat (mm)

Stomach 2-5 1.7-3.6

Duodenum 3-6 2.0-2.5

Jejunum 2-5 2.0-2.5

Ileum 2-4 2.5-3.2

Colon 2-3 1.4-2.5

Motility

4-5 contractions / minute

BUT extremely variable ....

THUS mostly not useful

Luminal content

Food, mucus, fluid, gas

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8

1

2

3

4

Which one is the dog ?

THE STOMACH

Radiography

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9

Contrast radiography

Anatomy

1: esophagus; 2. pars cardiaca; 2’. cardiasphincter; 3. fundus ventriculi; 4. corpus

ventriculi; 5. pars pylorica; 6. pars cranialis duodeni

2

4

1

3

5

6

2’2’

2

4

1

3

5

6

7/6/2010

10

•Volume of the stomach depends on its content and on the size of the dog

• Large volumes of foot in short period of time

consequences for US: fast of 12-18 hours to reduce gastric contents

Gastric emptying:

• Liquids are emptied in an exponential pattern without evidence of a

lag phase

• Solid food is emptied with a lag phase of varying length (depending

on the composition of the ingesta, temperature) and follows a more

linear pattern afterwards

Consequences on US:

• No fluid in the stomach

• Foot depends on time and content of last meal

Specificities in cats

Stomach:

Fat in the gastric submucosa

From Heng HG, Wrigley HR, Kraft SL, Powers BE. Fat is responsible for an intramural

radiolucent band in the feline stomach wall. Vet Radiol Utrasound 2005;46:54-56.

Ileum:

Prominent submucosa & musculature

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11

Wall thickness:

< 5 mm (may be difficult to measure)

7/6/2010

12

Carcinoma

Gastric ulcer

US signs:

•mucosal defect, loss of layer, hyperechoic center (crater), clear

demarcation normal versus affected segment

• decreased gastric motility, fluid accumulation

Gastric wall edema

• mostly underlying inflammation and ulceration

• altered layering (DDX: neoplasia) !!!!

• thin inner hypoechoic border

7/6/2010

13

THE SMALL INTESTINE

Anatomy

1

2

3

4

jejunal

lymph node

ommentum

1. stomach; 2. duodenum; 3. jejunum;

4. ileum; 5. cecum; 6. colon

1

2

3

4

1

2

3

3

3

4

5

6

7/6/2010

14

Canine 2-5m; feline: 0,8 -1,3m (3,5 x body length)

• Duodenum: peyer plates

• Jejunum: 6-8 spirals, very moveable

• Ileum: merge not in het caecum but in the colon ascendens

3

4

1. stomach; 2. duodenum; 3. pancreas; 4. spleen

1

2

1

4

3

2

1

2

3

4

7/6/2010

15

US - Histology

Level of the duodenum

1: pylorus, 2: pars cranialis duodeni, 3: villi

A. Mucosa B. Submucosa (strong vascularisation) C. Muscularis D. Serosa

2

1

3

A

B

CD

Intestinal villi at the level of the duodenum

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16

L 0.45 cm

2004: > 5 mm jejunum

> 6 mm duodenum

Intussusception

7/6/2010

17

Acute obstruction

• Foreign body NOT SUFFICIENT

• Dilation small intestine (gas):

• dog: - 1.6 x high body L5

• cat: > 12 mm

• Displacement or folds

Foreign bodies

• Great variation in size, shape and echogenicity

• Bright interface associated with strong shadowing highly

suggestive of a FB (= feces in colon !)

• Some are easily identified (balls), others are not

• GI parasites may mimic a FB

• Fluid accumulation, useful indicator

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18

Normal or ileus ?

If ileus: Mechanical or Functional ?

Chronic obstruction: mostly normal• Minimal to moderate intestine dilation (more fluid)

• Gravel sign

• Decreased serosal detail not always easy

• Free peritoneal gas

Dilation Normal

What happens in between ?

?

7/6/2010

19

Enteritis Neoplasia

- Diffuse

- Symmetrical

- Reactional lymph nodes

- Focal

- Asymmetrical

- Tumoral lymph nodes

Loss of parietal layers = excellent positive predictive value

0.82 cm

0.66 cm

• Thickened wall

Enteritis

•Mildly thickened wall

•Mucosa: increased echogenicity

L 0.65 cm

Enteritis

7/6/2010

20

• Thickening wall: > 5 mm

• Thickened muscularis

L 0.69 cm

Enteritis ?

Mucosal fibrosis in cats

From Penninck D. et al. Vet Radiol Ultrasound 2010

Lymphangiectasia

7/6/2010

21

Corrugated intestinal wall

• Pancreatitis (50%)

• Peritonitis/ Perforation

• Enteritis

• Neoplasia

• Entrapment

• Incidental

Leiomyosarcoma

L 1.49 cm

Intra-mural, focal massa

Lymphoma

• Thickened and symmetrical

hypechogenic wall

• Loss of layers

Sonography of the liver

Federica Rossi

1

Sonography of the liver

Federica Rossi

SRV, Dipl. ECVDI

Sasso Marconi (BO) - Italy

SonographicSonographic keykey--pointspoints

�� locationlocation

�� sizesize

�� shapeshape, , marginsmargins

�� echogenicityechogenicity

�� echotextureechotexture//architecturearchitecture of the of the parenchymaparenchyma

�� hepatobiliaryhepatobiliary systemsystem

�� vesselsvessels

Location Location

2

LiverLiver sizesize

�� subjectivesubjective

assessmentassessment

�� distancedistance betweenbetween

stomachstomach and and diaphragmdiaphragm increasedincreased

�� extensionextension ventralventral toto

the the stomachstomach

�� roundingrounding marginsmargins

LiverLiver sizesize

Bolognese, 5 KgBolognese, 5 Kg MixedMixed breedbreed dog, 7 Kgdog, 7 Kg

3

LiverLiver sizesize

HowHow muchmuch liverliver parenchymaparenchyma

surroundssurrounds the the gallbladdergallbladder??

LiverLiver sizesize

DecreasedDecreased

�� ChronicChronic hepatichepatic

diseasesdiseases evolvingevolving

toto hepatichepaticfibrosisfibrosis//cirrosiscirrosis

�� ShuntsShunts

IncreasedIncreased

�� MostMost hepatichepatic

disordersdisorders are are

associatedassociated withwithhepatomegalyhepatomegaly

NormalNormal hepatichepatic sizesize doesdoes notnot excludeexclude hepatichepatic diseasedisease

EchogenicityEchogenicity -- changeschanges

diffusediffuse changeschanges of of liverliver echogenicityechogenicity

compare compare toto::

falciformfalciform fatfat

renalrenal cortexcortex

spleenspleen

FocalFocal//multifocalmultifocal

4

HepatomegalyHepatomegaly -- DDDD

�� VenousVenous congestioncongestion ++++++

�� LLymphomaymphoma, , leukemialeukemia, , histiocytichistiocytic neoplasia +++neoplasia +++

�� Acute Acute hepatitishepatitis ++++

�� AmiloidosisAmiloidosis ++

HEPATOMEGAL Y + HEPATOMEGAL Y + HYPOHYPO--ECHOGENIC LIVERECHOGENIC LIVER

VenousVenous congestioncongestion

�� HepatomegalyHepatomegaly withwith hypoechogenichypoechogenic liverliver

�� EnlargedEnlarged hepatichepatic veinsveins withwith abnormalabnormal flowflow

�� Free Free abdominalabdominal fluidfluid

�� PortalPortal congestioncongestion –– splenicsplenic congestioncongestion

�� HeartHeart murmuremurmure (right (right heartheart diseasesdiseases, , pericardialpericardial diseasesdiseases, VCC , VCC compressioncompression or or

inv asioninv asion))

VenousVenous congestioncongestion

HVHV

CVV

FF

5

LYMPHOMALYMPHOMA

HepatomegalyHepatomegaly and :and :

1. 1. NormalNormal echogenicityechogenicity

2.2. Diffuse Diffuse hypoechogenicityhypoechogenicity

3.3. Diffuse Diffuse hyperechogenicityhyperechogenicity

4.4. FocalFocal or or multifocalmultifocal hypoechoichypoechoic lesionslesions

+ + lymphadenomegalylymphadenomegaly and and extrahepaticextrahepatic lesionslesions

(spleen)(spleen)

LYMPHOMA

6

Left kidney spleen

Mesenteric ln

Acute Acute hepatitishepatitis

UsUs usefuluseful toto excludeexclude otherother hepatichepatic diseasesdiseases and and toto

obtainobtain cytologicalcytological samplessamples

Maltese m 8 a

7

AmiloidosisAmiloidosis

�� ToTo bebe includedincluded in the DDin the DD

�� HystopathologicalHystopathological diagnosisdiagnosis


�� NonNon--neoplastic neoplastic infiltrativeinfiltrative diseasesdiseases

((fattyfatty or or glicogenglicogen infiltrationinfiltration):):

1. 1. DiabetesDiabetes mellitusmellitus

2. 2. SteroidSteroid hepatopathyhepatopathy

3. 3. HepaticHepatic lipidosislipidosis ((catscats), ), obesityobesity

�� Neoplastic diffuse Neoplastic diffuse diseasedisease: : lymphomalymphoma, , mastmast cellcell tumourtumour (dog)(dog)

HEPATOMEGAL Y + HEPATOMEGAL Y +

HYPERHYPER--ECHOGENIC LIVERECHOGENIC LIVER

VacuolarVacuolar hepatopathieshepatopathies

1.1. HepatomegalyHepatomegaly

2.2. HyperechogenicHyperechogenic liverliver


3. 3. IncreasedIncreased distaldistal

beambeam attenuationattenuation

((absorptionabsorption))

8

dog - diabetes

Cat – lipidosis DD obese c at!

DD: Dia, DD: Dia, LipLip, , CusCus, , LymLym

Look the Look the adrenalsadrenals!!!!!!!!

LiverLiver sizesize

DecreasedDecreased



toto hepatichepaticfibrosisfibrosis//cirrhosiscirrhosis

�� ShuntsShunts

IncreasedIncreased





9

CHRONICCHRONICHEPATITISHEPATITIS

�� LiverLiver sizesize fromfrom normalnormaltoto reducedreduced

�� IrregularIrregular marginsmargins

�� IncreasedIncreased echogenicit yechogenicit y

withwith mineralizationsmineralizations

�� attenuationattenuation of of periperi--portalportal echoesechoes

�� regenerativeregenerative nodulesnodules

FIBROSIS - CIRRHOSIS

Jack Russel f 1a

CIRRHOSIS

10

PSSPSS

LiverLiver sizesize

DecreasedDecreased



toto hepatichepaticfibrosisfibrosis//cirrhosiscirrhosis

�� ShuntsShunts

IncreasedIncreased





West West HighlandHighland male 2 ymale 2 y

Liver biopsy: Cu hepatopathy

11

FOCALFOCAL-- MULTIFOCAL MULTIFOCAL

HEPATIC LESIONSHEPATIC LESIONS

CystCyst ++++

CalcificationCalcification ++++

NodularNodular hyperplasiahyperplasia ++++++++

PrimaryPrimary or or metastaticmetastatic neoplasia +++neoplasia +++

HematomaHematoma ++

NecrosisNecrosis ++

AbscessAbscess, granuloma, granuloma ++

ANAN--

HYPERHYPER--

HYPOHYPO--, , HYPERHYPER--, ,

MIXEDMIXED

HEPATIC CYSTSHEPATIC CYSTS

SONOGRAPHIC SONOGRAPHIC FEATURESFEATURES

�� round round toto ovaloval

�� anhechoicanhechoic contentcontent

�� thinthin and regular and regular wallwall

�� distaldistal acousticacoustic

enhancementenhancement

HEPATIC CYSTSHEPATIC CYSTS

OftenOften are are incidentalincidental findingsfindings��frequentfrequent in in catscats((policysitcpolicysitc diseasedisease, , cystadenomacystadenoma))

DD: GBDD: GB

12

CYSTADENOMA (cat)

Gatto Persiano m 9a

HEPATIC CALCIFICATIONHEPATIC CALCIFICATION


�� wellwell defineddefinedhyperechoichyperechoic areasareas

�� variousvarious shapeshape and and sizesize

�� distaldistal shadowingshadowing

13

NODULAR HYPERPLASIANODULAR HYPERPLASIA

BenignBenign processprocess due due toto

accumulationaccumulation of of

�� regen erat edregen erat ed hepati chepati c cellscells

�� necro ticnecro tic and and at rophicat rophic

hepatichepatic p arench ymap arench yma

�� fatfat

�� dilateddilated hepati chepati c sinusoidssinusoids


FocalFocal or or multifocalmultifocal::

�� hypoechoichypoechoic ++++++

�� isoechoicisoechoic ++++

�� hyperechoichyperechoic ++++

�� complexcomplex mass +mass +

Up Up toto 70 % of old 70 % of old animalsanimals affectedaffected

HEMATOMA, NECROSIS, HEMATOMA, NECROSIS, ABSCESSABSCESS

SonographicSonographic featuresfeatures are are variablevariable and can and can bebe similarsimilar: :

1. acute 1. acute hemorragehemorrage: : hyperhyper--

2. 2. recentrecent hematomahematoma or or abscessabscess: : hypohypo-- or or anhechoicanhechoic

3. old 3. old hemorragehemorrage, , chronicchronic abscessabscess, , necrosisnecrosis: : mixedmixed//complexcomplex

HYSTORY, LAB WORK, FOLLOW UPHYSTORY, LAB WORK, FOLLOW UP

14

HEMATOMAHEMATOMA

H

coagulopathy

HEPATIC ABSCESSHEPATIC ABSCESS

Irregular external capsule and fluid content

F

F

CHRONIC HEPATITIS WITH CHRONIC HEPATITIS WITH

NECROSISNECROSIS

15

Hepatomegaly and hypoechoic

peripheral infarct in dog with IMHA

HEPATIC NEOPLASIAHEPATIC NEOPLASIA

PRIMARYPRIMARY

HEPITELIALHEPITELIAL::

�� HepatocellularHepatocellular: : adenoma, adenoma, ACAC

�� BiliarBiliar: adenoma, : adenoma, ACAC

MESENCHYMALMESENCHYMAL::

�� HemangiomaHemangioma, , hemangiosarcomahemangiosarcoma

�� Fibroma, fibrosarcomaFibroma, fibrosarcoma

�� OtherOther sarcomassarcomas((LeiomioLeiomio-- osteoosteo……))

METASTATICMETASTATIC

DOG:DOG:

�� CarcinomaCarcinoma: : gastricgastric, , pancreaticpancreatic, , intestinalintestinal, , mammarymammary

�� SplenicSplenic hemangiosarcomahemangiosarcoma

�� LymphomaLymphoma, mastocitoma, mastocitoma

CAT:CAT:

�� CarcinomaCarcinoma: : pancreaticpancreatic, , intestinalintestinal, , renalrenal

�� LymphomaLymphoma

HEPATIC NEOPLASIA HEPATIC NEOPLASIA ––

sonographicsonographic featuresfeatures

FOCALFOCAL

MULTIFOCALMULTIFOCAL

hypoechoichypoechoic

complexcomplex

hyperechoichyperechoic or or mixedmixed

multifocalmultifocal (carcinoma)(carcinoma)

solitarysolitaryh yperechoich yperechoiclessless likelylikely

DIFFUSEDIFFUSE

inhomogeneousinhomogeneous

parenchymaparenchyma

abnormalabnormal echostructureechostructure

sometimessometimes onlyonlychangechange

in in echogenicityechogenicity((lymphomalymphoma) )

16

HEPAT OCE LL ULA R C ARCI NO MA

HEMANGIOSARCOMA

LYMPHOMA

METASTATIC SARCOMA

SizeSize-- shapeshape-- echogenicityechogenicity

�� hepatomegalyhepatomegaly or or microepatiamicroepatia

�� regular or regular or irregularirregular marginsmargins

�� diffuse or diffuse or focalfocal changeschanges in in echogenicityechogenicityand and architecturearchitecture

�� otherother abdominalabdominal organsorgans

�� lymphlymph--nodesnodes

�� correlationcorrelation withwith clinicalclinical signssigns and and laboratorylaboratory resultsresults

UsUs findingsfindings are are notnotpatognomonicpatognomonic

list of DD list of DD diagnosisdiagnosis

FNA or FNA or biopsybiopsy

1

HEPATOBILIARY SYSTEMHEPATOBILIARY SYSTEM

SonographySonography isis the the preferredpreferred initialinitialimagingimaging techniquetechnique toto evaluateevaluate

diseasesdiseases of the of the hepatobiliaryhepatobiliary systemsystem

NORMAL GALLBLADDERNORMAL GALLBLADDER

��variable variable sizesize ((fastingfastingtime)time)

��anechoicanechoic contentcontent

��somesome sludgesludge

��thinthin wall (catwall (cat--1 mm, 1 mm, dogdog--2,3 mm)2,3 mm)

GB CATSGB CATS

2

�� GBGB

�� cysticcystic ductduct

�� hepatichepatic ductsducts

�� common bile common bile ductduct

major major duodenalduodenal

papillapapilla

dogdog catcat

BILIARY TRACTBILIARY TRACT

BILIARY TRACT BILIARY TRACT

�� ProximalProximal common bile common bile ductduct(CBD)(CBD)

-- ventralventral toto the the portalportal veinvein

-- easy easy toto foundfound in in catscats (up (up toto 4 mm 4 mm diameterdiameter) )

-- dog dog lessless visiblevisible (< 3 (< 3 mm)mm)

�� IntrahepaticIntrahepatic bile bile ductsducts notnotvisualizedvisualized in in normalnormalanimalsanimals

BILIARY SLUDGEBILIARY SLUDGE

��frequentfrequent findingfinding (old (old dogsdogs))

��originorigin and and significancesignificance notnotclearclear ((biliarybiliary stasisstasis?)?)

��positionalpositional changingchanging --> > ‚‚snowsnowstormstorm‘‘

��gravitygravity-- dependentdependent

horizontal horizontal „„fluidfluid lineline““betweenbetween bilebile and and corpuscularcorpuscularstructuresstructures

3

BILIARY SLUDGEBILIARY SLUDGE

�� ThickenedThickened and more and more

organizedorganized sedimentsediment: : ““SludgeSludge ballsballs””

�� DD: DD: wallwall massesmasses

BILIARY CALCULIBILIARY CALCULI

GALLBLADDER WALL GALLBLADDER WALL THICKENINGTHICKENING

��hepatitishepatitis, , cholecystitischolecystitis, , cholangiohepatitischolangiohepatitis ((congestioncongestion, , edemaedema))

�� hypoalbuminemiahypoalbuminemia ((dyscrasicdyscrasic edemaedema))

�� right right heartheart failurefailure

�� sepsissepsis

�� neoplasianeoplasia

4

GALLBLADDER WALL GALLBLADDER WALL

THICKENINGTHICKENING

must be differentiated from small amounts of peritoneal effusion

DD: COAGULOPATHY !!DD: COAGULOPATHY !!

FF

COLANGIOHEPATYTISCOLANGIOHEPATYTIS

5

ACUTE COLANGIOHEPATITISACUTE COLANGIOHEPATITIS

CHRONIC COLANGIOHEPATITISCHRONIC COLANGIOHEPATITIS

Sev ere Sev ere fibrosisfibrosis preventprevent distentiondistention of the GB lumenof the GB lumen

MUCOCELEMUCOCELE

�� BiliaryBiliary stasisstasis + + mucinousmucinoushyperplasiahyperplasia

�� gallbladdergallbladder distentiondistention

�� wallwall thickeningthickening

�� hyperechoichyperechoic kiwi kiwi likelikepattern, immobile pattern, immobile contentcontent

�� frequentlyfrequently, , butbut notnot alwaysalwaysassociatedassociated withwith bacterialbacterialinfectioninfection

�� possiblepossible perforationperforation((necrotizingnecrotizing colecystitiscolecystitis))

6

BILIARY OBSTRUCTIONBILIARY OBSTRUCTION

ACUTE OR CHRONICACUTE OR CHRONIC

UsUs veryvery usefuluseful toto identifyidentify the cause of the cause of obstructionobstruction: :

�� colelitiasiscolelitiasis, , sludgesludge

�� inflammationinflammation or neoplasia of the or neoplasia of the biliarybiliarytracttract or or adjacentadjacent structuresstructures ((liverliver, , duodenumduodenum, pancreas, , pancreas, lymphnodeslymphnodes, vena , vena porta)porta)


PROGRESSION OF SONOGRAPHIC PROGRESSION OF SONOGRAPHIC FINDINGS AFTER COMPLETE FINDINGS AFTER COMPLETE

OBSTRUCTION:OBSTRUCTION:

–– first: GB and first: GB and cysticcystic ductductdistentiondistention

–– after 48 after 48 hourshours: CBD : CBD distentiondistention, , extraextra--hepatichepatic ductsducts visiblevisible nearnear the GB the GB neckneck

–– after 5after 5--7 7 daysdays: : dilationdilation of of intraintra--hepatichepatic

bile bile ductsducts

BILIARY OBSTRUCTION

CBD > 5 mm

CBD acute obstruction

DuodenumDuodenum

PortalPortal veinvein

> 1 cm

7

BILIARY OBSTRUCTION

20 y old femal e cat

hepatomegaly

CBD

Duodenum

Duodenum

GB wall

BILIARY OBSTRUCTION

Urs Geissbühler

Mixed breed f 10y

8

BILIARY OBSTRUCTION

extraextra--hepatichepatic ductsducts

visiblevisible nearnear the GB the GB

neckneck (after > 48 (after > 48

hourshours of of obstructionobstruction))


DD of DD of biliarybiliary obstructionobstruction: : �� most common causes in dogs: most common causes in dogs:

��pancreatitispancreatitis

��neoplasianeoplasia

most common causes in cats:most common causes in cats:��biliarybiliaryor pancreatic or pancreatic neoplasianeoplasia

�� inflammatory diseases (pancreatitis, inflammatory diseases (pancreatitis, cholangiohepatitischolangiohepatitis, , cholecystitischolecystitis))

��cholelithiasischolelithiasis

BILIARY OBSTRUCTIONDog 6 y old chronic vomiting

9

questions?

Ultrasonography of the pancreas

Dominique Penninck

Dominique Penninck DVM, PhD, DACVR, DECVDI Tufts Cummings School of Veterinary Medicine USA Ultrasonography of the pancreas in dogs and cats Email:[email protected]

Technique and Normal Pancreas:

The pancreas is a thin, elongated organ made of 3 segments (left and right limbs and body), located along the greater curvature of the stomach and the mesenteric border of the descending duodenum. The anatomic landmarks used to locate the right pancreatic lobe are the right kidney, the descending duodenum with its straight course along the right abdominal wall, and the pancreatico-duodenal vein paralleling the descending duodenum. The right pancreatic lobe can be imaged from a ventral or lateral approach, with a longitudinal scan-plane orientation used to find the descending duodenum and right kidney. The pancreatic body can be imaged from ventrally or from the right side with the animal in a dorsal, left or right lateral recumbent position by moving the scan plane craniomedial to the proximal descending duodenum and caudal to the pyloric antrum. The portal vein represents a useful landmark as it is located just dorsal and to the left of the body of the pancreas. A transverse scan just caudal to the porta hepatis and pylorus may be used to locate this vein and the body of the pancreas. The left pancreatic lobe is more difficult to image in dogs, because

of gas interference in the adjacent stomach and transverse colon. However, in cats, the left limb is larger and can more easily identified than the right limb. High frequency (>7.5 MHz) sectorial transducers are recommended to evaluate the pancreas, especially in cats and small-to-medium-sized dogs. The normal pancreas is isoechoic to slightly hyperechoic to the adjacent liver lobes, and nearly isoechoic to the surrounding mesenteric fat. There are no reported size ranges in dogs. In cats, the mean thickness measurements for the right pancreatic lobe, body, and left pancreatic lobe were 4.5mm (range 2.8 - 5.9), 6.6mm (range 4.7 - 9.5), and 5.4mm (range 3.4 - 9.0) respectively. The pancreatic duct had a mean diameter of 0.8mm (range 0.5 - 1.3). Pancreatic Disorders: Most pancreatic disorders result in focal or diffuse thickening and decreased echogenicity of the pancreas. Pancreatitis has various ultrasonographic appearances depending on the severity, duration and extent of pancreatic and peripancreatic tissue inflammation. In acute pancreatitis, the pancreas appears enlarged and diffusely hypoechoic while the surrounding fat appears moderately hyperechoic as the result of fat saponification. In dogs, the right limb of the pancreas tends to be most commonly affected while in cats; the changes tend to be more severe in the body and left limb. In cats, pancreatic enlargement, and diffuse change in pancreatic and surrounding fat echogenicity are often less obvious. In severe hemorrhagic, necrotizing pancreatitis, irregular hypoechoic area(s) represent necrosis and hemorrhage of part of the pancreas and peripancreatic tissue. Pancreatic edema appears as numerous hypoechoic stripes demarcating pancreatic lobulation and dissecting the enlarged pancreas. It can be seen in several clinical conditions, including edematous pancreatitis. Focal acute pancreatitis may contain combined areas of pancreatic necrosis, hemorrhage and surrounding inflamed mesentery. The hypoechoic and anechoic areas corresponding to collections of hemorrhage and necrotic tissue may, with chronicity, become more organized and develop into pseudocyst or abscess. In chronic pancreatitis, the pancreas can be within normal range for size and the parenchyma often is inhomogeneous. In cats, chronic pancreatitis is twice more frequent than acute pancreatitis. Pancreatic nodular hyperplasia is occasionally seen in the pancreas of older dogs and cats. Well-defined hypoechoic to isoechoic nodules that can vary in size can be disseminated throughout the pancreas. Pancreatic exocrine tumors such as adenocarcinoma arise from acinar cells or ductal epithelium. Even though these tumors are rare, they are the most common

type of pancreatic neoplasia in small animals. They tend to develop in the central portion of the gland. As they grow, they may compress the common bile duct, invade the adjacent gastric and duodenal segments, and frequently metastasize to the liver. They often are poorly echogenic nodules or masses; at times they are partially mineralized. Insulinomas are the most commonly encountered endocrine tumors in dogs. The ultrasound detection rate varies depending on the size and distribution of the lesions, the equipment quality and the operator’s experience. Insulinomas can present as a solitary nodule, multiple nodules or an ill-defined area of abnormal echogenicity. The size of the pancreatic lesions varies greatly, but a majority of the lesions tends to be small (less than 2 cm) and be poorly echogenic. A few references: Etue S.M., Penninck D.G., Labato M.A., Pearson S., Tidwell A. Ultrasonography of the normal feline pancreas and associated anatomical landmarks: a prospective study of 20 cats. Vet Radiol Ultrasound 2001;42:330-336. Hecht S., Penninck D.G., Mahony O.M., King R., Rand W.M Relationship of pancreatic duct dilation to age and clinical findings in cats. Vet Radiol Ultrasound 2006;47:287-294. Hecht S., Penninck D.G., Keating J.H Imaging findings in pancreatic neoplasia and nodular hyperplasia in 19 cats. Vet Radiol Ultrasound 2007;48:45-50. Lamb C.R., Simpson K.W., Boswood A., Matthewman L.A. Ultrasonography of pancreatic neoplasia in the dog: a retrospective review of 16 cases. Vet Rec 1995;37:65-68. Nyland T.G., Mulvany M.H., Strombeck D.R. Ultrasonic features of experimentally induced, acute pancreatitis in the dog. Vet Radiol Ultrasound 1983:24:260-266. Moon M.L., Panciera D.L., Ward D.L., Steiner J.M., Williams D.A. Age-related changes in the ultrasound appearance of the normal feline pancreas. Vet Radiol Ultrasound 2005;46, 138-142. Murtaugh R.J., Herring D.S., Jacobs R.M., DeHoff W.D.(1985) Pancreatic ultrasonography in dogs with experimentally induced acute pancreatitis. Vet Radiol Ultrasound 26:27-32. Salisbury S.K., Lantz G.C., Nelson R.W., Kazacos E.A. Pancreatic abscess in dogs: Six cases (1978-1986). J Am Vet Med Assoc 1988;193:1104-1108.

Saunders H.M. Ultrasonography of the pancreas. In: Problems in Veterinary Medicine 1991; 3:583-603. Saunders H.M., VanWinkle T.J., Drobatz K., Kimmel S.E., Washabau R.J. Ultrasonographic findings in cats with clinical, gross pathologic, and histologic evidence of acute pancreatic necrosis: 20 cases (1994-2001) J Am Vet Med Assoc 2002;221:1724-1730. VanEnkevort B.A., O’Brien R.T., Young K.M. Pancreatic pseudocysts in 4 dogs and 2 cats: ultrasonographic and clinicopathologic findings. J Vet Intern Med 1999;13:309-313.

Ultrasonography of abdominal

lymphnodes

Jimmy Saunders

06.07.2010

1

Ultrasonography of the abdominal

lymph nodes

Jimmy H. Saunders

Ghent University

ANATOMY

ANATOMY

From: www.medical-look.com

06.07.2010

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ANATOMY

VISCERAL LYMPH NODES PARIETAL LYMPH NODES

PARIETAL LYMPH NODES

Iliosacral lymphocenter:

- Medial iliac

- Hypogastric

- Sacral (inconsistent)

Lombo-aortic lymphocenter:

- Lombo-aortic

- Renal

LOMBO-AORTIC LYMPH NODES

Location: along the abdominal aorta and cauddal

vena cava from the diaphragm to the deep circumflex

iliac arteries

Number: 12

Size: 1-2cm in the dog (the biggest), 0.5-1.8cm in

the cat

Drainage: muscles, vertebrae, kidneys, bladder,

adrenal glands, ovaries, uterus, testes, more caudal

lymph nodes

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RENAL LYMPH NODES

Location: near the renal vessels (they are part of

the lombo-aortic)

Number: -

Size: 1cm in the dog, 0.5-1.4cm in the cat

Drainage: musculature, urogenital tract, adrenals,

more caudal lymph nodes

MEDIAL ILIAC LYMPH NODES

Location: lateral margins of the caudal aorta and

corresponding external iliac artery (the right one

is more ventral)

Number: 0-2

Size: 2-6cm in the dog, 0.3-2.8cm in the cat

Drainage: dorsal part of the abdomen, caudal part

of the digestive and urogenital tract

Medial iliac lymph node

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HYPOGASTRIC/SACRAL LYMPH NODES

Location: (differentiation is difficult !)

- hypogastric: in the angle between the internal iliac and

the median sacral arteries

- sacral: near the median sacral artery

Number: 1- 3 (sacral only in 50% of dogs)

Size: 1-3cm in the dog, 0.1-2cm in the cat

Drainage:

- hypogastric: bladder, caudal part genital tract, tail,

pelvis, femoral lymph nodes

- sacral: adjacent musculature, tail, caudal uterus

VISCERAL LYMPH NODES

Mesenteric (Cr & Cd) lymphocenter:

- Jejunal

- Colic

- Caudal mesenteric

Celiac lymphocenter:

- Hepatic

- Gastric

- Splenic (inconsistent)

- Pancreatico-duodenal (inconsistent)

HEPATIC LYMPH NODES

Location: adjacent to the portal vein, just caudal the

porta hepatis

- left: lesser omentum dorsal to the common bile duct

- right: adjacent to the pancreatic body

Number: single to multiple

Size: 1-6cm in the dog (Rt < Le), 0.2-3cm in the cat

Drainage: stomach, duodenum, pancreas, liver

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Hepatic lymph node

GASTRIC LYMPH NODES

Location: along the lesser curvature of the stomach

(from cardia to pylorus), embedded in the lesser

omentum - near the right gastric artery

Number: 1-5

Size: 0.5-2.5cm in the dog, 0.1-2cm in the cat

Drainage: esophagus, stomach,, liver, diaphragm,

peritoneum, mediastinum

SPLENIC LYMPH NODES

Location: along the splenic vessels. Between the

hilus of the spleen and the left pancreatic lobe,

close from the junction splenic and portal veins

Number: 1-5

Size: 0.5-4cm in the dog, 0.2-2cm in the cat

Drainage: spleen, esophagus, stomach, pancreas,

liver, omentum, diaphragm, gastric lymph nodes

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Splenic lymph node

PANCREATICO-DUODENAL

LYMPH NODES

Location:

- near the cranial duodenal flexure between pylorus and

right pancreatic lobe

- meeting point of the cranial pancreaticoduodenal and

right gastroepipolic vein

Sometimes: along the right pancreatic lobe (1-2, small)

Number: inconsistent

Size: small in the dog, 0.3-1.5cm in the cat

Drainage: duodenum, pancreas, stomach, omentum

JEJUNAL LYMPH NODES

Location: two elongated structures near the

root of the mesentery

Number: 2

Size: 0,5-20cm in the dog, 0,5-8cm in the cat

Drainage: jejunum, ileum, pancreas

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Jejunal lymph node

COLIC / CAUDAL MESENTERIC

LYMPH NODES

Location: the mesocolon

- near the ascending or transverse lymph nodes (colic) -

near the ileocolic junction (1-2)

- near the descending lymph node (caudal mesenteric, 2-5)

Vascular landmarks: near the ileocolic vein, middle colic

vein

Size: 1-2.5cm in the dog, 0.1-3cm in the cat

Drainage: ileum, cecum, colon, rectum

Sacral lymph nodeColic lymph node

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Lymph node = LN Seen in ... % of cats Size (in mm)

Hepatic LN 70 L=7.6, W=2.9 (normal: L=<20, W=<10)

Gastric LN 30 L=5.1, W=1.9 (normal: L=5-6)

Splenic LN 60 L=8.4, W=3.2 (normal: L=5-20)

Pancreatico-duodenal LN 60 L=8.4, W=4.6 (normal: L=10, W=5)

Jejunal LN 90 L=20.1, W=5.0 (normal: L=<60, W=3-7)

Renal LN 50 L=6.1, W=3.5

Cecal LN 40 L=11.8, W=4.1 (normal: L=3-15, W=5-9)

Colic LN 40 L=9.0, W=3.1 (normal: L=12)

Caudal mesenteric LN 10 L=6.0, W=2.1

Aortic lumbal LN 60 L=9.9, W=3.2 (normal: L=5-6, W=3-4)

Medial iliac LN 100 L=13.5, W=4.5 (normal: L=20, W=2.7)

Sacral LN 40 L=9, W=3.1 (normal: L=12)

US IN CATS

US FEATURES

ECHOGENICITY

Subjective evaluation

Uniform, iso- to hypoechoic to the surrounding tissues

Abnormal: non-uniform and hypo- or anechoic

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Normal: slender = length > thickness

Abnormal: plump with rounded edges

Way to evaluate: short to long axis ratio

SHAPE

Border definition = sharpness of the borders of a lymph node

Normal lymph node:

sharp, regular borders

sharpness of the borders depends of the difference in acoustic impedance

Irregular border: may suggest an invasion growth compatible with

malignancy

MARGINS

Transmission of the echoes through a lymph node give clues

about its (abnormal) composition

fluid-filled acoustic enhancement: necrosis, abscess, cyst

dense structure (mineralized) acoustic shadowing: dystrophic

with chronicity (reactive, metastatic)

ACOUSTIC TRANSMISSION

From: Nyman H.T, O’Brien R.T. The sonographic evaluation of lymph nodes. Clin Tech Small Anim Prac 2007;22:128-137

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YOUNG ANIMAL

Till +/- 1 year old

Lymph nodes are bigger than in the adult

Lymph nodes have a hypoechoic halo

THE DISEASED NODE

THE DISEASED NODES

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Aim: demonstrate the amount, distribution and architecture of blood

vessels within the lymph node

Normal: orderly arrangement of branching arteries starting from the hilus

or no vascularisation visible

Metastatic lymph nodes:

Peripheral perfusion pattern due to initial deposition of tumor cells in the

marginal and medullary sinuses inducing aberrant vessels

With tumor progression: periphery + central vessels

Vessel morphology: irregular diameter, branching pattern, intravascular

shunts, blind-ending vessels

COLOR / POWER DOPPLER

COLOR / POWER DOPPLER

From: Nyman H.T, O’Brien R.T. The sonographic evaluation of lymph nodes. Clin Tech Small Anim Prac 2007;22:128-137

Metastasis perianal gland

carcinoma - peripheral

Reactive - hilarLymphoma - mixed

VASCULAR FLOW INDICES

Two indices may be useful when used in combination with the echogenicity,

hilus, short to long axis ratio, blood flow distribution

Resistive index (RI):

peak systolic velocity-end diastolic velocity / peak systolic velocity Pulsatility index (PI):

peak systolic velocity-end diastolic velocity / time-averaged max. velocity

Theory:

Inflamed lymph node: decreased vascular resistance because of vasodilatation

Metastatic lymph node: increased vascular resistance because of compression

by tumor cells or vessels in the lymph node and/or tumor-evoked angiogenesis

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Neoplastic nodes Inflammatory nodes

Shape Round Oval

S/L axis 0.55 0.55

Hilus Narrow or absent Usually present

Echogenicity Often hypoechoic Isoechoic

Border Sharp Varied

Posterior enhancement Often present Often absent

Blood flow distribution Primarily peripheral or mixed Hilar

RI High, 0.65 Low, 0.65

PI High, 1.45 Low, 1.45

(Nyman et al., 2004)

Doppler

B-mode

THE DISEASED NODE

THE DISEASED NODE

Using the size of the lymph node, distribution of vascular flow

within the lymph node, and pulsatility index (PI), a correct

diagnosis can be obtained in:

- 77% of the cases between normal, reactive, lymphoma and

metastatic

- 89% of the cases between benign and malignant

QUALITATIVE EVALUATION

• Increased intranodal vascular signals

• Different patterns for:

• normal lymph nodes

• reactive lymph nodes

• metastatic lymph nodes

• lymphoma

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ENHANCEMENT PATTERNS

NORMAL,

REACTIVE

METASTASES

LYMPHOMA. .. .. ... .

..

..

...

.. ...

. .

BASELINEARTERIAL

PHASE

PARENCHYMAL

PHASE

NORMAL,

REACTIVE

BASELINEARTERIAL

PHASE

PARENCHYMAL

PHASE

REACTIVE: diffuse intense homogeneous enhancement

because of intense vascularisation with a rich cortical

capillary circulation


METASTASES

BASELINEARTERIAL

PHASE

PARENCHYMAL

PHASE

METASTASES:

• generally less vascularized than the adjacent normal

parenchyma = perfusion defects

• avascular areas of necrosis, sometimes confluent


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LYMPHOMA. .. .. ... .

..

..

...

.. ...

. .

BASELINEARTERIAL

PHASE

PARENCHYMAL

PHASE

LYMPHOMA: variable appearance

• arterial phase:

• low grade: similar to reactive

• high grade: diffuse, heterogeneous, dotted because of hypertrophic arterial

vessels larger than in other forms of lymphadenopathy

• parenchymal phase: punctiform aspect throughout parenchyma


Lymph node perfusion (quantitative)

Quantitative study: still experimental

Sentinel lymph node - lymphosonography: still experimental

Subcutaneous injection

Normal Malignant

Under investigation…

seminar 7 ultrasonography of the gastrointestinal tract ... · gastrointestinal tract, liver,...

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