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Diagnostic Imaging of Dogs With Suspected Por to Systemic Shunting

Diagnostic Imaging of Dogs With Suspected Por to Systemic Shunting

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Contrast radiography is the
definitive technique for
diagnosing all forms of
portosystemic shunting (PSS).
I Ultrasonography is an accurate,
noninvasive diagnostic test for
congenital PSS.
I Scintigraphy is a good screening
test for all types of PSS.
I Knowing the morphology of an
intrahepatic shunt helps plan
surgery.

University of London Christopher R. Lamb, MA, VetMB, MRCVS, DACVR, DECVDI
University of Tennessee Gregory B. Daniel, DVM, MS, DACVR
Contrast radiography is the
definitive technique for
diagnosing all forms of
portosystemic shunting (PSS).
I Ultrasonography is an accurate,
noninvasive diagnostic test for
congenital PSS.
I Scintigraphy is a good screening
test for all types of PSS.
I Knowing the morphology of an
intrahepatic shunt helps plan
surgery.

University of London Christopher R. Lamb, MA, VetMB, MRCVS, DACVR, DECVDI
University of Tennessee Gregory B. Daniel, DVM, MS, DACVR

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Published by: Hospital Veterinário e Pet Shop Dr. Hato on Sep 17, 2011
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01/22/2014

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I
Contrast radiography is thedefinitive technique fordiagnosing all forms ofportosystemic shunting (PSS).
I
Ultrasonography is an accurate,noninvasive diagnostic test forcongenital PSS.
I
Scintigraphy is a good screeningtest for all types of PSS.
I
Knowing the morphology of anintrahepatic shunt helps plansurgery.
Comments? Questions? 
Email:
compendium@medimedia.com
Web:
VetLearn.com
Fax:
800-556-3288Article #4 (1.5 contact hours)
Refereed Peer Review
KEYFACTS
Diagnostic Imaging of Dogs with SuspectedPortosystemic Shunting
University of London
Christopher R. Lamb, MA, VetMB, MRCVS, DACVR, DECVDI
University of Tennessee
Gregory B. Daniel, DVM, MS, DACVR 
ABSTRACT:
Contrast radiography, ultrasonography, and scintigraphy may all be used in the diag-nostic workup of dogs suspected of having portosystemic shunting (PSS). Contrast radiography(portal venography), although invasive, is the definitive method for demonstrating shunts in anyanatomic site. Ultrasonography is a convenient, noninvasive method for diagnosing congenitalPSS, determining shunt morphology, and assessing other abdominal structures. Doppler ultra-sonography is a more demanding technique that may be used to look for signs of portal hyperten-sion and acquired PSS. Scintigraphy is a useful alternative noninvasive technique for diagnosing alltypes of PSS and is a method for measuring the proportion of portal blood that bypasses the liver.There appears to be limited potential for prognosis based on any of these imaging modalities.
P
ortosystemic shunting (PSS) is a well-recognized condition in dogs thatcauses a variety of clinical signs, including stunted growth, polyuria andpolydipsia, vomiting, ataxia, seizures, and altered behavior.
1
PSS may beclassified as primary or secondary. Primary (congenital) PSS occurs as a single(or occasionally double) macroscopic vascular connection between the portalvein or a portal tributary and the caudal vena cava or other systemic vein.Congenital PSS may be divided anatomically into intrahepatic and extrahe-patic forms.
2
Intrahepatic PSS, which occurs mainly in large-breed dogs, isdescribed according to its position in the liver as left-, central-, or right-divi-sional
3
(Figure 1). The morphology of left-divisional shunts is compatible withpatent ductus venosus. Irish wolfhounds are predisposed to patent ductusvenosus, whereas Old English sheepdogs, golden and Labrador retrievers, and Australian cattle dogs are predisposed to central-divisional shunts.
2–5
Extrahe-patic PSS usually connects a major tributary of the portal vein, such as thesplenic or gastric vein, with the caudal vena cava (Figure 1).Occasionally, theshunting vessel drains into the azygos vein.Congenital extrahepatic PSS usu-ally affects small breeds, particularly terriers, miniature schnauzers, miniaturepoodles, shih tzus, and Lhasa apsos.
1,4
CE
626Vol. 24, No. 8August 2002www.VetLearn.com
 
Secondary (acquired) PSS takes the form of multiple,small extrahepatic vessels in the omentum or retroperi-toneum near the kidneys, which drain directly or indi-rectly into the caudal vena cava
2,6
(Figure 1). AcquiredPSS develops in response to chronic portal hyperten-sion, which occurs most often as a result of hepaticfibrosis or cirrhosis.
6,7
Breed-associated hepatopathiesmay lead to portal hypertension and acquired PSS inGerman shepherds, American cocker spaniels, Dober-man pinschers, and Labrador retrievers.
6
Portal hyper-tension may also occur in young dogs secondary tocongenital anomalies, such as portal vein atresia
8
orhepatic arterioportal fistula.
9
ROLE OF DIAGNOSTIC IMAGING
The role of diagnostic imaging in dogs with signs of PSS is to determine whether PSS is present, to deter-mine whether the lesion is congenital or acquired, andto assess the severity of the shunting. Also, diagnosticimaging enables preoperative morphologic assessmentof intrahepatic PSS. This is useful because the mor-phology largely dictates which techniques may be usedfor surgical treatment, thereby possibly reducing surgi-cal time. Complications occur commonly during surgi-cal treatment of dogs with intrahepatic shunts, particu-larly if surgery is prolonged because the shunt isdifficult to find.
4,10
Compendium 
August 2002Portosystemic Shunting 627
www.VetLearn.com
Figure 1ANormal anatomyFigure 1BLeft-divisional shuntFigure 1CCentral-divisional shuntFigure 1DRight-divisional shuntFigure 1E—Congenital extrahepatic shuntFigure 1F—Acquired extrahepatic shuntFigure 1—
 Anatomy of the liver and types of portosystemic shunts.
(A)
Hepatic divisions, lobes, and normal pattern of branching of the portal vein (
PV 
, caudal aspect;
= caudate lobe;
LL 
= left lateral lobe;
LM 
= left medial lobe;
= papillary process of caudatelobe;
= quadrate lobe;
RM 
= right medial lobe;
RL 
= right lateral lobe).
(B)
Left-divisional shunt. This arises from a left branchof the PV and drains into the left hepatic vein
(LHV) 
via the patent ductus venosus
(arrow) 
. The confluence of ductus and LHV isusually dilated and is known as the ampulla (
 A 
;
CVC 
= caudal vena cava).
(C)
Central-divisional shunt. The PV has a relatively straight course into the right medial lobe, where it forms a localized dilation on the ventral aspect of the CVC. The communicationbetween the PV and the CVC is via a foramen
(arrow) 
.
(D)
Right-divisional shunt. The shunting vessel passes within the right lat-eral or caudate lobe, sometimes forming a wide loop before draining into the CVC.
(E)
Congenital extrahepatic PSS. A singleanomalous vessel connects portal tributaries with the CVC.
 Arrows 
indicate direction of blood flow.
(F)
 Acquired extrahepatic PSS.This often develops secondary to hepatic disease that inhibits blood flow through the liver. Portal tributaries may be dilated. Flowin the portal vein may be hepatofugal
(dashed arrow) 
. (A through D were redrawn from Lamb CR: Ultrasonography of portosys-temic shunts in dogs and cats.
Vet Clin North Am Small Anim Pract 
28:725–753, 1998; with permission).
CentralRightLeftPVCVCPVCVCPVShuntCVCCVCMultipleshuntsCVC
 
The diagnostic imaging techniques reported mostfrequently in relation to PSS in small animals are portalvenography, ultrasonography, and scintigraphy. Radiog-raphy and ultrasonography provide information princi-pally about the structural abnormalities in dogs withPSS, whereas scintigraphy enables assessment of abnor-mal blood flow. Each of these imaging modalities hasdifferent strengths and weaknesses (Table 1).
Radiography
Survey radiography of the liver enables a limited eval-uation of its position, size, shape, and opacity.
11
Thesize of the liver is usually inferred from the appearanceof its caudoventral border as seen on a lateral radio-graph and from the position of the stomach or spleen, which may be displaced cranially when the liver issmall. A small liver usually has a blunt caudal borderthat lies within the costal arch (Figure 2). In dogs,hepatic volume is usually determined based on a sub- jective assessment. There is a fair correlation betweenlinear dimensions of the liver and its volume,
12
butattempts to estimate hepatic volume from abdominalradiographs of dogs have proved imprecise.
Contrast Radiography
Portal venography, although invasive, is the definitivemethod for demonstrating shunts in any anatomic site.Various techniques for injecting contrast medium intothe portal vein have been described, including operativemesenteric portography, cranial mesenteric angiography,and percutaneous splenoportography.
13–17
Portal venog-raphy is the optimal method for assessing shunt location(intra- versus extrahepatic) and morphology.
3,16,17
Operative mesenteric portography, although invasive,is a relatively simple and direct technique. It involvestaking radiographs immediately after injecting contrastmedium into a catheter placed surgically in a jejunalvein; therefore, it is necessary either to have a radiogra-phy room that is clean enough for abdominal surgery or to use mobile radiographic equipment in surgery.This technique produces good opacification of the por-tal vein and usually enables PSS to be readily detected
13,14
(Figure 3). It is frequently used in combination withsurgery to treat congenital PSS, and the same jejunalvein catheter is used to measure portal blood pressureduring shunt attenuation. Alternatively, selective catheterization of the cranialmesenteric artery via a femoral arteriotomy and injec-tion of contrast medium opacifies the portal vein aftercirculation through the intestinal vessels.
13–15
This tech-nique is used less often than operative mesenteric por-
628Small Animal/Exotics
Compendium 
August 2002
www.VetLearn.com
Figure 2—
Reduced hepatic volume as seen in a lateral abdom-inal radiograph. The caudal border of the liver is flattened andlies within the costal arch
(arrow) 
.(
St 
= stomach;
Sp 
= spleen.)
Table 1. Comparison of Imaging Techniques for Detecting Features of Portosystemic Shunts in Dogs
FeatureSurvey RadiographyPortal VenographyUltrasonographyScintigraph
Reduced hepatic volume +++++++ Anomalous vessel++++++Intra- versus extrahepatic location+++++++Portal hypertension+++++Shunt fraction+++++Renal enlargement+++++Urate urolithiasis++
+ = Limited information; ++ = useful information; +++ = detailed information, accurate assessment often possible.

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