Sonopath Forum

ICCJ Intusussception?

– 8 year MN Lab ADR with vomting and diarrhea since New Years

– Blood work including cPLI unremarkable

– abdominal ultrasound showed mild dilation of some loops of SI; no obstructive patterns in the stomach and a severely dilated colon or cecum (not sure how to tell the difference) at ICCJ.

– the ICCJ LN is enlarged and there is a mild inflammatory pattern in the region but no free fluid, intra-abdominal gas

– it looks like the ileum is entering the cecum/colon in various views at the ICCJ

– intusussception?

– 8 year MN Lab ADR with vomting and diarrhea since New Years

– Blood work including cPLI unremarkable

– abdominal ultrasound showed mild dilation of some loops of SI; no obstructive patterns in the stomach and a severely dilated colon or cecum (not sure how to tell the difference) at ICCJ.

– the ICCJ LN is enlarged and there is a mild inflammatory pattern in the region but no free fluid, intra-abdominal gas

– it looks like the ileum is entering the cecum/colon in various views at the ICCJ

– intusussception?

Comments

rlobetti

January 6, 2019 at 8:59 am -

Looks like a

Looks like a ICCJ intusussception but with the enlarged lymph node would consider underlying primary intestinal disease. Needs surgery with intestinal and lymph biopses as well.

franklinanimalclinic

January 6, 2019 at 7:47 pm -

Good afternoon

Good afternoon everyone…Just nosing around here working on my Dx skills….Could you indicate the LN you’re refencing…I think its visable in the second clip just ventral to the ICCJ; but would’nt mind confirmation

Thanks from a budding sonopathologist 🙂

Sam

Pankatz

January 6, 2019 at 8:24 pm -

Hi Sam
The ICCJ LN is best

Hi Sam

The ICCJ LN is best seen in the first clip. I have labelled it with an arrow. I see what you may be looking at in the second clip. It could be a pole of the LN here or a blood vessel.

Jacquie

franklinanimalclinic

January 6, 2019 at 8:28 pm -

Thanks
Sam

Thanks

Sam

Pankatz

January 6, 2019 at 12:53 pm -

Thanks Remo have recommended

Thanks Remo have recommended surgical explore and biopsy. Can you tell the difference between cecum and colon on ultrasound and which one may be involved here?

Jacquie

Liz

January 12, 2019 at 5:51 am -

Curious what you find on

Curious what you find on explore. Please update when you find out!

Pankatz

January 12, 2019 at 7:48 am -

Hi Liz
Pet was referred to

Hi Liz

Pet was referred to OVC and was treated symptomatically for 24 hours. Clinical signs resolved and I assume so did sonographic findings. They attempted FNA’s of the LN’s but came back non-diagnostic. Internist most concerned about neoplasia. So unfortunately no definitive answers as of yet.

bhylands77

January 18, 2019 at 3:28 am -

The regional LN is a little

The regional LN is a little reactive and the surrounding fat is mildly inflamed. I am not convinced of an ICCJ intusussception. The fluid that is collecting in the ascending colon to me is highlighting the Ileocolic valve area more clearly making you suspect that there is an intususseption.

You do not have the cecum captured in any of the images or videos. When you image the cecum you should be able to identify the individual lymphatic nodules seen in the sub mucosa layer. These will appear as oval hypoechoic to anechoic nodules . They are symmetrically aligned and positioned equi distant from each other. When they become reactive they become hypertrophied and are seen to coalesce together.

I think that the real issue was the accumulation of fluid in the colon. For those particular cases I once again look for evidence of bacterial inflammation as seen with the US emergence of lymohatic nodules in the sub mucosa of the descending colon. There is so much to be found when you look for it and co relate it to anatomical pathology. It is so revealing.

If the nodules are up then there is usually bacterial overgrowth. If the case does not respond to flagyl or tylosin then I sometimes resort to fecal transplants. This is in cases when they are non responsive to the usual medical treatments.

We could do a full seminar on just colon wall pathology alone. There is more to meet the eye.

Liz

January 18, 2019 at 3:34 am -

This is fascinating Bob! I’ve

This is fascinating Bob! I’ve never looked closely at the submucosal wall of the cecum before, but I will next time I scan something! 🙂 If you have a chance and could post any pics of what you’re referring to, I’d love to see it!

– Liz

Edited to add: You said, “US emergence of lymohatic nodules in the sub mucosa of the descending colon” is indicative of bacterial overgrowth. Does this same thing not show up with lymphoma or inflammatory bowel disease? In other words, is this more indicative of bacterial overgrowth than other infiltrative diseases?

bhylands77

January 18, 2019 at 1:46 pm -

Here is a still image clearly

Here is a still image clearly demonstrating the sub mucosal LN’s in the wall of the sub mucosa. So the question to ask here ( as there is always a conversation going on with you and your machine ) why are they suddenly become visible in this patient?

Hint , they disapear as soon as the pet responds to metronidazole and the diarrhea clears up.

I had beautiful videos to share with you but they would not load to this site due to their format,sorry.

As for the cases of inflammatory bowel disease I will ask you the same question. Knowing what the pathological changes that are expected with that condition what would you expect to see on US?

KV CVT SonoPath

January 18, 2019 at 1:52 pm -

Hi Bob what is the format?

Hi Bob what is the format? Maybe I can help you get the videos up.

bhylands77

January 18, 2019 at 4:20 pm -

…..exportcolon

…..exportcolon lnImage03.wmv

So I guess WMV?

KV CVT SonoPath

January 18, 2019 at 4:41 pm -

Ok if you have time send me

Ok if you have time send me your images via We Transfer. http://www.wetransfer.com

I can probably convert them. Thx! 🙂

bhylands77

January 18, 2019 at 5:24 pm -

I will try later on this

I will try later on this evening. Having a crazy day.

Liz

January 19, 2019 at 11:23 am -

Thanks for taking the time

Thanks for taking the time Bob!!! I CAN clearly see those nodules. Very cool.

bhylands77

January 19, 2019 at 2:51 pm -

Kelly, I sent it to

Kelly, I sent it to sonopathmusic.com. I hope that this works for you,Bob.

KV CVT SonoPath

January 19, 2019 at 4:53 pm -

I’m sorry, can you send them

I’m sorry, can you send them to info@sonopath.com? I don’t have access to the other address. My apologies I shoukd have specified.

January 19, 2019 at 3:26 pm -

This looks like typhlitis to

This looks like typhlitis to me with hot mesenteric LN. Im not convinced of neoplasia other than maybe the LN as the intestinal/.colonic walls maintain mural detail. Dilated cecum nearly always outpouches to the left at the ICJ in a cul de sac fashion to differentiate it from colon that heads south to the pelvis. When really dilated like this case then its like the ileum termination pokes its head into the cecal pool. With the enhanced surrounding fat and LN then I would think typhlitis til proven otherwise. No double or triple layering like an intussusception. They are often painful on palpation as well. If you ca get an fna of the LN on these cases do a second stick and draw back with the syringe with saline so you can culture as well.

January 19, 2019 at 3:31 pm -

Maximum file size: 30

Maximum file size: 30 MB
Allowed extensions: mov flv mpg mpeg wmv mp4 avi

formats are good Bob but videos can only be plugged in at the beginning of a thread unfortunately. Have to ask the IT gods why that is with drupal but we are in a long rebuild on this monster site so hopefully the sw upgrade resolves this.

If you send the video to info@sonopath.com the crew will start a thread for you or just start a new thread and add the url to this one.

If you ever need to convert a file I love movavi and convert everything to MP4 which is universal. But our site does this for you if using the listed formats above… just video needs to start a thread.

bhylands77

January 19, 2019 at 5:52 pm -

Kelly, the transfer site is

Kelly, the transfer site is not letting me change your address info, sorry.

January 21, 2019 at 6:21 am -

Another note that Remo and i

Another note that Remo and i discussed is that this could be a sliding ICJ intussusception just not an “onion” at the time of the sonogram as there are no duplicated layers here. Dilated cecum will happen with GI shut down (GI or metabolic) and gastroenteritis/typhlitis but to me its a red flag for the clinical sonographer as the GI is to be moving otherwise the Gi pathogens throw a party, intestinal dysbiosis, toxin absorption cesspool… cecum dilated patients are usually pretty sick in my experience and I think intestinal toxin absorption often has a lot to do with that. Whats in the lower GI needs to move on after water and electrolyte absorption. I’m more likely to call typhlitis when palpation of the cecum is painful or + murphy sign there or enhanced fat on the cecal wall but with C dilation and hot adjacent nodes there certainly is some level of inflammation so it becomes semantics at that point. I like to culture and cyto (to rule out round cell neoplasia) those hot nodes as you can get some bad bugs off those nodes if you chase the culture which supports the bacterial/toxin issue in my premise.

bhylands77

January 21, 2019 at 1:32 pm -

I am not sure that we can say

I am not sure that we can say with 100% certainty that the dilated section of the GI tract is in fact caecum. In my opinion it is dilated ascending colon. For it to be caecum it is missing the characteristic alignment of lymph node nodules within the sub mucosa. Their pattern is very different from that of the wall of the colon. When a cecum is inflamed due to bacterial influence they hypertrophy and in felines will coalesce to image as an anechoic band. There is no evidence of that here.

As for the regional lymph node, once again the islets of lymphocytes that are present in the periphery of the node are only marginally reactive. The surrounding fat is hyperechoic but interestinfly, I often find it to be that way in many normal dogs. I may be out to lunch on all of this but I really think that you would need more images of the whole colon to call it one way or another. If the rest of the colon is normal then I have to rethink a few things. I enjoy these discussions

Pankatz

January 21, 2019 at 2:35 pm -

Thanks for this Bob
I have

Thanks for this Bob

I have never heard of looking at nodules in the cecum wall as you described. Very interesting! I have seen them in the descending colon in cats. Do you have a reference paper on that, that I could review?

Jacquie

bhylands77

January 21, 2019 at 6:28 pm -

Jacquie, ask and you shall

Jacquie, ask and you shall receive! You can so much active pathology if that is what you are looking for.

January 24, 2019 at 6:35 pm -

Just posted an

Just posted an intussusception with FB here for your interest

https://sonopath.com/forum/gi-linear-fb-intussusception-12-yr-boston

bhylands77

January 24, 2019 at 7:18 pm -

I jast saw it eric, still

I jast saw it eric, still waiting for the videos to load. Really beautiful images.

January 24, 2019 at 8:01 pm -

Just click on the arrows they

Just click on the arrows they work

January 25, 2019 at 9:40 am -

Darn it Bob now I have to get

Darn it Bob now I have to get new glasses to look for this lol!