Sonographic Things That Make You Go “Hmmmmm…”
The “ADR” (Ain’t Doin’ Right) Patient & The Sonogram
Many times we, as veterinary practitioners, are faced with case presentations
that do not provide an opportunity for diagnostic direction during the preliminary
or even second level diagnostic work-up. Often the patient history, clinical exam,
complete blood count, blood chemistry panel, urinalyses, cultures, blood
pressures and other first and second level diagnostic tools provide unrewarding
results. The clinical sonogram can often be the instrument that allows the
practitioner to select the correct direction when faced with a diagnostic
“crossroads.”
It is essential for the clinical sonographer that is faced with such a case to be
able to remain objective. The sonographer must strive to attain adequate
knowledge and experience in upper level sonographic maneuvers and image
recognition regarding adrenal structure and pathology, gastrointestinal layering
and motility patterns, pyloric outflow views, common bile duct and biliary imaging,
and recognition of subtle changes in deviation from a normal, well-defined
curvilinear contour to organ parenchyma that may lead us to the underlying
pathology without, at the same time, looking too far into a presentation and
creating a pathology that isn’t the cause of the patient’s clinical signs. Patient
reaction to probe pressure may also allow the clinical sonographer to be drawn
into a pathological region. These “Ain’t Doin’ Right” cases often demonstrate only
subtle sonographic changes that lead the clinical sonographer into the correct
diagnostic or therapeutic direction.
How many times do we see feline and canine pancreatitis, for example, result
negative for enzyme markers but be evidently present on the sonogram and
confirmed on FNA or Biopsy or be responsive to appropriate medical therapy.
Elusive adrenal tumors with vena caval invasion are observed with increasing
frequency as we continue to improve our imaging abilities and technology. Partial
biliary obstruction (calculi, bile plugs, neoplasia) with associated local and
isolated inflammation and discomfort (+ Murphy sign) may cause a patient to
become anorexic and “not doing right” with minimal to no detectable hepatic
enzyme elevations in the initial phases of the disease. Obstructive urinary
disease (i.e. Ureterolithiasis) may also be elusive in the initial diagnostic phases
and may even self resolve prior to arriving at the diagnosis if the stone is passed
before the diagnostic race can detect it. Focal or multifocal bowel disease is a
classic example of how the body attempts to patch the transmural pathology
(such as bowel infarctions, mural IBD, and infiltrative neoplasia). In these cases,
reactive omentum attempts to block eminent perforation without necessarily
providing detectable systemic parameters, such as leukocytosis, until further
progressed phases of the disease allow systemically detectable parameters to be
identified.
The body’s immune system with its local and systemic immunological
components is present in order to fight disease locally as well as systemically.
Acute and chronic inflammation is designed to “wall-off” the pathology in the case
of local disease, and search and destroys systemic pathology in the global theme
in order to keep the harmful effects away from the rest of the “archipelago.” Case
examples of this “island vs. the archipelago” phenomenon will be presented this
hour.
The sonogram can be very effective in visualizing the occult and smoldering
pathology as well as confirming the systemically eruptive disease. Listed here
are some pathologic presentations that fit these criteria of bland initial diagnostic
parameters but subtle to dramatic sonographic presentations that led to the
correct passage through the “diagnostic crossroads” into case resolution. These
frequent presentations, as well as others, have repeatedly been encountered in
my practice as a mobile clinical sonographer:
Adrenal Disease:
• Adenocarcinoma
• Pheochromocytoma
• Caval invasion and thrombosis associated with adrenal neoplasia
• Addison’s disease (flat and isoechoic adrenal structure) (Study pending)
Hepatic Disease:
• Occult infiltrative or mass neoplasia
• Gall bladder mucoceles and perforations (Study pending)
• Biliary obstructions, perforations and neoplasia
• Portal vein thrombosis
• Portosystemic and intrahepatic shunts (Study pending) Gastrointestinal
Disease:
• Bowel Infarctions (Study Pending)
• Foreign bodies
• Occult neoplasia
• Perforations
• Ulcerative Disease Urinary disease
• Obstructive renoliths
• Ureterolithiasis
• Neoplasia
• Occult pyelonephritis Abdominal Neoplasia • Carcinomatosis •
Lymphomatosis
• Other neoplasia
Pancreatic Disease
• Feline Pancreatitis
• Pancreatic Necrosis/Sequestrum
• Pancreatic Abscess
• Sectorial Pancreatic Inflammation (Study Pending)
• Carcinoma
• Lymphoma
• Pancreatic Duct Calculi Thoracic Disease
• Pulmonary Thromboembolism
• Neoplasia
• Lung Torsion
• Occult Cardiac Disease (DCM, Arrhythmias, Neoplasia) The following abstracts that I and my team have done that reiterate the
concepts communicated in this presentation: Full abstracts and
PowerPoint presentations may be found on the RESOURCES tab on
wwww.SonoPath.com ECVIM 2009.
SONOGRAPHIC CRITERIA FOR THE DIAGNOSIS OF
GASTROINTESTINAL OBSTRUCTION IN 39 DOGS AND CATS.
E Lindquist1,
D Casey2, J Frank.1 ECVIM 2009. CLINICAL PARAMETERS IN DOGS WITH SONOGRAPHICALLY
DIAGNOSED SURGICAL BILIARY DISEASE
E. Lindquist1, A Brown2, J Bush1,
J Frank.1
ECVIM 2009. INTRAOPERATIVE ULTRASOUND FOR PRECISE BIOPSY AND
RESECTION OF TRANSABDOMINALLY DETECTED INTESTINAL LESIONS IN
3 CATS. Lindquist E, Casey D, Frank J.
ECVIM 2010. SONOGRAPHIC WHOLE BODY PARAMETERS OF
PORTOSYSTEMIC SHUNTS IN 38 DOGS & CATS.
E Lindquist1, D Casey2, J
Frank1
ECVIM 2011. SONOGRAPHIC PARAMETERS OF ADRENAL GLANDS IN 19
ADDISONIAN DOGS. Lindquist E, Lobetti R, Frank J.
ACVIM 2013. ADRENAL GLAND ULTRASONOGRAPHY IN DOGS WITH
HYPOADRENOCORTICISM. Lobetti R, Lindquist E, Frank J.