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CVM 6101 Radiographic Anatomy of the Abdomen

Travis C. Saveraid, DVM, DACVR Medical Imaging Department College of Veterinary Medicine University of Minnesota

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CVM 6101 [Imaging Anatomy]

· Goals & Expectations:

­ Identify specific structures or parts thereof ­ Understand why the views (projections) look as they do ­ Keep in mind that the items listed in the "to know" lists are from the perspective of practicing radiologists ­ If asked, be able to describe what soft-tissue (muscle, tendon, ligament, vessel, or alimentary/parenchymal) structure(s) attach to, pass through, or lie in contact with a given anatomic landmark or region

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CVM 6101 [Imaging Anatomy]

· Approach:

­ Introductory lectures defining the important structures and how they are viewed radiographically ­ Open session, instructor proctored group laboratory exercises wherein actual radiographs of the anatomic structures are viewed and understood ­ Web-based self-study sets both available on CD and from the web site http://www.academicserver.cvm.umn.edu/radiology//

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CVM 6101 [Imaging Anatomy]

· Sources of Information:

­ ­ ­ ­ Anatomy Textbooks Radiographic Anatomy Textbooks General Veterinary Imaging Textbooks U-MN Medical Imaging web site http://www.academicserver.cvm.umn.edu/radiology/

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· · · · · · · · · · · · · · · · ·

1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19)

liver spleen left and right kidneys urinary bladder small intestine colon rectum prostate gland left and right diaphragmatic crura diaphragmatic cupola approximate area of the adrenal glands approximate area of the pancreas xiphoid of the sternum approximate area of the uterus approximate area of the left and right ovaries stomach: cardiofundic, body, and pylorus/pyloric antrum regions cecum approximate area of the caudal vena cava, aorta, and iliac (sublumbar) lymph nodes region of the falciform fat

To Know List

Abdominal CT images (single slice)

Sagittal Dorsal

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· Left parasagittal

· Midline sagittal

· Right parasagittal (*3 different dogs)

Normal Lateral Views

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Normal VD Views

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Normal Canine Abdomen

Normal (Fat) Feline

Normal (Fat) Feline

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Interpretive Background: Abdomen

· Peritoneal organs (surrounded by peritoneum and obscured by peritoneal fluid) include liver, spleen, pancreas, alimentary organs, urinary bladder, uterus, ovary, prostate (depending on location) and mesenteric lymph nodes · Retroperitoneal organs (only partially surrounded by peritoneum and NOT obscured by peritoneal fluid) include great vessels, kidneys, adrenal glands, ureters (except very distal), urethra and retroperitoneal lymph nodes

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CVM 6101 [Imaging Anatomy]

· Diaphragm:

­ V D/D V and R L/L R views ­ Beware of superimposed structures including vertebrae, ribs, sternebrae, lungs, stomach, nipples, fascial planes, trachea, etc. ­ Remember, the diaphragm is a sling-like muscle that "actively" contracts (caudally) and "passively" relaxes (cranially) [numerous influences such as lungs, abdominal fat, etc.]

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CVM 6101 [Imaging Anatomy]

· Diaphragm: Specific Morphology

­ Hiatus for caudal vena cava ­ Hiatus for aorta ­ Hiatus for esophagus (esophagus, vagal n)

· For more review, see normal thoracic lecture

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CVM 6101 [Imaging Anatomy]

Diaphragm

­ Aortic hiatus

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CVM 6101 [Imaging Anatomy]

Diaphragm

­ CVC hiatus

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CVM 6101 [Imaging Anatomy]

Diaphragm

­ Esophageal hiatus

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CVM 6101 [Imaging Anatomy]

· Stomach:

­ V D/D V and R L/L R as well as horizontalbeam views ­ Beware of superimposed structures including vertebrae, ribs, sternebrae, lungs, stomach, nipples, fascial planes, liver, etc. ­ Remember, the stomach is like a wine skin with an outlet on both ends (distension changes its shape) ­ The stomach responds to forces from regional organs and masses by changing shape

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CVM 6101 [Imaging Anatomy]

· Stomach: Broad Anatomic Regions

­ ­ ­ ­ Cardia Fundus Body Pylorus

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Normal Abdominal Architecture

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Interpretive Background: Abdomen

· Useful interpretive criteria:

­ Liver size influences the "fundic-pyloric" axis

· Normally parallel to last 2-3 ribs on lateral view · Normally perpendicular to spine on VD/DV views

­ Large liver or right-sided liver mass displaces pylorus caudally and to the left

· remember F-P axis effect

­ Small liver allows pylorus to drift cranially

· remember F-P axis effect

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Fundic-pyloric axis

· Normal axis between perpendicular to spine and parallel to caudal ribs

CVM 6101 [Imaging Anatomy]

· Stomach:

­ Appearance changes depending on DV (sternal recumbency) vs. VD (spinal recumbency) views (with the X-ray beam is centered on the last rib):

· On DV views, the gas is primarily in the cardiac region with less in the pyloric region; fluid is in the body region · On VD views, the fluid is primarily in the cardiac region with less in the pyloric region; air is in the body region · Appearance may vary depending on the relative amounts of fluid and gas UNIVERSITY OF MINNESOTA

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CVM 6101 [Imaging Anatomy]

Stomach

­ DV ­ Gas in cardia and pyloric antrum

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CVM 6101 [Imaging Anatomy]

Stomach

­ VD ­ Gas in body/fundus

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CVM 6101 [Imaging Anatomy]

· Stomach:

­ Appearance changes depending on R vs. L recumbent lateral views (with the X-ray beam is centered on the last rib):

· On R lateral views, the gas is primarily in the cardiac region with fluid in the pyloric region (may look like ball) · On L lateral views, the gas is primarily in the pyloric region with fluid in the cardiac region · Appearance may vary depending on the relative amounts of fluid and gas UNIVERSITY OF MINNESOTA

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CVM 6101 [Imaging Anatomy]

Stomach ­ R lateral recumbency ­ Gas in cardia ­ Fluid in pylorus

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CVM 6101 [Imaging Anatomy]

Stomach

­ L lateral recumbency ­ Gas in pylorus ­ Fluid in cardia

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CVM 6101 [Imaging Anatomy]

· Stomach: Specific Morphology

­ Gastroesophageal Junction ­ Rugae ­ Pyloric Antrum/pylorus

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CVM 6101 [Imaging Anatomy]

Stomach

­ Gastroesophageal Junction

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CVM 6101 [Imaging Anatomy]

Stomach ­ Rugae

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CVM 6101 [Imaging Anatomy]

Stomach ­ Pyloric Antrum

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CVM 6101 [Imaging Anatomy]

· Small Intestine:

­ V D/D V and R L/L R and horizontalbeam views ­ Beware of superimposed structures including vertebrae, ribs, stomach, nipples, kidneys, spleen, fascial planes, urinary bladder, etc. ­ Remember, relative amounts of small bowel gas varies by species (dogs, 30 ­ 60 %; cats, nearly gasless)

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Interpretive Background: Abdomen

· Useful interpretive criteria: ­ Small bowel can be compared to the width and length of the lumbar vertebral bodies: · Normal canine or feline small bowel are less than 3 rib widths or less than the height of a lumber vertebral body in diameter · Concern should arise if the diameter approaches the width of a lumber vertebral body · Surgical intervention is often indicated if the diameter equals or exceeds the length of a lumber vertebral body

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CVM 6101 [Imaging Anatomy]

· Small Intestine : Broad Anatomic Regions

­ Duodenum

· Descending · Ascending

­ Jejunum ­ Ileum

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CVM 6101 [Imaging Anatomy]

Small Intestine

­ Note gas-fluid "relationship" ­ Note gas-fluid "distribution" ­ Beware of influences by other regional organs including retroperitoneal fat

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Normal Abdominal Architecture

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CVM 6101 [Imaging Anatomy]

· Small Intestine :

­ Appearance changes depending on DV vs. VD and R vs. L lateral recumbency views (with the X-ray beam is centered on the last rib):

· Gas and fluid distribution should be even · Gut diameter should be randomly varied, but some degree of uniformity · Beware of measuring gut wall on recumbent views

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Intestinal wall thickness?

Gravity Wall Gas

Cross-section axial Wall +Fluid

Cross-section sagittal

Gas

CVM 6101 [Imaging Anatomy]

Small Intestine ­ Lateral recumbency

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CVM 6101 [Imaging Anatomy]

Small Intestine

­ Dorsal recumbency (VD)

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CVM 6101 [Imaging Anatomy]

· Large Intestine:

­ V D/D V and R L/L R with occasional horizontal-beam views ­ Beware of superimposed structures including vertebrae, ribs, pelvis, lidneys, stomach, nipples, fascial planes, urinary bladder, prostate gland, small intestine, etc. ­ Remember, colonic and cecal gas as well as stool diameter are highly variable

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CVM 6101 [Imaging Anatomy]

· Large Intestine : Broad Anatomic Regions

­ ­ ­ ­ Ascending colon Cecum (big difference between dog and cat) Transverse colon Descending colon

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Normal Abdominal Architecture

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CVM 6101 [Imaging Anatomy]

Large Intestine

­ Lateral view ­ Post-barium enema

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CVM 6101 [Imaging Anatomy]

Large Intestine

­ Ventrodorsal view

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CVM 6101 [Imaging Anatomy]

· Large Intestine :

­ Appearance (basically gas and fluid shifts, not stool movement) changes depending on R vs. L or dorsal vs. ventral recumbent views (with the X-ray beam is centered on the last rib): ­ Varied recumbency can foster differentiating normal variation from abnormal

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CVM 6101 [Imaging Anatomy]

· Liver:

­ V D/D V and R L/L R and, when indicated, horizontal-beam views ­ Beware of superimposed structures including vertebrae, ribs, sternebrae, lungs, stomach, nipples, fascial planes, small intestine, and (occasionally) colon, etc.

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CVM 6101 [Imaging Anatomy]

· Liver: Broad Anatomic Regions

­ ­ ­ ­ ­ ­ ­ Left lateral lobe Left medial lobe Quadrate lobe Porta hepatis (hilus) Right medial lobe Right lateral lobe Caudate lobe: · Caudate process (R kidney) · Papillary process

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Normal Abdominal Architecture

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Liver Sagittal

CVM 6101 [Imaging Anatomy]

Liver

­ L lateral recumbency ­ R lateral recumbency

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CVM 6101 [Imaging Anatomy]

Liver

­ Dorsal recumbency

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Liver Mass

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CVM 6101 [Imaging Anatomy]

Gall Bladder

­ Normally not seen on survey radiographs ­ Opacified with iodinated contrast medium ingested or injected parenterally ­ Opacified with iodinated contrast medium via direct injection ­ Contained (roughly) between the R medial and quadrate liver lobes UNIVERSITY OF MINNESOTA

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CVM 6101 [Imaging Anatomy]

· Spleen:

­ V D/D V and R L/L R views ­ Beware of superimposed structures including vertebrae, ribs, sternebrae, lungs, stomach, small bowel, large bowel, kidneys, pancreas, occasionally urinary bladder, nipples, fascial planes, etc. ­ Remember, the spleen is attached to the stomach by the gastrosplenic ligament, but the spleen can move around freely within limits (beyond which it becomes a splenic torsion)

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CVM 6101 [Imaging Anatomy]

· Spleen: Broad Anatomic Regions

­ Head ­ Body ­ Tail

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Normal Abdominal Architecture

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CVM 6101 [Imaging Anatomy]

Spleen

­ Lateral view (1o tail)

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CVM 6101 [Imaging Anatomy]

Spleen

­ VD View (1o body)

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Splenic Mass

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CVM 6101 [Imaging Anatomy]

· Pancreas:

­ V D/D V and R L/L R views ­ Typically pancreas is NOT visible (exception fat cats) ­ Remember, pancreas has a close relationship to the greater omentum, the descending duodenum and the transverse colon/stomach interface

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CVM 6101 [Imaging Anatomy]

· Pancreas: Broad Anatomic Regions

­ Head (bile ducts) ­ Right limb ­ Left limb

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Normal Abdominal Architecture

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CVM 6101 [Imaging Anatomy]

Pancreas "regions"

­ R lateral view ­ Pancreatitis (haze caudal to stomach)

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CVM 6101 [Imaging Anatomy]

Pancreas "regions"

­ VD view ­ Pancreatitis (haze in RUQ)

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Pancreatic Mass

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CVM 6101 [Imaging Anatomy]

· Kidneys & Ureters:

­ V D/D V and R L/L R views ­ Beware of superimposed structures including vertebrae, ribs, stomach, nipples, spleen, pancreas, small bowel, large bowel, occasionally urinary bladder, fascial planes, etc. ­ Remember, kidneys and the proximal +/- 80% of the ureters are functionally retroperitoneal

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Interpretive Background: Abdomen

· Kidneys & Ureters

­ Kidney size (on VD view) is compared to the length of the 2nd lumbar vertebral body

· Normally dog kidneys between 2.5 and 3.5 L-2 lengths · Renal pelvic width (seen only with intravenous contrast medium) is no more than 2 ­ 3 mm · Normally cat kidneys between 2.4 and 3.0 L-2 length ­ Note with advancing age, old cat kidneys (particularly when neutered) approach 2.0 L-2 UNIVERSITY OF MINNESOTA lengths Veterinary Medical Center

CVM 6101 [Imaging Anatomy]

· Kidneys & Ureters: Broad Anatomic Regions

­ Parenchyma:

· Cortex · Medulla

­ Hilus (sinus) ­ Pelvis ­ Pelvic recesses

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Dorsal Plane CT and MR images

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Cranial margin of right kidney

· Not usually visible (dogs) because of close relationship with the liver in the renal fossa of the caudate process of the caudate liver lobe

CVM 6101 [Imaging Anatomy]

Kidneys & Ureters

­ R lateral view ­ Preferred because R recumbency fosters kidney cranial-caudal separation

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CVM 6101 [Imaging Anatomy]

Kidneys & Ureters

­ VD view ­ Preferred because available measurements are standardized from the VD view against the length of L2 vertebral body

R

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CVM 6101 [Imaging Anatomy]

Kidneys & Ureters

­ R lateral view ­ Intravenous urogram (iodine) [L stricture]

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CVM 6101 [Imaging Anatomy]

Kidneys & Ureters

­ VD view ­ Intravenous urogram (iodine) [L stricture]

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Kidney Mass

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CVM 6101 [Imaging Anatomy]

Adrenal Glands

­ Normally not seen on survey radiographs ­ Very close to aorta and caudal vena cava (e.g. tumor invasion problem) ­ Masses displace ipsilateral kidney ­ L adrenal mass

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Left Adrenal Mass

CVM 6101 [Imaging Anatomy]

· Urinary Bladder and Urethra:

­ V D/D V and R L/L R views ­ Beware of superimposed structures including vertebrae, pelvis, small bowel, large bowel nipples, fascial planes, etc. ­ Remember, bladder is a "holding tank" for urine delivered from the kidneys via the ureters; size and shape are, therefore, variable

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CVM 6101 [Imaging Anatomy]

· Urinary Bladder: Broad Anatomic Regions

­ Trigone: · 2 ureters · 1 urethra ­ Apex

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CVM 6101 [Imaging Anatomy]

· Urethra: Broad Anatomic Regions

­ Male:

· Prostatic portion (within prostate gland) · Membranous portion (from prostate gland to the tuber ischii) · Penile portion (from the tuber ischii to the external urethral orifice)

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CVM 6101 [Imaging Anatomy]

Urinary Bladder

­ R lateral view

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CVM 6101 [Imaging Anatomy]

Urinary Bladder

­ VD view

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CVM 6101 [Imaging Anatomy]

Urinary Bladder and Urethra in a male dog

­ Positive contrast (iodine), distension urethrocystogram ­ Lateral view ­ URETHRAL NOTE: prostatic portion larger than either membranous or penile portions

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CVM 6101 [Imaging Anatomy]

Urinary Bladder and Urethral in a male dog

­ Positive contrast (iodine) urethrocystogram ­ VD view ­ URETHRAL NOTE: prostatic portion larger than either membranous or penile portions

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CVM 6101 [Imaging Anatomy]

· Uterus & Ovaries:

­ V D/D V and R L/L R views ­ Beware of superimposed structures including vertebrae, urinary bladder, bony pelvis, colon and small bowel, stomach, nipples, fascial planes, prepuce/penis, etc. ­ Remember, the ovaries and uterus are both intraperitoneal (mix with bowel, hard to find) ­ Normal ovaries and uterus on rarely seen on survey films

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CVM 6101 [Imaging Anatomy]

Uterus & Ovaries: Broad Anatomic Regions

­ Uterus:

· Horns · Body · Cervix

­ Ovaries

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Ovarian Mass

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CVM 6101 [Imaging Anatomy]

Uterus & Ovaries

­ Enlarged L ovary ­ VD view

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CVM 6101 [Imaging Anatomy]

Uterus (spoon technique)

­ R lateral view ­ NOTE: from dorsal to ventral colon uterine body urinary bladder

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CVM 6101 [Imaging Anatomy]

Uterus (spoon technique)

­ R lateral view ­ NOTE: from dorsal to ventral colon uterine body urinary bladder

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CVM 6101 [Imaging Anatomy]

· Uterus & Ovaries: Contrast Morphology

­ Hysterosalpingogram

· · · · Cervix Uterine body Uterine horns Oviduct

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CVM 6101 [Imaging Anatomy]

· Uterus & Ovaries: Contrast Morphology

­ Retrograde vaginogram

· · · · Vestibule Vagina External urethral orifice Cervix

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CVM 6101 [Imaging Anatomy]

· Prostate Gland:

­ V D and R L/L R views ­ Beware of superimposed structures including vertebrae, pelvis, colon/rectum, urinary bladder, nipples, fascial planes, prepuce, etc. ­ Remember, the prostate gland position varies with age so position may be as much a function of age as it is size

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CVM 6101 [Imaging Anatomy]

Prostate Gland: Broad Anatomic Regions

­ ­ ­ ­ R lobe L lobe Urethral fossa Note: Not normally visible on neutered dogs.

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CT Prostate Sagittal

CVM 6101 [Imaging Anatomy]

Prostate Gland

­ Lateral view ­ NOTE: should be a uniform soft tissue opacity

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CVM 6101 [Imaging Anatomy]

Prostate Gland

­ VD view

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Interpretive Background: Abdomen

· Useful interpretive criteria:

­ Prostate gland size (on lateral view) in the dog is measured against the distance between the sacral promontory and the leading edge of the pubic bone (pubic-promontory distance)

· Normally dog prostate gland less than 70 % of the pubicpromontory distance in planes either perpendicular or parallel to the pubic-promontory plane · Position of canine prostate gland varies with age and it is not abnormal to find the prostate gland outside the pelvic canal in older dogs apparently without prostatic disease · Remember, neutering should effectively render the canine prostate gland indistinguishable after 4-6 months unless there are other complications UNIVERSITY OF MINNESOTA

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Prostatic Measurement

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Interpretive Background: Abdomen

· Useful interpretive criteria:

­ Normally cat prostate glands are not seen and the role of radiography or ultrasonography in feline prostatic disease has yet to be determined

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CVM 6101 [Imaging Anatomy]

Sublumbar Lymph Nodes

[medial iliac & lumbar aortic]

­ Normally not seen on survey radiographs ­ Retroperitoneal ­ Lateral view

Normal medial iliac lymph node

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Sublumbar Mass

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CVM 6101 [Imaging Anatomy]

Sublumbar Lymph Nodes

[medial iliac & lumbar aortic]

­ Masses displace descending colon and urinary bladder ventrally ­ Lateral view

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CVM 6101 [Imaging Anatomy]

Major Abdominal Vessels

­ Caudal Vena Cava (CVC) and Aorta (mostly retroperitoneal) ­ Portal Vein (intraperitoneal) ­ Normally not seen on survey radiographs ­ Local/regional masses may invade

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Aorta

CVM 6101 [Imaging Anatomy]

Major Abdominal Vessels

­ Caudal Vena Cava (mostly retroperitoneal) ­ Normally not seen on survey radiographs ­ Local/regional masses may invade

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CVM 6101 [Imaging Anatomy]

Major Abdominal Vessels

­ Aorta (mostly retroperitoneal) ­ Normally not seen on survey radiographs ­ Local/regional masses may invade

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CVM 6101 [Imaging Anatomy]

Major Abdominal Vessels

­ Portal Vein (intraperitoneal) ­ Normally not seen on survey radiographs ­ Subject to anatomic anomalies

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CVM 6101 [Imaging Anatomy]

· Remember:

­ Radiation is "through and through" ­ Medial Lateral = Lateral Medial *EXCEPT for effects of gravity on gas, fluid, and organ shape ­ Patient anatomy, cooperation, and status may dictate how views are made ­ Oblique views facilitate clarification (less superimposition)

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Specific References: ABDOMEN

· Grandage J: Posture, gravity and radiographic interpretation. J Am Vet Radiol Soc 22:80, 1979. · Grandage J: Radiology of the dog's diaphragm. J Small Anim Pract 15:1, 1974. · Bhargava AK, Rudy JL, Diesem CD: Radiographic anatomy of the pleura in dogs as visualized by contrast pleurography. J Am Vet Radiol Soc 10:61, 1969.

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General References: ABDOMEN

· Thrall DE (ed): Textbook of Veterinary Diagnostic Radiology. WB Saunders, Philadelphia, 2002. · Burk RL, Feeney DA: Small Animal Radiology and Ultrasonography. Saunders/Elsevier, Philadelphia, 2003

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