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Ultrasound and the Nonacute Abdomen: the Abdominal Organs

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Ultrasound and the Nonacute Abdomen: the Abdominal Organs IN-DEPTH: ULTRASOUND OF THE THORAX AND ABDOMEN Ultrasound and the Nonacute Abdomen: The Abdominal Organs Mary Beth Whitcomb, DVM The ability of ultrasound to detect abnormalities of the kidneys, liver, and spleen has made tremen- dous strides over the past 10 years due to technological advancements in ultrasound equipment and increased availability of skilled equine ultrasonologists. As our knowledge base continues to grow, increased awareness is important for owners and veterinarians to understand the diagnostic potential of abdominal ultrasound. Evaluation of abdominal organs is best performed as part of a complete abdominal ultrasound exam. Ultrasound-guided procedures are often required to differentiate be- tween various infectious, inflammatory, and neoplastic disorders. Author’s address: Clinical Large Animal Ultrasound, Department of Surgical and Radiological Sciences, University of California, One Shields Avenue, Davis, CA 95616; e-mail: [email protected]. © 2012 AAEP. 1. Introduction Admittedly, mastery of abdominal ultrasound re- Evaluation of the abdominal organs, including the quires experience and patience, much more so than kidneys, liver, and spleen, is generally performed as basic ultrasound of the acute abdomen. Similar to part of a complete ultrasound examination in non- any anatomic region, however, cursory examination acute patients.1 Many horses with hepatic, renal, is possible by a motivated practitioner equipped or splenic abnormalities present with nonspecific with appropriate ultrasound equipment. It is clinical signs3–6 similar to those in horses with gas- equally important for field practitioners to under- trointestinal tract disorders. Complete blood count stand our increased ability to diagnose and treat (CBC) and serum chemistry analysis may be unre- disorders of abdominal organs in the referral set- markable or show only evidence of inflammation ting. Ultrasound findings often help guide treat- such as hyperfibrinogenemia and hyperglobuline- ment planning, including the need for medical mia. Subsequently, a full exam is required to max- therapy or surgical intervention. Not only do we imize diagnostic yield in many cases. In other gain valuable information about the appearance of horses, clinical exam findings and serum biochemis- abdominal organs, ultrasound-guided biopsy and/or try analysis may indicate primary renal or hepatic aspirate can be used to determine the underlying etiology, to establish an appropriate treatment plan, disease, in which case the examiner may choose to 1–2 focus on the urinary tract or liver, respectively. and for prognostication. Although horses with abdominal organ disorders in- frequently present as acute colic patients, cursory Ultrasonographic Technique examination of abdominal organs can yield important A low-frequency (2–5 MHz) curvilinear transducer is information during routine colic ultrasound exams. necessary to evaluate abdominal organs in the adult NOTES 28 2012 ր Vol. 58 ր AAEP PROCEEDINGS Orig. Op. OPERATOR: Session PROOF: PE’s: AA’s: 4/Color Figure(s) ARTNO: 1st disk, 2nd beb spencers 12 1-23 3280 IN-DEPTH: ULTRASOUND OF THE THORAX AND ABDOMEN C O C L O O L R O Fig. 1. Region to be clipped for complete abdominal ultra- R sound. The left abdomen is clipped in similar fashion. Fig. 2. Time-gain compensation controls adjusted properly for deep cavity imaging. horse due to their deep location (15 to 30 cm) relative to the skin surface. This transducer is available for ventral abdomen. Structures evaluated from the most of today’s ultrasound machines, the majority of left side of the abdomen include the left kidney, which are able to obtain exceptionally high-quality spleen, stomach, and left liver lobe. The left dorsal abdominal images. In contrast, a rectal transducer and ventral colons are seen predominantly from the can only penetrate to 5 to 10 cm, which is insuffi- left ventral abdomen. cient to image the left kidney and the majority of the Scanning depth should be adjusted frequently spleen, liver, and right kidney from the transcuta- during the exam to best image the superficial and neous window. A rectal transducer can be used to deep parenchyma of each organ. No single depth image the caudal portion of the left kidney and setting is appropriate for all abdominal organ imag- spleen during transrectal examination. ing. An abdominal program or preset should be For the highest quality images, the entire abdo- selected to maximize abdominal detail. Time-gain men should be clipped with #40 blades, especially in compensation controls should also be adjusted for older, obese, or thick-coated horses that tend to im- deep cavity imaging (Fig. 2). F2 F1 age poorly (Fig. 1). Alcohol saturation can produce diagnostic quality images, but the subtle nature of Renal and Urinary Tract Ultrasound many ultrasonographic findings in the nonacute ab- Specific indications for renal ultrasound include domen may not be detectable without clipping. azotemia, hematuria, pollakiuria, dysuria, or abnor- After clipping, the skin should be cleaned with a wet mal findings of cystoliths, ureteroliths, or left renal sponge to remove dirt and debris, and ultrasound gel enlargement on rectal palpation.7–11 It is impor- is then applied. tant to remember that horses with significant renal A systematic approach to each exam is important abnormalities may present with a normal CBC and for consistency and to improve diagnostic yield. serum biochemical profile.12 At the University of California, Davis (UC Davis), The left kidney is visible transcutaneously and the entire abdomen is evaluated in the majority of transrectally. Transcutaneously, the left kidney is nonacute patients presenting to the Large Animal located deep to the spleen in the left PLF region and Ultrasound Service. Each side of the abdomen is the left 15th to 17th ICS at a scanning depth of 20 to divided into three regions: (1) paralumbar fossa/ 30 cm (Fig. 3). The best images are often obtained F3 flank region (PLF); (2) 5th through 17th intercostal in the left 16th to 17th ICS; however, the kidney spaces (ICS) from the ventral lung margins to the should be imaged from all possible windows. At costochondral junctions; and (3) ventral abdomen UC Davis, we routinely use a “special” technique to from the sternum to the inguinal region. The exam image the left kidney that entails placing the trans- should be performed in the same manner, regardless ducer caudal to the last rib, midway between the of clinical suspicion of cause. Structures evaluated tuber coxae and stifle, and aiming in a dorsocranial from the right side of the abdomen include the ce- direction. By applying gradual force with each ex- cum and cecal mesentery, right kidney, right liver piration, the transducer is effectively brought closer lobe, duodenum, and right dorsal colon. The right to the left kidney and a superior image obtained ventral colon is primarily visualized from the right than with traditional techniques. Transrectally, AAEP PROCEEDINGS ր Vol. 58 ր 2012 29 Orig. Op. OPERATOR: Session PROOF: PE’s: AA’s: 4/Color Figure(s) ARTNO: 1st disk, 2nd beb spencers 12 1-23 3280 IN-DEPTH: ULTRASOUND OF THE THORAX AND ABDOMEN C O C L O O L R O R Fig. 3. Normal appearance of the left kidney (LK) as seen from the left 16th ICS. The renal cortex is hypoechoic to the adjacent Fig. 4. Ultrasonographic appearance of an end-stage left kidney spleen and a clear corticomedullary junction is visible. Dorsal is in a horse with chronic renal failure. The kidney is small and to the right. shows large hyperechoic areas consistent with fibrosis, scarring, nephrolithiasis, or mineralization. Renal parenchyma is nearly unrecognizable. Dorsal is to the right. the left kidney is typically visible at arm’s length; however, only the caudal portion of the kidney can be seen. The right kidney is seen dorsally in the th th Renal parenchyma is seldom distorted in horses right 15 to 17 ICS at a more superficial scanning with acute renal failure; however, a clearly visible depth of 15 to 20 cm, compared with the left kidney. and discrete corticomedullary junction is often pres- The right kidney cannot be imaged transrectally in ent. Renal abscesses have been reported and ap- most horses. pear as variably shaped hypoechoic or hyperechoic Renal ultrasonographic parameters include size, areas within the renal cortex and/or medulla.12 shape, cortical echogenicity (hypoechoic to the adja- The kidneys are the second most common abdominal cent spleen), cortical thickness, medullary echoge- organ to be affected in horses with internal Coryne- nicity (hypoechoic to the cortex), and bacterium pseudotuberculosis infection. Care corticomedullary distinction. The renal pelvis should be taken not to misinterpret the hypoechoic should be evaluated for the presence of nephroliths area visible in the deep medullary portion of the and dilation (pyelectasia). Reported renal size right kidney for a mass or abscess. Hematuria is measurements are somewhat variable, and horse not uncommon in horses with renal abscessation. size should be considered when interpreting mea- Renal neoplasia is relatively uncommon in horses surements. In our experience, normal adult kid- but may be encountered with some regularity at neys range from 5 to 9 cm in width and 15 to 19 cm referral hospitals. Renal adenocarcinoma is the in length; however, a recent study reported smaller most common primary tumor, producing large measurements than that described by Reef and that 1,13 masses that completely efface renal parenchyma of our
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