When Enough is Enough: Ultrasound-Guided Ascent Into Heaven

Ashley C. Barfield April 4, 2007 When Enough is Enough: Ultrasound-Guided Ascent Into Heaven

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 Winston Counterman14-year-old miniature Schnauzer

CBC Mild leukocytosis Moderate anemia Severe thrombocytopenia Chemistry BUN = 50 ALKP = 272 AMYL = 1287 TGL = 214 ALB = 1.9 Labwork Abnormalities

Radiographic Abnormality RDVM noted decreased serosal detail consistent with abdominal effusion

Large heterogenous splenic mass and multiple heterogenous nodules The Good Stuff

Large heterogenous hepatic mass and multiple nodules Liver…It’s So Good

Bilaterally decreased corticomedullary definition, multiple heterogenous nodules, multiple cysts, one hypoechoic nodule Kidney: Not just for breakfast anymore

Grossly enlarged and heterogenous right medial iliac lymph node And the Badness

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

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.

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 Pumpkin Rogers12 year-old spayed DSH

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) Labwork Abnormalities

Mildly thickened small and large intestinal walls Again, the Good Stuff

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

When Enough is Enough: Ultrasound-Guided Ascent Into Heaven