Ultrasound of the Spleen Wendy Blount, DVM Free PowerPoint Templates

Indications for Spleen Ultrasound Palpable mass in the abdomen or pendulous abdomen Fluid in the abdomen Abdominal trauma (AFASTSM) Abdominal pain Enlarged spleen or mid-abdominal mass seen on radiograph Staging of neoplasia (usually with FNA) Free PowerPoint Templates

Indications for Spleen Ultrasound Evaluation of anemias, thrombocytopenias and lymphadenopathies Hemorrhagic pericardial effusion Ventricular arrhythmia Free PowerPoint Templates

Patient Preparation Place in dorsal or right lateral recumbency Right lateral recumbency for: Compromised & deep chested patients Head of the spleen on deep chested dogs (intercostal) Landmarks for finding the spleen: Head is caudal to the stomach Spleen often mostly in the left abdomen Tail can range from right to caudal relative to the head Free PowerPoint Templates

Transition Adjustments Depth - Adjust according to size of spleen More shallow for cats, deeper for giant spleens & the canine head of the spleen Frequency - usually 6-7.5 MHz (higher) Gain and Contrast – usually no change from liver TGC - Bottom levers may need to go to the middle for head of spleen (they were right for liver) Top levers may need to go right for body/tail of spleen Free PowerPoint Templates

Image Views Sagittal & transverse Views (4 each = 8) 1. & 5. Head (cranial) – under the rib cage 2. & 6. Cranial Body 3. & 7. Hilus – splenic vein 4. & 8. Tail (caudal or right) Free PowerPoint Templates

Image Views Sagittal & transverse Views (4 each = 8) 1. & 5. Head (cranial) – under the rib cage 2. & 6. Cranial Body 3. & 7. Hilus – splenic vein 4. & 8. Tail (caudal or right) Free PowerPoint Templates

Image Views Sagittal & transverse Views (4 each = 8) 1. & 5. Head (cranial) – under the rib cage 2. & 6. Cranial Body 3. & 7. Hilus – splenic vein 4. & 8. Tail (caudal or right) Free PowerPoint Templates

Mark Jackson – Merdidian TX Free PowerPoint Templates

Telemedicine Videos Saggital – head and cranial body of spleen Free PowerPoint Templates

Telemedicine Videos Saggital – head and cranial body of spleen Free PowerPoint Templates

Telemedicine Videos Saggital – head and cranial body of spleen Saggital – hilus and tail of spleen Free PowerPoint Templates

Telemedicine Videos Saggital – head and cranial body of spleen Saggital – hilus and tail of spleen Free PowerPoint Templates

Telemedicine Videos Saggital – head and cranial body of spleen Saggital – hilus and tail of spleen Include hilus in both Free PowerPoint Templates

Video Academy of Veterinary Imaging: dorsal recumbency http://education.soundeklin.com Oncura: lateral recumbency (no video) Ultrasound of the Spleen Free PowerPoint Templates

Goals – Spleen Ultrasound Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Free PowerPoint Templates

Goals – Spleen Ultrasound Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) spleen stomach stomach liver Free PowerPoint Templates

Goals – Spleen Ultrasound Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) spleen stomach stomach liver Free PowerPoint Templates

Goals – Spleen Ultrasound Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Free PowerPoint Templates

Goals – Spleen Ultrasound Normal echotexture spleen Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Mottled spleen - neoplasia Free PowerPoint Templates

Goals – Spleen Ultrasound Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Mottled spleen with irregular margins - neoplasia Free PowerPoint Templates

Goals – Spleen Ultrasound Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Mottled spleen –lymphoid hyperplasia Mottled spleen - neoplasia Free PowerPoint Templates

Goals – Spleen Ultrasound Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Search for hypoechoic or hyperechoic nodules (+FNA) Assess size of spleen if markedly enlarged Free PowerPoint Templates

Goals – Spleen Ultrasound hemangiosarcoma Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Search for hypoechoic or hyperechoic nodules (FNA) Assess size of spleen myelolipoma infarct lymphoma Free PowerPoint Templates

Goals – Spleen Ultrasound Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Search for hypoechoic or hyperechoic nodules (FNA) Assess size of spleen if markedly enlarged Spleen – target lesions Free PowerPoint Templates

Goals – Spleen Ultrasound Evaluate splenic margins for normal shape Normal tail is bluntly pointed, margins smooth Look for passive congestion (enlarged splenic veins) Look for infarction, thrombosis, torsion Torsion – hypoechoic spleen with pronounced hyperechoic trabeculae Starry Sky Effect Free PowerPoint Templates

Goals – Spleen Ultrasound Evaluate splenic margins for normal shape Normal tail is bluntly pointed, margins smooth Look for passive congestion (enlarged splenic veins) Look for infarction, thrombosis, torsion Splenic torsion – Starry Sky No Doppler activity Free PowerPoint Templates

Goals – Spleen Ultrasound Evaluate splenic margins for normal shape Normal tail is bluntly pointed, margins smooth Look for passive congestion (enlarged splenic veins) Look for infarction, thrombosis, torsion Splenic infarct – Starry Sky with hyperechoic wedge Free PowerPoint Templates

Tips – Spleen Ultrasound The size of the canine spleen varies a great deal Sedation can make it very large The normal feline spleen is much smaller than canine Use a light touch or standoff pad for the feline spleen Look more cranial and lateral in the cat than in the dog May be under the last rib in the cat Folded spleen or thickness >10mm indicates splenomegaly in the cat In cats, splenomegaly is almost always pathologic Free PowerPoint Templates

Tips – Spleen Ultrasound The size of the canine spleen varies a great deal Sedation can make it very large The normal feline spleen is much smaller than canine Use a light touch or standoff pad for the feline spleen Look more cranial and lateral in the cat than in the dog May be under the last rib in the cat Folded spleen of thickness >10mm indicates splenomegaly in the cat In cats, splenomegaly is almost always pathologic Free PowerPoint Templates

Tips – Spleen Ultrasound Splenic veins are less plentiful than hepatic veins Splenic veins more prominent with passive congestion Body and tail are very mobile – location can vary Can go along the greater curvature, so the tail falls near the right kidney Can go along the left body wall, so the tail falls near the bladder If marked splenomegaly, can fold over so that the tail falls back near the left kidney and the head of the spleen Free PowerPoint Templates

Tips – Spleen Ultrasound Hilus identified by the hypoechoic “Y” formed by the splenic vein (“whale tail” sign) Try right lateral recumbency if having difficulty distinguishing liver from spleen When determining whether a mass arises from the spleen or is adjacent to the spleen, look at the capsule Splenic mass displaces the hyperechoic capsule outward Splenic capsule shows up best when perpendicular to ultrasound beam Free PowerPoint Templates

Tips – Spleen Ultrasound DDx focal lesions in the spleen: Cyst, abscess (peliosis), granuloma Gas is tip-off for abscess (acoustic shadow) Necrotic tumor can look like an abscess Neoplasia – target lesions more likely metastatic malignant – primary or metastatic Benign – myelolipoma, fibroma Hematoma, extramedullary hematopoiesis Nodular hyperplasia, lymphoid hyperplasia Infarct (wedge shaped) Free PowerPoint Templates

Tips – Spleen Ultrasound DDx diffusely hypoechoic splenomegaly: Nodular hyperplasia Extramedullary hematopoiesis Passive congestion Lymphoid hyperplasia Infection – bacterial, rickettsial, fungal Immune mediated disease Lymphoma, mast cell tumor, myeloproliferative disease Irregular splenic capsule with no focal lesions most often due to nodular hyperplasia Free PowerPoint Templates

Tips – Spleen Ultrasound DDx honeycomb splenomegaly: Lymphoma is most common Mast cell tumor Myeloproliferative disease Splenic thrombus should Increase index of suspicion For lymphoma Black halo around the spleen can indicate subscapsular hemorrhage (trauma) Free PowerPoint Templates

Pitfalls – Spleen Ultrasound Make sure you follow the head of the spleen by fanning up under the left ribcage until it disappears Spleen will appear largest here Try standing if you can’t reach the edges of the spleen head Do not misinterpret this as a mass Masses are usually abnormal in echotexture and echogenicity Hilar hyperechoic tissue is often a benign myelolipoma Can’t differentiate benign vs. malignant on ultrasound Free PowerPoint Templates

Pitfalls – Spleen Ultrasound Can’t always detect diffuse disease based on echogenicity changes Do a fine needle aspiration cytology FNA of spleen indicated for any chronically ill dog Can’t reliably assess spleen size except marked enlargement in dogs Beware aspirating the hypoechoic nodule in the liver and the spleen Risk of hemorrhage Free PowerPoint Templates

Gary Kniffin – Round Rock, TX Free PowerPoint Templates

Summary PowerPoint – Ultrasound of the Spleen .pdf of PowerPoints – Ultrasound of the Spleen (1 and 6 slides per page) Spleen Ultrasound TIPs Sheet Animated PowerPoint – Scanning the Spleen Videos: Oncura - Ultrasound of the Spleen (no audio), Video Case Examples Hidden slides: indications, patient prep, Transition adjustments

Acknowledgments Stephanie Lisciandro, ACVIM (Internal Medicine) Chapter 4: Focused or COAST3 – Spleen Focused Ultrasound Techniques for the Small Animal Practitioner Editor Greg Lisciandro Bob Cole, ACVR Auburn University The Academy of Veterinary Imaging 2409 Avenue J, Suite C Arlington, TX 76006 (800) 268-5354

Acknowledgments John Mattoon, Danelle Auld, Thomas Nyland Chapter 4: Abdominal Ultrasound Scanning Techniques Small Animal Diagnostic Ultrasound Editors Nyland and Mattoon – 3rd Edition 2014 Thomas Nyland, John Mattoon, Eric Herrgesell. Erik Wisner Chapter 7: Spleen Small Animal Diagnostic Ultrasound Editors Nyland and Mattoon – 3rd Edition 2014 John P. Graham, MVB, MSc, DVR, MRCVS Diplomate, ECVDI, Diplomate, ACVR Diagnostic Imaging in Dogs and Cats Nestle Purina – Clinical Handbook Series