Hi Jacquie I see you were

Hi Jacquie I see you were listening attentively is in Salzburg at IVUSS and thx for using my “abby-normal” description LOL.

First point on your history: I’m assuming the severe PUPD is solid usg in the 1.010 range or so but I can’t tell you how many times confusion occurs in reality of our hectic day and PUPD is confused for dysuria pollakuria so just being fiscal here… then we scan the patient and urethral tumor or stones or uti and concentrated usg 1030 and there is a cushings workup in the mix that never really needed to happen which may have been false + for non adrenal illness +/- white coat effect. This happens often in my world so for clarity I went on a long post below for everyone to refer to based on this dilemma I see out there.

Regarding your image set and case:

The right adrenal is an example of “abby-normal”… a little heterogenic parenchyma but contour holding I would say age related here because you can still make out the infratructure and still holds the arrow shape and curvilinear aspects.

The left adrenal on the other hand is swollen, loss of cm detail and dramatically hypoechoic suggest somethign is hypersecretory wiht a push on the left renal artery. Pheo or adenoca are primary diffs here no invasion that I can see and nice views. Try a serial bp to check hypertension.

I agree somewhat with Randy based on literature (thx for the input randy good point) for sure re big adrenal little adrenal and ADH….but its sometimes its not that simple when you throw myelolipomas in the mix, mets to the adrenal like lsa, necrosis and infarcts, inflammatory disease, nodular hyperplasia and “abby-normal” findings that we see over and over..functional and non functional adenomas….in an ugly way sometimes I wish they would all just invade the cvc then we know its pheo or adenoca and go from there but without invasion its a guessing game and a lot of factors to consider so here is how I approach it to be as efficient as possible and give the owner solid direction overnight:

Re adrenal pathology:

Check USG first is usg not < 1.020 its NOT cushings or at least not full cushings yet and may be “emerging.” Always get a USG before running dynamic function tests and a urine cortisol to screen … cheap easy and need a urine anyway to check USG first and foremost.

If usg is concentrating then not cushings. If urine cortisol is not elevated its not cushings.

So if usg 1.030 for example and urine cort not elevated then no need for LDDST because LDDST is famous for false + with non adrenal illness (potential pheo here for example) and acth stim can do this as well but not as readily.

If usg is < 1.020 could be cushings or many other causes of PU including eating a bag of doritos and a 6 pack of beer or salty jerky treats.. ensure PU repeatable and other causes of usg <1.020 are not present… uti, hypertension, medullary washout, psychogenic, DI…. partial water dep in order potentially.

Check BP: 50% of cushings dogs are hypertensive and pheo dogs may be hyper or hypo so serial non white coat effect BP throughout the day key in the initial workup.

So if Im thinking cushings in a dog keep him for the day in a BP friendly part of clinic:

BP and first UA with cortisol.

If USG < 1020, cortisol in urine and looks physically cushingoid then ACTH stim if not looking cushingoid physically then LDDST.

If concentrating urine > 1.020 then regardless:

Culture urine (preferably in house and send out for ID if any growth) and maybe emprically tx abs for a week and do US looking for other disease that may cause false +… UTI pancreatitis neoplasia….

Patient in clinic one day and you have your answers between the info that day and overnight=diagnostic efficiency and less dynamic function test moguls to navigate.

You can even torb the doing during the day to take the edge off I have spoke to a couple of cardiologists and we all agree butorphanol or buprenex will not significantly affect the BP as we use it for echos as well. So if hypertension calm in quiet area on torb=true hypertension… study need to be done but Im not going into the cardio research snake pit those guys are mean lol:)

Bottom line on this case of your posted presentation: left adrenal>>bad swollen loss of detail and deviation of the left renal artery tells me it needs to come out before it finds its way to the CVC throught he phrenic vein. Maybe comes back benign but if my dog I’m screening for hyperention and he’s on the sx table in the next couple of days with ecg and bp monitoring during and after sx for adrenaline surges.

You could 25 g fna this as well for more info if you are comfortable with the procedure but my experience says out with left adrenal given the strong potential for badness:)

Nice post 🙂

 
 
Lol “abby-normal” was

Lol “abby-normal” was jokingly a code for essentially non pathological age related changes…not clean normal that you could but in a book like a 3 year old adrenal but a non pathological aged adrenal or heterogenous functional changes in organs without distorting contour or strong deviation from architecture. Its part of my “curviulinear theory lecture to detecting pathology” from normal to abby normal to inflammatory to neoplasia enhancing gut feelings before deciding to sample.

I will being doing a lot of this wiht different organ systems in our 2 day lecture in Puerto Rico in february (Plug Plug:) hers the link:

http://sonopath.com/products

Marty Feldman photo from Mel Brooks Young Frankenstein was the symbol for that “abby-normal” if you remember the movie:)

Here’s a comparison on an aged adrenal gland: Uniform swelling on cranial pole minor hetero parenchymal changes no clinical issues…. and of course, Marty… rest his soul…

= “abby-normal”:)