Practicals

Question 1

Systemic approach to reading abdominal radiographs

Answer 1

Question 2

Answer 2

*Loss of serosal detail

Possible causes of poor serosal detail? Young dog with brown fat, ascites, peritonitis

The pylorus is displaced dorsally and caudally. Most likely cause? GDV

(loss of serosal due to lymphoma effusion)

Question 3

Answer 3

* Stomach markedly distended with gas

* Pylorus displaced dorsally and cranially

* Soft tissue band in the middle of the fundus which gives the appearance of dividing the fundus into two halves. This is known as compartmentalisation.

* Pathognomonic for GDV

* Gaseous distension of the SI

* Dilation of the caudal thoracic oesophagus with gas

Ventral vertebral spondylysis at T12-13, T13-L1, L3-L4 and L5-L6– increased mobility in the vertebrae leading to formation of osteophytes… cats with hypervitaminosis A

Question 4

Answer 4

Corn cob

Question 5

Answer 5

* Overdistended loops are stacked on top of each other

* hair pin like bends in the overdistended loops of SI

*Mechanical obstruction: Intussusception, luminal obstrution or extraluminal– could be neoplasia– CHANG. Linear FB possible but pattern of gas makes it less likely

Question 6

What are the parameters for determining SI overdistension in the cat? Different from the dog?

Answer 6

Question 7

Answer 7

* Cloth foreign body within the colon

Clinical problem??

Question 8

Answer 8

* liver is enlarged– margins are rounded and extended well beyond the costal arch

* Pylorus is dispalced dorsally and caudally

Question 9

Answer 9

* large soft tissue abdominal mass

* SIs are displaced dorsally and caudally on the lateral projection and to the right on the VD projection

* Splenic Mass

Question 10

Answer 10

Renal and cystic calculi

* Radiopaque calculi in the renal pelves

* Radiopaque calculi in the urinary bladder

* Are there any calculi within the urethra?

What are the types of radiopaque calculi? Silica….Urate, and occasionally cystine are radioluscent

Some mineral solutes precipitate to form crystals in urine; these crystals may aggregate and grow to macroscopic size, at which time they are known as uroliths (calculi or stones).

Question 11

Answer 11

* urinary bladder is distended

* Enlarged prostate

* dorsal displacement of the colon

* Cranial displacement of the SIs

Prostatomegaly

Question 12

Answer 12

* multiple, large, tubular soft tissue opacities within the mid-caudal abdomen consistent with enlarged fluid-filled uterus. Not displacement of the SI craniodorsally by the enlarged uterus

* Enlargement of the medial iliac LNs

* not nipples seen on VD

Pyometra

Question 13

Answer 13

* Contrast study with barium sulphate

* Air filled pylorus

* Contrast study at 30 minutes, 45 minutes, 3.5 hours….at 3.5 hours no contrast in the colon

What is the time the contrast is expected to reach the colon in a normal dog?

* Unilateral conical mural filling defects orad to the FB. Most likely represent lymphoid tissue called Peyers Patches. Often seen in the canine duodenum and are usually less abundant in the jejunum

**rate of gastric administration varies drastically between animals… if gastric emptying time is longer than 30-60 minutes strong evidence for a gastric outflow obstruction

Question 14

Answer 14

Normal intravenous pyelogram (IVP). Iodinated contrast medium was injected IV and it’s renal excretion is documented radiographically.

* Lateral projection taken to ensure there is not an excessive amount of faecal material in the colon. Important when doing a urinary contrast study.

* Increased opacity of the kidneys compared to the survey radiographs

* at 2 minutes– contrast in the renal pelvis and part of the ureters…. the incomplete filling of both ureters which is normal and due to ureteral peristalsis. The most distal part of the left ureter on the VD projection– normal ending of the ureter into the trigone area of the urinary bladder

Question 15

Answer 15

Retrograde vaginourethrocystogram

Vaginal stricture

Question 16

Answer 16

Ectopic ureter: 3-6 month old dogs, female dogs affected 8 times more frequently than male dogs.

Ectopic ureters (EUs) are the most common cause of urinary incontinence in young dogs. An ectopic ureter is defined as a ureteral opening in any area other than the normal position in the trigone of the bladder. UI is the most common clinical sign in dogs with EUs and is usually diagnosed in dogs prior to one year of age; however EUs should be considered in any dog with UI, particularly when the history is unknown. Breeds reported to be at risk include the Golden Retriever, Labrador Retriever, Siberian Husky, Newfoundland and English Bulldog. Although unilateral EUs have been reported to be more common, bilateral EUs were significantly more common in a recent study, which suggests that careful imaging of the urinary tract should be performed prior to surgery in order to obtain the best clinical outcome. EUs are uncommon in male dogs and these animals are often asymptomatic.

Question 17

Head of the spleen v. tail of the spleen

Answer 17

Head of the spleen is fixed cranially but the tail can be anywhere

Question 18

Answer 18

* dorsal abdominal mass to the right of the midline

* lateral projection of the displacement of the intestines cranioventrally and caudoventrally

* Medial displacement of the ascending colon by the mass

* excellent contrast around the dorsal and caudal aspect of the mass

Right renomegaly

Question 19

Answer 19

* multiple small gas bubbles within the SI

* Bizarre shape of these gas bubbles, which are fragmented and some are comma shaped

* tight bunching (plicated appearance of the SI)

* Linear FB

* Radiopaque FB ventral to the left cranial quadrant

* Radiopaque FB in the stomach

Question 20

Tiggy

2 yo Entire Female Boxer

History: anorexia, vomiting, depression, weight loss, abdominal pain, lethargy, 6 days prior to referral. No prior history of problems and no known access to toxins etc

* Physical exam: poor body condition, depressed and painful abdomen. Rest WNL

Answer 20

DDX:

GI obstruction (6 days with no resolution)

Gastroenteritis (would have resolved or concurrent diarrhoea)

Pancreatitis (just a little young so not top of list)

(not chronic enough for IBD)

(neoplasia a bit young)

** Haematology, Biochemistry, U/S– afast to rule out pyo and obstruction

** haematology- WNL

* decreased albumin, normal TP, Lipase and amylase high, azotaemia, glucose high, cholesterol high…. Na increased

Not likely pyo because no neutrophilia

* Pancreatitis or kidney problem

** next step USG.. 1.012, 1+ protein, occasional cast, rest NSF

** RG: NSF

* U/S bilaterally shrunken with poor contrast between medulla and cortex

** Congenital renal dysplasia (found on post mortem)

Lesson: Lipase and amylase are excreted through the kidneys, increase in lipase and amylase with renal failure… sometimes pancreatitis can be associated with renal failure. Ideal to get urine sample to get USG before you start fluids. But you shouldn’t delay if severely dehydrated.

** Sometimes what the owners perceive as being normal is not normal

Question 21

Lesson from relationship between pancreatitis and renal failure

Answer 21

Lesson: Lipase and amylase are excreted through the kidneys, increase in lipase and amylase with renal failure… sometimes pancreatitis can be associated with renal failure. Ideal to get urine sample to get USG before you start fluids. But you shouldn’t delay if severely dehydrated.

** Sometimes what the owners perceive as being normal is not normal

Question 22

Louis– staffy, 2 yo

* Abdominal pain for 2 days, frequent retching and vomiting undigested food, no significant abnormalities referral blood work, PE: Ropey saliva, abdominal pain, dehydration

Problem list: depression, excessive salivation (nausea?), vomiting, abdominal pain

Answer 22

DDX: GI obstruction (2 day onset, no diarrhoea)

Gastro– 24-48 hours before diarrhoea comes through

RG shows bone in the thoracic cavity– salivating because it was painful. Retching from trying to swallow causing pain.

Lesson:

Must differentiate regurgitation from vomiting when getting patient history

Always look in the thoracic cavity if unable to find FB in the abdominal cavity but highly suspicious

Question 23

Curly

14 yo male Curly coated retriever, moderately overweight (BCS 4/5)

5 day history of vomiting and anorexia– no other concurrent medical problems

Exam findings:

dry MM, normal temp, tachycardia (148/min), normal RR 24/min, tender cranial abdomen, prostatomegaly

Answer 23

Problem list

* vomiting (5 days), abdominal pain, dehydration, tachycardia (likely secondary to dehydration and pain, but what if doesn’t resolve once corrected those?), anorexia

* Metabolic disease (need to rule out)

* Pancreatitis (a bit old to get it for the first time, usually middle age, but on the list)

* GI neoplasia (nothing else fits except age, overweight, no other clinical signs)

* Something else….

Routine bloods and RG or something different?? Yes

* Increased haematocrit (dehyd), neutrophilia, lymphopenia (stressed), rest unremarkable… inc urea, inc albumin, inc ALP, inc cholesterol, low Na, K, and Cl, high bicarbonate

SNAP pancreatic lipase positive

RG: abnormal loop of intestine (duodenal dilation), stomach dilated (pylorus)

** Metabolic alkalosis, hypokalaemia

** after rehydrated and correction of electrolytes– exploratory laparotomy

* Duodenal FB**

Lesson: even old dogs can ingest FB, just because you get a positive SNAP don’t neglect to image the abdomen. Duodenom FB inc lipase, amylase, and SNAP pancreatic lipase

WHy metabolic alkalosis? When animals vomiting normally– vomiting HCl. So you lose Cl and H+, more likely to be metabolically alkalotic… (duodenal contents are alkalotic)… Na goes whereever Cl goes.. helps you understand where the FB might be

Question 24

Emma

7 yo Border Collie

* Receiving pred 10 mg sid and azathioprine 25 mg sid for non-regenerative IMHA

24 hour history of vomiting, anorexia, adipsia, lethargy, weakness

Exam: markedly obese (BCS 5/5), dull and weak, inc temp, tachycardia, weak pulses, pale MM, tachypnoea, hypotension

Problem list: vomiting, hypotension, tachycardia, tachypnoea, pyrexia, anorexia, weakness/lethargy, historical IMHA

Answer 24

1. Pancreatitis
2. Septic peritonitis

** Because evidence of multi organ failure or disease

3. Disseminated protozoal infection or some other type of infection

** metabolic dx she would be a bit unwell first before really unwell

** peracute presentation, < 24 hours signs

** Haematology is boring because hasn’t been enough time

* Biochemically:

• azotaemia, hyperCa, ALP and ALT increased, inc cholesterol, low Na, low K, not alkalotic, low Cl, high amylase, high lipase, gross lipaemia

Increased glucose– likely from stress or pred– excess steroids can cause hyperglycaemia

* increased neutrophils, lymphopenia

U/S– AFAST– (don’t want to move it at this stage as we are pumping fluids into her and trying to stablize)

* not much free fluid but the pancreas is enlarged, hypoechoic.. fat in the mysentery is hyperechoic

* Not always free fluid with pancreatitis– may sample if can’t tell if septic or sterile

** Severe pancreatitis

Perfusion, analgesia (lignocaine and ketamine infusion), nutrition (naso-oesophageal enteral nutrition), control vomiting (maropitant), haemodynamic status and urine status– monitor

** stopped azathioprine– one of the two drugs known to induce pancreatitis in dogs (other one is potassium bromide)– did not stop pred…. as it does not directly cause pancreatitis but does make them polyphagic. Needs to lose weight for its own benefit… but fat restricted diets don’t cause weight loss in animals… low fat, high protein to cause weight loss. Follow up serum triglycerides and cholesterol

** most dogs fully recover from acute pancreatitis– recover function and therefore can go on their normal diet as well

Question 25

Johnson

* 8 yo MN Siamese

* Decreased appetite over past few weeks

* Previously vomited 1-2 times per month, now vomiting once daily

* Slight weight loss

* Exam: no physical abnormalities

Problem list: weight loss with decreased appetite, vomiting, no treatment at moment

Answer 25

DDX: Renal disease, Lymphoma, IBD, dietary sensitivity, cholangiohepatitis, chronic pancreatitis, (hyperthyroidism– expect goiter, inc. appetite)

* Biochemistry

* Urinalysis (for kidney dx but would be really severe because the cat is vomiting so would also expect to see azotaemia)

* up to 75% of cats with pancreatitis have concurrent disease: interstitial nephritis, cholangioheptatitis or IBD

** chronic pancreatitis would be unlikely to be the primary cause…

unlikely dietary related because of the weight loss

* how concerned you and the client are about the status of the cat… depends on whether you want to and are able to conduct further investigations– best to do before the cat gets really sick and debilitated… better chance of good recover and less morbidity associated with the investigation

** but O said no, tx trial with Antibiotics.. so did U/S– unremarkable

** exploratory laparotomy or endoscopy??

histopathology consistent with IBD in duodenum (L-P infiltrate within the duodenum; stomach unremarkable); small cell lymphoma within the ileum…. PCR test can differentiate between inflammation and neoplasia.

* Small cell lymphoma + IBD–> good prognosis– median survival time more than 2 years (half can live more than 2 years)… not really nasty. Dont’ need full multi agent chemotherapy. Main stay is prednisolone and chorambucil… still give cobalamin (B12) every now and again

Lessons:

* serum cobalamin significant consequences on GI function in cats and needs supplementation

* IBD may cause reactive hepatitis but main DDX is concurrent cholangiohepatitis

* Absence of intestinal change on U/S does not rule out IBD or other infiltrative disease

* Need distal SI (ileum) biopsies to definitively diagnose

Question 26

5 yo MN Matese X

6 month history

Waxing/ waning episodes of diarrhoea

Toby is a 5yo MN Maltese Terrier X

BCS 3/9, borborygmus, lethargic, TPR al lnormal, no other abnormal findings

He presents with a six month history of waxing / waning episodes of diarrhoea that lasted approximately 7 days.
Approximately 2kg weight loss in that time frame.
His diet was a supermarket brand dry and wet dog food, with occasional treats. But the episodes could not be connected to dietary or other triggers. And did not appear to resolve with fasting. Spontaneous resolution was reported with no particular therapies implemented.
The other dog in the household was fine and no scavenging behaviour was reported.
The dogs were both mostly indoor dogs.
Parasite prophylaxis was intermittent, but vaccinations were current.

Within the last week Toby had become completely anorectic, and for the last two days he had been vomiting.

On physical examination Toby was underweight with a body condition score of 3/9.
There was marked borborygmus identified
Toby was very lethargic
Abdominal palpation was unremarkable.
Rectal showed very soft to fluid, yellow to brown faecal material.
Other vital parameters were normal.

Answer 26

Primary or secondary GI disease? If it was secondary would expect other signs e.g. PU/PD… going on for quite a while. Vomiting and diarrhoea is more suggestive of intestinal disease– more likely PRIMARY

* Treatment trial or further investigation?? Further investigation… 4 months ago when bright and happy treatment trial.. but now he is sick

* Haematology– inflammatory leukogram, mild anaemia

* Biochem- mild azotaemia, USG really concentrated (so pre renal– dehydration)… low albumin… so once you correct dehydration may correct findings

* TLI for function (PLI for inflammation)**– consider EPI– not top of the list because he is not eating with EPI they are ravenous.

* Abdominal U/S– look for intestinal wall layering thickness… mass effects.

* No faecal analysis… not from a kennel, good prophylaxis

*ACTH stim test- next step after this is invasive so you want to rule out everything– have no ruled out atypical addison’s disease… glucocorticoid deficiency (electrolytes were normal)– can have decreased appetite… base blood sample measure cortisol, synthetic ACTH, measure cortisol an hour later. At the moment supply issues with synthetic ACTH.. so really expensive… so can also run basal cortisol– if it is high then don’t do stim part.. if high, we know he has sufficient cortisol. If low, we do the stimulation

** Addison’s– minerocorticoid crisis– hypoperfusion of the intestinal tract… get diarrhoea but UNK how or why. Often appetite decreased.

Abdominal U/S– very mild lymphadenopathy and mild thickening of the SI mucosa diffusely in the proximal duodenum.

** Obtain biopsy’s by endoscopy? or exlap? Albumin is likely to drop once rehydrated… sick dog.. so anaemia might get worse and hypoalbuminaemia… so with exlap would be concerned about dehiscence with intestinal biopsy’s– as high as 30%. Choose endoscopy sampling this dog. Also put in a feeding tube because hasn’t been eating for 7 days. Limitations with endoscopy: diameter of the scope as to what size animal you can do (Saint Bernards… just get into the proximal duodenum… but smaller dogs can get pretty far). Since this dog had no LI signs, we only needed to sample the upper SI.

Push enteroscopy– sleeve– means you can go all the way to the jejunum (don’t have at werribee)

* Histopath– severe inflammation, lymphatic dilation

Diagnosis: Severe IBD with secondary lymphangiectasia

Treatment: Hydrolysed or hypoallergenic diet (transition, might wait until he is improving). Immunosuppressives (pred and azathionone(or chlorambucil)). Antibiotics.