Hello all,
This is a dog that had GVD surgery 2 days ago, now presenting with lethargy and elevation of liver enzymes. It was quite difficult to follow CBD to the level of the papilla due to presence of gas, even if I turned the dog around .
Hello all,
This is a dog that had GVD surgery 2 days ago, now presenting with lethargy and elevation of liver enzymes. It was quite difficult to follow CBD to the level of the papilla due to presence of gas, even if I turned the dog around .
Have you seen extrahepatic bile duct obstruction secondary to GVD surgery? There was a scant amount of free fluid as well, could this be due to portal hypertension? I plan to rescan the dog in 24-48 hrs and repeat liver enzymes to check progression, the size of the gallbladder didn’t seem a concern at this time. Pancreas was echogenic but no large. Any thoughts appreciated, cheers, Silvana
Comments
That’s a pretty thick cbd and
That’s a pretty thick cbd and GB owing to edema, inflammation and less likely neoplasia. When there is free fluid then the Gb becomes double layered such as ascites cases but this does not excuse the cbd. The echogenicity of the cbd would also suggest chronic disease.
With the patient in 45 degree right lateral recumbency you can scan right subcostal or right 11-13 intercostal to avoid the gastric gas floating on top and scan underneath it letting gravity work for you. You will work your bicep a bit but can hold the probe like a beer can with the patient laying on your hand so you don’t work your muscles as much, Spread out the pressure and follow the cbd. I have yet to run into a case that I have not been able to run the cbd in this way. I would be concerned here for a bile plug, bile duct tumor, stone or inflammatory extension from the right panc base, Portal hypertension will only occur if the liver is diffusely pathological such as CAH or cirrhosis and pv forward flow will be under 20 cm/sec for sure but usually under 18 cm.sec. See image of pv velocity in a true portal hypertension case. If the free fluid is associated and next to the Gb or cbd then always suspect pathology with what the fluid lies next to and look at that structure’s integrity…such as an echogenic ill-defined friable cbd here.
That’s a pretty thick cbd and
That’s a pretty thick cbd and GB owing to edema, inflammation and less likely neoplasia. When there is free fluid then the Gb becomes double layered such as ascites cases but this does not excuse the cbd. The echogenicity of the cbd would also suggest chronic disease.
With the patient in 45 degree right lateral recumbency you can scan right subcostal or right 11-13 intercostal to avoid the gastric gas floating on top and scan underneath it letting gravity work for you. You will work your bicep a bit but can hold the probe like a beer can with the patient laying on your hand so you don’t work your muscles as much, Spread out the pressure and follow the cbd. I have yet to run into a case that I have not been able to run the cbd in this way. I would be concerned here for a bile plug, bile duct tumor, stone or inflammatory extension from the right panc base, Portal hypertension will only occur if the liver is diffusely pathological such as CAH or cirrhosis and pv forward flow will be under 20 cm/sec for sure but usually under 18 cm.sec. See image of pv velocity in a true portal hypertension case. If the free fluid is associated and next to the Gb or cbd then always suspect pathology with what the fluid lies next to and look at that structure’s integrity…such as an echogenic ill-defined friable cbd here.
Here is the pv pw Doppler
Here is the pv pw Doppler image showing slow forward flow indicating portal hypertension. The liver had diffuse parenchymal changes which is nearly always the case whether chronic inflammatory or neoplastic and only a couple of times did have i seen it with lipidosis or suppurative hepatitis.
Here is the pv pw Doppler
Here is the pv pw Doppler image showing slow forward flow indicating portal hypertension. The liver had diffuse parenchymal changes which is nearly always the case whether chronic inflammatory or neoplastic and only a couple of times did have i seen it with lipidosis or suppurative hepatitis.
Thanks for the tips, I did
Thanks for the tips, I did scan in right lateral but flat to the table, not underneath… I can see the benefits now. Anyways, the dog was put ti sleep last night for fast deterioration. I can’t still make the connexion with GVD surgery or complications… First I though that acute rotation of the pylorus/ duodenum will misplace the pancreas and the duct as well, but you are right, changes look a bit more chronic in nature. So, possibly she already had mild bile duct obstruction at the time of surgery? Will try that view in normal patients to get familiar with, cheers Eric.
Thanks for the tips, I did
Thanks for the tips, I did scan in right lateral but flat to the table, not underneath… I can see the benefits now. Anyways, the dog was put ti sleep last night for fast deterioration. I can’t still make the connexion with GVD surgery or complications… First I though that acute rotation of the pylorus/ duodenum will misplace the pancreas and the duct as well, but you are right, changes look a bit more chronic in nature. So, possibly she already had mild bile duct obstruction at the time of surgery? Will try that view in normal patients to get familiar with, cheers Eric.
I am thinking yes there was a
I am thinking yes there was a bile duct issue concurrently mainly from the chronic cbd appearance but would need more views to say more and this is of course conjecture but makes a nice story:)
I am thinking yes there was a
I am thinking yes there was a bile duct issue concurrently mainly from the chronic cbd appearance but would need more views to say more and this is of course conjecture but makes a nice story:)