2013 Null

IN-DEPTH: ULTRASOUND OF THE THORAX AND ABDOMEN
Ultrasound and the Nonacute Abdomen: The

Abdominal Organs
Mary Beth Whitcomb, DVM
The ability of ultrasound to detect abnormalities of the kidneys, liver, and spleen has made tremen-
dous strides over the past 10 years due to technological advancements in ultrasound equipment and
increased availability of skilled equine ultrasonologists. As our knowledge base continues to grow,
increased awareness is important for owners and veterinarians to understand the diagnostic potential
of abdominal ultrasound. Evaluation of abdominal organs is best performed as part of a complete
abdominal ultrasound exam. Ultrasound-guided procedures are often required to differentiate be-
tween various infectious, inflammatory, and neoplastic disorders. Author’s address: Clinical Large
Animal Ultrasound, Department of Surgical and Radiological Sciences, University of California, One
Shields Avenue, Davis, CA 95616; e-mail: mbwhitcomb@ucdavis.edu. © 2012 AAEP.
1. Introduction Admittedly, mastery of abdominal ultrasound re-

Evaluation of the abdominal organs, including the quires experience and patience, much more so than
kidneys, liver, and spleen, is generally performed as basic ultrasound of the acute abdomen. Similar to
part of a complete ultrasound examination in non- any anatomic region, however, cursory examination
acute patients.1 Many horses with hepatic, renal, is possible by a motivated practitioner equipped
or splenic abnormalities present with nonspecific with appropriate ultrasound equipment. It is
clinical signs3– 6 similar to those in horses with gas- equally important for field practitioners to under-
trointestinal tract disorders. Complete blood count stand our increased ability to diagnose and treat
(CBC) and serum chemistry analysis may be unre- disorders of abdominal organs in the referral set-
markable or show only evidence of inflammation ting. Ultrasound findings often help guide treat-
such as hyperfibrinogenemia and hyperglobuline- ment planning, including the need for medical
mia. Subsequently, a full exam is required to max- therapy or surgical intervention. Not only do we
imize diagnostic yield in many cases. In other gain valuable information about the appearance of
horses, clinical exam findings and serum biochemis- abdominal organs, ultrasound-guided biopsy and/or
try analysis may indicate primary renal or hepatic aspirate can be used to determine the underlying
disease, in which case the examiner may choose to etiology, to establish an appropriate treatment plan,
focus on the urinary tract or liver, respectively. and for prognostication.1–2
Although horses with abdominal organ disorders in-
frequently present as acute colic patients, cursory Ultrasonographic Technique
examination of abdominal organs can yield important A low-frequency (2–5 MHz) curvilinear transducer is
information during routine colic ultrasound exams. necessary to evaluate abdominal organs in the adult
NOTES
28 2012 Ⲑ Vol. 58 Ⲑ AAEP PROCEEDINGS
Orig. Op. OPERATOR: Session PROOF: PE’s: AA’s: 4/Color Figure(s) ARTNO:
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Fig. 1. Region to be clipped for complete abdominal ultra- R
sound. The left abdomen is clipped in similar fashion. Fig. 2. Time-gain compensation controls adjusted properly for
deep cavity imaging.
horse due to their deep location (15 to 30 cm) relative

to the skin surface. This transducer is available for ventral abdomen. Structures evaluated from the
most of today’s ultrasound machines, the majority of left side of the abdomen include the left kidney,
which are able to obtain exceptionally high-quality spleen, stomach, and left liver lobe. The left dorsal
abdominal images. In contrast, a rectal transducer and ventral colons are seen predominantly from the
can only penetrate to 5 to 10 cm, which is insuffi- left ventral abdomen.
cient to image the left kidney and the majority of the Scanning depth should be adjusted frequently
spleen, liver, and right kidney from the transcuta- during the exam to best image the superficial and
neous window. A rectal transducer can be used to deep parenchyma of each organ. No single depth
image the caudal portion of the left kidney and setting is appropriate for all abdominal organ imag-
spleen during transrectal examination. ing. An abdominal program or preset should be
For the highest quality images, the entire abdo- selected to maximize abdominal detail. Time-gain
men should be clipped with #40 blades, especially in compensation controls should also be adjusted for
older, obese, or thick-coated horses that tend to im- deep cavity imaging (Fig. 2). F2
F1 age poorly (Fig. 1). Alcohol saturation can produce
diagnostic quality images, but the subtle nature of Renal and Urinary Tract Ultrasound
many ultrasonographic findings in the nonacute ab- Specific indications for renal ultrasound include
domen may not be detectable without clipping. azotemia, hematuria, pollakiuria, dysuria, or abnor-
After clipping, the skin should be cleaned with a wet mal findings of cystoliths, ureteroliths, or left renal
sponge to remove dirt and debris, and ultrasound gel enlargement on rectal palpation.7–11 It is impor-
is then applied. tant to remember that horses with significant renal
A systematic approach to each exam is important abnormalities may present with a normal CBC and
for consistency and to improve diagnostic yield. serum biochemical profile.12
At the University of California, Davis (UC Davis), The left kidney is visible transcutaneously and
the entire abdomen is evaluated in the majority of transrectally. Transcutaneously, the left kidney is
nonacute patients presenting to the Large Animal located deep to the spleen in the left PLF region and
Ultrasound Service. Each side of the abdomen is the left 15th to 17th ICS at a scanning depth of 20 to
divided into three regions: (1) paralumbar fossa/ 30 cm (Fig. 3). The best images are often obtained F3
flank region (PLF); (2) 5th through 17th intercostal in the left 16th to 17th ICS; however, the kidney
spaces (ICS) from the ventral lung margins to the should be imaged from all possible windows. At
costochondral junctions; and (3) ventral abdomen UC Davis, we routinely use a “special” technique to
from the sternum to the inguinal region. The exam image the left kidney that entails placing the trans-
should be performed in the same manner, regardless ducer caudal to the last rib, midway between the
of clinical suspicion of cause. Structures evaluated tuber coxae and stifle, and aiming in a dorsocranial
from the right side of the abdomen include the ce- direction. By applying gradual force with each ex-
cum and cecal mesentery, right kidney, right liver piration, the transducer is effectively brought closer
lobe, duodenum, and right dorsal colon. The right to the left kidney and a superior image obtained
ventral colon is primarily visualized from the right than with traditional techniques. Transrectally,
AAEP PROCEEDINGS Ⲑ Vol. 58 Ⲑ 2012 29
Orig. Op. OPERATOR: Downloaded

Session PROOF: from https://cabidigitallibrary.org
PE’s: by 2800:e2:8f80:975:ac9:adf3:b8ad:2433, on 11/04/24.
Terms AA’s: 4/Color Figure(s) ARTNO:
Subject to the CABI Digital Library & Conditions, available at https://cabidigitallibrary.org/terms-and-conditions
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Fig. 3. Normal appearance of the left kidney (LK) as seen from
the left 16th ICS. The renal cortex is hypoechoic to the adjacent Fig. 4. Ultrasonographic appearance of an end-stage left kidney
spleen and a clear corticomedullary junction is visible. Dorsal is in a horse with chronic renal failure. The kidney is small and
to the right. shows large hyperechoic areas consistent with fibrosis, scarring,
nephrolithiasis, or mineralization. Renal parenchyma is nearly
unrecognizable. Dorsal is to the right.
the left kidney is typically visible at arm’s length;

however, only the caudal portion of the kidney can
be seen. The right kidney is seen dorsally in the Renal parenchyma is seldom distorted in horses
right 15th to 17th ICS at a more superficial scanning with acute renal failure; however, a clearly visible
depth of 15 to 20 cm, compared with the left kidney. and discrete corticomedullary junction is often pres-
The right kidney cannot be imaged transrectally in ent. Renal abscesses have been reported and ap-
most horses. pear as variably shaped hypoechoic or hyperechoic
Renal ultrasonographic parameters include size, areas within the renal cortex and/or medulla.12
shape, cortical echogenicity (hypoechoic to the adja- The kidneys are the second most common abdominal
cent spleen), cortical thickness, medullary echoge- organ to be affected in horses with internal Coryne-
nicity (hypoechoic to the cortex), and bacterium pseudotuberculosis infection. Care
corticomedullary distinction. The renal pelvis should be taken not to misinterpret the hypoechoic
should be evaluated for the presence of nephroliths area visible in the deep medullary portion of the
and dilation (pyelectasia). Reported renal size right kidney for a mass or abscess. Hematuria is
measurements are somewhat variable, and horse not uncommon in horses with renal abscessation.
size should be considered when interpreting mea- Renal neoplasia is relatively uncommon in horses
surements. In our experience, normal adult kid- but may be encountered with some regularity at
neys range from 5 to 9 cm in width and 15 to 19 cm referral hospitals. Renal adenocarcinoma is the
in length; however, a recent study reported smaller most common primary tumor, producing large
measurements than that described by Reef and that masses that completely efface renal parenchyma
of our own clinical experience.1,13 (Fig. 6).14,15 Renal mestastasis of other tumor F6
Small kidneys are generally associated with types has also been reported.1
chronic renal failure.7 Affected kidneys often show
a distorted shape, increased cortical echogenicity
and thickness, and poor corticomedullary distinction
and may have nephrolith(s) or peripelvic mineral-
ization. Some are nearly unrecognizable as kid-
F4 neys (Fig. 4). In some horses with chronic renal
failure, one kidney may appear to be end-stage and
nonfunctional, with the contralateral kidney show-
ing enlargement but relatively normal renal
parenchyma.7
Enlarged kidneys with or without increased corti-
cal echogenicity and thickness may be secondary to C
acute renal failure, urolithiasis, nephritis, pyelone- O
phritis, hydronephrosis, abscessation, or, less com- L
monly, neoplasia.1,7,9 –12 Interventional procedures
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such as ultrasound-guided biopsy or aspirate are
often necessary to differentiate between potential Fig. 5. Perirenal edema (arrows) in a 4-day-old foal with acute
diagnoses. Horses with acute renal failure may renal failure. Note the distinct corticomedullary junction that is
have perirenal edema, seen as an anechoic fluid often noted in horses with acute renal failure. Dorsal is to the
F5 layer between the renal capsule and cortex (Fig. 5). right.

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Fig. 6. Renal enlargement and diffuse effacement of renal pa- Fig. 8. Transrectal image of a large cystolith (arrow) within the
renchyma in a horse with renal adenocarcinoma of the left kid- urinary bladder of a 20-year-old Arabian gelding with hematuria.
ney, visualized from the left paralumbar fossa region. Dorsal is
to the right.
ters are evaluated individually (Fig. 9), beginning at F9

the bladder trigone and following each as far crani-
Horses with urolithiasis can present with hema- ally as possible. The left ureter can regularly be
turia after exercise, azotemia, and occasionally with followed along its length to the left kidney. The
signs of colic.8,10,11 Urolithiasis is regularly en- majority of the right ureter is also visible; however,
countered by clinicians at our hospital. Nephro- the ureteropelvic junction with the right kidney is
liths are easily recognized as hyperechoic structures rarely visible in normal or abnormal horses. The
within the renal pelvis that cast hard shadows (Fig. presence of ureteral motility is helpful to differenti-
F7 7). Renal sludge appears similarly but may pro- ate ureters from blood vessels and the vas deferens
duce a “dirty” or less distinct shadow. Differentia- in male horses. The normal appearance of the cau-
tion between nephroliths and renal sludge is not dal ureters has been described.16 Ureteroliths can
straightforward. Care should be taken not to mis- be identified along the length of the ureter (Fig. 10). F10
interpret the hyperechoic appearance of the renal In the author’s experience, urolithiasis is often as-
pelvis as nephrolithiasis. All horses with urolithi- sociated with ureteral wall thickening regardless of
asis should undergo transcutaneous evaluation of the location of the stone. Most importantly, in
both kidneys and transrectal evaluation of the en- cases of urolithiasis, the examiner should be re-
tire urinary tract to rule out additional uroliths and minded to perform bladder endoscopy after ultra-
for evidence of underlying renal disease. Transrec- sound examination. Gas that is introduced during
tal evaluation of the bladder and ureters is also endoscopy will obscure ultrasonographic visualiza-
indicated in horses with distention of the renal pel- tion of urinary structures, and its hyperechoic ap-
F8 vis because a downstream cystolith (Fig. 8) or uret- pearance can be easily confused with uroliths.
erolith may be the cause for renal pyelectasia. Idiopathic renal hematuria should be a differen-
Using a transrectal approach, the left and right ure- tial in horses with a large amount of frank blood in
their urine.8,10 Affected kidneys show distention of
the renal pelvis with echogenic material consistent
with hemorrhage and clot formation. Renal archi-
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Fig. 7. Large nephrolith within the renal pelvis of the left kid- L
ney, visible from the left paralumbar fossa region, in a horse that O
presented for pollakiuria and microscopic hematuria due to a R
bladder stone. The horse had a previous bladder stone removed
3 years earlier, at which time nephroliths were also noted. Dor- Fig. 9. Normal transrectal image of the midportion of the right
sal is to the right. ureter.

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Fig. 10. Transrectal image of an obstructive ureterolith within
the proximal portion of the right ureter in a 14-year-old Quarter Fig. 11. Normal transcutaneous image of the right liver lobe
Horse mare with persistent azotemia despite the removal of sev- (RLL) obtained from the right 13th ICS showing normal sharp
eral bladder stones 5 months prior. Right renal ultrasound re- margins, echotexture, and fine vascular markings. Dorsal is to
vealed severe distention of the renal pelvis with echogenic the right.
material.
it may occasionally be positioned deep to the spleen,

tecture is often otherwise unremarkable. Horses in which case the LLL margins will appear falsely
are typically unilaterally affected. Removal of the rounded. Echogenicity of the LLL should be hy-
affected kidney has not been reported to be effective poechoic to the adjacent spleen (Fig. 12). Scanning F12
because the contralateral kidney may subsequently depth ranges from 10 to 30 cm and should be
become affected. Biopsy has not been rewarding in changed in each ICS to best evaluate the superficial
horses to reveal the underlying cause of idiopathic and deep parenchyma of the liver.
renal hematuria. Ultrasonographic abnormalities include hepato-
Renal cysts may be identified as an incidental megaly, rounded margins (Fig. 13), changes in echo- F13
finding in normal horses. In such cases, a singular genicity (usually increased), decreased fine vascular
cyst is typically present. Multiple small cortical markings, biliary/vascular fibrosis/inflammation,
cysts may be found in horses with acute or chronic hepatoliths, biliary distention, and, less commonly,
renal failure. evidence of abscessation or neoplasia. Hepatomeg-
aly and rounded margins may be seen with multiple
Liver disease processes, including hepatitis, cholangio-
The liver is generally evaluated as part of a complete hepatitis, obstructive cholelithiasis, and neopla-
abdominal ultrasound but may be the primary focus sia.17,18 Decreased fine vascular marking (FVM) is
in horses with elevated hepatic enzymes. Similar a nonspecific but significant finding and is often
to horses with renal disease, horses with significant overlooked by less experienced imagers due to its
hepatic abnormalities may have normal hepatic en- subtle nature. Decreased FVM causes the liver to
zymes.12 In such cases, clinicians should resist the appear dense and similar in echotexture to the
temptation to dismiss abnormal hepatic ultrasound spleen. It may be the only sonographic abnormal-
findings as a potential cause of clinical signs. Bi- ity in some horses with primary liver disease, in-
opsy may prove useful to document the presence of
active liver disease in such cases.
The right liver lobe (RLL) is visible ventral to the
F11 lung margins in the right 8th to 15th ICS (Fig. 11),
although visibility can be quite variable within
these ICS. The RLL should not extend to or beyond
the costochondral (CC) junctions, in which case it is
considered to be enlarged. The left liver lobe (LLL)
is visible caudal to the heart in the left cranioventral
abdomen in the 7th to 10th ICS. The LLL extends
from the ventral lung margins to the CC junctions. C
The LLL may be considered enlarged when it ex- O
tends into the left cranioventral abdomen; however,
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this may be present in some horses without hepatic R
pathology. The margins of the LLL are often diffi-
cult to evaluate due to shadowing created by the Fig. 12. Normal ultrasonographic appearance of the left liver
overlying CC junctions. In most horses, the LLL is lobe (LLL) as visualized from the left 7th ICS. Note that the LLL
located superficial to the adjacent spleen; however, is hypoechoic to the adjacent spleen. Dorsal is to the right.

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Fig. 13. Rounding of the right liver lobe margins is evident in Fig. 15. A dilated bile duct adjacent to portal vein creates the
this horse with hepatitis, confirmed via ultrasound-guided liver “parallel channel sign” (arrows) within the right liver lobe in this
biopsy. Liver margins also extended to the costochondral junc- horse with obstructive hepatolithiasis. No hepatoliths were vis-
tions (not shown in this image) in most ICS, consistent with ible in the RLL; however, multiple stones were visible within the
hepatomegaly. Dorsal is to the right. left liver lobe. Dorsal is to the right.
cluding horses with pyrrolizidine alkaloid toxicosis abscessation can create hypoechoic and/or hyper-
F14 (Fig. 14). Horses with obstructive cholelithiasis echoic areas within the liver.12,20 The liver is the
are infrequently encountered at our hospital but can most common site for abdominal C. pseudotubercu-
demonstrate a “parallel channel sign” secondary to losis infection, in which single to multiple coalescing
distention of the bile duct adjacent to the portal vein hypoechoic areas can be found.12 Hepatic neoplasia
F15 (Fig. 15).18 The obstructive hepatolith may not be is relatively uncommon. Affected livers often dem-
visible. When present, hepatoliths can be of vari- onstrate a diffusely heterogeneous appearance, al-
able echogenicity and create variable acoustic shad- though discrete metastatic masses can be seen (Fig.
owing, in contrast to that seen with urolithiasis (Fig. 17).21,22 Ultrasound-guided biopsy is often neces- F17
F16 16). Biliary or vascular inflammation or fibrosis is sary to differentiate between hepatic abscessation
a nonspecific finding with many hepatic disorders and neoplasia.
that creates multiple small hyperechoic parallel
lines scattered diffusely throughout hepatic paren- Spleen
chyma. These occasionally cast shadows, and care Splenic abnormalities generally cause nonspecific
should be taken not to confuse this appearance with clinical signs such as reduced appetite, weight loss,
hepatoliths. Similarly, “starry sky” pattern was re- fever, depression, and malaise.6,12,21–26 Splenic
cently described in which multiple hyperechoic foci disorders may occasionally cause colic symptoms in
were found throughout the renal parenchyma in some horses, as neoplastic invasion of splenic tissue
horses with granulomas. These regions showed and other disorders can produce abdominal pain.
variable shadowing and were differentiated from It is rare for clinical features to direct a clinician to
hepatoliths by their extrabiliary location.19 Hepatic
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Fig. 16. Two large hepatoliths within a markedly distended bile
Fig. 14. Lack of fine vascular markings is evident within the duct in the right liver lobe of a 19-year-old Thoroughbred mare
right liver lobe (RLL) in this horse with pyrrolizidine alkaloid with weight loss and mild depression. Note the weak shadows
toxicosis confirmed via ultrasound-guided biopsy. Note the created by each hepatolith. Multiple similar-appearing hepato-
dense appearance of the RLL, which appears similar to splenic liths were seen throughout both liver lobes. This image was
echotexture. LC indicates large colon. Dorsal is to the right. obtained from the right 8th ICS. Dorsal is to the right.

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Fig. 17. A single metastatic mass (arrows) within the right liver
lobe of a 28-year-old Quarter Horse mare with chronic diarrhea Fig. 19. Diffuse effacement of splenic parenchyma by heteroge-
and reduced appetite. Ultrasound-guided biopsy of this lesion neous tissue (arrows) in a 13-year-old Quarter Horse gelding with
confirmed adenocarcinoma. The entire wall of the large colon B-cell lymphoma confirmed by ultrasound-guided biopsy. Nor-
(bracket) was severely thickened throughout the abdomen, as mal-appearing splenic tissue is present dorsal to the lymphoma-
seen deep to the RLL in this image. Dorsal is to the right. tous spleen (arrowheads). Dorsal is to the right.
implicate the spleen as the source of clinical signs, tutions. Lymphoma is the most common splenic
with the exception of palpable splenic enlargement tumor in horses. Horses with splenic lymphoma
during rectal examination. Therefore, most splenic often have an enlarged spleen and show diffuse in-
abnormalities are identified during a complete ab- filtration of splenic tissue with heterogeneous tissue
dominal ultrasound exam. of mixed echogenicity (Fig. 19).1,2,21 Discrete F19
The spleen is the predominant feature of the left masses may also be seen.5,6 Other tumor types
abdomen and is visible throughout most left ICS, the have been reported, including squamous cell carci-
PLF region, and left ventral abdomen. The spleen noma, melanoma, and hemangiosarcoma,5,22,25 but
often extends to or slightly to the right of ventral cannot be differentiated by their ultrasonographic
midline in normal horses. Splenomegaly is difficult appearance alone (Fig. 20). Interventional proce- F20
to objectively document because the normal spleen dures such as biopsy or aspirate are required to
may show rightward displacement in horses with differentiate between tumor types and to rule out
gastric distention or colon displacements. The infectious or inflammatory causes.
spleen is the most echogenic of the three abdominal Horses presenting with hemoabdomen should be
organs and should show an evenly homogeneous carefully evaluated for evidence of splenic hema-
F18 echogenicity (Fig. 18). The spleen appears less vas- toma and/or splenic fracture.23,24 Splenic hemato-
cular than the liver, although the splenic vein is mas can appear as small to large, irregularly shaped
typically visible adjacent to the stomach. hypoechoic areas, similar to other disorders such as
The spleen is the least commonly affected abdom- splenic abscessation or even neoplasia. Careful
inal organ in horses; however, splenic neoplasia is
encountered with some frequency at referral insti-
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Fig. 20. One of several splenic masses (arrows) in a horse with
Fig. 18. Transcutaneous image of the normal spleen reveals a disseminated hemangiosarcoma. Additional intrasplenic and
diffusely homogeneous echogenicity. The splenic vein is visible extrasplenic masses were found throughout the abdomen and
adjacent to the greater curvature of the stomach. Dorsal is to showed a highly variable ultrasonographic appearance. Dorsal
the right. is to the right.

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Fig. 21. An irregularly shaped hypoechoic area (arrow) within Fig. 22. Ultrasonographic diagnosis of an intrasplenic wire (ar-
the spleen of a horse with internal Corynebacterium pseudotuber- rows) and associated abscess involving the cranial portion of the
culosis infection, confirmed via ultrasound-guided aspiration and spleen near the stomach. The abscess is visualized as a nearly
culture. Multiple hypoechoic areas were seen throughout the anechoic area surrounding the wire tip (arrow, right im-
spleen. Note the lack of encapsulation in this abscess. Dorsal age). The wire was confirmed via abdominal radiography, and
is to the right. ultrasound-guided aspiration of the abscess yielded mixed
growth, including two strains of Escherichia coli. Dorsal is to the
right.
consideration of the complete clinical picture is im-

portant to prioritize differentials. Hypoechoic ar-
eas may also be seen in horses with splenic they are expensive and do not necessarily guarantee
abscessation caused by C. pseudotuberculosis (Fig. needle visibility. Free-hand ultrasound-guided
F21 21) or other infectious agents.12,23 Similar to he- techniques can be mastered with practice and pro-
patic C. pseudotuberculosis abscessation, splenic ab- vide the ultrasonographer with the most flexibility
scesses often lack a visible capsule. This can create throughout the procedure. The use of anatomic
confusion for less experienced imagers who often landmarks as the sole means to collect samples from
expect to see a well-defined capsule in horses with abdominal organs should not be used. Such tech-
abscessation. Ultrasound-guided aspiration is niques place the horse at increased risk for penetra-
highly useful for pathogen identification and selection of bowel or neighboring structures due to
tion of appropriate antimicrobial therapy. Ultra- significant variability in the location and thickness
sonographic resolution of splenic abscesses appears of abdominal organs. Ultrasound-guided sampling
to be more prolonged in our experience (3 to 4 is generally considered the standard of care at refer-
months in some horses), compared with liver and ral institutions.
renal abscesses. Migrating foreign bodies such as Biopsies and aspirates of the liver, kidneys, and
ingested wires may also cause splenic abscessation spleen are performed at our hospital on a routine
F22 (Fig. 22). The presence of hyperechoic gas echoes basis to differentiate between various infectious, in-
within splenic abscesses should heighten suspicion flammatory, and neoplastic pathologies that may
for wire migration, especially when located in close appear similarly on ultrasound examinations.29
proximity to the stomach. Abdominal radiographs Clotting profiles are often obtained before sampling
are indicated to either confirm or identify a wire as to reduce the risk of postprocedural hemorrhage,
the source of abscessation. although this has been infrequently reported in
horses.29,30 All procedures are performed using
Ultrasound-Guided Procedures sterile technique, including sterile skin preparation
As stated earlier, dramatic ultrasonographic abnor- and sterile gloving of the transducer’s and ultra-
malities may be present in horses without blood sonographer’s hands. The ideal site for biopsy or
work abnormalities specific to that organ.12 The aspirate is identified that will maximize acquisition
converse may also be true.27,28 In either case, ul- of a diagnostic sample while avoiding vital struc-
trasound-guided biopsy should be performed in tures. This varies from horse to horse and depends
horses with a high index of suspicion for hepatic, on the location of visible pathology. Wite-Out® is
renal, or splenic disease regardless of the source of useful to mark the skin surface to aid in re-identifi-
information (clinical, hematologic, or ultrasono- cation of the intended collection site after skin prep-
graphic). Ultrasound guidance allows accurate aration. A skin block is used in the majority of
needle placement into affected regions and increases cases. The most important aspect of sampling is for
the likelihood of a diagnostic sample. It also pre- the needle to remain within the ultrasound beam
vents inadvertent entry into major blood vessels and from skin to target. This is best accomplished
abdominal viscera compared with blind sampling when the ultrasonographer guides both the trans-
techniques. Automatic biopsy instruments are ducer and the biopsy instrument (Fig. 23, A and B). F23
preferable. Biopsy needle guides may be used, but It is equally important to consider the “throw” of the

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Fig. 23. A, Sterile technique to obtain a splenic biopsy. After sterile skin preparation, the transducer’s and ultrasonographer’s
hands are sterilely gloved. Although an assistant is used to steady and fire the biopsy instrument, the ultrasonographer is
responsible for guiding the needle so that it remains within the ultrasound beam (B) to guarantee needle visibility. C, The needle
(arrowheads) is visible near the hypoechoic splenic nodule (arrows) but is positioned to account for the 2-cm “throw” of the needle so
that the nodule is sampled (D) while simultaneously preventing sampling of the nearby left kidney (LK).
needle so that adjacent structures are not inadver- 3. Mair TS, Taylor FG, Pinsent PJ. Fever of unknown origin in
tently penetrated by the biopsy needle during sam- the horse: a review of 63 cases. Equine Vet J 1989;21:260 –
265.
ple acquisition (Fig. 23, C and D). We generally 4. Mair TS, Hillyer MH. Chronic colic in the mature horse.
collect two biopsy samples and submit one for histo- Equine Vet J 1997;29:415– 420.
pathologic analysis and one for culture and sensitiv- 5. East LM, Savage CJ. Abdominal neoplasia (excluding uro-
ity. Culture and sensitivity results should be used genital tract). Vet Clin North Am Equine Pract 1998;14:
to guide antimicrobial selection. 475– 493.
6. East LM, Savage CJ, Traub-Dargatz JL. Weight loss in the
2. Summary horse: a focus on abdominal neoplasia. Equine Vet Educ
1999;11:174 –178.
Abdominal ultrasound has been extremely reward- 7. Divers TJ, Yeager AE. The value of ultrasonographic exam-
ing at our hospital to assist in the diagnosis of mul- ination in the diagnosis and management of renal diseases in
tiple disorders of abdominal organs and the horses. Equine Vet Educ 1995;7:334 –341.
gastrointestinal tract, covered in the previous ses- 8. Schott HC. Hematuria. In: Robinson NE, editor. Current
sions. In some horses, abnormalities are straight- Therapy in Equine Medicine, 4. Philadelphia: WB Saunders
Company; 1997:489 – 491.
forward and readily detectable by veterinarians 9. Kisthardt KK, Schumacher J, Finn-Bodner ST, et al. Severe
with some abdominal ultrasound experience, renal hemorrhage caused by pyelonephritis in 7 hors-
whereas other disorders produce more subtle find- es: clinical and ultrasonographic evaluation. Can Vet J
ings and require the trained eye of a veteran ultra- 1999;40:571–576.
sonographer well versed in the nuances of 10. Schumacher J, Schumacher J, Schmitz D. Macroscopic he-
abdominal imaging. In either situation, the use of maturia of horses. Equine Vet Educ 2002;14:201–210.
11. Ehnen SJ, Divers TJ, Gillette D, et al. Obstructive nephro-
ultrasound has transformed how we diagnose, treat, lithiasis and ureterolithiasis associated with chronic renal
and manage horses that present with a wide variety failure in horses: eight cases (1981–1987). J Am Vet Med
of clinical signs. Assoc 1990;197:249 –253.
12. Pratt SM, Spier SJ, Carroll SP, et al. Evaluation of clinical
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IN-DEPTH: ULTRASOUND OF THE THORAX AND ABDOMEN

Ultrasound and the Nonacute Abdomen: The

Mary Beth Whitcomb, DVM

1. Introduction Admittedly, mastery of abdominal ultrasound re-

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horse due to their deep location (15 to 30 cm) relative

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the left kidney is typically visible at arm’s length;

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ters are evaluated individually (Fig. 9), beginning at F9

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it may occasionally be positioned deep to the spleen,

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consideration of the complete clinical picture is im-

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