I am still learning to work with my recently purchased machine so I am not uploading any images at this time. I can (probably) figure out how to do that in the near future if you need to see the images.
I am still learning to work with my recently purchased machine so I am not uploading any images at this time. I can (probably) figure out how to do that in the near future if you need to see the images.
I have a case of ascites that I am trying to find the source of. The liver did not appear subjectively congested to me although I didn’t get the key comparison of CVC to aorta at the diagphragm. However, I have seen a lot of congested livers and this one seemed pretty mild. I did find a small heterogeneous mass on the left liver lobe. (~1.5 cm). It did have some adhered mesentery that appeared hyperechoic at that location. The rest of the abdomen was normal aside from moderate anechoic ascites (colleague has already drained the abdomen once).
I also imaged the heart. The dog is a small breed older dog and has endocardiosis of the mitral valve. The tricuspid valved morphology appeared normal to me. There is TR with a gradient of 47.6 and PI with a velocity of 3.5. The MPA:Ao is 1.16. LA:Ao is 2.2.
I am trying to sort out a dog with moderate pulmonary hypertension, no evidence of cardiac remodeling in response to the PH (although there is in response to the MVD) with significant ascites, who also has a liver mass. Can you help me figure out how to definitively nail down the cause of the ascites? I assume the ascites is a transudate, although I am just the imaging doctor, not the primary on the case.
Thanks!
Suzanne
Comments
Hi Suzanne!
pulmonary
Hi Suzanne!
pulmonary hypertension of this degree is frequently seen in dogs with advanced DMVD and they usually do not have significant ascites (some liver congestion as evidenced by enlarged liver veins can be present, though. But they usually do not start with ascites until the PAP exceeds 65-70 mm Hg, some do tolerate >80 mm Hg without ascites). A short term onset of moderate PHT does not have to cause visible right heart remodelling. But the fact that you did not see right heart remodelling rules out any underestimation of pulmonary vascular resistance due to right heart failure. As a general rule: A DMVD patient usually develops left sided CHF prior to pulmonary hypertension-caused right sided CHF (given that the PHT is postcapillary).
The fact that you did not see any liver congestion increases the probablity that the ascites is not due to cardiac disease. If the ascites is pure transsudate then it arises from a pre-sinusoidal process (likely “prehepatic”). If it’s a modified transsudate its caused by a post-sinusoidal process (“intra or post-hepatic”). Hypoalbuminemia or all other causes of ascites (neoplasia, hemascos etc) should as well be taken into consideration.
What I would do is: abominocentesis and fluid analysis, if the CVC is hardly visualized try bubbles into the V saphena.
Best regards!
Peter
Thanks for the very helpful
Thanks for the very helpful answer! Just once clarification, what do you mean by “hemascos” as a cause of ascites? I will look into fluid analysis and check the bloodwork.
Thanks again,
Suzanne
Hi Suzanne!
pulmonary
Hi Suzanne!
pulmonary hypertension of this degree is frequently seen in dogs with advanced DMVD and they usually do not have significant ascites (some liver congestion as evidenced by enlarged liver veins can be present, though. But they usually do not start with ascites until the PAP exceeds 65-70 mm Hg, some do tolerate >80 mm Hg without ascites). A short term onset of moderate PHT does not have to cause visible right heart remodelling. But the fact that you did not see right heart remodelling rules out any underestimation of pulmonary vascular resistance due to right heart failure. As a general rule: A DMVD patient usually develops left sided CHF prior to pulmonary hypertension-caused right sided CHF (given that the PHT is postcapillary).
The fact that you did not see any liver congestion increases the probablity that the ascites is not due to cardiac disease. If the ascites is pure transsudate then it arises from a pre-sinusoidal process (likely “prehepatic”). If it’s a modified transsudate its caused by a post-sinusoidal process (“intra or post-hepatic”). Hypoalbuminemia or all other causes of ascites (neoplasia, hemascos etc) should as well be taken into consideration.
What I would do is: abominocentesis and fluid analysis, if the CVC is hardly visualized try bubbles into the V saphena.
Best regards!
Peter
Thanks for the very helpful
Thanks for the very helpful answer! Just once clarification, what do you mean by “hemascos” as a cause of ascites? I will look into fluid analysis and check the bloodwork.
Thanks again,
Suzanne
Susanne take a look at this
Susanne take a look at this case i just uploaded. Go to the basic search and put in
“working through ascites”
http://www.sonopath.com/members/case-studies/cases/neoplasia-carcinomatosis-epithelial-origin-pancreas-diagnosed-abdominal-f
the reasoning in this case works thorugh most causes of ascites.
Susanne take a look at this
Susanne take a look at this case i just uploaded. Go to the basic search and put in
“working through ascites”
http://www.sonopath.com/members/case-studies/cases/neoplasia-carcinomatosis-epithelial-origin-pancreas-diagnosed-abdominal-f
the reasoning in this case works thorugh most causes of ascites.