Optimising Liver and Spleen Ultrasound Imaging in Small Animals

Introduction well good evening everyone and thanks for for attending and I believe this meeting is heavily oversubscribed so I'm sure it's the topic that's the UM the draw not the speaker but I know we this meeting was put together after a conversation that Mike had from Celtic SMR and I had just after the lockdown we had a number of ultrasounds meeting to plan for the year and then with lockdown and called 19 and all these plans had to go out the window so make suggestions well why don't we do and a series of webinars and the CPD that way and so after a bit of tuning and drawing and planning what we decided to to learn over the next few weeks is a series of practical webinars so the first one tonight is delivering spleen and after that we're going to look at bladder and kidneys as their next webinar and adrenals pancreas lymph nodes as the one after that three and echocardiography number four and then more maybe too late cause number five so they're still in the planning at the moment having finished them but we'll see how they go and I think one of the challenges that that we had with this was a technical challenge in that a lot of ultrasound is video and you know certainly from a teaching point of view video is is really useful I'm technically beaming that out to you guys and is that someone that's just hi Marcus Peter here I think I think we've got a few people in the chat saying they can't hear you some can some can't I can see you're I can hear you so I can I know you're not muted but yeah yours happiness or everyone definitely not muted can everyone actually see the screen okay and is the quality of the image on the screen okay and this made me down to your own bandwidth and which could be a limiting factor and if that's the case that's probably nothing that can do it unfortunately so I'm just going to crack on a fatso key Pete yeah yeah I think so mark yeah most people seem to be able to hear stories where everyone who can't okay so today's topic of tonight's topic is practical ultrasound of the liver and the spleen Tip of the Day and I'm going to start with a tip of the day and a man is never ever ever perform a liver stone or a scheme or a spleen scan and I would always urge you to perform a full abdominal ultrasound scan and because if you do just the liver scam or a spleen scan you're going to miss something and it will come back to bite you so although we're talking about liver and spleen tonight and we would be wanting you to do a full of Domino ultrasound scan in practice so here's Topics the topics that we've got for tonight and we're going to kick off with a bit on patient preparation we really have to start at the beginning here so patient preparation we'll talk a little bit about probes and we'll talk about understanding the buttons that's why I call driving the ultrasound machine and and then we'll talk about optimizing the image and the liver and the spleen are two very different organs in terms of optimizing your imaging for these organs then we're going to talk a little bit about some clinical cases so nothing highbrow at all and and we'll finish off and we're going to have a break and then I'm going to set up this machine that you can see here this is the p50 and so let's get p50 i am we're going to set this up and actually scan my dog and I'm going to try I'm streaming this to you live so it's it's a bit risk we'll see how it goes I hope I hope it goes well and I hope that you can all see the videos that we produce so I Good Practice think a good starting point is to just talk about good practice when you're doing an ultrasound scan I go into a lot of practices with my job and you know you see the ultrasound machine sitting in the corner and the jail was all dried on the probes and you know you look at the Clippers and the Clippers are filthy I think it's good practice to make sure that your Clippers are well looked after well maintained and that they don't have jagged teeth and that they're clean and because the last thing you want to do really is send your patient home covered in scratches or even worse you know a client having to come back for for some antibiotics because their dog's developed a skin infection so clipper maintenance I think absolutely essential and probe disinfection between patients it's worth or thinking about that as well I use these crystal solo of design wipes and I wipe my palms between each patients and so that I can satisfy myself at least that I've done everything and to prevent any cross-contamination so how do I like to Preparing Patients prepare my patients um I like my patients to be starved overnight and and then when it comes to clipping you want to do a proper clip so and what I mean by that is that it's a full clip from the caudal ribs right away to be quite high so I think it's really important that the owner is me that we just know how you're going to do that clip make sure you've got permission make sure that well warned and if you've got a consent form for that I think even better to make sure that the communication is done properly and I personally like to apply some spirit to degrease the skin and improve the and the jail sucking into the skin and I'll hear some of you gasping in the background there and because I think there are some manufacturers or ultrasound machines and ultrasound probes you say don't ever ever like spirit come anywhere near your probes and because it will damage the probes my take a man is that spirit if you allowed to dry thoroughly and it's completely dry it's evaporating before you get started and it shouldn't damage the probes but you know if you have a policy in your practice that is says otherwise then I would go with the practice policy the next thing is to make sure that your gel is soaked in well into the patient and even better if you can get a nurse to to do that about 15 minutes before you start it can really make a difference to the quality of the imaging that you can do so the next thing to think about is looking after your patient and make sure that they're comfortable so I like to have my patients on a nice soft bed and I like to handle them as gently as possible take your time with them and I used loads of these things adapt all fairly pet remedy I'm sure there's lots of other ones and but really it's to try and get the patient as calm as possible and especially if I'm doing an echo and these are great things but for echocardiography when we really don't want to face so I do like to sedate my patients for an abdominal ultrasound scan because I think certainly if you're doing a very detailed scan you need that abdomen to be as relaxed as possible so in my opinion sedation is quite important and the next thing to think about especially this time of year and after the lovely day that we've had if you've got air conditioning I think that's a real boon and because the last thing you want a dog that's pounding and pounding and pounding because it really impacts on the quality of the imaging that we can do and I mean like so I'm off to gone so if we then if we talk about probes and oxide machines come Probes with lots and lots of different choices probe wise but if we were just going to have a look at they're the go-to probe that you would want for doing an abdominal ultrasound scan I would be thinking about a micro convex probe that is capable of running at a middling range so you know between eight and four megahertz maybe and and that would be the sort of probe that will do most of your abdominal ultrasound scan if you've got the luxury of having a second probe I would be thinking about having a linear probe like this one here and that would be a higher frequency probe so higher frequency probes run at a higher frequency and what they do is they allow you to see fine detail so the good for fine red resolution but that is at the expense of the depth and high frequency probes and maybe not so good at penetrating deep into tissues so really for doing an abdominal ultrasound scan and doing a really thorough abdominal scan I do tend to chop and change between and different probes depending on what I'm wanting to see so for a liver for example your starting point certainly would be a middling range Prag that is capable of running it quite more frequencies to allow you to get the depth of penetration that you need and to see into the my back and then and for all you learner drivers out there driving an ultrasound machine and I think is really important to be able to understand how to drive your machine or all the buttons do and so I think your starting point at least and when you're doing an abdominal ultrasound scan is select your boob like this and then and tell the Machine that you're doing an abdominal ultrasound scan you don't want to be using an echo setting to do an abdominal scan sounds really basic and on but it is so important that you do select things properly to make a huge difference to the quality and the imaging that you can do the next thing to be able to understand is what I call the four magic buttons and I'll explain what they are in a Depth minute the four magic buttons are the depth the game the time game compensation and and the focus so let's drill this down into what these different buttons do and because it's really important to understanding how to drive your older sewing machine so the depth essentially is just the number of centimeters and depth that you're scanning into the tissues so for an abdominal ultrasound scan I would be thinking about altering the depth all the time during that scan so what I would want to do is find for example here you've got the left adrenal and find the area of interest and that should fill about three-quarters of the screen and move on to the next structure the kidney would want to change the depth again so that the kidney fills the quarter's of the screen if we want to then move to the liver and the liver can be you know sitting at 1012 even 15 centimeters depth you want to change the depth so that you can see the whole of that without the next button to think Game about is your game and and the game you want to say so that it's not too high like this that's a very snowy image and and you don't want to have your game too low so that's very dark so it's just a case of adjusting again just to get it right for your own eye and for your like the next thing to think about the four magic buttons and is the time game Game Compensation compensation and the time game compensation is simply a game switch and the corresponds to a part of the screen so this first game switch corresponds to this part of the screen this game switch here corresponds to that part of the screen and so we go on all the way down so what you can see in this example here is a turn the game down for this portion of the screen and you can see this dark area as a result of the game being turned then and then this one here what we've done is we increase the game in this portion and you can see the gain and a band across and the image that you can see there why is that important and that's important because allows you to alter the gain different portions of the screen so that you can even up the image and the great example of that is if you're scanning the liver and want you sometimes find when you first beat your probe on the liver is that the image is too bright at the top here yet it's too dark at the bottom so what you'd want to do is touch the game up in the bottom portion of the screen and maybe knock it back a little bit in the top portion of the screen that way you can see and the image of the liver is even all the way through it so that's the time game compensation the Focus next one and one that we all forget about but it's really really important is the focus and usually when the focus is is running and you can see the most three little triangles or sorry a mystery in this one it's it's three little triangles there and the focal point is is a triangle that shows quite often on a dot on this side of the screen of the other side of the screen and that shows you where the focal point is so what you want to do is whenever you get to a need of interest on the organ your scanning you want to just think about getting the focal point level with the area of interest because what you'll find is that the Machine settings and the background will alter as you move the focal point up and down and to optimize the area of interest that you're looking at and okay in some machines you can increase the number of focal points and I think one of the downsides of doing that is it quite often it reduces the frame rate that's the four magic buttons it's also Frequency important I think to think about the frequency that your probe is running at because with most modern probes these days you can actually you can see range that the probe was running out and so what you would want to do example on the left here is of turn that frequency range down so that it's running the programs running at a lower range of frequencies and and that would be for optimizing good penetration so you might want to alter the frequency and drop it down and for doing a letter scanned realize and if you select a high frequency range then that is for better resolution that will give you better resolution may not give you the same level of penetration so if we're comparing tonight we're comparing the spleen and the liver and I was looking at the liver as I say I would want to maybe select a lower frequency to get good penetration if I was scanning the spleen the spleen just sits one or two centimeters below the skin so and we don't need that penetration and so it's okay to crank up there and the frequency of the probe is running out or even better even swap to high frequency that linear probe that I was talking about before and that can really optimize the the quality of the original that you can get out of your Linux can and then there aren't other settings on Dynamic Range the machine that you can you can twiddle with and and change and so dynamic range is one of them and here's a good example on the left this left adrenal is running at a higher than that dynamic range and so what you get is a less contrast the image but more trying grayscale realize with the lower dynamic range but you've got was a very very contrast the image what you see very white so I would argue that and it probably was is useful for looking at heart where there's a higher dynamic range of compression and is useful for and looking at fine differences in grayscale so for an abdominal scan and I think that's something that could be useful to change so it's been able to understand what these different and buttons do when you change them and then most machines there's other buttons that you get and Zoom these are less important to you your scan and but if this zoom for example I use zoom all the time in both abdominal ultrasound scans and echoes so here's an example this is my dog from the other day and this is me scanning her liver and I've basically taken the zoom and blown the whole make call image right up see how much more detail you can get with there I just do it once more a little drink at the same thing it's not wine by the way too early for wine to that soon great thing to have a nanomachine fantastic other buttons to Calipers consider and calicoes I think almost every ultrasound machine these days has calipers and again back to this adrenal gland and if you've got calipers and or you find a measure lesion I would say a measure and because these calipers can measure quite accurately and certainly for the adrenal glands we once you find the adrenal glands we really want to know exactly and how big they are because that that can help your Diagnostics and then there's other buttons labeling you can label you can Slow Motion Replay annotate you can put arrows in and you can change the color of the map the color map or the chroma Mac and and and also be aware that whenever you press the freeze button and if you go to the track of all and most ultrasound machines and you can scroll back and some machines have got the ability to replay and replay in slow motion so here's an example and from a dog scan two days ago so this is a dog's liver it's very very abnormal on the left this is your normal black-and-white ultrasound imaging that you've got here and the image on the right what I've done with that is I've change their color map so the chroma map has changed and just to see if we can see any more detail and I've added some arrows and to sure where the liver is and I've annotated as bit as well and I've also used the slow motion loop playback and so that you can you can see things again in more detail these are useful things they're not essential but they're useful things to to to play with em and to help you feel imaging and ultimately to demonstrate to the client what you've what you've been doing when you've done your own scan so other things that you can do to improve the image and it might Improving the Image sound really simple but if you can struggling to get a good image you can change the distance or reduce the distance between the probe and a and interest I might just be by moving the probe into a different part of the body and to Luke from a different angle it may be pressing harder or less hard I think there's a sweet spot as well where you just get at the right pressure and you just get the best image and that's something that comes with experience it comes with time and other things that tips if you like things that you can do you can pull the far away sometimes if you haven't clicked enough and on client won't allow you to click enough fur some things you can just move the skin anyway and to give you a bigger window into the other here we're interested in or even just to try soaking some more gel in for the area it's not ideal but it's just something else that you can do and then ultimately one of the other things to think about is to swap your probe for the high frequency probe as I said before when I'm doing that domina wall to science man I'll use the micro convex probe as my go to probe and I'll use their the linear probe and to look at the high detail of structures so small structures structures close to the skin anything that I won't see in high detail I would want to use the linear probe and we'll have a play with that tonight hopefully that will work when we when we do to provide scan as well so before we Ultrasound Physics move on to just looking at some images and soif are just thinking about the physics of ultrasound so I said nothing hydro I like things that you really simple so um this is my view of of understanding the ultrasound and image and how it's displayed on the screen so different tissues have got different levels of echo jenessa T and so what you find is that by all healing and fluids tend to be black and then soft tissues tend to have increasing echogenicity so the muscle renal cortex liver fat spleen prostate these soft tissues have got increasingly cogent st and then when you get too bored and gas on organ boundaries and you find that there and the same images displayed as hyper quick or white if I was to summarize that what I mean by Maya is that fluids are black soft tissues are different shades of grey and born gas and organ boundaries are I've recorded quite simple hopefully so let's look at the liver and the liver is split into different lobes it's a big organ in the body and if you do not scan the liver systematically and scan the whole of that organ you will miss things so it's really important that you just think about the anatomy where everything is located and make sure that you you satisfy yourself that you scan the whole of that River so what does it look like the normal liver normal liver has got a Corsica texture Normal Liver so what you can see here the liver on the right and a spleen on the left and so the liver has got a core is coarser than the spleen of course echo texture it's a medium a kajin st is darker than this bloom when you see them side by side and the portal veins are the dominant vessels and these are the ones that have got the hyper quick walls and the hepatic veins are the ones where you can't see the walls at all hepatic veins tend to dream and oscillate and into the cottage in a cave portal vein enters the level at the porta hepatis and that's on the right and the gall bladder you find the rate of midline as well and we'll talk about this a little bit later but the gall bladder wall is normally less than one millimeter thick as well so hey how do Liver Scan you approach a liver scan and I think as I said before you must make sure you scan all the liver lobes and try and do in at least two different planes so I tank tend to try and do a long axis view of the liver on the left the mid portion and the right and then a short axis view on the left mid portion on the right and and I tend to do an intercostal use well especially in some of these dogs where the liver sit you know right up and under the rib cage and I think that's important so to be able to do all of that you tend to have to look at the liver with the dog and right lateral recumbent see left lateral recumbent see and dorsal recumbent see I know some scenographer like to do endorsed or the company can do anything and dorsal recumbent see it's just what you perfect preferences the other thing to think about is that when you're scanning the the liver the cranial portion of the abdomen and that's an opportunity for you to look into the diaphragm and I diagnose no end of pericardial effusions pleural effusions masses in the chest just simply because I took the time to look through the diaphragm to the other side of the diaphragm and into the chest don't forget to do that when you're doing you and abdominal ultrasound scan and then what I like to do is then focus on the liver and look at the liver size so if the liver comes beyond the costal arch and I would be thinking well this liver could be lashed look at the liver lobe edg's I'll be shocked and pointy or on the rounded because that will give you an idea of whether the liver swollen or not I would ask the question is there an abdominal effusion and what's the albumin level blood albumin level and I then look at the gallbladder and things to think about is the gallbladder the bile duct is there any evidence of obstruction to an flow of bile I says the porta hepatis called vena cava and the hepatic vasculature and sometimes we'll use colorful or Dhokla and just to have a look at lesions and then if you have evidence of dilated and hepatic veins so these are the ones that don't have white walls to them and I would be wanting to ask the question okay if the hepatic venous congestion is there something going on in the heart you know what's the differentials for hepatic venous congestion so right-sided congestive heart failure and pericardial effusion tamponade and obstruction to the caudal vena cava so if I can't find a reason for it I'm thinking about following the quadrant in a caver forward as far as you can possibly go to see if there's any evidence of obstruction and if you still don't find anything the next thing to do and is to do an echo and see if you can see a reason for it there and chest x-ray or a CT scan or both or all of them so here's the technique and I tend to stop in the middle and the longitudinal plane so the button is where my thumb is and I'm pointing fairly clearly from that point so that's your longitudinal plane centrally and then I sweep up to the left's again in longitudinal plane I sweep down to the right again and longer signal plane so I've looked at the central portion a left portion and the right portion then what I do is I will take my probe 90 degrees so now the button is facing the dogs spine and then I'm going to sweep the probe and cranially and causally and the central region and again do the same thing in the right side of the liver and the same again in the left side of the liver so that I can satisfy myself that I've scanned the whole of that River and I would do that with the dog in right lateral recumbent C because I said dorsal recumbent C and and left lateral recumbent C and and then even have a link intercostal a as well and if you can't satisfy yourself you've seen the whole of that like that so okay and here's some normals so this Liver Images is a normal liver that you can see here and we're pointing down to the right it looks like because we've got the gallbladder you can see the diaphragm diaphragmatic line this dogs obviously sedated I can see that their heart is beating the other side of the diaphragm in the chest and and you can get an appreciation of they the fact that this dogs deliver lobe is pointy so it's not rounded it's not swollen and if you look carefully as well there's two liver looms here and and you can see them both slaving against each other so here's one lobe and here's the other logo if you look carefully if you've got good quality imaging you can see these slobs sliding against each other I always say be aware of the structures that lie close by and because I've had no end of people say I think there's a machinist this dog's liver and quite often it's the stomach the stomach stomach just six codling does this dog reason and there's deliver there's the stomach hopefully you can see that that's normal normal liver so what about liver dad Liver Normalities normalities on dr. sound and we often classify these as focal multifocal are generalized and and we say that nodules are less than three centimeters masses are greater than three centimeters and then we talk about the echo Genest here of the abnormality so there can be an Ocoee hypoid hetero echoic am and hyper boy i call hyper yep Anatoli and and these will give you some differentials Differentials depending on on what you seeing so anechoic lesions tend to be cysts necrosis abscesses cystic tumors on bile always so that basically fluid hai koi Koyuk tends to be nodular hyperplasia hematoma lymphoma complex s metastasis herminia plasia and the grossest and so it goes on hydrochloric there's a whole world of differentials and there's a whole world of differentials for mixed a kitchen st so you can practically see and from looking at a liver lesion exactly what it is all you can do is get the list of differentials however if you see a target region so that's a region where you've got a high poly quick rim and a hyper aquatic center and it said that that gives an eighty percent positive predictive value from the equation or metastatic disease Diagnosis there was a paper that was published in ej sap March 2012 and but leaked at liver lesions on ultrasound to see whether you could make a tentative diagnosis based on what you saw and what they found what we concluded was that really at the end of the day to get the diagnosis you need to take a biopsy and so you can't really tell what what the lesion is just by looking at it however Examples I think you get a good impression so here's some examples of some abnormal livers so there's a cat's liver and this lever has got multifocal generalized makes the echogenicity masses and if you look at the corner of this liver just here on the edge of this liver and as you as we play this video back and forth and some of this liver is ranged at the 80s as well and then we see things like Multifocal hypoechoic nodules this multifocal hypoechoic nodules so we we think about all the differentials that that that could be and quite often these can be back your hip atop see some of these pushing occasionally play sometimes an ugly confirmed on fna and Linear probe then this is the same dog and what I've done in this case is sin has changed probe probes to linear probe in a high frequency group just to show you how much detail that you can see so if you have a look at this you can see much more detail these multifocal hypoechoic nodules and then here's something which Focal hyper is a focal hyper a quick nodules if I remember rightly this was a diabetic dog and this was just an incidental finding and that diabetic done and then this is a cat that has got multifocal mix Beca genestein nodules and Massie's and as you can see there's an effusion here and it's quite cellular fluid and and these have got the impression that these are target lesions so the highpoint could roam the ag's hyper record in the middle and in fact I think there's some central necrosis going on and I would be thinking about Mia please earlier and absolutely for sure and then if you've Endstage liver never seen cirrhosis or an end-stage liver this is the sort of thing that you'd see so the giveaway is that 10 you've got an effusion and because of the blood argument is so low and and this liver is hyper echoic and fibrotic and the outline is rounded as no sharp edges to it at all and and the outline is is irregular as well so that's her and her name stage liver unfortunately and then this is a this is a Labrador Abdomen swollen beak amendments is a breed of dog and it came in and he said copy she's abdomen really swollen and I winked at them and I said Robert you know be sure the dog hasn't just jumped the fence and because that would be the most likely thing in your case because you're hopeless I know the guy really well by the way and anyway I had to look at her and I thought for this abdomen this woman and as a flow and so pop the scanner on and this is what I found so there was a lot of fluid in the abdomen large volume is Katie's and I leapt at this liver and I thought this liver doesn't look normal at all in actual fact the biochemistry the blood work was not very helpful and and the long and short of it was that 10 I ended up opening this daughter to have a look and to take a biopsy and this was the fluid that we got from the abdomen and and this is what the liver looked like it was a bit chaotic it just wasn't normal at all she took some biopsies and this came back as ëifí bruising and chronic active hepatitis with vacuum and hair photography and interesting this dog did make a good recovery with with treatment and then don't forget other things that that that you find in the liver so I talked about hepatic venous congestion before this is what it looks like and so you get a big fat hepatic vein and there's no bright white walls today it's not a portal beam and I thinks it is big big within the liver and to my eye is then drawn to the other side of the diaphragm to see what's going on and it's not clear and this one but this one did telecard to the fusion so this was a tamponade case and then if we look at the gaunt lines Gall bladder obstruction and in the biliary system and we find the gall bladder over to the right of midline and excise can Bailey and I get a lot of people that see well you know I've scanned this dog and it's gone wild is huge it must have an obstruction and and what you have to remember is that if a dog has been stabbed or anorexic then and quite often they the bile will collect in the gall bladder so you can have quite a big gallbladder and without a banana pathology there at all gall bladder wall tends to be normal with less than one millimeter in cats and less than two to three millimeters and dogs and and quite often in some dogs you will see a of slugs in the Galt line and that's not always an abnormal and so if you're seeing a Lane where gravity has allowed the gallbladder sludge to and settle and that that would be that would be slit rather than anything else and it's unusual to see an gallbladder sledging cats and that would be more representative of cholecystitis and the common bile duct and so if you're trying to decide whether you've got brilliant obstruction I would look at the common bile duct and the normal in dogs is up to three millimeters and normal in cats is up to four millimeters and in the normal bile duct and dogs it's more difficult you know it's less commonly seen so if your bile duct is enlarged and I would be having a hunt to see whether there's any evidence of an obstruction so try and follow that all the way to the end the judean them if possible and see if as a see if it's obstructed at any point along the way so Gall bladder abnormalities here's some some examples of abnormalities so if you ever see a key me fill in the gallbladder that's most likely to represent a gallbladder mucousy on so what you get is these this telling pattern let's talked about we straight striations that come off the central portion and and here's another example here so you can see that you've got this mucus seal in the middle mice tell a pattern and you can almost imagine this is real sluggy sticky and you can see stuff that's in there horrible stuff and it's interesting and the presence of Cushing's disease increases the risk of gall blood and mucus eels by 29 times and I read that somewhere so and I would always be thinking about if I find a gall bladder mucus seal a it's worthwhile I'm getting my size for the adrenal glands and see if there's any evidence of Cushing's syndrome and B probably want to eat talking to a surgeon and in case this thing ruptures I mean some Gall stones other incidental things that you some things find and not commonly at all but this is a relatively recent case and this dog had some gall stones so what you're seeing is a great hyper quick signal which represents that stone and you can see some shadowing artifact beyond back which is showing that you've got a really solid mineral type of density so what about the spleen Spleen anatomically we just think about where that's between six it sits on the left hand side and tends to form a strap like structure that sits just under the skin and runs across to the other side so Echogenic capsule what does it look like an ultrasound to office got an echogenic capsule the parenchyma is a very homogenous and finely textured and and it's got a medium to high level echo pattern so that means it's greater compared to the liver delivers more coarse and slightly less icky Jennie so that's how you differentiate the spleen and the liver in actual fact and you can in some dogs if the stomach's not full you can actually get the spleen and the liver sitting in the same image and so that you can compare and echogenicity of the two different types of tissue so where do we start and I tend to start on the left and and set your depth to shallow so the spleen is one of these organs where you know you can really go to town on your frequency you can crank the frequency right up or even change to a linear probe and has because they sit is so superficial and you can get some beautiful detail on this balloon that way so you set your depth to shallow get your focal point in line with the spleen as I say high frequency cruel and but make sure just remember it's a big organ so scan the spleen all the way down until you don't off the end of it and then that's in the short axis and then do the same in a long axis view all the way down and remember the portion explained that six and under the ribcage here and so you have to actively think about looking up there I've seen em lassies tucked under here before that have been missed and just simply because of probes not being proof and up into that region don't forget to do that as well so what about optimizing the image of the spleen well this one gets the thumbs down and so what is wrong with this um I think the dead setting is just rubbish you're not seeing any details of this wing at all and this is why driving your doctor so machine is so important and it's important to know how to change the depth and how to change your focal point and how to change your game etc etc so you can really see what's going on so that's rubbish and the way that that one's been optimised here's your next one so I've got this given mr. thumbs up so this is a normal spleen microphone vex probe and actually it's my dog now and scan the other day using the P 50mm Linear high frequency probe and then yeah we've moved to a linear high frequency probe here and look at the detail you see I think actually my depth is could be optimized a bit better than that but yeah that's a nice view of the spleen looking at the detail that's normal spleen so what about the abnormal spleen so this is a dog that that came Abnormal spleen in it was a little bit pale a little bit tachycardic and when I put my hands on the abdomen I just felt as a small fluid fill and I was thinking mmm and I bet you this dogs explaining and butcher or something going on pop the probe on and this is what we saw so here's this bling here and you can see High index of suspicion quite clearly there's a mass of some sort on the end of the spleen it's cavitating and so I've got a high index of suspicion for you mind you sarcoma and it looks like it's ruptures so the next thing to do was to get this dog opened up and this is it just the last Hemangioma part of the spleen being removed and here what you can just see where that lesion is just here and this was confirmed as a human you saw a corner but do remember that and there are other things that can cause mass effects on this women I've seen something before that Luke as if they're going to come back is and hemangioma and come back as as hematomas so and it's always worthwhile sending these our face to pathology and I'm sure where we've all seen these in practice lots of them so here's another another spleen this is a dog that had a parrot sea of unknown Parrot spleen origin and and I scanned they stalled as part of the workup and we really couldn't get to the bottom of why this dog had and had this pride X here and I found this on the spleen I couldn't really link that with the primates here and I toll but my concern was that I'm looking at this there's quite a thin capsule to this and this is at risk of drug change so I discussed it with the owner and me when I said yeah I think we should take this out and send it off and see what we get so this is what it was it didn't look like anything and nasty at all and there was another lesion on the other end as well as you can see there so what came back was splenic nodular hyperplasia but the pathologist did see that it's not uncommon for hematoma formation to occur and these can rupture causing hemoperitoneum so I felt maybe am justified in doing what I did but lo and behold and this dog pyrexia of unknown origin suddenly disappeared and the only explanation I can give for that is that I let evil spirits oh and because there's nothing scientific and I don't think about what we what we did but yeah I felt we've done something for that Don and so here's one of the more unusual and spleens so this has got lots of unusual spleen hypoechoic modules in the spleen and I didn't like what I saw when I when I saw this one and we discussed it and the excisional biopsy owner wanted me to just do an excisional biopsy and this was if being performed this is one of these lovely ldsd of us which I'm not sure you can get that see a trigger just about exposing fun so you like this we had people with but they just came back there's something that I'd never heard of before amore Pacific is to a city called Max and was a pretty grim prognosis and again we all know they all have got the answer as to what was going on there and then this is this is a bit over splenic disease again but I thought I would p2n if you've never seen it before like form and explain and so if you see multiple small high-quality quick nodules and with those spotty data texture that is highly suggestive of a lymphoma and don't forget when we're talking about splenic disease splenic disease can we also be a cause of ectopic than curricular rhythm so if you're trying to work out why a dog has got a ventricular rhythm and you can't find a cardiac cause it's always worthwhile just scanning the spleen to see for then any pathology going on in this blue and the other thing while we're talking about it if you do find a splenic mass always scan my heart because 25 percent of dogs with splenic in mind you sarcomas also have a concurrent mass in the heart and if you're looking for where to find that it's usually at the junction of the right ventricle and I atrium so if I just play this next video and here's the spleen and you can see quite clearly there's a mass in this flame so we bended an echo and lo and behold the most also a mass at the junction of the right atrium and the right ventricle so this is a right parasternal long axis view of the heart right atrium right ventricle left atrium ventricle so here's your mass here that's concurrent right here trill and splenic in mind you circle map