Diagnostic Imaging General Notes

Notes:
PERITONEUM & RETROPERITONEUM
Retroperitoneal fluid: Surprisingly, it is di icult/impossible to determine if abdominal fluid is in the

retroperitoneum or peritoneum on ultrasound, even by specialists. It is more easily determined by a
lateral radiograph. Retroperitoneal fluid due to trauma: As described in the lectures, an excretory
urogram should be performed in patients that have retroperitoneal fluid after being hit by a car, to
determine if the ureter/s are ruptured. Iohexol is injected intravenously and there will be extravasation of
contrast from the ureters into the retroperitoneum if they are ruptured. Revise this in Contrast Studies
from the Introductory Course for more information if desired. Retroperitoneal fluid without trauma:
Specialist ultrasound or CT is required to determine if there is a bleeding adrenal gland tumour or other
less likely cause.
KIDNEY & URETERS
An excretory urogram can be performed to examine the ureters. It is no longer used to examine the
kidneys as ultrasound has replaced this.
Imaging evaluation for the ureters:
 Ruptured ureter due to trauma – an excretory urogram is performed as described in

the Retroperitoneum lecture.
 Obstructed ureter - which is usually caused by a calculus. Hydronephrosis is seen on ultrasound
which is strongly suspicious for a ureter obstruction and enough to guide further treatment unless
the owner can a ord surgery and it is detected quickly enough so renal function is not lost. If the
owner wants to pursue surgery (which has to be performed ASAP) then the patient is referred and
the surgeon will decide on further imaging (usually specialist ultrasound or CT). Excretory
urograms are uncommonly performed for this now as ultrasound has replaced it.
 Ectopic ureter – in these patients the distal end of the ureter does not enter in the correct
location in the bladder. These are best evaluated with a CT excretory urogram so they are better
referred. They are infrequently able to be diagnosed on radiographic excretory urogram in GP
practice - see the image below for an example of one that is easily seen on radiographs.
BLADDER AND URETHRA
 In a patient with haematuria and stranguria, are there calculi in the bladder? Ultrasound is
available in most practices and this is preferred for evaluation for calculi as all calculi are seen on
ultrasound. However almost all calculi are seen on radiographs so a single lateral radiograph is
also commonly performed to answer this question. A double contrast cystogram is not performed
any more as ultrasound has replaced this. Positive contrast cystogram or pneumocystogram are
not indicated.
 In a male dog with stranguria, is there a calculus obstructing the urethra? A single lateral
radiograph can be performed as almost all calculi are radiopaque. A positive contrast
urethrogram can be performed, particularly if no calculi are seen on the radiograph, which will
detect non-opaque calculi and other causes (neoplasia, stricture). The penile urethra can be
examined by ultrasound but a linear transducer is required and a high level of skill so it is
infrequently performed in general practice.
 In an old patient with haematuria, is there bladder neoplasia? Ultrasound is the preferred
modality. This has replaced the double contrast cystogram which is not performed any more.
4
 Is the bladder ruptured? This can occur after being hit by a car or iatrogenically during
catheterisation. First AFAST is performed to confirm the fluid and obtain a sample to test if the
fluid is urine or haemorrhage (by comparing the fluid creatinine level with blood creatinine). If the
fluid is due to uroabdomen, then a positive contrast cystogram is performed to further evaluate
for a rupture. It cannot be determined by ultrasound; both an empty bladder and a non-empty
bladder do not rule out a bladder rupture.
 Is the urethra ruptured? In male dogs with severe pelvic fractures, a urethrogram should be
performed to check the urethra has not been traumatised/ruptured by the sharp ends of the bone
fractures.
 Why does a male cat get repeated obstructions? Very uncommonly a urethrogram is performed
to evaluate for this, but it is very fiddly and usually negative; it may be worth referring these
patients. Male cats are usually obstructed with ‘sludge’ associated with feline urological
syndrome (refer to medicine lectures for the most current name for this), rather than calculi, so
usually no imaging is done for these patients (they are just unblocked etc).
 Is there prostatic disease, in a dog with stranguria and haematuria? Ultrasound is the only
modality to use for this. Ultrasound guided fine needle aspirates can be performed if indicated.
STOMACH
 What is causing a fluid distended stomach? DDX – functional ileus (gastroenteritis,

pancreatitis), high obstruction (pyloric outflow obstruction, proximal duodenal obstruction), or a
small intestinal obstruction (there are usually dilated small intestine as well as the dilated
stomach). Ultrasound is the modality of choice for a high obstruction, but it is very difficult and
usually referral ultrasound is needed. An upper gastrointestinal contrast study can be performed,
but all the fluid needs to first be suctioned from the stomach (via a nasogastric tube) before the
barium is instilled into the stomach via a stomach/nasogastric tube. They can be hard to interpret
as the contrast will be slow to empty the stomach in both a functional ileus and obstruction, so
the filling defect from a foreign body is relied upon – send the images to teleradiology. A
pneumogastrogram can be performed to look for a pyloric outflow obstruction in those patients
with not enough gas in the stomach to see this on plain radiographs (the fluid should be removed
from the stomach first).
 Does the stomach contain ingesta or foreign material? Take serial radiographs every 6-8 hours.
This is preferred over ultrasound, even specialist ultrasound. Sometimes foreign material is seen
which has a very black (anechoic) shadow and the shape is highly suggestive; recognising this
requires a high level of skill, usually specialist. Remember how long ingesta can remain in the
stomach – see the lecture.
 Is there a GDV? Do a right lateral radiograph. If it is not obvious, also take a dorsoventral (DV) and
sent it to teleradiology.
SMALL INTESTINE
 Is there a small intestinal obstruction? In GP practice, radiographs are best and can be sent to
teleradiology; this is one of the best uses of teleradiology and some companies give you an
answer within an hour. Often follow-up radiographs are required and sometimes an upper
gastrointestinal barium study is required. In referral practice or if specialist ultrasound is readily
available, proceeding straight to specialist ultrasound is best.
 Is there a linear foreign body? This is the most common mechanical gastrointestinal disease in
cats. It is almost always seen on radiographs; send to teleradiology if not sure. It can be
diagnosed by GP level ultrasound skills, just be sure not to mistake corrugation of small intestine
(due to enteritis) for plication (linear foreign body).
5
 Is there an intussusception? Ultrasound is best and it can be diagnosed by GP level ultrasound
skills. An upper gastrointestinal barium study will also diagnose it.
 Is the abnormality in the small intestine or colon (eg foreign body, dilated bowel)?
Pneumocolonogram! This is a great study and easy and quick to perform. Ultrasound for this
usually requires specialist level skills. An upper gastrointestinal barium study will diagnose it but
is much more involved.
COLON
 Is there constipation? This is determined with a combination of knowledge of when the patient
last defaecated and evaluation of radiographs. For example, the patient may be straining
(tenesmus) with no faeces produced with colitis and an empty colon (due to prior diarrhoea) and
the owner thinks they are constipated.
 Where is the colon? Pneumocolonogram!

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Notes:

PERITONEUM & RETROPERITONEUM

Retroperitoneal ﬂuid: Surprisingly, it is di icult/impossible to determine if abdominal ﬂuid is in the

KIDNEY & URETERS

Imaging evaluation for the ureters:

 Ruptured ureter due to trauma – an excretory urogram is performed as described in

BLADDER AND URETHRA

 What is causing a fluid distended stomach? DDX – functional ileus (gastroenteritis,

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