Approach to abdominal radiography Flashcards
How can you get the most out of your radiographs?
Discuss abdominal radiography?
The standard views are left or right lateral and ventrodorsal
All the abdominal organs have a soft tissue/fluid radiopacity. Visualisation of individual organs depends on the natural contrast provided by fat between organs. As a result, adjacent organs may not contrast well with each other.
Visualisation of individual organs depends on several factors:
- Exposure factors (including use of a grid)
- Differences in thickness of organs
- The amount of fat within the abdomen
- The contents of the abdominal organs
- The presence of fluid or gas within the peritoneal space
Discuss this case?
Case 1
- 10 year old, neutered male, domestic long- haired cat
- Pre-existing bronchial asthma
- Progressive weight loss, variable appetite, vomiting –months
- Small, irregular, mobile mass palpated in cranial/mid-abdomen
- Even with a previous diagnosis of bronchial asthma, seeing the state of the lungs on this radiograph you would really want to take a thoracic radiograph to make sure that the bronchial thickening was not confused with any nodules. Bronchial asthma does not normally look this bad in cats.
- Enlarged descending colon (red arrow): some mineralised fragments are not surprising as things accumulate here.
- However the opacities in the area of the SI (yellow arrow) is not normal.
- The single biggest characteristic of obstruction would be dilation of intestinal loops. Generalised dilation of loops would be more associated with ileus.
- Without a contrast study it is difficult to say whether the loops are thickened.
- Despite the longevity of the clinical signs there seems to be good falsiform fat pad .
- Contrast not so clear as would be ideal so possible that some fluid exists in the abdominal cavity but no concern of vast amounts of fluid.
Discuss this case?
Case 1
10 year old, neutered male, domestic long- haired cat
Pre-existing bronchial asthma
Progressive weight loss, variable appetite, vomiting –months
Small, irregular, mobile mass palpated in cranial/mid-abdomen
- Dystrophic calcification of the gut wall is another differential rather than material silting up in these area due to possible obstructions.
- Either way it is very concerning.
GRAVEL SIGNS: the equivalent to whats left in the sink after you run the water away.
Discuss this case?
Case 1
10 year old, neutered male, domestic long- haired cat
Pre-existing bronchial asthma
Progressive weight loss, variable appetite, vomiting –months
Small, irregular, mobile mass palpated in cranial/mid-abdomen
Either dystrophic calcification or gravel signs- red arrows.
Discuss this case?
Case 1
10 year old, neutered male, domestic long- haired cat
Pre-existing bronchial asthma
Progressive weight loss, variable appetite, vomiting –months
Small, irregular, mobile mass palpated in cranial/mid-abdomen
- This itself is NOT a foreign body: it is too bitty and looks like it would go through if the intestinal movements were normal. If in any doubt you may want to repeat radiographs within a day but here this imaging is likely enough.
- Consider the bronchia asthma when considering GA for surgery and the recovery from GA.
- For signs that are progressively getting worse, a neoplasia must be right to the top for the ddx. Ultrasound would thus be useful to clarity what is going on in this area of the abdomen but also assessing local lymph nodes and possible metastases.
What was the outcome for case 1?
Case 1
10 year old, neutered male, domestic long- haired cat
Pre-existing bronchial asthma
Progressive weight loss, variable appetite, vomiting –months
Small, irregular, mobile mass palpated in cranial/mid-abdomen
Outcome
- Laparotomy –constricting annular neoplasm mid-jejunum with nearly completely occluded lumen. Mildly dilated proximal bowel with liquid and solid contents.
- Other areas of thickened jejunum and very enlarged jejunal lymph nodes.
- Diagnosis –malignant neoplasia with metastasis (most likely adenocarcinoma)
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Discuss this case?
Case 2
- 12 year old, entire male, large crossbreed dog
- Lethargy and reluctance to walk, poor appetite
- Slightly pale mucous membranes, panting on mild exertion
- Grossly distended abdomen with large mass palpated
- Right kidney visible, left is not. Retroperitoneal area looks good.
- Stomach axis is not being displaced caudally. Gas in the Fundus (yellow arrow).
- Liver margin is in tact (red arrow).
- NB. the caecum is often confused for gas in dilated loops of the small intestines. However this gas in caecum is normal (blue arrow).
- Very rare for intestines to be displaced cranially by any liver neoplasia (even if pedunculated). More likely due to the position to be a splenic haemangiosarcoma.
- This could be a prostatic cyst (as a male), this could be a fluid filled cyst: abdominal US would be a good way of checking. Using US for LN enlargement, other organ involvement and metastases : haemangiosarcomas favour positioning in the liver, spleen and right atrium (which you could again ultrasound).
- NB. therefore if you have a case with a pericardial effusion, you should check the spleen as the haemangiosarcoma could have originated in the heart.
- Is the reluctance to walk from abdominal pain? Is slightly pale mm due to cardiovascular compromise? Pain? Abdominal bleed?
- Arguably there are no signs of significant abdominal bleeding: however with these cases these dogs tend to have several mini bleeds (each of which is followed by maybe a few days of lethargy).
Discuss this case?
Case 2
12 year old, entire male, large crossbreed dog
Lethargy and reluctance to walk, poor appetite
Slightly pale mucous membranes, panting on mild exertion
Grossly distended abdomen with large mass palpated
Caecum on the RIGHT (blue arrow).
Gas in fundus of stomach (red arrow).
Discuss case 2 outcome?
Case 2
12 year old, entire male, large crossbreed dog
Lethargy and reluctance to walk, poor appetite
Slightly pale mucous membranes, panting on mild exertion
Grossly distended abdomen with large mass palpated
Case 2 Outcome
- Exploratory laparotomy –large splenic mass with evidence of local metastasis
- Euthanasia
- Haemangiosarcoma
Identifying metastases before starting surgery is the ideal situation to give the owners time to consider euthanasia. Although arguably euthanasia whilst under GA for surgery is not always a bad thing.
Discuss case 3
Case 3
- Six year old, neutered male DSH cat
- Intermittent diarrhoea and weight loss
- Not eating and reluctant to drink
- Dehydration
- Distended, tense abdomen
- Just about acceptable for a cat but would not be for a dog where you may want to use preferential exposures for the thorax and the abdomen.
- LN enlargement seen (yellow arrow): these actually drain the abdomen so will enlarge here even without pathology in the thorax. This is mainly the case in cats rather than dogs.
- The gassy structures in the abdomen must be SI loops (red arrow) although you cannot see the layers of the lining.
- Possible gas in the fundus and pylorus, meaning that the gastric axis (blue line) is displaced (not quite paralleling the ribs) by a mass in the cranial region of the abdomen in the sight of the liver.
- The poor contrast in this radiograph is likely from abdominal fluid.
- A thoracic radiograph would be needed if the possibility of surgery is there. However in this case, if it had not been a ‘catogram’ then and abdominal radiograph alone would indicate that you do some US and fluid analysis.
Discuss case 3
Case 3
Six year old, neutered male DSH cat
Intermittent diarrhoea and weight loss
Not eating and reluctant to drink
Dehydration
Distended, tense abdomen
More caudally there is loss of serosal detail and generalised soft tissue opacity of the cranial abdomen. This radiograph is not particularly useful.
NB. soft tissue opacity is indistinguishable to fluid opacity.
Discuss case 3
Case 3
Six year old, neutered male DSH cat
Intermittent diarrhoea and weight loss
Not eating and reluctant to drink
Dehydration
Distended, tense abdomen
Discuss case 3
Case 3
Six year old, neutered male DSH cat
Intermittent diarrhoea and weight loss
Not eating and reluctant to drink
Dehydration
Distended, tense abdomen
Possible tracheal bronchial LN enlargement possible but cannot be confirmed from this (blue arrows).
Discuss Case 4
- 15 month old, entire female, small crossbreed dog
- Vomiting for two days
- Not eating or drinking
- Dull and dehydrated
- Tense, painful abdomen
- Distended gas filled loops of SI is a primary concern (blue arrows).
- Fluid filled loop of SI (red arrow).
- More caudally there seems to be some more normal looking gas in more normal looking loops of SI.
- Some definition of external and internal layers of wall of SI in caudal SI.
- Dilated gas filled loops of SI is a hallmark for acute SI obstruction. This is conferred by the more normal looking caudal loops of SI.
This phenomenon of the ‘pile up’:
- Gas and fluid filled distended loops of SI stacking in the cranial and ventral abdomen. This is commonly how the loops present.
- This could be a restrictive neoplasia. Peritonitis, hypokalaemia and pancreatitis can all be associated with ileus which we would suspect if this distension was more generalised throughout the whole bowel.
- However, given the age and presentation it is likely that the animal has eaten something that it disagrees with. You cannot rule out a FB at this point.
Discuss SI size?
Discuss case 5
- Case 5
- 7 year old, neutered female, German Shepherd dog
- Sudden onset depression, panting and weakness after a run.
- Very depressed and weak. Tachycardia, tachypnoea. Pulses weak, pale mucous membranes, prolonged capillary refill time.
- Abdomen distended and tense.
- ‘Double bubble’ (yellow arrows) sign with the soft tissue fold/compartmentalisation (pink arrow), also referred to as an inverse C: it is the shelf of soft tissue which is indicative that this is a torsion and not just a dilation. This is a gastric torsion.
- Bubbles of gas in the stomach wall (necrosis), streaks in the liver (air going up into the hepatic portal vein from a necrotic stomach): these are made prognostic factors.
- Mineralisation like this in the SI be worrying but not so much in the stomach (red arrow).
- Splenic torsion is likely with gastric torsion leading to splenic congestion leading to a mass on radiography (blue arrow).
Discuss case 5 putcome?
Case 5
7 year old, neutered female, German Shepherd dog
Sudden onset depression, panting and weakness after a run.
Very depressed and weak. Tachycardia, tachypnoea. Pulses weak, pale mucous membranes, prolonged capillary refill time.
Abdomen distended and tense.
Outcome
- Fluid therapy/orogastric decompression/ surgical gastric repositioning and gastropexy/ splenectomy
- Uneventful recovery
- Fluid therapy, gastric decompression and oxygen support are best to start.
- If you cannot tube to decompress then use of a high bore needle is indicated.
- Splenectomy can be used, particularly when you can find blood clots in vasculature to the spleen. The spleen is surplus to requirement in most dogs.
