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Limit missed ultrasound diagnosis by having a system

Introducing a systematic approach to ultrasound is important to prevent missing a diagnosis.


Here’s a few pointers that may avoid fear of failure, to identify important structures and prevent missing pathology, when performing small animal ultrasound:



Preparing the patient adequately every time


There is a temptation to limit the size of the clip patch when performing ultrasound. While this is appropriate for point of care scans, assessing cases in an emergency for fluid, I would encourage you to be bolder in clipping appropriately for an abdominal ultrasound exam. The area needs to be extensive, particularly in large dogs. Key anatomy, such as the right kidney, may be easier to scan and assess with an approach between the caudal ribs on the right side.


Having a system

Many vets start scanning in the centre of the abdomen, and find the structure they are familiar with, then move on to the next. But how often do we get distracted and not even complete a basic scan?


Maybe you are looking for a bladder stone. Do you just look at the bladder? Just like on X-ray, even if we see a radio-opaque bladder stone at first glance, it would be remiss if we do not then check the rest of the abdomen and urinary tract.


Scanning in two planes


Every organ should be scanned in two orthogonal planes, every scan.


Convention is to have the cranial end of the dog on the LEFT of the screen when scanning in a longitudinal or sagittal plane. When scanning in a transverse plane the right of the patient should be on the LEFT of the screen (as a DV radiograph is displayed). We are assessing 3D structures, so if there is a mass, or defect on one side of an organ, it may be passed over if not assessed with different planes.


Assess the whole structure and nothing but the structure, in it’s entirety every time.


It can be easy to see one small slice of the spleen, in two planes and then move on to other structures. Did you look for and assess the head of the spleen underneath the ribs? It’s essential to examine each and every organ in turn completely, by fanning and rocking the probe, to examine all of the margins and parenchyma.  


Avoiding organ specific scans


Just like when we have a distraction on clinical exam, if we set out to examine just one organ or just one region with ultrasound, it’s very likely we will miss other significant problems, if we don’t at least attempt to assess basic structures.


How many times does a dog present with renal problems, only to have liver disease in addition? We are quite used to doing a ‘full biochemical screen’, rather than just a renal screen, at the start of an investigation. Why not check both kidneys on ultrasound, on every case of cystitis, rather than just checking the bladder?


A full abdominal scan might be precautionary, but you are also less likely to miss other abnormalities. If you don't look, you won't find!


Suggested basic scan:

Liver, GB, Spleen (head and body), Stomach, SI, Left kidney, Right kidney, Urinary Bladder


Suggested advanced scan:

Liver, GB, Spleen (head and body), Stomach, SI, Left kidney, Right kidney, Urinary Bladder

PLUS – duodenum, jejunum, ileocolic junction, portal vein, aorta, CVC, L&R medial sub-iliac lymph nodes, mesenteric lymph nodes, pancreas (left limb, body, right limb), L adrenal, R adrenal, Prostate/Uterus, ovaries/testes.


For a more detailed discussion on the views and images advised, please see below two separate guidelines published by the British Medical Ultrasound Society (BMUS) and by the European College of Veterinary Diagnostic Imaging (ECVDI), published in the last two years.


Giving yourself enough time and space


Have a suitable area, free from interruptions for the time needed to complete a thorough assessment of your patient.


Many practices do not have a dedicated scanning room, but consider using a consulting room, where you can dim the lights and keep the patient quiet and calm, rather than in the middle of the prep room or kennels!


Sedation and analgesia


Essential for any animal with abdominal pain, sedation can be useful for even amenable dogs and cats.


When stressed they might tense their abdominal muscles, so it’s harder to apply pressure, one of the essential movements in ultrasound.  


Agreement with the team to document scans


With larger veterinary teams, and flexible working patterns more common in practices, it might not be possible for the same clinician to follow up on cases.


It’s important to know exactly what has happened over the course of treatment, and having an agreed system in place will prevent confusion and allow for improved patient care.


Abnormal findings can be documented and monitored. Repeated scans can be useful. For example, dogs with pancreatitis don't always have lesions visible on ultrasound in the first 36-72 hours of an acute episode.


If you would like further information about how to implement a practice protocol for ultrasound scanning, please get in touch using the contact form.



We also offer in house training for building confidence of the whole team, around imaging and diagnostic ultrasound.


References


Sombrio MS, Mai W, Buch D, Grotti GC, Luciani MG, Froes TR (2023) Accuracy and reliability of tele-ultrasonography in detecting gastrointestinal obstruction in dogs and cats. Journal of Small Animal Practice https://onlinelibrary.wiley.com/doi/10.1111/jsap.13604


Seiler GS, Cohen EB, d’Anjou M, French J, Gaschen L, Knapp S, Salwei RM and Saunders HM (2022) ACVR and ECVDI consensus statement for the standardization of the abdominal ultrasound examination. Veterinary Radiology and Ultrasound https://onlinelibrary.wiley.com/doi/10.1111/vru.13151


 
 
 

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