This patient is an 11y old MN, Jack Russell presented for chronic vomiting (over weeks months, did not used to be daily) which is now getting worse (acute-daily) with weight loss and lethargy and anorexia. Biochemistry: moderately increased liver enzymes, ALP and ALT, normla TBil, mild azotemia (BUN 35 and CRE 1.6, max 25 and 1.4 respectively). UA not avialable. CBC neutrophilia and slight anemia.
I saw the dog vomit just before doing the ultrasound…it looks like bloddy to me, but no signs of black stains in vomit from digested blood.
Ultrasound reveals:
This patient is an 11y old MN, Jack Russell presented for chronic vomiting (over weeks months, did not used to be daily) which is now getting worse (acute-daily) with weight loss and lethargy and anorexia. Biochemistry: moderately increased liver enzymes, ALP and ALT, normla TBil, mild azotemia (BUN 35 and CRE 1.6, max 25 and 1.4 respectively). UA not avialable. CBC neutrophilia and slight anemia.
I saw the dog vomit just before doing the ultrasound…it looks like bloddy to me, but no signs of black stains in vomit from digested blood.
Ultrasound reveals:
_Pancreas: ill defined, with edematous and nodular pattern (hypoechoic nodules), very reactive hyperechoic surrounding mesentery, some corrugated pattern of surrounding SI loops.
Stomach: generally thickened wall with focal thickening and loss of layering detail affecting all layers on grater curvatur fundus region. Hyperechoic band in the mucosal aspect of the most thickened wall.
-Liver: diffusely hyperechoic with few poorly defined hypoechoic nodular areas in caudal aspect of the organ (left medial and lateral lobes).
-Reactive regional Lns
-Adrenals: Left adrenal presents a cranial pole of 0.43cm and a caudal pole round measuring 0.7cm. farily normal echogenicity. R adrenal: 0.53cm cranial pole, 0.67 caudal pole. there is very reactive mesentery around both glands. Difficult to stablish a normal echogenicity of the glands themselves. They appear normal to me. (measures wise? in theory normal but the difference in the cranial and caudal pole in left gland is concerning)
-Bladder stones and sediments (incidental finding)
-Kidneys: hyperechoic cortexes with slight perirenal fluid on cranial poles of both. Cranial pole of LK has irregular margin of cortex. Suspect related to regional peritonitis. Lk has some distrophic mineralization, no discrete calculus. no pyelectasia. Both kidneys have slight loss of CM definition, other than this, they are pretty good.
last time I sampled stomach, it came very inconclusive and sparsely cellular…And I am a bit concerned about sampling such an ill dog…I requested coex profile and I would attempt fundus and liver…and…pancreas. It looks neoplasia to me…since the gastric changes are asymetric, but…what does it look to you? What about the adrenals? I think any changes in them are likely due to the peritonitis, cause the gross changes are more in stomach and pancreas and it doesnt look like the type of spreading pattern to expect from adrenal, right?
Thanks for any input.
Comments
The sotmach is thick but
The sotmach is thick but detail is conserved.., tough for an fna to give you anything on this but the hypoechoic portion of pancreas and that liver nodule are fna-able, scope for stomach ideally or open up and shopping spree of bx. Pancreatitis and gastritis with nodular hyperplasia is much more common in older chronic vomiting dogs with acute on chronic disease as opposed to neoplasia with this presentation so its important to not bring up cancer with the owner only as a lesser possibilijty. I would fna panc and liver and try the stomach, treat for pancreatitis and gastritis 3 days and rescan then or earlier if the pet is circling the drain. Keep helicobacter covered in the tx.
******Please note to try to keep text to straight bullet points in order for the community to sort through a post quickly while keeping the subject matter to a couple of organ systems directly related to the problem at hand…i.e. in this case stomach panc and liver nodule.
i.e. in this case:
> 11 Yr JRT chonic V, Possible Melena sap alt bun elevations
> stomach thick, panc mixed echogenic, and live rnodules
>Q: Neoplasia or chronic pancreatitis gastritis and nod hyperplasia
or something along those lines…faster for the user to upload and faster for us to filter through:)
Note the red rules in upper left for the forum. great post just a bit long…becomes a telemed consultation at that point which is available of course:
info@sonopath.com for information
http://sonopath.com/spa or go to the “upload telemed cases” icon on the home page.
Please keep posting I just have to guide the rules:)
Regards
The sotmach is thick but
The sotmach is thick but detail is conserved.., tough for an fna to give you anything on this but the hypoechoic portion of pancreas and that liver nodule are fna-able, scope for stomach ideally or open up and shopping spree of bx. Pancreatitis and gastritis with nodular hyperplasia is much more common in older chronic vomiting dogs with acute on chronic disease as opposed to neoplasia with this presentation so its important to not bring up cancer with the owner only as a lesser possibilijty. I would fna panc and liver and try the stomach, treat for pancreatitis and gastritis 3 days and rescan then or earlier if the pet is circling the drain. Keep helicobacter covered in the tx.
******Please note to try to keep text to straight bullet points in order for the community to sort through a post quickly while keeping the subject matter to a couple of organ systems directly related to the problem at hand…i.e. in this case stomach panc and liver nodule.
i.e. in this case:
> 11 Yr JRT chonic V, Possible Melena sap alt bun elevations
> stomach thick, panc mixed echogenic, and live rnodules
>Q: Neoplasia or chronic pancreatitis gastritis and nod hyperplasia
or something along those lines…faster for the user to upload and faster for us to filter through:)
Note the red rules in upper left for the forum. great post just a bit long…becomes a telemed consultation at that point which is available of course:
info@sonopath.com for information
http://sonopath.com/spa or go to the “upload telemed cases” icon on the home page.
Please keep posting I just have to guide the rules:)
Regards
Yes, I’ll keep posting, no
Yes, I’ll keep posting, no problem. Thanks for the tip.thanks, at least I’ll try more for liver and pancreas.
Yes, I’ll keep posting, no
Yes, I’ll keep posting, no problem. Thanks for the tip.thanks, at least I’ll try more for liver and pancreas.
If it’s ok to ask again: I
If it’s ok to ask again: I don’t really see the layer detail in the thickened area… I really thought the detail was lost… Could you may be point or may be I just have the wrong concept of “detail loss”… May be a picture of some with detail loss??
I would much appreciate that. Thanks:)
If it’s ok to ask again: I
If it’s ok to ask again: I don’t really see the layer detail in the thickened area… I really thought the detail was lost… Could you may be point or may be I just have the wrong concept of “detail loss”… May be a picture of some with detail loss??
I would much appreciate that. Thanks:)
Ok so your point is valid and
Ok so your point is valid and that fundic mucosa is very abnormal but we are dealing with dropout of the echo signals in the far field which doesnt allow you to truly evaluate mural detail like you can in the near field. 90% of that thickening is mucosa and its at an oblique angle so it even seems excessively thick whereas if you get it to long axis it will be smaller but still thick I’m sure. So I drew up some arrows. The short arrows are the serosa, the curved arrows indicate muscularis, and the medium arrows indicate submucosa. All the rest are rugal folds that are hypertrophied. This doesnt rule out neoplasia and you would have to change angles to be sure and I think its fair to say some detail loss but the dropout makes it more prominent than it is. That being said you have echogenic fat attached to the serosa in your video which means there is transmural inflammation or an extention of the pancreatic inflammation adhered to the serosa of the stomach. Bottom line needs sampling. But note the arrow indications in the near field to the left are clearer than the ones in the far field to the right. So getting that tissue closer to the body wall and enhancing resolutions maybe with a linear probe or changing frequency to 12MHz will clear this up even further. Also usually gastric neoplasia spikes some regional LN and I’m not seeing any readily here. Hope this helps
Ok so your point is valid and
Ok so your point is valid and that fundic mucosa is very abnormal but we are dealing with dropout of the echo signals in the far field which doesnt allow you to truly evaluate mural detail like you can in the near field. 90% of that thickening is mucosa and its at an oblique angle so it even seems excessively thick whereas if you get it to long axis it will be smaller but still thick I’m sure. So I drew up some arrows. The short arrows are the serosa, the curved arrows indicate muscularis, and the medium arrows indicate submucosa. All the rest are rugal folds that are hypertrophied. This doesnt rule out neoplasia and you would have to change angles to be sure and I think its fair to say some detail loss but the dropout makes it more prominent than it is. That being said you have echogenic fat attached to the serosa in your video which means there is transmural inflammation or an extention of the pancreatic inflammation adhered to the serosa of the stomach. Bottom line needs sampling. But note the arrow indications in the near field to the left are clearer than the ones in the far field to the right. So getting that tissue closer to the body wall and enhancing resolutions maybe with a linear probe or changing frequency to 12MHz will clear this up even further. Also usually gastric neoplasia spikes some regional LN and I’m not seeing any readily here. Hope this helps
So in other words loss of
So in other words loss of mural detail indicates loss of layering between the mucosa, submucosa, muscularis and serosa…. you can say loss of mucosal detail here for sure but mural detail maybe a little but would have to play US physics gymnastics to define it truly at less depth and higher resolution.
So in other words loss of
So in other words loss of mural detail indicates loss of layering between the mucosa, submucosa, muscularis and serosa…. you can say loss of mucosal detail here for sure but mural detail maybe a little but would have to play US physics gymnastics to define it truly at less depth and higher resolution.
So, EL, Thanks for all this
So, EL, Thanks for all this explanation and drawing. It helps a lot. I can see clearly the difference between the left and right side of the image and I just could not recognize the submucosa in the right. I also spotted the messnteric adhesions or attachment but wasn’t sure whether it was some artefact.
So, unfortunately, that’s the only probe we have and it doesn’t go higher than 8.8MHz unless I’m missing something from the usage of the machine? So no high resolution option.
Dog is already much better. I will update if I can take samples this Friday.
Thanks again:)
So, EL, Thanks for all this
So, EL, Thanks for all this explanation and drawing. It helps a lot. I can see clearly the difference between the left and right side of the image and I just could not recognize the submucosa in the right. I also spotted the messnteric adhesions or attachment but wasn’t sure whether it was some artefact.
So, unfortunately, that’s the only probe we have and it doesn’t go higher than 8.8MHz unless I’m missing something from the usage of the machine? So no high resolution option.
Dog is already much better. I will update if I can take samples this Friday.
Thanks again:)
So, had the chance to Scan
So, had the chance to Scan again. Plan was FNA, But… There is moderate ascites and increase Pain and decreasing ALB, it doesn’t seem to be coming from kidneys.
Suddenly I don’t want to FNA this dog… Am a right to believe so or I am being influenced by the recent posts about FNA complications? There’s nothing better in this case from last scan on Tuesday.
I can’t get the targets close enough to the wall and I fear the mobility of the fluid will move them when I put the needle.
The COEX PANNEL was normal 2 days ago but today low platelets(100 min 200). So…am I being rational or scared( I think both)
Thanks for any advice
So, had the chance to Scan
So, had the chance to Scan again. Plan was FNA, But… There is moderate ascites and increase Pain and decreasing ALB, it doesn’t seem to be coming from kidneys.
Suddenly I don’t want to FNA this dog… Am a right to believe so or I am being influenced by the recent posts about FNA complications? There’s nothing better in this case from last scan on Tuesday.
I can’t get the targets close enough to the wall and I fear the mobility of the fluid will move them when I put the needle.
The COEX PANNEL was normal 2 days ago but today low platelets(100 min 200). So…am I being rational or scared( I think both)
Thanks for any advice
if the albumin isnt < 1.5
if the albumin isnt < 1.5 g/dl (low oncotic pressure pushing ascites) then the ascites is very concerning and has to have an inflammatory or mechanical congestion issues (lymphatic obstriuction, passive congestion, portal hypertension…) such as paraneoplastic . So if anything tap the ascites and spin it down, culture the fluid and make slides of the sediment right away. You may get a dx from that sediment. The liver nodule is the easiest thing to fna here from left intercostal 11-13 toward the sternum should put you at a good angle. You would have to push heavy from the right to get the panc.
Pancreatic carcinoma spits out fluid like this but so does pancreatitis but pancreatitis usually does it early and this was not the case before. Panc carcinoma gives ascites when it invades lymphatics so chase the panc carcinoma cells possibly in the fluid wihth the slide technique described above.
If you search ascites in the forum search on the bottom left of this page a ton of applicable posts come up: https://sonopath.com/forum?keys=ascites
or try searching ascites in the sonopath basic search and see what does this:
http://sonopath.com/members/case-studies/search?text=ascites&species=All
Let us know how it goes..
if the albumin isnt < 1.5
if the albumin isnt < 1.5 g/dl (low oncotic pressure pushing ascites) then the ascites is very concerning and has to have an inflammatory or mechanical congestion issues (lymphatic obstriuction, passive congestion, portal hypertension…) such as paraneoplastic . So if anything tap the ascites and spin it down, culture the fluid and make slides of the sediment right away. You may get a dx from that sediment. The liver nodule is the easiest thing to fna here from left intercostal 11-13 toward the sternum should put you at a good angle. You would have to push heavy from the right to get the panc.
Pancreatic carcinoma spits out fluid like this but so does pancreatitis but pancreatitis usually does it early and this was not the case before. Panc carcinoma gives ascites when it invades lymphatics so chase the panc carcinoma cells possibly in the fluid wihth the slide technique described above.
If you search ascites in the forum search on the bottom left of this page a ton of applicable posts come up: https://sonopath.com/forum?keys=ascites
or try searching ascites in the sonopath basic search and see what does this:
http://sonopath.com/members/case-studies/search?text=ascites&species=All
Let us know how it goes..
Thank you! I’ll let you know.
Thank you! I’ll let you know.
Thank you! I’ll let you know.
Thank you! I’ll let you know.