1. Free PowerPoint Templates Ultrasound of the Spleen Wendy Blount, DVM

2. Palpable mass in the abdomen or pendulous abdomen Palpable mass in the abdomen or pendulous abdomen Fluid in the abdomen Fluid in the abdomen Abdominal trauma (AFAST SM ) Abdominal trauma (AFAST SM ) Abdominal pain Abdominal pain Enlarged spleen or mid-abdominal mass seen on radiograph Enlarged spleen or mid-abdominal mass seen on radiograph Staging of neoplasia (usually with FNA) Staging of neoplasia (usually with FNA) Free PowerPoint Templates Indications for Spleen Ultrasound

3. Evaluation of anemias, thrombocytopenias and lymphadenopathies Evaluation of anemias, thrombocytopenias and lymphadenopathies Hemorrhagic pericardial effusion Hemorrhagic pericardial effusion Ventricular arrhythmia Ventricular arrhythmia Free PowerPoint Templates Indications for Spleen Ultrasound

4. Free PowerPoint Templates Patient Preparation Place in dorsal or right lateral recumbency Place in dorsal or right lateral recumbency Right lateral recumbency for: Right lateral recumbency for: Compromised & deep chested patients Compromised & deep chested patients Head of the spleen on deep chested dogs (intercostal) Head of the spleen on deep chested dogs (intercostal) Landmarks for finding the spleen: Landmarks for finding the spleen: Head is caudal to the stomach Head is caudal to the stomach Spleen often mostly in the left abdomen Spleen often mostly in the left abdomen Tail can range from right to caudal relative to the head Tail can range from right to caudal relative to the head

5. Free PowerPoint Templates Transition Adjustments Depth - Adjust according to size of spleen Depth - Adjust according to size of spleen More shallow for cats, deeper for giant spleens & the canine head of the spleen More shallow for cats, deeper for giant spleens & the canine head of the spleen Frequency - usually 6-7.5 MHz (higher) Frequency - usually 6-7.5 MHz (higher) Gain and Contrast – usually no change from liver Gain and Contrast – usually no change from liver TGC - Bottom levers may need to go to the middle for head of spleen (they were right for liver) TGC - Bottom levers may need to go to the middle for head of spleen (they were right for liver) Top levers may need to go right for body/tail of spleen Top levers may need to go right for body/tail of spleen

6. Free PowerPoint Templates Image Views Sagittal & transverse Views (4 each = 8) 1. & 5. Head (cranial) – under the rib cage 2. & 6. Cranial Body 3. & 7. Hilus – splenic vein 4. & 8. Tail (caudal or right)

7. Free PowerPoint Templates Image Views Sagittal & transverse Views (4 each = 8) 1. & 5. Head (cranial) – under the rib cage 2. & 6. Cranial Body 3. & 7. Hilus – splenic vein 4. & 8. Tail (caudal or right)

8. Free PowerPoint Templates Image Views Sagittal & transverse Views (4 each = 8) 1. & 5. Head (cranial) – under the rib cage 2. & 6. Cranial Body 3. & 7. Hilus – splenic vein 4. & 8. Tail (caudal or right)

9. Academy of Veterinary Imaging: dorsal recumbency http://education.soundeklin.com Oncura: lateral recumbency (no video) Ultrasound of the Spleen Ultrasound of the Spleen Free PowerPoint TemplatesVideo

10. Assess echogenicity relative to fat, liver, kidney Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Compared to the liver at the head (Liver-Stomach-Spleen) Free PowerPoint Templates Goals – Spleen Ultrasound

11. Assess echogenicity relative to fat, liver, kidney Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Compared to the liver at the head (Liver-Stomach-Spleen) Free PowerPoint Templates Goals – Spleen Ultrasound spleen liver stomach stomach

12. Assess echogenicity relative to fat, liver, kidney Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Compared to the liver at the head (Liver-Stomach-Spleen) Free PowerPoint Templates Goals – Spleen Ultrasound spleen liver stomach stomach

13. Assess echogenicity relative to fat, liver, kidney Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Compared to the liver at the head (Liver-Stomach-Spleen) Free PowerPoint Templates Goals – Spleen Ultrasound spleen liver liver stomach stomach

14. Assess echogenicity relative to fat, liver, kidney Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Compared to the liver at the head (Liver-Stomach-Spleen) Free PowerPoint Templates Goals – Spleen Ultrasound spleen liver liver stomach stomach

15. Assess echogenicity relative to fat, liver, kidney Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Spleen has finer echotexture than liver & falciform fat Free PowerPoint Templates Goals – Spleen Ultrasound Mottled spleen - neoplasia Normal echotexture spleen

16. Assess echogenicity relative to fat, liver, kidney Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Spleen has finer echotexture than liver & falciform fat Free PowerPoint Templates Goals – Spleen Ultrasound Mottled spleen with irregular margins - neoplasia

17. Assess echogenicity relative to fat, liver, kidney Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Spleen has finer echotexture than liver & falciform fat Free PowerPoint Templates Goals – Spleen Ultrasound Mottled spleen –lymphoid hyperplasia Mottled spleen - neoplasia

18. Assess echogenicity relative to fat, liver, kidney Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Spleen has finer echotexture than liver & falciform fat Search for hypoechoic or hyperechoic nodules (+FNA) Search for hypoechoic or hyperechoic nodules (+FNA) Assess size of spleen if markedly enlarged Assess size of spleen if markedly enlarged Free PowerPoint Templates Goals – Spleen Ultrasound

19. Assess echogenicity relative to fat, liver, kidney Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Spleen has finer echotexture than liver & falciform fat Search for hypoechoic or hyperechoic nodules (FNA) Search for hypoechoic or hyperechoic nodules (FNA) Assess size of spleen Assess size of spleen Free PowerPoint Templates Goals – Spleen Ultrasound myelolipoma hemangiosarcoma infarct lymphoma

20. Assess echogenicity relative to fat, liver, kidney Assess echogenicity relative to fat, liver, kidney Fat is SLiCK – white  black Fat is SLiCK – white  black Fat  Spleen  Liver  Cortex of Kidney Fat  Spleen  Liver  Cortex of Kidney Compared to the kidney cortex at the cranial body Compared to the kidney cortex at the cranial body Compared to the liver at the head (Liver-Stomach-Spleen) Compared to the liver at the head (Liver-Stomach-Spleen) Assess whether echotexture is normal or mottled Assess whether echotexture is normal or mottled Spleen has finer echotexture than liver & falciform fat Spleen has finer echotexture than liver & falciform fat Search for hypoechoic or hyperechoic nodules (FNA) Search for hypoechoic or hyperechoic nodules (FNA) Assess size of spleen if markedly enlarged Assess size of spleen if markedly enlarged Free PowerPoint Templates Goals – Spleen Ultrasound Spleen – target lesions Liver – target lesions

21. Evaluate splenic margins for normal shape Evaluate splenic margins for normal shape Normal tail is bluntly pointed, margins smooth Normal tail is bluntly pointed, margins smooth Look for passive congestion (enlarged splenic veins) Look for passive congestion (enlarged splenic veins) Look for infarction, thrombosis, torsion Look for infarction, thrombosis, torsion Torsion – hypoechoic spleen with pronounced hyperechoic trabeculae Torsion – hypoechoic spleen with pronounced hyperechoic trabeculae Starry Sky Effect Starry Sky Effect Free PowerPoint Templates Goals – Spleen Ultrasound

22. Evaluate splenic margins for normal shape Evaluate splenic margins for normal shape Normal tail is bluntly pointed, margins smooth Normal tail is bluntly pointed, margins smooth Look for passive congestion (enlarged splenic veins) Look for passive congestion (enlarged splenic veins) Look for infarction, thrombosis, torsion Look for infarction, thrombosis, torsion Free PowerPoint Templates Goals – Spleen Ultrasound Splenic torsion – Starry Sky No Doppler activity

23. Evaluate splenic margins for normal shape Evaluate splenic margins for normal shape Normal tail is bluntly pointed, margins smooth Normal tail is bluntly pointed, margins smooth Look for passive congestion (enlarged splenic veins) Look for passive congestion (enlarged splenic veins) Look for infarction, thrombosis, torsion Look for infarction, thrombosis, torsion Free PowerPoint Templates Goals – Spleen Ultrasound Splenic infarct – Starry Sky with hyperchoic wedge

24. The size of the canine spleen varies a great deal The size of the canine spleen varies a great deal Sedation can make it very large Sedation can make it very large The normal feline spleen is much smaller than canine The normal feline spleen is much smaller than canine Use a light touch or standoff pad for the feline spleen Use a light touch or standoff pad for the feline spleen Look more cranial and lateral in the cat than in the dog Look more cranial and lateral in the cat than in the dog May be under the last rib in the cat May be under the last rib in the cat Folded spleen of thickness >10mm indicates splenomegaly in the cat Folded spleen of thickness >10mm indicates splenomegaly in the cat In cats, splenomegaly is almost always pathologic In cats, splenomegaly is almost always pathologic Free PowerPoint Templates Tips – Spleen Ultrasound

25. The size of the canine spleen varies a great deal The size of the canine spleen varies a great deal Sedation can make it very large Sedation can make it very large The normal feline spleen is much smaller than canine The normal feline spleen is much smaller than canine Use a light touch or standoff pad for the feline spleen Use a light touch or standoff pad for the feline spleen Look more cranial and lateral in the cat than in the dog Look more cranial and lateral in the cat than in the dog May be under the last rib in the cat May be under the last rib in the cat Folded spleen of thickness >10mm indicates splenomegaly in the cat Folded spleen of thickness >10mm indicates splenomegaly in the cat In cats, splenomegaly is almost always pathologic In cats, splenomegaly is almost always pathologic Free PowerPoint Templates Tips – Spleen Ultrasound

26. Splenic veins are less plentiful than hepatic veins Splenic veins are less plentiful than hepatic veins Splenic veins more prominent with passive congestion Splenic veins more prominent with passive congestion Body and tail are very mobile – location can vary Body and tail are very mobile – location can vary Can go along the greater curvature, so the tail falls near the right kidney Can go along the greater curvature, so the tail falls near the right kidney Can go along the left body wall, so the tail falls near the bladder Can go along the left body wall, so the tail falls near the bladder If marked splenomegaly, can fold over so that the tail falls back near the left kidney and the head of the spleen If marked splenomegaly, can fold over so that the tail falls back near the left kidney and the head of the spleen Free PowerPoint Templates Tips – Spleen Ultrasound

27. Hilus identified by the hypoechoic “Y” formed by the splenic vein Hilus identified by the hypoechoic “Y” formed by the splenic vein Try right lateral recumbency if having difficulty distinguishing liver from spleen Try right lateral recumbency if having difficulty distinguishing liver from spleen When determining whether a mass arises from the spleen or is adjacent to the spleen, look at the capsule When determining whether a mass arises from the spleen or is adjacent to the spleen, look at the capsule Splenic mass displaces the hyperechoic capsule outward Splenic mass displaces the hyperechoic capsule outward Splenic capsule shows up best when perpendicular to ultrasound beam Splenic capsule shows up best when perpendicular to ultrasound beam Free PowerPoint Templates Tips – Spleen Ultrasound

28. DDx focal lesions in the spleen: DDx focal lesions in the spleen: Cyst, abscess (peliosis), granuloma Cyst, abscess (peliosis), granuloma Gas is tip-off for abscess (acoustic shadow) Gas is tip-off for abscess (acoustic shadow) Necrotic tumor can look like an abscess Necrotic tumor can look like an abscess Neoplasia – target lesions more likely metastatic Neoplasia – target lesions more likely metastatic malignant – primary or metastatic malignant – primary or metastatic Benign – myelolipoma, fibroma Benign – myelolipoma, fibroma Hematoma, extramedullary hematopoiesis Hematoma, extramedullary hematopoiesis Nodular hyperplasia, lymphoid hyperplasia Nodular hyperplasia, lymphoid hyperplasia Infarct (wedge shaped) Infarct (wedge shaped) Free PowerPoint Templates Tips – Spleen Ultrasound

29. DDx diffusely hypoechoic splenomegaly: DDx diffusely hypoechoic splenomegaly: Nodular hyperplasia Nodular hyperplasia Extramedullary hematopoiesis Extramedullary hematopoiesis Passive congestion Passive congestion Lymphoid hyperplasia Lymphoid hyperplasia Infection – bacterial, rickettsial, fungal Infection – bacterial, rickettsial, fungal Immune mediated disease Immune mediated disease Lymphoma, mast cell tumor, myeloproliferative disease Lymphoma, mast cell tumor, myeloproliferative disease Irregular splenic capsule with no focal lesions most often due to nodular hyperplasia Irregular splenic capsule with no focal lesions most often due to nodular hyperplasia Free PowerPoint Templates Tips – Spleen Ultrasound

30. DDx honeycomb splenomegaly: DDx honeycomb splenomegaly: Lymphoma is most common Lymphoma is most common Mast cell tumor Mast cell tumor Myeloproliferative disease Myeloproliferative disease Splenic thrombus should Splenic thrombus should Increase index of suspicion For lymphoma Black halo around the Black halo around the spleen can indicate subscapsular hemorrhage (trauma) Free PowerPoint Templates Tips – Spleen Ultrasound

31. Make sure you follow the head of the spleen by fanning up under the left ribcage until it disappears Make sure you follow the head of the spleen by fanning up under the left ribcage until it disappears Spleen will appear largest here Spleen will appear largest here Try standing if you can’t reach the edges of the spleen head Try standing if you can’t reach the edges of the spleen head Do not misinterpret this as a mass Do not misinterpret this as a mass Masses are usually abnormal in echotexture and echogenicity Masses are usually abnormal in echotexture and echogenicity Hilar hyperechoic tissue is often a benign myelolipoma Hilar hyperechoic tissue is often a benign myelolipoma Can’t differentiate benign vs. malignant on ultrasound Can’t differentiate benign vs. malignant on ultrasound Free PowerPoint Templates Pitfalls – Spleen Ultrasound

32. Can’t always detect diffuse disease based on echogenicity changes Can’t always detect diffuse disease based on echogenicity changes Do a fine needle aspiration cytology Do a fine needle aspiration cytology FNA of spleen indicated for any chronically ill dog FNA of spleen indicated for any chronically ill dog Can’t reliably assess spleen size except marked enlargement in dogs Can’t reliably assess spleen size except marked enlargement in dogs Beware aspirating the hypoechoic nodule in the liver and the spleen Beware aspirating the hypoechoic nodule in the liver and the spleen Risk of hemorrhage Risk of hemorrhage Free PowerPoint Templates Pitfalls – Spleen Ultrasound

33. Summary PowerPoint – Ultrasound of the Spleen, Spleen Ultrasound CasesUltrasound of the Spleen Spleen Ultrasound Cases.pdf of PowerPoints – Ultrasound of the Spleen, Spleen Ultrasound CasesUltrasound of the SpleenSpleen Ultrasound Cases Spleen Ultrasound TIPs Sheet Animated PowerPoint – Scanning the Spleen Animated PowerPoint Video: Ultrasound of the SpleenUltrasound of the Spleen (no audio)

34. Bob Cole, ACVR Auburn University The Academy of Veterinary Imaging 2409 Avenue J, Suite C Arlington, TX 76006 (800) 268-5354 Acknowledgments Stephanie Lisciandro, ACVIM (Internal Medicine) Chapter 4: Focused or COAST 3 – Spleen Focused Ultrasound Techniques for the Small Animal Practitioner Editor Greg Lisciandro

35. Acknowledgments John Mattoon, Danelle Auld, Thomas Nyland Chapter 4: Abdominal Ultrasound Scanning Techniques Small Animal Diagnostic Ultrasound Editors Nyland and Mattoon – 3 rd Edition 2014 Thomas Nyland, John Mattoon, Eric Herrgesell. Erik Wisner Chapter 7: Spleen Small Animal Diagnostic Ultrasound Editors Nyland and Mattoon – 3 rd Edition 2014 John P. Graham, MVB, MSc, DVR, MRCVS Diplomate, ECVDI, Diplomate, ACVR Diplomate, ECVDI, Diplomate, ACVR Diagnostic Imaging in Dogs and Cats Nestle Purina – Clinical Handbook Series