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Practical

VN TIMES

Ultrasonography: a whistle-stop tour

DURING the past decade, nurses in human medicine have begun to incorporate limited ultrasonography (US) into obstetric nursing practice. Guidelines have been established for the perinatal nurses that provide the recommended content for the didactic and clinical preparation needed. Foetal US examination provides useful information on the foetal status and complements the foetal heart assessment just like in veterinary medicine (Figure 1). Unfortunately, in veterinary medicine no such established role for the veterinary nurse exists, although, in some referral centres, nurses have become more involved in US procedures. With the introduction of cheaper equipment, it is hoped that in the not-too-distant future, veterinary nurses may play a major supportive role in US, as they have done for many years in radiography. This article aims to give a short introduction to US, the objective being to involve veterinary nurses in the diagnostic procedure and to highlight how use of this well-established medium can be made more rewarding. Examination of the thorax using US to study heart dis-

FrankBusch, PhD, MRCVS

gives a guide to the techniques and equipment used in ultrasonography in the veterinary practice

ease often necessitates more specialised equipment, and therefore is not covered in this article.

TErMInology
Ultrasound: High-frequency sound waves. Ultrasound waves can be bounced off tissues using special devices. The echoes are then converted into a picture called a sonogram. Ultrasonography allows us to get an inside view of soft tissues and body cavities, without using invasive techniques. It is often used to examine a foetus during pregnancy. There is no convincing evidence of any danger from this. Transducer probe: The probe is the main component of the ultrasound machine. The probe produces the sound waves and receives the echoes. Take good care of it its the most expensive part of the ultrasound machine. Transducer probes come in many shapes and sizes, as shown in Figure 2. The shape determines its field of view, and the frequency of emitted sound waves determines how

deep the sound waves penetrate and the resolution of the image. In small animal practice, 5.0MHz and 7.5MHz transducers are used for the majority of work. In addition to probes that can be moved across the surface of the body, some probes are designed to be inserted through body openings (vagina, rectum, oesophagus) so that they can get closer to the organ being examined (uterus, prostate gland, stomach); being closer to the organ can give more detail. In veterinary medicine we deal primarily with the so-called B-mode (two-dimensional and real-time US). The strength of the returning echo determines the shades of black, grey or white. The depth is assessed by the time taken for the echo to return to the transducer. The echo strength is related to the acoustic impedance of tissue; ie, resistance to flow of sound waves. Very little US is reflected by even small amounts of fluid, hence the monitor will show a black picture (described as anechoic areas or echolucent areas). Conversely, strong echoes, such as those from fibrous tissue, will ultimately create a white picture on the monitor (described as hyperechoic or echodense areas). The ultrasound beam is blocked by air and bone. In the UK, we are usually taught to start from the bladder and continue the US journey cranially towards the liver and diaphragm.

Figure 3. Bladder (left) and bladder and haemabdomen. has been cleaned since its last use. Never use spirit to clean the probe; use a soft cloth or tissue instead. The patient Hopefully, your patient wont be the spiteful tortoiseshell cat that usually terrorises the neighbourhood or the biting Rotti from hell. But, if sedation is required, so be it. You should aim to clip the hair from the entire abdomen in most cases, but certainly the caudal abdomen when doing pregnancy exams. Make the owner aware of the extent of shaving necessary and ensure you have consent from the owner with regard to sedation and/ or shaving. Modus operandi There is no right or wrong way of holding the probe, as long as you keep your wrist relaxed and feel that you get good connection between the probe and the skin. Use a silent mini-hoover to remove the hair off the body surface and lots of lubrication of ultrasound-specific gel. Placing the ultrasound gel container in a jug of warm water will avoid a cooling effect on the patient and will be more comfortable when you apply it to the skin. Additionally, apply a good portion of gel on to the probe. The patient will need to be restrained in lateral and/or dorsal recumbency. ciate the normal appearance of the different organs) and for the detection of ascites (Figure 4??). In all animals with a radiographic diagnosis of decreased serosal detail or decreased detail in the retroperitoneal space, a US examination is indicated to collect the fluid for analysis and to rule out a bleeding mass or a cause of the ascites. Often a mass is not visible on the radiographs but can be seen on US. In some cases US-guided aspirates can be obtained and lead to a definitive or presumptive diagnosis. Ultrasound is a very sensitive tool for assessing the feline kidney in cats with renal disease. Normal feline kidneys are 3cm to 4.5cm in length and have a well-defined cortical and medullary interface. The diseased kidney will often appear hyperechoic and is very irregular. In cats with cystic disease the kidney is very enlarged and will have numerous cysts in the renal cortex and the medulla (Figure 4?).

an IMagIng Tour
Start by trying to locate the bladder and remember that US is more difficult on a small or empty bladder, and diffuse bladder thickening is more difficult to see on the empty bladder. Very little ultrasound is reflected by fluid, hence, you should be able to find the bladder easily as it will show up as a black area on your monitor in the caudal abdomen (Figure 3). US imaging of the abdomen is generally more sensitive than radiology for evaluation of the parenchymal organs (you will soon learn to appre-

nurSIng InpuT
If you are conducting the US examination yourself or are assisting your veterinary surgeon, there are a number of preparatory steps to be taken. The setting Find a quiet room that can be darkened. Always easier said than done, but it is important to undertake a complete ultrasound examination including all the organs even if the patient presented for a problem relating to one organ only. A rushed US exam is just not possible and significant findings can be missed. Equipment Set the unit up safely, ideally on a trolley, so the machine can be rotated around the patient. Switch the machine on only after you have attached the probe to the unit and after you have made sure the probe

Figure 1. Ultrasound can be used in the assessment of the foetal heart in human and animal patients.

B
Figure 4. A feline kidney with polycystic kidney disease (above). Figure 5 (A) Most hepatic masses are are easily seen on ultrasonography. (B) There is usually a marked change in the echogenicity and texture of the cancerous mass compared to the surrounding tissue.

Figure 2. There are many types of transducer probe.

DECEMBER 2006
Small kidneys usually have an irregular appearance on both US and radiographic studies. This irregular appearance is due to fibrosis and scarring of the damaged portion of the kidney and secondary capsular irregularity. On ultrasound examination the kidneys can appear hyperechoic or striated. Renal and lower urinary tract calculi can be seen on radiographic images, but some calculi are not obvious. These include urates and some of the struvite calculi. The calcium oxalate calculi are usually very opaque and are easily seen on survey studies. The calculi seen in small animals are obvious on US examination. The calculi are very echogenic and cause a large amount of shadowing in the distal field. Evaluation of the liver with ultrasound is often more rewarding than with radiographic exams. An abdominal ultrasound is indicated for all animals in which an enlarged liver or mass is seen on radiography. There is usually a remarkable change in the echogenicity and texture of the mass compared to the surrounding liver tissue (Figures 5 and 6). Another benefit is that if a mass is present it can be aspirated or biopsy samples can be obtained. In dogs and cats with unregulated diabetes, the liver is often echogenic and enlarged. The echogenicity changes are most consistent with fat deposition in the liver. Evaluation of the icteric animal should include ultrasound as a baseline test to rule out hepatic causes such as obstruction of the biliary tree, gall bladder disease and liver masses. One cause of icterus and elevated bilirubin is a mucocele (Figure 6). This is a mass-like accumulation of very thick bile and debris that can cause the gall bladder to rupture. As you may know, the gall bladder is not routinely visualised on radiographs. US examination of the spleen is indicated in all animals with a palpably enlarged spleen or one that appears enlarged and irregular on radiography. It is very easy to discern from the other abdominal organs as it is normally very echogenic (Figure 7) and very superficial. In the cat it is usually confined to the right side and is around 1-2cm in width. The enlarged spleen in the cat may extend across the mid-abdomen and will usually cover the left kidney. In animals with torsion of the spleen, the spleen is very hypoechoic and there is a variable amount of ascites present. Splenic masses are often complex in texture and this may represent haemorrhage in and around the mass or may be secondary to the cell type in the mass. Bear in mind that in animals that are sedated or anaesthetised the spleen can be moderately enlarged. Even if enlarged, the texture remains normal; the spleen does not become hypoechoic. US imaging of the small intestine is very useful in defining masses and interrogation of the wall layers of the bowel. The most prominent wall layer of the bowel is the mucosal layer and this is universally very hypoechoic (Figure 8). On US the normal width of the small intestinal wall is up to 5mm and, in the cat, it is closer to 4mm. Bowel wall width changes are often accompanied by an increase in the size of one or more layers of the small intestine. The lymph nodes, pancreas and other small structures, such as the adrenal glands, cannot be seen using survey abdominal radiographs or even contrast studies. The adrenal glands lie in close proximity to each kidney. Normal glands are bilobed and are sometimes difficult to find on routine examinations. In animals with adrenal hyperplasia the glands can become easy to see as they are large and, in some cases, irregular. Approximately 50 per cent of adrenal tumours can mineralise. The pancreas lies caudal to the stomach in the left cranial abdomen and has a similar texture to the mesentery. On the right side of the animal, the pancreas is superficial and lies medial to the duodenum over the right kidney. In cases of pancreatitis the pancreas becomes very enlarged and is usually hypoechoic. This region of decreased echogenicity is surrounded by echogenic mesentery, which is reactive. Most pancreatic masses are of mixed echogenicity and can be well or poorly defined. And dont forget to think outside the box whoever came up with the idea to scan the eye? Well, its a very useful tool in diagnosing retrobulbar abscesses (Figure 9) or ophthalmic neoplasias.

Practical
By improving standards of training, increasing responsibility and raising the bar for VNs, it is hoped this will lead to higher morale and increased job satisfaction. It isnt an unrealistic expectation that nurses should become more involved in diagnostic procedures and that the veterinary team would benefit, and you could increase your career options. References can be obtained from the author on request (masterkwerky@aol.com)

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Figure 6. Gall bladder mucocele.

Figure 7. Spleen with splenic nodule.

Figure 8. Small intestine.

Figure 9. Retrobulbar abscess.