This week’s KCC was all about ultrasound. It can be very different to look at clips of other people’s scans rather than at your own. This is good practice for the oral boards.
Case 1
Case 1 was an older female spayed domestic short hair cat with vomiting. The scan showed a hypoechoic liver, mildly enlarged, with possible mineralized bile ducts. Not much time was spent on the liver. The common bile duct was enlarged and tortuous. There were a few brief glimpses of the duodenal papilla, but there was no obvious mass or stone. The pancreatic duct of the left limb of the pancreas was also enlarged, and the pancreas was thickened and mildly hypoechoic. No flow was evident on color Doppler examination. There was a 1 cm anechoic cystic structure near the duodenal papilla. The duodenum itself looked normal. There was also a very small effusion. Differential diagnoses included the triad of feline inflammatory diseases; cholangiohepatitis, pancreatitis, +/- inflammatory bowel disease (no evidence of that on the scan). The cystic structure could have been pancreatic or a dilation of bile duct. Diagnosis: Triaditis (cholangiohepatitis, pancreatitis, IBD) and a pancreatic cyst.
Case 2
1 year old mixed breed dog with vomiting. The ultrasound showed a fluid-filled stomach that was mildly enlarged. Just caudal to the stomach, there was a dilated loop of small intestine. It was fluid filled for approximately 10 cm, then narrowed to normal size. There was normal wall layering at this site, however the lumen contained clean-shadowing material. This was irregular in shape, and had a linear segment that was visible on the oral side. There was no plication to suggest a linear foreign body. In the far field, there was a brief view of a hypermotile bowel loop that was fluid filled. The diagnosis was foreign body obstruction in the proximal jejunum. At surgery, a chewed up toy was removed. The keys here were to recognize the distended loop, the clean-shadowing foreign material (not dirty shadowing like gas), and the proximal location because of the fluid filled stomach.
Case 3
8 year old Border Collie with episodes of collapse for 1 week. This echocardiogram showed a pericardial effusion. The pericardium was visible as a thin, sharp line. The ventricular walls of the heart collapsed inward during diastole, indicating tamponade. A view of the right atrium showed a hyperechoic, fusiform area of tissue, as well as a nodular triangular area on the right atrium. The diagnosis was right atrial mass with pericardial effusion and probable thrombus. Hemangiosarcoma was diagnosed at surgery, with a blood clot near the mass.
On case 2, was it possible to distinguish an obstruction in the proximal jejunum vs. distal duodenum? If you identify a linear portion to the foreign body but no plication, do you still worry that there could be a linear FB-type component to the obstruction? Since we would be headed to surgery at that point, it probably doesn’t matter in terms of case management.
On case 3, does the shape, location, and/or demonstration of blood flow within the mass-like structures indicate mass vs. thrombus? Is it usually possible to distinguish the two reliably?
These were great cases! We haven’t had ultrasounds in our KCC yet. I figured if we did that we would be given still images – not something I am looking forward to.
Thanks!
For case 2, it could have been either proximal jejunum or distal duodenum. You could see the stomach near the distended loop, but it was not traced orally to any recognizable landmarks. That’s one of the limitations to looking at someone else’s scan, you can only comment on what is included. Since there was a linear object visible, I would definitely include linear foreign body as a possibility in the report.
For case 3, it’s hard to use Doppler because both masses are in constant motion. The thrombus looked more hyperechoic and less attached to the cardiac wall than the actual mass. Several people commented that right atrial masses often look nodular, or “foamy”.
It’s worth taking clips of good cases for KCC type sessions. Keep a video tape in the machine, or store some clips if you can!