When Enough is Enough: Ultrasound-Guided Ascent Into Heaven

Ashley C. Barfield

April 4, 2007

Winston Counterman14-year-old miniature Schnauzer

• Several months of weight loss

• Vomiting 2-3 times a day for 3 days

• Decreased energy

• Small amount of diarrhea for 3 days

• Recent diet change

Labwork Abnormalities

CBC• Mild leukocytosis• Moderate anemia• Severe

thrombocytopenia

Chemistry• BUN = 50• ALKP = 272• AMYL = 1287• TGL = 214• ALB = 1.9

Radiographic Abnormality

RDVM noted decreased serosal detail consistent with abdominal effusion

The Good Stuff

Large heterogenous splenic mass and multiple heterogenous nodules

Large heterogenous hepatic mass and multiple nodules

Liver…It’s So Good

Kidney: Not just for breakfast anymore

Bilaterally decreased corticomedullary definition, multiple heterogenous nodules, multiple cysts, one hypoechoic nodule

And the Badness

Grossly enlarged and heterogenous right medial iliac lymph node

The Sauce

Large amount of echogenic peritoneal fluid, consistent with hemorrhage (accompanied by a normal pancreas); aspiration yielded fluid hemorrhagic in appearance

Interpretation

“These findings are consistent with metastatic neoplasia.”

-- Tony Pease DVM MS

How to Save Winston?• Aspirates of liver, spleen, kidney, lymph node

• Thoracic radiographs (additional met check)

• Transfusion and surgical resection of bleeding mass

• Surgical resection/debulking of other masses

• Chemotherapy and radiation therapy based on histopath results

• Serial imaging to monitor progress during therapy

Winston’s owner elected humane euthanasia to prevent further suffering.

Pumpkin Rogers12 year-old spayed DSH

• 6-month history of chronic weight loss

• Watery diarrhea of unknown duration

• No change in appetite or energy level

• No PU/PD or vomiting

• FELV/FIV negative indoor cat

Labwork Abnormalities

CBC• Mild normochromic,

normocytic anemia• Thrombocytopenia• Hypoproteinemia• Stress leukogram

(elevated SEGS & monos, decreased lymphs)

Chemistry• Hypoalbuminemia• Hypoglobulinemia• Mildly elevated ALT• Mildly elevated ALKP

Labwork Abnormalities

Urinalysis• 1+ proteinuria• 4+ bilirubinuria

T4 = 0.53 (1-4)

Again, the Good Stuff

Mildly thickened small and large intestinal walls

Bowel walls also fluid-filled

Top differentials:• Neoplasia• Inflammatory

bowel disease

Hyperechoic kidneys with decreased corticomedullary distinction

Hypoechoic liver

Peritoneal fluid & possible pancreatic edema

IBD or Lymphoma?

• Full-thickness or endoscopic intestinal biopsies

• Mesenteric lymph node aspirates

• Liver and kidney aspirates

What if it’s the big K?Met check/staging• Thoracic rads• Peripheral lymph node aspirates• Serial imaging during therapy

Prognosis• 6 months to >2 years • severity of disease (histopathologic grade and tumor

phenotype)

• response to chemotherapy

Pumpkin’s Situation

• Loss of 50% of body mass in 6 months

• Potential involvement of liver and kidneys

• Owners elected no further diagnostics

• Owners elected pred and ice cream therapy

Pumpkin died at home the next day