Dr Ruth Clark
BVSc MRCVS
VVS Commercial Manager
In this cautionary tale, we are reminded that the most exciting findings aren’t always the most relevant to the case and of the value of having an experienced ultrasonographer on hand to assist!
Kwazi, a 13yr old MN DSH was brought to his usual vet by his concerned owner. His owner had noticed that he had lost weight, was vocalising more than usual, and had started laying near his water bowl.
Kwazi had a history of megacolon (subtotal colectomy previously performed) and subclinical hypertrophic cardiomyopathy. He is prescribed a hypoallergenic diet for ongoing GIT issues.
Kwazi’s vet performed routine blood tests. Haematology indicated mild anaemia. Further blood work showed he was azotaemic (Iris Kidney stage 2) with an SDMA of 22 (High). He was normotensive and had proteinuria with UPC of 0.6 (normal = 0.0 – 0.4). T4 was normal.
Following abdominal radiography, Kwazi’s vet had some concerns regarding the size of Kwazi’s kidneys. Fortunately, Kwazi’s vet works for a Virtual Veterinary Specialist (VVS) partner practice, with full access to VVS’s integrated technology system. This means that VVS specialists can virtually assist vets at the practice whenever necessary. In this case, VVS Diagnostic Imaging Specialist Dr Christelle le Roux was on hand to live-guide Kwazi’s vet through a full abdominal ultrasound examination, using the VVS platform. Together, they found that the entire small intestinal tract demonstrated marked anechoic thickening of the muscularis layer, with retention of wall layering. The muscularis thickness was greater than that of the mucosa, which is an abnormal finding. There was a diffuse infiltrative enteropathy, most consistent with either inflammatory bowel disease (for example lymphoplasmacytic infiltration) or small cell lymphoma.
The kidneys were found to have mildly hyperechoic cortices but were within normal dimensions. Dr Le Roux felt that these observations were consistent with the history of renal disease.
When examining the liver, Dr le Roux noticed at least two poorly defined, hypoechoic regions. One was a conglomeration of small cystic structures in the right lobe, along the diaphragm, and the other was near the neck of the gall bladder. She felt that these were likely to be of little significance clinically but should be monitored ultrasonographically in future.
Completely unexpectedly, Dr le Roux then noticed a tortuous, large calibre aberrant vessel in the right cranial abdomen. She was able to guide Kwazi’s vet through a detailed examination of this abnormality to assess its interaction with the portal vein and surrounding structures. Together they ascertained that this vessel was coursing in a craniodorsal direction towards the caudal vena cava but was not seen to connect with it. Dr le Roux advised that this was an extrahepatic portosystemic shunt. She concluded that although this was a rare and very interesting finding, it was likely to be of little clinical significance and that the focus should remain on the thickened loops of intestine.
Colour flow doppler image showing blood flow in the portosystemic shunt.
Kwazi is not a straightforward case and a multidisciplinary approach is warranted in such cases. VVS’ Internal Medicine specialist, Dr Stephanie Sorrell advised that a portosystemic shunt is a congenital problem, that has been present since birth. Surgical management is more complicated in cats, particularly due to the high risk of post attenuation neurological disorders. Given the lack of compatible clinical signs, ongoing monitoring is advised. If clinical signs develop then medical management could be considered
Dr Sorrell also advised that Kwazi’s vet now has a number of options regarding next steps. Intestinal biopsies should be considered, and these can be performed either via ex-lap, or endoscopically. Histopathology of intestinal biopsies would allow differentiation between the two most likely differentials of inflammatory bowel disease or small cell lymphoma. Alternatively, trial treatment can be considered. Dr Sorrell would advise transitioning to Purina HA, as this diet is beneficial for both IBD and the shunt. In the future it is important to be aware that drugs which require hepatic metabolism should be used with caution given the presence of a portosystemic shunt.
If further monitoring of Kwazi’s hypertrophic cardiomyopathy is required, then VVS’s Cardiology team are also on hand to help.
Kwazi’s owner can rest assured that Kwazi will get the best possible care, with a truly holistic treatment plan, from their own vet whom they know and trust.
Kwazi’s vet was new to the practice and previously had little experience of using the practice ultrasound machine. She was excited by what she had achieved under Dr le Roux’s guidance and felt more confident to tackle further ultrasonography cases. Kwazi’s vet will receive her CPD certificate via e-mail and can use this procedure towards her RCVS CPD requirements log.
Kwazi’s vet’s practice is a VVS member practice. This means that the VVS workstation and equipment stay in the practice and all vets at the practice can use this equipment to seek specialist support whenever they need it.
Benefits of the VVS Virtual system include:
- Patients receive world-class specialist care.
- Patients are treated in their usual practice, by vets that know them and their owners.
- Patients and owners do not have to travel to referral centres.
- Vets keep cases (and revenues) in house.
- Vets are upskilled, as they learn from VVS specialists.
- Time with a VVS specialist counts towards CPD hours, meaning that vets gain CPD whilst also bringing in practice revenue and without having days away from the practice.
- Vets have reassurance that they never need work alone. VVS’s friendly specialists become part of the practice team.
- COVID guidelines are easy to follow as all consults are virtual.