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"Working Through the Ascites on Ultrasound": Our Case of the Month April 2014

Patient Information

Age
9 Years
Gender
Male, Neutered
Species
Feline

Keywords

History

Clinical Signs

CBC

Images

Irregular omentum with echogenic fluid.
Multiple heterogenous nodular changes were noted which were hypoechoic and hyperechoic throughout the liver.
A hyperechoic nodule is noted in the live rin the near field which may be metastatic or an incidental benign finding such as a lipogranuloma. Ascites is present and an ill defined hypoechoic portion of the pancreas at 3-4 cm in the right portion of the image. The irregular and nodular omentum is consistent with neoplastic spread such as that of carcinomatosis or lymphomatosis

Working through the distended abdomen cat with the roughened hair coat. Where is that fluid coming from? Let the clinical sonography and critical thinking roll to the diagnosis in this classic "working through the ascites on ultrasound."

History

A 9-year-old MN DSH was presented for evaluation of ascites. On physical examination a distended abdomen and weight loss was evident. Fluid analysis revealed a moderate neutrophilic exudate - suspected bacterial sepsis. CBC showed neutrophilia, monocytosis, and mild anemia whereas serum chemistry was within normal limits.

Clinical Differential Diagnosis

Bacterial peritonitis. Feline infectious peritonitis. Neoplasia- intra-abdominal, liver, spleen, kidney, pancreas, mesenteric lymph node. Chemical - urine, bile.

Image Interpretation

The abdomen in this patient presented moderate amount of echogenic free fluid. Multiple heterogenous nodular changes were noted which were hypoechoic and hyperechoic throughout the liver. This is suggestive for metastatic event. Some internal structure deviation was noted. The deep right liver revealed a collapsed gallbladder with surrounding parenchymal nodular changes with impingement upon the gallbladder. The vena cava was normal. The hepatic veins were subnormal in size. This is indicative of an increased possibility of feline infectious peritonitis. The pancreatic region revealed multiple nodular hypoechoic changes with irregular surrounding omentum.

Sonographic Differential Diagnosis

Bi-cavitary effusion. Nodular pancreatic and hepatic changes. This is highly suggestive for dual cavity neoplasia such as carcinomatosis or possible feline infectious peritonitis. An abdominocentesis with cytospin and immediate slide preparation would be recommended for a definitive diagnosis. Alternatively, fine-needle aspirates of the pancreas and liver nodules would be warranted. Very poor long term prognosis.

Sampling

FNA of liver revealed carcinoma (suspected metastatic). FNA of pancreas: carcinoma. Comments: Given the appearance of the slides as well as the sonographic description, the pancreas is likely the site of primary neoplasia, with metastases to the liver. The neoplastic cells appear epithelial but do not contain zymogen granules typical of normal pancreatic cells. This could be because the cells are sufficiently anaplastic as to have lost this feature, but other sources should be considered as well.

DX

Pancreas: carcinoma. Liver: carcinoma (suspected metastatic).

Outcome

The patient was humanely euthanized.

Videos

The deep right liver revealed a collapsed gallbladder with surrounding parenchymal nodular changes with impingement upon the gallbladder.
Moderate amount of echogenic free fluid.
Multiple heterogenous nodular changes were noted with hypoechoic and hyperechoic throughout the liver.
The pancreatic region revealed multiple nodular hypoechoic changes with irregular surrounding omentum.