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Ultrasonography

Ultrasonography. Liver & Gall Bladder VCA 341 Dr. LeeAnn Pack lpack@upei.ca. Indications for U/S. Ascites Hepatomegaly/microhepatia Cranial abdominal mass Icterus Metastasis check/tumor hunt Fever of unknown origin Biopsy. U/S Technique. Scanhead placed directly under sternum

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Ultrasonography

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  1. Ultrasonography Liver & Gall Bladder VCA 341 Dr. LeeAnn Pack lpack@upei.ca

  2. Indications for U/S • Ascites • Hepatomegaly/microhepatia • Cranial abdominal mass • Icterus • Metastasis check/tumor hunt • Fever of unknown origin • Biopsy

  3. U/S Technique • Scanhead placed directly under sternum • Often angled cranially • Almost like you are aiming for the heart • Begin in a transverse scan plan and set depth to see the diaphragm echogenic line • Then switch to sagittal to see all the lobes • Intercostal techniques • used to further visualize liver lobes • Often used in deep chested dogs

  4. Normal Anatomy • Size of liver • Assessed subjectively (rads are superior) • Parenchyma • Homogenous, uniform • Interrupted only by portal & hepatic veins • Portal veins have echogenic walls • Hepatic veins = black tubes • Hepatic arteries are not seen

  5. Normal Anatomy • Echogenicity • Dog: Spleen > liver > kidney • Cat: Spleen = liver > kidney • Texture • More coarse texture than spleen

  6. Normal Anatomy

  7. Normal Anatomy

  8. Normal Anatomy

  9. Normal Anatomy

  10. Vasculature • Portal veins • More echogenic than hepatic veins due to surrounding fibro-fatty tissue • Less visible with PSS, fibrosis, & cirrhosis • Hepatic veins • Best seen cranially near diaphragm (emptying into vena cava) • Walls not visible

  11. Vasculature

  12. Hepatic Congestion

  13. Pathology • Diffuse disease • Focal or multifocal disease

  14. Diffuse Disease • Often noticed with changes in echogenicity • Compare with spleen and kidney • US is least valuable for recognizing or differentiating diffuse liver diseases • A biopsy is often necessary

  15. Diffuse Disease • Hypoechoic changes • Diffuse infiltration • Lymphoma • Leukemia • Amyloidosis • Passive congestion • Right heart failure – also see hepatic venous enlargement • Acute hepatitis often normal but maybe dec. with enhancement of periportal echoes

  16. Diffuse Disease • Hyperechoic changes • Hepatic lipidosis (fatty infiltration) • Diabetes mellitus • Chronic hepatitis • Ascites maybe present • Fibrosis/Cirrhosis • Liver usually small • Steroid hepatopathy • Lymphosarcoma (less common)

  17. Diffuse Disease

  18. Focal Disease • Cysts • Abscess • Hematoma • Nodular hyperplasia • Hemorrhage • Necrosis • Granuloma • Neoplasia • Primary • Metastatic

  19. Focal Disease • Cysts • Thin, well-defined walls • No internal echos • Sharp distinct borders • Acoustic enhancement • Congenital or acquired • Oddballs • Irregular walls • Septations, debris

  20. Focal Disease • Cysts • Percutaneous aspiration of the cyst by US guidance and cytologic evaluation with bacterial culture warranted • On serial exams – usually little to no change in size • Typically an incidental finding unless polycystic disease replaces large amt of parenchyma, compresses other structures or cyst becomes infected

  21. Hepatic Cyst

  22. Focal Disease • Abscess • Mixed echogenicity • Aspirate indicated

  23. Focal Disease • Hematoma • Mixed echogenicity – echogenicity changes with age • Acute = echogenic • Then = anechoic or hypoechoic until clot occurs • Late = clot organization - echogenic • Margins generally irregular & poorly defined • Can’t differentiate from necrosis, abscess or tumor

  24. Focal Disease • Nodular hyperplasia • May occur in up to 60% of older dogs • Variable appearance • Not able to differentiate with U/S alone • Biopsy indicated

  25. Nodule in Liver

  26. Neoplasia • Appearance is variable • Diffuse • Focal, multifocal • Cell type obtained by US FNA or Biopsy • Metastatic neoplasia can not be differentiated from neoplasia, nor can the tumor type be ascertained from the US appearance alone

  27. Hepatic Neoplasia

  28. Shunts • Congenital Portosystemic Shunts • Patent ductus venosus • Not all intrahepatic shunts are seen (large dogs) • Shunting vessel may be seen in extrahepatic shunts (small dogs) • Why are shunts reported in the literature to be easy to find but they are not? • May detect a shunt but if not does not rule it out

  29. Indications for U/S Gall Bladder • Thickened wall • Stones • Mucoceles • Cholestasis • Cholecystitis • “Sludge” • Icterus

  30. U/S Technique Gall Bladder • How to find it? • Anechoic, round to oval structure to right of midline

  31. Normal Anatomy Gall Bladder • Wall is thin echogenic line • Size of GB is variable • Cat GB is kind of bi-lobed

  32. Feline Bi-lobed GB Gall Bladder

  33. Pathology Gall Bladder • Kiwi-shaped extensions • Gallbladder mucocele • Hypoechoic areas in wall • Edema • Acute inflammation • Large, hyperechoic sediment • Gallstones – usually cause acoustic shadowing

  34. GB Mucocele Gall Bladder

  35. GB Mucocele Gall Bladder

  36. GB Mucocele Gall Bladder

  37. GB Mucocele + perf Gall Bladder

  38. Cholelith Gall Bladder

  39. Biliary Calculi Gall Bladder

  40. Sludge in GB Gall Bladder

  41. Thickened GB Wall Gall Bladder

  42. Pathology Gall Bladder

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