This is a 14 y old FN DSH feline with history of fecal vomiting for the past few days and constipation.
This is a 14 y old FN DSH feline with history of fecal vomiting for the past few days and constipation.
Biochemistry at presentation is AZOTEMIA which resolved 2 days later with fluid therapy. I was requested to perform an US when this ct was still full of feces. Patien is quite agressive (and sore) so very limited information was obtained from the first scan. Basically, renal architecture was pretty much conserved and not enough changes seemed to correlate with levels of azotemia. At this point there was no signs of renal lithiasis (or may be it was missed) but definitely no signs of pyelectasia nor ureteric dilation. An abnormal ICCJ or intestinal mass is visualized. Patient was scheduled for a hydrating enema and some xrays and rescheduled the scan after enema under heavier sedation or GA.
On the second scan, the feces are still there, the abnormal ICCJ also is there but now it looks more like a possible intussusception AND i find a very obvious 0.5cm bright calculus in renal crest and a pyelectasia with proximal ureteric dilation that reaches next to where the abnormal intestinal area is. I cannot find a clear calculus )no distal shadow that I can see) in the most distal ureteric abrupt narrowing.
There is slight amount of free fluid in dependant areas and reactive hyperechoic mesentery.
Questions are: can anybody throw some light into this exam and also…is it possible that an abnormal ICCJ can obstruct ureter due to adherences, inflammation etc..? Is there intussuception?
First video is from first exam
Second and third videos are form the second exam.
I know this case is surgical, I still would like to know about the images.
Thanks in Advance for any light into this case.
Comments
This looks like ileocecal
This looks like ileocecal carcinoma or LSA (frequent invaders of this region) or potential complicated IBD but if no other lesions in the bowel then ileocecocolic resection and removal of any local LN is the way to go. You can screen the pathology with US-guided FNA at the angles i show with arrows form your screen shots of the videos. LSA should exfoliate on fna easily whereas carcionoma may be tough and you may need to use the corkscrew technique to carve out with a 20g but try 22 g first and see what you get or just remove it. Be sure to angle away form the mesenteric artery in this region… I usually just use my probe hand to push the artery out of view before planning out my angle by getting the hypoechoic diagnostic pathology right up against the body wall before sampling.
Reactive mesentery (fuzzy fat) from any pathology can tie up ureters but there may be a simple stricture from prior stone passage as well having nothing to do with the intestinal pathology.
Reactive mesentery attaches to the serosa of the pathology owing to expansive serosal stretch and cytokine relase>chemotaxis and so forth… mesentery is the body’s band-aid and it tells you exactly where the problem is and often comes wiht a + Murphy sign (pain upon imaging) when scanning.
The intestinal lesion here looses mural layering so its not an intussusception but meets neoplastic criteria even though complicated IBD/bowel infarctions (less likely becauise not enough inflammation) can do this as well. Intussusceptions have extra layers as opposed to loss of layering like this lesion.
Check out the layering on these intussusceptions in the archive and compare to your lesion:
http://sonopath.com/members/case-studies/search?text=intussusception&species=All
This looks like ileocecal
This looks like ileocecal carcinoma or LSA (frequent invaders of this region) or potential complicated IBD but if no other lesions in the bowel then ileocecocolic resection and removal of any local LN is the way to go. You can screen the pathology with US-guided FNA at the angles i show with arrows form your screen shots of the videos. LSA should exfoliate on fna easily whereas carcionoma may be tough and you may need to use the corkscrew technique to carve out with a 20g but try 22 g first and see what you get or just remove it. Be sure to angle away form the mesenteric artery in this region… I usually just use my probe hand to push the artery out of view before planning out my angle by getting the hypoechoic diagnostic pathology right up against the body wall before sampling.
Reactive mesentery (fuzzy fat) from any pathology can tie up ureters but there may be a simple stricture from prior stone passage as well having nothing to do with the intestinal pathology.
Reactive mesentery attaches to the serosa of the pathology owing to expansive serosal stretch and cytokine relase>chemotaxis and so forth… mesentery is the body’s band-aid and it tells you exactly where the problem is and often comes wiht a + Murphy sign (pain upon imaging) when scanning.
The intestinal lesion here looses mural layering so its not an intussusception but meets neoplastic criteria even though complicated IBD/bowel infarctions (less likely becauise not enough inflammation) can do this as well. Intussusceptions have extra layers as opposed to loss of layering like this lesion.
Check out the layering on these intussusceptions in the archive and compare to your lesion:
http://sonopath.com/members/case-studies/search?text=intussusception&species=All
THANKS SOOOO MUCH FOR SUCH
THANKS SOOOO MUCH FOR SUCH QUICK RESPONSE!!! THIS IS JUST SO HELPFUL!!!
So …I did take samples with FNA and we are awaiting results. but they were blood contaminated, so im not sure how much diagnosis we will get from there.
The idea of the intussuception only came after having seen and re-seen the videos so many times that I thought may be I was missing something so, just wanted to double check.
Thanks for all the input. Its been extremely valuable. I will let you know how this goes since cat will be reassessed again tomorrow.
THANKS
THANKS SOOOO MUCH FOR SUCH
THANKS SOOOO MUCH FOR SUCH QUICK RESPONSE!!! THIS IS JUST SO HELPFUL!!!
So …I did take samples with FNA and we are awaiting results. but they were blood contaminated, so im not sure how much diagnosis we will get from there.
The idea of the intussuception only came after having seen and re-seen the videos so many times that I thought may be I was missing something so, just wanted to double check.
Thanks for all the input. Its been extremely valuable. I will let you know how this goes since cat will be reassessed again tomorrow.
THANKS
You are very welcome glad to
You are very welcome glad to be of help! Your response confirms why we built SonoPath:)
You are very welcome glad to
You are very welcome glad to be of help! Your response confirms why we built SonoPath:)
just to update.
This cat was
just to update.
This cat was sent for intestinal resection surgery. The histopathology came back with metastatic intestinal adenocarcinoma.
Thanks again for your help in this case.
surgeon has not mentioned anything about the R ureter being obstructed. I will give him a call and enquire. Im surprised…it looked very clearly obstructed to me.
just to update.
This cat was
just to update.
This cat was sent for intestinal resection surgery. The histopathology came back with metastatic intestinal adenocarcinoma.
Thanks again for your help in this case.
surgeon has not mentioned anything about the R ureter being obstructed. I will give him a call and enquire. Im surprised…it looked very clearly obstructed to me.
So, I called the surgeon.
So, I called the surgeon. Nothing abnormal was detected in right ureter… And apparently no adherences neither… If this finding only happened in between scans… I don’t know how it resolved by itself… Cat is recovering but prognosis of course is guarded…
So, I called the surgeon.
So, I called the surgeon. Nothing abnormal was detected in right ureter… And apparently no adherences neither… If this finding only happened in between scans… I don’t know how it resolved by itself… Cat is recovering but prognosis of course is guarded…
That ureter is about 0.2 cm
That ureter is about 0.2 cm wide so he likely missed it… remember as a rule we are scuba divers as sonographers and surgeons fish from a boat:) we see much more than they do… even the best of them. Not a pedantic statement just a reality that few wish to admit but its true…. just look at the last intestinal lsa case that a surgeon cut as mild IBD on bx.when you had all the criteria for intestinal neoplasia and they didn;t allow intraoperative ultrasound to pin point the lesion… I’ve had this scenario happen tons of times in my career and wa sth emain stimulous to do the intraop us abstract for ECVIM 2009 (http://sonopath.com/resources/research-publications). Its a reality that likely will never go away in my lifetime so matter how hard I yell from the soap box lol. Surgeons I have a solid relationship with get it and understand it but if its a “blind relationship” where the surgeon hasn’t been in many cases with you where liues the issue. When you don’t have scans with conversations on the front and back end of the case with the surgeion then you likely get less precise or discordant results… same discussion for cytologists-sonographers. Fostering relationships with these specialties in your area are key and an integral part of a sonography business…have a dinner meeting and tell them what you are about and how you can work together an ddiscuss IOP US for example. You will likely impress them…you did a nice scan and said what was there that’s all you can do and let progressive history play out.
That ureter is about 0.2 cm
That ureter is about 0.2 cm wide so he likely missed it… remember as a rule we are scuba divers as sonographers and surgeons fish from a boat:) we see much more than they do… even the best of them. Not a pedantic statement just a reality that few wish to admit but its true…. just look at the last intestinal lsa case that a surgeon cut as mild IBD on bx.when you had all the criteria for intestinal neoplasia and they didn;t allow intraoperative ultrasound to pin point the lesion… I’ve had this scenario happen tons of times in my career and wa sth emain stimulous to do the intraop us abstract for ECVIM 2009 (http://sonopath.com/resources/research-publications). Its a reality that likely will never go away in my lifetime so matter how hard I yell from the soap box lol. Surgeons I have a solid relationship with get it and understand it but if its a “blind relationship” where the surgeon hasn’t been in many cases with you where liues the issue. When you don’t have scans with conversations on the front and back end of the case with the surgeion then you likely get less precise or discordant results… same discussion for cytologists-sonographers. Fostering relationships with these specialties in your area are key and an integral part of a sonography business…have a dinner meeting and tell them what you are about and how you can work together an ddiscuss IOP US for example. You will likely impress them…you did a nice scan and said what was there that’s all you can do and let progressive history play out.